20944 exercise hcp book:20944 exercise hcp book...can be made. when a patient’s understanding of...

Exercise programme

I N F O R M AT I O N F O R H E A LT H C A R E

P R O F E S S I O N A L S

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Contents PageSection 1. Acknowledgements 2

Section 2. Message from ANSA 3

Section 3. Foreword 4

Section 4. IntroductionIntroduction 5

– Disclaimer 5

Section 5. How to use 6

Section 6. Key messagesKey messages 10

Section 7. Why and WhoWhy your patients should exercise 11What exercises should your patients do? 13Who can exercise? 13Assessment and categorisation of patient’s physical capacity 14

Section 8. Components neededComponents needed to start an exercise programme 15

– 1. Staff support and education 15– 2. Motivating patients 15– 3. Ensure that exercise is safe 15– 4. Footwear and clothing 16– 5. Exercising safely 16

Tips for succeeding 16– Managing expectations 16– Commitment 17

Section 9. PlanningPlanning for an exercise programme 18Do’s and don’ts 19

Section 10. Monitoring progressMonitoring progress 20

– Using the Exercise Diary 20– The DASI patient questionnaire and sit-to-stand assessment 21– The DASI score sheet 22– The Exercise on Dialysis 4-week progress chart 23

Section 11. Exercise on dialysisExercises to carry out on dialysis 24

Section 12. Exercise off dialysisExercises to carry out away from dialysis 26References 30Further information 31

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Roche would like to thank the following contributors who have kindly offered their expertise in developing this programme:

Authors Clinical ContentNatasha McIntyreRGN, MSc PGDip HCE

Dr Patrick NaishConsultant Nephrologist Chair, Renal Association Exercise Group

Chiew H. Kong PhD, SRN.Clinical Scientist, Renal Unit, Lister Hospital, Stevenage

Pelagia Koufaki PhD.Lecturer, University of Stirling, Scotland

Sharleen Cook, BSc (Hons)Physiotherapist, King College Hospital, London

Roche would like to thank the Advisory Board Members:-

Advisory Board MembersTimothy F Statham OBE, Chief Executive, National Kidney FederationMarion Higgins, Patient RepresentativeMichael Scott, Patient RepresentativeChris Payne, Patient Representative

Carol Anderson, Advanced Kidney Care Manager; Belinda Dring, Anaemia and Predialysis Nurse Specialist; Lynn Fullerton,Anaemia Nurse Specialist; Helen Hurst, Advanced Nurse Practitioner; Catherine Johnson, Anaemia and Predialysis Sister;Jane Macdonald, Lead Nurse, Renal Services; Kate Taylor, Practice Development Lead; Jackie Waller, Anaemia Co-ordinator;Gillian Wood, Anaemia Co-ordinator

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DisclaimerYou should ensure that patients have consulted their doctor before attempting any of the exercises outlined inthis programme. As with any exercise programme, patients should stop immediately if they feel faint, dizzy,unwell or experience chest pain and they should contact their doctor or a nurse.


Message from ANSA

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Message from ANSAThe Renal team faces constant challenges in the 21st century; demands on our time have never been higher. In an increasingly busy NHS, there is often an overwhelming feeling that we are all working to our capacity. Patient volume continues to increase, dialysis facilities are overstretched, survival rates improve and early diagnosis means that nephrology nurses’ responsibilities are extended even further.

With few exceptions, the more information and preparation provided to our patients, the better they are able toadjust to changes in lifestyle imposed by renal replacement therapies. However the NHS Institute has found thatnurses in acute settings spend an average of only 40% of their time on direct patient care. The challenge is toreverse this trend, to release time from unnecessary activities and reinvest this in direct care and education.

ANSA supports time, a patient education programme developed by patients and healthcare professionals incollaboration with Roche which provides us with an opportunity to inform motivate and empower our patients, at a pace that suits the individual and environment which in turn has the potential to positively impact on outcomes.

Catherine JohnsonPresidentAnaemia Specialist Nurse Association

www.anaemianurse.orgHelpline: 01483 724472


Foreword

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Foreword Muscle wasting and weakness are almost universal in the renal failure population. Their effects are compounded by the average age of patients being taken onto dialysis (approximately 65 years), comorbidity, particularlycardiovascular and diabetic, and the de-conditioning effects of chronic disease and hospitalisation. These problemssignificantly impair the capacity to undertake activities of daily living and to remain living independently.

There is much evidence to suggest that rehabilitation interventions in the dialysis and CKD populations areassociated with improvements in physical functioning and strength. Despite this, there are very few programmes of routine rehabilitation for renal failure patients in the UK.

The exercise component of the time programme is aimed at informing and empowering the multi-disciplinary renalcare team and their patients to regard physical rehabilitation as an integral part of the routine treatment packagefor all people with renal failure. It provides the means for the care team to raise awareness and to initiate a simpleprogramme of exercises to improve flexibility, balance and muscle strength that is applicable to CKD, peritoneal and haemodialysis patients. Examples of formal and individually defined assessments of the effects of increasedphysical activity are given. A series of training days is planned to provide detailed advice and practical guidance tosupport this written material, and help its implementation.

Dr Patrick Naish, Consultant NephrologistChair, Renal Association Exercise Group

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Introduction

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IntroductionThis programme is designed to enable you to introduce a low intensity exercise programme into your unit that can be easily used by the majority of dialysis patients. Research suggests that lower intensity programmes of exercise are sustainable for a larger number of patients. However there are other, more specific benefits withusing a higher intensity programme, which may require more specialist equipment, knowledgeand assessment.

This resource contains materials to motivate and encourage your patients to take part in low-intensity exercise,both during and after dialysis therapy. Most of the activities require just a few minutes of your time, although youcan of course spend longer talking to patients about these if you are able to. Patients can then be provided withmaterials to read in the unit and other materials to take home.

This manual should provide you with all the background information you might require in order to successfully run the scheme in your unit. It is not designed to provide guidance for running a more specialist, higher intensityexercise programme.

If you have successfully used this programme and want to introduce a higher intensity programme theninformation can be found by contacting your physiotherapy unit. For further advice you can also contact thechairman of the Renal Association Exercise Group, Dr Patrick Naish via the Renal Association website,www.renal.org.

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DisclaimerYou should ensure that patients have consulted their doctor before attempting any ofthe exercises outlined in this programme. As with any exercise programme, patientsshould stop immediately if they feel faint, dizzy, unwell or experience chest pain andthey should contact their doctor or a nurse.


How to use

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How to use

About timeThe time programme is an initiative created to help empower renal patients and healthcare professionals, with the aim of improving patient care and strengthening the relationship that patients have with staff. To this end,t.i.m.e. stands for Time to Inform, Motivate and Empower. The title and concept of time has been chosen to represent this educational initiative for its ability to portray the idea that with a little time and focus, great gainscan be made.

When a patient’s understanding of their condition and their treatment is improved, there is increased satisfaction,empowerment and ultimately health outcomes. This greater patient understanding is what the time programmeseeks to achieve by offering an integrated education campaign involving patients and healthcare professionalsalike.

time is designed to be systematically implemented in the renal unit and, once in place, key messages can beeffectively delivered using 3 minute blocks of time. This is important as, in today’s busy renal unit, time is at apremium, and this programme is built on the premise that if small efficiencies were made in the way that staffcarry out care, these 3 minute blocks of time could be freed up and utilised to improve the care for patients.

Developed in conjunction with healthcare professionals and patient representatives, the time programmecomprises resources that can be used by the individual renal unit to create their own targeted education campaign delivering consistent, clear and useful messages for renal patients.

time exercise programmeThe time exercise programme has been developed to highlight the benefits that physical activity affords to peoplewith kidney disease, and guide them through an appropriate exercise regimen. The materials described below willhelp you develop an exercise education programme in your renal unit.

The following guide shows briefly what materials are included in the exercise programme and how they may beused. Not all materials are designed to be used with every patient. Rather, a range of materials has been developedto help meet the needs of individuals.

PostersThe education programme begins the minute a patient walks into the unit. These three posters are displayed in areas such as the waiting room to raise awareness about the benefits of exercise. The posters could be rotated to maintain interest (for example a different one for each month). They are specifically designed not to provide all information, but to initiate thoughts and comments, leading to dialogue with the healthcare professional.

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FlashcardsThe key messages in the exercise programme are communicated via flashcards.

They are designed to give clear and consistent messages in a short space of time. In addition to a key message, each flashcard shows a frequently asked question,

the answer to which is revealed on the back of the card. Patients can either read theflashcards themselves, or nurses can use them as a prompt during discussion. Ideally

they could be placed in a prominent position on the ward so that patients and staff can easily access them. Theyalso have a wipeable surface.

Patient information manual This contains detailed information for those patients who wish to read more. The manual outlines suggested exercises for patients to carry out both on and off dialysis. The information guides are designed to be kept on the unit for patients to read whilst having treatment.

Healthcare professional information manual This guide contains, and elaborates on, the information presented in the PatientInformation Manual. It may be used by staff interested to read more about exercise forrenal patients and/or for general staff training. This guide is also designed to explain inmore detail how and when patients should use the exercise programme, and how to use the monitoring tools.

Exercise on dialysis cardThe exercise on dialysis card is designed to be available at each dialysis station. It is double sided and demonstrates how to do seven simple exercises whilst patients are on dialysis. The exercises should initially be demonstrated by a healthcare professional, and the card is designed as a prompt so that the patient can initiate safe exercise on their own. The card also gives handy hints about when and how to exercise, and how to build an exercise programme.

Exercising on dialysis progress chartThe exercising on dialysis progress chart is designed to record progress of patients who choose to exercise whilst on dialysis, should staff or the patient wish to monitor this. There is space on the sheet to monitor progress for each of the seven exercises, including how many were done and the exertion used (see the Rate of Perceived Exertion scale below). Each sheet is designed to be

filled out over a period of 4 weeks, and it is recommended that exercise regimens be reviewedbetween nurse and patient at this interval.

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Exercise diaryThe exercise diary contains a guide to the recommended exercises in the programme and is designed to be given to a patient in order to help them carry out exercises at home. At the back of the diary, patients are encouraged to monitor their progress by setting personal goals (e.g. aiming to climb their stairs at home or walk around the block). Alternatively, the patient may choose a more structured approach using the Duke Activity Status Index (DASI) (see below) with the ‘sit-to-stand’ assessment (see the Monitoring Progress section of this manual).

The DASI patient questionnaire and score sheet The DASI (Duke Activity Status Index) is a scale to measure a patient’s functional capacityand is currently used in a range of clinical settings. It consists of 12 ‘yes or no’ questionson activities of daily living that the patient can fill out easily. The questionnaire is thenassessed by staff using the score sheet to generate a DASI score which can be recordedin the back of the patient’s exercise diary. This monitoring can be a helpful motivator forpatients and/or used as a simple early warning for deterioration that may need socialwork involvement.

The rate of perceived exertion scale (RPE)Used throughout the materials in the time exercise programme, this scale monitors how much exertion the patient feels they are using to complete an exercise or activity. Ideally, for exercise training to be effective, levels of exertion should be between the values of 12-16 on the scale.

Ankle weights The ankle weights are for patients to use when performing the exercises on or offdialysis as demonstrated in the programme. These come in two weights, 0.5 kgand 1 kg. The exercise on dialysis card shows how patients can use these toincrease resistance as their strength improves. The weights should be given toindividuals for their own use and not shared between patients, to reduce any riskof infection.

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Round Britain walk and pedometers The Round Britain Walk can be used a fun way to ‘kick start’ interest in exerciseparticipation. It is a challenge based around a poster of Britain showing avirtual walking route which has been divided into sections. Teams orindividuals then use pedometers to accrue steps which are converted tomiles and plotted on the Round Britain map each week. Once a patient (or unit) has reached a walking milestone, they can collect a certificate and postcard from the corresponding destination on the Round BritainWalk map. Certificates and postcards are provided as part of theprogramme to be given out by unit staff as appropriate.

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Key messages

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Key messagesThe key messages that you should aim to convey to your patients when discussing the importance of exercise are:

1. Regular exercise can improve their ability to increase their daily life activities2. Regular exercise can help them to maintain or improve their independence3. Regular exercise can improve mood and decrease anxiety and depression4. Regular exercise can help to improve heart function, health and build basic muscular strength5. Most people on any form of dialysis can do some form of exercise6. Side effects of exercise in dialysis patients are very rare7. Exercise can be done whilst on or away from dialysis8. They should aim to exercise at least three times a week, building up from small amounts of time towards at least

30 minutes at each session9. Seeing small improvements can help motivation10. Setting realistic goals is key11. Exercise whilst on haemodialysis may help to improve their dialysis adequacy

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Why and Who

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Why your patients should exerciseResearch has shown that exercise is beneficial to dialysis patients in a number of ways.

• Increased independence• Elderly patients on dialysis have 50% less functional ability than healthy age-matched

controls, (Sterky et al., 2005). By improving their physical abilities, elderly patients can become more independent, making them more likely to take control of their condition and less susceptible to depression

• Improved physical functioning • Exercise can lead to improved physical functioning. This can be measured by asking the patient to complete

a number of simple tasks, including the completion of five sit-to-stand cycles (STS-5), stair climbs or walks of50 m along the same corridor, and assessing improvements over time (Koufaki et al., 2002)

• Improved quality of life • End stage renal disease patients tend to have a poor quality of life (Al-Arabi et al., 2006, Cleary et al., 2005).

Exercise can improve patient quality of life to an extent that they choose to continue exercising after theirexercise programmes have finished (Kolewaski., 2005)

• CV risk reduction• Patients who have undergone coronary artery bypass grafts (CABG) benefit from

cardiac rehabilitation exercises (Kutner et al., 2006). Patients who exercised hadbetter left ventricular function at rest and during exercise, although any benefit in long term cardiac mortality and morbidity still requires further research (Deligiannis et al., 2004)

• Increased efficacy of dialysis• Exercise may improve the efficacy of dialysis (Kong et al,1999)

• Reduction in antihypertensive medication• Exercise results in a decrease in the amount of antihypertensive medication a patient requires. 54% of

patients taking exercise had a reduction in the antihypertensive medication they required, versus 12.5% inthe control group (p=0.008; Miller, 2002)

• May help towards desired weight reduction• Exercise can play an important role in motivating patients to increase their

activity levels. It also encourages weight loss for those patients trying to reduce their BMI in order to increase eligibility for joining the transplant waiting list

The US Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines also recommend regular exercise for patients on dialysis.

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The US KDOQI guidelines support their recommendations with an assessment of the strength of supportingevidence (where A=strong, B=moderately strong and C=weak). These are listed in brackets after each statement.

US/KDOQI guidelines on exercise• 14.2 All dialysis patients should be counselled and regularly encouraged by nephrology and dialysis staff to

increase their level of physical activity. (B)• 14.2a Unique challenges to exercise in dialysis patients need to be identified in order to refer patients

appropriately (e.g. to physical therapy or cardiac rehabilitation) and to enable the patients to follow regimenssuccessfully. Such challenges include orthopaedic/musculoskeletal limitations, cardiovascular concerns, andmotivational issues. (C)

14.3 Measurement of physical functioning• 14.3a Evaluation of physical functioning and re-evaluation of the physical activity programme should be

done at least every 6 months. (C)• 14.3b Physical functioning can be measured using physical performance testing or questionnaires

(e.g. SF-36). (C)• 14.3c Potential barriers to participation in physical activity should be assessed in every patient. (C)

14.4 Physical activity recommendations• 14.4a Many dialysis patients are severely deconditioned and therefore may need a referral for physical therapy

to increase strength and endurance to the point where they are able to adopt the recommended levels ofphysical activity

• 14.4ai Patients who qualify for cardiac rehabilitation should be referred to a specialist. (C)• 14.4aii The goal for activity should be for cardiovascular exercise at a moderate intensity for 30 minutes

on most, if not all, days per week. Patients who are not currently physically active or are severelydeconditioned/frail, should start at very low levels and durations, and gradually progress to this recommended level. (C)

14.4b Follow-up• 14.4bi Physical functioning assessment and encouragement for participation in physical activity should be

part of the routine patient care plan. Regular review should include assessment of changes in activity andphysical functioning. (C)

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What exercises should your patients do?Recommended exercises are grouped into three types which are described in more detail later on: Flexibility, Stamina and Cardiovascular (the FSC programme).

Flexibility: these exercises use gentle muscle stretching and bending movements, and ideally should be carried out every day

Stamina: these exercises strengthen muscles by using resistance aids to make muscles work harder. These should be carried out every 2 to 3 days depending on the patient’s fitness level

Cardiovascular: these are designed to improve performance of the heart, lungs and circulation. For patients with symptomatic cardiac problems, advice should be sought from the patient’s GP or consultant

Who can exercise?Before a patient embarks on an exercise programme, their suitability should be assessed (Bayliss, 2006)

Table 1. Patients who should and should not exercise

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Patients who should exercise Patients who should not exercise

• Patients who are haemodynamically stable duringdialysis treatment

• Patients with controlled co-morbidities

• Patients with stable cardiac profiles

• Patients with uncontrolled cardiac profiles, angina at rest, or who have had a cardiac event in the past 6 weeks

• Patients who are breathless at rest and have visible oedema

• Patients who are haemodynamically unstable during dialysis

• Patients with symptomatic bone disease

• Patients with a body temperature of above 38˚C(101.0˚F) or another acute infection

• Patients with poor diabetic control

• Patients with uncontrolled hypertension – cautionshould be taken if a patients resting blood pressurejust before exercising is >160/100 or <100/60

• Patients with a suspected or known aneurysm

Adapted from: Koufaki P and Mercer TH (2007)


Assessment and categorisation of patient’s physical capacityIt is important to categorise patient’s physical capacity so that appropriate exercise advice and rehabilitationprogrammes can be constructed. Below is a suggested scale of capacity, together with examples of rehabilitationmethods.

Table 2. Categories of physical capacity and suggested rehabilitation methods for patients

The programme of exercise rehabilitation and promotion of the time programme is mainly aimed at categories B and C. All patients on dialysis have significant degrees of muscle wasting and weakness. Therefore even thosepatients who are living independently without aids will benefit from rehabilitation. The above categorisation maybe useful to guide choices of rehabilitation input and provide a structure for risk and safety assessment.

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Categories of physical capacity Examples of rehabilitation methods

A. High-functioning, independent living

B. Physically impaired but independent living

C. Physically impaired but dependent

D: Those with limb amputations, musculoskeletal or cerebrovascular disease

Promotion of a physically active lifestyle, and liaisonwith local gyms

Exercising whilst on dialysis

Graded muscle strengthening rehabilitation, aimed at improving capacity to undertake activities ofdaily living

Provision of compensatory aids that support themaximum achievable independent functioning, with graded muscle strengthening rehabilitation


Components needed

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Components needed to start an exercise programmeThe recommended exercise intensity for dialysis patients is usually just very low, at only 40% to 60% of maximalcapacity. Usually, this is less than the intensity required for most activities of daily living, but the exerciseprogramme extends the duration of activity. However, patients with uncontrolled cardiac disease or severemusculoskeletal impairments and conditions such as those listed in Table 1 (on page 13) should be assessed by the appropriate healthcare professional before beginning exercise.

1. Staff support and educationStaff support for an exercise programme is critical to its success (Bayliss, 2006). This role can be carried out by anurse who has attended the time programme training course or another staff member with a special interest inexercise.

They should understand the benefits of exercise to their dialysis patients, should know how to start a patient on anexercise programme, and how to motivate patients to continue. Involving other members of the multidisciplinaryteam, e.g. physiotherapists or dietitians may also help with implementation of the time programme.

2. Motivating patients Patients need continuous and consistent education, delivered to them in a style that is suitable for their level ofmotivation. Some patients may not want to read a lot of information about the benefits of exercise and prefer tolearn by experiencing the benefits for themselves. These patients are more easily motivated using tools such as the‘Round Britain Walk’ challenge to encourage them to exercise more. Other patients will prefer to read about thebenefits to exercise before they embark on any training, and may therefore prefer to read the patient programmeon exercise before exercising.

Patients who are tired after simple exertion around the home may find it difficult to believe that they canundertake an exercise programme. Use the flashcards provided with the time programme to explain that even asmall increase in activity brings health benefits and that once patients become fitter and more mobile they willfind they have more energy to exercise further.

3. Ensure that exercise is safeBefore your patients embark on an exercise regime, you must assess whether it safe for them to do so (see Table 1,page 13). This decision should be made in conjunction with the multidisciplinary team.

In the short term, patients may be worried about potential musculoskeletal injuries. However, although this risk isincreased in patients with renal disease, weight-bearing or strengthening exercises can, in the long term, increasebone density and reduce the risk of fracture (Johansen, 2005).

The risk of a patient having a cardiac event whilst participating in a maximum intensity exercise is low (0.005%)and this risk decreases even further if the exercise programme is of sub-maximal intensity (Johansen, 2005).The time programme is a programme of low intensity exercises and so this risk is lower still. Over the long term,participating in exercise programmes will decrease this risk even further.

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4. Footwear and clothingEnsure that patients wear appropriate clothing and footwear. Any comfortable and loose fitting clothing is suitable, preferably layered so that items can be removed or added as needed. Good footwear is essential,particularly for diabetic patients. Properly designed shoes will have good padding, arch supports and uppers thatallow air to circulate. Diabetics in particular must be encouraged to consult a clinician as soon as possible if thereare any signs of foot problems.

5. Exercising safelyYou should ensure that patients are aware of how to manage their condition when exercising.

Diabetes:• Exercise increases the uptake of glucose into muscles and lowers glucose levels in blood. The magnitude of this

change depends on the intensity and duration of the exercise. If the patient becomes fit enough to exercise forone hour or more, they should then be monitored both before and after exercise in case there is a dramatic dropin blood glucose during exercise.

• Ensure that the patient has good glycaemic control. If not, then this should be addressed first.• Visual impairment should not be a reason for exclusion from this programme.

Fluid and diet management:• Patients should be made aware that their fluid and dietary restrictions still apply when they are exercising, and

that they should not deviate from any fluid or dietary restrictions that were in place before they began theirexercise programme.

Anaemia:• Although anaemia may impair exercise capacity, it in no way contraindicates exercise rehabilitation. Muscle

weakness (and not anaemia) is the most important cause of physical impairment.

Tips for succeeding

Managing expectations• It is important to acknowledge that change takes place through a series of steps and it is

unrealistic to expect overnight improvement• Expect to see change in months, not days• Don’t expect to be able to achieve challenging targets on the first day; but hold on to the

belief that every exercise session, however small, is another step on the way• Patients are likely to feel tired immediately after a session, but once they have recovered,

they will find they have more energy than before

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Commitment• Helping patients to take up more exercise can seem an unrewarding task as people change their habits slowly,

and often require multiple attempts. However, in the long term, helping patients to exercise can be verysatisfying as those who do succeed feel real benefit

• Patients need to acknowledge that change is needed, and to make a commitment to exercise, leading to theadoption of a realistic plan to achieve their goals

The next section describes the considerations to bear in mind when putting together an appropriate exercise planfor your patients.

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Planning

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Planning for an exercise programmeHow often should patients exercise? • Current guidance is that low to moderate intensity aerobic exercise three or more times per week should be

recommended to all patients who are able to undertake it (Johansen, 2006)

How hard and when should patients exercise?• Patients can exercise both on and off dialysis. Exercise on dialysis should be low intensity and not interfere with

the dialysis procedure or equipment. The safest time to exercise during dialysis is during the second and thirdhours of treatment

• Intensity of exercise that leads to improvement in physical capacity (also known as conditioning) occurs at workrates graded ‘somewhat hard’ to ‘hard’ (12-16 on the Rating of Perceived Exertion [RPE] scale). Patients shouldbe taught to work at this from this level from the start. As their fitness improves, so the amount of work theycan achieve at this level of perceived exertion will increase.

How should patients monitor their progress? • Patients should use the Rate of Perceived Exertion (RPE) Scale to note how their fitness improves over time

Level 6 is equivalent to sitting on a chair and not exerting themselves at all. Exercise training is usually undertakenat RPE levels of between 12 and 16. Monthly assessments should be carried out to ensure that the intensity ofexercise is achieving these desired RPE levels.

How to use the Rate of Perceived Exertion ScaleThe patient should carry out an exercise and then shown the RPE scale and asked to rate their level of exertion. If the rating is below 12, the intensity of the exercise should be increased to give an RPE of between 12 and 16. This may be done by increasing repetitions or weight as instructed on the ‘Exercise on dialysis for better health’cards. If the rating is above 16, then consider reducing weight or repetitions to achieve a rating of 12-16.

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Rate of Perceived Exertion

6 Rest7 Very, Very Light8 Very Light Warm-Up and Cool-Down910 Fairly Light1112 Somewhat Hard1314 Conditioning15 Hard1617 Very Hard18 Slow Down!19 Very, Very Hard20


• Patients should:• Make sure that breathing is at a level where conversation is possible• Understand that complete recovery should be possible within one hour• Start slowly, then increase effort, and then end slowly• Expect mild discomfort due to the effort, but not pain• Expect mild soreness in muscles unused to exercise, but not so severe that it prevents activity

• If patients experience one or more of these symptoms, advise them to step down the intensity of the activityuntil they have become fitter. Remind patients that exercise does not have to feel ‘hard’ to be of use. So long as they are more active than they were before, and for longer periods, they will be benefiting from the effectsof exercise

A tip to help patients assess the difficulty of their exercise:• If they can complete a sentence in one breath, the activity is too easy or low intensity for them• If they are unable to say the same sentence at all, the activity is too difficult or high intensity for them• They should be able to complete the sentence by taking breaths in between words

Do’s and don’tsWhen to exercise:Patients should avoid temperature extremes when exercising outside. • If it is very hot or cold, wait until temperatures are comfortableWhen not to exercise:

• They have a fever (body temperature >101.0°F or 38°C)• They have missed a dialysis session• They have a new illness that has not yet been treated• They experience pain while exercising• They have poor diabetic control• They have uncontrolled hypertension• They are breathless at rest with peripheral oedema• If they have had a cardiac event within the last six weeks

If patients are exercising vigorously there is a danger that they may become too hot, leading to possible hypotension.

When to stop:• Patients should stop exercising and should alert their dialysis team if any of the following symptoms emerge.

• Uncomfortable shortness of breath• Chest pain or pressure• Irregular heartbeat• Nausea• Leg cramps• Dizziness or light-headedness• Pain or pressure in neck or jaw• Excess fatigue• Blurring of vision

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Monitoring progress

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Monitoring progress• As patients become fitter they will be able to exercise for longer and/or will be able to

do specific exercises more quickly. Either of these parameters can be used to monitorprogress. However, do encourage patients to have realistic expectations: adding 1-2 repetitions per month to the time that they can carry out ‘hard’ exercise is fine

• Patients can also be encouraged to take up activities they previously enjoyed (e.g. swimming,recreational walking), if they feel well enough to do so

Using the exercise diaryShow patients how to use the progress charts in the exercise diary provided with the timeprogramme materials. This diary is primarily designed to encourage patients to exercise inbetween dialysis sessions. For each activity the patient should record how long they exercisedfor, how far they were able to go, or what weights they were able to use. There will be somedips if they become ill or have to reduce levels of activity, but patients should be encouraged tothink about their long term progress and not to be discouraged by the occasional setback.

Exercise diary: personalised progress chartThis is a personalised set of goals used to assess progress. The patient can use this chart to set threepersonalised goals that they aim to reach over the course of the following year. Goals may be either quality-of-life based (e.g. to climb their stairs at home without stopping), or based around more formal exercise goals(e.g. to swim 5 lengths of their local swimming baths). You should review their progress once every 3 monthsand adjust or extend these goals if necessary.

Exercise diary: STS-60 and DASI progress chartThis is a more formal assessment chart that can be used to assess progress at 3-monthly intervals. It consists of two assessments:

1) The sit-to-stand in 60 seconds (STS-60)This assesses how many sit-to-stand exercises a patient can do in 60 seconds. The patient sits upright in a chair of standard height (around 45 cm) with their arms crossed over their chest, like an Egyptian mummy. The patient then stands up and then sits down again. Each one of these cycles counts as 1 sit-to-stand.

2) The Dukes Activity Status Index (DASI)The DASI is a simple self-reported physical capacity questionnaire. When used alongside a clinical assessment(e.g. the STS-60) you can assess and monitor variability in physical function (Alonso, 1999). It is based on the patient’s ability to perform some common activities of daily living. The questionnaire provided with thisprogramme should be completed by the patient and the score given to each answer by the member of the care team.

Note: As the DASI is a physical capacity questionnaire, it is mainly useful for the less able bodied person toassess progress. The more able bodied people may score high scores and progress may not so easily be seen inthis group of people, using this tool.

Both the DASI and the STS-60 assessments should be carried out by a nurse or physiotherapist in thehealthcare setting and should only take a few minutes to complete.

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The DASI patient questionnaire (to be completed by the patient)

DUKE ACTIVITY STATUS INDEX (Hlatky et al., 1989)

Name: Date:

Can you: (please circle yes or no)

1. Take care of yourself, that is, eat, dress, bathe or use the toilet? Yes/No

2. Walk indoors, such as around your house? Yes/No

3. Walk a block or two on level ground? Yes/No

4. Climb a flight of stairs or walk up a hill? Yes/No

5. Run a short distance? Yes/No

6. Do light work around the house like dusting or washing dishes? Yes/No

7. Do moderate work around the house like vacuuming, sweeping floors or carrying groceries? Yes/No

8. Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Yes/No

9. Do garden work like raking leaves, weeding or pushing a lawn mower? Yes/No

10. Have sexual relations? Yes/No

11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis Yes/Noor throwing a ball?

12. Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing? Yes/No

(To be completed by staff) Duke Activity Status Index (DASI) = sum of “Yes” replies

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The DASI score sheet (to be used by staff)

DUKE ACTIVITY STATUS INDEXScore sheet

Scores are only given for ‘yes’ replies

1. Take care of yourself, that is, eat, dress, bathe or use the toilet? 2.75 Yes/No

2. Walk indoors, such as around your house? 1.75 Yes/No

3. Walk a block or two on level ground? 2.75 Yes/No

4. Climb a flight of stairs or walk up a hill? 5.50 Yes/No

5. Run a short distance? 8.00 Yes/No

6. Do light work around the house like dusting or washing dishes? 2.70 Yes/No

7. Do moderate work around the house like vacuuming, 3.50 Yes/Nosweeping floors or carrying groceries?

8. Do heavy work around the house like scrubbing floors or liftingor moving heavy furniture? 8.00 Yes/No

9. Do garden work like raking leaves, weeding or pushing a lawn mower? 4.50 Yes/No

10. Have sexual relations? 5.25 Yes/No

11. Participate in moderate recreational activities like golf, bowling,dancing, doubles tennis or throwing a ball? 6.00 Yes/No

12. Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing? 7.50 Yes/No

Duke Activity Status Index (DASI) = sum of “Yes” replies

The higher the score is, the more physically active a person is according to this set of activities of daily living. The DASI score should be completed every three months and the score entered into the back of the exercise diary to monitor progress.

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Using the Exercising on Dialysis 4 week progress chartThis chart monitors progress using the exercise on dialysis regime provided with this programme. It is designed tobe used at every dialysis session and each chart lasts for 4 weeks before starting a new one.

The chart is provided as a tear-off pad available as part of the time programme materials. The date of each dialysissession should be written in the appropriate box at the top of the chart. There is a space to write how many of each exercise was completed by the patient and what weights (if any) were used. Rate of Perceived Exertion (RPE)should also be noted at baseline and 4 weekly intervals to monitor that the exercise is at the right intensity for thepatient. The charts can be kept with patient records on the dialysis unit. Patients should be encouraged to fill thischart out for themselves if appropriate.

Before a patient embarks on an exercise regime, their suitability should be assessed and staff should use Table 1 (on page 13) in the ‘Who can exercise section’ as a guide.

THE EXERCISING ON DIALYSIS – 4 WEEK PROGRESS CHART

Week 1 Week 1 Week 1 Week 1 Week 2 Week 2 Week 2 Week 3 Week 3 Week 3 Week 4 Week 4 Week 4 Week 4 RPE Baseline RPE Exercise date 5 mins warm up (tick if done) 1 reps reps reps reps reps reps reps reps reps reps reps reps Heel raise sets sets sets sets sets sets sets sets sets sets sets sets wt wt wt wt wt wt wt wt wt wt wt wt 2 reps reps reps reps reps reps reps reps reps reps reps reps Ankle flex sets sets sets sets sets sets sets sets sets sets sets sets wt wt wt wt wt wt wt wt wt wt wt wt 3 reps reps reps reps reps reps reps reps reps reps reps reps Knee sets sets sets sets sets sets sets sets sets sets sets sets extension wt wt wt wt wt wt wt wt wt wt wt wt 4 reps reps reps reps reps reps reps reps reps reps reps reps Knee to sets sets sets sets sets sets sets sets sets sets sets sets chest lifts wt wt wt wt wt wt wt wt wt wt wt wt 5 reps reps reps reps reps reps reps reps reps reps reps reps Outer sets sets sets sets sets sets sets sets sets sets sets sets thigh lift wt wt wt wt wt wt wt wt wt wt wt wt 6 reps reps reps reps reps reps reps reps reps reps reps reps Front sets sets sets sets sets sets sets sets sets sets sets sets thigh lift wt wt wt wt wt wt wt wt wt wt wt wt 7 reps reps reps reps reps reps reps reps reps reps reps reps Straight sets sets sets sets sets sets sets sets sets sets sets sets leg raise wt wt wt wt wt wt wt wt wt wt wt wt 5 mins cool down (tick if done)

Date (insert)

KeyReps: The number of repetitions of each exercise completed Sets: If built up to sets, number of sets (of 10-15 repetitions) completedWeight: The amount of weight used for the exercise. Enter 1 of 3 options:N = weight not used 0.5 = 0.5 kg weights used 1 = 1 kg weights used

Rating of Perceived Exertion (RPE)If RPE at any time less than 12, consider increasing repetitions/weight If RPE at any time between 12-16, then exercise regime at right intensityIf RPE at any time more than 16, consider reducing repetitions/weight


Exercise on dialysis

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Exercises to carry out on dialysisThe following exercises can be carried out by patients whilst they are on the dialysis machines. The safest times forthem to carry these out are the second and third hours after dialysis has started. It is important that the patientsmaintain good posture at all times during these exercises, and that they breathe regularly as they complete them.Breathe out during the difficult part and breathe in during the easy part of the exercise. The patient should sit withtheir back straight and, where appropriate, well supported in their dialysis chair and keep the parts of their bodythat are not exercising as still as possible.

Over time they should aim to build up the intensity of these exercises.1. They should start without any weights and repeat each of the exercises as many times as you can manage2. They should then progress to completing a set of 10-15 repetitions3. Once they are comfortable with this they should aim to progress to 3 sets of 10-15 repetitions4. Once they are able to do this comfortably they can then progress to adding 0.5 kg weights to each leg and follow

the above steps again5. Once they complete steps 1-3 with 0.5 kg weights, they can progress to completing them with 1 kg weights

instead

Patients should begin their exercise programme with 5 minutes of warm-up exercises. These can be a low intensityversion of the exercises they are about to carry out, without any addition of weights.

Exercise 1: Heel raises1. Sit towards the front of your dialysis chair with your back straight and

your knees bent at 90°2. Lift your heel up and then lower it back down slowly3. Repeat with the other legWhen you progress to adding weights to this exercise, you should have theweight resting on the knees and not around the ankles

Exercise 2: Ankle flex1. Sit on dialysis chair with your back well supported2. Raise one leg straight out in front of you3. Flex your foot so that your toes are pointing towards the ceiling4. Slowly point your toes down and then flex up again5. Return leg to original position6. Repeat with the other leg

Exercise 3: Knee extension1. Sit towards the front of your dialysis chair with your feet on the floor2. Straighten one leg so that it is out in front of you3. Keep your toes pointing up towards the ceiling4. Slowly bend your leg back and place your foot back on the floor5. Repeat with the other leg

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Exercise 4: Knee to chest lifts1. Sit on dialysis chair with your back well supported or lie down2. Bring one knee up to the chest and lower slowly3. Repeat with the other leg

Exercise 5: Outer thigh lift1. Sit on a chair with your back well supported2. Slowly move one leg sideways away from your body by 30-40°,

concentrating on the muscles of your outer thigh3. Return leg to original position4. Repeat with the other leg

Exercise 6: Front thigh lift1. Sit on a chair with your back well supported2. Roll up a towel and place this under your knee3. Slowly lift your foot up and place back down again4. Repeat with the other leg

Exercise 7: Straight leg raise1. Sit on a chair with your back well supported2. Slowly lift your leg up by 30-40° and place back down again3. Repeat with the other leg

Patients should end their exercise programme with 5 minutes of cool-down exercises. These can be a low intensity version of the exercises they have just completed, without any addition of weights.

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Exercise off dialysis

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Exercises to carry out away from dialysisThe following exercises can be carried out by patients away from their dialysis sessions. It is important that theymaintain good posture at all times during these exercises, and breathe regularly as they complete them. Whereappropriate, they should sit with their back straight and well supported in their dialysis chair and keep the parts of their body that are not exercising as still as possible.

As with the exercises on dialysis, patients should aim to build up the intensity of these exercises as follows.1. They should start without any weights and repeat each of the exercises as many times as they can manage2. They should then progress to completing a set of 10-15 repetitions3. Once they are comfortable with this they should aim to progress to 3 sets of 10-15 repetitions4. Once they are able to do this comfortably they can then progress to adding 0.5 kg weights to each leg and follow

the above steps again5. Once they complete steps 1-3 with 0.5 kg weights, they can progress to completing them with 1 kg weights

instead.

Patients should take care to breathe properly and to make sure they do not hold their breath during the exercises.They should breathe out during the difficult part and breathe in during the easy part of the exercise.Patients should begin their exercise programme with 5 minutes of warm-up exercises. These can be a low intensityversion of the exercises they are about to carry out, without any addition of weights, or you can look out for theexercises labelled as ‘warm-up or cool-down exercises’. The exercises labelled ‘conditioning exercises’ are goodexercises for building up stamina, and muscular strength during your exercise routine.

Warm-up or cool-down exerciseExercise 1: Neck stretch1. Sit on a chair with your back well supported2. Look straight ahead3. Slowly look up towards the ceiling, moving your whole head4. Slowly look down towards the floor, moving your whole head5. Look straight ahead again6. Slowly move your head to look over your left shoulder7. Repeat to your right side8. Look straight ahead again9. Tip your head towards your left shoulder, keeping your head facing

forwards the whole time10. Repeat to your right side

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Warm-up or cool-down exerciseExercise 2: Shoulder shrug and rotation1. Sit on a chair with your back well supported2. Shrug your shoulders up to your ears3. Hold for a few seconds4. Lower and repeat5. Make forward circles with your right shoulder6. Repeat with your left shoulder7. Make backwards circles with your right shoulder8. Repeat with your left shoulder

Warm-up or cool-down exercise

Exercise 3: Trunk rotation1. Sit on a chair with your back well supported2. Cross your arms and raise so that your elbows are pointing

out straight in front of you3. Keeping your nose in line with your watchstrap,

twist your body to the left of you4. Return to a forward facing position5. Repeat towards your right


Exercise 4: Ankle flex1. Sit on a chair with your back well supported2. Raise one leg straight out in front of you3. Flex your foot so that your toes are pointing towards the ceiling4. Slowly point your toes down and then flex up again5. Return leg to original position6. Repeat with the other leg


Exercise 5: Calf stretches1. Stand up with your back straight using the back of a chair for support2. Step back with your right leg only3. Press your right heel into the floor4. Bend your left leg slightly, so that you can feel the stretch in your right calf5. Hold the stretch in your leg6. Repeat with the other leg

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Conditioning exercise

Exercise 6: Stair step1. Stand up with your back straight, facing a small step2. Balance yourself carefully e.g. use a wall3. Step onto the step with your right foot, and then with your left4. Slowly step back down off the step with your right foot,

and then your left

5. Repeat stepping with your left foot before your right


Exercise 7: Arm curl1. Sit on a chair with your back well supported2. Keep your elbows close to your sides3. With your palms facing up, make your hands into fists4. Slowly lift one fist up to your shoulder5. Lower slowly6. Repeat with the other arm7. A weight can be lifted for further resistance and a can of food may be

used if a formal weight is unavailable


Exercise 8: Upright row1. Sit on a chair with your back well supported2. Place a single weight on your lap3. Pick this up with both hands, with palms facing downwards4. Slowly raise your arms, keeping the weight as close to your body as

possible and pointing your elbows outwards5. Lower slowly


Exercise 9: Knee extension1. Sit towards the front of your chair with your feet on the floor2. Straighten one leg so that it is out in front of you3. Keep your toes pointing up towards the ceiling4. Slowly bend your leg back and place your foot back on the floor5. Repeat with the other leg

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Exercise 10: Sit-to-Stand1. Stand in front of a chair, facing away from it. Make sure that the chair

cannot move backwards at all2. Cross your arms in front of your body3. Move down into the chair as though you are going to sit down on it,

but stop before you do sit4. Hold your position just above the chair seat5. Stand back up so that you are upright again


Exercise 11: Back leg swing1. Stand up with your back straight using the back of a chair for support2. Slowly lift one leg backwards and point your toes outwards3. Take care not to arch your back4. Lower your leg back down onto the floor5. Repeat with the other leg


Exercise 12: Heel raise1. Stand up with your back straight using the back of a chair for support2. Lift your heels up so that you are standing on the balls of your feet3. Lower your heels back down slowly

You can intersperse the exercises with half star jumps, and with running onthe spot for one minute bursts. This helps to break up the exercises a little.

Half star jumps1. Stand with your back straight and your hands on your hips2. Move your right arm sideways and up so that it is over your head3. At the same time, step sideways with your right leg4. Return leg to centre and arm to hips5. Repeat with your left arm and leg

Running on the spot1. Stand with your back straight2. Run on spot for one minute, at an intensity that you can manage

Patients should end their exercise programme with 5 minutes of cool-down exercises. These can be a low intensityversion of the exercises they have just completed, without the addition of any weights, or you can look out for theexercises labelled as ‘warm-up or cool-down exercises’.

If your patients do not have the time to complete all of these exercises at home, they should do as many of them asthey can, taking care to ensure that they are exercising different muscle groups and not focusing on one area only.

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ReferencesAl-Arabi S. Quality of life: subjective descriptions of challenges to patients with end stage renal disease. Nephrol Nurs J. 2006; 33(3): 285-292.

Alonso, J. Measuring functional status of chronic coronary patients. Eur Heart J 1997; 18: 414-419.

Bayliss D. Starting and managing an intradialytic exercise programme. Nephrology News and Issues August 2006 47-49.

Cleary J, Drennan J. Quality of life of patients on haemodialysis for end-stage renal disease. J Adv Nurs. 2005; 51(6): 577-586.

Deligiannis A. Cardiac adaptations following exercise training in hemodialysis patients. Clin Nephrol 2004; 61(S1): S39-45.

Hlatky MA, Boineau RE, Higginbotham MB et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989; 15; 64(10):651-654.

Johansen KL. Exercise and chronic kidney disease: current recommendations. Sports Med 2005; 35(6): 485-499.

K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J KidneyDis. 2005; 45 (4 Suppl 3): S1-153.

Kolewaski CD, Mullally MC, Parsons TL et al. Quality of life and exercise rehabilitation in end stage renal disease.CANNT J. 2005; 15(4): 22-29.

Kong CH, Tattersal JE, Roger N et al. The effect of exercise during haemodialysis on solute removal. Nephrol DialTransplant 1999; 14: 2927-2931.

Koufaki P, Mercer TH, Naish P. Effects of exercise training on aerobic and functional capacity of end-stage renaldisease patients. Clin Physiol and Funct Imaging 2002; 22: 115-124.

Koufaki P and Mercer TH (2007). Exercise assessment for people with End Stage Renal Failure. In Winter E, Jones A,Davison R, Bromley P and Mercer TH (Eds). Sport and Exercise Physiology Testing Guidelines: The British Associationof Sport and Exercise Science Guide, Volume Two: Exercise and Clinical Testing. London, Routledge. pp.199-208.

Kutner NG, Zhang R, Huang Y et al. Cardiac rehabilitation and survival of dialysis patients after coronary bypass. J Am Soc Nephrol. 2006; 17(4): 1175-1180.

Ley P. Communicating with Patients: Improving communication, satisfaction and compliance. Chapman and HallPress, London,1988.

Miller BW, Cress CL, Johnson ME et al .Exercise during hemodialysis decreases the use of antihypertensivemedications .Am J Kidney Dis. 2002; 39(4): 828-833.

Sterky E, Stegmayr BG. Elderly patients on haemodialysis have 50% less functional capacity than gender- and age-matched healthy subjects. Scand J Urol Nephrol. 2005; 39(5): 423-430.

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Further informationPlease ask your Roche representative if you need any further information or require reprints of any of the clinical papers mentioned in this programme.

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Supported by the NKF and ANSA.

www.kidney.org.ukHelpline: 0845 601 02 09

www.anaemianurse.orgHelpline: 01483 724472

The information contained and referenced herein is for informational purposes only. It is designed to support, not replace, an ongoing patient – healthcare professional relationship and should not beconstrued as the giving of medical advice nor relied on as the basis for any decision or action.


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20944 exercise hcp book:20944 exercise hcp book...can be made. when a patient’s understanding of...

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