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R.T. is a 46-year-old right-handed man who had attended college on a 4-year baseball pitching scholarship. He pitched for 3 years and was sidelined as a result of overuse injury toward the end of the fourth season. R.T. is currently employed in a manufacturing facility. His job requires constant standing and lifting heavy boxes (often overhead). His right shoulder has been persistently painful for the last 2 years, but the pain has increased over the last few weeks such that he is unable to lift anything over his head. Outside of work, he has a sedentary lifestyle, except for walking 10 minutes per day to the train station. He has occasionally sought medical care for complaints of right shoulder pain. He has a 5-year history of essential hypertension that is stable on current drugs. He has no other co-morbidities. One week ago, R.T. had elective arthroscopic right shoulder girdle repair. He was referred to an outpatient physical therapy clinic. His body mass index is 27 kg/m2. Resting vitals are as follows: blood pressure 130/82 mm Hg; heart rate 66 bpm. R.T.’s current medication includes hydrochlorothiazide and labetalol and an opiate analgesic to reduce postsurgical pain. During initial evaluation, the therapist assessed right upper extremity pain-free passive range of motion. Active range of motion was significantly limited by pain and postsurgical guidelines. R.T. expressed extreme urgency in regaining right arm function in order to return to work. The therapist has worked closely with the referring surgeon. The established treatment protocol involves immersion in a pool to allow buoyancy to facilitate pain-free movement of the upper extremity. The 35°C temperature promotes muscle relaxation and decreases guarding. R.T. entered the pool up to his neck and under the guidance of the therapist, began right upper extremity movements. After 15 minutes in the water, R.T. complained of shortness of breath and started up the pool stairs with the assistance of the therapist. At the top of the stairs, the patient felt lightheaded and was assisted to a chair; he fainted, losing consciousness for several seconds. Once the patient was stable, his vitals were taken in a seated position as quickly as possible: blood pressure 90/50 mm Hg and heart rate 74 bpm. The patient was coherent and returned to standing after several minutes.


Hypertension is the most common cardiovascular disease as well as a precursor to other cardiovascular dysfunctions. The prevalence of hypertension increases with age, and varies based on race/ethnicity, education, and coexisting morbidities. Sustained arterial hypertension damages blood vessels; such changes in the kidney, heart, and brain lead to an increased incidence of renal failure, coronary disease, cardiac failure, and stroke.

Clinical research has consistently documented that aerobic activity is an effective nonpharmacologic approach for controlling hypertension and its sequelae. Other nonpharmacologic therapies include a diet low in sodium and fat (eg, Dietary Approaches to ...

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