Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Intradialytic Stretching Exercises on Fatigueand

Muscle Cramps
Chandralekha.C.Sa*, R. Mercy Russelin Prabha, b
a*
AssistantProfessor,Department of Medical Surgical Nursing, Assisi College of Nursing, Erumeli,Kerala, India
b
. Associate Professor, Department of Medical Surgical Nursing, NIMS College of Nursing, Neyyattinkara, Kerala, India

Abstract:- Hemodialysis is one of the most widely sustained, any more therapies tailored to replace all or most
accepted treatment modalities in patients with chronic of the functions of the kidney are essential, which constitute
renal failure. Although Hemodialysis can prolong life it Renal replacement therapy(RRT).5
can lead to several complications. The aim of the present
study was to determine the effect of intradialytic Hemodialysis is a lifesaving treatment for ESRD in
stretching exercises on fatigue and muscle cramps which substances move from the blood through a
among patients undergoing Hemodialysis at NIMS semipermeable membrane and into a dialysis solution. It
Hospital, Neyyattinkara, Kerala. The objectives of the helps to correct fluid and electrolyte imbalances and to
study are to assess the level of fatigue perceived among remove waste products .1 Following a hemodialysis the
clients undergoing Hemodialysis before and after patient normally feels weak and fatigued sometimes even
intradialytic stretching exercise in both experimental too tired to eat. Sudden drops in Blood pressure may cause
and control group, To assess the frequency and severity the patient to become weak, dizzy and nauseated. Fluid and
of muscle cramps among clients undergoing electrolyte levels drops rapidly and cause the patient to feel
Hemodialysis before and after intradialytic stretching lethargic and have muscle cramps.4
exercise in both experimental and control group and to
determine the effect of intradialytic stretching exercise Chronic renal failure and its treatment can severely
on fatigue and muscle cramps among clients undergoing compromise quality of life of people affected by the disease.
hemodialysis in control and experimental group. Caring for the client with CRF involves many challenges.
Orlando’s Theory of Deliberative Nursing Process was Numerous physical and psychosocial manifestations are
used as conceptual framework in this study. Quasi associated with renal disease and its treatment. Self
experimental pretest posttest with control group design management is integral to ensure a good quality of life.
was used in this study. The data was collected from 60 Nurses can support self management through education of
samples. Data was analyzed using descriptive and clients ,planning for exercise programs and through
inferential statistics. The present study reveals that supportive communication.3
majority of the clients undergoing Hemodialysis
experience moderate to severe fatigue. Intradialytic 1.1 Need and Significance of the study
stretching exercises proven to decrease fatigue at the Chronic renal failure is a progressive damaging and
level of significance (p<0.01). The study also reveals that irreversible disturbance of renal function in which the
there is significant improvement in frequency and body’s ability in preserving metabolism and water or
severity of muscle cramps after implementing electrolyte balance would decrease, uremia is more. More
intradialytic stretching exercises. than 60,000 people die annually because of kidney failure all
over the world.6
Keywords:- Intradialytic Stretching Exercises; Effect;
Fatigue; Muscle Cramps; Hemodialysis Patients. It is estimated that in India about 1,00 000 persons
suffering from End stage renal disease each year, of which
I. INTRODUCTION only about 20,000 get treated.7

Chronic kidney disease (CKD) is an umbrella term that Fatigue which can be conceptualized on a continuum
describes kidney damage or a decrease in the glomerular from extreme tiredness to high energy, has been reported to
filtration rate for three or more months. Chronic kidney affect 60% to 97% of chronic Hemodialysis patients.8
disease is associated with decreased quality of life, increased
health care expenditures and premature death. If untreated Fatigue is one of the most frequent symptoms of
can result in End stage renal disease (ESRD) and necessitate patients with end stage renal disease undergoing
renal replacement therapy ie. dialysis or kidney maintenance dialysis therapy. The prevalence of fatigue
transplantation.2Chronic kidney disease (CKD) is an ranges from 60% to as high as 97% in end stage renal
important public health problem affecting more than 10% of disease patients on long term dialysis therapy. 9
the general population. It is a silent disease and if not
detected and treated early, may progress to End stage renal Muscle cramps are common complication of
disease (ESRD). When the kidney’s fail and life cannot be Hemodialysis treatment occurring frequently. It can involve

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Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
the legs, most commonly in the feet, and involve arms, II. MATERIALS AND METHODS
hands and abdominal muscles. It is estimated that 33to 86
percent of patients receiving dialysis have experienced 2.1 Research approach
cramps.10 A Quantitative and evaluative approach was adopted
for this study.
Intradialytic exercise programs are important to
enhance patient physical functioning, exercise capacity and 2.2 Research design
improve overall health. Exercise during the treatment does The research design adopted in the present study is
not interfere with the treatment, and often the patients are Quasi experimental pre test post test with control group
more stable hemodynamically. Also exercise during dialysis design.
improves clearances by opening up vascular beds in the
working muscles, exposing more tissue to the dialysis 2.3 Variables
procedure.1 Independent Variable - Intradialytic stretching exercise
Dependent variable - Fatigue and Muscle cramps
The incidence of ESRD in NIMS Hospital is
increasing at an alarm state. The reported cases of Chronic 2.4 Setting of the study
renal failure admitted from 2009-2012 are as follows: The present study was conducted inHemodialysis unit of
NIMS Hospital Neyyattinkara, Kerala
In Hemodialysis unit researcher observes that majority
of the patients undergoing Hemodialysis experience severe 2.5 Populationand sample
fatigue and muscle cramps and found out the necessity of The population for the present study were all
implementing therapeutic nursing interventions in reducing Hemodialysis patients. The samples selected for the present
the severity of complications. As an interventional measure study were patients who are undergoing Hemodialysis at
the researcher focused on the importance of NIMS Hospital, Neyyattinkara.
practisingintradialytic stretching exercises like toe taps ,arm
curls, straight leg raise, seated marching in reducing the The total sample consists of 60 hemodialysispatients
severity of complications. So the researcher felt interested in who satisfies the sample selection criteria , out of which 30
assessing the effect of intradialytic stretching exercises on were in the experimental group and 30 were in control
fatigue and muscle cramps among dialysis patients. group.

1.2Objectives of the study Purposive sampling technique was used to select the
 To assess the level of fatigue perceived among clients samples for the present study.
undergoing hemodialysis before and after intradialytic
stretching exercise in both experimental and control 2.6 Sampling Criteria
group. Inclusion criteria
 To assess the frequency and severity of muscle cramps Hemodialysis patients;
among clients undergoing hemodialysis before and after  Age group of 20-60 years
intradialytic stretching exercise in both experimental and  All the gender
control group.  have stable cardiac profiles
 To determine the effect of intradialytic stretching  have no musculoskeletal impairments
exercise on fatigue and muscle cramps among clients Exclusion criteria
undergoing hemodialysis in control and experimental Hemodialysis patients;
group.  irregular for hemodialysis
 have femoral catheters
1.3Hypothesis  have known psychiatric disorders
H1 - There will be a significant improvement in reduction of  weak and critically ill
Fatigue and Muscle cramps after performance of
intradialytic stretching exercises. 2.7 Tools& Technique
1. Structured questionnaire consisted of;
1.4 Conceptual framework Part 1- Socio demographic data (12items)
Conceptual frame work is based on Orlando’s Theory Part 2-Clinical data (3 items)
of Deliberative Nursing process (1990). Orlando’s theory 2. Multidimensional Assessment of Fatigue Scale
radically shifted the nurses focus from medical diagnoses to 3. PENN Spasm Frequency Scale
nursing diagnoses that is to find and meet the client’s
immediate goals.

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Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Figure- 1:Schematic representation of Research Methodology

2.8 Data collection procedure

The study was conducted after getting the permission III. RESULTS AND DISCUSSION
from the ethical committee of NIMS hospital. The main
study was conducted among 60 Haemodialysis patients, 3.1 Description of the socio demographic and clinical
selected by purposive sampling. Data collection period was variable characteristics under study.
one month. Prior to data collection, theinvestigator  Among the samples ,26.7% of samples in experimental
introduces self and explain regarding the study and assures group belongs to age group of 51-60yrs ,23.3% belongs
the confidentiality of the information provided by the study to age group of 61-70yrs &41-50 yrs,13.3% belongs to
participants. Informedconsent obtained. ThirtyHemodialysis the age group of 20-30 yrs&31-40yrs whereas 30% of
patients each was assigned to both the experimental group samples in control group belongs to the age group of 51-
and control group. The investigator taught theintradialytic 60 yrs,26.7% belongs to the age group of 61-70 yrs,23.3
stretching exercises on the first day to the experimental %belongs to the age group of 41-50 yrs,13.3% belongs to
group and made the patients to perform intradialytic the age group of 31-40yrs,6.7% belongs to the age group
stretching exercise. The exercise duration is 30 minutes in of 20-30yrs.
the non access extremities. This exercise program is on 3  Among the samples in experimental group 66.7% of
days ie, either Monday, Wednesday, Friday or samples are males and 33.3% are females, in control
Tuesday,Thursday, Saturday. Intradialytic stretching group 56.7% of samples are females and 43.3% of
exercises consists of arm curls, seated marching, toe taps samples are males.
and lower leg raise. Pre testscore taken before teaching  Among the samples in experimental group 76.7% of
exercises. Post test score was obtained after 3 weeks on samples are married, 23.3% are single ,whereas in
Friday/Saturday when they came for Hemodialysis after control group 80% of samples are married ,16.7% are
successful completion of exercise program. Data collection single,3.3% are separated/divorced
process was concluded by thanking each participant.

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Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
 Among the samples in experimental group 40% of hypotension after 10% of samples experience
samples have primary education,36.7% have college hypotension.
education,13.3% have professional education, 6.7% have  Among the samples in experimental group53.3% of
high school education,3.3% are illiterate ,whereas in samples are undergoing Hemodialysis with
control group 40% of samples have primary education Ultrafiltration rate of 3L,30% with4L,13.3% with
,30% have college education,23.3% have high school 2L,,3.3% with 5L,whereas in control group 46.7% with
education,6.7% have professional education. 4L, 20% with 5L,16.7% with 2L&3L.
 Among the samples in experimental group 30% of  Among the samples in experimental group 96.7% of
samples are Govt.employees,26.7% are private samples are undergoing Hemodialysis with rate of blood
employees,20% are unemployed and coolie flow through the dialyzer at a rate of 251-
workers,3.3% are agriculture workers, whereas in control 300ml/min,3.3% with 201-250ml/min whereas in control
group 26.7% are private employees & group 83.3% with 251-300ml/min,16.7% with 201-
unemployed,23.3%a re coolie workers,20% 250ml/min.
agriculture,3.3% Govt.employees. 3. 2 Description of Fatigue scores based on group
 Among the samples in experimental group 46.7% of  Among the samples during the pre test in experimental
samples have family income<5000,20% have family group 86.7% of samples experience severe fatigue
income of 5001-10000&10001-15000,13.3% have ,13.3% experience moderate fatigue whereas in control
family income of >15000 ,whereas in control group group 83.3% experience severe fatigue and 16.7%
43.3% have family income of 5000-10000,30% have experience moderate fatigue
family income of <5000,20% have family income of  Among the samples duringpost test in experimental
>15000,6.7% have family income of 10001-15000 group 56.7% of samples experience severe fatigue
 Among the samples in experimental group 56.7% of ,43.3% experience moderate fatigue whereas in control
samples are Hindus ,33.3% are Christians ,10% are group 86.7% experience severe fatigue and 13.3%
Muslims ,whereas in control group ,50% are Christians experience moderate fatigue.
,43.3% are Hindus,6.7% are Muslims. 3.3 Description of the effectiveness of intradialytic
 Among the samples in experimental group 76.7% of stretching exercises on fatigue
samples belongs to nuclear family,16.7% belongs to joint  Among the samples the mean post test score of
family,6.7% belongs to extended nuclear family, whereas experimental group is significantly higher than the mean
in control group 56.7% belongs to nuclear family,26.7% pretestscore p (<0.05). Hence it is evident that there is
belongs to joint family,16.7% belongs to extended significant improvement in fatigue scores in the
nuclear family. experimental group after implementing intradialytic
 Among the samples in experimental group 76.7% of stretching exercises
samples resides in rural area,23.3% resides in urban area,  Among the samples results shows there is no statistically
whereas in control group 73.3% resides in rural significant difference between mean pretest and post test
area,26.7% resides in urban area fatigue scores p (>0.05) of patients in the control group.
 Among the samples in experimental group 96.7% of
samples gets support from family,3.3% gets support from
Mean SD N Mean Paired P
relatives, whereas in control group 70% gets support
Difference t
from family,16.7% gets support from friends,13.3% gets
support from relatives.
 Among the samples in experimental group 50% of Pre 45.9 4.6 30 5.9 11.8 0.000
samples have both diabetes mellitus and test
hypertension,33.3% of samples have none of the Post
disease,10% have hypertension,6.7% have Diabetes test 40.0 3.4 30
mellitus whereas in control group 33.3% have Diabetes
mellitus &Hypertension,23.3% have Diabetes mellitus
Table -1: Mean standard deviation and t value of overall
13.3% have hypertension and 13.3% have Diabetes
fatigue before and after intervention in experimental
mellitus, hypertension & coronary artery disease
group.
 Among the samples in experimental group 50% of
n=60
samples are undergoing hemodialysis since more than
one year ,30% since 6-12 months,20% since <6months
** Significant at 0.01 level
whereas in control group 50% since >1year,40% since 6-
12 months,10% since <6 months. Table. revealed that the mean post test score of
 Among the samples in experimental group before experimental group is significantly higher than the mean pre
hemodialysis none of the samples experience test score ( p <0.05). Hence it is evident that there is
hypotension, during 36.7% of samples experience
significant improvement in fatigue scores in the
hypotension , after 23.4% of samples experience
experimental group after implementing intradialytic
hypotension whereas in control group before stretching exercises.
hemodialysis none of the samples experience
hypotension, during 60% of samples experience

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Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Table-2:Mean standard deviation and t value of overall
Severity Pre Test Post Z# P
fatigue before and after intervention in control group.
f % Test
n=60
f
Mean SD N Mean Paired P %
Difference t Mild 1 3.3 0 0.0
Moderate 13 43.3 16 53.3 0.655
Pre 44.0 3.9 30 0.2 12.7 0.215 Severe 16 53.3 14 0.45
test 46.7
Post Table. 4 Effectiveness of intradialytic stretching
test 43.8 3.6 30 exercises on severity of muscle cramps in control group

3.4 Description of the effectiveness of intradialytic The above findings shows there is no statistically
stretching exercises on frequency and severity of muscle significant difference between pretest and post test severity
cramps. of muscle cramps scores ( p>0.05) of patients in the control
Table shows there is no statistically significant group.
difference between mean pretest andpost test fatigue scores
(p>0.05) of patients in the control group. 3.3 Discussion
 Among the samples results reveals that the post test The present study focused to determine the effect of
score of experimental group is significantly higher than intradialytic stretching exercises on fatigue and muscle
the pre test score (p<0.05) .Hence it is evident that there cramps among patients undergoing Hemodialysis at NIMS
is significant improvement in frequency of muscle Hospital Neyyattinkara. The findings of the study have been
cramps scores in the experimental group after discussed based on the objectives of the study and findings
implementing intradialytic stretching exercises. of other similar studies.
 Among the samples results reveals no statistically
significant difference between pretest andpost test A study was conducted to determine the effect of
frequency of muscle cramps scores ( p>0.05) of patients stretching exercises protocols on reduction of leg cramp
in the control group. during hemodialysis among patient admitted with renal
 Among the samples results revealed that the post test failure. Quasi- experiment research design was applied. This
score of experimental group is significantly higher than study was conducted in Al .AzarAssuit Medical Hospital
the pre test score (p<0.05) .Hence it is evident that there dialysis unit. Thesubjects of this study consists of 60
is significant improvement in severity of muscle cramps patients with muscle cramps during hemodialysis. The three
scores in the experimental group after implementing tools included in the study are tools of socio - demographic
intradialytic stretching exercises. data , Patient information about muscle cramps &
 Among the samples results reveals no statistically management & tool of evaluated patient knowledge and
significant difference between pretest andpost test skills after performance exercises. Results shows that there
severity of muscle cramps scores ( p>0.05) of patients was lack of knowledge & skills related to muscle cramps
in the control group. beforenursing instruction protocol, but there was statistical
significant difference after performance of exercises. It was
Severity Pre Test Post Z# P found also thathigh significant difference between before &
f Test after performance of exercises. The study concluded the
% f importance of performance exercises for patient undergoing
% dialysis to prevent cramps. There is clearly a need for
Mild 0 0.0 12 40.0 effective education regarding recognition of individual
Moderate 4 13.3 18 60.0 0.000 patient need and appropriate intervention strategies in
Severe 26 86.7 0 5.04** muscle cramps in dialysis patient . Nurses, in partnership
0.0 with patient, relatives and other health professionals can
help to empower the individual to manage their cramps.

Table.3 Effectiveness of intradialytic stretching exercises The present study also reveals that there is significant
on severity of muscle cramps in experimental group improvement in frequency and severity of muscle
cramps in the experimental group after implementing
**Significant at 0.01 level intradialytic stretching exercises.

The above table revealed that the post test score of

experimental group is significantly higher than the pre test
score (p<0.05) .Hence it is evident that there is significant
improvement in severity of muscle cramps scores in the
experimental group after implementing intradialytic
stretching exercises.

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Volume 5, Issue 11, November – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
IV. CONCLUSION

The present study reveals that majority of the clients

undergoing hemodialysis experience moderate to severe
fatigue and intradialytic stretching exercises had shown to
decrease fatigue. The study also reveals that there is
significant improvement in frequency and severity of muscle
cramps after implementing intradialytic stretching exercises.

4.1 Nursing implications

The present study has got implications in the field
of nursing service, nursing administration, nursing education
and nursing research.
 Stretching exercises can be used by the nursing
professionals who are working in dialysis unit.
 Nursing professionals can use stretching exercises as a
non-pharmacological intervention in case of various
situations like pain, fatigue,muscle cramps etc.
 Nurse educator should educate the students regarding
stretching exercises and its implementation to decrease
pain, fatigue, muscle cramps etc..
 The study is relevant for the nurse administrators to
determine the need of stretching exercises in dialysis
unit.
 Similar studies can be done with a large sample.
 This study will be a motivation for the beginning
researcher to conduct similar studies.

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