(Hypertension. 2000;35:838.)
© 2000 American Heart Association, Inc.
Scientific Contributions |
Progressive Resistance Exercise and Resting Blood Pressure
A Meta-Analysis of Randomized Controlled Trials
From the Department of Kinesiology and Physical Education (G.A.K.) and Office for Health Promotion (K.S.K.), Northern Illinois University, De Kalb.
Correspondence to Dr George A. Kelley, Meta-Analytic Research Group, Department of Kinesiology and Physical Education, Anderson Hall, Room 233, Northern Illinois University, DeKalb, IL 60115-2854. E-mail gkelley{at}niu.edu
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Abstract—Hypertension is a major public health problem affecting an estimated 43 million civilian, noninstitutionalized adults in the United States (24% of this population). The purpose of this study was to use the meta-analytic approach to examine the effects of progressive resistance exercise on resting systolic and diastolic blood pressure in adult humans. Studies were retrieved via (1) computerized literature searches, (2) cross-referencing from original and review articles, and (3) review of the reference list by 2 experts on exercise and blood pressure. Inclusion criteria were as follows: (1) trials that included a randomized nonexercise control group; (2) progressive resistance exercise as the only intervention; (3) adult humans; (4) journal articles, dissertations, and masters theses published in the English-language literature; (5) studies published and indexed between January 1966 and December 1998; (6) resting systolic and/or diastolic blood pressure assessed; and (7) training studies lasting a minimum of 4 weeks. Across all designs and categories, fixed-effects modeling yielded decreases of
2% and 4% for resting
systolic and diastolic blood pressure, respectively
(mean±SD systolic, -3±3 mm Hg; 95% bootstrap CI, -4
to -1 mm Hg; mean±SD diastolic, -3±2 mm Hg;
95% bootstrap CI, -4 to -1 mm Hg). It was concluded that
progressive resistance exercise is efficacious for reducing resting
systolic and diastolic blood pressure in adults.
However, a need exists for additional studies that limit enrollment to
hypertensive subjects as well as analysis of data with an
intention-to-treat approach before the effectiveness of progressive
resistance exercise as a nonpharmacological intervention can be
determined.
Key Words: exercise • blood pressure • meta-analysis
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Hypertension, defined as resting systolic and/or diastolic blood pressure
140/90 mm Hg, is a major
public health problem affecting an estimated 43 million civilian,
noninstitutionalized adults in the United States (24% of this
population).1 Recently, the Sixth Report of the Joint
National Committee on the Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure2 recommended adherence to
the physical activity guidelines outlined in the Surgeon General’s
Report3 for lowering resting blood pressure. This includes
moderately intense aerobic exercise at 40% to 60% of maximum oxygen
consumption, such as 30 to 45 minutes of brisk walking on most days of
the week.3 It has been suggested that progressive
resistance exercise may also lower resting blood pressure, possibly by
reducing peripheral resistance at rest.4
However, absent from the previous recommendations was the promotion of
progressive resistance exercise for controlling resting blood pressure
levels. This is not surprising given the lack of statistically
significant and positive findings regarding the use of progressive
resistance exercise as a nonpharmacological intervention for
controlling resting blood pressure in adults.5 6 7 8 9 10 11 12 13 14 15 For
example, only 7% and 13% of the aforementioned studies reported
statistically significant reductions in resting systolic and
diastolic blood pressure, respectively. However, most of
these studies suffer from small sample sizes, thus increasing the risk
of incorrectly concluding that progressive resistance exercise has no
positive effect on resting systolic and diastolic
blood pressure in adults. Additionally, because some of the studies
were not specifically testing the hypothesis of progressive resistance
exercise on blood pressure, the standardized mechanisms for assessing
blood pressure may not have been as rigorous as those studies
specifically testing for such a hypothesis. Consequently, the lack of
observed effect in these studies could be due to measurement bias.
Furthermore, use of the vote-counting method (counting the number of
studies yielding statistically significant versus nonsignificant
results and declaring the one with the most votes the winner) has been
criticized because (1) it does not incorporate sample size into the
vote, (2) it does not allow one to determine the magnitude of the
treatment effect, and (3) it has been shown to have very low
power.16 Meta-analysis is a quantitative approach
in which individual studies addressing a common problem are
statistically combined to arrive at conclusions about a body of
research.16 Meta-analysis allows one to (1)
improve power for primary outcomes and subgroup analyses, (2)
help resolve uncertainty when studies disagree, (3) improve estimates
of treatment effectiveness, and (4) answer questions not posed at the
start of individual trials.17 A need exists to use a
quantitative approach to examine the effects of progressive resistance
exercise on resting systolic and diastolic blood
pressure in adults. Thus, the purpose of this study was to use the
meta-analytic approach to examine the effects of progressive resistance
exercise as a nonpharmacological intervention for reducing resting
systolic and diastolic blood pressure in adult
humans. |
Methods |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Data Sources
Computerized literature searches of articles indexed between January 1966 and December 1998 were performed with the use of MEDLINE, Embase, Current Contents, Sport Discus, and Dissertation Abstracts International databases. However, since computer searches have been shown to yield less than two thirds of relevant articles,18 the reference lists from both original and review articles retrieved were also reviewed to identify any studies that had not been previously identified and that appeared to contain information on the topic of interest. In addition, 2 experts on exercise and blood pressure (Dr James Hagberg and Dr Douglas Seals) reviewed our reference list for thoroughness and completeness.
Study Selection
Inclusion criteria for this study were as follows: (1)
randomized trials that included a nonexercise control group; (2)
progressive resistance exercise as the only intervention; (3) adult
humans (aged 18 and older) as subjects; (4) journal articles,
dissertations, and masters theses published in the English-language
literature; (5) studies published and indexed between January 1966 and
December 1998; (6) resting systolic and/or
diastolic blood pressure assessed; and (7) training
studies lasting a minimum of 4 weeks.
Data Extraction
Coding sheets that could hold 241 items were developed and used
in this investigation. To avoid interobserver bias, all data
were independently extracted by 2 authors. The authors then met and
reviewed every item for accuracy and consistency.
Disagreements were resolved by consensus. The major categories of
variables coded included (1) study characteristics, (2) physical
characteristics of subjects, (3) blood pressure assessment
characteristics, and (4) exercise program characteristics.
Statistical Analysis
Primary and Secondary Outcomes
The primary outcomes in this study were changes in resting
systolic and diastolic blood pressure,
analyzed separately. Since all studies were parallel trials,
net changes in blood pressure were calculated as the difference
(exercise minus control) of the changes (initial minus final) in these
mean values. Pooled effect sizes were calculated by assigning weights
equal to the inverse of the total variance for net changes in blood
pressure. Because of the small sample size in this study, bootstrap
resampling (5000 iterations) was used to generate 95% bootstrap
confidence intervals (BCI) around mean effect size changes for resting
systolic and diastolic blood
pressure.19 The number of iterations chosen was based on
previous research demonstrating that improvement of estimation accuracy
was limited beyond 5000 iterations.20 If the 95% CI
included zero (0.00), it was concluded that there was no effect of
progressive resistance exercise on blood pressure.
Heterogeneity of net changes in resting
systolic and diastolic blood pressure was examined
with the Q statistic.16 For all analyses, a
fixed-effects model was used if results were homogeneous,
while a random-effects model was used if heterogeneity
was present.21
To examine the influence (sensitivity) of each study on the overall results, analyses were also performed with each study deleted from the model. Cumulative meta-analyses, ranked by year, were also performed for net changes in resting systolic and diastolic blood pressure to examine at what point in time, if any, the primary outcome measures stabilized.
Publication bias (the tendency for studies to be published that yield
statistically significant and positive results) was examined with the
Kendall 
rank correlation test
(r).22 This consisted
of correlating observed outcomes, ie, changes in resting
systolic and diastolic pressure, with sample size.
Study quality was assessed with a 3-item questionnaire designed to
assess bias, specifically, randomization, blinding, and
withdrawals/dropouts.23 The minimum number of points
possible was 0, and the maximum was 5. All questions were designed to
elicit responses of yes (1 point) or no (0 points). Completion of the
questionnaire required <10 minutes per study. The questionnaire has
been shown to be both valid (face validity) and reliable (researcher
interrater agreement, r=0.77; 95% CI, 0.60 to
0.86).23 We chose this scale over numerous
others24 because it appears to be the most valid and
reliable scale that currently exists and has been successfully used in
the past.25
Secondary outcomes, ie, changes in body weight, body mass index, percent body fat, lean body mass, maximum oxygen consumption, and resting heart rate, were examined with the same methods as those for examining net changes in resting systolic and diastolic blood pressure.
Moderator Analysis
For categorical variables as well as study quality, subgroup
analyses were performed with ANOVA-like procedures for
meta-analysis.16 Net changes in resting
systolic and diastolic blood pressure were examined
when data were partitioned according to source of publication (journal
compared with other), country in which study was conducted (United
States compared with other), study quality (<2 compared with 2),
whether subjects were hypertensive or not (systolic, <140
mm Hg compared with 140 mm Hg; diastolic,
<90 mm Hg compared with 90 mm Hg), type of blood
pressure instrument used (electronic compared with manual), position of
subject when blood pressure was assessed (sitting compared with
supine), and type of progressive resistance training program
(conventional compared with circuit). Because of the potential for a
lack of rigor in the assessment of blood pressure and subsequent
increase in measurement bias for those studies not specifically testing
the hypothesis of progressive resistance exercise on blood pressure, we
also performed subgroup analysis according to those studies
that were specifically testing for such a hypothesis compared with
those that were not. Randomization tests (5000 iterations) were used to
determine the significance level for between group differences, while
95% BCI were generated from 5000 iterations.
To examine the influence of continuous variables on changes in resting systolic and diastolic blood pressure, least squares regression models, calculated with each effect size weighted by the reciprocal of its variance, were used.16
Unless otherwise noted, all data are reported as mean±SD. All CIs
reported were based on 5000 bootstrap iterations, corrected for bias.
The 
level for a type I error was set at P
0.05. The
level for between-group differences for subgroup analyses was
derived from randomization tests (5000 iterations). Bonferroni
adjustments were not made because of the increased risk of a type II
error.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Study Characteristics
A total of
11 700 studies were located, and the title and
abstract were reviewed to determine whether they met the criteria for
inclusion. Of these, 12 studies met the necessary
criteria5 6 7 8 9 10 11 12 13 14 15 26 ; however, we were unable to include 1
study in the final analysis because of inability to obtain
missing blood pressure data.26 Thus, our percent loss that
met our inclusion criteria was 8%. The per person time to code each
study once ranged from 0.52 to 1.75 hours (mean±SD, 0.96±0.40 hours).
Six of the studies were published in
journals,6 8 10 11 12 15 and 5 were doctoral
dissertations.5 7 9 13 14 Nine of the studies were
conducted in the United States5 6 7 8 9 11 12 13 14 and 1 each in
Belgium15 and Australia.10 The 11 studies
included in the final analysis represented initial
and final blood pressure assessment in a total of 320 subjects (182
exercise, 138 control). There were a total of 14 exercise and 12
control groups, from which a total of 15 primary outcomes were
generated (some studies had >1 group and/or assessed blood pressure in
>1 position). The average number of subjects in each group ranged from
6 to 31 in the exercisers (mean±SD, 13±6) and 5 to 22 in the controls
(mean±SD, 12±5). For those groups in which data were available,
percent dropout, defined as the number of subjects who did not complete
the study, ranged from 0% to 58% in the exercise groups (mean±SD,
18±20%) and 0% to 38% in the control groups (11±13%). All of the
studies appeared to use an analysis-by-protocol approach in the
analysis of their blood pressure data. Study quality ranged
from 1 to 3 (mean±SD, 2±1).
Subject Characteristics
Initial subject characteristics for the exercise and control
groups are shown in Table 1. For those
groups that reported such data, the percentage of men ranged from 0%
to 100% (mean±SD, 50±42%). Three studies reported that all of the
subjects were male,5 11 15 another 3 reported that all of
the subjects were female,7 9 12 and 4 reported that both
men and women were included.6 8 10 14 For the 4 studies
that reported information on race, all reported that the majority of
subjects were white.5 6 7 14 Two studies reported that none
of the subjects were taking any antihypertensive medications before or
during the study,14 15 another reported that subjects were
taken off antihypertensive medications 4 weeks before being screened
for the study,6 and another reported that some subjects
were taking antihypertensive medications both before and during the
study.8 One study that included hypertensive subjects did
not report any information about antihypertensive
therapy.11 Three studies10 11 12 reported that
none of the subjects smoked cigarettes, while 1 reported that some of
the subjects smoked.5 None of the studies reported
information on the consumption of alcohol. The 3 studies that provided
information on diet reported that no significant changes in diet
occurred throughout the study.6 7 10 All of the studies
reported that the subjects were previously inactive before the start of
the investigation.5 6 7 8 9 10 11 12 13 14 15
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Blood Pressure Assessment Characteristics
For those studies that reported information on the type of
instrument used to assess resting blood pressure, 3 reported using a
manual sphygmomanometer,6 8 15 3 used an electronic
sphygmomanometer,9 10 14 and 1 used a semielectronic
sphygmomanometer.7 Five studies assessed resting blood
pressure with the subject in the seated
position,6 8 11 12 13 3 in the supine
position,5 7 10 and 1 in both the sitting and supine
positions.15 For those studies that reported such
data,5 6 8 9 10 12 14 15 the number of measures taken to
arrive at a mean blood pressure level ranged from 3 to 20. The rest
period before assessment of resting blood pressure ranged from 5 to 15
minutes,7 8 11 12 13 14 15 while the rest period between
assessments ranged between 1 and 5 minutes.5 6 7 8 15 Three
studies used the fifth Korotkoff sound to assess resting
diastolic blood pressure,6 8 12 while 1 used
the fourth Korotkoff sound.15 Only 2 studies reported the
time after the last exercise session before resting blood pressure was
assessed, with 1 reporting assessment 24 hours after
exercise8 and the other 36 to 72 hours after
exercise.7 While none of the studies reported any specific
information on blinding, 3 studies reported using a random-zero
sphygmomanometer in the assessment of resting blood
pressure.6 8 15
Training Program Characteristics
Length of training in the studies ranged from 6 to 30 weeks
(mean±SD, 14±6 weeks), frequency from 2 to 5 times per week
(mean±SD, 3±1 times per week), intensity from 30% to 90% of 1
repetition maximum (RM) (mean±SD, 35±7%), and duration from 20 to 60
minutes per session (mean±SD, 38±14 minutes). The number of sets per
exercise session ranged from 1 to 4 (mean±SD, 2±1), while the number
of exercises performed ranged from 6 to 14 (mean±SD, 10±3). Because
most studies reported the range versus the mean for the number of
repetitions performed as well as the rest period between exercises, we
were unable to calculate an overall mean, SD, and between-group range
of means for these data. However, the within-group number of
repetitions performed for each set ranged between 4 and 50, while the
rest period between sets ranged from 15 to 120 seconds. Compliance,
defined as the percentage of exercise sessions attended, ranged from
89% to 93% (mean±SD, 91±2%). Five of the studies reported using a
circuit training protocol.5 6 10 11 12
Primary and Secondary Outcomes
Initial and final blood pressure results for each study are
shown in Table 2. Initial resting
systolic blood pressure ranged from 104 to 151 mm Hg in
the exercise groups (mean±SD, 125±14 mm Hg) and from 99 to
153 mm Hg in the control groups (mean±SD, 125±16 mm Hg).
For resting diastolic blood pressure, initial values ranged
from 63 to 96 mm Hg in the exercise groups (mean±SD, 76±10
mm Hg) and from 57 to 95 mm Hg in the control groups (mean±SD,
75±11 mm Hg). Across all designs and categories, decreases of
2% and 4% were found for resting systolic and
diastolic blood pressure, respectively
(mean±SDsystolic, -3±3 mm Hg; 95% BCI, -4 to
-1 mm Hg; mean±SD diastolic, -3±2 mm Hg;
95% BCI, -4 to -1 mm Hg). Primary outcome results were based
on a fixed-effects model because of a lack of statistically significant
heterogeneity for both resting systolic
(Q=15.89, P=0.32) and diastolic (Q=14.42,
P=0.42) blood pressure. When limited to study results that
appeared in journals, no publication bias was found for changes in
either resting systolic or diastolic blood pressure
(systolic, r=0.23,
P=0.42; diastolic,
r=-0.15, P=0.59). With each
study deleted from the model once, changes ranged from -2 to -3
mm Hg for resting systolic blood pressure and -2 to -4
mm Hg for resting diastolic blood pressure. Cumulative
meta-analysis, ranked by year, showed that changes had remained
constant over time (systolic range, -2 to -4 mm Hg;
diastolic range, -3 to -4 mm Hg).
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For secondary outcomes, small but statistically significant decreases were found for percent body fat (mean±SD, -2±1%; 95% BCI, -3% to -2%), while statistically significant increases were found for lean body mass (mean±SD, 4±1 kg; 95% BCI, 3 to 7 kg). No statistically significant changes were found for body weight, body mass index, maximum oxygen consumption, or resting heart rate. We were unable to compare changes in muscular strength between exercise and control groups because of missing data for the control groups. Thus, percent change in muscular strength was reported for exercise groups only with increases ranging from 15% to 62% (mean±SD, 34±12%).
Moderator and Regression Analyses
No statistically significant differences or relationships were
observed when changes in resting systolic and
diastolic blood pressure were partitioned or regressed
according to (1) study characteristics, (2) blood pressure assessment
characteristics, (3) physical characteristics, and (4) training program
characteristics.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The overall results of this study suggest that progressive resistance exercise results in small reductions in resting systolic and diastolic blood pressure. While such small reductions may do little in reducing cardiovascular disease morbidity and mortality, it has been shown that small reductions similar to these have resulted in a decreased risk for stroke and coronary heart disease.27 More importantly, it does not appear that progressive resistance exercise raises resting blood pressure. Although the results are promising, additional definitive research on stage 2+ hypertensives is needed.
An interesting finding of this study was the paucity of outcomes for
hypertensive subjects. Only 20% of the outcomes were based on a mean
initial resting systolic blood pressure 140 mm Hg,
while only 13% had a mean initial resting diastolic blood
pressure 90 mm Hg. It may be that the addition of more studies
in which enrollment was limited to hypertensive subjects would have
resulted in greater decreases in resting blood pressure. Since
hypertensive adults probably have the most to gain from lowering their
resting blood pressure, future studies need to limit enrollment to
subjects initially classified as hypertensive. Since persons with
isolated systolic hypertension (systolic blood pressure
>140 mm Hg and diastolic blood pressure <90
mm Hg2 ) routinely are not treated with pharmacological
agents, the inclusion of these types of subjects in future studies
would also seem warranted. In our investigation, decreases of 3
mm Hg were found for the only study in which the summary means
resulted in the subjects being classified as having isolated
systolic hypertension.8 In addition, since
antihypertensive medication use was reported in only 4
studies,6 8 14 15 the inclusion of such information as
well as its potential interaction should be taken into account in
future study designs.
The fact that we included 1 study with some hypertensive subjects who continued to take antihypertensive medications during the study8 as well as another study that did not provide information on antihypertensive therapy in its subjects11 could be thought to affect our overall results. However, as previously described, sensitivity analysis with each of these studies deleted from the model did not have a significant effect on our overall results. Despite this, it would appear plausible to suggest that future studies interested in the independent effects of progressive resistance exercise on resting blood pressure withdraw all subjects from antihypertensive medications before participation in the study.
Another interesting finding of this study was the fact that no differences were found for changes in resting blood pressure between studies that used a conventional compared with a circuit protocol. A conventional protocol generally consists of lifting heavier weights with longer rest periods, while a circuit protocol consists of lifting lighter weights with shorter rest periods between exercises. However, while we are not aware of any cardiovascular problems in healthy or unhealthy subjects as a result of heavy progressive resistance exercise, the large increases in both systolic and diastolic blood pressure that have been demonstrated during heavy weightlifting may warrant caution, especially for those at risk for cardiovascular complications. For example, increases of 320 and 250 mm Hg have been shown to occur in peak systolic and diastolic blood pressure, respectively, during a 1-repetition maximum lift.28
The fact that it appeared that almost all of the studies used an analysis-by-protocol versus intention-to-treat approach limits our ability to judge the effectiveness of progressive resistance exercise for reducing resting blood pressure in adults. An analysis-by-protocol approach is used to judge whether a treatment is efficacious, that is, whether the treatment works or not. In this design, the results from subjects who drop out of the treatment group are not included in the final analysis. In contrast, an intention-to-treat approach, which is designed to judge whether a treatment is effective or not, includes dropouts in the final analysis.29 Unfortunately, few clinical trials attempt to address the question of effectiveness. It is important that future clinical trials examining the effects of progressive resistance exercise on resting blood pressure in adults include an examination of the effectiveness of such an intervention. This may be especially true given the fact that only 16% of adults between the ages of 18 and 64 years in the United States reported that they participate in a regular program of progressive resistance exercise.30
In conclusion, meta-analysis of included studies supports the efficacy of progressive resistance exercise for reducing resting systolic and diastolic blood pressure in adults. However, a need exists for additional studies that limit enrollment to hypertensive subjects as well as analysis of data using an intention-to-treat approach so that the effectiveness of progressive resistance exercise as a nonpharmacological intervention can be determined.
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Acknowledgments |
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This study was supported by a standard grant-in-aid from the American Heart Association (Illinois–Springfield Affiliate) (MESH9807859X).
Received October 11, 1999; first decision August 27, 1999; accepted October 11, 1999.
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