This article was downloaded by: [University of Sherbrooke] On: 02 May 2015, At: 10:40 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sports Sciences Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rjsp20
The BASES expert statement on exercise therapy for people with chronic kidney disease a
b
c
Pelagia Koufaki , Sharlene Greenwood , Patricia Painter & Thomas Mercer
d
a
School of Health Sciences, Queen Margaret University, UK
b
Renal Exercise and Rehabilitation Team, King’s College Hospital, London, UK
c
Department of Physical Therapy, University of Utah, Salt Lake City, USA
d
School of Health Sciences, Queen Margaret University, Edinburgh, UK Published online: 25 Mar 2015.
Click for updates To cite this article: Pelagia Koufaki, Sharlene Greenwood, Patricia Painter & Thomas Mercer (2015): The BASES expert statement on exercise therapy for people with chronic kidney disease, Journal of Sports Sciences, DOI: 10.1080/02640414.2015.1017733 To link to this article: http://dx.doi.org/10.1080/02640414.2015.1017733
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Sports Sciences, 2015 http://dx.doi.org/10.1080/02640414.2015.1017733
SHORT COMMUNICATION
The BASES expert statement on exercise therapy for people with chronic kidney disease
PELAGIA KOUFAKI1, SHARLENE GREENWOOD2, PATRICIA PAINTER3 & THOMAS MERCER4
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
1
School of Health Sciences, Queen Margaret University, UK, 2 Renal Exercise and Rehabilitation Team, King’s College Hospital, London, UK, 3Department of Physical Therapy, University of Utah, Salt Lake City, USA and 4School of Health Sciences, Queen Margaret University, Edinburgh, UK (Accepted 6 February 2015)
Abstract Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in this patient population. Physical inactivity has emerged as a significant and independent risk factor for accelerated deterioration of kidney function, physical function, cardiovascular function and quality of life in people in all stages of CKD. CKD specific research evidence, combined with the strong evidence on the multiple health benefits of regular and adequate amounts of PA in other cardiometabolic conditions, has resulted in physical inactivity being identified by national and international CKD clinical practice guidelines as one of the multiple risk factors that require simultaneous and early intervention for optimum prevention/management of CKD. Despite this realisation, physical inactivity is not systematically addressed by renal care teams. The purpose of this expert statement is therefore to inform exercise and renal care specialists about the clinical value of exercise therapy in CKD, as well as to provide some practical recommendations on how to more effectively translate the existing evidence into effective clinical practice. Keywords: physical activity, exercise rehabilitation, haemodialysis, renal failure
Introduction Chronic kidney disease (CKD) is a long-term metabolic condition, characterised by gradual loss of the kidneys’ regulatory and excretory functions. It is categorised into 5 stages (CKD1–5) based on the kidneys’ estimated glomerular filtration rate (eGFR). Stage 5 (eGFR < 15 ml/min/1.732) marks the introduction of renal replacement therapy (RRT), such as dialysis or transplantation, to sustain life. The Health Survey for England (2009) estimates that about 4–6% (2.7 million) of the adult population have CKD 3–5 (GRF < 60 ml/min/1.732), with worldwide prevalence estimated around 8–16% (Jha et al., 2013). The incidence of new CKD5 patients in the UK has almost doubled in the last 10 years, with ~55,000 people currently receiving RRT (UK Renal Registry, 2010). This may reflect the rising prevalence of diabetes, obesity and hypertension, all
of which accelerate loss of kidney function and multi-system dysfunction. Suboptimal physical activity (PA) levels and an ageing demographic, further contribute to muscle loss and weakness, low cardiovascular reserve capacity, frailty and disability, severely compromised quality of life (QoL) and premature mortality in CKD (Jha et al., 2013). Physical inactivity has yet to be routinely addressed by renal multidisciplinary care teams (RMDT) despite meriting early intervention for optimum disease prevention and management, as highlighted in national and international CKD clinical practice guidelines. Professionals without “Health Care Professions Council” registration, such as clinical exercise physiologists and clinical exercise scientists/specialists, are often included as key members of research RMDT, promoting exercise. A compelling case has been made for appropriately trained and qualified exercise
Correspondence: Pelagia Koufaki, School of Health Sciences, Queen Margaret University, Queen Margaret University Drive, Edinburgh, EH216UU, UK. E-mail: [email protected] © 2015 Taylor & Francis
2
P. Koufaki et al.
professionals to be also included in the clinical RMDT, to ensure the development and delivery of effective exercise training interventions/services and to support the sustainability of PA behaviour change (Bennett et al., 2010), across the range of in-centre, outpatient community and home-based settings. It is thus the purpose of this statement to outline the clinical importance of exercise therapy for patient benefit and inform exercise and renal health care professionals about the implementation and sustainability requirements for an exercise-based rehabilitation approach in this patient population.
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Background and evidence Participation in regular and adequate PA is the basis for good physical function, healthy living and well-being (Start active, stay active, 2011). Epidemiological reports indicate that physical inactivity is an independent risk factor for the development and progression of CKD and associated complications. In studies where prevalent comorbidities (diabetes, hypertension, cardiovascular disease) are controlled for, people with low PA levels are 10 times more likely to develop CKD. Higher PA levels are also associated with up to 37% reduction in the rate of kidney function loss in people older than 65 years with CKD 2–3. As people with CKD 2–5 have substantially reduced PA and function levels, the clinical importance of doing “some” PA compared to “none”, confers an independent all cause and cardiovascular mortality risk reduction of up to 50%. People with CKD 3–5 with better scores in objectively measured physiological fitness (VO2 peak, muscle strength), functional capacity (gait speed, sit-to-stand performance) and also in patient-reported outcomes (activities of daily living (ADL)) are characterised by longer event-free survival, better mental health, less frequent hospitalisations, less functional limitations and better overall QoL. Illustratively, VO2 peak >17.5 ml · kg−1 · min−1 was associated with better survival rates over 3.5 years in patients on haemodialysis. Gait speed >1.3 m · s−1 was associated with 18–26% reduced risk of rapid kidney function decline in CKD 2–4. Patient reported physical function composite score (PCS), from the SF-36 questionnaire, indicated that a one point increase corresponded to 2% reduction in mortality rate, whilst a total PCS < 25 was associated with 93% increased risk of death and 56% increased risk of hospitalisation in patients on dialysis (Koufaki, Greenwood, Macdougall, & Mercer, 2013; Painter & Roshanravan, 2013). Given the clinical importance of PA and physical function related outcomes in patients with CKD, it has been speculated that favourable modification of
these outcomes via PA based interventions may also confer favourable short, medium and longer term health benefits. Interestingly, a long-term observational practice-based evidence report on dialysis related outcomes based on 20,920 patients in 12 countries (the DOPPS study; Tentori et al., 2010) reported that “simply” the provision of exercise in a dialysis unit was associated with better QoL and physical functioning, better sleep quality, less intrusiveness of body pain or anorexia, more positive affect and fewer depressive symptoms. Provision of exercise in a dialysis unit was also associated with 38% higher odds of patients taking up exercise and units that had patients exercising more than once per week had a 37% reduced risk of all cause mortality and 27% reduced risk of hospitilisation due to fractures compared to patients who exercised less than once per week. Moreover, based on research evidence, the clinical effectiveness of exercise therapy in CKD can be summarised as follows: 1. Despite the high-risk status of patients with CKD, no fatal or serious exercise-related adverse events have been reported (Heiwe & Jacobson, 2011). This may reflect the strict selection criteria that research studies have applied, including biases in volunteer inclusion and/or the individualised and supervised interventions employed. Expected and minor adverse events include post-exercise hypotensive episodes, fatigue and increased muscle soreness. 2. In CKD5, short-term (2–6 months) structured and supervised moderate intensity aerobic training programmes (mainly cycling), induce a systematic and large improvement in cardiorespiratory fitness (VO2 peak) by 17–50%, with an overall mean difference between treatment and control groups of 5.22 ml · kg−1 · min−1 (Segura-Orti, 2010; Smart & Steele, 2011). Such improvement exceeds the clinically important criterion of 1 MET (3.5 ml · kg–1 · min–1). Larger average improvements in cardiovascular fitness were associated with interventions delivering regular and progressive increases in exercise volume, lasting at least 6 months, performed on non-dialysis days and including an additional resistance-training component. 3. In CKD2–4, short to medium term (12– 78 weeks), low to moderate intensity aerobic training in supervised or self-managed settings, produced a small systematic improvement in VO2 peak (~9% or ~2 ml · kg–1 · min–1). Although this amount of improvement is substantially smaller than seen in CKD5 training studies, it may be clinically important, as it equates to the per year natural decline in VO2
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Exercise therapy in CKD peak, observed in pre-dialysis patients. Accordingly, early exercise intervention may be enough to slow the decline in cardiovascular reserve capacity in CKD2-4 (Koufaki et al., 2013). 4. In CKD2-5, overall QoL indices were improved with exercise training. Improved scores in the self-reported physical function sub-scores of the questionnaires used, appeared to be the main drivers for the overall improvement. Other elements of QoL such as vitality, social function, general health did not show a systematic change (Heiwe & Jacobson, 2011). 5. Well-designed and progressive resistance-only training programmes, delivered in outpatient settings, have the potential to produce large improvements in muscle strength and small improvements in lower body muscle cross sectional area in all stages of CKD (Cheema, Chan, Fahey, & Atlantis, 2014; Heiwe & Jacobson, 2011). 6. Inconsistent improvements were noted for objectively measured functional capacity indices (walking speed/distance, sit-to-stand performance). There is limited and inconsistent data on the efficacy of exercise interventions to favourably modify other cardiovascular and metabolic risk factors and residual kidney function. These observations may reflect the small number of trials (patients) and the large variability in individual responses and exercise dose.
Implementation and evaluation of exercise therapy in routine care of CKD Surveys conducted in the UK, Europe and the USA (Greenwood, Koufaki, Rush, Macdougall, & Mercer, 2014; Johansen, Sakkas, Doyle, Shubert, & Dudley, 2003; Krause R. 2004) aimed to gather information and document practice patterns and attitudes of nephrologists and the RMDT towards exercise counselling for patients with CKD. Collectively, they reported that even though almost 100% of respondents recognised the importance of regular PA and exercise for patient benefit, less than 50% recommended PA and less than 25% facilitated access to exercise programmes by referring patients to clinical and/or community services or by providing written advice and information on PA options. Renal medicine services should evolve to incorporate renal exercise rehabilitation options as part of comprehensive and integrated renal care package, which should include “exercise on prescription” under the direction of healthcare services with continuity of
3
care extended and supported under the direction of community-based services. Based on the existing research evidence, we suggest that renal exercise rehabilitation services should aim to ● Increase physiological reserve capacity ● Improve muscular strength and reduce physical function limitations (or halt deterioration for as long as possible) ● Reduce number and severity of CKD specific symptoms Longer-term aims should include provisions in order to further support patients to increase and sustain adequate levels of daily PA for health benefits, better QoL and well-being and reduced morbidity and mortality. The following key components should be incorporated in an exercise-based rehabilitation plan.
PA counselling and “exercise on prescription” All people diagnosed with CKD should be considered by primary care services as primary candidates to benefit from individualised, brief, advice and intervention as per NICE and NHS Health Scotland (2014) Physical Activity guidelines and specified pathways. All CKD 4–5 patients should have at least one session with a renal rehabilitation professional every 6 months (or more frequently according to needs) to assess physical function, PA status, and readiness to change PA behaviour. Support for change should be provided for patients by supplying specific written information about local opportunities for PA, or referring to structured and supervised rehabilitation in the community or renal services (PA Pathways). Verbal and written plans should be noted on patients’ medical records with clearly identified personal goals and targets. Priority for structured and supervised “exercise on prescription” should be given to people with at least one of the following: ● Poor functioning in ADL ● Severe muscle weakness and function ● Symptoms of CV and respiratory discomfort during ADL ● Fear of exercise and lack of confidence ● No previous exercise experience ● Serious psychological disorders People with well controlled underlying conditions who do not meet any of the above criteria should be considered for an initial evaluation in order to receive:
4
P. Koufaki et al.
● a referral to a community supported PA programme ● a written but self-managed PA and exercise plan until the next follow up re-evaluation meeting
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Assessment Detailed history of past and present chronic conditions, risk factors and treatments should be recorded and considered in the development of individualised “exercise on prescription” and advice. A list of medications and dosage, should also be recorded and displayed on the exercise prescription sheet. A comprehensive assessment of the patient’s physical, mental and social health should be regularly performed using objective and subjective measurement tools and used as the basis for monitoring progression and readjusting the “exercise on prescription” plan. Assessment of physical health should include measurement of symptoms and function (behaviour, ability and capacity (Koufaki & Kouidi, 2010) and the health “problems” that can be addressed via exercise should be highlighted.
Safety and contraindications For a detailed account of absolute and relative contraindications to measurement of physical function and exercise training in patients with CKD refer to Koufaki and Mercer (2007). It is important to consider the following safety precautions when advising/ supervising exercise in people with CKD: ● Postpone exercise if glucose levels are >250 mg · dl−1 or
Journal of Sports Sciences Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rjsp20
The BASES expert statement on exercise therapy for people with chronic kidney disease a
b
c
Pelagia Koufaki , Sharlene Greenwood , Patricia Painter & Thomas Mercer
d
a
School of Health Sciences, Queen Margaret University, UK
b
Renal Exercise and Rehabilitation Team, King’s College Hospital, London, UK
c
Department of Physical Therapy, University of Utah, Salt Lake City, USA
d
School of Health Sciences, Queen Margaret University, Edinburgh, UK Published online: 25 Mar 2015.
Click for updates To cite this article: Pelagia Koufaki, Sharlene Greenwood, Patricia Painter & Thomas Mercer (2015): The BASES expert statement on exercise therapy for people with chronic kidney disease, Journal of Sports Sciences, DOI: 10.1080/02640414.2015.1017733 To link to this article: http://dx.doi.org/10.1080/02640414.2015.1017733
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Sports Sciences, 2015 http://dx.doi.org/10.1080/02640414.2015.1017733
SHORT COMMUNICATION
The BASES expert statement on exercise therapy for people with chronic kidney disease
PELAGIA KOUFAKI1, SHARLENE GREENWOOD2, PATRICIA PAINTER3 & THOMAS MERCER4
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
1
School of Health Sciences, Queen Margaret University, UK, 2 Renal Exercise and Rehabilitation Team, King’s College Hospital, London, UK, 3Department of Physical Therapy, University of Utah, Salt Lake City, USA and 4School of Health Sciences, Queen Margaret University, Edinburgh, UK (Accepted 6 February 2015)
Abstract Chronic kidney disease (CKD) is becoming a serious health problem throughout the world and is one of the most potent known risk factors for cardiovascular disease, which is the leading cause of morbidity and mortality in this patient population. Physical inactivity has emerged as a significant and independent risk factor for accelerated deterioration of kidney function, physical function, cardiovascular function and quality of life in people in all stages of CKD. CKD specific research evidence, combined with the strong evidence on the multiple health benefits of regular and adequate amounts of PA in other cardiometabolic conditions, has resulted in physical inactivity being identified by national and international CKD clinical practice guidelines as one of the multiple risk factors that require simultaneous and early intervention for optimum prevention/management of CKD. Despite this realisation, physical inactivity is not systematically addressed by renal care teams. The purpose of this expert statement is therefore to inform exercise and renal care specialists about the clinical value of exercise therapy in CKD, as well as to provide some practical recommendations on how to more effectively translate the existing evidence into effective clinical practice. Keywords: physical activity, exercise rehabilitation, haemodialysis, renal failure
Introduction Chronic kidney disease (CKD) is a long-term metabolic condition, characterised by gradual loss of the kidneys’ regulatory and excretory functions. It is categorised into 5 stages (CKD1–5) based on the kidneys’ estimated glomerular filtration rate (eGFR). Stage 5 (eGFR < 15 ml/min/1.732) marks the introduction of renal replacement therapy (RRT), such as dialysis or transplantation, to sustain life. The Health Survey for England (2009) estimates that about 4–6% (2.7 million) of the adult population have CKD 3–5 (GRF < 60 ml/min/1.732), with worldwide prevalence estimated around 8–16% (Jha et al., 2013). The incidence of new CKD5 patients in the UK has almost doubled in the last 10 years, with ~55,000 people currently receiving RRT (UK Renal Registry, 2010). This may reflect the rising prevalence of diabetes, obesity and hypertension, all
of which accelerate loss of kidney function and multi-system dysfunction. Suboptimal physical activity (PA) levels and an ageing demographic, further contribute to muscle loss and weakness, low cardiovascular reserve capacity, frailty and disability, severely compromised quality of life (QoL) and premature mortality in CKD (Jha et al., 2013). Physical inactivity has yet to be routinely addressed by renal multidisciplinary care teams (RMDT) despite meriting early intervention for optimum disease prevention and management, as highlighted in national and international CKD clinical practice guidelines. Professionals without “Health Care Professions Council” registration, such as clinical exercise physiologists and clinical exercise scientists/specialists, are often included as key members of research RMDT, promoting exercise. A compelling case has been made for appropriately trained and qualified exercise
Correspondence: Pelagia Koufaki, School of Health Sciences, Queen Margaret University, Queen Margaret University Drive, Edinburgh, EH216UU, UK. E-mail: [email protected] © 2015 Taylor & Francis
2
P. Koufaki et al.
professionals to be also included in the clinical RMDT, to ensure the development and delivery of effective exercise training interventions/services and to support the sustainability of PA behaviour change (Bennett et al., 2010), across the range of in-centre, outpatient community and home-based settings. It is thus the purpose of this statement to outline the clinical importance of exercise therapy for patient benefit and inform exercise and renal health care professionals about the implementation and sustainability requirements for an exercise-based rehabilitation approach in this patient population.
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Background and evidence Participation in regular and adequate PA is the basis for good physical function, healthy living and well-being (Start active, stay active, 2011). Epidemiological reports indicate that physical inactivity is an independent risk factor for the development and progression of CKD and associated complications. In studies where prevalent comorbidities (diabetes, hypertension, cardiovascular disease) are controlled for, people with low PA levels are 10 times more likely to develop CKD. Higher PA levels are also associated with up to 37% reduction in the rate of kidney function loss in people older than 65 years with CKD 2–3. As people with CKD 2–5 have substantially reduced PA and function levels, the clinical importance of doing “some” PA compared to “none”, confers an independent all cause and cardiovascular mortality risk reduction of up to 50%. People with CKD 3–5 with better scores in objectively measured physiological fitness (VO2 peak, muscle strength), functional capacity (gait speed, sit-to-stand performance) and also in patient-reported outcomes (activities of daily living (ADL)) are characterised by longer event-free survival, better mental health, less frequent hospitalisations, less functional limitations and better overall QoL. Illustratively, VO2 peak >17.5 ml · kg−1 · min−1 was associated with better survival rates over 3.5 years in patients on haemodialysis. Gait speed >1.3 m · s−1 was associated with 18–26% reduced risk of rapid kidney function decline in CKD 2–4. Patient reported physical function composite score (PCS), from the SF-36 questionnaire, indicated that a one point increase corresponded to 2% reduction in mortality rate, whilst a total PCS < 25 was associated with 93% increased risk of death and 56% increased risk of hospitalisation in patients on dialysis (Koufaki, Greenwood, Macdougall, & Mercer, 2013; Painter & Roshanravan, 2013). Given the clinical importance of PA and physical function related outcomes in patients with CKD, it has been speculated that favourable modification of
these outcomes via PA based interventions may also confer favourable short, medium and longer term health benefits. Interestingly, a long-term observational practice-based evidence report on dialysis related outcomes based on 20,920 patients in 12 countries (the DOPPS study; Tentori et al., 2010) reported that “simply” the provision of exercise in a dialysis unit was associated with better QoL and physical functioning, better sleep quality, less intrusiveness of body pain or anorexia, more positive affect and fewer depressive symptoms. Provision of exercise in a dialysis unit was also associated with 38% higher odds of patients taking up exercise and units that had patients exercising more than once per week had a 37% reduced risk of all cause mortality and 27% reduced risk of hospitilisation due to fractures compared to patients who exercised less than once per week. Moreover, based on research evidence, the clinical effectiveness of exercise therapy in CKD can be summarised as follows: 1. Despite the high-risk status of patients with CKD, no fatal or serious exercise-related adverse events have been reported (Heiwe & Jacobson, 2011). This may reflect the strict selection criteria that research studies have applied, including biases in volunteer inclusion and/or the individualised and supervised interventions employed. Expected and minor adverse events include post-exercise hypotensive episodes, fatigue and increased muscle soreness. 2. In CKD5, short-term (2–6 months) structured and supervised moderate intensity aerobic training programmes (mainly cycling), induce a systematic and large improvement in cardiorespiratory fitness (VO2 peak) by 17–50%, with an overall mean difference between treatment and control groups of 5.22 ml · kg−1 · min−1 (Segura-Orti, 2010; Smart & Steele, 2011). Such improvement exceeds the clinically important criterion of 1 MET (3.5 ml · kg–1 · min–1). Larger average improvements in cardiovascular fitness were associated with interventions delivering regular and progressive increases in exercise volume, lasting at least 6 months, performed on non-dialysis days and including an additional resistance-training component. 3. In CKD2–4, short to medium term (12– 78 weeks), low to moderate intensity aerobic training in supervised or self-managed settings, produced a small systematic improvement in VO2 peak (~9% or ~2 ml · kg–1 · min–1). Although this amount of improvement is substantially smaller than seen in CKD5 training studies, it may be clinically important, as it equates to the per year natural decline in VO2
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Exercise therapy in CKD peak, observed in pre-dialysis patients. Accordingly, early exercise intervention may be enough to slow the decline in cardiovascular reserve capacity in CKD2-4 (Koufaki et al., 2013). 4. In CKD2-5, overall QoL indices were improved with exercise training. Improved scores in the self-reported physical function sub-scores of the questionnaires used, appeared to be the main drivers for the overall improvement. Other elements of QoL such as vitality, social function, general health did not show a systematic change (Heiwe & Jacobson, 2011). 5. Well-designed and progressive resistance-only training programmes, delivered in outpatient settings, have the potential to produce large improvements in muscle strength and small improvements in lower body muscle cross sectional area in all stages of CKD (Cheema, Chan, Fahey, & Atlantis, 2014; Heiwe & Jacobson, 2011). 6. Inconsistent improvements were noted for objectively measured functional capacity indices (walking speed/distance, sit-to-stand performance). There is limited and inconsistent data on the efficacy of exercise interventions to favourably modify other cardiovascular and metabolic risk factors and residual kidney function. These observations may reflect the small number of trials (patients) and the large variability in individual responses and exercise dose.
Implementation and evaluation of exercise therapy in routine care of CKD Surveys conducted in the UK, Europe and the USA (Greenwood, Koufaki, Rush, Macdougall, & Mercer, 2014; Johansen, Sakkas, Doyle, Shubert, & Dudley, 2003; Krause R. 2004) aimed to gather information and document practice patterns and attitudes of nephrologists and the RMDT towards exercise counselling for patients with CKD. Collectively, they reported that even though almost 100% of respondents recognised the importance of regular PA and exercise for patient benefit, less than 50% recommended PA and less than 25% facilitated access to exercise programmes by referring patients to clinical and/or community services or by providing written advice and information on PA options. Renal medicine services should evolve to incorporate renal exercise rehabilitation options as part of comprehensive and integrated renal care package, which should include “exercise on prescription” under the direction of healthcare services with continuity of
3
care extended and supported under the direction of community-based services. Based on the existing research evidence, we suggest that renal exercise rehabilitation services should aim to ● Increase physiological reserve capacity ● Improve muscular strength and reduce physical function limitations (or halt deterioration for as long as possible) ● Reduce number and severity of CKD specific symptoms Longer-term aims should include provisions in order to further support patients to increase and sustain adequate levels of daily PA for health benefits, better QoL and well-being and reduced morbidity and mortality. The following key components should be incorporated in an exercise-based rehabilitation plan.
PA counselling and “exercise on prescription” All people diagnosed with CKD should be considered by primary care services as primary candidates to benefit from individualised, brief, advice and intervention as per NICE and NHS Health Scotland (2014) Physical Activity guidelines and specified pathways. All CKD 4–5 patients should have at least one session with a renal rehabilitation professional every 6 months (or more frequently according to needs) to assess physical function, PA status, and readiness to change PA behaviour. Support for change should be provided for patients by supplying specific written information about local opportunities for PA, or referring to structured and supervised rehabilitation in the community or renal services (PA Pathways). Verbal and written plans should be noted on patients’ medical records with clearly identified personal goals and targets. Priority for structured and supervised “exercise on prescription” should be given to people with at least one of the following: ● Poor functioning in ADL ● Severe muscle weakness and function ● Symptoms of CV and respiratory discomfort during ADL ● Fear of exercise and lack of confidence ● No previous exercise experience ● Serious psychological disorders People with well controlled underlying conditions who do not meet any of the above criteria should be considered for an initial evaluation in order to receive:
4
P. Koufaki et al.
● a referral to a community supported PA programme ● a written but self-managed PA and exercise plan until the next follow up re-evaluation meeting
Downloaded by [University of Sherbrooke] at 10:40 02 May 2015
Assessment Detailed history of past and present chronic conditions, risk factors and treatments should be recorded and considered in the development of individualised “exercise on prescription” and advice. A list of medications and dosage, should also be recorded and displayed on the exercise prescription sheet. A comprehensive assessment of the patient’s physical, mental and social health should be regularly performed using objective and subjective measurement tools and used as the basis for monitoring progression and readjusting the “exercise on prescription” plan. Assessment of physical health should include measurement of symptoms and function (behaviour, ability and capacity (Koufaki & Kouidi, 2010) and the health “problems” that can be addressed via exercise should be highlighted.
Safety and contraindications For a detailed account of absolute and relative contraindications to measurement of physical function and exercise training in patients with CKD refer to Koufaki and Mercer (2007). It is important to consider the following safety precautions when advising/ supervising exercise in people with CKD: ● Postpone exercise if glucose levels are >250 mg · dl−1 or
