Exercise for Dialysis Patients

Amanda Newberry, M.Ed.Exercise PhysiologistUniversity of VirginiaRenal Services

CRN Meeting November 2010

Objectives To provide knowledge and supporting data on benefits of

intradialytic exercise

To encourage incorporating exercise into routine patient care plan

To provide information on beginning a unit based exercise program

To describe the procedures and operations of a current unit based exercise program

Physical Functioning

The ability of an individual to perform activities required in their daily lives.

PF of dialysis patients is LOW!

0

20

40

60

80

100

Gen

Pop

COPD CHF Post MI HD

1. Ware et al: Health Institute; 1994

Self-Reported Physical Functioning Scale ScoresResults from SF-36 Questionnaire

84

50

5669

50

Untrained

sedentary normal males

sedentary normal females

50

40

30

20

10

0

max

imal

oxy

gen

up

take

(m

l/kg

/min

)

20 30 40 50 60 70

age

(*Average VO2peak in 14 studies - pre EPO)

Used with permission from P. Painter, PhD

Oxygen Uptake in Adult Hemodialysis Patients*

Measures of Physical Functioning

Short Physical Performance Battery

• Gait speed (4 meters)

• Sit to stand (time for 5 )

• Standing balance tests

Other measures• 6 min walk test

20

22

24

26

28

30

Baseline Post I nd. PostInctr.

interventionno intervention

Sec

on

ds*

* seconds taken to stand up and sit down 10 times

p=.004

2. Rex Demonstration Project Painter, et al: AJKD 35(3): 482-492, 2000

Sit to Stand to Sit Test

Physical Inactivity leads to…

Overall decline in physical well-being

Poor physical performance

Fluid build up in tissues

Loss of bone strength

Loss of appetite

Muscle wasting

Hypertension

Dependence

Fatigue

3. Johansen K L: JASN Express, 2007

Relationship between sedentary behavior/low CRF and higher mortality among patients with ESRD

Benefits

Physiological Benefits Reduced risk of cardiovascular mortality Decreased use of antihypertensive medications Favorable adaptation of body composition Reduced C-reactive protein/increased albumin Improved removal of toxins by dialysis Improved exercise capacity Improved blood pressure control Improved lipid profile

• Esp increased HDL and reduced TG Increased hematocrit

• Prior to EPO therapy Improved glucose regulation

Psychological Benefits Reduced subjective fatigue symptoms Improved perception of physical functioning Improved perception of general health Reduced anxiety Improved mental health Reduced experience of bodily pain Increased vitality Improved psychological profile

• Reduced anxiety, hostility, and depression, and increased participation in pleasant activities

Functional Benefits

Improved muscle strength Increased 6-min walk distance Reduced risk of falls in the elderly Maintenance of independence

Clearance

During dialysis:• Urea removed from blood

• Urea retained in peripheral body compartments• Urea and creatinine distributed in body water

• Muscle water content high

• Muscle mass = ~40-45% total body weight

• Much of solute mass will be held within muscles

• Some body tissue is unexposed to dialysis

4. Kong, et al: Nephrol Dial Transplant. 1999; 14: 2927-2931.

Clearance

After dialysis:• Urea re-equilibrates and a rebound results

• Limits the efficiency of dialysis

With exercise:• Muscle blood flow increases

• Potential increase from 3-4ml/min per 100g to 80ml/min per 100g

• More tissue mass is exposed to the dialysis treatment

4. Kong, et al: Nephrol Dial Transplant. 1999; 14: 2927-2931.

4. Kong, et al: Nephrol Dial Transplant. 1999; 14: 2927-2931.

Improved urea Kt/V with exercise

Cramping

Timing of exercise Type of exercise Intensity of exercise

Start slowly, Progress gradually!!!

Exercise: A Vital Sign

Exercise Rx

Surgeon General’s report:

“significant health benefits can be obtained by including a moderate amount of

physical activity….on most, if not all, days of the week”.

American College of Sports Medicine (ACSM)

“Exercise Prescription: every patient, every visit, every time”www.exerciseismedicine.org

Exercise is MedicineTM

Guiding principles:

• Exercise and physical activity are important to health and the prevention and treatment of many chronic diseases

• More should be done to address physical activity and exercise in healthcare settings

• ACSM and AMA are making efforts to bring a greater focus on physical activity and exercise in healthcare settings

Program Implementation

New Program Resources

Life Options Rehabilitation Advisory Council (LORAC)5

• “Exercise for the Dialysis Patient”• A Guide for the Dialysis Team

• Author: Patricia Painter, PhD

Staff Responsibility to Exercise• Carlson L, Carey S. ACKD Vol 6, No 2 pp172-

180, 19996

Steps to developing an exercise program

Gaining staff support

• Edu/inservice

• Case presentations Commitment to developing a program

• Group input

• Assurance of willingness of staff to participate Assess available resources

• Staff interest

• Teamwork

• Interested patients

• Local programs6. Carlson L, Carey S. ACKD, 1999

Steps to developing an exercise program

Develop a program

• Smaller working groups (care planning, motivation/education, exercise programming)

• Staff responsibilities identified

• Facilitate a sense of ownership amongst staff Start program

• Start slowly (one shift, one bay, interested pts)

• Progress gradually Ongoing evaluation

• CQI

• Patient reassessment

• Patient programs 6. Carlson L, Carey S. ACKD, 1999

UVA SitFit Exercise Program

8 Units 800 patients 50% patient participation 78% exercise compliance

UVA SitFit Exercise Program

One Exercise Physiologist Exercise Leader at each unit

• Technician or RN

Monthly QAPI Reports Monthly Compliance Reports Quarterly Exercise Team

meetings

Beyond the science…

Setting expectations Potential for patient to exercise Motivating a non-motivated patient

Barriers to Exercise

Sickness Fatigue Lack of equipment Lack of motivation Depression Lack of encouragement

Most can be resolved through exercise!

Influences on Patient Physical Activity

Patient Physical

Activity

Physician Family

Health Care System Health Care

Workers

Society

6. Carlson L, Carey S. ACKD, 1999

Exercise Options

Cycle (Monark)

Hand Weights Ankle Weights

Oxystepper

Cycle

Arm curls

Toe Taps

Lower Leg Raises

Seated Marching

Straight Leg Raises

“Rear-End” Squeezes!!

Contact

Amanda Newberry, M.Ed

University of Virginia

Renal Services

Exercise Program Coordinator

• Email: alh9t@virginia.edu

• Office: (434)243-6218

1. Ware JE, Kosinski M, Keler SD. SF-36 Physical and Mental Health Summary Scales: A User’s Manuel. 2nd ed. Boston: Health Institute; 1994.

2. Painter P, Carlson L, Carey S, Paul SM, Myll J. Physical functioning and health related quality of life changes with exercise training in hemodialysis patients. Am J Kidney Dis. 2000; 35(3):482-492.

3. Johansen K. Exercise in the End-Stage Renal Disease Population. J Am Soc Nephrol 18: 1845-1854, 2007

4. Kong C, Tattersall J, Greenwood R, Farrington K. The effect of exercise during haemodialysis on solute removal. Nephrol Dial Transplant. 1999; 14: 2927-2931.

5. Carlson L, Carey S. Staff Responsibility to Exercise. ACKD Vol 6, No 2 (April) pp 172-180, 1999

6. Life Options Rehabilitation Advisory Council. Exercise: A Guide for the Dialysis Team. 1995; Table 2: pp 7.