To evaluate the best time (early or delayed) in the acute post-operative period to start physiotherapy for patients who have undergone axillary dissection for breast cancer.

MEDLINE was searched from 1976 using the terms 'physical therapy', 'mastectomy', 'time factors' and 'shoulder movement'. The reference lists of included studies were searched for additional references.

Study designs of evaluations included in the review

True or quasi-experimental studies that compared early start physiotherapy with late-start physiotherapy.

Specific interventions included in the review

Early start physiotherapy (1-2 days postoperative) and late-start physiotherapy (5-7 days post-operative).

Participants included in the review

Women who had undergone axillary dissection for breast cancer.

Outcomes assessed in the review

Wound draining volume, wound drainage duration and range of motion.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review.

The internal and external validity of the studies was assessed using the following criteria: randomisation, matching procedure, blinding, description of drop-outs, reliability of measurement instruments, controlling for co-interventions, comparability of patient characteristics between groups, description of duration and content of physiotherapy.Each item was scored as 0 if it was not fulfilled and 1 if it was fulfilled. The methodological quality of the studies was assessed independently by two reviewers.

The authors do not report how data were extracted from primary studies. Effect sizes and their 95% confidence intervals (CI) were calculated.

How were the studies combined?

The effect sizes were pooled using the methods of Cooper and Hedges (see Other Publications of Related Interest no.1).

How were differences between studies investigated?

Heterogeneity was investigated statistically using the Q statistic.

Six randomised controlled studies (n=257) and one quasi-experimental study (n not reported). Only the randomised controlled trials were included in the meta-analysis.

Quality scores ranged from 27-73% of the maximum score.

Wound draining volume (n=6 RCTs).

Effect size ranged from 0.02-0.90, pooled effect size based on 5 RCTs = 0.35 (95% CI: 0.17, 0.53), this is equivalent to a mean difference of 101.5 ml (95% CI: 94.91, 108.1). Heterogeneity was not significant (p>0.10).

Wound draining duration (n=5 RCTs).

Effect size ranged from 0.2-1.01 with a pooled effect size of 0.37 (95% CI: 0.17-0.57), this is equivalent to a mean difference of 0.93 days (95% CI: 0.41, 1.47). Heterogeneity was not significant (p>0.20).

Range of motion (n=6 RCTs).

Studies were too heterogeneous in terms of the point in time that the range of motion was evaluated and the definition of the full range of motion for data to be pooled. In three studies there was no significant difference between the treatment groups at 2-4 weeks post-operation. In four studies there were no reported differences between the groups 4-6 months after the operation.

On the basis of the meta-analysis it can be concluded that late-start physiotherapy is more advantageous than early start. The wound draining volume and the wound draining duration were significantly smaller in the group that started physiotherapy after the 5-7th day compared to the group that started physiotherapy on the 1st or 2nd day post-operatively. The two studies with the highest quality scores found the greatest effect size.

A reasonable review of the area. The review was limited by the literature search not being very extensive, with only one database searched. In addition, the authors did not attempt to locate unpublished material, thus the results may be subject to publication bias. Very few methodological details, such as the number of reviewers involved in assessing studies for inclusion and in data extraction, were provided. Study details, other than results, were not presented in a table, which would have been helpful in reviewing the results. Inclusion criteria were clearly presented and study quality was assessed appropriately and discussed in the results. The statistical methods used to pool results were appropriate for the data and heterogeneity was formally investigated. The authors conclusions follow from the results presented but should be interpreted with some degree of caution due to the limitations highlighted above.

Practice: Physiotherapy for these patients should be started 5 to 7 days after surgery. It is important to include research data in refresher courses for physiotherapists.

Research: further research is needed into, for example, the influence of type of mobilisation exercises.

1. Cooper, H. Hedges, LV. the Handbook of research synthesis. New York: Russell Sage Foundation, 1994

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.