Journal of Human Hypertension (1997) 11, 641–649

 1997 Stockton Press. All rights reserved 0950-9240/97 $12.00

ORIGINAL ARTICLE
The effectiveness of exercise training in
lowering blood pressure: a meta-analysis
of randomised controlled trials of 4 weeks
or longer
JA Halbert1, CA Silagy1, P Finucane2, RT Withers3, PA Hamdorf4 and GR Andrews5
1
Department of General Practice, Flinders University of South Australia, Bedford Park SA 5042;
2
Rehabilitation, Aged and Extended Care, Repatriation General Hospital, Daw Park SA 5041; 3Exercise
Physiology, School of Education, Flinders University of South Australia, Bedford Park SA 5042; 4Centre
for Physical Activity in Ageing, Hampstead Centre, Royal Adelaide Hospital, Adelaide SA 5000; 5Centre
for Ageing Studies, Flinders University of South Australia, Bedford Park SA 5042, Australia

Objective: To identify the features of an optimal exercise
programme in terms of type of exercise, intensity and
frequency that would maximise the training induced
decrease in blood pressure (BP).
Data identification: Trials were identified by a system-
atic search of Medline, Embase and Science Citation
Index (SCI), previous review articles and the references
of relevant trials, from 1980 until 1996, including only
English language studies.
Study selection: The inclusion criteria were limited to
randomised controlled trials of aerobic or resistance
exercise training conducted over a minimum of 4 weeks
where systolic and diastolic BP was measured.
Results: A total of 29 studies (1533 hypertensive and
normotensive participants) were included, 26 used aero-
bic exercise training, two trials used resistance training
and one study had both resistance and aerobic training
groups. Aerobic exercise training reduced systolic BP
by 4.7 mm Hg (95% CI: 4.4, 5.0) and diastolic BP by 3.1
mm Hg (95% CI: 3.0, 3.3) as compared to a non-exercis-
ing control group, however, significant heterogeneity
was observed between trials in the analysis. The BP
reduction seen with aerobic exercise training was inde-
pendent of the intensity of exercise and the number of
exercise sessions per week. The evidence for the effect
of resistance exercise training was inconclusive.
Conclusions: Aerobic exercise training had a small but
clinically significant effect in reducing systolic and dias-
tolic BP. Increasing exercise intensity above 70% VO2
max or increasing exercise frequency to more than
three sessions per week did not have any additional
impact on reducing BP.

Keywords: blood pressure; hypertension; physical training; exercise

Introduction tors such as hypertension, hypothesizing that this

There is good epidemiological evidence from obser-
vational studies that supports the role of physical
inactivity as an independent risk factor for coronary
heart disease (CHD).1,2 This association persists even
after adjustment of the potential confounders such
as gender, age, blood pressure (BP) and smoking
status.
Despite the evidence from observational studies,
there have not been any randomised controlled
trials examining the effect of physical activity on
morbidity and mortality from CHD. This is largely
due to the methodological difficulties associated
with such a trial, which would require very large
numbers of participants followed over a prolonged
period. An interim approach is to examine the role
of physical activity in reducing known CHD risk fac-
Correspondence: Ms Julie Halbert, Department of General Prac-
tice, Flinders Medical Centre, Bedford Park SA 5042, Australia
Received 14 January 1997; revised and accepted 14 June 1997
might lead to a reduction in CHD mortality and mor-
bidity.
Observational studies have shown that active
people have BP levels around 5 mm Hg lower than
inactive subjects.3 Even if the absolute benefit from
the lower BP may be small, from a public health per-
spective it has the potential to substantially decrease
mortality and morbidity within the community if a
sufficiently large proportion of the population
increase their level of physical activity.
While a number of reviews have examined the
effects of various forms of exercise training on BP,3–6
none of them have attempted to identify the para-
meters of an exercise programme which would
maximise the decrease in BP. Despite this lack of
evidence, the American College of Sports Medicine7
has developed guidelines which recommend aerobic
exercise at 50–85% of maximum oxygen uptake
(VO2 max) with a minimum of three sessions per
week. While this sort of programme is quite success-
ful in producing often substantial improvements in
cardiorespiratory fitness, there is considerably less
evidence for its effectiveness in changing BP.
 Exercise training and blood pressure
JA Halbert et al
642
The published reviews also had methodological
shortcomings. Only one review4 examined both
resistance and aerobic training with the remaining
three reviews including trials of aerobic training
exclusively.3,5,6 The inclusion criteria for studies
varied considerably, with only one meta-analysis
including only randomised controlled trials;6 the
other three included studies with and without con-
trol groups, reporting overall results for controlled
as well as uncontrolled studies.
The aim of this review, therefore, was to identify
the features of an optimal exercise programme, in
terms of type of exercise, intensity, frequency and
duration, that would maximise the training-induced
decrease in BP.
Materials and methods
Inclusion/exclusion criteria
To be included in this review, studies had to be ran-
domised, controlled trials involving an aerobic or
resistance training programme of at least 4 weeks
duration. Trials had to include BP as either the pri-
mary outcome measure or as a secondary outcome.
Trials with a cross-over design were included pro-
vided that the order of the treatments was random-
ised and the order effects were not significant. Trials
involving both hypertensive and normotensive sub-
jects were included provided that the participants
were sedentary adults who were healthy apart from
their hypertension. Trials were excluded when the
published report did not state that the participants
were randomly allocated, when it was not possible
to determine the intensity of the exercise pro-
gramme or when multi-faceted co-intervention was
present (eg, exercise plus weight-loss or exercise
plus salt-reduction).
Identification of trials and data extraction
The included trials were identified from a system-
atic search of the years 1980 to 1995, using the elec-
tronic databases: Medline, Embase and Science
Citation Index; previous review articles, and exten-
sive examination of references from relevant trials.
Only studies published in the English language
were included.
The information extracted from the trials
included: total number of participants randomised,
number of participants who completed the trial, age
and sex of the participants, hypertensive or normo-
tensive, information on the training programme
(type of exercise, intensity, number of sessions per
week), activities during the control period, methods
of statistical analysis, body composition measures,
adherence rates, BP information (position, equip-
ment, protocol of measurement) and body weight
changes during the control and training periods.
Quality assessment
The methodological quality of the studies included
in the review was assessed using the scheme
described in the Cochrane Collaboration Handbook,8
which involves assessing the quality of the allo-
cation (ie, control of selection bias at entry). This is
the only type of bias which has been empirically
shown to result in systematic differences in assess-
ment of the effect size. A three-point rating scale was
used, with a grading of: (A) if the effort to control
selection bias had been maximal (ie, central ran-
domisation by an independent third party); (B) if
there had been some effort to control selection bias
(eg, by use of sealed envelopes); and (C) if there had
been little or no effort to control selection bias at
entry. The score allocated to each trial is included
in Table 1. It should be noted that in many cases,
the score allocated to the studies included in this
review may have been more a reflection of the qual-
ity of reporting than the methodological quality of
the trials themselves. This is because information
was often lacking in the published reports about the
methods of randomisation used.
Data analysis
The effect of exercise on the systolic and diastolic
BPs was assessed independently. The effect was
measured as the difference (in mm Hg) between the
mean change in BP (baseline – final value) in the
two groups. The variance of this difference should
be calculated using the paired baseline and final BP
measurements for each individual. However, none
of the trials presented sufficient information for this
to be done. Consequently, we adopted a conserva-
tive approach and calculated the variance of the dif-
ference between the means, assuming that the base-
line and final BP measurements were unpaired.
The pooled effect size is a weighted average of the
individual effects, with the weightings inversely
proportional to the variance of each individual
effect.9 Ninety-five per cent confidence intervals (CI)
were calculated for the pooled effect size. Tests of
heterogeneity were performed using the Mantel–
Haenszel method.10 Other results are reported as
mean ± s.d.
Results
Descriptive data of included trials
Thirty-nine trials were identified which appeared to
meet the inclusion criteria for the review. Of these,
10 were subsequently excluded (see Appendix),
either because the results were incomplete and not
obtainable from the authors (eight trials) or the inter-
vention included weight or sodium reduction as
part of the treatment regimen (two trials). A total of
29 trials (involving 1533 participants) were, there-
fore, included in the review.11–39
The characteristics of the trials included in the
review are shown in Table 1. Five of the included
studies23,25,27,31,39 had a cross-over design; the
remainder were parallel group design. Eleven trials
included participants of both sexes, four trials
involved women only, thirteen trials men only and
one trial32 did not specify the gender of the subjects.
The mean number of participants per study was 53
(range 7–300) and the ages of the participants ranged
from 18–79 years.
 Exercise training and blood pressure
JA Halbert et al

643
Table 1 Characteristics of included exercise trials

Trial No. of Characteristics of participants Description of exercise programme Duration of Quality

(Author, year) participants study score
(weeks)

Anderssen 1995 97 Males and females, mean age Endurance programme of walking and 52 C
45 yr, hypertensive aerobics at 50% VO2 max for 60 min, 3×
per week
Blumenthal 1991 92 Males and females aged 29–59 Two groups: (1) Walking and jogging 17 C
yr, hypertensive programme at 70% VO2 max for 25 min,
3× per week; (2) resistance training
programme
Braith 1994 44 Males and females aged 60–79 Walking programme at either; 26 C
yr with BP ,140/90 mm Hg (1) moderate intensity 77% VO2 max
(2) high intensity 87% VO2 max, 3× week
Cox 1996 30 Males only aged 20–50 yr, 120– Cycle ergometer exercise at 60–70% VO2 16 C
160% of ideal body weight, max, for 30 min, 3× per week
normotensive
Duncan 1985 56 Males only aged 21–37 yr with Walking and jogging programme at 62% 16 C
SBP 140–160 mm Hg and DBP VO2 max, for 60 min, 3× per week
90–104 mm Hg
Duncan 1991 53 Females only aged 20– 40 yr, Walking programme of three intensities: 24 B
with BP ,160/90 mm Hg (1) 30%, (2) 45% and (3) 76%, VO2 max,
for 60, 45 and 30 min, 5× per week
Hagberg 1989 30 Gender unknown, mean age Walking and jogging programme with two 39 C
64 yr, hypertensive, BP intensities: (1) 53% and (2) 73% VO2 max
.150/85 mm Hg 45–60 min, 3× per week
Hamdorf 1992 66 Females only, aged 60–70 yr, Walking programme at 56% VO2 max for 26 C
normotensive 45 min, 2× per week
Harris 1987 26 Males only, aged 24–40 yr, Resistance training programme, 3× per 9 C
hypertensive, SBP 140–160 week
mm Hg, DBP 90–95 mm Hg
Hellenius 1993 78 Males only, aged 35–60 yr, DBP Walking and jogging programme at 50% 52 C
,100 mm Hg VO2 max, 30–40 min, 2–3× per week
King 1991 300 Males and females aged 50–65 Waking and jogging programme at two 52 B
yr, normotensive intensities: (1) 43% and (2) 76% VO2 max
for 40 min, 3× per week
Kukkonen 1982 54 Males only, aged 35–50 yr, Cycling, walking and jogging at 52% VO2 17 C
normotensive max for 50 min, 3× per week
Leon 1996 16 Males only, aged 22–40 yr, Brisk walking at 40% VO2 max for 45 min, 12 C
normotensive 5× per week
Lindheim 1994 45 Females only, aged 42–59 yr, Walking and cycling ergometer exercise at 26 C
normotensive 52% VO2 max for 30 min, 3× per week
Marceau 1993 9 Males and females, aged 35–54 Cycle ergometer exercise at two intensities: 10 C
yr, DBP 90–114 mm Hg (1) 50% and (2) 70% VO2 max for 30–45
min, 3× per week
Martin 1990 19 Males only, aged 18–60 yr, DBP Walking and jogging programme at 61% 10 C
90–114 mm Hg VO2 max for 30 min, 4× per week
Nelson 1986 13 Males and females aged 25–62 Cycle ergometer exercise at 65% VO2 max 4 C
yr, BP .150/90 mm Hg for 45 min, 3 or 7× per week
Okumiya 1996 42 Males and females, aged 75–87 Light aerobic exercise programme 24 C
yr (mean age 78.8 yr), (walking, game playing) at ,70% VO2 max
normotensive for 60 min, 2× per week
Oluseye 1990 42 Females only, aged 20–50 yr, Jogging and running programme at 67% 12 C
normotensive VO2 max for 50 min, 3× per week
Posner 1992 247 Males and females, mean age Cycle ergometer exercise at 70% VO2 max 17 C
69 yr, normotensive for 30 min, 3× per week
Reid 1994 7 Gender unknown, aged 18–60 Cycle ergometer exercise at 65% VO2 max 12 C
yr, hypertensive, DBP 90–100 for 30 min, 3× per week
mm Hg
Rogers 1996 18 No information on gender Treadmill waking and jogging at two 13 C
breakdown, mean age 40.5 yr intensities: (1) 40–50% VO2 max and (2)
70–80% VO2 max, for 45 min, 3× per
week
Tanabe 1989 31 Males and females, aged 23–63 Cycle ergometer exercise at 50% VO2 max 12 C
yr, hypertensive for 30 min, 3× per week

(Continued)
 Exercise training and blood pressure
JA Halbert et al
644
Table 1 (Continued)
Trial No. of Characteristics of participants
(Author, year) participants
Urata 1987 20 Males only, aged 32–60 yr,
hypertensive, BP .140/90
mm Hg
Vanhoof 1996 19 Males only, normotensive, BP
,160/95 mm Hg
Vanhoof 1989 26 Males only, mean age 39 yr,
hypertensive, BP ,160/95
mm Hg
Vroman 1989 11 Males only, mean age 24 yr,
normotensive
Wang 1995 23 Males only, mean age 21.4 yr,
normotensive
Wignen 1994 19 Males only, aged 22– 44 yr,
hypertensive
Quality score – control of selection bias at entry, high to low score A to C.
The majority of exercise training programmes
used a combination of techniques. For the purposes
of analysis, walking, jogging and running were
grouped together (13 trials), cycling (either a bicycle
or more commonly a cycle ergometer) (10 trials), a
combination of cycling and walking/running/
jogging (three trials) and two trials of resistance
training only.19,36 The average intensity of the aero-
bic exercise was 62% VO2 max, with a range of 30–
87% VO2 max. The average duration of the training
programmes was 18.9 weeks (range 4–52) with an
average frequency of 3.2 ± 0.8 sessions per week.
Twenty-two studies used qualified personnel to
supervise the training sessions, and 11 stud-
ies12,16,18,21,23,25,28,30,32,35,36 reported on the adherence
to the exercise programme by providing a percent-
age of sessions attended. No systematic changes
were noted in body weight during the training per-
iod across the 29 trials.
Twelve of the studies 11–14,18,21,26–28,31,36,39 used a
random-zero sphygmomanometer to measure BP, 12
studies used a standard mercury sphygmoman-
ometer and two studies failed to indicate the equip-
ment used. In addition, three studies 12,14,25 meas-
ured 24-h ambulatory BP. There was an absence of
information on the time delay between the last exer-
cise session and the post-training BP measurement.
Only one trial21 of those which included parti-
cipants of both genders, analysed the results separ-
ately according to gender.
Quality of the included studies
Only two of the studies provided any information
about the method of assignment (Table 1). The only
studies to provide statistical analysis of all participants
who were randomised initially were the studies in
which there were no dropouts.13,19,24,27–29,33,34,37,38 The
majority of the studies were analysed on an ‘on ran-
domised treatment basis’. Only four studies21,28,31,32
indicated that the assessment staff were blinded to
the treatment of the participants, although in 12
studies the use of random zero sphygmomanometer,
while not strictly blinding the measurer did guard
Description of exercise programme Duration of Quality
study score
(weeks)
Cycle ergometer exercise at 50% VO2 max 10 C
for 60 min, 3× per week
Resistance training programme, 3× per 16 C
week
Cycle ergometer, walking and jogging 17 C
programme at 75% VO2 max for 60 min,
3× per week
Cycle ergometer exercise at 80% VO2 max 12 C
for 30 min, 4× per week
Cycle ergometer exercise at 60% VO2 max 8 C
for 30 min, 5× per week
Cycle ergometer exercise at 75% VO2 max 6 C
for 45 min, 3× per week
against digit preference. To examine the possibility
of publication bias, funnel plots were constructed to
determine the relationship between the number of
participants and the decrease in BP (Figures 1 and
2).
Effectiveness of aerobic exercise
Aerobic exercise training resulted in decreases of 4.7
mm Hg (95% CI: 4.4, 5.0) for systolic BP and 3.1
mm Hg (95% CI: 3.0, 3.3) for diastolic BP above
those achieved in the non-exercising control groups
(Table 2), although significant heterogeneity was
noted in both cases. Based on indirect comparisons,
there was no difference in the effect of the intensity
or frequency of the aerobic exercise programme on
the decrease in BP. Similarly, only five
trials16,17,21,25,32 directly compared high vs low exer-
cise intensity. The decrease in BP was −0.7 mm Hg
(95% CI: −1.9, 0.4) for systolic and 0.1 mm Hg (95%
CI: −0.7, 1.0) for diastolic BP. Only one trial27 com-
pared exercise seven times vs three times per week
and found differences of 5.0 mm Hg (95% CI: 2.5,
7.5) and 2.0 mm Hg (95% CI: −0.2, 4.2) for systolic
and diastolic BPs respectively.
Effectiveness of resistance exercise
The pooled results from resistance exercise train-
ing12,19,36 found no statistically significant effects.
However, these results are based on three small
trials with a total of 49 exercising participants.
Discussion
Aerobic exercise training had a small but statisti-
cally significant effect in reducing systolic and dia-
stolic BPs. In contrast, there was insufficient evi-
dence to make any definitive conclusion about the
effect of resistance training since there were only
three small trials.12,19,36 The effect of aerobic training
on BP was independent of the intensity of exercise,
and the number of sessions of exercise training per
week. These reductions in BP are consistent with
 Exercise training and blood pressure
JA Halbert et al

645

Figure 1 Funnel plot of the relationship between the number of subjects and the change in systolic blood pressure (SBP) for individual
trials.

Figure 2 Funnel plot of the relationship between the number of subjects and the change in diastolic blood pressure (DBP) for individual
trials.

Table 2 Exercise-induced changes in systolic and diastolic BPs

Training gp Control gp Decrease in BP

n n mm Hg (95% CI)

Aerobic exercise programmes

number of study groups = 27

SBP 982 790 4.7 (4.4, 5.0)

DBP 982 790 3.1 (3.0, 3.3)

Resistance exercise programmes

number of study groups = 3
SBP 49 49 0.4 (−0.5, 1.4)
DBP 49 49 1.5 (0.8, 2.3)

Note: Positive values for decrease in BP indicate a decrease in post-training BP.

 Exercise training and blood pressure
JA Halbert et al
646
those found in previous reviews, 3–6 however, they
need to be interpreted cautiously in view of the sig-
nificant heterogeneity between trials included in all
of the comparisons.
In order to determine an optimal exercise pro-
gramme to maximise the decrease in BP, the effec-
tiveness of different training schedules need to be
directly compared. While Arroll and Beaglehole4
stated that aerobic exercise programmes of lower
intensity resulted in decreases in BP which were
slightly greater than programmes of higher intensity,
this was not a finding of the indirect comparisons
made in the current review. Unfortunately, the train-
ing programmes of the included trials were fairly
homogeneous using similar training methods, inten-
sities and session durations and were predomi-
nantly contrasted with no-training control groups
rather than training programmes with different fea-
tures. In addition, there is still an absence of infor-
mation about exercise at lower intensity (less than
60% VO2 max) or activity that is conducted in sev-
eral short bouts over the duration of the day instead
of the more traditional 30 min, three times per week.
Only one trial27 directly compared exercise training
three vs seven times per week. The results showed
that the decrease in systolic and diastolic BPs was
larger the more frequent the training sessions
(P , 0.01) which is in contrast to the indirect com-
parisons of the summary estimates derived from the
current meta-analysis. This discrepancy may be due
to the criteria established by the current review to
categorize trials according to training frequency,
with the majority comprising three or less sessions
per week vs only four trials with more than three
exercise sessions per week. A study to directly com-
pare exercise at ,70% VO2 max vs .70% VO2 max
would require a total of 44 participants in order to
detect a 5 mm Hg difference between groups.
The lack of changes in body weight during the
training period in the present meta-analysis were
consistent with the findings of previous reviews in
which any overall changes in body weight were
either not significant5,6 or were small decreases of
approximately 1.0 kg.3
A limitation on drawing any firm conclusions
from this meta-analysis was the generally poor
methodological quality of trials included in the
review. The major defects included: failure of the
investigators to state the method used to randomly
allocate the participants, the absence of blinding in
the measurement of BP, and the absence of infor-
mation relating to the procedure used to measure
BP. The majority of the trials also failed to provide
information on the adherence of participants to the
exercise programme and did not document any asso-
ciated changes in body weight which occurred dur-
ing the training period. In earlier reviews, which
included trials of varying methodological quality,
the better controlled studies generally showed
smaller changes in BP, of around 5 mm Hg for sys-
tolic and 3 mm Hg for diastolic BP.3,4 These
decreases in BP are consistent with the findings of
this meta-analysis.
One of the major limitations of meta-analyses
based on smaller trials is the possibility of publi-
cation bias.40 The funnel plots indicate that publi-
cation bias may be a problem since the plots are
skewed towards more trials showing larger
reductions in BP without the expected number of
small trials showing no effect (or increase) in BP.
Significant heterogeneity was found between
trials included in all of the comparisons. This find-
ing was not surprising given the extremely diverse
results from individual trials ranging from moderate
increases in BP through to large decreases in post-
training BP. Possible contributors to the heterogen-
eity include: the variability in the age of the
included subjects, differences in pre-training BP lev-
els, small sample sizes and varying exercise pro-
grammes. However, there was inadequate data avail-
able from the individual trials to explore this
further. When the data was re-analysed using a ran-
dom effects model, which takes greater account of
potential heterogeneity than a fixed effect model, the
effect sizes were not quantitatively different, how-
ever, the 95% confidence intervals were consistently
wider (see Tables 3 and 4). In addition to methodol-
ogical differences, a failure to adjust the BP results
for differences in body weight or changes in sodium
intake could mask any underlying changes in BP.
Two included trials did not demonstrate an effect of
exercise training on resting BP, however, they did
report statistically significant changes in 24-h ambu-
latory BP measurements;25 and clear cardiac adap-
tations such as a 6% increase in cardiac index and
decrease in vascular resistance at rest.39 This sug-
gests that further examination of the effect of exer-
cise on ambulatory BP profiles is warranted.
Two of the earlier reviews included participants
of varying BP levels3,4 and one reviewer conducted
separate meta-analyses of hypertensive5 and normo-
tensive subjects.6 Only one review found a signifi-
cantly greater reduction in BP in hypertensive vs
normotensive participants; the other reviews found
no significant differences. In the current meta-analy-
sis, the change in BP after exercise training was also
not significantly different amongst hypertensive and
normotensives, although the results are based on an
indirect comparison.
In conclusion, aerobic exercise training is effec-
tive in producing a small but significant decrease in
both systolic and diastolic BPs. Unfortunately, these
changes in BP are unlikely to be of any significant
clinical therapeutic effect amongst most hyperten-
sive subjects. However, they reinforce the value of
aerobic exercise as an adjunct to the use of pharma-
ceutical antihypertensive therapy. While these
changes in BP may have little impact on the individ-
ual, from a population perspective, the effect of
exercise is likely to be similar in magnitude to
reducing dietary sodium intake.41 If large numbers
of people were able to achieve even modest
increases in their level of exercise, the small
reduction in BP may translate to a significant public
health benefit. For example, a recent modelling exer-
cise42 indicated that a 2 mm Hg decrease in diastolic
BP across the population may result in a 17%
decrease in the prevalence of hypertension, 6%
decrease in CHD and a 15% reduction in the inci-
dence of stroke and transient ischaemic attacks.
 Exercise training and blood pressure
JA Halbert et al

647
Table 3 Effect of exercise (aerobic and resistance) training on systolic BP using both a fixed effect and a random effect model to calculate
effect size

Training gp Control gp Decrease in BP in mm Hg

n n (95% confidence interval)

Fixed effect Random effect

Aerobic programmes 982 790 4.7 (4.4, 5.0) 4.6 (3.5, 5.7)

Training intensity (VO2 max)

,70% 491 416 4.6 (4.2, 5.0) 5.9 (4.3, 7.4)
.70% 491 374 4.8 (4.4, 5.2) 3.1 (1.2, 4.9)

Training frequency (sessions per week)

,3 883 705 4.7 (4.4, 5.0) 4.5 (3.4, 5.6)
.3 99 85 4.2 (3.2, 5.3) 5.0 (1.2, 8.8)

Blood pressure status

hypertensive 306 230 4.0 (3.3, 4.7) 5.0 (2.7, 7.3)
normotensive 676 560 4.8 (4.5, 5.1) 4.4 (3.2, 5.7)

Resistance exercise 49 49 0.4 (−0.5, 1.4) 3.3 (−2.7, 9.3)

Table 4 Effect of exercise (aerobic and resistance) training on diastolic BP using both a fixed effect and a random effect model to
calculate effect size

Training gp Control gp Decrease in BP in mm Hg

n n (95% confidence interval)

Fixed effect Random effect

Aerobic programmes 982 790 3.1 (3.0, 3.3) 2.4 (1.4, 3.3)

Training intensity (VO2 max)

,70% 491 416 4.3 (4.1, 4.6) 3.0 (1.5, 4.6)
.70% 491 374 2.5 (2.3, 2.7) 1.5 (0.5, 2.6)

Training frequency (sessions per week)

,3 883 705 3.2 (3.0, 3.4) 2.5 (1.6, 3.4)
.3 99 85 1.8 (1.0, 2.7) 1.9 (−3.0, 6.7)

Blood pressure status

hypertensive 306 230 3.6 (3.1, 4.1) 3.6 (1.4, 6.7)
normotensive 676 560 3.1 (2.9, 3.3) 1.6 (0.5, 2.7)

Resistance exercise 49 49 1.5 (0.8, 2.3) 1.4 (−0.3, 3.1)

There is insufficient evidence to justify the pro- References

motion of training programmes which are more
intensive than 70% VO2 max in lowering BP. This
finding is encouraging since the exercise adherence
literature indicates that activities of lower inten-
sities are associated with lower injury rates and are
more acceptable to the average individual than exer-
cise at higher intensities.43 Further research is
required to identify the optimal frequency of exer-
cise training.
Acknowledgement
The authors wish to acknowledge the valuable
assistance of Dr Bruce Arroll in reading and com-
menting on the manuscript.
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Appendix
Studies which met the inclusion criteria for the
meta-analysis but were subsequently excluded
1 Allen DHG, Puddey IB, Morton AR, Beilin LJ. A con-
trolled study of the effects of aerobic exercise on anti-

hypertensive drug requirements of essential hyperten-
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4 Kingwell BA, Jennings GL. Effects of walking and
other exercise programs upon blood pressure in nor-
mal subjects. Med J Aust 1993; 158: 234 –238.
5 Kinoshita A et al. What types of hypertensives respond
better to mild exercise therapy? J Hypertens 1988; 6:
S631–S633.
6 Kostis JB et al. Superiority of nonpharmacologic ther-
Exercise training and blood pressure
JA Halbert et al
649
apy compared to propranolol and placebo in men with
mild hypertension: a randomized, prospective trial.
Am Heart J 1992; 123: 466–474.
7 Meredith IT et al. Exercise training lowers resting renal
but not cardiac sympathetic activity in humans.
Hypertension 1991; 18: 575–582.
8 Meredith IT et al. Time-course of the antihypertensive
and autonomic effects of regular endurance exercise in
human subjects. J Hypertens 1990; 8: 859–866.
9 Suter E et al. Effects of self-monitored jogging on
physical fitness, blood pressure and serum lipids: a
controlled study in sedentary middle-aged men. Int J
Sports Med 1990; 11: 425–432.
10 Tashiro E et al. Crossover comparison between the
depressor effects of low and high work-rate exercise in
mild hypertension. Clin Exp Pharmacol Physiol 1993;
20: 689–696.