Reliability and Agreement of the 10-Repetition Maximum Test in Breast Cancer Survivors

Abstract

The aim of this study was to evaluate the reliability and agreement between the test and retest of the 10-repetition maximum (10-RM) test for leg press and bench press in breast cancer survivors (BCS). Thirty-one BCS participated in this study, age 54.87 ± 5.7 years. All performed 10-RM tests and retests for the leg press 45° and the bench press. For reliability analyses, an intraclass coefficient correlation (ICC) and coefficient of variation (CV) were performed. The limits of agreement were calculated using a Bland-Altman plot with 95% CIs. For absolute and relative error of measurement, we used standard error of measurement and minimally detectable change. The result showed a high reliability for the bench press and leg press; ICC of 0.94 and 0.98, respectively. CV was <10% for both exercises. The systematic error were 1.5 kg (10%) and 6.1 (8%) for the bench press and leg press, respectively. The standard errors of measurements were 0.96 kg (6.08%) and 4.11 kg (5.27%) for the bench press and leg press, respectively. The minimally detectable changes were 2.72 kg (17.20%) and 5.62 kg (7.21%) for the bench press and leg press, respectively. In breast cancer survivors, the muscular strength measurement for the 10-RM test showed a high to very high rate of reliability and agreement, with acceptable error of measurement.

Full text

ORIGINAL RESEARCH
published: 26 September 2019
doi: 10.3389/fonc.2019.00918
Frontiers in Oncology | www.frontiersin.org 1September 2019 | Volume 9 | Article 918
Edited by:
Jisun Kim,
University of Ulsan, South Korea
Reviewed by:
Justin Y. Jeon,
Yonsei University, South Korea
Won Kim,
University of Ulsan, South Korea
*Correspondence:
Carlos Alexandre Vieira
vieiraca11@gmail.com
Specialty section:
This article was submitted to
Women’s Cancer,
a section of the journal
Frontiers in Oncology
Received: 26 June 2019
Accepted: 03 September 2019
Published: 26 September 2019
Citation:
Santos WDNd, Siqueira GDdJ,
Martins WR, Vieira A, Schincaglia RM,
Gentil P and Vieira CA (2019)
Reliability and Agreement of the
10-Repetition Maximum Test in Breast
Cancer Survivors. Front. Oncol. 9:918.
doi: 10.3389/fonc.2019.00918
Reliability and Agreement of the
10-Repetition Maximum Test in
Breast Cancer Survivors
Wanderson Divino Nilo dos Santos 1, Gabriel Dutra de Jesus Siqueira 1,
Wagner Rodrigues Martins 2, Amilton Vieira 2, Raquel Machado Schincaglia 3, Paulo Gentil 1
and Carlos Alexandre Vieira 1
*
1College of Physical Education and Dance, Federal University of Goias - UFG, Goiânia, Brazil, 2College of Physical
Education, University of Brasilia - UnB, Brasilia, Brazil, 3College of Nutrition, Federal University of Goias - UFG, Goiânia, Brazil
The aim of this study was to evaluate the reliability and agreement between the test and
retest of the 10-repetition maximum (10-RM) test for leg press and bench press in breast
cancer survivors (BCS). Thirty-one BCS participated in this study, age 54.87 ±5.7 years.
All performed 10-RM tests and retests for the leg press 45◦and the bench press. For
reliability analyses, an intraclass coefficient correlation (ICC) and coefficient of variation
(CV) were performed. The limits of agreement were calculated using a Bland-Altman plot
with 95% CIs. For absolute and relative error of measurement, we used standard error of
measurement and minimally detectable change. The result showed a high reliability for
the bench press and leg press; ICC of 0.94 and 0.98, respectively. CV was <10% for
both exercises. The systematic error were 1.5 kg (10%) and 6.1 (8%) for the bench press
and leg press, respectively. The standard errors of measurements were 0.96 kg (6.08%)
and 4.11 kg (5.27%) for the bench press and leg press, respectively. The minimally
detectable changes were 2.72 kg (17.20%) and 5.62 kg (7.21%) for the bench press and
leg press, respectively. In breast cancer survivors, the muscular strength measurement
for the 10-RM test showed a high to very high rate of reliability and agreement, with
acceptable error of measurement.
Keywords: muscle strength, muscular measurement, strength training, resistance training, cancer
INTRODUCTION
The assessment of muscle strength has been used to monitor and prescribe strength training (1).
Muscular strength has been associated with high level of functional capacity and to decrease the risk
of death from all natural causes (2,3). The evaluation of muscle strength in breast cancer survivors
(BCS) is a significant issue, because breast cancer (BC) treatment could reduce muscle strength
after surgery and it may persist over the long-term (4). Therefore, in rehabilitation settings, the
assessment of muscular strength is an important strategy to guide exercise prescription in these
patients (5,6).
Muscular strength loss in BCS is one of the side effects of BC treatment (surgery, chemotherapy,
and radiotherapy), that could be explained by multiple factors such as: fatigue; lymphedema;
decreased in shoulder, elbow, and wrist mobility; pain in the shoulder joint; and psychological
changes such as kinesiophobia (7–13). These conditions could interfere with the reliability of
maximum force tests and the strength outcomes during resistance training (14). In addition, these
side effects of BC treatment pose a challenge for health professionals who work with resistance
training for BC patients or survivors.

Santos et al. Reliability and Agreement of the 10-Repetition Maximum Test
The one-repetition maximum test (1-RM) is considered the
“gold standard” to measure maximum muscle strength in a non-
laboratory setting. The 1-RM test is safe and has been applied in
studies with BCS and BC patients (15–17). However, there is a
lack of data regarding the reliability of this measurement within
this population. To our knowledge, a single study presented only
the coefficient of variation (CV) data for the bench press and leg
press (18). Moreover, the 1-RM receive some criticism during a
rehabilitation scenario such as risk of injury (19).
As an alternative to the 1-RM test, some studies with BCS used
predictive formulas according to the results of multiple repetition
tests (5-10RM) to estimate the maximum strength by 1-RM (20–
23). Another method to estimate dynamic muscle strength is the
repetition maximum test based on a goal of repetitions, as in
the 10-RM test. The 10-RM test has been used to evaluate the
load achieved in resistance training (RT) in different populations
(24–30). Therefore, taking into consideration the characteristics
of BCS, it seems that there is a natural concern with muscular
strength tests for upper limbs, and maybe that could interfere
on reliability of measurement. For this reason, it is possible that
muscular strength for lower limbs could be more reliable than
upper limbs. In addition, there is little information on the data of
reliability and agreement of muscular strength tests in BCS, thus
the performance of reliability studies is necessary.
The objective of this study was therefore to evaluate the
reliability and agreement between the test and retest of the 10-
RM test in upper and lower limbs in BCS. Our hypothesis was
that the 10-RM test is reliable, and that the reliability is higher for
the lower limbs.
MATERIALS AND METHODS
Design and Participants
In this reliability and agreement study, 31 BCS were included
between February and October 2017. The BCS were contacted
via phone calls and face-to-face interactions at the Mastology and
Oncology Ambulatory of the University Hospital of the Federal
University of Goias, Brazil. The eligibility criteria were: (1)
confirmed BC stages I to III; (2) between 40 and 65 years old; (3)
being in menopause (31); (4) not involved in any regular exercise
program for the last 6 months; (5) completed cancer-related
therapies including surgery, chemotherapy and/or radiotherapy
at least 6 months prior to enrolling; (6) currently undergoing
hormone therapy (tamoxifen or aromatase inhibitor); (7)
received medical clearance for exercise training. Patients were
excluded from the study if they had musculoskeletal limitations
that could compromise exercise performance and/or any
uncontrolled chronic disease that could represent a risk to
their health.
The study was approved by Research Ethics Committee of the
Federal University of Goias (CAAE: 50717115.4.0000.5083), and
by the Research Ethics Committee of the Clinical Hospital of the
Federal University of Goias (CAAE: 50717115.4.3001.5078). All
participants provided written consent.
Procedures
After a measure of body composition, the participants answered
medical history and sociodemographic questionnaire and the
FIGURE 1 | Experimental design. IPAQ, International Physical Activity
Questionnaire; 10-RM, 10-repetition maximum.
International Physical Activity Questionnaire (IPAQ—short
version) (32). They then performed the 10-RM test at 2 different
days within 2– 4 days in between. At day 1, the participants were
familiarized with Leg press 45◦and Bench press exercises and
then performed the 10-RM test (Figure 1).
Anthropometry and Body Composition Assessments
Body mass index (BMI) was calculated based on body mass
and height [BMI =weight (kg)/height squared (m2)]. Fat and
lean mass were assessed using dual energy X-ray absorptiometry
(DXA) (General Electric Healthcare R
model, Madison, WI,
USA). Data were analyzed using GE Medical Systems LunarTM
software. A professional technician performed the assessments
of DXADuring the DXA, participants remained in a supine
position with their lower limbs relaxed, and the upper limbs were
positioned along the body with forearms pronated. DXA’s were
calibrated and tested as recommended by the manufacturer. After
analysis of the entire body area, the total body mass, lean body
mass and fat mass were registered.
Ten Repetition Maximum Test
The 10-RM test and retests were performed by the leg press 45◦
(Rocha, Leg Press 45◦, Goias, Brazil) and bench press exercises
with free-weight, plate-loaded (Supplementary Material). Both
exercises techniques followed the recommendation from the
National Strength and Conditioning Association (NSCA) (33).
During the 10-RM test and retest, the participants were
informed and supervised by two experienced exercise science
professionals. The same exercise science professionals supervised
the measurements. The participants had three to five 10-RM
attempts for each exercise.
The warm-up consisted of one set of 10 repetitions with 50%
of the estimated 10-RM load, by rating of perceived exertion 5–6
(0–10) in the first day. For leg press, the warm-up represented
∼30–40% of their body mass. For bench press, we chose to
use only the weight of the barbell (the barbell weighted 6 kg)
to perfume the warm-up on the first day. The load used to
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Santos et al. Reliability and Agreement of the 10-Repetition Maximum Test
perform the warm-up during the 10-RM retest was based on the
maximum load achieved on the first day (10-RM test).
The 10-RM load was determined if they were able to complete
the 10th repetition but not be able to perform the 11th
repetition. If the volunteer were able to performed more than
10 repetitions, the load was increased by 5–10%. The resting
interval between each attempt was 3 min, and the resting inter val
between exercises was 5 min. The cadence was not controlled,
but participants were oriented to perform the concentric phase
as fast as possible but control the eccentric phase. Leg press 45◦
was performed first, followed by the bench press. All participants
performed the bench press until touching the barbell on the
sternum/breast. The 10-RM retest was performed 3–4 days later,
using the maximum load achieved on the 10-RM test as reference
to perform the first attempt (34).
Statistical Analyses
Descriptive statistics were presented as mean and standard
deviation (SD). The intraclass coefficient correlation (ICC) and
coefficient of variation (CV =SD divided by mean of test and
retest ×100) was used for evaluation of reliability (35). The ICC
form used was a two-way mixed effect, mean of k measurements
and consistency agreement (36). The ICC and CV are present
as mean and 95% of confidential interval (CI). The analyses
of measurement error, absolute and relative, of the 10-RM test
and retest was also investigated using the standard error of
measurement [(SEM); SEM absolute =SD of the mean test-retest
score divided by the square root of 1—ICC; SEM relative =SEM
absolute score divided by mean test-retest scores and multiplying
by 100] and minimally detectable change [(MDC); MDC absolute
=1.96 ×the square root of 2 ×SEM; MDC relative =
MDC absolute score divided by mean of test-retest scores and
multiplying by 100] (37). In addition, the limits of agreement
were calculated using a Bland–Altman plot with 95% CIs (38).
The Munro’s classification of reliability was used to interpret the
ICC coefficients: 0.50–0.69 reflects moderate correlation; 0.70–
0.89 reflects high correlation; and 0.90–1.00 indicates very high
correlation. Statistical analyses were performed using MedCalc
Software (version 18.11.6) and Statistical Package for the Social
Sciences Software (version 22).
RESULTS
Participants
The sociodemographic, cancer treatment status, and
anthropometric characteristics of the participants are presented
in Table 1.
Reliability and Agreement Between Test
and Retest of 10-RM
The comparison between 10-RM test and retest showed high to
very high reliability for the leg press 45◦and bench press. For
the leg press 45◦and bench press exercises the ICC were 0.98
and 0.94, respectively. CV was below 10% for both exercises. The
results of reliability are presented in Table 2.
The agreement between the 10-RM test and retest
demonstrated that the results from the retest showed higher
TABLE 1 | Characteristics.
Characteristics N=31
Age (year)—mean (SD) 54.87 (5.7)
Education—no. (%)
<8 years of the study 15 (48.4)
>8 years of the study 16 (51.6)
Self-reported race—no. (%)
Caucasian 20 (64.5)
Non Caucasian 11 (35.5)
Occupation—no. (%)
Homemaker or cleaner 6 (19.4)
Housewife 16 (51.6)
Nurse 1 (3.2)
Retired 5 (16.1)
Saleswoman 2 (6.5)
Teacher 1 (3.2)
Marital status—no. (%)
Single 7 (22.6)
Married 16 (51.6)
Divorced 4 (12.9)
Widow 4 (12.9)
Arterial hypertension—no. (%) 9 (29)
Diabetes—no. (%) 3 (9.7)
Months since cancer diagnosis—mean (SD) 40.68 (14.8)
Cancer stage—no. (%)
I 10 (32.3)
II 17 (54.8)
III 4 (12.9)
Breast surgery—no. (%)
Lumpectomy 1 (3.2)
Lymphadenectomy 1 (3.2)
Mastectomy and breast reconstruction 1 (3.2)
Mastectomy 13 (41.9)
Mastectomy and quadrantectomy 1 (3.2)
Quadrantectomy 13 (41.9)
Quadrantectomy and breast reconstruction 1 (3.2)
Months since breast surgery—mean (SD) 29.03 (15.4)
Axillary lymph nodes removed—mean (SD) 4.86 (4.3)
Chemotherapy—no. (%) 26 (83.9)
Adjuvant 14 (45.2)
Neoadjuvant 12 (38.7)
Missing data 5 (16.1)
Radiotherapy—no. (%) 28 (90.3)
Hormone therapy—no. (%)
Tamoxifen 27(87.1)
Aromatase inhibitors 4 (12.0)
Self-reported lymphedema—no. (%) 13 (41.9)
Anthropometry and body composition
Weight (kg)—mean (SD) 68.67(11.4)
Height (cm)—mean (SD) 157.08 (6.2)
BMI—mean (SD) 27.85(4.5)
Body fat (%)—mean (SD) 46.36(5.90)
Body fat mass (kg)—mean (SD) 31.18(8.33)
Body lean mass (kg)—mean (SD) 35.26(4.64)
Level physical activity (MET-h/wk)—mean (SD) 23.38 (26.40)
SD, standard deviation; BMI, body mass index; MET, metabolic equivalent of task.
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Santos et al. Reliability and Agreement of the 10-Repetition Maximum Test
TABLE 2 | Analysis of reliability and agreement between 10-RM test and retest.
Exercises 10-RM test
(mean ±SD)
10-RM retest
(mean ±SD)
CV
(95% CI)
ICC
(95% CI)
SEM
(SEM%)
MDC
(MDC%)
Leg press (kg) 74.84 (28.50) 80.97 (29.70) 5.87 (3.19–8.55) 0.98 (0.96–0.99) 4.11 (5.27) 5.62 (7.21)
Bench press (kg) 15.03 (3.79) 16.55 (3.70) 7.27 (4.10–10.45) 0.94 (0.87–0.97) 0.96 (6.08) 2.72 (17.20)
10-RM, 10-repetition maximum; SD, standard deviation; kg, kilogram; CV, coefficient of variation; ICC, intraclass coefficient correlation; CI, confidential interval; SEM, standard error of
measurement; MDC, minimally detectable change; LOALB, limits of agreement lower boundary; LOAUB, limits of agreement upper boundary.
FIGURE 2 | Bland-Altman plot of 10-RM for the leg press 45◦(A) and the bench press (B). The dotted line represent the limits of agreement upper and lower
boundary. The continue line on the center of plot represent the systematic bias. The continue line on the Y axis represent the mean difference between 10-RM retest
and test, and on the X axis represent the mean of 10-RM retest and test.
load than the test situation performed at day 1 (systematic bias
values in Figures 2A,B are positives because the analysis were
performed with 10-RM retest as first method and 10-RM test
as second method for to build the Bland-Altman plots). The
Bland-Altman plots (Figure 2) showed the mean difference with
95% IC limits of agreement.
The relative difference between the test and the retest was
predicted in 8.3% (limits of agreement for upper and lower
boundary 28 and −11%) and 10.3% (limits of agreement for
upper and lower boundary 34 and −13%) for the leg press 45◦
and the bench press, respectively.
The relative and absolute SEM and MDC are presented in
Table 2.
DISCUSSION
This study aimed to evaluate the reliability and agreement
between the 10-RM test and retest for the leg press 45◦
and bench press exercises in BCS. We found a high to
very high rate of reliability and agreement with lower and
acceptable CV (CV <10%), SEM (absolute and relative) and
MDC (absolute and relative) between the 10-RM test and
retest for both the leg press 45◦. and bench press However,
a higher value was found in the 10-RM retest situation,
for both exercises. To our knowledge, this study is the
first to evaluate the 10-RM test reliability in BCS, and the
results suggest that 10-RM test could be used to measure
muscular strength.
In general, a few studies have previously reported the
reliability of test and retest 10-RM. In older people, Farinatti et al.
(27) described high reliability of the 10-RM test for the dumbbell
bench press (ICC 0.90; typical error 1.61 kg) and knee extension
(ICC 0.96; typical error 2.01 kg) in elderly healthy women (68 ±4
years old). Farinatti et al. (39) reported a high ICC for the barbell
bench press in young (22 ±2 years old) and elderly women (69
±7 years old) (0.91 and 0.90, respectively). For the leg press 45◦,
a high ICC (0.99) was reported in young healthy people (24 ±3
years old) (40). Monteiro et al. (41) also reported a high ICC for
the leg press 45◦(0.92) and the bench press (0.90) in adult women
(37.6 ±1.7 years old). Our study found a similar reliability to
those studies. Therefore, it seems that the 10-RM test reliability
for BCS is similar to that of healthy individuals of different ages.
The CV of 10-RM test showed be <10% for lower and upper
limbs. That was similar compare to 1-RM in BCS (18). Winter-
Stone et al. (18) reported CV of the 6.6 and 7.5% for the leg
press and chest press, respectively. We found a similar CV for
the leg press 45◦and bench press for 10-RM, 5.87 and 7.27%,
respectively. Moreover, our results suggest that lower limbs have
a better reliability than upper limb exercise, as we hypothesized.
It could be explain by lower capacity of lifting for upper limbs
compare to lower limbs, this may be result of sides effects of
breast cancer treatments.
The 10-RM retest achieved higher load than 10-RM test
situation, which may suggest some training effects either in
technique or muscle strength of the first exercise test. A
repeated strength measurement could provide a process of the
learning of task, improving the ability/skill to perform the
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Santos et al. Reliability and Agreement of the 10-Repetition Maximum Test
movement. Bernardi et al. (42) showed that skill acquisition to
perform maximal voluntary contraction allows better control
of neuromuscular system which could provide higher force
generation through the trials. Grosicki et al. (43) also found
higher value of 1-RM in the second trial than the first trial of
assessment in young adults and older people, women and men,
for leg press, leg extension and biceps curl. The same behavior
was observed by Amarante do Nascimento et al. (44). They found
that the second day of testing was higher than first day, but
similar with the third day in 1-RM load for bench press and leg
extension in elderly women (65 ±4 years old) (44). Thus, the
muscle strength values could be reached in the second or third
trial of measurement.
The 10-RM test could be useful in the real word for prescribing
or monitoring the load of the training. The use of percentage
of 1-RM test may present a large variability in the number of
repetition performance. Grosicki et al. (43) showed that using
60% and 80% of 1-RM test the participants were able to perform
28.8 (±9.2)/23.3 (±16.3) and 17 (±6.5)/12.8 (±7.8) repetitions
in younger and older women, respectively. Hence, the session of
training would be high or low effort, if use the percentage of 1-
RM test. Therefore, it seems that using the load reached from
10-RM test could be more precisely to prescribe and monitor
the number of repetitions during the training session, and that
may be one advantages of 10-RM test compared to 1-RM test.
Another advantage of 10RM test could be a better perception
of safety and acceptance in BCS, since there have been reported
knesiohpobia, fear of movement (11,45). In addition, repetition
to failure as 10-RM might be used to predict 1-RM loads for
the bench press/chest press (46–48) and leg press 45◦/horizontal
(47–49), with a low error of measurement. However, we did not
investigate the accuracy of the 10-RM load to predict a 1-RM
load in BCS. Future studies could investigate the accuracy of the
10-RM test to predict a 1-RM load in BC patients and BCS.
STRENGTHS AND LIMITATIONS
The study has important strengths. The tests were supervised
by two experienced exercise physiologists/professionals that
provided better control of the 10-RM test and guaranteed the
safety and confidence for the participants to perform higher load,
and the homogeneity of the tests. One limitation of the present
study included the lack of assessment of shoulder range of motion
during the bench press test. However, we think this limitation was
eliminated by the experienced physiologists.
CONCLUSION
In conclusion, muscular strength measurement using 10-
RM test has a good to excellent rate of reliability and
agreement, with acceptable error of measurement. Due to
lack of information about the reliability of 1-RM test in
BCS, 10-RM test could be an interesting alternative for
diagnosis and prescription in this population. Therefore, the
10-RM test may be used to evaluate the muscular strength
in BCS. The new studies with BC patients and BCS could
report the reliability of the maximum force production on
isoinertial exercises.
DATA AVAILABILITY
The datasets generated for this study are available on request to
the corresponding author.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by Research Ethics Committee of the Federal
University of Goias (CAAE: 50717115.4.0000.5083), and by the
Research Ethics Committee of the Clinical Hospital of the
Federal University of Goias (CAAE: 50717115.4.3001.5078). The
patients/participants provided their written informed consent to
participate in this study.
AUTHOR CONTRIBUTIONS
WS and CV performed the study concept and design. WS
and GS supervised the muscle assessments. WS, RS, and WM
conducted the analyses. WS wrote the original draft of the
manuscript. AV, WM, PG, and CV wrote, reviewed, and edited
the manuscript.
FUNDING
PG receives a Research Grant from CNPq (304435/2018-0).
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fonc.
2019.00918/full#supplementary-material
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
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