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Rev Inst Cinc Sade

2007; 25(2):141-6

Efeito de um programa de reabilitao cardaca fase III realizado em


piscina teraputica e no solo, em mulheres hipertensas

Effect of a cardiac rehabilitation program phase III carried out on


hypertensive women in a therapeutic pool and on the ground

Marilita Falngola Accioly*


Raquel Ferrari Piotto**

Resumo
Introduo Exstudos epidemiolgicos identificam a associao inversa entre a prtica regu-
lar de atividade fsica e a incidncia ou risco de desenvolvimento da hipertenso arterial. O obje-
tivo deste estudo foi verificar as adaptaes cardiovasculares induzidas pelo treinamento fsico
aerbio na presso arterial sistlica (PAS), presso arterial diastlica (PAD) e freqncia carda-
ca (FC) em mulheres com hipertenso arterial sistmica (HAS), submetidas ao programa de rea-

solo). Material e Mtodos Foram estudadas oito voluntrias, sedentrias com idade mdia de
bilitao cardiovascular-fase III, realizado em piscina teraputica (PRC piscina) e no solo (PRC

62,12 9,52 anos, com HAS, que faziam uso de medicao hipotensora, a dosagem da medica-
o em uso no foi alterada. Foram formados dois grupos: G1: quatro voluntrias submetidas ao
PRC piscina e G2: quatro voluntrias submetidas ao PRC solo. Foi realizado anamnese, teste de
caminhada de seis minutos e programa de reabilitao cardiovascular-fase III, que constou de
aquecimento, endurance e volta calma, aplicado trs vezes por semana durante oito semanas.

clculo de Karvonen. Aplicou-se teste t de student com nvel de significncia de 5%. Resultados
A intensidade de esforo foi de 60% a 85% da reserva da freqncia cardaca, utilizando-se o

Ao analisar o efeito do PRC piscina e PRC solo identificou-se diminuio estatisticamente signi-

monstrando maior efetividade do PRC solo. Concluso Sugere-se que o treinamento aerbio
ficante para as variveis PAS (p=0,03) e PAD (p=0,02) do G2, fato que no ocorreu ao G1, de-

promove adaptaes morfofuncionais no sistema cardiovascular, sendo um importante coadju-


vante no tratamento no farmacolgica da hipertenso arterial sistmica.
Palavras-chave: Hipertenso, reabilitao; Exerccio; Esforo fsico; Terapia por exerccio

Abstract
Introduction Epidemiological studies have been identifying an inverse association between
the regular practice of physical activity and the incidence or risk of developing arterial
hypertension. The purpose of this I study was verify cardiovascular adaptations induced by
aerobic physical training on the systolic blood pressure (SBP), diastolic blood pressure (DBP)
and heart rate (HR) in women with systemic arterial hypertension (SAH), subjected to

on the ground (CRP ground). Material and Methods Eight sedentary volunteers with an average
cardiovascular rehabilitation program - phase III carried out in a therapeutic pool (CRP pool) and

age of 62.12 9.52 and SAH were studied. They had been on a hypotensive drug and its dose
was not changed. Two groups were formed: G1: four volunteers subjected to the CRP pool and
G2: four volunteers subjected to the CRP ground. Anamnesis, a six-minute walk test and a
cardiovascular rehabilitation program - phase III were carried out, which consisted of warming
up, endurance and cooling down. These tests were applied three times a week during 8 weeks.

test to student was applied with 5% of significance level. Results Effects of CRP pool and CRP
Effort intensity was 60% to 85% of cardiac frequency reserve using the Karvonen calculation. The

ground were analyzed and a statistically significant decrease was identified for SBP (p=0.03) and

ground. Conclusion The results of the research, suggested that aerobic training promotes
DBP (p=0.02) variable of G2, which did not occur in G1, showing higher effectiveness of CRP

morphological and functional adaptation on the cardiovascular system, which is an important


adjuvant in non-pharmacological treatment of systemic arterial hypertension.
Key words: Hypertension, rehabilitation; Exercise; Exertion; Exercise therapy

Introduo que de um veloz processo de urbanizao, hbitos pr-


prios da vida em cidades, como: sedentarismo, tabagis-
A sociedade brasileira encontrase em fase acelera- mo, estresse e refeies freqentes em cadeias de
da de transio epidemiolgica, neste estgio, a rebo- fastfoods, se acompanham de aumentos proporcionais

* Fisioterapeuta. Mestre em Educao Fsica pela Universidade Estadual de Campinas (Unicamp). Doutoranda em Cincias da Sade da Faculdade de
Medicina de So Jos do Rio Preto (Famerp). Professora da Disciplina Fisioterapia Clnica: Cardiologia da Universidade Paulista (UNIP) So Jos do Rio
Preto, SP. E-mail: marilita@terra.com.br
** Fisioterapeuta. Mestranda do Curso de Ps-Graduao da Famerp.
142

na prevalncia de obesidade, diabetes, hipertenso ar- minuio na resistncia vascular sistmica e, conse-
terial e acidente cerebrovascular. Diante a dificuldade qentemente, na presso arterial seria outro mecanismo
de acesso a servios de sade e precrio nvel de infor- alternativo proposto para explicar a queda na presso
mao por parte de expressiva parcela dos habitantes arterial ps-exerccio 15,19,20.
de aglomerados urbanos, mais vidas humanas acabam Uma reduo significativa nos nveis pressricos
sendo precocemente ceifadas graas maior exposi- conseguida com treinamento de baixa intensidade
o e vulnerabilidade a fatores ambientais nocivos no (50% do consumo de oxignio de pico). Assim, o
aparelho cardiovascular. exerccio fsico de baixa intensidade diminui a presso
Nos pases desenvolvidos, ao contrrio, retardase o arterial porque provoca reduo no dbito cardaco, o
momento de sucumbir s doenas degenerativas, em que pode ser explicado pela diminuio na freqncia
retribuio direta ao atendimento mdico universal de cardaca de repouso e do tnus simptico no corao,
alta qualidade e ao maior acesso do pblico leigo aos em decorrncia de menor intensificao simptica e
meios de instruo sobre cuidados preventivos14. No maior retirada vagal15,19-20. A reduo da presso arterial
Brasil, em 2003, 27,4% dos bitos foram decorrentes de aps exerccio fsico em hipertensos atribuda
doenas cardiovasculares, atingindo 37% quando so tambm, a alteraes humorais relacionadas
excludos os bitos por causas mal definidas, a princi- produo de substncias vasoativas, como o peptdeo
pal causa de morte em todas as regies do Brasil o natriurtico atrial ou ouabana-like, modulada
acidente vascular cerebral, acometendo as mulheres centralmente20. O efeito hipotensor do exerccio fsico
em maior proporo16. foi associado a concomitantes aumentos de
Entre os fatores de risco para mortalidade, a hiper- prostaglandina e da excreo urinria de sdio e
tenso arterial explica 40% das mortes por acidente reduo dos nveis plasmticos de catecolaminas.
vascular cerebral e 25% daquelas por doena corona- Alm disso, o treinamento fsico de intensidade leve es-
riana7. timula a gerao de dopamina renal e ativa o sistema
So muitas as estratgias de interveno capazes cinina-calicrena renal, resultando em natriurese e redu-
de fornecer meios de tratamento da hipertenso o da presso arterial21, bem como, da renina plasm-
arterial (HA), podendo ser citadas algumas tica e o aumento na produo de cido ntrico20.
modificaes no estilo de vida, como hbitos Durante a atividade fsica, a presso arterial sistlica
dietticos e volume de atividade fsica13. No que diz eleva-se com o aumento da intensidade do exerccio,
respeito, especificamente, a esta ltima, estudos devido o aumento do dbito cardaco e do volume sist-
epidemiolgicos vm identificando associao inversa lico, no devendo ultrapassar 230 mmHg, caso isso
entre sua prtica regular e a incidncia ou risco de ocorra, o exerccio dever ser interrompido. A presso
desenvolvimento da hipertenso arterial 3,5. Existem diastlica varia pouco menos que 10 mmHg, ocorrendo
evidncias de que o treinamento com exerccios um aumento rpido, o exerccio tambm dever ser
aerbios acarrete, em mdio e longo prazo, reduo interrompido11.
nas presses sistlica e diastlica1,2,5,10. A Sociedade Brasileira de Cardiologia recomenda
A atividade fsica promove adaptaes fisiolgicas fa- que os indivduos hipertensos iniciem programas de
vorveis, resultando em melhora da qualidade de vida12. exerccio fsico regular, desde que submetidos ava-
A prtica regular de exerccios moderados ajuda a man- liao clnica prvia. Os exerccios devem ser de in-
ter a presso arterial sob controle, melhora a capacida- tensidade moderada, de trs a seis vezes por semana,
de cardiorrespiratria, reduz os nveis plasmticos alte- em sesses de 30 a 60 minutos de durao, realizadas
rados de glicose e insulina (diabetes), a anormalidade com freqncia cardaca entre 60% e 80% da mxima
no perfil lipoprotico, melhora a circulao sangnea, ou entre 50% e 70% do consumo mximo de
controla o peso e melhora o bem-estar geral4,8. oxignio25.
Melhor condio fsica, em pessoas que no apresen- Este estudo teve por objetivo analisar as adaptaes
tem riscos cardiovasculares, tem grande associao com cardiovasculares induzidas na presso arterial sistlica,
menor risco de mortalidade, j que, na maioria dos estu- presso arterial diastlica e freqncia cardaca, em
dos realizados, o exerccio fsico diminui a presso arterial mulheres com hipertenso arterial sistmica leve, sub-
de hipertensos, em mdia de 10 mmHg, tanto na presso metidas a Programa de Reabilitao Cardiovascular
sistlica quanto na diastlica. Estes valores foram ana- fase III, realizado no solo e em piscina teraputica.

Material e Mtodos
lisados depois de os indivduos serem submetidos a
treinamento do tipo aerbio e em repouso22.
O efeito crnico, isto efeito do treinamento fsico, na
reduo presso arterial est relacionada a fatores he- Foram estudados oito indivduos do sexo feminino,
modinmicos, humorais e neurais20. Dentre os fatores sedentrios com idade mdia de 62,12 9,52 anos,
hemodinmicos verificou-se, tanto em ratos esponta- com hipertenso arterial sistmica (HAS) grau leve, que
neamente hipertensos quanto em humanos, que o exer- faziam uso de medicao hipotensora (beta bloqueado-
ccio fsico promove reduo da presso arterial por di- res e diurticos). A dosagem da medicao em uso no
minuio no dbito cardaco que est associada ao de- foi alterada durante a pesquisa.
crscimo da freqncia cardaca, uma vez que no fo- As voluntrias foram divididas aleatoriamente em dois
ram observadas alteraes no volume sistlico18,20. A di- grupos, a saber:

Accioly MF, Piotto RF. Efeito de um programa de reabilitao cardaca fase III realizado em piscina teraputica e no solo, em mulheres
hipertensas. Rev Inst Cinc Sade. 2007; 25(2):141-6.
143

Grupo 1 (G1): quatro voluntrias submetidas ao Pro- As voluntrias do Grupo 1 foram submetidas ao
grama de Reabilitao Cardiovascular fase III realiza- Programa de Reabilitao Cardiovascular fase III em
do em piscina teraputica a 34 C (PRC-piscina). piscina teraputica a 34C (PRC piscina), seguindo o
Grupo II (G2): quatro voluntrias submetidas ao Pro- protocolo:
grama de Reabilitao Cardiovascular fase III, realiza- 1) Aquecimento: 10-15 minutos, contendo exerccios
do no solo (PRC-piscina). de alongamento e exerccios aerbios em geral;
Todas as voluntrias preencheram os requisitos dos 2) Endurance: 15-20 minutos, sendo realizado
critrios de incluso do estudo, foram informadas a exerccios aerbios: caminhada, corrida, step,
r e s p eit o de suas participaes no mesmo e exerccios dinmicos tanto para membros superiores
assinaram, voluntariamente, o termo de consentimento e inferiores.
livre esclarecido. 3) Volta calma: 10-15 minutos, constando de alon-
Foi realizada inicialmente, uma anamnese com o gamentos e relaxamento.
objetivo de conhecer os hbitos de vida, volume de ati- A FC foi verificada no repouso, durante o exerccio e
vidade fsica diria e condies de sade pregressas e aps a volta calma e a PA no repouso e aps a volta
atuais. Dando-se ateno aos aspectos como uso de calma.
medicamentos, doenas prvias, cirurgias sofridas. O Grupo 2 foi submetido ao Programa de Reabilita-
Em seguida, com o objetivo de avaliar a capacidade o Cardiovascular fase III, no solo (PRC solo) seguin-
fsica e de verificar o comportamento das variveis car- do o protocolo:
diovasculares, tais como: presso arterial (PA) e fre- 1) Aquecimento: 10-15 minutos, realizando exerccios
qncia cardaca (FC) durante o esforo fsico, de alongamento e exerccios aerbios em geral;
realizou-se o teste da caminhada de 6 minutos (TC6 2) Endurance: 15-20 minutos sendo realizado esteira
min)9. O teste foi realizado, num percurso de 60 metros ergomtrica eltrica, bicicleta ergomtrica e
em um corredor plano, as voluntrias foram orientadas caminhada.
a caminhar de acordo com sua tolerncia ao exerccio 3) Volta calma: 10-15 minutos, constando de
no perodo de 6 minutos, estando cientes de que alongamentos e relaxamento.
poderiam reduzir o ritmo das passadas ou at mesmo o Sendo mensurados a FC e a PA no repouso, durante
exame por definitivo, se necessrio, frases de incentivo o exerccio e aps a volta calma.
foram utilizadas durante a caminhada. Caso as Para a determinao da intensidade de esforo foi
voluntrias interrompessem a caminhada, o cronmetro utilizado o mtodo de reserva da FC, tambm conheci-
continuava acionado, ao trmino do teste, distncia do como mtodo de Karvonen17, que utiliza o seguinte
percorrida foi avaliada. O monitoramento da PA foi clculo:
realizado antes e aps a execuo do teste e da FC Variao da FC alvo = ([FC mxima - FC repouso] x
antes, durante e aps o TC6 min, por meio de Ft) + FC repouso
cardiofrequencmetro. Sendo:
Utilizou-se para clculo do valor previsto, ou de refe- FC mxima = Freqncia cardaca de repouso -
rncia, para distncia no TC6 min, as equaes propos- idade
tas por Enright e Sherril17 (1998), determinando-se o FC repouso = Freqncia cardaca de repouso
percentual do previsto para cada teste realizado pelas FT = Fator de treinamento variando de 60% a 85%
voluntrias. da reserva da freqncia cardaca segundo as
Distncia TC6 (m) = (2,11 x altura cm) (2,29 x peso Diretrizes da ACSM American College of Sports
kg) (5,78 x idade) + 667 m Medicine1 (2000).
Para a classificao da hipertenso arterial foram Durante a fase de endurance, quando as voluntrias
utilizados a metodologia e os valores de referncia atingiram a intensidade do treinamento, estipulada pelo
estipulados pela V Diretrizes Brasileiras de Hipertenso clculo de Karvonen e definida como zona alvo de trei-
Arterial25 (2004), conforme mostrado na Tabela 1. namento, o exerccio foi mantido constante (velocidade

Tabela 1. Classificao da presso arterial de acordo com a


e carga), para que ocorresse o steady state na FC da
medida casual no consultrio (> 18 anos)
zona alvo.

Classificao Sistlica Diastlica


O Programa de Reabilitao Cardiovascular fase III,
tanto em piscina teraputica, quanto no solo, foi realiza-
tima < 120 < 80 do duas vezes por semana com durao de 1 hora ca-
Normal < 130 < 85 da sesso num perodo de oito semanas.

Anlise estatstica
Limtrofe 130 139 85 89
Hipertenso
Estgio I (leve) 140 159 90 99
Estgio II (moderado) 160 179 100 109 A anlise descritiva dos dados compreendeu valores
Esttio III (grave) > 180 > 110
Hipertenso sistlica isolada > 140 < 90
de mdia e desvio padro para nveis de PAS, PAD e
FC. Nesse caso, foram comparados valores para os
Quando as presses sistlica e diastlica de um paciente situam- grupos G1 e G2. Aplicou-se teste t para o estudo
se em categorias diferentes, a maior deve ser utilizada para comparativo entre os grupos. Admitiu-se erro a de 5%
classificao da presso arterial.
com nvel de significncia para p< 0,05.

Accioly MF, Piotto RF. Efeito de um programa de reabilitao cardaca fase III realizado em piscina teraputica e no solo, em mulheres
hipertensas. Rev Inst Cinc Sade. 2007; 25(2):141-6.
144

Resultados e Discusso no ter havido modificaes na dosagem dos medica-


mentos durante a realizao da pesquisa.
As voluntrias tinham idade mdia 62,12 9,52 anos Silva et al.24 (2006) estudando 10 indivduos do sexo
como demonstrado na Tabela 2. masculino e seis do sexo feminino de meia idade,

Tabela 2. Valores de mdia (M) e desvio padro (DP) para


observaram, em 16 semanas de treinamento fsico aer-

idade das voluntrias do Grupo 1 e Grupo 2


bio, trs vezes por semana, com intensidade da carga
de trabalho variando entre 70% e 80% da freqncia
Voluntrias Idade (anos) cardaca mxima atingida no teste de avaliao funcio-
nal, redues estatisticamente significantes (p< 0,05)
Grupo 1 da PAS e PAD para os voluntrios do sexo masculino e
A 67
B 68 da PAS (p< 0,05) para as voluntrias do sexo feminino,
C 69 aps o perodo de treinamento.
D 62 As pesquisas realizadas pelos grupos de Fisiologia
Grupo 2 da Atividade Motora da Escola de Educao Fsica e
E 44 Esporte da Universidade de So Paulo e pela Unidade
F 52 de Reabilitao Cardiovascular e Fisiologia do Exerccio
G 63
e Unidade de Hipertenso do Instituto do Corao da
Faculdade de Medicina da Universidade de So Paulo24
H 72
Mdia 62,12
DP 9,52 identificaram que somente o treinamento fsico realizado
em intensidade leve a moderada, correspondente a
55% do VO2 de pico, atenuou a hipertenso arterial de
A Tabela 3 demonstra os valores de mdia e desvio ratos com hipertenso severa quando comparados a ra-
padro, referentes PAS, PAD e FC de repouso, tos sedentrios e treinados em 85% do VO2 de pico. O
iniciais, ou seja, prvios a aplicao do Programa de mecanismo hemodinmico envolvido na atenuao da
Reabilitao Cardiovascular fase III em piscina (G1) e hipertenso nesses animais foi reduo do dbito car-
no solo (G2) e aps a sua aplicao. daco associada bradicardia de repouso e reduo do
Ao verificar os dados iniciais, pr-tratamento (Tabela tnus simptico cardaco. Outra importante contribuio
3), identificou-se que ambos os grupos (G1: PASr = 145 deste grupo de pesquisadores foi o estudo do efeito do
12,91 mmHg; PADr = 87,5 5,00 mmHg; G2: PASr = treinamento fsico sobre a sensibilidade dos reflexos
142 15,00 mmHg, PADr = 87,5 5,00 mmHg) esta- pressorreceptor e cardiopulmonar em ratos esponta-
vam no grau leve de hipertenso arterial, segundo a V neamente hipertensos. Neste aspecto, observaram que
Diretrizes Brasileiras de Hipertenso Arterial25 (2004), a o treinamento fsico restaura a sensibilidade do reflexo
qual define como grau leve, valores pressricos de PAS pressorreceptor e cardiopulmonar, alm de aumentar a
entre 140-159 mmHg e de PAD entre 90-99 mmHg. atividade aferente pressorreceptora a variaes na
Quando se analisou o efeito do Programa de Reabili- presso arterial.
tao Cardiovascular fase III aplicado durante oito se- Vrios estudos demonstraram6,19,24 o efeito benfico do
manas, realizado em piscina teraputica (G1) e no solo exerccio fsico crnico na hipertenso arterial sendo
(G2), identificou-se diminuio estatisticamente signifi- dependente do tipo do exerccio fsico, da intensidade e
cante para as variveis PAS (p = 0,03) e PAD (p = 0,02) durao do mesmo. Identificou-se no presente estudo,
do G2, j no G1 houve uma pequena reduo destas melhor reposta hipotensora aps o PRC no grupo que
variveis, porm sem significncia estatstica, demons- realizou exerccio fsico no solo (G2) quando compara-
trando maior efetividade do Programa de Reabilitao do, ao que realizou na piscina teraputica (G1), poss-
Cardiovascular fase III realizado no solo. vel que tal fato se justifique pela dificuldade no controle
Estas redues implicam modificaes adaptativas da intensidade de esforo, de se atingir e manter a zona
nas respostas da presso arterial ao exerccio fsico, em alvo de treinamento no exerccio realizado na piscina.
portadores de hipertenso arterial sistmica de grau le- Entretanto, necessrio um estudo mais aprofundado
ve, entretanto deve-se considerar que as voluntrias fa- sobre esta questo inclusive com casustica maior.
ziam uso de medicao anti-hipertensiva, apesar de Quanto a varivel FCr, aps a aplicao do Programa

Tabela 3. Valores de mdia (M) e desvo padro (DP) para presso arterial sistlica de repouso; presso arterial diastlica de
repouso e freqncia cardaca de repouso das voluntrias submetidas a Programa de Reabilitao Cardaca-fase III
realizado em piscina (G1) e no solo (G2), pr e ps a sua aplicao
Varivel G1 pr (n = 04) G1 ps (n = 4) P G2 pr (n = 4) G2 ps (n=4) P
mdia DP mdia DP mdia DP mdia DP
PASr (mmHg) 145 12,91 140 8,16 0,537 142 15,00 120 11,7 0,034
PADr (mmHg) 87,5 5,00 86,25 4,78 0,730 87,5 5,00 67,5 9,57 0,020
FCr 83,75 4,78 80 4,08 0,278 89,25 11,08 77,5 9,57 0,277

n = nmero de voluntrias; p = nvel de significncia; PASr = presso arterial sistlica; PADr = presso arterial diastlica de repouso; FCr =
freqncia cardaca de repouso, mmHg = milmetros de mercrio; bpm = batimentos por minuto.

Accioly MF, Piotto RF. Efeito de um programa de reabilitao cardaca fase III realizado em piscina teraputica e no solo, em mulheres
hipertensas. Rev Inst Cinc Sade. 2007; 25(2):141-6.
145

de Reabilitao Cardiovascular fase III notou-se redu- os efeitos do treinamento fsico aerbio realizado no
es de seus valores nos dois grupos (G1: 83,75 4,78 solo e em piscina teraputica em hipertensos, possibili-
bpm para 80 4,08 bpm e G2: 86,25 11,08 para 77,5 tando assim, uma anlise mais conclusiva.

Concluso
9,57), embora sem diferena estatisticamente signifi-
cante, o G2 apresentou maior reduo.
H uma relao direta entre a freqncia cardaca
de repouso ou submxima e risco de desenvolvimento Sugere-se que o exerccio fsico aerbio realizado no
de doenas cardiovasculares, ou seja, indivduos com solo e na piscina teraputica promove adaptaes mor-
menor freqncia cardaca em repouso ou menor taqui- fofuncionais do sistema cardiovascular, evidenciada pe-
cardia durante o exerccio fsico submximo apresen- la bradicardia de repouso e reduo dos nveis press-
tam menor probabilidade de desenvolverem car- ricos, sendo, portanto um importante coadjuvante no
diopatias23. A bardicardia de repouso ps-treinamento tratamento no farmacolgica da hipertenso arterial
pode estar associada reduo do tnus simptico sistmica.
sobre o corao23. O treinamento com os exerccios aerbios, realizados
Tendo em vista a pequena amostragem utilizada e a no solo, mostrou-se mais eficaz na reduo da PAS,
ausncia de um grupo controle, considera-se necess- PAD e FC do que o treinamento com exerccios aer-
rio a continuidade e aprofundamento do estudo, sobre bios na piscina teraputica.

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7. Chobanian AV, Bakris GL, Black HR, Cushman
WC, Green LA, Izzo JL, et al. The Seventh Report 14. Kaiser S.E. Evidncias reais e imaginrias no tra-
of the Joint National Committee on Prevention, De- tamento da hipertenso arterial. In: Programa de
tection, Evaluation, and Treatment of High Blood Educao Continuada da Sociedade Brasileira de
Pressure: the JNC 7 report. JAMA. 2003;289(19): Cardiologia. Mdulo I. Rio de Janeiro: Diagraphic;
2560-72. 2003. v.1, n.1. p.9.

Accioly MF, Piotto RF. Efeito de um programa de reabilitao cardaca fase III realizado em piscina teraputica e no solo, em mulheres
hipertensas. Rev Inst Cinc Sade. 2007; 25(2):141-6.
146

15. Legramante JM, Galante A, Masseco M, Attanasio 21. Sakai T, Ideishi M, Miura S, Maeda H, Tashiro E,
A, Raimondi G, Pigozzi F, et al. hemodynamic and Koga M, et al Mild exercise activates renal
autonomic correlates of post exercise hypotension dopamine system in mild hypertensives. J Hum
in patients with mild hypertension. Am J Physiol Hypertens.1998;12(6):355-62.
Regul Integr Comp Physiol. 2002;282:1037-43.
22. Seals DR, Tanaka H, Clevenger CM, Monahan KD,
16. Lotufo PA. Stroke in Brazil: a neglected disease. Reiling MJ, Hiatt WR, et al. Blood pressure
So Paulo Med J;123 (1): 3-4, 2005. reductions with exercise and sodium restriction in
postmenopausal women with elevated systolic
pressure: role of arterial stiffness. J Am Coll Cardiol.
17. Mcardle WD, Katch FI, Katch VL. Fisiologia do
2001;38(2):506-13.
exerccio: energia, nutrio e desempenho
humano. 4a ed. Rio de Janeiro: Guanabara
Koogan; 1998. p.300-8. 23. Seccareccia F, Menotti A. Physical activity, physical
fitness and mortality in a sample of middle aged
menfollowed-up 25 years. J Sports Med Phys
18. Nami R, Mondillo S, Agricola E, Lenti S, Ferro G,
Fitness. 1992;32(2):206-3.
Nami N, et al. Aerobic exercise training fails to
reduce blood pressure in nondipper-type
hypertension. Am J Hypertens. 2000;13:593-600. 24. Silva E, Ottero NA, Sakabe DI, Gallo Jr L, Ferreira
Filho P, Catai MA. Efeito agudo e crnico do
treinamento fsico aerbio sobre a resposta da
19. Negro CE, Rondon MUPB. Exerccio fsico,
presso arterial sistmica de indivduos hipertensos.
hipertenso e controle barorreflexo da presso
Rev Soc Cardiol Estado de So Paulo.
arterial. Rev Bras Hipertens. 2001;8:89-95.
2006;1(Supl.A):9-20.

20. Negro CE, Rondon MUPB, Kuniyosh FHS, Lima


25. Sociedade Brasileira de Hipertenso. Sociedade
EG. Aspectos do treinamento fsico na preveno
Brasileira de Cardiologia. Sociedade Brasileira de
da hipertenso arterial. Rev Bras Hipertens.
Nefrologia. V Diretrizes Brasileiras de Hipertenso
2001;4 [citado em 11 maio 2003] Disponvel em:
Arterial. Arq Bras Cardiol. 2004;83(Supl.4):7-22.
http//www.sbh.org.br/revista/2001_2001_V4.

26. Teixeira JAC. Hipertenso arterial sistmica e


atividade fsica. Rev SOCERJ. 2000;13:25-30.

Recebido em 24/10/2006
Aceito em 20/12/2006

Accioly MF, Piotto RF. Efeito de um programa de reabilitao cardaca fase III realizado em piscina teraputica e no solo, em mulheres
hipertensas. Rev Inst Cinc Sade. 2007; 25(2):141-6.
Rev Inst Cinc Sade
2007; 25(2):147-52 PHYSIOTHERAPY

Effect of a cardiac rehabilitation program phase III carried out on


hypertensive women in a therapeutic pool and on the ground

Marilita Falngola Accioly*


Raquel Ferrari Piotto**

Abastract
Introduction Epidemiological studies have been identifying an inverse association between
the regular practice of physical activity and the incidence or risk of developing arterial
hypertension. The purpose of this I study was verify cardiovascular adaptations induced by
aerobic physical training on the systolic blood pressure (SBP), diastolic blood pressure (DBP)
and heart rate (HR) in women with systemic arterial hypertension (SAH), subjected to

on the ground (CRP ground). Material and Methods Eight sedentary volunteers with an average
cardiovascular rehabilitation program - phase III carried out in a therapeutic pool (CRP pool) and

age of 62.12 9.52 and SAH were studied. They had been on a hypotensive drug and its dose
was not changed. Two groups were formed: G1: four volunteers subjected to the CRP pool and
G2: four volunteers subjected to the CRP ground. Anamnesis, a six-minute walk test and a
cardiovascular rehabilitation program - phase III were carried out, which consisted of warming
up, endurance and cooling down. These tests were applied three times a week during 8 weeks.

test to student was applied with 5% of significance level. Results Effects of CRP pool and CRP
Effort intensity was 60% to 85% of cardiac frequency reserve using the Karvonen calculation. The

ground were analyzed and a statistically significant decrease was identified for SBP (p=0.03) and

ground. Conclusion The results of the research, suggested that aerobic training promotes
DBP (p=0.02) variable of G2, which did not occur in G1, showing higher effectiveness of CRP

morphological and functional adaptation on the cardiovascular system, which is an important


adjuvant in non-pharmacological treatment of systemic arterial hypertension.
Key words: Hypertension, rehabilitation; Exercise; Exertion; Exercise therapy

Introduction Among the mortality risk factors, arterial hypertension


accounts for 40% of deaths caused by stroke and 25 %
Brazilian society finds itself in an accelerated stage of of deaths by coronary diseases7.
epidemiological transition, linked with a rapid process of There are many strategies of intervention capable of
urbanization, and a life style compatible with life in big providing treatment for arterial hypertension (AH), eg
cities such as: sedentarism, smoking, stress, and frequent changes in life style, such as dietary habits and the
meals at fast food chains. This results in a proportionate amount of physical activity13. In respect specifically to
increase in the prevalence of obesity, diabetes, arterial the latter, epidemiological studies have identified an
hypertension and stroke. Together with the difficulty of inverse association between the regular practice of
access to health services and the poor level of information physi cal activity and the incidence o r ri s k o f
available to many people in urban centers, this causes developing arterial hypertension3,5. There is evidence
more human lives to end prematurely due to greater that aerobic physical training promotes, in the mid or
exposure and vulnerability to environmental factors long term, a reduction of the systolic blood pressure
harmful to the cardiovascular system. (SBP) and diastolic blood pressure (D B P ) 1, 2, 5, 1 0 .
In developed countries, on the contrary, the onset of Physical activity promotes favorable physiological
degenerative diseases is delayed due to a higher adaptations, resulting in an improvement of life
quality health service and to greater access by the quality 12. The regular practice of moderate exercise
public to information on preventative care14. In Brazil, in helps maintain the arterial pressure under control,
2003, 27,4% of deaths were related to cardiovascular improves the cardiorespiratory capacity, reduces the
diseases, rising to 37% when deaths due to non- blood levels of glucose and insulin (relevant for
defined causes are excluded: the major cause of death diabetes), controls the lipoprotein profiles, improves
in most regions of Brazil is stroke, particularly amongst the blood circulation, controls weight and improves
women16. general well-being4,8.

* Physiotherapeutic MSc in Physical Education, Universidade Estadual de Campinas (Unicamp). Doctor3 Degree, Health Sciences, School of Medicine, So
Jos do Rio Preto (FAMERP). Professor, Discipline Physiotherapy Clinic, Cardiology, Universidade Paulista (UNIP), So Jos do Rio Preto. E-mail:
marilita@terra.com.br
** Physiotherapeutic. Masters Degree, Graduate Course, FAMERP.
148

A better physical condition in people who do not intake25.


present cardiovascular risks, has a significant associa- The aim of this study was to analyse the cardiovas-
tion with less risk of mortality, since, in the majority of cular adaptations induced in the systolic arterial pressu-
studies carried out, it has been found that physical re, diastolic arterial pressure and heart rate in women
exercise decreases the blood pressure in hypertensive with moderate systemic arterial hypertension, submitted
people by an average of 10 mmhg, either in the systolic to a Cardiac Rehabilitation Program-phase III, carried
or the diastolic pressure. These values were obtained out in a therapeutic pool and on the ground.

Material and Methods


after the subjects were submitted to aerobic training and
at rest22.
The chronic effect, that is, the effect of the physical
training in the reduction of the arterial blood pressure is Eight female sedentary volunteers were studied, with
related to hemodynamic, humoral and neural factors20. an average age of 62,12 9,52 years, with moderate
Among the hemodynamic factors, it has been verified, systemic arterial hypertension (SAH) , who made use of
in spontaneously hypertensive rats as well as in hypotensive medication (beta-blockers and diuretics).
humans, that physical exercise promotes reduction in The medication dose was not changed during the
arterial blood pressure by a reduction in the cardiac research.
debt which is associated with the decrease of heart The volunteers were divided at random in two groups:
rate, when no alteration in the systolic volume18,20 was Group 1 (G1): four volunteers were submitted to a
observed. The decrease in the systemic vascular Cardiac Rehabilitation Program phase III carried out in
resistance and, consequently, in the arterial pressure a therapeutic pool at a temperature of 34 C (CRP-pool).
would be another alternative mechanism proposed to Group 2 (G2): four volunteers were submitted to a
explain a drop in the arterial pressure after Cardiac Rehabilitation Program phase III carried out
exercising15,18,20. on the ground (CRP-ground).
A significant decrease in pressure levels is obtained All the volunteers fitted the criteria for their inclusion in
with low intensity exercise (50% of peak oxygen intake). the study, they were all informed of their participation in
Therefore, low intensity physical exercise decreases it and all of them gave written informed consent.
arterial pressure because it promotes a reduction in the Initially an anamnesis was carried out with the aim of
cardiac debt, that could be explained by the decrease finding out more about the life style, amount of daily
in the heart rate at rest and in the cardiac sympathetic physical activity and previous and current health condi-
tone due to a smaller sympathetic intensification and a tions of the volunteers. Special attention was given to
greater vagal removal15,19-20. aspects such as: use of medication, previous diseases
A decrease of arterial blood pressure after physical and surgery undergone.
training in hypertensive subjects is also attributed to Then, with the aim of evaluating the physical capacity
humoral alteration linked to the production of vasoactive and to verify the behavior of cardiovascular variables,
substances such as the atrial natriuretic peptide or such as: arterial pressure (AP) and heart rate (HR)
ouabain-like, centrally modulated20. during physical effort the 6 minutes walking test (6
The hypotensive effect of physical training was minWT)9 was carried out. This test was carried out over
associated with a concomitant increase in prostaglan- a distance of 60 meters on a flat surface corridor. The
dins and urinary sodium excretion and reduction of volunteers were advised that they should walk
plasmatic catecholamine levels. Moreover, physical trai- according to their exercise tolerance within a period of
ning of moderate intensity stimulates the generation of time of 6 minutes, and they were also aware that they
renal dopamine and activates the kallikrein-kinin system could reduce the pace or even stop the exercise if
in the kidney, resulting in natriuresis and arterial blood necessary. Incentives were shouted to them during the
pressure reduction21, as well as,plasmatic renine and an walk. If the volunteers interrupted the walk the chrono-
increase in the production of nitric acid20. meter would be kept on, and at the end of the test, the
During physical activity, the systolic blood pressure distance would be evaluated. The monitoring of the AP
rises with the increase of the exercise intensity, due to was carried out before and after the test and the
an increase of the cardiac debt and to the systolic monitoring of the HR before, during and after the 6
volume, but must not exceed 230 mmHG: If this minWT, using a cardiofrequencymeter.
occurs, exercise must be stopped. The diastolic In order to work out the predicted value, or reference
pressure varies little, less than 10 mmHG, and if a value, for the distance in the 6 minWT, the equations
rapid increase occurs, exercise must also be proposed by Enright and Sherril17 (1998) were used,
stopped11. determining the percentage of the predicted value for
The Brazilian Society of Cardiology recomends that each test carried out by the volunteers.
hypertensive subjects start regular programs of physical Distance 6minWT = (2,11 x height cm) (2,29 x
exercise, following a previous clinical evaluation. weight kg) (5,78 x age) + 667 m
Exercise should be of moderate intensity, from three to For the classification of the arterial hypertension the
six times a week in sessions of 30 to 60 minutes, carried methods and the reference values stipulated by the V
out with a heart rate between 60 % and 80% (maximum) Brazilian Guidelines for the Arterial Hypertension 25
or between 50% and 70% of the maximum oxygen (2004), as shown in Table 1, were used.

Accioly MF, Piotto RF. Effect of a cardiac rehabilitation program phase III carried out on hypertensive women in a therapeutic pool and
on the ground. Rev Inst Cinc Sade. 2007; 25(2):147-52.
149

Table 1. Classification of arterial pressure according to mea-


sures taken randomly at a doctors surgery (> 18
TF = Training Factor ranging from 60% to 85% of the
years old)
reserve heart rate according to Guidelines of the
American College of Sports Medicine1 (2000).
Classification Systolic Diastolic During the endurance phase, at the moment the
Excellent < 120 < 80 volunteers reached the intensity of the training stipulated by
Normal < 130 < 85 the Karvonen method and defined as Target Training Zone,
Border line 130 139 85 89 the exercise was kept steady (speed and weight) in order
Hypertension to obtain the steady state in the HR at the target zone.
Stage I (light) 140 159 90 99 The Cardiac Rehabilitation Program phase III, both in
Stage II (moderate) 160 179 100 109 the therapeutic pool and on the ground was carried out
Stage III (serious) > 180 > 110 twice a week for 1 hour each session within a period of eight
Isolated systolic hypertension > 140 < 90
weeks. It was applied the test t for the comparative study

Statistical analysis
When the systolic and distolic pressure of a patient are situated in
different categories, the higher one must be used for the arterial
pressure classification
The descriptive analysis of data comprised of mean
The volunteers from Group 1 were submitted to a values and the standard deviation for the SAP, DAP and
Cardiac Rehabilitation Program phase III in a thera- HR levels. In this case values from groups G1 and G2
peutic pool at a temperature of 34C (CRP-pool),
were compared. The test t was applied for the compara-
following this protocol:
tive study between the groups. An error a of 5% was
1) Warm-up: 10-15 minutes, holding stretching exerci-
admitted with a significance level of p< 0,05.
ses and aerobic exercises in general;
Results and Discussion
2) Endurance: 15-20 minutes, with aerobic exercises,
walking, jogging, step, dynamic exercises for either
upper or lower limbs.
The volunteers were at an average age of 62, 12
3) Cooling down: 10-15 minutes, holding stretching
exercises and relaxation. 9,52 years as demonstrated in Table 2.

Table 2. Mean Values (MV) and Standard Deviation (SD) for


The HR was checked at rest, during exercise and
the volunteers age from Group 1 and Group 2
after cooling down and the AP was checked at rest and

Volunteers Age
after cooling down.
Group 2 was submitted to the Cardiac Rehabilitation
Program phase III, on the ground (CRP-ground) Group 1
following this protocol: A 67
1) Warm up: 10-15 minutes, holding stretching B 68
exercises and aerobic exercises in general; C 69
2) Endurance: 15-20 minutes, carried out on a D 62
treadmill, exercise bike and walking. Group 2
E 44
3) Cooling down: 10-15 minutes, holding stretching
F 52
exercises and relaxation. G 63
The HR and the AP were checked at rest, during the H 72
exercise and after cooling down. Mdia 62,12
To determine the effort intensity the reserve method of DP 9,52
HR, also known as The Karvonen method17, was applied
here using the following calculation:
Variation of the Target HR= ([HR maximum - HR Table 3 shows mean values and the standard
resting] x TF) + HR resting deviation , in what refers to SAP, DAP and resting HR,
As being: prior to the application of the Cardiac Rehabilitation Pro-
HR maximum = Maximum Heart Rate age gram phase III in the pool (G1) and on the ground (G2)
HR resting = Resting Heart Rate and after its application

Table 3. Mean Values (MV) and Standard Deviation (SD) for the resting systolic arterial pressure; resting diastolic arterial pressure
and resting heart rate of the volunteers submetted to the Cardiac Rehabilitation Program - Phase III carried out in the pool
(G1) and on the ground (G2), pre and post application
Variable G1 pr (n = 04) G1 ps (n = 4) P G2 pr (n = 4) G2 ps (n=4) P
MV SD MV SD MV SD MV SD
RSAP (mmHg) 145 12,91 140 8,16 0,537 142 15,00 120 11,7 0,034
RDAP (mmHg) 87,5 5,00 86,25 4,78 0,730 87,5 5,00 67,5 9,57 0,020
FCr 83,75 4,78 80 4,08 0,278 89,25 11,08 77,5 9,57 0,277

n = number of volunteers; p = significance level; rSAP = resting systolic arterial pressure; rDAP = resting diastolic arterial pressure; rHR =
resting heart rate, mmHg = milimeters of mercury; bpm = beatings per minute

Accioly MF, Piotto RF. Effect of a cardiac rehabilitation program phase III carried out on hypertensive women in a therapeutic pool and
on the ground. Rev Inst Cinc Sade. 2007; 25(2):147-52.
150

By verifying the initial data, pre-treatment (Table 3), it observed that physical training restores sensitivity to the
was identified that both groups (G1: RSAP =145 12,91 cardio-pulmonary and pressorreceptor reflexes, and
mmHg; RDAP = 87,5 5,00 mmHg; G2: RSAP = 142 moreover, increase the pressorreceptor activity of the
15,00 mmHg, PADr = 87,5 5,00mmHg) were with light arterial pressure variables.
arterial hypertension, according to the V Brazilian Several studies demonstrate6,19,24 the beneficial effect
Guidelines for Arterial Hypertension25 (2004), which of chronic physical exercise for arterial hypertension,
defines as light level , pressure values of SAP between being dependent on the type of physical exercise, the
140-159 mmHg and of DAP between 90-99 mmHg. intensity and duration of it. The present study identified a
When the effect of Cardiac Rehabilitation Program better hypotensive result after the CRP, in the group that
phase III applied for eight weeks, carried out in a carried out physical exercise on the ground (G2) when
therapeutic pool (G1) and on the ground (G2), was compared with the group that carried out exercise in the
evaluated, a statisticaly significant decrease was identified therapeutic pool (G1). It is possible that this fact is
for the variables SAP (p=0,03) abd DAP (p=0,02) for G2, justified by the difficulty in controlling the intensity of the
whereas in the G1 there was a slight reduction of these effort and difficulty in achieving and keeping the target
variables, however, without statistical significance, zone of training in the exercise carried out in the pool.
showing greater effectivity of the Cardiac Rehabilitation However a deeper study of this question is needed,
Program phase III carried out on the ground. together with a higher number of volunteers.
These reductions imply adaptative modifications of Regarding the resting HR, after the application of the
arterial pressure due to physical exercise in subjects Cardiac Rehabilitation Program phase III , the
with light systemic arterial hypertension, however, it reduction of its values was noticed in both groups (G1:
should be noted that the volunteers made use of 83,75 4,78 bpm for 80 4,08 bpm and G2: 86,25
hypotensive medication, although there were no 11,08 for 77,5 9,57), although without a statistically
changes in the medication dose during the study. significant difference, the G2 presented a greater
Silva et al.24 (2006) studying 10 male subjects and 6 reduction.
female middle aged subjects within a period of 16 There is a direct relation between the resting heart
weeks of aerobic physical training, three times a week, rate or sub-maximum and the risk of developing
with intensity of the work load between 70% and 80% of cardiovascular diseases, that is, subjects with a lower
the maximum heart rate achieved at the functional resting heart rate or lower tachicardy during the sub-
evaluation test, observed a statistically significant maximum physical exercise present a smaller
reduction (p < 0,05) for the SAP and DAP for the male probability in developing cardiopathies 23 . Resting
volunteers and SAP (p < 0,05) for the female volunteers, bradicardy post-training can be associated with the
after the training period. reduction of the cardiac sympathetic tone23.
The researches carried out by the groups of study on Taking into account the small sampling used and the
Physiology of the Motor Activity of the School of Physical lack of a control group, it is necessary that studies
Education and Sport of the University of So Paulo and continue on the effects of aerobic physical training
by the Cardiac Rehabilitation Unity and the Physiology carried out on the ground and in a therapeutic pool,
of Exercise and Hypertension Unity of the Heart Institute making a more conclusive analysis possible.
of the School of Medicine University of So Paulo24
identified that only the physical training carried out with Conclusion
a light or moderate level corresponding to 55% of peak
VO2, have attenuated the hypertension in rats with It is suggested that aerobic physical training carried
severe hypertension when compared to sedentary rats out on the ground and in a therapeutic pool promotes
and trained at 85% of peak VO2. The hemodynamic morphofunctional adaptations on the cardiovascular
mechanism involved in the attenuation of hypertension in system, proved by the resting bradicardy and the
these animals was the reduction of the cardiac debt reduction on the pressure levels, therefore being an
associated with resting bradicardy and reduction of the important aid in the non-medication treatment of the
cardiac sympathetic tone. Another important contri- systemic arterial hypertension.
bution from these research teams was the study of the Aerobic exercises carried out on the ground showed
effect of physical training on the sensitivity of presso- more efficiency in the reduction of the SAP, DAP and HR
rreceptor and cardio-pulmonary reflexes in sponta- compared to aerobic exercises carried out in the
neously hypertensive rats. Regarding that, it was therapeutic pool.

Accioly MF, Piotto RF. Effect of a cardiac rehabilitation program phase III carried out on hypertensive women in a therapeutic pool and
on the ground. Rev Inst Cinc Sade. 2007; 25(2):147-52.
151

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Accioly MF, Piotto RF. Effect of a cardiac rehabilitation program phase III carried out on hypertensive women in a therapeutic pool and
on the ground. Rev Inst Cinc Sade. 2007; 25(2):147-52.
152

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23. Seccareccia F, Menotti A. Physical activity, physical 25. Sociedade Brasileira de Hipertenso. Sociedade
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menfollowed-up 25 years. J Sports Med Phys Nefrologia. V Diretrizes Brasileiras de Hipertenso
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26. Teixeira JAC. Hipertenso arterial sistmica e


atividade fsica. Rev SOCERJ. 2000;13:25-30.

Received in 24/10/2006
Accepted in 04/12/2006

Accioly MF, Piotto RF. Effect of a cardiac rehabilitation program phase III carried out on hypertensive women in a therapeutic pool and
on the ground. Rev Inst Cinc Sade. 2007; 25(2):147-52.