Land- and water-based aerobic exercise program on health-related outcomes in breast cancer survivors (WaterMama): study protocol for a randomized clinical trial

BACKGROUND

Breast cancer is a prevalent form of cancer among women worldwide, often accompanied by physical and psychological side effects due to the disease and the treatment's aggressiveness. Regular physical exercise has emerged as a non-pharmacological approach to improve the quality of life of breast cancer survivors. We herein report the protocol of the WaterMama Study, which aims to evaluate the effects of land- or water-based aerobic exercise programs, compared to a health education program, on cancer-related fatigue and other health-related outcomes in breast cancer survivors.

METHODS

The WaterMama trial is a randomized, single-blinded, three-arm, parallel, superiority trial. We aim to recruit 48 women ≥ 18 years of age who have completed primary treatment for stage I-III breast cancer. Participants are randomly allocated in a 1:1:1 ratio to 12-week interventions of aerobic exercise training programs either in the aquatic or land environment (two weekly 45-min sessions) plus health education (a weekly 45-min session), or an active-control group receiving health education alone (a weekly 45-min session). The primary outcome is cancer-related fatigue, and the secondary outcomes include cardiorespiratory fitness, muscular performance, muscle morphology, functional capacity, mental health, cognitive function, pain, and quality of life. Outcomes assessments are conducted before and after the 12-week intervention period. The analysis plan will employ an intention-to-treat approach and per protocol criteria.

DISCUSSION

Our conceptual hypothesis is that both aerobic exercise programs will positively impact primary and secondary outcomes compared to the health education group alone. Additionally, due to its multi-component nature, we expect the aquatic exercise program promote more significant effects than the land exercise program on cancer-related fatigue, muscular outcomes, and pain.

TRIAL REGISTRATION

The study was prospectively registered at ClinicalTrials.gov NCT05520515. Registered on August 26, 2022. https://clinicaltrials.gov/ct2/show/NCT05520515.

Cardiorespiratory Parameters Comparison Between Incremental Protocols Performed in Aquatic and Land Environments by Healthy Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

Physical properties of water cause physiological changes in the immersed human body compared with the land environment. Understanding the magnitude of cardiorespiratory alterations might ensure adequate intensity control during aquatic exercise programs.

OBJECTIVE

We aimed to compare the oxygen uptake (VO₂), heart rate (HR), and rating of perceived exertion (RPE) parameters during aquatic and land incremental tests.

METHODS

Four databases (PubMed, LILACS, EMBASE, and SPORTDiscus) were searched in September 2020. Eligibility criteria included studies in a crossover design comparing aquatic and land incremental tests for healthy individuals with at least one of the following parameters: VO₂ (maximal, VO_2max; anaerobic threshold, VO_2AT), HR (HR_max; HR_AT), and RPE (RPE_max; RPE_AT). The random-effects meta-analysis included mean difference and 95% confidence interval for VO₂ and HR or standardized mean difference for RPE. The Joanna Briggs Institute Critical Appraisal tool was adapted to assess methodological quality.

RESULTS

Twenty-eight studies were eligible and included in the meta-analysis. Aquatic protocols showed lower values compared with land for VO_2max (- 7.07 mL.kg^-1.min^-1; - 8.43 to - 5.70; n = 502), VO_2AT (- 6.19 mL.kg^-1.min^-1; - 7.66 to - 4.73; n = 145), HR_max (- 11.71 bpm; - 13.84 to - 9.58; n = 503), and HR_AT (- 15.29 bpm; - 19.05 to - 11.53; n = 145). RPE_max (0.01; - 0.16 to 0.18; n = 299) and RPE_AT (- 0.67; - 1.35 to 0.02; n = 55) values were similar between aquatic and land protocols.

CONCLUSIONS

Our study reinforces the specificity of the environment during incremental tests for prescribing exercises based on physiological parameters as VO₂ and HR parameters presented lower values in aquatic protocols than land protocols. Conversely, RPE seems an interchangeable measure of exercise intensity, with similar values during the protocols in both environments. Substantial levels of heterogeneity were present for the VO_2max and HR_max meta-analyses, and as such, results should be interpreted with attention. PROTOCOL REGISTRATION: This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42020212508).

Anaerobic Threshold in a Water-Based Exercise: Agreement Between Heart Rate Deflection Point and Lactate Threshold Methods

ABSTRACT

Alberton, CL, Andrade, LS, Pinheiro, RB, and Pinto, SS. Anaerobic threshold in a water-based exercise: agreement between heart rate deflection point and lactate threshold methods. J Strength Cond Res 35(9): 2472-2478, 2021-The purpose of this study was to compare and assess the agreement of the heart rate (HR) and rating of perceived exertion (RPE) corresponding to the anaerobic threshold (AT) between HR deflection point (HRDP) and lactate threshold (LT) methods during a water-based exercise in young men. Sixteen young men (24 ± 6 years) performed the experimental protocol, which comprised the performance of a maximal incremental test during the water-based stationary running exercise. The initial cadence corresponded to 90 b·min-1, with 10 b·min-1 increases every 3 minutes up to exhaustion. Heart rate was monitored every 30 seconds while blood lactate concentrations and RPE were measured at the end of each 3-minute bout. Anaerobic threshold was identified by HRDP and LT methods by experienced physiologists. Paired Student's t-test, Bland-Altman analysis, and Pearson correlation were used for data analysis (α = 0.05). As results, there was agreement between HRDP and LT methods for HR, while RPE presented significant higher values for the HRDP method, resulting in an absence of acceptable agreement between methods. In addition, strong relationships (p ≤ 0.001) were verified between methods of AT determination for HR (r = 0.786) and RPE (r = 0.916). Therefore, based on the agreement between HRDP and LT methods, the HR determined by HRDP may be a valid parameter used for the intensity prescription of water-based stationary running exercise in young men during water aerobics programs and may be considered more reliable than RPE.

Validity of differentiated ratings of perceived exertion for use during aquatic cycling

BACKGROUND

Although aquabiking has become widespread, the assessment of the intensity for aquatic cycling remains poorly defined.

METHODS

This study investigated the validity of differentiated ratings of perceived exertion (dRPE) recorded from the chest (RPE-chest) and legs (RPE-legs) during aquatic cycling and aimed to determine a simple and accurate estimate of dRPE to regulate aquabiking. Twelve active young subjects performed a pedaling task on an immersed ergocycle using randomly imposed cycling cadences ranging from 50 to 100 rpm in 3-minute steps interspersed by 3-minute active recovery periods. dRPE and cardiorespiratory responses (heart rate [HR]; percentage of heart rate peak value [%HR<inf>peak</inf>]; oxygen uptake [V̇O<inf>2</inf>]<inf>;</inf> and percentage of peak oxygen uptake [%V̇O<inf>2peak</inf>]) were measured during the last minute of each level.

RESULTS

The data described three-step relationships between dRPE and rpm. RPE-chest and RPE-legs increased linearly only for cadences between 60 and 90 rpm (r=0.81 and r=0.88, respectively; P<0.001). At these cadences, significant relationships were also observed between dRPE and all the physiological data (highest Pearson product moment for %V̇O<inf>2peak</inf>: 0.81 for RPE-chest and 0.88 for RPE-legs, P<0.0001). Last, the classic signal dominance from the legs was observed (RPE-legs>RPE-chest, P<0.0001) but was reduced compared with data obtained during dryland cycling, suggesting a modulating effect of the aquatic medium.

CONCLUSIONS

Cycling cadence was the better estimator of RPE-legs, which seemed to be the more appropriate dRPE to regulate the intensity of aquabiking in a safe range of pedaling rates.

Long-Term Effects of Three Water-Based Training Programs on Resting Blood Pressure in Older Women

The aim of the study was to compare the effects of three water-based training on blood pressure (BP) in older women. A total of 57 participants were randomized into the following groups: (a) aerobic training (AT), (b) concurrent training in which resistance training progresses to the use of resistive equipment (CTRE), and (c) concurrent training in which resistance training progresses to multiple sets (CTMS). The participants trained twice a week for 16 weeks. Systolic BP decreased from pretraining to after 8 weeks of training and, subsequently, to after 16 weeks of training (AT: -6.53 mmHg, CTRE: -10.45 mmHg, and CTMS: -10.73 mmHg). Diastolic BP decreased from pretraining to after 8 and 16 weeks of training (AT: -6.23 mmHg, CTRE: -4.61 mmHg, and CTMS: -6.19 mmHg). Furthermore, 16% of the AT participants, 23% of the CTRE participants, and 28.5% of the CTMS participants were no longer classified as hypertensive. Water-based aerobic and concurrent training are efficient nonpharmacological measures to reduce BP in older women.

Relationship between Oxygen Uptake, Heart Rate, and Perceived Effort in an Aquatic Incremental Test in Older Women

Different parameters can be used to control the intensity of aerobic exercises, a choice that should consider the population and exercise environment targeted. Therefore, our study aimed to verify the relationship between oxygen uptake (VO₂), heart rate (HR), rating of perceived exertion (RPE), and cadence during an aquatic incremental test in older women. Nine older women (64.3 ± 4.4 years) engaged in a water-based aerobic training performed an aquatic incremental test using the stationary running exercise (cadence increases of 15 b·min⁻¹ every 2 min) until participants’ volitional exhaustion. VO₂, HR, and RPE data were measured, and the percentage of peak VO₂ (%VO_2peak) and percentage of maximal HR (%HR_max) were calculated. Linear and polynomial regression analyses were performed (α = 0.05). Polynomial regressions revealed the best adjustments for all analyses. Data showed a significant relationship (p < 0.001) between %VO_2peak and %HR_max (r = 0.921), %VO_2peak and RPE (r = 0.870), and %HR_max and RPE (r = 0.878). Likewise, significant relationships between cadence (p < 0.001) and %VO_2peak (r = 0.873), %HR_max (r = 0.874), and RPE (r = 0.910) were also observed. In summary, the physiological, subjective, and mechanical variables investigated were highly associated during an aquatic incremental test to exhaustion in older women. Therefore, these different parameters can be employed to adequately prescribe water-based programs according to preference and availability.

Head-Out Water-Based Protocols to Assess Cardiorespiratory Fitness-Systematic Review

The aquatic environment offers cardiorespiratory training and testing options particularly for individuals unable to adequately train or test on land because of weight bearing, pain or disability concerns. No systematic review exists describing cardiorespiratory fitness protocols used in an aquatic environment. This review investigated the different head-out water-based protocols used to assess cardiorespiratory fitness. Our comprehensive, systematic review included 41 studies with each included paper methodological quality assessed using the statistical review of general papers checklist. Diverse protocols arose with three major categories identified: conducted in shallow water, deep water, and using special equipment. Thirty-seven articles presented data for peak/maximal oxygen consumption (VO_2peak/VO_2max). Twenty-eight of 37 studies predefined criteria for reaching a valid VO_2peak/VO_2max with shallow water exercise demonstrating 20.6 to 57.2 mL/kg/min; deep water running 20.32 to 48.4 mL/kg/min; and underwater treadmill and cycling 28.64 to 62.2 mL/kg/min. No single, accepted head-out water-based protocol for evaluating cardiorespiratory fitness arose. For clinical use three cardiorespiratory fitness testing concepts ensued: water temperature of 28–30 °C with difference of maximum 1 °C between testing participants and/or testing sessions; water depth adapted for participant aquatic experiences and abilities; and intensity increment of 10–15 metronome beats per minute.

Land vs. water HIIE effects on muscle oxygenation and physiological parameter responses in postmenopausal women

Muscle oxygenation (MO) status is the dynamic balance between O₂ utilization and O₂ delivery. Low-impact high-intensity interval exercise MO responses in the exercise and recovery stage are still unclear. We compared the differences in MO and physiological parameters between high-intensity interval water-based exercise (WHIIE) and high-intensity interval land bike ergonomic exercise (LBEHIIE) in postmenopausal women. Eleven postmenopausal women completed WHIIE or LBEHIIE in counter-balanced order. Eight sets were performed and each exercise set included high intensity with 80% heart rate reserve (HRR) in 30 s and dynamic recovery with 50% HRR in 90 s. Muscle tissue oxygen saturation index (TSI), total hemoglobin (tHb), oxy-hemoglobin (O₂Hb), and deoxy-hemoglobin (HHb) were recorded. Blood lactate, heart rate and rating of perceived exertion (RPE) were measured at pre and post-exercise. Under similar exercise intensity, RPE in WHIIE was lower than that in LBEHIIE. The heart rate in WHIIE was lower than that in LBEHIIE at 1 and 2 min post-exercise. During the dynamic recovery, TSI, tHb, and O2Hb in water were higher than on land. A negative correlation was found between the change in TSI and lactate concentration (r = − 0.664). WHIIE produced greater muscle oxygenation during dynamic recovery. Muscle TSI% was inversely related to blood lactate concentration during exercise in water.

Randomized Clinical Trial of Water-Based Aerobic Training in Older Women (WATER Study): Functional Capacity and Quality of Life Outcomes

BACKGROUND

The purpose of this study was to investigate the effects of 2 water-based aerobic training programs on functional capacity and quality of life (QoL) of older women.

DESIGN

Randomized clinical trial.

METHODS

A total of 41 women (64.3 [3.1] y) were randomized into a continuous (CTG) and an interval (ITG) water-based aerobic training group. Training programs were performed with exercise intensity based on rating of perceived exertion throughout 12 weeks (twice a week). Functional tests with and without dual-task and QoL questionnaire were applied pretraining and posttraining. Per protocol and intention to treat analysis were conducted using generalized estimating equations, with Bonferroni post hoc test (α = .05).

RESULTS

The per protocol analysis showed an increase in the 30-second chair stand (6% [12%] vs 18% [13%]), 6-minute walk (4% [7%] vs 2% [8%]), and 5-m habitual gait velocity (6% [11%] vs 4% [7%]) tests after CTG and ITG training groups. In addition, the intention to treat analysis revealed an increase in the 30-second chair stand test (7% [13%] vs 12% [13%]) and physical domain of QoL (8% [26%] vs 14% [22%]) after CTG and ITG training groups, as well as an increase in the gait velocity with verbal task after CTG (6% [11%]).

CONCLUSIONS

Both water-based aerobic training programs induced similar improvements in the functional capacity and maintained the QoL perception in older women.

Acute Effects of Water-Based Concurrent Training Intrasession Exercise Sequences on Energy Expenditure in Young Women

BACKGROUND

To compare the acute effects of water-based aerobic-resistance and resistance-aerobic concurrent training (CT) sessions on energy expenditure (EE) during and postexercise in young women.

METHODS

Nine active women (24 [3] y; 60 [5] kg) completed 4 sessions: (1) familiarization, (2) aquatic maximal test to determine the heart rate corresponding to the anaerobic threshold, (3) CT protocol with aerobic-resistance sequence, and (4) CT protocol with resistance-aerobic sequence. Both protocols started and ended with the participants in the supine position for 30 minutes to perform resting and postexercise oxygen consumption measurements. The water-based resistance protocol comprised 4 sets of 15 seconds at maximal velocity, and the water-based aerobic protocol was performed at a continuous intensity (heart rate corresponding to the anaerobic threshold). EE measurements were calculated based on oxygen consumption and the corresponding caloric equivalent. Paired t test was used to compare the EE values between the water-based CT intrasession exercise sequences (α = .05).

RESULTS

There was no difference between the water-based aerobic-resistance and resistance-aerobic in total EE (330.78 vs 329.56 kcal; P = .96), EE per minute (7.35 vs 7.32 kcal·min-1; P = .96), and postexercise EE (63.65 vs 59.92 kcal; P = .50).

CONCLUSIONS

The intrasession exercise sequence during water-based CT had no influence on the EE in young women.

Water-based exercises in pregnancy: Apparent weight in immersion and ground reaction force at third trimester

BACKGROUND

The morphological alterations during pregnancy may affect the biomechanical loads during exercise practice. Aquatic exercises may suit pregnant women, who are recommended to exercise with low vertical ground reaction force loads. Therefore, the study aimed to determine the apparent weight reduction during immersion and the vertical ground reaction force of three specific water-based exercises in pregnant women at the third trimester.

METHODS

Eleven pregnant women volunteered to take part in the study [32.0 (SD 1.3) weeks, 28.1 (SD 5.7) years, 72.5 (SD 10.1) kg]. The protocol started with the participants immersed to the xiphoid process depth for the apparent weight assessment. Then, three water-based exercises (stationary running, frontal kick and butt kick) were randomly performed at a pre-selected cadence, with 5-min interval. The vertical ground reaction force was measured in each exercise and peak, impulse, contact time and swing time were determined. Repeated measures ANOVA was used (α = 0.05).

FINDINGS

The apparent weight reduction resulted a mean of 82.9 (SD 6.5)% of body weight. Peak, impulse, contact time and swing time revealed no significant difference between exercises (P > 0.05). Values of peak of vertical ground reaction force ranged from 0.67 to 0.72 units of body weight.

INTERPRETATION

Pregnant women at the third trimester can benefit from the apparent weight reduction during immersion for exercising. The three water-based exercises presented similar vertical ground reaction force values, which are considered as low odds for musculoskeletal injuries. Therefore, these findings highlight the safety of the water-based exercise program during pregnancy.

Energy expenditure and EPOC between water-based high-intensity interval training and moderate-intensity continuous training sessions in healthy women

The present study compared the energy expenditure (EE) during and after two water aerobics protocols, high-intensity interval training (HIIT) and moderate continuous training (CONT). A crossover randomized design was employed comprising 11 healthy young women. HIIT consisted of eight 20s bouts at 130% of the cadence associated with the maximal oxygen consumption (measured in the aquatic environment) with 10s passive rest. CONT corresponded to 30 min at a heart rate equivalent to 90-95% of the second ventilatory threshold. EE was measured during and 30 min before and after the protocols and excess post-exercise oxygen consumption (EPOC) was calculated. Total EE during session was higher in CONT (227.62 ± 31.69 kcal) compared to HIIT (39.91 ± 4.24 kcal), while EE per minute was greater in HIIT (9.98 ± 1.06 kcal) than in CONT (7.58 ± 1.07 kcal). Post-exercise EE (64.48 ± 3.50 vs. 63.65 ± 10.39 kcal) and EPOC (22.53 ± 4.98 vs.22.10 ± 8.00 kcal) were not different between HIIT and CONT, respectively. Additionally, oxygen uptake had already returned to baseline fifteen minutes post-exercise. These suggest that a water aerobics CONT session results in post-exercise EE and EPOC comparable to HIIT despite the latter supramaximal nature. Still, CONT results in higher total EE.

Acute effects of high-intensity interval training and moderate-intensity continuous training sessions on cardiorespiratory parameters in healthy young men

PURPOSE

The aim of the present study was to compare the energy expenditure (EE) during and after two treadmill protocols, high-intensity interval training (HIIT) and moderate continuous training (CONT), in young adult men.

METHODS

The sample was comprised by 26 physically active men aged between 18 and 35 years engaged in aerobic training programs. They were divided into two groups: HIIT (n = 14) which performed eight 20 s bouts at 130% of the velocity associated with the maximal oxygen consumption on a treadmill with 10 s of passive rest, or CONT (n = 12) which performed 30 min running on a treadmill at a submaximal velocity equivalent to 90-95% of the heart rate associated with the anaerobic threshold. Data related to oxygen consumption ([Formula: see text]) and EE were measured during the protocols and the excess post-exercise oxygen consumption (EPOC) was calculated for both sessions.

RESULTS

No difference was found between groups for mean [Formula: see text] (HIIT: 2.84 ± 0.46 L min^-1; CONT: 2.72 ± 0.43 L min^-1) and EE per minute (HIIT: 14.36 ± 2.34 kcal min^-1; CONT: 13.21 ± 2.08 kcal min^-1) during protocols. Regarding total EE during session, CONT resulted in higher values compared to HIIT (390.45 ± 65.15; 55.20 ± 9.33 kcal, respectively). However, post-exercise EE and EPOC values were higher after HIIT (69.31 ± 10.88; 26.27 ± 2.28 kcal, respectively) compared to CONT (55.99 ± 10.20; 13.43 ± 10.45 kcal, respectively).

CONCLUSION

These data suggest that supramaximal HIIT has a higher impact on EE and EPOC in the early phase of recovery when compared to CONT.