Training & Testing
Health-Promoting Effects of Serial vs. Integrated Combined
Strength and Aerobic Training
Authors
Konstantina Karatrantou1, Vassilis Gerodimos1 , Keijo Häkkinen2 ,
Andreas Zafeiridis3
Affiliations
1 Department of Physical Education and Sport Science, University
of Thessaly, Trikala, Greece
2 Department of Biology of Physical Activity, University of
Jyväskylä, Finland
3 Department of Physical Education and Sport Science at Serres,
Aristotle University of Thessaloniki, Serres, Greece
Key words
health, concurrent training, aerobic dance, calisthenics,
­cardiovascular adaptations, neuromuscular adaptations
accepted after revision 23.08.2016
Bibliography
DOI http://dx.doi.org/10.1055/s-0042-116495
Published online: 2016 | Int J Sports Med 2017; 38: 55–64
© Georg Thieme Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Dr. Konstantina Karatrantou
Department of Physical Education and Sport Science
Karies, Trikala
University of Thessaly
Introduction
The American College of Sports Medicine recommends that healthy
adults should engage in moderate to vigorous physical activity 3–5
times per week. An ideal training program entails both cardiores-
piratory and neuromuscular exercises aiming to improve or pre-
serve physical fitness and health [16]. There is evidence that com-
bining aerobic and strength exercises is more effective than either
form of training alone in counteracting the detrimental effects of
a sedentary lifestyle on the cardiovascular and musculoskeletal sys-
tems [24]. More specifically, combining aerobic and strength exer-
cises improved to a greater extent maximal oxygen consumption,
blood pressure, the muscle strength and power of lower and upper
limbs, and body composition profile [24]. The main drawback of
combined training programs is the introduction of the so-called
“interference effect”, which hinders the development of muscle
strength and/or power [3, 4, 13, 20, 28].
Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
Thieme
42100 Trikala
Greece
Tel.: + 30/243/1047 005, Fax: + 30/243/1047 002
kokaratr@pe.uth.gr
Abs tr ac t
Combined strength and aerobic training programs are widely used for
improving markers of physical fitness and health. We compared the
efficiency of a serial and an integrated combined training program on
health and overall fitness in middle-aged females. 54 females
(46.7 ± 4.5 yrs) were assigned to a serial (SCG) or an integrated (ICG)
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combined training group or to a control group (CG). The SCG and ICG
performed a 3-month training combining aerobic dance and calisthen-
ics. The 2 training programs differ in the sequence of aerobic and
strength exercises. SCG performed the strength exercises prior to aer-
obic; in ICG, the aerobic and strength exercises were altered in a prede-
termined order. Body composition/circumferences, blood pressure,
respiratory function, flexibility, balance, muscle strength/endurance,
power and aerobic capacity were measured before and after training.
SCG and ICG significantly increased muscle strength and endurance,
power, aerobic capacity, flexibility, balance, fat-free mass and respira-
tory function (p < 0.001–0.05), while significant reductions were ob-
served for blood pressure, heart rate and body fat/circumferences
(p < 0.001–0.05). However, there were no significant differences be-
tween SCG and ICG after training. Serial and integrated combined train-
ing programs confer analogous adaptations and can be used inter-
changeably for counteracting the detrimental effects of sedentary
lifestyle on indices of physical fitness and health.
With this in mind, research has been focusing on examining the
efficacy of different combined aerobic and strength training pro-
grams to find the most effective exercise-training regimen for im-
proving indices of physical fitness, functional capacity and meta-
bolic health. There are 2 forms of combined training programs: the
serial method (strength loading is completed prior to aerobic in
each training session or vise-versa) and the integrated method (aer-
obic and strength routines are altered repeatedly during the train-
ing session) [6–8]. The numerous studies in young and only a few
in middle-aged and elderly individuals that examined the effects
of either serial or integrated combined training programs on indi-
ces of physical fitness and health have reported improvements
[13, 24, 28, 37, 38] or no change [14, 33, 36, 38] on cardiovascular
and neuromuscular performances and on body composition pro-
file. Thus, the efficacy of serial or integrated combined training pro-
grams on indices of health and physical fitness, particularly in un-
trained middle-aged individuals, should be further investigated.
55
 Training & Testing
To our knowledge, studies comparing serial vs. integrated com-
bined training have not been conducted in sedentary middle-aged
females. The only study that directly compared the effectiveness
of serial vs. integrated combined training has been conducted in
collegiate young athletes. Integrated combined training resulted
in slightly greater aerobic and neuromuscular adaptations com-
pared to the serial regimen [7, 8]. Age and physical fitness, howev-
er, are associated with different cardiovascular responses [15], pe-
ripheral fatigue development [26] and substrate utilization [23]
during exercise; these age- and fitness-dependent responses may
affect the aerobic and neuromuscular adaptations [9, 27]. Further-
more, it has been suggested that the “interference effect” between
strength and aerobic training is mostly evident in less conditioned
individuals and that the integrated combined training mode may
reduce or eliminate the “interference effect” in this population be-
cause such programs are associated with less muscle soreness and
faster muscle recovery [6–8].
Thus, the objectives of this study were to examine and to direct-
ly compare the effects of the serial and integrated training pro-
grams combining low-impact aerobic dance and calisthenics exer-
cises on indices of health, overall fitness and functional capacity in
untrained middle-aged females.
Materials and Methods
Participants
54 pre-menopausal middle-aged women (40–51 years-old) were
recruited to participate in this study. Prior to the study, the sub-
jects’ health (health history questionnaire, resting electrocardio-
gram and echocardiogram examined by a cardiologist) and activ-
ity status were assessed [1]. All subjects: a) were healthy and free
of any illness, disease and injury, b) did not report use of any med-
ication, and c) did not participate in regular physical activity for at
least one year prior to the study. Before the initiation of the study,
participants were informed about the experimental procedures
and possible risks during the study, and signed an informed con-
sent form. The study was conducted according to the Declaration
of Helsinki and the ethical approval was granted by the Ethics Com-
mittee of the university. Additionally, the study methods met the
ethical standards of the International Journal of Sports Medicine
[19].
Study design
Following the initial health screening, the subjects performed 3 fa-
miliarization sessions to get accustomed to the instrumentation
and the experimental procedures. Thereafter, indices of health,
overall fitness and functional capacity were assessed on 3 separate
days. 2 days following the pre-training testing, the subjects were
randomly allocated to either a SCG (n = 18; age: 46.9 ± 4.9 yrs; body
mass: 76.3 ± 3.8 kg; height: 164 ± 7 cm), an ICG (n = 18; age:
46.4 ± 3.7 yrs; body mass: 73.6 ± 15.8 kg; height: 162 ± 6 cm) or to
a CG (n = 18; age: 46.3 ± 4.2 yrs; body mass: 72.6 ± 15.2 kg; height:
160 ± 6 cm). During the study, the SCG and ICG participated in a
3-month combined training program. 2 days after the completion
of training, the pre-training measurements were repeated in the
same order and at the same time of the day. The SCG and ICG were
instructed to avoid any type of other physical activity during the
56
Thieme
study, whereas the CG was instructed to maintain their normal daily
living activities. Subjects were instructed to: a) retain their regular
dietary habits during the study, b) abstain from any caffeine, to-
bacco and alcohol consumption for at least 24 h before testing,
c) avoid physical activity for 48 h prior to testing, and d) have suffi-
cient rest the night before the testing.
Training programs
The SCG and ICG participated in a 3-month combined training pro-
gram (3 days/week). Each training session lasted 62–82 min and
consisted of 10-min warm-up (5-min dance, 5-min stretching ex-
ercises), 45–65 min combined training program, and 7-min cool-
down (3-min dance, 4-min stretching exercises). The training load
of aerobic and strength routines was equated between the 2 train-
ing groups. More specifically, both SCG and ICG performed the
same exercises, during the aerobic and strength workouts, using
equivalent intensity, duration, volume and frequency of training
(▶ Table 1). To ensure that the 2 protocols elicited similar physio-
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logical strain, we performed real-time monitoring of the partici-
pants’ heart rate during the exercise session and obtained the rat-
ing of perceived exertion (RPE) at the completion of the exercise
session. The mean heart rate and RPE were not different between
the 2 groups during the training sessions (64 ± 5.5 % of HRmax and
13.1 ± 1.5 RPE in the SCG vs. 66 ± 6.4 % of HRmax and 13.8 ± 1.2 RPE
in the ICG). Thus, the 2 training programs differ only in the se-
quence of aerobic and strength training. That is, in SCG the strength
training was performed prior to aerobic training, while in ICG the
aerobic and the strength training were altered in a predetermined
order (3-min dance/2-min calisthenics exercises).
The aerobic training program consisted of low-impact aerobic
dance movements for major muscle groups such as forward and
backward march, step touch, knee lift, heel up, kick, lateral lung-
es, grapevine, squats, V-step and turn step, etc. Arm movements
at the shoulder level and above the head were also incorporated in
the aerobic dance chorography. We selected a low-impact aerobic
dance because (i) it is a safe, efficient and enjoyable mode of exer-
cise, which induces significant physical and mental health benefits
in individuals with low physical fitness and (ii) it is widely used in
fitness and rehabilitation centers for improving indices of health
and overall fitness in sedentary individuals.
During the aerobic workout, participants held a medium resist-
ance anti-stress ball in each hand and squeezed the balls simultane-
ously while performing aerobic dance movements. Our training pro-
tocol aimed to improve maximal handgrip strength and endurance,
as digit and forearm muscles were not significantly engaged during
the calisthenics routines of our program. The intensity (65–85 % of
the age-predicted HRmax; 105–120 bits/min) and the duration (18–
36 min) of aerobic training progressively increased [16] during the
training program (▶Table 1). The participants’ heart rate was mon-
itored in real time, throughout the exercise session, using the Polar
Team Solution system (Science Technologies, Kempele, Finland) to
ensure compliance with the target exercise heart rate.
The strength training program consisted of calisthenics exercis-
es for all major muscle groups including routines for the lower (stat-
ic forward lunges and step up) and upper body (push-ups and dips),
as well as, for abdominal and dorsal trunk muscles. The intensity
during the calisthenics exercises was modified by increasing pro-
Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
▶Table 1 Strength and endurance training program of the 3-month training intervention.

Weeks
1–2 3–5 6–8 9–12
Serial Combined Group
Aerobic dance
Intensity ( % HRmax) 65–75 % 70–75 % 73–80 % 75–85 %
Rhythm (bits/min) 105 110 110–115 115–120
Duration (min) 18–27 27 36 36
Strength training
Sets 2–3 3 4 4
Reps/set
Lunges/Step-up/Push-ups 10 10–12 12 12
Curl-up/Dorsals 10 10–12 12–15 15
Dips 5–6 6–8 7–9 7–10
Rest time/set (s)
Curl-up/Dorsals 40–50 40–50 40–50 40–50
Lunges/Step-up 60 60 60 60

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Push-ups/Dips 90 90 90 90
Integrated Combined Group
Aerobic dance
Intensity ( % HRmax) 64–76 % 70–76 % 72–82 % 74–85 %
Rhythm (bits/min) 105 110 110–115 115–120
Duration (set × time) 6–9 × 3 min 9 × 3 min 12 × 3 min 12 × 3 min
Strength training
Sets 2–3 3 4 4
Reps/set
Lunges/Step-up/Push-ups 10 10–12 12 12
Curl-up/Dorsals 10 10–12 12–15 15
Dips 5–6 6–8 7–9 7–10
Rest time/set (s) – – – –

% HRmax: percentage of the age-predicted maximum heart rate as recorded during the training program by the Polar Team Solution System

gressively the number of repetitions and sets during the training
period. More specifically, the number of repetitions (5–15RM) and
sets (2–4) of the strength exercises progressively increased during
the training program [16] (▶Table 1). All exercises were performed
at a slow to moderate speed (1-sec concentric phase, 2-sec isomet-
ric phase and 3-sec eccentric phase).
Testing procedures
Prior to physical fitness testing, the participants performed a stand-
ardized 10-min warm-up (5-min stationary cycling, 5-min static
and dynamic stretching exercises).
Health indices
Body mass and height were measured using a calibrated physician’s
scale (Seca, Hamburg, Germany). Waist and hip circumferences
were measured using a conventional measuring tape, and the
waist-to-hip ratio was calculated [1]. Body composition (percent-
age of body fat- %BF, fat mass-FM, fat-free mass-FFM) was assessed
using the bioelectrical impedance method (Maltron 900) [1]. Blood
pressure [1] and respiratory function (forced vital capacity-FVC,
forced expiratory volume in 1s-FEV1) [2] were also measured using
an electronic blood pressure monitor (A&D-UA-851) and a porta-
ble spirometer (Micro Medical Micro), respectively.
Physical fitness
Lower body muscle strength and power: Vertical jumping perfor-
mance was assessed using the squat jump test (SJ) with a force-plat-
form (Bertec Corp., Worthington, OH), as previously described by
Tsourlou et al. [38]. The isokinetic peak torque of knee extensors
and knee flexors muscles was also measured [38] using a Cybex
Norm dynamometer. The isokinetic protocol included 5 maximal
concentric and eccentric knee extension and flexion efforts at an-
gular velocity of 60o/s. The moments were corrected for the effects
of gravity, and the repetition with the highest moment (Nm) was
used for analysis.
Muscular strength and endurance of the upper body: Handgrip
strength was measured using a portable hydraulic dynamometer
(Jamar 5030J1, Horsham, USA). The maximal testing protocol con-
sisted of 3 maximal isometric contractions (5s) for each hand with
1-min rest between trials [17]. The highest recorded value of the 3
attempts was considered as the maximal voluntary contraction

Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64 57
 Training & Testing Thieme

(MVC). Thereafter, handgrip endurance strength was measured at
a target value of 50 % MVC. The subjects were instructed to sustain
the target value for as long as possible. The trial was terminated
when the strength declined by 10 % of the target value for more
than 3 s [21]. The time in seconds at each hand was recorded and
considered for analysis. Furthermore, muscular endurance of the
abdominal muscles, chest and biceps muscles, as well as triceps
muscles, were assessed using the “1-min curl-up test,” the modi-
fied “knee push-up test” and the “1-min dip test,” respectively [1].
Finally, the muscular endurance of the trunk extensors muscles was
also evaluated using the “Ito test” [22].
Cardiorespiratory fitness: Cardiorespiratory fitness was assessed
using the submaximal treadmill walking test consisting of three
4-min stages [12]. The participant started the 4-min walking test
protocol at an initial velocity that corresponded to 60 % of her
age-predicted HRmax and 0 % grade. The walking speed then re-
mained stable and the incline was increased every 4 min by 5 %. HR
was continuously recorded over 10-s intervals using chest belt
at the completion of each stage and at the first, second and third
minute following the termination of walking test.
Functional capacity
The flexibility was assessed with the sit-and-reach test using a
Flex-Tester box (Novel Products Inc, Rockton, IL) [1]. Static balance
and dynamic balance were also evaluated using the 1-min single
limb stance test with eyes opened and closed [11, 30] and the
timed up-and-go test [29], respectively.
Statistical analysis
All data are presented as means ± SD, and were analyzed using SPSS
18.0. The normality of data was examined using the Shapiro-Wilk
test. 2-way ANOVAs (group × time; 3 × 2) with repeated measures
on “time” factor were used to analyze the data. Sidak pairwise com-
parisons were applied to locate the significantly different means
within and between groups. One-way ANOVAs were used between
groups to compare the relative changes from pre- to post-training

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telemetry (Polar Electro, Kempele, Finland). At the end of each in fitness and health indices. The effect sizes were calculated using
stage, the RPE was obtained using the 20-point Borg scale. Partic- the equation: d = difference between means/pooled SD. The level
ipants’ heart rate was also measured prior to walking test protocol, of significance for all statistical analyses was set at p < 0.05.

▶Table 2 Health indices in the serial concurrent (SCG), integrated concurrent (ICG) and control (CG) groups pre- and post-training. Values are
means ± SD.

Variables Group Pre-training Post-training % Percent change

Body mass (kg) SCG 76.34 ± 13.79 74.88 ± 13.84 * − 2.03 ± 2.55 †
ICG 73.58 ± 15.83 71.62 ± 14.59 * − 2.56 ± 2.76 †
CG 72.64 ± 15.17 73.07 ± 15.26 0.58 ± 1.51
Body fat ( %) SCG 39.31 ± 6.22 36.76 ± 6.11 * ‡ − 7.12 ± 4.18 †
ICG 38.08 ± 7.31 35.09 ± 6.27 * ‡ − 8.43 ± 5.33 †
CG 38.52 ± 7.59 38.86 ± 7.51 0.93 ± 1.83
Body fat (kg) SCG 30.87 ± 9.98 28.36 ± 9.69 * ‡ − 9.36 ± 6.57 †
ICG 29.04 ± 11.90 26.91 ± 9.98 * ‡ − 11.32 ± 8.08 †
CG 29.09 ± 11.85 29.48 ± 11.84 1.52 ± 2.63
Fat free mass (kg) SCG 45.86 ± 4.91 46.90 ± 5.29 * ‡ 2.15 ± 2.04 †
ICG 44.55 ± 4.54 45.71 ± 5.24 * ‡ 2.41 ± 1.89 †
CG 43.72 ± 4.18 43.77 ± 4.41 0.05 ± 1.73
Waist-to-hip ratio SCG 0.87 ± 0.05 0.85 ± 0.06 * ‡ − 2.01 ± 2.73 †
ICG 0.87 ± 0.04 0.85 ± 0.03 * ‡ − 2.70 ± 2.29 †
CG 0.88 ± 0.05 0.88 ± 0.05 − 0.34 ± 0.84
Systolic BP (mmHg) SCG 106.83 ± 10.13 102.64 ± 8.55 * ‡ − 4.07 ± 3.47 †
ICG 112.52 ± 9.87 104.92 ± 10.12 * ‡ − 7.49 ± 6.19 †
CG 110.79 ± 12.81 112.44 ± 11.20 1.59 ± 3.19
Diastolic BP (mmHg) SCG 74.28 ± 8.42 70.86 ± 7.32#‡ − 4.84 ± 5.53 †
ICG 77.42 ± 9.09 71.65 ± 10.13 * ‡ − 8.45 ± 6.79 †
CG 76.44 ± 10.49 78.25 ± 9.92 5.97 ± 4.93
FVC (L) SCG 3.31 ± 0.52 3.42 ± 0.50 # ‡ 3.29 ± 4.37 ‡
ICG 3.19 ± 0.41 3.38 ± 0.32 # ‡ 5.87 ± 4.37 ‡
CG 3.10 ± 0.43 3.08 ± 0.40 − 2.70 ± 3.07
FEV 1 (L) SCG 2.62 ± 0.42 2.72 ± 0.42 * ‡ 3.92 ± 4.59 ‡
ICG 2.65 ± 0.30 2.77 ± 0.27 * ‡ 4.62 ± 3.39 ‡
CG 2.59 ± 0.34 2.55 ± 0.32 − 2.96 ± 2.81

BP: blood pressure, FVC: forced vital capacity, FEV1: forced expiratory volume in 1 s; * p < 0.01 vs. pre-training in SCG and ICG, #p < 0.05 vs. pre-train-
ing in SCG and ICG, †p < 0.01 vs. CG, ‡p < 0.05 vs. CG

58 Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
Results
Health indices
ANOVAs showed significant “group × time” interaction effects on
health indices (p < 0.01–0.001; ▶ Table 2). Specifically, mean val-
ues for %BF, body circumferences, and arterial blood pressure were
significantly lower and FFM, FVC and FEV1 were significantly high-
er at post-training vs. the respective pre-training values in SCG and
ICG (p < 0.01). In CG, all the above variables did not change. Com-
parisons between groups revealed that pre-training values for all
health indices were not different among groups, while all post-train-
ing health indices significantly improved in SCG and ICG vs. CG
(p < 0.01–0.05) with no differences between SCG and ICG. The per-
cent changes from baseline to post training for all health indices
were significantly greater in SCG and ICG vs. CG (p < 0.01).
Physical fitness and functional capacity
The ANOVA test indicated significant “group × time” interaction ef-
fects on SJ performance and isokinetic peak torque (p < 0.001;
(p < 0.001; ▶ Table 4), as well as on curl-up, Ito, push-up and dip
tests (p < 0.001; ▶Table 4). Furthermore, significant “group × time”
interaction effects were observed on cardiorespiratory fitness
(p < 0.001; ▶Table 5), on flexibility, as well as on static and dynam-
ic balance (p < 0.001; ▶ Table 6). Both training programs signifi-
cantly increased SJ performance, isokinetic peak torque, muscle
strength and endurance of upper body, flexibility and static balance
(p < 0.01;d = 0.66–5.48), while significantly decreasing all
post-training heart rate, RPE and dynamic balance values (time at
TUG test) (p < 0.01). In CG, indices of physical fitness and function-
al capacity did not change throughout the study. Post-hoc com-
parisons between groups revealed that power, lower and upper
body muscle strength and endurance, flexibility and static balance
mean values were significantly greater in SCG and ICG vs. CG at the
post-training time point (p < 0.01–0.05;d = 0.81–6.21); pre-train-
ing values were not different between groups. Whereas heart rate,
RPE and dynamic balance (score at TUG test) were significantly
lower in the 2 training groups vs. CG (p < 0.01; d = 0.81–2.13). Fur-

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▶ Table 3), on maximal and endurance handgrip strength thermore, there were no differences between SCG and ICG for all

▶Table 3 Muscle strength and power of lower body in the serial concurrent (SCG), integrated concurrent (ICG) and control (CG) groups pre- and
post-training. Values are means ± SD.

Variables Group Pre-training Post-training % Percent change

Concentric peak torque (Nm)
Extensors preferred leg SCG 111.94 ± 23.29 136.61 ± 17.68 * † 18.66 ± 8.80 †
ICG 110.67 ± 20.07 134.00 ± 20.01 * † 17.61 ± 5.33 †
CG 109.00 ± 20.11 108.72 ± 19.71 − 0.19 ± 2.32
Extensors non-preferred leg SCG 110.44 ± 22.87 136.06 ± 18.04 * † 19.28 ± 8.51 †
ICG 112.89 ± 26.54 136.50 ± 21.50 * † 18.03 ± 8.07 †
CG 112.67 ± 21.10 112.39 ± 20.87 − 0.23 ± 1.97
Flexors preferred leg SCG 68.33 ± 11.19 85.61 ± 10.64 * † 20.34 ± 7.06 †
ICG 70.00 ± 11.74 87.50 ± 10.79 * † 20.02 ± 8.91 †
CG 71.06 ± 10.99 68.44 ± 9.36 − 3.91 ± 9.26
Flexors non-preferred leg SCG 64.83 ± 14.95 85.50 ± 10.21 * † 24.55 ± 12.22 †
ICG 64.78 ± 13.77 86.39 ± 12.80 * † 25.33 ± 8.70 †
CG 66.17 ± 11.60 64.28 ± 9.99 − 2.86 ± 8.37
Eccentric peak torque (Nm)
Extensors preferred leg SCG 167.61 ± 44.67 193.56 ± 39.51 * † 14.25 ± 7.00 †
ICG 170.44 ± 31.74 194.72 ± 36.36 * † 12.42 ± 2.80 †
CG 164.44 ± 30.48 163.83 ± 29.41 − 0.27 ± 1.78
Extensors non-preferred leg SCG 161.72 ± 36.78 190.78 ± 37.34 * † 15.36 ± 7.82 †
ICG 166.67 ± 38.37 194.78 ± 38.33 * † 14.77 ± 5.76 †
CG 162.83 ± 30.63 161.67 ± 30.24 − 0.72 ± 1.52
Flexors preferred leg SCG 94.28 ± 16.78 113.39 ± 12.04 * † 17.32 ± 8.55 †
ICG 93.67 ± 14.36 111.28 ± 15.65 * ‡ 15.76 ± 6.65 †
CG 94.67 ± 16.26 92.61 ± 15.58 − 2.38 ± 7.70
Flexors non-preferred leg SCG 93.06 ± 17.76 113.44 ± 11.18 * † 18.35 ± 10.34 †
ICG 94.22 ± 19.46 111.61 ± 16.31 * ‡ 16.05 ± 8.68 †
CG 93.11 ± 15.67 92.00 ± 15.94 − 1.46 ± 6.85
Vertical jumping ability SCG 12.64 ± 3.84 15.40 ± 3.39 * ‡ 18.96 ± 12.13 †
Squat jump (cm) ICG 13.67 ± 3.07 16.61 ± 3.00 * ‡ 18.18 ± 7.68 †
CG 13.02 ± 2.98 12.62 ± 2.67 − 2.69 ± 3.11

* p < 0.01 vs. pre-training in SCG and ICG, †p < 0.01 vs. CG, ‡p < 0.05 vs. CG

Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64 59
 Training & Testing Thieme

▶Table 4 Muscle strength and endurance of upper body in the serial concurrent (SCG), integrated concurrent (ICG) and control (CG) groups pre- and
post-training. Values are means ± SD.

Variables Group Pre-training Post-training % Percent change

Maximal HG
Preferred hand (kg) SCG 32.31 ± 5.18 35.67 ± 4.86 * † 9.64 ± 4.58 †
ICG 31.39 ± 6.61 35.44 ± 5.68 * † 11.69 ± 8.94 †
CG 31.08 ± 6.13 30.61 ± 6.23 − 1.65 ± 2.83
Non-preferred hand (kg) SCG 31.11 ± 4.80 35.44 ± 4.68 * † 12.24 ± 6.21 †
ICG 30.78 ± 5.26 35.19 ± 5.30 * † 12.57 ± 6.88 †
CG 30.33 ± 4.65 29.86 ± 4.79 − 1.71 ± 2.73
Endurance HG
Preferred hand (s) SCG 62.28 ± 23.84 94.06 ± 4.64 * † 33.75 ± 15.42 †
ICG 59.39 ± 13.49 89.00 ± 4.54 * † 30.61 ± 15.13 †
CG 63.02 ± 21.79 63.94 ± 22.27 0.96 ± 8.41
Non-preferred hand (s) SCG 56.79 ± 20.14 80.34 ± 22.76 * † 28.02 ± 19.38 †
ICG 56.19 ± 16.49 79.36 ± 24.12 * † 26.91 ± 20.16 †
CG 53.17 ± 18.97 55.03 ± 18.98 3.30 ± 8.13

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Sit-up (reps) SCG 9.06 ± 4.29 17.67 ± 2.54 * † 48.90 ± 21.57 †
ICG 8.67 ± 3.07 16.50 ± 2.73 * † 47.49 ± 17.16 †
CG 9.78 ± 4.10 9.28 ± 3.58 − 4.88 ± 8.92
Ito test (s) SCG 68.52 ± 30.60 142.22 ± 55.05 * † 47.88 ± 21.52 †
ICG 75.56 ± 45.44 141.83 ± 74.11 * † 45.89 ± 19.56 †
CG 77.16 ± 46.92 75.78 ± 45.89 − 1.62 ± 3.37
Push-ups (reps) SCG 3.50 ± 2.75 13.72 ± 4.64 * † 75.78 ± 16.83 †
ICG 3.61 ± 2.43 12.44 ± 4.54 * † 71.82 ± 14.53 †
CG 4.39 ± 3.42 3.83 ± 3.09 − 19.07 ± 26.90
Dip test (reps) SCG 2.67 ± 1.71 11.11 ± 4.42 * † 77.94 ± 12.26 †
ICG 2.72 ± 2.49 10.44 ± 4.02 * † 73.63 ± 21.42 †
CG 3.22 ± 2.67 2.83 ± 2.41 − 11.11 ± 19.80

HG: handgrip; reps: repetitions; * p < 0.01 vs. pre-training in SCG and ICG, †p < 0.01 vs. CG

post-training measurements. At the completion of the training pro-
gram, the percent changes from baseline for all indices of physical
fitness and functional capacity were significantly greater in SCG
and ICG vs. CG (p < 0.01).
Discussion
The serial combined training program including aerobic and
strength training within the same training session is widely used in
healthy and diseased populations for reducing the prevalence of
health risk factors and as a complementary therapy in the treat-
ment of chronic diseases [3, 4, 35]. The integrated approach is an-
other form of combined training, which has been gaining popular-
ity as a more enjoyable exercise modality compared to the serial
method. To the best of our knowledge, this is the first study to com-
pare the efficacy of serial and integrated combined training pro-
grams in improving health and physical fitness indices in untrained
individuals. This study showed that both serial and integrated
3-month training programs combining aerobic dance and calis-
thenics exercises in the same training session for middle-aged un-
trained females (i) decreased body fat, body circumferences and
blood pressure, (ii) increased fat free mass and respiratory func-
tion, and (iii) improved all indices of overall fitness and functional
capacity. The magnitude of training effects did not differ between
the serial and integrated combined training programs.
The major distinction between the integrated and the serial
form of combined training is that the continuous alterations of en-
durance and strength exercises in the former method abolish the
condition where the fatigue of the first exercise mode adversely af-
fects the execution of the second exercise mode [6–8]. Also, there
is a notion that the repeated alternations of aerobic and strength
exercises make the exercise session more pleasant for the general
population compared to the serial method. Despite that both forms
of combined training programs (serial and integrated) have been
used in fitness and rehabilitation facilities; this is the first study to
directly compare their effectiveness in untrained individuals.
The findings of the present study showed that in untrained mid-
dle-aged females the magnitude of cardiovascular and neuromus-
cular adaptations is relatively similar after 12 weeks of either a se-
rial or an integrated training program. Thus, the results of our study
demonstrate that both training regimens may be used interchange-
ably in healthy individuals and in those with impaired functional
capacity for improving health risk factors, overall fitness, and qual-
ity of life. We should bear in mind, however, that a prolonged train-
ing period ( > 12 weeks) may result in different training adaptations
between the 2 combined training programs. This view is support-

60 Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
▶Table 5 Cardiorespiratory fitness in the serial concurrent (SCG), integrated concurrent (ICG) and control (CG) groups pre- and post-training. Values are
means ± SD.

Variables Group Pre-training Post-training % Percent change

HRrest (beats/min) SCG 72.33 ± 5.73 67.78 ± 5.88 * † − 6.89 ± 4.82 †
Sitting ICG 73.89 ± 7.40 68.14 ± 5.27 * † − 8.47 ± 7.36 †
CG 73.39 ± 7.52 77.00 ± 6.57 4.80 ± 2.60
HRtest (beats/min) SCG 117.61 ± 10.82 102.92 ± 7.83 * † − 14.21 ± 4.00 †
Stage 1 ICG 118.44 ± 7.87 101.97 ± 6.70 * † − 16.29 ± 5.91 †
CG 116.22 ± 8.67 119.17 ± 7.88 2.51 ± 1.63
Stage 2 SCG 141.22 ± 12.20 120.89 ± 8.40 * † − 16.75 ± 4.37 †
ICG 137.89 ± 11.88 118.97 ± 8.94 * † − 15.99 ± 6.72 †
CG 138.11 ± 9.05 141.39 ± 8.89 2.32 ± 1.23
Stage 3 SCG 167.44 ± 11.98 147.44 ± 10.70 * † − 13.61 ± 2.90 †
ICG 161.72 ± 14.18 141.22 ± 12.48 * † − 14.61 ± 4.79 †
CG 163.11 ± 11.34 165.39 ± 10.94 1.39 ± 1.15
HRrec (beats/min) SCG 121.83 ± 19.01 99.78 ± 16.27 * † − 22.67 ± 10.30 †
1st min ICG 120.56 ± 14.26 98.44 ± 16.25 * † − 24.06 ± 15.65 †

Downloaded by: Università degli Studi di Torino. Copyrighted material.

CG 121.56 ± 17.57 124.56 ± 16.64 2.54 ± 1.53
2nd min SCG 103.17 ± 16.30 88.17 ± 13.02 * † − 17.06 ± 7.42 †
ICG 103.28 ± 11.62 87.80 ± 12.80 * † − 19.14 ± 14.06 †
CG 105.67 ± 14.46 109.44 ± 15.41 3.34 ± 2.63
3rd min SCG 96.56 ± 12.90 84.72 ± 11.39 * † − 14.09 ± 5.21 †
ICG 95.83 ± 10.11 82.61 ± 10.12 * † − 16.69 ± 11.27 †
CG 96.83 ± 9.97 100.56 ± 10.48 3.64 ± 2.71
RPEtest SCG 9.39 ± 1.82 7.33 ± 1.68 * † − 31.04 ± 28.16 †
Stage 1 ICG 9.56 ± 1.29 7.00 ± 1.37 * † − 39.11 ± 22.18 †
CG 9.61 ± 1.46 10.56 ± 1.54 8.77 ± 6.07
Stage 2 SCG 13.11 ± 1.71 9.72 ± 2.05 * † − 40.01 ± 32.88 †
ICG 12.17 ± 1.65 9.28 ± 1.60 * † − 32.93 ± 18.01 †
CG 12.39 ± 1.85 13.44 ± 1.95 7.62 ± 6.58
Stage 3 SCG 16.44 ± 1.38 13.50 ± 2.38 * † − 25.13 ± 23.87 †
ICG 15.39 ± 1.79 12.28 ± 2.02 * † − 27.06 ± 15.62 †
CG 15.78 ± 1.90 16.94 ± 1.80 6.81 ± 5.79

HR rest: heart rate values at rest in sitting position, HRtest: heart rate values during the submaximal exercise, HRrec: heart rate values following the
submaximal exercise, RPEtest: rating of perceived exertion during the submaximal exercise. * p < 0.01 vs. pre-training in SCG and ICG, †p < 0.01 vs. CG

ed by the findings of a previous study reporting signs of an inter-
ference effect on neural adaptations after 24 weeks of combined
training in a regimen employing endurance routines prior to
strength routines [13]. Furthermore, there is evidence that the
metabolic demands may differ after the completion of serial and
integrated combined programs. For, example, Di Blasio et al. [10]
showed that the post-exercise (recovery) energy expenditure (ox-
ygen consumption) is significantly greater after the integrated than
after the serial combined protocol. On the other hand, simply
changing the order of endurance and strength exercises (2 forms
of serial combined training) does not seem to affect the energy ex-
penditure during [39, 40] or after exercise [10]. There are, howev-
er, studies which demonstrate that the order of endurance and
strength exercise may affect the post-exercise energy expenditure
[39, 40].
Previous studies that employed serial combined training also
using aerobic dance for endurance training and calisthenics or re-
sistance exercises in young, middle-aged or elderly females showed
similar improvements in body composition [14, 24, 38], aerobic
capacity [14, 18, 24], diastolic blood pressure [24], maximal
strength/power, balance and agility/speed of movement. Others,
however, failed to observe training adaptations after the imple-
mentation of serial combined training programs using aerobic
dance and calisthenics in similar populations [14, 36, 38]. The rea-
sons for the opposing findings may be only speculated upon. Dif-
ferences in subjects’ characteristics, loading parameters, frequen-
cy of training, but mainly the order of exercises, may all amplify the
interference effect and reduce the efficacy of serial combined train-
ing programs in improving neuromuscular performance [3, 4]. For
example, several studies reported that residual fatigue caused by
a prior endurance training, reduce the neural input to the endur-
ance-exercised muscle resulting in decrements in force output and
the rate of force development, as well as attenuation of neuromus-
cular adaptations [13]. Recent findings, however, dispute this view
showing that the order of exercises during the combined training
session has no effect on the development of muscle strength and/

Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64 61
 Training & Testing Thieme

▶Table 6 Flexibility and balance values in the serial concurrent (SCG), integrated concurrent (ICG) and control (CG) groups pre- and post-training. Values
are means ± SD.

Variables Group Pre-training Post-training % Percent change

Flexibility
Sit and reach (cm) SCG 26.86 ± 7.28 32.03 ± 5.36 * † 17.24 ± 12.85†
ICG 24.53 ± 8.40 30.64 ± 6.41 * † 21.66 ± 12.79†
CG 24.36 ± 9.33 23.94 ± 9.05 − 1.36 ± 3.02
Static balance
Opened eyes
Right leg (s) SCG 40.38 ± 3.61 55.67 ± 2.66 * † 27.66 ± 21.10†
ICG 38.71 ± 2.67 53.33 ± 2.66 * † 29.00 ± 22.96†
CG 40.93 ± 3.61 39.14 ± 2,66 − 5.20 ± 12.20
Left leg (s) SCG 40.96 ± 14.35 54.99 ± 6.31 * † 26.31 ± 21.44†
ICG 38.83 ± 14.92 54.14 ± 9.00 * † 30.09 ± 21.74†
CG 40.24 ± 15.83 39.77 ± 15.65 − 1.18 ± 3.70
Closed eyes
Right leg (s) SCG 11.98 ± 7.60 20.07 ± 11.23 * ‡ 40.63 ± 17.33†

Downloaded by: Università degli Studi di Torino. Copyrighted material.

ICG 10.75 ± 6.70 19.83 ± 9.59 * ‡ 44.50 ± 20.17†
CG 10.91 ± 6.87 10.55 ± 6.85 − 4.82 ± 16.90
Left leg (s) SCG 10.72 ± 6.30 18.52 ± 11.44 * ‡ 39.88 ± 16.98†
ICG 10.92 ± 7.26 20.25 ± 10.89 * ‡ 43.96 ± 18.42†
CG 10.57 ± 5.51 9.71 ± 5.16 − 11.72 ± 29.29
Dynamic balance
TUG test (s) SCG 4.31 ± 0.57 3.71 ± 0.32 * † − 16.26 ± 11.57†
ICG 4.53 ± 0.52 3.96 ± 0.45 * † − 14.72 ± 8.62†
CG 4.46 ± 0.54 4.56 ± 0.48 * † 2.23 ± 2.74

* p < 0.01 vs. pre-training in SCG and ICG, †p < 0.01 vs. CG, ‡p < 0.05 vs. CG

or power [35]. It is possible that the relatively low level of physical
fitness of the untrained middle-aged females in our study, in con-
junction with the order of exercises during the serial combined
training program, attenuated the interference effect and promot-
ed the neuromuscular adaptations of our study.
While numerous studies have examined the effects of serial
combined training programs on indices of health, overall fitness
and functional capacity, only a few have evaluated the training ad-
aptations following an integrated combined training method. In
the context of our observations, Takeshima et al. [37], who em-
ployed a 12-week integrated exercise training program consisting
of aerobic dance and resistance exercises (duration: 50 min, 30-sec
alternating bouts of aerobic dance and resistance exercises), re-
ported comparable improvements in body fat, aerobic capacity
and muscle strength in a mixed sample of elderly males and fe-
males. A study by Schiffer et al. [33], however, found that a 12-week
integrated combined training program alternating 5-min blocks of
strength routines and aerobic dance did not improve body compo-
sition and muscle endurance of the trunk extensors muscles in sed-
entary middle-aged females. The discrepancy of our and Takeshi-
ma’s findings with those of previous study [33] may be related to the
loading parameters and/or the training protocol used. Unfortunate-
ly, several previous studies that used aerobic dance as a training mo-
dality do not describe adequately the loading parameters (intensity
and/or duration) of the aerobic dance session and their progression
throughout the training period; thus comparisons of training pro-
grams between our and previous studies are difficult to make.
The only previous study that has compared the training adap-
tations of a serial and an integrated combined training program
was performed in young athletes [6–8]. The authors reported that,
for most variables, the integrated combined training was discern-
ibly superior in improving cardiovascular and neuromuscular per-
formance compared to the serial method [7, 8]. The discrepancy
in the findings of our study compared to the previous study [7, 8]
may be related to the independent and/or interactive effects of the
training status of the participants, the age and gender of the par-
ticipants and/or the training program. For example, there is a con-
sensus that greater exercise stimulus elicits greater adaptations
[34]. In the study by Davis et al., the participants exercised at much
higher heart rate during resistance training in the integrated vs. the
serial methods (65 vs. 32 % of heart rate reserve, respectively). This,
possibly resulted in a higher average heart rate for the entire train-
ing session and a higher muscular stress during the resistance rou-
tines in the integrated training group, favoring cardiovascular and
neuromuscular adaptations. In our study, the average heart rate
during training did not differ between the 2 methods (64 and 66 %
of HRmax for serial and integrated, respectively). Also, Davis et al.
performed a treadmill exercise, while we used aerobic dance for
endurance training. It has been suggested that the type of endur-
ance training performed during the combined training programs

62 Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
may influence the degree of hypertrophy and strength gains and
thus, needs to be carefully considered [35]. Aerobic dance, for ex-
ample, as opposed to treadmill running, includes muscle actions
(i. e., knee lifts, squats, lateral lunges and shoulder press with wrist
weights or anti-stress ball, etc.) that induce or mimic neural re-
sponses observed during strength exercises inducing hypertrophy
and strength gains especially in untrained individuals. Furthermore,
dance is a mode of physical exercise that involves explosive moves
and demands substantial energy from both aerobic and anaerobic
metabolic pathways [32].
We incorporated into the aerobic workout specific movements
using anti-stress balls in order to improve handgrip strength be-
cause it is important for many everyday life activities, and it is a
good indicator of hand function and overall functional capacity
[31]. Reduced handgrip strength has been also associated with
functional decline and disability during daily routines, as well as
with increased risk of cardiovascular mortality and future morbid-
ity/mortality in middle-aged individuals [25].
In conclusion, both serial and integrated training programs (3
months, 3 sessions/week) combining aerobic (low-impact aero-
bics) and strength (calisthenics) exercises improved to the same
extent the health and physical fitness indices compared to the con-
trol (non-exercised) group. Hence, both methods might be consid-
ered equally safe and effective and could be used interchangeably
for ameliorating the age-associated loss of cardiovascular and neu-
romuscular functions in sedentary middle-aged individuals. The
fitness practitioners should consider, however, that untrained mid-
dle-aged individuals had more difficulty with following the repeat-
ed alterations in aerobic and strength exercises; thus, the serial
method might be more appropriate for them, especially at the early
stages of training. Our findings are clearly limited to healthy un-
trained individuals; future studies should examine the safety and
efficacy of combined training methods, particularly integrated
methods, in individuals with chronic diseases (e. g., cardiovascular
and diabetes). For example, individuals with insulin-dependent di-
abetes, may benefit from the repeated alterations of aerobic and
strength exercises by reducing their risk of hypoglycemia [5]. Fur-
ther studies are needed to elucidate the physiological pathways
underlying the improvements in health and physical fitness indices
following the 2 training regimens.
Acknowledgements
We would like to thank the participants of the study for volunteer-
ing their time. Additionally, no external financial support was re-
ceived for this research.
Conflict of interest
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Karatrantou K et al. Health-Promoting Effects of Serial … Int J Sports Med 2017; 38: 55–64
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