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Journal of Chiropractic Medicine logoLink to Journal of Chiropractic Medicine
. 2007;6(2):56–65. doi: 10.1016/j.jcme.2007.04.002

Effects of exercise and custom-made orthotics on blood pressure and heart rate variability: a randomized controlled pilot study

John Zhang 1,⁎
PMCID: PMC2647082  PMID: 19674695

Abstract

Objective

The objective of this study is to use randomized controlled research design to investigate the effect of an exercise program and custom-made flexible orthotics on heart rate variability and blood pressure at varying stages of exercise over a 5-month period.

Methods

Thirteen ping-pong players were recruited and randomly assigned into control and experimental groups. Both groups had the same exercise program, and only the experimental group wore custom-made flexible orthotics. Exercise effects were compared before and after the training using heart rate variability and blood pressure. The study lasted 5 months with 1 data collection per month except in the fourth month.

Results

Ten male players (6 in the experimental group) completed the study. The average age of the participants was 44 ± 16 years. The blood pressure in the experimental group significantly decreased after the 5-month study period and after each exercise session. The blood pressure did not change significantly after each exercise session in the control group. The heart rate was significantly increased immediately after exercise and remained at a higher level after the 20 minutes of rest at the end of each day's exercise session. The average resting heart rate decreased from 69.7 ± 1.708 to 66.8 ± 4.480 (P < .05) in the experimental group but increased from 69.7 ± 1.708 to 90.7 ± 2.808 (P > .05) in the control group. The total power reflecting the total autonomic activity was significantly decreased immediately after exercise and after the 20-minute rest period at the end of the exercise session in both the control and experimental groups.

Conclusions

There were positive changes in cardiac and vascular autonomic regulations with exercise training when combined with foot orthotics.

Introduction

Research evidence has suggested that the autonomic nervous system activities are affected by exercise in normal and disease conditions.1-4 Questions remain as to how trained athletes' heart rate variability (HRV) and blood pressure (BP) change at different stages of exercise, namely, before, during, and after an exercise program. Because BP is strongly influenced by the autonomic nervous system in daily activities,5 it is interesting to investigate the interaction of the autonomic nervous system with BP under an exercise program. It is known that long-term BP is determined by fluid homeostasis.5 Short-term BP changes during daily activities are not reliable indicators of BP changes.5,6 Therefore, this study was designed to investigate both short-term (1 day) and long-term (5 months) continuous exercise program on BP and HRV in recreational athletes.

There are many studies on the effect of exercise on BP and HRV. Sharma and Deepak7 explored the possibility of a short duration of supervised physical training on cardiovascular performance and attempted to look into the changes in the autonomic tone as assessed by HRV. They studied 25 healthy adult male subjects who underwent 15 days of moderate physical training on a bicycle ergometer. Heart rate (HR) and BP response to exercise and during recovery were monitored and autonomic activity (tone) was assessed by HRV in a resting condition, and all the parameters were compared before and after physical training. Heart rate response to graded exercise on the bicycle ergometer showed a significant decrease at the second, third, fifth, and sixth minute during exercise after physical training, and systolic BP response showed a significant decrease at fourth, fifth, and sixth minute during exercise after physical training. They concluded that even a short duration of physical training results in favorable cardiovascular performance and it may be ascribed to autonomic modulation.

Information regarding the effect of a custom-made flexible orthotics on the autonomic nervous system and BP is very limited. However, this area of research is directly related to athletic performance in 2 important aspects. The first is the direct effect of the autonomic nervous system activities on athletic performance, BP and HRV. The second is the comfort of shoes with corrective orthotics that promote athletic performance and reduce existing pain.8,9 For the first aspect, no study has documented that custom-made flexible orthotics affect the autonomic nervous system function. For the second aspect, there are many studies showing improved performance of workers using orthotics but less evidence for athletes.10-14

The purpose of this study is to use a randomized controlled research design to investigate the effect of an exercise program and custom-made flexible orthotics on HRV and BP at varying stages of exercise. The hypothesis was that exercise and custom-made orthotics have a positive impact on the HRV and BP. Therefore, the null hypothesis was that exercise and custom-made flexible orthotics would not induce positive changes in HRV and BP during the study period.

Methods

Design

This is a randomized controlled study. A random table was used for subject assignment to either the experimental or the control group.15 Both groups had the same exercise program, and only the experimental group worn custom-made flexible orthotics. The exercise effects were compared before and after the training. This study was approved by the Logan College of Chiropractic Institutional Review Board (Chesterfield, MO). All subjects read and signed institutional review board–approved informed consent documents before they underwent any study-related procedure. No sample size estimate was used in this pilot study because of the size limitation of the sports club.

Subjects

Subjects from different racial, sex, and age groups were recruited in this study. Each subject was a ping-pong club member for the previous 5 years and was an active member in the club. Only subjects who played at least twice a week or no less than 6 hours per week were included. Any individual with coronary heart diseases, serious uncontrolled hypertension, or other diseases, such as osteoporosis, were excluded from the study. All players agreed to participate in the study without monetary compensation.

Method

Heart rate variability

Biocom's (Biocom, Seattle, Wash) Heart Rhythm Scanner was used in the HRV data collection with digital signal processing software. The heart scanner records electrocardiographic (ECG) signal, computing the instantaneous changes of HRV after each recording session. The heart rhythm scanner is an ECG unit that connects the unit to the subjects through 3 small electrodes that attached to the left arm, right arm, and left leg. No additional gels were needed for the electrodes. Special care was given to clean the skin surface to improve skin conductance. Data cleaning techniques were used to remove noise in the ECG signals to improve the quality of HRV measurements. This included checking each ECG tracing to make sure that accurate ECG R-R intervals were recorded for HRV analysis.

Blood pressure

BIOPAC (BIOPAC Systems Inc, Goleta, Calif) BP measurement equipment was used for the study. The device uses manual control for BP measurements to reduce instrumental errors.

Custom-made flexible orthotics

All foot orthotics were custom-made first by scanning the subjects' feet in the research laboratory, and necessary information was sent to Foot Levelers (Roanoke, Va) for fabrication. It took about 6 to 8 days to receive the orthotics after the order was made. The custom-made flexible orthotics were fit to Foot Levelers's standard sports shoes for comfort and easy application. This eliminated the need for athletes to fit the orthotics to their own shoes.

Study protocol

The study lasted 5 months with 1 data collection per month except in the fourth month. During each data collection, BP and HRV data were collected 3 times (ie, baseline, between games, after games). The ping-pong club met twice a week on Tuesday and Thursday between 6:30 and 10:00 pm on a regular basis. Each player was allowed 10 minutes of warm-up before competitive play. The baseline HRV and BP were recorded before the warm-up period. After 1 player played with 2 other players, the between-the-game data were collected right after the second game. No rest was allowed for this data collection to detect the peak HR and BP changes. The third data collection of HRV and BP was at the end of the playing period when all subjects were to have rested for at least 20 minutes to cool off from the games before the data were collected.

Data collection

The data were collected by the researcher on the study site from 6:30 to 10:00 pm regularly on Tuesdays and Thursdays. The manual BP measurements provided reliable readings of the subjects' BP. The HRV recording was an objective reading of the subjects' real-time ECG, which was believed to be reliable. There were no computer crashes or any mechanical damages to any research equipment during the data collection period.

Statistical analysis

All continuous data were expressed as mean ± SD. Student t test was used for comparisons of continuous variables measured in the study. Statistical analysis was performed using SPSS 12 (SPSS Inc, Chicago, Ill). A probability of less than .05 was considered significant.

Results

Thirteen ping-pong players were recruited and 10 player's data were included in the data analysis (10 male, 6 in the experimental group). Three players left the club because of job transfer or other personal reasons while participating in the study (Fig 1). The average age of the participants was 44 ± 16 years. During the 5-month study period, there were no adverse events that occurred with or without wearing the foot orthotics.

Fig 1.

Fig 1

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Study flow chart.

The BP responses before, during, and after exercise in the 5-month study are shown in Tables 1 and 2. The BP in the experimental subjects was significantly decreased after the 5-month study period. Significant BP decrease was observed in the experimental group before, during, and after each exercise session (Fig 2). The BP did not decrease before, during, and after each exercise session in the control group (Fig 3).

Table 1.

Five-month BP response before, during, and after exercise in the experimental group

Experimental Group
Before EX
 During EX
 After EX
Systolic Diastolic Systolic Diastolic Systolic Diastolic
First Month Mean 128.000 84.167 119.667 82.333 116.667 83.833
SD 11.314 3.920 10.614 4.082 9.180 3.488
t 0.026 0.194 0.025 0.809
Second Month Mean 122.667 82.833 117.000 81.667 118.333 80.333
SD 7.659 5.456 5.762 3.670 7.528 1.966
t 0.137 0.545 0.189 0.286
Third Month Mean 125.200 84.400 117.200 84.400 113.600 81.600
SD 10.354 4.336 12.215 6.066 12.837 3.578
t 0.025 1.000 0.035 0.108
Fifth Month Mean 121.167 81.667 119.000 81.000 111.667 80.333
SD 2.041 2.658 1.673 2.449 7.528 4.457
t 0.108 0.709 0.035 0.328
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EX, Exercise.

Table 2.

Five-month BP response before, during, and after exercise in the control group

Control Group
Before EX
 During EX
 After EX
Systolic Diastolic Systolic Diastolic Systolic Diastolic
First Month Mean 126.833 83.000 123.500 84.667 126.667 83.667
SD 14.148 6.293 14.963 6.772 8.733 6.623
t 0.337 0.185 0.952 0.465
Second Month Mean 125.333 83.333 121.000 82.333 120.000 84.333
SD 8.641 5.317 7.127 4.457 6.325 3.882
t 0.290 0.415 0.170 0.741
Third Month Mean 124.000 82.000 125.500 80.833 121.333 81.167
SD 7.899 5.060 10.913 4.834 11.075 5.456
t 0.479 0.135 0.371 0.259
Fifth Month Mean 118.333 82.667 114.000 78.000 113.333 77.333
SD 13.292 5.888 14.859 5.367 13.003 6.282
t 0.071 0.052 0.042 0.072
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Fig 2.

Fig 2

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Blood pressure changes in the experimental group.

Fig 3.

Fig 3

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Blood pressure changes in the control group.

The HRV responses are shown in Tables 3-10. The HR was significantly increased immediately after exercise. Many players' HRs were more than 150 beats per minute immediately after the 2 games and gradually decreased during the 5 minutes of HRV data collection. The decrease of HR during the resting period was uneven between the players. Younger players' HRs decreased faster than older players. Among the older players with similar ages, the decrease in HR was related to the total power of the individual. Subjects with lower total power or a small HRV had slower return of HR. Individuals with higher total power decreased HR faster after exercise. The HR for most players remained at a higher level after the 20 minutes of rest at the end of each day's exercise session. Some players did not show significant HR reduction during the 20-minute rest period. The average resting HR (baseline HR before each data collection) was decreased from 69.7 ± 1.708 to 66.8 ± 4.480 (P < .05) in the experimental group but increased from 69.7 ± 1.708 to 90.7 ± 2.808 (P > .05) in the control group. The total power reflecting the total autonomic activity was significantly decreased immediately after exercise and after the 20-minute rest period at the end of the exercise session in both the control and experimental groups.

Table 3.

Heart rate variability of the experimental group in the first month

First Month Experimental Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 69.700 1.709 106.800 4.613 0.008 86.733 9.834 0.117
Mean RR 861.300 21.328 562.433 24.188 0.006 697.900 82.071 0.103
SDNN 53.967 15.653 36.900 4.900 0.287 32.333 16.772 0.296
RMS-SD 37.300 4.453 16.070 6.109 0.059 22.600 12.917 0.218
Total Power 822.400 358.289 68.567 22.743 0.062 495.233 622.474 0.576
VLF 306.700 149.266 26.167 5.248 0.087 159.367 177.479 0.512
LF 367.167 170.553 31.100 18.460 0.062 291.833 410.820 0.791
HF 148.500 98.144 11.300 2.740 0.131 44.067 34.683 0.265
LF Norm 71.733 7.267 69.367 14.545 0.778 75.933 12.889 0.394
HF Norm 28.267 7.267 30.700 14.660 0.774 24.067 12.889 0.394
LF/HF 2.700 1.127 2.700 1.400 1.000 4.533 3.980 0.384
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RR, R-R interval; SDNN, SD of the normal-to-normal heartbeats; RMS, root mean squared; VLF, very low frequency; LF, low frequency: HF, high frequency; Norm, normalized.

Table 4.

Heart rate variability of the experimental group in the second month

Second Month Experimental Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 71.100 4.457 95.960 17.534 0.028 85.650 7.566 0.327
Mean RR 846.740 56.027 642.060 116.272 0.009 703.550 62.296 0.316
SDNN 47.200 6.256 33.340 10.062 0.222 33.350 9.122 0.100
RMS-SD 35.875 9.936 21.620 9.673 0.183 37.400 17.253 0.608
Total Power 620.250 132.641 205.720 178.776 0.046 239.900 91.217 0.053
VLF 360.375 114.015 118.220 105.503 0.090 54.950 30.618 0.280
LF 184.975 95.149 57.980 49.501 0.047 103.600 36.204 0.254
HF 74.875 43.573 29.500 25.605 0.297 81.350 85.631 0.546
LF Norm 68.325 16.541 68.040 9.795 0.929 63.300 22.203 0.358
HF Norm 31.675 16.541 31.960 9.795 0.929 36.700 22.203 0.358
LF/HF 2.900 1.917 2.440 1.448 0.860 2.350 2.051 0.049
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Table 5.

Heart rate variability of the experimental group in the third month

Third Month Experimental Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 66.800 4.480 101.525 6.663 0.006 93.550 4.273 0.002
Mean RR 901.425 60.979 592.825 37.175 0.006 642.300 29.380 0.003
SDNN 62.175 20.663 33.325 3.195 0.067 33.150 9.112 0.111
RMS-SD 37.875 10.135 13.850 10.414 0.069 25.975 6.589 0.182
Total Power 1228.200 705.731 161.925 146.018 0.066 265.375 191.254 0.098
VLF 575.525 252.195 70.575 43.490 0.029 114.625 110.537 0.075
LF 527.100 384.792 68.950 73.431 0.110 112.100 63.155 0.117
HF 125.525 80.131 22.375 34.695 0.136 38.575 33.418 0.185
LF Norm 78.875 6.035 83.025 9.414 0.492 75.250 7.942 0.508
HF Norm 21.100 6.067 16.975 9.414 0.495 24.750 7.942 0.506
LF/HF 4.025 1.307 6.125 3.135 0.208 3.475 1.861 0.653
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Table 6.

Heart rate variability of the experimental group in the fifth month

Fifth Month Experimental Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 75.517 11.303 104.483 16.036 0.001 95.000 14.027 0.023
Mean RR 811.350 137.696 585.167 85.783 0.001 642.660 92.990 0.019
SDNN 47.150 13.036 51.017 46.899 0.870 32.360 13.230 0.202
RMS-SD 33.700 15.620 54.350 70.008 0.538 24.420 13.985 0.330
Total Power 566.017 315.657 265.033 419.101 0.313 348.000 243.786 0.401
VLF 234.500 141.543 143.200 227.547 0.523 177.400 197.433 0.629
LF 261.117 175.158 72.200 110.187 0.125 134.140 95.474 0.252
HF 70.417 37.963 49.583 81.919 0.654 36.440 47.250 0.334
LF Norm 76.400 8.389 62.033 9.615 0.095 83.200 9.743 0.362
HF Norm 23.583 8.386 37.967 9.615 0.094 16.740 9.746 0.354
LF/HF 3.983 2.751 1.800 0.727 0.162 6.300 3.029 0.384
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Table 7.

Heart rate variability of the control group in the first month

First Month Control Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 69.700 1.709 117.567 4.891 0.031 100.767 7.304 0.185
Mean RR 861.300 21.328 510.800 20.756 0.040 597.500 41.830 0.177
SDNN 53.967 15.653 36.700 12.950 0.821 21.267 11.296 0.431
RMS-SD 37.300 4.453 16.733 8.776 0.086 14.800 8.107 0.196
Total Power 822.400 358.289 44.600 12.401 0.162 122.000 138.609 0.352
VLF 306.700 149.266 27.633 17.789 0.236 31.367 22.912 0.281
LF 367.167 170.553 9.133 6.028 0.199 77.700 102.561 0.794
HF 148.500 98.144 7.800 6.056 0.157 12.933 13.271 0.304
LF Norm 71.733 7.267 52.567 33.739 0.634 81.300 5.575 0.179
HF Norm 28.267 7.267 47.433 33.739 0.634 18.700 5.575 0.179
LF/HF 2.700 1.127 3.500 5.200 0.706 4.733 1.986 0.214
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Table 8.

Heart rate variability of the control group in the second month

Second Month Control Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 79.100 7.661 106.525 11.281 0.010 102.150 1.768 0.185
Mean RR 763.550 71.020 568.025 61.217 0.010 587.600 10.324 0.235
SDNN 40.400 12.147 20.450 6.011 0.094 28.500 3.111 0.256
RMS-SD 28.475 3.550 15.400 8.730 0.114 15.350 10.960 0.473
Total Power 475.600 340.010 84.575 108.809 0.111 99.750 9.546 0.349
VLF 217.175 205.756 22.525 21.053 0.158 56.550 42.639 0.180
LF 196.500 120.124 51.000 84.403 0.061 31.450 20.294 0.408
HF 61.925 37.776 11.025 6.917 0.102 11.750 12.799 0.313
LF Norm 75.000 5.855 65.025 30.745 0.531 77.600 12.587 0.550
HF Norm 25.000 5.855 34.975 30.745 0.531 22.400 12.587 0.550
LF/HF 3.200 1.143 5.825 6.033 0.414 4.300 2.970 0.500
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Table 9.

Heart rate variability of the control group in the third month

Third Month Control Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 90.700 2.828 114.250 12.657 0.183 106.550 5.020 0.062
Mean RR 661.950 20.435 528.300 58.548 0.127 563.600 26.446 0.027
SDNN 32.150 0.212 24.800 1.273 0.090 29.750 3.323 0.472
RMS-SD 22.700 0.849 15.300 10.182 0.517 14.100 10.465 0.477
Total Power 386.400 223.021 92.850 94.116 0.192 294.900 65.902 0.561
VLF 140.250 100.904 53.300 55.013 0.227 163.050 113.632 0.239
LF 206.100 107.480 34.050 40.941 0.170 116.250 34.719 0.536
HF 39.950 14.637 5.450 1.768 0.206 15.600 13.011 0.431
LF Norm 83.200 2.404 68.550 35.709 0.646 89.250 6.010 0.254
HF Norm 16.800 2.404 31.450 35.709 0.646 10.750 6.010 0.254
LF/HF 5.000 0.849 7.950 10.112 0.731 10.050 6.152 0.407
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Table 10.

Heart rate variability of the control group in the fifth month

Fifth Month Control Group
Before
 During
 After
Mean SD Mean SD t Mean SD t
Heart Rate 75.425 5.309 106.200 8.283 0.002 92.800 6.280 0.000
Mean RR 798.400 56.651 567.525 44.571 0.001 648.800 45.556 0.000
SDNN 45.000 11.265 34.700 3.477 0.089 33.650 12.600 0.101
RMS-SD 24.375 12.654 19.225 9.506 0.622 19.050 5.807 0.373
Total Power 824.050 494.609 103.700 53.225 0.051 458.525 415.737 0.003
VLF 562.275 327.365 31.450 14.445 0.044 210.500 181.828 0.037
LF 216.450 154.426 47.325 33.125 0.080 226.250 231.452 0.909
HF 45.275 39.088 24.950 33.531 0.501 21.575 21.520 0.093
LF Norm 82.725 10.387 69.650 23.898 0.289 88.125 7.771 0.584
HF Norm 17.275 10.387 30.350 23.898 0.289 11.875 7.771 0.584
LF/HF 7.250 6.094 4.550 4.227 0.546 10.000 5.943 0.670
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Discussion

The current study was designed to investigate the effect of exercise and custom-made flexible orthotics in athletes who perform exercise on regular basis over a 5-month period. The null hypothesis was that exercise and orthotics had no effect on BP and HRV. The study rejected the null hypothesis by demonstrating significant decreases in BP and HRV before, during, and after the exercise program with foot orthotics in the experimental group. No significant BP changes were observed in the control group. Significant increase in resting HRV was seen in the experimental group.

The reason behind selecting the 5-month study period was to allow the players to respond to the exercise program and the new orthotics to influence the autonomic nervous system activities. It has been reported by Loimaala et al,16 Perini et al,17 and Stein et al18 that short-term aerobic training had no effects on resting cardiac autonomic modulation in older people. A study by Iwasaki et al19 suggested a short-term positive effect of exercise training on HRV showing an increase at 3- and 6-month time points of regular training with an even decrease at 9 and 12 months. Uusitalo et al20 performed a 5-year study on exercise and HRV with 1 data collection per year. They found beneficial cardiovascular and autonomic effect.

Potential confounding factors, such as medication, diseases, and smoking, could have a strong effect on HRV and BP, which could cover the effect of physical activity and orthotics. In this study, all subjects were not taking any medications during the entire study period, none smoked cigarettes, and none had known cardiovascular diseases. In addition, all members of the current study performed the same level of exercise for at least 5 years, which reduced nonhomogeneity in their former activity levels. Because all subjects played the same sport during the study period, the effect of physical activity was more consistent than in a heterogeneous study16 of different levels and kinds of exercises. Therefore, all these factors strengthened the current study.

The present study used 5-minute ECG recording for HRV analysis, which was a short-term recording compared with 24-hour recording. Goldsmith et al21,22 measured 24-hour recordings, whereas others measure short recordings of at least 5 minutes. Some randomized longitudinal exercise training studies have used 24-hour HRV.16,23-25 There are only 2 randomized exercise training interventions using short-term HRV recordings reported.26,27 Among the randomized longitudinal studies,16,23-27 a positive effect of aerobic training on daytime HRV has been found in 3 studies,23-25 all using 24-hour recordings. In the other randomized studies, significant effects have not been found, even with a significant increase in maximal aerobic capacity. In addition, none of the randomized longitudinal studies found a significant effect on nighttime HRV. Some of the nonrandomized studies using short-term HRV recordings have found a positive effect of exercise training on HRV.19,28 Many studies have reported the changes of HRV in relation to athletic activities.29-35

Blood pressure was significantly decreased over the 5-month study period. This finding was not seen in the study of Uusitalo et al.20 Radaelli et al29 found an increase in sympathetic modulation of peripheral vessels with aerobic training in patients with chronic heart failure but not in healthy controls. Recent studies shown different response of moderate exercise training19 compared with heavy training in healthy athletes in BP variability.30 It has been hypothesized by researchers20 that BP changes associated with exercise training could result in vascular remodeling through adaptation of endothelium and smooth muscle19 rather than changes in vasomotor activity.

The orthotics seemed to assist players enhance the exercise program to achieve beneficial changes in BP and HRV. The significant BP decreases were only observed in the experimental group with orthotics. Because of the small sample size, the results were not conclusive. It only points to the positive direction for combing comfortable orthotics with an exercise program. In personal communication with club members, they all reported that the orthotics were comfortable to wear during exercise as well as during regular nonexercise period. This correlates with previously documented feedback.12-14,36,37 Because the orthotics used in the study were fitted into sports shoes, the break-in period was shortened for comfortable game wearing. There were 2 areas of improvement needed in the orthotics as noted by the participants. One suggestion was to use softer leather for athletic shoes for greater comfort and the second was to strengthen the shoe rubber adhesives, which loosened after 5 months of wear in 1 player's shoes.

The present study has some limitations. The most obvious was the small sample size, which was because of the small size of the sports club. Another factor that may potentially affect the results of the study was lack of blinding. This factor was minimized by using objective HRV analysis and reliable BP measurements. Another limitation is the cooling-off period used in the study for each day's final data collection. It was desirable to rest longer than 20 minutes after the final game to observe the return of HR to resting state. This answers the question of how much time is needed for a complete recovery from an exercise program. In this study, the exercise ended late at night, so it was impossible to extend the cooling period for the data collection sessions. Therefore, this 20-minute cooling-off period was chosen by compromise. It was noted in the study that many players' HR were still 10 to 30 beats higher than the resting baseline heartbeats.

Conclusion

The present randomized controlled pilot study of exercise and orthotics showed a significant decrease in BP and increase in HRV over the 5-month study period. The study demonstrated a potential benefit of combing exercise with orthotics to improve cardiovascular health in recreational athletes.

Acknowledgments

The custom-made shoe orthotics was provided free of charge to the subjects by Foot Levelers, Inc.

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