Exercise for Dialysis Patients Amanda Newberry, M.Ed. Exercise Physiologist University of Virginia...
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Transcript of Exercise for Dialysis Patients Amanda Newberry, M.Ed. Exercise Physiologist University of Virginia...
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: [email protected]
• 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.