real correction

KENYATTA UNIVERSITY DEPARTMENTAL POST GRADUATE PRESENTATIONS
ON 25TH AUGUST 2016
Present:
1. Dr. Gitahi Theuri Chairing
2. Dr. Gitonga Rintaugu
3. Dr. Muthomi Nkatha
4. Dr. Bulinda Hannington
5. Mr. George Kiganjo
6. Lilian Bonaveri
7. Kevin cheruiyot
8. Bonface kimanthi
9. Penenah Muthoni
10. Abraham Mwangi
11. Rhoda Wanzetse
12. George Kimani
13. Florence Muthoni
14. Karobia Anthony
15. Luka Boro
16. 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

i
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

ii
Table of Contents
CHAPTER 1.........................................................................................................................................................................................1
BACKGROUND ..................................................................................................................................................................................1
PROBLEM STATEMENT....................................................................................................................................................................2
JUSTIFICATION..................................................................................................................................................................................3
RESEARCH QUESTION......................................................................................................................................................................3
1.4 MAIN OBJECTIVE .......................................................................................................................................................................3
1.4.2 SPECIFIC OBJECTIVE...............................................................................................................................................................3
THE NULL HYPOTHESIS....................................................................................................................................................................4
1.5.2 ALTERNATIVE HYPOTHESIS...................................................................................................................................................4
1.6 CONCEMPTUAL FRAMEWORK ................................................................................................................................................4
THEORY FRAMEWORK ....................................................................................................................................................................5
CHAPTER 2.0: LITERATURE REVIEW..............................................................................................................................................6
2.1 Epidemiology..............................................................................................................................................................................6
2.1.1Etiology.....................................................................................................................................................................................7
2.1.2.1 Obstructivesleep 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

iii
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...................................................................................................................................15
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..........................................................................................................................................................................20
3.12 Logistic and ethical considerations....................................................................................................................................20
3.13 Measurement of variables ..................................................................................................................................................20
3.13.2 Exercise intensity...............................................................................................................................................................20
Appendix 1 ......................................................................................................................................................................................22
EXERCISE PROGRAM......................................................................................................................................................................24
VENUE: ST.MMML4H TENT ..........................................................................................................................................................24
Session:............................................................................................................................................................................................24
Work out..........................................................................................................................................................................................25
Cool down .......................................................................................................................................................................................27
References.......................................................................................................................................................................................28
Appendix 2 ......................................................................................................................................................................................29
THE COSTING OF THE RESEARCH PROGRAM ............................................................................................................................29
HUMAN RESOURCE .......................................................................................................................................................................30

1
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)

2
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 )

3
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.

4
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
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
Pulsepressure≥ 50
Mean pressure ≥ 106
Dependent variable
Normotensive
Systolic ≤139 mmHg
Diastolic≤89 mmHg
Pulsepressure≤ 50
Mean pressure ≤ 106

5
THEORY FRAMEWORK
EXERCISES
LOWERS RENAL
RENAL FLOW
LOWERS
RAAS
LOWERS
HYPERTENSION
LOWERS
GFR
Increases
GFF
LOWERS
VASOPRESSIN
ACTIVITY LOWERS
BLD
VOLUM
E
ANS
Lowers sympathetic
Increases
parasympathetic
Lowers vasotone
Vasodilation/veno
dilation
BARORECEPTORS
INCREASE ACTIVITY
MEDULLA
OBLONGATA-
increased activity
 INCREASES BLOOD IN
SKELETAL MUSCLES
 INCREASE VENOUS
CAPACITANCE
 ↑ CAPILLARY
CAPACITANCE
DECREASE BLD
VOLUME INTHE
VESSSELS

6
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

7
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 sleepapnea
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

8
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

9
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

10
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
Hypertension
categories
Systolic And Diastolic
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

11
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

12
(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.

13
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

14
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

15
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

16
 Increase growth like insulin factor
 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 )

17
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

18
=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
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

19
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 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 Researchinstruments.
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

20
3.11 Data analysis.
SPSS and student T test will be used
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)

21
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
# 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

22
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).
17 Very hard
18
19 Extremely hard
20 Maximal exertion

23
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
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 MenVO2 Max Norms for Men - Measuredin 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
A
VO2 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

24
Appendix 3
EXERCISE PROGRAM
VENUE: ST.MMML4H TENT
INSTRUCTOR: YOUNGER LONGER TRAINER
TRAINEE: Patients with resistant hypertensive, normotensive, controlled tensives
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 systememployed: 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

25
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
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

26
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
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 Repeatedtwice- 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,

27
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
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

28
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
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

29
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
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

30
HUMAN RESOURCE PERSONS
Number Profession Number
required
Service Service
charge per
item
Total
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
2,000.00 96,000.00

31
week for 6
weeks
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
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

32
APPENDIX 6
Legal consent form

33
APPENDIX 7
Subject`s informed consent form

34
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
5. ECG-
6. Cardiac Index – echocardiogram
7. BMI
8. Lipid profile
9. Number of antihypertensive drugs

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