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Medicine & Science in Sports & Exercise:
doi: 10.1249/MSS.0b013e3182663117
Clinical Sciences

Effects of Fractionized and Continuous Exercise on 24-h Ambulatory Blood Pressure

BHAMMAR, DHARINI M.; ANGADI, SIDDHARTHA S.; GAESSER, GLENN A.

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Author Information

School of Nutrition and Health Promotion, Healthy Lifestyles Research Center, Arizona State University, Phoenix, AZ

Address for correspondence: Glenn Gaesser, Ph.D., School of Nutrition and Health Promotion, Arizona State University, 500 N 3rd Street, Phoenix, AZ, 85004-0698; E-mail: glenn.gaesser@asu.edu.

Submitted for publication February 2012.

Accepted for publication June 2012.

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Abstract

Purpose: The objective of this study is to compare the effects of fractionized aerobic exercise (three 10-min exercise sessions) and continuous exercise (one 30-min exercise session) on 24-h ambulatory blood pressure (ABP).

Methods: Eleven healthy prehypertensive subjects (28.3 ± 8.0 (SD) yr) completed three randomly assigned conditions: 1) three 10-min sessions of aerobic exercise (3 × 10 min), 2) one continuous 30-min session of aerobic exercise (1 × 30 min), and 3) a nonexercise control trial (control). The mode of exercise was walking on a motor-driven treadmill at 75%–79% of maximum heart rate (HRmax) (60%–65% V˙O2peak). Twenty-four-hour ABP was monitored with an automated ABP device (Oscar 2™; SunTech Medical, Morrisville, NC). Linear mixed models were used to compare 24-h ABP responses between trials.

Results: The mean ± SD 24-h systolic blood pressure (SBP) was significantly lower during the 3 × 10-min trial (127 ± 15 mm Hg) compared with control (130 ± 15 mm Hg) (P < 0.001). Although both 3 × 10-min and 1 × 30-min trials reduced SBP compared with control during daytime/evening (1300–2300 h), only the 3 × 10-min trial reduced SBP during nighttime (2300–0800 h, 118 ± 16 vs 122 ± 14 mm Hg, P = 0.024) and the following morning (0800–1200 h, 127 ± 15 vs 131 ± 15 mm Hg, P = 0.016). For 24 h, 26.7% of SBP values during 3 × 10 min were normal (i.e., <120 mm Hg) compared with 18.3% for 1 × 30 min and 19.4% for control (P < 0.001).

Conclusions: In prehypertensive individuals, fractionized exercise (e.g., three 10-min aerobic exercise sessions spread and effective exercise alternative to continuous exercise for cardiovascular risk reduction in this population.

Cardiovascular disease (CVD) accounts for one in every three deaths in the United States, leading to an estimated $286.6 billion in health care costs (22). Hypertension is a major independent risk factor for CVD that affects 76.4 million Americans (22). From 1997 to 2007, the death rate from hypertension increased 9%, and the actual number of deaths due to hypertension rose by 35.6% (22). Suboptimal blood pressure (BP >115/75 mm Hg) is the number one attributable risk factor for death throughout the world (29) and is associated with a 62% increased risk of cerebrovascular disease and 49% increased risk of ischemic heart disease, thus showing that even prehypertensive BP values less than the standard threshold of 140/90 mm Hg contribute to an increased risk of vascular mortality (29). It is estimated that 69.7 million people in the United States older than 20 yr have prehypertension (21). Exercise along with dietary modification is recommended as primary therapy in the management of prehypertension as per Joint National Commission 7 (JNC 7) guidelines (2). Given that 67% of American adults engage in some leisure time physical activity lasting at least 10 min per session (22), it may be useful to characterize the effects of multiple short bouts of exercise during the day on BP.

Cardiovascular disease (CVD) accounts for one in every three deaths in the United States, leading to an estimated $286.6 billion in health care costs (22). Hypertension is a major independent risk factor for CVD that affects 76.4 million Americans (22). From 1997 to 2007, the death rate from hypertension increased 9%, and the actual number of deaths due to hypertension rose by 35.6% (22). Suboptimal blood pressure (BP >115/75 mm Hg) is the number one attributable risk factor for death throughout the world (29) and is associated with a 62% increased risk of cerebrovascular disease and 49% increased risk of ischemic heart disease, thus showing that even prehypertensive BP values less than the standard threshold of 140/90 mm Hg contribute to an increased risk of vascular mortality (29). It is estimated that 69.7 million people in the United States older than 20 yr have prehypertension (21). Exercise along with dietary modification is recommended as primary therapy in the management of prehypertension as per Joint National Commission 7 (JNC 7) guidelines (2). Given that 67% of American adults engage in some leisure time physical activity lasting at least 10 min per session (22), it may be useful to characterize the effects of multiple short bouts of exercise during the day on BP.

Aerobic exercise training frequently leads to a reduction in BP, which may in part be due to the phenomenon of postexercise hypotension (PEH) (12). The accumulation of physical activity throughout the day has been shown to reduce BP in prehypertensive and hypertensive individuals (18,20). With regard to structured exercise, sessions as short as 10 min can produce PEH (12). In prehypertensive individuals, Park et al. (20) found that four 10-min walks performed once per hour in the morning were more effective than one 40-min walk in reducing subsequent 12-h ambulatory BP (ABP). In normotensive men and women, Angadi et al. (1) demonstrated that three 10-min bouts of exercise performed 4 h apart were superior to 30 min of continuous exercise performed in the morning for lowering seated BP throughout the afternoon and early evening. However, PEH is significantly greater after exercise in the afternoon compared with exercise in the morning (6,7), and thus, the results of Angadi et al. may have been due in part to the timing of the 30-min continuous exercise bout. To our knowledge, the effect on 24-h ABP of three 10-min bouts of exercise spread throughout the day compared with a 30-min bout of exercise performed in the afternoon has not been reported for prehypertensive individuals.

Because ABP monitoring is emerging as a better prognostic marker than office BP concerning cardiovascular morbidity and mortality (15,23), we compared the effects on 24-h ABP of three short 10-min sessions of exercise performed 4 h apart and one 30-min bout of continuous exercise performed in the afternoon to a nonexercise control day. On the basis of previous work (1,20), we hypothesized that fractionized exercise would be more effective than one continuous exercise session in lowering 24-h ABP.

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METHODS

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Participants

Nonsmoking prehypertensive sedentary adult men and women aged 28.3 ± 8.0 yr were recruited through fliers posted around the Arizona State University campuses. Prehypertension was defined as per JNC 7 criteria (systolic BP of 120–139 mm Hg or diastolic BP of 80–89 mm Hg) taken from an average of three BP measurements taken on two separate days 3 d apart (2). Participants were excluded if they had a history of hypertension, cardiovascular or renal disease, endocrine/metabolic dysfunction, alcohol abuse, and smoking; if they were on any vasoactive medications; or if they answered “yes” to any of the seven questions of the physical activity readiness questionnaire. The Arizona State University Institutional Review Board approved this study, and volunteers provided written informed consent.

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BP screening

Three BP measurements were taken on two separate days (a total of six measurements) with an automated BP monitor (Dinamap® PRO 100 Vital Signs Monitor; GE Healthcare, Little Chalfont, UK) with the subject in a seated position according to the protocol described by the JNC 7 guidelines (2). On the first day, BP was taken in both arms to detect possible differences that might be attributable to peripheral vascular disease (2). The arm with the highest BP was used for screening on the second day (28). Subjects were asked to refrain from exercising or ingesting caffeine during the 30 min preceding the measurement (2). If subjects met the criteria for prehypertension, height (cm) and body weight (kg) (Detecto metric weighing scale and stadiometer, Webb City, MO) were measured.

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Assessment of peak oxygen uptake

Peak oxygen uptake (V˙O2peak) was determined using a progressive continuous modified Balke protocol on a motor-driven treadmill. Subjects began walking at 3.3 mph, 0% grade for the first min. Grade was then increased to 2% for 1 min and then by 1% increments every subsequent minute. After a 25% grade was reached, speed increased by 0.5 mph (13.4 m·min−1) every minute. The test was terminated at the point of volitional exhaustion.

Pulmonary ventilation and gas exchange were monitored continuously for determination of V˙O2 (True One 2400 Metabolic Measurement System; Parvo Medics, Inc., East Sandy, UT). Flow and gas calibration were performed before each test. Heart rate was measured continuously using an HR monitor (Polar Electro OY, Kempele, Finland). V˙O2peak was defined as the highest 15-s average for V˙O2 during the exercise test. It was estimated that 75%–79% of achieved maximum heart rate (HRmax) corresponded to 60%–65% V˙O2peak, and this was used to guide the intensity of the exercise sessions (24).

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Experimental design

Each participant was randomly assigned to complete each of the three conditions: 1) nonexercise control day (control), 2) one continuous 30-min session (1 × 30 min) at 60%–65% V˙O2peak (75%–79% HRmax), and 3) three 10-min sessions (3 × 10-min) at the same intensity used for 1 × 30 min. The three conditions were separated by at least 7 d and were performed on the same day of the week to minimize differences in subjects’ daily routines.

Subjects first reported to the laboratory at 0900 h for the 3 × 10-min trial and at 1200 h for the control and 1 × 30-min trials. Subjects were asked to refrain from exercise for at least 48 h before their visit. Subjects were also advised to refrain from ingesting caffeine for at least 12 h before their visit and for the duration of the ABP monitoring. After arriving at the laboratory, subjects rested quietly in a chair for at least 10 min before being fitted with the ABP device. Baseline BP was measured using the ABP device. For the control trial, subjects were free to leave the laboratory after the investigator made sure the ABP device was operating properly.

For the two exercise conditions, subjects walked on a motor-driven treadmill at 75%–79% HRmax. Heart rate was measured continuously via a Polar heart rate monitor during each exercise session. Treadmill speed and/or incline were adjusted, if necessary, to maintain heart rate within the desired range. Timing of the 3 × 10- and 1 × 30-min exercise sessions was based on previous reports (1,20). The three 10-min exercise sessions were performed during a 30-min window between 0915 and 0945 h, 1315 and 1345 h, and 1715 and 1745 h. After each of the first two 10-min exercise sessions, subjects were free to leave the laboratory until the subsequent exercise session. The continuous 30-min bout of exercise was performed between 1215 and 1245 h.

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24-h ABP monitoring

The 24-h ABP monitoring was performed with the Oscar 2™ ABP System (SunTech Medical, Morrisville, NC) using an appropriately sized cuff (16). The Oscar 2™ has been validated in accordance to the standards of British Hypertension Society, European Society of Hypertension International Protocol, and the Association for Advancement of Medical Instrumentation (4,5,8,17). The intraclass correlation coefficient for 24-h ABP monitoring is estimated at 0.95 for SBP and 0.90 for diastolic blood pressure (DBP) (11). To familiarize subjects with using the Oscar 2™ ABP System, a 24-h ABP monitoring habituation trial was performed after the V˙O2 peak test session that preceded the three experimental trials.

The ABP monitor was programmed to measure BP every 15 min until 2300 h, every 60 min from 2300 to 0800 h the next day, and every 15 min from 0800 to 1200 h the next day. ABP monitoring began 5 min after the 1 × 30-min session and 5 min after the initial 3 × 10-min session. Other than routine activities of daily living, subjects were asked to refrain from any physical activity (control trial) or any additional physical activity other than the structured exercise sessions in the laboratory (both exercise trials) and to return to the laboratory the next day at 1200 h.

Subjects were instructed to relax and straighten the arm during the recording interval for daytime ABP monitoring (17). In addition, subjects were given an activity diary to document their body posture during each BP measurement during their waking hours (16,17). Participants were excluded from data analysis if they had more than 20% missing BP values (19) or if they had more than two consecutive hours of missing data during the 24-h ABP monitoring period.

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Statistical methods

Data are expressed as means ± SD. All P values were calculated assuming two-tailed alternate hypothesis; P < 0.05 was considered statistically significant. Statistical analysis included ABP data collected from 1300 h (to coincide shortly after the 1 × 30-min session was completed), until 1200 h the next day. Linear mixed models were used to detect differences in systolic, diastolic, and mean BP by treatment condition over the entire measurement period and during the periods of 1300–2300, 2300–0800, and 0800–1200 h. The analysis was conducted in a hierarchical fashion using the restricted maximum likelihood model and “variance components” covariance error structure. Both fixed and random effects were explored in the model. Treatment condition and time were used as fixed effects, and time was also used as a random effect to account for both interindividual and diurnal variations in ABP. Addition of age, sex, V˙O2peak, and body mass index did not improve model fit and were therefore not used as covariates. Post hoc analyses were performed using the Bonferroni adjustment for multiple comparisons. One-way ANOVA was used to test for differences in baseline (i.e., pre-ABP monitoring) BP values between the three trials. Chi-square tests were used to compare frequency differences in body posture during the BP measurements and were also used to compare frequency difference in BP load between the three trials. Pairwise comparisons in frequency differences were made using the z-test, and the Bonferroni correction was applied in the statistical software to appropriately adjust the P value. The SPSS software (SPSS 20.0; IBM Corporation, Armonk, NY) was used for all statistical analyses.

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RESULTS

Twenty-one subjects were screened for this study, and 14 met the prehypertension criteria. One subject dropped out because of time constraints, one was excluded because of >20% missing BP values over the 24-h ABP monitoring period on all study sessions (19), and one subject was excluded because of six consecutive hours of missing data during one study session. Consequently, data from 11 prehypertensive participants were used in the data analysis. Subject characteristics are summarized in Table 1.

Table 1
Table 1
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There were no significant differences in baseline systolic (P = 0.719), diastolic (P = 0.844), or mean arterial (P = 0.840) BPs (Table 2). There were no significant differences in body posture logged at the time of ABP measurement between the three trials (P = 0.203, chi-square test). The majority of ABP values were obtained while sitting (55%–60%), with the remainder largely either standing (approximately 13%) or lying down (approximately 20%, mostly sleeping).

Table 2
Table 2
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The pattern of SBP over 24 h for all three conditions is shown in Figure 1A (3 × 10 min vs control) and B (1 × 30 min vs control). Although BP data were collected from 0900 to 1300 h for the 3 × 10-min session and between 1200 and 1300 h for the control trial, because there were no comparable BP values from the 1 × 30-min condition, those data neither are shown nor were included in the analysis. Furthermore, we previously reported that a 10-min exercise session in the morning had no effect on postexercise BP (1).

Figure 1
Figure 1
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There was a significant main effect across the three trials for 24-h SBP (P < 0.001), for the daytime/evening period (1300–2300 h) (P = 0.008), for the nighttime period (2300–0800 h) (P = 0.029), and in the next-day morning period (0800–1200 h) (P = 0.007) (Table 2). There was also a significant main effect for treatment condition on nighttime (2300–0800 h) mean arterial pressure (MAP, P = 0.037) (Table 2). There were no differences in DBP between the trials (P = 0.289).

Results of all post hoc analyses are shown in Table 2. Twenty-four-hour SBP was significantly lower during the 3 × 10-min trial (127 ± 15 mm Hg) as compared with the control (130 ± 15 mm Hg) (P < 0.001) but was not different compared with 1 × 30 min (128 ± 13 mm Hg, P = 0.191). There were no differences in 24-h SBP between 1 × 30 min and control (P = 0.099). Compared with control (133 ± 13 mm Hg), daytime/evening (1300–2300 h) SBP was lower during both 3 × 10 min (130 ± 14 mm Hg, P = 0.011) and 1 × 30 min (131 ± 12 mm Hg, P = 0.044). During the nighttime period (2300–0800 h), SBP in the 3 × 10-min condition (118 ± 16 mm Hg) was significantly lower than control (122 ± 14 mm Hg, P = 0.024) but not different from 1 × 30 min (120 ± 14 mm Hg, P = 0.499). In addition, nighttime MAP was significantly lower during the 3 × 10 min (82 ± 13 mm Hg) as compared with the control (85 ± 12, P = 0.031). During the next-day morning (0800–1200 h), ambulatory SBP for 3 × 10 min (127 ± 15 mm Hg) was lower than both 1 × 30 min (131 ± 12 mm Hg, P = 0.025) and control (131 ± 15 mm Hg, P = 0.016).

Figure 2 shows that for 24 h, 26.7% of SBP values during 3 × 10 min were normal (i.e., <120 mm Hg) compared with 18.3% for 1 × 30 min and 19.4% for control (P < 0.001, chi-square test, P < 0.05, z-test). There was a significantly greater percentage of prehypertensive SBP values during the 1 × 30-min condition (52.3%) compared with both 3 × 10 min (43.9%) and control (45.5%) (P < 0.05, z-test). During 1300–2300 and 0800–1200 h there was a lower BP load (SBP measurements ≥140 mm Hg) for 3 × 10-min (21.8%) and 1 × 30-min (18.8%) conditions compared with control (29.7%) (P < 0.001, chi-square test, P < 0.05, z-test) (Fig. 3A). The BP load did not differ between 3 × 10 min and 1 × 30 min (P > 0.05, z-test). During 2300–0800 h (mainly sleeping), the BP load (SBP values ≥120 mm Hg) was significantly lower for 3 × 10 min (41.4%) compared with control (59.1%) (P = 0.014, chi-square test, P < 0.05, z-test) (Fig. 3B). During 2300–0800 h, the 1 × 30-min trial was not different from either 3 × 10 min or control (P > 0.05, z-test).

Figure 2
Figure 2
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Figure 3
Figure 3
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DISCUSSION

The main finding of this study is that only fractionized exercise performed as three 10-min aerobic exercise sessions during the day (morning, midday and afternoon) reduced 24-h ambulatory SBP compared with control. These SBP reductions were observed during the waking hours, including the afternoon/evening period (1300–2300 h) and in the morning the day after exercise (0800–1200 h), as well as during the nocturnal sleep period. Reductions in ambulatory SBP after continuous exercise were limited to the afternoon/evening (1300–2300 h) after the 1 × 30-min exercise session. Neither fractionized exercise nor continuous exercise had any effect on 24-h ambulatory DBP.

Angadi et al. (1) previously demonstrated that fractionized exercise was superior to continuous exercise with respect to PEH in healthy, normotensive individuals. However, their subjects were part of a study that required them to be confined to a clinical research center, and thus, results from that study may not be applicable to free-living conditions in individuals with higher BPs. Prehypertensive individuals are a critical target population because they are at risk for developing hypertension and at risk for CVD morbidity and mortality (9,10).

Furthermore, the 30-min exercise bout in the study of Angadi et al. (1) was conducted in the morning, and data from Jones et al. (7) showed that the BP reduction after a continuous 30-min bout of exercise performed in the morning was less marked when compared with afternoon exercise. Thus, the results of Angadi et al. may have been due in part to the fact that two of the 10-min exercise bouts occurred in the afternoon and not necessarily due to the fractionized nature of the exercise sessions. The current study was designed to take into account this effect modifier, and hence, the continuous exercise bout was performed in the afternoon. In this study, 3 × 10 min lowered SBP compared with control over the entire 24 h and during the three distinct measurement periods from 1300 to 2300 h, 2300 to 0800 h, and 0800 to 1200 h. Fractionized exercise also lowered ambulatory SBP compared with 1 × 30 min in the next-day morning (0800–1200 h). Because 1 × 30 min was found to reduce SBP compared with control only during 1300–2300 h, the results of the present study support our previous findings (1) and suggest that for reductions in SBP for a 24-h period, fractionized exercise is superior to continuous exercise even when the continuous bout is performed in the afternoon.

It has previously been suggested that a vigorous 10-min walk at breakfast, lunch, and dinner might potentially lead to significant reductions in BP that would last nearly every hour of the day (25). Although the fractionized routine did not reduce ABP during the morning after the first 10-min session, SBP was reduced significantly for much of the remainder of the day, during the night and during the morning of the day after exercise. Even exercise bouts as short as 3 min, when accumulated throughout the day (e.g., ten 3-min sessions), have been shown to result in significantly lower BP the following day (13). The results of this study strengthen findings from previous studies and suggest that short exercise sessions may be a viable strategy for BP control in prehypertensive individuals.

The estimation of systolic BP load (percentage of readings ≥140 mm Hg while awake and ≥120 mm Hg while asleep) has been recommended in the analysis of ABP data (30). BP load is associated with target organ damage and an adverse cardiovascular risk profile independent of average 24-h systolic ABP values (14). Wallace et al. (26) showed significant reductions in systolic and diastolic BP load after 50 min of treadmill walking at 50% V˙O2max despite showing no changes in average 24-h SBP or DBP values. The current study shows that both fractionized and continuous exercise reduce SBP load during (predominantly) awake time, but that fractionized exercise may be better than one continuous bout for reducing SBP load during (predominantly) sleep time. This latter result may be due in part to the fact that the last 10-min exercise bout during the fractionized trial occurred approximately 5 h later in the day than the single 30-min session and thus could have a residual PEH effect that would be more likely to be observed in the evening and overnight period.

There is a circadian variation in the frequency of cerebrovascular and cardiovascular events, and the early morning rise in BP could be an underlying physiological mechanism that might trigger these vascular events (3). The present study suggests that fractionized exercise may help attenuate the early morning rise in SBP (Fig. 1 and Table 2), which could potentially influence this early morning rise in risk of cerebrovascular and cardiovascular events. This attenuation of the early morning rise in BP was not observed after continuous exercise.

There are some limitations to this study. Because physical activity and posture influence BP, a potential limitation of ABP monitoring in free-living conditions is the lack of control over activities and body posture. However, there were no significant differences in subjects’ reported activities or posture between the three conditions. Thus, we have confidence in our finding that the lower 24-h ABP during the 3 × 10-min trial was due to the fractionized nature of the exercise and not due to differences in posture or activities of daily living during three conditions. Also, this study did not explore potential mechanisms for PEH. This would have been difficult because ABP took place outside the laboratory. Mechanistic studies suggest that reductions in SBP after exercise could be attributable to reductions in peripheral resistance, catecholamine levels, and/or α-adrenergic receptor activity (12).

The JNC 7 recommends lifestyle modification as first-line therapy for treating prehypertension or preventing the development of hypertension. An integral part of lifestyle modification is physical activity (2). The present study offers a feasible and effective alternative to the traditional 30-min bout of exercise, which may be of value when formulating exercise prescriptions for prehypertensive individuals. The JNC 7 report also recommends the use of ABP monitoring for gathering information about BP during daily activities and sleep and for diagnosing white coat hypertension (2). The present study shows that fractionized exercise has a significant effect on SBP as measured by 24-h ABP monitoring, hence further supporting the value of exercise prescriptions, which include fractionized exercise for BP reduction (1,13,20).

In conclusion, three 10-min exercise sessions performed morning, midday, and afternoon resulted in reductions in 24-h ambulatory SBP that were greater than those observed on a day in which one 30-min exercise session was performed in the afternoon. The reduction in ambulatory SBP of 3–4 mm Hg (compared with Control) could potentially reduce stroke mortality by up to 8%, reduce cardiovascular mortality by up to 5%, and reduce all-cause mortality by up to 4% (27). Given that perceived lack of time is a leading cause of physical inactivity, this type of fractionized exercise may offer a viable therapeutic option for reducing ambulatory SBP in prehypertensive adults.

No funding was received for this research.

The authors have no conflict of interest to declare.

The results of the present study do not constitute endorsement by the American College of Sports Medicine.

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Keywords:

POSTEXERCISE HYPOTENSION; FRACTIONATED EXERCISE; CONTINUOUS EXERCISE; SHORT BOUTS OF EXERCISE

©2012The American College of Sports Medicine

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