renal rehabilitation: the benefits, barriers and exercise options

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It is well documented that patients with chronic kidney disease (CKD) demonstrate lower levels of physical activity (Johansen and Painter, 2012; Koufaki et al, 2013), skeletal muscle

wasting (Johansen et al, 2000; van den Ham et al, 2005; Cheema, 2008), and self-reported difficulties with activities of daily living (Padilla et al, 2008; Greenwood et al, 2012). Lower levels of physical activity have been associated with a higher risk of cardiovascular disease and mortality within the CKD patient population (O’Hare et al, 2003; Odden et al, 2004; Beddhu et al, 2009).

The majority of the past 30 years of research into exercise and CKD has focused on the patients receiving haemodialysis therapy (Cheema and Singh, 2005; Segura-Orti, 2010; Heiwe and Jacobson, 2011; Smart and Steele; 2011). Evidence evaluating the effect and efficacy of exercise rehabilitation in patients at stages 2–4 of the CKD trajectory, and recipients of kidney transplants, continues to expand. The evidence suggests that a regular supervised exercise programme can lead to improvements in physical capacity (Kouidi et al, 1997), functional ability (Greenwood et al, 2012), and a decrease in the self-reporting of depression (Kouidi et al, 1997; Greenwood et al, 2012) and anxiety (Greenwood et al, 2012) in patients with CKD (Kouidi et al, 1997).

Despite these findings, renal rehabilitation is not offered routinely across the UK. Further large randomised controlled trials evaluating the effects and desirable level of exercise in this patient group are warranted to enable further commissioning of this service. This review aims, through reflecting on the literature, to highlight benefits and barriers to exercise for patients with CKD, and to describe the types of exercise approaches available to support the provision of routine renal rehabilitation.

Exercise and chronic health conditionsExercise is considered an important component of treatment and is commonly recommended in

chronic disease groups, such as chronic obstructive pulmonary disease (Nici et al, 2006; Lacasee et al, 2007; Ries et al 2007) and cardiac disease (Jolliffe et al, 2001). A strong inverse relationship exists between reduced exercise capacity and increased mortality in the general population, and multiple patient groups, such as those with hypertension (Myers et al, 2002; Carnethon et al, 2005; Kokkinos et al, 2009; Segura-Orti, 2010; Howden et al, 2012). The NHAMES III Study, a large observational study of 15 368 participants, found that physical inactivity is associated with increased mortality in patients with and without CKD (Beddhu et al, 2009). Therefore, it is possible to surmise that exercise rehabilitation can be potentially beneficial for reducing mortality in patients with CKD. Unfortunately, exercise therapy is not considered part of the routine care package for

Ellen O’Connor n Senior Renal Rehabilitation Physiotherapist, King’s College Hospital, London

n ellen.o’[email protected]

Pelagia Koufaki n PhD Research Fellow, Clinical Exercise Physiology, Queen Margaret University, Edinburgh

Rachel Clark n Senior Renal Rehabilitation Physiotherapist, King’s College Hospital, London

Herolin Lindup n Assistant Practitioner, Physiotherapy, King’s College Hospital, London

Thomas H Mercer n Professor of Rehabilitation Sciences and Research Theme Lead

Iain Macdougall n Professor of Clinical Nephrology, King’s College Hospital, London

Sharlene Greenwood n Clinical Lead and Renal Specialist Physiotherapist, King’s College Hospital, London

Renal rehabilitation: the benefits, barriers and exercise optionsThis article discusses the benefits of well-designed exercise provision, appropriate for chronic kidney disease (CKD), such as enhanced functional capacity, improvements in quality of life, and weight maintenance. However, these things are not usually provided as part of routine care for CKD patients.

n exercise n rehabilitation n chronic kidney disease n physical function n physical activity

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the CKD population, despite research reporting that enough scientific evidence exists to suggest benefits of exercise across the whole spectrum of CKD (Heiwe and Jacobson, 2011; Howden et al, 2012).

The lack of commissioning of renal specific rehabilitation programmes is thought to be due to a lack of adequately-powered, randomised and controlled studies (Howden et al, 2012), and variations with the dosage of exercise prescription (Cheema and Singh, 2005; Macdonald et al, 2009), making it difficult to draw any firm conclusions about safety and effectiveness.

To encourage activity and exercise for patients with CKD, an appreciation of the benefits and barriers to exercise participation is crucial, and should hopefully be enough to encourage the renal multidisciplinary team (MDT) to start providing exercise rehabilitation to patients with CKD while further outcomes of some of the large trials being conducted in this area of patient care are awaited. This review aims to highlight the benefits of, and barriers to, exercise within this patient group, and to make suggestions for future research.

Benefits of exercise in patients with CKDAlthough the benefits of exercise within the CKD patient population are often highlighted in the literature, exercise rehabilitation is not a part of usual care for patients with CKD. For discussion purposes, some of the benefits can be divided into improvements concerning:

n Functional capacity n Quality of life n Weight loss and weight maintenance.

Improved functional capacityPatients with CKD demonstrate reductions in physical activity (Johansen et al, 2000; O’Hare et al, 2003; Beddhu et al, 2009; Leehey et al, 2009; Mustata et al, 2011); muscle strength (van den Ham et al, 2005; Roshanravan et al, 2013); peak oxygen uptake (VO2 peak) (Painter et al, 2011; Sietsema, 2004; Smart and Steele, 2011); functional capacity; and difficulty to perform daily activities (Padilla et al, 2008; Roshanravan et al, 2013).

Functional capacity and ability to perform activities of daily living are often measured in clinical practise by tests such as the 6-minute walk test (6MWT); incremental shuttle walk test (ISWT); sit to stand 60 (STS60); 3-metre timed up and go test (TUAG); stair climb/descent tests; and gait speed or self-reporting questionnaires (Steffen et al, 2002; Greenwood et al, 2012).

VO2 peak is a measure of the peak oxygen uptake during a maximal exercise test and is often used to

determine cardiovascular fitness and make inferences to functional capacity. Exercise intervention has been shown to increase VO2 peak in stages 2–4 CKD (Eidemak et al, 1997; Leehey et al, 2009; Mustata et al, 2011; Gregory et al, 2011; Headley et al, 2012), patients receiving haemodialysis therapy (Cheema and Singh, 2005; Cheema, 2008; Segura-Orti, 2010; Smart and Steele; 2011), and transplant recipients (Painter et al, 2002; 2003; Kouidi et al,2012). The largest increase in VO2 peak can be found following a combination of aerobic and strengthening exercise programme for 6 months in patients receiving haemodialysis therapy (Cheema and Singh, 2005, Smart and Steele; 2011; Koufaki et al, 2013).

Padilla et al’s (2008) small study of 32 pre-dialysis patients with CKD found a significant correlation between VO2 peak and all measures of physical function, such as gait speed, STS60 and 6MWT. A 12-week pragmatic supervised combination exercise class of 77 patients across the CKD trajectory showed significant improvement in most clinical functional capacity tests: increased ISWT distance (239.4±125.5m to 344.2±186.1m); reduced TUAG speed (9.3±3.45 seconds to 7.0±1.8 seconds); increased STS60 repetitions (20.3±7.1 to 24.52 ±7.6 repetitions); decreased SCD time (32.72± 22.62 to 23.7±12.0 seconds); and improved DASI score (Duke Activity Status Index—a measure of self-reported physical function) (24.8±10.8 to 33.6±13.0 score) (Greenwood et al, 2012).

Studies by Fitts et al (1999) and Heiwe et al (2001) further demonstrate improvements in 6MWT by 3.9–62 metres and TUAG from 11 seconds to 9 seconds following exercise intervention in the pre-dialysis patients. The improvements in functional capacity, which were objectively and subjectively reported, may improve performance of activities of daily living, and increase levels of independence for these patients, regardless of their CKD stage.

Quality of lifeLittle evidence exists investigating the quality of life and self-reported physical function in CKD patients. Resistance exercise has been shown to induce significant improvements in self-reported physical function in patients receiving haemodialysis therapy, as evaluated with the SF-36 questionnaire (Segura-Orti, 2010). Significant improvements in the self-reported questionnaire sickness impact profile (SIP) (Fitts et al, 1999) were also demonstrated following exercise intervention in patients with stage 2–4 CKD.

Pragmatic provision of renal rehabilitation has been evaluated as effective, and has demonstrated improvements not only in physical capabilities, but also improvements in self-reported anxiety (from a


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score of 7.1±4.3 to 5.95±4.15) and depression (from a score of 7.0±3.5 to 5±3.54) in one of the only NHS-delivered programmes in the UK (Greenwood et al, 2012). This psychological improvement following exercise intervention is also described by Kouidi et al (1997), suggesting the potential holistic benefits of an exercise and educational approach for patients with CKD. More research is advocated to investigate the effects of exercise on quality of life and self-reporting of physical function.

Weight loss and maintenanceObesity has been identified as an independent risk factor for the development and progression of CKD (Navaneethan et al, 2009). Weight loss is important in CKD patients, and has been postulated to prevent development and progression of CKD (Navaneethan et al, 2009); the incidence and development of type 2 diabetes mellitus (Orazio et al, 2009); and obesity, which is common in the first year following kidney transplantation (Kobus et al, 2011). A body mass index score (BMI) of greater than 30 kg/m2 often excludes patients from being considered as a candidate for kidney transplantation (Cook et al, 2008), as it is associated with poor outcome and increased risk for delayed graft function (Meier-Kriesche et al, 2002).

A 12-month programme consisting of individualised exercise prescription, motivational interviewing techniques, dietary management advice, and the use of orlistat medication, has been shown to induce significant reductions in BMI (35.7 kg/m2 to 33.2 kg/m2) and waist circumference (112.9 cm to 100 cm) in obese patients with CKD (Cook et al, 2008). This study also showed improved exercise capacity (6MWT improved by 45%); improvements in functional measures, such as the STS60 (improved by 30%); and the DASI, which improved by 50% in this pragmatic approach to weight loss (Cook et al, 2008).

MacLaughlin et al (2010; 2012) reported significant weight loss at 6 months, which was maintained at 24 months in the same patient cohort. MacLaughlin et al (2010; 2012) suggested that compliance and attendance leads to sustainable weight loss and the improved systolic blood pressure observed in the study. The holistic MDT approach described in the study resulted in three patients receiving a kidney transplant, and nine achieving a place on the waiting list (MacLaughlin et al, 2010).

These studies suggest that a pragmatic, MDT, holistic, weight-management approach can lead to sustained weight loss in CKD patients, improved exercise capacity and increased chance of consideration for kidney transplantation.

Barriers to exercise in patients with CKDTo ensure compliance with exercise recommendations, identifying barriers and problem solving can be essential. Delgado and Johansen (2012) surveyed 100 patients receiving haemodialysis therapy to determine their thoughts towards physical activity and barriers to participation, and found 98% strongly agreed that a sedentary lifestyle was a health risk, and believed that increasing physical activity is beneficial for good health. Of the patient group, 92% reported one or more barriers to participation, the most highly reported being: fatigue on dialysis (67%) and non-dialysis days (40%); shortness of breath (48%); and lack of motivation (42%) (Delgado and Johansen, 2012). Often barriers can be problem-solved through a holistic patient-centred approach, using motivational interviewing techniques, to aid adherence and stimulate the patient’s own motivation for change (Rollnick et al, 2008).

While considering barriers to exercise, it is crucial to consider the beliefs of the renal MDT towards exercise or physical activity in patients with CKD. Staff members caring for patients receiving haemodialysis therapy may consider patients as being too old for exercise (Bennett et al, 2010), unlikely to be interested in exercise, or too unwell to exercise (Delgado and Johansen, 2012). Bennett et al (2010) suggests that involving a renal-specific physiotherapist or exercise physiologist in patient care improves their motivation through specific exercise prescription, takes away the pressure from the other haemodialysis staff, and assists in changing the ‘exercise culture’ and beliefs of patients and staff within the haemodialysis unit.

Overcoming patient barriers to exercise participation often involves an individualised holistic evaluation of the patient’s biopsychosocial picture, and determining what would be best suited to the patients’ needs and lifestyle.

Exercise approaches for patients with CKDA variety of exercise options for patients with CKD have been reported in the literature including; home exercise programmes (Eidemak et al, 1997; Painter et al, 2002; 2003; Sharif et al, 2008), supervised exercise classes (Kouidi et al 1997; Greenwood et al, 2012), and exercise on dialysis (Konstantinidou et al, 2002; Cheema and Singh, 2005; Cheema, 2008; Ouzouni et al, 2009; Smart and Steele, 2011). The patient’s choice of exercise will depend on individual factors such as medical history, physical capabilities, transport options, associated costs and general preferences.


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Patients receiving haemodialysis therapy should be given the option to either exercise during dialysis or exercise on non-dialysis days. Koufaki et al’s (2013) review of the renal exercise literature depicts that the highest rate of improvements in VO2 peak is achieved on non-dialysis days (43% non-dialysis days, 33% during dialysis, and 37% home exercise). However, exercise on non-dialysis days are associated with higher drop-out rates (17% on dialysis compared with 24% off dialysis) (Koufaki et al, 2013) and therefore exercising these patients during dialysis may be the better option. One may surmise that exercise on dialysis is more convenient for the patients receiving haemodialysis therapy (Delgado and Johansen, 2012) and other patients with CKD should be considered individually and holistically to identify barriers and problem solve strategies to ensure compliance.

Routine specific renal exercise classes in the UK remain scarce and the optimal recommendations for exercising patients with CKD are still to be determined (Johansen and Painter, 2012). Patients with known cardiovascular disease and CKD could potentially benefit from referral to cardiac rehabilitation programmes (Venkataraman et al, 2005; Johansen and Painter, 2012).

Due to the similarities of numerous past medical history with potentially reduced functional capacity in patients with cardiac disease or CKD, Johansen and Painter (2012) suggested the possibility of following the American Heart Association recommendations for CKD patients (Gibbons et al, 2002). The guidelines recommend older adults should be achieving 30 minutes of moderate intensity exercise five times a week (Gibbons et al, 2002), which is very similar to the physical activity guidelines in the UK (Bull, 2010) for 150 minutes moderate-intensity exercise per week. Patients with CKD should be encouraged to participate in regular exercise, and referral to exercise specialists, such as physiotherapists, to assess and prescribe exercise in a safe and effective way, would be beneficial.

ConclusionThe literature reveals that well-designed exercise provision, appropriate for each stage of CKD, may be beneficial. Potential benefits include, improved functional capacity, potential improvements in quality of life, and weight loss and weight maintenance. Despite the supporting evidence, and reported beliefs of the importance of exercise in CKD, it is not usually provided as part of routine care for patients with CKD.

Renal rehabilitation, as a pragmatic approach to rehabilitation for patient at all stages of the CKD trajectory, has been evaluated as effective, and has

demonstrated improvements for patients not only in terms of physical capabilities, but also in self-reported anxiety and depression (Kouidi et al, 1997; Greenwood et al, 2012). It may be suggested that the holistic benefits of exercise and education for CKD patients is warranted.

While further research is required to evaluate the different types of exercise for CKD patients, there is enough evidence to suggest that encouraging appropriate exercise in this patient population, and the use of physiotherapists to individually assess and prescribe exercise intervention, would not only be good practice but also be of benefit to this patient population. To successfully involve CKD patients in exercise rehabilitation, patients must be assessed in a holistic manner to identify individual patient barriers, potential benefits for each patient, and to determine individualised exercise plans. One could suggest that physiotherapists, working within a renal MDT, are ideally positioned to confidently and appropriately fulfil this task.

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Key points n Patients with chronic kidney disease (CKD) demonstrate reduced functional capacity, and physical activity, skeletal muscle wasting and difficulty with activities of daily living

n Exercise intervention has been shown to improve exercise capacity, self-reported levels of anxiety and depression, and weight loss and maintenance in the CKD patient population

n Barriers to compliance within this patient group include fatigue, lack of motivation and preconceptions of the patient’s capabilities by the renal MDT

n An individualised, holistic, approach to exercise in CKD could ensure barriers are identified, facilitating better compliance.

n Further researchers, with adequately powered, randomised, and controlled studies, are required to ensure that relevant outcomes are produced to encourage commissioning of renal specific rehabilitation programmes

n Encouraging patients to participate in regular physical activity is important in this patient group


renal rehabilitation: the benefits, barriers and exercise options

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