Patients in hemodialysis seem to have a restricted physical function, low physical activity level and poor Health-Related Quality of Life (HRQOL) and therapeutic exercise seems to have a positive effect on these areas (Segura-Ortí et al 2018). However, therapeutic exercise is still not used as a regular part of the treatment of patients in dialysis, unlike in patients with cardiac or respiratory pathologies (Segura-Ortí 2010).
Virtual reality (VR) is already widely used in several neurological conditions to maintain and improve physical function. VR programs allow the patient to perform exercise in a game-like situation. It has recently been studied in hemodialysis patients with good results in improving their physical function, physical activity and HRQOL. (Segura-Ortí, García-Testel 2019)
The aim of this blog post is to introduce evidence on the effectiveness of exercise in the treatment of dialysis patients, with a focus on virtual training, and to answer the following questions:
- is exercise therapy a useful treatment method and
- is virtual training a useful therapeutic tool for patients in dialysis?
Chronic kidney disease (CKD) is a general term for disorders that affect the structure and function of the kidney. A poorly functioning kidney means that the waste products aren’t cleaned properly from the blood and not enough liquids are removed from the body. (Munuais- ja maksaliitto 2020c)
Medication, nutrition and lifestyle changes can be used in the early stages of the disease to slow down its progress. In a difficult CDK dialysis or kidney transplant are required as treatment. Dialysis is partially replacing the function of the kidney, and can be done either at home or in a treatment unit. It can be done through the blood (hemodialysis) or using the peritoneum (peritoneal dialysis). Dialysis helps for the symptoms of CKD, and the goal is also to prevent additional diseases and to improve the quality of life. (Munuais- ja maksaliitto 2020a)
According to Segura-Ortí et al (2018), CKD patients in hemodialysis have a restricted physical function, low physical activity level and poor HRQOL, that get gradually and progressively worse. Exercise can slow down the process of the disease (Munuais- ja maksaliitto 2020b), as well as the deteriorations mentioned above.
Interdialytic exercise, or out-of-clinic exercise, has advantages with offering more options for the patient compared to exercise done during dialysis. It also gives the possibility optimize the dose of physical activity, especially if the exercise is supervised. However, the interdialytic exercise programs are often carried out without supervision. This may lead to disadvantages when it comes to patient safety, compliance, adherence and self-efficacy. Therefore, consultation with a physical therapist is reasoned to ensure safe and appropriate exercise. The most common types of exercise protocols are home-based walking programs, resistance training in a fitness center and combined training which includes aerobic, resistance and/or educational components. (Fang et al 2019)
Out-of-clinic, low intensity, exercise programs performed outside dialysis seem to have a positive effect on the physical condition of the dialysis patients (Manfredini et al 2017) and out-of-clinic resistance training seems to improve the physical function, but all these results have been somewhat inconsistent (Fang et al 2019).
In the exercise protocols done during the dialysis, or intradialytic, both endurance and resistance training have been widely used. One of the advantages of intradialytic exercise is that it is thought to be the most feasible to implement, since the staff is there to help implement the program and the patients often don’t have much else to do during the dialysis. The disadvantage with intradialytic exercise is limited options for exercise. The most practical options are cycling and lower-body resistance training. Intradialytic aerobic exercise seems to improve the physical function of the patients, but hasn’t been proven to effect on Vo2 peak, quality of life, blood pressure or arterial stiffness. Intradialytic resistance training been able to provide some improvements in muscle strength, but the changes in physical function seem to be inconsistent. (Fang et al 2019)
VR programs are interactive computer-generated simulations that allow the user to participate in immersive virtual reality. They have been widely used in the field of neurorehabilitation, with improvements in balance, gait speed and mobility. (Segura-Ortí, García-Testal 2019)
The patient performs exercise in a virtual setting, and the exercise is very game-like. The program used in hemodialysis studies is designed with a playful scheme, which is thought to make the patients more cooperative. The patient tries to catch moving targets and avoid obstacles by moving their leg. The game can be adjusted according to the level of each patient. The equipment needed is a TV, a computer and a Ms Kinect. (Segura-Ortí et al 2018)
VR programs are not yet widely researched in the area of renal patients. In one recent study all patients participated in a combined i.e. aerobic and strength training program for 16 weeks. Thereafter, the group was divided into two subgroups: a combined training group or a virtual training group. Both groups trained for four weeks. The virtual training group received similar results as the combined training group in the improvements in physical function. Both groups had also improved their physical function after the first 16 weeks of combined training, which might have led to an improvement in motivation for the remaining 4 weeks of training in both groups. This study indicates, however, that virtual training could be a possible option for the intradialytic exercise. (Segura-Ortí et al 2018)
In a 12-week randomized controlled trial done with the same technology as before performing only VR training, there was a significant improvement in the physical function, self-reported physical activity and health-related quality of life, compared to the usual care. (Segura-Ortí and García-Testal 2019)
Both health care professionals and patients assume that VR programs may have lower risks than the conventional unsupervised physical activity programs, Furthermore, VR programs allow higher amount of patients to participate in the training (even deconditioned patients), because of its adaptability. VR is also perceived more like a game rather than training, which may result in higher adherence than specific exercise and training regimens. VR is also simple and comfortable to implement, since it does not require expertise with exercise prescription. The time used for starting the VR training session is also minimal and the need for exercise professionals on site is decreased. Another great advantage of the VR programs is the low cost. (Segura-Ortí and García-Testal 2019)
According to several researches (Segura-Ortí et al 2018), (Manfredini et al 2017) exercise therapy improve the physical function as well as the HRQOL of the patients with CKD. Exercise can also slow down the progress of the disease and improve the patients’ abilities in coping with the illness and treatments (Munuais- ja Maksaliitto 2020b)
It still seems to be unclear which type of exercise is the best. However, different types of exercise programs have shown to improve physical function, physical activity and health-related quality of life of the patients. Therefore, it should be stated, that most important thing could simply be to stay physically active.
VR has shown good results in the treatment of CKD. The advantages of virtual training are that it is easy to use, it does not take that much time or equipment, and that it seems to be more fun than doing traditional exercise. Because of the simple set up virtual training would not necessarily need any extra resources but could be done by the regular dialysis-staff. Virtual training seems to be a good option for the future, but more research is needed to determine its effectiveness and safety.
Fang, H.Y., Burrows, B.T., King, A.C. and Wilund, K.R., 2020. A Comparison of Intradialytic versus Out-of-Clinic Exercise Training Programs for Hemodialysis Patients. Blood Purification, 49(1-2), pp.151-157.
Manfredini, F., Mallamaci, F., D’Arrigo, G., Baggetta, R., Bolignano, D., Torino, C., Lamberti, N., Bertoli, S., Ciurlino, D., Rocca-Rey, L. and Barillà, A., 2017. Exercise in patients on dialysis: a multicenter, randomized clinical trial. Journal of the American Society of Nephrology, 28(4), pp.1259-1268.
Munuais- ja maksaliitto. 2020a. Dialyysihoito. Accessed: 12.2.2020. Available: https://www.muma.fi/sairaudet/munuaiset/dialyysihoito (External link).
Munuais- ja maksaliitto. 2020b. Liikunta. Accessed: 12.2.2020. Available: https://www.muma.fi/sairaudet/munuaiset/sairastuneen_arki/liikunta (External link).
Munuais- ja maksaliitto. 2020c. Munuaisten vajaatoiminta. Accessed: 12.2.2020. Available: https://www.muma.fi/sairaudet/munuaiset/munuaisten_vajaatoiminta (External link)
Segura-Ortí, E., 2010. Ejercicio en pacientes en hemodiálisis: revisión sistemática de la literatura. Nefrología (Madrid), 30(2), pp.236-246.
Segura‐Ortí, E., Pérez‐Domínguez, B., Ortega‐Pérez de Villar, L., Meléndez‐Oliva, E., Martínez‐Gramage, J., García‐Maset, R. and Gil‐Gómez, J.A., 2019. Virtual reality exercise intradialysis to improve physical function: A feasibility randomized trial. Scandinavian journal of medicine & science in sports, 29(1), pp.89-94.
Segura‐Ortí, E. and García‐Testal, A., 2019. Intradialytic virtual reality exercise: Increasing physical activity through technology. Seminars in dialysis, 32(4), pp. 331-335.