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
56
60
69
50
50
40
20
0
Gen
Pop
1. Ware et al: Health Institute; 1994
COPD
CHF Post MI
HD
maximal oxygen uptake (ml/kg/min)
Oxygen Uptake in Adult
Hemodialysis Patients*
50
Untrained
40
30
sedentary normal males
sedentary normal females
20
10
(*Average VO2peak in 14
studies - pre EPO)
0
20
30
40
50
age
Used with permission from P. Painter, PhD
60
70
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
p=.004
Seconds*
28
26
24
intervention
no intervention
22
20
Baseline Post I nd.
Post
Inctr.
* 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

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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

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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


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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:

With exercise:
• Urea re-equilibrates and a rebound results
• Limits the efficiency of dialysis
• 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
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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 pp172180, 19996
Steps to developing an exercise
program
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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
6. Carlson L, Carey S. ACKD, 1999
• Patient programs
UVA SitFit Exercise Program
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8 Units
800 patients
50% patient participation
78% exercise compliance
UVA SitFit Exercise Program
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One Exercise Physiologist
Exercise Leader at each unit
• Technician or RN
Monthly QAPI Reports
Monthly Compliance Reports
Quarterly Exercise Team
meetings
Beyond the science…
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Setting expectations
Potential for patient to exercise
Motivating a non-motivated patient
Barriers to Exercise
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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
Health Care
System
6. Carlson L, Carey S. ACKD, 1999
Society
Health Care
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.
2.
3.
4.
5.
6.
Ware JE, Kosinski M, Keler SD. SF-36 Physical and Mental Health
Summary Scales: A User’s Manuel. 2nd ed. Boston: Health Institute;
1994.
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.
Johansen K. Exercise in the End-Stage Renal Disease Population. J
Am Soc Nephrol 18: 1845-1854, 2007
Kong C, Tattersall J, Greenwood R, Farrington K. The effect of
exercise during haemodialysis on solute removal. Nephrol Dial
Transplant. 1999; 14: 2927-2931.
Carlson L, Carey S. Staff Responsibility to Exercise. ACKD Vol 6, No
2 (April) pp 172-180, 1999
Life Options Rehabilitation Advisory Council. Exercise: A Guide for the
Dialysis Team. 1995; Table 2: pp 7.