Can Walking Lower Blood Pressure in Adults?

The aim of this commentary is to discuss from a rehabilitation perspective the Cochrane Review “Walking for hypertension” by Lee et al.1 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008823.pub2/full), published by Cochrane Hypertension. This Cochrane Corner is produced in agreement with American Journal of Physical Medicine & Rehabilitation by Cochrane Rehabilitation with views of the review summary authors in the “implications for practice” section. BACKGROUND Hypertension refers to the condition in which blood presses against the artery walls with a persistently too high degree of force.1 Hypertension is typically diagnosed when the resting systolic blood pressure reading is 140 mm Hg or greater, or the resting diastolic blood pressure reading is 90 mm Hg or greater on 2 different days.2 With approximately 1.28 diagnoses,2 associated with 7 to 10 million deaths worldwide each year,3 hypertension remains a major public health concern. Hypertension has been recognized as a predominant risk factor for premature mortality, disability, and various morbidities, including cardiovascular disease, stroke, heart failure, kidney disease, and dementia.4,5 The causes of hypertension are often associated with modifiable lifestyle factors, and current guidelines encourage the use of nonpharmacological interventions for hypertension management and prevention.1 Cardiac prevention and rehabilitation programs increasingly offer preventive measures and methods for incorporating healthy changes into the daily routines of people at high risk of developing hypertension.6 Individuals with hypertension who receive rehabilitation services after a cardiac event or stroke are exposed to numerous physical and therapeutic approaches intended to improve blood pressure control.6 Understanding which of these approaches best serves this population by reducing mortality and morbidity rates and favoring positive outcomes is of high clinical relevance in the rehabilitation field. Walking is a low-cost physical activity that can be easily implemented into people’s daily routines as part of a healthy lifestyle change. However, the efficacy of walking for the improved control of blood pressure remains uncertain. Therefore, Lee et al.1 have conducted a review to examine the effects of walking on blood pressure and heart rate in adults.1 Walking for Hypertension (Lee et al.,1 2021). WHAT IS THE AIM OF THE COCHRANE REVIEW? This Cochrane Review aimed to investigate whether walking serves as an effective intervention for improving the control of blood pressure and heart rate in adults. WHAT WAS STUDIED IN THE COCHRANE REVIEW? The populations analyzed in this review were normotensive and hypertensive adults 16 yrs or older. The intervention was walking, either within the community or in a laboratory-based setting, including nonstair and nonuphill treadmill walking. Walking interventions that were combined with other lifestyle changes were excluded. Eligible comparisons included nonexercising or nonintervention controls. The primary outcome was systolic blood pressure, and the secondary outcomes were diastolic blood pressure and heart rate. SEARCH METHODOLOGY AND UP-TO-DATENESS OF THE COCHRANE REVIEW The review authors searched for published and unpublished randomized controlled trials through March 2020 in 14 databases, including the Cochrane Hypertension Specialized Register via the Cochrane Register of Studies, the Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The study language was not a search restriction. WHAT WERE THE MAIN RESULTS OF THE COCHRANE REVIEW? The review included 73 randomized controlled trials (n = 6473 participants). From the 69 randomized controlled trials (n = 5197) that reported outcomes by gender, it was found that most participants were female (3122 women vs. 2075 men) and with ages ranging from 16 to 84 yrs. Findings on systolic and diastolic blood pressures, heart rate, and adverse events are reported hereinafter. Systolic Blood Pressure Data analyzed from 5060 participants (73 studies) showed that individuals in the walking intervention group had lower systolic blood pressure than those in the nonintervention group (mean difference [MD], −4.11 mm Hg; 95% confidence interval [CI], −5.22 to −3.01 mm Hg; moderate certainty of evidence). Evidence showed significant changes in favor of the intervention for 491 participants 40 yrs or younger (MD, −4.41 mm Hg; 95% CI, −6.17 to −2.65 mm Hg; 14 studies; moderate certainty of evidence); 1959 participants aged between 41 and 60 yrs (MD, −3.79 mm Hg; 95% CI, −5.64 to −1.94 mm Hg; 35 studies; low certainty of evidence); and 2610 participants 60 yrs or older (MD, −4.30 mm Hg; 95% CI, −6.17 to −2.44 mm Hg; 24 studies; low certainty of evidence). Both women (MD, −5.65 mm Hg; 95% CI, −7.89 to −3.41 mm Hg; n = 1149, 22 studies) and men (MD, −4.64 mm Hg; 95% CI, −8.69 to −0.59; n = 203, 6 studies) in the intervention group had lower systolic blood pressure readings than those in the nonintervention group, although the certainty of evidence was low for this outcome. Diastolic Blood Pressure With 69 studies (4711 participants) examining the effects of walking on diastolic blood pressure, the outcome data showed that overall, people in the intervention group had lower diastolic readings than those in the nonintervention group (MD, −1.79 mm Hg; 95% CI, −2.51 to −1.07 mm Hg; n = 4711; low certainty of evidence). Although smaller than the reduction recorded for systolic blood pressure, the reduction in diastolic blood pressure was significant for all age groups: age of 60 yrs of greater (MD, −1.33 mm Hg; 95% CI, −2.40 to −0.26 mm Hg; n = 2490; 23 studies; low certainty of evidence); age between 41 and 60 yrs (MD, −1.74 mm Hg; 95% CI, −2.95 to −0.52 mm Hg; n = 1730; 32 studies; low certainty of evidence); and age of 40 yrs or less (MD, −3.01 mm Hg; 95% CI, −4.44 to −1.58 mm Hg; n = 491; 14 studies; moderate certainty of evidence). Walking produced significant changes in favor of the intervention group for both women (MD, −2.69 mm Hg; 95% CI, −4.16 to −1.23 mm Hg; n = 1000; 20 studies; low certainty of evidence) and men (MD, −2.54 mm Hg; 95% CI, −4.84 to −0.24 mm Hg; n = 203; 6 studies; moderate certainty of evidence). Heart Rate Twenty-six studies with 1747 participants showed that resting heart rate was significantly lower among participants in the intervention group (MD, −2.76 beats per minute; 95% CI, −4.57 to −0.95 beats per minute; n = 1747; low certainty of evidence) than in the nonintervention group. Adverse Events Adverse events were only reported by 21 studies of which 16 declared no adverse events. A total of 8 intervention related adverse events were reported in 5 studies, with knee pain the most common, but including hospitalization among patients with chronic heart failure. Because of the limited details reported in the randomized controlled trials, the association between intervention and adverse events remains unclear. WHAT WERE THE AUTHORS’ CONCLUSIONS? The review authors concluded that walking lowers systolic and diastolic blood pressure and heart rate, independently of age and sex. When moderate walking is embedded in a lifestyle change plan, 3 to 5 times weekly for up to 150 mins, blood pressure reduction is detectable after 3 mos. Walking is less costly and associated with fewer adverse effects than pharmacological interventions and should largely be promoted as a preventive approach to decrease premature death, morbidity, and disability rates caused by hypertension. WHAT ARE THE IMPLICATIONS OF THE COCHRANE EVIDENCE FOR PRACTICE IN REHABILITATION? This Cochrane review provides evidence on exercise added to routine daily physical activity; walking, an easily accessible exercise, might lower blood pressure in persons with and without hypertension. High blood pressure is a significant risk factor in cardiovascular disease; hence, primary and secondary prevention measures are crucial in many rehabilitation areas. Exercise and other lifestyle changes are included in several of the current guidelines for cardiac and neurologic rehabilitation. Cardiac rehabilitation is recommended for persons with hypertension and heart-related problems. It includes exercise training and lifestyle modification measures such as physical activity and nutritional counseling, weight control, lipid and blood pressure management, smoking cessation, and psychosocial management.6 Both European and American clinical practice guidelines for the management of arterial hypertension recommend regular aerobic exercise; this may include at least 30 mins of moderate dynamic exercise 5 to 7 d/wk, 90 to 150 mins/wk of aerobic dynamic resistance, or three sessions/week of isometric resistance.7,8 Exercise can also benefit and prevent heath issues among persons without hypertension but with other health conditions. For instance, American and Canadian guidelines for the secondary prevention of stroke recommend physical activity to reduce sedentarism. After a transient ischemic attack or stroke, participating in aerobic training up to 4 to 7 d/wk, with a minimum of 150 mins in total (spread into sessions of 10 mins or more) can prevent recurrent stroke and improve muscle strength, functioning, mental health, and quality of life.9,10 Likewise, moderate-to-vigorous–intensity aerobic exercise may increase functioning and minimize secondary complications and cardiometabolic disorders in persons with spinal cord injury.11,12 For persons with multiple sclerosis, regular physical activity may improve flexibility, decrease symptoms, and minimize risk of depression.13,14 In general, people with or without disabilities can achieve significant fitness and health benefits from activity levels well below the 150 mins/wk recommended by the World Health Organization.15,16 However, when developing and implementing guidelines for disability-specific physical activity, the needs, values, and preferences of the single individual must be considered. Physical activity shall be encouraged in parallel with other interventions (e.g., behavioral, occupational) and services (e.g., policy, transportation, accessibility) to control barriers that hamper physical and social activities, recovery, and perceived sense of well-being among persons with disabilities. Considering the many potential benefits of exercise for managing hypertension, cardiovascular health, and supporting neuroprotection and motor functions (such as balance, strength and gait), more evidence regarding exercise programs is essential. In particular, we encourage further studies in populations with different health conditions and from all world regions, including low- and middle-income countries where cardiovascular disease and disability overall are highly prevalent.

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