The Effect of Head-Neck Stretching Exercises After Thyroidectomy on Postoperative Pain Level and Wound Healing- Randomised Controlled Trial
Phase: NA
Conditions: Postoperative Pain, Postoperative Wound Complication
Sponsor: Acelya Turkmen

 
The Effect of Head-Neck Stretching Exercises After Thyroidectomy on Postoperative 
Pain Level and Wound Healing- Randomised Controlled Trial 
 
 
 
 
 
 
 
 
NCT number: 2018/1763 
 
Document date: December 14, 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Abstract 
Background: Thyroid diseases are one of the most common health problems all over the 
world. After thyroidectomy, patients often experience discomfort such as neck pain, shoulder 
stiffness, shoulder movement difficulty, choking or pressing feeling. Head-neck stretching 
exercises provide neuromuscular coordination and flexibility in patients by reducing pain and 
muscle weakness.  
Methods: This research was carried out as a pre‐test / post‐test control group experimental 
design study in 82 patients in the general surgery clinic of a university hospital in Istanbul  
Results: 79.2% of the patients participating in the study were women. 67.07% of them had no 
chronic disease. The diagnosis of 62.19% was multinodular goiter. 70.73% of them had 
undergone total thyroidectomy surgery. The average of the Visual Analogue Scale (VAS) of 
patients in experimental group on 1st postoperative day was 2.20± 2.22, it was 3.00 ± 2.10 in 
control group. There was no significant difference between patients in experimental and 
control groups in discomfort and pain in the neck after 1 week and 1 month of surgery. 
However, a significant difference within the groups in neck pain and discomfort at 1st week 
and 1st month was observed (p <0.05). The difference between the scores given by the 
participant in the experimental and control groups regarding the healing of their wounds 1 day 
and 1 week after surgery was significant (p <0.05), but there was no significant difference 
between the scores given by the evaluator. 
Conclusion:It was found that the head-neck stretching exercise was an effective nursing 
intervention in reducing neck pain and disability in the patients, but no difference detected 
between the 2 groups. It was found that it had no positive or negative effect on wound 
healing.  
Introduction 
 
Thyroid hormones are responsible for many metabolic activities in human physiology. 
It increases the basal metabolic rate, affects protein synthesis and helps growth of long bones. 
However, when thyroid functions change in the human body, the individual can be negatively 
affected and some individuals may require surgical intervention (Takamura et al. 2005). 
Thyroid surgery is a prominent treatment for goiter, hyperthyroidism, thyroid nodules or 
thyroid carcinoma (Cooper et al. 2009).  
It has been reported that the most important complications after thyroidectomy are 
laryngeal nerve damage and hypoparathyroidism (Bellantone 2002). Therefore, patients 
generally suffer from uncomfortable symptoms such as neck pain, shoulder stiffness, 
difficulty moving shoulders, choking or pressing feeling. In addition, it is indicated that in the 
early postoperative period, patients experience limitation in neck movement and have a 
robotic walking style in order to prevent possible neck pain and protect the incision area. It is 
emphasized that these symptoms persist for a while after the operation and negatively affect 
the daily life of the patient (Takamura et al.2005).   
Neck stretching exercises which include basic movements of the neck are simple and 
effective exercises. Stretching exercises provide neuromuscular coordination and flexibility in 
patients by reducing pain and muscle weakness (Nakamura, Kodama, and Mukaino 2014). 
For this reason, neck stretching exercises should be performed in early postoperative period 
and a nurse should teach the patient the head-neck stretching exercises and ensure the patient's 
comfort after thyroidectomy. 
 
 

1. Materials and Methods 
 
1.1. Study Design and Setting 
This study was planned and conducted as an experimental study with a pre-test and 
post-test control group in order to determine the effect of post-thyroidectomy head-neck 
stretching exercises on postoperative pain level and wound healing. 
The research was conducted between January 2019 and August 2020 in a university 
hospital in Istanbul, with institutional permission (10/01 / 2019-7470) and ethics committee 
permissions (2018/1763).  
1.2. Selection Criteria 
Patients who consent verbally and written to participate in the study after being 
informed about the study, who were 18 years of age and over, who could understand the 
information given, who could read, write and speak in Turkish, who have not any problem 
preventing verbal communication were included in the study. Patients who suffers from 
cervical problems before surgery were excluded from the study. 
1.3. Assessment and Management Policy 
Routine nursing care (use of analgesics, IV fluid therapy and wound care) was applied 
to patients in experimental group after thyroidectomy. A brochure was developed in line with 
the literature on head-neck stretching exercises. Since the patients came to the clinic on 
surgery day, the exercises developed by the researchers in line with the literature were 
examined by the patient on the first postoperative day. The exercises were performed 
synchronously with the researcher and the patient. The application took approximately 10-15 
minutes. The patient was asked to perform the exercises 3 times a day, in the morning, noon 
and evening for a month, provided that each movement was 5 times. Then, the "Patient and 
Observer Scar Rating Scale (POSAS) " was applied.  
The pain level of the patient on postoperative day 1 was evaluated using VAS. For 
further evaluations, the patient was called by phone at the 1st week and 1st month. Neck pain 
and discomfort status was evaluated with the “Neck Pain and Disability Scale” (NPDS), and 
then the scar appearances with the “Patient and Observer Scar Assessment Scale” by 
requesting neck photographs at the 1st week and 1st month. 
Routine nursing care (use of analgesics, IV fluid therapy and wound care) was applied 
to the control group after thyroidectomy. Follow-up of the patients with the scales applied in 
the experimental group were also performed to the control group at the same intervals. After 
thyroidectomy, patients were called by phone in the 1st week and 1st month. “Neck pain and 
discomfort scale” and “Patient and Observer Scar Rating Scale” were applied again in both 
phone calls. Photographs of the scar appearance at the 1st week and the 1st month were 
requested from the patients. 
Neck Pain and Disability Scale (NPDS): Evaluation of pain intensity, Turkish 
Validity and Reliability were conducted with using the Neck Pain and Disability Scale by 
Biçer et al. (2004). The scale consists of 15 items. Each item measures the severity of pain, 
and evaluates the interaction of professional, social and functional aspects of life, and the 
presence and extent of emotional factors. Each item has a 10 cm visual analog scale. It is 
divided into 6 sections at equal intervals by vertical bars. Each item is between 0-5 points. It 
is stated that the Neck Pain and Discomfort Scale is not suitable to be used on the first 
postoperative day, it is more correct to use from 1st week. Therefore, postoperative pain was 
evaluated with VAS in the study. In the analysis, Cronbach's alpha coefficient of the Neck 
Pain and Discomfort Scale was 0.952, and the test-retest reliability coefficient was 0.929. 

Patient and Observer Scar Rating Scale (POSAS): In the evaluation of the wound 
site, the Patient and Observer Scar Assessment Scale, which was made by Yalılı (2014), was 
used. The scale consists of 7 items, 6 of them are for evaluating the scar (pain, itching, color, 
elasticity, thickness and irregularity assessment) and 1 evaluating the general opinion about 
the scar. Each item has a Likert-type score ranges from 1 to 10. 1 indicates normal skin, 10 
indicates worst scar assessment. The lowest score in scale, which is 6, demonstrates normal 
skin, the highest score 60 demonstrates the worst possible scar. The scale score is calculated 
over the first 6 items. In the analysis, the Cronbach's alpha coefficient of the scale was 0.914 
for PSAS, 0.724 for the OSAS, and the test-retest reliability coefficient was 0.756 for PSAS 
and 0.580 for the OSAS. 
1.4. Sample Size and Statistical Analysis 
G*Power Version 3.1.9.2 was used in the sample size calculation of the study. Sample 
size was calculated with repeated measures ANOVA test statistics. In the line with the results 
obtained by Ayhan et al. (2016), in order to find a significant difference between experimental 
and control groups in pain level and wound healing with head-neck stretching exercises, 
within the 95% confidence interval (α = 0.05), the sample size to be reached for the medium 
effect size of f = 0.25 Cohen at 0.80 power was calculated as 82 patients. Patients meeting the 
research criteria were divided into experimental and control groups by using a computerized 
randomization program (https://www.randomizer.org/).  
The data obtained from the research was evaluated by using 2013 version of IBM 
SPSS Statistics 21 program “(IBM SPSS- Statistical PackagefortheSocialSciencesfor 
Windows, Version 22.00, Armork, NY).” In evaluation of study data, besides descriptive 
statistical methods (mean, standard deviation, median, frequency, ratios, minimums, and 
maximum); Student t-Test were used in order to evaluate the qualitative values for the two-
group comparisons of the data with normal distribution; Mann Whitney U test and Kruskal-
Wallis H test were used for the two-group comparisons of the data without normal 
distribution. Pearson Correlation Analysis and Spearman's Correlation Analysis were used to 
evaluate the relationships between parameters. The results were evaluated at the significance 
level of p <0.01 and p 0.05 and at 95% confidence intervals. 
2. Results 
 
2.1. Distribution of Introductory Features 
Specific characteristics (age, gender, marital status, educational status, job status, 
economic status) of the patients in the experimental and control groups were homogeneous 
(p> 0.05) (Table 1). 
The average age of the experimental group participants who perform head-neck 
exercises was 46.10 ± 13.124, and the average age of the control group participants was 47.17 
± 13.670.  72.50% (n = 29) of the experimental group and 85.71% (n = 36) of the control 
group participants were women; 42.50% (n = 17) of the experimental group, 54.76% (n = 23) 
of the control group were primary school graduates; 30% (n = 12) of the experimental group 
participants, 33.33% (n = 14) of the control group participants were working actively and 
67.50% (n = 27) of the experimental group and 83.33% (n = 35) of the control group was 
determined to have a medium economic level (Table 1). 
 
 

Table 1. Distribution of Introductory Features (N = 82) 
Individual Features 
Experimental 
Group (n=40) 
Control Group 
(n=42) 
Total 
(N=82) 
Test 
Mean±SD 
Mean±SD 
Mean±SD 
  
p 
Age (year) 
46.10±13.124 
47.17±13.670 
46.65±13.335 
-0.360 
0.720 
 
 
n 
% 
n 
% 
n 
% 
 
p 
Gender 
Female 
29 
72.50 
36 
85.71 
65 
79.27 
2.177 
0.140 
Male 
11 
27.50 
6 
14.29 
17 
20.73 
Marital Status 
 
Married 
35 
87.50 
29 
69.05 
64 
78.05 
6.295 
0.098 
Single 
2 
5 
7 
16.67 
9 
10.97 
Divorced 
0 
0 
3 
7.14 
3 
3.66 
Widow 
3 
7.50 
3 
7.14 
6 
7.32 
Educational 
Status 
 
Literate 
7 
17.50 
5 
11.90 
12 
14.63 
2.408 
0.492 
Primary 
school 
graduate 
17 
42.50 
23 
54.76 
40 
48.79 
High school 
graduate 
11 
27.50 
7 
16.67 
18 
21.95 
University 
and senior 
5 
12.50 
7 
16.67 
12 
14.63 
Working 
condition 
Working 
12 
30 
14 
33.33 
26 
31.71 
0.241 
0.971 
Housewife 
20 
50 
21 
50 
41 
50 
Retired 
5 
12.50 
4 
9.53 
9 
10.98 
Other 
3 
7.50 
3 
7.14 
6 
7.31 
Economical 
situation 
Low 
11 
27.50 
5 
11.91 
16 
19.51 
3.235 
0.198 
Middle 
27 
67.50 
35 
83.33 
62 
75.61 
High 
2 
5 
2 
4.76 
4 
4.88 
 : Pearson Correlation Test, t: Independent Sample t-Test, Avg: Average, SD: Standard Deviation, = Pearson 
Chi-Square Test  
2.2. Distribution of Characteristics Regarding Health Status and Surgical 
Intervention  
 
The health status characteristics of the patients in the experimental and control groups 
(diagnosis, chronic disease status, movement status, status of having neck surgery) were 
similar. There was no statistically significant difference between the health status 
characteristics of the two groups (p> 0.05) (Table 2). 
The diagnosis of 62.50%  (n = 25) of the experimental group and 61.90% (n = 26) of 
the control group was MNG. It was observed that 25% (n = 10) of the experimental group 
patients had chronic disease, 12.50% (n = 5) of the patients with chronic disease had heart 
failure and 62.50% (n = 25) were active in daily life. It was stated that 40.48% (n = 17) of the 
control group patients had chronic disease, 16.68% (n = 7) of the patients with chronic disease 
had hypertension and 69.05% (n = 29) were active in daily life (Table 2). 
Total thyroidectomy was applied to 67.50% (n = 27) of the experimental group and 
73.81% (n = 31) of the control group (Table 2). 
 
 

Table 2. Distribution of Characteristics Regarding Health Status and Surgical 
Intervention (N=82) 
Features 
 
Experimental 
Group (n=40) 
Control 
Group (n=42) 
Total 
(N=82) 
Test 
 
 
n 
% 
n 
% 
n 
% 
 
p 
Diagnosis 
MNG 
25 
62.50 
26 
61.90 
51 
62.19 
0.971 
0.914 
Cancer 
13 
32.50 
13 
30.96 
26 
31.71 
Hyperthyroidism 
1 
2.50 
1 
2.38 
2 
2.44 
Graves disease 
1 
2.50 
1 
2.38 
2 
2.44 
Planjuan goiter 
0 
0 
1 
2.38 
1 
1.22 
Chronic 
İllness 
Condition 
Yes 
10 
25 
17 
40.48 
27 
32.93 
2.222 
0.136 
No 
30 
75 
25 
59.52 
55 
67.07 
Existing 
Chronic 
Diseases 
 
 
 
 
 
 
 
9.308 
0.97 
Diabetes mellitus 
4 
10 
5 
11.90 
9 
10.98 
Hypertension 
1 
2.50 
7 
16.68 
8 
9.76 
Heart failure 
5 
12.50 
2 
4.76 
7 
8.53 
Asthma 
0 
0 
1 
2.38 
1 
1.22 
All of 
 
0 
0 
2 
4.76 
2 
2.44 
Movement 
State 
Active 
25 
62.50 
29 
69.05 
54 
65.85 
0.748 
0,688 
Medium moving 
10 
25 
10 
23.81 
20 
24.39 
Motionless 
5 
12.50 
3 
7.14 
8 
9.76 
Having had 
neck surgery 
Yes 
5 
12.50 
5 
11.90 
10 
12.19 
0.007 
0.934 
No 
35 
87.50 
37 
88.10 
72 
87.81 
Type of 
surgery 
Total thyroidectomy 
27 
67.50 
31 
73.81 
58 
70.73 
3.277 
0.194 
Partial thyroidectomy 
10 
25 
11 
26.19 
21 
25.61 
Lobectomy 
3 
7.50 
0 
0 
3 
3.66 
MNG: Multinodüler goither, = Pearson Chi-Square Test 
 
2.3. Evaluation of the VAS and NPDS Score Average After Surgery 
 The average VAS of the experimental group and control group was 2.20 ± 2.22 and 
3.00 ± 2.10, respectively and there was no statistically significant difference (p>0.05) (Table 
3). 
There was no statistically significant difference between the mean neck pain and 
disability scores of the patients in the experimental and control groups at 1 week and 1 month 
after surgery (p = 0.316>0.05) (p = 0.104>0.05) (Table 3). However, analysis (Wilcoxon 
signed-rank test) was conducted to examine whether there was a difference between 1 week 
and 1 month after surgery in the patients of experimental and control group in terms of neck 
pain. The p value of the experimental and control groups was found to be 0.000. In 
conclusion, there was a statistically significant difference between the mean scores of neck 
pain and disability 1 week after surgery and 1 month after surgery in the experimental and 
control groups (p <0.05). While the mean neck pain score of the experimental group patients 
1 week after surgery was 28.5 ± 20.18, the mean neck pain score 1 month after surgery was 

11.35 ± 16.66. The mean neck pain score of the control group patients 1 week after surgery 
was 32.78 ± 19.89, while the mean neck pain score 1 month after surgery was 14.00 ± 13.84. 
(Table 3). 
Table 3. Evaluation of the VAS and NPDS Score Average After Surgery (N=82) 
Evaluation 
of 
VAS 
(0-10) 
Average Score 
Experimental Group 
(n=40) 
Control Group 
(n=42) 
t 
p 
Mean±SD 
Mean±SD 
VAS score averages on the 1st 
postoperative day 
2.20±2.22 
3.00±2.10 
-1.674 
0.099 
Neck 
Pain 
and 
Discomfort 
Assessment 
Experimental Group 
(n=40) 
Control Group 
(n=42) 
Z 
p 
Mean±SD 
Mean±SD 
NPDS- One week after surgery 
28.50±20.18 
32.78±19.89 
-1.002 
0.316 
POSAS (2)- One month after 
surgery 
11.35±16.66 
14.00±13.84 
-1.627 
0.104 
1t 
-4.65 
-4.80 
 
 
p 
0.000 
0.000 
 
 
SD: Standart Deviation, t: Independent Samples Test, 1t: Wilcoxon Signed Ranks Test, Z: Mann-Whitney U Test 
 
 
2.4. Comparison of Postoperative POSAS Score Average 
The difference between the scores given by the participants of experimental and 
control groups regarding the healing of wounds 1 day after surgery and 1 week after surgery 
was significant (p <0.05). However, it was found that there was no statistically significant 
difference between the scores given by the researcher for healing of the wounds of the 
patients in the experimental and control groups (Table 4). 
 
Table 4. Comparison of Postoperative POSAS Score Average 
Patient 
and 
Observer 
Scar 
Assessment 
Experimental Group 
(n=40) 
Control Group 
(n=42) 
Z 
p 
Mean±SD 
Mean±SD 
Patient monitoring 
 
 
 
 
PSAS- One day after surgery  
33.70±6.71 
29.73±6.63 
-2.844 
0.004 
 
 
 
1t 
p 
PSAS (2)- One week after 
surgery  
26.55±6.35 
23.14±7.43 
2.225 
0.029 
PSAS (3)- One month after 
surgery  
16.22±7.13 
17.61±7.65 
-0.852 
0.397 
Analysis of repeated measurements within the group 
2 
69.354 
58.072 
 
 

p 
0.000 
0.000 
 
 
Observer monitoring 
 
 
1t 
p 
OSAS- One day after surgery  
15.12±6.26 
15.38±5.53 
-0.196 
0.845 
 
 
 
Z 
p 
OSAS (2)- One week after 
surgery  
21.35±4.71 
19.50±5.72 
-1.526 
0.127 
 
 
 
1t 
p 
OSAS (3)- One month after 
surgery  
26.57±6.11 
24.02±6.68 
1.80 
0.076 
Analysis of repeated measurements within the group 
2 
48.962 
36.454 
 
 
p 
0.000 
0.000 
 
 
SD: Standart Deviation, 1t: Wilcoxon Signed Ranks Test, 2: Friedman test, Z: Mann-Whitney U Test 
Discussion 
Thyroid disease is one of the most common health problems in Turkey and all over the 
world. Gender is one of the unchangeable risk factors in thyroid diseases. Studies have 
reported that women experience more thyroid-related problems and neck pain than men 
(Takamura et al. 2005 Chung et al. 2007; Worni et al. 2008; Çağlayan and Çelik 2010; 
Haunch et al. 2014; Jang et al. 2014; Lang et al. 2015; Li et al. 2018; Ha et al. 2018; Al 
Qubaisi and Haigh 2019; Genç et al. 2019). The result obtained in this study was similar to 
the studies performed. 
Thyroidectomy is the most commonly used surgery method in the treatment of 
diseases related to thyroid gland (Delbridge 2003). As in present study, previous studies also 
stated that total thyroidectomy is mostly performed surgical intervention in thyroid diseases 
(Sosa 2006; Chung et al. 2007; Worni et al. 2008; Brown, de Souza and Cohen 2011; 
Spanheimer et al. 2011; Haunch et al. 2014; Lang et al. 2015; Ha et al. 2018; Al Qubaisi and 
Haigh 2019).  
Post-thyroidectomy neck pain is one of the most important problems seen in the first 
36 hours after surgery. Patients usually recover quickly after surgery, but may feel 
uncomfortable due to this problem. Similar to this study, in other studies it was observed that 
the neck pain level experienced by the patients on the first day after surgery was below 5 
points (Ryu et al. 2013; Chai et al. 2016; Ha et al. 2018; Miccoli et al. 2010; Atasayar 2016; 
Barua et al. 2016).  
During thyroidectomy surgery, due to hyperextension applied to the neck, nociceptive 
stimuli originating from anatomical structures in the cervical region may cause neck pain. In 
this study, we did not find a significant difference in terms of pain and disability between the 
groups in which we did and did not exercise head-neck stretching, but the average pain and 
disability scores of the group who did not exercise were higher. When the literature is 
reviewed, it is stated that head-neck stretching exercises increase the flexibility of the neck 
and reduce neck pain (Nakamura, Kodama and Mukaino 2014). In other studies, it was stated 
that patients who underwent thyroidectomy experienced neck pain and disability after surgery 
and this pain negatively affected their daily life (Takamura et al. 2005; Roerink et al. 2017; 
Rodríguez ‐ Torres et al. 2019).Takamura et al. (2005) stated that there was a significant 
relationship between the neck pain levels of the patients who exercised in the postoperative 
1st week and the 1st month, and the neck pain of the patients decreased significantly in the 1st 

month. Ayhan et al. (2016) found that the rate of neck pain and disability at 1 week and 1 
month after thyroidectomy was less in the group of patients who performed stretching 
exercises; Jang et al. (2014) reported that in the first 3 months after surgery, the stretching 
group experienced less neck pain and disability than those who did not. 
In the present study, we could not find any positive or negative effects of head-neck 
stretching exercises performed on patients in the experimental group on wound healing. 
Studies have reported that head-neck stretching exercises increase the movement function of 
the neck, but their effects on wound healing are controversial (Takamura et al. 2005; Chan, 
Lui and So 2010; McNeely et al. 2010; Ayhan et al. 2016). 
Conclusion 
In the study, which was planned to determine the effect of post-thyroidectomy head-
neck stretching exercises on postoperative pain level and wound healing, head-neck stretching 
exercises decreased the average neck pain and disability scores of the patients after 
thyroidectomy, although there was no significant difference between the group who did and 
did not exercise. At the same time, it was observed that head-neck stretching exercises did not 
affect wound healing positively or negatively after thyroidectomy. We think that studies in 
larger groups investigating the effect of post-thyroidectomy head-neck stretching exercises on 
pain and disability can be found statistically effective.  
 
 
GRediT Authorship Contribution Statement 
Acelya Türkmen: Conceptualization, Data curation, Methodology, Investigation, Formal 
analysis, Writing-original draft, Editing. Ikbal Cavdar: Methodology, Editing, Writing-
review, Resources. Nihat Aksakal: Data curation, Writing-review, methodology, Analysis. 
Declaration of Competing Interest 
None 
Acknowledgements 
We would like to thank all who contributed materially to our study as participating 
investigators. 
Funding Sources 
None to be disclosed by the aouthors. 
Funding 
None. 
Ethical Approval 
Before starting the study, permission from the institution (10/01/2019-7470) and ethics 
committee permissions (2018/1763) were obtained. 
 
 
 
 

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