Patients with CKD are physically inactive, and regardless of age, have levels of physical functioning similar to (or lower than) to older adults [1]. There is robust epidemiologic evidence that low physical function and physical inactivity are associated with poor clinical outcomes [2] [3] [4] (full text)). These associations are documented in earlier stages of CKD, in ESRD and renal transplantation.
Questionnaires administered were related to levels of mobility/autonomy and physical functioning, self-reported physical activity, quality of life, and perceived barriers to physical activity. In particular, the level of self-reported physical functioning/autonomy was evaluated by the Katz Independence in daily living questionnaire (ADL, Activities of Daily Living questionnaire), a self-reported test on mobility and performance based on 18 items describing different levels of autonomy in physical activity related to participation in 6 life activities.
For patient-related barriers to physical activity the questionnaire from Delgado & Johansen was used [5] (full text), which includes questions related to different categories of disease- and patient-specific barriers to physical activity: psychological barriers, physical barriers, economical barriers, lack of time and comorbidities.
The level of physical activity was derived from the 94-item Human Activity Profile (HAP) [6], whichincludes the assessment of activities across a wide range of energy requirements.
Table 1 illustrates demographic and clinical characteristics of the 261 patients enrolled with complete data. Patients were divided in active and inactive according to the HAP questionnaire (Figure 1).
Table 1. Clinical and demographic characteristics
Variable
All patients, N=261
Inactive, N=172
Active, N=89
P
Age, years (SD)
67.1 (14.4)
70.5 (12.9)
60.1 (14.5)
<0.001
Males (%)
60.2
57.6
65.2
0.290
BMI, Kg/m2 (SD)
24.6 (5.0)
24.8 (4.8)
24.1 (5.58)
0.280
Active smoker, %
11.5
8.6
17.3
0.087
Secondary school or lower, %
75.3
85.8
56.4
Bachelors degree or higher, %
24.7
14.2
43.6
Dialysis vintage, months
median (1st-3rd quartile)
49 (24-101)
49 (26-101)
74.6 (74.3)
0.677
KT/V (SD)
1.3 (0.5)
1.4 (0.5)
0.365
Diabetes, %
25.3
32.0
12.4
COPD, %
17.4
23.7
5.6
Peripheral artery disease, %
31.8
36.7
22.5
0.029
Amputation, %
4.7
4.5
1.000
Coronay artery disease, %
24.8
28.4
18.0
0.091
Heart failure, %
8.9
9.0
Charlson index (SD)
6.9 (2.4)
7.5 (2.3)
5.8 (2.3)
Serum albumin,g/dL, n (DS)
3.9 (0.4)
3.9 (0.5)
0.621
Hemoglobin, g/dL (DS)
11.2 (1.2)
11.1 (1.3)
11.4 (1.2)
0.133
C reactive protein, mg/L median (1st-3rd quartile)
2.0 (1.0-7.0)
3.0 (1.0-8.0)
2.0 (1.0-5.0)
0.233
Karnofski score (SD)
73.5 (20.1)
67.4 (17.3)
87.2 (18.3)
Two hundred fourty-eight participants (90.2%) reported at least one barrier to physical activity, 237 (86.2%) reported at least two barriers, 31 (11.3%) reported at least three barriers, and 30 (10.9%) reported at least four barriers. Table 2 illustrates the prevalence of barriers reported in the entire cohort and stratified by level of activity.
Table 2. Reported barriers to physical activity
Barriers
All patients, (N=261)
%
Inactive (N=172)
Active, (N=89)
No place to exercise
21.0
24.4
14.6
0.094
No safe place to exercise
21.3
24.9
0.043
Don’t want to be seen
13.9
17.1
7.9
0.065
No exercise partner
27.8
0.111
Fatigue on dialysis days
65.0
70.2
55.1
0.022
Fatigue on non-dialysis days
34.0
38.8
0.033
Pain on dialysis days
39.6
48.0
23.6
Pain on non-dialysis days
31.2
39.2
15.7
Lack of time on dialysis days
45.1
43.2
48.9
0.463
Lack of time on non-dialysis days
27.2
19.1
0.197
Too many medical appointments
22.4
26.5
0.044
I’m not willing to
46.1
52.1
34.8
0.012
Feeling too old
29.8
36.1
0.004
Shortness of breath
38.0
45.0
0.002
Fear of getting hurt
39.5
45.6
28.1
0.009
Sadness
46.7
41.6
0.508
Feeling of helplessness
40.1
42.3
36.0
0.397
Inability to travel
37.1
45.3
21.4
Too many medical problems
42.6
49.1
30.3
0.006
Family concern
15.9
16.6
0.818
Physician concern
5.8
7.7
2.3
0.134
Chest pain
23.1
0.001
Ulcers on legs and feet
8.1
9.5
0.403
Amputation
5.3
3.4
0.553
Table 3 illustrates the univariate analysis of the reported barriers.
Table 3. Univariate analysis of barriers to physical activity
Barrier
OR (95% CI)
1.887 (0.951;3.746)
0.069
1,734 (0.897;3.351)
0.101
2.409 (1.010;5.746)
0.047
1.758 (0.929;3.324)
0.083
1.921 (1.130;3.266)
0.016
1.933 (1.091;3.424)
0.024
2.983 (1.681;5.296)
3.451 (1.805;6.598)
0.796 (0.475;1.335)
0.387
1.584 (0.845;2.967)
0.151
2.105 (1.066;4.153)
0.032
2.033 (1.196;3.454)
2.577 (1.379;4.817)
0.003
2.489 (1.409;4.397)
2.143 (1.233;3.723)
0.007
1.234 (0.734;2.072)
0.428
1.304 (0.767;2.216)
0.327
3.050 (1.691;5.504)
2.216 (1.287;3.816)
1.161 (0.568;2.372)
0.682
3.625 (0.799;16.436)
0.095
5.040 (1.909;13.303)
1.757 (0.622;4.965)
0.288
1.612 (0.425;6.113)
0.482
At multivariable analysis, after adjusting for age, sex and comorbidity burden, the number of endorsed barriers (OR 1.095, 95% CI 1.029 to 1.165; P=0.004), pain on dialysis days (OR 2.585, 95% CI 1.295 to 5.158; P=0.007), and chest pain (OR 3.199, 95% CI 1.077 to 9.500; P=0.036) were independently associated with physical inactivity.
Lack of time for exercise counseling and the firm belief about low compliance/interest by the patients toward exercise were the most frequent barriers reported by nephrologists (N=50) and nurses (N=94).
Chronic hemodialysis patients have a low physical activity level. Also, we identified a number of patient-related and health personnel-related barriers to physical activity in chronic hemodialysis patients. Solutions for these barriers should be addressed in future studies aimed at increasing the level of physical activity in this population.
[1] Johansen KL, Chertow GM, Kutner NG et al. Low level of self-reported physical activity in ambulatory patients new to dialysis. Kidney international 2010 Dec;78(11):1164-70
[2] Johansen KL, Delgado C, Bao Y et al. Frailty and dialysis initiation. Seminars in dialysis 2013 Nov-Dec;26(6):690-6
[3] Painter P, Roshanravan B The association of physical activity and physical function with clinical outcomes in adults with chronic kidney disease. Current opinion in nephrology and hypertension 2013 Nov;22(6):615-23
[4] Johansen KL, Kaysen GA, Dalrymple LS et al. Association of physical activity with survival among ambulatory patients on dialysis: the Comprehensive Dialysis Study. Clinical journal of the American Society of Nephrology : CJASN 2013 Feb;8(2):248-53 (full text)
[5] Delgado C, Johansen KL Barriers to exercise participation among dialysis patients. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association 2012 Mar;27(3):1152-7 (full text)
[6] A systematic review of the Human Activity Profile.
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