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Journal of Exercise Physiologyonline
June 2017
Volume 20 Number 3
Editor-in-Chief
Official Research Journal of
Tommy
the American
Boone, PhD,
Society
MBA
of
Review
Board
Exercise
Physiologists
Todd Astorino, PhD
Julien Baker,
ISSN 1097-9751
PhD
Steve Brock, PhD
Lance Dalleck, PhD
Eric Goulet, PhD
Robert Gotshall, PhD
Alexander Hutchison, PhD
M. Knight-Maloney, PhD
Len Kravitz, PhD
James Laskin, PhD
Yit Aun Lim, PhD
Lonnie Lowery, PhD
Derek Marks, PhD
Cristine Mermier, PhD
Robert Robergs, PhD
Chantal Vella, PhD
Dale Wagner, PhD
Frank Wyatt, PhD
Ben Zhou, PhD
JEPonline
Physical Exercise Program Carried Out in Primary
Health Care Units Improves Exercise Tolerance and
Economy of Movement
Camila B. Papini1, Priscila M. Nakamura2, Grace A. G. de Oliveira 3,
Danilo R. Bertucci4, Eduardo Kokubun5
1Science
Sport Departament, Federal University of Triangulo
Mineiro, Uberaba / MG, Brazil, 2Federal Institute of Education,
Science and Techonology of South of Minas Gerais, Muzambinho /
MG, Brazil, 3Departament of Gerontology, Federal University of São
Carlos, São Carlos / SP, Brazil, 4Postgraduated Program in in Motor
Science, UNESP, Rio Claro / SP, Brazil, 5Department of Physical
Education, Sao Paulo State University,
Rio Claro / SP, Brazil
ABSTRACT
Official Research Journal
of the American Society of
Exercise Physiologists
ISSN 1097-9751
Papini CB, Nakamura PM, Oliveira GAG, Bertucci DR, Kokubun
E. Physical Exercise Program Carried Out in Primary Health Care
Units Improves Exercise Tolerance and Economy of Movement.
JEPonline 2017;20(3):100-109. The purpose of this study was to
evaluate the effect of a 1 yr exercise program carried out in Primary
Health Care Units (PHCU) concerning the variables related to
cardiorespiratory fitness (CF). A quasi-experimental study was
performed with 22 women (56.35 ± 9.25 yrs old). The intervention
was comprised of 3, 90-min sessions·wk-1. The subjects’ CF was
measured via submaximal incremental treadmill test through indirect
calorimetry. A significant difference in the subjects’ final exercise
time (in minutes) was found between the initial test and the 1 yr test
[Baseline (BL) = 6.36 ± 3.2 and at 1 yr (1Y) = 10.80 ± 5.0 min; P =
0.004] and final exercise stage (BL = 2.2 ± 1.2 and 1Y = 3.6 ± 1.7, P
= 0.004). The number of completed minutes and stages during the
treadmill test was significantly increased after the 1 yr physical
exercise program carried out in the PHCU. Thus, the subjects’
exercise tolerance and economy of movement were improved.
Key Words: Economy of Movement, Exercise Intervention, Exercise
Tolerance, Primary Health Care Units
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INTRODUCTION
Maintaining or improving the cardiorespiratory fitness of adults is important throughout life,
regardless of age. Cardiorespiratory fitness is inversely related to mortality by coronary
disease, cerebral vascular accident, and all mortality causes (17). In addition, it is
increasingly clear that poor cardiorespiratory fitness is an important predictor for metabolic
syndrome (18). Hence, the potential benefit of increased cardiorespiratory fitness should be
considered for primary prevention of numerous chronic diseases such as obesity,
hypertension, and type 2 diabetes mellitus.
Despite the fact that cardiorespiratory fitness is linked to a genetic component as well as to
gender, age, and clinical conditions of the cardiovascular system, it can be influenced by
external factors (especially physical activity and fitness training levels) (4,8). Structured
physical exercise interventions result in beneficial changes in the structure and function of the
heart and lungs (7). Perhaps, the most obvious physiological adaptation is the increase in
maximal oxygen uptake and exercise tolerance, the improvement in submaximal exercise
intensities, the decrease in expired ventilation, heart rate, and blood pressure at rest and
during exercise (1).
Considering both the relationship between cardiorespiratory fitness and health and the high
prevalence of physical inactivity (26), it is necessary to elaborate, implement, and evaluate
physical exercise programs that focus on adults, elderly, and children. Primary Health Care
Centers are a convenient setting to carry out exercise programs since they are responsible
for promoting the client and/or patient’s health and quality of life (11). In Brazil, in particular,
~40% of the Primary Health Care Centers have physical activity interventions (11). Programs
carried out in the SUS (Public Health Brazilian System, Sistema Único de Saúde, in
Portuguese) can reach individuals with low socioeconomic and schooling level since the
Health Units are mostly located in areas of high vulnerability in Brazil. Then, given the studies
by Codogno et al. (6) and Turi et al. (25) that show the increase in the level of physical
activity and the practice of walking are effective in the mitigation of health care expenditures
in the Brazilians users of SUS.
Presently, however, the development of physical exercises programs in Primary Health Care
is limited by the lack of materials, inappropriate places to perform physical exercises, and the
difficulty in monitoring the intensity of exercise. Despite these difficulties, numerous physical
exercises programs carried out in the Brazilian Public Health System have resulted in large
health benefits related to cardiorespiratory fitness (20,21,23). The purpose of this study was
to evaluate the effect of 1 year of physical exercise program carried out in Primary Health
Care Units on exercise tolerance and economy of movement through an indirect calorimetric
method in women.
METHODS
Subjects
This 1 year quasi-experimental study was developed in two Primary Health Care Units in Rio
Claro City, Brazil. Adult females were recruited by flyers and newspaper advertisements. The
participants were assigned to the intervention group based upon proximity from their
residence, considering the “territorialization principle” of SUS.
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Forty-nine subjects were recruited at the beginning of intervention. As a result of either
voluntary dropout or failure to meet the inclusion criterion for the study with a frequency of
75% attendance in the sessions, 22 subjects (56.35 ± 9.25 yrs old) remained in the
intervention after 1 year (Figure 1). The study was approved by the Human Research Ethics
Committee of Biosciences Institute, UNESP, protocol number 2308.
Figure 1. Flow Chart of Subjects and Dropouts.
Physical Exercise Intervention
The community based exercise intervention used in this study was comprised of 3, 90-min
sessions·wk-1 of physical exercises. The intervention was designed to meet current
recommendations for physical activity (2,22) and all sessions were guided by a physical
education professional. The sessions were divided into warm-up activities (10 min), moderate
intensity aerobic exercise (50 min), strength-training exercises (20 min), and cool-down
activities (10 min). Thus, the participants performed 150 min of aerobic exercises, 60 min of
strength exercises, and 30 min of stretching exercises weekly.
The warm-up and cool-down activities included static stretching exercises and articular
movements. Static stretching was maintained for a minimum period of 15 to 30 sec, twice for
each muscle group. The subjects were advised to sustain a muscle stretch that did not cause
pain. The strength-training exercises were performed using free weights, exercise mats, and
latex exercise bands. Exercises included all major muscle groups, and were performed in 3
sets of 30 sec followed by 1 min of recovery.
The aerobic exercises consisted of walking at moderate intensity (60 to 70% of peak heart
rate). The target zone for exercise was calculated using the equation HR peak = 206 − (0.88
× age) (13). All subjects were encouraged to maintain a subjective effort of a rating of
perceived exertion between 13 and 15 on the 20-point Borg color scale (5,24) during walking.
Four subjects were randomly selected to measure the intensity of their activity twice a month
using a cardiac rate monitor (Polar® model FS1, Polar Electro Oy, Finland) and the
subjective effort scale. The cardiac rate and the Borg scale were monitored each 10 min of
the session.
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Cardiorespiratory Fitness Test
The subjects’ cardiorespiratory fitness was measured via submaximal incremental treadmill
test (ATL3®, Inbrasport, Brasil) through indirect calorimetry using a gas analyzer (VO2000,
Medgraphics, St. Paul, Minnesota, USA) and a medium flow pneumotachograph (6 to 120
L·min-1). The ergoespirometric test data were collected in each of 3 breaths by Aerograph
Software. The subjects answered the Readiness Activity PAR-Q questionnaire before the test
and performed an adaptation on the treadmill using the neoprene masks. They performed the
test at baseline (BL) and after 1 yr (1Y) of intervention.
The test was initiated at 4 km·h-1 with no incline. In the second stage, the speed was
increased to 5.6 km·h-1 with no incline. In the next stages, the speed was maintained and the
incline was increased by 2.5% in each 3-min stage.
The subjects’ Maximum Heart Rate (HRmax) was calculated according to the equation:
HRmax = 220 – age (16). Heart rate was monitored during the test (using a Polar® model
FS1, Polar Electro Oy, Finland). The scale BORG was also used during every minute of the
test to monitor the subjective effort perception (5).
The test was interrupted when the subject reached 85% of HRmax, which was either
previously estimated by the equation (HR85% = (HRmax x 85)/100) or when the subject
reached the BORG 15 (in case of the subject’s medicated with beta-blockers) or by voluntary
exhaustion (before reaching 85% of HRmax). The final BORG and HR reached in the test
were used to verify if the test interruption was the same in pre- and post-evaluation.
The variables used to verify the changes in cardiorespiratory fitness were: (a) final time and
stage (exercise tolerance) reached in the tests; and (b) energy cost (economy of movement)
for each stage. The subject’s energy cost was calculated via Delta (absolute difference of
VO2 (mL·kg-1·min-1) between pre- and post-tests, using the equation: D = VO2 pre – VO2 post.
The corresponding difference was calculated in percentage (%) after.
Statistical Analysis
The data normality was verified through Shapiro-Wilk test. Descriptive data were reported as
means and standard deviations. The paired Student´s t-Test was used to compare the
changes in final VO2 and final HR. The paired Wilcoxon test was used to compare the final
BORG, stage and time reached in the tests. Statistical analyses were conducted using SPSS
17.0, with the alpha level set at P<0.05. The VO2 Delta values (energy cost) in BL and 1Y
were compared using descriptive analysis. The Stages 6 and 7 were not analyzed due to the
small number of subjects who reached these stages.
RESULTS
The statistical analyses showed no differences (P>0.05) between BL and 1Y for final HR,
VO2, and BORG as presented in Table 1. Significant differences were indicated between
tests for final time and final stage reached in the ergoespirometric test.
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Table 1. Comparison Between Ergoespirometric Variables Related to Exercise
Tolerance at Baseline and After 1 Yr of intervention.
Baseline
1 yr
P value
HRfinal (beats·min-1)
140.4 ± 14.88
140.6 ± 15.89
0.869
VO2final (mL·kg-1·min-1)
19.28 ± 3 .37
19.30 ± 3.45
0.972
BORGfinal
14.5 ± 2.17
15.35 ± 1.38
0.115
Final Time (min)
6.36 ± 3.45
10.80 ± 5.00
0.004*
2.2 ± 1.2
3.6 ± 1.7
0.004*
Final Stage
HRfinal = Final Heart Rate; VO2final = Final Oxygen Uptake; BORGfinal = Subjective Effort Scale
Reached at the End of Test
The Table 2 shows the Delta value (absolute changes) and the percentage changes (%) for
energy cost, and the number of subjects that completed each stage in baseline and after 1 yr
of intervention. Few subjects could complete more than 3 or 4 stages at baseline. However,
most subjects completed the 3 stages and some of them completed from 4 to 7 stages after 1
yr of intervention. Table 2 points out that the negative Delta in each stage indicates a
decrease in VO2 after 1 yr of intervention. The decrease in Delta value ranged around 12% to
21%.
Table 2. Energy Cost (VO2 – mL·kg-1·min-1), Delta (Absolute Changes) and Percentage
Changes (%) for Each Stage at Baseline and After 1 Yr of Intervention.
Stages
Baseline
n
1 Yr
n
Delta
%
1
14.56 ± 2.77
22
11.63 ± 3.10
22
-2.93
20.1
2
18.41 ± 3.13
17
16.03 ± 3.62
21
-2.38
12.9
3
20.61 ± 2.23
9
16.83 ± 3.73
14
-3.78
18.3
4
22.01 ± 2.16
4
17.69 ± 3.83
10
-4.32
19.6
5
22.99 ± 3.24
2
17.55 ± 2.51
8
-5.44
23.66
6
20.37
1
21.27 ± 1.98
3
-
-
7
-
0
22.91
1
-
-
-The Stages 6 and 7 were not compared due the small number of subjects.
105
DISCUSSION
The results indicate that the intervention carried out in Primary Health Care was effective in
improving the variables related to cardiorespiratory fitness. The significant difference for final
time and stage between the tests indicates that the subjects developed a greater exercise
tolerance. Moreover, the increase in the subjects’ exercise tolerance was confirmed by the
low energetic cost presented in each stage at baseline and after 1 yr of intervention. It was
also observed that at baseline, few subjects completed more than 3 or 4 stages, while most
of the subjects completed the 3 stages and others completed from 4 to 7 stages after 1 yr.
These results indicate an improvement in walking capacity and greater endurance.
The intervention offered in this study incorporated the physical activity recommendation of
150 min of moderate aerobic exercise combined with 60 min of resistance muscle exercises
weekly (2,22). This exercise prescription is adequate to promote physiological adaptations
that result in an improvement of cardiovascular and respiratory functions and, consequently,
an increase in exercise tolerance along with a low energetic cost during the walking
movement.
Similar results were also found by other studies. Belli et al. (3) evaluated 9 sedentary
subjects (53.4 ± 2.3 yrs old) that performed 12 months of intervention, which consisted of
walking 3 times·wk-1 from 20 to 60 min. The results corroborate our study once an increase of
the final speed and final time reached in the incremental test was observed. Additionally, the
VO2peak had a significant increase after 12 months of intervention. Although VO2 max was
not evaluated in our study, the increase in final time and stage between tests suggest a
possible increase.
Nakamura et al. (21) evaluated the effect of a 10-yr physical exercise program carried out in
a Primary Health Care setting. The subjects included 409 females (50.0 ± 26 yrs old) and 64
males (64.0 ± 10 yrs old). The authors concluded that the subjects’ cardiorespiratory fitness
was improved once the subjects significantly decreased the time to perform the walking test
over the 10-yr period.
Being functionality independent is an important goal among older adults. However, some
physiological alterations that occur with the natural process of aging can make it difficult to
achieve. Additionally, the aging process among elderly individuals decreases the total energy
available to perform the daily physical activities (27). Therefore, it is evident of the importance
in improving or maintaining the cardiorespiratory fitness levels throughout the course of life.
While cardiorespiratory fitness usually presents a progressive increase with the course of
chronological age, starting with the third decade of life in untrained individuals both the
cardiovascular and respiratory systems suffer a decrease with age of ~10% every decade
(10). According to Hagberg (14), elderly individuals who maintain their physical activity level
can minimize the natural cardiorespiratory fitness decline at a rate of 5% per decade, which is
half the decline in relation to sedentary people. Thus, the increase or maintenance of physical
activity levels such as the participation in a physical exercise program is important to healthy
aging.
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The similar values for the final VO2, HR, and BORG in baseline and after 1 yr indicate that
both tests were performed until the same criteria interruption (85% of HRmax and BORG 15).
One of the study limitations was not to perform the maximum effort test until the subjects’
voluntary exhaustion to verify the improvement in cardiorespiratory fitness. The submaximal
effort test had to be performed once the guidelines recommended that the maximum effort
test should not be performed when some risk factors were presented by the subjects (such
as hypertension, diabetes, advanced age, and when there was not a doctor present)
(1,9,12,15,19).
Although direct determination of VO2 max is the most accurate method to measure
cardiorespiratory fitness, it requires a maximal level of exertion that increases the risk of
adverse events in individuals with an intermediate to high risk of cardiovascular problems.
Walk tests are accessible to anybody without locomotion impairments, and they are useful
when running is not advisable, such as in obese or elderly individuals. Thus, the test protocol
choice with the incremental incline was made in reference to the physical conditions of the
subjects. Some of the subjects did not have sufficient mobility to walk very quickly and/or run
on the treadmill.
Some studies (20,23) that assessed the VO2 max of participants have demonstrated that
physical exercise programs carried out in the Primary Health Care setting are effective in
improving cardiorespiratory fitness in mature adults and in elderly individuals. Petrella et al.
(23) evaluated 131 healthy subjects (>65 yrs old) in a Primary Health Care setting that
involved counseling and exercise prescription for a period of 1 yr. The results indicated that
was a significant increase of 11% in VO2 max after 6 months and a 12% increase after 1 yr.
Monteiro et al. (20) investigated the effect of a physical exercise program carried out in a
Primary Health Care setting that involved 16 participants (56 ± 3 yrs old) over a 4-month
period. The program resulted in a 42% improvement in VO2 max.
Although the VO2 max of subjects in the present study was not assessed, the findings do
indicate that there was a decrease in the subjects’ energy cost and an increase in exercise
tolerance. Being able to walk at 5.6 km·h-1 with some incline is an improvement that is
consistent with a better quality of life. Elderly people do not need to reach advanced stages in
the treadmill test considering the amount of effort needed to perform their daily activities.
It should be pointed out that the small number of subjects after 1 yr of intervention was due to
the difficulty to maintain 75% of attendance in the sessions. Although the subjects who did
not meet 75% of attendance were excluded from statistical analysis, they were not excluded
from the program. This decision on behalf of the participants was considered important since
there was no physical exercise program offered in other locations, especially since the
participants were allocated a Health Unit near their residence (which is consistent with the
“territorialization principle” of SUS).
Considering the relation between cardiorespiratory fitness and improvement in health and the
benefits that regular aerobic exercise promotes in participants, it is imperative (especially with
regard to the participants’ physiological and functional concerns) that such community-based
exercise programs are designed, implemented, and evaluated. The development of physical
exercise programs in Primary Health Care in Health Units throughout Brazil is a good
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strategy to improve cardiorespiratory fitness of the users of the lower income populations in
terms of low socioeconomic status and schooling.
CONCLUSIONS
The physical exercise program carried out in Health Units was effective in promoting an
improvement in variables related to cardiorespiratory fitness. The significant increase of final
time and stage indicates that the participants developed a greater exercise tolerance.
Moreover, the decrease obtained in energy cost reflects an economy of movement during
walking. The participants were able to expend less physical effort for the same intensity of
exercise. These improvements should have a positive impact on the daily physical activities
and quality of life of the participants.
ACKNOWLEDGMENTS
The authors thank CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior,
in Portuguese), Brazil.
Address for correspondence: Camila B. Papini, PhD, Science Sport Departament, Federal
University of Triangulo Mineiro - Av. Getúlio Guarita, 159, Nossa Senhora da Abadia,
Uberaba City, Minas Gerais, zip-code 38.025-440, Email: [email protected]
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