Background: Individuals with chronic kidney disease (CKD) often experience reduced muscle strength and diminished health-related quality of life (HRQoL), and engaging in regular exercise may improve ...them. The aim of this study was to assess the effect of intradialytic exercise using non-immersive virtual reality (VR) on body composition of patients with CKD on hemodialysis (HD). Methods: This was a substudy in a clinical trial of intradialytic exercise intervention using a non-immersive VR game in which the patient interacted by moving the lower limbs. Body composition was determined by BCM Fresenius multifrequency stereoscopic bioimpedance. Body mass index (BMI), fat tissue index (FTI), lean tissue index (LTI), extracellular/intracellular water (EIW), and phase angle (PA) were recorded in 52 patients, 24 in the control group (CG) and 28 in the exercise group (EG). Results: Statistically significant differences were observed between both groups. The LTI increased in the EG while it decreased in the CG. The FTI and the EIW decreased in the EG compared to the increase observed in the CG. Conclusions: Intradialytic exercise using non-immersive VR was associated with an increase in LTI and a decrease in FTI of CKD patients on HD.
La activación del paciente es un concepto que se refiere a la voluntad de gestionar su salud y atención médica. Para evaluarla, se ha desarrollado y validado una medida de activación del paciente ...(PAM). Diversos estudios informan baja activación en pacientes con enfermedades crónicas. No obstante, la información sobre activación de pacientes en tratamiento con hemodiálisis es escasa. El objetivo del presente estudio es describir el nivel de activación de pacientes en tratamiento crónico de una unidad de hemodiálisis (HD) y su relación con los parámetros de control de la enfermedad.
Estudio observacional transversal en pacientes con enfermedad renal crónica avanzada en tratamiento crónico con HD. Se incluyeron 96 pacientes. La activación se midió con el cuestionario PAM-13. Se estudió su relación con variables descriptivas (edad, sexo, comorbilidad, estudios, hábitat) y variables de control de la enfermedad (acceso vascular, flujo sangre, potasemia, fosfatemia, ganancia interdialítica). Para ello se emplearon como métodos estadísticos la prueba de correlación de Spearman, modelo de retrogresión lineal múltiple y modelo logístico.
La puntuación media (desviación estándar SD) de PAM-13 fue de 63,19 (15,21). La activación se asociaba significativamente con el acceso vascular (p = 0,003), flujo de sangre (p = 0,024), y ganancia interdialítica de los pacientes (p = 0,008).
La activación de pacientes en tratamiento crónico con hemodiálisis es baja. Una mayor activación se relaciona con disponer de fístula arteriovenosa, con mayor flujo sanguíneo y con menor ganancia interdialítica. Son necesarios futuros estudios que confirmen y apliquen nuestros resultados.
Patient activation is a concept that refers to the willingness to manage one's health and medical care. To assess it, a patient activation measure (PAM) has been developed and validated. Several studies report low activation in patients with chronic diseases. However, information on activation in hemodialysis patients is scarce. The aim of the present study is to describe the activation level of patients on chronic treatment in an HD unit and its relationship with disease control parameters.
Cross-sectional observational study in patients with advanced chronic kidney disease on chronic HD treatment. Ninety-six patients were included. Activation was measured with the PAM-13 questionnaire. Its relationship with descriptive variables (age, sex, comorbidity, studies, habitat) and disease control variables (vascular access, blood flow, potassaemia, phosphataemia, interdialytic gain) was studied. For this purpose, Spearman's correlation test, multiple linear regression model and logistic model were used as statistical methods.
The mean (SD) PAM-13 score was 63.19 (15.21). Activation was significantly associated with vascular access (P = .003), blood flow (P = .024), and interdialytic gain of patients (P = .008).
Activation in patients on chronic hemodialysis treatment is low. Higher activation is related having an arteriovenous fistula, higher blood flow and lower interdialytic gain. Future studies are needed to confirm and apply our results.
Abstract
Background
Engagement in exercise by haemodialysis (HD) patients has been shown to generate benefits both in terms of improved functional capacity and in the health-related quality of life. ...The use of non-immersive virtual reality (VR) games represents a new format for the implementation of intradialysis exercise. Some studies have shown that engaging in exercise for 6 months reduces the consumption of antihypertensive drugs and decreases the time spent admitted to hospital among individuals receiving HD treatments. The objective of this study was to evaluate changes in the consumption of healthcare resources and micro-costing for patients on HD who completed a VR exercise program.
Materials and methods
Design: This study is a secondary analysis of a clinical trial. The participants performed an intradialysis exercise program with non-immersive virtual reality for 3 months. The variables were recorded in two periods: 12 months before and 12 months after the start of the exercise program.
Results
The micro-costing analysis showed a significant decrease in the mean cost, in euros, for the consumption of laboratory tests − 330 (95% CI:− 533, − 126;
p
= 0.003), outpatient visits − 351 (− 566, − 135;
p
= 0.003), and radiology tests − 111 (− 209, − 10;
p
= 0.03) in the 12 months after the implementation of the exercise program relative to the 12 months prior to its start.
Conclusion
The implementation of intradialysis exercise programs decreased the expenditure of some healthcare resources. Future studies could help clarify if longer interventions would have a stronger impact on these cost reductions.
Patient activation is a concept that refers to the willingness to manage one's health and medical care. To assess it, a patient activation measure (PAM) has been developed and validated. Several ...studies report low activation in patients with chronic diseases. However, information on activation in hemodialysis patients is scarce. The aim of the present study is to describe the activation level of patients on chronic treatment in an HD unit and its relationship with disease control parameters.
Cross-sectional observational study in patients with advanced chronic kidney disease on chronic HD treatment. Ninety-six patients were included. Activation was measured with the PAM-13 questionnaire. Its relationship with descriptive variables (age, sex, comorbidity, studies, habitat) and disease control variables (vascular access, blood flow, potassaemia, phosphataemia, interdialytic gain) was studied. For this purpose, Spearman's correlation test, multiple linear regression model and logistic model were used as statistical methods.
The mean (SD) PAM-13 score was 63.19 (15.21). Activation was significantly associated with vascular access (P = 0.003), blood flow (P = 0.024), and interdialytic gain of patients (P = 0.008).
Activation in patients on chronic hemodialysis treatment is low. Higher activation is related having an arteriovenous fistula, higher blood flow and lower interdialytic gain. Future studies are needed to confirm and apply our results.
La activación del paciente es un concepto que se refiere a la voluntad de gestionar su salud y atención médica. Para evaluarla, se ha desarrollado y validado una medida de activación del paciente (PAM). Diversos estudios informan baja activación en pacientes con enfermedades crónicas. No obstante, la información sobre activación de pacientes en tratamiento con hemodiálisis es escasa. El objetivo del presente estudio es describir el nivel de activación de pacientes en tratamiento crónico de una unidad de HD y su relación con los parámetros de control de la enfermedad.
Estudio observacional transversal en pacientes con enfermedad renal crónica avanzada en tratamiento crónico con HD. Se incluyeron 96 pacientes. La activación se midió con el cuestionario PAM-13. Se estudió su relación con variables descriptivas (edad, sexo, comorbilidad, estudios, hábitat) y variables de control de la enfermedad (acceso vascular, flujo sangre, potasemia, fosfatemia, ganancia interdialítica). Para ello se emplearon como métodos estadísticos la prueba de correlación de Spearman, modelo de regresión lineal múltiple y modelo logístico.
La puntuación media (SD) de PAM-13 fue 63.19 (15.21). La activación se asociaba significativamente con el acceso vascular (P = 0.003), flujo de sangre (P = 0.024), y ganancia interdialítica de los pacientes (P = 0.008).
La activación de pacientes en tratamiento crónico con hemodiálisis es baja. Una mayor activación se relaciona con disponer de fístula arteriovenosa, con mayor flujo sanguíneo y con menor ganancia interdialítica. Son necesarios futuros estudios que confirmen y apliquen nuestros resultados.
Background: Exercise improves the physical function of people suffering from chronic kidney disease on hemodialysis (HD). Virtual reality is a new type of intradialysis exercise that has a positive ...impact on physical function. Intradialysis exercise is recommended during the first 2 h, but its safety in the last part of the dialysis session is unknown. Methods: This was a pilot sub-study of a clinical trial. Several hemodynamic control variables were recorded, including blood pressure, heart rate, and intradialytic hypotensive events. These variables were recorded during three different HD sessions, one HD session at rest, another HD session with exercise during the first two hours, and one HD session with exercise during the last 30 min of dialysis. The intradialysis virtual reality exercise was performed for a maximum of 30 min. Results: During exercise sessions, there was a significant increase in heart rate (6.65 (4.92, 8.39) bpm; p < 0.001) and systolic blood pressure (6.25 (0.04,12.47) mmHg; p < 0.05). There was no difference in hemodynamic control between the sessions with exercise during the first two hours and the sessions with exercise during the last 30 min. There was no association between intra-dialytic hypotensive events at rest (five events) or exercise at any point (two vs. one event(s), respectively). Conclusion: performing exercise with virtual reality at the end of a hemodialysis session is not associated with hemodynamic instability.
Abstract Background and Aims People with chronic kidney disease on hemodialysis present many comorbidities, including malnutrition and frailty. These factors contribute to a sedentary lifestyle, ...cognitive impairment, and decreased emotional well-being. Intradialytic exercise with non-immersive virtual reality may improve health-related quality of life and functional capacity in these individuals. The GoodRENal project was developed to create a digital intradialytic health platform to improve health-related quality of life. This study aimed to test the feasibility of the GoodRENal intradialytic platform and to identify participants’ opinions about the use of the platform. Method People on hemodialysis treatment from Spain, Greece and Sweden were included. Non-immersive virtual reality games were created to educate on food intake aiming to better control potassium, phosphate, sodium and liquids. It also aimed at increasing physical activity during HD sessions, improving cognitive skills and enhancing psychological well-being. An Azure Kinect camera was used to capture the movement and all activities were designed as dual-tasks, so the movement of lower limbs was promoted in every game. During a trial session, patients were asked about their perception of the platform through a questionnaire designed to evaluate their opinion. It consisted of 10 general questions, 6 questions for the Physical Activity games, 4 for the Nutrition games, 6 for the Cognition games and 7 for the Psychology games. Every question was rated with a Likert scale. Answers are presented in three categories ‘agree’ (4 or 5 out of 5), ‘neither agree nor disagree’ (3 out of 5), and ‘disagree’ (1 or 2 out of 5). Results 27 participants were included in this study (Spain n = 9; Greece n = 10; Sweden n = 8). Participants’ mean age was 64.6 years, 9 women, with a hemodialysis vintage, median 27 months (minimum 4- maximum 240). The questions with a higher degree of agreement or disagreement are summarized. In terms of general feedback on the GoodRENal platform, more than 90% of respondents found the instructions easy to follow and that playing the games was a pleasant break during the hemodialysis session. Furthermore, they disagreed with the statement that the back was tiring. The questions related to the physical activity games with the highest rate of agreement related to the ideas that the program provides a good workout (80% agreement), the possibility to have more exercises (70% agreement) and that it was fun (60% agreement). Regarding the nutrition games, more than 70% agreed that they had gained new knowledge about what to eat and about 60% felt motivated to modify what they ate. For the cognition games, more than 80% maintained attention during the games, but only 35% felt motivated to engage in cognitively stimulating activities. Finally, regarding the games aimed at emotional well-being, 30% of the patients indicated that they felt good about the exercises. Conclusion The GoodRENal platform is a feasible strategy to increase physical activity during hemodialysis treatment, as well as to improve nutritional information and cognitive status of patients. As a general impression the platform was easy to follow and it was a nice break. Future studies should take into account participants’ opinion to improve the content of a digital intradialytic health platform.
Abstract Background and Aims People with chronic kidney disease on hemodialysis have low levels of physical activity and low lower-limbs muscle strength, partly due to the sedentary lifestyle, and a ...big number of hours sitting or in a recumbent position. The GoodRENal project aimed at creating an intradialysis health platform to improve health-related quality of life. The present study focused on the impact of the GoodRENal intradialysis platform on lower-limbs muscle strength. Method People in hemodialysis treatment from Spain were included. Participants were randomized into two groups, the GoodRENal or the usual care group. The participants used the GoodRENal platform for 12 weeks, 3 times a week. Games using non-immersive virtual reality were created aiming at educating on nutritional habits, increasing physical activity during the HD session, improving cognitive skills and increasing psychological well-being. All of them included dual tasks, so that the movement of the legs was used in every game. An Azure Kinect camera was used to capture the movement and all activities were dual, so that movement of lower limbs was promoted in every game. A handheld dynamometer was used to assess hip flexors and abductors muscle strength during the hemodialysis session. This procedure has proven to be reliable and save. An ANOVA mixed model (group and time factors) was used to analyze the results. Results 19 participants were included (Control n = 9; GoodRENal n = 10). Participants’ mean age was 73.4 years for the control and 68.3 years for the GoodRENal group, with a hemodialysis vintage, median 34 months (minimum 3- maximum 277) and 25 months (minimum 5- maximum 48) for the control and GoodRENal groups. Right hip flexor muscles changed in the control group over time: Baseline 124.7 (23.2) N; 4 weeks 121.3 (20.3) N; 12 weeks 119.0 (21.1) N. In the GoodRENal group, the data were: Baseline 116.7 (34.7) N; 4 weeks 124.7 (36.7) N; 12 weeks 142.7 (44.7) N. The ANOVA showed a significant time × group interaction (F = 11.347 p < 0.001) with a significant improvement in the GoodRENal group. Left hip abductor muscles changed in the control group over time: Baseline 124.5 (24.0) N; 4 weeks 123.0 (26.1) N; 12 weeks 122.0 (24.7) N. In the GoodRENal group, the data were: Baseline 111.1 (30.4) N; 4 weeks 119.2 (33.0) N; 12 weeks 138.5 (36.3) N. The ANOVA showed a significant time × group interaction (F = 15.218 p < 0.001) with a significant improvement in the GoodRENal group. Both left hip flexors (F = 19.055 p < 0.001) and abductors (F = 15.036 p < 0.001) showed a significant time per group interaction, with an improvement in the GoodRENal group. Conclusion The GoodRENal platform is a feasible strategy to increase the muscle strength of the hip flexors and abductors muscles. Future studies with bigger samples should confirm these results.
Abstract
Background and Aims
People in hemodialysis experience fatigue, weakness, weight loss, exhaustion, and low physical activity - all criteria of the frail phenotype. Frailty is a critical issue ...in the hemodialysis population due to its link to negative health outcomes, but few studies have focused on frailty in this population, despite the knowledge that frailty can be reversed with early detection and treatment. Our group has previously shown that non-immersive virtual reality exercise during hemodialysis is a safe method to improve physical function and health-related quality of life. The aim of this study is to analyze the impact of an intradialysis non-immersive virtual reality exercise program on frailty in the hemodialysis population.
Method
A randomized trial (the REVID study) included two groups of patients, exercising at different times during the dialysis session. The present study includes participants from REVID study who, once the study finished, continued exercising at their preferred time during the hemodialysis treatment. All participants were evaluated using the five Fried frailty phenotype criteria: unintentional weight loss of more than 4.5 kg in the past year, exhaustion was assessed using two questions from the Center for Epidemiological Studies Depression (CES-D) scale, weakness was measured using a handgrip dynamometer, walking speed was assessed by timing the 4.6m distance covered at the participant's normal pace, and physical activity was measured using the short version of the Minnesota Leisure Time Physical Activity questionnaire. Each of the five criteria was scored as 0 (not frail-related) or 1 (frail-related). Participants were then stratified into three groups: a score of 0/5 for robust or not frail, a score of 1-2/5 for pre-frail, and a score of 3-5/5 for frail. After the frailty phenotype assessment, all participants performed an intradialytic exercise program consisting of a non-immersive virtual reality game (Treasure Hunting) adapted to the dialysis session. The game consists of catching treasures and avoiding bombs by moving the lower extremities, with a progressive duration of 15 to 45 minutes. Adherence to the exercise program was measured as a percentage (number of sessions attended divided by the number of sessions offered). All assessments and interventions were conducted at Hospital de Manises in Valencia, Spain from September to December 2022.
Results
The study included 12 subjects with a mean age of 71.8 (13.9) years, 9 of whom were male, median time in Hemodialysis 20 (11.3 - 56 interquartile range) months. Out of the 12 participants, 2 were classified as robust, 5 as pre-frail, and 5 as frail. A chi-square test showed a significant change in the frailty phenotype of the participants after the exercise intervention (15.400; P = 0.003). At the end of the program, 3 participants were classified as frail, 7 as pre-frail, and 2 as robust. 2 participants improved from being frail to pre-frail. Furthermore, five participants (four frail and one pre-frail) reduced the number of criteria associated with the frail phenotype. No worsening in the frailty phenotype was reported among the participants. The average adherence to the exercise program throughout the study was 54.4 (11.2) %.
Conclusion
This study suggests that an intradialytic exercise program consisting of a non-immersive virtual reality can be useful in mitigating and managing frailty in the hemodialysis population.
Abstract
Background and Aims
People with advanced stages of chronic kidney disease (CKD) undergoing hemodialysis often suffer from comorbidities that together with malnutrition and frailty contribute ...to a sedentary lifestyle, and cognitive and emotional impairments. Intradialytic non-immersive virtual reality exercise programs may improve the health-related quality of life and physical function of people undertaking hemodialysis. The aim of the GoodRENal project was to test the feasibility of an intradialytic holistic virtual-reality platform designed to combine exercise with efforts to improve nutrition and psychological well-being as well as cognitive functioning and to assess the impact on physical, nutritional and psychological variables.
Method
People undergoing hemodialysis for at least 3 months who were medically stable, from Spain (Hospital de Manises), Sweden (Skane University Hospital and Karolinska Institutet), and Greece (Aristotle University of Thessaloniki) were selected and randomized into the GoodRENal intradialysis intervention group and a control group (usual care). The GoodRENal group was exposed to a platform that consisted of several Virtual Scenarios (games) for each one of the targeted treatment areas: Physical Activity, Nutritional Information, Psychological Well-being and Cognitive Functionality. Specifically, these scenarios (“games”) are aimed to make participants move (Physical Activity), learn aspects related to nutrition that they must follow (Nutritional Information), improve their psychological state (Psychological Well-being), and practice their cognitive abilities (Cognitive Functionality). The interaction with the Virtual Scenarios was designed to minimize “invasive” and “annoying” features by using a depth camera (AZURE Kinect), so that the patient, through the movement of their lower extremities (legs) was able to carry out the interaction. The control group carried out the usual care in the unit.
The test battery included physical variables (lower-limb muscle strength, Sit-to-stand to sit test 10 repetitions, 4-meters gait speed, and 6-minute walking test), nutritional variables (short-form food question, 7-point subjective global assessment, body weight, and handgrip strength), psychological variables (depression and anxiety), and cognitive variables. Differences between groups (GoodRENal vs usual care) will be analyzed with a mixed ANOVA model for repeated measures.
Results
The study so far includes 55 participants (mean age 65.4 ± 13 years), 17 females, median time on hemodialysis 48 months). The program, which starts in 2023, will last 12 weeks, until the middle of May 2023.
Conclusion
The evaluation of the GoodRENal platform will show if this is a feasible holistic treatment for improving the physical, nutritional, psychological and cognitive condition of people undertaking hemodialysis.
Abstract
Background and Aims
People suffering from Chronic kidney disease (CKD) have lower levels of physical activity than their healthy counterparts. The lower level of physical activity is ...associated with impaired physical function in people undertaking hemodialysis. The COVID-19 pandemic has worsened the physical activity level of this cohort. Intradialysis exercise programs have a positive impact on many functional variables, but despite these proven benefits exercise interventions are scarce in clinical practice. Our group is implementing strategies to increase clinical applicability of exercise programs. Virtual reality (VR) intradialysis programs improve function of patients. The main aim of this study was to analyze the impact of an intradialytic non-immersive VR exercise program on physical activity level of people undertaking hemodialysis treatment.
Methods
A randomized trial (the REVID study) included two groups of patients, exercising at different times during the dialysis session for up to 12 months. The present study includes participants from the REVID study who, once the study finished, continued exercising at their preferred time during the hemodialysis treatment, with the only support of the health professionals at the HD unit. Adherence to the exercise program was measured as a percentage (number of sessions attended divided by the number of sessions offered). The physical activity level was evaluated using the Human Activity Profile (HAP) questionnaire. The HAP scale is self-administered and a list of 94 daily activities; the maximal activity score (MAS) and adjusted activity score (AAS) were calculated in this evaluation. Depending on the outcome of the HAP, patients were classified as having physical activity levels that were “impaired” (<53 points), “moderately active” (53–74 points), or “active” (>74 points). These patients had been exercising The intradialytic exercise consisted of a non-immersive VR game called ‘Treasure Hunt’ in which the participant try to catch targets and avoid obstacles by moving their lower limbs (hip flexion, abduction and adduction, and knee flexion and extension). The difficulty level of the game was graduated according to the characteristics of each player and the patients were allowed to change their legs during the game at their convenience. The impact of the program on physical activity level was analyzed with a non-parametric test for paired simples (p<0.05).
Results
This study included 11 participants, mean age 71.6 (13.9) years, 9 males, median dialysis vintage 18 months (10 to 50 interquartile range), and Charlson index 6.3 (2.2). The AAS at the baseline of the REVID study was 66 (58-72 interquartile range). The median time that participants exercised in the REVID study was 12 months (6 to 18 months interquartile range). After 3 months of the present study, when they exercised at any time during dialysis, they maintained their physical activity level, from a median AAS of 69 (interquartile range 52-71), to a Median of 70 (interquartile range 41-74). The changes were non-significant. The mean adherence to the exercise sessions was 54.6 (11.7)%.
Conclusion
This study suggests that an intradialysis virtual reality exercise program maintains the physical activity level of elderly patients undertaking HD. Most of the participants in this long-term intervention were male and moderately active. Future interventions should include an ‘exercise champion’ professional in the units to recruit women and les conditioned participants, and to achive higher adherence rates.
