Clin Physiol Funct Imaging (2018) 38, pp163–175 doi: 10.1111/cpf.

12412

REVIEW ARTICLE

Physiological responses during the practice of

synchronized swimming: a systematic review

tia Ponciano1 , Maria Luiza de Jesus Miranda1, Miwako Homma2, Joa
Ka ~o Marcelo Queiroz Miranda1,




Aylton J. Figueira Junior , Cassio De Miranda Meira Junior and Danilo Sales Bocalini1
1 3

1
Translational Physiology Laboratory, Postgraduation in Physical Education of Sao Judas Tadeu University, Sao Paulo, SP, Brazil, 2University of Tsukuba,
Institute of Health and Sport Sciences, Japan and 3School of Arts, Sciences and Humanities, University of Sao Paulo, SP, Brazil

Summary

Correspondence
Katia Ponciano, Translational Physiology Labora-
tory. Postgraduation in Physical Education os Sao
Judas Tadeu University, Taquari Street 546,
Mooca, Sao Paulo, SP, Brazil
E-mail: kcapristi@gmail.com
Accepted for publication
Received 19 June 2016;
accepted 25 November 2016
Key words
athletes; competitions; physiological responses;
review; synchronized swimmers
This study is aimed at analysing the scientific literature related to physiological
responses in synchronized swimmers, produced from 2006 to 2016. A systematic
review was conducted using electronic databases (Google Scholar, PubMed,
SportDiscus, Web Science, Scielo and Scopus) in national and international journals.
The articles were selected using the following inclusion criteria: composed samples
of synchronized swimmers of both sexes, articles in English, Spanish and Por-
tuguese, published from 2006 to 2016. Ten studies were included. The concentra-
tion of the articles and their publication was as follows: Europe (77%) and North
America (23%). The protocols used analyse physiological responses in synchro-
nized swimmers athletes during competitions or laboratory tests, lactate measure-
ments, heart rate, rates of perceived exertion, VO2 and lung volume. The subjects
of 100% of the studies included in this review were athletes of junior and senior
categories who volunteered. Only 03 of the 10 studies have compared the physio-
logical responses in volunteers who were not synchronized swimmers to synchro-
nized swimmer athletes. The studies were conducted using different
methodologies, which makes it difficult to compare them, so the standardization of
instruments and definitions is essential for the scientific advancement in this field.
In addition, it would be interesting to expand the research of these physiological
responses in synchronized swimmers using base level or beginners as sample.

(eight athletes), free combination (ten athletes) and highlight

Introduction
Synchronized swimming (SS) is an Olympic sport with rules
governed by the Manual for Synchronized Swimming, Judges,
Coaches and Referees (FINA, 2013). Its practice incorporates
elements and/or adaptations of other sports such as swim-
ming, rhythmic gymnastics, ballet and dance. SS requires
some specific items such as strength, kinesthetic knowledge
and complex technical skills (Yamamura et al., 1999; Pazikas
et al., 2005; Alentejano et al., 2008).
According to the FINA Handbook, competitions are com-
posed of two sessions: figures (without music) and routines
(with music and choreography). The figures are performed
without music, artistic swimsuits, accessories and even
make-up; the athletes must wear black swimsuits and white
caps (Fugita & Ponciano, 2013), thus providing an essentially
technical score. The athletes can compete in the following cat-
egories: solo (individual swimmer), duet (two athletes), team
routines (ten athletes) (FINA, 2013).
The technical routine involves performing predetermined
elements which are selected every 4 years. The free routine
has no figure requirements so it allows more flexibility to
demonstrate grace, artistry performance and creativity
(Rodr
ıguez-Zamora et al., 2012). Solo, duet and team routines
have five mandatory elements nowadays (FINA, 2013).
Considering the complexity of this modality, the search
for ways of improving the performance through technical
efficiency and artistic factors, as well as its growing popular-
ity and professionalization and the clarification of the physio-
logical changes that occur during its practice becomes
important.
Some studies (Davies et al., 1995; Chu, 1999; Mountjoy,
1999; Yamamura et al., 1999; Ebine et al., 2000; Pazikas et al.,
2005; Alentejano et al., 2008, 2010; Rodr
ıguez-Zamora et al.,
2012, 2013) have analysed the physiological responses in figures

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175 163

164 Physiological responses during the practice, K. Ponciano et al.
and routines; however, the samples, the conditions of the techni-
cal analysis and the analysed physiological parameters are varied.
The purpose of this study was to describe items of analysis
of the scientific studies related to the physiological responses
during the practice of synchronized swimming (SS) in accor-
dance with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) Statement (Liberati
et al., 2009; Shamseer et al., 2015).
Method
Search strategy and selection of studies
The electronic search of articles published in English language
was conducted in the following databases: Google Scholar,
PubMed, SportDiscus, Web Science, Scielo and Scopus using as
descriptors SS and physiological responses – alone or in
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175
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combination. The selection of the articles followed these inclu-
sion criteria: synchronized swimmers of both sexes; samples con-
taining physiological analysis; publication date from January
2006 to May 2016. The following components were used as
exclusion criteria: results about biomechanics, nutrition, motor
learning and psychological studies, dissertations and theses.
The procedure consisted primarily of reading the title of the
manuscripts and analysing the abstracts of all the selected articles.
In all the databases, 92 scientific articles were found and only arti-
cles that met the inclusion and exclusion criteria were selected.
After this selection, the full text of all chosen articles was
obtained and subsequently examined under the established
criteria. This analysis excluded 18 articles that were duplicated
and over 64 articles with titles and abstracts which did not
contain physiological responses besides other studies with no
relation to the modality in accordance with the inclusion cri-
teria, as shown at Fig. 1.
Figure 1 Flow chart of selection of articles.
 1475097x, 2018, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cpf.12412 by Uni Da Biera Interior, Wiley Online Library on [09/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Physiological responses during the practice, K. Ponciano et al. 165

Table 1 PEDro quality scale analysis of the ten selected studies.

Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria Criteria
Author/Year/Country 1 2 3 4 5 6 7 8 9 10 11

Naranjo et al. (2006) Yes No No Yes No No No Yes Yes Yes Yes

Bante et al. (2007) Yes No No Yes No No No Yes Yes Yes Yes
Alentejano et al. (2008) Yes No No Only one No No No Yes Yes _ Yes
group
Alentejano et al. (2010) Yes No No Yes No No No Yes Yes Yes Yes
Alentejano et al. (2012) Yes No No Yes No No No Yes Yes Yes Yes
Rodr
ıguez-Zamora Yes No No Yes No No No Yes Yes Yes Yes
et al. (2012)
Rodr
ıguez-Zamora Yes No No Yes No No No Yes Yes Yes Yes
et al. (2013)
Schaal et al. (2013) Yes No No Only one No No No Yes Yes – Yes
group
Rodr
ıguez-Zamora Yes No No Yes No No No Yes Yes Yes Yes
et al. (2014)
Schaal et al. (2015) Yes No No Only one No No No Yes Yes – Yes
group

All trials indexed on Physiotherapy Evidence Database (PEDro) are assessed for methodological quality and statistical reporting using the PEDro
Scale that considers the following criteria: (1) eligibility criteria and source of participants; (2) random allocation; (3) concealed allocation; (4)
baseline comparability; (5) blinding of subjects; (6) blinding of therapists; (7) blinding of assessors; (8) measures of key outcomes from more
than 85% of participants; (9) intention-to-treat analysis; (10) between-group statistical comparisons; (11) point measures and measures of vari-
ability.

Table 2 Number of articles found in each database at every stage. without experience in the modality and three other studies
(Naranjo et al., 2006; Alentejano et al., 2012; Schaal et al.,
‘Synchronized Selected titles 2013) did not mention training experience but reported that
swimming’ AND/OR and abstracts their samples were composed of athletes.
‘physiological (accordingly to
responses’ inclusion and
In the last 10 years, studies on SS (Alentejano et al., 2008;
Database 2006–2016 exclusion criteria) Rodr
ıguez-Zamora et al., 2012, 2013; Rodr
ıguez-Zamora et al.,
2014) have focused their physiological analysis during routine
Google Scholar 74 64 performances. The variables that are most investigated are as
PubMed 05 05
Web Science 03 03
follows: blood lactate concentration (Naranjo et al., 2006;
Scopus 05 04 Bante et al., 2007; Rodr
ıguez-Zamora et al., 2012, 2013; Schaal
SportDiscus 05 03 et al., 2013, 2015), heart rate (HR) (Naranjo et al., 2006;
Scielo 00 00 Bante et al., 2007; Alentejano et al., 2012, 2010; Rodr
ıguez-
TOTAL 92 79 Zamora et al., 2012, 2013; Schaal et al., 2013, 2015;
Rodr
ıguez-Zamora et al., 2014), oxygen consumption
(Naranjo et al., 2006; Bante et al., 2007; Alentejano et al.,
2010, 2012; Schaal et al., 2013), rates of perceived exertion
Results
(Rodr
ıguez-Zamora et al., 2012, 2013; Schaal et al., 2013,
Table 1 presents the ranking of the methodological quality of 2015; Rodr
ıguez-Zamora et al., 2014), two analytical condi-
the studies related to interventions format through the data- tions in apnea (Naranjo et al., 2006; Alentejano et al., 2008,
base PEDro (Physiotherapy Evidence Database). 2010, 2012; Rodr
ıguez-Zamora et al., 2013) and alternating
Combining all search methods, we identified ten articles apnea – with the face in and out of the water (Alentejano
fulfilling the inclusion criteria as seen in Table 2. et al., 2008, 2010; Rodr
ıguez-Zamora et al., 2013).
Table 3 contains the sample characterization (athlete or Table 4 shows the basic characteristics of studies regarding
non-athlete) of the selected studies. The selected studies have their type, sample, evaluation protocol and the investigated
samples aged between 13–23 years, age average of 19
13 parameters. All 10 (100%) studies were cross-sectional. All of
 2
67 years; average of training experience years in SS of them had junior and senior athletes as samples (Naranjo et al.,
8
01  2
55 years for studies using athletes in the junior 2006; Alentejano et al., 2008, 2010, 2012; Rodr
ıguez-Zamora
and senior groups (Bante et al., 2007; Alentejano et al., 2008, et al., 2012, 2013; Schaal et al., 2013, 2015; Rodr
ıguez-
2010; Rodr
ıguez-Zamora et al., 2012, 2013; 2014). Three Zamora et al., 2014) and one of them (Bante et al., 2007)
studies (Naranjo et al., 2006; Alentejano et al., 2010, 2012) analysed youth and senior athletes. Regarding the protocols,
investigated the responses using a control group (CG) the use of rates of perceived exertion is recent, and it has

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175
 Table 3 Description of the sample characterization (athlete and non-athlete) of the ten selected studies.

Author (year) –
Country Age Height Body mass (kg) Body fat (%) Lean body mass (kg) Years of SS practice (years)

Naranjo et al. 16
08  2
78 (SS) 161
38  5
88 (SS) 53
45  5
88 (SS) Not available Not available Not available
(2006) – Spain 23
92  3
65 (CG) 173
00  9
23 (CG) 65
04  6
45 (CG)
Bante et al. 21
6  0
1 (SS – Senior) 167
5  1
1 (SS – Senior) 56
8  1
2 (SS – Senior) 21
4  0
8 (SS – Senior) 25
9  0
3 (SS – Senior) 9 (SS – Senior)
(2007) – Greece 13
8  0
9 (SS – Youth) 160
1  1
2 (SS – Youth) 44
8  1
6 (SS – Youth) 23
1  0
8 (SS – Youth) 21  0
4 (SS – Youth) 5 (SS – Youth) (average
and deviation are
not mentioned)
Alentejano et al. 20  1
8 (SS) 173
3  4
1 (SS) 58
3  4
0 (SS) Not available Not available 10  3
0 (SS)
(2008) – Canada
Alentejano et al. 18  2 (SS) 170
6  5
2 (SS) 60
5  6
9 (SS) Not available Not available 9  4
0 (SS)
166 Physiological responses during the practice, K. Ponciano et al.

(2010) – Canada 22  3 (CG) 169
2  8
9 (CG) 65
4  8
8 (CG) 0 (CG)
Alentejano et al. 18  2 (SS) 169
1  7
0 (SS) 58
0  7
3 (SS) Not available Not available Not available
(2012) – Canada 18  2 (SS) 171
2  3
2 (SS) 62
6  6
1 (SS)
23  2 (CG) 165
1  7
7 (CG) 66
5  11
9 (CG)
21  2 (CG) 172
7  8
7 (CG) 65
3  7
1 (CG)
Rodr
ıguez-Zamora 21
4  3
6 (SS – Senior) 163
7  5
1 (SS – Senior) 53
2  5
3 (SS – Senior) Not available Not available 8
7  1
5 (SS – Senior)
et al. (2012) – Spain 15
1  1
0 (SS – Youth) 168
9  8
0 (SS – Youth) 54
3  6
3 (SS – Youth) 11
7  3
3 (SS – Youth)
Rodr
ıguez-Zamora 17
9  3
5 (SS – Senior) 165
1  6
3 (SS – Senior) 52
4  5
5 (SS – Senior) Not available Not available 9
8  3
1 (SS – Senior)
et al. (2013) – Spain
Schaal et al. 20
3  1
8 (SS – Senior) 170
1  4
8 (SS – Senior) 61
1  4
6 (SS – Senior) Not available Not available Not available
(2013) – France
Rodr
ıguez-Zamora 17
4  3
0 (SS – Senior) 164
0  6
1 (SS – Senior) 52
0  6
4 (SS – Senior) Not available 19
2  1
4 (SS – Senior) 9
3  2
6 (SS – Senior)
et al. (2014) – Spain
Schaal et al. 20
4  0
4 (SS – Senior) Not available Not available Not available Not available 2
5  0
4 (SS – Senior)
(2015) – France

SS, synchronized swimming; CG, control group.

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 Table 4 Essential characteristics of the ten selected studies.

Author (year) – Type

Country Journal of study Sample Evaluation protocol Significant results

Naranjo et al. International Cross- 25 athletes Were made test 1 and test 2 in cycle In SS athletes was observed had significant increase in VE, VO2 e VCO2 in test 2
(2006) – Spain Journal Sports sectional SS athletes (13) ergometer at the same intensity. when compared test 1, without changes in HR. The respiratory quotient (RQ)
Medicine and volleyball HR; VE; VC; BF; VT; VO2; VCO2 remained constant and similar values for blood lactate with no significant
athletes (12 CG) and LA were analysed difference. The CG had higher increased VE, VO2 e VCO2 in test 2 than those in
the swimmers. HR and blood lactate increased. The VE vs VCO2 relationship
showed two different slopes for both tests.
Bante et al. (2007) The Journal of Cross- 16 SS athletes Anthropometric variables were The ectomorph somatotype predominated In both groups. Performance scores
– Greece Sports Medicine sectional Youth (8) and measured and the somatotype (average scores of the 4 compulsory figures) were higher for senior compared
and Physical Senior (8) checked. The tests included warm- to youth (78
4  0
6 versus 71
2  0
7). VO2peak in the senior and youth
Fitness up exercises outside the water, athletes was similar and also no difference in VO2 at the end of the routine
swimming and the specific of between senior and youth athletes. The LA concentration at the VO2peak test was
performing 4 compulsory figures significantly higher in senior compared to youth athletes but after the simulated
and routine. PETCO2; LA; HR; VE; routine was similar in the both groups and significantly lower compared with
BF; VO2peak and VO2 were analysed the VO2peak test. No difference was found between the two categories of
swimmers and between the two tests for both absolute and normalized EPOC
values. Senior and youth athletes had similar VO2 kinetics parameters. However,
t and t1/2 were significantly higher after the routine compared to VO2peak test
for both categories. PETCO2 responses during recovery from the VO2peak and the
simulated routine showed the PETCO2 after the VO2peak was similar in senior
and youth athletes. PETCO2 during the first 90 s of the recovery from the
VO2peak test averaged 40
6  2 and decreased to 34
5  1
5 mmHg during the
second 90 s. Similarly, PETCO2 decreased from 42
9  1
8 at the first 90 s to
37
2  1
4 mmHg at the last 90 s of recovery. Interestingly, the mean PETCO2
during the second half of the recovery was higher after the routine test,
compared with the VO2peak. And the mean breathing frequency was higher
following the VO2peak test compared with the simulated routine, only during
the first half of recovery. The VE in absolute values was higher in senior
compared to youth athletes in both tests. VE was higher following the VO2peak
test compared with the simulated routine only during the first half of recovery

(continued)

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Physiological responses during the practice, K. Ponciano et al. 167

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 Table 4 (Continued)

Author (year) – Type

Country Journal of study Sample Evaluation protocol Significant results

Alentejano et al. International Cross- 11 SS athletes The time analysis was made from
(2008) – Canada Journal of Sports sectional the videotaped performance of the
Physiology and 11 top soloists during finals. The
Performance total time out of the water, the
number of times the swimmers had
their face in or out of the water,
and the longest and the second
longest face immersion (FI). For
the purpose of this analysis, FI
periods were considered the time
the swimmers were holding their
breath or exhaling underwater. All
There were no significant differences between the top soloists and those placing
7th to 11th in any of the FI times measured. The majority (10/11, 91%) of the
longest FI periods occurred in the first third of the solo. Four of 11 solos (36%)
began with the longest FI period. The second longest FI period varied
considerably, with 27% (3) of the soloists having the second longest FI period
in the first third of the solo, 45% (5) in the second third and 27% (3) in the
last third. There was a significant difference for the TM scores (top
group = 95
1  1
7 versus bottom group = 91
3  1
0; mean  SD). As
would be expected, relative and absolute distance was significantly correlated
(r = 0
975, P<0
05), and the years of experience of the athletes correlated with
the TM scores (r = 0
693, P<0
05). No other significant correlations were
found between any of the variables
168 Physiological responses during the practice, K. Ponciano et al.

technical merit scores (TM) were

noted
Alentejano et al. Research in Sports Cross- 30 women The study required that each The SS athletes had longer apnea periods than the CG. The SS group had
(2010) – Canada Medicine sectional 15 SS athletes and participant attended 3 laboratory significantly longer BH times compared with the CG. BH times increased
15 active female sessions, 2 orientation sessions and significantly in both groups from BH 1 to BH 5. The principal reason described
university 1 experimental test. BH times, by the SS stopping BH was involuntary lung movements – could not, 6 –
students (CG) PETO2; PETCO2; reasons for ending (40%) and by the CG was panic 5 – (33
3%). There was a significant main
BH; VO2; HR and SaO2 were effect for HR 15 s prior to BH (SS>C), at the onset of BH (SS >C), and at 30 s
analysed and 45 s during BH (SS<C, respectively). There was a significant main effect for
SaO2 regarding BH independent group of time, which indicates that the SaO2
decreased as increased BH times. The estimated oxygen required, the measured
from SS during BH ranged from 5
2% to 44
5% lower than the estimated
values, but in only one case (BH 4 for SS) was the net result significantly
different from zero. The C group had only 6
7% and 6
8% lower for two out of
five trials, but none of the net results were significantly different from zero. The
HR during recovery significantly increased between the end of the BH to 10 s
after the BH ended and significantly decreased between 10 s after BH and 25 s
after BH for the SS. Trends for EPBHOC were very similar independent of the
groups. Both groups were very near total recovery (in reaching the baseline
relative to VO2) by 25 s into recovery

(continued)

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 Table 4 (Continued)

Author (year) – Type

Country Journal of study Sample Evaluation protocol Significant results

Alentejano et al. Journal of Human Cross- 30 women The procedures were the same as
(2012) – Canada Kinetics, Section sectional 15 SS athletes and those used in the previous study by
– Aquatic 15 active female the same authors (2010). The
Activities university subjects were instructed to
students (CG) determine the peak oxygen
consumption (VO2 peak) while
immersed in water and how to use
the apparatus custom designed for
underwater exercise using a
modified Monark ergometer. BH
times, PETO2; PET CO2; VO2; HR,
SaO2 and VE were analysed
Schaal et al. Applied Cross- 11 SS athletes This study investigated the effect of
(2013) – France Physiology, sectional whole-body cryostimulation
Nutrition and (WBC), contrast-water therapy
Metabolism (CWT), active recovery (ACT) and
passive condition (PAS) protocols
on the parasympathetic reactivation
and metabolic parameters of
recovery in elite synchronized
swimmers who performed 2
simulated competition ballets (B1
and B2 with phases of apnea
adding up to 64% of the total
time) separated by 70 min.
VO2peak; LA during VO2max400;
HRV and RPE were analysed
The PETO2 was significantly lower for SS when the BH trials were performed in
an ascending order. The results also indicated that as BH time increased, PETO2
decreased significantly for SS and CG, but no differences were observed for
PETCO2. PETCO2 was significantly higher for SS than for C but not PETO2 when
the BH trials were performed in descending order. Note that two BH untrained
subjects from the ’10 s initial’ group were only able to finish one 25 s BH
period. There was a significant decrease in HR after the 20 and 25 s BH during
exercise for the SS group regardless of the order that the BH was performed.
However, HR significantly decreased in the C group only when the BH was
performed in a descending order. VE was significantly lower for SS compared to
C after 20 s of BH when the BH trials were performed in a descending order of
duration. Furthermore, VE decreased significantly after 5 s for both groups when
BH for 20 and 25 s regardless of the order. There was also significant decrease
within 5 s for the C group during the 10 s BH when performed in an
ascending order. As well, VE significantly decreased after 25 s of recovery for
both groups and conditions the 25 s BH period
Each ballet caused significant decreases in HRV indices. At PreB2, all HRV indices
had returned to PreB1 levels in the CWT, PAS and ACT protocols, whereas the
WBC protocol yielded a two- to fourfold increase in vagal-related HRV indices,
compared with PreB1. WBC and ACT were the only protocols to yield
significantly higher VO2peak values at B2 than at B1, with gains of 5
4  3
2%
and 3
4  2
9%, respectively. Every swimmer reached a higher VO2peak during
B2 after using WBC in recovery. RPEm values peaked at PostB1 and PostB2, and
returned to resting levels at the end of recovery (PreB2) for all protocols except
WBC, during which RPEm remained slightly but significantly elevated, compared
with PreB1. PAS was the only protocol associated with significantly higher RPEm
at PostB2 than at PostB1. The RPEg values were significantly lower at PreB2 than
at PreB1 after a shorter second warm-up for all protocols except WBC
(P = 0
07). PAS was also associated with significantly lower ratings on the
visual analog scale than all other protocols

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(continued)
Physiological responses during the practice, K. Ponciano et al. 169

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 Table 4 (Continued)
Author (year) – Type
Country Journal of study Sample Evaluation protocol
Rodr
ıguez-Zamora PLOS ONE Cross-sectional 34 SS athletes All routines were performed during
et al. (2012) – www.plosone. Youth (24) and actual competition. The total
Spain org Senior (10) competition score (TCS) for a
technical routine is composed of
separate scores for execution and
overall impression; for free
routines, the TCS is composed of
separate scores for technical merit
and artistic impression. In both
cases, TCS is up to a maximum of
100 points. All routines were
continuously recorded using a
digital video camera. LApeak; HR
and RPE were analysed
Rodr
ıguez-Zamora International Cross-sectional 17 SS athletes All routines were performed during
et al. (2013) – Journal Sports Senior (07) and actual competition. The total
Spain Medicine Junior (10) competition score (TCS) for a
technical routine is composed of
separate scores for execution and
overall impression; for free
routines, the TCS is composed of
separate scores for technical merit
and artistic impression. In both
cases, TCS is up to a maximum of
100 points. All routines were
continuously recorded using a
digital video camera. LApeak; HR
and RPE were analysed
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Significant results
The pattern of HR response during the execution of the six routine programmes
was similar in most of the HR parameters for the entire group of swimmers.
However, significant differences were noted in recovery HR (HRpost3 and
HRpost5) between the TS and the FT routines. Likewise, HRpost3 was higher in
TD as compared to FT routines. Although HRpre was significantly higher in
juniors than in seniors. The maximal values resting blood lactate were attained
at the 5th or 7th min during the recovery period in all cases. For the entire
group of swimmers, LApeak was higher in the FS routine than in the TD and FT.
LApeak was also significantly higher in the FD than in the FT routines. About the
RPE scores in all groups and routines, values for FS and FD exercises were
higher than both team routines FT and TT. In both duet routines, FD and TD,
scores were higher than in TT. RPE scores were significantly higher in juniors
than in seniors. In the senior group, RPE values were higher in the FS routine
170 Physiological responses during the practice, K. Ponciano et al.
than in both team routines FT and TT. The TS and FD elicited higher RPE values
than TT. Swimmers attained higher scores in the FT than in the TD. Even if this
was an absolute competition, seniors were rated higher than juniors. TCS
performance scores negatively correlated with HRpre and HRmin and positively
correlated with HRrange
RPE scores for all routines ranged from 6 (‘hard–very hard’) to 10 (‘extremely
hard’) and did not differ among the four different routines. Likewise, the
pattern of the HR response was not different among routines for any of the
studied parameters. Differences were noted among routines in LApeak, with
lower values in TD than in TS and FD. No significant differences were observed
among routines in MIM, IMmax and TIM >10 s. NIM was higher in FD than in
TD and TS and also higher in FS than in TS. Differences were also observed in
TIM, with higher values in FD than in FS, and in both technical routines, TD
and TS. Differences were also noted in RIM %, which was higher in TS than in
TD and FS. The TS showed lower NIM >10 s than FD. About RPE, significant
correlations between performance (TCS), and physiological and immersion
parameters during SS routines were found. About linear correlation coefficients
between competitive performance (TCS) and physiological parameters and IM
parameters showed TCS positively correlated with LApeak and 2 immersion
parameters (NIM and IMmax) and inversely correlated with MIM and HRpre
(continued)
 Table 4 (Continued)

Author (year) – Type

Country Journal of study Sample Evaluation protocol Significant results

Rodr
ıguez-Zamora The Journal of Cross-sectional 10 SS athletes The athletes performed TD and FD The HR profiles corresponding to one of the participants before, during and after
et al. (2014) – Strength and Senior (3) and routines in two different situations: 2 FD routines performed during T and C. An almost identical pattern was
Spain Conditioning Junior (07) training (T) and competition (C). observed, where in HR, after a period of intense anticipatory pre-activation
Research HR and RPE were analysed quickly increases, interspersed with periods of marked HR decrease. The mean
RPE scores corresponded to the ‘hard’ to ‘extremely hard’ verbal anchored
levels, and differences observed between C and T scores were not significant.
No differences were observed between routines (TD versus FD). The correlation
coefficient between T and C values for all parameters was highest for HRrange
followed by HRmin and HRmean and lowest for HRpre. The HRpeak correlation
closely approached statistical significance. Rate of perceived exertion during
competition was also significantly correlated with RPE during training. Rate of
perceived exertion was inversely correlated with HRmin and HRmean and
positively correlated with HRrange

(continued)

© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175
Physiological responses during the practice, K. Ponciano et al. 171

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 Table 4 (Continued)
Author (year) – Type
Country Journal of study Sample Evaluation protocol
Schaal et al. Medicine and Cross-sectional 10 SS athletes After 1 week of normal training
(2015) – France Science in Sports (BASE), the swimmers performed
& Exercise two 2-wk IT periods randomized
order: one control IT period
(ITCON), during which no specific
recovery strategy was allowed (i.e.
no massages, hydrotherapy, sauna/
steam baths) and one that included
daily WBC sessions (ITWBC). The
two periods of IT were separated
by a 9-day taper period consisting
of light training. The contrast in
training load between BASE and
each IT was measured using the
method introduced by Foster et al.
Although the original method used
a 10-point modified Borg scale of
perceived exertion to describe the
intensity of each training session,
we used the original 6–20 Borg
scale (4) that the swimmers were
well accustomed. Exercise training
load; physiological response to
exercise submaximal and maximal;
sleep; resting endocrine parameters;
and effects of training overload on
the physiological response were
analysed
BH, breath holding; SS, synchronized swimming; CG, control group; HR, heart rate; VE, ventilation; VT, volume tidal; BF, breathing frequency; VO2, oxygen uptake; VCO2, carbon dioxide production;
LA, blood lactate; VO2peak, peak oxygen uptake; PETCO2, end-tidal carbon dioxide pressure; RPE, rates of perceived exertion; TS, technical solo; TD, technical duet; TT, technical team; FS, free solo; FD,
free duet; FT, free team; IT, intensified training; WBC, whole-body cryostimulation; ITCON, control IT.
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175
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Significant results
The number of training hours remained the same during BASE, ITWBC and ITCON,
but the overall training load for each period, expressed as the product of RPE
versus minutes, increased for each period. There was no difference in training
load between ITWBC and ITCON. Exercise at the end of each period, IT periods
resulted in a significant decrease in LA and HR; however, RPE was lower during
s1, s2 and s3 after ITWBC compared with BASE. Changes in RPE at all
submaximal intensities were directly correlated with the change in perceived
fatigue upon waking. The physiological response to maximal had significant
decrease in mean TT400 speed which was observed from BASE to ITCON. The
difference in swim speed between ITWBC and ITCON was nuclear. The decrease
in performance during ITCON was accompanied by significant reductions in
LAB400 and a-amylases400. After both IT, changes in 400-m speed from BASE
showed large and very large correlations to changes in HR400 and cortisols400.
RPE400 did not change significantly but showed a moderate inverse correlation
172 Physiological responses during the practice, K. Ponciano et al.
to cortisols400. About sleep variables, the swimmers retired to bed 40  11 and
49  10 min later during ITWBC and ITCON compared with BASE and got up in
the morning 52  8 and 38  7 min later, respectively. Although it was
unclear whether bed time occurred earlier during ITWBC than ITCON, ITWBC was
associated with a trivial to very large positive effect on the get-up time. As a
result, ITWBC had a small to large positive effect on the total amount of time in
bed compared with ITCON. During ITCON, sleep latency increased because the
swimmers took an additional 11  5 min to fall asleep. The actual sleep
duration was significantly decreased during ITCON compared with BASE, with
swimmers losing 21  7 min of sleep per night, whereas no changes were
observed during ITWBC. Compared with ITCON, ITWBC had a significant positive
effect on actual sleep duration. ITCON showed a significant decrease in sleep
efficiency from BASE. Changes in perceived fatigue from BASE to both IT also
showed large correlations with changes in RPE at s1, s2 and s3. Fasted waking
cortisol did not change significantly from BASE to either IT period. There was
no significant difference in waking a-amylases between any of the conditions.
However, the change in resting a-amylases was negatively correlated with
change in sleep efficiency and trended towards a positive correlation with the
change in sleep latency and perceived fatigue during both IT conditions

been included as analysis in this modality since 2012
(Rodr
ıguez-Zamora et al., 2012, 2013; Rodr
ıguez-Zamora
et al., 2014; Schaal et al., 2013, 2015). Additionally, HR and
lactate analysis were the most commonly used parameters in
the publications especially when associated with apnea peri-
ods. On the other hand, the experimental designs are quite
diverse, with no standardization.
Discussion
This review study intended to present and analyse the existing
information on the physiological responses during the practice
of SS in the scientific literature. Its results may help planning
the choices of adequate tools for analysis of physiological
responses as well as develop new studies in the area.
Several studies have investigated physiological responses
during different types of training in SS, in the performance of
figures (Gemma & Wells, 1987; Homma, 1994; Homma &
Takahashi, 1999), execution of technical and free routines
(Yamamura et al., 2000) and the simulation of competitive
performance of routines (Chatard et al., 1999; Pazikas et al.,
2005) in order to quantify internal load training.
One of the most important focus of investigation on the SS
variables are the physiological effects during the time that the
players stay underwater, in apnea. However, there is no
known literature that quantifies the total amount of time that
synchronized swimmers stay underwater while performing a
routine. Maybe these long underwater sequences in routine
emphasize important aspects of athletes’ training in different
countries.
One of the ten selected studies investigated the relationship
between the duration of the apnea periods with the scores
awarded to the routines. In this study, there was a significant
difference in the technical merit scores for top soloists when
compared to the lowest score soloists (Alentejano et al.,
2008), but there were no significant differences between the
top soloists and those placed in the 7th to 11th position
regarding the capability to be underwater, measured in time.
This may explain the substantial score difference between the
top solo group (high scores) and the solo group with lower
performances (low score). The study (Alentejano et al., 2008)
that correlated the technical merit scores with the apnoea per-
iod of synchronized swimmers in a solo competition was
based on the old rules. It would be important to make new
investigations taking into consideration the new rules, once
the technical merit item has been modified. In the old rules,
the technical merit item was evaluated regarding three aspects
– execution, synchronization and difficulty. Now, the techni-
cal merit term does not exist and the three aspects were sepa-
rated – now the difficulty aspect is evaluated separately from
execution and synchronization.
In the study by Bante et al. (2007), the findings show that the
scores awarded to senior athletes were higher when compared
to youth athletes in the four studied figures. It is expected that
the more experienced the athlete is, higher is his/her capability
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Physiological responses during the practice, K. Ponciano et al. 173
to be underwater in longer apnea periods, showing better
breathing and cardiac capacity, an adaptive metabolic response
to this sport (Rodr
ıguez-Zamora et al., 2012). Other study
(Rodr
ıguez-Zamora et al., 2012) observed that senior athletes
were rated higher than juniors in all routines analysed. The
scores are related to more experience (Alentejano et al., 2008).
Alentejano et al. (2008) found in the study that the athletes
performed relatively long underwater sequences that were
repeated six to eight times during a solo event and the study by
Alentejano et al. (2010) adds that the SS athletes had longer
apnea periods if compared to the CG. The HR average during
breath holding (BH) times increased significantly in both
groups from BH 1 to BH 5, in four different moments. The SS
group had significantly higher HR average during two initial
BH moments compared with the CG. However, the SS group
had a significant decrease in the HR average in the two final BH
moments. This result showed adaptive physiological response
in SS group, corroborating with study by Rodr
ıguez-Zamora
et al. (2012).The study by Alentejano et al. (2010) used a ques-
tionnaire that investigated psychophysiological factors which
were responsible for the interruption of apnea periods. The
answers of both SS and CGs are shown in percentages: utiliza-
tion of involuntary movements (40% versus 20%); need to
breathe (20% versus 20%); panic (1% versus 5%); tight chest
(2% versus 1%); dizziness (1% versus 1%); head started to hurt
(NA versus 6
6%); legs started to shake (NA versus 6
6%).
These factors should be known and regarded as important dur-
ing apnea periods, especially when associated with increased
duration. The training time can contribute to a better psycho-
logical and physiological response, that is greater tolerance, and
the fear factor practically ceases after longer practice of this
modality (Dujic & Breskovic, 2012). Additionally, Schagatay
et al. (2000) suggests that training reduces anxiety and increases
self-confidence resulting in increased time in apnea periods for
the subjects. The findings of this study (Alentejano et al., 2010)
are relevant in relation to the psychological factors that influ-
ence the apnea periods interruption. There may be tools to assist
technical and physical coaches and sports psychologists in meet-
ing alternatives to enhance and increase the athletes’ apnea
capability, mainly for base athletes.
Other important physiological factor is HR. Rodr
ıguez-
Zamora et al. (2012) observed that after a period of anticipa-
tory pre-activation, the HR increases rapidly and progressively
to high levels of tachycardia interspersed with periods of
intense bradycardia during intense exercise in apnea. The pat-
tern of HR response during the performance of six routines
was similar in all swimmers. On the other hand, there was a
significant difference in the HR recovery (after 30 and 50 )
between the technical solo routines compared to free team
(FT). The findings about the HR in the study by Rodr
ıguez-
Zamora et al. (2012) corroborate those of Alentejano et al.
(2010), reporting that the HR anticipatory response occurred
at an early stage in all swimmers at high intensities and the
cardiovascular demands are also increased with the HR and
their approach to maximal levels, interspersed with periods of

174 Physiological responses during the practice, K. Ponciano et al.
bradycardia during intense movements in apnea. These find-
ings may lead to training alternatives to apnea and intensifica-
tion of bradycardia even in the beginning of routines, what
may minimize tachycardia in the initial periods.
With respect to ventilatory responses, different protocols
were used. Naranjo et al. (2006) observed a significant increase
in ventilation (VE), oxygen uptake (VO2) and carbon dioxide
production (VCO2) without significant difference of HR and
blood lactate for the SS group in test two compared with test
one. Regarding the CG, the observed values of ventilation (VE),
oxygen uptake (VO2) and carbon dioxide production (VCO2)
were considerably higher and showed significant difference in
HR and blood lactate in test two compared with test one. Bante
et al. (2007) observed similar VO2 peak values in senior and
youth synchronized swimmers at the end of the routine. Again
in this study, Naranjo et al. (2006) observed an adaptive meta-
bolic response to this sport when compared with other groups.
Evaluating the O2 saturation, Alentejano et al. (2010) found
no significant changes during the apnea periods; however, the
arterial blood saturation (SaO2) values of synchronized swim-
mers were lower compared to the CG, even though their oxy-
gen (O2) consumption was higher during apnea. The
mechanism underneath this response is directly related to the
ability of synchronized swimmers to remain in apnea. During
BH, there is a decrease in HR and, consequently, in cardiac
output, causing the blood flow to be led to essential demands,
that is heart and brain (Alentejano et al., 2010).
Rodr
ıguez-Zamora et al. (2012) mention that cardiovascular
demands of all SS competitive routines are better described during
actual competitions with a large number of subjects. Since the HR
responses are largely related to BH responses, it seems logical to
assume that non-specific laboratory tests would not accurately
reproduce specific cardiovascular loading and thus miss an impor-
tant feature of specific adaptation to SS performance.
Regarding blood lactate, Rodr
ıguez-Zamora et al. (2012)
found lactate peaks in all subjects in the free solo (FS) perfor-
mances when compared to the technical duet (TD) as well as
the FT executions. The examination of blood lactate response
in free trials showed higher values in free duet (FD) than in
the FT performances. Thus, considering the lactate values pre-
sented in the studies (Rodr
ıguez-Zamora et al., 2012, 2013;
Schaal et al., 2013), it is possible to consider that the SS per-
formance has anaerobic predominance regardless of the anal-
ysed routine. According to Rodr
ıguez-Zamora et al. (2012),
the high levels of lactate peaks obtained in FS and FD demon-
strate that there is a specific effect of the apnea periods, as
well as a glycolytic metabolic activation in the muscles used,
besides the training adaptations.
It is known that the rates of perceived exertion are consid-
ered an important variable, resulting in the integration of
afferent signals from the skeletal muscles (peripheral) and the
central cardiorespiratory system (Borg, 1982). In addition, it
can help quantify the internal training load (Rodr
ıguez-
Zamora et al., 2014; Schaal et al., 2015), considering that few
studies (Rodr
ıguez-Zamora et al., 2012, 2013; Schaal et al.,
© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd 38, 2, 163–175
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2013, 2015; Rodr
ıguez-Zamora et al., 2014) have investigated
the rates of perceived exertion responses during the practice
of SS.
Rodr
ıguez-Zamora et al. (2012) showed higher rating per-
ceived exertion values in athletes during the performance of FS
and FD routines compared to the technical and FT ones possibly
due to the longer apnea periods and duration of the solo routi-
nes (Rodr
ıguez-Zamora et al., 2013). Rates of perceived exer-
tion were significantly higher in juniors when compared with
seniors, hence indicating that seniors perceived their perfor-
mance to be less strenuous. These findings may suggest that the
use of rating perceived exertion can be an important tool in
training the SS athletes, mainly base athletes.
Rodr
ıguez-Zamora et al. (2014) used rates of perceived exer-
tion to find that the internal load used in duets was the same dur-
ing training and competition. Additionally, Rodr
ıguez-Zamora
et al. (2012) demonstrated that lower rates of perceived exertion
values in senior athletes compared to junior athletes can be
understood as more experience in the modality, higher levels of
automaticity in the performance of the task, lower levels of prec-
ompetitive anxiety and more attention during the execution of
the routine. Motor changes and psychological changes can be
related to the apnea periods of the athletes. In addition to the
artistic development and demonstration, technical and acrobatic
skills demand long and high intensity of training, improving
thus strength, flexibility and aerobic and anaerobic exercise
capacity (Liang et al., 2005; Mountjoy, 2009).
Limitations of this study
In the present study, two main limitations must be consid-
ered. The total papers analysed in this study used different
methodological strategies, that is some studies from this
review used laboratory tests and others used real competition
situation. Additionally, the majority of the studies have inves-
tigated senior athletes, disregarding other categories.
Conclusion
More investigations should be done to encourage the clarifica-
tion of physiological responses in different competitions on SS
in different categories. A standardization of tools and similar
methodological settings in the studies is necessary in both
competitive environment and laboratory. Only two studies in
this review (Alentejano et al., 2008; Rodr
ıguez-Zamora et al.,
2012) correlated the apnoea periods with the scores in
the performance routines using the manual of rules of the last
quadrennium. New studies are necessary once the rules were
modified in 2013. This review also brought other important
information related to the anaerobic predominance in this
modality, considering the lactate values presented in the stud-
ies (Rodr
ıguez-Zamora et al., 2012, 2013; Schaal et al., 2013).
This review may also suggest to SS athletes different alterna-
tives of training to improve and increase apnoea periods, since
apnoea was the study focus of the present review and it is a
 1475097x, 2018, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cpf.12412 by Uni Da Biera Interior, Wiley Online Library on [09/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Physiological responses during the practice, K. Ponciano et al. 175

characteristic of the SS modality. Therefore, it is important to
highlight that the apnoea training may contribute to intensify
bradycardia periods in the beginning of the routine and possi-
bly minimize tachycardia. It would be interesting to study ath-
letes from other categories of synchronized swimming and
athletes who are starting in the modality in the future.
Besides, new investigations should be proposed to the male
genre. Men already practice synchronized swimming for years
and had their first official participation in the 16 FINA World
Championship Kazan – 2015 mixed duet.

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