Effectiveness of Proprioceptive Neuromuscular Facilitation for Improving for Shoulder Biomechanical Parameters, Function, and Pain After Axillary Lymph Node Dissection: a Randomized Controlled Study
Phase: NA
Conditions: Breast Cancer, Muscle Strength
Sponsor: Istanbul Medipol University Hospital

 
 
 
Effectiveness of proprioceptive neuromuscular facilitation for improving  for 
shoulder biomechanical parameters, function, and pain after axillary lymph node 
dissection: a randomized controlled study 
 
 
Study Protocol and Statistical Analysis  
 
 
NCT NO: 10840098-604.01.01-E.184 
 
Ethics committee approval date: 25/12/2019 
Document update date: 19/01/2022 
 
 
 
 
 
 
 
 
 
 
 

Breast cancer is the most common type of cancer affecting women of all ages worldwide. An 
increase in the incidence of breast cancer is observed with the effect of widespread screening 
programs today. Improved and comprehensive treatment options (surgery, radiotherapy, 
systemic adjuvant and neoadjuvant therapy, hormonal therapy) have increased the survival rate 
and life expectancy. This has necessitated a focus on the short, medium and long term 
complications of breast cancer treatment and their management. Axillary lymph node dissection 
and radiotherapy are associated with pain, physical symptoms, and decreased functional 
abilities in the upper extremity. This study aimed to compare the potential effects of 
proprioceptive neuromuscular facilitation (PNF) technique on muscle strength, pain and 
functionality in this patient group with progressive resistance exercise (PRT). 
Inclusion Criteria: 
• 
Individuals diagnosed with stage II-III breast cancer 
• 
30-65 years old 
• 
ALND was performed by the same surgeon regardless of breast resection level. 
• 
Receiving radiotherapy 
• 
Individuals who spent the first six months after surgery were included in the study. 
Exclusion Criteria: 
• 
Diagnosed with stage IV or metastatic breast cancer 
• 
Developing bilateral breast cancer 
• 
Developing lymphedema in the postoperative period 
• 
Any contraindication to exercise 
• 
Participating in any physiotherapy program for the upper extremity in the last 6 
months 
• 
Have significant cardiac, pulmonary or metabolic comorbid disease 
• 
Individuals with communication problems were excluded from the study. 
 
The study was designed as a randomized, controlled, single-blind, prospective study to 
compare the effectiveness of PNF technique and progressive resistance exercise. Patients who 
applied to Istanbul Medipol University General Surgery Department for routine control after 
breast cancer treatment were determined. Individuals who were willing to participate and met  
the inclusion criteria were divided into 3 groups (PNF, progressive resistant ex., control) using 
the website www.randomizer.org. 
 
Document update date: 19/01/2022 

 
Proprioceptive Neuromuscular Rehabilitation group 
 
 
The PNF technique was performed in the supine position with the hip joints of the patients in 
30° flexion and the lower extremities in semi-flexion. The application was performed in 2 
different diagonal and 4 different patterns (flexion-abduction-external rotation/extension-
abduction-internal rotation, and flexion-adduction-external rotation/extension-abduction-
internal rotation) of the upper extremity. When starting the exercise, the muscles were first 
brought to their longest position and the patient was asked to move in the direction of the pattern 
with resistance (concentric contraction) and to maintain this position for 6 seconds at the end 
of the pattern (isometric contraction). Then, while the therapist was taking the patient's arm to 
the starting position, the patient was asked to prevent movement (eccentric contraction). All of 
these moves counted as one repetition. 3 sets of 8-12 repetitions were performed for each 
pattern. 
Progressive Resistance Exercise Group 
 
Strengthening exercises targeting the upper extremity main muscles were applied to the PRE 
group with progressive resistance. Dumbbells and sandbags were used as resistance equipment. 
resistance intensity; 50-80% of a repetition maximum (RM) was determined according to the 
patient's tolerance. The exercises were applied as 8-12 repetitions and 3 sets. A rest period of 
60-90 seconds was allowed between each set. After the 4th week of the training, 1 RM was 
measured again and the resistance density was updated. The 8 strengthening exercises to be 
applied were created by taking examples from the literature and in accordance with the 
"Guidelines for implementing exercise programs exercise programs for cancer patients". These 
exercises are: "dumbbell fly", "triceps extension", "biceps curl up", "one-arm bent over row", 
"dumbbell sides rise", "lifting the arm forward", "wrist curl" and side lying shoulder internal -
external rotation". 
Control Group 
The patients in the control group were instructed to continue their usual daily lives (not 
changing their physical activity levels, diet, drug use, etc.) until the date of re-evaluation after 
the initial evaluation. Information was given about the upper extremity normal range of 
motion exercises that they could apply at home, and a brochure was given.  

Document update date: 19/01/2022 
Primary Outcome Measure: 
 
1.Isokinetic dynamometer 
Humac Norm, model 770, Computer Sports Medicine Inc., Stoughton, USA was used to 
biomechanically evaluate shoulder flexors/extensors, abductor/adductors, internal/external 
rotators. Muscle strength was measured at 60°/s, muscle strength at 120°/s, endurance at 180°/s 
angular velocity and in concentric/concentric mode. 5 repetitions at 60°/s and 120°/s angular 
velocity, and 15 repetitions at 180°/s angular velocity were performed at the measured active 
range of motion. The measurement was performed only on the operated side upper extremity. 
A rest period of 2 minutes was provided between series of each muscle group and 5 rest periods 
between different movement patterns. For each angular velocity, the first trial was subtracted, 
and the average peak torque value of the remaining repetitions (the force produced by the 
individuals at the maximum during the angular velocity) was recorded in Newton-meters (Nm). 
It was applied before and after the 8-week treatment protocol. 
2.Disabilities of the Arm, Shoulder, and Hand (DASH) 
The scale includes 30 questions about symptoms (5 items) and functionality (25 items). In this 
study, business/sport-specific additional modules of the scale were not used. Each item offers 
5 answer options and is scored on a likert scale from 1 to 5. 1: reflects 'no difficulty' and 5: 
reflects 'serious difficulties'. The resulting scores for all items are then used to calculate the total 
score from 0 (no disability) to 100 (most severe disability) (16). It is accepted as the most 
consistent test in terms of construct validity and responsiveness in examining upper extremity 
problems in individuals undergoing breast cancer treatment. It was applied before and after the 
8-week treatment protocol. 
3.Visual Analogue Scale (VAS) 
The patients were asked to mark their pain levels in the breast, shoulder and axilla regions on 
the affected side during rest and activities of daily living on a 10 cm scale (0=no pain, 10=worst 
pain ever experienced). The distance (cm) between the zero point and the point marked by the 
patient indicates the level of pain. It was applied before and after the 8-week treatment protocol.  
Document update date: 19/01/2022 

4.Global Rating Of Change Scale (GRC) 
The Global Rating of Change Scale (GRC) contains a single question in which the patient can 
rate how much he has improved retrospectively from his own perspective. The validity and 
reliability of the GRC scale has been verified and is widely used in the assessment of change 
for musculoskeletal problems. 7 different answers (-3: much worse, 2: worse, -1: slightly worse, 
0: the same, 1: a little better, 2: quite good, 3 They were asked to answer by choosing one of 
the :much better) options. In scoring, scoring can be done according to a 7-point Likert 
evaluation, as well as calculations can be made using negative scores. This scale was applied 
only to the study groups in the post-treatment measurement. It was applied only at the end of 
the 8-week treatment protocol. 
Statistical analysis 
In the descriptive statistics of the data, mean, standard deviation, median minimum, maximum, 
frequency and ratio values were used. The distribution of variables was measured with the 
Kolmogorov-Smirnov test. Kruskal-wallis, mann-whitney u test was used in the analysis of 
quantitative independent data. Wilcoxon test was used in the analysis of dependent quantitative 
data. Chi-square test was used in the analysis of qualitative independent data, and fischer test 
was used when the chi-square test conditions were not met. SPSS 27.0 program was used in the 
analysis. 
 Document update date: 19/01/2022