Repeatability and reproducibility of a home physical exercise manual

Corresponding address: Guilherme Henrique de Lima Matias – Instituto de Medicina Integral Professor Fernando Figueira (Imip) – Jornalista Hercílio Celso Street, 577, apt. 303, Candeias – Jaboatão dos Guararapes (PE), Brazil – Zip Code: 54450-170 – E-mail: guilhermehenriquelm@yahoo.com.br – Financing source: Nothing to declare – Conflict of interests: Nothing to declare – Presentation: June 29th, 2017 – Accepted for publication: Apr. 20th, 2018– Approved by the Ethics Committee of Imip, CAEE 1.574.833. Repeatability and reproducibility of a home physical exercise manual Repetibilidade e reprodutibilidade de um manual de exercícios físicos domiciliares Repetibilidad y reproducibilidad de un manual de ejercicios físicos domiciliarios Guilherme Henrique de Lima Matias1, Ana Clara Carvalho Gonçalves Guerra1, Breno Augusto Bormann de Souza Filho2, Jurema Telles de Oliveira Lima1, Cleber Nascimento do Carmo2, Inês Echenique Mattos2


INTRODUCTION
Cancer, defined as the uncontrolled growth of cells in the body 1 , has its incidence increased with advancing age, becoming up to 16 times more lethal in individuals aged 65 years or more 2,3 .Among the various types, breast cancer is the most frequent and the one with the highest mortality among women in developed and developing countries [4][5][6] .
Treatments for breast cancer include one or more therapeutic modalities 7, which are associated with the presence of various side effects 8,9 .In hormone therapy 10 , the agents used are associated with adverse effects, including loss of bone mineral density, arthralgia, and cardiovascular disease 11 .In addition, inadequate lifestyle habits, such as physical inactivity, may compromise the physical fitness and quality of life of women undergoing this type of treatment [12][13][14][15][16] .
Physical activity is considered an important healthrelated factor before and after a diagnosis of cancer 17,18 .However, patients with breast cancer are generally less physically active and have longer sedentary time 12,19 , which increases side effects and contributes to a reduction in the motivation for adopting physical activity [20][21][22] .However, clinical settings do not have the necessary support to accompany, stimulate and provide services that help change behavior for the functional self-care of these individuals 23 .
One of the ways to achieve physical activity is through the development of booklets 24,25 .The implementation of educational resources contributes to lifestyle and health changes 23,26 .However, if such material is difficult to understand, especially as regards what is intended to be passed on and what is assimilated by the target public, it may instead pose health risks 27,28 .In this context, this study was designed to check the level of reproducibility and repeatability of a manual of physical exercises at different levels of schooling in elderly women with breast cancer.

Design and ethical aspects of the study
This is a cross-sectional study conducted from August to November 2016, involving elderly women diagnosed with breast cancer using hormone therapy and followed at the Adult Oncology Outpatient Clinic of IMIP, located in Recife, Brazil.Twenty-two elderly women were enrolled after a sample calculation that considered physical ability (Agility and Balance) for the "sitting, walking" test at an average of 6.0+1.0 seconds in the intervention group, accepting a significance level of 0.05 and a power of 0.99.For the aforementioned study, there was no sample attrition.

Recruitment/Selection
The recruitment of elderly women to participate in the study was carried out through an analysis of medical records to check eligibility criteria.The inclusion criteria were: age between 60 and 74 years; diagnosis of breast cancer stage I or II, and being in use of hormone therapy for breast cancer.The exclusion criterion was the presence of some absolute contraindication to physical exercise 29 .

Intervention protocol
The aims and benefits of this study were explained to all participants, who signed an ICF in accordance with resolution 466/2012.Sociodemographic and clinical epidemiological data were collected to characterize the sample.
Subsequently, the participants received a home physical exercise manual called "Gymnastics to do at home: A manual adapted for patients with breast cancer" 30 , which was prepared from the exercises included in the first version of the Gymnastics to do at Home 31 manual, both designed for improving the physical abilities of the elderly, with orientations in general and the amount of daily and weekly repetitions of suggested exercises.
Participants were informed that after six weeks, the execution of the exercises contained in the manual would be analyzed.Exercises in the manual were performed for 45 days by the elderly women alone and with no contact with researchers, after which they returned to be evaluated by two health professionals, a physical education professional and a physiotherapist.
The analysis of the execution of the movements was performed by both raters simultaneously without previous contact between them, in a reserved place.The elderly were asked to perform each of the 12 exercises contained in the manual, in the order described.They were allowed to check the manual freely while doing the exercises.No command or assistance from the raters was provided.

Instrumentation
For the analysis of human movement, we used the qualitative method which, according to Hay & Reid 32 , is a "subjectively based assessment, visual observation", where each rater analyzed the execution of each movement using a structured form with the dichotomous variable (right = 1; wrong=2).

Data analysis
Data were initially analyzed using descriptive statistics and chi-square/Fisher's exact tests to check differences in responses between categories.Subsequently, the agreement or reproducibility between the two raters was tested by obtaining the simple kappa coefficient (k), with its given interpretation 33 .
For tie-breaking criteria and data formulation, evaluations carried out by the physical education professional were taken as a reference because these are professionals responsible for prescribing, supervising, analyzing and evaluating in the areas of physical activities, sports and the like, according to CONFEF 34 .

RESULTS
Respecting sample calculation, a total of 22 elderly women (mean age 66.2±3.5 years) participated in the study.No statistical differences were observed across the elderly according to sociodemographic and clinical characteristics (Table 1).Table 2 presents p-values of inter-rater concordance by the Kappa coefficient and its interpretation according to the qualitative analysis of performance of exercises after six weeks using the manual.A "near-perfect" agreement between raters was observed in all exercises.All exercises presented a statistically significant p-value (p = 0.01), where 6 exercises were performed correctly, 4 incorrectly and 2 with equal shares (50%) for "correct" and "incorrect".Table 3 shows the relationship between the level of education of the women of age and the amount of correct/incorrect execution of the movements described in the manual.In exercise 6 was observed a significant relation (p=0.03) between the execution of exercises for women of age with secondary education compared to those with higher education; in exercise 4 (p=0.06),only a tendency was observed.

DISCUSSION
Some studies have investigated the relationship between the benefits of performing home rehabilitation and obtaining the same results as in a hospital setting in order to reduce expenditures [35][36][37] .However, the purpose of this study was to investigate the reproducibility and repeatability of a home physical exercise manual at different levels of schooling in elderly women with breast cancer, postsurgery and hormone therapy.
Our study found a high level of agreement between raters regarding the execution of exercises contained in the manual.The results show that the exercises were performed correctly by the elderly.However, for some exercises, incorrect execution of the movement was observed.Albrecht states that individuals in social isolation tend to struggle more to understand exercise instructions 38 , because patients see the people around them as a support for the proposed exercises 39 .
Another limiting factor that can cause wrong execution of the movement is the fear of pain, which consequently leads the person to stop exercising 40 .
Ceccato 41 in his study shows that individuals with higher levels of education have a better understanding of the treatment for type 2 diabetes mellitus.Souza 42 observed that the technique of applying eye drops by the elderly is significant connected to those with higher education.
A manual delivered to the population should be accessible to all individuals.In this sense, Oliveira 25 shows that health education materials should, in average, be understandable by individuals with six years of schooling, which is the case in the manual used here, where individuals with no education can understand and perform the exercises correctly.
The adversity of incorrect execution of the movement in exercise 6 among lower-educated women of age compared to those with higher education in our study may be related to the volume of images contained in the exercise.The exercise that presents incorrect assessment in the group of individuals with education lower than primary education is among the three exercises of a total of twelve contained in the manual that have three pictures in their description, compared to two images occurring in the cases of exercises where education levels showed no significant difference.The lower amount of images can be a way to improve the organization, appearance and understanding of the exercises, thus providing their correct execution, since images associated with writing make it easier to comprehend them 43 .
The present study appears to be the first to investigate the level of reproducibility of a manual from the achievement of beneficiaries themselves.However, our study has some limitations, such as small sample size, which restricts the extrapolation of the results to the entire Brazilian elderly population with breast cancer, due to the low representativeness in the mentioned service; lack of adherence analysis, even if this is not the purpose of the study; short duration of the intervention protocol, characterized by the possibility of sample attrition and complications in the disease; and the absence of comparison of individual training without supervision in healthy and cancerous elderly women.

CONCLUSION
The evaluation protocol was sufficient to check the reproducibility and repeatability of the home physical exercise manual.This evaluation is extremely important because, in the majority of cases, evaluations made with instructional manuals take place in the functional effectiveness of these with its target audience, failing to emerge in the correct execution of the movement.Furtheremore, the manual managed to reach older women of all levels of schooling.Thus, the manual presents promising characteristics for its use in outpatient health services that promote functional self-care of their patients.With these results, together with the available literature, it is possible to ascertain the importance of physical exercise at home and the use of new technologies such as instructional manuals for exercises aimed at the rehabilitation and health improvement of women with breast cancer.This new technology can be considered as a low-cost and proven reproducibility practice for public health, assisting physiotherapists and physical rehabilitation professionals in general in offering guidelines with higher quality and safety to users in health services.However, it is important to carry out research addressing protocols with a greater number of individuals and studies that investigate the use of exercises in the form of DVDs in combination or in contrast with the printed manual.

Table 1 .
Descriptive statistics of clinical and epidemiological characteristics of elderly women with breast cancer

Table 1 .
Continuation Table2.Percentage of inter-rater agreement, Kappa coefficient and its interpretation obtained in the qualitative analysis of performance of the exercise *Results of significance tests for kappa coefficients.APA: Almost perfect agreement.

Table 3 .
Distribution of results of physical exercises, according to schooling level