THERAPY-Magazin
Sports therapy during dialysis
Discover how professionally guided exercise during haemodialysis improves endurance, muscle strength, and quality of life in patients with kidney failure. Learn about session structure, safety, and training benefits.
Lars Timm
International Sales Account Manager, THERA-Trainer
Increasing the physical performance of patients with end-stage renal disease during haemodialysis
End-stage renal disease (ESRD) is almost always accompanied by a reduction in physical performance in affected patients, which inevitably leads to restrictions in everyday life. Anaemia, acidosis, glucose transport disorders, hyperkalaemia, polyneuropathy and osteopathy are mentioned in the literature as the most important performance-reducing factors [3]. In direct comparison with people of the same age without kidney disease, the activity level of haemodialysis patients (HDPs) is reduced by about 35% [7]. According to Gomes et al. 2015, not even 21% of HDPs reach the WHO-recommended minimum activity level of 10,000 steps per day. The reasons for this are varied and range from fatigue to a lack of exercise opportunities [5].
Worldwide scientific studies have already shown that physical training in HDPs has a significant positive effect on performance, quality of life and social life [6]. These effects can be observed in all performance classes, but the effect is even more significant in severely debilitated patients than in HDPs with good physical performance [1]. As HDPs are confined to the treatment chair or bed for up to 1,000 hours a year, physical training during dialysis is the optimal solution for improving performance in a time-efficient and effective way.
Nevertheless, a survey from 2017 shows that about 2/3 of dialysis facilities do not yet offer sports therapy training programmes during dialysis, even though 70% of the patients would gladly make use of such an offer. The reasons for the lack of such an offer range from a lack of space in the facilities and funding problems to scepticism among staff towards the training intervention [8]. However, a structured, professionally guided sports therapy intervention is safe even for severely affected patients and the benefits far outweigh the risks. But how can a training session like this be methodically structured and implemented?
Worldwide scientific studies have already shown that physical training in HDPs has a significant positive effect on performance, quality of life and social life [6]. These effects can be observed in all performance classes, but the effect is even more significant in severely debilitated patients than in HDPs with good physical performance [1]. As HDPs are confined to the treatment chair or bed for up to 1,000 hours a year, physical training during dialysis is the optimal solution for improving performance in a time-efficient and effective way.
Nevertheless, a survey from 2017 shows that about 2/3 of dialysis facilities do not yet offer sports therapy training programmes during dialysis, even though 70% of the patients would gladly make use of such an offer. The reasons for the lack of such an offer range from a lack of space in the facilities and funding problems to scepticism among staff towards the training intervention [8]. However, a structured, professionally guided sports therapy intervention is safe even for severely affected patients and the benefits far outweigh the risks. But how can a training session like this be methodically structured and implemented?
Methodical structure of a sports therapy training session for HDPs
This kind of training intervention is always essentially divided into 3 phases. The shunt arm must never be under load during any of these phases.
This kind of training intervention is always essentially divided into 3 phases. The shunt arm must never be under load during any of these phases.
Warm-up phase:
Any training intervention, whether for healthy or impaired individuals, should always start with a warm-up programme. Tasks to improve mobility are particularly suitable for this, in order to mobilise the joints and prepare the body for the physical strain ahead. Mobilisation must include all parts of the body, with special attention paid to spinal mobility. Correct instruction and execution are essential for the positive effect of these exercises. Jerky and bouncy movements should be avoided.
Any training intervention, whether for healthy or impaired individuals, should always start with a warm-up programme. Tasks to improve mobility are particularly suitable for this, in order to mobilise the joints and prepare the body for the physical strain ahead. Mobilisation must include all parts of the body, with special attention paid to spinal mobility. Correct instruction and execution are essential for the positive effect of these exercises. Jerky and bouncy movements should be avoided.
Worldwide scientific studies have already shown that physical training in haemodialysis patients has a significant positive effect on performance, quality of life and social life.
Main phase:
Mobilisation of the joints should be complemented by dynamic stretching of the fascial connective tissue structures. Coordination ability, which is often impaired, should also be promoted through targeted exercises. The focus of strength training should be on leg strength, but for a balanced development of the total body musculature, strengthening exercises for the trunk and upper extremities must also be considered. During the strengthening exercises, it is imperative to pay attention to physiological posture in order to prevent injuries. Bed ergometers should be used for vital endurance training. The passive function of these training devices enables even very weak patients to participate in the training programme.
Mobilisation of the joints should be complemented by dynamic stretching of the fascial connective tissue structures. Coordination ability, which is often impaired, should also be promoted through targeted exercises. The focus of strength training should be on leg strength, but for a balanced development of the total body musculature, strengthening exercises for the trunk and upper extremities must also be considered. During the strengthening exercises, it is imperative to pay attention to physiological posture in order to prevent injuries. Bed ergometers should be used for vital endurance training. The passive function of these training devices enables even very weak patients to participate in the training programme.
Bed ergometers should be used for vital endurance training. The passive function of these training devices enables even very weak patients to participate in the training programme.
Cool-down phase:
The training session ends with relaxation and breathing exercises, which have a calming effect on the patient to prevent muscle tension. Through mindfulness exercises, the body can be consciously perceived, which leads to improvements in wellbeing [4].
The training session ends with relaxation and breathing exercises, which have a calming effect on the patient to prevent muscle tension. Through mindfulness exercises, the body can be consciously perceived, which leads to improvements in wellbeing [4].
When and how often should training take place?
To ensure a high effectiveness of training, it should be carried out regularly and over a longer period of time. Two to three training sessions per week are recommended for HDPs, each during the first 3 hours of dialysis treatment. In this early period of treatment, dehydration is not yet so far advanced, while potassium values have already normalised and hyperacidity is partially balanced. As a general rule, patients should train regularly at medium load rather than infrequently at high load.
To ensure a high effectiveness of training, it should be carried out regularly and over a longer period of time. Two to three training sessions per week are recommended for HDPs, each during the first 3 hours of dialysis treatment. In this early period of treatment, dehydration is not yet so far advanced, while potassium values have already normalised and hyperacidity is partially balanced. As a general rule, patients should train regularly at medium load rather than infrequently at high load.
Load control:
Optimal load control is essential, especially for HDPs, as both an overload and underload should be avoided at all costs. Both subjective and objective parameters can be used to control loads.
The RPE scale (also known as the Borg scale) is often used for subjective training control [2]. Here, the patient describes the subjectively perceived degree of exertion during the training. However, this self-perception can be impaired or flawed, especially in inexperienced patients. This potential source of error can be avoided by carefully introducing the patient to this control tool. The patient learns how to correctly assess the load through different exercises. During the main phase of the training session, exertion should be perceived as “somewhat strenuous”, during the warm-up and cool-down phases the exertion should be in the “very light” range. Due to the susceptibility to error in self-assessment, care staff should also regularly check for possible signs of overload (compressed breathing, pallor around mouth and nose).
Optimal load control is essential, especially for HDPs, as both an overload and underload should be avoided at all costs. Both subjective and objective parameters can be used to control loads.
The RPE scale (also known as the Borg scale) is often used for subjective training control [2]. Here, the patient describes the subjectively perceived degree of exertion during the training. However, this self-perception can be impaired or flawed, especially in inexperienced patients. This potential source of error can be avoided by carefully introducing the patient to this control tool. The patient learns how to correctly assess the load through different exercises. During the main phase of the training session, exertion should be perceived as “somewhat strenuous”, during the warm-up and cool-down phases the exertion should be in the “very light” range. Due to the susceptibility to error in self-assessment, care staff should also regularly check for possible signs of overload (compressed breathing, pallor around mouth and nose).
To ensure a high effectiveness of training, it should be carried out regularly and over a longer period of time.
The load is controlled objectively mostly by measuring the heart rate. A stress test on the bicycle ergometer can be used to make accurate predictions about exercise level and heart rate. If such a test is not possible for medical or logistical reasons, a stress test can also be performed with the bed ergometer, whereby the load is relativised using the Borg scale. The test should be stopped at a load of “Borg 15-16”. The training pulse is then calculated using the Karvonen formula. Recommendations on training pulse rate based solely on formulas are not recommended due to the high level of heart rate variability and the associated susceptibility to error.
How can the training be increased?
At the beginning of training, significant increases in performance can be achieved even at low load. In order to be able to constantly guarantee the optimal load level, the training intensity must be constantly adjusted. Especially in patients with hypertension, high-intensity training should be avoided. The load should be increased very cautiously and initially adjusted by volume and not by higher exercise intensity. Sufficient recovery phases should also be ensured.
At the beginning of training, significant increases in performance can be achieved even at low load. In order to be able to constantly guarantee the optimal load level, the training intensity must be constantly adjusted. Especially in patients with hypertension, high-intensity training should be avoided. The load should be increased very cautiously and initially adjusted by volume and not by higher exercise intensity. Sufficient recovery phases should also be ensured.
Endurance training:
-Increasing training time
-Increasing training frequency
-Increasing training intensity
Strength training:
-Increasing number of repetitions
-Increasing number of sets
-Increasing intensity
-Increasing training time
-Increasing training frequency
-Increasing training intensity
Strength training:
-Increasing number of repetitions
-Increasing number of sets
-Increasing intensity
Contraindications:
Before any sports therapy intervention, a detailed discussion must take place with the attending physician in order to define the training goals and exclude possible contraindications. As part of this examination, a stress test can often also be carried out for load control. The most common contraindications are (Fuhrmann 2016):
-Resting blood pressure above 180/100 mmHg
-Severe heart failure
-Non-treatable cardiac arrhythmias
-Serum potassium <3.5 or >6.5 mmol/l
-Neg. base excess <5mmol/l
-Central venous temporary rigid dialysis catheters
Before any sports therapy intervention, a detailed discussion must take place with the attending physician in order to define the training goals and exclude possible contraindications. As part of this examination, a stress test can often also be carried out for load control. The most common contraindications are (Fuhrmann 2016):
-Resting blood pressure above 180/100 mmHg
-Severe heart failure
-Non-treatable cardiac arrhythmias
-Serum potassium <3.5 or >6.5 mmol/l
-Neg. base excess <5mmol/l
-Central venous temporary rigid dialysis catheters
Any training intervention, whether for healthy or impaired individuals, should always start with a warm-up programme.
Conclusion:
When it comes to professionally conducted sports therapy training during dialysis, the positive effects far outweigh the risks.
So the message to facilities is to get started!
With trained staff and the appropriate training equipment, patients can benefit significantly from the training sessions and their positive effects with a little extra effort.
Many ready-made training plans are already available for structured training and do not have to be devised from scratch.
When it comes to professionally conducted sports therapy training during dialysis, the positive effects far outweigh the risks.
So the message to facilities is to get started!
With trained staff and the appropriate training equipment, patients can benefit significantly from the training sessions and their positive effects with a little extra effort.
Many ready-made training plans are already available for structured training and do not have to be devised from scratch.
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Cycling
Dialyse Trainings-Therapie
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THERAPY 2023-II
THERAPY Magazine
Lars Timm
International Sales Account Manager, THERA-Trainer
Lars Timm studied Sports
Science with a focus on
rehabilitation in Freiburg i.Br.
and M.Sc. Sports Engineering
at KIT Karlsruhe.
References:
- Anding, Kirsten; Bär, Thomas; Trojniak-Hennig, Joanna; Kuchinke, Simone; Krause, Rolfdieter; Rost, Jan M.; Halle, Martin (2015): A structured exercise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence. In: BMJ open 5 (8), e008709. DOI: 10.1136/bmjopen-2015-008709.
- Borg, G. A. (1982): Psychophysical bases of perceived exertion. In: Medicine and science in sports and exercise 14 (5), S. 377–381.
- Daul, A. E. (2011): Körperliches Training und Dialyse. In: Nephrologe 6 (6), S. 537–547. DOI: 10.1007/s11560-011-0574-y.
- Fuhrmann, I.; Degenhardt, S.; Anding-Rost, K.; Krause, R.: Strukturiertes Training während der Hämodialyse. In: ReNi 2016.
- Gomes, Edimar Pedrosa; Reboredo, Maycon Moura; Carvalho, Erich Vidal; Teixeira, Daniel Rodrigues; Carvalho, Laís Fernanda Caldi d‘Ornellas; Filho, Gilberto Francisco Ferreira et al. (2015): Physical Activity in Hemodialysis Patients Measured by Triaxial Accelerometer. In: BioMed research international 2015, S. 645645. DOI: 10.1155/2015/645645.
- Gomes, Edimar Pedrosa; Reboredo, Maycon Moura; Carvalho, Erich Vidal; Teixeira, Daniel Rodrigues; Carvalho, Laís Fernanda Caldi d‘Ornellas; Filho, Gilberto Francisco Ferreira et al. (2015): Physical Activity in Hemodialysis Patients Measured by Triaxial Accelerometer. In: BioMed research international 2015, S. 645645. DOI: 10.1155/2015/645645.
- Johansen, K. L.; Chertow, G. M.; Ng, A. V.; Mulligan, K.; Carey, S.; Schoenfeld, P. Y.; Kent-Braun, J. A. (2000): Physical activity levels in patients on hemodialysis and healthy sedentary controls. In: Kidney international 57 (6), S. 2564–2570. DOI: 10.1046/j.1523-1755.2000.00116.x.
- Ohnhäuser, T.; Schloten, N. (2017): Multidimensionale Analyse der Ursachen für die niedrige Prävalenz der ambulanten Peritonealdialyse in Deutschland. Ergebnisbericht. Universität zu Köln.
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