O R I G I N A L R E S E A R C H

Effect of Telerehabilitation Versus
In-Clinic Rehabilitation Delivery on
Self-Efficacy in Breast
Cancer–Related Lymphedema
Erin E. Helm, PT, DPT, PhD1,2; Brenda Crowley, COTA3; Tara L. Crowell, PhD4;
Mary Lou Galantino, PT, PhD, MS, MSCE, FAPTA5,6,7,8

1Director of Program Development, Specialty Rehabilitation Inc, Hockessin, DE; 2Adjunct, Physical Therapy, Widener
University, Chester, PA; 3Clinician, Specialty Rehabilitation Inc, Hockessin, DE; 4Professor, Public Health, Stockton
University, Galloway, NJ; 5Professor, Physical Therapy, Stockton University, Galloway, NJ; 6Adjunct Scholar, University
of Pennsylvania, Philadelphia, PA; 7Visiting Professor, University of the Witwatersrand, Johannesburg, South Africa; and
8Clinician, Christiana Health Care System, Wilmington, DE

Background: Individuals with breast cancer–related lymphedema (BCRL) require self-management strategies
to reduce risk of infection, exacerbation, and/or progression of lymphedema. The coronavirus pandemic thrust
the medical field into the world of telehealth; both patients and providers were forced to reduce in-person
treatments and engage in this new platform of rehabilitation delivery. The role of telehealth in promotion
of self-management for BCRL is unknown. Purpose: This study examines self-efficacy during cancer rehabili-
tation for in-clinic versus telehealth visits among individuals with BCRL during the pandemic quarantine April
to November 2020. Methods: Forty women who recently completed oncology rehabilitation for BCRL were
asked to complete demographics and 2 Likert surveys, including the Exercise Self-Efficacy Scale (ESES) and the
Self-Care Self-Efficacy Scale (SCSE), to compare the efficacy of telehealth versus in-person treatment modal-
ities. Results: Thirty-two participants completed the survey and indicated that the percentage of telehealth
visits was less than face-to-face visits. Despite this, the participants indicated numerous positive moderately
strong correlations between self-care self-efficacy and exercise self-efficacy for both types of visits (P < .05).
Limitations: Self-report surveys by a convenience sample, multifactorial characteristics of rehabilitation treat-
ment across modes, and varying severity of lymphedema may limit study findings. Conclusion: Telehealth
provided safe and effective care to participants and bolstered confidence in self-care and self-management
of BCRL. Data support that telehealth visits can be considered an essential part of comprehensive cancer reha-
bilitation care. Future research is needed to establish and optimize practice guidelines in both health delivery
systems. (Rehab Oncol 2023;41:82–88) Key words: lymphedema, oncology, self-management, telehealth

Rehabilitation Oncology
Copyright C© 2022 Academy of Oncologic Physical Therapy, APTA.

The authors declare no conflicts of interest.

Online Publication date: December 20, 2022

Received: October 27, 2021; Accepted: August 2, 2022

Correspondence: Erin E. Helm, PT, DPT, PhD, Specialty Rehabilitation
Inc, 26 Wesley Dr, Hockessin, DE 19707 (erin@specialtyrehab.net).

DOI: 10.1097/01.REO.0000000000000326

The coronavirus 2019 (COVID-19) pandemic has
accelerated the growth of telehealth services across the
United States. This effect has fostered creativity in health
care delivery. Given the complexity of cancer services dur-
ing a pandemic, many people who underwent cancer treat-
ment were unable to access rehabilitation and exercise
services.1

Quality care of individuals living with a cancer di-
agnosis requires a team-based approach. A recent review
underscored that telehealth is an essential tool in the de-
livery of cancer care to enable timely ongoing support for
exercise interventions for those affected by cancer.1 It is es-
sential for survivors of cancer to continue to engage in and

Copyright © 2022 Academy of Oncologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.

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mailto:erin@specialtyrehab.net


maintain regular exercise under the guidance of qualified
health professionals incorporating evidence-based clinical
guidelines.

Because of the COVID-19 pandemic, follow-up can-
cer care has been severely affected with increased con-
cerns regarding risk of infection associated with hospital or
clinic attendance, as well as reduced workforce and work-
flow constraints.2 The effect of COVID-19 on survivors
of cancer extends beyond medical complications of the
illness itself to include exacerbation of physical and psy-
chosocial challenges, related to reduced access to medical
and support services.2 Survivors likely to be dispropor-
tionately impacted by COVID-19–related closures include
individuals requiring manual treatment to address chronic
impairment–related side effects, including breast cancer–
related lymphedema (BCRL). Survivors of breast cancer
requiring manual techniques demonstrate increased dis-
tress with interruptions to rehabilitation services.3

Roughly 1 in 5 survivors of breast cancer will de-
velop upper extremity lymphedema.4 Incidence of up-
per extremity lymphedema varies on the basis of the ex-
tent of axillary surgery,5,6 radiation therapy,7 and time
frame of assessment8 in addition to lifestyle9 and addi-
tional adjuvant treatment factors.4,10 A prospective surveil-
lance model is recommended to provide proactive ed-
ucation to individuals at risk for BCRL, as well as to
provide clinical assessment and identification of breast
cancer–related impairments and functional limitations.11

Proactive education allows increased confidence in the
ability to self-identify lymphedema symptoms and man-
age risk factors and improves adherence to risk reduc-
tion strategies.12 Early identification of BCRL and self-
management strategies may prevent progression to ad-
vanced clinical stages.13-15

Telehealth implementation in the oncology popula-
tion has demonstrated increases in physical activity,16,17

improved quality of life, increased self-efficacy, and re-
duced depression, distress, and stress.18 Use of telehealth
to facilitate education and improve health-related self-
efficacy for management of various chronic conditions has
been well documented.19,20 According to Bandura,21 self-
efficacy regulates an individual’s motivation to persevere
in the face of difficulties through cognitive, motivational
affective, and decisional processes. Among survivors of
cancer, a positive relationship exists between increased
self-efficacy and improved health behaviors,22 distress, and
quality of life.18,23-25 Individuals with BCRL require it-
erative education to instill the ability to self-manage the
condition, and it is necessary to reduce risk of infection
and reduce hospitalization rates and health care costs.13,26

However, telehealth to promote self-efficacy in manage-
ment of BCRL has yet to be explored.

Thus, the current study used a retrospective cohort
to explore perceptions of telehealth versus in-clinic treat-
ment delivery for BCRL management. The effect of tele-
health treatment on self-efficacy for the management of
BCRL was examined. It was hypothesized that use of tele-
health services in rehabilitation would support improved

self-management strategies versus in-clinic visits. Under-
standing perceptions regarding telehealth versus in-clinic
treatment will allow for improved delivery of care.

METHODS

Participants

Individuals who previously received cancer-related
rehabilitation services for BCRL at a single accredited can-
cer center between April and November 2020 were iden-
tified. A convenience sample of 40 women with a diag-
nosis of BCRL were invited to enroll in the retrospective
cohort study. Participants were contacted via phone call
and provided verbal informed consent to participate, with
rights of subjects protected. Inclusion criteria for partic-
ipation included a diagnosis of BCRL and rehabilitative
treatment received between April and November 2020.
Individuals not willing to participate or provide consent
were excluded. Study approval was granted through Inter-
nal Review Boards at Christiana Care Health System and
Stockton University.

Survey Measures

Upon agreement to participate, the participants were
sent an e-mail link to complete an electronic survey re-
garding their rehabilitation experience and self-efficacy
for managing their condition. The electronic survey was
provided through Qualtrics (Provo, Utah) and was anony-
mous. Included within the survey were 2 valid and reli-
able instruments, the Exercise Self-Efficacy Scale (ESES)27

and the Self-Care Self Efficacy scale (SCSES). The ESES
is a self-reported scale ranked from 0 to 100, with 0 an-
choring not confident and 100 extremely confident, which
captures how the responder feels about his or her exer-
cise habits.28 The total score is calculated by summing
up the responses to each of the 10 questions. A higher
number on the score represents a higher self-efficacy for
exercise. The SCSES29 included 10 items, which ranked
via (1) not confident, (2) somewhat confident, and (3)
extremely confident, and measured effective and sustain-
able self-care behavioral changes. Cultural ideation shapes
the ways individuals interpret and report their self-care
self-efficacy, and the SCSES has cross-cultural and cross-
national utility for research.29 Participant satisfaction for
in-clinic and telehealth visits was assessed with 4 ques-
tions, 2 questions per visit type. Using an 11-point scale
ranging from 0 “worst” to 10 “best,” the participants were
asked to rate their in-clinic and telehealth experiences. In
addition, a Likert scale was used to rank telehealth and in-
clinic experiences from “Greatly exceeded expectations”
to “Definitely did not meet expectations.”

Data Analysis

Data analysis was performed with SPSSv25 (27.0,
IBM Corp, New York). Aggregate data were de-identified
and used to statistically examine overall satisfaction with

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telehealth and in-person rehabilitation sessions as well
as the relationships between frequency of services, self-
efficacy, and participant satisfaction. Participant character-
istics were used in aggregate for demographic and covariate
analysis. Specifically, the Self-Efficacy Scale was analyzed
separately for each item. Self-efficacy was assessed for both
each item and for a total scale score. This provides infor-
mation on individual-specific efficacy along with overall
average self-efficacy score.

RESULTS

Participants

A total of 48 women with a diagnosis of BCRL were
initially contacted via phone call regarding study partici-
pation. A maximum of 3 attempts were made to contact
eligible participants. Of the 48 women contacted, 8 did
not answer or provide a return call. The remaining eligible
individuals consented to participation. Although 40 indi-
viduals initially participated in the study, 32 completed
all survey questions. Of the 32 individuals, all were fe-
male with a breast cancer diagnosis ranging from stage I
through stage IV (Table 1), with varied diagnoses includ-
ing ductal carcinoma in situ, inflammatory breast cancer,
and metastatic disease. Age ranged from 19 to 78 years (M
= 59.78, SD = 12.38 years). More than a quarter of women
reported minority status while most participants (65.6%)
indicated White. Education was also provided with more
of a mixed distribution than race (Table 1). For this anal-
ysis, education was then collapsed into those with 4-year
college degrees and above and those without.

Information was obtained from participants includ-
ing total visits and more specifically their telehealth vis-
its. The majority of participants indicated 20 or less vis-
its. The breakdown is as follows: 6 participants (18.75%)
received “no telehealth visits”; 22 participants (68.75%)
received “less than 25% visits via telehealth”; 2 partici-
pants (6.25%) received “25% to 50% of their visits via
telehealth”; and 2 (6.25%) participants received “50% or
more telehealth visits.” Given the unequal distribution of
telehealth visits, differences between percentage of tele-
health and other variables were unattainable. Twenty-two
of 26 participants responded that telehealth either met or

TABLE 1
Demographics

Sample = 32

Age range, y 59.78 (SD: 12.38)
19-78

Race
White 21 (65.6%)
Black or African American 8 (25.0%)
American Indian or Alaskan Native 1 (3.1%)
Asian 1 (3.1%)
Other 1 (3.1%)

Education
Less than high school 2 (5%)
High school graduate or GED 4 (10%)
Some college 4 (10%)
2-y degree 6 (15%)
4-y degree 7 (17.5%)
Professional degree 9 (22.5%)

Cancer stage
Stage 1 7 (21.9%)
Stage 2 11 (34.4%)
Stage 3 9 (28.1%)
Stage 4 1 (3.1%)
Unknown 2 (6.2%)

exceeded their expectations. Three participants reported
having technical issues while on zoom. However, despite
these more favorable ratings of telehealth, 100% of par-
ticipants who received both visit types indicated that they
prefer in-clinic over telehealth.

Participants were asked about specific rehabilitation
services they received: 23 of 29 responded. Primary treat-
ments rendered across inpatient and telehealth visits in-
cluded 52% with difficulty moving an upper extremity,
followed by 30% with chemotherapy-induced neuropa-
thy and 18% with complaints of cancer-related fatigue.
None of the participants had difficulty moving lower ex-
tremities. Given limited variance and small sample size,
a correlation coefficient matrix was performed to explore
the relationship between telehealth and self-efficacy. Both
telehealth and in-clinic experience ratings demonstrated
significant moderate to strong correlations for all compo-
nents of the SCSE (Table 2). Ratings of telehealth expe-
rience and ESES were not significantly correlated for 4 of
5 questions (Table 3). Significant correlations were noted

TABLE 2
Self-Care Self-Efficacy Scale

Self-Care Self-Efficacy Scale Telehealth In-Clinic

Keep yourself stable and free of symptoms N = 28 (r = 0.507); P = .006 N = 32 (r = 0.694); P = .000
Follow treatment plan you have been given N = 28 (r = 0.616); P = .000 N = 31 (r = 0.515); P = .003
Persist in following treatment plan even when difficult N = 28 (r = 0.402); P = .002 N = 28 (r = 0.671); P = .000
Monitor your condition routinely N = 28 (r = 0.673); P = .000 N = 31 (r = 0.493); P = .005
Persist in monitoring when difficult N = 28 (r = 0.673); P = .000 N = 31 (r = 0.493); P = .005
Recognize changes in health as they occur N = 28 (r = 0.516); P = .005 N = 32 (r = 0.697); P = .000
Evaluate the importance of your symptoms N = 28 (r = 0.476); P = .01 N = 32 (r = 0.593); P = .000
Do something to relieve your symptoms N = 28 (r = 0.581); P = .001 N = 32 (r = 0.609); P = .000
Persist in finding a remedy for your symptoms N = 28 (r = 0.567); P = .002 N = 31 (r = 0.564); P = .001
Evaluate how well the remedy works N = 28 (r = 0.598); P = .002 N = 31 (r = 0.603); P = .000

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TABLE 3
Exercise Self-Efficacy Scale

Exercise Self-Efficacy Questions Telehealth In-Clinic

When I am worried about my appearance due to swelling and/or
compressions garment

NS N = 30 (r = 0.375); P = .041

When I am experiencing lymphedema-related symptoms (eg, pain,
heaviness, numbness/tingling, swelling)

NS N = 31 (r = 0.602); P = .000

When I fear making my lymphedema worse N = 25 (r = 0.375); P = .06 N = 28 (r = 0.364); P = .057a

When I am unsure what exercise advice to follow NS NS
When I am not certain whether I am doing an exercise correctly NS N = 29 (r = 0.338); P = .073a

Abbreviation: NS, not significant.
aApproaching significance.

for in-clinic experience and ESES for 2 of 5 questions, with
1 additional question approaching significance.

Finally, the total self-efficacy score for self-care was
computed for both modes of delivery by summing partic-
ipants’ responses to all 10 items and dividing by 10. The
semantic differential scale ranges from 1 = not confident
to 5 = extremely confident and the total confidence score
for participants ranged from 2.80 to 4.80, with a mean of
4.3097 (SD: 0.53), indicating an above average total confi-
dence score.

Exploring the relationship between education, self-
efficacy, and self-management, independent t tests were
analyzed between 2 levels of education (4-year degree or
more and less than 4-year degree). Again, education was
collapsed to create a new variable with 2 levels because of
the low and unequal sample size between multiple levels
of education. Results indicate only 1 difference, that is,
approaching a statistically significant difference between
education and patients’ response on the question “when I
fear making my lymphedema worse”; those with less than
a 4-year degree (N = 16) resulted in a mean of 3.00 (SD:
1.36) and participants with a 4-year degree or more (N =
13) had a mean of 3.83 (SD: 1.03), t = −1.840 (df = 25),
P = .07. Other differences may exist, but with such a low
sample size for each level of education, there may not be
enough power to identify these differences in this study.

DISCUSSION

Statistical analysis demonstrates the potential for tele-
health as an effective alternative to in- person treatment
for individuals with BCRL undergoing oncology-related
rehabilitation. Participants responded that overall they felt
more confident in progressing their treatment plan, and
monitoring their conditions at home, even when difficult.
The ability to monitor and recognize changes in a con-
dition, as well as self-manage symptoms, is particularly
important for individuals with lymphedema.12,14,15,30

Previous literature indicates that early identification
reduces progression to lymphedema of greater severity.31

Left unmanaged, lymphedema can result in a chronic in-
flammatory state within the tissue, increasing risk of tissue
fibrosis, infection, and impaired wound healing.32 Despite
the self-efficacy reported for monitoring and managing

BCRL, all participants reported a preference for in-clinic
treatment. However, when in-clinic visits are unavailable,
these results indicate that positive telehealth experiences
(regardless of preference) may result in self-efficacy for the
management of BCRL.

All individuals in the current study preferred in-clinic
treatment versus telehealth. This finding is supported by
recent literature.33 The current study examined participant
experiences in 2020, during the height of the 2020 COVID-
19 pandemic, during closure, and subsequent limited re-
turn to in-person rehabilitation treatments. The nature of
closures and reopening of services required instinctive and
impromptu clinician treatment planning for telehealth vis-
its, as well as participant adeptness at managing telehealth
platforms. The average age of the participants sampled was
60 years, and it is plausible that comfort level in the on-
line platform may have played a role; however, only 3
of 29 individuals in the study reported technology issues
while using telehealth services. Favorability and prefer-
ence for in-clinic versus telehealth visits may also have
been influenced by distress associated with limitations in
access to services during the COVID-19 pandemic,3 com-
pounded by potentially limited development of a thera-
peutic alliance with telehealth treatments versus in-person
treatments.34,35 Telehealth was a new platform of care de-
livery for the 3 therapists providing care to participants
within the current study. The ease of adjustment to and
adeptness at telehealth may have differed across therapists
and influenced treatment approaches, patient satisfaction,
and development of self-efficacy among participants. De-
velopment of telehealth-based treatment plans with assess-
ment of comfort with technology, ease of use, access, and
education level may improve individual treatments and,
therefore, may further increase the efficacy of these visits
in turn bolstering confidence in individuals with BCRL.
Further clinician training to foster the patient therapist re-
lationship may also improve ratings of telehealth versus
in-clinic treatments.

Self-efficacy for exercise did not demonstrate a sig-
nificant relationship with positive experiences in tele-
health; however, it was noted in 2 of 5 components
with in-person visits. The findings indicate that self-
efficacy for exercise was not related to positive tele-
health experiences. The ability to promote activity through

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telehealth-based rehabilitation in the oncology population
has shown limited promise.36 It is important to note that
women were not solely treated for complications from
BCRL but additional cancer-related impairments includ-
ing chemotherapy-induced neuropathy, shoulder dysfunc-
tion postsurgery, and cancer-related fatigue secondary to
previous or concurrent treatment. The clustering effect
of side effects37 may have limited the focus on exercise
implementation. Complete decongestive therapy for lym-
phedema consists of 2 phases. The initial phase (phase 1)
focuses on reduction of the affected part and improve-
ment of the tissue through manual lymphatic drainage,
short stretch compression bandaging, exercise, and skin
care. Phase 2, the maintenance phase, consists of ongoing
self-management to maintain gains achieved in phase 1
through self-lymphatic drainage, exercise, continued skin
care and monitoring, and compression.38,39 The ability to
demonstrate improved tissue texture, mobility, and girth
within a treatment session versus participant performance
of techniques in this population may have increased fa-
vorability to in-clinic treatments. However, the ability to
manage the condition is paramount to reducing infection
risk, as well as reducing exacerbations and progression of
the condition.

Similar self-efficacy scores for self-management of
BCRL indicate that the self-management phase can be pro-
vided effectively using telehealth. In a recent study, teach-
ing self-manual complete decongestive therapy to women
with BCRL proved effective in maintaining or improving
the benefits of complete decongestive therapy and can be
used as a self-care tool in the management of BCRL40. Re-
search in telehealth use in other chronic conditions indi-
cates telehealth to promote improved self-efficacy and self-
reliance.41 The participants in the current study may also
be best served through a combination of in-clinic manual
treatment as needed, with telehealth to foster self-reliance
and self-efficacy; however, further research is required to
fully elucidate.

Rehabilitation practitioners must be prepared to em-
brace technologies and service delivery models valued in
the new post-COVID-19 health care environment. Tele-
health will be valued for its effectiveness and cost-efficiency
in addition to the cultivation of self-efficacy.42 Stakehold-
ers and policy makers must realize that oncology rehabil-
itation services delivered via telehealth technologies can
empower people to be active participants in improving
quality of life and are an integral component in achieving
optimal survivorship.43-45

Limitations

A convenience sample of individuals with BCRL lim-
its generalizability of this study results to additional onco-
logic cohorts. In addition, 8 participants did not complete
the study providing response rate and nonresponse errors,
which may also limit generalizability. The grade of lym-
phedema and phase of treatment was not disclosed within
the current survey due to potential recall bias; therefore, it

is unknown how the grade/severity of lymphedema and re-
quirement of manual treatment influenced current results.
Familiarity with rehabilitative services was also not as-
sessed in the current survey. The therapist-client relation-
ship is critical for success and may have been influenced
by use of telehealth treatment at initiation of treatment
versus later within the rehabilitation interval as well as by
differences in therapist approach to telehealth. Given the
small sample size, the power to run varied analyses was
limited. Three participants noted technology issues; how-
ever, the type of issue was not identified in the current
study. Future studies examining barriers to telehealth care
delivery among various populations may provide greater
insight into technology issues. More studies on a larger
scale are needed to confirm these study findings.

CONCLUSION

There is value for telehealth to rehabilitate women
with a diagnosis of BCRL. Further research needs to
distinctly explore self-efficacy across various modes and
dosage of delivery. Rehabilitation practitioners must ad-
vocate for inclusion in future studies and articulate the
distinct value of telehealth in rehabilitation for cancer sur-
vivorship, chronic disease management, and health promo-
tion. Further research is necessary to validate the efficacy
and cost-effectiveness of rehabilitation assessments and in-
terventions delivered through telehealth technologies.

ACKNOWLEDGMENTS

The authors thank Lisa Marshall, owner of Specialty
Rehabilitation Inc, and staff for optimal patient care during
the COVID-19 pandemic.

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