Patients' perspectives on the implementation of intra-dialytic cycling--a phenomenographic 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.

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.

A Comprehensive Exercise (COMEX) Intervention to Optimize Exercise Participation for Improving Patient-Centered Outcomes and Physical Functioning in Patients Receiving Hemodialysis: Development and Pilot Testing

Rationale & Objective

To address the need for an intradialytic exercise program that is easily delivered in clinical setting, engaging and scalable, we developed a novel COMprehensive EXercise (COMEX) program based on input from patients receiving hemodialysis (HD), dialysis staff members and nephrologists. The objective of this study was to determine the feasibility, safety, and acceptance of COMEX during HD.

Study Design

Single-arm prospective pilot feasibility study.

Setting & Participants

Seventeen patients receiving in-center HD.

Intervention

Three-month participation in the COMEX program, which included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components.

Outcomes

Data on recruitment, adherence, safety and acceptability were collected. Additional assessments were performed to evaluate changes in physical functioning, patient-reported symptoms, and objectively measured sleep and physical activity. We also examined the feasibility of obtaining skeletal muscle biopsies and blood samples to explore molecular mechanisms of muscle atrophy and to assess platelet mitochondrial function and adaptation to exercise during HD.

Results

Thirteen of the 17 (76%) participants completed the 3-month intervention. The mean participant age was 63.6 ± 15.1 years. In total, 46% of participants were males, and 55% were White. The mean body mass index was 38.7 ± 11.6 kg/m2. There were no reported adverse effects, and the adherence rate to exercise sessions was high with 88% of the sessions completed. Patient satisfaction was high, as 100% of the patients would recommend the program to other dialysis patients. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples.

Limitations

Small sample size, lack of an onsite exercise professional, and technological issues with telemedicine behavioral motivation.

Conclusions

The COMEX intradialytic exercise intervention is safe and acceptable to patients, and outcome measures were feasible to obtain. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Funding Source

This work is supported by pilot award from P30 DK079307 (PI, Jhamb).

Trial Registration

ClinicalTrials.gov, NCT03055299.

Plain-Language Summary

We tested a new COMprehensive EXercise (COMEX) program to deliver exercise during dialysis. This 3-month program included video-based dialysis chair exercises (aerobic and resistance) integrated with educational and motivational components. Our study shows COMEX was feasible, had high satisfaction and adherence, and was safe. It was feasible to collect data on physical functioning, patient-reported symptoms, and objective sleep and physical activity and to obtain muscle biopsies and blood samples. Future studies should consider including exercise professionals to facilitate progression through a personalized exercise protocol.

Hemodynamic Tolerance of Virtual Reality Intradialysis Exercise Performed during the Last 30 Minutes versus the Beginning of the Hemodialysis Session

Background: Exercise improves the physical function of people suffering from chronic kidney disease on hemodialysis (HD). Virtual reality is a new type of intradialysis exercise that has a positive impact on physical function. Intradialysis exercise is recommended during the first 2 h, but its safety in the last part of the dialysis session is unknown. Methods: This was a pilot sub-study of a clinical trial. Several hemodynamic control variables were recorded, including blood pressure, heart rate, and intradialytic hypotensive events. These variables were recorded during three different HD sessions, one HD session at rest, another HD session with exercise during the first two hours, and one HD session with exercise during the last 30 min of dialysis. The intradialysis virtual reality exercise was performed for a maximum of 30 min. Results: During exercise sessions, there was a significant increase in heart rate (6.65 (4.92, 8.39) bpm; p < 0.001) and systolic blood pressure (6.25 (0.04,12.47) mmHg; p < 0.05). There was no difference in hemodynamic control between the sessions with exercise during the first two hours and the sessions with exercise during the last 30 min. There was no association between intra-dialytic hypotensive events at rest (five events) or exercise at any point (two vs. one event(s), respectively). Conclusion: performing exercise with virtual reality at the end of a hemodialysis session is not associated with hemodynamic instability.

Feasibility of Intradialytic Cycling Program in a Remote Community Hemodialysis Unit: Mixed-Methods Analysis of Implementation

BACKGROUND

There is growing evidence demonstrating the benefits of intradialytic cycling. However, there are relatively few centers where this practice has been adopted with no reports from hemodialysis units in rural, remote, and northern locations. Maintaining mobility and quality of life for patients on kidney replacement therapy living in remote northern communities is inhibited by inclement weather and lack of access to resources and infrastructure that support physical activity. The integration of intradialytic cycling during hemodialysis offers patients a form of safe physical activity year-round.

OBJECTIVE

This study focuses on better understanding the feasibility and acceptability of implementing intradialytic cycling in a remote northern geographical context.

DESIGN

A feasibility study using a mixed-methods explanatory design was adopted for this study.

SETTING

The research is conducted in Prince George, British Columbia.

PARTICIPANTS

The participants are patients attending a community-based dialysis unit in remote northern British Columbia and health professionals working in the same facility.

METHODS

Quantitative measures were captured through cycling logbooks and quality of life measure, and qualitative data were obtained through semi-structured interviews and analyzed using thematic analysis.

RESULTS

Six (43%) eligible patients used leg ergometers more than once for a median of 2.5 (interquartile range: 1-4) months and 87% of hemodialysis sessions. Participants cycled for a median of 65 (interquartile range: 39-76) minutes per session, with frequent variability noted between participants and different hemodialysis sessions for the same participant. Nine patients completed the European Quality of Life Health Questionnaire prestudy, with 5 (56%) also completing it poststudy. Interviews with 9 patients, 4 nurses, and 1 physiotherapist led to the identification of themes instrumental to implementation: a supportive community dialysis unit, shared responsibility, knowledge of patients/providers, and benefits associated with engagement. Themes that were identified as being key to acceptability in this remote dialysis unit were trust, connection, and engagement through common values.

LIMITATIONS

Due to dialysis unit size, we had a small number of participants.

CONCLUSIONS

This study demonstrates the feasibility of implementing best practice in a remote community and provides insight into the elements of context and participation that contribute to acceptability in the implementation of intradialytic cycling.

Motivation, Barriers, and Suggestions for Intradialytic Exercise-A Qualitative Study among Patients and Nurses

Background: Intradialytic exercise is an effective intervention to reduce morbidity and mortality and increase quality of life among patients with chronic kidney disease undergoing dialysis. However, implementing and sustaining it in clinical practice has proved challenging. To identify how to best design an effective and sustainable intervention in clinical practice, we aimed to explore hemodialysis patients’ and nurses’ attitudes towards intradialytic exercise, including their motivation, anticipated barriers, and suggestions for the design of a proposed exercise program. Methods: Data were collected through qualitative semistructured interviews with patients and focus group interviews with nurses and analyzed inductively with content analysis. Results: Overall, patients’ and nurses’ attitudes towards intradialytic exercise were positive. Patients were motivated by their expectations about perceived benefits, such as improved quality of life and reduced musculoskeletal pain. Their main concern was triggering dialysis machine alarms and disturbing nurses. Nurses were more skeptical of intradialytic exercise and concerned about patient safety. Patients and nurses had several ideas on how to design a safe and motivating intradialytic exercise intervention. Conclusion: The analysis of patients’ and nurses’ experiences and attitudes generated recommendations for an intradialytic exercise program. Recommendations include individually tailored programs that are safe and that patients can do independently, continuous collaboration between patients, nurses, physicians, and physiotherapists, and educating nurses about the benefits and safety of intradialytic exercise.

Addressing feasibility challenges to delivering intradialytic exercise interventions: A theory-informed qualitative study

BACKGROUND

Intradialytic exercise (IDE) may improve physical function and health-related quality of life. However, incorporating IDE into standard hemodialysis care has been slow due to feasibility challenges. We conducted a multicenter qualitative feasibility study to identify potential barriers and enablers to IDE and generate potential solutions to these factors.

METHODS

We conducted 43 semi-structured interviews with healthcare providers and patients across twelve hospitals in Ontario, Canada. We used the Theoretical Domains Framework and directed content analysis to analyze the data.

RESULTS

We identified eight relevant domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: lack of staff expertise to oversee exercise, uncertainty regarding exercise risks, benefits, and patient interest, lack of knowledge regarding exercise eligibility; 2) Human, material and logistical resources: staff concerns regarding workload, perception that exercise professionals should supervise IDE; space, equipment, and scheduling conflict concerns; 3) Social dynamics of the unit: local champions and patient stories contribute to IDE sustainability.We developed a list of actionable solutions by mapping barriers and enablers to behavior change techniques. We also developed a feasibility checklist of 47 questions identifying key factors to address prior to IDE launch.

CONCLUSIONS

Evidence-based solutions to identified barriers and enablers to IDE and a feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.

Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: the PEDAL RCT

BACKGROUND

Whether or not clinically implementable exercise interventions in haemodialysis patients improve quality of life remains unknown.

OBJECTIVES

The PEDAL (PrEscription of intraDialytic exercise to improve quAlity of Life in patients with chronic kidney disease) trial evaluated the clinical effectiveness and cost-effectiveness of a 6-month intradialytic exercise programme on quality of life compared with usual care for haemodialysis patients.

DESIGN

We conducted a prospective, multicentre randomised controlled trial of haemodialysis patients from five haemodialysis centres in the UK and randomly assigned them (1 : 1) using a web-based system to (1) intradialytic exercise training plus usual-care maintenance haemodialysis or (2) usual-care maintenance haemodialysis.

SETTING

The setting was five dialysis units across the UK from 2015 to 2019.

PARTICIPANTS

The participants were adult patients with end-stage kidney disease who had been receiving haemodialysis therapy for > 1 year.

INTERVENTIONS

Participants were randomised to receive usual-care maintenance haemodialysis or usual-care maintenance haemodialysis plus intradialytic exercise training.

MAIN OUTCOME MEASURES

The primary outcome of the study was change in Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score (from baseline to 6 months). Cost-effectiveness was determined using health economic analysis and the EuroQol-5 Dimensions, five-level version. Additional secondary outcomes included quality of life (Kidney Disease Quality of Life Short Form, version 1.3, generic multi-item and burden of kidney disease scales), functional capacity (sit-to-stand 60 and 10-metre Timed Up and Go tests), physiological measures (peak oxygen uptake and arterial stiffness), habitual physical activity levels (measured by the International Physical Activity Questionnaire and Duke Activity Status Index), fear of falling (measured by the Tinetti Falls Efficacy Scale), anthropometric measures (body mass index and waist circumference), clinical measures (including medication use, resting blood pressure, routine biochemistry, hospitalisations) and harms associated with intervention. A nested qualitative study was conducted.

RESULTS

We randomised 379 participants; 335 patients completed baseline assessments and 243 patients (intervention, n = 127; control, n = 116) completed 6-month assessments. The mean difference in change in physical component summary score from baseline to 6 months between the intervention group and control group was 2.4 arbitrary units (95% confidence interval -0.1 to 4.8 arbitrary units; p = 0.055). Participants in the intervention group had poor compliance (49%) and very poor adherence (18%) to the exercise prescription. The cost of delivering the intervention ranged from £463 to £848 per participant per year. The number of participants with harms was similar in the intervention (n = 69) and control (n = 56) groups.

LIMITATIONS

Participants could not be blinded to the intervention; however, outcome assessors were blinded to group allocation.

CONCLUSIONS

On trial completion the primary outcome (Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score) was not statistically improved compared with usual care. The findings suggest that implementation of an intradialytic cycling programme is not an effective intervention to enhance health-related quality of life, as delivered to this cohort of deconditioned patients receiving haemodialysis.

FUTURE WORK

The benefits of longer interventions, including progressive resistance training, should be confirmed even if extradialytic delivery is required. Future studies also need to evaluate whether or not there are subgroups of patients who may benefit from this type of intervention, and whether or not there is scope to optimise the exercise intervention to improve compliance and clinical effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83508514.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 40. See the NIHR Journals Library website for further project information.

Hemodialysis patients perceived exercise benefits and barriers: the association with health-related quality of life

BACKGROUND

Patients on hemodialysis have less exercise capacity and lower health-related quality of life than healthy individuals without chronic kidney disease (CKD). One of the factors that may influence exercise behavior among these patients is their perception of exercise benefits and barriers. The present study aimed to assess the perception of hemodialysis patients about exercise benefits and barriers and its association with patients' health-related quality of life.

METHODS

In this cross-sectional study, 227 patients undergoing hemodialysis were randomly selected from two dialysis centers. Data collection was carried out using dialysis patient-perceived exercise benefits and barriers scale (DPEBBS) and kidney disease quality of life short form (KDQOL-SF). Data were analyzed using SPSS software ver. 21.

RESULTS

The mean score of DPEBBS was 68.2 ± 7.4 (range: 24 to 96) and the mean KDQOL score was 48.9 ± 23.3 (range: 0 to 100). Data analysis by Pearson correlation coefficient showed a positive and significant relationship between the mean scores of DPEBBS and the total score of KDQOL (r = 0.55, p < 0.001). Moreover, there was a positive relationship between the mean scores of DPEBBS and the mean score of all domains of KDQOL.

CONCLUSION

Although most of the patients undergoing hemodialysis had a positive perception of the exercise, the majority of them do not engage in exercise; it could be contributed to the barriers of exercise such as tiredness, muscle fatigue, and fear of arteriovenous fistula injury. Providing exercise facilities, encouraging the patients by the health care provider to engage in exercise programs, and incorporation of exercise professionals into hemodialysis centers could help the patients to engage in regular exercise.

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.

The Effects of Exercise Training on Physical Performance and Self-efficacy in Hemodialysis Patients: A Randomized Controlled Clinical Trial

Background:

Hemodialysis patients are faced with challenges in carrying out their daily activities. Self-efficacy is a social cognitive concept that can affect behavioral control in these patients. Hence, the purpose of the present study was to investigate the effects of exercise training on physical performance and self-efficacy in hemodialysis patients.

Materials and Methods:

This randomized controlled clinical trial was conducted on 60 hemodialysis patients who visited hospitals affiliated to Mazandaran University of Medical Sciences in Sari, Iran. The participants were randomly divided into two groups. The patients in the intervention/exercise group received the 8-week exercise program. Patients in the control group received routine care. The Six-Minute Walk Test (6MWT) was used to assess the patients' functional ability and the Exercise Self-Efficacy Scale (ESES) and Chronic Disease Self-Efficacy Scale (CDSES) were used to assess their self-efficacy before and 2 and 8 weeks after the intervention. For statistical analysis, independent t-test and paired t-test were used.

Results:

The comparison of self-efficacy between the exercise group and control group after 8 weeks of intervention showed a significant difference between the groups in terms of the CDSES (F_1,43= 22.92, p < 0.001) and ESES (F_1,38= 10.84, p < 0.001) results. Moreover, the comparison of mean distance walked based on the 6MWT showed significant changes in this variable (F₁= 2.05, p = 0.015).

Conclusions:

The designed exercise program can improve self-efficacy and physical performance in hemodialysis patients. This intervention is recommended for hemodialysis patients due to its effectiveness, simplicity, and uncomplicated characteristics

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.

Comparison of intradialytic versus home-based exercise programs on physical functioning, physical activity level, adherence, and health-related quality of life: pilot study

Intradialytic exercise (ID) programs are effective and safe for hemodialysis (HD) patients to avoid functional deterioration. However, exercise is not routinely undertaken in most HD units, and we do not know if home-based (HB) programs are as effective as ID programs. The purpose of this study was to compare the effects of 16 weeks of ID exercise versus a HB exercise program for HD patients. A total of 46 patients were randomly assigned to the ID group (n = 24) or HB group (n = 22). They completed a 16-week combined exercise program 3 times/week. We measured physical activity level, physical functioning, depression level, and health-related quality of life at baseline and after 16 weeks. A significant time effect was found in both groups for the physical activity level (p = 0.012). There was also a significant group-time interaction effect for the one-leg standing test (OLST) (p = 0.049) and a significant time effect for the Short Physical Performance Battery (p = 0.013), timed up-and-go test (p = 0.005), sit-to-stand-10 (p = 0.027), right and left hand handgrip (p = 0.044, p < 0.001), one-heel left leg raise (p = 0.019), and 6-minute walking (p = 0.006), depression (p = 0.017). HRQoL remained unchanged. There was no difference between the two interventions on the tested outcomes (besides OLST). Both interventions were associated with positive changes of the physical activity levels and physical function.

How can health professionals contribute to the internet of things body of knowledge

Purpose

Internet of Things (IoT) as the new technological paradigm has found many applications in different domains. Nowadays, more than 30,000 records related to IoT research can be accessed in Scopus (Scopus.com). Health care is the one of domains which benefits from IoT. However, observations indicate that most active researchers in this area are technical people not health professionals. The purpose of this paper is to understand how health professionals can contribute to the IoT body of knowledge.

Design/methodology/approach

IoT professionals are asked to provide their views regarding research concerns, and the collected data are analyzed by phenomenography research methodology.

Findings

Findings indicate that health professionals can contribute through providing information, requirement or standards for developing IoT systems or devices. They can also introduce new applications or domains for which IoT is fit.

Originality/value

This paper tries to fill the gap concerning the lack of attention to undertaking IoT-related research from health professionals’ side and highlights ways that health professionals can contribute IoT body of knowledge.

Intradialytic virtual reality exercise: Increasing physical activity through technology

Intradialytic exercise can improve physical function and health-related quality of life (HRQoL) in hemodialysis (HD) patients, but is not implemented in routine clinical practice. Virtual reality (VR) exercise has resulted in benefits in non-dialysis contexts, but implementation in HD patients has been limited. The aim of this review was to provide an overview of VR, present the results of a 12-week intradialytic VR exercise intervention, and compare VR to conventional exercise. The secondary aim was to review the effect of VR exercise during the last 30 minutes of the HD session on hemodynamic stability. We conclude that VR exercise during HD is safe and can improve physical function and HRQoL, and can be performed safely toward the end of the HD session.

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.

Terapias de sustitución de la función Renal: Metaestudio y síntesis de evidencias cualitativas

El objetivo del presente estudio fue sintetizar en términos de evidencias cualitativas o evidencias Q hallazgos derivados de estudios cualitativos frente al tema de las terapias de sustitución de la función renal (TSFR). Método: metaestudio cualitativo desarrollado en cuatro momentos. Resultados: se integraron 75 estudios. De los cuales, 52 exploraban experiencias relacionadas con hemodiálisis (HD), 10 de diálisis peritoneal (DP), 6 trasplante, 6 DP y HD al mismo tiempo y 1 estudio exploró las 3 TSFR. Los estudios incluidos describen y representan el fenómeno de vivir en una condición de cronicidad y estar sometido a una TSFR de manera muy semejante, que se agruparon en patrones comunes del fenómeno, estos son descritos en tres grandes temáticas: la metamorfosis de la vida; dolores diversos y la terapia invade la vida. Conclusión: los resultados dan cuenta de la estrecha interrelación de las dimensiones humanas, por esto el fenómeno de vivir en una TSFR genera una transfiguración el “Ser”, como totalidad, pues no es posible desligar una dimensión de otra, de allí la importancia de pensar la atención de las necesidades en perspectiva relacional y no jerarquizada.

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.

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.

Design and methods of CYCLE-HD: improving cardiovascular health in patients with end stage renal disease using a structured programme of exercise: a randomised control trial

BACKGROUND

There is emerging evidence that exercise training could positively impact several of the cardiovascular risk factors associated with sudden cardiac death amongst patients on haemodialysis. The primary aim of this study is to evaluate the effect of an intradialytic exercise programme on left ventricular mass.

METHOD AND DESIGN

Prospective, randomised cluster open-label blinded endpoint clinical trial in 130 patients with end stage renal disease on haemodialysis. Patients will be randomised 1:1 to either 1) minimum of 30 min continuous cycling thrice weekly during dialysis or 2) standard care. The primary outcome is change in left ventricular mass at 6 months, assessed by cardiac MRI (CMR). In order to detect a difference in LV mass of 15 g between groups at 80 % power, a sample size of 65 patients per group is required. Secondary outcome measures include abnormalities of cardiac rhythm, left ventricular volumes and ejection fraction, physical function measures, anthropometric measures, quality of life and markers of inflammation, with interim assessment for some measures at 3 months.

DISCUSSION

This study will test the hypothesis that an intradialytic programme of exercise leads to a regression in left ventricular mass, an important non-traditional cardiovascular risk factor in end stage renal disease. For the first time this will be assessed using CMR. We will also evaluate the efficacy, feasibility and safety of an intradialytic exercise programme using a number of secondary end-points. We anticipate that a positive outcome will lead to both an increased patient uptake into established intradialytic programmes and the development of new programmes nationally and internationally.

TRIAL REGISTRATION NUMBER

ISRCTN11299707 (registration date 5(th) March 2015).

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.

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.

Patients' perception of comfort facilitators during hemodialysis procedure: a qualitative study

Background:

The patients receiving hemodialysis spend a lot of their lifetime in the hemodialysis departments, which is an unpleasant experience. Therefore, some interventions are necessary to relieve this experience.

Objectives:

The current study aimed to explore the hemodialysis patients' perceptions of comfort facilitators during the hemodialysis procedure.

Patients and Methods:

This study was conducted by a qualitative content analysis approach. Twenty four patients receiving hemodialysis participated in this study by purposive sampling. The sampling was over when the data saturation occurred. The semi-structured interviews were applied as the main data gathering tool. The data analysis was conducted by conventional qualitative content analysis in eight phases.

Results:

Three themes emerged: The presence of competent nurses, the delightful presence of the others, and coping with comfort obstacles. Each theme consisted of some categories.

Conclusions:

It seems that to achieve the patients' comfort during the hemodialysis procedure, the health care teams, hospitals in charge and the patients themselves have to do their best to provide the patients' comfort.