**3. Physical fitness and physical functioning and self-evaluation in patients with CKD**

The physical fitness and physical functioning (= the ability and capacity to perform activities of daily living) is severely reduced in adults with CKD (Kettner-Melsheimer et al 1987;

The Importance of Exercise Programs in Haemodialysis Patients 433

Many adults with CKD experience difficulties in walking if the ground is not level, as in the case of stairs or steps, uphill slopes, etc. In such conditions, they experience physical resistance very quickly. Many elderly with CKD also have difficulties in performing everyday chores, such as managing their personal hygiene, making their bed, hanging up laundry, vacuum-cleaning, lifting things, rising from a squatting position, cleaning, etc. They also experience difficulty in performing a physical activity over a prolonged period of time, for instance, hanging up laundry, without having to pause several times, which they have not had to do prior to the disease. Most of the patients also have difficulties in

Adults with CKD may also experience temporal stress since they cannot do as much as they would have liked to. They need more time to perform various activities, partly due to "internal demands", like the need for physical rest and partly due to their experiences of external demands as a result of all the medical appointments and other appointments. All these factors may have a negative impact on the patients' level of activity and participation as well as their social life (Heiwe et al 2003). It seems urgent to do something for these

Rehabilitation has a positive effect on physical fatigue and improves both 'endurance' and physical 'performance', which, in turn, could reduce the need for more time to be able to perform everyday chores or other physical activities. It would then be possible for the patients to find more time for their own activities, increasing their physical activity level. It is important to make clear to patients that just by putting time and effort into physical exercise or activity they can improve several aspects of their experience of fatigue, reduced physical fitness and temporal stress. It is, though, important that appointments for physical exercise training are co-ordinated, as far as possible, with the patients' other medical appointments. This would give the patients more time to perform their own physical

It is also important that physiotherapists consider patients' views when reflecting upon and interpreting how they can support and strengthen patients in their effort to be able to

Adults with CKD are subjected to multiple physiological and psychological stressors. Welch et al (1999) have for instance showed that the most common treatment-related stressors in patients with haemodialysis are fluid limitations, the length of dialysis and vacation limitations. When adults with CKD rank the stressors that they are subjected to, it is limitation of physical activity which is the number one stressor (Lok et al 1996). Therefore, it is important to include questions concerning physical activity when meeting these patients. Coping has been proposed as an important mediating factor with regard to adaptation to illness. Coping refers to 'an individual's efforts to master demands that are appraised (or perceived) as exceeding or taxing his or her resources. It is a process that may consist of behaviours and intra-psychic responses designed to overcome, reduce or tolerate these demands (Lazarus et al 1984). There are many ways in which coping responses can be grouped, but the two general categories of coping strategies are problem-solving efforts and strategies aimed at the regulation of emotions (Lazarus et al 1984). Problem-focused coping refers to efforts to improve the troubled person-environment relationship by changing things, for instance by seeking information about what to do. Emotional-focused (or palliative) coping refers to thoughts or actions whose goal is to relieve the emotional impact

perform physical activities as well as social activities that are of importance to them.

performing physical activities at the same pace as they did prior to the CKD.

patients.

activities.

Kouidi et al 1998; Heiwe et al 2003; Johansen et al 2003; Heiwe et al 2005). It is declining from 70% of the expected norm in a pre-uremic phase to 50% of the expected norm when starting dialysis therapy (Painter et al 1986; Kettner-Melsheimer et al 1987; Brodin et al 2001). However, also ageing decreases muscle mass. The median age at dialysis start in Sweden is 66 years. The muscle mass in 70-year old person is 25% lower compared with 25 year old persons (Klitgaard et al 1990).

Patients with a renal transplant have a lower physical fitness of approximately 70-80% of the age-matched controls (Painter et al 1986). Here, the corticosteroids, still a basic immunosuppressive treatment, contribute to muscular atrophy. Thus, the physical fitness in adults with CKD is reduced and affects the capacity of the patients to perform activities in everyday life and occupational tasks.

Physical functioning in patients with CKD is affected by several factors like consequences of CKD in it-self, the original disease process that brought about the patient's kidney disease and the treatment of CKD which may have further detrimental effects (Marlowe et al 2001). The main factors causing reduced physical fitness are anaemia (Clyne et al 1987; McMahon et al 1999) and muscular weakness (Bohannon et al 1994; Johansen et al 2003). This results in fatigue and increasing inactivity, which in turn reduces physical fitness even further and increases impairments in physical functioning (Bohannon et al 1994; Nielens et al 2001; Johansen et al 2003).

Today, anaemia is successfully corrected by erythropoietin treatment and results in an improved, but not normalised, physical fitness (McMahon et al 1999). When analysing muscle biopsies it has been shown that adults with CKD have muscular histopathological abnormalities already in the pre-uremic phase (Heiwe et al 2005). The causes of muscular weakness in patients with CKD have, however, not been fully elucidated. Muscle atrophy, a neuropathic process and myopathy are potential causes of the muscular weakness. It is suggested that myopathy is due to abnormal energy metabolism (Thompson et al 1993), secondary hyperparathyreoidism (Ritz et al 1980), malnutrition (Guarnieri et al 1983), prolonged physical inactivity (Jones et al 1990) and to uraemia itself (Sakkas et al 2003).

It is important that the consultant renal physiotherapist, renal nurse, renal dietician and renal physician have an understanding of limitations in physical fitness and physical functioning that adults with CKD are expected to face and how various unique issues may alter the treatment approach. All training methods have to start with cautions and feed-back to the patients.

It has been shown that adults with CKD experience limitations in their daily life due to insufficient physical fitness. In a previous study (Heiwe et al 2003) it was shown that adult with CKD experience fatigue both mental and physical fatigue. This results in a reduced physical fitness and reduced physical functioning in terms of impact on performance and endurance. The experienced fatigue appeared frequently and varied in strength.

The informants described having a more or less always-present mental fatigue, which was experienced as something that they really had to fight to overcome. Feeling listless and paralysed by fatigue was a common trait of this group of descriptions. The feeling of physical fatigue appeared as soon as they started performing a physical activity and could vary in extent from day to day. They experienced muscular weakness and rapid onset of tiredness. Pagels et al (2006) have shown that when asked to rate the level of physical activity 40% of the adults being in a pre-uremic phase had a low activity and 11% were mostly sitting or lying down. Thus, the daily basic walks became an effort.

Kouidi et al 1998; Heiwe et al 2003; Johansen et al 2003; Heiwe et al 2005). It is declining from 70% of the expected norm in a pre-uremic phase to 50% of the expected norm when starting dialysis therapy (Painter et al 1986; Kettner-Melsheimer et al 1987; Brodin et al 2001). However, also ageing decreases muscle mass. The median age at dialysis start in Sweden is 66 years. The muscle mass in 70-year old person is 25% lower compared with 25-

Patients with a renal transplant have a lower physical fitness of approximately 70-80% of the age-matched controls (Painter et al 1986). Here, the corticosteroids, still a basic immunosuppressive treatment, contribute to muscular atrophy. Thus, the physical fitness in adults with CKD is reduced and affects the capacity of the patients to perform activities in

Physical functioning in patients with CKD is affected by several factors like consequences of CKD in it-self, the original disease process that brought about the patient's kidney disease and the treatment of CKD which may have further detrimental effects (Marlowe et al 2001). The main factors causing reduced physical fitness are anaemia (Clyne et al 1987; McMahon et al 1999) and muscular weakness (Bohannon et al 1994; Johansen et al 2003). This results in fatigue and increasing inactivity, which in turn reduces physical fitness even further and increases impairments in physical functioning (Bohannon et al 1994; Nielens et al 2001;

Today, anaemia is successfully corrected by erythropoietin treatment and results in an improved, but not normalised, physical fitness (McMahon et al 1999). When analysing muscle biopsies it has been shown that adults with CKD have muscular histopathological abnormalities already in the pre-uremic phase (Heiwe et al 2005). The causes of muscular weakness in patients with CKD have, however, not been fully elucidated. Muscle atrophy, a neuropathic process and myopathy are potential causes of the muscular weakness. It is suggested that myopathy is due to abnormal energy metabolism (Thompson et al 1993), secondary hyperparathyreoidism (Ritz et al 1980), malnutrition (Guarnieri et al 1983), prolonged physical inactivity (Jones et al 1990) and to uraemia itself (Sakkas et al 2003). It is important that the consultant renal physiotherapist, renal nurse, renal dietician and renal physician have an understanding of limitations in physical fitness and physical functioning that adults with CKD are expected to face and how various unique issues may alter the treatment approach. All training methods have to start with cautions and feed-back

It has been shown that adults with CKD experience limitations in their daily life due to insufficient physical fitness. In a previous study (Heiwe et al 2003) it was shown that adult with CKD experience fatigue both mental and physical fatigue. This results in a reduced physical fitness and reduced physical functioning in terms of impact on performance and

The informants described having a more or less always-present mental fatigue, which was experienced as something that they really had to fight to overcome. Feeling listless and paralysed by fatigue was a common trait of this group of descriptions. The feeling of physical fatigue appeared as soon as they started performing a physical activity and could vary in extent from day to day. They experienced muscular weakness and rapid onset of tiredness. Pagels et al (2006) have shown that when asked to rate the level of physical activity 40% of the adults being in a pre-uremic phase had a low activity and 11% were

endurance. The experienced fatigue appeared frequently and varied in strength.

mostly sitting or lying down. Thus, the daily basic walks became an effort.

year old persons (Klitgaard et al 1990).

everyday life and occupational tasks.

Johansen et al 2003).

to the patients.

Many adults with CKD experience difficulties in walking if the ground is not level, as in the case of stairs or steps, uphill slopes, etc. In such conditions, they experience physical resistance very quickly. Many elderly with CKD also have difficulties in performing everyday chores, such as managing their personal hygiene, making their bed, hanging up laundry, vacuum-cleaning, lifting things, rising from a squatting position, cleaning, etc. They also experience difficulty in performing a physical activity over a prolonged period of time, for instance, hanging up laundry, without having to pause several times, which they have not had to do prior to the disease. Most of the patients also have difficulties in performing physical activities at the same pace as they did prior to the CKD.

Adults with CKD may also experience temporal stress since they cannot do as much as they would have liked to. They need more time to perform various activities, partly due to "internal demands", like the need for physical rest and partly due to their experiences of external demands as a result of all the medical appointments and other appointments. All these factors may have a negative impact on the patients' level of activity and participation as well as their social life (Heiwe et al 2003). It seems urgent to do something for these patients.

Rehabilitation has a positive effect on physical fatigue and improves both 'endurance' and physical 'performance', which, in turn, could reduce the need for more time to be able to perform everyday chores or other physical activities. It would then be possible for the patients to find more time for their own activities, increasing their physical activity level. It is important to make clear to patients that just by putting time and effort into physical exercise or activity they can improve several aspects of their experience of fatigue, reduced physical fitness and temporal stress. It is, though, important that appointments for physical exercise training are co-ordinated, as far as possible, with the patients' other medical appointments. This would give the patients more time to perform their own physical activities.

It is also important that physiotherapists consider patients' views when reflecting upon and interpreting how they can support and strengthen patients in their effort to be able to perform physical activities as well as social activities that are of importance to them.

Adults with CKD are subjected to multiple physiological and psychological stressors. Welch et al (1999) have for instance showed that the most common treatment-related stressors in patients with haemodialysis are fluid limitations, the length of dialysis and vacation limitations. When adults with CKD rank the stressors that they are subjected to, it is limitation of physical activity which is the number one stressor (Lok et al 1996). Therefore, it is important to include questions concerning physical activity when meeting these patients.

Coping has been proposed as an important mediating factor with regard to adaptation to illness. Coping refers to 'an individual's efforts to master demands that are appraised (or perceived) as exceeding or taxing his or her resources. It is a process that may consist of behaviours and intra-psychic responses designed to overcome, reduce or tolerate these demands (Lazarus et al 1984). There are many ways in which coping responses can be grouped, but the two general categories of coping strategies are problem-solving efforts and strategies aimed at the regulation of emotions (Lazarus et al 1984). Problem-focused coping refers to efforts to improve the troubled person-environment relationship by changing things, for instance by seeking information about what to do. Emotional-focused (or palliative) coping refers to thoughts or actions whose goal is to relieve the emotional impact

The Importance of Exercise Programs in Haemodialysis Patients 435

 An already high cardiovascular risk factor and co-morbidity burden (Yao et al 2004; Venkataraman et al 2005) will increase even more due to the severely reduced level of

Published articles concerning effects of physical exercise on patients with CKD started to appear in the 1980s. Since then, interest in effects of physical exercise has increased in renal medicine, and today there are numerous published articles showing positive effects of exercise training. Data from previously and recently published studies have shown that

 Muscular hypotrophy, -strength, -endurance & physical functioning (Kouidi et al 1998; Mercer et al 2002; Painter et al 2002; DePaul et al 2002; Sakkas et al 2003; Heiwe et al

The structure and number of capillaries and mitochondria (Kouidi et al 1998; Sakkas et

 Cardiac performance (i.e. augmentation of cardiac vagal activity, decrease of vulnerability to arrhythmias) and improvement of coronary risk profiles

Depression, performance of pleasant activities in daily living and health-related quality

Nutritional parameters and energy expenditure using SWA, SenseWearTM Armband

A review article, based on 29 trials on this issue, shows that exercise training in dialysis patients improves arterial compliance, cardiac autonomic control and left ventricular systolic function. Moreover, exercise diminishes oxidative stress, blood pressure and inflammation. As shown in Table 1, significant effects of exercise and training were found. It is interesting to notice that haemoglobin levels, s-albumin, PCR (protein catabolic rate) and KT/V increase. This tells us that less erythropoietin is needed, which means that training is cost-effective. The patients have better protein intake. They probably eat more to get energy. The recommended protein intake at training in general is 1.6-1.7 g/kg. The recommendations for uremic patients in dialysis are a protein intake above 1.3 g/kg body

Also, the decrease in CRP is an interesting finding. CRP is connected to residual renal function (Pecoits-Filho et al 2003). The low inflammatory process in the dialysis patients becomes thus better after 6 months of repeated cycle training and this might be an adequate prescription! Actually, today the physiotherapists give prescriptions on physical activities like the doctors do on medication. The difficulties could be the compliance or adherence of the patient to the physical program suggested but the same problem exists with the

Here is a prescription or suggestions to patients with CKD. To obtain improvements it is, however, important that the exercise program has an adequate intensity, frequency and

duration. Examples and type of exercises are given (Table 2).

exercise training in adults with CKD can affect the following factors:

Aerobic capacity (Painter et al 1986; Painter et al 2002; DePaul et al 2002)

of life (Suh et al 2002; Molsted et al 2004; van Vilsteren et al 2005)

2005; McIntyre et al 2006; Heiwe & Jacobson 2011)

Blood pressure (Goldberg et al 1983; Pechter et al 2003)

physical activity

al 2003, Cheema et al 2010)

(Venkataraman et al 2005)

(Cupusti A el al 2011)

weight.

prescribed drugs.

Glucose metabolism (Goldberg et al 1983)

Circulating cytokines (Cheema BS et al 2010)

of stress (for example, bodily or psychological disturbances). Although both sets of strategies are brought to bear on most stressful events, problem-solving efforts are especially useful for managing controllable stressors, and emotional-regulation efforts are well suited to managing the impact of uncontrollable stressors.

It has been shown that in order to cope with the limited physical fitness three coping activities are used: 1) avoiding physical activities, 2) adjusting pace and 3) scheduling. The strategies were problem-focused, and patients used active-, avoidant- and social-support coping strategies. When coping with limited physical fitness, adults with CKD tend to use coping strategies that have a positive short-term outcome. These strategies are, however, also associated with negative long-term outcomes. The individual is placed in an evil circle where the physical functioning decreases as the experience of mental and physical fatigue increases (Heiwe et al 2004). It is therefore important that renal physicians and renal nurses identify these patients and refer them to a renal physiotherapist at an early stage, so that they can get information and help with physical exercise training. This could contribute to the patients' own resources which can then be used to improve the level of participation and also to improve some parts of the patient's social life.

All people employ different combinations of problem-focused and emotion-focused methods to cope with stress. The conditions determining our coping methods in specific situations are complex and at present largely unknown, but they are likely to depend on the conditions being faced, the options available to us and our personality. An issue often emerging in discussions about coping is whether some coping processes are more effective than others. For instance, whether avoidant responses to stressful events are more adaptive or whether more confrontational coping methods are superior. However, coping processes have both positive and negative consequences for an individual. A behaviour that might be effective from, say, the physiological perspective might have devastating consequences for the psychological or sociological domains. Moreover, what is an optimal response in one situation at a particular point in time may be damaging in some other situation or at a different point in time. Most people appear to use a variety of coping strategies to deal with a stressor. Successful coping may depend more on a match of different coping strategies to the features of the stressful event than on the relative efficacy of one coping strategy over another. Therefore, when meeting a patient with CKD and evaluating his or her coping and adaptation, the health-care provider must take into account diverse levels of analysis (physiological, psychological, sociological), short versus long-term consequences and the specific nature of the situation in question.
