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Abstract

Objective:

To compare the effects between telerehabilitation and in-person rehabilitation on physical function, pain and quality of life in patients with breast cancer after surgery.

Design:

Randomized, controlled, and parallel study that involved post-surgical oncological breast surgery patients who were female and aged between 18 and 70 years. The study was conducted in an outpatient environment, and the participants were randomized using a computer system. Population was divided into 2 groups: G1 (n = 20), who received face-to-face care, and G2 (n = 24), who received telerehabilitation. Participants were followed for 15 and 45 days postoperatively. The study’s primary outcomes were based on 44 patients (n = 44). Values of changes in quality of life, range of motion (ROM), muscle strength, and upper limb functionality were compared for both groups during the 15 to 45 day postoperative.

Results:

Both groups exhibited progressive improvements in range of motion, muscle strength, functionality, and quality of life over time (15- and 45-days post-operatively [PO]), indicating a positive response to treatment. Patients in G2 demonstrated more significant improvements in range of motion and muscle strength, as well as better functionality and quality of life compared to G1, particularly after 45 days PO. Additionally, G2 exhibited a more significant reduction in fatigue after 45 days PO.

Conclusions:

Telerehabilitation is a viable option with good usability, and has been shown to produce results similar to in-person physiotherapy in most cases, and even superior in some. Long-term intervention studies are needed for the development of telerehabilitation.

Keywords

breast cancer postoperative period telerehabilitation

Background

Breast cancer is the most prevalent tumor in women worldwide.¹ In Brazil, it is estimated that there will be 73 610 new cases of cancer from 2023 to 2025, with an estimated risk of 66.54 new cases per 100 000 women. The highest estimated risk is observed in the Southeast region of the country.² Breast cancer treatment typically involves surgery, chemotherapy, radiotherapy, and hormonal therapy. These treatments have been shown to reduce the recurrence and mortality of breast cancer. However, they can also generate adverse effects in patients.³

It is essential that breast cancer patients who have undergone post-operative (PO) treatment receive physical rehabilitation to manage any functional limitations that may arise.⁴ However, physical barriers such as limited access to public transportation and a lack of specialized services in certain regions make it challenging for some cancer patients to receive physical rehabilitation. Telerehabilitation presents a promising solution for providing quality and effective care to these individuals.⁵

The use of technology in home care for patients undergoing breast cancer treatment rehabilitation provides physiological and psychological benefits.⁶ Therefore, it is a valuable resource that can be applied safely. It can also serve as an alternative to face-to-face interventions for people who may face financial difficulties in attending health services.⁷

Telerehabilitation is a strategy that can help reduce the side effects of breast cancer surgery, such as lymphedema, limited upper limb movement, fatigue, and loss of muscle strength. It is a good option for maintaining physiotherapeutic assistance. However, there are few studies investigating telerehabilitation models for breast cancer patients.⁸

Telerehabilitation programs increase patients’ involvement with proposed exercises due to integration with technology and comprehensive audiovisual and interactive characteristics. These specifications are not typically found in individualized home exercise programs guided by explanatory leaflets.^9,10

Telerehabilitation programs can be applied to patients in various stages, including the postoperative period, advanced stages such as stage IV, and for breast cancer survivors.^5,11,12 It is a safe practice for cancer patients to engage in unsupervised exercise as long as it is prescribed appropriately and guided properly.¹³

Thus, the current study aimed to test the hypothesis that telerehabilitation can induce physical improvements in post-operative breast cancer patients, including increased upper limb functionality, muscle strength, and shoulder range of motion (ROM), as well as improved quality of life and reduced pain and fatigue. To compare the effects between telerehabilitation and in-person rehabilitation on physical function, pain and quality of life in patients with breast cancer after surgery.

Methods

Study Design

This is a randomized, balanced (1:1), controlled, parallel study, with blinding of participants, using the Consolidated Trial Reporting Standards as a development guide, the CONSORT.¹⁴ The study was conducted in the outpatient department of a renowned hospital specializing in oncology and infectious diseases. Data was collected between March and November 2022.

The research was conducted in compliance with the Code of Ethics of the World Medical Association (Declaration of Helsinki) and Resolution No. 466 of December 12, 2012, and No. 51 of April 7, 2016, which approve research regulatory guidelines and standards involving human subjects. The study began after approval by the Research Ethics Committee with a Certificate of Presentation of Ethical Appreciation: 55413421.0.0000.5634. The study was registered with the Brazilian Clinical Trials Registry (REBEC), with approval number: U1111-1281-7187 (https://ensaiosclinicos.gov.br/rg/RBR-4292nhn). Additionally, all participants have signed the Free and Informed Consent Form.

Participants

The study sample consisted of patients who were in the postoperative period of oncological breast surgery. The sample size was calculated for a population of 96 patients undergoing surgery during a period of 1 year, with a confidence level of 95% and a sampling error of 10%, resulting in a minimum sample size of 38 patients.

Systematic sampling was performed based on the sequence of surgeries. Patients were randomized into corresponding groups using an allocation list created by a researcher who was not involved in the study. The randomization was conducted through the website randomization.com (http://www.randomization.com). Participants were randomly assigned to 1 of 2 treatment groups using simple randomization procedures with computer-generated random numbers until their reassessment.

The research utilized the PICOS methodology. The study population consisted of female post-surgical breast cancer patients aged between 18 and 70 years old. The intervention was telerehabilitation, while the comparator was face-to-face rehabilitation. The outcomes measured were range of motion for flexion, abduction, internal rotation, and external rotation movements, muscle strength for the same movements, health-related quality of life, fatigue associated with cancer, and pain.

The eligibility criteria for this study included female patients between the ages of 18 and 70 who were diagnosed with stage I, II, or III breast cancer and underwent surgical treatment. Additionally, patients were required to meet certain functional criteria, including a shoulder flexion and abduction range of motion equal to or greater than 90°, internal and external rotation range of motion greater than or equal to 45°, and a muscular strength rating of 4 on the scale Medical Research Council, all movements verified in the preoperative assessment were included.

Exclusion criteria included lack of access to electronic video reproduction equipment, inability to perform pre-operative or post-intervention assessment movements, scar dehiscence, inflammatory processes in the limb ipsilateral to the surgery, and bilateral mastectomies or breast reconstruction surgery.

Data Collection

Regarding study participants, the hospital provided the number of surgeries performed per month. Therefore, the evaluator randomized the patients to be allocated into 2 groups. Group 1 (G1) was assigned to receive the usual physiotherapy model, which included an explanatory leaflet and in-person monitoring. Group 2 (G2) was assigned to receive telerehabilitation, which involved receiving exercise videos to be performed at home.

After surgery, participants were approached during their immediate post-operative period while being admitted to the reference hospital’s surgical clinic. If they agreed to participate in the study, patients were informed about the protocol they would follow based on randomization, and were informed that they were randomly distributed into their group. On the 15th postoperative day, after removing the drain and stitches, the research participants were evaluated after obtaining consent for the evaluation. A reassessment was carried out using the same instruments as the initial assessment 30 days after the end of the protocol (Figure 1).

Figure 1.

Description of data collection.

Instruments

The assessment for both groups consisted of a researcher-created form containing sociodemographic and clinical data. Upper limb functionality was evaluated using the “Shoulder, Arm and Hand Disability questionnaire. – (DASH).” The questionnaire comprises 30 self-administered questions, referring to the week prior to completion, and uses a 5-point Likert scale. The total score ranges from 0, indicating no dysfunction, to 100, indicating severe dysfunction.¹⁵

Regarding fatigue and quality of life, the Functional Assessment of Cancer Therapy/ Fatigue (FACT-F). This questionnaire was developed specifically to measure fatigue in cancer patients. It consists of a 40-item questionnaire, 27 of which are Functional Assessment of Cancer Therapy-General (FACT-G), to assess overall quality of life, and 13 specific items on Fatigue.¹⁶

Pain was assessed using the visual analog scale (VAS), which instructs the patient to rate their pain on a scale of 0 to 10, with 0 indicating no pain and 10 indicating the most severe pain they have ever experienced. The range of movement was measured by goniometry with a CARCI^® goniometer. The degrees of shoulder movement were evaluated, namely: flexion, extension, abduction, external rotation and internal rotation bilaterally.

Upper limb muscular strength was assessed using a digital dynamometer (E-Lastic^®) by measuring the maximum isometric strength in kilograms (kg) for shoulder joint flexion, extension, abduction, external rotation, and internal rotation. Participants performed 3 repetitions of the same joint movement, and the result was calculated as the arithmetic mean of the 3 values.

Interventions

The G1 group was provided with explanatory material in printed form during the immediate postoperative period until the 15th day of PO, in the form of a leaflet. This is the standard care provided by the oncological rehabilitation service of the research institution. This instrument provides guidelines for post-operative care, including exercises and their recommended frequency until stitches and drains are removed, as well as instructions for caring for the arm on the same side as the surgery. The home exercises prescribed in the explanatory leaflet are the same as those that G2 patients performed during this period.

Additionally, the G1 group received in-person physiotherapy sessions starting on the 15th day after the operation, following the initial guidance period. The physiotherapeutic care protocol was divided into 2 parts: active-free and resistance exercises for the upper and lower limbs, as well as aerobic exercise. This protocol was carried out twice a week for a period of 4 weeks, totaling 8 sessions (Figure 2). G1 was not provided with any additional instructions for completing exercises at home.

Figure 2.

Protocols performed by group G1 and G2.

An asynchronous telerehabilitation protocol was implemented for the G2 group. Exercise videos were sent via instant messaging applications to be performed until the 15th day of post-operation. The videos included active-free exercises that covered all planes of movement of the shoulder joint, such as flexion, extension, abduction, adduction, internal and external rotations of the shoulder, using a small ball, support, and wall support, these were the same exercises performed by G1 until the 15th postoperative day, but the instruction was carried out using a printed explanatory leaflet. The videos also included standard guidelines for post-operative care, as well as instructions for caring for the arm on the same side as the surgery.

After the 15th postoperative day, the G2 group received an exercise protocol via instant messaging applications, divided into: active-free and resistance exercises for the upper and lower limbs, in addition to aerobic exercise. This protocol was designed to be performed twice a week for a period of 4 weeks, totaling 8 days of exercises through telerehabilitation (Figure 2).

In addition, participants in G2 received weekly video calls to monitor their adherence to the telerehabilitation protocol, address any questions about the exercises, or report any adverse effects of the therapy. Video calls began in the first week of the G2 protocol, with 1 video call per week, totaling 6 video calls until the end of the G2 protocol.

The study protocol was developed by the researchers following guidelines for prescribing exercise to people with cancer. The protocol recommends practicing aerobic exercises, such as walking, and strength training exercises with resistance at least 2 days a week, involving both upper and lower limbs.¹⁷

The patients’ effort level was evaluated and their aerobic exercise was monitored using a color-coded version of the Borg Category Ratio Scale, which has a score range of 0 to 10. This scale was provided to the patients before the protocols were initiated.¹⁸ In the initial assessment, patients who underwent the telerehabilitation protocol were provided with elastic bands that generated moderate force. They were able to maintain control during the exercises.

Participants in groups G1 and G2 who presented postoperative physical complications, such as lymphedema secondary to cancer, axillary mesh syndrome, adhesive capsulitis, winged scapula, peripheral neuropathy caused by chemotherapy, and intercostobrachialgia, were excluded from the research.

Study Outcomes

The study’s primary outcomes regarding the use of telerehabilitation in the postoperative period were changes in range of motion, muscle strength, and upper limb functionality compared to in-person physiotherapy. Secondary outcomes included quality of life, changes in participants’ fatigue and pain compared to face-to-face physiotherapy.

Statistical Methods

Data normality was assessed using the Shapiro-Wilk test. Quantitative variables were presented as median and interquartile range, while non-parametric variables were presented as median and interquartile range to standardize the presentation of the data and enhance the table’s comprehensibility.

The comparison of quantitative variables between groups G1 and G2 was conducted using the student’s t-test for parametric data and the Mann-Whitney test for non-parametric data. The chi-square test was used for categorical or nominal data. A significance level of P = .05 was adopted to reject the null hypothesis.

Results

Patient recruitment occurred between March and November 2022. Patients underwent evaluation 15 days post-operation and were re-evaluated on the 45th day post-operation upon completion of the protocol.

Four patients from group G1 were excluded from the study: 3 were lost to follow-up due to incomplete protocol and 1 had the intervention discontinued due to physical complications during the post-operation period. However, the G2 group did not experience any loss as all randomly assigned patients were available for analysis. As a result, the retention rate of participants in G1 was approximately 83%, while it was 100% in G2.

Figure 3 displays the flowchart for the recruitment, participation, allocation, and analysis of study participants.¹⁴ Regarding sociodemographic characteristics, the study population has an average age of approximately 50 years old, with the majority residing in the interior regions of Pará. Additionally, most participants had more than 8 years of education and no history of smoking (Table 1).

Figure 3.

Recruitment and participation of patients in the study (Moher et al).¹⁴

Table 1.

Description of Sociodemographic and Clinical Data.

Variable	Total	G1	G2	P-value
Age^a	50.06 (±10.8)	49.3 (±10.07)	50.7 (±11,55)	.664
Home^b				.336
Metropolis	16 (36.36%)	6 (52.94%)	7 (29.17%)
Interior	28 (63.64%)	14 (47.06%)	17 (70.83%)
Education^b				.746
Up to 8 years of study	12 (27.28%)	6 (30%)	6 (25%)
Over 8 years of study	32 (72.73%)	14 (70%)	18 (75%)
Smoking^b				.710
Yes	9 (20.45%)	5 (25%)	4 (16.67%)
No	35 (79.55%)	15 (75%)	20 (83.33%)
Surgery^b				.301
Mastectomy	18 (40.91%)	10 (50%)	8 (33.33%)
Quadrantectomy	14 (31.82%)	7 (35%)	7 (29.17%)
Sectorectomy	12 (27.27%)	3 (15%)	9 (37.5%)
Axillary approach^b				1.000
Lymphadenectomy	33 (75%)	15 (75%)	18 (75%)
Sentinel lymph node	11 (25%)	5 (25%)	6 (25%)
Neoadjuvant radiotherapy^b				.382
Yes	23 (52.27%)	12 (60%)	11 (45.83%)
No	21 (47.73%)	8 (40%)	13 (54.17%)
Neoadjuvant chemotherapy^b				.259
Yes	36 (81.82%)	18 (90%)	18 (75%)
No	8 (18.18%)	2 (10%)	6 (25%)
Hormone therapy^b				.078
Yes	11 (25%)	8 (40%)	3 (12.5%)
No	33 (75%)	12 (60%)	21 (87.5%)
Positive molecular receptor
Estrogen^b				.050
Yes	30 (68.18%)	17 (85%)	13 (54.17%)
No	14 (31.82%)	3 (15%)	11 (45.83%)
Progesterone^b				.763
Yes	22 (50%)	11 (55%)	11 (45.83%)
No	22 (50%)	9 (45%)	13 (54.17%)
HER 2^b				.060
Yes	16 (36.36%)	4 (20%)	6 (25%)
No	28 (63.64%)	16 (80%)	18 (75%)

Values presented as mean and standard deviation.

Values presented as absolute frequency and percentage.

In terms of clinical characteristics, the data shows that a significant number of patients underwent breast-conserving surgeries, such as quadrantectomy and sector resection, as well as lymphadenectomy as the primary axillary approach, and neoadjuvant chemotherapy (Table 1). There was no statistical difference between the G1 and G2 groups in relation to sociodemographic and clinical characteristics.

When analyzing the data related to G1, we observed progressive improvements in range of motion, muscle strength, functionality, and quality of life throughout the period of face-to-face rehabilitation after breast cancer surgery. ROM data show a progressive increase over time in all directions of movement evaluated (flexion, abduction, extension, internal and external rotation of the shoulder). The results also indicate an increase from baseline in upper limb muscle strength in movements such as shoulder flexion and abduction. These findings suggest a positive response to face-to-face rehabilitation treatment in this specific group of patients, indicating the effectiveness of this approach.

The data from G2 also show a gradual improvement in range of motion, muscle strength, functionality, and quality of life during the telerehabilitation period after breast cancer surgery. The ROM data indicate a gradual increase over time in all directions of movement assessed, including shoulder flexion, abduction, extension, internal and external rotation. Additionally, the results show a progressive increase in upper limb muscle strength during movements such as shoulder flexion and abduction. This analysis offers valuable insights into the suitability and safety of telerehabilitation treatment for this particular patient group in the short term.

Regarding range of motion, in G2, there was a significant increase in range of motion, such as flexion and abduction, compared to the face-to-face rehabilitation group (G1). This improvement was particularly notable on the 45th postoperative day, suggesting that telerehabilitation can promote a faster recovery of range of motion after 45 days postoperatively; however, it is noted that the numerical gain in flexion and abduction from the 15th day to the 45th day for G1 was higher than G2, demonstrating the importance and efficiency of face-to-face rehabilitation (Table 2).

Table 2.

Median Data, Interquartile Range and P-value for ROM.

Movements	G1 (degrees)	G2 (degrees)	P-value (inter group)
Flexion (15th PO day)	125 (94-148)	156.5 (130-178)	.0041
Flexion (45th PO day)	161 (146-171)	180 (176.5-180)	.0001
P-value (Intra group)	.0001	.0001	-----
Abduction (15th PO day)	103 (90-144)	168 (143-180)	.0047
Abduction (45th PO day)	163 (143-176)	180 (180-180)	.0001
P-value (Intra group)	.0009	.0045	-----
Extension (15th PO day)	43 (30-45)	45 (45-45)	.0109
Extension (45th PO day)	45 (43-45)	45 (45-45)	.0105
P-value (Intra group)	.0148	.0233	-----
Internal Rotation (15th PO day)	89 (64-90)	90 (86-90)	.1515
Internal Rotation (45th PO day)	90 (74-90)	90 (90-90)	.1000
P-value (Intra group)	.1766	.1480	-----
External Rotation (15th PO day)	63.5 (38-90)	90 (73.5-90)	.0287
External Rotation (45th PO day)	90 (67-90)	90 (90-90)	.2900
P-value (Intra group)	.0326	.1014	-----

Regarding muscle strength, G2 participants also showed a significant increase in muscle strength in several movements, such as flexion and abduction, especially on the 45th postoperative day, compared to the face-to-face rehabilitation group (G1). This suggests that telerehabilitation can be applied with the aim of improving upper limb muscle strength in post-operative breast cancer patients (Table 3).

Table 3.

Median Data, Interquartile Range and P-value for Muscle Strength.

Movements	G1 (kg)	G2 (kg)	P-value
Flexion (15th PO day)	3.8 (3.2-4.8)	4.8 (3.6-7.3)	.0813
Flexion (45th PO day)	4.6 (3.6-5.2)	5.7 (4.5-7.9)	.0116
Abduction (15th PO day)	5.6 (4.4-6.8)	7.8 (6.6-10)	.0110
Abduction (45th PO day)	7.1 (5.4-8.6)	9.4 (6.5-13.4)	.0318
Extension (15th PO day)	6.8 (5.6-8.6)	6.2 (4.8-9.4)	.7358
Extension (45th PO day)	7.6 (6.9-9)	7.2 (5.7-8.5)	.2993
Internal rotation (15th PO day)	4.9 (3.6-5.4)	5.4 (3.6-6.6)	.3075
Internal rotation (45th PO day)	5.5 (4.4-6.3)	5.35 (4.6-6.6)	.9906
External rotation (15th PO day)	4.2 (3.6-4.6)	4 (3.6-5.2)	.8041
External rotation (45th PO day)	4.5 (3.8-5.2)	4.8 (4-5.6)	.7052

G2 patients showed significantly better functionality, less fatigue and a better health-related quality of life compared to G1, both on the 15th and 45th postoperative days. In G1, the median DASH on the 15th day was 30.41 and on the 45th it was 13.74. In G2, the median on the 15th day was 14.58 and on the 45th, 1.66. According to the classification of the DASH questionnaire, the values indicate a moderate to severe functional limitation in the G1 group on the 15th day, while on the 45th day they indicate a mild to moderate functional limitation. In G2, the scores indicate a mild functional limitation on the 15th postoperative day, which improves to minimal to no functional limitation on the 45th postoperative day (Table 4).

Table 4.

Median, Interquartile Range and P-value Data for Functionality, Quality of Life, Fatigue and Pain.

Variables	G1	G2	P-value
DASH (15th PO day)	30.41 (15.83-50)	14.58 (5-22.5)	.0215
DASH (45th PO day)	13.74 (7.91-18.33)	1.66 (0-6.66)	.0004
FACT-G (15th PO day)	84.5(77-91)	91 (77-102)	.1594
FACT-G (45th PO day)	95 (81.5-99)	103.5 (96-106)	.0024
FACT-F (15th PO day)	121.5 (102-136)	113.5 (97-149)	.9337
FACT-F (45th PO day)	131 (119-143)	148.5 (139-156)	.0010
EVA (15th PO day)	5 (0-5)	0 (0-2)	.0122
EVA (45th PO day)	0.5 (0-4.5)	0 (0-0)	.0047

In G1, the median FACT-G on the 15th day was 84.5 and on the 45th day was 95. In G2, the median FACT-G on the 15th day was 91 and on the 45th day was 103.5. FACT-G scores indicate good health-related quality of life in both groups, with significant improvements over time, especially in the G2 group (Table 4).

Participants in G1 showed a mild to moderate improvement in fatigue between days 15 and 45 postoperatively, with an increased median of 131. This suggests a reasonable recovery, but with persistent levels of fatigue. In group G2, a more significant variation in fatigue was observed between days 15 and 45 postoperatively, with an increased median of 148.5. This more substantial improvement indicates a more significant reduction in fatigue after telerehabilitation compared to in-person rehabilitation (Table 4).

Although the data regarding pain present a statistically significant difference, it is noted that G2 patients did not present pain on the 15th and 45th postoperative day. Therefore, telerehabilitation can also promote a more comprehensive recovery, including functional and quality of life aspects (Table 4).

During the entire research process, possible adverse events due to the interventions were monitored, G1 was evaluated during face-to-face monitoring and G2 through video calls, and it was verified that patients in G1 and G2 did not suffer any adverse events due to the interventions.

Discussion

Physical rehabilitation during the post-operative period of breast cancer surgery has been shown to improve the functionality of patients who have undergone procedures such as mastectomy or quadrantectomy with removal of axillary lymph nodes. This rehabilitation can improve the range of motion of the shoulder ipsilateral to the surgery and reduce pain.¹⁹

However, the current face-to-face rehabilitation model may limit access for some cancer patients. Therefore, telehealth systems, such as telerehabilitation, are a safe and viable resource for cancer patients, as demonstrated by Batalik et al,²⁰ with good adherence rates. Therefore, this study aimed to examine the impact of telerehabilitation on the physical function, pain, and quality of life of breast cancer patients after surgery.

The retention rate for participants receiving face-to-face rehabilitation was approximately 83% and 100% for patients receiving telerehabilitation, demonstrating good adherence for both face-to-face and telerehabilitation. In a study²¹ that evaluated the effects of 12 weeks of telerehabilitation, the adherence rate was observed, verified through the frequency with which patients reported undergoing remote monitoring, was 80% throughout the research period and no adverse events occurred. serious injuries related to training during the intervention. In this study, participants did not experience any type of physical impairment during the implementation of the treatment protocols.

The research findings indicate that patients who underwent the telerehabilitation protocol had significantly higher range of motion than the group that underwent face-to-face physiotherapy in flexion, abduction, extension movements on the 15th and 45th PO days. In terms of muscular strength, a statistically superior result was noted for flexion and abduction movements on the 15th day of PO and abduction on the 45th day.

There was a statistically significant difference in shoulder functionality and pain variables between the group that received in-person physiotherapy and telerehabilitation on both the 15th and 45th postoperative days. On the 45th day, the quality of life and fatigue variables were statistically higher in the group that underwent telerehabilitation. No changes in content were made.

Telerehabilitation systems, including telephone and mobile applications, are widely used for physical rehabilitation of breast cancer patients. This resource has been proven effective and has good usability for managing oncological complications compared to other interventions, such as usual care. Therefore, these technologies can be used to manage pain and prescribe physical activities, potentially improving the quality of life of these patients.²²

The study shows that the G2 group, which underwent the telerehabilitation protocol, experienced greater gains in range of motion for almost all shoulder movements compared to the face-to-face care group, both on the 15th and 45th day post-operation. These results suggest that exercises, even when performed remotely, can improve mobility and reduce musculoskeletal complications related to post-operative oncological breast surgery.

To support this finding, a study by Steiner et al observed that a 3 month exercise program conducted through an app was advantageous and well-received by patients as a means of continuing face-to-face treatment. Additionally, participants demonstrated an average improvement of 8.3° in all shoulder movements during the follow-up period.²³

The improved ROM results for the group that underwent telerehabilitation may be attributed to the fact that patients often struggle to adhere to outpatient services during the initial phases of rehabilitation through face-to-face exercises, making recovery more challenging, particularly for shoulder movements ipsilateral to surgery.²⁴

Early guidance on exercises aimed at range of motion of the shoulder ipsilateral to surgery during the postoperative period is essential for maintaining functional ROM, as demonstrated in our study protocol. According to Yang et al,²⁵ prescribing shoulder movements in the initial PO period, guided by a specialized professional or at least their education, can reduce fear of movement, which can later lead to more serious physical disabilities.

The study also analyzed shoulder muscle strength during the postoperative period. Results showed higher values for flexion and abduction movements on the 15th day of PO and abduction on the 45th day, indicating that the telerehabilitation protocol was more effective in increasing the strength of the muscles responsible for these movements compared to in-person physiotherapy.

In a systematic review and meta-analysis study, the effect of a telehealth-based exercise intervention on the physical activity of patients with breast cancer was evaluated. The study found that an exercise program carried out remotely can improve the strength of the patients’ shoulder muscles, presenting a statistically significant difference compared to face-to-face rehabilitation.²⁶

However, there were no significant changes in muscle strength for shoulder extension, internal and external rotation movements between the group that underwent face-to-face physiotherapy and telerehabilitation, both on the 15th and 45th postoperative days. This lack of significant change may be due to the short 6-week intervention period.

According to studies by Galiano-Castillo et al,²⁷ who carried out a personalized Internet-based exercise program over a period of 8 weeks for patients with breast cancer, showed significant improvements favoring the group that performed telerehabilitation, increasing handgrip strength both on the side ipsilateral to surgery and on the side contralateral.

The research findings indicate that patients who underwent the telerehabilitation protocol on the 15th and 45th postoperative days showed significant values for shoulder functionality, as verified by the DASH questionnaire.

Early physical therapy interventions, such as mobility exercises, range of motion exercises, manual therapy, lymphedema education, and scar treatment, have been shown to reduce the incidence of functional complications in the arm and shoulder of patients who have undergone surgery for breast cancer.²⁸ Therefore, our study supports the importance of early guidance in improving the functionality of these patients.

Additionally, a systematic review and meta-analysis conducted by Peng et al²⁶ found that telehealth can enhance upper body function in patients, as evaluated by DASH. This intervention can increase physical activity levels, leading to improved physical performance and reduced fear of shoulder movements.

According to Jiang et al²⁹ study, aerobic and resistance exercises can be beneficial in reducing fatigue in breast cancer patients. The study found that a 12-week program of combined resistance and aerobic exercise improved the quality of life for women who had completed breast cancer treatment. Additionally, the program resulted in a decrease in lack of concentration and fatigue, as well as fewer symptoms of insomnia and pain that can occur with treatment.³⁰

However, the study’s data on quality of life and fatigue showed a statistically significant difference for the G2 group only after the 45th day post-operation period. This highlights the importance of longer follow-up periods for these patients.

Telerehabilitation was shown to improve self-reported symptoms of fatigue and quality of life in our study. In line with this, Singleton et al³¹ in their study emphasizes that eHealth interventions had a wide reach, with high acceptance among several patients (international and multilingual) with breast cancer and these had a significant positive impact on quality of life, anguish and fatigue, given that there are greater interaction between staff and patient.

Furthermore, Galiano-Castillo et al²⁷ demonstrated that the benefits of telerehabilitation on fatigue and quality of life are long-lasting, even after the 8-week intervention program of resistance and aerobic exercises. The positive effects on quality of life, fatigue, and pain were maintained for 6 months after the intervention.

However, some patients may face challenges adhering to regular group exercise rehabilitation in outpatient clinics due to mobility and sociodemographic issues. Therefore, telerehabilitation has emerged as a safe, practical, and effective alternative to in-person care, particularly for physical rehabilitation services.³²

Therefore, even with the positive results of this research on telerehabilitation in the postoperative period for breast cancer, these findings must be analyzed with caution and taking into account the reduced duration of the interventions performed. In addition, the patient’s preference for remote or face-to-face training must be considered.

In a study comparing the effectiveness of face-to-face rehabilitation and telerehabilitation over 8 weeks, it was found that face-to-face outpatient treatment was more effective in recovering functional capacity of the upper limb ipsilateral to the surgery and improving quality of life. The findings of this study contrast with the data presented in the survey. This difference may be due to the shorter evaluation period of 45 days for the interventions in this study.¹¹

A survey that assessed the interest in and preferences for exercise among patients undergoing treatment for breast cancer found that the majority of participants preferred in-person exercise counseling with an exercise specialist at a center or hospital immediately after their surgery. This fact may be a barrier to implementing telerehabilitation programs in which patients opt for in-person monitoring.³³

The use of telerehabilitation appears to be more effective in situations where in-person treatment is not possible, such as in cases of limited social participation, as in the COVID-19 pandemic. Telerehabilitation may also be preferred by patients after completing at least one face-to-face session to learn and perform prescribed exercises, making it an important tool for continuing the suggested treatments^5,34 The main limitation of the study was the lack of long-term follow-up of the groups to determine the differences between the therapies. For those wishing to access supplementary material, it will be available online upon request.

Conclusion

Telerehabilitation is a promising and effective alternative for post-surgical breast cancer patients. The data reveal significant improvements in physical function, quality of life and reduction in fatigue over time, highlighting the feasibility of this approach in the context of post-operative recovery. Comparison with in-person rehabilitation indicates that telerehabilitation can produce similar or even superior results in some aspects, highlighting its potential as a valuable treatment option, in addition to demonstrating a safe approach for patients with breast cancer. However, additional long-term studies are needed to fully evaluate the impact of telerehabilitation and confirm its long-term effectiveness. These results have implications for clinical practice, offering a positive and innovative perspective on the postoperative management of patients with breast cancer.

Supplemental Material

sj-doc-1-ict-10.1177_15347354241256314 – Supplemental material for Comparison of Effects Between Telerehabilitation and In-Person Rehabilitation After Breast Cancer Surgery: A Randomized Controlled Study

Supplemental material, sj-doc-1-ict-10.1177_15347354241256314 for Comparison of Effects Between Telerehabilitation and In-Person Rehabilitation After Breast Cancer Surgery: A Randomized Controlled Study by Leonardo Breno do Nascimento de Aviz, Camila Ferreira Alves, Carolina Lima da Fonte, Lorena de Nazaré Rocha Corrêa, Raphaely Cristiny Sanches Progênio, Laerte Jonatas Leray Guedes, Laura Maria Tomazi Neves and Saul Rassy Carneiro in Integrative Cancer Therapies

Footnotes

Data Availability

The data that support the findings of this study are available from the corresponding author, Leonardo Breno do Nascimento de Aviz, upon reasonable request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior - Brasil (CAPES) - Finance Code 001.

Trial Registration

The research was submitted to the Brazilian Clinical Trial Registry (REBEC), with approval number: U1111-1281-7187 ().

ORCID iD

Leonardo Breno do Nascimento de Aviz

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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