F. Herrero1, 2 A. F. San Juan1 S. J. Fleck3 C. Foster4 A.

Lucia1

Effects of Detraining on the Functional Capacity of Previously Trained Breast Cancer Survivors
Clinical Sciences

Abstract
The purpose of this study was to assess the effects of a relatively short (8-weeks) period of detraining on cardiorespiratory capacity, dynamic strength endurance, task specific functional muscle capacity and quality of life (QOL) of breast cancer survivors who had previously undergone a combined supervised (aerobic and resistance) training program. Eleven women survivors of stage I II ductal breast carcinoma (47 7 yrs) entered the study and performed a battery of tests (including anthropometric evaluation, a graded cycle ergometer test, tests of strength endurance [leg and bench press] and the sit-stand test) and completed a specific QOL questionnaire (EORTC-C30) at three time points: i) before, ii) after an exercise program (including aerobic and resistance exercises) of 8-weeks duration, and iii) after a subsequent 8-weeks period of training cessation. Training-induced improvements in strength endurance, muscle functional ca-

Key words O2peak exercise disease resistance quality of life sit-stand V test
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Introduction
Numerous studies have reported the beneficial effects of aerobic exercise training on the physical work capacity of cancer patients and/or survivors [5, 22]. Results from these reports consistently show an improvement in functional capacity after training. Due to the high incidence and good survival rate of breast cancer patients, many investigations have evaluated breast cancer patients and survivors [5]. Fewer controlled studies [13, 26, 31] have evaluated the effects of concurrent resistance and aerobic training in cancer patients/survivors. Resistance exercise should

be an integral component of any exercise training program for cancer patients/survivors, as it attenuates the muscle atrophy induced by both treatment and sedentary living habits in cancer patients/survivors and also contributes to an improved overall physical capacity. We recently reported significant improvements in several indicators of functional capacity (i.e., peak oxy O2peak]), dynamic strength endurance, task specific gen uptake [V functional muscle capacity (i.e., performance in the sit-stand test) and quality of life (QOL) in survivors of breast cancer after a short-term (8 weeks), prescribed training program, including both resistance and endurance exercise [13].

Affiliation Universidad Europea de Madrid, Madrid, Spain 2 Gabinete Mdico Deportivo del Ayuntamiento de Miranda de Ebro, Burgos, Spain 3 Sport Science Department, Colorado College, Colorado Springs, CO, USA 4 Department of Exercise and Sport Science, University of Wisconsin La Crosse, La Crosse, WI, USA
1

Correspondence n 28670 Madrid Spain Alejandro Luca, MD, PhD Universidad Europea de Madrid Villaviciosa de Odo Phone: + 34 9 16 6478 00 Fax: + 34 916 16 82 65 E-mail: alejandro.lucia@uem.es Accepted after revision: April 21, 2006 Bibliography Int J Sports Med 2007; 28: 257 264 Georg Thieme Verlag KG Stuttgart New York DOI 10.1055/s-2006-924348 Published online November 16, 2006 ISSN 0172-4622

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pacity (sit-stand test) and QOL were not significantly changed after detraining (p > 0.05 for post-training vs. detraining comparisons). The lack of significant loss in muscle strength endurance occurred despite significant losses in estimated total muscle mass after detraining (27.3 2.4 kg) compared with post-training (28.5 2.9 kg). In contrast, cardiorespiratory ca O2peak of pacity was significantly decreased during detraining (V 29.0 4.6 vs. 22.7 3.9 ml kg 1 min1 at post-training vs. detraining, p < 0.01). In conclusion, cancer survivors who have participated in a combined training program can retain some of the training gains (particularly improved QOL and muscle strength endurance/functional performance) after a relatively short duration detraining period.

To our knowledge, no longitudinal investigation has assessed the magnitude of functional capacity loss of previously trained cancer patients/survivors after a period of training cessation (i.e., detraining). This research approach would allow answering, at least partly, several questions of practical applicability, namely: How fast does detraining occur in this population? Which of the com O2peak, muscle strength, etc.) is (are) mon fitness indices (i.e., V more affected by the detraining process? And, to what extent is the training-induced improvement in QOL affected by training cessation? These are important questions as it is unrealistic to assume that previously sedentary subjects who enroll in a scientific study including supervised, individualized training will continue with a similar training program after completing participation in the study. Accordingly, it was the purpose of this study to assess the effects of an 8-week detraining period on cardiorespiratory capacity, dynamic strength endurance, task specific functional muscle capacity (i.e., performance in the sit-stand test) and QOL of breast cancer survivors who have previously undergone an 8-week combined (aerobic and resistance) supervised training program.

Table 1 Stage of disease and treatment protocol (with respect to surgery and chemotherapy) of the 11 study subjects
Subject number Stage of disease Type of surgery Chemotherapy protocol CFM CFM CFM CFM A + CFM CFM CFM CFM CFM CFM CFM Time posttreatment (months) 24 30 58 36 50 24 24 45 24 31 36

1 2 3 4 5 6 7 8 9 10 11

I I I II II II II II I II I

Lumpectomy Lumpectomy Lumpectomy Lumpectomy MRM MRM RM RM Lumpectomy Lumpectomy Lumpectomy

Methods
Subjects Before entering the study, informed consent was obtained from each participant and the study was approved by the local human investigations committee. A preliminary screening for subject selection was performed in the medical database of the Oncology department of Hospital Comarcal Santiago Apstol (Miranda de Ebro, Spain). A total of 40 subjects were contacted by telephone. Interested potential subjects underwent a preliminary medical examination and completed a lifestyle questionnaire prior to the start of the study. After consent of the attending oncologist, subjects were deemed eligible for the study if they met each of the following conditions: 1) postmenopausal women surviving breast cancer (2 to 5 years posttreatment; age range: 40 60 years); 2) physical activity level: walking than a total of 30 60 min1 two days week1 and performing no strenuous exercise such as running, cycling, swimming or resistance training; and 3) previous anticancer treatment consisting of surgery with axillary lymphadenectomy and both post-surgery radiotherapy and chemotherapy. Women were excluded from the study if they had cardiac disease (New York Heart Association II or greater), uncontrolled hypertension (blood pressure > 160/90 mmHg), uncontrolled pain, or any other condition that contraindicated exercise training in cancer patients or survivors [22], e.g., increased risk of bone fractures, severe anemia (< 8 g/dL) or a platelet count lower than 50 109/L. Women with lymphedema were also excluded. Eleven women entered the study. All were survivors of stage I II ductal breast carcinoma (Table 1). The mean ( SD) age, body mass and body mass index of the participants at the start of the study was: 47 7 yrs, 64.0 7.3 kg and 25.2 3.2 kg m2, respectively. Study design Cardiorespiratory exercise capacity, dynamic strength endurance, task specific functional muscle capacity (i.e., performance in the sit-stand test) and QOL were evaluated three times: (i) beHerrero F et al. Cancer and Detraining Int J Sports Med 2007; 28: 257 264

258

fore and (ii) after the 8-week training program that is described below, and (iii) after a subsequent 8-week period of training cessation. Testing at all three times was performed over four consecutive days. On the first day, blood samples were obtained from an antecubital vein to determine hematocrit and hemoglobin levels followed by the cardiorespiratory exercise test and the assessment of QOL using a questionnaire. Two days after the first test day, functional muscle performance was determined using a sitstand test. On the fourth day, dynamic upper and lower-body muscle dynamic strength endurance were measured on a bench and leg-press machine, respectively. This testing sequence allowed the effects of a short duration detraining period on the measured variables to be assessed. Intervention (I): training program Subjects followed an 8-week training program consisting of three weekly sessions of 90-min duration. The pre- and posttraining data of eight subjects have been previously published [13]. All sessions were performed in the same community fitness club and supervised by the same qualified personnel. Each session started and ended with a 10-min warm-up and cool-down period consisting of cycle ergometer pedalling at very light workloads and stretching exercises for all major muscle groups. The 70-min core portion of the training session was divided into resistance and aerobic training. Resistance training included 11 exercises engaging the major muscle groups (chest press, shoulder press, leg extension, leg curl, leg press, leg calf rise, abdominal crunch, low back extension, arm curl, arm extension, and lateral pull-down). All exercises were performed through the full range of motion normally associated with correct technique for each exercise. Stretching exercises of muscles involved in an exercise were performed at the end of each set of resistance exercises. During the first 4 weeks, subjects performed two and one set of exercises for large (e.g., leg press) and small muscle groups (e.g., arm extension), respectively, and all sets were performed at a resistance that allowed 12 15 repetitions. Thereafter, the re-

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All the subjects received radiotherapy. MRM: modified radical mastectomy; RM: radical mastectomy; CFM: cyclophosphamide, methotrexate, and 5-fluorouracil; A: adriamycin

sistance used was individually adjusted to allow the completion of 8 10 repetitions for three sets of the large muscle group exercises and two sets of the small muscle group exercises. The resistance used for each exercise was increased by 5 10% when the subject could perform the prescribed maximal repetitions per set. After an increase in resistance, the repetitions per set typically decreased to the low end of the prescribed repetition range (12 or 8 repetitions). Abdominal and lower back exercises were performed for 15 20 repetitions per set. The recovery period between i) sets of each resistance exercise, and ii) between each different type of resistance exercise gradually decreased from 90 to 60 s and from 60 to 30 s, respectively, from the start to the end of the training program. At the beginning of the program, aerobic training consisted of pedalling on a cycle ergometer for 20 min at 70% of the peak heart rate (HRpeak) observed during the pretraining cardiorespiratory test. The duration and intensity of the sessions was gradually increased during the 8-week period so the subjects completed 30 min of continuous pedalling at 80 % of HRpeak by the end of the training program. For subjects in the poorest physical condition it was sometimes necessary to divide the first aerobic training sessions into shorter time intervals in order to complete the total 20-min target duration (e.g., 2 bouts of 10 min). Blood total creatine kinase (CK) levels were measured every week to ensure that the training program did not induce excessive muscle damage, i.e., levels < 167 IU l1 [7]. Intervention (II): detraining period During the 8-week period following the above described training program, the subjects were instructed to follow their usual sedentary lifestyle (i.e., walking than a total of 30 60 min1 two days week 1 and performing no strenuous exercise, such as running, cycling, swimming or resistance training). Their physical activity levels were recorded by weekly interviewing to corroborate that they actually returned to a sedentary lifestyle. Testing procedures before and after the training period and after detraining On the first day of testing, blood samples were obtained from an antecubital vein (between 8:30 and 9:00 a. m.) to determine erythrocyte count, hematocrit and hemoglobin levels with a Sysmex NE-1500 (Sysmex Medical Electronics, Hamburg, Germany) hematology analyzer. After obtaining the blood sample, the exercise cardiorespiratory test was performed, followed by the assessment of QOL using a questionnaire developed by the European Organization for Research and Treatment of Cancer (EORTC): the EORTC QLQ-C30 [1, 9]. We used the third version (3.0), which has been shown to be valid and reliable when applied to Spanish cancer patients [3]. This questionnaire includes 30 items relating to physical, role, social, emotional, cognitive and functioning, and a global scale of QOL (maximum score of 100). For simplicity, we did report the results of the global scale and the six main items, e.g., physical functioning, role functioning, etc. All cardiorespiratory exercise tests were performed at the same time of the day (10:00 14:00 h) under similar environmental conditions (temperature 20 8C; relative humidity 45 55 %; barometric pressure 720 mmHg) on an electrically braked cycle

PPO = POf + ([t/60 10]) where POf is the power output (W) of the last completed workload, t is the time (in s) the last uncompleted workload was maintained, 60 is the duration (in s) of each completed workload, and 10 is the power output difference (W) between consecutive workloads. Heart rate and blood pressure were monitored during the tests using 12-lead ECG tracings and a manual pressure cuff. Peak heart rate (HRpeak) was recorded as the highest average value obtained for any continuous 20-second period. The workload eliciting the ventilatory threshold (VT) was determined using the criteria of an increase in both the ventilatory equivalent of oxy EV O21) and end-tidal pressure of oxygen (PetO2), with gen (V no increase in the ventilatory equivalent of carbon dioxide EV CO21) [23]. Two independent experienced observers de(V tected VT. If there was disagreement, we obtained the opinion of a third investigator. Forty-eight hours after the cardiorespiratory exercise test, functional muscle performance was determined using a sit-stand test [12]. For this test, we used a straight-backed chair (40 cm high) and asked each subject to sit and stand as fast as possible five times with their arms folded across their chest. The subject was timed from the initial sitting position to the final standing position at the end of the fifth stand by using a stopwatch to the nearest 0.01 s [11]. One day after the sit-stand test, dynamic upper and lower-body muscle dynamic strength endurance were measured on a bench and leg-press machine (Salter, Barcelona, Spain), with a load of 30 35 % and 100 110% of pretraining body mass, respectively. Each subject was instructed to perform each exercise to momentary muscular exhaustion. Any repetitions not performed with a full range of motion were not counted. Previous research has also used strength endurance tests to assess the dynamic muscle strength of healthy women and the physiological effects of resistance training [24, 25]. A warm-up period including aerobic
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ergometer (Variobike 600; Marquette Hellige; Freiburg, Germany). Subjects refrained from performing physical activity during the 24 h-period before the tests. After a warm-up period of 5 min with no load, power output was increased from an initial value of 20 W by 10 W min1. Subjects maintained pedal cadence within the range of 60 70 rev min1. The cadence monitor was placed in view of the subject during each test, and a designated investigator insured that they maintained the required pedalling cadence throughout the duration of the test. The tests were terminated upon volitional exhaustion and/or when cadence could not be maintained at a minimum of 60 rev min1. Respiratory gas-exchange data were measured breath-by-breath using open circuit spirometry (Oxycon Delta, Jaeger, Viasys Healthcare, Hoechberg, Germany). Volume calibration and calibration of the gas analyzers were performed automatically by the system before each test using a computer controlled explosive decompression device and both ambient and reference gases (15 % O2, 5.5 % CO2, respectively), as recommended by the manufacturer. Peak oxygen O2peak) and peak respiratory exchange ratio (RERpeak) uptake (V were recorded as the highest value obtained for any continuous 20-second period. The peak power output (PPO) was computed as follows [18]:

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Table 2 Individual values of subjects creatine kinase (CK) levels (IU l1) during the study
Subject number Pretraining 1 1 2 3 4 5 6 75 67 137 73 88 86 103 42 52 39 89 63 86 169 138 398 80 109 35 300 53 290 2 83 72 122 81 67 91 97 54 46 42 90 3 90 115 112 90 81 115 96 55 62 57 83 Training (weeks) 4 93 65 136 115 98 90 108 60 56 48 81 5 77 75 145 87 53 105 100 81 59 72 77 6 87 78 101 55 87 116 105 74 74 66 85 7 81 100 87 64 68 97 93 78 63 69 80 8 74 63 90 100 73 80 83 71 76 71 93
1

Posttraining

Detraining

83 47 57 105 85 81 112 64 104 63 106

75 58 68 92 68 61 124 81 86 99 97

and stretching exercises ( 10 min), and warm-up sets preceded each test. In an effort to eliminate anticipated learning effects and establish reliability of both sit-stand and dynamic strength endurance tests [11], before the start of the study the subjects performed: 1) three to four familiarization sessions with both types of tests over a 1-week period that were followed by, and 2) tests repeated on two consecutive days which showed significant (p < 0.001) intra-class correlation coefficients (r = 0.991, r = 1.00 and r = 0.991) and low coefficients of variation ( 1.6 %, 0.0% and 4.7 %) for sit-stand, bench and leg press tests, respectively.
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and VT), dynamic strength endurance (bench press, leg press), and performance in the sit-stand tests over time, i.e., pre-, post-, and detraining, respectively. The Tukey test was used post hoc when indicated by the ANOVA. The Friedman test was used to compare nonparametric variables (QOL [global scale and physical function]) over time, i.e., pre-, post-, and detraining, respectively. Data are expressed as mean SD and median and interquartile ranges for parametric and nonparametric variables, respectively. The level of significance was set at 0.05 for all statistical comparisons.

Body composition was assessed indirectly through changes in body mass and subcutaneous skinfolds. Skinfold measurements were made (in triplicate) by the same researcher at three sites (triceps, abdominal, and suprailiac) to estimate % body fat [15]. Total muscle mass (kg) was estimated from anthropometrical data following the prediction equation developed by Lee et al. [19] using multi-slice magnetic resonance imaging: muscle mass (kg) = height (m) (0.00744 CAG2 + 0.00088 CGT2 + 0.00441 CCG2) + 2.4 gender 0.048 age (yrs) + 7.8 where CAG is corrected arm girth, CTG is corrected thigh girth, CCG is corrected calf girth, and gender equals 1 for male and 0 for female. Limb girths were corrected for subcutaneous adipose tissue thickness as follows: the skinfold caliper measurement (S) was assumed to be twice the subcutaneous adipose tissue thickness, and the corrected girths (Gm) were calculated as Gm = limb girth S (in cm). Statistics In our longitudinal, interventional design, each subject served as her own control to assess the effects of detraining on previously trained cancer survivors. Accordingly, a repeated-measures ANOVA was used to compare mean values of body composition (body mass, fat mass and muscle mass, % body fat, % muscle mass); blood variables (hemoglobin, hematocrit and erythrocyte O2peak, PPO, HRpeak, RERpeak, count); cardiorespiratory variables (V
Herrero F et al. Cancer and Detraining Int J Sports Med 2007; 28: 257 264

Results
Previous research with eight of the present subjects demonstrated significant improvements after the aforementioned 8-week training program in each of the same variables examined in the present study indicative of functional capacity, body composition and QOL, whereas no change was observed in a matched breast cancer survivor control group not engaging in any type of training program [13]. In the present study, adherence to training averaged 92.8 2.0 % (individual values ranging from 83.3 to 100%). No major adverse effects and no important injuries or health problems were noted in any of the subjects. All individual values for total CK during the training program were within normal levels (< 167 IU l1), except in four subjects during the 1st week of the training program (Table 2). This indicates little or no muscle damage due to performing the entire training program, including the resistance training portion of the program. The normal CK values, coupled with the positive adaptations to the training program (see below, i.e., increased muscle functional performance, etc.), indicate muscle damage or soreness did not limit adaptations to the training program. All eleven subjects resumed a sedentary lifestyle (i.e., no formal aerobic or resistance training and walking than a total of 30 60 min1 two days week 1) during the detraining period.

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7 8 9 10 11

Except for four subjects in the first week of the training period, all samples were within the normal range for CK levels (0 167 IU l [7])

Table 3 Pre-, post-, and detraining results (expressed as median [i.e., 50th percentile] and interquartile percentiles) of quality of life (QOL) assessed with the questionnaire developed by the European Organization for Research and Treatment of Cancer (EORTC): the EORTC QLQ-C30 [1, 9]
Pretraining Percentiles Items Global health status Physical functioning Role functioning Emotional functioning Cognitive functioning Social functioning Fatigue 25th 58.3 80 100 66.7 66.7 66.7 0 50th 66.7 93.3 100 83.3 100 100 22.2 75th 75 100 100 100 100 100 33.3 Post-training Percentiles 25th 75 93.3 100 83.3 100 83.3 0 50th 83.3 100 100 91.7 100 100 11.1 75th 100 100 100 100 100 100 11.1 Detraining Percentiles 25th 66.7 86.7 66.7 66.7 83.3 100 0 50th 75 93.3 100 91.7 100 100 0 75th 83.3 100 100 100 100 100 33.3 p < 0.001 p < 0.05 n.s. n.s. n.s. n.s. n.s. p < 0.01 p < 0.05 n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. Time effect Pre- vs. posttraining Pre- vs. detraining Post- vs. detraining

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n.s. n.s. n.s. n.s. n.s.

Except for four subjects in the first week of the training period, all samples were within the normal range for CK levels (0 167 IU l1 [7]); n.s.: nonsignificant statistical difference (p > 0.05)

Table 4 Pre-, post-, and detraining mean (SD) for parametric variables (i.e., anthropometric and blood variables)
Pretraining Post-training Detraining Time effect Pre- vs. posttraining Pre- vs. detraining Post- vs. detraining

Anthropometric variables Body mass (kg) Fat mass (kg) Muscle mass (kg) Body fat (%) Muscle mass (%) Blood variables Hemoglobin (g dL1) Hematocrit (%) Erythrocyte count ( 10 L )
6 1

64.0 (7.3) 14.2 (4.1) 27.2 (2.1) 21.9 (4.2) 42.7 (3.6) 13.8 (0.9) 41.4 (2.2) 4.7 (0.3)

64.1 (7.1) 12.9 (3.5) 28.5 (2.9) 19.9 (3.8) 44.5 (3.4) 13.7 (0.9) 41.2 (2.9) 4.6 (0.2)

64.1 (7.0) 14.2 (3.8) 27.3 (2.4) 21.9 (3.8) 42.7 (3.3) 13.6 (0.8) 40.8 (2.1) 4.6 (0.3)

n.s. p < 0.01 p < 0.001 p < 0.001 p < 0.001 n.s. n.s. n.s.

p < 0.01 p < 0.01 p < 0.01 p < 0.01

n.s. n.s. n.s. n.s.

p < 0.01 p < 0.01 p < 0.01 p < 0.01

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n.s.: nonsignificant statistical difference (p > 0.05)

Quality of life (QOL) There was a significant time effect in both the global scale (p < 0.001) and physical function scale (p < 0.05), as measured by the EORTC QLQ-C30 (Table 3). The significant improvement in both variables with training was not followed by a significant change after the detraining period compared with post-training values (p > 0.05) (Table 3). No other statistical effect was found for the rest of the items being evaluated. Body composition We observed a significant time effect for total and % muscle mass (p < 0.01), % body fat (p < 0.01) and fat mass (p < 0.05) (Table 4). Post hoc analysis revealed that total and % muscle mass, and total fat mass and % body fat significantly increased and decreased, respectively, with training (p < 0.01) but returned again to pre-

training values after the detraining period. Detraining values were significantly different than post-training values (p < 0.01) for all the aforementioned variables. Blood oxygen transport capacity No significant time effect was found for erythrocyte count, hematocrit or hemoglobin levels (p > 0.05), indicating no significant variations in blood oxygen transport capacity over the study period which could alter subjects exercise capacity (Table 4). Cardiopulmonary exercise tests O2peak, PPO and VT was found (Table A significant time effect for V 5). These three variables improved significantly with training (p < 0.05), but returned to baseline values after the detraining O2peak (p < 0.01), PPO (p < 0.05) and period. Detraining values of V
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Table 5 Pre-, post-, and detraining mean (SD) values for parametric variables (i.e., results of cardiopulmonary exercise tests, and results of strength endurance and functional tests)
Pretraining Post-training Detraining Time effect Pre- vs. post-training Pre- vs. detraining Post- vs. detraining

Cardiopulmonary exercise tests Peak values O2peak (mL kg 1 min1) V PPO : body mass (W kg ) HRpeak (b min1) RERpeak
1

26.7 (5.6) 1.5 (0.4) 169 (8) 1.1 (0.06) 15.6 (2.4) 0.7 (0.2) 119 (16) 0.8 (0.09) 1.4 (3.8) 11.6 (6.8) 7.89 (0.86)

29.0 (4.6) 1.9 (0.4) 170 (7) 1.2 (0.1) 16.3 (2.9) 0.9 (0.2) 117 (13) 0.8 (0.04) 3.8 (6.0) 23.6 (7.9) 7.21 (0.72)

22.7 (3.9) 1.5 (0.5) 164 (12) 1.2 (0.06) 11.6 (3.1) 0.6 (0.2) 117 (15) 0.7 (0.08) 1.8 (4.5) 19.6 (4.3) 7.66 (0.66)

p < 0.001 p < 0.001 n.s. n.s. p < 0.001 p < 0.01 n.s. n.s. p < 0.01 p < 0.001 p < 0.05

p < 0.05 p < 0.01 n.s. n.s. p < 0.05 p < 0.05 p < 0.05

n.s. n.s. n.s. n.s. n.s. n.s. n.s.

p < 0.01 p < 0.05 p < 0.01 p < 0.01 n.s. n.s. n.s.

Sit and stand test (s)

O2peak: peak oxygen uptake; HRpeak: peak heart rate; RERpeak: peak respiratory exchange ratio; n.s.: nonsignificant statistical difference (p > 0.05); PPO: peak power output; V O2: oxygen uptake; PO: power output; HR: heart rate; RER: respiratory exchange ratio VT: ventilatory threshold; V

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VT (p < 0.01) were significantly decreased after detraining compared with post-training. On the other hand, RERpeak and HRpeak did not change over the study period (p > 0.05). This supports that the subjects performed the three cardiorespiratory exercise tests at a comparable effort. Thus, the results we obtained in maximal cardiorespiratory variables (i.e., significant improve O2peak, PPO and subsequent decrement ment after training in V after detraining) were solely attributable to our intervention (training and detraining) and not to any potential variation in the subjects effort level between the three evaluations. Dynamic strength endurance and muscle functional performance A significant time effect was found for bench (p < 0.01) and leg press strength endurance (p < 0.001) and the sit-stand test (p < 0.05) (Table 5). Performance in these tests significantly improved with training (p < 0.05), but this improvement was not followed by a significant decrease after the detraining period compared with post-training values (p > 0.05).

they also seem to be rapidly lost. Although previous controlled studies [5, 22] have shown the beneficial effects of regular exercise training on the functional capacity of cancer patients/survivors, to the best of our knowledge, this is the first attempt to determine the nature and magnitude of detraining effects that occur after a prior training period. Further, we used a supervised, individualized prescribed training program (aerobic and resistance exercises) and a complete approach to assess the effects of training/detraining on cardiorespiratory exercise capacity, dynamic strength endurance, task specific functional muscle capacity and, most important, QOL. This is not to say, nevertheless, that our study is not without limitations. Seasonal variations in the human physiological responses to exercise due to endogenous circannual rhythms [2] could have influenced, at least partly, our results, as the study lasted four months in total. Most important, the assessment of a control group at the time point corresponding to the end of the detraining period would have strengthened our findings. O2peak were signifiAfter the detraining period, mean values of V cantly lower than those observed after the training program (mean decrease of 6 ml kg1 min1). The magnitude of the O2peak with deconditioning ( 22 %) clearly surpassed loss in V the gains previously obtained with training ( 8 %). This finding O2peak reflects the upper limit of the is of clinical relevance as V bodys aerobic functioning and it is the parameter that is most widely used to characterize the effective integration of the central nervous, cardiopulmonary, and metabolic systems and to assess the functional capacity of patients with various diseases [6]. O2peak) is also a powerful indicator of Peak oxygen uptake (V health status and of mortality (e.g., a 3.5 ml kg 1 min1 reduction is associated with a 12 % decrease in the survival rates in patients with cardiovascular disease) [29]. Our results are in agree-

Discussion
The main finding of our study was that the QOL, dynamic strength endurance and task specific functional muscle capacity of breast cancer survivors, who have previously undergone an 8-week combined (aerobic and resistance) supervised training program, is not significantly decreased after an 8-week deconditioning period. In contrast, cardiorespiratory exercise capacity O2peak, VT) is significantly impaired by relatively short-term (V detraining. Thus, as opposed to training gains in strength endurance and muscle functional capacity, training-induced gains in O2peak and VT appear relatively quickly (i.e., 8 weeks), although V
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VT O2 at VT (mL kg1 min1) V PO : body mass (W kg ) at VT HR at VT (b min1) RER at VT Bench press (n reps.) Leg press (n reps.)
1

Strength endurance and functional tests

ment with previous research with healthy adults demonstrating O2peak decrease toward pretraining values after 8 weeks of a V training cessation. For instance, Klausen et al. [17] reported O2peak of adult males after 8 weeks of dea 15 % decrease in the V training, which was, in turn, accompanied by a decrease in muscle fiber capillarization. In previously sedentary women, the O2peak comeffects of an 8-week endurance training program on V pletely disappeared after 4 12 weeks of deconditioning ( 25 % mean decrement in comparison with post-training values) [32]. O2peak due to a short detraining period appears Thus, the loss of V to be of the same magnitude in women breast cancer patients as in healthy adults. O2) eliciting the VT also showed a In our subjects, the workload (V significant decrement after cessation of training ( 29 % decrease) compared to post-training values. This is also in agreement with previous research with healthy subjects [21]. Our results are similar to those reported by Ready and Quinney [30], i.e., rapid, par O2peak and VT of nonathallel increase and decrease in both the V letes after a 9-week endurance training program and a subsequent 6 9 week deconditioning period, respectively. This finding is also of clinical relevance, as VT is an indicator of functional capacity in patients with chronic diseases and in deconditioned individuals [27]. Indeed, the VT is considerably decreased in patients with cardiovascular disease compared to healthy controls and tends to decrease with the severity of the disease [10, 27]. Improvements in VT result in attenuation of breathlessness, improved exercise capacity at submaximal levels, and contribute to the well-being of patients during their daily activities [16]. On O2peak for the other hand, one potential advantage of VT over V quantifying training gains and/or detraining losses is that the possible risks and discomfort associated with maximum exercise testing are avoided [27]. Thus, future training interventions on cancer patients with very low physical capacity and an inability to stress their cardiorespiratory system maximally due to severe muscle weakness could potentially use VT as a primary outcome measure. Although mean values of dynamic strength endurance (as determined by the leg and bench press tests) tended to be lower at detraining compared with post-training, statistical significance was not reached due to the existing interindividual variation, e.g., four subjects did not show impaired leg press performance after the 8-week period of training cessation. In contrast, the pat O2peak and VT with detraining was statistitern of decrement in V cally significant and consistent among all the subjects. The results of the sit-stand tests were in agreement with those obtained in the strength endurance tests. Detraining values did not return to pretraining values after the 8-week deconditioning period. The detraining-induced loss in performance ( 6 %) was less than the training-induced gain ( 9 %). This result is of practical relevance as the sit-stand test reflects the ability to perform lowerbody functional tasks involving rapid movements. Important physical abilities such as balance, coordination, muscle strength and the ability to generate torque are performance determinants in this test [11]. Thus, in postmenopausal women, as those studied here, the most important training-induced gain (and relatively low decay after detraining) in performance during the sit-stand test could indicate a reduced risk of falling and subsequent bone injury.

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It could be argued that our study is limited by the fact that we did not assess the training/detraining effects on maximal muscle strength, i.e., 1RM tests. Although improvements in the ability to perform such tests are of obvious interest for athletic young populations, we believe they would be of little practical relevance for older, nonathletic people, such as the postmenopausal women evaluated here. In populations such as this, maximal strength is not a main determinant of their ability to perform physical activities of daily living, which are mostly submaximal-strength tasks, e.g., climbing stairs, sitting and rising from a chair, etc. Thus, a test of submaximal strength or submaximal power for repeated contractions appears more suitable to evaluate training or detraining outcomes. Compared with post-training, patients QOL was not significantly decreased after training cessation. This finding is of particular relevance since long-term fatigue with subsequent decreases in QOL is a serious problem for cancer survivors. Up to 30 % may experience this symptom for years after termination of treatment [22]. Berglund and colleagues [4] showed that fatigue with subsequently impaired QOL persisted (and was the most commonly reported symptom) in 68 % of women survivors of breast cancer who were treated with adjuvant chemotherapy between two and 10 years previously and were otherwise healthy and recurrence-free at the time of follow-up, as were our subjects. Although previous controlled studies have demonstrated the beneficial effect of exercise programs in patients with cancer
Herrero F et al. Cancer and Detraining Int J Sports Med 2007; 28: 257 264

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Our results indicating that the gains in muscle functional performance obtained by survivors of cancer are not completely lost after a short period of training cessation, as opposed to significant decreases in cardiorespiratory capacity, are in overall agreement with previous research conducted in healthy populations. A recent study on healthy postmenopausal women has shown that the gains in dynamic muscle (leg and arm) strength induced by an 8-week resistance training program surpassed the decrements after a subsequent 8-week training cessation period [8]. It is generally accepted in athletic populations that muscular strength suffers a limited decay after short periods of training stoppage [28]. Lemmer et al. found that both young (20 30 yrs) and old men and women (65 75 yrs) showed the majority of strength loss after 12 weeks of detraining [20]. This is in contrast with other muscular characteristics (particularly muscle capillary density), which can show marked decrements within only 2 3 weeks of training cessation [28]. One reason for the relative slower decay in muscle strength compared to oxidative capacity may be that short-term resistive exercise detraining may specifically affect the strength or the size of the type II muscle fibers, while leaving other aspects of neuromuscular performance (i.e., motor unit recruitment) uninfluenced [14]. Our findings suggest that, in deconditioned individuals, the slower decay that occurs in muscle strength and functional performance is attributable to some degree of maintenance in neuromuscular performance, as opposed to hypertrophic changes. Indeed, the subjects estimated muscle mass decreased to baseline values after the 8week period of training cessation (Table 4). At least in previously trained individuals, it is accepted that longer periods of training stoppage (> 8 week) are necessary to cause marked decreases in muscle strength attributable to both muscle atrophy and diminished neural activation [28].

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[5, 22], we believe that our results uniquely demonstrate the efficacy of even a brief period of formal exercise programming in developing, and retaining training induced benefits during a short period of training cessation. Maybe due to the fact that, in clinical settings, resistance exercise generally has been considered inappropriate for frail or diseased individuals, little research has been conducted on the potentially beneficial effects of resistance training on the physical work capacity of cancer patients or survivors. The findings of the present study indicate the efficacy of incorporating resistance exercises into a training program for this group. When regular exercise has to be stopped, for any reason, for a relatively short time period (e.g., due to disease recurrence, side effects such as anemia or infections, lack of time or motivation to continue training, etc.), patients QOL and some of the benefits of a combined short-term aerobic and resistance training do not seem to be significantly affected. This might allow these individuals to resume training with a higher level of motivation and to regain post-training fitness levels faster after a detraining period. In conclusion, survivors of breast cancer who have previously enrolled in a combined training program (aerobic and resistance exercises) partially retain some of the training gains (i.e., improved QOL and muscle strength endurance/functional performance) after a detraining period of relatively short duration (8 weeks).

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Acknowledgement of Financial Support

This research was supported by a grant from Universidad Europea de Madrid (reference number: UEM2004/02).
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References
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