https://menj.journals.ekb.eg MNJ Print ISSN: 2735-3974 Menoufia Nursing Journal Online ISSN: 2735-3982 Faculty of Nuring DOI: ------Menoufia University

Effect of Intradialytic Range of Motion Exercises on Efficacy and Blood pressure among Patients Undergoing Sahar A. Mohamed1, Amal A. Kanona2, Nahed F. El-Gahsh3 1B.Sc. Nursing, 2Assistant Professor of Nursing, 3Assistant Professor of Nursing Medical Surgical Department, Faculty of Nursing, Menofia University

Abstract: Background: End stage renal disease is a major public health problem in developing countries. Purpose: To determine the effect of intradialytic exercises on dialysis efficacy and blood pressure among patients undergoing hemodialysis. Setting: The hemodialysis unit of Menoufia University Hospital. Sampling: A consecutive sample of 50 adult hemodialysis patients were selected and divided alternatively into two equal groups: 25 patients for each group (study - control). Instruments: Four instruments were used for data collection: Structural interview questionnaire, bio-physiological instrument, and observational checklist. Results: There was a reduction in mean one month after intervention and mean of blood pressure (128.48 ± 9.70 Vs 134.55 ±3.78). Conclusions: Intradialytic exercises were effective in improving dialysis efficacy and blood pressure scores for patients undergoing hemodialysis. Recommendations: A health teaching program about intradialytic exercises should be carried out for all hemodialysis patients to improve dialysis efficacy and blood pressure. Besides, a colored booklet should be available and distributed to all hemodialysis patients. Key words: Blood pressure, Dialysis efficacy, Intra dialytic exercises. Introduction Kidney disease is defined as a global adequate waste removal, and normal public health problem that affects more hormonal function. To survive, people than 750 million persons worldwide. with ESRD must undergo some form of Chronic kidney disease (CKD) is not a renal replacement therapy, namely, a functionally static process because it is peritoneal dialysis, or hemodialysis a progressive one that can lead to end- (HD), or kidney transplantation stage renal disease (ESRD). ESRD (Parsons et al., 2016a). substantially alters the patient’s End-stage renal disease is associated lifestyle and imposes increased with severe morbidity, mortality, high morbidity and mortality in those cost for management and different patients (Webster et al., 2017). impacts on general health and patient End-stage renal disease (ESRD) is the wellbeing. More than 90% of patients point in kidney failure when almost diagnosed with end-stage renal disease (ESRD) regularly receive hemodialysis 90% of renal function has been lost, rendering the body unable to maintain (HD) as renal replacement therapy. proper fluid and electrolyte balance, During the last three decades, patients

MNJ, Vol. 5, No. 2, Nov 2020, PP: 39-54 39 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. who receive maintenance dialysis hemodialysis patients in Menoufia globally increased dramatically. In governorate was 483(pmp) (El- 2010 it was estimated that the number Zorkany, 2017). of patients on dialysis was more than 2 The maintenance hemodialysis (MHD) million worldwide, and modeling data patients are profoundly deconditioned, suggest this number will more than often vulnerable, and older with muscle double by 2030 (United States Renal wasting and altered nutritional status. Data System, 2019). Hemodialysis leads to distinct The prevalence of ESRD continues to metabolic changes such as increase in many countries: more than hypovolemia, electrolyte imbalance, 2000 person per million populations and systemic inflammation (Cano et al., (pmp) in Japan, about 500 pmp in the 2017; Kono et al., 2018). USA, and about 800 pmp in the The hemodialysis nurse has an essential European Union. In developing role in hemodialysis unit, as the dialysis countries, the figures vary from less nurse typically operates the than 100 pmp in sub-Saharan Africa to hemodialysis machine that extracts about 400 pmp in Latin America and blood from the patient, cleans it and more than 600 pmp in Saudi Arabia returns it into the body. Other HD (El-Arbagy et al., 2016). nurses' responsibilities include Patients with end-stage renal disease administration of treatments, have only two options in order to stay monitoring patient vital signs especially alive: life-long dialysis (hemodialysis blood pressure, communicating or peritoneal dialysis) or renal procedure details with patients, and transplantation. Of these options, assessing the effectiveness of dialysis is considered the treatment of procedures, as well as being choice. The majority of patients receive responsible for the cleanliness of work hemodialysis, as patients on area. It is also the responsibility of the hemodialysis account for dialysis nurse to be sympathetic, caring, approximately 98.7% of patients patient, positive and responsible when receiving hemodialysis and 1.3% who caring for patients (Alyaseen, 2019). received peritoneal dialysis (Gaipov et- Exercises are very important non- al., 2020). pharmacological method for primary Hemodialysis (HD) is a life-changing and secondary prevention of process as it requires the ESRD patient cardiovascular disease. Physical to visit the dialysis unit usually 3 times activity ameliorates cardiovascular risk per week for 3-5 hours. As one would factors such as blood pressure (BP) and expect, this lifestyle change decreases lipid profiles as well as dialysis the quality of life (QOL) of these efficacy (Abd El-Halim et al., 2017a; patients as compared to healthy adults. Anding et al., 2015). In fact, the more advanced the CKD Intradialytic exercise (IDE) is defined stage, the more impaired the QOL as exercise training program during the (Aggarwal et al., 2016). hemodialysis (HD) session aiming to In Egypt, the total prevalence of increase strength and endurance of HD patients on dialysis increased from 225 patients and hence targeting various person per million (pmp) in 1996 to physiological and psychosocial 483 pmp in 2008 (according to last parameters. The nature of the IDE Egyptian renal registry). In Menoufia, includes resistance, aerobic and the total prevalence rate of stretching, and using different

40 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. equipment. IDE has shown to have a nausea, vomiting, tremors, abnormal positive effect on the overall health and mental function and increase of blood hospitalization rate of HD patients pressure measurements. Also, they are (Kouidi et al., 2019). liable to develop uremia and Intradialytic exercise revealed strong hypertension (Ferrans & Powers, positive correlations with dialysis 2017). In Egypt, although all patients efficacy, blood pressure, high- undergoing hemodialysis suffer from sensitivity C-reactive protein, arterial the same complaints, limited researches stiffness, health-related QOL, and were done to alleviate their sufferings. depression (Sheng et al., 2014). Therefore, this study is conducted to Moreover, several researches have determine the effect of intradialytic proven that exercise during exercises on dialysis efficacy and blood hemodialysis is easy and safe showing pressure among patients undergoing significant changes in physical and hemodialysis. psychological conditions, which Research Hypotheses positively influence their social life The following research hypotheses are (Motedayen et al., 2017a). formulated in an attempt to achieve the The intradialytic exercises results in aim of the study: increased muscle blood flow and 1) Patients who participate in opened capillary surface area. Patients intradialytic range of motion doing exercises during dialysis have exercises (study group) will have a toxic substances, also called uremic higher dialysis efficacy score than toxins in the blood. This results in patients who don't participate in malaise, paraesthesia, peripheral intradialytic range of motion circulatory disturbance, mental exercises (control group). impairment and muscle dysfunction move through the dialyzer with a large 2) Patients who participate in flux from the tissue to the vascular intradialytic range of motion compartment (Parsons et al., 2016 b; exercises (study group) will Silva & Marinho, 2015). experience more stable blood pressure than patients who don't An exercise protocol can lead to participate in intradialytic range of improvement in many functions, such motion exercises (control group). as blood pressure, heart function (especially ventricular function in Methods hemodialysis patients), muscle strength, Research Design: and respiratory capacity, and reduce muscle atrophy, with excellent results Quasi-experimental (study and control). for the quality of life. Range of motion Setting: exercises can be considered as a routine care while delivering hemodialysis as it The study was carried out in the is performed for 15 min/day, three Hemodialysis Unit of Menoufia times a week during dialysis sessions University Hospital, Shebin El-Kom, (Heiwe & Jacobson, 2018; Mohamed & Menoufia Governorate, Egypt. Soliman, 2015). Sample: Significance of the study A consecutive sample of 50 patients Worldwide, hemodialysis is a undergoing hemodialysis. Inclusion physically stressful procedure. These criteria were a) Being under patients suffer from weakness, fatigue, hemodialysis for more than 2 months.

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 41 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. b) Receiving hemodialysis sessions 3 Instrument two: sphygmomanometer: times per week. Exclusion criteria It is a mercury sphygmomanometer. It were a) Adhering to other exercise is made by Omron group in China. programs to be sure about the effect of Instrument three: Dialysis efficacy exercises on dialysis efficacy and blood and blood pressure recording chart: It pressure. b) Instability in hemodynamic was developed by the researcher. It parameters before and during the contained 2 items. exercises to prevent deterioration of patient's condition. c) Patients who . Part one: Dialysis efficacy: Dialysis have musculoskeletal problems. efficacy was assessed by evaluating Sample size calculation: the urea reduction ratio. It was determined at a baseline and on a Based on the previous studies that examined the same outcomes and found monthly basis during the exercises significant differences and on the total program. number of patients under hemodialysis . Part two: Assessment of systolic at University Hospital; 2079 patients and diastolic blood pressure. (Statistical administrative records of Instrument four: Observational Menoufia University Hospital, 2018), a checklist: It was developed by the consecutive sample of 50 patients of researcher to investigate the patient's both sexes undergoing hemodialysis practice of intradialytic range of motion were selected. Patients were assigned exercises. It contained exercises related randomly and alternatively into two to 3 parts of the body (wrist, elbow and equal groups for applying the treatment ankle). These exercises were done by protocol. the patients and checked by the Study group (I): Those patients did researcher to decide whether or not intradialytic range of motion exercises they were effective. for 10 to 15 minutes in the first two Validity of Instruments: hours of every hemodialysis session for a period of two month. All Instruments were tested for face and content validity by 5 experts in the Control group (II): Those patients field of Medical-Surgical Nursing were exposed only to routine hospital Department Faculty of Nursing, care. Menoufia University. Modifications Instruments: were done to ascertain relevance and completeness. Reliability of Structured Instrument one: Instruments: Interviewing Questionnaire: This instrument was developed by the The reliability of Instruments was done researcher to identify the characteristics to determine the extent to which items of the sample. It contained two parts. in the instruments were related to each Part one: Social characteristics: It was other by Cronbach's Co-efficiency included of 6 questions related to Alpha for instruments two (a=.727) and patient's age, sex, education, for instruments three (a=.721). So it can occupation, marital status and be concluded that the instruments have residence. Part two: Medical data: It adequate level of reliability. Pilot contained 4 items about the past study: medical history, hemodialysis, A pilot study was conducted before practicing sports and patients' vital data collection on 10% of the sample (5 signs in the first session. patients). This was performed to test

42 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. the clarity and applicability of the collection was done between 8 am and instruments. Necessary modifications 5 pm. were done. For the study group, the intradialytic Ethical consideration: range of motion exercises was explained using a A written consent was obtained from colored illustrative all participants for participation in the booklet prepared by the researcher. study after explanation of the purpose This booklet included data about renal failure, hemodialysis and the of study. All patients were reassured that any information obtained would be intradialytic range of motion exercises. confidential and would only be used for The researcher explained everything the purpose of the study. The researcher about these exercises (definition, affirmed that participation in the study benefits, precautions, and description of was entirely voluntary. Anonymity of each exercise). Afterwards, the patients was assured through coding demonstration was done for every the data. Patients were also informed patient in the study group using that refusal to participate wouldn't instrument three (Observational affect their care. checklist). During this session, reinforcement was carried out Procedure: according to each patient needs. The A letter was submitted from the Dean researcher demonstrated the following of the Faculty of Nursing to the exercises: directors selected settings. Data were . 20 rounds per minute (RPM) collected over a period of 2 months clockwise of wrist and ankles from March, 2020 to May, 2020.The researcher entered the room of patients, . 20 RPM counter-clockwise introduced herself to them and . 20 times full flexion and extension explained the purpose of the study. of the wrist Patients who agreed to participate in . 20 times full flexion and extension the study and fulfilled the inclusion of the elbow joint criteria were interviewed individually by the researcher. The included patients . 20 RPM of rotating the ankles were divided alternatively into two clockwise equal groups (25 patients for each . 20 RPM of rotating the ankles group). The patients in the morning counter-clockwise shift were selected to be involved in the study group and the patients in the . 20 times full flexion and extension afternoon shift were included in control of the ankles group. The researcher deal with the The intradialytic exercises were done study group (I) first then control for 15 minutes, 3 times per week, group(II) to avoid the contamination of during the first 2 hours of each dialysis data. session. No exercise was carried out At the beginning of the first session: during the second half of the session. Body parts that were connected to Social characteristics of each patient dialysis machine were excluded. were obtained using instrument one Systolic and diastolic blood pressures (Structured interview questionnaire). were assessed before and after each Dialysis efficacy and blood pressure hemodialysis session. were recorded in a chart. Data At the beginning of the follow up session: Blood samples were drawn to

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 43 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. obtain serum urea concentration. Then, Results: urea reduction ratio was estimated to Table (1): showed that, the mean ages assess the dialysis efficacy for every of study and control groups were patient in the study group by using 40.28±10.83and 41.72±9.44years old, instrument two (Bio physiologic respectively. More than half 60% and measurement instrument). The 52%of the studied patients in the study researcher refreshed the previous and control groups were males, knowledge and then a re- respectively. Concerning marital demonstration for the intradialytic status, the majority of the studied exercises was done using instrument patients (80% and 88%) in the study three (Observational checklist). and control groups were married. Systolic and diastolic blood pressures Regarding level of education, 52% of were assessed pre- and post-patient the studied patients in the study group dialysis session and recorded to and 44% of the studied patients in the evaluate the patients' blood pressure. control group had diploma. In relation Evaluation of all patients of both to occupation, more than one third groups was carried out twice; at the end (40% and 36%) of study and control of the first month and at the end of the groups had a hand work, respectively. follow up session to assess the effect of There were no statistically significant intradialytic range of motion exercises differences between both groups on dialysis efficacy and blood pressure. regarding social characteristics. Blood pressure: Systolic and diastolic blood pressures were measured before Table (2): shows that the mean of urea and after hemodialysis session. Then, reduction ratio (dialysis efficacy) on the mean of blood pressure measures pre intervention (baseline) for study was estimated at the end of every and control groups was 59.40±10.84 month for every patient to be prepared and 63.29±11.29, respectively. Also, for comparison A comparison was done the mean of urea reduction ratio one between both groups to determine the month post- intervention for study and effect of intradialytic exercises on control groups was 61.44±8.44 and dialysis efficacy and blood pressure 60.40±14.63, respectively. So, there among patients undergoing were no statistically significant hemodialysis. differences between study group and control group on pre-intervention and Statistical Analysis: one-month post-intervention. The collected data were tabulated and Meanwhile, the mean of urea reduction analyzed by SPSS (statistical package ratio two-month post-intervention for for the social science software) study and control groups was statistical package version 20 on IBM 67.14±10.19 and 59.66±12.99, compatible computer(SPSS, Chicago, respectively. So, there were statistically IL, USA).Two types of statistics were significant differences between study done: Descriptive statistics: expressed and control group regarding urea as mean and standard deviation (X+SD) reduction ratio at a level of P=0.02. for quantitative data or number and Figure (I): revealed that the mean of percentage (No & %) for qualitative urea reduction ratio (dialysis efficacy) data. Analytic statistics (Pearson Chi- 2 on pre intervention (baseline) for study square test (χ ) & Fisher`s Exact Test, and control groups was 59.40 and Student t- test, Repeated-Measures 63.29, respectively. Also, the mean of ANOVA, ANOVA test (parametric urea reduction ratio one-month post- test, Pearson correlation).

44 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. intervention for study and control regarding SBP post patient connection groups was 61.44and 60.40, first month. respectively. So, there were no Regarding the 2nd month, there were statistically significant differences highly statistically significant between study group and control group differences between the study and on pre-intervention and one-month control groups regarding means of SPB post-intervention. Meanwhile, the mean pre- and post-patient connection at 1% of urea reduction ratio two-month post- level of significance. There were intervention for study and control statistically significant differences groups was 67.14 and 59.66, between the study and control groups respectively. So, there was statistically regarding mean DBP pre- and post- significant difference between study patient connection at 5% level of and control group regarding urea significance. reduction ratio. Regarding study group, means of SBP Regarding study group, there were no first and second month were137.93 ± statistically significant difference 11.17 & 134.52 ± 9.62, respectively, between pre-intervention (baseline) & and means of DBP first and second one month post-intervention. month were 85.09 ± 5.36& 82.64 ± Meanwhile, there were statistically 3.45, respectively. So, there were significant differences between pre- statistically significant differences intervention (baseline) & two-month between the first and second month post-intervention and between one- concerning SBP & DBP for the study month post-intervention & two-month group. post-intervention. Regarding control group, means of Regarding control group, there were SBP first and second month were no statistically significant difference 144.80 ±8.68& 145.0 ±8.51, between pre-intervention (baseline), respectively, and means of DBP first one-month post-intervention and two- and second month were 86.91 ±6.46 & month post-intervention (Repeated 85.10 ±2.29, respectively. So, there is measures). no statistically significant difference This means that patients who in the between the first and second month study group had higher dialysis efficacy concerning SBP & DBP for the control scores (Urea reduction ratio) than group. patients in the control group. Also, there were statistically significant Table (3): showed that: regarding the differences between the study and 1st month, there were no statistically control groups regarding mean SBP significant differences between the first month and mean DBP second study and control groups regarding month. There were highly statistically means of SPB pre-patient connection significant differences between the first month, means of DBP pre- and study and control groups regarding post-patient connection first month. means of SPB post-patient connection. Meanwhile, there were statistical Figure (II): showed that, regarding differences between means of SBP study group, means of SBP first and post-patient connection in the first second month were 137.93 & 134.52, month for the two groups 128.48 ± 9.70 respectively, and means of DBP first & 134.55 ±3.78, respectively. So, there and second month were 85.09 & 82.64, was a statistically significant difference respectively. So, there were statistical between the study and control groups

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 45 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis.

differences between the first and fourth week. Regarding the 1st week, second month concerning SBP & DBP. about two thirds of the patients (64%) nd Regarding control group, means of did poor exercises. Regarding the 2 SBP first and second month were week, about half of patients did 144.80 & 145.0, respectively, and acceptable exercises while about half of means of DBP first and second month them did good exercises 52% & 48%, were 86.91 & 85.10, respectively. So, respectively. So, there were differences there was no difference between the between the first and the fourth weeks first and second month concerning SBP regarding the total scores of the & DBP. patients' practice. Table (4): shows the total scores of Table (5): shows that there was high significant positive correlations of patients in the first and the fourth week. Regarding the 1st week, about two mean motion exercises score at the thirds of the patients (64%) did poor fourth week with the urea reduction exercises. Regarding the 2nd week, ratio one-month post-intervention about half of patients did acceptable (P<0.001). There were negative exercises while about half of them did correlations between mean motion good exercises 52%&48, respectively. exercises score at fourth week and So, there were statistical differences means of systolic blood pressure and between the first and the fourth weeks diastolic blood pressure post one- regarding the total scores of the month exercises. So, there were patients' practice. statistically significant differences at 5% level of significance. Figure (III): shows the total score of patients' practice at the first and the Table (1): Social Characteristics of the Studied Patients. Demographic Studied groups characteristics Study group Control group (n=25) (n=25) χ2 P value NO. % NO. % Age (years): Mean ± SD 40.28 ± 10.83 41.72 ±9.44 t- test = 0.61 Range 25.0 – 61.0 23.0 – 56.0 0.50 ns Sex: Male 15 60.0 13 52.0 0.32 ns FET 0.56 Female 10 40.0 12 48.0 Marital status: Single 4 16.0 0 0.0 Widow 1 4.0 2 8.0 5.42 ns 0.14 Married 20 80.0 22 88.0 Divorced 0 0.0 1 4.0 Education level: Illiterate 4 8.0 6 24.0 ns Read & write 4 8.0 7 28.0 3.18 0.36 Diploma 13 52.0 11 44.0 High education 4 8.0 1 4.0 Occupation: Hand work 10 40.0 9 36.0 ns Administrative work 7 28.0 5 20.0 0.91 0.82 No work 1 4.0 1 4.0 Housewife 7 28.0 10 40.0

46 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis.

Table (2): Means of urea reduction ratio of the studied groups on pre, post and follow up tests.

Urea reduction ratio Studied groups Study group Control group (n=25) (n=25) Students` P value Mean ± SD Mean ± SD t- test Range Range pre-intervention 59.40 ± 10.84 63.29 ±11.29 0.22 1.22 ns (baseline): 16.23 – 75.0 40.0 – 96.0 One-month post- 61.44 ± 8.44 60.40 ±14.63 0.30ns 0.76 intervention: 30.76 – 83.33 6.34 – 94.52 Two-month post- 67.14 ± 10.19 59.66 ±12.99 0.02 2.27(s) intervention: 52.54 – 91.84 6.53 – 74.76 Repeated measures 4.74 0.58 ANOVA P value 0.02(s) 0.54ns Post hoc test P1= 0.43ns P1= 0.48 ns P2= 0.02 (s) P2= 0.24 ns P3= 0.006 (s) P3= 0.83ns

Figure (I): Urea reduction ratio of the studied groups.

90

80

70

60 67.14 59.66

SD 50 ± 61.44 60.4 40 Mean 59.4 63.29 30

20

10

0 Study group Control group

Urea reduction ratio pre-intervention (baseline) Urea reduction ratio one month post-intervention Urea reduction ratio two month post-intervention

Table (3): Mean blood pressure measurement of the studied groups on pre, post and follow up tests.

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 47 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis.

Mean Blood pressure Studied groups measurements Study group Control group Students` P value (n=25) (n=25) t- test Mean±SD Mean±SD Mean SBP pre patient ns 147.38 ± 15.37 155.05 ±17.27 1.65 0.10 connection first month:

Mean SBP post patient S 0.007 128.48 ± 9.70 134.55 ±3.78 2.91 connection first month:

Mean DBP pre patient ns 0.62 90.11 ± 9.58 91.71 ±3.17 0.49 connection first month:

Mean DBP post patient ns 0.25 80.07 ± 3.37 81.11 ±3.0 1.15 connection first month: Mean SBP pre patient HS 0.001 144.93 ± 11.20 157.83 ±13.85 3.66 connection second month:

Mean SBP post patient HS 0.001 124.11 ± 8.68 132.16 ±6.90 3.62 connection second month:

Mean DBP pre patient S 0.009 87.05 ± 3.56 89.63 ±3.13 2.73 connection second month:

Mean DBP post patient S 0.009 78.23 ± 3.60 80.56 ±2.31 2.72 connection second month: Mean SBP first month: 137.93 ± 11.17 144.80 ±8.68 2.43 S 0.01 Mean SBP second month: 134.52 ± 9.62 145.0 ±8.51 4.07 HS <0.001 Paired t test 2.44 S 0.16 ns P value 0.02 0.86 Mean DBP first month: 85.09 ± 5.36 86.91 ±6.46 0.78 ns 0.43 Mean DBP second month 82.64 ± 3.45 85.10 ±2.29 2.97 S 0.005 Paired t test 2.33 S 0.87 ns P value 0.03 0.39 Figure (II) Mean blood pressure measurements of the studied groups.

160 140 144.8 137.93 120 134.52 145

100 80 85.09 86.91 Mean 60 82.64 85.1 40 20 0 Study group Control group

Mean SBP first month Mean SBP second month Mean DBP first month Mean DBP second month

48 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis.

Table (4): Distribution of total score of patients` practice of intradialytic range of motion exercises in the first and fourth weeks

Total score of patients' practice Items At 1st week At 4th week χ21 p-value No. % No. % Poor practice 16 64.0% 0 0.0% Acceptable practice 6 24.0% 13 52.0% 23.979 0.000 Good practice 3 12.0% 12 48.0%

Figure (III): Total score of patients' practices.

Total score of patients' practice

70.00% 64.00%

60.00% 52.00% 48.00% 50.00%

40.00% At 1st week 24.00% 30.00% At 4th week

20.00% 12.00% 10.00% 0.00% 0.00% Poor practice Acceptable good pratice practice

Table (5): Correlation between patients` mean motion exercises score & blood pressure and urea reduction ratio

Mean motion exercises score at fourth week R P value (Pearson correlation coefficient) Urea reduction ratio one- 0.67 <0.001 HS month post-intervention: Mean SBP first month -0.44 0.02 S Mean DBP first month -0.50 0.01 S Discussion End-stage renal disease (ESRD) is either dialysis or renal transplantation. defined as a health problem that Hemodialysis is the most common requires long-term and costly care. form of treatment modalities for renal The standard management of ESRD is replacement therapy offered in

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 49 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. hospital based units. In Egypt, the (2018a); Parsons et al. (2016) and Sun prevalence of dialysis patients is et al. (2016) who found that there was presumed to be increasing (El-Besely a significant improvement in URR et al., 2018). after 8 weeks of intradialytic exercises Basically, a vital point within the program. However, the results were in management of patients undergoing disagreement with Vaithilingham et maintenance hemodialysis is the al. (2015) who found no changes in assessment of the dialysis efficacy. equilibrated spKt/V or URR in 12 HD Inadequacy of dialysis is responsible patients who performed intradialytic for disability and mortality for exercises on average of 13 dialysis patients. So, to improve min/dialysis session for a period of 4 prognosis of dialysis patients it's weeks. One possible explanation for necessary to enhance adequacy of this discrepancy could be that dialysis (Bayoumi & Al Wakeel, exercises should be done two months 2019). or more in order to enhance urea removal and therefore improve Previous literature has documented a dialysis efficacy. variety of potential benefits that ESRD patients may achieve from The results of this study showed that exercise training such as improvement the intradialytic range of motion in urea , decrease in blood exercises improved the dialysis pressure, increase in aerobic capacity, efficacy of the study group. So reduced need for antihypertensive hypothesis (1) was accepted. medications, and improvement of the In relation to improving blood removal of toxins through dialysis pressure after practicing (ElShemy et al., 2016). intradialytic range of motion Hence the purpose of the present exercises, the current study study was to determine the effect of hypothesized that patients who did intradialytic range of motion exercises intradialytic range of motion exercises on dialysis efficacy and blood (study group) had more improvement pressure among hemodialysis patients. in blood pressure than patients who didn't do intradialytic exercises Intervention & two-month post- (control group). intervention, the intradialytic exercise resulted in a substantial increase in Regarding systolic blood pressure, the dialysis efficacy scores. As intra result of the current study showed that there was statistically significant dialysis exercises increased the muscle blood flow and opened the difference between the study and capillary surface area which control groups in the first month. subsequently increased the flux of Also, there was a high statistically urea from the tissue to the vascular significant difference between the compartment. Such an increase study and control groups in the second resulted in an increase in serum urea month. clearance and improvement in the Regarding diastolic blood pressure, dialysis efficacy. These findings the result of the current study showed clearly indicated that exercise can be that there was statistically significant used as an adjunctive therapy to difference between the study and enhance dialysis efficacy. The results control groups in the second month. of current study were in agreement This came in accordance with the with the findings of Mohseni et al. results done by Henrique et al. (2018)

50 Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. and Reboredo et al. (2016) who stated the positive effect of intradialytic that at the end of the exercise exercise on , program, there was a statistically physiological parameters, biochemical significant reduction in systolic blood markers and quality of life. Also pressure. Also, this finding was Cheema et al. (2017) quoted that it is consistent with the findings of Miller widely accepted that exercise is et al. (2017) which showed that beneficial in patients with end stage intradialytic exercises was safe during renal failure and that it leads to HD and led to significant reductions improvement of physical functioning in systolic and diastolic blood in general. pressure measurements. The present study presented that there Moreover, reduction of BP may be was no statistically significant relation due to reduction of blood volume of total scores of exercises (reduction in the cardiac load), performance with socio-demographic because of favorable effects of characteristic as sex and educational exercise on the peripheral vascular level of study group two months post resistance, sympathetic nervous exercises. This finding was similar to system activity and also possibly to Motedayen et al. (2017b) indicating the -angiotensin system that there was no statistically according to Deligiannis et al. (2019). significant difference between the The results of this study showed that socio-demographic characteristics and the intradialytic range of motion the exercise performance of the study exercises improved the blood pressure group. measurements of the study group. So, Correspondingly, Paluchamy & hypothesis (2) was accepted. Vaidyanathan (2018b) reported that exercises during hemodialysis session In relation to exercises performance: Intradialytic exercise is (intra dialtic) increased the muscle safe and effective but underutilized. It blood flow. Thereby, there was more is well documented that dialysis removal of waste products and as a patients have low levels of physical result there was an improvement in functioning and low exercise dialysis efficacy and improvement in performance (Bennett et al., 2017). blood pressure measurements. The present study showed that there Also, Abd El-Halim et al. (2017b) were many benefits for intradialytic reported reduction of systolic and exercises for hemodialysis on dialysis diastolic blood pressure after efficacy and blood pressure. These practicing intradialytic exercises for a findings came in line with Mohamed period of three months. They reported & Soliman (2015) who reported the that this reduction may be due to the benefits of exercise training on effect of exercise on the peripheral fatigue, electrolytes level and blood vascular resistance, sympathetic pressure in hemodialysis patients. nervous system activity and the renin- Also, these findings were in angiotensin system. agreement with Mohseni et al. From the forgoing discussion, it can (2018b) who reported that there was a be concluded that the intradialytic positive effect of intradialytic exercise range of motion exercises are on dialysis efficacy in hemodialysis effective non pharmacologic patients. Also, these findings were in intervention for improving dialysis agreement with Paluchamy & Vaidyanathan (2018a) who reported

Menoufia Nursing Journal, Vol. 5, No. 2, Nov 2020 51 Effect of Intradialytic Range of Motion Exercises on Dialysis Efficacy and Blood pressure among Patients Undergoing Hemodialysis. efficacy and blood pressure among Hemodialysis Patients. Med. J. hemodialysis patients. Cairo Univ, 85 (5), 1789-1794. Conclusions: Aggarwal, H. K., Jain, D., Pawar, S., & Yadav, R. K. (2016). Health- Based on the findings of this study, related quality of life in it can be concluded that: different stages of chronic 1) Intradialytic exercises have a high kidney disease. Qjm, 109 (11), significant effect on improving the 711-716. dialysis efficacy (urea reduction ratio) among study group Alyaseen, F. (2019). The Patient care compared to control group and Complications of undergoing hemodialysis. Hemodialysis Procedure for Renal Failure Patients: A 2) The mean systolic and diastolic Descriptive Study at El-Nasiriya blood pressure measurements have City, South of Iraq, Global been significantly improved among Pharma Technology,10(3),356- study group compared to control 365. group after application of intradialytic exercises undergoing Anding, K., Bar, T., Trojniak- hemodialysis. Hennig, J., Kuchinke, S., Krause, R., & Rost, J.M.et al. Recommendations: (2015). A structured exercise A. Recommendations for patients: programme during haemodialysis for patients with  A health teaching program should chronic kidney disease: clinical be carried out for hemodialysis benefit and long-term patients at hemodialysis unit about adherence. BMJ Open, 5(8), the importance of intradialytic e008709. exercises to help them improve their quality of life. Bayoumi, M& Al Wakeel, J. (2019). Impacts of exercise programs on  A colored booklet about the hemodialysis patient’s quality of disease, complications of life and physical fitness. Qual hemodialysis, how to overcome it Prim Care, 23, 192-200. and intradialytic exercises should be available and distributed to all Bennett, P., Breugelmans, L., hemodialysis patients. Barnard, R., Agius, M., Chan, D., & Fraser, D. (2017). B. Recommendation for further Sustaining a hemodialysis researches: exercise program: A review,  Replication of the study using a Semin Dial, 18 (9), 62-73. larger sample from different Besely, W.N., Faheim, S& Aly, M. geographical areas is important to (2020). Effect of Implementing help generalize results. a health education program for References: nurses on satisfaction level of patients undergoing Abd El-Halim, E.M., Aziz, A.G., hemodialysis, IOSR Journal and Baligh, E., El-Khashab, S., & Health Science, 7(4), 45-57. El-Sayed, S.H. (2017). Blood Pressure Response to Cano, N.J., Fouque, D& Roth, H. Intradialytic Resisted Exercise (2017). Intradialytic parenteral Training in Regular nutrition does not improve

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