Renal Conditions: Moving on up together Being active in CKD

1. Renal Conditions: Moving on up togetherBeing active in CKD Heather MacKinnon Physio Clinical Academic Kidney Lifestyle Team University of Leicester | University Hospitals of Leicester

2. Overview • Why be active? • What should people with CKD do? • Other projects around the UK • Barriers and motivators • Motivation • Cheap tips

3. Why be active? Improved metabolic function Improved bone health Reduced risk of CKD progression Cardiovascular benefits Improved quality of life Increasing activity Improved mortality risk Improved physical function Improved sleep Improved muscle mass and function Reduce inflammation

4. Activity: How much physical activity should people with CKD do? • Same as everybody else • Less than everybody else • More than everybody else

5. Activity: How much physical activity should people with CKD do? NHS Recommendations • 150mins per week of moderately vigorous physical activity + strength exercises • 2 x per week

6. What?

7. K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients 2005 • 14.2 All dialysis patients should be counseled and regularly encouraged by nephrology and dialysis staff to increase their level of physical activity. • 14.2.a Unique challenges to exercise in dialysis patients need to be identified in order to refer patients appropriately (e.g., to physical therapy or cardiac rehabilitation) and to enable the patients to follow regimens successfully. Such challenges include orthopedic/musculoskeletal limitations, cardiovascular concerns, and motivational issues. • 14.3.a Evaluation of physical functioning and re-evaluation of the physical activity program should be done at least every 6 months. • 14.3.b Physical functioning can be measured using physical performance testing or questionnaires (e.g., SF-36). • 14.4.a Many dialysis patients are severely deconditioned and therefore may need a referral for physical therapy to increase strength and endurance to the point where they are able to adopt the recommended levels of physical activity. 14.4.a.i Patients who qualify for cardiac rehabilitation should be referred to a specialist. • 14.4.a.ii The goal for activity should be for cardiovascular exercise at a moderate intensity for 30 minutes most, if not all, days per week. Patients who are not currently physically active should start at very low levels and durations, and gradually progress to this recommended level. • Physical functioning assessment and encouragement for participation in physical activity should be part of the routine patient care plan. Regular review should include assessment of changes in activity and physical functioning

8. Chronic kidney disease in adults: assessment and management (CG182) 2015 • 1.4.6 Encourage people with CKD to take exercise, achieve a healthy weight and stop smoking.  Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min) 2015 • We suggest that patients with diabetes and CKD stage 3b or higher (eGFR <45mL/min) perform additional physical exercise at least three times 1/2 to 1 hour/week to reduce fat mass and improve QoL (2D).

9. Types of activity • Aerobic- activities which make your heart go faster and make you breathe a bit deeper, such as walking, cycling, swimming and helps to build your endurance • Resistance - this is exercises that make you stronger and usually involves a weight or using your own body weight as resistance. These can help your muscles work together better and can also help you do your usual activities more efficiently and so make them feel easier to do. • Flexibility - this is stretching exercises that help you move easily. It is often considered as the most neglected form of fitness but flexibility is vital for our body to function to the best of its ability. • Balance - these exercises mean that you are less likely to fall.

10. Intensity

11. Ideas from other centres…

12. Kings College Hospital Renal Rehab Services • 12 week programme, running twice per week (Mon/Wed or Tues/Thurs). • KCH and GSTT are the only centres who currently run the programme. • Class consists of one hour of aerobic and resistance exercise. • Education session following one session per week.

13. Renal Rehab at Kings Home Exercise Programmes: For individuals who are unable to attend the RR programme a home exercise programmes is provided. Patients can also be referred to local gym/ exercise services. Assessments • Each patient has an individual assessment. • Outcome measures are completed to assess the individuals level of function. • These include: • ISWT, 6MWT, TUAG, STS60 • HADS and DASI questionnaires • From this individual programmes are set. • Focus on the individuals needs and goals.

14. Supervised exercise in CKD - Leicester • Randomised trial • CKD patients stages 3b-5 (eGFR <45 ml/min/1.73m2) • 6-week control period • 12-week exercise intervention • 2 groups • 30 minutes of aerobic exercise 3x/week @70-80% HRmax • 20-30 minutes aerobic exercise 3x/week @70-80% HRmax + progressive resistance exercise 2x/week (leg extension & leg press, 3 x 10-12 reps @70% 1RM)

15. Supervised exercise in CKD - Leicester

16. Self-directed programmes - Leicester • SPArK • Self-directed Programme to increase health through Physical Activity in Chronic Kidney Disease • individual • PACT • Physical Activity Changing Together • group

17. SPArK • Individual intervention • Based on the Theory of Planned Behaviour • 8/52 walking and strength training intervention period • Education and goal setting session at start of intervention period using Motivational Interviewing • Telephone support every 2/52 during intervention period • Pedometers used to support monitoring • Subjective and objective outcome measures pre- and post intervention

18. PACT • 3 hour Group education and goal-setting session • Based on the Social Cognitive Theory • 8/52 walking intervention period • Telephone support x2 during intervention period • Pedometers used to support monitoring • Subjective and objective outcome measures pre- and post intervention

19. Progress so far… • SPArK • Feasibility testing concluded • Data analysis ongoing • PACT • Writing for publication • Results: • Mean increase of 2127 steps/day from baseline • Trends towards improvements in physical performance measures, QoL, patient activation & knowledge • Feasible to implement • Acceptable to patients

20. Pre-emptive rehabilitation to prevent dialysis-associated morbidity (PREHAB) • PREHAB is a programme of exercise, nutritional intervention and multidisciplinary education in patients approaching and commencing dialysis • RCT intervention v usual care • 10 weeks in pre-dialysis phase • Monthly follow-up til dialysis commenced (incl home ex programme) • Individualised and group education to promote activity, nutrition and QoL for first 6months of dialysis

21. PREHAB Exercise Intervention • Supervised exercise class + dietetic review + MDT education • 15 minute aerobic warm-up (seated/standing) • 30 minute gym circuit • 10 exercises • alternating cardiovascular with resistance training • 10 minute cool down

23. Leicester - Intra-dialytic cycling • Intradialytic cycling programme established in 2011 • Programme design included training for HD staff, and strategies to engage them with exercise delivery • More acceptable to patients than hospital or home-based exercise • Well tolerated by patients, no documented serious adverse events • Being tested in both PEDAL and CYCLE-HD • Used in Clinical Practice

24. CYCLE-HD Leicester & Kettering • One month run-in period • Aiming at least 30 minutes continuous moderate intensity exercise (RPE 13-15, RPM ~70) every session • Six months duration • Supervised by trained exercise professionals or nursing staff each session

25. Transplant service at Kings • Physio within an MDT transplant clinic • Review • New patients • Annual reviews • As required • Exercise and physical activity planning • Motivational interviewing • Refer to Renal Rehab as appropriate (Greenwood et al 2014, O’Connor et al 2017)

26. PACE – HIIT in Transplant patients - Leicester Feasibility study exploring potential use of HIIT to enhance cardiovascular health in RTRs 8 weeks of training; 3 times per week; supervised 3 groups Testing baseline, mid- and post-training 3 month follow up Currently recruiting

27. PACE – HIIT in Transplant patients - Leicester 3 groups Moderately-vigorous cycling 35mins at RPE12-14 (equivalent to ~60% V̇O2 peak) HIIT A 16-min with intervals of 4, 2 and 1 min 80% progressing to 90% V̇O2 peak separated by a 2 min active rest (~60% V̇O2 peak) HIIT B (30 min) 4 intervals of 4 min 80% progressing to 90% V̇O2 peak separated by 3 min active rest (~60% V̇O2 peak) final 5 recovery minute stage

28. How to support my patients?

29. Cheap as chips…. • Brief advice • Step counters on phone • Weights using milk bottles… • NKF TIME resources • Leaflet for HCP’s & patients • Exercise diary including education and specific details of exercises • Exercise flash cards • RPE poster • https://britishrenal.org/education/timeproject/

30. Activity: How tough is the sit-to-stand 60? • How many can you do?

31. Barriers and motivators to exercise • 1088 questionnaires • Leicester, Kettering, Nottingham • Mean age 63.11 years • Mean EGFR=38.2 mL/min/1.73m2 “What might help people with kidney disease be more active?” “What can make it difficult for people with kidney disease to be more active?”

32. Barriers to being active • Physical • Fatigue • General malaise • Shortness of breath • Musculo-skeletal issues • Social • Cost • Family responsibilities • Psychological • Anxiety • Low mood • Reduced motivation

33. Facilitators • Education • Support from professionals, peers and family members • Motivation • Enjoyment • Access to equipment.

34. What is motivation? • Explains initiation, direction, persistence and termination of behaviour • A state rather than a trait • Influenced by self-efficacy and perceived importance • Patient-centred goals • Start with something small and realistic… • Fundamentals of Motivational Interviewing

35. Guiding principles – “spirit” of MI • Behaviour change through conversation • Exploring ambivalence • Collaborative partnership between patient and clinician • Express empathy • Evocative - connecting patient with health behaviour change and what they care about • Develop discrepancy • Honours patient autonomy • Roll with resistance – ambivalence = hopes, desires and fears • Support self-efficacy (Miller & Rollnick, 2002)

36. Take home message • Reduced physical activity correlates with increased mortality and morbidity • Start gently and build up • Aim for 150mins/week + strength x2 • Patient-centred goals • Renal Rehab Network • To join e-mail alice.smith@leicester.ac.uk

37. Thanks for listening Heather MacKinnon hjm24@le.ac.uk Heather.j.mackinnon@uhl-tr.nhs.uk