Physical exercise as complementary treatment in prostate cancer

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1 Apunts Med Esport. 2010;45(166): ORIGINAL ARTICLE Physicl exercise s complementry tretment in prostte cncer Bernt C. Serdà *, Pilr Monrel b nd Arntz del Vlle b Deprtment of Nursing, ECIS Reserch Group, University of Giron (UdG), Giron, Spin B Deprtment of Psychology, ECIS Reserch Group, University of Giron (UdG), Giron, Spin Received November 30, 2009; ccepted Jnury 17, 2010 KEYWORDS Strength-endurnce progrm; Arteril hypertension; Prostte cncer; Urinry incontinence; Qulity of life Abstrct Introduction: This rticle presents how physicl exercise cn be considered s complementry tretment in prostte cncer. The rticle presents the design nd implementtion of strength-endurnce physicl exercise progrm dpted to prostte cncer. The initil model corresponds to the guidelines of the Americn College of Sports Medicine (ACSM, 1998). Adpting nd trnsforming the progrm included the most common symptoms relting to the illness nd its tretments. Mteril nd methods: The study design is qusi-experimentl. The smple consisted of 33 subjects in tretment phse. Study vribles were nthropometric mesures, strengthendurnce, hypertension, ftigue, incontinence, pin nd qulity of life. Results: After 24 weeks of the progrm, significnt improvement in the strengthendurnce cpcity ws observed. This result ws more evident in lower limbs. There were lso improvements in hypertension, urinry incontinence nd pin. In conclusion, the improvement in qulity of life is due to the improvement of the functionl nd physicl cpcity of ill person Consell Ctlà de l Esport. Generlitt de Ctluny. Published by Elsevier Espñ, S.L. All rights reserved. * Author for correspondence. E-mil ddress: [email protected] (B. C. Serdà) /$ - see front mtter 2009 Consell Ctlà de l Esport. Generlitt de Ctluny. Published by Elsevier Espñ, S.L. All rights reserved.

2 82 B.C. Serdà et l PALABRAS CLAVE Progrm fuerzresistenci; Hipertensión rteril; Cáncer de próstt; Incontinenci urinri; Clidd de vid El ejercicio físico como terpi complementri en el cáncer de próstt Resumen Introducción: Este rtículo present el ejercicio físico como un terpi complementri en el trtmiento del cáncer de próstt. En concreto presentmos el diseño e implementción de un progrm de ejercicio físico de fuerz-resistenci dptdo l cáncer de próstt. El modelo bse corresponde l guí de l Americn College Sports Medicine Position Stnd (ACSM, 1998). L dptción y l trnsformción del progrm incluyen los síntoms más hbitules reltivos l enfermedd y sus trtmientos. Mteril y métodos: El diseño del estudio es cusiexperimentl, con un muestr de 33 prticipntes en fse de trtmiento. Ls vribles de estudio son ls vribles ntropométrics, fuerz-resistenci, tensión rteril, ftig, incontinenci, dolor y clidd de vid. Resultdos: Al finlizr 24 semns de progrm, se observ un mejor significtiv de l cpcidd de l fuerz-resistenci, más evidente en ls extremiddes inferiores. Tmbién mejor l hipertensión rteril, l incontinenci urinri y el dolor. Conclusiones: Estos resultdos demuestrn que l mejor de l clidd de vid viene medid por l mejor de l cpcidd físic y funcionl del enfermo Consell Ctlà de l Esport. Generlitt de Ctluny. Publicdo por Elsevier Espñ, S.L. Todos los derechos reservdos. Introduction The lck of physicl ctivity nd the sedentry lifestyles of the popultion re responsible for helth, socil nd economic problems. The min im of the Ntionl Institute of Helth (NIH) nd the Americn College of Sports Medicine (ACSM) is the promotion of physicl exercise in ll popultion groups for the improvement of helth nd prevention of illness. The long term objectives re to enhnce performnce in the undertking of dily ctivities nd to reduce the risk of pthologies ssocited with sedentry lifestyle, such s coronry pthologies, obesity, type 2 dibetes, hypertension, brin hemorrhge nd cncer 1. The recommendtions re similr to those put forwrd by the Americn Hert Assocition nd the Centres for Disese Control nd Prevention (CDC) 2. There re currently three generl perspectives on the reltionship between physicl exercise nd helth: rehbilittive, preventtive, nd perspective oriented to wellbeing. From the rehbilittive perspective, Airsk 3 found tht physicl exercise cn be considered s n instrument for the recovery of the debilitted or dmged corporl function nd the llevition of its effects on the humn orgnism. Physicl ctivity my be compred to mediction nd seen s therpy tht is complementry to medicl phrmcologicl tretment for pthologies such s coronry disese, obesity, type 2 dibetes, hypertension, brin hemorrhge nd cncer. This rticle focuses on the rehbilittive perspective of physicl exercise in reltion to prostte cncer for improvement of the qulity of life (QoL) of subjects being treted for the illness. The principl risk fctor for prostte cncer is ge (the verge ge for dignosis is 75) followed by environmentl influences nd lifestyles 4. The survivl rte t 5-yers is 76.5% nd there is very high rte of morbidity cused by tretments. For these resons, the priority objective for socil-helth intervention in cses of men suffering prostte cncer is improvement in QoL 5. QoL is subjective, dynmic, multidimensionl concept of modulr prdigm nd difficult mesurement 6. The QoL reltive to cncer is subjective experience of the illness tht is contrsted with expecttions, vlues nd individul interests 7 nd corresponds with the dilectic tht is estblished between subjective nd objective spects. The result of this reltionship determines the pprecition or stisfction of the functioning of the ptient with tht which is perceived s possible or idel 8. The reserch corpus shows tht the design nd implementtion of strength-endurnce exercise progrmme s complementry tretment for the prostte cncer ptient cn reduce nd even revert the physicl nd psychosocil degenertion nd improve the QoL of the older mle The mjority of progrmmes re bsed on the generl guidelines recommended by the Americn College Sports Medicine-Position stnd tht is imed t the promotion of physicl exercise in helthy individuls 12. These progrmmes re not specificlly dpted to the illness nd its tretment; they re excessively generic, incomplete, inflexible nd inefficient 13. The effectiveness of the progrmme is subject to the mngement nd control of the vribles tht determine the chrcteristics of the ctivity. These vribles must be dpted nd trnsformed in ccordnce with the most common symptoms identified in the process nd tretment of prostrte cncer nd the comorbidity of the older mle 14. The considertion of these spects fcilittes the comptibility of the strength-endurnce progrmme nd its promotion for the llevition of the degenertion nd incpcity cused by

3 Physicl exercise s complementry tretment in prostte cncer 83 the disese nd its tretment 15. A progrmme bsed on these chrcteristics would result in greter effectiveness in the development of musculr strength-endurnce nd be reflected in the qulity of the ptient s bsic motor ptterns 16,17, delying the onset of ftigue, reducing the processes of osteopeni nd osteoporosis provoked by ssocition with the fctors of ge, hormone tretment nd inctivity. This, in turn, would reduce the risk of the fllfrcture-dependence chin rection often found in these debilitted ptients 18, thereby improving the QoL nd survivl possibilities of the older mle suffering from prostte cncer 19. The objectives of this rticle re: To present progrmme of strength-endurnce physicl exercise, dpted to the needs of prostte cncer ptients, in considertion of the significnt vribles detiled in studies with helthy or ill subjects with noncrcinogenic pthologies. To evlute the physicl nd psychosocil results obtined fter 24 weeks of the implementtion of the progrmme. Mterils nd methods Loclity nd prticipnts After receiving pprovl from the Reserch Ethics Committee, the exercise progrmme ws implemented t the Figueres Hospitl (Giron, Spin), between October 2006 nd October Three conditions were required for ptient inclusion: A histologicl dignosis of prostte cncer, t ny stge of its pthology, in the process of tretment. The undertking of medicl exmintion in order to certify tht the individul demonstrted no contrindictions to the progrmme of exercise. The giving of informed consent by mens of signture. Exclusion criteri were the presence of ny other pthology tht contrindicted temporry or permnent prticiption in physicl exercise ctivities, with bsolute contrindictions being groups III nd IV of the New York Hert Assocition clssifiction of crdic disese, uncontrolled rteril hypertension, psychitric illness nd the inbility to understnd or spek Spnish. Rndom smple selection There were 36 prticipnts. Selection ws rndom, bsed on the clinicl history number nd the ppliction of the SPSS v.15 progrm. The exercise progrmme The progrmme ws designed for period of 24 weeks: 16 weeks under the direct or indirect supervision of physicl eduction professionl nd 8 weeks of utonomous work by the ptient. There were two 90-minute sessions per week which included 1 or 2 series of 8-12 repetitions of 10 correltive exercises for working the muscles of the qudriceps, pectorls, ischiotibils, deltoids, bdominls (ntihypertensive), biceps, triceps, 2 dorsls nd the pelvic floor. It lso included pelvic floor wreness nd control exercises nd posterior strengthening of the wekened res, bsed on exercises originting in, nd mking use of, the overflow energy of the helthy muscles. Intensity ws between 50% to 70% of 8 RM, s previously clculted using the Lnder test 20. There ws n incrementl progression of repetitions, series nd weight. Once the subject reched 12 repetitions of the second series, weight ws incresed, s long s the weekly weight increse ws no more thn 10% of 8RM. There ws strict limit of 70% of 8 RM to void the risk of testosterone secretion. Individul perception of the intensity of controlled exertion ws bsed on modified Borg CR subjective exertion scle. The progrmme ws therefore flexible nd dpted to ech subject in considertion of their functionl cpcity, stge of illness nd symptomtology. Initil nd finl evlution Evlution of direct vribles The pre-test evlution included: nmnesis, sociodemogrphic questionnire; n nthropometric study; the mesurement of rteril tension; questionnire on tretment toxicity; visul nlog scles of pin nd urinry incontinence; questionnire on previous exercise hbits bsed on the Godin test 22 ; sub-mximl step-test corresponding to the modified Cndin Aerobic Fitness Test (mcaft) 23, controlling the frequency, rteril tension nd the subjective perception of exertion with the Borg CR- 10 scle. 1RM (Lnder) ws clculted by mens of n estimtion bsed on the Strength-endurnce test of the trunk nd lower limbs, in ccordnce with the ASEP protocol 24. Questionnires on QoL nd Ftigue were lso completed by the subjects. The registrtion of nthropometric vribles followed the protocol 25 nd consisted of: weight; body mss index; wist-hip rtio; wist mesurement; the sum of the seven skinfold mesurements (pectorl, midxillry, triceps, subscpulr, bdominl, suprilium nd thigh) nd the percentge of ft mss, estimted by mens of the Jckson nd Pollock formul 26. A biochemicl nlysis evluted levels of free testosterone, blood lipids (totl cholesterol, high nd low density lipoproteins in cholesterol nd triglycerides) nd SAP levels. QoL ws mesured wit the FACT-P, Functionl Assessment Cncer Therpy Scle-Prostte [Rnge: 0-156] (4th version). Ftigue ws mesured by mens of the FACIT ftigue scle (4th version) [Rnge: 0-52]. Intensity of incontinence ws evluted by using visul nlog ctegoricl scle of four ctegories from 0: not wet to 10: completely soked. Pin intensity ws mesured with visul nlog numericl scle: 0: no pin to 10: unberble pin. Strength-endurnce ws estimted from the totl number of musculr contrctions completed in cycle of 22 repetitions/minute mrked by metronome ( Korg MA-30

4 84 B.C. Serdà et l model) progrmmed to 44 bets/minute nd with light weight. Sub-mximl musculr exertion ws considered s the mximum weight tht the subject could lift for 8 repetitions whilst mintining the correct posture. The weight used ws 70% of the 8RM clculted from the results of the strength-endurnce test, bsed on the Lnder formul. The test involved two groups of muscles: those of the trunk, concentrting on the pectorls, using horizontl bench; nd the lower limbs, concentrting on the thighs, using leg press. Mximum musculr strength ws indirectly (hypotheticlly) clculted from the 8RM with the Lnder formul 27. This vlue llowed the clibrtion of individul exercise intensity in ccordnce with the progrmmed percentges. Viscerl bdominl ftty tissue ws mesured with CTscnner. In week 24 the sme vribles were evluted, with the exception of the nmnesis nd the socio-demogrphic questionnire. Evlution of co-vribles The following section explins the evlution of the covribles, including the integrted dherence model, symptoms reltive to illness nd the moleculr observtion unit. The nmnesis identified the secondry symptoms reltive to illness nd tretment. These were tringulted with the symptoms registered in the clinicl histories. The design of the strength progrmme llowed flexible dpttion to the symptom of urinry incontinence. The progrmme developed ctive retention strength nd coordintion of the strited muscles of the deep boundries of the pelvic floor; this compensted for the mlfunctioning of the dmged sphincters nd resulted in greter continence control. The dherence model ws bsed on current models using vribles identified in studies tht were relted to the tking of regulr physicl exercise. The model used included didctic strtegy, introduced in stges, which progressively incresed utonomy, trnsferring control of the ctivity from the supervisor to the subject. The objective ws tht the subject would continue the progrmme t the end of the experimentl phse. Support given during the progrmme ensured focus on the most wekened vribles. Perception of control nd self-sufficiency were emphsised. Results were evluted by mens of the questionnire devised by Godin 22. The moleculr observtion unit evluted the technicl fctors ssocited with strength-endurnce ctivities. Observtion gurnteed the helth of the subject by reducing the risk of injury. The following fctors were evluted using the Likert scle: corporl posture t rest nd in contrction; the biomechnics of contrction, including respirtory ssocition; the correct completion of the progrmme; the trnsference of working lod nd the qulity of the bsic motor ptterns in the process of scending nd descending in the step exercise [rnge: 0-30]. The comments of the observer were lso considered. A weekly observtion took plce which ws videoed. An verge ws clculted for the first phse of the progrmme (weeks 1-6) nd the utonomous stge (weeks 18-24). Clcultion of smple size nd sttisticl nlysis The smple size clculted for the detection of difference between groups of 5.0 points ws the result of the FACT-P test (stndrd devition [SD] = 9). The test ws pplied to two lines with n lph risk of 5% nd bet risk of.05. The number of subjects required ws 33. For pired dt in the continuous vribles tht followed norml distribution, the t Student-Fisher test ws used with number of degrees of liberty (n-1). For the continuous vribles tht did not follow norml distribution the Wilcoxon or Mn Whitney U non-prmetric test for pired dt ws employed. The χ 2 test ws used for the nlysis of ctegoricl vribles. A multivrite model ws designed with dimensions tht integrted the QoL questionnire. The significnt vribles of the multivrite model were studied nd they explin the vrition of the QoL test bsed on multiple linel regression model. The SPSS version 15 progrmme ws used for the sttisticl nlyses. Significnce level ws set t 5%. Of the 46 subjects referred by the Urology service of Figueres Hospitl, smple of 36 subjects ws selected for the study. Attendnce t the sessions ws over 93% (30 of 32 sessions). In the course of the study, 3 subjects left the progrmme due to cognitive problems, metsttic osseous pin nd crdic insufficiency. The CONSORT flow digrm illustrtes the study smple procedure (Figure 1). At the end of the study (week 24) it ws found tht 100% of the smple hd dhered to the ctivities, hving been influenced by the vribles: perception of control; selfsufficiency; identifiction with the therpy; control of incontinence nd pin; nd stisfction (Figure 1 nd Tble 1). Results The results re presented s follows: Sections 1-7 del with the results of the direct vribles nthropometric, crdiovsculr efficiency t rest, crdiovsculr efficiency t sub-mximl exertion, rteril pressure, muscle strength, QoL (FACT-P), urinry incontinence, ftigue nd pin; Section 8 describes urinry incontinence nd QoL; Section 9 considers the multivrite model of the dimensions tht mke up the QoL questionnire; the results of the covrints reltive to dherence to the progrmme re given in Section 10 nd results of the moleculr observtion unit re shown in Section Anthropometric vribles The nthropometric vribles showed tht t the strt of the progrmme the subjects crried concentrtion of bdominl ft. By the end of the progrmme there ws significnt reduction of ll mesurements nd typicl devitions (Td) of the vribles, with the exception of weight (Tble 2).

5 Physicl exercise s complementry tretment in prostte cncer 85 Urology Service of Figueres Hospitl Referrls N = 47 Rndomiztion SPSS V.15 Phone contct N = 47 N = 8 Preinterventionl medicl review Agree to prticipte N = 39 Not gree to prticipte Justifiction 3 excluded Distnce (2) Trnsport (1) Not interested (3) Inbility (2) Criteri Signed informed consent Crdic rrythmi (2) Neurologicl disorder (1) N = 36 Abndonment Exercise progrm strt N = progrm weeks completed N = 8 Justifiction Cognitive problems (1) Metsttic bone pin (1) Hert filure (1) Figur 1 CONSORT flowchrt. There ws significnt reduction in ech of the seven skinfold mesurements; the two tht sw the gretest reduction were in the bdominl re the suprilium registered n verge difference of 6.22 nd the bdominl skinfold registered n verge difference of The skinfold tht registered the lest difference ws the pectorl (4.75). 2. Crdiovsculr vribles t rest There ws significnt fll in crdiovsculr vribles t rest. Tble 3 detils the chnges registered for hert rte, systolic rteril pressure nd distolic rteril pressure t rest. 3. Crdiovsculr efficiency vribles t submximl exertion There ws significnt lowering of the crdiovsculr vribles t sub-mximl exertion. The subjective perception of effort lso registered significnt reduction, s did systolic rteril tension, while distolic rteril tension fell, though not significntly (Tble 4). 4. Ctegoristion of rteril pressure vribles in ccordnce with the JNC-6 In ccordnce with the Joint Ntionl Committee (JNC) 28 evlution, there ws 50% fll in rteril hypertension (Tble 5). 5. Description of musculr strength The percentge increse in both endurnce nd 8RM ws greter in the lower limbs thn in the upper body. In the pectorl group, strength-endurnce incresed by 57.83% nd 8RM by 22.76%. In the lower limbs musculture, strength-endurnce incresed by 61.45% nd 8RM by 45.49% (Tble 6).

6 86 B.C. Serdà et l Tble 1 Clinicl nd epidemiologicl chrcteristics of the prticipnts Vrible Intervention group (n=33) Age (yers) x (DS) [rnge] (7.22) [55-83] Weight (Kg) x (DS) [rnge] (11.60) [ ] BMI (Kg/m 2 ) x (DS) [rnge] (2.99) [ ] Arteril tension (mm Hg) SAP x (DS) DAP x (DS) (21.31) (11.03) Hert rte t rest (bets/minute) x (DS) 74 (10.74) TNM Tumour clssifiction, n (%) Stge I Stge II Stge III Stge IV Unknown 0 (0) 13 (39.39) 18 (54.54) 1 (3.03) 1 (3.03) SPA dignosis (ng/ml) x (DS) [rnge] (24.32) [2.84 >100] SPA t strt of progrmme (ng/ml) x (DS) [rnge] 0.55 (1.36) [ ] Tretment, n (%) Surgicl (P) Hormonl (ADT) Combined R + ADT P + ADT Socio-demogrphic questionnire Civil sttus Mrried Widowers Single Occuption Retired Active Previous erobic exercise, n (%) Ct 1 3 times per week Intense Moderte Light Ct 2 < 2 times per week Intense Moderte Light 15 (45.45) 15 (45.45) 1 (3.03) 2 (6.06) 30 (90.90) 2 (6.06) 1 (3.03) 31 (93.93) 2 (6.06) 24 prticipnts (72.72%) 1 prticipnt (3.03%) 11 prticipnts (33.33%) 12 prticipnts (36.36%) 9 prticipnts (27.27) 5 prticipnts (15.15%) 4 prticipnts (12.12%) Previous strength-endurnce exercise, n (%) 3 times per week < 2 times per week BMI: body mss index; SAP: systolic rteril pressure; DAP: distolic rteril pressure; SPA: specific prostte ntigen; P: prosttectomy; ADT: ndrogenic deprivtion therpy; R+ADT: rdiotherpy combined with ndrogenic deprivtion therpy; P+ADT: prosttectomy combined with ndrogenic deprivtion therpy 0 (0) 0 (0) 0 (0)

7 Physicl exercise s complementry tretment in prostte cncer 87 Tble 2 Anthropometric vribles Description of prmeter Pre-test Post-test Pre-test/post-test Vribles n x Td x Td x Td p* Weight (Kg) BMI (Kg/m 2 ) * WHR * WM * 7 skinfolds (mm) * FM-7 (%) Chnges observed in the 24 weeks of the intervention progrmme. BMI: body mss index; WHR: wist-hip rtio; WM: wist mesurement; 7 skinfolds: sum of the seven body skinfolds; FM-7 (%): ft mss, expressed s percentge; Td: typicl devition; x : men. p*: significnce vlue p<.05. Tble 3 Crdiovsculr vribles t rest Description of prmeter Pre-test Post-test Pre-test/post-test Vribles n x Td x Td x Td p* HR-R * SAP-R * DAP-R Chnges observed in the 24 weeks of the intervention progrmme. HR-R: hert rte t rest (bets/min); SAP-R: systolic rteril pressure t rest (mmhg); DAP-R: distolic rteril pressure t rest (mmhg); Td: typicl devition; x : men. p*: significnce vlue p<.05. Tble 4 Crdiovsculr prmeters in the sub-mximl strength test Description of prmeter Pre-test Post-test Pre-test/post-test Vribles n x Td x Td x Td p* HR sub-mx * SAP sub-mx * DAP sub-mx * Borg sub-mx VO 2mx <.001 Chnges observed in the 24 weeks of the intervention progrmme. p*: significnce vlue p<.05. HR sub-mx : sub-mximl hert rte (bets/min); SAP sub-mx : sub-mximl systolic rteril pressure (mmhg); DAP sub-mx : sub-mximl distolic rteril pressure (mmhg); Borg sub-mx : Borg sub-mximl scle of subjective perception of exertion; VO 2 mx : mximum oxygen consumption [ml kg 1 min 1 ]; Td: typicl devition; x : men. 6. Qulity of life The verge FACT-P vrible showed significnt increse by the end of the progrmme (Tble 7). 7. Urinry incontinence, ftigue nd pin There ws significnt reduction in incontinence nd pin. The fll in levels of ftigue ws not significnt (Tble 8). 8. Ctegoristion urinry incontinence nd the difference in the FACT-P QoL questionnire The vrible of the ctegoricl nlog visul scle ws ctegorised in two groups: Group 1 showed less improvement in urinry incontinence nd Group 2 showed more improvement. The urinry incontinence vrible ws compred with the QoL (FACT-P) questionnire before nd fter the progrmme. The verge, ccording to the FACT-P

8 88 B.C. Serdà et l Tble 5 Arteril pressure vribles Ctegories Arteril pressure Pre-test (n=33) Post-test (n=33) SAP/DAP (mmhg) n % n % 1 Optiml <120 / nd < Norml / nd Norml-high / nd/or AHT 4 Stge / nd/or Stge / nd/or Stge / nd/or ISH 140 /< All vribles re vlues t rest. If SAP or DAP re in different ctegories, the recommended intervl is the lowest indicted. SAP: systolic rteril pressure; DAP: distolic rteril pressure; ISH: isolted systolic hypertension; AHT: rteril hypertension; mmhg: millimetres of mercury. Tble 6 Chnges in mens nd typicl devition (Td) of musculr strength Description of prmeter Pre-test Post-test Pre-test-Post-test Vribles Grup Rng n x Td x Td x Td p* Pre-test Post-test Mend Pec [2-23] [7-42] <.001* LL [8-50] [10-90] <.001* 8RM Pec [ ] [ ] <.001* LL [ ] [ ] <.001* Chnges observed in the 24 weeks of the intervention progrmme. p*: significnce vlue p<.05. Mend: musculr endurnce; 8RM: sub-mximl exertion, clculted using Lnder formuls 1,20 ; Pec: pectorl; LL: lower limbs; Td: typicl devition; x : men. There ws higher significnce in musculr-strength endurnce nd sub-mximl exertion. The effect ws greter in the lower limbs (Tble 7). Lnder Formul (1985): Weight rised (Kg) / [ NR]. Tble 7 Chnges in mens nd typicl devition (Td) of FACT-P Description of prmeter Pre-test Post-test Relted differences Questionnrie Rnge n x Td x Td x Td p* FACT-P [0-156] * Chnges observed in the 24 weeks of the intervention progrmme. p*: significnce vlue p<.05. FACT-P: QoL questionnire on prostte cncer; Td: typicl devition; x : men. Multivrite model of the dimensions tht mke up the dimensions of the FACT-P QoL questionnire. questionnire, in Group 2 (more improvement) ws higher (x =14.75) thn the verge for Group 1 (x = 2.95) (t of student = 2.15; p =.039) (Tble 9). 9. Multivrite model of the dimensions of the FACT-P QoL questionnire The multiple linel regression model (Tble 10) nlysed differences in post nd pre-intervention vlues, for the QoL test nd ech of the dimensions. In ddition, it considered the coefficient bet for ech independent vrible if the sign ws positive, the vlue of the vrible hd incresed; if the sign ws negtive, the vlue of the vrible hd decresed. The vribles of the multivrite model tht were significnt nd explin the vrition in the QoL test scores were: the generl physicl stte of helth; emotionl condition nd symptoms reltive to prostte cncer. Nonsignificnt vribles were fmily nd socil environment nd the ftigue scle. R 2 =.933%.

9 Physicl exercise s complementry tretment in prostte cncer 89 Tble 8 Chnges in mens nd typicl devition of urinry incontinence, ftigue nd pin Description of prmeter Pre-test Post-test Relted differences Questionnrie Rng n x Td x Td x Td p* VAS-UI [0-10] * FACIT [0-52] VAS-P [0-10] Chnges observed in the 24 weeks of the intervention progrmme. p*: significnce vlue p <.05. VAS-UI: visul nlogue scle of urinry incontinence; FACIT: ftigue questionnire; VAS-P: visul nlogue scle of pin; x : men; Td: typicl devition. Tble 9 Urinry incontinence Description of prmeter Relted differences T test for equlity of mens Questionnire VAS-C n x Td t p* FACT-P DIF 1 (n=15) (n=18) FACT-P DIF: the difference in the result of the QoL questionnire between the finl vlue on finlising the intervention nd the initition of the intervention. VAS-C: visul nlogue scle of continence; Td: typicl devition; x : men. 1: less improvement in urinry incontinence; 2: more improvement in urinry incontinence. Tble 10 FACT multiple regression FACT Questionnire dimensions T Bet p* 1. PWB: Physicl wellbeing SWB: Socil nd fmily wellbeing EWB: Emotionl wellbeing PCS: Other concerns FACIT: Ftigue scle R 2 =.933% p*: significnce vlue p <.05. Tble 11 FACT coefficients FACT-P Questionnire dimensions T Bet p* 1. PWB: Physicl wellbeing EWB: Emotionl wellbeing PCS: Symptoms p*: significnce vlue p <.05. PCS: in the QoL questionnire, PCS refers to other concerns, ttributed to symptoms reltive to illness nd tretment. New coefficients were obtined from the significnt vribles (Tble 11). 10. Integrted dherence model Adherence to the exercise progrmme ws 100%. The results showed tht the subjects utonomously continued with the exercise progrmme due to the perception of improvement in the symptoms of incontinence nd pin nd generl post-exercise session feeling of wellbeing. Perception of control, self-sufficiency nd willpower vribles were decisive in continunce in the long-term. Two vribles not included in the model tht should be mentioned re knowledge of the therpeutic dose nd psychosocil distrction during the ctivity. 11. Moleculr observtion unit The group verge in the first phse, weeks 1-6, ws 12.5 points. The verge for the finl, utonomous phse, weeks 18-24, ws 24 points. The observtions in the finl phse highlighted the improvement in the qulity of bsic motor ptterns, especilly in coordintion when scending nd descending in the mcaft sub-mximl erobic step test. Discussion The results show tht strength-endurnce exercise significntly improves the QoL of prostte cncer ptients. The QoL questionnire reveled improvements in the physicl dimension (including reduction of pin), the functionl dimension (including improved continence) nd the emotionl dimension. There ws cler nd evident progress in the sub-mximl nd strength-endurnce vribles. As in the work of Lthm 17, it ws noted tht n increse in strength hd positive retroction effect on the cpcity, technicl execution nd qulity of the bsic motor ptterns when wlking nd scending-descending the step. This result ws confirmed by both the chnges identified in the periodic

10 90 B.C. Serdà et l checks of the moleculr observtion unit nd the mcaft sub-mximl erobic step test. The improvement in strength-endurnce ws superior to sub-mximl strength. In both cses, the improvement ws greter in the lower limbs thn the trunk. This result should be seen in the context of the fct tht in older people, the nturl physiologicl loss of strength usully occurs erlier in the lower limbs thn in the upper body. Moreover, the increse in extensor strength in the lower limbs correltes with the increse in wlking speed, self-perception nd the restortion of blnce 29. This reduces the risk of fll nd frcture nd contributes to generl improvement of QoL 30. The increse in strength correltes with the hlting of the ctbolic process in the musculr system nd n improvement in the condition of srcopeni tht is ggrvted by cncer. The recupertion of the musculr mss nd the intensity nd qulity of the musculr contrction genertes n efficient movement rc. These fctors signl generl improvement in functionlity nd the bility nd movement demnded by dily life ctivities, retrding the mnifesttion of ftigue nd resulting in n improved self-perception of helth by older people Age nd hormone tretment re fctors tht provoke n ccelerted loss of osseous minerl density 34. A strengthendurnce progrmme is n idel therpy to retrd the process of osteoporosis nd reduce the risk of frctures, s exercise increses bone density, porosity nd solidity 35. Reserch hs reveled direct, proportionl reltionship between musculr-endurnce exercise nd osseous minerl density. This effect hs lso been identified in older people, lthough the degree of chnge depends on the initil condition of the bone structure 32. Aginst this, it should be recognised tht musculrendurnce exercise involves greter risk of injury to soft tissue prts, minly the tendinous intersections 36. This risk is higher in people suffering illnesses nd this underlines the importnce of determining the most efficient exercise progrmme for obtining the gretest benefits for the osseous nd musculr structure nd minimising the risk of injury. The review of previous studies showed tht the minimum durtion of n exercise progrmme imed t incresing osseous minerl density is 24 weeks 37. The progrmme used in this study ws 24 weeks nd this overcomes one of the methodologicl limittions tht hve been identified in other similr studies 10. The results obtined justify the effect of strength-exercise on osseous helth, though the importnce of the promotion of good nutritionl hbits, especilly the ingestion of clcium, should not be forgotten 38. The degenertion of musculr-skeletl cpcity nd, especilly, the lower limbs is cuse of the fll-frcturedependence trid of the older person. This risk increses enormously when the individul is in frgile physicl condition 29,39. The impct of fll on osteoporotic bone often results in frcture, with the consequent loss of mobility nd the possible genertion of post-fll syndrome due to functionl dependence 40. The initil effect or the exercise progrmme ws improved musculr conditioning nd this led to better osseous helth. Osteomusculr improvement llows the older person to mintin utonomy nd this reduces the risk of dependence tht is often cused by cncer nd the tretment of the disese Crdiovsculr, metbolic nd nthropometric decompenstion is common in prostte cncer ptients. The effect is provoked by the deficit in the secretion of testosterone. The pre-test phenotype of the prticipnts in this study ws Type II (ndroid). The excess ft in the bdominl re ws identified by wist girth, wist-hip rtio nd the two biggest skinfolds suprilium nd bdominl. The inter-bdominl ft deposit directly correlted with the crdiovsculr risk fctors. If these indictors re not reverted they become morbimortlity risk fctors 44. ACSM 12 erobic type exercise is recommended for reducing obesity. The results of this study show tht strengthendurnce exercise is effective for improving tissue qulity. The results showed significnt reduction in the nthropometric vribles: BMI, wist girth, the sum of the seven skinfolds nd the percentge of body ft. This result correltes with the crdiovsculr improvements identified through the diminution of the vribles: hert rte, rteril tension nd the subjective perception of exertion (t rest nd sub-mximl) lthough the exct significnce of the reltionship ws not clerly defined. The post-test showed greter cpcity to exercise t higher intensity nd more efficient post-exercise crdiovsculr recovery. There ws grdul fll in rteril tension tht ws evident nd significnt from the sixth week of the progrmme. At the end of the first experimentl phse the subgroup of subjects with hypertension ws reduced by 50% due to the fll in systolic rteril pressure. Results further confirm tht the progrmme hd significnt ntihypertensive effect on the systolic rteril pressure of the subgroup of subjects with hypertension 45 lthough it cnnot be confirmed tht the effect is long-term. The crdiovsculr improvement corrobortes the principle of the interreltionship between cpcities: the improvements in strength-endurnce nd sub-mximl strength generted n dpttion in erobic cpcity registered in the vribles of crdiovsculr efficiency t rest nd in the mcaft sub-mximl fitness test. This ws evidenced in reduction of crdiovsculr stress with more exercise nd lower subjective perception of the exertion required. More reserch is necessry in order to quntify the reltionship between n exct degree of strength exercise nd its effect on crdiovsculr helth. The improvements in the nthropometric profile nd crdiovsculr response, s described bove, re determinnts in the overll progress of fctors tht re interrelted with the metbolic system. This effect ws identified through the joint nlysis derived from the reduction of the vribles concerning lipids in the blood, rteril tension t rest nd during ctivity, the reduction in bdominl obesity nd improved glycemi tht indicted greter sensibility to insulin 46. These results re in line with those of Wrburton nd confirm tht improvements in the metbolic syndrome correlte with improvements in the functionl dimension nd the QoL of the older person 32.

11 Physicl exercise s complementry tretment in prostte cncer 91 The progrmme mnged to reduce, control nd revert symptoms of incontinence, ftigue nd pin. This effect ws chieved by the cpcity of the progrmme to dpt to the most common symptoms ssocited with the illness nd its tretment. For exmple, in reltion to incontinence, the strength progrmme included the mngement of three consecutive phses: the sensory perception of the pelvic floor; strengthening; nd irrdited overflow exercises from the helthy musculture to the trophied nd dmged muscles of the pelvic floor. This model, orgnised in phses nd dpted to the symptom of incontinence, chieved significnt improvement in the QoL of the subgroup ffected by urinry incontinence, s compred with the non-ffected sub-group or the results of similr progrmmes tht were not ble to be dpted to symptoms 47. The specific mechnisms tht medite the improvement re consciousness nd continence control. This result my hve hd further, positive impct on other dimensions of the QoL questionnire, for exmple, recovery of socil network. The Americn Society of Clinicl Oncology (2008), confirm tht QoL is strong nd independent indictor in cncer survivl. In this study, the dimensions of the QoL questionnire tht sw significnt improvement were personl functionl cpcity, emotionl wellbeing nd the dimension tht included symptoms reltive to the illness (incontinence, pin nd ftigue). From the first phse of the progrmme, contextulised study for the multidisciplinry promotion of the vribles tht correlte with dherence ws undertken; the bsis of the study being older men suffering from prostte cncer nd their sociofmilil environment. This construct did not consider dherence exclusively s finl vlue of the study but s contingent support offered in the experimentl stge, in reltion to the wekest vribles concerning perception of control, self-sufficiency nd perception of improvement. It is cler tht this encourged the utonomous continunce of the progrmme once the experimentl phse ws complete the dherence level ws 100%. It is worth noting tht other (new) significnt vribles tht should be integrted into the model re knowledge of the therpeutic dose nd psychosocil distrction. A globl considertion of the results leds us to the controversy nd debte concerning the effectiveness of popultion screening nd dignosis of prostte cncer bsed on the SAP test. This lso rises the question of the need for low-risk prostte cncer tretment; question tht is justified by the chin of joint or sequentil risk fctors tht determine the metbolic syndrome of the older mle being treted for prostte cncer. In this study, we hve identified: overweight, rteril hypertension (with isolted systolic hypertension), high hert rte t rest, high cholesterol, n incresed level of high density lipoproteins, excessive sturted fts in the diet nd sedentry lifestyle. The combintion of these fctors significntly increses the risk of crdiovsculr illness 48. If, to this profile, we dd the secondry effects of the illness nd its tretment, such s urinry incontinence, sexul dysfunction or impotence, ftigue, distress, socil isoltion etc., it cn be seen tht the impct of prostte cncer tretment on the QoL of the sufferer is greter thn the impct of the illness itself. We conclude this section with reference to Trish, who commented tht the identifiction of these fctors exposes the drk, silent nd unknown fce of ndrogen deprivtion tretment 49. Conclusions The strength-endurnce progrmme is nturl, non-invsive intervention tht is economicl nd effective nd cn complement socio-helth ttention nd tretment. Long term metbolic decompenstion supposes high risk of crdiovsculr pthologies. These risks re ggrvted by cncer tretment, both in terms of expectncy nd QoL. Given this sitution, proctive helth inititives re justified s they my meliorte secondry effects nd the risks generted by cncer tretment s well s leding to improvements in physicl nd functionl cpcity nd the generl helth of the ptient. The strength progrmme led to improved strengthendurnce nd sub-mximl strength cpcity. The generl improvement in strength ws greter in the lower limbs thn in the trunk. There ws trnsfer of strength to erobic cpcity nd to bsic motor pttern skills. Functionl progress hd positive effect on ll other QoL dimensions. The progrmme reduced crdiovsculr risk through the diminution of the nthropometric vribles, bove ll, the percentge of ftty tissue (especilly in the bdominl re) nd the level of rteril tension. The progrmme hd n ntihypertensive effect tht ws most evident in the subjects tht suffered hypertension. There ws significnt effect on systolic rteril pressure from the sixth week of the progrmme. The results justify the flexibility nd cpcity of the progrmme to dpt to the symptoms of urinry incontinence, ftigue nd pin. The reduction in the intensity of these symptoms led to improvements in the psychologicl nd socil wellbeing of the subjects. There ws significnt improvement in the crdiovsculr vribles t rest nd t sub-mximl exertion nd in the subjective perception of strength. The results confirm tht the progrmme is vlid, sustinble nd the best intervention imed t the older mle suffering from prostte cncer. This type of progrmme llows direct control of the vitl signs of life nd reduces the risk of dyspnoe nd flling. Furthermore it llows for immedite tretment in the cse of emergency. Conflict of interest The uthors hve no conflicts of interest. References 1. Booth FW, Gordon SE, Crlson CJ, Hmilton MT. Wging wr on modern chronic diseses: primry prevention through exercise biology. J Appl Physiol. 2000;88:

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