ARTICLE PRESENTATION

Presented by:
Ms.Supritha.Birnur
1 st year MSc
Nursing
 ABOUT THE JOURNAL
NAME OF THE JOURNAL : NMS journal
VOLUME : 04

ISSUE : 01

YEAR : 2015

PUBLISHER NAME :Publisher

Kashan University of Medical Sciences
EIDITOR IN CHIEF : Negin Masoudi Alavi
Professor, Ph.D in Nursing Education, Department of Medical
Surgical Nursing, Trauma Nursing Research Center, Kashan
University of Medical Sciences, Kashan, Iran
WEBSITE :
PHONE NUMBER: +98-9131615864
PERIODICITY
[Frequency of Publication] : Quarterly
NUMBER OF ISSUES PER YEAR : 4 issues per year

MONTH(S) OF PUBLICATION :February ,May, August,

November

TYPE OF JOURNA: Peer reviewed

 TITLE OF THE ARTICLE
Comparing the Effects of Active and Passive Intradialytic
Pedaling Exercises on Dialysis Efficacy, Electrolytes,
Hemoglobin, Hematocrit, Blood Pressure and Health-
Related Quality of Life

NAME OF THE AUTHOR(S)

Azra Sadat Musavian 1Department of Health
(Community Health Nurse), Kashan University of
Medical Sciences, Kashan, IR Iran
Alireza Soleimani 2Department of Internal Medicine,
Kashan University of Medical Sciences, Kashan, IR Iran
Negin Masoudi Alavi3, Trauma Nursing Research
Center, Kashan University of Medical Sciences,
Kashan, IR Iran
Alimohammad BaseriDepartment of Dialysis,
Akhavan Hospital, Kashan University of Medical
Sciences, Kashan, IR Iran
 INTRODUCTION

In end stage renal disease (ESRD) approximately 90% of

renal function is lost, and body is not able to maintain fluid and
electrolyte balance, adequate waste removal, and normal hormone
function . Several types of renal replacement therapies are
available; however, hemodialysis (HD) is the most common
method . Nowadays, more than two million people with renal
failure are treated by Hemodialysis worldwide . Hemodialysis, is a
time-consuming procedure that takes at least 3 to 5 hours a day,
two or three times a week . Dialysis induces notable metabolic
changes including hypovolemia due to ultrafiltration, and rapid
changes in electrolyte concentrations and systemic inflammation,
which can all adversely affect physical function .
Despite regular HD treatment to replace some of the
kidney functions, HD patients suffer from a symptoms
characterized by the "uremic" syndrome. These are
typically manifested as autonomic and motor
neuropathies, cardiac and skeletal muscle myopathies,
peripheral vascular changes, anemia, dysfunction of
bone metabolism, immunologic compromise, and an
assortment of physiologic complaints such as nausea,
vomiting, insomnia and fatigue.A high-quality dialysis
improves the quality of life and increases the survival
rate in patients with ESRD .
An intradialytic exercise program can improve serum
urea clearance and dialysis efficacy . Moreover, an
intradialytic exercise increases muscle blood flow and
open capillary surface area in working muscles that will
result in a greater flux of urea and other toxins from the
tissue to the vascular compartment for the subsequent
removal at the dialyzer . Also, the exercise or regular
physical activity in hemodialysis can improve the
control of high-blood pressure and diabetes and also
increase the health-related quality of life.
Moreover, exercise can increase the blood-flow to the
muscles that consequently reduce the pain in these
patients . A recent study showed that moderate exercise
had positive effects on physical and mental health.
These include improvements in aerobic capacity, lower
extremity muscle strength, systolic blood pressure, and
lipid metabolism
Quality of life (QOL) is an important criterion for
measuring the health care effectiveness, perceived
health, sense of wellbeing and predicting the mortality
and morbidity rates in patients.
Physical activity can improve QOL . It has been
confirmed that the physical activity reduces
morbidity and mortality in patients with chronic
renal failure . People who are physically inactive
have a 20% to 30% increased risk of mortality .
Although most exercise programs have been
instituted between dialysis sessions, recent
investigations have promoted the concept of
intradialytic exercise as a convenient
intervention to improve patients’ compliance .
The exercises are usually performed during the early
phase of hemodialysis because cardiovascular responses
are more stable during the early phase of hemodialysis .
The reduced activity may be attributed to several factors
such as anemia, impaired blood-flow to the limbs, loss
of the heart function and reduced daily physical
activities . Despite the positive effects of exercise in
hemodialysis patients in theory, studies had mixed
results. Parsons et al. have reported that an eight-week
exercise program during hemodialysis had no
significant effects on dialysis efficacy, blood pressure,
and QOL in patients with ESRD.
However, in another study, a five-month program of 30
min exercise in the first two hours of the dialysis showed
an increase in dialysis efficacy. However, no changes
were observed in the levels of hemoglobin, potassium,
albumin, and QOL . In another study, Makhlough et al.
have reported that an eight-week intradialytic aerobic
exercise in hemodialysis patients did not affect the
dialysis efficacy but significantly reduced the phosphorus
and potassium levels . Smart et al. also reported that
exercise is useful and may improve dialysis efficiency
(kt/v), serum potassium and depression in hemodialysis
patients . Girija et al. have demonstrated that exercise in
hemodialysis patient increases the quality of life through
reducing the stress level .
However, in a study by McMurray et al. no
significant changes were observed in phosphorus
levels and in systolic and diastolic blood pressures
after the intradialytic pedaling exercise . Fallahi et
al. also examined the effects of exercise during
hemodialysis on dialysis efficacy, serum phosphorus
level, hemoglobin and blood pressure. He found
that an hour of exercise during hemodialysis could
significantly reduce the patients’ systolic blood
pressure. The exercise program also increased the
dialysis efficacy and had slight positive effects on
phosphorus and hemoglobin levels .
Due to the progressive reduction in muscular activity of
patients with ESRD, their muscular strength will
gradually reduce. Most studies on intradialytic exercise
have used passive exercise and few studies have
examined the effects of active exercise during
hemodialysis. Moreover, the patients have limited
ability to perform active exercise during hemodialysis
session.
 AIM OF THE STUDY

The aim of this study was to evaluate the effect of

intradialytic stretching training on Restless Legs
Syndrome (RLS) and sleep quality among patients
undergoing hemodialysis.
 METHODOLOGY

• RESEARCH APPROACH: Quantitative Research

Approach
• RESEARCH DESIGN: Quasi Experimental study
• VARIABLES:
- Independent Variable :patients undergoing
haemodialysis.
- Dependent Variable intradialytic exercise
• RESEARCH SETTING:
The study was conducted at the Akhavan Hospital in
Kashan, Iran.
• SAMPLES: The study sample involved all eligible
hemodialysis patients in the dialysis center
• SAMPLE SIZE: The total sample size was
estimated to be 16.
• SAMPLING TECHNIQUE:
INCLUSION CRITERIA

The study includes :

• Patients under hemodialysis for at least three months,
• Receiving hemodialysis three times a week,
• For at least 240 minutes (4 hours) per treatment,
• Age between 15 to 80 years old.
EXCLUSION CRITERIA

The study excludes:

• Patients with a history of cardiovascular diseases,
myocardial ischemia in the last 6 months,
cerebrovascular accidents, and pulmonary,
musculoskeletal and immune disorders
• unstable angina,
• cardiac ischemia,
• severe persistent hypertension,
• severe hypotension (systolic blood pressure < 90
mmHg),
• severe uncontrolled diabetes,
• fever (body temperature > 38°C) during the study
period
• not adhering to the exercise program.
 DISCERPTION OF TOOL

Instrument :
1. Demographic questionnaire
2. A questionnaire for measuring the QOL among the
patients
3. A checklist for recording the blood pressure and
other biochemistry tests and dialysis efficacy.
 DATA COLLECTION PROCEDURE

• The patients were under study for 8 months. The first 8

weeks were considered as the control period. All patients
were dialyzed using high-flux dialyzer membranes (made
by SOHA Co. Iran), the blood-flow rate of 350 mL/min
and bicarbonate-dialysate, flow rate of 500 mL/min by
Gambro AK95 apparatus (made in Swiss) or Ferzinus
apparatus (made in Germany).
• Afterwards, for eight weeks, the patients received the
passive intradialytic exercise using the electrically
powered Mini-Bike (Made in China) adapted to the
patient's bed.
• All patients performed passive pedaling with a
moderate speed for 30 minutes per session
(performed as three 10-minute exercise bouts with a
20-minute recovery period between the bouts) during
the first 2 hours of dialysis session.
• After 8 weeks of washout (17), the active intradialytic
pedaling exercise was performed similarly for eight
weeks, except that the Mini-Bike did not connect to
the electrical power and patients pedaled the Mini-
Bike actively.
• The type of the dialysis apparatus, dialyzer membrane
and the blood and dialysate flow rates were kept
unchanged for all patients during the study.
 DATA ANALYSIS
• Data were analyzed using SPSS 13.0 software (SPSS Inc,
Chicago, Illinois, USA).
• Mean and standard deviation were calculated for quantitative
variables.
• Kolmogorov-Smirnov test was used to determine if the data were
normally distributed.
• Paired t-test and the Wilcoxon signed rank and Friedman tests
were used to compare the variables.
• To analyze the difference between the variables in different time
intervals, the repeated measure analysis of variance was used.
• In all tests, the level of significance was considered to be less than
0.05.
 Table 1.
Demographic Characteristics of the Participants a

Variables
a Frequency
Gender
Male 13 (81.2)
Female 3 (18.8)
Marital status
Single 3 (18.8)
Married 13 (81.2)
Level of education
Illiterate 5 (32.2)
Elementary school 6 (37.5)
High school 4 (25)
University education 1 (6.2)
Medical diagnosis
Diabetes mellitus 9 (56.2)
Hypertension 2 (12.5)
Polycystic disorders 2 (12.5)
Unknown 2 (12.5)
Genetic 1 (6.2)
Duration of dialysis 2.27 ± 2.09
Age 51.98 ± 1.57
Table 2.
Mean and Standard Deviation of Dialysis Efficacy and Blood Parameters After
Performing Passive Exercise a
Intervention Before 4 Weeks After Statistical 8 Weeks After Statistical
Variables Passive passive Values Passive Values
Exercise Exercise Exercise
Dialysis T = 0.058, P T = 1.446, P
1.32 ± 0.30 1.27 ± 0.29 1.43 ± 0.49
efficacy value = 0.954 value = 0.169
T = 0.328, P T = 0.435, P
URR 65.99 ± 7.28 65.93 ± 8.67 67.3 ± 22.26
value = 0.747 value = 0.670
T = 0.673, P T = 1.178, P
Hemoglobin 11.25 ± 1.62 11.46 ± 1.61 11.87 ± 2.02
value = 0.511 value = 0.257
T = 2.078, P T = 2.015, P
Hematocrit 34.08 ± 4.36 35.26 ± 3.90 36.21 ± 4.89
value = 0.055 value = 0.062
Z = 1.371, P Z = 0.155, P
Potassium 4.32 ± 0.75 4.33 ± 0.41 4.32 ± 0.41
value = 0.170 value = 0.877
T = 1.443 P T = 1.437, P
Calcium 8.44 ± 1.00 8.85 ± 0.88 8.89 ± 0.99
value = 0.169 value = 0.171
T = 0.171 P T = 0.211, P
phosphorus 4.82 ± 0.76 4.79 ± 1.14 4.80 ± 0.83
value = 0.867 value = 0.836
Table 3.
Mean and Standard Deviation of Dialysis Efficacy and Blood Parameters
After Performing the Active Exercise a

Intervention Before Active 4 Weeks After Statistical 8 Weeks After Statistical

Variables Exercise Active Exercise Values Active Exercise Values

Dialysis 1.39 ± 0.26 1.38 ± 0.43 T = 0.531, P 1.33 ± 0.28 T = 1.000, P

efficacy value = 0.603 value = 0.335

T = 1.092, P T = 1.364, P
URR 68.48 ± 6.91 66.75 ± 9.36 value = 0.292 66.20 ± 7.09 value = 0.196

T = 0.237, P T = 0.355, P
Hemoglobin 10.59 ± 1.82 10.61 ± 1.78 value = 0.816 10.69 ± 1.87 value = 0.729

Hematocrit 33.18 ± 6.13 34.00 ± 4.79 T = 0.848, P 30.86 ± 5.26 T = 1.905, P

value = 0.410 value = 0.079

Z = 0.827, P Z = 1.350, P
Potassium 5.03 ± 1.07 4.77 ± 0.96 value = 0.408 4.54 ± 0.50 value = 0.177

T = 0.393 P T = 1.187, P
Calcium 8.77 ± 0.96 8.67 ± 1.15 value = 0.700 9.09 ± 0.76 value = 0.257

T = 5.626, P T = 3.441, P
phosphorus 4.85 ± 0.96 4.12 ± 0.75 value = 0.000 4.21 ± 0.64 value = 0.004
Table 4.
Repeated-Measure ANOVA of the Variables Between the Passive and Active Exercises a

Variables Degree of Freedom Mean of Square F statistics P Value

Dialysis efficacy 1 0.02 0.431 0.517

Dialysis efficacy ×
1 0.133 2.89 0.1
Type of exercise
URR 1 0.033 0.001 0.973
URR × Type of
1 38.25 1.347 0.256
exercise
Hgb 1 1.63 1.32 0.259
Hgb × Type of
1 0.799 0.647 0.428
exercise
Hct 1 2.11 0.326 0.573
Hct× Type of
1 45.99 7.081 0.013
exercise
Potassium 1 1.14 3.01 0.094
Potassium × Type of
1 1.11 2.94 0.097
exercise
Calcium 1 1.01 3.29 0.08
Calcium × Type of
1 0.121 0.198 0.66
exercise
phosphorus 1 1.127 3.56 0.069
phosphorus × Type
1 1.76 4.91 0.035
of exercise
Table 5.
Mean and Standard Deviation of Systolic and Diastolic Pressures in Patients Performing Passive
and Active Intradialytic Exercise

Beginnin End of End of

TimeBlood Chi-
g of 4th 8th P Value a df
Pressure Square
Study Week Week

Passive exercise

Systolic 13.38 ± 12.56 ± 13.31 ±

0.058 2 5.698
pressure 2.12 1.50 2.21

Diastolic 8.06 ± 7.56 ± 7.69 ±

0.039 2 6.488
pressure 0.77 0.62 0.70

Active exercise

Systolic 12.94 ± 13.31 ± 14.00 ±

0.255 2 2.735
pressure 1.91 2.33 2.03

Diastolic 7.81 ± 8.00 ± 8.29 ±

0.296 2 2.438
pressure 0.91 1.03 0.72
Table 6.
Comparing the Mean and Standard Deviation of Quality of Life Scores Before and
After Performing Intradialytic Exercise a

General Health Number of Before After P Value b

Questions

Changes in health 5 42.50 ± 19.32 55.31 ± 20.69 0.028

Physical 1 74.18 ± 26.64 70.31 ± 16.37 0.016

functioning

Limitations due to
physical problems 10 58.43 ± 25.34 65.00 ± 20.08 0.057

Limitations due to
emotional 4 57.81 ± 36.19 78.12 ± 36.37 0.027
problems

Social functioning 3 53.75 ± 39.13 60.00 ± 44.72 0.538

Bodily pain 2 68.12 ± 28.33 76.25 ± 19.95 0.165

Vitality 2 55.62 ± 33.05 68.12 ± 25.87 0.076
Mental health 4 60.93 ± 22.22 65.93 ± 21.30 0.198
Overall quality of 5 65.93 ± 25.50 77.50 ± 18.25 0.088
life

General health 36 510.31 ± 169.27 616.56 ± 169.16 0.007

 CONCLUSSION

The passive intradialytic exercise had a positive effect

on blood pressure. The active exercise could decrease
the serum phosphorus and potassium levels. Moreover,
both exercise programs could significantly improve the
QOL. Both active and passive intradialytic exercises
can have some beneficial effects.