Water and Land-based Aerobic Training in Breast Cancer Survivors

First, the participants are kept seated at rest for 5 min in a calm environment to take heart rate (HR) measurements at rest using a heart rate monitor (H10, Polar, Finland). Peak oxygen consumption (VO2peak), oxygen uptake in the first ventilatory threshold (VO2VT1) and oxygen uptake in the second ventilatory threshold (VO2VT2) are determined from a maximal incremental treadmill test (KIKOS, São Paulo - São Paulo, Brazil). Warming up is carried out for 3 min with a gradual increase in speed until reaching 3 km.h-1, and then the test starts at 3 km.h-1 with sequential increments of 0.5 km.h-1 every minute, and a 1% increase in grade every 2 min until maximum effort. The test is finished when the participant can no longer to exercise at a given workload, indicating exhaustion. All tests are supervised by a trained exercise physiologist and a physician.

The maximum dynamic muscle strength of knee extensors will be measured through the one-repetition maximal test (1RM) performed in an extension chair. The 1RM value is considered the greatest load that the participant could lift for one complete repetition (i.e., concentric and eccentric phase) following a predetermined cadence (i.e., approximately 2 s per phase) controlled by a digital app (Metronome). The 1RM of each participant is determined within five attempts, and at least 3 min of rest interval was given between trials. A new load was estimated using correction factors (Lombardi, 1989) for the subsequent trial when the participant could perform more than one complete repetition. The test is rescheduled if the value of 1RM is not determined between the five attempts. According to a previous study from our laboratory (Andrade et al. 2020), the range of motion is individualized for each participant and controlled by a range of motion custom-build device.

The same knee extension machine is used to assess dynamic muscular endurance. To do so, participants perform the maximal number of bilateral knee extension repetitions at 60% of their 1RM. The test cadence (2 s for each contraction phase) and range of motion are the same for the 1RM test. The post-intervention assessment is performed using the same absolute load employed at baseline (i.e., 60% of baseline 1RM).

The Arm Curl test is performed to measure the strength of the upper limbs. Starting at full elbow extension and holding a 2 kg dumbbell in each hand, participants are instructed to perform the maximal number of elbow crunches over the full range of motion for 30 s. The test is performed with both upper limbs.

The 30-s Chair-Stand test is performed to measure the strength of the lower limbs. Participants are instructed to sit and stand up from a chair 43 cm high from the seat, without the aid of the upper limbs, as many times as possible during 30 s.

The 8-ft Up-and-Go test is performed to measure agility and dynamic balance. Participants are instructed to get up from the chair (43 cm), turn around a marker that will be 2.44m, and return to the starting position. The shortest time of two attempts will be considered as a result.

The Chair Sit-and-Reach test is performed to measure the flexibility of the lower limbs. Participants sit on the front edge of a chair and extend one leg straight out in front of the hip, with foot flexed and heel resting on the floor (the other leg is bent, foot flat on the floor). The object is to reach as far forward as possible toward (or past) the toes. The investigator uses a ruler noting the cm left to reach the toe (negative score) or the cm that went past the toe (positive score).

The Back Scratch test is performed to measure the flexibility of the upper limbs. Participants are instructed to try to touch the middle fingers of both hands together behind the back. The investigator uses a ruler noting the cm left to reach the middle fingers (negative score) or the cm that the middle fingers overlapped (positive score).

The 6-min Walk test is performed to measure aerobic fitness. The course proposed in the original test is 45.72 m rectangular. The course will be adapted for a straight line with 30 m length, demarcated with cones every 3 m. Participants are instructed to walk for 6-min in a flat 30m course, in which the total distance walked "as fast as possible" is assessed.

Transversal images of the four portions of the quadriceps femoris are obtained by B-mode ultrasonography with a 7.5 megahertz linear array probe. Images of the vastus lateralis (VL), rectus femoris (RF), and vastus intermedius (VI) muscles are obtained at the midpoint between the anterosuperior iliac spine and the upper edge of the patella, whereas the vastus medialis (VM) is assessed at 30% of the distance between the lateral condyle and the greater trochanter of the femur. All images will be analyzed using the ImageJ software (National Institutes of Health, USA, version 1.37). The muscle thickness will be assessed as the distance from each muscle's superior and inferior muscle aponeurosis. Overall quadriceps femoris muscle thickness will be calculated as the sum of each muscle thickness (i.e., RF + VL + VM + VI).

Transversal images of the four portions of the quadriceps femoris are obtained by B-mode ultrasonography with a 7.5 megahertz linear array probe. Images of the VL, RF, and VI muscles are obtained at the midpoint between the anterosuperior iliac spine and the upper edge of the patella, whereas the VM is assessed at 30% of the distance between the lateral condyle and the greater trochanter of the femur. All images will be analyzed using the ImageJ software. Muscle quality will be determined by the echo intensity values, which will be calculated from gray-scale analysis using the standard histogram function in ImageJ. The echo intensity of the quadriceps femoris will be calculated as the mean of echo intensity values of the four individual quadriceps femoris muscles ((RF + VL + VM + VI)/4).

HADS was developed by Zigmond and Snaith (1983), with translation and validation for the Brazilian population (Botega et al., 1995). It is an instrument composed of 14 items, seven of which form the anxiety subscale and the other seven the depression subscale, allowing the assessment of symptoms in the previous week. Each HADS item has four response options ranging from 0 to 3, reaching a maximum of 21 points in each subscale.

Aspects of perceived cognitive function will be measured using the Functional Assessment of Cancer Therapy - Cognitive Function - Version 3 questionnaire (FACT-Cog-v3). This instrument was developed specifically for cancer patients, consisting of 37 items, organized into four sections: perceived cognitive impairments, comments from others, perceived cognitive abilities and impact on quality of life (Wagner et al., 2009). Each FACT-Cog-v3 item has five response options (not at all = 0; a little bit = 1; somewhat = 2; quite a bit = 3; very much = 4), and the higher the score mean a better perceived cognitive function. The recall period should only consider the past 7 days.

Aspects of objective cognitive function are measured by the Trail Making Test (TMT). The version validated for the Brazilian population of TMT (Carvalho \& Caramelli, 2020) is used to assess domains such as attention, motor skills, processing speed and cognitive flexibility (Bowie \& Harvey, 2006). In the first part of the instrument (TMT-A), participants will have to draw a line connecting the numbers from 1 to 25 in ascending order. Then, letters (A-L) will be added so that the participants trace a line again following a numerical (1-13) and alphabetical order, interleaved (TMT-B). Participants will be instructed to maintain pencil-to-paper contact during the test. A shorter runtime indicates better performance.

Aspects of objective cognitive function are also measured by the Controlled Oral Word Association Test (COWAT). The COWAT is used to assess verbal fluency, working memory and inhibitory control (Ross et al., 2007). In this test the participants will have to speak as many words as possible that start with the letters "F", "A" and "S", within 1 minute for each letter. Proper names, repeated words and variations in gender, number and conjugation will not be considered. The greater number of words evoked in each test indicates better verbal fluency.

BPI-B is validated in Brazilian cancer patients (Ferreira et al., 2011). This instrument is composed of nine multidimensional items that assess: pain intensity, pain interference in the patient's life, pain location and treatments for pain control and relief (Cleeland \& Ryan, 1994). The answers (scales from 0 to 10) should correspond to the pain felt at the time of the questionnaire and in the last 24 hours. The scores will be calculated by the average of the total of items. The higher the score, the greater the severity of pain.

The FACT-B is a 37-item instrument designed to measure five domains of quality of life in breast cancer patients: physical (seven items), social/family (seven items), emotional (six items), functional (seven items) well-being, as well as a breast-cancer subscale (ten items). The answers are presented on a 5-point Likert scale. Participants are instructed to select the number that best represents their answer for the last seven days. Online written permission was obtained to use this questionnaire in the study. Its Portuguese-translated version is a valid and reliable tool (Michels et al., 2012).