Adherence to the Exercise Program in Patients with Chronic Kidney Disease Undergoing Haemodialysis at a Tertiary Care Hospital

Introduction

Chronic kidney disease (CKD) is recognized as one of the current health problems. It progresses to end-stage renal disease (ESRD) and cardiorespiratory disease, thus decreasing the quality of life and function.¹ There has been increased mortality rates in the patients diagnosed with CKD, with associated complications pertaining to diabetes, hypertension, mineral bone disorders. The cardiovascular risks related to ESRD have been well established and accounts to the mortality.² Deaths due to cardiovascular disease (CVD) among those on dialysis is found to have increased, thus showing a relationship between the renal disease and cardiovascular events. The mortality in ESRD with cardiovascular disease is higher when compared with the healthy individuals.³ The disease is found to be associated with greater health-related expenditures, and decreased health related quality of life (HRQoL). There has been a noted decrease in the functional status in patients with ESRD, setting a greater demand for activities of daily living (ADL).⁴ Patients with CKD are often overlooked when it comes to exercise programs.⁵ Physical inactivity also shows significant reduction in ADL and HRQoL.

Adherence is defined as “the extent to which a person’s behavior corresponds with agreed recommendations from a health care provider” and is considered to be an important prerequisite for the success of exercise programs for musculoskeletal disorders.⁶ Patients who adhere to regular exercise programs are less likely to be prone to recurrent musculoskeletal problems and it also aids in reducing the risk of illness. It promotes functional ability and may improve the quality of life.

Regular physical activity plays an important role in the prevention of chronic diseases. It can prevent and reduce the risk of complications of chronic diseases. Exercises and physical activity have been credited to improve the HRQoL in people with ischemic heart disease, hypertension, CKD and diabetes. By enhancing the strength of the muscles, bones, and joints through exercising, people with CKD can improve their balance and coordination. By increasing the physical activity levels of individuals with CKD, it is possible to decrease their risk of CVD and improve their physical functioning, thus preventing premature death.

Despite the benefits of exercise, patients are not exposed to the exercise regime during haemodialysis or at home. In spite of the decreased physical activity levels among the CKD, the prescription of exercise for CKD patients undergoing dialysis is relatively lower when compared with prescribed exercise for other chronic diseases. Moreover, exercise can improve the strength and aerobic capacity. Considering the noted benefits of physical activity, exercise must be considered as a major component of renal rehabilitation.⁷

Another notable factor to be considered in administering a resisted exercise programme for patients with CKD is evaluating the adherence to the exercise programme. Studies have shown that non-adherence can also be another remarkable factor which leads to faulty decision making by the physiotherapist on the outcome of the therapy. Adherence to exercise programme is enhanced by family support, goal setting and guidance from healthcare professionals, facilities to perform exercise, enjoyment and social interaction.⁸

The lack of awareness among the population and very few evident studies in Indian population can be attributed to the minimal use of the exercise guidelines for patients with CKD. Barriers to exercise during hemodialysis have been reported by the patients, staff and nephrologist, some of which can be modified.⁹ Some of the factors leading to lower participation by the haemodialysis patients are lack of motivation and time, frequent hospitalizations, the patient’s reluctance in understanding that exercise can alleviate the symptoms.^10,11 Thus, it is essential to check the adherence to exercise programme in the Indian population. This study is published as a pre-print with DOI: https://doi.org/10.21203/rs.3.rs-16160/v2 .

Materials and Methods

This observational study aimed to evaluate the adherence to exercise programme during dialysis and at home by patients diagnosed with CKD undergoing dialysis and to identify potential barriers to patient adherence. The study was a part of the interventional study which included a structured exercise program developed considering clinical practice guidelines for patients with CKD undergoing dialysis. The exercise program was tested through a pilot study and exercise modification was carried out substantially. Despite the benefits and acceptance by the patients, adherence by the patients to these exercises is low and there is a need to analyze this. The present study was conducted in a tertiary super speciality hospital in Mysore, India with full-fledged dialysis unit and physiotherapy department.

A total of 48 patients undergoing dialysis as outpatients in a tertiary hospital, willing to actively participate were recruited for the study using convenience sampling for a duration of three months. Written informed consent was obtained from the participants and verbal informed consent from the non-participants for their contribution to data recording at home. Ethical clearance from the institutional ethical committee of the medical college and hospital and permission from the hospital authorities was obtained prior to the commencement of the study.

Subjects diagnosed with Chronic Kidney Disease (CKD) undergoing haemodialysis as outpatients at a tertiary hospital were included. The patients underwent dialysis for three days in a week, on alternative days as outpatients. Most of the patients were accompanied by their spouse or relatives. The procedure was explained to the patient and the attendant. The importance of exercises was explained and consent was obtained for their participation. The recruited patients were screened for their participation in the exercise program and patients with history of recent fractures of extremities, neurologically unstable, psychologically unstable and cognitive impairment patients were excluded from the study.

The baseline outcome measures included the range of motion of all joints of both upper and lower limbs, strength of biceps, triceps, quadriceps, hamstrings, abductors and adductors of hip were checked by maximum repetition rate (MRR) testing using appropriate colored resistance bands. The exercises included in the intervention programme were warm up, stretching exercises, strengthening exercises for the upper limb and lower limb musculature using resistance bands of various resistance marked by its colors and aerobic exercises using pedo-cycle. The resistance color was selected based on the MRR. The duration of pedo cycle exercises were based on the heart rate monitored during dialysis, and the discomfort response by the patients. All these exercises were carried out during haemodialysis through a structured exercise protocol, which was tailored, based on the baseline evaluation.

A structured home exercise program (HEP) was prescribed and taught to the patients to be followed on the remaining five days of the week during the period they did not undergo dialysis. The HEP was administered with an exercise booklet, which had description of exercise parameters and diagrams. A patient diary was maintained by the treating physiotherapist including the details of the active days the patients underwent the exercise programme, as well as the number of days they performed the home exercise programme (HEP). At the end of three months, adherence to the exercise was evaluated through a standard questionnaire which contained observational checklist for adherence to exercise. The adherence to all the exercises taught during haemodialysis and at home was checked at every visit using patient diary. Adherence was enhanced by collective training with an encouraging environment adopted during the dialysis¹² and involved multiple measurements like attendance, intensity, and duration.¹³ In this study, the adherence to the exercise program was defined with respect to the attendance, the number of subjects who could cope and complete the study. The attendance was measured through percentile and the barriers were noted through statement of problems reported by the patient and their attenders.

Results

Forty-two patients undergoing dialysis as outpatients in the hospital consented to participate in the study, of which 35 were men and seven were women, with a mean age of 47 years (SD ±12) for men and 43 years (SD±11) for women. The patients’ progress data recorded in the formulated diary yielded the number of patients who adhered to the exercise programme during dialysis and at home. The adherence to exercise during haemodialysis is shown graphically in Figure 1. The exercise adherence percentile during first two weeks, both at dialysis and HEP was 100%, and after third week, both the exercise during haemodialysis and HEP showed a decline in terms of adherence. The HEP showed a drastic decline from 100% to 67% in the fifth week (Figure 2). At the end of 12 weeks, 52% adhered to exercises during dialysis and 48% adhered with HEP. The questionnaire analysis revealed lack of interest and decreased motivation among the participants, including other reasons such as hospitalization, surgeries and feeling sick.

Discussion

The present study aimed to analyze if the patients undergoing dialysis as outpatients were performing the prescribed exercise programme during dialysis as well as at home, as HEP. As evident from the results, only 52% of the patients who enrolled for the study completed the prescribed set of exercises to be done during dialysis as well as at home as HEP. Nearly half the patients (48%) did not adhere to the exercise programme for the entire duration of three months, and there was a drastic decline in adherence to both the HEP as well as during dialysis and only 48% performed the HEP for the entire period of three months. The study conducted on adherence by A. Williams' et al., reported that patients on dialysis for less than two years showed higher adherence rates compared to those who underwent dialysis for more than six years. The reasons stated were feeling sick, hospitalizations, surgeries and decrease in motivation. In the present study, majority of the patients reported lack of motivation to perform the exercises on a regular basis. It could be stated that due to hospitalizations and sickly feeling, despite assisted help in the hospital, the participants in this study reported lack of interest to perform the exercise. This could also be one of the many reasons for the decreased motivation to adhere to home exercise program. Adherence to the exercise regimen, both HEP and during dialysis was 52% and 48%, respectively, indicating that adherence to the exercises by patients with CKD was average. This poor compliance was observed even though there was reduced muscle strength, poor endurance, contributing to decrease in quality of life with increased morbidity and mortality rates in patients undergoing dialysis. Therefore, it is imperative to take appropriate measures to increase motivation levels in patients undergoing dialysis to perform exercises on a regular basis, both during dialysis and as HEP. This can ameliorate the quality of life by improving strength and endurance, thereby improving flexibility and reducing dependence; thus the mortality and morbidity rates among patients with CKD can be lowered. Exercise prescription to CKD patients should be examined with motivational factor taken into consideration. A special care to include counseling on exercise is needed to improve the adherence rate.

Conclusion

Adherence to exercise during dialysis and to HEP was 52% and 48%, respectively, indicating moderate adherence to exercises by patients with CKD. The study concludes that the factors having an impact on adherence must be addressed as a multidisciplinary team. The lower rates of adherence to exercise may be an indicator to plan appropriate and safe exercise interventions to improve patient’s quality of life. It is essential to consider the patients’ adherence while prescribing any new exercise programs in patients undergoing dialysis.

Declarations

Ethics approval and consent to participate

The project “role of exercise on fatigue in patients undergoing haemodialysis as outpatients in a tertiary hospital” has been cleared and approved by the Institutional Ethical Committee of JSS Medical College, JSSAHER, formerly and JSS University, with reference no 29/2007/2017-18.

Please Note: This study is a part of the project titled as given above.

Competing interests

The author(s) declare(s) that they have no competing interests

Funding & Acknowledgements

This study is a part of the main study funded by Rajiv Gandhi University of Health Sciences, Bangalore, India.

Conflict of Interest

None