Free Health Essays - Exercise Breast Cancer
Exercise Benefits On Shoulder Function of Breast Cancer Survivors
Introduction
Breast cancer is a very prevalent disease in women in North America however early detection and diagnosis has become more frequent. Previously doctors would not counsel patients to exercise they would send them home from surgery and adjuvant therapy with a list of activities to avoid and tell them to continue with activities of daily living (ADL). Traditionally doctors advised patients to avoid repetitive and strenuous activities with the upper body (Bicergo, D., & Brown, K., 2006). Many cancer survivors would report declines in physical functioning, including basic body mobility and in leisure activities (Bennett, J., et al., 2006).
Since survival rate is increasing doctors are recognizing how exercise can improve functional capacity, increase muscle strength and fight fatigue that is often experienced by cancer patients after treatment (Matheson, G., May 2000).
Physical exercise has been identified as a central element of rehabilitation for many chronic diseases and has been successful in improving the quality of life and reducing mortality (McNeely, M., et al., 2006). Evidence recently seen suggests that moderate levels of physical activity may reduce the risk of reoccurrence of breast cancer (McNeely, M., et al., 2006). One study that was funded by the National Institute of Health reported that exercise after breast cancer treatment would help increase the chances for survival and reduce the risk of the cancer coming back (Holmes et al., 2005).
Also the psychological impact on the individual is very important and is most beneficial if the exercise is enjoyable, develops new skills, incorporates social interaction, and takes place in an environment that engages mind and spirit (Courneya, K., et al., 2002).
Recently doctors are looking at aerobic training to help improve survivors physiologically and psychologically. Some researchers have looked into dragon boating, which is considered an appropriate activity for breast cancer survivors because it is non weight bearing, relatively safe, strenuous and repetitive upper body activity (Sabistron, C., et al., 2004).
There have been numerous studies done on breast cancer and quality of life. However more research needs to be done on exercise benefits, shoulder function and with resistance exercise because most are done with aerobic training (McNeely, M., et al., 2006). As Dr. McKenzie states he “feels that cancer rehabilitation is where cardiac rehabilitation was 25 years ago” (Matheson, G., May 2000). Present research is not clear on the “correct” exercise prescription, more research needs to be done (Matheson, G., May 2000).
Breast Cancer
General Information
Breast cancer is the most frequently diagnosed cancer in Canadian women.
One in every nine women in Canada will develop breast cancer in their lifetime and one in twenty-seven will die (Ward, A., 2007). Therefore health care professions need to know guidelines and precautions for exercising after breast cancer (Courneya, K., et al., 2002).
Breast cancer starts in the cells of the breast. Each breast consists of glands, ducts and fatty tissue (Canadian Cancer Society, 2007). Cancer cells may start within the ducts this is called ductal carcinoma or in the lobules called lobular carcinoma (Canadian Cancer Society, 2007). Ductal carcinoma is the most common type of cancer (Canadian Cancer Society, 2007).
There is no single cause of breast cancer but some factors may increase the risk of developing it: age, risk increases with increasing age; a woman who has had breast cancer in one breast has increased risk of getting cancer again; family history of breast cancer; family history of ovarian cancer; never having given birth or giving birth for the first time after age 30; beginning menstruation at a young age; reaching menopause later than average; taking hormone replacement therapy for more than 5 years and a history of breast biopsies showing certain breast changes such as increased number of abnormal cells which are not cancerous (Canadian Cancer Society, 2007). Other possible risk factors are smoking, diet, drinking alcohol, taking oral contraceptives, physical inactivity and obesity (Canadian Cancer Society, 2007).
To diagnose breast cancer a diagnostic mammogram will be done to determine how big and the tissues involved (Canadian Cancer Society, 2007). A biopsy is usually necessary to make definite diagnosis of cancer. Cells are removed from the body and checked under a microscope (Canadian Cancer Society, 2007). If the cells are cancerous, they need to be studied further to see how fast they are growing determining what stage of breast cancer (Canadian Cancer Society, 2007).
Once diagnosis has been accomplished the doctors will determine the stage of breast cancer. The stage describes the tumour size and tells if the cancer has spread beyond the breast or into the lymph nodes (Canadian Cancer Society, 2007). Early stage breast cancers are Stage I the tumour size is 2 cm or smaller and the cancer has not spread outside of the breast and Stage II the tumour is 2-5 cm. There is no lymph node involvement in either of these stages (Canadian Cancer Society, 2007). Early stage breast cancer such as stage I and II have an excellent prognosis with a five year survival rate of over 90 percent.
Currently, there are over two million women in North America who are breast cancer survivors (Ward, A., 2007). The death rates of breast cancer are declining over recent years because of early detection and more advanced treatment options (Battaglini, C., et al., 2006). Since many women are now surviving breast cancer but they are still receiving little informed advice on what kind of exercises or activities they are allowed or should do (Kent, H., 1996).
Many women experience secondary complications after surgery and treatment, such as quality of life (QOL), weight gain, sleep disturbances, poor body image, fatigue, increased risk of osteoporosis, cardiovascular disease, premature menopause, decreased strength of the upper extremities and decreased shoulder mobility (Bicergo, D., et al., 2006). Recommendations with regard to physical activity are generally conservative and direct patients as to what they can or cannot do rather than what they can or should be doing (McKenzie, D., 1998). Since researchers do not have enough information to go on about exercise prescription the doctors tend to be cautious when advising patients (Kent, H., 1996). However rehabilitation goals are to get women back to activity and work following treatment “without fear” (Kent, H., 1996).
Mastectomy Surgery
Mastectomy surgery is surgical removal of the breast (Whelan, T., et al., 1999). The entire breast will be removed, some lymph nodes under the arm may be removed to determine if cancer has spread which is called axillary dissection (Whelan, T., et al., 1999). From the surgery there is a healing scar that runs across the chest and a drain is inserted near the scar under the arm to remove excess fluid (Whelan, T., et al., 1999). After the surgery you may have some pain or nausea, or may not feel like eating (Canadian Cancer Society, 2007). From treatment arm morbidity must be monitored which has a negative impact on quality of life (Kwan, W., et al., 2002).
Effects to body
Post surgery involves management of treatment related morbidities which include poor upper extremity function (Westrup, J., et al., 2005). These effects to the body interfere with the patient's ability to maintain functional independence (Westrup, J., et al., 2005). One study showed that 54% of women reported a decline in upper body function over the follow up period after treatment (Westrup, J., et al., 2005). Depending on the type of cancer and treatment the effects may be acute or chronic (Battaglini, C., et al., 2006).
Frequently results in decreased strength and range of motion of the affected shoulder and arm (Ward, A., 2007). Impaired shoulder range of motion (ROM), and muscular endurance are common side effects of treatment that regularly leads to a decreased of QOL (Sprod, L., et al., 2005). This makes simple tasks such as pulling an object off of a shelf or reaching overhead difficult (Sprod, L., et al., 2005). Other side effects may include fatigue, nausea, pain, difficulty sleeping, lowered self-concept, anxiety and depression (Ward, A., 2007).
Tight muscles due to the surgery and treatment can compromise shoulder function. Pectoralis minor and major muscles and the clavipectoral fascia result in fibrotic changes from surgery and therapy (Levangie, P., & Humphrey, E., 2000). By having the pectoralis minor muscle tight the scapula are protracted and anteriorly tipped, as well as showing limitations in retraction, elevation and upward rotation.
Tightness of the pectoralis minor muscle and the changes in scapular position can change the position of the acromion, narrow the suprahumeral space, and increase the chance of impingement (Levangie, P., & Humphrey, E., 2000). With the involvement of clavipectoral fascia since it surrounds the pectoralis muscles and attaches to the clavicle and coracoid process it may lack extensibility and could restrict clavicular motion (Levangie, P., & Humphrey, E., 2000).
Effects to the body from surgery often includes numbness and discomfort on the inside of the arm where nerves were cut and pain, discomfort or numbness of the chest (Whelan, T., et al., 1999). Sometimes stiffness of the shoulder, and collection of fluid in the scar that may need to be drained is seen after surgery. Rarely after a mastectomy is infection or arm swelling a result (Whelan, T., et al., 1999).
Shoulder Function
Range of Motion - Normal
Scapulothoracic (ST) joint consists of the scapula and thorax. The position and motion of the ST joint needs to be understood to show how the glenoid fossa moves to receive the rotating humeral head and how the scapula moves to maintain the proper length tension in the muscles that move the humerus (Levangie, P., & Humphrey, E., 2000). The scapula is attached to the thorax anatomically by the articulation between the acromion of the scapula and the lateral end of the clavicle and by the articulation between the clavicle and the manubrium of the sternum (Levangie, P., & Humphrey, E., 2000).
The ST joint is capable of motions such as elevation, depression, protraction, retraction, upward and downward rotation (Levangie, P., & Humphrey, E., 2000). The ST joint contributes to elevation by upwardly rotating the glenoid fossa. The trapezius and serratus anterior muscles make important contributions to producing the upward rotation of the scapula that is required for flexion and abduction of the shoulder (Levangie, P., & Humphrey, E., 2000).
The ST joint needs to achieve 60 degrees of contribution to get normal elevation of the shoulder (Levangie, P., & Humphrey, E., 2000). The acromioclavicular (AC) joints mobility allows for anterior and posterior tipping and medial and lateral rotation of the scapula to maintain appropriate contact of the scapula on the thorax (Levangie, P., & Humphrey, E., 2000).
The glenohumeral (GH) joint is the articulation of the humeral head with the smaller glenoid fossa. The glenoid labrum increases the depth of the glenoid fossa (Levangie, P., & Humphrey, E., 2000). The supraspinatus, infraspinatus, teres minor and subscapularis muscles work during active flexion, and abduction of the GH joint to offset the upward pull of the deltoid muscle, stabilize the GH joint, and change the rotary force of the deltoid (Levangie, P., & Humphrey, E., 2000).
The supraspinatus muscle may be called upon to assist with limiting inferior translation of the humeral head by gravitational forces. The infraspinatus and teres minor muscles make an additional contribution to GH abduction by providing the lateral rotation necessary to clear the greater tubercle (Levangie, P., & Humphrey, E., 2000).
As a result of the multi-dimensional roles of supraspinatus, infraspinatus, teres minor and subscapularis muscles chronic overuse results in degenerative changes that increase with age even if such changes are not symptomatic (Levangie, P., & Humphrey, E., 2000). The supraspinatus muscle is particularly vulnerable because it is either active or passively stretched during a large potion of a person's waking hours (Levangie, P., & Humphrey, E., 2000).
The GH joint consists of normal ranges of motion at these movements:
Shoulder abduction 170-180 degrees
Shoulder flexion 160-180 degrees
Shoulder extension 50-60 degrees
Lateral or external rotation 80-90 degrees
Medial or internal rotation 60-100 degrees
Shoulder adduction 50-70 degrees
Horizontal abduction/adduction 130 degrees and
Upward/downward rotation of the scapula
These ranges of motion can be measured with a goniometer. Ranges of motion need to be determined in active, passive and resisted testing.
Active range of motion is the patient actually doing the movement themselves and determining when pain is present.
Passive range of motion is when the therapist takes the patient into the range and therapist gets an end feel (Anderson, M., et al., 2005). A normal end feel for shoulder flexion, extension, lateral rotation, medial rotation, and horizontal abduction is tissue stretch; adduction is tissue approximation; horizontal adduction can be tissue stretch or approximation; and shoulder abduction is bone to bone or tissue stretch (Anderson, M., et al., 2005). Resisted testing is when the shoulder is put in midrange of action and therapist resists the motion. This is graded between 1-5, a 5 is full strength.
Activities of Daily Living - Normal
The shoulder complex plays an important role in the activities of daily living (ADL) (Magee, D., 2006). Limitation of function can greatly affect the patient. For example, placing the hand behind the head to comb their hair requires full lateral rotation (Magee, D., 2006). The functional assessment may be based on activities of daily living, work, or recreation, because these activities are of most concern to the patient.
ADL can be divided into two groups: basic and instrumental. Basic items are eating, bathing, dressing, transferring from bed to chair and walking across a room. Instrumental items are house keeping, grocery shopping, making food and driving (Kell, R., et al., 2001). ROM is necessary for good mobility, coordination and ADL (Kell, R., et al., 2001).
Benefits of Free Weight Training
General Information
In healthy women resistance training programs increase metabolism, improve muscular endurance and coordination, increase muscular strength and promote the development of lean body tissue (Battaglini, C., et al., 2006). Weight training may be beneficial for survivors for several reasons, it has been shown to positively affect chronic disease risk factors and increase a sense of control over their lives during the waiting period of 5 years (Ohira, T., et al., 2005).
Studies that are requiring exercise to be measured are done after recovery from surgery or treatment due to the fact that women are too tired and researchers do not want to measure exercise levels at that time because results may be skewed (Holmes, M., et al., 2005).
Researchers from Harvard Medical School determined that exercise would increase the chances of survival as well as reduce the risk of cancer coming back (Holmes, M., et al., 2005). However regular participation in exercise needs to be done to receive benefits (Courneya, K., Blanchard, C., & Laing, D., 2001).
In the Ohira study done in 2005 physiological and psychological benefits were little to unknown in weight training for breast cancer survivors at that time not many studies looked at weight training (Ohira, T., et al., 2005). Resistance training was not part of the exercises and rehabilitation guidelines for the ASCM before 1990; this was when it was first recognized as a significant component for healthy adults (Pollock, M., et al., 2000). In the study “Exercise for Breast Cancer Survivors” by Courneya, K., et al they looked at research evidence and clinical guidelines for exercise recommendations for healthy breast cancer survivors (Courneya, K., et al., 2002). Resistance training is best done if they mimic everyday activity, they should be done at a moderate to slow controlled speed, through the full ROM and proper technique (Pollock, M., et al., 1998).
Musculoskeletal system
The musculoskeletal system consists of three components; muscular
strength, endurance and flexibility (Kell, R., et al., 2001). Muscular endurance is the ability of a muscle to perform repeated contractions against a load for an extended period of time (Kell, R., et al., 2001).
Weight training exercise can help reverse muscle atrophy and activate skeletal muscle (McKenzie, D., 1998). Muscle fiber hypertrophy has been shown to require 16 or more workouts before individuals show significant benefits and effects (Kravitz, L., 1996). Exercise encourages skeletal muscle contractions to provide the primary pumping mechanism for lymphatic and venous drainage (Bicergo, D., Brown, K., et al., 2006).
Routine physical activity can improve musculoskeletal fitness and evidence suggests that enhanced musculoskeletal fitness is associated with improvement in overall health status and a reduction in the risk of chronic disease and disability (Warburton, D., et al., 2006). Many ADL do not require a large amount of aerobic activity but depend on musculoskeletal components (Warburton, D., et al., 2006).
With musculoskletal fitness declining an individual may lose the capacity to perform daily activities such as reaching up into a cupboard for a glass (Warburton, D., et al., 2006). This signifies a cycling of decline, where reduced musculoskeletal fitness leads to inactivity and further dependence (Warburton, D., et al., 2006). Enhanced musculoskeletal fitness is positively associated with functional independence, mobility, glucose homeostasis, bone health, psychological well being and overall QOL (Warburton, D., et al., 2006). In Ohira's study of weight training in breast cancer survivors showed improvements in lean muscle mass and upper body strength (Ohira., et al., 2005).
ACSM made the following guidelines for the amount and kind of training for muscular endurance and strength (Pollock, M., et al., 1998). Resistance training should consist of a program that progresses, is designed specifically for each person and provide work for all muscle groups (Pollock, M., et al., 1998). For the amount of work that should be done it is recommended one set, 10-15 repetitions of 8-10 exercises is sufficient 2-3 times a week, however if multiple sets can be done greater benefits will be seen (Pollock, M., et al., 1998).
Cardiovascular system
Resistance training has been shown to modify the myocardium which results in positive changes in heart rate, stroke volume and cardiac output (Kell, R., et al., 2001). The increase in heart rate is associated with an increased sympathetic stimulation at the start of exercise (Kell, R., et al., 2001). Moderate intensities, 40-60% of 1 repetition maximum of resistance training exhibit the largest increases in heart rate response, while at higher intensities of 1 repetition maximum the heart response is increased but not as much (Kell, R., et al., 2001). Research also indicates a small to moderate increase in cardiac output during endurance strength training (Kell, R., et al., 2001).
Herrero states in his study that, “increased muscle mass and strength induced by resistance training result in an attenuated cardiovascular stress response to any given load because the load now represents a lower percentage of the maximal voluntary contraction” (Herrero, F., et al., 2005).
Quality of Life
The study funded by the National Institutes of Health showed that exercising after breast cancer treatment would increase women's chances of survival, as well as reduce the risk of cancer coming back (Holmes, M., et al., 2005).
In the WTBS study conducted by Ohira et al which was the first randomized study performed to evaluate the effects of weight training on depression and QOL among breast cancer survivors (Ohira, T., et al., 2005). Through improvements in physical strength and muscle mass, the results of the study showed that weight training had beneficial effects on physical and psychosocial QOL scores (Ohira, T., et al., 2005).
Performing upper body exercises such as resistance training are not necessarily contraindicated. Recent research has shown that earlier concerns about vigorous activity may be false (Courneya, K., et al., 2002).
Range of motion of shoulder
Resistance exercises can help women regain their normal range of shoulder and arm movement and may help to prevent lymphedema by pumping lymph fluid out of the arm through the undamaged lymph vessels (Ward, A., 2007).
Resistance training exercises should be done through out the full range of motion for maximum benefit (Pollock, M., et al., 1998).
Muscular Strength
Resistance exercises performed at a moderate to high intensity 2-3 times a week for three to six months improves muscular endurance and strength in women of all ages by 25-100% depending on the activity and how the individual's fitness is starting (Pollock, M., et al., 2000). In the first few weeks of training, changes in strength are associated with neural adaptations, which create more efficient neural pathways to the muscle (Kravitz, L., 1996).
A lack of peak muscle power due to the muscle wasting phenomenon associated with treatment and the sedentary lifestyle has the inability to reach actual maximal heart rate levels and could also reflect decreased physical fitness (Herraro, F., et al., 2006). In the study performed by Herrero F et al called Cancer and Exercise had important findings is training for power. Training improved peak absolute power and power expressed relative to body mass which is important to perform daily activities and improve individuals sense of independence and emotional well being (Herrero, F., et al., 2005).
Benefits of Aerobic Training
General Information
To optimize the benefits of aerobic training, a General Aerobic Exercise
Recommendations for Cancer Survivors were produced by the American College of Sports Medicine (ACSM) shown below (Courneya, K., et al., 2002). A recommended frequency is 3-5 days per week, with a maximal heart rate of 55-65%, or 50-75% of heart rate reserve (Pollock, M. et al., 1998). The duration of training is suggested between 20-60 minutes of continuous or intermittent exercise depending on training level and activity (Pollock, M. et al., 1998). Activities that are acceptable include walking, hiking, running, jogging, cycling, cross country skiing, aerobic dance, rope skipping, rowing, stair climbing, swimming, skating, team sports and/or combined activities (Pollock, M. et al., 1998).
Cardiorespiratory exercise is beneficial psychologically as well as physiologically for cancer rehabilitation (Sprod, L., et al., 2005). Such aerobic programs have shown to decrease psychological distress, improve mood states, improve body image, increase functional capacity, decrease fatigue, prevent weight gain, and improve quality of life (Sprod, L., et al., 2005). Regular aerobic activity has been found to improve vascular function and results in a shear stress mediated improvement in endothelial function which is a health benefit to a number of disease states (Warburton, D., et al., 2006).
Regular participation in aerobic training will show benefits but adherences to programs need to be made (Courneya, K., et al., 2001).
Cardiovascular system
The best indicator of cardiorespiratory fitness is peak oxygen uptake (VO2peak). VO2peak is an exceptional indicator of health status and an independent predictor of mortality in both healthy and unhealthy individuals (Herrero, F., et al., 2005). In cancer survivors training improvements in maximal cardiorespiratory capacity are commonly estimated through indirect variables, such as maximal walking or the distance covered during a treadmill test (Herrero, F., et al., 2005).
VO2peak achieved during a graded maximal exercise is considered the single best indicator of aerobic physical fitness (Herrero, F., et al., 2005). When VO2peak is expressed relative to body mass, it is an indicator of health status and predictor of mortality (Herrero, F., et al., 2005).
Cardiorespiratory fitness such as peak oxygen uptake (VO2peak) can be lower by 50% in survivors of cancer. The main reasons for the decline are the sedentary lifestyle during illness and treatment and the long term effects of chronic fatigue (Herrero, F., et al., 2006). VO2peak is considered by the World Health Organization as a key indicator of aerobic physical fitness (Herrero, F., et al, 2006).
Few studies have assessed VO2peak in survivors of cancer and less data available concerning cardiorespiratory fitness (Herrero, F., et al., 2006). Diseased or deconditioned individuals fail to stress their cardiorespiratory system maximally, demonstrating a “plateau phenomenon” in VO2 values, because of the unpleasant symptoms of exhaustion, dyspnea and/or pain. This often results in testing ending early and an underestimation of VO2 maximal values (Herrero, F., et al., 2006).
Quality of Life
Walking is the natural choice of most survivors and has direct implications for activities of daily living (Courneya, K., et al., 2002). Cycle ergometry offers many advantages that include a sitting position and leg exercise that minimize the effects of ataxia, cognitive impairment, limitations in upper body movement and arm lymphedema (Courneya, K., et al., 2002). Any aerobic fitness activity that meets the ACSM guidelines should be reasonable after breast cancer (Courneya, K., et al., 2002).
Purpose and Hypothesis statement
To date, many studies (Sprod, et al, 2005; Courneya, K., 2001; Herrero, F., 2006) have been reported on aerobic training and shoulder function of breast cancer survivors. Other studies have looked at aerobic and resistance training such as Ohira, T., et al (2006) but strictly on quality of life and depressive symptoms. Even though this study did report benefits of exercise on quality of life, we are unsure of the effects on shoulder mobility and muscular endurance with free weight training.
Therefore the purpose of this study is to evaluate shoulder function by testing range of motion and muscular endurance using a free weight training, aerobic training and untrained (control) groups of breast cancer survivors. It could be hypothesized that free weight training of the upper quadrant will improve shoulder mobility and muscular endurance in breast cancer survivors.
Methods
Study group
Sixty female subjects between the ages of 35-60 years old will be recruited from the Juravinski Cancer Centre in Hamilton, Ontario. They will be breast cancer survivors who had early stage breast cancer either Stage I or II, had mastectomy surgery and adjuvant therapy. The women will have completed their therapy 3-6 months prior and have been discharged by their doctor and been told they are cancer free and “healthy”. They have been discharged from all cancer treatment and are not doing anything for rehabilitation.
The patients will receive detailed written information about the study and receive an informed consent form if they are willing to participate (see Appendix A). Must fill out a health and physical activity questionnaire prior to admission. (see Appendix B)
Inclusion criteria is as follows: filling out a quality of life questionnaire (QLQ C-30), health questionnaire, be cancer free, post treatment discharged from all cancer related treatment, postmenopausal, have a decreased range of motion (ROM) in the affected shoulder and have a decreased quality of life.
Exclusion criteria is as follows: cardiovascular problems, heart disease, diabetes, full range of motion of the affected shoulder, uncontrolled hypertension, uncontrolled pain or any other condition that contraindicates exercise.
Design
The study is a randomized, single blinded, exercise intervention controlled study. The randomization procedure will take place after the baseline examination is completed and eligibility is determined. The treatment assignment will be done by a researcher who will not have anything to do with the study procedure; they randomly placed the 60 participants by computer allocation. The 60 participants will then be placed into the three intervention groups, free weight (FW), aerobic exercise (AE) and untrained (UT), 20 women in each.
The athletic therapist for each group will stay with that group throughout the 26 weeks. The exercise group will participate in the gym, the aerobic training group will participate in the local lake and the untrained group will do their protocol at home. Each group, FW, AE, and UT will not meet and will not discuss or compare the exercise interventions. All participants will participate in a dynamic flexibility program before any of the group activities. ( see Appendix E)
Exercise Interventions
All groups will participate in the study for 26 continuous weeks. They will all participate three times a week and this will help with the training effect. For all women dynamic flexibility will be addressed pre exercise, QOL will be assessed, muscular endurance and ROM. Common factors in the two exercise groups will be time, frequency, ROM of shoulder joint, QOL of patient, muscular endurance and dynamic flexibility.
In the free weight training group, they will perform 26 weeks of training supervised by the therapist to ensure participants are performing proper technique. They will not participate in other training programs during the study.
All exercise sessions were conducted at the local gym. These women will meet three times a week for one hour for 26 weeks. The rest period between sets will be 30 to 60 sec at 50-70% of 1RM. All the subjects assigned to the free weight training group will perform exercises at sub maximal levels at 50-70% of their predicted maximum strength. These weights used are obtained from the baseline assessment.
The movements for each exercise should be performed at a moderate speed, three seconds for concentric phase and three seconds for the eccentric phase of movement during each repetition for each exercise (Battaglini, C., et al., 2007). Since there is such a large age range for participation in the study and lack of specific guidelines for exercise among cancer patients, the above guidelines are thought to be appropriate based on the ASCM guidelines (Pollock, M., et al., 1998).
However, we know that muscular endurance will show improvements between 3 and 6 months using this type of protocol (Pollock, M., et al., 2000). The eight common weight training exercises that will be performed in this order using free weights are bench press, overhead press, lateral dumbbell raise and forward flexion, bicep curls, dumbbell row, dumbbell extension, and external rotation of the shoulder. (See APPENDIX F) Every day of participation the women will follow the same order of exercises and protocols.
Safe and effective execution of all exercises in the protocol need to be done and to ensure this the therapists will be present at all exercise dates (Ohira, T., et al., 2006).
In the aerobic exercise group they will be performing dragon boat paddling. McKenzie (1998) has researched the benefits and appropriateness of dragon boating on breast cancer survivors. It is a strenuous, repetitive upper body activity that projects a visible message to all people with breast cancer (McKenzie, D., 1996). It is non weight bearing, is associated with a lower risk of injury than a weight bearing activity such as running.
It is safe as long as proper technique is accomplished and with proper technique the paddler can recruit a reasonable amount of muscle mass and induce positive adaptations in the musculoskeletal and cardiovascular systems (McKenzie, D., 1996). The improvement in strength can carry over to everyday activity (McKenzie, D., 1996).
The training intensity can be varied simply by pulling harder (McKenzie, D). The individuals will be performing this exercise at 60-80% HR max, three times a week for one hour for 26 weeks. The women will work for 90 sec and rest for 30-45 sec. This exercise will be focusing on technique as well as keeping HR within the range prescribed.
The untrained group of patients assigned will receive a leaflet flyer with advice and simple exercises for the arm/shoulder for the first weeks/months following surgery and have no further contact with the therapist (Beurskens, C., et al., 2007). This group will continue with their protocol at home, they will come in for testing like the other groups but will not have any intervention with their therapist.
Baseline characteristics and Exercise Tests
The QOL Questionnaire - We will be using the European Organization for Research and Treatment of Cancer (EORTC) QOL Questionnaire (QLQ C-30). It is a validated instrument commonly used to assess the QOL of cancer survivor patients. It consists of five functional scales (physical, role, cognitive, emotional and social), three symptom scales, and a global QOL scale. The scores from the global QOL and the functional subscales are used to compare the QOL of various groups in the study (Herrero, F., et al., 2006). The questionnaire includes 30 items relating to physical, social, emotional, and cognitive functioning and a global scale of QOL (Herrero, F., et al., 2006). (See APPENDIX C)
This test will be performed at baseline and at all other testing points. The QOL questionnaire scoring will be added and averaged and later graphed to show comparisons between groups.
ROM in degrees: A goniometer will be used to measure testing in all active ranges of motion of the shoulder. ROM measures include flexion, extension, abduction, adduction, external rotation and internal rotation of the shoulder joint. (See APPENDIX G) This test will be performed at baseline and at all other testing points. The ranges of motion will be averaged from participants and graphed showing results.
Activities of Daily Living - objective test of can they do it or not: pulling sweater over head, fastening a bra, doing up a zipper, reaching for a glass in the cupboard overhead, lifting groceries and putting on their seatbelt. This test will be included in the health questionnaire. This test will be performed first within the health questionnaire and in later testing by itself. (see Appendix D)
Muscular endurance - A one repetition maximal (1 RM) lift is determined, once determined take 50-70% of the weight to determine what they will be doing in training. This is a submaximal test. By using the 1RM chart determine weight and then calculate 50-70% of 1RM to perform activities. (See APPENDIX H)
This test will be performed at baseline testing to determine weight to be lifted and at testing points to determine muscular endurance. In testing the patient will perform as many repetitions as she can. This will be added from each, average and graphed.
Outcome Assessments
Baseline will be performed at the time of inclusion, at 3 months (13 weeks), and 6 months (26 weeks).
Expected Outcomes
Outcomes if hypothesis supported
Subjects in the free weight training group will have improved range of motion and muscular endurance in the shoulder joint, which results in better quality of life. (Figure inserted - graph with quality of life and another graph with ROM and muscular endurance) This means that an exercise program with free weights is more effective on range of motion and muscular endurance then the aerobic exercise group and the untrained group.
Outcomes if hypothesis not supported
The expected outcomes if the hypothesis is not supported could be:
subjects in the free weight training group and aerobic exercise group will show no differences in range of motion , aerobic exercise will have improved range of motion than the free weight training group, free weight training group, aerobic exercise group and untrained group will all have the same results, or Untrained group will have better results than the free weight training group. The hypothesis is not supported due to the following reasons.
The aerobic exercise group will get the same range of motion in the shoulder joint as free weights provide, the endurance of paddling is more effective than performing weights at the selected repetitions and frequency. If there were no differences between the groups it may indicate that no matter what activity you do range of motion can be improved which will increase the individuals quality of life due to the fact something of benefit occurred. Generally a positive correlation between improvement in range of motion and muscular endurance with a women's quality of life.
Limitations of the study may be the study size it may be too small to provide accurate results, the age range may be too great of a range to determine what could occur in the overall population of breast cancer survivors, the breast cancer stage and surgery may have been inappropriate, free weight training exercises could have been varied or made more functional, the order of exercises that we did in the study may be incorrect creating some exercises to be harder than others, the technique of the exercises may have been improper, the lack of focus on whole body exercise may have altered potential results, since everyday activity does not include just the upper body and finally testing times may be too soon or delayed to show greatest changes of range of motion and muscular endurance.
References
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Appendix
(will include at end)
Appendix A - Informed Consent Form
Appendix B - Health/Physical Questionnaire
Appendix C - QLQ C - 30 QOL Questionnaire
Appendix D - ADL
Appendix E - Dynamic Flexibility Exercises
Appendix F - Free Weight Exercises
Appendix G - Goniometer to assess ROM and shoulder movements
Appendix H - 1 RM Chart
