Exercise for the Prevention and Treatment of Hypertension – Implications and Application

3 Key Points:

  • Regular aerobic exercise results in reductions in blood pressure of 5-7 mmHg among individuals with hypertension and these reductions translate to a reduced risk of CVD of 20-30%.
  • Emerging research suggests that dynamic resistance exercise may also serve as an efficacious strategy to lower blood pressure to levels similar to aerobic exercise.
  • Special consideration should be given to signs/symptoms or presence of disease, concomitant drug therapy, and other comorbidities in order to optimize CVD risk reduction and improve overall health. The goal of preparticipation screening should be to risk classify individuals at risk for an adverse or life threatening response to exercise while decreasing barriers to physical activity participation.

Cardiovascular disease (CVD) is the leading cause of death in the United States (U.S.) and accounts for 1 out of every 3 deaths in U.S. adults. High blood pressure (BP) or hypertension is the most common, costly, but modifiable major risk factor for the development of CVD and premature mortality, affecting nearly half (46%) of U.S. adult population (PMID: 30700139).

Hypertension is the most common, costly, and modifiable CVD risk factor.

In 2017, The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released new guidelines, which now define ‘hypertension’ as:

  • having a resting systolic BP (top number) of 130 mmHg or greater
  • having a resting diastolic BP (bottom number) of 80 mmHg or greater
  • taking antihypertensive medication
  • being told by a physician or health professional on at least two occasions that one has high BP
  • or any combination of these criteria

Blood Pressure Guidelines Zaleski

The ACSM recommends that individuals with hypertension engage in moderate intensity, aerobic exercise 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

Participation in regular exercise is a key modifiable determinant of hypertension and is recognized as a cornerstone therapy for the primary prevention, treatment, and control of high BP. On average, regular aerobic exercise lowers resting systolic BP 5-7 mmHg, while resistance exercise lowers resting systolic BP 2-3 mmHg among individuals with hypertension. These BP reductions follow the “law of initial values” such that individuals with higher baseline BP values experience even greater reductions in BP from exercise training. In other words, exercise works best in those who can stand to benefit the most.

BP reductions of this magnitude lower overall CVD risk by 20-30%. For these reasons all major public health organizations universally recommend aerobic exercise for the primary prevention and treatment of hypertension. Similar to a drug prescription, individuals can be “prescribed” an exercise prescription for the prevention, treatment, and control of high BP following the FITT principle:

Frequency: How often?

Intensity: How hard?

Time: How long?

Type: What kind?

Specifically, the ACSM recommends the following exercise prescription for individuals with hypertension:

Frequency:

For aerobic exercise, 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

The frequency of aerobic exercise is slightly greater than those with normal BP (i.e., 3-5 d/wk). In fact, individuals with hypertension are encouraged to engage in greater frequencies of aerobic exercise than those with normal BP because we know that a single bout of aerobic exercise results in immediate reductions in BP of 5-7 mmHg, that persist for up to 24 hr (i.e., postexercise hypotension). For this reason, individuals with hypertension are encouraged to exercise on most days of the week in order to benefit from the acute effects of aerobic exercise on BP.

Intensity:

Moderate [i.e., 40-<60% VO2R or 11-14 on a scale of 6 (no exertion) to 20 (maximal exertion) level of physical exertion or an intensity that causes noticeable increases in heart rate and breathing] for aerobic exercise; moderate to vigorous (60-80% 1RM) for resistance; and stretch to the point of feeling tightness or slight discomfort for flexibility.

New and emerging evidence suggest that the magnitude of the BP reductions that result from aerobic exercise occur as a direct function of intensity, such that the more vigorous the intensity, the greater the resultant BP reductions (PMID: 26423529). Individuals who are willing and able may consider progressing to more vigorous intensities, however, the risk-to-benefit ratio has not yet been established.

Time:

For aerobic exercise, a minimum of 30 min or up to 60 min/d for continuous or accumulated aerobic exercise. If intermittent, begin with a minimum of 10 min bouts.

New and emerging research has shown that short bouts of exercise (3-10 min) interspersed throughout the day may elicit BP reductions similar in magnitude to one continuous bout of exercise and may be a viable antihypertensive lifestyle strategy for individuals with limited time.

Type:

For aerobic exercise, emphasis should be placed on prolonged, rhythmic activities using large muscle groups such as walking, cycling, or swimming. Resistance training may supplement aerobic training and should consist of 2-4 sets of 8-12 repetitions for each of the major muscle groups. For flexibility, hold each muscle 10-30 s for 2-4 repetitions per muscle group. Balance training (neuromotor) exercise training is also recommended in individuals at high risk for fall (i.e., older adults) and is likely to benefit younger adults as well.

Blood pressure reductions appear to occur in a dose-response manner such that greater volumes of exercise elicit greater reductions in blood pressure. Progression to the Ex Rx should be gradual, avoiding large increases in any of the FITT components of the Ex Rx, especially intensity for most individuals with hypertension.

A recent meta-analysis demonstrated dynamic resistance exercise training to result in BP reductions similar in magnitude to aerobic exercise training (PMID: 27680663). These results suggest that the antihypertensive benefits of resistance exercise training may have been largely underestimated and warrant reappraisal in the near future. Note that, inhaling and breath-holding while engaging in the actual lifting of a weight (i.e., Valsalva maneuver) can result in extremely high BP responses, dizziness, and even fainting and should be avoided during resistance training.

Practical Applications

Accurate BP assessment is critical for a) the initial diagnosis of hypertension and b) to establish a baseline BP to properly evaluate the influence of lifestyle intervention strategies across time. Proper patient positioning and preparation are critical for ensuring accuracy of BP values. Caffeine, exercise, and smoking should be avoided at least 24 hr before BP assessment. Prior to the first reading, the patient should be:

  • seated quietly and not talking for at least 5 min prior to or during the measurements
  • legs uncrossed and flat on the floor
  • bladder empty
  • back supported upright
  • arm supported at heart level
  • with an appropriate sized cuff

American Heart Association standards state that BP should be measured three times in each arm, separated by at least 1 min, and averaged. This is particularly important given that the first reading is often the highest reading. Preferably, the same exercise professional should measure BP on the same patient and using the same BP monitoring device. Approximately ~25% of patients experience “white-coat hypertension” such that BP readings obtained in the presence of a healthcare provider appear elevated, however, home or ambulatory BP values are within normal ranges. Patients with suspected white-coat hypertension may be referred to their healthcare provider for proper evaluation.

Appropriate preparticipation health screening should be implemented to identify at-risk individuals who may require medical clearance before they begin an exercise program (PMID: 2647375). Although exercise is safe for most individuals, there is a small risk of cardiovascular complications in certain susceptible individuals, particularly among sedentary adults with known or underlying CVD who perform vigorous-intensity exercise they do not usually engage in. The ACSM preparticipation guidelines emphasize the public health message that exercise is important for all individuals and largely triages individuals on the basis of current physical activity levels, desired exercise intensity, and the presence of known or underlying CVD, metabolic, and/or renal disease.

As such, individuals with hypertension cleared to exercise (by the preparticipation algorithm or healthcare provider) should be encouraged to progress gradually, avoiding large increases in any of the components of the FITT. Progression should begin by increasing exercise duration over the first 4-6 wk, followed by an increase in frequency and intensity to achieve the recommended volume of 150 min/wk or 700-2000 kcal/wk over the next 4-8 mo. Progression may be individualized based on tolerance and preference in a conservative manner.

Lifestyle modifications, such as regular aerobic exercise, are fundamental for the prevention, treatment, and control of hypertension. When lifestyle interventions are not effective in achieving treatment BP goals, antihypertensive therapy may be required to optimize CVD risk reduction. Whenever possible, an interdisciplinary, collaborative approach involving the patient, healthcare provider(s), and exercise professional will largely improve lifestyle and pharmaceutical adherence, translating to greater BP control and overall health, which is the ultimate goal in the treatment of hypertension.


Author: Amanda Zaleski, PhD is an American Heart Association Postdoctoral Fellow in Amanda Zaleski PhDthe Department of Kinesiology at the University of Connecticut. She is also a Project Manager and Evidence-Based Credentialed Analyst for the forthcoming ACSM Hypertension Position Stand Update and Co-Chair of the Communications Committee for New England ACSM.


Recommended Reading: New Blood Pressure Guidelines, Preparticipation Screening

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Midwest Orthopaedics at Rush (MOR) Sports Performance Center

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David Heidloff, Athletico’s Manager of The Sports Performance Center at MOR in Oak Brook Illinois, talks with Dr. Charles Bush-Joseph and Steve Kashul about the opening of the brand new Sports Performance Center at Rush in Oak Brook IL, what services it offers and how it is different than a typical strength and conditioning facility.

At Midwest Orthopaedics at Rush (MOR) Sports Performance Center, our goal is to bridge the gap between sports medicine and sports performance. Using evidence-based methods and the world’s best equipment at our state-of-the-art facility, we are helping athletes of all levels transition from injury to a confident return to their sport. Our programs don’t just get you back to activity, they also enhance performance – building strength, improving agility, addressing injury risk factors, and bolstering confidence for athletes returning to sport.

Within our new facility in Oak Brook is a state-of-the-art sports performance center dedicated to helping patients confidently return to sport after injury with programs such as a functional sports assessment. Additional services are also available such as blood flow restriction training, video throwing assessment, strength and conditioning services and video gait analysis.

Our team has extensive experience working with athletes from the professional teams like the Chicago Bulls, Chicago White Sox and Chicago Fire as well as little leagues and club soccer teams. We believe all athletes deserve access to effective strength and conditioning programming derived from medically sound foundations.

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Ask the Doctor!

This regular segment of ‘Ask the Doctor’ addresses questions submitted by Sports Medicine Weekly followers. Dr. Charles Bush-Joseph is sitting in for Dr. Brian Cole from Midwest Orthopaedics at Rush and will be discussing the medical side of MLB teams signing free agents and obtaining players via trades along with:

  • Treatment protocol for tennis elbow.
  • When signs of muscle soreness should not be ignored.

Dr. Bush-Joseph is a graduate of the University of Michigan Medical School in 1983, he is currently a Professor at Rush University Medical Center and the Associate Director of the Rush Orthopaedic Sports Medicine Fellowship Program. Dr. Bush-Joseph is a respected educator of medical students, residents, fellows, and practicing orthopedic surgeons lecturing at numerous national educational meetings. He serves on the editorial board of several national orthopedic journals, including the prestigious American Journal of Sports Medicine.dr. charles bush-joseph

Long involved in the care of high school, collegiate, and recreational athletes, Dr. Bush-Joseph is a team physician for the Chicago White Sox Major League Baseball Club and Associate Team Physician for the Chicago Bulls. Through his experience with high-profile professional athletes, Dr. Bush-Joseph was elected to the Major League Baseball Medical Advisory Board and president of the Major League Baseball Team Physician Association for 2012.

This exclusive group of team physicians advises the Major League Baseball Commissioner on medical policy and emerging trends in training and the medical care of the elite athlete. Academically, Dr. Bush-Joseph is nationally renown with leadership roles in several national orthopedic societies and president of the American Orthopaedic Society for Sports Medicine. He has authored over 140 published manuscripts and book chapters.

Sports Medicine Weekly on 670 The Score

If you have a question to be addressed on an upcoming show, please click here to submit your question.

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Strategies to Naturally Detox your Body

In this segment Steve Kashul & Karen Malkin discuss her best tips to naturally detox your body with real food and lifestyle strategies.

Your Path to Wellness: Whether you’re looking to lose those last 10-15 lbs., lower cholesterol, kick sugar, balance hormones, or double your energy, what you eat can make a huge difference! The evidence-based programs below have changed my life as well as hundreds of my clients around the world. In all of my programs, each session builds on the last. By the end of our work together, you will look—and feel—completely different than you do right now.

14 Day Transformations: We offer three 2-week cleanses to meet you wherever you’re at in your wellness journey: Foundations, Master Your Metabolism, and Toxin Takedown. LEARN MORE

Private Coaching: For those who seek extra support, we offer the deep-dive experience of private, 1:1 coaching with Karen either conducted in her office or virtually. LEARN MORE

Corporate Initiatives: Whether you’re in need of a simple Lunch & Learn or a 6- to 12-month-long integrative wellness program for your employees, we’ve got you covered.
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