KENYATTA UNIVERSITY DEPARTMENTAL POST GRADUATE PRESENTATIONS ON 25TH AUGUST 2016

Present:

1. Dr. Gitahi Theuri Chairing2. Dr. Gitonga Rintaugu3. Dr. Muthomi Nkatha4. Dr. Bulinda Hannington5. Mr. George Kiganjo6. Lilian Bonaveri7. Kevin cheruiyot8. Bonface kimanthi9. Penenah Muthoni10. Abraham Mwangi11. Rhoda Wanzetse12. George Kimani13. Florence Muthoni14. Karobia Anthony15. Luka Boro16. Muasya Vincent Recording

CONCEPT PRESENTATIONS

CONCEPT PRESENTER: George Mwangi E67/OL/25263/14

TITLE: Randomized controlled trial of the cardiovascular effects of young longer fitness program in cure of resistant hypertension at Mulumba hospital, Kiambu

COMMENTS:

Need to refocus title to make it precise Is your study about cure or management? When will the BP be measured? Is it before or after exercise? What treatment /fitness program will you expose your subjects to? FITT principle? Why Mulumba hospital? Are there more cases of resistant hypertension? Consider dropping the word CURE in the title. How will you categorize your hypertension subjects? What is the upper limit of BP you will allow for your subjects? How will you control

Verdict: Effect suggested changes and prepare a proposal.

ASSIGNED SUPERVISORS

Dr. Gitahi Theuri

Dr. Mundia Francis

REFOCUSED TITLE

INSTEAD OF: Randomized controlled trial of the cardiovascular effects of young longer fitness program in cure of resistant hypertension at Mulumba hospital, Kiambu

CHANGED TO: RANDOMIZED CONTROLLED TRIAL OF CARDIOVASCULAR EFFECTS OF “YOUNGER LONGER” PHYSICAL FITNESS PROGRAMME IN MANAGEMENT OF RESISTANT HYPERTENSION

1. I have replaced “in cure of “ for “ in management of “2. I have removed completely the venue because this type of research cannot whatsoever be

affected by the choice of a venue. Body`s physiological response will only respond to physical, mechanical and chemical stresses only and venue is none of this . In this case I have omitted it

3. The third question of when the participant`s blood pressure will be measure, the answer is –before and after performance, there will be also measurement following the patient`s completion of the session or during the exercise if the participant complain of exhaustion.

4. The fourth question is purely a technical question on the component of the sessions in an acronym FITT (Frequency, Intensity, Time and type). In this respect I have included a paragraph in my introduction on literature review of the structure of this pioneer fitness programme.

5. The fifth question is concerning the choice of the venue, besides being a level four hospital, St. Matia`s Mulumba Mission hospital location is quite accessible, located east of Thika town three kilometers along Thika-Garisa highway. This Hospital`s management team is a very friendly team and has offered a tent fifty by thirty five feet for the chapter two of “younger longer” physical fitness programme.St.MMML4H also has a vibrant MOPC where the MO i/c of the hospital confess that there are a substantial cases of resistant hypertension but adds that he cannot disclose the data before approval of my research from my University research committee board and that of the hospital

6. The sixth question was an advise and admonition for removal of the word “cure” as per research credibility to set realizable objectives and in this respect I have dropped the word “cure” for the “management of “

7. Question seven is concerned with how I will classify my hypertensive subjects. I intend to use American Heart Association, five staging method as elaborated in my literature review under section 2.3 headed diagnosis. This will be done by a qualified physician when I will identify my subjects.

8. The eighth question is asking me about the high limit of the BP I will allow my subjects to exercise in a resting BP ≥ 200/110 brachia artery leadings and during exercise testing a BP ≥ 220/115 mmHg ( study by Stan Reent,PharmD of American Heart Association 2016 )

9. The question of how I will control my experiment, the control group will be “blinded” and they will be monitored as in the normal MOPC attendant but their attendance will be more emphasized so that those randomized may not miss to attend and that their parameters of heath will be monitored. These are blood pressure, heart rate, cardiac index, Vo2 max, ECG during exercise testing. Announcement will be made for all those who have a particular BP ≥ 140/90 mmHg and taking three or more antihypertensive of which one is a diuretic will all benefit for a free clinical evaluation and investigation which will apply for the two groups. Heart rate will be monitored all the time the training group will be exercising with ambulatory heart rate monitoring machine. From this readings VO2 max will be calculated from the equation VO2 max= 15.3 HRmax/HRrestml/min/kg

RANDOMIZED CONTROLLED TRIAL OF CARDIOVASCULAR EFFECTS OF “YOUNGER LONGER” PHYSICAL FITNESS PROGRAMME IN MANAGEMENT OF RESISTANT HYPERTENSION.

GEORGE KIMANI MWANGI (BSc. in Physiotherapy JKUAT)

E67/OL/25263/2014

LIST OF ABBREVIATIONS

RAAS: RENIN ANGIOTENSIN ALDOSTERONE SYSTEM

NCD: NON-COMMUNICABLE DISEASES

HTN: HYPERTENSION

BLD: BLOOD

ATP: ADENOSINE TRIPPHOSPHATE

ADP: ADENINE DI NUCLEOTIDE PHOSPHATE

NADP+: NICOTINAMIDE ADENINE DIPHOSPHATE

NADPH+: DIHYDROXY NICOTINAMIDE ADENINE DINUCLEOTIDE PHOSPHATE

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Table of Contents

CHAPTER 1...................................................................................................................................................................1

BACKGROUND..............................................................................................................................................................1

PROBLEM STATEMENT.................................................................................................................................................2

JUSTIFICATION.............................................................................................................................................................2

RESEARCH QUESTION..................................................................................................................................................3

1.4 MAIN OBJECTIVE....................................................................................................................................................3

1.4.2 SPECIFIC OBJECTIVE............................................................................................................................................3

THE NULL HYPOTHESIS.................................................................................................................................................3

1.5.2 ALTERNATIVE HYPOTHESIS..................................................................................................................................3

1.6 CONCEMPTUAL FRAMEWORK...............................................................................................................................3

THEORY FRAMEWORK.................................................................................................................................................5

CHAPTER 2.0: LITERATURE REVIEW.............................................................................................................................6

2.1 Epidemiology.........................................................................................................................................................6

2.1.1Etiology................................................................................................................................................................7

2.1.2.1 Obstructive sleep apnea...................................................................................................................................7

2.1.2.2 Drug induced resistant hypertension...............................................................................................................7

2.1.2.3 Secondary aldosterone....................................................................................................................................8

2.1.2.4 Arteriosclerosis, arteriosclerosis and atherosclerosis......................................................................................8

2.2 Prevalence..............................................................................................................................................................9

2.3 Diagnosis................................................................................................................................................................9

2.3.1 Pre hypertensive ( systolic of 120 to 139 mmHg ) and /or diastolic of 80 to 89 mmHg)...................................10

2.3.2 Hypertension stage 1 ( 140 to 159 mmHg ) and /or a diastolic 90 to................................................................10

2.3.3 Hypertension stage 2........................................................................................................................................10

2.3.4 Hypertensive crisis BP ≥ 180/110 mm Hg..........................................................................................................11

2.4 TREATMENT.........................................................................................................................................................11

2.5 PROGNOSIS..........................................................................................................................................................11

2.6 EXERCISES............................................................................................................................................................12

2.6.1 Definition..........................................................................................................................................................12

2.6.2 Modes of exercises...........................................................................................................................................13

2.1.1Exercise chains are either open kinetics............................................................................................................13

2.6.1.2 Calisthenics or non-calisthenics.....................................................................................................................13

2.6.1.3. Length change are either shortening............................................................................................................13

2.7 Energy systems are three.....................................................................................................................................13

2.7.1 Aerobic energy system......................................................................................................................................14

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2.8 Tempo..................................................................................................................................................................14

2.8.1 Component of exercises (1) warm up (2) work out (3) cooling down...............................................................14

2.9 Principles of exercises : Specificity of exercises and adaptability.........................................................................14

2.10 Physiological benefits for exercises....................................................................................................................14

CHAPTER 3.................................................................................................................................................................17

3.0 Methodology........................................................................................................................................................17

3.1 Study design-randomized controlled trial............................................................................................................17

3.2 Measurement of variables...................................................................................................................................17

3.3 Study area............................................................................................................................................................18

3.4 Target population.................................................................................................................................................18

3.4.1 Exclusion criteria...............................................................................................................................................18

3.4.2 Inclusion criteria................................................................................................................................................18

3.5 Sampling technique..............................................................................................................................................19

3.6 Sample size..........................................................................................................................................................19

3.6.1unit of analysis...................................................................................................................................................19

3.7 Research instruments..........................................................................................................................................19

3.8 Pre-testing............................................................................................................................................................19

3.9 validity and reliability...........................................................................................................................................19

3.10 Data collection techniques.................................................................................................................................19

3.11 Data analysis......................................................................................................................................................19

3.12 Logistic and ethical considerations.....................................................................................................................20

3.13 Measurement of variables.................................................................................................................................20

3.13.2 Exercise intensity............................................................................................................................................20

Appendix 1.................................................................................................................................................................22

EXERCISE PROGRAM..................................................................................................................................................22

VENUE: ST.MMML4H TENT........................................................................................................................................22

Session:......................................................................................................................................................................22

Work out....................................................................................................................................................................23

Cool down..................................................................................................................................................................25

References.................................................................................................................................................................26

Appendix 2.................................................................................................................................................................27

THE COSTING OF THE RESEARCH PROGRAM.............................................................................................................27

HUMAN RESOURCE....................................................................................................................................................28

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CHAPTER 1

BACKGROUND

“Younger longer” is a physical fitness programme which has been in existence for many years at

Thika Level 5 Hospital practiced at lunch hour. A second chapter is now running at St. Matias

Mulumba Mission Hospital of Kiambu county The program which is composed of many

callisthenic type of exercises has been noted to reduce the weight of those who participates and

make them look radiant and “health “.This program`s effect on cardiovascular has never been

tested .More so it would be interesting to find out its effect on blood pressure of those whose

blood pressure has resisted treatment. Would those who have been inflicted by this plague of

hypertension live younger longer without their blood pressure making them progress to CCF? ,

stroke, heart attack or renal disease? The answer to such a question would require longitudinal

prospective study which would be very expensive to monitor. All that would be required is

patients who are hypertensive to embrace this program but in order for them to continue with it,

it has to be proved that it works in reducing blood pressure. This can only be achieved by putting

this programme through a scientific process to prove its worth in treatment of resistant

hypertension.

A global brief on HYPERTENSION by WHO 2013 describes hypertension as a silent

invisible killer and a public health crisis affecting more than one billion people and killing more

than 9.3 million people. 45% of these hypertensive patients have resistant hypertension which

causes 55% of the above deaths (Chen et al 2013). Resistant hypertension is defined as

hypertension that remain equal to or above 140mmHg/90mmHg despite treatment with three

antihypertensive drugs of which one of them is a diuretic ( Calhoun et al 2012).Resistant

hypertension is also defined as hypertension that is poorly responsive to treatment and requires

multiple drugs to control it to acceptable ranges (Yaxley etal,2013)This chronic disease which is

also referred to as treatment resistant hypertension is serious especially due to its association

with increased risks of stroke, ischemic heart diseases, heart attack and kidney failure (Persel and

Stephen, Hypertension 57.6 (2011)). This type of hypertension is on the rise due to the increase

in aging population and with heaviness (Calhoun et al, 2008), AHA Scientific statement)

1

Unlike drugs, exercises prescription has barely been possible for lack of well-developed

exercise programs in hypertensive patients (Nolte et al, 2013).This comes out clearly right from

the definition of resistant hypertension “is blood pressure that remains above or is equal to

140mmHg/90mmHg despite treatment with three antihypertensive which includes at least one

diuretics” .This definition is silent on intervention by exercises or fitness levels of the individuals

Yet despite the plethora of antihypertensive drugs, hypertension still remains a health problem by

resisting the drugs (Papademetrious et al, 2011). In this exercise programme there are 15

exercises for warm up, 30 exercises for work outs and 10 exercises for cooling down ideal for

group exercises to accompany the drug therapy. Resistance hypertension is defined as blood

pressure equal to or greater than 140/90mmhg in spite of three or more antihypertensive,

diuretics being one of them or any blood pressure controlled by four or more drugs (Dimeo et al,

2012).what type of exercises a hypertensive patient should perform at what intensity, duration

and frequency and for how long remains an issue for many patients prescribed exercises let alone

the “which ones” to be done. The program “younger longer through programmed exercises”

essentially includes two modes of exercises, the aerobic and stretching exercises

PROBLEM STATEMENT

The side effect and the cost of antihypertensive medications have led to a consensus about a need

to have a non-pharmacological treatment alone or adjunctive to drug therapy ( Schein et al 2001)

Also aconsiderable number of people fail to reach the target blood pressure despite the

appropriate life style advice and standard medical intervention, (Yaxley et al, 2015). The

percentage of such people is said to range from 5 % to 10 % of all people who are hypertensive

who are below50 years (Dimeo etal,2012 ) but going by the above definition and considering

whatever cause of this resistant hypertension is, the prevalence is considered to be higher 30%

and above (V. Papademetrious etal,2011). Resistance hypertension is the most primary factor for

stroke, myocardial infarction, end liver diseases, renal disease etc. (Faselis et al, 2011). High

blood pressure is usually difficult to control but resistant hypertension is blood pressure that is

difficult to control despite the right antihypertensive medications and adherence to the regime

(Viera et al, 2009).With the awareness of the aftermaths of the persistent above goal of the

resistant hypertension despite, such patients who adhere to the medications despite the failure to

achieve optimal blood pressure would be perhaps more than willing to include exercise in their

endeavors ( Dimeo et al 2012 )

2

JUSTIFICATION

Physical activity is recommended by European and American guidelines for management of

hypertension however it remains elusive whether exercises /physical activity can reduce resistant

hypertension (Dimeo et al, 2011).The number of patients with resistance hypertension is growing

day by day, possibly due to the increasing number of aging people and other comorbidity

illnesses for example diabetes, obesity, renal and liver diseases (Faselis et al.2011).These

conditions make hypertension more difficult to treat. Studies on hypertension and exercises has

been few and even fewer on resistant hypertension (Ribeiro et al, 2015).To depart from or

supplement the traditional exercise of walking, jogging or running on a treadmill, this program

will provide a group dynamic opportunity where participants will learn the training best skills

from one another for in every `jig` there will be individuals who will display it better than others.

If this program proves effective as it prospects, it should be a prescription to accompany drug

management of hypertension in our hospital settings. This is because it requires only a space and

an instructor who have participated in the training for six weeks.

RESEARCH QUESTION

1. What is the effect younger longer fitness program on resistant hypertension?

2. Can twenty four session spread in six weeks at a frequency of four session per week, 55

to 60 minutes per session induce reduction of blood pressure in patients suffering from

resistant hypertension?

1.4 MAIN OBJECTIVE

To clinically include exercise in our hospitals as a distinctive prescription for management of

resistant hypertension and create a space for its demonstration.

1.4.2 SPECIFIC OBJECTIVE

1. To demonstrate that younger longer fitness program can be effective in helping to lower

systolic blood pressure in resistance hypertension.

2. To demonstrate that younger longer fitness programme can be effective in helping to

lower diastolic blood pressure in resistance hypertension.

3

THE NULL HYPOTHESIS

There`s no significant difference of blood pressure between those who underwent the programme

and those who didn`t

1.5.2 ALTERNATIVE HYPOTHESIS

There`s significant lowering of blood pressure between those who underwent the programme of

younger longer than those who didn`t.

1.6 CONCEMPTUAL FRAMEWORK

CONCEPT: EXERCISE CAN DISTINCTIVELY AND ADJUCNTIVELY TREAT

HYPERTENSION IF DONE APPROPRIATELY

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Independent variable

EXERCISE

Mode –aerobic Intensity vo2max ( 50-750 ) Volume-repetition +session

time ( 55-65 minutes ) Frequency ( 4 times a

week ) Time to goal – 6 weeks )

Hypertension

Systolic ≥ 140 mmHg

Diastolic ≥ 90 mmHg

Pulse pressure ≥ 50

Mean pressure ≥ 106

Dependent variable

Normotensive

Systolic ≤ 139 mmHg

Diastolic ≤ 89 mmHg

Pulse pressure ≤ 50

Mean pressure ≤ 106

THEORY FRAMEWORK

5

EXERCISES

LOWERS RENAL

RENAL FLOWLOWERS

RAAS

LOWERS

HYPERTENSION

LOWERS

GFR

Increases

GFF

LOWERS

VASOPRESSIN

ACTIVITY LOWERS BLD

VOLUME

ANS

Lowers sympathetic

Increases parasympathetic

Lowers vasotone

Vasodilation/venodilation

BARORECEPTORS

INCREASE ACTIVITY

MEDULLA OBLONGATA-increased activity

INCREASES BLOOD IN SKELETAL MUSCLES

INCREASE VENOUS CAPACITANCE

↑ CAPILLARY CAPACITANCE

DECREASE BLD VOLUME IN THE VESSSELS

CHAPTER 2.0: LITERATURE REVIEW

Systemic arterial hypertension (defined as blood pressure > 140mmHg/90mmHg) is the leading

risk factor for the four eventual fatal events (stroke, heart attack, end renal and liver disease)

(Hendricks et al 2012). If this arterial hypertension persists despite treatment with three

antihypertensive drugs of which one of them is a diuretic it is then referred to as resistant

hypertension. Patients whose blood pressure is controlled with four or more antihypertensive

drugs are also regarded to have resistant hypertension (CA Calhoun et al, 2011). High blood

pressure is usually difficult to control and resistant hypertension is blood pressure that is difficult

to control despite the right antihypertensive medications and adherence to the regime (Viera et

al, 2009).A diagnosis of true resistant hypertension should only be made only after a thorough

assessment to exclude apparent or pseudo-resistant hypertension(A Mya teal,2012).Resistant

hypertension should not be confused with uncontrolled hypertension which steps from non-

compliant to treatment. This resistant hypertension, has been shown to resist drugs and has yet to

be demonstrated to resist drugs with say exercises and diet interventions combined(Rebeiro

etal,2015) This implies that such patients whose physiology is not responding to correct the

anomaly needs together with antihypertensive other interventions which are non-

pharmacological (F.Dimeo et al,2012). Resistant hypertension has no known etiology but has

multifactorial secondary causes .drug –induced hypertension, obstructive sleep apnea, primary

aldosteronism .With the awareness of the aftermaths of the persistent of above goal of blood

pressure despite adherence to medications, such patients would be perhaps more than willing to

include exercise regime to their endeavors ( F. Dimeo et al 2012 ).

2.1 Epidemiology

The Persons with treatment resistant hypertension are increasing in numbers due to increase in

incidence rate. Numerous cross-section prevalent studies and large numbers of longitudinal

prospective studies have reviewed increasing prevalence of resistant hypertension from 5%-10%

in 2005 to a mean point prevalence 30%-45% especially among the advancing in age with more

than one comorbidity (P.A Sarafidis etal, 2011).The socio-economic burden on these population

with continuing increasing risk of both cerebral and cardiac events is makes them poorer and

vulnerable to stress. This has leads to increased mortality and morbidity rate .More than 1 billion

6

adults globally suffer from hypertension representing 25% world population. More than seven

million people die annually from events related to hypertension making it the leading cause of

death among the NCDs (D.A Calhoun et al 2008)

2.1.1Etiology

Resistant hypertension is a compensatory phenomenon caused by vasoconstriction of main,

middle size arteries and arterioles due to atheroma and arteriosclerosis respectively .It’s a

reaction to overcome hypoxia of the tissue ( Theodre A.Cochen 2011,in his brief review of

historical trends of hypertension ) . In 1912 Sir William Osler in his public address to Glasgow

Southern Medical society on association of arteriosclerosis and hypertension he stated that in this

group of cases its significant to recognize that the extra pressure is purely a mechanical affair

……………get it off your head, if possible that the primary feature is the elevated blood

pressure and particularly the feature to treat. In recent times resistant hypertension has been

associated with obstructive sleep apnea, post-secondary aldosterone and drug induced

hypertension (Dimeo et al 2012).

2.1.2.1 Obstructive sleep apnea

Obstructive sleep apnea is stopping to breathe while one is asleep measured at a scale of apnea-

hypoxia index ≥ 10 events/hour resulting from repetitive collapse of pharyngeal airway during

sleep (white et al 2012). This causes the sympathetic autonomic nervous system undue

stimulation which leads to resistant hypertension. Several processes have been blamed for this,

falling of lung volume during sleep, edema due to pooling of blood to the pharyngeal area,

physiological anomaly of respiratory drive and the negative reflex associated to control normal

breathing (White et al 2012).This sequela can positively be affected by exercises.

2.1.2.2 Drug induced resistant hypertension

Several classes of pharmacological agents can increase blood pressure and contribute to its

treatment resistant. Paradoxically, some drugs meant for lowering hypertension raises it, the

prediction for such drugs whether to raise or lower blood pressure depends on renin levels

(Alderman et al, 2010).Given their widespread use non-narcotic analgesics including NSAIDs

aspirin and acetaminophen are probably the most offending. These drugs inhabit the enzyme

7

cyclooxygenase which catalyze the production of prostaglandin from arachidonic acid. This is

produced in the endothelial cells of the blood vessel which in form of prostacyclin is a local

vasodilator and thus lowers blood pressure (Calhoun et al, 2008). In the events of its inhibition

blood pressure is bound to rise. Prostaglandin made by catalyzing effect of COX 1 has protective

effect on gastro-intestinal tract which prevents its ulceration. Exercises decrease renal flow of the

blood thus decreasing to some extent the role of the kidney in regulation of blood pressure which

has been interfered with by the NSAIDs in the inhibition of the prostaglandin. In the peripheral

vascularization, exercise causes vasodilation and venodilation of blood vessels both in the skin

and the skeletal muscles thus lowering the blood pressure

2.1.2.3 Secondary aldosterone

Aldosterone is a mineralocorticoid derived from cholesterol and is almost exclusively produced

in zona glomerulosa of the adrenal gland. It controls minerals in the blood plasma by causing the

reabsorption of sodium ions in the distal convoluted tubule. Sodium is co-transported with water

and thus aldosterone controls the volume of the blood. Majorly aldosterone production is

stimulated by Renin Angiotensin Aldosterone Axis. In secondary aldosterone’s, other anomaly

other than the adrenal gland causes the high level of plasma aldosterone. This disorder is caused

RAAS axis in an ischemic kidney where by more sodium ions are reabsorbed in the distal tube

and more potassium and hydrogen are lost which may lead to hypokalemia and hyper alkalinity

(Chrosous et al, 2015). Since exercises reduce the renal blood flow, excretory role of the kidney

is supplemented and as such blood pressure is controlled with exercise training

2.1.2.4 Arteriosclerosis, arteriosclerosis and atherosclerosis.

These are terms which are usually confused which leads to faulty intervention. They all cause

hypertension and have different meaning. Arteriosclerosis a non-atheromatous loss of elasticity

or hardening of major and middle sized arteries whose total cross section is estimated at 24.5 cm2

holding10% volume of the circulating blood while arteriolosclerosis also refers to non-

atheromatous loss of elasticity or hardening of arterioles whose total cross section is estimated

400 cm2 holding 1% volume of the circulating blood (Lam et al 2012). On the other hand

atherosclerosis is narrowing, hardening or loss of elasticity arteries due to infiltration of tunica

intima lamina by white blood cells and fatty acids resulting in formation of form cells of

macrophages forming a fatty strict which grows into multiple hard lesion called plaques (Urbina

8

et al,2008) . The cause is turbulent flow due to continued raised blood pressure that erodes the

endothelial cells triggering migration of leucocytes, monocytes (macrophages) neutrophils and

fatty acids, connective tissues into the base of tunica intima.

2.2 Prevalence

The reported prevalence of hypertension worldwide is varied with India recording the least

(3.4% male and 6.8% female) and Poland recording the highest (68.9 % male and 72.8 %

female) (Kearney et al, 2015.) But in an overall, approximately 20% of the worldwide adults are

hypertensive and it increase with age ( Dreisbach et al 2014, epidemiology of research).The

prevalence dramatically raises in individuals above 60 years to 50%. More than one billion

people in the world suffer from hypertension, causing an annual mortality of more than 7.1

million( Dreisbach et al,2014) In sub-Sahara Africa , hypertension in rural community River

State , Niger Delta of Nigeria , prevalence was 20.5% male and 20.1% female (CA Alikor etal,

2013) .In rural Kenya the prevalence of hypertension is estimated to be 23.7% (Hendrick et al

2012) but Health Heart Africa and Kenya Demographic Survey 2012 state that one in three

individuals within the age group ≥ 55 years are hypertensive

2.3 Diagnosis

Hypertension is diagnosed in terms of persistent sign of systemic arteries in brachial artery blood

pressure measured using a sphygmomanometer in millimeters of mercury ( Theodore A Kotchen

2012 , brief review of historical trends and milestone in hypertensive research ). The mercury

Sphygmomanometer has essentially been replaced with aneroid and electronic devices. Mercury

is still used for calibrating these devices and standardized protocols have been recommended to

assure their accuracy. Blood pressure ≥ 140/90 mmHg is regarded as hypertensive. American

Heart Association has described five categories of blood pressure by staging both the systolic

and diastolic in ranges of millimeters of mercury as follows in the below chart

Hypertension Systolic And Diastolic

9

categories

Categories of

hypertension

Systolic (mmHg) And Diastolic ( mmHg)

Normal blood

pressure

>120 Or >80

Pre hypertension 120 to 139 Or 80 to 89

Hypertension stage 1 140 to 159 Or 90 to 99

Hypertension stage 2 160 to 179 Or 100 to 109

Hypertension crisis

(emergency care

needed )

≥ 180 Or ≥110

2.3.1 Pre hypertensive (systolic of 120 to 139 mmHg) and /or diastolic of 80 to 89 mmHg)

This BP range is supposed to warn this population that they stand a risk of progressing to

hypertension and Doctor`s advises them to change their life style and should not take medicine

2.3.2 Hypertension stage 1 (140 to 159 mmHg) and /or a diastolic 90 to

In this range these populations are regarded to be hypertensive and are recommended to change

their life style and advised to start with a diuretic this time distal convoluted tube thiazide. A

diuretic lowers blood pressure by helping the body to get rid of extra water and sodium.

Diuretics are usually very effective, have few side effects and are inexpensive

2.3.3 Hypertension stage 2

Systolic of 160 mmHg and over up to 179 mmHg and a diastolic of 100 mmHg to 109 mmHg

then you have stage 2 hypertension. Treatment here is lifestyle modification, take a diuretic and

another hypertensive. May be a third type if necessary. Normally more than two thirds of these

patients require more than three antihypertensive

10

2.3.4 Hypertensive crisis BP ≥ 180/110 mm Hg

Patients who attends outpatient with complains of severe headache, severe anxiety, nose bleeding

and a BP ≥ 180/110 mmHg are scared by the look of medical stuff. Emergency measures,

admission with administration of hydralazine in most cases. A planned admission and when

these patients walked themselves to the hospital occasionally but not such patients leave the

hospital paralyzed one side of the body. Hypertensive crises must include physical activity to

overcome tissue hypoxia

2.4 TREATMENT

Pathogenesis and etiology of hypertension remains unclear consequently treatment of

hypertension currently is based on using of drugs with an emphasis to reducing the elevated

blood pressure rather than treating the cause (B.C Berk et al 2004).The antihypertensive

medications are viz: Diuretics, beta blockers , nitroglycerines , alpha blockers , sympathomimetic

, calcium channel blockers , potassium channel blockers , ACE antagonist and inhibitors etc.

Treatment resistant hypertension is treated using three or more antihypertensive of which one

must be a diuretic to deal with tissue volume problem. In addition to taking more than three

antihypertensive medications patients who have drug resistant hypertension are strongly advised

to make behavioral and dietary modification such as losing weight , exercising , reducing sodium

intake an increasing potassium intake as advised by the physician (Persell et al,2011).Note that

physicians emphasizes more on antihypertensive management and there has to be advocacy for

the other behavioral factors and to come up with a novel treatment exercise package need be

meticulously developed. Post exercise hypotension has been observed in in many incidences of

raise blood pressure which proves that exercises can lower elevated blood pressure just like the

antihypertensive. Can drug resistant hypertension resist exercises just as it resist antihypertensive

medications? This is the question this experiment will answer.

2.5 PROGNOSIS

55% of cardiovascular, cerebral malady fatal events are cause by treatment resistant hypertension

(Chen et al 2013). End organ disease increase for more than 2 fold for those suffering from

apparent treatment resistant hypertension. Apparent treatment resistant hypertension has been

blamed for 50% end renal disease and its eventual mortality rate. Stroke and mortality, morbidity

and DALYs are also reported to be complications from apparent treatment resistant hypertension

11

(Daugherty et al, 2012). 50% heart failure are also caused by resistant hypertension and if these

are caused by also hypertension that is also controlled by antihypertensive with 3

antihypertensive or multiple antihypertensive then it means that treatment with antihypertensive

may be a failure and not with understanding a novel treatment protocol need to be instituted.

2.6 EXERCISES

2.6.1 Definition

There so many definition of exercise but the most striking one I came across is one by Oxford

dictionary press describing an exercise as an activity requiring physical effort, carried out to

sustain or improve health or fitness. Other dictionaries e.g Cambridge English dictionary define

it as a physical activity that you do to make your body strong and healthy yet another dictionary

Macmillan dictionary defines exercise as a physical activity that you do repeatedly to make part

of your body strong or more healthy . The first definition brings out the idea of voluntary

movement “effort” and effort depicts that there is humoral-neural involvement and thus

voluntary contraction of muscles. The motor functions after receiving of commands to perform

functions depicts that there is a motor intention from thoughts. This is due to the ability of the

cortex cells to convert thoughts to an electrochemical impulse (Zscholarish et al, 2013). Through

pre-synaptic motor nerve action potential acetylcholine anchors across the synapse the

electrochemical impulse created by cortex cells from the thoughts (Castillo et al, 2015). The

neural muscular joint picks it up and through the “T” tubules of the sarcolemma exciting the

sarcoplasmic reticulum to release calcium ions and also allows more calcium into the cells whose

concentration is less twelve thousand times in the cytoplasm than in the extracellular. Calcium

ions increased levels initiate muscle contraction by troponin C which weakens the troponin-

tropomyosin relax able protein. This displaces tropomyosin which exposes the binding site on

the actin and the thick myosin with its ATP on the head seizes the opportunity splitting the ATP

thus initiating the cross-bridge which triggers the latchet mechanism causing the actin thin

filament to slide on the thick myosin. One troponin reaction exposes seven sites for the head of

myosin to attach. Note this process requires enzyme myosin ATPase. This is a demand the

presence of enzyme and oxygen which are the main factors in physical fitness and good health.

12

2.6.2 Modes of exercises

Before beginning any exercise program, a clinical evaluation by a physician is recommended to

rule out potential risks. Once health and fitness level are determined and any physical restriction

identified, the individual exercise program should begin under supervision of a health care or

other trained health professional ( Mishra et al , 2011).Exercise programme normally followed by

the participants are referred to as modes .Majorly there are three modes of exercises and two

exercise chains .The exercise modes are

Aerobic

Stretching exercises

Anaerobic (Strengthening exercises and explosive movements )

2.1.1Exercise chains are either open kinetics (single or double lose packs) or closed chain

(double closed pack.

2.6.1.2 Calisthenics or non-calisthenics.

The exercise mode is the program of the exercise followed by the trainer and trainee the

exercise done are in two types calisthenics (without machines or equipment) or non-

calisthenics (with machines or equipment assisted) and the chains of exercises are open and

closed kinetic exercise

Types of muscle contraction are isotonic (with change of length) or isometric (without change in

length but change in tone)

2.6.1.3. Length change are either shortening (concentric) or lengthening (eccentric)

2.7 Energy systems are three

High energy phosphate ( ATP-CP) ,ATP stored in muscles and creatine

stored in muscles combining with ADP and inorganic Phosphate used in the first 3 second and

next 8-12 seconds of initial stages of exercises. This system is also referred to as anaerobic

alactic energy system

Glycolysis or anaerobic lactic system where by the body involves cells

active systems and enzymes in breaking glucose or glycogen in absence of oxygen which is the

next energy system and occurs in the next 30 to 90 seconds following the 10 or 15 seconds of

the first energy system making it may be a maximum of 120 second

13

2.7.1 Aerobic energy system

This is as well referred to as mitochondria activity system which is slowest and

thrives in presence of oxygen .This is involvement of enzymes, coenzymes and

electron transfer system which produces water and ATP

2.8 FITT

How hard (intensity), how long (volume, duration of exercises), how often (frequency) time

taken per session or time to goal (target training weeks) (Hawley, 2002) Type (mode e.g aerobic,

anaerobic)

2.8.1 “younger longer” Component of exercises (1) warm up (2) work out (3) cooling down

Acronym FITT for younger longer fitness program

Frequency – four consecutive days in a week

Intensity – moderate for warming up, severe in working out, low intensity in cooling down

Time – 55 to 65 minutes

Type – mobilizing exercise of the trunk component in double closed chain, stretching exercises

and aerobic. Aerobic is the dominant type in case of “younger longer”

2.9 Principles of exercises: Specificity of exercises and adaptability

Exercise would only be beneficial if they are done according to the intended objective and

in principle eg cardio exercises must affect the heart rate (Burgomaster et al 2007)

Adaptability .The body is unique in that the body systems used adapt to the physical stress

they are exposed to. In low resistant exercises high intensity like sprinting the phosphagen

energy system is fanned/improved or example the biceps of a carpenter develop to be big

and body builders develop body “ cuts “

Cardiorespiratory exercises must affect the heart rate and pulse rate

Endurance exercises not the same with cardiovascular exercises brings out the essence of

time length accompanied with exercises

Resistant exercises not necessarily strengthening

14

2.10 Physiological benefits for exercises

Decreases/lowers heart rate at ret and work

Increases the adaptability of left ventricle

Decreases work of heart wall/sarcomere

Allows the cardiac output increase to a higher maximal level

Decreases or reverses ST segmental depression

Increases dimension of coronary arteries collaterals formed in case of exercises as a result

of ischemic heart attacks

Increases cardiac work rate

Increase peak power output

Increases VO2max

Increases total blood volume

Increase tone of peripheral veins

Increases central blood volume

Increases resting stroke volume

Better sustained Ejection Fraction during vigorous effort

Increases A-V oxygen difference which increases ventilation

Increases ventricular fibrillation threshold

Increases respiratory of muscles

Increases vital capacity

Increases maximal voluntary ventilation

Decrease fat mass increase lean mass

LOWERS BLOOD PRESSURE

IMPROVES LIPID PROFILE

Increases flexibility

Strengthens tendons and articular cartilages

Decreases catecholamine

Decrease creatine kinase during exercises

Increase oxidative enzymes during exercises

Decreases serum lactate dehydrogenase during exercises

Increase growth like insulin factor

15

Increase bone density

Increase muscle development

Increase maximal muscle force

Increase neuronal firing

Increase fraction of total pool of motor neurons

Increases relaxation of antagonists

Lengthens diastolic phase and decreases heart rate which improves myocardial perfusion

Altered balance between sympathetic and parasympathetic drives to cardiac pacemaker

SA node ( adapted from Hes 800 exercises in chronic diseases )

16

CHAPTER 3

3.0 Methodology

Pseudo resistance, including lack of blood pressure control secondary to poor medication

adherence or white coat hypertension must be excluded. Exercise tress test must be done,

electrocardiogram tests for the patients must also be done. All base line investigation to rule out

exercise contraindication like fasting blood sugars, random blood sugars, full hemogramme and

taking of blood pressure before and after exercises .Resting heart rate and that of during

exercises will be monitored using pulse rate monitors. Maximum age predicted heartrate will be

calculated.

3.1 Study design-randomized controlled trial

Patients with hypertension will be recruited from list of patients screened at Kaindutu Slum in

Thika Town by Health Heart Africa, Hunduma Centre of Kiambu County, Medical Outpatient of

TL5H, Medical Outpatient of St.M.M.ML4H, Records from CIPLA free camp at

ST.M.M.ML4H, Records from HHA by the staff of ST.M.M.ML4H, Records from Various

clinics of physicians at Thika Town. One big record will be made which will serve as the

sampling frame .Those who have Resistant hypertension will be identified by two medical

doctors. Simple randomized sampling (Rotary) will be used and still by simple randomization

process two groups will be chosen one which will undergo the younger longer fitness program

for 6 weeks which will be compared with the control group

3.2 Measurement of variables

BP (dependent), Blood pressure during recruitment will be measured by six nurses to verify what

will be on record using an Omron digital machines and patients will be taught how to measure

blood pressure at home. At least we will identify 12 patients who will be provided with Omron

digital machine who will be requested to use the machine strictly alone and not share with

anybody else for record purposes. Exercise intensity and duration (Independent factor) will be

taken by Master s of exercise science and sport of Kenyatta University. AN exercise pulse rate

monitor will be used and intensity will be calculated by % Maximal age predicted heart rate

=0.6463× VO2 max + 37.182 (Swain et al, 1994) which is only applied for a heart rate rage of 63

% to 92 %. From this equation the independent variable will be calculated. SPSS and student T

17

test will be used for analysis which will also be applied to the controlled group and compared.

Another estimate of VO2max equation is by Uth-Sorenen-OvergaardPedersen estimate VO2max

=15.3×HRMAX/HRREST ml/min/kg

3.3 Study area

Kiandutu (a slum at Thika) location of study, cords from MOPC records of TL5H,

ST.MMML4H, HHA, CIPLA, CHURCH ADVERTISEMENTS –St. Matias Mulumba Hospital

HHA staff.

3.4 Target population.

Patients with resistant hypertension as screened by HHA at Kiandutu Slam in Thika, record from

MOPCs of TL5H and ST.MMML4H,Huduma centre record, Record from Various physician in

Thika Town, CIPLA records at ST.MMML4H, Records from HHA of ST.MMML5H.

3.4.1 Exclusion criteria.

By aid of consent form which will rule out other types of hypertension eg white coat blood

pressure, uncompliant to drugs, risks which can be exacerbated by exercises

eg.CCF,Symptomatic peripheral arterial occlusive disease,Aortic insufficiency or stenosis more

than stage 1, Hypertrophic obstructive cardiomyopathy , uncontrolled atrial/ventricular flutter or

fibrillation,Systolic BP ≥ 180 mmHg , signs of acute ischemia in exercise ECG,And a change of

antihypertensive medicine I the last 4 weeks before the inclusion of the study or the follow up

period.

3.4.2 Inclusion criteria. Those patients who have a BP ≥ 140/90 mmHg and on more than 3

antihypertensive of which one of them is a diuretic ( eg loop diuretics frusemide, bumetanide,

torsemide, Thiazide diuretics – hydrochlorothiazide, hydroflumethiazide, chlorthalidone,

esidrix , zaroxolyn, Potassium –sparing diuretics ( aldactone,dyrenuim ), CCB,beta blockers ,

ARBs ( angiotensin receptor blockers ) , ACE inhibitors ,nitroglycerines , angiotensin II type 1

blockers , aliskren , α-blockers – moxonide, clonide and minoxidil . the preexisting

antihypertensive medicine will remain unchanged throughout the study . To minimize the bias of

compliance of antihypertensive drug intake during the study all the patient will be insistently and

18

repeatedly be requested to take care of an accurate drug intake. Written informed consent will be

obtained from all participants before the study.

3.5 Sampling technique.

From the above enlisted records of antihypertensive patients a list will be made which will serve

as a sample frame from which a sample size will be drawn from

3.6 Sample size.

Will be drawn from the above explained sample frame.

3.6.1unit of analysis

Test statistic (student t test, SPSS)

3.7 Research instruments.

Omron brachial digital blood pressure machine , ambulatory pulse rate monitor,

glucometer ,ECG monitor, lipid profile , chest x-ray film for heart size assessment, treadmill ,

antihypertensive medicines , Human resource ,medical officers (3), physician consultants ,

Nurses (6) , record health information officer, phlebotomist (2) , physiotherapist (2), exercise

scientist (3 ) , exercise trainer (3) , transport and a supervisor to coordinate all the activities.

3.8 Pre-testing.

Will be done at Kenyatta University exercise science lab with permission from the chair

3.9 validity and reliability.

The training programme has taken care of these two research characteristics because the trainer

will be required to follow it religiously

3.10 Data collection techniques.

BP recording will be done prior to exercises and after the exercises and in each session, intensity

and duration of exercise will be emphasized

3.11 Data analysis.

SPSS and student T test will be used

19

3.12 Logistic and ethical considerations.

Consent for the Research will be obtained from Kenyatta University School of applied Human

sciences research committee, Kiambu county ministry of health research committee and from

TL5H and ST. MMML4H respective research committees.

3.13 Measurement of variables

At the commencement of the exercises training blood pressure will be taken by six nurses , two

will be per patient .The patient will be sited with knees apart and at 90o and will be given 5

minutes to rest , two sets of machine will be made available ,2 sphygmomanometer BP machine

and 2 Omron digital machine . After 5 minutes rest patient will be taken blood pressure on the

left and right brachial arteries simultaneously using sphygmomanometer and then Omron digital

machine will follow. These initial readings will be recorded on a form which will be provided

and will be done for both control and the study group. Resting heart rate will also be recorded

from the Omron digital machine. Consecutive blood pressures for patients will always be taken

before and after exercises. Random blood sugars will be taken for all patient before starting the

study to avoid undiagnosed diabetes mellitus .ECG will be mandatory before the study

commences. Chest x-ray will be one of the investigation to be instituted for the size of the heart

dimension which will be reported by a qualified radiologist

3.13.2 Exercise intensity .Ambulatory pulse rate monitors will be used for this purpose. All the

patients participating in the study will be fitted with a heart rate monitor which will monitor

exercising heart rate which will be recorded immediately after exercises. The maximum heart

rate will be recorded and the mode heart rate. A provisional converting table for VO2max will be

provided for all participants. The two equations provided at section 3.2 (measurement of

variables) will be used for the calculations. Borgs rating for perceived exertion scale (RPE)

20

APPENDIX 1

The scale is as follows

TO GAUGE THE INTENSITY OF PHYSICAL EXERCISES

Borgs Rating of Perceived Exertion (RPE) Scale

While doing physical activity, we want you to rate your perception of exertion. This feeling should reflect how heavy and strenuous the exercise feels to you, combining all sensations and feelings of physical stress, effort, and fatigue. Do not concern yourself with any one factor such as leg pain or shortness of breath, but try to focus on your total feeling of exertion.

Look at the rating scale below while you are engaging in an activity; it ranges from 6 to 20, where 6 means "no exertion at all" and 20 means "maximal exertion." Choose the number from below that best describes your level of exertion. This will give you a good idea of the intensity level of your activity, and you can use this information to speed up or slow down your movements to reach your desired range.

Try to appraise your feeling of exertion as honestly as possible, without thinking about what the actual physical load is. Your own feeling of effort and exertion is important, not how it compares to other people. Look at the scales and the expressions and then give a number.

6 – No exertion at all 7 – Extremely light 8 9 – Very light 10 11 – Light 12 13 – Somewhat hard 14 15 – Hard 16 17 – Very hard 18 19 – Extremely hard 20 – Maximal exertion

21

# Level of Exertion

6 No exertion at all

7  

7.5 Extremely light (7.5)

8  

9  Very light

10  

11 Light

12  

13 Somewhat hard

14  

15 Hard (heavy)

16  

17 Very hard

18  

19 Extremely hard

20 Maximal exertion

9 corresponds to "very light" exercise. For a healthy person, it is like walking slowly at his or her own pace for some minutes

13 on the scale is "somewhat hard" exercise, but it still feels OK to continue.

17 "very hard" is very strenuous. A healthy person can still go on, but he or she really has to push him- or herself. It feels very heavy, and the person is very tired.

19 on the scale is an extremely strenuous exercise level. For most people this is the most strenuous exercise they have ever experienced.

Borg RPE scale© Gunnar Borg, 1970, 1985, 1994, 1998

This will be taught to the participants by MSc exercise science students of KU and will assist in

monitoring patient’s fatigability using this scale to correlate it with the VO2max and heart rate.

APPENDIX 2

Bruce treadmill test protocol The Bruce treadmill test protocol was designed in 1963 by Robert. A. Bruce, MD, as non-invasive test to assess patients with suspected heart disease. In a clinical setting, the Bruce treadmill test is sometimes called a stress test or exercise tolerance test. Today, the Bruce Protocol is also one common method for estimating VO2 max in athletes. VO2 max, or maximal oxygen uptake, is one factor that can determine an athlete's capacity to perform sustained exercise and is linked to aerobic endurance. VO2 max refers to the maximum amount of oxygen that an individual can utilize during intense or maximal exercise. It is measured as "milliliters of oxygen used in one minute per kilogram of body weight" (ml/kg/min). The Bruce Treadmill Test is an indirect test that estimates VO2 max using a formula rather than using direct measurements that require the collection and measurement of the volume and oxygen concentration of inhaled and exhaled air. This determines how much oxygen the athlete is using. The Bruce Protocol The Bruce Protocol is a maximal exercise test where the athlete works to complete exhaustion as the treadmill speed and incline is increased every three minutes (See

22

chart). The length of time on the treadmill is the test score and can be used to estimate the VO2 max value. During the test, heart rate, blood pressure and ratings of perceived exertion are often also collected. Bruce Treadmill Test Stages Stage 1 = 1.7 mph at 10% Grade Stage 2 = 2.5 mph at 12% Grade Stage 3 = 3.4 mph at 14% Grade Stage 4 = 4.2 mph at 16% Grade Stage 5 = 5.0 mph at 18% Grade Stage 6 = 5.5 mph at 20% Grade Stage 7 = 6.0 mph at 22% Grade Stage 8 = 6.5 mph at 24% Grade Stage 9 = 7.0 mph at 26% Grade The Bruce Protocol Formula for Estimating VO2 Max For Men VO2 max = 14.8 - (1.379 x T) + (0.451 x T²) - (0.012 x T³) For Women VO2 max = 4.38 x T - 3.9 T = Total time on the treadmill measured as a fraction of a minute (ie: A test time of 9 minutes 30 seconds would be written as T=9.5).

Because this is a maximal exercise test, it should not be performed without a physician's approval and without reasonable safety accommodations and supervision. Bruce Protocol Norms for Men VO2 Max Norms for Men - Measured in ml/kg/min Age Very Poor Poor Fair Good Excellent Superior 13-19 <35.0 35.0-38.3 38.4-45.1 45.2-50.9 51.0-55.9 >55.9 20-29 <33.0 33.0-36.4 36.5-42.4 42.5-46.4 46.5-52.4 >52.4 30-39 <31.5 31.5-35.4 35.5-40.9 41.0-44.9 45.0-49.4 >49.4 40-49 <30.2 30.2-33.5 33.6-38.9 39.0-43.7 43.8-48.0 >48.0 50-59 <26.1 26.1-30.9 31.0-35.7 35.8-40.9 41.0-45.3 >45.3 60+ <20.5 20.5-26.0 26.1-32.2 32.3-36.4 36.5-44.2 >44.2 AVO2 Max Norms for Women VO2 Max values for Women as measured in ml/kg/min Age Very Poor Poor Fair Good Excellent Superior 13-19 <25.0 25.0-30.9 31.0-34.9 35.0-38.9 39.0-41.9 >41.9 20-29 <23.6 23.6-28.9 29.0-32.9 33.0-36.9 37.0-41.0 >41.0 30-39 <22.8 22.8-26.9 27.0-31.4 31.5-35.6 35.7-40.0 >40.0 40-49 <21.0 21.0-24.4 24.5-28.9 29.0-32.8 32.9-36.9 >36.9 50-59 <20.2 20.2-22.7 22.8-26.9 27.0-31.4 31.5-35.7 >35.7 60+ <17.5 17.5-20.1 20.2-24.4 24.5-30.2 30.3-31.4 >31.4

lso See: VO2 Max Norms for Women

Appendix 3

EXERCISE PROGRAM

VENUE: ST.MMML4H TENT

INSTRUCTOR: YOUNGER LONGER TRAINER

TRAINEE: Patients with resistant hypertensive, normotensive, controlled tensives

23

Mode: aerobic, stretching

Type of exercises: Calisthenics

Exercise chains: open and closed chain kinetics

Muscle contractions: both isometrics and isotonic

Contraction mode: Both concentric and eccentrics

Energy system employed: Phosphagen, Glycolysis and Aerobic

Duration of session: 55- 65 minutes

Frequency: 4 times in a week

Tempo: high (maximal) intensity

Time to goal: 6 weeks

Time of exercise: 4.55 pm – 6pm

Session:

Calling class to order: warm up (284 activities in 15 minutes)

“finding energy line” instruction “ imagine its early in the morning and you`ve just have risen

from bed ,lifting your right hand bending it backward with your left hip ,trunk in back extension,

make a fist ,bend your elbows, retract your shoulders tighten your fist, your arms, your back,

your gluteal , your thighs , your legs , your feet, your toes, common tighten, tighter and tighter

and tighter

1. Breathing exercises in all coronal , sagittal and horizontal plane × 4

2. “ let’s go igo-meaning facing up and biting 40 times

3. “ Masaai” imitating a Masaai dance – repeated 40 times

4. Neck movements : flexion , extension , rotation , circumduction in all plains × 10 times

each

5. Shoulder movements , flection , abduction , elevation , circumduction , horizontal

flection and extension in all plains × 10

24

6. “ Aeroplane “ shoulders abducted in coronal plain, fist formation , elbow flexion each ×

10

7. Trunk ( divided into four quadrant in sanding in an anatomical position ) flection ,

extension in all plains × 10

8. Lower trunk rotation to the right and left × 10 in horizontal plain

9. “ hips flexed and opposite extended –rocking forward and backed –repeat each side × 10

10. Squatting × 2

Work out (640 activities)- 30 minutes

1. “ Single Alice “ posture – anatomical standing position right shoulder flexed arm

elevated in back extension , left leg in hyper extension open chain kinetic of lt.leg

crisscrossing with hand with the arm in alternate shoulder flexion × 10 , repeat with

alternative limbs × 10

2. “Double Alice “. Shoulders in flexion arms elevated with rt leg drawn in hyper extension.

Action :front swing in extension of both upper limbs with open kinetic rt. lower limb

flexion to crisscross the leg with the hands × 10 .Repeat with the lt.leg × 10

3. Extended rt. foot forward step with a draw back in hip extension × 10 .Repeat with the lt

foot × 10

4. “Ngucu” (a kikuyu dance step). Action : stepping from a central point towards the right

then lt. and stepping back to the same point with the rt. then lt × 20

5. Forward and back step with the rt. foot and kicking from behind of the same rt. foot and

kicking with same from behind and alternating from rt to lt × 20

6. Marching on the spot “ narrow “ × 20 “ March wide “ × 20

7. “ march wide ,march narrow” × 20

8. “A march and a tap with hill front “× 20. Repeat with the sides ,rt alt.lt × 20 and behind

step after a march × 20

9. A spot march and front step , then a march and step on the side and behind once in the

three directions × 20

10. Skip and skip × 20

11. A skip and clap under the knee × 20

12. Hip curls in coronal plane hips immoderately abducted side swing to the rt. alternating to

the lt. × 20

25

13. Running on the sport run × 40 counts

14. Low jump “ jump on the spot jump” jump one two three jump – “ Miriam” jump × 3 each

× 10

15. “Susan`s jump” command: apart together across apart together is a combination of double

open chain in hip abduction followed by midline hip adduction of alternate foot × 20

16. “Mitugo`s jump “command: from behind .forward, from behind forward. whose Mitugo`s

eee… Mitugo,…aaa….× 20 Repeat- the hip is drawn far in extension then with a swing

flung in a pendular manner an open kinetic chain of one leg is alternated rt and lt

17. Number 16 exercise is repeated but this time the hips are hyperextended far behind and

front × 20

18. “Njogu`s jump” Command: feet apart far apart right left they go, right left they go whose

Njogu`s oh..ooh Njogu`s × 20 Repeated twice- alternate side open chain

19. “Munyambo`s jump “Command: sea shore Munyambo`s eee , Munyambo`s

aaa….Munyambo`s eee..Munyambo`s aaa…× 20 A repeat this exercise one central point

open chain kinetic swing to the left and alternatively to the right with at no any time

when both feet are together on the surface at the same time

20. “Wambugu`s jump” Command: astride and close, a stride and close, a stride and close, a

stride and close, whose Wambugu`s..eee.. Wambugu`s..aaaa, .. Wambugu`s eee,

Wambugu`s aaa × 20 A repeat . This exercise is double open chain kinetics in hip

abduction followed by double close chain kinetics in adduction

21. “Helen`s jump “command: feet inclined forward, head drawn backward, eyes fixed up

backward on the ceilings …. Who’s …. Helen`s ooooh …Helen`s..eeee, Helen`s ooooh,

Helen`s eee, × 20 Repeat. This exercise is an alternate single open chain kinetic which is

a rhythmical forward slide away from the backward inclined trunk

22. Negating Helen`s jump

23. ‘Miriam’s jump” Command : jump on the spot jump, jump , one , two , three , jump

high , × 20 Repeat This exercise is a double kinetic chain with knees alternating from

flexion to extension

24. Star jump × 40

26

Cool down (364 activities) – 15 minutes

1. 16 times forced coughing

2. Scissor stand trunk stretching lt × 10 , rt , × 10

3. Imitating forward stroke in swimming × 10

4. Imitating back stroke in swimming × 10

5. Breathing exercises in all coronal , sagittal and horizontal plane × 4

6. “ let’s go igo-meaning facing up and biting 40 times

7. “ Masaai” imitating a Masaai dance – repeated 40 times

8. Neck movements : flexion , extension , rotation , circumduction in all plains × 10 times

each

9. Shoulder movements , flection , abduction , elevation , circumduction , horizontal

flection and extension in all plains × 10

10. “ Aeroplane “ shoulders abducted in coronal plain, fist formation , elbow flexion each ×

10

11. Trunk ( divided into four quadrant in sanding in an anatomical position ) flection ,

extension in all plains × 10

12. Lower trunk rotation to the right and left × 10 in horizontal plain

13. “ hips flexed and opposite extended –rocking forward and backed –repeat each side × 10

14. Squatting × 3

References

1. Williams Ganong review of medical physiology 2008

2, Calhoun et al 2012

3. Yaxley et al 2013

4. Persel and Stephen hypertension

5. Nolte et al 2013

27

6. Papademeterius et al 2009

7. Dimeo et al 2012

8. Viera et al 2009

9. Rubetro et al 2015

10. Lam et al 2012

11.Urbin et al 2008

Appendix 4

THE COSTING OF THE RESEARCH PROGRAM

Number of

item

Item description Number

required

Cost per item Total cost

1 Omron BP machine 12 8,000.00 96,000.00

2 Sphygmomanometer 2 2,500.00 5,000.00

28

3 Ambulatory heart

rate monitor

12 6,300.00 75,600.00

4 Glucometer 1 5,000.00 5,000.00

5 Glucostick 1packet 5,000.00 5,000.00

6 ECG investigations 12 patients 1,000.00 12,000.00

7 Chest x-ray 12 patients 500.00 6,000.00

Total 204,600

HUMAN RESOURCE PERSONS

Number Profession Number

required

Service Service

charge per

item

Total

29

1 Community

owned

resource

person (corp)

2 Mediation in the

Kiandutu slams

for 4 days in 4

weeks

1,000.00 8,000.00

2 Extension

health worker

1 Coordination of

the activities in

the slam for 4

days in 4 weeks

1.500.00 6,000.00

3 Information

health record

officer

Recording and

analysis of data

50,000.00 50,000.00

4 Nurse 6 Monitoring of

BP 4 days in 4

weeks

2,000.00 48,000.00

5 Phlebotomist 1 Monitoring of

blood sugars for

4 days in 4

weeks

100.00 9,600

6 Trainer 2 Conducting the

exercise

program 4days a

week for 6

weeks

2,000.00 96,000.00

7 Exercise

stress test

administrator

2 Asses exercise

stress test for 12

patients twice

3,000.00 72,000.00

8 Medical

officer of

health

2 Follow up of 24

patients for 4

appointments

1,000.00 96,000.00

30

9 Consultant 1 Assessment and

definition of

patients with

resistant

hypertension

2,000.00 48,000.00

10 Research

director

24 days for

the 24

sessions

Antihypertensive

drugs

administration

3,000.00 72,000.00

11 Transport of

the patient

Control 4

days ,study

group 24

days

Transport of

patients

300.00 87,600

Total 593,200

Total cost 204,600 + 372,400 = 797,800. 00

APPENDIX 6

Legal consent form

31

APPENDIX 7

Subject`s informed consent form

32

APPENDIX 8

Clinical evaluation form

Name ………………………………………

Gender …………..

Age …………..

1. BP (resting) rt brachial artery …………lt. brachial artery………

2. Chest x-ray heart size

3. EST (Bruce protocol) – Vo2 max

4. Resting heart rate

33

5. ECG-

6. Cardiac Index – echocardiogram

7. BMI

8. Lipid profile

9. Number of antihypertensive drugs

34