ppt.Hypertension and Exercise

by Dr.Vinod K Ravaliya, K M Patel Institute of Physiotherapy.. current issues in management of Hypertension.

1. Current issuesCurrent issues !!! !!!
NON-PHARMACOLOGICAL NON-PHARMACOLOGICAL
MANAGEMENT OF MANAGEMENT OF
HYPERTENSION HYPERTENSION
Dr.Vinod K. RavaliyaDr.Vinod K. Ravaliya
Cardiothoracic Physiotherapy Cardiothoracic Physiotherapy
KMPIP,KARAMSADKMPIP,KARAMSAD

2. What is Hypertension?
Increase in the blood pressure above Increase in the blood pressure above
normal value is known as hypertension normal value is known as hypertension
or high blood pressureor high blood pressure..

3. British Hypertension society
Classification of blood pressure levels
Category Systolic blood pressure
(mm Hg)
Diastolic blood pressure
(mm Hg)
Blood pressure
Optimal
Normal
High Normal
<120
<130
130 – 139
<80
<85
85 -89
Hypertension
Grade 1 (mild)
Grade 2 (moderate)
Grade 3 (severe)
140 – 159
160 – 179
>180
90 – 99
100 – 109
>110
Isolated Systolic Hypertension
Grade 1
Grade 2
140 – 159
>160
<90
<90

4. It was estimated that almost 1/3It was estimated that almost 1/3
rdrd
of BP related deaths of BP related deaths
occurred in normotensive individuals with blood pressureoccurred in normotensive individuals with blood pressure
SBP : 120 – 139SBP : 120 – 139
DBP : 80 – 89DBP : 80 – 89
Stamler J, Neaton JD et al. Arch. Of internal medicine, 1993 ; 153 : 598 – 615.Stamler J, Neaton JD et al. Arch. Of internal medicine, 1993 ; 153 : 598 – 615.
Blood pressure, systolic and diastolic and cardiovascular risks : US Blood pressure, systolic and diastolic and cardiovascular risks : US
population data. population data.

5. The Joint national committee VII report on prevention, The Joint national committee VII report on prevention,
detection, evaluation and treatment of high blood detection, evaluation and treatment of high blood
pressure.pressure.
Chobanian AV, Black HR et al.2003Chobanian AV, Black HR et al.2003

6. JNC VII Classification of blood JNC VII Classification of blood
pressurepressure
BP
Classification
SBP, mm
Hg
DBP, mm
Hg
Lifestyle
modifications
Without Compelling
Indications
Normal <120 And <80 Encourage
Pre hypertension120-139
Or
80-89
Yes
No antihypertensive
drug indicated
Stage 1
Hypertension
140-159
Or
90-99
Yes
Thiazide-type
diuretics for most.
May consider ACEI,
ARB, BB, CCB, or
combination
Stage 2
Hypertension
> 160 Or >100 Yes
Two-drug
combination for most†
(usually thiazide-type
diuretic and ACEI or
ARB or BB or CCB)

7. Indeed blood pressure is a continuum and any increase Indeed blood pressure is a continuum and any increase
above normal value confers additional independent risk above normal value confers additional independent risk
of coronary heart disease, stroke, CHF, end stage renal of coronary heart disease, stroke, CHF, end stage renal
disease, peripheral vascular disease. disease, peripheral vascular disease. (McMahon S, Peto R et (McMahon S, Peto R et
al.2002)al.2002)
3 mm Hg in SBP - 8% in stroke mortality3 mm Hg in SBP - 8% in stroke mortality
- 5% in CAD mortality- 5% in CAD mortality
(National High blood pressure education programme working group (National High blood pressure education programme working group
report, 1993.)report, 1993.)

8. The lifetime risk of developing hypertension is The lifetime risk of developing hypertension is
estimated to be 90% at the age of 55 years estimated to be 90% at the age of 55 years (Vasan (Vasan
RS et al.2002, JAMA)RS et al.2002, JAMA)
Each increment of 20mmHg (SBP) and 10mmHg Each increment of 20mmHg (SBP) and 10mmHg
(DBP) doubles the risk of CVD across the entire BP (DBP) doubles the risk of CVD across the entire BP
range from 115\75 to 185\115 mmHg range from 115\75 to 185\115 mmHg

9. What causes hypertension? What causes hypertension?
Essential hypertension

11. Probable mechanisms :
• Rennin - angiotensin system
• Peripheral resistance vessels
• Overactivation of sympathetic
nervous system

12. Secondary causes of hypertension:
• Chronic steroid therapy

• Reno vascular disease
• Chronic kidney disease
• Primary aldosteronism
• Pheochromocytoma
• Coarctation of aorta
• Thyroid \Parathyroid disease

13. Management of hypertension: Management of hypertension:
PharmacologicalPharmacological
NonpharmacologicalNonpharmacological
Why not pharmacological exclusively?
Failure of hypertension control point towards :
• non-compliance with treatment
• long term usage of drug
• increased risk of cardiovascular events
• economic-constraint

14. Is there any alternative?

15. Modifiable risk factors for Essential Modifiable risk factors for Essential
Hypertension :( JNC VII Guidelines)Hypertension :( JNC VII Guidelines)
ObesityObesity
Physical inactivityPhysical inactivity
Alcohol consumptionAlcohol consumption
Diet Diet
Stress & anxietyStress & anxiety

16. Weight reduction Weight reduction

17. BMI (>/= 25kg/m2)BMI (>/= 25kg/m2)
Essential hypertensionEssential hypertension
78%-in male78%-in male
65%-in female65%-in female
(Vasant RS, Larson MG et al, 2001)(Vasant RS, Larson MG et al, 2001)

18. Dolls, Bovet P et al, 2002

20. Confusion?
fasting
exercise
surgery drugs

21. FastingFasting
No energy input ensures negative energy No energy input ensures negative energy
balancebalance
Weight loss is rapid but this is disadvantageWeight loss is rapid but this is disadvantage
Disadvantage is a large portion of weight loss Disadvantage is a large portion of weight loss
is from lean body mass.is from lean body mass.
Nutrient deficit occurNutrient deficit occur
ketogenicketogenic

22. SurgerySurgery
Alteration of gastrointestinal tract capacityAlteration of gastrointestinal tract capacity
Advantage-Caloric restriction is less Advantage-Caloric restriction is less
necessarynecessary
Disadvantage-risks of surgeryDisadvantage-risks of surgery

23. Exercise Exercise
Evidence supports that level of regular Evidence supports that level of regular
physical activity is more effective than physical activity is more effective than
dieting for long term weight control.dieting for long term weight control.
(French, S.A., et al. 1994)(French, S.A., et al. 1994)
Increased caloric expenditure through Increased caloric expenditure through
aerobic type exercise is a significant option aerobic type exercise is a significant option
for unbalancing the energy equation to bring for unbalancing the energy equation to bring
out both weight loss and a favorable out both weight loss and a favorable
modification in body composition.modification in body composition.
(Ballor, and Kessey et al.1994(Ballor, and Kessey et al.1994))

24. Calorie expenditure > Calorie intake by 10%Calorie expenditure > Calorie intake by 10%
Net 3500 kcal energy burning gives 0.45 kg body fat Net 3500 kcal energy burning gives 0.45 kg body fat
loss.loss.
A meta analysis by staessen et al. showed that mean A meta analysis by staessen et al. showed that mean
SBP & DBP reductions were 1.6/1.1 mmHg per kg of SBP & DBP reductions were 1.6/1.1 mmHg per kg of
body weight by aerobic program.body weight by aerobic program.
18 month weight loss program associated with 77% 18 month weight loss program associated with 77%
reduction in incidence of hypertension.reduction in incidence of hypertension.
(He J, Whelton PK et al.2000)(He J, Whelton PK et al.2000)
The exact mechanism by which weight reduction lowers The exact mechanism by which weight reduction lowers
blood pressure is not known.blood pressure is not known.

25. Probable mechanism:Probable mechanism:
- Decreased concentration of renin and - Decreased concentration of renin and
aldosterone .aldosterone .
(Engel S, Sharma AM et al. 2001)(Engel S, Sharma AM et al. 2001)
- Decrease in activity of sympathetic - Decrease in activity of sympathetic
nervous system.nervous system.
(Esler M, Lambert G et al.2006) (Esler M, Lambert G et al.2006)

26. Physical activityPhysical activity

27. Physical activity
Endurance
training
Resistance
training
Isometric
program

28. Endurance trainingEndurance training
Reduces blood pressure through:Reduces blood pressure through:
-Reduction in systemic vascular resistance-Reduction in systemic vascular resistance
-decrease in renin - angiotensin activity-decrease in renin - angiotensin activity

29. A meta analysis of RCTA meta analysis of RCT
Systolic Blood Pressure
Diastolic Blood Pressure
4.7 mm Hg
3.1 mm Hg
Systemic Vascular
Resistance
7.1%
Plasma noradrenaline 29%
Plasma rennin 20%
Body Weight 1.2 kg
Waist Circumference 2.8 cm
% Body Fat 1.4%
HDL 0.032 mmol/l
104 study groups involved
Intervention Duration – 4 weeks
Endurance Training program
Fagard RH et al, 2006, Sept.

31. A meta analysis of 54 RCTs showed net reduction of A meta analysis of 54 RCTs showed net reduction of
3.8 mm Hg (SBP) and 2.6 mm Hg (DBP) in 3.8 mm Hg (SBP) and 2.6 mm Hg (DBP) in
hypertensive individuals performing aerobic hypertensive individuals performing aerobic
exercise.exercise.
(Whelton SP, Chin A et al, 2002)(Whelton SP, Chin A et al, 2002)
Recommended exercise protocol :Recommended exercise protocol :
–Frequency :-Frequency :- > 3 sessions/week > 3 sessions/week
–Intensity :-Intensity :- > 70% VO2 max > 70% VO2 max
–Type :-Type :- aerobic exercise aerobic exercise
–Time :-Time :- > 45 mins > 45 mins
More than these
values have no
added benefits
Halbert JA, Silagy CA et al, 1997

32. Resistance TrainingResistance Training
Strength exercise can even be used for lowering Strength exercise can even be used for lowering
blood pressure.blood pressure.
The actual blood pressure response depends on :The actual blood pressure response depends on :

•isometric componentisometric component
•exercise intensityexercise intensity
•Muscle mass activatedMuscle mass activated
•number of repetitionsnumber of repetitions
•duration of contractionduration of contraction
•involvement of valsalva maneuverinvolvement of valsalva maneuver
Bjarnason – Wehrens B, Mayer – Berger W et al, 2004

33. However, a need exists for additional well designed However, a need exists for additional well designed
studies on this topic before a recommendation can studies on this topic before a recommendation can
be made regarding the efficacy of resistance be made regarding the efficacy of resistance
exercise as a non pharmacologic therapy for exercise as a non pharmacologic therapy for
reducing the resting blood pressure in hypertensive reducing the resting blood pressure in hypertensive
individuals.individuals.
Kelley G et al, 1997Kelley G et al, 1997

34. Isometric ExerciseIsometric Exercise
Isometric exercise such as weight lifting can have a Isometric exercise such as weight lifting can have a
pressor effect and therefore should be avoided. pressor effect and therefore should be avoided.
Thus it is strictly contraindicated.Thus it is strictly contraindicated.
(Krousel(Krousel Wood MA, Muntner P et al, 2004)Wood MA, Muntner P et al, 2004)

35. Moderation in alcohol consumptionModeration in alcohol consumption
Effects of alcohol reduction on BP showed a dose Effects of alcohol reduction on BP showed a dose
dependent decline in BPdependent decline in BP
X in X, He J et al. 2001X in X, He J et al. 2001
Clinical Studies show that BP falls 4 to 5 mm Hg in Clinical Studies show that BP falls 4 to 5 mm Hg in
days or weeks with abstinence from alcoholdays or weeks with abstinence from alcohol
The JNC VII recommends that alcohol intake should The JNC VII recommends that alcohol intake should
be no more thanbe no more than
–2 drinks/day (male)2 drinks/day (male)
–1 drink/day (female)1 drink/day (female)

36. For drinkersFor drinkers
– < 20 – 30 gm/day (male)< 20 – 30 gm/day (male)
– < 10 – 20 gm/day (female< 10 – 20 gm/day (female))
Puddey IB et al, 1992.Puddey IB et al, 1992.

37. Dietary Modification
Reduce Salt Intake
Approximately 6 gm/day can prevent
hypertension (trials of hypertension
prevention collaborative research group,
1997)
Salt Intake reduction 6 gm/day.
7.11 mm Hg (SBP) & 3.88 mm Hg (DBP)
in hypertensives.
Mac Gregor GA et al, 2002

38. Reduce Stroke Deaths by 14% and Coronary deaths by Reduce Stroke Deaths by 14% and Coronary deaths by
9% in hypertension.9% in hypertension.
Consume foods low in salt (SRD)Consume foods low in salt (SRD)
Avoid pickles, processed foods, chips and chutneys.Avoid pickles, processed foods, chips and chutneys.

39. Increase potassium intakeIncrease potassium intake
High potassium intake – reduce blood pressureHigh potassium intake – reduce blood pressure
Consume foods such as fruits, vegetables and Consume foods such as fruits, vegetables and
especially coconut.especially coconut.

40. Stress and Anxiety ControlStress and Anxiety Control
Meditation was in one study to reduce SBP and DBP by Meditation was in one study to reduce SBP and DBP by
10.7 mm Hg and 6.4 mm Hg over a period of 3 months10.7 mm Hg and 6.4 mm Hg over a period of 3 months
Schneider RH Alexander CN et al, 1995Schneider RH Alexander CN et al, 1995
Progressive muscle relaxation lower SBP by 4.7 mm Progressive muscle relaxation lower SBP by 4.7 mm
Hg and DBP by 3.3mm Hg.Hg and DBP by 3.3mm Hg.
Yoga is also widely believed to reduce blood pressureYoga is also widely believed to reduce blood pressure
Damodaran A, Patil N, Suryavanshi et al, 2002Damodaran A, Patil N, Suryavanshi et al, 2002
However, these interventions are with limited and However, these interventions are with limited and
uncertain efficacy. Therefore more trials are needed to uncertain efficacy. Therefore more trials are needed to
confirm its effectconfirm its effect..

41. conclusionconclusion
Hypertension is a silent killer.Hypertension is a silent killer.
Cardiopulmonary Physiotherapy is an integral Cardiopulmonary Physiotherapy is an integral
part of health service.part of health service.
Evidence supports that exercise is the Evidence supports that exercise is the
cornerstone for hypertension control, then cornerstone for hypertension control, then
why it is not being utilized.why it is not being utilized.
This is the time, physiotherapist must This is the time, physiotherapist must
emerge and show their potential to beat emerge and show their potential to beat
paramount disorder like hypertension where paramount disorder like hypertension where
even pharmacological management fails.even pharmacological management fails.