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Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital.

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Presentation on theme: "Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital."— Presentation transcript:

1 Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital

2 Physiological capacity, functional capacity and functional status in ESRD Compared with age, gender and physical activity-matched healthy control subjects ESRD patients are characterised by:  35% impairment of peak aerobic power (VO 2 peak)   60% impairment of muscle function (strength, power)  75% of ESRD patients report  physical activity & functional status

3 VO 2 peak and survival Survival as function of baseline VO 2peak for 175 ambulatory ESRD patients (Sietsema et al 2004 Kidney International, 65, ) > 

4 Limiting Factors to Exercise in ESRD Anaemia Autonomic Dysfunction Cardiovascular Dysfunction Abnormal Peripheral Metabolism Skeletal Muscle Structure & Function Physical Inactivity

5 Disuse-Disability Spiral

6 Exercise Intervention Formats Prescribed supervised exercise  In dialysis unit (Koufaki et al, 2002)  In rehabilitation gymnasium (Mercer et al, 2002) Prescribed unsupervised exercise  Cycle ergometer at home (Konstantinidou et al., 2002)  Walking at home (Painter et al., 2000) Unsupervised exercise  Coaching & counselling (information, video)  Walking & exercise diary (Fitts et al, 1999) Encouragement to be physically active  Education & counselling (information, demonstration)  Lifestyle & activity choices (Tawney et al., 2000)

7 Structured Supervised Exercise Haemodialysis Unit  dialysis day (before & during dialysis)  non-dialysis day CAPD & HD  rehabilitation gymnasium

8 Gas analyser

9 Exercise Training Modes Aerobic Training  Cycle ergometer (on & off-dialysis)  Walking (CAPD and HD non-dialysis days) Resistance Training  Body weight resisted exercises  Light weights & Therabands  Fixed weight machines Combined Aerobic and Resistance Training  Circuit training (CAPD)  Higher-intensity interval training HD

10 Safety: Contraindications & Exclusion Criteria Uraemic complications  Hyperkalaemia  Excess inter-dialytic weight gain Cardiovascular complications  Recent MI  Severe hypertension  Pulmonary congestion  Peripheral oedema Uncontrolled diabetes Recent cerebrovascular event  Residual weakness  Balance disturbance

11 Safety: Exercise During Haemodialysis Stationary cycling during dialysis Safe and effective  Moore et al. (1993 & 1998)  VO 2 Peak on and off dialysis  Unaffected by prior 1 hour of HD  Safe at least up to 2 hours Associated with  frequency of:  Symptomatic hypotension  Muscle cramping  Post-haemodialysis fatigue More efficient fluid removal?

12 Safety of Exercise Training Exercise tolerance assessment  Individualised exercise prescription  Based on VO 2 Peak Warm-up  Regular monitoring during exercise sessions  Heart rate, blood pressure, Ratings of Perceived Exertion, work rate Cool-down Controlled Progression  Establish behaviour (make it routine)  Increase exercise tolerance (gradually  duration) Periodic reassessment of exercise tolerance  Individualised exercise prescription

13 Feasibility of Exercise Training Staff support  Physicians, nurses, dieticians, physiotherapists, occupational therapists Patient interest  Patient Associations  Unit newsletter  Dialysis unit ‘culture’ Patient profile  People are different! Exercise modes/equipment available  Be creative  Match exercise to patient and not vice versa

14 Bikes

15 Paraphernalia

16 Testing

17 Incremental exercise testing  3 minutes unloaded  Every minute 15 W  RPE every min  Until patient can tolerate  Measure VO 2 peak

18 Short exercise capacity test (SECT)  Strength testing  3 minutes unloaded  Every 15 sec ↑ by 15W  Measure maximal power  Exercise prescription is based on 50% of this

19 Training

20 Exercise Training Studies 32 exercise training studies published since 1979  Randomised controlled, non-randomised controlled and uncontrolled Most common outcome measures  VO 2 peak  Peak exercise capacity (watts)  Quality of life  Psychological well-being  Self-reported functional status Other reported outcome measures  Functional capacity (sit-to-stand, walk tests)  Heart rate variability  Muscle morphology/biochemistry  Nutritional state (SGA)

21 Randomised Controlled Studies 9 randomised controlled studies  163 exercisers (9-43 per study)  121 controls (6-30 per study)  Age (36-59) Programme characteristics  Duration: 6 months (3-12)  Exercise frequency: 3 (3-5) per week  Exercise duration: min  Exercise intensity:  60-80% HRmax  90% Ventilatory Threshold Median  VO 2 peak =  24% (0-43%)

22 Non-Randomised Controlled Studies 6 non-randomised controlled studies  50 exercisers (5-13 per study)  36 controls (4-7 per study)  Age (38-62) Programme characteristics  Duration: 4 months (2.5-39)  Exercise frequency: 3 (2-5) per week  Exercise duration: 30 min (15-60)  Exercise intensity:  60-80% HRmax  RPE 13 Median  VO 2 peak =  17% (0-23%)

23 Uncontrolled Studies 9 uncontrolled studies  65 exercisers (7-18 per study)  Age (42-60) Programme characteristics  Duration: 6 months (2-6)  Exercise frequency: 3 (3-5) per week  Exercise duration: 30 minutes (12-60)  Exercise intensity:  60-80% HRmax  90% Ventilatory Threshold Median  VO2 peak =  18% (0-48)

24 Effectiveness of Exercise Training Few studies involve direct comparisons of types of exercise Konstantinidou et al. (2002) 6 month study (~50 years age)  (A) Supervised outpatient renal rehabilitation  3 x 60 min/week (30' intermittent aerobic exercise; HRmax + resistance training) Maintenance: basketball & swimming  (B) Exercise during dialysis  3 x 60 min/week (bed cycle ergometer; 30 min continuous aerobic exercise; 70% HRmax + lower limb strength & flexibility exercise  (C) Unsupervised home-based moderate exercise  5 x 30 min/week (cycle ergometer; 50-60% HRmax + flexibility and muscular endurance exercises)  (D) Control group

25 Effectiveness of Exercise Training Findings: (A) Supervised outpatient  Dropout = 24%  Peak exercise capacity = 43% (B) On dialysis  Dropout = 17%  Peak exercise capacity = 24% (C) Home-based  Dropout = 17%  Peak exercise capacity = 17%  Exercise on non-dialysis days most effective  Exercise training during HD technically feasible and effective  Unsupervised exercise was effective and safe

26 Potential of Exercise Rehabilitation   Exercise tolerance & functional capacity   Capability for activities of daily living   Comorbidity (B.P., Insulin Resistance)   Quality of Life & psychological well-being  Anabolic effect (  muscle mass)


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