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The Importance of Exercise for Chronic Kidney Disease Patients
PATIENT EDUCATION Feature Editor: Catherine M. Goeddeke-Merickel, MS, RDN, LD
The Importance of Exercise for Chronic Kidney Disease Patients Danielle L. Kirkman, PhD,* Shannon Lennon-Edwards, RD, PhD,*† and David G. Edwards, PhD*
Intended Audiences: Patients Across All Stages of Chronic Kidney Disease Including Those Receiving Renal Replacement Therapy
D
UE TO FATIGUE and muscle weakness, patients with chronic kidney disease (CKD) have low levels of physical activity.1 The decline in physical capacity in this patient cohort is noteworthy as it is associated with deconditioning and muscle wasting, declining kidney function, and an increased risk of comorbidities such as cardiovascular disease.2 Thus, a downward spiral between disease, disuse, and deconditioning exists leading to a reduced quality of life, increased hospitalization rates, and mortality. Increasing physical activity is therefore an essential aspect of disease prevention and management in CKD patients. Current National Kidney Foundation Kidney Disease Outcomes Quality Initiatives (NKF KDOQI) guidelines for clinical practice suggest that encouraging participation in physical activity should be part of the routine care plan.3 These guidelines recommend ‘‘cardiovascular exercise at a moderate intensity for 30 minutes on most, if not all, days per week and those patients who are not currently physically active or are severely deconditioned should start at very low levels and durations and gradually progress to this recommended level’’.3 Over three decades of research has revealed a myriad of health benefits as a result of regular exercise in patients with CKD. These benefits include increased physical fitness and muscle strength; prevention of muscle wasting; improvement in cardiovascular health; improved nutritional parameters; and a reduction of chronic inflamma*Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. †Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware. Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to David G. Edwards, PhD, Department of Kinesiology and Applied Physiology, University of Delaware, 201Q Health Sciences Complex, Newark, DE 19713. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2014.07.012
Journal of Renal Nutrition, Vol 24, No 6 (November), 2014: pp e51-e53
tion.4 In addition to physiological benefits, exercise improves health-related quality of life and has shown psychological benefits such as decreases in anxiety, stress, and depression in this patient population.5 Despite current guidelines and favorable evidence, exercise is still not prescribed as part of routine care for CKD patients. The multidisciplinary nephrology team is an integral part of encouraging and integrating physical activity and regular exercise into clinical practice. The nephrology dietitian is especially key because this individual can easily combine counseling for healthy eating habits with the need for exercise. The information provided is aimed to promote physical activity counseling and empower health providers to prescribe exercise a routine part of care for CKD patients.
References 1. Johansen KL, Chertow GM, Ng AV, et al. Physical activity levels in patients on hemodialysis and healthy sedentary controls. Kidney Int. 2000;57:2564-2570. 2. Painter P, Roshanravan B. The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Curr Opin Nephrol Hypertens. 2013;22:615-623. 3. Bolton K, Beddhu S, Campese V, et al. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45:S7-S153. 4. Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev. 2011:CD003236. 5. Ouzouni S, Kouidi E, Sioulis A, Grekas D, Deligiannis A. Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients. Clin Rehabil. 2009;23:53-63. 6. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377-381. 7. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1435-1445.
e51
GET READY Increasing physical activity levels has many benefits for patients with CKD: Reduces the risk of heart disease: physical activity helps manage your blood pressure and cholesterol, makes your heart more efficient, and improves the health of your blood vessels. Improves muscle health: physical activity helps keep you strong and maintain your ability to carry out everyday activities. Keeps you fit: As you become fitter, you can do more with less effort helping you to remain independent and have a better quality of life. Reduces stress, anxiety and depression leaving you feeling revitalized and relaxed.
GET SET Set your goals: Share your physical activity goals and health goals with health care providers, fellow patients, friends, and family to create a support network that will help you to achieve them. Split your main goal into smaller, weekly realistic, achievable goals. For example: Main goal: ‘‘In 6 months time, I would like to be able to walk 3 miles/week.’’ Smaller goals: ‘‘By next week, I will make sure I have a comfortable pair of shoes to start walking’’; ‘‘Over the next 2 weeks, I will go for a 10-minute walk before I start my dialysis treatment.’’
Identify potential barriers that may prevent you from achieving your goals in advance and make a plan to overcome these barriers. For example: ‘‘I will ask a friend who also wants to increase their activity levels to walk with me in the morning, that way when I don’t feel like walking I will have someone to motivate me’’.
GO Walking Walking regularly is an easy and convenient way to increase your physical activity levels. Research has shown that walking 30 minutes/day most days of the week has many health benefits in patients with kidney disease. Using a pedometer to count the number of steps you take per day is a good way to monitor your walking activity. Starting with your current daily step count, increase your daily step count by 10% each week until you reach the recommended 10,000 steps/day. Dialysis Patients Can Increase Physical Activity Levels During Dialysis Taking part in physical activity during your dialysis session is a convenient way to increase your activity levels in a supervised setting when you would usually be sedentary. Speak to your health care providers about getting equipment that will allow you to exercise during dialysis. Monitoring the Difficulty of Your Physical Activity Using the ‘‘Ratings of Perceived Exertion’’ scale6 is a good way to measure how hard your physical activity is and to monitor your progress. This scale allows you to rate how difficult you feel during any activity. The activity ratings range from 6 (sitting on the couch, no exertion) to 20 (extremely hard, the most difficult activity you have ever done). Ideally, physical activity should gradually be increased until Ratings of Perceived Exertion falls between 12 and 16.
Rating of Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Extremely Light
Little or no effort. How you feel lying in bed or sitting in a chair. Can talk or sing easily without feeling breathless
Very Light Fairly Light
Target Range How you should feel with activity and exercise. Can comfortably talk but not sing without gasping for breaths
Somewhat Hard Hard Very Hard
How you feel with the hardest work you have ever done. Cannot say more than a few words without gasping for breath. Don’t work this hard!
Extremely Hard
Keep Safe Consult your doctor before you increase your physical activity or exercise. You should not exercise if: You have chest pains or you have suffered a cardiac event in the last 6 wk. You are short of breath when at rest and you have visible swelling from fluid overload You have an acute infection or a fever You have poor control of your diabetes or blood pressure Be aware of the following when increasing your physical activity: Stop any activity if you experience chest pain, dizziness or unusual shortness of breath. Sometimes you may have increased thirst levels when increasing your physical activity. Be aware of your fluid restrictions. Monitor your blood sugar closely during any activity if you have diabetes. Slow your activity down if: You feel very tired or not able to continue You are too short of breath to talk You do not feel fully recovered after 1 h of exercise You have an unusually high heart rate
Perceived Exertion Scale Exercise Recommendations Type Aerobic exercise involves rhythmic activity of large muscle groups that can be continuously maintained. Examples include walking, jogging, cycling, rowing, and swimming. Goal: increase physical fitness; reduce cardiovascular risk Resistance exercises use weight or resistance using free weights, weight machines, resistance bands, medicine balls, or your own body weight. Goal: increase muscle mass and muscle strength Flexibility exercises can be static (eg, bending over to touch your toes with out bending your knees) or dynamic (eg, high knees or back kicks). Goal: increase range of motion; reduce exercise-related injury risk Balance exercises include walking backwards, heel toe walking in a straight line, or standing on one leg at a time. Goal: fall prevention
Frequency $5 d/wk
Intensity
Duration
Moderate to hard (RPE 12-15; $30 min noticeable increases in heart rate and breathing)
2-3 d/wk (nonconsecutive Moderate to hard (RPE 12-15; 8 to 10 exercises targeting upper days) 60%-80% one repetition and lower body large muscle maximum) groups, 10 to 15 repetitions
$2 d/wk (perform on the same days as aerobic or resistance exercises)
10 min targeting major muscle groups. Hold each static stretch for 10 to 30 s. Repeat each stretch 3 to 4 times
$3 d/wk
Based on American Heart Association and American College of Sports Medicine recommendations for physical activity in older adults.7
Helpful Links www.kidney.org/atoz/content/stayfit.cfm. www.britishrenal.org/AboutUs/Time/Exercise.aspx.
The Importance of Exercise for Chronic Kidney Disease Patients Danielle L. Kirkman, PhD,* Shannon Lennon-Edwards, RD, PhD,*† and David G. Edwards, PhD*
Intended Audiences: Patients Across All Stages of Chronic Kidney Disease Including Those Receiving Renal Replacement Therapy
D
UE TO FATIGUE and muscle weakness, patients with chronic kidney disease (CKD) have low levels of physical activity.1 The decline in physical capacity in this patient cohort is noteworthy as it is associated with deconditioning and muscle wasting, declining kidney function, and an increased risk of comorbidities such as cardiovascular disease.2 Thus, a downward spiral between disease, disuse, and deconditioning exists leading to a reduced quality of life, increased hospitalization rates, and mortality. Increasing physical activity is therefore an essential aspect of disease prevention and management in CKD patients. Current National Kidney Foundation Kidney Disease Outcomes Quality Initiatives (NKF KDOQI) guidelines for clinical practice suggest that encouraging participation in physical activity should be part of the routine care plan.3 These guidelines recommend ‘‘cardiovascular exercise at a moderate intensity for 30 minutes on most, if not all, days per week and those patients who are not currently physically active or are severely deconditioned should start at very low levels and durations and gradually progress to this recommended level’’.3 Over three decades of research has revealed a myriad of health benefits as a result of regular exercise in patients with CKD. These benefits include increased physical fitness and muscle strength; prevention of muscle wasting; improvement in cardiovascular health; improved nutritional parameters; and a reduction of chronic inflamma*Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. †Department of Behavioral Health and Nutrition, University of Delaware, Newark, Delaware. Financial Disclosure: The authors declare that they have no relevant financial interests. Address correspondence to David G. Edwards, PhD, Department of Kinesiology and Applied Physiology, University of Delaware, 201Q Health Sciences Complex, Newark, DE 19713. E-mail: [email protected] Ó 2014 by the National Kidney Foundation, Inc. All rights reserved. 1051-2276/$36.00 http://dx.doi.org/10.1053/j.jrn.2014.07.012
Journal of Renal Nutrition, Vol 24, No 6 (November), 2014: pp e51-e53
tion.4 In addition to physiological benefits, exercise improves health-related quality of life and has shown psychological benefits such as decreases in anxiety, stress, and depression in this patient population.5 Despite current guidelines and favorable evidence, exercise is still not prescribed as part of routine care for CKD patients. The multidisciplinary nephrology team is an integral part of encouraging and integrating physical activity and regular exercise into clinical practice. The nephrology dietitian is especially key because this individual can easily combine counseling for healthy eating habits with the need for exercise. The information provided is aimed to promote physical activity counseling and empower health providers to prescribe exercise a routine part of care for CKD patients.
References 1. Johansen KL, Chertow GM, Ng AV, et al. Physical activity levels in patients on hemodialysis and healthy sedentary controls. Kidney Int. 2000;57:2564-2570. 2. Painter P, Roshanravan B. The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Curr Opin Nephrol Hypertens. 2013;22:615-623. 3. Bolton K, Beddhu S, Campese V, et al. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis. 2005;45:S7-S153. 4. Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database Syst Rev. 2011:CD003236. 5. Ouzouni S, Kouidi E, Sioulis A, Grekas D, Deligiannis A. Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients. Clin Rehabil. 2009;23:53-63. 6. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377-381. 7. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1435-1445.
e51
GET READY Increasing physical activity levels has many benefits for patients with CKD: Reduces the risk of heart disease: physical activity helps manage your blood pressure and cholesterol, makes your heart more efficient, and improves the health of your blood vessels. Improves muscle health: physical activity helps keep you strong and maintain your ability to carry out everyday activities. Keeps you fit: As you become fitter, you can do more with less effort helping you to remain independent and have a better quality of life. Reduces stress, anxiety and depression leaving you feeling revitalized and relaxed.
GET SET Set your goals: Share your physical activity goals and health goals with health care providers, fellow patients, friends, and family to create a support network that will help you to achieve them. Split your main goal into smaller, weekly realistic, achievable goals. For example: Main goal: ‘‘In 6 months time, I would like to be able to walk 3 miles/week.’’ Smaller goals: ‘‘By next week, I will make sure I have a comfortable pair of shoes to start walking’’; ‘‘Over the next 2 weeks, I will go for a 10-minute walk before I start my dialysis treatment.’’
Identify potential barriers that may prevent you from achieving your goals in advance and make a plan to overcome these barriers. For example: ‘‘I will ask a friend who also wants to increase their activity levels to walk with me in the morning, that way when I don’t feel like walking I will have someone to motivate me’’.
GO Walking Walking regularly is an easy and convenient way to increase your physical activity levels. Research has shown that walking 30 minutes/day most days of the week has many health benefits in patients with kidney disease. Using a pedometer to count the number of steps you take per day is a good way to monitor your walking activity. Starting with your current daily step count, increase your daily step count by 10% each week until you reach the recommended 10,000 steps/day. Dialysis Patients Can Increase Physical Activity Levels During Dialysis Taking part in physical activity during your dialysis session is a convenient way to increase your activity levels in a supervised setting when you would usually be sedentary. Speak to your health care providers about getting equipment that will allow you to exercise during dialysis. Monitoring the Difficulty of Your Physical Activity Using the ‘‘Ratings of Perceived Exertion’’ scale6 is a good way to measure how hard your physical activity is and to monitor your progress. This scale allows you to rate how difficult you feel during any activity. The activity ratings range from 6 (sitting on the couch, no exertion) to 20 (extremely hard, the most difficult activity you have ever done). Ideally, physical activity should gradually be increased until Ratings of Perceived Exertion falls between 12 and 16.
Rating of Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Extremely Light
Little or no effort. How you feel lying in bed or sitting in a chair. Can talk or sing easily without feeling breathless
Very Light Fairly Light
Target Range How you should feel with activity and exercise. Can comfortably talk but not sing without gasping for breaths
Somewhat Hard Hard Very Hard
How you feel with the hardest work you have ever done. Cannot say more than a few words without gasping for breath. Don’t work this hard!
Extremely Hard
Keep Safe Consult your doctor before you increase your physical activity or exercise. You should not exercise if: You have chest pains or you have suffered a cardiac event in the last 6 wk. You are short of breath when at rest and you have visible swelling from fluid overload You have an acute infection or a fever You have poor control of your diabetes or blood pressure Be aware of the following when increasing your physical activity: Stop any activity if you experience chest pain, dizziness or unusual shortness of breath. Sometimes you may have increased thirst levels when increasing your physical activity. Be aware of your fluid restrictions. Monitor your blood sugar closely during any activity if you have diabetes. Slow your activity down if: You feel very tired or not able to continue You are too short of breath to talk You do not feel fully recovered after 1 h of exercise You have an unusually high heart rate
Perceived Exertion Scale Exercise Recommendations Type Aerobic exercise involves rhythmic activity of large muscle groups that can be continuously maintained. Examples include walking, jogging, cycling, rowing, and swimming. Goal: increase physical fitness; reduce cardiovascular risk Resistance exercises use weight or resistance using free weights, weight machines, resistance bands, medicine balls, or your own body weight. Goal: increase muscle mass and muscle strength Flexibility exercises can be static (eg, bending over to touch your toes with out bending your knees) or dynamic (eg, high knees or back kicks). Goal: increase range of motion; reduce exercise-related injury risk Balance exercises include walking backwards, heel toe walking in a straight line, or standing on one leg at a time. Goal: fall prevention
Frequency $5 d/wk
Intensity
Duration
Moderate to hard (RPE 12-15; $30 min noticeable increases in heart rate and breathing)
2-3 d/wk (nonconsecutive Moderate to hard (RPE 12-15; 8 to 10 exercises targeting upper days) 60%-80% one repetition and lower body large muscle maximum) groups, 10 to 15 repetitions
$2 d/wk (perform on the same days as aerobic or resistance exercises)
10 min targeting major muscle groups. Hold each static stretch for 10 to 30 s. Repeat each stretch 3 to 4 times
$3 d/wk
Based on American Heart Association and American College of Sports Medicine recommendations for physical activity in older adults.7
Helpful Links www.kidney.org/atoz/content/stayfit.cfm. www.britishrenal.org/AboutUs/Time/Exercise.aspx.