Intradialytic Exercises During Hemodialysis
Condition: Kidney Failure, Chronic
MeSH terms: Renal Insufficiency; Kidney Failure, Chronic
Study type: Interventional

Summary: 
      Aim. To investigate the effect of an intradialytic aerobic and resistance cycling exercise
      program (IARCEP) on depression, fatigue, and quality of life (QOL) in end-stage renal disease
      (ESRD) patients receiving haemodialysis, and further determine the effect of mediation
      through self-efficacy and resilience in patients receiving the IARCEP.

      Background. Depression and fatigue are common in ESRD patients undergoing haemodialysis,
      which negatively affects their QOL. Exercise can mitigate this effect. Patient's
      self-efficacy and resilience may be crucial mediators in exercise.

      Design. This study was a randomised controlled trial. Method. Seventy-six participants were
      randomly assigned to either a control or exercise group. Both groups received routine care;
      whereas the exercise group participated the 3- months IARCEP. Data were collected at
      baseline, the first, second, and third months, over a 14 months in 2013-2014.
    

Detailed description: 
      According to the United States Renal Data System (2015), in 2013, 88.2% of all incident cases
      of ESRD involved renal replacement therapy with haemodialysis, ESRD is highly prevalent in
      Taiwan, with 2,902 cases per million people; 89.7% of cases in 2012 involved maintenance
      haemodialysis treatment as the renal replacement therapy. Patients generally receive
      haemodialysis 3 days per week, and each session generally takes 4 hr. Beginning dialysis
      induces multiple physical and psychological stressors in patients. In particular, the
      importance of intervention programs improving psychosocial function should be noted
      considering disease and its long-term treatment. High depression and fatigue are crucial for
      consideration in the global care of dialysis patients because these factors are associated
      with mortality. A significant correlation exists between reduced physical activity and
      increased depression or fatigue; with decreased activity, muscle strength decreases, which
      exacerbates depression and fatigue.

      Depression is the most common psychosocial problem observed in ESRD patients undergoing
      haemodialysis, with a prevalence between 27.9% and 40.2% associated with a high risk of
      hospitalisation and prolonged hospital stay, reduced quality of life (QOL), decreased
      adherence to dialysis prescriptions, and increased medical comorbidity.

      Fatigue is another critical concern caused by haemodialysis; ESRD patients receiving
      haemodialysis have reduced red blood cell production, thus causing fatigue, the prevalence of
      which ranges between 53% and 97%. Fatigue has a negative effect on the physical function,
      ability to perform daily activities, QOL, and even survival of patients. QOL is the
      subjective perception of an illness and corresponding treatment regarding physical,
      psychological, and social well-being; however, QOL serves as a prognostic measure and
      predictor of survival. ESRD patients receiving haemodialysis have a lower QOL than do other
      patients with other chronic illnesses and general population. Lower health-related QOL is
      associated with higher rates of hospitalisation and lower rates of survival among patients
      undergoing haemodialysis. Therefore, identifying effective interventions to assist ESRD
      patients receiving haemodialysis in managing their physical, psychological, and social
      problems is critical.

      Regular exercise could improve general health in many chronically ill patients. Planned
      exercise programs are nonpharmacological interventions that can safely and effectively
      improve depression, fatigue, and QOL. For ESRD patients undergoing haemodialysis, many
      previous studies have shown that exercise decreases fatigue and depression, and improves QOL.
      Accordingly, an intradialytic exercise program should be considered as a possible therapeutic
      approach for improving fatigue, depression, and QOL in ESRD populations and should be
      encouraged by and performed in haemodialysis centres. Although the benefits of related
      exercise programs are known, an effective intradialytic exercise program for routine therapy
      has not yet been developed. Few previous studies have implemented exercise programs to
      examine the effects of psychological factors and QOL on patients receiving haemodialysis in
      Taiwan.

      Exercise self-efficacy is a crucial mediator of health behaviour. Self-efficacy is a key
      construct in social-cognitive theory, in which personal beliefs correspond to an individual's
      perceived ability to successfully perform specific tasks and activities. Pertaining to
      beliefs in a person's ability to manage prospective situations, self-efficacy beliefs focus
      on mediating change in individual behaviours. Thus, self-efficacy has a mediating effect on
      depression resulting from stressful events. Self-efficacy as a mediator complements family
      and healthcare provider support in diminishing the negative impact of depression in
      haemodialysis patients. Relevantly, resilient people tend to have apparent adaptive
      behaviours, particularly those related to somatic health. Resilience specifically refers to
      smooth and rapid recovery from setbacks that may occur in a person's life. As such,
      psychological resilience is considered a protective mechanism that operates in the presence
      of negative stressors. People who are maladaptive with low competence and low adversity score
      lower on these measures than resilient and competent groups do. Exercise self-efficacy,
      resilience, and exercise behaviour are interrelated. Self-efficacy may motivate people to
      perform their physical activity. However, the true effect of exercise programs fails to
      account for the mediating effects of exercise self-efficacy and resilience.

      Purpose Statements The purpose of this study was to investigate the effect of an
      intradialytic aerobic and resistance cycling exercise program (IARCEP) on depression,
      fatigue, and QOL in ESRD patients receiving haemodialysis, and to further determine the
      effect of mediation through exercise self-efficacy and resilience in patients receiving the
      IARCEP.

      METHODS Research Design and Participants This study adopted a randomised controlled trial
      design. ESRD participants were recruited from a haemodialysis centre in an 872-bed regional
      hospital in Northern Taiwan. Data were collected over a 14 months in 2013-2014. The exercise
      group received routine nursing care in addition to the IARCEP for 3 months. The control group
      received only routine care in the same study period. A randomisation procedure was performed
      outside of the study site by two nurse researchers. Permuted-block randomisation, for which
      every block comprised four patients, was adopted to balance the number of patients in the
      exercise and control groups. A randomisation list was drawn using random computer-generated
      sequences. Information regarding these sequences was separately placed in opaque, sealed
      envelopes to ensure that the participants were randomly allocated to the exercise or control
      group. Outcomes were repeatedly measured four times at baseline and the first, second, and
      third months.

      Intradialytic aerobic and resistance cycling exercise program (IARCEP) An exercise program
      brochure for the IARCEP was made available to the exercise group participants to ensure that
      stationary cycling would be performed appropriately. A horizontal electromagnetic cycle
      ergometer (Medical Exercise Peddler 3000, Medi-Bike, Taiwan) was used for the participants'
      cycling performance. The exercise was performed during the first 2 hr of each haemodialysis
      session (30 min per session, 3 sessions per week for 3 months). All participants were
      assessed for cardiac and other medical contraindications to exercise by using PAR-Q.
      Participants were required to perform stationary cycling at an intensity of 11-13 out of 20,
      corresponding to the rate of perceived exertion on the Borg scale, whereby the intensity was
      65%-85% of the participant's maximal capacity, representing the level at which cardiovascular
      health can be maintained. Exercise was paused when the participants had systolic blood
      pressure over 180 mmHg, diastolic blood pressure over 95 mmHg, heartbeat under 60 beats/min,
      or pulse oxyhaemoglobin saturation (SpO2) under 88%. The participants' cardiac rhythm was
      continuously monitored. Blood pressure and SpO2 was also measured every 5 min. The criteria
      for interrupting exercise included physical exhaustion, chest pain, dyspnoea, dizziness, and
      significant instabilities in heartbeat or blood pressure. Immediately following exercise, the
      participants were assisted with removing the stationary cycling gear to adopt a comfortable
      position for the immediate assessment of blood pressure, heart rate, and SpO2. Participants
      were included in the subsequent analysis if they performed the aforementioned exercise
      procedure at least 10 times per month.
    

Intervention name(s): Medical Exercise Peddler 3000, Medi-Bike, Taiwan
Intervention type(s): Device
Intervention description(s): A horizontal electromagnetic cycle ergometer (Medical Exercise Peddler 3000, Medi-Bike, Taiwan) was used for the exercise program. The cycling equipment includes the resistance of 6 Levels, from Level 1 the lightest to Level 6 the heaviest. Other indicators examined are RPM (rotary per minute), DICT (The distance for this exercise), TIME (The time of exercise). This is the simplest way to use this Motion Exercise Machine. Press the "ST / SP (Start/ Stop)" button to start an exercise program for 30 minutes.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Health Services Research
Keywords: Nursing; ESRD; hemodialysis; intradialytic exercise; depression; fatigue; Quality Of Life; self-efficacy; resilience