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Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
- 1 -
Use of low volume, high effort resistance training to manage blood
pressure in hypertensive patients inside a public hospital: a proof of
concept study
Camila Simões Seguro (1), Ana Cristina Silva Rebelo (2), Anderson Garcia Silva (1),
Matheus Malaquias Alves dos Santos (1), John Sebastião Cardoso (1), Valéria
Apolinário (3), Paulo Cesar Veiga Jardim (3), Paulo Gentil (1,3)
(1) Faculty of Physical Education and Dance, Federal University of Goiás, Goiânia, Brazil; (2)
Institute of Biological Sciences, Federal University of Goiás, Goiânia, Brazil; (3) Hypertension
League, Federal University of Goiás, Goiânia, Brazil
This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits
any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Abstract
Physical exercise has been shown to have an important role in the prevention and treatment of
arterial hypertension. However, the general exercise recommendations are time consuming,
which might be detrimental to exercise adoption. Based on this, minimal doses of exercise have
been suggested as an alternative approach and this report investigates the feasibility and effects
of low volume and high effort resistance training for hypertensive patients in a hospital setting.
This is a pilot non-randomized prospective study where 15 sedentary hypertensive patients (11
women and 4 men) performed 24 resistance training sessions over 12 weeks at a public hospital.
The resistance training sessions consisted of two sets of four exercises, with a rest interval of
two minutes between sets. Systolic blood pressure (SBP) and diastolic blood pressure (DBP)
were measured 10 minutes before and 10 minutes after each training. No injuries or intercurrence
were reported during the study. SBP decreased significantly when compared the first and last
sessions, when the measures were performed at rest (152 ± 16 mmHg vs. 122 ± 9 mmHg vs,
p<0.05), and after (137 ± 13 mmHg vs. 115 ± 5 mmHg, p<0.05) the resistance training session.
Similarly, DBP also decreased significantly when the values from the last session were compared
with the first session, when measured at rest (83 ± 14 mmHg vs 73 ± 9 mmHg, p<0.05). Low
volume and high effort resistance training seems to be a feasible non-pharmacological strategy
to help controlling blood pressure in hypertensive patients within a hospital.
Key Words: exercise is medicine, aging, cardiopathy, diabetes, resistance exercise, strength
training
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
Arterial hypertension is the most common chronic
noncommunicable disease among the elderly and
represents one of the greatest challenges in public health.1
Most guidelines recommend lifestyle modifications (e.g.,
increased physical activity, smoking cessation, moderate
alcohol consumption, improved dietary choices) as an
important strategy to prevent and manage
hypertension.2,3 In this sense, physical exercise, such as
aerobic and resistance exercise, is considered one of the
most important non-pharmacological treatments.2
Specifically regarding resistance training there is
evidence that it can prevent and treat high blood pressure
at all stages.4 However, the guidelines for hypertensive
patients are not consensual.2,5,6 One important aspect of
exercise prescription is time commitment, since lack of
time is an important barrier for exercise adoption.7 In this
regard, low volume and high effort resistance training
(i.e. one to two sets of 8-12 repetitions of 4 exercises,
taking approximately 20 minutes per session) has gained
notoriety for improving health and functional parameters,
especially in older people.8,9 In a case study, Seguro et al.
reported that only 40 minutes of exercise per week was
sufficient to promote positive cardiovascular and
metabolic changes in a hypertensive and diabetic
patient.10 A similar approach adopted by Costa et al.9
produced functional benefits in older women. Therefore,
the use of such strategy might be useful as an adjunct in
the treatment of hypertensive patients, especially
considering that resistance training might reduce resting
blood pressure,11,12 and that muscle strength is associated
Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
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with lower mortality in hypertensive patients.13
Considering that gyms and fitness centers are not
accessible for many people, the use of such strategy in a
hospital setting, might be an interesting therapeutic
strategy. The performance of resistance training within a
hospital might increase adherence and the safety
perception, especially when patients are classified or
perceive themselves as having higher risk. Moreover, the
environment will allow a closer multidisciplinary work,
with the physical proximity of different professionals.
However, information regarding the use of low volume
and high efforts resistance training in a group of
hypertensive patients in a hospital setting are lacking.9
Furthermore, safety and efficacy might be perceived as
important barriers by the patients and hospital managers.
Based on this, we conducted a proof of concept study in
order to investigate the feasibility and effects of low
volume and high effort resistance training for
hypertensive patients in a hospital setting. Our hypothesis
is that low-volume, high-effort exercise can lower blood
pressure and that it may be applied in hospitals.
Materials and Methods
Participants
Fifteen sedentary patients (11 women and 4 men, mean
age 63.5±4.7 years) participated in the study (Table 1).
The inclusion criteria for the study were: (i) to be
diagnosed with arterial hypertension, characterized by
values ≥ 140 mmHg for [Systolic Arterial Pressure
(SBP)] or ≥ 90 mmHg for [Diastolic Arterial Pressure
(DBP)] according to 7th Brazilian Arterial Hypertension
Guidelines; (ii) aged over 40 years; (iii) currently being
under regular treatment to control blood pressure; (iv) to
not participate in any type of systematic physical
exercise. Exclusion criteria were: (i) decompensated
cardiac failure; (ii) acute myocardial infarction or stroke
in the last three months; (iii) chronic renal failure; (iv)
mobility limitations; and (v) any physical or mental
limitation that could impair the practice of exercises. All
participants were informed of the potential risks and
benefits of the study and signed an informed consent
form. All experimental procedures were approved by the
University Human Research Ethics Committee (approval
number: 57297316.7.0000.5083) and conformed to the
principles outlined in the Declaration of Helsinki. At the
beginning of the treatment all patients used losartan 50
mg two times per day, five patients used amlodipine
besylate 5 mg per day, three used atenolol 50 mg two
times per day, two used hydrochlorothiazide 25 mg per
day, one patient used simvastatin 20 mg per day and
acetylsalicylic acid 100 mg per day (Table 2). Times of
medications were controlled and maintained constant
during the study period.
Table 1. Participant’s characteristics
Women (11)
Men (4)
Age
62.6 ± 5.0
66.0 ± 3.2
RTP
First RT session
Last RT session
First RT session
Last RT session
Before
After
Before
After
Before
After
Before
After
Heart rate, bpm
80 ± 9
82 ± 10
80 ± 8
85 ± 8
78 ± 9
80 ± 9
79 ± 7
87 ± 9
SBP, mmHg
151 ± 16
137 ± 14
121 ± 9
114 ± 5
147 ± 16
135 ± 14
122 ± 10
114 ± 6
DBP, mmHg
82 ± 14
76 ± 12
72 ± 14
68 ± 14
80 ± 14
75 ± 12
71 ± 9
67 ± 9
Table 2. Participant’s medication before and after resistance training
Before RT
After RT
Losartan 50mg
15 patients 2x/day
10 patients 1x/day
5 patients 2x day
Amlodipine besylate 5mg 5 patients 1x/day 2 patients 1x/day
Atenolol 50mg 3 patients 2x/day 1 patient 1x/day
Hydrochlorothiazide 25mg 2 patients 1x/day 2 patients 1x/day
Simvastatin 20mg 1 patient 1x/day 1 patient 1x/day
Acetylsalicylic 100mg 1 patient 1x/day 1 patient 1x/day
Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
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Study Design
The study was carried out at a public hospital with
ambulatory visits at the Physical Education department
and the patients were referred by an accredited
cardiologist. All sessions were performed in an exercise
room inside the hospital. The room has 12 0m2 and
contained one leg press 45º, one pulldown machine, one
cable seated row, two bars, one dumbbell kit (2 to 10 kg)
and weight plates. Each patient performed 24 resistance
training sessions over 12 weeks, with at least 48 hours
between them. HR, SBP and DBP were measure before
and after resistance training. All patients were instructed
to report any change in medication during the study
period and this was confirmed by their physicians. The
resistance training sessions lasted approximately 20
minutes. Participants were instructed to maintain their
usual diet during the study. During the study, the
participants were constantly monitored for injuries and
any possible negative outcome associated with the
intervention.
Blood pressure and heart rate
SBP, DBP and HR were measured immediately before
and 10 minutes after each resistance training session
using a validated digital blood pressure monitor
(OMRON, HEM-705CP, China). Before each measure,
the patient remained seated for 10 minutes. The
procedures followed the 7th Brazilian Arterial
Hypertension Guidelines14,15. The comparisons involved
the measures performed in first and last training session
(i.e. pre training values at the first training session vs. pre
training values at the last training session; post training
values at the first training session vs. post training values
at the last training session). The standard error of the
measure and intraclass correlation coefficient for SBP,
DBP and HR were 3.7 mmHg and 0.98, 4.6 mmHg and
0.84, and 3.1 bpm and 0.94, respectively.
Resistance Training intervention
The participants performed resistance training two times
per week, separated by at least 48 hours, between 8 and
10 a.m. The participants had the possibility of training in
different days; therefore, if the lost a session, they could
perform it in the next available day. The research staff
maintained constant contact with all the participants
through telephone and instant messages in order to
motivate adherence and monitor adverse events. All
resistance training sessions were performed following a
minimum dose approach,16 and were individually
supervised by certified and qualified physical education
professionals.17 The resistance training sessions were
composed of four multi joint exercises (leg press, lat
pulldown, deadlift and incline dumbbell bench press).18
Two sets were performed for each exercise with two–
minutes rest interval between sets. During the first four
resistance training sessions the participants performed
10–12 repetitions to volitional fatigue. After the fifth
resistance training session, patients performed 6–9
repetitions to momentary muscle failure with rests of two
minutes between sets, as defined by Steele et al.16,19 The
participants were instructed to maintain two seconds in
the concentric and eccentric phase, without rest in the
transition phase. Workloads were adjusted whenever
necessary to maintain the target range of repetitions.8,10
Statistical Analysis
According to the Shapiro–Wilk test, all variables
presented a normal distribution (p > 0.05), except SBP
measured after the first and last resistance training
session and DBP measured after the first resistance
training session. Student’s paired t-tests were used to
compare variables with normal distribution and
Wilcoxon test to compare those without normal
distribution. Descriptive statistics was used to describe
the mean and standard deviation of participants' age. All
statistical analyses were performed with the GraphPad
Prism software (version 5.0, San Diego, CA, USA). The
significance level was set p ≤ 0.05.
Results and Discussion
All patients initially selected concluded the study and no
injuries were reported. There were no differences in HR
when comparing pre and post intervention values, either
Fig 1. Heart rate, systolic (SBP) and diastolic blood pressure (DBP) before and after the first and last resistance
training session. Pre - measures performed before the training session. Post - measures performed immediately
after the training session.
Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
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measured before or after training session. SBP measured
before (SBPpre ∆: 18.7 ± 8.0% [29 ± 15 mmHg]) and
after (SBPpost ∆: 15.4 ± 9.0% [22 ± 15 mmHg]) the last
resistance training session decreased significantly from
the corresponding values in the first resistance training
session. DBP measured before (DBPpre ∆: 11.2 ± 12.1%
[10 ± 11 mmHg]) and after (DBPpost ∆: 8.5 ± 15.9% [7
± 13 mmHg]) the last resistance training session
decreased significantly from the corresponding values in
the first resistance training session (Figure 1). A
posteriori calculation revelated that the observed power
was >0.99 for both SBPpre and SBPpost, 0.71 for
DBPpre and 0.6 for DBPpost (Figure 2). During the study
period eight patients reported dizziness and low blood
pressure, which lead the physician to adjust the patients'
medication. At the end of the 12 weeks, eight patients
reduced the amount of losartan to once daily, three
decreased amlodipine, two decreased atenolol and the
patient who used simvastatin had the medication
suspended.
The purpose of this study was to test the effects of low
doses of high effort resistance training performed inside
a hospital. The study showed that 20-minute sessions of
resistance training carried out over 12 weeks, 2 times per
week, were able to significantly reduce SBP and DBP in
hypertensive adults with 100% adherence and no report
of injuries. Whilst medication reduction was not the
primary endpoint of the study, it is interesting to note that
such reductions occurred with a concomitant decrease in
the amount of medications used. The volunteers were
taking medications to control hypertension for more than
5 years and their records showed a progression or
stability in the amount and dose of medication. However,
during the study, many patients have reported sleepiness
and discomfort in daily activities, which lead the
physician to reevaluate the anti-hypertensive medication
prescription. The dose Losartan fell by half in two-thirds
of the patients, three decreased amlodipine and atenolol
decreased in two patients. Although previous meta-
analysis showed that resistance training is able to reduce
resting blood pressure,11 the results of the studies are not
consensual. In this regard, our findings are contrary to a
previous study published by Gomes in which
hypertensive patients performed seven exercises (bench
press, leg press, seated row, knee extension, arm barbell
curls, leg curl, front elevation and abduction the hip) for
12 weeks.20 The exercises were performed with three sets
of 10 repetitions and two-minute interval between sets,
resulting in a duration of approximately 40 minutes.
Different form our findings, there were no changes in
resting blood pressure. 20 The divergence between the
results is not clear. Traditionally, 150 minutes of
moderate-intensity physical activity or 75 minutes of
vigorous intensity physical activity are recommended as
non-pharmacological treatments for hypertension.2,6,21
However, our study shows that small doses of high effort
resistance training (~40 minutes per week) were able to
significantly reduce blood pressure. The reductions in
blood pressure found in our study may be clinically
relevant for hypertensive people, since it has been shown
that the decrease of 20 mmHg on systolic and 10 mmHg
in diastolic blood pressure represents a 50% decrease in
mortality risk by stroke, ischemic disease and other
vascular diseases.22,23
The choice of small number of repetitions (<10) was for
safety reasons, since it promotes lower acute increases in
blood pressure, HR, double product,24–26 and promotes
better autonomic modulation than performing a higher
number of repetitions.27 Resistance training sessions
were composed of four multi-joint exercises, with two
sets for each exercise, two minutes interval between sets
and a speed of two seconds in both eccentric and
concentric phase. Multi-joint exercises were selected due
to the evidence that they are more efficient in improving
general physical fitness, maximal oxygen uptake and
muscular strength than single joint exercises,18 and there
is also evidence that the addition of single joints exercises
to a multi-joint exercise program does not lead to
morphological or functional benefits.28,30 Movement
velocity was controlled to improve movement quality
and because previous studies showed that higher speed
resulted in higher blood pressure responses.31 In relation
Fig 2. Heart rate, systolic (SBP) and diastolic blood pressure (DBP) before and after the first and last resistance
training session. Pre - measures performed before the training session. Post - measures performed immediately
after the training session.
Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
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to training volume, there is evidence that an increase in
the number of sets does not bring additional functional
benefits to older people.32,33 Therefore, we opted to
perform only two sets two times a week in order to adhere
to the minimum dose approach mentioned previously.8,9
These results might be applicable in a hospital setting in
a multidisciplinary perspective because of the constant
need to monitor the patients and adjust the medications.
The present results can also serve as a parameter for
future research, since most guidelines suggest relatively
high doses of resistant training concomitant to aerobic
training for the management of hypertension.2,6,21,34 Our
findings suggest the possibility of a non-pharmacological
intervention as an aid in the management of arterial
hypertension, with a considerably less time commitment
than indicated by most guidelines. Considering the high
prevalence of hypertension, it would be interesting to
consider the inclusion of low doses of physical exercises
as a first line of treatment in clinical environments, such
as clinics and hospitals, this might increase adherence
and optimize the occupation of the facilities. It is
important to note that the patients have been previously
advised to participate in regular physical activity over the
previous years, since this is a standard procedure in the
hospital; however, none have spontaneously participated
in an exercise program before the study. Therefore, we
believe that offering this possibility inside the hospital
might have important practical applications.
This study has some important limitations. First, there
was no rigid dietary control. Although, patients were
advised to not change their diets, we are not able to
confirm if they followed the recommendations. However,
it is worth noting that the volunteers have been receiving
the same nutritional counselling for the previous years,
so it's unexpected that there have been relevant
modifications after the beginning of the study. Another
important methodological limitations are the small and
mixed sample and the absence of a control group;
however, for institutional and ethical reasons the
treatment option was offered to all participants.
However, as we do not have a non-exercise control
group, we are unable to provide an estimation of sample
size for future clinical trials. A non-exercise control
group would be necessary to estimate the “true effect
size” after account for random error. In addition, the
participants were stable for years, and there were no
changes in their medications prior to the study, therefore
it is expected that the reported effects were due to the
training protocol. It is important to note that patients were
under treatment in a reference center, which makes it
safer to apply high intensity workouts. In cases of higher
risk as in less controlled patients, it is important to
analyze the strategies to be applied individually. In
addition to these main limitations, it should be noted that
the patients were predominantly women.
We conclude that low volume and high effort resistance
training is a feasible non-pharmacological strategy to
control blood pressure in hypertensive patients within a
hospital. It is important to note that the intervention was
performed in litle space and with minimum equipments
that bring wide perspectives of general application.
List of acronyms
DBP – diastolic blood pressure
HR – heart rate
SBP – systolic blood pressure
Authors contributions
CS and PG designed the intervention; CS, ACR, PCVJ
and PG performed the analysis; CS, MMAS, JSC, VA
and PG conduced and supervised the intervention; CS,
ACR, MMAS, JSC, VA, PCVJ and PG writing—review
and editing; All authors have read and agreed to the
published version of the manuscript..
Acknowledgments
The authors would like to thank all the voluntary
participants and the mangers of Hospital da Clínicas de
Goiania, Brasil.
Funding
PG received a Research Grand from CNPq
(304435/2018-0).
Conflict of Interest
The authors declare no competing interests.
Ethical Publication Statement
We confirm that we have read the Journal’s position on
issues involved in ethical publication and affirm that this
report is consistent with those guidelines.
Corresponding Author
Paulo Gentil, PhD, Human Movement Assessment
Laboratory, Faculty of Physical Education and Dance,
Federal University of Goiás (UFG), Brasil.
ORCID iD: 0000-0003-2459-4977
E-mail: paulogentil@hotmail.com
E-mail and ORCID of co-authors
Camila Simões Seguro: miaseguro@hotmail.com
ORCID iD: 0000-0001-5898-9833
Ana Cristina Rebelo:
anacristina.silvarebelo@gmail.com
ORCID iD: 0000-0002-9214-5025
Anderson Garcia Silva:
andersongarciasilva@hotmail.com
ORCID iD: 0000-0002-6550-3069
Matheus Malaquias Alves dos Santos:
matheus.edfi@gmail.com
ORCID iD: NO ORCID
John Sebastião Cardoso: johnscsilva@gmail.com
ORCID iD: 0000-0002-7018-5173
Valéria Apolinário: valeria.fisiohc@yahoo.com
ORCID iD: NO ORCID
Paulo Cesar Veiga Jardim: fvjardim.ufg@gmail.com
ORCID iD: 0000-0002-5333-013X
Resistance training to treat blood pressure in a hospital
Eur J Transl Myol 31 (1): 9547, 2021 doi: 10.4081/ejtm.2021.9547
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Submission: December 4, 2020
Revision received: January 4, 2021
Accepted for publication: January 5, 2021
