EXERCISE FOR THE PATIENT A Prescribing Guide

Developed by The Life Options Rehabilitation Advisory Council Supported by Amgen Renal Advances Administered by Medical Media Associates, Inc. EXERCISE

Exercise for the Dialysis Patient A Prescription Guide

A Project of The Life Options Rehabilitation Advisory Council Supported by An Educational Grant from Amgen Inc. Developed by Medical Education Institute, Inc.

Advisory Council: Members at Large

Christopher Blagg, MD Spero Moutsatsos, MS Northwest Kidney Centers ESRD Network of Florida, Inc. , Washington Tampa, Florida

Kenneth Chen, MS John Newmann, PhD, MPH Amgen Inc. Health Policy Research & Analysis, Inc. Thousand Oaks, California Reston, Virginia

Ann Compton, RN, MSN Patricia Painter, PhD Medical College of Virginia UCSF Transplant Service Richmond, Virginia San Francisco, California

Erwin Hytner George Porter, MD Safety Harbor, Florida Oregon Health Sciences University Portland, Oregon Nancy Kutner, PhD Emory University John Sadler, MD Department of Rehabilitation Medicine University of Maryland Atlanta, Georgia Baltimore, Maryland

Bruce Lublin Michael Savin, PhD Hartland, Wisconsin Amgen Inc. Thousand Oaks, California Donna Mapes, DNSc, RN Amgen Inc. Theodore Steinman, MD Thousand Oaks, California Beth Israel Hospital Boston, Massachusetts Anthony Messana, BSC Dialysis Clinics, Inc. Beth Witten, ACSW, LSCW Nashville, Tennessee Johnson County Dialysis Lenexa, Kansas

1 Acknowledgements Medical Education Institute, Inc. and the Life Options Rehabilitation Advisory Council gratefully acknowledge the contributions of the many people who have made this exercise publication possible. Our thanks go to: Amgen Inc. for its generous support of the Life Options project, including this and other efforts to make rehabilitation a reality for people with end-stage renal disease; Contributors and reviewers for their valuable input and careful reading of manuscripts, including Christopher R. Blagg, MD, Geoffrey E. Moore, MD, Derrick Latos, MD, Peter Lundin, MD, George Porter, MD, Theodore Steinman, MD, Teri Bielefeld, PT, CHT, and Bruce Lublin; The project staff, including Paula Stec Alt, Gay Petrillo Boyle, William Hofeldt, Gary Hutchins, Cathy Mann, Karen Miller, Edith Oberley, Jill Pitek, Paulette Sacksteder, Dorian Schatell, and Nicole Thompson. About the Authors

Patricia Painter, PhD, is an exercise physiologist who has worked with both dialysis and transplant patients for more than ten years. She has conducted several studies about the effects of exercise on people with end-stage renal disease and has published numerous articles on the subject. She developed and tested one of the first protocols for in-center exercise programs for dialysis patients. She is currently affiliated with the University of California-San Francisco Transplant Rehabilitation Project and the Stanford Center for Research in Disease Prevention (SCRDP) at Stanford University Medical School, Palo Alto, California. Christopher R. Blagg, MD, is Executive Director of the Northwest Kidney Centers and a Professor of Medicine in the Division of Nephrology at the in Seattle. He is one of the founders of the Renal Physicians Association and is currently a member of the Executive Committee of the American Society of Artificial and Internal Organs. Dr. Blagg received his medical degrees and postgraduate training at the University of Leeds in England. Geoffrey E. Moore, MD, is Medical Director, Cardiopulmonary Rehabilitation at the University of Pittsburgh Heart Institute in Pittsburgh. He is also a Fellow of the American College of Sports Medicine and former Research Associate at the Stanford Center for Research in Disease Prevention (SCRDP) at the Stanford University School of Medicine. Dr. Moore has conducted several studies concerning the effects of exercise on people with end-stage renal disease and has published articles on this subject. He received his medical degree at Southwestern Medical School.

The information in this guide is offered as general background for the clinician who is interested in encouraging patients to increase their physical activity. The guide is not intended to provide practice guidelines or specific protocols and cannot substitute for the physician’s medical knowledge and experience with individual patients. Amgen Inc., the Medical Education Institute, Inc., or the authors cannot be responsible for any loss or injury sustained in connection with, or as a result of, the use of this guide. 2 EXERCISE How to Prescribe Exercise

ncorporating exercise into the activities utilize large muscle groups in medical care plan of dialysis a rhythmic manner; walking, cycling, I patients offer great potential. and swimming are examples. Improvements in mental health and Choosing an aerobic activity requires attitude, as well as physical functioning, common sense; the risks of exercising are very real possibilities. Experience outdoors in an unsafe area or in proves it! extreme weather, for example, are not Goals of Exercise worth the benefits. Indoor alternatives For a dialysis patient, the goal of an are often available. exercise prescription is to develop a Some patients find exercise bicycles to be program that safely and effectively a good way to maintain cardiovascular increases physical activity and improves fitness without leaving home. Exercise physical functioning. bicycles are convenient and may be Several standardized activities (see page purchased “used” at low cost. Patients 12) may be used to assess physical func- with muscle weakness or joint problems tioning. These activities require strength, may be comfortable using an exercise flexibility, and agility and simulate bicycle because the bicycle supports their activities of daily living. Clinicians may weight. This assistance may also allow use the results of performance-based them to work out for longer periods. tests to guide their recommendations. Water exercises can also be very benefi- The types of activity that are “prescribed” cial. Water helps support body weight, vary greatly. Encouraging enjoyable which can be an advantage for patients physical activities will increase regular who are obese or have orthopedic participation. Elderly patients with problems. Swimming distance is easily extremely low activity levels may measured in laps, so progress can be respond well to the suggestion that they followed. Even non-swimmers can “do a little more” around the house. benefit from walking against the Although aerobic benefits may not be resistance of waist-deep water. As fitness realized, low-level activities can improve improves, walking in deeper water and confidence, flexibility, and mood. moving the arms add more resistance. Exploring the types of activity available There are a number of excellent water to improve cardiovascular fitness, aerobics courses in many communities; muscle strength, and flexibility can help they are easy on the joints, fun, motiva- both patients and physicians work tional, and permit progress in an together on a realistic exercise program. individualized manner. Cardiovascular Fitness Recommending Cardiovascular fitness can only be Cardiovascular Exercise obtained by aerobic or cardiovascular Parameters exercise. This type of exercise puts a Frequency volume load on the heart, increasing To improve cardiovascular fitness, the venous return to the heart. Aerobic ultimate exercise goal is 30 minutes of 3 activity three or four times per week. the risk of precipitating a cardiovascular Activities that can be prescribed to build Ideally, patients could build up to this event increases – particularly in indi- endurance include: level of activity gradually. Realistically, viduals at high risk for heart disease or however, dialysis patients just beginning with known heart disease. • Aerobics • Bicycling to exercise may not be able to sustain Appropriate exercise intensity will • Cross-country skiing even low to moderate cardiovascular depend on the patient’s initial level of • Jogging activity for more than a few minutes. conditioning. A low-intensity program • Rowing These individuals may benefit from typically involves simply increasing • Stair-stepping several five-minute sessions each day, routine physical activity. Prescribed • Swimming gradually increasing by a minute or two activities may include gardening or just • Walking each day, until they are able to do a strolling down the street – moving the single 20-minute session. For some, muscles, but not significantly increasing this session may include several rest the work of the heart or respiratory system. Other activities that may breaks which may decrease in length as improve cardiovascular This is probably the most appropriate conditioning progresses. fitness if done at a initial exercise prescription for patients moderate level: Duration who are elderly, who have significant • Badminton • Basketball Exercise duration is the (recommended) comorbidities, who have known cardiac • Canoeing • Dancing length of an exercise session needed to disease or are at very high risk for cardiac • Fencing • Handball achieve fitness benefits. Most studies disease, or who have been sedentary. • Jumping rope • Martial Arts have reported on sessions of 30-minute Prescribing higher intensity exercise for • Racquetball • Skating duration, three or four days a week, for these individuals may be discouraging. • Skiing • Soccer cardiovascular benefits, enhanced blood • Softball • Squash A moderate exercise intensity involves pressure control, and improvement in • Table tennis • Tennis activity at approximately 60% of an lipoprotein and HDL cholesterol profiles. • Volleyball* individual’s maximal capacity, a level at Recommended duration is often longer which cardiovascular health benefits can (up to one hour) if weight management be obtained. Because dialysis patients is a goal. typically have a very low maximal For dialysis patients, duration begins capacity, activity at 60% does not with getting up to do something at represent tremendous exertion. Dialysis whatever level they can. Even five patients exercising at a moderate minutes represents more activity than intensity should not sweat profusely in they would get sitting on the couch! The mild weather or become totally exhausted. optimal prescription would suggest a Moderate exercise will increase gradual progression of activity – up to respiration and heart rate somewhat 30 minutes of continuous exercise. above resting levels. Exercise Intensity Individuals who are fairly fit and are Perhaps the most difficult component of accustomed to exercise can tolerate an exercise program to prescribe, exercise activity at a higher intensity (80% of intensity outlines how hard a patient maximal capacity). This is probably should work. It is at this point that the safe, except in cases of known heart risks of exercise must be carefully disease. There may also be an increased considered. As an individual works risk of orthopedic or musculoskeletal * A forearm protector, like those used in archery, may be helpful. harder (ie, closer to maximal capacity), problems at higher intensity. 4 • If experiencing chest pains or pressure Prescribing Exercise When to exercise*: Intensity for Dialysis • If nauseated Patients • If experiencing irregular or rapid • When temperatures are A common way to prescribe exercise heartbeats comfortable, avoiding the very hot or cold times of the day intensity in healthy individuals is to • If experiencing leg cramps recommend a target heart rate. Exercise • If dizzy or lightheaded during or heart rates are prescribed by calculating after exercise When not to exercise*: the age-predicted maximal heart rate • If there is muscle or joint pain (220 minus age) and multiplying by • When body temperature is over Another appropriate way to prescribe 60% to 75%. Prescription of exer- 101.0° F (38.3° C) exercise intensity for dialysis patients is to cise intensity according to heart • When more than one dialysis use a rating of perceived exertion. This rate does not work in dialysis session has been missed rating, also called a work effort scale patients. There are several reasons: • When there is a new illness that (see Figure 1), is an accepted and well- (1) they have abnormal exercise heart has not been diagnosed (ie, the documented measure of subjective levels rate responses; (2) medications that person is medically unstable) of effort. The scale ranges from 6 to 20, affect heart rate response to exercise • When exercise causes pain with effort descriptions at each level. Six may be prescribed and used by patients, is rest. The work effort is greater with depending on blood pressure readings; progressively higher intensity exercise. and (3) fluid status can affect heart Signs and symptoms that should be reported response to exercise. For dialysis patients, the prescription of to physicians*: effort should be in the 12 to 16 range: Instead of being guided by target heart • Pain or pressure in chest, no greater than sixteen for individuals rates, then, dialysis patients should neck, or jaw who can tolerate moderate activity; no learn to watch for symptoms and signs • Excessive fatigue, not related greater than twelve for individuals in a of excessive exertion. to lack of sleep low-intensity program. • Unusual shortness of breath The physician and staff may want to ensure • Dizziness or lightheadedness Patients should be instructed that that patients understand the following: during or after exercise exercise does not have to feel hard. • Persistent rapid or irregular How to determine appropriate Instead, the exercise should be “fairly heart rate during or after exercise intensity*: light” to start and gradually move to exercise • Make sure breathing is at a level “somewhat hard” or “hard” as condi- where conversation is possible tioning improves. • Feel complete recovery within one hour It is important to remember that day-to- • Start slowly, increase effort, end slowly day variations in endurance are normal • Expect some mild discomfort of effort, for dialysis patients and the schedule of but not pain exercise may need to be adjusted • Expect some mild soreness after accordingly. exercise, but not so severe it prevents activity Intensity Variations During Exercise When to discontinue exercise*: Warm-up periods are an important (and re-evaluate medical status part of any cardiovascular exercise and/or program): * Adapted from Fitness After : session. They serve to get muscles warm • When too tired to keep up the effort level Building Strength Through Exercise, copyright and get blood flowing to the working National Kidney Foundation, New York, New • If there is unusual shortness of breath York, 1990, and used with permission. 5 muscles. Jumping right into “somewhat the session, there should be two or three hard” or “hard” exercise without minutes of “very light” cool-down. warming up puts additional stress on the heart. Warming up may also help Muscle Strengthening prevent dysrhythmia and muscle fatigue Muscle strength is increased by placing and can make the exercise itself feel easier. an overload on the muscle. Overloading is achieved by making the muscle work It is equally important to cool down harder than it is used to working. In at the end of an exercise session. strength training this means generating Working muscles demand increased more force. The appropriate amount of blood flow. If an individual stops exer- resistance will depend on the initial cise abruptly after working at a “some- strength of the muscle. Strengthening what hard” or “hard” intensity, he or exercise may be particularly important she will have blood pooling and may for individuals who are elderly or for those experience hypotension and dizziness who have lost significant muscle mass. that could lead to fainting. The primary concern with resistance In general, the intensity of exercise during training is the risk of orthopedic or a session should vary, starting with an musculoskeletal problems, especially in easy warm-up for three to four minutes dialysis patients with bone disease. (low-level, very slow biking, walking) There is an additional concern related that feels “very light” on the scale. After to excessive blood pressure responses, the warm-up, the patient should with high-intensity resistance training. eventually aim for “somewhat hard” or It is recommended that individuals “hard” (12 to 16 on the scale) intensity with poorly controlled hypertension use activity lasting 30 minutes. Some people only very light weights (with increased may want to push for higher levels of repetitions) and avoid high-intensity exertion for short periods. At the end of strength training.

Figure 1. Work Effort Scale 6 Rest How To Use This Scale This scale can be used to monitor 7 Very, Very Light exercise intensity or work effort. Use 8 the number six to rate the level of Very Light Warm-Up & Cool-Down 9 work you do while sitting in a chair at rest. When you exercise faster or hard- 10 Fairly Light er, the work will feel harder to you. Use 11 this scale to rate how hard it feels to 12 you. Monitor your feelings of exertion Somewhat Hard Conditioning throughout your exercise session. 13 Your warm-up should feel “Very Light” 14 (rating of 8 - 9 on the scale). After your warm-up, increase your effort 15 Hard (by walking faster, pedaling against 16 resistance, swinging your arms, etc.) 17 until it feels “Somewhat Hard” or “Hard” Very Hard (rating of 12 - 16 on the scale.) If your 18 effort seems “Very Hard” or “Very, Very 19 Hard,” slow down! End your exercise Very, Very Hard Slow Down! with a cool-down period that feels 20 “Very Light” (8 -9 on the scale). 6 A prescription for muscle strengthening sporting goods and medical supply can range from calisthenics-type stores. Thera-Bands come in varying exercises, to use of a Thera-Band®, hand levels of resistance and are gentle to the weights, ankle weights, or multi-station muscles. The muscle movements in resistance machines. Thera-Band exercises are exactly the same as those done with hand weights. Calisthenics Resistance training must be individual- Resistance Machines ized. It may be helpful to begin with a Dialysis patients who begin to use physical therapy referral to design a weight machines should use only the program of calisthenics-type exercise lightest weight setting for the first several that uses body weight against gravity as sessions to determine how well they resistance, especially for people who are tolerate the resistance. If their muscles very unaccustomed to exercise and who are adapted to the movement and to the are very weak. When the patient is ready, weight, and if they are lifting the a follow-up program can be designed weights properly, they can then move up for independent use at home. to the next weight. Any increase in the amount of weight lifted should come Hand Weights very slowly and gradually. Particularly Once an individual can do more than in patients with known bone disease or 10 repetitions of each calisthenics patients who have not adhered to their exercise, the next step is to add small phosphate binder regimen, there is a hand weights or Thera-Band® exercises. risk of tendon rupture with sudden, Dialysis patients should begin with a heavy weight lifting. Using light weights weight that they can comfortably lift 10 with additional repetitions is probably or 12 times. Weight training first most appropriate. progresses by increasing the number of times the weight is lifted (repetitions). Flexibility When the patient can do 10 or 12 repeti- Flexibility is improved through calis- tions of each of the exercises prescribed thenics, which stretch muscles gently (one set), he or she should gradually and gradually. These exercises are work up to doing two sets and then important for increasing range of three. After the patient is routinely doing motion and facilitating the reaching, three sets of 10 or 12 repetitions, it is bending, and lifting activities of daily time to increase the weight by one or living. Gentle stretching may also help two pounds. Small hand weights can be prevent muscle pulls or tears during purchased inexpensively at sporting other activities – either daily living, goods stores (often $.50/lb), or soup recreational, or associated with an cans, syrup jugs, detergent bottles filled exercise training program. Illustrated with water, socks filled with coins, or flexibility exercises are included in A other household objects may be used. Guide for People on Dialysis. Thera-Band® Thera-Bands are stretchy strips of material available for sale by the yard at Thera-Band is a registered trademark of The Hygenic Corporation. 7 Special EXERCISE Exercise Concerns in

the Dialysis hen possible, it is best to intra-abdominal pressure and may recommend that patients compromise the catheter, causing leaks. Population Westablish an exercise routine. Mechanisms can be developed to clamp off the tubing so patients can exercise For Patients empty, then continue with the exchange Hemodialysis patients may be most after the session. comfortable, have the most normal metabolic/physiological conditions, and CAPD patients can use an exercise respond most appropriately to exercise bicycle even with the bag attached – of on the day after dialysis. During the first course it is vital to keep the bag away hour or two following dialysis, patients from the pedals. Swimming is also may feel fatigued and uncomfortable. possible, with extra effort to cover the After dialysis removes fluid, the cardio- catheter site and clean it diligently vascular system compensates by vascular afterward to prevent infection. Choice of constriction to maintain blood pressure. swimming site is important. Sea water Exercise causes vasodilation, which and chlorinated pool water have less could result in hypotension. This is bacteria than freshwater lakes or ponds. especially true of maximal testing done For Nonambulatory Patients immediately after dialysis. Exercise modes may have to be modified In general, then, high-intensity exercise to facilitate exercise for patients who is not appropriate right after dialysis. cannot walk. Patients who have lower Scheduling exercise on nondialysis days extremity amputations should be referred is an obvious solution. Stable patients to physical therapy for design of an who adhere to diet and fluid regimens appropriate program that utilizes the can exercise at moderate intensity on patient’s remaining capabilities or dialysis days. employs altered equipment (such as an exercise bicycle) so that a patient with an Individuals who gain excessive amounts amputation can use it safely. Many upper of weight between dialysis treatments body exercises for strengthening and probably should avoid exercise immedi- flexibility can be done in a seated position. ately before dialysis because they already have additional cardiac stress from the For Patients with Diabetes* extra fluid. Particular care must also be Daily exercise can play an important taken with individuals who have problems role in glucose management for maintaining a stable potassium level or patients with all types of diabetes. who are noncompliant with their diet. Exercise facilitates rapid uptake of glu- For CAPD Patients cose into the muscles, and, like insulin, lowers the level of glucose in the blood. CAPD patients may feel more comfortable The magnitude of change in blood glu- if they drain fluid out of the abdomen cose level induced by exercise will vary and exercise when they are empty or depending on exercise intensity, dura- partially empty, to permit optimal * For more information, refer to The Fitness tion, and the individual patient. Book for People with Diabetes, Guyton diaphragm expansion. Attempting to Homsby, Jr (ed), American Diabetes Assn. exercise with a full abdomen increases Council on Exercise, 1994. 8 For the most part, diabetic dialysis dosage or increase carbohydrate intake patients exercise at very low intensity prior to exercising. Patients need to be and are unable to exercise for long cautioned that exercise may have pro- periods of time. Therefore, exercise- longed effects on glucose uptake. induced changes in blood glucose levels The risk of exercise-induced hypoglycemia may not be significant. may be minimized if patients take the As patients become more fit and increase following precautions: exercise intensity and duration, close • Monitor blood glucose frequently monitoring of blood glucose may be when initiating an exercise program required. Physicians and patients will to determine patient response. Note need to note the timing of medications, that changes induced by low level insulin administration, and food intake activities may be less than changes as well as blood glucose levels before associated with more intense activities and after exercise. This is especially or longer exercise sessions important if exercise sessions are longer • Decrease insulin dose by 1 to 2 units than one hour. A comparison of pre- as prescribed by the physician, or and post-exercise blood glucose levels increase carbohydrate intake (10 to15 will reveal changes and aid in glucose grams per one-half hour of exercise) management. prior to each exercise session If blood glucose falls dramatically, then • Inject insulin into an area, such as, the food intake prior to exercise may be abdomen, that is not active during recommended. In general, an additional exercise 15 to 30 grams of carbohydrates for • Avoid exercise during periods of maxi- every hour of exercise may be required. mum insulin activity If blood glucose level prior to exercise is • Eat carbohydrate snacks before and greater than 250 mg/dL and ketones are during prolonged exercise sessions present, exercise is contraindicated on that (ie, greater than 60 minutes) day. Exercise may exacerbate the glucose • Know the signs and symptoms of imbalance, and glucose control should hypoglycemia. (Patients who take beta- be improved before beginning exercise. blockers may be unable to experience If blood glucose is lower than 100 mg/dL, symptoms and must closely monitor exercise should be deferred since the risk changes in blood glucose levels) of hypoglycemia is great. In most situa- • Exercise with a partner tions, patients can eat carbohydrates Recommended exercise intensity for and allow blood glucose to increase patients with diabetes is similar to rec- before beginning the exercise session. ommended intensity for other patients, Risk of Hypoglycemia ie., between 40% to 80% of peak exercise Hypoglycemia can occur during exercise capacity. Patients should use the Work or up to 24 hours following exercise. To Effort Scale (pg 6) to gauge intensity. counteract this response, the diabetic For insulin-dependent diabetics, an patient may need to reduce insulin exercise program that calls for frequent 9 (daily) exercise sessions of short dura- For Patients with tion (20 to 30 minutes) may be pre- Cardiovascular Disease ferred. For noninsulin-dependent dia- Patients with coronary artery disease betics, caloric expenditure will be and angina are at higher risk for cardiac optimized in an exercise program that events during exercise. It is important to calls for less frequent exercise sessions of assess these individuals thoroughly and longer duration (40 to 60 minutes). initiate appropriate medical or surgical Exercise is contraindicated for diabetic therapy before permitting them to start patients with an active retinal hemor- on a vigorous exercise program. Cardiac rhage or recent treatment for retinopa- rehabilitation programs are specifically thy (eg., laser treatments). Patients with designed to provide exercise monitoring retinopathy should not perform activities and supervision for individuals with that cause excessive jarring or marked cardiac disease, myocardial infarction, increases in blood pressure. Therefore, angina, angioplasty, mild valvular any weight training for these patients disease, or bypass surgery. should avoid use of heavy weights. does cover cardiac rehabilitation for many patients. For Patients with Bone or If appropriate, patients can be discharged Joint Disease to exercise independently at home or in Individuals with bone disease, joint supervised exercise at a YMCA or other problems, or orthopedic problems community program. Many cardiac should avoid activities such as jogging, rehabilitation programs “graduate” heavy weight training, and high-impact patients into a program where they are aerobic dance. Individuals who begin to minimally supervised. experience joint discomfort in their exercise training program may have to Aerobic exercise that puts an increased change to a nonweight-bearing activity volume/pressure load on the heart is such as cycling or swimming. probably contraindicated for individuals with severe valvular disease. Medical It is possible to develop increased management of the valvular disease flexibility and muscle strength despite and/or surgical treatment may be renal bone disease. However, patients indicated, depending on the medical with bone disease may be at high risk plan for the patient. If the valvular for fractures or tendon ruptures, since disease is mild, the patient may benefit the connections at the tendon level and from exercise training. However, if bone level may be weakened. In addition regurgitation or insufficiency increases to avoiding high-impact activities, these with exercise, as evidenced by exercise patients should not attempt significant echocardiography, exercise training is grades on a treadmill that would put probably not appropriate. If there is no tremendous stress on the Achilles tendon. change with exercise, the patient is Very light weight training, strengthening, probably fairly stable with exercise and and resistance exercises will probably be will probably tolerate it well. well tolerated and may prevent or slow the progression of bone disease. 10 Patients with a pericardial effusion should not exercise if the effusion is large. Appropriate medical management should be initiated and the effusion resolved before an exercise training program is initiated. Small effusions should not prohibit low-level exercise. Finally, an individual in congestive heart failure due to volume overload associated with inadequate dialysis, or who is just starting dialysis, should be adequately dialyzed and have fluid balance stabilized before starting an exercise training program. For Blind Patients Blind patients can be physically active. The dialysis unit may want to seek out special programs for the blind, but, in general, use of an exercise bike or pool can be appropriate. Vision is not necessary for use of an exercise bicycle; listening to television or audiotapes may make the exercise more interesting. Walking is also a possibility for patients with guide dogs or walking companions or on a treadmill with handrails. For Patients with Neuropathy Foot care is always a concern for any patient with neuropathy. These patients must be taught to inspect their feet daily, maintain good hygiene, and wear appropriate socks and shoes. It may be advisable for patients with neuropathy to wear aqua-shoes, reef-walkers, or other protective footwear when parti- cipating in water exercise because they may not feel their feet hitting the bottom of the pool.

11 Performance EXERCISE Based Tests

hysicians and staff who want to The second component is handrail use, assess their patients’ physical which has two categories: P functioning or establish base- 0 = requires handrail; line performance measures prior to the 1 = does not require handrail. start of an exercise program may consider conducting one or more of these perfor- The third component is stair climbing, mance-based tests. which has two categories: 0 = does not alternate steps; and Please Note: These tests have not been 1 = alternates steps. validated, nor is there currently any data that show that these tests can The highest possible score is 6. measure change resulting from any Higher scores indicate higher physical exercise intervention. functioning. Sit to Stand Test Lift/Reach This test is performed using a standard This is a test of upper extremity strength chair (46 cm height). Subjects sit down, and endurance. The patient stands facing then stand completely, then sit down a table with two shelves above it – one again as many times as possible in a at shoulder height and the second period of one minute. slightly above the head. The patient lifts an object that weighs 25% of the patient’s Walking Performance body weight. The patient lifts the object This test is performed on a marked from the table to the first shelf then to distance (indoors) of 20 feet. Patients the second shelf. The number of lifts first walk the distance at the “normal performed in one minute can be recorded. comfortable speed,” then again at their “maximum safe speed without References Bohannon RW, Hull D, Palmeri D. Muscle running.” The time required to traverse strength impairments and gait performance the 20 feet each time can be recorded. deficits in candidates. Am J Kidney Dis., 1994;24:480-485. Stair Climbing Bohannon RW, Smith J, Hull D, et al. Deficits in Stair climbing ability is assessed by lower extremity muscle and gait performance scoring three components. among renal transplant candidates. Submitted for publication in Archives of Physical Medicine The first component is assistance, which and Rehabilitation. has five categories: Bohannon RW, Walsh S. Association of paretic 0 = fully dependent; lower extremity muscle strength and standing balance with stair-climbing ability in patients 1 = requires maximum assistance with stroke. J Stroke Cerebrovasc Dis. (assistance effort > subject effort); 1991;1:129-133. 2 = requires moderate assistance (subject effort > assistant effort); 3 = requires minimum assistance (touch or light help); and 4 = requires no physical assistance. © Medical Education Institute, Inc. 1995 12 Supported by An Educational Grant from

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