1. 10 slides on… Rehabilitation in older people with CKD Dr Sharlene Greenwood King’s College Hospital

2. What is rehabilitation? Physical activity has been defined as “any bodily movement produced by skeletal muscles that results in caloric expenditure” The related term exercise is defined as “physical activity that is planned, structured, repetitive, and results in the improvement or maintenance of one or more facets of physical fitness” Exercise-based rehabilitation is usually provided by a physiotherapist or appropriately trained exercise professional but advice to increase physical activity can be provided by any of the multi-disciplinary team

3. Why is rehabilitation important? Muscle wasting and weakness almost universal for patients with CKD and this worsens as disease process progresses Patients with CKD typically have approximately 50% of the exercise capacity of non-uraemic, healthy, sedentary people. Physical inactivity doubles the risk of developing heart disease AND Cardiovascular disease remains the leading cause of death in patients with CKD. Patients with CKD have an impaired capacity for activities of daily living Physical function low in patients at all stages of CKD Association of low self-reported physical function and increased odds of death

4. And why in older people with kidney disease? CKD is associated with: – accelerated physical deterioration – decreased mobility – decreased capacity for independence – Increased risk of falling 40% HD patients have significant falls-related injuries each year 54% result in fractures

5. What are the barriers to provision of exercise therapy? Competing medical issues Lack of time Lack of expertise Lack of funding Fear of adverse events Lack of clearly defined best programme

6. How can you minimise risk of exercise training? Obtain consent and clear with doctor Have practised procedures in place Start exercises slowly and progress gradually Always use a warm up and cool down Remember: “Not taking part is more of a risk than taking part”

7. How can you maintain compliance with a programme? Support – Doctors & nurses – Family/friends Facilities Enjoyment – Minimise injury – Varied & enjoyable programme – Group participation? – Games Regularly organised Monitor progress – Fitness tests – Progress charts – Goals – Rewards

8. So what types of exercise can be done? Exercise on dialysis – Thrice weekly cycling during haemodialysis with adapted cycles

9. Exercise options cont… Outpatient supervised renal rehabilitation class or cardiac rehab classes Weight management programmes Home exercise programme – walking and cycling diaries Local walking groups Exercise on Referral to a council gym programme

10. Further reading Koufaki P, Greenwood S, Painter P, Mercer T. The BASES expert statement on exercise therapy for peopleThe BASES expert statement on exercise therapy for people with chronic kidney disease. J Sports Sci. 2015 Mar 25:1-6. with chronic kidney disease. Greenwood SA, Koufaki P, Rush R, Macdougall IC, Mercer TH. Exercise counselling practices in the UK renal multi-disciplinary team. Nephron Clinical Practice 2014 (DOI:10.1159/000363453) Greenwood SA, Naish P, Clark R, O'Connor E, Pursey VA, Macdougall IC, Mercer TH, Koufaki P. Intra-dialytic exercise training: a pragmatic approach. J Ren Care. 2014 Sep;40(3):219-26. Greenwood SANaish PClark RO'Connor EPursey VAMacdougall ICMercer THKoufaki PJ Ren Care. Koufaki P, Greenwood SA, Macdougall IC, Mercer TH. Exercise therapy in individuals with chronic kidney disease: a systematic review and synthesis of the research evidence. Annu Rev Nurs Res. 2013;31:235-75. doi: 10.1891/0739- 6686.31.235. Koufaki PGreenwood SAMacdougall ICMercer THAnnu Rev Nurs Res. Greenwood, S. A, Lindup, H., Taylor, K., Koufaki, P., Rush, R., Macdougall, I.C. and Mercer, T.H. Evaluation of a pragmatic exercise rehabilitation programme in chronic kidney disease. Nephrology Dialysis Transplantation 2012 0: 1–9doi: 10.1093/ndt/gfs272 Cook S.A., MacLaughlin H. and Macdougall I.C. A structured weight management programme can achieve improved functional ability and significant weight loss in obese patients with chronic kidney disease. Nephrology Dialysis Transplantation 2008; 23: 263-268.