Factors influencing exercise participation by older adults requiring chronic hemodialysis: a qualitative study

Perceptions of healthcare providers on benefits, risks and barriers regarding intradialytic exercise among haemodialysis patients

PURPOSE

Clinical guidelines call for the inclusion of exercise interventions in every patient's dialysis session, but these recommendations are rarely adopted. Healthcare providers play a key role in this. Therefore, the aim of this study was to explore how healthcare providers perceive the benefits, risks and barriers of intradialytic exercise (IDE).

METHODS

We conducted 21 individual, semi-structured interviews with 11 nurses, 5 nephrologists, 3 training assistants and 2 managers from two dialysis centres in Slovakia. Verbatim transcripts of digitally recorded interviews were thematically analysed using MAXQDA®.

RESULTS

Participants reported the benefits of IDE as improvements in patients' physical and psychosocial functioning, independence and self-efficacy, clinical profile and quality of therapy. As risks of IDE, they most frequently reported exercise-related damage to vascular access, insufficient individualization of training and musculoskeletal injuries. The presence of psychological problems among patients was reported as a major barrier for initiating and maintaining patients' exercise. Other reported barriers included limitations in financial and personnel resources of haemodialysis care.

CONCLUSIONS

Safe and sustainable implementation of IDE, which might improve a patient's well-being, need to be prescribed in alignment with the patient's clinical profile, be delivered individually according to the patient's characteristics and requires adjustments in the available resources.

Barriers and Facilitators to Exercise in Older Adults Awaiting Kidney Transplantation and Their Care Partners

Rationale & Objective

Despite guidelines calling to improve physical activity in older adults, and evidence suggesting that prekidney transplant physical function is highly associated with posttransplant outcomes, only a small percentage of older patients treated with dialysis are engaged in structured exercise. We sought to elucidate barriers and facilitators of exercise among older adults treated with dialysis awaiting transplant and their care partners.

Study Design

Individual, in-depth, cognitive interviews were conducted separately for patients and care partners through secure web-conferencing.

Setting & Participants

Twenty-three patients (≥50 years of age, treated with dialysis from the University of San Francisco kidney transplantation clinic, with a short physical performance battery of ≤10) and their care partners.

Analytical Approach

All audio interviews were transcribed verbatim. Three investigators independently coded data and performed qualitative thematic content. The interview guide was updated iteratively based on the Capability Opportunity Motivation Behavior model.

Results

Patients' median age was 60 years (57 ± 63.5) and care partners' median ages was 57 years (49.5 ± 65.5). Thirty-nine percent of patients and 78% of care partners were female, 39% of patients and 30% of care partners self-identified as African American, and 47% of dyads were spouse or partner relationships. Major themes for barriers to pretransplant exercise included lack of understanding of an appropriate regimen, physical impairments, dialysis schedules, and safety concerns. Major facilitators included having individualized or structured exercise programs, increasing social support for patients and care partners, and motivation to regain independence or functionality or to promote successful transplantation.

Limitations

Participants geographically limited to Northern California.

Conclusions

Although patients and care partners report numerous barriers to pretransplant exercise and activity, they also reported many facilitators. An individualized, structured, home-based exercise program could circumvent many of the reported barriers and allow older patients to improve pretransplant physical function.

A Current State of the Art and Science of Exercise in Dialysis: A Narrative Review

Purpose of the review

The purpose of the review is to discuss current proven benefits and problems of integrating exercise in the care of people receiving dialysis by reviewing literature from the last few years and identifying important questions that still need to be asked and answered.

Methods

A focused review and appraisal of the literature were done. Original peer-reviewed articles, review articles, opinion pieces and guidelines were identified from PubMed and Google Scholar databases. Only sources in English were accessed. Search terms "exercise" and "dialysis" were used to find active recruiting randomized trials in various clinical trial registry platforms.

Key findings

Numerous studies have demonstrated the benefits of exercise training in individuals receiving dialysis, limited by factors such as short duration of follow-up and inconsistent adverse event reporting and outcomes selected. Notable gaps in exercise research in dialysis include ways to maintain programs and patient motivation, studies in peritoneal dialysis and home hemodialysis patients, and how best to define and measure outcomes of interest.

Implications

This review summarizes the current state of exercise in people receiving dialysis and serves as a call to action to conduct large, randomized controlled trials to improve the quality of evidence needed to implement and sustain innovative, exercise interventions, and programs for this population.

Game-based intradialytic non-weight-bearing exercise training on gait speed and balance in older adults with diabetes: a single-blind randomized controlled trial

Older adults with diabetes receiving hemodialysis have impaired gait speed and balance compared to the general population, which have been associated with increased risks of falls and mortality. This study evaluated the effectiveness of a game-based intradialytic exercise training program (iExergame) on improving gait speed and balance. This was a single-blind randomized controlled trial. The intervention group (IG) received iExergame training using real-time audiovisual feedback with wearable inertial sensors. The control group (CG) received conventional training without any technology. Both trainings were intradialytic, non-weight-bearing, and used ankle range of motion. Gait and balance parameters were collected at baseline and 4-week follow-up. Data from 70 adults (age 64.2 ± 9.0 years) were analyzed. Compared to the CG, the IG showed greater changes between baseline and 4-week follow-up in several parameters. Gait parameters included faster speeds and longer stride lengths, particularly during dual task walking (p < 0.050). Balance parameters included reductions in center of mass (p = 0.004), ankle (p < 0.001), and hip (p = 0.010) sways during semi-tandem stance, particularly in users of assistive devices. iExergame training could improve gait speed and balance in this population and might be an option to increase intradialytic exercise adherence while reducing burdens of exercise administration.

A blended e-health intervention for improving functional capacity in elderly patients on haemodialysis: A feasibility study

Introduction

Physical exercise showed to be beneficial for frail older adults on haemodialysis (HD). However, there are several obstacles hindering the regular practice of exercise, such as transportation difficulties, lack of time, fatigue and comorbidities. E-health in this regard has many potential advantages and could be useful for motivating HD patients to increase their level of physical activity. The aim of this study was to evaluate the feasibility of a blended e-health intervention for elderly HD patients who individually exercise at home while under remote supervision of a physiotherapist.

Material and methods

Patients over 60 years of age with sufficient cognitive and motoric resources to perform a simple physical test battery and to use a tablet-computer were recruited from four HD outpatient facilities. Following baseline assessment at home, the participants were visited by a physiotherapist (PT). The PT set an individual exercise programme and explained how to use the web-based interface. During the 12 weeks of training, the PTs remotely supervised the patients' progress. At 12 weeks follow-up a second assessment took place.

Results

Twenty-two patients were recruited to participate in the study. Seven patients dropped out of the blended programme and 15 patients concluded the programme. The average training frequency of the 15 participants concluding the study was 1.5 times a week [range 0.2-5.8]. The duration of a training session was between 20 and 40 min. The usability of the system was deemed positive. Regarding the efficacy of the intervention, no significant improvement of any measured parameter was found, and effect sizes were small to medium.

Conclusion

A blended e-health intervention supported by a web-based application for exercising at home under remote supervision of a PT is feasible in a HD population including older patients. However, before planning a randomized controlled trial, strategies to increase the recruitment rate and the adherence to such a blended intervention should be further developed, e.g., to improve the recruitment procedures and lower the expectable drop-out rate. Furthermore, the dosage of the blended programme should be adapted to the patients' physical performance levels in future trials.The study was registered on the website clinicaltrials.gov with ID NCT04076488.

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care

OBJECTIVE

Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease.

DESIGN AND METHODS

Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved.

RESULTS

We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders.

CONCLUSIONS

We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

Effect of Online Home-Based Training on Functional Capacity and Strength in Two CKD Patients: A Case Study

Chronic kidney disease (CKD) is a clinical condition characterized by the loss of kidney function over time, as well as several complications affecting gastrointestinal, cardiovascular, and musculoskeletal systems. Physical exercise seems to induce positive adaptations in CKD patients, without side effects. Usually, these patients show a reduced physical activity and physical performance. The aim of this case-report was to evaluate the effects of an online training protocol on functional capacity and on muscle mass, in CKD stage III patients. Methods: Two CKD (stage III according to KDIGO guidelines) participants (1 female, Patient A; 1 male, Patient B) were enrolled and they performed an online tailored-supervised combined training lasting 12 weeks, including multi-joint strength exercises using TheraBand and an aerobic session at 65–70% of the patients' heart rate reserve. Results: Both patients showed an improving trend on functional capacity (6 minutes walking test: Patient A = +3%; Patient B = +5.3%) and on strength of the upper arms (handgrip strength test-right: Patient A = +13.4%; Patient B = +19.1%; handgrip strength test-left: Patient A = +42.8%; Patient B= +12.9%), as well as a reduction in inflammation and oxidative stress biomarkers. The protocol was feasible, and no side effects were evidenced. These case studies suggest that the online combined training can produce beneficial effects in CKD patients under conservative therapy, by reducing the CKD-related complications and improving the adherence to exercise of this population of patients, overcoming logistic barriers such as transportation, availability of facilities, and working and personal-life schedule.

Physical Exercise in People with Chronic Kidney Disease-Practices and Perception of the Knowledge of Health Professionals and Physical Activity and Sport Science Professionals about Their Prescription

There is evidence on the need to include physical exercise as a treatment for diseases. A large number of professionals are involved in this, but it is not known how physical exercise is prescribed and which professionals are involved. This research has two objectives: (a) to find out the current practices in Spain regarding the prescription of physical exercise in patients with Chronic Kidney Disease (CKD) and (b) to analyse the perception that different health and physical activity professionals have of their knowledge to prescribe of physical exercise in the treatment of CKD. This is an empirical research with an ex post facto retrospective analysis of the information in a descriptive and correlational way. A total of 692 health and sports professionals participated. A questionnaire validated by a committee of experts was administered. Descriptive analyses were carried out and the differences in the study variables were analysed using Chi-square tests and one-factor Analysis of Variance. From the results obtained, we conclude there is a need to develop specific training programmes in the field of physical exercise for health professionals, as well as the establishment of multiprofessional teams for the prescription of physical exercise in CKD treatment, including physical exercise professionals (Cafyde).

Applying A Biopsychosocial Framework to Achieve Durable Behavior Change in Kidney Disease

Chronic disease self-management is the establishment and maintenance of behaviors needed to be an active participant in one's health care and experience the best health outcomes. Kidney disease self-management behaviors to slow disease progression include engaging in exercise or physical activity; adhering to a diet low in sodium, potassium, and phosphorus; monitoring laboratory parameters; managing complex medication regimens; coping with disease-related emotional distress; and communicating effectively with providers. Durable behavior change has been difficult to achieve in kidney disease, in part because of an incomplete understanding of the multilevel factors determining chronic disease self-management in this patient group. The biopsychosocial model of chronic illness care posits that an individual's health outcomes result from biological, psychological, social, and environmental factors as part of a multilevel systems hierarchy. Although this theoretical model has been used to comprehensively identify factors driving self-management in other chronic conditions, it has been applied infrequently to behavioral interventions in kidney disease. In this scoping review, we apply the biopsychosocial model of health to identify individual, interpersonal, and systems-level drivers of kidney disease self-management behaviors. We further highlight factors that may serve as novel, impactful targets of theory-based behavioral interventions to understand and sustain behavior change in kidney disease.

Mobility in Older Adults Receiving Maintenance Hemodialysis: A Qualitative Study

RATIONALE & OBJECTIVE

For older adults, maintaining mobility is a major priority, especially for those with advanced chronic diseases like kidney failure. However, our understanding of the factors affecting mobility in older adults receiving maintenance hemodialysis is limited.

STUDY DESIGN

Descriptive qualitative study.

SETTING AND PARTICIPANTS

Using purposive sampling, we recruited 1) persons aged ≥ 60 years receiving maintenance hemodialysis and 2) care partners (≥ 18 years) providing regular support to an older adult receiving hemodialysis. During a single in-person home visit, we assessed mobility using the Short Physical Performance Battery (SPPB) and conducted individual one-on-one interviews regarding important personal factors related to mobility.

ANALYTIC APPROACH

Descriptive statistics were used for demographic and SPPB data. Transcripts underwent thematic coding, informed by the International Classification of Function framework of mobility. We used conceptual content analysis to inductively extract themes and subthemes.

RESULTS

We enrolled 31 older adults receiving hemodialysis (42% female, 68% Black) with mean age of 73±8 years and mean dialysis duration of 4.6±3.5 years; mean SPPB was 3.6±2.8 points. Among 12 care partners (75% female, 33% Black), mean age was 54±16 years and mean SPPB was 10.1±2.4 points. Major themes extracted were: 1) mobility represents independence; 2) mobility is precarious; 3) limitations in mobility cause distress; 4) sources of encouragement and motivation are critical; and 5) adaptability is key.

LIMITATIONS

Modest sample from single geographic area.

CONCLUSIONS

For older adults receiving hemodialysis, mobility is severely limited and is often precarious in nature, causing distress. Older adults receiving hemodialysis and their care partners have identified sources of encouragement and motivation for mobility, and cite an adaptable mindset as important. Future studies should conceptualize mobility as a variable condition, and build upon this outlook of adaptability in the development of interventions.

Barriers and facilitators to exercise in haemodialysis patients: A systematic review of qualitative studies

AIMS

The purpose of this systematic review is to synthesize the results of qualitative research and to identify the barriers and facilitators to exercise in haemodialysis patients from the perspectives of haemodialysis patients, caregivers and dialysis staff members.

DESIGN

Systematic review of qualitative studies.

DATA SOURCES

Qualitative studies were extracted from MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, PubMed, CBM, CNKI and WanFang Database from inception of each database until July 2020. Qualitative research and mixed method research including barriers and/or facilitators to exercise in haemodialysis patients were included.

REVIEW METHODS

The systematic search method SPIDER (sample, phenomenon of interest, design, evaluation, research type) was used. Thematic synthesis of qualitative data was used.

RESULTS

284 studies were screened and 10 studies published between 2007 and 2020 were finally included in this review. The review included 180 patients, 70 dialysis staff members and seven caregivers. Five analytical themes were identified: disease distress, perception of exercise, environmental restrictions, spirit strength and hospital management. Barriers include disease distress, perception of exercise (security issue), environmental restrictions and hospital management. Facilitators include perception of exercise (exercise being considered beneficial, preference for exercise) and spirit strength (from religious beliefs). It is the spiritual strength (from family and friends, from dialysis staff members) that is both the barrier and the facilitator.

CONCLUSION

There are many barriers in popularizing exercise among haemodialysis patients. Future intervention measures and health policies should strengthen the facilitators and reduce the barriers, so as to promote the clinical practice of exercise for haemodialysis patients.

IMPACT

This review summarizes the barriers and facilitators to exercise in haemodialysis patients. The results of this study have an impact on research, practice and health policy setting. The exercise level of haemodialysis patients can be improved by using the facilitators and solving the barriers.

Reasons for Nonparticipation in a Sustained Hemodialysis Intradialytic Exercise Program

OBJECTIVE(S)

Patients with end-stage kidney disease requiring hemodialysis suffer frailty and poor physical function. Exercise can improve physical function; however, barriers exist to intradialytic exercise programs. The objective of this study was to explore patients' reasons for not exercising in an extant intradialytic exercise program.

DESIGN AND METHODS

We conducted a retrospective analysis reporting the reasons for not exercising in an intradialytic exercise program in two hemodialysis centers over a 4-week period. We explored whether patient characteristics and the presence of an exercise professional were associated with missed exercise sessions.

RESULTS

Seventy-five patients participating in the intradialytic exercise program completed 57% of prescribed intradialytic exercise sessions. The three most frequently reported reasons from patients not exercising were refusal (24%), followed by fatigue (19%) and symptoms (14%). Patients were more than twice as likely to exercise if a kinesiologist was present (odds ratio [OR]: 2.26, confidence interval [CI]: 1.5, 3.4 P = .03). They were less likely to exercise if they were women (OR: 0.66, CI: 0.45, 0.95 P = .002), had been on dialysis greater than 60 months (OR: 0.55, CI: 0.37, 0.80 P < .002), or had more than two comorbid conditions (OR: 0.63, CI: 0.43, 0.90, P = .01).

CONCLUSION

Patient adherence to intradialytic exercise programs is strongly associated with the presence of exercise professionals.

Patient experiences of sleep in dialysis: systematic review of qualitative studies

RATIONALE AND OBJECTIVE

Sleep problems affect more than half of patients receiving dialysis and are associated with increased risk of mortality, cardiovascular events, depression and impaired functioning and quality of life. Symptoms such as fatigue and exhaustion may be attributed to sleep problems or sleep disorders, as well as the burden of kidney disease and treatment. This study aims to describe the patient perspectives on the reasons, impact and management of sleep problems in dialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies that report patient experience and perspectives on sleep in dialysis.

SETTING AND POPULATION

Patients receiving dialysis.

SEARCH STRATEGY AND SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, reference lists and PhD dissertations were searched from inception to August 2019.

DATA EXTRACTION

All text from the results/conclusion of the primary studies.

ANALYTICAL APPROACH

Thematic synthesis.

RESULTS

We included 48 studies involving 1156 participants from 16 countries. We identified six themes: dominating demands of treatment (with subthemes of: demanding and relentless schedule, regret for wasted time); scheduling and control (managing sleep routines, napping and nocturnal sleep disruption, meditative aids); disruptions due to dialysis (unsettled sleep, hypervigilance and worry); symptoms depriving sleep (difficulty falling asleep, constant waking); overwhelmed and without choice (futility of sleep, uncontrollable exhaustion, restlessness is irrepressible); and as a coping mechanism (avoiding anxiety, alleviating symptoms, combating boredom).

LIMITATIONS

Most studies were conducted in high-income, English-speaking countries.

CONCLUSION

The treatment and symptom burden of dialysis disrupts and deprives patients of sleep, which leads to overwhelming and uncontrollable exhaustion. Better management of symptoms and effective strategies to manage sleep routines may improve sleep quality for better overall health in patients receiving dialysis.

Fit for Dialysis: a prospective 2-site parallel intervention trial of a filmed research-based drama to increase exercise amongst older hemodialysis patients

PURPOSE

The present study aimed to evaluate the impact of a filmed research-based drama-Fit for Dialysis-and an exercise program on patients' physical activity and fitness outcomes.

METHODS

Nineteen (10 at the intervention site, 9 at the control site) older patients with a medical diagnosis of hemodialysis-dependent end-stage renal disease were recruited from two acute care hospitals in urban central Canada where they were receiving out-patient hemodialysis care. Participants at the intervention site viewed Fit for Dialysis prior to participating in a 16-week exercise program. Participants at the control site participated only in the 16-week exercise program. Physical activity, measured by total intradialytic exercise time (TIDE), and physical fitness, measured by the Two-Minute Walk Test (2MWT). Secondary measures included: Timed Up and Go (TUG), Grip Strength, Duke Activity Status Index (DASI), Godin Leisure-Time Exerciser Questionnaire (GLTEQ), and pedometer step count.

RESULTS

TIDE, TUG, and GLTEQ were better at the intervention site compared to the control site at all time points measured. However, the change over time was not different between the sites. The 2MWT improved over time at the intervention site for those who exercised consistently. No significant differences between sites, or over time were found for any of the other measures.

CONCLUSIONS

Further research is needed to determine the effectiveness of this intervention to facilitate the incorporation of exercise into the care and treatment of HD patients.

Association of motivations and barriers with participation and performance in a pedometer-based intervention

BACKGROUND

A randomized trial of a pedometer-based intervention with weekly activity goals led to increased walking among dialysis patients. However, the association of participant-expressed motivations and barriers to participation and performance in such an intervention has not been determined.

METHODS

Thirty dialysis patients were randomized to a 12-week pedometer-based intervention with weekly step goals. Participants were asked about motivations and barriers to the increasing activity via weekly semi-scripted telephone interviews. We examined the association of these motivations and barriers with achieving weekly goals, reaching overall targets and increasing steps through multivariable linear and logistic regression analyses adjusted for age, sex, body mass index, dialysis modality and baseline steps.

RESULTS

The most common motivations were desire to maintain/improve functional ability (30%) and activity (30%). The most common barriers were health-related (33%). Motivation to maintain/improve functional ability was associated with achieving weekly goals 17.9% more often [95% confidence interval (CI) 1.7-34.2] and with a greater increase in steps (1524 steps; 95% CI 61-2989) than those lacking this motivation. Experiencing a health-related barrier was not associated with the decreased achievement of weekly goals but was associated with lower odds of reaching overall targets (odds ratio = 0.06; 95% CI 0.01-0.53) and a smaller increase in steps (-1640 steps, 95% CI -3244 to -36). No patients who reported weather/environmental barriers or safety concerns reached overall targets.

CONCLUSIONS

Participants who express a desire to maintain/improve functional ability may be particularly suited for activity interventions. Health-related setbacks should be met with revised goals. Reporting environmental or safety concerns may merit lowering overall targets.

Perceptions of Physical Activity in African American Older Adults on Hemodialysis: Themes From Key Informant Interviews

OBJECTIVE

To determine key themes underlying the perceptions of older (≥65y) adults on hemodialysis regarding physical activity using qualitative methodology.

DESIGN

Semistructured key informant interviews.

SETTING

Academic medical center.

PARTICIPANTS

Convenience sample of older adults on hemodialysis (N=10).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Interview transcripts were coded and analyzed using the framework method to extract themes and subthemes. Participants also answered Likert statements regarding their perceptions of physical activity, and the responses were tallied.

RESULTS

Ten older adults on hemodialysis participated (mean age 73±5y; 60% women); all were African American. All participants stated physical activity would make them feel better. The major themes that emerged were barriers and facilitators. Facilitators included internal motivators, family and friend support, and feasibility of incorporating physical activity into routine activities. Barriers were lack of motivation, health issues, and environmental restrictions.

CONCLUSIONS

Physical activity potentially could prevent the physical decline commonly seen in older adults on hemodialysis. Yet information regarding the perceptions of this population toward physical activity is sparse. Although the study is limited by selection bias, our study presents qualitative evidence that black older adults on hemodialysis desire physical activity for their health. Future interventions to increase physical activity in this population should consider leveraging existing facilitators, such as the support of family and friends, and use strategies to address barriers like minimal motivation.

Effects of 12 months of detraining on health-related quality of life in patients receiving hemodialysis therapy

PURPOSE

Limited data exist regarding the effects of detraining on functional capacity and quality of life (QoL) in the hemodialysis population. The aim of the current study was to assess whether the discontinuation from a systematic intradialytic exercise training program will affect aspects of health-related QoL and functional capacity in hemodialysis patients.

METHODS

Seventeen hemodialysis patients (12 Males/5 Females, age 60.8 ± 13.6 year) participated in this study. Patients were assessed for functional capacity using various functional capacity tests while QoL, daily sleepiness, sleep quality, depression and fatigue were assessed using validated questionnaires at the end of a 12-month aerobic exercise program and after 12 months of detraining.

RESULTS

The detraining significantly reduced patients' QoL score by 20% (P = 0.01). More affected were aspects related to the physical component summary of the QoL (P < 0.001) rather than those related to the mental one (P = 0.096). In addition, the performance in the functional capacity tests was reduced (P < 0.05), while sleep quality (P = 0.020) and daily sleepiness scores (P = 0.006) were significantly worse after the detraining period. Depressive symptoms (P = 0.214) and the level of fatigue (P = 0.163) did not change significantly.

CONCLUSIONS

Detraining has a detrimental effect in patients' QoL, functional capacity and sleep quality. The affected physical health contributed significantly to the lower QoL score. It is crucial for the chronic disease patients, even during emergencies such as lockdowns and restrictions in activities to maintain a minimum level of activity to preserve some of the acquired benefits and maintain their health status.

Outcome Expectations for Exercise and Decisional Balance Questionnaires Predict Adherence and Efficacy of Exercise Programs in Dialysis Patients

The purpose of this study was to define if Outcomes Expectations for Exercise (OEE) and Decisional Balance (DB) scales predict adherence to guided exercise programs and associate with the improvement in physical performance in the dialysis population. Participants (n = 40; age 63.6 ± 12.5 years) completed OEE and DB questionnaires before randomization to the experimental group (n = 20) and control group (n = 20) of a two-phased exercise program—the experimental group received eight weeks of supervised functional exercise and exercise counseling (1st phase) before commencing eight weeks of home-based exercise on non-dialysis days (2nd phase). Both groups performed intradialytic cycling on dialysis days during both study phases. Patients with above-median OEE and DB scores (>3.15 and >1.3, respectively) expressed significantly better adherence to intradialytic cycling (89% vs. 76%, 89% vs. 77%, respectively, p < 0.05). Experimental group patients with an above-median OEE (but not DB) score had significantly better adherence to supervised and home-based functional exercise (93% vs. 81% and 85% vs. 60%, respectively, p < 0.05). Baseline DB score predicted the final result in the hand-grip test and 6-min walk test. Low OEE and, to a lesser degree, low DB questionnaire scores associate with inferior adherence to dialysis bundled and home-based exercise programs and may help define patient subsets in need of intensified motivational input by exercise caregivers.

Role of Physical Performance Assessments and Need for a Standardized Protocol for Selection of Older Kidney Transplant Candidates

The older adult population (65 years or older) with advanced or end-stage kidney disease is steadily growing, but rates of transplantation within this cohort have not increased in a similar fashion. Physical deconditioning, resulting in poor post-transplantation outcomes, is a primary concern among older renal patients. The assessment of physical function often holds more weight in the selection process for older candidates, despite evidence showing benefits of transplantation to this vulnerable population. Although several frailty assessment tools are being used increasingly to assess functional status, there is no standardized selection process for older candidates based on these assessment results. Also, it is unknown if timely targeted physical therapy interventions in older patients result in significant improvement of functioning capacity, translating to higher listing and transplantation rates, and improved post-transplantation outcomes. It is therefore of upmost importance not only to incorporate an effective objective functional status assessment process into selection and waitlist evaluation protocols, but also to have targeted interventions in place to maintain and improve physical conditioning among older renal patients. This paper reviews the commonly utilized assessment tools, and their applicability to older patients with renal disease. We also propose the need for definitive selection and waitlist management guidelines to formulate a streamlined assessment of functional capacity and transplant eligibility, as well as a process to maintain functional status, thereby increasing the access of older patients to renal transplantation.

Facilitators and Barriers to Exercise Influenced by Traditional Chinese Culture: A Qualitative Study of Chinese Patients Undergoing Hemodialysis

Introduction: Exercise is recommended for patients undergoing hemodialysis to decrease morbidity and mortality. However, their exercise level is lower than healthy people. Understanding reasons behind their sedentary lifestyle is required. Traditional Chinese culture may have a profound impact on patients’ perceptions of exercise, particularly with regard to the relationship of overwork and kidney function and family members’ attitudes toward patients’ participation in exercise. Therefore, we sought to explore the facilitators and barriers to exercise influenced by traditional Chinese culture. Methods: We conducted semistructured interviews with 44 Chinese patients residing in Nantong of Jiangsu Province undergoing hemodialysis, aged 25 to 77 years. Interview questions focused on their perceptions of, attitudes to, and experiences with exercise. Each interview was digitally recorded and lasted from 40 to 60 minutes. Conventional content analysis was used to understand facilitators and barriers to exercise within their experience and perceptions. Findings: We found that specific Chinese cultural health beliefs informed by traditional Chinese medicine strongly affected patients’ attitudes and behaviors toward exercise. Participants in this study tended to believe that overwork impairs kidney functions and viewed strenuous exercise as overwork. Although participants admitted the benefits of exercise, they rejected strenuous exercise and regarded nearly all modalities of exercise with or without facilities (except walking) as strenuous exercise. The most common barriers to exercise were lack of motivation, bad weather, negative attitudes of family members toward patients’ doing exercise, and insufficient exercise information resources. The most common facilitators found in this study were their increased physical well-being and confidence from exercise. Group exercise supported by family members and positive attitudes toward obtaining exercise information were also motivators. Discussion: Chinese patients undergoing hemodialysis reported more barriers than facilitators to exercise. Perceptions and attitudes toward exercise informed by traditional Chinese culture may be hidden barriers to exercising. Our findings indicated that culturally sensitive and patient-centered exercise interventions for Chinese patients are urgently needed.

Benefits and Barriers to and Desired Outcomes with Exercise in Patients with ESKD

BACKGROUND AND OBJECTIVES

Patients with ESKD are sedentary. When patient-identified barriers to exercise are addressed, recruitment and retention in exercise trials remain low, suggesting that the trial design may not resonate with them. Therefore, we conducted a survey of patients on dialysis to assess perceived benefits and barriers to exercise and discover preferred outcomes and exercise type by dialysis modality and age in anticipation of designing future randomized, controlled trials.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

English- and French-speaking patients with ESKD treated with hemodialysis or peritoneal dialysis were recruited from two tertiary care hospitals in Ottawa and Montreal, Canada. Summary descriptive statistics were used to describe patient responses; then, they were separated by dialysis modality and age category.

RESULTS

The survey was completed by 423 participants. Current activity levels were similar across modalities (P=0.35); 78% of younger patients walked at least 10 minutes at a time on 3 or more days compared with only 58% of older patients (P=0.001). The two most desired benefits of exercise were improved energy (18%) and strength (14%). The third priority differed, such that improved sleep, maintenance of independence, and longevity were selected by patients on peritoneal dialysis, patients on in-center hemodialysis, and patients on home hemodialysis, respectively. Older patients were most interested in improvements in energy, strength, and maintenance of independence, whereas younger patients were interested in improving energy, longevity, and transplant candidacy. Only 25% of patients were able to exercise without difficulty; the major barriers for the remaining patients were feeling patients were feeling too tired (55%), short of breath (50%), and too weak (49%). If patients were to exercise, they wanted to exercise at home (73%) using a combination of aerobic and resistance training (41%), regardless of modality or age category.

CONCLUSIONS

The majority of patients undergoing maintenance dialysis in two tertiary hospitals in Ottawa and Montreal report similar desired outcomes and barriers, with greater differences by age category than modality.

Implications of Frailty for Peritransplant Outcomes in Kidney Transplant Recipients

Purpose of Review

Research over the past few decades points to the importance of frailty, or the lack of physiologic reserve, in the natural history of chronic diseases and in modifying the impact of potential interventions. End-stage kidney disease (ESKD) and the intervention of kidney transplantation are no exception. We review the recent epidemiologic and cohort-based evidence on the association between frailty and kidney transplant outcomes and provide a framework of questions with which to approach future research endeavors and clinical practice.

Recent Findings

Frailty in kidney transplant candidates can be measured in numerous ways, including descriptive phenotype, description scores, functional testing, and surrogate measures. Regardless of the metric, the presence of frailty is strongly associated with inferior pre- and posttransplant outcomes compared to the absence of frailty. However, some frail patients with ESKD can benefit from transplant over chronic dialysis. Evidence-based approaches for identifying frail ESKD patients who can benefit from transplant over dialysis, with acceptable posttransplant outcomes, are lacking. Interventional trials to improve frailty and physical function before transplant (prehabilitation) and after transplant (rehabilitation) are also lacking.

Conclusion

Frailty is increasingly recognized as highly relevant to peritransplant outcomes, but more work is needed to: 1) tailor management to the unique needs of frail patients, both pre- and posttransplant; 2) define phenotypes of frail patients who are expected to benefit from transplant over dialysis; and 3) develop interventions to reverse frailty, both pre- and post-transplant.

Implementing a theory-based intradialytic exercise programme in practice: a quality improvement project

BACKGROUND

Research evidence outlines the benefits of intradialytic exercise (IDE), yet implementation into practice has been slow, ostensibly due to a lack of patient and staff engagement. The aim of this quality improvement project was to improve patient outcomes via the introduction of an IDE programme, evaluate patient uptake and sustainability and enhance the engagement of routine haemodialysis (HD) staff with the delivery of the IDE programme.

METHODS

We developed and refined an IDE programme, including interventions designed to increase patient and staff engagement that were based on the Theoretical Domains Framework (TDF), using a series of 'Plan, Do, Study, Act' (PDSA) cycles. The programme was introduced at two UK National Health Service HD units. Process measures included patient uptake, withdrawals, adherence and HD staff involvement. Outcome measures were patient-reported functional capacity, anxiety, depression and symptomology. All measures were collected over 12 months.

RESULTS

A total of 95 patients were enrolled in the IDE programme; 64 (75%) were still participating at 3 months, decreasing to 41 (48%) at 12 months. Adherence was high (78%) at 3 months, decreasing to 63% by 12 months. The provision of IDE by HD staff accounted for a mean of 2 (5%) sessions per 3-month time point. Patients displayed significant improvements in functional ability (P = 0.01) and a reduction in depression (P = 0.02) over 12 months, but the effects seen were limited to those who completed the programme.

CONCLUSIONS

A theory-based IDE programme is feasible and leads to improvement in functional capacity and depression. Sustaining IDE over time is complicated by high levels of patient withdrawal from the programme. Significant change at an organizational level is required to enhance sustainability by increasing HD staff engagement or access to professional exercise support.

Fit for Dialysis: a qualitative exploration of the impact of a research-based film for the promotion of exercise in hemodialysis

BACKGROUND

Exercise improves functional outcomes and quality of life of older patients with end-stage renal disease undergoing hemodialysis. Yet exercise is not promoted as part of routine care. Health care providers and family carers rarely provide encouragement for patients to exercise, and the majority of older patients remain largely inactive. There is thus the need for a shift in the culture of hemodialysis care towards the promotion of exercise for wellness, including expectations of exercise participation by older patients, and encouragement by health care providers and family carers. Film-based educational initiatives hold promise to effect cultures of best practice, but have yet to be utilized in this population.

METHODS

We developed a research-based film, Fit for Dialysis, to promote exercise for wellness in hemodialysis care. Using a qualitative approach, we evaluated the effects that resulted from engagement with this film (e.g. knowledge/attitudes regarding the importance of exercise-based principles of wellness) as well as the generative mechanisms of these effects (e.g. realism, aesthetics). We also explored the factors related to patients, family carers, and health care providers that influenced engagement with the film, and the successful uptake of the key messages of Fit for Dialysis. We conducted qualitative interviews with 10 patients, 10 health care providers, and 10 family carers. Data were analyzed using thematic analysis.

RESULTS

The film was perceived to be effective in increasing patients', family carers' and health care providers' understanding of the importance of exercise and its benefits, motivating patients to exercise, and in increasing encouragement by family carers and health care providers of patient exercise. Realism (e.g. character identification) and aesthetic qualities of the film (e.g. dialogue) were identified as central generative mechanisms.

CONCLUSIONS

Fit for Dialysis is well-positioned to optimize the health and wellbeing of older adults undergoing hemodialysis.

TRIAL REGISTRATION

NCT02754271 ( ClinicalTrials.gov ), retroactively registered on April 21, 2016.

Interaction of healthcare staff's attitude with barriers to physical activity in hemodialysis patients: A quantitative assessment

Background and aim of the study

In hemodialysis patients, sedentarism is a potentially modifiable mortality risk factor. We explored whether healthcare staff’s attitude towards exercise interacts with patient-perceived barriers in modifying the level of physical activity in this population.

Methods

In this prospective, cross-sectional, multicenter study we recruited 608 adult patients and 330 members of the healthcare staff in 16 hemodialysis units in Italy. We assessed patient-perceived barriers to, and healthcare staff’s attitude towards, exercise by specific questionnaires. We fitted multilevel linear models to analyze the relationships of either barriers or staff’s attitude, and their interaction, with a measure of patient self-reported physical activity (the Human Activity Profile–Adjusted Activity Score [HAP-AAS]), adjusting for multiple confounders. We also employed latent class analysis to dichotomize patients into those endorsing or not endorsing barriers.

Results

Most barriers were negatively associated with the HAP-AAS (adjusted change attributable to a given barrier ranging between -5.1 [“Feeling too old”, 95% Confidence Interval: -9.4 to -0.8] and -15.6 [“Ulcers on legs and feet”, 95%CI: -24.8 to -6.5]. We found a significant interaction between staff’s attitude and barriers (adjusted P values ranging between 0.03 [“I do not believe that it is physician’s or nurse’s role providing advice on exercise to patients on dialysis”] and 0.001 [“I do not often ask patients about exercise”]). A beneficial effect of a proactive staff’s attitude was evident only in patients not endorsing barriers.

Conclusions

Barriers and non-proactive staff’s attitude reduce physical activity in hemodialysis patients. Patients not endorsing barriers benefit the most from a proactive staff’s attitude.

Barriers to exercise for patients with renal disease: an integrative review

Renal disease is a common health condition that leads to loss of physical function, frailty, and premature loss of independence in addition to other severe comorbidities and increased mortality. Increased levels of physical activity and initiation of exercise training is recommended in the current guidelines for all patients with renal disease, but participation and adherence rates are low. The barriers to exercise and physical activity in patients with renal disease are not well defined and currently based on patient provider perception and opinion. There have been no published reviews that have synthesized published findings on patient reported barriers to exercise. This integrative literature review therefore aimed to identify the current understanding of patient reported barriers to regular exercise. This integrative review found that patient perceived barriers to exercise are not consistent with the barriers that have been identified by renal disease specialists and healthcare providers, which were disinterest, lack of motivation, and being incapable of exercise. The patient reported barriers identified through this review were complex and diverse, and the most frequently reported patient perceived barrier to exercise was low energy levels and fatigue. It is clear that additional research to identify patient perceived barriers to exercise is needed and that patient directed interventions to address these barriers should be developed. This integrative review provides information to the interdisciplinary nephrology team that can be used to tailor their assessment of barriers to exercise and provide exercise education for patients with renal disease.

Exercise and CKD: Skeletal Muscle Dysfunction and Practical Application of Exercise to Prevent and Treat Physical Impairments in CKD

Patients with chronic kidney disease experience substantial loss of muscle mass, weakness, and poor physical performance. As kidney disease progresses, skeletal muscle dysfunction forms a common pathway for mobility limitation, loss of functional independence, and vulnerability to disease complications. Screening for those at high risk for mobility disability by self-reported and objective measures of function is an essential first step in developing an interdisciplinary approach to treatment that includes rehabilitative therapies and counseling on physical activity. Exercise has beneficial effects on systemic inflammation, muscle, and physical performance in chronic kidney disease. Kidney health providers need to identify patient and care delivery barriers to exercise in order to effectively counsel patients on physical activity. A thorough medical evaluation and assessment of baseline function using self-reported and objective function assessment is essential to guide an effective individualized exercise prescription to prevent function decline in persons with kidney disease. This review focuses on the impact of kidney disease on skeletal muscle dysfunction in the context of the disablement process and reviews screening and treatment strategies that kidney health professionals can use in clinical practice to prevent functional decline and disability.

Prehabilitation for the Frail Patient Approaching ESRD

Frailty is a distinct phenotype that is highly prevalent in chronic kidney disease (CKD) and appears to be more prevalent with decreasing glomerular filtration rate. Exercise training or intervention to increase physical activity may ameliorate poor physical functioning and frailty, and even may improve survival in patients with CKD. Although exercise interventions improve outcomes across the spectrum of CKD, including patients treated with dialysis, patients treated with dialysis face barriers to exercise that patients with predialysis CKD do not. Rehabilitation at earlier stages of CKD (or prehabilitation before dialysis) might be more beneficial than not addressing the decreasing physical functioning and low physical activity until patients are receiving dialysis. This review summarizes available literature on frailty in the CKD and end-stage renal disease population, including exercise interventions and the limited evidence for prehabilitation as a strategy.

Intradialytic Exercise is Medicine for Hemodialysis Patients

When a person's kidneys fail, hemodialysis (HD) is the most common treatment modality. With a growing number of patients requiring this life-sustaining treatment, and with evidence illustrating the significant physical dysfunction of this population, encouraging exercise is essential. The use of intradialytic exercise, as a novel and efficient use of time during HD, is well established in Australia and some European nations; however, it is slower to start in North America. While a large number of small studies have demonstrated numerous benefits and safe delivery of intradialytic exercise training for patients with end-stage kidney disease, intradialytic exercise is rarely delivered as standard of care. It is of utmost importance for health care staff to overcome barriers and bring theory into practice. Included in this report are current recommendations from governing bodies, expert opinion, as well as established policies and procedures from a successful intradialytic exercise program in Canada.

A prospective 2-site parallel intervention trial of a research-based film to increase exercise amongst older hemodialysis patients

Background

Evidence suggests that exercise training for hemodialysis patients positively improves morbidity and mortality outcomes, yet exercise programs remain rare and are not systematically incorporated into care. We developed a research-based film, Fit for Dialysis, designed to introduce, motivate, and sustain exercise for wellness amongst older hemodialysis patients, and exercise counseling and support by nephrologists, nurses, and family caregivers. The objective of this clinical trial is to determine whether and in what ways Fit for Dialysis improves outcomes and influences knowledge/attitudes regarding the importance of exercise for wellness in the context of end-stage renal disease.

Methods/Design

This 2-site parallel intervention trial will recruit 60 older hemodialysis patients from two urban hospitals. The trial will compare the film + a 16-week exercise program in one hospital, with a 16-week exercise-only program in another hospital. Physical fitness and activity measures will be performed at baseline, 8 and 16 weeks, and 12 weeks after the end of the program. These include the 2-min Walk Test, Grip Strength, Duke Activity Status Index, and the Timed Up-and-Go Test, as well as wearing a pedometer for one week. Throughout the 16-week exercise program, and at 12 weeks after, we will record patients’ exercise using the Godin Leisure-time Exercise Questionnaire. Patients will also keep a diary of the exercise that they do at home on non-dialysis days. Qualitative interviews, conducted at baseline, 8, and 16 weeks, will explore the impact of Fit for Dialysis on the knowledge/attitudes of patients, family caregivers, and nephrology staff regarding exercise for wellness, and in what ways the film is effective in educating, motivating, or sustaining patient exercise during dialysis, at home, and in the community.

Discussion

This research will determine for whom Fit for Dialysis is effective, why, and under what conditions. If Fit for Dialysis is proven beneficial to patients, nephrology staff and family caregivers, research-based film as a model to support exercise promotion and adherence could be used to support the National Kidney Foundation’s guideline recommendation (NKF-KDOQI) that exercise be incorporated into the care and treatment of dialysis patients.

Trial registration

NCT02754271 (ClinicalTrials.gov), retroactively registered on April 21, 2016.

Knowledge, barriers and facilitators of exercise in dialysis patients: a qualitative study of patients, staff and nephrologists

BACKGROUND

Despite growing evidence on benefits of increased physical activity in hemodialysis (HD) patients and safety of intra-dialytic exercise, it is not part of standard clinical care, resulting in a missed opportunity to improve clinical outcomes in these patients. To develop a successful exercise program for HD patients, it is critical to understand patients', staff and nephrologists' knowledge, barriers, motivators and preferences for patient exercise.

METHODS

In-depth interviews were conducted with a purposive sample of HD patients, staff and nephrologists from 4 dialysis units. The data collection, analysis and interpretation followed Criteria for Reporting Qualitative Research guidelines. Using grounded theory, emergent themes were identified, discussed and organized into major themes and subthemes.

RESULTS

We interviewed 16 in-center HD patients (mean age 60 years, 50% females, 63% blacks), 14 dialysis staff members (6 nurses, 3 technicians, 2 dietitians, 1 social worker, 2 unit administrators) and 6 nephrologists (50% females, 50% in private practice). Although majority of the participants viewed exercise as beneficial for overall health, most patients failed to recognize potential mental health benefits. Most commonly reported barriers to exercise were dialysis-related fatigue, comorbid health conditions and lack of motivation. Specifically for intra-dialytic exercise, participants expressed concern over safety and type of exercise, impact on staff workload and resistance to changing dialysis routine. One of the most important motivators identified was support from friends, family and health care providers. Specific recommendations for an intra-dialytic exercise program included building a culture of exercise in the dialysis unit, and providing an individualized engaging program that incorporates education and incentives for exercising.

CONCLUSION

Patients, staff and nephrologists perceive a number of barriers to exercise, some of which may be modifiable. Participants desired an individualized intra-dialytic exercise program which incorporates education and motivation, and they provided a number of recommendations that should be considered when implementing such a program.

Randomised factorial mixed method pilot study of aerobic and resistance exercise in haemodialysis patients: DIALY-SIZE!

OBJECTIVES

For people with end-stage renal disease requiring haemodialysis, exercise can improve aspects of quality of life (QoL). However, the relative benefits and risks of different types of exercise in this population are unknown. Therefore, this pilot study aimed to evaluate the feasibility of a main study evaluating the efficacy of cycling and resistance exercise each performed during the haemodialysis treatment on QoL.

METHODS

In this factorial (2×2) pilot trial, 31 haemodialysis patients were randomised to cycling, resistance, cycling and resistance, or an attention control. Feasibility was defined a priori by criteria on recruitment, fidelity to the protocol and patient response to the intervention. To better understand feasibility, we conducted interviews with dialysis unit staff and trial participants. As secondary outcomes, we estimated the main effect of cycling and weights each compared with control on QoL, physical function and strength.

FINDINGS

We exceeded the target accrual of 28 participants over 12 weeks. Irrespective of exercise group allocation, adherence was high; of the 1038 training sessions offered, 87% were initiated and over 80% of exercise sessions were performed as per protocol. Progression based on perceived exertion, individual instruction and interactions with the kinesiologist facilitated acceptability across exercise groups. Using an attention control, measures of contamination and attrition were low. Important barriers to unit staff readiness for the intervention were initial safety and workflow concerns, unit workload and onerous data collection. Secondary outcomes were not statistically significant. Adverse events were low and did not increase with a higher volume of exercise.

CONCLUSIONS

The main study is feasible with minor modifications. In addition to practical assistance, involvement from unit staff could increase patient participation and improve trial implementation. Strategies to increase acceptability of the intervention for staff include improving workflow integration and using a prestudy demonstration phase to introduce the intervention.

TRIAL REGISTRATION NUMBER

NCT02234232.

Nível de atividade física de pacientes em hemodiálise: um estudo de corte transversal

RESUMO Este estudo avaliou o nível de atividade física de pacientes em tratamento hemodialítico, verificando sua relação com variáveis sociodemográficas e laboratoriais. Foi realizado estudo de corte transversal composto por 108 sujeitos com doença renal crônica sob hemodiálise, sendo constituídos os grupos "ativo" e "sedentário". Foram avaliados dados socioeconômicos (questionário semiestruturado), características da doença renal, nível de atividade física (International Physical Activity Questionnaire - IPAQ) e dados laboratoriais (hematócrito, hemoglobina, creatinina, albumina, ureia) dos últimos exames registrados em prontuários. 8% dos pacientes da amostra foram identificados como sedentários, e 70,4% não receberam orientação para a realização de atividade física (p=0,013). Não foram observadas correlações entre o nível de atividade física e os dados socioeconômicos, clínicos e os parâmetros bioquímicos. Concluiu-se que indivíduos doentes renais crônicos em terapia renal substitutiva do tipo hemodiálise apresentam baixo nível de atividade física. Este achado está relacionado com a frequência de orientações a esse respeito para a população em diálise, não estando relacionado a dados sociodemográficos, clínicos e bioquímicos avaliados.

A Qualitative Study to Explore Patient and Staff Perceptions of Intradialytic Exercise

BACKGROUND AND OBJECTIVES

Randomized, controlled trials show that regular exercise is beneficial for patients on hemodialysis. Intradialytic exercise may have additional benefits, such as amelioration of treatment-related symptoms. However, the factors that influence the implementation of intradialytic exercise are largely unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Individual semistructured interviews were conducted with a purposive sample of patients on hemodialysis who had participated in a pilot randomized, controlled trial on intradialytic exercise and dialysis staff that worked in the unit during the trial. The trial took place from July to December of 2014 and enrolled 31 patients. Interviews were conducted from April to December of 2014. Interview coding followed an inductive and broad-based approach. Thematic analysis was used to group codes into common themes, first individually and then, across staff and patient interviews.

RESULTS

Twenty-five patients and 11 staff were interviewed. Three themes common to both groups emerged: support, norms (expected practices) within the dialysis unit, and the role of the dialysis nurse. The support of the kinesiologist enhanced patients' confidence and sense of capability and was a key component of implementation. However, the practice of initiating exercise at the start of the shift was a barrier to staff participation. Staff focused on the technical aspects of their role in intradialytic exercise, whereas patients viewed encouragement and assistance with intradialytic exercise as the staff's role. An additional theme of no time (for staff to participate in intradialytic exercise) was influenced by its low priority in their workflow and the demands of the unit. The staff's emphasis on patients setting up their own equipment and enhanced social interaction among participants were additional themes that conveyed the unintended consequences of the intervention.

CONCLUSIONS

The kinesiologist-patient interactions and staff readiness for intradialytic exercise were important factors in the implementation of intradialytic exercise. Understanding how unit workflow and the personal values of staff can influence implementation may improve the design of intradialytic exercise interventions.

Increasing the uptake of exercise programs in the dialysis unit: a protocol for a realist synthesis

BACKGROUND

For people with end-stage kidney disease on hemodialysis, exercise during the dialysis treatment (intradialytic exercise) may promote exercise adherence and enhance aspects of the dialysis treatment. However, intradialytic exercise programs are complex and how to adapt program components to local context so that the program is more likely to attain its intended health outcomes have not been well described. To increase the uptake of exercise in clinical practice, more evidence is needed on how contextual factors influence the program's impact.

METHODS

Using the realist approach, we aim to understand how the processes and structures of intradialytic exercise programs work to influence patient participation according to different contextual factors. The focus of a realist review is explanatory and aims to develop and test theory on how contextual factors trigger specific processes or behaviors (or "mechanisms") to produce outcomes. Using the realist context-mechanism-outcome configuration of theory development, we will use a range of sources to develop initial candidate theories: a scoping review of published papers and the gray literature, and discussion with stakeholders. To provide a theoretical basis for how contextual factors could work to influence patient participation in intradialytic exercise (IDE), several of our preliminary theories will be based on dominant theories of exercise adherence and behavior change. To support or refute these initial theories, we will synthesize data from a systematic literature review and semi-structured interviews with intradialytic exercise program stakeholders, sampled from a range of programs worldwide.

DISCUSSION

The complexity of intradialytic exercise programs poses challenges to their implementation. Using the "context, mechanism, outcome" approach, the knowledge gained from this study will be used to develop general recommendations for renal care providers and administration on how to adapt components of an intradialytic exercise programs according to different contextual factors in order to promote patient participation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033335.

Knowledge among nephrologists about the importance of exercise in the intradialytic period

[Purpose] To assess knowledge among nephrologists at hemodialysis services about routine intradialytic therapeutic exercise, in the city of Recife. [Subjects and Methods] A cross-sectional study, consisting of 49 nephrologists working in public and/or private hemodialysis services, who responded to a semi-structured questionnaire about their academic background, medical residency, and knowledge about exercise during the intradialytic period. [Results] About 56.3% practiced for more than 10 years as nephrologists, 69.4% did not receive information about intradialytic physical exercise while in residency, 81.6% considered intradialytic exercise to be important, and 53.0% did not prescribe exercise during hemodialysis. About 61.2% consider the level of physical activity among their patients to be poor. Nephrologists graduating within 2 years were 10 times more likely to prescribe exercise, compared to those with more than 2 years since graduation. [Conclusion] Our study found that the nephrologists interviewed do not usually prescribe intradialytic therapeutic exercise, despite understanding its importance as part of the treatment process. It is necessary to update doctors about the importance of exercise for patients during the intradialytic period, as well as to incorporate this knowledge at the undergraduate level.

Patient and Staff Perceptions of Intradialytic Exercise before and after Implementation: A Qualitative Study

Introduction

Despite guidance and evidence for the beneficial effects of intradialytic exercise (IDE), such programmes are rarely adopted within practice and little is known about how they may best be sustained. The Theoretical Domains Framework (TDF) was used to guide the understanding of the barriers and facilitators to initial and ongoing IDE participation and to understand how these are influential at each stage.

Materials and Methods

Focus groups explored patient (n=24) and staff (n=9) perceptions of IDE prior to the introduction of a programme and, six months later, face to face semi-structured interviews captured exercising patients (n=11) and staffs’ (n=8) actual experiences. Data were collected at private and NHS haemodialysis units within the UK. All data were audio-recorded, translated where necessary, transcribed verbatim and subject to framework analysis.

Results

IDE initiation can be facilitated by addressing the pre-existing beliefs about IDE through the influence of peers (for patients) and training (for staff). Participation was sustained through the observation of positive outcomes and through social influences such as teamwork and collaboration. Despite this, environment and resource limitations remained the greatest barrier perceived by both groups.

Conclusions

Novel methods of staff training and patient education should enhance engagement. Programmes that clearly highlight the benefits of IDE should be more successful in the longer term. The barrier of staff workload needs to be addressed through specific guidance that includes recommendations on staffing levels, roles, training and skill mix.

A nurse-led case management program on home exercise training for hemodialysis patients: A randomized controlled trial

BACKGROUND

Patients on maintenance hemodialysis suffer from diminished physical health. Directly supervised exercise programs have been shown to be effective at improving physical function and optimizing well-being. However, nurses seldom include an exercise intervention in the care plan for hemodialysis patients.

OBJECTIVES

The purpose of this study was to examine the effects of a 12-week nurse-led case management program on home exercise training for hemodialysis patients.

DESIGN

The study was a randomized, two-parallel group trial.

SETTINGS

Hemodialysis units in two tertiary hospitals in Nanjing, mainland China.

PARTICIPANTS

One hundred and thirteen adult patients who have been in stable condition while on dialysis treatment for more than 3 months were recruited and randomly assigned to either the study group (n=57) or the control group (n=56).

METHODS

Both groups underwent a brief weekly in-center exercise training session before their dialysis sessions for the first 6 weeks. The study group received additional nurse case management weekly for the first 6 weeks and biweekly for the following 6 weeks. The intervention was to facilitate patients in performing regular exercise at home. Outcome measures, including gait speed, 10-repetition sit-to-stand performance, and quality of life were collected at baseline, and at 6 and 12 weeks into the program.

RESULTS

The results revealed that patients in the study group demonstrated greater increases in normal gait speed [F(1,111)=4.42, p=0.038] than the control group. For the study group, a mean increase of 12.02 (±3.03)centimeters/second from baseline to week 12 was found. With regard to the fast gait speed, there was a marginally significant between-group effect [F(1,111)=3.93, p=0.050]. The study group showed a mean improvement of 11.08 (±3.32)cm/s, from baseline to week 12. Patients from both groups showed improvements in their 10-repetition sit-to-stand performance. The between-group differences approached significance [F(1,111)=3.92, p=0.050], with the study group showed greater improvement than the control group. The time taken by the patients in the study group to complete the 10-STS test increased by 5.75 (±3.88)s from baseline to week 12. Significant improvements in quality of life across three time points were found only in the study group.

CONCLUSIONS

Home exercise using a nurse-led case management approach is practical and effective in improving the physical function and self-perceived health of stable hemodialysis patients.

Self-reported physical activity in patients on chronic hemodialysis: correlates and barriers

BACKGROUND AND AIMS

The knowledge of the barriers that are associated with decreased physical activity (PA) in patients on chronic hemodialysis (PCH) may be of primary importance for the nephrologists. Thus, we aimed to assess the barriers associated with the absent or reduced PA in PCH of a Mediterranean country.

METHODS

Patients were invited to answer the question 'How often do you exercise during your leisure time?'. Also, patients included in the study were asked to answer questions regarding barriers to physical activity lower than desired.

RESULTS

We studied 105 patients. Forty (38.1%) patients reported to never exercise, 6 (5.7%) reported to exercise less than once/week, 4 (3.8%) once/week, 23 (21.9%) two to three times/week, 12 (11.4%) four to five times/week and 20 (19%) daily. Overall, 46 (43.8%) patients never exercised or exercised less than once/week ('inactive') and 59 (56.2%) did exercise more often ('active'). At the multivariate analysis, reduced walking ability, fatigue on the non-dialysis days, and shortness of breath were independently and negatively associated with PA. The same results were found when the reduced model of the multivariate logistic backward regression was built introducing in the model also clinical and laboratory variables.

CONCLUSION

In PCH, fatigue on the non-dialysis days, reduced walking ability, and shortness of breath are barriers independently associated to decreased PA. Knowledge about the causes and mechanisms that generate these barriers has to be acquired.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives

INTRODUCTION

Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers.

METHODS

Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software.

RESULTS

Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers.

CONCLUSIONS

Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

The impact of an exercise physiologist coordinated resistance exercise program on the physical function of people receiving hemodialysis: a stepped wedge randomised control study

Background

Exercise during hemodialysis treatments improves physical function, markers of cardiovascular disease and quality of life. However, exercise programs are not a part of standard therapy in the vast majority of hemodialysis clinics internationally. Hemodialysis unit-based accredited exercise physiologists may contribute to an increased intradialytic exercise uptake and improved physical function.

Methods and design

This is a stepped wedge cluster randomised controlled trial design. A total of 180 participants will be recruited from 15 community satellite hemodialysis clinics in a large metropolitan Australian city. Each clinic will represent a cluster unit. The stepped wedge design will consist of three groups each containing five randomly allocated cluster units, allocated to either 12, 24 or 36 weeks of the intervention. The intervention will consist of an accredited exercise physiologist-coordinated program consisting of six lower body resistance exercises using resistance elastic bands and tubing. The resistance exercises will include leg abduction, plantar flexion, dorsi flexion, straight-leg/bent-knee raise, knee extension and knee flexion. The resistance training will incorporate the principle of progressive overload and completed in a seated position during the first hour of hemodialysis treatment. The primary outcome measure is objective physical function measured by the 30-second sit to stand test. Secondary outcome measures include the 8-foot timed-up-and-go test, the four square step test, quality of life, cost-utility analysis, uptake and involvement in community activity, self-reported falls, fall’s confidence, medication use, blood pressure and morbidity (hospital admissions).

Discussion

The results of this study are expected to determine the efficacy of an accredited exercise physiologist supervised resistance training on the physical function of people receiving hemodialysis and the cost-utility of exercise physiologists in hemodialysis centres. This may contribute to intradialytic exercise as standard therapy using an exercise physiologist workforce model.

Trial registration

Current Controlled Trials ACTRN12612001223820.

Exercise training for adults with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients.

OBJECTIVES

We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010.

SELECTION CRITERIA

We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence.

AUTHORS' CONCLUSIONS

There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.

Availability, characteristics, and barriers of rehabilitation programs in organ transplant populations across Canada

Rehabilitation is receiving increasingly more attention from the medical community in the management of individuals' pre- and post-organ transplantation. A cross-sectional descriptive survey was administered to all known transplant programs across Canada to explore the availability, characteristics, and barriers of rehabilitation programs pre- and post-heart, lung, kidney, and liver transplantation. Of the 58 programs surveyed, 35 agreed to participate (nine heart, six lung, 13 kidney, seven liver), and six refused for a response rate of 71%. Twelve transplant programs that offered rehabilitation were identified (six heart, five lung, one liver). All rehabilitation programs identified included aerobic exercises, strength training, and education and involved a multidisciplinary team. The Six Minute Walk Test and the Medical Outcomes Short Form-36 questionnaire were the most commonly used outcome measures. In kidney and liver transplant programs, over 50% of respondents from these programs cited lack of funding, shortage of health care personnel, and a low volume of patients in a centralized region as barriers to providing rehabilitation programs. Rehabilitation can play an integral role in pre- and post-transplantation management, and barriers to access and provision of rehabilitation for organ transplant populations should be examined further.