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The Cochrane Database of Systematic Reviews logoLink to The Cochrane Database of Systematic Reviews
. 2021 Feb 24;2021(2):CD008823. doi: 10.1002/14651858.CD008823.pub2

Walking for hypertension

Ling Ling Lee 1,, Caroline A Mulvaney 2, Yoko Kin Yoke Wong 3, Edwin SY Chan 3, Michael C Watson 4, Hui Hsin Lin 5
Editor: Cochrane Hypertension Group
PMCID: PMC8128358  PMID: 33630309

Abstract

Background

Increased physical activity has been recommended as an important lifestyle modification for the prevention and control of hypertension. Walking is a low‐cost form of physical activity and one which most people can do. Studies testing the effect of walking on blood pressure have revealed inconsistent findings.

Objectives

To determine the effect of walking as a physical activity intervention on blood pressure and heart rate.

Search methods

We searched the following databases up to March 2020: the Cochrane Hypertension Specialised Register, CENTRAL (2020, Issue 2), Ovid MEDLINE, Ovid Embase, CINAHL, PsycINFO, SPORTDiscus, PEDro, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also searched the following Chinese databases up to May 2020: Index to Taiwan Periodical Literature System; National Digital Library of Theses and Dissertation in Taiwan; China National Knowledge Infrastructure (CNKI) Journals, Theses & Dissertations; and Wanfang Medical Online. We contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

Selection criteria

Randomised controlled trials of participants, aged 16 years and over, which evaluated the effects of a walking intervention compared to non‐intervention control on blood pressure and heart rate were included.

Data collection and analysis

We used standard methodological procedures expected by Cochrane. Where data were not available in the published reports, we contacted authors. Pooled results for blood pressure and heart rate were presented as mean differences (MDs) between groups with 95% confidence intervals (CIs). We undertook subgroup analyses for age and sex. We undertook sensitivity analyses to assess the effect of sample size on our findings.

Main results

A total of 73 trials met our inclusion criteria. These 73 trials included 5763 participants and were undertaken in 22 countries. Participants were aged from 16 to 84 years and there were approximately 1.5 times as many females as males. The characteristics of walking interventions in the included studies were as follows: the majority of walking interventions was at home/community (n = 50) but supervised (n = 36 out of 47 reported the information of supervision); the average intervention length was 15 weeks, average walking time per week was 153 minutes and the majority of walking intensity was moderate. Many studies were at risk of selection bias and performance bias.

Primary outcome

We found moderate‐certainty evidence suggesting that walking reduces systolic blood pressure (SBP) (MD ‐4.11 mmHg, 95% CI ‐5.22 to ‐3.01; 73 studies, n = 5060). We found moderate‐certainty evidence suggesting that walking reduces SBP in participants aged 40 years and under (MD ‐4.41 mmHg, 95% CI ‐6.17 to ‐2.65; 14 studies, n = 491), and low‐certainty evidence that walking reduces SBP in participants aged 41 to 60 years (MD ‐3.79 mmHg, 95% CI ‐5.64 to ‐1.94, P < 0.001; 35 studies, n = 1959), and those aged 60 years of over (MD ‐4.30 mmHg, 95% CI ‐6.17 to ‐2.44, 24 studies, n = 2610). We also found low certainty‐evidence suggesting that walking reduces SBP in both females (MD ‐5.65 mmHg, 95% CI ‐7.89 to ‐3.41; 22 studies, n = 1149) and males (MD ‐4.64 mmHg, 95% CI ‐8.69 to ‐0.59; 6 studies, n = 203).

Secondary outcomes

We found low‐certainty evidence suggesting that walking reduces diastolic blood pressure (DBP) (MD ‐1.79 mmHg, 95% CI ‐2.51 to ‐1.07; 69 studies, n = 4711) and heart rate (MD ‐2.76 beats per minute (bpm), 95% CI ‐4.57 to ‐0.95; 26 studies, n = 1747). We found moderate‐certainty evidence suggesting that walking reduces DBP for participants aged 40 years and under (MD ‐3.01 mmHg, 95% CI ‐4.44 to ‐1.58; 14 studies, n = 491) and low‐certainty evidence suggesting that walking reduces DBP for participants aged 41 to 60 years (MD ‐1.74 mmHg, 95% CI ‐2.95 to ‐0.52; 32 studies, n = 1730) and those aged 60 years and over (MD ‐1.33 mmHg, 95% CI ‐2.40 to ‐0.26; 23 studies, n = 2490). We found moderate‐certainty evidence that suggests walking reduces DBP for males (MD ‐2.54 mmHg, 95% CI ‐4.84 to ‐0.24; 6 studies, n = 203) and low‐certainty evidence that walking reduces DBP for females (MD ‐2.69 mmHg, 95% CI ‐4.16 to ‐1.23; 20 studies, n = 1000). Only 21 included studies reported adverse events. Of these 21 studies, 16 reported no adverse events, the remaining five studies reported eight adverse events, with knee injury being reported five times.

Authors' conclusions

Moderate‐certainty evidence suggests that walking probably reduces SBP. Moderate‐ or low‐certainty evidence suggests that walking may reduce SBP for all ages and both sexes. Low‐certainty evidence suggests that walking may reduce DBP and heart rate. Moderate‐ and low‐certainty evidence suggests walking may reduce DBP and heart rate for all ages and both sexes.

Plain language summary

The effect of walking on blood pressure control

Review question

Can walking lower blood pressure?

Background

Hypertension or elevated blood pressure is a major risk factor for cardiovascular diseases, such as coronary heart disease, stroke, and heart failure. Lowering blood pressure to normal levels is effective in reducing the risks of these diseases. Many of the risk factors relating to hypertension, such as physical inactivity, a diet high in salt and fat, or cigarette smoking, are related to lifestyle. Physical activity is recognised as an essential component of a healthy lifestyle. However many people may find it difficult to undertake exercise that fits into their daily lives. Walking is a low‐cost activity and one which many people can do. Previous studies have shown inconsistent results of the effect of walking on blood pressure control.

Study characteristics

We included 73 trials involving 5763 participants from 22 countries, published up to March 2020. These trials included both males and females; with an age range from 16 to 84 years with approximately half aged over 60 (51%) and 39% aged 41 to 60 years with various health conditions. The types of walking activity varied, including home‐, community‐, school‐, or gym‐based walking several times a week with different intensity levels.

Key results

We found moderate‐certainty evidence suggesting that walking reduces systolic blood pressure (SBP). We found moderate‐certainty evidence suggesting that walking reduces SBP in participants aged 40 years and under and low‐certainty evidence that walking reduces SBP in participants aged 41 and over. We also found low certainty‐evidence suggesting that walking reduces SBP in females and males. We found low‐certainty evidence suggesting that walking reduces diastolic blood pressure (DBP) and heart rate. Only 21 studies reported a total of eight adverse events, with knee injury reported five times as an adverse event. Many studies did not report how participants were allocated to the walking and control groups and whether those who assessed outcomes knew to which group a participant belonged. However, our outcomes of blood pressure and heart rate are objective measures and thus are less likely to be influenced by knowledge of whether a participant was in a walking or control group. Our findings suggest that moderate‐intensity walking, three to five times per week, of 20 to 40 minutes duration, and 150 minutes per week for approximately three months could have an effect on lowering blood pressure.

Summary of findings

Background

Description of the condition

Hypertension is responsible for approximately nine million deaths worldwide each year (Lim 2012) and an estimated 1.13 billion people globally have hypertension, with two‐thirds living in low‐ and middle‐income countries (WHO 2019). The premature death and disability caused by hypertension can have a considerable financial toll on families, health services, and national finances (WHO 2013). Hypertension is also a risk factor for various health problems, such as myocardial infarction, heart failure, chronic kidney disease, stroke, peripheral artery disease, and atrial fibrillation (Qamar 2018). Epidemiologic studies show that cardiovascular disease (CVD) events, such as coronary heart disease, stroke, and heart failure, are associated with elevated blood pressure levels (Amici 2009; Pini 2008; Rodriguez 2014). Observational studies document a progressive increase in heart disease risk as blood pressure rises above 115/75 mmHg ( Lawes 2008; Lewington 2002). A recent meta‐analysis of prospective cohort studies demonstrates that even just a stage I hypertension (systolic blood pressure (SBP) 130 to 139  mmHg or diastolic blood pressure (DBP) 80 to 89  mmHg) is associated with those CVD events and its morbidity and mortality (Han 2019).

Lowering blood pressure to standard targets has been found to be effective in reducing the risks of coronary artery disease and stroke (Lewington 2002; Staessen 2001; Vargas‐Urocoechea 2019), and effective control of stage 1 hypertension was found to prevent more than 10% of CVD (Han 2019). The report to the Eighth Joint National Committee for Detection, Evaluation, and Treatment of High Blood Pressure (JNC‐8) recommends that individuals achieve a target SBP <140 mmHg and DBP lower than 90 mmHg (James 2014; Lawes 2008; Lewington 2002). SBP is suggested as a better predictor of adverse health events than DBP (Ettehad 2016; Haider 2003).

Hypertension control through pharmacological treatment has led to substantial benefits in the primary prevention of morbidity and mortality from cardiovascular diseases (Ettehad 2016; Law 2009; Li 2019; Musini 2019; Blood Pressure Lowering Treatment Trialists 2000; Blood Pressure Lowering Treatment Trialists 2008; Wright 2018). Given some of the drawbacks to the pharmacological treatment of hypertension, such as discontinuation of the drug treatment due to potential adverse effects and the level of adherence with prescribed medication, non‐pharmacological interventions play an important role in controlling hypertension (Bonilla Ocampo 2018; Hagberg 2000).

There are several non‐modifiable risk factors for hypertension including a family history of hypertension, age over 65 years and co‐existing diseases (e.g. kidney disease and diabetes), but modifiable risk factors for hypertension include use of tobacco and consumption of alcohol, high fat diet, excessive salt consumption, physical inactivity and obesity (WHO 2002; WHO 2019). These modifiable risk factors for hypertension are related to lifestyle.

As hypertension is associated with lifestyle factors, all of the current guidelines highlight the role of non‐pharmacological interventions in hypertension management (James 2014; Whelton 2002; WHO 2003; Williams 2004). When most people with hypertension fall into the categories of high‐normal to stage 1 blood pressure elevations, which are lower than the level at which physicians often begin to prescribe antihypertensive medications (Wang 2004), lifestyle modifications maybe even more important than pharmacological treatment to control blood pressure.

Description of the intervention

Lifestyle physical activity interventions have been recommended as a way of lowering blood pressure and reducing the risk of heart disease (James 2014; Williams 2004). Some randomised controlled trials have provided evidence of the benefits of physical activity on reduction in SBP (Duru 2010; Murphy 2006), however, other studies found no such benefits (Elley 2003; Lawton 2008; Liira 2014). These contradictory data could result from methodological differences in the type of physical activity used in the intervention (frequency, duration, intensity, mode of supervision), target population, or overall study design. In addition, many people may find it difficult to fit physical exercise into their daily lives. Walking is one of the easiest forms of low‐cost physical activity and one which many people can do.

How the intervention might work

Evidence from randomised and non‐randomised trials suggests that walking may lead to improvements in SBP and DBP (Kelley 2001; Lee 2006). Walking, as an everyday activity for most people, is likely to be the most relevant low‐to‐moderate‐intensity activity, and brisk walking is a common and feasible form of sustainable dynamic aerobic exercise (Mabire 2017; Tschentscher 2013). For adults aged 18 and over, walking is the most popular physical activity (Afonso 2001; Australian Bureau of Statistics 2003; National Institutes of Health 1996), and the most common leisure activity among both men and women (Australian Bureau of Statistics 2003; Crespo 1996; Office for National Statistics 2003).

Why it is important to do this review

Results from previous studies examining the effect of walking interventions on blood pressure have been inconsistent. A meta‐analysis of walking programs for blood pressure management found beneficial effects either from various study designs (Kelley 2001); limited in a specific population, such as inactive adults (Oja 2018) or those with type 2 diabetes (Cai 2014); complex interventions, such as combining walking, jogging and/or running (Nieman 2013, Shabaaninia 2017, Sijie 2012); or compared a walking intervention with participants in the control group who also received an intervention, such as active pedometer‐based walking intervention (Vetrovsky 2018) or lifestyle modification, such as health education (Zhang (張舒) 2012) or salt reduction (Subramanian 2011). More evidence from randomised controlled trials in the general population and investigation of the effect of walking alone on blood pressure is needed. The purpose of this review is to examine whether walking is effective in controlling blood pressure.

Objectives

To determine the effect of walking as a physical activity intervention on blood pressure and heart rate.

Methods

Criteria for considering studies for this review

Types of studies

We included individually‐randomised parallel group controlled trials. We excluded cluster‐randomised studies due to the risk of contamination and we did not include cross‐over trials due to possible carry‐over effects of the intervention.

Types of participants

Both hypertensive and normotensive adults aged 16 years and over.

Types of interventions

Walking interventions including community, laboratory‐based (e.g. treadmill), or non‐stair and non‐uphill treadmill walking were included. Mixed interventions of walking with other modes of physical activity, such as jogging, or other forms of lifestyle modification, such as dietary salt reduction, were excluded.

The comparison was non‐exercising and non‐intervention controls.

Types of outcome measures

All outcome measures of: systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) as continuous data.

Primary outcomes

Systolic blood pressure (SBP) (continuous): measured by any standard devices, such as electronic or traditional mercury sphygmomanometer, or 24 hours ambulatory blood pressure measurement in millimetres of mercury (mmHg) pressure units.

Secondary outcomes
  1. Diastolic blood pressure (DBP) (continuous): measured by any standard devices, such as electronic or traditional mercury sphygmomanometer, or 24 hours ambulatory blood pressure measurement in mmHg.

  2. Heart rate (HR) (continuous): measured by any standard devices in beats per minute (bpm).

Search methods for identification of studies

Electronic searches

The Cochrane Hypertension Information Specialist conducted systematic searches in the following databases for randomised controlled trials without language, publication year, or publication status restrictions:

  • Cochrane Hypertension Specialised Register via the Cochrane Register of Studies (CRS‐Web) (searched 8 March 2020);

  • Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies (CRS‐Web) (2020, Issue 2);

  • MEDLINE Ovid (from 1946 onwards), MEDLINE Ovid Epub Ahead of Print, and MEDLINE Ovid In‐Process & Other Non‐Indexed Citations (searched 7 March 2020);

  • Embase Ovid (searched 7 March 2020);

  • CINAHL EBSCO (searched 9 March 2020);

  • SPORTDiscus EBSCO (searched 11 March 2020);

  • PsycINFO EBSCO (searched 9 March 2020);

  • Physiotherapy Evidence Database (PEDro) (searched 11 March 2020);

  • ClinicalTrials.gov (www.clinicaltrials.gov) (searched 11 March 2020);

  • World Health Organization International Clinical Trials Registry Platform (https://apps.who.int/trialsearch) (searched 11 March 2020).

Databases were searched from the date of inception. The Information Specialist modelled subject strategies for databases on the search strategy designed for MEDLINE. Where appropriate, they were combined with subject strategy adaptations of the sensitivity‐ and precision maximising search strategy designed by Cochrane for identifying randomised controlled (as described in Chapter 4 of the Cochrane Handbook for Systematic Reviews of Interventions Version 6 (Lefebrve 2019). We present the search strategies for major databases in Appendix 1.

The review authors also searched the following databases from the date of inception:

  • Index to Taiwan Periodical Literature System (searched 18 May 2020);

  • National Digital Library of Theses and Dissertations in Taiwan (searched 18 May 2020);

  • China National Knowledge Infrastructure (CNKI)‐Journals, Theses & Dissertations (searched 18 May 2020);

  • Wanfang Medical Online (searched 18 May 2020).

Searching other resources

  • The Cochrane Hypertension Information Specialist searched the Hypertension Specialised Register segment (which includes searches of MEDLINE and Epistemonikos for systematic reviews) to retrieve existing systematic reviews relevant to this systematic review, so that we could scan their reference lists for additional trials. The Specialised Register also includes searches of CAB Abstracts & Global Health, CINAHL, ProQuest Dissertations & Theses and Web of Knowledge.

We checked the bibliographies of included studies and any relevant systematic reviews identified for further references to relevant trials. Where necessary, we contacted authors of key papers and abstracts to request additional information about their trials. We did not perform a separate search for adverse effects of interventions used for the treatment of hypertension. We considered adverse effects described in the included studies only.

Data collection and analysis

Selection of studies

All titles and abstracts identified through the searches were scanned by two review authors (LLL and HHL) independently for eligibility of inclusion. Abstracts that did not meet all the inclusion criteria were rejected. Any discrepancies were discussed and resolved by a third review author (CM). Full‐text articles for all included titles and abstracts were then retrieved and assessed by two review authors (LLL and HHL) to determine whether they met the inclusion criteria. Uncertainties concerning the appropriateness of studies for inclusion in the review were discussed and resolved through consultation with a third review author (CM). We have produced a PRISMA flow chart (Figure 1) showing how we selected our studies for inclusion in the review.

1.

1

Data extraction and management

A data extraction form was used to extract data on population, study methods, intervention, and outcomes. Two review authors independently extracted data (CM and LLL; EC and YW) and then compared the data. Any discrepancies were identified and resolved via discussion. We extracted data on study aim, inclusion and exclusion criteria, description of the intervention and control, and outcomes of interest. Special care was taken to avoid the inclusion of multiple reports pertaining to the same individuals, for example in trials reporting outcomes over multiple time periods. Where data were not available in the published trial reports, we contacted authors requesting missing information, and studies were excluded when data were not available.

Assessment of risk of bias in included studies

Using the Cochrane 'Risk of bias' tool (RoB1), two review authors (CM and LLL; EC and YW) independently assessed each study by examining randomisation procedure; allocation concealment; blinding of participants, intervention providers, and outcome assessors; incomplete outcome and losses to follow‐up. Discrepancies were resolved by discussion between the two review authors and, if needed, by consulting a third review author.

Measures of treatment effect

The mean blood pressure and heart rate differences from baseline to follow‐up in the intervention and control groups were compared and pooled using the weighted mean difference (WMD) approach (see Cochrane Collaboration: http://www.epi.bris.ac.uk/cochrane/stats3.html). The appropriateness of conducting meta‐analysis was checked by assessing clinical, methodological, and statistical homogeneity. Where insufficient information about the variance has been provided in trial reports, we calculated variances and took the correlation of baseline and final blood pressure measurements (Follmann 1992) into account. We contacted trial authors to collect the data insufficiently reported in the original trial, such as systolic or diastolic blood pressure readings at either baseline or follow‐up, and trials were excluded when the requested data were not available.

Unit of analysis issues

The unit of analysis was each participant. For studies with more than two arms, we included only arms that met the inclusion criteria of the review.

Dealing with missing data

We addressed the issue of missing data by requesting information from the original study authors. Where such attempts were unsuccessful and data could not be obtained, or estimates had to be derived by making further assumptions, the robustness of the overall findings was assessed through sensitivity analyses.

Assessment of heterogeneity

We used forest plots, Chi2 tests, and I²to test for heterogeneity between the results of the studies in the review. We regarded a level of heterogeneity above 50% as substantial or high, as explained in the Cochrane Handbook for Systematic Reviews of Interventions, Section 9.5.2 (Higgins 2011). Where significant heterogeneity existed, explanations were sought for the sources of heterogeneity such as differences in the design or methodological characteristics.

Assessment of reporting biases

The possibility of publication bias was examined using funnel plots. If there was evidence that publication bias did exist, the trim‐and‐fill method (Duval 2000; Peters 2007) was used. This method estimates and adjusts for the numbers and outcomes of studies estimated as being missing and provides a sensitivity analysis to assess the robustness of the results to the likely degree of publication bias in the literature.

Data synthesis

We checked the appropriateness of conducting meta‐analysis by assessing for clinical and design homogeneity and presented the pooled results of SBP and DBP, and heart rate as mean differences (MDs) between groups and 95% Confidence Intervals (CIs). Random‐effects models were used to take account of statistical heterogeneity between combinable studies. We used Cochrane Review Manager 5.4 (RevMan 2014 [Computer program]) for data synthesis.

Subgroup analysis and investigation of heterogeneity

Subgroup analyses according to age and sex were carried out among the studies with sufficient information. Pooled results for SBP and DBP and heart rate were presented as MDs between groups and 95% CIs. Statistical heterogeneity was quantified by I². Random‐effects models were used to allow for statistical heterogeneity present between studies.

Sensitivity analysis

We performed sensitivity analyses to assess the effect of walking on blood pressure in studies we assessed at low risk of overall bias. We also performed a sensitivity analysis for studies assessed at low risk of attrition bias.

Summary of findings and assessment of the certainty of the evidence

We used the GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) (Guyatt 2011) to assess the certainty of the evidence for each estimate of intervention effect (Schünemann 2019a; Schünemann 2019b). We rated the certainty of the evidence by assessing the 'Risk of bias' evaluation, indirectness of evidence, inconsistency (considering I² and P value), imprecision of effect estimates (95%CI or small size of effect), and potential publication bias. We rated the certainty of the evidence as high, moderate, low or very low. We downgraded the evidence from 'high certainty' by one level for serious limitations or by two levels for very serious study limitations. We present key findings of the review in the 'Summary of findings' tables, including a summary of the amount of data, the magnitude of the effect size and the overall certainty of the evidence.

Results

Description of studies

Results of the search, included and excluded studies are described as follows.

Results of the search

Our initial searches identified 51,195 potentially relevant papers. After the removal of duplicates and initial screening, 7565 records remained. After conducting a further assessment on the basis of title and abstract, we excluded 7166 records and obtained the full text of 399 studies. After screening the full text of these 399 studies, 73 studies remained (Figure 1). Three studies are ongoing and will be considered in updates of this review when needed (Characteristics of ongoing studies).

Included studies

Seventy‐three randomised controlled trials involving 6473 participants met our inclusion criteria and were included in the review. Of the 6473 participants randomised into the 73 trials, 5763 received the eligible intervention and 5060 were analysed. The details of the methods, participants, intervention, comparison group, and outcome measures for each of the included trials are shown in the Characteristics of included studies. Further study details are presented in Table 4. The trials were published over a 30‐year period between 1991 and 2020, with 10 published during the 1990s, 23 during the 2000s, and 40 in 2010 to 2020.

1. Baseline characteristics of included studies.
Study ID Participants randomised n Country Study population Mean age (SD) or range Male/total (%) Mean baseline SBP (SD)(mmHg) Mean baseline DBP (SD)(mmHg) Mean baseline HR (SD)(beats/min)
Araiza 2006 30 USA type 2 diabetes mellitus, free from advanced secondary complications of diabetes. Range 33 to 69; IG: 49 (SD 11); CG:51 (SD 10) NR IG: 140.6 (SD 21.4); CG: 136.6 (SD 19.3) IG: 80.7 (SD 12.2); CG: 77.6 (SD 8.9) NR
Arija 2017 419 Spain Older primary health‐care patients (attending primary health care facilities) IG: 64.5 (SD 9.2); CG: 66.99 (SD 10.28) 84/364 (23.2%) IG: 131.06 (SD 15.94); CG: 135.32 (SD 16.62) IG: 76.75 (SD 9.09); CG: 75.96 (SD 9.86) NR
Baker 2008 80 UK Sedentary general population Range 18 to 65; IG: 47.3 (SD9.3); CG: 51.2 (SD7.9) 16/79 (20.3%) IG: 118.2 (SD 17.9); CG: 119.9 (SD 15.9) IG: 75.1(SD 11.4); CG: 75.5 (SD 11.8) IG: 68.6 (SD 7.2); CG: 67.9 (SD 8.6)
Bang 2016 60 Korea General population (Office workers) IG: 42.22 (SD 11.44); CG: 37.37 (SD 9.32) 3/45 (6.67%) IG: 121.39 (SD 16.02); CG: 112.52 (SD 12.49) IG: 79.00 (SD 9.37); CG: 72.85 (SD 9.35) NR
Baross 2017 24 UK Sedentary young adults IG: 20.9 (SD 2.0); CG: 21.3 (SD 2.0) 13 (54%) IG: 126.7 (SD 3.7); CG: 127.9 (SD 4.2) IG: 77.7 (SD 3.0); CG: 77.0 (SD 1.8) IG: 66.0 (SD 3.1); CG: 67.4 (SD 2.7)
Bayat 2018 120 Iran Woman with Type 2 Diabetes IG: 53.77 (SD 6.52); CG: 52.06 (SD 6.28) 0 (0%) IG: 126.04 (SD 16.69), CG: 130.9 (SD 15.64) IG: 74.9 (SD 10.85); CG: 85.0 (SD 10.0)  
Bell 2010 140 Canada Sedentary general population Male: 49 (SD 11); Female: 50 (SD 9) NR IG: 124 (SD 14); CG: 125 (SD 13) IG: 78 (SD 9); CG: 80 (SD 9) IG: 73 (SD 9); CG: 76 (SD 11)
Braith 1994 30 USA Normotensive elderly adults Range 60 to 79; IG: 66 (SD 5); CG: 66 (SD 5) NR IG: 121 (SD 10); CG: 121 (SD 12) IG: 72 (SD 8); CG: 74 (SD 5) IG: 71 (SD 8); CG: 65 (SD 8)
Brandon 2006 52 USA Obese sedentary adults (total: 37.93; AAE: 34.0 (SD 7.2); AAC: 36.0 (SD 8.4); WE: 40.5 (SD 7.1); WC: 42.0 (SD 9.7) 0 (0%) AAE: 110.0 (SD 11.9); AAC: 103.9 (SD 15.6); WE: 111.0 (SD 14.9); WC: 115.0 (SD 18.1) AAE: 69.7 (SD 8.9); AAC: 63.8 (SD 14.6) WE: 67.0 (SD 10.3); WC: 68.5 (SD 10.2) NR
Brenner 2020 48 Canada Patients with vascular problems IG 68.6 (SD 6.87);
CG 63.7 (SD 8.47) 21/33 (63.6%) IG: 124 (SD 15); CG: 132 (SD 14) IG: 67 (SD 8); CG: 69 (SD 11) IG: 63 (SD 12); CG: 66 (SD 13)
Brown 2014 94 UK General population (Office workers) IG1: 46.3 (SD 9.4); IG2: 39.3 (SD 10.3); CG: 40.2 (SD 11.0) 74 (78.7%) IG1: 135.1 (SD 12.3); IG2: 128.9 (SD 15.1); CG: 133.3 (SD 10.5) IG1: 86.0 (SD 7.6); IG2: 81.5 (SD 11.9); CG: 79.5 (SD 7.1) IG1: 67.1 (SD 10.0); IG2: 63.6 (SD 10.1); CG: 64.6 (SD 12.5)
Chan 2018 164 Hong Kong Hypertensive patients IG: 63.22 (SD 11.11); CG: 65.13 (SD 10.22) 80 (48.8%) IG: 138.15 (SD17.39); CG: 142.49 (SD19.12) IG: 79.74 (SD 10.51); CG: 82.59 (SD 10.68) NR
Chiang 2019 32 Taiwan College students with obesity IG1: 19.17 (SD 1.03); IG2: 20.64 (SD 1.80); CG: 19.36 (SD 1.12) NR IG1: 121.92 (SD 15.70); IG2: 121.36 (SD 11.48); CG: 127.00 (SD 17.18) IG1: 76.92 (SD 12.06); IG2: 79.55 (SD 8.85); CG: 74.33 (SD 11.06) IG1: 75.92 (SD 10.13) IG2: 78.3 (SD 10.02) CG: 79.78 (SD 7.85)
Coghill 2008 67 UK Hypercholesterolaemic men Range 45 to 65 67 (100%) IG: 138.04 (SD 15.61); CG: 140 (SD 15.63) IG: 89.90 (SD 9.93); CG: 88.32 (SD 9.52) NR
Cooper 2000 90 UK Sedentary adults with unmedicated hypertension 150‐180 mmHg Range 25 to 63; IG: 46.2 (SD 9.4); CG: 49.4 (SD 8.9) 72 (80%) IG: 139.8 (SD 12.7); CG: 135.7 (SD 9.3) IG: 89.5 (SD 9.6); CG: 87.6 (SD 8.5) NR
Dong 2007 120 China Patients with chronic heart failure IG: 61.7 (SD 12.3); CG: 61.9 (SD 12.1) 66 (55%) IG: 149.10 (SD 44.50); CG: 147.2 (SD 44.1) NR IG: 104 (SD 25); CG: 105 (SD 21)
Dong 2012 51 China White coat hypertension patients Range 45 to 71; IG: 53.75 (SD 16.42); CG: 54.26 (SD 17.18) 29 (56.9%) IG: 129.51 (SD 25.42); CG: 127.96 (SD 23.13) IG: 82.09 (SD 17.23); CG: 83.46 (SD 18.52) NR
Duncan 1991 102 USA Sedentary pre‐menopausal women Range 20 to 40 0 (0%) IG1: 105 (SD 8); IG2: 109 (SD 9); IG3: 108 (SD 6); CG: 108 (SD 8) IG1: 70 (SD 7); IG2: 74 (SD 8); IG3: 73 (SD 9); CG: 74 (SD 7) NR
Dureja 2014 10 India Young adults (post‐graduate students) Range 19 to 25 10 (100%) IG: 116 (SD 5.47); CG: 123 (SD 10.36) IG: 79 (SD 8.94); CG: 82.0 (SD 11.51) NR
Foulds 2014 90 Canada General population Range 20 to 65; total: 44 (SD 13) 21/58 (36.2%) IG1: 116 (SD 16.11); IG2: 111.22 (SD 11.39); IG3: 108.28 (SD 11.58); IG4: 115.15 (SD 11.31);CG: 114.6 (SD 16.97) IG1: 75.2 (SD 10.3); IG2: 72.3 (SD 7.14); IG3: 68.2 (SD 9.17); IG4: 74.9 (SD 11);CG: 69.2 (SD 8.6) NR
Fritz 2013 213 Sweden Overweight general population, & individuals with IGT or T2DM Range 45 to 69; total: 60 (SD 5.3) 95 (44.6%) IG1_NGT: 138 (SD 12.5); IG2_IGT: 141 (SD 14.0); IG3_T2DM: 143 (SD 13.2);CG1_NGT: 137 (SD 15.0); CG2_IGT: 141 (SD 13.0); CG3_T2DM: 144 (SD 12.6) IG1_NGT: 85 (SD 7.9);
IG2_IGT: 84 (SD 7.8);
IG3_T2DM: 85 (SD 7.6);CG1_NGT: 84 (SD 8.8); CG2_IGT: 86 (SD 9.4); CG3_T2DM: 83 (SD 7.4) NR
Geddes 2009 15 USA Multiple sclerosis adults IG: Range 40 to 64; CG: Range 22 to 50 3/12 (25%) NR baseline SBP NR baseline DBP NR
Gilson 2007 70 UK General population (University employees office workers) Male: 41 (SD 11); Female: 42 (SD 11) 7 (10%) IG1: 121.7 (SD 17.3); IG2: 119.0 (SD 7.4); CG: 121.6 (SD 9.9) IG1: 85.6 (SD 12.1); IG2: 85.7 (SD 10); CG: 82.9 (SD 7.3) NR
Gradidge 2018 132 South Africa Obese women (university staff) IG: 44.4 (SD 11.5); CG: 37.4 (SD 8.78) 0 (0%) IG: 127 (SD 14.7); CG: 122 (SD 15.6) NR NR
Hamdorf 1999 49 Australia Elderly sedentary women Range 79 to 91; IG: 82.4 (SEM 0.66); CG: 83.1 (SEM 0.69) 0 (0%) IG: 144.6 (SEM 4.9); CG: 149.3 (SEM 5.1) IG: 72.6 (SEM 2.2); CG: 77.7 (SEM 2.5) IG: 74.4 (SEM 2.1)
CG: 72.7 (SEM 1.7)
Headley 2017 49 USA Stage 3 chronic kidney disease adults IG: 58 (SD 8.0); CG: 57.1 (SD 9.0) 30/46 (65.2%) IG: 126.4 (SD 17.8); CG: 133.7 (SD 19.2) IG: 79.5 (SD 10.2); CG: 79.1 (SD 10.7) IG: 64.3 (SD 8.9); CG: 65.5 (SD 12.3)
Herzig 2014 78 Finland Impaired fasting glucose/ glucose tolerance adults IG: 58.1 (SD 9.9); CG: 59.5 (SD 10.8) 18/68 (26.5%) IG: 138.5 (SD 16.4); CG: 150.4 (SD 20.2) IG: 83.8 (SD 8.0); CG: 85.4 (SD 9.5) NR
Higashi 1999b 27 Japan Essential hypertensive adults IG: 53 (SD 10); CG: 51 (SD 8) 20 (74%) IG: 155.0 (SD 6.6); CG: 155.4 (SD 8.3) IG: 96.0 (SD 4.9); CG: 97.6 (SD 4.3) IG: 71.8 (SD 9.7); CG: 73.1 (SD 6.4)
Holloway 1997 102 USA Sedentary middle‐aged Range 20 to 50 unknown IG1_XS: 113.6 (SD 9.8); IG2_T: 113.4 (SD 11.1); IG3_S: 116.7 (SD 10.0); CG: 114.5 (SD 12.3) IG1_XS: 80.0 (SD 7.3); IG2_T: 81.9 (SD 9.1); IG3_S: 83.5 (SD 8.7); CG: 82.7 (SD 6.0) IG1_XS: 76.4 (SD 9.0) IG2_T:77.0 (SD 8.8) IG3_S: 75.9 (SD 6.3) CG:78.6 (SD 10.1)
Hua 2006 47 Canada Hypertensive adults IG‐Male:55.8 (SD 9.5);
IG‐Female: 56.3 (SD 9.6) CG‐Male: 55.9 (SD 10.2) CG‐Female:58.5 (SD 11.3) 20/40 (50%) IG‐Male: 140 (SD 11); IG‐Female: 141 (SD 16); CG‐Male: 142 (SD 15); CG‐Female: 141 (SD 17) IG‐Male: 92 (SD 7); IG‐Female: 87 (SD 9); CG‐Male: 91 (SD 11); CG‐Female: 88 (SD 9) IG‐Male: 69 (SD 7); IG‐Female: 75 (SD 12); CG‐Male: 75 (SD 15); CG‐Female: 70 (SD 12)
Karstoft 2013 34 Denmark Type 2 diabetes adults IG_CWT: 60.8 (SD 2.2); IG_IWT: 57.5 (SD 2.4); CG: 57.1 (SD 3.0) 20/32 (62.5%) IG_CWT: 155 (SD 5.4); IG_IWT: 138 (SD 3.3); CG: 142 (SD 4.3) IG_CWT: 90.0 (SD 1.8); IG_IWT: 85.0 (SD 2.8); CG: 86.6 (SD 3.5) NR
Khalid 2013 30 Egypt Hypertensive post‐menopausal women Range 40 to 50; IG: 52.9 (SD 2.6); CG: 52.7 (SD 2.2) 0 (0%) IG: 148 (SD 5.6); CG: 154 (SD 6.7)    
Koh 2010 43 Australia Long‐term haemodialysis patients IG: 52.1 (SD 13.6); CG: 51.3 (SD 14.4) 19/31 (61.3%) IG: 143 (SD 32) CG: 145 (SD 18) IG: 78 (SD 16); CG: 80 (SD 9) IG: 73 (SD 9); CG: 74 (SD 10)
Kukkonen‐Harjula 1998 116 Finland Healthy middle‐aged adults Range 30 to 55; IG: 42.1 (SD 5.1); CG: 40.3 (SD 4.5) 55 (47.4%) IG: 118 (SD 12) CG: 75 (SD 11) NR
Kurban 2011 60 Turkey Type 2 diabetes adults IG: 53.77 (SD 8.2); CG: 53.57 (SD 6.6) 29 (48%) IG: 129.17 (SD 12.1); CG: 124.83 (SD 14.59) IG: 78.83 (SD 6.78); CG: 77.88 (SD 10.53) NR
Lee 2007 202 Taiwan Hypertensive adults (mild / moderate) IG: 71.3 (SD 6.4); CG: 71.3 (SD 5.7) 118 (58.4%) IG: 152.0 (SD 10.5); CG: 152.4 (SD 11.1) IG: 83.5 (SD 11.2); CG: 80.6 (SD 8.8) NR
Li 2018 100 China University teachers IG: 42.26 (SD 8.63); CG: 42.39 (SD 8.35) 48/100 (48%) (22+26) IG: 112.69 (SD 13.74); CG: 118.95 (SD 14.99) NR NR
Li 2003 48 USA Elderly sedentary adults Range 60 and above; IG: 72 (SD 6.4); CG: 73.3 (SD 7.3) 9/40 (22.5%) IG: 133.64 (SD 9.68); CG: 132.17 (SD 13.62) IG: 81.5 (SD 9.41); CG: 81.22 (SD 8.59) NR
Lin 2000 22 Taiwan Borderline hypertensive adolescents / students Range 16 to 18 22 (100%) IG1: 140 (SD 11.14); IG2: 137.75 (SD 6.69); CG: 145.67 (SD 10.33) IG1: 92.25 (SD 3.45); IG2: 91.75 (SD 4.06); CG: 93.67 (SD 4.27) NR
Ming 2018 64 China Elderly patients with Coronary Heart Disease and Hypertension IG: 63.18 (SD 5.42); CG: 62.76 (SD 5.54) 40 (62.5%) IG: 136.79 (SD 7.03); CG: 137.32 (SD 7.44) IG: 95.88 (SD 4.10); CG: 96.30 (SD 4.52) IG: 83.18 (SD 8.14); CG: 83.55 (SD 8.09)
Moreau 2001 24 USA Postmenopausal women with borderline stage 1 hypertension IG: 53 (SE 2); CG: 55 (SE 1) 0 (0%) IG: 142 (SE 3); CG: 142 (SE 3) IG: 84 (SE 1); CG: 86 (SE 2) IG: 77 (SE 3); CG: 77 (SE 3)
Murphy 1998 47 UK Sedentary middle‐aged women IG1: 44.8 (SD 8.4); IG2: 48.0 (SD 5.5); CG: 47.3 (SD 4.1) 0 (0%) IG1_short bout: 125.5 (SD10.8); IG2_long bout: 124.2 (SD11.1); CG: 128.6 (SD13.3) NR NR
Murphy 2006 37 UK Sedentary general population (civil servants) IG: 41.4 (SD 7.5); CG: 40.8 (SD 10.0) 13 (35%) IG: 120.4 (SD 19.7); CG: 116.5 (SD 1 3) IG: 77.2 (SD 9.4); CG: 74.6 (SD 9.0) NR
Murtagh 2005 48 UK Sedentary general population (university staff/students) 45.7 (SD 9.4) 17 (35%) IG1_single bout: 117.9 (SD 12.0); IG2_accumulated bout: 121.7 (SD 11.2); CG: 117.5 (SD 18.1) IG1_single bout: 74 (SD 9.8) IG2_accumulated bout: 75.4 (SD 6.6); CG: 73.1 (SD 10.6) NR
Nemoto 2007 246 Japan General population adults Range 44 to 78; 63 (SD 6) 60 (24%) Wcnt_male: 141 (SE 2); Wcnt_female: 135 (SE 3); Wint_male: 146 (SE 2); Wint_female: 140 (SE 3); CG_male: 143 (SE 2); CG_female: 142 (SE 3) Wcnt_male: 85 (SE 2); Wcnt_female: 81 (SE 2); Wint_male: 87 (SE 3); Wint_female; 85 (SE 2); CG_male: 84 (SE 2); CG_female: 83 (SE 2) Wcnt_male: 81 (SE 3); Wcnt_female: 78 (SE 1); Wint_male: 75 (SE 3); Wint_female; 81 (SE 2); CG_male: 80 (SE 3); CG_female: 79 (SE 1)
Neumann 2006 25 USA Older adults with Silent Myocardial Ischaemia Range 56 to 83; IG: 71 (SE 2); CG: 63 (SE 2) 17 (68%) IG: 134 (SE 3); CG: 140 (SE 6) IG: 76 (SE 3); CG: 80 (SE 2); IG: 71 (SE 3); CG: 71 (SE 3)
Pagonas 2014 72 Germany Hypertensive outpatients IG: Range 42 to 79CG: Range 43 to 77 31 (43.1%) IG: 137.9 (SD 12.3); CG: 133.1 (SD 12.1) IG: 78.1 (SD 8.9); CG: 73.8 (SD 6.4) NR
Palmer 1995b 27 USA Sedentary middle‐aged premenopausal women Range 29 to 50; 37.4 0 (0%) IG: 117.1 (SD 14); CG: 122.6 (SD 13.8) IG: 80.9 (SD 10.6); CG: 77.6 (SD 11.2) IG: 74 (SD 10.8); CG: 71 (SD 6.5)
Pernar 2017 41 Sweden Prostate cancer patients Range 54.5 to 81.7 41 (100%) IG: 170; CG: 162 IG: 93; CG: 89 NR
Pospieszna 2017 39 Poland Postmenopausal women (healthy volunteers) Range 52 to 72; IG: 62 (SD 3.79); CG: 62 (SD 1.12) 0 (0%) IG: 134.7 (SD 21.23); CG: 132.16 (SD 3.8) IG: 75.8 (SD 7.06); CG: 78.58 (SD 1.96) NR
Ready 1996 79 Canada Sedentary postmenopausal women Range 50 and above; 61.3 (SD 5.8) 0 (0%) IG1_3D: 134 (SD 18); IG2_5D: 131 (SD 20); CG: 131 (SD 16) IG1_3D: 77 (SD 11); IG2_5D: 76 (SD 9) CG: 77 (SD 10) NR
Romero 2019 55 USA Sedentary elderly female Range 60 to 75 0 (0%) IG: 143.67 (SD 21.91); CG: 146.07 (SD 24.18) IG: 84.41 (SD 15.19); CG: 82.96 (SD 10.29) NR
Sakuragi 2006 20 Japan Sedentary general population (female college students) Range 20 to 22; IG: 19.4 (SD 1.4); CG: 20.1 (SD 1.2) 0 (0%) IG:93.324(SD17.55);CG:100.13(SD18.09) IG:43.779(SD14.18);CG:50.054(SD11.72) Figure 2
Salesi 2014 32 Iran Elderly women Range 50 to 55 0 (0%) IG: 136.0 (SD 12.1); CG: 131.1 (SD 8.7) IG: 83.1 (SD 10.1); CG: 80.3 (SD 3.8) NR
Saptharishi 2009 58 India Confirmed hypertensive / pre‐hypertensive patients IG: 22.4 (SD 1.3); CG: 22.5 (SD 1.4) 39 (67.2%) IG: 128.6 (SD 7.7); CG: 123.1 (SD 10.2) IG: 87.4 (SD 4.8); CG: 82.9 (SD 7.1) NR
Serwe 2011 60 USA Sedentary office women Range 18 to 50; IG1: 37.1 (SD 7.2); IG2: 38.2 (SD 7.3); CG: 36.3 (SD 8.1) 0 (0%) IG1: 115.1 (SD 10.5); IG2: 117.7 (SD 12.1); CG: 120.9 (SD 9.2) IG1: 73.4 (SD 8.1); IG2: 73.2 (SD 8.7); CG: 72.7 (SD 7.2) IG1: 68.4 (SD 10.4); IG2: 65.8 (SD 6.0); CG: 72.7 (SD 9.5)
Shenoy 2010 40 India T2DM patients Range 40 to 70; IG: 53.15 (SD 4.4); CG: 51 (SD 5.4) 29 (73%) IG: 122 (SD 13.8); CG: 131 (SD 12.7) IG: 85.6 (SD 16.1); CG: 86.0 (SD 7.2) IG: 82.7 (SD 10.6); CG: 81.0 (SD9.7)
Stanton 1996 102 New Zealand Sedentary, essential hypertension volunteers IG: 55.2 (SE 1.4); CG:53.8 (SE 1.5) 42/89 (47.2%) IG: 142.9 (SE 2.5); CG: 145.3 (SE 2.6) IG: 88.4 (SE 1.4); CG: 94.0 (SE 1.4) NR
Stutzman 2010 25 Canada Sedentary normal & overweight 20 weeks pregnant women IG_normal weight: 30.4 (SD 4.2); IG_overweight: 28.8 (SD 6.9); CG_normal weight: 25.8 (SD 3.0); CG_overweight: 26.2 (SD 5.6) 0 (0%) IG_normal weight: 111 (SD 12); IG_overweight: 114 (SD 14); CG_normal weight: 109 (SD 7); CG_overweight: 107 (SD 8) IG_normal weight: 76 (SD 11); IG_overweight: 75 (SD 10); CG_normal weight: 74 (SD 4); CG_overweight: 72 (SD 4) NR
Tudor‐Locke 2004 60 Canada Sedentary overweight T2DM patients Range 40 to 60; total: 52.7 (SD 5.2); IG: 52.8 (SD 5.7) CG: 52.5 (SD 4.8) 26/47 (55.3%) IG: 138.2 (SD 17.2); CG: 130.1 (SD 15.9); IG: 81.5 (SD 9.5); CG: 78.9 (SD 8.0) IG: 76.4 (SD 11.8) CG: 77.0 (SD 9.7)
Tudor‐Locke 2020 120 USA Sedentary overweight/obese and postmenopausal women Range 45 to 75; IG1: 62.6 (SD 6.5); IG2: 61.7 (SD 6.2); CG: 58.4 (SD 5.8) 0 (0%) IG1: 127.6 (SD 16.6); IG2: 125.2 (SD 12.7); CG: 122.5 (SD 13.9) IG1: 78.7 (SD 8.0); IG2: 75.5 (SD 7.6); CG: 77.3 (SD 7.3) NR
Tully 2005 31 UK Sedentary middle‐aged adults Range 50 to 65; IG: 55.52 (SD 3.99); CG: 57.75 (SD 4.64) 13 (42%) IG: 129.94 (SD 8.61); CG: 125.78 (SD 14.02) IG: 78.47 (SD 4.16); CG: 77.22 (SD 7.74) NR
Tully 2007a 106 UK Sedentary middle‐aged adults (civil servants) Range 40 to 61; IG1_3D: 47.8 (SD 5.97); IG2_5D: 46.37 (SD 4.76); CG: 49.05 (SD 6.31) 42 (39.6%) IG1_3‐Day: 134 (SD 15); IG2_5‐Day: 133 (SD 15); CG: 128 (SD 15) IG1_3‐Day: 87 (SD 11); IG2_5‐Day: 87 (SD 11); CG: 83 (SD 10) IG1_3‐Day: 69 (SD 12); IG2_5‐Day: 72 (SD 10); CG: 75 (SD 11)
Tully 2011 12 UK Sedentary university students 21.16 (SD 6.17) 2 (16.7%) IG: 120 (SD 15.62); CG: 131.67 (SD 11.85) IG: 79.00 (SD 8.23); CG: 86.33 (SD 8.50) NR
Venturelli 2011 24 Italy Late stage Alzheimer's disease patients Range 65 and above; IG: 83 (SD 6); CG: 85 (SD 5); 0 (0%) IG: 132 (SD 10); CG: 133 (SD 6) IG: 84 (SD 5); CG: 84 (SD 3) NR
Wallis 2017 46 Australia Severe OA patients rated as grade III or IV affecting at least one of the tibiofemoral compartments Range 50 to 84; IG: 68 (SD 8); CG: 67 (SD 7) 26 (56.5%) IG: 142 (SD 10); CG: 138 (SD 24) IG: 82 (SD 10); CG: 81 (SD 11.1) NR
Wang (王正斌) 2014 62 China Patients with hypertension and Diabetes Mellitus Range 40 to 70; IG: 55.8 (SD 9.3); CG: 57.4 (SD 8.9) 39 (62.9%) IG: 143 (SD 11); CG: 141 (SD 14) IG: 81 (SD 11); CG: 88 (SD 9) NR
Wang 2014 53 Taiwan Sedentary postmenopausal women Range 45 to 70; IG: 56.9 (SD 6.2) CG: 55.1 (SD 7.8) 0 (0%) IG: 124.6 (S D9.2); CG: 127 (SD 10.1) IG: 76.8 (SD 8.1) CG: 79 (SD 9.4) NR
Wang 2016 61 China Hypertensive coal miners Range 18 to 64; IG: 49.61 (SD 4.91); CG: 48.50 (SD 6.31) 31/48 (64.6%) IG: 134.83 (SD 17.43); CG: 143.97 (SD 20.91) IG: 82.39 (SD 12.94); CG: 87.63 (SD 10.48) NR
Westhoff 2007 54 Germany Sedentary Isolated Systolic Hypertension elderly patient Range 60 and above; IG: 67.2 (SD 4.8); CG: 68.9 (SD 5.2) 26 (48.1%) IG: 136.6 (SD 12.7); CG: 134.8 (SD 11) IG: 76.3 (SD 7.3); CG: 72.8 (SD 7.2) Figure 2
Xiao 2010 124 China Elderly Type 2 Diabetes Mellitus patients IG: 65.84 (SD 6.32); CG 65.82 (SD 6.39) 36/112 (32.1%) IG: 141.82 (SD 16.23); CG 141.05 (SD 20.06) IG: 82.91 (SD 9.94); CG 84.04 (SD 10.15) NR
Yan 2010 418 China Patients with Congestive Heart Failure IG: 61.2 (SD 11.8); CG: 62.5 (SD 11.6) 261 (62.4%) IG: 123.1 (SD 21.9); CG: 125.6 (SD 20.2) IG: 68.6 (SD 10.8); CG: 68.5 (SD 10.6) IG: 74.2 (SD 15.7) CG: 77.1 (SD 15.2)
Yu 2018 231 China Elderly patients with Isolated Systolic Hypertension IG1: 82.96 (SD 2.06); IG2: 83.01 (SD 2.09); CG: 83.44 (SD 1.99) 139/211 (65.9%) IG1: 141.67 (SD 5.95); IG2: 140.87 (SD 6.45); CG: 141.94 (SD 5.22) IG1: 63.2 (SD 3.59); IG2: 62.36 (SD 2.84); CG: 63.43 (SD 3.11) NR

CG: control group; CWT: continuous walking training; IG: intervention group; IGT: impaired glucose tolerance; IWT: intermittent walking training; NGT: normal glucose tolerance; NR: not reported; OA: Osteoarthritis; SD: standard deviation; SE: standard error; T2DM: type 2 diabetes mellitus; Wcnt: moderate‐intensity continuous walking training group; Wint: high‐intensity interval walking training group

Study and participant characteristics

The mean age of participants ranged from 16 to 84 years; and there were approximately 1.5 times as many female participants as male ones (3122 versus 2075). Among the trials that reported data about sex, the majority recruited both male and female participants (n = 49 trials), 20 recruited only women and four only men. Hua 2006 and Nemoto 2007 recruited both male and female participants and provided outcome data for each. Sample sizes ranged from 10 to 396. The majority of the trials were conducted in the USA (n = 14) and the UK (n = 12); with nine in China; seven in Canada; four in Taiwan; three each in Australia, India, and Japan; two each in Finland, Germany, Iran, and Sweden; and one each in Denmark, Egypt, Iran, Italy, Korea, Poland, New Zealand, Poland, Spain, and Turkey (Table 4). Among the 73 trials included in the current review, nearly one quarter (n = 17, 23%) reported that they recruited hypertensive participants, while 15 reported that they recruited non‐hypertensive participants (21%).

Interventions and comparators

Among the trials that clearly stated the setting of their interventions (n = 71), the walking interventions were mainly carried out at home/in the community (n = 50) (such as indoor or outdoor walking, nature/city/campus walking, or daily walking), or in the laboratory with the treadmill or stepper (n = 16). There was a total of 36 trials conducting supervised walking programs among the 47 trials reported the information of supervision. The prescription of walking interventions varied widely in the 73 included trials, and included treadmill walking (n = 18), outdoor walking (n = 17), brisk walking (n = 16), and Nordic walking (n = 6). Participants in the control groups received no intervention. In order to be able to compare the length of time of each intervention, we decided to present the time of the intervention in weeks and thus when the length of the intervention was presented as months, we calculated months into weeks using the following formula: number of months*4.33 weeks. On the basis of this calculation, the intervention length ranged from four to 64 weeks, including 12 to 13 weeks in 26 trials and 24 to 26 weeks in 13 trials. Moreau 2001 conducted two outcome measures at both 12 and 24 weeks, respectively and Chan 2018 conducted three at three, six, and nine months, respectively, and we conservatively used the data obtained at the shortest intervention length, which is 12 weeks (three months). The average length of the intervention among all studies was 15 weeks. In terms of frequency and duration of walking, most trials prescribed walking three to five sessions per week and 20 to 40 minutes per session. Among the 77 walking intervention groups that clearly stated the prescription for weekly walking frequency and duration of walking per session, the walking time per week ranged widely from 10 to 845 minutes. The average walking duration per week was 153 minutes (range 150 to 180) prescribed by 22 studies. The second and third most frequently prescribed duration were a walking duration of 90 to 100 minutes per week prescribed by 13 studies and 120 to 149 minutes prescribed by 12 studies.

Among the walking groups that provided information for classifying measures of the walking intensity, 27 intervention groups used maximum heart rate (in the form of either a percentage or calculated heart rate); 24 each reported a walking intensity as VO2max (in the form of either a percentage or calculated VO2max) and walking distance per hour (e.g. 6.5km/hour), per day (e.g. 3 km/day) or per second (e.g. 1.6 to 1.8 metres/second), respectively. Fourteen studies reported the ratings of perceived exertion using the Borg Scale of Perceived Exertion (Borg 1982), and eight used the percentage of heart rate reserve. Of these, 14 walking group intensities were measured using mixed methods, such as walking distance per hour plus the percentage of the maximum heart rate. The intensity of walking varied from minor to high and the majority of the walking groups were moderate intensity (n = 62), with 13 low intensity, 11 self‐paced, and five high intensity.

Funding sources

More than one‐third of the trials included in the current review failed to report their funding sources (n = 32) and studies that clearly reported the funding support received funding from governments (n = 24), private sector (n = 11), both (n = 3), or were self‐funded (n = 3).

Excluded studies

The reasons for study exclusion are mainly due to non randomisation, not just walking but multiple interventions, intervention control groups, or the unavailability of outcome data (see Characteristics of excluded studies).

Risk of bias in included studies

We have summarised our judgments of the risks of bias in Figure 2 and Figure 3. Full details of our judgments of risk of bias are presented in Characteristics of included studies tables.

2.

2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

3.

3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Random sequence generation

Of the 73 included studies, 27 described a method of random sequence generation that we judged to be at low risk of bias. In most studies, researchers used a computerised random number generator. We judged 45 studies to be at unclear risk of random sequence generation due to insufficient information available to make a judgment. We judged one study (Nemoto 2007)  to be a high risk of bias because there were reassignments after randomisation and it was not defined how many participants were reassigned.

Allocation concealment

Only 13 studies described a method of allocation concealment that we judged to be at low risk of bias. For the majority of studies (n = 59), we were unable to judge the risk of allocation bias as these studies failed to report sufficient information on which to make a judgment. We judged one study (Nemoto 2007) to be a high risk of allocation bias because some participants were moved from their allocated group to be in the same group as their partner or to a more convenient administrative centre.

Blinding

Blinding of participants and personnel

Given the nature of the intervention, it was difficult to blind participants and personnel and thus we judged 42 of the 73 included to be at high risk of performance bias. We judged five studies to be at low risk of performance bias. The authors for the remaining 26 studies failed to provide sufficient information regarding blinding of participants and personnel and we, therefore, judged these studies to be at unclear risk of performance bias.

Blinding of outcomes assessors

Fifty‐two studies failed to report information on the blinding of outcomes assessors and therefore we judged the risk of detection bias to be unclear. Blinding of outcome assessment was deemed appropriate in 19 trials and we judged these trials to be at low risk of bias for this domain. We judged the remaining two trials (Cooper 2000; Koh 2010) to be at high risk of detection bias as both authors clearly stated that outcome assessors were not blinded to group assignment.

Incomplete outcome data

The majority of the included studies provided information regarding withdrawals or losses to follow‐up (n = 64). Among the studies that provided sufficient information, the dropout rate varied substantially from 0 to 37% in the 73 included studies. We judged 21 studies to have a high risk of bias due to incomplete outcome data, i.e. the dropout rate was equal to or greater than 20%. There are 45 studies using per‐protocol (PP) analysis, 17 studies using intention‐to‐treat (ITT), and two studies reported both ITT and PP. In addition, there are three studies that performed more than one randomisation in their trial (Nemoto 2007Neumann 2006Stutzman 2010). In Karstoft 2013, a total of three randomisations was carried out and there were five participants entering the trial twice firstly into the control and then into the intervention group.

Selective reporting

We judged all 73 included studies to be at low risk of selective reporting bias because they either reported the data of the primary outcome and/or secondary outcomes in the published paper or provided the outcome data we needed when we contacted them. Ten studies were prospectively registered with a clinical trial registry, and therefore the majority of studies (n = 63) were not.

Other potential sources of bias

In the study by Brenner 2020, participants in both the intervention and control groups received follow‐up phone calls after the first week of the program, and at two‐week intervals during the 12‐week intervention period. Also, in the study by Chan 2018, the participants in all trial arms were encouraged or invited to participate in weekly non‐exercised based community socialisation activities during the three‐month intervention period (Chan 2018). For both studies, these activities are likely to have highlighted the issue regarding the importance of lifestyle modification and thus may have resulted in contamination of the control group participants. This may lead to a dilution in any observed difference between the intervention and control groups in both studies.

To check for publication bias, we produced a funnel plot using the mean difference (MD) for the effects of walking on SBP and DBP against the standard error (SE). An inspection of the two funnel plots shows symmetrical plots, with the effect estimate equally distributed around the mean (Figure 4; Figure 5). This suggests that publication bias is not an issue for this review.

4.

4

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.1 systolic blood pressure [mmHg].

5.

5

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.2 diastolic blood pressure [mmHg].

Effects of interventions

See: Table 1; Table 2; Table 3

Summary of findings 1. Walking compared to no intervention (overall) for control of blood pressure.

Walking compared to no intervention (overall) for hypertension
Patient or population: adults with or without hypertension
Setting: general population
Intervention: walking
Comparison: no intervention (overall)
Outcomes Anticipated absolute effects* (95% CI) № of participants
(studies) Certainty of the evidence
(GRADE) Comments
Effect with no intervention
mmHg
Effect with Walking
mmHg
Systolic blood pressure  The mean systolic blood pressure was ‐1.30 MD 4.11 lower
(5.22 lower to 3.01 lower) 5060
(73 RCTs) ⊕⊕⊕⊝
MODERATE 1 2 Walking interventions probably reduce systolic blood pressure.
Diastolic blood pressure  The mean diastolic blood pressure was ‐0.73  MD 1.79 lower
(2.51 lower to 1.07 lower) 4711
(69 RCTs) ⊕⊕⊝⊝
LOW 2 3 Walking interventions may reduce diastolic blood pressure.
Heart rate [beats/min] The mean heart rate [beats/min] was ‐0.41 beats/min MD 2.76 beats/min lower
(4.57 lower to 0.95 lower) 1747
(26 RCTs) ⊕⊕⊝⊝
LOW 2 4 Walking interventions may reduce heart rate.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidenceHigh certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1 Not downgraded one level for risk of bias even though more than half of included studies failed to report details of randomisation and allocation concealment. This is because a sensitivity analysis based on trials judged as being at low risk of bias also showed a statistically significant reduction of SBP: Weighted Mean Difference= ‐4.31, 95% CI: ‐7.99 to ‐0.63, P = 0.02, I2 = 0%, n = 235.

2 Downgraded one level for inconsistency on the basis of statistically significant heterogeneity.

3 Downgraded one level for risk of bias; More than half of the included studies failed to report details of randomisation and allocation concealment. The sensitivity analysis based on trials judged as being at low risk of bias failed to show a statistically significant reduction of DBP: Weighted Mean Difference = ‐0.47, 95% CI: ‐2.54 to 1.61, P = 0.66, I2 = 18%, n = 235.

4 Downgraded one level for risk of bias; More than half of included studies failed to report details of randomisation and allocation concealment and there is no data for further sensitivity analysis.

Summary of findings 2. Walking compared to no intervention by age for control of blood pressure.

 
Patient or population: adults with or without hypertension
Setting: general population
Intervention: walking
Comparison: no intervention, by age
Outcomes Anticipated absolute effects* (95% CI) № of participants
(studies) Certainty of the evidence
(GRADE) Comments
Effect with no intervention 
mmHg 
Effect with Walking
mmHg
SBP
age <=40
The mean SBP was 1.71 MD 4.41 lower
(6.17 lower to 2.65 lower) 491
(14 RCTs) ⊕⊕⊕⊝
MODERATE 1 Walking interventions probably reduce systolic blood pressure in adults aged equal to or less than 40 years.
SBP
age 41‐60
The mean SBP was ‐1.88  MD 3.79 lower
(5.64 lower to 1.94 lower) 1959
(35 RCTs) ⊕⊕⊝⊝
LOW 1 2 Walking interventions may reduce systolic blood pressure in adults aged 41 to 60 years.
SBP
age >60
The mean SBP was ‐2.21 MD 4.30 
lower
(6.17 lower to 2.44 lower)
2610
(24 RCTs) ⊕⊕⊝⊝
LOW 1 2 Walking interventions may reduce systolic blood pressure in adults aged over 60 years.
DBP  
age <=40
The mean DBP was ‐0.24  MD 3.01 lower
(4.44 lower to 1.58 lower) 491
(14 RCTs) ⊕⊕⊕⊝
MODERATE 1 Walking interventions probably reduce diastolic blood pressure in adults aged equal to or less than 40 years.
DBP  
age 41‐60
The mean DBP by age 41‐60 was ‐0.87 MD 1.74 lower
(2.95 lower to 0.52 lower) 1730
(32 RCTs) ⊕⊕⊝⊝
LOW 1 2 Walking interventions may reduce diastolic blood pressure in adults aged 41 to 60 years.
DBP  
age >60
The mean DBP  was ‐0.86 MD 1.33 lower
(2.40 lower to 0.26 lower) 2490
(23 RCTs) ⊕⊕⊝⊝
LOW 1 2 Walking interventions may reduce diastolic blood pressure in adults aged over 60 years.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment.

2 Downgraded one level for inconsistency; there was statistically significant heterogeneity.

Summary of findings 3. Walking compared to no intervention by sex for control of blood pressure.

 
Patient or population: adults with or without hypertension
Setting: general population
Intervention: walking
Comparison: no intervention, by sex
Outcomes Anticipated absolute effects* (95% CI)   № of participants
(studies) Certainty of the evidence
(GRADE) Comments
Effect with no intervention
mmHg
Effect with Walking
mmHg
SBP in males The mean SBP was ‐1.22  MD 4.64 lower
(8.69 lower to 0.59 lower) 203
(6 RCTs) ⊕⊕⊝⊝
LOW 1 2 Walking interventions may lower systolic blood pressure in male adults.
SBP in females The mean SBP was ‐0.48 MD 5.65 lower
(7.89 lower to 3.41 lower) 1149
(22 RCTs) ⊕⊕⊝⊝
LOW 2 3 Walking interventions may reduce systolic blood pressure in female adults.
DBP in males The mean DBP was ‐1.81  MD 2.54  lower
(4.84 lower to 0.24 lower) 203
(6 RCTs) ⊕⊕⊕⊝
MODERATE 2 Walking interventions probably reduce diastolic blood pressure in male adults.
DBP in females The mean DBP was
0.53
MD 2.69 lower
(4.16 lower to 1.23 lower) 1000
(20 RCTs) ⊕⊕⊝⊝
LOW 2 3 Walking interventions may reduce diastolic blood pressure in female adults.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; 
GRADE Working Group grades of evidenceHigh certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Large 95% confidence intervals.

2 Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment.

3 Downgraded one level for inconsistency; there was statistically significant heterogeneity.

See Table 1; Table 2; Table 3.

Primary outcome

Overall, we found that walking reduced systolic blood pressure (SBP) compared to the non‐intervention control groups (mean difference (MD) ‐4.11 mmHg, 95% confidence interval (CI) ‐5.22 to ‐3.01, P < 0.00001, I² = 53%) on the basis of 73 trials, 5060 participants (Analysis 1.1). The funnel plot for SBP did not show serious small‐study bias (Figure 4). Using GRADE to assess the certainty of the evidence, we downgraded the evidence by one level for inconsistency because there was significant heterogeneity (moderate‐certainty evidence). We did not downgrade one level for risk of bias even though more than half of the included studies failed to report details of randomisation and allocation concealment. This is because a sensitivity analysis based on trials judged as being at low risk of overall bias showed a reduction of SBP (MD ‐4.31 mmHg, 95% CI ‐7.99 to ‐0.63, P = 0.49, I² = 0%).

1.1. Analysis.

1.1

Comparison 1: Walking vs non‐intervention control, Outcome 1: systolic blood pressure

Our analyses showed that walking statistically and significantly lowered SBP in participants in all three age groups. Thus, when comparing participants who received the intervention with those in the control groups, participants aged 40 years and under showed a MD of ‐4.41 mmHg (95% CI ‐6.17 to ‐2.65, P < 0.00001, I² = 0%; 14 studies, n = 491), participants aged 41 to 60 years showed a MD of ‐3.79 mmHg (95% CI ‐5.64 to ‐1.94, P < 0.001, I² = 61%; 35 studies, n = 1959), and those aged 60 years of over showed a MD of ‐4.30 mmHg (95% CI ‐6.17 to ‐2.44, P < 0.001, I² = 60%; 24 studies; n= 2610) (Analysis 2.1). We graded the evidence in the age group of less than or equal to 40 years as moderate due to the concern of risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment; we graded the certainty of the evidence as low in the age groups of 41 to 60 and over 61 due to the two concerns of risk of bias when the majority of included studies failed to report details of randomisation and allocation concealment, and inconsistency when there was statistically significant heterogeneity.

2.1. Analysis.

2.1

Comparison 2: Walking vs non‐intervention control: subgroup analysis by age, Outcome 1: SBP by Age

Regarding sex, the outcome data of the subgroup analysis showed that walking interventions statistically lowered SBP in both females (MD ‐5.65 mmHg, 95% CI ‐7.89 to ‐3.41, P < 0.00001, I² = 44%; 22 studies, n = 1149) and males (MD ‐4.64 mmHg, 95% CI ‐8.69 to ‐0.59, P = 0.02, I² = 29%; 6 studies, n = 203) (Analysis 3.1). We graded the evidence for males and females with low certainty as there were risks of bias, imprecision (large 95% confidence interval), and inconsistency, i.e. significant heterogeneity.

3.1. Analysis.

3.1

Comparison 3: Walking vs non‐intervention control: subgroup analysis by sex, Outcome 1: SBP by Sex

Regarding intervention characteristics, when we consider only the trials with a statistically significant reduction in SBP in the current review, the average walking duration per week (mean = 151 minutes/week. range: 60 to 220 minutes) was similar to the walking duration per week in the trials with negative results (mean = 157 minutes/week. range: 10 to 845 minutes). In terms of intensity of walking, moderate walking is the major prescription (n = 14 intervention groups) in the trial with a significant reduction in SBP, five were self‐paced; one each was high and low intensity.

Secondary outcomes

see Table 1; Table 2; Table 3

Overall, compared to the non‐intervention control group, we found that walking reduced both diastolic blood pressure (DBP) (MD ‐1.79 mmHg, 95% CI ‐2.51 to ‐1.07, P < 0.00001, I² = 53%; 69 studies, n = 4711) (Analysis 1.2) and heart rate (HR) (MD ‐2.76 bpm, 95% CI ‐4.57 to ‐0.95, P = 0.003, I² = 65%; 26 studies, n = 1747) (Analysis 1.3). We graded the evidence for changes in DBP and HR as low certainty as there were concerns of both inconsistency (statistically significant heterogeneity) and risk of bias as more than half of included studies failed to report details of randomisation and allocation concealment.

1.2. Analysis.

1.2

Comparison 1: Walking vs non‐intervention control, Outcome 2: diastolic blood pressure

1.3. Analysis.

1.3

Comparison 1: Walking vs non‐intervention control, Outcome 3: heart rate [beats/min]

We found that walking reduced DBP according to subgroup analyses for all three age groups. Our analysis for study participants aged 60 years and over showed an MD of ‐1.33 mmHg (95% CI ‐2.40 to ‐0.26; 23 studies, n = 2490) while our analysis of participants in the age group 41 to 60 years showed an MD of ‐1.74 mmHg (95% CI ‐2.95 to ‐0.52; 32 studies, n = 1730), and participants aged 40 years and under showed a MD of ‐3.01 mmHg (95% CI ‐4.44 to ‐1.58; 14 studies, n = 491) (Analysis 2.2). While these reductions in DBP were statistically significant, the reduction in DBP for each age group was smaller than that seen for reductions in SBP for the corresponding age groups. We graded the certainty of evidence for the analysis for participants aged 40 years and under as moderate because we downgraded one level for risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment. For the analyses of DBP and participants aged 41 to 60 years and 60 years and over we graded the evidence as low because we downgraded one level for risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment and we downgraded one level for inconsistency.

2.2. Analysis.

2.2

Comparison 2: Walking vs non‐intervention control: subgroup analysis by age, Outcome 2: DBP by Age

As with SBP, we found that walking reduced DBP for both males and females, however, the reductions in DBP were not as great as those seen in SBP. Thus, walking interventions saw a statistically significant reduction in DBP among females (MD ‐2.69 mmHg, 95% CI ‐4.16 to ‐1.23, P = 0.0003, I² = 43%; 20 studies, n = 1000) and males (MD ‐2.54 mmHg, 95% CI ‐4.84 to ‐0.24, P = 0.03, I² = 0%; 6 studies, n = 203) when compared to females and males in control groups (Analysis 3.2). We graded the evidence for DBP and men as moderate; we downgraded the evidence one level for risk of bias due to the majority of included studies failing to report details of randomisation and allocation concealment. We graded the evidence for DBP and women as low; we downgraded the evidence one level for risk of bias due to the majority of included studies failing to report details of randomisation and allocation concealment and one level for inconsistency as there was statistically significant heterogeneity.

3.2. Analysis.

3.2

Comparison 3: Walking vs non‐intervention control: subgroup analysis by sex, Outcome 2: DBP by Sex

We found that walking significantly reduced the HR of participants in the walking groups compared to those in control groups (‐2.76 bpm, 95% CI ‐4.57 to ‐0.95, P < 0.001, I² = 65%).

Sensitivity analyses

Sensitivity analyses were undertaken to assess the effect of walking in high‐quality studies only, where high‐quality studies were defined as those with a low risk of overall bias. Only four studies met our definition of low risk of bias (Baker 2008; Stanton 1996; Venturelli 2011; Wallis 2017). Walking was still found to be effective in lowering SBP by a statistically significant mean of 4.31 mmHg (95% CI ‐7.99 to ‐0.63, P = 0.02, I² = 0%; 4 studies, n = 235) (Analysis 4.1), but did not significantly lower DBP (MD ‐0.43 mmHg, 95% CI ‐2.78 to 1.92, P = 0.72, I² = 18%) (Analysis 4.2).

4.1. Analysis.

4.1

Comparison 4: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias, Outcome 1: systolic blood pressure

4.2. Analysis.

4.2

Comparison 4: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias, Outcome 2: diastolic blood pressure

A sensitivity analysis was also performed to evaluate the effect of the walking interventions in 41 studies (n = 3480) with a low risk of attrition bias. Walking was found to lower SBP by a mean of 4.67 mmHg (95% CI: ‐6.25 to ‐3.09, P < 0.001, I² = 65%) (Analysis 5.1) and significantly lower DBP by a mean of 2.23 mmHg (95% CI ‐3.20 to ‐1.26, P < 0.001, I² = 64%) (Analysis 5.2).

5.1. Analysis.

5.1

Comparison 5: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias, Outcome 1: systolic blood pressure

5.2. Analysis.

5.2

Comparison 5: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias, Outcome 2: diastolic blood pressure

Adverse events

Of the 73 included trials, only 21 reported adverse events. Of this 21, 16 reported no adverse events and a total of eight events was reported by the remaining five studies with Kukkonen‐Harjula 1998 reporting two events (one participant with a stress fracture and another one with a knee injury); Li 2003 reporting one participant with a bruised foot; Tudor‐Locke 2020 reporting one participant with knee pain; Wallis 2017 reporting two participants with knee pain and one participant who tripped; and Westhoff 2007 reporting one participant with knee pain and two participants with events considered unrelated to the intervention, namely, acute cholecystitis and a change in medication. Thus, while few studies specifically reported adverse events, knee pain seemed to be the most common adverse event. (see Characteristics of included studies). Several studies reported incidences that occurred during the intervention period. Brenner 2020 reported that two participants dropped out due to hip fracture; one dropped out from the study by Chan 2018 due to health problems, 60 dropped out of the Yan (嚴華) 2010a study due to hospitalisation, and several participants were reported as injured in the studies by Baker 2008 and Karstoft 2013.

Additional analyses

Sample size may impact trial outcomes at different levels. We examined the impact of the study sample size on the effects of walking on blood pressure in the current review. We undertook a post hoc subgroup analysis that entailed comparing studies having a sample size greater than 30 participants with studies having a sample size equal to or less than 30 for the outcomes of SBP and DBP. The analyses showed a statistically significant reduction in SBP in both sample sizes. The group with a study sample size of less than or equal to 30 saw a mean reduction in SBP of 7.06 mmHg (95% CI ‐9.47 to ‐4.66, P < 0.00001, I² = 35%), while the group with trial sample sizes over 30 showed a smaller mean reduction of 3.48 mmHg (95% CI ‐4.69 to ‐2.27, P < 0.00001, I² = 54%) (Analysis 6.1). Similarly, the analyses showed a statistically significant reduction in DBP in both sample sizes. The group with a study sample size of less than or equal to 30 saw a mean reduction in DBP of 2.92 mmHg (95% CI ‐5.02 to ‐0.82, P = 0.006, I² = 61%) while the group with trial sample sizes over 30 showed a smaller mean reduction of 1.57 mmHg (95% CI ‐2.32 to ‐0.82, P < 0.0001, I² = 50%) (Analysis 6.2).

6.1. Analysis.

6.1

Comparison 6: Walking vs non‐intervention control: sample size per trial ≦30 vs. >30, Outcome 1: SBP

6.2. Analysis.

6.2

Comparison 6: Walking vs non‐intervention control: sample size per trial ≦30 vs. >30, Outcome 2: DBP

We carried out subgroup analyses using baseline SBP and DBP to classify participants into two sets of comparison groups, one is normotensives compared to high normal and hypertensive participants and the other is normotensives compared to hypertensives only. The classification was based on two current hypertension guidelines, American Heart Association (Unger 2020) and European Society of Cardiology (Williams 2018), which defined SBP as normotensives <130 mmHg, high normal ≥130 mmHg, and hypertension ≥140 mmHg; DBP as normotensives <85 mmHg, high normal ≥85 mmHg, and hypertension ≥90 mmHg. Geddes 2009 did not provide baseline SBP and DBP data for us to be able to carry out the classification and therefore was not included in these subgroup analyses.

We found a similar magnitude of walking effect on both normotensive SBP compared to either higher than high normal (MD ‐4.14 mmHg, 95% CI ‐5.28 to ‐3.00, P = 0.45; 72 studies, n = 5048, Analysis 7.1) or higher than hypertensive (MD ‐4.24 mmHg, 95% CI ‐5.52 to ‐2.97, P = 0.29; 54 studies, n = 3630, Analysis 8.1). This is similar when compared normotensive to higher than high normal DBP (MD ‐4.06 mmHg, 95% CI ‐5.24 to ‐2.88, P = 0.65; 68 studies, n = 4699, Analysis 7.2), and compared to higher than hypertensive DBP (MD ‐4.39 mmHg, 95% CI ‐5.67 to ‐3.10, P = 0.03; 60 studies, n = 4223, Analysis 8.2). There was a similar reduction between the two DBP subgroup analyses (‐4.39 versus ‐4.24) but the reduction in DBP comparing normotensive with higher than hypertensive was a statistically significant difference. Additionally, there was significant heterogeneity between the subgroups of normotensive and higher than hypertensive DBP (Chi² = 4.50, df = 1, P = 0.03, I² = 77.8%, n = 4223, Analysis 8.2), but not in other subgroup analyses to this purpose.

7.1. Analysis.

7.1

Comparison 7: Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal), Outcome 1: SBP

8.1. Analysis.

8.1

Comparison 8: Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive), Outcome 1: SBP

7.2. Analysis.

7.2

Comparison 7: Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal), Outcome 2: DBP

8.2. Analysis.

8.2

Comparison 8: Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive), Outcome 2: DBP

We carried out further statistical analyses to test the association between baseline and change SBP and so for DBP. The association is weak (SBP: r= ‐0.142; DBP: r= ‐0.285) and not statistically significant in the association of baseline and change SBP (P = 0.23) but statistically significant in DBP (P = 0.02).

Discussion

Summary of main results

Our review aimed to determine the effect of a walking intervention on blood pressure. We included 73 randomised controlled trials in the meta‐analysis and revealed that walking alone can lower both systolic and diastolic blood pressure (SBP/DBP) statistically and clinically, regardless of age, sex, or baseline blood pressure. We also found that the effect of walking on lowering blood pressure exists after undertaking sensitivity analyses with just high‐quality studies or those not at risk of attrition bias. Among the four high‐quality studies, which were defined as no risk of biases regarding allocation, performance, attrition, and measurement, our findings suggest that walking can lower SBP by 4.31 mmHg (P = 0.02), but less likely to effectively lower DBP (WMD = ‐0.43, P = 0.71). The effect of walking on lowering blood pressure is also evidenced even when we omitted the studies with a dropout rate greater than 20%. It was found that a walking intervention could significantly lower SBP by 4.67 mmHg (P < 0.00001) and DBP by 2.23 mmHg (P < 0.00001).

Previous research has shown that a reduction in blood pressure is associated with the management of the mortality of the cardiovascular disease. Lowering SBP by 2 mmHg of SBP is related to approximately a 10% decrease in stroke mortality and a 7% decrease in mortality from vascular risks in adults (Lewington 2002). A more recent paper by Ettehad 2016 showed that a reduction in SBP of 10 mmHg reduced the risk of major cardiovascular disease (CVD) events by 20%, coronary heart disease (CHD) by 17%, stroke by 27% and all‐cause mortality by 13%. Our review found that walking interventions could lower SBP from 3.01 to 5.22 mmHg (MD ‐4.11) and DBP from 1.07 to 2.51 (MD ‐1.79), which were of greater magnitude than the reduction of 2 mmHg SBP and could be considered clinically significant. These small reductions in blood pressure are similar to those reported by previous systematic reviews which investigated interventions of walking among the younger population (Hanson 2015Tschentscher 2013). Walking may also serve as an effective, useful adjunct to pharmacological therapy for controlling hypertension. For those who are normotensive, walking interventions may be useful in further reducing or preventing an increase in blood pressure.

The age of the study participants may mediate the effect of walking on blood pressure reduction (Lee 2010a). It is noteworthy that the result of subgroup analysis by different age groups showed that walking intervention demonstrated a similar reduction of SBP in the age group of over 60 to that observed in the age group of equal to or less than 40. Though previous studies found a tendency of an association between older people and a greater reduction in SBP and DBP (Burt 1995; Lee 2010a), this effect of walking on blood pressure reduction may result from higher baseline blood pressure levels among older adult participants. In the current review, we found a similar effect of walking on both normotensive SBP and DBP compared to either higher than high normal or higher than hypertensive.

When there are no sex differences on the effect of walking on lowering blood pressure, we found that females have slightly more reduction and more precisely than males in both SBP and DBP. This finding is inconsistent with those of previous studies (Carpio‐Rivera 2016; Christou 2005) that have suggested that males appeared to have a greater reduction in blood pressure than females. The menstrual cycle and menopausal impact might confound the acute‐ and long‐term effects of physical activity on the changes in blood pressure among the female population (Christou 2005). This inconsistency might also be due to that, in the current review, the total number of female participants is around 1.5 times compared to that of males. Previous studies argued that researchers have usually neglected adult females (Carpio‐Rivera 2016), but this did not appear to be the case in walking trials. In general, this review supports the finding that age and sex are less likely to change blood pressure response to physical activity.

The sample size could impact the research outcome widely and adequate sample sizes are required to provide sufficient power to generate robust results. According to our post hoc subgroup analyses using sample sizes greater and less than 30 participants per trial for the outcomes of SBP and DBP, there was a statistically significant reduction of both SBP and DBP in the two different sample sizes, whereby the studies with sample sizes equal to or less than 30 showed a much larger effect but less precisely, i.e. wider 95% confidence intervals than those in the studies with sample sizes greater than 30. This differs from a previous systematic review that found that walking interventions are likely to be effective according to studies with larger sample sizes (Lee 2010a). Most of the included studies in the current review did not report the power calculation for estimating adequate sample size. A small sample size could result in greater bias due to variations in the participants or contribute towards a positive result when the observed effects are far larger than the true differences between the groups (Altman 1997). Small sample size could also make the generalisability of the results challenging. Therefore, a proper sample size calculation is crucial for the robust interpretation and generalisation of the effect of the intervention.

There are insufficient data to examine the long‐term effect of walking on blood pressure. As only three studies reported follow‐up data on blood pressure in the months after the intervention ceased, it is unclear whether the benefits can persist or if further intervention is needed to maintain the benefit. The evidence showed that the cessation of exercise may lead to a rapid loss of benefit with regard to blood pressure (Moker 2014). The previous research revealed that the application of behaviour modification theories, such as increased exercise self‐efficacy among older participants might prolong the ongoing benefits of walking with regard to blood pressure management (Chiu 2015).

Overall completeness and applicability of evidence

We searched and screened relevant databases carefully to identify all relevant randomised controlled trials that investigated the effect of walking intervention on blood pressure control compared with a non‐intervention control group. Our searches were carried out across multiple databases and we screened carefully all reference lists of the included studies and relevant systematic reviews, together with a hand search of all articles citing the included studies to enhance the completeness of the systematic review.

We identified 73 studies that met our inclusion criteria and included data from 5060 participants in the meta‐analysis for our primary outcome of change in SBP. We included data from 69 studies and 4711 participants in the meta‐analysis for the secondary outcome of change in DBP. Fewer studies (n = 26) and participants (n = 1747) provided data for the meta‐analysis of the secondary outcome of change in heart rate (HR). These 73 studies included walking interventions only and thus other modes of activity such as jogging or lifestyle modifications such as dietary salt reduction were excluded. There were sufficient participants to undertake subgroup analyses of changes in SBP and DBP by age and sex. Our findings that walking can result in a statistically and clinically significant reduction in SBP and DBP were robust to subgroup analysis according to age and sex.

Walking is the activity that the majority of the population can do and is seen as a low cost, low risk, common and feasible mode of physical activity in different age groups for decades (Asikainen 2004; Kraus 2019; Morris 1997; Mutrie 2004). Therefore, walking is often recommended by healthcare professionals as a form of exercise for health promotion and preventing health problems (Kraus 2019; Pate 1995). The findings from the current meta‐analysis are applicable to blood pressure management among both normotensive and hypertensive populations.

Quality of the evidence

We judged the certainty of the evidence of the effect of walking on SBP as moderate rather than high because of lack of clarity around randomisation procedures, allocation concealment and blinding of participants, study personnel, and outcome assessors. There was also some inconsistency across trials, which was related in part to differences in study populations and to differences in walking interventions. In this circumstance, we decided not to downgrade the certainty of this evidence because that sensitivity analysis on the basis of low risk of bias trials showed a significant reduction of SBP. However, we judged the certainty of the evidence of the effect of walking on DBP and HR as low because of the inconsistency across trials and the lack of clarity around randomisation procedures, allocation concealment, and blinding of participants, study personnel, and outcome assessors. A sensitivity analysis on the basis of low risk of bias trials showed a non‐significant reduction of DBP and there were data for us to carry out a similar sensitivity analysis on HR. While we assessed many of the studies at risk of performance bias, it should be noted that the outcomes of interest for this review are objective so even if participants and assessors are aware of group assignment, this knowledge is less likely to influence the outcome data than if we were analysing subjectively‐assessed outcomes.

Potential biases in the review process

Approximately one quarter (n = 19, 26%) of the 73 included trials were multi‐arm trials. An example is a study by Brown 2014, where one intervention consisted of a nature walking group with participants following a walking route through trees and parks while a second intervention comprised a built walking group(BW) following a route through housing estates, and a third control arm followed normal activities. With such studies, where the walking intervention groups met our inclusion criteria, we combined them and calculated a mean change in outcome measures for the combined group, thus creating a single‐pair wise comparison with the control group. In some multi‐arm trials, one or more of the intervention groups did not meet our inclusion criteria and thus we excluded those findings from our analyses. Where we did combine groups, we were cautious to ensure that combining groups did not result in double‐counting of participants. A number of studies, for example, Chan 2018 and Moreau 2001 collected outcome data at a number of time points. We used the data collected at the shortest intervention period so that the data collection was most similar for the majority of studies. However, our findings may have changed if we used data from the last time period of data collection as it may be that fewer participants continued with the intervention as time went on. For those studies that did not provide sufficient data, we contacted study authors and received responses from approximately 10%. Some study details and data remain missing which may influence the findings of our review.

Agreements and disagreements with other studies or reviews

Our meta‐analysis investigated the effect of a walking intervention compared to a non‐intervention control group on blood pressure control using randomised controlled trials and revealed that walking significantly lowered both systolic and diastolic blood pressure, and heart rate among the adult participants, regardless of their age or sex. The results of the current meta‐analysis support the findings of earlier reviews that a walking intervention can lower either SBP (Bravata 2007) or DBP (Murphy 2007; Qui 2014), or both (Hanson 2015; Herrod 2018; Kelley 2001; Oja 2018; Tschentscher 2013). These findings are also consistent with a previous systematic review, which found that group walking could cause a statistically significant reduction in both SBP (3.72 mmHg, P < 0.001) and DBP (3.14 mmHg, P < 0.001) (Hanson 2015). Herrod 2018 reported that undertaking aerobic exercise regularly over at least three months can lead to 5 mmHg to 6 mmHg reduction in SBP and 2 mmHg to 3.5 mmHg in DBP among participants aged over 65 years (Herrod 2018).

However, one systematic review found no effect of walking on SBP and DBP control (Cai 2014), and two did not find a statistically significant reduction in SBP (Murphy 2007; Qui 2014). One systematic review using standardised mean differences and a random‐effects model found a small but statistically significant reduction in both SBP (‐0.213 mmHg, P = 0.001) and DBP (‐0.166 mmHg, P = 0.006) (Oja 2018). The systematic review undertaken by Bravata 2007 found that the use of pedometers has a similar effect on SBP reduction (‐3.8 mmHg, P < 0.001) as our finding, but a relatively small reduction in DBP (‐0.3 mmHg, P = 0.001). This slightly differs from the findings of Cai 2014 that the use of a pedometer was not statistically effective in reducing neither SBP (‐1.13 mmHg, P = 0.18) nor DBP (‐1.49 mmHg, P = 0.25). Among patients with type 2 diabetes, a recent meta‐analysis by Qui 2014 found that walking was associated with DBP reduction but not a significant reduction in SBP.

Walking prescriptions in the included studies of the current review mainly followed the general recommendations of physical activity for adults (ACSM 2018; US Dept of Health & Human Sciences 2018; US Dept of Health & Human Sciences 2018; Bull 2020), which involved participating in moderate‐intensity aerobic physical activity for a minimum of 30 minutes on five days per week or vigorous‐intensity exercise for a minimum of 20 minutes on three days per week. Walking can be considered as either a low‐intensity activity (e.g. walking at an easy or moderate pace) or moderate exercise (e.g. brisk or very brisk walking) (Hamilton 2008; Tanasescu 2002US Dept of Health & Human Sciences 2018), and occasionally greater than moderate‐intensity (Murtagh 2002Tanasescu 2002).

The previous review (Brown 1995) and guideline (ACSM 2018) pointed out that low‐ to moderate‐intensity exercise could have a similar effect on blood pressure reduction as does high‐intensity training among hypertensive people, while low‐ to moderate‐intensity exercise may even have a greater impact on SBP (Hagberg 2000). Among the trials that found a statistically significant reduction in SBP (n = 21 trials) with clearly stated intensity prescription (n = 16 intervention groups), the present review observed that moderate‐intensity walking is the major prescription of walking (n = 14 groups), with only one trial prescribing high‐intensity walking, and one trial prescribing low‐intensity walking. Consistent with this finding, previous studies found a greater, longer‐lasting blood pressure reduction after reaching exercise intensity of 75% VO2max (Quinn 2000; Huang 2006; Cox 2001), which were seen as the moderate‐intensity level of exercise.

Previous studies have found that higher baseline blood pressure was associated with a greater reduction in blood pressure (Lee 2007; Nemoto 2007). Given the similar reduction in BP we saw among normotensive and hypertensive people and the weak association between baseline and change in blood pressure, we conclude that the effect of walking is similarly beneficial to those defined as normotensive and hypertensive. This is consistent with a later study (Rahman 2019) that found the benefits of medicinal blood pressure treatment, regardless of baseline blood pressure.

Authors' conclusions

Implications for practice.

We found moderate‐ to low‐certainty evidence that walking can lower systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). Our findings suggest that these findings are relevant for all adults of any age, for both men and women and for those defined as normotensive and hypertensive according to baseline blood pressure levels. World Health Organization (WHO) guidelines recommend that aerobic physical activity should be undertaken in moderate‐intensity for 150 to 300 minutes per week; with muscle‐strengthening activities twice a week to have additional health benefits (Bull 2020). Findings from this review suggest that walking of moderate‐intensity, undertaken three to five times per week, of 20 to 40 minutes duration, and 150 minutes per week for approximately three months may lower blood pressure.

Walking is an attractive intervention for the prevention, control, and management of high blood pressure, representing both a cheaper treatment alternative to medication and one with less risk of adverse events and side effects for patients. Furthermore, the consequent reduction in the risk of cardiovascular diseases as a result of controlling blood pressure represents substantial savings in the treatment costs of chronic diseases and relieving the burden of national and global health expenditures.

Implications for research.

Future studies should focus on the impact on blood pressure control of different walking environments, such as walking in the laboratory or gymnasium, and walking in the countryside or city. The neighbourhood, place of work, or peer pressure may also play a crucial role in motivation regarding physical activity. Finding alternatives or phased walking interventions for those who are less able to take up a walking activity are also warranted. Furthermore, studies that focus on those with different co‐morbidity or those with poorly controlled hypertension where medications may have limited effect, are required. Given that we found few studies that had collected data on adverse events, and from those studies that did, knee pain was the most common adverse event, it is essential that future studies collect data on adverse events that might be related to the walking intervention. The long‐term benefits of walking interventions on blood pressure reduction require further research. In terms of study design, future studies should adopt rigorous trial designs aim to reduce the risk of bias by using transparent methods of random sequence generation and allocation concealment, ensuring study attrition is minimised and blinding outcome assessors where possible and then report those properly. Only then, the quality and certainty of published evidence on this topic can be raised. 

What's new

Date Event Description
8 March 2021 Amended Corrected minor typos in the text

History

Protocol first published: Issue 11, 2010
Review first published: Issue 2, 2021

Notes

An earlier version of this review was funded by the Tzu Chi College of Technology (TCCT‐971B31 2007.08.01‐2008.07.31). It was carried out without meta‐analysis and was published in the International Journal of Nursing Studies (New Reference).

Acknowledgements

We are extremely grateful to Cochrane Hypertension Managing Editor, Ciprian Jauca, for his consistent support and assistance throughout the whole process of this review; the assistance from the Cochrane Hypertension Information Specialist, Douglas Salzwedel, for his design and update of the English reference search, and his support in this field; the searches of the English references of Stephen Adams and Chinese ones of Ching‐Ju Fang (方靜如). We would also like to thank the Cochrane Hypertension Group editors for their input; the peer reviewers for their thorough and constructive comments and the Copy Editor, Heather Maxwell, for her effort on the draft of this review.

Appendices

Appendix 1. Search strategies

Database: Ovid MEDLINE(R) and Epub Ahead of Print, In‐Process & Other Non‐Indexed Citations, Daily and Versions(R) <1946 to March 06, 2020>
Search Date: 7 March 2020
1     exp walking/ 
2     (walk$ or gait or locomot$ or stride$ or stroll$ or treadmill$).tw,kf. 
3     or/1‐2
4     exp hypertension/ 
5     essential hypertension/ 
6     (antihypertens$ or hypertens$ or prehypertens$).tw,kf. 
7     exp blood pressure/ 
8     (blood pressur$ or bloodpressur$).tw,kf. 
9     ((arterial adj2 pressur$) or (diastolic adj2 pressur$) or (systolic adj2 pressur$)).tw,kf.
10     (bp or dbp or sbp).tw,kf. 
11     or/4‐10 
12     randomized controlled trial.pt. 
13     controlled clinical trial.pt.
14     randomized.ab.
15     placebo.ab. 
16     clinical trials as topic/ 
17     randomly.ab. 
18     trial.ti. 
19     or/12‐18 
20     animals/ not (humans/ and animals/) 
21     ((ocular or portal or pulmonary) adj (arterial or hypertens$)).ti. 
22     (eclamp$ or preeclampsi$ or pregnan$).ti. 
23     or/20‐22 
24     19 not 23 
25     3 and 11 and 24

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: Cochrane Hypertension Specialised Register via Cochrane Register of Studies (CRS‐Web)                                                                                                                                                                                                 Search Date: 8 Search Date: March 2020                                                                                                                                                                                                                                                                                                                                                                
#1 (walk* OR gait OR locomot* OR  stride* OR stroll* OR treadmill*) AND INSEGMENT
#2 RCT:DE A ND INSEGMENT
#3 Review:ODE AND INSEGMENT
#4 (#2 OR #3) AND INSEGMENT
#5 #1 AND #4 AND INSEGMENT

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: Cochrane Central Register of Controlled Trials (Issue 2, 2020) via Cochrane Register of Studies (CRS‐Web)                                                                                                                                                                                         Search Date: 8 March 2020                                                                                                                                                                                                                                                                                                                                                  
#1 MESH DESCRIPTOR Walking EXPLODE ALL AND CENTRAL:TARGET
#2 (walk* OR gait OR locomot* OR stride* OR stroll* OR treadmill*) AND CENTRAL:TARGET
#3 (#1 OR #2) AND CENTRAL:TARGET
#4 MESH DESCRIPTOR Hypertension AND CENTRAL:TARGET
#5 MESH DESCRIPTOR Essential Hypertension AND CENTRAL:TARGET
#6 (antihypertens* OR hypertens* OR prehypertens*) AND CENTRAL:TARGET
#7 (blood OR arterial OR diastolic OR systolic) NEAR2 pressur* AND CENTRAL:TARGET
#8 (bp OR dbp OR sbp) AND CENTRAL:TARGET
#9 (#4 OR #5 OR #6 OR #7 OR #8) AND CENTRAL:TARGET
#10 #3 AND #9 AND CENTRAL:TARGET

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: Embase <1974 to 2020 March 05>
Search Date: 7 March 2020
1     exp walking/ 
2     (walk$ or gait or locomot$ or stride$ or stroll$ or treadmill$).tw. 
3     or/1‐2
4     exp hypertension/ 
5     (antihypertens$ or hypertens$ or prehypertens$).tw. 
6     exp blood pressure/ 
7     (blood pressur$ or bloodpressur$).tw.
8     ((arterial adj2 pressur$) or (diastolic adj2 pressur$) or (systolic adj2 pressur$)).tw. 
9     (bp or dbp or sbp).tw. 
10     or/4‐9 
11     randomized controlled trial/ 
12     crossover procedure/
13     double‐blind procedure/ 
14     (randomi?ed or randomly).tw. 
15     (crossover$ or cross‐over$).tw. 
16     placebo.ab. 
17     (doubl$ adj blind$).tw.
18     assign$.ab.
19     allocat$.ab. 
20     or/11‐19 
21     (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.) 
22     ((ocular or portal or pulmonary) adj (arterial or hypertens$)).ti. 
23     (eclamp$ or preeclampsi$ or pregnan$).ti. 
24     or/21‐23 
25     20 not 24
26     3 and 10 and 25 

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: EBSCO CINAHL (1982 to Present)

Search Date: 9 March 2020

S21     S3 AND S12 AND S20   
S20     (S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19)     
S19     (MH "Quantitative Studies")    
S18     (MH "Random Assignment")     
S17     TI (randomi* OR randomly) OR AB (randomi* OR randomly)     
S16     ( TI (singl* blind*) OR (doubl* blind*) ) OR ( AB (singl* blind*) OR (doubl* blind*) )     
S15     TI (clinic* trial*) OR AB (clinic* trial*)     
S14     PT Clinical Trial     
S13     (MH "Clinical Trials+")     
S12     (S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11)   
S11     TI (bp OR dbp OR sbp) OR AB (bp OR dbp OR sbp)     
S10     TI (diastolic N1 pressur*) OR (systolic N1 pressur*) OR AB (diastolic N1 pressur*) OR (systolic N1 pressur*)     
S9     TI (arterial N1 pressur*) OR AB (arterial N1 pressur*)     
S8     TI (blood pressur* OR bloodpressur*) OR AB (blood pressur* OR bloodpressur*)     
S7     MJ Blood Pressure
S6     (MH "Blood Pressure+")     
S5     (TI (antihypertens* OR hypertens* OR prehypertens*) ) OR ( AB (antihypertens* OR hypertens* OR prehypertens*) )     
S4     (MH "Hypertension+")   
S3     S1 OR S2 
S2     TI ( (walk* OR gait OR locomot* OR stride* OR stroll* OR treadmill*) ) OR AB ( (walk* OR gait OR locomot* OR stride* OR stroll* OR treadmill*) )   
S1     (MH "Walking+")    

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: EBSCO PsycINFO (1950 to Present)

Search Date: 9 March 2020
S20     S3 AND S11 AND S19    
S19     (S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18)    
S18     TI blind* OR AB blind*
S17     AB allocat*     
S16     AB assign*    
S15     TI trial* OR AB trial*  
S14     AB control group*  
S13     TI controlled OR AB controlled     
S12     TI (randomi* OR randomly) or AB (randomi* OR randomly)   
S11     (S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10)    
S10     TI (bp OR dbp OR sbp) OR AB (bp OR dbp OR sbp)     
S9     TI ( (diastolic N1 pressur* OR systolic N1 pressur*) ) AND AB ( (diastolic N1 pressur* OR systolic N1 pressur*) )    
S8     TI (arterial N1 pressur*) OR AB (arterial N1 pressur*)    
S7     TI blood pressur* OR AB blood pressur*    
S6     SU Blood pressure    
S5     (TI (antihypertens* OR hypertens* OR prehypertens*) ) or ( AB (antihypertens* OR hypertens* OR prehypertens*) )     
S4     SU Hypertension     
S3     S1 OR S2    
S2     TI ( (walk* OR gait OR locomot* OR stride* OR stroll* OR treadmill*) ) or AB ( (walk* OR gait OR locomot* OR stride* OR stroll* OR treadmill*) )   
S1     SU Walking     
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: EBSCO SPORTDiscus (1949 to Present)

Search Date: 11 March 2020

S20    (S3 AND S11 AND S19)   
S19    (S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18)   
S18    TI blind* OR AB blind*    
S17    AB allocat*    
S16    AB assign*    
S15    TI trial* OR AB trial*  
S14    AB control group*    
S13    TI controlled OR AB controlled  
S12    TI (randomi* OR randomly) OR AB (randomi* OR randomly)  
S11    (S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10)    
S10    TI (bp OR dbp OR sbp) OR AB (bp OR dbp OR sbp)   
S9    TI (diastolic N1 pressur*) OR (systolic N1 pressur*) OR AB (diastolic N1 pressur*) OR (systolic N1 pressur*)    
S8    TI (arterial N1 pressur*) OR AB (arterial N1 pressur*)   
S7    TI (blood pressur*) OR AB (blood pressur*)   
S6    SU Blood pressure   
S5    TI (antihypertens* OR hypertens* OR prehypertens*) OR AB (antihypertens* OR hypertens* OR prehypertens*)    
S4    SU Hypertension   
S3    S1 OR S2    
S2    TI ( (walk* or gait or locomot* or stride* or stroll* or treadmill*) ) or AB ( (walk* or gait or locomot* or stride* or stroll* or treadmill*) )    
S1    SU Walking    

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: PEDro <1929 to Present>

Search Date: 11 March 2020

Abstract & Title: antihypertens*
Therapy: fitness training
Method: clinical trial OR systematic review
Score of at least 7/10

Abstract & Title: blood pressure
Therapy: fitness training
Method: clinical trial OR systematic review
Score of at least 7/10

Abstract & Title: hypertens*
Therapy: fitness training
Method: clinical trial OR systematic review
Score of at least 7/10

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: ClinicalTrials.gov

Search Date: 11 March 2020

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Other terms: randomized 
Study type: Interventional Studies (Clinical Trials)
Study Results: All Studies
Intervention/treatment: treadmill OR walking
Outcome Measure: blood pressure 

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: WHO International Clinical Trials Registry Platform (ICTRP)

Search Date: 11 March 2020

blood pressure AND randomi* AND walk*  
hypertens* AND randomi* AND walk*
blood pressure AND randomi* AND treadmill 
hypertens* AND randomi* AND treadmill 

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: Index to Taiwan Periodical Literature System

Search Date: 18 May 2020

#1 (健走 + 健步 + 踏步 + 快走 + 快步 + 跑走 + 慢走 + 慢步 + 走路 + 步行 + 腳踏 + 滑步 + 跑步機 + 漫步機 + 橢圓機) * (收縮壓 + 舒張壓 + 血壓 + 心跳 + 心律 + 心率 + 心肺) * (實驗 + 試驗 + 隨機 + 對照 + random* + controlled + trial) [Search Fields: Article Title, Keywords, Author, Abstract]

#2 (walking + tread* + “running machine” + “running machines” + “Pedlar inexpensive ergometer” + "elliptical trainer" + "elliptical trainers" + gait* + locomot* + stride*) * (SBP + DBP + BP + pressure + hypertens* + antihypertens* + heart* + HR + rhythm* + cardi*) * (random* + controlled + trial) [Search Fields: Article Title, Keywords, Author, Abstract]

#3 #1 or #2

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: National Digital Library of Theses and Dissertations in Taiwan

Search Date: 18 May 2020

(健走.ti,kw or 健步.ti,kw or 踏步.ti,kw or 快走.ti,kw or 快步.ti,kw or 跑走.ti,kw or 慢走.ti,kw or 慢步.ti,kw or 走路.ti,kw or 步行.ti,kw or 腳踏.ti,kw or 滑步.ti,kw or 跑步機.ti,kw or 漫步機.ti,kw or 橢圓機.ti,kw or walking.ti,kw or tread*.ti,kw or "running machine".ti,kw or "running machines".ti,kw or "Pedlar inexpensive ergometer".ti,kw or "elliptical trainer".ti,kw or "elliptical trainers".ti,kw or stride*.ti,kw) and (收縮壓.ti,kw,ab or 舒張壓.ti,kw,ab or 血壓.ti,kw,ab or 心跳.ti,kw,ab or 心律.ti,kw,ab or 心率.ti,kw,ab or 心肺.ti,kw,ab or SBP.ti,kw,ab or DBP.ti,kw,ab or BP.ti,kw,ab or pressure.ti,kw,ab or hypertens*.ti,kw,ab or antihypertens*.ti,kw,ab or heart*.ti,kw,ab or HR.ti,kw,ab or rhythm*.ti,kw,ab or cardi*.ti,kw,ab) and (實驗.ti,kw,ab or 試驗.ti,kw,ab or 隨機.ti,kw,ab or 對照.ti,kw,ab or random*.ti,kw,ab or controlled.ti,kw,ab or trial.ti,kw,ab)

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: China National Knowledge Infrastructure (CNKI): Journals, Theses & Dissertations

Search Date: 18 May 2020

(TI=(健走+健步+踏步+快走+快步+跑走+慢走+慢步+走路+步行+腳踏+滑步+跑步機+漫步機+橢圓機+跑台+跑臺+平板+踏車+walking+ tread+"running machine"+"running machines"+"Pedlar inexpensive ergometer"+"elliptical trainer"+"elliptical trainers"+stride) or KY=(健走+健步+踏步+快走+快步+跑走+慢走+慢步+走路+步行+腳踏+滑步+跑步機+漫步機+橢圓機+跑台+跑臺+平板+踏車+walking+ tread+treadmill+treadmills+"running machine"+"running machines"+"Pedlar inexpensive ergometer"+"elliptical trainer"+"elliptical trainers"+stride)) and (SU=(收縮壓+舒張壓+血壓+心跳+心律+心率+心肺+SBP+DBP+BP+pressure+hypertension+hypertensive+antihypertensive+antihypertension+heart+HR+rhythm+rhythms+cardiopulmonary)) and (SU=(隨機+對照+控制組+random+randomly+randomized+randomised))

(This interface does not support truncation queries)

‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Database: Wanfang Med Online: Journals, Theses & Dissertations

Search Date: 18 May 2020

((題名=健走 OR 健步 OR 踏步 OR 快走 OR 快步 OR 跑走 OR 慢走 OR 慢步 OR 走路 OR 步行 OR 腳踏 OR 滑步 OR 跑步機 OR 漫步機 OR 橢圓機 OR 跑台 OR 跑臺 OR 平板 OR 踏車) OR (關键词=健走 OR 健步 OR 踏步 OR 快走 OR 快步 OR 跑走 OR 慢走 OR 慢步 OR 走路 OR 步行 OR 腳踏 OR 滑步 OR 跑步機 OR 漫步機 OR 橢圓機 OR 跑台 OR 跑臺 OR 平板 OR 踏車)) AND (收縮壓 OR 舒張壓 OR 血壓 OR 心跳 OR 心律 OR 心率 OR 心肺) AND (隨機 OR 對照 OR 控制組)

Data and analyses

Comparison 1. Walking vs non‐intervention control.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
1.1 systolic blood pressure 73 5060 Mean Difference (IV, Random, 95% CI) ‐4.11 [‐5.22, ‐3.01]
1.2 diastolic blood pressure 69 4711 Mean Difference (IV, Random, 95% CI) ‐1.79 [‐2.51, ‐1.07]
1.3 heart rate [beats/min] 26 1747 Mean Difference (IV, Random, 95% CI) ‐2.76 [‐4.57, ‐0.95]

Comparison 2. Walking vs non‐intervention control: subgroup analysis by age.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
2.1 SBP by Age 73 5060 Mean Difference (IV, Random, 95% CI) ‐4.12 [‐5.22, ‐3.01]
2.1.1 Age <=40 14 491 Mean Difference (IV, Random, 95% CI) ‐4.41 [‐6.17, ‐2.65]
2.1.2 Age 41‐60 35 1959 Mean Difference (IV, Random, 95% CI) ‐3.79 [‐5.64, ‐1.94]
2.1.3 Age >60 24 2610 Mean Difference (IV, Random, 95% CI) ‐4.30 [‐6.17, ‐2.44]
2.2 DBP by Age 69 4711 Mean Difference (IV, Random, 95% CI) ‐1.79 [‐2.51, ‐1.07]
2.2.1 Age <=40 14 491 Mean Difference (IV, Random, 95% CI) ‐3.01 [‐4.44, ‐1.58]
2.2.2 Age 41‐60 32 1730 Mean Difference (IV, Random, 95% CI) ‐1.74 [‐2.95, ‐0.52]
2.2.3 Age >60 23 2490 Mean Difference (IV, Random, 95% CI) ‐1.33 [‐2.40, ‐0.26]

Comparison 3. Walking vs non‐intervention control: subgroup analysis by sex.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
3.1 SBP by Sex 26 1352 Mean Difference (IV, Random, 95% CI) ‐5.49 [‐7.43, ‐3.56]
3.1.1 Male 6 203 Mean Difference (IV, Random, 95% CI) ‐4.64 [‐8.69, ‐0.59]
3.1.2 Female 22 1149 Mean Difference (IV, Random, 95% CI) ‐5.65 [‐7.89, ‐3.41]
3.2 DBP by Sex 24 1203 Mean Difference (IV, Random, 95% CI) ‐2.67 [‐3.85, ‐1.48]
3.2.1 Male 6 203 Mean Difference (IV, Random, 95% CI) ‐2.54 [‐4.84, ‐0.24]
3.2.2 Female 20 1000 Mean Difference (IV, Random, 95% CI) ‐2.69 [‐4.16, ‐1.23]

Comparison 4. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
4.1 systolic blood pressure 4 235 Mean Difference (IV, Random, 95% CI) ‐4.31 [‐7.99, ‐0.63]
4.2 diastolic blood pressure 4 235 Mean Difference (IV, Random, 95% CI) ‐0.43 [‐2.78, 1.92]

Comparison 5. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
5.1 systolic blood pressure 41 3480 Mean Difference (IV, Random, 95% CI) ‐4.67 [‐6.25, ‐3.09]
5.2 diastolic blood pressure 41 3480 Mean Difference (IV, Random, 95% CI) ‐2.23 [‐3.20, ‐1.26]

Comparison 6. Walking vs non‐intervention control: sample size per trial ≦30 vs. >30.

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
6.1 SBP 73 5040 Mean Difference (IV, Random, 95% CI) ‐4.12 [‐5.23, ‐3.02]
6.1.1 sample size <= 30 15 321 Mean Difference (IV, Random, 95% CI) ‐7.06 [‐9.47, ‐4.66]
6.1.2 sample size >30 58 4719 Mean Difference (IV, Random, 95% CI) ‐3.48 [‐4.69, ‐2.27]
6.2 DBP 69 4691 Mean Difference (IV, Random, 95% CI) ‐1.79 [‐2.51, ‐1.08]
6.2.1 sample size <= 30 15 321 Mean Difference (IV, Random, 95% CI) ‐2.92 [‐5.02, ‐0.82]
6.2.2 sample size >30 54 4370 Mean Difference (IV, Random, 95% CI) ‐1.57 [‐2.32, ‐0.82]

Comparison 7. Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal).

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
7.1 SBP 72 5048 Mean Difference (IV, Random, 95% CI) ‐4.14 [‐5.28, ‐3.00]
7.1.1 Normotensive <130 33 2057 Mean Difference (IV, Random, 95% CI) ‐3.68 [‐5.12, ‐2.24]
7.1.2 High normal and Hypertensive ≧130 39 2991 Mean Difference (IV, Random, 95% CI) ‐4.54 [‐6.23, ‐2.85]
7.2 DBP 68 4699 Mean Difference (IV, Random, 95% CI) ‐4.06 [‐5.24, ‐2.88]
7.2.1 Normotensive <85 53 3920 Mean Difference (IV, Random, 95% CI) ‐3.91 [‐5.26, ‐2.55]
7.2.2 High normal and Hypertensive ≧85 15 779 Mean Difference (IV, Random, 95% CI) ‐4.57 [‐7.07, ‐2.07]

Comparison 8. Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive).

Outcome or subgroup title No. of studies No. of participants Statistical method Effect size
8.1 SBP 54 3630 Mean Difference (IV, Random, 95% CI) ‐4.24 [‐5.52, ‐2.97]
8.1.1 Normotensive <130 33 2057 Mean Difference (IV, Random, 95% CI) ‐3.68 [‐5.12, ‐2.24]
8.1.2 Hypertensive ≧140 21 1573 Mean Difference (IV, Random, 95% CI) ‐5.21 [‐7.66, ‐2.76]
8.2 DBP 60 4223 Mean Difference (IV, Random, 95% CI) ‐4.39 [‐5.67, ‐3.10]
8.2.1 Normotensive <85 53 3920 Mean Difference (IV, Random, 95% CI) ‐3.91 [‐5.26, ‐2.55]
8.2.2 Hypertensive ≧90 7 303 Mean Difference (IV, Random, 95% CI) ‐7.82 [‐11.16, ‐4.47]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Araiza 2006.

Study characteristics
Methods Aim: quote: "To determine whether a recommendation to accumulate 10000 steps per day, as documented by use of a pedometer, would result in significant improvements in parameters of glycemic control, insulin sensitivity, cardiovascular risk, lipid profile, and oxidative stress in sedentary patients with type 2 diabetes mellitus."
Design: parallel 2‐group RCT (1:1) matched
Power/sample size calculation: yes (post hoc)
Participants No. randomised:30 (15 in IG, 15 in CG)
No. completers: 30
Country: USA
Study population: Type 2 diabetes mellitus (free from advanced secondary complications of diabetes)
Ethnicity: NR
Gender: NR
Age: mean 51 (SD 10) in IG, 49 (SD 11) in CG; range 33 to 69
Smokers: NR
Hypertension: no
Mean baseline BP:
SBP = 140.6 (SD 21.4) in IG, 136.6 (SD 19.3) in CG;
DBP = 80.7 (SD 12.2) in IG, 77.6 (SD 8.9) in CG .
Inclusion criteria:
participants with type 2 diabetes mellitus with oral therapy, but free from advanced secondary complications of diabetes.
Exclusion criteria:
pregnant or lactating women, anaemia (haemoglobin <11 g/100 mL for males, haemoglobin <10 g/100 mL for females), cardiovascular disease, hypertension (SBP >180 mmHg and/or DBP >110 mmHg), or orthopedic limitation for walking.
Interventions IG: Active group:
The protocol consisted of a 10‐day baseline period during which the participants were asked not to change their physical activity habits.
  • Duration: (accumulated steps)

  • Intensity: NR

  • Frequency: accumulated 10,000 steps/day, >=5 days/week

  • Intervention period: 6 weeks

  • Pedometer: Yamax Digiwalker step counter, positioned on the waist, in‐line with the right mid‐thigh.

  • Facilitator: NR


CG: Control group: quote: "The control group was instructed to maintain their normal activity habits throughout the 6‐week intervention."
Outcomes Review outcomes reported: SBP, DBP
Measurement method: BP (SBP/DBP) was measured with participant in the seated position with an automated monitor at study weeks 0 and 6.
Primary/Main outcome of manuscript: BMI, percentage of body fat, BP, waist circumference, and resting energy expenditure (REE)
Adherence: the active increased steps per day by an average of 69% to 10410 (SD 4162).
Adverse event: NR
Notes PARTICIPANT Trial registration: NR
Funding sources: NIH NCRR GCRC grant 5M01‐RR00997 from the University of New Mexico GCRC.
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk No information
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk It is unlikely that the participants and investigators were blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk no dropout
ITT analysis
Selective reporting (reporting bias) Low risk 0nly 1 endpoint measurement at 6 weeks
Other bias Low risk No other bias

Arija 2017.

Study characteristics
Methods Aim: to assess short‐ and medium‐term effectiveness of 9 months supervised physical activity programme including social cultural activities on CVD risk in adults accessing primary healthcare facilities
Design: parallel 2‐group RCT (3:1)
Power/sample size calculation: yes
Participants No. randomised: 419 (305 in IG, 114 in CG)
No. completers: 364
Country: Spain
Study population: primary healthcare patients (attending primary healthcare facilities)
Ethnicity: NR
Gender: male 23.2% (only can roughly estimated from the following information: "76.8% women" in abstract)
Age: mean 64.5 (SD 9.2) in IG, 66.99 (SD 10.28) in CG (mean age: 65.19)
Smokers: 7.9% in IG, 4.20% in CG
Hypertension: 54.2% in IG, 57.3% in CG
Mean baseline BP:
SBP = 131.06 (SD 15.94) in IG, 135.32 (SD 16.62) in CG;
DBP = 76.75 (SD 9.09) in IG, 75.96 (SD 9.86) in CG, (see manuscript Table 4)
Inclusion criteria:
adults accessing the primary care facilities
Exclusion criteria:
Quote: "an episode of ischemic heart disease (<6 months previously), or an acute episode of arthritis which would limit the ability to walk, or having a lung or heart disease with dyspnea (mild to moderate effort dyspnea) which would limit the individual’s ability to undertake the proposed exercise regimen"
Interventions IG: walking group:
Walking itineraries and cultural activities were pre‐set. Walking itineraries were, on average, a five‐km circuit in and around the city. Group sizes ranged from 15 to 30 participants. Monthly socio‐cultural activities included: visits to museums and libraries, cultural exhibitions, tourist attractions and dance lessons.
  • Duration: 60‐minute/session

  • Intensity: 396 METs/minutes/week over 120 minutes in 2 walking sessions per week of 60 minutes each

  • Frequency: 1 session/day, 2 days/week, plus monthly socio‐cultural activities

  • Intervention period: 39 weeks (9 month*4.33)

  • Pedometer: NR

  • Facilitator: yes, supervised walking by healthcare professionals; a physical activity specialist was responsible for the standardisation of procedures and for the training of the primary care nurses.


CG: control group: received usual care from healthcare personnel, and were recommended to follow their habitual lifestyle.
Outcomes Review outcomes reported: SBP, DBP; AEs (at 2 years)
Measurement method : BP was measured with a manual sphygmomanometer with the participants resting for at least five minutes. Three recordings were taken and the average of the second and third readings was used in the statistical analyses.
Primary/Main outcome of manuscript: overall CVD risk
Adverse event: NR, cardiovascular event objective outcomes (hospital records)
Notes Trial registration: NCT02767739
Funding sources: private sector (Department of Health of the Generalitat of Catalonia, the Catalan Society of Family and Community Medicine (CAMFIC) and the Nursing Association Family and Community (AIFICC))
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Computer‐generated random number table
Table 1 in manuscript
Allocation concealment (selection bias) Unclear risk No information
Table 1 in manuscript
Blinding of participants and personnel (performance bias)
All outcomes Low risk No other co‐interventions
Closely supervised by healthcare professionals
Closely monitored for adherence
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information about blood pressure assessor
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 13.1% in 9‐month follow‐up
45 out of 305 (14.8%) in IG and 10 out of 114 (8.8%) in CG
refer to Figure 1
PP analysis
Selective reporting (reporting bias) Low risk only 1 endpoint measurement at 9 months; only 1 analysis.
AE: only 1 endpoint measurement at 2 years for CVD events; only 1 analysis.
Other bias Low risk no other bias

Baker 2008.

Study characteristics
Methods Aim: to evaluate short‐term effects of a pedometer‐based walking programme on health outcomes in general population not meeting current physical activity guidelines.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised: 80 (1 withdrawn after randomisation, resulting 39 in IG, 40 in CG)
No. completers: 79
Country: UK (Scotland)
Study population: general population (from lowest socio‐economic groups surrounding community of a West of Scotland University)
Ethnicity: NR
Gender: male 20.3% (16/79)
Age: mean 47.3 (SD 9.3) in IG, 51.2 (SD 7.9) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 118.2 (SD 17.9) in IG, 119.9 (SD 15.9) in CG;
DBP = 75.1 (SD 11.4) in IG, 75.5 (SD 11.8) in CG;
HR = 68.6 (SD 7.2) in IG, 67.9 (SD 8.6) in CG
Inclusion criteria:
independently ambulatory, English speaking, age 18 to 65, self‐classified as not meeting current physical activity recommendation, completed Physical Activity Readiness Questionnaires for readiness, and personal physician's approval of participation.
Exclusion criteria:
not meeting inclusion criteria
Interventions IG: walking group:
An initial semi‐structured physical activity consultation based on the Transtheoretical Model of exercise behavior change.
Followed by a 12‐week walking programme involving a graduated increase in the participants' mean daily step‐count over the first six weeks to a target of 3,000 accumulated steps above their baseline value for 5 days/week. In the following six weeks, participants maintained this intensity for at least 5 days/week.
  • Duration: participants were advised on the nature of the intensity and duration of the desired increases in walking. (gradually increase from 1500 to 3000 steps/day from baseline value)

  • Intensity: moderate brisk walking (100 steps/minute) and 12 to 14 on Borg scale

  • Frequency: 3 to 5 days/week

  • Intervention period: 12 weeks

  • Pedometer: yes

  • Facilitator: yes, researchers for physical activity consultation


CG: Control group: maintain normal walking levels for 12 weeks.
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: quite: "Blood pressure and HR was measured using an automated blood pressure monitor (Omron HEM‐907, Bannockburn, IL). On each visit blood pressure measurements were performed three times with a rest period of one minute between measurements. Three measurements of resting heart rate were also recorded simultaneously by the blood pressure monitor. The average of these measurements is reported in these results."
Primary/Main outcome of manuscript: steps per day measured by Omron HJ‐109E Step‐O‐Meter and International Physical Activity Questionnaire (IPAQ).
Compliance/Adherence: 64% (definition: 25 out of 39 participants achieved an increase of 15,000 steps per week)
Adverse event: NR (5 were injured, 3 in TG and 2 in CG, but was not identified as adverse event)
Notes Trial registration: NR
note: study name was Walking for Well‐being in the West (WWW)
Funding sources: Government(Walking for Well‐being in the West (WWW) study was funded by the Scottish Government (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518560/))
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Independent interactive voice response system (by phone)
refer to Table 4
Allocation concealment (selection bias) Low risk Quote: "Randomization was carried out via an independent interactive voice response system (IVRS) which concealed all details of the randomization method from the end users."
Independent interactive voice response system (by phone)
refer to Table 4
Blinding of participants and personnel (performance bias)
All outcomes Low risk Quote: "Researchers who conducted the physical activity consultations were not blinded to group assignment in order to implement the physical activity intervention." "Additional researchers...were blinded to group assignment."
refer to Table 3 and 4
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote:"Additional researchers who performed physiological measurements were blinded to group assignment."
Incomplete outcome data (attrition bias)
All outcomes Low risk Ddropout 19.0% (15 out of 79 dropouts) was acceptable
7 out of 39 (18%) in IG, 8 out of 40 (20%) in CG.
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Bang 2016.

Study characteristics
Methods Aim: to determine the physical and psychological effects of an urban forest‐walking program for office workers.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes (In order to test the difference between the two groups of the two sides, the significance level was .05, power .80, and the effect size was.80 using G * Power 3.1 program. As a result, the number of subjects required was 26 per group, A total of 52 patients.)
Participants No. randomised: 60 (30 in IG, 30 in CG)
No. completers: 45
Country: Korea
Study population: sedentary office workers
Ethnicity: NR
Gender: male 0%
Age: mean age 39.8 ( 42.22 (SD 11.44) in IG, 37.37 (SD 9.32) in CG)
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 121.39 (SD 16.02) in IG, 112.52 (SD 12.49) in CG
DBP = 79.00 (SD 9.37) in IG, 72.85 (SD 9.35) in CG
Inclusion criteria:
60 school faculty and researchers who voluntarily submitted their application announcements to the campus from 6 September 26 2014 to 8 October 2014 and recruited on a first‐come‐first‐served basis.
Exclusion criteria: NR
Interventions IG: Forest walk: City centre forest walk program ‐ Forest walk at park in lunch time. Lunch of rice ball or sandwich was provided.
  • Duration: 1 hour/day

  • Intensity: 6.5 km/hour

  • Frequency: twice a week

  • Intervention period: 5 weeks

  • Pedometer: monitor was provided and amount of physical activity can be seen by both participants and researchers.

  • Facilitator: NR


CG: Control (CON) group: Maintain normal daily routine
Outcomes Review outcomes reported: SBP, DBP (Table 1 and 2)
Measurement method: BP (no HR) was measured using an automated blood pressure monitor after 10‐minute rest.
Primary/Main outcome of manuscript: SBP, DBP (no HR), body composition analysis, bone density, depression, quality of life
Adverse event: NR
Notes Trial registration: NR
Funding sources: Korean government
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Computerised randomisation procedure; refer to Table 1 (baseline information only from completer)
("low risk": because all participants were from a same hospital)
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Co‐interventions: lunch provided to intervention group participants
No details provided
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 25% (15 out of 60 dropouts)
12 (36.4%) in TG and 3 (11.1%) in CG
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 2 years for CVD events
Only 1 analysis
Other bias Low risk No other bias

Baross 2017.

Study characteristics
Methods Aim: to compare the effects on resting SBP, DBP, and mean arterial pressure (MAP) of 6 weeks of training, involving either (i) simultaneous walking and isometric handgrip (WHG), (ii) walking only (WLK), (iii) isometric handgrip only (IHG), or (iv) control conditions (CON).
Design: parallel 4‐group RCT (1:1:1:1)
Power/sample size calculation: No
Participants No. randomised: 24 (12 in IG, 12 in CG);
(12 in WHG and12 in IHG groups excluded)
No. completers: 24
Country: UK
Study population: sedentary young adults
Ethnicity: NR
Gender: male 54% (13/24)
Age: mean 20.7 (SD 1.6) for IG, 21.3 (SD 2.0) for CG
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 126.7 (SD 3.7) for IG; 127.9 (SD 4.2) for CG;
DBP = 77.7 (SD 3.0) for IG; 77.0 (SD 1.8) for CG
Resting HR = 66.0 (SD 3.1) for IG; 67.4 (SD 2.7) for CG
Inclusion criteria:
healthy sedentary participants, who were university students who had not participated in regular exercise training (3 or more times per week) for 12 months prior to enrolment in our study.
Exclusion criteria:
if they reported any recent (6 months) history of medical treatment for serious illness such as high blood pressure, orthopaedic injury, viral illness, or surgical procedure, habitually active students
Interventions IG: Walking (WLK) group: treadmill walking using a mains powered treadmill (GX100, Powerjog, Birmingham, UK).
  • Duration: 30 minute/session

  • Intensity: 6.5 km/hour

  • Frequency: 1 session/day, 4 days/week

  • Intervention period: 6 weeks

  • Pedometer: NR

  • Facilitator: all training sessions were performed in a consistent laboratory environment under supervision.


CG: Control (CON) group: maintain normal daily routine
Note: WHG (simultaneous walking and isometric handgrip exercise) and IHG (isometric handgrip exercise) groups excluded
Outcomes Review outcomes reported: SBP, DBP, resting heart rate
Measurement method: quote: "resting baseline measures (heart rate and blood pressure) were recorded using a heart rate monitor (Polar Beat, Polar Electro, Kempele, Finland) and an automatic blood pressure monitor (UA‐767 Plus, A&D Company, Ltd., Tokyo, Japan)."
Primary/Main outcome of manuscript: Resting HR, SBP, DBP and mean arterial pressure (MAP)
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "were randomly allocated" but no details reported
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Participants not blinded.
Quote:"All training sessions were carried out at the University of Northampton in a consistent laboratory environment under supervision."
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
refer to Table 1
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
Other bias Low risk no other bias

Bayat 2018.

Study characteristics
Methods Aim: quote: "To evaluate the effect of regular walking for 3 months on some glycemic indexes and blood pressure in women with type 2 diabetes"
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 120 (60 in IG, 60 in CG)
No. completers: 100
Country: Iran
Study population: Type II diabetic women
Ethnic: NR
Gender: male 0%
Age:mean 53.77 (SD 6.52) in IG, 52.06 (SD 6.28) in CG
Smokers: no
Hypertension: no
Mean baseline BP:
SBP = 126.04 (SD 16.69) in IG, 130.9 (SD 15.64) in CG;
DBP = 74.9 (SD 10.85) in IG, 85.0 (SD 10.0) in CG.
Inclusion criteria:
women with type 2 diabetes, aged ranged 50 to 70, none of them used tobacco or drugs, had no history of stroke, heart, kidney disease, proteinuria, or neurological and lumbar disc disease.
Exclusion criteria: not specified
Interventions IG: Walking group:
  • Duration: walked quote: "30 minutes from 7 to 10 am"

  • Intensity: moderate physical activity: quote "According to the recommendation of the European Federation of Sports Medicine Associations (the last edition of 2017), participants involved in moderate physical activity (RPE 10 to 14) at least three times a week."

  • Frequency: (not specified)

  • Intervention period: 3 months

  • Pedometer: no

  • Facilitator: no


CG: Control group: quote: "The control group did not have any physical activity during regular study, such as regular walking."
"Both groups took 500 mg of metformin and 5 mg of glibenclamide daily."
Outcomes Review outcomes reported: SBP, DBP
Measurement method : quote "A standard mercury brachial barometer was used to measure the blood pressure of type 2 diabetic patients." "Blood pressure of the subjects was taken in the sitting position after 10 minutes of rest, the legs were placed on the floor, and the hand was measured at the heart level. Blood pressure was measured twice in both pre‐test and post‐test, and the mean of these two was recorded as the patient's blood pressure at each turn."
Primary/Main outcome of manuscript: glycaemic indexes and BP
Compliace/Adherance: walking group completion rate 92% of prescribed walking steps/day
Adverse event: NR
Notes Trial registration: NR
Funding sources: Arabian government
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Qquote: "were randomly assigned" but no details reported
refer to Table 1 and 2
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1 and 2
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk According to the information author provided:
Dropout 20 out of 120 (16.7%)
10 out of 60 (16.7%) in IG and 10 out of 60 (16.7%) in CG drop outs
PP analysis
Selective reporting (reporting bias) Low risk SBP and DBP were reported at 3 months
Only 1 analysis
Other bias Low risk No other bias

Bell 2010.

Study characteristics
Methods Aim: to compare the improvements in fitness and health‐related parameters from aerobic fitness training program and pedometer‐based walking program in sedentary men and women.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised: 140 (69 in IG and 71 in CG);
(71 in Fitness training group excluded)
No. completers: 88
Country: Canada
Study population: general population from urban city
Ethnic: NR
Gender: NR
Age:mean 49 (SD 11) in men, 50 (SD 9) in women
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 124 (SD 14) in IG, 125 (SD 13) in CG;
DBP = 78 (SD 9) in IG, 80 (SD 9) in CG.
HR = 73 (SD 9) in IG, 76 (SD 11) in CG
Inclusion criteria:
Quote: “a successful completion of a physical examination by a physician; between the ages of 25 and 65 years; no known cardiorespiratory or other disease (e.g. diabetes mellitus); sedentary (no regular physical activity and less than a mean of 5500 baseline steps per day for a 7‐day period); ability to walk and participate in a moderate physical activity program; and willingness to be randomly assigned to any of the experimental groups.”
Exclusion criteria:
Quote: “any blood parameter measured during pre‐testing was at a level considered to be clinically unhealthy, if their pre‐exercise heart rate was at or above 100 beat × minute–1, or their resting systolic or diastolic blood pressure was at or above 145 mmHg systolic and 95 mmHg diastolic.”
Interventions IG: Walking (pedometer‐based walking) group:
Accumulated walking steps, progressively overloaded every 3 weeks for the first 12 weeks followed by an additional 4‐ and 8‐week increase in steps over the final 12 weeks, resulting in a progressive increase in the number of steps until 10,000 steps per day were prescribed during the last 8 weeks of the 24‐week program. Participants in the walking group were counselled to attain the target number of daily steps by increasing their walking during the morning, afternoon or evening time periods or during breaks at work. No exercise intensity guidelines or heart‐rate monitors were provided.
  • Duration: 5618 steps/d (week 1 to 3), 6499 steps/d (week 4 to 6), 7379 steps/d (week 7 to 9), 8260 steps/d (week 10 to 12), 9141 steps/d (week 13 to 16), 10,000 steps/d (week 17 to 24)

  • Intensity:1185 kJ/d (week 1 to 3), 1371 kJ/d (week 4 to 6), 1557 kJ/d (week 7 to 9), 1743 kJ/d (week 10 to 12), 1929 kJ/d (week 13 to 16), 2115 kJ/d (week 17 to 24)

  • Frequency: 7 days/week

  • Intervention period: 24 weeks

  • Pedometer: yes

  • Facilitator: no


CG: Control group: the control group was requested to not begin nor change their amount of daily physical activity while participating in the study and was offered an activity program after completion of the study as an incentive to adhere to these guidelines.
Note: fitness training group excluded from this description.
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method : submaximal HR, BP, rating of perceived exertion, ventilatory threshold (VT), and peak oxygen uptake (VO2) were determined during a graded exercise test on a treadmill.
Primary/Main outcome of manuscript: fitness (ventilatory threshold, peak oxygen uptake) and health‐related parameters (waist circumference, hip circumference, BMI, HR and BP) measured at baseline and week 24.
Adverse event: NR
Notes Trial registration: NR
Note: study duration of 6 months was been clearly described as 24 weeks in the original article
Funding sources: Governement (Grant from the Canadian Institutes of Health Research. Kerry S. Courneya (4th author) is supported by the Canada Research Chairs Program.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly assigned to..." but no details reported.
refer to Table 2
Allocation concealment (selection bias) Unclear risk No information
refer to Table 2
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Quote:"were blinded to the name of the subject and the time of the test"
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Oobjective outcomes
Quote:"were blinded to the name of the subject and the time of the test"
Incomplete outcome data (attrition bias)
All outcomes High risk 26 out of 69 (37.7%) in IG and 26 out of 71 (36.6%) in CG
refer to Figure 1
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 24 weeks
only 1 analysis
Other bias Low risk No other bias

Braith 1994.

Study characteristics
Methods Aim: to determine the effects of 6 months of moderate‐ and high‐intensity walking exercise on resting BP in normotensive elderly subjects (60 to 79 years).
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised: 30 (19 in moderate intensity group, 11 in control group)
(14 in high intensity group excluded)
No. completers: 30
Country: USA
Study population: general population (elderly volunteers)
Ethnic group: NR
Gender: male 45% (20/44*100%) included the group we excluded
Age: mean 66 (SD 5) in IG, 66 (SD 5) in CG.
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 121 (SD 10) in IG121 (SD 12) in CG;
DBP = 72 (SD 8) in IG74 (SD 5) in CG;
HR = 71 (SD 8) in IG65 (SD 8) in CG.
Inclusion criteria:
Quote: “male and female volunteers aged 60 to 79 years, sedentary but otherwise healthy persons with no contraindications to exercise.”
Exclusion criteria:
“(1) 2 consecutive resting systolic or diastolic BP measurements >140 or >90 mmHg, respectively;
(2) >0.3 mV of horizontal or downsloping ST‐segment depression at 0.08 second from the J point;
(3) significant arrhythmias;
(4) angina pectoris; and
(5) exercise‐induced bundle branch block.”
Interventions IG: Walking (moderate intensity) group:
  • Duration: increased 5 minutes every 2 weeks until it reached 40 minutes and then to 45 minutes/session (week 14 to 26)

  • Intensity: 70% of maximal heart rate reserve

  1. started training by walking for 20 minutes at 50% of their maximal heart rate reserve;

  2. progressed to 70% of heart rate reserve by week 8;

  3. after completion of the graded exercise test during week 14, the exercise target heart rate was adjusted in accordance with changes in resting heart rate;

  4. then continued training at 70% of heart rate reserve for an additional 13 weeks.

  • Frequency: 3 session/week

  • Intervention period: 26 weeks

  • Pedometer: No

  • Facilitator: NR


CG: Control group: control group participants were instructed to maintain their usual diet and salt intake during the study period.
Note: IG2_high: high intensity walking group that trained with uphill treadmill jogging excluded according to the following description: "all subjects in the high‐intensity group trained by walking uphill on a treadmill."
Outcomes Review outcomes reported: resting SBP, DBP
Measurement method: quote: "subjects did not participate in strenuous physical activity for a minimum of 24 hours before these measurements. Heart rate and BP were measured after 20 minutes of seated rest in a quiet room.The same trained observer made all BP measurements by auscultation using a Hawksley random‐zero sphygmomanometer in the arm with the highest BP during the initial visit. Heart rate was measured by palpitation."
Primary/Main outcome of manuscript: resting SBP, DBP (at baseline,week 13 and 26), HR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly stratified to 1 of 3 groups" but no details reported.
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and personnel not blinded.
refer to Table 2
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk According to the outcome table 1 and 2, the dropout rate was 0% since the participant number was the same in two tables.
ITT analysis
Selective reporting (reporting bias) Low risk Measurement at 3 months and 6 months (all reported)
Both 3‐month and 6‐month analysis reported
Other bias Low risk No other bias

Brandon 2006.

Study characteristics
Methods Aim: the effects of a 16‐week dose if brisk walking on body composition and blood pressure in sedentary and obese African America and White women.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised: 52 (15 in AAE, 13 in WE, 12 in AAC, 12 in WC)
No. completers: 36
Country: USA
Study population: general population (from urban university and local government agencies.)
Ethnicity: African American: 51.92% (27/52), white: 48.08% (25/52)
Gender: male 0% (0/52)
Age: mean 34.0 (SD 7.2) in AAE, 40.5 (SD 7.1) in WE, 36.0 (SD 8.4) in AAC, 42.0 (SD 9.7) in WC. (mean age 37.93)
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 110.0 (SD 11.9) in AAE, 111.0 (SD 14.9) in WE; 103.9 (SD 15.6) in AAC, 115.0 (SD 18.1) in WC;
DBP = 69.7 (SD 8.9) in AAE, 67.0 (SD 10.3) in WE; 63.8 (SD 14.6) in AAC, 68.5 (SD 10.2) in WC.
Inclusion criteria:
Quote: “Sedentary (exercise less than twice a week for the past six months), weight stability, age 18 to 50 years, body fat (>27% body fat).”
For the IG: able to successfully walk three miles per session after the first two weeks of orientation.
Exclusion criteria:
Quote: “past history of cardiovascular disease, present signs or symptoms of cardiovascular disease, resting SBP>160mmHg and resting DBP>100mmHg, or taking blood pressure or other medication that contraindicated exercise. Participants with two or more coronary heart disease risk factors obtained physical approval before participating in the study. Women who were on or had been on diets or weight loss medications affecting body weight within the last six months were excluded from the study.”
Interventions IG: Walking group (AAE, WE)
The first 2 weeks were used for conditioning and providing instruction on the brisk walking, training the ability of walking 3 miles for a session. The last 16 weeks constituted the training intervention. The walking sessions took place outside on courses, or on indoor track or treadmill on rainy day. The participants were instructed for making up and recording missed sessions within a week.
  • Duration: 3 miles/session (single bout)

  • Intensity: self‐paced, as brisk as possible, the goal was to walk at 3.5 mph.

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 16 weeks

  • Pedometer: NR

  • Facilitator: NR


CG: Control group (AAC, WC): were asked not to exercise outside the program
All study participants were instructed not to change their present lifestyle and dietary habit.
Outcomes Review outcomes reported: SBP, DBP
Measurement method : all BP values were measured with a calibrated sphygmomanometer and stethoscope on the right arm. The same technician and equipment were used for all BP measurements in this study.
Primary/Main outcome of manuscript: body compositions (BMI, waist and hip circumferences, per cent body fat, bone marrow density, body density‐skinfold fatness) and blood pressure measured at baseline and week 18.
Compliance/Adherence: 87.6+‐8.9% (Quote:"Only subjects that completed 75% of the training intervention were included in the data analyses.)
Adverse event: NR
Notes Trial registration: NR
note: mean baseline BP in Table 1 and table 5 had some differences.
Definition: 75% of the completion of the training interventions
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "The women were randomly assigned based on race…” Randomisation method was not clearly described.
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk High dropout rates: 16/52 = 30.8%
there was no explanation regarding the high dropout rate in the article
refer to Table 2
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 18 weeks
only 1 analysis
Other bias Low risk No other bias

Brenner 2020.

Study characteristics
Methods Aim: to determine the circulatory and autonomic effects, as well as the effects on walking performance of a progressive, 12‐week, home‐based, low‐intensity (pain‐free walking) exercise program in patients with PAD.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:48 (27 in IG, 21 in CG)
No. completers: 33
Country: Canada
Study population: patients with vascular problems (from a cohort study held at a vascular clinic at an acute care hospital)
Ethnicity: NR
Gender: male 63.6% (21/33), [66.7% (12/18) in IG, 60% (9/15) in CG]
Age: mean 68.56 (SD 6.87) in IG, 63.67 (SD 8.47) in CG.
Smokers: 48.5% (16/33) in total, [44.4% (8/18) in IG, 53.3% (8/15) in CG]
Hypertension: NR
Mean baseline BP:
SBP = 124 (SD 15) in IG, 132 (SD 14) in CG.
DBP = 67 (SD 8) in IG, 69 (SD 11) in CG
HR = 63 (SD 12) in IG, 66 (SD 13) in CG
Inclusion criteria:
  1. 18 years or older

  2. diagnosed with stable PAD, expressing symptoms of IC, and having an ankle‐brachial index (ABI) 0.9


Exclusion criteria:
  1. unable to read or write English

  2. resided in a nursing home

  3. already involved in an exercise program

  4. wheelchair dependent

  5. had angina, congestive heart failure, chronic obstructive pulmonary disease, severe arthritis, or limb amputation

  6. had non‐compressible arteries (ABI > 1.2)

  7. cognitively impaired

Interventions IG: Walking group:
Verbal and written instructions regarding Borg Ratings of Perceived Exertion (RPE) Scale and the Borg CR‐10 Pain Scale were offered. Logbooks rather than activity monitors were applied due to funding limitations. Both groups received follow‐up phone calls after the first week of the program and at 2‐week intervals to address any concerns. For members of the exercise group, to address any questions about the exercise intervention and to ensure compliance with the program.
  • Duration: mean 33.7‐minute/session (to begin walking 0.4 km per day with a gradual increase every 2 weeks to reach 3.2 km per day at the end of 12 weeks)

  • Intensity: low Intensity. Less than 40% of HRR and an RPE between 11 and 13 until they felt minimal claudication pain (Borg CR‐10 score 2) then to record time, distance, HR, RPE, and pain score in their activity log

  • Frequency: 5 days per week (mean 4.3 (SD 2.1) days/week

  • Intervention period: 12 weeks

  • Pedometer: no

  • Facilitator: no


CG: Control group:
Continue with normal lifestyle and record in an activity log the type and amount of physical activity during the week, the duration of activity, and HR.
Outcomes Review outcomes reported: HR and BP
Measurement method: at rest in the supine position and during upright standing at baseline and after 12 weeks. Participants rested comfortably in the supine position in a quiet, dimly lit room. HR and BP were measured using a BpTRU machine (Model BPM‐300, VSM Medtech Ltd., Coqitlam, BC). The upright standing data were measured following an adaptation period of 3 minutes in the upright, free‐standing position.
Primary/Main outcome of manuscript: HR, BP, heart rate variability (HRV), and heart rate reserve
Compliance/Adherence: duration, mean 33.7 minute/session with 95 ± 11% compliance; frequency, mean 4.3 (SD 2.1) days/week with 97 ± 37% compliance; and walking distance, mean 74 + 9% compliance.
Adverse event: NR
Notes Trial registration: NR
Funding sources: Queen’s University, School of Nursing Freda Paltiel Award and a Southeastern Ontario Academic Health Sciences Innovation Grant
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Rrandom assignment, participants randomly selected a sealed envelope that contained an assignment to groups. However, quote: "for each participant who did not complete testing following the exercise program," a new participant was recruited. There is no information for how the new participant was recruited.
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants were not blinded and personnel was unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 31.3% (15 out of 48 dropouts)
9 out of 27 (33.3%) in IG, 6 out of 21 (28.6%) in CG
refer to Table 1, 3, 4.
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
Other bias Unclear risk The follow‐up phone calls to both intervention and control groups after the first week of the program and at 2‐week intervals during the 12‐week intervention period may increase the awareness of the need of lifestyle modification among participants in the control group and may cause the concern of information contamination.

Brown 2014.

Study characteristics
Methods Aim: to measure the impact of lunchtime walking on employee's physical activity levels and health markers.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: yes
Participants No. randomised: 94 (32 in IG1, 33 in IG2, 29 in CG)
No. completers: 73
Country: UK
Study population: general population (office workers)
Ethnicity: white 98% (92/94), Indian 2% (2/94)
Gender: male 78.7% (74/94)
Age: mean 42 years (SD 10.6)
Smokers: 0%
Hypertension: NR
Mean baseline BP:
SBP = 135.1 (SD 12.3) in IG1, 128.9 (SD 15.1) in IG_built; 133.3 (SD 10.5) in CG;
DBP = 86.0 (SD 7.6) in IG1; 81.5 (SD 11.9) in IG2, 79.5 (SD 7.1) in CG
HR = 67.1 (SD 10.0) in IG1; 63.6 (SD 10.1) in IG_built; 64.6 (SD 12.5) in CG
Inclusion criteria:
18 to 65 years office workers, consider themselves healthy and able to undertake fairly intense exercise.
Exclusion criteria:
Quote: "known cardiovascular and/or neurological conditions or taking of medication that affects these systems."
Interventions IG1_nature : Nature Walking (NW) group:
The walking route provided for the NW group consisted of trees, spaces of maintained grass, public footpaths, and country lanes. They are able to walk individually or with others.
  • Duration: 20‐minute/session (approximately 2 km; i.e. 6km/hour)

  • Intensity: 12 on the Rate of Perceived exertion (RPE) scale (Borg 6–20)

  • Frequency: 2 lunchtime sessions/week

  • Intervention period: 8 weeks

  • Pedometer: yes (ActiPed)

  • Facilitator: NR


IG2_built : built walking (BW) group:
The walking route for the BW group primarily composed of paved footpaths adjacent to roads, housing estates, and industrial areas. They are able to walk individually or with others.
  • Duration: 20‐minute/session (approximately 2 km; i.e. 6km/hour)

  • Intensity: 12 on the Rate of Perceived exertion (RPE) scale (Borg 6–20)

  • Frequency: 2 lunchtime sessions/week

  • Intervention period: 8 weeks

  • Pedometer: yes (ActiPed)

  • Facilitator: NR


CG: Control (waiting) group: normal level of activities.
  • Pedometer: yes (ActiPed) for monitoring physical activity

Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method : a Polar HR monitor (Polar Electro UK Ltd, Warwick, UK) was used to view HR throughout the testing procedure.
Resting BP measurement was taken using an electronic BP monitor (MX3 basic, Omron, Lake Forest, IL, USA) with the cuff placed on the participant’s upper right arm.
Primary/Main outcome of manuscript: HR and HR variability
Adverse event: NR
Notes Trial registration: ISRCTN005716448
Funding sources: Governement(The British Heart Foundation (non‐clinical PhD studentship FS/10/32/28204) and Economic and Social Research Council as part of UK Research and Innovation (project number RES‐064‐27‐0019) supported this study.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "Randomisation for the grouping of the participants was generated by a computer program"
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 21 out of 94 = 22.3%
5 out of 32 in Nature walking (15.6%), 6 out of 33 in Built walking (18.2%), 10 out of 29 in control group (34.5%) dropouts
refer to Figure 1, Table 2
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Chan 2018.

Study characteristics
Methods Aim: to compare Tai Chi with brisk walking in effects of reducing cardiovascular disease risk factors and improving psychosocial well‐being.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: yes
Participants No. randomised: 164 (82 in IG, 82 in CG);
(82 in Tai Chi group excluded)
No. completers: 144
Country: Hong Kong
Study population: hypertensive adults
Ethnicity: NR
Gender: male 48.8% ((42+38)/164)
Age: mean 63.22 (SD 11.11) in IG, 65.13 (SD 10.22) in CG.
Smokers: Yes, 11.0% (5+13)/164)
Hypertension: 100%
Mean baseline BP:
SBP = 138.15 (SD 17.39) in IG, 142.49 (SD 19.12) in CG.
DBP = 79.74 (SD 10.51) in IG, 82.59 (SD 10.68) in CG.
Inclusion criteria:
  1. hypertension,

  2. at least two but not more than three CVD risk factors, defined by the American Heart Association (American Heart Association, 2017a) as diabetes, dyslipidaemia, hypertension, overweight, physical inactivity and smoking."


Exclusion criteria: NR
Interventions IG: Brisk walking group:
To ensure intervention fidelity, a pulse oximeter was provided to each participant to measure HR during brisk walking.
Self‐reported logbooks were provided for the participants to record heart rate, frequency and duration of brisk walking. The research assistant collected the logbooks weekly and encouraged the participants’ adherence to the intervention.
Weekly non‐exercise community activities were arranged for 3 months as attention control activities to balance the socialiSation among groups.
  • Duration: 30 minutes/day, 150 minutes/week

  • Intensity: moderate, 5 to 6 km/30 minutes/day; participants were advised to reach an individualised HR equal to a moderate‐intensity exercise, which was based on their age.

  • Frequency: ≧5 days/week

  • Intervention period: 13 weeks (3 months*4.33)

  • Pedometer: NR

  • Facilitator: NR


CG: Control group:
Usual activity without self‐report log books, but weekly non‐exercise community activities for 12 weeks as attention control activities to balance the socialisation among three groups.
Note: Tai Chi group excluded
Outcomes Review outcomes reported: SBP and DBP
Measurement method: the participants were asked to sit for at least 10 minutes in a quiet location. BP was then measured twice at 5‐minute intervals using a digital BP monitor (CARESCAPEV100, GE Healthcare). The average of the two BP readings was used for analysis. Data were collected at baseline, 3, 6, and 9 months.
Primary/Main outcome of manuscript: BP
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: Health Medical Research Fund, Food and Health Bureau, Hong Kong SAR (No. 12130041).
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "The randomisation list was stored in a password‐protected computer only accessible by the research staff responsible for participant allocation."
Allocation concealment (selection bias) Low risk Quote: "The randomisation list was stored in a password‐protected computer only accessible by the research staff responsible for participant allocation."
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Quote: "The research assistants responsible for data collection were blinded to group assignment."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.2% (20 out of 164 dropouts)
6 out of 82 (7.3%) in IG, 14 out of 82 (17.1%) in CG
refer to Fig. 1
GEE models used for accommodating missing data
ITT analysis
Selective reporting (reporting bias) Low risk only 1 endpoint measurement at 3 months
only 1 analysis
Other bias Unclear risk The participants in the brisk walking and control groups were arranged to participate in non‐exercise community socialisation activities weekly during the 3‐month intervention period. These activities may cause information contamination between groups and may increase awareness of lifestyle modification among control group participants.

Chiang 2019.

Study characteristics
Methods Aim: to investigate the differences in body composition and metabolic syndrome (MS) under a daily 12,000‐step strategy with or without moderate‐intensity walking exercise in college students with obesity
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised:32 (12 in IG1, 11 in IG2, 9 in CG)
No. completers: 32
Country: China
Study population: college students with obesity and did not regularly engage in physical activity (≥18 years)
Ethnicity: NR
Gender: NR
Age: mean 19.17 (SD 1.03) in IG1, 20.64 (SD 1.80) in IG2, 19.36 (SD 1.12) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 121.92 (SD 15.70) in IG1, 121.36 (SD 11.48) in IG2, 127.00 (SD 17.18) in CG.
DBP = 76.92 (SD 12.06) in IG1, 79.55 (SD 8.85) in IG2, 74.33 (SD 11.06) in CG.
HR = 75.92 (SD 10.13) in IG1, 78.3 (SD 10.02) in IG2, 79.78 (SD 7.85) in CG
Inclusion criteria:
participants with obesity aged 18 years or older who did not regularly engage in physical activity were recruited. The inclusion criterion for participants were no diabetes or other chronic diseases.
Exclusion criteria: NR
Interventions All three groups were required to attend a procedure instruction session on different day before the intervention and were issued a smartwatch (ZenWatch 3, ASUSTeK Computer Inc. Taipei, Taiwan) for step monitoring during the 8‐week intervention. Participants from WEG and WSG must report back to the lab weekly for verification of any missing or incorrect data recording on the exercise log.
IG1: Walking Step Goal (WSG) group:
  • Duration: NR

  • Intensity: 12,000 steps/day from Monday to Friday

  • Frequency: 5 days/week

  • Intervention period: 8 weeks

  • Pedometer: Smartwatch (ZenWatch 3, ASUS TeK Computer Inc., Taipei, Taiwan) for step monitoring

  • Facilitator: No


IG2: Walking Exercise (WEG) group:
  • Duration: NR but request to complete 30 minutes of continuous moderate‐intensity on 3 days per week

  • Intensity: 12,000 step/day from Monday to Friday + moderate‐intensity (i.e., 103 steps per minute) on 3 days per week

  • Frequency: 5 days/week including 30 minutes of continuous moderate‐intensity on 3 days per week

  • Intervention period: 8 weeks

  • Pedometer: Smartwatch (ZenWatch 3, ASUS TeK Computer Inc., Taipei, Taiwan)

  • Facilitator: yes (participants were monitored by professional instructors during the exercises in order to maintain a steady brisk walking pace)


CG: Control group: not given any instructions regarding exercise during the intervention and was asked to maintain a similar daily routine including diet. A smartwatch (ZenWatch 3, ASUSTeK Computer Inc., Taipei, Taiwan) was offered for step monitoring
Outcomes Review outcomes reported: SBP and DBP, resting HR
Measurement method: prior to measuring resting HR, SBP, DBP, and blood biomarkers, participants were asked to refrain from intense activity, smoking, caffeine consumption, and avoid the foods rich in sugar and fat for 24 hours and to fast for 12 hours before blood sampling. All resting values were obtained after a 10 minutes seated resting.
Primary/Main outcome of manuscript: Weight (wt), BMI, body fat (FAT), visceral fat area (VFA), skeletal muscle mass (SMM), waist circumference (WC), hip circumference (HIP), HDL‐C, HR, DBP, SBP and blood biomarkers (fasting glucose (FG), and TG levels).
Compliance/Adherence: WSG 94.5% (11340.46/12000*100%; mean 11340.46 (SD 743) steps per day. WEG 102.4% (12288/12000*100%; mean 12288 (SD 721) steps per day.
Adverse event: NR
Notes Trial registration: Australian New Zealand Clinical Trials Registry, (ACTRN12618001237279)
Funding sources: Chinese Culture University and Ministry of Science and Technology, Republic of China (Taiwan) (No. 105–2815‐C‐034‐028‐H).
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Participants "were randomly assigned" but no details reported.
Allocation concealment (selection bias) Unclear risk The "grouping methods" for assigning study groups "was confidential to the participants" but not sure what kind of methods has been confidential to study participants.
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk No information
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Coghill 2008.

Study characteristics
Methods Aim: to investigate whether a home‐based physical activity program meeting current guidelines was effective in improving the lipid profile in hypercholesterolaemic men.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised:67 (38 in IG, 29 in CG)
No. completers: 67
Country: UK
Study population: middle‐aged hypercholesterolaemic men
Ethnicity: NR
Gender: male 100%
Age: range 45 to 65 years
Smokers: 0%
Hypertension: NR
Mean baseline BP:
SBP = 138.04 (SD 15.61) in IG, 140 (SD 15.63) in CG;
DBP = 89.90 (SD 9.93) in IG, 88.32 (SD 9.52) in CG
Inclusion criteria:
middle‐aged (45 to 65 years) male non‐smokers, with hypercholesterolaemia defined as TC6.2mmol/L (NCEP III, 2001) and/or a TC/HDLC ratio≥6; who were not receiving pharmacological treatment for hypercholesterolaemia or other conditions related to CHD, including both type 1 and 2 diabetes; sedentary (defined as no regular moderate or vigorous physical activity in excess of 30 minutes a day on at least five days a week over the last three months) and able to undertake a program of walking.
Exclusion criteria: NR
Interventions IG: Brisk Walking group: Wear times of accelerometer, total activity energy expenditure, and any bout of moderate activities ≥30 minutes or high intensity activity ≥20 minutes were recorded in a diary by participants.
  • Duration: walk briskly for at least 30 minutes/session

  • Intensity: 12 to 14 RPE (= energy expenditure 5 to 7.5kcal/minute)

  • Frequency: at least 5 days/week

  • Intervention period: 12 weeks

  • Pedometer: accelerometer was worn during walking hours.

  • Facilitator: NR


CG: Control group: control group participants were requested to maintain their current activities of daily living
Outcomes Review outcomes reported: SBP, DBP
Measurement method: quote: "Blood pressure and resting heart rate were measured with a Spacelabs 90207 monitor."
Primary/Main outcome of manuscript: SBP, DBP
Adverse event: NR
Notes Trialregistration: NR
Funding sources: Private sector (Frenchay Hospital Trustees, Bristol funded the blood assays for this project.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "randomization group inside a sealed opaque envelope"
Allocation concealment (selection bias) Low risk Quote:"Participants were allocated by a researcher blinded to the randomisation process who selected and opened each envelope with the participant at the point of randomisation."
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
refer to Figure 1
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk No dropout
refer to figure 1, table 1, 2
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Cooper 2000.

Study characteristics
Methods Aim: Quote:“The effect of a six‐week programme of moderate intensity exercise on daytime ambulatory blood pressure (10.00am to 10.00pm) among unmedicated, sedentary adults aged 25 years to 63 years with office blood pressure of 150 mmHg to 180 mmHg systolic and/or 91 mmHg to 110 mmHg diastolic.” Hypertensive adults
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised: 90 (48 in IG, 42 in CG)
No. completers: 86
Country: UK
Study population: unmedicated hypertensive patients adults (recruited from general practices and workplaces of two large companies)
Ethnicity: NR
Gender: male 80% (72/90)
Age: mean 46.2 (SD 9.4) in IG, 49.4 (SD 8.9) in CG.
Smokers: NR
Hypertension: 100% hypertensive patients (SBP 150 to 180, DBP 91 to 110)
Mean baseline BP:
SBP = 139.8 (SD 12.5) in IG, 137.0 (SD 10.9) in CG;
DBP = 89.5 (SD 9.6) in IG, 88.4 (SD 9) in CG.
Inclusion criteria:
Quote:“be aged 18 years to 64 years, not be receiving pharmacological blood pressure or lipid lowering treatment, be sedentary, and have a resting office blood pressure of 150 mmHg to 180 mmHg (systolic) and/or 91 mmHg to 110 mmHg (diastolic).”
Exclusion criteria: NR
Interventions IG: Walking group: Participants were asked to expend a daily 150 kcal to 200 kcal in 30 minutes of physical activity (equivalent to 30 minutes of brisk walking) in addition to their normal levels of activity for at least 5 days a week.
  • Duration: 30 minutes/session

  • Intensity: Moderate physical activity, 150 to 200 kcal expenditure daily

  • Frequency: 1 session/day, 5 days/week

  • Intervention period: 6 weeks

  • Pedometer: Wore an accelerometer on each exercising day

  • Facilitator: Yes, biweekly; participants met with the researchers after two and four weeks to replace diaries and to resolve problems encountered in achieving the exercise target.


CG: Control group: Participants were asked to maintain their usual levels of physical activity over the subsequent six weeks. All participants were requested not to change other aspects of their lifestyle during the intervention period.
Outcomes Review outcomes reported: SBP, DBP
Measurement method : daytime ambulatory blood pressure was measured using SpaceLabs 90207 monitors programmed to record a reading every 15 minutes between 9.00 am and 10.00 pm.
Primary/Main outcome of manuscript: Office and ambulatory SBP, DBP, and weight measured at baseline and week‐6.
Compliance/Adherence: 89% compliance
100% compliance was defined as recording that exercise was undertaken on 30 of 42 days
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This study was funded by the NHS Executive South and West Research and Development Directorate. The Department of Social Medicine at the University of Bristol is the main centre for the MRC Health Services Research Collaboration.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"Block randomisation within strata defined by sex was used to generate the allocation, with six intervention and five control conditions within each block of 11."
refer to Table 1
Allocation concealment (selection bias) Low risk Opaque envelope prepared by others
Quote:"…, an opaque envelope with the treatment allocation was opened to reveal the participant’s treatment allocation. Randomisation envelopes were prepared by a member of the research team not involved in data collection and researchers collecting data were unaware of the allocation of participants until opening each envelope."
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes High risk "The researcher responsible for administering the collection of data at six‐week follow‐up was not blinded to treatment allocation."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 4.4% (4 out of 90)
1 out of 48 (2.1%) in IG, 3 out of 42 (7.1%) in CG
Planned ITT, but excluded dropouts in analysis
refer to Table 2
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 6 weeks
Only 1 analysis
Other bias Low risk No other bias

Dong (董兆強) 2007.

Study characteristics
Methods Aim: to investigate the effect of physical training on insulin resistance among the patients with chronic heart failure (CHF).
Design: parallel 2‐group RCT (65:55)
Power/sample size calculation: NR
Participants No. randomised: 120 (65 in IG, 55 in CG)
No. completers: 120
Country: China
Study population: hospitalised congestive heart failure (CHF) patients (NYHA Ⅱ‐Ⅲ)
Ethnicity: Chinese
Gender: male 55% ((36+30)/120)
Age: mean 61.7 (SD 12.3) in IG; 61.9 (SD 12.1) in CG
Smokers: NR
Hypertension: 20.8% (25 primary hypertension with 14 in IG and 11 in CG)
Mean baseline BP:
SBP = 149.10 (SD 44.50) in IG, 147.2 (SD 44.1) in CG.
HR = 104 (SD 25) in IG, 105 (SD 21) in CG
Inclusion criteria:
① Hospitalised NYHA Ⅱ‐Ⅲ CHF patients with stable condition for at least 2 months;
  1. age between 43 to 75;

  2. no lung disease or limb disability was noted.


Exclusion criteria:
  1. diabetes mellitus,

  2. obesity,

  3. uncontrolled HTN,

  4. endocrine disease,

  5. cerebral stroke,

  6. peripheral vessel disease,

  7. degenerative joint disease,

  8. active pericarditis or myocarditis,

  9. moderate to severe aortic stenosis,

  10. impending surgery for valve regurgitation and severe insufficiency of liver/kidney function.

Interventions IG: Training group:
Participants were encouraged to walk to and from on a relatively stable 40‐metre hallway for 6 minutes per session.
Routine medication treatment and the 6‐minute walking distance exercise were continued till 20 weeks. HR, BP and EKG were monitored during each session.
  • Duration: 6‐minute/session

  • Intensity: (6‐minute walking distance)

  • Frequency: twice a day/week, 7 days/week = 14 sessions/week

  • Intervention period: 20 weeks

  • Pedometer: no

  • Facilitator: NR


CG: Routine therapy group: routine medication treatment
Outcomes Review outcomes reported: meanBP and HR
Measurement method: before and after the 20‐week intervention
Primary/Main outcome of manuscript: homeostasis model assessment‐insulin resistance (HOMA‐IR), insulin resistance index (ISI), left ventricular ejection fraction (LEVF), left ventricular fractional shortening (LVFS), 6‐minute walking distance, HR and mean BP
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomly divided" using "random table" but no details reported
Allocation concealment (selection bias) Unclear risk NR, study groups allocator
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
65 completers in training group, 55 completers in control group
refer to table 2, 3
Unsure ITT or PP analysis
Selective reporting (reporting bias) Unclear risk Only 1 endpoint measurement at 20 weeks
Only 1 analysis
Only provided SBP but not DBP without reason, DBP data could not obtained from author contact
Other bias Low risk no other bias

Dong (董雅娟) 2012.

Study characteristics
Methods Aim: to observe influence of aerobic exercise on blood pressure in patients with white coat hypertension (WCH).
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 51 (26 in IG, 25 in CG)
No. completers: 51
Country: China
Study population: white coat hypertensive patients
Ethnicity: Chinese
Gender: male 56.9% ((16+13)/51)
Age: mean 53.75 (SD 16.42) in IG, 54.26 (SD 17.18) in CG
Smokers: NR
Hypertension: 100% (white coat hypertension)
Mean baseline BP:
24 hours mean SBP (mSBP) = 129.51 (SD 25.42) in IG, 127.96 (SD 23.13) in CG;
24 hour mean DBP (mDBP) = 82.09 (SD 17.23) in IG, 83.46 (SD 18.52) in CG
Inclusion criteria:
  1. diagnostic standard of WCH;

  2. volunteered to participate in the present study.


Exclusion criteria:
  1. diagnosed hypertension;

  2. could not walk properly because of bone and joint diseases;

  3. diagnosed with severe disease

Interventions IG: Walking group: Adopted WHO recommendation of “mild hypertension exercise plan”: Exercise was done in the morning and evening.
  • Duration: continuing for 50 to 80 minutes/session; warming‐up and cooling down for 5 to 10 minutes each

  • Intensity: walking on flat ground with constant speed every day, adjusting the velocity according to self‐measured HR controlled below 100 beats/minute for about 50 to 60% maximum oxygen consumption

  • Frequency: >=5 days/week, 10 to 16 sessions/week

  • Intervention period: 3 months

  • Pedometer: no

  • Facilitator: NR


CG: Control group: not undergoing exercise
Outcomes Review outcomes reported: Office SBP (OSBP), Office DBP(ODBP), Ambulatory 24‐hour mean SBP (mSBP). Ambulatory 24‐hour mean DBP (mDBP), Ambulatory daytime SBP (dSBP) and Ambulatory daytime DBP (dDBP). We used mSBP and mDBP only.
Measurement method: office BP: after resting for 30 minutes in sitting position, OSBP and ODBP were measured at right upper arm by mercury standard cuff sphygmomanometer.
Ambulatory BP: non‐invasive portable (America type AMR4) ambulatory blood pressure monitor was used for measurement. Cuff (22 cm 12 cm) was tied to right upper arm of participant automatically aerated and measured every 30 minutes in daytime (6:00 to 22:00) and every 60 minutes at night (22:00 to 6:00 of second day), effective was de fined as recorded monitoring times ≥80% within 24 hours.
Primary/Main outcome of manuscript: Office SBP(OSBP), Office DBP(ODBP), Ambulatory 24‐hour mean SBP (mSBP) DBP (mDBP), ambulatory daytime SBP (dSBP) and DBP (dDBP)
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomly divided" mentioned in abstract but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 0% (0/51)
26 in exercise group, 25 in control group
refer to table 1, 2
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 3 months
Only 1 analysis
Other bias Low risk No other bias

Duncan 1991.

Study characteristics
Methods Aim: the effects of a 24‐week walking program with different exercise intensity on the risk of cardiovascular disease in sedentary premenopausal women.
Design: parallel 4‐group RCT (1:1:1:1)
Power/sample size calculation: Yes
Participants No. randomised: 102 (29 in IG1, 26 in IG2, 26 in IG3, 21 in CG)
No. completers: 59 (16 in IG1, 12 in IG2, 18 in IG3, 13 in CG)
Country:USA
Study population: general population (premenopausal female volunteers)
Ethnicity: 81% White, 17% black, and 2% Hispanic.
Gender: male 0% (0/102)
Age: range 20 to 40
Smokers: 0%
Hypertension: NR
Mean baseline BP: (data only reported for 59 study completers)
SBP = 105 (SD 8) in IG1, 109 (SD 9) in IG2, 108 (SD 6) in IG3, 108 (SD 8) in CG;
DBP = 70 (SD 7) in IG1, 74 (SD 8) in IG2, 73 (SD 9) in IG3, 74 (SD 7) in CG
Inclusion criteria:
20 to 40 years of age, sedentary menopausal women with blood pressure below 160/90mmHg, total serum cholesterol levels below 6.59 mmol/L, and serum triglyceride levels below 2.25 mmol/L;"if they:
  1. did not smoke;

  2. consumed fewer than three alcoholic drinks per day;

  3. did not currently receiver dietary interventions;

  4. did not have cardiopulmonary and/or musculoskeletal diseases; and

  5. did not regularly exercise more than 1 day per week in the previous 6 months.”


Exclusion criteria: NR
Interventions IG1_aerobic: walking (aerobic walkers) group:
  • Duration: gradually increase to 4.8 km/session (by week 7 and maintain) (start with 2.4 km)

  • Intensity: initially 70% of 8.0 km/hour, and gradually increasing to 100% (week 14 to week 24).

  • Frequency: 5 days/week

  • Intervention period: 24 weeks


IG2_brisk: walking (brisk walkers) group:
  • Duration: gradually increase to 4.8 km/session (by week 7 and maintain) (start with 2.4 km)

  • Intensity: Initially 70% of 6.4 km/hr, and gradually increasing to 100% (week 14 to week 24).

  • Frequency: 5 days/week

  • Intervention period: 24 weeks


IG3_stroller: walking (strollers) group:
  • Duration: gradually increase to 4.8 km/session (by week 7 and maintain) (start with 2.4 km)

  • Intensity: Initially 70% of 4.8 km/hour, and gradually increasing to 100% (week 14 to week 24).

  • Frequency: 5 sessions/week

  • Intervention period: 24 weeks


Walking on a tartan‐surfaced 1.6‐km track, starting at 2.4 km, and gradually increasing to 4.8 km by the week 7, till the completion of the study.
Subsequently from week 8 to 24, the walking intensity depends on the allocated group.
  • Pedometer: NR

  • Facilitator: yes, an exercise physiologist


CG: Control group: remaining sedentary for the duration of the study and were not contacted except to schedule follow‐up testing.
All groups advised not to change dietary, exercise (other than prescribed) or other life style habits
Outcomes Review outcomes reported: resting BP (at baseline and week‐24)
Measurement method: the same trained observer made all measurements with a mercury sphygmomanometer. The mean of the three readings on the third day was used as baseline and follow‐up values. SBP andDBP were recorded at the first and fifth phases of Korotkoffs sounds.
Primary/Main outcome of manuscript:sSerum lipid and lipoprotein levels, maximal oxygen uptake (VO2 max), nude body weight, and percentage of body fat measured at baseline and week‐24.
Adverse event: no
Notes Trial registration: NR
Funding sources: private sector (This study was supported by a grant from the Naturalizer division of Brown Shoe Co, St Louis, Mo)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"random assignment" but no details reported
Table 1 results only from 59 completers, not all 102 randomised
Allocation concealment (selection bias) Unclear risk No information
Table 1 results only from 59 completers, not all 102 randomised
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded and personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Low risk 0bjective outcomes
Quote:"All baseline and posttest‐dependent variables (except percentage of body fat) were measured by personnel who were blinded to individual participant group assignments."
Incomplete outcome data (attrition bias)
All outcomes High risk 13 out of 29 (44.8%) in IG (aerobic), 14 out of 26 (53.8%) in IG (brisk), 8 out of 26 (30.8%) in IG (strollers), 8 out of 21 (38.1%) in CG.
refer to Table 3
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 24 weeks
Only 1 analysis
Other bias Low risk No other bias

Dureja 2014.

Study characteristics
Methods Aim: to investigate the effect of treadmill training on blood pressure among young post‐graduate students.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:10 (5 in IG, 5 in CG)
No. completers: 10
Country: India
Study population: post graduate students
Ethnicity: NR
Gender: male 100%
Age: range 19 to 25 years
Smokers: NR
Hypertension:NR
Mean baseline BP:
SBP = 116 (SD 5.47) in IG, 123 (Sd10.36) in CG
DBP = 82.0 (SD 11.51) in IG, 79 (SD 8.94) in CG
Inclusion criteria:19 to 25 years, college students
Exclusion criteria:NR
Interventions IG: Walking (experimental) group: treadmill walking with increasing intensity
  • Duration: 10 minutes (week 1), 15 minutes (week 2), 20 minutes (week 3), 25 minutes (week 4) per session

  • Intensity: 5 km/hour (week 1), 7 km/hour (week 2), 8 km/hour (week 3), 10 km/hour (week 4)

  • Frequency: 1 session/day, 6 days/week

  • Intervention period:4 weeks

  • Pedometer: no

  • Facilitator: all participants completed a 4‐week training program. 


CG: Control group: NR
Outcomes Review outcomes reported: SBP, DBP
Measurement method: not mentioned
Primary/Main outcome of manuscript: Pre‐test, post‐test SBP, DBP
Adverse event: NR
Notes Trialregistration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "Participants were randomly assigned to" but no details reported
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk no dropout
refer to Tables 2, 3, 4,5
ITT analysis
Selective reporting (reporting bias) Low risk Only measurement at 4 weeks
Only 1 analysis
Other bias Low risk No other bias

Foulds 2014.

Study characteristics
Methods Aim: to examine the dose–response relationship between exercise volume and intensity with derived health benefits including volumes and intensity of activity well below international recommendations.
Design: parallel 6‐arm RCT (1:1:1:1:1:1) (1 control + 4 brisk walking groups + 1 running group)
Power/sample size calculation: NR
Participants No. randomised:90 (75 in walking group, 15 in CG).
(17 in running group excluded)
No. completers: 58
Country: Canada
Study population: general population (healthy and active)
Ethnicity: NR
Gender: male 36% (21/58)
Age: mean 44 (SD13), range 20 to 65 years
Smokers: NR
Hypertension: 0%
Mean baseline BP: NR
Inclusion criteria:
Quote: "participants represented a range of ages, from 20 to 65 years of age, who were not previously diagnosed with diabetes or cardiovascular disease. All participants were cleared using the Physical Activity Readiness Questionnaire for Everyone (PAR‐Q+) (Warburton et al. 2011). Participants in this training program include only individuals who responded ‘No’ to each of the PAR‐Q+ questions."
Exclusion criteria: NR
Interventions IG1: walking (10‐minute brisk walking once/week) group
  • Duration: 10 minute/session

  • Frequency: once/week

  • Intervention period: 13 weeks


IG2: Walking (10‐minute brisk walking 3 times/week) group
  • Duration: 10 minutes/session

  • Frequency: 3 times/week

  • Intervention period: 13 weeks


IG3: Walking (30‐minute brisk walking 3 times/week) group
  • Duration: 30 minutes/session

  • Frequency: 3 times/week

  • Intervention period: 13 weeks


IG4: Walking (60‐minute brisk walking 3 times/week) group
  • Duration: 60 minutes/session

  • Frequency: 3 times/week

  • Intervention period: 13 weeks

  • Intensity: brisk walking

  • Pedometer: NR

  • Facilitator: yes, a qualified exercise professional


CG: Control group: control group prescribed no additional exercise training.
Note: the group of 30‐minute running 3 times/week was excluded
Outcomes Review outcomes reported: SBP, DBP
Measurement method: resting BP was evaluated following 3 minutes of seated rest (BP‐TRU, VSM Medical, Vancouver, BC).
Primary/Main outcome of manuscript: body composition and exercise capacity (VO2 max)
Adverse event: No
Notes Trialregistration: NR
running group (N = 17) outcome was not extracted
Funding sources :private sector (This research was supported by the Physical Activity Support Line, the Canada Foundation for Innovation, the BC Knowledge Development Fund, the Canadian Institutes of Health Research (CIHR), the Michael Smith Foundation for Health Research (MSFHR), and the Natural Sciences and Engineering Research Council of Canada (NSERC))
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"were assigned randomly" but no details reported
refer to Table 1 (72 completers, 114 randomised)
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk 7 out of 114 did not start
32 out of 90 drop outs (35.6%) (25% to 47% in each group)
Quote:"Attrition rates (18 to 47 %)" no reasons given for drop outs
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 13 weeks
Only 1 analysis
Other bias Low risk No other bias

Fritz 2013.

Study characteristics
Methods Aim: The effects of Nordic walking on cardiovascular risk factors were determined in overweight individuals with normal or disturbed glucose regulation.
Design: Parallel 6‐arm RCT
Power/sample size calculation: Yes
Participants No. randomised:213 [87 in IG (53 in NGT, 14 in IGT, 20 in T2DM),126 in CG (75 in NGT, 21 in IGT, 30 in T2DM)]
No. completers: 203
Country: Sweden
Study population: overweight individuals with IGT or T2DM, and normal OGTT
Ethnicity: Caucasian
Gender: male 44.6% (95/213)
Age: mean 60 (SD 5.3), range 45 to 69 years.
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 
NGT: 138 (SD12.5) in IG, 137 (SD 15.0) in CG;
IGT: 141 (SD 14.0) in IG, 141 (SD 13.0) in CG;
T2DM: 143 (SD13.2) in IG, 144 (SD 12.6) in CG
DBP =
NGT: 85 (SD 7.9) in IG, 84 (SD 8.8) in CG:
IGT: 84 (SD 7.8) in IG, 86 (SD 9.4) in CG;
T2DM: 85 (SD7.6) in IG, 83 (SD 7.4) in CG
Inclusion criteria:
Quote: "age 45–69 years, body mass index (BMI) >25 kg/m2 and HbA1c for individuals with T2DM between 7.4% and 9.3% of the National Glycohemoglobin Standardization Program standard (57–78 mmol/mol of the International Federation of Clinical Chemistry standard)"
Exclusion criteria:
Quote: "physical impairments, symptoms of angina pectoris (i.e. chest pain on physical strain), atrial fibrillation determined by electrocardiogram, systolic blood pressure (SBP) or diastolic blood pressure (DBP) >160 or >100 mmHg, respectively, and insulin treatment."
Interventions Intervention group:
IG1_NGT: Walking (NGT) group: Normal glucose tolerance
IG2_IGT:Walking (IGT) group: Impaired glucose tolerance
IG3_T2DM:Walking (T2DM) group: type 2 diabetes mellitus
  • Duration: additional 5 hours walking with poles (Nordic walking)/week

  • Intensity: prescribed as a pace that caused slight shortness of breath and perspiration

  • Frequency: NR

  • Intervention period: 17 weeks (4 months)


After 2 months, the participants in the intervention group received a supportive telephone call from an assisting nurse.
  • Pedometer: 25 consecutive participants ( 11 controls and 14 Nordic walkers) wore an accelerometer in a belt around the waist for 7 days from morning to bedtime, recording physical activity was recorded as total activity counts per minute, minutes per day of inactivity, low, moderate or vigorous activity.

  • Facilitator: an exercise physiologist provided instructions for Nordic walking.


Control group:Quote: "The participants in the control group were instructed to maintain their habitual physical activity."
CG1_NGT:Control (NGT) group
CG2_IGT:Control (IGT) group
CG3_T2DM:Control (T2DM) group
Quote: "All participants were also instructed not to change their usual eating habits."
Outcomes Review outcomes reported: SBP, DBP
Measurement method: SBP and DBP (Speidell & Keller Tonometer)
Primary/Main outcome of manuscript: BMI, waist circumference, blood pressure, glucose tolerance, clinical chemistry, maximal oxygen uptake (peak VO2) and self‐reported physical activity (questionnaire)
Adverse event: No
Notes Trialregistration: NR
Funding sources: Government and private sector (This study was supported by the Strategic Research Programme in Diabetes at Karolinska Institutet, the Stockholm County Council, the Swedish Heart Lung Foundation and the Swedish Research Council, Stockholm)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"For the randomisation procedure, blinded labels with the participants' names were drawn from a box and assigned to either the control or intervention group "
Allocation concealment (selection bias) Low risk Quote:"..drawn from a box and assigned to either the control or intervention group."
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 4.7% (10 out of 213)
6 as 6.9% in TG and 4 as 3.2% in CG
refer to Table 2 (ITT analysis)
Quote:"Follow‐up data were missing for ten participants, and the principle of last‐observation‐carried‐forward was applied in those cases. Analysis was performed as intention‐to‐treat."
Selective reporting (reporting bias) Low risk Only measurement at 4 months
Only 1 analysis
Other bias Low risk No other bias

Geddes 2009.

Study characteristics
Methods Aim: to investigate the effects of a 12‐week home walking program on cardiovascular parameters, fatigue perception, and walking distance in persons with multiple sclerosis (MS).
Design: parallel 2‐group RCT (2:1)
Power/sample size calculation: NR
Participants No. randomised:15 (9 in IG, 6 in CG)
No. completers: 12
Country: USA
Study population: adult multiple sclerosis patients (18 to 65 years)
Ethnicity: NR
Gender: male 25% (3/12)
Age: mean 51.3 in IG (range 40 to 64 years), 34.7 in CG (22 to 50 years) (mean age 45.83)
Smokers: NR
Hypertension: NR
Mean baseline BP: NR
Inclusion criteria:
adults between the ages of 18 and 65 with a diagnosis of MS greater than 1 year, no history of exacerbation within 6 months prior to the study, no regular participation in an aerobic exercise program within 6 months prior to the study, the ability to walk independently 100 metres with or without resting (may use intermittent or constant unilateral assistance such as a cane, crutch, or a brace), and an Expanded Disability Status Score (EDSS) < 6.0.
Exclusion criteria:
if they had cardiovascular, pulmonary, or orthopaedic conditions that precluded them from participating in an aerobic conditioning program.
Interventions IG: Walking group: home walking program; participants maintained weekly exercise log including RPE values and received biweekly telephone calls to monitor compliance.
  • Duration: gradually increased from 15 minutes/session for week 1 to 2, 20 to 30 minutes/session for weeks 3 to 12


For the first 2 weeks, the participants walked 5 minutes below the lower limits of their THR range, followed by 15 minutes of walking within their THR range, and then a 5‐minute cool down below their THR range. During weeks 3 through 12, participants increased their training time in the THR range to 20 to 30 minutes.
  • Intensity: individualised based on the results of the 6MWT

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 12 week

  • Pedometer: NR

  • Facilitator: NR


CG: Control group: the control group was asked to refrain from any regular exercise during the 12‐week period. Control group participants were offered the opportunity to participate in the home walking program with monitoring upon completion of the study.
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method: the sphygmomanometer cuff, Polar Fitwatch Heart Rate Monitor
Primary/Main outcome of manuscript: 6 min walk test, Physiological Cost Index (PCI)
Compliance/Adherence: NR
Adverse event: no
Notes Trialregistration: NR
Funding sources: private sector (This study was partially supported by the New York Chapter Research Designated Fund)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Coin toss
Table 1 is only for completers
Allocation concealment (selection bias) Unclear risk Coin toss
Table 1 is only for completers
Blinding of participants and personnel (performance bias)
All outcomes High risk Quote: "Neither the researchers nor participants were blinded in the study."
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 20.0% (3 out of 15)
1 out of 9 (11.1%) in IG, 2 out of 6 (33.3%) in CG
PP analysis,Three participants (2 control and 1 experimental) were excluded from data analysis due to poor compliance
refer to p.3, Table 2
Selective reporting (reporting bias) Low risk Only measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Gilson 2007.

Study characteristics
Methods Aim: the impact of two walking interventions, 15‐minute brisk walking and accumulated walking steps, on work day step counts and health status.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised: 70 (23 in IG1, 23 in IG2, 24 in CG)
No. completers: 64
Country: UK
Study population: university employees (volunteers of the UK academic and administrative)
Ethnicity: NR
Gender: male 10% (7/70)
Age: mean 42 (SD 11) in female, and 41 yrs (SD 11) in male
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 121.7 (SD 17.3) in IG1, 119.0 (SD 7.4) in IG2, 121.6 (SD 9.9) in CG;
DBP = 85.6 (SD 12.1) in IG1, 85.7 (SD 10) in IG2, 82.9 (SD 7.3) in CG
Inclusion criteria: NR (convenience sample)
Exclusion criteria: NR (convenience sample)
Interventions IG1_route: Walking ("working routes") group:
Brisk and continuous walking; at least 15‐minute walking around campus; participants received detailed guidance of expectations and goals prior the study, and reinforced by weekly group emails through the intervention phase.
  • Duration: at least 15‐minute/session

  • Intensity: continuous brisk walking

  • Frequency: 1 session/day, 5 days/week

  • Intervention period: 10 weeks


IG2_task: Walking ("walking in task") group:
The accumulation of step counts through work day; participants received detailed guidance of expectations and goals prior the study, and reinforced by weekly group emails through the intervention phase.
  • Duration: Accumulated step counts through the working day

  • Intensity: NR

  • Frequency: 5 days/week

  • Intervention period: 10 weeks

  • Pedometer: yes, only in 1st, 5th, 10th week

  • Facilitator: no


CG: Control group: received no intervention and continued with normal behaviour.
Outcomes Review outcomes reported: SBP, DBP were measured at baseline and week‐10
Measurement method: SBP/DBP (Accoson sphygmomanometer)
Primary/Main outcome of manuscript: per cent body fat, waist circumference, and BP
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: “randomly assigned” “based on random number tables”
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote: "pretest and posttest measures were administered by trained instructors who …. were blind to the intervention status."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 6 out of 70 (8.6%)
2 in working routes TG (8.7%), 2 in Walking in task TG (8.7%), 2 in CG (8.3%) dropout
refer to Tables
PP analysis
Selective reporting (reporting bias) Low risk Only measurement at week 10
only 1 analysis
Other bias Low risk No other bias

Gradidge 2018.

Study characteristics
Methods Aim: to determine if an intervention of walking, a primary form of physical activity amongst African populations, could influence the body composition and blood pressure of a cohort of African women employed at a rural‐based South African university.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 132 (66 in IG, 66 in CG)
No. completers: 115
Country: South Africa
Study population: obese women
Ethnicity: NR
Gender: male 0%
Age: Mean 44.4 (SD 11.5) in IG, 37.4 (SD 8.78) in CG.
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP= 127 (SD 14.7) in IG, 122 (SD 15.6) in CG.
Inclusion criteria: women aged ≥18 years and employed at the university.
Exclusion criteria: pregnant, illiterate or injured women
Interventions IG: Walking group:
Using treadmills (Jkexer Sprint 9875A), the walking intervention took place during lunch breaks at the Human Movement Sciences gymnasium, University of Venda. Hydration with water was encouraged and the ambient room temperature was kept at 18 degrees Celsius.
  • Duration: 30 minutes/session; light stretching before the 30‐minute walking programme

  • Intensity: moderate intensity with walking speed 5 to 5.5 km/hour, rating of perceived exertion score of 4 to 8/10, and gradient (0.5 to 1.5 degrees) throughout the intervention

  • Frequency: 3 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: yes, qualified research assistants; the participants were monitored throughout the activity for any exaggerated physiological changes, including increasing angina, drop in SBP >10 mmHg from baseline, fatigue, dyspnoea, wheezing, leg cramps, by qualified research assistants.


CG: Control group: did not receive any treatment
Outcomes Review outcomes reported: BP
Measurement method: BP was measured on the right arm with the participant in a seated position using the Omron BP monitor (M6, Europe). The average of the latter two of three measurements was recorded after the participants had rested for at least 10 minutes
Primary/Main outcome of manuscript:bBody mass, stature, waist and hip circumference, BP
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "distance randomisation", "49 of these participants were randomly selected into an intervention group" but not sure how the random sequence was generated
Allocation concealment (selection bias) Low risk Quote: "the researchers were blinded to the assignment sequence, as the research assisstants allocated the participants into either the intervention or control group."
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 12.9% (17 out of 132 dropouts)
17 out of 66 (25.8%) in IG, 0 out of 66 (0%) in CG
High dropout rate in intervention group without reason
refer to Table 1
PP analysis
Selective reporting (reporting bias) Unclear risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
DBP measured but not reported and could not obtained data from author contact
Other bias Low risk No other bias

Hamdorf 1999.

Study characteristics
Methods Aim: investigate the effect of a progressive, twice‐weekly walking programme on habitual activity patterns, body composition and functional/social characteristics among previously sedentary 79‐ to 91‐year old females
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:49 (25 in IG, 24 in CG)
No. completers: 38
Country: Australia
Study population: community dwelling women (sedentary yet participating in community life and not functionally impaired)
Ethnicity: NR
Gender: male 0% (0/49)
Age: mean 82.4 (SEM 0.66) in IG, 83.1 (SEM 0.69) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 144.6 (SEM 4.9) in IG, 149.3 (SEM 5.1) in CG;
DBP = 72.6 (SEM 2.2) in IG, 77.7 (SEM 2.5) in CG
HR = 74.4 (SEM2.1) in IG, 72.7 (SEM1.7) in CG
Inclusion criteria:
sedentary women in their age of ninth decade; sedentary level determined from each participant's response to an activity questionnaire.
Exclusion criteria: contraindications to the exercise testing, medication usage and ECG irregularities.
Interventions IG: Walking (training) group: outdoor walking with free transportation for each session.
  • Duration: graduated increase to 25 minutes/session @ week 22 (5 minutes/day @ week 1)

  • Intensity: 40% heart rate reserve and 72.9% maximum heart rate.

  • Frequency: 1 session/day, 2 days/week

  • Intervention period: 26 weeks

  • Pedometer: NR

  • Facilitator: yes, by two experienced fitness instructors.


CG: Control group: asked not to engage in any physical activity outside the study
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: Resting SBP and DBP were measured using a random zero sphygmomanometer after 10 minutes of rest in a seated position.
Primary/Main outcome of manuscript: resting SBP/DBP, recovery SBP/DBP, spirometry, skinfolds, habitual activity profiles
Adverse event: No
Notes Trial registration: NR
Funding sources: Government and private sector (This research was supported by grant No. 944042 from the National Health and Medical Research Council of Australia and from a Special Purposes fund from the Royal Adelaide Hospital.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Coin toss
refer to Table 2
Allocation concealment (selection bias) Unclear risk Quote: "toss coin" and no other details
refer to Table 2
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 22.4% (11 out of 49)
7 out of 25 in IG (28%), 4 out of 24 in CG (16.7%)
Completers only analysis
Quote: "Two dropped out of the control group on medical advice while three withdrew due to family commitments. Drop out in the training group was due to medical reasons (n=2), overseas travel (n=1) and family commitments (n=3)"
refer to Tables
PP analysis
Selective reporting (reporting bias) Low risk Measurement at 3 and 6 months
Only 1 analysis
Other bias Low risk No other bias

Headley 2017.

Study characteristics
Methods Aim: To determine whether a relationship exists between post‐exercise hypotension (PEH) prior to training and changes in resting blood pressure values following 16 weeks of training in stage 3 CKD patients.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 49 (27 in IG, 22 in CG)
No. completers; 46
Country: USA
Study population: chronic kidney disease patients
Ethnicity: NR
Gender: male 65.2% (30/46)
Age: 58 (SD 8.0) in IG; 57.1 (SD 9.0) inCG
Smokers: 0%
Hypertension: 95.7%
Mean baseline BP:
SBP = 126.4 (SD 17.8) in IG; 133.7 (SD 19.2) in CG
DBP = 79.5 (SD 10.2) in IG; 79.1 (SD 10.7) in CG
resting HR = 64.3 (SD 8.9) in IG; 65.5 (SD 12.3) in CG
Inclusion criteria:
ageD 35–70 years, had a glomerular filtration rate of 30–59 mL/minute per 1.73m2 and had either diabetes mellitus or hypertension as the primary cause of their kidney disease.
Patients with both diabetes and hypertension were also included.
Exclusion criteria:
  1. cigarette smoking,

  2. current involvement in an exercise programme,

  3. atrial fibrillation. and

  4. the presence of any absolute contraindication to exercise as defined by the American College of Sports Medicine.

Interventions IG: Walking group: participants who were randomised to T were asked to attend three supervised training sessions per week for 16weeks. Participants initially trained at 50% to 60% VO2peak for 15 to 30 minutes and then gradually increased to a total of 55 minutes.The average weekly duration of exercise was 129.2 ± 8.6 minutes. If a participant missed a session, they were given a 2‐week period during which they could make up that session.
  • Duration: gradually from 15 to 30 minutes to 55 minutes/session

  • Intensity: 50% to 60% VO2peak

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 16 weeks

  • Pedometer: NR

  • Facilitator: yes


CG: Control group: control group participants were told to continue as physician told them and not start any new exercise routine.
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: Quote: "SBP and DBP blood pressure readings were taken with a calibrated automated sphygmomanometer (Tango; Sun Tech Medical, Morrisville, NC, USA)." "Subjects were fitted with a 24h ambulatory blood pressure monitor (ABPM; Spacelabs Healthcare, Issaquah, WA, USA) that they wore on the nondominant arm for the next 24h period."
Primary/Main outcome of manuscript: BP, HR
Compliance/Adherence: adherence to the programme was computed by taking the total number of sessions completed and dividing it by 48 sessions and expressing this as a percentage.
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government(This study was supported by the National Heart, Lung and Blood Institute of grant no. 1R15HL096097‐01)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "... randomized to the treatment group (T) or to the control group (C) but no details reported.
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk 0bjective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk 3 out of 49drop outs (6.1%)
2 in TG (7.4%) and 1 in CG (4.5%) drop outs
PP analysis
Selective reporting (reporting bias) Low risk Measurement at 16 weeks
Only 1 analysis
Other bias Low risk No other bias

Herzig 2014.

Study characteristics
Methods Aim: to investigate the effects of a 3‐month structured aerobic walking exercise on fasting and 2‐hour glucose and insulin concentrations and lipid homeostasis in sedentary overweight people with impaired fasting glucose and/or impaired glucose tolerance.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: Yes
Participants No. randomised: 78 (38 in IG, 40 in CG)
No. completers: 68
Country: Finland
Study population: outpatients at high‐risk for T2DM
Ethnicity: Caucasian
Gender: male 26.5% (18/68)
Age: mean 58.1 (SD 9.9) for IG; 59.5 (SD 10.8) for CG [68 completers only]
Smokers: NR
Hypertension: 52.9 % (36/68)
Mean baseline BP:
SBP = 138.5 (SD 16.4) for IG; 150.4 (SD 20.2) for CG;
DBP = 83.8 (SD 8.0) for IG; 85.4 (SD 9.5) for CG
Inclusion criteria:
with the FINDRISC questionnaire for T2D scores >15 were selected for the study,
the WHO criteria for impaired fasting glucose (>=5.6 and <7.0 and 2‐h glucose <7.8 mmol/L) or
impaired glucose tolerance (fasting glucose <7.8 and 2‐h glucose >=7.8 and <11.1 mmol/L).
Exclusion criteria:
exclusion criteria were any functional limitation or chronic disease that might have limited the training and testing of the cardiovascular and respiratory systems,
any medication for diabetes or current vigorous PA for more than 75 minutes per week as revealed by a questionnaire or physician’s examination.
Interventions IG: Walking group: the training sessions of the intervention group were carried out in an indoor sports hall.
  • Duration: graduated increase to 45‐minute/session (starting two x 20 minutes in first 6 weeks + stretching)


Walking was followed by a 5‐minute stretching and balance training, a 20‐minute walk and a 10‐minute stretching and balance exercise. After 1.5 months the 5‐minute stretching and balance training between the two 20‐minute walks were eliminated, and walking time was increased to 45 minutes.
  • Intensity: low (speed: 3km/hour, 2 MET)

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 13 weeks (3 months)

  • Pedometer: accelerometer data were recorded through the whole 3‐month study

  • Facilitator: yes, athletic instructor and a physician 3 times/week during the structured exercises


CG: Control group: the control group participants met research assistants once a week for downloading the data from the accelerometers.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: Quote: "Heart rate was recorded using a heart rate monitor (M61, Polar Electro, Kempele, Finland)"
"Blood pressure and blood lactic acid (Lactate Pro, Argray Inc., Kojo, Japan) were measured at each resistance level."
Primary/Main outcome of manuscript: metabolic parameters (e.g. fasting glucose, total cholesterol, insulin etc) (see Table 2)
Adverse event: NR
Notes Trial registration: NCT01649219
Funding sources: Government and private sector(The Finnish Diabetes Foundation and EVO funds from Pohjois‐Pohjanmaa Hospital District and Oulu University Hospital)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Computerised random number generation
refer to Table 1 (SBP imbalance)
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.8% (10 out of 78)
5 out of 38 (13.2%) in IG & 5 out of 40 (12.5%) in CG dropouts
33/35 and 35/40 included in analysis
PP analysis
Selective reporting (reporting bias) Low risk Measurement at 12 weeks
only 1 analysis
Other bias Low risk No other bias

Higashi 1999b.

Study characteristics
Methods Aim: the effects of a 12‐week, 30‐minute brisk walking program on endothelial function and forearm haemodynamics in patients with essential hypertension
Design: parallel 2‐group RCT (3:1)
Used for sample size calculation: NR
Participants No. randomised:27 (20 in IG, 7 in CG)
No. completers: 27
Country: Japan
Study population: mild to moderate hypertension patients
Ethnicity: Japanese
Gender: male 74% (20/27)
Age: mean 53 (SD 10) in IG, 51 (SD 8) in CG
Smokers: 29.6% (8/27)
Hypertension: 100%
Mean baseline BP:
SBP = 155.0 (SD 6.6) in IG, 155.4 (SD 8.3) in CG;
DBP = 96.0 (SD 4.9) in IG, 97.6 (SD 4.3) in CG
Heart rate =71.8 (SD 9.7) in IG, 73.1 (SD 6.4) in CG
Inclusion criteria:
BP between 140 to 170 or 90 to 110mmHg.
Quote: “No patient had a history of cardiovascular or cerebrovascular disease, diabetes mellitus, hypercholesterolemia, liver disease, or renal disease.
All patients were essentially sedentary and did not exercise regularly.”
Exclusion criteria:
Quote: “alcohol intake greater than ethanol 30 mL/day.”
Interventions IG: Walking (exercise) group:
Participants were asked not to change their original behavioral and dietary habits, especially the intake of sodium, potassium, calories, and alcohol. Exercise performance sheet, recorded by the participants, and 24‐hour urinary excretion of sodium and potassium were checked by the investigators every four weeks during the interview.
  • Duration: 30 minutes/session

  • Intensity: brisk walking

  • Frequency: 5 to 7 sessions/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: NR


CG: Control group: participants were asked not to engage in any physical activity outside the study.
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: not mentioned
Primary/Main outcome of manuscript: endothelial function
Adverse event: NR
Notes Trial registration: NR
note: data from Protocol 2 only
Funding sources: government This study was supported in part by a grant‐in‐aid for Scientific Research from the Ministry of Education, Science and Culture of Japan and Japan Heart Foundation grant for research on hypertension and vascular metabolism and a grant from Research Foundation for Community Medicine)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomised" but no details reported
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
At start of study? Intervention arm n = 20, Control arm n = 7; At follow up? Intervention arm n = 20, Control arm n = 7
refer to table 2
Unsure ITT or PP analysis
Selective reporting (reporting bias) Low risk Only 1 analysis
Other bias Low risk No other bias

Holloway 1997.

Study characteristics
Methods Aim: to compare psychological state, resting heart rate, and resting blood pressure of sedentary adults among different walking intervention groups.
Design: parallel 5‐group RCT (4 interventions + 1 control groups)
Power/sample size calculation: No
Participants No. randomised:83 (8 dropouts, resulting 58 in IG [22 in XC, 21 in T, 15 in S], 17 in CG)
(19 in stationary bicycle excluded)
No. completers: 75
Country: USA
Study population: general population (volunteers)
Ethnicity: NR
Gender: male 47.9% [45/(45 + 49), 94 completers only] [this 94 include bicycle]
Age: range 23 to 49 years (only in abstract), male range 20 to 40), female range 20 to 50
Smokers: NR
Hypertension: NR
Mean baseline BP
SBP = 113.6 (SD 9.8) in IG1_XS, 113.4 (SD 11.1) in IG2_T, 116.7 (SD 10.0) in IG3_S, 114.5 (SD 12.3) in CG.
DBP = 80.0 (SD 7.3) in IG1_XS, 81.9 (SD 9.1) in IG2_T, : 83.5 (SD 8.7) in IG3_S, 82.7 (SD 6.0) in CG
HR = 76.4 (SD 9.0) in IG1_XS, 77.0 (SD 8.8) in IG2_T, 75.9 (SD 6.3) in IG3_S, 78.6 (SD 10.1) in CG
Inclusion criteria:
men between 20 and 40 years of age, women between 20 and 50 years
Exclusion criteria:
Quote: "anyone who responded NO to any of the PAR‐Q questions, or YES to 2 or more of the Major Coronary Risk Factors questions"
"Those on mood altering or blood pressure altering medications, and those who had been regular exercises within the 6 months preceding the study"
Interventions Participants signed up for a practice session and orientation held at the LaCross YMCA, where training took place. The training site was chosen due to its convenience for accessibility, childcare, and open hours. In the last 4 weeks, interval training was added to add variety and further improve conditioning. Self‐selected intensity level (HR and 15‐points Borg scale) was recorded in personal exercise logs, which was used to verify attendance of unsupervised sessions.
  • Duration: graduated from 20 minutes in week 1, 25 minutes in week 2, 30 minutes in week 3, 40 minutes in week 4, 35 to 45 minutes in weeks 5 to 12

  • Intensity: self‐selected intensity level (65% to 90%HRmax and 15‐points Borg scale)

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: No

  • Compliance/Adherence: NR. Participants who missed more than 3 sessions were eliminated from the study.


IG1_XC: Walking (XC, Cross‐country ski simulator) group: participants exercised only on NordicTrack Achiever model (NordicTrack, Inc., Chaska, MN) and only at LaCrosse YMCA.
IG2_T: Walking (T, Treadmill) group: participants exercised only on Trimline1100 motorised treadmill (Roadmaster Corporation, Irving, TX) and only at LaCrosse YMCA.
IG3_S: Walking (S, Stepper) group: participants exercised only on Precor 721E hydraulic steepper (Precor, Inc., Bothell, WA) and only at LaCrosse YMCA.
CG: Control group: not to alter activity levels or modify diet.
Note: stationary bicycle excluded from analysis
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method:quote: "Resting blood pressure was measured with the occluding cuff, auscultation method, all pressures were taken with a mercury sphygmomanometer..."
Primary/Main outcome of manuscript: psychological state, resting heart rate, resting blood pressure.
Compliance/Adherence: NR. Participants who missed more than 3 sessions were eliminated from the study.
Adverse event: NR
Notes Trial registration: No
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "...were randomly assigned to..." and no details reported
completers only
Allocation concealment (selection bias) Unclear risk Quote:"...were randomly assigned to..." and no details reported
completers only
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded, research personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk 8 out of 102 drop outs (7.8%)
Completers PP analysis
Selective reporting (reporting bias) Low risk Measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Hua 2006.

Study characteristics
Methods Aim: to determine the effects of a low‐intensity exercise conditioning programme on BP, HR, and cardiac autonomic function in men and women with mild hypertension
Design: parallel 2‐group RCT
Power/sample size calculation: yes
Participants No. randomised: 47 (7 dropouts, 20 in IG [male = 10, female = 10], 20 in CG [male = 10, female = 10])
No. completers: 40
Country: Canada
Study population: sedentary hypertensive men and women
Ethnicity: NR
Gender: male 50% (20/40)
Age: range 56 to 59
Smokers: non‐smokers
Hypertension: hypertensive participants
Baseline BP: SBP = 140 (SD 11) in IG1‐male, 141 (SD16) in IG2‐female, 142 (SD 15) in CG1‐male, 141(SD17) in CG2‐female;
DBP = 92 (SD 7) in IG1‐male, 87 (SD 9) in IG2‐female, 91 (SD 11) in CG1‐male, 88 (SD 9) in CG2‐female;;
resting HR = 69 (SD 7) in IG1‐male, 75 (SD 12) in IG2‐female, 75 (SD15) in CG1‐male, 70 (SD 12) in CG2‐female
Inclusion criteria:
  1. "age>35 years;

  2. diagnosed with mild hypertension with BP>135/85 mmHg;

  3. the approval of the physician to participate if participants answered YES to one of the seven questions on the Physical Activity Readiness Questionnaire (PAR‐Q)."


Exclusion criteria:
  1. "smoker;

  2. on hormone replacement therapy;

  3. previous diagnosis of stroke, heart failure, ischemic heart disease, myocardial infarction, vascular disease and/or renal disease;

  4. currently participating in more than two aerobic physical activity sessions per week;

  5. co‐morbid conditions that limited exercise activity; or

  6. did not have appropriate family physician's approval."

Interventions IG1_M / IG2_F: Walking group
It was suggested that not to exercise within 2 hours of consuming a large meal, alcohol or caffeine, and not to make any dietary change, but encouraged to begin each walking session with a 5 to 10 minutes warm‐up and end with a 5 to 10 minute cool‐down.
Participants were also instructed recording walking sessions and reasons from stopping in the exercise log.
All the participants received a phone call or email from the researcher every 3 weeks to monitor their progress and to answer any questions. They returned to the lab by the end of week 12 for re‐assessment and logs were collected.
  • Duration: graduated from 0.8 km/day in week 1and 2, added 0.4 km per week to 4.8 km/day in week 12

  • Intensity: low, 40% maximal heart rate reserve; 11 to 13 RPE on Borg’s scale and self‐monitor HR by radial artery palpation with verbal and written instructions.

  • Frequency: 4 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: NR


CG1_M / CG2_F: Control group: maintaining current level of activity. An activity log was used to obtain weekly activities.
Outcomes Review outcomes reported: SBP, HR
Measurement method: Quote: "A BpTRU (Model BPM‐300, VSM MedTech Ltd., Coquitlam, BC) automated, non‐invasive BP monitor was used to measure BP and HR."
Primary/Main outcome of manuscript: BP, HR, cardiac autonomic function
Compliance/Adherence: Quote:"3.75 sessions/week, a minimum of three sessions per week were considered compliance"
IG1_M: Walking (male) group
  • Compliance/Adherence: 3.52 (SD 1.00) sessions/week


IG2_F: Walking (female) group
  • Compliance/Adherence: 3.97 (SD 0.52) sessions/week


Compliance/Adherence: a minimum of three sessions per week were considered compliance
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"... were randomized to ... " (p.29) but no details reported
refer to Table 4 in thesis (p.42)
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk dropout 14.9% (7 out of 47)
6 in TG (23.1%) and 1 in CG (4.8%) drop outs
refer to Table 5 (p.45)
PP analysis
Selective reporting (reporting bias) Low risk Measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Karstoft 2013.

Study characteristics
Methods Aim: to test the feasibility of free‐living walking training in patients with type 2 diabetes
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: a priori power calculations indicated that n = 12 in each training group would be sufficient to detect significant changes in glycaemic control.
Participants No. randomised: 32 (total 3 rounds of randomisation; final 12 in IG1, 12 in IG2, 8 in CG)
No. completers: 32
Country: Denmark
Study population:T2DM patients
Ethnicity: NR
Gender: male 62.5% (20/32)
Age: mean 60.8 (SD 2.2) in IG1; 57.5 (SD 2.4) in IG2; 57.1 (SD 3.0) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 155 (SD 5.4) in IG1; 138 (SD 3.3) in IG2; 142 (SD 4.3) in CG;
DBP = 90.0 (SD 1.8) in IG1; 85.0 (SD 2.8) in IG2, 86.6 (SD 3.5) in CG
Inclusion criteria:
confirmed T2DM by OGTT and sedentary
Exclusion criteria:
Quote: “The use of exogenous insulin, weight instability (>2 kg/6 months), physical activity (>150 min/week), and evidence of liver, renal, and cardiopulmonary disease and diseases contraindicating physical activity.”
Interventions IG1_CWT: Walking (continuous‐walking training) group:
Walking above the target intensity, obtained from VO2 peak test.
  • Duration: 60 minutes/session

  • Intensity: 55% of peak energy expenditure rate according to VO2 peak test

  • Frequency: 1 session/day, 5 days/week

  • Intervention period: 17 weeks (4 months)


IG2_IWT: Walking (interval‐walking training) group:
Walking cycles of 3 minutes of the fast walking (above the target intensity) and 3 minutes of slow walking (below the target intensity).
  • Duration: 60 minutes/session

  • Intensity: 70% of the peak energy‐expenditure rate, and were instructed to perform IWT consisting of cycles of 3 minutes of fast walking(above the target) and 3minutes of slow walking (below the target)

  • Frequency: 1 session/day, 5 days/week

  • Intervention period: 17 weeks (4 months)

  • Pedometer: yes, JD Mate pedometer.

  • Facilitator: no


CG: Control group: continue habitual lifestyle for 4 months and had their JD Mate pedometer data uploaded monthly.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: not mentioned
Primary/Main outcome of manuscript: physical activities and energy intake expenditure parameters (Table 1 and 2)
Adverse event: NR (one participant in continuous walking group dropped out due to a knee injury was reported but not identified as adverse event)
Notes Trial registration: NR
Funding sources: Government(This study was primarily funded by DD2 (The Danish Centre for Strategic Research in Type 2 Diabetes, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469283/) supported by the Danish Agency for Science (grants 09‐067009 and 09‐075724 to B.K.P.).)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk A total 3 randomisations done, first 24 to 8/8/8, then the 5 out of 8 from control randomised to 2 IG, then additional randomisation of 5 to the 2 IG. There were five participants entering the trial twice as control then intervention.
refer to Table 1 (SBP difference between IG and CG)
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Nature of intervention cannot be blinded
5 participants contributed to both CG and IG. Quote: "Subjects in the CON group were offered re‐randomisation into a training group after the CON period. Five subjects accepted, adding n = 3 to the CWT group and n = 2 to the IWT group."
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout 6.9% (2 out of 29)
2 in TG and 0 in CG
A total 3 randomisation done: first 24 to 8/8/8, then the 5 out of 8 from control randomised to 2 IG, then additional randomisation of 5 to the 2 IG. There were five participants entering the trial twice as control then intervention.
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
only 1 analysis
Other bias Low risk No other bias

Khalid 2013.

Study characteristics
Methods Aim: to investigate the effects of moderate exercise training on nitric oxide levels in postmenopausal hypertension.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised: 30 (15 in IG, 15 in CG)
No. completers: 25
Country: Egypt
Study population: postmenopausal, hypertensive & overweight/obese women
Ethnicity: NR
Gender: male 0% (0/25)
Age: mean 52.9 (SD 2.6) in IG, 52.7 (SD 2.2) in CG, range 40 to 50.
Smokers: NR
Hypertension: 100% (SBP 140 to 160 mmHg, DBP over 90 to 100 mmHg)
Mean baseline BP:
SBP = 148 (SD 5.6) in IG; 154 (SD 6.7) in CG;
DBP = 94 (SD 4.1) in IG; 95 (SD 4.2) in CG
Inclusion criteria:
experienced at least one year of postmenopausal hypertension, their ages ranged from 40 to 50 years; Body Mass Index (BMI) ranged from 30 to 36 Kg/m2, their Blood Pressure (BP) ranged from 140 to 160 mmHg (systolic ‐ SBP) over 90 to 100 mmHg (diastolic ‐ DBP)
Exclusion criteria:
on any postmenopausal hormone therapy such as oestrogen, previous history of hypertension or receiving any anti‐hypertensive drugs, history of diabetes or any other pathology within the spectrum of metabolic syndrome, orthopedic or neuromuscular disorders that could have interfered with the training program.
Interventions IG: Walking group: electric treadmill walking. The program consisted of three phases followed by a relaxation period. These phases were: 1‐warming up phase, 2‐ conditioning stimulus phase, 3‐cooling down phase.
  • Duration: 20‐minute/session at least

  • Intensity: 60% to 70% of maximum HR

  • Frequency: 1 session/day, 3 days/week, a total of 24 sessions

  • Intervention period: 8 weeks

  • Pedometer: NR

  • Facilitator: NR


CG: Control group: NR
Outcomes Review outcomes reported: SBP, DBP
Measurement method: not mentioned
Primary/Main outcome of manuscript: SBP, DBP, NO
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "A computer‐generated, simple randomisation procedure was used"
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Low risk Quote: "the medics who measured the blood pressure and all other variables incorporated in this study were blinded as to the allocation of the participants to both groups (exercise and control)."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 16.7% (5 out of 30)
3 out 15 (20%) in IG, 2 out of 15 (13.3%) in CG dropouts
PP analysis on completers only (Figure 1)
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Koh 2010.

Study characteristics
Methods Aim: to compare the effects of 6 months of supervised intradialytic or unsupervised home‐based exercise training and usual care on physical function, arterial stiffness, and self‐reported health.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: yes
Participants No. randomised:43 (21 in IG, 22 in CG )
(27 in Intradialytic‐exercise group trained on a cycle ergometer excluded)
No. completers: 31
Country: Australia
Study population: adult haemodialysis patients
Ethnicity: NR
Gender: male: 61.3% (19/31)
Age: mean 52.1 (SD 13.6) in IG; 51.3 (SD 14.4) in CG
Smokers: NR
Hypertension: 38.7% (12/31) (Table 2)
Mean baseline BP:
SBP = 143 (SD 32) in IG, 145 (SD 18) in CG;
DBP = 78 (SD 16) in IG, 80 (SD 9) in CG;
HR = 73 (SD 9) in IG, 74 (SD 10) in CG.
Inclusion criteria:
“Patients aged >18 years on stable adequate dialysis therapy with urea reduction ratio >70% for >3 months”.
Exclusion criteria:
Quote:“Patients with unstable angina, those with lower‐limb amputation, or those who met or exceeded the exercise recommendation of 120 minutes of moderate intensity physical activity per week”.
Interventions IG: Walking (home‐based exercise) group: Fortnightly telephone contacts were given by investigators to provide encouragement and allow feedback.
  • Duration: graduated increase to 45 minutes/session by week 24 (starting from 15 minutes)

  • Intensity: self‐reported RPE 12 to 13 on Borg scale; to increase intensity by walking faster or on an incline

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 26 weeks

  • Facilitator: yes

  • Pedometer: NR


CG: Control (Usual care) group: brochures about exercise benefits were given while participants were requested to maintain usual lifestyle.
Note: intradialytic‐exercise group trained on a cycle ergometer excluded
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: central blood pressures and AIx were estimated using radial applanation tonometry performed on the non‐fistula arm using customized software (SphygmorCor 7.01).
Primary/Main outcome of manuscript: physical function (6‐minute walk distance) and arterial stiffness (aortic pulse wave velocity) and self‐reported health
Adverse event: No
Notes Trial registration: ACTRN12608000247370
Intrdialytic‐exercise group (ID) is excluded in this analysis (n = 27) because intervention is not walking
Funding sources: private sector (This project was funded by the Clifford Craig Medical Research Trust.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"...unrestricted computer‐generated random numbers."
refer to Table 1 (completers only)
Allocation concealment (selection bias) Low risk Assigned by staff not associated with trial
Blinding of participants and personnel (performance bias)
All outcomes High risk Quote:"It was not possible to blind participants or researchers to group assignment."
refer to Table 1 (some did not receive home‐base exercise)
Blinding of outcome assessment (detection bias)
All outcomes High risk 0bjective outcomes
Quote:"It was not possible to blind participants or researchers to group assignment."
Incomplete outcome data (attrition bias)
All outcomes High risk dropout 27.9% (12 out of 43)
Start of study: home‐based exercise n = 21, Control n = 22; At follow up: home‐based exercise n = 15/21 = 71.4%, Control n = 16/22 = 72.7%
PP analysis (completers only)
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 26 weeks
Only 1 analysis
Other bias Low risk No other bias

Kukkonen‐Harjula 1998.

Study characteristics
Methods Aim: to study the effects of walking training on maximal aerobic power, serum lipoproteins, and plasma fibrinogen as indicators of health‐related fitness in healthy middle‐aged men and women.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: Yes
Participants No. randomised: 117 (1 excluded after randomisation, 58 in IG, 58 in CG)
(one woman in the exercise group was excluded because of arrhythmia during maximal exercise testing, n = 116.)
No. completers: 108
Country: Finland
Study population: healthy middle‐aged adults
Ethnicity: NR
Gender: male 47.4% (55/116)*100%; completers only
Age: mean 42.1 (SD 5.1) in IG, 40.3 (SD 4.5) in CG; range 30‐55 years.
Smokers: 0%
Hypertension: 0%
Mean baseline BP:
SBP = 118 (SD 12) in IG,
DBP = 75 (SD 11) in IG
Inclusion criteria:
30 to 55 years old, non‐smokers, premenopausal (women), and clinically healthy with no disabilities precluding exercise training.
Exclusion criteria:
  1. regular medication (except for hormonal contraception in women)

  2. physical exercise more than twice weekly;

  3. BMI > 33 kg/m2.

Interventions IG: Walking group: the target intensity of exercise for 50 minutes was 74% to 81% of HRmax, which is equivalent to 65% to 75% of VO2max.
  • Duration: 50 minutes (+5 to 10‐minute warm‐up and cool‐down)

  • Intensity: 65% to 75%VO2max or 74% to 81% HRmax

  • Frequency: 1 session/day, 4 days/week

  • Intervention period: 15 weeks

  • Pedometer: yes

  • Facilitator: yes


CG: Control group: were told not to change their eating or physical activity habits.
Outcomes Review outcomes reported: exercise heart rate, (SBP, DBP ‐> pending from author)
Measurement method: blood pressure measurements were taken after the participants had been resting in a sitting position for 5 minutes, using a random zero sphygmomanometer (Hawksley & Sons Ltd, Lancing, Sussex, England).
Primary/Main outcome of manuscript: exercise capacity, lipid biomarkers
Adverse event: 2 (one stress fracture and one knee injury leading to surgery)
Quote:"Two severe injuries resulted from the training (one stress fracture and one knee injury leading to surgery). Other reasons for discontinuation were not related to training."
Notes Trial registration: NR
Funding sources: Government. The study was supported by grants from the Finnish Ministry of Education and Polar Electro Oy (Kempele, Finland).
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "Randomization was stratified according to sex and submaximal oxygen consumption (divided into thirds)" but no details of randomisation
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 6.8% (8 out of 116)
5 out of 58 in IG (8.6%), 3 out of 58 (5.2%) in CG dropouts
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 15 weeks
oOnly 1 analysis
Other bias Low risk No other bias

Kurban 2011.

Study characteristics
Methods Aim: to determine the effect of chronic regular exercise on ischaemia‐modified albumin levels and oxidative stress in T2DM.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised:60 (30 in IG, 30 in CG)
No. completers: 60
Country: Turkey
Study population: T2DM patients
Ethnicity: NR
Gender: male 48% (29/60)
Age: mean 53.77 (SD8.2) in IG; 53.57 (SD 6.6) in CG.
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 129.17 (SD 12.1) in IG, 124.83 (SD 14.59) in CG;
DBP = 78.83 (SD 6.78) in IG, 77.88 (SD 10.53) in CG.
Inclusion criteria:
sedentary, T2DM patients with blood pressure ≧ 140/90mmHg. None of the patients had macro‐ or microvascular complication including retinopathy and proteinuria.
Exclusion criteria:
Quote:“Malignant disease, infectious disease, chronic obstructive lung disease, liver disease, kidney disease, and patients with joint or muscle disease.”
Interventions IG: Walking group:
  • Duration: 50 minutes/session (10‐minute warm‐up + 30‐minute walking + 10‐minute cool‐down exercise)

  • Intensity: moderate, aerobic exercise

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 13 weeks (3 months)

  • Pedometer: NR

  • Facilitator: yes, an certified exercise instructor.


CG: Control group: participants remained sedentary throughout the study period.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: not reported
Primary/Main outcome of manuscript: ischaemia‐modified albumin levels and oxidative stress (total antioxidant status and total oxidant status)
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomly divided" but no details reported
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Unlikely that research personnel and participants blinded
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
Start of study? Intervention n = 30, Control n = 30; At follow up, no mention of dropouts; not sure if Intervention n = 30/30 = 100%? Control n = 30/30 = 100%?
refer to Table 1
Unsure ITT or PP analysis
Selective reporting (reporting bias) Low risk Only measurement at 3 months
Only 1 analysis
Other bias Low risk No other bias

Lee 2007.

Study characteristics
Methods Aim: the effect of a community‐based walking intervention on blood pressure among older people aged 60.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised:202 (102 in IG, 100 in CG)
No. completers: 184
Country: Taiwan
Study population: elderly mild‐to‐moderate hypertensive patients (60+ years)
Ethnicity: NR
Gender: male 58% (118/202)
Age: mean 71.3 (SD 6.4) in IG, 71.3 (SD 5.7) in CG
Smokers: 21.8% (44/202)
Hypertension: 100%
Mean baseline BP:
SBP = 152.0 (SD 10.5) in IG, 152.4 (SD 11.1) in CG;
DBP = 83.5 (SD 11.2) in IG, 80.6 (SD 8.8) in CG
Inclusion criteria:
Quote:“Being resident in a local township, aged 60 years and over and with a resting systolic blood pressure between 140 mmHg and 179 mmHg and thereby classified as having mild to moderate hypertension”
Exclusion criteria: NR
Interventions IG: Walking (community‐based walking intervention) group: based on the self‐efficacy theory, participants were telephone‐contacted or in‐person interviewed by one of the research members to reinforce motivation and solve barriers to promote increased walking. A median of 6 contacts was given, it was more frequent in the first 3 months than the last 3 months.
  • Duration: NR (individualised)

  • Intensity: NR (individualised)

  • Frequency: NR (individualised)

  • Intervention period: 26 weeks

  • Pedometer: yes; pedometers were provided as a motivator to facilitate participants' walking

  • Facilitator: no


CG: Control (usual care) group: participants received usual primary health care involving self‐initiated contact with health services as required.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: BP measured quote:"using a traditional mercury sphygmomanometer
Primary/Main outcome of manuscript: change in SBP, exercise self‐efficacy score, self reported walking frequency, DBP
Adverse event: NR
Notes Trial registration: no
Funding sources: self‐funded
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "A series of numbered, opaque, sealed envelopes were used to randomly allocate participants to one of the two arms of the trial. To prevent an imbalance in size of study groups, blocks of 12 were used. The randomisation list and the block size were concealed..."
refer to Table 1
Allocation concealment (selection bias) Low risk Quote:" A series of numbered, opaque, sealed envelopes were used to randomly allocate participants to one of the two arms of the trial. To prevent an imbalance in size of study groups, blocks of 12 were used. The randomisation list and the block size were concealed..."
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and personnel were not blinded
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote: "All outcome measures were recorded during face‐to‐face interviews by four trained interviewers who were blinded to study group allocation and trained in questionnaire administration and blood pressure measurement."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 8.9% (18 out of 202)
11 out of 102 in IG (10.8%), 7 out of 100 in CG (7%) dropouts
refer to Table 2 and figure 1
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 6 months
Only 1 analysis
Other bias Low risk no other bias

Li (李虎) 2018.

Study characteristics
Methods Aim: to investigate the effect of long‐term walking on health status.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:100 (50 in IG, 50 in CG)
No. completers: 80
Country: China
Study population: university teachers
Ethnicity: Chinese
Gender: male 48% (22+26)
Age: mean 43.63 (SD 8.26) in IG; 43.24 (8.67) in CG
Smokers: NR
Hypertension: yes
Mean baseline BP:
SBP = 118.95 (SD 14.99) in IG, 112.69 (SD 13.74) in CG
(DBP was not reported.)
Inclusion criteria:
  1. volunteers agreed with randomisation, signed informed consent and were willing to provide daily step count and health profile data;

  2. no contraindication for walking;

  3. not allergic or having skin problem with sport bracelet for long‐term use.


Exclusion criteria: NR
Interventions IG: Walking group:health seminar with positive feedback each month.
  • Duration: NR

  • Intensity: 10,000 steps per day using Xioami bracelet for step count

  • Frequency: 7 sessions/week

  • Intervention period: 64.3 weeks (450 days)

  • Pedometer: yes (Xioami bracelet)

  • Facilitator: NR


CG: Control group: no bracelet for step count, neither seminars nor feedback; measurement for health profile twice before and after intervention.
Outcomes Review outcomes reported: SBP
Measurement method: SBP was obtained from regular health examination data from belonged universities.
Primary/Main outcome of manuscript: questionnaire including height, BMI, waist‐hip ratio, sleeping condition, perceived pressure level, and history with hypertension, diabetes mellitus and hyperlipidaemia. Health profile measured SBP, blood sugar, LDL, cholesterol, TG, and HDL.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: Office of Research, Beijing Jiaotong University (016JB00050), National Natural Science Foundation of China(81641175), Peking University People's Hospital(RDB2015—10, RDY2016—15), 2015 Osteoarthritis Research Society International (OARSI), 2016 International Cartilage Regeneration & Joint Preservation Society (ICRS), 2016 Beijing love Joint Health Community Foundation
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomly divided" but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 20% (20 out of 100 dropouts)
42 completers in walking group, 38 completers in control group
refer to table 1
PP analysis
Selective reporting (reporting bias) Unclear risk Only 1 endpoint measurement at 450 days
Only 1 analysis
Only provided SBP but not DBP without reason, DBP data could not obtained from author contact
Other bias Low risk no other bias

Li 2003.

Study characteristics
Methods Aim: to evaluate the efficacy of cobblestone‐mat walking as a physical activity to improve selected health‐related outcomes.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised: 48 (24 in IG, 24 in CG) (2 did not receive intervention, 6 declined, leaving 40 in study)
No. completers; 40
Country: USA
Study population: sedentary elderly adult (60+ years, general population)
Ethnicity: white 90% (36/40)
Gender: male 22.5% (9/40)
Age: mean 72 (SD 6.4) in IG, 73.3 (SD 7.3) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 133.64 (SD 9.68) in IG, 132.17 (SD 13.62) in CG;
DBP = 81.5 (SD 9.41) in CG, 81.22 (SD 8.59) in CG
Inclusion criteria:
Quote:“being 60 years of age or older, not participating in regular physical activity (i.e., in the previous 2 months, no more than 90 min of structured group exercise per week), being an independent ambulator able to walk without the use of aids, having no progressive or debilitating conditions that would limit participation in moderate‐intensity exercise, having a physician’s approval for participation, and having no severe foot or ankle problems.”
Exclusion criteria: NR
Interventions IG: walking (cobblestone‐mat walking) group:
Walk on cobblestone mat for 12 to 25 minutes/session over the 8‐week study period. Foot‐rolling activity was provided between sets, and each participant was also given a pair of cotton socks to be worn
  • Duration: 45‐minute/session (starting from 12‐minute/session)

  • Intensity: NR

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 8 weeks

  • Pedometer: NR

  • Facilitator: yes


CG: Control group: participants were instructed to continue their usual physical activities and were also invited to four meetings to meet one another. A cobblestone‐mat walking program was provided at the end of the study.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: a trained and experienced research assistant used an aneroid sphygmomanometer to measure resting SBP and DBP.
Primary/Main outcome of manuscript: HRQoL (SF‐12 IADL) and self‐care activities
Compliance/Adherence: n = 18 (79%), compliance was defined by attending 15 or more sessions (24 sessions in total). 22/24 IG & 18/24 CG received intervention
Adverse event: 1 (oOne had a bruise on the ball of her foot and Cobblestone‐Mat Walking subsequently dropped out of the study)
Notes Trial registration: NR
Funding sources: Government(Preparation of this manuscript was supported in part by Grant No. AG18394 from the National Institute on Aging.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "computer program to generate random numbers "
refer to Table 1 & 2
Allocation concealment (selection bias) Low risk Quote:"Before enrolment of the first study participant, a research statistician not working on the study used a computer program to generate random numbers for group assignment."
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Participants not blinded.
Quote:"The principle investigators were blinded to the assignment"
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
Quote:"The principle investigators were blinded to the assignment" but not use if it included outcome assessor(s).
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout: not in final analysis 16.7% (8 out of 48)
2 out of 24 in TG (8.3%) and 6 out of 24 in CG (25.0%) dropout
Dropout: non completer 27.1% (13 out of 48)
7 out of 24 in IG (29.2%) & 6 out of 24 in CG (25%) dropout
refer to Figure 1
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
Only 1 analysis
Other bias Low risk no other bias

Lin 2000.

Study characteristics
Methods Aim: to examine the effects of brisk walking on blood pressure in teenagers with higher blood pressure.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: no
Participants No. randomised:22 (8 in IG1, 8 in IG2, 6 in CG)
No. completers: 22
Country: Taiwan
Study population: borderline hypertensive adolescents (students)
Ethnicity: Chinese
Gender: male 100% (22/22)
Age: range 16 to 18 years
Smokers: NR
Hypertension: 100% borderline
Mean baseline BP:
SBP = 140 (SD 11.14) in IG1, 137.75 (SD 6.69) in IG2, 145.67 (SD 10.33) in CG;
DBP = 92.25 (SD 3.45) in IG1, 91.75 (SD 4.06) in IG2, 93.67 (SD 4.27) in CG
Inclusion criteria:
16 to 18 male teenagers with resting SBP≥140 mmHg and resting DBP≥90 mmHg.
Deny use of anti‐hypertensives.
Exclusion criteria: NR
Interventions IG: Walking group:
  • Duration: 30 minutes/session

  • Intensity: brisk walking with Maximal heart rate: 130 to 140 bpm (monitor by Polar)

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 12 weeks


IG: Walking group:
  • Duration: 10 minutes/session

  • Intensity: brisk walking with maximal heart rate: 130 to 140 bpm (monitor by Polar)

  • Frequency: 3 sessions/day, 3 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: Yes


CG: Control group:maintaining current activity and dietary habit
Outcomes Review outcomes reported:SBP, DBP
Measurement method: resting blood pressure assessed by Sanken model SM‐301, Tokyo Japan
Primary/Main outcome of manuscript: blood pressure and blood composition (refer to Table 1)
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomised" but no details reported
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
no information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
refer to Table 1
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
only 1 analysis
Other bias Low risk No other bias

Ming (明輝) 2018.

Study characteristics
Methods Aim: to examine the effect of long‐distance brisk walking on haemodynamics and cardiopulmonary function in elderly patients with coronary heart disease complicated with hypertension.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 64 (32 in IG, 32 in CG)
No. completers: 64
Country: China
Study population: hospitalised patients with percutaneous coronary intervention (PCI)
Ethnicity: Chinese
Gender: male 62.5% ((21+19)/64)
Age: mean 63.18 (SD 5.42) in IG; 62.76 (SD 5.54) in CG
Smokers: No
Hypertension: 100%
Mean baseline BP:
SBP = 136.79 (SD 7.03) in IG, 137.32 (SD 7.44) in CG.
DBP = 95.88 (SD 4.10) in IG,96.30 (SD 4.52) in CG.
HR=83.18 (SD 8.14) in IG, 83.55 (SD 8.09) in CG
Inclusion criteria:
  1. age between 60 to 80;

  2. Confirmed diagnosis with coronary heart disease complicated with hypertension;

  3. caregiver or family were informed with the study details and signed consent;

  4. patients successfully survived from the PCI surgery.


Exclusion criteria:
  1. mental problem refrained from cooperation and intervention;

  2. mobile restriction from long‐distance brisk walking; ③transmissible disease such as AIDS and TB;

  3. noted cancer or malignant tumour mass.

Interventions IG: Walking group:
During the long‐distance brisk walking, participants were asked to keep head up high and straight, open arms and keep shoulders and hips in vertical line along with the ground, and breathe in accordance with steps.
  • Duration: 30 to 70 minutes/session

  • Intensity: brisk walking 120 to 140 steps/minute (participants could adjust their own speed in the beginning and gradually increased to the preferred speed; If any palpitation, dizziness or discomfort was noted, participants were able to gradually speed down to stop walking; participants were also free to decrease some level of intensity if fatigue or tiredness was noted.)

  • Frequency: 1 to 2 session/day, 7 to 14 session/week or daily distance of 4.5 to 6.0 km

  • Intervention period: 40 weeks

  • Pedometer: NR

  • Facilitator: NR


CG: Control group: routine medication treatment.
Outcomes Review outcomes reported: SBP, DBP, mean arterial pressure, and heart rate
Measurement method: before and after 40 weeks.
Primary/Main outcome of manuscript: SBP, DBP, mean arterial pressure, heart rate, left ventricular ejection fraction, mitral velocity and late flow velocity ratio, cardiopulmonary function and life quality.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "random‐number method" but no details reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
32 completers in walking group, 32 completers in control group
This study requested elderly patients with coronary heart disease to walk briskly 20 to 140 steps for 30 to 70 minutes per session and 7 to 14 sessions/week for around 10 months. There is not sufficient information to judge the attrition.
refer to table 1 to 3
Unsure ITT or PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 10 months
Only 1 analysis
Other bias Low risk No other bias

Moreau 2001.

Study characteristics
Methods Aim: the effects of daily walking on lowering blood pressure in postmenopausal women with borderline to stage 1 hypertension.
Design: parallel 2‐group RCT (3:2)
Power/sample size calculation: NR
Participants No. randomised: 24 (15 in IG, 9 in CG)
No. completers: 24
Country: United States
Study population: postmenopausal women with borderline stage 1 hypertension
Ethnicity: NR
Gender: male: 0% (0/24)
Age: mean 53 (SE 2) in IG; 55 (SE 1) in CG
Smokers: 0%
Hypertension:100% borderline
Mean baseline BP:
SBP = 142 (SE 3) in IG, 142 (SE 3) in CG;
DBP = 84 (SE 1) in IG, 86 (SE 2) in CG
HR = 77 (SE 3) in IG, 77 (SE 3) in CG
Inclusion criteria:
postmenopausal (for at least 1 year) women with borderline to stage 1 hypertension (SBP of 130 to 159 mmHg and/or DBP of 85 to 99 mmHg, determined on the basis of repeated seated BP recordings at rest on two separate days), were not participating in regular physical activity (< 2 days/week ) within the past year.
Non‐smokers, had no orthopaedic limitations to walking, and were absent of known CVD as assessed with a health history questionnaire.
Exclusion criteria: NR
Interventions IG: Walking (exercise) group:
self‐reported daily log sheets with any additional physical activity was collected biweekly. Participants were asked not to change any lifestyle activity other than walking.
  • Duration: graduated increase, initially 1.4 km/day above individual baseline walking steps, which was measured in the first week; increased 0.5 km/day until 3 km/day by the 3rd week when the desired walking steps were achieved; accumulated walking steps.

  • Frequency: 7 sessions/week

  • Intensity: self‐selected, comfortable pace

  • Intervention period: 24 weeks

  • Pedometer: yes

  • Facilitator: no


CG: Control group:
not to change daily activity and subsequently wore a pedometer 1 week each month to document their walking.
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method: blood pressure was measured in the left arm by brachial artery sphygmomanometer with at least 3 minutes separating each
measurement.
Primary/Main outcome of manuscript: blood pressure
Adverse event: NR
Notes Trial registration: NR
Funding sources: private sector(research was supported by an American College of Sports Medicine Foundation Research Grant.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomised" but no details reported
refer to Figure 1 and 2
Allocation concealment (selection bias) Unclear risk no information
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants not blinded. Personnel not blinded.
Blinding of outcome assessment (detection bias)
All outcomes Low risk objective outcomes
Quote:"Blood pressure and heart rate were measured at rest in triplicate by the same trained observer who was blinded to the group assignment as previously described"
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout: NR
At start of study: Intervention n = 15, Control arm n = 9; At follow up: data not reported? Intervention n = 15/15 = 100%?, Control arm n = 9/9 = 100%?
refer to table 1
Unsure ITT or PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 24 weeks
Only 1 analysis
Other bias Low risk No other bias

Murphy 1998.

Study characteristics
Methods Aim: to compare the effects of short and long bouts of brisk walking in sedentary women
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised:47 (16 in IG1, 16 in IG2, 15 in CG)
No. completers: 34
Country: UK
Study population: sedentary middle‐aged women
Ethnicity: NR
Gender: male 0% (0/47)
Age: mean 44.4 (SD 6.2); 44.8 (SD 8.4) in IG1, 48.0 (SD 5.5) in IG2, 47.3 (SD 4.1) in CG
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 125.5 (SD 10.8) in IG1_SB; 124.2 (SD 11.1) in IG2_LB; 128.6 (SD 13.3) in CG
Inclusion criteria:
Quote: "None was employed in manual work and none had engaged in regular physical activity (defined as more than one 20‐min bout per week) during the preceding 6 months. "
Exclusion criteria:
Quote: "history of cardiovascular disease; resting arterial blood pressure >150 mmHg systolic or >95 mmHg diastolic; body mass index >= 30 kg·m‐2; diabetes; musculoskeletal condition or injury; taking any pharmacotherapeutic drug."
Interventions IG_SB: walking (Short‐bout: 3*10 minutes) group: participants in the short‐bout group split this into three 10‐minutes sessions at intervals of ≧4 hours. Training was performed outdoors on the campus of the University of Ulster.
  • Duration: 10 minutes/session

  • Frequency: 3 sessions/day, 5 days/week

  • Intensity: 70% to 80% of maximal heart rate

  • Intervention period: 10 weeks


IG_LB: Walking (long‐bout: 30minutes) group: participants in the long‐bout group were free to select the time of day at which they did their one 30‐minute bout. Training was performed outdoors on the campus of the University of Ulster.
  • Duration: 30 minutes/session

  • Frequency: 1 session/day, 5 days/week

  • Intensity: 70% to 80% of maximal heart rate

  • Intervention period: 10 weeks

  • Pedometer: NR

  • Facilitator: yes, one of the five training days each week training


CG: Control group: usual lifestyle
Outcomes Review outcomes reported: SBP only
Measurement method: blood pressure measured by mercury‐in‐glass sphygmomanometer
Primary/Main outcome of manuscript: exercise capacity, SBP, anthropometric variables
Adverse event: 0
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly assigned" but no details reported
refer to Table 1 (completers only)
Allocation concealment (selection bias) Unclear risk No information
Completers only
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk no information
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote: "Duplicate measurements of arterial blood pressures were made by an observer who was blinded to subjects' group assignment "
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 27.7% (13 out of 47)
4 out of 16 long IG (25%), 4 out of 16 short IG (25%), 5 out of 15 CG (33.3%) dropouts
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 10 weeks
Only 1 analysis
Other bias Low risk No other bias

Murphy 2006.

Study characteristics
Methods Aim: to examine the effects of 45 minutes walking, 2 days/week on fitness, BP, body composition, lipids and C‐reactive protein (CRP).
Design: parallel 2‐group RCT (3:2)
Power/sample size calculation: NR
Participants No. randomised: 37 (23 in IG, 14 in CG)
No. completers: 33
Country: UK
Study population: general population adults (sedentary civil servants)
Ethnicity: NR
Gender: male 35% (13/37)
Age: mean 41.5 (SD 9.3); 41.4 (SD 7.5) in IG, 40.8 (SD 10.0) in CG
Smokers: 0%
Hypertension: 0%
Mean baseline BP:
SBP=120.4 (SD 19.7) in IG, 116.5 (SD 13) in CG;
DBP=77.2 (SD 9.4) in IG, 74.6 (SD 9.0) in CG
Inclusion criteria: NR
Exclusion criteria:
Quote: "physically active lifestyle, age > 65 years, resting BP > 159/99 mmHg, total cholesterol > 6.2 mmol· L‐1, fasting blood glucose > 7.0 mmol· L‐1, body mass index (BMI) > 34.9 kg· m‐2, current cigarette smokers, individuals with cardiovascular, pulmonary or metabolic disease, pain or discomfort in the chest, dizziness or heart murmur. In addition, individuals taking medication known to interfere with lipid metabolism, and females who were pregnant or planning to become pregnant in the following five months were excluded from taking part in the study."
Interventions IG: Walking group: single bout and outdoors walking; Only 12 walkers wore pedometer to record steps in week 0, 4 and 8.
  • Duration: graduated increase to 45 min/session (25 min @ week 1; 35 min @ week 2; 45 minutes for week 3 to week 8)

  • Intensity: moderate; self‐paced

  • Frequency: 2 days/week

  • Intervention period: 8 weeks

  • Pedometer: yes, 12 walkers and all controls wore pedometer on weeks 0, 4 and 8.

  • Facilitator: NR


CG: Control group: wore pedometer to record steps in weeks 0, 4 and 8.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: duplicate measurements of BP were taken two minutes apart using an automated device (Omron 705 CP; Omron Matsusaka Co. Ltd., Japan)
Primary/Main outcome of manuscript: blood pressure, lipids, CRP and body composition
Compliance/Adherence: % of prescribed sessions (16 sessions in total) were completed. Compliance was high with walkers completing 83.9 ± 18.9% of prescribed sessions.
Adverse event: 0
Notes Trial registration: NCT00284479
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk C‐reactive protein "randomised controlled study" but no details reported
refer to Table 1 (completers only)
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1 (completers only)
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 10.8% (4 out of 37)
2 out of 23 IG (8.7%), 2 out of 14 CG (14.3%) dropouts
refer to Table 3
Quote: "Four individuals dropped out of the study due to: illness (1 control), moving job (1 control), family circumstances (1 walker) and lack of interest (1 walker)."
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
only 1 analysis
Other bias Low risk No other bias

Murtagh 2005.

Study characteristics
Methods Aim: to evaluate the effectiveness of instructing sedentary individuals to undertake 20‐minute brisk walking (in one continuous bout or two 10‐minute bouts) 3 days per week, on fitness and other cardiovascular disease (CVD) risk factors in previously sedentary adults.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised: 48 (19 in IG1_Single bout, 18 in IG2_Acumulated bout, 11 in CG)
No. completers: 32
Country: UK
Study population: sedentary general population (University staff or students)
Ethnicity: NR
Gender: male 35% (17/48)
Age: mean 45.7 (SD 9.4)
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 117.9 (SD 12.0) in IG1_Single bout, 121.7 (SD 11.2) in IG2_Acumulated bout, and 117.5 (SD 18.1) in CG;
DBP = 74 (SD 9.8) in IG1_Single bout, 75.4 (SD 6.6) in IG2_Acumulated bout, and 73.1 (SD 10.6) in CG.
Inclusion criteria: NR
Exclusion criteria:
Quote: "History of cardiovascular or metabolic disease, resting blood pressure > 140/90 mmHg, body mass index > 30 kg m‐2, musculoskeletal condition or injury, taking medications known to interfere with lipid metabolism, or a physically active lifestyle (Defined as engaging in more than 20 min of planned exercise per week during the preceding 4‐week period)."
Interventions IG_SB: Walking (single‐bout) group:
Treadmill walking: treadmills at the university were free of use. During one session each week, walking was supervised and heart rate and walking speed were monitored continuously. A self‐reported training diary recoding walking duration, speed, distance and all walking notes was collected in week 12.
  • Duration: 20 minutes/session

  • Frequency: 1 session/day, 3 days/week

  • Intensity: moderate (walk briskly)

  • Length: 12 weeks

  • Pedometer: NR

  • Facilitator: yes, once a week


IG_AB: walking (accumulated‐bout) group:
Treadmill walking: treadmills at the university were free of use. During one session each week, walking was supervised and heart rate and walking speed were monitored continuously. A self‐reported training diary recoding walking duration, speed, distance and all walking notes was collected in week 12.
  • Duration: 10 minutes/session

  • Frequency: 2 session/day, 3 days/week

  • Intensity: moderate (briskly)

  • Pedometer: NR

  • Facilitator: yes, once a week


CG: Control group: no training
Outcomes Review outcomes reported: SBP, DBP
Measurement method: blood pressure measured by validated automated device (Omron 705CP; Omron Matsusaka Co. Ltd., Japan)
Primary/Main outcome of manuscript: body composition, blood pressure and lipids
Compliance/Adherence: compliance was defined as completing at least 60% of prescribed sessions [7] and, as a result, two subjects were excluded (1 single‐bout walker, 1 accumulated‐bout walker)
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomised" but no details reported
refer to Results (32 completers only)
Allocation concealment (selection bias) Unclear risk No information
refer to Results (32 completers only)
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 33.3% (16 out of 48) 4 out of 19 single IG (21%), 9 out of 18 accumulated IG (50%), 3 out of 11 CG (27.3%) dropouts
Quote: "Fourteen subjects dropped out of the study due to: time pressures with work/study (2 single‐bout walkers, 3 accumulated‐bout walkers); personal circumstances (1 single‐bout walker, 2 accumulated‐bout walkers, 1 control); lack of interest (1 accumulated‐bout walker); starting medication (1 accumulated‐bout walker); moving job (1 accumulated‐bout walker); and starting a personal exercise programme (2 control)."
Quote: "Compliance was defined as completing at least 60% of prescribed sessions [7] and, as a result, two subjects were excluded (1 single‐bout walker, 1 accumulated‐bout walker)." Data are therefore presented for 32 subjects (17 women) who completed the study.
Data were from completers only
refer to Result
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Nemoto 2007.

Study characteristics
Methods Aim: whether the high‐intensity interval walking training increased thigh muscle strength and peak aerobic capacity and reduced blood pressure more than moderate‐intensity continuous walking training.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: the statistical power to detect their significant changes after training in the continuous and interval walking groups was >0.8 at α of 0.05 except for SBP in men from the continuous walking group (0.74) and DBP in men from the interval walking group (0.53).
Participants No. randomised: 246 (16 in Wcnt_male, 59 in Wcnt_female, 19 in Wint_male, 68 in Wint_female, 25 in CG_male, 59 in CG_female.)
Wint: high‐intensity interval walking training group
Wcnt: moderate‐intensity continuous walking training group
No. completers: 139
Country: Japan
Study population: general population adults
Ethnicity: NR
Gender: male: 24% (60/246)
Age: mean 63 (SD 6), range 44 to 78
Smokers: 0%
Hypertension: 0%
Mean baseline BP:
SBP=141 (SE 2) in Wcnt_male, 135 (SE 3) in Wcnt_female, 146 (SE 2) in Wint_male, 140 (SE 3) in Wint_female, 143 (SE 2) in CG_male, 142 (SE 3) in CG_female;
DBP=85 (SE 2) in Wcnt_male, 81 (SE 2) in Wcnt_female, 87 (SE 3) in Wint_male, 85 (SE 2) in Wint_female; 84 (SE 2) in CG_male, 83 (SE 2) in CG_female.
HR=81 (SE 3) in Wcnt_male, 78 (SE 1) in Wcnt_female, 75 (SE 3) in Wint_male, 81 (SE 2) in Wint_female, 80 (SE 3) in CG_male, 79 (SE 1) in CG_female.
Inclusion criteria:
Quote: “Nonsmoking middle‐aged and older adults (44 to 78 years) with no history of cardiovascular or pulmonary diseases”
Exclusion criteria: NR
Interventions WCNT: walking (continuous moderate‐intensity training) group:
Participants were instructed to walk more than 8000 steps per day for a minimum of 4 days a week. Pedometers were given and returned to administration centre once a month to review the compliance. Only 18 participants in this group wore accelerometer to monitor intensity and steps.
  • Duration: 8000 steps/day

  • Intensity: 50%VO2peak

  • Frequency: min 4 days/week

  • Intervention period: 22 weeks (Training between 18 May and 15 Oct. 2004)


WINT: walking (high‐intensity interval walking) group:
Participants were divided into 5 subgroups and invited to a community office near their homes. Instruction of repeating the following regimen 4 or more times per week: 5 or more sets of 2 to 3‐minute low‐intensity walking intervals (at approximately 40% of the pre‐training VO2peak), followed by a 3‐minute interval of high‐intensity walking (70% to 85% VO2peak for walking) was given. Participants were instructed to reach target levels every 2 weeks, and needed to return to local office to review compliance and load the pedometer/accelerometer data.
  • Duration: 25 to 30 minutes/day

  • Intensity: 5 or more sets of 2‐ to 3‐minute low‐intensity walking intervals (at approximately 40% of the pre‐training VO2peak); followed by a 3‐minute interval of high‐intensity walking (>70% but <85% VO2peakfor walking).

  • Frequency: minimum 4 days/week

  • Intervention period: 22 weeks (5 months*4.33) (Training between 18 May and 15 Oct 2004)

  • Pedometer: Yes, Omron, JH‐005, Kyoto, Japan

  • Facilitator: NR


CG: Control (no walking training) group: Remaining sedentary life.
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method: SBP and (DBP were measured by auscultation after the participant had been sitting for 10 minutes in a room
Primary/Main outcome of manuscript: VO2peak (by graded cycling exercise and by graded walking exercise), isometric knee extension and flexion forces were measured at baseline and week‐20.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This study was supported in part by grants from the Ministry of Health, Labor, and Welfare (Comprehensive Research on Aging and Health), the Japan Society for Promotion of Science, and the Ministry of Economy, Trade, and Industry of Japan.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) High risk Quote: "a few of the participants were married couples and wanted to join the same group, and others, who lived a distance from an administrative center, wished to be assigned to the interval walking group so that they could visit a local community office nearer their homes. For these reasons, minor reassignments were made..."
There were "minor" reassignments after randomisation and it was not defined how many participants were reassigned.
refer to Table 4
Allocation concealment (selection bias) High risk Quote: "a few of the participants were married couples and wanted to join the same group, and others, who lived a distance from an administrative centre, wished to be assigned to the interval walking group so that they could visit a local community office nearer their homes. For these reasons, minor reassignments were made..."
In this case, the information of allocation is unlikely to be concealed.
refer to Table 4
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk High dropout (total 107 out of 246 randomised, 43.5%)
24 out of 75 (32.0%) in Moderate intensity TG, 45 out of 87 (51.7%) in High intensity TG, and 38 out of 84 (45.2%) in CG drop outs
refer to Figure 1
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 5 months
Only 1 analysis
Other bias Low risk No other bias

Neumann 2006.

Study characteristics
Methods Aim: the potential attenuating effects of 6 months of walking (aerobic exercise) versus control on cardiovascular reactivity (CVR) to anger‐provoking stressors in sedentary older adults who manifest exercise‐induced silent myocardial ischaemia (SI) and have no history of overt coronary artery disease (CAD).
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 25 (14 in IG, 11 in CG)
No. completers: 20 (9 dropouts, 4 CG re‐enter as IG)
Country:USA
Study population: adults with Silent Myocardial Ischemia (Baltimore‐Washington metropolitan area and the Charlestown Retirement Community)
Ethnicity: NR
Gender: male 68% (17/25)
Age: mean 71 (SE 2) in IG, 63 (SE 2) in CG
Smoker: 0%
Hypertension: NR
Mean baseline BP:
SBP = 134 (SE 3) in IG, 140 (SE 6) in CG;
DBP = 76 (SE 3) in IG, 80 (SE 2) in CG;
resting HR = 71 (SE 3) in IG, 71(SE 3) in CG
Inclusion criteria:
older (age 56–83 years), nonsmokers with at least a high school education and without a history of symptomatic CAD.
Exclusion criteria:
Quote: “history of overt CAD, resting‐ECG evidence of CAD as defined by significant Q waves, major ST segment abnormalities, left‐bundle‐branch block, complex arrhythmias, poorly controlled hypertension (blood pressure >180/105 mmHg), stroke, peripheral arterial disease, poorly controlled hyperlipidaemia (low‐density lipid concentrations >190 mg/dl or plasma triglycerides >400mg/dl), diabetes mellitus, dementia (Mini‐Mental State Examination score <24), history of psychiatric disorders, current smoking, history of heavy alcohol consumption (>14 drinks per week), or other comorbid diseases that would interfere with the ability to participate in the study. Participants were also excluded if they had severe hypertension requiring multiple antihypertensive medications (3+) because of potential safety concerns of temporarily discontinuing their medications during the measurements of CVR.”
Interventions IG: Walking (exercise) group:
The duration and intensity of sessions were gradually increased until participants were walking for 40 minutes at 70% of their heart rate reserve or at their ischaemic threshold as determined during their exercise‐treadmill test.
  • Duration: graduated increase to 40 minutes/sessions

  • Intensity: 70% of their heart rate reserve; aiming at increasing the participants’ VO2max by 10% or more, without changing their weight.

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 26 weeks (6 months)

  • Pedometer: no

  • Facilitator: yes, by exercise physiologists


CG: Control (wait‐list) group: the wait‐list controls received no further contact for 6 months before post‐control testing.
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method: all BP and HR data were collected oscillometrically at 60‐s intervals during rest and task periods with an automated vital‐signs monitor (Dinamap Model # 1846SX, Critikon, Tampa, FL).
Primary/Main outcome of manuscript: cardiovascular reactivity (SBP, DBP, HR), Spielberger’s State‐Trait Personality Inventory questionnaires, lipoprotein lipids and glucose levels
Compliance/Adherence: attended >75% of the exercise sessions
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This work was supported by National Institute on Aging (NIA) K24 AG 00930, NIA R29 AG15112, a Department of Veteran Affairs Geriatric Research, Education and Clinical Center Grant (GRECC), a VA Merit Grant, and the University of Maryland Claude D.Pepper Older Americans Independence Center (P60‐AG12583).)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomised" but no details reported a total of two randomisation performed: 25 randomised to 14/11, the 6 and 3 lost, then the controls randomised again to become intervention (+4). Turn out become 12 in IG and 8 in CG.
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 36.0% (9 out of 25)
6 out of 14 in IG (42.9%), 3 out of 11 in CG (27.3%) dropouts
refer to Figure 1
Quote: "Four participants dropped out of the exercise‐training protocol because of time conflicts, and 2 participants experienced adverse health events not associated with study participation but precluding them from further participation. During the 6‐month waiting period, 1 participant from the control group experienced an adverse health event not associated with study participation but precluding the individual from further participation in the study, and 2 participants refused to return for post‐control assessment."
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 6 months
Only 1 analysis
Other bias Low risk No other bias

Pagonas 2014.

Study characteristics
Methods Aim: to investigates the impact of an aerobic exercise program on BPV
Design:Parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised:72 (36 in IG, 36 in CG)
No. completers: 66
Country: Germany
Study population: hypertensive outpatients (hypertension clinic or press)
Ethnicity: NR
Gender: male 43.1% (31/72)
Age: mean 65.3 (range 42 to 79) in IG, 67.7 (range 43 to 77) in CG
Smokers: ex‐smokers 15.3% (11/72)
Hypertension: 100%
Mean baseline BP:
daytime ambulatory SBP = 137.9 (SD 12.3) in IG, 133.1 (SD 12.1) in CG
daytime ambulatory DBP = 78.1 (SD 8.9) in IG, 73.8 (SD 6.4) in CG
Inclusion criteria:
current antihypertensive treatment with at least one antihypertensive drug and/or office blood pressure >=140/90 mmHg.
Exclusion criteria:
Quote: "regular engagement in physical exercise training in the past 4 weeks prior to inclusion in the study, symptomatic peripheral arterial occlusive disease, aortic insufficiency or stenosis >stage I, hypertrophic obstructive cardiomyopathy, congestive heart failure (>NYHA II), uncontrolled cardiac arrhythmia with haemodynamic relevance, systolic office BP >=180mmHg, signs of acute ischemias in exercise ECG, change of antihypertensive medication in the past 4 weeks prior to inclusion in the study or during follow‐up period."
Interventions IG: Walking (exercise) group:
Walking on a treadmill according to an interval‐training pattern; training was performed in the hospital. Training sessions were carried out with a target‐lactate concentration of 2.0±0.5 mmol/L in capillary blood slightly above the aerobic threshold.
  • Duration: graduated increase to 36 minutes/session (3 minutes/day x 5 times (week 1); 5 minutes/day x 4 times (week 2), 8 minutes/day x 3 times (week 3), 10 minutes/day x 3 times (week 4), 15 minutes/day x 2 times (week 5). In the sixth and further weeks, exercise was progressively increased to 30, 32 and 36 minutes and carried out without interruption.)

  • Intensity: NR

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 10 weeks ((8+12)/2)

  • Pedometer: NR

  • Facilitator: yes, by a study nurse and a physician


CG: Control (sedentary) group: NR
Outcomes Review outcomes reported: SBP, DBP
Measurement method: assessment of 24‐hour‐ABP monitoring and physical performance were conducted before and after the observation period. 24‐hour‐ABP monitoring was performed using Spacelabs 90 207 monitors (Spacelabs, Redmond, WA, USA).
Primary/Main outcome of manuscript: a change in systolic BPV measured as the CV of systolic daytime ABP.
Compliance/Adherence: minimum of 8 weeks
Adverse event: NR
Notes Trial registration: NR
Note: included Dimeo study participants, not separately analysed resistant hypertension subset.
Funding sources: private sector (The study was supported by the Gertrud und Hugo Adler Stiftung, Georgensgmu¨ nd, Germany.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "Participants were randomly assigned to an exercise program or sedentary control."
Quote: "A total of 72 patients, who met the inclusion criteria, were randomized by lot to either the exercise group (36 patients) or the control group (36 patients, Figure 1)."
No details about the randomisation procedure
refer to Table 1 & 2
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Quote: "The aerobic exercise program consisted of walking on a treadmill according to an interval‐training pattern. Training was performed in the hospital. Patients were supervised during training by a study nurse and a physician."
Insufficient information about control group and not sure if the nurse and physician had any opportunity to care participants in control group.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Measurement of 24‐hour ambulatory blood pressure was used.
Incomplete outcome data (attrition bias)
All outcomes Low risk dropout 8.3% (6 out of 72)
3 out of 36 in IG (8.3%) & 3 out of 36 in CG (8.3%) dropouts
refer to Figure 1 (dropout)
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 8 to 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Palmer 1995b.

Study characteristics
Methods Aim: the psychological effects of an 8‐week walking program on attributional style, scores of depression, self‐esteem, and physical fitness in females.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 27 (16 in IG, 11 in CG)
No. completers: 27
Country: USA
Study population: non‐exercising, premenopausal, female volunteers (recruited from the general public via radio and newspaper) announcements.
Ethnicity: NR
Gender: male 0% (0/27)
Age: mean 37.4; range 29 to 50
Smokers: NR
Hypertension:0%
Mean baseline BP:
SBP = 117.1 (SD 14) in IG, 122.6 (SD 13.8) in CG;
DBP = 80.9 (SD 10.6) in IG, 77.6 (SD 11.2) in CG;
HR = 74 (SD 10.8) in IG, 71 (SD 6.5) in CG
Inclusion criteria:
non‐exercising, premenopausal women
Exclusion criteria:
Quote: "history of heart disease or other significant health problems and those who reported having been highly fit in the past 3 years were not eligible for participation."
Interventions IG: Walking group: walking in university coliseum.
  • Duration: gradually increase to 55 minutes/session (starting from 20 minutes)

  • Intensity: 60% to 70% of estimated maximum heart rate, participants were instructed to measure their carotid halfway the walking to ensure the intensity reached 60% to 70% of estimated maximum heart rate

  • Frequency: lacking data of walking frequency per week

  • Intervention period: 8 weeks

  • Pedometer: NR

  • Facilitator: yes


CG: Control group: non walking, wait‐list
Outcomes Review outcomes reported: SBP, DBP, resting heart rate
Measurement method: resting heart rate and blood pressure were measured by digital blood‐pressure cuff
Primary/Main outcome of manuscript: psychological outcomes
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "Participants were randomly assigned to either a walking group...... or nonwalking, ......" and no other details about randomisation.
refer to Table 2
Allocation concealment (selection bias) Unclear risk No information
There is no information about control group participants.
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk No dropout
refer to table 2
ITT analysis
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Pernar 2017.

Study characteristics
Methods Aim: the feasibility of a randomised walking group intervention to improve quality of life, circulating biomarkers, and morbidity among men with newly diagnosed prostate cancer.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:41 (21 in IG, 20 in CG)
No. completers: 36
Country: Sweden
Study population: newly diagnosed prostate cancer patients
Ethnicity: NR
Gender: male 100% (41/41)
Age: range 61.7 to 81.7 years in IG; 54.5 to 81.6 years in CG
Smokers: 48% in IG; 50% in CG
Hypertension: NR
Mean baseline BP:
SBP = 170 in IG, 162 in CG;
DBP = 93 in IG, 89 in CG
Inclusion criteria:
histological diagnosis of prostate cancer without evidence of distant metastases, had completed initial treatment at least 1 month prior to study enrolment, and had a life expectancy of at least 5 years, the ability to speak Swedish and be mentally and physically able to complete the questionnaires and clinical exam and to participate in group walking sessions.
Exclusion criteria:
physical or mental impairment
Interventions IG: Walking group: participants were assigned to groups of 6 to 8 men, based on the participants’ availability for walking on specific times of the day. For the 11‐week intervention, the men walked together weekly in their groups for 1 hour along with a research nurse who answered patients’ questions about prostate cancer and led discussions. On other days, the men were instructed to wear pedometers to monitor the number of steps they took on a given day. In addition, they recorded their daily number of steps in a diary.
  • Duration: self‐paced, encouraged to maintain 10,000 steps per day.

  • Frequency: 7 sessions/week

  • Intensity: NR

  • Intervention period: 11 weeks

  • Pedometer: Yes, Timex W‐180 US 621 095000

  • Facilitator: yes.


CG: Control (usual care) group: received no intervention other than their usual medical care
Outcomes Review outcomes reported: SBP, DBP
Measurement method: not mentioned, only physical exam by research nurse
Primary/Main outcome of manuscript: quality of life and circulating biomarker
Compliance/Adherence: walked within 1000 steps of the study goal of 10,000 steps per day on average over the 11 weeks
Adverse event: NR
Notes Trial registration: NR
1. Convert % Difference in mean change in column 7 of Table 2 into Difffference in mean change score by dividing by 100.
E.g. for SBP ‐8.51 = ‐8.51/100 = ‐0.0851 = mean difference of change scores = MD
2. Similarly covert 95%CI limits i.e. ‐21.23 and 4.21 become ‐0.2123 and 0.0421
3. Now use Revman Claculator, enter N, MD and 95%CI limits into the bottom set of boxes to get the SE of the mean diff of change score.
4. Use the MD and this SE to enter into GIV data type for meta‐analysis.
5. For SBP, MD = ‐0.085, SE (MD) = 0.0638
6. For DBP, MD = ‐0.0002, SE (MD) = 0.0321
Funding sources: Private sector(C.H. Pernar and S.C. Markt are supported by National Institutes of Health (NIH) training grants (T32 ES 007069, T32 CA 09001). This project was supported in part by funding from the Prostate Cancer Foundation (PCF). L.A. Mucci and J.R. Rider are PCF Young Investigators.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "randomised to the study through a random number generator... "
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.2% (5 out of 41)
4 out of 21 (19.0%) in walking group, 1 out of 20 usual care group (5.0%) dropouts
refer to Figure 1 and author provided information
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 11 weeks
Only 1 analysis
Other bias Low risk No other bias

Pospieszna 2017.

Study characteristics
Methods Aim: to test if Nordic walking training would be increased endothelial nitric oxide synthase (eNOS) activity and, consequently, greater capacity for nitric oxide (NO) formation in the vascular endothelium.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised: 39 (20 in IG, 19 in CG)
No. completers: 39
Country: Poland
Study population: healthy postmenopausal women (recruited through public advertisement)
Ethnicity: NR
Gender: male 0% (0/39)
Age: mean 62 (SD 3.79) in IG, 62 (SD 1.12) in CG; range: 52 to 72
Smokers: data collected but NR
Hypertension: no
Mean baseline BP:
SBP = 134.7 (SD 21.23) in IG, 132.16 (SD 3.8) in CG;
DBP = 75.8 (SD 7.06) in IG, 78.58 (SD 1.96) in CG.
Inclusion criteria:
postmenopausal volunteers; good health status; aged between 52 and 72.
Exclusion criteria:
Quote: "exclusion criteria for volunteers included inflammatory disorders, recent infections, renal or hepatic insufficiency, active coronary artery disease, diabetes, hypertension (>160/100 mmHg), heart failure, the use of hormonal replacement therapy, and supplementation with antioxidants within 3 months prior to enrolment."
Interventions Training group: Nordic walking
  • Duration: 60 minutes/session

  • Frequency: 3 times/week

  • Intensity: 90% of ventilatory threshold (VT) intensity

  • Intervention period: 12 weeks

  • Pedometer: no

  • Facilitator: yes


Control group: were asked to continue their daily routines, without any major changes, especially in the level of everyday physical activity
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: after the participants spent a further 5 minutes resting in the supine position, the level of blood pressure and heart rate at rest were measured.
Primary/Main outcome of manuscript: endothelial NOS activity, TAC and oLAb concentration
Compliance/Adherence: quote: "Participants in the training group performed a 12‐week supervised NW training, preceded by individual demonstrations of the proper walking technique. Each physical workout took place outdoors and consisted of 60‐minute sessions of exercise (50 minutes of walk with 90% of ventilatory threshold [VT]intensity, 5‐minute warm‐up, and 5‐minute stretching), repeated three times per week."
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This work was partially financed by the City of Poznan as part of the "Academic and Scientific Poznari" strategy)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly divided into a training group ... and a control group"
"Both groups were similar with regard to anthropometric parameters, such as body mass, BMI, or height. None of the accepted women changed their nutritional approach during the analysed 12‐week period. In particular, the levels of salt and alcohol intake were unchanged. Women assigned to the control group were asked to continue their daily routines, without any major changes, especially in the level of everyday physical activity."
No other details about randomisation
Allocation concealment (selection bias) Unclear risk Quote: "randomly divided into a training group ... and a control group"
"Both groups were similar with regard to anthropometric parameters, such as body mass, BMI, or height. None of the accepted women changed their nutritional approach during the analysed 12‐week period. In particular, the levels of salt and alcohol intake were unchanged. Women assigned to the control group were asked to continue their daily routines, without any major changes, especially in the level of everyday physical activity."
No other details about allocation concealment
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Unclear risk 39 randomised but the number of participants at outcome measures was not reported
Unsure ITT or PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Ready 1996.

Study characteristics
Methods Aim: the effect of walking volume on aerobic fitness, serum lipids, and body composition in women post‐menopause, a population at risk for coronary artery disease.
Design: Parallel 3‐group RCT (1:1:1)
Power/sample size calculation: yes
Participants No. randomised: 79 (27 in IG1_3D, 27 in IG2_5D, 25 in CG)
No. completers: 56
Country: Canada
Study population: sedentary postmenopausal women (50+)
Ethnicity: NR
Gender: male 0% (0/79)
Age: mean 61.3 (SD 5.8) (56 completers)
Smokers: 0%
Hypertension: NR
Mean baseline BP:
SBP = 134 (SD 18) in IG1_3D, 131 (SD 20) in IG2_5D, 131 (SD 16) in CG;
DBP = 77 (SD 11) in IG1_3D, 76 (SD 9) in IG2_5D, 77 (SD 10) in CG.
Inclusion criteria:
Quote: “post‐menopausal status (no menstrual periods in the past 12 months), over 50 yrs of age, absence of hormone replacement therapy or medication to lower serum cholesterol, nonsmoker status, a sedentary lifestyle (exercising less than 30 min/wk), physical ability to exercise, and a body mass index of 34 or less. Total serum cholesterol levels less than 8.0 mmol/l and serum triglyceride less than 4.2 mmol/l"
Exclusion criteria:
Quote: "of these 30 were screened out for medical reasons, including medications that interfere with serum lipids, or presence of disease that would preclude unsupervised walking (e.g., known heart disease)."
Interventions IG_3D: Walking (3 days/week) group:
  • Duration: 60 minutes/session

  • Frequency: 1 session/day, 3 days/week

  • Intensity: 60% VO2peak

  • Intervention period: 24 weeks


IG_5D: Walking (5 days/week) group:
  • Duration: 60 minutes/session

  • Frequency: 1 session/day, 5 days/week

  • Intensity: 60% VO2peak

  • Intervention period: 24 weeks


Participants were instructed to walk a complete 60 minutes first, and then gradually increased the intensity thereafter. Walkers were requested to attend at least 4 supervised session at the university track (5 times per week) in the first 2 week, and at least one per week thereafter. Unsupervised sessions took place in a variety of settings including community tracks, fitness facilities, parks, and public roads.
  • Pedometer: no

  • Facilitator: yes, 4 supervised walking classes in first 2 weeks, and at least 1/week thereafter


CG: Control group: participants were asked to maintain sedentary lifestyle
Outcomes Review outcomes reported: SBP, DBP
Measurement method: no mention on blood pressure measurement.
Heart rate was monitored with an ECG (Cardio Tracer, Birtcher Medical Systems) using a CM5lead.
Primary/Main outcome of manuscript: aerobic fitness, serum lipids, and body composition
Compliance/Adherence:walkers must walk an average of at least 150 minutes/week and 240 minutes/week to successfully complete the study.
Adverse event: NR
Notes Trial registration: NR
Funding sources: private sector (This study was supported by the Canadian Fitness and Lifestyle Research Institute (https://www.cflri.ca/who‐we‐are, project #931R014), the Manitoba Medical Service Foundation, and the Centre on Aging at the University of Manitoba.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly assigned" but no details reported
Completers only
Allocation concealment (selection bias) Unclear risk No information
Completers only
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 29.1% (23 out of 79)
8 out of 27 (29.6%) in 3‐day walking, 10 out of 27 5‐day walking (37.0%), 5 out of 25 (20.0%) in CG dropouts
Unspecific reasons for each group
refer to Figure 1
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 24 weeks
Only 1 analysis
Other bias Low risk No other bias

Romero 2019.

Study characteristics
Methods Aim: to investigate the effects of a pedometer on motivating Mexican‐American female participants, ages sixty to seventy‐five years old, to increase their physical activity to lower weight and /or blood pressure.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 55 (27 in IG, 28 in CG)
No. completers: 55
Country: USA
Study population: general population (women)
Ethnicity: Mexican‐American
Gender: male 0%
Age: range 60 to 75
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 143.67 (SD 21.91) in IG. 146.07 (SD 24.18) in CG;
DBP = 84.41 (SD 15.19) in IG, 82.96 (SD 10.29) in CG.
Inclusion criteria:
Mexican‐American females aged 60 to 75 years
Exclusion criteria: NR
Interventions IG: Walking group:
the treatment group participants completed simple entry logs to record the number of steps and facilitate the evaluation of the program. Each participant in the treatment group was contacted once a week via telephone to remind recording daily steps.
  • Duration: NR

  • Intensity: NR

  • Frequency: 7 days/week

  • Intervention period: 12 weeks

  • Pedometer: yes as a motivational tool (brand unknown)

  • Facilitator: NR


CG: Control group:
participants did not receive a pedometer or entry logs, only education on the importance of diet and exercise on the pretest meeting. They were instructed to return at the end of the twelve weeks to complete a posttest.
Outcomes Review outcomes reported: BP
Measurement method: weight, systolic and diastolic blood pressure were measured at baseline and a follow‐up meeting 12 weeks later.
Primary/Main outcome of manuscript: weight, systolic and diastolic blood pressure
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Randomly assigned but no detailed information provided
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 0% (0/55)
refer to Table 3
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Sakuragi 2006.

Study characteristics
Methods Aim: the effects of daily walking on subjective symptoms as well as on mood and autonomic nervous function in people who take no medication but have some general physical complaints.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised: 20 (12 in IG,8 in CG)
No. completers: 15
Country: Japan
Study population: healthy college students from general population
Ethnicity: NR
Gender: male 0% (0/20)
Age: range 20 to 22
Smokers: 0%
Hypertension: 0%
Mean baseline BP: figure 2.
Inclusion criteria:
normotensive nonsmokers
Exclusion criteria:
Quote: "exercised regularly two or more times per week for at least 30 min during the preceding 12 months and those who took medication on a regular basis"
Interventions IG: Walking group: without altering other habitual activities during the study period
  • Duration: 60 minutes/session

  • Frequency: 1 session/day, 6 days/week

  • Intensity: 6 km/hour (rapid walk)

  • Intervention period: 4 weeks

  • Pedometer: wore lifestyle record machine (Lifecorder, Suzuken, Japan) to record motor activities by acceleration sensors

  • Facilitator: NR


CG: Control group: wore lifestyle record machine from the previous week to the end of the study to ensure a level of daily activity.
Outcomes Review outcomes reported: SBP, DBP, HR
Measurement method: an occlusion cuff of appropriate size was attached to the left arm with a tonometry sensor on the radial artery at the wrist to measure blood pressure (BP) waveform (Colin, Japan).
Primary/Main outcome of manuscript: psychological indices (Cornell medical index questionnaire, profile of mood states, and frontal alpha laterality ratio) and autonomic indices (Blood pressure and ECG variance under orthostatic condition) measured at baseline and week 4.
Compliance/Adherence: walkers whose average amount of exercise calculated from the Lifecorder data did not increase by more than 1.2 kcal/kg/day would be excluded.
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk No information ‐ Quote: "All subjects were normotensive non‐smokers and were randomly assigned into two groups: a walking group (n=12) and a control group (n=8)."
Completers only
Allocation concealment (selection bias) Unclear risk Completers only
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 25% (5 out of 20)
Completer‐only analysis
refer to table 1
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 4 weeks
Only 1 analysis
Other bias Low risk No other bias

Salesi 2014.

Study characteristics
Methods Aim: to investigate the effect of 8‐week walking program on metabolic syndrome indexes in non‐athlete menopausal women
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 32 (16 in IG, 16 in CG)
No. completers: 32
Country: Iran
Study population : elderly women
Ethnicity: NR
Gender: male 0%
Age: range 50 to 55 years
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP=136.0 (SD 12.1) in IG, 131.1 (SD 8.7) in CG;
DBP = 83.1 (SD 10.1) in IG, 80.3 (SD 3.8) in CG
Inclusion criteria:
aged 50 to 55, healthy inactive, fulfilling at least three criteria of ATPIII, at least 2 years of menopause, physical health, no regular exercise (at least 3 sessions a week) over the last 6 months before the study, not using hormone therapy
Exclusion criteria: NR
Interventions IG: walking group: walking with 60% heart rate reserve and for 30 minutes for the first two weeks. From the third week, every 2‐week sessions increased by 10 minutes and intensity increased by 5%. So that the session was with 75% heart rate reserve and 60 minutes at last week. Walking at own time (not treadmill)
  • Duration: gradually increase from 30 minutes to 60 minutes

  • Intensity: gradually increase from 60% heart rate reserve to 75% heart rate reserve

  • Frequency: 3 sessions per week

  • Intervention period: 8 weeks

  • Pedometer: not mentioned

  • Facilitator: not mentioned


CG: Control group: everyday normal activities with no physical exercise
Outcomes Review outcomes reported: SBP, DBP
Measurement method:. measure by sphygmomanometer
Primary/Main outcome of manuscript: SBP, DBP
Compliance/Adherence: completed all session
Adverse event: NR
Notes Trial registration: NR
Funding sources: Egyptain government
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk The randomisation method was not described, the sample size is equal at the two groups.
Based on Table 1, weight, BMI, fat% and waist to hip ratio seems to be comparable at the two groups before the program.
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk There was no missing value for the outcomes before and after the program at the two groups.
refer to table 1, 2
According to the outcome table 1 and 2, the dropout rate was 0% since the participant number was the same in tables.
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 analysis
Other bias Low risk No other bias

Saptharishi 2009.

Study characteristics
Methods Aim: to measure the efficacy of physical exercise, reduction in salt intake, and yoga, in lowering BP among young (20 to 25) pre‐hypertensives and hypertensives, and to compare their relative efficacies.
Design: parallel 4‐group RCT (1:1:1:1)
Power/sample size calculation: NR
Participants No. randomised:58 (28 in IG, 30 in CG);
(27 in Yoga group and 28 in Salt intake reduction excluded)
No. completers: 56
Country: India
Study population: confirmed hypertensives/pre‐hypertensives
Ethnicity: NR
Gender: male 69.6% ((20+19)/56)
Age: mean 22.4 (SD 1.3) in IG; 22.5 (SD 1.4) in CG
Smokers: NR
Hypertension: 100% pre‐hypertensive and hypertensive
Mean baseline BP:
SBP = 128.6 (SD 7.7) in IG, 123.1 (SD 10.2) in CG;
DBP = 87.4 (SD 4.8) in IG, 82.9 (SD 7.1) in CG
Inclusion criteria:
pre‐hypertensives (SBP130 to 139 mmHg and/or DBP 85 to 89 mmHg) and hypertensives.
Exclusion criteria:
severe hypertension
Interventions IG: walking (physical exercise) group:
  • Duration: 50 to 60 minutes/session

  • Intensity: brisk walking

  • Frequency: 1 session/day, 4 days/week

  • Intervention period: 8 weeks

  • Pedometer: NR

  • Facilitator: yes, the investigator accompanied walkers on several occasions


CG: Control group: NR
Note: yoga and salt intake reduction groups excluded
Outcomes Review outcomes reported: SBP, DBP
Measurement method: blood pressure was measured using the mercury sphygmomanometer.
Primary/Main outcome of manuscript: SBP, DBP
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This study was sponsored by the Indian Council of Medical research (ICMR), New Delhi under the Short Term Studentship scheme (STS‐2007).)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "using a standardized randomization process, with a random number generator (SPSS 13.0)."
refer to Table 1 (completers only)
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 3.4% (2 out of 58)
1 out of 28 in walking group (3.6%) & 1 out of 30 in control group (3.3%) dropouts
refer to Table 1
Both ITT and PP done
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
only 1 analysis
Other bias Low risk No other bias

Serwe 2011.

Study characteristics
Methods Aim: to compare changes in PA between participants assigned to walk daily in accumulated shorter bouts, one continuous session and control group.
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: Yes
Participants No. randomised: 60 (20 in IG_LB, 20 in IG_SB, 20 in CG)
No. completers: 53
Country: USA
Study population: sedentary office women
Ethnicity: NR
Gender: male: 0% (0/60)
Age: mean 37.1 (SD 7.2) in IG_LB, 38.2 (SD 7.3) in IG_SB, 36.3 (SD 8.1) in CG; range 18 to 50
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 115.1 (SD 10.5) in IG_LB, 117.7 (SD 12.1) in IG_SB, and 120.9 (SD 9.2) in CG;
DBP = 73.4 (SD 8.1) in IG_LB, 73.2 (SD 8.7) in IG_SB, 72.7 (SD 7.2) in CG
Resting HR = 68.4 (SD 10.4) in IG_LB, 65.8 (SD 6.0) in IG_SB,72.7 (SD 9.5) in CG
Inclusion criteria:
Quote: “premenopausal healthcare workers between the ages of 18 and 50 years, inactive (i.e., did not engage in ≥30 minutes of daily physical activity either continuous or accumulated on >2 days/week for the past 3 months, per self‐report), free of cardiovascular, pulmonary, neurological, metabolic, or orthopedic disorders that could interfere with safe walking without an assistive device.”
Exclusion criteria:
participants who averaged >7500 steps/day, postmenopausal, taking medication known to affect blood pressure or being pregnant.
Interventions IG_LB: walking (long bout) group:
  • Duration: 30 minutes/session

  • Frequency: 1 session/day, 5 days/week

  • Intensity: moderate walking pace, 60% to 70% heart rate reserve

  • Intervention period: 8 weeks


IG_SB: Walking (short bout) group:
  • Duration: 10 minutes/session,

  • Frequency: 3 sessions/day, 5 days/week

  • Intensity: moderate walking pace, 60% to 70% heart rate reserve

  • Intervention period: 8 weeks

  • Pedometer: Yes

  • Facilitator: NR


CG: Control group: maintaining normal physical activity levels and diet during the 8‐week intervention period.
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement method: participants measures of resting blood pressure with a mercury sphygmomanometer and stethoscope.
Primary/Main outcome of manuscript: physical activity assessed via steps=day obtained by pedometer. Fitness (6MWT)
Compliance/Adherence: completed ≥80% of the prescribed walking bouts
Adherence to prescribed intensity: Quote: "During week 8 of the walking program, 51.6% of the participants were in the recommended heart rate range of 60%–70% HRR, 38.7% of participants averaging below the recommended range and 9.7% of participants averaging above the recommended heart rate range. Average heart rate from week 4 of the intervention was not significantly different from the week 8 average heart rate (t=‐0.481, p=0.636). Week 4 and week 8 heart rate averages were positively correlated (r=0.564, p=0.015). The LB group followed recommended heart rate ranges with greater consistency than did the SB group (Table 3)."
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (This work was supported by funding from a College of Health Sciences Research Award and from a Career Development Award from the National Institute on Aging (K01AG025962))
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "participants deemed eligible were randomized to one of three study groups (control, LB, or SB group) and underwent initial pre‐intervention assessments." but no other details.
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Quote: "All educational materials, assessments, and follow‐up calls were scripted to have each participant receive the same information and treatment." but Unlikely that research personnel and participants blinded
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 11.7% (7 out of 60)
Quote: "Of the 60 women enrolled, 53 completed the study" "Of the 7 who did not complete the study, 1 was from the control group" (1/20, 5%), "3 were from the Short Bout group" (3/20, 15%), "and 3 were from the Long Bout group." (3/20, 15%)
refer to Table 1
ITT analysis
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Shenoy 2010.

Study characteristics
Methods Aim: to analyse the effects of 8 weeks of aerobic walking using a heart rate monitor (HRM) and pedometer for monitoring exercise intensity on glycaemic outcomes, fasting blood glucose (FBG), cardiovascular fitness and well‐being in type 2 diabetes patients.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 40 (20 in IG, 20 in CG)
No. completers: 40
Country: India
Study population: T2DM patients
Ethnicity: NR
Gender: male 73% (29/40)
Age: mean 53.15 (SD 4.4) in IG; 51.00 (SD 5.4) in CG
Smokers: NR
Hypertension: excluded if uncontrolled hypertension
Mean baseline BP:
SBP = 122 (SD 13.8) in IG, 131 (SD 12.7) in CG;
DBP = 85.6 (SD 16.1) in IG, 86.0 (SD 7.2) in CG;
Resting HR = 82.7 (SD 10.6) in IG; 81.0 (SD 9.7) in CG
Inclusion criteria:
Quote: “Diagnosed with type 2 diabetes, aged between 40 and 70 years, not taking insulin, without physical limitation, were not enrolled in other physical activity program previously or simultaneously and with the duration of diabetes between 1 and 10 years.”
Exclusion criteria:
Quote: "Evidence of coronary artery disease, uncontrolled hypertension, advanced retinopathy or neuropathy, severe orthopedic/cardiovascular/respiratory conditions restricting physical activity"
Interventions IG: Walking group: a pilot study was conducted to estimate an average steps they could walk at 50% to 60% of maximum heart rate in 30 minutes, counted for 3000 steps for most participants. Participants were informed and trained to be familiar with the intensity and the body work until they can self‐monitor the exercise intensity.A self‐recorded diary log reported steps count and RHR. Participants were asked to maintain their diet habit during the program and advised regarding eating 1 to 2 hours before exercise avoiding hypoglycaemia and maintaining hydration level.
  • Duration: 30‐minute/session

  • Intensity: moderate, 50% to 70% of maximum heart rate (at least 4000 steps in 35 to 40 min duration, up to 70% max HR in 8 weeks)

  • Frequency: 1 session/day, 5 days/week

  • Intevention period: 8 weeks

  • Pedometer: yes

  • Facilitator: yes


CG: Control group: no training but continued with medication as before and not engaged in any kind of active exercise intervention during the entire study period
Outcomes Review outcomes reported: SBP, DBP, resting HR
Measurement methods: blood pressure: Sphygmomanorneter‐Lifecare (N and B Medical Products Co.).
Heart rate: Polar S410™ heart rate monitor (CE0537, Finland).
Primary/Main outcome of manuscript: glycaemic outcomes, fasting blood glucose, cardiovascular fitness parameters and general well‐being
Adverse event: NR
Notes Trial registration: NCT01293253
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly assigned to one of the following two groups by a random lottery approach: the experimental group (group A) or control group (group B)" but no further details
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Unlikely that research personnel and participants blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk No dropout
ITT analysis; Start of study: Intervention n = 20, Control n = 20; At follow‐up: Intervention n = 20/20 = 100%, Control n = 20/20 =100%
refer to Table 2
Selective reporting (reporting bias) Low risk Reported measurement at 8 weeks
Only 1 analysis
ITT analysis
Other bias Low risk No other bias

Stanton 1996.

Study characteristics
Methods Aim: the effect of moderate exercise (three 40‐minute sessions of brisk walking a week for 6 months) on mood state in sedentary, mildly hypertensive volunteers.
Design: parallel 4‐group RCT
Power/sample size calculation: yes (Thesis 7.1.10 Statistical Power)
Participants No. randomised: 102 (53 in IG, 49 in CG);
(55 in exercise + salt restriction and 51 in Salt restriction only excluded)
No. completers: 89
Country: New Zealand
Study population: mild hypertensive adults (recruited through participants’ general practitioners and through advertisements in community newspapers)
Ethnicity: European (n = 179, 99%), Pacific Island (n = 1, 1%), Chinese (n = 1, 1%) (from Thesis Table 8.3)
Gender: male: 52% (95/181; 181 refers to the overall completers only from four groups)
Age: mean 55.2 (SE 1.4) in IG, CG:53.8 (SE 1.5) in CG, range 26 to 71)
Smokers: 13/181 (181 refers to the overall completers from four groups; from thesis Table 8.3)
Hypertension: 100% essential hypertension
Mean baseline BP: (From Thesis Table 8.8)
SBP = 142.9 (SE 2.5) in IG, 145.3 (SE 2.6) in CG;
DBP = 88.4 (SE 1.4) in IG, 94.0 (SE 1.4) in CG.
Inclusion criteria:
Quote: “Essential hypertension, aged between 20 and 69 inclusive, a sedentary lifestyle, and being managed by a primary care doctor.”
Exclusion criteria:
Quote: “Symptomatic coronary heart disease, immobility that restricted walking, current diastolic blood pressure greater than 105 mmHg or a systolic blood pressure greater than 180 mmHg, and currently performing regular moderate activity. This excluded persons who were involved in more than 2 hours of moderate leisure time activity per week other than housework or gardening.”
Interventions Extracted from Thesis:
IG: Walking (exercise) group (Group B): brisk walking. A weekly diary was used to note health problems experienced during the week as well as compliance with medication.
  • Duration: 40 minutes/session

  • Intensity: moderate (Table 2)

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 26 weeks

  • Pedometer: NR

  • Facilitator: NR


CG: Control group (Group D)
Note: Group A Exercise + salt restriction and Group C Salt restriction excluded
Outcomes Review outcomes reported: SBP, DBP
Measurement methods: blood measured with Hawksley random zero sphygmomanometer
Primary/Main outcome of manuscript: mood state (measured at baseline and week‐26)
Adverse event: NR
Notes Trial registration: Auckland Blood Pressure Control Study
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "Participants were randomised at the time of the baseline interview..." Thesis section 7.1.3 Randomisation
Balance baseline characteristics in Thesis Table 8.8
Allocation concealment (selection bias) Low risk Quote: "Participants were randomised at the time of the baseline interview..." Thesis section 7.1.3 Randomisation
Balance baseline characteristics in Thesis Table 8.8
Blinding of participants and personnel (performance bias)
All outcomes Low risk Quote: "Therefore the doctors were unblinded ..." Thesis 7.1.3 Randomisation
"The participants in the four intervention sub‐groups were thus blind to each other's intervention." p.152
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
BP measured blindly
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.7% (13 out of 102)
181 (87%) completed the study, 177 (85%) completed the primary outcome measurement
Group B. Exercise only: 46/53, 87% completed
Group D. Control: 43/49, 88% completed
refer to thesis and table I, II
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 26 weeks
Only 1 analysis
Other bias Low risk No other bias

Stutzman 2010.

Study characteristics
Methods Aim: to measure the effects of a 16‐week low‐intensity walking program in healthy, normal weight, and overweight/obese pregnant women on BP, heart rate variability (HRV), and BRS.
Design: Parallel 2‐group RCT
Power/sample size calculation: Yes
Participants No. randomised: 25 (2 excluded & 1 withdraw after randomisation; 11 in IG [normal = 5, overweight = 6], 11 in CG [normal = 5, overweight = 6])
No. completers: 22
Country: Canada
Study population: healthy women who were 20 weeks pregnant
Ethnicity: NR
Gender: male 0% (0/22)
Age: mean 30.4 (SD 4.2) in IG_norm, 28.8 (SD 6.9) in IG_overweight; 25.8 (SD 3.0) in CG_norm, 26.2 (SD 5.6) in CG_overweight, ranged between 20 and 69 inclusive
Smokers: non‐smoker during pregnancy
Hypertension: 0%
Mean baseline BP:
SBP = 111 (SD 12) in IG_norm, 114 (SD 14) in IG_overweight; 109 (SD 7) in CG_norm, 107 (SD 8) in CG_overweight,
DBP = 76 (SD 11) in IG_norm, 75 (SD 10) in IG_overweight; 74 (SD 4) in CG_norm, 72 (SD 4) in CG_overweight
Inclusion criteria:
healthy pregnant women at 20 (+ 2) weeks gestational age met the inclusion criteria of:
(a) singleton pregnancy,
(b) sedentary lifestyle (defined as ≤ 2 sessions of aerobic exercise per week, and
(c) approval of the attending physician.
Exclusion criteria:
"(a) alcohol or drug dependence,
(b) hypertension, diabetes, or comorbid medical conditions, or reasons that contraindicated exercise,
(c) cigarette smoking during pregnancy, and
(d) medical reasons or treatments that would confound the measurement of HRV and BRS."
Interventions 1. Walking group:
IG_overweight: overweight,
IG_norm: Normal weight
Walking groups received verbal and written instructions for a 16‐week, progressive, low‐intensity walking program, an walking log, and the Borg 15‐point (6 to 20) RPE scale. Single bout. Activity log was collected at completion of the 16‐week period, and biweekly call or email from the researcher was provided to answer any questions and to assess/promote compliance.
  • Duration: self‐paced, graduated from 0.6km/day to 3.0km/day by week 16

  • Intensity: low, <40% of the heart rate reserve with RPE 11 to 13 on Borg scale; taught participants how to monitor their HR response to exercise by radial artery palpation

  • Frequency: 5 sessions/week

  • Intervention period: 16 weeks

  • Pedometer: no

  • Facilitator: yes, on the first day of the walking program.


2. Control group:
CG_overweight : overweight
CG_norm: normal weight
An activity log to record daily physical activity was given and collected at completion of the 16‐week period. Biweekly call or email from the researcher was provided to answer any questions and to assess/promote compliance.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: maternal BP (arm) and HR were measured using a BpTRU (Model BPM‐300, VSM MedTech Ltd., Coquitlam, BC, Canada) BP monitor.
Primary/Main outcome of manuscript: BP pressure, HRV, and baroreflex sensitivity (BRS)
Compliance/Adherence: at least three exercise sessions per week.
Adverse event: NR
Notes Trial registration: NR
Funding sources: None
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk By minimization method: quote: "Participants were assigned to one of four groups based on exercise group and BMI category. The first two subjects within each weight group, normal or overweight/obese, were randomized by coin toss to either an exercise (walking) group or a non‐exercise control group. Subsequent participants were then assigned to either the exercise (walking) group (n=11) or the non‐exercise control group (n=11) based on BMI so that the weight categories were equally represented in each exercise group."
refer to Table 1
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Unlikely that research personnel and participants blinded
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12% (3 out of 25)
refer to table 1, 2
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 16 weeks
Only 1 analysis
Other bias Low risk No other bias

Tudor‐Locke 2004.

Study characteristics
Methods Aim: examining the effectiveness of the FSP (First Step Program) with a larger sample and a control group, also examining whether increased PA (Physical activity) was related to improvements in cardiovascular health, glycaemic control and lipid profiles.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised:60 (30 in IG, 30 in CG)
No. completers: 47
Country: Canada
Study population: sedentary overweight T2DM patients
Ethnicity: NR
Gender: male 55% (26/47)
Age: range 40 to 60; mean 52.7 (SD 5.2); 52.8 (SD 5.7) in IG, 52.5 (SD 4.8) in CG
Smokers: 68% quote: "17% of the participants smoked cigarettes regularly, 13% smoked occasionally, 38% were former smokers "
Hypertension: quote: "55% of total sample"
Mean baseline BP:
SBP = 138.2 (SD 17.2) in IG, 130.1 (SD 15.9) in CG;
DBP = 81.5 (SD 9.5) in IG, 78.9 (SD 8.0) in CG;
Resting HR = 76.4 (SD 11.8) in IG, 77.0 (SD 9.7) in CG. (n = 47 completers)
Inclusion criteria:
“(1) aged 40 to 60 years;
(2) minimum 3 months post diagnosis of type II diabetes;
(3) treated by diet alone or by oral hypoglycaemic medications (not insulin);
(4) no PA limitations or documented heart conditions;
(5) not currently in an exercise program; and
(6) < 8800 steps/day (defined as insufficiently active determined via a 3‐day, blinded pedometer protocol)”
Exclusion criteria: NR
Interventions IG: walking (FSP) group:
Four weekly group meetings were held during the adoption phase (initial 4 weeks), participants were given pedometers and the program manual containing goal‐setting and problem‐solving exercises, as well as calendars for self‐monitoring steps/day. During the adherence phase (subsequent 12 weeks), participants were asked to use their pedometers and calendars for goal‐setting and self‐monitoring. No specific advise concerning diet or glycerol control was given. Thanking postcards were mailed at 6 and at 10 weeks. Pedometers and calendars were returned at the 16‐week assessment. Accumulated walking steps per day were calculated.
  • Duration: self‐set goal of daily step and walking time

  • Intensity: NR

  • Frequency: 7 days/week

  • Intervention period: 16 weeks

  • Pedometer: yes

  • Facilitator: yes, PA experts


CG: Control group: wait‐list control group
Outcomes Review outcomes reported: resting HR, SBP, DBP
Measurement method: resting HR and BP were measured by a registered nurse. (method not mentioned)
Primary/Main outcome of manuscript: daily PA assessed by pedometer (steps/day).
Adverse event: quote: "No FSP participants reported having noteworthy musculoskeletal pain or problems during the intervention."
Notes Trial registration: NR
note: adoption phase (week 1 to 4), adherence phase (week 5 to 16)
Funding sources: private sector (This project was supported by a grant from the Canadian Diabetes Association. Additional support for the development of First Step Program educational resources was provided by a Canadian Diabetes Association Award supported by Bayer Corporation.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "Those individuals who agreed to participate were randomly assigned to either the First Step Program (FSP) group or the wait‐list control group (CONTROL)" but no further details about randomisation.
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Blinding of participants and personnel not possible
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 21.7% in 16‐week follow‐up (13 out of 60), 6 as 20.0% in TG and 7 as 23.3% in CG
Dropout 36.7% in 24‐week follow‐up (22 out of 60), 14 as 46.7% in TG and 8 as 26.7% in CG
47 completers analysis only
47/60 = 78.3% randomised (baseline/outcome)
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 16 weeks
Only 1 analysis
Other bias Low risk No other bias

Tudor‐Locke 2020.

Study characteristics
Methods Aim: to evaluate these potential effects in sedentary/low‐active postmenopausal women randomised to a usual behaviour control group or one of the 2 lifestyle step‐counting walking interventions (basic vs enhanced; differing only on their discrepant emphases on physical activity intensity)
Design: parallel 3‐group RCT (50:50:20)
Power/sample size calculation: yes
Participants No. randomised: 120 (50 in IG1, 50 in IG2, 20 in CG)
No. completers: 115
Country: USA
Study population: non‐exercising, overweight/obese and postmenopausal women (45 to 75 years)
Ethnicity: white 75.5% in IG1, 76.6% in IG2, and 52.6% in CG.
Black 22.5% in IG1, 19.2% in IG2, and 47.4% in CG.
Other 2.0% in IG1, 4.3% in IG2, and 0% in CG
Gender: male 0%
Age: mean 62.6 (SD 6.5) in IG1, 61.7 (SD 6.2) in IG2, 58.4 (SD 5.8) in CG
Smokers: yes (0% in IG1, 6.4% in IG2, and 0% in CG)
Hypertension: yes (26.5% in IG1, 12.8% in IG2, and 15.8% in CG.)
Mean baseline BP:
SBP = 127.6 (SD 16.6) in IG1, 125.2 (SD 12.7) in IG2, 122.5 (SD 13.9) in CG.
DBP = 78.7 (SD 8.0) in IG1,75.5 (SD 7.6) in IG2, 77.3 (SD 7.3) in CG
Inclusion criteria:
  1. non‐exercising (assessed initially via self‐report of regular exercise habits over the past 6 months),

  2. overweight/obese ([BMI], 25 kg/m2 to 45 kg/m2 or waist circumference, > 88 cm),

  3. postmenopausal women,

  4. aged 45 to75 years,

  5. Taking less than 7500 steps per day during a screening assessment with an NL‐1000 was indicative of a sedentary lifestyle,

  6. BP <180/< 100 mmHg,

  7. type 2 diabetes, who were not currently taking insulin, had glucose control within acceptable limits


Exclusion criteria:
significant cardiovascular disease/disorders (including diabetes) or other significant medical conditions considered life‐threatening, potentially interfering with or being aggravated by exercise, donating blood before 6 weeks of study, losing ≥ 20 kg in the previous year of study, having been hospitalised for mental illness within the previous 5 years of study, or planning to be out of the area for more than 3 weeks over the next 3 months after study commenced.
Interventions All intervention participants monitored their daily step counts and walking behaviour using the NL‐1000 accelerometer (New Lifestyle Inc, Lee's Summit, MO) and calendars (to record steps per day). Steps per day and active minutes derived from the NL‐1000 are reported as process variables for both intervention arms, indicative of program adherence.
IG1: Basic walking group:
In addition to the walking step goal, participants also attended weekly meetings to engage in intervention‐supported behavioural feedback, reflection, and goal setting for the subsequent week.
  • Duration: at least 10,000 step/day

  • Intensity: (no direction provided with regard to walking intensity/speed/cadence)

  • Frequency: 7 days/week and mean 3.5 (SD 2.2) days per week as a result

  • Intervention period: 12 weeks

  • Pedometer: yes, NL‐1000 accelerometer (New Lifestyle Inc, Lee's Summit, MO) and used calendars to record steps per day;

  • Facilitator: NR


IG2: Enhanced walking group:
Participants were instructed on how to count their cadence while walking a set time and experience what walking at a cadence of at least 100 steps per minute felt like.
  • Duration: at least 10,000 steps per day + a daily goal of 30 active minutes by taking at least 3,000 to 4,000 of their 10,000 steps per day + at least 100 steps per minute to reach a moderate intensity.

  • Intensity: (please see above)

  • Frequency: 7 days/week and mean 3.4 (SD 2.1) days per week as a result

  • Intervention period: 12 weeks

  • Pedometer: yes, NL‐1000 accelerometer (New Lifestyle Inc, Lee's Summit, MO)

  • Facilitator: NR


CG: Control group: continued with normal routines and lifestyle, and participated to the baseline and 3‐month assessments.
Outcomes Review outcomes reported: SBP and DBP
Measurement method: NR, outcomes were measured at baseline and after 12‐week intervention.
Primary/Main outcome of manuscript: BP, anthropometric measurements (height, weight, and waist circumference), fasting blood glucose and insulin, flow‐mediated dilation and gait speed.
Compliance/Adherence: defined by average weekly values for steps per day and/or active minutes. 96.0% (9,602/10,000*100%) in basic walking group and 100.0% (10,508/10,000*100%) in enhanced walking group.
Adverse event: 1 dropout due to knee pain, in Consort chart
Notes Trial registration: ClinicalTrials.gov (NCT01519583)
Funding sources: American Heart Association and National Institutes of Health (center grants: P30 DK072476 and U54 GM104940)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "Enrolled participants were randomly assigned" on the basis of "computer‐generated program". A biostatistician oversees the computer‐generated program that were used to randomly assign participants to groups.
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk The Principal Investigator were blinded to participants' randomised allocation status but participants were unlikely to be blinded to their allocation status.
Blinding of outcome assessment (detection bias)
All outcomes Low risk The assessment staff were blinded to participants' randomised allocation status.
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 4.2% (5 out of 120 dropouts)
4 out of 100 (4.0%) in IG, 1 out of 20 (5%) in CG
refer to Table 1
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 3 months
Only 1 analysis
Other bias Low risk No other bias

Tully 2005.

Study characteristics
Methods Aim: to examine the effects of 30‐minute self‐paced, non‐supervised, brisk walking, 5 days per week on traditional cardiovascular risk factors (BP, BMI, cholesterol), Framingham risk score, and fitness in people aged 50–65 years.
Design: parallel 2‐group RCT (2:1)
Power/sample size calculation: NR
Participants No. randomised: 31 (21 in IG, 10 in CG)
No. completers: 26
Country: UK
Study population: sedentary middle‐aged adults from urban GP
Ethnicity: NR
Gender: male 42% (13/31)
Age: mean 55.52 (SD 3.99) in IG; 57.75 (SD 4.64) in CG; range 50 to 65.
Smokers: NR
Hypertension: no quote:"severe, uncontrolled hypertension"
Mean Baseline BP:
SBP = 129.94 (SD 8.61) in IG,125.78 (SD 14.02) in CG;
DBP = 78.47 (SD 4.16) in IG, 77.22 (SD 7.74) in CG
Inclusion criteria: quote:“Individuals aged between 50 and 65 years, with no history of (1) coronary heart disease, (2) peripheral vascular disease, (3) musculoskeletal disease, (4) pulmonary disease, (5) diabetes mellitus, or (6) severe, uncontrolled hypertension.”
Exclusion criteria:
Quote:“Individuals who were currently prescribed lipid lowering medication, had a body mass index (BMI) over 35 kg/m2, or blood pressure (BP) greater than 140/90 mmHg were excluded.
Females who were postmenopausal (no menstrual period in the last 12 months) and had begun taking hormone replacement therapy in the previous 3 months were excluded.”
Interventions IG: Brisk walking group:
  • Duration: 30‐minute/session, or multiple at least 10‐minute/session (accumulated 30 minutes/day)

  • Intensity: slightly breathless but still able to converse

  • Frequency: 5 days/week

  • Intervention period: 12 weeks

  • Pedometer: yes, Oregon Scientific PE316CA

  • Facilitator: No


CG: Control group: participants were asked to maintain their habitual lifestyle and not change their activity. They were also given a diary and asked to record any exercise they performed over the 12 weeks.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: blood pressure was measured using a standardised auscultation procedure
Primary/Main outcome of manuscript: body composition, blood pressure, functional capacity, blood lipids, and Framingham risk score.
Compliance/Adherence: defined by expressing the number of minutes walked as a percentage of the number of minutes prescribed by the protocol
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"using computer‐generated random numbers on a 2:1 basis. "
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Blinding of participants and personnel not possible
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote:"Baseline anthropometric and functional capacity measurements were made by observers blinded to individual's group allocation."
Incomplete outcome data (attrition bias)
All outcomes Unclear risk Dropout 16.1% (5 out of 31)
4 out of 21 (19%) in IG, 1 out of 10 (10%) in CG dropouts
based on 26 completers analysis only
26 out of 31 randomised (baseline/outcome)
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Tully 2007a.

Study characteristics
Methods Aim: to determine the effects of unsupervised home‐based walking at and below the current recommended level of exercise on cardiovascular risk factors and functional capacity in healthy sedentary adults, using pedometers for self‐monitoring.
Design: parallel 3‐group RCT (2:2:1)
Power/sample size calculation: Yes
Participants No. randomised: 106 (44 in IG1_3D, 42 in IG2_5D, 20 in CG)
No. completers: 93
Country: UK
Study population: sedentary middle‐aged adults (civil servants) (aged 40 to 61) (email invitation to employees from Northern Ireland Civil Service <NICS> departments.)
Ethnicity: NR
Gender: male 39.6% (42/106)
Age: mean 47.8 (SD 5.97) in IG1_3D, 46.37 (SD 4.76) in IG2_5D, 49.05 (SD 6.31) in CG
Smokers: NR
Hypertension: 0%
Mean baseline BP:
SBP = 134 (SD 15) in IG1_3D, 133 (SD 15) in IG2_5D, 128 (SD 15) in CG;
DBP = 87 (SD 11) in IG1_3D, 87 (SD 11) in IG2_5D, 83 (SD 10) in CG
HR = 69 (SD 12) in IG1_3D, 72 (SD 10) in IG2_5D, 75 (SD 11) in CG
Inclusion criteria:
aged 40 and order, quote:“sedentary (defined by self‐reported as not having undertaken more than one session of moderate intensity exercise each week over the past six months), blood pressure less than 140/90 mmHg; no history of musculoskeletal, pulmonary, or cardiac disease that would limit the ability to exercise; and taking no drugs with effects on lipid metabolism”
Exclusion criteria: NR
Interventions IG_3D: Walking (3‐day) group
  • Duration: 30‐minute/session, or multiple at least 10‐minute/session (accumulated 30 minutes/day)

  • Intensity: mild shortness of breath (Borg scale 0 to 10)

  • Frequency: 3 days/week

  • Intervention period: 12 weeks


IG_5D: walking (5‐day) group
  • Duration: 30‐minute/session, or multiple at least 10‐minute/session (accumulated 30 minutes/day)

  • Intensity: mild shortness of breath (Borg scale 0 to 10)

  • Frequency: 5 days/week

  • Intervention period: 12 weeks

  • Pedometer: yes

  • Facilitator: no


CG: Control group: participants were asked to maintain their current lifestyle for 12 weeks, and a self‐reported diary recording any exercise taken above what they would normally do.
Outcomes Review outcomes reported: SBP, DBP,HR
Measurement method: arterial blood pressure and heart rate were measured in the seated position after three minutes of rest, using a validated automatic sphygmomanometer (Omron Devices M5I, USA)
Primary/Main outcome of manuscript: BP, serum lipids, BMI, waist:hip ratio, and functional capacity
Compliance/Adherence: adherence was similar within the three day (89%) and the five day (83%) groups
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government(The researcher (MT) was supported by funding from the Department of Education and Learning NI.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"using computer generated random numbers"
refer to Table 1
Allocation concealment (selection bias) Low risk Quote:"The allocation was determined at a remote location..."
Blinding of participants and personnel (performance bias)
All outcomes High risk Blinding of participants and personnel is not possible.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote:"Baseline and 12 week samples were analysed at the same time, with blinding to the group allocation."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.3% (13 out of 106)
5 out of 44 (11.4%) in IG3d, 6 out of 42 (14.3%) in IG5d, 2 out of 20 (10%) in CG dropouts
refer to Figure 1 and Table 2
ITT analysis: quote:"Data were analysed using an intention to treat procedure, substituting baseline data for those at 12 weeks for the participants who withdrew during the study."
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Tully 2011.

Study characteristics
Methods Aim: to determine the effects of taking 10,000 steps per day on fitness and cardiovascular risk factors in sedentary university students.
Design: parallel 2‐group RCT (2:1)
Power/sample size calculation: Yes
Participants No. randomised: 12 (8 in IG, 4 in CG)
No. completers: 12
Country:UK
Study population: sedentary Queen’s University Belfast students
Ethnicity: NR
Gender: male 16.7% (2/12)
Age: mean 21.16 (SD 6.17)
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 120 (SD 15.62) in IG, 131.67 (SD 11.85) in CG;
DBP = 79.00 (SD 8.23) in IG, 86.33 (SD 8.50) in CG
Inclusion criteria:
sedentary students who were willing to participate in a walking program.
Exclusion criteria:
any known disease that would prevent from taking regular exercise.
Interventions All intervention and control group participants were asked to complete weekly diaries recording the number of steps they took per day, and returned to the researcher biweekly. The researcher would post new ones and phone or email participants to resolve any difficulties.
IG: walking (10,000 step) group:
  • Duration: accumulated 10,000 step/day

  • Intensity: NR

  • Frequency: 7 sessions/week

  • Intervention period: 6 weeks

  • Pedometer: yes

  • Facilitator: no


CG: Control group: wearing pedometer without modifying any aspect of lifestyle.
Outcomes Review outcomes reported: SBP, DBP
Measurement method:BP and HR were using a Digital Sphygmomanometer (Omron M5‐I, Japan).
Primary/Main outcome of manuscript: BP, exercise capacity, body composition.
Compliance/Adherence: measured as the number of days of data that was returned on the diaries as a percentage of the total number of days in the program
Adverse event: NR
Notes Trial registration: NR
Funding sources: Government (Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, Research and Development Office for the Northern Ireland Health and Social Services and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"using computer generated random numbers..."
refer to Table 1 (small sample size)
Allocation concealment (selection bias) Unclear risk Quote:"using computer generated random numbers by a researcher not involved in the day‐to‐day running of the trial."
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk No information
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote:"Measurements were made at baseline (pre‐intervention) and after 6 weeks (postintervention) in the university Physical Education Centre by the same researcher, who was blinded to the group allocation."
Incomplete outcome data (attrition bias)
All outcomes Low risk Quote:"All participants completed the trial."
"All participants in the 10,000 step group met their daily goal and significantly increased their daily step count over the course of the study (Table 2)."
ITT analysis
Selective reporting (reporting bias) Low risk Reported measurement at 6 weeks
Only 1 analysis
Other bias Low risk No other bias

Venturelli 2011.

Study characteristics
Methods Aim: the feasibility of an institution‐based walking program carried out together with family member caregivers could reduce the functional, cognitive, and physical decline of nursing home residents in the later stages of Alzheimer disease.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised: 24 (12 in IG, 12 in CG)
No. completers: 21
Country: Italy
Study population: late stage Alzheimer's disease patients (65+) in nursing home
Ethnicity: NR
Gender: male 0% (based on the inclusion criteria, 35 participants (5 men and 30 women) were selected; three caregivers declined and were excluded from the study; a multidisciplinary diagnostic evaluation team reviewed the clinical files of the 32 selected residents and excluded 7 (5 men and 2 women) because of severe heart disease, and another 1 due to reduced oxygen saturation during the walking test. Therefore all 24 participants are women.)
Age: mean 83 (SD 6) in IG, 85 (SD 5) in CG.
Smokers: NR
Hypertension: 16.7% (4/24)
Mean baseline BP:
SBP = 132 (SD 10) in IG; 133 (SD 6) in CG;
DBP = 84 (SD 5) in IG; 84 (SD 3) in CG.
Inclusion criteria:
quote:“65 years of age or older, dependent on assistance in 2 or more personal ADLs according to the Barthel index, Mini‐Mental State Examination (MMSE) maximum score of 15 and minimum of 5, and absence of mobility limitations, minimum score of 23, according to the Performance Oriented Mobility Assessment (POMA) index, and constant oxygen saturation during walking (SpO2 > 85%).”
Exclusion criteria:
severe heart disease and reduced oxygen saturation during the walking test.
Interventions IG: Walking group:
Single bout walking alone the hallway in the Alzheimer’s care unit (ACU). Cookie were offered after walking as positive psychological reinforcement. A walking log recording session times and number of laps was checked before and after each visit.
  • Duration: 30 minutes/session

  • Intensity: moderate

  • Frequency: 1 session/day, 4 days/week

  • Intervention period: 24 weeks

  • Pedometer: NR

  • Facilitator: yes, caregivers (Participants walked arm in arm with their caregivers (husbands, wives, sons, or daughters), and encouraged to walk with the fastest speed, while the caregivers were trained to walk in accordance to the participants' pace.)


CG: Control group: routine care. Nursing home residents in the control group participated in the daily organized activities like bingo, patchwork sewing, and music therapy.
Outcomes Review outcomes reported: SBP, DBP
Measurement method:DBP and SBP were measured using a standard sphygmomanometer device (Heine G7, Germany)
Primary/Main outcome of manuscript: cognitive function (MMSE), Barthel Index
Adverse event: 0
Quote: "No adverse events related to the exercise program were observed during the experiment period nor did any event influence participation in the sessions. One woman in the walking group left the study after 6 weeks due to a serious medical condition (stroke); 2 people in the control group (reduced from 12 to 10 participants) also left the program because of serious health problems (heart failure and stroke)."
Notes Trial registration: NR
Funding sources: none
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote: "using StatPlus for Macintosh, version 2009 (AnalystSoft Inc, Alexandria, Virginia)"
refer to Table 1 and 2
Allocation concealment (selection bias) Low risk Quote:"...The head nurse of the ACU (not involved in the residents' assessments) did the participants' randomization using StatPlus for Macintosh, version 2009 (AnalystSoft Inc, Alexandria, Virginia)."
Blinding of participants and personnel (performance bias)
All outcomes Low risk Quote:"...the members of the research team did not know to which group each participant had been assigned."
"No‐one on the research team was present during the walking exercise (afternoon); however, the head nurse of the ACU was always present. Before each intervention she checked the participants' health status and their ability to walk that day (exclusion criteria were fever, constipation treatment, low blood pressure, or other serious medical conditions)."
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote: "an evaluation was done before and after the experiment period in a blind way and the members of the research team did not know to which group each participant had been assigned.);"
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 12.5% (3 out of 24)
1 as 8.3% in TG and 2 as 16.7% in CG
Quote: "The walking group had a 93.4% + 3.2% presence at the 96 scheduled training sessions (90 + 2 training days); individual numbers of visits during the 24 weeks of the program are shown in Figure 2, panel B."‐ "
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 24 weeks
Only 1 analysis
Other bias Low risk No other bias

Wallis 2017.

Study characteristics
Methods Aim: to evaluate the effect of a dosed walking program on knee pain for patients with severe knee osteoarthritis (OA).
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised:46 (23 in IG, 23 in CG)
No. completers: 39
Country: Australia
Study population: severe OA patients rated as grade III or IV affecting at least one of the tibiofemoral compartments (50+)
Ethnicity: NR
Gender: male 56.5% (26/46)
Age: mean 68 (SD 8) in IG; 67 (SD 7) in CG
Smokers: 12 (26%) were current smokers
Hypertension: 60.9% (28/46)
Mean baseline BP:
SBP = 142 (SD 10) in IG, 138 (SD 24) in CG;
DBP = 82 (SD 10) in IG, 81 (SD 11.1) in CG
Inclusion criteria:
aged at least 50 years and living independently in the community; diagnosed with severe knee OA rated as grade III or IV affecting at least one of the tibiofemoral compartments determined radiographically; a cardiovascular risk profile with 2 total risk factors using stage 2 of the Adult Exercise Screening Tool; able to participate safely in the moderate‐intensity physical activity trial using stage 1 of the Adult Exercise Screening Tool; able to communicate in English.
Exclusion criteria:
lived in supported accommodation such as a nursing home; reported daily resting level of pain to be 9 or 10 on a 0 (no pain) to 10 (worst possible pain) Numerical Pain Rating Scale as this level of pain may be indicative of a more serious pathology; had high levels of psychological distress as measured by the Kessler 10 questionnaire with a K10 score >29; had a cognitive impairment measured by the Short Portable Mental Status Questionnaire with a score of 7 or less; had a systemic arthritic condition such as rheumatoid arthritis; had a neurological condition that affected walking; had knee surgery or intra‐articular corticosteroid injection within past six months; had used oral corticosteroids within 4 weeks.
Interventions IG: walking group:
No formal instructions on warming up or stretching were provided. Participants continued taking their usual medications and other non‐surgical treatments to manage their knee osteoarthritis and used normal assistive devices such as a cane.
  • Duration: in bouts of at least 10‐minute/sessions

  • Intensity: moderate intensity (Rate of Perceived Exertion Scale level 3 out of a 0 to 10)

  • Frequency: 7 sessions/week (70 minutes/week)

  • Intervention period: 12 weeks in the community

  • Pedometer: yes

  • Facilitator: quote: "...there was regular physiotherapy supervision and monitoring each week, including one‐to‐one supervised walking sessions or group supervised walking sessions based on patient preference..."


CG: Control group: usual care. Participants and their health professionals were advised with written information not to include a prescription of physical activity in the 12‐week study period.
Outcomes Review outcomes reported: SBP, DBP
Measurement method: resting SBP and DBP (mmHg) was measured using an electronic blood pressure machine in sitting.
Primary/Main outcome of manuscript: average knee pain
Compliance/Adherence: participants completed at least 9 out of 12 of the weekly dose of 70 minutes.
Adverse event: quote: "Three participants in the walking group had minor adverse events; two reported increased knee pain and were not able to continue the program after week 1, and one tripped during a supervised walking session and had to seek medical management due to knee pain. This participant continued the program following 2 days of rest. There were no serious adverse events." 3 knee pain were defined as minor adverse events as a short‐term exacerbation of a knee pain levels up to a week after the sessions, trips or falls without any serious sequelae or hospital admission.
Notes Trial registration: yes (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367588)
Funding sources: private sector (The research received $24,704 from La Trobe University's research focus area on Sport, Exercise and Rehabilitation.)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Quote:"using a permuted block design with a computer random number generator "
refer to Table 1
Allocation concealment (selection bias) Low risk Quote:"Participants were randomly assigned using a permuted block design with a computer random number generator using sealed opaque envelopes prepared by an independent researcher with no role in recruitment or assessment."
refer to Table 1
Blinding of participants and personnel (performance bias)
All outcomes Low risk Quote:"Intervention and control participants were non‐blinded to their group allocation" but possibly all participants were treated independently by their physicians who would not have knowledge of group allocation.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote:"The primary and secondary outcomes were collected at baseline and post‐intervention (week 13) by an assessor blinded to group allocation."
Incomplete outcome data (attrition bias)
All outcomes Low risk 1 out of 23 withdrew after randomisation
Dropout 15.2% (7/46)
7 out of 23 in IG (30.4%) , 0 out of 23 in CG dropouts
refer to Fig. 1
Both ITT and PP analysis done
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Wang (王正斌) 2014.

Study characteristics
Methods Aim: to explore the effects of walking exercise on glycometabolism, dynamic blood pressure and the quality of life of patients with both hypertension and type 2 diabetes on the basis of conventional drug treatment.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: no
Participants No. randomised: 62 (32 in IG, 30 in CG)
No. completers: 62
Country: China
Study population: cardiovascular clinic or hospitalised patients with both hypertension and type 2 diabetes (medicated)
Ethnicity: Chinese
Gender: male 62.9% ((20+19)/62)
Age: mean 55.8 (SD 9.3) in IG; 57.4 (SD 8.9) in CG
Smokers: No
Hypertension: 100%
Mean baseline BP:
SBP = 143 (SD 11) in IG, 141 (SD 14) in CG;
DBP = 81 (SD11) in IG, 88 (SD 9) in CG
Inclusion criteria:
  1. age between 40 to 70 years old;

  2. primary hypertension;

  3. diabetic mellitus (DM),

  4. basic step counts less then 5000 steps/day.


Exclusion criteria:
  1. secondary hypertension;

  2. moderate to severe hypertension with BP> 160/110 mmHg;

  3. uncontrolled DM;

  4. atrial or ventricular arrhythmia, tachycardia (HR> 100 bpm);

  5. acute myocarditis of pericarditis;

  6. acute coronary syndrome;

  7. thromboembolism;

  8. skeletomuscular disorders such as fracture, osteoarthritis, or joint injury refrained from exercise;

  9. complex diagnosis with CVA, malignant tumour, or predicted lifespan less than 1 year.

Interventions IG: walking exercise group:
Participants had to walk more than 10,000 steps per day regardless of duration or intensity, but should avoid arduous exercise that could result in fatigue in the next day. Diabetes reminder with personal information and sugar products or chocolate should be carried at all time. When hypoglycaemic syndrome such as dizziness, palpitation, and hunger was occurred, participants should suspend walking and have some sugar. Another situation to suspend walking was when blood pressure was elevated, and participants should undergo medical treatment immediately. When chest tightness and asthma were happened during walking, participants should take rest and decrease walking intensity in accordance with their health situation.
  • Duration: more than 10,000 steps/day

  • Intensity: NR

  • Frequency: 7 sessions/week

  • Intervention period: 12 weeks

  • Pedometer: Yes, Omron HJ‐005 (wore everyday and return to the researcher for recording data monthly)

  • Facilitator: NR


CG: Control group: conventional drug treatment and community care
Outcomes Review outcomes reported: dynamic blood pressure parameters
Measurement method: blood pressure was taken by CB2300A (Wusih) ambulatory blood pressure monitor before and after 3‐month intervention. Blood pressure monitor cuff belt was tightened on right upper arm, measure interval was 20 minutes in the daytime (0600 to 2200) and 30 minutes at night (2201 to 0559). On measurement day, there was no activity restriction but participants should record any activity of that day and avoid smoke as well as alcohol beverage. Effective data of SBP 70 to 220 mmHg, DBP 40 to 130 mmHg, and pulse pressure 20 to 110mmHg were recorded, otherwise were taken as ineffective and abandoned.
Primary/Main outcome of manuscript: fasting plasma glucose, glycated haemoglobin‐A1C, fasting insulin, the homeostasis model of assessment for insulin resistance index, the homeostasis model of assessment for insulin sensitivity, dynamic blood pressure parameters and quality of life.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk "Quote:randomly divided" using "random number table" but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 0% (0/62)
32 completers in exercise group, 30 completers in control group
refer to table 1 to 3
ITT analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 3 months
Only 1 analysis
Other bias Low risk No other bias

Wang (王聰) 2016.

Study characteristics
Methods Aim: to discuss the influences of 8 weeks of walking and health education on blood pressure..
Design: parallel 4‐group RCT (1:1:1:1)
Power/sample size calculation: yes
Participants No. randomised: 61 (31 in IG, 30 in CG)
(31 in Health Education only and 32 in Walking+Health Education groups excluded)
No. completers: 48
Country: China
Study population: hypertensive patients (from Datong Coal Mine Group central factory)
Ethnicity: Chinese
Gender: male 64.6% ((21+10)/48)
Age: Range 18 to 64; mean 49.61 (SD 4.91) in IG, 48.50 (SD 6.31) in CG.
Smokers: yes (44.5% in IG; 46.6% in CG)
Hypertension: 100%
Mean baseline BP:
SBP = 134.83 (SD 17.43) in IG, 143.97 (SD 20.91) in CG.
DBP = 82.39 (SD 12.94) in IG, 87.63 (SD 10.48) in CG
Inclusion criteria:
  1. hypertension class Ⅰ (140 to 159/90 to 99 mmHg) and class Ⅱ (160 to 179/110 to 109 mmHg) patients,

  2. age between 18 to 64, working above the well


Exclusion criteria:
  1. hypertension class Ⅲ patients with resting BP 180/110 mmHg,

  2. hypertension complications including cerebrovascular disease, heart failure, chronic renal failure and severe retinopathy; or hypertension comorbidity such as diabetes and coronary syndrome,

  3. skeletomuscular injuries as jointitis or muscle soreness.

Interventions IG: walking group:
  • Duration: mean 55.74 (SD 4.34) minutes/session

  • Intensity: 70% HRmax by heart rate monitor watch to keep heart rate at target intensity during walk

  • Frequency: 5 sessions/week (total: 42 sessions)

  • Intervention period: 8 weeks

  • Pedometer: yes

  • Facilitator: NR


CG: Control group: no intervention control
Note: a total of four groups and two groups excluded: 1.walking + health education on exercise and diet 2.health education on exercise and diet only
Outcomes Review outcomes reported: BP
Measurement method: participants were sitting and resting for at least 10 minutes, and Omron HEM‐1000 electronic sphygmograph was used to measure twice with interval of 1 to 2 minutes. The average of the two measurement was taken for analysis, but if the difference of the two measurement was more than 5mmHg, whether SBP or DBP, the third measurement was taken and averaged with the two for analysis.
Primary/Main outcome of manuscript:BP
Compliance/Adherence: adherence rate to 42 walking session: 76.9% (mean 32.28 (SD 7.97)) in walking IG and 87.6% (mean 36.78 (SD 5.79)) in walking plus health education IG.
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote:"randomly divided" but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes High risk Dropout 21.31%, 13/61: 13/31 in walking group (41.94%), 0 (30/30) in control group dropouts
18 out of 31 completers in walking group, 30 completer in control group
refer to table 1, 2
PP analysis
High risk due to high attrition rate in walking group
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 8 weeks
Only 1 analysis
Other bias Low risk No other bias

Wang 2014.

Study characteristics
Methods Aim: to explore the overall effects of a supervised endurance‐exercise training program on the risk components of MS, serum IL‐6 levels, and exercise capacity of postmenopausal women
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised:53 (7 withdrawn, resulting23 in IG, 23 in CG)
No. completers: 46
Country: Taiwan
Study population: sedentary postmenopausal women from general population (aged 45 to 70)
Ethnicity: Chinese
Gender: male 0%
Age: mean 56.9 (SD6.2) in IG, 55.1 (SD7.8) in CG, range 45 to 70 (46 completers only)
Smokers: 0%
Hypertension: 0%
Mean baseline BP:
SBP =124.6 (SD 9.2) in IG, 127 (SD 10.1) in CG;
DBP = 76.8 (SD8.1) in IG, 79 (SD 9.4) in CG
(46 completers only)
Inclusion criteria:
  1. postmenopausal women aged 45 to 70 years;

  2. a sedentary lifestyle (not exercising > 30 minutes on >3 days/week) for the past 6 months; and

  3. not taking any medication including lipid‐lowering agents, nonsteroidal antiinflammatory drugs, antihypertension drugs, and hormone‐replacement therapy.


Exclusion criteria:
  1. the presence of chronic heart failure;

  2. a positive history or clinical signs of ischaemic heart disease;

  3. diabetes mellitus (fasting glycaemia > 126 mg/dL);

  4. systolic blood pressure (SBP) > 160 mmHg or diastolic blood pressure (DBP) > 100 mmHg; and

  5. orthopedic limitations.

Interventions IG: walking group:
Treadmill walking 3 times/week for 12 weeks in a laboratory near the metabolic and cardiovascular outpatient department of the study hospital. Exercise training began with 10 min of warming up and ended with 10 minutes of cooling down.
  • Duration: 30 minutes/session

  • Intensity: 60% to 80% of HRR

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: yes, by one of research staff members


CG: Control group: maintain customary lifestyle
Outcomes Review outcomes reported: SBP, DBP
Measurement method: BP was measured using a calibrated automated oscillometric blood‐pressure monitor (Datascope, Mahwah, NJ, USA).
Primary/Main outcome of manuscript: exercise capacity, interleukin‐6 level
Compliance/Adherence: dividing the number of attendances by the total of 36 training sessions
Adverse event: NR
Notes Trial registration: NR
Funding sources: none
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk refer to Table 1, 46 completers only
Quote: "No statistically significant differences were observed in basic characteristics or in the data on the study variables between the exercise and control groups at baseline (Table 1)."
Allocation concealment (selection bias) Unclear risk No information
refer to Table 1, 46 completers only
Blinding of participants and personnel (performance bias)
All outcomes Unclear risk Quote: "The individual‐based exercise training program was supervised by one of our research staff members."
Not sure if the research staff had other role in the trial.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes
Quote: "Study variables were measured by one of the members of our research staff, who was unaware of the group allocation of the participants."
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 7 out of 53 (13.2%).
Quote: "Those who withdrew said they were too busy (n=3),had to care for family members (n=3), or had fallen ill (n=1)."
"The adherence rate of exercise participants was calculated by dividing the number of attendances by the total of 36 training sessions; the mean adherence rate was measured to be 98% in the exercise group."
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Westhoff 2007.

Study characteristics
Methods Aim: the impact of pulse pressure on the cardiovascular effects of a 12‐week aerobic physical exercise program in elderly hypertensives.
Design: Parallel 2‐group RCT (1:1)
Power/sample size calculation: yes
Participants No. randomised: 54 (27 in IG, 27 in CG)
No. completers: 51
Country: Germany
Study population: sedentary Isolated Systolic Hypertension elderly patient (aged 60+) (hypertensive outpatient clinic)
Ethnicity: NR
Gender: male 48% (26/54)
Age: mean 67.2 (SD 4.8) in IG, 68.9 (SD 5.2) in CG.
Smokers: 7.4% (4/54)
Hypertension: 100%
Mean baseline BP:
systolic ABP = 136.6 (SD 12.7) in IG, 134.8 (SD 11) in CG;
diastolic ABP = 76.3 (SD 7.3) in IG, 72.8 (SD 7.2) in CG.
Inclusion criteria:
Quote: "current antihypertensive treatment, diastolic ambulatory blood pressure (ABP) ≤ 90 mmHg, age of ≥ 60 years."
Exclusion criteria:
Quote: "regular engagement in physical exercise training in the past 12 weeks prior to inclusion in the study, symptomatic peripheral arterial occlusive disease, aortic insufficiency or stenosis >stage I, hypertrophic obstructive cardiomyopathy, congestive heart failure (>NYHA II), uncontrolled cardiac arrhythmia with haemodynamic relevance, systolic office BP≥180 mmHg, signs of acute ischaemia in exercise ECG, change of antihypertensive medication in the past 6 weeks prior to inclusion in the study or during follow‐up period"
Interventions IG: walking (exercise) group:
treadmill walking. During the first week, training consisted of 5 workloads of 3 minutes; between workloads, patients walked with half‐speed for 3 minutes. Exercise duration was gradually increased and reached 30, 32, and 36 minutes in the sixth and further weeks and was carried out without interruption. As exercise heart rate decreased by more than 5/minute as a result of training adaptation, treadmill speed was increased by 0.5 km/hour or elevation was increased by 3% to maintain training intensity.
  • Duration: exercise duration was gradually increased and reached 30, 32, and 36 minutes in the sixth and further weeks and was carried out without interruption

  • Intensity: Lactate concentration of 2.5 ±0.5 mmol/L in capillary blood slightly above the aerobic threshold

  • Frequency: 1 session/day, 3 days/week

  • Intervention period: 12 weeks

  • Pedometer: NR

  • Facilitator: yes, by a physician


CG: Control group: sedentary activity and usual care of accurate drug intake.
Outcomes Review outcomes reported: 24‐hour ABP, exercise BP
Measurement method: 24‐Hour ABP monitoring was performed using Spacelabs 90207 monitors (Spacelabs, Redmond, Wash., USA).
Primary/Main outcome of manuscript: 24‐hour ABP, pulse pressure, arterial compliance and endothelial function
Adverse event:
Quote:"One patient stopped within the first session due to knee pain, 1 patient discontinued the program after 4 weeks due to acute cholecystitis, and 1 patient had a change of medication within the observation period."
Quote: "In the control group, 4 patients denied to redo the treadmill stress test. In these cases, the last observations of the treadmill test were carried forward."
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "According to these criteria, 54 patients (27 male, 27 female) were enrolled and randomized to exercise and control group by lot ( fig. 1 )." but no other details about randomisation.
Characteristics of study groups are identical (Table 1)
Allocation concealment (selection bias) Unclear risk No information
Blinding of participants and personnel (performance bias)
All outcomes High risk Blinding of participants and personnel not possible
Quote: "During training, patients were continuously supervised by a physician."
Not sure if there was other co‐intervention provided in the training process.
Blinding of outcome assessment (detection bias)
All outcomes Low risk Objective outcomes: ambulatory blood pressure monitoring
Quote: "The American College of Sports Medicine criticizes that in most studies on endurance training, BP was not measured by a blinded observer or an automated device and emphasizes the need for studies using 24‐hour ABP monitoring [28]. We complied with this recommendation”
Quote: "The computer‐assisted calculation of vessel diameters was conducted in a blinded fashion as published previously [21, 22]”
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 5.6% (3 out of 54)
3/27=11.1% in exercise group and 0/27 = 0% in control group
PP analysis
Selective reporting (reporting bias) Low risk Reported measurement at 12 weeks
Only 1 analysis
Other bias Low risk No other bias

Xiao (肖卉) 2010.

Study characteristics
Methods Aim: to investigate the effects of exercise on blood glucose and blood pressure in elderly diabetes patients.
Design: parallel 2‐group RCT (1:1)
Power/sample size calculation: NR
Participants No. randomised: 124 (62 in IG, 62 in CG)
No. completers: 112
Country: China
Study population: elderly diabetes residents
Ethnicity: Chinese
Gender: male 32.1% ((17+19)/112)
Age: mean 65.84 (SD 6.32) in IG, 65.82 (SD 6.39) in CG.
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 141.82 (SD 16.23) in IG, 141.05 (SD 20.06) in CG.
DBP = 82.91 (SD 9.94) in IG, 84.04 (SD 10.15) in CG.
Inclusion criteria:
  1. live in Tianjin Shi ≧5 years;

  2. age≧50 and retired;

  3. diagnosis with Type 2 DM.


Exclusion criteria:
  1. severe ischaemia;

  2. diabetic kidney disease;

  3. ketonuria;

  4. proliferative diabetic retinopathy;

  5. severe hypertension;

  6. limitation of activity.

Interventions IG: walking group:
  • Duration: 30 minute/session (walking in the morning at 09:00)

  • Intensity: target heart rate 170‐age; participants were taught to measure radial artery after walking to confirm walking intensity at target heart rate; self perceived adequate sweating, feeling relaxed and happy as well as good appetite after walking were also indicators for proper intensity.)

  • Frequency: 3 sessions/week

  • Intervention period: 24 weeks

  • Pedometer: no

  • Facilitator: NR


CG: Control group: usual care and lifestyle.
Outcomes Review outcomes reported: BP
Measurement method: before and after intervention.
Primary/Main outcome of manuscript: total physical activity metabolic equivalent, fasting serum glucose, 2‐hour postprandial blood glucose, BP.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly divided" using "random table" but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 9.7% (12 out of 124 dropouts)
55/62 completers in intervention group, 57/62 completers in control group
refer to table 2 to 3
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 6 months
Only 1 analysis
Other bias Low risk No other bias

Yan (嚴華) 2010a.

Study characteristics
Methods Aim: to evaluate the rehabilitation effects of walking training based on medicine therapy on heart function in patients with congestive heart failure (CHF).
Design: parallel 3‐group RCT (1:1:1)
Power/sample size calculation: NR
Participants No. randomised: 418 (212 in IG, 206 in CG)
(203 in unscheduled exercise group excluded)
No. completers: 396
Country: China
Study population: CHF (LVEF ≦45%) patients (clinic and hospitalised)
Ethnicity: Chinese
Gender: male 62.4% ((132+129)/418)
Age: mean 61.2 (SD 11.8) in IG, 62.5 (SD 11.6) in CG
Smokers: NR
Hypertension: NR
Mean baseline BP:
SBP = 123.1 (SD 21.9) in IG, 125.6 (SD 20.2) in CG.
DBP = 68.6 (SD 10.8) in IG, 68.5 (SD 10.6) in CG.
HR= 74.2 (SD 15.7) in IG, 77.1 (SD 15.2) in CG
Inclusion criteria:
  1. CHF (LVEF≦ 45%).


Exclusion criteria:
  1. asthma;

  2. COPD;

  3. abnormal liver function;

  4. severe A‐V block;

  5. severe bradycardia (HR< 60 bpm, cardiogenic shock, sick sinus syndrome including sinoatrial block, and hypotension SBP< 90 mmHg);

  6. dyspnoea refrained from exercise.

Interventions IG: Exercise group:
Participants walked slowly as warming‐up and cool‐down. In consideration of temperature, the walking time was day or night in summer and at noon in winter. Walking training was based on individual 6‐minute walking test. Starting from 10% to 20% 6‐minute walking distance, heart rate was kept at 5 to 10 bpm more than resting HR; BP, ECG and self‐perceived fatigue were also monitored. Participants felt energised normally after each session and the intensity and frequency were gradually increased.
  • Duration: from 25 to 40 to 40 to 60 minutes/session; walked on flat square such as leisure square or pavement; 5 to 10 minutes of slow walking as warming‐up and cool‐down; rest for 3 to 5 minutes according to individual condition.

  • Intensity: from 2000 to 3000 to 3000 to 5000 steps (2 to 3km) lasting for 20 minutes

  • Frequency: 4 to 6 days/week

  • Intervention period: 26 weeks (6 months); followed‐up at least every 2 weeks by phone or clinic visit for 6 months to record exercise training, medication, cardiovascular events, reasons for hospitalisation and frequency of re‐hospitalisation)

  • Pedometer: no

  • Facilitator: yes


CG: Control group: usual lifestyle
Note: a total of 3 groups and only exercise (walking) and control groups included
Outcomes Review outcomes reported: BP and HR
Measurement method: participants were lying for at least 10 minutes and measured with right upper arm. Korotkoff maneuver was applied and the average of three measurements was taken for analysis. Heart rate was detected by stethoscope through chest auscultation.
Primary/Main outcome of manuscript: resting HR, BP, 6‐minute walking test and echocardiography were measured before and after exercise training.
Compliance/Adherence: NR
Adverse event: NR
Notes Trial registration: NR
Funding sources: Guangxi Science and Technology Development Program (0592007‐2)
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Unclear risk Quote: "randomly divided" but no detail reported
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Participants and investigators were unlikely to be blinded.
Blinding of outcome assessment (detection bias)
All outcomes Unclear risk Objective outcomes
No information
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 5.26% (22 out of 418 dropouts)
203 out of 212 completers in group A (walking group), 193 out of 206 completers in group C (control group)
refer to table 1, 2
PP analysis
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 6 months
Only 1 analysis
Other bias Low risk No other bias

Yu (余冰清) 2018.

Study characteristics
Methods Aim: to explore the effect of low‐ and moderate‐intensity exercise on the cardiovascular events and risk factors in phlegm dampness elderly patients with isolated systolic hypertension, and to determine the suitable exercise intensity for the elderly.
Design: Parallel 3‐group RCT (1:1:1)
Power/sample size calculation:yes
Participants No. randomised: 231 (77 in IG1, 77 in IG2, 77 in CG)
No. completers: 211
Country: China
Study population: phlegm dampness elderly population with isolated systolic hypertension
Ethnicity: Chinese
Gender: male 65.9% ((44+52+43)/211)
Age: mean 82.96 (SD 2.06) in IG1, 83.01 (SD 2.09) in IG2, 83.44 (SD 1.99) in CG
Smokers: yes (43.1% in IG1, 43.5% in IG2, 41.4% in CG)
Hypertension: 100%
Mean baseline BP:
SBP = 141.67 (SD 5.95) in IG1, 140.87 (SD 6.45) in IG2, 141.94 (SD 5.22) in CG;
DBP = 63.20 (SD 3.59) in IG1, 62.36 (SD 2.84) in IG2, 63.43 (SD 3.11) in CG
Inclusion criteria:
  1. diagnosed hypertension (SBP≧140mmHg, DBP<90mmHg) according to 2010 Chinese guidelines for the management of hypertension, but under adequate control;

  2. phlegm dampness≧40 according to Constitution in Chinese Medicine Questionnaire;

  3. Age≧ 80;

  4. New York Heart Association Classification Ⅰ or Ⅱ;

  5. Global Initiative for Chronic Obstructive Lung Disease Classification Ⅰ or below;

  6. muscle power for extremities grade Ⅳ and able to follow study protocol;

  7. no regular exercise within 6 months (regular exercise was taken as duration≧20 minutes/session, ≧2 sessions/week);

  8. both participants and caregivers agreed to join and signed informed consent.


Exclusion criteria:
  1. secondary hypertension;

  2. aortic dissection, cardiomyopathy, moderate to severe valve disease, and malignant arrhythmia;

  3. severe liver and kidney disease;

  4. acute and chronic respiratory failure;

  5. acute and chronic gastrointestinal bleeding;

  6. Type 1 and 2 DM with severe complications;

  7. malignant tumour with predicted lifespan< 1 year;

  8. newly diagnosed acute coronary syndrome within 6 months and hemorrhagic stroke accompanied with neuromuscular syndrome;

  9. any disease In combination with skeleton and joints problems refrained from exercise;

  10. use beta‐blockers or drugs for heart rate maintenance;

  11. unable to communicate due to cognitive problems or geriatric organic mental disorders.

Interventions Adaptive training was performed one week before formal training. Participants walked on a treadmill with EKG monitor, so that participants could experience the target intensity by heart rate and self‐perceived level of moderate intensity in Borg scale, and the EKG abnormality could be detected at the same time. The formal training was carried out in the rest room for retired military cadres. Participants were free to talk during walk; adequate sweating and fatigue after walk could be alleviated from rest. Overall participants should feel good and there should be no dizziness, headache, nausea or vomit.
The walk should be suspended when the following situation occurred: ①signs for insufficient perfusion: paleness, cyanosis, and cold sweating; ②unchanged or even decreased heart rate during walk; ③angina pectoris; ④participants asked for stop; ⑤other occasional events.
IG1: Lo‐ intensity group:
  • Duration: 60 minutes/session (warm‐up 10 to 15 minutes + reach target heart rate for 30 minutes + cool‐down for 10 to 15 minutes); in consideration of age, the 30‐minute of target heart rate was divided into three 10‐minute walking, thus there were two intervals of 10 to 15 minutes resting in between the 10‐minute walk.

  • Intensity: 50% maximum heart rate; participants wore WeLoop now 2 (Guangdong YF Technology Limited) to monitor heart rate during walking.

  • Frequency: 3 sessions/week

  • Intervention period: 24 weeks

  • Pedometer: NR

  • Facilitator: physicians and nurses in the rest room facilitated the whole process.


IG2: Moderate‐intensity group
  • Duration: 60 minutes/session (warm‐up 10 to 15 minutes + reach target heart rate for 30 minutes + cool‐down for 10 to 15 minutes); in consideration of age, the 30‐minute of target heart rate was divided into three 10‐minute walking, thus there were two intervals of 10 to 15 minutes resting in between the 10‐minute walk.

  • Intensity: 70% maximum heart rate; participants wore WeLoop now 2 (Guangdong YF Technology Limited) to monitor heart rate during walking.

  • Frequency: 3 sessions/week

  • Intervention period: 24 weeks

  • Pedometer: NR

  • Facilitator: physicians and nurses in the rest room facilitated the whole process.


CG: Control group: maintaining the original lifestyle
Outcomes Review outcomes reported: blood pressure and blood pressure variability (24h SSD and 24h DSD)
Measurement method:
①BP was detected by Microlife BP 3BTO and taken in the 900th Hospital of Joint Logistics Support Force before intervention by researchers; afterwards it was taken in the rest room for retired military cadres by the physicians or nurses one hour before each session, but only data measured in the sixth month were used for analysis. For each measurement, participants were sitting in a quiet room and resting for mood stabilisation for at least 5 minutes. Right upper arm was exposed and kept at the same level of heart with hand palm up when stretch into the BP monitoring device. There were three data in each measurement but only took average of the last two for analysis.
②24‐hour ambulatory BP measurement was detected by MQY‐ABPⅠ. The BP cuff belt was tightened at the right upper arm of the participants, and measured every 30 minutes in the daytime (0600 to 2200), every 60 minutes at night (2200 to 0600). Effective measurement was defined as >80% of effective data. The data were counted for SD of 24‐hour ambulatory mean SBP and SD of 24‐hour ambulatory mean DBP.
Primary/Main outcome of manuscript: vascular function(ankle brachial index, pulse wave velocity), blood pressure, blood pressure variability (SD of 24‐hour ambulatory mean SBP and SD of 24‐hour ambulatory mean DBP), Homocysteine, blood glucose (fasting blood glucose,glycated haemoglobin), blood lipid (total cholesterol, triglycerides, LDL‐C, HDL‐C), BMI waist‐hip ratio and phlegm dampness constitution score.
Compliance/Adherence: participants who attended less than 80% were ceased to be included in the trial.
Adverse event: NR
Notes Trial registration: NR
Funding sources: NR
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence generation (selection bias) Low risk Random sequence generation and randomisation procedure was clearly stated (p.3)
Allocation concealment (selection bias) Unclear risk NR
Blinding of participants and personnel (performance bias)
All outcomes High risk Quote: "...participants and investigators were not blinded..."
Blinding of outcome assessment (detection bias)
All outcomes Low risk Outcome assessors were blinded to participants' randomised allocation status.
Incomplete outcome data (attrition bias)
All outcomes Low risk Dropout 8.7% (20 out of 231 dropouts)
141 out of 154 completers in intervention group, 70 out of 77 completers in control group
refer to table 2.1 to 2.3 and figure 2.1
PP analysis (211 completers only)
Selective reporting (reporting bias) Low risk Only 1 endpoint measurement at 6 months
Only 1 analysis
Other bias Low risk There is no other bias

ABI: ankle‐brachial index; ABP: ambulatory blood pressure; AE(s): adverse event(s); BMI: body mass index;BP: blood pressure; BPM: beat per minute; BRS: baroreflex sensitivity; CAD: coronary artery disease; CG: control group;CHF: congestive heart failure; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; CRP: C‐reactive protein; CRV: heart rate variability; CVD: cardiovascular disease; DBP: diastolic blood pressure; HDL‐C: high‐density lipoprotein cholesterol; HR: heart rate;HRQoL: health‐related quality of life; HRT: hormone replacement therapy;IC: intermittent claudication; IG: intervention group;IGT: impaired glucose tolerance; IPAQ: International Physical Activity Questionnaire; ITT: intention‐to‐treat; LDL‐C: low‐density lipoprotein; LEVF: left ventricular ejection fraction; MET: metabolic equivalent of task; MMSE: Mini‐Mental State Examination; NGT: normal glucose tolerance; NI: no information;No.: number;NR: not reported;OA: osteoarthritis;OGTT: oral glucose tolerance test; PAD: peripheral arterial disease; PCI: percutaneous coronary intervention; PP: per protocol; RCT: randomised controlled trial;RPE: rating of perceived exertion; SBP: systolic blood pressure;SD: standard deviation; SE: standard error; SEM: standard error of the mean; SF‐12 IADL: Short Form 12 instrumental activities of daily living; TC: total cholesterol; TG: triglyceride; T2DM: type 2 diabetes mellitus; 6MWT: six‐minute walk test.

The following studies converted results from SE (reported) to SD [SD=SE*sqrt(n)]:

Hamdorf 1999; Karstoft 2013; Moreau 2001; Nemoto 2007; Stanton 1996.

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Ades 1995 Not a randomised controlled trial
Adragna 1985 Not just walking intervention
Albright 1992 Not just walking intervention
Aldred 1995 Excluded after contacting author
Andersen 2013 Stair climbing
Anderson 2015a Outcome data were not available
Anderson 2015b Outcome data were not available
Aoike 2012 Not just walking intervention
Arakawa 1993 Not walking intervention
Arija 2018a Not just walking intervention
Arija 2018b Not just walking intervention
Asbury 2008 Not just walking intervention
Asikainen 2002aStudyII Active control
Asikainen 2002bStudy I Active control
Asikainen 2003 Active control
Baraas 2011 Not just walking
Baraas 2013 Blood pressure was not measured
Baria 2012 Excluded after contacting author
Barone 2009 Not just walking intervention
Barroso 2008 Non walking intervention
Belli 2011 Not just walking intervention
Bergstrom 2009 Not just walking intervention
Bhammar 2012 Intervention only on one exercise session (1 day)
Bhammar 2017 Intervention only on one exercise session (1 day)
Blumenthal 1991 Not just walking intervention
Boer 2014 Not just walking intervention
Bonet 2003 Active control
Boyne 2011 Non walking intervention
Brawley 2000 Excluded after contacting author
Brekke 2013 Non walking intervention
Bronas2011 Not just walking and active control
Brun 2008 Non‐walking intervention, walking is just a test
Calfas 2001 Active control
Carrier 2008 Not just walking intervention
Carroll 1995a Not just walking intervention
Carroll 1995b Outcome data not reported separately for the treadmill walking intervention group
Casal 1984 Abstract, insufficient information for outcome extraction
Cashin 2008 Not just walking intervention
Castello 2011 Not a usual blood pressure measurement
Chan 2013 No blood pressure data
Chanruengvanich 2006 Non‐walking intervention, walking is just a test
Chen (陳佳萍) 2016 Active control
Chen ( 陳宣蘭) 2015 No blood pressure data
Chen (陳美娟) 2017 No blood pressure data
Chen 2007 Not a randomised controlled trial
Chen 2014 Insufficient information for data extraction
Chomiuk 2013 Not a randomised controlled trial
Clark 2017 Not just walking intervention and active control
Collins 2003 Excluded after contacting author
Collins 2005 Excluded after contacting author
Collins 2007 Not just walking intervention
Collins 2010a Active control
Collins 2010b No blood pressure data
Collins 2011a Excluded after contacting author
Collins 2011b Excluded after contacting author
Collins 2011c Excluded after contacting author
Cononie 1991 Not just walking intervention but walking plus jogging
Cooper 2001 Active control
Cotes 1963 Active control
Coulon 2013 Not just walking intervention and not a a randomised controlled trial
Crowther 2008 Non walking intervention
Cui 2010 Non walking intervention
Dahllof 1976 Not just walking
Dasgupta 2014 Author contacted excluded because of insufficient information
da Silva 2002 Not just walking intervention
Davey 2000 Non walking intervention
Dean 1989 No blood pressure data
Deligiannis 1999 Non walking intervention
De Vito 1999 Not just walking intervention
Devonish 2007 No blood pressure data
Digenio 1999 Non walking intervention
Di Loretoc 2005 Non walking intervention
Dimeo 2012 Part of Pagonas 2014
Dowman 2013 Non walking intervention
Dressendorfer 1995 Not just walking intervention but walking and cycling
Duncan 1985 Not just walking itnervention
Dunn 1997 Not just walking intervention
Duyur 2006 Iinsufficient information for data extraction
Elley 2006 Due to intervention period being too short, less than one week (4 days)
Ettinger 1997 Excluded after contacting author
Fan 2018 Not a randomised controlled trial
Figueroa 2007 Not a randomised controlled trial
Filho 2013 Not just walking intervention
Finkelstein 2016 Intervention of this study was incentive to exercise
Flo 2011 Blood pressure was not measured
Fox 2011 Not a randomised controlled trial
Fukahori 1999 Author contacted, excluded
Gettman 1976 Active control
Giannuzzi 2003 Not just walking intervention
Gibellini 2000 Not a randomised controlled trial
Gill 1984 Non walking intervention
Goldstein 1977 Non walking training
Gram 2010 Active control
Grant 2004 Non walking intervention
Grosse 2001 Not just walking intervention
Guo 2011 Active control
Hagberg 1989a Non walking intervention
Hagberg 1989b Not a randomised controlled trial
Halbert 2000 Non walking intervention and another intervention control
Hambrecht 2000 Not just walking intervention
Hamdorf 1992 No tandard deviation (SD) data for outcome data extraction
Hamdorf 1993 Insufficient information for outcome data extraction
Hardman 1994 Not a randomised controlled trial
Hass 2001 Not a randomised controlled trial
Havlik 2005 Active control
Headley 2008 Just tested acute aerobic effect
Hiatt 1994 Not just walking intervention
Higashi 1999a Duplicated with the other 1999 paper, used the other paper
Hinkleman 1993 From outcome extraction Excel file
Hu 2016 No pure control group
Huang 2006 Non walking intervention
Huiskes 2009 Not a randomised controlled trial
Hurley 2019 From outcome extraction Excel file
Iida 2011 Active control: control was slow walking
Isaacs 2007 Non walking intervention
Jennings 1997 Not a randomised controlled trial
Jerome 2012 Active control
Jessup 1994 Not just walking
Jessup 1996 Blood pressure was not measured
Jette 1988 Outcome data were not available
Jiang 2004 Active control
Jiang 2007 Non walking intervention
Jiang 2013 No controls
Jo 1989 Not a randomised controlled trial and not just walking intervention
Johnson 2007 Non walking intervention
Kaltsatou 2011 Non walking intervention
Katz‐Leurer 2007 Non walking intervention
Kerse 2005 Non walking intervention
Kim 2010 insufficient information for data extraction
King 1991 Not just walking intervention
Kingwell 1993 Not just walking intervention
Kinoshita 1988 Non walking tervention
Klonizakis 2009a Excluded after contacting author
Klonizakis 2009b Blood pressure was not measured
Kobayashi 2001 Not a randomised controlled trial
Koh 2009 Protocol
Kolbe‐Alexander 2006 Active control
Kolt 2009 Protocol
Lamb 2002 Control group got advice on physical activity
Larsen 1969 Not just walking intervention
Lee 2001 Not a randomised controlled trial
Leehey 2009 Not just walking intervention
Leon 1996 Not just walking intervention
Ley 2013 Unspecific exercise intervention
Li (李合) 2018 Not a randomised controlled trial
Li 2005 Active control
Liang ( 梁曉琳) 2015 N blood pressure data
Liao 1987 Non walking intervention
Lima 2009 Tested acute effect of walking
Lin (林麗娟) 2010 Not a randomised controlled trial
Lin 2009 Active control
Liu (劉彥平) 2019 Active control
Llaberia 2013 Llaberia 2013 is the abstract of Arija 2017 and therefore was excluded.
Look Ahead Research Group 2010 Non walking intervention
Low 2007 Active control
Lunde 2012 Walking is a test
Mackey 2011 Author contacted excluded previously
Mackey 2011 Author contacted excluded previously
Marceau 1993 Not just walking
Martins 2010 Resistence training
Mason 1977 Not a randomised controlled trial
McAuley 2003 Active control
McDermott 2004 No blood pressure outcome data
McDermott 2013 Blood pressure was not measured
Mentz 2013 Multiple exercise interventions
Mereles 2006 Non walking intervention, walking is a test
Milecki 2013 Non‐RCT nor walking intervention
Miller 1993 Not a randomised controlled trial
Minus‐Grimes 2013 Insufficient information for data extraction
Miyashita 2008 Not a resting or accumulated blood pressure but quotw: "Blood pressure was measured in a seated position immediately after each bout of walking"
Mohammed 2016 Not just walking, not a usual way to measure blood pressure.
Molmen‐Hansen 2012 Walking/running
Monteiro 2010 Active control
Motlagh 2017a Not just walking intervention
Motlagh 2017b Blood pressure was not an outcome
Motoyama 1995 No blood pressure data
Motoyama 1998 Non walking intervention
Moul 1993 Active control
Mucha 2007 Excluded after contacting author
Muda 2006 Not just walking intervention
Myers 1999 Not just walking intervention but walking and diet restriction
Nam 2012 Multiple exercise interventions:treadmill walking, stationary cycle, stair‐stepper
Neto 2010 Not a randomised controlled trial
Newton 2002 Active control
Ngomane 2019 Only a 30‐minute intervention
Nieman 2013 Not just walking intervention
Nomura 1984 Not a randomised controlled trial
Norris 1990 Not a randomised controlled trial
Nussbaum 2013 Not a randomised controlled trial, non walking intervention
Oberman 1999 Not a randomised controlled trial
Obesity 2007 Not a randomised controlled trial
Oerkild 2012 Unspecific exercise intervention
Ogata 2012 Walking is a test but not an intervention
Ohta 2012 Intervention is bench‐step exercise
Okamoto 2013 Walking is a test but not an intervention
Oldroyd 2001 Non walking intervention
Osbak 2011 Multiple exercise interventions: treadmill walking, stationary cycling
Özdirenç 2004 Non walking intervention
Pal 2011 Active control
Paolillo 2013 Not a randomised controlled trial
Park 2005 Not a randomised controlled trial
Park 2006a Active/treatment control
Park 2006b Active control
Park 2014b Not a randomised controlled trial
Pascoalino 2015 Walking and jogging
Peel 1999 Non walking intervention
Pereira 2015 Abstract, not enough information for risk of bias and outcome extraction
Petersen 2013 Abstract, not enough information for ridsk of bias and outcome extraction
Petrella 1998 Not a randomised controlled trial
Piette 2011 Active control
Pinto 2006 Not a randomised controlled trial
Pitsavos 2011 Non walking intervention
Pollock 1971 Not a randomised controlled trial
Povoa 2010 Active control
Probart 1991 Blood pressure was not measured
Puggaard 2000 Not just walking intervention
Puig‐Ribera 2015 Cluster randomisation (n = 6)
Purzycka 2011 Not a randomised controlled trial
Qi 2011 Excluded after contacting author
Qiu (邱方) 2016 Non‐human study
Quinn 2006 Active control
Rauramaa 1986 Walking + jogging
Ready 1995 No outcome data
Reeder 2008 Not just walking intervention
Ren (任強) 2015 No blood pressure data
Ressl 1977 Non walking intervention
Richter 2010 Not just walking
Rogers 1996 Not a randomised controlled trial and a non walking intervention
Roghani 2012 Control group data was not collected in the study
Romain 2019 The 30‐second sprint is probably like a running and therefore twas excluded
Rosety‐Rodriguez 2011 Not a randomised controlled trial
Ross 2000 Walking + jogging
Roviaro 1984 Not just a walking intervention
Rudd 1967 Not a randomised controlled trial and not a walking intervention
Sandroff 2016 Blood pressure was not measured
Santana 2016 Not a walking intervention
Santiago 1995 Excluded after contacting author
Saremi 2010 Not a randomised controlled trial
Sari‐Sarraf 2015 Intervention is not pure walking but walking plus running
Saxena 2016 Intervention only on one exercise session
Seals 1991 Active control
Seals 1997 Not a randomised controlled trial
Seminario 1999 Not just a walking intervention
Seo 2010 Multiple aerobic and resistence exercise
Shabaaninia 2017 Not just walking intervention but quote: " treadmill interval aerobic running"
Shin 1999 Not a randomised controlled trial
Shvedko 2019 Active control
Sijie 2012 Not just walking intervention
Simons 2006 Active control and not just walking intervention
Sims 2012 Not a randomised controlled trial
Sivarajan 1981 Not just walking intervention
Sivarajan 1982 Not just walking intervention
Skvortsova 2010 Not a randomised controlled trial
Skvortsova 2011 Not a randomised controlled trial
Sohn 2007 Walking plus sodium reduction
Song 2017a Tthe main focus of the study is steps but not blood pressure
Song 2017b Not just walking intervention
Sousa 2013 Not just walking intervention
Staffileno 2001 Multiple interventions
Staffileno 2007 Not just walking
Staudter 2011 Excluded after contacting author
Stefanick 1998 Not just walking intervention
Stensel 1993 Excluded after contacting author
Stensel 1994 Blood pressure was not measured
Steptoe 1990 Non walking intervention
Subramanian 2011 Not just walking intervention
Svacinova 2003 Blood pressure was not measured, active control. Not a randomised controlled trial
Talakad 2011 Non walking intervention
Talbot 2011 Active control
Tanaka 1998a No mention of randomisation
Tang 2019 Walking + medication
Tao 2004 Not just walking
ter Bogt 2011 Not just walking
Thomas 2010 Not just walking intervention
Thompson 1988 Non walking intervention
Tian (田野) 2014 No blood pressure data
Tjonna 2008 Non walking intervention study
Toledano‐Zarhi 2011 Not just walking intervention
Torrente 2017 This study excluded the control arm and keeping only the park‐walking group and relaxation exercise group, and using the days they were not exercising (before training, and 1 & 3 weeks after training) as their “own” control. The author did not analyse the data in the way that they randomised participants.
Tsai 2002a Not just walking but walking + jogging
Tsai 2002b Not just walking but walking + jogging
Tsoukas 1995 Not just walking intervention
Tsuji 1990 Not a randomised controlled trial
Tully 2004 Reference could not be found
Tully 2007 Not a randomised controlled trial
Ubels 1999 Not a randomised controlled trial
Uemura 2012 Not just walking
Van Dyck 2013 Excluded after contacting author
van Sluijs 2005a Non walking intervention
van Sluijs 2005b Non walking intervention
Venojarvi 2013 No biood pressure data
Verity 1989 Pseudo‐randomised controlled trial
Vetrovsky 2018 Active control
Vicente‐Campos 2012 Non walking intervention
Waib 2011 Non walking intervention
Wanderley 2010 Blood pressure was not measured
Wanderley 2013 Not just walking intervention
Wang (王漫卓) 2017 Not just walking
Wang (王磊) 2016 Not just walking intervention
Wang (王純) 2007 Not a randomised controlled trial
Wang (王錦雲) 2005 Not a randomised controlled trial
Wang 2011 Not a randomised controlled trial
Wang 2012 Not just walking intervention
Weinstein 2013 Blood pressure was not measured and active control
Welsh 1985 Not a randomised controlled trial
Whitehurst 1991 Not a randomised controlled trial
Whitney 1991 Non walking intervention
Whitney 1993 Non walking intervention
Wijnen 1994 Non walking intervention
Wilmore 1970 Non walking intervention
Wilson 2010 Excluded after contacting author
Wing 1998 Non walking intervention
Wong 2018 Stair‐climbing exercise
Woolf‐May 1999 Not a randomised controlled trial, and no blood pressure measurement
Wu 2007 Not a randomised controlled trial
Xie 2015 Insufficient information for outcome extraction
Yates 2009 Active control
Yeater 1990 Excluded after contacting author
Yu (于進) 2003 No blood pressure data
Yuenyongchaiwat 2018 Not a randomised controlled trial
Zeng (曾玉萍) 2014 No blood pressure data
Zhang (張舒) 2012 No blood pressure data
Zhang 2015 Insufficient information for outcome extraction, refer to Zhang 2016 full‐text paper
Zhang 2016 Active control and only provided percentage of change score but the parameters are unclear
Zhou (周玉萍) 2015 Active control
Zoellner 2011 Not a randomised controlled trial and active control

Characteristics of ongoing studies [ordered by study ID]

Actrn 2015.

Study name Prescribing the maximum tolerated dose of walking for people with severe knee osteoarthritis: a Phase II, randomised controlled trial
Methods Aim: to test the effects of a prescribed walking program of 70 minutes per week for 12 weeks
Design: a Phase II, randomised controlled trial
Participants People with severe knee osteoarthritis and at least moderate risk of cardiovascular disease
44 participants in total
Both male and female
Inclusion criteria
  • Adult aged at least 50 years and living independently in the community.

  • Diagnosed with severe knee osteoarthritis rated as grade III or IV determined radiogaphically.

  • Have a cardiovascular risk profile with at least 2 total risk factors using stage 2 of the Adult Exercise Screening Tool.

  • Able to participate safely in the moderate‐intensity physical activity trial using stage 1 of the Adult Exercise Screening Tool.

  • Able to understand English.


Exclusion criteria
  • Live in supported accommodation such as a nursing home.

  • Report daily resting level of pain to be 9 or 10 on a 0 (no pain) to 10 (worst possible pain) Numerical Pain Rating Scale.

  • Have very high levels of psychological distress as measured by the Kessler 10 questionnaire with a K10 score > 29.

  • Have an intellectual impairment as measured by the Short Portable Mental Status Questionnaire with a score of 7 or less.

  • Have a systemic arthritic condition such as rheumatoid arthritis.

  • Have a neurological condition that affects walking.

  • Had knee surgery or intra‐articular corticosteroid injection within past six months.

  • sing oral corticosteroids within four weeks.

Interventions Intervention group
standard care+prescription "of a walking dose of 70 minutes per week, of at least moderate intensity using the rate of perceived exertion scale with a score of at least 3/10, in bouts of at least 10 minutes. The weekly dose will be completed for 12 weeks in the community. The walking doses will be completed in the community using normal assistive devices, such as a walking stick if required. Participants will continue taking their usual medications and other normal strategies to manage their knee osteoarthritis."
"To increase the likelihood of adherence to the intervention and maximise the effectiveness of the intervention, we will use the following behavioural change techniques and strategies: Single planning session of up to 30 minutes with goal setting ‐ a physiotherapist will assist the participant to determine when and where to complete the dose of walking; Supervision ‐ physiotherapist supervision of one session of walking weekly; Monitoring ‐ each participant will wear a pedometer to self monitor the number of steps each week. They will also complete a logbook to record number of steps and time spent walking each week. A physiotherapist will monitor their progress with a weekly phone call or send weekly SMS reminders; Engaging social supports ‐ each participant will be encouraged to walk with a friend, or family member or other research participant."
Control group
standard care only for pain, cardiovascular risk, function and quality of life
Outcomes Primary outcome: average knee pain over the previous week measured by a 0 to 10 Numerical Pain Rating Scale. [Baseline and post intervention (Week 12)]
Secondary outcomes:
  • Resting blood pressure ‐ systolic and diastolic (mmHg) using a blood pressure monitor[Baseline and post intervention (week 12)]

  • 30‐second chair stand test as per OARSI functional performance measure guidelines [Baseline and post intervention (week 12)]

  • 40 metre (4 x 10 metres) fast paced walk test as per OARSI functional performance measure guidelines[Baseline and post intervention (week 12)]

  • Body mass index (kg/m2) using scales for weight and tape measure for height[Baseline and post intervention (week 12)

  • various other irrelevant outcomes

Starting date 14 January 2015
Contact information Mr Jason Wallis
jason.wallis@easternhealth.org.au
+61 3 9895 3715
Box Hill Hospital Building B, Level 3 8 Arnold Street Box Hill VIC 3128, Australia
Notes Trial registration: ACTRN12615000015549

Actrn 2017.

Study name Activity for Wellbeing: promoting well‐being through physical activity in aged care workers
Methods Aim: to study the efficacy of using a need‐supportive, person‐centred physical activity program for improving and maintaining physical activity participation and psychological well‐being in frontline aged care workers
Design: cross‐over study with block randomisation
Participants Aged: 18 years or over
Sex: males and females
25 participants in total
Inclusion criteria
• Current employee of ACH group
• Able to speak fluent English
• At least 18 years of age
• Ability to engage in moderate physical activity (as defined by the American College of Sports Medicine (ACSM)) and complete all outcome measures (including the Six Minute Walk)
• Not currently meeting ASCM recommendations for physical activity (greater than or equal to 30 minutes of moderate cardio‐respiratory exercise per day, 5 days per week)
Exclusion criteria: no exclusion criteria, but volunteers who have previously diagnosed conditions or signs or symptoms of disease as indicated on the Adult Pre‐exercise Screening System will need to provide medical clearance prior to participation in the study.
Interventions Intervention
  • Pedometer‐based intervention with person‐centred activity plan aimed at assisting the participant to meet ACSM recommendations for physical activity

  • Participants will also be taught how to use affect and ratings of perceived exertion to regulate exercise intensity, and the use of a pedometer and interactive website for monitoring step counts

  • Weekly contacts via the dashboard page of the program website for providing feedback on goal‐setting, motivational statements and active encouragement and support (12 contacts over the course of 12‐weeks), or email contacts


Wait‐list control
Outcomes Primary outcome: 2‐day activity recall
Secondary outcomes: resting blood pressure at baseline, 12 weeks (post‐intervention) and 6‐month follow‐up (9 months post baseline); 6 minute Walk distance; BMI etc.
Starting date 21/09/2017
Contact information Ms Merilyn Lock
merilyn.lock@mymail.unisa.edu.au
+61 8 8302 1752
Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences. Playford Bldg. City East Campus, University of South Australia, Adelaide, SA, 5001, Australia
Notes Trial registration: ACTRN12617001395325

Nct 2009.

Study name Diabetic Kidney Disease: influence of Exercise therapy on Physical and Vascular Function. (DKD‐EXT)
Methods Aim: to investigate the effect of a 12‐week walking exercise program on vascular endothelial function, arterial stiffness/compliance, and vascular health biomarkers in men and women with pre‐dialysis type 2 diabetic kidney disease (DKD)
Design: parallel RCT 2 arms
Participants Men and women with pre‐dialysis type 2 diabetic kidney disease (DKD)
122 enrolled
Interventions
  • Experimental: exercise

    • blended supervised‐home‐based exercise training 3 to 4 times/week for 12 weeks. Intervention: behavioral: exercise

  • No Intervention: control group asked to continue usual activities

Outcomes Primary outcomes
Eendothelial function measured by brachial artery flow mediated vasodilation [Time Frame: at week 0 and at week 12]
Endothelium‐mediated change in vascular tone
Secondary outcomes
  • Arterial stiffness measured by pulse wave velocity [Time Frame: at week 0 and at week 12]

  • Circulating markers of vascular health [Time Frame: at week 0 and at week 12] C‐reactive protein, isoprostane F2, Asymmetric dimethylarginine

  • Aerobic capacity [Time Frame: at week 0 and at week 12] Peak oxygen consumption

  • Blood pressure [Time Frame: at week 0 and at week 12]

  • 24‐hour albuminuria [Time Frame: at week 0 and at week 12] assessed in 30 participants measured inmg/g creatinine

Starting date October 2009
Contact information No information
Notes Trial registration: ClinicalTrials.gov Identifier: NCT02112071;
0905M66282
K23DK082638-04 ( U.S. NIH Grant/Contract )
22275 ( Other Identifier: University of Minnesota )

BMI: body mass index; RCT: randomised controlled trial.

Differences between protocol and review

Since considerable time passed from the publication of the protocol (Lee 2010b) and the completion of the review, a number of differences arose between protocol and review.

  1. We refined our definition of walking to include flat walking only and to not include stair walking and uphill treadmill walking.

  2. We updated the background section to include more recently published references.

  3. We included data on adverse events where it was provided by included studies.

  4. We undertook a post‐hoc analysis of the effect of walking intervention on blood pressure control by study sample size.

  5. We undertook a post hoc analysis of the effect of walking intervention on blood pressure control by the baseline blood pressure.

  6. Hui‐Hsin Lin and Yoko Kin Yoke Wong are authors on the review but were not authors on the protocol. They undertook screening of papers, data extraction and analysis.

  7. Douglas Salzwedel was author on the protocol but is not author on the review. His contribution was acknowledged under Acknowledgements.

Contributions of authors

Ling‐Ling Lee (LLL) formulated the idea for the review and developed the basis for the protocol.

LLL, Caroline A Mulvaney (CM), Michael C Watson (MW) drafted the protocol.

Hui‐Hsin Lin (HHL), LLL, CM independently screened articles for inclusion or exclusion.

Yoko Kin Yoke Wong (YW), HHL, CM, LLL, MW extracted data and checked data entry.

CM, YW, Edwin SY Chan (EC), LLL, MW assessed the risk of bias of all included studies.

LLL, YW, CM conducted data analysis and interpretation of the study result.

LLL, CM, MW contributed to drafting and editing of the final draft of the review.

LLL, CM drafted and edited the final review.

All review authors reviewed and approved the final version.

Sources of support

Internal sources

  • Tzu Chi College of Technology, Taiwan

    TCCT‐971B31

External sources

  • National Science Council of Taiwan, Taiwan

    NSC 100‐2410‐H‐277‐005

Declarations of interest

Ling‐Ling Lee: none known

Caroline A Mulvaney: none known

Michael C Watson: none known

Edwin SY Chan: none known

Hui‐Hsin Lin: none known

Yoko Kin Yoke Wong: none known

Edited (no change to conclusions)

References

References to studies included in this review

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Xiao (肖卉) 2010 {published data only}

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Yan (嚴華) 2010a {published data only}

  1. Yan H, Fu CH, Zou EF, Fu YH, Chen LY, He DM, et al. Walk exercise training produces rehabilitation effects on heart function for patients with chronic heart failure [步行運動訓練對慢性充血性心力衰竭患者心臟的康復]. Chinese Journal of Cardiovascular Rehabilitation Medicine 2010;19(1):2-4 and 30. [DOI: 10.3969/j.issn.1008-0074.2010.01.01] [DOI] [Google Scholar]
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Yu (余冰清) 2018 {published data only}

  1. Yu BC. The effect of different exercise intensity on the cardioVascularevents and its risk factors in phlegm dampness elderly patients with isolated systolic hypertension [thesis] [不同運動強度對痰濕質老老年ISH患者心腦血管事件及危險因素的影響]. Fujian University of Traditional Chinese Medicine 2018:1-67.

References to studies excluded from this review

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Mackey 2011 {published data only}

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