PT on the Net Research

Dialysis and Exercise


Question:

I have a 41-year-old client who is on a dialysis. This client hasn't exercised in about five years. I would like some advice as to where to start and gradually progress him toward attaining his goals of optimum fitness.

Answer:

The following should be used as a guideline and is not intended to replace medical advice.

Working with any client who suffers from a complex medical condition such as this can be a challenging but ultimately rewarding experience. Your client’s success will be dependant on his individual response to exercise and treatment.

Many clients who have reached the point of undergoing dialysis have greatly reduced physical function and a poor tolerance of exercise in general, so the key word for exercise prescription is “function.” Exercise responses are characterized by a blunted heart rate response and excessive blood pressure increases. Another potential complication is anemia, which has previously been a large factor in limiting exercise, although treatment with erythropoietin (EPO is a hormone given to stimulate the production of red blood cells by the body) is now helping to combat that. Despite this, the evidence to justify inclusion of both resistance training and aerobic work is powerful, with several studies showing a wide range of benefits across the board. Furthermore, 30 percent of dialysis patients are also diabetic, and the benefits of exercise for that condition are well established.

Looking closer at exercise variables, research has shown positive results using exercise programs based around three training sessions a week. These are best performed on non-dialysis days with total workout time between 20 to 60 minutes.

As you are aiming to increase functional ability, typically with everyday tasks, it would seem sensible to take a multi-disciplinary approach that uses a combination of aerobic work, resistance training and dedicated flexibility work. The key with this is going to be patient and gradual progression, with constant monitoring of the client’s progress and health status.  For example, the stationary or recumbent bike is a good place to begin with the aerobic work, initially using short bouts of work and recovery. Be aware that muscle fatigue is likely to be the limiting factor here, so keep resistance low and give consideration to where you use it during the workout. An example would be to work with 30 seconds of pedaling at a work cadence, followed by two minutes of recovery cadence for a total of 10 to 15 minutes aiming to gradually reduce the recovery interval. You can also progress by either adding another interval (increasing total volume), changing modality (increasing intensity) or increasing the work interval length (increasing density). 

With resistance training, you will also be able to make some really tangible and targeted improvements in your client’s health. Remember, improving function is the key here so where possible, aim to use movement patterns that will have the greatest crossover to everyday life for the client such as sit-to-stand movements and PNF patterns using balls, cables or bands. Begin by working with single sets of 12 to 15 repetitions on each exercise and aim to progress by increasing volume gradually. Sets should not be completed to failure, merely to fatigue. Where possible, try to favor bodyweight over external loading for greater functional crossover and the associated benefits on balance, coordination, motor skills and self confidence.

Flexibility work can be integrated with the strength training, with PNF type techniques used to help correct muscular imbalances used alongside more active flexibility drills such as those commonly seen in yoga or Pilates.

Finally, be aware of potential complications and resist the urge to push too hard, too soon. Remember, we tend to see our clients when they are at the gym. Therefore, we only get a snapshot of how they are in general, both in mind and body. It is also possible (and perhaps likely) that you will encounter setbacks and “bad days.” Recognizing these is important so you can adjust your program accordingly. This will be a tough undertaking for your client, and he may find it hard to maintain motivation, so perhaps the most important factor will be your encouragement, enthusiasm and education about the many benefits of regular exercise on his health and function. Best of luck!

References:

  1. Clyne N (2004) Physical working capacity and muscle strength in chronic renal failure are improved by exercise. Lakartidningen 101(50):4111-5.
  2. Headley et al (2002) Resistance training improves strength and functional measures in patients with end-stage renal disease. American Journal of Kidney Disease 40(2):355-64
  3. Konstantinidou et al (2002) Exercise training in patients with end-stage renal disease on haemodialysis: comparison of three rehabilitation programs. Journal of Rehabilitative Medicine 34(1):40-5
  4. Kouidi et al (2004) Outcomes of long-term exercise training in dialysis patients: comparison of two training programs. Clinical Nephrology 61:S31-8
  5. Mustata et al (2004) Impact of an exercise programme on arterial stiffness and insulin resistance in haemodialysis patients. American Journal of the American Society of Nephrology 15:2713-2718
  6. Painter P.L (1997) Renal Failure in ACSM Exercise Management for Persons with Chronic Diseases and Disabilities