Exercise during dialysis
Kinesiologist-guided functional exercise
Kinesiologist-guided functional exercise in addition to intradialytic cycling program in end-stage kidney disease patients: a randomised controlled trial
This was a prospective, randomised, controlled, interventional trial comparing two strategies of exercise pre scription and counselling in prevalent HD patients. Seventy-three HD patients were approached in the HD units of the University Medical Centre in Ljubljana, Slovenia. The inclusion criteria were the following: end-stage kidney disease, renal replacement therapy with HD>3 months, age 18–90 years, capable of independent walking and feeding, in a stable medical condition. Criteria for non-inclusion were: chronic malignant or infectious dis ease, uncontrolled arterial hypertension with an average of the last fve in-centre pre-dialysis blood pressure values above 180/100 mm Hg, angina pectoris of Canadian Cardiovascular Society grade 2–4, New York Heart Association heart failure grade 3 or 4, the presence of a psychotic illness or a mental disability, a history of limb amputation (more than 2 fngers on the lower limb and/or more than 2 fngers on the upper limb) or any other condition that might cause clinical instability of the patient (e.g. repetitive gastrointestinal haemorrhages, liver cirrhosis with frequent exacerbations, advanced dementia with poor cooperation of the patient).
Study exclusion (withdrawal) criteria contained any intercurrent illness or trauma that prevented the patient to continue with the exercise program for a period longer than 14 days, the occurrence of an acute illness lasting more than 3 weeks or ending less than 3 weeks before the end of the study, or if the patient has had prescribed medication for it at the end of the study, diagnosis of malignant disease during the course of the research and withdrawal of the consent to participate. National Medical Ethics Committee approval (Ministry of Health, Republic of Slovenia, approval document number 0120-97/2017-3 KME 68/03/17) and written informed consent were obtained in all cases. Te study complies with the Declaration of Helsinki, as revised in 2013. Te study was registered at ClinicalTrials.Gov (Clinicaltrials.gov identifer: NCT03334123) on November 7, 2017.
The primary endpoint was the 10 repetition sit-to-stand test time (STS-10) at week 8, which measures lower limb strength19. The rationale for the choice of this endpoint was based on our previous research showing the superiority of this test in sensitivity to uraemia efects, the strength of association with activities of daily living, and a relatively large defcit at this test in dialysis patients compared to other physical performance tests17,20.
The secondary endpoints were: the aerobic capacity assessed by the six-minute walk test21, hand-grip strength22 assessed with calibrated hydraulic hand dynamometer (Jamar, Patterson Medical, Warrenville, Ilinois), lower body fexi bility by sit-and-reach test23, balance by Stork test20 on a foam pad (Airex, Sins, Switzerland) and upper body fex ibility with back scratch test24. All tests were executed as previously described17,25,26 in a fixed order to minimize patient fatigue. Before the tests, we measured height, weight, and body composition using bioimpedance analysis (Body Composition Monitor, Fresenius AG, Bad Homburg, Germany). The first functional test executed was a six-minute walk test followed by a hand-grip strength test, sit-and-reach test, balance Stork test, and back scratch test. It took approximately 40 minutes for a patient to complete all outcome assessments (including rest periods). The testing was performed on dialysis-free days: patients who were on dialysis on Tuesday-Tursday-Saturday schedule were tested on Friday and patients who were dialyzed on Monday-Wednesday-Friday schedule were tested on Saturday. Outcomes were assessed at three time points: before the intervention (T1), afer eight weeks (T2, end of phase 1), and afer 16 weeks (T3, end of phase 2). Te same assessors were assigned to individual endpoint assessments at all times and were blinded to treatment allocation. Patients and in-center dialysis care providers were not blinded.
After baseline testing, the patients were randomised using a computer program and allocated in a 1:1 ratio to the experimental group (EXP) or the active control group (CON). We concealed allocation to patients and dialysis staf before the start of the study by including and allocating patients according to a list, which was assessed by researchers only. For the frst eight weeks of intervention (phase 1), the experimental group per formed guided functional training led by a kinesiologist prior to each HD procedure.
During these sessions, they received counselling to accurately master the functional exercise routines and transfer these skills to a home environment in the second phase of the study. Besides, they performed a cycling program during dialysis on the customized ergometer (Model B’ft Mini, Lemco, Denmark) during the frst half of the dialysis procedure.
The control group performed the intradialytic program of cycling only, with the same instructions as the experimental group. Specifcally, intradialytic cycling was supervised by the same kinesiologist who aimed to continuously progress the cycling load (resistance) or time with maintaining the rate of perceived exertion of 4th to 5th grade on a 10-grade Borg scale.
Initial intradialytic cycling duration was set to 15minutes with a gradual increase in time and intensity to reach the duration of up to 60minutes. Te speed of increase in load and duration was individu alised according to each patient rated perceived exertion (RPE) response and their motivation. Tis prescription strategy was the same in both study groups. RPE was graded using the Borg 10-grade scale, which is useful for
In this study, we examined the effect of functional training added to basic intradialytic cycling and investigated the feasibility and sustainability of functional exercise transfer to an unsupervised home environment. Results demonstrate signifcant superiority of experimental training strategy concerning the primary study endpoint associated with lower extremity performance. Superiority in balance, hand-grip strength and upper body fexibility was also shown.
Although signifcant intra-group improvements in 6-minute walk test distance were found in the experimental group, the efects did not reach statistical signifcance compared to the control group. Importantly, patients were able to maintain gained positive efects of supervised in-centre functional training in the second phase of the study, where they successfully transferred mastered functional training routines to their home on non-dialysis days.
In the experimental group, we found a large 10 second (36%) absolute mean improvement in the 10 repetition sit-to-stand test time (Table 3), which was larger than the results found in previous studies with improvements ranged from 2.5 to approximately 6 seconds29–32.
We believe that this substantial efect was due to the relatively modest baseline physical performance, which is typical for dialysis subjects, relatively large training input in terms of volume and intensity, and due to individualisation of exercise program to each individual. The magnitude of this change is not only clinically meaningful since it covers more than the relative magnitude of diference to untrained healthy subjects, but it is also signifcantly and meaningfully larger than the improvement found in
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Authors thank prof. Ivan Čuk for his continued support and help during the execution of this study. Te study was funded by the public Slovenian Research Agency (Grant No. P3-0323).
Š.B., J.B.P., V.H., J.P. & M.P. designed the study. J.B.P., V.H. & M.P. secured the funds, equipment, and staf. Š.B., V.H., J.P. & M.P. oversight the intervention and endpoint assessments. Š.B., J.P. & M.P. analysed results. Š.B. & J.P. drafed the manuscript. All authors reviewed and approved the fnal manuscript.
Te authors declare no competing interests.
Supplementary information is available for this paper at https://doi.org/10.1038/s41598-020-62709-1.
Correspondence and requests for materials should be addressed to M.P.
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