Rowing Training in Breast Cancer Survivors: A Longitudinal Study of Physical Fitness

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle Rowing T aining in B eas Cance Su i o s: A Longi udinal S udy o Physical Fi ness Juan Ga ala-González 1, Ismael Gál ez-Fe nández 2,* , Pe e Me cadé-Melé3and JoséCa los Fe nández-Ga cía2 1Depa men o Physical Educa ion and Spo s, Uni e si y o Se ille, 41013 Se ille, Spain; [email p o ec ed] 2Depa men o Didac ics o Languages, A s and Spo , Uni e si y o Malaga, Andalucia-Tech, IBIMA, 29071 Malaga, Spain; [email p o ec ed] 3Depa men o S a is ics and Econome ics, Uni e si y o Malaga, Andalucia-Tech, 29071 Malaga, Spain; [email p o ec ed] *Co espondence: [email p o ec ed] Recei ed: 5 May 2020; Accep ed: 6 July 2020; Published: 9 July 2020   Abs ac : The aim o his s udy was o de e mine whe he a owing aining p og am leads o imp o emen s in physical i ness and body composi ion in women who ha e su i ed b eas cance (53.70 ± 7.88 yea s). The pa icipan s (n =30) comple ed a wel e-week aining p og am consis ing o h ee sessions pe week, wi h each session las ing om six y o nine y minu es. An an h opome ic and gene al physical i ness assessmen was pe o med be o e and a e he p og am. The esul s showed s a is ically signi ican imp o emen s in all he physical i ness es s pe o med: si and each (2.82 cm); back sc a ch, dominan (3.29 cm); back sc a ch, non-dominan (4.59 cm); coun e mo emen jump (1.91 cm); hand g ip, dominan (2.54 kg ); hand g ip, non-dominan (2.53 kg ); chai s and (2.56 ep); and six-minu e walk (51.56 m). In addi ion, a signi ican imp o emen was obse ed in he e iciency o he ca dio ascula sys em measu ed by hea a e, in bea s pe minu e (bpm), bo h be o e ( − 12.63 bpm) and a e he six-minu e walk es ( − 11.46 bpm). The e alua ed body composi ion pa ame e s also imp o ed, speci ically o al lean mass (2.18 kg) and he pe cen age o o al body a ( − 2.63%). We can he e o e conclude ha owing aining p og ams can be a s a egy o be conside ed o imp o ing physical i ness in his popula ion gi en he imp o emen ob ained in bo h an h opome ic and physical i ness a iables, hus leading o be e heal h and quali y o li e. Keywo ds: b eas cance ; owing; i ness; an h opome y; hea a e 1. In oduc ion Acco ding o he In e na ional Agency o Resea ch on Cance (IARC), b eas cance is he mos common cance wo ldwide, a ec ing 2.1 million indi iduals each yea and is he leading cause o dea h among women. In 2018, app oxima ely 627,000 women los hei li es o b eas cance [1]. Acco ding o he 2018 IARC s udy, 4% o women wo ldwide will ha e b eas cance a some ime in hei li es [ 2 ]. This pe cen age is inc easing, and i is expec ed ha in 2040, he pe cen age o women who will be a ec ed by his ype o cance will double, ising o 8% o he global popula ion [3]. In con as , b eas cance is no longe a al bu is becoming ch onic, as he a e o su i o s is abo e 70% i e yea s a e in e en ion. This pe cen age is associa ed wi h he e ec i eness o ea men s, o he inc ease in ea ly diagnosis and o he p e en ion o elapse [ 4 , 5 ]. Howe e , he isk o elapse 20–30 yea s a e diagnosis is a he high [ 6 ]. The inc ease in li e expec ancy o hese indi iduals is e idence ha mo e people a e li ing wi h he side e ec s o b eas cance ea men (loss o muscle mass and s eng h, loss o mobili y and disabili y o he uppe ex emi ies, lymphedema, a igue and ca diac oxici y) [7]. In . J. En i on. Res. Public Heal h 2020,17, 4938; doi:10.3390/ije ph17144938 www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2020,17, 4938 2 o 12 Physical ac i i y dec eases he du a ion and in ensi y o a igue [ 8 , 9 ], educes anxie y and dep ession [ 10 ], inc eases muscle mass and s eng h, dec eases disabili y in he uppe ex emi ies [ 11 ] and imp o es quali y o li e [ 12 , 13 ], as well as es o ing and e en imp o ing unc ionali y and well-being in women who ha e o e come b eas cance [ 14 ]. Se e al me a-analyses and e iews a i m ha physical ac i i y also con ibu es o educing he isk o b eas cance ecu ence [ 15 – 28 ], while o he s ha e ob ained neu al esul s, implying ha physical ac i i y does no cause any changes [ 29 – 31 ]. Cu en ly, he li e a u e p o ides no scien i ic e idence on he p esc ip ion and s uc u e o physical exe cise o b eas cance su i o s [ 17 , 18 ]. Consequen ly, his s udy ollowed he ecommenda ions o he Ame ican College o Spo s Medicine (ACSM), which s a e ha cance su i o s should pe o m 150 min o mode a e ae obic ac i i y o 75 min o igo ous ae obic ac i i y pe week and esis ance aining wo days pe week [ 32 ]. Physical exe cise plays an impo an ole in imp o ing quali y o li e [ 11 ] and p e en ing o delaying he onse o o he diseases in cance su i o s [ 15 – 24 ] by imp o ing ae obic capaci y and muscle s eng h [ 11 ] and educing a igue [ 8 ], all o which a e key elemen s in eco e y om his disease and i s sequelae [32]. Wi h ega d o exis ing s udies on physical ac i i y and b eas cance , we highligh he s udy by Di Blasio e al. (2017) in which hey ca ied ou a s eng h p og am esul ing in imp o ed physical i ness [ 33 ]. The s udy by Keilani e al. (2016) implemen ed an ae obic p og am and ound imp o emen s in quali y o li e and physical i ness [ 34 ]. S udies ha implemen ed mixed p og ams [ 35 – 37 ] epo ed imp o emen s in physical i ness and body composi ion. Among hem is he esea ch by Dieli-Conw igh e al. (2018), in which a combined 16-week ae obic and esis ance p og am signi ican ly imp o ed i ness, wi h inc eases in bo h uppe and lowe ex emi y s eng h [ 35 ]. Simila ly, Thomas e al. (2018) ca ied ou a 12-mon h aining p og am, inding a dec ease in body a (0.9%; 1 kg/m 2 ) and an inc ease in lean mass (0.5 kg), as well as imp o ed uppe and lowe ex emi y s eng h [ 36 ]. Modali ies such as yoga and pila es also p o ide bene icial esul s in join mobili y, muscle s eng h and quali y o li e [ 20 , 23 , 27 ]. Finally, se e al s udies on he e ec s o d agon boa aining p og ams on b eas cance su i o s ha e iden i ied imp o emen s in join mobili y anges [38], s eng h in di e en body segmen s [38,39] and quali y o li e [40–42]. In ou s udy, owing was p esc ibed as he basis o a physical exe cise p og am. This spo was chosen because i in ol es he muscles o bo h he lowe and uppe ex emi ies [ 43 ] and almos all he muscles o he body [ 44 ], al hough he main ea u e di e en ia ing owing om mos o he spo s is he cyclic and al e na ing ac ion o he lexion and ex ension o he uppe and lowe limbs and he s abilizing muscles o he unk and back du ing paddling o enhance echnique [ 45 ]. While he exis ing li e a u e on physical ac i i y and b eas cance is sca ce, in he case o owing and b eas cance i is non-exis en . Fo his eason, we belie e ha ou s udy may ep esen an impo an ad ance in he p esc ip ion o heal hy exe cise o b eas cance su i o s. Se e al s udies ha e been conduc ed on d agon boa aining and b eas cance [ 42 , 46 – 49 ], al hough a b ie biomechanical analysis e eals ha his is an asymme ic spo equi ing compensa o y e o and a se ies o di icul mo emen s ha a e no ecommended in his popula ion. In con as , owing is a comp ehensi e spo ha de elops he lowe , uppe , on , back, igh and le sides o he body in almos iden ical p opo ions, since he mo emen is symme ical. A he same ime, he posi ion o he body segmen s is much mo e ad isable o women who ha e su e ed om cance and su ge y a ec ing he uppe limbs, since owing does no equi e o ced mo emen s. The aim o his s udy was o de e mine how a aining p og am based on he spo o owing may a ec physical i ness and body composi ion in women who ha e su i ed b eas cance . 2. Ma e ials and Me hods 2.1. Design and Pa icipan s The pa icipan s, all o whom we e b eas cance su i o s, and whose main cha ac e is ics a e in Table 1, we e ec ui ed in o a owing club. Once selec ed, hey me wi h he p ojec coo dina o , who In . J. En i on. Res. Public Heal h 2020,17, 4938 3 o 12 explained he na u e o he s udy, indica ing ha hei anonymi y would be main ained a all imes, ollowing he e hical conside a ions o Spo and Exe cise Science Resea ch [ 50 ] and in acco dance wi h he p inciples included in he Decla a ion o Helsinki [ 51 ], which de ines e hical guidelines o esea ch on human subjec s, and he Uni e si y o M á laga ga e he egis e ed iden i ica ion numbe o he e hics commi ee: 2020/REGSED-17007. All he pa icipan s signed a w i en in o med consen o m. In addi ion, du ing he en i e in e en ion and he ea e , ac ion was aken unde he p o isions o O ganic Law 3/2018, o 5 Decembe , on he P o ec ion o Pe sonal Da a and he gua an ee o digi al igh s ega ding he p o ec ion o pe sonal da a in he Spanish legisla ion. Table 1. Cha ac e is ics o he sample abou b eas cance . Age (Yea s) Yea s om Diagnosis B eas (%) S age (%) Su ge y (%) 53.70 ±7.88 6.57 ±5.02 Righ 26.09 I 4.35 P ese a ion 53.52 II 30.43 To al Mas ec omy 39.13 Le 73.91 III 52.17 IV 8.7 Double Mas ec omy 4.35 2.2. Ins umen s Weigh was measu ed o he nea es 0.1 kg using a Tani a model BC730 scale, ollowing he p o ocol o he manu ac u e o clo hing and p e ious in ake o liquids o ood. Heigh was measu ed o he nea es 0.1 cm wi h a SECA model 213 po able s adiome e , acco ding o he F ank u plane o body posi ioning. In he e alua ion o body a and muscle mass, a dual-ene gy X- ay densi ome e (DXA, Hologic Explo e , Wal ham, MA, USA) was used. In addi ion, pa icipan s comple ed he physical i ness es s desc ibed below: The si and each es [52] is used as a gene al es o lexibili y. The subjec si s on he loo wi h knees s aigh , legs ex ended and wi h he soles o he ee p essed i mly agains he box. The a ms a e ex ended o wa d wi h he palms acing downwa ds on he uppe su ace o he scale. In his posi ion, he subjec eaches o wa d as a as possible and holds he posi ion. The sco e is he mos dis an poin eached and held on he ou h mo emen . The es adminis a o s ands close beside he scale and eco ds he mos dis an line ouched by he inge ips o bo h hands. I he hands each une enly, he hand eaching he sho e dis ance de e mines he sco e. The sco e is eco ded o he nea es hal inch. I he each appea s o be exac ly hal -way be ween wo lines, he sco e is based on he las line ac ually ouched. The bes alue o wo obse a ions was conside ed. The scale on he si and each box has an accu acy o 5 mm. The hand g ip es [ 53 ] is used o measu e he maximum isome ic s eng h o he hand and o ea m muscles. To s a , he hand dimension is i s measu ed, and hen he g ip a ea o he dynamome e is adjus ed acco ding o he leng h o he hand. Measu emen s we e ob ained unde s anda dized condi ions, wi h he pa icipan s in he sea ed posi ion, elbow a nine y deg ees and handle adjus ed o he second posi ion. A e ecei ing an explana ion o he p ocedu es and becoming amilia ized wi h he ins umen , maximum g ip s eng h should be applied o 3 o 5 s. The p ocedu e was pe o med h ee imes wi h each hand al e na ely, wi h an in e al o one minu e be ween each measu emen . The highes alue o h ee obse a ions o each hand was conside ed. A TKK-5401 model digi al hand dynamome e was used, which has a measu ing ange o 0.5 o 100 kg- o ce (kg ) and a minimum uni o measu emen o 0.1 kg . The coun e mo emen jump [ 54 ] measu es explosi e and elas ic o ce. I is pe o med wi h he subjec s a ing om an up igh posi ion and wi h he hands on he hips. Then, an upwa d jump is pe o med by means o lexion ollowed as quickly as possible by ex ension o he legs. Knee lexion should each an angle o nine y deg ees and he unk should be p e en ed om bending in o de o elimina e any posi i e in luence on he jump o he han om he lowe ex emi ies. The legs du ing he ligh phase should be ex ended and he ee a he momen o con ac wi h he pla o m should be In . J. En i on. Res. Public Heal h 2020,17, 4938 4 o 12 suppo ed i s by he me a a sal a ea and hen by he back o he oo . Measu emen s we e aken wi h he My Jump 2 mobile applica ion [55]. The six-minu e walk es [ 56 ] is a ca dio- espi a o y unc ion es ha measu es he maximum dis ance a subjec can walk o six minu es on a la su ace. The hea a e pe minu e is aken be o e and a e he es . The chai s and es [ 57 ] assesses lowe ex emi y s eng h by measu ing he numbe o imes he pa ien si s down and s ands up om a chai , s abilized o sa e y. The subjec si s in he cen e o he chai , wi h ee sp ead apa and es ing on he loo . The a ms a e c ossed and held close o he ches . F om he si ing posi ion, he subjec s ands up comple ely and hen si s down again, epea ing his cycle o 30 s. The inal sco e is ob ained by coun ing he o al numbe o ull squa s (each ime he subjec s ands up). The back sc a ch es [ 58 ] e alua es lexibili y in he uppe ex emi ies. The subjec s ands up and wi h he dominan hand mus ouch he shoulde o he same a m. Wi h he inge s ex ended, he subjec mus ad ance along he back, b inging he elbow up un il ying o each he middle o he back. The o he a m eaches a ound he back wi h he palm acing ou wa ds, he goal being o ouch he middle inge s o bo h hands behind he back. The dis ance be ween he ips o he middle inge s o bo h hands is measu ed. I he inge ips ouch, he sco e is ze o. I hey do no ouch, he sco e is nega i e, and i hey o e lap, he sco e is posi i e. 2.3. P ocedu e Each pa icipan , ba e oo and wea ing ligh clo hing, unde wen an ini ial an h opome ic assessmen o weigh and heigh o calcula e BMI. Subsequen ly, each pa icipan pe o med he physical es s in he ollowing o de : hand g ip, coun e mo emen jump, back sc a ch, si and each, chai s and and six-minu e walk. A e he ini ial assessmen , he pa icipan s comple ed a p og am o wel e consecu i e weeks o owing aining (Table 2). Fo his p og am, each week included h ee days o aining las ing be ween six y and nine y minu es pe session. These sessions we e supe ised by a pe sonal aine who ensu ed a endance, co ec execu ion o he asks and he in ensi y o he sessions, in addi ion o excluding om he s udy hose pa icipan s who did no mee a leas 90% pa icipa ion. The aining pe iod was di ided in o h ee s ages, wi h each s age las ing ou weeks and each week ha ing h ee sessions. The in ensi y and echnical di icul y o hese s ages was p og essi ely inc eased and was egula ed h ough he subjec i e pe cep ion o he e o o he pa icipan s, using he Bö g scale [59]. Table 2. Exe cise p esc ip ion design o he p og am. S age Con en 1Ini ial phase wi h mobili y exe cises, p op iocep i e exe cises and pos u al con ol exe cises. Main phase wi h owing aining. Final phase wi h s e ching. Bö g scale 5–6. 2Ini ial phase wi h mobili y exe cises, p op iocep i e exe cises and pos u al con ol exe cises. Main phase wi h owing aining. Final phase wi h s e ching. Bö g scale 6–7. 3Ini ial phase wi h mobili y exe cises, p op iocep i e exe cises and pos u al con ol exe cises. Main phase wi h owing aining. Final phase wi h s e ching. Bö g scale 7–8. A he end o he wel e-week aining p og am, he pa icipan s we e e-e alua ed using he same p ocedu e used in he ini ial e alua ion. 2.4. Da a Analysis The da a we e collec ed in an Excel sp eadshee , including age, heigh , weigh , BMI, he esul s o he di e en es s and pa icipan a ilia ions. S a is ical analyses we e pe o med using he S a is ical Package o Social Sciences, e sion 25 (IBM Co p., New Yo k, NY, USA). In . J. En i on. Res. Public Heal h 2020,17, 4938 5 o 12 To examine whe he he e we e signi ican di e ences esul ing om he owing aining, we analyzed he di e ences be ween he means o each a iable p e- and pos - aining and hen conduc ed pa ame ic es ing wi h S uden ’s - es o ela ed samples (pai ed da a). P io o his analysis, he no mali y o he dis ibu ion was e i ied h ough he Shapi o–Wilk es (p- alue >0.05 in all he a iables unde s udy). Rega ding women’s age, 30.43% a e aged 41 o 50, 52.17% om 51 o 60 yea s old and 17.39% om 61 o 70 yea s old. 3. Resul s Table 3shows he means o he di e en a iables bo h be o e and a e aining as well as hei di e ences and compa isons o de e mine whe he he e a e s a is ically signi ican di e ences. All he pa icipan s showed imp o emen s in all he a iables s udied. In addi ion, hese di e ences we e all s a is ically signi ican excep in he a iables weigh , BMI and o al body a , which al hough hey imp o ed a e aining, we e no s a is ically signi ican : (di Weigh Pos -P e = − 0.37 ± 2.58; = − 0.798; p=0.431; di BMI Pos -P e = − 0.14 ± 1.02; = − 0.786; p=0.438; di To al Body Fa Pos -P e = − 1.77 ± 7.6; = − 1.28; p=0.211). The a iables si and each (di Pos -P e =2.82 ± 1.87; =8.24; p=0.000); back sc a ch, dominan (di Pos -P e =3.29 ± 3.15; =5.72; p=0.000); back sc a ch, non-dominan (di Pos -P e =4.59 ± 3.90; =6.44; p=0.000); coun e mo emen jump (di Pos -P e =1.91 ± 1.71; =6.12; p=0.000); hand g ip, igh (di Pos -P e =2.54 ± 1.56; =8.93; p=0.000); hand g ip, le (di Pos -P e =2.53 ± 1.91; =7.22; p=0.000); chai s and (di Pos -P e =2.56 ± 1.71; =8.19; p=0.000); hea a e a he s a o he 6-min walk es (di Pos -P e = − 12.63 ± 14.68; = − 4.71; p=0.000); hea a e a he end o he 6-min walk es (di Pos -P e = − 11.46 ± 28.39; = − 2.21; p=0.000); dis ance a elled in he 6-min walk es (di Pos -P e =51.56 ± 48.26; =5.85; p=0.000); o al lean mass (di Pos -P e =2.18 ± 4.81; =2.48; p=0.019); and pe cen age o o al body a (di Pos -P e = − 2.63 ± 5.43; = − 2.65; p=0.013) all showed signi ican ly posi i e di e ences be ween p e- and pos - aining. P ac ically all he a iables ha show s a is ically signi ican di e ences p esen he size o he e ec s, calcula ed om he Cohen’s d o a pai ed sample, being g ea e han 0.8. The e o e, he di e ences a e s a is ically signi ican and clinically ele an . Table 3. S a is ical analysis o he s udied a iables. Mean ± s anda d de ia ion; di e ences, -s uden es , e ec size and p- alue. Va iables P e es Pos - es Di Pos -P e -S uden E ec Size p Weigh (kg) 68.67 ±10.98 68.29 ±10.79 −0.37 ±2.58 −0.798 0.14 0.431 BMI (kg/m2)26.34 ±3.78 26.19 ±3.67 −0.14 ±1.02 −0.786 0.14 0.438 To al body a (kg) 27.62 ±6.79 25.85 ±6.29 −1.77 ±7.60 −1.28 0.23 0.211 To al lean mass (kg) 40.43 ±4.61 42.61 ±3.45 2.18 ±4.81 2.486 0.45 0.019 * Pe cen age o o al body a (%) 40.07 ±4.84 37.44 ±4.88 −2.63 ±5.43 −2.657 0.48 0.013 * Si and each es (cm) 0.87 ±6.61 3.69 ±6.57 2.82 ±1.87 8.242 1.51 0.000 ** Dominan back sc a ch es (cm) −2.19 ±8.22 1.10 ±6.54 3.29 ±3.15 5.726 1.04 0.000 ** Non-dominan back sc a ch es (cm) −6.64 ±7.47 −2.05 ±5.72 4.59 ±3.90 6.44 1.18 0.000 ** Coun e mo emen jump es (cm) 14.67 ±4.30 16.58 ±4.28 1.91 ±1.71 6.128 1.12 0.000 ** Dominan hand g ip es (kg ) 23.89 ±4.56 26.44 ±5.00 2.54 ±1.56 8.933 1.63 0.000 ** Non-dominan hand g ip es (kg ) 21.73 ±4.37 24.26 ±4.06 2.53 ±1.91 7.229 1.32 0.000 ** Chai s and es ( ep) 14.90 ±2.41 17.46 ±2.75 2.56 ±1.71 8.194 1.50 0.000 ** S a ing hea a e a six-minu e walking es (bpm) 98.43 ±16.72 85.80 ±9.79 −12.63 ±14.68 −4.712 0.86 0.000 ** Final hea a e a six-minu e walking es (bpm) 143.26 ±32.64 131.80 ±18.62 −11.46 ±28.39 −2.212 0.40 0.000 ** Dis ance in six-minu e walking es (m) 611.23 ±87.01 662.80 ±85.82 51.56 ±48.26 5.852 1.07 0.000 ** *=p<0.05; ** =p<0.001. In he ollowing g aphs, he a iables can be obse ed g ouped acco ding o s eng h, ae obic, hea a e, lexibili y and an h opome y. The g aphs show how he a iables ha e e ol ed be o e and a e aining and a i y he di e ences ha ha e been analyzed in Table 2. Figu e 1shows how all s eng h a iables imp o e a e aining, wi h s a is ically signi ican di e ences. The chai s and es is he one wi h he g ea es absolu e di e ence (di Pos -P e =2.56 ±1.71). In . J. En i on. Res. Public Heal h 2020,17, 4938 6 o 12 In . J. En i on. Res. Public Heal h 2020, 17, x 6 o 12 In he ollowing g aphs, he a iables can be obse ed g ouped acco ding o s eng h, ae obic, hea a e, lexibili y and an h opome y. The g aphs show how he a iables ha e e ol ed be o e and a e aining and a i y he di e ences ha ha e been analyzed in Table 2. Figu e 1 shows how all s eng h a iables imp o e a e aining, wi h s a is ically signi ican di e ences. The chai s and es is he one wi h he g ea es absolu e di e ence (di Pos -P e = 2.56 ± 1.71). Figu e 1. S eng h a iable. P e = p e es ; Pos = pos - es ; CMJ = coun e mo emen jump es ; DH = dominan hand g ip es ; NDH = Non-dominan hand g ip es ; CH = chai s and es ; ep = epe i ions. Figu e 2 shows he ae obic a iable, dis ance in he six-minu e walking es , and a clea imp o emen is obse ed a e aining (di Pos -P e = 51.56 ± 48.26). Figu e 2. Dis ance in he six-minu e walking es . P e = p e es ; Pos = pos - es ; 6mw = six-minu e walking es . Figu e 3 g aphically analyzes he hea a e a iables and clea ly shows how hese wo a iables dec ease signi ican ly due o aining. Figu e 1. S eng h a iable. P e =p e es ; Pos =pos - es ; CMJ =coun e mo emen jump es ; DH =dominan hand g ip es ; NDH =Non-dominan hand g ip es ; CH =chai s and es ; ep = epe i ions. Figu e 2shows he ae obic a iable, dis ance in he six-minu e walking es , and a clea imp o emen is obse ed a e aining (di Pos -P e =51.56 ±48.26). In . J. En i on. Res. Public Heal h 2020, 17, x 6 o 12 In he ollowing g aphs, he a iables can be obse ed g ouped acco ding o s eng h, ae obic, hea a e, lexibili y and an h opome y. The g aphs show how he a iables ha e e ol ed be o e and a e aining and a i y he di e ences ha ha e been analyzed in Table 2. Figu e 1 shows how all s eng h a iables imp o e a e aining, wi h s a is ically signi ican di e ences. The chai s and es is he one wi h he g ea es absolu e di e ence (di Pos -P e = 2.56 ± 1.71). Figu e 1. S eng h a iable. P e = p e es ; Pos = pos - es ; CMJ = coun e mo emen jump es ; DH = dominan hand g ip es ; NDH = Non-dominan hand g ip es ; CH = chai s and es ; ep = epe i ions. Figu e 2 shows he ae obic a iable, dis ance in he six-minu e walking es , and a clea imp o emen is obse ed a e aining (di Pos -P e = 51.56 ± 48.26). Figu e 2. Dis ance in he six-minu e walking es . P e = p e es ; Pos = pos - es ; 6mw = six-minu e walking es . Figu e 3 g aphically analyzes he hea a e a iables and clea ly shows how hese wo a iables dec ease signi ican ly due o aining. Figu e 2. Dis ance in he six-minu e walking es . P e =p e es ; Pos =pos - es ; 6mw =six-minu e walking es . Figu e 3g aphically analyzes he hea a e a iables and clea ly shows how hese wo a iables dec ease signi ican ly due o aining. In . J. En i on. Res. Public Heal h 2020,17, 4938 7 o 12 In . J. En i on. Res. Public Heal h 2020, 17, x 7 o 12 Figu e 3. Hea a e in he six-minu e walking es . P e = p e es ; Pos = pos - es ; SHR = s a ing hea a e; FHR = inal hea a e; bpm = bea s pe minu e. Figu e 4 g aphically displays he lexibili y a iables whe e hey all p esen be e esul s a e aining, all o which a e s a is ically signi ican . Figu e 4. Flexibili y a iable. P e = p e es ; Pos = pos - es ; SR = si and each es ; DBS = dominan back sc a ch es ; NDBS = non-dominan back sc a ch es . Figu e 5 shows he an h opome ic a iables whe e all o hem imp o e a e he aining es s. These di e ences a e s a is ically signi ican . Figu e 3. Hea a e in he six-minu e walking es . P e =p e es ; Pos =pos - es ; SHR =s a ing hea a e; FHR = inal hea a e; bpm =bea s pe minu e. Figu e 4g aphically displays he lexibili y a iables whe e hey all p esen be e esul s a e aining, all o which a e s a is ically signi ican . In . J. En i on. Res. Public Heal h 2020, 17, x 7 o 12 Figu e 3. Hea a e in he six-minu e walking es . P e = p e es ; Pos = pos - es ; SHR = s a ing hea a e; FHR = inal hea a e; bpm = bea s pe minu e. Figu e 4 g aphically displays he lexibili y a iables whe e hey all p esen be e esul s a e aining, all o which a e s a is ically signi ican . Figu e 4. Flexibili y a iable. P e = p e es ; Pos = pos - es ; SR = si and each es ; DBS = dominan back sc a ch es ; NDBS = non-dominan back sc a ch es . Figu e 5 shows he an h opome ic a iables whe e all o hem imp o e a e he aining es s. These di e ences a e s a is ically signi ican . Figu e 4. Flexibili y a iable. P e =p e es ; Pos =pos - es ; SR =si and each es ; DBS =dominan back sc a ch es ; NDBS =non-dominan back sc a ch es . Figu e 5shows he an h opome ic a iables whe e all o hem imp o e a e he aining es s. These di e ences a e s a is ically signi ican . In . J. En i on. Res. Public Heal h 2020,17, 4938 8 o 12 In . J. En i on. Res. Public Heal h 2020, 17, x 8 o 12 Figu e 5. An h opome y a iable. P e = p e es ; Pos = pos - es ; W = weigh ; BMI = body mass index; TBF = o al body a ; TLM = o al lean mass; TBFP = pe cen age o o al body a . To sum up, he esul s in Table 3 a e displayed g aphically in he i e igu es. All ae obic, s eng h and lexibili y a iables imp o e, since hey p esen highe alues a e aining. Hea a e a iables imp o e by dec easing ensions a he end o he ac i i y. Finally, he an h opome ic a iables imp o e by lowe ing he alue o weigh , body mass index, o al body a and pe cen age o o al body a , in addi ion o inc easing he o al lean mass once he owing ac i i y is inished. 4. Discussion The s udy o b eas cance om he pe spec i e o physical ac i i y is ela i ely ecen , as demons a ed by he limi ed li e a u e and ecommenda ions published by he ACSM [31] less han six mon hs ago. A p e ious analysis iden i ied only a small numbe o a icles indica ing ha physical ac i i y causes nei he a posi i e no a nega i e eac ion in b eas cance su i o s [29–31]. Mos s udies, howe e , ha e ound ha physical ac i i y in indi iduals wi h b eas cance leads o a ange o imp o emen s, he mos no able being a dec ease in he pe cep ion o a igue [8,9] and he delay o absence o o he diseases such as b eas cance ecu ence [15–24]. Physical ac i i y has been shown o imp o e quali y o li e in b eas cance su i o s [12,13] and unc ionali y [14] in an isola ed way o associa ed wi h aspec s o physical i ness, including bo h join mobili y and muscle s eng h [20,23,27]. Th ough ac i i ies such as yoga o pila es [20,23], ae obic ac i i ies [32], speci ic s eng h p og ams [33], combined ae obic and muscle s eng h exe cises [35–37] o he p ac ice o d agon boa [42,46–48], imp o emen s in physical i ness ha e been ound, especially in s eng h in he ex emi ies [36,37] as well as in body composi ion [35]. Se e al s udies ha e conduc ed ae obic [33] o s eng h p og ams [34], which esul ed in imp o emen s in quali y o li e and physical i ness. Howe e , i should be no ed ha mos o he p e ious s udies implemen ed mixed in e en ions ollowing he ecommenda ions o he ACSM [32]. In ou owing aining p og am, he du a ion was wel e weeks, and he indings iden i ied signi ican imp o emen s in bo h he an h opome ic and physical i ness a iables analyzed. These esul s a e in line wi h hose o Dieli-Conw igh e al. (2018) and Thomas e al. (2018), in which imp o emen s in an h opome ic a iables we e epo ed a e a p og am o six een weeks and wel e mon hs, espec i ely [35,36]. In ou s udy, based on he adminis a ion o a owing aining p og am, imp o emen s we e obse ed in all body composi ion pa ame e s e alua ed h ough DXA, which dec eased o al body a and pe cen age o o al body a and inc eased lean mass (Table 3). All o hese imp o emen s we e signi ican and g ea e han in any p e ious s udies in he li e a u e. In addi ion, he esul s pe aining o physical i ness showed signi ican imp o emen s in he di e en s anda dized es s ha measu e a wide ange o mani es a ions o physical i ness including Figu e 5. An h opome y a iable. P e =p e es ; Pos =pos - es ; W =weigh ; BMI =body mass index; TBF = o al body a ; TLM = o al lean mass; TBFP =pe cen age o o al body a . To sum up, he esul s in Table 3a e displayed g aphically in he i e igu es. All ae obic, s eng h and lexibili y a iables imp o e, since hey p esen highe alues a e aining. Hea a e a iables imp o e by dec easing ensions a he end o he ac i i y. Finally, he an h opome ic a iables imp o e by lowe ing he alue o weigh , body mass index, o al body a and pe cen age o o al body a , in addi ion o inc easing he o al lean mass once he owing ac i i y is inished. 4. Discussion The s udy o b eas cance om he pe spec i e o physical ac i i y is ela i ely ecen , as demons a ed by he limi ed li e a u e and ecommenda ions published by he ACSM [ 31 ] less han six mon hs ago. A p e ious analysis iden i ied only a small numbe o a icles indica ing ha physical ac i i y causes nei he a posi i e no a nega i e eac ion in b eas cance su i o s [ 29 – 31 ]. Mos s udies, howe e , ha e ound ha physical ac i i y in indi iduals wi h b eas cance leads o a ange o imp o emen s, he mos no able being a dec ease in he pe cep ion o a igue [ 8 , 9 ] and he delay o absence o o he diseases such as b eas cance ecu ence [15–24]. Physical ac i i y has been shown o imp o e quali y o li e in b eas cance su i o s [ 12 , 13 ] and unc ionali y [ 14 ] in an isola ed way o associa ed wi h aspec s o physical i ness, including bo h join mobili y and muscle s eng h [ 20 , 23 , 27 ]. Th ough ac i i ies such as yoga o pila es [ 20 , 23 ], ae obic ac i i ies [ 32 ], speci ic s eng h p og ams [ 33 ], combined ae obic and muscle s eng h exe cises [ 35 – 37 ] o he p ac ice o d agon boa [ 42 , 46 – 48 ], imp o emen s in physical i ness ha e been ound, especially in s eng h in he ex emi ies [36,37] as well as in body composi ion [35]. Se e al s udies ha e conduc ed ae obic [ 33 ] o s eng h p og ams [ 34 ], which esul ed in imp o emen s in quali y o li e and physical i ness. Howe e , i should be no ed ha mos o he p e ious s udies implemen ed mixed in e en ions ollowing he ecommenda ions o he ACSM [ 32 ]. In ou owing aining p og am, he du a ion was wel e weeks, and he indings iden i ied signi ican imp o emen s in bo h he an h opome ic and physical i ness a iables analyzed. These esul s a e in line wi h hose o Dieli-Conw igh e al. (2018) and Thomas e al. (2018), in which imp o emen s in an h opome ic a iables we e epo ed a e a p og am o six een weeks and wel e mon hs, espec i ely [35,36]. In ou s udy, based on he adminis a ion o a owing aining p og am, imp o emen s we e obse ed in all body composi ion pa ame e s e alua ed h ough DXA, which dec eased o al body a and pe cen age o o al body a and inc eased lean mass (Table 3). All o hese imp o emen s we e signi ican and g ea e han in any p e ious s udies in he li e a u e. In . J. En i on. Res. Public Heal h 2020,17, 4938 9 o 12 In addi ion, he esul s pe aining o physical i ness showed signi ican imp o emen s in he di e en s anda dized es s ha measu e a wide ange o mani es a ions o physical i ness including uppe ex emi y and hip ange o mo ion, lowe and uppe ex emi y s eng h, ae obic capaci y and hea a e a es and a e p olonged e o . Consequen ly, he esul s o ou s udy can con ibu e o imp o ing he heal h and quali y o li e o women who ha e o e come b eas cance , o e ing hem a new s a egy o physical exe cise p esc ip ion o a p oblem ha a ec s mo e han wo million women each yea . 5. Conclusions Ou esea ch o e s a no el me hodological p oposal o physical exe cise p esc ip ion a e b eas cance h ough a aining p og am based on owing, a cyclic and symme ical spo ha combines o e all s eng h wi h ae obic endu ance. This new p oposal has a ela i ely sho du a ion, wel e weeks, and is capable o b inging abou imp o emen s in all aspec s o physical i ness and ca diac unc ion du ing s ess, as well as in an h opome ic pa ame e s such as a and lean mass. Au ho Con ibu ions: I.G.-F. and J.G.-G. concei ed and concep ualized he s udy. I.G.-F. and P.M.-M. collec ed and analyzed he da a. I.G.-F., J.C.F.-G., J.G.-G. and P.M.-M. conduc ed he necessa y li e a u e e iews and d a ed he i s manusc ip . J.C.F.-G. p o ided c i ical eedback and helped shape he analysis and manusc ip . All au ho s con ibu ed o he e ision and w i ing o he inal d a . All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch was unded by he “Resea ching in Spo Sciences” esea ch g oup (CTS-563) o he Andalusian Resea ch Plan. Acknowledgmen s: We would like o hank he Real Club Medi e aneo o Malaga, i s owing cap ain: Juan Ca los Ma il Rod í guez and he eam o he Malaga D agon Boa BCS o opening hei doo s o us, gi ing us all he acili ies in he wo ld and o gi ing us he mos impo an hing: hei ime and inspi ing us wi h hei impe us and ene gy, hanks o which we can p esen he i s esul s o his s udy. To Ma ia Repice, o he help wi h he English e sion o his manusc ip . Finally, we would also like o hank Alejand o S á nchez o his pa icipa ion in he da a collec ion o his s udy. Con lic s o In e es : The au ho s decla e no con lic o in e es . Re e ences 1. Wo ld Heal h O ganiza ion. B eas Cance : P e en ion and Con ol. A ailable online: h ps://www.who.in / opics/cance /b eas cance /en (accessed on 11 Ap il 2020). 2. In e na ional Agency o Resea ch on Cance . Cance Today. A ailable online: h ps://gco.ia c. / oday/home (accessed on 14 Ap il 2020). 3. In e na ional Agency o Resea ch on Cance . Cance Tomo ow. 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E ec s o a 12-week esis ance and ae obic exe cise p og am on muscula s eng h and quali y o li e in b eas cance su i o s: S udy p o ocol o he EFICAN andomized con olled ial. Medicine 2019 ,98, e17625. [C ossRe ] 8. Rome o-Ba que o, C. Ac i idad í sica en el iempo lib e p e iene en e medades ca diacas/ca dio ascula es: Una e isión sis emá ica. Re . Ibe oam. Cienc. Ac . Física y Depo e 2020,9, 1–22. [C ossRe ]