Motivation, Barriers, and Suggestions for Intradialytic Exercise-A Qualitative Study among Patients and Nurses

Perceptions of healthcare providers on benefits, risks and barriers regarding intradialytic exercise among haemodialysis patients

PURPOSE

Clinical guidelines call for the inclusion of exercise interventions in every patient's dialysis session, but these recommendations are rarely adopted. Healthcare providers play a key role in this. Therefore, the aim of this study was to explore how healthcare providers perceive the benefits, risks and barriers of intradialytic exercise (IDE).

METHODS

We conducted 21 individual, semi-structured interviews with 11 nurses, 5 nephrologists, 3 training assistants and 2 managers from two dialysis centres in Slovakia. Verbatim transcripts of digitally recorded interviews were thematically analysed using MAXQDA®.

RESULTS

Participants reported the benefits of IDE as improvements in patients' physical and psychosocial functioning, independence and self-efficacy, clinical profile and quality of therapy. As risks of IDE, they most frequently reported exercise-related damage to vascular access, insufficient individualization of training and musculoskeletal injuries. The presence of psychological problems among patients was reported as a major barrier for initiating and maintaining patients' exercise. Other reported barriers included limitations in financial and personnel resources of haemodialysis care.

CONCLUSIONS

Safe and sustainable implementation of IDE, which might improve a patient's well-being, need to be prescribed in alignment with the patient's clinical profile, be delivered individually according to the patient's characteristics and requires adjustments in the available resources.

Increasing Accessibility to Intradialytic Cycling in Rural and Remote Settings: Program Report

Purpose of program

Access to exercise and rehabilitation is often lower in rural or remote areas and hemodialysis (HD) dependence imposes additional barriers. Intradialytic cycling (IDC) can improve HD-related symptoms, such as leg cramping, restless legs, and symptoms of depression, as well as physical function and fitness, but access to exercise professionals with this expertise is limited. To promote access to IDC in rural and remote HD units, we describe the implementation and initial evaluation of a novel IDC program using virtual assessment to safely prescribe and individualize IDC.

Sources of information

We developed and piloted a protocol for virtual IDC assessment and prospectively collected metrics informed by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to support future quality improvement activities.

Methods

Rural HD units were defined as per Alberta Kidney Care North (AKC-N)'s operations. The virtual IDC program components were: HD unit education sessions, support and interest from local unit staff and those receiving HD, a bike, a supervising kinesiologist, a stable Internet connection, a nurse present during the 25-minute initial virtual assessment, and virtual follow-up every 3 to 4 weeks with the kinesiologist. The initial assessment consists of a virtual bike test where the participant performs a graded, symptom-limited cycling trial with documentation of vital signs and rating of self-perceived exertion (relative intensity). The data are used to prescribe IDC (frequency, intensity, time). The HD unit staff learn participant and bike set-up, confirm safe exercise parameters for that day, adjust the bike intensity, and take vital signs. Outcomes for evaluating the impact of the IDC program using the RE-AIM health framework were selected.

Key findings

Out of the 24 HD units in AKC-N, 18 units were defined as either remote or rural (75%). Four of the units (22%) adopted the program, which was less than our target of 30% of units. Individual-level participation (Reach) within those units ranged widely (1-67%) with only one unit reaching the target of at least 30% individual-level participation. Reasons for starting IDC were intradialytic cramping, restless legs, deconditioning, and boredom during HD. Reasons for non-participation were lack of interest and a desire to sleep. Routine exercise program questionnaires on health-related quality of life for program effectiveness were not consistently completed by participants. All virtual assessments were completed as per protocol with a nurse (100% fidelity); however, tests often needed to be re-scheduled due to technical issues with Wi-Fi, limited unit staffing, operational demands, and/or safety concerns. At 1 year, all 4 units continued to participate with 2 additional HD units starting the following year.

Limitations

Reach could be improved by introducing intradialytic exercise to individuals at HD initiation, prior to moving to their local satellite HD unit. Existing measures of program effectiveness may not be relevant to program participants or feasible to implement without an on-site exercise professional. Technical issues and navigating the busy schedules of unit staff were limitations to completing tests as scheduled.

Implications

Implementing a protocolized approach with virtual support can increase accessibility to an evidence-based treatment in HD units without exercise professionals. For people requiring HD, reach may be improved with early education and exposure at HD start and with orientation sessions for staff. Adding a virtual IDC assessment day for staff as part of their routine monthly task schedule may promote institutionalization. Formalized follow-up sessions for kinesiologists and nurses to discuss program concerns would benefit the program in the future. Completion of program effectiveness measures may be improved by selecting more individualized options, for example, person-reported measures related to the individual's reason for referral.

Comparisons of Intradialytic Exercise Versus Home-Based Exercise in Hemodialysis Patients: A Narrative Review

With the increasing prevalence of end-stage kidney disease, the number of patients requiring hemodialysis (HD) continues to rise. While life-sustaining, HD is often associated with adverse effects such as muscle loss, physical deconditioning, fatigue, and compromised health-related quality of life (HRQoL). Recent research suggests that intradialytic exercise (IDE) and home-based exercise (HBE) may mitigate these adverse effects and improve patient outcomes. However, the existing literature mainly focuses on the outcomes of both exercises, whereas the comparison of types is often omitted. Hence, this review consolidates findings from studies investigating the effectiveness, implementation, safety, feasibility, and adherence of different types of IDE and HBE in HD patients. Overall, the current literature bolsters the significance of IDE and HBE for improving health in HD patients. IDE and HBE enhance physical function, cardiopulmonary capacity, HRQoL, and cognitive well-being. Some research proposed an indirect link between IDE and survival rates. Despite these benefits, challenges remain in implementing these exercise modalities, including patient adherence and the feasibility of routine exercise during HD sessions. Integrating these exercises into routine care allows healthcare providers to enhance outcomes for HD patients. Further research is suggested to optimize exercise protocols and explore long-term effects and cost-effectiveness.

Nurses' and medical doctors' attitudes towards exercise for people with chronic kidney disease in Denmark

BACKGROUND

Implementation of exercise training in people with kidney failure may be affected by clinicians' attitudes.

OBJECTIVES

To investigate Danish nephrology nurses' and medical doctors' attitudes towards: exercise for people undergoing dialysis; use of physical activity interventions in chronic kidney disease; and to compare Danish and previously reported Australian nurse attitudes.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Nurses and medical doctors from the nephrology field in Denmark.

MEASUREMENTS

The questionnaire attitudes towards exercise in dialysis, and questions about exercise advice, counselling and interventions.

RESULTS

Nephrology nurses (n = 167) and 17 medical doctors (women 92%, age 47 ± 11 years) from 19 dialysis units participated. There were no differences between nurses' and medical doctors attitudes about training. Ninety-five % and 88% of nurses and medical doctors, respectively, agreed that most people undergoing dialysis could benefit from exercise. Exercise training was offered to people undergoing haemodialyses in 88% of 17 departments. Danish nurses reported more positive attitudes than Australian towards exercise (p < 0.05). Ninety-five % and 86% of the Danish and Australian nurses, respectively, agreed/strongly agreed that most people undergoing dialysis could benefit from exercise. Six % and 35% of the Danish and Australian nurses, respectively, agreed/strongly agreed that most people with dialysis were too sick to exercise.

CONCLUSION

Danish nephrology nurses and medical doctors had mostly positive attitudes to exercise training to people undergoing dialysis, and exercise to people with dialysis was offered frequently. Danish and Australian nurses had positive attitudes to exercise to people undergoing dialysis, it was however more positive in Danish nurses.