EPIDEMIOLOGY

Is Concurrent Training Efficacious

Antihypertensive Therapy? A Meta-analysis
LAUREN M. L. CORSO1,2, HAYLEY V. MACDONALD1,2,3, BLAIR T. JOHNSON2,4, PAULO FARINATTI5,
JILL LIVINGSTON1, AMANDA L. ZALESKI1,2,6, ADAM BLANCHARD1, and LINDA S. PESCATELLO1,2
1
Department of Kinesiology, University of Connecticut, Storrs, CT; 2Institute for Collaboration on Health, Intervention and
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Policy (InCHIP), University of Connecticut, Storrs, CT; 3Department of Kinesiology, The University of Alabama, Tuscaloosa,
AL; 4Department of Psychological Sciences, University of Connecticut, Storrs, CT; 5Instituto de Educa0 ão Fı́sica e Desportos,
Universidade do Estado do Rio de Janeiro, Rio de Janeiro, BRAZIL; 6Henry Low Heart Center, Department of Cardiology,
Hartford Hospital, Hartford, CT

ABSTRACT

CORSO, L. M. L., H. V. MACDONALD, B. T. JOHNSON, P. FARINATTI, J. LIVINGSTON, A. L. ZALESKI, A. BLANCHARD,

and L. S. PESCATELLO. Is Concurrent Training Efficacious Antihypertensive Therapy? A Meta-analysis. Med. Sci. Sports Exerc.,
Vol. 48, No. 12, pp. 2398–2406, 2016. Aerobic exercise training and, to a lesser degree, dynamic resistance training, are recommended
to lower blood pressure (BP) among adults with hypertension. Yet the combined influence of these exercise modalities, termed concurrent
exercise training (CET), on resting BP is unclear. Purpose: This study aimed to meta-analyze the literature to determine the efficacy of CET
as antihypertensive therapy. Methods: Electronic databases were searched for trials that included the following: adults (919 yr), controlled
CET interventions, and BP measured pre- and postintervention. Study quality was assessed with a modified Downs and Black Checklist.
Analyses incorporated random-effects assumptions. Results: Sixty-eight trials yielded 76 interventions. Subjects (N = 4110) were
middle- to older-age (55.8 T 14.4 yr), were overweight (28.0 T 3.6 kgImj2), and had prehypertension (systolic BP [SBP]/diastolic BP
[DBP] = 134.6 T 10.9/80.7 T 7.5 mm Hg). CET was performed at moderate intensity (aerobic = 55% maximal oxygen consumption,
resistance = 60% one-repetition maximum), 2.9 T 0.7 dIwkj1 for 58.3 T 20.1 min per session for 19.7 T 17.8 wk. Studies were of
moderate quality, satisfying 60.7% T 9.4% of quality items. Overall, CET moderately reduced SBP (db = j0.32, 95% confidence
interval [CI] = j0.44 to j0.20, j3.2 mm Hg) and DBP (db = j0.35, 95% CI = j0.47 to j0.22, j2.5 mm Hg) versus control (P G 0.01).
However, greater SBP/DBP reductions were observed among samples with hypertension in trials of higher study quality that also examined
BP as the primary outcome (j9.2 mm Hg [95% CI = j12.0 to j8.0]/j7.7 mm Hg [95% CI = j14.0 to j8.0]). Conclusions: Among
samples with hypertension in trials of higher study quality, CET rivals aerobic exercise training as antihypertensive therapy. Because of
the moderate quality of this literature, additional randomized controlled CET trials that examine BP as a primary outcome among samples
with hypertension are warranted to confirm our promising findings. Key Words: ENDURANCE TRAINING, HYPERTENSION,
RESISTANCE TRAINING, SYSTEMATIC REVIEW

H
ypertension is the most common, costly, and pre-
ventable cardiovascular disease (CVD) risk factor,
affecting one in three (80 million) American adults
Address for correspondence: Lauren M. L. Corso, M.S., M.L.S. (ASCP)CM,
Department of Kinesiology, University of Connecticut, Gampel Pavilion
Room 206, 2095 Hillside Rd., U-1110, Storrs, CT 06269-1110; E-mail:
Lauren.Lamberti@uconn.edu.
Submitted for publication April 2016.
Accepted for publication July 2016.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal_s Web site (www.acsm-msse.org).
0195-9131/16/4812-2398/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2016 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000001056
(29). Adults with hypertension are at disproportionate risk
for developing CVD and are three to four times more likely
to die from CVD than those without hypertension (13,29).
Since 2010, the incidence of hypertension has not improved,
underscoring the need for cost-effective, sustainable lifestyle
intervention strategies to prevent, treat, and control hyper-
tension that include regular participation in exercise (33).
Aerobic exercise training lowers blood pressure (BP)
5–7 mm Hg, whereas dynamic resistance training lowers
BP 2–3 mm Hg among adults with hypertension (31).
Even modest reductions in BP of ~5 mm Hg can reduce the
risk of heart disease by 8% and stroke by 14%, substantiating
the clinical importance of exercise as an antihypertensive life-
style therapy (3). Accordingly, the American College of Sports
Medicine (ACSM) recommends 30 min of moderate-intensity
aerobic exercise on most, preferably all, days of the week

2398

Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
supplemented by dynamic resistance training 2–3 dIwkj1
as an antihypertensive lifestyle therapy (31).
Despite the ACSM recommendations, it is not well under-
stood how the combined effect of aerobic and dynamic resis-
tance exercise training, termed concurrent exercise training
(CET), influences resting BP among adults with high BP.
More specifically, CET is defined as aerobic and resistance
training performed in close proximity to each other (i.e., in a
single session or on separate days) (10,25). Nonetheless, pri-
mary level CET trials often do not disclose the proximity of
the aerobic and resistance exercise components, nor do they
describe the order in which they are applied (i.e., aerobic
performed before vs after resistance exercise). Thus, the
working definition of CET remains loosely characterized,
which may contribute to the inconsistencies in this literature
(4,8,17,30,44).
To date, five meta-analyses (4,8,17,30,44) have exam-
ined the BP response to CET and report SBP/DBP re-
ductions ranging from 0 to 4 mm Hg. These meta-analyses
examined a variety of clinical populations; Chudyk et al.
(4), Hayashino et al. (17), and Zou et al. (44) included
adults with type 2 diabetes mellitus; Pattyn et al. (30) in-
cluded those with the metabolic syndrome; and Cornelissen
et al. (8) included adults absent of CVD or other chronic
conditions. Cornelissen et al. (8), Chudyk et al. (4), and
Pattyn et al. (30) included trials that examined CET only,
whereas Hayashino et al. (17) and Zou et al. (44) examined
CET studies that also involved dietary cointervention. Finally,
only Cornelissen et al. (8) and Hayashino et al. (17) examined
resting BP as a primary outcome. No meta-analyses focused
exclusively on adults with hypertension per se; nonetheless,
three did report the baseline BP of the participants. Of those
meta-analyses that disclosed the baseline BP of their sample,
only ~30% (n = 9) involved adults with hypertension (8,17,30).
Despite four of the five meta-analyses reporting a measure of
heterogeneity (8,17,30,44), moderator analyses were rarely
performed in an attempt to explain the variability in the BP
response to CET. Finally, these meta-analyses did not quan-
tify the CET frequency, intensity, time, and type (FITT) of the
intervention, nor did they examine how the proximity or order
of the aerobic and resistance exercise components were
implemented and how they may have influenced the BP re-
sponse to CET (4,8,17,30,44).
Therefore, the purposes of our meta-analysis were to de-
termine the efficacy of CET as antihypertensive therapy and
to examine important potential moderators of the BP re-
sponse to CET.
METHODS
This meta-analysis is reported consistent with the Pre-
ferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) Statement (28).
Search Strategy and Selection Criteria
Aided by a medical librarian (JL), multiple electronic
databases (PubMed, Cumulative Index to Nursing and Allied
CONCURRENT TRAINING AND HIGH BLOOD PRESSURE
Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Health Literature, Web of Science, SportDiscus, and Scopus)
were searched from their inception until January 31, 2015. The
full search strategy appears in Supplemental Digital Content
(see Document, Supplemental Digital Content 1, Systematic
Search Terms and Full Search Strategy for each Electronic
Database, http://links.lww.com/MSS/A729). Qualifying CET
trials included the following: adult populations (919 yr old),
had a nonexercise control or comparison group, measured BP
pre- and postintervention for the CET and control groups, and
reported the FITT of the CET intervention. Cross-sectional
studies, epidemiological study designs, weight loss, or phar-
macological trials were excluded. Because hypertension rarely
occurs in isolation (i.e., clusters with metabolic or CVD risk
factors) (24), only studies that included populations with
disease(s) or health conditions unrelated to CVD (e.g., cancer,
HIV/AIDS) were excluded.
Potentially relevant reports were screened in triplicate
(LML, HVM, and AB) first by title, then title and abstract,
and last by full-text review. Reference lists of included
studies, recent reviews, and meta-analyses were searched for
additional qualifying reports.
Data Extraction: Coding and Reliability
Coded variables were extracted using a standardized coding
form and coder manual previously developed by a team of
experts (LSP, BTJ, and TBHM) and pilot tested. Two trained
coders (LML and AB) independently extracted and entered
study information with high reliability across all dimensions
(mean Cohen_s k = 0.83 and Pearson_s r = 0.87) (18). Coding
disagreements were resolved through discussion with a third
EPIDEMIOLOGY
independent party (HVM and LSP). Data were extracted as
reported by study authors and included study characteristics
(e.g., randomization and methodological study quality),
sample characteristics (e.g., age and baseline BP), and fea-
tures of the CET intervention (e.g., FITT).
Data Extraction: Methodological Study Quality
Methodological study quality was assessed with a modi-
fied version of the Downs and Black Checklist (12) and
gauged as a percentage of items satisfied out of a possible
33-point total. This checklist has been widely used for
health-related outcomes and is considered one of the most
comprehensive quality assessment tools available (9). Details
of the modified version of the Downs and Black Checklist
appear in Supplemental Digital Content 2 (see Document,
Supplemental Digital Content 2, Modified Downs and Black
Checklist, http://links.lww.com/MSS/A733). Study quality
was quantified as low (e16 points, e50%), moderate (916 to
23, 50% to 69%), or high (Q24, Q70%) (5). Overall method-
ological study quality, study quality subscales (i.e., reporting,
external validity, bias, confounding, and power), and indi-
vidual quality items (i.e., BP-focused primary outcomes) were
examined in analyses to determine their influence on the BP
response to CET.
Medicine & Science in Sports & Exercised 2399
 Effect Size Calculations
The standardized mean difference effect size (between-
group, db) was used to quantify the effectiveness of CET as
antihypertensive therapy, defined as the mean difference in
resting SBP/DBP between the CET and the control groups
post- versus preintervention divided by the pooled SD,
correcting for small sample size bias and baseline differ-
ences (1,18). We disaggregated comparisons for trials with
more than one CET intervention (1). Effect sizes were cal-
culated for each CET and control group and analyzed sep-
arately for the different comparisons.
Twenty-five CET trials involved an ‘‘active content’’
control group; that is, the control group was randomized to
usual care for chronic disease, minimal effect stretching
routines, relaxation, or educational information sessions on
health rather than a nonexercise wait-list control. To ex-
amine the potentially confounding effects that an active
content control group (15) may have had on the between-
group, db, effect size, we examined the within-group, dw,
effect size, defined as the mean BP difference in resting BP
post- versus preintervention for the independent CET and
control group, divided by the preintervention SD (1,21).
Negative d values were set to indicate greater BP reductions
were observed for the CET compared with the control group
(i.e., between-group, db) or relative to baseline (i.e., within-
group, dw). The magnitude of d was interpreted as 0.20,
0.50, and 0.80 for small, medium, and large BP reductions,
respectively (7). Last, we transformed d values arithmeti-
cally to provide the equivalent BP change in millimeters of
mercury for ease of clinical interpretation.
EPIDEMIOLOGY
Publication Bias
We assessed the potential for publication bias using fun-
nel plots (i.e., observed d values were plotted in contrast to their
standard errors), which were visually examined for asym-
metry and the presence of outliers. In addition, the methods
for detecting publication bias of Begg and Mazumdar (2) and
Egger et al. (14) were used to further examine suspected
asymmetry. Two effect sizes from the same study (11), one
for SBP and one for DBP, were determined to be outliers (i.e.,
more than three SD values than the mean). To reduce their
influence on our results, they were windsorized to be the
same magnitude as the next largest SBP and DBP effect sizes
(16). Contour-enhanced funnel plots of the distribution of
the within-group (dw) effect sizes appear with and without
winsorization for SBP and DBP in Supplemental Digital
Content 3 (see Figure, Supplemental Digital Content 3, Contour
Enhanced Funnel Plots of Windsorized and Unwindsorized
Effect Sizes, http://links.lww.com/MSS/A734).
Cochran_s Q (i.e., the Q statistic) was used to determine the
presence (or absence) of heterogeneity (6). Higgins_s I2 sta-
tistic and corresponding 95% confidence interval (CI) were
used to gauge the degree or extent of heterogeneity present in
the sample (19,20). I2 values range from 0% (homogeneity)
to 100% (greater heterogeneity); a CI that does not include
2400 Official Journal of the American College of Sports Medicine
Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
0% indicates that the hypothesis of homogeneity is rejected
and an inference of heterogeneity is merited (19,20).
Moderator Analysis
In the presence of significant heterogeneity, separate mod-
erator analyses were used to explain variability in the BP re-
sponse to CET and control by examining theoretically driven
a priori moderators. These moderators included the follow-
ing: study characteristics (e.g., randomized vs nonrandomized
controlled trial, number of CET arms, and methodological
study quality), sample characteristics (e.g., age, medication
use, and baseline BP), and features of the CET intervention
(e.g., FITT and the order and proximity of aerobic and re-
sistance exercise). Weighted regression models with a maxi-
mum likelihood estimation of the random-effects weights, the
inverse variance for each dw, were used to explain variability
in dw for SBP and DBP for the CET and control interventions.
All interaction terms were generated with moderators and
tested for significance. Continuous moderators were mean
centered, and categorical variables were contrast coded before
generating interaction terms or performing multiple moderator
analyses (22). Windsorized within-group, dw, effect sizes for
the CET and the nonexercise control or comparison group
were evaluated separately in moderator analyses.
Multiple moderator models. We did not rely only on
significant bivariate meta-regression analyses when exam-
ining a priori moderators in multiple moderator models. Sig-
nificant or trending moderators were examined in conjunction
with the model coefficient and R2 values (i.e., between-study
variance explained by covariate) to examine the influence of
individual moderators on the BP response to CET (43). To best
minimize the influence of any methodological differences be-
tween trials, overall methodological study quality, study qual-
ity subscales, or individual quality (e.g., BP-focused primary
outcomes) dimensions were controlled for and incorporated
into multiple moderator models when feasible (22,43).
The moving constant technique. The moving con-
stant technique (22) was applied to estimate the magnitude
of the weighted mean effect sizes (dw+) at different levels of
interest for individual moderators, including extreme values,
and clinical thresholds$(e.g., BP classification) (3). These
estimates, or predicted d wþ values, and their CIs statistically
control for the influence of other moderators in the model,
holding them constant at their mean values.
Additive models. For SBP and DBP, additive models
were generated from the final multiple moderator models that
represented the greatest potential antihypertensive benefit
resulting from CET. Individual moderators were assessed
within the same$model at the level that yielded the greatest BP
reduction (i.e., d wþ and 95% CI). Overall, these models iden-
tified the ideal sample or study profile that results in optimal
antihypertensive therapy.
Statistical Computing
Results are presented as mean T SD unless otherwise in-
dicated. Differences in baseline characteristics between the
http://www.acsm-msse.org
 EPIDEMIOLOGY
FIGURE 1—Flow chart detailing the systematic search of potential reports (k) and selection process of included CET trials. CINAHL, Cumulative
Index to Nursing and Allied Health Literature.

CET and the control groups were examined using t-tests and Of note, 33% (k = 25) of interventions used an ‘‘active con-
one-way ANOVA. Analyses were performed using Stata tent’’ control comparison, whereas the remaining inter-
13.1 (Stata Corp, College Station, TX) (40) with macros for ventions (67%, k = 51) used a nonexercise control group
meta-analysis (26) and incorporated random-effects assump- (Table 1). A general description of each CET and control
tions. Significance was set at P G 0.05. TABLE 1. Features of the nonexercise control or comparison group (k = 76).
Characteristics k Mean T SD Range
Participants enrolled in control at baseline (n) 76 27.4 T 34.9 6–208
RESULTS Participants in control post-CET (n) 76 24.9 T 30.5 6–252
Control or comparison group FITT
Study characteristics. In total, 68 trials qualified for Frequency (sessions per week) 14 1.7 T 1.4 0.3–3
inclusion in our meta-analysis. Eight trials included multiple Intensitya – – –
Time (min per session) 5 61.0 T 19.5 35–90
CET arms, yielding 76 interventions (k). The systematic search Type of control group
and selection process of the included CET trials is shown in Education 8 10.5%
Stretching or relaxation routine 8 10.5%
Figure 1. A list of included trials is available in Supplemental Chronic disease management 9 11.8%
Digital Content 4 (see Document, Supplemental Digital Nonexercise or wait-list control 51 67.1%
Content 4, Supplementary Reference List, http://links.lww. All statistics are presented as mean T SD unless otherwise stated. k, number of observa-
com/MSS/A730). Most of the included CET trials were ran- tions; FITT, frequency, intensity, time, and type of the control or comparison group; n =
number of study-level participants.
domized controlled trials (84.2%, k = 64) with only a mi- a
Intensity was not reported or estimated for the control or comparison group. All control
nority examining BP as a primary outcome (14.5%, k = 11). or comparison groups were designed to not elicit training effects.

CONCURRENT TRAINING AND HIGH BLOOD PRESSURE Medicine & Science in Sports & Exercised 2401

Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 TABLE 2. Baseline sample characteristics for CET (k = 76) and nonexercise control or Features of the CET interventions. On average,
comparison (k = 76) groups.
CET was performed 2.9 T 0.7 dIwkj1 at moderate intensity
Total Sample (N = 4110)
(aerobic exercise training = 55% maximal oxygen consumption;
Control Concurrent
Characteristics k (n = 1965) (n = 2144) dynamic resistance training = 60% of one-repetition maxi-
Age (yr) 76 55.9 T 14.5 55.8 T 14.4 mum), 58.3 T 20.1 min per session for 19.7 T 17.8 wk (Table 3).
Women in sample (%) 68 54.8 T 34.3 54.5 T 34.0 More than half of the included CET interventions failed to
Body composition
Body weight (kg) 48 76.6 T 13.4 76.3 T 12.8
report the order (65.8%, k = 50) and proximity (57.9%, k =
Waist circumference (cm) 19 92.4 T 14.4 98.0 T 9.7 44) of the individual aerobic and resistance exercise compo-
Body mass index (kgImj2) 58 27.9 T 3.6 28.0 T 3.6 nents. Of those that disclosed these details, 7.9% (k = 6)
Body fat (%) 23 32.5 T 6.7 32.4 T 6.8
Fat mass (kg) 6 28.8 T 11.5 28.9 T 9.8 performed aerobic and resistance exercise on separate days
Fat free mass (kg) 9 51.4 T 9.3 50.8 T 8.5 (i.e., ‘‘combined training’’). The remainder of interventions
Health status
Sedentary (% sample)a 35 95.3 T 18.3 98.1 T 9.2
performed both modalities on the same day using the follow-
Absent of CVD-related chronic disease 43 56.6% ing protocols: circuit training (i.e., alternating between aerobic
or health conditions (% sample)b and resistance exercise) (6.6%, k = 5), aerobic first followed
CVD-related chronic disease or health 33 43.4%
conditions (% sample)c by resistance exercise (15.8%, k = 12), or resistance first
Medication use (% sample) 36 94.3 T 23.4 88.9 T 31.9 followed by aerobic exercise (11.8%, k = 9). The majority of
BP medication use (% sample) 31 90.3 T 30.0 93.5 T 25.0
Resting hemodynamics
Pre-SBP (mm Hg) 75 135.1 T 10.7 134.6 T 10.9 TABLE 3. Features of the CET program (k = 76).
Pre-DBP (mm Hg) 68 80.6 T 10.3 80.7 T 7.5
Pre-HR (bpm) 30 69.8 T 5.7 70.8 T 6.9 Characteristics k Mean T SD Range
Strength and fitness measuresd Participants enrolled at baseline (n) 76 30.9 T 34.6 6–280
Oxygen uptake (mLIkgj1Iminj1) 32 25.7 T 6.6 25.1 T 6.4 Participants post-CET (n) 76 27.4 T 29.7 7–249
Handgrip strength (kg) 5 21.3 T 3.0 21.3 T 2.9 Adherence (% exercise sessions completed) 18 84.9 T 10.2 55–100
Attrition (%) 76 7.9 T 12.9 0–56
All statistics are presented as mean T SD unless otherwise noted. k = number of observations.
CET FITT
a
Sedentary = participation in G30 min of moderate-intensity physical activity G2 dIwkj1 or
Length (wk) 76 19.7 T 17.8 3–144
absence of physical activity data or samples that were reported as sedentary at baseline.
b Frequency (dIwkj1) 66 2.9 T 0.73 1–5
Absent of CVD-related chronic disease or health conditions = participants were reported
Intensity
as free from CVD-related chronic disease or health conditions.
c Aerobic exercise intensity&
CVD-related chronic disease or health conditions reported alone or as comorbid conditions
Maximum HR (%) 33 68.8 T 8.6 53–85
within the sample included arthritis, CVD, diabetes, hypertension, metabolic syndrome, and
HR reserve (%) 11 66.3 T 8.5 44–75
kidney disease.
d Oxygen uptake (%V̇O2max) 6 62.5 T 15.1 40–75
Oxygen uptake was reported by 32 CET and control interventions; only peak or maximal
Borg rating of perceived exertion 3 11.7 T 1.9 10–13
tests are summarized. Handgrip strength was reported by five CET and control trials; only
Metabolic equivalent unita 76 4.7 T 1.4 2–8
trials that reported handgrip strength in kilograms are summarized.
Resistance exercise intensity*
One-repetition maximum (%) 27 63.5 T 10.3 45–80
Ten-repetition maximum (%) 3 81.7 T 22.5 60–105
EPIDEMIOLOGY

Maximum voluntary contraction (%) 4 64.8 T 16.7 40–75

intervention appears in Supplemental Digital Content 5 (see Borg rating of perceived exertion 3 11.7 T 1.9 10–13
Metabolic equivalent unita 76 4.2 T 1.4 3–8
Table, Supplemental Digital Content 5, Summary Table of Average intensity (metabolic equivalent unit)a 76 4.4 T 1.2 2–8
Included Concurrent Exercise and Control Interventions, Time
http://links.lww.com/MSS/A732). Aerobic exercise
Session length (min per session) 42 35.1 T 15.3 15–80
Overall, included trials were of moderate methodological Resistance exercise
study quality, satisfying 60% or 20 points on the augmented Session length (min per session) 31 32.3 T 18.7 10–75
No. exercises per session 44 8.01 T 2.2 3–13
Downs and Black Checklist, indicating this literature No. sets per exercise 49 3.1 T 3.5 1–27
displayed considerable variability in scores (39.4% to 84.8%, No. reps per set 51 11.8 T 2.9 8–20
Average session length (min per session) 56 58.3 T 20.1 20–120
13 to 28 points). Only five trials were considered of higher Type of CET
quality (Q70% items satisfied). Of the five study quality sub- Same day, single exercise session 26 34.2%
scales, trials were most likely to satisfy external validity Aerobic before resistance 9 11.8%
Aerobic after resistance 12 15.8%
(93.9% T 21.56%), confounding (66.0% T 16.8%), and bias Alternating or circuit style 5 6.6%
(70.1% T 10.4%) with substantial deficiencies in reporting Separate days, ‘ combined training’’ 6 7.9%
Order of modalities not reportedb 50 65.8%
(53.5% T 17.3%) and power (12.5% T 26.0%). Proximity of modalities not reportedc 44 57.9%
Sample characteristics. More than half of the CET
All statistics are presented as mean T SD unless otherwise stated. k, number of observa-
interventions (k = 43) included samples that were absent of tions; FITT, frequency, intensity, time, and type of the CET intervention.
a
CVD-related chronic disease or health conditions, whereas the b
Estimated metabolic equivalent unit.
Order of exercise modalities refers to whether the aerobic or dynamic resistance training
remaining interventions (k = 33) reported that they included components were performed first.
populations with known chronic disease(s) and health con- c
Proximity of exercise modalities refers to whether the aerobic and dynamic resistance
ditions related to CVD that included type 2 diabetes, CVD, training components were performed in a single session or on separate days (‘‘combined
training’’) and aerobic exercise intensity was reported by all CET interventions; only those
metabolic syndrome, and chronic kidney disease, or a combi- that report maximum HR, HR reserve, oxygen uptake, and Borg rating of perceived exertion
nation of these chronic diseases and health conditions. Baseline are summarized.
*Resistance exercise intensity was reported by all CET interventions; only those that report
sample characteristics did not differ between the CET and the one-repetition maximum, 10-repetition maximum, maximum voluntary contraction, and Borg
nonexercise control or comparison groups (P 9 0.05) (Table 2). scale of perceived exertion are summarized.

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the CET interventions were supervised (64.5%, k = 49); 9.2%
of the interventions incorporated a combination of super-
vised and unsupervised exercise, and 2.6% were unsupervised
(k = 2). Eighteen (23.4%) interventions failed to report the
level of supervision during the CET sessions. Adherence
to the CET intervention ranged from 55% to 100% with an
average attrition rate of 84.9%.
BP assessment methods. BP was most commonly
assessed using automated methods (34.2%, k = 26) in the
seated (25%, k = 19) position. Unfortunately, 46.1% (k = 35)
of the trials failed to disclose details of the BP measurement.
CET interventions rarely reported the use of standard labo-
ratory measurement protocols (3.6%, k = 3), and only one study
assessed BP under ambulatory conditions (36). Details related
to BP assessment methods are available in Supplemental
Digital Content 6 (see Table, Supplemental Digital Content 6,
Blood Pressure Assessment Methodology Table, http://links.
lww.com/MSS/A735).
The antihypertensive effects of CET. For the between-
group comparisons, CET lowered SBP 3.2 mm Hg (db+ = j0.32,
95% CI = j0.44 to j0.20) and DBP 2.5 mm Hg (db+ = j0.35,
95% CI = j0.47 to j0.22) compared with control. Collec-
tively, these effect sizes lacked homogeneity (I2 [95% CI]:
SBP = 68.6% [60.3–75.2]; DBP = 65.7% [55.8–73.4]).
For the within-group (dw+) comparisons, CET lowered SBP
3.6 mm Hg (dw = j0.36, 95% CI = j0.44 to j0.27) and DBP
3.9 mm Hg (dw = j0.39, 95% CI = j0.49 to j0.29) post-
versus preintervention. The nonexercise control or comparison
group lowered SBP 1.1 mm Hg (dw+ = j0.11, 95% CI = j0.18 to
j0.22), but DBP was not different post- versus preintervention
(P 9 0.05). The distribution of these effect sizes displayed
significant heterogeneity for both the CET (I2 [95% CI]: SBP =
57.0% [44.4–66.7]; DBP = 70.1% [61.8–76.6]) and the con-
trol or comparison (SBP = 43.3% [25.3–57.0]) groups. The
mean between-group (db+) and within-group (dw+) effect sizes
and homogeneity statistics appear in Supplemental Digital
Content 7 (see Table, Supplemental Digital Content 7, Table of
Mean Effect Sizes, http://links.lww.com/MSS/A731).
Multiple moderator analyses. Multiple moderator
models for SBP and DBP appear in Tables 4 and 5, respectively.
SBP was reduced more among samples with hypertension
(5.3 mm Hg) compared with prehypertension (2.9 mm Hg)
and those with normal BP (+0.9 mm Hg) (P = 0.01). Fur-
thermore, even larger SBP reductions were observed among
samples with hypertension when trials examined BP as a pri-
mary study outcome (7.6 mm Hg) versus those that did not
(3.1 mm Hg) (P = 0.01). We also observed greater SBP re-
ductions among studies of higher (3.6 mm Hg) than lower
(1.9 mm Hg) study quality (P = 0.01).
Additive model: CET elicited the greatest potential SBP
reductions (9.2 mm Hg, 95% CI = 12.0–8.2) among samples
with hypertension in higher-quality trials that examined BP
as a primary outcome. These effects were not influenced by
the order (i.e., aerobic performed before vs after resistance
exercise) or proximity (i.e., in a single session or on separate
days) of the aerobic and resistance exercise components but
these were controlled in our final models (see Additive Model,
Table 4). Among the control or comparison groups, greater
SBP reductions were observed among the ‘‘active content’’
(1.9 mm Hg) than the nonexercise or wait-list control groups
(0.0 mm Hg) (P = 0.01).
DBP was reduced to the greatest extent among samples with
hypertension (5.6 mm Hg) compared with prehypertension

EPIDEMIOLOGY
(3.6 mm Hg) and those with normal DBP (1.5 mm Hg) (P = 0.01).

TABLE 4. Multiple moderator analysis of the SBP response to CET (k = 76).

$

Study Dimension/Level k d wþ (95% CI) a

A P $ (mm Hg)b
Resting SBP of the concurrent exercise sample j0.747 0.001
Normal SBP = 115 T 3 mm Hg 3 0.29 (0.07 to 0.52) 0.9
Prehypertension SBP = 135 T 10 mm Hg 61 j0.29 (j0.39 to j0.19) j2.9
Hypertension SBP = 145 T 9 mm Hgc 11 j0.59 (j0.71 to j0.47) j5.3
Methodological study quality j0.245 0.01
Lower quality = 50% T 10% 13 j0.19 (j0.32 to j0.07) j1.9
Median quality = 60% T 10% 58 j0.28 (j0.38 to j0.17) j2.8
Higher quality = 70% T 10%c 5 j0.36 (j0.46 to j0.25) j3.6
SBP of concurrent exercise sample  primary study outcome 0.537 0.001
BP-focused primary study outcome
Normal = 115 T 3 mm Hgd 0
Prehypertension = 135 T 10 mm Hg 71 j0.34 (j0.51 to j0.17) j3.4
Hypertension = 145 T 9 mm Hgc 5 j0.84 (j1.0 to j0.64) j7.6
Non-BP-focused primary study outcome
Normal = 115 T 3 mm Hg 3 j0.08 (j0.24 to 0.07) j0.2
Prehypertension = 135 T 10 mm Hg 66 j0.25 (j0.32 to j0.18) j2.5
Hypertension = 145 T 9 mm Hg 7 j0.34 (j0.44 to j0.24) j3.1
Additive model
Separate days 16 j1.01 (j1.21, j0.82) j9.2
Same days 60 j0.82 (j1.10, j0.59) j7.2
A, standardized coefficients; $, change; k, number of observations.
$
a
Predicted d values ( d wþ ) and 95% CI statistically control for each moderator in the model except for the moderator/level of interest. This model also controls for (not shown) whether the
concurrent exercise intervention was performed on the same day or different days (A = j0.12, P = 0.06) and whether BP was primary study outcome (A = 0.11, P = 0.08). SBP $ (in mm
$ $

Hg) = d wþ (95% CI) that was back translated. For each moderator and level of interest, d wþ was transformed using the SD corresponding to the concurrent exercise sample mean
(SD = 10 mm Hg) except normal BP (SD = 3 mm Hg) and hypertension (SD = 9 mm Hg).
b
Estimated weighted mean effect size (95% CI); estimate of the DBP reductions pre- to post-CET intervention.
c
Moderator dimensions and levels that conferred the largest SBP reductions and were used in the additive SBP models.
$
d
Insufficient cases to provide and estimation of d wþ .

CONCURRENT TRAINING AND HIGH BLOOD PRESSURE Medicine & Science in Sports & Exercised 2403

Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 TABLE 5. Multiple moderator analysis of the DBP response to CET (k = 68).
$
Study Dimension/Level k d wþ (95% CI) a
A P $ (mm Hg)b
Resting DBP of the concurrent exercise sample j0.445 0.001
Normal = 75 T 7 mm Hg 3 j0.21 (j0.36 to j0.06) j1.5
Prehypertension = 85 T 7 mm Hg 61 j0.49 (j0.64 to j0.33) j3.6
Hypertension = 95 T 7 mm Hgc 11 j0.77 (j0.99 to j0.54) j5.6
Methodological study quality j0.277 0.012
Lower quality = 50% T 10% 13 j0.23 (j0.41 to j0.05) j2.3
Median quality = 60% T 10% 58 j0.36 (j0.50 to j0.21) j3.6
Higher quality = 70% T 10%c 5 j0.48 (j0.63 to j0.33) j4.8
Additive model
Separate days 16 j1.11 (j1.40, j0.84) j7.7
Same days 60 j0.88 (j1.23, j0.53) j6.3
A, standardized coefficients; $, change; k, number of observations.
$
a
Predicted d values ( d wþ ) and 95% CI statistically control for each moderator in the model except for the moderator/level of interest. This model also controls for (not shown) whether the
concurrent exercise intervention was performed on the same day or different days (A = j0.12, P = 0.06) and whether BP was primary study outcome (A = 0.11, P = 0.08). DBP $ (in
$ $
mm Hg) = d wþ (95% CI) that was back translated. For each moderator and level of interest, d wþ was transformed using the SD corresponding to the concurrent exercise sample
mean (7 mm Hg).
b
Estimated weighted mean effect size (95% CI); estimate of the DBP reductions pre- to post-CET intervention.
c
Moderator dimensions and levels that conferred the largest DBP reductions and were used in the additive DBP models.

Greater DBP reductions were also observed among studies
of higher (4.8 mm Hg) than lower (2.3 mm Hg) study
quality (P = 0.013).
Additive model: CET elicited the greatest potential DBP
reductions among samples with hypertension in higher-quality
trials (7.7 mm Hg, 95% CI = 14.0–8.3). Consistent with SBP,
neither the order nor the proximity of the aerobic and resis-
tance exercise components (see Additive Model, Table 5)
proved statistically significant. Consistent with SBP, neither
the order nor the proximity of the aerobic and resistance
exercise components influenced the BP response to CET but
were controlled for in our final models.
DISCUSSION
EPIDEMIOLOGY
profile, cardiorespiratory fitness, and muscle endurance and
strength for overweight adults (27). As a result, it appears that
CET may be a more comprehensive approach to achieving
health benefits than aerobic training alone. These results
suggest that the current ACSM exercise recommendations for
hypertension (35) should be expanded to include specifics of
the FITT exercise prescription for CET.
Our meta-analysis is the first to examine methodological
study quality as a moderator of the BP response to CET. Un-
like previous meta-analyses (4,8,17,30,44), we quantitatively
examined methodological study quality independently and
interactively with other moderators to best determine the in-
fluence of study quality dimensions on the BP response to
CET. We found greater BP reductions in studies of higher
(Q70% items satisfied) than lower (e50% items satisfied)

The purposes of our meta-analysis were to investigate the
efficacy of CET as antihypertensive therapy and to exam-
ine important potential moderators of the BP response to CET.
On average, we found that moderate-intensity CET performed
~3 dIwkj1 for ~60 min per session modestly reduced BP on
average ~3 mm Hg compared with control. Notably, we found
that BP reductions after CET exhibited a dose–response
relationship such that SBP/DBP reductions were greatest
among samples with hypertension (5/6 mm Hg) than with
prehypertension (3/4 mm Hg) and normal BP (+1/2 mm Hg).
The change in BP was examined as a primary study outcome
versus studies in which it was not (for SBP only: 8 vs 3 mm
Hg), and among trials of higher than lower methodological
quality (4/5 vs 2/2 mm Hg). The greatest potential BP-
lowering effects from CET occurred among samples with
hypertension in trials of higher methodological quality fo-
cusing on BP as a primary outcome (~8–9 mm Hg).
Our findings demonstrate that CET appears to lowers BP to
levels that are comparable with or even greater than aerobic
exercise training for adults with hypertension (~5–9 mm Hg)
(33,34). Of note, three trials in our meta-analysis directly
compared the antihypertensive effects of aerobic exercise to
CET and reported no group differences (38,39,41). The ad-
dition of resistance training to aerobic exercise (e.g., CET)
may allow for simultaneous benefit in the cardiometabolic
methodological study quality (~5 vs ~2 mm Hg). Yet we
found the quality of this literature to be of only moderate
quality, leaving open the possibility that other potential risks
of sample bias and threats to validity exist. One potential
source of bias in this literature is that few interventions spe-
cifically examined the antihypertensive effects of CET. In
fact, only 14% (k = 11) of interventions examined BP as a
primary study outcome. Among these studies, BP reductions
were more than twice the magnitude of those reported in trials
with BP as a secondary outcome (~8 vs 3 mm Hg). Further-
more, because of poor disclosure of BP assessment methods,
it is unclear how the BP assessment methodology may have
influenced the BP response to CET (see Table, Supplemental
Digital Content 5, Summary Table of Included Concurrent Ex-
ercise and Control Interventions, http://links.lww.com/MSS/A732).
Of note, one-third of the studies in our sample incorporated
‘‘active content’’ (32.9%, k = 25) versus ‘‘nonexercise’’ or
wait-list control groups (69.1%, k = 51). Those with the active
content comparison groups experienced small but significant
SBP reductions of ~1 mm Hg, whereas DBP was not different
pre- to postintervention among the ‘‘nonexercise’’ or wait-list
control groups (0 mm Hg). The use of ‘‘active content’’ control
groups is paradoxical because they may themselves act as in-
terventions and may not be appropriate to use for the targeted
comparisons (15). As a result, their use generally reduces the

2404 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
effectiveness of the intervention being studied, as gauged by
between-group comparisons (15). Indeed, CET elicited BP re-
ductions of ~1 mm Hg when compared with the active content
control groups and ~5 mm Hg when compared with the
nonexercise or wait-list control groups. We evaluated other
potential sources of bias (i.e., randomized controlled trials vs
not, number of CET interventions) and found that these did
not influence the BP response to CET. Nonetheless, we ac-
knowledge that additional unidentified sources of bias that
may have affected BP outcomes may exist in this literature.
There were limitations to our meta-analysis. There were no
FITT characteristics that emerged as moderators of the BP
response to CET in our meta-analysis, which may be due to
86% (k = 6) of the included interventions that failed to fully
disclose this important information. Moreover, nearly 70%
(k = 26) of the primary level CET trials in our meta-analysis did
not include samples with hypertension, calling into question
the generalizability of this literature to adults with hyperten-
sion. Furthermore, only one study (42) reported the timing of
the BP measurement after the last exercise training session;
therefore, it is unclear if the authors appropriately isolated
acute exercise effects from the more long-term training effects
of CET on BP (32–34). These observations illustrate the need
for additional primary level trials that address these limitations
so that more definitive conclusions can be made about the
antihypertensive effects of CET.
Our meta-analysis has important strengths. The trial selec-
tion process was comprehensive, including multiple databases.
Furthermore, our search strategy was absent of publication
year restrictions and language filters, and it permitted the
inclusion of gray/unpublished literature. As a result, our
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