Francini, L

Galanti, Giorgio

Maffulli, N

Mascherini, Gabriele

Petri, C

Stefani, Laura

English

Florence Research

Translational Medicine @ UniSa - ISSN 2239-9747 2015, 11(7): 39-43  39 Università degli Studi di Salerno EXERCISE AS PRESCRIPTION THERAPY: BENEFITS IN CANCER AND HYPERTENSIVE PATIENTS  Laura Stefani1, Nicola Maffulli2, Gabriele Mascherini1, Lorenzo Francini1, Cristian Petri1, Giorgio Galanti1. 1Sports Medicine Center, Florence, Italy. 2Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery,University of Salerno, Salerno, Italy; and Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Institute of Health Sciences Education, Centre for Sports and Exercise, UK laura.stefani@unifi.it; gabriele.mascherini@unifi.it; lorenzo.francio@gmail.com; cristian.petri25@gmail.com; giorgio.galanti@unifi.it Corresponding author: Nicola Maffulli Keywords: exercise therapy, life style, chronic disease, body composition   ABSTRACT: PURPOSE  Exercise therapy in patients with metabolic  chronic disease  produces   several positive response. This study aims  to verify  the effects  of fast  walking associated to a resistance exercise to reduce cardiovascular risk factor. METHODS:  Two  groups  of  subjects (10 cancer  survivors and 19 hypertensive patients) were   evaluated  by  6-Minute Walking Test (6MWT), bioimpedance, ,  the Sit & Reach Test (S&R) evaluate  the flexibility, Handgrip and 30’’ Chair Test for muscular strength. Patients were tested before and after 3 months of regular physical exercise. RESULTS: A significant  change in anthropometric parameters  was observed (BMI: T0 =  29.2±6.8, T3= 27.4±4.4 kg/m2  p<.001; waist circumference: T0=92.5±14.1, T3=92.1±12.8 cm, p<.05) in the  hypertensive  population.  A  predominant  improvement  of  the  cardiovascular parameters was observed in the cancer survivors (rest DBP T0=76.4±6.5, T3=72.2±7.1 mmhg p<.05; 6MWT: T0=487.8±116.0, T3= 525.6±117.3 m  p<.05; S&R: T0= 0.4±7.4, T3=4.1±6.1 cm p<.05). CONCLUSION: A combined aerobic and resistance exercise programme can  improve cardiovascular  risk factors in hypertensive  subjects. The same  programme induces improvement in exercise  tolerance and  flexibility  variables in cancer survivors.   INTRODUCTION: Marked technological and pharmacological advances in the management of cardiovascular disease and its associated risk factors have been made [1]. The positive effects of exercise as a prescription therapy, especially fast walking programme, in patients with chronic metabolic disease have been recently demonstrated  [2]. Hypertension remains a major public health problem [3]. Cancer is the second  cause of death, and is superimposed to metabolic conditions including obesity or overweight. Non supervised exercise programmes have been proposed in both cancer and hypertensive patients  [4]. Many clinical trials in this field are limited to  a few weeks, and do not investigate the effects of the combination of the aerobic and resistance  exercise. In addition, the global response and the possible differences between these two conditions after a short period of training  have not been investigated. The present study aims to verify the possible impact of a non supervised aerobic exercise programme associated to resistance exercise on several anthropometric and haemodynamic variables in cancer and hypertensive patients.  METHODS: Two groups of subjects (one composed of 5 female breast and 5 male colon overweight cancer survivors, aged 48.8 ±4.6, in good clinical conditions, previously treated with chemotherapy,  without   evidence of  cardiovascular disease;  the  other of  19 subjects, aged 54.3± 3.7 affected by  mild hypertension  under pharmacological management) took part in the present study. They were prescribed an exercise programme composed of aerobic (fast walking) and resistance exercises (home based exercises for the upper and lower limb, without weight lifting at the beginning of the programme). Lifestyle was evaluated by a questionnaire to ascertain their levels of physical activity. Following the ACSM guidelines, the intensity of aerobic exercise was set at 60% maximal effort  for at  least three times a week for at least three months  The resistance exercises programme included simple exercises: home based isotonic exercise for the upper and lower limb, without weight lifting at the beginning of the program. Initially, we recommended 2 sets of 10 repetitions per each set to increase according to subjective perception, never exceeding 3 sets of 20 repetitions for each exercise. Flexibility exercises involving the calf muscles, quadriceps and hamstring consisted of one set of static stretching exercises in which the subject maintained the stretch for at least one minute.  The aerobic exercise prescription was based on the results of the 6-Minute Walking Test (6MWT): heart rate, respiratory rate, systolic and diastolic blood pressure (DBP) were assessed at rest and at the end of the test [5]. The intensity  of the  aerobic  exercise was  Translational Medicine @ UniSa - ISSN 2239-9747 2015, 11(7): 39-43  40 Università degli Studi di Salerno obtained by the  formula (HRt = 60%  × (HRmax − HRrest) + HRrest,) where HRt is the target heart rate, HRmax is maximum heart rate, and HRrest is heart rate at rest. Heart  rate values were  evaluated  using a  dedicated software (Zephyr Bioharness model 9600.0091, Annapolis, Maryland U.S.A.) for  telemetry using an elastic strap placed on the chest. The  heart rate corresponding to 60%  of the final value  obtained was the target of the intensity of  the  exercise  corresponding  to  the maximum tolerated effort per each subject. Following  the  ACSM  guidelines, the duration of the aerobic exercise per session  was 30 minute for at  least  3 times  a week, up  to a maximum of  150 min per week. The duration of the aerobic  exercise, was established  also from  the  effective effort tolerance  derived from the CR10  scale  evaluation  at  the  end  of  the 6MWT test.  The results of the 6MWT were  integrated with the CR10 score to determine the final intensity of the aerobic exercise in term of heart rate  per minute  [6]  We measured the distribution of the Intra (ICW) and Extracellular (ECW) water by Bioimpedance (BIA) analysis [7] The data collected were processed with a dedicated software (Bodygram pro 3.0). We measured weight, height, Body Mass Index (BMI), Basal Metabolism (BM), Phase Angle (PA), Free Fat Mass (FFM), Fat Mass (FM), Total Body Water (TBW), Extra Cellular Water (ECW), Intra Cellular Water (ICW), Body Cellular Mass (BCM).  For resistance exercise prescription, the muscle strength of the upper and lower limbs  and flexibility were evaluated by the Sit & Reach Test (S&R), the Handgrip, and the 30” Chair Test [8]. All the tests were performed at baseline and after 3 month of regular physical exercise. RESULTS: At baseline, both groups were at the upper limits of the overweight range. After 3 months of regular and unsupervised mixed exercises, a  significant reduction of anthropometric variables was evident (Tab. 1) Blood Pressure remained unchanged. The cardiovascular and resistance exercises variables improved significantly in the cancer group, but remained unchanged in the hypertensive group (Tab. 1)                                                                          Translational Medicine @ UniSa - ISSN 2239-9747 2015, 11(7): 39-43  41 Università degli Studi di Salerno        . Cancer T0 Cancer T3 p value Hypertensive T0 Hypertensive T3 p value Age (years) 48.8 ± 4.6   54.3±3.7   Height (cm) 165.5±12.0 165.5±12.0 NS 163.5±10.0 163.5±10.0 NS Weight (kg) 82.2±23.5 80.6±21.6 NS 77.9±16.6 76.2±15.8 <0.00 BMI (kg/m2) 30.3±10.3 29.8±9.7 NS 29.2±6.8 27.4±4.4 <0.00 Abdominal (cm) 92.4±19.2 90.9±17.3 NS 92.5±14.1 92.1±12.8 <0.05 waist (cm) 109.2±21.1 110.5±19.2 NS 101.1±8.6 101.0±8.5 NS Abd/Waist 0.8±0.1 0.8±0.1 NS 0.9±0.1 0.9±0.1 NS RZ (ohm) 542.7±91.2 569.7±104.1 <0.05 520.5±82.8 513.4±86.0 NS XC (ohm) 59.9±10.5 61.4±11.6 NS 58.1±17.6 55.9±12.3 NS PA (°) 6.4±1.1 6.2±0.7 NS 6.4±1.4 6.2±1.1 NS TBW (Lt) 38.1±8.2 37.0±7.9 <0.04 39.9±8.6 38.1±8.1 NS ECW (Lt) 16.9±3.9 16.7±3.8 NS 17.5±3.7 17.2±3.9 <0.05 ICW (Lt) 21.2±4.9 20.3±4.6 NS 20.9±4.8 21.9±4.2 NS BMR (kcal) 1521.1±152.8 1525.0±182.7 NS 1536.4±187.5 1556.1±174.5 NS Rest HR (bpm) 77.1±9.2 74.0±12.4 NS 76.3±12.1 71.2±9.9 NS HR 6'WT (bpm) 137.4±12.9 131.5±15.2 NS 126.9±18.2 127.9±15.3 NS RR 6'WT (bpm) 30.0±6.7 29.0±5.3 NS 42.5±19.6 39.5±9.1 NS rest SBP (mmhg) 121.7±8.7 118.3±13.2 NS 128.3±7.5 126.9±12.5 NS rest DBP (mmhg) 76.4±6.5 72.2±7.1 <0.05 82.0±7.1 78.1±9.9 NS SBP 6'WT (mmhg) 141.7±10.9 135.3±7.1 NS 153.8±8.3 141.8±12.0 NS DBP 6'WT (mmhg) 73.7±6.3 70.6±6.8 NS 75.6±8.6 72.5±6.4 NS  6'M WT (m) 487.8±116.0 525.6±117.3 <0.05 590.0±67.3 575.4±56.9 NS CR10 5.7±3.3 4.9±2.9 NS 3.0±2.1 2.7±2.1 NS Sit & Reach (cm) 0.4±7.4 4.1±6.1 <0.05 -5.2±8.3 -6.2±6.5 NS Chair Test (rip) 11.8±2.2 14.1±3.9 NS 16.6±3.4 16.4±2.8 NS Hand Grip right (kg) 29.3±17.2 27.5±5.1 NS 36.3±10.2 33.8±11.6 NS Hand Grip left (kg) 30.5±13.4 27.2±5.6 NS 34.0±9.1 33.2±11.9 NS Table 1: results of 3 months of exercise in all parameters evaluated Legend: BMI (Body Mass Index); Abd/Waist (Abdominal/waist); RZ (Resistance);  XC(Reactance); PA (Phase Angle); TBW (Total Body Water); ECW (Extra Cellular Water); ICW (Intra Cellular  Water); BMR (Body Metabolic Rate); HR(Heart Rate); HR6’WT(Heart Rate 6 minute  Walking Test); RR 6’WT (Respiratory Rate 6 minute Walking Test); SBP(Systolic Blood Pressure); DBP (Diastolic Blood  Pressure); CR10(Category-Ratio scale of Effort),   Translational Medicine @ UniSa - ISSN 2239-9747 2015, 11(7): 39-43  42 Università degli Studi di Salerno DISCUSSION The  number of cancer survivors is now growing. In parallel, the amount of aged subjects with increased cardiovascular risk is increasing (11,12). The presence of metabolic syndrome in cancer represents often the main reason to introduce new treatment strategies. The onset of metabolic syndrome in cancer survivors may cause the long term morbidities the complications of which can interfere with cancer treatment and worsen  the quality of  life. Regular physical exercise has antinflammatory effects, which may benefit cancer patients (13). The adipose tissue is the primary site of production of inflammatory factors, as IL6, TNF, and it can be responsible, in the tumorgenesis process, for the activation of distant metastases(14).Aerobic  [9] and resistance exercise [10] can each produce  significant positive effects on body fitness, muscle function and body composition, both in hypertensive patients and  in cancer survivors. The combination of aerobic and resistance exercise can reduce the metabolic risk factors in cancer survivors and in hypertensive patients.  The present study has shown that in cancer survivors a short period of mixed aerobic and resistance exercises, a predominant  improvement in aerobic exercise tolerance and flexibility. This is not the case in hypertensive patients, in whom it is possible that the duration and intensity of the exercise programme used in the present study is not sufficient to elicit the desired effect.   These results support the short term efficacy of non supervised  and combined aerobic and resistance exercise programme.  The effects of such exercise programme are different in these two groups of patients, and will need  further investigations with larger cohorts and longer follow up. Nevertheless, the results are promising, and may result in a greater rate of exercise prescription in these patients, with reduction of cardiovascular risk factors and improvement in quality of life.   Acknowledgments The authors all the individuals who took part in the research study described in this manuscript.  References  1.  Myron L, Weisfeldt and Susan J, Zieman. Advances in the prevention and treatment of cardiovascular disease. Health Aff 2007;26;25-37 2.  Thompson P.D. ; Buchner D; Piña I.L., et al. Exercise and Physical Activity in the Prevention and Treatment of Atherosclerotic Cardiovascular Disease  2003;107:3109-3116 3. Drazner MH. The progression of Hypertensive Heart Disease. American Heart Association, 2011;123:327-334 4. Stefani  L, Mascherini G, Scacciati I, De Luca  A, Maffulli N, Galanti G  Positive  effects  of the use of accelerometry on lifestyle awareness of overweight hypertensive  patients Asian Journal of Sports Medicine  2013 vol 4 n4, 241-248 5.  Solway S, Brooks D, Lacasse Y, Thomas S. A qualitative systematic overview of the measurement properties of functional walk tests used in the cardiorespiratory domain. Chest 2001;119:256–270 6. Borg GAV. Psycho-physical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377–381. 7. Lukaski HC, Piccoli A, Bioelectrical Impedance Vector Analysis for Assessment of Hydration in Physiological States and Clinical Conditions, Handbook of Anthropometry, 2012, pp 287-305 8. Shephard RJ Measurements of fitness. The Canadian experience. J Sports Med Phys Fitness.1991 Sep;31(3):470-80. 9. Guinan E, Hussey J, Broderick JM, Lithander FE, O’Donnell D, Kennedy MJ, Connoly EM. The effect of aerobic exercise on metabolic and inflammatory markers in breast cancer survivors: a pilot study. Support Care Center,2013;21(7):1983-92 10. Strasser B, Steindorf K, Wiskemann J, Ulrich CM Impact of resistance training in cancer survivors: a meta-analysis. Med Sci Sports Exerc.2013 Nov;45(11):2080-90. doi: 10.1249/MSS.0b013e31829a3b63. 11. American Cancer Society, Intramural Research 2012, Cancer Treatment & Survivorship Facts & Figures 2012-2013 12. Xue F, Michels KB..Diabetes, metabolic syndrome, and breast cancer: a review of the current evidence. Am J Clin Nutr. 2007 Sep;86(3):s823-35 13. Wilma Kuijpers1, MSc; Wim G Groen; Neil K Aaronson; Wim H van Harten  A Systematic Review of Web-Based Interventions for Patient Empowerment and Physical Activity in Chronic Diseases: Relevance for Cancer Survivors.J Med Internet Res 2013;15(2):e37) doi:10.2196/jmir.2281 14. A M Lorincz, S Sukumar. Molecular links between obesity and breast cancer  Endocrine-Related Cancer (2006) 13 279–292   Translational Medicine @ UniSa - ISSN 2239-9747 2015, 11(7): 39-43  43 Università degli Studi di Salerno  

Exercise as prescription therapy: benefits in cancer and hypertensive patients.

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Exercise as prescription therapy: benefits in cancer and hypertensive patients.

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