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Implementing Exercise: What Do We Know? Where Do We Go?
Implementing Exercise: What Do We Know? Where Do We Go? Patricia Painter Exercise capacity, physical functioning, and physical activity are all low in patients with CKD treated with dialysis. Although there is robust evidence that these patients benefit from regular exercise training and/or increasing physical activity, the nephrology community has not adopted recommendations and encouragement for physical activity as a part of the routine care plan. This article reviews what is known regarding the implementation of exercise and provides suggestions as to how exercise counseling might become a routine part of the care of patients with CKD. Q 2009 by the National Kidney Foundation, Inc. All rights reserved. Key Words: Exercise, Physical activity, Exercise programming, CKD
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t is well documented that regular physical activity or exercise training is beneficial for patients with CKD. The benefits in patients treated with dialysis have been reported in over 45 studies that are summarized in a systematic review by Cheema and Singh.1 The benefits include improved clinical profiles (ie, reduced cardiovascular risk and function), physical functioning (improved exercise capacity, strength, and physical performance), and quality of life. Additionally, although the mechanism remains undetermined, regular physical activity and higher physical functioning is associated with improved outcomes, specifically reduced cardiac and overall mortality and lower hospitalization rate.2-6 Despite clear-cut documentation of low levels of physical functioning and physical activity and the robust evidence of the benefits of regular exercise in dialysis patients, regular assessment of physical functioning and encouragement for increased physical activity or regular exercise participation are still not a routine part of the medical care of renal patients and are given minimal attention or advocacy within the nephrology community. Thus, the challenge remains as to how to efficiently and effectively deliver a program of en-
From the School of Nursing, University of Minnesota, Minneapolis, MN. Address correspondence to Patricia Painter, PhD, School of Nursing, University of Minnesota, 6-149 Weaver-Densford Hall MC 1331, 308 Harvard St SE, Minneapolis, MN 55104. E-mail: [email protected] Ó 2009 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/09/1606-0013$36.00/0 doi:10.1053/j.ackd.2009.07.010
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couragement of physical activity and/or exercise training within the system of care for renal patients. This article discusses physical activity levels, barriers to participation, current practices, and various strategies to develop effective programs for patients on dialysis.
Historical Background The first suggestion that dialysis patients may require some innovative exercise programming came in the early 1980s in comparing 2 studies. In one of the first exercise training studies published by Shalom and colleagues,7 the concluding paragraph stated ‘‘a 12-week program of exercise conditioning can dramatically improve the work capacity of patients on dialysis, . The overall impact of this type of program may be limited by a low rate of sustained participation.’’ The exercise program required hemodialysis patients to attend an outpatient cardiac rehabilitation program on their off-dialysis days. Of the 14 patients who enrolled in the program and completed testing, 7 attended at least half of the training sessions. The patients who attended .50% of the sessions experienced improved exercise capacity of 45%. The others did not change in their exercise capacity. In contrast, in 1986, Painter and colleagues8 reported the effects of an exercise program that was delivered using a stationary cycle during the dialysis treatment and reported significant improvements in exercise capacity (VO2peak) and improvements in blood pressure. This study reported participation in 91% of all sessions in the first 3 months (monitored by study staff) and 75% during the second 3 months, which was self-monitored. It is intuitively
Advances in Chronic Kidney Disease, Vol 16, No 6 (November), 2009: pp 536-544
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obvious and clearly shown in these 2 studies that regular participation is necessary for benefits to be realized and that the type of programming may make a difference. Thus, it is critical to develop programs that facilitate participation to maximize effectiveness.
Physical Activity Levels in CKD Patients The assessment of physical activity remains fraught with measurement challenges9; however, questionnaires are widely used, despite the shortcomings of recall, self-report, and quantification of energy expenditure of various activities. Activity monitors and step counters provide a bit more quantification of movement; however, neither provides information on intensity of effort and neither is able to assess activities in which the mode of activity is something other than walking or jogging. Despite measurement issues, it is fairly well documented that physical activity is low in patients treated with hemodialysis. The Dialysis Morbidity and Mortality Study (DMMS) Wave 2 included a question on the frequency of participation in regular physical activity during their leisure time. Possible answers ranged from never or almost never to daily. The DMMS included 4,024 new patients starting hemodialysis or peritoneal dialysis patients in 1996 and 1997. Of these, 502 were excluded because they were unable to ambulate, and 2264 had complete data on the physical activity question.4 In those with physical activity data, the frequency of participation was 19.8% daily or almost daily, 5.5% 4 to 5 times per week, 18.4% 2 to 3 times per week, 21.2% 1 or less than 1 time per week, and 35.1% never.4 The DMMS Wave 2 question only assessed frequency of physical activity in leisure time, did not define physical activity, and did not assess intensity or duration of activity. Updated guidelines for physical activity and the elderly and those with chronic conditions published by the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) are more specific in their recommendations for frequency duration and intensity of activity for health benefits (details later).10
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In accordance with these updated recommendations, the Renal Network 11 surveyed renal patients11 using a questionnaire that included the following sequence of questions: Do you do any regular physical activity? If yes, how many days per week? and How many minutes per session? It also included the following question to gauge the intensity of the activity: ‘‘How hard do you exert yourself during your activity?’’ Response options were ‘‘very easy,’’ ‘‘easy,’’ ‘‘somewhat hard,’’ ‘‘hard,’’ and ‘‘very hard.’’ One thousand twenty-three surveys were returned and included 83% treated with hemodialysis, 10% with peritoneal dialysis, and 6.8% with functioning transplants. Although 53% stated they participated regularly in physical activity, of these, only 24% participated at levels recommended by the AHA/ACSM (13.2% of the total respondents). The difference between those who report some physical activity and those participating in the recommended levels was intensity of effort of the exercise. Seventyfour percent of those reporting some physical activity met the recommended frequency criteria (of 3 or more days per week), and 47% met the criteria of 30 minutes or more per session, whereas only 34% reported an exertion level of ‘‘somewhat hard’’ or higher (compared with 100% of those in the recommended level). Johansen and colleagues12 used 3-dimensional accelerometers to measure physical activity over 7 days in a group of 34 hemodialysis patients and compared them with a control group of healthy individuals of similar ages. They found significantly lower activity in the dialysis patients (P ,.0001) with the difference between the dialysis patients and controls increasing with age. They provide the example that for a male of age 30, predicted activity would be 15% lower for a dialysis patient than for a healthy sedentary person, whereas a male of age 70 on dialysis patient would be predicted to be 57% less active than a sedentary person without CKD. Zamojska and colleagues13 used step counters in 60 hemodialysis patients to determine average steps accumulated over 48 hours. They found that the dialysis patients accumulated only 48% of the steps that healthy subjects accumulated (689662357vs healthy controls
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14,18165383, P ,.001). There are suggestions in the literature that a desirable number of steps for health benefits is around 10,000 per day.14
Barriers to Physical Activity in CKD It is not difficult to think of reasons why patients with CKD treated with dialysis do not participate in regular physical activity. There have been 3 studies that identify barriers to participation in physical activity in dialysis patients.11,15,16 In the study by Goodman and Ballou,15 the most frequently cited barrier to physical activity was ‘‘lack of motivation,’’ and the strongest facilitator for physical activity participation was ‘‘desire to feel healthy.’’ Kontos and colleageus16 reported results from a qualitative study that patients felt that the nurses’ lack of encouragement to exercise, transportation issues, and the use of exercise equipment that precludes participation during the dialysis treatment were all barriers to participation. They also identified fatigue and depression as exercise impediments. In the Network 11 survey, the top reasons cited for not participating in regular physical activity were ‘‘I’m just not motivated,’’ ‘‘I’m too tired,’’ I’m too sick,’’ and ‘‘I have no place to exercise or exercise equipment.’’ Interestingly, some of the key barriers reported by patients can be improved through regular exercise (ie, fatigue, depression, lack of energy, and lack of strength). The most frequent benefits cited in the Network 11 survey by those who participated in regular physical activity were ‘‘improved energy levels,’’ ‘‘improved muscle strength,’’ and ‘‘enhanced ability to do the things I need to do in life.’’
Current Practice for Physical Activity Promotion The question remains as to why patients with CKD remain physically inactive. The Network 11 survey11 asked ‘‘What do you think is the best way to get people with kidney disease to increase their physical activity.’’ The top responses were ‘‘encouragement and recommendations from the physician’’; ‘‘make it a part of the routine education of patients when they get kidney disease’’; and ‘‘encouragement from family/friends’’ and ‘‘encouragement from health care team.’’ There have
been several studies that provide some insight into current practices. Kontos and colleagues16 also found that patients seemed to be in need of encouragement from the dialysis nursing staff, with 1 patient stating that ‘‘if it were discussed, that would certainly motivate me.’’ In June 2000, the Rehabilitation Committee of the ESRD Network of New York (Network 2) surveyed the 200 dialysis clinics in the Network to learn about their exercise programs, to identify units with successful programs, and to identify factors that may be barriers to developing successful programs.17 Ninety-one percent of the units (n¼182) returned the survey. Fourteen percent (26 units) offered an exercise program. On average, 20 patients per unit participated, most while dialyzing. There was about a 25% patient dropout rate primarily because of medical problems, loss of interest, and staff shortages. The major barriers identified were as follows: (1) nephrologists were either not interested or not convinced of the benefits of exercise for their patients; (2) nephrologists were concerned about the safety of exercise; (3) staffing issues were of concern, including funding and lack of time; and (4) patients lacked information about the benefits of exercise. A second survey was performed by the Life Options Advisory Council staff in cooperation with the ESRD Network of Texas and Council of Nephrology Social Workers of North Texas.18 The survey used the Unit Self-Assessment Tool, which was developed to quantify and catalog ongoing rehabilitation efforts within dialysis clinics (www.lifeoptions.org). The tool is a self-scored checklist of 100 possible rehabilitation activities that was organized according to the 5 core principles of rehabilitation. The exercise category consisted of 20 activities divided into levels of difficulty or complexity, each of which was given 1 point for scoring. Thus, the highest possible score for the exercise category was 20. One hundred sixty-nine centers completed the survey (68% response rate). Exercise practice was the lowest of all rehabilitation practices, with an average of 3.762.9 activities in the units. Only 21% of facilities had any advanced exercise activities (ie, support of local fitness events among renal patients; providing for exercise programming outside of the unit; and providing in-center, organized fitness activities during dialysis).
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Another study has determined that staff within the dialysis clinics are not routinely encouraging patients to participate in regular physical activity.19 One hundred dialysis staff with direct patient care responsibilities (nursing staff, patient care technicians, dieticians, or social workers) in 5 clinics completed questionnaires to assess encouragement for physical activity practices. Although 45% stated that their patients would benefit from increasing physical activity, 34% never asked about physical limitations, and 24% never or rarely encouraged patients to be more physically active. Only 32% stated that they regularly encouraged patients to be active. Predictors of low physical activity encouragement among dialysis staff were (1) job position (ie, not professionally trained), (2) agreement with the statement ‘‘It is not my responsibility to help patients increase their physical functioning,’’ (3) a perception of a lack of skills for motivating patients to exercise, and (4) agreement with the statement ‘‘dialysis patients lack motivation to exercise.’’ Kontos and colleagues16 also reported that although dialysis staff acknowledged the potential benefits of exercise for their patients, they felt that they did not have time to encourage patients to exercise, and thus low priority was placed on exercise in the overall treatment plans. Additionally, these dialysis nurses were uncomfortable with regard to use of in-center exercise equipment. It is clear from these data that, although patient care staff members think exercise is important and they want their patients to improve their levels of functioning, no consistent training is provided or policies/responsibilities in place within the units for staff to either assess functioning or encourage exercise. As dialysis staff who participated in the Kontos study emphasized, a ‘‘change in the medical culture’’ is needed to elevate the priority of exercise for well being in patient care plans. Exercise counseling practices among nephrologists caring for patients on dialysis were the topic of a survey reported by Johansen and colleagues.20 The investigators surveyed a total of 505 nephrologists attending the Meeting of the American Society of Nephrology (October 2001), 277 of whom were from the United States. Although 98.6% of
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the US nephrologists stated that physical activity is beneficial for patients on dialysis, only 48.9% often ask about physical activity, and only 28.5% routinely prescribe exercise for their patients. Additionally, only 4.3% of the nephrologists provide written material about exercise to their patients. Characteristics that were significantly associated with noncounseling behavior in multivariate analysis were as follows: no time for physical activity counseling (P , .0001), not confident in counseling ability (P¼.005), physical activity not as important as other medical concerns (P¼.051), younger age of physician (P , .0001), male sex (P¼.013), and lower percentage of practice that was primary care (P¼.035). The authors suggest that these findings are consistent with the current practice, which emphasizes management of the dialysis procedure and specific side effects of kidney disease and not physical functioning and attention to factors that affect well-being and quality of life and maintaining independence. A smaller group of nephrologists mostly from Europe completed a similar questionnaire at the 2003 World Congress of Nephrology.21 This survey indicated that 95% agreed on the fact that the sedentary lifestyle is an important risk factor in CKD patients; 78% thought that it is the responsibility of the nephrologist to advise patients about physical activity. Thirty-three percent stated that they offered in-center exercise training programs, and 15% said patients participate in out-center exercise groups. Huang and colleagues22 used Medicare expenditure data to evaluate the cost-effectiveness of referral to cardiac rehabilitation in hemodialysis patients after coronary artery bypass graft surgery. They reported that referral to cardiac rehabilitation was 13% lower for dialysis patients than for the general population of coronary artery bypass graft surgery patients and that cardiac rehabilitation was associated with longer cumulative life and was cost-effective. This clearly indicates that there is underutilization of even the resources that are already available for our patients.
Physical Activity Recommendations There is general agreement that the recommendations for physical activity for dialysis
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patients should be no different than those for the general population.10 Recommended components include cardiovascular exercise training, strengthening exercise, flexibility, and balance exercises. The recommendations for older adults may be most appropriate for the general dialysis population. Studies following these recommendations have reported no adverse responses, and it is generally accepted that such activity is well tolerated and results in benefits detailed elsewhere in this issue (VanVleck/Parsons). The following are the physical activity guidelines for older adults as outlined by the AHA/ACSM. To promote and maintain health, older adults need moderate-intensity aerobic physical activity for a minimum of 30 minutes on 5 days each week or vigorous-intensity aerobic activity for a minimum of 20 minutes on 3 days each week. Moderate-intensity aerobic (cardiovascular) activity involves a moderate level of effort relative to an individual’s aerobic fitness. On a 10-point scale, where sitting is 0 and all-out effort is 10, moderate-intensity activity is a 5 or 6 and produces noticeable increases in heart rate and breathing. On the same scale, vigorous-intensity activity is a 7 or 8 and produces large increases in heart rate and breathing. For example, given the heterogeneity of fitness levels in older adults, for some older adults a moderate-intensity walk is a slow walk, and for others it is a brisk walk. To help prevent unhealthy weight gain, some older adults may need to exceed minimum recommended amounts of physical activity to a point that is individually effective in achieving energy balance while considering diet and other factors that affect body weight. To further promote and maintain skeletal health, older adults should engage in extra muscle strengthening activity and higher-impact weight-bearing activities as tolerated. To maximize strength development, a resistance (weight) should be used that allows 10 to 15 repetitions for each exercise. The level of effort for muscle-strengthening activities should be moderate to high. On a 10-point scale, where no movement is 0 and maximal effort of a muscle group is 10, moderate-intensity effort is a 5 or 6 and high-intensity effort is a 7 or 8. To maintain the flexibility necessary for regular physical activity and daily life, older
adults should perform activities that maintain or increase flexibility on at least 2 days each week for at least 10 minutes each day. To reduce risk of injury from falls, communitydwelling older adults with substantial risk of falls (eg, with frequent falls or mobility problems) should perform exercises that maintain or improve balance.
Screening for Exercise In the AHA/ACSM guidelines for physical activity for older adults and chronic conditions,10 there is no discussion about the need for stress testing because the physical activity recommended is low level and individualized according to tolerance and progresses gradually. An excellent piece by Moore23 published in 1995 provides an excellent discussion on the risks of exercise for patients with renal disease. He states that there are disease-dependent and disease-independent risks, with most exercise risk manifested as disease independent, the most common being musculoskeletal injuries, which will be more likely in people who are more sedentary. Fracture may be more likely in dialysis patients with long-standing uncontrolled hyperparathyroidism, and the prudent approach with these individuals would be exercise that involves light resistance, non–weight-bearing activities. Given the high prevalence of diabetes in the dialysis population, loss of blood glucose control during exercise may be of concern. These patients must learn their own glucose response to exercise and adjust their diet and insulin accordingly. Exercise during dialysis may prevent severe drops in glucose, given that the dialysate glucose will serve as a form of a glycemic clamp, with blood glucose levels drifting toward the dialysate concentration. Sudden death and myocardial infarction are the most feared risks of exercise, given the high prevalence of cardiovascular disease in dialysis patients. Although a few thousand dialysis patients have participated in clinical or investigative exercise programs, no exercise-induced adverse cardiovascular events have been reported. It is probable that the level of exercise that most dialysis patients are able to perform for exercise training is similar to the energy level required for most
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activities of daily living, so the risk may be less than in those who do vigorous sports. Because the goal of exercise in older individuals and those with chronic disease (including dialysis patients) is to reduce sedentary behavior and to increase moderate activity (giving less emphasis to attaining high levels of activity),10 screening with stress testing may not be indicated and actually may present a barrier to participation. As long as individualized guidelines and recommendations are provided and appropriate referrals are made to cardiac rehabilitation, physical therapy, and clinical exercise physiologists, then risk will be minimal. It should be remembered that the data in the general population indicate that those who are least active are at greatest risk for myocardial infarction24,25 and sudden death26 during vigorous exercise, thus neglecting routine recommendations and encouragement for physical activity places patients at higher risk for negative cardiovascular events and poor outcomes.
Implementation Strategies It is unclear what strategy for implementing programs is best for patients with renal disease and whether this population has different programming needs than the general population. Renal patients have benefited from independent home exercise (studied in dialysis and transplant patients), structured outpatient supervised exercise training (reported in predialysis, dialysis and transplant), and exercise during the hemodialysis treatment. Physical therapy/occupational therapy is another viable possibility, and benefits have been reported in elderly dialysis patients.27 A description of physical therapy/occupational therapy interventions for patients with renal failure is presented in the current issue by Nussbaum. Each strategy has pros and cons, but the bottom line should always be that most patients can benefit from increased physical activity, and, at the bare minimum, all patients should receive educational information on the benefits of increased physical activity and how to get started and progress with a program. Such information is available free from the Life Options Renal Rehabilitation Advisory Council in the form of a booklet
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for patients titled ‘‘Exercise: A Guide for People on Dialysis.’’28 This information is appropriate for all renal patients, regardless of treatment and includes basic flexibility and strengthening exercises and guidelines for starting and progressing with cardiovascular exercise. It is available at www.lifeoptions.org. Encouragement from the health care team and incorporation of education/information on exercise into the routine care plan have been identified by patients as key facilitators for increasing physical activity.11,16 Thus, some mechanism to include assessment of physical activity, physical functioning levels, and education and ongoing encouragement for physical activity must be developed for the routine care plan. This could be done for all incident and prevalent patients, in the form of providing the Life Options booklet with ongoing follow-up as a part of the clinic visit or regular queries about and encouragement for physical activity participation by the dialysis staff. Patients can certainly exercise independently at home. The Renal Exercise Demonstration Project29 assessed physical functioning and provided patients with information about what they could do at home using the Life Options patient booklet. They reported increases in self-reported physical activity, from 12% participating in recommended levels of cardiovascular exercise at baseline to 30% after 8 weeks of independent home exercise. The independent home exercise resulted in significant improvements in gait speed, chair stand time, 6-minute walk time, self-reported physical functioning, and the physical composite score on the Short Form-36 questionnaire. Painter and colleagues30 also implemented a homebased independent exercise intervention over the first year of kidney transplant and reported 67% participation rates at 1 year and significant benefits in health-related fitness measures. Supervised outpatient exercise is also effective in improving physical function, physical fitness, and quality of life in patients with renal disease. Most early studies were performed in a supervised program either within an established cardiac rehabilitation program or structured in a similar way. Considering the time demands placed on patients on hemodialysis related to the treatment and
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medical visits as well as challenges with ambulation, transportation, and general mobility, problems with adherence have been reported with structured programs held on off-dialysis days. Nonetheless, benefits are achieved for those who are able to attend exercise sessions regularly, and the magnitude of benefits are similar from such a program in patients on hemodialysis and transplant recipients.31 The problem of adherence to outpatient exercise held on nondialysis days can be addressed by intadialytic exercise programming. It is feasible to use a cycle ergometer during the hemodialysis treatment. This is accomplished by having the patient pedal from the recliner (the ergometer is pushed up to the chair, and the patients’ feet are strapped to the pedals). Cycling during the dialysis treatment is best tolerated during the first hour of the treatment32 and does not interfere with the dialysis treatment in any way. In fact, during exercise the patient is more hemodynamically stable because systolic blood pressure increases with exercise. The benefits of intradialytic exercise have been well described by Cheema and colleagues,33 and, in addition to the many benefits related to physical function and clinical measures, cycling exercise has been shown to increase solute removal during the dialysis treatment, specifically phosphate34 urea, creatinine, and potassium.35 Cycling during dialysis also increases uptake of amino acids from parental nutrition.36 Resistance exercise can also be safely performed during the dialysis treatment as shown by Johansen and colleagues37 and Cheema and colleagues,38 and patients can obtain benefits of increased muscle size, strength, and improved physical function. About 50% of dialysis clinics in the Ruhr Area of Germany offer intradialytic exercise that includes bed cycling progressing from passive cycling to active cycling, exercises to improve strength, coordination, and flexibility.39 They also include progressive muscle relaxation and elements of play. These sessions are supervised by trained sports therapists. They have had up to 75% of patients participating in clinics, most of whom are older patients (average age 72 years) who participated in an average of 85% of possible sessions.
The benefits of an intradialytic exercise program go beyond direct benefits for patients. Such a program can change the atmosphere of a dialysis unit, bringing a sense of wellness to the environment and may change attitudes of staff toward patient ability. Patients often report feeling less fatigue and stiffness after the treatment, experiencing fewer hypotensive episodes, less muscle cramping, and feeling less anxious during the treatment. Intradialytic exercise also provides a supervised setting for motivating patients (by staff and other patients) and for dealing with any adverse responses to exercise (which have never been reported in research studies or clinical programs). There has been 1 study comparing 3 rehabilitation strategies in hemodialysis patients.40 Unsupervised home-based exercise (n¼10) involved stationary cycling recommended for at least 5 days per week 30 minutes per session at a heart rate of 50% to 60% of maximal rate. They were provided flexibility and muscular strengthening exercises and were contacted regularly by the study staff and had periodic home visits during their exercise session. Supervised outpatient exercise (n¼16) was held on nondialysis days. The exercise consisted of three 60-minute sessions per week with a 4:1 patient to leader ratio. The session consisted of a 10-minute warm-up on a cycle ergometer or treadmill and 30-minute intermittent cardiovascular exercise that included calisthenics, steps, and flexibility exercise at a heart rate of 60% to 70% of maximal heart rate. After 2 months, low-weight resistance training was added. After 3 months, sports such as basketball and swimming were added once a week. The third strategy was intradialytic exercise during the dialysis treatment (n¼10) using cycling exercise 3 times per week for 60 minutes per session. The target heart rate was about 70% of maximal heart rate. Thirty minutes were spent using a cycle ergometer, and 30 minutes were for strength and flexibility exercises for the lower extremities. The supervised outpatient program had the highest dropout rate over 6 months (24%) compared with the home exercise or the in-center program (17% for each). Peak oxygen uptake increased by 42% in the outpatient group, by 24% in the in-center program, and by 22% in the home exercise group.
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Summary A change in the culture of treatment of renal patients must occur in order to convey a clear message about the value of physical activity in this patient population. This can be done through changes in health care provider practice in assessing physical functioning and physical activity as a routine part of their assessment and recommending and encouraging participation in regular physical activity as a part of the patient care plan. Participation can happen in outpatient supervised settings, at the dialysis center, before or during the dialysis treatment, or independently at home or in a community-based program; patients just need to know that this is an important part of their care and their well-being. The recommendations should be individualized to meet the needs, goals, and ability of the patient, with programming being that which maximizes participation. In any case, the levels of physical functioning and physical activity in these patients are so low that any effort to increase physical activity is likely to be beneficial. In addition to the dramatic need to improve physical functioning and well-being in patients with CKD, there are nationally published practice guidelines for the management of hypertension, lipid abnormalities, cardiovascular risk, and diabetes (all of which are relevant comorbidities in patients with renal disease and include increased physical activity as a first step of treatment). The DOQI guidelines for management of cardiovascular disease also include a guideline stating: ‘‘All dialysis patients should be counseled and regularly encouraged by nephrology and dialysis staff to increase their level of physical activity.’’ Thus, there is plenty of reason to incorporate assessment of physical functioning and physical activity and recommendations and encouragement for increasing physical activity in patients with kidney disease. Figuring out the best way to make that all happen is the challenge for the nephrology community, and it may take reaching out to rehabilitation and exercise professionals for guidance and new ideas. At the very least, recognizing that nephrologists may not have the time, training, or inclination to learn to give a full exercise prescription, the following can be done within
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the short visits with patients: (1) ask about physical activity participation and help identify barriers; (2) recommend increasing activity if levels are low by recommending walking whenever feasible (unless the patient is nonambulatory or has gait instability or other contraindications to exercise; ie, unstable angina, uncontrolled heart failure, and uncontrolled hypertension); (3) provide educational materials (ie, ‘‘Exercise for the Dialysis Patient’’ available free from www. lifeoptions.org); and (4) refer to a trained health care professional who is qualified to work with exercise patients with chronic disease, such as physical/occupational therapists, cardiac rehabilitation specialists, or clinical exercise physiologists. These referrals should then be regularly followed up during the routine clinic visits to assess participation and progress and provide encouragement.
References 1. Cheema B, Singh MAF: Exercise training in patients receiving maintenance hemodialysis: A systematic review of clinical trials. Am J Nephrol 25:352-364, 2005 2. DeOreo PB: Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization and dialysis-attendance compliance. Am J Kidney Dis 30:204-212, 1997 3. Knight E, Ofsthun N, Teng M, et al: The association between mental health, physical function and hemodialysis mortality. Kidney Int 63:1843-1851, 2003 4. O’Hare AM, Tawney K, Bacchetti P, et al: Decreased survival among sedentary patients undergoing dialysis: Results from the Dialysis Morbidity and Mortality Study Wave 2. Am J Kidney Dis 41:447-454, 2003 5. Sietsema KE, Amato A, Adler SG, et al: Exercise capacity as a prognostic indicator among ambulatory patients with end stage renal disease. Kidney Int 65: 719-724, 2004 6. Stack AG, Molony DA, Rives T, et al: Association of physical activity with mortality in the US dialysis population. Am J Nephrol 45:690-701, 2005 7. Shalom R, Blumenthal JA, Williams RS: Feasibility and benefits of exercise training in patients on maintenance dialysis. Kidney Int 25:958-963, 1984 8. Painter PL, Nelson-Worel JN, Hill MM, et al: Effects of exercise training during hemodialysis. Nephron 43: 87-92, 1986 9. Tudor-Locke C, Meyers AM: Methodological considerations for researchers and practioners using pedometers to measure Physical Activity. Res Quarterly Exerc Sport 72:1-12, 2001 10. Nelson M, Rejeski W, Blair S, et al: Physical activity and public health in older adults: Recommendations from the American College of Sports Medicine and
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the American Heart Association. Med Sci Sports Exerc 39:1435-1445, 2007 Painter P, Ward K, Nelson R: Self-reported physical activity in ESRD patients. Submitted for publication July 2009. Johansen KL, Chertow GM, Ng AV, et al: Physical activity levels in patients on hemodialysis and healthy controls. Kidney Int 57:2564-2570, 2000 Zamojska S, Szklarek M, Niewodniczy M, et al: Correlates of habitual physical activity in chronic haemodialysis patients. Nephrol Dial Transplant 21:1323-1327, 2006 LeMasurier GC, Sidman CL, Corbin CB: Accumulating 10,000 steps: Does this meet current physical activity guidelines? Res Q Exerc Sport 74:389-395, 2003 Goodman ED, Ballou M: Perceived barriers and motivators to exercise in hemodialysis patients. Nephrol Nursing J 31:23-29, 2004 Kontos PC, Miller K, Brook D, et al: Factors influencing exercise participation by older adults requiring chronic hemodialysis: A qualitative study. Int J Urol Neprhol 39:1303-1311, 2007 Bluestone PA, Rasmussen G, Rogers T: Exercise Programs at Network 2 Dialysis Units. CMS Forum of ESRD Networks Annual Meeting 2002 Braun-Curtin R, Klag MJ, Bultman DC, et al: Renal rehabilitation and improved patient outcomes in Texas dialysis facilities. Am J Kidney Dis 40:331-338, 2002 Painter PL, Carlson L, Carey S, et al: Determinants of exercise encouragement practices in dialysis staff. ANNA J 31:67-74, 2004 Johansen KL, Sakkas GK, Doyle J, et al: Exercise counseling practices among nephrologists caring for patients on dialysis. Am J Kidney Dis 41:171-178, 2003 Krause R: Nephrologists’ view of exercise training in chronic kidney disease. Clin Nephrol 61(suppl 1): S2-S4, 2004 Huang Y, Zhang R, Culler SD, et al: Costs and effectiveness of cardiac rehabilitation for dialysis patients following coronary bypass. Kidney Int 74:1074-1084, 2008 Moore GE: Selecting dialysis patients for an exercise program. Semin Dial 8:42-44, 1995 Mittleman MA, Maclure M, Tofler GH, et al: Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. N Engl J Med 329:177-1683, 1993 Willich SN, Lewis M, Lowel H, et al: Physical exertion as a trigger of acute myocardial infarction. N Engl J Med 329:1684-1690, 1993 Siscovick DS, Weiss NS, Fletcher RH, et al: The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med 311:874-877, 1984
27. Pianta T, Kutner NG: Improving physical functioning in the elderly dialysis patient: Relevance of physical therapy. ANNA J 26:11-14, 1999 28. Painter PL: Exercise for individuals with end-stage renal disease in Goldberg L, in Elliot DL (ed.): Exercise for Prevention and Treatment of Illness. Philadelphia, PA, F.A. Davis, 1994, pp 289-300 29. Painter PL, Carlson L, Carey S, et al: Physical functioning and health related quality of life changes with exercise training in hemodialysis patients. Am J Kidney Dis 35:482-492, 2000 30. Painter PL, Tomlanovich S, Hector L, et al: A randomized trial of exercise training following renal transplantation. Transplantation 74:42-48, 2002 31. Van den Ham ECH, Kooman JP, Schols AMWJ, et al: The functional, metabolic and anabolic responses to exercise training in renal transplant and hemodialysis patients. Transplantation 83:1059-1068, 2007 32. Moore GE, Painter PL, Brinker KR, et al: Cardiovascular response to submaximal stationary cycling during hemodialysis. Am J Kidney Dis 31:631-637, 1998 33. Cheema BSB, Smith BCF, Singh MAF: A rationale for intradialytic exercise training as standard clinical practice in ESRD. Am J Kidney Dis 45:912-916, 2005 34. Vaithilingham I, Polkinghorne K, Atkins R, et al: Time and exercise improve phosphate removal in hemodialysis patients. Am J Kidney Dis 43:85-89, 2004 35. Kong C, Tattersal J, Greenwood R, et al: The effect of exercise during hemodialysis on solute removal. Nephrol Dial Transplant 14:2927-2931, 1999 36. Pupim LB, Flakoll PJ, Levenhagen DK, et al: Exercise augments the acute anabolic effects of intradialytic parenteral nutrition in chronic hemodialysis patients. Am J Physiol Endocrinol Metab 286: 589-597, 2004 37. Johansen KL, Mullligan K, Schambelan M: Anabolic effects of nandrolone decanoate in patients receiving dialysis: A randomized controlled trial. J Am Med Assoc 281:1275-1281, 1999 38. Cheema B, Abas H, Smith BCF, et al: Progressive exercise for anabolism in kidney disease (peak): A randomized controlled trial of resistance training during hemodialysis. J Am Soc Nephrol 18:15941601, 2007 39. Daul AE, Schafers RF, Daul K, et al: Exercise during hemodialysis. Clin Nephrol 61:S26-S30, 2004 40. Konstantinidou E, Koukouvou G, Kouidi E, et al: Exercise training in patients with end stage renal disease on hemodialysis: Comparison of three rehabilitation programs. J Rehabil Med 34:40-45, 2002
I
t is well documented that regular physical activity or exercise training is beneficial for patients with CKD. The benefits in patients treated with dialysis have been reported in over 45 studies that are summarized in a systematic review by Cheema and Singh.1 The benefits include improved clinical profiles (ie, reduced cardiovascular risk and function), physical functioning (improved exercise capacity, strength, and physical performance), and quality of life. Additionally, although the mechanism remains undetermined, regular physical activity and higher physical functioning is associated with improved outcomes, specifically reduced cardiac and overall mortality and lower hospitalization rate.2-6 Despite clear-cut documentation of low levels of physical functioning and physical activity and the robust evidence of the benefits of regular exercise in dialysis patients, regular assessment of physical functioning and encouragement for increased physical activity or regular exercise participation are still not a routine part of the medical care of renal patients and are given minimal attention or advocacy within the nephrology community. Thus, the challenge remains as to how to efficiently and effectively deliver a program of en-
From the School of Nursing, University of Minnesota, Minneapolis, MN. Address correspondence to Patricia Painter, PhD, School of Nursing, University of Minnesota, 6-149 Weaver-Densford Hall MC 1331, 308 Harvard St SE, Minneapolis, MN 55104. E-mail: [email protected] Ó 2009 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/09/1606-0013$36.00/0 doi:10.1053/j.ackd.2009.07.010
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couragement of physical activity and/or exercise training within the system of care for renal patients. This article discusses physical activity levels, barriers to participation, current practices, and various strategies to develop effective programs for patients on dialysis.
Historical Background The first suggestion that dialysis patients may require some innovative exercise programming came in the early 1980s in comparing 2 studies. In one of the first exercise training studies published by Shalom and colleagues,7 the concluding paragraph stated ‘‘a 12-week program of exercise conditioning can dramatically improve the work capacity of patients on dialysis, . The overall impact of this type of program may be limited by a low rate of sustained participation.’’ The exercise program required hemodialysis patients to attend an outpatient cardiac rehabilitation program on their off-dialysis days. Of the 14 patients who enrolled in the program and completed testing, 7 attended at least half of the training sessions. The patients who attended .50% of the sessions experienced improved exercise capacity of 45%. The others did not change in their exercise capacity. In contrast, in 1986, Painter and colleagues8 reported the effects of an exercise program that was delivered using a stationary cycle during the dialysis treatment and reported significant improvements in exercise capacity (VO2peak) and improvements in blood pressure. This study reported participation in 91% of all sessions in the first 3 months (monitored by study staff) and 75% during the second 3 months, which was self-monitored. It is intuitively
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obvious and clearly shown in these 2 studies that regular participation is necessary for benefits to be realized and that the type of programming may make a difference. Thus, it is critical to develop programs that facilitate participation to maximize effectiveness.
Physical Activity Levels in CKD Patients The assessment of physical activity remains fraught with measurement challenges9; however, questionnaires are widely used, despite the shortcomings of recall, self-report, and quantification of energy expenditure of various activities. Activity monitors and step counters provide a bit more quantification of movement; however, neither provides information on intensity of effort and neither is able to assess activities in which the mode of activity is something other than walking or jogging. Despite measurement issues, it is fairly well documented that physical activity is low in patients treated with hemodialysis. The Dialysis Morbidity and Mortality Study (DMMS) Wave 2 included a question on the frequency of participation in regular physical activity during their leisure time. Possible answers ranged from never or almost never to daily. The DMMS included 4,024 new patients starting hemodialysis or peritoneal dialysis patients in 1996 and 1997. Of these, 502 were excluded because they were unable to ambulate, and 2264 had complete data on the physical activity question.4 In those with physical activity data, the frequency of participation was 19.8% daily or almost daily, 5.5% 4 to 5 times per week, 18.4% 2 to 3 times per week, 21.2% 1 or less than 1 time per week, and 35.1% never.4 The DMMS Wave 2 question only assessed frequency of physical activity in leisure time, did not define physical activity, and did not assess intensity or duration of activity. Updated guidelines for physical activity and the elderly and those with chronic conditions published by the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) are more specific in their recommendations for frequency duration and intensity of activity for health benefits (details later).10
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In accordance with these updated recommendations, the Renal Network 11 surveyed renal patients11 using a questionnaire that included the following sequence of questions: Do you do any regular physical activity? If yes, how many days per week? and How many minutes per session? It also included the following question to gauge the intensity of the activity: ‘‘How hard do you exert yourself during your activity?’’ Response options were ‘‘very easy,’’ ‘‘easy,’’ ‘‘somewhat hard,’’ ‘‘hard,’’ and ‘‘very hard.’’ One thousand twenty-three surveys were returned and included 83% treated with hemodialysis, 10% with peritoneal dialysis, and 6.8% with functioning transplants. Although 53% stated they participated regularly in physical activity, of these, only 24% participated at levels recommended by the AHA/ACSM (13.2% of the total respondents). The difference between those who report some physical activity and those participating in the recommended levels was intensity of effort of the exercise. Seventyfour percent of those reporting some physical activity met the recommended frequency criteria (of 3 or more days per week), and 47% met the criteria of 30 minutes or more per session, whereas only 34% reported an exertion level of ‘‘somewhat hard’’ or higher (compared with 100% of those in the recommended level). Johansen and colleagues12 used 3-dimensional accelerometers to measure physical activity over 7 days in a group of 34 hemodialysis patients and compared them with a control group of healthy individuals of similar ages. They found significantly lower activity in the dialysis patients (P ,.0001) with the difference between the dialysis patients and controls increasing with age. They provide the example that for a male of age 30, predicted activity would be 15% lower for a dialysis patient than for a healthy sedentary person, whereas a male of age 70 on dialysis patient would be predicted to be 57% less active than a sedentary person without CKD. Zamojska and colleagues13 used step counters in 60 hemodialysis patients to determine average steps accumulated over 48 hours. They found that the dialysis patients accumulated only 48% of the steps that healthy subjects accumulated (689662357vs healthy controls
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14,18165383, P ,.001). There are suggestions in the literature that a desirable number of steps for health benefits is around 10,000 per day.14
Barriers to Physical Activity in CKD It is not difficult to think of reasons why patients with CKD treated with dialysis do not participate in regular physical activity. There have been 3 studies that identify barriers to participation in physical activity in dialysis patients.11,15,16 In the study by Goodman and Ballou,15 the most frequently cited barrier to physical activity was ‘‘lack of motivation,’’ and the strongest facilitator for physical activity participation was ‘‘desire to feel healthy.’’ Kontos and colleageus16 reported results from a qualitative study that patients felt that the nurses’ lack of encouragement to exercise, transportation issues, and the use of exercise equipment that precludes participation during the dialysis treatment were all barriers to participation. They also identified fatigue and depression as exercise impediments. In the Network 11 survey, the top reasons cited for not participating in regular physical activity were ‘‘I’m just not motivated,’’ ‘‘I’m too tired,’’ I’m too sick,’’ and ‘‘I have no place to exercise or exercise equipment.’’ Interestingly, some of the key barriers reported by patients can be improved through regular exercise (ie, fatigue, depression, lack of energy, and lack of strength). The most frequent benefits cited in the Network 11 survey by those who participated in regular physical activity were ‘‘improved energy levels,’’ ‘‘improved muscle strength,’’ and ‘‘enhanced ability to do the things I need to do in life.’’
Current Practice for Physical Activity Promotion The question remains as to why patients with CKD remain physically inactive. The Network 11 survey11 asked ‘‘What do you think is the best way to get people with kidney disease to increase their physical activity.’’ The top responses were ‘‘encouragement and recommendations from the physician’’; ‘‘make it a part of the routine education of patients when they get kidney disease’’; and ‘‘encouragement from family/friends’’ and ‘‘encouragement from health care team.’’ There have
been several studies that provide some insight into current practices. Kontos and colleagues16 also found that patients seemed to be in need of encouragement from the dialysis nursing staff, with 1 patient stating that ‘‘if it were discussed, that would certainly motivate me.’’ In June 2000, the Rehabilitation Committee of the ESRD Network of New York (Network 2) surveyed the 200 dialysis clinics in the Network to learn about their exercise programs, to identify units with successful programs, and to identify factors that may be barriers to developing successful programs.17 Ninety-one percent of the units (n¼182) returned the survey. Fourteen percent (26 units) offered an exercise program. On average, 20 patients per unit participated, most while dialyzing. There was about a 25% patient dropout rate primarily because of medical problems, loss of interest, and staff shortages. The major barriers identified were as follows: (1) nephrologists were either not interested or not convinced of the benefits of exercise for their patients; (2) nephrologists were concerned about the safety of exercise; (3) staffing issues were of concern, including funding and lack of time; and (4) patients lacked information about the benefits of exercise. A second survey was performed by the Life Options Advisory Council staff in cooperation with the ESRD Network of Texas and Council of Nephrology Social Workers of North Texas.18 The survey used the Unit Self-Assessment Tool, which was developed to quantify and catalog ongoing rehabilitation efforts within dialysis clinics (www.lifeoptions.org). The tool is a self-scored checklist of 100 possible rehabilitation activities that was organized according to the 5 core principles of rehabilitation. The exercise category consisted of 20 activities divided into levels of difficulty or complexity, each of which was given 1 point for scoring. Thus, the highest possible score for the exercise category was 20. One hundred sixty-nine centers completed the survey (68% response rate). Exercise practice was the lowest of all rehabilitation practices, with an average of 3.762.9 activities in the units. Only 21% of facilities had any advanced exercise activities (ie, support of local fitness events among renal patients; providing for exercise programming outside of the unit; and providing in-center, organized fitness activities during dialysis).
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Another study has determined that staff within the dialysis clinics are not routinely encouraging patients to participate in regular physical activity.19 One hundred dialysis staff with direct patient care responsibilities (nursing staff, patient care technicians, dieticians, or social workers) in 5 clinics completed questionnaires to assess encouragement for physical activity practices. Although 45% stated that their patients would benefit from increasing physical activity, 34% never asked about physical limitations, and 24% never or rarely encouraged patients to be more physically active. Only 32% stated that they regularly encouraged patients to be active. Predictors of low physical activity encouragement among dialysis staff were (1) job position (ie, not professionally trained), (2) agreement with the statement ‘‘It is not my responsibility to help patients increase their physical functioning,’’ (3) a perception of a lack of skills for motivating patients to exercise, and (4) agreement with the statement ‘‘dialysis patients lack motivation to exercise.’’ Kontos and colleagues16 also reported that although dialysis staff acknowledged the potential benefits of exercise for their patients, they felt that they did not have time to encourage patients to exercise, and thus low priority was placed on exercise in the overall treatment plans. Additionally, these dialysis nurses were uncomfortable with regard to use of in-center exercise equipment. It is clear from these data that, although patient care staff members think exercise is important and they want their patients to improve their levels of functioning, no consistent training is provided or policies/responsibilities in place within the units for staff to either assess functioning or encourage exercise. As dialysis staff who participated in the Kontos study emphasized, a ‘‘change in the medical culture’’ is needed to elevate the priority of exercise for well being in patient care plans. Exercise counseling practices among nephrologists caring for patients on dialysis were the topic of a survey reported by Johansen and colleagues.20 The investigators surveyed a total of 505 nephrologists attending the Meeting of the American Society of Nephrology (October 2001), 277 of whom were from the United States. Although 98.6% of
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the US nephrologists stated that physical activity is beneficial for patients on dialysis, only 48.9% often ask about physical activity, and only 28.5% routinely prescribe exercise for their patients. Additionally, only 4.3% of the nephrologists provide written material about exercise to their patients. Characteristics that were significantly associated with noncounseling behavior in multivariate analysis were as follows: no time for physical activity counseling (P , .0001), not confident in counseling ability (P¼.005), physical activity not as important as other medical concerns (P¼.051), younger age of physician (P , .0001), male sex (P¼.013), and lower percentage of practice that was primary care (P¼.035). The authors suggest that these findings are consistent with the current practice, which emphasizes management of the dialysis procedure and specific side effects of kidney disease and not physical functioning and attention to factors that affect well-being and quality of life and maintaining independence. A smaller group of nephrologists mostly from Europe completed a similar questionnaire at the 2003 World Congress of Nephrology.21 This survey indicated that 95% agreed on the fact that the sedentary lifestyle is an important risk factor in CKD patients; 78% thought that it is the responsibility of the nephrologist to advise patients about physical activity. Thirty-three percent stated that they offered in-center exercise training programs, and 15% said patients participate in out-center exercise groups. Huang and colleagues22 used Medicare expenditure data to evaluate the cost-effectiveness of referral to cardiac rehabilitation in hemodialysis patients after coronary artery bypass graft surgery. They reported that referral to cardiac rehabilitation was 13% lower for dialysis patients than for the general population of coronary artery bypass graft surgery patients and that cardiac rehabilitation was associated with longer cumulative life and was cost-effective. This clearly indicates that there is underutilization of even the resources that are already available for our patients.
Physical Activity Recommendations There is general agreement that the recommendations for physical activity for dialysis
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patients should be no different than those for the general population.10 Recommended components include cardiovascular exercise training, strengthening exercise, flexibility, and balance exercises. The recommendations for older adults may be most appropriate for the general dialysis population. Studies following these recommendations have reported no adverse responses, and it is generally accepted that such activity is well tolerated and results in benefits detailed elsewhere in this issue (VanVleck/Parsons). The following are the physical activity guidelines for older adults as outlined by the AHA/ACSM. To promote and maintain health, older adults need moderate-intensity aerobic physical activity for a minimum of 30 minutes on 5 days each week or vigorous-intensity aerobic activity for a minimum of 20 minutes on 3 days each week. Moderate-intensity aerobic (cardiovascular) activity involves a moderate level of effort relative to an individual’s aerobic fitness. On a 10-point scale, where sitting is 0 and all-out effort is 10, moderate-intensity activity is a 5 or 6 and produces noticeable increases in heart rate and breathing. On the same scale, vigorous-intensity activity is a 7 or 8 and produces large increases in heart rate and breathing. For example, given the heterogeneity of fitness levels in older adults, for some older adults a moderate-intensity walk is a slow walk, and for others it is a brisk walk. To help prevent unhealthy weight gain, some older adults may need to exceed minimum recommended amounts of physical activity to a point that is individually effective in achieving energy balance while considering diet and other factors that affect body weight. To further promote and maintain skeletal health, older adults should engage in extra muscle strengthening activity and higher-impact weight-bearing activities as tolerated. To maximize strength development, a resistance (weight) should be used that allows 10 to 15 repetitions for each exercise. The level of effort for muscle-strengthening activities should be moderate to high. On a 10-point scale, where no movement is 0 and maximal effort of a muscle group is 10, moderate-intensity effort is a 5 or 6 and high-intensity effort is a 7 or 8. To maintain the flexibility necessary for regular physical activity and daily life, older
adults should perform activities that maintain or increase flexibility on at least 2 days each week for at least 10 minutes each day. To reduce risk of injury from falls, communitydwelling older adults with substantial risk of falls (eg, with frequent falls or mobility problems) should perform exercises that maintain or improve balance.
Screening for Exercise In the AHA/ACSM guidelines for physical activity for older adults and chronic conditions,10 there is no discussion about the need for stress testing because the physical activity recommended is low level and individualized according to tolerance and progresses gradually. An excellent piece by Moore23 published in 1995 provides an excellent discussion on the risks of exercise for patients with renal disease. He states that there are disease-dependent and disease-independent risks, with most exercise risk manifested as disease independent, the most common being musculoskeletal injuries, which will be more likely in people who are more sedentary. Fracture may be more likely in dialysis patients with long-standing uncontrolled hyperparathyroidism, and the prudent approach with these individuals would be exercise that involves light resistance, non–weight-bearing activities. Given the high prevalence of diabetes in the dialysis population, loss of blood glucose control during exercise may be of concern. These patients must learn their own glucose response to exercise and adjust their diet and insulin accordingly. Exercise during dialysis may prevent severe drops in glucose, given that the dialysate glucose will serve as a form of a glycemic clamp, with blood glucose levels drifting toward the dialysate concentration. Sudden death and myocardial infarction are the most feared risks of exercise, given the high prevalence of cardiovascular disease in dialysis patients. Although a few thousand dialysis patients have participated in clinical or investigative exercise programs, no exercise-induced adverse cardiovascular events have been reported. It is probable that the level of exercise that most dialysis patients are able to perform for exercise training is similar to the energy level required for most
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activities of daily living, so the risk may be less than in those who do vigorous sports. Because the goal of exercise in older individuals and those with chronic disease (including dialysis patients) is to reduce sedentary behavior and to increase moderate activity (giving less emphasis to attaining high levels of activity),10 screening with stress testing may not be indicated and actually may present a barrier to participation. As long as individualized guidelines and recommendations are provided and appropriate referrals are made to cardiac rehabilitation, physical therapy, and clinical exercise physiologists, then risk will be minimal. It should be remembered that the data in the general population indicate that those who are least active are at greatest risk for myocardial infarction24,25 and sudden death26 during vigorous exercise, thus neglecting routine recommendations and encouragement for physical activity places patients at higher risk for negative cardiovascular events and poor outcomes.
Implementation Strategies It is unclear what strategy for implementing programs is best for patients with renal disease and whether this population has different programming needs than the general population. Renal patients have benefited from independent home exercise (studied in dialysis and transplant patients), structured outpatient supervised exercise training (reported in predialysis, dialysis and transplant), and exercise during the hemodialysis treatment. Physical therapy/occupational therapy is another viable possibility, and benefits have been reported in elderly dialysis patients.27 A description of physical therapy/occupational therapy interventions for patients with renal failure is presented in the current issue by Nussbaum. Each strategy has pros and cons, but the bottom line should always be that most patients can benefit from increased physical activity, and, at the bare minimum, all patients should receive educational information on the benefits of increased physical activity and how to get started and progress with a program. Such information is available free from the Life Options Renal Rehabilitation Advisory Council in the form of a booklet
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for patients titled ‘‘Exercise: A Guide for People on Dialysis.’’28 This information is appropriate for all renal patients, regardless of treatment and includes basic flexibility and strengthening exercises and guidelines for starting and progressing with cardiovascular exercise. It is available at www.lifeoptions.org. Encouragement from the health care team and incorporation of education/information on exercise into the routine care plan have been identified by patients as key facilitators for increasing physical activity.11,16 Thus, some mechanism to include assessment of physical activity, physical functioning levels, and education and ongoing encouragement for physical activity must be developed for the routine care plan. This could be done for all incident and prevalent patients, in the form of providing the Life Options booklet with ongoing follow-up as a part of the clinic visit or regular queries about and encouragement for physical activity participation by the dialysis staff. Patients can certainly exercise independently at home. The Renal Exercise Demonstration Project29 assessed physical functioning and provided patients with information about what they could do at home using the Life Options patient booklet. They reported increases in self-reported physical activity, from 12% participating in recommended levels of cardiovascular exercise at baseline to 30% after 8 weeks of independent home exercise. The independent home exercise resulted in significant improvements in gait speed, chair stand time, 6-minute walk time, self-reported physical functioning, and the physical composite score on the Short Form-36 questionnaire. Painter and colleagues30 also implemented a homebased independent exercise intervention over the first year of kidney transplant and reported 67% participation rates at 1 year and significant benefits in health-related fitness measures. Supervised outpatient exercise is also effective in improving physical function, physical fitness, and quality of life in patients with renal disease. Most early studies were performed in a supervised program either within an established cardiac rehabilitation program or structured in a similar way. Considering the time demands placed on patients on hemodialysis related to the treatment and
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medical visits as well as challenges with ambulation, transportation, and general mobility, problems with adherence have been reported with structured programs held on off-dialysis days. Nonetheless, benefits are achieved for those who are able to attend exercise sessions regularly, and the magnitude of benefits are similar from such a program in patients on hemodialysis and transplant recipients.31 The problem of adherence to outpatient exercise held on nondialysis days can be addressed by intadialytic exercise programming. It is feasible to use a cycle ergometer during the hemodialysis treatment. This is accomplished by having the patient pedal from the recliner (the ergometer is pushed up to the chair, and the patients’ feet are strapped to the pedals). Cycling during the dialysis treatment is best tolerated during the first hour of the treatment32 and does not interfere with the dialysis treatment in any way. In fact, during exercise the patient is more hemodynamically stable because systolic blood pressure increases with exercise. The benefits of intradialytic exercise have been well described by Cheema and colleagues,33 and, in addition to the many benefits related to physical function and clinical measures, cycling exercise has been shown to increase solute removal during the dialysis treatment, specifically phosphate34 urea, creatinine, and potassium.35 Cycling during dialysis also increases uptake of amino acids from parental nutrition.36 Resistance exercise can also be safely performed during the dialysis treatment as shown by Johansen and colleagues37 and Cheema and colleagues,38 and patients can obtain benefits of increased muscle size, strength, and improved physical function. About 50% of dialysis clinics in the Ruhr Area of Germany offer intradialytic exercise that includes bed cycling progressing from passive cycling to active cycling, exercises to improve strength, coordination, and flexibility.39 They also include progressive muscle relaxation and elements of play. These sessions are supervised by trained sports therapists. They have had up to 75% of patients participating in clinics, most of whom are older patients (average age 72 years) who participated in an average of 85% of possible sessions.
The benefits of an intradialytic exercise program go beyond direct benefits for patients. Such a program can change the atmosphere of a dialysis unit, bringing a sense of wellness to the environment and may change attitudes of staff toward patient ability. Patients often report feeling less fatigue and stiffness after the treatment, experiencing fewer hypotensive episodes, less muscle cramping, and feeling less anxious during the treatment. Intradialytic exercise also provides a supervised setting for motivating patients (by staff and other patients) and for dealing with any adverse responses to exercise (which have never been reported in research studies or clinical programs). There has been 1 study comparing 3 rehabilitation strategies in hemodialysis patients.40 Unsupervised home-based exercise (n¼10) involved stationary cycling recommended for at least 5 days per week 30 minutes per session at a heart rate of 50% to 60% of maximal rate. They were provided flexibility and muscular strengthening exercises and were contacted regularly by the study staff and had periodic home visits during their exercise session. Supervised outpatient exercise (n¼16) was held on nondialysis days. The exercise consisted of three 60-minute sessions per week with a 4:1 patient to leader ratio. The session consisted of a 10-minute warm-up on a cycle ergometer or treadmill and 30-minute intermittent cardiovascular exercise that included calisthenics, steps, and flexibility exercise at a heart rate of 60% to 70% of maximal heart rate. After 2 months, low-weight resistance training was added. After 3 months, sports such as basketball and swimming were added once a week. The third strategy was intradialytic exercise during the dialysis treatment (n¼10) using cycling exercise 3 times per week for 60 minutes per session. The target heart rate was about 70% of maximal heart rate. Thirty minutes were spent using a cycle ergometer, and 30 minutes were for strength and flexibility exercises for the lower extremities. The supervised outpatient program had the highest dropout rate over 6 months (24%) compared with the home exercise or the in-center program (17% for each). Peak oxygen uptake increased by 42% in the outpatient group, by 24% in the in-center program, and by 22% in the home exercise group.
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Summary A change in the culture of treatment of renal patients must occur in order to convey a clear message about the value of physical activity in this patient population. This can be done through changes in health care provider practice in assessing physical functioning and physical activity as a routine part of their assessment and recommending and encouraging participation in regular physical activity as a part of the patient care plan. Participation can happen in outpatient supervised settings, at the dialysis center, before or during the dialysis treatment, or independently at home or in a community-based program; patients just need to know that this is an important part of their care and their well-being. The recommendations should be individualized to meet the needs, goals, and ability of the patient, with programming being that which maximizes participation. In any case, the levels of physical functioning and physical activity in these patients are so low that any effort to increase physical activity is likely to be beneficial. In addition to the dramatic need to improve physical functioning and well-being in patients with CKD, there are nationally published practice guidelines for the management of hypertension, lipid abnormalities, cardiovascular risk, and diabetes (all of which are relevant comorbidities in patients with renal disease and include increased physical activity as a first step of treatment). The DOQI guidelines for management of cardiovascular disease also include a guideline stating: ‘‘All dialysis patients should be counseled and regularly encouraged by nephrology and dialysis staff to increase their level of physical activity.’’ Thus, there is plenty of reason to incorporate assessment of physical functioning and physical activity and recommendations and encouragement for increasing physical activity in patients with kidney disease. Figuring out the best way to make that all happen is the challenge for the nephrology community, and it may take reaching out to rehabilitation and exercise professionals for guidance and new ideas. At the very least, recognizing that nephrologists may not have the time, training, or inclination to learn to give a full exercise prescription, the following can be done within
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the short visits with patients: (1) ask about physical activity participation and help identify barriers; (2) recommend increasing activity if levels are low by recommending walking whenever feasible (unless the patient is nonambulatory or has gait instability or other contraindications to exercise; ie, unstable angina, uncontrolled heart failure, and uncontrolled hypertension); (3) provide educational materials (ie, ‘‘Exercise for the Dialysis Patient’’ available free from www. lifeoptions.org); and (4) refer to a trained health care professional who is qualified to work with exercise patients with chronic disease, such as physical/occupational therapists, cardiac rehabilitation specialists, or clinical exercise physiologists. These referrals should then be regularly followed up during the routine clinic visits to assess participation and progress and provide encouragement.
References 1. Cheema B, Singh MAF: Exercise training in patients receiving maintenance hemodialysis: A systematic review of clinical trials. Am J Nephrol 25:352-364, 2005 2. DeOreo PB: Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization and dialysis-attendance compliance. Am J Kidney Dis 30:204-212, 1997 3. Knight E, Ofsthun N, Teng M, et al: The association between mental health, physical function and hemodialysis mortality. Kidney Int 63:1843-1851, 2003 4. O’Hare AM, Tawney K, Bacchetti P, et al: Decreased survival among sedentary patients undergoing dialysis: Results from the Dialysis Morbidity and Mortality Study Wave 2. Am J Kidney Dis 41:447-454, 2003 5. Sietsema KE, Amato A, Adler SG, et al: Exercise capacity as a prognostic indicator among ambulatory patients with end stage renal disease. Kidney Int 65: 719-724, 2004 6. Stack AG, Molony DA, Rives T, et al: Association of physical activity with mortality in the US dialysis population. Am J Nephrol 45:690-701, 2005 7. Shalom R, Blumenthal JA, Williams RS: Feasibility and benefits of exercise training in patients on maintenance dialysis. Kidney Int 25:958-963, 1984 8. Painter PL, Nelson-Worel JN, Hill MM, et al: Effects of exercise training during hemodialysis. Nephron 43: 87-92, 1986 9. Tudor-Locke C, Meyers AM: Methodological considerations for researchers and practioners using pedometers to measure Physical Activity. Res Quarterly Exerc Sport 72:1-12, 2001 10. Nelson M, Rejeski W, Blair S, et al: Physical activity and public health in older adults: Recommendations from the American College of Sports Medicine and
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