Home About us Editorial board Ahead of print Browse Articles Search Submit article Instructions Subscribe Contacts Login 
  • Users Online: 387
  • Home
  • Print this page
  • Email this page


 
Previous article Browse articles Next article 
ORIGINAL ARTICLE
J Res Med Sci 2022,  27:84

Evaluating the effect of intradialytic cycling exercise on quality of life and recovery time in hemodialysis patients: A randomized clinical trial


1 Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Isfahan Kidney Diseases Research Center, Khorshid Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission29-Sep-2021
Date of Decision24-Apr-2022
Date of Acceptance10-May-2022
Date of Web Publication25-Nov-2022

Correspondence Address:
Dr. Safoora Shahzeidi
Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan
Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrms.jrms_866_21

Rights and Permissions
  Abstract 


Background: The aim of this study was to assess the effect of intradialytic cycling exercise on quality of life (QOL) and recovery time in patients who underwent hemodialysis. Materials and Methods: Hemodialysis patients were recruited from the referral dialysis centers affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. Patients were randomly assigned into the intervention and the control groups. Patients in the intervention group exercised on a stationary bike for 12 weeks (3 times per week for 30 min); however, patients in the control group received usual hemodialysis. The kidney disease QOL (KDQOL)-short-form version 1.3 was used to assess QOL. Patients were asked to answer the question “How long does it take to recover from a dialysis session?” to assess recovery time. Results: A total of 110 hemodialysis patients, including 60 in the intervention group and 50 in the control group were analyzed. A significant increase was observed in the generic (mean difference ± SE: 1.50 ± 0.44, P = 0.001), kidney disease (mean difference ± SE: 0.84 ± 0.28, P = 0.004), and overall QOL (mean difference ± SE: 1.18 ± 0.33, P = 0.001) scores after 12 weeks of intradialytic cycling exercise in the intervention group. Furthermore, a significant difference was noted between the intervention and the control group regarding the mean difference of all QOL scores after the intervention (P < 0.05). We also found a significant difference in the mean difference of recovery time between the intervention and the control group after the intervention (P < 0.001). Conclusion: KDQOL and recovery time could improve in hemodialysis patients after 12-week intradialytic exercise.

Keywords: Hemodialysis, intradialytic exercise, quality of life, recovery time


How to cite this article:
Moeinzadeh F, Shahidi S, Shahzeidi S. Evaluating the effect of intradialytic cycling exercise on quality of life and recovery time in hemodialysis patients: A randomized clinical trial. J Res Med Sci 2022;27:84

How to cite this URL:
Moeinzadeh F, Shahidi S, Shahzeidi S. Evaluating the effect of intradialytic cycling exercise on quality of life and recovery time in hemodialysis patients: A randomized clinical trial. J Res Med Sci [serial online] 2022 [cited 2022 Dec 3];27:84. Available from: https://www.jmsjournal.net/text.asp?2022/27/1/84/361980




  Introduction Top


End-stage renal disease (ESRD) is a significant public health issue with a rising prevalence worldwide. ESRD patients are treated with renal replacement methods comprising kidney transplantation or dialysis.[1],[2] Kidney transplantation is known as the optimal treatment option for ESRD patients; however, it is limited by the shortage of available organs. As a result, dialysis has become the more prevalent treatment in many parts of the world. Despite all advances in dialysis technology and care, the rate of morbidity and mortality remains high in ESRD patients.[3]

Quality of life (QOL) is a principal representative of medical care outcomes, which is considered a predictor of mortality and hospitalization in dialysis patients.[4],[5] Therefore, improving QOL through various interventions is crucial in dialysis patients. Exercise has been reported as a key element to enhance QOL in dialysis patients. A recent systematic review and meta-analysis of 20 randomized clinical trials (RCTs) comprising 677 ESRD patients receiving hemodialysis have reported that performing aerobic or combined exercises for at least 8 weeks improves health-related QOL.[6]

Recently, intradialytic exercise is considered an appropriate choice for dialysis patients considering its advantages compared to other exercise approaches such as higher removal of toxic agents, being time-efficient, and safe.[7],[8] Previous research has investigated the impact of intradialytic exercises on QOL in hemodialysis patients.[9],[10],[11],[12] Although, their results did not reach much consensus regarding differences in tools used to assess QOL as well as length, and type of exercise interventions. The results of a systematic review and meta-analysis of 24 studies with 997 hemodialysis patients indicated that intradialytic exercise could improve the physical subscale of QOL; however, no significant change was observed in the mental subscale of QOL.[7] This finding was approved by another systematic review and meta-analysis of the impact of intradialytic exercise on QOL in hemodialysis patients by Chung et al.[13] Due to the small number of included RCTs in these meta-analyses as well as their poor methodological quality, further RCTs are required to obtain more robust data on the effectiveness of intradialytic exercise on QOL in hemodialysis patients. The aim of the present study was to determine the impact of intradialytic exercise programs on QOL, and recovery time after dialysis sessions, as an important determinant of QOL in hemodialysis patients.


  Methods Top


Study design and patients

This randomized controlled clinical trial study was done on hemodialysis patients referred to Alzahra and Khorshid hospitals, Isfahan, Iran. The study protocol was approved by the ethics committee of the Isfahan University of Medical Sciences (Research project code: IR.MUI.MED.REC.1398.368). The protocol of the study was also registered in the Iranian Registry of Clinical Trials (IRCT code: IRCT20090905002417N22). All patients were fully informed of the research objectives and signed informed consent forms. Patients were eligible for inclusion in the study if they were adults (age ≥18 years) on hemodialysis for more than 3 months with a stable clinical condition. Patients with conditions that limit exercise ability such as cardiovascular diseases, respiratory diseases, and musculoskeletal abnormalities were excluded from the study. Furthermore, patients with catabolic conditions such as acute infection were excluded from the study.

Intervention

Patients were randomly assigned to the intervention and the control groups based on the random numbers table. Patients in the intervention group were trained to use a mini stationary bike (Medi-Bike Medical Exercise Peddler 3000, Medi-Bike, Taiwan) in a supine position for 30 min within the first 2 h of hemodialysis with a frequency of three times per week for 12 weeks. The exercise was performed under the supervision of a trained nurse. The blood pressure and heart rate were also monitored by dialysis nurses every 60 min.

Each exercise program comprised a 5-min warm-up, 20-min cycling at a desirable intensity following a 5-min cool-down. Depending on each patient's ability, the duration of cycling increased by 5 min gradually until they could cycle 20 min continuously. Patients in the control group continued a standard dialysis treatment and received no exercise plan.

Biochemical tests

Fasting blood samples were drawn before the midweek hemodialysis session to assess biochemical indices, including, the levels of serum triglyceride, total cholesterol, albumin, ferritin, total iron-binding capacity, and iron according to standard procedures. All patients were assessed biochemically at baseline and at the end of the intervention.

Data collection

The validated Persian version of the kidney disease QOL short form (KDQOL-SF) questionnaire, version 1.3, was used to collect data on QOL.[14] The questionnaire is divided into three main domains including physical component summary (PCS), mental component summary (MCS), and kidney disease domain. The kidney disease domain encompasses 11 subscales comprising symptoms, the effect of kidney disease on QOL, burden of kidney disease, work status, cognitive function, quality of social interactions, sexual function, sleep, social support, dialysis staff encouragement, and patients' satisfaction. PCS encompasses four subscales of physical function, role physical, pain, and general health. Energy/fatigue, social function, emotional well-being, and role emotional are four subscales of MCS. In the present study, we calculated the scores for the kidney disease, and generic domains (comprising PCS and MCS) separately. The mean of estimated scores was considered as the total KDQOL score. Patients were asked to reply to the question “How long does it take to recover from a dialysis session?” to assess recovery time.[15] All variables were assessed at baseline and 12 weeks after the intervention.

Statistical analysis

Quantitative data were expressed as mean + standard deviation (SD); while, qualitative data were presented by percentages. The normality of quantitative data was evaluated using the Kolmogorov–Smirnov test and Q-Q plot. To compare basic characteristics between the intervention and the control groups independent sample t-test and Chi-square test were used for continuous and categorical variables, respectively. A Paired samples t-test was used to compare means before and after intervention in the intervention and control groups. Means of study variables after intervention between the intervention and control groups were compared using analysis of covariance considering the baseline values as a covariate. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS, Inc., Chicago IL, USA; version 15). P < 0.05 was considered statistically significant.


  Results Top


In total, 150 patients were screened for possible inclusion in the study, of whom 139 patients were included and randomized in the intervention (n = 70) and the control (n = 69) groups. Of these, 60 patients in the intervention group and 50 patients in the control group completed 12 weeks of the intervention [Figure 1]. The basic characteristics of hemodialysis patients in the intervention and the control groups are summarized in [Table 1]. We found a significant difference in the mean age between the intervention and the control group (54.63 ± 14.96 vs. 62.54 ± 14.12) (P = 0.006). There was also a significant difference between the intervention and the control group regarding ESRD causes (P = 0.01). However, no significant difference was observed between the two groups regarding other basic variables (P > 0.05).
Figure 1: Study flow diagram

Click here to view
Table 1: Comparing basic characteristics of hemodialysis patients in the intervention and control groups

Click here to view


A significant increase was observed in the generic (mean difference ± SE: 1.50 ± 0.44, P = 0.001), kidney disease (mean difference ± SE: 0.84 ± 0.28, P = 0.004), and overall QOL (mean difference ± SE: 1.18 ± 0.33, P = 0.001) scores after 12 weeks of intradialytic cycling exercise in the intervention group. However, hemodialysis patients in the control group showed a significant reduction in the generic (mean difference ± SD:-0.65 ± 0.17, P < 0.001) and overall QOL (mean difference ± SE:-0.53 ± 0.17, P = 0.003) scores after 12 weeks of intradialytic cycling exercise. Furthermore, a significant difference was noted between the intervention and the control group regarding the mean difference of all QOL scores after the intervention (P < 0.05) [Table 2].
Table 2: Comparing aspects of quality of life, biochemical variables, and recovery time change between the intervention and control groups

Click here to view


After 12 weeks of intradialytic cycling exercise, recovery time significantly decreased in the intervention group (mean difference ± SE: −3.67 ± 0.46, P < 0.003); while, no significant change was observed in the control group (mean difference ± SE: −0.09 ± 0.42, P = 0.83). There was also a significant difference in the mean difference of recovery time between the intervention and the control group after the intervention (P < 0.001) [Table 2].

The assessment of biochemical parameters after 12 weeks of intervention showed a significant increase in mean serum albumin (mean difference ± SE: 0.16 ± 0.07, P = 0.02) and iron (mean difference ± SE: 25.48 ± 10.29, P = 0.02) in the intervention group. However, no significant changes were observed in the mean of other biochemical variables (P > 0.05). In the control group, there were no significant changes in the mean of biochemical variables (P > 0.05). In addition, the between-group comparison showed a significant difference between the intervention and the control group in the mean difference of serum albumin, triglyceride, and iron levels after the intervention (P < 0.05) [Table 2].


  Discussion Top


The level of daily physical activity and physical performance in hemodialysis patients is much less than in healthy individuals. Many reports have indicated that decreased physical activity affects various outcomes, including QOL in hemodialysis patients.[16],[17] The results of the present study indicated that intradialytic cycling exercise improved the KDQOL score. While many previous studies have investigated the effect of intradialytic exercise on QOL, there is a lack of agreement across their outcomes. Ouzouni et al. found a significant increase in the PCS score of the SF-36 after 10 months of intradialytic exercise training (a combination of cycling, strengthening, and flexibility exercises three times a week for 60–90 min); while, no significant change was observed in MCS score.[10] It has been suggested in a study by Musavian et al. that both active and passive intradialytic exercise significantly improved several aspects of the SF-36.[18] On contrary, the results of a multicenter RCT by Greenwood et al. indicated that 6 months of cycling exercise during dialysis resulted in no significant improvement in any KDQOL-SF scales.[12] We postulated that differences in sociodemographic and clinical variables, intradialytic exercise type and duration, and QOL assessment tools are associated with diverse outcomes of these studies.

Previous studies have reported that health-related QOL is strongly associated with recovery time in hemodialysis patients. According to these researchers, patients with longer recovery times have lower QOL compared to those with shorter recovery times.[15],[19] In the present study, we found that intradialytic cycling exercise significantly decreased dialysis recovery time. Although, the mechanisms through which intradialytic exercise improved recovery time remain to be explored.

Hypoalbuminemia is known as an important determinant of cardiovascular mortality in hemodialysis patients.[20] Meanwhile, the effect of intradialytic exercise on serum albumin levels remains controversial. In the present study, a significant improvement was noted in serum albumin levels in the intervention group. Moreover, the mean difference of albumin was comparable between the intervention and the control groups. Similarly, the results of a pilot RCT by Assawasaksakul et al. showed that serum albumin increased significantly after 6 months of intradialytic cycling exercise.[21] Contrary, the results of a study by Parsons et al. did not show a significant difference in serum albumin levels after 20 weeks of intradialytic exercise.[22] No significant inter or intragroup difference was also observed in serum albumin levels in a multicenter RCT by Cheng et al. on 132 hemodialysis patients.[23]

Our results failed to show a significant change in mean serum total cholesterol and triglyceride levels in the intervention group. However, there was a significant between-group difference in mean serum triglyceride level after 12 weeks of intradialytic cycling. Groussard et al. observed a significant reduction in serum triglyceride level after 3 months of intradialytic exercise; while, other lipid profile components did not change significantly across the intervention.[24] On the contrary, other studies failed to show the effect of intradialytic exercise on lipid profile.[25],[26]

There are several study limitations. A main limitation of the present study was the inclusion of higher functioning hemodialysis patients, which are not representative of the whole dialysis patients. Moreover, the current study was an unblinded RCT, which is susceptible to bias. Finally, we did not perform a comprehensive assessment and adjustment for QOL confounding variables. Thus, further long-term clinical trials by controlling confounding variables are suggested to determine the impact of intradialytic exercise on QOL and related determinants.


  Conclusion Top


Shor-term intradialytic cycling exercise is found to improve hemodialysis patients' QOL and dialysis recovery time. As a result, intradialytic cycling exercise should be considered an adjuvant therapeutic modality in hemodialysis patients.

Acknowledgments

The authors wish to acknowledge the study participants for their commitment to the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Leonberg-Yoo AK, Weiner DE. Epidemiology of end-stage renal disease. In: Core Concepts in Dialysis and Continuous Therapies. Vol. 2. Boston, MA: Springer; 2016. p. 3-13.  Back to cited text no. 1
    
2.
White SL, Chadban SJ, Jan S, Chapman JR, Cass A. How can we achieve global equity in provision of renal replacement therapy? Bull World Health Organ 2008;86:229-37.  Back to cited text no. 2
    
3.
Wasylynuk BA, Davison SN. An overview of advance care planning for patients with advanced chronic kidney disease: The basics. CANNT J 2016;26:24-9.  Back to cited text no. 3
    
4.
van Loon IN, Bots ML, Boereboom FT, Grooteman MP, Blankestijn PJ, van den Dorpel MA, et al. Quality of life as indicator of poor outcome in hemodialysis: Relation with mortality in different age groups. BMC Nephrol 2017;18:217.  Back to cited text no. 4
    
5.
Pei M, Aguiar R, Pagels AA, Heimbürger O, Stenvinkel P, Bárány P, et al. Health-related quality of life as predictor of mortality in end-stage renal disease patients: An observational study. BMC Nephrol 2019;20:144.  Back to cited text no. 5
    
6.
Huang M, Lv A, Wang J, Xu N, Ma G, Zhai Z, et al. Exercise training and outcomes in hemodialysis patients: Systematic review and meta-analysis. Am J Nephrol 2019;50:240-54.  Back to cited text no. 6
    
7.
Sheng K, Zhang P, Chen L, Cheng J, Wu C, Chen J. Intradialytic exercise in hemodialysis patients: A systematic review and meta-analysis. Am J Nephrol 2014;40:478-90.  Back to cited text no. 7
    
8.
Fang HY, Burrows BT, King AC, Wilund KR. A comparison of intradialytic versus out-of-clinic exercise training programs for hemodialysis patients. Blood Purif 2020;49:151-7.  Back to cited text no. 8
    
9.
Song WJ, Sohng KY. Effects of progressive resistance training on body composition, physical fitness and quality of life of patients on hemodialysis. J Korean Acad Nurs 2012;42:947-56.  Back to cited text no. 9
    
10.
Ouzouni S, Kouidi E, Sioulis A, Grekas D, Deligiannis A. Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients. Clin Rehabil 2009;23:53-63.  Back to cited text no. 10
    
11.
Martins do Valle F, Valle Pinheiro B, Almeida Barros AA, Ferreira Mendonça W, de Oliveira AC, de Oliveira Werneck G, et al. Effects of intradialytic resistance training on physical activity in daily life, muscle strength, physical capacity and quality of life in hemodialysis patients: A randomized clinical trial. Disabil Rehabil 2020;42:3638-44.  Back to cited text no. 11
    
12.
Greenwood SA, Koufaki P, Macdonald JH, Bhandari S, Burton JO, Dasgupta I, et al. Randomized Trial-PrEscription of intraDialytic exercise to improve quAlity of life in patients receiving hemodialysis. Kidney Int Rep 2021;6:2159-70.  Back to cited text no. 12
    
13.
Chung YC, Yeh ML, Liu YM. Effects of intradialytic exercise on the physical function, depression and quality of life for haemodialysis patients: A systematic review and meta-analysis of randomised controlled trials. J Clin Nurs 2017;26:1801-13.  Back to cited text no. 13
    
14.
Lindsay RM, Heidenheim PA, Nesrallah G, Garg AX, Suri R, Daily Hemodialysis Study Group London Health Sciences Centre. Minutes to recovery after a hemodialysis session: A simple health-related quality of life question that is reliable, valid, and sensitive to change. Clin J Am Soc Nephrol 2006;1:952-9.  Back to cited text no. 14
    
15.
Fardinmehr O, Farajzadegan Z, Naini AE, Mortazavi M, Gholamrezaei A. The validity and reliability of the Persian version of kidney disease quality of life questionnaire-short form (KDQOL-SF) in Iranian patients. J Isfahan Med Sch 2012;29:2159-68.  Back to cited text no. 15
    
16.
Zhang M, Kim JC, Li Y, Shapiro BB, Porszasz J, Bross R, et al. Relation between anxiety, depression, and physical activity and performance in maintenance hemodialysis patients. J Ren Nutr 2014;24:252-60.  Back to cited text no. 16
    
17.
Katayama A, Miyatake N, Nishi H, Uzike K, Sakano N, Hashimoto H, et al. Evaluation of physical activity and its relationship to health-related quality of life in patients on chronic hemodialysis. Environ Health Prev Med 2014;19:220-5.  Back to cited text no. 17
    
18.
Musavian AS, Soleimani A, Masoudi Alavi N, Baseri A, Savari F. Comparing the effects of active and passive intradialytic pedaling exercises on dialysis efficacy, electrolytes, hemoglobin, hematocrit, blood pressure and health-related quality of life. Nurs Midwifery Stud 2015;4:e25922.  Back to cited text no. 18
    
19.
Rayner HC, Zepel L, Fuller DS, Morgenstern H, Karaboyas A, Culleton BF, et al. Recovery time, quality of life, and mortality in hemodialysis patients: The Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis 2014;64:86-94.  Back to cited text no. 19
    
20.
Danielski M, Ikizler TA, McMonagle E, Kane JC, Pupim L, Morrow J, et al. Linkage of hypoalbuminemia, inflammation, and oxidative stress in patients receiving maintenance hemodialysis therapy. Am J Kidney Dis 2003;42:286-94.  Back to cited text no. 20
    
21.
Assawasaksakul N, Sirichana W, Joosri W, Kulaputana O, Eksakulkla S, Ketanun C, et al. Effects of intradialytic cycling exercise on daily physical activity, physical fitness, body composition, and clinical parameters in high-volume online hemodiafiltration patients: A pilot randomized-controlled trial. Int Urol Nephrol 2021;53:359-71.  Back to cited text no. 21
    
22.
Parsons TL, Toffelmire EB, King-VanVlack CE. Exercise training during hemodialysis improves dialysis efficacy and physical performance. Arch Phys Med Rehabil 2006;87:680-7.  Back to cited text no. 22
    
23.
Cheng YJ, Zhao XJ, Zeng W, Xu MC, Ma YC, Wang M. Effect of intradialytic exercise on physical performance and cardiovascular risk factors in patients receiving maintenance hemodialysis: A pilot and feasibility study. Blood Purif 2020;49:409-18.  Back to cited text no. 23
    
24.
Groussard C, Rouchon-Isnard M, Coutard C, Romain F, Malardé L, Lemoine-Morel S, et al. Beneficial effects of an intradialytic cycling training program in patients with end-stage kidney disease. Appl Physiol Nutr Metab 2015;40:550-6.  Back to cited text no. 24
    
25.
Afshar R, Shegarfy L, Shavandi N, Sanavi S. Effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis. Indian J Nephrol 2010;20:185-9.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Bogataj Š, Pajek J, Buturović Ponikvar J, Pajek M. Functional training added to intradialytic cycling lowers low-density lipoprotein cholesterol and improves dialysis adequacy: A randomized controlled trial. BMC Nephrol 2020;21:352.  Back to cited text no. 26
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
Previous article  Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed166    
    Printed0    
    Emailed0    
    PDF Downloaded22    
    Comments [Add]    

Recommend this journal