Development of a digital home self-care rehabilitation program for breast cancer patients post-surgery based on traditional Chinese medicine nursing diagnostics: a Delphi study

Abstract

Purpose

To develop a rigorous and standardized digital home self-care rehabilitation program for breast cancer patients’ post-surgery, based on traditional Chinese medicine (TCM) nursing diagnostics.

Methods

The initial draft of a digital rehabilitation module based on the WeChat mini-program was prepared through Literature research, patient surveys, expert interviews, And group discussions. A two-round Delphi method was used to consult 16 experts, revising, adding, and removing elements to finalize the rehabilitation plan.

Results

The response rate for both rounds of the Delphi expert consultation was 100%, with authority coefficients of 0.813 And 0.841, respectively, and Kendall’s coefficient of concordance values of 0.789 And 0.513 (both P < 0.001). The final plan includes 3 primary entries, 8 secondary entries, And 10 tertiary entries. Analytical hierarchy process results showed that the consistency ratio (CR) values for all matrices of the tertiary entries were < 0.1, meeting the requirements for consistency tests.

Conclusion

The constructed digital home self-care rehabilitation program for postoperative breast cancer patients, developed through evidence synthesis and expert consensus using Delphi consultation and AHP, is methodologically rigorous, reliable, and clinically applicable.

Trial registration

ClinicalTrials.gov Identifier: ITMCTR2024000368

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-025-09913-9.

Introduction

Breast cancer is the most commonly diagnosed malignancy among women, accounting for 24.5% of all female cancers [1], and its incidence continues to rise worldwide [2]. Although early detection And advancements in surgical And therapeutic approaches have improved the 5-year survival rate to approximately 90% [3], patients often experience persistent symptoms, complications, and psychological challenges throughout postoperative recovery [4–6]. These issues negatively affect long-term prognosis, functional recovery, and quality of life.

Orem’s self-care theory emphasizes enhancing patients’ self-care capacity, a strategy shown to be effective in managing postoperative side effects and improving the quality of life in breast cancer patients [7, 8]. In China, postoperative care is delivered primarily in the hospital setting, with rehabilitation efforts concentrated during the inpatient phase. Following discharge, patients often receive minimal support, and health education remains largely passive. In contrast, international models emphasize the implementation of structured rehabilitation programs that are oriented toward individual patient needs, extend beyond the acute hospitalization period, and actively engage patients in the recovery process.

Digital health technologies have emerged as promising tools to support such models. Mobile applications, wearable devices, telerehabilitation platforms, and virtual reality systems have been shown to improve adherence to rehabilitation, reduce symptom burden, and enhance functional recovery [9, 10]. However, most of these interventions are grounded in Western rehabilitation paradigms, often focusing on physical function, such as fatigue reduction or mobility enhancement, and offer limited cultural relevance for Chinese patients.

The effectiveness of digital rehabilitation depends not only on its delivery platform but also on whether the content is clinically appropriate and culturally acceptable. In this regard, traditional Chinese medicine (TCM) nursing provides a distinctive, holistic approach rooted in syndrome differentiation, yin–yang balance, and qi regulation [11]. TCM-based interventions, such as moxibustion, auricular massage, music therapy, and herbal diet prescriptions, support physical recovery and emotional well-being through non-pharmacological means [12]. These techniques align with Chinese cultural beliefs and patient expectations, offering an opportunity to enhance engagement and improve outcomes.

Several TCM-based mobile interventions delivered via WeChat have reported favorable outcomes in emotional regulation and compliance with recovery protocols [13, 14]. Nevertheless, existing interventions often lack systematic development, comprehensive expert consensus, or formal validation, which limits their scalability and clinical integration. To address this deficiency, we sought to create a structured, expert-informed digital home-based self-care rehabilitation program for postoperative breast cancer patients, grounded in traditional Chinese medicine nursing principles. By employing the Delphi method, this study aimed to establish a consensus-driven framework that facilitates personalized, culturally tailored rehabilitation and enhances patient engagement and long-term recovery.

Subjects and methods

Establishment of the research team

The research team includes two associate chief physicians of breast tumor surgery, one head nurse of the breast tumor department, one head nurse from the integrated traditional Chinese and Western medicine department, one nursing master’s degree supervisor, two nursing master’s degree students, and three internet information technology experts. The supervisor, associate chief physicians, and head nurses are responsible for the development of the rehabilitation module, selection of expert consultants, and guidance on the implementation of the program; the nursing master’s students are in charge of literature search, drafting of consultation questionnaires, distribution and collection of questionnaires, and data organization and analysis.

Drafting TCM diagnostic categories and rehabilitation module for postoperative breast cancer

Literature review

The research team conducted a literature review based on the “Diagnostic and Therapeutic Criteria of Traditional Chinese Medicine Diseases” [15], “Expert Consensus on Internal Treatment of Early Breast Cancer by TCM” [16], and the diagnostic methods in “Syndrome Differentiation Studies” [17]. They preliminarily identified eight TCM syndromes for postoperative breast cancer patients, including “spleen–stomach disharmony, qi and blood deficiency, qi and yin deficiency, liver and kidney deficiency, spleen and kidney deficiency, yin deficiency and depletion of fluid, yin deficiency and toxic heat, and disharmony pattern of thoroughfare and conception vessels.”

The research team designed a search strategy for postoperative breast cancer patients based on the disease symptoms exhibited according to different traditional Chinese medicine (TCM) syndromes, referencing the commonly used TCM nursing techniques in “Appropriate techniques for oncology TCM nursing” [18]. The search terms are as follows in Chinese “乳腺癌术后 (postoperative breast cancer)/乳癌术后 (post-mastectomy)/乳腺肿瘤术后 (post-breast tumor surgery)/乳腺癌根治术后 (post-radical mastectomy)” and “中医外治法 (TCM external therapy)/康复护理 (rehabilitation nursing)/中医护理 (TCM nursing)/中医护理技术 (TCM nursing techniques)/中医特色护理技术 (characteristic TCM nursing techniques)/中医护理适宜技术 (appropriate TCM nursing techniques)/穴位按摩 (acupoint massage)/穴位贴敷 (acupoint application)/耳穴按摩 (auricular massage)/耳穴压豆 (auricular point pressure)/耳穴贴压 (auricular patch)/隔姜灸 (ginger-separated moxibustion)/脐灸 (umbilical moxibustion)/艾灸 (moxibustion)/子午流注 (Ziwuliuzhu (midnight-noon ebb-flow) message aroma therapy)/五音疗法 (five-element music therapy)/五行音乐 (five-element music)/中国传统功法 (Chinese traditional exercises)/八段锦 (baduanjin)/太极 (tai chi).” The keywords included “功能障碍 (functional impairment)/癌因性疲乏 (cancer-related fatigue)/恶心呕吐 (nausea and vomiting)/化疗相关恶心呕吐 (chemotherapy-related nausea and vomiting)/睡眠障碍 (sleep disorders)/失眠 (insomnia)/焦虑 (anxiety)/抑郁 (depression)/焦虑抑郁 (anxiety and depression)/负性情绪 (negative emotions)/淋巴水肿 (lymphedema)/生活质量 (quality of life)/生命质量 (life quality).” The English search terms were “breast neoplasms/breast cancer/breast carcinoma/breast tumor/mammary cancer/postoperative breast cancer” “Chinese medicine nursing/rehabilitation nursing/rehabilitation/self-care/self-management/home nursing/home-based/technology of traditional Chinese medicine/traditional Chinese medicine characteristic nursing techniques/TCM nursing techniques/appropriate technology of traditional Chinese medicine nursing/massage/acupressure/moxibustion/auricular point therapy/music therapy/baduanjin/taiji.” The databases searched included CNKI, Wanfang, VIP, UpToDate, the Joanna Briggs Institute (JBI) Library, Cochrane Library, PubMed, Web of Science, And other websites related to breast cancer rehabilitation internationally. The inclusion criteria were clinical guidelines, recommendations, systematic reviews, And randomized controlled trials related to TCM external therapy for rehabilitation or self-care. The exclusion criteria included conference papers, duplicate publications, inaccessible full texts, and low-quality articles; non-Chinese or English articles were also excluded. The search spanned from January 2014 to December 2023. After deduplication And screening, 2109 papers were found, And 29 relevant documents were included, comprising 4 guidelines [19–22], 5 systematic reviews [23–27], 8 meta-analyses [28–35], And 2 evidence-based practices [36, 37], along with 10 clinical decisions [38–47].

Preliminary needs assessment via exploratory interviews

Using purposive sampling, a preliminary need assessment was conducted through semi-structured exploratory interviews with patients and experts to inform the initial construction of the rehabilitation module framework [48]. Based on Literature review And internal discussion, the research team developed separate interview outlines for experts And patients, as presented in Supplementary Table 1.

Notably, patient interviews were conducted in two tertiary hospitals specializing in TCM and integrated Chinese-Western medicine. Most patients expressed a strong interest in TCM-based home rehabilitation methods, indicating that these approaches could enhance their sense of control over their condition and offer diversified social support, particularly among those with prior direct or indirect experience with TCM-related treatments. Of note, the patient survey was exploratory and primarily intended to guide the initial construction of the rehabilitation module. Patients’ responses regarding rehabilitation willingness, goals, and preferred TCM methods were summarized in general terms and incorporated into the draft module framework, and a detailed thematic or statistical analysis was not performed, as the objective of this phase was module development rather than qualitative research.

From April to June 2023, 12 clinical medical staff from two tier 3 grade A TCM hospitals and integrated Chinese–Western medicine hospitals in Changsha, And 14 postoperative breast cancer patients hospitalized or revisiting these hospitals were selected as study subjects, based on the principle of information saturation. Through semi-structured face-to-face in-depth interviews, clinical experts were consulted on the methods of postoperative breast cancer symptom intervention using external TCM treatments. The study explored which appropriate TCM nursing techniques are suitable for home operation and their pathways of implementation in terms of safety and effectiveness. Patients were also asked about their rehabilitation willingness, rehabilitation goals, and preferences for choosing home self-care rehabilitation methods.

Forming the initial draft of the rehabilitation module

Based on literature analysis and evaluation, combined with the results of the semi-structured exploratory interviews, the research team initially formed a rehabilitation module that targets improvements in eight areas: improving the functionality of the affected limb, alleviating post-surgical body pain, relieving chemotherapy-related nausea, vomiting or chemotherapy-induced peripheral neuropathy, reducing anxiety and depressive negative emotions, alleviating sleep disorders, reducing cancer-related fatigue, enhancing body immunity, and preventing lymphedema in the affected limb. The TCM external treatment techniques involved include acupoint moxibustion on the affected limb, medicinal herbal fumigation of the affected limb, auricular point pressure, ginger-separated moxibustion, acupoint application (based on syndromes), meridian acupoint finger press massage (based on syndromes), aromatherapy, five-tone music therapy, medicinal herbal foot baths, and traditional TCM exercises including tai chi or baduanjin.

Delphi expert inquiry

Developing the questionnaire

The expert inquiry questionnaire consists of four parts: (1) a letter to experts, outlining the purpose, significance, and content of the research, along with questionnaire instructions. (2) Basic information about the experts, including name, age, education, professional title, field of expertise, and years of experience. (3) A survey on the experts’ familiarity with and judgment basis for the research content. (4) A questionnaire based on TCM syndrome differentiation for home digital rehabilitation modules for postoperative breast cancer patients: items in the inquiry use a 5-point Likert scale for scoring rationality, with 1 being “strongly disagree” And 5 being “strongly agree.” Experts assess the rationality and appropriateness of items and provide suggestions for modifications or additions/deletions. The second round of the questionnaire, based on the first round’s contents, further scores the importance of the rehabilitation module, including ranking the importance of various indicators and conducting pairwise comparisons of sub-level indicators.

Selecting experts

Criteria for including experts are the following: (1) having extensive experience as clinical or nursing experts in breast tumors, (2) having more than 6 years of work experience, (3) holding a bachelor’s degree or higher, (4) having a mid-level or higher professional title, (5) actively participating in this research, and (6) being able to provide timely feedback during the research period.

Implementing the inquiry

Questionnaires are distributed via email or on-site. Based on the results of the first round of inquiry And after discussion by the research team, the questionnaire is revised to form the second round. This second inquiry involves modifying And refining the module and its content until the results converge to form the final rehabilitation module and plan. Each round of the questionnaire has a filling period of 1–2 weeks, with a 4-week interval between the two rounds of expert inquiry. The selection criteria for items are: an average score for rationality > 3.5 and a coefficient of variation < 0.25 [49].

Statistical methods

The results of the inquiry are entered into Excel by two individuals And Analyzed statistically using SPSS 25.0 software. The questionnaire return rate and expert authority coefficient (Cr) indicate the level of active participation and authority of the experts, respectively. Cr is calculated as the average of the experts’ familiarity coefficient And judgment coefficient. A Cr value greater than 0.7 generally indicates a high level of expert authority. The degree of agreement and concentration of expert opinions is represented by Kendall’s coefficient of harmony (Kendall’s W) and the coefficient of variation (CV), with higher Kendall’s W and lower CV indicating higher degrees of expert opinion agreement and concentration. Generally, a CV ≤ 0.25 is considered optimal. A p value < 0.05 is considered statistically significant.

Results

Basic information of the inquired experts

A total of 16 experts with a high academic level in this research field were selected from Changsha, Guangzhou, Wuhan, and Fuzhou. The basic information of the expert group members is shown in Table 1.

Table 1.

Basic information on the members of the expert group

Items	Number of Participants (n)	Mean	Proportion (%)
Gender
Male	8		50.00
Female	8		50.00
Age (years)		39.38 ± 5.43
31~40	9		56.25
41~	7		43.75
Degree
Doctoral	7		43.75
Master	7		43.75
Bachelor	2		12.50
Title
Senior professional	4		25.00
Associate senior professional	7		43.75
Intermediate professional	5		31.25
Professional fields
Breast tumors	7		43.75
Rehabilitation medicine	2		12.50
Traditional Chinese medicine geriatric nursing	4		25.00
Clinical nursing management	3		18.75
Years of experience		14.25 ± 6.52
6~10	5		31.25
11~20	8		50.00
21~	3		18.75

Expert engagement and authority level

In this study, 16 questionnaires were distributed in each of the two rounds of Delphi inquiries, with a recovery rate of 100% for both rounds. The number of experts providing feedback or guidance was 14 And 10, respectively, indicating high levels of expert engagement. The coefficient values in the first round were Ca = 0.938, Cs = 0.688, and Cr = 0.813, while in the second round, they were Ca = 0.969, Cs = 0.712, and Cr = 0.841. With both rounds having Cr > 0.7, this demonstrates a high level of expert authority.

Degree of expert opinion coordination

The Kendall’s coefficients of harmony for the two rounds of expert inquiry were 0.789 (χ² = 214.591, P < 0.001) And 0.513 (χ² = 123.043, P < 0.001), respectively. The coefficient of variation (CV) for the first round of expert inquiry ranged from 0 to 0.329, And for the second round, it ranged from 0 to 0.130. These results indicate a good level of coordination and concentration of expert opinions, as shown in Table 2.

Table 2.

Consistency test results

Rounds	Kendall’s coefficient of concordance	χ2	P	CV
First	0.789	214.591	< 0.001	0~0.329
Second	0.513	123.043	< 0.001	0~0.130

Delphi inquiry results

In the first round of the expert consultation questionnaire, there were two parts, including 8 postoperative TCM syndrome categories And a postoperative rehabilitation plan, which comprises 3 primary indicators, 8 secondary indicators, And 10 tertiary indicators. Based on expert suggestions, clinical realities, and the statistical requirements of the Delphi method, the research team collectively evaluated and made the following modifications to the related modules in the TCM syndrome categories and tertiary indicators:

(1) The deletion of “yin deficiency and toxic fire” and “disharmony pattern of thoroughfare and conception vessels,” and the addition of “liver qi stagnation syndrome.” The “qi and blood deficiency” and “qi and yin deficiency” were merged into “qi and yin (Blood) deficiency.” Experts believe that breast cancer patients often experience emotional abnormalities due to liver Qi stagnation and Qi mechanism disorders, with a high incidence rate of depressive syndromes (66.1% [50]). The disorder is predominant throughout the entire rehabilitation process of breast cancer patients, mainly characterized by liver qi stagnation syndrome.

(2) Simplifying “relieving chemotherapy-related nausea, vomiting, or chemotherapy-induced peripheral neuropathy” to “relieving chemotherapy-related gastrointestinal reactions.” Experts believe that, based on TCM theory, rehabilitation modules related to improving Limb function, enhancing body immunity, And preventing lymphedema can effectively promote peripheral qi And blood circulation, alleviating chemotherapy-related peripheral neuropathy. Gastrointestinal reactions are more significant and common during postoperative chemotherapy, with an incidence rate as high as 90% [21], which should be actively addressed throughout the chemotherapy period.

(3) The addition of “walking (strolling/brisk walking)” and “resistance training” to the rehabilitation modules. Experts believe that avoiding a sedentary lifestyle and adopting a walking exercise plan (brisk walking) are easily accepted, safe, and feasible for breast cancer patients, effectively enhancing their physical activity capacity and improving negative emotions [51, 52]. Resistance exercises can strengthen muscle strength and have a trend to reduce the incidence of lymphedema [53].

(4) Changing “auricular point pressure” to “auricular massage.” Experts consider that internet hospitals are not yet widespread, and nurse home visit services are not well established. Auricular massage can promote blood and lymph circulation in the ear, activate meridians, regulate body yin and yang balance, and enhance body immunity, and is not restricted by location or time [54], making this method more universally applicable.

(5) Relegating “aromatherapy,” which can alleviate chemotherapy-related nausea, vomiting, and sleep disorders, to a non-essential rehabilitation module, incorporating it into the “popular science content” on the rehabilitation platform. Also, the “popular science content” section should include “diet therapy” based on different TCM syndromes and recommend medicinal diets.

(6) Deleting the TCM external treatment rehabilitation modules “acupoint massage” and “moxibustion” aimed at improving the function of the affected limb. Experts believe that self-implementation is inconvenient, and careless operation can easily cause burns on the affected limb.

(7) Removing the TCM external treatment rehabilitation modules “acupoint application” and “medicinal herbal application” aimed at alleviating chemotherapy-related nausea, vomiting, and preventing lymphedema of the affected limb. Experts consider that these two items involve the use of externally purchased medicines and that internet hospitals are not yet well established, lacking home universality.

(8) Merging some rehabilitation modules to form new rehabilitation modules. For instance, conducting “ginger-separated moxibustion” simultaneously with “five-tone music therapy,” and implementing “foot bath” while concurrently performing “auricular massage.”

(9) Defining the traditional TCM exercise “baduanjin” as a simple, economical, and effective method. Based on the needs of patients’ postoperative rehabilitation stages, “progressive baduanjin (first four forms)” is designated as a rehabilitation module. This module aims to promote the recovery of limb function during the transitional phase (postoperative second phase).

Finally, 6 TCM syndrome categories, 3 rehabilitation stages, 8 rehabilitation objectives, And 10 rehabilitation modules were determined, i.e., 3 primary indicators, 8 secondary indicators, And 10 tertiary indicators.

After the second round of inquiry, no items were modified. The final version of the home-based digital self-care rehabilitation program for postoperative breast cancer patients, based on TCM syndrome differentiation nursing, is detailed in Table 3. The results of the expert consultation, integrated with the analytic hierarchy process (AHP), display the weight of each item in Table 4, and all items have consistency ratio (CR) values of < 0.1, as indicated in Table 5.

Table 3.

Quantitative evaluation of TCM-based home rehabilitation modules categorized by syndrome differentiation, rehabilitation objective, and postoperative stage

TCM syndrome	Likert 5-level scoring ($\overline{X}$ ± S)	Coefficient of variation (CV)	Rehabilitation stages	Weight	Rehabilitation objectives	Peer-level weight	Global weight	Rehabilitation modules and opinions	Likert 5-level scoring ($\overline{X}$ ± S)	Coefficient of variation	Peer-level weight	Global weight*
Spleen–stomach disharmony	4.56 ± 0.51	0.112	First stage: 1–4 weeks post-surgery	0.333	A. Restore function to the affected limb	0.529	0.176	Module 1: arm rehabilitation exercise	5.00 ± 0.00	0	1	0.529
					B. Warm the meridians, improve circulation, and alleviate pain	0.173	0.058	Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.620	0.107
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.280	0.048
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.100	0.017
					C. Ease emotional stress	0.237	0.079	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.246	0.058
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.450	0.107
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.046	0.011
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.179	0.042
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.079	0.019
Qi and yin (blood) deficiency	4.56 ± 0.51	0.112			D. Improve sleep	0.061	0.020	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.064	0.004
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.112	0.007
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.073	0.004
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.474	0.029
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.277	0.017
			Second stage: 5–12 weeks post-surgery	0.333	A. Restore function to the affected limb	0.131	0.044	Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	1.000	0.131
					C. Ease emotional stress	0.253	0.084	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.125	0.031
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.223	0.056
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.028	0.007
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.039	0.010
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.087	0.022
								Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	0.102	0.026
Liver and kidney deficiency	4.75 ± 0.45	0.094						Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.396	0.100
					D. Improve sleep	0.034	0.011	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.030	0.001
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.083	0.003
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.038	0.001
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.361	0.012
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.134	0.005
								Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	0.084	0.003
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.271	0.009
					E. Alleviate chemotherapy-related gastrointestinal reactions	0.435	0.145	Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.563	0.245
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.154	0.067
								Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	0.088	0.038
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.195	0.085
					F. Unblock meridians, boost metabolism, and enhance immunity ·	0.074	0.025	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.031	0.002
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.355	0.026
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.043	0.003
Spleen and kidney deficiency	4.38 ± 0.50	0.114						Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.151	0.011
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.064	0.005
								Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	0.214	0.016
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.143	0.011
					G. Improve cancer-related fatigue	0.073	0.024	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.031	0.002
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.078	0.006
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.047	0.003
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.378	0.028
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.169	0.012
								Module 7: progressive baduanjin (first four forms)	4.81 ± 0.40	0.084	0.216	0.016
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.081	0.006
			Third stage: week 13 and beyond post-surgery	0.333	C. Ease emotional stress	0.062	0.021	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.197	0.012
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.285	0.018
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.020	0.001
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.028	0.002
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.081	0.005
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.285	0.018
Yin deficiency and depletion of fluid	3.87 ± 0.34	0.088						Module 9: baduanjin	5.00 ± 0.00	0	0.090	0.006
								Module 10: resistance training	4.19 ± 0.54	0.130	0.041	0.003
					D. improve sleep	0.060	0.020	Module 2: five-tone music therapy	5.00 ± 0.00	0.094	0.022	0.001
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.107	0.006
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.034	0.002
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.366	0.022
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.093	0.006
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.070	0.004
								Module 9: baduanjin	5.00 ± 0.00	0	0.241	0.014
								Module 10: resistance training	4.19 ± 0.54	0.130	0.068	0.004
					E. Alleviate chemotherapy-related gastrointestinal reactions	0.050	0.017	Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.524	0.026
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.091	0.005
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.100	0.005
								Module 9: baduanjin	5.00 ± 0.00	0	0.284	0.014
					F. Unblock meridians, boost metabolism, and enhance immunity	0.374	0.125	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.020	0.007
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.323	0.121
Liver qi stagnation syndrome	4.75 ± 0.45	0.094						Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.059	0.022
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.157	0.059
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.064	0.024
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.066	0.025
								Module 9: baduanjin	5.00 ± 0.00	0	0.286	0.107
								Module 10: resistance training	4.19 ± 0.54	0.130	0.026	0.010
					G. Improve cancer-related fatigue	0.124	0.041	Module 2: five-tone music therapy	5.00 ± 0.00	0	0.020	0.002
								Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.088	0.011
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.046	0.006
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.287	0.036
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.062	0.008
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.320	0.040
								Module 9: baduanjin	5.00 ± 0.00	0	0.154	0.019
								Module 10: resistance training	4.19 ± 0.54	0.130	0.024	0.003
					H. Increase muscle mass, reduce fat, and prevent lymphedema	0.330	0.110	Module 3: ginger-separated moxibustion + five-tone music therapy	4.75 ± 0.45	0.094	0.060	0.020
								Module 4: ear massage exercise	4.88 ± 0.34	0.070	0.021	0.007
								Module 5: ear massage exercise + warm water foot bath	4.94 ± 0.25	0.051	0.092	0.030
								Module 6: walking (strolling)	5.00 ± 0.00	0	0.031	0.010
								Module 8: meridian acupoint pressure rehabilitation exercise	4.13 ± 0.34	0.083	0.126	0.041
								Module 9: baduanjin	5.00 ± 0.00	0	0.299	0.099
								Module 10: resistance training	4.19 ± 0.54	0.130	0.372	0.123

^*The highest global weight within each rehabilitation objective category

Table 4.

Expert correspondence weighting table for the home digital self-care rehabilitation program for postoperative breast cancer patients based on traditional Chinese medicine evidence-based nursing care

Rehabilitation stages	Global weight	Rehabilitation objectives	Global weight	Rehabilitation modules and opinions	Likert 5-level scoring ($\overline{X}$ ± s)	Coefficient of variation	Global weight	Ranking
First stage: 1–4 weeks post-surgery	0.333	A. Restore function to the affected limb	0.220	Module 1: arm rehabilitation exercise This module outlines the recommended timing and sequence of postoperative exercises for upper Limb rehabilitation. It is advisable to perform two eight-beat cycles per session, 2–3 times daily, with each session lasting between 10 And 30 min. The process should emphasize gradual progression, with both the frequency and intensity of the exercises gradually increasing.	5.00 ± 0.00	0	0.176	2
		B. Warm the meridians, improve circulation, and alleviate pain	0.058	Module 2: five-tone music therapy This therapy involves selecting music tracks directly based on traditional Chinese medicine (TCM) syndrome types, with a recommended Listening duration of 30–60 min daily. Here are the details for each syndrome: disharmony of the spleen and stomach: (Gong tone) includes tracks such as “Ambush from ten sides,” “Rain hitting banana leaves,” and “Chasing the moon amongst colorful clouds.” Qi and yin (blood) deficiency: (Yu tone + Hui tone) includes tracks such as “Purple bamboo melody,” “Moon reflection on the second spring,” and “Spring breeze brings joy.” Deficiency of liver and kidney: (Jiao tone + Yu tone) includes tracks such as “Eighteen beats of a nomad flute,” “Three variations on the plum blossom,” and “Wild geese descending on the sandbank.” Deficiency of spleen and kidney: (Gong tone + Yu tone) includes tracks such as “Ambush from ten sides,” “Moonlit night on the autumn lake,” and “Three variations on the plum blossom.” Deficiency of yin fluids: (Shang tone) includes tracks such as “Spring snow,” “Three refrains on the yang pass theme,” and “Rainy night by the banana window.” Liver qi stagnation: (Jiao tone) includes tracks such as “Zhuang Zhou dreams of the butterfly,” “Loud celebration,” and “Heron forgets its machine.”	5.00 ± 0.00	0	0.040	10
		C. Ease emotional stress	0.184	Module 3: ginger-separated moxibustion + five-tone music therapy: first stage: ginger-separated moxibustion is applied to acupoints including Shenque (CV-8), Guanyuan (CV-4), Qihai (CV-6), Zusanli (ST-36), Sanyinjiao (SP-6), Taichong (LR-3), and Yongquan (KD-1). Second and third stages: ginger-separated moxibustion is applied to acupoints including Zhongwan (CV-12), Shenque (CV-8), Neiguan (PC-6), and Zusanli (ST-36). At the same time, corresponding five-tone music is played. The treatment is conducted once daily, with each session lasting 30 min. Special attention is given to timing the moxibustion between 09:30 And 11:30 AM or 3:00 And 5:00 PM, avoiding sessions on An empty stomach or late in the evening, ensuring to keep warm post-treatment And not bathing for 8 h afterward.	4.75 ± 0.45	0.094	0.253	1
Second stage: 5–12 weeks post-surgery	0.333	D. Improve sleep	0.051	Module 4: ear massage exercise Session 1: auricular clearance: rubbing the auricle, kneading the helix, pinching the ear screen, and sweeping the back of the ear. Session 2: ear body lift: lifting the ear tip, pulling the helix, tugging the earlobe, and kneading the ear body. Session 3: ear pit massage: kneading the tragus, the Antitragus, And the triangular fossa, and rubbing the ear root. Starting from the third postoperative week, the exercise is performed 2–3 times daily, each session lasting 8–10 min. During the first 3 weeks post-surgery, family members can assist based on the individual’s recovery condition.	4.88 ± 0.34	0.070	0.062	7
				Module 5: ear massage exercise + foot bath First stage: each night, 30 min before bedtime, feet are soaked in 38–40 °C warm water for 15–20 min until a slight sweat is produced. Second and third stages: each night, 30 min before bedtime, feet are soaked in 38–40 °C herbal Liquid for 15–20 min until a slight sweat is produced. For those without significant sleep disturbances, the bath is aimed at warming the channels to alleviate pain And promote fluid circulation And metabolism, with a bath formula of 10 g artemisia And 10 g safflower. For those with sleep disturbances, the bath formula includes 9 g Coptis, 16 g cinnamon, 20 g Parthenocissus, 20 g Albizia bark, 10 g Poria, 20 g sour jujube seeds, And 30 g Salvia. Concurrently, perform ear massage 1–2 times.	4.94 ± 0.25	0.051	0.099	4
		E. Alleviate chemotherapy-related gastrointestinal reactions	0.162	Module 6: walking (strolling, brisk walking) Walking is tailored to post-surgical recovery, avoiding a sedentary lifestyle. First stage: walk 1–2 times daily, each for 10–20 min. Second and third stages: brisk walk 1–2 times daily, each for 30 min, at An intensity of 60–70% of maximum heart rate.	5.00 ± 0.00	0	0.044	9
				Module 7: progressive baduanjin (first four forms) Based on the patient’s recovery, practice the first four movements of baduanjin progressively, which are two hands reach for the sky to adjust the triple burner (两手托天理三焦); drawing a bow to shoot a hawk (左右开弓似射雕); raise your hand on each side to adjust the spleen and stomach (调理脾胃须单举) Turn your head back to prevent illness and injury (五劳七伤往后瞧) This is done 1–2 times daily, each session lasting 20–30 min, gradually increasing the exercise intensity.	4.81 ± 0.40	0.084	0.077	6
Third stage: week 13 and beyond post-surgery	0.333	F. Unblock meridians, boost metabolism, and enhance immunity	0.150	Module 8: meridian acupoint pressure rehabilitation exercise This module involves applying acupressure to specific meridians and acupoints tailored to traditional Chinese medicine (TCM) syndromes, using techniques such as pressing, kneading, pushing, And tapping. The exercise is performed 2−3 times daily, each session lasting 30–40 min. The acupoints selected for each TCM syndrome are as follows: Disharmony of the spleen and stomach: choose Zhongwan (CV-12), Tianshu (ST-25), Zusanli (ST-36), and Gongsun (SP-4). Qi and yin (Blood) deficiency: select Qihai (CV-6), Xuehai (SP-10), Zusanli (ST-36), Yinlingquan (SP-9), and Sanyinjiao (SP-6). Deficiency of liver and kidney: use Sanyinjiao (SP-6), Taixi (KD-3), Taichong (LR-3), and Yongquan (KD-1). Deficiency of spleen and kidney: choose Zhangmen (LV-13), Zusanli (ST-36), Sanyinjiao (SP-6), and Taixi (KD-3). Deficiency of yin fluids: select Hegu (LI-4), Zusanli (ST-36), Sanyinjiao (SP-6), Taixi (KD-3), and Yongquan (KD-1). Liver qi stagnation: use Wuyi (ST-15), Danzhong (CV-17), Qimen (LR-14), and Taichong (LR-3).	4.13 ± 0.34	0.083	0.115	3
		G. Improve cancer-related fatigue	0.065	Module 9: baduanjin: finish the entire series: two hands reach for the sky to adjust the triple burner (两手托天理三焦); drawing a bow to shoot a hawk (左右开弓似射雕); raise your hand on each side to adjust the spleen and stomach (调理脾胃须单举) Turn your head back to prevent illness and injury (五劳七伤往后瞧) Shake your head and shake your tail to get rid of Xinhuo symptoms (摇头摆尾去心火) Two hands hold the legs to strengthen the kidneys and lower back (两手攀足肾腰) Clench your fists and look fiercely at those around you to improve strength and chi (攒拳怒目增气力) Fall seven times on your heels––dissolve all diseases (背后七颠百病消) Eight movements. Exercise 1–2 times daily, each session lasting 20–30 min.	5.00 ± 0.00	0	0.088	5
		H. Increase muscle mass, reduce fat, and prevent lymphedema	0.110	Module 10: resistance training This module involves resistance exercises using dumbbells. The exercises include bench presses, bicep curls, dumbbell shrugs, And upright rows, targeting the muscles of the chest, shoulders, And back. Perform these exercises every other day, completing two sets of each exercise with 8–12 repetitions per set, at 60–70% of maximum resistance. Each training session should last 20–30 min. Gradually increase the intensity and volume of the exercise based on personal fitness levels. Online appointments with a rehabilitation specialist are needed if necessary.	4.19 ± 0.54	0.130	0.048	8

Table 5 presents the results of the analytic hierarchy process (AHP) applied to all modules initially considered during the expert consultation process. Some modules shown in Table 5, such as module 2 under the stage 1 objective “warm the meridians, improve circulation, and alleviate pain,” were not included in the finalized rehabilitation program presented in Table 4, reflecting the outcome of subsequent expert consensus achieved during the Delphi process

Table 5.

Consistency test results

Consistency check value		λmax	CI	CR
First stage post-surgery		4.086	0.029	0.032
First stage post-surgery	B	3.007	0.003	0.007
	C	5.120	0.030	0.027
	D	5.069	0.017	0.015
Second stage post-surgery		6.293	0.059	0.046
Second stage post-surgery	C	7.316	0.053	0.039
	D	7.359	0.060	0.044
	E	4.037	0.012	0.014
	F	7.209	0.035	0.026
	G	7.223	0.037	0.027
Third stage post-surgery		6.077	0.015	0.012
Third stage post-surgery	C	8.381	0.054	0.039
	D	8.352	0.050	0.036
	E	4.031	0.010	0.012
	F	8.541	0.077	0.055
	G	8.565	0.081	0.057
	H	7.525	0.088	0.064

Discussion

This study conducted an extensive review of domestic and international literature on TCM syndrome differentiation nursing, breast cancer, postoperative care, digital home care, and self-care rehabilitation. Using the theory of TCM syndrome differentiation as a foundation, semi-structured interviews were conducted to assess the home rehabilitation needs of postoperative breast cancer patients. Based on these findings and clinical experience, an initial version of the home-based digital self-care rehabilitation program was developed. The program was then iteratively refined through two rounds of Delphi expert consultation and optimization using AHP, resulting in a scientifically sound and reliable digital rehabilitation plan.

Sixteen consulting experts from cities recognized for their strengths in Chinese medicine participated in the Delphi process. Among them, 87.5% Held graduate degrees, And 68.75% had more than 11 years of professional experience. Expert engagement was high, as evidenced by a 100% effective response rate in both rounds. The proportions of experts providing textual feedback were 87.5% And 62.5% in the first And second rounds, respectively. The Cr values were 0.813 And 0.841, while Kendall’s coefficients of concordance were 0.789 And 0.513 (both P < 0.001), indicating strong consensus. The integration of the Delphi method with the AHP facilitated the assignment of indicator weights, with all CR values remaining below 0.1, confirming logical consistency and scientific robustness. These findings collectively affirm the high reliability and validity of the finalized rehabilitation program.

TCM nursing, which emphasizes holistic care and syndrome differentiation, has demonstrated substantial benefits in reducing postoperative complications and improving clinical outcomes in breast cancer patients [55]. These approaches support personalized rehabilitation tailored to individual needs, thereby enhancing postoperative quality of life [56]. Additionally, family-based interventions can promote adherence to rehabilitation protocols, improve health literacy, alleviate psychological distress, and support reintegration into family roles [57]. Home-based rehabilitation exercises play a key role in strengthening self-care capacity and enhancing recovery after surgery [31]. In light of the strong demand for continued TCM-based care among discharged patients in China [58], as well as widespread public familiarity with these techniques, particularly among women [59], our present study identified syndrome-specific symptom profiles across different treatment stages to inform individualized rehabilitation strategies. The digital program developed in this study was structured around core symptom clusters observed at various postoperative stages. It standardizes rehabilitation content based on TCM syndrome differentiation and delivers personalized interventions through a WeChat-based platform. Patients access the interface by inputting their surgery date, completing a self-assessment of TCM-related symptoms (e.g., diet, taste, sleep, bowel movements, sweating, dizziness, fatigue), and uploading tongue images for remote diagnostic evaluation. Based on this information, the system generates individualized rehabilitation recommendations.

To enhance usability and cultural relevance, video tutorials were developed to demonstrate techniques such as ear massage, herbal foot baths, ginger-separated moxibustion, resistance training, and acupoint pressure exercises. Each video is accompanied by textual instructions detailing the rehabilitation objectives, method, frequency, intensity, duration, safety considerations, and therapeutic rationale. These modular tasks provide structured daily guidance, facilitating patient participation, health literacy, and self-management. The platform also offers real-time feedback and expert consultations, reinforcing informational and emotional support, and thereby improving patient adaptation and postoperative quality of life [60]. By standardizing post-discharge care and expanding access to home-based rehabilitation, the program fosters greater autonomy and self-efficacy among breast cancer survivors.

The rehabilitation modules developed in this program address a range of common postoperative issues in breast cancer patients, including pain, limb dysfunction, anxiety, depression, gastrointestinal discomfort related to chemotherapy, fatigue, immunosuppression, and lymphedema. Interventions consist of exercise therapy and non-pharmacological TCM-based therapies. Exercise therapy, incorporating both aerobic and resistance training, has been shown to enhance musculoskeletal health, improve sleep and mood, and increase physical resilience during and after cancer treatment [20]. It is also associated with reduced recurrence and mortality in breast cancer patients [30]. Clinical guidelines recommend initiating upper Limb exercises within 12 h post-surgery [61] And continuing for at Least 8 weeks post-discharge or until full restoration of shoulder joint function [62]. Combined aerobic and resistance exercises, such as walking with strength training, are more effective than either modality alone in improving physical outcomes [63]. Supervised resistance training increases muscle strength without elevating the risk of breast cancer-related lymphedema and may even help alleviate it [64]. It also counters treatment-induced fatigue and bone mineral loss [65], serving as a practical strategy for lymphedema self-management.

Baduanjin, a traditional form of Qigong characterized by eight simple movements, serves as both a non-pharmacological TCM intervention and a moderate-intensity aerobic activity [66]. It has been shown to improve sleep quality, cognitive function, mood, fatigue, and overall quality of life in breast cancer patients [34]. Due to its safety, accessibility, and low physical demands, baduanjin is particularly appropriate for elderly patients or those with functional limitations [29]. The first four movements, which focus on improving shoulder mobility and upper limb function, are incorporated into the early-stage modules of the program [67]. However, although the program demonstrates broad applicability, its effectiveness may vary based on individual patient characteristics. For instance, patients with severe complications, limited mobility, or cognitive impairments may require additional medical supervision, with adherence to the program likely influenced by factors such as health literacy, self-discipline, and the availability of external support. Therefore, future investigations are needed to examine the influence of these variables on program outcomes to further optimize its implementation.

Non-pharmacological TCM therapies, valued for their simplicity, safety, and non-invasive nature, provide complementary support to exercise therapy. Moxibustion, which applies heat to stimulate specific acupoints, is used to harmonize yin and yang, promote qi circulation, and enrich blood flow [68]. Clinical studies have demonstrated its benefits in reducing chemotherapy-induced leukopenia, gastrointestinal side effects, and fatigue, while also improving treatment adherence and safety [69]. Ginger-separated moxibustion, which combines the warming properties of ginger with heat stimulation, has been found to alleviate postoperative pain, stress, chemotherapy-related gastrointestinal symptoms, and fatigue, while also enhancing immune function [70]. Acupressure has similarly been shown to reduce chemotherapy-induced nausea and vomiting, as well as cancer-related fatigue [32], thereby improving both physical and emotional well-being in breast cancer patients [28, 71]. As a non-invasive alternative to acupuncture, acupressure is particularly suitable for home-based self-care, especially for managing the fatigue–sleep disturbance–depression symptom cluster [39], which affects up to 75% of patients after their first chemotherapy session [72].

Moreover, foot baths, another accessible home-based intervention, promote vasodilation, muscle relaxation, and mental calming, thereby improving sleep and reducing fatigue. According to TCM theory, the soles of the feet contain acupoints corresponding to the body’s internal organs via meridians, making them a focal point for disease prevention and treatment [73]. Empirical evidence supports the efficacy of warm foot baths in relieving pain, fatigue, and sleep disturbances in cancer patients undergoing radiotherapy and chemotherapy [74]. Herbal foot baths, which involve soaking the feet in a warm decoction of medicinal herbs, are a safe, cost-effective, and more efficacious alternative to plain warm water baths for postoperative sleep enhancement [75]. The platform facilitates online consultations with TCM experts, allowing for personalized herbal prescriptions tailored to patient symptoms. Ear acupoints, which reflect the functional status of internal organs through the auricle, are another TCM-based therapeutic target [76]. Ear massage can modulate neuroimmune signaling pathways [77, 78], promote qi and blood flow, and alleviate symptoms such as pain, fatigue, depression, and sleep disturbances [33, 46, 47, 76]. This low-cost, simple, and non-invasive method is especially suitable for at-home implementation [79]. Compared to auricular point pressure, ear massage offers greater feasibility in unsupervised settings by simultaneously stimulating multiple acupoints and enhancing circulatory and lymphatic functions [54]. Anxiety is a common psychological burden in breast cancer patients, often peaking at diagnosis and worsening during chemotherapy. Higher anxiety levels are particularly associated with being unmarried, reduced social interaction, and poor sleep quality [80, 81]. Music therapy, as a non-pharmacological intervention, has been shown to reduce pain, nausea, fatigue, and psychological distress [82], while enhancing emotional regulation and perceptions of self-control [83]. Five-tone music therapy, a traditional TCM psychological approach, is effective in alleviating symptoms of cancer-related depression and fatigue and improving treatment compliance and quality of life [42, 84]. While the rehabilitation modules provide valuable support in enhancing recovery, they are designed to complement, not replace, routine medical care, indicating that continued medical follow-up and physician guidance remain essential. Additionally, issues related to patient privacy, digital literacy, and individual variability in implementation may influence program adherence and standardization [85]. Therefore, further evaluation of long-term effectiveness and feasibility in real-world settings is warranted.

Limitations

This study has several limitations. First, the Delphi process involved a limited number of experts primarily from specific regions, which may limit generalizability. Second, the study focused on program development and validation, not on long-term clinical outcomes, which should be addressed in prospective research. Third, although patient interviews helped improve the modules, we did not perform a detailed analysis of patient feedback, which might have limited our understanding of how patients feel about using the program. In addition, the interview data were used only to support the design process, which might have reduced the depth of insight into patients’ views. Future research could include studies across different hospitals and combine both quantitative and qualitative methods to better test and improve the program, as well as perform a more systematic evaluation of patient experiences.

Conclusion

This study developed a practical digital self-care rehabilitation program for postoperative breast cancer patients based on TCM syndrome differentiation. It incorporates stage-specific rehabilitation needs and TCM symptom characteristics and provides structured guidance via a user-friendly mobile interface. The program offers clear, actionable care plans for clinical nurses and comprehensive, personalized self-care modules for patients. It supports holistic recovery and empowers patients in the post-discharge phase. Future studies will evaluate the program’s preliminary application effects and further refine it, advancing the use of TCM external treatments and non-pharmacological therapies in home settings to promote sustainable digital rehabilitation.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

Literature search analysis were performed by YH, QL, JRY, data investigation, statistical analysis were performed by YH, PL, The first draft of the manuscript was written by YH, Methodology, resource provision, writing review were performed by ZOY, Data platform support, access to funds were performed by QL, Data collation and proofreading were performed by JRY, Data survey, video shooting were performed by LXY, Data collation and proofreading, data platform information supplement were performed by YD, Resource provision were performed by JY, PG, Methodology, project management and supervision were performed by YYL, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

Partial financial support was received from the university-level research fund, which provided 10,000 CNY to cover expert consultation fees, meeting expenses, materials, and video production costs. The research leading to these results received funding from the Changsha Natural Science Foundation (2022) under Grant Agreement No. kq2208189, with partial support amounting to 20,000 CNY for meeting expenses, travel costs, and video production fees. This study was funded by the university-level research fund and partially supported by the 2022 Changsha Natural Science Foundation project. This work was supported by the university-level research fund (10,000 CNY) and the 2022 Changsha Natural Science Foundation (Grant Number kq2208189, 20,000 CNY).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of Affiliated Hospital of Hunan Academy of Traditional Chinese Medicine (No. 2024 [176]).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Competing interests

The authors declare no competing interests.