Todd Astorino, PhD
Julien Baker, PhD
Steve Brock, PhD
Lance Dalleck, PhD
Eric Goulet, PhD
Robert Gotshall, PhD
Alexander Hutchison, PhD
M. Knight-Maloney, PhD
Len Kravitz, PhD
James Laskin, PhD
YitAun Lim, PhD
Lonnie Lowery, PhD
Derek Marks, PhD
CristineMermier, PhD
Robert Robergs, PhD
Chantal Vella, PhD
Dale Wagner, PhD
Frank Wyatt, PhD
Ben Zhou, PhD
Official Research Journal of the American Society of
Exercise Physiologists
ISSN 1097-9751
25
December 2015
Volume 18 Number 6
online
Joamira Pereira Araújo 1,2 , Gabriel Rodrigues Neto 1,2 , Julio Silva 1 ,
Hidayane Gonçalves Silva 1,2 , Elísio Alves Pereira Neto 1 , Gilmário
Ricarte Batista 1,2 ,
João Marconio 1 ,
Vitor Bruno Torres¹, Rodrigo
Poderoso¹, Maria do Socorro Cirilo-Sousa 1
1 Department of Physical Education, Kinanthropometry and Human
Development Laboratory, Federal University of Paraíba, João Pessoa,
Brazil, 2 Department of Physical Education, Associate Graduate
Program in Physical Education UPE/UFPB, João Pessoa, Brazil
ABSTRACT
Araújo JP, Neto GR, Silva J, Silva HG, Neto EAPN, Batista GR,
Marconio J, Torres VB, Poderoso R, Cirilo-Sousa MS. Does Water
Aerobics with Blood Flow Restriction Change the Body Composition.
JEP online 2015;18(6):25-31. The present study aimed to analyze the chronic effect of water aerobics with blood flow restriction (BFR) on the body composition of middle-aged women. Twenty nine middleaged women (54 ± 4.1 yrs) were divided into 3 groups: (a) water aerobics with BFR (WAWTBFR), (b) water aerobics without BFR
(WAWOBFR); and (c) control group (CON). The water aerobics program lasted 8 wks (24 sessions), with three weekly sessions. The training groups (WAWTBFR and WAWOBFR) performed 4 sets (30 x
15 x 15 x 15) of repetitions. The WAWTBFR group performed the exercises using an adapted (18 cm wide) sphygmomanometer. The cuff pressure was recorded during both the exercises and the rest intervals between sets. The CON group was instructed to maintain their daily routine until the end of the program. Body mass, body mass index, lean muscle mass, and fat percentage were measured before and after the intervention. No significant differences (P > 0.05) occurred in the comparative analysis of body composition. Additionally, no significant differences in time interaction were observed (P > 0.05). In conclusion, water aerobics with BFR is apparently ineffective in positively affecting body composition.
Keywords : Women, Menopause, Kaatsu, Vascular occlusion

26
INTRODUCTION
Aging is a dynamic and progressive process (21) that promotes changes primarily in height and body composition (BC) (17). According to A ssunção et al . (3), there is a pattern of adiposity changes, consisting of an increase in fat mass in the first decades of aging, with a decline of adiposity in the later decades of aging. At ~70 yrs of age, the aging process stabilizing.
Accordingly, the American College of Sports Medicine (ACSM) (2) recommends that aging individuals participate in regular physical activities, including aerobics and strength training, with the goal of enabling healthy aging. Another option for this population is the method developed by the Japanese almost 50 yrs ago, which aims to use low-intensity loads (20-50% one-repetition maximum, 1RM) combined with blood flow restriction (BFR). This method has been used for increasing strength
(11,23), hypertrophy (1,8,11), local muscular endurance (9), and cardiorespiratory fitness (1,15).
These changes are similar to those promoted by high-intensity (≥80% 1RM) strength training (ST)
(10).
A review of the relevant literature showed that some studies assessed the effects of ST (12,16,20,22) and water aerobics (7,13,14,24) on BC. However, no studies were found that evaluated BC following the use of water aerobics with BFR.
The present study hypothesized that a group trained in water aerobics performed with BFR would show increased skeletal muscle mass and reduced total body mass, body fat mass, body mass index
(BMI), and body fat percentage when compared to a group trained in water aerobics without BFR and a control group. Therefore, the purpose of this study was to analyze the chronic effect of water aerobics with BFR on BC among middle-aged women.
METHODS
Subjects
Twenty nine middle-aged women (54 ± 4.1 yrs) participated in this study. The sample size was chosen between groups based on an estimated effect size of 0.8 for 1RM strength from our pilot study. Using G*Power software (GPower 3.1) (6), an estimated sample size of 15 people was recommended to appropriately observe statistical significance at the 0.05 alpha level (5) with a power level of 0.8. However, it was estimated that 29 people would be needed to be adequately powered for the post-hoc analysis. Individuals were randomly assigned into experimental groups using water aerobics with and without BFR in an aquatic environment (WAWTBFR and WAWOBFR, respectively) and one control group (CON).
The following inclusion criteria were used: (a) a woman aged between 45 and 59 yrs; (b) apparently healthy (without osteo-articular problems in the lower limbs, contraindicated for performing strength training); (c) answering the Physical Activity Readiness Questionnaire (PAR-Q) negatively; (d) no history of cardiovascular disease; (e) a non-smokers; (f) showing no type of trauma related to aquatic environments; and (g) normal range on the AnkleBrachial Index Test (0.90 ≥ ABI ≤ 1.40) that would indicate no peripheral arterial disease (18). Women who failed to follow the training sessions regularly or any stage of the tests were excluded from the study. After explaining the risks and benefits of the research, the volunteers freely signed an informed consent form prepared according to the
Declaration of Helsinki. The study was approved by the Ethics Committee for Research Involving

27
Human Subjects of the Health Sciences Centre /
Federal University of Paraíba, campus I João
Pessoa, under protocol No. 0341/13.
Procedures
Blood Flow Restriction Assessment
Total BFR was reached using a portable vascular Doppler (MedPej
®
DV -
2001, Ribeirão Preto, São
Paulo (SP), Brazil). The external compression for BFR during the intervention was performed according to the method by Laurentino et al. (10), using a specially adapted (18 cm wide x 80 cm long) sphygmomanometer, which was placed on the upper thigh area and inflated until the auscultation pulse in the tibial artery was interrupted. The cuff pressure used during the exercises was assessed at 80% of the necessary pressure for total BFR in the resting state. The cuff pressure was maintained between sets. The average pressure used throughout the experiment in the lower limbs was 96.96
± 10.49 mmHg.
Body Composition Evaluation
Lean muscle mass (BMI), body mass, and fat percentage were measured before and after the intervention using a BC analyzer (InBody 720 Biospace
®
, San Francisco, CA, USA) with direct segmental multi-frequency measurement and a tetrapolar eight-point tactile electrode system.
Strength Training Program
The water aerobics program consisted of two different workouts over 8 wks, with 3 weekly sessions
(totaling 24 sessions), controlled room temperature (from 26ºC to 29ºC), and immersion to the xiphoid process. The training groups (WAWTBFR and WAWOBFR) performed 4 sets, including 1 set with 30 repetitions and 3 sets with 15 repetitions. The WAWTBFR group performed the exercises using a specially adapted (18 cm wide x 80 cm long) sphygmomanometer. The cuff pressure was maintained during the exercises and in the breaks between sets. The WAWOBFR group performed the exercises without the specially adapted sphygmomanometer. The CON group was instructed to maintain their daily routine until completing the 8-wk monitoring to perform the evaluations.
The training sessions lasted 45 min and consisted of a warm-up, a main set, and stretching. The warm-up consisted of walking at a self-selected intensity. The main set was intended for specific strength exercises (hip flexion and extension, hip adduction and abduction, and knee flexion and extension), and stretching was standardized for the training groups, prioritizing the muscles involved in the main set.
The intervention groups performed the lower limb exercises: (a) hip flexion and extension; (b) hip adduction and abduction; and (c) knee flexion and extension, unilaterally. Hip flexion and extension were performed with the hip flexed to 90º. Hip adduction and abduction were performed with the leg extended sideways, and knee flexion and extension were performed flexing the knee to 90º. All exercises were performed on the edge of the pool to support the upper body with a perceived stress index ranging from 9 to 11 on the Borg 15-category scale (6-20) (4), with a 5% increase every six training sessions, following a 1-min interval between exercises.
Statistical Analysis
Data normality was assessed using the Shapiro-Wilk test and the homogeneity of variances using the
Levene
’s test. The variables showed normal distribution and homogeneity (P>0.05). The intraclass correlation coefficient (ICC) was used to test the reproducibility of the load between the 1RM tests and functional capacity and retesting. Descriptive data are expressed as means and standard deviations. Two-way analysis of variance (ANOVA) [groups (WAWTBFR x WAWOBFR x CON) x (pre

28 x post) conditions] were used to evaluate strength and functional capacity tests. Where appropriate, the Bonferroni post hoc test was used to determine specific differences. The effect size (ES) was used to assess the magnitude [trivial < 0.50, small = 0.50
–1.25, moderate = 1.25–1.90 and large >
2.0] of changes between the evaluations of study protocols (19), and the percentage of variation
(Δ%) was used to express the possible differences between significant changes. The level of significance was set at P<0.05. All statistical analyses were performed using the statistical software Statistical
Package for the Social Sciences (SPSS), version 18.0 (SPSS Inc., Chicago, IL, USA).
RESULTS
Comparative analysis of BC revealed that no significant differences occurred (P > 0.05). No significant differences in time interaction were observed (P > 0.05), as shown in Table 1.
Table 1. Body Composition of the Sample.
VARIABLE
BM
SMM
BFM
Xpre
± SD
60.0
±8.0
19.8
±1.8
23.4
±6.7
CONTROL
(n = 10)
Xpost
± SD
60.3
±8.2
19.7
±1.8
23.5
±6.5
Δ%
0.5
0.42
ES Xpre
± SD
0.03
-0.50 -0.05
0.01
61.3
±7.2
20.8
±1.9
22.6
±4.9
WAWOBFR GROUP
Xpost
± SD
61.6
±7.3
20.9
±1.6
22.9
±4.6
(n = 9)
Δ%
0.48
0.48
1.32
ES Xpre
± SD
0.04
0.05
0.06
60.1
±9.0
20.2
±2.9
23.3
±4.5
WAWTBFR GROUP
(n = 10)
Xpost
± SD
60.4
±8.9
20.2
±2.7
23.6
±4.7
Δ
%
0.4
9
0
ES
0.0
3
0
1.2 0.0
6
BMI
%BF
WHR
26.5
±3.9
38.0
±6.3
0.89
±0.04
26.3
±3.8
38.4
±5.9
0.89
±0.04
-0.75
1.05
0
0.05
0.06
0
25.4
±3.2
36.2
±4.7
0.89
±0.05
25.6.
±3.3
36.7
±4.0
0.89
±0.05
0.78
1.38
0
0.06
0.10
0
25.3
±2.7
38.0
±3.0
0.89
±0.05
25.5
±2.6
38.4
±2.9
0.91
±0.04
0.7
9
1.0
5
2.2
4
0.0
7
0.1
Note: CON = Control group; ES = Effect size; BM = Body mass; SMM = Skeletal muscle mass; BFM = Body
3
4 fat mass; BMI = Body mass index; %BF = Body fat percentage; WHR = Waist-hip ratio
DISCUSSION
The present study analyzed the chronic effect of water aerobics with BFR on BC among middle-aged women. To our knowledge, this study was the first to evaluate the chronic effect of water aerobics with BFR on BC. The main finding was that no significant differences occurred in any BC components in the intergroup and intragroup comparisons. Although no study has assessed the effect of water aerobics with BFR on BC, some studies have assessed positive effects of exercises performed in the aquatic environment, including BMI, fat percentage, and body fat mass reduction among the elderly
(7,13,14,24).
Vedana et al. (24) observed significant reductions in BMI (1.1%), fat percentage (1.6%), and body fat mass (5%) among the elderly of both genders after submitting them to 16 wks of water aerobics with

29
50-min sessions and a frequency of 2 sessions per week
. Mendonça et al. (14) reported positive effects on fat percentage (5.1%) and body fat mass (4.3%) after sedentary women underwent three weekly sessions of water aerobics lasting 45-55 min with cardiorespiratory components of muscular endurance and strength of the upper and lower limbs for 16 wks. Melo and Gavioni (13) only observed a significant reduction in the body fat mass of the legs (3%) of women evaluated using the dual-energy X-ray absorptiometry (DXA) method with 12 wks of water aerobics at a frequency of three times a week. However, the training protocol was not detailed in that study. Irandoust and
Taheri (7) reported significant reductions in BMI (5.6%), fat percentage (8.7%), and waist-hip ratio
(7.3%) among the elderly evaluated using the In Body 230, the same device used in the present study, after 12 wks of aquatic exercise.
The analysis of aforementioned results and the comparison with those from the present study reveal that a reduction in at least one Charlson Comorbidity Index component occurred in individuals who performed exercises in the aquatic environment, which did not occur in the present study. The difference between the studies may be because the intervention time of the present study was shorter than those in other studies (7,13,14,24), suggesting that 8 wks of water aerobics with BFR is apparently insufficient to promote BC changes. Another factor that would explain the results assessed herein is that the training sessions of the present study consisted only of strength exercises for lower limbs, whereas the training sessions of studies that found significant differences post-intervention consisted of higher training volumes, which could promote greater energy expenditure.
Some limitations of the present study are noteworthy, including, for example, the short period of intervention and a training protocol that targeted only the lower limbs plus a low volume of training, which was insufficient to promote changes in BC.
CONCLUSION
The results from this study suggest that water aerobics with BFR is apparently ineffective in positively affecting BC. However, these results are not conclusive because the intervention time was shorter and the volume of exercises performed was lower compared to other studies that applied similar methods and reported positive results, albeit without BFR. Therefore, it is suggested that further studies be conducted involving BFR in the aquatic environment with a longer time of intervention and with exercises targeting all body segments.
Address for correspondence: Gabriel Rodrigues Neto, MD, Department of Physical Education -
Associate Graduate Program in Physical Education UPE / UFPB, Federal Universit y of Paraíba,
University City, Research Center for Human Movement Sciences, Kinanthropometry Laboratory,
Room 06 and 08. Castelo Branco. João Pessoa – 58051-900, Brazil. / Phone: 55 083 09612-2726 Email: gabrielrodrigues_1988@hotmail.com
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