ACUTE AND CHRONIC CARDIOVASCULAR RESPONSE TO

16 WEEKS OF COMBINED ECCENTRIC OR TRADITIONAL

RESISTANCE AND AEROBIC TRAINING IN ELDERLY
HYPERTENSIVE WOMEN: A RANDOMIZED
CONTROLLED TRIAL
EDUARDO S. DOS SANTOS,1 RICARDO Y. ASANO,1 IRÊNIO G. FILHO,2 NILSON L. LOPES,2,3
PAULO PANELLI,2 DAHAN DA C. NASCIMENTO,1 SCOTT R. COLLIER,4 AND JONATO PRESTES1
Downloaded from https://journals.lww.com/nsca-jscr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkCPx9u3XmXKg11xMiEg4PP81mb+soKxWH0jxUv06U+7pQ== on 10/11/2018

1
Graduate Program on Physical Education, Catholic University of Brasilia, Brasilia, Brazil; 2Research Group in Exercise
Physiology (GEFEFIS), North-Northeast Cardiology Institute, Bahia, Brazil; 3Dom Pedro of Alcantara Hospital, Bahia,
Brazil; and 4Vascular Biology and Autonomic Studies Laboratory, Appalachian State University, Boone, North Carolina

ABSTRACT
dos Santos, ES, Asano, RY, Filho, IG, Lopes, NL, Panelli, P,
Nascimento, DdaC, Collier, SR, and Prestes, J. Acute and
chronic cardiovascular response to 16 weeks of combined
eccentric or traditional resistance and aerobic training in
elderly hypertensive women: A randomized controlled trial.
J Strength Cond Res 28(11): 3073–3084, 2014—Both aero-
bic (AT) and resistance training (RT) are recommended as
nonpharmacological treatments to prevent hypertension. How-
ever, there is a paucity of literature investigating the effects of
combined exercise modes (RT combined with AT) in elderly
hypertensive women. Thus, our aim was to compare the post-
exercise hypotension (PEH) response to both protocol models
and to assess the correlation between the degree of PEH after
ERT +54% and TRT +35%; p = 0.001 for both) and leg press
1RM (combined ERT +52% and TRT +33%; p = 0.001 for
both). The magnitude of decrease in SBP after acute exercise
was moderately correlated with the drop in SBP after chronic
training for the ERT combined with AT group (r = 0.64). Both
combined training protocols are effective in promoting benefits
in health-related factors (HDL, SBP, DBP, and 1RM). Consid-
ering the lower cardiovascular stress experienced during com-
bined ERT, this type of training seems to be the most suitable
for elders, deconditioned individuals, and hypertensives.
KEY WORDS blood pressure, hypertension, strength training,
postexercise hypotension, cardiovascular risk factors
INTRODUCTION

acute and chronic training. Furthermore, we also compared
several biochemical variables for each training group. Sixty
hypertensive older women were randomly assigned into non-
exercised control (no systematic exercise training throughout
the study), eccentric RT (ERT), and traditional RT (TRT). The
training programs consisted of 16 weeks of RT combined with
AT. Blood pressure (BP), biochemical profiles, and 1 repetition
maximum (1RM) were evaluated. There was a significant
increase in high-density lipoprotein (HDL) after both training
regimens pre- to posttraining (combined ERT +5% and TRT
+7%; p = 0.001 for both). There was a decrease in systolic BP
(SBP) (combined ERT 219% and TRT 221%; p = 0.001 for
both) and diastolic BP (DBP) (213% for both; p = 0.001 for
both). There was an increase in bench press 1RM (combined
Address correspondence to Dr. Jonato Prestes, jonatop@gmail.com.
28(11)/3073–3084
Journal of Strength and Conditioning Research
Ó 2014 National Strength and Conditioning Association
H
ypertension is a complex, multifactorial disease
characterized by high blood pressure (BP) levels
($140/90 mm Hg) with unknown specific
underlying causes. Associated risk factors
include age, overweight, insulin resistance, diabetes, race,
smoking status, socioeconomic levels, and hyperlipidemia
(23,33). Data from the National Center of Health Statistics
(10) have shown that the age-adjusted prevalence of hyper-
tension (both diagnosed and undiagnosed) from 2003 to
2006 was 75% for older women and 65% for older men,
demonstrating that, with age, women catch and surpass
men in the incidence of hypertension. Because hypertension
is a key factor in the development of cardiovascular disease
(CVD), which is the largest reported cause of death globally,
these data punctuate the need for effective treatments. Urban
Brazil is a unique location to study this disease because 68%
of the elderly population present with hypertension (27).
Although pharmacological therapy is commonly used to
treat elderly pre- to hypertensive patients, nonpharmaco-
logical strategies, including lifestyle modifications such as

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 Resistance Training in Elderly Hypertensive Women
physical activity, have been shown to be beneficial (28).
Among lifestyle modifications, guidelines predominantly
recommend aerobic training (AT) for lowering BP (43),
although both resistance training (RT) and AT can promote
substantial benefits of physical fitness and health-related fac-
tors, such as BP, serum lipids, glucose metabolism, cardiac
autonomic function, and muscular strength (8,9,18,29).
Moreover, postexercise hypotension (PEH) is claimed to
promote cardiovascular protection because of a significant
reduction in BP during the recovery period (40,41). Interest-
ingly, the degree of acute systolic and diastolic PEH was
associated with the magnitude of resting BP reduction after
8 weeks of AT at 65% of maximum oxygen consumption.
Furthermore, acute bouts of RT have been shown to elicit
a greater PEH when compared with AT, which may be
because of greater increases in peripheral blood flow; how-
ever, little is known regarding the potential differences in
outcomes from RT training modes (6).
Eccentric RT (ERT) has been shown to stimulate muscle
growth and allows a higher force production compared with
concentric training, maximizing the structural and functional
muscle responses at the lowest metabolic cost to the
individual. This is particularly interesting for frail elderly
individuals with low muscular and cardiorespiratory fitness,
especially because RT has also been shown to benefit
individuals with osteoporosis (15). Despite the potential of
RT for lowering BP (9), no randomized controlled trial has
investigated the effects of ERT combined with AT on acute
and chronic PEH in older hypertensive women. In addition,
some parameters, such as antihypertensive medications, age,
degrees of hypertension, and association between the mag-
nitude of PEH and chronic BP reductions in response to
different protocols of RT combined with AT, remain to be
determined. Nevertheless, we chose a combined training for
our experimental design because it has been shown to
induce greater benefits for weight loss, fat loss, and cardio-
respiratory fitness than AT and RT modalities alone (14,37).
In addition, because some people may have difficulty finding
time to exercise, it is important to combine the benefits of
AT and RT.
Thus, the aim of this study was twofold: (a) to compare
the PEH response to ERT and traditional RT (TRT)
combined with AT and (b) to assess the correlation between
the degree of hypotension in response to acute exercise and
the magnitude of change in resting BP. A secondary goal was
to compare chronic alterations in muscular strength and
biochemical profile in response to both regimens to under-
stand the causal mechanisms involved with our findings. We
hypothesized that both protocols would induce PEH and
the magnitude of change (D) in BP reduction after acute
exercise would correlate with the BP reduction after chronic
combined training. We also expected ERT combined with
AT to induce higher gains in muscular strength with similar
modifications in biochemical profile when compared with
TRT combined with AT.
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3074 Journal of Strength and Conditioning Research
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METHODS
Experimental Approach to the Problem
This was a randomized controlled trial designed to compare
the effects of combined ERT and TRT on BP and bio-
chemical profile in elderly hypertensive women. Both
training regimens included 20 minutes of AT plus whole
body RT performed during 16 weeks. Independent variables
were the training regimens, and the dependent variables
were BP, muscular strength, and biochemical parameters.
We also tested the correlation between acute BP responses
and the chronic decrease in BP. Combined training was
chosen because it has been shown to maximize improve-
ments in cardiovascular and health-related biochemical
parameters. Moreover, ERT was included because of its
proposed suitability for frail and diseased individuals.
Subjects
A total of 60 elderly female patients age 60–65 years with
essential hypertension were recruited and randomly assigned
to 1 of the 3 experimental groups: TRT combined with AT,
ERT combined with AT, or a nonexercised control group
with no systematic exercise training throughout the study
(C). Each patient completed a thorough physical examination
including a medical history screening, resting and exercise
electrocardiogram, manual BP measurement and anthropo-
metric and orthopedic evaluation before participation in the
study. All patients were classified with hypertension stage 1 or
2 according to the Seventh Report of the Joint National Com-
mittee on Prevention, Detection, Evaluation and Treatment of
High Blood Pressure (4) and were evaluated by an experi-
enced cardiologist. Participants were classified as sedentary
and untrained according to the International Physical Activity
Questionnaire (22) and the American College of Sports Med-
icine guidelines (2). Subjects with physical disabilities, diagno-
sis of diabetes, CVDs, hypertension (systolic blood pressure
[SBP] .180 mm Hg and diastolic blood pressure [DBP]
.110 mm Hg), musculoskeletal disease, or who smoked or
abused drugs/alcohol were excluded from the trial. This study
was approved by the Institutional Ethics Committee of
the Catholic University of Brası́lia (protocol 253/11) and
conformed to the Helsinki Declaration on the use of human
subjects for research. All subjects were informed of the pro-
cedures and provided a written informed consent to partici-
pate in the study.
Protocol
A randomized controlled trial study was carried out. Initially,
participants completed medical, anthropometric, body com-
position, and hemodynamic evaluations and 2 weeks of
familiarization to the exercises. After the familiarization
period, participants completed the 10 repetitions maximum
(10RM) testing in each exercise and were randomly assigned
to TRT or ERT combined with AT with 3 sessions per week
for 16 weeks. The hemodynamic parameters were evaluated
pre-exercise, 15, 30, 45, and 60 minutes after the first and last
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training session. All sessions were performed at the same instructed about maintaining proper exercise technique and
period of the day (between 10 AM and noon) to avoid any body position; (d) consistent verbal encouragement was
influence of the circadian rhythm on the measured cardio- provided during the testing procedures to all subjects. All
vascular variables. testing sessions were scheduled between the hours of 10:00 AM
and noon to avoid diurnal variation.
Familiarization and One Repetition Maximum and Ten
Combined Resistance and Aerobic Training Programs
Repetitions Maximum Tests
The selection of the periodization programs was based on
To avoid any influence of anxiety on BP and to ensure proper
the results of previous investigations (25,30,36). Participants
exercise form, all study participants completed 2 weeks of
initiated the training 72 hours after the 10RM tests and
familiarization before the beginning of the training programs,
completed 3 weekly training sessions for 16 weeks on Mon-
consisting of 1 exercise for each main muscle group with sets
days, Wednesdays, and Fridays. Traditional RT was per-
of 10–12 submaximal repetitions at 70% of estimated 10RM
formed as follows: weeks 1–5 at 70% of 10RM, weeks 6–11
with 1-minute rest intervals between sets and exercises. In this
at 80% of 10RM, and weeks 12–16 at 90% of 10RM, always
period, individuals were advised regarding proper RT tech-
performing 3 sets of 10 repetitions. The mean duration to
nique. After the familiarization period, 1RM tests were per-
complete 1 repetition was 3–4 seconds (both concentric and
formed on 2 different days separated by a minimum of 72
eccentric phases of the movement), whereas in the ERT the
hours. All tests were performed with 10-minute rest intervals
duration was 2–3 seconds. Loads for 10RM were updated
between each exercise. The testing order for the 458 leg press
every 4 weeks. Submaximal loads were chosen to avoid the
and barbell bench press RT exercises was random. The pro-
exacerbation of the hemodynamic response and/or Valsalva
tocol consisted of a light warm-up of 10 minutes of treadmill
maneuver, as there were no clinical intercurrences through-
walking followed by 8 repetitions at 50% of estimated 1RM
out the training period in these hypertensive women (35).
(according to the participants’ capacity verified in the 2 weeks
Progression for the ERT group was as follows: weeks 1–5 at
of familiarization). After a 1-minute rest, subjects performed
100% of 10RM, weeks 6–11 at 110% of 10RM, and weeks
3 repetitions at 70% of the estimated 1RM. After 3 minutes
12–16 at 120% of 10RM with 3 sets of 10 eccentric repeti-
of rest, participants completed 3–5 attempts interspersed with
tions. During ERT, the concentric phase of the movement
3- to 5-minute rest intervals, with progressively heavier weights
was completed by the strength and conditioning profes-
(;5%) until the 1RM was determined. A high intraclass cor-
sional, and the subject was only allowed to perform the
relation coefficient (ICC) was found for both exercises (R =
eccentric action. Training sessions lasted approximately
0.98). The range of motion and exercise technique were stan-
50–60 minutes, and cardiovascular parameters were moni-
dardized according to the descriptions of Tibana et al. (40).
tored during this time. No clinical outcomes during exercise
During the following week, 10RM tests and retests were
sessions were reported. Resistance exercises for both training
performed to determine the exact training load for each
programs were barbell bench press, 458 leg press, trunk
exercise on 2 nonconsecutive days with 72 hours between
extension, leg extension, arm curl, dorsiflexion, and lateral
tests. The 10RM tests were randomly performed to avoid an
raise. Rest intervals were fixed at 60 seconds between sets
effect of exercise order for the following exercises: barbell
and 90 seconds between exercises.
bench press, 458 leg press, trunk extension, leg extension,
After each RT session, individuals completed 20 minutes
arm curl, dorsiflexion, and lateral raise (Johnson, Cottage
of AT on a treadmill (Movement-PRO 150, Sao Paulo,
Grove, WI, USA). Before testing, subjects walked at a low
Brazil) at 65–75% of their estimated target heart rate (THR)
intensity for 5 minutes on a treadmill. The 10RM testing
as determined by the equation: THR = % (HRmax 2
procedures progressed as follows: (a) warm-up on each exer-
HRrest) + HRrest (17), where % = selected work percentage,
cise with 5–10 submaximal repetitions using a light load
HRmax = maximal heart rate, and HRrest = resting heart
(60% of the predicted 10RM); (b) 1-minute rest and load
rate. Heart rate (HR) was monitored in all training sessions
increments of 5–10% until the 10RM was found within 3–5
using a HR monitor. The estimated HRmax was calculated
attempts, using 3- to 5-minute rest intervals between them;
by the equation: HRmax = 208 2 (0.7 3 age) (39).
(c) subjects were instructed to lift and lower the load at
a constant velocity, taking approximately 2 seconds for each Hemodynamic Measurements
phase of the movement; (d) 10 repetitions were recorded, The SBP, DBP, and pulse pressure (PP) were measured and
with the maximal load determined by the last successful set calculated with an oscillometric device (Microlife 3AC1-1,
of repetitions, with individual supervision (42). Test/retest Widnau, Switzerland) according to the recommendations of
reliability for the 10RM was performed and a high ICC the Seventh Report of the Joint National Committee on
was found (R = 0.98) for all tested exercises. Prevention, Detection, Evaluation and Treatment of High
The following strategies were adopted to minimize testing Blood Pressure (4). The cuff size was adapted to the circum-
errors: (a) all subjects participated in a familiarization period ference of the arm of each patient according to the manufac-
before testing; (b) standardized instructions were provided to ture’s recommendations. Heart rate was measured using a HR
all subjects before the tests; (c) subjects were carefully monitor (Polar S810i; Polar Electo Oy, Kempele, Finland).

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 Resistance Training in Elderly Hypertensive Women

All BP measures were assessed in triplicate (measurements
separated by 1 minute; r = 0.98 for all measures) with the
mean value used for analysis. The hemodynamic measure-
ments were performed after 10 minutes of seated rest and at
15, 30, 45, and 60 minutes (times 1, 2, 3, and 4, respectively)
after the control or exercise sessions. The acute response was
analyzed in the first training session after familiarization to
RT and strength tests, whereas the chronic hypotension was
measured after the last training session. All measures of BP
were taken during 10 AM to noon to minimize diurnal BP
variability. During BP measurements, participants remained
seated quietly under a controlled room temperature. Partic-
ipants were advised to maintain their habitual activities and
diet (this was guaranteed by a dietary recall follow-up),
refrain from programmed exercise, and avoid smoking, alco-
hol and caffeine consumption.
Anthropometric and Body Composition Evaluation
Height and weight were measured and allowed the calcula-
tion of the body mass index. All circumferences were obtained
in triplicate using a nonelastic tape measure and averaged to
determine the final reported circumference. Body adiposity
index (BAI) was determined by the following formula: BAI =
(hip circumference)/([height 3 1.5] 2 18) (3).
Biochemical Parameters
Biochemical parameters were measured before and after
16 weeks of training. Briefly, participants reported to the
laboratory between 08:00 and 10:00 AM, after an overnight fast,
for blood withdrawal from the antecubital vein. Plasma trigly-
cerides and glucose levels were measured by enzymatic
CHOP-POD and Hexokinase methods, respectively. Total cho-
lesterol, high-density lipoprotein (HDL), and LDL were mea-
sured by the Automation Method. The turbidimetric method
with particles intensification reaction was used to measure
C-reactive protein with a spectrophotometer Cobas Mira Plus
(Roche Diagnostic, GmBH, Mannheim, Germany), calibrator
and control serum Biosystem (Bayer Diagnostics, Emeryville,
CA, USA). Creatinine was determined by the kinetic enzymatic
method by using the same spectrophotometer.
Statistical Analyses
Considering a power of 85% and an alpha error of 0.05 and
assuming a standard deviation of 5 mm Hg, the sample size
necessary to detect a mean decrease of 4 mm Hg in SBP and
DBP was calculated to be 60 individuals. For analyses of
normality and homogeneity, the Shapiro-Wilk and Levene
tests were used, respectively. To examine the response of the
biochemical and hemodynamic variables to the chronic
exercise intervention, an analysis of variance (ANOVA) (3 3
2, groups 3 moments [pre- and post-16 weeks]) was used.
For the strength variable 1RM, an ANOVA (2 3 2, group 3
moments [pre- and post-16 weeks]) was performed, and for
the area under the curve (AUC) hemodynamic variables, an
ANOVA (3 3 4, groups 3 time [time 1, time 2, time 3, and
time 4]) was conducted (1). When differences were indicated
between groups and moments, post hoc comparisons were
applied (11,12). For effect size calculation, the following
formula was applied: (pretest mean 2 posttest mean)/mean
of both SD (12). For determination of the magnitude of
effect sizes, we considered the following values for untrained
individuals: trivial (,0.50), small (0.50–1.25), moderate (1.25–
1.9), and large (.2.0) (34). To calculate the variations
within individuals, the coefficient of variation was used:
CV% = (SD/mean) 3 100.

TABLE 1. Subject characteristics.*

Variables C (N = 20) ERT (N = 20) TRT (N = 20)

Age (y) 63.1 (2.3) 64.2 (3.1) 62.6 (2.5)

Body mass (kg) 69.87 (11.90) 66.51 (13.93) 67.21 (11.18)
Height (m) 1.55 (0.04) 1.54 (0.05) 1.53 (0.05)
Body mass index (kg$m22) 28.98 (4.36) 27.79 (4.73) 28.47 (4.40)
Body adiposity index (%) 29.96 (5.66) 24.21 (2.61) 26.59 (4.59)
Waist (cm) 94.55 (9.24) 93.35 (11.56) 93.80 (10.40)
Hip (cm) 100.05 (13.84) 97.70 (6.76) 102.55 (9.77)
Neck (cm) 33.99 (3.63) 34.51 (2.55) 34.35 (2.80)
Waist-to-hip ratio 0.97 (0.25) 0.95 (0.07) 0.91 (0.08)
Systolic blood pressure (mm Hg) 160.70 (9.12) 162.70 (7.81) 163.05 (4.43)
Diastolic blood pressure (mm Hg) 89.85 (4.81) 85.50 (4.26)† 88.80 (3.60)
Medications (%)
Angiotensin-converting enzyme inhibitors 9 6 5
Angiotensin receptor blockers 6 5 10
Dihydropyridine calcium channel blockers 4 8 5

*Data are expressed by means and SD. N = sample number; C = control group; TRT = traditional resistance training; ERT =
eccentric resistance training.
†Significantly different from the C group and TRT (#0.05).

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 TABLE 2. Blood pressure and muscle strength at baseline and 16-week follow-up.*

SBP (mm Hg) DBP (mm Hg) PP (mm Hg)

PRE Post PRE Post PRE Post

Control group 160.70 (9.13) 162.55† (8.94) 89.85 (4.82) 90.10 (4.53) 70.85 (9.66) 72.45† (9.86)
CV% 2.68 5.50 5.36 5.03 13.65 13.61
ES 0.14 0.04 0.11
ERT group 166.05 (8.06) 135.20†z (8.80) 90.15 (4.26) 78.30†z§ (4.39) 75.90 (7.76) 56.90†z (8.40)
CV% 4.85 6.51 4.72 5.61 10.22 14.76
ES 2.48 1.84 1.59
TRT group 167.60z (4.31) 132.50†z§ (7.96) 91.25 (3.55) 79.20†z (3.17) 76.35 (5.05) 53.30†z§ (8.27)
CV% 2.57 6.01 3.89 4.01 6.61 15.51
ES 4.24 2.35 2.51

Bench press (kg) 458 leg press (kg)

PRE Post PRE Post

Control group
CV%

Journal of Strength and Conditioning Research

the
ES
ERT group 15.90 (1.48) 24.05†z§ (1.72) 69.00 (4.21) 105.15†z§ (4.00)
CV% 9.33 7.17 6.09 3.81
ES 3.48 5.82
VOLUME 28 | NUMBER 11 | NOVEMBER 2014 |

TRT group 16.20 (1.28) 21.88† (1.23) 68.25 (5.40) 90.80† (6.04)
CV% 7.91 5.64 7.91 6.65
ES 2.99 2.68

*Data are expressed by means and SD. TRT = traditional resistance training; ERT = eccentric resistance training; SBP = systolic blood pressure; DBP = diastolic blood pressure;
PP = pulse pressure; CV = coefficient of variation; ES = effect size.
†Differences within groups pre vs. post (#0.05).
zDifferences between eccentric vs. control at the same time point (#0.05); differences between traditional vs. control at the same time point (#0.05); differences between
eccentric vs. traditional at the same time point (#0.05).
§Significant exercise group 3 time interaction (#0.05).

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 Resistance Training in Elderly Hypertensive Women

Figure 1. Representation of the area under the curve (AUC) for SBP and diastolic blood pressure (DBP). zLower than control group at the same time point
(,0.05); †lower than pretraining values (time 1) (,0.05) time 1, 15 minutes after exercise; time 2, 30 minutes after exercise; time 3, 45 minutes after exercise;
time 4, 60 minutes after exercise.

The change in BP after acute exercise was calculated using Adherence to the training sessions was determined by
2 methods: (a) magnitude of BP was determined as the dividing the number of exercise sessions completed by the
difference between pre-exercise BP and the lowest BP in the total number of exercise sessions. Linear regression analyses
postexercise time period; (b) AUC quantified the difference were used to assess the relationship between the change in
between pre-exercise BP and postexercise BP during a period BP reduction after acute and chronic exercise. Correlation
of 60 minutes. The trapezoidal method was used by dividing coefficient values between 60.1 and 6 0.3, 60.4 and 6 0.6,
the postexercise period into 4 moments (time 1, time 2, time and .0.7 were considered weak, moderate, and strong,
3, and time 4) and summing the values as indicated in the respectively (12). An alpha level of #0.05 was considered
following formula (31): significant, and p values presented are 2-sided. Data are
. reported as mean 6 SD. All analyses were conducted with
AUCðmm  Hg$min21 Þ ¼ ðm0 þ m1 Þ3t1 2 SPSS version 18.0 (SPSS, Inc., Chicago, IL, USA).
.
RESULTS
þ ðm1 þ m2 Þ3t2 2
. From 75 recruited participants, only 60 subjects completed
þ ðm2 þ m3 Þ3t3 2 the study. The individuals who did not complete the study
. were disqualified because they failed to meet the study’s inclu-
þ ðm3 þ m4 Þ3t4 2: sion criteria for age (n = 6), resting BP (n = 4) or medical
history (n = 3), or they declined
because of personal reasons (n
= 2). The adherence to the
TABLE 3. Hypotension after acute and chronic exercise.* training sessions was .95%.
There were no adverse cardio-
Acute exercise Posttraining vascular responses to exercise
Control testing or training. No modifica-
DSBP (mm Hg) 0.21 (0.59) 0.31 (0.64) tions for medications (doses,
DDBP (mm Hg) 0.89 (0.91) 0.77 (1.17) types, etc.) were observed over
Eccentric resistance training the 16-week program. Subject
DSBP (mm Hg) 24.01 (0.37)† 26.94 (0.2)†z§
DDBP (mm Hg) 24.93 (0.98)† 212.03 (1.23)†z§ characteristics are summarized
Traditional resistance training in Table 1. There was no signif-
DSBP (mm Hg) 22.52 (0.38)† 24.17 (0.57)†§ icant difference between the
DDB (mm Hg) 24.17 (0.57)† 28.12 (1.10)†§ groups for body mass (F(2.57),
0.40, p = 0.66), height (F(2.57),
*Data are expressed by mean and SD. SBP = systolic blood pressure; DBP = diastolic
blood pressure. 0.45, p = 0.63), body mass index
†Differences between traditional and eccentric vs. control at the same time point (,0.01). (F(2.57), 0.34, p = 0.70),
zSignificant exercise group 3 time interaction (,0.01).
§Differences within groups pre vs. post (,0.01). BAI (F(2.57), 1.47, p = 0.23),
waist (F(2.57), 0.06, p = 0.93),
hip (F(2.57), 1.06, p = 0.35),
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Figure 2. The magnitude of change in systolic blood pressure (SBP) and diastolic blood pressure (DBP) after acute and chronic exercise. The magnitude of
change (D) in SBP after acute exercise was significantly correlated with the magnitude of change in resting SBP after chronic exercise for the eccentric group
(r = 0.64, p = 0.002, 0.9 6 0.253 [b 6 SE]). For the other analyses, the magnitude of changes in SBP and DBP after acute exercise was not significantly
correlated with the magnitude of changes in resting SBP and DBP after chronic exercise.

neck circumferences (F(2.57), 0.15, p = 0.85), waist-to-hip ratio
(F(2.57), 0.64, p = 0.52), and SBP (F(2.57), 0.58, p = 0.55). The
combined ERT group presented a lower DBP when compared
with C and TRT groups (F(2.57), 5.6, p = 0.006).
Hemodynamic Variables
There were significant group 3 time interactions for SBP
(Table 2). Both combined TRT (F(2.57) = 75.17, p = 0.001)
and ERT (F(2.57) = 75.17, p = 0.001) groups decreased SBP
after 16 weeks as compared with the C group. Additionally,
combined ERT (t(19) = 34.01, p = 0.001) and TRT (t(19) =
23.75, p = 0.001) groups decreased SBP after 16 weeks as
compared with the pre-intervention value, whereas the con-
trol group presented an increase of SBP after 16 weeks as
compared with initial values (t(19) = 5.28, p = 0.001). There
was a more pronounced drop in SBP for the combined TRT
group (F(2.114) = 63.32, p = 0.001) as compared with ERT.
Group 3 time interactions were also found for DBP and
PP, as both combined TRT (F(2.57) = 51.92, p = 0.001;
F(2.57) = 26.32, p = 0.001, respectively) and ERT groups
(F(2.57) = 51.92, p = 0.001; F(2.57) = 26.32, p = 0.001,
respectively) displayed lower values of DBP and PP as com-
pared with the C group. Moreover, combined TRT (t(19) =
46.62, p = 0.001; t(19) = 13.73, p = 0.001, respectively) and
ERT groups (t(19) = 29.60, p = 0.001; t(19) = 19.79, p = 0.001,
respectively) decreased DBP and PP posttraining as com-
pared with pre-intervention. The combined ERT group
exhibited a more pronounced drop in DBP as compared
with the TRT group (F(2.114) = 28.68, p = 0.001). However,
combined TRT induced a higher drop in PP (F(2.114) =
25.25, p = 0.001) vs. ERT.
Area Under the Curve: Acute Exercise
For DBP, the combined ERT (F(2.57) = 30.59, p = 0.001)
and TRT groups (F(2.57) = 30.59, p = 0.001) revealed lower
values at time 2 when compared with the C group. There
were differences within groups at the time 3 for SBP and
DBP, as indicated by the lower values at time 3 compared

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 3080

Resistance Training in Elderly Hypertensive Women

Journal of Strength and Conditioning Research
the

TABLE 4. Biochemical parameters at baseline and 16-week follow-up.*

TC (mg$dl21) LDL (mg$dl21) TG (mg$dl21) CRP (U$L21)

PRE Post PRE Post PRE Post PRE Post

Control group 201.30 (23.30) 206.50 (29.97) 129 (38.46) 130 (38.21) 141.75 (36.51) 144.35 (34.10) 0.61 (0.22) 0.77 (0.61)
CV% 11.58 14.51 29.81 29.20 25.75 23.62 36.47 80.01
ES 0.14 0.03 0.05 0.29
ERT group 209.50 (27.31) 193.70 (20.99) 149.25 (26.22) 140.85 (23.25) 156.15 (38.15) 143.95 (32.76) 0.80 (0.36) 0.69 (0.35)
CV% 13.04 10.84 17.57 16.51 24.43 22.75 44.86 51.09
ES 0.42 0.22 0.22 0.20
TRT group 211.65 (20.20) 195.80 (25.77) 148.60 (34.40) 139.10 (27.97) 157.45 (33.11) 147.60 (27.83) 0.87 (0.38) 0.78 (0.37)
CV% 9.54 12.90 23.15 20.11 21.03 18.86 43.79 46.69
TM

ES 0.48 0.20 0.21 0.12

Glucose (mg$dl21) Creatinine (mg$dl21) HDL (mg$dl21)

PRE Post PRE Post PRE Post

Control group 86.50 (20.65) 88.20 (20.12) 0.74 (0.12) 0.77 (0.11) 52.75 (4.89) 54.30 (11.01)
CV% 23.87 22.81 16.64 14.24 9.26 20.27
ES 0.06 0.14 0.15
ERT group 90.90 (12.55) 83.25 (7.49) 0.70 (0.13) 0.65† (0.13) 50.60 (3.50) 53.25z (3.64)
CV% 13.80 9.00 18.53 19.98 6.92 6.84
ES 0.47 0.25 0.38
TRT group 91.80 (13.97) 85.40 (9.48) 0.82§ (0.09) 0.78§ (0.07) 51.70 (6.74) 55.45z (4.80)
CV% 15.22 11.10 10.61 8.86 13.03 8.65
ES 0.34 0.36 0.41

*Data are expressed by mean and SD. TRT = traditional resistance training; ERT = eccentric resistance training; TC = total cholesterol; LDL = low-density lipoprotein; TG =
triglycerides; HDL = high-density lipoprotein; CRP = C-reactive protein; ES = effect size; CV = coefficient of variation.
†Differences between eccentric vs. control group at the same time point (#0.05).
zDifferences within groups pre vs. post (#0.05).
§Differences between traditional vs. eccentric at the same time point (#0.05).

Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.

with time 1 for combined TRT and ERT groups (F(3.228) =
3.06, p = 0.029). For the SBP at time 3, the combined ERT
group (F(2.57) = 4.50, p = 0.015) demonstrated lower values
when compared with C group, but no differences were
found between TRT and C groups. Additionally, DBP dis-
played lower values for the combined ERT (F(2.57) = 38.10,
p = 0.001) and TRT groups (F(2.57) = 38.10, p = 0.001) at
time 3 when compared with the C group. At time 4, the
combined ERT group (F(2.57) = 3.29, p = 0.039) demon-
strated lower values of SBP when compared with C group,
but no differences were found between TRT and C groups.
The combined ERT (F(2.57) = 30.31, p = 0.001) and TRT
groups (F(2.57) = 30.31, p = 0.001) demonstrated lower DBP
at the time 4 when compared with the C group (Figure 1).
Area Under the Curve: Chronic Exercise
There were differences between groups at time 2 for SBP
and DBP, which were revealed by the lower values of SBP
and DBP for the combined ERT (F(2.57) = 79.86, p = 0.001;
F(2.57) = 30.31, p = 0.001, respectively) and TRT groups
(F(2.57) = 79.86, p = 0.001; F(2.57) = 30.31, p = 0.001,
respectively) as compared with C group (Figure 1). Systolic
BP was decreased at time 3 vs. time 1 for the combined TRT
and ERT groups (F(3.228) = 3.10, p = 0.027). Diastolic BP
was decreased at time 2, time 3, and time 4 vs. time 1 for the
combined TRT and ERT groups (F(3.228) = 5.77, p = 0.001).
Moreover, DBP was reduced at time 3 for the combined ERT
(F(2.57) = 129.52, p = 0.001) and TRT groups (F(2.57) =
129.52, p = 0.001) as compared with the C group. A difference
between groups was also found at time 4, revealed by the
decreased values of SBP and DBP for the combined ERT
(F(2.57) = 86.64, p = 0.001; F(2.57) = 127.40, p = 0.001, respec-
tively) and TRT groups (F(2.57) = 86.64, p = 0.001; F(2.57) =
127.40, p = 0.001) as compared with the C group (Figure 1).
Group 3 time interactions were also found for the mag-
nitude of decrease in SBP and DBP (F(2.114) = 84.79, p =
0.001; F(2.114) = 116.60, p = 0.001, respectively), as both
combined TRT and ERT groups (F(2.57) = 437.30, p = 0.001;
F(2.57) = 211.28, p = 0.001, respectively) displayed lower
values of SBP and DBP as compared with the C group both
pre- and postintervention. Moreover, combined TRT and
ERT groups (t(19) = 11.80, p = 0.001; t(19) = 32.99, p =
0.001, respectively) decreased SBP and DBP posttraining
as compared with pre-intervention. There was a type of
training effect on SBP and DBP, revealed by the most pro-
nounced drop observed for the combined ERT group as
compared with the TRT group (F(2.114) = 84.79, p =
0.001; F(2.114) = 116.60, p = 0.001, respectively; Table 3).
The greatest reduction in DSBP after acute exercise was
moderately correlated with the chronic reduction in DSBP
(r = 0.64, p = 0.002; Figure 2) only for the combined ERT
group. There were no additional correlations for the acute
changes in DSBP and DDBP with the magnitude of changes
in resting SBP and DBP after chronic exercise (p . 0.05;
Figure 2).
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Muscular Strength
There were group 3 time interactions for bench press and
458 leg press 1RM, as combined ERT (t(19) = 55.99, p =
0.001; t(19) = 78.51, p = 0.001, respectively) and TRT groups
(t(19) = 44.65, p = 0.001; t(19) = 47.65, p = 0.001, respectively)
increased muscular strength as compared with pretraining
values, although the combined ERT increased by a higher
amount as compared with the TRT group (t(38) = 4.58, p =
0.001; t(38) = 8.85, p = 0.001, respectively; Table 2).
Biochemical Response to Chronic Exercise
There were no training effects or group 3 time interactions
on total cholesterol, LDL, TG, C-reactive protein, and glu-
cose (p . 0.05; Table 4). There were differences between
groups for creatinine, where the combined ERT group dem-
onstrated lower values than the C group (F(2.57) = 8.23, p =
0.005) and TRT (F(2.57) = 8.23, p = 0.002) after 16 weeks.
Additionally, the combined TRT group demonstrated higher
values of creatinine as compared with the ERT before the
intervention (F(2.57) = 5.53, p = 0.006). There was a differ-
ence within groups for HDL, indicating that both training
regimens induced an increase in HDL after 16 weeks (ERT
[t(19) = 24.7, p = 0.001] and TRT [t(19) = 25.07, p = 0.001]).
DISCUSSION
To the best of our knowledge, this is the first study to
compare the acute and chronic effects of TRT and ERT
protocols combined with AT on BP, biochemical variables,
and muscular strength in older hypertensive women. We
also investigated the correlation between the degree of PEH
with acute exercise and the magnitude of change in resting
BP after chronic training. The greatest finding of the study
was that both RT protocols induced a decrease in SBP, DBP,
and PP, whereas only the ERT combined with AT group
exhibited a correlation between the acute hypotension and
the chronic decrease of SBP. Moreover, both training
regimens improved HDL levels, whereas only the ERT
combined with AT group decreased creatinine values as
compared with the control group. There was also an
increase in upper- and lower-body muscular strength, with
superior results for the combined ERT group.
In this study, SBP, DBP, and PP were reduced following
both chronic TRT and ERT protocols combined with AT in
hypertensive older women. This is in accordance with
previous studies (9,38), demonstrating that dynamic RT
combined with AT can lower BP and also be used as pre-
vention against stroke (20). Mota et al. (24) found that
a whole-body RT program consisting of 3 sets of 8–12 rep-
etitions at 60–80% of 1RM resulted in a significant PEH in
elderly hypertensive women during the second, third (SBP),
and fourth (DBP) months of training. Additionally, resting
BP was significantly reduced after 16 weeks of training.
However, Mota et al. (24) used only TRT, whereas this study
compared combined TRT with combined ERT. Our data
reinforce that combined ERT can be used as a safe RT
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 Resistance Training in Elderly Hypertensive Women
method to chronically decrease BP in elderly hypertensive
women. Interestingly, it has been proposed that ERT pro-
vides more intense muscular work achieved at a lower met-
abolic expense, yielding a more efficient workout (19) while
providing a powerful tool for restoring muscular strength in
people with a limited capacity to train at high intensities
such as older adults. Furthermore, Reeves et al. (32) investi-
gated 9 older adults (74 6 3 years) assigned to a TRT pro-
tocol performing both concentric and eccentric contractions
and 10 older adults (67 6 2 years) assigned to an ERT pro-
tocol. Both groups trained 3 times per week for 14 weeks, at
80% of their 5RM, specific to each training mode. Although
ERT was performed with heavier absolute loads, ratings of
perceived exertion were consistently lower along training
weeks as compared with TRT.
We observed that the magnitude of SBP reduction after
acute exercise (post-acute exercise first week) was correlated
with the magnitude of SBP reduction after 16 weeks of
combined ERT (Figure 2). Liu et al. (21) have shown that
the magnitude of the acute SBP- and DBP-lowering with
exercise correlated with the extent of SBP- and DBP-
lowering after 8 weeks of a walking/jogging training
program (4 times per week, 30 minutes per session, 65%
maximum oxygen consumption) in prehypertensive individ-
uals. In addition, Collier et al. (7) have shown that sex differ-
ences exist in the BP lowering effects of resistance exercise
and that women reap the benefits of lowering their BP with-
out any deleterious effects such as arterial stiffening. These
results reinforce the idea that both RT and AT can promote
substantial benefits on BP in older hypertensive women.
Our results have important clinical implications in the
management of hypertension and suggest that individuals
with a greater acute peak decrease in BP experience a larger
total effect, which suggests that a short-term change in BP
after a single bout of combined ERT could be a predictor of
health-related efficacy, similar to previous studies with AT
protocols (13,21). Additionally, the acute reduction in BP
after the last training session was higher in the combined
ERT group when compared with the combined TRT group.
Thus, the specificity of a combined RT protocol, muscle
actions, and intensity might have contributed to this different
behavior in BP. However, because of the lack of a mechanis-
tic approach, the explanation of specific physiological path-
ways responsible for the BP reduction is beyond the scope of
this study. Possible explanations would be the faster adapta-
tions experienced during combined ERT, as it has been
shown that strength gains can occur after 7 days of ERT at
relatively low intensity and cardiovascular demand, reinforc-
ing the suitability of this type of training for the elderly in-
dividuals deconditioned as a result of an injury and the
chronically diseased (16).
Considering that strength declines with aging and that this
process is associated with numerous disability processes and
metabolic disturbances, such as increased fall risk, difficulty
in performing daily living activities, BP elevation, and
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3082 Journal of Strength and Conditioning Research
Copyright © National Strength and Conditioning Association Unauthorized reproduction of this article is prohibited.
dyslipidemia (5), our results contribute to the body of evi-
dence indicating that older adults can substantially increase
their strength after both combined TRT and ERT. One novel
finding of this study is the comparison of different protocols
of combined RT (TRT vs. ERT), which has shown the com-
bined ERT group demonstrated larger effect sizes and signif-
icantly higher strength values for the upper and lower
extremities when compared with TRT, although both were
effective in increasing strength values. Similarly, Reeves et al.
(32) verified that eccentric knee extensor torque (measured
in an isokinetic dynamometer) increased by a higher amount
in the ERT vs. TRT in elderly subjects. Again, this suggests
the usefulness of ERT combined with AT as an efficient tool
to counteract age-related decline in muscular strength. In
agreement with Peterson et al. (26), from a public health
perspective, these results confirm the value of whole-body
RT combined with AT for the prevention or treatment of
age-related declines in muscle function and metabolic dis-
turbances, as we also observed reductions in creatinine and
elevations in HDL.
To note, an important strength of this study was that diet
was controlled by a dietary recall follow-up and that we had
a control group, guaranteeing the effect of combined RT on
the BP reduction. However, the lack of an AT only group does
not allow us to make any conclusions regarding the isolated
effects of RT. Another limitation of this study was the lack of
control of antihypertensive medication dosage. Finally, during
ERT, some resistance exercises will require the assistance of
a spotter to complete the concentric phase of the movement,
which may limit the use of this training method.
PRACTICAL APPLICATIONS
Our results suggest that both RT protocols combined with AT
were effective in improving HDL levels and reducing BP after
16 weeks, and that the reduction of SBP after acute exercise
was correlated with the magnitude of change in BP after
chronic RT only in the eccentric protocol. Considering the
superior improvement in upper- and lower-body strength for
the ERT and the improvement in BP, the use of ERT
combined with AT proved to be safe and effective in elderly
hypertensive women. Thus, strength and conditioning profes-
sionals should advise elderly clients to perform ERT. However,
supervision is an important issue to avoid excessive loads in
frail populations. Moreover, when performing ERT with
traditional weight training machines and free weights, a spotter
is required to lift the weight during the concentric phase of
the movement. Some resistance exercises can facilitate this
process; for example, in the chest press, individuals can
perform the concentric phase by pressing a device with
their feet, or in the leg press one can push the knees with
the hands for the concentric and complete only the eccentric
movement. Additional randomized controlled trials are
required to elucidate the mechanisms responsible for these
results in elderly and other populations, such as metabolic
syndrome, obese, and diabetic subjects.

ACKNOWLEDGMENTS
The authors have no financial, consultant, institutional, or
other relationships that might lead to bias or a conflict of
interest. The results of this study do not constitute endorse-
ment of the product by the authors or the NSCA. All the
authors contributed to the study design, data collection, and
article preparation.
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