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Towards Exercise As Part Of Routine Care For Chronic Kidney Disease

Towards Exercise As Part Of Routine Care For Chronic Kidney Disease. Jamie Macdonald School of Sport, Health and Exercise Sciences University of Wales, Bangor. Introduction.

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Towards Exercise As Part Of Routine Care For Chronic Kidney Disease

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  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@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@plinth2000.comwww.plinth.co.uk • The bike is a Monark Rehab Trainer 881E http://www.monarkexercise.se/ UK distributor Hampden Sports Ireland Tel +44 28 90 701 444hampden@visport.co.uk • You will need an adapter to fit the chair to the bike: Living Life Tel: +44 1248 717 500 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 Exercise: early referral is necessary Macdonald et al., unpublished observations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 Somewhat 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. Drop out rate 24% 17% 17% CKD stage 5: When to train? Konstantinidou E et al., J Rehabil Med, 2002

  14. 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 Compliance Carlson & Carey, Adv Ren Replace Ther, 1999; Durstine J et al., Sports Med, 2000

  15. Rikli & Jessie Jones, Human Kinetics, 2000 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. Unstable angina Resting BP > 200:110mmHg Symptomatic orthostatic BP drop of >20mmHg 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 (>2mm) Uncontrolled diabetes Severe orthopedic conditions Serum potassium > 6mmol/L Severe osteodystophy Severe peripheral or cardiac neuropathy Contraindications for exercise ACSM Guidelines, 7th Ed., 2006; Christian & Barnard, Appl Physiol, 2005; Furhmann & Krause, Clin Nephrol, 2004

  20. Contraindications for exercise: blood chemistry Evans & Forsyth, Phys Ther, 2004

  21. Monitoring pre, during and post exercise • RPE > 16 • Chest discomfort • Extreme shortness of breath • Dizziness • Fainting • Black outs • Cramping/burning in legs • Tingling in jaw or hand • BP • Systolic < 250 or decrease > 10mmHg; • Diastolic < 115mmHg

  22. NB for diabetes/cardiac rehab/hypertension Intensity = RPE < 13 (ACSM Guidelines, 7th Ed., 2006; Evans & Forsyth, Phys Ther, 2004) Diuretics/beta blockers Access Fistula Abdomen Intradialytic Exercise: other precautions Furhmann & Krause, Clin Nephrol, 2004; Daul et al. Clin Nephrol, 2004

  23. Abnormal hemodynamic responses GXT Glucose > 300 > 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 > 170 Diastolic > 105mmHg Timing Diabetes-precautions ACSM Guidelines, 7th Ed., 2006; American Diabetes Association, 1993; Evans & Forsyth, Phys Ther, 2004

  24. Recommended references • See accompanying notes page

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