
==== Front
Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)12231-1
10.1016/j.heliyon.2024.e36200
e36200
Research Article
Multicomponent versus aerobic exercise intervention: Effects on hemodynamic, physical fitness and quality of life in adult and elderly cardiovascular disease patients: A randomized controlled study
Poli Luca a
Greco Gianpiero gianpiero.greco@uniba.it
a⁎
Cataldi Stefania stefania.cataldi@uniba.it
a⁎⁎
Ciccone Marco Matteo b
De Giosa Annamaria c
Fischetti Francesco a
a Department of Translational Biomedicine and Neuroscience (DiBraiN), University of Study of Bari, 70124, Bari, Italy
b Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Study of Bari, 70124, Bari, Italy
c ASL BA, Azienda Sanitaria Locale, 70132, Bari, Italy
⁎ Corresponding author. gianpiero.greco@uniba.it
⁎⁎ Corresponding author. stefania.cataldi@uniba.it
13 8 2024
30 8 2024
13 8 2024
10 16 e3620028 3 2024
1 8 2024
12 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Objective

Cardiovascular diseases (CVDs) remain a leading cause of mortality globally, emphasizing the need for effective preventive measures. This study aimed to investigate the effects of a multicomponent compared to an aerobic training program on the hemodynamic parameters, physical fitness, psychophysical health status and quality of life (QoL) of adults and elderly with stabilized CVDs.

Methods

Thirty-three subjects (19M and 14F; age 69.5 ± 4.9 years; BMI 27.34 ± 4.95 kg/m2) suffering from CVDs voluntarily participated in this 10-week randomized controlled study and were allocated into three groups: multicomponent training group (MTG; 6M, 6F; cardiorespiratory, resistance, flexibility and breathing exercises; 60′, 2d·wk-1), aerobic training group (ATG; 7M, 5F; aerobic-only training; 60′, 2d·wk-1) or a wait-list control group (CG; 6M, 3F; no PA). Hemodynamic parameters were assessed through resting hearth rate (RHR) and peripheral-systolic and diastolic blood pressure (P-SBP/P-DBP). Physical fitness was assessed via a 30” chair stand test (30CST), timed up and go (TUG) test, handgrip strength (HGS) test, and 2’ step test (TMST). The health status, QoL and enjoyment were evaluated with short form-12 (SF-12), world health organization quality of life-bref (WHOQoL-bref) and physical activity enjoyment scale (PACES), respectively.

Results

After the intervention, MTG showed significant improvements in hemodynamic parameters (95 % CI, RHR: 2.76 to 9.07; P-SBP: 3.28 to 13.71; P-DBP: 3.56 to 8.94; p < 0.001), physical fitness (95 % CI, 30CST: 4.42 to −1.90; TUG: 0.56 to 1.58; TMST: 35.24 to −18.58; Dominant HGS: 4.00 to −1.65; Undominant HGS: 2.87 to −0.79, p < 0.001) and enjoyment (PACES: 15.18 to −5.48, p < 0.001) compared to CG; ATG showed significant improvement in hemodynamic parameters (95 % CI, RHR: 1.76 to 8.07; P-SBP: 3.19 to 13.63; P-DBP: 4.47 to 9.85, p < 0.001), physical fitness (95 % CI, 30CST: 2.59 to −0.07; TUG: 0.03 to 1.05; Dominant HGS: 2.42 to −0.07, p < 0.05; TMST: 36.08 to −19.41, p < 0.001) and enjoyment (PACES: 14.68 to −4.98, p < 0.001) compared to CG. No significant changes were observed in QoL and SF-12 (p > 0.05). Significant differences between MTG and ATG were only found in physical fitness variables (95 % CI, 30CST: 3.21 to −0.45, p < 0.01; Dominant HGS: 0.00 to 3.00, p < 0.05).

Conclusions

Findings showed significant improvements in hemodynamic parameters and physical fitness suggesting the effectiveness of the multicomponent exercise program, similar to aerobic-only training, and greater efficacy for lower limb strength and dominant hand grip strength in adults and elderly with stabilized CVDs. Both exercise groups showed similar levels of enjoyment.

Keywords

Blood pressure
Physical activity
Resistance training
Aerobic training
Flexibility
Health status
==== Body
pmc1 Introduction

Cardiovascular diseases (CVDs) continue to pose a significant global health challenge, contributing substantially to morbidity and mortality rates. The prevalence of CVDs is consistently increasing, exerting a profound impact on individuals' physical well-being and quality of life (QoL) [1,2]. Effective management of CVDs requires multifaceted interventions addressing both the physiological and psychosocial dimensions of the disease [3].

Risk factors such as obesity, high blood pressure, hypercholesterolemia, ageing, and physical inactivity can predispose individuals to CVDs [[4], [5], [6]]. Physical activity has emerged as a pivotal therapeutic strategy in the management and prevention of CVDs, contributing to enhanced cardiovascular function, physical fitness, and overall QoL [7]. Furthermore, physical activity has been demonstrated to improve cardiovascular fitness, mitigate the risk of cardiovascular events, and improve various health outcomes in individuals with CVDs, irrespective of weight loss [[8], [9], [10], [11]].

CVDs encompass a range of conditions that affect the heart and blood vessels, including the most common hypertension, valvular heart disease, aortic valve disease, atrial fibrillation, and previous myocardial infarction. These conditions represent significant health challenges, often requiring a combination of medical treatments and lifestyle adjustments to manage effectively.

Hypertension is a prevalent yet often silent condition that can lead to severe complications if left untreated. Effective management involves lifestyle modifications such as adopting a heart-healthy diet, engaging in regular physical activity, maintaining a healthy weight, reducing alcohol and caffeine intake, quitting smoking, and managing stress, along with pharmacological treatment. These changes not only help control blood pressure but also contribute to overall cardiovascular health. Valvular heart disease, which includes dysfunctions such as stenosis or regurgitation of heart valves, presents with symptoms like shortness of breath, fatigue, and palpitations. Lifestyle management plays a crucial role in mitigating symptoms and preventing disease progression. Regular exercise, a balanced diet, smoking cessation, and weight management are essential components of care, alongside medical treatments and potential surgical interventions [12]. Aortic valve disease, involving conditions like aortic stenosis and regurgitation, can gradually lead to heart failure if unmanaged. While medications and surgical options are pivotal, lifestyle modifications are equally important. Patients are encouraged to maintain a physically active lifestyle, follow dietary recommendations, and avoid smoking, which collectively improve heart function and delay disease progression [13]. Also, atrial fibrillation, characterized by an irregular heartbeat, increases the risk of stroke and other complications. Managing atrial fibrillation effectively requires a combination of medications and lifestyle changes. Adopting a heart-healthy diet, engaging in regular physical activity, and avoiding excessive alcohol and caffeine intake are key strategies. Additionally, smoking cessation is critical in reducing the overall cardiovascular risk [14]. Finally, for individuals with a history of myocardial infarction, lifestyle management is vital in preventing recurrent heart attacks and promoting recovery. Cardiac rehabilitation programs, which include supervised exercise, nutritional counselling, and stress management, are integral to comprehensive care. Emphasizing a heart-healthy diet, regular physical activity, smoking cessation, and weight management can significantly enhance quality of life and reduce the risk of further cardiovascular events [[15], [16], [17]].

Exercise training, particularly aerobic and resistance exercises, has garnered attention as a non-pharmacological approach to managing CVDs. Research consistently indicates that aerobic training enhances exercise tolerance, reduces resting heart rate (RHR), and improves vascular function in individuals with CVDs [[18], [19], [20], [21]]. Moreover, aerobic exercise positively influences lipid profiles, glucose metabolism, and body composition, thereby contributing to the overall management of CVD risk factors [22,23]. Resistance training has been shown to improve muscle function, skeletal muscle mass, and insulin sensitivity, potentially leading to improved daily physical activities and reduced frailty, thereby supporting cardiovascular health [[24], [25], [26]]. Additionally, it may positively impact blood pressure regulation and endothelial function [5,27]. While aerobic exercise has long been championed for its cardiovascular benefits, recent research underscores the significance of strength training in mitigating CVDs risk factors and improving overall cardiovascular health [28]. Strength training, which can be included within so called resistance training, can improve muscular strength and endurance by exerting muscles against external resistance. This form of exercise has been associated with numerous cardiovascular benefits, including improved heart function, enhanced vascular health, and favorable modulation of traditional cardiovascular risk factors such as hypertension, dyslipidemia, and insulin resistance [29,30]. The underlying mechanisms by which strength training exerts its cardiovascular benefits are multifaceted. Physiologically, it enhances muscle mass and strength, which in turn improves glucose metabolism and insulin sensitivity, both critical factors in the management of type 2 diabetes and metabolic syndrome, conditions frequently comorbid with CVDs. Furthermore, strength training promotes favorable changes in body composition, reducing visceral fat, a key player in the development of atherosclerosis. The hemodynamic adaptations to resistance training, including reductions in resting blood pressure and improvements in arterial stiffness, further contribute to cardiovascular health [31]. Beyond its direct physiological effects, strength training also positively influences psychological well-being, reducing stress and anxiety levels, which are known contributors to cardiovascular risk [32]. Similarly, balance training can improve autonomic regulation, muscle strength, and coordination, contributing to better heart rate variability, functional capacity, and reduced fall risk. These improvements can enhance overall cardiovascular health and patient outcomes [33,34]. While exercise is generally beneficial, careful consideration of individualized exercise prescriptions is essential in individuals with CVDs. Close medical supervision, appropriate exercise intensity, and gradual progression are crucial to ensure safety and optimize outcomes. Pre-existing health conditions, medication regimens, and individual fitness levels should be considered when designing exercise programs.

The compromised blood flow and oxygen delivery associated with CVDs can affect the structural integrity and functional capacity of muscles, tendons, and ligaments supporting joint flexibility. Reduced oxygen supply may lead to tissue fibrosis, collagen cross-linking, and increased muscle stiffness, all contributing to limited joint flexibility and range of motion (ROM) [35]. Flexibility training can enhance joint and muscle range of motion, potentially improving functional capacity and quality of life for CVD patients. Flexibility training positively impacts the underlying mechanisms of CVDs, such as reducing arterial stiffness, improving endothelial function, and modulating autonomic balance. These physiological changes can enhance vascular health and lower cardiovascular risk [36]. Additionally, flexibility exercises are low impact, making them suitable for CVD patients who might struggle with more intense activities. Furthermore, chronic inflammation characteristic of CVDs can promote joint inflammation, further compromising flexibility [35]. Stretching exercises have been shown to reduce arterial stiffness and improve endothelial function [35,[37], [38], [39]].

The multifaceted nature of CVDs warrants a holistic approach to exercise prescription. Multicomponent training (MCT) protocols target multiple aspects of physical fitness, addressing not only cardiovascular endurance but also muscular strength, flexibility, and balance [40]. These components collectively contribute to enhanced functional capacity, reduced risk of falls, and improved QoL [40]. MCT program has been proposed as a possible physical exercise program design, recently [41]. Because it can incorporate various exercise modalities (such as aerobic, resistance, flexibility, and balance) into a single exercise session or routine, this type of exercise is appealing reducing the need for lengthy sessions while enhancing a variety of physical abilities and skills [41]. This MCT feature is crucial since CVDs patients tend to shy away from time-consuming physical exercise regimens, which may contribute to this population's low treatment adherence [42]. Few research have been done to far on how MCT affect older adults with CVDs [43]. It is important to note, for example, that De Moraes et al.'s findings [43] indicate that the reduction in response to the physical stimulus is inversely correlated with blood pressure levels prior to the start of the MCT. This suggests that volunteers with uncontrolled high blood pressure may exhibit greater drops in blood pressure values than those with controlled blood pressure. MCT appears to offer the most comprehensive benefits for CVDs patients. Preliminary studies have shown that this protocol can significantly reduce peripheral and central blood pressure, increase cardiorespiratory fitness, improve muscle strength, and enhance lean body mass [44]. It also leads to improvements in aerobic capacity, functional capacity, and QoL [45]. Moreover, MCT has demonstrated favorable effects on both physiological parameters, such as muscle strength, and biochemical markers, including lipid profiles and inflammation status [46]. Regular participation in MCT programs has been associated with increased oxygen transportation system capacity and physical working capacity in chronic heart disease patients [47].

However, the holistic impact of integrating these exercise modes into a unified multicomponent training protocol in CVDs field remains poorly explored. The effects of integrating multiple exercise modalities into an MCT for CVDs remain poorly understood. It is yet unclear whether this protocol can be more effective and safer than an aerobic training-only protocol in improving physiological and psychological parameters in subjects with stabilized CVDs. It has been demonstrated that regular physical activity enhances overall health in middle-aged, inactive individuals. Finding the most efficient and least time-consuming exercise training is crucial because most individuals do not have much time or willingness for it [48]. Furthermore, many studies on multicomponent exercise training lack well-controlled randomized trials or do not include an aerobic-only group [49] or a real non-treatment control group, which instead receives a lifestyle education sessions and diet information before beginning [44]. As a result, it's unclear if the benefits of multicomponent exercise stem from the individual additive benefits of each aerobic and resistance exercise or from the extra exercise duration.

Therefore, this study aimed to investigate the effects of a MCT versus an aerobic-only training program on the hemodynamic parameters, physical fitness, psychophysical health status and QoL of adults and elderly with stabilized CVDs. Also, we aimed to assess the enjoyment of different training protocols. It was hypothesized that the MCT group would experience greater improvements in hemodynamic parameters, cardiovascular fitness, muscular strength, flexibility, psychophysical health status and overall QoL compared to the aerobic training and control group. The MCT, as an integrated and varied protocol should, in addition, increase enjoyment of the program contributing to the most favorable outcomes.

2 Materials & methods

2.1 Participants and study design

This study used a randomized controlled study design conducted over 10-week period in a non-clinical setting, to compare two experimental groups and a waitlist control group at the pre- and post-intervention on all measured dependent variables. Eligible patients are randomly assigned to one of the three groups: Multicomponent training group (MTG), Aerobic training group (ATG) or no exercise wait-list control group (CG).

A computer-generated random number sequence, using an online Random Allocation Software (randomizer.org), was used to allocate participants to either the MTG, ATG or CG. Block randomization with varying block sizes was employed to ensure balanced group sizes. The allocation sequence was generated by an independent statistician not involved in participant recruitment or intervention delivery.

Participant enrollment was conducted by trained research assistants who screened potential participants, obtained informed consent, and collected baseline data. These assistants were blinded to the allocation sequence.

After completing enrollment and baseline assessments, participants were assigned to interventions using sequentially numbered, opaque, sealed envelopes containing group assignments. A research coordinator not involved in direct participant care or data collection opened the envelopes and communicated assignments to the intervention team. This process-maintained allocation concealment and reduced the risk of selection bias.

The intervention team, responsible for delivering the exercise protocols, was necessarily aware of group assignments but was instructed not to disclose this information to other study personnel or participants when possible.

This study did not involve human individuals from a clinical or therapeutic point of view. The procedures followed were in accordance with the ethical standards of the Helsinki Declaration and approved by the Ethics Committee of Bari University (protocol code 0030611|28/03/23).

Participants were recruited through the volunteer organization "Amici di Cuore" based in Bari (Italy) and a preliminary medical examination was performed before the start of the study (November 2023). The participants were diagnosed by board-certified cardiologists with extensive experience in cardiovascular medicine. Each cardiologist holds an MD degree with specialization in cardiology and has over 10 years of clinical practice, including diagnosing and managing various cardiovascular conditions. Their qualifications and experience ensure the accuracy and reliability of the diagnoses provided for the study. After consent from the corresponding cardiologist, participants were considered eligible based on the following inclusion criteria: age between 45 and 80 years, absence of serious medical conditions (unstable coronary heart disease, decompensated heart failure, severe pulmonary hypertension) or acute onset that would prevent safe participation in physical activity according to American College of Sports Medicine (ACSM), American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines [[50], [51], [52], [53]]; presence of stabilized CVDs; sedentary lifestyle, subjects who have not followed the WHO guidelines for aerobic and resistance exercise in the last 3 months [54]. Additionally, participants were excluded based on the following criteria: smoking; anticipated absence of more than one week during the intervention period; lack of sports suitability confirmed by a cardiologist; presence of joint pain, dizziness, chest pain or angina during physical exercise; high peripheric blood pressure: PBP ≥160/100.

An a priori power analysis [55] with an assumed type I error of 0.05 and a type II error rate of 0.20 (80 % statistical power) has calculated that 10 participants per group would be sufficient to observe moderate “Time x Group” interaction effects. However, thirty-three participants (19 males and 14 females, 69.5 ± 4.9 years) among those that have been contacted (n = 39; 21 males, 18 females) met all the above-mentioned eligibility criteria. The participants were allocated into three groups: MTG (n = 12, 6 males and 6 females) who underwent progressive multicomponent training (60 min, 2d·wk-1), ATG (n = 12, 7 males and 5 females) who underwent progressive aerobic-only training (60 min, 2d·wk-1) or a wait-list CG (n = 9, 6 males and 3 females) who did not engage in any structured physical activity during the intervention period. Among the CVDs diagnosed are included: hypertension (ICD-11, BA00.0) (n = 24), valvular heart disease (ICD-11, BA60) (n = 2), aortic valve disease (ICD-11, BA62) (n = 2), atrial fibrillation (ICD-11, BA81.0) (n = 1) and previous myocardial infarction (ICD-11, BA41) (n = 4). All participants were advised to maintain all their prescribed medications during the intervention, although we do not have assessed the medical treatment compliance rate. None of the participants followed a specific food plan. The study was carried out between the months of November 2023 and January 2024. All participants completed the study, no drop-out or adverse effects were observed. Adherence rate for the MTG was 92.92 %, for the ATG was 91.25 %. Fig. 1 shows the eligibility assessment of the participants.Fig. 1 Study flow diagram.

Fig. 1

2.2 Testing procedures

Data were collected and recorded at week 1 (Baseline) and after week 10 (Post-test), in the same place, in a climate-controlled (22–23 °C) room with relative air humidity of 40–60 % always in the morning to minimize circadian cycle effects. First, the anthropometric measurements were collected. Body height (in cm to the nearest 0.1 cm) was measured using a SECA® stadiometer, and body mass (in kg to the nearest 0.1 kg) was measured using a SECA® digital scale (0–200 kg, accuracy of 0.1 kg). The subjects were barefooted and wore light clothing during the measurements. Body mass index (BMI) was calculated as body weight (kg) divided by the square of body height (m2).

Second, resting heart rate (RHR) and peripheral blood pressure (systolic blood pressure: P-SBP; diastolic blood pressure: P-DBP) were measured, by medical staff, using the Sphygmocor XCEL (AtCor Medical, Itasca, IL, USA) automated oscillometric device. After a 5-min rest, a blood pressure cuff was applied to the participant's left arm, positioned over the brachial artery, while they were seated. The device took three consecutive measurements of brachial pressure, with a 2-min break between each reading. The average of the measurements taken was adopted.

Finally, the following measures were collected: (1) Physical Fitness: 30-s chair stand (30CST) test, Timed Up and Go (TUG) Test, Handgrip Strength (HGS) test and 2-Minute Step Test (TMST); (2) Psychological: Short Form Survey (SF-12), World Health Organization Quality of Life – Bref (WHOQoL-BREF) and Physical Activity Enjoyment Scale (PACES). In order to prevent the previous test from influencing the result of the next one, 5 min of rest was guaranteed between one motor test and the next. Psychological tests were administered under the supervision of a psychologist from the team two consecutively days before the motor tests, to avoid possible interferences. All participants were trained in a sporting club (Angiulli Gymnastics Club, Bari, Italy). One week before the pre-test, two familiarization sessions were held. Initial and ﬁnal test measurements were made at the same time of day and under the same experimental and treatment conditions. All measurements were performed and supervised by the same Adapted Physical Activity (APA) specialists, professional who focuses on modifying and adapting physical activities, exercises, and sports to meet the needs of individuals with disabilities, chronic conditions, or other special needs.

2.2.1 30-S chair stand (30CST) test

This test is one of the most important functional evaluation clinical tests because it measures lower body strength and relates it to the most demanding daily life activities (e.g., climbing stairs, getting out of a chair or bathtub or rising from a horizontal position) [56]. It is also able to assess functional fitness levels and the fatigue effect caused by the number of sit-to-stand repetitions (ICC = 0.95). It consists of standing up and sitting down from a chair as many times as possible (n) within 30 s. A standard chair (with a seat height of 42 cm) without armrests was used. Initially, the participants were seated on the chair with their back in an upright position. They were instructed to look straight forward and to rise after the “1, 2, 3, go” command at their preferred speed with their arms folded across their chest [57].

2.2.2 Timed up and go (TUG) test

This test is the one most used to assess the mobility of subjects. It assesses several aspects related to mobility such as static/dynamic balance and gait speed, along with lower limb strength. TUG results are predictors of several outcomes (i.e., falls, frailty, QoL and difficulty in performing daily activities) [[58], [59], [60], [61]]. Furthermore, it appears to be the best test of physical function in the prediction of cardiovascular disease in older adults [62] and the reliability of the test was found to be very high (ICC = 0.90) [63]. Subjects wear their regular footwear and can use a walking aid if needed (no one used it). Begin by having the patient sit back in a standard chair (height of 42 cm) with armrests and identify a line 3 m on the floor. Subjects were instructed to stand up from the chair, at the signal, and walk towards the line, at a self-selected speed, turn, walk towards the chair, and sit down again. At the go signal, timing starts and ends (s) when the subject sits back down [64].

2.2.3 Handgrip strenght (HGS) test

The handgrip strength test is a practical and validated instrument for assessing the maximum voluntary strength of the extrinsic and intrinsic muscles of the hand. Its results are an indicator of clinical conditions such as sarcopenia and correlate with general muscle strength (ICC dominant = 0.97; ICC undominant = 0.98). It may be a predictor of the incidence of chronic diseases, independence in daily life and nutritional status [65]. Grip strength was measured with a mechanic Smedley hand dynamometer (GIMA, Milan, Italy). The participants were positioned sitting in a straight-backed chair with feet on the floor, shoulder adducted with 0° flexion, elbow flexed to 90° and forearm in a neutral position; participants were instructed to hold the dynamometer and squeeze it as hard as possible for 5 s. The measurement was performed three times with an interval of 30 s between measurements and 60 s before evaluating the other hand. The mean of the two measurements, expressed in kilograms (Kg), was used for the analysis.

2.2.4 2-Minute Step Test (TMST)

The TMST aims to assess subjective aerobic capacity, a fundamental component of physical fitness (ICC = 0.90) [66]. Subjects standing near a wall measured the height of the iliac crest and the patella and placed a marker on the wall halfway between the two. At the starting signal, the subjects began stepping in place by raising their knees to the height of the mark on the wall, as many times as possible during the 2 min. The number of times the right knee reaches the mark represents the test score (n).

2.2.5 Short Form Survey (SF-12)

The SF-12 is a shortened version questionnaire of SF-36, consisting of 12 items assessing physical (PCS-12) and mental (MCS-12) health [67,68]. Designed as a general measure of health it can be used with the general population (Cronbach's α = 0.91). It comprises eight domains such as physical function, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. PCS and MCS were computed using the scores of 12 questions ranging from 0 to 100, where zero indicates the lowest level of health and 100 indicates the highest level of health.

2.2.6 World health organization quality of life – bref (WHOQoL-BREF)

The WHOQoL-BREF is a questionnaire, developed as a short version of the WHOQOL-100, available in multiple languages and in this study, the Italian version was used to assess the quality of life [69]. This self-administered questionnaire presents 26 items concerning the perception of individual health and well-being over the past two weeks. Scored in four domains: Domain 1: Physical health (Cronbach's α = 0.80), Domain 2: Psychological well-being (Cronbach's α = 0.75), Domain 3: Social relations (Cronbach's α = 0.65) and Domain 4: Environment health (Cronbach's α = 0.73) with all facet items scored as part of their hypothesized domain [70]. Zero points represent the worst possible state of health, while 100 points represent the best possible state of health with regard to the respective domain.

2.2.7 Physical ACtivity enjoyment scale (PACES)

The Physical Activity Enjoyment Scale (PACES) is a questionnaire utilized to evaluate an individual's subjective enjoyment of physical activity [71,72]. Comprising 16 items rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), the PACES includes nine positively framed items (e.g., "it energizes me") and seven negatively framed items (e.g., "it's boring") (with a Cronbach's alpha ranging from 0.78 to 0.89) [73]. This tool evaluates multiple aspects of enjoyment, such as positive affect, psychological engagement, and overall satisfaction with the activity [74,75]. Widely employed in research, the PACES aids in comprehending individuals' perceptions and attitudes toward physical activity, shedding light on motivational factors influencing exercise behavior. The PACES is typically administered to participants after each session.

2.3 Exercise intervention

Before starting the training session, blood pressure and resting heart rate were measured. For patient safety, the exercise session was only performed if P-SBP was between 110 and 180 mmHg and/or P-DBP between 50 and 100 mmHg and, also, resting heart rate between 50 and 100 bpm. Sessions were performed within two small groups. These groups were closely supervised by APA specialists. To monitor and adjust the training intensity (internal load) as the sessions progressed, the Borg Rating of Perceived Exertion (RPE) scale (6–20) [76] was employed at the end of each set of aerobic and resistance exercises, to adjust the load in Borg = 13 to 15 points [51], considering that the higher the number chosen, the more intense the exercise session was. The participants were prior familiarized with the scale.

The 10-week study period followed the initial data collection, with the MTG and ATG performing an intervention program consisting of twice-per-week (Monday and Wednesday) exercise sessions lasting 60 min each, usually performed from 3:30 p.m. to 4:30 p.m. Every single exercise session included an initial phase of muscle activation through a 10-min warm-up (brisk walk) to increase heart rate, improve muscle blood flow, and prepare the main joints for the subsequent work phase, a 40-min main exercise period and a 10-min cooldown period (breathing and stretching exercises).

2.3.1 Multicomponent training

During the main exercise period, cardiorespiratory training consisted of progressive aerobic exercises: controlled and rhythmic jumping jacks, step-ups on a sturdy platform (such as a low step or a stable surface), standing knee raises (alternating legs), brisk side steps or lateral leg raises. The exercises were performed at an intensity ensuring that the perceived exertion (RPE) stayed between 13 and 15 points on the Borg Scale (6–20). Finally, conclude with 3 min of light walking to facilitate recovery for the next phase of training. The main goal of this phase was to maintain a consistent exercise duration of ∼15 min while gradually intensifying the exercise stimuli.

Flexibility training consisted of specific exercises (thoracic extensions, cat to cows, overhead reach with stick and hips active internal rotation) targeting the main joint, performed maximally (1–3 sets) but avoiding pain. Duration was gradually increased from 30 to 60 s per repetition, repeating one to three times, before the threshold of pain. Participants were provided with rest intervals of 30–60 s between sets and exercises.

Resistance training consisted of exercises targeting various muscle groups: quadriceps (seated leg extension with anklet weight/half squat with chair), biceps brachii (unilateral curl with dumbbell), shoulder (shoulder press with dumbbell), triceps brachii (French press with dumbbell), pectoralis major (dumbbell chest press/dumbbell flyes), latissimus dorsi (dumbbell rows). The resistance training program adhered to the principle of gradually progressive load. Initially, participants performed a set of 10–15 repetitions, which progressed to three sets of 10–15 repetitions. Adjustments to the load were made to ensure that the perceived exertion (RPE) stayed between 13 and 15 points on the Borg Scale (6–20). Throughout the protocol, participants were provided with rest intervals of 60–120 s between sets and exercises to promote recovery. To prevent premature muscle fatigue, the exercises were carried out using an alternating training method based on muscle groups (upper muscle exercises were performed on Monday, and lower muscle exercises were performed on Wednesday). To avoid breath holding and any compromise in circulatory the significance of correct breathing was underscored.

The Cool down period consisted of breathing and stretching exercises. Stretching was performed maximally on all major muscle groups (1–3 sets per muscle group) avoiding joint pain. Duration was gradual from 10 to 30 s per stretch, repeating one to three times for a total of 60 s per stretch.

2.3.2 Aerobic training

During the main exercise period, lasting 40 min, aerobic training consisted of 25 min of progressive aerobic exercises: controlled and rhythmic jumping jacks, step-ups on a sturdy platform (such as a low step or a stable surface), standing knee raises (alternating legs), brisk side steps or lateral leg raises. Followed by 15 min of walking. The exercises were performed at an intensity ensuring that the perceived exertion (RPE) stayed between 13 and 15 points on the Borg Scale (6–20). Progression over the weeks will be given by maintaining the intensity in this range. The main goal of this phase was to maintain a consistent exercise duration while gradually intensifying the exercise.

The Cool down period consisted of breathing and stretching exercises. Stretching was performed maximally on all major muscle groups (1–3 sets per muscle group) avoiding joint pain. Duration was gradual from 10 to 30 s per stretch, repeating one to three times for a total of 60 s per stretch.

2.3.3 Statistical analysis

All statistical analyses were conducted using the JASP software v. 0.17.2.1 [77]. The Shapiro–Wilk test was used to test the normality of all variables. Levene's test was used to check the homogeneity of variances between groups. One-way ANOVA was used to compare at pre-test the anthropometric characteristics and all outcome measures between the three groups and to compare their pre-post differences. For a non-normal distribution of the dependent variables, the non-parametric Kruskal-Wallis's test was performed. In case of statistical significance, Tukey-Kramer (parametric) or Steel-Dwass (non-parametric) post hoc tests were performed.

A two-way ANOVA (group (Multicomponent/Aerobic/control) × time (pre/post-intervention)) with repeated measures was conducted to examine the effects of the intervention on all dependent variables. When ‘Time x Group’ interactions reached the level of significance, group-specific post hoc tests (i.e., Tukey's test) were conducted to identify the significant comparisons.

Eta squared (η2) for the non-parametric Steel-Dwass post hoc test and partial eta squared (η2p) for the two-way ANOVA were used to estimate the magnitude of the difference within each group and interpreted using the following criteria: small (η2p < 0.06), medium (0.06 ≤ η2p < 0.14), and large (η2p ≥ 0.14) effect size (ES). The ES for Tukey-Kramer post hoc pairwise comparisons was determined by Cohen's d, calculated as post-training mean minus pre-training mean divided by pooled SD before and after training and interpreted as small (0.20 ≤ d < 0.50), moderate (0.50 ≤ d < 0.79) and large (d ≥ 0.80) ES [78].

The statistical significance was set a priori at p ≤ 0.05.

3 Results

All the MTG and ATG participants completed the intervention, and no adverse effects were detected over the ten weeks. Table 1 shows the descriptive data of the study participants.Table 1 Characteristics at baseline of study participants.

Table 1	All Participants (n = 33)	Multicomponent Group (n = 12)	Aerobic Group (n = 12)	Control group (n = 9)	
Men, n	19 (57 %)	6 (50 %)	7 (59 %)	6 (66.6 %)	
Age (years)	69.57 (±4.91)	69.33 (±4.59)	68.91 (±4.35)	70.77 (±6.24)	
Height (m)	1.67 (±6.95)	1.66 (±7.28)	1.70 (±7.69)	1.66 (±4.83)	
Weight (kg)	76.76 (±15.23)	70.78 (±15.92)	82.40 (±9.50)	77.20 (±18.80)	
BMI (kg/m2)	27.34 (±4.95)	25.71 (±5.53)	28.55 (±3.11)	27.88 (±6.01)	
Note: data are expressed as mean (±SD). Abbreviations: BMI, Body Mass Index.

No statistically significant difference was found between the groups at pre-test about age, anthropometric characteristics, and all outcome measures (p > 0.05).

3.1 Hemodynamic parameters

A two-way ANOVA with repeated measures found significant ‘Time x Group’ interaction effects in: RHR (F = 11.323, p < 0.001, η2p = 0.43, large ES), P-SBP (F = 8.072, p = 0.002, η2p = 0.35, large ES), P-DBP (F = 20.521, p < 0.001, η2p = 0.57, large ES).

In the MTG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for RHR (95 % CI, 2.76 to 9.07) (t = 5.977, p < 0.001, d = 1.02, large ES), P-SBP (95 % CI, 3.28 to 13.71) (t = 5.194, p < 0.001, d = 0.88, large ES), P-DBP (95 % CI, 3.56 to 8.94) (t = 7.410, p < 0.001, d = 1.12, large ES).

In the ATG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for RHR (95 % CI, 1.76 to 8.07) (t = 4.967, p < 0.001, d = 0.85, large ES), P-SBP (95 % CI, 3.19 to 13.63) (t = 5.143, p < 0.001, d = 0.87, large ES), P-DBP (95 % CI, 4.47 to 9.85) (t = 8.496, p < 0.001, d = 1.28, large ES). No significant changes were found in the CG (p > 0.05).

3.2 Physical fitness parameters

A two-way ANOVA with repeated measures found significant ‘Time x Group’ interaction effects in 30CST (F = 27.749, p < 0.001, η2p = 0.64, large ES), TUG (F = 16.158, p < 0.001, η2p = 0.51, large ES), TMST (F = 39.255, p < 0.001, η2p = 0.72, large ES), (D)HGS (F = 12.121, p < 0.001, η2p = 0.44, large ES), (U)HGS (F = 11.479, p < 0.001, η2p = 0.43, large ES);

In the MTG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for 30CST (95 % CI, −4.42 to −1.90) (t = −8.005, p < 0.01, d = 1.59, large ES), TUG (95 % CI, 0.56 to 1.58) (t = 6.705, p < 0.001, d = 0.73, moderate ES), TMST (95 % CI, −35.24 to −18.58) (t = −10.303, p < 0.001, d = 2.20, large ES), (D)HGS (95 % CI, −4.00 to −1.65) (t = −7.695, p < 0.001, d = −0.37, small ES), (U)HGS (95 % CI, −2.87 to −0.79) (t = −5.602, p < 0.001, d = −0.22, small ES).

In the ATG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for 30CST (95 % CI, −2.59 to −0.07) (t = −3.371, p < 0.05, d = 0.67, moderate ES), TUG (95 % CI, 0.03 to 1.05) (t = 3.423, p < 0.05, d = 0.37, small ES), TMST (95 % CI, −36.08 to −19.41) (t = −10.622, p < 0.001, d = 2.27, large ES), (D)HGS (95 % CI, −2.42 to −0.07) (t = −3.395, p < 0.05, d = −0.16, small ES). No significant changes were found in the CG (p > 0.05).

3.3 Psychological parameters

A two-way ANOVA with repeated measures found significant ‘Time x Group’ interaction effects only in the PACES score (F = 13.949, p < 0.001, η2p = 0.48, large ES). No significant interaction was observed in the QoL and both components of SF-12 (p > 0.05).

In the MTG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for PACES (95 % CI, −15.18 to −5.48) (t = −6.798, p < 0.001, d = 1.61, large ES).

In the ATG, the post-hoc analyses revealed a significant improvement in the score from pre-to post-intervention for PACES (95 % CI, −14.68 to −4.98) (t = −6.469, p < 0.001, d = 1.53, large ES). No significant changes were found in the CG (p > 0.05).

3.4 Multicomponent versus aerobic exercise intervention

A comparison between the pre- and post-intervention differences of the groups was performed to evaluate the most effective training method.

For variables with a normal distribution, a one-way ANOVA was performed to compare the pre-post differences between the three groups. For 30CST, a significant difference was found between the groups (F = 27.749, p < 0.001, η2 = 0.649, large ES) and the Tukey-Kramer post-hoc test revealed a significant difference between MTG and ATG (95 % CI, −3.21 to −0.45) (t = −3.277, p < 0.01, d = 1.34, large ES).

For variables with a non-normal distribution, the non-parametric Kruskal-Wallis's test was performed to compare the pre-post differences between the three groups. For (D)HGS, a significant difference was found between the groups (H = 15.344, p < 0.001, η2 = 0.48, large ES) and the Steel-Dwass post-hoc test revealed a significant difference between MTG and ATG (95 % CI, 0.00 to 3.00) (Z = 2.427, p < 0.05, η2 = 0.08, moderate ES).

No significant differences were found between MTG and ATG for all other dependent variables (p > 0.05).

Pre- and post-intervention outcomes for all the variables considered and the statistical analysis results are shown in Table 2.Table 2 Changes after 10 weeks for all the dependent variables.

Table 2	Multicomponent Training Group (n = 12)	Aerobic Training Group (n = 12)	Control Group (n = 9)	
Variables	Pre-test	Post-test	Difference	Pre-test	Post-test	Difference	Pre-test	Post-test	Difference	
Absolute	%	Absolute	%	Absolute	%	
Hemodynamic	
Rest HR (bpm)	76.33 (±4.45)	70.41 (±5.36)a	−5.92 (±4.05)	−7.71 (±5.10)	77.33 (±3.02)	72.41 (±4.27)a	−4.92 (±3.80)	−6.32 (±4.73)	75.22 (±8.55)	76.11 (±8.52)	0.89 (±1.26)	1.21 (±1.78)	
P-SBP (mmHg)	135.50 (±10.80)	127.00 (±6.32)a	−8.5 (±7.93)	−5.98 (±5.02)	135.50 (±10.12)	127.08 (±12.74)a	−8.42 (±4.88)	−6.33 (±3.92)	132.77 (±7.48)	133.22 (±7.44)	0.45 (±1.01)	0.33 (±0.73)	
P-DBP (mmHg)	86.33 (±6.49)	80.08 (±5.41)a	−6.25 (±3.16)	−7.13 (±3.49)	85.75 (±4.53)	78.58 (±5.03)a	−7,17 (±3.58)	−8.33 (±4.06)	81.33 (±6.20)	81.88 (±5.68)	0.55 (±0.72)	0.73 (±0.98)	
Physical fitness	
30CST (n)	10.83 (±1.94)	14.00 (±2.55)a	3.17 (±1.58)b	29.71 (±16.18)	10.58 (±1.88)	11.91 (±1.50)a	1.33 (±1.07)b	14.49 (±14.47)	11.88 (±2.36)	10.55 (±1.33)	−1.33 (±1.41)	−9.72 (±9.58)	
TUG (s)	9.18 (±1.71)	8.11 (±1.37)a	−1.07 (±0.53)	−11.29 (±4.89)	9.83 (±1.21)	9.29 (±1.20)a	−0.54 (±0.55)	−5.47 (±5.59)	7.35 (±1.72)	7.66 (±1.47)	0.31 (±0.56)	5.59 (±10.55)	
(D)HGS (Kg)	31.25 (±6.98)	34.08 (±7.03)a	2.83 (±1.11)b	9.40 (±4.22)	32.83 (±7.18)	34.08 (±7.47)a	1.25 (±1.65)b	3.88 (±5.57)	28.33 (±8.58)	28.44 (±8.32)	0.11 (±0.78)	0.79 (±3.62)	
(U)HGS (Kg)	29.33 (±6.99)	31.16 (±7.09)a	1.83 (±1.02)	6.48 (±4.10)	31.08 (±8.21)	31.75 (±8.00)	0.67 (±1.23)	1.72 (±3.78)	28.22 (±9.61)	27.66 (±9.65)	−0.56 (±1.13)	−2.44 (±3.94)	
TMST (n)	51.25 (±12.41)	78.16 (±13.19)a	26.91 (±9.95)	58.02 (±32.88)	50.83 (±9.68)	78.58 (±9.08)a	27.75 (±9.59)	58.86 (±29.92)	56.66 (±13.85)	52.66 (±15.33)	−4 (±6.65)	7.59 (±14.05)	
Psychological	
SF12 (PCS-12)	48.03 (±8.76)	47.47 (±8.56)	−0.56 (±9.18)	−0.64 (±20.25)	48.26 (±8.45)	47.39 (±9.92)	−0.87 (±6.19)	−1.73 (±13.81)	46.35 (±10.94)	45.59 (±12.13)	−0.76 (±1.38)	−2.50 (±4.78)	
SF12 (MCS-12)	52.73 (±8.51)	51.65 (±7.77)	−1.08 (±9.60)	−0.19 (±22.76)	54.08 (±7.06)	55.56 (±3.49)	1.48 (±7.99)	4.59 (±16.86)	51.91 (±9.78)	50.94 (±9.35)	−0.97 (±2.79)	−1.62 (±4.92)	
WHOQoL (D1)	62.66 (±8.87)	65.33 (±13.33)	2.67 (±9.30)	4.19 (±14.29)	63.16 (±13.59)	65.83 (±12.32)	2.67 (±7.74)	5.86 (±15.51)	73.11 (±19.00)	71.11 (±18.73)	−2 (±7.15)	−2.36 (±8.99)	
WHOQoL (D2)	65.68 (±12.82)	67.83 (±16.04)	2.15 (±9.35)	3.48 (±14.74)	56.91 (±10.83)	62.50 (±13.43)	5.59 (±10.50)	11.23 (±25.77)	66.66 (±12.07)	66.00 (±13.55)	−0.66 (±5.56)	−1.19 (±8.39)	
WHOQoL (D3)	68.75 (±16.49)	75.58 (±13.82)	6.83 (±9.83)	13.39 (±20.44)	62.00 (±13.56)	66.66 (±11.09)	4.66 (±9.43)	10.41 (±19.38)	71.66 (±12.89)	69.66 (±11.75)	−2 (±6.02)	−2.42 (±7.80)	
WHOQoL (D4)	70.08 (±13.38)	68.75 (±15.85)	−1.33 (±8.45)	−1.91 (±12.48)	66.91 (±15.84)	70.50 (±12.58)	3.59 (±10.77)	8.87 (±25.21)	67.55 (±9.12)	65.33 (±9.50)	−2.22 (±4.49)	−3.21 (±6.59)	
PACES	62.25 (±6.36)	72.58 (±5.16)a	10.33 (±5.89)	17.32 (±10.66)	57.50 (±6.58)	67.33 (±6.63)a	9,83 (±6.32)	17.87 (±12.80)	61.11 (±7.13)	60.33 (±6.74)	−0.78 (±1.09)	−1.20 (±1.63)	
Notes. Data are expressed as mean (±SD). Psychological variables are shown in scores. Abbreviations: HR, Heart Rate; P-SBP, peripheral systolic blood pressure; 30CST, 30″ Chair Stand Test; TUG, Timed Up and Go Test, (D)HGS, Dominant Hand Grip strength, (U)HGS, Undominant Hand Grip Strength, TMST, 2 min Step Test; SF12 (PCS-12), Short Form-12 (Physical Component Score-12); SF12 (MCS-12), Short Form-12 (Mental Component Score-12); WHOQoL, World Health Organization quality of Life; PACES, Physical Activity Enjoyment Scale.

a Statistically significant difference within groups from pre-to post-intervention (Tukey-Kramer test, p < 0.05).

b Statistically significant difference between the Multicomponent and Aerobic group (Tukey-Kramer/Steel-Dwass test, p < 0.05).

4 Discussion

This study primarily aimed to investigate the effects of a multicomponent versus an aerobic-only exercise program on the hemodynamic parameters, physical fitness, psychophysical health status and QoL of adults and elderly with stabilized CVDs. Our findings suggests that multicomponent training could be as effective as aerobic training alone and even more effective in improving lower limb strength and dominant handgrip strength. Specifically, MCT revealed significant improvements in peripheral blood pressure (P-SBP and P-DBP) supporting the previously reported results of other combined training protocols in hypertensive subjects [5,79]. Whereas, Schroeder et al. [44] observed a reduction in P-DBP, but not in P-SBP, after 8 weeks of combined exercise training in previously sedentary adults with elevated blood pressure/hypertension and overweight/obese. The authors point to the short duration of the intervention as a possible cause of this contradiction. Many works observe a reduction in blood pressure after interventions lasting at least 12 weeks [31,80]. Our results showed that a 10-week MCT protocol may be sufficient to improve blood pressure in adults and the elderly with stabilized CVDs. Similarly, aerobic-only training led to a significant reduction of P-SBP and P-DBP values. Those results are in line with the extensive literature on aerobic training and blood pressure reduction that estimates a reduction, for every 30 min/week of aerobic activity, of about 1.78 mmHg for SBP and about 1.23 mmHg for DBP [81]. The observed reduction in blood pressure values may have several underlying physiological mechanisms, for example improving endothelial function by increasing the bioavailability of nitric oxide, which promotes vasodilation and reduces vascular resistance, leading to lower blood pressure. Moreover, both protocols could have reduced sympathetic nervous system activity and increases parasympathetic activity, together with improved baroreceptor sensitivity enhancing the body's ability to regulate blood pressure, resulting in lower blood pressure [49]. Both in the MTG and ATG, we found a significant reduction, in RHR that appears to be inversely correlated with life expectancy and positively correlated with cardiovascular and all causes of mortality [82]. These results are in line with previous studies of healthy older adults [21] or those with medical conditions [83]. It's known that regular aerobic and resistance exercise strengthens the heart muscle, allowing it to pump more efficiently with fewer beats per minute, also improves autonomic regulation by increasing parasympathetic (vagal) tone and reducing sympathetic activity, which lowers resting heart rate [21].

Furthermore, the results of our research work showed improvements in lower body strength among both MTG and ATG participants. Loss of muscle mass and strength was associated with increased arterial stiffness and subsequent higher blood pressure [84,85]. Specifically, the improvement noted in lower limb strength could be also important in decreasing the risk of falls and muscle injuries and better performance in daily activities, in adults and the elderly [86]; these results are in line with previous research, where after combined training was observed improvement in strength, especially of lower limb, in hypertensive patients [24] or subjects at risk of cardiovascular events [87]. Moreover, we observed a significant difference between the two training protocols in the 30CST, which highlights the greater effectiveness, for the same duration and frequency, of the MCT protocol. This suggests that, despite being administered at the same conditions, the MCT protocol yields superior improvements in lower body strength. These results are particularly relevant as enhanced performance in the 30CST reflects better functional capabilities, such as reduced risk of falls and muscle injuries, and improved performance in daily activities among adults and elderly.MCT, which includes resistance exercises, can stimulate muscle hypertrophy and neuromuscular adaptations, leading to increased lower limb strength. Paired with, similar to aerobic training-only, improved recruitment and synchronization of muscle fibers, which contribute to enhancing strength. We also observed increase in lower limb strength, although less than the MCT, in the aerobic training-only. In this regard, it should be considered that aerobic exercises require the continuous use of large muscle groups, particularly in the lower limbs; this repeated use leads to increased recruitment of muscle fibers [88]. It can also lead to hypertrophy, at some extent, of slow-twitch muscle fibers, especially in non-training subjects, contributing to improvements in muscular strength and endurance. Added to this is the ability to stimulate the production of new mitochondria in muscle cells (mitochondrial biogenesis) [89], promote angiogenesis, the formation of new capillaries in muscle tissue [90], and improve the synchronization of motor units during aerobic activity, which can lead to more effective and powerful muscle contractions. While not directly increasing maximal strength, these aspects allow muscles to do more work over time, which can lead to increased strength as a side effect [91].

Reduced functional mobility has been associated with the occurrence of future cardiovascular and all causes of mortality [62]. The TUG is the validated test most used to assess physical mobility, gait speed and balance, used as a predictor of falls and evaluation of dynamic balance, specifically in older adults and the elderly [92,93]. Furthermore, the TUG test has been associated with future cardiovascular mortality in women and subjects without obesity, diabetes, or cigarette smoking [62]. A recent meta-analysis showed that multicomponent training could be an optimal strategy to improve functional mobility, even more efficient than strength training only, in older adults [37]. Similarly, our results showed a significant decrease in time in the TUG test in the MTG. Also, aerobic training revealed a significant improvement in the TUG test, in line with previous work exploring the effects of aerobic activity on the elderly [94]. The mechanisms of action behind these improvements can be attributed to increased muscle mass and strength, particularly in the lower limbs. This improvement in strength helps people stand up from sitting more efficiently and walk with greater stability. Improved cardiovascular health, resulting in better oxygen delivery to muscles during exercise, also contributes to improved endurance during the walking component of the TUG test. Finally, improved joint range of motion makes it easier to perform the sitting-to-standing and turning movements, improving functional mobility and reducing risk of fall [95]. The improvement seen in the aerobic training-only group can be explained similarly to the improvements observed in the 30CST.

Similar to what has been observed in other studies [9], our study found statistically significant pre to post changes in handgrip strength values in the MTG and ATG compared to CG. This is despite the shorter duration and frequency of our protocol (2d·wk-1 for 10 weeks), compared with previous studies [9,96] (3d·wk-1 for 12 weeks). However, it should be noted that a meta-analysis aiming to evaluate the actual transfer effect of different types of exercise on handgrip strength showed only small effects, in healthy older adults [97]. Moreover, we observed a significant difference between multicomponent and aerobic training, in the (D)HGS value showing greater effectiveness of the multicomponent training protocol than aerobic training alone. The resistance exercises included in the MCT likely increased grip strength by improving muscle and tendon strength in the hands and forearms, along with increased recruitment and synchronization of motor units [98].

As expected, in the ATG, we observed a significant improvement in aerobic capacity which is important for individuals with CVDs contributing to better disease management. Similarly, and with no significant differences between the two training modalities, the same improvements were also found in the MTG. This finding supports previous research [5,9,99], which highlights the effectiveness of combined training in improving cardiovascular function in this population. Specifically, considering that aerobic training is the most common exercise for aerobic capacity and cardiovascular improvements [100,101], a good portion of these previous work's training volume was composed of aerobic training, from 25 [5] to 45 [9] or 50 min [99]. In our protocol, the time of each component of the main exercise period was roughly equally distributed (∼15′) and despite the shorter duration of the aerobic component, compared to previous studies, our work showed similar results.

Although several studies have reported that aerobic and combined training can improve psychophysiological well-being [102,103] and, despite improvements in parameters related to physical performance found in our study, the QoL and health status outcomes, contrary to what we expected, shown no significant changes in both MTG and ATG. However, should be noted that many studies observing improvement in QoL and perceived health status have been conducted over a longer time frame than the one we used, up to eight months in some cases [102]. Therefore, our shorter intervention time frame may not have been sufficient for participants to fully integrate their physical improvements into their daily lives and subsequently perceive enhancements in their overall QoL. This suggests a potential time lag between physiological adaptations and perceived well-being, highlighting the complex relationship between physical fitness and QoL. Another consideration is the baseline QoL and health status of our participants. Initial scores were relatively high, so there might have been limited room for improvement, resulting in a ceiling effect.

Enjoyment plays a dual role as both a predictor and an outcome of participation in physical activity. The anticipated enjoyment derived from physical activities can bolster exercise intentions, while the mere anticipation of positive emotions is indicative of both the initiation and perpetuation of physical activity [74]. The positive affective experiences during and after exercise can reinforce behavior, creating a feedback loop that promotes regular engagement in physical activity. This aligns with the hedonic theory of motivation, which posits that individuals are more likely to repeat activities they find pleasurable [104,105]. Our observation of high enjoyment levels, correlating with high adherence rates, suggests that designing exercise interventions that prioritize participant enjoyment could be a key strategy for improving long-term adherence to physical activity programs, particularly in populations with CVDs who may face additional barriers to exercise. The comparable enjoyment levels between multicomponent and aerobic training-only indicate that both types of training can provide satisfying experiences for participants. This is particularly noteworthy as it suggests that the additional components in the multicomponent training did not detract from the overall enjoyment of the exercise experience.

5 Strenghts and limitations

To the best of our knowledge, this is the first study aiming to assess and compare the effects of a multicomponent versus an aerobic-only training program on the hemodynamic parameters, physical fitness, psychophysical health status, QoL and enjoyment of adults and elderly with stabilized CVDs. This study offers new insights into the comparative effectiveness of MCT versus aerobic-only training in individuals with stabilized CVDs, addressing a gap in existing literature. The research could lay a foundation for future studies, encouraging further exploration into multifaceted exercise regimens and their impacts on these populations. The findings can inform subsequent research, promoting a deeper understanding of how different exercise modalities contribute to cardiovascular health. Furthermore, the study could provide clinicians with evidence-based guidance on incorporating MCT or aerobic training-only, according to specific need, into standard care protocols for patients with stabilized CVDs. Clinicians can use these insights to develop more personalized and effective treatment plans, optimizing patient outcomes and enhancing the overall management of CVDs. Finally, for patients, the study underscores the importance of engaging in comprehensive exercise programs that integrate various modalities. By understanding the multifaceted benefits, patients could be empowered to take an active role in their health management, fostering motivation and sustained engagement in physical activity.

However, this study has some limitations that should be considered. The lack of strict dietary and clinical control may, to some extent, account for a bias in the interpretation of the results obtained, although the randomization of the groups and having the aim of comparing two training methodologies and not simply observing the effects of exercise mitigated this bias. The relatively small sample size might limit the broader applicability of the results. Without long-term follow-up evaluation, it cannot be determined how sustainable the observed improvements are over time. It's also important to note that this study did not investigate the influence of nutrition, which is a significant factor in managing CVDs.

6 Conclusions

The findings showed that, likewise aerobic training, a 10-week multicomponent exercise protocol is effective in improving hemodynamic parameters and physical fitness in adults and elderly with stabilized CVDs, without adverse effects. Furthermore, the study highlighted the enjoyability of this training intervention, which can promote adherence. Notably, the multicomponent exercise protocol appeared more efficient than aerobic training alone in improving parameters related to lower limb strength and dominant hand grip strength.

However, although both exercise interventions led to significant physical and physiological improvements, QoL and perceived health status were not improved suggesting that these factors may take longer to reach the statistical significance. Further randomized controlled trials with a larger sample size are needed to strengthen these findings.

Funding

This research received no external funding.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Bari University (protocol code 0030611|28/03/23).

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

Data availability statement

Data will be made available on request.

CRediT authorship contribution statement

Luca Poli: Writing – review & editing, Writing – original draft, Methodology, Investigation, Data curation, Conceptualization. Gianpiero Greco: Writing – review & editing, Writing – original draft, Validation, Methodology, Data curation, Conceptualization. Stefania Cataldi: Resources, Methodology. Marco Matteo Ciccone: Visualization, Validation, Formal analysis. Annamaria De Giosa: Visualization, Validation, Software, Investigation, Formal analysis. Francesco Fischetti: Writing – review & editing, Supervision, Resources.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Gianpiero Greco is Associate Editor of Heliyon. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Saglietto A. Manfredi R. Elia E. D'Ascenzo F. De Ferrari G.M. Biondi-Zoccai G. Munzel T. Cardiovascular disease burden: Italian and global perspectives Minerva Cardiol Angiol 69 2021 10.23736/S2724-5683.21.05538-9
2 Townsend N. Kazakiewicz D. Lucy Wright F. Timmis A. Huculeci R. Torbica A. Gale C.P. Achenbach S. Weidinger F. Vardas P. Epidemiology of cardiovascular disease in Europe Nat. Rev. Cardiol. 19 2022 133 143 10.1038/s41569-021-00607-3 34497402
3 Adams M.L. Grandpre J. Katz D.L. Shenson D. Cognitive impairment and cardiovascular disease: a comparison of risk factors, disability, quality of life, and access to health care Publ. Health Rep. 135 2020 132 140 10.1177/0033354919893030
4 Kraus W.E. Powell K.E. Haskell W.L. Janz K.F. Campbell W.W. Jakicic J.M. Troiano R.P. Sprow K. Torres A. Piercy K.L. Physical activity, all-cause and cardiovascular mortality, and cardiovascular disease Med. Sci. Sports Exerc. 51 2019 1270 1281 10.1249/MSS.0000000000001939 31095084
5 Oliveira S.N.D. Moro A.R.P. Domingues W.J.R. Bezerra E.D.S. Effects of concurrent training with self-selected intensity on the physical fitness of hypertensive individuals Acta Sci. Health Sci. 40 2018 35739 10.4025/actascihealthsci.v40i1.35739
6 Tian D. Meng J. Exercise for prevention and relief of cardiovascular disease: prognoses, mechanisms, and approaches Oxid. Med. Cell. Longev. 2019 1 11 10.1155/2019/3756750 2019
7 Stewart J. Manmathan G. Wilkinson P. Primary prevention of cardiovascular disease: a review of contemporary guidance and literature JRSM Cardiovascular Disease 6 2017 204800401668721 10.1177/2048004016687211
8 Alves A.J. Viana J.L. Cavalcante S.L. Oliveira N.L. Duarte J.A. Mota J. Oliveira J. Ribeiro F. Physical activity in primary and secondary prevention of cardiovascular disease: overview updated WJC 8 2016 575 10.4330/wjc.v8.i10.575 27847558
9 Kambic T. Šarabon N. Lainscak M. Hadžić V. Combined resistance training with aerobic training improves physical performance in patients with coronary artery disease: a secondary analysis of a randomized controlled clinical trial Front. Cardiovasc. Med. 9 2022 909385 10.3389/fcvm.2022.909385
10 Nasi M. Patrizi G. Pizzi C. Landolfo M. Boriani G. Dei Cas A. Cicero A.F.G. Fogacci F. Rapezzi C. Sisca G. The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian society of cardiology-Emilia Romagna-Marche and SIC-sport J. Cardiovasc. Med. 20 2019 631 639 10.2459/JCM.0000000000000855
11 Soares-Miranda L. Siscovick D.S. Psaty B.M. Longstreth W.T. Mozaffarian D. Physical activity and risk of coronary heart disease and stroke in older adults: the cardiovascular health study Circulation 133 2016 147 155 10.1161/CIRCULATIONAHA.115.018323 26538582
12 Whelton P.K. Carey R.M. Aronow W.S. Casey D.E. Collins K.J. Dennison Himmelfarb C. DePalma S.M. Gidding S. Jamerson K.A. Jones D.W. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of cardiology/American heart association task force on clinical practice guidelines Hypertension 71 2017 1269 1324 10.1161/HYP.0000000000000066 2018 29133354
13 Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. Iung B. Lancellotti P. Lansac E. Rodriguez Muñoz D. 2017 ESC/EACTS guidelines for the management of valvular heart disease Eur. Heart J. 38 2017 2739 2791 10.1093/eurheartj/ehx391 28886619
14 January C.T. Wann L.S. Calkins H. Chen L.Y. Cigarroa J.E. Cleveland J.C. Ellinor P.T. Ezekowitz M.D. Field M.E. Furie K.L. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons Circulation 140 2019 10.1161/CIR.0000000000000665
15 Amini R. Rajabi M. Azami H. Soltanian A. The effect of self-management intervention program on the lifestyle of postmyocardial infarction patients J Edu Health Promot 10 2021 145 10.4103/jehp.jehp_902_20
16 Anderson L. Oldridge N. Thompson D.R. Zwisler A.-D. Rees K. Martin N. Taylor R.S. Exercise-based cardiac rehabilitation for coronary heart disease J. Am. Coll. Cardiol. 67 2016 1 12 10.1016/j.jacc.2015.10.044 26764059
17 Sachdeva P. Kaur K. Fatima S. Mahak F. Noman M. Siddenthi S.M. Surksha M.A. Munir M. Fatima F. Sultana S.S. Advancements in myocardial infarction management: exploring novel approaches and strategies Cureus 2023 10.7759/cureus.45578
18 Ashor A.W. Lara J. Siervo M. Celis-Morales C. Mathers J.C. Effects of exercise modalities on arterial stiffness and wave reflection: a systematic review and meta-analysis of randomized controlled trials PLoS One 9 2014 e110034 10.1371/journal.pone.0110034
19 Brito L.C. Peçanha T. Fecchio R.Y. Pio-Abreu A. Silva G. Mion-Junior D. Halliwill J.R. Forjaz C.L.M. Comparison of morning versus evening aerobic-exercise training on heart rate recovery in treated hypertensive men: a randomized controlled trial Blood Pres. Monit. 26 2021 388 392 10.1097/MBP.0000000000000545
20 Pedralli M.L. Eibel B. Waclawovsky G. Schaun M.I. Nisa-Castro-Neto W. Umpierre D. Pescatello L.S. Tanaka H. Lehnen A.M. Effects of exercise training on endothelial function in individuals with hypertension: a systematic review with meta-analysis Journal of the American Society of Hypertension 12 2018 e65 e75 10.1016/j.jash.2018.09.009 30482668
21 Reimers A. Knapp G. Reimers C.-D. Effects of exercise on the resting heart rate: a systematic review and meta-analysis of interventional studies JCM 7 2018 503 10.3390/jcm7120503 30513777
22 Nystoriak M.A. Bhatnagar A. Cardiovascular effects and benefits of exercise Front. Cardiovasc. Med. 5 2018 135 10.3389/fcvm.2018.00135 30324108
23 Franczyk B. Gluba-Brzózka A. Ciałkowska-Rysz A. Ławiński J. Rysz J. The impact of aerobic exercise on HDL quantity and quality: a narrative review IJMS 24 2023 4653 10.3390/ijms24054653 36902082
24 Islami F. Saghebjoo M. Kazemi T. Hedayati M. Gym and home-based combined training in men with primary hypertension: are they equally effective on functional fitness profile, body composition components, and biochemical parameters of hypertension? Clin. Exp. Hypertens. 43 2021 758 771 10.1080/10641963.2021.1960365 34467787
25 Katz A. Brief periods of resistance training enhance insulin sensitivity in humans Exp. Physiol. 104 2019 458 459 10.1113/EP087607 30702786
26 Paquin J. Lagacé J.-C. Brochu M. Dionne I.J. Exercising for insulin sensitivity – is there a mechanistic relationship with quantitative changes in skeletal muscle mass? Front. Physiol. 12 2021 656909 10.3389/fphys.2021.656909
27 Trevizani G.A. Seixas M.B. Benchimol-Barbosa P.R. Vianna J.M. Da Silva L.P. Nadal J. Effect of resistance training on blood pressure and autonomic responses in treated hypertensives J. Strength Condit Res. 32 2018 1462 1470 10.1519/JSC.0000000000001995
28 Shiroma E.J. Cook N.R. Manson J.E. Moorthy M. Buring J.E. Rimm E.B. Lee I.-M. Strength training and the risk of type 2 diabetes and cardiovascular disease Med. Sci. Sports Exerc. 49 2017 40 46 10.1249/MSS.0000000000001063 27580152
29 Shaibi G.Q. Cruz M.L. Ball G.D.C. Weigensberg M.J. Salem G.J. Crespo N.C. Goran M.I. Effects of resistance training on insulin sensitivity in overweight Latino adolescent males Med. Sci. Sports Exerc. 38 2006 1208 1215 10.1249/01.mss.0000227304.88406.0f 16826016
30 Hurley B.F. Roth S.M. Strength training in the elderly: effects on risk factors for age-related diseases Sports Med. 30 2000 249 268 10.2165/00007256-200030040-00002 11048773
31 Cornelissen V.A. Fagard R.H. Coeckelberghs E. Vanhees L. Impact of resistance training on blood pressure and other cardiovascular risk factors: a meta-analysis of randomized, controlled trials Hypertension 58 2011 950 958 10.1161/HYPERTENSIONAHA.111.177071 21896934
32 Ten Hoor G.A. Kok G. Peters G.-J.Y. Frissen T. Schols A.M.W.J. Plasqui G. The psychological effects of strength exercises in people who are overweight or obese: a systematic review Sports Med. 47 2017 2069 2081 10.1007/s40279-017-0748-5 28573402
33 Garber C.E. Blissmer B. Deschenes M.R. Franklin B.A. Lamonte M.J. Lee I.-M. Nieman D.C. Swain D.P. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise Med. Sci. Sports Exerc. 43 2011 1334 1359 10.1249/MSS.0b013e318213fefb 21694556
34 Mancia G. Kreutz R. Brunström M. Burnier M. Grassi G. Januszewicz A. Muiesan M.L. Tsioufis K. Agabiti-Rosei E. Algharably E.A.E. 2023 ESH guidelines for the management of arterial hypertension the task force for the management of arterial hypertension of the European society of hypertension: endorsed by the international society of hypertension (ISH) and the European renal association (ERA) J. Hypertens. 41 2023 1874 2071 10.1097/HJH.0000000000003480 37345492
35 Kato M. Nihei Green F. Hotta K. Tsukamoto T. Kurita Y. Kubo A. Takagi H. The efficacy of stretching exercises on arterial stiffness in middle-aged and older adults: a meta-analysis of randomized and non-randomized controlled trials IJERPH 17 2020 5643 10.3390/ijerph17165643 32764418
36 Farinatti P.T. Brandão C. Soares P.P. Duarte A.F. Acute effects of stretching exercise on the heart rate variability in subjects with low flexibility levels J. Strength Condit Res. 25 2011 1579 1585 10.1519/JSC.0b013e3181e06ce1
37 Lemos E.C.W.M. Guadagnin E.C. Mota C.B. Influence of strength training and multicomponent training on the functionality of older adults: systematic review and meta-analysis Rev. bras. cineantropom. desempenho hum. 22 2020 e60707 10.1590/1980-0037.2020v22e6070
38 Nishiwaki M. Yonemura H. Kurobe K. Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men SpringerPlus 4 2015 555 10.1186/s40064-015-1337-4 26435901
39 Suwa M. Imoto T. Kida A. Yokochi T. Iwase M. Kozawa K. Association of body flexibility and carotid atherosclerosis in Japanese middle-aged men: a cross-sectional study BMJ Open 8 2018 e019370 10.1136/bmjopen-2017-019370
40 Bouaziz W. Lang P.O. Schmitt E. Kaltenbach G. Geny B. Vogel T. Health benefits of multicomponent training programmes in seniors: a systematic review Int. J. Clin. Pract. 70 2016 520 536 10.1111/ijcp.12822 27291143
41 Cadore E.L. Rodríguez-Mañas L. Sinclair A. Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review Rejuvenation Res. 16 2013 105 114 10.1089/rej.2012.1397 23327448
42 Xavier P.B. Garcez A. Cibeira G.H. Germano A. Olinto M.T.A. Fatores Associados à Ocorrência de Hipertensão Arterial Em Trabalhadores Da Indústria Do Estado Do Rio Grande Do Sul, Brasil Arq. Bras. Cardiol. 2021 10.36660/abc.20190815
43 Moraes W.M.D. Souza P.R.M. Pinheiro M.H.N.P. Irigoyen M.C. Medeiros A. Koike M.K. Exercise training program based on minimum weekly frequencies: effects on blood pressure and physical fitness in elderly hypertensive patients Rev. bras. fisioter. 16 2012 114 121 10.1590/S1413-35552012005000013 22481693
44 Schroeder E.C. Franke W.D. Sharp R.L. Lee D. Comparative effectiveness of aerobic, resistance, and combined training on cardiovascular disease risk factors: a randomized controlled trial PLoS One 14 2019 e0210292 10.1371/journal.pone.0210292
45 Subías-Perié J. Navarrete-Villanueva D. Fernández-García Á.I. Moradell A. Lozano-Berges G. Gesteiro E. Pérez-Gómez J. Ara I. Gómez-Cabello A. Vicente-Rodríguez G. Effects of a multicomponent training followed by a detraining period on metabolic syndrome profile of older adults Exp. Gerontol. 186 2024 112363 10.1016/j.exger.2024.112363
46 Theodorou A.A. Panayiotou G. Volaklis K.A. Douda H.T. Paschalis V. Nikolaidis M.G. Smilios I. Toubekis A. Kyprianou D. Papadopoulos I. Aerobic, resistance and combined training and detraining on body composition, muscle strength, lipid profile and inflammation in coronary artery disease patients Res. Sports Med. 24 2016 171 184 10.1080/15438627.2016.1191488 27258806
47 Shuvalova N. Drandrov G. Lezhenina S. Karpunina A. Akimova V. Denisova E. Kupriyanova L. The effect of the combined aerobic and power training in the patients with chronic Heart Dis. 2020 10.14526/2070-4798-2020-15-1-158-164
48 Mohammadi H. Khoshnam M. Khoshnam E. Effects of different modes of exercise training on body composition and risk factors for cardiovascular disease in middle-aged men Int. J. Prev. Med. 9 2018 9 10.4103/ijpvm.IJPVM_209_16 29441186
49 Cornelissen V.A. Smart N.A. Exercise training for blood pressure: a systematic review and meta‐analysis JAHA 2 2013 e004473 10.1161/JAHA.112.004473
50 Billinger S.A. Arena R. Bernhardt J. Eng J.J. Franklin B.A. Johnson C.M. MacKay-Lyons M. Macko R.F. Mead G.E. Roth E.J. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American heart association/American stroke association Stroke 45 2014 2532 2553 10.1161/STR.0000000000000022 24846875
51 Liguori Gary American College of Sports Medicine (ACSM) ACSM's Guidelines for Exercise Testing and Prescription tenth ed. 2021 Wolters Kluwer Health USA 978-1-4963-3906-5
52 Pelliccia A. Sharma S. Gati S. Bäck M. Börjesson M. Caselli S. Collet J.-P. Corrado D. Drezner J.A. Halle M. ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease Eur. Heart J. 42 2020 17 96 10.1093/eurheartj/ehaa605 2021
53 Williams M.A. Haskell W.L. Ades P.A. Amsterdam E.A. Bittner V. Franklin B.A. Gulanick M. Laing S.T. Stewart K.J. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American heart association council on clinical cardiology and council on nutrition, physical activity, and metabolism Circulation 116 2007 572 584 10.1161/CIRCULATIONAHA.107.185214 17638929
54 Bull F.C. Al-Ansari S.S. Biddle S. Borodulin K. Buman M.P. Cardon G. Carty C. Chaput J.-P. Chastin S. Chou R. World health organization 2020 guidelines on physical activity and sedentary behaviour Br. J. Sports Med. 54 2020 1451 1462 10.1136/bjsports-2020-102955 33239350
55 Kang H. Sample size determination and power analysis using the G*power software J Educ Eval Health Prof 18 2021 17 10.3352/jeehp.2021.18.17 34325496
56 Macfarlane D.J. Chou K.L. Cheng Y.H. Chi I. Validity and normative data for thirty-second chair stand test in elderly community-dwelling Hong Kong Chinese Am. J. Hum. Biol. 18 2006 418 421 10.1002/ajhb.20503 16634026
57 Rikli R.E. Jones C.J. Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years Gerontol. 53 2013 255 267 10.1093/geront/gns071
58 Ekström H. Dahlin-Ivanoff S. Elmståhl S. Effects of walking speed and results of timed get-up-and-go tests on quality of life and social participation in elderly individuals with a history of osteoporosis-related fractures J. Aging Health 23 2011 1379 1399 10.1177/0898264311418504 21868721
59 Kojima G. Masud T. Kendrick D. Morris R. Gawler S. Treml J. Iliffe S. Does the timed up and go test predict future falls among British community-dwelling older people? Prospective cohort study nested within a randomised controlled trial BMC Geriatr. 15 2015 38 10.1186/s12877-015-0039-7 25887660
60 Wennie Huang W.-N. Perera S. VanSwearingen J. Studenski S. Performance measures predict onset of activity of daily living difficulty in community-dwelling older adults: performance measures predict onset of ADL difficulty J. Am. Geriatr. Soc. 58 2010 844 852 10.1111/j.1532-5415.2010.02820.x 20406319
61 Presta V. Galuppo L. Condello G. Rodà F. Mirandola P. Vitale M. Vaccarezza M. Gobbi G. Receiver operating characteristic analysis of posture and gait parameters to prevent frailty condition and fall risk in the elderly Appl. Sci. 13 2023 3387 10.3390/app13063387
62 Son K.Y. Shin D.W. Lee J.E. Kim S.H. Yun J.M. Cho B. Association of timed up and go test outcomes with future incidence of cardiovascular disease and mortality in adults aged 66 Years: Korean national representative longitudinal study over 5.7 years BMC Geriatr. 20 2020 111 10.1186/s12877-020-01509-8 32192437
63 De Buyser S.L. Petrovic M. Taes Y.E. Toye K.R.C. Kaufman J.-M. Goemaere S. Physical function measurements predict mortality in ambulatory older men Eur. J. Clin. Invest. 43 2013 379 386 10.1111/eci.12056 23398295
64 Steffen T.M. Hacker T.A. Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: six-minute walk test, berg balance scale, timed up & go test, and gait speeds Phys. Ther. 82 2002 128 137 10.1093/ptj/82.2.128 11856064
65 Lee S.Y. Handgrip strength: an irreplaceable indicator of muscle function Ann Rehabil Med 45 2021 167 169 10.5535/arm.21106 34233405
66 Bohannon R.W. Crouch R.H. Two-minute step test of exercise capacity: systematic review of procedures, performance, and clinimetric properties J. Geriatr. Phys. Ther. 42 2019 105 112 10.1519/JPT.0000000000000164 29210933
67 Kodraliu P. Mosconi N. Groth G.G. Subjective health status assessment: evaluation of the Italian version of the SF-12 health Survey. Results from the MiOS project J. Epidemiol. Biostat. 6 2001 305 316 10.1080/135952201317080715 11437095
68 Ware J.E. Kosinski M. Keller S.D. A 12-item short-form health Survey: construction of scales and preliminary tests of reliability and validity Med. Care 34 1996 220 233 10.1097/00005650-199603000-00003 8628042
69 Girolamo G.D. Rucci P. Scocco P. Becchi A. Coppa F. D'Addario A. Daru E. Leo D.D. Galassi L. Mangelli L. Quality of life assessment: validation of the Italian version of the WHOQOL-brief Epidemiol. Psichiatr. Soc. 9 2000 45 55 10.1017/S1121189X00007740 10859875
70 Skevington S.M. Lotfy M. O'Connell K.A. The world health organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group Qual. Life Res. 13 2004 299 310 10.1023/B:QURE.0000018486.91360.00 15085902
71 Carraro A. Young M.C. Robazza C. A contribution to the validation of the physical activity enjoyment scale in an Italian sample Soc. Behav. Pers. 36 2008 911 918 10.2224/sbp.2008.36.7.911
72 Kendzierski D. DeCarlo K.J. Physical activity enjoyment scale: two validation studies J. Sport Exerc. Psychol. 13 1991 50 64 10.1123/jsep.13.1.50
73 Carraro A. Valutare Il Piacere Nelle Attività Motorie: Il PACES-it ITALIAN JOURNAL OF EDUCATIONAL RESEARCH 2012 259 265
74 Mullen S.P. Olson E.A. Phillips S.M. Szabo A.N. Wójcicki T.R. Mailey E.L. Gothe N.P. Fanning J.T. Kramer A.F. McAuley E. Measuring enjoyment of physical activity in older adults: Invariance of the physical activity enjoyment scale (paces) across groups and time Int. J. Behav. Nutr. Phys. Activ. 8 2011 103 10.1186/1479-5868-8-103
75 Teques P. Calmeiro L. Silva C. Borrego C. Validation and adaptation of the physical activity enjoyment scale (PACES) in fitness group exercisers Journal of Sport and Health Science 9 2020 352 357 10.1016/j.jshs.2017.09.010 32768128
76 Borg G.A. Psychophysical bases of perceived exertion Med. Sci. Sports Exerc. 14 1982 377 381 7154893
77 JASP Team JASP 2023 Version 0.17.3
78 Cohen J. A power primer Psychol. Bull. 112 1992 155 159 10.1037/0033-2909.112.1.155 19565683
79 Lima L.G. Bonardi J.T.M. Campos G.O. Bertani R.F. Scher L.M.L. Moriguti J.C. Ferriolli E. Lima N.K.C. Combined aerobic and resistance training: are there additional benefits for older hypertensive adults? Clinics 72 2017 363 369 10.6061/clinics/2017(06)06 28658436
80 Sousa N. Mendes R. Abrantes C. Sampaio J. Oliveira J. A randomized 9-month study of blood pressure and body fat responses to aerobic training versus combined aerobic and resistance training in older men Exp. Gerontol. 48 2013 727 733 10.1016/j.exger.2013.04.008 23628502
81 Jabbarzadeh Ganjeh B. Zeraattalab-Motlagh S. Jayedi A. Daneshvar M. Gohari Z. Norouziasl R. Ghaemi S. Selk-Ghaffari M. Moghadam N. Kordi R. Effects of aerobic exercise on blood pressure in patients with hypertension: a systematic review and dose-response meta-analysis of randomized trials Hypertens. Res. 47 2024 385 398 10.1038/s41440-023-01467-9 37872373
82 Aune D. Sen A. ó’Hartaigh B. Janszky I. Romundstad P.R. Tonstad S. Vatten L.J. Resting heart rate and the risk of cardiovascular disease, total cancer, and all-cause mortality – a systematic review and dose–response meta-analysis of prospective studies Nutr. Metabol. Cardiovasc. Dis. 27 2017 504 517 10.1016/j.numecd.2017.04.004
83 Huang G. Shi X. Davis-Brezette J.A. Osness W.H. Resting heart rate changes after endurance training in older adults: a meta-analysis Med. Sci. Sports Exerc. 37 2005 1381 1386 10.1249/01.mss.0000174899.35392.0c 16118586
84 Son W.-M. Sung K.-D. Bharath L.P. Choi K.-J. Park S.-Y. Combined exercise training reduces blood pressure, arterial stiffness, and insulin resistance in obese prehypertensive adolescent girls Clin. Exp. Hypertens. 39 2017 546 552 10.1080/10641963.2017.1288742 28590143
85 Zhang Y. Miyai N. Abe K. Utsumi M. Uematsu Y. Terada K. Nakatani T. Takeshita T. Arita M. Muscle mass reduction, low muscle strength, and their combination are associated with arterial stiffness in community-dwelling elderly population: the Wakayama study J. Hum. Hypertens. 35 2021 446 454 10.1038/s41371-020-0355-z 32427885
86 Pedralli M.L. Marschner R.A. Kollet D.P. Neto S.G. Eibel B. Tanaka H. Lehnen A.M. Different exercise training modalities Produce similar endothelial function improvements in individuals with prehypertension or hypertension: a randomized clinical trial Sci. Rep. 10 2020 7628 10.1038/s41598-020-64365-x 32376984
87 Figueroa A. Park S.Y. Seo D.Y. Sanchez-Gonzalez M.A. Baek Y.H. Combined resistance and endurance exercise training improves arterial stiffness, blood pressure, and muscle strength in postmenopausal women Menopause 18 2011 980 984 10.1097/gme.0b013e3182135442 21540753
88 Fry C.S. Noehren B. Mula J. Ubele M.F. Westgate P.M. Kern P.A. Peterson C.A. Fibre type‐specific satellite cell response to aerobic training in sedentary adults J. Physiol. 592 2014 2625 2635 10.1113/jphysiol.2014.271288 24687582
89 Margolis L.M. Pasiakos S.M. Optimizing intramuscular adaptations to aerobic exercise: effects of carbohydrate restriction and protein supplementation on mitochondrial biogenesis Adv. Nutr. 4 2013 657 664 10.3945/an.113.004572 24228194
90 Song B.X. Azhar L. Koo G.K.Y. Marzolini S. Gallagher D. Swardfager W. Chen C. Ba J. Herrmann N. Lanctôt K. The effect of exercise on blood concentrations of angiogenesis markers in older adults, A Systematic Review and Meta-Analysis Neurobiol Aging 135 2023 15 25 10.1016/j.neurobiolaging.2023.12.004 38147807
91 Harber M.P. Konopka A.R. Undem M.K. Hinkley J.M. Minchev K. Kaminsky L.A. Trappe T.A. Trappe S. Aerobic exercise training induces skeletal muscle hypertrophy and age-dependent adaptations in myofiber function in young and older men J. Appl. Physiol. 113 2012 1495 1504 10.1152/japplphysiol.00786.2012 22984247
92 Nightingale C.J. Mitchell S.N. Butterfield S.A. Validation of the timed up and go test for assessing balance variables in adults aged 65 and older J. Aging Phys. Activ 27 2019 230 233 10.1123/japa.2018-0049
93 Northgraves M.J. Hayes S.C. Marshall P. Madden L.A. Vince R.V. The test-retest reliability of four functional mobility tests in apparently healthy adults IES 24 2016 171 179 10.3233/IES-160614
94 Joung H.J. Lee Y. Effect of creative dance on fitness, functional balance, and mobility control in the elderly Gerontology 65 2019 537 546 10.1159/000499402 31055579
95 López-López S. Abuín-Porras V. Berlanga L.A. Martos-Duarte M. Perea-Unceta L. Romero-Morales C. Pareja-Galeano H. Functional mobility and physical fitness are improved through a multicomponent training program in institutionalized older adults GeroScience 46 2023 1201 1209 10.1007/s11357-023-00877-4 37493861
96 Justine M. Hamid T.A. Mohan V. Jagannathan M. Effects of multicomponent exercise training on physical functioning among institutionalized elderly ISRN Rehabilitation 2012 2012 1 7 10.5402/2012/124916
97 Labott B.K. Bucht H. Morat M. Morat T. Donath L. Effects of exercise training on handgrip strength in older adults: a meta-analytical review Gerontology 65 2019 686 698 10.1159/000501203 31499496
98 Labata-Lezaun N. Canet-Vintró M. López-de-Celis C. Rodríguez-Sanz J. Aiguadé R. Cuadra-Llopart L. Jovell-Fernández E. Bosch J. Pérez-Bellmunt A. Effectiveness of a multicomponent training program on physical performance and muscle quality in older adults: a Quasi-experimental study IJERPH 20 2022 222 10.3390/ijerph20010222 36612544
99 Sardeli A.V. Gáspari A.F. Dos Santos W.M. De Araujo A.A. De Angelis K. Mariano L.O. Cavaglieri C.R. Fernhall B. Chacon-Mikahil M.P.T. Comprehensive time-course effects of combined training on hypertensive older adults: a randomized control trial IJERPH 19 2022 11042 10.3390/ijerph191711042
100 Sardeli A.V. Gáspari A.F. Chacon-Mikahil M.P. Acute, short-, and long-term effects of different types of exercise in central arterial stiffness: a systematic review and meta-analysis J. Sports Med. Phys. Fit. 58 2018 10.23736/S0022-4707.17.07486-2
101 Sardeli A.V. Griffith G.J. Dos Santos M.V.M.A. Ito M.S.R. Nadruz W. Chacon-Mikahil M.P.T. Do baseline blood pressure and type of exercise influence level of reduction induced by training in hypertensive older adults? A meta-analysis of controlled trials Exp. Gerontol. 140 2020 111052 10.1016/j.exger.2020.111052
102 Collins K.A. Fos L.B. Ross L.M. Slentz C.A. Davis P.G. Willis L.H. Piner L.W. Bateman L.A. Houmard J.A. Kraus W.E. Aerobic, resistance, and combination training on health-related quality of life: the STRRIDE-AT/RT randomized trial Front. Sports Act. Living 2 2021 620300 10.3389/fspor.2020.620300
103 De Souza L.N.N. De Carvalho P.H.B. Ferreira M.E.C. Quality of Life and Subjective Well-Being of Physically Active Elderly People: A Systematic Review 2018 JPES 2018
104 Van Cappellen P. Rice E.L. Catalino L.I. Fredrickson B.L. Positive affective processes underlie positive health behaviour change Psychol. Health 33 2018 77 97 10.1080/08870446.2017.1320798 28498722
105 Rhodes R.E. Kates A. Can the affective response to exercise predict future motives and physical activity behavior? A systematic review of published evidence Ann. Behav. Med. 49 2015 715 731 10.1007/s12160-015-9704-5 25921307
