EXERCISE FOR THE DIALYSIS 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. Seattle, 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 University of Washington 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 •