1. Exercise for Dialysis Patients Amanda Newberry, M.Ed. Exercise Physiologist University of Virginia Renal Services CRN Meeting November 2010

2. 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

3. Physical Functioning The ability of an individual to perform activities required in their daily lives. PF of dialysis patients is LOW!

4. 1. Ware et al: Health Institute; 1994 Self-Reported Physical Functioning Scale Scores Results from SF-36 Questionnaire 84 50 56 69 50

5. Untrained sedentary normal males sedentary normal females 50 40 30 20 10 0 maximal oxygen uptake (ml/kg/min) 20 30 40 50 60 70 age (*Average VO 2 peak in 14 studies - pre EPO) Used with permission from P. Painter, PhD Oxygen Uptake in Adult Hemodialysis Patients*

6. 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

7. 20 22 24 26 28 30 BaselinePost I nd.Post Inctr. intervention no intervention Seconds* * 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

8. 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

9. 3. Johansen K L: JASN Express, 2007 Relationship between sedentary behavior/low CRF and higher mortality among patients with ESRD

10. Benefits

11. 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

12. 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

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

14. 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.

15. 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.

16. Improved urea Kt/V with exercise

17. Cramping Timing of exercise Type of exercise Intensity of exercise Start slowly, Progress gradually!!!

18. Exercise: A Vital Sign

19. 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”.

20. American College of Sports Medicine (ACSM) “Exercise Prescription: every patient, every visit, every time” www.exerciseismedicine.org

21. Exercise is Medicine TM 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

22. Program Implementation

23. 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, 1999 6

24. 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

25. 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

26. UVA SitFit Exercise Program 8 Units 800 patients 50% patient participation 78% exercise compliance

27. 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

28. Beyond the science… Setting expectations Potential for patient to exercise Motivating a non-motivated patient

29. Barriers to Exercise Sickness Fatigue Lack of equipment Lack of motivation Depression Lack of encouragement Most can be resolved through exercise!

30. Influences on Patient Physical Activity Patient Physical Activity PhysicianFamily Health Care System Health Care Workers Society 6. Carlson L, Carey S. ACKD, 1999

31. Exercise Options Cycle (Monark) Hand WeightsAnkle Weights Oxystepper

32. Cycle

34. Arm curls

35. Toe Taps

36. Lower Leg Raises

37. Seated Marching

38. Straight Leg Raises

40. “Rear-End” Squeezes!!

42. Contact Amanda Newberry, M.Ed University of Virginia Renal Services Exercise Program Coordinator Email: alh9t@virginia.edualh9t@virginia.edu Office: (434)243-6218

43. 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.