The aging process is a continuous phenomenon accompanied by alterations in some physiological systems, collaborating with the development of geriatric syndromes and chronical diseases, such as hypertension (HTN) [
However, several evidences have been indicating that HTN not only is strongly associated with cardiovascular risk factors, but also can lead to physical and cognitive impairments in older adults in a time-dependent fashion [
Multicomponent exercise programs (MCEP) emerge as a possible type of physical exercise able to prevent the deleterious effects of aging on the organic system, improving physical functioning, and cognitive capacities [
Nevertheless, just one study, which was performed with a low-sample size, recorded the effects of a MCEP on functional parameters of hypertensive patients [
Therefore, the present study aimed to investigate the impact of a 6-month MCEP on physical function and cognitive parameters of normotensive (NTS) and hypertensive (HTS) older patients and verify if age can influence the adaptations in response to the exercise.
Based on aforementioned data, the alternative hypothesis
The present study has a quasi-experimental design, which aimed to investigate the effects of a 6-month multicomponent exercise program (MCEP) in the functional and cognitive parameters of normotensive (NTS) and hypertensive (HTS) older patients. Therefore, patients were undergoing functional and cognitive evaluations before and after 6 months of MCEP. All volunteers signed the informed consent form and completed all measurements. This study was approved by the Research Ethics Committee of the University of Campinas (UNICAMP). This study was developed in accordance with the Declaration of Helsinki and according to Resolution 196/96 of the National Health Council.
A total of 101 NTS and 117 HTS untrained patients were recruited from two specialized healthcare centers for older adults in a town located in the metropolitan area of São Paulo, Brazil. Volunteers were recruited by convenience and asked verbally by the medical team and researchers about their participation in the study. All subjects provided informed consent before enrolment.
The exclusion criteria were use of hormone replacement and/or psychotropic drugs, cerebrovascular disease (e.g., stroke), pulmonary disease, neurological or psychiatric disease (e.g., Parkinson’s or Alzheimer’s disease), musculoskeletal disorders, comorbidities associated with greater risk of falls and any kind of dizziness, and blurred vision or lightheadedness when rising or remaining standing for long, which could indicate orthostatic hypertension and/or labyrinthitis. The inclusion criterion was age ≥60 years. Patients of both genders were accepted in the present study. After the application of the exclusion and inclusion criteria, 218 older women were included in the analyses.
The volunteers were subdivided into NTS and HTS groups according to previous clinical diagnosis of HTN. Since both healthcare centers serve a large number of patients and the medical team (i.e., nurse, physician, and physical educator) is of limited size, the pathological conditions were simply recorded by the head physician and head nurse of each center. A specialist (i.e., cardiologist) who was not affiliated to and was outside the center then made the diagnosis of HTN, according to the guidelines [
In summary, before the participants began the activities in the centers where they were recruited, a medical consultation was conducted and an extensive list of medical exams was required (e.g., fasting blood glucose, fasting blood insulin). If the patient showed any signal of HTN, such as high blood pressure levels during the first visits in the centers, he/she was invited to measure blood pressure levels, at least, three times, during different periods of the day at home. If her/his blood pressure evaluations remained elevated, he/she was referred to a cardiologist. After they underwent specific medical consultation (i.e., cardiologist) and perform all specific exams (i.e., 24-hour ambulatory blood pressure monitoring [ABPM], home blood pressure) [
All volunteers were instructed to refrain from physical exercise for the 96 hours, as well as drinking coffee, alcoholic, and energy drinks during the 24 hours before all evaluations. Although alimentary ingestion was not controlled, subjects were instructed to maintain the habitual food intake throughout the period of the protocol. All volunteers ensure that these parameters were not altered during the protocol. Evaluations (pre and post) were performed 120 hours before and after the beginning and the end of the physical exercise program, respectively.
Before the performance of the tests, an experienced researcher detailed the procedures of each test. The volunteers performed all tests twice and the higher value recorded in each test was used in the analysis. During all tests, verbal encouragement was provided to ensure that volunteers reached the best performance possible. The present protocol was used by our group elsewhere [
Volunteers were requested to rise from a chair five times as fast as possible with their arms crossed in front of the body. The stopwatch was activated when the volunteer raised their buttocks off the chair and was stopped when the volunteer seated back.
The one-leg stand test was performed with the volunteers standing in a unipodal stance with the dominant lower limb, the contralateral knee remaining flexed at 90°, the arms remaining crossed in front of the chest, and the head being straight. A stopwatch (Moure Jar®, China) was activated when the volunteer raised their contralateral foot off the floor and was stopped when the contralateral foot touched the floor again.
To measure walking speed, a three-meter walking speed test was performed. Volunteers were required to walk a distance of five meters at their usual and fastest possible cadences (without running). Before the evaluation, both feet of each volunteer were to remain on the starting line. Measurement was initiated when a foot reached the one-meter line and was stopped when a foot reached the four-meter line. The one-meter intervals at the beginning and end were used to avoid early acceleration and/or deceleration.
The Time Up and Go (TUG) test involved getting up from a chair without the help of the arms, walking a distance of three meters around a marker placed on the floor, coming back to the same position, and sitting back on the chair. The test began when a researcher shouted a “go!” command. The stopwatch was activated when the volunteers got up from the chair and was stopped when they were seated again.
TUG cognitive test was accomplished to evaluate EF. This test is performed equally to the conventional TUG; however, a cognitive task (verbal fluency, animal category) must be accomplished during the motor task. Therefore, after the signal of the evaluator, the volunteer performed the route—stand up from the chair, walk three meters, turn around, walk three meters back, and sit down again—naming as many animals as he/she could remember. This task was performed out loud, allowing the evaluators to confirm if the volunteers were, in fact, accomplishing the task. The time spent to perform the task was recorded for evaluation [
The MCEP was performed twice a week, on nonconsecutive days, during 26 weeks at the fitness center of an institutional center for elderly care and living (Centro de Convivência do Idoso [CCI]), Poá, Brazil. The program was designed to offer exercises that would mimic activities of daily live (ADL) gestures, thereby inducing neuromuscular adaptations to maintain the subjects able to perform the ADL. Each exercise session was composed of twelve different exercises stations. The structure of each exercise session was defined by the sequence of one functional exercise followed, immediately, by a brief walk. Therefore, exercise session was composed of approximately 12 minutes of functional exercises, 24 minutes of walk, and 12 minutes of rest. Approximately each session of exercise was composed of 50 patients. A physical trainer professional with larger expertise on exercise training to older people supervised all sessions (OI). Volunteers were instructed to avoid the Valsalva maneuver during the performance of exercises.
The functional exercises were changed during the whole program. However, they always represented ADL with a large necessity of the activity of the lower limbs, as, for example, standing and sitting on the chair, picking up a weight off the floor and putting it on top of a structure, and transferring a weight from one place to another. Balance and proprioception exercises were also composed of functional exercises, as one-leg stand. At most three balance and/or proprioception exercises were used in each session. To complete the list of physical exercises, upper limbs resistance exercises were added.
All functional exercises were performed for one minute. The brief walk was performed for two minutes. Thus, after the end of each functional exercise, volunteers must walk from one point to another (30 m), around a cone, come back to the initial line (30 m), and start the path again until completing the two minutes. A rest interval of 60 seconds was adopted between the stations.
The control of exercise intensity was accomplished by the rating of perceived exertion (RPE) method using the adapted Borg scale (2001) (i.e., CR-10) [
Normality of data was tested using the
Subjects did not show adverse events during exercise sessions and evaluations, and they were not absent for more than three exercise sessions. There were no dropouts during the study, so that the adherence to the physical exercise program was 100%. Volunteers did not report any changes in food intake and in the number or class of medications use during the whole course of the present study.
Table
Comparison between the groups regarding the morphological and hemodynamic parameters.
Variables | NTS ( |
HTS ( |
---|---|---|
Subjects characteristics | ||
Age (years) |
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|
Body mass (kg) |
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|
Height (cm) |
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|
Body mass index (kg/m2) |
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|
Hemodynamic parameters | ||
SBP (mmHg) |
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|
DBP (mmHg) |
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|
MAP (mmHg) |
|
|
Data are presented as mean ± SD. NTS = normotensive group; HTS = hypertensive group; SBP = systolic blood pressure; DBP = diastolic blood pressure; MAP = mean arterial pressure.
Table
Effect size and its classification of behavior of functional parameters after the experimental session.
Variable | NTS | HTS | |
---|---|---|---|
Sit-to-stand (repetitions) | Pre |
|
|
Post |
|
|
|
ES | 0.07 (trivial) | 0.08 (trivial) | |
|
|||
One-leg stand (s) | Pre |
|
|
Post |
|
|
|
ES | −0.74 (small) | 0.15 (trivial) | |
|
|||
Usual walking speed (m/s) | Pre |
|
|
Post |
|
|
|
ES | 0.40 (trivial) | 0.46 (trivial) | |
|
|||
Maximal walking speed (m/s) | Pre |
|
|
Post |
|
|
|
ES | 0.48 (trivial) | 0.95 (small) | |
|
|||
TUG (s) | Pre |
|
|
Post |
|
|
|
ES | −0.07 (trivial) | 0.07 (trivial) | |
|
|||
TUG with a cognitive task (s) | Pre |
|
|
Post |
|
|
|
ES | −0.05 (trivial) | −0.14 (trivial) |
On the other hand, sit-to-stand, TUG, and TUG with a cognitive task did not show significant alterations. Qualitative analyses are in concordance with the hypothesis test, once the ES for sit-to-stand, TUG, and TUG with a cognitive task were near zero in NTS and HTS patients.
Table
Magnitude (% Δ) of effect in both groups.
Variable | NTS | HTS | |
---|---|---|---|
One-leg stand (s) | % Δ | 45.4 | 51.0 |
Usual walking speed (m/s) | % Δ | −20.4 | −12.0 |
Maximal walking speed (m/s) | % Δ | −48.1 | −40.4 |
Sit-to-stand (repetitions) | % Δ | −1.5 | −1.9 |
TUG (s) | % Δ | 1.5 | −1.4 |
TUG with a cognitive task (s) | % Δ | 1.3 | 3.8 |
NTS = normotensive; HTS = hypertensive; TUG = Time Up and Go.
The effects of multicomponent physical exercise on functional and cognitive parameters of NTS and HTS patients adjusted by age (<75 and ≥75) are shown in Table
Effect size and its classification of behavior of functional parameters after the experimental session adjusted by age.
Variable | NTS < 75 ( |
NTS ≥ 75 ( |
HTS < 75 ( |
HTS ≥ 75 ( |
|
---|---|---|---|---|---|
Sit-to-stand (repetitions) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | 0.07 (trivial) | −1.56 (moderate) | 0.14 (trivial) | −0.15 (trivial) | |
|
|||||
One-leg stand (s) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | −0.81 (small) | 0.37 (trivial) | −1.03 (small) | −1.34 (small) | |
|
|||||
Usual walking speed (m/s) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | 0.41 (trivial) | 0.16 (trivial) | 0.56 (small) | 0.15 (trivial) | |
|
|||||
Maximal walking speed (m/s) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | 1.34 (moderate) | 1.25 (small) | 0.59 (small) | 1.08 (small) | |
|
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TUG (s) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | −0.07 (trivial) | −0.22 (trivial) | 0.08 (trivial) | 1.19 (moderate) | |
|
|||||
TUG with a cognitive task (s) | Pre |
|
|
|
|
Post |
|
|
|
|
|
ES | 0 (trivial) | −0.97 (small) | −0.15 (trivial) | −0.14 (trivial) |
In turn, time to perform usual walking speed test was decreased in the youngest groups (i.e., NTS < 75 and HTS < 75), but not in the oldest groups (i.e., NTS ≥ 75 and HTS ≥ 75). Similar with the results from the maximal walking speed test, ES classification was not congruent with the hypothesis test, and ES classification was
The comparison between the magnitudes of alterations (% Δ) after multicomponent physical exercise in NTS and HTS patients adjusted by age is shown in the Table
Magnitude (% Δ) of effect in both groups adjusted by age.
Variable | NTS < 75 | NTS ≥ 75 | HTS < 75 | HTS ≥ 75 | |
---|---|---|---|---|---|
One-leg stand (s) | % Δ | 80.7 | 29.3 | 182.9 | 179.9 |
Usual walking speed (m/s) | % Δ | −9.9 | −3.6 | −9.0 | −5.1 |
Maximal walking speed (m/s) | % Δ | −32.16 | −32.9 | −35.2 | −30.4 |
Sit-to-stand (repetitions) | % Δ | 3.7 | 19.3 | 2.6 | 7.7 |
TUG (s) | % Δ | −3.4 | −3.3 | −1.3 | 2.5 |
TUG with a cognitive task (s) | % Δ | 6.3 | 17.3 | 7.2 | 8.4 |
NTS = normotensive; HTS = hypertensive; TUG = Time Up and Go.
The present study aimed to investigate and compare the effects of 6 months of a MCEP on the functional and cognitive parameters of NTS and HTS patients. Furthermore, we wished to verify if age was a confounding factor in this phenomenon, affecting the capacity of HTS patients to adapt to physical stimulus.
We hypothesized that the MCEP would be able to improve functional and cognitive parameters of NTS and HTS patients, regardless of age. Nevertheless, data of the present study partially refuted our
Regarding functional capacities (Tables
However, despite these beneficial results of MCEP in NTS patients, just one study [
Even if the present study also observed improvements in balance and mobility after MCEP, indicated by one-leg stand and walking speed, respectively, increase in lower-limb muscle strength was not shown by NTS and HTS patients. Interestingly, the time of intervention in the experiment performed by de Moraes et al. [
In turn, the dissimilarities among the protocols of MCEP can be indicated as a possible factor responsible for different results observed in the comparison. In fact, muscle strength is composed basically of a morphological (i.e., muscle mass) and a neural component (i.e., muscle recruitment) [
In the present study, each session of MCEP (~48 minutes) was composed predominantly by an aerobic component, due the time of walk performed between functional exercises (~24 minutes [50%]) and the time of walk performed inside the functional exercises, since some exercises required that the volunteer translocase from one location to another for one minute. This characteristic is a possible explanation for the lack of changes in muscle strength in the present study, since aerobic stimulus requires the predominant action of slow-twitch muscle fibers (type I), which have a high capacity to keep muscle working for a long time, avoiding muscular fatigue, considering that the resistance imposed to skeletal muscle contraction occurs in a low and/or low to moderate levels. However, these fibers have low capacity to generate tension, which impairs their capacity to cause large improvement in muscle strength and muscle mass. Indeed, evidences indicate that older adults who engaged for a long time in physical exercise programs with high aerobic component show muscle strength and muscle mass values similar to sedentary matched-controls [
Furthermore, both studies, the present study and the study of de Moraes et al. [
Therefore, taken together, these data indicate that, due to the prevalence of aerobic components in the exercise session, added to an inappropriate resistance component, the protocol of MCEP used in the present study was not a profitable stimulus to elicit morphological changes in muscular architecture, as well as being able to reach a threshold necessary to cause adaptations of the neuromuscular components associated with improvement in muscle strength. However, interestingly, the lack of changes in muscle strength did not impair the improvements in the performance of usual and maximal walking speed, as well as on balance test, observed in both groups after MCEP.
In this sense, it is known that muscle power, compared with muscle strength, seems to decrease early and in a larger magnitude during aging [
Besides the functional tests, the present study also investigated the effects of MCEP on EF in NTS and HTS patients, through dual task (TUG associated with a cognitive task). EF is a cognitive capacity composed of other cognitive domains (e.g., shifting, working memory, and inhibition), which allow the subject to create, develop, and perform a strategy to perform an aim, evaluate the outcomes, and, if necessary, change the strategy during or at the end of the task, creating new strategies for the future [
Just few evidences evaluated the effect of MCEP on cognitive domains in older adults [
This study was also developed to verify if age plus pathological condition (i.e., hypertension) could be a confounding factor in the magnitude of adaptations after MCEP. Our data accepted null hypothesis and show that age did not seem to alter the response of HTS patients after MCEP. Cross-sectional studies have been discussing the possibility that HTS patients present impairment on physical function [
Plausibility besides its theory is based on the continuous vascular damage in the arteries responsible for the transport of blood to the brain areas accountable for mobility (e.g., motor cortex), which could impair muscle movement throughout time and, consequently, muscle adaptations in response to physical exercise [
However, it is important to mention that a Mann–Whitney test was performed between HTS < 75 and HTS > 75 groups to evaluate differences between functional and cognitive tests. Again, data did not demonstrate significant differences between the magnitudes of alterations. Nonetheless, the
On the other hand, NTS ≥ 75 patients did not present significant improvement in performance after MCEP. These data are complicated to be discussed, since scientific literature pointed out the possibility that HTS patients show impairment in adaptations, but not NTS. In our view, the sample size (
Other potential limitations of our study should be mentioned. The present study has a quasi-experimental design. Therefore, inherent characteristics of this kind of approach, as the lack of randomization and the absence of a control group (sedentary NTS and HTS), must be assumed. Moreover, future studies that aim to use MCEP should increase the number of sets of resistance training in the protocol, since this approach can collaborate to increase in the magnitude of alterations after MCEP, mainly in muscle strength. Due to all the aforementioned data, which highlight the importance of muscle power in the context of aging and functional capacity, the measurement of dynamic muscle power should be added in the methodology. However, the present study indicates that this model of MCEP should be studied in better design models of scientific studies (i.e., clinical randomized trial). Lastly, more information about the cognitive status and level of education of the volunteers of the present study was not collected. These data are important and could collaborate to a better explanation about the results shown in the present study.
Therefore, the present study indicates that a 6-month MCEP is able to increase equally balance (i.e., one-leg stand test) and mobility (i.e., usual and maximal walking speed test) in NTS and HTN adults. Therefore, aging did not seem to be a confounding factor, impairing the capacity of older HTS patients to adapt to physical stimulus. Thus, the current data indicate that this MCEP can be used to improve muscle functionality of several hypertensive patients, independently of age. This seems to be a good option to public health programs that have the necessity to offer short-time services to several patients in the same time.
The authors alone are responsible for the content and writing of the paper
The authors report no conflicts of interest.
All authors participated in the development of the research project, analysis and interpretation of the data, and preparation of the manuscript.
The authors are grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for funding this research via scholarships to Hélio José Coelho Junior and Ricardo Yukio Asano. Bruno Rodrigues had financial support from the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and CNPq (BPQ). The authors are also grateful to Daisy dos Reis and Flávio Romano of the facility for older adults and all researchers of the Research Group on Chronic-Degenerative Diseases of Mogi das Cruzes University (Grupo de Pesquisa em Doenças Crônico-Degenerativas da Universidade de Mogi das Cruzes (GEDCD/UMC)) for their support.