RBCDH 2017 (19) - 5

Rev Bras Cineantropom Hum
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Rev Bras Cineantropom Hum 2017, 19(4)375-503

Nucidh – CDS/UFSC
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Universidade Federal de Santa Catarina
Campus Universitário – Trindade – P.O. box 476
Centro de Desportos – Departamento de Educação Física
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Ficha Catalográfica
Revista Brasileira de Cineantropometria & Desempenho
Humano / Universidade Federal de Santa Catarina.
Centro de Desportos . NuCIDH. — v.1, n.1 (1999) -
. Florianópolis : Imprensa Universitária, 1999 -
v. ; 28 cm
Anual 1999-2002; Semestral 2003-2005;

Trimestral 2006-2009; Bimestral 2010-
ISSN 1415-8426
1.Esportes Aspectos fisiológicos 2. Medicina do esporte

3. Saúde Pesquisa 4.Aptidão física 5.Antropometria
2.Periódicos I. Universidade Federal de Santa Catarina.
II . Centro de Desportos
Catalogação na fonte: Daurecy Camilo (Beto)

CRB-14/416)
Associação Brasileira
de Editores Científicos - ABEC
Sumário
Validation of anthropometric models in the estimation
of appendicular lean soft tissue
in young athletes 505
Validação de modelos antropométricos na estimação
da massa isenta de gordura e osso apendicular
em jovens atletas
Pedro Pugliesi Abdalla, Analiza Mónica Silva, Anderson dos Santos Carvalho, Ana Claudia Ros-
sini Venturini, Thiago Cândido Alves, André Pereira dos Santos, Dalmo Roberto Lopes Machado
Reproducibility of heart rate and perceptual

demands of game-based training drills in
handball players 515
Reprodutibilidade da frequência cardíaca e percepção de
demandas do treinamento baseado em jogos em atletas de
handebol
Gilles Ravier, Claire Hassenfratz, Romain Bouzigon
Relative age effect in Brazilian Basketball

Championship: Under 15 players 526
Efeito da idade relativa no Campeonato Brasileiro de Basquete:
Categoria sub-15
Helder Zimmermann de Oliveira, Dilson Borges Ribeiro Junior, Jeferson Macedo Vianna, Fran-
cisco Zacaron Werneck
Influence of functional and traditional training

on muscle power, quality of movement and quality
of life in the elderly: a randomized and
controlled clinical trial 535
Influência dos treinamentos funcional e tradicional na potência
muscular, qualidade de movimento e qualidade de vida em
idosas: um ensaio clínico randomizado e controlado
Leury Max Da Silva Chaves, Antônio Gomes De Rezende-Neto, Albernon Costa Nogueira, José
Carlos Aragão-Santos, Leandro Henrique Albuquerque Brandão, Marzo Edir Da Silva-Grigoletto
Prediction of cardiorespiratory fitness from

self-reported data in elderly 545
Predição da aptidão cardiorrespiratória através de dados
auto-relatados em idosos
Geraldo A Maranhao Neto, Aldair J Oliveira, Rodrigo Pedreiro, Silvio Marques Neto, Leonardo G
Luz, Henrique C Silva, Paulo TV Farinatti
Relationship between adiposity and heart rate

recovery following an exercise stress test
in obese older women 554
Relação entre a adiposidade e a recuperação da frequência
cardíaca após teste de esforço em mulheres idosas obesas
Cristiane Rocha da Silva, Bruno Saraiva, Dahan Cunha Nascimento, Luana Claudia Dias Bicalho,
Ramires Alsamir Tibana, Jeffrey M. Willardson, Jonato Prestes, Guilherme Borges Pereira
Rev Bras Cineantropom Hum 2017, 19(4)375-503

Obesity awareness among elders living in rural
area: a household survey 565
Autorreconhecimento da obesidade de idosos residentes em
áreas rurais: um inquérito domiciliar
Alisson Fernandes Bolina, Maycon Sousa Pegorari, Darlene Mara dos Santos Tavares
Dual Task Multimodal Physical Training in Alzheimer’s

Disease: Effect on Cognitive Functions and Muscle
Strength 575
Treinamento Físico Multimodal com Dupla Tarefa na Doença de
Alzheimer: Efeito nas Funções Cognitivas e na Força Muscular
Bruno Naves Ferreira, Emmanuel Dias de Sousa Lopes, Isadora Ferreira Henriques, Marina de
Melo Reis, Amanda Morais de Pádua, Karina de Figueiredo, Fernanda Aparecida Lopes Magno,
Flávia Gomes de Melo Coelho
Acute effects of passive static stretching

on the vastus lateralis muscle architecture
of healthy young men 585
Efeitos agudos do alongamento estático passivo sobre a
arquitetura muscular do vasto lateral de jovens saudáveis
Eurico Peixoto César, Letícia de Oliveira Teixeira, Daniel Vieira Braña Côrtes de Souza, Paulo
Sergio Chagas Gomes
Perceived neighborhood environment and leisure

time physical activity among adults
from Curitiba, Brazil 596
Ambiente percebido do bairro e atividade física no lazer em
adultos de Curitiba, Brasil
Adriano Akira Ferreira Hino1,2
Cassiano Ricardo Rech1,3
Priscila Bezerra Gonçalves1,2
Rodrigo Siqueira Reis1,4
Development of a Body Image Scale for Brazilian

women 608
Desenvolvimento de uma Escala de Imagem Corporal
para mulheres brasileiras
Catiane Souza, Erik Menger Silveira, Emanuelle Francine Detogni Shmit, Edgar Santiago Wagner
Neto, Letícia Miranda Resende da Costa, Cloud Kennedy Couto de Sá, Jefferson Fagundes Loss
Is the combination of interval and resistance training

more effective on physical fitness?
A systematic review and Meta-analysis 618
Será a combinação dos treinamentos intervalado e resistido
mais efetiva sobre a aptidão física em adultos? Uma revisão
sistemática e meta-análise
Francisco José de Menezes Junior, Íncare Correa de Jesus, Vera Lúcia Israel, Neiva Leite
Rev Bras Cineantropom Hum original article
DOI: http://dx.doi.org/10.5007/1980-0037.2017v19n4p505
Validation of anthropometric models in the

estimation of appendicular lean soft tissue
in young athletes
Validação de modelos antropométricos na estimação
da massa isenta de gordura e osso apendicular
em jovens atletas
Pedro Pugliesi Abdalla1,2
Analiza Mónica Silva3
Anderson dos Santos Carvalho 4,5
Ana Claudia Rossini Venturini1
Thiago Cândido Alves 4
André Pereira dos Santos 4,6
Dalmo Roberto Lopes Machado1,4.
Abstract – Magnetic resonance imaging and computer tomography are gold standards in the
measurement of muscle tissue (MT), but are expensive. Dual Energy X-Ray Absorptiometry
(DXA) is also costly but safer and allows for the measurement of Appendicular Lean Soft
Tissue (ALST), a strong predictor of MT. Alternatively, there are anthropometric models
that predict the ALST of Portuguese athletes with low cost/risk that have not been validated
in other populations. The aim of this study was to validate anthropometric Portuguese models
that predict ALST in young athletes or, if the validation fails, to propose new models. The
ALSTDXA of 174 young athletes was determined by DXA. Two anthropometric models
(ALSTmod1 and ALSTmod2) measuring ALST among Portuguese athletes were tested. To
validate the coefficient of determination, the difference (bias) and concordance correla-
tion coefficient between predicted and actual values were computed. Finally, association
between mean and difference of methods was verified. Validation failed and, for this reason,
new multiple regression models were proposed and validated using PRESS statistics. The
Portuguese models explained ~96% of the ALSTDXA variability. The difference between
ALSTmod1 and ALSTDXA (-0.7kg) was less than that found for the ALSTmod2 and ALSTDXA
(-2.3kg), with limits of agreement from 3.6 to -2.1 and from 6.1 to -1.5kg, respectively.
The new models included three predictive equations for ALST. Only ASLTmod1 was valid; 1 University of São Paulo. School
however, it was prone to bias, depending on the magnitude of ALST values. The newly of Physical Education and Sport.
proposed models present validity with greater concordance (r²PRESS=0.98), lower standard Postgraduate Program in Physical
error of estimate (SEEPRESS [kg]=0.91) and more homogeneous predicted extreme values. Education and Sport. Ribeirão Preto,
SP. Brazil.
Key words: Anthropometry; Body composition; DXA scan; Skeletal muscle; Sports.
2 University of Ribeirão Preto.
Resumo – Ressonância magnética e tomografia computadorizada são referências para medir o Nutrition Course. Ribeirão Preto, SP.
tecido muscular (TM), porém apresentam custo elevado. A Absorciometria Radiológica de Dupla Brazil.
Energia (DXA) é segura, embora ainda dispendiosa, permite medir a Massa Isenta de Gordura
e Osso apendicular (ALST), forte preditor do TM. Alternativamente, existem modelos antropo- 3 University of Lisbon. Faculty of
métricos preditivos da ALST de atletas portugueses com baixo custo/risco, porém sem validação Human Motricity. Lisbon, Portugal
para outras populações. Objetivou-se validar modelos antropométricos portugueses preditivos
da ALST em jovens atletas ou propor novos modelos, caso a validação falhe. A determinação 4 University of São Paulo. School of
da MIGOapDXA de 174 jovens atletas foi realizada por DXA. Dois modelos antropométricos Nursing of Ribeirão Preto. Interunit
(MIGOapmod1 e MIGOapmod2) de atletas portugueses foram testados para predizer ALST. Para Doctoral Program in Nursing. Ribei-
validação o coeficiente de determinação, a diferença (viés) e a concordância entre valores medi- rão Preto, SP. Brazil.
dos e preditos foram calculados. Finalmente, a associação entre média-e-diferença dos métodos
foi calculada. A validação falhou, assim foram propostos novos modelos de regressão múltipla 5 Visiting scholar at University of
validados por estatística PRESS. Os modelos portugueses explicaram ~96% da variabilidade da Coastal Carolina University, USA.
MIGOapDXA. A diferença entre MIGOapmod1 e MIGOapDXA (-0,7kg) foi menor do que MIGOap-
(-2,3kg), com limites de concordância de 3,6 a -2,1 e de 6,1 a -1,5kg, respectivamente. Os 6 Visiting scholar at University of
mod2
Illinois at Urbana-Champaign, USA.
novos modelos incluíram três equações preditivas para ALST. Somente MIGOapmod1 foi válido,
todavia mostrou grande tendência a vieses, conforme magnitude dos valores de ALST. Os novos
Received: 13 August 2017
modelos propostos mostraram validade com maior concordância (r²PRESS=0,98), menores erros
Accepted: 20 October 2017
de estimativa (EPEPRESS [kg]=0,91) e valores preditos mais homogêneos para casos extremos.
Palavras-chave: Absorciometria de raios x; Antropometria; Composição corporal; Esportes; Licença
Músculo esquelético. BY Creative Commom
Validation of Anthropometric Models of ALST in Young Athletes Abdalla et al.
INTRODUCTION
Skeletal muscular tissue (MT) is essential for athletic performance1,2, as it
is the most abundant body tissue in non-obese individuals1,3. Body com-
position comprises five levels: I) atomic; II) molecular; III) cellular; IV)
tissue; and V) total body3; MT belongs to the fourth level and corresponds
to 30 to 33% of the total body mass of young people4, while in adults it
corresponds to approximately 40%1.
The use of valid and easily applicable methods to quantify the MT
of young athletes is highly relevant to monitoring the effects of athletic
training on one’s MT structure, determining training loads in different
phases and balancing training routines with dietary prescriptions, enabling
the preservation of or increase in muscle mass to improve athletic perfor-
mance2. Even though MT represents a large part of one’s body structure4,
measuring it in live individuals is a complex task when compared to other
measures, such as fat or bone tissue.
Imaging methods were developed in the 1970s to analyze MT and
remain among the most used: Computed Tomography (CT), Magnetic
Resonance Imaging (MRI) and Dual Energy X-ray Absorptiometry
(DXA)5. The first measures using CT were performed in 1983 and in 1995
measures were performed using MRI5. Only in 1998 were both techniques
validated based on the only method that involves the direct measurement
of this component, the dissection of corpses6. The study showed that these
methods accurately quantify MT at the tissue level (IV). Nonetheless, these
methods are costly2 and difficult to apply, while CT exposes individuals
to radiation, which prevents applying it repetitively7.
A less costly and more accessible alternative method, when compared
to the previous ones, is DXA 2. It is considered safer because it involves
a minimum of radiation8 and is thus appropriate to measure the body
composition of children and adolescents9. Even though DXA only makes
measurements at level II3, it is possible to isolate body regions for analysis,
such as the upper limbs, lean mass of the measurement of bone and fat
mass called Lean soft tissue (LST)2. Appendicular LST (ALST), that is,
the sum of the LST of the upper and lower limbs, is equivalent to almost
all MT (level IV) in this region, with the exception of a small amount of
connective tissues and skin 2. Additionally, the MT that is present in the
both upper and lower limbs represent approximately 75% of MT in adults10.
Based on these proportions, comparisons11 were performed and mod-
els were proposed to estimate MT with ALST measures for adults12 and
children and adolescents using MRI4. These models included ALST, age
and sex as independent variables and explained 96% of the variability in
reference values. Additionally, they were validated in the study’s sub-sample
with very high correlation (r = 0.96 to 0.97), no statistically significant differ-
ences and good concordance between predicted and actual measurements.
The models proposed for adults12 were valid for children and mature ado-
lescents13, however, they overestimated the measurements of pre-pubertal
506
and pubertal individuals, with a mean difference of 0.5 kg4. Therefore, three
specific models were proposed for pre-pubertal and pubertal boys (n = 36)
and girls (n = 29). The MT measures were taken using MRI and ALST
was measured using DXA. The independent variables were: ALST, body
mass, height and interaction between ALST/height, explaining from 98%
to 99% of the variability of the reference method’s values4. Nonetheless,
even though DXA is safe and appropriate for the young population, it is
still an expensive method and cannot be recurrently used in practice2.
Anthropometry, on the other hand, is a highly applicable method
in the measurement of MT, given its low cost and accuracy, as long as a
minimum amount of training is provided 2. Models using anthropometry
were proposed to predict MT among the elderly14,15 and adult individuals7
using the dissection of corpses and MRI, respectively, with proven valid-
ity16,17. Only one study was found that proposes anthropometric models
to predict ALST in athletic children and adolescents2, using data from
Portuguese young individuals (176 boys and 92 girls). Even though the
authors performed cross validation and obtained good results, the validity
of these methods in other populations has not been tested. Specifically,
there are anthropometric differences with statistical significance between
Brazilian and Portuguese young individuals18, specifically height, an
independent variable that is necessary to predict ALST in the models
proposed. Therefore, this study’s objectives included: 1) validate Portuguese
anthropometric models to predict ALST in Brazilian young male athletes;
and, if validation fails, 2) propose new models.
METHODOLOGICAL PROCEDURES
Study’s design
This cross-sectional observational study addressed young Brazilian indi-
viduals who took part in sports clubs and whose parents or legal guard-
ians received clarification regarding the study’s procedures. Guidelines
concerning research involving human subjects were complied with and
consent was provided by the participants’ parents or legal guardians; the
Institutional Review Board at EEFE/USP approved the study (332007/
EEFE/04.04.2007-2006/32).
Sample
The sample was composed of 174 young male athletes aged between eight
and 18 years old who took part in different sports (soccer: n=146; athletics:
n=8; indoor soccer: n=19 and judo: n=1).
Inclusion/exclusion criteria
Medical exams were performed to ensure the individuals were healthy, had
no amputated limbs, took no medications that influenced on their metabo-
lism, appetite or growth. Only those regularly training at least three times
a week and having played competitively for at least one year were included.
Rev Bras Cineantropom Desempenho Hum 2017, 17(5):505-514 507

Measurement protocol
Each participant was assessed in a laboratory setting in the morning after a night
of rest. Data were collected in a single session and the same examiner performed
all measurements, before which, the individuals were invited to fully empty
their bladders. Total body scanning was performed with DXA of the individu-
als wearing shorts and shirts, which was followed by anthropometric measures
performed according to the recommendations found in the literature19,20.
Establishment of Appendicular Lean Soft Tissue (ALST)

The estimation of ALST using DXA (Scanner DPX-NT, GE Medical, Soft-
ware Lunar DPX enCORE 2007 v. 11.40.004, Madison, WI) was performed
considering the sum of the LST of the upper and lower limbs. The images of
limbs were isolated from the trunk and head (ROIs) using software-generated
standard cut-outs, which were manually adjusted when necessary. Specific
anatomic markers were used to define the lower limbs: LST that extends
from the traced and perpendicular line to the axis of the femoral neck and
angled with the pelvic flap to the tips of the phalanges. For the upper limbs,
the anatomic marker was LST that extends from the center of the arm to the
tips of the phalanges, following the procedures of the manufacturer’s manual.
Chronological Age and Anthropometric Measures

Age was considered the whole number nearest to the individual’s chrono-
logical age measured in years based on the decimal values of the year of birth.
The anthropometric measures necessary to estimate ALST based on
the models proposed by Quiterio et al.² included body mass (BM) in kg and
height (H) in cm, which were measured using a digital scale (Filizola, PL 200,
Campo Grande, MS, Brazil) and a wall-fixed stadiometer (Sanny Medical
Professional-ES2020, São Paulo, SP, Brazil) with 0.1 kg and 0.1 cm accuracy,
respectively. Three skinfold measurements (SKF) in mm: the thigh (SKF Thigh),
triceps (SKF Triceps) and calf (SKFCalf ) were measured with a Lange skinfold
caliper (Beta Technology, Cambridge, Maryland) with 1 mm accuracy. Three
perimeters (P) in cm: thigh (P Thigh), arm (PArm) and calf (PCalf ) were measured
using an inelastic and inextensible two-meter long metal tape measure (Sanny
Medical, Starrett SN-4010, São Paulo, SP, Brazil) with 0.1 cm accuracy.
Measures accuracy
The Absolute Technical Error of Measurement (TEM) and Relative Tech-
nical Error of Measurement (%TEM) were computed to ensure accurate
intra-observer measurements. In the days subsequent to data collection, the
measurements were replicated in 13 individuals, always within tolerance
intervals20, as previously described8.
Estimates of Appendicular Lean Soft Tissue (ALST)

The predictive models used for young male athletes (Body weight and
height model and Corrected muscle girth model) proposed by Quiterio et
al.², used to predict ALST, called here model 1 and 2, are:
508
ALSTmod1[kg] = -20.39 + (0.199*BM[kg]) + (3.29*sex[♂=1;♀=0]) + (14.2*H[m]) +
(0.19*Age[years])
ALSTmod2[kg] = 3.26 + 0.002 * (H[m]*CP Thigh[cm]²) + 0.007 * (H[m]*CPArm[cm]²) + 0.003 *

(H[m]*CPCalf[cm]²)
Where: BM=body mass; H=height; CP=corrected muscle perimeters; CP Thigh =P Thigh[cm]-

(π*SKF Thigh[cm]); CPArm=PArm[cm]-(π*SKF Triceps[cm]); CPCalf=PCalf[cm]-(π*SKFCalf[cm]); P=perimeters;
SKF=skinfold; π=3.1416.
Maturity
Participant maturity considered pubic hair development according to Tan-
ner’s self-assessment method13.
Statistical analysis
Mean, standard deviation, minimum and maximum values were used to
describe the sample. The coefficient of determination (r²), agreement ac-
cording to a Bland-Altman 21 plot were analyzed together with bias (the
mean of differences between predicted and actual values) and the concord-
ance correlation coefficient (ρc)22 to determine the validity of anthropo-
metric models in predicting ALSTDXA. Strength of concordance of ρc was
classified 23 as: poor (<0.90), moderate (0.90-0.95), substantial (0.95-0.99),
or almost perfect (>0.99). Association between the mean and differences
between predicted and actual values were verified. Any proposal of new
anthropometric models, if necessary, would consider stepwise multiple
linear regression, considering reduced multicolinearity (VIF<5)24 and
validation using PRESS statistics (the sum of the squares of residuals)25.
Statistical analyses were performed using SPSS v. 20 (Chicago, IL), plots
and ρc in the MedCalc® 2015 (v. 15.2); PRESS statistics in Minitab® (v.
17.3.1), all of which considered a level of significance established at α=0.05.
RESULTS
The descriptive analysis, absolute and relative TEM of all the study’s
variables are presented in Table 1. The %TEMs were within the expected
tolerance interval 20, both for the anthropometric variables (0.11% to 3.39%)
and body composition (0.01% to 1.42%).
Most individuals were classified Pubertal (n=128; 73.6%) when com-
pared to Pre-Pubertal (n=26; 14.9%) and Post-Pubertal (n=20; 11.5%).
Maturity was not, however, determinant in proposing models.
In the estimation of the variability of values measured by DXA, the Por-
tuguese models (ALSTmod1 and ALSTmod2) explained approximately 96.4% and
95.9% (r²), respectively, of the variability of the ALSTDXA of Brazilian athletes.
The results for concordance (Bland-Altman) portray the mean differ-
ences between actual and predicted values (Figure 1): ALSTmod1 slightly
underestimated ALSTDXA (a bias of -0.7±1.5 kg). Similarly, ALSTmod2
estimations underestimated ALSTDXA, however with greater magnitude
(a bias of -2.3±1.9 kg).

Table 1. Descriptive analysis of all the variables and Absolute (TEM) and Relative (%TEM)
Intraobserver Technical Error of Measurement.
Standard
Variables Mean Minimum Maximum TEM %TEM
Deviation
Chronological age (years) 13.5 2.8 7.9 18.4 - -
Sexual maturity (Tanner stages) 3.0 1.3 1.0 5.0 - -
Body Mass (BM) [kg] 48.6 14.7 22.8 80.4 0.27 0.29
Height (H) [m] 1.6 0.2 1.2 1.9 0.17 0.11
BMI (kg/m²) 18.6 2.6 13.4 25.1 - -
Skinfolds (SKF) [mm]
Triceps (SKF Triceps) 10.5 4.1 4.0 26.0 0.12 1.09
Thigh (SKF Thigh) 15.5 6.2 5.0 35.0 0.63 3.39
Calf (SKF Calf) 11.0 4.2 3.5 25.0 0.23 1.28
Perimeters (P) [cm]
Arm (PArm) 21.5 3.2 15.3 28.4 0.31 1.35
Medial thigh (P Thigh) 43.8 6.4 27.5 58.0 0.70 1.47
Medial Calf (PCalf) 30.9 3.9 22.2 40.7 0.37 1.17
Corrected muscle perimeters (CP) [cm]
Arm (CPArm) 18.2 3.3 11.9 26.2 - -
Thigh (CP Thigh) 39.5 6.7 23.4 54.0 - -
Calf (CPCalf) 27.5 3.9 18.5 34.5 - -
DXA
Bone Mineral Content (kg) 2.1 0.8 0.9 3.6 0.01 0.03
Fat Mass (kg) 6.7 3.7 1.5 21.1 0.22 1.42
ASLTDXA (kg) 18.5 6.6 6.9 30.5 0.03 0.14
ASLTmod1 (kg) 17.8 5.7 6.6 29.5 - -
ASLTmod2 (kg) 16.2 5.1 8.1 28.5 - -
Legends: ASLTDXA-Appendicular Lean Soft Tissue measured using DXA; ASLTmod1 and ASLTmod2-
Appendicular Lean Soft Tissue, estimated through anthropometric models 1 and 2 proposed by
Quiterio et al.².
The limits of agreement (Bland-Altman), considering an interval of

95% for both ASLTmod1 and ASLTmod2 (Figure 1), ranged between -2.1
and 3.6 and between -1.5 and 6.1kg, respectively. The Portuguese models
ASLTmod1 and ASLTmod2 were more accurate when ALST values were
low (below 18 kg and 11 kg, respectively). The regression line concern-
ing differences indicates a tendency of underestimation, as ALST values
increased (Figures 1a and b).
The strength of concordance between predicted and actual values was
substantial (ρc=0.966; CI 95%: 0.957 to 0.974) for ALSTmod1, but poor for
ASLTmod2 (ρc=0.878; CI 95%: 0.851 to 0.900). A moderate association
was also found (r=0.593; p<0.001) between the difference and mean of
methods for ASLTmod1 and ASLTDXA. Association between the difference
and mean of the methods for ASLTmod2 and ASLTDXA was even greater
(r=0.798; p<0.001).
Therefore, the validation of ASLTmod2 failed because it presents im-
portant bias, decreased ρc with significant association between difference
and mean. Hence, new anthropometric models were proposed to predict
ASLTDXA, called ASLTmod3, ASLTmod4 and ASLTmod5 (Table 2), based on
the same anthropometric variables used in the Portuguese models.
510
Figure 1. Bland-Altman plot and level of concordance between measurements of ALST in Kg using DXA (ALSTDXA) and values estimated
by anthropometric predictive models developed by Quiterio et al.²: 1 (ASLTmod1)-letter “a”; 2 (ASLTmod2)-letter “b”; and new proposed
models: 3 (ASLTmod3)-letter “c”; 4 (ASLTmod4)-letter “d” and 5 (ASLTmod5)-letter “e”.
Table 2. New models to predict Appendicular lean soft tissue (ALSTmod3, ALSTmod4 and ALSTmod5) of Brazilian young athletes.
Independent variables r 2 ad-

Models β SEE (kg) VIF
BM SKF Triceps SKF Thigh justed
ALSTmod3 0.433±0.09* -2.553±0.441 0.935 1.6831 1.000

ALSTmod4 0.429±0.01* -0.337±0.02* 1.233±0.330 0.978 0.9823 1.003
ALSTmod5 0.427±0.01* -0.197±0.03* -0.115±0.02* 1.620±0.305 0.982 0.8897 2.850
Legend: r²-coeficient of determination; SEE-standard error of estimate; VIF-Variance Inflation Factor; BM-Body Mass (kg); SKF- Skinfold
(mm); *-p<0.001.
The same statistical criteria previously used were applied to compare

the new models with the actual measures (r², concordance, ρc, association
between mean and differences). All models presented high r² (Table 2),
no bias or polarization of the mean (Figures 1c, 1d and 1e), and obtained
substantial (ρcmod3 =0.967; ρcmod4 =989) and almost perfect concordance
strength (ρcmod5=0,991); and there was no association between means and
differences of the methods (p>0.05).
The models tested with PRESS statistics presented values close
to the ideal values necessary for validation (PRESS mod3 =499.84;
PRESSmod4 =173.57 and PRESSmod5 =144.27), with r² PRESS close to 1
(r²PRESSmod3=0.934; r²PRESSmod4 =0.977 and r²PRESSmod5=0.981), and decreased
SEEPRESS (kg) (SEEPRESSmod3=1.695) or close to zero (SEEPRESSmod4 =0.999
and SEEPRESSmod5=0.911).
DISCUSSION
Only one of the anthropometric models designed by Quiterio et al.² to

predict ALST was validated in a sample of young athletes (ASLTmod1).

It presented high r², small limits of agreement and its estimates strongly
agreed with actual values (ALSTDXA). Nonetheless, the estimates of the
two models were prone to error when the individuals presented higher
ALST values. Even though model 1 was valid, it presented polarization
of the mean, underestimating ALST by approximately 1 kg . The newly
proposed models were validated by the PRESS method combining the
leave-and-out system with adjusted measures (prediction error) to obtain
a more accurate estimation of the models’ predictive performance8. The
new models presented greater agreement even for higher ALST and also
performed well in all the criteria considered in the Portuguese models (r²,
concordance, bias, ρc, association between mean and differences of methods).
To the best of our knowledge, the models proposed by Quiterio et
al.² are the only ones in the literature to estimate ALST (of the upper
and lower limbs, concomitantly) of young athletes using anthropometric
measures. Other studies proposed anthropometric models to predict ALST,
however, involved few students of both sexes (20 boys and 19 girls) who
did not practice vigorous exercise1. In some cases, they only estimate the
ALST of the lower limbs of male school-age athletes26. Previous stud-
ies1 committed conceptual errors in the nomenclature of the variable
measured by DXA, which was considered “Total Skeletal Muscle Mass”,
at level IV of human body composition (Organ-tissue level)3. Note that
DXA performs measurements only at level II (Molecular level). The ALST
estimates achieved with the Portuguese models in this study present r²
values (0.96 and 0.95) higher than those found in the Portuguese study
(0.91 and 0.93) in the same models 1 and 2, respectively. In the original
study, however, the estimates of the model did not present bias toward
error when the highest values of ALST were analyzed, as shown by the
Bland-Altman plot. Remarkable differences found for some variables
between the Portuguese subjects and those addressed in this study may
have contributed to inaccuracy of the models estimating higher ALST
(Figure 1a and 1b). On average, the athletes from the Portuguese study
were classified lower on the Tanner scale (1.7±0.7 vs. 3.0±1.3), but they
presented higher ALST (23.1±6.4 vs. 18.5±6.6 kg), Fat mass (10.5±7.0 vs.
6.7±3.7 kg), BMI (21.5±2.84 vs. 18.6±2.6), BM (64.5±15.8 vs. 48.6±14.7
kg), and height (1.72±0.15 vs. 1.60±0.20 m). The usual anthropometric
differences between Brazilian and Portuguese18 young individuals partly
explain the population differences, suggesting ethnic specificity of models
predicting body composition.
A limiting factor that may have led to greater inaccuracy in the Portu-
guese models involves the equipment used in this study (Scanner DPX-NT,
GE Medical), which is different from the equipment used in the original
study (DXA QDR-4500; Hologic, Walthman, MA). Body composition
measurement may differ between brands27,28,29, though such differences
have not been confirmed when specific comparisons are performed between
ALST measured using different DXA equipment30.
512
CONCLUSION
Only model 1 proposed by Quiterio et al.² satisfactorily met validity
criteria to estimate the ALST of young Brazilian athletes. The accuracy
of estimates of the two Portuguese models, however, depended on the
magnitude of ALST values. The newly proposed models complied with
all validation criteria, presenting highly accurate estimates: r2PRESS (0.93 to
0.98), low SEEPRESS (0.91 to 1.70kg) and satisfactory concordance regard-
ing the ALST of young Brazilian athletes, regardless of the magnitude of
the values. Nonetheless, before adopting models intended to predict the
body composition of young individuals, one has to consider population
differences that should be considered specifically.
Acknowledgment
We would like to thank the Interunit Doctoral Program in Nursing of
the School of Nursing of Ribeirão Preto of the University of São Paulo
(EERP-USP) and the Nutrition Course of the University of Ribeirão Preto
(UNAERP) for financial support for the translation of this article. This
research was supported by Coordination for the improvement of higher
education personnel program (CAPES, Brazil).
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514
Reproducibility of heart rate and perceptual

demands of game-based training drills in
handball players
Reprodutibilidade da frequência cardíaca e percepção
de demandas do treinamento baseado em jogos em
atletas de handebol
Gilles Ravier1
Claire Hassenfratz1
Romain Bouzigon1
Abstract – Game-based training are popular in team-sports; however there is a lack of

research specific to team handball. The aim of this study was to assess i) the test-retest
reliability of heart rate (HR), time spent in HR zone intensities and rating of perceived
exertion of a novel small-sided game, ii) and whether it is comparable to that of generic
intermittent shuttle running and match play with team handball players. Fourteen elite
male handball players completed each exercise comprising two periods of 10min inter-
spersed with 2min recovery in separate occasions and repeated them one week apart.
Exercises consisted of intermittent 30s-30s shuttle running (ISR), intermittent 30s-30s
small-sided game (with 3-a-side field players, 3vs3) and match play (with 6-a-side field
players, 6vs6). Mean HR demonstrated high level of reproducibility for the three drills
(r = 0.86-0.89, TEM = 2.21-2.63 bpm, CV = 1.23-1.55%). For time spent in heart rate
zones TEMs reached up 1.12, 1.40 and 2.48 min for ISR, 6vs6 and 3vs3, respectively.
Specifically for HR zone higher than 90% of HRmax, CVs showed wide extent of scores
with 9.73 (ISR), 27.39 (6vs6) and 108.29% (3vs3). Mean HR results suggest that physi-
ological response was consistent between sessions. Because of the poor reproducibility
for time spent in the target zone higher than 90% of HRmax, the efficiency of both 3vs3
and 6vs6 in improving aerobic power should be analysed with caution. The present results
suggest that reproducibility of physiological demand of ball-drills should be considered
before prescribing them as conditioning training.
Key words: Heart rate; Intensity; Perception; Reliability.
Resumo – O treino através do jogo é popular quando se trata de esportes coletivos. Contudo,
constata-se uma falta de estudos específicos sobre a prática do handball. Objetivou-se testar a
reprodutibilidade de um jogo com equipe reduzida através da análise da frequência cardíaca
(HR), do tempo decorrido nas diversas faixas de intensidade de HR e da percepção do esforço.
A reprodutibilidade do jogo com equipe reduzida foi comparada àquelas de um exercício padrão
de corrida e de um jogo de handball. Quatorze jogadores de handball masculino nível elite rea-
lizaram um mesmo exercício em duas ocasiões com uma semana de intervalo entre elas. Cada
exercício foi realizado em dois períodos de 10 minutos com dois minutos de intervalo entre cada
um. Os diferentes exercícios consistiram numa corrida intermitente de 30s-30s, realizadas em
ida e volta (ISR); um jogo com equipe reduzida intermitente de 30s-30s (com três jogadores em
cada equipe, 3vs3); e um jogo de handball (com 6 jogadores em cada equipe, 6vs6). A HR média
demonstrou um nível avançado de reprodutibilidade dos três exercícios (r = 0,86-0,89; TEM =
2,21-2,63 bpm; CV = 1,23-1,55%). No que se refere ao tempo decorrido nas diferentes faixas
de frequência cardíaca, os TEM (erros típicos de medição) foram 1,12, 1,40 e 2,48 minutos 1 Unit of formation and research in
respectivamente para ISR 6vs6 e 3vs3. Especificamente para a faixa de HR superior a 90% Sports. Laboratory Culture Sport
da frequência cardíaca máxima, os coeficientes de variação mostraram uma larga amplitude de Health Society. Department of Sport
valores, com 9,73 (ISR), 27,39 (6vs6) e 108,29% (3vs3). Os resultados da média da frequência and Health. University of Franche-
-Comté. Besançon, France.
cardíaca sugerem que a resposta fisiológica global é coerente nas duas sessões do mesmo exercício.
A reprodutibilidade reduzida no tempo decorrido na faixa superior a 90% da HRmax indica
Received: 13 June 2017
necessidade de cautela quando se trata do 3vs3 e 6vs6 para melhoria do potencial aeróbico. Os Accepted: 09 October 2017
resultados do estudo sugerem que a reprodutibilidade da demanda fisiológica dos exercícios com
bola deve ser considerada antes de sua utilização como treinamento físico. Licença
Palavras-chave: Frequência cardíaca; Intensidade; Percepção; Validade. BY Creative Commom
Heart rate response in handball drills Ravier et al.
INTRODUCTION
Handball is characterized as an intermittent team-sport with high intensity
technical skills and short sprints interspersed by low intensity activities
including walking and standing still which represent approximately 70-80%
of the total playing time1,2. Studies analysing the physiological demands
of handball match play from heart rate (HR) response reported average
values of 82% of the individual maximal HR (HR max) in elite adult 2 and
adolescent1 players.
Regarding the intermittent nature of handball game, conditioning train-
ing comprised commonly traditional interval-training exercises targeting the
ability to perform high-intensity actions and to rapidly recover during the
less intense periods. As an alternative, small-sided games (SSG) are widely
prescribed in team-sports to improve both match-specific aerobic and an-
aerobic fitness while involving technical and tactical skills of team players3-8.
Most of studies comparing the effect of ball drills with generic high intensity
intermittent runs showed that both training methods appeared equally ef-
fective at improving physiological capacities in team-sport players3,4,6,7,9,10.
Because of the success of game-based training methods in team-sports,
several researchers11-14 have focused on physiological and physical activities
of specific ball-drills. Thus, physiological demand of SSGs can be altered
by manipulating the exercise regime, duration of playing time, field dimen-
sion, coach encouragement, technical restrictions and/or rule modifications,
goalkeeper presence, and number of players involved. For instance, number
of players affects intensity of basketball SSGs11 with greater mean HR in
2vs2 than 3vs3 and 5vs5 (92.0%, 88.0% and 84.0% of HR max, respectively).
Concerning the conditioning training effectiveness, an exercise intensity
higher than 90% of HRmax is recommended throughout the training period
to improve physical fitness and match play performance7,9 with team-sport
players. Game-based drills may provide an aerobic stimulus comparable with
intermittent runs. However, they does not allow planning and control of
exercise characteristics such as motion activities, time duration of exercise
and recovery, and intensity involved, comparable with traditional interval
runs. Because these features depending on the tactical and technical requests
which are modulated according to the course of game, the between-session
reproducibility of the physiological responses and physical performance has
been analysed in previous studies with soccer5,13,15,16 and cricket games17.
For instance, comparing soccer ball-drills performed in continuous and
intermittent regimes, Hill-Haas et al.5 showed higher between-session
typical error of measurement scores for mean HR in continuous than in
intermittent regimen. It has been shown that intensity is another factor
affecting test-retest variability of physiological response in soccer SSGs13.
Indeed, reproducibility of HR was positively related to the exercise intensity.
When coaches prescribe game-based drill as conditioning exercise,
they expect that each training session elicit a similar physiological demand
throughout the training period. However, there is a lack of research related
516
to the test-retest intra-exercise comparison specific to team handball. In
this context, the present study aimed to assess whether the between-session
reliability of HR, time spent in HR zone intensities and rating of perceived
exertion of an intermittent (30s-30s) game-based drill with 3-a-side field
players is comparable to that of traditional intermittent running (30s-30s).
In addition, the assessment of reproducibility of handball match play (6vs6)
was important to consider reproducibility of game demands.
Participants
Fourteen male handball players (means ± SD: age 23.9 ± 4.3 years, range
19-34 years; body mass 85.1 ± 7.9 kg; height 188.8 ± 5.9 cm) consisting of 2
goalkeepers, 2 pivots, 6 backcourt and 4 wing players from the same team
involved in the professional French National Handball League volunteered
to participate in this study. Their training background was 12.5 ± 4.1 years
in handball. Each participant was medically screened and had no medical
or orthopaedic problem. The testing period was carried out between the
first and the second half of the competitive season. During the four months
preceding the beginning of the study, each participant had trained, on
average, seven times a week. The protocol and procedures were conducted
according to the recommendations of the Declaration of Helsinki. All
participants were informed of the research procedures, requirements, and
risks of the investigation as well as the right to terminate participation at
will. Each subject gave a voluntary written consent to participate in this
experiment, which was approved by the institutional research ethics com-
mittee and handball club review board.
Experimental design
This study employed a within subjects repeated measures experimental
design to analyse test-retest reliability of physiological and perceptual
demands of three specific conditioning exercises: intermittent shuttle
running (ISR), intermittent SSG opposing 3vs3 field players (3vs3), and
handball match play opposing 6vs6 field players (6vs6). Each session of
exercise comprised 2 periods of 10min interspersed with 2min of passive
recovery during which players were allowed hydration ad libitum. Players
were verbally encouraged by the coach to maximally perform during the
overall protocol. All testing sessions were performed at the same time of
day (5 to 7 PM) on regular indoor handball court (20x40m). Before each
experimental session, players completed a standardized 20 min warm-up,
after which a period of 5 min was planned to worn the heart rate device.
Participants were first tested with the Intermittent Fitness Test (IFT)18.
The IFT is a maximal intermittent incremental shuttle-run test that con-
sists of 30s shuttle runs interspersed with 15s periods of passive recovery.
The initial running velocity was set at 8km.h-1 and increased by 0.5km.h-1
for every subsequent stage. The running velocity reached at the last fully

completed stage was retained as the maximal velocity (V IFT). The peak
heart rate recorded was considered as player’s HR max.
The ISR consisted in 30s runs interspersed with 30s of passive recovery.
Running was completed over 40m shuttles which required three to four
180° directional changes within 30s of runs. Exercise intensity was set at
95% of the individual V IFT.
During the two handball games the referee was an official referee of
the French Handball Federation. The official rules were applied with the
exceptions of 1) throw-in after a goal was immediately made by goalkeeper
from his 6m area 2) investigators were available to replace the ball when
it was thrown out of the playing court 3) any infringement of the rules of
the game were sanctioned. However, the 2min exclusions were not pre-
sent. When the referee awarded a penalty, it was performed at the end of
the two 10min periods of the playing time and the fault was immediately
sanctioned with free-throw.
The 3vs3 was completed as interval-training consisting of 30s of
match play interspersed with 30s of passive recovery. The 3vs3 comprised
goalkeepers and three-a-side field players. Each team comprised six field
players with 3 of them playing the match while 3 others standing out of the
handball court. The status was reversed every 30s periods. So immediately
after the whistle of the timekeeper players leave the court to be substituted
simultaneously. Before leaving, the ball carrier makes pass to one of his
teammate getting into the court. The rotary organization allowed mini-
mizing interruption of the game. Concerning technical task constraint,
ball dribble was avoided during match play.
The 6vs6 consisted in continuous handball game opposing six-a-side
field players plus goalkeepers.
All participants were accustomed to the experimental exercises insofar
they performed as part of their in-season training regime. During the
experimental period, the study-related sessions were implemented in the
team’s regular weekly training schedule (Box 1).
Box 1. Experimental setup of training sessions.
Monday Tuesday Wednesday Thursday Friday Saturday

Week 1 HB HB
Morning
Afternoon HB HB HB HB IFT
Week 2 HB HB
Morning
Afternoon HB ISR 6vs6 3vs3 HB
Week 3 HB HB
Morning
Afternoon HB ISR 6vs6 3vs3 HB
HB: technical and tactical handball training.
518
Measures
The field players’ HR was continuously recorded at 2s intervals using HR
chest memory belt (Suunto, Vantaa, Finland) throughout experimental
exercises. The HR time course was analysed from the beginning to the end
of each 2 periods of 10min exercise while 2min inter-period recovery was
excluded. Mean HR (absolute and relatively to HRmax) and time spent
in HR zone (Tzone) for three intensity zones12,19 (<80%, [80-90[%, and
≥90% of HRmax) were determined for ISR, 3vs3 and 6vs6. Between 5 to
10min following the conclusion of each exercise, field players were required
to provide a rating of perceived exertion (RPE) of the overall difficulty
of the exercise using Borg’s category-ratio scale (CR10)21, which consists
of 11 statements ranging from 0 to 10 (from “nothing” to “maximum”).
Players were requested to make certain that their RPE score referred to
the intensity of the whole session rather than the most recent sequence
intensity to avoid the instant perception of the last effort.
The normality of the data distribution was checked with the Shapiro-Wilk
test. Test-retest reproducibility of HRmax, Time spent in HR zones and
CR10 was assessed using the change in mean between measurements, the
typical error of measurement and retest correlation of Pearson as described
by Hopkins21 and Hopkins et al.22. To assess the magnitude of the correla-
tion coefficient, the threshold values were 0.1, 0.3, 0.5, 0.7, and 0.9 for low,
moderate, high, very high and nearly perfect, respectively22. The change in
mean was tested with paired Student’s t-test. The typical error of measure-
ment (TEM) for each variable was calculated with raw values as the SD of
the within subject absolute change measure between test and retest divided
by √2. The coefficient of variation (CV) was determined from the typical
error of the log-transformed data (TEMln) and thereafter calculated as
specified in the following equation: CV(%) = 100.[exp(TEMln) -1] where
exp is the natural exponential function. The P ≤ 0.05 criterion was used
for establishing statistical significance.
RESULTS
Values are mean ±SD. Test-retest differences are presented in Table 1.
The between-session reliability and the variability for ISR, 3vs3 and
6vs6 are shown in tables 2, 3, and 4, respectively. The magnitude of the
correlation coefficient between sessions for HR and Tzones ranged between
high to nearly perfect for ISR, high to very high for 3vs3 and high to nearly
perfect for 6vs6. Concerning mean HR during ISR, 3vs3 and 6vs6, low
CVs were shown with 1.23, 1.55 and 1.48%, respectively, whereas high
values were observed for Tzones in all experimental exercises. The main
result was CVs for the Tzone≥ 90% of HRmax reaching 9.73, 27.39, and
108.29% for ISR, 6vs6, and 3vs3, respectively.

Table 1. Heart rate (HR, bpm), percentage of maximal HR (%HRmax), time spent in heart rate
zones (Tzone, min) and category-ratio scale (CR10, AU). * P ≤ 0.05
Variables Test Retest

ISR HR 176.2±6.6 174.7±5.7
%HRmax 89.6±2.9 88.8±2.1
Tzone≥90% (min) 11.3±4.4 9.9±3.6*
Tzone[80-90[% (min) 7.6±3.8 8.8±3.2*
Tzone<80% 1.1±0.9 1.3±0.7
CR10 7.5±1.3 7.5±0.9
3vs3 HR 171.4±6.8 170.5±6.3
%HRmax 87.2±3.4 86.7±3.1
Tzone≥90% 7.5±5.3 6.8±4.1
Tzone[80-90[% 10.6±4.1 10.9±3.0
Tzone<80% 1.9±2.3 2.2±2.2
CR10 4.6±1.3 5.0±1.8
6vs6 HR 171.1±6.2 171.3±6.6
%HRmax 86.5±3.7 86.6±3.6
Tzone≥90% 7.0±5.8 6.6±5.5
Tzone[80-90[% 9.8±4.2 10.5±3.9
Tzone<80% 3.2±2.0 2.9±1.9
CR10 3.7±1.2 5.1±1.3*
Table 2. The ISR test-retest reliability for heart rate (HR, bpm), percentage of maximal HR
(%HRmax), time spent in heart rate zones (Tzone, min) and category-ratio scale (CR10, AU).
Variables r (CI 95%) TEM (CI 95%) CV (CI 95%)

HR 0.89* (0.65-0.97) 2.21 (1.57-3.76) 1.23 (0.87-2.11)
%HRmax 0.87* (0.58-0.96) 1.12 (0.79-1.90) 1.23 (0.87-2.11)
Tzone≥90% 0.94* (0.81-0.98) 1.12 (0.79-1.89) 9.73 (6.80-17.07)
Tzone[80-90[% 0.94* (0.78-0.98) 1.01 (0.72-1.72) 24.44 (16.75-44.95)
Tzone<80% 0.60* (0.04-0.87) 0.54 (0.38-0.91) 59.29 (39.07-120.43)
CR10 0.74* (0.28-0.92) 0.65 (0.46-1.10) 9.79 (6.90-17.21)
CI: confidence interval; r: Pearson’s correlation; TEM: typical error of measurement; CV: coefficient
of variation; * P ≤ 0.05.
Table 3. The 3vs3 test-retest reliability for heart rate (HR, bpm), percentage of maximal HR
Variables r (CI 95%) TEM (CI 95%) CV (CI 95%)

HR 0.86* (0.56-0.96) 2.63 (1.86-4.46) 1.55 (1.10-2.65)
%HRmax 0.85* (0.55-0.96) 1.33 (0.95-2.27) 1.55 (1.10-2.65)
Tzone≥90% 0.78$ (0.37-0.93) 2.42 (1.71-4.10) 108.29 (68.17-247.57)
Tzone[80-90[% 0.58* (0.01-0.87) 2.48 (1.76-4.22) 31.89 (21.66-60.00)
Tzone<80% 0.79* (0.40-0.94) 1.06 (0.75-1.80) 52.21 (34.66-104.06)
CR10 0.44 (-0.18-0.81) 1.23 (0.87-2.08) 55.09 (36.51-110.61)
of variation; * P ≤ 0.05; $ P = 0.06.
520
Table 4. The 6vs6 test-retest reliability for heart rate (HR, bpm), percentage of maximal HR
Variables r (95% CI) TEM (95% CI) CV (95% CI)

HR 0.87* (0.54-0.97) 2.46 (1.69-4.50) 1.48 (1.02-2.72)
%HRmax 0.90* (0.62-0.98) 1.24 (0.85-2.27) 1.48 (1.02-2.72)
Tzone≥90% 0.95* (0.81-0.98) 1.31 (0.90-2.40) 27.39 (18.12-55.57)
Tzone[80-90[% 0.90* (0.61-0.98) 1.40 (0.96-2.55) 22.46 (14.95-44.76)
Tzone<80% 0.59$ (-0.02-0.90) 1.26 (0.87-2.31) 45.15 (29.21-97.42)
CR10 -0.09 (-0.68-0.57) 1.31 (0.90-2.40) 36.38 (23.77-76.28)
of variation; * P ≤ 0.05; $ P = 0.07.
DISCUSSION
This study aimed to assess the reproducibility of physiological and per-
ceptual responses to ISR, 3vs3 and 6vs6, from a test-retest design in two
identical test sessions performed one week apart with the same professional
handball players.
The main finding was that mean HR showed high level of reproduc-
ibility for the three experimental exercises, with a lack of significant dif-
ference between test-retest sessions, a very high reliability and a low vari-
ability (with CVs ranged between 1.23 and 1.55%). TEMs ranged between
2.21 and 2.63 bpm were similar to that reported by previous researches
in laboratory conditions23,24. Analysing test-retest reliability of mean HR
during 4min bouts on treadmill with three submaximal intensities (14,
16 and 18km.h-1), Saunders et al.24 reported small TEM (ranged from
2.9 to 3.7bpm) and coefficient of variation (1.7 to 2.4%) with elite male
distance runners. Similar results were reported by Peserico et al.23 during
submaximal intensity stages in three continuous incremental tests protocols
on treadmill for running velocity at 14km.h-1 while TEM reached up 7bpm
with lower velocities (8-12km.h-1). Furthermore, the present TEM scores
for ISR, 3vs3 and 6vs6 are in agreement with previous research reporting
values of 2.6 bpm for mean HR during 30min team-sport simulation on
a non-motorised treadmill in laboratory25.
Moreover, the small CVs results reported in the present study are
comparable with those of previous field-based research15. Indeed, Ade et
al.15 revealed CVs for mean HR ranged between 1.3-1.9% and 0.9-1.9%
for soccer intermittent SSGs (1vs1 and 2vs2) and high intensity running,
respectively. In the present study, mean HR results suggests that the
differences between experimental exercises concerning the possibility to
control and plan time characteristics and work intensity not influence the
high level of test-retest reliability. High scores of reproducibility reported
in the present study may be related to intensity of experimental drills that
displayed mean HR response higher than 86.5% of HRmax. Indeed, pre-
vious authors reported that SSG intensity improved test-retest reliability
of HR response during ball-drills13.

The time spent in HR zones is a variable widely used in team-sports in

order to estimate the physiological demand of match play1,2, to assess the
internal training load9,12 and to control the training stimulus during run-
ning exercises and ball-drills with basketball9, soccer7 and handball players14.
Among the present experimental exercises, the time spent in HR zones not
differed between sessions for ball-drills while values revealed test-retest differ-
ences for ISR. Time spent in HR zone decreases for intensity ≥90% HRmax
and increases for [80-90[% HRmax during ISR. This result might be due to
training adaptation and/or variation in motivation between sessions. Indeed,
with a RPE score reaching 7.5 the ISR load was perceived as very heavy and
involved high degree of motivation with team-sport players. Indeed, traditional
running training has been perceived to be more strenuous compared with
specific ball-drills in soccer players despite similar HR demand19,26. Conse-
quently, SSG training is thought to increase player compliance and motivation.
Regarding overall HR zone results, TEM reached up 1.12, 1.40 and
2.48min for ISR, 6vs6 and 3vs3, respectively. The lack of previous data
not allows an appropriate comparison with these reproducibility scores.
Anyway, when TEM was expressed in CVs, variability showed wide extent
of scores particularly for Tzone≥90% HRmax, from 9.73% during ISR to
108.29% during 3vs3. These results suggest a lower variability for ISR than
6vs6 and 3vs3. The marked CV scores observed for ball-drills concerning
time spent in HR zones might be due to differences in temporal character-
istics of high-intensity actions between test and retest. Due to tactical and
technical requested during the course of the game, time characteristics of
high-intensity actions cannot be planned during SSGs. For instance, Ade
et al.15 reported high variability in time-motion with CVs of 141% for total
sprint distance and 62% in total very-high-speed running distance during
intermittent soccer SSGs with elite players. Such inter-sessions difference
should affect substantially the HR response. Indeed, it has been shown
that modifications either in sprint distance or in exercise/rest ratio during
repeated sprint drills affected significantly HR response27. The low TEM
score for 3vs3 may be explained by the strategy of player’s rotation mode
(short intervals, 30s-30s). Even if the match play was not stopped every 30s
period (i.e. offensive players can score a goal without the defenders to be
ready), the latency occurred during the substitution for players could not
be avoided. Frequent exchanges of players (every 30s) may be considered
as a limitation for test-retest reliability (Table 3). The 3vs3 intermittent
format needed further analyze to control reproducibility with various pause
and effort durations, before to be prescribed by coaches.
The time spent in HR zone is widely used to control the aerobic stimulus
during conditioning drill. The present results may be analysed in the light
of previous studies analysing the effectiveness of conditioning training on
physical fitness with team-sport players. It has been shown that intermit-
tent running and SSG should elicit intensity higher than 90% of HRmax
to provide an appropriate stimulus for large changes in physical fitness and
match play performance7,9. Assessing time spent in HR zones during 25min
522
of intermittent soccer SSG, Impellizzeri et al.7 reported a total duration
of 9min spent within the target intensity (≥90% of HRmax) shown to be
effective in enhancing aerobic fitness and soccer performance. Conversely,
a ball-drill based-training involving 4min above 90% of HRmax over each
training session was not adequate for substantial improvement of aerobic
power with basketball players9. For practical aspects, present TEMs might
be considered in the light of these previous results. With a TEM of 1.1min
for total time spent above 90% of HRmax of 11.3min and 9.9min in test
and retest, respectively, the ISR is considered to be the most efficient in
improving aerobic power among our experimental drills. Conversely, due
to concomitant higher TEM and shorter duration spent within the target
intensity, both 3vs3 and 6vs6 needed further analyse to be considered as
conditioning drills specifically designed to improve aerobic power.
The reproducibility of RPE was higher in ISR than in both ball-drills.
The RPE score presented low variability between sessions for ISR with
TEM of 0.65 and CV of 9.79%. These results are in line with previous
research conducted in laboratory conditions23 and analysing reproducibility
of RPE in three continuous incremental exercises performed on treadmill
(TEM between 0.5 and 1.3 and CV between 5.2 to 15.3%). Nevertheless,
CV assessed for ISR was lower than that reported in field condition in
response to 8min bouts of submaximal intermittent running (10, 11.5 and
13 km.h-1, CV ≈ 31.9%) with team sport athletes28. In the present study,
CVs were four and six fold greater in 6vs6 and 3vs3, respectively when
compared with ISR, which showing high test-retest variability. Few studies
analysed reproducibility of RPE in SSG. Compared with our results, Ade
et al.15 reported smaller CVs (2.9-5.7%) for both running drills and soccer
SSG with elite players. However, these authors not specified if CV was
determined from raw or log transformed values which did not allow an
appropriate comparison 21. Finally, ISR and 6vs6 presented similar CVs to
that reported by Rampinini et al.13 with soccer SSGs (CV ranged between
5.5 and 31.0%). Because RPE evaluate psychophysiological strain of players,
involving interaction of perceptual, cognitive and metabolic processes a poor
between sessions reproducibility was expected. Nevertheless, ISR’s level
of reproducibility was similar with that observed in laboratory condition.
CONCLUSIONS
Mean HR response elicited by ISR, 3vs3 and 6vs6 demonstrated high level
of test-retest reproducibility with similar scores to that reported during
treadmill running in laboratory condition. Therefore, when coaches pre-
scribed one of these drills in separate occasions they can be confident in
expecting the same overall training demand. However, time spent in HR
zone higher than 90% of HRmax shown poor reproducibility for both ball-
drills while exercise design is kept consistent. Therefore, the effectiveness of
ball-drills used in this study to provide a sufficient stimulus for improving
aerobic power remains uncertain and should be analysed with caution.

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Relative age effect in Brazilian Basketball

Championship: Under 15 players
Efeito da idade relativa no Campeonato Brasileiro de
Basquete: Categoria sub-15
Helder Zimmermann de Oliveira1
Dilson Borges Ribeiro Junior 2
Jeferson Macedo Vianna 2
Francisco Zacaron Werneck 3
Abstract – In sport, the relative age effect (RAE) refers to the advantages of participation
and performance that athletes born in the first months of the selection year have in relation
to those within the same age category. The aim of the present study was to investigate the
RAE in athletes of the Brazilian Basketball Championship of the U-15 category in 2015,
analyzing differences between sexes, geographic region, competitive level and performance
of teams. The information of teams and the birth quarter (quartile) of 530 basketball play-
ers were obtained through the website of the Brazilian Basketball Confederation (www.
cbb.com.br). The results showed greater representation of male athletes born in the first
months of the year, the first and second divisions, of the Southeastern, Northern and
Mid-Western regions and in female medalists. It was concluded that the RAE is present
in Brazilian U-15 male basketball players, being higher in athletes of higher competitive
level, particularly in the Southeastern, Northern and Mid-Western regions of Brazil. In
addition, RAE proved to be associated with the winning of women’s medals.
Key words: Athletes; Basketball; Relative age.
1 University of Porto. Faculty of
Resumo – No esporte, o efeito da idade relativa (EIR) refere-se a vantagens de participação Sport. Porto. Portugal.
e desempenho que os atletas nascidos nos primeiros meses do ano de seleção possuem em relação
aos demais atletas dentro de uma mesma categoria etária. O objetivo do presente estudo foi 2 Federal University of Juiz de Fora.
Faculty of Physical Education and
investigar o EIR nos atletas do Campeonato Brasileiro de Basquetebol da categoria sub-15 em
Sports. Juiz de Fora, MG. Brazil.
2015, analisando diferenças entre os sexos, região geográfica, nível competitivo e desempenho
das equipes. As informações das equipes e o trimestre de nascimento (quartil) de 530 basque- 3 Federal University of Ouro Preto.
tebolistas foram obtidas através do site da Confederação Brasileira de Basketball (www.cbb. Sports Center. Laboratory of Studies
com.br). Foi observada maior representação de atletas nascidos nos primeiros meses do ano da and Research of Exercise and Sports
primeira e segunda divisões, das regiões Sudeste, Norte e Centro-Oeste do sexo masculino e nas (LABESPEE). Ouro preto, MG. Brazil.
equipes medalhistas do sexo feminino. Conclui-se que o EIR está presente em basquetebolistas
brasileiros da categoria sub-15 do sexo masculino, sendo maior nos atletas de nível competitivo Received: August 12, 2017
Accepted: September 21, 2017
mais elevado, particularmente nas regiões Sudeste, Norte e Centro-Oeste do Brasil. Além disso,
o EIR mostrou-se associado à conquista de medalhas no sexo feminino. Licença
Palavras-chave: Atletas; Basquetebol; Idade relativa. BY Creative Commom
INTRODUCTION
The need to understand sports excellence, performance and the selection of
athletes promotes the interest of several researches, becoming an important field
of investigation in the scientific community1,2. Several aspects may interfere with
the performance of young athletes, including the month of birth. Considering
January 1 and December 31 as the start and end of the selection year, respectively,
and that young athletes are normally grouped into age categories with an interval
of 2 years, there may be a difference of up to 24 months in the chronological age
of participants of a same age category, according to their birth date3.
The difference in chronological age among individuals of the same
age category is called relative age4. When the birth date distribution of a
selected group of athletes differs from the expected normal distribution,
with a greater representation of athletes born in the first months of the year,
there is a phenomenon known as the relative age effect (RAE)4. RAE has
directly and indirectly interfered with the selection or dropout of young
athletes, as selection considers body size and physical performance, and
coaches tend to choose the tallest, strongest and most agile, and most of
them are older5. Thus, RAE has been observed mainly in contexts of selec-
tion of young athletes for national teams and athlete development programs6.
RAE is more evident in sports in which performance is related to
strength, power and body size, predominantly in young athletes, and in
teams with higher competitive level7. In addition, some studies have shown
that RAE may also be associated with better performance8, being observed
in athletes belonging to winning teams, finalists and semi-finalists9.
In international basketball, RAE was often observed8,10-13, although
such phenomenon is not always observed14,15. In the context of Brazilian
basketball, the only study with adult athletes did not find RAE in basket-
ball players participating in the 2012 London Olympic Games16. In young
athletes, Cortela et al.17 found higher proportion of athletes born in the first
half of the year, but only among male Schoolchildren athletes. In athletes
of the 2015 Brazilian U-17 Championship, Oliveira et al.18 found RAE in
both sexes, also associating the results to the best teams.
Although studies partially analyzed RAE in Brazilian base category of
basketball, no research was found in the U-15 category alone and associ-
ated with other variables. It is important to point out that the first official
national championship takes place in this category, involving all states of
the country. This competition, the Brazilian U-15 Basketball Champion-
ship, the target of the present study, is the first selection process for the
formation of national and state teams, which attracts the attention of all
those involved in the training of athletes in Brazilian basketball. Therefore,
investigating the existence of RAE and possible relationships with other
variables in this category may contribute to a more appropriate selection
process to formation of basketball players.
Thus, the aim of the present study was to investigate RAE in U-15 athletes
of the 2015 Brazilian Basketball Championship, analyzing possible differences

Relative age effect in Brazilian Basketball Championship Oliveira et al.
between sexes, geographic region, competitive level and team performance.
All participants of the Brazilian U-15 Basketball Championship who played
in 2015 were analyzed (n = 530). Male athletes presented on average 15.0 ± 0.5
years, 70.4 ± 13.2 kg and 1.80 ± 0.09 m; female athletes 14.6 ± 0.8 years, 58.2 ±
9.3 kg and 1.68 ± 0.08 m. The information for the study was obtained from the
website of the Brazilian Basketball Confederation (CBB) (http://www.cbb.com.
br). The use of public data available on the internet for analysis has been described
in other studies without need for approval of the ethics research committee16,18-20.
The championship was played by 27 men’s teams and 26 women’s teams,
each representing one of the Brazilian States and the Federal District. The
teams are ranked in divisions (1st division: 10 teams, 2nd division: 8 teams,
3rd division: 9 teams), according to the classification obtained in the previ-
ous year’s championship. The championship is conducted separately by sex
and division. At the end of the championship, the three top-ranked teams
ascend to the top division, while the three worst teams are downgraded.
The month of birth of each player was categorized into quartiles: 1st
quartile (Q1): January to March; 2nd quartile (Q2): April to June; 3rd quartile
(Q3): July to September; 4th quartile (Q4): October to December. In order
to investigate the presence of RAE, the distribution of birth quartiles was
compared with the expected distribution in the reference population of
live births in Brazil in the years 2000 and 2001, using the Chi-Square test
(Χ2) and Odds Ratio (OR) with 95% confidence interval (CI). OR com-
pared the distribution of the first three quartiles with the last quartile, as
recommended by Cobley et al.7. Data from the reference population were
obtained from the Live Birth Information System (SINASC), extracted
from DATASUS (http://datasus.saude.gov.br/). In order to analyze possible
factors involved in RAE, the analysis of data was performed separately by
gender, geographic region, competitive level and performance (medalists -
athletes of teams that obtained the first three places; downgraded - athletes
of teams that finished in the last three places; and intermediaries - other
athletes). All analyses were performed in the SPSS statistical software ver-
sion 23.0 (IBM Corp., Armonk, NY), adopting significance level of 5%.
RESULTS
Table 1 shows the Χ2 test values f or the distribution of birthdates. Greater
representation of athletes born in the first two quartiles in relation to the
last two quartiles for all male athletes was observed.
Table 2 shows the Χ2 test values and the distribution of athletes by
quartile, taking into account the championship divisions. RAE was veri-
fied in the 1st division and 2nd division for males.
Table 3 shows the RAE in the Southeastern, Northern and Mid-
Western regions only for males, not being found for females.
528
Table 1. Evaluation of birth quartiles of athletes of the Brazilian U-15 Basketball Championship
Number (%) of athletes per quartile OR(95% Confidence Interval)

N X2 p
Q1(%) Q2(%) Q3(%) Q4(%) Q1xQ4 Q2xQ4 Q3xQ4
Population 6.322.235 1611004 1659471 1584085 1472675 N/A N/A N/A N/A N/A
(25.5) (26.2) (25.1) (23.3)
All 530 179 154 114(21.5) 83 31.91 <0.001* 1.97 1.65 1.28
(33.8) (29.1) (15.6) (1.38-2.81) (1.15-2.37) (0.88-1.85)
Female 260 71 81 59(22.7) 49 5.56 0.133 1.32 1.47 1.12
(27.3) (31.2) (18.8) (0.80-2.19) (0.90-2.41) (0.67-1.87)
108 73 34 2.90 1.90 1.50
Male 270 55(20.4) 38.06 <0.001*
(40.0) (27.0) (12.6) (1.73-4.85) (1.12-3.25) (0.87-2.60)
X 2: chi-square test; 1st Quartile (Q1): Jan-Mar; 2nd Quartile (Q2): Apr-Jun; 3rd Quartile (Q3): Jul-Sep; 4th Quartile (Q4): Oct-Dec. p <0.005;
N / A: Not applicable.
Table 2. Evaluation of birth quartiles of athletes of the Brazilian U-15 Basketball Championship

Division X2 P
Q1(%) Q2(%) Q3(%) Q4(%) Total Q1xQ4 Q2xQ4 Q3xQ4
Female
1st Division 28(28.0) 33(33.0) 18(18.0) 21(21.0) 100 4.25 0.236 1.21 1.40 0.80
(0.54-2.70) (0.64-3.05) (0.34-1.85)
2nd Division 20(25.0) 25(31.3) 19(23.8) 16(20.0) 80 1.22 0.748 1.14 1.39 1.09
(0.46-2.83) (0.57-3.37) (0.44-2.75)
3rd Division 23(28.8) 23(28.8) 22(27.5) 12(15.0) 80 3.082 0.379 1.75 1.71 1.70
(0.68-4.70) (0.67-4.35) (0.66-4.36)
Male
1st Division 43(43.0) 33(33.0) 15(15.0) 9(9.0) 100 26.642 <0.001* 4.37 3.26 1.55
(1.75-10.87) (1.29-8.22) (0.57-4.20)
2nd Division 36(45.0) 15(18.8) 19(23.8) 10(12.5) 80 17.705 <0.001* 3.28 1.33 1.76
(1.28-8.41) (0.48-3.68) (0.65-4.74)
1.76 1.47 1.29
3rd Division 29(32.2) 25(27.8) 21(23.3) 15(16.7) 90 3.495 0.321 (0.75-4.17) (0.61-3.52) (0.53-3.15)
X 2: chi-square test; 1st Quartile (Q1): Jan-Mar; 2nd Quartile (Q2): Apr-Jun; 3rd Quartile (Q3): Jul-Sep; 4th Quartile (Q4): Oct-Dec. p <0.005
Table 3. Evaluation of birth quartiles of athletes of the Brazilian U-15 Basketball Championship by geographic region

Region X2 P
Female N/A N/A N/A
Northern 21(30.0) 14(20.0) 23(32.9) 12(17.1) 70 4.404 0.221 1.60 1.04 1.78
(0.60-4.25) (0.37-2.88) (0.67-4.68)
Southern 5(16.7) 12(40.0) 5(16.7) 8(26.7) 30 4.099 0.251 0.57 1.33 0.58
(0.13-2.63) (0.34-5.15) (0.12-2.66)
Southeastern 14(35.0) 15(37.5) 7(17.5) 4(10.0) 40 7.31 0.062 3.19 3.32 1.63
(0.77-13.2) (0.80-13.63) (0.36-7.43)
Northeastern 21(26.3) 24(30.0) 19(23.8) 16(20.0) 80 0.891 0.828 1.19 1.33 1.10
(0.48-2.96) (0.54-3.25) (0.44-2.75)
Mid-western 10(25.0) 16(40.0) 5(12.5) 9(22.5) 40 5.458 0.141 1.01 1.57 0.52
(0.29-3.59) (0.47-5.24) (0.12-212)
Male
Northern 28(40.0) 20(28.6) 13(18.6) 9(12.9) 70 10.397 0.015* 2.85 1.98 1.32
(1.03-7.80) (0.71-5.55) (0.45-3.91)
Southern 10(33.3) 9(30.0) 7(23.3) 4(13.3) 30 2.206 0.531 2.30 1.99 1.63
(0.49-10.80) (0.42-9.45) (0.33-8.11)
Southeastern 17(42.5) 14(35.0) 6(15.0) 3(7.5) 40 11.639 0.009* 5.17 4.13 1.86
(1.13-23.51) (0.90-19.04) (0.36-9.67)
Northeastern 32(35.6) 25(27.8) 21(23.3) 12(13.3) 90 7.611 0.055 2.43 1.84 1.62
(1.00-5.93) (0.75-4.56) (0.64-4.08)
3.19 0.73 1.24
Mid-western 21(52.5) 5(12.5) 8(20.0) 6(15.0) 40 15.914 0.001* (0.90-11.36) (0.17-3.24) (0.31-4.96)
X2: chi-square test; 1st Quartile (Q1): Jan-Mar; 2nd Quartile (Q2): Apr-Jun; 3rd Quartile (Q3): Jul-Sep; 4th Quartile (Q4): Oct-Dec. p
<0.005. N / A: Not applicable

Regarding the team performance, RAE was verified only in females,

since in males, RAE was observed in all groups.
Table 4. Evaluation of birth quartiles of athletes of the Brazilian U-15 Basketball Championship by team classification

Division X2 p
Female
24(26.7) 35(38.9) 22(24.4) 9(10.0) 90 12.439 0.006* 2.43 3.44 2.26
Medalists
(0.92-6.41) (1.34-8.81) (0.85-6.01)
26(28.9) 24(26.7) 18(20.0) 22(24.4) 90 2.397 0.985 1.07 0.97 0.76
Intermediaries
(0.47-2.45) (0.42-2.20) (0.32-1.80)
21(26.3) 22(27.5) 19(23.8) 18(22.5) 80 0.149 0.985 1.06 1.08 0.98
Lowest ranking
(0.44-2.59) (0.45-2.62) (0.40-2.40)
Male
33(36.7) 27(30.0) 19(21.1) 11(12.2) 90 10.218 0.017* 2.74 2.17 1.60
Medalists
(1.10-6.77) (0.87-5.43) (0.62-4.14)
37(41.1) 24(26.7) 19(21.1) 10(11.1) 90 14.933 0.002* 3.37 2.12 1.76
Intermediaries
(1.35-8.44) (0.83-5.46) (0.67-4.63)
2.67 1.50 1.20
Lowest ranking 38(42.2) 22(24.4) 17(18.9) 13(14.4) 90 14.402 0.002*
(1.12-6.33) (0.61-3.70) (0.47-3.08)
X 2: chi-square test; 1st Quartile (Q1): Jan-Mar; 2nd Quartile (Q2): Apr-Jun; 3rd Quartile (Q3): Jul-Sep; 4th Quartile (Q4): Oct-Dec. p <0.005.
DISCUSSION
The aim of the present study was to investigate the presence of RAE in
Brazilian U-15 basketball athletes, analyzing possible intervening variables.
The presence of RAE was verified in males, in teams in the Southeastern,
Northern and Midwestern regions, and in first and second division athletes,
regardless of the team’s final classification. However, for females, RAE
was found only in the best ranked teams.
The results found in the present study corroborate those of the inter-
national literature10-12,21,22. Multiple factors related to the individual (birth
date, sex and maturation), task (type of sport, competitive level and game
position) and environment (sports system-division into categories, popular-
ity of sport, influence of family and coaches) interact for the occurrence of
RAE4,19,23. Of these factors, the emphasis on the physical aspects related to
the sport performance for the selection of talents and the grouping into age
categories that last about two years are pointed out as the main responsible
for the occurrence of RAE.
Regarding gender, RAE is particularly evident in males in various
modalities24, including basketball, so the results found confirm the findings
of other studies with U-15 basketball players in France5,11 and Spain 21,22.
Studying RAE in this category becomes important, since from 13 to 15
years, boys are in a period of great biological variability, as a function of the
growth spurt. In this period of adolescence, due to maturational processes,
chronologically older boys are generally taller and heavier, stronger and
faster, and exhibit greater cognitive abilities and greater sports experience,
resulting in temporary performance advantages over their peers chronologi-
cally within the same age category4.
530
In female athletes, RAE is not so evident 20 and tends to disappear in
adulthood8,14 and there are situations in which inverse RAE is observed 25.
Our findings for females do not corroborate the available literature. In
young female basketball players, RAE was observed in French girls aged
7-18 years5,11, in Brazilian schoolchildren17 and in U-17 athletes of the
2015 Brazilian Basketball Championship18. Some factors could explain the
inconsistency of findings in females such as: less competition in selective
processes and lower maturational variability in girls at ages when athletes
are usually selected 20,26.
In relation to the competitive level, the presence of RAE is directly
proportional to higher demand levels4,7, starting from sports training
programs21. In the present study, RAE was verified in the 1st and 2nd divi-
sion of the men’s Brazilian championship. This result corroborates results
found in Spanish basketball12, where the effect was found in the first three
divisions. The presence of RAE at higher competitive levels was found in
a meta-analysis with athletes of different modalities and countries7. Thus,
the results of the present study corroborate the premise that greater com-
petition in the selective process may aggravate RAE25.
In fact, the chronological age of young athletes in relation to their peers
has been considered a relevant factor, which affects the athlete’s chance of
achieving higher performance levels7,19. However, coaches and managers
should be careful in the conduction of selective processes, since the quality
of the evidence of the relationship between birth date and athletic success
is insufficient 27. In the present study, for example, RAE was not associ-
ated with the performance of men’s teams, but it was observed that RAE
could somehow influence the results for females, since this phenomenon
was found only in athletes from the best classified teams. Similar result
was found in U-17 Brazilian basketball players18.
The association of RAE with the final classification of the team found
in this study and in the study of Oliveira et al.18 suggest as a consequence
of RAE in the Brazilian Women’s Championship a better performance of
teams in the U-15 and U-17 categories. However, the same cannot be said
about the final classification of men’s teams. Other studies on the relation-
ship between RAE and performance in young basketball players found
that athletes born in the first months of the year had better performance
in three-point shot in the U-17 category of the world basketball champion-
ship8 and improved performance in some technical foundations for both
sexes in Polish basketball players of various categories28.
In the present study, caution is required in interpreting the relationship
between RAE and classification of teams in the championship, since the birth
year of athletes was not controlled in this analysis. It is known that in the
short term, coaches end up selecting older athletes based on their immediate
performance, implying better conditions and development opportunities,
unlike younger athletes who end up leaving the sport more frequently5,29.
Another relevant aspect in the analysis of RAE relates to the birth
place of athletes, in this study represented by the geographic region of each

team. RAE was observed in male athletes belonging to the Northern,

Southeastern and Mid-Western basketball federations. Some studies at-
tribute the cause of RAE to the context, more specifically between RAE
and the number of inhabitants of the city15,20. Although it is not possible
to attribute cause or relationship between the results found and other
studies, it is noteworthy that the Southeastern region has greater number
of teams, and also, have the states with more titles won in all editions of
the Brazilian Basketball championships.
As a practical implication, it is recommended that coaches, federations
and confederations know about RAE, the variables associated with this
phenomenon and its consequences in order to avoid early dropout of sports
practice29. In the base categories of French basketball, in boys, the highest
dropout occurs in those born in the 4th quartile, especially at 13-14 years,
while in girls, it occurs earlier, around 11-125. According to the study5,
athletes born in the 3rd and 4th quartiles tend to abandon basketball because
they are smaller, have lower performance, play less time and therefore ex-
perience fewer positive experiences, reducing their perceived competence.
Possible solutions to minimize this problem include, for example,
dividing age categories into intervals of at least 12 months4,11, and more
recently the combination of the annual rotation of the selection cutoff
point (January 1 and July 1) and additional training support to relatively
younger athletes has been considered a very effective strategy24. According
to Werneck et al.24, the strategy adopted must take into account not only
available scientific evidence, but also the logistics for its implementation
in practice, which often implies changes in the structure of competitions.
The way the Brazilian Base Basketball Championship was organized
may need to be adjusted to reduce RAE in the process of selecting young
basketball players.
CONCLUSION
The present study brings new contributions to the knowledge of the rela-
tive age effect in basketball in the hope that the selection of athletes in
basketball will advance in order to avoid athletes being early excluded from
the process of sports formation. It was concluded that RAE is present in
the U-15 category of basketball players who competed in the 2015 Bra-
zilian Basketball Championship. The presence of RAE was statistically
significant in male athletes, in athletes in the 1st and 2nd divisions, athletes
in the Southeastern, Northern and Mid-Western regions and presented a
relationship with the winning of medals in women.
Acknowledgments
CAPES (process No. 99999.002183 / 2015-03) and Federal University of
Ouro Preto for the financial support.
532
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534
Influence of functional and traditional training

on muscle power, quality of movement and
quality of life in the elderly: a randomized
and controlled clinical trial
Influência dos treinamentos funcional e tradicional na
potência muscular, qualidade de movimento e qualidade
de vida em idosas: um ensaio clínico randomizado
e controlado
Leury Max Da Silva Chaves1
Antônio Gomes De Rezende-Neto1
Albernon Costa Nogueira1
José Carlos Aragão-Santos1
Leandro Henrique Albuquerque Brandão1
Marzo Edir Da Silva-Grigoletto1,2
Abstract – Aging causes a reduction in the adaptive capacity of the organism. Therefore,
there is a decrease in physical fitness, making it difficult to perform basic movements and
the development of muscular power. Thus, to minimize this reduction, functional and
traditional training can both be used; however there is no clarity about which is most
effective. The aim of this study was to identify the influence of functional and traditional
training on muscle power, quality of movement and quality of life in the elderly. Forty-
four older women were randomly divided into functional group (FG n=18), traditional
group (TG n=15) and control group (CG n=11). Thirty-six sessions lasting 50 minutes
were performed. Quality of life (WHOQOL-bref ), quality of movement (FMS) and
muscular power were evaluated. FG and TG increased significantly in relation to control
group and to the initial FMS values. In FG and TG, muscle power significantly improved
compared to pre-test, but not in relation to the control group. Regarding quality of life,
only FG presented significant improvement. Both applied methods demonstrate the ability
to improve the quality of movement and muscle power. However, functional training
achieved better results in quality of life and movement.
Key words: Activities of daily living; Aging; Exercise.
Resumo – O envelhecimento ocasiona uma redução na capacidade adaptativa do organismo.

Por conseguinte, há uma diminuição na aptidão física dificultando a realização de movimentos
básicos e o desenvolvimento de potência muscular. Desse modo, entre a formas de minimizar
essa redução tanto treinamento funcional quanto o tradicional podem ser utilizado, contudo 1 Federal University of Sergipe.
não há clareza sobre qual o mais eficaz. Objetivou-se identificar a influência dos treinamentos Center for Biological and Health
Sciences. Department of Physical
funcional e tradicional na potência muscular, qualidade de movimento e de vida em idosas.
Education. Graduate Program in
Quarenta e quatro idosas foram randomicamente divididas em grupo funcional (GF n=18), Physical Education. São Cristovão,
tradicional (GT n=15) e controle (GC n=11). Foram realizadas 36 sessões com duração de 50 SE. Brazil.
minutos. Foram avaliadas a qualidade de vida (WHOQOL-bref ), qualidade de movimento
(FMS) e potência muscular. O GF e GT aumentaram significativamente em relação ao grupo 2 Scientific Sport. Aracaju, SE.
controle e aos valores iniciais no FMS. Na potência muscular os grupos GF e GT melhoraram Brazil.
significativamente comparado ao pré-teste, mas não em relação ao controle. Na qualidade de
vida apenas o GF apresentou melhora significativa. Ambos os métodos aplicados demostram a Received: September 20, 2017
Accepted: November 20, 2017
capacidade de melhorar a qualidade de movimento e potência muscular. Contudo o treinamento
funcional obteve resultados superiores na qualidade de vida e de movimento. Licença
Palavras-chave: Atividades Cotidianas; Envelhecimento; Exercício. BY Creative Commom
Functional training versus traditional training in the elderly Chaves et al.
INTRODUCTION
In the aging process, a series of physiological, psychological and structural
events occur, impairing the quality of movement, functional capacity and
autonomy1. Consequently, aspects such as decreased strength (dynapenia),
muscle mass (sarcopenia), muscular power and joint mobility, directly re-
flect in the incidence of falls and the performance of activities of the daily
living (ADL) in this population 2-4.
The main functional movements performed in everyday activities are a
combination of strength, balance, resistance, power among other capabilities
that at satisfactory levels allow safety and efficiency5,6. In addition, factors
such as mobility and joint stability are fundamental to provide better per-
formance in movements such as squatting, carrying some external load and
overcoming obstacles. An example is the functional walking action, in which
there is a relationship among ankle mobility, hip mobility and knee stability7.
In this context, functional training (FT) appears as an option to im-
prove the quality of movement used in ADLs and to stimulate the different
components of physical fitness in the elderly5,8. This method consists in the
application of integrated, multi-joint and multiplanar exercises aimed at
improving movements, core strength gains and neuromuscular efficiency
to the specific needs of each individual9.
Milton4 applied functional exercises in four weeks of intervention and
showed a 43% improvement in shoulder mobility, 13% in agility / dynamic
balance, 14% and 13% in upper and lower limb strength and 7% in cardiore-
spiratory capacity in comparison with a group that performed conventional
activity. However, it is not clear in the current literature the influence of
FT on the mobility and stability required for better quality of movement,
as well as its effects on muscle power and quality of life in older adults.
Other studies have analyzed traditional training - here understood as
classic bodybuilding, commonly performed in gyms – and found improve-
ments in physical fitness and health of the general population, being also
widely used in the elderly population. The gains in physical conditioning
associated with this method are very broad; however, we can highlight
the development of muscular power as one of the main benefits for older
adults10,11. Muscle power is directly related to functional parameters, and
should be stimulated in different types of interventions, including func-
tional training, but due to the greater control of load and safety provided
by fitness equipment, traditional strength training, despite the lower
specificity of exercises, can interestingly develop this capacity, reflecting
in other aspects related to elderly people such as quality of life2,3. Thus, the
aim of the present study was to identify the influence of functional and
traditional training on the quality of movement, muscle power and qual-
ity of life in the elderly. Our hypothesis is that specific training protocols
for ADLs should contain multiplanar exercises with greater activation of
stabilizing muscles, thus promoting better functionality and quality of life.
We believe that training protocols directed to ADLs are more efficient
536
in improving functionality and quality of life in the elderly due to the
principle of training specificity.
This is a study with experimental design for applying specific training in
groups of individuals, aiming to control the action of intervening factors
and to investigate the effects on dependent variables12.
Sample and sampling procedure

The sample size was calculated using GPOWER 2.0 software according to
Pacheco1, with variable movement quality. Thus, 44 older women were ran-
domly assigned to: Functional Group (FT n = 18, BMI = 29.0 ± 4.9 kg / m²),
Traditional Group (TT n = 15, BMI = 28.5 ± 5.5 kg / m²), and control group
(CG n = 11, BMI = 30.4 ± 5.9 kg / m²). Baseline data are shown in table 1.
The methodological procedures of the study were verbally explained and
participants agreed to voluntarily participate in the research by signing the
free and informed consent form. The study flowchart is presented in figure 1.
Figure 1. Study flowchart.
Inclusion and exclusion criteria

Inclusion criteria were: (1) 60 years of age or older, (2) complying with
initial assessments (medical, physical and nutritional), (3) not having any
joint or cardiac instability that would impair training, (4) agree in not
participating in any other type of regular physical activity other than the
prescribed training. Those who did not reach attendance of at least 85%
of training sessions were excluded from the sample.

Intervention
All groups performed training three times a week for 12 weeks, the time for
interval between sessions was 48 hours and each session lasted 50 minutes.
In TG and FG groups, the OMNI-GSE13 scale was used to control and
normalize the overall training intensity between groups.
After evaluations, participants went through two weeks of familiariza-
tion, in which 60% of the volume planned for the first session was applied,
and then they completed 36 sessions of progressive training.
Box 1. Activities applied in block 2 of the functional training group, and activities performed in block 3 of the functional and traditional
training groups.
Exercises Block 2 – Functional Training

Phase 1 (1-18 sessions) Phase 2 (18-36 sessions)
Up and down the step Jump under the step
Rope training linear Rope training linear
Vertical Throwing Ground Throwing
Displacement between cones Run and jump between cones
Ladder of linear agility Ladder of lateral agility
5 activities, 3 passages, 1’ per station, density of 1/1. OMI- 5 activities, 3 passages, 1’ per station, density of 2/1. OMINI-
NI-GSE: 6 to 7 at 60-70% of HRmax GSE: 6 to 7 at 60-70% of HRmax
Exercises Block 3 – Functional (FG) and traditional training (TG)
FG (1-18) TG (1-18) FG (18-36) TG (18-36)
Ground lifting (ketlebells) Squatting (Smith) Shouldering (bulgarian bag) Squatting (free)
Horizontal pull (Suspension Vertical pull (Articulated row) Horizontal pull (Suspension Vertical pull (Articulated row)
strap, OW) strap, OW)
Sit and stand up from bench Knee extension (Leg press Goblet Squats (Ketlebells) Knee extension (Extension
45 °) chair)
Vertical push up (elastic) Vertical push up (Vertical Push-ups (40 cm bench, OW) Horizontal push up
supine)
Farmers walk (ketlebells) Knee flexion (Flexor table) Farmers walk (ketlebells) Knee flexion unilateral (ankle
weight)
Vertical row (elastic) Front row Vertical row with knee lift Front row with neutral grip
(elastic)
Pelvic elevation (OW) Bilateral standing calf (OW) Pelvic elevation (OW) Calf (leg press 45 °)
Front plate (40 cm bench) Stiff (bar and weights) Front plate (step) Abdominal (curl up)
* The Anglo-Saxon name of some exercises described above is due to the frequent in the training area in Brazil, own weight (OW).
Functional Group (FG)

The training session was divided into 4 blocks: (1) 5’ of joint mobility with
1 series of 8” per exercise for the main body joints (waist, pelvic, knees and
ankles); (2) 15’ of activities organized in circuit that developed coordination,
power and agility; (3) 18’ also in circuit with multifunctional, integrated
and multi-joint exercises, specific to their daily needs, with 8 exercises, 2
series of 08-12 repetitions maximum at 70-85% of 1 RM and OMINI-
GSE scale between 7 and 8; (4) 5’ of high-intensity cardiometabolic work
(HIIT), through activities such as: tug of war, interval running and aerobic
gymnastics, with density of 1/1 and scale OMNI-GSE between 8 and 9.
The exercises performed in blocks 2 and 3 are shown in Box 1.
538
Traditional Group (TG)
The training session was divided into 4 blocks: (1) the same way as for FG;
(2) 15’ of continuous walking, with OMINI-GSE from 6 to 7; (3) 18’ of
traditional exercises in predominantly analytical machines with more iso-
lated neuromuscular work composed of 8 exercises, with 2 series of 08-12
maximum repetitions at 70-85% of 1 RM and OMINI-GSE scale between
7 to 8, also performed in circuit; (4) 5’ of high-intensity cardiometabolic
work (HIIT), also performed in the same way as for FG.
Both groups performed exercises at maximum concentric velocity
and the training progression occurred according to the level of ability and
comfort of the volunteer, for maintenance of 8 to 12 maximal repetitions
performed at density of 1/1 (30’’: 30’’), with load readjustment whenever
the range of repetitions was exceeded.
Control group
Participants performed stretches with submaximal joint amplitude levels
and relaxation practices, with frequency of three weekly sessions and du-
ration of approximately 50 min / session in order to maintain the sample.
Data collection procedures

Initially, anamnesis was carried out with questions regarding the charac-
terization of the level of health and physical activity (report of activities
of daily living and work). Afterwards, nutritional assessment was made
through a usual dietary recall14, to control and monitor feeding during the
training period.
The test battery was performed in three moments: pre-test (M1); retest
after two weeks of familiarization (M2); and after 12 weeks of interven-
tion (M3). Tests were performed in the following order: anthropometric
measurements, Questionnaires (Mini Mental State Examination and
WHOQOL-Bref), Functional movement screen and muscle power.
Tests
For the anthropometric characterization, body weight (kg) was measured
through a scale (Lider®, P150C, São Paulo, Brazil), with maximum capac-
ity of 150 kg. Height (cm) was determined through a stadiometer (Sanny,
ES2030, São Paulo, Brazil).
For better distribution of participants in the training programs, the
Mini Mental State Examination (MMSE) was used, which consists of a
score ranging from zero to 30 points that aims to provide data on various
cognitive parameters of any geriatric population15.
Quality of life was assessed based on the WHOQOL-Bref structured
questionnaire16, which values i ndividual perception in different groups and
situations. The test consists of 26 questions including four domains of life:
physical, psychological, social and environmental. Responses follow the
Likert scale (from 1 to 5; the higher the score, the better the quality of life).
The quality of movement has been verified through the Functional

Movement Screen™, which involves seven movement patterns that quali-

tatively evaluate mobility, stability and strength and assign a numerical
score to each pattern. The score of each test varies from 0 (pain during
the execution of the movement), 1 (non-execution of the movement), 2
(execution of the movement with some compensation) and 3 (perfect
execution of the movement). Each movement pattern was performed
three times, including bilateral ones, in order to obtain the best result.
The final score recorded will be the best judgment on each side and
the final result will be the worst score between the two sides for each
standard (in the case of tests that are bilaterally performed). The FMS
™ total score is the sum of all separate scores and the highest possible
score is 21 points17,18.
Muscle power was evaluated from two basic movement patterns, push
(vertical bench press and 45º leg press) and pull (articulated row). The load
established to evaluate muscle power was 50% of the value of a maximum
repetition for each standard and to quantify this value, the Muscle LabTR
software connected to a linear encoder was used. Ten repetitions were
performed with a standardized load for each standard (Supine - 15 kg,
Row - 10 kg, Leg press - 70 kg), then five repetitions were performed at
maximum concentric speed and only the highest value obtained for analysis
was considered.
Data analysis
Data were expressed through descriptive statistics (mean and standard
deviation) for all variables obtained. Then, 3x2 ANOVA with post hoc
Bonferroni test was performed to compare means and detect differences
among interventions. Data normality was measured by the Shapiro-Wilk
test and homogeneity by the Levene test.
Data were tabulated and analyzed using Statistical Package for Social
Sciences (SPSS), version 22, adopting significance level of 5% (p≤0.05).
All tests were two-tailed and the Effect Size (ES) was calculated according
to methodological procedures defined by Cohen19.
RESULTS
FG and TG increased significantly in relation to the control group and to
the initial values in the FMSTM (FG = 24.4% / ES: 1.1 / p: 0.004; TG =
13.4% / ES: 0.5 / p: 0.002). Regarding muscle power, FG and TG improved
significantly in relation to pretest (FG - 12.8% / TG - 15.7% - mean of
three standards), but not in relation to CG. Regarding quality of life, both
FG and TG improved in relation to CG, but only FG showed significant
improvements in relation to pretest (p: 0.001 / ES: 0.9). The results of
interventions on movement and life quality are presented in Figure 1 and
muscle power in Table 1.
540
Table 1. Characteristics of participants of the functional training (FG), traditional training (TG)
and control groups (CG) at the beginning of intervention. Values presented as mean and standard
deviation (M ± SD).
FG n=18 TG n=15 CG n=11

Age (years) 65.6±5.44 65.6±5.10 62.5±2.98
Weight (kg) 68.9±12.60 65.8±12.82 72.5 ±14.43
Height (cm) 154.0±5.28 152.0±6.98 154.4 ±7.84
BMI (kg/m²) 29.0±4.95 28.5±5.51 30.4 ±5.91
MMSE (points) 25.2±2.90 25.7±3.63 24.1±2.84
BMI: Body mass index; MMSE: Mini mental state examination. Significant difference between groups *.
Table 2. Changes in muscle power after 12 weeks of functional, traditional and control training
in pre-frail elderly women.
Tests Pre Post Δ% ES P

Vertical Supine (Watts)
FG 118.3±41.1 134.5±35.7* 13.60 0.39 0.001
TG 113.1±36.1 133.7±41.5* 18.20 0.57 0.001
CG 119.8±33.2 115.2±33.2 -3.90 -0.13 0.761
Leg Press 45º (Watts)
FG 337.0±91.6 376.4±107.4* 11.60 0.43 0.003
TG 337.7±96.8 371±111.1* 9.80 0.34 0.028
CG 322.8±88.8 343.1±107.5 6.20 0.22 0.458
Articulated row (Watts)
FG 152.6±43.8 173.4±49.4* 13.60 0.47 0.001
TG 144.4±39.6 172.2±42.2* 19.20 0.70 0.001
CG 158.6±39.4 165.6±45.3 4.40 0.17 0.596
Functional training (FG), traditional (TG) and control group (CG), Effect Size (ES). Statistical
difference from pre to post *, statistical difference in relation to GC A.
Figure 1. A - Changes in movement quality after 12 weeks of functional (FG) and traditional (TG) training. B - Changes in quality of life after
12 weeks of functional (FG) and traditional (TG) training. Statistical difference from pre to post *, statistical difference in relation to CG A.
DISCUSSION
The main finding of the present study was that in muscle power, both training
methods were efficient. However, only FG achieved significant improvements
in quality of movement and quality of life. Thus, physical exercises performed
at maximum concentric speed in more functional actions have greater influ-
ence on measures related to the performance of daily activities in the elderly.

Regarding the quality of movement, of studies analyzed, only Pacheco1

applied FMSTM in this population and did not find significant differences
between functional and traditional exercises in active and independ-
ent older adults. A possible explanation for this result is the evaluation
method used. It may not be sensitive enough to evaluate individuals who
do not have common dysfunctions of this age group. The physiological
adaptations in this variable are mainly at the level of motor control5, thus,
it seems that a multi-component, multi-joint and multiplanar training, as
applied in the present study can provide better results due to the greater
neuromotor complexity when compared to training performed on guided
machines. This is because such machines do not provide the motor and
neural readjustments during exercises, which are necessary in daily and
highly developed functional movements in FT.
In this way, for FMSTM, which qualitatively evaluates motor control
through joint mobility and stability, the training that most provided these
characteristics obtained higher results.
Comparing similar functional components, Krebs20 found that the
group that performed exercises within the TF proposal presented higher
maximal torque in the knee, better dynamic balance and coordination
during the execution of daily activities, in relation to the group that per-
formed strength training with elastics. In another study, Vreed 7 showed
that functional exercises produce greater gains in functional capacity when
compared to traditional exercises.
Muscle power is considered a better predictor of functionality for the
elderly population21. Byrne22 reported that a good intervention with physical
training should develop strength and muscle power for better performance
in the ADLs. In this variable, both types of training presented signifi-
cant increases in relation to pretest, since they emphasize the maximum
concentric velocity in the performance of movements. Corroborating the
results of this manuscript, Cadore2 using a combination of force exercises
performed at maximum concentric speed, balance and gait, also verified
significant increases in the muscle power of 24 fragile elderly women. It is
worth mentioning that in the present study, FG performed two blocks of
exercises with emphasis on the maximum execution speed (blocks 2 and 3)
and although TG performed only one (block 3), it is possible to visualize
the specificity of training performed by TG with the tests applied, that is,
the same exercises used in the evaluation were trained during intervention
and may have contributed to the results found.
The quality of life of the elderly population is directly related to the
ability to perform daily tasks safely and effectively23. The practice of physical
activity in general has a positive effect on quality of life24; however, training
programs focusing on multicomponent work, muscle power and functional
movement patterns have been efficient in this variable5. In the present study,
only FG demonstrated significant improvement in relation to pretest and
high Effect Size. These results are consistent with Whitehurst 25, which
when assessing QOL through the 36-Item Short-Form Health Survey
542
(SF-36), observed increases in the functioning scores and physical vitality
of subjects as a consequence of improved mobility after circuit of func-
tional exercises. After 25 weeks of functional balance training, Karóczi 26
did not find significant improvement in this variable, since there was no
improvement in the physical fitness components that are important for the
daily life of subjects and, consequently, for quality of life. The quality-of-
life questionnaire applied in the present study was the WHOQOL-Bref,
which includes four domains (physical, environmental, psychological and
social) even with global movements and focusing on the muscle power
of the FT, both methods influence physical domain, the other evaluated
components can be influenced by questions such as group cohesion and
practice space, for example, TG performed most of the training in an
enclosed space (bodybuilding room), while FG performed training in a
more open space, and these conditions may have contributed to affect the
perception of participants on the environment and how they feel about it.
The present research aimed at comparing the adaptive responses to
training protocols considered functional, due to differences among the char-
acteristics of each intervention and the test applied. Although the present
study has provided important information about the benefits of FT and
TT in muscle power, quality of movement and life, future studies should
apply longer interventions with greater number of volunteers by adding
specific test battery for the analysis of performance in ADLs. We believe
that this study may stimulate further research to confirm these findings.
CONCLUSIONS
Both methods demonstrate the ability to improve the quality of movement
and muscle power. However, functional training presented better results
regarding quality of life and movement. The present research shows that
a physical training program aimed at promoting multi-system adaptations
favorable to the health of older adults should focus on the improvement
of physical fitness components in specific exercises for the activities of the
daily living performed at maximum concentric speed, respecting the of
safety and functionality criteria.
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544
Prediction of cardiorespiratory fitness from

self-reported data in elderly
Predição da aptidão cardiorrespiratória através de dados
auto-relatados em idosos
Geraldo A Maranhao Neto1
Aldair J Oliveira1,2
Rodrigo Pedreiro1
Silvio Marques Neto1,3
Leonardo G Luz4
Henrique C Silva3
Paulo TV Farinatti1,5
Abstract – Cardiorespiratory fitness (CRF) is associated with several health outcomes.

Some non-exercise equations are available for CRF estimation. However, little is known
about the validation of these equations among elderly. The aim of this study was to exam the
validity of non-exercise equations with self-reported information in elderly. Participants
(n= 93) aged 60 to 91 years measured CRF using maximal cardiopulmonary exercise test.
Five non-exercise equations were selected. Data included in the equations (age, sex, weight, 1 Universidade Salgado de Oliveira.
height, body mass index, physical activity and smoking) were self-reported. Coefficient of Laboratório de Ciências da Atividade
determination (R2) of linear regressions with laboratory-measured VO2 peak ranged from Física. Programa de Pós Graduação
0.04 to 0.64. The Bland-Altman plots showed higher agreement between achieved and em Ciências da Atividade Física.
predicted CRF obtained by Jackson and colleagues, and Wier and colleagues equations. Niterói, RJ. Brasil.
On the other hand, the other equations showed lower agreement and overestimation.
2 Universidade Federal Rural do Rio
Our findings provide evidences that two non-exercise equations, previously developed,
de Janeiro. Departamento de Educa-
could be used on the prediction of CRF among elderly. ção Física e Desportos. Seropédica,
Key words: Physical fitness; Regression Analysis; Aged . RJ. Brasil.
3 Universidade do Grande Rio. Rio de

Resumo – A aptidão cardiorrespiratória (ACR) está associada a vários desfechos de saúde. Janeiro, RJ. Brasil.
Algumas equações sem exercício estão disponíveis para estimar a ACR. No entanto, pouco se
sabe sobre a validação dessas equações entre os idosos. Objetivo: O estudo foi desenvolvido com 4 Universidade Federal de Alagoas.
o objetivo de examinar a validade de equações sem exercício com informações auto-relatadas em Laboratório de Cineantropometria,
Atividade Física e Promoção da
idosos. Métodos: Os participantes (n = 93) com idades entre 60 e 91 anos foram submetidos ao
Saúde. Maceió, AL. Brasil.
teste de exercício cardiopulmonar máximo para avaliar a ACR. Cinco equações sem exercício foram
selecionadas. Os dados incluídos nas equações (idade, sexo, peso, altura, índice de massa corporal, 5 Universidade do Estado do Rio de
atividade física e tabagismo) foram auto-relatados. Resultados: O coeficiente de determinação Janeiro. Laboratório de Atividade
(R2) das regressões lineares com o VO2 pico, medido em laboratório, variou de 0,04 a 0,64. Os Física e Promoção da Saúde. Rio de
gráficos de Bland-Altman mostraram maior concordância entre a ACR obtida e prevista por Janeiro, RJ. Brasil.
Jackson e colaboradores, e equações de Wier e colaboradores. Por outro lado, as demais equações
mostraram menor concordância e superestimação. Conclusões: Nossos resultados fornecem evi- Received: 14 March 2017
Accepted: 30 September 2017
dências de que duas equações sem exercício, previamente desenvolvidas, poderiam ser usadas na
estimação da ACR em idosos. Licença
Palavras-chave: Aptidão física; Análise de Regressão; Idoso. BY Creative Commom
Cardiorespiratory fitness in elderly Maranhã Neto et al.
INTRODUCTION
Cardiorespiratory fitness (CRF) has been linked to numerous health condi-
tions, including coronary heart disease1, stroke2, high blood pressure3 and
all-cause mortality4. In fact, low levels of CRF reduce the overall efficiency
of the cardiovascular system. Additionally, CRF is directly associated with
muscle strength5 and flexibility6 and inversely associated with age7.
There are different strategies to evaluate the CRF. The most accurate
one is to determinate objectively CRF using progressive tests of maximum
effort with the direct oxygen consumption measured (VO2max). This
form of measurement is considered the “gold standard”. However, in large
populations this method shall not be indicated due to the high costs for im-
plementation and time spent on test. CRF can also be estimated by indirect
tests that typically use physical exercise concomitantly with equations which
estimate CRF based on information such as predicted maximum heart rate
(e.g. 220 – age), age, sex. Despite the indirect tests having less accurate
results than direct ones, they require a lower cost and logistic involved to
their achievement. An interesting alternative to evaluate the CRF would be
through prediction model without performing exercises. This method was
developed with the application of multiple regression equations containing
information on the weight, height, sex, age and lifestyle habits related to
CRF. When compared to the maximal tests, the results are less accurate,
however, when compared to submaximal tests presents similar estimate of
power and greater applicability in more numerous sample groups8.
The assessment of the CRF is an important physiological indicator
of the functional capacity among elderly 9. However, the application of
exercise tests in elderly may be limited due to orthopedic problems and a
high prevalence of frailty in this population10. The use of non-exercise equa-
tion for CRF evaluation could be a reasonable alternative. In this context,
identifying a simple, lower-cost and lower risk alternative assessment of
CRF would be of considerable importance to evaluate elderly.
The non-exercise equations have been an important alternative to eas-
ily predict the CRF by means of regression-based equations that usually
include variables of simple and quick assessment, such as anthropometric
measures, demographic characteristics, and daily life habits11,12. In this
sense, several authors13-16 have developed equations using only self-reported
data which have the advantages of been practicality and a low-cost alter-
native. However, the validation attributes of these non-exercise equations
were not further investigated among elderly. Therefore, the study was
designed with the aim of examining the validity of self-reported non-
exercise equations in elderly.
Subjects
All individuals admitted between March 2005 and April 2008 to be en-
546
gaged in the project “Idosos em Movimento Mantendo a Autonomia” were
included in the study. The sample was submitted to a medical-functional
evaluation including maximal exercise cardiopulmonary test, a wide ki-
nanthropometric evaluation and a clinical investigation, performed by
specialized physicians before starting the exercise program. In addition,
they also filled in the questionnaire about physical activity level. Individuals
presenting one or more of the following conditions were excluded: a) stable
or rest angina pectoris; b) paroxysmal or complex ventricular arrhythmias;
c) acute myocarditis or pericarditis; d) atrioventricular block of high-grade
and low ventricular rate; e) acute myocardial infarction within the previous
two years; f) severe aortic stenosis; g) severe hypertension or reactive to
exercise one; h) important injury on the left main coronary artery; i) his-
tory of pulmonary embolism, j) any acute disease, k) physical or emotional
limitations, l) drug intoxication; m) inability to understand the proposed
procedures and n) orthopedic problems that incapacitate the individual to
the participate or could be made worse by it. Thus, the study had the par-
ticipation of 93 individuals (54 men and 39 women ranged 60 to 91 years
old) that written informed consent was obtained from all participants, and
the research protocols were approved by the Ethics Committee of Social
Medicine Institute (CEP-IMS) from the Rio de Janeiro State University.
The research was conducted in Rio de Janeiro State University.
Procedures
The physical activity level was assessed using a Brazilian Portuguese ver-
sion of the Physical Activity Rating (PA-R). The PA-R is a progressive
scale with scores from 0 to 10 in which must be signaled the most suitable
option to the physical activity history in the last 30 days. Individuals with
“zero score” were classified as “physically inactive”; those with 1 point as
“slightly active”; those from 2 to 3 as “moderately active” and those with
4 points or more on the levels were moderate to high intensity. Detailed
information about the procedure is available in a previous publication17.
Participants performed a maximal cardiopulmonary exercise test on a
cycle ergometer, model Cateye EC-1600 (Cat Eye, Tokyo, Japan), using
the ramp protocol. An initial load of 25-50 watts was increased continu-
ously in increments of 5-15 watts/min until exhaustion. For the measure-
ment and analysis of expired gases, we used a metabolic analyzer VO2000
(MedGraphics, United States) with the measurement being held in ten
second intervals. For determining work rate (watts) based on the maximum
capacity for work estimated, to obtain the maximum effort between 6 and
12 minutes, according to the recommendations of the American Heart As-
sociation. Continuous monitoring of ECG was performed (ECG) 12-lead
(Micromed®, Brasilia, Brazil), with measurements of blood pressure at rest
every minute test, performed with aneroid sphygmomanometer WelchAlln
of Tycos® (Arden, USA). Subjects were verbally encouraged to exercise
to volitional fatigue. Interruption criteria were established for the tests,
according to the literature recommendations18. The test was interrupted by

maximum voluntary exhaustion. There was no limit imposed on the value

of heart rate (HR) to be achieved.
In order to assess the non-exercise equations which would be ap-
plied in the study, we used the literature search. In this sense, inclusion
criteria were adopted for the selection, as follows: (1) included elderly in
their sample, (2) validation of models through maximum effort tests with
direct oxygen consumption measured (“Gold Standard”), (3) provided
relevant information regarding the models adjustments (at least R square
and standard error of estimate - SEE), (4) include variables not only for its
statistical significance, but for its theoretical justification. This strategy was
used in a previous study19. In addition, the models should include variables
that could be self-reported by the respondent. The selected equations are
shown in Table 1 along with their respective standard error of estimate
(SEE), correlation and determination coefficients (R 2).
Table 1. Non-exercise Models Included in the present study.
Author AdjR 2 SEE (ml/

Sex Age n Equation r
(year) kg/min)
Jackson M 1393 56.363 + 1.921(PA-R) - 0.381(age) - 0.754

20-70 0.78 0.61 5.7
et al.14 F 150 (BMI) + 10.987 (sex 0-1)
M 390 34.142 + 0.133 (age) - 0.005 (age)2 + 11.403

Mattews
20-79 (sex 0-1) + 1.463 (PA-R) + 9.170 (height) -
et al.15 0.86 0.74 5.6
F 409 0.254 (weight)
M 21-82 2417 57.402 – 0.372 (age) + 8.596 (sex 0-1) +1.396

Wier et
(PA-R 0-10) - 0.683 (BMI) 0.80 0.64 4.9
al.16
F 19-67 384
39.390 – 0.409 (age) – 0.307 (weight) – 4.437

M 18-65 5136 (physical activity) 0.71 0.51 7.3
Cáceres et + 0.254 (height) – 3.081 (smoking)
al.13 31.733 – 0.244 (age) – 0.219 (weight) – 3.598
(physical activity) 0.65 0.42 5.7
F 18-65 3157
+ 0.151 (height) – 1.486 (smoking)
r- multiple correlation coefficient; Adj – adjusted; R 2- Coefficient of determination; SEE-Standard Error of Estimate; M-male; F- female;
sex: female=0 male=1;PA-R – Physical Activity Rating; physical activity: sedentary=0; active=1; BMI-Body Mass Index
Statistics Analysis
In order to investigate sex differences, the Student t-test and chi-square or
Fisher´s exact test were performed for count and categorical variables, re-
spectively. The relationship between achieved CRF and predicted CRF was
analyzed using linear regression, and the correlation coefficient, adjusted R 2
and SEE were calculated and compared. The visual analysis was carried out
using the Bland Altman plots to evaluate whether the estimated CRF varied
according to the achieved CRF levels. To help this analysis, 95% limits of
agreement (95%LoA) were established, calculated from the mean difference
between the reported and the measured. The statistical signiﬁcance for all
analyses was accepted as P<0.05 and if the 95% confidence interval (CI)
does not include the zero value. All calculations were performed using the
Stata version 12 software (StatacorpTM, College Station, TX, USA).
548
RESULTS
A summary of the descriptive statistics for all variables according to sex
were included in Table 2. It is also provides results from the significance
tests. In this line, significantly (p<0.05) differences were detected across
sex in the following variables: height, weight, BMI, and VO2 max. More
details can be seen in Table 2.
Table 2. Physical and demographic characteristics of participants (n = 93).
Characteristics Mean±SD
Male Female
p (95%CI)
(n=54) (n=39)
Age (years) 68.7±7 68.6±6 0.935 (-2.99-2.75)
Height (cm) 172.7±6 157.1±6 <0.001 (-18.9 --12.9)
Body weight (kg) 85.3±11 64.0±17 <0.001 (-27.5 - -15.2)
BMI(kg/m2) 28.6±5 25.9±4 0.007 (-4.68-0.74)
PA-R Score 1.9±1.4 1.5±1.6 0.189 (-1.03-0.21)
Inactive/Slightly active (%)* 42.5 48.7 0.07 (-0.136-0.256) †
Moderately/Highly active (%)* 57.5 51.3
Physically Active (%) 68.5 53.8 0.194 (-0.049-0.347)
HR max (bpm) 138 ± 27 142± 24 0.458 (-6.77-14.90)
VO2 max (ml/kg/min) 21±8 16±5 <0.001 (-7.72 - -2.07)
Risk factors and clinical history (%)
Hypertension 35.2 43.6 0.412 (-0.28-0.11)
Beta-blockers use 16.7 17.9 0.872 (-0.208-0.184)
Diabetes 9.3 5.1 0.456 (-0.154-0.238)
Dyslipidemia 22.2 17.9 0.614 (-0.156-2.00)
History of Miocardial Infarction 3.7 0 0.508 (-0.159-0.233)
*Generated from PA-R Score; BMI: body mass index; PA-R-Physical Activity Rating; HR
max: maximum resting heart rate; SD: standard deviation; VO2 max: maximal oxygen
consumption;†difference between Inactive/Slightly active and Moderately/Highly active; p: p-value;
significant for p<0.05; CI: confidence interval.
The results of the simple linear regressions relating laboratory-measure

VO2 MAX and VO2 max based on non-exercise equations are shown in
Table 3. The model which used VO2 max estimated by Matthews et al.15
explained 64% of the variance in laboratory-measure VO2max. However,
there was a 12% drop in the determination coefficient. On the other hand,
the models developed by Jackson et al.14 and Wier et al.16 showed only a 3%
and 5% drop, respectively. The CRF estimated by Cáceres et al.13 equations
explained only 17% for men and 4% for women.
The Bland-Altman plots (Figure 1) show a higher agreement between
achieved and predicted CRF obtained by the Jackson et al.14(a) and Wier
et al.16(c) models. In fact, there were more points close to zero in Wier et
al.16(c). The Matthews et al.15(b) plot shows that the majority of the samples
were above the zero-axis, representing an overestimation. A low agreement
is clearly observed in the Cáceres et al.13 plots (d and e).

Table 3. Coefficients of correlation and determination and standard error of estimate (SEE) from
simple linear regressions between cardiopulmonary fitness estimated by equations (independent
variable) and laboratory-measure VO2 max.
SEE
Author (Year) r Adj R 2
(ml/kg/min)
Jackson et al.14 0.76 0.57 4.6
Mathews et al. 15
0.79 0.64 4.4
Wier et al.16 0.77 0.58 4.6
Cáceres et al. Men
13
0.43 0.17 7.8
Cáceres et al.13 Women 0.22 0.04 4.7
r- correlation coefficient; Adj – adjusted; R 2- Coefficient of determination; SEE- standard error

of estimate
Figure 1. Bland Altman Plot between Achieved and Predicted ACR

Jackson et al.; (b) Matthews et al.; (c) Wier et al.; (d) Cacéres et al. Men; (e) Cáceres et al. Women;
Dotted lines – 95% limits of agreement (LoA)
550
DISCUSSION
The present study examined the validation of five non-exercise equations
(e.g., Jackson et al.14, Wier et al.16 and Matthews et al.15, Cáceres et al.13
for men and women) on predicting CRF in Brazilian elderly. Our results
showed reasonable indications of two equations: Jackson et al.14 and Wier
et al.16 which could be helpful on the determination of CRF among elderly.
On the other hand, the other three equations showed weaker validation
performance, and consequently, and should be avoided in this group. In fact,
Jackson et al.14 and Wier et al.16 had alreadly suggested that their equation
could be more accurate for low fit subjects and people older than 50 years.
This study is the first to assess the validity of only self-reported non-exer-
cise models in elderly. Mailey et al.20 tested the validity of the model proposed
by Jurca et al.21 in an elderly sample (60-80 years). The model included the
variables sex, age, BMI, self-reported physical activity and resting heart rate
(R 2 adjusted=0.51). Maranhão Neto et al.22 developed a model in a sample
of 60-91 year, including the variables age, self-reported fitness and relative
handgrip strength (R 2 adjusted=0.79). Variables such as resting heart rate and
handgrip strength demand appropriate equipment and preparation, which
limit the applicability of the models in population-based studies. Specifically,
the heart rate responses could be affected by hypertensive medications and
the handgrip test demand “motivation” from the subjects.
Our predictive values were slightly lower than the laboratory-measured
CRF for most equations. Some explanations for these findings could be pos-
tulated. First, our sample was smaller than the ones in which the original
equations were developed. Second, given that the equations were validated
for a large age spectrum, it is plausible to consider that the precision of the
estimates may not be identical in different age groups.
Taking into account the Bland-Altman plots, Jackson et al.14 and
Wier et al.16 equations had most of the points around zero highlighting a
reasonable validation without bias. Both equations used easily self-report
information (e.g., age, sex, weight, height and physical activity) and could
be used in a population approach. On the other hand, the Bland-Altman
plots of the other equations showed overestimation bias. These findings
reinforce the importance of comparing equations, even though they use
similar variables, aiming to access accurately CRF.
Although the equation developed by Matthews et al.15 explained 64%
of the laboratory-measure VO2 MAX variability, Bland-Altman plots
revealed an overestimation, and consequently, the lower accuracy of this
equation on estimate VO2 MAX in this group.
Through this research we found that many studies have been performed
in order to estimate CRF without exercise for the general population. The
main advantages found in this alternative are the lowest cost, the easier
applicability and the speed of data acquisition, mainly in large populations19.
Some limitations of the study should be noted. Although the predicted
values were close to that obtained from original equations, they were sys-

tematically lower. All the original equations were validated against VO2
max obtained from maximal treadmill tests treadmill tests which are known
to engage larger muscle mass and therefore elicit higher VO2 values23. The
adoption of a cycloergometer maximal exercise testing protocol to assess
the CRF is justiﬁed, mainly for safety reasons24,25.
Further, the findings of the study should be observed carefully due
to the specific sample. The subjects were interested in engaging in project
which involves physical activities and may present higher values of CRF
compared with the general population. In this sense, it is not possible to
state that the performance of these equations would be the same in other
populations.
The use of non-exercise equations in elderly has two major justifica-
tions: (1) the physical health problems which may limit the participation
in exercise tests26; (2) even in people without physical impairments, the
exercise tests could not be feasible due to high-cost, especially in low- and
middle-income countries.
CONCLUSION
This research provides evidence to support the use of a low-cost procedure
of estimating CRF based on two equations previously developed (e. g.
Jackson et al. (1990)14 and Wier et al.(2006)16). The prediction does not
involve any exercise testing, it provides reasonable estimates of CRF, and
could be useful in research settings. Future studies should address whether
non-exercise equations based on self-reported data could be used to follow
changes in CRF of elderly.
Acknowledgments
The authors report no declarations of interest. This study was partially
supported by grants from the Brazilian Council for the Technological
and Research Development (CNPq), National Council for the Improve-
ment of Higher Education (CAPES) and Carlos Chagas Foundation
for the Research Support in the State of Rio de Janeiro (FAPERJ) no.
E-26/203.237/2016.
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Relationship between adiposity and heart rate

recovery following an exercise stress test in
obese older women
Relação entre a adiposidade e a recuperação da
frequência cardíaca após teste de esforço em mulheres
idosas obesas
Cristiane Rocha da Silva1
Bruno Saraiva1
Dahan Cunha Nascimento1,2
Luana Claudia Dias Bicalho2
Ramires Alsamir Tibana3
Jeffrey M. Willardson4
Jonato Prestes1
Guilherme Borges Pereira1
Abstract – he aim of the present study was to compare differences in heart rate (HR)
response during and following exercise in obese older women with different percent body
fat levels. Ninety older, obese women aged 60-87 years participated in the study, were
categorized, and enrolled to one of two groups based on a lower percent body fat (LPBF
≤ 41.10 %) or higher percent body fat (HPBF > 41.10 %) as measured by dual-energy
x-ray absorptiometry. The peak HR during exercise and in the first and second minutes
of recovery period were compared between groups. The HPBF group presented a lower
peak HR during exercise (p =.001) and an impaired HR recovery (p =.001) when com-
pared to LPBF group. The present study demonstrated that older women who were in
exceedingly obese level have an impaired heart rate response during exercise and in the 1 Universidade Católica de Brasília.
recovery period, indicating possible autonomic dysfunction. Programa de Pós-Graduação em
Educação Física. Brasília, DF. Brasil.
Key words: Aging; Obesity; Heart rate.
2 Centro Universitário do Distrito
Resumo – O objetivo do presente estudo foi comparar a reposta da frequência cardíaca (FC) Federal. Brasília, DF. Brasil.
durante e após um teste de esforço entre mulheres idosas obesas com diferentes níveis de percen-
3 Universidade Federal do Mato
tual de gordura corporal. Noventa idosas obesas com idade entre 60-87 anos participaram desse Grosso. Departamento de Educação
estudo e foram separadas em dois grupos com base no baixo percentual (LPBF ≤ 41.10 %) e alto Física. Cuiabá, MT. Brasil.
percentual de gordura corporal (HPBF > 41.10 %) medido por absorciometria de raio-x de dupla
energia. A FC pico durante o teste e no primeiro e segundo minuto de recuperação foram compa- 4 Rocky Mountain College. Billings,
radas entre os grupos. O grupo HPBF apresentou FC pico inferior durante o teste (p = 0.001) MT. USA.
e também após o período de recuperação (p = 0.001) quando comparado com o grupo LPBF. Os
dados desse estudo demonstraram que mulheres idosas com alto percentual de gordura corporal Received: 20 March 2017
apresentaram FC pico inferior e menor recuperação da FC durante o período de recuperação,
indicando possivelmente uma disfunção autonômica. Licença
Palavras-chave: Envelhecimento; Frequência cardíaca; Obesidade. BY Creative Commom
INTRODUCTION
Recent research demonstrated an increase in the prevalence of individuals
classified as overweight or obese among the Brazilian population1. Obesity
is a medical condition characterized by excessive accumulation of body
fat, capable of triggering unfavourable changes in the heart and vascular
system and causing autonomic nervous system dysfunction 2.
The physiological variable, heart rate recovery (HRR), is an impor-
tant, non-invasive measure utilized after a stress test that provides useful
information about vagal control of the autonomic nervous system and
cardiovascular fitness3,4. A slower HRR has been associated with decreased
parasympathetic activity and reduced cardiovascular fitness5. Furthermore,
previous studies demonstrated a negative correlation between HRR and
mortality in healthy participants6 and individuals with high relative risk
of acute myocardial infarction7.
The increase in percentage body fat is also associated with autonomic
nervous system dysfunction of the cardiovascular system8. In obese subjects,
this impairment is reflected by reduced parasympathetic nervous system
function and/or sympathetic nervous system overactivity9. Furthermore, a
study in obese subjects with low levels of physical fitness revealed an impaired
chronotropic index and HRR during and after exercise stress testing10.
Several studies have shown that parameters of obesity negatively affect
HRR following exercise11-13. Barbosa et al.13 analysed the relationship be-
tween body mass index (BMI) and HRR after one minute of exercise and
demonstrated that obese subjects (>30 kg/m2) presented higher basal HR and
lower maximum HR accompanied by reduced chronotropic reserve. Deniz et
al.14 reported that HRR was impaired in young adult males with metabolic
syndrome as compared with obese subjects without metabolic syndrome. In
addition, Gondoni et al.15, demonstrated severely obese subjects (BMI > 40
kg/m2) exhibited lower HRR and a lower peak HR when compared with
subjects with normal BMI (< 25 kg/m2), and the blunted increase in HR
was the most important factor that influenced exercise capacity15.
Although BMI is an acceptable index in younger adults, errors occur
when assessing older adults, thereby limiting its use in this population.
Thus, the dual-energy x-ray absorptiometry (DEXA) method was chosen
because it allows a non-invasive measurement of body adiposity while ad-
justing for changes in lean body mass and better comprehension of obesity
measurement classification in the older adult population 16.
To date, HRR has not been directly investigated as a non-invasive cor-
relative tool to detect cardiovascular health with older women classified on
different levels of adiposity by DEXA. This information would be valuable
for the identification and monitoring of older adults with high cardiovascu-
lar risk pre- and post-exercise training. Thus, the aim of the present study
was to compare differences in HR response during and following exercise
in older women who were categorized into different groups based on body
fat percentage as determined by DEXA. The hypothesis of this study was

Adiposity and heart rate recovery Silva et al.
that older women classified as higher percent body fat (HPBF) would have
a lower peak HR during exercise and an impaired HRR following exercise
versus older women with a lower percent body fat (LPBF).
Participants
A convenience sampling of community-dwelling older (n = 157) women
from the Centro de Convivência do Idoso located at Catholic University of
Brasilia were recruited for participation in the present study. The present
study was approved by the Institutional Research Ethic Committee of
Catholic University of Brasília (protocol 45648115.8.0000.5650/2016).
To be elegible for participation in this study, women needed to be aged
60-100 years with body fat percentages ≥ 30% as assessed by DEXA. Of
those, 67 were excluded (did not meet inclusion criteria) leaving a total of
90 participants who met the inclusion criteria.
During the first visit, participants were interviewed and responded
anamnesis given by the researcher. During the second visit, participants
answered a questionnarie to obtain lifestyle information, use of medications,
and leisure type physical activity (LTPA)17. After that, participants were
submitted to a body composition assessment and exercise treadmill testing.
Participants were divided into two groups: LPBF (≤ 41.10 % = 50th
percentile) and HPBF (> 41.10 %). In addition, the cut-off values were
close to obese classifications using percent body fat (DEXA exam) as rec-
ommended by Gallagher et al.18 for African American (41 %) and Asian
(41 %) adults. The characteristics of the study participants are presented
in Table 2. Obesity was considering a cut-off point of 30% for women19.
Leisure type physical activity (LTPA)

The LTPA was evaluated based in a previous publication17. Subjects were
asked to classify the types, frequency, and duration of weekly LTPA com-
pleted by them during the previous month. On the basis of Ainsworth 20,
compedium of physical activities were defined using a metabolic equivalent
value (MET; 1 MET = 1 kcal per h/kg of bodyweight) of 3.5 METs for
a conditioning exercise, 3.0 METs for resistance training exercise (Cod
02130), 3.0 METs for walking exercise (Cod 17200), 4.0 METs for water
activities (Cod 18355), 5.0 METs for dancing (Cod 03020) and 2.5 METs
for stretching (Cod 02100) were used. The subjects indicating activities
in more than one intensity category, a weighted MET value was applied,
considering the length of time engaged in each category. Considering
LTPA volume as being the product of intensity (MET) and the duration
of exercise (h), the MET-h per week of each participant was calculated.
Anthropometrics and body composition

Anthropometric status was evaluated by the following measures: height
(to the nearest 0.1cm) and body weight (to the nearest 0.1 kg), and these
556
were used to calculate BMI (body weight/height²).
Percent body fat and fat-free mass were determined via DEXA (General
Electric-GE model 8548 BX1L, year 2005, Lunar DPX type, Software
Encore 2005; Rommelsdorf, Germany). The tests included a complete
body scan of the volunteers, in the supine position, with the apparatus
calibrated and operated by a technically trained professional. The legs were
secured by nonelastic straps at the knees and ankles, and the arms were
aligned along the trunk with the palms facing the thighs. The coefficient
of variation for the percent body fat estimated by DEXA was 8.74 and
15.92 % for the LPBF and HPBF groups, respectively. All metal objects
were removed from the participant before the scan.
Treadmill stress testing

Exercise testing procedures in the laboratory have been described in de-
tail elsewhere1321. Participants underwent a symptom-limited treadmill
test using a ramped protocol. The protocol used velocity initial and final
velocity was 3.0 km/h and 6.0 km/h, while the initial and final grade was
1.0 and 14.0 %, respectively and maximal exercise capacity within the
recommended range of 8 to 12 minutes. Participants were encouraged to
exercise until volitional-exhaustion. Achievement of 85% of age-predicted
maximum HR and/or respiratory exchange ratio > 1.02 were used for test-
ing termination 21. During each exercise stage and recovery stage, symp-
toms (chest discomfort, rate of perceived exertion, and dizziness), blood
pressure, and HR were recorded. Following peak exercise (maximum time
spent in the test), participants walked for a 2-minute cool-down period
at 2.0 km/h and 2.5 % grade22. Heart rate recovery was measured during
the 2-minute cool-down period and relative HRR indices were defined as
the absolute differences between peak HR and the HR values measured
at 60 s (HRR60s) and 120 s (HRR120s) of recovery. For safety purposes,
participants were permitted to lean on handrails during exercise.
Chronotropic incompetence was assessed as failure to achieve 85%
of the age-predicted HR. A chronotropic index less than 0.80 was also
considered by the following equation [(HRstage – HRrest)/(220 – age in
years – HRrest)] x 100 (Lauer et al.) 23. Maximal metabolic equivalent
(MET) level was calculated for each participant using the following equa-
tion: maximal MET level = (treadmill time in minutes X 1.750) + 10.5/3.5
(Farrel et al.)24. Maximal metabolic equivalent was calculated because it
represents a standard scale for expressing workload and is related with
all-cause mortality, coronary heart diseases, cardiovascular disease events,
and heart-rate recovery22,25.
Statistical analyses
All statistical analyses were conducted using SPSS software version 18.0
(Chicago, USA). Normality was verified by Shapiro-Wilk test. Independ-
ent t tests were used for comparisons between groups. For non-parametric
variables (disease, medications, chronotropic incompetence, and chrono-

tropic index), a Chi square for proportions was used and Cramer’s V test
of association was applied. First, the multiple linear regression utilized the
forward step elimination method for independent variables in the model
(percent body fat, BMI, MET, WC, WHR, hypertension, diabetes, and
age], according to recommendations from literature13,12,22 .The continuous
dependent variable (1 minute HR recovery) was chosen based on previous
research 22. It is noteworthy that the time constant of an earlier phase of the
heart rate (e.g. 30 seconds and 1 minute) decay might predominantly reflect
the rapid vagal reactivation 26. In the final model, the significant variables
were: percentage body fat, MET, and age. Secondly, a hierarchical multiple
regression with interactions between age and MET, age and percentage
body fat, and MET and percentage body fat was also applied. Third, to
determine whether the multiple regression model is a good fit for the data.
The R² for the overall model was 25.5% with an adjusted R² of 20.1%, and
a medium effect size. In addition, all variables added statistically signifi-
cantly to the model, F (6, 83) = (4.72), p = 0.001. Linearity was confirmed
by partial regression plots and a plot of studentized residuals against the
predicted values. Independence of residuals was verified, as assessed by
a Durbin-Watson statistic of 2.101. Homoscedasticity was confirmed,
as assessed by visual inspection of a plot of studentized residuals versus
unstandardized predicted values, and no evidence of multicollinearity
was present, as assessed by tolerance values greater than 0.1.). An a priori
power analysis for independent t-test, based on our pilot study (n = 53),
was used to determine the necessary sample size to have statistical power
at 80% 27. The sample power was calculated by the software G*Power
3.1.6, and determined that the study would be adequately powered with
a 0.75 effect size at 45 subjects per group. An alpha level of p < .05 was
considered significant.
RESULTS
No differences between groups for hypertension and diabetes (X²(1) =
1.21, Cramer’s V = 0.11) was observed. In addition, no difference between
groups in the use of diuretics (X²(1) = 0.18, Cramer’s V = 0.18), β-blockers
(X²(1) = 0.72, Cramer’s V = 0.08), calcium channel antagonists (X²(1) =
0.45, Cramer’s V = 0.07), angiotensin converting enzyme inhibiters (X²(1)
= 0.30, Cramer’s V = 0.05), and hypoglycemic medications (X²(1) = 1.21,
Cramer’s V = 0.11) was verified. The LPBF group presented a higher
frequency for statins use (X²(1) = 4.48, Cramer’s V = 0.22). In addition,
HPBF demonstrated a higher frequency of chronotropic incompetence
(X²(1) = 3.98, Cramer’s V = 0.21) and chronotropic index (X²(1) = 8.36,
Cramer’s V = 0.30) than LPBF group (Table 1).
The HPBF group presented a lower treadmill exercise time (p =.019),
peak O2 consumption (p =.001), chronotropic index (p =.001), peak heart
(p =.001), 1-minute relative HRR (p =.001), and 2-minutes relative HRR
(p =.015) versus the LPBF group. Furthermore, body weight (p =.001),
558
BMI (p =.001), and percent body fat (p =.001) were higher in the HPBF
group versus the LPBF group (Table 2).
Table 1. Diseases, medications and chronotropic incompetence characteristics of the subjects.
LPBF HPBF
X²
(n = 45) (n = 45)
Disease Yes No Yes No
Essential hypertension 32 (71.1) 13 (28.9) 34 (75.6) 11 (24.4) 0.634
Diabetes mellitus type 2 16 (35.6) 29 (64.4) 22 (48.9) 23 (51.1) 0.270
Medications
Angiotensin receptor blockers 16 (35.6) 29 (64.4) 22 (48.9) 23 (51.1) 0.200
Diuretics 20 (44.4) 25 (55.6) 18 (40.0) 27 (60.0) 0.670
β-blockers 6 (13.3) 39 (86.7) 9 (20.0) 36 (80.0) 0.396
Calcium channel antagonists 6 (13.3) 39 (86.7) 4 (8.9) 41 (91.1) 0.502
Angiotensin-converting enzyme 9 (20.0) 36 (80.0) 7 (15.6) 38 (84.4) 0.581
inhibiters
Statins 17 (37.8) 28 (62.2) 8 (17.8) 37 (82.2) 0.034*
Hypoglycemic Medications 10 (22.2) 35 (77.8) 6 (13.3) 39 (86.7) 0.270
Chronotropic evaluation
Chronotropic incompetence 11 (24.4) 34 (75.6) 20 (44.4) 25 (55.6) 0.046*
Chronotropic index 9 (20.0) 36 (80.0) 22 (48.9) 23 (51.1) 0.004*
Values are expressed as frequencies and percentage. * Statistically significant, X² = qui-square.
Table 2. Characteristics of the subjects.
Anthropometrics LPBF (n = 45) HPBF (n = 45) P

Mean (S.D.) Mean (S.D.)
Age, years 69.67 ± 6.11 (67.83 – 71.50) 66.60 ± 5.58 (64.92 – 68.28)* 0.015
Height, m 1.54 ± 0.05 (1.52 – 1.55) 1.54 ± 0.07 (1.51 – 1.56) 0.851
BMI, kg/m² 26.12 ± 3.18 (25.16 – 27.08) 31.53 ± 3.72 (30.42 – 32.65)* 0.001
Body fat, % 34.73 ± 3.97 (33.54 – 35.93) 44.92 ± 2.82 (44.07 – 45.76)* 0.001
Functional Capacity
MET/h per week 8.89 ± 6.38 (6.98 – 10.81) 8.90 ± 6.75 (6.87 – 10.93) 0.995
Exercise test variables
Treadmill exercise time, minute 8.05 ± 2.15 (7.40 -8.69) 7.03 ± 1.85 (6.47 -7.59)* 0.019
Peak O2 consumption, ml/kg 19.39 ± 2.71 (18.55 – 20.23) 17.07 ± 2.92 (16.19 – 17.96)* 0.001
Chronotropic index 0.97 ± 0.21 (0.90 – 1.03) 0.84 ± 0.20 (0.78 – 0.90)* 0.005
Systolic blood pressure, mmHg 127.03 ± 18.13 (121.58 – 132.48) 125.58 ± 11.65 (122.08 – 129.08) 0.652
Diastolic blood pressure, mmHg 73.25 ± 9.58 (70.37 – 76.13) 72.73 ± 9.03 (69.76 – 74.56) 0.557
Basal heart rate, bpm 75.42 ± 11.78 (71.88 – 78.96) 72.73 ± 9.03 (70.01 – 75.44) 0.228
Peak heart rate, bpm 146.36 ± 14.91 (141.87 – 150.84) 139.09 ± 18.05 (133.66 – 144.51)* 0.040
1 minute relative HRR, bpm 25.24 ± 10.31 (22.15 – 28.34) 18.84 ± 7.70 (16.53 – 21.16)* 0.001
2 minute relative HRR, bpm 35.71 ± 11.80 (32.03 – 39.39) 29.62 ± 9.73 (26.38 – 32.87)* 0.015
MET 17.09 ± 3.76 (15.96 – 18.22) 15.31 ± 3.25 (14.33 – 16.29)* 0.019
BMI = body mass index, LBF = low body fat percentage, HBF = high body fat percentage, VO2 = volume of oxygen consumed, * P < 0.05
low body fat group vs. high body fat group.
The addition of percent body fat (Model 1) led to statistically significant

increase in R² of 0.10, F(1,88) = 10.38, p =.002. Moreover, the addition of

the MET value (Model 2) was statistically significant (R² of 0.18, F(1,87)
= 8.57, p =.004). Also, the addition of age (Model 3) was statistically sig-
nificant (R² of 0.23, F(1,86) = 5.90, p =.017). For the model parameters
(Model 3), percentage body fat, MET, and age were statistically significant.
This value indicates that as aging increases by one unit, HRR decreases by
0.39 units. As percentage body fat increases by one unit, HRR decreases
by 0.50 units. However, as MET increases by one unit, HRR increases
by 0.61 units. This interpretation is true only if the effects of variables
introduced in the multiple regression are held constant. The addition of
interaction between age and MET (R² of 0.23, F (1,85) = 0.04, p =.826),
interaction between age and percent body fat (R² of 0.25, F(1,84) = 1.33,
p =.252), and interaction between MET and percent body fat (R² of 0.25,
F(1,83) = 0.45, p =.502) did not lead to a statistically significant increase
in R² (data not shown) (Table 3)
Table 3. Hierarchical multiple regression predicting 1 minute HRR from percent body fat, BMI,
and age.
1 minute HRR
Model 1 Model 2 Model 3
Variable B‡ Β† 95% CI for B B‡ Β† 95% CI for B B‡ Β† 95% CI for B
Constant 42.21* 24.37* 58.73*
Percent body fat - 0.50* - 0.32 - 0.81 - - 0.19 - 0.37* - 0.24 - 0.69 - - 0.06 - 0.50* - 0.32 - 0.82 - - 0.18
MET 0.78* 0.29 2.52 – 1.31 0.61* 0.23 0.07 – 1.15
Age - 0.39* - 0.24 - 0.71 - - 0.07
R² 0.10* 0.18* 0.23*
F 10.38* 9.92* 8.96*
∆R² 0.10 0.08 0.05
∆F 10.38 8.57 5.90
N = 88. * P < 0.05, ‡ = unstandardized beta, † = standardized beta, HHR = heart rate recovery.
DISCUSSION
The main findings from our analyses confirmed the hypothesis that older
adults who were classified in the HPBF group demonstrated a lower peak
HR during an exercise stress test and an impaired HRR 1-minute and
2-minutes after exercise.
During aging the cardiovascular system deteriorates as indicated by a
reduced maximal HR, ejection fraction, and maximal cardiac output during
exercise28. Reductions in β-adrenergic stimulated chronotropic response
largely explain the decrease in maximal HR with aging28 and contrib-
ute to an attenuated left ventricular contractile response to exercise28,29,.
Moreover, a lower synaptic concentration of norepinephrine, diminished
levels of circulating epinephrine, and impaired beta-adrenergic receptor
or post-receptor responsiveness might also explain an impaired HR re-
sponse to exercise, as seen in the current study wherein the HPBF group
had inferior treadmill exercise time versus the LPBF group2129. Although
with aging, heart rate is more accelerated after exercise due to the slow
560
withdrawal of norepinephrine in the bloodstream, there is evidence that,
shortly after physical exercise, vagal modulation is primarily responsible
for the drop in HR, especially in the first 30 seconds after exercise26.
In obese subjects, the activity of renin-angiotensin complex and sym-
pathetic nervous systems are also increased during a standardized treadmill
protocol when compared to lean subjects, despite hypertension status3. This
evidence may support the theory that a high percentage body fat might
potentiate abnormal chronotropic response and lower peak HR in the
group with more adiposity by the attenuated neurohormonal response to
exercise. Thus, this different neurohormonal response might help to explain
the disparity in their cardiovascular response (e.g. inferior chronotropic
index and higher percentage chronotropic incompetence) between HPBF
and LPBF subjects.
Regarding the impaired HRR after exercise, it could be inferred that
the HPBF group experienced delayed sympathetic nervous system with-
drawal compared with the LPFB group. In addition, a later stage para-
sympathetic reactivation might be prolonged in the HPBF group, which
contributed to impaired HRR following 1-minute and 2-minutes after
the treadmill exercise stress test. Although reasonable, these autonomic
responses to exercise are only speculated because these measurements were
not assessed in the present study.
Another hypothesis for the differences between groups is the existence of a
work load dependence of heart rate decay. Heart rate at the end of the exercise
is increased with increasing work load26. As we know, chemosensitive muscle
afferents in exercising legs are important in the regulation of autonomic nerve
activities during exercise. Thus, after cessation of exercise, metabolites might
persist stimulating the muscle afferents in exercising legs and attenuate vagal
reactivation26, while this must be confirmed in future studies.
Moreover, all-cause mortality is likely to be affected by this higher pro-
portion of chronotropic incompetence, chronotropic index, and attenuated
exercise HR response in the HPBF group. In addition, Lauer et al.23 demon-
strated that subjects who failed to reach 85% of their age-predicted maximum
HR and who had a low chronotropic index had higher death rates23.
In this study, after adjusting for covariates using hierarchical multiple
regression percentage body fat, MET, and age were negative determinants
of 1-minute HRR. The results are in line with three previous studies10,13,
that a higher percentage body fat and age were associated with an impaired
HRR. Moreover, a higher maximal MET level was associated with a
better HRR following 1-minute post treadmill exercise testing. Thus, a
better cardiorespiratory fitness is associated with a lower risk of all-cause
mortality, reduced risk for coronary heart disease, and all-cause mortality
in women than BMI30.
For the cardiorespiratory fitness (METs) calculated for treadmill ex-
ercise, it was verified that the HPBF group presented lower performance
than the LPBF group. Furthermore, it is important to mention that better
cardiorespiratory fitness is associated with a lower risk of all-cause mortal-

ity, reduced risk for coronary heart disease, and is a stronger risk factor of
all-cause mortality in women30.
The present study had some limitations that should be considered, such
as the lack of a direct measure of autonomic tone and heart rate variability.
Thus, the hypothesis that an autonomic imbalance is the main determinant
of HR behaviour warrants further investigation. Moreover, the convenience
sampling used in this study indicates that subjects from this study were
not specifically representative of the Brazilian population, as they were
recruited on a voluntary basis from the local community.
It is relevant to mention that, although no differences between groups
were found for the use of medications, the sample used in this study do
not offer enough statistical power to detect these differences. Some medi-
cations, such as nondihydropyridine calciun-channel, and beta blockers
might blunt heart rate recovery following exercise22.
CONCLUSION
In conclusion, older women classified with higher percentage body fat
presented a lower chronotropic index, lower peak HR, and an impaired
HRR after exercise. Overall, these findings emphasize that body fat may
be used to specify exercise prescription for older women who are also obese.
On the other hand, HRR active or passive is closely linked to vagal tone
modulation. As mentioned, the parasympathetic activity is considered as
a cardiovascular protection factor and a dysfunction in the cardiac vagal
tone, therefore, increases the risk of cardiovascular death26. Thus, the RFC
is a very important measure that should have special attention and can be
part of the clinical and / or physical evaluation of subjects, such as the
obese elderly population. Although the percentage body fat evaluated by
DEXA does not represent a practical tool for the assessment of an impaired
HRR after exercise in routine clinical practice. We encourage researchers
to verify another simple and low cost variable for the same goal.
Acknowledgements
The authors have no conflicts of interest that are directly relevant to the con-
tent of this manuscript. The authors thank the laboratory LAFIT (Daniele
Garcia and contributors). The authors also acknowledge the financial sup-
port from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
(CAPES) and Fundação de Apoio a Pesquisa do Distrito Federal (FAP/
DF). Authors would like to advise that all authors listed have contributed
to the work and approved the content of the submitted manuscript.
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564
Obesity awareness among elders living in rural

area: a household survey
Autorreconhecimento da obesidade de idosos residentes
em áreas rurais: um inquérito domiciliar
Alisson Fernandes Bolina1
Maycon Sousa Pegorari2
Darlene Mara dos Santos Tavares 3
Abstract – The acceptance of the disease is essential to health self-care, elder’s awareness
regarding obesity is suggested to influence their search for health services, and conse-
quently, in obesity’s treatment. This study aimed to verify obesity awareness of elders living
in rural areas and associated socioeconomic and demographic factors. We conducted a
cross-sectional household survey with 562 individuals, who were older than 60 years and
were rural residents from a Brazil southeast city. The identification of obesity awareness
was consisted in the agreement between the self-referred obesity and the diagnosis criteria
using the body-mass index >27Kg/m². The associated socioeconomic and demographic
factors were: gender, age range, marital status, education and income. Descriptive statisti-
cal analysis, Kappa index and logistic regression (p <0.05) were conducted. The highest
percentage of elders were men (53.6%), 60├ 70 years old (62.6%), married (67.8%),
studied for 4|-8 years (40.0%) and with an individual monthly income of one minimal
wage (45.7%). The prevalence of obesity according to the body-mass index was 34.7%
and the self-referred 15.1%, which was classified as regular agreement by the Kappa
coefficient (k= 0.232; p<0.001). The majority of the elders with obesity were not aware
of this condition (64.6%), with higher odds ratio for men than for women (OR=2.34;
CI=1.29-4.77). We found high obesity prevalence among elders residents in the rural area,
who did not recognize themselves with this condition. Moreover, elderly men presented
lower obesity awareness than women.
Key words: Body-mass index; Diagnosis; Elder; Obesity.
Resumo – A aceitação do agravo é essencial para o autocuidado, infere-se que o autorreconhe-

cimento do idoso acerca da obesidade influencia na procura de serviços de saúde e, consequente-
mente no seu tratamento. Este estudo objetivou verificar o autorreconhecimento da obesidade
de idosos rurais e os fatores socioeconômicos e demográficos associados. Trata de um inquérito 1 Universidade de São Paulo.
domiciliar e transversal com 562 idosos residentes na área rural de um município do Sudoeste Ribeirão Preto’s School of Nursing.
do Brasil. A identificação do autorreconhecimento da obesidade consistiu na concordância entre Ribeirão Preto, SP. Brazil.
a obesidade autorreferida e o critério de diagnóstico segundo o Índice de Massa Corporal >27
Kg/m2. Os fatores socioeconômicos e demográficos associados ao autorreconhecimento foram: 2 Universidade Federal do Amapá.
sexo, faixa etária, estado conjugal, escolaridade e renda. Foram realizadas análise descritiva, Physiotherapy Course. Macapá, AP.
Brazil.
coeficiente de Kappa e regressão logística (p<0,05). O maior percentual de idosos foi de homens
(53,6%), com 60– 70 anos (62,6%), casados (67,8%), 4 |- 8 anos (40,0%) de estudo e renda 3 Federal University of Triângulo
mensal individual de um salário mínimo (45,7%). A prevalência de obesidade de acordo com o Mineiro. Department of Nursing
Índice de Massa Corporal correspondeu a 34,7% e a autorreferida 15,1%, sendo caracterizada Education. Community Health
concordância regular de acordo com o coeficiente de Kappa (k= 0,232; p<0,001). A maioria dos Nursing Graduate Program. Uberaba,
idosos com obesidade não se reconheceu nesta condição (64,6%), com maiores razões de chance MG. Brazil.
entre o sexo masculino em relação ao feminino (OR=2,34; IC=1,29-4,77). Constatou-se alta
prevalência de obesidade nos idosos da zona rural, sendo que a maioria não se reconheceu nessa Received: 15 June 2017
condição. Também foi evidenciado que particularmente os homens idosos apresentaram menor
autorreconhecimento quando comparados às mulheres. Licença
Palavras-chave: Diagnóstico; Idoso; Índice de massa corporal; Obesidade. BY Creative Commom
Obesity awareness and elders living in rural area Bolina et al.
INTRODUCTION
Obesity has been considered as a public health problem, with expressive
prevalence in elderly population1. A nationwide study verified that 32.7%
and 12.4% of the Brazilian elders presented overweight and obesity, re-
spectively2. A survey conducted with elderly residents in the rural area of
this study city verified a significant obesity prevalence (34.4%)3, which
highlights the need to know the associated factors of this event, with the
intent of proposing health strategy.
The aetiology of obesity is complex and multifactorial, since it is a
consequence of genetic, environmental, life style and emotional factors4.
In general, this condition is due to an unbalance between energy intake
and consumption, which is accentuated by ageing5.
Alongside the ageing process, some physiological changes may predis-
pose to obesity. Among them, muscle-mass loss and consequently increase
in fat accumulation, especially in abdominal area, should be highlighted6.
The decrease in muscle mass is also responsible for a slower metabolism5,
which contributes to the appearance of the disease.
Additionally, previous reports in the literature have associated obesity
with changes in hormone levels, such as the faster reduction in endogenous
hormones and the change in appetite and self-image neuromodulators5.
Furthermore, elders have propensity to be more sedentary, which leads to a
low total daily energy expenditure and favour obesity in these individuals6.
Obesity may influence health status, as well as in life expectancy in
elders. Previous studies conducted with the elderly population demonstrated
this morbidity predicts mortality7, chronic diseases, systemic arterial
hypertension, diabetes mellitus, dyslipdemia8 and depressive symptoms9.
Considering the referred consequences, the assistance to obese elders
and their peculiarities is a relevant matter. Moreover, the perception and
knowledge about obesity influence in the search for health services, and
consequently, in its treatment10. Since the acceptance of the disease is es-
sential to health self-care, a question is raised: Does elders who presents
obesity recognize themselves in such condition?
Brazilian population surveys verified that the when using elders’ self-
referred measures (height and weight), an underestimation of the prevalence
of overweight and obesity occurred11,12, which might lead to negligence
regarding the care to this condition. Until then, no studies verifying obesity
awareness of elders were found.
In addition, rural area population may present restricted access to
health services due to transport limitations, distance from social and health
resources and low-income13. Those characteristics may aggravate the dif-
ficulties in obesity care and in monitoring this population. Hence, the
results from this study may guide the health strategies to treat and prevent
obesity among elders from rural areas.
The aim of this study was to verify obesity awareness among elders living
in rural areas and the associated socioeconomic and demographic factors.
566
This was a cross-sectional household survey conducted in the rural area of
Uberaba-MG city, which is located in southeast of Brazil. This investigation
is a segment of a larger study entitled “Health and quality of life of the
elderly population living in rural áreas of Uberaba city”. The population
was 1297 elders, who lived in the rural area and were registered by the
primary health care (PHC) in May 2010, which represents 100% elderly
population coverage in the area. In this study, individuals with 60 years
or older were considered elders, according to what is recommended to
developing countries, including Brazil.
Inclusion criteria was 60 years or older; to live in the rural area of
Uberaba-MG city; do not present cognitive decline; to consent with the
study; to be able to undergo anthropometrical assessment. From the total
sample, the exclusions due to do not attend the eligibility criteria: 105
(8.1%) due to cognitive decline; 75 (5.8%) did not consent with the study;
173 were not able to undergo anthropometrical assessment. Additionally,
other losses were: 11(0.8%) died; 7(4.4%) were not found by the researchers
in three visits; 117 (9%) changed from that address; 3 (0.2%) were hospital-
ized; and 79 (6.1%) were excluded due other reasons. Therefore, 562 elders
participated in this study (Figure 1).
Figure 1. Study population composition.
From March 2010 to March 2011 the data collection was conducted
in the elders’ residences by 14 trained interviewers. The interviews were
reviewed by field supervisors and, in the occurrence of inconsistencies,

they returned to the interviewer to be corrected.

Before the beginning of the interviews, the cognitive status of each
elder was assessed by the Mini Mental State Exam (MMSE), which had
been translated and validated to Brazilian population14. The scale score
range is 0-30 points, and the cut-off points were: 13 to illiterate people,
18 to people with 1-11 years of education and 26 to people with more than
11 years of education14.
The interview was conducted with elders who did not present cognitive
decline following the adopted criteria. The Brazilian OARS Multidimen-
tional Functional Questionnaire (BOMFAQ )15 was used to characterize
the socioeconomic variables, such as gender (female and male); age range
(60├ 70, 70├ 80, 80 or older in years); marital status (never married or
lived with a companion, married, widow and divorced); education (no
education, 1|-4, 4|-8, 8 and 9 or more years of education); and individual
income (no income, <1, 1-| 3, 3-| 5, > 5 minimum wages).
The anthropometric measures (weight and height) were assessed by a
portable digital scale and by a flexible and inelastic measure tape, which was
fixed in a wall, in a regular and plane surface, without baseboards; the elders
were barefoot, in a standing position, with both foots united and looking at
the horizon line3. With these anthropometric measures, the body-mass in-
dex (BMI) was calculated using the equation BMI = weight(kg) / height²(m).
In this study, obesity diagnosis criterion was defined by the elderly
specific BMI recommendations (BMI>27kg/m²)16, since it is more sensitive
to Brazilian population17. Despite the criticism regarding the use of BMI to
the obesity diagnosis in elders due to the ageing-related changes in the body
composition, the criterion choice was based in the fact that BMI is easy
to be measured and it is associated to morbimortality indicators in elders1.
In order to verify obesity awareness, firstly it was asked if the elder
presented obesity (yes or no) and, later, the answer was compared to the
diagnosed obesity according the adopted criterion in this investigation16.
Thus, when an elder who referred himself as obese and was diagnosed as
presenting this condition (BMI>27kg/m²), the situation was considered
as an elder who can identify himself as obese16.
An electronic dataset in Excel® Software was created to gather all the
collected data. The interviews information, after review and codification,
was processed in a computer, by two researchers, in double entry. When
the data typing was complete, the consistence between the entries in both
datasets was analysed. In the occurrence of inconsistent data, the original
interview was re-analysed and a correction was applied. Lastly, the dataset
was exported to the software Statistical Package for Social Science (SPSS)
version 22.0 to be analysed.
The descriptive analysis was done by simple frequency distribution. In
order to verify the obesity awareness an agreement analysis was conducted
using the Kappa coefficient, which strength was classified as: insignificant
(0), low (0.01-0.20), regular (0.21-0.40), moderate (0.41-0.60), substantial
(0.61-0.80) and almost perfect (0.81-0.99)18. To verify the associated so-
568
cioeconomic and demographic factors to obesity non-recognition a logistic
regression was conducted. Qualitative variables were re-categorized in a
way to become dichotomic: marital status (with or without a companion);
education (illiterate or literate); income (with or without income). Age
remained with the same categorization as before (60├ 70, 70├ 80 e 80
or older). The dependant variable was obesity awareness (yes or no) and
as independent variables gender, age range, marital status, education and
income. The tests were considered significant when p<0.05.
This study was approved by the Human Research Ethics Committee from
the Federal University of the Triângulo Mineiro (Approval number 1477).
The elders were contacted in their homes, where the aim of the research,
the consent form and relevant information was provided. Only after the ac-
ceptance and the signature in the consent form the interview was conducted.
RESULTS
In this study, the highest percentage of elders were men (53.6%), 60├ 70
years old (62.6%), married (67.8%), studied for 4|-8 years (40.0%) and
with an individual monthly income of one minimal wage (45.7%), Table 1.
The socioeconomic characteristics of the elders living in the rural area
are displayed in Table1.
Table 1. Frequency distribution of socioeconomic and demographic variables of elders living in

rural areas. Uberaba, Minas Gerais, Brazil, 2011.
Variables
n %
Women 261 46.9
Gender
Men 301 53.6
60 ├ 70 352 62.6
Age range 70 ├ 80 163 29.0
80 or more 47 8.4
Never married or never lived with a partner 46 8.2
Married 381 67.8
Marital status
Widow 97 17.3
Divorced 38 6.8
No education 114 20.3
1|-4 174 31.0
Education (in years) 4|-8 225 40.0
8 21 3.7
9 or more 28 5.0
Individual monthly income No income 60 10.7
<1 20 3.6
1 257 45.7
(in minimum wages) * 1-| 3 185 32.9
3-| 5 30 5.3
>5 10 1.8
* Minimum wage during the period of the data collection: R$ 545,00.

The sample included 562 elderly with mean height of 162.34±9.14 cm,
mean weight of 66.78±13.31 kg and BMI of 25.4±4.67 kg/m2.
Diagnosed obesity prevalence, following the adopted criteria, rep-
resented 34.7%, while the self-referred corresponded to 15.1%, Table 2.
Most of the elders with diagnosis of obesity were not aware that they
had this condition (64.6%), which is, a high percentage of false negatives
(low sensitivity). The specificity was much higher, in which 95.6% of the
elderly were aware of their condition of obesity. Through the kappa coef-
ficient, there was a regular agreement between self-reported obesity and
diagnosed according to the criterion adopted (k = 0.232; p<0.001), Table 2.
Table 2 presents the prevalence of self-referred and diagnosed obesity inelders.
Additionally, the agreement analysis by the Kappa coefficient is also displayed.
Table 2. Agreement about the self-referred and diagnosed obesity in elders living in rural areas.
Uberaba, Minas Gerais, Brazil, 2011.
Obesity (BMI)*
Self- Yes No Total
referred
Obesity n % n % n % κ** p†
Yes 69 35.4 16 4.4 85 15.1
No 126 64.6 351 95.6 477 84.9 0.232 <0.001
Total 195 34.7 367 65.3 562 100
*Obesity was defined as BMI >27 Kg/m ; *k: Kapa coefficient; †p<0.05.
2
In order to verify the socioeconomic and demographic factors associa-

tion with the obesity awareness, the data of 195 elders diagnosed as obese,
following the adopted criterion, was analysed.
Table 3, presents the logistic regression model to the socioeconomic
and demographic factors that were associated to obesity awareness.
Table 3. Frequency distribution according to the awareness of obesity and the logistic regression model of its associated factors. Uberaba, 2011.
Obesity awareness Regression models

Variables Yes No
n % n % OR (CI) p† OR* (CI) p†
Gender
Men 23 25.3 68 74.7 2.34(1.27-4.32) 0.006 2.48(1.29-4.77) 0.006
Women 46 44.2 58 55.8 1 1
Age range
60├ 70 51 37.2 86 62.8 1 1
70├ 80 16 33.3 32 66.7 0.84(0.42-1.68) 0.629 0.75(0.36-1.59) 0.466
80 or older 2 20.0 8 80.0 0.42(0.86-2.06) 0.286 0.48(0.93-2.46) 0.379
Marital Status
With a partner 49 34.5 33 65.5 1 1
Without a partner 20 37.7 93 62.3 0.86(0.45-1.67) 0.675 0.95(0.47-1.91) 0.898
Education
Literate 57 35.0 106 65.0 1 1
Illiterate 12 37.5 20 62.5 0.89(0.40-1.96) 0.784 1.01(0.43-2.36) 0.986
Income
With income 58 34.4 105 64.4 1 1
Without income 11 35.6 21 65.6 1.05(0.47-2.34) 0.896 1.49(0.63-3.52) 0.355
*OR: Adjusted odds ratio; p<0.05; 1: reference category.
570
Obese elderly men presented higher rates of do not identify them-
selves as presenting this condition, when compared to women (OR=2.34;
CI=1.29-4.77). Although there was an absence of statistical significant
difference, an increase in the self-referred obesity rates was evident with
the increase in age. Furthermore, marital status (p-0.898), education
(p=0.986) and income (p=0.355) were non-significant predictors, Table 3.
DISCUSSION
The concern with obesity in Brazil has been increasing due to the expand-
ing rates of this condition evidenced by population enquires19. We found
an expressive obesity prevalence among elders residents in the rural area.
Other investigations identified a variety of prevalence between elders who
lives in urban areas from Brazilian cities (48,7%)17 (49,6%)20 or who lives in
a rural area in China (7,1%)21 (29,1%)22. The variability may be due to the
location differences and the obesity diagnosis criterion that was adopted.
Moreover, national studies with elders living in rural areas are yet scarce,
which prejudices comparison with the findings.
The high prevalence of obesity in elders suggests the establishment
of monitoring, prevention and control programs for this disease, since it
causes adverse effects to health condition and quality of life worsening17.
Several strategies to reduce body weight are available, such as change in
lifestyle, healthy nutritional habits and exercising regularly23. However, the
perception and recognition of obesity are essential in the search for a health
service, and, consequently, in the effectiveness of these interventions10.
Most elders diagnosed with obesity according to their BMI, in the
present study, did not identify themselves as obese. Previous evidences
about health awareness have been suggesting that elders that suffers from
some chronic morbidity sometimes do not perceive themselves in that
condition when there are no disease consequences, which corroborates with
our data 24,25. In addition, elders tend to accept the adverse weight-related
adverse situations26, and, consequently, seek treatment for this condition
only when associated comorbidities manifestations occur. These findings
are concerning, since these individuals may develop some health condition
due to the lack of qualified treatment to obesity.
In contrast, the results show high specificity, which is, use of self-
recognition may contribute to identify those who are obese in the elderly
population. Until this moment, few studies have discussed obesity aware-
ness among elders. The literature about this theme is focused in the knowl-
edge about this population about their anthropometrical measures and in
their capacity of referring them11,12,27. Populational surveys verified only
the underestimation of the prevalences of overweight and obesity using
self-referred measures11,12.
Similar situation was observed in a rural area of Brazilian Northeast
region, in which the majority of the individuals did not know their weight
and height, especially among the elders27. This study found a regular agree-

ment between self-referred and diagnosed obesity, which reinforces the

need of the measurement of the anthropometrical characteristics for the
obesity diagnosis in the elders living in rural areas.
Despite its limitations, the use of BMI for the diagnosis of obesity has
been suggested in epidemiological studies, mainly, since it is easy to collect
associated to the fact that index is associated to morbimortality predictors
in elders1. However, the adoption of a more sensitive cutoff point is neces-
sary for the Brazilian elderly population (BMI >27 Kg/m 2)17.
Another aspect that that should be mentioned is that men presented
higher chances of do not identify themselves as obese when compared to
women. A study conducted in Brazilian Northeast region verified that men
were more satisfied with their body image when compared to women, even
when they were overweight 28. The hypothesis to these findings is related
to cultural and aesthetics aspects, which affect mostly women in a search
for a normality standard considered acceptable by society29. Additionally,
women present a better perception of signs and symptoms of a disease
when compared to men30.
Our results reinforce the need of strategies aiming to sensitise the
elderly, especially men, about the relevance of the nutritional status
monitoring. A fundamental question to these strategies effectiveness is
the knowledge about obesity and their consequences to health10. Interna-
tional evidence has shown that public education campaigns are effective
interventions in the empowerment of individuals in their self-care and in
the overweight control10.
In the context of rural areas, transport limitation, the distance of social
and health resources and unfavourable income may make more difficult
the elders access to health resources13. Since the population of this study
presented a complete coverage by the primary health care, the professionals
from this team may use health education during domiciliary visits, aiming
to create in elders living in rural areas the interest for their health condi-
tion, such as the awareness of obesity.
As limitations, this was a cross-sectional study, which prevents to
establish a causality association. Moreover, the use of the BMI as the
obesity diagnosis criterion presents limitation due to the changes in elders’
body composition. Other studies are necessary, in order to provide a broad
comprehension about obesity and their associated factors in elders and
allow new discussions in the scientific field.
CONCLUSION
The prevalence of diagnosed obesity corresponded to 34.7%, while the
self-referred obesity presented a prevalence of 15.1%. A regular agreement
was observed and the majority of the obese elders were not aware they were
obese. Men presented twice more chances of do not identify themselves
as obese, when compared to women.
Our findings reinforce the relevance of strategies that improve the knowl-
572
edge and perception of elders living in rural areas, especially men, regarding
obesity and its adverse effects, aiming to provide stimuli in the search of
qualified care and, consequently, the treatment and prevention of this disease.
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574
Dual Task Multimodal Physical Training in

Alzheimer’s Disease: Effect on Cognitive
Functions and Muscle Strength
Treinamento Físico Multimodal com Dupla Tarefa na
Doença de Alzheimer: Efeito nas Funções Cognitivas e na
Força Muscular
Bruno Naves Ferreira1
Emmanuel Dias de Sousa Lopes2
Isadora Ferreira Henriques1
Marina de Melo Reis 3
Amanda Morais de Pádua1
Karina de Figueiredo3
Fernanda Aparecida Lopes Magno1
Flávia Gomes de Melo Coelho1,3
Abstract – The aim of this study was to evaluate the effects of dual task multimodal
physical training (MPT) on the cognitive functions and muscle strength in older adults
with AD. Participants were 19 subjects with AD in the mild and moderate stages, divided
into training group (TG) and control group (CG). The TG performed dual task MPT for
12 weeks. Subjects were evaluated at the pre- and post-intervention moments. The Mini
Mental State Examination (MMSE), Clock Drawing Test (CDT) and Frontal Assessment
Battery (FAB) were used to assess cognition. For muscle strength, the Chair Lift and Sit
Test (CLST) and Manual Grasp Force (MGF) were used. The Wilcoxon test was used
to analyze pre and post intragroup moments. The TG showed a significant improvement
in FAB and CLST (p≤0.05) and a tendency to improve the MMSE score (p≤0.08). The
CG showed significant improvement in CLST (p≤0.05). Dual task MPT improves the
frontal cognitive functions and lower limb muscle strength of older adults with AD.
Key words: Alzheimer disease; Cognition; Exercise; Muscle strength.
1 Federal University of Triângulo Mi-
neiro. Graduate Program in Physical
Resumo – Objetivou-se avaliar os efeitos do treinamento físico multimodal (TFM) com dupla Education. Uberaba, MG. Brazil.
tarefa nas funções cognitivas e força muscular de idosos com DA. Participaram 19 indivíduos
2 Federal University of Triângulo
com DA no estágio leve e moderado, divididos em grupo treinamento (GT) e grupo controle
Mineiro. Graduate Program in Health
(GC). O GT realizou TFM com dupla tarefa por 12 semanas. Os idosos foram avaliados no Care. Uberaba, MG. Brazil.
momento pré e pós-intervenção. Para avaliação da cognição foram utilizados o Mini Exame do
Estado Mental (MEEM), Teste do Desenho do Relógio (TDR) e Bateria de Avaliação Frontal 3 Federal University of Triângulo Mi-
(BAF). Para a força muscular o Teste de Levantar e Sentar da Cadeira (TLSC) e Força de neiro. Department of Sport Sciences.
Preensão Manual (FPM). O teste de Wilcoxon foi utilizado para analisar os momentos pré e Uberaba, MG. Brazil.
pós-intragrupos. O GT apresentou melhora significativa na BAF e TLSC (p≤0,05) e tendência
de melhora no escore do MEEM (p≤0,08). O GC apresentou melhora significativa no TLSC Received: April 28, 2017
(p≤0,05). O TFM com dupla tarefa melhorou as funções cognitivas frontais e a força muscular
de membros inferiores de idosos com DA. Licença
Palavras-chave: Cognição; Doença de alzheimer; Exercício; Força muscular. BY Creative Commom
Multimodal Physical Training in Alzheimer’s Disease Ferreira et al.
INTRODUCTION
The aging of the Brazilian and world population is a contemporary fact,
which has caused an increase in chronic degenerative diseases that affect the
elderly population, among them Alzheimer’s disease (AD)1. AD is a neuro-
degenerative disease that affects different areas of human functioning, such
as cognitive, social, physical, behavioral, functional and metabolic2, being
the most common form of dementias, accounting for 60% to 80% of cases3.
AD has two classic neuropathological biomarkers, both of which lead
to neuronal death. Extracellularly, there is an excessive accumulation of
beta-amyloid plaques (Aβ) that prevent the passage of cellular nutrient
substrates by altering the local pH. There is formation of neurofibrillary
tangles caused by hyperphosphorylation of the Tau protein in the intracel-
lular medium, which disintegrates the microtubules of the cytoskeleton4.
This neuronal loss in older adults with AD is the main factor that triggers
memory deficit and the decline in cognitive functions5. In addition, older
adults with AD have lower peripheral concentrations of some biomarkers
such as Brain Derived Neurotrophic Factor (BDNF)6 and Insulin Growth
Factor-1 (IGF-1)7, and higher peripheral concentrations of inflammatory
biomarkers such as Interleukin-6 (IL-6 ) and Tumor Necrosis Factor
(TNF-α) 8, which are linked to cognitive decline.
In addition to sarcopenia due to the aging process, older adults with
AD present a marked decrease in the level of physical activity 9, which
contributes to reduce muscle strength. Garuffi 10 points out that older adults
with AD have lower strength of lower and upper limbs when compared
to those without dementia.
The benefits of physical exercise in mental health have been the focus
of studies in recent years, especially among older adults with cognitive im-
pairment and AD11-14. Among the types of physical exercises, multimodal
exercises stand out, which when associated with dual task has been shown
to improve functional capacity and cognition12. However, there are still
few studies in scientific literature that show improvement in cognition and
muscle strength as a result of multimodal training in older adults with AD.
Therefore, the aim of this study was to evaluate the effects of dual-task
multimodal physical training (MPT) on the cognitive functions and muscle
strength of older adults with AD.
Study Characterization and Ethical Aspects
This is a quasi-experimental study with a quantitative approach approved
by the Ethics Research Committee of the Federal University of Triângulo
Mineiro (UFTM) under protocol number 1.040.482.
Sample
Margin of error of 5%, statistical power of 80% and effect size of moderate
576
magnitude were used to calculate the sample size needed to produce repre-
sentative data, resulting in minimum size of 34 participants. Thus, a wide
dissemination of the “MoviMente” Extension Project (Exercise Program
for Older Adults with Alzheimer’s Disease) of the UFTM was carried
out in a period of two years to recruit the largest number of older adults
with AD. Publicity was made through media such as: television, radio,
electronic media, and visits were also made to older citizens in the city of
Uberaba, the Brazilian Alzheimer Association (ABRAZ, Uberaba-MG)
and medical offices (neurologists, geriatricians and psychiatrists). Of the 46
older adults recruited and evaluated, only 25 met the criteria to participate
in the study. During the experimental period, 06 gave up participating,
and in this way, 19 participants completed the study, as shown in figure 1.
Inclusion criteria were: elderly with clinical diagnosis of AD through
medical certificate, level of severity of mild or moderate dementia according
to the Clinical Dementia Rating Score (CDR), availability for participation
of evaluations, and participants and caregivers who agreed to the study
procedures signed the Free and Informed Consent Form.
Exclusion criteria were: presence of coronary disease, cardiac arrhyth-
mias, uncontrolled hypertension, angina symptoms, absolute restriction to
physical exercise, visual and auditory impairment, dizzying syndrome or
other limitations that made locomotion difficult, concomitant neuropsy-
chiatric conditions, non attendance in the pre-scheduled evaluations and
attendance of less than 70%.
After inclusion, participants were divided for convenience into control
group (CG) and training group (GT), which included 8 female participants
and 3 male participants, totaling 11 participants and the CG included 7
female participants and 1 male female participant, totaling 8 female par-
ticipants. The CG was instructed to follow their normal routine without
the practice of scheduled physical exercises, and GT participated in the
dual task MPT.
Evaluation Protocol
At the first moment, anamnesis with participants and their respective car-
egiver or relative was performed to identify socio-demographic data: age,
gender, schooling, marital status, profession, country of birth, children,
religion, address and telephone numbers; and clinical data: time of illness,
practice of physical activity, responsible physician, caregiver, use of glasses
and / or hearing aid, surgeries performed, comorbidities, restriction of
physical exercise and medications in use.
After inclusion of participants, two evaluations were scheduled, one at
the pre-intervention and the other at the post-intervention moment, with
a twelve-week interval between them.
Three instruments were used to assess cognition:
a) Mini Mental State Examination (MMSE): an instrument composed

of questions grouped into seven categories, each one planned with the

Figure 1. Illustrative scheme for sample recruitment.
purpose of evaluating specific cognitive functions, namely: temporal

orientation, spatial orientation, three word register, attention and calcu-
lation, recall of the three words, language and visuoconstructive ability.
The MMSE score varies from 0 to 30 points according to the years
of schooling, with lower values indicating possible cognitive deficit15.
b) Clock Drawing Test (CDT): task of drawing a clock with the insertion
of pointers marking a certain time (2h45m), and is intended to measure
executive functions (planning, abstract thinking, logical sequence and
executive processing monitoring). The test is based on a score from 0 to
10 points, and higher scores mean better performance in the executive
functions evaluated16.
c) Frontal Assessment Battery (FAB): evaluates frontal cognitive functions
composed of 6 subtests: “Similarities” (abstract reasoning), “Lexical Flu-
ency” (mental flexibility), “Motor Series” (programming), “Conflicting
Instructions” (sensitivity to interference), “Go - will not” (inhibitory
control) and “Grasp behavior” (primitive reflex). It ranges from 0 to 18
points, and high scores mean better performance in frontal functions17.
Two tests were used to evaluate muscle strength:
a) Chair Lift and Sit Test in 30 seconds (CLST): the test begins with the
participant sitting in the middle of the chair, with the back straight
and feet flat on the floor. The arms are crossed against the thorax. At
578
the sign “Attention! Go!”, the participant stands up, standing upright
and then returning to a fully seated position. The subject is encouraged
to sit completely the highest number of times in 30 seconds18.
b) Manual Grasping Strength (MGS): evaluated through an adjustable
and calibrated dynamometer with scale from 0 to 100 kilograms. The
subject is placed in the orthostatic position, and the appliance was
comfortably fixed in the forearm line, being parallel to the longitudinal
axis of the body. The proximal interphalangeal joint of the hand should
be adjusted under the bar that is then tightened between the fingers and
the tenar region. During manual grasping, the arm remains immobile,
with only the flexion of the interphalangeal and metacarpophalangeal
joints. Three measures were performed in the dominant hand and mean
values were obtained19.
Dual Task Multimodal Physical Training Protocol

The dual-task MPT protocol was performed three times a week on non-
consecutive days for 12 weeks. Each session lasted one hour. Sessions were
divided into activities and each day of the week was focused on different
components of functional capacity, namely: a) aerobic capacity and muscular
strength; b) aerobic capacity, agility and balance, and c) muscle strength,
agility and balance.
There was a progression during the protocol, increasing the difficulty
of exercises, intensity and volume, gradually and according to the capacity
of each participant.
The aerobic training intensity was maintained between 65% and 75%
of the maximum heart rate predicted for age, characterizing in general
training with aerobic predominance of moderate intensity. Heart rate was
assessed during sessions through the use of a Polar frequency meter.
In activities of balance and agility, progression occurred due to the
degree of difficulty of exercises, requiring an increase in the motor capacity
of participants. In addition, from the seventh week, cognitive tasks were
included simultaneously with motor tasks, that is, dual task. Participants
were instructed to perform a motor task (bounce a ball, walk, weight
exercises) and at the same time perform cognitive tasks, such as saying
words according to semantic criteria (names of animals, fruits, people
and objects), counting and naming figures. There was also progression in
cognitive tasks, for example, increase in the number of figures to be named
and inclusion of countdown.
In weight training, progression occurred every two weeks, and week
1 and 2 were adaptive (2 sets and 8 to 10 repetitions), in weeks 3 and 4,
there was an increase in the number of repetitions (2 sets and 10 to 15
repetitions), in weeks 5 and 6, there was an increase of sets (3 sets and 10
to 15 repetitions), in weeks 7 and 8, there was an increase of load (3 sets
and 10 to 15 repetitions and increase of the weight of dumbbells and ankle
weights), in weeks 9 and 10, there was inclusion of exercises with greater
degree of difficulty, and in weeks 11 and 12, increase in exercise loads,

as presented in Box 1. Two upper limb exercises (MMSS) and two lower
limbs exercises (MMII) were used for each session. The load increase was
according to the individuality of each participant, being guided by the
participant’s subjective perception of effort and by the perception of the
responsible physical education professional.
Box 1. Progression of training with weights
Week 1 2 3 4 5 6
Load 2x 8 to 10 rep 2x 10 to 15 rep 3x 10 to 15 rep
Week 7 8 9 10 11 12
3x 10 to 15 rep + In- 3x 10 to 15 rep + New 3x 10 to 15 rep
Load
crease load exercises Increase load
Descriptive data analysis was performed by mean and standard deviation.
For the sample characterization variables, the U Mann Whitney test was
used to verify differences between groups (TG and CG) at the time of
intervention, Mann Whitney U test for intergroup and Wilcoxon test for
intragroup comparisons.
RESULTS
The study had the participation of 19 older adults, 4 men and 15 women
in two groups, 11 in the TG and 8 in the CG. The U Mann Whitney test
pointed out that both groups were similar at pre-intervention time for all
variables. Table 1 presents the sociodemographic and clinical characteristics.
Table 1. Median and upper and lower limits of sociodemographic and clinical characteristics of
training (TG) and control (CG) groups
TG CG
Variables
(n=11) (n=8) p
Age (years) 78 (62-85) 76,5 (63-89) 1.0
Schooling (years) 5 (1-16) 4,5 (4-16) 1.0
Time of disease (months) 24 (6-48) 30 (8-120) 0.31
CDR (scores) 1 (1-2) 1 (1-2) 0.77
TG: Training group; GC: Control group; CDR: Clinical Dementia Rating Score.
p: U-Mann Whitney test
Regarding cognitive variables, TG showed significant improvement in

FAB (p≤0.05) and tendency to improve the MMSE score (p≤0.08), with
no significant difference in CDT (p = 0.931). The CG did not present
significant results in any of the cognitive variables (Table 2).
Regarding the strength variables, the TG showed a significant im-
provement in CLST (p = 0.006). CG presented similar results to TG in
the strength variables, evidencing improvement in CLST (p = 0.033) and
non-significant results in MGF (Table 3).
580
Table 2. Median and upper and lower limit of cognitive variables analyzed in the pre- and post-
intervention moments between training (TG) and control (CG) groups.
TG (n=11) CG (n=8)
Variables
Pre Post Pre Post
MMSE (scores) 17 (13-27) 21 (12-26)** 16 (5-29) 17,5 (13-30)
CDT (scores) 3 (1-10) 5 (2-10) 4 (1-10) 3 (2-10)
FAB (scores) 9 (6-14) 12 (4-16) * 9,5 (3-18) 10,5 (9-18)
*: Wilcoxon p≤0.05; **: Wilcoxon p≤0.08; MMSE: Mini Mental State Examination; CDT: Clock
Drawing Test; BAF: Frontal Evaluation Battery.
Table 3. Median and upper and lower limit of muscle strength variables analyzed in the pre- and
post-intervention moments between training (TG) and control (CG) groups.
TG (n=11) CG (n=8)
Variables
Pre Post Pre Post
CLST (scores) 10 (5-13) 12 (7-19)* 10 (0-14) 13 (0-16)*
MGF (kg) 22 (11-40) 23 (13-42) 23 (14-41) 23 (18-42)
*: Wilcoxon p≤0.05; CLST: Chair Lift and Sit Test; MGF: Manual Grasp Force.
DISCUSSION
Our main finding was that dual task MPT was able to improve the execu-
tive functions in the TG. These improvements bring significant benefits in
attention, planning, organization, strategy creation, operational memory
and thought flexibility. The CG did not present significant response to
cognitive variables.
Corroborating the results found, Coelho et al. 20 performed dual task
MPT for 16 weeks with frequency of 3 times a week on nonconsecutive
days and found improvement in the executive functions in the TG, spe-
cifically in abstraction, organization, motor sequence and performance in
attention. The CG had significant decline in planning, organization, and
motor sequencing. Another study with similar methodology11 also found
positive results in the frontal cognitive functions in the TG.
In addition, these two studies found significant CDT values in the
TG, which was not observed in the present study. Possibly, the duration
of the proposed training protocol of 12 weeks was not sufficient to pro-
mote significant CDT results. It is noteworthy that in the studies above,
double task was performed for a period of 16 weeks and for 6 weeks in
the present study.
The MMSE is an instrument frequently used to evaluate cognitive
functions in elderly patients with AD12. Our results did not show im-
provement in MMSE in none of the groups; however, a trend in the TG
(p≤0.08) was observed. However, Vreugdenhil et al.21 carried out a study
with 40 elderly patients with AD, allocating 20 participants in the TG and
20 in the CG. The TG performed a 16-week MPT and showed signifi-
cant improvement in cognitive functions through MMSE, while the CG
presented a significant decline. Corroborating these results, the literature
presents similar studies13,22. Nascimento et al.23 carried out a study with
MPT for 24 weeks and observed that the TG showed reduction in the

neuropsychiatric symptoms of AD, increasing the global cognitive func-

tions and improving the ability to perform daily activities.
The scientific literature has pointed out that multimodal physical
training seems to be the most appropriate type of exercise to promote
improvements in the cognitive functions of older adults with AD, corrob-
orating our study, which pointed out progress in the cognitive functions of
patients with AD after dual task MPT. In this sense, Coelho24 indicates
possible mechanisms by which intervention provided benefits in frontal
functions, among them: a) frontal cognitive functions were stimulated
during intervention - the “physical exercise demonstration” requires atten-
tion and abstraction, “continuous execution” requires motor sequencing,
and “permanence in the task” requires self-control; b) the dual task also
provided activation of cognitive functions and c) cognitive stimulation
associated with neurobiological, psychological and social effects of physical
exercise may have contributed to the improvement of cognitive functions.
The improvement in the performance of frontal cognitive functions
of patients with AD is extremely important, since they present a deficit of
executive functions, characterized by the decrease in the capacity of solving
problems, judgment of what is right or wrong, mental flexibility, organi-
zation and self-control, presenting a decline with the disease progression.
These losses make these individuals dependent to perform instrumental
activities that require cognition, such as cooking, shopping, handling money,
driving, among others, leading to loss of autonomy25. With the positive
effects of exercise on frontal cognitive functions, patients with AD conse-
quently increase their capacity to perform instrumental tasks, which provides
benefits in autonomy and directly interfere in aspects of their social life.
Regarding muscle strength, our study showed an increase in lower
limb strength in the TG, but did not present a significant result in upper
limb strength. However, the CG also showed positive results in lower
limb strength. The CG was instructed to follow their normal routine,
without performing any physical exercise program; however, the amount
of physical activity of the control group was not controlled, which may be
considered a study limitation. There are only few studies evaluating the
effect of MPT on the strength of older adults with AD. Nascimento26
applied a 16-week MPT with a sample composed of 17 participants in
the TG and 18 in the CG with no satisfactory results in upper and lower
limb strength for both groups. In contrast, the study by Coelho24 showed
improvements in the lower limb strength of elderly patients with AD after
16 weeks of dual task MPT.
Both elderly without dementia and those in the pre-dementia and early
stages of AD have compromised motor function27, with a decline in muscle
strength. Thus, the positive result observed in our study about lower limb
strength is important for maintaining and increasing muscular strength for
this population, since it will aid in the vital activities of their everyday life
such as: sitting and standing, walking with autonomy and safety, among
other everyday activities28. Regular physical exercise is considered a ben-
582
eficial alternative to attenuate the loss of muscular strength with aging,
bringing autonomy and social insertion 29, in addition to reducing the risk
of falls in older adults with AD30.
Although our study has demonstrated the positive effects of dual-task
multimodal physical training in AD patients, it is necessary to consider that
this study has limitations, among them the small number of participants
and the lack of sample randomization. These procedures were unavoidable
due to the difficulty of recruiting older adults with AD and the difficulty
of keeping participants in the program. It is noteworthy that caregivers
and family members were not always available to take participants to the
program or to carry out evaluations.
CONCLUSION
Dual task multimodal physical training provided improvements in frontal
cognitive functions and muscle strength in the lower limbs of elderly indi-
viduals with AD. It is important to emphasize that non-pharmacological
interventions, such as physical exercise, have provided a beneficial impact in
attenuating cognitive decline and improving motor function in elderly in-
dividuals with AD, representing a valuable contribution to this population.
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584
Acute effects of passive static stretching on

the vastus lateralis muscle architecture of
healthy young men
Efeitos agudos do alongamento estático passivo sobre
a arquitetura muscular do vasto lateral de jovens
saudáveis
Eurico Peixoto César1
Letícia de Oliveira Teixeira 2
Daniel Vieira Braña Côrtes de Souza1
Paulo Sergio Chagas Gomes 3
Abstract – The aim of the study was to investigate the acute effects of passive static
stretching (PSS) on the fascicle length (FL) and fascicle angle (FA) of the vastus later-
alis muscle (VL) in two different joint positions. Twelve physically active men (26.9 ±
7.5 years, 178.6 ± 7.0 cm, and 82.5 ± 16.8 kg) were placed in the prone position for the
acquisition of ultrasound images (US) of VL, registered with extended and totally flexed
knee up to the heel contact with the gluteus, before and after a PSS routine comprised of
three 30-s repetitions maintained in the maximal discomfort position as reported by the
participant. Results of the paired t-test indicated an increase in FL (16.2%; p = 0.012)
and reduction in FA (15.5%; p = 0.003) in pre vs. post stretching comparisons for the
extended knee position. There was also a significant increase in FL (34%; p = 0.0001)
and reduction in FA (25%; p = 0.0007) when compared the extended knee vs. flexed knee
positions. There were no significant differences in muscle architecture variables for the
flexed knee position. The results showed high and moderate correlation of FL and FA
for the extended (r = -0.89 and r = -0.74) and flexed knee (r = -0.76 and r = -0.78)
position, pre and post stretching, respectively. It was concluded that the static stretching
acutely affects the vastus lateralis muscle architecture only in the extended knee position,
but not in the flexed knee position.
Key words: Muscle stretching exercises; Skeletal muscle; Ultrasonography.
Resumo – O objetivo do estudo foi verificar os efeitos agudos do alongamento estático passivo
(AEP) sobre o comprimento (CF) e ângulo do fascículo (AF) do músculo vasto lateral (VL) em
duas diferentes posições articulares. Doze homens (26,9 ± 7,5 anos; 178,6 ± 7,0 cm; e 82,5 ±
16,8 kg), fisicamente ativos foram posicionados em decúbito ventral para aquisição de imagens
de ultrassonografia (US) do VL, registradas com joelho estendido e totalmente flexionado, até o
conato do calcanhar com o glúteo, antes e após uma rotina de AEP composta por três repetições
de 30 s com manutenção da posição no limite de desconforto relatado pelo participante. O teste 1 “Presidente Antônio Carlos” Uni-
versity. Barbacena, MG. Brazil
t de Student para amostras pareadas indicou aumento no CF (16,2%; p = 0,012) e redução
no AF (15,5%; p = 0,003) nas comparações pré vs. após alongamento na posição com o 2 Gama Filho University. Rio de
joelho estendido. Também houve aumento significativo do CF (34%; p = 0,0001) e Janeiro, RJ. Brazil.
redução do AF (25%; p = 0,0007) na comparação entre as posições de joelho estendido vs.
flexionado. Não foram encontradas diferenças significativas nas variáveis da arquite- 3 State University of Rio de Janeiro.
tura muscular investigadas na posição com o joelho flexionado. Os resultados apontaram Rio de Janeiro, RJ. Brazil.
para correlação alta e moderada do CF e AF com joelho estendido (r = -0,89 e r = -0,74)
e joelho flexionado (r = -0,76 e r = -0,78), pré e após alongamento, respectivamente. Received: March 23, 2017
Concluiu-se que o alongamento estático afeta de forma aguda a arquitetura muscular
do vasto lateral apenas na posição de joelho estendido, mas não na posição com joelho flexionado. Licença
Palavras-chave: Exercício de alongamento muscular; Músculo esquelético; Ultrassonografia. BY Creative Commom
Static stretching and muscle architecture César et al.
INTRODUCTION
Static stretching contributes to the reduction of passive stiffness and to
increase of range of motion (ROM)1. Changes in the muscle-tendon
mechanical properties are of great influence to increase the ROM of a
joint, being the effect attributed to the structure extensibility, including
sarcomeres, aponeuroses and connective tissues2. Among the different
types of stretching, static stretching one is one of the most commonly used,
where muscles are extended to the point of discomfort and maintained for
a certain period, with 30 seconds of insistence time repeated 3 to 4 times
to increase ROM and reduce passive stiffness3.
Although acute changes in muscle-tendon properties and passive
stiffness are well documented1,4 after static stretching exercises, little is
known about their effects on muscle architecture variables, such as fasci-
cle length (FL) and fascicle angle (FA). FA is the angle formed between
the insertion of the fascicle and the internal muscle aponeurosis and FL
is the distance from the junction point of the fascicle with the external
aponeurosis5. These muscular architecture variables drastically affect the
functional characteristics of a muscle and the force production capacity6,
since FA is related to the amount of contractile tissue per unit of muscle
area. Thus, in hypertrophied muscles, FA is significantly increased, and
higher FL is associated with higher muscle contraction rate5.
Changes in muscle architecture caused by conventional strength
training in trained youth and adults are already well documented, such
as increased cross-sectional area (CSA) and FA, but with less apparent
modifications in FL7-9. However, little is known about the isolated acute
effect of static stretching on muscle architecture. Most studies indicate
alterations generated in muscle architecture during stretching exercises
and not the acute effect generated after this routine10. Moreover, the few
studies that verified the acute effect of static stretching on muscle archi-
tecture showed controversial results, possibly due to the different methods
adopted and muscles tested11-13.
In the study conducted by Morse et al.1, no significant changes were
observed in FL and FA immediately after an extensive routine of five 1-min
repetitions of static stretching in the triceps sural muscle. However, muscle
architecture variables were measured during dorsiflexion movement and not
at rest. In contrast, Sá et al.13 measured FL and FA of the vastus lateralis
and femoral biceps muscles before, immediately after three 30 s repetitions
of static stretching and 10 min after three sets of strength exercises pre-
ceded by the stretching routine. The authors verified a significant increase
in the FL of femoral biceps immediately after the stretching routine, but
no alterations in FA and in these same muscle architecture variables of the
vastus lateralis muscle. It should be noted that in this study, US measure-
ments were performed in only one position (supine position).
According to Lieber and Friden6, muscle architecture and the muscle-
tendon composition differ profoundly between muscle groups and in dif-
586
ferent positions. In this sense, static stretching provides different effects as
a function of volume, insistence time in the discomfort position, intensity,
joint position and type of muscle group tested. In addition, as suggested by
Cè et al.11, possible changes in muscle architecture caused by static stretching
may explain the decline in strength performance presented by some studies,
but for a more correct conclusion, different joint positions should be tested,
since force production varies substantially according to this variable.
In this sense, due to the need to verify the isolated effect of static
stretching on the muscle architecture in different joint positions, the
present study aimed at verifying the acute effect of three 30-s repetitions
of passive static stretching (PSS) on muscle architecture variables of the
vastus lateralis muscle (VL) at two different knee angles.
The present study was approved by the Ethics Research Committee of the
Gama Filho University under protocol number 173.786. The involvement
of volunteers occurred after signing the informed consent form (ICF), in
addition to completing a questionnaire for risk stratification (Par-Q ), where
one or more positive answers to the seven questions in the questionnaire
served as exclusion criteria, and a detailed explanation of the objectives
and procedures of the present study. They were informed that at any time
they would be free to leave the study. The study was conducted according
to the recommendations defined in Resolution 466/2012 of the National
Health Council.
Sample
Twelve physically active men (26.9 ± 7.5 years, 178.6 ± 7.0 cm, and 82.5
± 16.8 kg) visited the laboratory on four different occasions. Volunteers
were invited through posters fixed in classrooms. Inclusion criteria were: a)
participant should be able to touch the heel in the gluteus during the knee
flexion movement; b) participant should practice physical exercises three or
more times per week; c) participant should not have any type of injury or
impairment in the right lower limb that restricted the knee flexion move-
ment. The first visit was aimed at familiarizing with procedures and the
completion of the ICF and the questionnaire for risk stratification. Visits
2 and 3 were used to determine the reliability of US measurements and in
the last visit, the experimental procedure was performed. The maximum
interval between visits was 72 h.
Instruments
FL and FA measurement images were obtained by ultrasound device
(LOGIQe, GE Healthcare, USA) with a 40 mm linear transducer and a
10 MHz excitation frequency. To avoid depression of the skin surface and
to maintain the same level of pressure on the muscle, an apparatus was used
to fit the transducer that surrounded the thigh by means of elastic bands,

being positioned at the measurement site. Gel was used for the acoustic
coupling (Ultrex-gel, Farmativa Indústria e Comércio Ltda).
All images were analyzed using public domain software (ImageJ,
National Institute of Health, USA, version 1.42). As the used transducer
used has 40 mm, an estimation model 14 was used to calculate FL using
the following equation: CF: (l1 + h) / (sen α). Where l1 is the visible FL
measured in the image; h is the vertical distance from the end point of
l1 to the superficial aponeurosis and α is the angle between the fascicle
and the deep aponeurosis. When aponeuroses were not parallel, the angle
between the fascicle and the deep aponeurosis was subtracted from the
angle of the measured fascicle (Figure 1A).
Procedures
In order to acquire the images, the following procedures were performed:
a) with participant standing, a marking was made at the center of the pa-
tella and at the point related to the anterior superior iliac crest. From these
two points, a straight line was drawn connecting them, thus identifying
the line of action of the rectus femoris muscle; b) from the center of the
patella, using the straight line drawn for the action of the rectus femoris,
a universal goniometer was positioned and 15° lateral was identified from
that point, identifying the line of action of the VL; c) the trochanteric and
lateral tibial points were marked to measure the femur length and; d) from
the line of action drawn from the VL, a proximal point was marked at
60% of the femur length, where the apparatus for fitting the US transducer
(Figure 1B) was positioned.
Figure 1. Procedure for FL estimation (A) and Identification of the anatomical site for placement
of the US transducer (B).
588
Once demarcations were made, the participant was placed in a ventral
decubitus position with the right knee extended and supported on a padded
apparatus and the distal part of the thigh wrapped in an inextensible band,
fixing the limb and ensuring that there was no hip rotation. Three US im-
ages were captured in this position, with an interval of about 1 min between
them. Then a passive, slow and gradual mobilization of the knee flexion
was performed until there was contact of the heel with the gluteus. In this
position, three more US images were recorded. After this procedure, with
the subject positioned in the ventral position, three repetitions of passive
static stretching were performed to the quadriceps, with a slow and gradual
knee flexion until the heel touched the gluteus. Then, hyperextension of
the participant’s hip was performed up to the limit of reported discomfort,
maintaining this position for 30 s. Subsequently, three US images of the
vastus lateralis muscle were captured with extended knee and three with
flexed knee. All images were analyzed and the mean results for each posi-
tion were used as the value for the statistical calculations.
The Shapiro-Wilk test showed normal distribution for variables tested. The
reliability of the measurement was made by means of the intraclass correla-
tion coefficient (ICC parallel method), of the typical measurement error
(TME), which according to Hopkins15, is determined by the relationship
between standard deviation of the differences obtained between measure-
ment pairs and the square root of two. Finally, the degree of agreement
among measures was verified, according to Bland and Altman16. The com-
parison between measures before and after the stretching routine for each
joint position was made through the Student t test for paired measures. In
addition, Pearson’s correlation was used to verify the relationship between
FL and FA in the different positions tested. Analyses were performed
using commercially available software (SPSS 17.0 for Windows®, IBM
Corporation, New York, USA, Prism 5.0 for Mac, Graphpad Software,
La Jolla, Calif., USA) and significance level of 5% was adopted.
RESULTS
The reliability results of FL and FA measurements were based on 10 of the
12 recruited subjects due to problems with the US measurement in two
of them, where the difference between the two tests in one section was
69.6% for one subject and 87.8% for the other. The reliability results for
FL were R = 0.916, BIAS 4.1 and TME 7.4% and for FA were R = 0.928,
BIAS 3.0 and TME 5.3%.
High reliability and reproducibility values of measurements and low
associated error are observed. ICC showed that for FL and FA, approxi-
mately 92% and 93%, respectively, of the variance in the mean among meas-
urements is real, denoting good association among measures performed.
The comparison between test and retest for the two variables showed no

significant statistical difference. TMEs were also low with values below

8.0% for both variables. The Bland-Altman graphic representations (Figure
2A and 2B) showed that in both dependent variables used, all measures are
within the determined confidence limits (± 1.96 SD) with low associated
error (BIAS) and absence of heterocedastic error.
Figure 2. Bland-Altman graphic representations for (A) Fascicle Angle and (B) Fascicle Length.
(°) = degrees.
The Student’s t-test for paired measures identified a significant increase

in FL (34%, p <0.05) and reduction in FA (25%; P <0.05) in the comparison
between extended and flexed knee positions (Figure 3A and 3B).
Figure 3. Comparison of FL (A) and FA (B) at extended and flexed knee positions. Columns represent
the means and standard deviations and the symbols connected by rows represent the raw data of
each subject tested. * FL (p = 0.0001) and FA (p = 0.0007).
Static stretching promoted a significant increase in FL (16.2%, p <0.05)

and in FA (15.5%, P <0.05) in the position with knee extended but not flexed
(FL , p = 0.430 and FA, p = 0.493) (Figure 4A and 4B). These results exceed
TME and indicate the real effect of the intervention on the study variables.
Figure 5 shows the relationships of FL and FA with extended knee
(5A and 5B) and flexed knee (5C and 5D), before and after stretching,
respectively, with a moderate to high correlation among variables for both
positions tested.
590
Figure 4. Effect of passive static stretching on FL (A) and FA (B) for the extended knee position.
Columns represent the means and standard deviations and the symbols connected by rows
represent the raw data of each subject tested. * FL (p = 0.012) and FA (p = 0.003).
Figure 5. Relationship between FL and FA for extended knee in pre (A) and post stretching (B)
conditions and the relationship between FL and FA for flexed knee pre (C) and post stretching (D)
conditions. r = Pearson’s correlation coefficient; (°) degrees.
DISCUSSION
The aim of the present study was to identify the acute effects generated in
the LV muscle architecture after static stretching. The main findings were a
significant increase of 16.2% in FL and reduction of 15.5% in FA in the pre
vs. post stretching for the extended knee position (Figure 4). In addition,
there was an increase in FL and reduction in FA when extended knee posi-
tion was compared with the flexed knee position (Figure 3). Considering
that all the differences reported here are greater than TMEs (7.4% for FL
and 5.3% for FA), it could be inferred that the effect of stretching on the

studied variables was real. However, no changes were observed in FL and

FA in the flexed knee position in the pre and post stretching comparisons.
It is well known that the arrangement of muscle fibers is directly as-
sociated with muscle strength production17. FA is associated with CSA
and muscle efficiency, that is, how much force generated in sarcomeres
is effectively transferred to aponeurosis. FL is related, in part, to muscle
contraction rate7. Some studies have reported the acute effect of static
stretching on muscle architecture1,11-13, but the results were inconsistent
with each other. While some authors observed an increase in FL and a
reduction of FA1,12 in the gastrocnemius muscle after 5 1-min repetitions
of static stretching, others only found FL changes for the vastus lateralis
muscle, but not for the femoral biceps muscle13 after three 30-s repetitions,
and did not find any type of alteration for the gastrocnemius muscle after
six 45-s repetitions11. Differences in the amount of stretching exercises
in the protocols to acquire US images, in the joint position in which the
measurements were made and in the muscle groups tested, may explain
such discrepancies in results.
In the present study, there was an increase in FL with concomitant
reduction in FA immediately after static stretching only in the extended
knee position, which reinforces some findings in literature1,12. However, no
change was observed for the flexed knee position. A possible explanation
for this would be the greater level of passive tension generated in the posi-
tion with more stretched muscle, which would remove all the additional
complacency caused by the stretching routine, being no longer possible
to change FL or FA. This hypothesis has already been demonstrated in
literature18,19.
Although studies have already investigated the acute effect of static
stretching on muscle architecture, a large part of them verified this dur-
ing stretching and used unusual volumes (e.g., 5 min) in a specific group
(gastrocnemius) and in only one joint position1,12. Another study that
measured the muscle architecture parameters after static stretching13 had
influence of strength training performed after stretching, which makes
it impossible to know its isolated effect. Therefore, the findings of the
present study may be important for understanding the isolated effect of
usual static stretching routines on the muscle architecture as a function of
the joint position in which the muscle is located, in addition to allowing
associations with force performance.
Some authors suggest an angle-dependent relationship, showing that
only in positions where the muscle is at a shorter length (e.g., extended
knee position), deleterious effects on force promoted by stretching are more
common. However, when the muscle is positioned at a greater length (e.g.,
flexed knee), the decrease in strength performance becomes less evident,
since more elongated muscle position is able to remove the additional
complacency caused by stretching18- 21. This fact may be associated to the
findings of the present study, where changes in FL and FA were observed
only for extended knee position.
592
It is important to emphasize that there are few studies that have veri-
fied the isolated acute effect of static stretching on the muscle architecture
variables studied here. Most of them identified changes in muscle archi-
tecture during stretching rather than after the session. Kato et al.2 verified
the changes in the medial gastrocnemius muscle architecture during five
60-s repetitions of static stretching and reported a significant but low
inversely proportional relation (r2 = 0.46; P <0.001), with the increase of
FL and concomitant reduction in passive torque from the first to the fifth
stretching session. These results indicate that changes in passive stiffness
associated with ROM gain after static stretching are strongly associated
with increased FL. Corroborating these findings, some studies have pointed
out that the effects of stretching on the passive stiffness of the muscle-
tendon unit occur mainly due to changes in the relative stiffness of the
muscle and not the tendon10,22,23. Another study sought to identify changes
in the gastrocnemius muscle architecture during stretching and reported
a gradual increase in FL and reduction in FA as ROM increased10 from
10° of plantar flexion to 30° of dorsiflexion. These findings corroborate the
results of the present study.
FA is the angulation of muscle fibers in relation to the muscle action
line . It has long been evidenced that during muscle contraction, a rota-
5
tion of the muscle fiber occurs, promoting its increase24. The same pattern
occurs for structural adaptations to strength training, which promotes
implications for the transfer of the force generated in the muscle fiber
to the aponeurosis, since, for muscles with the same AST and muscle
fiber length, a greater fascicle angle will promote lower efficiency in the
transmission of force from muscle fibers to aponeurosis25. Associations of
hypertrophy with increase in FA and also with reduction in muscle ef-
ficiency with concomitant increase in force production due to the increase
in the contractile material are pointed out in literature5,7. Thus, it may
be advantageous to present lower FA during muscle contraction, as this
will imply lower loss of efficiency in the transfer of force from the muscle
fiber to the tendon. However, there is little evidence for improved force
performance after stretching, which is most noticeable at positions where
the muscle is at a longer length, near its maximal ROM19.
CONCLUSION
It could be concluded that static stretching can acutely alter the muscle
architecture (FL and FA) of the VL muscle only in extended knee posi-
tion, but not in a very elongated position (flexed knee), probably due to
the higher levels of passive tension in the latter position, as is already well
documented in literature. In this case, it seems that the perceived changes
are exclusive to positions where the muscle is in shorter length, but not in
longer lengths. Thus, stretching routines such as that used in the present
study may be useful before sports practices that require increased ROM
or that force production is required at positions where muscle is stretched.

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Perceived neighborhood environment and

leisure time physical activity among adults
from Curitiba, Brazil
Ambiente percebido do bairro e atividade física no lazer
em adultos de Curitiba, Brasil
Adriano Akira Ferreira Hino1,2
Cassiano Ricardo Rech1,3
Priscila Bezerra Gonçalves1,2
Rodrigo Siqueira Reis1,4
Abstract – The aim of this study was to analyze the association between perceived
neighborhood characteristics and leisure time physical activity (PA) and the moderator
effect of gender, age, schooling and time spent working/studying on perceived environ-
ment and leisure PA in adults. This is a cross-sectional study conducted with 699 adults
(53.1% women), distributed from 32 census tracts selected according to walkability and
neighborhood income characteristics in Curitiba. Perceived neighborhood characteristics
were assessed using the Brazilian version of the Neighborhood Environment Walkability
Scale-Abbreviated (A-NEWS). Leisure time PA was evaluated through the long-version
IPAQ and walking and moderate to vigorous physical activity (MVPA) were analyzed
separately. PA classification considered ≥10 minutes/week and ≥150 minutes/week of
walking or MVPA. Associations were tested using a multilevel logistic binary model.
After adjusting for potential confounders, aesthetics perception was associated with
≥10 minutes/week of walking. Additionally, access to public places for leisure remained
associated with ≥10 minutes/week and ≥150 minutes/week of MVPA. The relationship
between perceived access to public spaces, walking and MVPA were stronger in women
and younger adults. It is concluded that a better perception of neighborhood aesthetics
was associated with the practice of walking and access to public spaces with the practice
of MVPA, respectively. 1 Pontifical Catholic University of
Paraná. Research Group on Physical
Key words: Adult; Environmental health; Leisure activities; Motor activity. Activity and Quality of Life. Curitiba,
PR. Brazil.
Resumo – Objetivou-se analisar a associação entre características percebidas do ambiente do 2 Pontifical Catholic University of
bairro e a prática de atividades físicas (AF) no lazer e verificar o efeito moderador do gênero, Paraná. Graduate Program in Health
faixa etária, escolaridade e tempo no trabalho/escola na relação entre a percepção do ambiente e Technology. Polytechnic School.
AF no lazer em adultos. Estudo transversal com 699 adultos (53,1% mulheres), residentes em 32 Curitiba, PR. Brazil.
setores censitários com diferentes características ambientais em Curitiba (walkability e renda).
As características percebidas do ambiente do bairro foram avaliadas pela versão em português 3 Federal University of Santa
do Neighborhood Environment Walkability Scale-Abbreviated (A-NEWS). A AF no lazer foi Catarina. Department of Physical
avaliada pelo IPAQ longo e a caminhada foi analisada separadamente da prática de atividades Education. Graduate Program in
Physical Education. Florianópolis,
físicas moderadas à vigorosas (AFMV). A classificação da AF no lazer considerou as pessoas que
SC. Brazil.
“realizam” ≥10 minutos/semana e ainda aquelas realizam ≥150 minutos/semana de caminhadas
ou AFMV. As associações foram testadas com um modelo logístico binário multinível. Após ajuste 4 Washington University in St. Louis.
para as potenciais variáveis de confundimento, observou-se que melhor percepção de estética foi Brown School. Prevention Research
associada a maior chance de adultos caminharem ≥10 minutos/semana no lazer. Além disto, Center in St. Louis. St Louis, MO.
maior percepção de acesso a espaços públicos de lazer foi associado a maior chance dos adultos United States of America.
realizarem ≥10 minutos/semana e ≥150 minutos/semana de AFMV. As associações entre acesso
a espaços públicos de lazer com caminhada e AFMV foram mais fortes entre mulheres e adultos Received: July 13, 2017
Accepted: August 14, 2017
mais jovens. Conclui-se que melhor percepção da estética do bairro foi associada à prática da
caminhada e o acesso a espaços públicos com a prática de AFMV. Licença
Palavras-chave: Adulto; Atividades de lazer; Atividade motora; Saúde ambiental. BY Creative Commom
INTRODUCTION
The construction and maintenance of environments conducive to the prac-
tice of physical activity has been recommended by specialists to mitigate
the impact of physical inactivity and obesity at global levels1, especially in
low- and middle-income countries such as Brazil, which suffers from the
high burden of chronic noncommunicable diseases. These recommendations
are based on the premise that environmental interventions are promising to
enable greater population coverage and for presenting better outcomes in
changing health-related behaviors2. Despite the importance attributed to
the environmental characteristics, especially to the neighborhood context,
there is still inconsistent evidence about which environmental characteris-
tics are determinants of physical activity practice, especially in Brazil, due
to its great territorial extension, climate variations, social and economic
inequality, among others3.
Evidence suggests that it would be important to test associations
between environmental characteristics and physical activity at the local
level, since these associations may be context-specific4. Therefore, there is
great limitation in considering these aspects in high-income countries as
possible environmental correlates for physical activity in Brazil. Moreover,
it is believed that part of inconsistencies observed in this relationship may
be due to the need to consider the type and volume specificities of physical
activity and also the sociodemographic factors of individuals. That is, it is
expected that the associations between the characteristics of the neighbor-
hood environment are different among different population subgroups.
Thus, when analyzing population subgroups, one can identify those
for which the neighborhood environment may be relevant to the practice
of physical activities. A study with Brazilian adults identified that the as-
sociation between safety perception and leisure time walking tends to be
significant only for women and people of high socioeconomic level 5. In
addition, no association was observed between the safety perception in the
neighborhood and moderate and vigorous activities and leisure time walk-
ing. However, a moderator effect of gender was observed, where perception
of walking safety is associated with walking during the day among women,
but not among men5. In addition, in Brazil, studies that have investigated
the characteristics of the neighborhood environment and its relationship
with physical activity have not used instruments in their full format5,6,
analyzing only some items of instruments such as A-NEWS 6-8 or even
only some specific environment domains5. Therefore, the inclusion of all
domains and items of the instrument may contribute to broadening the
understanding of the relationship between neighborhood environment and
physical activity. Thus, this study aimed to analyze the association between
perceived characteristics of the neighborhood environment and the practice
of leisure time physical activities and also to test the modifying role of
sociodemographic variables in this relationship in adults.

Perceived environment and leisure time physical activity Hino et al.
This cross-sectional study was conducted through a household survey in
adults from Curitiba, Paraná, Brazil, in 2010, which is part of a multicenter
study called IPEN - Study - International Physical Activity and Environ-
ment Study, conducted in 15 cities of 13 countries with the aim of analyzing
the relationship between the characteristics of the built environment and
the income of individuals on the practice of physical activity.
In order to select sites and participants, the role of the urban environ-
ment in the physical activity of individuals and communities was considered
as premise2. In this context, environmental characteristics with potential
impact on the physical activity performed in the daily movements are op-
erationalized and represented by the term “walkability”. To compose the
walkability score, four indicators were used: residential density, street con-
nectivity, diversified land use (entropy indicator), and commercial density9.
The primary sampling units were defined from the walkability char-
acteristics of the census tracts in the city of Curitiba (n = 2,125). For this
purpose, information based on the Geographic Information System pro-
vided by Institute of Research and Urban Planning of Curitiba was used.
Further details on the process of creating indicators can be found in the
study of project methods10.
In addition to the walkability score, the income score created from
the average income of those responsible for the households contained in
each census tract was considered. After identifying the walkability and
income score of all census tracts, 8th and 9th deciles were classified as high
walkability and high income, and 2nd and 3rd deciles were classified as low
walkability and low income. Sectors without households, composed of one
or two blocks and adjacent to sectors with extremely distinct categories of
income and walkability (e.g. a high walkability sector located alongside a
low walkability sector) were excluded. In all, 16 sectors of high walkability
and 16 of low walkability were selected, being eight of low income and
eight of high income.
The selection of households considered the minimum sample required
(n = 500 individuals) at each site participating in the IPEN-Study. This
estimate considers the combined analysis of all study sites to determine
variance of physical activity explained by the environment. However, for
purposes of analysis only of the city of Curitiba, a total sample of 704 people
was adopted. This over-sampling was established to increase the power of
analyses when considering only the sample of the city of Curitiba. In each
census tract, 22 households were systematically randomized, totaling 176
households per walkability and income stratum. In each household, an
adult aged 18-65 years was drawn.
In order to evaluate the level of physical activity, the leisure module of
the International Physical Activity Questionnaire (IPAQ ) was used, which
includes walking, moderate intensity physical activities (e.g. swimming,
moderate cycling, practicing sports) and physical activities of vigorous in-
598
tensity (e.g. running, speed cycling, gymnastics). This instrument has been
widely used in surveys conducted in countries around the world and has
been previously translated and validated for use in Brazilian adults11. The
physical activity measure recorded by the IPAQ is obtained by questioning
the number of days and average time per day performed in each activity.
In order to obtain measures on the environment perception, the ab-
breviated version of the Neighborhood Environment Walkability Scale
(A-NEWS) was used. This instrument assesses the perception of char-
acteristics of the neighborhood environment that may be associated with
walking and other types of physical activities such as residential density,
land use mix , accessibility to commerce, walking / pedaling structures,
street connectivity, aesthetics, safety in relation to traffic and crimes in
the neighborhood12. A-NEWS presented validity and reliability scores
in previous studies and was translated, adapted13 and previously used in
national studies5,8. The measure of residential density in the A-NEWS is
obtained by means of the perception of the predominant types of residences
in the neighborhood and has as options of response a 5-point likert scale
that ranges from “none” to “all”, with value 1 corresponding to answer op-
tion “none” and five as the option “all”. For all other questions, the answer
options were composed of a 4-point likert scale with “totally disagree”,
“partly disagree”, “partly agree” and “totally agree” options. The mean was
computed for each of the sub-scales (domains) in such a way that higher
values indicated higher values of the respective domain. Originally, eight
domains compose the instrument used in the present study; however, an
additional domain was computed in the present study based on the average
perception of the proximity of public spaces (parks, squares and cycle paths).
This domain was added so that it was possible to identify the perception
of access to public structures, since the issues of the “Walking / Pedaling
Structures” domain only address issues related to sidewalk quality. A pilot
study was conducted prior to data collection in a sample of 67 adults residing
in census tracts not drawn for the present study. A-NEWS presented high
reproducibility (test-retest with interval of 7-10 days between applications)
with the lowest intraclass correlation coefficient of 0.67 (95% CI = 0.47-
0.80) and the highest 0.95 (95% CI = 0.92-0.97).
In order to minimize the effect of neighborhood self-selection, 11
questions were used, addressing satisfaction with public transportation,
commerce, friends in the neighborhood, walking conditions, leisure op-
tions, public spaces for leisure, security, traffic, public services, general
satisfaction and if the person would change neighborhood if he could and
had options of dichotomous answers (yes and no). Questions had high
agreement percentage (> 80%) and suitable Kappa index (0.46-0.80).
The time that people are working and studying outside their home and
the time spent in the commuting to these places were evaluated, considering
that in these periods people are less likely to perform physical activities in
the context of leisure and are less exposed to the neighborhood environ-
ment. The occupation evaluation was carried out through four questions:

1) Do you work?; 2) How many days per week do you work?; 3) How many
hours a day do you work? 4) How much time per day do you spend com-
muting (going to work + back from work)? The same four questions were
applied to identify the time spent going to and coming back from school.
The sociodemographic information obtained was gender, age in years,
marital status (single, separated or widowed or married or living with
another person), number of children, economic classification based on
the Brazilian Economic Classification Criteria, schooling and Body Mass
Index (BMI) obtained from self-reported weight and height measures.
To test the study associations, a multilevel logistic model was used
to adjust estimates considering the sample design in which adult samples
were obtained from 32 census tracts. In order to compare the effects of
independent variables on the dependent variable, the A-NEWS domains
were continuously included, transformed into a Z-score, thus assuming
mean = 0 and standard deviation = 1. The dependent variable was the walk-
ing and the practice of leisure time moderate to vigorous physical activities
(MVPA) classified according to two different cutoff points. The first clas-
sification considered people who performed walking or MVPA for at least
10 minutes / week. The second considered those who reached the current
recommendations (≥150 minutes / week) walking or performing AFMV.
All analyses were performed in STATA version 12.0 with random intercept
without including explanatory variables in the second level. The sample
size (n = 699), considering alpha level at 5% and power of 80%, allows
detecting effect size greater than 1.25 and 1.37 for the walking outcome
(≥10 and ≥150 minutes / week) and 1.26 and 1.29 for MVPA (≥10 and
≥150 minutes / week). Two models were obtained being one crude model
and one adjusted model for variables that presented statistically significant
association in the crude model (p <0.05). Finally, interaction terms (gender
and perceived environment variables, age group and perceived environ-
ment variables, schooling and perceived environment variables and time
spent in work / study and perceived environment variables) were inserted
in the model to test the moderator effect of gender, age group, schooling
and time at work / study. For subgroups in which interactions presented a
statistically significant coefficient, stratified analyses were performed and
the results were presented in the graph format (Figure 1), showing the
predicted prevalence values a lready adjusted for the confounding variables
and with A- NEWS scores classified into tertiles.
RESULTS
The study sample was composed of 699 participants (53.1% women). The
final proportion of participants in relation to the number of eligible house-
holds (success rate) was 66.4%. Approximately two-thirds of participants
had less than 11 years of schooling and had children living at home. When
considering leisure time walking, 62.7% of adults reported not walking,
and only 12.6% walked at recommended levels. Regarding the practice of
600
moderate to vigorous physical activity, 68.2% do not perform this activity
while 22.8% perform at recommended levels for health (Table 1).
Table 1. Descriptive statistics of the sample characteristics. Curitiba, Paraná, Brazil (n = 699).
Variable Category n %
Men 328 46.9
Gender
Women 371 53.1
18-39 330 47.3
Age Group
40-65 367 52.7
0-11 433 61.9
Schooling (years)
>11 266 38.1
1st and 2nd tertiles (0-51,5) 463 66.2
Time spent in school work / school (hours/week)
3rd tertile (>51.5) 236 33.8
No 209 30.0
Children living at home
Yes 487 70.0
Low (1st tertile) 220 31.6
Satisfaction with the Neighborhood Intermediate 223 31.9
High (3 tertile)
rd
255 36.5
0-9 min/week 437 62.7
Leisure time walking 10-149 min/ week 172 24.7
≥150 min/ week 88 12.6
0-9 min/ week 475 68.2
Leisure time MVPA
10-149 min/ week 62 9.0

≥150 min/ week 159 22.8
MVPA: moderate to vigorous physical activity
After adjusting for potential confounding variables, it was observed

that people who work and / or study for a long period are less likely (OR
= 0.56, 95% CI = 0.40-0.79) of walking 10 or more minutes / week (Table
2). Among perceived environment variables, better esthetics perception
was associated with this outcome (OR = 1.23, 95% CI = 1.01-1.50). When
considering physical activity volumes at recommended levels, only working
and / or studying for a longer period were inversely associated with leisure
time walking (OR = 0.49; 95% CI = 0.28-0.86).
In the multivariate model, variables associated with MVPA were the
same even considering different cutoff points (MVPA ≥ 10 minutes / week
vs. ≥150 minutes / week), although the effect size was slightly higher for
physical activities performed at recommended levels. Women were less
likely to perform MVPA (Table 3) while higher education was positively
associated. The only environmental variable associated with MVPA was
access to public recreational spaces, considering both ≥10 minutes / week
(OR = 1.46, 95% CI = 1.19-1.80) and ≥150 minutes / week (OR = 1.59,
95% CI = 1.25-2.01).
Of the 152 tested interactions (9 independent variables x 2 dependent
variables x 4 moderating variables x 2 cutoff points), 11 were statistically
significant (p <0.05), of which three presented statistically significant

Table 2. Association between perceived environment domains and leisure time walking in adults. Curitiba, Paraná, Brazil (n = 699).
Leisure time walking (≥10 min./week) Leisure time walking (≥150 min./week)
Crude Adjusted Crude Adjusted
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Sociodemographic variables
Gender (ref=men) 0.87 (0.64-1.19) 0.92 (0.58-1.43)
Age group (ref=18-39 years) 1.31 (0.96-1.78) 1.67* (1.05-2.66) 1.44 (0.89-2.32)
Schooling (ref=0-11 years of school) 1.28 (0.93-1.75) 1.27 (0.81-2.02)
Satisfaction with the neighborhood 1.39* (1.01-1.91) 1.13 (0.80-1.60) 1.36 (0.86-2.15)
(ref=1st and 2nd tertiles)
Children at home (ref=no) 1.04 (0.74-1.46) 1.02 (0.62-1.68)
Time at work / school (ref=1st and 2nd 0.57* (0.41-0.80) 0.56* (0.40-0.79) 0.45* (0.26-0.79) 0.49* (0.28-0.86)
tertiles)
Perceived environment variables
Residential Density 1.16* (1.00-1.35) 1.08 (0.91-1.28) 1.08 (0.87-1.35)
Land use mix - Diversity 1.00 (0.86-1.17) 0.99 (0.78-1.24)
Land use mix - Accessibility 1.05 (0.90-1.23) 1.06 (0.84-1.34)
Street connectivity 1.00 (0.86-1.16) 0.99 (0.79-1.23)
Walking / Pedaling Structures 1.21* (1.04-1.42) 1.01 (0.83-1.24) 1.07 (0.85-1.35)
Aesthetics 1.32* (1.13-1.55) 1.23* (1.01-1.50) 1.27* (1.01-1.61) 1.28 (0.97-1.70)
Safety in relation to vehicle traffic 1.04 (0.89-1.21) 0.98 (0.78-1.23)
Safety in relation to crimes 1.04 (0.90-1.22) 1.34* (1.06-1.69) 1.23 (0.96-1.56)
Access to public spaces 1.19* (1.02-1.40) 1.07 (0.89-1.27) 1.24 (0.98-1.57)
OR: Odds Ratio; CI 95%: 95%Confidence Interval; * p <0.05.
Table 3. Association between perceived environment domains and MVPA in leisure time in adults. Curitiba, Paraná, Brazil (n = 699).
Leisure time MVPA (≥10 min./week) Leisure time MVPA (≥150 min./week)
Crude Adjusted Crude Adjusted
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Sociodemographic variables
Gender (ref=men) 0,47* (0.34-0.66) 0.54* (0.38-0.77) 0.41* (0.28-0.59) 0.49* (0.33-0.72)
Age group (ref=18-39 years) 0,63* (0.45-0.87) 0.79 (0.54-1.16) 0.55* (0.38-0.80) 0.70 (0.46-1.08)
Schooling (ref=0-11 years of school) 2,24* (1.58-3.17) 1.90* (1.30-2.78) 2.46* (1.67-3.61) 2.05* (1.34-3.12)
Satisfaction with the neighborhood 1,14 (0.81-1.62) 1.08 (0.73-1.58)
(ref=1st and 2nd tertiles)
Children at home (ref=no) 0,58* (0.40-0.82) 0.92 (0.61-1.40) 0.53* (0.36-0.78) 0.96 (0.60-1.51)
Time at work / school (ref=1st and 2nd 0,99 (0.70-1.40) 0.82 (0.55-1.21)
tertiles)
Perceived environment variables
Residential Density 1,41* (1.21-1.65) 1.12 (0.93-1.37) 1.45* (1.23-1.70) 1.09 (0.89-1.35)
Land Use Mix - Diversity 1,51* (1.27-1.81) 1.20 (0.97-1.47) 1.60* (1.31-1.96) 1.24 (0.98-1.56)
Land Use Mix - Accessibility 1,29* (1.07-1.54) 1.09 (0.89-1.34) 1.33* (1.09-1.64) 1.09 (0.87-1.37)
Street connectivity 1,05 (0.89-1.24) 1.15 (0.95-1.39)
Walking / Pedaling Structures 1,23* (1.02-1.48) 0.91 (0.74-1.12) 1.29* (1.05-1.59) 0.91 (0.72-1.15)
Aesthetics 1,13 (0.94-1.36) 1.07 (0.86-1.31)
Safety in relation to vehicle traffic 0,99 (0.83-1.17) 0.93 (0.77-1.12)
Safety in relation to crimes 0,96 (0.81-1.13) 1.01 (0.84-1.21)
Access to public spaces 1,69* (1.41-2.04) 1.46* (1.19-1.80) 1.85* (1.49-2.31) 1.59* (1.25-2.01)
MVPA: Moderate to Vigorous Physical Activity; OR: Odds Ratio; 95% CI: 95% Confidence Interval; * p <0.05.
602
association coefficient (p <0.05) in the analysis of subgroups (stratified
analysis). The association between perception of access to public leisure
spaces with walking (≥10 minutes / week) and MVPA (≥150 minutes /
week) was statistically significant only for women (Figures 1A and 1B,
respectively). In addition, it was observed that the association between
perception of access to public leisure spaces with MVPA (≥10 minutes /
week) is significant only for adults aged 18-39 years (Figure 1C).
Figure 1. Prevalence of leisure time walking and MVPA according to the score of access to leisure public spaces stratified by gender
and age group (Curitiba, PR - 2010, n = 699).
DISCUSSION
The study points out as the main result that the domains of the perceived
environment of the neighborhood are differentiated and independently
associated with leisure time walking and MVPA in adults. Positive percep-
tion of the neighborhood aesthetics was associated with greater chance of
walking for at least 10 minutes / week and the perception of access to public
spaces was associated with greater chance of performing MVPA regardless
of volume (≥10 or ≥150 minutes / week). In addition, the moderating role
of sociodemographic variables in the relationship between environmental
characteristics and leisure time physical activity was observed, indicating
that this association is gender specific and in some cases age group specific.
The practice of leisure time walking has been associated with a favorable
environment 14. Evidence from high-income countries has indicated that
sites with better esthetics are associated with higher prevalence of leisure
time walking15, but these findings are still inconsistent when compared
to findings of middle- and low-income countries, such as Brazil. For ex-
ample, studies conducted in Curitiba 16, São Paulo 17 and Recife18 found
no association between neighborhood aesthetics and leisure time physical
activity. Some factors may contribute to explain the lack of association
observed in the studies above. Although most of the studies have used
A-NEWS items, this measure was not analyzed as a scale with domains
composed of several items, but only a few questions, which may limit the
evaluation of these characteristics. In addition, these studies used as cutoff
point the practice of physical activities in 150 or more minutes per week
and few considered walking separately. Therefore, it is possible that more
accurate and sensitive measures are necessary to evaluate characteristics of

the neighborhood environment, and that aspects such as aesthetics, for ex-
ample, may be associated with lower leisure time walking volumes and not
necessarily with compliance with recommendations. Results observed in
studies carried out in other countries 19 have supported this hypothesis19,20.
When analyzing the practice of MVPA, the results of this study are
similar to those observed in national studies21,22 and in those conducted in
Latin America 23, suggesting that the perception of greater availability of
sites to practice physical activity may contribute to higher levels of physical
activity. In fact, this is the environmental characteristic that has been most
investigated. However, the results are less consistent when the existence or
accessibility to public places for the practice of physical activities is consid-
ered an important factor in terms of public health and equity. First of all,
most studies do not distinguish access to private leisure spaces (clubs, gyms
and gymnasiums) and public spaces (squares, parks and hiking trails). In
addition, almost all studies analyze only the perception of the environment
to obtain this information 23,24, which accentuates problems related to the
reverse causality in the findings, since active individuals can perceive more
precisely the accessibility to sites for the practice of physical activities1.
The results allow us reinforcing the hypothesis that environmental
characteristics associated with physical activity are specific not only to
the physical activity domain 25, but also to different types of activities in
the same domain (walking vs. MVPA). In the present study, esthetics was
associated with walking while the perception of greater access to public
spaces was associated with MVPA. However, data suggest that associations
are not necessarily specific to the volume of leisure time physical activity.
Access to public spaces was associated with greater chance of practicing
moderate to vigorous physical activities at both ≥10 minutes / week and
≥150 minutes / week. Neighborhood aesthetics was associated only with
walking ≥10 minutes / week. In this way, further studies are necessary
so that more robust conclusions about this relationship can be presented.
The hypothesis that the associations between perceived environment
characteristics and the practice of physical activities are moderated by
individual characteristics26 was confirmed in the present study. In gen-
eral, the moderating effect of these variables was more evident in MVPA
when compared with leisure time walking. Among the variables selected
as potential moderators, gender presented greater consistency in associa-
tions. The association between perceived environment characteristics and
leisure time physical activity was stronger among women. It is believed that
intrapersonal and interpersonal variables may help explain the different
associations between men and women. Environmental characteristics can
affect physical activity through different mechanisms. For example, a better
perception of the availability of leisure spaces was directly associated with
MVPA and also indirectly associated through increased self-efficacy27.
These data indicate that the perception of accessibility to leisure sites can
also promote changes in intrinsic motivational factors that in turn affect
levels of physical activity28. In general, it has been observed that women
604
have lower self-efficacy, social support and perceive more barriers to physi-
cal activity29, so environmental characteristics could act indirectly in these
variables, thus enhancing the effect of the environment perception on the
practice of physical activities 4. Moreover, activities performed by women
are not the same as those performed by men 30 and consequently the factors
associated with MVPA in each gender may be specific.
Regarding the age group, it was demonstrated that the association
between access to public spaces and MPAV was specific for younger adults
(18-39 years). One of the possible explanations for this result is the type
of physical activity performed by young adults. The practice of MPAV is
more prevalent among younger adults (40-65 years) while walking among
older adults (table 2 and table 3). Whereas MPAV is often described as
sports, activities performed in stations and exercise or running apparatus,
such activities require more infrastructure for practice. Such structures are
commonly found in public spaces of Curitiba. Therefore, it is possible that
these sites are frequented and used for the practice of MVPA. However,
the lack of information on the type of activity practiced by participants
limits the confirmation of this hypothesis.
This study has some limitations. Firstly, the cross-sectional design of
the study does not allow us identifying the meaning of associations ob-
served. In order to minimize the problem of reverse causality, a measure
of satisfaction with the neighborhood was included as a control variable
in the multivariate analyses. This procedure allows obtaining less inflated
effect sizes, but it is not yet possible to determine the true meaning of the
associations. In addition, the main confounding variables were included
in the analyses. The sampling plan allowed increasing the contrast among
environmental characteristics; however, it may have reduced the capacity to
extrapolate the findings for the entire population of Curitiba. Furthermore,
the final sample size (699 adults) was insufficient to detect associations of
small effect magnitude. The measure of physical activity was self-reported,
which may increase the chance of overestimation and, therefore, the oc-
currence of possible non-differential errors. However, comparisons with
different outcome levels were performed, thus increasing the comparison
with the response gradient. In addition, the measure used allowed specific
analyzes for domain and type of physical activity. Finally, although en-
vironmental perceptions may present problems to classify exposures, the
instrument used is recognized as reliable and allows identifying unique
characteristics of the environment, such as aesthetics and safety in the
neighborhood, which are not obtained by other methods11.
Thus, it could be concluded that a better perception of the neighborhood
aesthetics was associated to the practice of walking and access to public
spaces with the practice of MVPA. These associations were specific to the
type of physical activity performed and may be moderated by individual
characteristics.

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Development of a Body Image Scale for Brazilian

women
Desenvolvimento de uma Escala de Imagem Corporal
para mulheres brasileiras
Catiane Souza1
Erik Menger Silveira1
Emanuelle Francine Detogni Shmit1
Edgar Santiago Wagner Neto1
Letícia Miranda Resende da Costa1
Cloud Kennedy Couto de Sá 2
Jefferson Fagundes Loss 3
Abstract – Body image is an important parameter of body satisfaction and needs to be

evaluated with instruments developed and validated for a specific population. The aim of
this study was to develop and validate a scale to assess body image in Brazilian women. A
scale consisting of 11 silhouettes was prepared. Content validation was performed by seven
experts from different health areas. To assess repeatability (two consecutive assessments)
and reproducibility (reassessment after one week), an intentional sample stratified into four
groups according to the characterization of Brazilian women regarding nutritional status
was selected. Participants were 125 women aged 18-55 years and body mass index (BMI)
between 18.5 and 38.6 kg/m2. The Kappa coefficient (k) was used to assess repeatability
and reproducibility, considering the isolated responses of the current body, ideal body and
the difference between them, assumed as satisfactory when k≥0.6. For all trials, α=0.05.
During the content validation phase, the instrument developed was changed following
the evaluators’ suggestions and it was considered very suitable by six of seven evaluators.
The Kappa coefficient was good in isolated issues and in the difference between them
in both repeatability and reproducibility. The Body Image Scale was considered a valid
content, with good repeatability and reproducibility. Considering the instrument as low
cost and of rapid implementation/evaluation, it may be used to evaluate the body im-
age of Brazilian women with BMI between 18.5 and 38.6 kg/m2, in different contexts.
Key words: Body image; Brazil; Validation studies.
Resumo – A imagem corporal é um importante parâmetro de satisfação com o corpo e precisa 1 Federal University of Rio Grande
ser avaliada com instrumentos desenvolvidos e validados para uma população específica. O do Sul. Graduate Program in Human
estudo teve como objetivo desenvolver e validar uma escala para avaliação de imagem corporal Movement Sciences. Porto Alegre,
em mulheres brasileiras. Foi elaborada uma escala composta por 11 silhuetas. Sete experts, em RS, Brazil.
diferentes áreas da saúde fizeram a validação de conteúdo. Para avaliar a repetibilidade (duas
avaliações consecutivas) e a reprodutibilidade (reavaliação após uma semana) foi selecionada uma 2 State University of Feira de Santa-
amostra intencional estratificada em quatro grupos de acordo com a caracterização de brasileiras na. Collegiate of Physical Education,
segundo o seu estado nutricional. Participaram 125 mulheres de 18 a 55 anos e IMC de 18,5 a Department of Health. Feira de
Santana, BA, Brazil.
38,6 kg/m2. Para avaliar a repetibilidade e a reprodutibilidade, foram consideradas as respostas
isoladas do corpo atual, do corpo ideal e da diferença entre eles, por meio do Coeficiente Kappa 3 Federal University of Rio Grande do
(k), sendo que, seria considerado satisfatório k ≥ 0,6. Para todos os testes α = 0,05. Na fase de Sul. Department of Physical Educa-
validação de conteúdo o instrumento desenvolvido, e alterado conforme sugestões dos avaliado- tion, School of Physical Education,
res, foi considerado muito adequado por seis dos sete experts. A concordância Kappa foi boa nas Physiotherapy and Dance. Porto
questões isoladas e na diferença entre elas, tanto na repetibilidade, quanto na reprodutibilidade. Alegre, RS, Brazil.
A Escala de Imagem Corporal foi considerada com validade de conteúdo, apresentando uma boa
repetibilidade e reprodutibilidade. Sendo um instrumento de baixo custo e rápida aplicação/ Received: March 17, 2017
Accepted: August 15, 2017
avaliação, pode ser utilizado na avaliação da insatisfação com a imagem corporal de brasileiras
com IMC entre 18,5 e 38,6 kg/m2, em diferentes contextos. Licença
Palavras-chave:Brasil; Estudos de validação; Imagem corporal. BY Creative Commom
INTRODUCTION
More and more exposed bodies generate an incessant search for a massively
popular pattern in the media as ideal: young, handsome and muscular for
men and thin for women, without which it does not seem possible to find
happiness and success1,2. This excess disclosure of a pattern to be followed
affects, especially young women, the population that is the main target of
this social “pressure” in search of the perfect body, which can trigger vari-
ous inappropriate behaviors such as depression, eating disorders and / or
excess physical activities2-4. Since inappropriate behaviors can be considered
a large-scale problem5, different areas of knowledge such as pedagogy,
dance, medical sciences, psychology, philosophy, sociology, and physical
education have addressed this issue through body image6.
Body image is understood as the figuration of our body formed in
our mind about the body dimensions and information of the level of body
satisfaction or rejection, that is, the way in which the body presents itself
to us, not only as a cognitive construct, but also as a representation of de-
sires, emotions and socialization with other individuals7-9. Its evaluation
can be made by scales of silhouettes that provide a body design in which
the person should identify his / her current body and how he / she would
like it to be, and the difference of these responses has been understood as
a measure of body dissatisfaction10. This type of instrument takes advan-
tage of being compared to the others, because in addition to being more
practical, due to its rapid application and interpretation of results, it has the
capacity to collect data from large groups11, which makes it more suitable
for population research. The choice of the appropriate instrument for each
population is a delicate issue, since a scale must take into account ethno-
logical characteristics without attributing singularities to its silhouettes12.
Scagliusiet al.13 validated for the Brazilian population a scale developed
for the American population. However, this scale did not take into account
the specific characteristics of Brazilians, which is a problem12. Although
there is a test-retest reliability scale developed specifically for Brazilians14,
it presents some limitations, such as asymmetries and lateralized position
in silhouettes, which are factors that may make it difficult for participants
to choose at the time of test application15.
After reviewing the instruments to evaluate body image in the Brazilian
population, Carvalho and Ferreira16 reported that due to the complexity
and multidimensionality of the subject, there is still a need for an expres-
sive number of instruments that evaluate body image in this population.
Despite the advances in knowledge about the subject, a large number of
studies use non-validated measures, so that there is still a methodological
gap that makes it difficult to understand body image in the Brazilian
population17. Therefore, the present study aims to develop and validate a
scale for body image evaluation in Brazilian women. It should be pointed
out that specific instruments for the Brazilian reality guarantee that the
information obtained is reliable to the researched group, and can be applied

Body Image Scale for Brazilian women Souza et al.
in epidemiological, clinical, prevention and health promotion, socio-po-

litical and cultural contexts17,18.
Based on the existing instruments13,14,19, a scale was elaborated with 11
silhouettes representative of female bodies, which proportionally increase
from left to right in order to cover different body profiles of Brazilian
women. The literature indicates that the ideal number of silhouettes should
be greater than nine, since smaller number of silhouettes may limit the
choice and very high number may make it difficult to choose because it
causes confusion at the moment of evaluation15,19. In addition to the number
of available silhouettes, this type of instrument requires some care, such as
constant increase among adjacent silhouettes, the absence of body details
that may act as distracting elements or reflect specific ethnicities20, propor-
tional change among body regions and constant height among silhouettes19.
The instrument is composed not only of silhouettes but also of two
objective questions: “Which image represents your current body?” And
“Which image represents the body you would like to have?” (Figure 1). The
difference between response of the second and first question expresses the
level of body dissatisfaction. Body dissatisfaction can thus be numerically
expressed, starting from zero, the same answer in both questions, that is,
no dissatisfaction, reaching ten, maximum dissatisfaction. The numerical
result can still be positive or negative, representing the desire to be greater
or the desire to be smaller, respectively.
Seven experts in health areas related to movement (physical education,
physical therapy, dance and medicine) were invited to participate in the
content validation 21,22 of the Body Image Scale. These evaluators received
the Body Image Scale for evaluation, where they were asked to answer a
validation questionnaire composed of three objective questions, referring
to clarity, ease of understanding and instrument applicability, as well as
the analysis of each image separately. The evaluators were also able to add
suggestions and proposed changes to the instrument in a descriptive way.
After the instrument was changed according to suggestions, evaluators
responded a second time to the same validation questionnaire.
Both studies that validated scales for Brazilians used 4614 and 9813
subjects, did not present sample calculation or data necessary to support
the sample calculation of the present study. In order to overcome this
limitation, a sample calculation was performed considering power of 95%
and significance level of 5%. The values found by Di Pietro E Silveira 23
were used when validating the Brazilian version of the Body Image Ques-
tionnaire in 164 female university students. According to results of the
sample calculation, performed in an electronic sample calculator from the
Laboratory of Epidemiology and Statistics, Faculty of Medicine of the
University of the State of São Paulo24, an intentional sample was selected,
recruited in the community through oral invitation, and was composed of
610
125 women. For the sample to be representative of the nutritional status
of Brazilian women, four groups were stratified according to the Brazil-
ian characterization according to their nutritional status and to IBGE25,
based on the Body Mass Index (BMI). Thus, the sample consisted of 4%
of participants with BMI below 18.5 kg / m², 31% with BMI between
18.5 and 24.9 kg / m², 48% with BMI between 25 and 29.9 kg / m² and
17% with BMI greater than or equal to 30 kg / m². The present study was
approved by the Ethics Research Committee of the University where it
was developed, registered in the Brazil Platform under CAAE number
19256713.9.0000.5347. This research followed Resolution 466/12 of the
National Health Council.
On the first day of data collection, all participants signed the Free and
Informed Consent Form, shortly thereafter, body mass and height were
measured using a portable digital scale with sensitivity of 100 g (TechLine)
and a tape measure with sensitivity of 1 mm (Sanny, São Bernardo do
Campo, São Paulo). Each participant then received the Body Image Scale
represented in Figure 1, in a reserved place, and was asked to complete it.
With the intention of measuring the instrument repeatability, immediately
after, a new copy of the Body Image Scale was delivered. In order to avoid
that the participant simply repeated the number that had been chosen in the
previous application, based on the memory, in this new copy of the scale, the
numbers of silhouettes were replaced by letters in decreasing order (from “k”
to “a”). After exactly seven days, they were asked to re-fill only the original
version (with numbered silhouettes) to test the instrument reproducibility26.
Body Image Scale

Which of these images represents your current body?
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
Which of these images represents your ideal body?

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
Figure 1. Body Image Scale
The repeatability (application and reapplication of instruments in

successive moments) was evaluated from the two consecutive responses
(Body Image Scale identified by numbers and letters) performed on the
first day. Reproducibility (repeated application after one-week interval)
was assessed by considering the responses of the first evaluation of the

first day versus the responses of evaluation made one week later, both with
silhouettes identified by numbers. In order to evaluate repeatability and
reproducibility, the isolated responses of the current body, ideal body and
the difference between responses were considered. Statistical analysis was
performed using SPSS for Windows software (version 20.0) using Kappa
coefficient (k). In order to classify the Kappa coefficient results, the meth-
odology proposed by Schlademann et al.27 was adopted, which proposed
the following categorization: poor (k <0.2), intermediate (0.2 ≤ k <0.4),
moderate (0.4 ≤ k <0.6), good (0.6 ≤ k <0.8), and very good (k ≥ 0.8). To
be considered satisfactory, Kappa should be greater than or equal to 0.6.
In order to compare the results obtained with those found in literature, the
Pearson and Spearman correlations were also calculated for repeatability
and reproducibility data.
The answer to the first question of the Body Image Scale (which im-
age represents your current body?) is loaded with subjective information
and individual interpretations, influenced by cultural, regional, and other
issues. In this perspective, there is no “gold standard” with which the
answer can be compared in order to evaluate how representative of the
bodies evaluated are the scale of silhouettes. As a way to overcome this
limitation, and considering the BMI as an objective representation of the
body image of participants, the correlation between this index and the
answer to the first question of the Body Image Scale was calculated. It
is understood that a strong correlation means that the choice made from
the Body Image Scale is representative of body dimensions. To evaluate
whether there was a correlation between the result reported on the scale
as the current body and the BMI, a Spearman correlation coefficient was
applied. The significance level adopted in all tests was 5%28.
RESULTS
With the answers obtained in the first question, modifications to the
Body Image Scale were performed according to the evaluators’ sugges-
tions. To finalize the content validation process, evaluators were asked
to evaluate the new Body Image Scale. The seven experts answered the
validation questionnaire; however, one of the evaluators did not answer
the questions related to the individual evaluation of each image in none of
the two evaluations (Table 1). In view of the favorable result of the major-
ity of evaluators for the questions (1) clarity, ease of understanding and
applicability of the instrument’s scoring template model; (2) objectivity;
and (3) individual evaluation of images, it was considered that the Body
Image Scale (Figure 1) presented content validity, being able to move to
the second phase of the study.
The mean data from each group stratified by the BMI percentage of
Brazilian women, according to IBGE25, allowed characterizing the study
participants (Table 2).
612
Table 1. Results of the content validation of the body image scale by seven experts, presented by
the frequency response in each version.
Question Answers regarding the 1st version Answers regarding the 2nd version
VA A LA VA A LA
Regarding clarity, ease of understanding and applicabil- 2 5 0 6 1 0
ity of the instrument, in general, you consider it:
Y N P Y N P
Do you believe that this instrument meets the goal of 5 0 2 6 0 1
assessing how an individual perceives the shape and / or
size of her body in individuals over 18 years?
VA A LA NR VA A LA NR
As for the representation of image 1, do you consider: 2 2 2 0 5 1 0 0
VA = very adequate; A = adequate; LA = little adequate; Y = yes; N = no, P = partly; NR = no response.
Table 2. Sample characterization
˂18.5 18.5 to 24.9 25.0 to 29.9 ≥30

Groups by BMI (Kg/m²)
n=5 n=39 n=60 n=21
Height (m)
Mean 1.63 1.63 1.58 1.61
SD 0.08 0.08 0.06 0.05
Minimum 1.55 1.48 1.43 1.53
Maximum 1.73 1.78 1.71 1.72
Weight (kg)
Mean 49.0 57.3 66.1 85.7
SD 4.7 7.1 6.6 8.8
Minimum 44.1 44.5 51.7 70.3
Maximum 55.1 70.0 78.9 99.3
BMI (Kg/m²)
Mean 18.3 21.3 26.2 32.7
SD 0.2 1.4 0.9 2.5
Minimum 18.0 18.8 25.0 30.0
Maximum 18.4 21.4 28.9 38.6
Age (years)
Mean 19 27 31 35
SD 1 8 10 12
Minimum 18 19 18 19
Maximum 21 48 55 55
SD = standard deviation

In the evaluation of the instrument repeatability and reproducibility,

all evaluated items reached k equal to or higher than 0.6 (Table 3), values
considered satisfactory according to pre-established criteria. Significant cor-
relation (r = 0.67, p <0.05) was found between variables, body mass index
(BMI) and the silhouette indicated as the one that best represents the current
body (body figuration), performed by the Spearman’s correlation coefficient.
Table 3. Repeatability and Reproducibility of the Body Image Scale.
Test Repe Repro

Kappa (k) 0.74 0.63
Question 1 Pearson (r) 0.96 0.95
Spearman (ρ) 0.92 0.93
Kappa (k) 0.60 0.65
Question 2 Pearson (r) 0.79 0.84
Kappa (k) 0.71 0.68
Difference Pearson (r) 0.94 0.93
DISCUSSION
The results showed that the instrument was considered very adequate by six
of the seven experts that have previously evaluated it, in the content valida-
tion phase. Since these professionals are from different areas, the importance
of these results is highlighted, characterizing a possible multidisciplinary
applicability of the developed instrument. Through the results obtained in
the test-retest, it could be inferred that the scale is valid considering the
kappa agreement between the two consecutive evaluations (repeatability)
and between the two evaluations with a seven-day interval (reproducibility).
Other scales have already been suggested to evaluate body image, but the
Kappa index was not the statistic used for validation14,20,29. These studies use
only correlation to evaluate repeatability and reproducibility, but correlation
measures the linear relationship between two variables, while the Kappa in-
dex measures the degree of agreement present in multiple evaluations of the
same phenomenon, being more indicated for this purpose28,30. In addition, the
Pearson’s correlation is indicated for parametric data28, in case of validation
of scales, it is imperative that researchers recognize the non-interval nature
of the scale and use non-parametric statistics in their analyses19.
In order to establish a correlation between the results of the present
study and others already published, Pearson and Spearman’s correlation
coefficients were also calculated. When comparing the values obtained
in
the correlations with those found in literature, better results were observed
in the present study in comparison to the other studies13,14,20 which, like
this, propose scales of silhouettes for specific populations. For example,
Thompson and Gray20 showed high Pearson correlation r = 0.78, while
614
Goldberg et al.30 evaluated through the Spearman test the reproducibility
of the silhouette referred to as current, obtaining r = 0.69 and ideal, with
r = 0.31, but they define the scale as validated due to p <0.05 found in the
correlation, even though this value is not indicated for the interpretation
of the correlation results28. In scales available to Brazilians13,14, Scagliusiet
al.13 considered their instrument to be valid through correlation of BMI
with participants’ responses (current body r = 0.76 and ideal body r =
0.72). Kakeshitaet al.14 evaluated the reproducibility through Pearson’s
correlation and Student’s t-test, and the correlation ranged from r = 0.92
in the test-retest of the body silhouette pointed as current and r = 0.85 in
the test-retest of the desired body. The t-test was not significant in none
of the comparisons.
It is also possible to observe Spearman’s positive correlation r = 0.67
between participant’s BMI and the response indicated as representative
of the current body, which indicates good correlation between variables,
similar to results found using the Pearson’s correlation by Thompson and
Gray20 r = 0.59, and by Kakeshitaet al.14 who found r = 0.84.
The lack of an expert in the field of psychology during the content
validation phase can be pointed out as a study limitation, as well as the
lack of construct validity. Other limiting aspects are due to the fact that
only residents of Rio Grande do Sul participated in the sample, and the
fact that participants with more severe degrees of thinness and obesity
were not included in the sample, and there is no answer option for those
who do not they feel represented by none of the silhouettes.
CONCLUSIONS
The Body Image Scale was developed and considered with content valid-
ity, presenting good repeatability and reproducibility, as well as a good
correlation between the Silhouette indicated as the current body and the
individual’s BMI. As applicability, it could be considered that the instru-
ment has an accessible and simple evaluative character and could be easily
applied to assist in the process of evaluating body image dissatisfaction
among adult Brazilians with BMI between 18.5 and 38.6 kg / m2, repro-
ducing results similar to those found in literature. In addition, as it is a
low-cost and rapid application / evaluation instrument, it could be used in
epidemiological, clinical, health prevention or promotion, socio-political
and cultural contexts.
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Rev Bras Cineantropom Hum review article
Is the combination of interval and resistance

training more effective on physical fitness?
A systematic review and Meta-analysis
Será a combinação dos treinamentos intervalado e
resistido mais efetiva sobre a aptidão física em adultos?
Uma revisão sistemática e meta-análise
Francisco José de Menezes Junior1
Íncare Correa de Jesus1
Vera Lúcia Israel2
Neiva Leite1
Abstract – Interval training (HIIT / SIT) combined with resistance training (RT) has
been highlighted as a strategy for the improvement of health-related physical fitness mark-
ers (HRPF) in adults. Thus, the aim of this meta-analysis was to compare the efficacy of
combined training (HIIT / SIT + RT) with other exercise protocols on HRPF markers
in adults. A systematic search was performed in MEDLINE via PebMed, Cochrane-
CENTRAL, SPORTDiscus, LILACS, SCIELO and Scopus databases between Janu-
ary and March 2017, using the following keywords in English and Portuguese: physical
fitness, high-intensity interval training, sprint interval training, resistance training and
adults. The quality of studies was evaluated using the PEDro scale. After applying both
inclusion and exclusion criteria, nine articles were selected (n = 231). The extraction of
means and standard deviations from studies was performed independently by two authors
and the RevMan software was used to perform the meta-analysis. Combined training
interventions lasted from 6 to 12 weeks and generated greater increase in maximal oxygen
uptake than other forms of exercise. The combination of interval training and strength
training may be considered more effective to improve aerobic capacity levels in adults.
Key words: Adults; High-intensity interval training; Physical fitness; Resistance training;
Sprint interval training.
Resumo – O treinamento intervalado (HIIT/SIT) combinado com o treinamento de resis-

tência (TR) tem se destacado como estratégia para a melhora de indicadores de aptidão física
relacionados à saúde (AFRS) em adultos. Assim, o objetivo desta meta-análise foi comparar
a efetividade do treinamento combinado (HIIT/SIT + TR) com outros protocolos de exercício
sobre os indicadores de AFRS em adultos. Foi realizado a busca sistemática nas bases de dados 1 Federal University of Paraná.
eletrônicas MEDLINE via PubMed, Cochrane-CENTRAL, SPORTDiscus, LILACS, Department of Physical Education.
SCIELO e Scopus, entre janeiro e março de 2017, com a utilização dos seguintes descritores, em Post-Graduate Program in Physical
Education. Curitiba, PR. Brazil.
inglês e português: physical fitness, hight-intensity interval training, sprint interval training,
resistance training e adults. A qualidade dos estudos foi avaliada por meio da escala PEDro. 2 Federal University of Paraná.
Após a aplicação dos critérios de inclusão e exclusão, nove artigos foram selecionados (n= 231). A Department of Prevention and
extração das médias e desvios padrões dos estudos foi realizada de forma independente por dois Rehabilitation in Physical Therapy.
autores e utilizou-se o programa RevMan na condução da meta-análise. As intervenções com Post-Graduate Program in Physical
treinamento combinado (HIIT/SIT + TR) tiveram duração de 6 a 12 semanas e produziram Education. Curitiba, PR. Brazil.
maiores aumentos de absorção máxima de oxigênio que outras formas de exercício. A combina-
ção do treinamento intervalado e treinamento de força pode ser considerada mais eficaz para a Received: March 20, 2017
Accepted: October 09, 2017
melhora dos níveis de capacidade aeróbica em adultos.
Palavras-chave: Adultos; Aptidão física; Treinamento de resistência; Treinamento intervalado Licença
de alta intensidade. BY Creative Commom
INTRODUCTION
Western lifestyle is characterized by changes in dietary intake, increases in
dietary energy supply, reductions in levels of physical activity and increases
in time spent in sedentary behaviors1, and the adult population, due to its
social and economic relevance, deserves greater attention and policies aimed
at the maintenance and / or recovery of its physical and mental well-being2.
The maintenance of minimum performance indexes is necessary to
maintain adequate functional (strength / resistance and flexibility), motor
(cardiorespiratory fitness) and morphological levels (body composition)
of adequate health-related physical fitness (HRPF)3. In addition, regular
physical activity at all ages is essential to minimize the risk of incubation
and early development of chronic-degenerative diseases, thus enabling
longevity with higher quality of life, reduction of risk factors, health
promotion and performance of daily tasks and leisure activities4,5. Thus,
different intervention protocols with physical exercises have been used to
promote improvements in HRPF indicators, mainly in the reduction of
visceral fat and cardiovascular risk factors6.
Among the various exercise protocols proposed for obesity manage-
ment today, interval training has been highlighted as an efficient strategy
to achieve innumerable health benefits7,8. This method is characterized by
intense loads of exercise separated by a period of interval between series9,
with adaptive benefits superior to other types of training such as continuous
aerobic exercise, but with less training volume10. In addition, this training
protocol has helped to achieve greater adherence to exercise programs,
precisely because it presents an efficient dose of time and reduces the health
risks associated with obesity11.
Among the methodologies observed in the various studies that use the
principles of interval training, sprint interval training (SIT) is defined as
sprints of short duration (8 to 30 seconds), with intensity greater than 100%
of VO2max and interspersed with recovery periods8, while high-intensity
interval training (HIIT) is characterized by exercise sessions with intensi-
ties between 80% and 100% of maximum heart rate or aerobic capacity,
with duration between 60 and 240 seconds, which are within the aerobic
capacity of the individual (sub-maximum), but extremely intense9.
Another protocol widely used in literature is resistance training, since it
is an important component for weight loss by promoting body fat reduction
increased lean mass and muscle strength7,12. In addition, this protocol pro-
duces the EPOC effect (excessive post-exercise oxygen consumption), and
through this system, brings long-term benefits to individuals by increasing
basal metabolic rate and caloric expenditure and improves lipid oxidation14.
Although there is consensus in literature about the benefits of interval
and resistance training alone, it is important to analyze the effectiveness of
the combination of these two protocols, since the sum of benefits brought
by both seems to be an interesting strategy to improve the physical fit-
ness indicators, weight management and health enrichment in adults11,7.

Interval and resistance training Menezes et al.
Therefore, the aim of this meta-analysis is to compare the effectiveness of

combined training (HIIT / SIT + RT) with other exercise protocols on
HRPF indicators in adults.
The systematic review was conducted between January and March 2017,
following the recommendations of the Preferred Reporting Items for Sys-
tematic Review and Meta-analyses: The PRISMA Statement15, developed
in a methodical, explicit and reproducible manner with a clear question,
search strategy and well-defined inclusion and exclusion criteria, is aimed
at guiding future research and systematizing the knowledge produced 16.
The selection of descriptors used in the review process was done through
consultation with DECS (BIREME health sciences subject descriptors)
and MESH (Medical Subject Headings - controlled vocabulary used for
indexing articles for PubMed). The search was performed in six electronic
databases: MEDLINE (Medical Literature Analysis and Retrieval System
online) via PubMed, Cochrane-CENTRAL, SPORTDiscus, LILACS,
SCIELO (Scientific Electronic Library Online) and Scopus, using the
following language descriptors in English and Portuguese, respectively:
physical fitness (aptidão física), high-intensity interval training (treinamento
intervalado de alta intensidade), sprint interval training (treinamento in-
tervalado de Sprint), strength training (treinamento de força), resistance
training (treinamento de resitência) and adults (adultos) using Boolean
operators AND and OR to combine descriptors. Searches were carried
out by two researchers (F.J.M.J) and (I.C.J), independently, who started
reading the titles and abstracts, following for analysis of the articles in full.
Disagreements among reviewers were resolved by consensus.
Initially, 685 articles were identified, to which the inclusion and
exclusion criteria specified in Figure 1 were applied. The following inclu-
sion criteria were adopted: 1) only original articles; it was decided not to
include chapters of books, theses, dissertations and monographs, since the
performance of a systematic search of these is logistically infeasible; 2) only
studies that presented abstract, which were initially read; 3) studies carried
out over the last 10 years (2007-2017); 4) studies using only human sam-
ples; 5) studies with minimum intervention of six weeks; 6) studies with
combined HIIT / SIT and resistance training intervention. After applying
the inclusion criteria, 43 articles were selected. The following exclusion
criteria were applied: 7) repeated articles; 8) studies with population of
athletes or aiming at sports performance; 9) articles without control group;
10) studies that did not evaluate health-related physical fitness variables;
11) articles that include samples of adolescents and / or elderly, resulting
in the selection of nine articles.
Then, the selected articles were analyzed for their methodological
quality, following the evaluation protocol based on the adapted PEDro17
scale, composed of nine criteria judged to be important and susceptible of
620
Figure 1. Application of the inclusion and exclusion criteria.
being scored in the selected articles. The quality score was performed by
two investigators independently and the doubts were analyzed and decided
by a third evaluator for final decision.
Thus, the following aspects were evaluated: 1) Specified eligibility
criteria; 2) Randomization or random designation; 3) Secret allocation; 4)
Similar groups at the beginning; 5) Blind assessors; 6) Evaluations made
in at least 85% of the sample; 7) All evaluated subjects received interven-
tion according to allocation; 8) Results of intergroup comparisons were
described; 9) Study presents precision and variability measures for the re-
sults. The better the score, the better the quality of the article. Articles that
reached less than 6 points were considered of low methodological quality,
between 6 and 7, average quality and above 7, high methodological quality.
Data extraction was performed individually by two independent evalu-
ators, in which means and standard deviations (baseline) and post-inter-
ventions of health-related physical fitness indicators were obtained: body
composition (fat percentage), cardiorespiratory fitness (Relative VO2max in
kg / ml / min) and force (leg press and bench press, in kg). The RevMan
version 5.3 software was used to conduct the meta-analysis, for which the
standardized mean difference (SMD) and standard error (SE) of variables to
be analyzed between groups were calculated (combined HIIT / SIT + RT
training versus other training protocols): interval training (HIIT or SIT),
resistance training (RT) and continuous training combined with resistance
(CT + RT). In each study, the random effects model (DerSimonian-
Approach Laird)18 was calculated and combined, since samples were taken
from populations under various pre-intervention conditions.
To analyze the effects of the combined protocol (HIIT / SIT + RT)
versus other protocols, significance level of 5% and 95% confidence interval
(CI) were considered. The evaluation of the heterogeneity of the total vari-
ations in studies was analyzed by means of the Cochran Q statistic, where
I2 value of <25%, 25-50% and> 50% were considered small, medium and
large quantities of inconsistency19.
Finally, sensitivity analysis18 was performed, excluding studies that

presented high risk of bias, following the procedure in two moments in

order to verify changes in the results of the meta-analysis: 1) including
only studies that performed the concurrent training in the same session;
2) excluding studies classified with low methodological quality.
RESULTS
The final selection had nine articles, totaling 231 adults. Among the
selected studies, four performed interventions in samples with eutrophic
nutritional status20-23 and five in overweight populations24-28. Regarding
the origin of studies, we have identified researches carried out in Chile27,
Brazil 23, Norway28, United States20,26, Denmark 25, France24, Canada 22 and
Greece 21. Regarding the sex of subjects, there were studies with male
samples21,24-26, female20,22,23,27 and both sexes28.
Among the HRPF indicators analyzed, six studies evaluated body
composition, specifically fat percentage21,24,25,27,28, seven muscle strength
of lower limbs (leg press) and / or upper limbs (bench press)20-26 and seven
cardiorespiratory fitness, specifically VO2max in kg / ml / min.20,22,24-28.
In studies that used interval training, five used the combination of the
HIIT protocol with strength training21,23-25,28, while four adopted the SIT
principles for combined training20,22,26,27.
Regarding the methodological quality of studies, one was classified as
with low methodological quality20, six with medium quality21,23,24,26-28 and
two with high quality22,25.
Among the interventions used in the comparison with the combined
protocol (HIIT / SIT) + RT, three studies adopted HIIT / SIT22,27,28 seven
RT20,21,23,24,26-28 and two CT + RT24,25. The HIIT / SIT + RT protocols
used in the studies showed significant variation among themselves, in-
cluding combined training interventions in the same week, but not in the
same session 26-28, and the training frequency ranged from 2 to 5 times per
week. In relation to HIIT / SIT programs, exercises with running in the
terrestrial environment 23,26,27, in treadmill 20,24,25,28, in cycle ergometer21 or
during aerobic rowing exercises22 are observed.
The majority of interventions lasted 12 weeks, with the exception of
studies with six weeks21,22 and eight weeks20,23. The intensities of the interval
exercise among studies ranged from 70 to 100% HR max 25,27,28, 110 to 120%
VO2max 20, 9-10 points of the subjective effort perception (Borg scale 0-10)
22
and 120 to 150% of the lactate threshold 24. Regarding muscle strength
training, the load ranged from 9-10 points in the scale of subjective effort
perception of Borg22 and from 40 to 87% of 1RM. Details of groups and
training protocols are highlighted in Table 1.
In the intergroup analysis, the standardized mean difference (SMD) for
the fat mass variable did not reach statistical significance, corresponding to
0.03 and with [95% CI: (-18 to 0.23) p = 0.79; I² = 0%] respectively (Figure
2A). The SMD in the relative VO2max parameter was 0.24 ml / kg / min
[95% CI: (0.04 to 0.45) p = 0.02; I 2 = 0%] in favor of the combined group
622
(HIIT / SIT + RT) compared to the other training protocols (Figure 2B).
For muscle strength, both in the Leg Press and in the Bench Press, SMD
was not statistically significant (-0.57 [95% CI: (-1.71 to 0.57) p = 0.33, I²
= 95%: (-0.29 to 0.27) p = 0.96, I² = 0%]) (Figure 3AB).
Table 1. Main features of selected studies
Duration
References Sample data Groups (n) Volume - Frequency Intensity - Load
(weeks)
Álvarez et ♀ 40.1 ± 11.4 years ITb + RT (n=10) (HIIT) 7x20sx2min, 3x/week + (RT) 5 >85% HRmax, MF 12
al.27 exercises, 3x1minx2min, 2x/week: total , PR
5x/week
ITb (n=12) 7x20sx2min, 3x/week >85% HRmax, PR
RT (n=8) 5 exercises, 3x1minx2min, 2x/week MF
Buckley et ♀ 24.7 ± 5.4 years ITb + RTf (n=14) 6x1minx3min (20s of HIIT + 40s of RT) 9-10/10 EPR , PR 6
al.²² 3 exercises, 4-10rep: 3x/week
ITb (n=14) 6x1minx3min, 3x/week 9-10 EPR ; PR
Cantrell et ♂ 25.6 ± 6.1 years ITb + RT (n=7) (HIIT) 4-6x20sx4min + (RT) 6 exercises, 85% 1RM, ME 12
al.26 3x4-6repx2min: 2x/week each (total 4x/
week)
RT (n=7) 6 exercises, 3x4-6repx2min, 2x/week 85% 1RM
Fyfe et ♂ 29.6 ± 5.5 years ITa + RT (n=8) (HIIT) 6-11x2minx1min + (RT) 5 exer- 120-150% LL, 12
al.24 cises, 3-5x4-14rmx2-3min: 3x/week MF , PR
RT (n=8) 5 exercises, 3-5x4-14rmx2-3min, 3x/ MF .
week
CT+RT (n=7) 15-33min, 5 exercises, 3-5x4-14rmx2- 80-100% LL
3min, 3x/week
Laird et ♀ 20.3 ± 1.7 years ITbT + RT (n=13) (HIIT) 8x20sx10s + (RT) AB, 4 exercises: 110-120% VO2max, 8
al.20 3-5x3-10rep: 3x/week MF , 70-87%1RM
RT (n=13) 4 exercises, AB; 3-5x3-10rep, 3x/week. MF ; 70-87%1RM
Silva et ♀ 22.9 ± 14.1 years ITa + RT (n=11) (HIIT) 20-30minx1minx1min + (RT) 7 DP, VO2max 8
al.23 exercises, 2-3x8-18x2min: 2x/week
RT (n=12) 7 exercises, 2-3x8-18x2min, 2x/week, MF
CT+RT (n=10) 20-30min 95% vVO2max
Stensvold ♀ ♂ 50.9 ± 7.6 years IT + RTa (n=10) (HIIT) 4x4minx3min, 2x/week + RT AB, 70-95% HRmax, 12
et al.28 7 exercises, 2-3x8-20rep x *min, 1x/ AR ,
week: total 3x/week 40-80% 1RM
RT (n=11) AB, 7 exercises, 2-3x8-20repx *min, 3x/ 40-80%1RM
week.
ITa (n=11) 4x4minx3min, 3x/week. 70-95% HRmax, AR
Tsitkanou ♂ 21.8 ± 0.6 years ITa + RT (n=11) (HIIT) 10x1minx1min + (RT) 4 exercises: 85%RM, 100%MAP, 6
et al.21 4x 6rep x PR
3-5min: 2x/week.
RT (n=11) 4 exercises; 4x6repx3-5min; 2x/week. 85% RM
Wens et ♂ 47 ± 3 years ITa + RT (n=12) (HIIT) 5x1-2minx1min + (RT) 6 exer- 80-100% HRmax,
al.25 cises, 1-2 x 10-20 rep x *min: 2x/week ME
12
6-20min, 6 exercises, 1-2x10-20repx
CT+RT (n=11) 80-90% HRmax, ME
*min; 2x/week
IT - interval training; RT - resistance training; a - high intensity interval training (HIIT); b - sprint
intense training (SIT); CT - continuous aerobic training; MF - muscle fatigue; PR - passive rest;
AR - active rest; ME - maximum effort; MAP - maximum aerobic power; LL - lactate threshold;
HRmax - maximum heart rate; vVO2max - maximum oxygen uptake speed; RPE - Rating of Perceived
Exertion (Borg scale); * - not specified by the authors; AB = two training divisions.

Figure 2. Meta-analysis of the results of combined protocol (HIIT / SIT + RT) versus other exercise protocols in parameters fat mass
(A) and cardiorespiratory fitness (B), respectively. CI - confidence interval, HIIT / SIT + RT - high intensity interval training or sprint
interval training combined with resistance training, IV - inverse variance, SD - standard deviation, total - number of participants in
each study group.
DISCUSSION
The aim of this meta-analysis was to analyze the effectiveness of combined
training (HIIT / SIT + RT) compared to other exercise protocols on the
HRPF indicators of adults. Our search indicates that interventions using
this combined training demonstrate more effective adaptations related to
cardiorespiratory fitness when compared to other intervention protocols.
624
Figure 3. Meta-analysis of the results of combined protocol (HIIT / SIT + RT) versus other exercise protocols in parameter strength,
leg press, in kg (A) and bench press, in kg (B), respectively. CI - confidence interval, HIIT / SIT + RT - high intensity interval training or
sprint interval training combined with resistance training, IV - inverse variance, SD - standard deviation, total - number of participants
in each study group
Our findings are similar to those that reported increased maximal oxygen
uptake in patients with hypertension 29, overweight and obese adolescents10
and in patients with chronic heart failure30.
The present data suggest that combined training (HIIT / SIT + RT)
may promote higher VO2max benefits when compared to other training
methods, specifically when compared with the RT method, although
HIIT / SIT training as well as combined CT + RT training may also
promote benefits in VO2max 24,28. Our results corroborate with the findings
of a meta-analysis conducted in 2013 comparing interval training with
other exercise protocols, including HIIT / SIT + RT on cardiorespiratory
fitness in elderly patients with chronic heart failure, in which the authors
pointed out a greater effectiveness in results in protocols that combine in-
terval training and resistance training in cardiorespiratory fitness, provided
that with similar energy expenditure30.
In this sense, combining these two types of training, adaptations are
expected in skeletal muscle mass, peripheral nervous tissue and other
tissues directly involved during training31. However, significant changes

related to muscle strength in the bench press and leg press exercises were
not observed, suggesting that the gains in these physical fitness variables
are similar between training methods. However, it is important to note
that few studies have equated volumes and / or weekly frequency between
HIIT / SIT + RT intervention and the other comparison groups, which
may underestimate the results of the other control groups, especially those
who performed HIIT and RT alone. On the other hand, intervention
protocols combining interval training and resistance training have some
distinct characteristics in the prescription characteristics, which can con-
tribute to the inconsistency in the improvement of these variables in favor
of this exercise method.
In addition, combining strength training with interval training has
been recommended for the maintenance of physical fitness and functional
capacity throughout adulthood32, indicating increases in ribosomal activity,
mitochondrial function and gene expression of skeletal muscles, culminat-
ing in increases in cardiorespiratory fitness, strength, resistance and muscle
mass33. It is worth emphasizing the importance of maintaining physical
fitness throughout adult life as a relevant factor for the reduction of the
development of risk factors, which favor the development of chronic car-
diometabolic diseases34; however, our results did not indicate a decrease in
the fat percentage in adults who performed the HIIT / SIT + RT training.
However, an important bias risk was the fact that only one study
controlled the diet variable24. Diet is a factor that has great influence in
manipulating morphological factors such as body composition. One study
showed that increased protein intake associated with caloric reduction may
provide greater fat mass decrease and lean mass increase when compared
to low protein intake in trained individuals35.
The findings in literature are widely controversial regarding the com-
bination of exercises of distinct metabolic pathways in a single session,
suggesting that they exert a metabolic dispute called concurrent training31.
It is assumed that in this method, residues from one exercise can influence
the metabolic adaptations of the other36. Although data are still unclear,
based on the results presented this assumption may not apply, because both
concurrent or combined HIIT / SIT + RT training in the same week can
bring significant results in physical fitness, as well as HIIT and RT alone.
The implementation of the combined program (HIIT / SIT + RT)
can minimize training time, a factor that has been predominant in the
choice of interventions37. These results may help in the elaboration of
new researches and identify the limitations in the studies to conduct new
interventions using this type of protocol in populations of varied ages.
In addition, the characteristics of this combined training protocol have
reinforced the growing interest in this type of exercise in recent years,
becoming an interesting strategy in increasing VO2max and in maintaining
other health-related physical fitness indicators.
In this sense, it was observed that the HIIT / SIT + RT protocol can
be used in adults with different nutritional status, reinforcing the appli-
626
cability and versatility of this type of training. In addition, the HIIT /
SIT + RT method has been applied in different age groups, for example in
elderly patients with heart failure38, in adolescents34, as well as in athletes
to improve physical fitness indicators related to sports performance39.
The present study has limitations that deserve to be pointed out. The
small number of individuals in each study selected as well as samples in
different health conditions are factors that may interfere with the analyses,
because although training with athletes has been excluded, the subjects’
initial condition may be a relevant bias. Due to the great variety of weekly
frequency, load and duration among HIIT / SIT + RT protocols studied,
future studies should focus on analyzing which protocols make better
control of total volume and caloric expenditure of training sessions, as
well as diet control, so that distortions can be minimized and satisfactory
results can be better elucidated and disseminated to the general population.
CONCLUSION
In conclusion, the studies found suggest that the use of interval training
(HIIT / SIT) combined with strength training in adults may be more
efficient for improving cardiorespiratory fitness when compared to other
exercise protocols. However, our results are insufficient and new analyses
should be conducted for a better understanding of the optimization of effects
and greater knowledge of metabolic adaptations of this protocol in adults.
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Rev Bras Cineantropom Hum

Editor Científico Expediente Indexada

Rev Bras Cineantropom Hum 2017, 19(4)375-503

Anual 1999-2002; Semestral 2003-2005;

1.Esportes Aspectos fisiológicos 2. Medicina do esporte

Catalogação na fonte: Daurecy Camilo (Beto)

Reproducibility of heart rate and perceptual

Relative age effect in Brazilian Basketball

Influence of functional and traditional training

Prediction of cardiorespiratory fitness from

Relationship between adiposity and heart rate

Rev Bras Cineantropom Hum 2017, 19(4)375-503

Dual Task Multimodal Physical Training in Alzheimer’s

Acute effects of passive static stretching

Perceived neighborhood environment and leisure

Development of a Body Image Scale for Brazilian

Is the combination of interval and resistance training

Validation of anthropometric models in the

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):505-514 507

Establishment of Appendicular Lean Soft Tissue (ALST)

Chronological Age and Anthropometric Measures

Estimates of Appendicular Lean Soft Tissue (ALST)

ALSTmod2[kg] = 3.26 + 0.002 * (H[m]*CP Thigh[cm]²) + 0.007 * (H[m]*CPArm[cm]²) + 0.003 *

Where: BM=body mass; H=height; CP=corrected muscle perimeters; CP Thigh =P Thigh[cm]-

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):505-514 509

The limits of agreement (Bland-Altman), considering an interval of

Independent variables r 2 ad-

ALSTmod3 0.433±0.09* -2.553±0.441 0.935 1.6831 1.000

The same statistical criteria previously used were applied to compare

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):505-514 511

predict ALST was validated in a sample of young athletes (ASLTmod1).

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):505-514 513

11. Wang ZM, Visser M, Ma R, Baumgartner RN, Kotler D, Gallagher D, et al.

Reproducibility of heart rate and perceptual

Abstract – Game-based training are popular in team-sports; however there is a lack of

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):515-525 517

Box 1. Experimental setup of training sessions.

Monday Tuesday Wednesday Thursday Friday Saturday

HB: technical and tactical handball training.

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):515-525 519

Variables Test Retest

CR10 3.7±1.2 5.1±1.3*

Variables r (CI 95%) TEM (CI 95%) CV (CI 95%)

CR10 0.74* (0.28-0.92) 0.65 (0.46-1.10) 9.79 (6.90-17.21)

Variables r (CI 95%) TEM (CI 95%) CV (CI 95%)

Variables r (95% CI) TEM (95% CI) CV (95% CI)

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):515-525 521

The time spent in HR zones is a variable widely used in team-sports in

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):515-525 523

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):515-525 525

Relative age effect in Brazilian Basketball

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):526-534 527

between sexes, geographic region, competitive level and team performance.

Number (%) of athletes per quartile OR(95% Confidence Interval)

Number (%) of athletes per quartile OR(95% Confidence Interval)

Number (%) of athletes per quartile OR(95% Confidence Interval)

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):526-534 529

Regarding the team performance, RAE was verified only in females,

Number (%) of athletes per quartile OR(95% Confidence Interval)

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):526-534 531

team. RAE was observed in male athletes belonging to the Northern,

Rev Bras Cineantropom Desempenho Hum 2017, 17(5):526-534 533

Influence of functional and traditional training

ALSTmod2[kg] = 3.26 + 0.002 * (H[m]CP Thigh[cm]²) + 0.007 (H[m]CPArm[cm]²) + 0.003