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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 22  |  Issue : 2  |  Page : 86-96

The effect of intradialytic aerobic training on physical performance and quality of life among hemodialysis patients


1 Nephrology Unit, Department of Internal Medicine, Alexandria University, Alexandria, Egypt
2 Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt

Date of Submission04-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication19-May-2022

Correspondence Address:
Dr. Hesham A Elghoneimy
Nephrology unit, Department of Internal Medicine, Faculty of Medicine, Alexandria University 17 Champollion Street, El Messallah, Alexandria 2113
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jesnt.jesnt_35_21

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  Abstract 


Background Patients with chronic kidney disease and end-stage kidney disease have reduced physical performance and impaired quality of life. The aim of this work is to study the effect of intradialytic aerobic training using a pedal on physical performance and quality of life among hemodialysis (HD) patients.
Patients and methods This experimental study was conducted on 30 adult patients with end-stage kidney disease on maintenance HD for more than 3 months. Mentally or physically unfit patients, patients with overt ischemic heart disease or cardiac decompensation, severe anemic patients (hemoglobin≤8 g/dl), patients with advanced chronic kidney disease-mineral and bone disorder, patients with advanced lower limbs joints disease, and those with amputation of the lower limb were excluded. Patients were divided into two groups; each group consisted of 15 patients. Group A performed intradialytic aerobic exercise for 30 min three times/week for 8 weeks. Group B was a control group.
Results There was significant improvement in the distance walked in 6-min walk test in the exercise group (P=0.04). Moreover, there was significant improvement in the main scales of kidney disease quality-of-life short form, version 1.3, Arabic version (Kidney Disease Component Summary, Physical Composite Scale, and Mental Composite Scale) (P<0.001, P=0.018, and P=0.037, respectively).
Conclusion Exercise has a beneficial effect on the physical performance and quality of life in HD patients.

Keywords: aerobic training, hemodialysis, physical performance, quality of life


How to cite this article:
Elghoneimy HA, El-Deeb AE, Younis GA, Abd El-Kader MM, El-Wakil HS. The effect of intradialytic aerobic training on physical performance and quality of life among hemodialysis patients. J Egypt Soc Nephrol Transplant 2022;22:86-96

How to cite this URL:
Elghoneimy HA, El-Deeb AE, Younis GA, Abd El-Kader MM, El-Wakil HS. The effect of intradialytic aerobic training on physical performance and quality of life among hemodialysis patients. J Egypt Soc Nephrol Transplant [serial online] 2022 [cited 2022 Jul 5];22:86-96. Available from: http://www.jesnt.eg.net/text.asp?2022/22/2/86/345439




  Introduction Top


Health-related quality of life (HRQOL) is related to a patient’s functioning, well-being, and general health perception in physical, psychological, and social domains [1]. A close relationship between QOL, morbidity, and mortality is present in all chronic diseases, including chronic kidney disease (CKD) and end-stage kidney disease (ESKD) [2].

Both subjective and objective tools are used to assess HRQOL in patients with CKD and ESKD [3]. Subjective measures involve patient-reported outcomes, which can be defined as measurements of any aspect of a patient’s health status that comes directly from the patient, without interpretation by the physician. The importance of patients’ perceptions of their own physical and mental functioning has been emphasized. Thus, the recommended HRQOL assessments in the United States involve a patient-reported outcome. The value of patient reports instead of health care provider reports is underscored by the difference between patients and physician assessments of their problems. This allows individualizing of the treatment plans [3].

Moreover, the health care provider sometimes uses objective assessment measures to detect the effect of health on the QOL and generate intervention strategies. For example, physical functioning can be tested by questionnaires, such as SF-36, or by objective measures, such as six-min walk test, the chair sit and reach, or 8-foot up and go [4].

Patients with CKD and ESKD have an increased risk of functional impairment, regardless of age, sex, associated comorbidities, and cardiovascular events [5]. This impairment is also found in patients with milder CKD (mean GFR 50 ml/min/1.73 m2) [6], causing limitation in the ability to perform activities of daily living [7].

Regular exercise is an important part of rehabilitating patients with chronic illnesses, including CKD and ESKD. Exercise participation needs good cooperation between doctors, nurses, and patients [8]. There are different methods to realize an exercise program. Generally, three exercise training methods are applied in patients with ESKD [9]: the supervised outpatient program in a rehabilitation center, a home-based exercise training program, and exercise training during the first hours of the hemodialysis (HD) session in the dialysis unit.


  Patients and methods Top


This study was a single-center trial conducted in the Hemodialysis Unit of Alexandria University Hospital. A total of 138 patients in the center were screened for being eligible in the study. After application of the preset inclusion and exclusion criteria, only 30 patients were eligible for the study. Informed consent from the patients and local ethical committee approval have been obtained. The practical work has been carried out in accordance with the Declaration of Helsinki.

Patients were divided into two groups: group A included 15 patients who performed exercise during HD session, and group B included 15 patients who were not assigned to any exercise program (as a control group).

Inclusion criteria

Patients with ESKD on maintenance HD for more than 3 months and older than 18 years were included in the study.

Exclusion criteria

Mentally or physically unfit patients, patients with overt ischemic heart disease or cardiac decompensation, severe anemic patients (hemoglobin≤8 g/dl), patients with advanced CKD-mineral and bone disorder, patients with advanced lower limbs joints disease, and those with amputation of the lower limb were excluded.

All patients were subjected to the following:
  1. Demographic data recording, including age, sex, residency, and employment.
  2. Thorough history taking, with emphasis on cause of ESKD, the duration of HD, previous history of cardiovascular events, comorbidities (mainly diabetes and hypertension), lower limb problems, and drug history.
  3. Complete physical examination, with emphasis on cardiac examination, BMI, and lower limb examination.
  4. Routine laboratory investigations: complete blood picture, serum urea, creatinine, calcium, and phosphorus.
  5. ECG to exclude any ischemic changes, and echocardiography to exclude patients with cardiac decompensation.
  6. Six-min walk test: the patient was instructed to walk as far as possible for 6 min in a 50-m hallway back and forth. The patient was permitted to slow down, stop, and rest as necessary. He may lean against the wall while resting but resume walking as soon as he was able. A demonstration was done in front of the patient, and then the test was done for each patient separately. The distance walked in 6 min was recorded. The test was done before the HD session [10].
  7. Quality-of-life assessment score, kidney disease quality-of-life short form (KDQOL-SFTM, version 1.3, Arabic version) [11]: the questionnaire consists of the generic SF-36 [12], and 11 multi-item scales focused on quality of life issues specific to patients with kidney disease. Subscales of the Kidney Disease Component Summary (KDCS) are (a) symptoms/problems (six items), (b) effects of kidney disease (four items), (c) burden of kidney disease (three items), (d) work status (two items), (e) cognitive function (three items), (f) quality of social interaction (three items), (g) sexual function (two items), (h) sleep (four items), (i) social support (two items), (j) dialysis staff encouragement (two items), and (k) patient satisfaction.
    • The 11 kidney disease-specific subscales can be averaged to form the KDCS [13]. The scales for Mental Composite Scale (MCS) and Physical Composite Scale (PCS) were derived from eight subscales, originally developed for the SF-36: (a) physical functioning, (b) role-physical, (c) bodily pain, (d) general health, (e) vitality, (f) social functioning, (g) role-emotional, and (h) mental health [14]. The items of overall health and change in health are interpreted separately [15].
  8. Exercise training program for 8 weeks: group A performed an 8-week intradialytic aerobic training course three times per week during the first half of the HD session for 30 min using a pedal. Blood pressure (BP) and pulse rate were measured before starting the exercise, and patients with severe hypertension BP more than 180/110 or hypotension BP less than 110/70 or tachycardia heart rate more than 110 were excluded from the session. Missed exercise sessions were completed after the 8 weeks, so every patient completed 24 exercise sessions. Of the 15 patients, 12 completed the program. Patients reported knee pain and dialysis-related hypotension as the main reasons for not completing the program. Group B did not perform any exercise.
  9. Outcome measures: the following were measured after the exercise program:
    • Six-min walk test: the test was repeated in the same way it was done first after 8 weeks in the control group and after 1 week of finishing the exercise program in the exercise group before the HD session [10].
    • KDQOL-SFTM, version 1.3, Arabic version: the questionnaire was repeated after 8 weeks in the control group and after 2 weeks of finishing the exercise program in the exercise group [11].


Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0. (IBM Corp., Armonk, New York, USA). Qualitative data were described using numbers and percentages. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, median, and interquartile range. The significance of the obtained results was judged at the 5% level.

The used tests were the χ2 test for categorical variables to compare between different groups, whereas Student t test was used for normally distributed quantitative variables to compare between two studied groups. Paired t test was used for normally distributed quantitative variables to compare between two periods in the same group. Mann–Whitney test was used for abnormally distributed quantitative variables to compare between two studied groups, whereas Wilcoxon signed-rank test was used for abnormally distributed quantitative variables to compare two periods in the same group.


  Results Top


The baseline characteristics of the studied patients are shown in [Table 1]. No significant differences were found between the two studied groups as regards age, sex, cause of kidney disease, duration of dialysis, dry weight, and BMI.
Table 1 Baseline characteristics of studied patients

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As shown in [Table 2], there was no significant difference between the two groups regarding baseline laboratory investigations, such as hemoglobin, serum urea, creatinine, calcium, phosphorus, and urea reduction ratio (P=0.422, 0.176, 0.136, 0.762, 0.156, and 0.935, respectively).
Table 2 Comparison between the two studied groups according to baseline laboratory data

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After the exercise program, the mean distance walked in group A was 286.67±94.88 m, which was statistically significantly greater than before exercise (P=0.04). In group B, the mean distance after 8 weeks was 239.0±65.17 m, which was not statistically significantly different from the initial assessment (P=0.994).

The percent change in group A was 8.19±8.44, whereas in group B was −0.74±2.87. There was a statistically significant difference between patients in the two studied groups (P=0.006) ([Table 3]).
Table 3 Comparison between the two studied groups according to 6-min walk test

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As shown in [Table 4], in group A, there was a significant improvement after the exercise program in quality of social interaction, symptom and problem list, the effect of kidney disease, and dialysis staff encouragement (P=0.017, P<0.001, P=0.005, and P=0.003, respectively). There was no significant improvement in the burden of kidney disease, cognitive function, sexual function, sleep, social support, work status, and satisfaction (P=0.081, 0.083, 1, 0.771, 0.317, 1, and 0.317, respectively). In group B, there was only a significant improvement in dialysis staff encouragement (P=0.004), and there was a significant deterioration in the effect of kidney disease (P=0.005).
Table 4 Comparison between the two studied groups according to scales of Kidney Disease Component Summary

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In group A, there was a significant improvement after the exercise program in general health perception (P=0.012). There was no significant improvement in pain, physical functioning, and role limitation caused by physical problems (role-physical) (P=0.665, 0.317, and 0.083, respectively). In group B, there was no significant improvement in any scale.

In group A, there was a significant improvement after the exercise program in energy and fatigue (P=0.004). There was no significant improvement in emotional well-being, social function, and role limitation caused by emotional problems (role-emotional) (P=0.111, 0.104, and 0.317, respectively). In group B, there was no significant improvement in any scale ([Table 5]).
Table 5 Comparison between the two studied groups according to scales of Physical Composite Scale and Mental Composite Scale

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As shown in [Table 6], after the exercise program, the mean KDCS in group A was 61.06±12.56, which was statistically significantly different from before exercise (P<0.001). In group B, the mean KDCS after 8 weeks was 53.08±9.41, which was not statistically significantly different from the initial assessment (P=0.928). The percent change in group A was 13.31±7.90, whereas in group B was 3.37±9.30. There was a statistically significant difference between patients in the two studied groups (P=0.007).
Table 6 Comparison between the two studied groups according to different parameters

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After the exercise program, the mean PCS in group A was 37.89±8.05, and this was statistically significantly different from before exercise (P=0.018). In group B, the mean after 8 weeks was 33.25±6.12, which was not statistically significantly different from the initial assessment (P=0.990). The percent change in group A was 9.65±14.21, whereas in group B was −0.88±3.04. There was a statistically significant difference between patients in the two studied groups (P=0.016).

After the exercise program, the mean MCS in group A was 43.87±8.34, which was statistically significantly different from before exercise (P=0.037). In group B, the mean after 8 weeks was 43.24±6.06, which was not statistically significantly different from the initial assessment (P=0.980). The percent change in group A was 7.83±10.48, whereas in group B was −0.04±3.01. There was a statistically significant difference between patients in the two studied groups (P=0.041).

Regarding overall health after the exercise program, the mean in group A was 55.83±12.40, which was statistically significantly different from before exercise (P=0.014). In group B, the mean after 8 weeks was 52.0±8.62, which was not statistically significantly different from before the initial assessment (P=0.912). The percent change in group A was 18.26±19.54, whereas in a group B was −0.35±11.63. There was a statistically significant difference between the patients in the two studied groups (P=0.009).

Regarding the change in health after the exercise program, the mean in group A was 39.58±12.87, which was statistically significantly different from before exercise (P=0.046). In group B, the mean after 8 weeks was 31.67±14.84, which was not statistically significantly different from the initial assessment (P=0.819).

The percent change in group A was 33.33±49.24, whereas in group B was −3.33±12.91. There was no statistically significant difference between patients in the two studied groups (P=0.103).

In univariate analysis, a decreased calcium level and pre-exercise scores were predictors of increased percent change in KDCS (P=0.036, 0.004). Regarding MCS, a decrease in pre-exercise score was a predictor of increased percent change (P=0.009). Regarding overall health, an increase in age was a predictor of increased percent change (P=0.021) ([Table 7] and[Table 8]).
Table 7 Univariate linear regression analysis of factors affecting 6-min walk test, Kidney Disease Component Summary, and Physical Composite Scale in group A

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Table 8 Univariate linear regression analysis of factors affecting Mental Composite Scale, overall health, and health change in group A

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All variables with P value less than 0.05 in the univariate analysis were included in the multivariate analysis. The percent of change in KDCS was independently associated with the pre-exercise score (P=0.016) ([Table 9]).
Table 9 Univariate and multivariate linear regression analyses for the parameters affecting percent of change in Kidney Disease Component Summary in group A

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  Discussion Top


Despite improvements in treatment, patients with ESKD undergoing maintenance HD continue to report reduced daily physical activity, lower exercise tolerance, and poorer HRQOL than individuals in the general population of similar ages [16].

To improve the quality of care, it is now recognized that rehabilitation programs need to be integrated into the routine care of these patients [17].

The present study included 30 patients older than 18 years on regular HD − 15 patients performed the intradialytic aerobic exercise program using a pedal for 30 min three times per week for 8 weeks, whereas the other 15 patients did not perform any exercise (as a control group).

Overall, 80% of the exercise group completed the program. Patients reported knee pain and dialysis-related hypotension as the main reasons for not training. This is similar to other studies which showed that the adherence rate to intradialytic exercise is 75±19% and showed that the main causes were vascular access stability issues, tiredness, and dialysis-related hypotension [18].

Regarding physical performance, our study used the 6-min walk test as a measure of physical performance. In group A, the mean distance before exercise was 263.75±87 m. In group B, the mean was 241±65.85 m. This is similar to other studies showing the mean distance in patients with ESKD ranges from 210 to 330 m [19],[20],[21]. These results prove that patients with ESKD have a lower physical function when compared to normal individuals, who have a mean of 698±96 m [22].

Our study showed improvement in the distance of the 6-min walk test after the exercise program (286.67±94.88 m), which was statistically significantly different from before exercise (P=0.04), with a percent change of 8.19±8.44. Other studies supported this, showing improvement in the physical performance of patients with ESKD after the exercise program. Bayoumi and Al Wakeel [21] detected an improvement in physical performance in patients with ESKD after 8 weeks three times/week intradialytic aerobic training manifested as improvement in the chair, arm curl, @@@2-min step test, the chair sit and reach, 8-foot up and go, and back scratch tests (all P<0.001). Umami et al. [23] detected an improvement in gait speed by 8% after 12 weeks three times/week intradialytic aerobic training on a cycle ergometer. Koh et al. [19] compared the effect of intradialytic exercise versus home-based aerobic exercise for 6 months and detected an improvement in physical performance after three times/week intradialytic aerobic training on a cycle ergometer manifested as 14% improvement in 6-min walk test, whereas in the home-based exercise group doing thrice-weekly unsupervised walking, the improvement in 6-min walk test was 11%. This greater improvement is explained by the longer duration of study in comparison with our study.

Regarding the effect of the exercise program on QOL, our study used KDQOL-SFTM, version 1.3, Arabic version, as a measure of QOL in our patients. The study showed that the baseline KDCS in the exercise group was 54.56±14.01 and 51.98±11.27 in the control group. The baseline PCS in the exercise group was 34.73±7.62 and 33.61±6.32 in the control group. The baseline MCS in the exercise group was 41.36±10.57 and 43.28±6.1 in the control group. This is similar to scores in patients with ESKD. Manavalan et al. [24] studied the QOL in patients with CKD and ESRD and showed that the mean KDCS, PCS, and MCS in patients with ESKD were 56.99±10.24, 29.97±7.61, and 40.43±11.32, respectively. These scores are less than those in a normal population (50±10 in MCS and PCS) [14]. The difference between ESKD and the general population is related to ESKD complications, comorbidities, and impaired physical performance.

The current study showed improvement in the three main components of the KDQOL-SFTM: KDCS, PCS, and MCS. Moreover, overall health improved by 18.26±19.35% (P=0.014) and health improvement improved by 33.33±49.24 (P=0.046). The percent change in the KDCS was 13.31±7.90% (P<0.001), with significant improvement in some domains of KDCS (quality of social interaction, symptom/problem list, the effect of kidney disease, and dialysis staff encouragement), whereas there was no significant improvement in other domains (burden of kidney, cognitive function, sexual function, sleep, social support, work status, and satisfaction). However, Bayoumi and Al Wakeel [21] detected a significant improvement in all domains of KDCS (except sexual function) in addition to overall health in patients with ESKD after 8 weeks three times/week intradialytic aerobic training.

Regarding PCS and MCS, the improvement in PCS was 9.64±14.21% (P=0.018), whereas in MCS was 7.83±10.48% (P=0.037). Regarding domains of PCS and MCS, it showed significant improvement in general health and vitality but not other domains. These findings are supported by other studies investigating the effect of exercise on QOL. Bae et al. [25] investigated the effect of 12 weeks of intradialytic aerobic training on a stationary bicycle and showed 14.7% improvement in QOL measured by SF-36. Dobsak et al. [26] compared the effect of intradialytic exercise to intradialytic electromagnetic stimulation of leg extensors for 20 weeks and detected a significant improvement in PCS and MCS in the exercise group (P=0.006 and 0.001, respectively), whereas the electromagnetic stimulation group showed significant improvement only in MCS (P<0.001) but no significant improvement in PCS (P=0.101). However, Bayoumi and Al Wakeel [21] detected an improvement in all domains of PCS and MCS and overall health in patients with ESKD patients after 8 weeks three times/week intradialytic aerobic training.


  Conclusion Top


Patients with ESKD have decreased physical performance and impaired QOL in comparison with the normal population. Exercise training is beneficial in the management of patients with ESKD besides dialysis and medical treatment. Exercise has a positive effect on physical performance and QOL.

Financial support and sponsorship

Nil.Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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