Presentation on theme: "Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital."— Presentation transcript:
Exercise on Dialysis Exercise rehabilitation in Chronic Kidney Disease Dr Alex Crowe Countess of Chester Hospital
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
VO 2 peak and survival Survival as function of baseline VO 2peak for 175 ambulatory ESRD patients (Sietsema et al 2004 Kidney International, 65, 719-724) >
Limiting Factors to Exercise in ESRD Anaemia Autonomic Dysfunction Cardiovascular Dysfunction Abnormal Peripheral Metabolism Skeletal Muscle Structure & Function ------------------------ ------------- ---------------------------- - ----------- Physical Inactivity
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)
Structured Supervised Exercise Haemodialysis Unit dialysis day (before & during dialysis) non-dialysis day CAPD & HD rehabilitation gymnasium
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
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?
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
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
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)
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: 20-60 min Exercise intensity: 60-80% HRmax 90% Ventilatory Threshold Median VO 2 peak = 24% (0-43%)
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%)
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