PROFORMA FOR REGISTRATION OF SUBJECT

FOR DISSERTATION

SHIJI MATHEW

1st YEAR M.Sc. (NURSING)

MEDICAL SURGICAL NURSING

YEAR 2012-2014

ST. PHILOMENA’S COLLEGE OF NURSING

#4 CAMPBELL ROAD, VIVEKNAGAR P. O

BANGALORE 560047

0

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS

FOR DESSERTATION.

1 NAME OF THE CANDIDATE AND ADDRESS MS. SHIJI MATHEW

ST. PHILOMENA’S COLLEGE OF

NURSING,#4 CAMPBELL

ROAD,VIVEKNAGAR P.O

BANGALORE -560047

2 NAME OF THE INSTITUTION ST. PHILOMENA’S COLLEGE OF

NURSING.

3 COURSE OF THE STUDY AND SUBJECT M.SC NURSING

MEDICAL SURGICAL NURSING

4 DATE OF ADMISSION TO COURSE 04.JUNE.2012

5 TITLE OF THE TOPIC “A STUDY TO ASSESS THE EFFECT OF

INTRADIALYTIC ISOMETRIC

STRETCHING EXERCISES ON FATIGUE

AND GENERAL MYALGIA AMONG

PATIENTS UNDERGOING HEMODIALYSIS

IN A SELECTED HOSPITAL,BANGALORE.

1

6. BRIEF RESUME OF THE INTENDED WORK

6.1. NEED FOR THE STUDY

“Fatigue is here, in my body, in my legs and eyes. That is what gets you in the end. Faith

is only a word, embroidered.”

― Margaret Atwood, TheHandmaid's Tale

Chronic renal failure, which is otherwise known as End Stage Renal Disease is

the most common chronic disease that is budding up in the world today. The body

equilibrium is maintained when an individual take adequate amount of food and when his

body excretes the waste materials accordingly. When the kidney fails to function

appropriately it results in chronic renal failure. As a result there will be accumulation of

toxic wastes in the body which can affect other systems also.1

Around 2,786,000 people are affected by chronic renal disease worldwide.2 In

Australia, a survey done from 1991-2009, it was concluded that there was an increase in

the number of renal patients that is from 13% to 33%3. Also in USA in 2002, new

patients per year were 80,000 which had increased to 30 million by 2010.4According to a

survey conducted in 2004 including 122 countries,92% of the population is affected by

renal disease, out of which 99%are taking treatment. In India the incidence of renal

2

failure is increasing to higher rates. According to study conducted in India in 2010,almost

7.85 million people out of 1 billion population are suffering from chronic renal

failure.4More than two lakh patients who are suffering from renal failure in Karnataka.

Chronic renal disease is becoming more prevalent worldwide due to lifestyle,

hereditary and improper life practices. Poorly controlled diabetes and increased blood

pressure increases the risk of chronic kidney disease. According to National kidney and

urologic disease information clearing house, 1,80,000 people in US is affected with

chronic kidney disease as a result of diabetes.5According to a case control study

conductedin Virginia, 42% of both insulin dependent and non-insulin dependent diabetic

patients are at high risk for end stage renal disease than non-diabetic persons.6

The ultimate treatment of chronic renal disease is dialysis. Dialysis helps to

improve the health standards of the patients and thereby increases the life span into few

more years. Now there are2,164,000 patients worldwide who are undergoing dialysis as a

treatment for ESRD. Out of that1,9,29,000 patients is undergoing hemodialysis (89%)

and 2, 35,000is taking peritoneal dialysis (11%).7

In India, only 16.2%of the ESRD patients are getting peritoneal dialysis as

treatment.8Majority of ESRD patients that is around 20,000patients receive

3

hemodialysis.9In Karnataka it is noticed that 20.27%of patients will have continuous

hemodialysis and rest of others will fail to follow up.

Though hemodialysis plays a vital role as life saving procedure, it also has many

side effects and complications. The main side effects that are prevalent in the

hemodialysis are fatigue, muscle cramps, hypotension, fluid overload, nausea, vomiting,

headache and general myalgia.10Many End Stage Renal Disease (ESRD) patients

experience debilitating fatigue. Fatigue can be a continuum from extreme tiredness to

high energy. Deteoriation of health is common phenomenon among patients who are

undergoing dialysis. They suffer from high fatigue and pain due to frequent puncturing of

fistula. During 2009, kidney news reported that a recent study conducted by Jhamb M

revealed that 60-97%dialysis patients suffered from fatigue.11 The importance of fatigue

to patients with kidney disease is underscored by the observation that 94% of

hemodialysis patients endorsed a willingness to undergo frequent dialysis if there would

be an associated increase in energy level whereas only 19% is not willing for

hemodialysis due to fatigue.

According to United States Renal Data System 2003, annual data report 2,87,494

people in USA has undergone dialysis.12Among them 95% is reported to have fatigue and

there were 55%complaints of general myalgia in dialysis. The present cross-sectional

study was conducted from January to April 2009, in three hemodialysis units in Kuala

Lumpur and Malaysia. In this study the multidimensional fatigue inventory and

4

depression anxiety and stress score were used to determine the level of fatigue,

depression, anxiety and stress of hemodialysis patients. The data were obtained from a

sample of 116. A total of 56(54.4%) and 47(46.6%) respondents experienced a high level

and a low level of fatigue respectively.13

According to UCL discovery, dialysis patients show different symptoms due to

dialysis. The study was conducted among 550 hemodialysis patients and the study

revealed that 82% of the patients suffered from fatigue and 75% of the patients suffered

from pain.14Thesetwo were the most prominent symptoms that have been highlighted in

the study. According to survival debate conducted in Japan, Asian Americans will have

lower surviving rate than Japanese. The fatigue observed in patients who underwent

dialysis usually associated with an impaired quality of care. In India, the studies proved

that the dialysis patients will be suffering from severe fatigue of 44.7%.15

In order to overcome the general myalgia and fatigue certain exercises are in

practice rather than the medications. Several exercises have found out to be effective in

relieving fatigue and general myalgia. There are researches conducted to see the

effectiveness of graded exercises and other therapies on fatigue and myalgia. The result

shows that 84%of the participants were improved by graded exercises.90%myalgia can

be improved by the exercises.

5

According to studies it is proved that exercise can improve the muscle strength

which in turn will improve cardiovascular function and quality of life. As there are lots of

limitation placed on physical inability in renal patients isometric stretching exercises are

best suited to improve muscular strength which in turn improves the level of muscle

atrophy and fatigue in 95.7%of dialysis patients.16

Researcher came across complaints of fatigue and pain due to continuous

hemodialysis in many patients. Patients were not able to cope up with fatigue and pain

that affected the quality of life. Also the above mentioned studies and statistics prove the

prevalence of fatigue and pain in dialysis patients’ worldwide. All these combine

influenced the researcher to choose this topic for research study.

6.2. REVIEW OF LITERATURE:

A literature review is a broad, comprehensive , in depth, systematic and critical review of

scholarly publication which is related to topic.17

Review of literature in this study is organized under the following titles:

Literature related to

1 Prevalence of renal disease.

2 Impact of hemodialysis on patients with renal disease.

3. Fatigue and general myalgia on hemodialysis patients.

6

4. Effectiveness of exercises on intradialytic patients.

5. Effectiveness of isometric stretching exercise.

6.2.1 LITERATURE RELATED TO PREVALENCE OF RENAL DISEASE

Cohort study was conducted to assess the prevalence of chronic kidney disease

and progression of disease over time among patients enrolled in Houston West Nile .139

samples were selected. Prevalence was assessed by kidney disease outcomes quality

initiative criteria and urinary abnormalities. Result was 40% of participants had evidence

of Chronic Kidney Disease, 10% were in stage 3 or greater while 30% were in stage 1 or

2.There was an average change in GFR -3.7 ml/mt.18

A retrospective study was conducted to assess prevalence of chronic kidney

disease in population. A systematic review of 26 published data that is available in

MEDLINE was included. The studies were conducted in different population and the

number of participants ranged from 237-65181. The median prevalence of CKD was

7.2% in persons aged 30 years or older. Patients aged 64 years or older, the prevalence

was 23.4% to 35.8%. 9.35%were seen in men and 13% in women. African Americans

had a lower prevalence than Asians.19

7

To assess the prevalence of chronic kidney disease and its association with risk

factors in disadvantageous population, a cross sectional study comprised of 1000 samples

of age between 15-65 years were selected. Serum creatinine was measured by alkaline

pirate method and GFR by using Cockcroft-Gault and Modified Dietary Rrestriction

Diet. The analysis discovered that 13.1% of participants were detected to have chronic

kidney disease by MDRD and 16%had chronic kidney disease by Cockcroft-Gault

equation. Also 4.1% of participants were detected to have diabetes, 11.6% had

hypertension and 7.7%have proteinuria.20

6.2.2 LITERATURE RELATED TO IMPACT OF HEMODIALYSIS ON

PATIENTS WITH RENAL DISEASE:

A study was conducted to measure the quality of life of the dialysis patient. A

convenient sampling method was used to recruit patient from the outpatient units of

dialysis centre.Pearsons product moment correlation was used to examine the relationship

between the demographic variables and the overall quality of life score .The mean of the

total score was 132.5 with SD 16.68 varying between 97-179.The items means score was

3.34.21

A cross sectional study was conducted to explore the association of emotional

regulation strategy, preappraisal , suppression and their impact on patient wellbeing and

8

kidney disease management. With 106 samples of hemodialysis patients undergoing renal

replacement therapy and 94 friends or relatives were selected for the study. Outcome

parameters were measured using positive and negative affect scale, the Brief COPE

questionnaire and Brief symptom inventory. Suppression was associated with less

emotional coping (r=-0.29 p<0.01) and greater dissatisfaction with support received from

other people. (r=-0.34 P, 0.01).22

6.2.3 LITERATURE RELATED TO FATIGUE AND GENERAL MYALGIA ON

HEMODIALYSIS PATIENTS

A study was conducted in India in tertiary center to assess the prevalence of

fatigue, sleeplessness and their association among hemodialysis patients and their co-

relation with frequency and duration of hemodialysis. Convenient sampling

of47patientswasdoneand study was for more than 3 months of duration. The result

showed 68.1%of the patients are poor sleepers and 44.7% reported fatigue, 59.7% had

moderate depression and 12.6% had severe depression.23

A randomized cross over multicenter study was done to assess the fatigue in

hemodialysis patients with and without diabetes mellitus.30 hemodialysis patients were

taken as samples. Theywere asked to take dialysate glucose G200 and G100along with

the medicine. Fatigue was assessed by fatigue severity scale.Results showed that fatigue

9

was more in diabetes patients, G200=5.0+1.0, G100=4 compared tonon-diabetes patients

G200=3.5+2, G100=3.0+2.24

To assess the prevalence, cause, severity and management ofpain a prospective

cohort study was conducted with 205 Canadian hemodialysis patients. A complete

questionnaire incorporated with brief pain inventory followed by McGill pain

questionnaire was used. The result was 103 patients that are 50% had suffered from pain.

Patients with longer hemodialysis therapy had pain than patients with shorter dialysis

period.25

6.2.4 LITERATURE RELATED TO EFFECTIVENESS OF EXERCISES ON

INTRADIALYTIC PATIENTS

Twelve hemodialysis patients were selected to perform incremental constant work

rate cycle exercises test to determine endurance time, peak work rate, lower extremity

strength, power and fatigability. At the end of the study the endurance level increased

to144%.Quadriceps strength, power and fatigability increases to 16%, 15% and 43%

respectively.26

.

Databases from the year of 2005-2009 which were collected from CINAHL,

MEDLINE, MedicLatina, SportDicus were reviewed to assess the effectiveness of

exercise on hemodialysis patients.640 patients were included in 16 studies. Standard

10

mean deviation was used to summarize the effects of exercises.Moderate evidence exists

on positive effects of aerobic training on peak oxygen consumption at the graded exercise

test (SMD 6.55; CI 95%: 4.31-8.78). There is high evidence on positive effects of

strength training on health related quality of life (SMD 11.03; CI 95%: 5.63-16.43).27

The researcher conducted a blind placebo controlled study on hemodialysis

patient with erythropoietin on aerobic exercise and muscle strength. The intervention was

progressive isotonic exercises and ergometric exercises for experimental group for 12

weeks and 5 months. While control group underwent non progressive exercises. They

inferred that the mean score on the physical function subscale of short form of 36 of 76 of

100. The exercise programme improved physical impairment measures and general

myalgia but had no effect on quality of life.28

6.2.5 LITERATURE RELATED TO EFFECTIVENESS OF ISOMETRIC

STRETCHING EXERCISE:

A randomized pilot trial study was done to measure the effect of intradialytic low

intensity strength training or stretching exercises which was conducted twice weekly. A

totalof 48 sessions of exercise program were given for 50 participants of age 69 ± 13

11

years who is receiving hemodialysis for 3-4years.The measurement was done with base

line median short physical performance battery score.ShortPhysical Performance Battery

score showed improvement in strength training group when compared to control group

with scores of 21.1% vs. 0.2%respectively.29

The purpose of the study was to investigate the hypothesis that reductions in Na+,

K+, ATPase activity are associated with neuromuscular fatigue following isometric

exercise. These results demonstrate that Na+, K+, ATPase activity is reduced by sustained

isometric exercise and this is due to loss of excitability30

Above mentioned studies gives the evidence of patients undergoing hemodialysis

suffers from fatigue and general myalgia which had become the inevitable part of their

life.

6.3. STATEMENT OF THE PROBLEM:

“A STUDY TO ASSESS THE EFFECT OF INTRADIALYTIC ISOMETRIC

STRETCHING EXERCISES ON FATIGUE AND GENERAL MYALGIAAMONG

PATIENTS UNDERGOING HEMODIALYSIS IN A SELECTED HOSPITALS IN

BANGALORE”.

12

6.4. OBJECTIVES OF THE STUDY

The objectives of the study are to:

1. assess the level of fatigue and general myalgia among hemodialysis patients.

2. assess the effect of intradialytic isometric stretching exercises among hemodialysis

patients.

3. associate the effect of intradialytic isometric stretching exercises on fatigue and general

myalgia with selected demographic variables.

6.5. HYPOTHESIS:

H1: There will be a statistically significant difference in the level of fatigue following

intradialytic isometric stretching exercises as measured by fatigue scale,p<0.05 level of

significance.

H2: There will be a statistically significant difference in the level of general myalgia

following intradialytic isometric stretching exercises as measured by general myalgia

scale<0.05 level of significance.

H3: There will be a statistically significant association between the level of fatigue

following intradialytic isometric stretching exercises with demographic variables<0.05

level of significance.

13

H4: There will be a statistically significant association between the level of general

myalgia following intradialytic isometric stretching exercises among hemodialysis

patients.

6.6. OPERATIONAL DEFINITION OF TERMS:

EFFECT:

In this study, it refers to the desired change in level of fatigue and general myalgia

following intradialytic isometric stretching exercises among hemodialysis patients.

INTRADIALYTIC ISOMETRIC STRETCHING EXERCISES:

It refers to the type of static exercise where the patient perform isometric

resistance of the muscle groups and researcher opposes with mild stretching for a period

of 7-15 seconds followed by relaxation for 20 seconds during 2 hours of dialysis.

FATIGUE:

In this study, it refers to physical and mental exhaustion triggered by repeated

cycles of dialysis.

14

GENERAL MYALGIA:

General myalgia is a generalized body pain associated with metabolic changes in dialysis

patients.

6.7. ASSUMPTIONS

The study is based on the following assumptions:

Fatigue and general myalgia is common among dialysis patients.

Intradialytic isometric stretching exercises minimizes general myalgia and fatigue among

hemodialysis patients.

6.8. DELIMITATIONS:

The study is delimited to:

Patients undergoing dialysis in St. Philomena’s Hospital.

7. MATERIALS & METHODS:

7.1. SOURCE OF DATA:

Hemodialysis patients in St .Philomena’s Hospital, Bangalore.

7.1.1 Research Design:

15

Pre experimental one group pretest posttest research design is selected to conduct study.

E

O2

E: Experimental group; hemodialysis patient.

O1:pretest;level of fatigue and general myalgia

X:Treatment;intradialytic isometric stretching exercises

O2:posttest; general myalgia and fatigue level

7.1.2 Settings:

The study will be conducted in hemodialysis unit of St.Philomena’s hospital whichis a

500 bedded hospital with 8 bedded hemodialysisunit with 16patients undergoing

hemodialysis everyday.

7.1.3Population:

Patients undergoing three cycles of hemodialysis in a week in the hemodialysis unit of St.

Philomena’s hospital, Bangalore.

7.2 METHODS OF DATA COLLECTION

7.2.1 Sample Size:

The sample size consists of 30 hemodialysis patients who satisfy the sample selection

criteria.

16

E:EXPERIMENTAL GROUP

Hemodialysis patients

O1: PRE TEST

Level of fatigue and general myalgia

X: TREATMENT

Intradialytic isometric stretching exercises

O2: POST TEST

Fatigue and general myalgia level

7.2.2 Sampling Technique:

Non probability, convenient sampling technique.

7.2.3 Inclusion Criteria:

The clients who are

between the age group of 20 to 60 years.

Undergoing more than three cycles of hemodialysis in a week.

able to read and write in English, Tamil, Hindi or Kannada.

willing to participate in the study.

7.2.4 Exclusion Criteria:

The clients who are

with upper and lower limb pathologies.

Emergency hemodialysis patients.

7.2.5 Tools Used For Study

Instruments used for the study:

Section A:

To assess the demographic variables-age, sex, educationalstatus lifestyle, occupation,

income and associated disease conditions.

17

Section B:

Fatigue scale

General myalgia scale.

7.2.6 Data Collection Method:

Formal permission will be obtained from head of the institution.

Ethical clearance have been obtained from Institution Ethical Review Board(IERB) of St.

Philomena’s Hospital.

Informed consent will be taken from hemodialysis patients.

Pre exercise fatigue and general myalgia level will be measured.

Administration of intradialytic isometric stretching exercises.

Post exercise level of fatigue and general myalgia.

7.2.7 Data Analysis Method:

Data analysis will be done by using descriptive and inferential statistics.

Descriptive statistics:

Mean, median and standard deviation is used.

Inferential statistics:

Paired‘t’ test and chi square test is done.

18

7.3. DOES THE STUDY REQUIRE ANY INTERVENTIONS OR

INVESTIGATIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN

OR ANIMAL?

Yes, intervention in the form of intradialytic isometric stretching exercise will be

administered for hemodialysis patients.

7.4. HAS THE ETHICAL CLEARANCE BE OBTAINED FROM YOUR

INSTITUTIONS IN CASE OF PATIENTS?

Ethical clearance has been obtained from Institution Ethical Review Board (IERB) of St.

Philomena’s Hospital, Bangalore.

19

8. LIST OF REFERENCES:

1.Lewis S L,Heitkember M M etal.Medical Surgical Nursing .2nd

Edition.Missouri:Mosby;2006.1136-1139

2.Availablefromhttp://www.visionfmc.com/files/download/ESRD/

ESRD_Patients_in_2011.pdf

3.Availablefromhttp://www.kidney.org.au/HealthProfessionals/CKDinAustralia/tabid/

622/Default.aspx

4. Available from http://ndt.oxfordjournals.org/content/21/1/232.full.pdf

5. Available from http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/

6. Perneger.V.T, Whelton.K.P.et al.End stage renal disease attributable to diabetes

mellitus.Annals of internal medicine.1994; 121(12):912-918

Available on https://annals.org/article.aspx?articleid=708264

7. Available from

http://www.vision-fmc.com/files/download/ESRD/ESRD_Patients_in_2011.pdf

8. Mahajan .S, Tiwari.C.S.et al.Factorsaffecting the use of peritoneal dialysis among the

ESRD population in India: Asingle center study. Peritoneal Dialysis International.2004;

24:538-541

Available from http://pdiconnect.com/content/24/6/538.full.pdf

9. Khanna.U.Economics of dialysis in India. Indian Journal Of Nephrology.2009;19(1):1-

4

20

10.Smeltzer S C,Bare BG.Brunner and Suddharth textbook of Medical Surgical

Nursing,7th edition .Newyork:Elseiver Publications.1523

11. Jhamb.M.Patients with kidney fatigue-are familiar with the background.American journal of

kidney disease:2008;52(2):353-365

Available from http://www.nephrologia.com/DNN2011/eloadasok/N/04/413N.ppt

12. Available from http://www.rightdiagnosis.com/k/kidney_dialysis/prevalence.htm

13. Letchmi.S, Das.S.etal.Fatigue experience by patients receiving maintenance dialysis

in hemodialysis units. Nurse Health Science. 2001; 60(4): Available from: http://www.bri-

shur.com/medline/mem_query?r=1&mem=8922&page=5

14. CaplinB.Kumar.patient perspective of hemodialysis – associated symptoms.

Nephrology dialysis transplantation.2011; 26(8)

Available from http://discovery.ucl.ac.uk/1348340/

15. Joshwa.B.Khakka.C.D.etal.Fatigue, depression and sleep problem among

hemodialysis patients in tertiary care center. Saudi journal of kidney disease and

transplantation.2012; 23(4):729-735

Available fromhttp://www.sjkdt.org/article.asp?issn=1319-

2442;year=2012;volume=23;issue=4;spage=729;epage=735;aulast=Joshwa

16. Kouidi.E, Albani.M.etal.Effects of exercise training in muscle atrophy in

hemodialysis patients. Nephrology dialysis transplantation.1998; 13:685-699

21

Available from http://ndt.oxfordjournals.org/content/13/3/685.full.pdf

17. Sharma.S.K.Nursing Research And Statistics.NewDelhi:Elsevier Pubications;2011.70-71

18. Nolan.S, Podoll.S.A.etal.Prevalence of chronic kidney disease and progression of

disease over time among patients enrolled in Houston West Nile.Plos one(cited

2012).2017;7(7)

Availablefrom:http://www.plosone.org/article/info%3Adoi

%2F10.1371%2Fjournal.pone.0040374

19. Zhang.L.Q, Rothenbacher.D.Prevalence of CKD in population based studies: systematic

review.BMC Public health centre: 2008

Available from:http://www.biomedcentral.com/1471-2458/8/117/

20. Huda.N, Rashid.etal.Prevalence of CKD and its association with renal failure in

disadvantageous population. International journal of nephrology.2012

Available from:http://www.hindawi.com/journals/ijn/2012/267329/

21. Weety Luk.Quality of life for Hong Kong dialysis patients. Journal of advanced

nursing.2001;135(2):218-227

Available from http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.2001.01839.x/

abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

22

22. Sarah.G, Matthew.W.etal.Emotional regulation, affect, psychosocial functioning and

wellbeing in hemodialysis patients. American journal of kidney disease.2008;51(4),651-

662

Available from http://cat.inist.fr/?aModele=afficheN&cpsidt=20263581

23. Joshwa.B.Khakka.C.D.Fatigue, depression and sleep problem among hemodialysis

patientsin tertiary care center. Saudi journal of kidney disease and

transplantation.2012;23(4):729-735

Available fromhttp://www.sjkdt.org/article.asp?issn=1319-

2442;year=2012;volume=23;issue=4;spage=729;epage=735;aulast=Joshwa

24. Raiman.G.J, Kruse.A.etal.Fatigue in hemodialysis patients with or without diabetes:

Results from a randomized controlled trial of two glucose containing dialysate.American

diabetic association, 2010;33(9):21

Available fromhttp://care.diabetesjournals.org/content/33/9/e121.full

25. Davison. Pain in hemodialysis patients: prevalence ,cause, severity and

management .Am J Kidney Dis.2003;42(6):1239-47

Available fromhttp://www.ncbi.nlm.nih.gov/pubmed/14655196

26. Storer.W, Richard.C.etal.Endurance exercise training during hemodialysis improves

strength, power, fatigability and physical performance in maintenance hemodialysis

patients. Nephrology dialysis transplantation.2005;20(5):1429-1437

Available fromhttp://ndt.oxfordjournals.org/content/20/7/1429.short

23

27. Segura.E.Exercise in hemodialysis patients: systematic

review.Nefrologia.2010;30(2):236-246

Available fromhttp://scielo.isciii.es/pdf/nefrologia/v30n2/evidencia.pdf

28. Paul.V.D.Eager.T.etal.The effectiveness of aerobic and muscle strength training in

patients receiving hemodialysis and EPO.American journal of kidney disease.2002;

40:1219-1229

Available fromhttp://www.cebp.nl/media/m1048.pd

29. Chen.L.T,Godfrey.etal.Effect of intradialytic,low intensity strength training on

functional capacity in adult hemodialysis patients: a randomized pilot trial. Nephrology

dialysis transplantation.2009;25(6)

Available fromhttp://ndt.oxfordjournals.org/content/25/6/1936.short

30. Fowels.H.J, Green.H.J.etal.Human neuromuscular fatigue is associated with altered

Na+ K+ ATPase activity following isometric exercise. Journal of applied

physiology.2002;92(4):1585-1593

Available from http://www.jappl.org/content/92/4/1585.short

24