presentation title here - hospital authority...to avoid hypotensive episodes, intra-dialytic...
TRANSCRIPT
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HAPPY Program
Timmi Yick Physiotherapist I
Tseung Kwan O Hospital
HAemodialysis Patient PhYsical Exercise program --- Pilot Physiotherapy exercise training program for Haemodialysis patients in Tseung Kwan O Hospital
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Hong Kong Situation
• About 8000 End Stage Renal Disease patients requiring renal replacement therapies in year 2012
• Incidence ~1000 yearly
Prevalence 1,192 pmp
Incidence rate 157 pmp
Hong Kong
Hong Kong Renal Registry (2013) USRDS Annual Report (2014)
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Problems of Chronic Kidney Disease
– Exercise capacity (60%-70% of healthy age-matched individuals)
– Physical strength
– Risk of fall
– Cardiovascular morbidity & mortality
– Quality of life (QOL)
ACSM (2014); Neil et al (2011)
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Exercise for Haemodialysis Patients
Physical Improvements • Better control of BP, DM & lipid profile • Exercise capacity • Muscle wasting • QOL • Risk of falls • Efficiency of dialysis
Jung et al (2011); Kong et al (1999)
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Benefits of Exercise On HD Patients
Psychological Improvements Motedayen et al (2014)
Reduced subjective fatigue symptoms
Improved Perception of general health
Reduced Anxiety
Reduced Depression
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Benefits of Intra-Dialytic Exercise
• During haemodialysis, patients pedal on bike 5-20 mins followed by rest to achieve 60 mins
• Plasma level of urea, creatinine and potassium levels were measures pre / post / 30 mins post-dialysis
Results: Rebound of solutes were sign. after exercise
(1999)
The effect of exercise during haemodialysis on solute removal
Chiew H.Kong, James E. Tattersall, Roger N. Greenwood and Ken Farrington
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Evidence-Based Practice
• Combining aerobic and resistance training delivered on non-dialysis days for at least 6 months offers greatest change in peak VO2
Neil S et al (2011)
• Uptake and adherence of exercise may be
maximised by presence of physiotherapist during each dialysis session
Matthew T et al (2006)
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Aim of HAPPY Program
• Provide a one stop service for exercise program for HD patients
• Establish home exercise plan & promote active lifestyle
• Improve clinical outcomes & self-esteem
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Patient Journey
Patients recruited into HAPPY program by Nephrologists
Physiotherapist Initial Assessment
Intra- Dialytic Exercise
+ Home
Exercise Program
Refer NAHC Fall
Prevention clinic for
fall risk pt PT 6 months Re-Ax
PT 3 months Re-Ax
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Exercise Training Regime
1. Intra-dialytic exercise – Weekly aerobic or
resistance exercise with gradual progression
– Individualized target depends on previous assessment
– Progression depends on RPE level
Cycling exercise
Sandbag exercise
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Safety Monitoring Intra-Dialytic Exercise
BP / HR
Arterial & Venous Pressure/ Blood flow
Matthew T et al (2006)
To avoid hypotensive episodes, intra-dialytic exercise is done during initial first 2 hours of HD • Pre and Post vital signs checking • Continuous monitoring vitals and RPE level
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Exercise Training Regime
2. Home exercise program • Both aerobic training and
resistance exercise
• Exercise recommendations according to ACSM guideline
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Special Considerations on Exercise
• Start with light intensity & shorter duration (10-15mins)
• Exercise progression • Initially duration • Then intensity
• Intermittent exercise with rest • Monitor RPE • No exercise immediately post HD
Rate of Perceived Exertion 6
7 Very, very light 非常輕微 (甚至微不足道)
8 9 Very light 很輕微
10 11 Fairly light 頗輕微 12
13 Somewhat hard 有點辛苦
14 15 Hard 辛苦 16 17 Very Hard 很辛苦 18
19 Very, very hard 異常辛苦
20
Rate of Perceived Exertion (Borg GAV 1982)
ACSM (2014)
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Outcome Measures
• Six Minute Walk Test Exercise Capacity
• Time Up and Go Test Mobility & Balance
• Short-Form Health Survey (SF-36) QOL
• 0-10 Point Scale Self Efficacy on Exercise
• Satisfaction Questionnaire Patient Satisfaction
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Results
From Jan 2014 – March 2015:
Baseline 6 Months % Change 6 Minute Walk Test 275 meters 307.3 meters 11.75%
Time Up and Go Test 18 seconds 12.6 seconds 30% Total SF-36 49 59.5 21.4%
SF-36: Physical Health 44.5 58.5 31.5% SF-36: Mental Health 47.5 55.8 17.5%
Self Efficacy 4.8 6.5 35.4%
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Six Minute Walk Test
After 6 Months of training: 11.75%
250
260
270
280
290
300
310
Baseline 3 Months 6 Months
275
310 307.3
Meters
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Time Up And Go Test
0
5
10
15
20
Baseline 3 Months 6 Months
18 13.5 12.6
Seconds
After 6 Months of training: 30%
* <10 Seconds: Freely Independent in mobility
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Total score of Short-Form Health Survey
0
10
20
30
40
50
60
Baseline 3 Months 6 Months
49 51.5 59.5
After 6 Months of training: 21.4%
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Short-Form Health Survey
0
20
40
60
Baseline 3 Months 6 Months
44.5 48.8 58.5
After 6 Months of training: 31.5%
Physical Health
40
45
50
55
60
Baseline 3 Months 6 Months
47.5 50.5 55.8
Mental Health
After 6 Months of training: 17.5%
Physical and Mental Health score approaching HK Norm: 50
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Self Efficacy On Exercise (0-10)
0
1
2
3
4
5
6
7
Baseline 3 Months 6 Months
4.8 6.5 6.5
After 6 Months of training: 35.4%
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Patients’ Subjective Improvements
Health Condition
Agree Neutral
67%
33%
Stronglyagree
Agree Neutral
17%
50%
33%
Balance
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Conclusion
A 6 months exercise program for CKD pt with HD treatment is effective to 1. ↑ Exercise capacity 2. ↑ Mobility & Balance 3. ↑ Quality of life
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Future Planning
• Recruit more patients in HAPPY program
• Continuity of exercise
• Build up patients’ regular exercise habit
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Reference
1. American College of Sports Medicine. ACSM’s Guidelines for exercise testing and prescription. (2014) Ninth edition. p305-308
2. Chiew H. Kong et al. The effect of exercise during haemodialysis on solute removal. (1999) Neprhology Dialysis Transplantation 14: 2927-2931
3. Cindy LK Lam et al. Population norm of Chinese SF-12 health survey_version 2 of Chinese adults in Hong Kong. (2010) Hong Kong Pract; 32:77-86
4. Jung Tae-Du et al. Intradialytic exercise programs for hemodialysis Patients. (2011) Chonnam Medical Journal 47:61-65
5. Matthew Torkington et al. Uptake of and adherence to exercise during hospital haemodialysis. (2006) Physiotherapy 92: 83-87
6. Neil Smart. Michael Steele. Exercise training in haemodialysis patients: A systematic review and meta-analysis. (2011) Nephrology 16: 626-632
7. Thomas W Storer et al. Endurance exercise training during haemodialysis improves strength, power, fatigability and physical performance in maintence haemodialysis patients. (2005) Nephrology Dialysis Transplantation 20: 1429-1437
8. United States renal data system. 2014 Annual Data Report (2014) http://www.usrds.org/2014/view/Default.aspx
9. Ying Wang. Meg J Jardine. Benefits of exercise training in patients receiving haemodialysis: a systematic review and meta-analysis. (2011) British Journal of Sports Medicine 45(14): 1165-1166
10. Yiu Wing Ho et al. Hong Kong renal registry report 2012. (2013) Hong Kong Journal of Nephrology 2013 (15), 28-43
11. Yongyau Wu et al. Effect of individualized exercise during maintenance haemodialysis on exercise capacity and health-related quality of life in patients with uraemia. (2013) Journal of International Medical Research 42(3): 718-727
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Acknowledgement
Dr Elaine Ho, AC. TKOH Dr Yeung Shing, AC. TKOH Mr Tony Au, DM of IRS. TKOH Ms Catherine Cheung, SPT. TKOH Ms Tammy Fung, SPT. TKOH Ms Winnie Choi, PTI. TKOH