Cantarero-Villanueva, I., Fernández-Lao, C., Cuesta-Vargas, A. I., Del Moral-Avila, R., Fernández-de-Las-Peñas, C., & Arroyo-Morales, M. (2013). The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 221–230.

DOI Link

Study Purpose

To examine the effectiveness of an eight-week aquatic exercise program on cancer-related fatigue and physical and psychological outcomes in patients with breast cancer.

Intervention Characteristics/Basic Study Process

Patients were randomly assigned to exercise groups or usual care control groups. The intervention consisted of an eight-week program of water-based exercises, three times per week, in a heated deep swimming pool. Sessions lasted 60 minutes each and included a warm-up and cool-down. Exercise intensity was maintained according to recommendations for moderate exercise as stated by the American College of Sports Medicine and American Heart Association. Groups of 10 to 12 women participated in the exercise program. Data were collected at baseline, eight weeks, and six months.

Sample Characteristics

  • The sample was comprised of 61 participants.
  • Mean participant age was 48 years.
  • All participants were female.
  • All participants had breast cancer. 
  • The majority had undergone radiation and chemotherapy after surgery. 
  • All had completed treatment other than ongoing hormone therapy.
  • Of the participants, slightly more than 60% were married and 70% to 75% were postmenopausal.
  • At baseline, all patients reported 32 to 38 minutes of activity per day. 
  • All had completed treatment within the previous 18 months.


  • Single site
  • Outpatient
  • Spain

Phase of Care and Clinical Applications

Patients were undergoing the transition phase after active treatment.

Study Design

This was a single-blind, randomized, controlled trial.

Measurement Instruments/Methods

  • Piper Fatigue Scale
  • Profile of Mood States (POMS)
  • Multiple sit-to-stand test
  • Trunk curl static endurance test


  • ANOVA showed a significant difference in all dimensions of fatigue and overall fatigue over time, between groups, with greater improvement in fatigue in the aquatic exercise group (p < 0.001). The overall effect size for total fatigue was d = 1.51 (95% confidence interval [CI] [1.13, 1.90]) at eight weeks. The overall effect size for severity of fatigue was d = 0.68 (95% CI [1.14, 1.22]). The intergroup effect size for total fatigue at six months was d = 0.87 (95% CI [0.48, 1.26]).
  • Leg and abdominal muscle endurance for the sit-to-stand and abdominal curl tests was significantly higher in patients in the exercise group (p < 0.001).
  • Groups showed a significant difference over time in favor of exercise (p = 0.029).
  • The six-month follow-up revealed no effect of exercise on depression.


Deep-water exercise reduced fatigue, provided a short-term improvement in leg and abdominal muscle endurance, and resulted in some short-term reduction in depression. Effects on muscle endurance and depression declined after the eight-week program. Apparent effects on fatigue lasted six months.


  • The study had a small sample size, with less than 100 participants.
  • The study had a risk of bias due to lacking an appropriate attentional control condition.
  • Unintended interventions or applicable interventions not described would influence results.
  • The authors either did not know the components of patients' ongoing physical activities or did not describe them.
  • The authors provided no information about adherence to the exercise program.
  • The authors did not present an intention-to-treat analysis.
  • The sample was very homogeneous, which limited the generalizability of the study.
  • The authors did not address whether the exercise itself or involvement in group activity affected depression. 

Nursing Implications

The study adds to the large body of evidence showing the effectiveness of various types of exercise in the treatment of fatigue in patients with breast cancer. Nurses can recommend various types of exercise for their patients.