Role of physical activity in renal rehabilitation:narrative review

Ahmed Lateef Alkhaqani

1Ministry of health,Al-Najaf Direction,Al-Sadder Medical Hospital,Al-Najaf 00964,Iraq.

Abstract Background: Renal rehabilitation is a process that consists of a series of activities that are intended to improve the health of people with chronic kidney disease.A person with chronic kidney disease requires intensive nursing care,support from other healthcare providers,and an interdisciplinary team of professionals. Objective: This article aims to teach these aspects of renal nursing rehabilitation, highlight the effect of rehabilitation in patients with chronic kidney disease to avoid renal complications, and improve self-care activities.Conclusion: Rehabilitation of renal patients is a multidisciplinary task that the medical team must perform.Physiotherapy teams are crucial to the development of patients’exercise programs. Support from family and renal nurses and care teams is of great importance. All parties play an important role,and integrated team approaches can make rehabilitation very effective. Recommendation: Clinicians should counsel patients with chronic kidney disease; increasing physical activity levels in vulnerable older people, including older people, promotes health through regular physical activity, including exercise and endurance.

Keywords:renal rehabilitation; nursing role; chronic kidney disease; exercise training

Background

Chronic kidney disease (CKD) is a public health problem worldwide.Recent epidemiological surveys of large-scale population samples showed that CKD diagnosis rates in the general population were 479 per 100,000 people. In addition,studies around the world have shown that the prevalence of adults is generally similar, ranging from 10%to 16%, depending on the diagnostic criteria used. In patients with chronic kidney disease, exercise endurance, which is measured as maximal oxygen uptake, etc., is lowered, and this phenomenon becomes more pronounced with the progression of renal dysfunction.Chronic kidney disease is associated with poor physical condition,and skeletal muscle wasting is associated with chronic kidney disease [1].This is due to the combination of uremic acidemia, malnutrition of protein and energy, and inflammation cachexia, leading to and exacerbating a sitting lifestyle. Together, these factors lead to a progressive downward spiral of deconditioning [2].

Since residents of high-income countries population, a huge opportunity because older people are the fastest-growing demographic,it is expected that many older adults with CKD will need care and help. Moreover, there are an estimated 154 million diabetes patients worldwide, which is expected to double over the next 20 years. This increase is most pronounced in developing countries. The progression of CKD causes impairments and poor quality of life and requires appropriate rehabilitation strategies[3].

Renal rehabilitation(RR)is a treatment that aims to slow or stop the progression of chronic kidney disease, delay the start of dialysis, and reduce the need for dialysis. There are two main goals of renal rehabilitation for patients with chronic kidney diseases: restoring kidney function and improving quality of life.Renal rehabilitation is a necessary part of chronic kidney disease rehabilitation. There are many aspects that nurses should be aware of when helping patients with renal issues. As the nurses are responsible for providing care to these patients, they need to know how to assess and manage their condition [4]. The overall rehabilitation aims to enable persons with disabilities to lead the life they desire, considering any restrictions imposed on their activities for disease, injury, illness, and personal circumstances[5].

The goal of any rehabilitation program is to improve patient outcomes. However, certain prerequisites must be met before any renal rehabilitation program can be successful and before most patients will be interested in pursuing rehabilitation. Patients must feel well enough physically and emotionally to have the motivation and enthusiasm to participate in a successful rehabilitation effort.Improved technology and knowledge about how to help rehabilitate patients have created new challenges and opportunities for hemodialysis staff. Rehabilitation in action creates a sense of excitement in the facility. More importantly, both patients and staff benefit from improved patient outcomes. Rehabilitated patients can live more active lives; these patients also are more rewarding for staff to work with.

Nurses are key players in renal rehabilitation as they work and serve as critical team members; as such, they know how to be sensitive to the needs of their patients [6]. Nurses can provide broader care to patients and their families by providing assessment and psychosocial care, which includes understanding needs, building relationships,assessing readiness for change, providing education about the progression of kidney disease,and planning for care[7].Nurses play a vital role in the patient’s renal rehabilitation. Nurses work extensively with patients to help them plan their care more effectively [8]. They help manage symptoms and identify early signs that may require medical intervention [9]. This review aims to highlight the effects of rehabilitation on chronic kidney disease patients.

What is renal rehabilitation?

The rehabilitative process is unique in treating disabled people according to a holistic approach to support a person’s independent living and autonomy. Renal rehabilitation has been defined by the“World Health Organization”(WHO)as“the use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration”. Other is defined as coordinated, multifaceted interventions designed to improve a kidney patient’s physical,psychological, and social functioning and stabilize, slow, or even reverse the progression of renal deterioration, thereby reducing morbidity and mortality. For people on dialysis, rehabilitation means living long and well despite the challenges of kidney disease. The first step to successful renal rehabilitation is ensuring that the clinical prerequisites of anemia control, adequate dialysis, well-functioning vascular access, and proper nutrition are in place. In addition,research indicates that people on dialysis are more likely to experience positive outcomes and better quality of life when they are informed about their disease and its treatments; have solid support systems;exercise regularly, remain active and productive, and engage in self-care. The combination of good clinical care and rehabilitation management can help dialysis patients return to active and fulfilling lives.

In 1993 the Life Options Rehabilitation Advisory Council (LORAC)developed a comprehensive approach to renal rehabilitation based on the "5E's:" Encouragement, Education, Exercise, Employment, and Evaluation. Since then, the 5E's have served as the basis for numerous Life Options Rehabilitation Program activities. Renal rehabilitation includes five main components: such as exercise training, diet, and fluid management, medication and medical surveillance, education,and psychological and occupational counselling. The first step to the success of renal rehabilitation is the assurance that the clinical requirements for preventing anemia, appropriate dialysis, exercise,adequate access to vascular systems,and appropriate nutrition are met[10].

In the hemodialysis setting, encouragement, or rewarding positive progress toward rehabilitation goals,helps patients form attitudes that will allow them to participate actively in life. As hemodialysis professionals, beliefs about patients’ capabilities are crucial to their quality of life. Positive patient, family, and staff attitudes are key to successful patient rehabilitation. Autonomy and independence improve quality of life.Encouragement is an effective and inexpensive way to foster autonomy in any setting [11].

Dialysis patients who learn right from the start that they can pursue hobbies, exercise, work and enjoy their family lives are more likely to become involved and responsible. They are also less likely to develop long-term dependence on others. Assuring patients that a productive,fulfilling life on dialysis is possible and educating them continually about topics important to them can build positive attitudes toward treatment and rehabilitation and help patients be more independent.Knowledge is power: the more patients know about end-stage renal disease (ESRD), its treatments, and rehabilitation options, the more they will be encouraged to reach their potential. Education helps patients function as treatment team members and make appropriate choices. Learning coping strategies enhances patients’ feelings of control. Patients gain control through education, increase dignity,self-worth,and belief in their intelligence and reduce negative feelings about the illness. Patient education can also reduce fear and increase hope. Effective patient education meets patient-identified needs,involves patients as active participants, takes advantage of individual learning styles, and addresses barriers[12].

Yet, it is clear that most dialysis patients have not yet achieved or cannot maintain their full employment potential. However, many patients want to work. Targeting these willing and able patients for return-to-work efforts would almost double the number of employed working-age patients. The advantages of working for patients are rooted in common sense and the medical literature. Working may enhance both psychosocial adaptation and financial status for able and willing patients. Employment and/or active engagement in life often improve dialysis patient outcomes. Positive facility policies are key to successful vocational rehabilitation. Patients working,attending school, volunteering, and keeping active should generally continue to do so. Early education and support are needed to improve employment outcomes [11].

Dialysis patients lose a considerable amount of exercise capacity for reasons that are not fully understood, leaving them with minimal functional reserve. Conditioning the body through exercise is the gradual process of improving flexibility, muscle strength, and endurance. Exercise improves physical and functional status and psychological well-being. Dialysis patients can exercise safely. Given the low levels of physical functioning in dialysis patients,exercise may be even more important for dialysis patients than for healthy people[13].

Today, evaluation of patient outcomes has become an integral component of all healthcare delivery, including successful renal rehabilitation programming.Evaluation helps healthcare professionals determine whether changes improve patient outcomes in care delivery. Because evaluation is essential, it is our responsibility, as healthcare providers, to become familiar with the evaluation so measurement of outcomes can be routinely incorporated into dialysis facilities. Outcomes evaluation benefits patients, staff, facilities, and society. Patients and staff may need help understanding the rationale for outcome assessments. Improving patient care requires systematic evaluation of the structure, process, and care outcomes. Different disciplines perform outcomes evaluation for different purposes.Traditionally, evaluation efforts have fallen into the realm of academic research.

Effect of chronic kidney disease on physical performance and function

It is estimated that one out of five adults globally are physically inactive.A large prospective cohort study clearly shows that sedentary behavior is associated with various health conditions. Among the changes caused by chronic kidney failure, there are muscle imbalances.Some studies have shown that muscle fiber atrophy is due to a balance between protein synthesis and degradation. Synthesis may be reduced or increased decomposition [14]. Physical inactivity is the cause of cardiovascular disease. Many observational studies in the general population have consistently reported that more significant physical activity is associated with lower risks of myocardial infarction, stroke, and cardiovascular [15]. Lack of exercise leads to obesity, diabetes, and hypertension and is independently related to CKD development and functional decline[16].

Abnormal functional balance and physical performance are frequently the problems in patients with maintenance hemodialysis.Patients with CKD generally suffer from reduced activity level [17],and muscle weakness resulting in impaired physical function and loss of balance during everyday tasks, which are major contributors to increased mortality in patients with CKD 11. Chronic kidney diseases are often reported to have decreased skeletal muscle, decreased strength, and decreased exercise capacity, and patients have experienced fatigue, loss of power or increased need to rest every day[18], and poor levels of physical functioning, which can contribute to a downward spiral of physical inactivity and deconditioning [4, 19].Patients with chronic kidney disease, low self-reporting, or low physical performance are likelier to die from kidney disease[20].The lifestyle of sedentary patients with chronic renal disease usually begins at the beginning of CKD,and it is an important factor leading to a decrease in physical performance concomitant to the decline in Glomerular filtration rate (GFR) [21]. Chronic kidney diseases have systemic effects such as appetite loss, chronic inflammation, anemia,metabolic acidity, muscle loss, and reduced physical performance[22].

Recent studies have shown that chronic kidney diseases have a systemic effect on physical performance, reporting a deterioration in walking capacity, muscle strength and fatigability, balance, and fine motor skills as GFR declines[23].It has been shown that patients with mild to moderate CKD suffer from reduced physical performance and self-reported physical function. Similar evidence was reported in a Swedish cohort and in the“African American Study of Kidney Disease and Hypertension”(AASK).

Rehabilitation of the patient with chronic kidney disease

Rehabilitation is part of physical medicine and an essential health strategy for dealing with disabilities. The rehabilitation process for patients with CKD may take a long time and require tolerance and insistence from both patients and their families. The rehabilitation process involves identifying the patient’s problems and need, relating the problems to relevant factors of the person and environment,defining rehabilitation goals, planning and implementing the measures, and assessing the effects. Education for persons with disabilities is crucial to developing knowledge and skills in self-care,management, and decision-making. World Health Organization,2015;Having partners in rehabilitation, persons with disabilities and their families can better deal with their health. Although hemodialysis remains lifelong, patients face mental, physical and social problems associated with their illness and treatment throughout their lives[24].The primary goal of rehabilitation is to avoid complications, reduce weakness, and improve self-care activities. The second goal is to return a patient to a state of optimal functioning [25]. Efficient rehabilitation promotes the outcome of body function. The improvement encourages change in functional independence measures [26].

Renal rehabilitation begins when patients are in an acute condition in the hospital, after the diagnosis of renal disease, and when the life-threatening problem has been controlled. At this early stage, the priority is to avoid complications, making certain that the appropriate management of health function, in general, encourages continued self-care activity and provides psychological assurance to patients and their families [27]. After this stage of kidney disease, care must be changed to detect residual physical and mental effects, and reparation for these deficits is emphasized. Furthermore, rehabilitation is highly recommended to begin as soon as possible while maintaining medical continuity. In addition, patients are highly encouraged to receive the necessary treatments to adjust, improve and restore the level of functional independence. The renal rehabilitation is coordinated to improve kidney patients’ physical, psychological, and social functioning [11]. According to the specific nephrological deficit that occurs in kidney disease, the nursing usually organized the care at the patient’s home and considered the needed instruction to the patient and his family. They need both education and support in the provision of care plans. Carers may need to remind them to pay attention to health and well-being concerns[28].

Exercise has a variety of health benefits for chronic kidney disease patients. Exercise rehabilitation programs combining lifestyle education with exercise can promote habitual exercise by increasing physical activity behaviours and facilitating chronic disease self-management. Rehabilitation programs improve people’s daily lives suffering from chronic kidney disease, typically going over 6 to 12 weeks [10]. Exercise in CKD management is also considered the most important research priority for patients and caregivers [29].Exercise rehabilitation can help maintain the body’s function in the CKD,but the long-term clinical effectiveness is unknown[2].Effective rehabilitative measures include fitness, strength, and resistance training, training on over-ground walking, movement therapy with constraint-induced,pharmacologic modification of spasticity,or direct current stimulation [25].

The benefits of rehabilitation according to World Health Organization,2020

· Rehabilitation is an essential component of universal health care and a crucial strategy for achieving sustainable development goals “ensure healthy lives and promote well-being for all ages”.

· Rehabilitation can help people suffering from various diseases including acute and chronic diseases. Combining it with other medical procedures such as medical and surgical care will help achieve the best possible result. Rehabilitation can assist in reducing, treating, or avoiding complications associated with various medical conditions such as stroke, chronic kidney disease, and fracture.

· Rehabilitation helps reduce the crippling impact of chronic health conditions such as cardiovascular disease, diabetes, and cancer by providing patients with self-management plans and the assistive products they need to treat pain or other problems.

· Rehabilitation is a cost-effective investment for people and society.It assists in avoiding expensive hospitalization,shortens stay in the hospital, and avoids re-admission. Rehabilitation also enables people to continue education and work, live independently at home, and reduce dependence on financial or supplementary assistance.

Nursing role in chronic kidney disease rehabilitation

Kidney failure is the leading cause of the lack of adults’ physical activity in the United States, emphasizing the importance of effective rehabilitation to help patients reach their optimum independence level. Nurses play an important role in chronic kidney disease rehabilitation. They can assess the patient’s condition and help them reach their therapeutic goals through interventions such as education,counselling, and exercise programs. The nursing rehabilitation for renal aims are to:

· Improving the physical functioning of the muscle.

· Increase muscle strength, movement, and fitness.

· Improving heart and lung function.

· Better control of blood sugar and reduced blood pressure.

· Control body weight and improve self-esteem.

· Reducing the risk of secondary complications and related conditions.

· Counteract/reverse the side effects of steroid treatment, such as muscle wasting, osteoporosis, and weight gain after transplantation.

· Improve the quality of life and sleep better.

Through rehabilitation, primary care nurses have a significant role to play in ensuring that chronic kidney diseases are adequately educated and maintained in health care [30]. Also, he/she plays an important role in managing patients with CKD and improving the patient's health condition. It is beneficial to help people understand their situation and to educate them on informed long-term treatment decisions. They can improve the patients’ self-management by translating therapy skills into meaningful activities [31].

Exercise training as a physical rehabilitation method

Adults with chronic kidney diseases suffer from severe impairments in physical function (daily life activity). Low physical activity levels and poor physical function are closely related to these patients' mortality rate and clinical results, regardless of the treatment modality. In the last 30 years, the number of published studies on the effects of regular exercise training on chronic kidney disease in adults has been increasing. The first step in rehabilitation intervention is based on exercise prescriptions [3]. Patients with chronic kidney diseases need a variety of therapies to maintain normal body function.Hemodialysis is essential in regulating the body's homeostasis and thus patients'general well-being.

Furthermore, patients must perform daily independent and self-care activities. Resistance training (also called strength training or weight training) is the progressive use of different load movements. It speeds to improve muscle strength, power, and endurance [32]. Resistance exercises are one of the modalities of exercise that is chosen to enhance physical condition [33]. Using resistance training, there is a new shift from post-injury rehabilitation to injury prevention [32].Training is defined as planning, structured, repetitive physical activity. It is important to understand that resistance exercise training in CKD is safe and will not adversely or negatively impact skeletal injuries if conducted with a qualified instructor monitoring technique and progression [32]. Resistance training focuses mainly on strengthening muscles and muscle groups by exercising against external resistance such as “free weights, bodyweight, medicine balls,or even common household products” [34]. Many rehabilitation strategies and methods can be used to delay the decline of functions and improve residual capabilities. Appropriate exercise should be planned for those with mild comorbidities and not severe limitations in the early stage of chronic kidney disease. Physical activity,including exercise and resistance, is recommended to positively impact cardiovascular, respiratory, physical, and self-reported health.Moderate to high-intensity strength training improves patients’quality of life with chronic kidney diseases, muscle mass,and performance.

Resistance exercise has a proven effect on muscle strengthening and muscle protein synthesis. The benefits of resistance training in older children,adolescents, and healthy adults have been well documented.In healthy adults, Ferrando et al. demonstrated that moderate resistance exercise can ameliorate the decreases in skeletal muscle protein synthesis and strength that accompany inactivity [35].Repeated resistance exercise training increases the mean cross-sectional area of fibres; expansion of the microvascular network is required to ensure the delivery of oxygen and amino acids needed for muscle growth. Strength training stimulates various positive neurological adaptations and promotes physical and mental health.Studies show that regular progressive resistance training develops:Muscle strength and size, increasing bone mass [36]. Not all patient with CKD has to perform regular exercises.

Moreover, as reported by the “American College of Cardiology Foundation/American Heart Association”, several contraindications are specific to CKD patients, such as symptomatic heart arrhythmias,peripheral oedema, and pulmonary congestion. In addition, specific rehabilitative interventions must be designed whenever multiple comorbidities, e.g., polyarticular arthritis, heart failure, and neurological disturbances,contribute to the disability.Recently,a new model for the care of CKD patients has been proposed, ranging from traditional disease-based models to patient-focused individualized approaches[37]. Various guidelines, mainly from the American Heart Association and the American College of Sport and Medicine, describe resistance exercise training in healthy populations and populations with different comorbidities and different age groups [38]. The American Diabetes Association, 2014 reported that “lifestyle modifications (such as diet and exercise) were associated with a greater decrease in blood pressure and blood sugar control compared to medication with a greater emphasis on aerobic exercise training”[39].

Conclusion

The number of chronic kidney disease patients is increasing worldwide,becoming a priority health issue.Rehabilitation effectively reduces the burden of disabilities, improving and promoting disability activities and participation. Based on their clinical and functional conditions, chronic kidney disease subjects should receive training in exercises or comprehensive multi-dimensional strategies and objective-focused interventions. Since severe CKD suffers from complex disorders,patients and caregivers should discuss the intended treatment goals and outcomes. Structured prevention programs and rehabilitation strategies to reduce the risk factors of chronic kidney diseases can reduce disability and associated social costs.

Recommendation

Renal rehabilitation should improve patients’ quality of life and biological life with chronic kidney disease. Renal rehabilitation is a viable,effective,safe secondary prevention strategy based on CKD and offers promising models for new rehabilitation fields. Future randomized control studies should focus more on the effects of exercise and rehabilitation programs, as these topics and types of exercise have not been studied as much as cardiovascular exercise. In addition, urgent efforts need to be made to increase the rate of renal rehabilitation implementation. Clinicians should advise patients with chronic kidney disease, including older persons with poorer health, to increase the level of physical activity and target regular physical activity, including aerobic exercise and endurance, which is beneficial to health.