運動訓練對血液透析病人生理、心理狀態之成效

rr~~~~#*~~~~~~~~~~~~*

~%

***********************

The effects of exercise training on physiological and

psychological status in hemodialysis patients

***********************

tt:l jlia5Jt :

NSC89-2320-B-037-039

7

J3

31

a

~~~ A.:~~~·~ ~.*~#.

;f.Jt;.

*::ta

%

e?.#

n

z

14- :

Abstract

We examined the effects of a 12-week exercise training (ET) program on the exercise tolerance, blood biochemistry, resting blood pressure, and resting heart rate in 17 patients undergoing hemodialysis (15 men, 2 women; mean age, 40.35 ± 12.93 years). The patients undenvent ET on bike weekly three times. The

mean peak aerobic capability (V02 max) of the patients increased by 41.12 %

after ET ( pre- and post-exercise, 0.85± 0.17 P.J: 1.20± 0.30 ml/kg/min; t=-6.655

p=O.OOO ). The mean depression scores of the patients decreased by 7.56 % after

ET ( pre- and post-exercise, 28.06± 6.66 P.J: 25.94± 6.28; t=-2.423 p=0.028).There

were no significant changes in biochemistry, resting BP and fIR. We conclude that structured aerobic ET is safe and can improve the functional capability and depression in HD patients.

Literature review

The exercise capacity, as measured by the maximal aerobic capacity

(V02nlllX ), can be reduced by up to 50% in chronic dialysis patients compared with healthy individuals. MUltiple factors, such as anemia, concurrent coronary artery disease, low total arterial oxygen content, and depression may lead to the debilitation of dialysis patients.

Deconditioning and disability are major problems in ESRD (Karmiel, 1996 p74). When an individual is diagnosed with ESRD, the patient suffered from disease-related complications such as cardiovascular disease, hypertension, anemia, musculoskeletal change and depressed (Painter & Zimmerman, 1986 ; Karmiel, 1996) and a long significant period of reduced activity or bed rest often follows (Painter, 1994). The complications of [<:SRD and a sedentary lifestyle leads to a downward spiral of deconditioning that futher limits physical capacity (Painter, 1994).

ET has well documented beneficial effects in a variety of cardiac disorders. ESRD patients present many cardiovascular complications that arc the main reason for death in up to 50 % of these patients ( Deligiannis et aI., 1999).

Maximal oxygen uptake in liD patients range from 15 to 25 ml/kg/min and their maximal metabolic equivalents (METs) are frequently lower than 3.5

( Deligiannis et al., 1999 ). The effort of correcting their anemia by using human recombined erythropoietin over the last few years has improved physical

capacity by 20 %; it remains, however, significantly limited ( Deligiannis et al.,

1999 ). There have been a number of studies which have demonstrated that

aerobic exercise training significantly improves the physical and psychosocial condition of ESRD patients on liD ( Deligiannis et al., 1999 ). ESRD patients in Taiwan are often excluded from ET programmes, so we conduct this study to explore the physiological and psychological benefits of ET programmes

This study was designed to assessed the feasibility of ET program in liD patients in Taiwan and to obtain preliminary data regarding the physiological and psychological effects of 12-week supervised endurance ET.

The beneficial effects of exercise on the physical capacity of dialysis patients

were well documented, with the patients' V02nllix increased by 23°;;) to 42% after

training.

3

---~---~~~----Methods

The study was descriptive and correlational, using a one -group pre­ test/post-test design. The treatment, a 12-week exercise training program, was executed between the pre- and post-tests for all subjects. The independent variable of this study was the 12-week ET program. The dependent variables were selected physiological outcomes ( changes in exercise capacity after a 12­ week ET program and biochemistry data and psychological outcomes (changes in depression status). The study was conducted at the hemodialysis center of a

teaching hospital in southern Taiwan. It was reviewed and approved by the

National Scientific Council (NSC) Committee. Ethical approval for the study was obtained from the institutions and written consent was obtained from eligible patients after they had been informed of the study.

Sample

Subjects were selected by purposive sampling. Criteria for inclusion in the sample were: 1) undergoing regular lID treatment for three times per week, at least 3 months; 2) aged older than 18 years 3)condition stable .Criteria for exclusion were: 1) congestive heart failure; 2) cardiac arrhythmias; 3) recent myocardial infarction or unstable angina; 4) unstable hypertension (resting systolic blood pressure over 200mmIlg or resting diastolic blood pressure over 110 mmllg); 5) any orthopedic or musculoskeletal problems that hinder exercise; 6) consistent weight gains of greater than 4.5 kg from Friday ( or Saturday) dialysis treatment to Monday (or Tuesday) dialysis treatment.

Treadmill Test

Two maximal exercise tests with the same protocol, one before and one after the exercise training, were administered to measure each subject's exercise capacity. At baseline, each subject underwent a symptom-limited treadmill stress test using the Chi-Mei protocol (a modification of Bruce protocol). The test was terminated when the subjects complained of legs fatigue, dyspnea or exhaustion. During the test the ECG(electrocardiogram) and BP of each individual were monitored and recorded every 3 min. The following parameters were obtained during the stress test: (1) VOz peak oxygen consumption rate attained; (2) the peak heart rate; (3) the peak BP; (4) the duration of exercise; and (5) the peak metabolic equivalent (MET peak). Oxygen uptake (VOz ), which is expressed in terms of liters of oxygen per minute or milliliters of oxygen per kilogram body weight per minute (ml/kg/min), was determined by analyzing the fractions of

oxygen and carbon dioxide in the expired air (Painter, 1994, pp s2),

(cardiopulmonary exercise testing system, Medical Graphics Corporation, St Paul. MN). The results of graded exercise test (GXT) before exercise training were used as a basis for determining the exercise prescription during training.

Procedure

Patients who met the selection criteria were asked to participate in the study on orientation day. A thorough explanation ofthe study protocol was provided by the investigator and an informed consent \,\ras obtained from each subject. On the same day, subjects were asked to complete the questionnaires of depression.

Exercise training began as soon as possible after orientation day. The program was conducted three times per week for 12 weeks. Each exercise session lasted for 45 to 50 minutes, with 5 to 10 minutes of warm-up, 20 to 30 minutes of upright aerobic bike exercise, and 5 to 10 minutes of cool-down. The intensity of ET was determined by dividing the workload by the VOzmax. The target

training zone was set at 70%) to 85% ofthe maximum heart rate as determined in

the baseline treadmill stress test. Heart rate, O2 Saturation and DP during

exercise was monitored and recorded by Osmiter. To avoid overexertion, the Borg Scale is used to determined exercise intensity rather than target heart rate, because some patients were taking beta-blockers medication which could inhibit

the increment in heart rate during exercise( Tesch & Kaiser, 1983) In this study,

the exercise intensity was kept between score 10 and 13 of the rating of perceived exertion (RPE), ranging from fairly light to somewhat hard (Borg, 1970). Each subject's exercise prescription was periodically adjusted to ensure gradual increase in overall exercise performance. Exercise was terminated if 1) the patient requested, 2) the heart rate exceeded the maximum heart rate, 3) systolic BP decreased by greater than 10 mm Hg with hypotensive symptoms, or 4) cardiac arrhythmia occurred. All subjects at the start and end of the ET underwent blood biochemistry tests, treadmill exercise testing and filled out the questionnaires of depression.

Data Analysis

The SPSS for Windows version 8.0 was used for data analysis. Descriptive statistics were computed for demographic data and study variables. Differences in outcome variables were determined by the paired t-test. All results are

expressed as mean +/-SD. Pvalue less than .05 was regarded as statistically significant.

5

---'--~""---ll.esults

Sample Characteristics

Seventeen patients finished the study( 15 men, 2 women; mean age, 40.35± 12.93 years).

Exercise Capacity

After exercise training, a significant improvement in physical capacity of the

lID patient was found with the mean V02max increased by 41.12% from .85+1-.17

to 1.20+1-.30ml/kg/min (p=.OOO), the mean oxygen uptake increasing from 3.97+1­

1.12 metabolic equivalents (METs) to 5.50 +/- 1.72(p=.002) . Blood Biochemistry Parameters and Resting BP, HR

This study could not show any significant changes in the following parameters in the lID patients during the study period: hemoglobin, hematocrit, RBC, BUN,

Serum creatinine, uric acid, triglyceride, cholesterol, HDL, LDL and blood sugar. There was no significant change in the hemoglobin, hematocrit and RBC,

although an increasing trend was observed (baseline l{f postexercise

k

also no significant change in the Resting BP and Resting IIR. Depression Scores

Improvement in the depression outcome was observed in the study sample.

After 12-week exercise training, the depression score decreased from 28.06+1-6.66

Discussion

Most patients stopped exercise during test because of leg fatigue or a general feeling of fatigue rather than not being able to reach their maximal functional level.

In this study, the V02max and depression improved significantly after 12 weeks of ET. we could not show any beneficial effects of exercise on the patients' hematocrit, hemoglobin, RBC, BUM, serum creatinine, uric acid level. In the literature, only Goldberg et al reported an increase in hematocrit after training, whereas others reported no change.

Exercise can bring about a decrease in low-density lipoprotein and an increase in HDL cholesterol levels in healthy people (Goldberg L & Elliot DL 1987.) and other studies on hemodialysis( Goldberg Ap, Geltman EM, Hagberg

JM, 1983), but the observation was not found in our study. It is possible that

favorable changes in lipid profile only in selected patients over a long training period.

In addition to ET, the subjects received personal attention and support from the exercise training staff. Socialization is an important fringe benefit of the intervention program and very likely contributes to the favorable effect seen upon depression. In addition, changes in other health-related behaviors accompanying the ET could have contributed to the depression improvement. However, lID patients with depression usually lack the motivation to commence an exercise on their own. Therefore, active counseling and encouragement from health professional are necessary to improve physical functioning of the

depressed patients on dialysis.

In conclusion, stationary bicycling during lID is safe and feasible. The ESRD patients experienced significant improvements in exercise capacity and depressed status after exercise training. However, without a control group, it can't be concluded that exercise outcomes are a result ofthe ET.

References:

Aistars J. Fatigue in the cancer patient: A conceptual to a clinical problem.

Oncology Nursing Forum 1987; 14:25-30.

All patients were found to exercise within 400_{A, to 70(Yo THR, an appropriate}

range for an elderly, unwell population (intensity of exercise) (American College of Sports Medicine, 1991).

American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription 1995;\Vaverly: Williams & Wqilkins.

BAppSc, PI.,. Stressors, coping mechanisms and quality of Life Among dialysis patients in Australia. Journal of Advanced Nursing 1996;23:873-881.

Brannon FJ, Foley M\V, Starr JA, Black MG. Cardiopulmonary rehabilitation: basic theory and application.Phiiadelphia:Davis,1993.

,

Brass EP, Hiatt WR. Carnitine metabolism during exercise. Life Sciences 1994;54: 1383-1393.

Brunier G, Graydon J. The inflecence of physical activity on Fatigue in patients with end Stage renal disease on hemodialysis. Americian Nephrology Nurses Association Journal 1993;20:457-461.

Cardenas DD, Kutner NG. The problem of fatigue in Dialysis patients. Nephron 1982;30:336-340.

Carney RM, McKevitt PM, Goldberg AP, Hagberg .J, Delmez .lA, Harter

IlR. Psychological effects of exercise training in Hemodialysis patients._Nephron 1983;33: 179-181.

Carney RM, Wetzel RD, Hagberg J, Goldberg AP. The Relationship

between depression and aerobic capacity in hemodialysis patients. Psychosomatic Med.1986;48:143-147.

Castellino P, Bia M, DeFronzo RA. Metabolic response to exercise in dialysis patient. Kidney International 1987j32:877-883.

Chiou CPo Correlations of functional status of hemodialysis patients in Taiwan. Dissertation, University of Pennsylvania 1997.

};'itts SS, Guthrie MR, Blagg CR. Rehabilitation should Parallel the course of the disease: Counseling and exercise coaching for Patients. J. Am. Soc. Nephrol 1996;7: 1386.

Fitts SS. Physical benefits and challenges of exercise for People with chronic renal disease. Journal of Renal Nutrition 1997;7:123-128.

Frantz A. 2\leasuring activity tolerance:perceived exertion. Home Health Focus 1995;2:30.

Goldberg AP, Geltman EM, Gavin JR, Carney RM, Hagberg JM, Delmez JA, Naumovich A, Oldfield MH, Harter IIR. Exercise training reduces coronary risk and effectively rehabilitates Hemodialysis patients. Nephron 1986;A2:311­ 316.

Goldberg Ap, Geltman EM, Hagberg .JM Therapeutic benefits of exercise training in patiaents on maintenance dialysis. Kidney Int 1983 24:S303-S309, (suppl)

Goldberg L, Elliot D.L. The effect of exercise on lipid metabolism in men and women. Sports Med 1987;4: 307-321.

Gurklis .JA, Menke EM. Identification of stressors and Use of coping methods in chronic hemodialysis patients. Nursing Research 1988;37:236-239.

Hagberg .1M, Goldberg AP, Ehsani AA, Heath GW, Delmez .lA, Harter HR. Exercise training improves hypertension in Hemodialysis patients. American .Journal Nephro 1983;3:209-212.

Harter IlR. Exercise in the dialysis patient. Semin Dialysis 1994;7:192-198. Hinrichsen GA, Lisberman .lA, Pollack A, Stenberg H. Depression in hemodialysis patients. Psychomatics 1989;30:284-289.

Horton ES. Exercise and diabetes mellitus. Med Clin North Am. 1988; 72:1301-1321.

Kim MJ, McFarland GK, McLane AM. Pocket Guide to Nursing Diagnosis(5th ed) 1993;Philadelphia:Mosby.

Moore GE et al. Determinants of V02 peak in patients with end-Stage renal disease. Med. Sci. Sports Exerc. 1993;25:18-23.

Moore GE, Parsons DB, Stray-Gundersen .I, Painter PL, Brinker KR, Mitchell .III. Uremic myopathy limits aerobic capacity in Hemodialysis patients. American Journal of Kidney Diseases 1993;22:277-287.

Moore GE. Exercise prescription in renal failure. In K. Shankar (Eds),

Exercise prescription 1998; Philadelphia: Hanley & Belfus:pp.145-151.

Moore GE. Selecting dialysis patients for an exercise program. Semin Dial 1995;8:42-44.

Painter P, Carlson L. Case study of anemia patient: Epoetin alfa-focus on

exercise. ANNA Journal 1994;21 :304-307.

Painter P, Messer-Rehak D, Hanso P, Zimmerman SW, Glass NR. Exercise capacity in hemodialysis, CAPD, and renal transplant patients. Nephron

1986;42:47 -51.

Painter P, Zimmerman SW. The role of exercise in thelong term

rehabillitation of patients with end stage renal disease. AANNT J 1983; 1 0:41-46.

Painter P. The importance of exercise training in rehabilitation of patients with end-stage renal disease. American Journal Kidney Disease 1994;24:S2-S9.

Painter PL, Nelson-Worel IN, lIilI MM, Thornbery DR, Shelp WR,

Harrington AR, Weinstein AB. Effects of exercise Training during hemodialysis. Nephron 1986;43:87-92.

Painter PL. Renal failure. American College of Sports Medicine (Eds.), ACSM's Exercise Management for Persons with Chronic Disease and Disabilities (pp.89-93). United States of Aamerican: Braun-Brumfield. 1997.

Parfrey PS, Vavasour HM, Henry S, Bullock M, Gault MIl. Clinical features and severity of nonspecific symptoms in dialysis patients. Nephron

1988;50: 121-128.

Pate RR, Pratt M, Blair SN, I1askell WL, Macera CA, Bouchard C, Buchner D. et al. Physical activity and public health: A recommendation from the Centers for Diease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407.

Piper B. Fatigue. In pathophysiological Phenomena in Nursing: Human Response to Illness 1986: pp219-234.

Porter GA. Assessing the outcome of rehabilitation in patients With end­ stage renal disease. American Journal kidney Disease 1994;24:S22-S27.

Ream E, Richardson A. Fatigue: a concept analysis. Int..J.Nurs. Stud. 1996;33 :519-529.

Ross DL, Grabeau GM, Smith S, Seymour M, Knierim N, Pitetti KII. Efficacy of exercise for end-stage renal disease Patients Immediately following high-efficiency hemodialysis: A piolt study. American Journal Nephrol

1989;9:376-383.

Rostand SG et al. Cardiovascular complication in reanl Failure. Journal American Soc. NephroI1991;2:1053-1062.

Schreiber WK, Huber W. Psychological situation of dialysis Patients and

their families. Dialysis & Transplantation 1985; 14:696-698.

Sensky T. Psychosomatic aspects of end-stage renal failure. Psychother Psychosom 1993;59:56-68.

Shalom R, Blumenthal JA, Williams RS, McMurray RG, Dennis VW. Feasibility and benefits of exercise training in patients on maintenance dialysis. Kidney Internal 1984;25:958-963.

Shephard RJ, Kavanagh T, Klavora P. Mood state during Post-coronary cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 1985;5 :480­ 484.

Siskovick DS, Weiss NS, Feltcher lUI, Lasky T. The incidence of primary cardiac arrest during vigorous exercise. N. Engl J Med. 1984;311 :874-877.

Sklar All, Riesenberg LA, Silber AK, Ahmed W, Ali A. Postdialysis fatigue. Americian Journal Kidney Disease 1996;28:732-736.

Tesch PA, Kaiser P. Effects of beta-adrenergic blockage on O₂ uptake during

submaximal and maximal exercise. J Appl PhysioI1983;54:901-905.

Tesch, P.A., Kaiser, P. Effects of beta-adrenergic blockage on O₂ uptake

during submaximal and maximal exercise. J Appl Physiol1983 54: 901-905. The Borg Scale, a subjective rating of exertion, is used to determine exercise intensity rather than target heart rate (TIIR), an objective rating, due to the fact that many patients. Receive beta blocker therapy, which depresses heart rate (Tesch & Kaiser, 1983)

Williams A, Stephens R, McKnight T et al. Factors affecting Adherence of

end-stage Renal disease patients to an exercise programme. Br. J, Sports Med.

1991;25:90-93.