Long-term effects of multicomponent training in the body composition and physical fitness of breast cancer survivors: a controlled and experimental study with clustering analysis

Long-term effects of multicomponent training in the body composition and physical fitness of breast cancer survivors: a controlled and experimental study with clustering analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Long-term effects of multicomponent training in the body composition and physical fitness of breast cancer survivors: a controlled and experimental study with clustering analysis Samuel Gonçalves Almeida Encarnação, André Schneider, Roberto Gonçalves Almeida, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5362882/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in Scientific Reports → Version 1 posted 13 You are reading this latest preprint version Abstract Introduction: Multicomponent training is suggested as an efficient way to address the side effects of long-term treatment in breast cancer survivors and reduce the age-related relapse risk in these patients. This study aimed to evaluate the impact of a multicomponent training intervention on breast cancer survivors' physical fitness and body composition. Methods: This experimental and controlled study included 19 breast cancer survivors with 64.0 ± 8.6 years, to evaluate long-term effects (36 weeks) of multicomponent training on body composition [body weight (kg), body mass index, body fat (%), lean mass (kg), body water (%), basal metabolism (Kcal) and visceral fat (index)] and physical fitness [Upper limb strength (repetitions), lower limb strength (repetitions), upper limb flexibility (cm), lower limb flexibility (cm), dynamic balance (seconds), and aerobic fitness (repetitions)]. Bayesian statistical tests were employed to analyze the reduced dataset size, considering a Bayes factor ≥ 10 as the cutoff for significant differences. Hierarchical clustering identified participant improvements using Manhattan distance, and clusters were ranked by responsiveness. Results: The experimental improved body weight, body fat percentage, and physical fitness after the intervention, while no changes were observed in the control group. Cluster analysis showed that higher responders varied from 28% to 86% across variables, while others showed lower, but still positive, responses. Discussion and Conclusion: The multicomponent physical exercise program effectively improved all physical fitness variables but was limited in body composition, exposing improvements only in body weight and % body fat. The intervention did not cause any side effects or injury to the participants. Health sciences/Oncology/Cancer/Breast cancer Health sciences/Health care/Public health neoplasms physical exercise rehabilitation oncology functionality activities of daily living Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Breast cancer is the most prevalent form of cancer worldwide, characterized by the development of malignant cells in the mammary glands, which can invade surrounding tissues and metastasize to other areas of the body [ 1 ]. This disease is highly heterogeneous, with a complex etiology influenced by genetic predispositions, behavioral (lifestyle) and environmental factors [ 2 ]. In 2020, an estimated 2.3 million new cases of breast cancer were diagnosed globally [ 3 ]. In 2022, the disease led to approximately 670,000 deaths [ 1 ], solidifying its position as the leading cause of cancer-related mortality among women [ 4 ]. Survival rates for breast cancer vary significantly across the globe. The 5-year survival rate in developed countries is approximately 80%, while in developing nations, it drops to below 40% [ 5 ]. Limited resources and infrastructure in developing countries often impede efforts to improve outcomes, particularly in early detection, diagnosis, and treatment [ 6 ]. Over the past few decades, breast cancer epidemiology has been extensively studied. Between 2010 and 2019, the incidence rate increased by 0.5% annually, driven by factors such as disease stage at diagnosis, aging populations, and overall population growth [ 7 – 10 ]. As a result, global incident cases have risen by 128% over the last thirty years. Projections suggest that by 2040, there will be more than 3 million new cases of breast cancer annually [ 11 , 12 ]. These results call for attention to lifestyle in developed populations, where exposure to some risk factors may be controlled. Current breast cancer treatment and management employ a multifaceted approach tailored to the disease's type, stage, and progression. This includes targeted therapies, hormonal treatments, radiotherapy, chemotherapy, and surgery [ 4 ]. However, survivors often face heightened risks of comorbid conditions such as sarcopenia, osteoporosis, and cardiovascular disease, which can adversely affect their quality of life, cardiorespiratory fitness, muscle strength, and bone health [ 13 ]. These health issues are partly attributed to cancer treatments—such as chemotherapy, radiotherapy, and hormonal therapy—and are exacerbated by factors like obesity and a sedentary lifestyle. The treatments can also lead to fatigue, insomnia, nausea, vomiting, neuropathy, cardiotoxicity, and reduced muscle strength, resulting in both physiological and psychological challenges [ 4 , 14 – 16 ], Additionally, significant loss of upper limb mobility, strength, and muscle mass further compromises life satisfaction and quality of life for these patients [ 17 – 19 ]. For these reasons, behavioral strategies based on active living and wellbeing have been promoted in cancer patients and survivors [ 20 , 21 ]. In line with the previous information, physical exercise complementary therapies have emerged as a powerful non-pharmacological strategy to mitigate treatment side effects and enhance the quality of life, cardiorespiratory fitness, and muscle strength among breast cancer survivors [ 22 ]. Current guidelines advocate for health promotion counseling emphasizing physical activity [ 23 ]. Exercise can improve cancer-related health indicators, support a healthy energy balance, and reduce the risk of cardiovascular diseases, which are a leading cause of death among survivors [ 24 ]. Various studies have explored different exercise modalities, including aquatic exercises [ 25 ], Pilates interventions [ 26 ], cognitive-behavioral therapy [ 27 ], and aerobic and resistance-based exercises [ 28 ]. While these studies highlight short-term benefits, research on the long-term effects of these interventions remains limited. Survivors often experience persistent psychological and physiological issues, as well as complications from surgery [ 29 , 30 ]. Thus, understanding the long-term impact of exercise programs is crucial from a clinical perspective for breast cancer survivors [ 31 ]. Long term analysis are hard to perform because of the difficulties related to drop-in and -out [ 32 , 33 ]. Despite strong evidence supporting physical activity and exercise-specific programs' role in cancer prevention and treatment, some modalities, like multicomponent training, show potential for improvements but currently lack sufficient robust evidence [ 34 ]. Multicomponent training integrates various physical qualities—strength, cardiorespiratory endurance, flexibility, and balance—into a single session, typically lasting about 60 minutes [ 35 ]. The research on multicomponent training for breast cancer patients is crucial to assess how this intervention can enhance rehabilitation, body composition, and functional fitness. As medical advancements extend life expectancy, understanding the rehabilitation needs of older adults becomes increasingly important [ 36 , 37 ]. Establishing new theoretical, methodological, and analytical frameworks is essential for guiding cancer research in this demographic [ 37 ]. Studies indicate that individuals' response to training programs can vary substantially due to factors such as prior physical condition, intensity and frequency of physical activity, as well as individual biological characteristics [ 38 ]. Therefore, it is essential to recognize that, although everyone can show improvements, the magnitude of these changes tends to be different for each person [ 39 , 40 ]. To identify these variations, this study used to cluster analysis, grouping participants according to their training responses. That said, concerning the difficulties of long-term analysis in this type of population and the lack of research regarding multicomponent exercise-based therapy and special multicomponent training programs, there’s a need to understand the effectiveness of this therapy better. Upon that, this study aims to evaluate the long-term effects of multicomponent training on body composition and functional fitness among breast cancer survivors. We propose the following hypotheses: (1) multicomponent training will improve body composition in breast cancer survivors; and (2) it will enhance functional fitness. MATERIALS AND METHODS Study design This is an experimental and controlled study, enrolling the long-term effects of a multicomponent training program in the breast cancer survivors’ body composition and physical fitness. The training sessions had a duration of 50-55 minutes, with evaluations conducted over the course of one week. Participants were also encouraged to continue their daily activities throughout the study. Figure 1 illustrates the timeline of the evaluation and exercise phases during the program. Sample and sampling A total of 19 breast cancer survivors were included in this study, 7 in the experimental group (EG), and 12 in the control group (CG). The following inclusion criteria were considered for participation in the multi-component training sessions: (i) previous diagnosis of breast cancer; (ii) having undergone definitive surgery, regardless of the type; (iii) having undergone post-surgical treatment, such as chemotherapy, radiotherapy, immunotherapy, endocrine therapy, or a combination of these; and (iv) having finished treatment before starting the multi-component training program. The established exclusion criteria were: (i) the presence of serious clinical conditions related to other chronic diseases that would hinder participation in the multi-component training sessions; (ii) the use of medications that could compromise participation in the sessions; and (iii) the presence of severe cardiovascular, muscular, metabolic, or articular complications that would impair the ability to participate in the program. At the end of the intervention, seven women completed the program, with one dropout due to the need for a new surgical procedure. The control group was composed of breast cancer survivors who did not participate in any intervention during the experimental period. Unlike the group that underwent the multicomponent training, these participants were not subjected to any exercise or specific protocol during the study. However, they were regularly (every 4 weeks) instructed to maintain their daily life routines, especially physical activity levels. The absence of intervention allowed the results to be compared directly with the intervention group, highlighting the possible effects of physical training on survivors' recovery and quality of life. The study design is illustrated in the flowchart (Figure 2). Informed Consent Statement: “Written informed consent has been obtained from the patient(s) to publish this paper.” Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the Higher Institute of Educational Sciences of the Douro (nº: 2.576). Data collection For the data collection, a team of interns was trained to effectively apply research instruments to obtain information about the body composition, functional fitness, and quality of life of breast cancer survivors. The assessments took place in three stages: at the beginning of the program (baseline of the multicomponent training), after 6 months of training, and again at the end of 9 months. During these phases, the following data were collected: Body composition variables included Body Mass Index (BMI), expressed in kg/m², calculated from height measurements (in cm) and body weight (in kg). The classification of Body Mass Index (BMI) followed the standards established by the World Health Organization (WHO) (37), defining normal between 18.50 and 24.99; overweight between 25 and 29.99; Class I obesity between 30 and 34.99; and Class II obesity between 35 and 39.99. Additionally, we performed bioimpedance analysis, obtaining information about body composition, lean muscle mass (in kilograms), body fat percentage, bone mass (in kilograms), visceral fat, basal metabolism (in kilograms), and body water percentage. All bioimpedance measurements were taken with the volunteers wearing lightweight clothes and barefoot, using a digital bioimpedance scale (Tanita DC-430 digital weighing scale with 0.1g precision, Illinois, USA). The evaluation of functional capacity variables was performed using the functional fitness test developed by Rikli & Jones [41], which measures the main physical parameters related to functional mobility. This assessment included six items: strength of the upper limb and arm undergoing surgery, measured by the arm curl test; strength of the lower limb, evaluated by the 30-second chair stand test; flexibility of the upper limb, assessed by the back scratch test; flexibility of the lower limb, measured by the sit and reach test on the chair; dynamic balance, evaluated by the Timed Up and Go (TUG) test; and aerobic endurance, measured by the 2-minute step test. Multicomponent training The program was held at the Gymnasium of the School of Education at the Polytechnic Institute of Bragança, with three sessions per week, on Mondays, Thursdays, and Fridays, lasting one hour per training session. The multicomponent training sessions were divided into three stages: the first one, a general warm-up, aimed at preparing the participants' cardiorespiratory, joint, and muscular systems; the second stage, the main core of the session, where exercises focused on resistance, aerobic activities, flexibility, and static and dynamic balance were performed; and finally, the third stage, focused on relaxation, aiming to provide rest and recovery for the body after training. Figure 3 below shows the full multicomponent training protocol for breast cancer survivors. Statistical analysis The normality of the data was checked with the Shapiro-Wilk test. The statistical power was calculated a priori in R, statistical computing language (34), to define the minimal sample size for this study. We set a moderate effect size for independent and paired t-tests (d = 0.50), and an alpha of 95% for statistical significance, and we had a sample size of 54 subjects. This way, our sample presented a poor statistical power (< 0.4) to capture real significant differences (reject the null hypothesis). In this way, we worked with more robust statistics that do not need the assumption of minimal sample size [42,43], which is better described in the next section of statistical analysis. Due to the reduced statistical power of the prior recruited sample in this study, we applied statistical procedures based on Bayesian assumptions. For this purpose, the paired and two-sample Bayesian T-tests were employed in the datasets identified as parametric and the Bayesian versions of the Man-Whittney test for two samples and the Wilcoxon signed-rank test for paired samples were employed for the non-parametric datasets. Bayesian paired and unpaired statistical tests are well-described to work robustly in small datasets where assumptions such as statistical power are broken [43]. These statistical tests are based on the prior probability which is a hypothesis of an occurrence of an unseen event, thus, right analyze real data the prior probability is compared with post-prior probability, and the hypothesis for significance in rejecting the null hypothesis and accepting the alternative hypothesis is updated and validated [44]. For this purpose, we considered the main metric of significance, which is the Bayes factor, considering Jeffreys’s [45] cut-offs of (≤ 3 = Anecdotal evidence, between 3 and 10 = Moderate evidence, > 10 = Strong evidence). Thus, we considered only differences classified with a strong level of evidence to reject the null hypothesis in a 95% confidence interval [43,45]. In addition, a hierarchical clustering method was employed considering the absolute pre-post differences from the variables with significant differences identified by the Bayesian paired statistical tests, aiming to characterize the participants with higher or smaller levels of improvements based on a between/within-subjects comparison (personalized clustering) [46]. For this purpose, we calculated the Manhattan distance, which works [45] and is recognized to be slightly more robust than other distance methods, such as Euclidean distance when dealing with outliers or as in our case, where the small datasets where the individual differences can bias the clustering results [47]. The clustering results reported the number of participants for each cluster (X-axis) and the Manhattan distance (Y-axis). The Silhouette score was calculated to check the best final number of clusters, considering the cut off < 0.5 to consider a good separation for the determined number of clusters [48]. The hierarchical clustering nodes visualized in the plots were cut with a red dashed line aiming to determine the more representative number of clusters. In addition, the clusters with the higher responders were labeled with 1, with 2, 3 and so on representing the less respondent participants. The percentual of sample size represented by each cluster were also reported. All the statistical, clustering analysis and respective graphic creation were performed in R, statistical programming language [49]. RESULTS Baseline comparison results Table 1 shows the results of body composition and physical fitness at the study’s baseline originated from the comparison between the experimental and control groups. The Bayesian tests showed that, after comparing prior to post probabilities, EG had higher height, higher visceral fat concentration at the baseline, reduced upper limb strength the arm surgically underwent, and smaller aerobic fitness than the control group. Table 1. Baseline results of the comparison between body composition and physical fitness between the control and experimental groups. Variable EG (n = 7) CG (n=11) Bayes Factor Prob. Sig. 95% IC Age (years) 64 ± 8.66 56.3 ± 10.3 1.016017 ±0% Anecdotal Height (cm) 1.63 0.65 161 ± 4.51 3.08049e+20 ±0% Moderate Body weight (kg) 64.59 ± 8.40 73.15 ± 12.2 1.212361 ±0% Anecdotal BF% 39 (2.4) 35 (4.75) 0.6120044 ±0% Anecdotal Lean mass (kg) 43.3 ± 4.94 41.1 ± 3.51 0.6120044 ±0% Anecdotal Body Watter % 45 (1.5) 49 (5.09) 0.1315774 Anecdotal Basal Metabolism (Kcal) 1374. ± 156. 1291 ± 108. .7005798 ±0% Anecdotal Visceral Fat 9 (3) 6 (3) 3152.451 # Strong Upper limb strength (rep) 13.6 ± 4.65 16.6 ± 1.90 0.04737735 Anecdotal Upper limb strength int. arm (rep) 7 ± 4.16 18.4 ± 2.76 292.0518 ±0% # Strong Lower limb strength (rep) 17.6 ± 3.69 20.9 ± 6.20 1.270417 ±0% Anecdotal Upper Limb Flexibility (cm) -4 ± 3.70 -2.56 ± 4.55 0.498694 ±0% Anecdotal Lower limb flexibility (cm) 4.57 ± 3.74 3.11 ± 6.81 0.4690581 ±0% Anecdotal Dynamic balance (sec) 4.96 ± 0.866 4.14 ± 0.502 3.637471 ±0.01% Moderate Aerobic Fitness (rep) 37 ± 14.7 112 ± 8.94 8899.25 Strong Note: Data is described in mean ± standard deviation for parametric data and in median (interquartile range) for non-parametric data. #: significant differences with strong level evidence provided by the Bayes factor outputs. Experimental results Table 2 shows the results of the pre-post comparison between CG and EG groups. The Bayesian paired tests revealed significant post-prior probability differences after 36 weeks of physical exercise training in favor of the EG considering reductions in body weight (pre =73.16 ± 2.22, post = 71.49 ± 12.1 kg) as well as in body fat percentage (pre = 36.9 ± 5.03, post = 32.91 ± 5.86%). There were also improvements in physical fitness, with increases in upper limb strength (pre = 13.57 ± 4.65, post = 27.71 ± 3.45 repetitions), similarly increasing in upper limb strength of the arm underwent chirurgic intervention (pre = 7 ± 4.16, post = 20.57 ± 6.92 repetitions), as well increases in the lower limb strength (pre = 17.57 ± 3.69, post = 25.43 ± 3.31 repetitions), and increases in aerobic fitness (pre = 37 ± 14.65, post = 134.57 ± 28.18 repetitions). Therefore, there were not any changes in CG after 20 weeks. Table 2. Results of pre-post comparison of body composition and physical fitness for the experimental and control group. Variable Group Pre Post Bayes Factor Prob. Sig. 95% IC Body weight (kg) EG 73.16 ± 2.22 71.49 ± 12.1 15.15472 ±0% # Strong CG 64 (9) 63 (11) 0.337071 Anecdotal BMI (Index) EG 27.43 ± 2.51 26.86 ± 3.02 1.175075 ±0.02% Anecdotal CG 25 (5) 25 (4) 0.2301768 Anecdotal BF% EG 36.9 ± 5.03 32.91 ± 5.86 34.86926 ±0% # Strong CG 31 ± 6 31 ± 6 1.075933 ±0.02% Anecdotal Lean mass (kg) EG 43 ± 5 44 ± 5 1.729713 ±0% Anecdotal CG 41 ± 4 41 ± 3 0.4237328 ±0.01% Anecdotal Body Watter % EG 45.91 ± 3.05 45. 8 ± 3.78 0.3607712 ±0% Anecdotal CG 49 (5) 50 (6) 0.1301105 Anecdotal Basal Metabolism (Kcal) EG 1367 (179) 1350.14 (183) 1.003316 Anecdotal CG 1291 ± 107.6 1296.38 ± 95.28 0.3963878 ±0.01% Anecdotal Visceral Fat EG 9 (3) 8 (3) 6.995007 Moderate CG 5 (3) 5 (2) 2.999471 Anecdotal Upper Limb Strength (rep) EG 13.57 ± 4.65 27.71 ± 3.45 1022.022 ±0% # Strong CG 16.4 ± 1.9 17.8 ± 2.94 0.800111 ±0.02% Anecdotal Upper Limb Strength int. arm (rep) EG 7 ± 4.16 20.57 ± 6.92 121.3942 ±0% # Strong CG 18.43 ± 2.76 16.71 ± 3.64 0.5027359 ±0.01% Anecdotal Lower limb strength (rep) EG 17.57 ± 3.69 25.43 ± 3.31 206.5508 ±0% # Strong CG 23 ± 6.96 23.78 ± 4.52 0.3475993 ±0% Anecdotal Upper Limb Flexibility (cm) EG -4 (5) 4 (3.5) 0.003955486 Anecdotal CG -2.56 ± 4.55 -2.2 ± 5.82 0.3209674 ±0.01% Anecdotal Lower limb flexibility (cm) EG 4.57 ± 3.74 9.14 ± 4.6 1.73919 ±0% Anecdotal CG 3.11 ± 6.81 4 ± 4.27 0.371723 ±0.01% Anecdotal Dynamic balance (sec) EG 4.96 ± 0.87 3.91 ± 0.38 8.260729 ±0% Moderate CG 4.14 ± 0.5 4.35 ± 0.61 0.8045248 ±0.02% Anecdotal Aerobic fitness EG 37 ± 14.65 134.57 ± 28.18 157.2803 ±0% # Strong CG 122.11 ± 19.33 122 ± 18.53 0.3216269 ±0% Anecdotal Note: Data is described in mean ± standard deviation for parametric data and in median (interquartile range) for non-parametric data. #: significant differences with strong level evidence provided by the Bayes factor outputs. Figure 4 shows the hierarchical clustering results from the variables with significant pre-post 36 weeks of multicomponent training in the EG. In general, regarding the variables with statistically significant differences, all participants have individual improvements. Specifically within the hierarchical cluster results, respective to the body weight reductions (Silhouette score = 0.77) (Figure 4-A), there were two clusters, cluster 1 [higher responders (28%)]: participant 1 [3.3 kg], and 5 [2.7 kg], and cluster 2 [lower responders (71%)]: participants 2 [0.8 kg], 3 [1.4 kg], 4 [1.2 kg], 6 [0.9 kg], and 7 [1.4 kg]. For body fat percentage reductions (Silhouette score = 0.75) (Figure 4-B), the HC identified also two clusters, were cluster 1 [higher responders (57%)]: participants 1 [4.9%], 2 [4.8%], 3 [6.9%) and 4 [4.7 %], and cluster 2 [lower responders (43%)]: participants 5 [2 %], 6 [2%], and 7 [2.6%]. For upper limb strength improvements (Silhouette score = 0.68) (Figure 4-C) there were three clusters, cluster 1 [high responders (86%)]: participants 1, 3, and 4 [17 repetitions], cluster 2 [mild responders (43%)]: participants 2 [13 repetitions], 5 [14 repetitions], and 7 [12 repetitions], and cluster 3 [lower responder (14%)]: characterized by only the participant 6 [9 repetitions]. For the upper limb strength improvements of the arm underwent to surgical procedure (Silhouette score = 0.56) (Figure 4-D), there were also two clusters, cluster 1 [higher responders (71%)]: participants 1 and 7 [13 repetitions], 2 and 4 [16 repetitions], and 3 [21 repetitions], and cluster 2 [lower responders (29%)]: participants 5 [9 repetitions], and 6 [9 repetitions]. For the lower limb strength (Silhouette score = 0.80) (Figure 4-E) there were two principal clusters, were cluster 1 [higher responders (43%)]: participants 1 [11 repetitions], 6 and 7 [10 repetitions], and cluster 2 [lower responders (57%)]: participants 2 [7 repetitions] 3, 4 [6 repetitions], and 5 [5 repetitions]. Regarding aerobic fitness (Silhouette score = 0.62) (Figure 4-F), there were two clusters, were cluster 1 [higher responders (29%)]: participants 3 [154 repetitions], and 7 [124 repetitions], and cluster 2 [lower responders (71%)]: participants 1 [70 repetitions], 2 [95 repetitions], 4 [72 repetitions], 5 [70 repetitions], and 6 [98 repetitions]. These results prove that all the participants improved similarly, and there were some fewer responder subjects, indicating that the intervention was positive, but not in the same meaningful for all patients. After outputting the clustering results, we developed a mind map (Figure 5) to offer a structured approach to guide clinical decisions after identifying each patient's individual response to multi-component training. Based on the analysis of performance variables and each patient's specific responses, the mind map suggests personalized directions for the continuation of treatment, either through intensifying certain components of the program or adjusting the training modality. This process ensures a more effective intervention adapted to the needs and progress of each individual. DISCUSSION The objective of this study was twofold: first, to test the hypothesis that multicomponent training improves body composition in breast cancer survivors, and second, to evaluate its impact on physical fitness. Based on the statistical results, weight and fat percentage reduction was observed in the experimental group after the 36-week intervention. Additionally, improvements were noted across all physical fitness variables. These findings fully support the study’s hypothesis that multicomponent training enhances physical fitness, as improvements were observed in all measured variables. However, the results only partially support the hypothesis regarding body composition improvements, as significant changes were observed in weight and fat percentage but not in other body composition metrics. Therefore, this hypothesis is partially rejected. As previously mentioned, both body weight and body fat percentage were reduced. Regarding body weight, cluster analysis reveals that multicomponent training resulted in predominantly lower responses among the patients in the study. In contrast, when analyzing the reduction in fat percentage, the clusters indicate that the intervention had varying effects on individuals: 4 participants were classified as higher responders, while 3 were lower responders, suggesting that the intervention had a moderate impact on the participants' weight status. Reductions in body weight are crucial for preventing cancer [6], during [50], or after treatment [6]. Excess body fat tissue releases inflammatory cytokines that contribute to low-grade chronic inflammation, commonly known as "inflammaging." This process involves inflammation that disrupts cell cycle regulation, damages cells, and impairs proteostasis, all of which promote the expression of carcinogenic genes and increase cancer risk [51]. Regarding the change in strength in the upper limbs of the study participants, there was a similar increase in strength in the upper limb that underwent surgical intervention and in the one that was not submitted. The cluster analysis for this variable was subdivided into three groups for increased strength in the upper limbs, in which 3 patients were considered high responders, 3 patients were mild responders and only 1 patient was low responder. This allows us to understand that multicomponent training tends to be efficient in improving the strength of patients' upper limbs after the intervention since 6 of the 7 participants analyzed were responsive, whether high or light. In contrast, only one patient was slightly responsive, showing increased upper limb strength. When analyzing the improvement in strength in the upper limb submitted to surgical intervention, cluster 1 was observed with five patients as the greatest responders, and cluster 2, with two patients as the lowest responders. This makes it clear that multicomponent training effectively improves the strength of the upper limbs of patients undergoing the surgical process, given the characteristics of patients' responsiveness to this issue. This shows the relevance of this type of activity for improving the quality of life of patients recovering from breast cancer, as it contributes to the return to routine instrumental activities of daily living which require good control of the upper limbs such as managing finances or medications, food preparation, housekeeping, and laundry, thus contributing to the recovery of their independence [52]. When analyzing the variable improvement in the strength of the lower limbs of breast cancer survivors undergoing multicomponent training, two clusters were observed. The first cluster was linked to higher responders, with three patients as group members. The second cluster covered the lowest responders (four patients) submitted to the present study. This distribution allows us to understand that multicomponent training presented a divergent impact on the individuals’ lower limb strength, showing that the training did not evoke the same level of changes in the subjects. However, even at different levels, the intervention proposed by the present study proved to improve the strength of the lower limbs, which is a positive result, considering that this contributes to helping patients in their daily lives, facilitating their ambulation and independence of performance your daily tasks such as climbing stairs, walking at the street and moving carrying objects [52]. This result is consistent with previous studies reporting strength gains with regular practice of muscle resistance exercises, both for lower and upper limbs, as evidenced by the meta-analysis by Guideline [53], which suggests that multicomponent strength training improves strength similarly to exclusive resistance training programs. Although multicomponent training is not exclusively focused on strength, it is expected that cumulative improvements will occur in the long term. Short-term interventions, such as those lasting 12 weeks, may not lead to significant changes in various dimensions of physical fitness [54], but positive results were still observed within this short period of time. There are studies that after only 9 weeks of multicomponent training showed significant differences in favor of multicomponent training in all study variables [55], but literature indicates that longer programs, like the 9 months of this intervention, produce more noticeable chronic effects [56].Regarding changes in aerobic fitness, the clustering results revealed the presence of two clusters. The first cluster is composed of higher responders, consisting of two individuals, while the second cluster comprises lower responders, consisting of five individuals. These results indicate that the intervention primarily led to low-grade improvements among participants. Despite this predominance of lower responders, the intervention still resulted in increases in aerobic fitness for all participants, which is a positive outcome of the training. This improvement in aerobic capacity is aligned with the results of studies on long-term multicomponent training, such as one conducted over 32 weeks [57] and another over 27 weeks [58]. Aerobic fitness is associated with enhanced antioxidant defense, protecting cells from damage and regulating cellular function [48]. Additionally, improving aerobic fitness is an essential strategy for alleviating fatigue symptoms related to cancer treatment and post-treatment [58,59]. Cluster analysis is important because it helps us understand how each person responds to treatment by grouping those with similar responses. This is crucial to adjust the intervention when necessary. For example, if a patient is not responding well to the initial treatment, cluster analysis can help identify what is happening and suggest changes, either in the approach or type of exercise. This process is similar to medical practice, where doctors adjust a patient's medication when the initial treatment response is not satisfactory, always seeking a more effective and personalized treatment [60]. In the present study, we had some relevant limitations that should be considered in future studies on this topic, given more realistic and concrete results. Among these points, we can mention our small experimental sample, which makes it difficult to have a broader view of the population reality, which could be considerably different and complex. Furthermore, another limiting factor was the shorter analysis period of the control group (20 weeks) compared to the group undergoing the proposed intervention (36 weeks). It is necessary to analyze both groups for at least the same period of time to understand better the result and the difference at the end of the intervention between these two portions. Studies with a larger sample, both CG and EG, help understand how the intervention was studied in the group in question, considering different origins, ethnicities, ages, and other population variables. Finally, for subsequent studies, the use of biochemical and molecular tests is relevant to understand, even more in-depth, the results of multicomponent training in the target groups of breast cancer patients in different stages of the pathology. However, it is important to highlight some strengths of the present study: (i) This is a novelty approach with 32 weeks of duration using multicomponent training exercise-based therapy; (ii) this is a controlled trial with high level of evidence; (iii) the study provided a cluster of reactions to treatment; (iv) it is possible to define strategies for treatment in agreement with the responders. That said, the study suggests that each participant reacts differently to the exercise-based therapy and should be reevaluated periodically to adjust the treatment. CONCLUSION The multicomponent physical exercise program effectively improved all physical fitness variables. In contrast, the improvements in the body composition outcomes were limited, exposing improvements only in body weight and % body fat. Finally, the intervention did not cause any side effects or injury to the participants. Declarations ETHICS APPROVAL The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the Higher Institute of Educational Sciences of the Douro (nº: 2.576). ETHICS STATEMENT Informed consent to participate in this study was obtained from all subjects and/or their legal guardians prior to participation. CONSENT FOR PUBLICATION All authors confirm that they have read, reviewed and approved the final version of the manuscript, agreeing to its submission for publication. DATA AVAILABILITY STATEMENT Data is provided within supplementary information files AUTHORS’ CONTRIBUITION Samuel Encarnação: Responsible for developing the methodology for statistical analysis, performing the analyses, creating Figures 2 and 4, as well as reviewing the manuscript. André Schneider: Contributed to writing the Introduction and methodology, developed Figures 1 and 5, and participated in reviewing the manuscript. Roberto Almeida: Responsible for writing the Discussion section. Luciano Bernardes: Collaborated on writing the Discussion, developed Figure 3, and reviewed the manuscript. Pedro Forte: Worked on reviewing the manuscript. Miguel Monteiro: Participated in reviewing the manuscript. Helder Jaime: Financed the article submission and contributed to reviewing the manuscript. ACKNOWLEDGEMENTS Not Applicable FUNDING This work was co-financed by the European Regional Development Fund (FEDER) through the programme INTERREG VI-A Spain-Portugal (POCTEP) 2021–2027: Novas Sociedades Longevas (0137_NSL_6_E). CONFLICT OF INTEREST STATEMENT All authors declare that there are no conflicts of interest regarding the publication of this manuscript. References Breast cancer [Internet]. [cited 2024 Sep 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/breast-cancer Sun YS, Zhao Z, Yang ZN, Xu F, Lu HJ, Zhu ZY, et al. Risk Factors and Preventions of Breast Cancer. Int J Biol Sci. 2017;13(11):1387–97. Ficarra S, Thomas E, Bianco A, Gentile A, Thaller P, Grassadonio F, et al. Impact of exercise interventions on physical fitness in breast cancer patients and survivors: a systematic review. Breast Cancer Tokyo Jpn. 2022 May;29(3):402–18. Akram M, Iqbal M, Daniyal M, Khan AU. Awareness and current knowledge of breast cancer. Biol Res. 2017 Oct 2;50(1):33. Coleman MP, Quaresma M, Berrino F, Lutz JM, Angelis RD, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008 Aug 1;9(8):730–56. Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer. 2008 Oct 15;113(8 Suppl):2221–43. Iacoviello L, Bonaccio M, de Gaetano G, Donati MB. Epidemiology of breast cancer, a paradigm of the “common soil” hypothesis. Semin Cancer Biol. 2021 Jul;72:4–10. Kelsey JL, Gammon MD. The epidemiology of breast cancer. CA Cancer J Clin. 1991;41(3):146–65. Giaquinto AN, Sung H, Miller KD, Kramer JL, Newman LA, Minihan A, et al. Breast Cancer Statistics, 2022. CA Cancer J Clin. 2022 Nov;72(6):524–41. Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Allen C, Barber RM, Barregard L, Bhutta ZA, et al. Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study. JAMA Oncol. 2017 Apr 1;3(4):524–48. Xu Y, Gong M, Wang Y, Yang Y, Liu S, Zeng Q. Global trends and forecasts of breast cancer incidence and deaths. Sci Data. 2023 May 27;10(1):334. Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast Edinb Scotl. 2022 Dec;66:15–23. Ording AG, Garne JP, Nyström PMW, Frøslev T, Sørensen HT, Lash TL. Comorbid Diseases Interact with Breast Cancer to Affect Mortality in the First Year after Diagnosis—A Danish Nationwide Matched Cohort Study. PLOS ONE. 2013 Oct 9;8(10):e76013. Shapiro CL, Recht A. Side Effects of Adjuvant Treatment of Breast Cancer. N Engl J Med. 2001 Jun 28;344(26):1997–2008. Neil-Sztramko SE, Kirkham AA, Hung SH, Niksirat N, Nishikawa K, Campbell KL. Aerobic capacity and upper limb strength are reduced in women diagnosed with breast cancer: a systematic review. J Physiother. 2014 Dec 1;60(4):189–200. Parker PA, Youssef A, Walker S, Basen-Engquist K, Cohen L, Gritz ER, et al. Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer. Ann Surg Oncol. 2007 Nov;14(11):3078–89. Hayes SC, Johansson K, Stout NL, Prosnitz R, Armer JM, Gabram S, et al. Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care. Cancer. 2012 Apr 15;118(8 Suppl):2237–49. Hidding JT, Beurskens CHG, Van Der Wees PJ, Van Laarhoven HWM, Nijhuis-van Der Sanden MWG. Treatment Related Impairments in Arm and Shoulder in Patients with Breast Cancer: A Systematic Review. Macleod U, editor. PLoS ONE. 2014 May 9;9(5):e96748. Mols F, Vingerhoets AJJM, Coebergh JW, van de Poll-Franse LV. Quality of life among long-term breast cancer survivors: a systematic review. Eur J Cancer Oxf Engl 1990. 2005 Nov;41(17):2613–9. Speck RM, Courneya KS, Mâsse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2010 Jun;4(2):87–100. Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. CA Cancer J Clin. 2016;66(1):43–73. Zagar TM, Cardinale DM, Marks LB. Breast cancer therapy-associated cardiovascular disease. Nat Rev Clin Oncol. 2016 Mar;13(3):172–84. Lindquist H, Enblom A, Dunberger G, Nyberg T, Bergmark K. WATER EXERCISE COMPARED TO LAND EXERCISE OR STANDARD CARE IN FEMALE CANCER SURVIVORS WITH SECONDARY LYMPHEDEMA. Lymphology. 2015 Jun;48(2):64–79. Şener HÖ, Malkoç M, Ergin G, Karadibak D, Yavuzşen T. Effects of Clinical Pilates Exercises on Patients Developing Lymphedema after Breast Cancer Treatment: A Randomized Clinical Trial. J Breast Health. 2017 Jan;13(1):16–22. Sun H, Huang H, Ji S, Chen X, Xu Y, Zhu F, et al. The Efficacy of Cognitive Behavioral Therapy to Treat Depression and Anxiety and Improve Quality of Life Among Early-Stage Breast Cancer Patients. Integr Cancer Ther. 2019 Jan;18:153473541982957. Dieli-Conwright CM, Courneya KS, Demark-Wahnefried W, Sami N, Lee K, Sweeney FC, et al. Aerobic and resistance exercise improves physical fitness, bone health, and quality of life in overweight and obese breast cancer survivors: a randomized controlled trial. Breast Cancer Res. 2018 Dec;20(1):124. Leach HJ, Danyluk JM, Nishimura KC, Culos-Reed SN. Evaluation of a Community-Based Exercise Program for Breast Cancer Patients Undergoing Treatment. Cancer Nurs. 2015;38(6):417–25. Qiu H, Ren W, Yang Y, Zhu X, Mao G, Mao S, et al. Effects of cognitive behavioral therapy for depression on improving insomnia and quality of life in Chinese women with breast cancer: results of a randomized, controlled, multicenter trial. Neuropsychiatr Dis Treat. 2018;14:2665–73. Gokal K, Wallis D, Ahmed S, Boiangiu I, Kancherla K, Munir F. Effects of a self-managed home-based walking intervention on psychosocial health outcomes for breast cancer patients receiving chemotherapy: a randomised controlled trial. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2016 Mar;24(3):1139–66. Dong X, Yi X, Ding M, Gao Z, McDonough DJ, Yi N, et al. A Longitudinal Study of a Multicomponent Exercise Intervention with Remote Guidance among Breast Cancer Patients. Int J Environ Res Public Health. 2020 May 14;17(10):3425. Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. J Support Oncol. 2012;10(5):171–7. Sadjapong U, Yodkeeree S, Sungkarat S, Siviroj P. Multicomponent Exercise Program Reduces Frailty and Inflammatory Biomarkers and Improves Physical Performance in Community-Dwelling Older Adults: A Randomized Controlled Trial. Int J Environ Res Public Health. 2020 May 26;17(11):3760. Amjad A, Kordel P, Fernandes G. A Review on Innovation in Healthcare Sector (Telehealth) through Artificial Intelligence. Sustainability. 2023 Apr 14;15(8):6655. R project. R: The R Project for Statistical Computing [Internet]. 2022 [cited 2023 Jan 7]. Available from: https://www.r-project.org/ Eriksson O, Jauhiainen A, Maad Sasane S, Kramer A, Nair AG, Sartorius C, et al. Uncertainty quantification, propagation and characterization by Bayesian analysis combined with global sensitivity analysis applied to dynamical intracellular pathway models. Bioinformatics. 2019 Jan 15;35(2):284–92. Ly A, Verhagen J, Wagenmakers EJ. Harold Jeffreys’s default Bayes factor hypothesis tests: Explanation, extension, and application in psychology. J Math Psychol. 2016 Jun;72:19–32. A healthy lifestyle - WHO recommendations [Internet]. [cited 2024 Sep 20]. Available from: https://www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle---who-recommendations Rikli RE, Jones CJ. Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years. The Gerontologist. 2013 Apr;53(2):255–67. Koopman BO. Harold Jeffreys. Theory of probability. Oxford University Press, Oxford1939, vii+ 380 pp. J Symb Log. 1943;8(1):34–5. Zhang Z, Murtagh F, Poucke SVV, Lin S, Lan P. Hierarchical cluster analysis in clinical research with heterogeneous study population: highlighting its visualization with R. Ann Transl Med. 2017 Feb;5(4):75–75. Xu R, Wunsch D. Survey of clustering algorithms. IEEE Trans Neural Netw. 2005 May;16(3):645–78. Maechler M, original) PR (Fortran, original) AS (S, original) MH (S, Hornik [trl K, maintenance(1999-2000)) ctb] (port to R, et al. cluster: “Finding Groups in Data”: Cluster Analysis Extended Rousseeuw et al. [Internet]. 2023 [cited 2024 Sep 25]. Available from: https://cran.r-project.org/web/packages/cluster/index.html Anderson AS, Renehan AG, Saxton JM, Bell J, Cade J, Cross AJ, et al. Cancer prevention through weight control—where are we in 2020? Br J Cancer. 2021 Mar;124(6):1049–56. Ligibel JA, Bohlke K, May AM, Clinton SK, Demark-Wahnefried W, Gilchrist SC, et al. Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline. J Clin Oncol Off J Am Soc Clin Oncol. 2022 Aug 1;40(22):2491–507. Anderson AS, Martin RM, Renehan AG, Cade J, Copson ER, Cross AJ, et al. Cancer survivorship, excess body fatness and weight-loss intervention—where are we in 2020? Br J Cancer. 2021 Mar;124(6):1057–65. Hanahan D. Hallmarks of Cancer: New Dimensions. Cancer Discov. 2022 Jan;12(1):31–46. Klassen O, Schmidt ME, Ulrich CM, Schneeweiss A, Potthoff K, Steindorf K, et al. Muscle strength in breast cancer patients receiving different treatment regimes. J Cachexia Sarcopenia Muscle. 2017 Apr;8(2):305–16. Garatachea N, Pareja-Galeano H, Sanchis-Gomar F, Santos-Lozano A, Fiuza-Luces C, Morán M, et al. Exercise attenuates the major hallmarks of aging. Rejuvenation Res. 2015 Feb;18(1):57–89. Janjua S, Brown M, Parker R, Prue G, Closier P, Cramp F. Physical activity for the management of cancer‐related fatigue in adults. Cochrane Database Syst Rev. 2022 Dec 1;2022(12):CD015348. Additional Declarations No competing interests reported. Supplementary Files DataSetBreastCancerMTC.csv Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 11 Feb, 2025 Reviews received at journal 08 Feb, 2025 Reviewers agreed at journal 23 Jan, 2025 Reviews received at journal 28 Dec, 2024 Reviews received at journal 27 Dec, 2024 Reviewers agreed at journal 21 Dec, 2024 Reviewers agreed at journal 19 Dec, 2024 Reviewers agreed at journal 19 Dec, 2024 Reviewers invited by journal 17 Dec, 2024 Editor assigned by journal 17 Dec, 2024 Editor invited by journal 06 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 30 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5362882","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":379949969,"identity":"5355ee34-4a0c-4389-b873-c4879f3d59ce","order_by":0,"name":"Samuel Gonçalves Almeida Encarnação","email":"","orcid":"","institution":"Universidad Autónoma de Madrid (UAM)","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"Gonçalves Almeida","lastName":"Encarnação","suffix":""},{"id":379949971,"identity":"9fa8eb5a-b354-4757-aab2-ad4db0279a8f","order_by":1,"name":"André Schneider","email":"","orcid":"","institution":"Instituto Politécnico de Bragança (IPB)","correspondingAuthor":false,"prefix":"","firstName":"André","middleName":"","lastName":"Schneider","suffix":""},{"id":379949972,"identity":"e86624a6-9704-4fef-a18b-41f2d9b3a6cb","order_by":2,"name":"Roberto Gonçalves Almeida","email":"","orcid":"","institution":"Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Roberto","middleName":"Gonçalves","lastName":"Almeida","suffix":""},{"id":379949973,"identity":"c338097f-a1e4-4682-bff9-dfa98d5547b7","order_by":3,"name":"Luciano Bernardes","email":"","orcid":"","institution":"Universidade Federal de Viçosa","correspondingAuthor":false,"prefix":"","firstName":"Luciano","middleName":"","lastName":"Bernardes","suffix":""},{"id":379949974,"identity":"0a71c725-1655-48b3-a879-093c92aef778","order_by":4,"name":"Pedro Forte","email":"","orcid":"","institution":"Instituto Superior de Ciências Educativas do Douro (ISCE Douro)","correspondingAuthor":false,"prefix":"","firstName":"Pedro","middleName":"","lastName":"Forte","suffix":""},{"id":379949975,"identity":"b22e19ec-96d0-4d4a-9642-5e9f8b1e25c8","order_by":5,"name":"Helder Jaime Fernandes","email":"","orcid":"","institution":"Instituto Politécnico de Bragança","correspondingAuthor":false,"prefix":"","firstName":"Helder","middleName":"Jaime","lastName":"Fernandes","suffix":""},{"id":379949977,"identity":"f35f379a-1d08-4544-9bdb-1ef11bb0dcc5","order_by":6,"name":"António Miguel Monteiro","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYPACCQYG9sYGZuI1HABp4TkI1iJBrBaQ2gQG4rToTjt87PGHCot8fsnHbY8LGO7UEdRidjst3eDAGQnLmbMT241nMDwjbIvZ7RwziYNtEgYGtxPbpHkYDhOr5R9Qy82DJGlpAGq5wUi0lrQ0iTPHJAwke0B+MXgm2UBYS/IxiYqaOgN+9uPPHhdU3OEnaAsyYGNgMDhAkg6QFgYStYyCUTAKRsGIAAACpztZZymV4AAAAABJRU5ErkJggg==","orcid":"","institution":"Instituto Politécnico de Bragança","correspondingAuthor":true,"prefix":"","firstName":"António","middleName":"Miguel","lastName":"Monteiro","suffix":""}],"badges":[],"createdAt":"2024-10-30 17:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5362882/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5362882/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-01702-y","type":"published","date":"2025-09-30T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70581725,"identity":"0e3c28b7-bf69-4a92-a8f0-d0f299a7efc8","added_by":"auto","created_at":"2024-12-04 15:18:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45306,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of evaluation and multicomponent training in the breast cancer survivors.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/e3a0cf21529d3d7b3e2f15d9.png"},{"id":70581724,"identity":"38f6415b-a01e-425e-aee3-b63c3d6e3c08","added_by":"auto","created_at":"2024-12-04 15:18:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":60013,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/81c90fd153dfd4b2dd238765.png"},{"id":70581096,"identity":"1ce4893c-c35d-4331-a667-084665b35572","added_by":"auto","created_at":"2024-12-04 15:10:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":181856,"visible":true,"origin":"","legend":"\u003cp\u003eMulticomponent training organization during the 9 months of study follow-up.\u003c/p\u003e\n\u003cp\u003eNote: IR: Interval Rest; KB: Kettlebell; DB: Dumbbell.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/917a0fd886800f3ad32269e4.png"},{"id":70581102,"identity":"0c5bf4f7-9997-4e52-ba63-7d464a3be3dd","added_by":"auto","created_at":"2024-12-04 15:10:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52824,"visible":true,"origin":"","legend":"\u003cp\u003eHierarchical Clustering Results of Variables with Significant Pre-Post Differences After 36 Weeks of Multicomponent Training in the Experimental Group. Part. (participant), BW (body weight), BF % (body fat percentage), ULS (upper limb strength), ULS – Interv. arm (arm which underwent surgical procedure), LLS (lower limb strength), AF (aerobic fitness).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/0a378c5f1952b13e973f3fa6.png"},{"id":70581098,"identity":"1c28e280-8705-45ce-ba13-26b31e0baaac","added_by":"auto","created_at":"2024-12-04 15:10:11","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":194923,"visible":true,"origin":"","legend":"\u003cp\u003eMind map about the possible decision making based on individual response to Intervention.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/d9f6d96fa76d86d49b7b227f.png"},{"id":92883939,"identity":"0e0e8d06-4225-4d59-882e-acb252435817","added_by":"auto","created_at":"2025-10-06 16:11:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1283610,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/8b87d926-cb0d-493e-990b-51863e08291d.pdf"},{"id":70581100,"identity":"e89d1a50-b16c-4375-a913-c7e1dfd1c6b8","added_by":"auto","created_at":"2024-12-04 15:10:11","extension":"csv","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":514771,"visible":true,"origin":"","legend":"","description":"","filename":"DataSetBreastCancerMTC.csv","url":"https://assets-eu.researchsquare.com/files/rs-5362882/v1/8bc881985f0d0d510809113c.csv"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term effects of multicomponent training in the body composition and physical fitness of breast cancer survivors: a controlled and experimental study with clustering analysis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreast cancer is the most prevalent form of cancer worldwide, characterized by the development of malignant cells in the mammary glands, which can invade surrounding tissues and metastasize to other areas of the body [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This disease is highly heterogeneous, with a complex etiology influenced by genetic predispositions, behavioral (lifestyle) and environmental factors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2020, an estimated 2.3\u0026nbsp;million new cases of breast cancer were diagnosed globally [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2022, the disease led to approximately 670,000 deaths [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], solidifying its position as the leading cause of cancer-related mortality among women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurvival rates for breast cancer vary significantly across the globe. The 5-year survival rate in developed countries is approximately 80%, while in developing nations, it drops to below 40% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Limited resources and infrastructure in developing countries often impede efforts to improve outcomes, particularly in early detection, diagnosis, and treatment [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver the past few decades, breast cancer epidemiology has been extensively studied. Between 2010 and 2019, the incidence rate increased by 0.5% annually, driven by factors such as disease stage at diagnosis, aging populations, and overall population growth [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As a result, global incident cases have risen by 128% over the last thirty years. Projections suggest that by 2040, there will be more than 3\u0026nbsp;million new cases of breast cancer annually [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These results call for attention to lifestyle in developed populations, where exposure to some risk factors may be controlled.\u003c/p\u003e \u003cp\u003eCurrent breast cancer treatment and management employ a multifaceted approach tailored to the disease's type, stage, and progression. This includes targeted therapies, hormonal treatments, radiotherapy, chemotherapy, and surgery [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, survivors often face heightened risks of comorbid conditions such as sarcopenia, osteoporosis, and cardiovascular disease, which can adversely affect their quality of life, cardiorespiratory fitness, muscle strength, and bone health [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese health issues are partly attributed to cancer treatments\u0026mdash;such as chemotherapy, radiotherapy, and hormonal therapy\u0026mdash;and are exacerbated by factors like obesity and a sedentary lifestyle. The treatments can also lead to fatigue, insomnia, nausea, vomiting, neuropathy, cardiotoxicity, and reduced muscle strength, resulting in both physiological and psychological challenges [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], Additionally, significant loss of upper limb mobility, strength, and muscle mass further compromises life satisfaction and quality of life for these patients [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For these reasons, behavioral strategies based on active living and wellbeing have been promoted in cancer patients and survivors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with the previous information, physical exercise complementary therapies have emerged as a powerful non-pharmacological strategy to mitigate treatment side effects and enhance the quality of life, cardiorespiratory fitness, and muscle strength among breast cancer survivors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Current guidelines advocate for health promotion counseling emphasizing physical activity [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Exercise can improve cancer-related health indicators, support a healthy energy balance, and reduce the risk of cardiovascular diseases, which are a leading cause of death among survivors [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Various studies have explored different exercise modalities, including aquatic exercises [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], Pilates interventions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], cognitive-behavioral therapy [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and aerobic and resistance-based exercises [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. While these studies highlight short-term benefits, research on the long-term effects of these interventions remains limited. Survivors often experience persistent psychological and physiological issues, as well as complications from surgery [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Thus, understanding the long-term impact of exercise programs is crucial from a clinical perspective for breast cancer survivors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Long term analysis are hard to perform because of the difficulties related to drop-in and -out [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite strong evidence supporting physical activity and exercise-specific programs' role in cancer prevention and treatment, some modalities, like multicomponent training, show potential for improvements but currently lack sufficient robust evidence [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Multicomponent training integrates various physical qualities\u0026mdash;strength, cardiorespiratory endurance, flexibility, and balance\u0026mdash;into a single session, typically lasting about 60 minutes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe research on multicomponent training for breast cancer patients is crucial to assess how this intervention can enhance rehabilitation, body composition, and functional fitness. As medical advancements extend life expectancy, understanding the rehabilitation needs of older adults becomes increasingly important [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Establishing new theoretical, methodological, and analytical frameworks is essential for guiding cancer research in this demographic [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies indicate that individuals' response to training programs can vary substantially due to factors such as prior physical condition, intensity and frequency of physical activity, as well as individual biological characteristics [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Therefore, it is essential to recognize that, although everyone can show improvements, the magnitude of these changes tends to be different for each person [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. To identify these variations, this study used to cluster analysis, grouping participants according to their training responses.\u003c/p\u003e \u003cp\u003eThat said, concerning the difficulties of long-term analysis in this type of population and the lack of research regarding multicomponent exercise-based therapy and special multicomponent training programs, there\u0026rsquo;s a need to understand the effectiveness of this therapy better. Upon that, this study aims to evaluate the long-term effects of multicomponent training on body composition and functional fitness among breast cancer survivors. We propose the following hypotheses: (1) multicomponent training will improve body composition in breast cancer survivors; and (2) it will enhance functional fitness.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is an experimental and controlled study, enrolling the long-term effects of a multicomponent training program in the breast cancer survivors\u0026rsquo; body composition and physical fitness. \u0026nbsp;The training sessions had a duration of 50-55 minutes, with evaluations conducted over the course of one week. Participants were also encouraged to continue their daily activities throughout the study. Figure 1 illustrates the timeline of the evaluation and exercise phases during the program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 19 breast cancer survivors were included in this study, 7 in the experimental group (EG), and 12 in the control group (CG).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following inclusion criteria were considered for participation in the multi-component training sessions: (i) previous diagnosis of breast cancer; (ii) having undergone definitive surgery, regardless of the type; (iii) having undergone post-surgical treatment, such as chemotherapy, radiotherapy, immunotherapy, endocrine therapy, or a combination of these; and (iv) having finished treatment before starting the multi-component training program. The established exclusion criteria were: (i) the presence of serious clinical conditions related to other chronic diseases that would hinder participation in the multi-component training sessions; (ii) the use of medications that could compromise participation in the sessions; and (iii) the presence of severe cardiovascular, muscular, metabolic, or articular complications that would impair the ability to participate in the program. At the end of the intervention, seven women completed the program, with one dropout due to the need for a new surgical procedure.\u003c/p\u003e\n\u003cp\u003eThe control group was composed of breast cancer survivors who did not participate in any intervention during the experimental period. Unlike the group that underwent the multicomponent training, these participants were not subjected to any exercise or specific protocol during the study. However, they were regularly (every 4 weeks) instructed to maintain their daily life routines, especially physical activity levels. The absence of intervention allowed the results to be compared directly with the intervention group, highlighting the possible effects of physical training on survivors\u0026apos; recovery and quality of life. The study design is illustrated in the flowchart (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Written informed consent has been obtained from the patient(s) to publish this paper.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the Higher Institute of Educational Sciences of the Douro (n\u0026ordm;: 2.576).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the data collection, a team of interns was trained to effectively apply research instruments to obtain information about the body composition, functional fitness, and quality of life of breast cancer survivors. The assessments took place in three stages: at the beginning of the program (baseline of the multicomponent training), after 6 months of training, and again at the end of 9 months. During these phases, the following data were collected:\u003c/p\u003e\n\u003cp\u003eBody composition variables included Body Mass Index (BMI), expressed in kg/m\u0026sup2;, calculated from height measurements (in cm) and body weight (in kg). The classification of Body Mass Index (BMI) followed the standards established by the World Health Organization (WHO) (37), defining normal between 18.50 and 24.99; overweight between 25 and 29.99; Class I obesity between 30 and 34.99; and Class II obesity between 35 and 39.99. Additionally, we performed bioimpedance analysis, obtaining information about body composition, lean muscle mass (in kilograms), body fat percentage, bone mass (in kilograms), visceral fat, basal metabolism (in kilograms), and body water percentage. All bioimpedance measurements were taken with the volunteers wearing lightweight clothes and barefoot, using a digital bioimpedance scale (Tanita DC-430 digital weighing scale with 0.1g precision, Illinois, USA).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe evaluation of functional capacity variables was performed using the functional fitness test developed by Rikli \u0026amp; Jones\u0026nbsp;[41], which measures the main physical parameters related to functional mobility. This assessment included six items: strength of the upper limb and arm undergoing surgery, measured by the arm curl test; strength of the lower limb, evaluated by the 30-second chair stand test; flexibility of the upper limb, assessed by the back scratch test; flexibility of the lower limb, measured by the sit and reach test on the chair; dynamic balance, evaluated by the Timed Up and Go (TUG) test; and aerobic endurance, measured by the 2-minute step test.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMulticomponent training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe program was held at the Gymnasium of the School of Education at the Polytechnic Institute of Bragan\u0026ccedil;a, with three sessions per week, on Mondays, Thursdays, and Fridays, lasting one hour per training session. The multicomponent training sessions were divided into three stages: the first one, a general warm-up, aimed at preparing the participants\u0026apos; cardiorespiratory, joint, and muscular systems; the second stage, the main core of the session, where exercises focused on resistance, aerobic activities, flexibility, and static and dynamic balance were performed; and finally, the third stage, focused on relaxation, aiming to provide rest and recovery for the body after training. Figure 3 below shows the full multicomponent training protocol for breast cancer survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe normality of the data was checked with the Shapiro-Wilk test. The statistical power was calculated a priori in R, statistical computing language (34), to define the minimal sample size for this study. We set a moderate effect size for independent and paired t-tests (d = 0.50), and an alpha of 95% for statistical significance, and we had a sample size of 54 subjects. This way, our sample presented a poor statistical power (\u0026lt; 0.4) to capture real significant differences (reject the null hypothesis). In this way, we worked with more robust statistics that do not need the assumption of minimal sample size [42,43], which is better described in the next section of statistical analysis. Due to the reduced statistical power of the prior recruited sample in this study, we applied statistical procedures based on Bayesian assumptions. For this purpose, the paired and two-sample Bayesian T-tests were employed in the datasets identified as parametric and the Bayesian versions of the Man-Whittney test for two samples and the Wilcoxon signed-rank test for paired samples were employed for the non-parametric datasets. Bayesian paired and unpaired statistical tests are well-described to work robustly in small datasets where assumptions such as statistical power are broken [43]. These statistical tests are based on the prior probability which is a hypothesis of an occurrence of an unseen event, thus, right analyze real data the prior probability is compared with post-prior probability, and the hypothesis for significance in rejecting the null hypothesis and accepting the alternative hypothesis is updated and validated [44]. For this purpose, we considered the main metric of significance, which is the Bayes factor, considering Jeffreys\u0026rsquo;s [45] cut-offs of (\u0026le; 3 = Anecdotal evidence, between 3 and 10 = Moderate evidence, \u0026gt; 10 = Strong evidence). Thus, we considered only differences classified with a strong level of evidence to reject the null hypothesis in a 95% confidence interval [43,45]. In addition, a hierarchical clustering method was employed considering the absolute pre-post differences from the variables with significant differences identified by the Bayesian paired statistical tests, aiming to characterize the participants with higher or smaller levels of improvements based on a between/within-subjects comparison (personalized clustering) [46]. For this purpose, we calculated the Manhattan distance, which works [45] and is recognized to be slightly more robust than other distance methods, such as Euclidean distance when dealing with outliers or as in our case, where the small datasets where the individual differences can bias the clustering results [47]. The clustering results reported the number of participants for each cluster (X-axis) and the Manhattan distance (Y-axis). The Silhouette score was calculated to check the best final number of clusters, considering the cut off \u0026lt; 0.5 to consider a good separation for the determined number of clusters [48]. The hierarchical clustering nodes visualized in the plots were cut with a red dashed line aiming to determine the more representative number of clusters. In addition, the clusters with the higher responders were labeled with 1, with 2, 3 and so on representing the less respondent participants. The percentual of sample size represented by each cluster were also reported. All the statistical, clustering analysis and respective graphic creation were performed in R, statistical programming language [49].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eBaseline comparison results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 shows the results of body composition and physical fitness at the study\u0026rsquo;s baseline originated from the comparison between the experimental and control groups. The Bayesian tests showed that, after comparing prior to post probabilities, EG had higher height, higher visceral fat concentration at the baseline, reduced upper limb strength the arm surgically underwent, and smaller aerobic fitness than the control group.\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline results of the comparison between body composition and physical fitness between the control and experimental groups.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eEG (n = 7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003eCG (n=11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003eBayes Factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eProb. Sig. 95% IC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e64 \u0026plusmn; 8.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e56.3 \u0026plusmn; 10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e1.016017 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e1.63 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e161 \u0026plusmn; 4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e3.08049e+20 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBody weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e64.59 \u0026plusmn; 8.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e73.15 \u0026plusmn; 12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e1.212361 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBF%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e39 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e35 (4.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.6120044 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLean mass (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e43.3 \u0026plusmn; 4.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e41.1 \u0026plusmn; 3.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.6120044 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBody Watter %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e45 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e49 (5.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.1315774\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBasal Metabolism (Kcal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e1374. \u0026plusmn; 156.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e1291 \u0026plusmn; 108.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e.7005798 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eVisceral Fat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e6 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e3152.451\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eUpper limb strength (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e13.6 \u0026plusmn; 4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e16.6 \u0026plusmn; 1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.04737735\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eUpper limb strength int. arm (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e7 \u0026plusmn; 4.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e18.4 \u0026plusmn; 2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e292.0518 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLower limb strength (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e17.6 \u0026plusmn; 3.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e20.9 \u0026plusmn; 6.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e1.270417 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eUpper Limb Flexibility (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e-4 \u0026plusmn; 3.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e-2.56 \u0026plusmn; 4.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.498694 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLower limb flexibility (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e4.57 \u0026plusmn; 3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e3.11 \u0026plusmn; 6.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e0.4690581 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDynamic balance (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e4.96 \u0026plusmn; 0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e4.14 \u0026plusmn; 0.502\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e3.637471 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAerobic Fitness (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e37 \u0026plusmn; 14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.6667%;\"\u003e\n \u003cp\u003e112 \u0026plusmn; 8.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7115%;\"\u003e\n \u003cp\u003e8899.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.6218%;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Data is described in mean \u0026plusmn; standard deviation for parametric data and in median (interquartile range) for non-parametric data. #: significant differences with strong level evidence provided by the Bayes factor outputs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExperimental results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 shows the results of the pre-post comparison between CG and EG groups. The Bayesian paired tests revealed significant post-prior probability differences after 36 weeks of physical exercise training in favor of the EG considering reductions in body weight (pre =73.16 \u0026plusmn; 2.22, post = 71.49 \u0026plusmn; 12.1 kg) as well as in body fat percentage (pre = 36.9 \u0026plusmn; 5.03, post = 32.91 \u0026plusmn; 5.86%). There were also improvements in physical fitness, with increases in upper limb strength (pre = 13.57 \u0026plusmn; 4.65, post = 27.71 \u0026plusmn; 3.45 repetitions), similarly increasing in upper limb strength of the arm underwent chirurgic intervention (pre = 7 \u0026plusmn; 4.16, post = 20.57 \u0026plusmn; 6.92 repetitions), as well increases in the lower limb strength (pre = 17.57 \u0026plusmn; 3.69, post = 25.43 \u0026plusmn; 3.31 \u0026nbsp;repetitions), and increases in aerobic fitness (pre = 37 \u0026plusmn; 14.65, post = 134.57 \u0026plusmn; 28.18 repetitions). Therefore, there were not any changes in CG after 20 weeks.\u003c/p\u003e\n\u003cp\u003eTable 2. Results of pre-post comparison of body composition and physical fitness for the experimental and control group.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"684\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eBayes Factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eProb. Sig. 95% IC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBody weight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e73.16 \u0026plusmn; 2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e71.49 \u0026plusmn; 12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e15.15472 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e64 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e63 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.337071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBMI (Index)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e27.43 \u0026plusmn; 2.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e26.86 \u0026plusmn; 3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.175075 \u0026plusmn;0.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e25 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e25 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.2301768\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBF%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e36.9 \u0026plusmn; 5.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e32.91 \u0026plusmn; 5.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e34.86926 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e31 \u0026plusmn; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e31 \u0026plusmn; 6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.075933 \u0026plusmn;0.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eLean mass (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e43 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e44 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.729713 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e41 \u0026plusmn; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e41 \u0026plusmn; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.4237328 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBody Watter %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e45.91 \u0026plusmn; 3.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e45. 8 \u0026plusmn; 3.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.3607712 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e49 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e50 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.1301105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eBasal Metabolism (Kcal)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1367 (179)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1350.14 (183)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.003316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1291 \u0026plusmn; 107.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1296.38 \u0026plusmn; 95.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.3963878 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eVisceral Fat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e8 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e6.995007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2.999471\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUpper Limb Strength (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e13.57 \u0026plusmn; 4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e27.71 \u0026plusmn; 3.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1022.022 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e16.4 \u0026plusmn; 1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e17.8 \u0026plusmn; 2.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.800111 \u0026plusmn;0.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUpper Limb Strength int. arm (rep)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e7 \u0026plusmn; 4.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e20.57 \u0026plusmn; 6.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e121.3942 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e18.43 \u0026plusmn; 2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e16.71 \u0026plusmn; 3.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.5027359 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eLower limb strength (rep)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e17.57 \u0026plusmn; 3.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e25.43 \u0026plusmn; 3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e206.5508 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e23 \u0026plusmn; 6.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e23.78 \u0026plusmn; 4.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.3475993 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eUpper Limb Flexibility (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-4 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.003955486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-2.56 \u0026plusmn; 4.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e-2.2 \u0026plusmn; 5.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.3209674 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eLower limb flexibility (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4.57 \u0026plusmn; 3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e9.14 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.73919 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3.11 \u0026plusmn; 6.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4 \u0026plusmn; 4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.371723 \u0026plusmn;0.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eDynamic balance (sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4.96 \u0026plusmn; 0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e3.91 \u0026plusmn; 0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e8.260729 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4.14 \u0026plusmn; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4.35 \u0026plusmn; 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.8045248 \u0026plusmn;0.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 186px;\"\u003e\n \u003cp\u003eAerobic fitness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e37 \u0026plusmn; 14.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e134.57 \u0026plusmn; 28.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e157.2803 \u0026plusmn;0%\u003cstrong\u003e\u003csup\u003e#\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eStrong\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003eCG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e122.11 \u0026plusmn; 19.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e122 \u0026plusmn; 18.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.3216269 \u0026plusmn;0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eAnecdotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Data is described in mean \u0026plusmn; standard deviation for parametric data and in median (interquartile range) for non-parametric data. #: significant differences with strong level evidence provided by the Bayes factor outputs.\u003c/p\u003e\n\u003cp\u003eFigure 4 shows the hierarchical clustering results from the variables with significant pre-post 36 weeks of multicomponent training in the EG. In general, regarding the variables with statistically significant differences, all participants have individual improvements. Specifically within the hierarchical cluster results, respective to the body weight reductions (Silhouette score = 0.77) (Figure 4-A), there were two clusters, cluster 1 [higher responders (28%)]: participant 1 [3.3 kg], and 5 [2.7 kg], and cluster 2 [lower responders (71%)]: participants 2 [0.8 kg], 3 [1.4 kg], 4 [1.2 kg], 6 [0.9 kg], and 7 [1.4 kg]. For body fat percentage reductions (Silhouette score = 0.75) (Figure 4-B), the HC identified also two clusters, were cluster 1 [higher responders (57%)]: participants 1 [4.9%], 2 [4.8%], 3 [6.9%) and 4 [4.7 %], and cluster 2 [lower responders (43%)]: participants 5 [2 %], 6 [2%], and 7 [2.6%]. For upper limb strength improvements (Silhouette score = 0.68) (Figure 4-C) there were three clusters, cluster 1 [high responders (86%)]: participants 1, 3, and 4 [17 repetitions], cluster 2 [mild responders (43%)]: participants 2 [13 repetitions], 5 [14 repetitions], and 7 [12 repetitions], and cluster 3 [lower responder (14%)]: characterized by only the participant 6 [9 repetitions]. For the upper limb strength improvements of the arm underwent to surgical procedure (Silhouette score = 0.56) (Figure 4-D), there were also two clusters, cluster 1 [higher responders (71%)]: participants 1 and 7 [13 repetitions], 2 and 4 [16 repetitions], and 3 [21 repetitions], and cluster 2 [lower responders (29%)]: participants 5 [9 repetitions], and 6 [9 repetitions]. For the lower limb strength (Silhouette score = 0.80) (Figure 4-E) there were two principal clusters, were cluster 1 [higher responders (43%)]: participants 1 [11 repetitions], 6 and 7 [10 repetitions], and cluster 2 [lower responders (57%)]: participants 2 [7 repetitions] 3, 4 [6 repetitions], and 5 [5 repetitions]. Regarding aerobic fitness (Silhouette score = 0.62) (Figure 4-F), there were two clusters, were cluster 1 [higher responders (29%)]: participants 3 [154 repetitions], and 7 [124 repetitions], and cluster 2 [lower responders (71%)]: participants 1 [70 repetitions], 2 [95 repetitions], 4 [72 repetitions], 5 [70 repetitions], and 6 [98 repetitions]. These results prove that all the participants improved similarly, and there were some fewer responder subjects, indicating that the intervention was positive, but not in the same meaningful for all patients.\u003c/p\u003e\n\u003cp\u003eAfter outputting the clustering results, we developed a mind map (Figure 5) to offer a structured approach to guide clinical decisions after identifying each patient\u0026apos;s individual response to multi-component training. Based on the analysis of performance variables and each patient\u0026apos;s specific responses, the mind map suggests personalized directions for the continuation of treatment, either through intensifying certain components of the program or adjusting the training modality. This process ensures a more effective intervention adapted to the needs and progress of each individual.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe objective of this study was twofold: first, to test the hypothesis that multicomponent training improves body composition in breast cancer survivors, and second, to evaluate its impact on physical fitness. Based on the statistical results, weight and fat percentage reduction was observed in the experimental group after the 36-week intervention. Additionally, improvements were noted across all physical fitness variables. These findings fully support the study’s hypothesis that multicomponent training enhances physical fitness, as improvements were observed in all measured variables. However, the results only partially support the hypothesis regarding body composition improvements, as significant changes were observed in weight and fat percentage but not in other body composition metrics. Therefore, this hypothesis is partially rejected.\u003c/p\u003e\n\u003cp\u003eAs previously mentioned, both body weight and body fat percentage were reduced. Regarding body weight, cluster analysis reveals that multicomponent training resulted in predominantly lower responses among the patients in the study. In contrast, when analyzing the reduction in fat percentage, the clusters indicate that the intervention had varying effects on individuals: 4 participants were classified as higher responders, while 3 were lower responders, suggesting that the intervention had a moderate impact on the participants' weight status. Reductions in body weight are crucial for preventing cancer\u0026nbsp;[6], during\u0026nbsp;[50], or after treatment\u0026nbsp;[6]. Excess body fat tissue releases inflammatory cytokines that contribute to low-grade chronic inflammation, commonly known as \"inflammaging.\" This process involves inflammation that disrupts cell cycle regulation, damages cells, and impairs proteostasis, all of which promote the expression of carcinogenic genes and increase cancer risk\u0026nbsp;[51].\u003c/p\u003e\n\u003cp\u003eRegarding the change in strength in the upper limbs of the study participants, there was a similar increase in strength in the upper limb that underwent surgical intervention and in the one that was not submitted. The cluster analysis for this variable was subdivided into three groups for increased strength in the upper limbs, in which 3 patients were considered high responders, 3 patients were mild responders and only 1 patient was low responder. This allows us to understand that multicomponent training tends to be efficient in improving the strength of patients' upper limbs after the intervention since 6 of the 7 participants analyzed were responsive, whether high or light. In contrast, only one patient was slightly responsive, showing increased upper limb strength. When analyzing the improvement in strength in the upper limb submitted to surgical intervention, cluster 1 was observed with five patients as the greatest responders, and cluster 2, with two patients as the lowest responders. This makes it clear that multicomponent training effectively improves the strength of the upper limbs of patients undergoing the surgical process, given the characteristics of patients' responsiveness to this issue. This shows the relevance of this type of activity for improving the quality of life of patients recovering from breast cancer, as it contributes to the return to routine instrumental activities of daily living which require good control of the upper limbs such as managing finances or medications, food preparation, housekeeping, and laundry, thus contributing to the recovery of their independence\u0026nbsp;[52].\u003c/p\u003e\n\u003cp\u003eWhen analyzing the variable improvement in the strength of the lower limbs of breast cancer survivors undergoing multicomponent training, two clusters were observed. The first cluster was linked to higher responders, with three patients as group members. The second cluster covered the lowest responders (four patients) submitted to the present study. This distribution allows us to understand that multicomponent training presented a divergent impact on the individuals’ lower limb strength, showing that the training did not evoke the same level of changes in the subjects. However, even at different levels, the intervention proposed by the present study proved to improve the strength of the lower limbs, which is a positive result, considering that this contributes to helping patients in their daily lives, facilitating their ambulation and independence of performance your daily tasks such as climbing stairs, walking at the street and moving carrying objects\u0026nbsp;[52]. This result is consistent with previous studies reporting strength gains with regular practice of muscle resistance exercises, both for lower and upper limbs, as evidenced by the meta-analysis by Guideline\u0026nbsp;[53], which suggests that multicomponent strength training improves strength similarly to exclusive resistance training programs. Although multicomponent training is not exclusively focused on strength, it is expected that cumulative improvements will occur in the long term. Short-term interventions, such as those lasting 12 weeks, may not lead to significant changes in various dimensions of physical fitness\u0026nbsp;[54], but positive results were still observed within this short period of time. There are studies that after only 9 weeks of multicomponent training showed significant differences in favor of multicomponent training in all study variables\u0026nbsp;[55], but literature indicates that longer programs, like the 9 months of this intervention, produce more noticeable chronic effects\u0026nbsp;[56].Regarding changes in aerobic fitness, the clustering results revealed the presence of two clusters. The first cluster is composed of higher responders, consisting of two individuals, while the second cluster comprises lower responders, consisting of five individuals. These results indicate that the intervention primarily led to low-grade improvements among participants. Despite this predominance of lower responders, the intervention still resulted in increases in aerobic fitness for all participants, which is a positive outcome of the training. This improvement in aerobic capacity is aligned with the results of studies on long-term multicomponent training, such as one conducted over 32 weeks\u0026nbsp;[57]\u0026nbsp;and another over 27 weeks\u0026nbsp;[58]. Aerobic fitness is associated with enhanced antioxidant defense, protecting cells from damage and regulating cellular function [48]. Additionally, improving aerobic fitness is an essential strategy for alleviating fatigue symptoms related to cancer treatment and post-treatment\u0026nbsp;[58,59].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Cluster analysis is important because it helps us understand how each person responds to treatment by grouping those with similar responses. This is crucial to adjust the intervention when necessary. For example, if a patient is not responding well to the initial treatment, cluster analysis can help identify what is happening and suggest changes, either in the approach or type of exercise. This process is similar to medical practice, where doctors adjust a patient's medication when the initial treatment response is not satisfactory, always seeking a more effective and personalized treatment\u0026nbsp;[60].\u003c/p\u003e\n\u003cp\u003eIn the present study, we had some relevant limitations that should be considered in future studies on this topic, given more realistic and concrete results. Among these points, we can mention our small experimental sample, which makes it difficult to have a broader view of the population reality, which could be considerably different and complex. Furthermore, another limiting factor was the shorter analysis period of the control group (20 weeks) compared to the group undergoing the proposed intervention (36 weeks). It is necessary to analyze both groups for at least the same period of time to understand better the result and the difference at the end of the intervention between these two portions. Studies with a larger sample, both CG and EG, help understand how the intervention was studied in the group in question, considering different origins, ethnicities, ages, and other population variables. Finally, for subsequent studies, the use of biochemical and molecular tests is relevant to understand, even more in-depth, the results of multicomponent training in the target groups of breast cancer patients in different stages of the pathology. However, it is important to highlight some strengths of the present study: (i) This is a novelty approach with 32 weeks of duration using multicomponent training exercise-based therapy; (ii) this is a controlled trial with high level of evidence; (iii) the study provided a cluster of reactions to treatment; (iv) it is possible to define strategies for treatment in agreement with the responders. That said, the study suggests that each participant reacts differently to the exercise-based therapy and should be reevaluated periodically to adjust the treatment.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe multicomponent physical exercise program effectively improved all physical fitness variables. In contrast, the improvements in the body composition outcomes were limited, exposing improvements only in body weight and % body fat. Finally, the intervention did not cause any side effects or injury to the participants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the Higher Institute of Educational Sciences of the Douro (n\u0026ordm;: 2.576).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent to participate in this study was obtained from all subjects and/or their legal guardians prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors confirm that they have read, reviewed and approved the final version of the manuscript, agreeing to its submission for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within supplementary information files\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORS\u0026rsquo; CONTRIBUITION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSamuel Encarna\u0026ccedil;\u0026atilde;o: Responsible for developing the methodology for statistical analysis, performing the analyses, creating Figures 2 and 4, as well as reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eAndr\u0026eacute; Schneider: Contributed to writing the Introduction and methodology, developed Figures 1 and 5, and participated in reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eRoberto Almeida: Responsible for writing the Discussion section.\u003c/p\u003e\n\u003cp\u003eLuciano Bernardes: Collaborated on writing the Discussion, developed Figure 3, and reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003ePedro Forte: Worked on reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eMiguel Monteiro: Participated in reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003eHelder Jaime: Financed the article submission and contributed to reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was co-financed by the European Regional Development Fund (FEDER) through the programme INTERREG VI-A Spain-Portugal (POCTEP) 2021\u0026ndash;2027: Novas Sociedades Longevas (0137_NSL_6_E).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that there are no conflicts of interest regarding the publication of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBreast cancer [Internet]. [cited 2024 Sep 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/breast-cancer\u003c/li\u003e\n\u003cli\u003eSun YS, Zhao Z, Yang ZN, Xu F, Lu HJ, Zhu ZY, et al. Risk Factors and Preventions of Breast Cancer. Int J Biol Sci. 2017;13(11):1387\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eFicarra S, Thomas E, Bianco A, Gentile A, Thaller P, Grassadonio F, et al. Impact of exercise interventions on physical fitness in breast cancer patients and survivors: a systematic review. Breast Cancer Tokyo Jpn. 2022 May;29(3):402\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eAkram M, Iqbal M, Daniyal M, Khan AU. Awareness and current knowledge of breast cancer. Biol Res. 2017 Oct 2;50(1):33. \u003c/li\u003e\n\u003cli\u003eColeman MP, Quaresma M, Berrino F, Lutz JM, Angelis RD, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008 Aug 1;9(8):730\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eAnderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer. 2008 Oct 15;113(8 Suppl):2221\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eIacoviello L, Bonaccio M, de Gaetano G, Donati MB. Epidemiology of breast cancer, a paradigm of the \u0026ldquo;common soil\u0026rdquo; hypothesis. Semin Cancer Biol. 2021 Jul;72:4\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eKelsey JL, Gammon MD. The epidemiology of breast cancer. CA Cancer J Clin. 1991;41(3):146\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eGiaquinto AN, Sung H, Miller KD, Kramer JL, Newman LA, Minihan A, et al. Breast Cancer Statistics, 2022. CA Cancer J Clin. 2022 Nov;72(6):524\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eGlobal Burden of Disease Cancer Collaboration, Fitzmaurice C, Allen C, Barber RM, Barregard L, Bhutta ZA, et al. Global, Regional, and National Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life-years for 32 Cancer Groups, 1990 to 2015: A Systematic Analysis for the Global Burden of Disease Study. JAMA Oncol. 2017 Apr 1;3(4):524\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eXu Y, Gong M, Wang Y, Yang Y, Liu S, Zeng Q. Global trends and forecasts of breast cancer incidence and deaths. Sci Data. 2023 May 27;10(1):334. \u003c/li\u003e\n\u003cli\u003eArnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast Edinb Scotl. 2022 Dec;66:15\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eOrding AG, Garne JP, Nystr\u0026ouml;m PMW, Fr\u0026oslash;slev T, S\u0026oslash;rensen HT, Lash TL. Comorbid Diseases Interact with Breast Cancer to Affect Mortality in the First Year after Diagnosis\u0026mdash;A Danish Nationwide Matched Cohort Study. PLOS ONE. 2013 Oct 9;8(10):e76013. \u003c/li\u003e\n\u003cli\u003eShapiro CL, Recht A. Side Effects of Adjuvant Treatment of Breast Cancer. N Engl J Med. 2001 Jun 28;344(26):1997\u0026ndash;2008. \u003c/li\u003e\n\u003cli\u003eNeil-Sztramko SE, Kirkham AA, Hung SH, Niksirat N, Nishikawa K, Campbell KL. Aerobic capacity and upper limb strength are reduced in women diagnosed with breast cancer: a systematic review. J Physiother. 2014 Dec 1;60(4):189\u0026ndash;200. \u003c/li\u003e\n\u003cli\u003eParker PA, Youssef A, Walker S, Basen-Engquist K, Cohen L, Gritz ER, et al. Short-term and long-term psychosocial adjustment and quality of life in women undergoing different surgical procedures for breast cancer. Ann Surg Oncol. 2007 Nov;14(11):3078\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eHayes SC, Johansson K, Stout NL, Prosnitz R, Armer JM, Gabram S, et al. Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care. Cancer. 2012 Apr 15;118(8 Suppl):2237\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eHidding JT, Beurskens CHG, Van Der Wees PJ, Van Laarhoven HWM, Nijhuis-van Der Sanden MWG. Treatment Related Impairments in Arm and Shoulder in Patients with Breast Cancer: A Systematic Review. Macleod U, editor. PLoS ONE. 2014 May 9;9(5):e96748. \u003c/li\u003e\n\u003cli\u003eMols F, Vingerhoets AJJM, Coebergh JW, van de Poll-Franse LV. Quality of life among long-term breast cancer survivors: a systematic review. Eur J Cancer Oxf Engl 1990. 2005 Nov;41(17):2613\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSpeck RM, Courneya KS, M\u0026acirc;sse LC, Duval S, Schmitz KH. An update of controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. J Cancer Surviv. 2010 Jun;4(2):87\u0026ndash;100. \u003c/li\u003e\n\u003cli\u003eRunowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. CA Cancer J Clin. 2016;66(1):43\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eZagar TM, Cardinale DM, Marks LB. Breast cancer therapy-associated cardiovascular disease. Nat Rev Clin Oncol. 2016 Mar;13(3):172\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eLindquist H, Enblom A, Dunberger G, Nyberg T, Bergmark K. WATER EXERCISE COMPARED TO LAND EXERCISE OR STANDARD CARE IN FEMALE CANCER SURVIVORS WITH SECONDARY LYMPHEDEMA. Lymphology. 2015 Jun;48(2):64\u0026ndash;79. \u003c/li\u003e\n\u003cli\u003eŞener H\u0026Ouml;, Malko\u0026ccedil; M, Ergin G, Karadibak D, Yavuzşen T. Effects of Clinical Pilates Exercises on Patients Developing Lymphedema after Breast Cancer Treatment: A Randomized Clinical Trial. J Breast Health. 2017 Jan;13(1):16\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eSun H, Huang H, Ji S, Chen X, Xu Y, Zhu F, et al. The Efficacy of Cognitive Behavioral Therapy to Treat Depression and Anxiety and Improve Quality of Life Among Early-Stage Breast Cancer Patients. Integr Cancer Ther. 2019 Jan;18:153473541982957. \u003c/li\u003e\n\u003cli\u003eDieli-Conwright CM, Courneya KS, Demark-Wahnefried W, Sami N, Lee K, Sweeney FC, et al. Aerobic and resistance exercise improves physical fitness, bone health, and quality of life in overweight and obese breast cancer survivors: a randomized controlled trial. Breast Cancer Res. 2018 Dec;20(1):124. \u003c/li\u003e\n\u003cli\u003eLeach HJ, Danyluk JM, Nishimura KC, Culos-Reed SN. Evaluation of a Community-Based Exercise Program for Breast Cancer Patients Undergoing Treatment. Cancer Nurs. 2015;38(6):417\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eQiu H, Ren W, Yang Y, Zhu X, Mao G, Mao S, et al. Effects of cognitive behavioral therapy for depression on improving insomnia and quality of life in Chinese women with breast cancer: results of a randomized, controlled, multicenter trial. Neuropsychiatr Dis Treat. 2018;14:2665\u0026ndash;73. \u003c/li\u003e\n\u003cli\u003eGokal K, Wallis D, Ahmed S, Boiangiu I, Kancherla K, Munir F. Effects of a self-managed home-based walking intervention on psychosocial health outcomes for breast cancer patients receiving chemotherapy: a randomised controlled trial. Support Care Cancer Off J Multinatl Assoc Support Care Cancer. 2016 Mar;24(3):1139\u0026ndash;66. \u003c/li\u003e\n\u003cli\u003eDong X, Yi X, Ding M, Gao Z, McDonough DJ, Yi N, et al. A Longitudinal Study of a Multicomponent Exercise Intervention with Remote Guidance among Breast Cancer Patients. Int J Environ Res Public Health. 2020 May 14;17(10):3425. \u003c/li\u003e\n\u003cli\u003eWolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. J Support Oncol. 2012;10(5):171\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eSadjapong U, Yodkeeree S, Sungkarat S, Siviroj P. Multicomponent Exercise Program Reduces Frailty and Inflammatory Biomarkers and Improves Physical Performance in Community-Dwelling Older Adults: A Randomized Controlled Trial. Int J Environ Res Public Health. 2020 May 26;17(11):3760. \u003c/li\u003e\n\u003cli\u003eAmjad A, Kordel P, Fernandes G. A Review on Innovation in Healthcare Sector (Telehealth) through Artificial Intelligence. Sustainability. 2023 Apr 14;15(8):6655. \u003c/li\u003e\n\u003cli\u003eR project. R: The R Project for Statistical Computing [Internet]. 2022 [cited 2023 Jan 7]. Available from: https://www.r-project.org/\u003c/li\u003e\n\u003cli\u003eEriksson O, Jauhiainen A, Maad Sasane S, Kramer A, Nair AG, Sartorius C, et al. Uncertainty quantification, propagation and characterization by Bayesian analysis combined with global sensitivity analysis applied to dynamical intracellular pathway models. Bioinformatics. 2019 Jan 15;35(2):284\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eLy A, Verhagen J, Wagenmakers EJ. Harold Jeffreys\u0026rsquo;s default Bayes factor hypothesis tests: Explanation, extension, and application in psychology. J Math Psychol. 2016 Jun;72:19\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eA healthy lifestyle - WHO recommendations [Internet]. [cited 2024 Sep 20]. Available from: https://www.who.int/europe/news-room/fact-sheets/item/a-healthy-lifestyle---who-recommendations\u003c/li\u003e\n\u003cli\u003eRikli RE, Jones CJ. Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years. The Gerontologist. 2013 Apr;53(2):255\u0026ndash;67. \u003c/li\u003e\n\u003cli\u003eKoopman BO. Harold Jeffreys. Theory of probability. Oxford University Press, Oxford1939, vii+ 380 pp. J Symb Log. 1943;8(1):34\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eZhang Z, Murtagh F, Poucke SVV, Lin S, Lan P. Hierarchical cluster analysis in clinical research with heterogeneous study population: highlighting its visualization with R. Ann Transl Med. 2017 Feb;5(4):75\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eXu R, Wunsch D. Survey of clustering algorithms. IEEE Trans Neural Netw. 2005 May;16(3):645\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eMaechler M, original) PR (Fortran, original) AS (S, original) MH (S, Hornik [trl K, maintenance(1999-2000)) ctb] (port to R, et al. cluster: \u0026ldquo;Finding Groups in Data\u0026rdquo;: Cluster Analysis Extended Rousseeuw et al. [Internet]. 2023 [cited 2024 Sep 25]. Available from: https://cran.r-project.org/web/packages/cluster/index.html\u003c/li\u003e\n\u003cli\u003eAnderson AS, Renehan AG, Saxton JM, Bell J, Cade J, Cross AJ, et al. Cancer prevention through weight control\u0026mdash;where are we in 2020? Br J Cancer. 2021 Mar;124(6):1049\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eLigibel JA, Bohlke K, May AM, Clinton SK, Demark-Wahnefried W, Gilchrist SC, et al. Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline. J Clin Oncol Off J Am Soc Clin Oncol. 2022 Aug 1;40(22):2491\u0026ndash;507. \u003c/li\u003e\n\u003cli\u003eAnderson AS, Martin RM, Renehan AG, Cade J, Copson ER, Cross AJ, et al. Cancer survivorship, excess body fatness and weight-loss intervention\u0026mdash;where are we in 2020? Br J Cancer. 2021 Mar;124(6):1057\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eHanahan D. Hallmarks of Cancer: New Dimensions. Cancer Discov. 2022 Jan;12(1):31\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eKlassen O, Schmidt ME, Ulrich CM, Schneeweiss A, Potthoff K, Steindorf K, et al. Muscle strength in breast cancer patients receiving different treatment regimes. J Cachexia Sarcopenia Muscle. 2017 Apr;8(2):305\u0026ndash;16. \u003c/li\u003e\n\u003cli\u003eGaratachea N, Pareja-Galeano H, Sanchis-Gomar F, Santos-Lozano A, Fiuza-Luces C, Mor\u0026aacute;n M, et al. Exercise attenuates the major hallmarks of aging. Rejuvenation Res. 2015 Feb;18(1):57\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eJanjua S, Brown M, Parker R, Prue G, Closier P, Cramp F. Physical activity for the management of cancer‐related fatigue in adults. Cochrane Database Syst Rev. 2022 Dec 1;2022(12):CD015348. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"neoplasms, physical exercise, rehabilitation, oncology, functionality, activities of daily living","lastPublishedDoi":"10.21203/rs.3.rs-5362882/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5362882/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eMulticomponent training is suggested as an efficient way to address the side effects of long-term treatment in breast cancer survivors and reduce the age-related relapse risk in these patients. This study aimed to evaluate the impact of a multicomponent training intervention on breast cancer survivors' physical fitness and body composition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This experimental and controlled study included 19 breast cancer survivors with 64.0 ± 8.6 years, to evaluate long-term effects (36 weeks) of multicomponent training on body composition [body weight (kg), body mass index, body fat (%), lean mass (kg), body water (%), basal metabolism (Kcal) and visceral fat (index)] and physical fitness [Upper limb strength (repetitions), lower limb strength (repetitions), upper limb flexibility (cm), lower limb flexibility (cm), dynamic balance (seconds), and aerobic fitness (repetitions)]. Bayesian statistical tests were employed to analyze the reduced dataset size, considering a Bayes factor ≥ 10 as the cutoff for significant differences. Hierarchical clustering identified participant improvements using Manhattan distance, and clusters were ranked by responsiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe experimental improved body weight, body fat percentage, and physical fitness after the intervention, while no changes were observed in the control group. Cluster analysis showed that higher responders varied from 28% to 86% across variables, while others showed lower, but still positive, responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and Conclusion:\u003c/strong\u003e The multicomponent physical exercise program effectively improved all physical fitness variables but was limited in body composition, exposing improvements only in body weight and % body fat. The intervention did not cause any side effects or injury to the participants.\u003c/p\u003e","manuscriptTitle":"Long-term effects of multicomponent training in the body composition and physical fitness of breast cancer survivors: a controlled and experimental study with clustering analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-04 15:10:06","doi":"10.21203/rs.3.rs-5362882/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-11T08:37:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-08T13:23:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216113844833651227763537831560779401238","date":"2025-01-23T07:23:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-28T23:10:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-27T05:14:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108927423250632870360460343312180617894","date":"2024-12-21T12:36:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166106464390723185585108416334758815448","date":"2024-12-19T09:07:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245357465803769878383094738177832931983","date":"2024-12-19T07:45:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-12-17T07:22:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-12-17T07:16:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-11-06T07:58:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-06T07:55:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-10-30T17:43:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3bbe40f7-bc9a-4122-985e-d976e0cbcd1a","owner":[],"postedDate":"December 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":40460414,"name":"Health sciences/Oncology/Cancer/Breast cancer"},{"id":40460415,"name":"Health sciences/Health care/Public health"}],"tags":[],"updatedAt":"2025-10-06T16:06:13+00:00","versionOfRecord":{"articleIdentity":"rs-5362882","link":"https://doi.org/10.1038/s41598-025-01702-y","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-09-30 15:57:32","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2024-12-04 15:10:06","video":"","vorDoi":"10.1038/s41598-025-01702-y","vorDoiUrl":"https://doi.org/10.1038/s41598-025-01702-y","workflowStages":[]},"version":"v1","identity":"rs-5362882","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5362882","identity":"rs-5362882","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}