Strength Training Programs for Clients with High Blood Pressure

The Importance of Safe Training for High Blood Pressure 

I remember sitting in a college class, listening to my professor talking about training people with high blood pressure. I was so worried that I was going to end up making their heart explode. Many clients later, I’m here to tell you (and my younger self) that is not the case. With a little common sense and some help from this article, you’ll be training clients with high blood pressure with safety and confidence.

High blood pressure (also frequently called HBP or hypertension) occurs when the flow or force of blood against arterial walls is higher than the normal range. We’ll be talking about those ranges and what they mean for your clients later in the article. If blood pressure remains high, without being controlled by lifestyle or medication, it can have detrimental effects on the body, including causing heart attacks and strokes.

Knowing this, training clients with high blood pressure is a balancing act, with a lot of push and pull. We help them push their bodies for physiological improvement, but we also have to know when to pull back to keep them safe. The better this scale is balanced, the more our clients can reap the benefits of exercise. What used to be a cardio-only prescription has now evolved into a multi-faceted approach to include cardio and resistance training as the most effective means for lowering blood pressure.

Who Has High Blood Pressure?

If you’re thinking it would just be easier to decline training anyone with high blood pressure, your chances of finding clients might be rather slim (and you would miss out on training some fabulous people). The World Health Organization estimates that 1.4 billion people, or 33% of the population, had hypertension in 2024, and that number has certainly grown since then. Fitness professionals can play a big role in reducing this number. 

Out of those 1.4 billion people, 44% don’t know they have hypertension. As trainers, we can use the PAR-Q+ and other screening procedures to help these people get to a medical provider who can make that diagnosis and help your clients start treatment. Another 44% of affected people have been diagnosed and are being treated for it, but only 23% of people actually have the condition under control. 

While not every person can or will work with medical providers and fitness professionals to lower their blood pressure, many will. By learning about hypertension and how to train clients who have it, you’re opening up a window of income for yourself and a door to better health for your clients.

Pre-Session Essentials: The “Green Light” Checklist

While you probably don’t need to be worried about your client’s heart exploding like I was, there are precautions that need to be taken seriously when training a client with high blood pressure. This starts with your screening procedures and initial consultation. 

When you first meet a client or begin onboarding them, one of the first steps should be using screening tools like the PAR-Q+, liability waivers, and health history questionnaires. These industry-standard screening tools are put in place to help your clients stay safe and keep you out of legal trouble. They can help you open a discussion about their blood pressure. If a client has signs or symptoms that may indicate high blood pressure, whether it is diagnosed or not, clearance from a medical provider is recommended. A doctor’s note isn’t just a formality—it’s a roadmap, one that will make your job a whole lot easier.

Medications that Affect Blood Pressure & Exercise

Maybe your client already knows that they have high blood pressure and are being treated for it. Before you jump into training, you need to know what medications they’re on and how those medications can affect exercise. Some of these medications include:

• Beta-blockers: These lower the heart rate at rest and during exercise. They can lower maximal aerobic capacity and cause fatigue. Do not use heart rate training zones. Instead, use perceived exertion scales or other subjective methods.
• Diuretics (Water Pills): These help remove excess salt and water from the body. They can cause dehydration, electrolyte imbalances, and reduce overall blood volume. It can also impair heat regulation, making exercise potentially unsafe in hot or humid conditions. Encourage regular fluid and appropriate electrolyte consumption before, during, and after exercise. Keep the session in a climate-controlled environment where possible.
• Alpha Blockers, Calcium Channel Blockers, and ACE Inhibitors: These inhibit hormones, calcium, and enzymes that can cause blood vessels to constrict, letting blood vessels remain more open, thus reducing blood pressure. They typically have a lesser effect on exercise, but can cause dizziness and a fast drop in blood pressure if exercise abruptly stops. When training clients, plan for adequate time to cool down after the main portion of the workout and monitor the client as their heart rate returns to normal.

Blood Pressure Ranges and the Stop Number

While most clients will not need to have their blood pressure continuously monitored throughout your sessions together, it is important to know how to take blood pressure and how it is categorized. Blood pressure is a reading of two numbers portrayed as a fraction. The top number is a person’s systolic blood pressure, and the bottom number is their diastolic blood pressure. Blood pressure is taken with a cuff called a sphygmomanometer that temporarily restricts blood flow to the arm. 

It can be taken manually with a stethoscope and cuff (which requires training and practice) or with an automated machine that reads blood pressure. If performed by someone trained in blood pressure reading, manual recordings of blood pressure are considered the gold standard, but digital output from machines is effective for simple monitoring and non-clinical use. 

As defined by the American College of Cardiology and the American Heart Association. The four categories of blood pressure are:

• Normal Blood Pressure: Lower than 120/80 mm Hg.
• Elevated Blood Pressure: The top number (systolic blood pressure) is 120-129 mm Hg, and the bottom number (diastolic blood pressure) is below 80 mm Hg.
• Stage 1 Hypertension: The top number is 130-139 mm Hg, or the bottom number is 80-89 mm Hg. Remember, it doesn’t have to be both. It can be one or the other.
• Stage 2 Hypertension: The top number is 140 mm Hg or above, or the bottom number is 90 mm Hg or above.
• Severe Hypertension / Hypertensive Emergency: When the blood pressure exceeds 180/120 mm Hg, this is considered a hypertensive emergency, and exercise should be stopped immediately and not resumed until cleared by a medical provider. 
  • If a client has symptoms including chest pain, shortness of breath, numbness, weakness, vision changes, back pain, or difficulty speaking, call 911.
  • If a client has a blood pressure of 180/120 mm Hg or above, but does not have any symptoms, their healthcare provider should be called.

For many clients with high blood pressure, standard exercise intensity measuring procedures may be inaccurate due to medications. Use these blood pressure ranges as a guide and choose an appropriate method of measuring exercise intensity. Read on to the end of the article for other ways to monitor your clients during your sessions together.

Programming Strategies for the Hypertensive Client: Building The Workout Program 

Before we jump into exercises, let’s talk about the physiology behind programming for clients with high blood pressure. Three principles will help you create effective programs while keeping your client safe:

• Maintain consistent breathing throughout exercises. Holding your breath causes an increase in blood pressure, increasing the likelihood of an adverse event. It deprives the body of oxygen, which the muscles need to effectively perform movements. Methods like the Valsalva Maneuver are generally not recommended for individuals with hypertension, as they can cause a spike in blood pressure and intra-abdominal pressure, as well as dizziness and fainting.
• Vary forms of exercise in each session and program. When selecting the order of exercises, keep the body moving in different ways and vary which muscles are being used. One example is to alternate upper and lower body exercises. This helps keep blood circulating, rather than letting it pool. Include both strength and aerobic training in programs to create a safe and well-rounded program.

Pro Tip: Research has shown that regular isometric handgrip training (such as squeezing a grip strengthener or ball) can lower blood pressure in hypertensive patients. This is a simple exercise that can be added in as part of the warm-up or between sets. 

• Balance the sticking point. In exercise, the sticking point is that small moment of time or isometric hold between the concentric and eccentric parts of an exercise. It is the lowest point in your squat before you stand back up. It’s the hold at the bottom of your push-up, and the moments your chin is at the bar in a pull-up. While you’re only in any of these positions for a very short time, it is the point in the exercise when people are most likely to hold their breath. Since we know that breath retention for clients’ hypertension can be dangerous, we want to cue and coach our clients on their breathing through those moments. 

Exercise Selection and Programming

The selection and programming of exercises for clients with high blood pressure is very similar to programming for any other client. The primary focus is on keeping the body moving throughout an exercise and minimizing prolonged isometric holds. 

Try to group exercises that are done in the same or a similar position. For example, perform floor exercises together, then move to seated exercises, and then 9m to standing exercises. This is not a hard and fast rule, but it does help reduce drastic changes in blood pressure when a client quickly changes position from supine or prone to seated or standing (or vice versa). 

As a general rule for your programming, be cautious of any exercise where the head is positioned below the level of the heart, such as a handstand or a downward dog yoga pose. These exercises create an immediate and intense increase in intracranial and ocular pressure that can trigger a hypertensive event. 

Practical Applications:

• Instead of the traditional supine l barbell bench press, try a seated chest press machine. 
  • Benefits: It keeps the head above the heart and provides a stable, controlled environment if dizziness occurs.
• Instead of prone leg curls, try seated leg curls. 
  • Benefits: These prevent the “head-down” rush of blood and make it easier to monitor the client’s face for signs of distress.
• Instead of floor glute bridges, try standing cable pull-through. 
  • Benefits: These achieve hip extension without the rapid postural shift required to lift the hips from the floor and avoid isometric holds. 
• Instead of supine skull crushers, try standing cable tricep pushdowns. 
  • Benefits: These maintain consistent vertical alignment, reducing the risk of lightheadedness mid-set.

When programming the load and volume of your hypertensive clients’ workouts, most exercises should be performed in a moderate range, with higher reps (e.g., 10-15 reps) at lower weights or intensities (e.g., 40-60% 1RM). Be sure to incorporate rest periods between each set to provide time for the blood pressure and heart rate to come down adequately. Often, clients with high blood pressure may need longer rest and recovery times than other populations. This also applies to the cool-down. We know people love to skip the cool-down, but those with hypertension need a proper cool-down. If they’re short on time, it’s better to forgo that last set or accessory exercise in favor of the cool-down. 

Pro Tip: Part of making sure your client cools down means that you need to stick around until their cool-down is done. It can be tempting to stick them on a treadmill or tell them to stretch on their own while you head off to another client or off to break. Please don’t. Be present with your clients to see how they recover. Part of our role as trainers is ensuring our clients’ safety from start to finish. Their cool-down can tell you a lot about how the session went and how their body is reacting to the exercise. This can help you with future sessions and programming.

Monitoring Tools Beyond the Heart Rate Monitor

All of these techniques and strategies can be a lot to remember, so let’s keep this part simple. As you program and train clients with hypertension, focus on how they’re feeling and responding, rather than objective metrics. This will tell you more about how they’re really performing and make exercising within recommended guidelines much easier.

Rate of Perceived Exertion (RPE) scales are the primary intensity gauge to use when your client’s medications make heart rate measurements unreliable. My personal favorite is a Modified Borg/RPE scale that measures exertion on a scale of 1-10, rather than the standard 6-20. It’s easy for clients to understand and simple for you to measure.

The Talk Test is another simple, low-tech way to ensure that your clients aren’t over-exerting themselves. It’s also a great way to note their breathing and keep their breath consistent.

Client feedback is a valuable metric during training sessions. Listen to what they’re saying, and what they’re not saying. Watch for silent signs such as flushing, excessive sweating, or sudden headaches, as these may indicate a rising blood pressure.  

When you’re working with a hypertensive client, know what their typical symptoms are and how they manifest. Some clients whose blood pressure is uncontrolled may need to have their blood pressure checked or monitored before, during, and after training sessions. If a client is consistently having blood pressure related diffifulties during your sessions, they should be referred to their medical provider. Some clients may need more supervision than a personal trainer can provide, so know where your scope of practice ends and stick to it.

Taking the Pressure Off

When it comes to training hypertensive clients, the pressure is on, but you can take it off. Mindful programming and careful client monitoring can play a substantial role in helping clients control their blood pressure. Remember that the goal here is long-term blood pressure reduction, not one-rep maxes. Know when to refer your client to a physician. As a fitness professional, your role is to bridge the gap between receiving medical clearance and reduced blood pressure through safe, results-driven programming

Liability insurance protects you as a fitness trainer in case of incidents during personal training sessions. Working with clients carries risk, which is why Insure Fitness Group offers professional and general liability insurance under one policy to safeguard your career. 

Learn more about liability insurance for personal trainers and start protecting you and your clients today.