The Hypertensive Client Who Wants to Start With Swings and Get-Ups
Marcus, 52, is a recreational cyclist who books a 6-session kettlebell introduction. His intake form lists stage 1 hypertension (average home readings 142/88 mmHg), type 2 diabetes managed with metformin, and a BMI of 31. He takes a beta-blocker, so his heart rate stays near 62 bpm at rest and rises slowly. He reports two episodes of light-headedness while lifting a box overhead in the past month, and he had a right rotator cuff repair 4 years ago; he now has pain-free shoulder flexion to 155° but discomfort at end range under load. His goal is to complete a 10km charity walk and 'get strong.' He has never used kettlebells. He is eager to start swings and Turkish get-ups in session 1, and he has already bought a 20kg bell. He has no recent medical clearance and his GP's note simply says 'okay to exercise.'
1. Before session 1, what screening, clearance, and referral steps do you take - and what do you tell Marcus about the 20 kg bell?
Read the worked answer
Do not start loaded training yet. The combination of stage 1 hypertension, a beta-blocker, exertional light-headedness, and a prior rotator cuff repair puts Marcus in a higher-risk category. The GP note 'okay to exercise' is too nonspecific for the plan he wants.
- Ask the physician three targeted questions: (1) any restriction on Valsalva, overhead loading, or high-intensity intervals; (2) what blood-pressure and symptom thresholds should stop a session; (3) whether the light-headedness has been evaluated.
- Because beta-blockade blunts heart rate, do not use predicted max HR or a heart-rate zone to set intensity. Use RPE, the talk test, and symptom monitoring.
- Hold swings and Turkish get-ups until cleared; the get-up combines overhead loading, rolling, and rapid position changes.
- Do not diagnose the dizziness. Document the referral and train only within your scope.
Tell him the 20 kg bell stays home for now; an 8–12 kg bell is more appropriate for learning.
2. Design the first three sessions with exercise selection and monitoring parameters. Justify each choice.
Read the worked answer
Sessions 1–3 should build hinge and carry capacity, not conditioning.
- Session 1: box squat to stand, kettlebell deadlift from the floor with 12 kg, two-hand carry with 12 kg, wall push-up. Teach breathing without breath-holding. Monitor before, during (after each set), and after.
- Session 2: repeat the deadlift with 16 kg if symptom-free, add suitcase carry, seated floor press with 8 kg, and tall-kneeling halos without load.
- Session 3: hinge drill, goblet squat with 12 kg, farmer carry, and step-ups.
Keep sets to 3–5, reps 5–8, rest 60–90 seconds, RPE 11–13. Stop for dizziness, chest pain, unusual shortness of breath, or a marked change in perceived effort. Avoid rapid head-position changes. Recheck symptoms each session.
Reasoning: low-complexity, low-overhead work lets you observe tolerance while avoiding the specific triggers - overhead load, Valsalva, and fast transitions.
3. On session 2 he says he feels fine and asks to try a Turkish get-up with the 20 kg bell. What is your response, and what documentation do you make?
Read the worked answer
Decline the 20 kg get-up. Say: 'I can't coach that safely until your physician clears overhead loading and we build the positions with a lighter bell.' Offer a no-load or 4–8 kg half-get-up only after clearance. If he insists, do not proceed; you can end the session or switch to an approved exercise.
Document: date, what he requested, your exact advice, the referral, and his response. Send the physician a short note with his consent. This protects him and shows a reasoned scope decision.