after 
 undergoing a mastectomy , the patients experience lymphedema and sensory changes due to 
 physical changes along with restriction of the range of motion of the shoulder joints and 
 upper extremity muscle weakening1 . although treatments such as radiation therapy and anti - cancer therapy are implemented as a 
 prescription immediately after surgery to reduce recurrence and mortality , these treatments 
 are reported to greatly affect the quality of life of the patients due to their adverse 
 effects that cause physical changes2 . radiation therapy and other anti - cancer therapies cause nerve lesions , lymphedema , muscle 
 pain , headache , weight gain , a sense of fatigue , cognitive disorders , and feelings of 
 anxiety and depression in patients3 . concern over rehabilitation treatment and the quality of life after a mastectomy is 
 discussed as an important issue . many studies have implemented rehabilitation programs to 
 resolve physical , emotional , and functional problems experienced after a mastectomy and 
 psychological issues appearing in return to society4 . in addition , rehabilitation of lymphedema patients is achieved 
 through exercise , which is regarded as the most effective method of restoring their physical 
 and psychological functions5 . a previous study reported that lymphedema patient groups that received exercise treatment 
 in combination with mental treatment showed significantly higher physical indexes and better 
 depression and anxiety conditions than groups that received only mental treatment and that 
 exercise performed by lymphedema patients consequently led to not only physical improvement 
 but also psychological improvement in terms of depression and anxiety6 . existing exercise methods for mastectomy patients have been reported to increase the heart 
 rate by 6080% through aerobic exercises , and physical changes have been reported7 . these exercises were performed with a view 
 to increasing the patients range of joint motion , and many cases where these exercise 
 caused pain have been reported8 . 
 meanwhile , proprioceptive neuromuscular facilitation ( pnf ) exercises , which are patient 
 self - exercise methods conducted through pnf techniques , require patients to move within 
 their ability to move without pain9 , 10 , thereby enabling the patients to perform 
 exercises with relatively less pain . therefore , pnf exercises are regarded as an important 
 element in reducing and preventing injuries due to exercise9,10,11 . not many studies have been conducted on the effect of these 
 exercises within the range of no pain on the depression and psychological variables of 
 patients . therefore , this study was conducted to examine the effects of exercises applied with pnf 
 techniques performed for 30 minutes per session , three times per week , after receipt of 
 radiation therapy following mastectomy on depression and anxiety in patients with lymphedema 
 and to prepare basic date for creation of self - directed exercise programs for lymphedema 
 patients that will enable them to perform exercises within the range of no pain . the subjects of this study were 45 patients selected from among those who showed lymphedema 
 after receiving anti - cancer therapy following a mastectomy after being diagnosed with breast 
 cancer at d university hospital located in b metropolitan city . information on the purposes , 
 procedures , and risks of the experiment was provided to the recruited participants in the 
 experiment , and prior written consent was received from the participants . in this study , the subjects were divided into three groups and performed exercises for 30 
 minutes per session , three times per week for 16 weeks , and questionnaire surveys were 
 conducted every four weeks . the pnf exercises were performed using rhythmic initiation ( ri ) , 
 which is a pnf technique , for 10 minutes as warm - up exercises , and main exercises were 
 performed for 20 minutes using a combination of isotonic ( ci ) , contract - relax , and 
 hold - relax techniques . the pnf+ super lizer group performed the same warm - up exercises as 
 those in the pnf group for 10 minutes and was irradiated with light by a super lizer during 
 performance of the main exercises . the pnf+manual lymph drainage ( mld ) group performed the 
 same warm - up exercises as those in the pnf group for 10 minutes followed by the same main 
 exercises as those in the pnf group for 10 minutes and received mld treatment for 10 
 minutes . finishing mld treatment was implemented . in this study , the psychological variables 
 of the patients were measured using the standard korean versions of the beck anxiety 
 inventory ( bai ) and beck depression inventory ( bdi ) , which are mental state rating scales 
 for anxiety and depression respectively . the bai and bdi are scales consisting of 21 
 questions and are measuring methods with high reliability and validity that have been the 
 most widely used since 1961 , which is when they were proposed . after rating , the mental 
 states of the patients and their levels of satisfaction with the different treatment methods 
 were evaluated using the average values . the effects of the 
 treatment methods ( pnf , pnf+super lizer , pnf+mld ) on the lymphedema patients after 
 mastectomy were verified by 3  2 repeated measures anovas . post hoc comparisons were 
 conducted using contrast tests to verify changes over time ( before the experiment , at 4 , 8 , 
 12 , and 16 weeks , and after the experiment ) . study patients baseline and demographic characteristicsvariablepnf+superlizer(n=17)pnf(n=17)pnf+mld(n=18)age ( years)53  151  153  1height ( cm)158  1160  1159  1weight ( kg)62.3  0.963.4  1.266.0  1.6bmi ( kg / m)24.93  0.4124.92  0.4626.21  0.63a total of 52 participants ( pnf+super lizer , 17 ; pnf , 17 ; pnf+mld , 18 ) were included 
 in the final analysis . in the pnf+super lizer group , the mean age and bmi were 
 531  years and 24.93  0.41 , respectively .. the beck depression score changed significantly during the five assessment 
 periods ( p<0.0001 ) ; however , there was no significant difference between the treatment 
 groups ( p=0.094 ) . post hoc analyses revealed that there was a significant improvement in 
 beck depression score from 4 weeks in all three groups . the interaction between group and 
 time was also statistically significant ( p=0.035 ; table 
 2table 2 . depression and anxiety after mastectomy at five assessment points by treatment 
 group ( mean  sem ) ( value : meansem)groupvariablepnf+super lizer(n=17)pnf(n=17)pnf+mld(n=18)depressionbefore treatment28.241.13a28.291.13a28.441.10a4 wks26.121.13b25.061.13b23.891.10b8 wks24.351.13c22.771.13c19.561.10c12 wks21.531.13d19.471.13d17.391.10d16 wks17.771.13e16.351.13e14.281.10eanxietybefore treatment35.771.63a32.881.63a37.331.58a4 wks27.411.63b25.351.63b26.001.58b8 wks21.121.63c20.771.63c21.281.58c12 wks15.881.63d17.181.63d15.111.58d16 wks12.471.63d13.061.63e11.941.58d values are meanssem , and the holm - sidak method was used for multiple 
 comparisons . a total of 52 participants ( pnf+super lizer , 17 ; pnf , 17 ; pnf+mld , 18 ) were included 
 in the final analysis . in the pnf+super lizer group , the mean age and bmi values are meanssem , and the holm - sidak method was used for multiple 
 comparisons . p values are derived from the between - group effect . regarding the time course changes in beck depression score in the pnf+super lizer , pnf , and 
 pnf+mld groups , there were significant decreases in beck depression score compared with the 
 previous value at all assessment points , and there were also significant differences between 
 the pnf+super lizer and pnf+mld groups at 4 and 8 weeks . regarding the time course changes in beck anxiety score in the pnf+super lizer , pnf , and 
 pnf+mld groups , there were significant decreases in beck anxiety score compared with the 
 previous value at all assessment points ; however , there was no significant difference 
 between the three groups . in this study , the patients psychological variables were observed before the pnf , 
 pnf+super lizer , and pnf+mld treatment methods were applied , at 0 , 4 , 8 , 12 , and 16 weeks of 
 treatment , and after the treatment . based on the results , pnf+mld can be considered an 
 effective treatment for depression in lymphedema patients after mastectomy . the results were 
 consistent with a previous report indicating that exercise therapy has effects that 
 significantly improve physical condition and relieve depression and anxiety12 . . 
 therefore , there are limitations in the interpretation of the results because there were 
 difficulties in setting the control group . however , on reviewing a previous clinical study , 
 it can be seen that lymphedema patients have limitations in activities and experience 
 anxiety and depression13 . another study 
 reported that although anxiety and depression were significantly relieved after performing 
 aerobic exercises , self - regard was not changed14 . however , the aforementioned study reported that patients who 
 participated in the exercise program showed improvement in psychological variables compared 
 with patients who did not participate in the exercise program . examining the effects of 
 exercises using pnf techniques is considered clinically meaningful . if future studies are 
 conducted on the motility of lymphedema patients , more significant results could be 
 obtained .