Resistance exercise training is more effective than interval aerobic training in reducing blood pressure during sleep in hypertensive elderly patients

Journal of Strength and Conditioning Research Publish Ahead of Print
DOI: 10.1519/JSC.0000000000002354
Resistance exercise training is more effective than interval aerobic
patients
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Running head: Resistance training in sleep blood pressure
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training in reducing blood pressure during sleep in hypertensive elderly
Rodrigo F. Bertani, Giulliard O. Campos, Diego M. Perseguin, José M.T.
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Bonardi, Eduardo Ferriolli, Julio C. Moriguti, Nereida K.C. Lima
Department of Internal Medicine, Division of General Clinical Medicine and
Geriatrics, Ribeirão Preto Medical School, University of São Paulo, FMRP-USP,
Ribeirão Preto, Brazil.
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Disclosure of funding: Scholarship to Rodrigo F. Bertani supported by CAPES
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(Brazil).
Corresponding author:
Nereida Kilza da Costa Lima ([email protected])
Address: Av. Bandeirantes, 3900
14048-900
Ribeirão Preto – SP Brasil
Tel: 55-16-3602-2464
Fax: 55-16-3633-6695
Copyright ª 2017 National Strength and Conditioning Association
ABSTRACT
An appropriate fall in blood pressure (BP) during sleep is known to be related to a
lower cardiovascular risk. The objective of the present study was to compare the
effect of different types of training on hypertensive elderly patients under treatment in
terms of pressure variability assessed by the nocturnal decline in BP. Hypertensive
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elderly subjects under pharmacological treatment were randomly assigned to the
following groups: 12 weeks of continuous aerobic training (CA), interval aerobic
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training (IA), resistance training (R), or control (C). All subjects underwent ambulatory
blood pressure monitoring prior to and 24 hours after the last exercise session. The
results were assessed using the mixed effects model. A greater nocturnal decline in
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diastolic BP compared to the wakefulness period was observed in R in comparison to
C (11.0±4.1 vs. 6.0±5.7 mmHg, p=0.01) and to IA (11.0±4. vs. 6.5±5.1 mmHg,
p=0.02). No fall in BP during a 24-hour period was observed in training groups
compared to C, perhaps because the subjects were mostly non-dippers, for whom
the effect of training on BP is found to be lower. In conclusion, resistance training
promoted a greater nocturnal fall in BP among hypertensive elderly subjects under
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treatment compared to IA subjects.
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Key words: non-dippers; older individuals; hypertension; resistance exercise
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INTRODUCTION
The regular practice of physical exercise has been recommended to
elderly persons with various chronic comorbidities in order to reduce
cardiovascular risk and to maintain functional capacity.
Several physical training protocols have been tested on various groups in
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order to determine the magnitude of the benefits of exercise and to determine
which protocol would be more effective in promoting beneficial changes in the
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elderly. More recently, some studies have included interval aerobic training,
which permits variations in intensity during the sessions, alternating more
intensive and less intensive periods (7, 15, 25).
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The nocturnal fall in systolic and diastolic blood pressure (BP) is
considered to be physiological when the reduction is 10 to 20% compared to BP
during wakefulness. BP falls of less than 10% (attenuated decline) or of more
than 20% (exacerbated decline) are associated with greater cardiovascular risk
(2, 3,13).
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Despite the evidence of the beneficial effects of various exercise
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modalities on BP variability (4, 6), a literature review did not reveal any
comparative studies on elderly persons that would include continuous aerobic,
interval aerobic and resistance training. Thus, the objective of the present study
was to compare the effects of these different types of training on hypertensive
elderly subjects under treatment in terms of BP variability assessed by the
nocturnal BP decline.
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METHODS
Experimental Approach to the Problem
This was a non-blind, controlled study consisting of groups randomly assigned
to different interventions. The different types of physical training represented the
independent variable and BP plus its fall during sleep represented the dependent
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variables.
Subjects
The study was conducted on 70 pre-selected subjects of both sexes aged 60
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years or older, residing in the city of Ribeirão Preto, SP, Brazil, and followed up at the
Teaching Health Center of the Ribeirão Preto Medical School, University of São
Paulo (FMRP-USP). The subjects were hypertensive, were regularly taking
prescribed medications and had no experience with aerobic and/or resistance
training.
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The Research Ethics Committee of the Teaching Health Center, FMRP-USP,
approved the study (number 1.092.824) and all subjects gave written informed
to
participate.
The
volunteers
were
previously
submitted
to
an
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consent
electrocardiogram and to a treadmill stress test in addition to routine laboratory tests
for the determination of thyroid stimulating hormone (TSH), creatinine, urea, sodium,
potassium, glycaemia, and blood count. Exclusion criteria were: a positive test for
ischemia, moderate or severe left ventricular hypertrophy, left ventricular systolic
dysfunction of any degree, moderate or severe left ventricular diastolic dysfunction,
presence of arrhythmias, alcohol intake of more than seven doses per week, renal
insufficiency
(creatinine
>
1.5),
diabetes,
uncontrolled
hyperthyroidism
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or
hypothyroidism,
anemia with hemoglobin < 12 g/dL, limiting pneumopathy,
musculoskeletal conditions that would limit the execution of aerobic or resistance
exercises, and basal systolic BP (SBP) ≥160 and/or diastolic BP (DBP) ≥ 100 mmHg
(Omron – HEM 4031). After exclusion of two subjects due to changes in the
ergometric test and of seven subjects who dropped out of the study prematurely by
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being unable to train at the standardized time, 61 subjects were randomized to the
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various groups and completed the study.
Procedures
The subjects were randomly assigned to 4 groups: continuous aerobic training
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(CA), interval aerobic training (IA), resistance training (R), and control group (C), with
each group consisting of 15 participants except for R, which consisted of 16
participants. Mean age was similar for all groups (CA: 67.3±5.4 years; IA: 68.1±5.8
years; R: 67.7±5.8 years; C: 66.6±5.2 years; p>0.05). Sex distribution also did not
differ among groups (p>0.05), with a total of 41 women and 20 men.
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The CA and IA groups were managed with intensities previously calculated by
means of the treadmill stress test, with 70% of maximum heart rate for CA and a
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duration of 20 minutes plus 5 warm-up minutes and 5 cool-down minutes, for a total
of 30 minutes of training. The intensities for the IA group were 60 and 80% of
maximum heart rate alternating every 2 minutes for 20 minutes, plus 5 warm-up
minutes and 5 cool-down minutes, for a total of 30 minutes of training.
The R group was first submitted to one maximum repetition (1RM) evaluation,
which consists of obtaining maximum load on the equipment in up to five attempts,
with 3-minute intervals between them. The attempts during which the participants did
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not complete one execution or two repetitions correctly were not validated. If the
subject did not achieve the maximum load in up to five attempts, the test was
considered not to be valid for that specific type of equipment. The sessions for the R
group consisted of two series of each proposed exercise with 6 to 10 repetitions, with
50% 1RM load for warm-up. The experimental series was started two minutes after
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warm-up with 75% 1RM, with a volume of 6 to 10 submaximal repetitions. Training
was always started 7 days after the 1RM test. Nine resistance exercises routinely
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used in gyms were chosen. Three types of training equipment were chosen by
permitting exercises similar to the movements used in daily life: bench press, leg
press and open row. The other six were incorporated in order to characterize a
session of resistance exercises: leg extensor bench, dumbbell curl, flexor bench,
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adductor chair, abductor chair, and triceps pulley.
The control group did not perform supervised physical activities during the
study period, but maintained its previous routine activities.
The training program lasted 12 weeks with three sessions per week on
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alternate days, for 36 sessions.
Ambulatory blood pressure monitoring (ABPM) was performed before the
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beginning of treatment and one day after the end of training. ABPM was employed
using a SPACELABS MEDICAL monitor model 90207 for BP measurement, installed
by the researcher, always starting at 10 am, permitting automatic 24-hour BP
recording. The device was programmed to obtain measurements every 15 minutes
during the period from 07 to 23 hours (wakefulness) and every 30 minutes from 23 to
07 hours on the following morning (sleep). Data were recorded on the device and
obtained by cable connection with a computer at the conclusion of each blood
pressure monitoring cycle.
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The subject received a diary for the detailed recording of daily activities during
ABPM. Delta SBP and DBP was calculated between the wakefulness and sleep
periods.
Statistical Analyses
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Data were analyzed statistically using a mixed effects model adjusted for age, sex
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and body mass index with the aid of the SAS® 9 software (17). In this model, the
subjects were considered to be the random effect and the groups, times and
RESULTS
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interaction between them were considered to be the fixed effects.
Table 1 shows the SBP and DBP values obtained for the four groups before
and after the study period. Table 2 shows the difference (delta) between the pressure
values obtained during wakefulness and sleep.
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Figures 1A and 1B illustrate 24-hour SBP before and after the training period,
respectively. Figures 2A and 2B illustrate DBP, showing an important nocturnal fall in
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it in the R group compared to control and compared to group IA. The maximum DBP
fall occurred at 1 pm.
DISCUSSION
The present study demonstrated the effect of resistance training on
hypertensive subjects regarding the potentiation of the nocturnal fall in DBP,
with
a
decline
of
more
than
10%
after
the
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intervention.
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The nocturnal fall in BP is associated with better sleep quality and with a lower
cardiovascular risk (13,16,20).
Few studies have assessed the fall in BP after different exercise
modalities. Regarding the effects of a single exercise session, a study that
assessed the nocturnal fall in BP after a single session of aerobic exercise
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revealed a beneficial effect on prehypertensive diabetic subjects (11). On the
other hand, hypertensive elderly subjects under treatment submitted to a single
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session of a circuit of resistance exercises showed nocturnal elevation of SBP
and DBP (18). By comparing a single session of aerobic or resistance exercise
in 10 diabetic patients, Morais et al. (10) demonstrated a greater nocturnal BP
fall after resistance exercise than after aerobic exercise, in agreement with the
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findings of the present study.
Considering the effect of physical training, Sturgeon et al. (23) studied 23
middle-aged subjects submitted to 6 months of continuous aerobic training and
did not detect a difference between dippers and non-dippers before or after the
intervention. Another study detected nocturnal DBP elevation after 8 weeks of
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resistance training in middle-aged prehypertensive and obese individuals (1).
Mechanisms underlying the increased reduction in BP during sleep
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among those undergoing resistance training at this point are purely speculative
and suggest additional study to define them. However, maybe the findings
favoring the R intervention lie in fewer episodes of awakening and a better
quality of sleep (16). Another explanation may lie in the potential that a greater
recruitment of muscle mass during acute exercise would lead to a higher HR
and BP, with subsequent adaptation to chronic training.
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This might be associated with a reduction of stimulation of the muscle
metaboreceptors and mechanoreceptors and a net reduction in muscle
sympathetic nerve activity (8,19).
We did not detect a significant difference in 24-hour BP after the
different types of training applied, a fact that may have been due to the time and
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intensity of the exercises performed. Previous studies that evaluated the fall in
BP after 3 months of continuous aerobic exercise did not detect a fall in BP over
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a 24-hour period among subjects who did not show a physiological nocturnal
decline in BP, suggesting that other mechanisms may be involved in this
subtype of hypertensive individuals (12). In the current study, assessment of the
mean basal nocturnal fall in training groups revealed that the subjects submitted
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to the exercise protocols were non-dippers. Another study also did not detect a
fall in BP after 6 months of aerobic training despite the occurrence of benefits
such as the reduction of carotid artery intima-media thickness and improved
nitric oxide levels (5). On the other hand, a fall in BP was detected after
resistance training alone (24) and after aerobic training alone (9, 14, 22) or in
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combination with aerobic training (9, 21, 22) among hypertensive subjects
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under treatment.
PRACTICAL APPLICATIONS
Resistance training with nine resistance exercises routinely used in
gyms, conducted 3 times a week for 12 weeks, with 75% 1RM, after adequate
warm-up, with a volume of 6 to 10 submaximal repetitions, promoted a greater
nocturnal fall in DBP during sleep among hypertensive older subjects under
treatment compared to control and continuous aerobic training.
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Among patients with an attenuated BP decline, the implementation of R can be
of help for the nocturnal BP pattern, increasing the decline, which is associated
with a better cardiovascular risk. This is an additional benefit of resistance
training, which has already been indicated for the improvement and
maintenance of functionality and the prevention of sarcopenia in elderly
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subjects.
CAPES - Brazil (scholarship).
Nothing to disclosure.
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REFERENCES
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Acknowledgments
1.Ash, GI, Taylor, BA, Thompson, PD, MacDonald, HV, Lamberti, L, Chen, MH,
Farinatti, P, Kraemer, WJ, Panza, GA, Zaleski, AL, Deshpande, V, Ballard, KD,
Mujtaba, M, White, CM, and Pescatello, LS. The antihypertensive effects of
2017.
C
aerobic versus isometric handgrip resistance exercise. J Hypertens 35:291-299,
A
2. Bloomfield, D, and Park, A. Night time blood pressure dip. World J Cardiol
7:373-376, 2015.
3. Davidson, MB, Hix, JK, Vidt, DG, Brotman, DJ. Association of impaired diurnal
blood pressure variation with a subsequent decline in glomerular filtration rate.
Arch Intern Med 166:846–852, 2006.
4. De-Brito, LC, Rezende, RA, da-Silva-Junior, ND, Tinucci, T, Casarini, DE,
Cipolla-Neto, J, and Forjaz, CL. Post-Exercise Hypotension and Its Mechanisms
Copyright ª 2017 National Strength and Conditioning Association
9
Differ after Morning and Evening Exercise: A Randomized Crossover Study.
PLoS One 10: e0132458, 2015.
5. Feairheller, DL, Diaz, KM, Kashem, MA, Thakkar, SR, Veerabhadrappa, P,
Sturgeon, KM, Ling, C, Williamson, ST, Kretzschmar, J, Lee, Grimm, H, Babbitt,
DM, Vin, C, Fan, X, Crabbe, DL, and Brown, MD. Effects of Moderate Aerobic
J Clin Hypertens (Greenwich) 16: 504–510, 2014.
D
Exercise Training on Vascular Health and Blood Pressure in African Americans.
TE
6. García-Ortiz, L, Recio-Rodríguez, JI, Martín-Cantera, C, Cabrejas-Sánchez, A,
Gómez-Arranz, A, González-Viejo, N, Nicolás, EI, Patino-Alonso, MC, and A
Gómez-Marcos, MA. Physical exercise, fitness and dietary pattern and their
relationship with circadian blood pressure pattern, augmentation index and
C
EP
endothelial dysfunction biological markers: EVIDENT study protocol. BMC Public
Health 2010; 10: 233, 2010.
7. García-Pinillos, F, Laredo-Aguilera, JA, Muñoz-Jiménez, and M, LatorreRomán, PA. Effects of 12-week concurrent high-intensity interval strength and
endurance training programme on physical performance in healthy older people.
8.
C
J Strength Cond Res 31:146-153, 2017.
Lawrence
MM, Cooley
A
Factors influencing isometric
ID, Huet
YM, Arthur
ST, Howden
exercise training-induced reductions
in
R.
resting
blood pressure. Scand J Med Sci Sports 25:131-42, 2015.
9. Lima, LG, Bonardi, JTM, Campos, GO, Bertani, RF, Scher, LML, Moriguti, JC,
Ferriolli, E, Lima NKC. Combined aerobic and resistance training: are there
additional benefits for older hypertensive adults? Clinics (Sao Paulo) 72:363-369,
2017.
Copyright ª 2017 National Strength and Conditioning Association
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10. Morais, PK, Campbell, CS, Sales, MM, Motta, DF, Moreira, SR, Cunha, VN,
Benford, RE, and Simões, HG. Acute resistance exercise is more effective than
aerobic exercise for 24h blood pressure control in type 2 diabetics. Diabetes
Metab 37:112-117, 2011.
11. Morais, PK, Sales MM, Almeida JA, Motta-Santos D, Sousa CV, Simões HG.
D
Effects of aerobic exercise intensity on 24-h ambulatory blood pressure in
individuals with type 2 diabetes and prehypertension. J Phys Ther Sci 27:51-56,
TE
2015.
12. Nami, R, Mondillo, S, Agricola, E, Lenti, S, Ferro, G, Nami, N, Tarantino, M,
Glauco, G, Spanò, E, and Gennari, C. Aerobic exercise training fails to reduce
blood pressure in nondipper-type hypertension.Am J Hypertens. 13:593-600,
C
EP
2000.
13. Ohkubo, T, Imai, Y, Tsuji, I, Nagai, K, Watanabe, N, Minami, N, Kato, J,
Kikuchi, N, Nishiyama, A, and Aihara, A. Relation between nocturnal decline in
blood pressure and mortality. The Ohasama Study. Am J Hypertens 10:1201–
1207, 1997.
C
14. Pagonas, N, Vlatsas, S, Bauer, F, Seibert, FS, Zidek, W, Babel, N,
Schlattmann, P, and Westhoff, TH. Aerobic versus isometric handgrip exercise in
A
hypertension: a randomized controlled trial. J Hypertens. 2017. [Epub ahead of
print].
15. Pattyn, N, Vanhees, L, Cornelissen, VA, Coeckelberghs, E, De Maeyer, C,
Goetschalckx, K, Possemiers, N, Wuyts, K, Van Craenenbroeck, EM,
and
Beckers,
trial
PJl.
The
long-term
effects
of
a
randomized
comparing aerobic interval versus continuous training in coronary artery disease
Copyright ª 2017 National Strength and Conditioning Association
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patients: 1-year data from the SAINTEX-CAD study. Eur J Prev Cardiol 23:11541164, 2016.
16. Pepin JL, Borel, AL, Tamisier, R, Baguet, JP, Levy, P, Dauvilliers, Y.
Hypertension and sleep: overview of a tight relationship. Sleep Med Rev 18:509519, 2014.
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17. Schall, R. Estimation in generalized linear models with random effects.
Biometrika 78:719-727, 1991.
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18. Scher LM, Ferriolli E, Moriguti JC, Scher R, Lima NK. The effect of different
volumes of acute resistance exercise on elderly individuals with treated
hypertension. J Strength Cond Res 25:1016-1023, 2011.
19. Secher NH, Amann M. Human investigations into the exercise pressor reflex.
C
EP
Exp Physiol 97:59–69, 2012.
20. Sherwood A, Bower JK, Routledge FS, Blumenthal JA, McFetridge-Durdle
JA,
Newby
LK,
Hinderliter
AL.
Nighttime
blood
pressure
dipping
in
postmenopausal women with coronary heart disease. Am J Hypertens 25:10771082, 2012.
C
21. Son WM, Sung KD, Cho JM, Park SY. Combined exercise reduces arterial
stiffness, blood pressure, and blood markers for cardiovascular risk in
A
postmenopausal women with hypertension. Menopause 24:262-268, 2017.
22. Sousa, N, Mendes, R, Abrantes, C, Sampaio, J, and Oliveira, J. A
randomized 9-month study of blood pressure and body fat responses to aerobic
training versus combined aerobic and resistance training in older men. Exp
Gerontol 48:727-733, 2013.
Copyright ª 2017 National Strength and Conditioning Association
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23. Sturgeon, KM, Fenty-Stewart, NM, Diaz, KM, Brinkley, TE, Dowling, TC, and
Brown, MD. The relationship of oxidative stress and cholesterol with dipping
status before and after aerobic exercise training. Blood Press 18:171-179, 2009.
24. Trevizani, GA, Seixas, MB, Benchimol-Barbosa, PR, Vianna, JM, Pinto da
Silva, L, and Nadal, J. Effect of resistance training on blood pressure and
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autonomic responses in treated hypertensives. J Strength Cond Res. 2017
[Epub ahead of print]
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25. Wewege, M, van den Berg, R, Ward, RE, and Keech, A. The effects of highintensity interval training vs. moderate-intensity continuous training on body
composition in overweight and obese adults: a systematic review and meta-
A
C
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analysis. Obes Rev 18:635-646, 2017.
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Table 1: Twenty-four- hour systolic (S) and diastolic (D) blood pressure during
CA (n=15)
IA (n=15)
S Pre 24 h (mmHg)
129.5±7.4
131.6±14.7 126.9±10.0
130.9±10.4
S Post 24 h (mmHg)
125.5±12.3 128.9±12.4 128.2±10.3
128.0±11.7
S Pre Wake (mmHg)
130.7±8.2
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wakefulness and sleep before (Pre) and after (Post) a period of training.
R (n=16)
134.1±15.0 129.1±10.7
S Pre Sleep (mmHg)
134.7±10.6
130.2±12.8
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S Post Wake (mmHg) 127.7±13.1 131.5±12.0 131.9±10.1
C (n=15)
126.8±10.4 126.5±15.0 121.9±11.3
123.3±12.8
S Post Sleep (mmHg) 120.9±12.7 124.0±14.4 121.2±11.8
123.7±12.2
D Pre 24 h (mmHg)
73.6±8.3
77.2±10.0
78.6±10.8
71.9±8.2
76.6±10.9
74.3±8.2
76.3±11.5
77.3±7.4
81.2±10.8
76.3±9.1
80.5±10.6
D Post Wake (mmHg) 74.5±8.7
78.9±11.3
78.1±7.9
78.3±12.3
D Pre Sleep (mmHg)
73.3±11.3
69.1±7.9
70.2±11.1
72.5±11.2
67.1±9.8
72.3±10.9
D Post 24 h (mmHg)
72.1±9.3
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D Pre Wake (mmHg)
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75.5±7.6
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D Post Sleep (mmHg) 67.3±8.0
CA: continuous aerobic training group; IA: interval aerobic training group; R:
resistance training group, C: control group.
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Table 2: Fall in systolic (S) and diastolic (D) arterial pressure during sleep compared
to wakefulness before (Pre) and after (Post) a period of training.
IA (n=15)
R (n=16)
C (n=15)
S Pre (mmHg)
4.0±10.3*
7.5±5.8
7.2±9.1
11.5±9.8
S Pre (%)
3.0
5.6
5.5
8.5
S Post (mmHg)
6.8±8.8
7.5±8.0
10.8±6.2
6.5±10
S Post (%)
5.3
5.7
8.2
5.0
D Pre (mmHg)
5.2±5.4*
7.9±3.8
7.2±6.1
10.3±8.5
D Pre (%)
6.7
9.8
9.4
12.8
D Post (mmHg)
7.3±5.2
6.5±5.1
11.0±4.1*#
6.0±5.7&
D Post (%)
9.8
8.2
14.0
7.7
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D
CA (n=15)
CA: continuous aerobic training group; IA: interval aerobic training group; R:
resistance training group, C: control group. *P=0.01 vs. C Post; #P=0.02 vs. AI Post;
P=0.03 vs. C Pre.
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Figure legends
Figure 1A: Systolic blood pressure (BP) in the 24 hours before the research protocol.
CA: continuous aerobic training group; IA: interval aerobic training group; R:
resistance training group, C: control group.
Figure 1B: 24- h systolic blood pressure (BP) one day after the research protocol.
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CA: continuous aerobic training group; IA: interval aerobic training group; R:
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resistance training group, C: control group.
Figure 2A: Diastolic blood pressure (BP) in the 24 hours before the research protocol.
CA: continuous aerobic training group; IA: interval aerobic training group; R:
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resistance training group, C: control group.
Figure 1B: 24-h diastolic blood pressure (BP) one day after the research protocol.
CA: continuous aerobic training group; IA: interval aerobic training group; R:
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C
resistance training group, C: control group.
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