A Mobile App with Virtual Physical Therapy Support for Shoulder Rehabilitation Following Breast Reconstruction: A Pilot Study

Introduction: Breast cancer is the most common cancer for Canadian women and one in five breast cancer survivors (BCS) will elect to have breast reconstruction. Despite the benefits of reconstruction, residual shoulder dysfunction is a problem for many. This study introduces a mobile application (app)-based shoulder rehabilitation program developed to address functional outcomes of the shoulder, for women who have had breast reconstruction. Purpose: To investigate the feasibility and effectiveness of a shoulder rehabilitation program, delivered by a mobile app, ShApp (Avicenna™), to improve functional outcomes through easy access to rehabilitation for post-reconstruction BCS. Additionally, to evaluate the validity and reliability of ShApp for measuring shoulder range of motion (ROM) in a population of BCS. Methods: A randomized controlled study design was used. Twenty-two women (mean age 46.91, SD 9.84) were recruited. Sixteen women completed the study after being enrolled and randomized into two groups (control or rehabilitation). The main inclusion criteria were women aged 18 years and older with a mobile phone capable of app download and second device for videoconferencing. The main exclusion criteria were health-related issues that would interfere with their ability to complete the program. The program began 6 weeks post-operatively. During the 8-week app program, both groups had access to the app’s educational material, while the rehabilitation group also had access to its exercise program. Outcome measures (shoulder ROM and function, pain, fatigue, and quality of life [QoL]) were all collected on the app at Week 1, 4, and 8, during a videoconference via the Zoom platform with the two physical therapist (PT) evaluators (one blinded and one not blinded to groupings). At program completion, participants answered an anonymous satisfaction survey. Between and within group differences for all measures were analyzed using two-way repeated measures analysis of variance (ANOVA; p < .05) or Friedman’s test (p < .05). Results: Both control (n = 10) and rehabilitation (n = 12) groups showed improved ROM as measured by ShApp, with statistically significant overall effects for extension (control: p = .005; rehab: p = .022) and flexion (control: p = .038). No statistically significant changes were found for abduction, internal or external rotation. Scores for the 36-Item Short Form Health Survey (SF-36) indicated a statistically significant time x group interaction, F(2, 40) = 3.53, p = .039. Post-hoc comparisons showed statistically significant differences for the rehabilitation group between Week 1 (M = 49.08, SD = 14.00) and Week 8 (M = 68.17, SD = 14.33), p = .005, and between Week 4 (M = 58.08, SD = 12.80) and Week 8 (M = 68.17, SD = 14.33), p = .031. A statistically significant main effect of time was also observed, F(2, 40) = 13.14, p < .001, with post-hoc comparisons between Week 1 (M = 53.14, SD = 15.96) and Week 4 (M = 59.73, SD = 14.69), p = .025; Week 1 (M = 53.14, SD = 15.96) and Week 8 (M = 66.32, SD = 15.88), p = .001; and Week 4 (M = 59.73, SD = 14.69) and Week 8 (M = 66.32, SD = 15.88), p = .025. No between-group differences were observed. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores showed statistically significant improvement over time in both groups (control: p = .028; rehab: p < .001), with notable gains in the rehabilitation group from Week 1 to Week 8 (p = .003). A very strong correlation was found between evaluation methods for left shoulder extension at Week 4, rs(6) = .918, p = .011, with moderate reliability, intraclass correlation coefficient (ICC) = 0.72, and significant agreement, β = .650, p = .014. Other ROM measures demonstrated strong correlations and moderate agreement, though limited reliability. Data completeness was affected by missing app entries, likely due to user error. There were no adverse responses and participants reported high satisfaction, highlighting ease of use and helpful content. Conclusion: The app program together with PT support is feasible and effective and women in both groups appeared to have improved shoulder flexion and extension ROM at the completion of the eight-week program. Although not significant, the rehabilitation group also appeared to have improved QoL, shoulder function, and fatigue compared to the control group. A strong correlation, moderate intraclass correlation coefficient (ICC) value, and significant agreement between ShApp and visual inspection for ROM values when data were complete, support its concurrent validity and provides evidence of reliability for measuring shoulder ROM. The addition of high participant satisfaction further substantiates ShApp’s functionality.

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