Orientation and Information Provision

Orientation and Information Provision

PEP Topic 
Lymphedema
Description 

Orientation and information provision is the act of providing patients and others information about their disease, treatment, and services to be provided. This often includes general information about the organization, staff members with whom the patient may interact, physical structures and layout, and transportation or parking. The intervention differs from psychoeducational interventions in that it is not interactive with patients or families and does not include components such as support or counseling. Orientation and information provision may be done via print or electronic media. In addition to lymphedema, this type of intervention has been examined in oncology for effects in anxiety and depression.

Effectiveness Not Established

Research Evidence Summaries

Fu, M.R., Axelrod, D., Guth, A.A., Cartwright, F., Qiu, Z., Goldberg, J.D., . . . Haber, J. (2014). Proactive approach to lymphedema risk reduction: A prospective study. Annals of Surgical Oncology, 21, 3481–3489.

doi: 10.1245/s10434-014-3761-z
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Study Purpose:

To evaluate the safety, feasibility, and acceptability of the Optimal-Lymph-Flow™ program for patients with breast cancer and to evaluate its benefit when introduced presurgically

Intervention Characteristics/Basic Study Process:

The Optimal-Lymph-Flow™ (OLF) program is a patient self-care program designed to reduce the development of lymphedema through specific exercises and behaviors to improve lymph flow and reduce or maintain body mass index (BMI). Participants were recruited preoperatively and followed prospectively for 12 months after surgery. Trained nurses provided each participant with the study intervention through a 30-minute face-to-face meeting. Participants were trained in various exercise techniques and then did a return demonstration (shoulder, breathing, and pumping exercises). They also were instructed in a nutrition-balanced and portion-appropriate diet to maintain preoperative BMI. Participants’ limb volume was measured with a Perometer, and BMI was measured with bioimpedance presurgery, two to four weeks after surgery, and at 6–12 months. Any patient with a limb volume measurement ≥ 10% was referred for complete decongestive therapy. If a 5% increase in limb volume occurred, patients were instructed to increase OLF activities, and limb volume was rechecked a few weeks later.

Sample Characteristics:

  • N = 140
  • AVERAGE AGE = 56 years (SD = 11.8 years, range = 25–84 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: First-time diagnosis of breast cancer (stages 1–3)
  • OTHER KEY SAMPLE CHARACTERISTICS: Women aged greater than 21 years and scheduled for surgical treatment including lumpectomy, mastectomy, sentinel lymph node biopsy, or axillary lymph node dissection; excluded stage 4 breast cancer, preexisting lymphedema, patients with a history of breast cancer, and bilateral breast cancer

Setting:

  • SITE: Single site    
  • SETTING TYPE: Other  
  • LOCATION: New York, United States

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care

Study Design:

Prospective, longitudinal, quasi-experimental design with repeated measures

Measurement Instruments/Methods:

  • The safety of the OLF program was assessed by asking participants if the program created any discomfort or injury at each follow-up visit.
  • The feasibility of the program was evaluated in terms of intervention delivery time by the trained nurses.
  • The acceptability of the program was assessed by asking the participants if the program helped the them to (a) understand how to reduce the risk of lymphedema, (b) reduce the fear and anxiety of developing lymphedema, and (c) develop a plan to reduce the risk of lymphedema.
  • Lymph volume changes were measured by an infrared Perometer, and BMI was measured by a bioimpedance device.

Results:

One-hundred and thirty-four participants completed the study. At each follow-up visit, no participants reported injury or discomfort associated with the OLF program, making it safe. It took about 30 minutes for the trained nurses to deliver the program, making it feasible. Greater than 90% of the patients reported that the OLF program helped them reduce their fear and anxiety of developing lymphedema, making it acceptable.

The majority (97%) of patients maintained or improved their preoperative limb volumes and BMIs at the study endpoint of 12 months following surgery.

All four women who experienced a 10% lymph volume increase two to four weeks post-surgery and at six months decreased their lymph volume to less 5% at the 12-month visit. BMI did not change significantly. No control group was used, so the benefits of this treatment could not be determined.

Conclusions:

This educational and behavioral program may be effective to enhance lymphedema risk reduction. The study provided initial evidence for an emerging change in lymphedema care from treatment focus to proactive risk reduction.

Limitations:

  • Baseline sample/group differences of import
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Other limitations/explanation: Single-site study

Nursing Implications:

Studies with more rigorous research designs (i.e., randomized, controlled trials) are needed to replicate the findings from this study, evaluate the effectiveness of the OLF program, and determine the dosage and contribution of individual components of the program.

Fu, M.R., Axelrod, D., & Haber, J. (2008). Breast-cancer-related lymphedema: Information, symptoms, and risk-reduction behaviors. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing/Sigma Theta Tau, 40(4), 341–348.

doi: 10.1111/j.1547-5069.2008.00248.x
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Study Purpose:

To explore the effect of providing lymphedema information on breast cancer survivors’ symptoms and practice of risk-reduction behaviors

Intervention Characteristics/Basic Study Process:

All data collection was completed in person. The first author was available to answer questions and assist participants with physical disabilities (i.e., to provide help with reading, marking, or writing). Data were collected from August 22, 2006–May 1, 2007 in New York City, NY.

Sample Characteristics:

  • The study sample (N = 136) was comprised of female patients with breast cancer.
  • Mean age of patients was 54 years.
  • Seventy-four percent of patients were White, 59% were married, and 44% held a graduate degree.

Setting:

The study took place at New York University Cancer Center.

Study Design:

The study used a cross-sectional, descriptive design.

Measurement Instruments/Methods:

The study used the Lymphedema and Breast Cancer Questionnaire to assess lymphedema-related symptoms and the Lymphedema Risk-Reduction Behavior Checklist.

Results:

Fifty-seven percent of patients reported that they received lymphedema information. On average, participants had three lymphedema-related symptoms. Only 18% of participants were free of symptoms. Participants who received information reported significantly fewer symptoms (t = 3.03, p < 0.00) and practicing more risk-reduction behaviors (t = 2.42, p = 0.01).

Conclusions:

Providing lymphedema information has an effect on symptom reduction and more risk-reduction behaviors being practiced among survivors of breast cancer.

Limitations:

  • The study used a cross-sectional design.
  • The majority of the sample were highly educated and White.

Nursing Implications:

In the study, nurses were ranked as the second-most important source of lymphedema information or education after pamphlets. In clinical practice, nurses and other healthcare professionals could consider taking the initiative to provide adequate and accurate information and engage survivors of breast cancer in supportive dialogues concerning lymphedema risk reduction

Sato, F., Ishida, T., & Ohuchi, N. (2014). The perioperative educational program for improving upper arm dysfunction in patients with breast cancer: A controlled trial. Tohoku Journal of Experimental Medicine, 232, 115–122. 

doi: 10.1620/tjem.232.115
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Study Purpose:

To determine the benefit of an educational program on arm and shoulder function for patients with breast cancer given prior to surgery and axillary lymph node dissection three months postoperatively

Intervention Characteristics/Basic Study Process:

The intervention group received a three-month educational program on how to monitor arm function, exercises, and how to prevent shoulder dysfunction and lymphedema. Patients were taught how to assess their shoulder function and then were taught how to exercise the arm to improve range of motion postoperatively and reduce the risk of lymphedema. Upper extremity dysfunction included swelling, pain, numbness, weakness, and loss of range of motion on the affected side. The control group received routine care.                                                                                                                                                                                                    

Sample Characteristics:

  • N = 149  
  • AGE ≥ 20 years
  • FEMALES: 100%
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients with breast cancer were divided into two groups, those receiving axillary lymph node dissections (ALNDs) and those receiving sentinel lymph node dissections (SLNDs). Within these two groups, patients selected to be either in the intervention or the control group. Exclusion criteria included bilateral breast cancer or recurrence.

Setting:

  • SITE: Single site    
  • SETTING TYPE: Other    
  • LOCATION: Miyagi, Japan

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Assessment of postoperative arm function

Study Design:

This was a longitudinal controlled trial that was not randomized. There was a control group and an intervention group.

Measurement Instruments/Methods:

  • All measurements were taken at hospital admission, one week postoperatively when the drains were removed, one month postoperatively, and at the close of the study three months postoperatively. 
  • Arm girth measurements included two points, forearm girth and upper arm girth, and comparison to the unaffected side.
  • For grip strength, a standard dynamometer was used, and differences between dominant and nondominant were determined.
  • Shoulder range of motion included three planes, flexion, abduction, and horizontal extension. Differences were calculated.
  • Subjective Perception of Post-Operative Functional Impairment of the Arm (SPOFIA) given preoperatively
  • Disabilities of the Arm, Shoulder, and Hand (DASH)

Results:

Of the 149 patients in the study, 69 received ALND and 80 received SLNB. Thirty-nine of the patients from the ALND group and 51 patients from the SLNB group participated in the intervention, and the remaining 30 ALND patients and 29 SLNB patients participated in the control group. Participants were similar in demographic and disease background. In the SLNB group, there were no significant differences in any outcomes between the study intervention and control groups. In the ALND group, there was a significant increase in grip strength through three months postoperatively in the intervention group compared to the control group (p = 0.04). There was a significant improvement in the study intervention group's SPOFIA scores compared to the control group over time (p = 0.02). 

Conclusions:

Patients with training prior to breast cancer surgery and ALND developed grip strength and perceived improved arm function compared to those who did not receive training and education. No lymphedema was assessed after two months postoperatively. The exercises and the type of intervention were not described. The outcomes of the program require additional randomized studies.

Limitations:

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)

 

Nursing Implications:

Patients with breast cancer usually fail to discuss many symptoms in the DASH or SPOFIA assessment tools. If patients are taught to report these symptoms and not to consider them normal or anticipated, particularly right after surgery, nurses might refer rehabilitation earlier.

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