Bruno Bavaresco Gambassi, PhD1,2,3,4,5,6, Beatriz de Sá Mota, B.SC.1, David Guilherme Marques, B.SC.1, Daniel Yakovi Ribeiro, B.SC.1, Vinícius Silva, B.SC.1, Luiz Alexandre Nunes, MsC2, Fabiano de Jesus Furtado Almeida, PhD2, Mayara Aragão, MsC6,7, Celsiane do Espírito Santo Costa, M.SC. STUDENT1,4, Roberto Bianco, PhD2, María Rúa-Alonso, PhD8, Paulo Adriano Schwingel, PhD1,6,7
1Laboratory of Education and Research in Exercise and Cardiovascular Health in Older Adults, Ceuma University, São Luís, Brazil;
2Ceuma University, São Luís, Brazil;
3Postgraduate Program in Management and Health Care, Ceuma University, São Luís. Brazil;
4Postgraduate Program in Physical Education, Federal University of Maranhão, São Luís, Brazil;
5Interuniversity Network for Healthy Aging, Latin America and the Caribbean, Talca Universidad, Chile;
6Human Performance Research Laboratory, University of Pernambuco, Petrolina, Brazil;
7Postgraduate Program in Rehabilitation and Functional Performance (PPGRDF), University of Pernambuco, Petrolina, Brazil;
8Performance and Health Group, Faculty of Sports Sciences and Physical Education, Department of Physical Education and Sports, University of A Coruna, A Coruña, SpainDOI: https://doi.org/10.5770/cgj.29.895
ABSTRACT
Background
Combining power training (PT) with endurance training (ET) offers health benefits for older adults. However, little is known about the effects of PT plus ET on arterial stiffness and hemodynamic parameters in previously trained hypertensive older adults. Additionally, the effects of exercise order—PT followed by ET versus ET followed by PT—on arterial stiffness and hemodynamic parameters remain unclear in older adults.
Objective
This study aimed to a) examine the effects of concurrent training (CT) on arterial stiffness and hemodynamic parameters in previously trained hypertensive older adults; and b) to investigate the effects of concurrent PT and ET exercise order on arterial stiffness and hemodynamic parameters in previously trained hypertensive adults.
Methods
Older adults with grade 1 hypertension were randomized into two groups: PT then ET group (DPTETG) and ET then PT group (ETDPTG). Both groups trained twice weekly for 16 weeks. Arterial stiffness and hemodynamic parameters were measured at baseline and after 16 weeks.
Results
No significant changes in arterial stiffness or hemodynamic parameters emerged after 16 weeks in either group (p > .05).
Conclusion
This study demonstrates that 16 weeks of different exercise orders of concurrent power and ET do not change arterial stiffness and hemodynamic parameters in older adults with hypertension.
Key words: older adults, hypertension, arterial stiffness, intervention
Studies have demonstrated various benefits of traditional resistance training (RT) and endurance training (ET) on health parameters in older adults. Traditional RT has improved bone mineral density, and functional and cardiovascular parameters in older adults.(1–4) Moreover, aerobic training improves cardiovascular and metabolic parameters.(5–7)
In this sense, combining traditional RT with ET in training programs is recommended to achieve several health benefits for older adults.(8,9) Additionally, according to Izquierdo et al.,(9) combining traditional RT with ET sequentially in the same session is called concurrent training. On the other hand, performing traditional RT and ET on separate days is called combined training.(9)
In addition to practicing traditional RT with ET, Izquierdo et al.(8) also recommend power training (PT) for optimal aging and maintenance of functional capacities. Combining traditional RT or PT with ET is the most effective method for enhancing neuromuscular and cardiorespiratory functions in older adults.(9)
Although studies have observed the benefits of associating PT with ET for older adults’ health,(10–13) little is known about the effect of these combinations on arterial stiffness in hypertensives, for which concurrent training involving PT seems promising.(12) Arterial stiffness decreased, and hemodynamic parameters improved after hypertensive older adults practiced only eight weeks of concurrent training involving PT and ET.(12) In the same line, pulse pressure and systolic blood pressure improved in older adults after PT associated with ET in the same session.(13)
Despite the benefits of combining traditional RT or PT with ET to older people’s arterial stiffness,(14,15,12) there is no consensus on the effects of combined or concurrent training on hypertensive older people’s hemodynamic parameters.(16,17) This may be due to baseline blood pressure values and different manipulations of training variables. In this sense, contraction speed of resistance exercises, rest intervals between exercises and sets, protocol order (traditional RT or PT plus ET vs. ET plus traditional RT or PT), and different protocol structures (concurrent or combined training) may interfere with cardiovascular adaptations.
In this context, the order of exercises may influence the chronic physiological adaptations to training.(15,18,19) While previous studies have examined the effects of different exercise orders involving concurrent training on maximal dynamic strength, aerobic capacity, and muscle quality,(18,19) limited evidence is available regarding the effects of concurrent training comprising PT followed by ET versus ET followed by PT on arterial stiffness and hemodynamic parameters in older adults.
As a reduction in arterial stiffness in older women after ET or RT has been demonstrated,(20) it is essential to determine whether specific combinations or sequences of these modalities may further enhance improvements in the vascular health of hypertensive older adults. Additionally, as both PT and ET seem to increase nitric oxide production in older adults,(21,22) it is important to ascertain whether manipulating exercise order augments the production of this and other vasoactive substances involved in reducing arterial stiffness and improves hemodynamic parameters in this population.
Considering that arterial stiffness poses a risk of death, and that the manipulation of training variables can interfere with cardiovascular adaptations, more studies are needed to explore the effects of different combined and concurrent training protocols on arterial stiffness in hypertensive older adults. Thus, strength and conditioning professionals may have additional exercise training information and possibilities to improve cardiovascular health in this population.
Given the above, this study aimed to a) examine the effects of concurrent training on arterial stiffness and hemodynamic parameters in previously trained hypertensive older adults; and b) to investigate the effects of concurrent PT and ET exercise order on arterial stiffness and hemodynamic parameters in previously trained hypertensive adults.
This interventional, randomized study was conducted upon approval by the Ethics Committee at an institution affiliated with one of the authors. All participants signed an informed consent form after learning about the study approach and procedures they would undergo, and the potential risks and benefits. The study was conducted following the Helsinki Declaration of 1975.
The sample size calculation was utilizing G*Power software (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany, version 3.1.9.4, 2019), adhering to Beck’s recommendations.(23) The a priori sample size calculation was performed considering an ANOVA (F-test), α = 0.05, power = 0.95, and a large effect size for PWV (arterial stiffness) (η2p ≥ 0.14/effect size f = 0.403).(12) Accordingly, 12 older adults per group would be needed. To account for possible dropouts, 13 participants were selected per group (Figure 1).
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FIGURE 1 Flow diagram of participants | ||
Inclusion criteria consisted of being 60 years old or above, able to walk with or without assistance, performing basic daily activities, having engaged in regular exercise training for the past six months, and clinically diagnosed with hypertension by a cardiologist. Exclusion criteria included experiencing disabling pain during exercise, inability to perform exercise sessions, and inability to participate in evaluations.
Thirty older adults were recruited by publicizing the project through digital media (e.g., Instagram). The 26 selected older adults were randomized with a computer-generated list of random numbers, and allocation concealment was ensured using opaque and sequentially numbered sealed envelopes. They were randomly assigned to the dynamic power training plus endurance training group (DPTETG) (n = 13) and the endurance training plus dynamic power training group (ETDPTG) (n = 13). The process plan is graphically depicted in Figure 1.
After signing an informed consent form, participants visited the research facilities for familiarization with the experiment site, tests, and equipment used, as well as an explanation about the assessments and the exercise program.
All assessments (arterial stiffness, hemodynamic parameters, and body composition) were performed before and after 16 weeks of training by the same experienced exercise physiologists using identical procedures, blinded regarding group allocation. The experiments were performed in a quiet air-conditioned room (22° to 24°C) always in the morning (07:00 to 11:00 am) at the Laboratory of Assessment and Physiology of Ceuma University in four distinct phases.
During the initial phase (familiarization, two weeks), the exercises were applied to familiarize the participants with the initial and final positions of the exercises and concentric and eccentric movement speeds. The exercise professionals controlled the concentric and eccentric movement speed through verbal/tactile cues. To get familiarized with PT, participants performed two sets of six repetitions at an easy intensity, applying the rate of perceived exertion (RPE).(24,25) In addition, the target perceived exertion level during ET (walking) was set at an easy intensity on an adapted Borg Scale of 1–10.(26)
In the second phase (1 week), experienced exercise physiologists administered the initial assessments.
In the third phase (16 weeks), experienced strength and conditioning professionals assisted with the two protocols.
Lastly, in the fourth phase (1 week, after ending the protocols), experienced exercise physiologists administered the final assessments.
Assessments of arterial stiffness and hemodynamic parameters were carried out in a quiet, air-conditioned room (22° to 24°C) during the morning hours in the Laboratory of Assessment and Physiology at Ceuma University, pre- and post-interventions. Participants were instructed to avoid exercise for 24 hours and abstain from caffeinated or alcoholic beverages for 24 hours before evaluations. Blood pressure (BP) was measured using a validated, automatic monitor (HEM-7130, Omron Healthcare Inc., Lake Forest, IL). During the assessment, participants were instructed to remain silent. The cuff was placed on the arm about 2 cm above the cubital fossa.(27) BP was measured three times on each side, with a 1-minute interval between each attempt.(27) When the identified difference between the sides is with a value > 10 mmHg in the first reading, new measurements were taken.(27) Otherwise, the first measurement was discarded, and the average of the last two measurements on each side was considered.(25) Additionally, the side with the highest average value was considered for the assessment pre- and post-intervention.(27) The arm with the highest BP values was used to assess central systolic blood pressure, central diastolic blood pressure, pulse pressure, central pulse pressure, and pulse wave velocity through of the triple pulse wave velocity method, by an automated oscillometric device (Arteris AOP, Cardio Sistemas Comercial Industrial Ltda, São Paulo, SP, Brazil).(12)
The protocols were described following the recommendations of the Basic Guidelines for the Application of the Main Variables of RT in the Elderly.(28) PT was performed with free-weight, machine, and elastic bands (strong) (LIVEUP® SPORTS, Araucária, PR, Brazil).
During the main phase of the exercise program, training sessions were performed with moderate intensity according to RPE,(24–26) twice a week over 16 weeks, with a minimum 48-hour rest interval provided between each exercise session in the same week. The RPE was reported after the end of each set of exercises (PT and ET), and if the participant reported an RPE below the expectations (low intensity), the stimulus (weight, tension of the elastic band, and walking speed) was increased (moderate intensity).(24,25)
The exercises were performed at full amplitude, except for the squat (90°) and lateral elevation (90°) exercises, with concentric contractions performed as fast as possible, while the eccentric contractions were performed slowly within 3 seconds.
Protocol consisted of the following sequence (without intervals of absolute rest throughout the session). Participants did not perform the sequences in the same order.
Participants in both intervention groups (PTET and ETPT) will perform the same walking time. In the 16 weeks, both groups were walking at moderate intensity.(26) Exercise professionals were supervising each group of older adults to monitor them and control intensity, in the same format as the RT and PT monitoring (trainer/trainee ratio of 1:4).
The exercise training volume was increased over the 16 weeks, as shown below:
Participants performed the same exercises as the DPTETG, starting with ET and ending with dynamic PT.
Statistical analysis was conducted using Prism software (GraphPad Inc., San Diego, CA; Version 8.4.3, 2020). Descriptive statistics were analyzed using Bartlett’s test, and normality was assessed with the Kolmogorov-Smirnov test. Mean values and standard deviations (SD) were calculated for each dependent variable. A two-way analysis of variance (ANOVA) with repeated measures on the “time” factor was used to evaluate the effects of the protocols (“group” × “time”). In cases where a significant interaction effect was observed, Bonferroni post hoc tests were used to identify within-group changes over time. Statistical significance was set at p ≤.05 for all analyses, which were two-tailed. Effect sizes (ES) were calculated using partial eta-squared (η2p) values, classified as small (η2p ≥ 0.01), medium (η2p ≥ 0.06), or large (η2p ≥ 0.14) according to Espirito Santo and Daniel.(29)
In this study, 20 older adults diagnosed with grade 1 hypertension completed the pre- and post-16-week measurements and had their data included in the statistical analysis (ETDPTG: n = 9; DPTETG: n = 11). Their clinical characteristics are shown in Table 1.
TABLE 1 Baseline clinical characteristics of the participants (n = 20)
There were no significant time effects, group effects, or time vs. group interaction in pulse wave velocity (PWV), pulse pressure, and central pulse pressure (p > .05) after 16 weeks of intervention (Table 2). Additionally, all participants in both groups had lower baseline PWV values than expected according to age and blood pressure levels.
TABLE 2 Changes in arterial stiffness and hemodynamic parameters at baseline and after 16 weeks of intervention (n = 20)a
There were no significant time effects, group effects, or time vs. group interaction in systolic blood pressure (SBP), diastolic blood pressure (DBP), central SBP, and central DBP (p > .05) after 16 weeks of intervention (Table 2).
The main finding of this study is that arterial stiffness did not decrease in hypertensive older adults after practicing different protocols (order of exercises) of concurrent PT. To our knowledge, this is the first study to investigate the effects of the order of exercises in concurrent power and endurance training on arterial stiffness and hemodynamic parameters in previously trained hypertensive older adults. This may have influenced the findings, considering that in all studies involving the benefits of concurrent or combined training, the sample consisted of older adults with no history of training for at least six months.(10–12,14,15)
A study by our group demonstrated reduced arterial stiffness and improved hemodynamic parameters in hypertensive older adults after eight weeks of concurrent training (PT plus ET), although they had not trained for at least six months.(12) Likewise, previous studies have demonstrated the benefits of different concurrent training protocols on arterial stiffness of postmenopausal women and older adults with no history of exercise training for at least six months before starting the protocol.(14,15,30,31)
The reduction in arterial stiffness in older adults with and without hypertension and no history of training appears to occur in a short period (6–12 wks).(14,15,12) Hence, participants may have begun this study with positive adaptations from previous training. This can be evidenced by the individual PWV values (Figure 2). All participants in both groups had lower baseline PWV values than expected according to age and blood pressure levels, as observed in Figure 2. Further research with the same characteristics as the present study is needed to confirm this hypothesis.
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FIGURE 2 Pulse wave velocity (in meters per second) categorized by age and blood pressure levels (grade 1 hypertension), along with individual arterial stiffness values before and after the interventions; a pulse wave velocity (PWV) of 11.1 m/s is a reference value for individuals with grade 1 hypertension aged 60 to 69 years, while a PWV of 12.9 m/s is a reference value for those aged 70 years or older | ||
Besides the lack of reduction in arterial stiffness, the present study did not find any improvement in hemodynamic parameters in hypertensive older adults. Although combining RT with ET provides several benefits for hypertensive older people’s health,(16) there is still no consensus on the effects of concurrent and combined training on this population’s arterial stiffness and blood pressure.(16,17)
Similarly, recent research by our group(10) found no improvement in blood pressure levels in previously trained older adults after practicing concurrent training protocols with different volumes. In this sense, studies involving exercise and blood pressure mostly involve older adults without prior exercise training.(12,32,33)
One hypothesis to explain our findings is the baseline blood pressure levels. Those participants in this research (ETDPTG: SBP; 125.1 ± 15.8 mmHg; DPTETG: SBP; 126.2 ± 10.6 mmHg) may justify the lack of statistical change in this variable. In the same sense, older adults with controlled blood pressure levels did not decrease after different concurrent training protocols.(10,33) The groups with repetitions to failure (120 ± 12 mmHg), repetitions not to failure (122 ± 12 mmHg), and repetitions not to failure with equalized volume (126 ± 15 mmHg) had SBP values close to those of the sample in this research.(33) Most studies observe the benefits of exercise in older adults with high blood pressure.(12,32,34)
In that regard, research by Sardeli et al.(17) indicates that baseline blood pressure values, rather than the type of exercise and age, primarily determined the blood pressure response to exercise, predicting 74 and 53% of the reductions in SBP and DBP, respectively. Another hypothesis for the lack of statistical change may be that the loss of participants, leaving a smaller sample, may have impacted the data analysis.
Although the present study did not demonstrate statistically significant changes in arterial stiffness and hemodynamic parameters in hypertensive older adults following different concurrent training protocols, the findings nonetheless present relevant clinical implications.
Considering that aging is associated with increased arterial stiffness, and that a 1 m/s rise in PWV is associated with 14%, 15%, and 15% increases in total cardiovascular events, cardiovascular mortality, and all-cause mortality, respectively,(35) a reduction of Δ = 0.2 m/s after the performance of PT combined with ET represents clinically meaningful potential for hypertensive older adults. In this regard, the observed reduction in present research (Δ = −0.2 m/s) is consistent with the findings of Park et al.,(36) who also reported an improvement in arterial stiffness (Δ = −0.2 m/s) following 12 weeks of concurrent training.
In addition, it found a significant clinical reduction in SBP in both groups (ETDPTG: SBP; Δ = −5.1 mmHg; DPTETG: SBP; Δ = −8.9 mmHg). These findings indicate a reduced risk of mortality from stroke and coronary artery disease.(37) Additionally, the DPTETG had a 4.8 mmHg reduction in DBP, which can prevent coronary heart disease and stroke events.(38)
Finally, the following study limitations stand out: the lack of a control group, participants of both sexes, time since hypertension diagnosis, different orders of exercises performed by participants, and the lack of maximum repetition testing to estimate the workload in each exercise. On the other hand, our findings may encourage further studies on this topic.
This study demonstrates that 16 weeks of different exercise orders of concurrent PT and ET do not change arterial stiffness and hemodynamic parameters in previously trained hypertensive older adults. On the other hand, no adverse effects were observed, even in the context of a cardiovascular risk condition such as arterial hypertension. Hence, we suggest further studies on the effects of different concurrent training protocols in older adults with quite abnormal arterial stiffness and high blood pressure.
The authors are grateful to the volunteers who participated in this study.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare that we have none.
This study will be financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES) [under Finance Code 001] and was supported by Fundação de Amparo à Ciência e Tecnologia do Estado de Pernambuco (FACEPE) [grant numbers APQ-0246-4.06/14 and APQ-1413-4.08/21]. María Rúa-Alonso acknowledges the financial support received from the Xunta de Galicia (Consellería de Cultura, Educación, Formación Profesional y Universidades) through the Xunta de Galicia Postdoctoral Fellowships (ED481B-2024-077).
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Correspondence to: Bruno Bavaresco Gambassi, PhD, Ceuma University, Department of Physical Education, São Luís, MA, Brazil. Address: Rua Josué Montello, 1 - Renascença II, São Luís - MA, 65075-120, Brazil, E-mail: professorbrunobavaresco@gmail.com
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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 29, No. 2, JUNE 2026