Korean J Urol Oncol 2011;9(1):9-16

The Effects of 12 Week's Combined Exercise Intervention on Physical Function and after ; Preliminary Study

Mi-Sook Kim1, Sung-Woo Park2,3, Moon Kee Chung2,3 1Division of Sports Science, Pusan National University, 2Department of Urology, 3Medical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea

Purpose: The purpose of this study was to determine the effects of exercises on physical function, body sway, and urinary incontinence after radical prostatectomy. Materials and Methods: All of the subjects were elderly males who were diagnosed with T2 cancer. After laparoscopic radical prostatectomy, subjects were recruited based on the surgeon’s recommendations and finally 9 patients were included. The combined exercise was composed of resistance exercise, pelvic flexibility exercise and Kegel exercise. These exercises were mainly performed by sports experts with the use of a ball and an elastic band. Following a 12-week exercise intervention, the physical functions were assessed based on functional fitness, flexibility and balance function. The body composition was also measured using a body composition analyzer (Inbody 720, Biospace Co. Korea). Urinary incontinence and voiding symptoms were evaluated using a pad test and an ICIQ questionnaire. Results: After a 12-week exercise intervention, physical fitness showed a significant increase in dominant grip strength, sit-and-reach, chair stand, and sit-ups, except body composition. The body sway test for balance ability showed a significant improvement, as well as urinary incontinence. No adverse events occurred in any patients. Conclusions: In current preliminary study, the combined exercise intervention after radical prostatectomy, may help improve physical fitness, balance, and hastening the return to continence. The findings support the safety and importance for a clinical trial of exercises after surgery. Further controlled trials are warranted to demonstrate the efficacy of an exercise intervention in elderly patients following radical prostatectomy. (Korean J Urol Oncol 2011;9:9-16) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏 Key Words: Exercise, Physical activity, Prostate cancer, Prostatectomy

Most of the patients with prostate cancer have been reported INTRODUCTION to be ≥60 years of age. If patients want to return to their daily lives, they must recover general physical function. Thus, atten- Many studies have been conducted to examine the methods tion should be directed to exercise intervention, which is essen- for preserving urinary incontinence and erectile function, as tial in improving physical and psychological quality of life.1-5 well as oncologic outcome in patients with prostate cancer. Some Western studies have reported that exercise intervention improves physical activity, reduces fatigue, strengthens immune Received November 23, 2010, Revised December 10, 2010 (1st), 1,3,4 December 12, 2010 (2nd), Accepted March 10, 2011 function, and improves the quality of life. It has also been Corresponding Author: Moon-Kee Chung, Department of Urology, reported that post-operative Kegel exercises, as well as lower Medical Research Institute, Pusan National University Yangsan extremity fitness, is helpful for achieving urinary continence.5 Hospital, Beomo-ri, Mulgeum-eup, Yangsan 626-770, Korea. Tel: 82-55-360-2670, Fax: 82-55-360-2164, E-mail: mkchung@ Exercise interventions are classified as aerobic exercises, pusan.ac.kr muscle strength training, and flexibility exercises. Aerobic ex- 9 10 대한비뇨기종양학회지：제9권 제1호 2011 ercises are routinely performed by walking, running, and bicy- Because of a surgical history due to ankle problems, re-hos- cling, and have a major impact on the cardiovascular system. pitalization due to a urethral stricture, frequent school absences Muscle strength training are effective in reducing fatigue occur- and new employment, 6 patients were disenrolled from the ring following the treatment of cancers, as well as increasing study. Therefore, 9 patients eventually completed the 12-week muscle strength.1,4 In addition, aerobic exercises play a role in exercise intervention. restoring mental health, such as depression, after cancer 2. Measurements treatment.1,5 In Western society where prostate cancer commonly occurs, The measurement categories include functional fitness, flexi- studies have been conducted to examine the exercise inter- bility, urinary incontinence, and body composition. In addition, ventions following hormone therapy or radiotherapy in the field the safety which might occur during the treatment was assessed. of sports medicine. However, no studies have reported the ef- First, the functional fitness, muscle strength/muscle endurance, fects of exercise intervention performed following radical flexibility, and body compositions were included according to prostatectomy. the recommendations of the American College of Sports Given this background, we conducted this preliminary study Medicine (ACSM).6 To measure muscle endurance as repre- to obtain baseline data about the safety and efficacy of exercise sentative of functional fitness, sit-to-stand exercises were per- intervention in patients following radical prostatectomy. In the formed for the lower extremities, sit-ups were performed for current study, we developed a 12-week program for pelvic floor the abdomen, and dominant grip strength was measured for the exercises consisting of muscle strength and flexibility training, upper extremities (dynamometer TKK5401; Takei, Tokyo, and Kegel exercises to improve continence as well as physical Japan). Flexibility was measured by performing a sit-and-reach function following laparoscopic radical prostatectomy in elderly (flexibility test SH-9600G; Helmas, Seoul, Korea). To assess patients with prostate cancer. The exercise interventions were balance function, the body sway test was performed using a performed by a specialist in sports medicine. Balance D&T (Saehan Dana Medical, Seoul, Korea). The se- verity of urinary incontinence was measured using a 1-hour pad MATERIALS AND METHODS test. ‘Urinary continence’, was defined as a loss of ＜1g on a 1-hour pad-test. In addition, subjective incontinence symptoms 1. Patients were checked by International Consultation on Incontinence From June 2007 to March 2008, the current study was con- Questionnaire (ICIQ). The 1-hour pad test and ICIQ were re- ducted in 15 patients with prostate cancer who underwent lapa- peated at pre-exercise intervention (post-operative week 3) and roscopic radical prostatectomy in the department of urology of post-exercise intervention (post-operative week 15). our medical institution. The inclusion criteria were as follows: The body sway test is a method in which an assessment is (1) male patients ≥65 years of age who underwent laparo- performed to measure balance function in the anterior-posterior scopic radical prostatectomy for the management of local pros- direction and left-right sway, as well as a fall. During the test, tate cancer (cT1-2); (2) an ECOG performance status of 0 or patients were placed straight on a balance plate and then strived 1; and (3) patients who obtained a complete understanding of to maintain a balance with the feet according to the instructions exercise intervention and then submitted a written informed of the program. Their performance was evaluated based on nu- consent. merical scores following a 3-minute test. If the scores were The exclusion criteria were as follows: (1) patients who re- higher, this would lead to a determination that the degree of ceived adjuvant therapy prior to or following surgery; (2) pa- body sway was relatively higher. To analyze the body composi- tients who presented with severe post-operative complications; tion using a body composition analyzer (Inbody 720; Biospace (3) patients with a past history of intrapelvic surgery; (4) pa- Co., Seoul, Korea), the fat mass (FM), skeletal muscle mass tients in whom there were diseases that may affect the function (SMM), body mass index (BMI), and waist-hip ratio (WHR) of the ; and (5) patients who had limitations for were measured. receiving exercise intervention, i.e., those with serious car- The measurement was performed on the first visit (post-oper- diovascular events or spinal or articular diseases. ative week 3) and the final visit (post-operative week 15) for Mi-Sook Kim, et al：Combined Exercise Intervention after Prostatecetomy 11 the exercise intervention. The exercise intervention was im- 3. Design of the exercise program plemented for a total of 12 weeks, including a 2-week adapta- tion period and a 2-week period for basal physical strength. Pelvic floor exercises were mainly performed. With reference Exercise was performed 3 times every other day during the to the literature about exercise intervention for elderly pa- week (Monday, Wednesday, and Friday), for which the exercise tients,7-9 the exercise conditions were designed based on the in- time was prolonged at 10-minute intervals in the early stage tensity, time, frequency, and pattern. Because exercise inter- and this was followed by a resting period at 20-minute vention was performed on elderly patients, the heart rate was intervals. Thus, the total exercise time was 40-60 minutes. The monitored during the exercises. Exercise intervention was per- exercise intervention was performed by a professor and a teach- formed according to the instructions of specialized personnel ing assistant from the department of sports medicine of the on a mat. The exercise program was initiated during post-oper- same university. ative week 3 and was conducted for 12 weeks thereafter.

Table 1. The patterns of exercise consisted of combined exercises, resistance exercises, pelvic flexibility exercises, and Kegel exercises I. Post-operative weeks 1-4 (adaptation period) 1. Receiving education about post-operative symptoms 2. Performing Kegel exercises, recognizing the parapelvic muscles 3. Performing pelvic floor flexibility fitness: performing pelvic exercises, while sitting on a ball (Fig. 1A) II. Post-operative weeks 5-8 (ball exercises) 1. Performing pelvic exercises while sitting on a ball 2. Performing lower extremity exercises, while placing a ball on the wall (Fig. 1B) 3. Lifting a heel on the ball while standing face-to-face with the wall (Fig. 1C) 4. Lifting up and down on the ball while spreading and bending the legs (Fig. 1D) 5. Performing flank exercises while having a ball in the hand (Fig. 1E) 6. Squeezing the ball with the adductor muscles while lying on a table (Fig. 1F) III. Post-operative weeks 9-12 (elastic band exercises) 1. Lifting the object with an elastic band (Theraband; The Hygenic Co., Akron, USA) lateral, anterior, and posterior to the patient’s arms (Fig. 2A) 2. Lifting the legs and then spreading them while attaching an elastic band to the foot (Fig. 2B)

Fig. 1. Ball exercise. (A) The pelvic floor flexibility fitness while sitting on a ball. (B) Lower extremities exercise while placing a ball on the wall. (C) Lifting a heel on the ball while standing face-to-face with the wall. (D) Lifting up and down the ball while spreading and bending the legs. (E) The flank exercise while having a ball in the hand. (F) Squeezing the ball with the adductor muscle while lying on the Table. 12 대한비뇨기종양학회지：제9권 제1호 2011

Table 2. Patients characteristics Age (yrs) 68.4±5.36 Preoperative PSA (ng/ml) 8.2±5.8 Pelvic lymphadenectomy, No. (%) 4(44.4) T stage pT2b 3(33.3) pT2c 6(66.6) Gleason score 9 1(11.1) 8 1(11.1) 4＋3 3(33.3) 3＋4 3(33.3) 6 1(11.1) Posterior enhancement, No. (%) 9 (100) Nerve sparing, No. (%) 4(44.4) Bilateral 3(33.3) Unilateral 1(11.1) Duration of catherterization (day) 7.0±0 Fig. 2. Elastic band exercise. (A) Lifting the object with an elastic SD: standard deviation. band (Theraband) lateral, anterior, and posterior to the patient’s arms. (B) Lifting the legs and then spreading them while attaching an elastic band to the foot. vention, at the time of the initiation of exercise intervention, the mean age was 68±5.36 years, the height was 165.2±4.39 The patterns of exercise consisted of combined exercises, re- cm, and the weight was 63.19±7.77kg. The patient character- sistance exercises, pelvic flexibility exercises, and Kegel istics including peri-operative data were shown Table 2. exercises. Details of combined exercise were described in Table 1. In categories regarding the functional fitness following the The intensity of the exercise with an elastic band was set exercise intervention, maneuvers such as dominant grip strength, at 50-70% of one repetition maximum (1-RM), which was ad- sit-ups, and chair stand were performed. In categories regarding justed to express the variable degree of elasticity depending on flexibility, a sit-and-reach was performed. All of these maneu- the color. The length of extension was set at 30-60cm. vers were statistically significant (p＜0.05; Table 3). In addi- The intensity of exercise was set to be within a range tion, the body sway was significantly improved following the (45-75%) of the maximum heart rate (HRmax) and 9-13 Rated exercise intervention (p=0.007; Table 3). In categories about the Perceived Exertion (RPE), based on the individual differences, body composition seen following the exercise intervention, by synchronously considering a heartbeat clock (Polar-400; however, there were no notable changes in such parameters as Polar Co., Finland) and the subjective intensity of exercise fat mass, skeletal muscle mass, body mass index (BMI), and (RPE; Borg scale). waist-to-hip ratio (WHR; p＞0.05; Table 3). The amount of urinary incontinence using pad test was sig- 4. Statistical analysis nificantly improved simultaneously with ICIQ score (p＜0.001; Statistical analysis was performed using SPSS, version 12.0, p=0.024, respectively; Table 3). Continence rate at pre-exercise for which measurements were expressed as the mean±SD. intervention and post-exercise intervention were 22.2% (2/9) Measurements were compared using the Wilcoxon signed rank and 77.7% (7/9), respectively (p=0.063; Table 3). test for continuous parameters and the NcNemar test for catego- In the current preliminary study, six patients were disenrolled. rical parameter prior to and following the exercise intervention. All of these disenrollments occurred due to reasons which were Statistical significance was set at a p=0.05. not associated with the exercise intervention (Table 4). There were no side effects or safety failures occurring as a result of RESULTS exercise intervention. Based on an exercise diary which patients designed themselves following the completion of the exercise In a total of nine patients who completed the exercise inter- intervention, it was found that all of the patients were satisfied Mi-Sook Kim, et al：Combined Exercise Intervention after Prostatecetomy 13

Table 3. Effects of combined exercise intervention in patients who underwent laparoscopic radical prostatectomy Variables Pre-exercise Post-exercise p-value Functional physical fitness Grip strength (kg) 29.29±6.22 33.32±4.15 0.018 Sit-ups (times/30sec) 9.56±4.67 12.89±4.28 0.002 Chair stand (times/30sec) 9.56±2.13 14.33±1.73 ＜0.001 Sit-and-reach (cm) −3.10±8.66 2.84±6.29 ＜0.001 Body composition Fat mass (kg) 15.27±4.37 15.94±4.69 0.312 Skeletal muscle mass (kg) 44.40±3.30 45.51±4.10 0.124 BMI (kg/m2) 23.12±2.64 23.60±2.70 0.082 WHR (ratio) 0.95±0.03 0.94±0.03 0.218 Balance Body sway (score) 3,997.7±3,113.0 4,647.7±2,546.4 0.007 Incontinence Pad test (g) 59.67±49.41 1.67±1.41 ＜0.001 Continence rate 22.2% (2/9) 77.7% (7/9) 0.063 ICIQ 10.0±4.9 5.9±5.1 0.024 BMI: Body mass index, WHR: Waist-hip ratio, ICIQ: International Consultation of Incontinence Questionnaire.

Table 4. Reasons for disenrollment due to the increased synthesis of anti-oxidative enzymes which Patients Reasons for disenrollment lower these detrimental oxygen radicals, there are contradictory effects in preventing the increased synthesis of oxygen 1 Orthopedic surgery for a pre-existing ankle problem 10 2 Transurethral surgery for a urethral stricture radicals. In addition, an intake of low-fat diet, fiber-containing 3-4 Non-compliance with follow-up due to a long distance foods and regular exercise have been reported to delay the from the center to the home growth of prostate cancer cells by approximately 30%.14 5-6 New employment after surgery Most of the studies have been conducted to examine the ef- fects of exercise intervention in patients with prostate cancer with the effectiveness and safety of exercise intervention fol- following the use of androgen deprivation therapy or lowing the completion of the first 4-week program. radiotherapy. There are no studies focusing on the reinforce- ment of pelvic floor and limb muscles following the radical DISCUSSION prostatectomy, as shown in our series. Courneya et al.3 classi- fied 155 patients with prostate cancer who underwent androgen In patients with cancer, mechanisms by which the internal deprivation therapy into two groups (82 patients in the exercise changes occur due to the exercise may include hormonal mod- group and 73 patients in the control group), then performed a ification, alterations of the immune system, prevention of obe- 12-week resistance exercise twice a week at an intensity of sity, and the metabolism of oxygen radicals. In patients with 60-70% 1-RM. According to these authors, there were no prostate cancer, the exercise gives rise to the decreased secre- changes in the body compositions and PSA level, although the tion of male hormones and this can suppress the growth of quality of life was improved due to the decreased fatigue. Segal prostate cancer cells.10-12 In the immune system, exercise in- et al. also reported that there were significant effects in creases the synthesis of natural killer cells, macrophages, and strengthening the physical activity, reducing the fatigue and im- cytokines, and can thereby enhance the immune function proving the cognitive functions in the group in which the same against tumor cells.13 Furthermore, it inhibits the increased se- exercise intervention was performed.15 Galvão et al.16 per- cretion of estrogen in overweight patients. It also affects the formed a 20-week resistance exercise of the upper and lower secretion of metabolic hormones, such as insulin and leptin, extremities solely for 10 prostate cancer patients in the exercise which is one of the appetite suppressants. Thus, it can suppress group in whom androgen deprivation therapy was performed. the invasiveness of prostate cancer cells.10 An abrupt initiation According to these authors, of the categories associated with of the exercise would increase the synthesis of detrimental oxy- functional fitness, muscle endurance and physical balance func- gen radicals. During the persistent exercise therapy, however, tion were improved; however, there were no changes in the 14 대한비뇨기종양학회지：제9권 제1호 2011 body fat at the corresponding sites. BMI, and WHR. In addition, there were no changes in the Windsor et al.17 demonstrated the effects of aerobic exercise amount of muscle, but it was slightly increased. This is one through a randomized, controlled trial in 66 patients with pros- of the types of exercise intervention attempting to enhance the tate cancer who underwent radiotherapy. These authors also isotonic and isometric properties among the methods of a com- noted that it was effective in reducing the fatigue following the plex exercise program in which the muscle strength can exert radiotherapy. Segal et al.18 conducted a randomized, controlled the force with a ball and an elastic band. This implies the char- trial in which the aerobic and resistance exercise were per- acteristics of resistance exercise that the effects of muscle formed following radiotherapy. According to these authors, strength training through the current program would have a aerobic exercise function and the body composition ratio were more positive impact on the amount of skeletal muscles rather improved in the aerobic exercise group and muscle strength, than the alterations in body composition. aerobic exercise function, body composition ratio, and fatigue Elderly patients who underwent prostatectomy are susceptible were improved in the resistance exercise group. to a fall injury due to the weakness of muscles in the lower Exercise intervention following the treatment of cancer was extremities because of damage to the pelvic floor muscles. composed of aerobic, resistance, and flexibility exercises. Accordingly, the body sway test was included in the current Aerobic exercise is performed at an intensity of 40-85% of the study. In the elderly, due to decreased balance function, the heart rate reserve (HRR) maximum, 3-5 times a week for 20-60 weakness of muscle strength in the lower extremities and the minutes. It is also considered a major training program for the deranged postures due to impaired cooperativeness, flexibility, cardiovascular system. It is recommended that a muscle and proprioceptive functions, problems may occur in the nerv- strength training be performed at an intensity of 50-80% 1-RM, ous and musculoskeletal systems. Due to decreased vision or 1-3 times and for 1-4 sets. Furthermore, it is also recommended unstable posture, the functions of controlling physical balance that flexibility training be performed 2-3 times a week for 2-4 are impaired. This eventually leads to the increased occurrence sets and for 10-30 seconds for each exercise.2,19 We performed of fatal cases of fall injuries in elderly patients.20 In our series, the treatments in an office-based manner in elderly patients. We the body sway test showed a marked improvement in most also concentrated on muscle strength training or flexibility rath- parameters. This might be based on not only the effects of bal- er than aerobic exercise because there are many patients who ance training associated with the weight transfer to the ankles, have cardiovascular risk following surgery. knees, and hip joints performed in a standing position, but also In the early stage of the current study, due to the weakness those of exercise intervention with a ball and an elastic band in physical strength and cardiopulmonary function in the pa- reinforcing the muscle strength in the lower extremities with tients, exercise intervention could not be performed continuously. the use of such muscles, as the quadriceps femoris, biceps fem- Moreover, the posture was altered to a lordosis or a kyphosis oris, gluteus muscle, and hamstrings. due to the aging, and this led to the occurrence of severe pain In several studies, pelvic floor muscle tranining for urinary in the back and pelvis. Owing to this, there were some cases incontinence after radical prostatectomy was better than no pelvic in which standing or anterior flexion could not be performed. floor muscle tranining in hastening the return to continence.21 On assessment of the health-related physical factors prior to the Men treated with -enhanced pelvic floor muscle tra- implementation of exercise intervention, the flexibility was nining returned to continence more quickly, within 1-2 months found to be the lowest. Accordingly, the flexibility training was after radical prostatectomy, than men with no pelvic floor mus- performed to improve posture and joint mobility. Following cle tranining. However, within 3-4 months there were no sig- this, the left anterior flexion was notably improved. Besides, nificant differences in the rates of continence between on the assessment categories associated with muscle strength groups.22,23 Biofeedback-enhanced pelvic floor muscle tranining and muscle endurance, such parameters as grip strength, was no more effective than oral or written pelvic floor muscle sit-to-stand, and sit-up were continuously improved. This might tranining instruction.24,25 Recently, Centemero et al.26 performed be due to the effects of systemic muscle strength training with randomized controlled study about the effect of preoperative an elastic band. However, there were no significant changes in pelvic floor muscle exercise. 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