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

Psychometrically validated questionnaires to measure the effects and benefits/barriers to physical exercise in hemodialysis patients: a systematic review

PURPOSE

To provide a critical assessment, summarize, and synthesize the evidence from studies using psychometrically validated questionnaires to assess the effects and benefits/barriers of physical exercise in hemodialysis patients.

METHODS

The search was performed on six electronic databases. It was conducted following the PRISMA statement and the PICO framework. The methodological quality was assessed using the MMAT. Were used the quality criteria for psychometric properties developed by Terwee et al.

RESULTS

Overall, 70 studies were included, and 39 questionnaires identified, evaluating 13 outcomes. The quality of the psychometric properties of the questionnaires was not always described; only 13 presented positive ratings on > =6/9 properties. The most assessed measure was criterion validity, and the least assessed criteria was responsiveness. The most outcome measured by these questionnaires was quality of life using SF-36, followed by psychological health using the BDI. The DPEBBS was the only instrument identified that assessed the benefits and barriers of exercise.

CONCLUSION

Quality of life and depression were the most frequent outcomes. Other measures contemplating physical, mental, cognitive performance, and especially of the perceptions benefits and barriers to exercise should be further investigated. We have clearly identified the need for more studies evaluating psychometric measures that have not been tested satisfactorily or hardly been tested at all.

Home-based exercise in patients on maintenance dialysis: a systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The impact of home-based exercise on physical performance and quality of life (QoL) in patients on maintenance dialysis has not yet been fully established.

METHODS

We searched four large electronic databases to identify randomized controlled trials (RCTs) reporting the impact of home-based exercise interventions vs. usual care or intradialytic exercise interventions, on physical performance and QoL in patients on dialysis. The meta-analysis was performed using fixed effects modeling.

RESULTS

We included 12 unique RCTs involving 791 patients of various ages on maintenance dialysis. Home-based exercise interventions were associated with an improvement of walking speed at the 6 Minutes Walking Test [6MWT; nine RCTs; pooled weighted mean differences (WMD): 33.7 m, 95% confidence interval (CI) 22.8-44.5; P < 0.001; I2 = 0%) and in aerobic capacity as assessed by the peak oxygen consumption (VO2 peak; 3 RCTs; pooled WMD: 2.04 ml/kg/min, 95% CI 0.25-3.83; P = 0.03; I2 = 0%). They were also associated with improved QoL, as assessed by the Short Form (36) Health (SF-36) score. Stratifying the RCTs by control groups, no significant difference was found between home-based exercise and intradialytic exercise interventions. Funnel plots did not reveal any significant publication bias.

CONCLUSIONS

Our systematic review and meta-analysis showed that home-based exercise interventions for 3-6 months were associated with significant improvements in physical performance in patients on maintenance dialysis. However, further RCTs with a longer follow-up should be conducted to assess the safety, adherence, feasibility, and effects on QoL of home-based exercise programs in dialysis patients.

Cost-Effectiveness of Prolonged Physical Activity on Prescription in Previously Non-Complying Patients: Impact of Physical Activity Mediators

In Sweden, physical activity on prescription (PAP) is used to support patients in increasing their levels of physical activity (PA). The role of healthcare professionals in supporting PA behavior change requires optimization in terms of knowledge, quality and organization. This study aims to evaluate the cost-effectiveness of support from a physiotherapist (PT) compared to continued PAP at a healthcare center (HCC) for patients who remained insufficiently active after 6-month PAP treatment at the HCC. The PT strategy was constituted by a higher follow-up frequency as well as by aerobic physical fitness tests. The analysis was based on an RCT with a three-year time horizon, including 190 patients aged 27-77 with metabolic risk factors. The cost per QALY for the PT strategy compared to the HCC strategy was USD 16,771 with a societal perspective (including individual PA expenses, production loss and time cost for exercise, as well as healthcare resource use) and USD 33,450 with a healthcare perspective (including only costs related to healthcare resource use). Assuming a willingness-to-pay of USD 57,000 for a QALY, the probability of cost-effectiveness for the PT strategy was 0.5 for the societal perspective and 0.6 for the healthcare perspective. Subgroup analyses on cost-effectiveness based on individual characteristics regarding enjoyment, expectations and confidence indicated potential in identifying cost-effective strategies based on mediating factors. However, this needs to be further explored. In conclusion, both PT and HCC interventions are similar from a cost-effectiveness perspective, indicating that both strategies are equally valuable in healthcare's range of treatments.

Outcome Expectations and Older Adults with Knee Osteoarthritis: Their Exercise Outcome Expectations in Relation to Perceived Health, Self-Efficacy, and Fear of Falling

Outcome expectations are a determinant of exercise engagement and adherence. However, the factors that influence outcome expectations for exercise remain poorly understood for people with knee osteoarthritis. In this paper, a cross-sectional study was conducted by recruiting 211 older adults from three clinics in Southern Taiwan. This study explored older adults with knee osteoarthritis exercise outcome expectations and perceived health, self- efficacy, and fear of falling. The older adults completed the Outcome Expectations for Exercise Scale (OEES), the pain and physical function subscales of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Perceived Health Status Scale, the Self-Efficacy for Exercise scale (SEE- C), the Activities-Specific Balance Confidence Scale (ABC), the Geriatric Depression Scale (GDS). Multiple logistic regression models were used to determine associations between outcome expectations for exercise and physical and psychosocial outcomes in the knee OA population. Among the participants of the cross-sectional study, the mean age was 72.04 (SD = 5.53) years, and 71.6% were female. Higher outcome expectations for exercise were associated with higher physical function (OR = 0.98; 95% CI [0.96−1.99]; p = 0.007), better perceived health (OR = 1.30; 95% CI [1.12−1.51]; p < 0.001), greater self-efficacy (OR =1.03; 95% CI [1.01−1.04]; p = 0.006), and less fear of falling (OR = 3.33; 95% CI [1.21−9.19]; p = 0.020). Thus, the results indicated that outcome expectations for exercise among the participants were significantly associated with physical function, perceived health, self-efficacy, and fear of falling. These findings suggest the importance of personal factors in the design of interventions to promote exercise behavior changes among elderly patients with Knee Osteoarthritis.

Physical exercise and cognitive training interventions to improve cognition in hemodialysis patients: A systematic review

Introduction

Patients with chronic kidney disease treated with hemodialysis (HD) have lower cognitive abilities compared to the age-matched healthy population. Recently, physical exercise and cognitive training have been presented as possible interventions to improve cognitive abilities both in the general population and in patients with chronic diseases. To date, there is no general overview of the current knowledge on how these interventions affect cognitive abilities in HD patients and what tests are used to measure these effects.

Methods

Three electronic databases were searched for randomized controlled studies of physical exercise or cognitive training interventions that examined effects on cognitive abilities/performance in HD patients.

Results

Six articles were included. All included studies used physical exercise as an intervention, with one study also including tablet-based cognitive training. Four studies included an intradialytic approach and two included a home-based intervention. Intervention lasted. A significant intervention effect was observed in three studies compared with the control condition.

Conclusion

The present review suggests that physical exercise might improve or at least not worsen cognitive performance in HD patients, whereas the effect of cognitive training has not yet been adequately studied. There is a need for more sensitive and specific cognitive tests to adequately measure the effects of interventions in the HD population.

Exercise training for adults undergoing maintenance dialysis

BACKGROUND

Dialysis treatments weigh heavily on patients' physical and psychosocial health. Multiple studies have assessed the potential for exercise training to improve outcomes in adults undergoing dialysis. However, uncertainties exist in its relevance and sustainable benefits for patient-important outcomes. This is an update of a review first published in 2011.

OBJECTIVES

To assess the benefits and safety of regular structured exercise training in adults undergoing dialysis on patient-important outcomes including death, cardiovascular events, fatigue, functional capacity, pain, and depression. We also aimed to define the optimal prescription of exercise in adults undergoing dialysis.

SEARCH METHODS

In this update, we conducted a systematic search of the Cochrane Kidney and Transplant Register of Studies up to 23 December 2020. The Register includes studies identified from CENTRAL, MEDLINE, EMBASE, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov as well as kidney-related journals and the proceedings of major kidney conferences.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of any structured exercise programs of eight weeks or more in adults undergoing maintenance dialysis compared to no exercise or sham exercise.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane risk of bias tool. Whenever appropriate, we performed random-effects meta-analyses of the mean difference in outcomes. The primary outcomes were death (any cause), cardiovascular events and fatigue. Secondary outcomes were health-related quality of life (HRQoL), depression, pain, functional capacity, blood pressure, adherence to the exercise program, and intervention-related adverse events.

MAIN RESULTS

We identified 89 studies involving 4291 randomised participants, of which 77 studies (3846 participants) contributed to the meta-analyses. Seven studies included adults undergoing peritoneal dialysis. Fifty-six studies reported aerobic exercise interventions, 21 resistance exercise interventions and 19 combined aerobic and resistance training within the same study arm. The interventions lasted from eight weeks to two years and most often took place thrice weekly during dialysis treatments. A single study reported death and no study reported long-term cardiovascular events. Five studies directly assessed fatigue, 46 reported HRQoL and 16 reported fatigue or pain through their assessment of HRQoL. Thirty-five studies assessed functional capacity, and 21 reported resting peripheral blood pressure. Twelve studies reported adherence to exercise sessions, and nine reported exercise-related adverse events. Overall, the quality of the included studies was low and blinding of the participants was generally not feasible due to the nature of the intervention. Exercise had uncertain effects on death, cardiovascular events, and the mental component of HRQoL due to the very low certainty of evidence. Compared with sham or no exercise, exercise training for two to 12 months may improve fatigue in adults undergoing dialysis, however, a meta-analysis could not be conducted. Any exercise training for two to 12 months may improve the physical component of HRQoL (17 studies, 656 participants: MD 4.12, 95% CI 1.88 to 6.37 points on 100 points-scale; I² = 49%; low certainty evidence). Any exercise training for two to 12 months probably improves depressive symptoms (10 studies, 441 participants: SMD -0.65, 95% CI -1.07 to -0.22; I² = 77%; moderate certainty evidence) and the magnitude of the effect may be greater when maintaining the exercise beyond four months (6 studies, 311 participants: SMD -0.30, 95% CI 0.14 to -0.74; I² = 71%). Any exercise training for three to 12 months may improve pain (15 studies, 872 participants: MD 5.28 95% CI -0.12 to 10.69 points on 100 points-scale; I² = 63%: low certainty evidence) however, the 95% CI indicates that exercise training may make little or no difference in the level of pain. Any exercise training for two to six months probably improves functional capacity as it increased the distance reached during six minutes of walking (19 studies, 827 participants: MD 49.91 metres, 95% CI 37.22 to 62.59; I² = 34%; moderate certainty evidence) and the number of sit-to-stand cycles performed in 30 seconds (MD 2.33 cycles, 95% CI 1.71 to 2.96; moderate certainty evidence). There was insufficient evidence to assess the safety of exercise training for adults undergoing maintenance dialysis. The results were similar for aerobic exercise, resistance exercise, and a combination of both aerobic and resistance exercise.

AUTHORS' CONCLUSIONS

It is uncertain whether exercise training improves death, cardiovascular events, or the mental component of HRQoL in adults undergoing maintenance dialysis. Exercise training probably improves depressive symptoms, particularly when the intervention is maintained beyond four months. Exercise training is also likely to improve functional capacity. Low certainty evidence suggested that exercise training may improve fatigue, the physical component of quality of life, and pain. The safety of exercise training for adults undergoing dialysis remains uncertain.

A Systematic Review of Handgrip Strength Measurement in Clinical and Epidemiological Studies of Kidney Disease: Toward a Standardized Approach

In chronic kidney disease (CKD), handgrip strength (HGS) is recommended as a surrogate measure of protein-energy status and functional status. However, it is not routinely used because of inconsistencies such as the optimal timing of the HGS measurement and unclear guidance regarding technique. We aimed to determine the extent of variation in the protocols and methods of HGS assessment. We aimed to identify clinical and epidemiological studies conducted on CKD that reported on the use of HGS as an outcome. A systematic literature search identified n = 129 studies with a total participant population of n = 35,192. We identified large variations in all aspects of the methodology including body and arm position, repetitions, rest time, timing, familiarization, and how scores were calculated. The heterogeneous methodologies used reinforce the need to standardize HGS measurement. After reviewing previously employed methodology in the literature, we propose a comprehensive HGS assessment protocol for use in CKD.

Exercise training in chronic kidney disease-effects, expectations and adherence

There is increasing evidence showing the health benefits of physical activity, such as better survival and possibly even a slower decline in kidney function, in people with chronic kidney disease (CKD). There is convincing evidence that exercise training improves physical function measured as aerobic capacity, muscle endurance strength and balance at all ages and all stages of CKD. In fact, long-term adherence to well-designed and adequately monitored exercise training programmes is high. In general, patients express interest in exercise training and are motivated to improve their physical function and health. A growing number of nephrologists regard physical activity and exercise training as beneficial to patients with CKD. However, many feel that they do not have the knowledge to prescribe exercise training and suppose that patients are not interested. Patients state that support from healthcare professionals is crucial to motivate them to participate in exercise training programmes and overcome medical, physical and psychological barriers such as frailty, fatigue, anxiety and fear. Equally important is the provision of funding by healthcare providers to ensure adequate prescription and follow-up by trained exercise physiologists for this important non-pharmacological treatment.

The Decisional Balance Toward Health Behaviors Among Patients With Hypertension

The decisional balance is related to the transtheoretical model, and involves weighting the pros and cons of performing a behavior. The study aimed to assess hypertensive patients' decisional balances about smoking, weight control, and physical exercise. A cross-section descriptive correlation design was used, and 110 patients were recruited using convenience sampling in outpatient clinics. The decisional balance was measured using "Decisional Balance Scales," which assess an individual's decisional balance related to smoking, weight control, and physical exercise behaviors. The results predicted that Jordanian hypertensive patients with higher physical exercise decisional balance and higher weight decisional balance had lower smoking decisional behaviors. Nurses can foster health promotion and behavioral change by employing interventions that improve decisional balances. Improving the decisional balance of one behavior would have a positive impact on other behaviors. Thus, designing multidimensional interventions might be effective for modifying different types of health behaviors, and fostering health promotion practices.

Lower Central Fat Increase Risk of One-Year Muscle Mass Loss in Menopausal Women

Background

Hormonal changes had been found in menopausal women. Muscle and bone mass decline after menopause and with aging, increasing the risk for sarcopenia and osteoporosis in later life. Only a few studies suggest that menopausal hormonal changes have an effect on the decline in muscle mass.

Objectives

This study aimed at evaluating the risk of muscle mass loss in menopausal women.

Materials and Methods

Menopausal women from routine physical health examination were eligible for this study. Muscle mass was determined using dual-energy X-ray absorptiometry at baseline and 1 year later. All of the patients underwent the assessments for liver and kidney function, diabetes, and hypertension, and associated comorbidities were recorded.

Results

A total of 172 patients were enrolled. 70 patients had muscle loss at 1 year, and the other 102 did not had loss. The mean age was 70.26 ± 9.93 years at the muscle loss group, while 69.25 ± 10.50 at the nonprogress group (p = 0.531). The mean body mass index was 22.96 ± 1.91 kg/m² at the muscle loss group, while 23.33 ± 3.71 kg/m² at the nonprogress group (p = 0.433). The baseline trunk limb fat mass ratio was 1.01 ± 0.20 in the muscle loss group and 1.12 ± 0.26 in the no muscle loss (p = 0.004). Using muscle mass loss as the outcome, logistical regression analysis showed that a baseline trunk limb mass ratio could predict muscle loss, and a higher baseline trunk limb mass ratio was associated with less muscle loss, while a lower trunk limb mass ratio was associated with increased muscle mass loss (p = 0.01).

Conclusion

This is the first study to investigate the risk of muscle mass loss in menopausal women. Menopausal women with higher central fat had less muscle mass loss, while lower central fat was a risk factor for muscle mass loss. Chronic kidney disease was also a risk factor for muscle mass loss in menopausal women in this study.

Functional training added to intradialytic cycling lowers low-density lipoprotein cholesterol and improves dialysis adequacy: a randomized controlled trial

Background

Exercise has various positive effects on hemodialysis patients. However, there is no clear evidence which type of exercise yields better results. This study aimed to determine the effects of guided functional training added to the intradialytic cycling on dialysis adequacy and biochemical parameters in hemodialysis patients. Additionally, we aimed to investigate if patients could transfer functional exercise to an unsupervised home environment and retain gained improvements.

Methods

Randomization was done to a functional training intervention group (INT) (n = 20) or intradialytic cycling control group (CON) (n = 20). The INT attended a pre-dialysis functional training in the first 8 weeks. In the second 8 weeks, they performed functional exercises at unsupervised home environment on non-dialysis days. During the whole study, both groups participated in the intradialytic cycling program.

Results

Both groups demonstrated a significant increase in dialysis adequacy (Kt/V) in the eight (0.15, 95% CI 0.06 to 0.24; p = 0.003 for INT and 0.21, 95% CI 0.11 to 0.3; p < 0.001 for CON) and the 16th study week (0.13, 95% CI 0.03 to 0.24; p = 0.017 for INT and 0.13, 95% CI 0.03 to 0.22; p = 0.013 for CON) compared to their baseline values with no significant between-group differences. At week eight, the total cholesterol was significantly lowered in the INT (− 0.34 mmol/L, 95% CI − 0.6 to − 0.07; p = 0.016) and remained lower at week 16 (− 0.32 mmol/L, 95% CI − 0.64 to − 0.01; p = 0.049) with no significant changes in the CON. Low-density lipoprotein levels in the INT were significantly reduced after 8 weeks (− 0.35 mmol/L, 95% CI − 0.64 to − 0.06; p = 0.022) and remained reduced after 16 weeks (− 0.28 mmol/L, 95% CI − 0.52 to − 0.03; p = 0.030). There were no significant differences found for albumin, high-density lipoprotein cholesterol, triglycerides, C-reactive protein, and hemoglobin in both groups.

Conclusions

We demonstrated that functional training added to intradialytic cycling improved lipid profile and dialysis adequacy. Additionally, the effects of the unsupervised, home-based program were preserved during the second study phase. This study supports the assumption that combined training is more effective compared to solely intradialytic exercise.

Trial registration

ClinicalTrials.Gov, NCT03334123. Registered 07 November 2017.

Perspective of Dose and Response for Individualized Physical Exercise and Training Prescription

Physical interventions are used to increase physical (sports) performance and considered as effective low-cost strategies in the fields of healthcare, disease or injury prevention, and medical treatment. In general, a considerable amount of evidence buttress the application of physical interventions in various fields as it has been demonstrated to contribute to the maintenance and recovery of physical performance, cognitive function, and overall state of health. To implement physical interventions effectively, it is essential to provide an appropriate exercise and training prescription. Exercise and training prescription are key for "dose" specification and for the individualization (personalizing) of physical exercise and training, precisely adjusted and controlled like medication. Since the physiological response to physical interventions is demonstrably individual and dependent on many influencing factors, individualization is an emerging approach aiming to maximize the efficiency of an intervention by accounting for the interindividual heterogeneity. The present brief viewpoint article aims to distinguish and to redefine between the terms dose and response in order to improve the understanding of practitioners, the methodology of study protocols, and to relate future findings to the actual biological (interindividual) variability of acute and chronic responses.