Addressing Knowledge Gaps in Intradialytic Exercise

• Author / Creator

  Thompson, Stephanie E

• End-stage renal disease (ESRD) requiring hemodialysis (HD) is associated with poor health outcomes including low quality of life and physical functioning. The association between quality of life (QoL), mortality and hospitalization is well established; however, few interventions have been shown to improve QoL in this population. Regular exercise is a promising therapeutic tool for decreasing the disease and treatment-related burden imposed by ESRD. As the majority of people with ESRD receive HD in a hospital or facility three times per week, delivering exercise during the HD treatment (intradialytic exercise, [IDE]) is an opportunity to increase exercise participation. However, in contrast to other chronic diseases, outpatient exercise programs for people with ESRD have not been adopted into routine practice. In part, the underuse of exercise in practice can be explained by key knowledge gaps: limited data on the relative benefits and risks of different types of exercise in people with ESRD, methodological limitations in trial design, and the lack of attention to the practical challenges and complexity of delivering an exercise program during the HD treatment. Based on these knowledge gaps, this three part, mixed-method thesis investigates how to increase the uptake of IDE. First, to evaluate the feasibility of a main efficacy trial aimed at evaluating two types of IDE (cycling and resistance) on QoL and physical performance, a mixed-method, randomized factorial pilot trial was conducted. Second, to understand the factors that influence IDE implementation, concurrent with the trial, a qualitative interpretive descriptive study was conducted. Third, to evaluate how the complex and variable aspects of an IDE program influence patient participation in IDE, a study protocol has been proposed where the realist line of inquiry will be used to synthesize knowledge from a literature review and interviews with IDE stakeholders worldwide. The main findings from the pilot trial were: feasibility of recruitment, high patient acceptability, and low measures of contamination and attrition with the use of an attention control. Progression based on perceived exertion and individual instruction facilitated acceptability of the intervention among patients. There were no serious adverse events and the frequency of other adverse events, including hypotension and vascular access dysfunction was low across all groups. Intervention effects on the secondary outcomes (QoL, physical performance) were not statistically significant. Beyond the need for practical assistance with IDE delivery, staff engagement with IDE was necessary to maintain the integrity of the intervention and was also perceived by patients as important. However, due to factors at the individual and system level, there was a lack of staff readiness for IDE. These factors were explored further in the qualitative study. Common themes from patient and staff interviews were: support, norms (expected practices) within the dialysis unit, and the role of the dialysis nurse. Staff described a lack of support from management and the additional theme of “no time” (for staff to participate in IDE) was influenced by its low priority in their workflow and the demands of the unit. Staff focused on the technical aspects of their role in IDE while patients viewed encouragement and assistance with IDE as the staff’s role. The support of the kinesiologist enhanced patients’ sense of capability and was a key component of implementation as was delivering IDE in keeping with unit norms. The staff’s emphasis on patients setting-up their own equipment and enhanced social interaction among trial participants were additional themes that conveyed the unintended consequences of the intervention. These findings provide guidance to researchers, clinicians, and renal program administrators on IDE implementation. To improve trial design, researchers should consider using novel methods of blinding and evaluating adverse events that are relevant to IDE. Staff readiness for IDE could be improved with better workflow integration, greater support from management, better understanding of staff’s personal values of exercise, and by understanding priorities and values within the unit as a whole. Incorporating social support into IDE interventions could increase their effectiveness and greater social interaction among IDE participants is a potential means of improving patients’ satisfaction with HD care. Findings from the realist synthesis extend this work by identifying where and how to resources could be allocated to an IDE program so that it is more likely to be effective in increasing patient participation.  

• Subjects / Keywords

  • Exercise
  • Hemodialysis
  • Intradialytic
  • End-stage renal disease

• Graduation date

  Fall 2016

• Type of Item

  Thesis

• Degree

  Doctor of Philosophy

• DOI

  https://doi.org/10.7939/R3125QN5C

• License

  This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.