**4. Evidence based effects of exercise training in patients with CKD**

There is scientific evidence showing that if adults with CKD do not exercise only having a certain level of physical activity in their daily living:


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

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

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

**4. Evidence based effects of exercise training in patients with CKD** 

There is scientific evidence showing that if adults with CKD do not exercise only having a

 The muscle mass and physical fitness will continue to decrease (Painter et al 1986; Kettner-Melsheimer et al 1987; Bohannon et al 1994; Brodin et al 2001; Heiwe et al 2001;

 The patient's possibility to maintain, for him or her, a satisfyingly active and social life will be reduced = reduced health-related quality of life (Brodin et al 2001; Fukuhara et

Sakkas et al 2003; Heiwe et al 2005; McIntyre et al 2006; Zamojska et al 2006)

to managing the impact of uncontrollable stressors.

also to improve some parts of the patient's social life.

specific nature of the situation in question.

certain level of physical activity in their daily living:

al 2003; Heiwe et al 2003; Heiwe et al 2004)

 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 physical activity

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


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 weight.

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 prescribed drugs.

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).

The Importance of Exercise Programs in Haemodialysis Patients 437

Get the patient informed about the importance of physical training in CKD both in

To make the patient independent in the daily life and to keep/increase the quality of

 Diminish the risk of cardiovascular disease, osteoporosis and loss of muscle mass. Increase/maintain muscular strength and endurance, balance as well as the sub

> Standing heel-rise test. Sit-to-stand-to-sit

> > shoulder abduction

performed

Timed "Up & Go"

Isometric leg strength.

Grimby Frändin

rate

 Stairs Muscular strength One repetition maximum (1RM)

Functional capacity 6-minutes walking test with patient's experienced leg fatigue,

Stand on one leg Functional reach

correlating to muscular mass

Physical capacity Standardized, symptom limited ergometer cycling with

 For patients with secondary kidney diseases it is important to consider the original disease at assessment of physical capacity, general advice and follow-up. For patients

 Maximal number of muscle contractions with a strain corresponding to 50 % of 1RM and at fixed frequency.

with loading corresponding to 50% of 1RM. Unilateral isotonic shoulder flexion, bilateral isometric

 Maximal number of seconds the patient is able to maintain an isometric muscle contraction, for example knee extension,

breathlessness and possible cardiac pain is rated by the patient according to Borg's CR-10 scale and the total effort according to Borg's RPE-scale before and after the test

Walking 30 meters in self-selected normal rate and maximal

GRIPPIT(grip strength), Jamar hand dynamometer:

Disability Rating Index (DRI). Activity rating according to

patient's experienced leg fatigue, breathlessness and possible cardiac pain is rated by the patient according to Borgs CR-10 scale and the total effort according to Borg's RPE-scale.

**5. Details and aim of physical training** 

maximal oxygen uptake. Minimize the risk of fall accident.

Minimize depression.

Dynamic muscular

Static muscular endurance

Self-rated physical level of activity

Quality of life SF-36

Notes: **General about CKD 4-5** 

endurance

life.

dialysis and after kidney transplantation.


Table 1. 29 studies and effects of physical activity in dialysis patients on metabolic and nutritional parameters. (Cheema BS, Sing MA 2005).


**Borg´s RPE scale** = Borg rating of perceived exertion. It was constructed in the 60-ties by Gunnar Borg, professor in perception and psychophysics in Stockholm. The scale indicates different degrees of effort from 6 to 20. The rated RPE shows a linear relation to workload and heart pulse frequency. It is used within rehabilitation and training (Borg 1970).

**VO2 peak**: This is the oxygen uptake which reflects the maximal performance of the individual. This has to be measured before start of programme and this helps to adjust the programme for each individual. **Reps** = repetitions, **RM** repetition maximum see page 2

Table 2. Prescription on physical activities in patients with CKD and explanations
