The Effectiveness of Neck Stretching Exercises Following Total Thyroidectomy on Reducing Neck Pain and Disability: A Randomized Controlled Trial

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1 The Effectiveness of Neck Stretching Exercises Following Total Thyroidectomy on Reducing Neck Pain and Disability: A Randomized Controlled Trial Hatice Ayhan, PhD, RN Sevinc Tastan, PhD, RN Emine Iyigün, PhD, RN Erkan Oztürk, MD Ramazan Yildiz, MD Semih Görgülü, MD Keywords disability, neck stretching exercises, neck pain, thyroidectomy ABSTRACT Background: Although there are a limited number of studies showing effects of neck stretching exercises following a thyroidectomy in reducing neck discomfort symptoms, no study has specifically dealt with and examined the effect of neck stretching exercises on neck pain and disability. Objective: To analyze the effect of neck stretching exercises, following a total thyroidectomy, on reducing neck pain and disability. Methods: A randomized controlled trial was conducted. The participants were randomly assigned either to the stretching exercise group (n = 40) or to the control group (n = 40). The stretching exercise group learned the neck stretching exercises immediately after total thyroidectomy. The effects of the stretching exercises on the participants neck pain and disability, neck sensitivity, pain with neck movements as well as on wound healing, were evaluated at the end of the first week and at 1 month following surgery. Results: When comparing neck pain and disability scale (NPDS) scores, neck sensitivity and pain with neck movement before thyroidectomy, after 1 week and after 1-month time-points, it was found that patients experienced significantly less pain and disability in the stretching exercise group than the control group (p <.001). At the end of the first week, the NPDS scores (mean [SD] = 8.82 [12.23] vs [12.09]), neck sensitivity scores (median [IR] = 0 [.75] vs [4.0]) and pain levels with neck movements (median [IR] = 0 [2.0] vs. 3.5 [5.75]) of the stretching exercise group were significantly lower than those of the control group. However, there was no significant difference between the groups with regard to the scores at the 1-month evaluation (p >.05). Linking Evidence to Action: Neck stretching exercises done immediately after a total thyroidectomy reduce short-term neck pain and disability symptoms. INTRODUCTION Today, thyroid operation is the preferred treatment when a diagnosis of goiter, hyperthyroidism, solitary thyroid nodules, or thyroid carcinoma is made. When there is a diagnosis of thyroid carcinoma and nodules with the possibility of cancer, a total thyroidectomy is preferred (Cooper et al., 2009). The primary and most feared complications following a thyroidectomy are reported to be recurrent laryngeal nerve palsy and hypoparathyroidism (Bellantone et al., 2002; Erdogan et al., 2000). In addition, patients frequently experience discomfort symptoms in their neck such as neck pain, stress and pressure in the neck, shoulder stiffness, and shoulder and neck movement difficulties (Takamura et al., 2005). Discomfort symptoms occur because patients necks remain in a hyperextended position during the prolonged operation. In addition, during the early postoperative period, patients were observed in the current study to not move their necks and to walk robotically, possibly to prevent exacerbating the neck pain and to protect their incisions, as was similarly reported by Takamura et al. (2005). It has been argued that, after a while, poor or mistaken posture leads to mechanical neck pain (Binder, 2007). Experiencing neck discomfort symptoms has negative effects on patients quality of life after a thyroidectomy (Takamura et al., 2005). In routine clinical practice, neck movements are recommended to avoid these negative experiences. Neck stretching exercises, including basic movements 224 Worldviews on Evidence-Based Nursing, 2016; 13:3,

2 of the neck, are known to be the simplest and most effective exercises. Stretching exercises improves flexibility and neuromuscular coordination, reduces pain and muscle weakness; it also improves physical activity encourages proper posture (Nakamura, Kodama, & Mukaino, 2014). However, these exercises negatively affect muscle strength when it s done for a long time and incorrectly (Rubini, Costa, & Gomes, 2007). Background Numerous studies indicate that stretching exercises following several types of operations, are one of the most efficient ways to reduce pain, improve functionality, and avoid morbidity (Chung, Lee, Hwang, & Park, 2013; Reeve et al., 2010). However, there are a limited number of studies showing the same positive effects of planned and regular neck stretching exercises following a thyroidectomy (Jang, Chang, Kim, Moon, & Son, 2014; Takamura et al., 2005). These studies argue that when planned and regular neck stretching exercises are initiated early, they are efficient in reducing neck discomfort symptoms and have no negative effect on incision healing (Jang et al., 2014; Takamura et al., 2005). However, these studies only looked at neck pain and neck stiffness in patients who experienced partial or total thyroidectomies and the data were obtained using an interview survey that was not tested for validity and reliability. Neck pain leads to negative physical, psychological, and social difficulties in patients daily lives and may cause disability (Bicer, Yazıcı, Camdeviren, & Erdogan, 2004). Therefore, treatments to reduce neck pain should address not only the severity of the pain but also the effect on patients functionality. There are several scales that evaluate neck pain and related disability for which validity and reliability are established (Jordan, Manniche, Mosdal, & Hindsberger, 1998; Leak et al., 1994; Vernon & Mior, 1991; Wheeler, Goolkasian, Baird, & Darden, 1999). Evaluation of neck pain and the related disability should not only include the data obtained from these scales, which include the subjective judgments of patients, but should also include clinical parameters. Clinical parameters included neck sensitivity and pain with neck movements evaluated by physical examination (Kose, Hepguler, Atamaz, & Oder, 2007). Although a limited number of studies have addressed the efficiency of stretching exercises (to decrease pain) used by patients who had partial or total thyroidectomy (Jang et al., 2014; Takamura et al., 2005), no study has specifically dealt with and examined the effect of neck stretching exercises on neck disability and the related dysfunction. The specific aim of this study was to analyze the effects of neck stretching exercises, following a total thyroidectomy, on reducing neck pain and disability. Ethical Consideration Ethical permission was granted by the ethical board of the institution (Number: / ). The patients that participated in the study were read the permission document and signed a document confirming their volunteer participation before surgery. METHODS Design and Setting A randomized controlled trial was conducted at the general surgery clinic of a training and research hospital in Turkey between May 15, 2013, and June 30, Participants and Recruitment A total of 80 volunteer patients who experienced a total thyroidectomy and who were older than 18 years participated in the study. None had any mental problem that interfered with communication. Participants with certain conditions were excluded from the sample: (a) those who received neck dissection during thyroidectomy, (b) those who received a neck drain during the thyroidectomy, (c) those who previously experienced a partial thyroidectomy, (d) those who experienced neck pain before the operation, and (e) those who had cervical problems before the operation. The study included only those participants who had total thyroidectomy because neck pain is much more likely due to the longer operation time as compared to a partial thyroidectomy (Qin et al., 2014). Intervention Data were collected concerning sociodemographic and clinic characteristics of patients, baseline assessments were made related to neck pain and disability. Subjects were randomly assigned either to the stretching exercise group or to the control group. Block randomization was used for patient randomization according arrival sequence. Computer-generated random number tables were also used. The block randomization method is designed to randomize subjects into groups that result in equal sample sizes. This method is used to ensure a balance in sample size across groups over time (Suresh, 2011). This process was executed by a researcher who was not involved in the randomization process and who also provided stretching exercise training to the stretching exercise group. All surgeons and evaluator involved in this study were blind to the patient s group assignment. The participants had total thyroidectomies performed by three different surgeons who were not aware of which participant had been assigned to which group (stretching exercise or control). All participants were placed in the same position during the thyroidectomy. More specifically, they were in the supine position and their heads were in a hyperextended position, which allowed to the surgeons to see their thyroid glands. A pillow was placed under their shoulders and a donut pillow was used to support their heads and the backs of their necks. Following the operation, all participants received intravascular nonsteroidal anti-inflammatory drugs for analgesia. On the morning of the first day of the postoperative period, the stretching exercise group learned how to conduct neck Worldviews on Evidence-Based Nursing, 2016; 13:3,

3 Neck Stretching Exercises Following Total Thyroidectomy stretching exercises from the primary researcher. The stretching exercises consisted of eight steps: 1. Relax shoulders and neck sufficiently, 2. look down, 3. turn face to the right, 4. turn face to the left, 5. incline head to the right, 6. incline head to the left, 7. turn shoulders round and round, 8. slowly raise hands fully then lower them. Patients were asked to perform five replicates of each stretching exercise, three times per day (morning, afternoon, and evening) for 1 month (Takamura et al., 2005). The first therapy session was monitored and the participants were given feedback about how they performed the stretching exercises. In addition, to increase adherence to the exercises at home, the participants were given a training brochure about the stretching exercises assigned. They were told that the stretching exercises would not cause the wound to open or bleed. The control subjects were told that they should move their necks as they did before the operation. All participants were discharged in the afternoon of the first day of the postoperative period. During the control visits of the participants at the end of the first week and at 1-month periods following the operation, their neck pain and disability as well as healing of the wound was checked. During these controls, the patients were asked whether they exercise regularly. All patients said that they completed their exercises as recommended. Outcome Measures Primary outcome. The primary outcome of this study was the levels of neck pain and disability of the patients. Neck pain and disability were evaluated through both the Neck Pain and Disability Scale (NPDS) and by clinical parameters at the end of the first week and 1 month after the thyroidectomy. The NPDS was developed by Wheeler et al. (1999). Its reliability and validity in the Turkish context was established by Bicer et al. (2004). The NPDS consists of 20 items. The participants responded to each item and were scored on a 10-cm visual analog scale, ranging between 0 (normal function)and5(severelylimitedfunc- tion). The items analyze the severity of neck pain and its effect on occupational, recreational, social, and daily life activities in relation to emotional factors. The total score from the NPDS ranges from 0 to 100. Higher scores indicate stronger effects of the neck pain. Cronbach s alpha coefficient of the NPDS was found to be 0.93 by Wheeler et al. (1999) and 0.86 in the study by Bicer et al. (2004). In this study, Cronbach s alpha coefficient of the NPDS was found to be 0.93, both after the 1-week evaluation and after the 1-month evaluation. The clinical parameters were based on physical neck examinations. More specifically, the clinical parameters included neck sensitivity and pain with neck movement. Neck sensitivity was based on the evaluation of painful locations during neck palpation. Light and deep palpations were applied to specific areas of neck (total 10 area: cervico-occipital junction, the two trapezius muscles (left, right), and cervical vertebrae from C2 to C7) in order to evaluate neck sensitivity. Patients were asked whether they have pain during these palpations. Scores were recorded for each area as 0 point (no pain), 1 point (pain with deep palpation), and 2 points (pain with light palpation). The maximum score from this examination was 20 points. In order to analyze the pain during the neck movements, participants were asked to do seven neck movements including flexion, extension, right-lateral flexion, left-lateral flexion, looking left, looking right, and rotation. Following the completion of the neck movements, participants were asked to describe their pain and their answers were scored using the following scale: 0 (no pain),1(light pain),and 2(severe pain). The maximum score from this evaluation was 14 (Kose et al., 2007). Secondary outcome. The secondary outcome of the study was the participants views about the healing and cosmetics of the wound. Healing of the wound was evaluated visually by the physician at the control visits at the 1-week and the 1-month periods. The physicians searched for indicators of poor healing such as seroma, adhesion, infection, and hypertrophic scar. With regard to the cosmetic considerations the participants were asked the following question: What do you think about your scar? They were asked to respond using one of three choices: satisfied, average, ordissatisfied (Takamura et al., 2005). Sample Size The sample was determined using a power and sample size program (Dupont & Plummer, 1990). It was predicted that the NPDS scores of the participants who exercised would be 20 points less than those of the controls. Based on this prediction, the number of the participants in each group was estimated to be at least 38 with 95% reliability interval and 80% power. There were 80 participants, 40 of whom were assigned to the stretching exercise group. Data Analysis The data collected were analyzed through the SPSS 15.0 (Chicago, IL, USA) program. The One-Sample Kolmogorov Smirnov test was employed to analyze the conformity of the measured values to the normal distribution. The distribution of age and of the NPDS scores conformed to a normal distribution (p >.05). Repeated measure ANOVA was used to compare the scores of neck pain and disability before and after total thyroidectomy. Student s t test was used to make comparisons between the mean NPDS scores and the ages within the groups 1 week and 1 month after thyroidectomy. For comparison of the operation time and the other scale scores, the 226 Worldviews on Evidence-Based Nursing, 2016; 13:3,

4 Assessed for eligibility (n = 125 ) Enrollment Excluded (n =45) Declined to participate (n =5) Cervical Hernia (6) Drain (n =5) Neck Dissection (n =6) Previous subtotal thyroidectomy (n = 23) Randomized (n = 80) Allocation Allocated to stretching exercise group ( n =40) Routine Care Regular neck stretching exercises Allocated to control group (n = 40) Routine Care Follow -Up Lost to follow-up (n =0) One week One month Lost to follow-up (n =0) One week One month Analysis Analyzed (n = 40) Analyzed (n = 40) Figure 1. Flow of Participants Through Trial. Mann-Whitney U test was used. The Pearson s chi-square test was employed to analyze the differences among the categorical distinctions. p-values <.05 were accepted as statistically significant. RESULTS Characteristics of Study Participants A total of 125 patients were enrolled in the study, but 45 were excluded. Therefore, 80 patients participated (Figure 1). The mean age of the participants was 46.7 years (SD = 12). Most (78.8%) were women and nearly half (47.5%) had elementary school diplomas. For most of the participants (62.5%), the reason for total thyroidectomy was to treat thyroid papillary cancer. The mean duration of the anesthesia was minutes (SD = 27.1). As mentioned earlier, the participants were randomly assigned either to the stretching exercise group or to the control group. The participants in both groups were similar in terms of mean age, gender, educational background, diagnosis, and operating time (p >.05; Table 1). Effects of Neck Stretching Exercises Primary outcomes. When comparing NPDS scores before thyroidectomy, after 1-week and after 1-month time-points (Table 2), it was found that patients experienced significantly less pain and disability in the stretching exercise group than the control group (p <.001). The mean NPDS score (SD) was 8.82 (12.23) in the stretching exercise group and (12.09) in the control group for the evaluation made 1 week after the total thyroidectomy. The difference between the groups was statistically significant (p <.001, 95% CI = 16.04, 26.87). At the 1-month evaluation no significant difference in terms of the NPDS scores was found between the groups (mean [SD], stretching exercise group = 1.72 [2.74], control group = 3.52 [6.56]; p =.114, 95% CI = ). Neck sensitivity was significantly lower in the stretching exercise group at the before thyroidectomy, after 1-week and after 1-month time-points (p <.001; Table 2). Neck sensitivity was significantly less in the stretching exercise group in contrast to the control group at the 1-week evaluation (median [IR] = stretching exercise group = 0 [.75], control group = 2.00 [4.0]; p <.001, 95% CI =.86, 2.88). At the 1-month evaluation no significant difference in terms of neck sensitivity was found between the groups (median [IR] = stretching exercise group, 0 [.0]; control group 0 [1.0], p =.158, 95% CI =.06,.51; Table 2). When comparing pain with neck movement levels before thyroidectomy, after 1-week and after 1-month time-points (Table 2), it was found that patients experienced significantly Worldviews on Evidence-Based Nursing, 2016; 13:3,

5 Neck Stretching Exercises Following Total Thyroidectomy Table 1. Demographics and Characteristics of Patients Age Exercise group Control group (n = 40) (n = 40) p-value Mean (SD) (11.24) (12.77).268 Gender, n (%) Female 30 (75.0) 33 (82.5).586 Male 10 (25.0) 7 (17.5) Education, n (%) Elementary school 18 (42.7) 21 (52.5) High school 8 (17.0) 9 (22.5).477 University or higher Diagnosis, n (%) Multinodular goiter Follicular neoplasm Papillary thyroid carcinoma Operating time (minute) 15 (37.5) 10 (25.0) 8 (20.0) 8 (20.0) 7 (17.5) 7 (17.5) (62.5) 25 (62.5) Median (IR) 105 (15) 105 (30) 217 Note. SD = standard deviation; IR = ınterquartile range. less pain in the stretching exercise group than the control group (p <.001). The analysis of the pain level with neck movement showed that the median score (IR) of the stretching exercise group was 0 (2.0) and 3.5 (5.75) in the control group at the evaluation made 1 week after the total thyroidectomy. This difference was determined to be statistically significant (p <.001, 95% CI= 1.49, 3.75). However, no significant difference was identified in the evaluation made 1 month after the total thyroidectomy (median [IR] = stretching exercise group, 0 [.0], control = group 0 [1.75], p =.150, 95% CI =.20,.80). Secondary outcome. The evaluation of the incision areas in terms of poor healing of wounds showed that only one participant from each group experienced the formation of a seroma. These observations were made 1 week after the total thyroidectomy. With regard to participant satisfaction with the surgical scar (Table 3), the results indicate that 1 week after the surgery 75% of the stretching exercise subjects and 65% of the control subjects were satisfied with their scars. However, this difference was not statistically significant (p =.465). The results of the analysis carried out 1 month after the total thyroidectomy were also not significantly different (p =.465). DISCUSSION The aim of the study was to analyze the effectiveness of the neck stretching exercises, performed following a total thyroidectomy, on reducing neck pain and disability. The stretching exercise group and the control group did not vary in terms of sociodemographic characteristics. Moreover, most of the participants were women. A similar gender pattern was observed in other similar studies (Jang et al., 2014; Takamura et al., 2005). As it has been shown, mostly women experience thyroid-related problems (Li et al., 2010; Loy et al., 2004). Women also report pain symptoms more frequently than men (Barsky, Peekna, & Borus, 2001), making the involvement of women as participants an advantage for this study. The findings of the study indicated that neck stretching exercises significantly reduce both neck pain and disability 1 week after the total thyroidectomy. Similarly, Takamura et al. (2005) stated that neck discomfort was less in the stretching exercise group 1 week after a total thyroidectomy. Jang et al. (2014) also reported that neck discomfort and limitations on movement were much less in the stretching exercise group during evaluations made 2 weeks after a thyroidectomy. However, in this study, no significant differences were determined between the groups in terms of neck pain and disability, or neck sensitivity and pain with neck movements, 1 month after the total thyroidectomy. Jang et al. (2014) also did not find any significant difference between stretching exercise and control groups in terms of neck discomfort and range of motion 3 months after a thyroidectomy. Inconsistent with the present findings, Takamura et al. (2005) stated that neck discomfort symptoms were significantly less in the stretching exercise group in contrast to the control group after 1 month and even 1 year after a thyroidectomy. Taken together, these data demonstrate that neck stretching exercises are effective to reduce short-term neck pain and disability 1 week after surgery. Neck pain and disability ameliorate naturally within 1 month after the thyroidectomy. In our clinical observations based on this prior research, initially (1 week control visit), we realized that patients tended to move robotically because of their neck pain but moved more naturally at the 1-month control. These study results are confirmed our clinical observations. Although it is well established that stretching exercises reduce movement limitations and improve functionality in the patients who have undergone an operation, there is disagreement over the effect of stretching exercise on wound healing (Chan, Lui, & So, 2010; McNeely et al., 2010). In the systematic review by McNeely et al. (2010), the authors state that upper extremity stretching exercises completed in the early 228 Worldviews on Evidence-Based Nursing, 2016; 13:3,

6 Table 2. Effect of the Neck Exercises on Primary Outcomes NPDS Exercise group Control group 95% confidence (n = 40) (n = 40) p-value a interval (CI) Baseline 0(0) 0(0) NA One week, Mean (SD) 8.82 (12.23) (12.09) < One month, Mean (SD) 1.72 (2.74) 3.5 (6.56) F/p b 48.79/p <.001 Neck sensitivity Baseline 0(0) 0(0) NA One week, Median (IR) 0(.75) 2.0 (4.0) < One month, Median (IR) 0(.0) 0(1.0) F/p b 13.26/p <.001 Pain with neck movements Baseline 0 (0) 0 (0) NA One week, Median (IR) 0 (2.0) 3.5 (5.75) < One month, Median (IR) 0(.0) 0 (1.75) F/p b 15.90/p <.001 Note. NPDS = neck pain and disability score; SD = standard deviation; IR = interquartile range. a Student s t test and Mann-Whitney U. b Repeated measures ANOVA. period after a mastectomy improves shoulder movement, but increases the level and amount of wound drainage (McNeely et al., 2010). The side effect of the stretching exercises completed in the early period after an operation should be analyzed in relation to the wound. In this study, complications of poor wound healing were observed in only two participants (2.5 %), one from the control group and the other from the stretching exercise group. Edema, seroma and incision site infections are expected complications after thyroidectomy. The incidence ranges from.3% to 7% (Celik et al., 2011; Dener, 2002). In this study, seroma rate is similar to the literature. The views of the stretching exercise and control groups about their scars were found to be similar both 1 week and 1 month after the total thyroidectomy. In previous studies, there was also no significant difference between the patients opinions regarding their scars (Jang et al., 2014; Takamura et al., 2005). In addition to this, Jang et al. (2014), stated that in the stretching exercise group there was significantly less wound adhesion and hypertrophic scar formation than in their control group. These results indicate that neck stretching exercises have no negative effect on wound healing in accordance with both clinical and patients opinions. Surgical nurses should take a leadership role in changing practice, strategizing a plan, and providing patients with the most updated best practice recommendations. In this study, the evidence strongly supported the efficacy of stretching exercises as an intervention for patient undergoing a total thyroidectomy in the early period. Nurses should include stretching exercises into care and follow-up protocols after total thyroidectomy. In addition, nurses should properly teach these exercises to patients and evaluate postoperative neck pain and disability. LIMITATIONS This study has some limitations. First, it was carried out in a single institution. Therefore, future studies should focus on more than one institutional context. In addition, patient s adherence to the exercises regime was evaluated using self-reporting approach during visits so the actual fidelity of the intervention may differ. In future studies, patients could be telephoned in an attempt to increase adherence. Another limitation was that during the evaluation of the wound, no objective measurement tool was used. In future studies, scar evaluation scales may be used for this purpose and in addition, similar studies should Worldviews on Evidence-Based Nursing, 2016; 13:3,

7 Neck Stretching Exercises Following Total Thyroidectomy Table 3. Satisfaction of Participants Regarding Surgical Scar One week, n (%) Exercise group Control group (n = 40) (n = 40) p-value satisfied 30 (75) 26 (65) average 10 (25) 14 (35).465 dissatisfied One month, n (%) satisfied 30 (75) 26 (65) average 10 (25) 14 (35).465 dissatisfied be carried out on the patients who underwent thyroidectomy with neck dissection. LINKING EVIDENCE TO ACTION Patients experience neck pain and disability after a total thyroidectomy. These problems spontaneously ameliorate 1 month after the operation. Neck stretching exercises in the early postthyroidectomy period facilitate neck movement and reduce neck pain and disability, as well as neck sensitivity 1 week after surgery. Neck stretching exercises in the early postthyroidectomy period have no negative effect on wound healing. CONCLUSIONS Following a thyroidectomy, patients experience neck movement problems and tend not to move their necks. Therefore, neck movements are limited due to rigidity, which causes neck pain and disability. These problems reduce naturally 1 month after the thyroidectomy. However, planned and regular neck stretching exercises started immediately after a thyroidectomy significantly reduce short-term neck pain and disability symptoms. In addition, neck stretching exercises started in the early post-thyroidectomy period have no negative effect on wound healing. Neck stretching exercises that were started in the early postthyroidectomy period encourage patients to move their necks and improve their rehabilitation. Therefore, nurses should teach and supervise neck stretching exercises in the early period after thyroidectomy. Providing training brochures about the stretching exercises to the patients increases the possibility of doing these stretching exercises at home. Nurses should evaluate patients neck pain and disability after thyroidectomy with subjective and clinical data. WVN Author information Hatice Ayhan, Faculty Member, Department of Surgical Nursing, School of Nursing, Gulhane Military Medical Academy, Turkey; Sevinc Tastan, Associate Professor, Department of Surgical Nursing, School of Nursing, Gulhane Military Medical Academy, Turkey; Emine Iyigün, Associate Professor, Department of Surgical Nursing, School of Nursing, Gulhane Military Medical Academy, Turkey; Erkan Oztürk, Associate Professor, Department of General Surgery, Gulhane Military Medical Academy, Turkey; Ramazan Yildiz, Assistant Professor, Department of General Surgery, Gulhane Military Medical Academy, Turkey; Semih Görgülü, Professor, Department of General Surgery, Gulhane Military Medical Academy, Turkey The authors thank the patients participating in the study. They also thank Associate Professor Cengizhan Acikel for support with statistical analyses. Address correspondence to Dr. Hatice Ayhan, Gulhane Military Medical Academy, School of Nursing, Etlik Ankara/Turkey, 06010; hayhan@gata.edu.tr Accepted 1 March 2015 Copyright C 2016, Sigma Theta Tau International References Barsky,A.J.,Peekna,H.M.,&Borus,J.F.(2001).Somaticsymptom in women and men. Journal of General Internal Medicine, 16, Bellantone, R., Lombardi, C. P., Bossola, M., Boscherini, M., De Crea, C., & Alesina, P. (2002). Total thyroidectomy for management of benign thyroid disease: Review of 526 cases. World Journal of Surgery, 26, Bicer, A., Yazıcı, A., Camdeviren, H., & Erdogan, C. (2004). Assessment of pain and disability in patients with chronic neck pain: Reliability and construct validity of the Turkish version of the neck pain and disability scale. Disability and Rehabilitation, 26(16), Binder, A. (2007). The diagnosis and treatment of nonspecific neck pain and whiplash. Europa Medicophysica, 43(1), Celik, A.S., Erdem, H., Guzey, D., Celebi, F., Celik, A., Birol, S., & Kaplan, R. (2011). The factors related with postoperative complications in benign nodular thyroid surgery. Indian Journal of Surgery, 73(1), doi: /s Chan,D.N.S.,Lui,L.Y.Y.,&So,W.K.W.(2010).Effectivenessof exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: Systematic review. Journal of Advanced Nursing, 66(9), doi: /j x Chung, C. W., Lee, S., Hwang, S. W., & Park, E. H. (2013). Systematic review of exercise effects on health outcomes in women 230 Worldviews on Evidence-Based Nursing, 2016; 13:3,

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