Resistance training offers numerous benefits for overall health, including improvements in muscle strength, bone density, and body composition. For individuals managing high blood pressure, the prospect of resistance training might seem concerning due to temporary blood pressure spikes during exercise. However, when approached with proper understanding and specific modifications, resistance training can be a beneficial component of a comprehensive health regimen for hypertensive clients.
Understanding Blood Pressure’s Response to Exercise
When engaging in resistance exercise, blood pressure experiences two distinct effects: an acute, temporary increase during the activity itself, caused by muscle contraction and vessel compression, and a chronic, long-term reduction in resting blood pressure over time. For hypertensive individuals, this acute systolic blood pressure (SBP) increase can be more pronounced, sometimes reaching values as high as 238 mmHg systolic and 140 mmHg diastolic during exertion. During very heavy lifts, peak pressures can even exceed 300/200 mmHg, or in extreme cases, 480/350 mmHg.
While these temporary elevations may seem alarming, they are typically transient and well-managed as the cardiovascular system adapts. Consistent resistance training leads to favorable chronic adaptations, significantly lowering resting blood pressure over weeks and months [1, 2]. Meta-analyses indicate reductions in resting systolic blood pressure by approximately 4.7 to 10.42 mmHg and diastolic blood pressure by about 3.5 to 4.84 mmHg [1, 2, 3]. These long-term reductions contribute meaningfully to cardiovascular health, demonstrating that sustained benefits outweigh temporary risks when training is performed appropriately.
Appropriate Resistance Training Systems
Selecting the right resistance training system is important for individuals with hypertension, aiming to maximize benefits while minimizing acute blood pressure fluctuations. Two effective approaches that manage cardiovascular load are Circuit Training and Peripheral Heart Action (PHA) Training.
Circuit Training involves performing a series of exercises one after another with minimal rest between each station, typically followed by a longer rest period between full circuits [2, 4]. This continuous movement keeps the heart rate moderately elevated throughout the session, akin to a blend of aerobic and strength work. For example, a circuit might include exercises like leg press, chest press, seated row, shoulder press, and bicep curls, performed for 10-15 repetitions with only 15-30 seconds of rest between each exercise, and then a 1-2 minute rest after completing all exercises in the circuit [2]. This structure has been shown to reduce systolic blood pressure by an average of 6.10 to 10.1 mmHg and diastolic blood pressure by about 2.88 mmHg [3, 4].
Peripheral Heart Action (PHA) Training is another system designed to maintain continuous blood circulation by alternating exercises between upper and lower body muscle groups with little to no rest between movements [1, 2]. For instance, a PHA sequence might involve a set of squats immediately followed by a set of overhead presses, then lunges, and then rows, with minimal pause. This rapid shifting of blood flow between distant body regions helps to avoid blood pooling and keeps the cardiovascular system engaged throughout the workout [1, 4]. Studies suggest PHA training can lead to significant reductions in systolic blood pressure and improve muscular strength, making it a viable option for those with elevated blood pressure [1, 3].
Key Modifications for Hypertensive Clients
Implementing specific modifications within any resistance training program is important for clients with hypertension, ensuring safety and maximizing the positive impact on blood pressure regulation. These adjustments address variables like intensity, volume, rest periods, and breathing techniques.
Regarding intensity, it is generally recommended to use lighter to moderate weights. This often translates to lifting at 40-60% of one-repetition maximum (1RM), or even up to 80% 1RM as fitness improves [1, 5]. Instead of focusing solely on the weight lifted, the Rate of Perceived Exertion (RPE) scale is a useful tool, where clients aim for a “somewhat hard” effort, typically an RPE of 12-13 on a 6-20 scale [3, 4]. This approach helps avoid lifting to muscle failure, which can cause undesirable blood pressure spikes [1].
Appropriate volume typically involves performing 2-3 sets per exercise, with repetitions ranging from 10 to 15 [5, 1]. This rep range, combined with moderate intensity, contributes to a safer and more effective training stimulus. Shorter rest periods between sets are often preferable within circuit or PHA training, usually ranging from 30 to 60 seconds [2, 4]. This strategy helps to prevent a full recovery of blood pressure between sets, thereby avoiding another sharp rise from a lower baseline and instead maintaining a more consistent, moderate cardiovascular load throughout the session.
Proper breathing technique is the most important modification. Clients must avoid the Valsalva maneuver, which involves exhaling forcefully against a closed airway [1, 3]. This action can rapidly increase intra-abdominal and intrathoracic pressure, leading to significant elevations in blood pressure that could be risky for hypertensive individuals, with reported spikes sometimes exceeding 400 mmHg systolic [5]. Instead, individuals should be instructed to breathe continuously and rhythmically, exhaling during the concentric (lifting) phase of the exercise and inhaling during the eccentric (lowering) phase [1].
Training Approaches to Approach with Caution
While resistance training offers significant benefits for hypertensive clients, certain approaches can pose risks and should be approached with caution or avoided entirely. These methods are associated with significant and rapid increases in blood pressure that may be unsafe.
Heavy, low-repetition lifting, such as that seen in powerlifting or training in the 1-5 repetition range, can cause significant and rapid elevations in blood pressure [2, 4]. The physiological reason for this risk stems from the intense muscle contraction and mechanical compression of blood vessels, which significantly increase peripheral resistance and, consequently, blood pressure [5]. This type of training is generally not recommended for individuals managing hypertension.
Maximal lifts, including testing one-repetition maximum (1RM), should also be avoided. These attempts often involve maximal effort and can lead to the highest recorded blood pressure values during resistance exercise [3, 5]. The peak pressures occur as individuals push to exhaustion, even with submaximal loads, making 1RM testing particularly unsuitable for hypertensive clients, especially in the initial stages of a program [1].
Prolonged or high-intensity isometric exercises, which involve muscle contraction without joint movement (like long-held wall sits or planks to failure), can also lead to significant acute blood pressure spikes [2, 4]. While some forms of isometric training have shown promise in chronically lowering resting blood pressure over time [2, 5], sustained, intense isometric contractions can acutely compress blood vessels and cause a rapid and significant rise in pressure, posing a risk for those with pre-existing hypertension [5]. Therefore, caution is advised, and lower intensity, shorter duration isometric holds may be more appropriate if included at all.