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Exercise and Dialysis

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					        Exercise for
      Dialysis Patients


Amanda Newberry, M.Ed.
Exercise Physiologist
University of Virginia
Renal 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!
       Self-Reported Physical
       Functioning Scale Scores
       Results from SF-36 Questionnaire



                      100
                                84
                        80                            69
                                                56
                        60
                                        50                    50
                        40

                        20
                          0
                                Gen      COPD   CHF Post MI   HD
                                Pop



1. Ware et al: Health Institute; 1994
     maximal oxygen uptake (ml/kg/min)
                                               Oxygen Uptake in Adult
                                               Hemodialysis Patients*
                                         50

                                         40                             Untrained


                                         30
                                                                           sedentary normal males

                                         20                                sedentary normal females


                                         10
                                                                                    (*Average VO2peak in 14
                                         0                                          studies - pre EPO)
                                              20   30   40    50   60     70

                                                             age
Used with permission from P. Painter, PhD
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
       Sit to Stand to Sit Test
                           30

                           28                                   p=.004
                Seconds*




                           26

                           24
                                                                         interve ntion
                                                                         no intervention
                           22

                           20
                                  Ba seline Post I nd.   Post
                                                        Inc tr.
                       * seconds taken to stand up and sit down 10 times

2. Rex Demonstration Project Painter, et al: AJKD 35(3): 482-492, 2000
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
       Relationship between sedentary behavior/low
       CRF and higher mortality among patients with
       ESRD




3. Johansen K L: JASN Express, 2007
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.
       Improved urea Kt/V with exercise




4. Kong, et al: Nephrol Dial Transplant. 1999; 14: 2927-2931.
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 programs
                                            6. 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
         Physician                                     Family




                                    Patient Physical
                                        Activity




                                                        Society
     Health Care
       System                        Health Care
6. Carlson L, Carey S. ACKD, 1999     Workers
Exercise Options

     Cycle (Monark)    Oxystepper




      Hand Weights    Ankle Weights
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.

				
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