Towards Exercise As Part Of Routine Care For Chronic Kidney Disease

1
Towards Exercise As Part Of Routine Care For
Chronic Kidney Disease

• Jamie Macdonald
• School of Sport, Health and Exercise Sciences
• University of Wales, Bangor

2
Introduction

• These slides are designed to form a resource to
  help in setting up exercise in your dialysis
  unit. Please also read the notes pages
  accompanying the slides. Stars () denote
  particular caution is required.
• These slides are not recommended guidelines or
  advice- they simply highlight some issues that
  you may need to address if setting up an exercise
  program.
• Please remember patient safety is your
  responsibility and I accept no responsibility as
  a consequence of you using this advice.
  Furthermore, views or opinions expressed in these
  slides are solely mine and do not represent those
  of the University of Wales, Bangor the Renal
  Association/British Renal Society or any
  particular NHS trust.
• Any comments or additional information would be
  greatly received.
• Jamie Macdonald (j.h.macdonald_at_bangor.ac.uk)

3
Equipment for intradialytic exercise

• Option 1 (see picture on next slide, roughly
  1000)
• The chairs we used are made by Plinth 2000. Tel
  44 1449 767887 sales_at_plinth2000.com
  www.plinth.co.uk
• The bike is a Monark Rehab Trainer 881E
• http//www.monarkexercise.se/
• UK distributor
• Hampden Sports Ireland
• Tel [phone] hampden_at_visport.co.uk
• You will need an adapter to fit the chair to the
  bike
• Living Life Tel [phone]
• http//www.byw-bywyd.co.uk/enq_cu.html

4
Equipment for intradialytic exercise
Macdonald J et al., Clin Physiol Funct Imaging,
2005
5
Exercise intervention goals in CKD
Accessible safe/effective enjoyable early
referral
6
Exercise early referral is necessary
Macdonald et al., unpublished observations
7
Exercise prescription
8
Setting exercise intensity
6 No exertion at all 7 Extremely
light 8 9 Very Light 10 11 Light 12 13 Som
ewhat hard 14 15 Hard (heavy) 16 17 Very
hard 18 19 Extremely hard 20 Maximal
exertion

• Rating of perceived exertion (Borg, 1998)
• Heart rate reserve method
• Target (HRmax HRrest x intensity) HRrest

9
CKD stage 1-5 cardiovascular exercise

• Mode walking, cycling, swimming, low level
  aerobics, stepping
• Frequency 3 days/week
• Intensity 50-70 HRreserve, RPE 12 15
• Duration build up to 30min
• Progression
• Increase duration then intensity
• (Koufaki P et al., Clin Physiol Funct Imaging,
  2002)

Adapted from Ehrman et al., Human Kinetics, 2003
Kouidi E et al., Artif Organs, 2002
10
CKD stage 1-5 strengthening exercise?

• Mode Theraband, very low level hand/ankle
  weights
• Intensity 40-60 1RM
• Frequency 2 3 days/week
• Sets 3 sets for major muscle groups
• Reps 12 15
• Progression 1 set of 12 reps, increase gradually
  (1-2lb week)

Adapted from Ehrman et al., Human Kinetics, 2003
Volker K et al., Clin Nephrol, 2004
11
CKD stage 1-5 strengthening exercise an
alternative

• NB uncontrolled diabetes/hypertension
• Mode PRT machines
• Intensity 80 1RM, RPE 15 - 17
• Frequency 2 3 days/week
• Sets 3 sets for major muscle groups
• Reps 8
• Progression Reassess 1 RM regularly

Castaneda C et al., Ann Intern Med, 2001 Headley
et al., Am J Kidney Dis, 2002 Cheema B et al., J
Aging Phys Act, 2004 abstract Mercer et al.,
Cachexia, 2005 abstract
12
Flexibility

• Every day
• After warmed up
• 2 4 stretches per muscle group
• Static, unassisted (do not bounce or use PNF)
• Push till feel tightness, not pain
• Yoga, Tai Chi?

13
CKD stage 5 When to train?
Konstantinidou E et al., J Rehabil Med, 2002
14
Compliance

• Support
• Doctors nurses
• Family/friends
• Facilities
• Enjoyment
• Minimize injury
• Varied enjoyable program
• Group participation?
• Games

• Regularly organised
• Monitor progress
• Fitness tests
• Progress charts
• Goals
• Rewards

Carlson Carey, Adv Ren Replace Ther, 1999
Durstine J et al., Sports Med, 2000
15
Monitoring progress functional capacity
16
Monitoring progress body composition
Macdonald et al., Nephrol Dial Transplant, In
Submission
17
Risks
Adapted from Franklin et al. Chest 1998
18
Safety screening

• Standard physiological exam GXT
• Cardiovascular
• Respiratory
• Muscular system
• Neurological exam
• Stable condition
• Anaemia
• Fluid
• Monthly bloods

ACSM Guidelines, 7th Ed., 2006
19
Contraindications for exercise

• Unstable angina
• Resting BP gt 200110mmHg
• Symptomatic orthostatic BP drop of gt20mmHg
• Critical aortic stenosis
• Acute systemic illness
• Uncontrolled dysrhythmias or tachycardia
• Congestive heart failure
• 3 degree AV block

• Active peri / myo carditis
• Recent embolism
• Thrombophlebitis
• Resting ST segment displacement (gt2mm)
• Uncontrolled diabetes
• Severe orthopedic conditions
• Serum potassium gt 6mmol/L
• Severe osteodystophy
• Severe peripheral or cardiac neuropathy

ACSM Guidelines, 7th Ed., 2006 Christian
Barnard, Appl Physiol, 2005 Furhmann Krause,
Clin Nephrol, 2004
20
Contraindications for exercise blood chemistry
Hb (g/dL) lt 8
Hct () lt 25
Glucose (mg/dL) gt 300 gt 240 with ketosis
Potassium (mEq/L) lt 3.2 gt5.1
White blood cells (cells/mm3) lt 5,000 with fever
Platelets (cells/mm3) lt20,000
Evans Forsyth, Phys Ther, 2004
21
Monitoring pre, during and post exercise

• RPE gt 16
• Chest discomfort
• Extreme shortness of breath
• Dizziness
• Fainting
• Black outs
• Cramping/burning in legs
• Tingling in jaw or hand
• BP
• Systolic lt 250 or decrease gt 10mmHg
• Diastolic lt 115mmHg

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Exercise other precautions

• NB for diabetes/cardiac rehab/hypertension
• Intensity RPE lt 13 (ACSM Guidelines, 7th Ed.,
  2006 Evans Forsyth, Phys Ther, 2004)
• Diuretics/beta blockers
• Access
• Fistula
• Abdomen
• Intradialytic

Furhmann Krause, Clin Nephrol, 2004 Daul et
al. Clin Nephrol, 2004
23
Diabetes-precautions

• Abnormal hemodynamic responses
• GXT
• Glucose
• gt 300
• gt 240mg/dL with ketosis
• Monitoring pre 4-6hrs post exercise
• Careful foot care
• Insulin / oral hypoglycaemic agents requirements
• Adequate hydration

• Avoid hot/cold environments
• Identify as diabetic
• Peripheral neuropathy / lower extremity vascular
  disease
• Avoid high impact activities
• Retinopathy / CV complications
• No PRT
• Correct techniques/Valsava
• BP
• Systolic gt 170
• Diastolic gt 105mmHg
• Timing

ACSM Guidelines, 7th Ed., 2006 American Diabetes
Association, 1993 Evans Forsyth, Phys Ther,
2004
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Recommended references

• See accompanying notes page