ANTICANCER RESEARCH 32: 3229-3234 (2012)

Gentle Strength Training in Rehabilitation of Breast

Cancer Patients Compared to Conventional Therapy
THORSTEN SCHMIDT1, BURKHARD WEISSER2, WALTER JONAT3,
FREERK THEEAGNUS BAUMANN4 and CHRISTOPH MUNDHENKE3

1Comprehensive Cancer Center North, Breast Oncology, University Hospital for Women, Kiel, Germany;
2Institute of Sport Science, Kiel, Germany;
3University Hospital for Women, Kiel, Germany;
4German Sport University Cologne, Cologne, Germany

Abstract. Movement therapy during the rehabilitation of (fatigue) (1). Several studies have shown that in addition to
breast cancer has become more important over the last drug therapy, physical training has a positive effect on
years. Patients and Methods: In a randomized controlled disease- and treatment-associated symptoms such as fatigue,
study the feasibility of gentle strenght training was nausea and reduced muscular and cardiovascular
compared to conventional gymnastic exercises during performance (1-7). In the past the target of sports and
rehabilitation of breast cancer patients. The aim oft this exercise therapy in rehabilitation after breast cancer, was
study was to identify alternative sports intervention in the only seen to be focusing in improving quality of life and
treatment of breast cancer patients. The intervention group fatigue. Meanwhile studies have shown a decrease in relapse
(IG) was lifting standardized weights weekly (50 % of rate due to increased physical activity (8).
h1RM), while the control group (CG) received conventional The first sport intervention studies in patients with cancer
gymnastic exercises. A bicycle ergometry adjusted to the focused on the effects and influence of endurance training
WHO system was performed with all participants at study (9, 10). Although more and more studies on strength training
entry (T0), after three (T1) and six months (T2). The quality in oncology, during recent years, have shown that targeted
of life was measured by standardized report forms (EORTC strength training in the different therapy phases offers an
QLQ C30 Version 3 and BR23). Results: Both methods option for the treatment of cachexia, the experience is limited
showed a slight improvement in submaximal endurance to only a few studies (11-13). This phenomenon is also seen
performance, a significant improvement in the subjective in rehabilitation, where almost exclusively, gymnastics as a
feeling of effort (IG: 75 W: <0.01, CG: 75 W <0.01), in sport and endurance training are found, whereas strength
psychosocial and psychological parameters like quality of training intervention is under-represented.
life (IG: <0.01, CG <0.01) and in fatigue (IG: <0,01, CG: The present study uses gentle strength training as a sports
<0.01). Conclusion: This study shows positive effects for intervention in the rehabilitation of patients with breast
gentle strength lifting in the rehabilitation of breast cancer cancer to evaluate the impact on the psyche (e.g. quality of
patients and turned out to be a probate alternative to life and depression) and the changes in submaximal
gymnastic exercises. endurance conductivity.

As a result of adjuvant chemo- or radiotherapy a large Patients and Methods

proportion of women with breast cancer suffer from
extraordinary physical, mental and spiritual exhaustion For this prospective, randomized study, female patients with breast
cancer were recruited at the Breast Oncology Unit at the Kiel
University Hospital (OB/GYN, UKSH, Kiel, Germany). The study
was reviewed positively by the examination board.
Correspondence to: Thorsten Schmidt, Ph.D. Comprehensive Cancer Out of 60 patients screened, 38 patients were enrolled in the
Center North, Breast Oncology Unit at Kiel University Hospital for study and were randomized in a gentle strength training group as
Women, Michaelisstrasse 16, 24105 Kiel, Germany. Tel: +49 an intervention group (IG) and in a conventional gymnastics
4315972180, Fax: +49 4315972539, e-mail: [email protected] exercise group as a control group (CG). Inclusion and exclusion
criteria are shown in Tables I and II. The study was supervised by
Key Words: Breast cancer, gentle strength training, quality of life, breast oncologists and researchers of the Institute of Sports
physical activity, rehabilitation. Science at Kiel University. The patients were recruited in the

0250-7005/2012 $2.00+.40 3229

 ANTICANCER RESEARCH 32: 3229-3234 (2012)

Table I. Inclusion criteria for study participation. Table III. Anamnestic and anthropometric parameters of the intervention
of the control group.
Inclusion criteria
Anamnestic and anthropometric Intervention Control
Breast cancer patients after lumpectomy or mastectomy parameter group group
Stage I-III
Completed chemotherapy Number 15 18
Completed radiotherapy Age (years) (mean±d) 58±8.41 55±10.59
Age: 18-70 years Height (cm) (mean±d) 171±6.32 167±6.32
BMI: 18-30 Weight (kg) (mean±d) 82±15.15 72±15.52
Time from diagnosis (in months (mean±d) 8.66±5.61 10.2±4.98
Chemotherapy and radiotherapy (n) 8 13

Table II. Contraindications or study participation.

Recording quality of life. The European Organization for
Contraindication
Research and Treatment of Cancer (EORTC) has developed
Acute infectious disease
several questionnaires to reveal the quality of life of patients with
Severe cardiac disease (New York Heart Association
functional class III myocardial infarction <3 months) cancer in a multidimensional approach. The questionnaire EORTC
Severe pulmonary insufficiency QLQ C30, version 3 BR23, especially developed for patient with
Renal insufficiency (glomerular filtration rate <30%) breast cancer as a basis for the recording of changes at the
Serious neurological disorders psychological level, was used for the study (5, 18). The results
Less than 10,000 platelets section focuses on the items of the questionnaire, quality of life
Hemoglobin 8g/dl and fatigue.
Limited walking distance, no walking or no stability
The training. During the study, the IG was trained with the training
method, gentle strength training as strength endurance training. The
control group carried out a weekly conventional gymnastic exercise
unit such as chair or floor exercises with various sports equipment.
hospital at the end of their treatment. Randomization was During the gentle strength training workout, the individual training
alternately (1:1) carried out into the intervention and control series was not carried out until the last repetition as in conventional
groups. All patients were in the postoperative, post-chemotherapy strength training, meaning the complete short-term fatigue of the
and post-radiotherapy phase. An overview of the sample muscle, but was significantly stopped before. The criterion for
description (age, height, weight, primary diagnosis, therapy completion of each series was the subjective feeling of stress which
method) are shown in Table III. Due to secondary diseases is still disregarded in strength training (19). For the subjective
(osteoarthritis) or time difficulties caused by professional activities assessment of the impact of perceived exertion the scale of stress
during the randomized study, five out of 38 patients left the study: rating according to Borg was used (16).
four withdrew from the IG and one from the CG. The data of 33 The American College of Sports Medicine recommends a
patients were used for the analysis, out of which 15 patients were training load of 50% of one repetition maximum (1RM) (20).
in the IG and 18 in the CG. Therefore, on the basis of h1RM measurement, a training plan for
Endurance tests as step stress tests were carried out by all every participant was developed, where at the very beginning of the
patients before (T0) the first sports and movement unit, again after gentle strength training programme the intensity of h1RM was set at
three months (T1) and then after six months (T2). A determination 50%, with 20 repetitions during one training set per device. Any
of body height and body weight was used to record the body mass further increase in intensity was based on the Borg scale.
index (BMI). To determine the initial stress level a hypothetical
maximum force test was performed with all members of the IG Measurement of endurance. The endurance test was used to verify
(h1RM) (14). With the help of a quantitative survey at the time endurance and was performed at all study time points. The test was
points mentioned above with the questionnaires EORTC QLQ C30 preceded by a medical and a sports therapeutic examination. Only
and the BR23 module, somatic complaints, feelings, fears and after all contraindications (Table II) for a step stress test were
concerns, as well as the health status and quality of life status, were excluded, was the test performed.
recorded and evaluated (3, 15). The two groups were compared with Due to the temporal proximity to medical therapy a bicycle
each other at the end of the study. The flow chart in Figure 1 shows ergometer was used for the examination, according to the WHO
a trial profile during the study. scheme (15) (Figure 2), performed with a submaximal load and an
The IG completed one training set of 20 repetitions with a upper pulse limit of 220 minus age as a termination criterion of the
hypothetical 50% of the maximum weight, using 11 workout test and a maximum loading of 100 W. At the end of each exercise
machines. The training took place on the following devices: squat, level, the heart rate, blood pressure and the subjective perceived
chest press, leg curl, rowing, leg extension, upper arm curl, upper exertion, based on a numerical scale according to Borg, were
arm extensors, shoulder press, abdominal bench and lats pull down. recorded (16).
The CG exclusively completed gymnastic exercises. For half a year The test was terminated when the upper heart rate limit was
both groups received their training programme once per week for reached, a systolic blood pressure of 200 mmHg was exceeded (17),
one hour for each workout. the number of rotations could not be maintained, or the patient

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 Schmidt et al: Physical Activity in Rehabilitation of Patients with Breast Cancer

Figure 1. Trial profile during the study.

expressed discomfort or complained that the burden was too much.

Strength test. The h1RM (hypothetical maximum weight for one
repeat) is a dynamic maximum force test. The test is performed
according to the repetition method, where the sports therapist
chooses the weight, so that the patient cannot carry out more than
20 repeats (14). The testing took place on all devices, comprising
the content of the training of the IG.

Statistics. For data analysis descriptive data such as mean and

standard deviation were used. The α-level of significance was set at
≤0.05. The comparisons between the two groups were performed
using an independent t-test and the changes within the group using
analysis of variance. Figure 2. Bicycle ergometer training according to the WHO scheme.

Results

A non-significant improvement in submaximal endurance

exercise capacity was seen in the IG. At the start at T0, the (T0/T1/T2) (50 W: <0.01, 75 W: <0.01, 100 W: <0.01), the
Watt capacity of every participant per kilogram of body improvement in the CG was only highly significant at 50 W
weight in the IG was 1.18. This increased at T2 to 1.21 (<0.01) and at 75 W (<0.01) (Table IV).
W/kg/body weight (>0.05). In the CG, this value decreased The quality of life (Table V) at T0 was not equal in both
from 1.47 W/kg/body weight at T0 to 1.38 W/kg/body groups; It was estimated to be poorer in the IG. At T2, the
weight at T2 (>0.05). quality of life in both groups was estimated to be equal. In a
A significant change in BMI over the course of the study comparison (two-factorial analysis of variance) of quality of
was not detected (p>0.05). Weight reduction was measured life scores at the three different time points, significant
in both groups. In the IG, the BMI at T0 was 28.04 kg/m2 improvements in both groups were seen (IG: <0.01, CG:
and at T2 it was 27.01 kg/m2; in the CG, at T0 it was 25.81 <0.01). A comparison of values between the groups showed
kg/m2, compared to 25.10 kg/m2 at T2. no significant difference. Furthermore a highly significant
The results of the subjective assessment of the impact of improvement in fatigue symptoms occured in both groups
perceived exertion showed a significant improvement in both (IG: <0.01, CG: <0.01) (Table VII). There were no
groups. While the improvement in the IG was highly significant differences between the two groups at T0
significant at all three load levels during the course (=0.774) and T2 (=0.630) by the t-test.

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 ANTICANCER RESEARCH 32: 3229-3234 (2012)

Table IV. Subjective effort in the intervention and control group in training to Borg scale (16). Data are means±SD.

T0 T1 T2 p-Value

IG CG IG CG IG CG IG CG

50 Watt 11.8±1.667 12.1±1.664 10.6±2.33 9.94±2.0 9.46±2.41 8.42±2.35 <0.01 <0.01

75 Watt 14±2.11 14.52±1.84 12.26±3.5 12.36±1.40 11.85±2.57 11.68±2.27 <0.01 <0.01
100 Watt 16±1.2 15.866±4.24 15.41±2.49 14.53±3.5 14.28±3.78 14.05±2.98 <0.01 n.s.

Discussion Table V. Quality of life score at the three measuring points in the
intervention group (IG) and control group (CG). Data are means±SD.

A scientific evaluation of strength training in the Group T0 T1 T2 p-Value

rehabilitation of patients with breast cancer and comparisons
of methods of training interventions have not yet been IG 59±16.62 67±19.92 76±12.93 <0.01
sufficiently performed. This investigation, conducted with 33 CG 67±17.23 75±17.95 77±15.27 <0.01
patients, confirms previous data (1, 3, 5, 7, 12, 18, 21, 22)
that physical activity has a positive impact on the quality of
life and fatigue. The intervention comparison shows that a
conventional gymnastic exercise programme as well as a Table VI. Fatigue at the three measuring points in the intervention
gentle strength training programme lead to a significantly group (IG) and control group (CG). Data are means±SD.
improved quality of life and reduced fatigue symptoms. De
Group T0 T1 T2 p-Value
Backer et al. had similar results in a study of patients with
different cancer entities after the impact of an 18-week IG 49±23.7 31±20.22 26±23 <0.01
strength training programme (22). Pure strength training in CG 47±17.79 23±14.2 34±26 <0.01
the rehabilitation of breast cancer patients was led by Ohira
et al. (12). The training programme resulted in a significant
increase in muscle strength, which correlated with
improvements in physical function scales of the EORTC training programme represent effective methods, leading to an
questionnaire (12). Our own results are thus consistent with improvement in quality of life and reduce symptoms of fatigue
results from other studies. and subjective feeling of perceived exertion. Gentle strength
In both groups, a weight reduction was seen. Chlebowski training can be viewed as an effective means for sport
et al. and Goodwin et al. describe a causal relationship therapeutic rehabilitation aftercare for patients with breast
between obesity and the risk of developing breast cancer (23, cancer and is a probate alternative to gymnastic exercises.
24). According to the evaluation criteria of the World Cancer
Research Fund (WCRF), there is convincing evidence Conflicts of Interest
through different studies that a high BMI is associated with
a worse prognosis for women with breast cancer (25). This No potential conflicts of interest were disclosed.
factor plays an important role in risk reduction and should
be controlled in other studies (23, 24). Acknowledgements
The treatment methods, gentle strength training and
conventional gymnastic exercise, should not be regarded as The Author wish to acknowledge Dr. Ortrud Stremme and the
competitors, but as an extension of the therapeutic nursing staff of the University Hospital Schleswig-Holstein,
opportunities. In their study Courneya et al. found that Department of Gynaecology and Obstetrics for their cooperation in
recruiting patients.
patients with breast cancer may have preferences for a
particular training method and that this preference influences
the effectiveness of the training programme. Patients who References
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