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

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)

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)

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)

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

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

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)

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

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

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

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

Exercise Training Regime

2. Home exercise program • Both aerobic training and

resistance exercise

• Exercise recommendations according to ACSM guideline

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)

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

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%

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

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

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%

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

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%

Patients’ Subjective Improvements

Health Condition

Agree Neutral

67%

33%

Stronglyagree

Agree Neutral

17%

50%

33%

Balance

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

Future Planning

• Recruit more patients in HAPPY program

• Continuity of exercise

• Build up patients’ regular exercise habit

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

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