Swapna Mary A1, Dr. N Gayathri Priya2
1Associate Professor, Medical Surgical Department, Sarvodaya College of Nursing, No.11/2, A.D. Halli, Magadi Main Road, Bangalore – 560079
2Reader, Obstetrics & Gynecology Department, Sri Ramachandra College of Nursing, Sri Ramachandra University, Porur, Chennai –600116
Corresponding Author Email:
ABSTRACT:
Generally patients with ESRD have lower physical activities, muscle performance and quality of life (QOL) than do healthy subjects. Numerous studies have suggested that exercise could improve many indicators of physical functioning, improve self-reported physical functioning and also improve QOL in ESRD patients. In addition, considering that cardiovascular diseases (CVD) is major cause of death in patients with advanced CKD, exercise and regular physical activity have the potential to reduce cardiovascular mortality in ESRD patients. Many of the known benefits of exercise in the general population are of particular relevance to the ESRD population. In addition, the poor physical functioning that is experienced by patients who are on dialysis is potentially addressable through exercise interventions. The study of exercise in the ESRD population dates back almost 30 years, and numerous interventions, including aerobic training, resistance exercise training, and combined training programs, have reported beneficial effects. Recently, interventions during hemodialysis sessions have become more popular and have been shown to be safe. It is time that we incorporate exercise into the routine care of patients who are on dialysis, but identification of an optimal training regimen or regimens, according to patient characteristics or needs, is still needed to facilitate implementation of exercise programs.
KEYWORDS: ESRD, hemodialysis, chronic kidney diseases, exercise, physical activity.
INTRODUCTION:
Regular exercise is important for everyone – and that includes people with kidney disease. Regular exercise will help you feel better, stronger, and give you more energy. One needs to make a commitment of time in order to plan to do some type of exercise on most, if not all, days of the week1. Patients with chronic kidney disease are less active than sedentary individuals without chronic kidney disease 2,3. O’Hare et al.4 reported that sedentary dialysis patients had a higher risk of death within 1 year than those who reported at least some participation in physical activity.
Physical inactivity is also a strong predictor of cardiovascular mortality in patients with earlier stages of chronic kidney disease 5 and represents a potentially modifiable risk factor. In addition to cardiovascular risks associated with physical inactivity, several studies have also highlighted the link between inactivity and poor physical functioning and fitness in patients with chronic kidney disease 2,4,6. Given these strong associations between physical inactivity and mortality in dialysis patients4,7 and the potential improvements in physical functioning associated with increasing activity 8, it is unclear why patients with chronic kidney disease do not exercise. The Surgeon General, and more recently, the Center for Disease Control and Prevention 9 and American Heart Association 10 recommend at least 150 min of weekly moderate intensity physical activity (i.e. 30 min on at least 5 days) 10,11.
Benefits of regular exercise
Regular exercise has the following benefits for people with kidney disease:
· Improved heart function
· Better blood pressure control
· Reduce the risk of diabetes
· Helps to control glucose in those with diabetes
· Improves muscle strength
· Helps with anxiety and depression
Additionally, regular exercise may help with weight management. The saying “use it or lose it” is true– especially for people with kidney disease. Staying in bed or sitting around all the time will make you lose muscle strength and muscle mass, which will make it harder to do things you need to do. If you continue to just sit around, you may end up not being able to move on your own and could become disabled. If you get moving, you can maintain and even increase your strength, and keep doing the things you need to do in your life. People on dialysis, who exercise regularly, report they sleep better, have more energy and more muscle strength, and are better able to do the things they have to do in their lives1.
Getting started
For people on dialysis or those at any stage of chronic kidney disease, exercise is highly recommended. Before you start any activity, however, be sure to do the following three steps.
1. Talk with your doctor
The most important thing to do is talk to your doctor. He/she can tell what exercise is best for you because he/she will know what you can and can’t do depending on your current stage of kidney disease and treatment. Your doctor most likely will be very happy that you are asking about exercise. He/she can also help you to talk with a physical therapist. These are the experts who help people will all sorts of ailments begin to exercise. Together, your doctor and the physical therapist can watch your progress, help you monitor your activity level and make your exercise program fun.
2. Decide what kind of exercise you like
Most people enjoy walking. Walking is one of the least strenuous exercises we can do, but it’s also one of the healthiest. Walking helps with many bodily functions all at the same time.
Exercise
Helps with digestion
Increases your energy level
Reduces cholesterol levels
Helps control your blood sugar and blood pressure
Lowers the risk of heart disease
Helps you to sleep better
Helps to decrease stress
3. Get started
Many people on dialysis say they are too tired to exercise. They think that if they exercise they will be even more tired. The fact is, even a little bit of exercise, 15-20 minutes a day, will help you feel LESS tired. This means that by not exercising you will have lower energy and feel more tired. The longer you wait to exercise, the more tired and weak you will become.
A very common side effect of kidney failure is muscle wasting. This means that people with kidney disease are more prone to losing the muscle in their bodies. If you exercise, however, you can help keep your muscles from shrinking. You can even get back the muscle that you lost if you exercise regularly.
Stretch
Another reason why many dialysis patients feel they cannot exercise is because they feel they are simply too weak to do anything. It is easier to start exercising if you stretch first. Stretching is something almost all dialysis patients can do, and is a way to get the blood to the body parts that work when you are exercising. It is also helpful to stretch your legs, arms and back before walking or starting any other form of exercise. Proper stretching reduces the chance of cramping and helps you to exercise more comfortably. It also helps you to unwind when you are done exercising.
Start slowly
Don’t think that you will need to become a runner or an athlete to exercise effectively. Exercise at your own pace and you can build up over time. It is best if you can do at least 15-20 minutes a day, at least three to four days every week. Remember to start slowly and ask your doctor before you do any type of exercise program. If you can start to exercise at least three times a week and keep it up for two weeks, you will be able to maintain a regular exercise program more easily12.
Choosing exercise
People with chronic kidney disease can benefit from some type of regular exercise. There are several types of exercise:
1) Stretching or flexibility exercises improve the movement of joints, help in reaching above your head, and reduce stiffness in muscles.
2) Strengthening or resistance exercises will increase strength of muscles.
3) Cardiovascular or endurance exercise (also called “aerobic” exercise) such as walking or cycling improves the function of the heart and circulation, and results in improved endurance and energylevels1.
Diagram of potential adverse effects of sedentary behaviour and chronic kidney disease and potential beneficial effects of exercise interventions20.
Dialysis exercise adequacy DEA=FTA/100
A formula to measure the dialysis exercise adequacy (DEA) is proposed that takes into account the frequency (F) and duration(T) of the exercise in hours and the age (A) of the person in years; thus DEA=FTA/100. If John, a 70-year-old male on dialysis, exercised three times per week on dialysis for 30 minutes (0.5 hour) per exercise episode, his DEA would be 1.05:3 x 0.5 x 70/100 = 1.05If John was 50 years old, his DEA would be:3 x 0.5 x 50/100 = 0.75A minimum DEA “target” could be established (for example,1.0) that considers the amount and frequency of exercise relative to the age of the person. Thus the older a person on dialysis the less they are expected to exercise, not dissimilar to the non-dialysis community. Longer, more frequent exercise will increase a person’s DEA. Clinicians may even consider a maximum DEA for people on dialysis, particularly those with comorbidconditions13.
Barriers to perform physical activities
In the general population, reported barriers to achieving recommended levels of physical activity have included lack of access to exercise facilities and concerns about environmental safety14. Personal and social factors such as education, income, poor self-efficacy and lack of energy are also common correlates15, especially among African-Americans16. A recent study reported that most nephrologists were not routinely assessing physical activity and counseling patients to increase their activity despite published guidelines recommending that they do so 17,18. However, lack of counseling among nephrologists is probably not the sole reason for the patients’ low levels of physical activity. In a study by Goodman et al.19, lack of motivation and interest were among the factors cited as limiting patient participation in physical activity. To date, there have been few studies to evaluate predictors of lack of physical activity in this patient population. Our aim is to carefully delineate patients’ perceived barriers to physical activity in a racially and ethnically diverse hemodialysis population in the hope that this information can be used in the development of strategies to motivate patients to achieve adequate levels of physical activity.
CONCLUSION:
Physical inactivity among adults with chronic kidney disease (CKD), particularly among patients undergoing haemodialysis (HD), is a long-standing clinical problem and a scarcely investigated issue. Thus, a low degree of physical activity in HD patients is a common and persistent burden in various countries. Adequate amounts of exercise in the framework of non-demanding programmes are a priority. Hence, the identification of the minimal effective volume of physical activity needed to obtain health benefits in sedentary patients is at center-stage if we have to effectively promote physical exercise in this population. Constant-load low-volume interval training improves muscle oxidative capacity and induces the enrolment of CKD patise programmes is a challenging undertaking at all CKD stages, from the early stages to chronic kidney failure 21.
REFERENCE:
1. www.kidney.org
2. 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.
3. Kutner NG, Zhang R, Huang Y, et al. Depressed mood, usual activity level, and continued employment after starting dialysis. Clin J Am SocNephrol 2010; 5:2040-2045.
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 2003; 41:447-454.
5. Shlipak MG, Fried LF, Cushman M, et al. Cardiovascular mortality risk in chronic kidney disease: comparison of traditional and novel risk factors. JAMA 2005;293:1737-1745.
6. Kutner NG, Zhang R, Huang Y, et al. Cardiac rehabilitation and survival of dialysis patients after coronary bypass. J Am SocNephrol 2006; 17:1175-1180.
7. Sietsema KE, Amato A, Adler SG, et al. Exercise capacity as a predictor of survival among ambulatory patients with end-stage renal disease. Kidney Int 2004; 65:719-724.
8. Johansen KL. Exercise in the end-stage renal disease population. J Am SocNephrol 2007; 18:1845-1854.
9. Physical Activity is Essential to Healthy Aging. Physical Activity. 2010. http://www.cdc.gov/physicalactivity/everyone/guidelines/olderadults.html (2 December 2010, date last accessed).
10. American Heart Association Guidelines. 2010. http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/GettingActive/American-Heart-Association-Guidelines_UCM_307976_Article.jsp (3 December 2010).
11. Office of the Surgeon General. Physical Activity and Health: A Report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services; 1996.
12. http://www.kidneyspace.com/index.php/topic,2517.msg15842.html%20-%20msg15842 « on: October 11, 2009, 11:39:57 AM PDT »
13. Bennett, P. N. (2012). Exercise adequacy in dialysis. Renal Society of Australasia Journal, 8(2), 52-53.
14. Humpel N, Owen N, Leslie E. Environmental factors associated with adults' participation in physical activity: a review. Am J Prev Med 2002; 22:188-199.
15. King AC, Castro C, Wilcox S, et al. Personal and environmental factors associated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women. Health Psychol 2000; 19:354-364.
16. Ainsworth BE, Wilcox S, Thompson WW, et al. Personal, social, and physical environmental correlates of physical activity in African-American women in South Carolina. Am J Prev Med 2003; 25 3 Suppl 1:23-29.
17. Johansen KL, Sakkas GK, Doyle J, et al. Exercise counseling practices among nephrologists caring for patients on dialysis. Am J Kidney Dis 2003; 41:171-178.
18. Delgado C, Johansen KL. Deficient. counseling on physical activity among nephrologists. Nephron ClinPract 2010; 116:c330-c336.
19. Goodman ED, Ballou MB. Perceived barriers and motivators to exercise in hemodialysis patients. NephrolNurs J 2004; 31:23-29.
20. http://jasn.asnjournals.org/content/18/6/1845/F2.expansion.html. Johansen K L JASN 2007; 18:1845-1854
21. Johansen KL, Painter P. Exercise in individuals with CKD. Am J Kidney Dis 2012; 59:126-134.
Received on 17.08.2014 Modified on 06.09.2014
Accepted on 24.09.2014 © A&V Publication all right reserved
Int. J. Adv. Nur. Management 3(1):Jan. - Mar., 2015; Page 69-72
DOI: