Research Review By Dr. Joshua Plener©


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Date Posted:

January 2021

Study Title:

Blood Pressure Screening by Outpatient Physical Therapists: A Call to Action and Clinical Recommendations


Severin R, Sabbahi A, Albarrati A et al.

Author's Affiliations:

Department of Physical Therapy, College of Applied Health Sciences, University of Illinois; College of Applied Medical Sciences, King Saud University, Saudi Arabia.

Publication Information:

Physical Therapy 2020; 100: 1008-19.

Background Information:

Cardiovascular disease remains the leading cause of mortality for both men and women, despite improved medical interventions (1). Specifically, hypertension, which is a modifiable risk factor for cardiovascular disease, is the elevation of blood pressure above a predetermined cut-off point (2). Hypertension affects approximately 34% of the population in the USA and is a leading cause of mortality. One reason for this is the fact that hypertension can be asymptomatic, even as numbers reach critical levels (> 180/120 mmHg) (3). However, when hypertension is known to the individual, the Center for Disease Control and Prevention reports that only approximately 50% of cases are effectively controlled (3). To illustrate, it has been reported that one-half of patients stop taking their medications within 1 year of starting (4). Even in patients who adhere to their medication, significant blood pressure increases during exercise may occur (5), which is associated with risks of major cardiovascular events and mortality (2, 6, 7). Other factors that impair effective hypertension screening and management include the presence of white coat hypertension, masked hypertension and measurement error.

Hypertension is more prevalent in individuals with disabilities compared to those without disabilities, especially individuals with mobility limitations (8). One study reported that 75% of outpatient orthopedic physical therapists reported at least 25% of their current case load included patients with diagnosed cardiovascular disease or at a moderate or severe risk for its development (9). An effective management strategy for hypertension is early detection which can reduce mortality, morbidity and health care costs (10-12). Studies have demonstrated that screening by non-physician health care providers can improve the detection and management of hypertension (12-14).

It is uncertain what the data may show about chiropractic practices, but it has been demonstrated that outpatient physical therapy practices seldomly measure blood pressure, with only 10-15% of therapists measuring resting blood pressure on all new patients (9, 15). Rationales for the lack of screening include a lack of perceived importance, lack of clinic policy and time constraints (9, 15, 16). Therefore, a change in clinician perceptions regarding the importance of blood pressure screening may be required in order to facilitate screening at outpatient clinics. This article is a call to action for routine blood pressure measurement by outpatient physical therapists (and chiropractors!) through establishing the importance of screening, providing evidence-based recommendations on screening, and discussing potential future directions regarding screening and clinical management.

Although this paper was written from a physical therapy perspective, this information is also highly relevant to chiropractors, who often act in a primary care capacity.


Ethical Duty to Screen:

Several physical therapy organizations suggest that physical therapists have a duty to protect the safety and optimize the overall health of patients (the same could be said for chiropractors). Following this mandate, the implementation of routine blood pressure screening in outpatient physical therapy practices seems appropriate in order to ensure the overall health of patients is assessed. It is likely that physical therapists see a significant number of patients without a prior physician referral and therefore, this may be the only opportunity for early detection of elevated blood pressure.

Equipment Requirements:

The following equipment recommendations for outpatient practice settings include 1 stethoscope per therapist, 1 standard aneroid (manual) blood pressure cuff for every 2 therapists, 1 small and 1 large blood pressure cuff per clinic and 1 child cuff for clinics providing care to patients younger than 12 years of age (15). Additionally, 1 thigh cuff would be warranted to examine the lower extremity. It is important to ensure enough equipment is at the clinic in order to have the appropriate cuff sizes available.


The two most popular ways to measure blood pressure in clinic are aneroid devices, which are manually measured, and oscillometric devices which are used for automatic measurements. Both approaches measure blood pressure accurately (17, 18).
<br/ /> Manual auscultatory blood pressure measurements are based on the identification of sounds resulting from the return of arterial blood flow following a period of temporary occlusion, known as Korotkoff sounds. The systolic pressure is detected as the cuff deflates allowing blood to return to the artery in a turbulent fashion, causing vibration along the arterial wall making a tapping sound which can be heard. The diastolic pressure is determined once the cuff pressure falls below the diastolic pressure, blood flow is restored to the artery and the arterial wall no longer vibrates, resulting in the tapping sound disappearing, with silence heard when auscultating.

Automatic oscillometric devices operate on the principle of vibrations in the arterial wall which are detected and transduced into electrical signals. The devices inflate the blood pressure cuff to about 20mmHg above the patient’s systolic blood pressure and as the cuff deflates, the arterial wall vibrations transfer through the air inside the cuff into a transducer in the monitor. The point of maximal oscillation (vibration) is identified by the device and corresponds to the mean intra-arterial pressure. Systolic and diastolic pressures are estimated based on the maximal point of oscillation by the device.

There are advantages and disadvantages to both blood pressure techniques. Automatic oscillometric devices reduce the white coat response compared to manual measurements (19, 20), as blood pressure can be taken with the clinician outside of the patient’s room. In addition, automatic devices are less susceptible to what is referred to as an auscultatory gap, which is a period of diminished or absent Korotkoff sounds, resulting in an underestimation of systolic blood pressure (21). However, automatic devices measure blood pressure by detecting vibration, therefore they cannot be used to measure blood pressure during exercise (20, 22) whereas manual devices can.

A new method to measure blood pressure is wrist monitors. This may be more useful for obese patients where cuff sizing options are limited (23). However, the accuracy of these devices has been demonstrated to overestimate blood pressure (22, 23).

Automatic auscultatory devices have been proposed as an alternative to manual and oscillometric devices (24, 25). These devices combine the best features of manual and oscillometric options, however this may be too costly for routine outpatient physical therapy practices.

Equipment Function and Calibration:

Routine equipment checks and maintenance are essential to ensure accurate readings are taken. Prior studies demonstrated 22% of aneroid gauges used in physical therapist practices are not adequately calibrated (26, 27). Therefore, maintenance and regular calibration ranging from 6 months to 2 years is essential to measure blood pressure accurately. Standardized calibration protocols exist such as the one recommended by the European Society of Hypertension (18). This procedure involves connecting a Y-tube connector allowing for a synchronized comparison of the mercury and aneroid gauges at 50 mmHg increments to ensure proper readings throughout the entire range. As opposed to mercury sphygmomanometers, the use of digital pressure gauges could be used to conduct these inspections.

BP Cuff Size Selection:

Not selecting the appropriate cuff size can result in significant blood pressure measurement error (22). Therefore, having proper cuff sizes is vital to ensure accurate readings. It is recommended that the cuff should have a bladder length that is 80% and a width that is at least 40% of the arm circumference (22). The bladder refers to the plastic inflatable piece inside the outer cuff wrap. Two methods to ensure proper sizing is to determine the radius of the blood pressure measurement site or use the index line and reference range printed on the blood pressure cuff. If the index line falls outside the refence range, a different sized cuff is required.

Standardized Measurement Technique:

The standard measurement position includes having the individual in a seated position resting for 5 minutes prior to obtaining the measurement (28, 17). Their feet should be flat on the floor and uncrossed with their back supported. Their arm should be positioned with the shoulder in a mid-point of flexion and the elbow fully extended and pronated. If the arm is above or below the right atrium level, readings may be underestimated or overestimated respectively. During the initial exam, blood pressure measurement of both arms is recommended, and the side of the higher reading should be used for future readings. Additional controls should be employed for speaking, sneezing, coughing and isometric contraction of the surrounding musculature during measurement (29). Any deviation from the standard position can impact the blood pressure readings. Some positioning errors such as the patient talking and a full urinary bladder can impact blood pressure by as much as 10-15 mmHg (22).

Forearm, Thigh and Calf Blood Pressure Measurement:

For situations where upper arm measurements are not possible, a forearm measurement may be indicated. As well, if an upper extremity measurement is not possible, a calf or thigh measurement would be indicated.

Measurements using alternative locations follow the same standard measurement procedures with a few exceptions. First, the auscultation of the Kortokoff sounds would take place at the artery below the site of cuff inflation. Second, a supine position would be the best option to limit muscular contraction of the lower extremity. Third, bony structures of the ankle or wrist may interfere with sound transmission through the stethoscope and therefore manual palpation or use of a Doppler to obtain the systolic blood pressure may be indicated. Finally, the established values for blood pressure classification are for an upper arm measurement and variability may exist in different parts of the arterial tree (22). In these circumstances, more regular measurements are required. For example, distal arteries may have an increased systolic blood pressure whereas diastolic blood pressure may be decreased (22).
Standing Blood Pressure and Response to Position Change:
Some increases in blood pressure are expected when going from supine to sitting and standing. For example, diastolic pressure in sitting can be 5 mmHg higher than supine (30). An orthostatic response would be considered abnormal if the systolic blood pressure decreases by 20 mmHg or greater or the diastolic pressure decreases by 10 mmHg or greater as the individual moves to a more upright position. It is recommended to take the measurements at 1 and/or 3-minute time frames after the position change (31). A condition known as initial orthostatic hypotension is defined as no decrease in systolic pressure and/or a decrease in diastolic pressure of > 20 mmHg within the first 15 seconds of standing but correcting within 30-60 seconds (32). If there is an abnormal response to positional changes, appropriate referrals are required.

Blood Pressure Response to Exercise:

Blood pressure measurement during exercise may provide a more robust assessment of a patient’s hemodynamic stability and clinical prognosis (33-35). The cardiovascular system is expected to increase cardiac output in order to match the increase in metabolic demand of working muscles. A normal response to dynamic exercise is blood pressure increasing in systolic pressure and no change or a slight drop in diastolic pressure. A failure of the systolic pressure to increase with increased workloads indicates inadequate cardiac output, while a rapid increase in systolic blood pressure with a minimal increase in workload would indicate high total peripheral resistance and thus impaired vascular function such as arterial stiffness (7).

During exercise, an increase of 8-12 mmHg of systolic blood pressure per metabolic equivalent with a plateau at peak exercise is expected (36). The normal increase from rest is 55 to 65 mmHg for systolic blood pressure in men and 45 to 60 mmHg in women, however depending on the individual’s age, these are variable (37). Diastolic blood pressure values change to a greater degree in women with values increasing across their lifespan (37).

Blood Pressure Screening During Exercise:

From a safety standpoint, it is important for physical therapists to monitor blood pressure responses to exercise during treatment sessions. It has even been demonstrated that blood pressure response to exercise serves as a valuable prognostic marker for future cardiovascular events, independent of resting blood pressure levels (29). However, measurements during and following exercise are underutilized. Exercise hypertension is an exaggerated response to exercise, defined as a reading greater than or equal to the 90th percentile relative to normative data (65, 68). Those with exercise hypertension have a 1.4-3.0 increased relative risk for cardiovascular events compared to normal blood pressure individuals (38).

In addition to issues surrounding elevated blood pressure during exercise, an abnormally low blood pressure response to exercise has been demonstrated to be a strong prognostic factor of cardiovascular events and all-cause mortality, independent of clinical presentation or exercise intensity (33). During an exercise test, if a persistent decrease in systolic blood pressure of 10 mmHg or greater is noted with increased workload, the test should be terminated (36, 39).

Measurement of Blood Pressure During Exercise:

In the absence of automated blood pressure devices, clinicians should rely on manual auscultatory methods. During low to moderate intensity exercise, accurate measure using manual methods are possible (7). However, as exercise intensity increases, blood pressure measurements may become increasingly difficult to auscultate. Blood pressure should be measured at rest, during exercise and post exercise. If blood pressure can’t be measured during exercise, measuring immediately after exercise in the same exercise position can occur. This would be referred to post-exercise blood pressure and not exercise blood pressure. Within 6 minutes after exercise, the systolic blood pressure should return to pre-exercise levels and in some cases, a post exercise hypotensive response may be present (40).

Exercise Management for Hypertension:

Exercise has been demonstrated to be as effective as pharmacologic therapy in terms of treatment effectiveness for hypertension (40, 41). Although the benefits of exercise therapy have been well-established, only 15% of American adults with hypertension have been reported to meet the exercise recommendations (42). An aerobic exercise program for 90 to 150 minutes per week at 65 – 75% of the patient’s heart rate reserve can result in a systolic blood pressure reduction of about 5-8 mmHg in hypertension individuals and 2-4 mmHg in normotensive individuals (43, 44). Decreases of this amount have been shown to reduce the risk of stroke by 14%, coronary artery disease by 9% and total mortality by 7% (40, 45).

Clinical Application & Conclusions:

Hypertension is a serious medical condition that affects a significant portion of the population. In order to effectively manage this condition, communication between all health care professionals needs to occur. With the large body of literature demonstrating the need for physical therapists, and other clinical professionals (i.e. chiropractors) to consistently measure blood pressure in patients, it is only logical this is carried out in outpatient clinics. Simple blood pressure measures performed in outpatient clinics have the ability to reduce burden on the health care system and identify hypertensive patients early before a serious medical emergency occurs.

Rehabilitation professionals are uniquely situated to not only screen for hypertension, but also to provide effective evidence-based exercise interventions to help manage these patients.

Study Methods:

This was a “Perspective” article. Therefore, no statistical analysis was conducted nor was a specific description of their methodology provided.

Study Strengths / Weaknesses:

  • The authors discuss a broad range of topics in order to effectively make their arguments.
  • This article is a perspective piece and therefore doesn’t follow the same rigor as a systematic review. This could result in a biased look at the literature on this topic.

Additional References:

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