11 Turoń-Skrzypińska Agnieszka, Tomska Natalia, Uzdzicki Artur, Przybylski Tomasz, Dutkiewicz Grażyna, Rotter Iwona. Physical activity amongst hemodialysed patients – why lack of motivation to exercise is present? Pedagogy and Psychology of Sport. 2020;6(2):11-17. elSSN 2450-6605. DOI http://dx.doi.org/10.12775/PPS.2020.06.0 2 .00 1 https://apcz.umk.pl/czasopisma/index.php/PPS/article/view/PPS.2020.06.0 2 .00 1 https://zenodo.org/record/3737237 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2020; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 05.03.2020. Revised: 25.03.2020. Accepted: 02.04.2020. Physical activity amongst hemodialysed patients – why lack of motivation to exercise is present? Agnieszka Turoń-Skrzypińska1, Natalia Tomska2, Artur Uzdzicki3, Tomasz Przybylski4, Grażyna Dutkiewicz5, Iwona Rotter6 1, 2, 6 Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 54, 71-210, Szczecin, Poland. 3,4 Student Science Club “KINEZIS” at the Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University in Szczecin, Żołnierska 54, 71-210, Szczecin, Poland. 5 Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University in Szczecin, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland Key words: Physical activity, hemodialysis, chronic kidney disease Abstract In recent years a great interest in rehabilitation and physical activity amongst hemodialysed patients have developed. Despite having numerous exercise options, adverse effects of a lack of movement still are seen in this group of patients. The reasons of insufficient physical activity amongst hemodialysed patients are complications related to https://zenodo.org/record/3737237 https://apcz.umk.pl/czasopisma/index.php/PPS/article/view/PPS.2020.06.02.001 http://dx.doi.org/10.12775/PPS.2020.06.02.001 12 chronic diseases and renal replacement therapy. For patients suffering from kidney failure it is crucial to adhere to recommendations relating to regular physical activity in order to maintain health and good quality of life. 13 Manuscript In recent years a great interest in rehabilitation and physical activity amongst hemodialysed patients have developed. According to NKF-KDOQI (National Kidney Foundation Kidney Disease Outcomes Quality Initiative) guidelines hemodialysed patients are advised to perform regular physical activity. Moreover, all medical personnel (especially nephrologists, physiotherapists, nephrology nurses) should encourage patients to take up physical activity [1]. Hemodialysed patients can choose from variety of exercise: walking, dancing, yoga or fully personalised training programs. In certain Dialysis facilities patients are able to train using cycloergometers or use personalised training programs while dialysis is being performed. Despite this recommendations patients suffering from end – stage renal disease are frequently less physically active compared to same – age population without any kidney – related diseases [2-5]. Worsening health, fatigue, malaise and renal replacement therapy makes it harder to maintain proper physical activity, which leads to worsening of physical capacity, degenerative changes of muscle and bone tissue, and increased risk of fractures [6- 9]. The reasons of insufficient physical activity amongst hemodialysed patients are most often complications related to chronic diseases and renal replacement therapy. Other reasons include uremic atrophy and disfunction of skeletal muscles, anaemia, oxidative stress, neurohormonal disorders, depression, anxiety and psychosocial disorders [8-12]. Reports about problems in handling everyday activities may be another confirmation that hemodialysed patients lack proper physical activity. It was proven that amongst hemodialysed patients aged more than 65 years old 83% needs assistance with performing household activities, 81% with shopping, 80% with laundry, 68% with preparing meals, 52% with walking on stairs, 49% with moving around the apartment, 48% with bathing [13,14]. An important issue related to lack of physical activity in hemodialysed patients is Frailty Syndrome, characterised as lower physical performance and malaise. It was shown that in end – stage renal disease it is significantly more common than in equal – age population [15,16]. Presence of several factors related to the presence of chronic kidney disease and necessity to undergo renal replacement therapy also decrease the ability to take up physical activity. Factors causing absence of exercise are: feeling tired, lack of motivation, absence of partners, no safe environment to perform exercise, frequent doctor’s appointments, fear of falling or fear of damaging vascular access for hemodialysis. Despite patients frequently are interested in taking up training, listed limitations often doesn’t allow them to participate [17- 19]. Moreover, chronic illness and renal – replacement therapy result in decreasing motor abilities, reduce amount of available time and even interfere with circadian rhythm. Another compound problem in this population is presence and development of disability [20]. Also fluid intake restrictions may further decrease one’s physical activity [21]. It needs to be highlighted than patients undergoing hemodialysis are frequently reluctant to taking up exercise programs, which often makes cooperation in this area difficult [22,23] – in spite having the opportunity to exercise in some Dialysis facilities in Poland, even during hemodialysis, patients often don’t use it at all [20]. As mentioned, lack of proper motivation, and lack of perspective to fully recover may make exercise unattractive. It is crucial to formulate adequate recommendations to the patient, explain them and highlight their importance [17]. Complex nephrological rehabilitation program should be performed taking under consideration general assumptions of cardiological rehabilitation – but after targeted modifications. Type and intensity of physical activity should always be individually chosen for each patient, taking under consideration all diseases and contraindications. For nephrological patients physical activity which don’t result in creating oxygen debt is most 14 recommended – e.g. Nordic walking or bike exercises [24-26]. Most frequent form of everyday physical activity, which is safe and available, is walking [11]. In literature there is plenty of experimental papers in which pedometers or accelerometers were used as a simple measuring tool to monitor patient’s activity in rehabilitation programs for hemodialysed patients (Nowicki et al.). Pedometers are often used not only for objective evaluation of one’s physical activity [27,28], but also to provide everyday motivation for further increase of activity [27,29]. In recent research it was shown, that games basing on augmented reality may increase mean time of physical activity amongst young people [30-35]. Perhaps a well-designed app may also encourage hemodialysis patients to exercise more? Another interesting solution to the problem of lacking physical activity is telerehabilitation, in similar matter as in cardiologic telerehabilitation programs. Telerecorders providing healthcare professionals with patients parameters such as EKG graph, BPM and BP could also remind patients to exercise more. Telerehabilitation would also provide sense of security guaranteed by live – monitoring [36,37]. A perfect solution would be creation of interdisciplinary medical centres oriented on complex nephrological rehabilitation and providing education about the need to exercise and all the possible benefits [5,19]. Physical activity in hemodialysed patients is essential in prevention of cardiovascular incidents, improvement of biochemical test results and decreasing body mass. Professional rehabilitation programs would also provide safe methods to perform exercise, as patient medical history will be considered [38]. Patients suffering from chronic kidney disease are proven to benefit from physical activity in numerous ways [13]. Regular exercise improves physical and mental health, biochemical test results, hemodialysis efficiency and graft’s function [26,39-41]. Numerous research shows that both low – intensity and high – intensity exercise are effective for hemodialysis patients [42]. Personalised low – frequency exercise, in home conditions are generally well – tolerated and are suitable for patients aged above 65 years old with end – stage renal disease, and lead to improvement of physical condition [2,43]. Similar results may be obtained using supervised cycloergometer training programs [44]. Chronic Kidney Disease has a great impact on public health, mostly related to renal – replacement therapy and progression of disability. However, physical activity of hemodialysed patients is still too low – in spite of recommendations. The problem of low physical activity among patients undergoing dialysis is being frequently discussed. It is crucial to encourage hemodialysed patients to take up more exercise, to introduce proper monitoring gear and new forms of activity. Benefits of regular physical activity needs to be discussed more [45,46]. References 1. Nelson RG., Tuttle KR., Bilous RW., Gonzalez-Campoy JM., Mauer M., Molitch ME et al. (2012). KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis, 60 (5): 850–886. 2. Baggetta R., D’Arrigo G., Torino C., ElHafeez SA., Manfredini F., Mallamaci F., et al. (2018). Effect of a home based, low intensity, physical exercise program in older adults dialysis patients: a secondary analysis of the EXCITE trial. BMC Geriatr. 18 (1): 248. Doi: 10.1186/s12877-018-0938-5. 3. Bowlby W., Zelnick LR., Henry C., Himmelfarb J., Kahn SE., Kestenbaum B., et al. (2016). Physical activity and metabolic health in chronic kidney disease: a cross-sectional study. BMC Nephrol. 17 (1): 187. Doi: 10.1186/s12882-016-0400-x. 4. Kopple JD., Storer T., Casburi R. (2005). Impaired exercise capacity and exercise training in maintenance hemodialysis patients. J Ren Nutr. 15 (1): 44–48. 15 5. Szymańska A., Filaszkiewicz M., Niemczyk M. (2017). Aktywność fizyczna u pacjentów leczonych hemodializami. Nefrol. Dial. Pol. 21, 173–175. 6. Arem H., Moore SC., Patel A., Hartge P., Berrington de Gonzalez A., Visvanathan K., et al. (2015). Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 175 (6): 959-967. Doi: 10.1001/jamainternmed.2015.0533. 7. Block GA., Klassen PS., Lazarus JM., Ofsthun N., Lowrie EG., Chertow GM. (2004). Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol. 15 (8): 2208-2218. Doi: 10.1097/01.ASN.0000133041.27682.A2. 8. Kalantar-Zadeh K., Kuwae N., Regidor DL., Kovesdy CP., Kilpatrick RD., Shinaberger C. S., et al. (2006). Survival predictability of time-varying indicators of bone disease in maintenance hemodialysis patients. Kidney Int. 70 (4): 771–780. Doi: 10.1038/sj.ki.5001514. 9. Storer TW. (2013). Exercise Training for Individuals with Advanced Chronic Kidney Disease. W: Joel D., i in., red: Nutritional management of renal disease. 3rd ed. Amsterdam: Academic Press. 739–773. ISBN: 978-0-12-391934-2. 10. Castaneda C., Gordon PL., Parker RC., Uhlin KL., Roubenoff R., Levey AS. (2004). Resistance training to reduce the malnutrition-inflammation complex syndrome of chronic kidney disease. Am J Kidney Dis. 43 (4): 607-616. 11. Hsieh RL., Lee WC., Huang HY., Chang CH. (2007). Quality of life and its correlates in ambulatory hemodialysis patients. J Nephrol. 20 (6): 731–738. 12. Tudor-Locke C. (2001). A preliminary study to determine instrument responsiveness to change with a walking program: physical activity logs versus pedometers. Res Q Exerc Sport. 72 (3): 288–292. Doi: 10.1080/02701367.2001.10608962. 13. Cook WL., Jassal SV. (2008). Functional dependencies among the elderly on hemodialysis. Kidney Int. 73 (11): 1289-1295. Doi: 10.1038/ki.2008.62. 14. Kurella TM., Covinsky KE., Chertow GM., Yaffe K., Landefeld CS., McCulloch CE. (2009). Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 361 (16): 1539–1547. Doi: 10.1056/NEJMoa0904655. 15. Fried LP., Tangen CM., Walston J., Newman AB., Hirsch C., Gottdiener J., et al. (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 56 (3): M146-56. 16. Wuerth D., Finkelstein SH., Finkelstein FO. (2005). The identification and treatment of depression in patients maintained on dialysis. Semin Dial. 18 (2): 142–146. Doi: 10.1111/j.1525-139X.2005.18213.x. 17. Delgado C., Johansen K.L. (2012). Barriers to exercise participation among dialysis patients. Nephrol Dial Transplant. 27 (3): 1152-1157. Doi: 10.1093/ndt/gfr404. 18. Goodman ED., Ballou MB. (2004). Perceived barriers and motivators to exercise in hemodialysis patients. Nephrol Nurs J. 31 (1): 23–29. 19. Jayaseelan G., Bennett PN., Bradshaw W., Wang W., Rawson H. (2018). Exercise Benefits and Barriers: The Perceptions of People Receiving Hemodialysis. Nephrol Nurs J. 45 (2): 185–219. 20. Wojczyk A. (2014). Problemy codziennego życia hemodializowanych pacjentów. Piel Zdr Publ. (4): 143–148. 21. Birmelé B., Le Gall A., Sautenet B., Aguerre C., Camus V. (2012). Clinical, sociodemographic, and psychological correlates of health-related quality of life in chronic hemodialysis patients. Psychosomatics. 53 (1): 30-37. Doi: 10.1016/j.psym.2011.07.002. 22. Nowicki M., Murlikiewicz K., Jagodzińska M. (2010). Pedometers as a means to increase spontaneous physical activity in chronic hemodialysis patients. J Nephrol. 23 (3): 297–305. 16 23. Stewart AL., Hays RD., Wells KB., Rogers WH., Spritzer KL. Greenfield S. (1994). Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the Medical Outcomes Study. J Clin Epidemiol. 47 (7): 719–730. 24. Barinow-Wojewódzki A. (2013). Fizjoterapia w chorobach wewnętrznych. PZWL, Warszawa. ISBN: 978-83-200-4387-7. 25. Rutkowski B. (2007). Leczenie nerkozastępcze. Wyd. Czelej, Lublin. ISBN:978-83- 60608-11-1. 26. Qiu Z., Zheng K., Zhang H., Feng J., Wang L., Zhou H. (2017). Physical Exercise and Patients with Chronic Renal Failure: A Meta-Analysis. Biomed Res Int. Doi: 10.1155/2017/7191826. 27. Cobo G., Gallar P., Gama-Axelsson T., Di Gioia C., Qureshi AR., Camacho R., et al. (2015). Clinical determinants of reduced physical activity in hemodialysis and peritoneal dialysis patients. J Nephrol. 28 (4): 503-510. Doi: 10.1007/s40620-014-0164-y. 28. Hiraki K., Shibagaki Y., Izawa KP., Hotta C., Wakamiya A., Sakurada T., et al. (2017). Effects of home-based exercise on pre-dialysis chronic kidney disease patients: a randomized pilot and feasibility trial. BMC Nephrol. 18 (1): 198. Doi:10.1186/s12882-017- 0613-7. 29. Akber A., Portale AA., Johansen KL. (2014). Use of pedometers to increase physical activity among children and adolescents with chronic kidney disease. Pediatr nephrol. 29 (8): 1395-1402. Doi: 10.1007/s00467-014-2787-6. 30. Hino K., Asami Y., Lee JS. (2019). Step Counts of Middle-Aged and Elderly Adults for 10 Months Before and After the Release of Pokémon GO in Yokohama, Japan. J Med Internet Res. 21 (2): e10724. Doi: 10.2196/10724. 31. Graells-Garrido E., Ferres L., Caro D., Bravo L. (2017). The effect of Pokémon Go on the pulse of the city: a natural experiment. EPJ Data Sci. 6 (1): 667. Doi: 10.1140/epjds/s13688-017-0119-3. 32. Kogan L., Hellyer P., Duncan C., Schoenfeld-Tacher R. (2017). A pilot investigation of the physical and psychological benefits of playing Pokémon GO for dog owners. Comput Human Behav. 76: 431–437. Doi: 10.1016/j.chb.2017.07.043. 33. Liu W., Ligmann-Zielinska A. (2017). A Pilot Study of Pokémon Go and Players' Physical Activity. Games Health J. 6 (6): 343–350. Doi: 10.1089/g4h.2017.0036. 34. Nigg CR., Mateo DJ., An J. (2017). Pokémon GO May Increase Physical Activity and Decrease Sedentary Behaviors. Am J Public Health. 107 (1): 37–38. Doi: 10.2105/AJPH.2016.303532. 35. Wong FY. (2017). Influence of Pokémon Go on physical activity levels of university players: a cross-sectional study. Int J Health Geogr. 16 (1): 8. Doi: 10.1186/s12942-017-0080- 1. 36. Jankowska M., Haarhaus M., Qureshi A.R., Lindholm B., Evenepoel P., Stenvinkel P. (2017). Sclerostin─A Debutant on the Autosomal Dominant Polycystic Kidney Disease Scene? Kidney Int Rep. 2 (3): 81–485. Doi: 10.1016/j.ekir.2017.01.001. 37. Piotrowicz E., Piotrowicz R. (2013). Cardiac telerehabilitation: current situation and future challenges. Eur J Prev Cardiol. 20 (2): 12–16. Doi: 10.1177/2047487313487483c. 38. Weber-Nowakowska K., Gębska M., Myślak M., Żyżniewska-Banaszak E., Stecko M. (2017). Rola aktywności fizycznej w leczeniu pacjentów z przewlekłą chorobą nerek. Pomeranian J Life Sci. (63): 27–30. 39. Kong CH., Tattersall JE., Greenwood RN., Farrington K. (1999). The effect of exercise during haemodialysis on solute removal. Nephrol Dial Transplant. 14 (12): 2927– 2931. 40. Chung YC., Yeh ML., Liu YM. (2017). Effects of intradialytic exercise on the 17 physical function, depression and quality of life for haemodialysis patients: a systematic review and meta-analysis of randomised controlled trials. J Clin Nurs. 26 (13-14): 1801-1813. Doi: 10.1111/jocn.13514. 41. Mohseni R., Emami Zeydi A., Ilali E., Adib-Hajbaghery M., Makhlough A. (2013). The Effect of Intradialytic Aerobic Exercise on Dialysis Efficacy in Hemodialysis Patients: A Randomized Controlled Trial. Oman Med J. 28 (5): 345–349. Doi: 10.5001/omj.2013.99. 42. Anding K., Bär T., Trojniak-Hennig J., Kuchinke S., Krause R., Rost JM., et al. (2015). A structured exercise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence. BMJ open. 5 (8): e008709. Doi: 10.1136/bmjopen-2015-008709. 43. Manfredini F., Mallamaci F., D'Arrigo G., Baggetta R., Bolignano D., Torino C., et al. (2017). Exercise in Patients on Dialysis: A Multicenter, Randomized Clinical Trial. J Am Soc Nephrol. 28 (4): 1259–1268. Doi: 10.1681/ASN.2016030378. 44. Koh. KP., Fassett RG., Sharman JE., Coombes JS., Williams AD. (2010). Effect of intradialytic versus home-based aerobic exercise training on physical function and vascular parameters in hemodialysis patients: a randomized pilot study. Am J Kidney Dis. 55 (1): 88– 99. Doi: 10.1053/j.ajkd.2009.09.025. 45. Krause R. (2004). WGRR-European Working Group on Renal Rehabilitation and Exercise Physiology (affi liated to the ERA-EDTA), KfH-Kuratorium für Dialyse und Nierentransplantation e.V., Nephrological Centre BerlinMoabit: Nephrologists’ view on exercise training in chronic kidney disease (results of the questionnaire at the WCN 2003. Clin Nephrol. (61): 2–4. 46. Hornik B. Janusz-Jenczeń M., Włodarczyk I. (2017). Przestrzeganie zaleceń aktywności fizycznej przez chorych hemodializowanych. W: Dybińska E., Szpringer M., Asienkiewicz R.: Profilaktyka i edukacja zdrowotna. Wydawnictwo Naukowe Neurocentrum, Lublin. 109-122. ISBN: 978-83-61495-79-6.