Thesis (1)

EFFECTS OF AN IN-CENTER RESISTANCE TRAINING PROGRAM ON

FUNCTIONAL MEASURES, STRENGTH, AND QUALITY OF LIFE IN

END STAGE RENAL DISEASE

______________________

A Thesis

Presented to The

Faculty of Springfield College

______________________

In Partial Fulfillment

Of the Requirements for the Degree

Master of Science

______________________

By

Jennifer McKinnon

December, 2014

i

Dedication

I am dedicating my thesis to my mother, Cathy, who has

always been a positive role model in my life. My mother

has been a lifelong example of hard work and perseverance.

In the face of adversity and many challenges along the way,

she has always pushed through and did what she had to do to

make things work. She has taught me the importance of hard

work, honesty and integrity, being humble in every

situation, and never giving up. My mother has not lived

the easiest of lives, yet she is constantly pushing

forward, kindly and hopefully, yet never backing down from

her beliefs all the while. She is a strong, beautiful

person inside and out and I can only hope to be the kind of

person she is one day. Thank you, mom, for providing a

wonderful example for me and others in your life, and

instilling in me many of the same virtues and passions that

you have continued to demonstrate.

ii

Acknowledgments

First, I would like to thank Pioneer Valley Dialysis

and the Western Massachusetts Kidney Center for allowing

this study to be done in their facilities. I would also

like to thank all of the patients who volunteered to take

part in the study, despite not always having a great deal

of energy to expend. Next, I would like to thank Dr.

Headley for guiding me in my graduate school experience and

being a great teacher. I would like to thank Dr. Matthews

for all of your help and statistical knowledge. Dr. Dodge,

thank you for your help and allowing the use of the manual

muscle test apparatus for the data collection. A large

thank you to Michael Bruneau for donating so much of your

time, effort, and knowledge throughout the entire research

process. It was incredibly helpful to have your assistance

and support whenever it was needed.

Lastly, I would like to thank Dan Soule for his

endless support throughout the entire graduate school

process. Without your multi-dimensional help the last few

years, I would not be where I am today.

December 2014 J. R. M.

iii

Table of Contents

Page

Dedication . . . . . . . . . . . . . . . . . . . . . . i

Acknowledgments . . . . . . . . . . . . . . . . . . . ii

List of Tables . . . . . . . . . . . . . . . . . . . . v

List of Figures . . . . . . . . . . . . . . . . . . . vii

Abstract . . . . . . . . . . . . . . . . . . . . . . . 2

Introduction . . . . . . . . . . . . . . . . . . . . . 3

Method . . . . . . . . . . . . . . . . . . . . . . . . 7

Subjects . . . . . . . . . . . . . . . . . . . . . 8

Measuring Instruments . . . . . . . . . . . . . . 8

Procedures . . . . . . . . . . . . . . . . . . . . 12

Statistical Analyses . . . . . . . . . . . . . . . 14

Results . . . . . . . . . . . . . . . . . . . . . 14

Discussion . . . . . . . . . . . . . . . . . . . . 18

References . . . . . . . . . . . . . . . . . . . . . . 25

Appendix A. RESEARCH DESIGN . . . . . . . . . . . . . 35

Statement of the Problem . . . . . . . . . . . . 36

Definition of Terms . . . . . . . . . . . . . . 36

Delimitations . . . . . . . . . . . . . . . . . . 39

Limitations . . . . . . . . . . . . . . . . . . . 40

Hypotheses . . . . . . . . . . . . . . . . . . . 40

Appendix B. REVIEW OF LITERATURE . . . . . . . . . . . 41

Frailty . . . . . . . . . . . . . . . . . . . . . 44

iv

Dialysis and Aerobic Training . . . . . . . . . . 53

Muscle Evaluation . . . . . . . . . . . . . . . . 67

Combination Training . . . . . . . . . . . . . . 73

Resistance Training . . . . . . . . . . . . . . . 80

Summary . . . . . . . . . . . . . . . . . . . . . 96

Appendix C. INFORMED CONSENT FORM . . . . . . . . . . 98

Appendix D. MEDICAL HISTORY FORM . . . . . . . . . . . 101

Appendix E. DATA SHEET . . . . . . . . . . . . . . . 103

Appendix F. EXERCISE SHEET . . . . . . . . . . . . . 104

Appendix G. SF-36 . . . . . . . . . . . . . . . . . . 105

Appendix H. SHORT PHYSICAL PERFORMANCE BATTERY. . . . 110

Appendix I. INFORMATIONAL FLYER . . . . . . . . . . . 115

Appendix J. YMCA MEMBERSHIP FORM . . . . . . . . . . 117

Appendix K. STATISTICS TABLES. . . . . . . . . . . . . 118

BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . 138

v

List of Tables

Table Page

1. Descriptive Statistics for Subjects . . . . 29

2. Descriptive Statistics for Short Physical

Performance Battery (SPPB). . . . . . . . . 30

3. Descriptive Statistics for Manual Muscle

Test (MMT) in Pounds. . . . . . . . . . . . 31

K4. 2x2 Mixed Factorial ANOVA Comparing PCS

Scores from the SF-36 Between Baseline

and 8-Weeks . . . . . . . . . . . . . . . .118

K5. 2x2 Mixed Factorial ANOVA Comparing MCS

Scores from the SF-36 Between Baseline

and 8-Weeks . . . . . . . . . . . . . . . .119

K6. 2x3 Mixed Factorial ANOVA Comparing SPPB

Total Balance Scores Over Three Time

Periods for Treatment and Control Groups. .120

K7. 2x3 Mixed Factorial ANOVA Comparing SPBB

Gait Speed Test Scores Over Three Time

Periods for Treatment and Control Groups. .121


Chair Stand Scores Over Three Time Periods

for Treatment and Control Groups. . . . . .122


Total Scores Over Three Time Periods for

Treatment and Control Groups. . . . . . . .123

K10. 2x3 Mixed Factorial ANOVA Comparing Right

Biceps MMT Scores Over Three Time Periods

for Treatment and Control Groups. . . . . .124

K11. 2x3 Mixed Factorial ANOVA Comparing Left

Biceps MMT Scores Over Three Time Periods

for Treatment and Control Groups . . . . . 125


Shoulder MMT Scores Over Three Time Periods

for Treatment and Control Groups . . . . .126

vi


Shoulder MMT Scores Over Three Time Periods



Calf MMT Scores Over Three Time Periods for

Treatment and Control Groups . . . . . . .128


Calf MMT Scores Over Three Time Periods



Quadriceps MMT Scores Over Three Time Periods



Quadriceps MMT Scores Over Three Time Periods



Hamstrings MMT Scores Over Three Time Periods



Hamstrings MMT Scores Over Three Time Periods



Adductor MMT Scores Over Three Time Periods



Adductor MMT Scores Over Three Time Periods



Abductor MMT Scores Over Three Time Periods



Abductor MMT Scores Over Three Time Periods


vii

List of Figures

Figure Page

1. Schematic diagram illustrating study design

and testing session flow. . . . . . . . . . 34

1 Running head: END STAGE RENAL DISEASE

Effects of an In-center Resistance Training Program on

Functional Measures, Strength, and Quality Of Life in End

Stage Renal Disease

Jennifer McKinnon

Springfield College

2


Abstract

The purpose of this study was to examine the effects of an

8-week resistance training program on quality of life,

strength, and functional ability of end-stage renal disease

(ESRD) patients on dialysis. A total of 10 dialysis

patients completed the study with 5 in the training group

and 5 in the control group. Resistance training was

performed in an intra-dialytic setting during the first

hour of dialysis using bands and ankle weights. Patients

exercised major muscle groups which included: biceps,

shoulders, quadriceps, hamstrings, calves, hip

adductors/abductors, and core. Measurements for QOL were

assessed by the SF-36 at baseline and 8-weeks.

Measurements for strength and functional ability were

assessed at baseline, 4-weeks, and 8-weeks, using an MMT

and the SPPB, respectively. 2x2 and 2x3 ANOVA’s with

repeated measures were computed (p = 0.05). Strength

measures improved for the treatment group in the MMT calf,

hamstring, and quadriceps muscles when compared to the

control group. SPPB results demonstrated improvements in

chair stand performance and total score. In conclusion,

resistance training programs are safe and effective for

ESRD patients and can result in strength and functional

improvements.

3


Effects of an In-center Resistance Training Program on

Functional Measures, Strength, and Quality

Of Life in End Stage Renal Disease

The amount of patients with end-stage renal disease

(ESRD) who are treated with dialysis and transplantation in

the United States has risen by over 57% between 1995 and

2010 (Chen et al., 2010). As a result, healthcare

financial expenditure has increased and averages around $28

billion annually. Patients with ESRD are increasingly

sedentary and have low functional abilities compared with

healthy individuals of the same age (Headley et al., 2002).

These components often result in patients becoming quite

frail (Brown & Johansson, 2010). Frailty is characterized

by poor physical performance, weakness, exhaustion,

fatigue, low physical activity, and poor nutrition. In

turn, frailty is also associated with a higher risk of

hospitalization and death for dialysis patients in

particular (Chen et al., 2010). ESRD patients are also at

higher risk for cardiovascular disease and other serious

comorbidities due to their poor overall health state

(Howden, Fassett, Isbel, & Coombes, 2012). Despite various

medical advancements, patients continue to be limited

physically, which results in negative impact on health,

quality of life, activities of daily living, and morbidity

4


and mortality outcomes (Painter, 2005). Thus, researchers

and healthcare providers continue to search for a safe and

effective program to improve these factors.

Strength training, or resistance training, is known to

increase physical performance and functional capacity,

improve muscular strength and function, decrease blood

pressure, and improve inflammation (Chen et al., 2010).

The effects of resistance training can also improve quality

of life, nutrition, and increase independence for dialysis

patients (Chen et al., 2010). The primary focus of care

for dialysis patients is on disease management as opposed

to prevention. Despite research that indicates vast

improvements in this patient population, exercise is still

a very under-utilized tool (Johansen, 2005).

Researchers have examined the effect of exercise on

dialysis patients focusing primarily on aerobic training

(Chen et al., 2010). Peak oxygen uptake (VO2peak) is often

used as the primary measure within these studies. Due to

the fact that VO2peak is a widely recognized physiological

measure pertaining to exercise capacity, it is considered

to be a valid measure of physical function and fitness

(Chen et al., 2010). While several researchers have

reported increases in VO2peak following aerobic training in

this patient population, the increases are somewhat modest

5


and it has not yet been fully established as to how it

actually improves the lives of patients with ESRD (Howden

et al., 2012). Researchers have examined a combination of

resistance and aerobic training, yet the primary emphasis

still tends to remain on the aerobic training portion

(Segura-Orti, Kouidi, & Lison, 2009).

Although some researchers have studied a combination

of aerobic and resistance training, few have focused on

resistance training alone for this population. Muscle

strength is a vital determinant of physical function and

independence in older populations and those with chronic

disease. As previously stated, dialysis patients are weak

compared to healthy individuals. Weakness is a major

limitation to physical function and quality of life for

patients with ESRD. Muscle strength has been shown to be

an important predictor for gait speed and other factors

that impact upon activities of daily living (Segura-Orti et

al., 2009).

The majority of studies involving training ESRD

patients involve a protocol of exercise on non-dialysis

days. The theory behind exercise on non-dialysis days is

that patients are too tired and fatigued during dialysis to

participate in physical activity. Researchers, therefore,

have hypothesized that patients will be more energized and

6


motivated to move on their days off of dialysis (Chen et

al., 2010). However, dialysis patients have been reported

to feel too weak and apprehensive to begin a program due to

complications with their fistula or musculoskeletal injury,

for instance (Chen et al., 2010). As a result, most of

these studies have had low compliance rates from dialysis

patients.

A study that addresses the previously mentioned

barriers is necessary in order to determine the range of

benefits for dialysis patients. Since most researchers

only include subjects who have no other comorbidities, more

current studies should involve frail subjects of an older

age group. According to the American College of Sports

Medicine, this detrained population has the most to gain

from an exercise program (Thompson, Gordon, & Pescatello,

2009). By performing the exercise program within the first

hour or two of dialysis, the compliance component would

also be addressed. The patients would be coming in for

dialysis regardless and would not have to do any extra

driving or take any extra time out of their daily

schedules. Resistance training was chosen for the current

study due to its known effects on musculoskeletal function

and its ability to be done in a primarily seated position.

7


Few studies have examined older dialysis patients due

to their decreased functional ability and higher incidence

of comorbidities. Older and more deconditioned patients,

however, have the most to gain from training. The current

study was designed to examine the impact of an in-center

resistance training program on functional measures,

strength, and quality of life in end-stage renal disease

patients on dialysis. Due to evidence showing that

resistance training builds muscle, the researcher

hypothesized that a resistance training program would

improve functional ability and muscular strength, which in

turn, would also improve quality of life in the ESRD

patient population.

Method

The study was designed to determine the effects of a

resistance training program on dialysis patients over an

eight week period. Effects that were examined include

strength measures, the Short Physical Performance Battery

(SPPB) testing (Freire, Guerra, Alvarado, Guralnik, &

Zunzunegui, 2012) for functional capacity of activities of

daily living, frailty, and the SF-36 for quality of life.

Measurements were taken at baseline, a four-week period

halfway into the training period, and post-training at

eight weeks.

8


Subjects

Patients from the XXXXXXX XXXXXX Dialysis Center and

the XXXXXXX XXXX Kidney Center in Western Massachusetts

were recruited for the current study. The subjects

included 10 (n = 5 in experimental group, n = 5 in usual

care group) patients who were asked to sign an Informed

Consent Form (Appendix C) prior to testing. A

comprehensive medical history was obtained prior to

admission into the study (Appendix D). Subjects whose

physicians did not approve their participation were not

allowed to do the study. Subjects who suffered from any

recent or current musculoskeletal injury and were not

physically able to perform the necessary exercises were

excluded from the study. In total, about 40 patients were

approached during recruitment. Of these, four patients

were not medically cleared for participation.

Measuring Instruments

In this study, the researcher measured strength using

dynamometry. Specifically, the Lafayette Manual Muscle

Testing (MMT) System was used (Model 01165, Lafayette,

Indiana), which is an ergonomic hand-held device for

objectively quantifying muscle strength. The accuracy for

this instrument is determined to be ± 1 % over full scale

or ± 0.2 lbs (Lafayette Instrument Company, 2009). The

9


test is performed with the researcher applying force to the

limb of a patient or subject. The objective of the test is

for the researcher to overcome the patient’s resistance.

The MMT records the peak force and the time required to

achieve the outcome. This dynamometer is portable, easy

and efficient, and offers several different features and

functions. Some of the features include three molded

plastic stirrups with pads, automatic or manual storage of

data, a measurement range of 0-300 lbs, and an LCD display

with different menu options. In a study from Martin and

colleagues (2006), 20 participants (9 men and 11 women)

between the ages of 61 and 81 years were recruited in order

to test the hand-held dynamometer (HHD) against the gold

standard Biodex dynamometry when examining strength

measures. There was a correlation between the measures (r

= 0.91, p < 0.0001) and classification of individuals into

tertiles of muscle strength showed favorable agreement

between the two measurement methods (Kappa =0.69, p <

0.0001) (Martin et al., 2006).

Functional ability and activities of daily living were

measured by The Short Physical Performance Battery (SPPB)

(Brazier et al., 1992). The SPPB is a tool designed to

quantify physical performance and decline over time. The

test focuses primarily on lower extremity function and

10


includes a 4-m walk to measure gait speed, one chair stand

(followed by 5 timed chair stands, if the first is

successfully completed), and balance stands with the feet

held in different positions for 10 s each. The test battery

is designed to be easily administered in a variety of

contexts or settings, can be administered after a short

course of training, and takes about 10 min to complete.

Each test within the battery is scored 0-4 with a maximum

score of 12. Scores are then summed to compute one final,

overall score. The test has been shown to be predictive of

risk of disability among community-dwelling older patients

(Brazier et al., 1992). In addition, use of the test has

predicted patient mortality, the need for admission to a

nursing home and reliance on health care among the general

older population, as well as continued decline in

activities of daily living (ADLs). Additionally, the SPPB

has been successful in predicting the development of

disability (inability to perform ADLs or decreased

mobility) among those individuals who had no disability at

the time of administering the test. Test-retest

reliability was evaluated using individuals over the age of

65 and has a reported Intra-class Correlation Coefficient

(ICC) of .90 with an inter-rater reliability ICC between

.73 and .82 with a 95% confidence interval. Independent

11


samples t-tests were used to compare means and establish

validity, which was analyzed to be high (Freire et al.,

2012).

Quality of life (QOL) was measured using the SF-36

(Medical Outcomes Study, Rand Corporation), which is a

multi-purpose, short-form health survey with 36 questions.

The SF-36 yields an 8-scale profile of functional health

and well-being scores, as well as psychometrically-based

physical and mental health summary measures and a health

utility index. The eight scaled scores are the weighted

sums of the questions from each section and each scale is

directly transformed into a 0-100 scale on the assumption

that each question carries equal weight. It is a generic

measure, as opposed to one that targets a specific age,

disease, or treatment group. Accordingly, the SF-36 has

been useful in surveys of general and specific populations,

comparing the relative burden of diseases, and in

differentiating the health benefits produced by a wide

range of different treatments. Both internal consistency

and test-retest reliability have been shown to be high for

the SF-36 with coefficients greater than .75 and a 95%

confidence interval. Distribution of scores conformed to

expected values for validity demonstrating both internal

and external consistency (Brazier, et al., 1992).

12


Procedures

The subjects (N = 10) were patients from Western

Massachusetts who receive dialysis three times per week for

about 4 hrs each session. Each subject was given detailed

instructions on the exercise protocol prior to testing. An

initial pilot session was used to determine a subject-

specific workload that would elicit a rate of perceived

exertion (RPE) of either 3 or 4 (moderate to somewhat hard)

on a graduated Borg scale of 1 to 10 (Borg, 1970).

Patients performed resistance exercise which encompassed

the major muscle groups. Exercises included: bicep curls,

lateral shoulder raises, anterior shoulder raises, seated

row, triceps extension, bent leg raises, leg extension,

calf raises, hip adduction squeeze, hip abduction, and sit-

to-stands. Postural exercises which included chin tucks

and scapular retractions in addition to core and breathing

exercises where the core is engaged were also part of the

exercise routine. Exercises were performed using ankle

weights, resistance bands, and dumbbells. Exercise

progression was gradual and modifications were sometimes

necessary due to the type of diseased population involved.

Once the RPE was reduced to a 2 for a patient, weight was

increased. Patients were instructed to perform each

exercise once for 8-12 repetitions. Certain exercises

13


(bicep curls, anterior and lateral shoulder raises, row,

and triceps extension) were performed in the waiting room

prior to dialysis due to the motion required. The arm with

the fistula was also worked prior to dialysis in the

waiting room since it cannot be used during. Training was

performed at the beginning of each dialysis session to

ensure minimal fatigue.

A usual care control group (n = 5) was used to assess

differences in effects of training. The control group

proceeded with their typical dialysis care. No resistance

training was performed by this group. The subjects in this

group were given the same testing as the experimental

group.

Testing was performed at baseline, four weeks after

the start of training, and post training after eight weeks.

The testing was performed during the mid-week dialysis

session in order to allow for the most normal bodily fluid

distribution. Differences in strength were assessed using

manual muscle testing at each testing interval. SPPB

testing was used to determine changes in ability for ADL’s

during each testing interval as well. Scores from the SF-

36 were obtained at baseline and post training only to

assess any changes in QOL from the time between the start

of the program and the end of training.

14


Statistical Analyses

Functional ability and strength were measured three

times (pre, mid, & post) and QOL was measured twice (pre &

post). A 2 x 3 mixed factorial ANOVA was computed for

strength and functional ability. This was based on time

(pre, 4 weeks, & 8 weeks) and group (strength, or

experimental, & control). A 2 x 2 mixed factorial ANOVA

was computed for QOL based on SF-36 scores. The alpha

level was set at 0.05 and all statistical analyses were

performed using IBM-SPSS (version 21.0).

Results

The results will be reported in different sections of

the document based on the type of testing. They will be

described in the following subsections; Descriptive

Characteristics of Subjects, SF-36, SPPB, and MMT.

Descriptive Characteristics of Subjects

A total of 10 subjects (6 male, 4 female) completed

the study. Subjects ranged in age from 44 to 74 years of

age with a mean age of 59.3 ± 11.5 years. The majority of

subjects were in the overweight to obese category based on

BMI (M = 34.78 kg/m2 ± 10.01 kg/m2). The average height and

weight for the 10 subjects was 67.6 cm ± 4.09 cm and 102.1

kg ± 28.2 kg, respectively. As for ethnicity, 50% of

subjects were Caucasian, 30% were Hispanic, and 20% were

15


African American (Table 1). ANOVA summary tables can be

found in Appendix K.

The QOL variable assessed by the SF-36 health

questionnaire was analyzed with a 2 X 2 mixed factorial

ANOVA. The SPPB and MMT results were analyzed using a 2 X

3 mixed factorial ANOVA. Mauchly’s test of sphericity was

used to test for the basic assumption of homogeneity of

variance when more than two time points were analyzed. If

significant differences existed, the Greenhouse-Geisser

statistic was used to adjust for the degrees of freedom.

Simple effects tests were conducted as post hoc tests for

significant interactions. Results of these analyses are

described below in the following sections; SF-36, SPPB, and

MMT.

SF-36

Results from the SF-36 health and QOL questionnaire

were divided between the physical component score (PCS) and

the mental component score (MCS). Mean PCS baseline scores

were 26.90 ± 7.01 and 32.78 ± 6.96 for treatment and

control groups, respectively. The 8-week mean PCS scores

were 28.88 ± 11.35 and 33.24 ± 2.88 for the treatment and

control groups, respectively. The baseline MCS scores were

55.22 ± 13.68 for the treatment group and 45.02 ± 11.55 for

the control group. The 8-week MCS scores for the treatment

16


group were 58.94 ± 6.61 and 43.86 ± 13.92 for the control

group. No significant interactions or main effects were

found for the MCS or the PCS.

SPPB

No significant interactions existed for total balance,

gait speed, chair stand, and total score. No significant

main effects for time or group existed for total balance

and gait speed. For group, significant differences existed

for the chair stand score and total score. Significant

time effects were found for chair stand and total score.

Significant differences existed between baseline and 8-week

testing as well as 4-week testing and 8-week testing (p =

.03) for the chair stand. The total SPPB score demonstrated

a significant time interaction between baseline and 8-weeks

(p = .05).

MMT

Significant interactions existed for calf (right and

left), quadriceps (right and left), and hamstrings (right

and left). Simple effects tests were conducted to

determine where the significant differences existed. Both

the right and left calf force increased in the treatment

group from baseline to 8-week testing (p = .00 and p = .03,

respectively) while the left calf force also improved from

4-weeks to 8-weeks (p = .01). Both the right and left

17


quadriceps demonstrated significant time effects for the

treatment group between baseline and 8-weeks (p = .00 and p

= .00, respectively). Additionally, significant time

effects existed for the treatment group for the left

quadriceps for baseline to 4-week testing and 4-week to 8-

week testing (p = .00 and p = .01, respectively). There

were significant time effects for the right and left

hamstring force measurements from baseline to 8-weeks (p =

.01 and p = .03, respectively). A significant time effect

also existed for the treatment group from baseline to 4-

weeks for the right hamstring (p = .02). In addition, a

significant time effect existed from 4-weeks to 8-weeks for

the control group (p = .01).

Significant differences were found between groups for

the right calf and the left quadriceps MMT measurements.

The control group demonstrated higher left calf strength

values than the treatment group at baseline (p = .04; A =

20.00, B = 40.86) and for the right quadriceps (p = .02; A

= 28.02, B = 36.74). However, there were no significant

changes over time for the control group. No significant (p

> .05) differences were found for biceps, shoulders, hip

adductors, or hip abductors based on treatment condition.

18


Discussion

The purpose of the research was to determine whether 8

weeks of resistance training would improve strength,

activities of daily living, and quality of life in ESRD

patients on dialysis. The researcher hypothesized that the

strength training protocol would increase strength

measures, increase ability and ease for activities of daily

living, and improve quality of life following 8 weeks (3

times per week) of training the major muscle groups.

Overall, the treatment group demonstrated improvements in

repeated chair stands and total scores for activities of

daily living. Significant treatment group improvements

were also evident in strength scores for hamstrings,

quadriceps, and calves, as demonstrated by the MMT

measurements.

No differences were observed in QOL based on the SF-36

questionnaire following the 8-week training program.

Resistance training is known to increase muscle mass and

strength which can result in increased independence for

frail populations which, in turn, may result in

improvements in quality of life. Dialysis patients often

display lower than average (when compared to healthy

populations) PCS and MCS scores on the SF-36 health-related

quality of life questionnaire. Segura-Orti et al. (2008)

19


found similar results after administering the questionnaire

to 27 dialysis patients who were randomized to either a 24-

week resistance program compared with low intensity aerobic

program. The PCS and MCS sections of the SF-36 at baseline

were found to be lower than the general population. The

intra-dialytic training program did not statistically

affect the SF-36 scores (Segura-Orti et al., 2008). Slight

improvements in the scores were demonstrated, however,

which should be of some value. An increase of 5 points on

the PCS has been associated with a 10% increased survival

(DeOreo, 1997). The minimal clinically important

difference (MCID) is defined as the minimal difference in

scores of an outcome measure that is perceived by patients

as beneficial or harmful (Keurentjes et al., 2012). The

MCID value for the SF-36 is different depending on the

patient population but ranges from 3-5 score units for ESRD

patients (Pagels, Soderkvist, Medin, Hylander, & Heiwe,

2012). In the current study, the treatment group

demonstrated differences for both PCS and MCS score domains

between baseline and 8-week testing. The scores were

indicative of meeting the MCID value (PCS baseline = 26.90

± 7.01 and 8 week = 28.88 ± 11.35; MCS baseline =

55.22±13.68 and 8-week = 58.94 ± 6.61).

http://www.bjr.boneandjoint.org.uk/search?author1=J.+C.+Keurentjes&sortspec=date&submit=Submit

20


The SPPB has been used to determine the functional

ability especially for very frail populations. The test

battery includes balance, gait, and lower body strength,

all scored together for a total overall score. After the

8-week resistance training protocol, the lower body

strength (tested by repeated chair stands) and the total

overall scores were improved for the training group and no

differences observed in the control group. This is in

accordance with the MMT results which demonstrated

significant improvements for lower body muscle groups

(calves, quadriceps, and hamstrings) and will be discussed

in detail later. Segura-Orti et al. (2008) found that

resistance training during hemodialysis resulted in

improvements in METs and physical performance testing (sit-

to-stand-to-sit tests and 6-min walk tests) after 24 weeks

of training. Although no differences were observed in

change over time between the two groups, a significant

change was observed in intragroup analysis for the training

group. After 8-weeks of training, the researcher

demonstrated differences for the repeated chair stands

(between baseline and 8-weeks and between 4-week and 8-week

testing) and total scores (between 4-week testing and 8-

week testing). Physical limitation has been shown by low

SPPB scores, which has been shown to predict disability

21


when scores are less than 7 (Chen et al., 2010). In

addition, a change in SPPB scores of one point has been

found to be clinically meaningful for functional capacity

(Chen et al., 2010). Findings for the current study

demonstrated treatment group scores at baseline increasing

from an average of 4.40 ± 2.97 to 6.40 ± 2.61 (p = .03)

after completion of the 8-week training program. These

findings indicate improvements for this population in only

8 weeks which could be beneficial for functional ability in

a very frail population.

Dynamometry is one of the most common ways to assess

muscle strength and the MMT is a portable, easy, and

accurate form of measurement. While no differences were

evident in bicep or shoulder strength in the current study,

lower body strength improved after 8 weeks of training in

the treatment group. A low intensity intra-dialytic

strength training study exhibited significant improvements

from baseline in knee extensor strength with twice weekly

sessions for 48 sessions total (Chen et al., 2010). Lower

body exercises were performed using ankle weights with two

sets of eight repetitions for each exercise. Headley et

al. (2002) also demonstrated increased strength and

functional capacity after 12 weeks of resistance training

in patients with ESRD; however, the training protocol was

22


performed outside of the dialysis center on non-dialysis

days. Results from the current study demonstrate that

significant strength differences are possible after only

eight weeks of training, with some effects seen in only

four weeks. For instance, a significant interaction was

observed between baseline testing and 8-week testing and 4-

week testing and 8-week testing in the left calf for the

treatment group. Also, left hamstring results demonstrated

an interaction between 4-week testing and 8-week testing

for the treatment group.

A limitation of the current study was the potential

variability between MMT measurements since this was reliant

on the tester strength overcoming the patient strength. To

address this issue, the same tester was used for each

patient throughout the three testing periods in order to

minimize error. Another limitation was that the SPPB is

more commonly used for very old and frail populations.

Since there was a range of fitness levels between the

patients, this may have not been the most appropriate test

to use for functional ability. Finally, the study may have

also been limited by the small sample size.

Currently, a randomized control study (Bennett,

Breugelmans, Chan, Calo, & Ockerby, 2012) is underway in

Australia to examine the impact of an exercise physiologist

23


coordinated resistance exercise program on the physical

function of dialysis patients. A total of 180 participants

will be recruited from 15 hemodialysis clinics and will

consist of three groups in which patients will be allocated

to either 12, 24, or 36 weeks of the exercise intervention

(Bennett et al., 2013). The intervention will consist of

six lower body resistance exercises using resistance bands

and tubes and will be done in a seated position during the

first hour of dialysis treatment. The primary outcomes are

physical function, quality of life, cost-utility analysis,

falls risk, medication use, blood pressure, and morbidity.

Results of the study are expected to determine whether it

is effective to employ the use of an accredited exercise

physiologist supervised resistance training program for

dialysis patients, as well as the cost-utility of exercise

physiologists in dialysis centers (Bennett et al., 2013).

Studies like Bennett et al. (2013) and the current study

could show the benefits and efficacy of utilizing exercise

physiologists in dialysis centers, something that has not

been tested in this patient population.

In conclusion, an 8-week, intra-dialytic resistance

training program demonstrated strength improvements in

hamstring, quadriceps, and calf muscle groups.

Additionally, the current resistance training program also

24


showed significant improvements in functional ability for

repeated chair stands and total scores for the SPPB. In

order to demonstrate improvements in quality of life

measures and other strength measures, future studies may

want to explore longer training periods, a larger sample

size, and possibly utilize a program with some combination

of resistance and aerobic exercise. No injuries were

reported during this study, also demonstrating that a

properly supervised, progressive resistance training

protocol is safe for dialysis patients.

25


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Gordon, N. F., Pescatello, L. S. (2009). ACSM’s

Guidelines for Exercise Testing and Prescription.

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Bennett, P. N., Breugelmans, L., Chan, D., Calo, M., &

Ockerby, C. (2013). A Combined Strength and Balance

Exercise Program to Decrease Falls Risk in Dialysis

Patients: A Feasibility Study. Journal Of Exercise

Physiology Online, 15(4), 26-39.

Borg, G. (1970). Institute of Applied Psychology: Self

Appraisal of Physical Performance Capacity. Reports

from the institute of applied psychology, The

University of Sweden, 32(e-book).

Brazier, J., Harper, R., Jones, N., O'Cathain, A., Thomas,

K., Usherwood, T., & Westlake, L. (1992). Validating

the SF-36 health survey questionnaire: New outcome

measure for primary care. British Medical Journal

(Clinical Research Ed.), 305(6846), 160-164.

Brown, E., & Johansson, L. (2010). Old age and frailty in

the dialysis population. Journal of Nephrology, 23(5),

502-507.

Chen, J., Godfrey, S., Ng, T., Moorthi, R., Liangos, O.,

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Ruthazer, R., & ... Castaneda-Sceppa, C. (2010).

Effect of intra-dialytic, low-intensity strength

training on functional capacity in adult haemodialysis

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European Dialysis and Transplant Association -

European Renal Association, 25(6), 1936-1943.

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DeOreo, P. B. (1997). Hemodialysis patient-assessed

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hospitalization, and dialysis-attendance compliance.

American Journal Of Kidney Diseases: The Official

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212.

Freire, A., Guerra, R., Alvarado, B., Guralnik, J., &

Zunzunegui, M. (2012). Validity and reliability of the

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older adult populations in Quebec and Brazil. Journal

of Aging and Health, 24(5), 863-878.

doi:10.1177/0898264312438551

Headley, S., Germain, M., Mailloux, P., Mulhern, J.,

Ashworth, B., Burris, J., & ... Jones, M. (2002).

Resistance training improves strength and functional

measures in patients with end-stage renal disease.

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doi:10.2165/11630800-000000000-00000

Johansen, K. (2005). Exercise and chronic kidney disease:

Current recommendations. Sports Medicine (Auckland,

N.Z.), 35(6), 485-499.

Keurentjes, J. C., Van Tol, F. R., Fiocco, M., Schoones, J.

W., & Nelissen, R. G. (2012). Minimal clinically

important differences in health-related quality of

life after total hip or knee replacement: A systematic

review. Bone and Joint Research, 1(5), 71-77.

Lafayette Instrument Company. (2009). Lafayette manual

muscle testing system. Retrieved from:

http://www.lafayetteevaluation.com/product_detail.asp?

itemid=26

Martin, H. J., Yule, V. V., Syddall, H. E., Dennison, E.

M., Cooper, C. C., & Sayer, A. (2006). Is hand-held

dynamometry useful for the measurement of quadriceps

strength in older people? A comparison with the gold

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standard biodex dynamometry. Gerontology, 52(3), 154-

159. doi:10.1159/000091824

Pagels, A. A., Soderkvist, B. K., Medin, C., Hylander, B.,

& Heiwe, S. (2012). Health-related quality of life in

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Segura-Ortí, E., Kouidi, E., & Lisón, J. (2009). Effect of

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Fitness Journal, 13(4), 23-26.

29


Table 1

Descriptive Statistics for Subjects (N = 10)

___________________________________________________________

Variable M SD Min. Max.

___________________________________________________________

Age (yr) 59.30 11.49 44.00 74.00

BMI (kg/m2) 34.79 10.01 19.30 48.70

Height (cm) 67.60 4.09 60.00 73.00

Weight (kg) 102.08 28.26 66.09 145.50

___________________________________________________________

30


Table 2

Descriptive Statistics for Short Physical Performance

Battery (SPPB)

___________________________________________________________

Variable Baseline 4 Week 8 Week

___________________________________________________________

Balance T 2.00±1.58 2.60±0.89 3.20±1.10

C 3.40±0.89 3.60±0.55 3.40±0.89

Gait Speed T 1.50±0.58 1.25±0.50 1.25±0.50

C 1.00±0.00 1.00±0.00 1.20±0.45

Chair Stands T 1.00±1.00 1.20±1.30 2.00±1.87

C 1.60±0.89 2.00±1.22 2.20±1.48

Total T 4.40±2.97 5.00±2.55 6.40±2.61

C 6.40±0.89 6.60±1.67 6.80±2.49

___________________________________________________________

T = Treatment Group, C = Control Group. Values represented

in M ± SD, p < .05.

Each score was based on time in seconds

31


Table 3

Descriptive Statistics for Manual Muscle Test (MMT) in

Pounds (N = 10)

___________________________________________________________

Variable Group Baseline 4 Week 8 Week

___________________________________________________________

Biceps

Right T 32.44±5.98 35.84±8.16 46.96±9.63

C 27.88±5.98 32.14±8.16 30.28±9.63

Left T 29.66±6.91 27.54±6.54 38.00±6.90

C 31.32±6.91 32.14±6.54 30.94±6.90

Shoulder

Right T 31.86±8.36 31.28±6.75 32.50±6.39

C 32.80±8.36 29.80±6.75 29.40±6.39

Left T 30.14±7.02 31.60±6.96 31.62±4.62

C 28.68±7.02 23.38±6.96 25.70±4.62

Calf

Right T 20.00±5.98 25.66±5.05 33.36±5.69a

C 40.86±5.98* 32.94±5.05 36.82±5.69

Left T 19.84±7.81 23.24±2.73c 25.20±4.97a

C 37.24±7.81 28.56±2.73 30.58±4.97

Quadriceps

Right T 28.02±2.12 32.94±5.42 40.72±4.82a

C 36.74±2.12 38.40±5.42 35.18±4.82

32


Left T 23.22±5.94b 28.74±4.67c 41.82±4.78a

C 34.30±5.94* 33.40±4.67 30.22±4.78

Hamstrings

Right T 21.56±4.67 35.36±5.52c 34.80±3.44a

C 27.84±4.67 26.54±5.52 26/80±3.44

Left T 23.18±4.60 32.36±6.52 33.06±5.48a

C 31.91±20.18 25.42±14.24c 31.86±15.65

Adductors

Right T 23.40±6.54 26.26±6.21 29.20±4.70

C 29.14±15.75 23.78±12.53 23.46±6.45

Left T 23.42±7.80 23.84±7.46 29.04±3.29

C 25.50±21.17 19.36±8.63 20.94±8.22

Abductors

Right T 27.78±8.00 32.50±9.48 36.80±12.32

C 34.20±19.74 32.32±17.74 31.16±7.23

Left T 29.18±12.92 36.64±11.82 38.62±6.83

C 29.40±8.50 31.18±20.15 27.80±8.30

___________________________________________________________

* Control significantly greater than treatment

a – 8-week significantly greater than baseline

b – 4-week significantly greater than baseline

c – 8-week significantly greater than 4-week

33


Figure Caption

Figure 1. Schematic diagram illustrating study design and

testing session flow.

34


35


Appendix A

RESEARCH DESIGN

Patients with end stage renal disease (ESRD) are

increasingly sedentary and have low functional abilities

compared with healthy individuals of the same age (Headley

et al., 2002). Many dialysis patients, especially older

patients, can be classified as frail (Chen et al., 2010).

Frailty is characterized by poor physical performance,

weakness, exhaustion and fatigue, low physical activity,

and poor nutrition. Frailty, in turn, is also associated

with a higher risk of hospitalization and death for

dialysis patients in particular (Chen et al., 2010).

Despite various medical advancements, patients continue to

be limited physically, which then results in a negative

impact on health, quality of life, activities of daily

living, and morbidity and mortality outcomes (Painter,

2005).




pressure, and improve markers of inflammation (Chen et al.,

2010). Resistance training can also improve quality of

life, nutrition, and independence for dialysis patients

(Chen et al., 2010). The primary focus of care for

36


dialysis patients is on disease management as opposed to

prevention. Despite the research that indicates vast



Statement of the Problem

The current study was designed to measure the changes

in strength, functional ability, and quality of life in

ESRD patients on dialysis following an in-center resistance

training program. The researcher measured strength,

functional ability, and quality of life over an eight week

in-center training session.

Definition of Terms

Several terms were utilized in this study, which include:

Activities of Daily Living

Activities of daily living (ADL’s) include any basic

self-care tasks that one must do on a daily basis. These

include tasks such as eating, dressing, bathing, using a

restroom, and rising from a seated position, among others

(Segura-Ortí, Kouidi, & Lisón, 2009).

Dialysis

Dialysis is the process of separating smaller solute

molecules from larger ones in a solution by means of

diffusion through a selectively permeable membrane, used to

37


filter the blood of metabolic wastes, urea, and excessive

ions (Craig & King, 2006).

End Stage Renal Disease

The fifth stage of chronic kidney disease (CKD), end

stage renal disease is the loss of kidney function, usually

requiring dialysis (Johansen, 2005).

Fistula

The National Kidney Foundation (NKF) defines a fistula

as a dialysis access port that is made by joining an artery

to a vein under the skin in order to make a bigger blood

vessel (Smart & Titus, 2011).

Frailty

Brown and Johansson (2010) defined frailty as a

syndrome involving the decline of multiple systems, where

physiological instability leaves the individual at risk for

loss of, or further deterioration in, function when exposed

to perceived minor stressors, such as cold weather. It

encompasses 3 of the following 5 features: weight loss

(unintentional weight loss of at least 5% of the previous

year’s body weight), weakness (determined by grip

strength), slow walking speed, low physical activity and

self-reported exhaustion.

38


Functional Ability

Painter (2005) defined physical functioning and

functional ability as a multi-factorial approach

encompassing many individual factors that comprise an

individuals’ ability to perform activities of daily living

independently.

Quality of Life

The term quality of life (QOL) is a multi-dimensional

approach that references the general well-being of

individuals. The term is used in a wide range of contexts,

including the fields of development and healthcare (Felce &

Perry, 1995).

Resistance Training

Resistance training is defined as a method of exercise

designed to enhance musculoskeletal strength, power, and

local muscular endurance. Resistance training encompasses

a wide range of training modalities including, weight

machines, free weights, medicine balls, elastic cords or

bands, and body weight. Resistance training will be

operationally defined as the strength enhancing modality of

performing exercises using free weights for the upper body

and ankle weights for the lower body (Bulckaen et al.,

2011).

39


Strength

Strength is a measurement of external force production

by a human subject in a specific exercise, such as knee

extension or hand grip, and may be performed either

statically or dynamically, the latter in either concentric

or eccentric mode, at a specified angular velocity (Chen et

al., 2010). Dynamometry will be operationally defined as

the isometric measurement of muscle strength using manual

muscle testing (MMT) with a hand-held device (Martin et

al., 2006).

Delimitations

The current study was delimited by the following factors.

1. Only subjects who were medically cleared and signed

a consent form were included in the study.

2. Only subjects who were diagnosed with chronic

kidney disease and were currently on dialysis were included

in the study.

3. Subjects involved in this study were from the

Western Massachusetts area.

4. Only subjects with no significant musculoskeletal

injury or limitation which restricted the ability to

perform the required exercises were included in this study.

40


Limitations

Certain limitations should be taken into consideration when

interpreting the results of this research.

1. No attempt was made to control for any other pre-

existing conditions or comorbidities so as not to leave out

a patient population that had the most potential for

benefit derivation.

2. The results of the investigation were limited to

the accuracy of the instrument used during testing.

3. The effort from the subjects could not be

controlled during training and testing sessions.

Hypotheses

The following hypotheses were tested within the context of

this research investigation:

1. No significant mean difference in mean strength,

functional scores, and quality of life scores would exist

between baseline and post-training.

2. No significant mean difference in mean strength,

functional scores, and quality of life scores would exist

between the training group and the control group.

3. No significant group by time interaction would

exist for strength, functional scores, or quality of life

scores in the ESRD subjects.

41


Appendix B

REVIEW OF LITERATURE

The number of patients with end-stage renal disease,

(ESRD) treated with dialysis and transplantation in the

United States, has risen by over 57% over the last fifteen

years (Chen et al., 2010). This has resulted in increased

healthcare financial expenditure that averages around $28

billion annually (Chen et al., 2010). Patients with ESRD

are increasingly sedentary and have low functional

abilities compared with healthy individuals of the same age

(Headley et al., 2002). Frailty is characterized by poor

physical performance, weakness, exhaustion and fatigue, low

physical activity, and poor nutrition. This, in turn, is

also associated with a higher risk of hospitalization and

death for dialysis patients in particular (Chen et al.,

2010). ESRD patients are also at higher risk for

cardiovascular disease and other serious comorbidities due

to their poor overall health state (Howden, Fassett, Isbel,

& Coombes, 2012). Despite various medical advancements,

patients continue to be limited physically, which then

results in negative impacts on health, quality of life,

activities of daily living, and morbidity and mortality

outcomes (Painter, 2005).

42





pressure, and improve inflammation (Chen et al., 2010).

The effects of resistance training can also increase

quality of life, nutrition, and independence for dialysis

patients (Chen et al., 2010). The primary focus of care

for dialysis patients is on disease management as opposed

to prevention. Despite the research that indicates vast



Most of the studies that have looked at the effect of

exercise on dialysis patients have focused on aerobic

training. VO2peak is often used as the primary measure

within these studies. Due to the fact that VO2peak is a

widely recognized physiological measure pertaining to

exercise capacity, it is considered to be a valid measure

of physical function and fitness. While several studies

have reported increases in VO2peak following aerobic training

in this patient population, the increases are somewhat

modest and it has not yet been fully established as to how

it actually improves the lives of patients with ESRD

(Johansen, 2005). Other studies have done a combination of

43


resistance and aerobic training, yet the primary emphasis

still tends to remain on the aerobic training portion.

Fewer studies have focused on resistance training

alone for this population. Muscle strength is a vital

determinant of physical function and independence in older

populations and those with chronic disease. As previously

stated, dialysis patients are weak compared to healthy

individuals. Weakness is a major limitation to physical

function and quality of life for patients with ESRD.

Muscle strength has been shown to be an important predictor

for gait speed and other factors of activities of daily

living (Johansen, 2005).

The majority of studies involving training ESRD

patients involve a protocol of exercise on non-dialysis

days. The theory behind this is that dialysis patients are

too tired and fatigued during dialysis to partake in

physical activity. Therefore, it is often thought that

they will be more energized and motivated to move on their

days off of dialysis. However, dialysis patients have been

reported to feel too weak and nervous to begin a program

due to complications with their fistula or musculoskeletal

injury, for instance (Johansen, 2005). Therefore, these

studies have had low compliance rates from the patients to

even begin a program.

44


Upon review of the literature on this topic, studies

which look at aerobic training on non-dialysis days seems

to be the most common type. Other studies have looked at a

combination of aerobic and resistance training. Even fewer

have looked at such variables as resistance training or

intra-dialytic training. The following studies discuss some

form of exercise training for dialysis patients and the

outcome variables that follow as a result.

Frailty

Since dialysis management has been changing over time

as a result of the age changes in the dialysis population,

there are many overlapping problems with gerontology and

nephrology care (Brown & Johansson, 2010). Frailty is

common in dialysis patients at any age, but especially so

for older dialysis patients. It is now considered to be a

more sensitive marker of morbidity and mortality than

chronological age alone (Brown & Johansson, 2010).

Integration of the geriatric concept of frailty into

dialysis care has major potential to improve identification

of high risk patients. Johansen, Chertow, Jin, and Kutner

(2007) used data from the U.S. Renal Data System (USRDS) to

determine the prevalence and predictors of frailty among

dialysis patients and to discover the degree to which

frailty was linked with death and hospitalizations.

45


Primary outcome variables included time to death, time to

first all-cause hospitalization or death, or time to first

non-vascular access-related hospitalization or death up to

one year after study enrollment (Johansen et al., 2007).

A total of 2,275 patients were included in an analytic

cohort who completed the patient questionnaire from the

Dialysis Morbidity and Mortality Study (DMMS). This was a

prospective study of 3,931 dialysis patients (approximately

equally distributed between hemodialysis and peritoneal

dialysis) who started therapy in 1996 or early 1997.

Questionnaires were distributed by dialysis unit personnel

and included demographic information, comorbid conditions,

quality of life (SF-36), nutritional status, pre-ESRD care,

and laboratory data. For frailty, a score of < 75 on the

PF scale of the SF-36 was used for a marker of weakness and

slowness while a score of <55 on the vitality scale of the

SF-36 was used to define poor endurance or exhaustion

(Johansen et al., 2007). About two thirds of the subject

population met the criteria for being frail (Johansen et

al., 2007). Age was found to be related to frailty, yet a

significant number of patients from younger age groups were

also found to be frail (including 44% of patients under 40

years of age and more than half of patients between the

ages of 40 and 50) and women were more likely to be frail

46


than men in all age groups (Johansen et al., 2007). In

addition, frailty was more common in patients with comorbid

conditions and patients on hemodialysis were more likely to

be frail than patients on peritoneal dialysis (Johansen et

al., 2007).

Following univariate analysis, the frail patients were

over three times as likely to die within one year, than

those who were not classified as frail. The frail patients

were also more likely to be hospitalized for any reason or

die when compared with those who were not considered to be

frail (Johansen et al., 2007). The results were not

significantly different when limited to patients who were

over the age of 65 years (Johansen et al., 2007). The

study showed that a very high proportion of ESRD patients

met the definition of frailty and that frailty was found to

be predictive of poor outcomes among this patient

population. However, there were some limitations from this

study which included no longitudinal evaluation, no blood

samples were obtained to explore links, and the particular

patient cohort was slightly younger and healthier than the

general ESRD population.

Lo, Chiu, and Sarbjit (2008) designed a prospective

cohort study to examine the links between elderly dialysis

patients and changes in functional status associated with

47


hospitalization. Since so many older dialysis patients

experience high levels of mortality and morbidity, frailty

and functional limitations commonly coincide with this

patient population. Acute hospitalization is a determinant

of functional disability in the general population and is

predictive of mortality and/or the need for long-term care

(Lo et al., 2008). Due to high rates of disability and

functional impairment in dialysis patients, the researchers

composed a pilot study to examine functional limitations at

the time of hospital admission and one week following

discharge in dialysis patients who were admitted to a

single acute care setting in a three month period.

All patients (n = 30) were 65 years of age or older

and completed both baseline and post-discharge assessments.

Baseline data was collected and included age, sex, cause of

end-stage renal disease, reason for admission, and living

circumstances prior to admission. Patients were assessed

within 24 hours of being admitted to the hospital and again

one week after discharge. Testing included the 4-item

Basic Activity of Daily Living (BADL) measure, the Lawton-

Brody Scale of Instrumental Activities of Daily Living

(IADL), the timed up-and-go (TUG) physical performance test

and grip strength, and cognitive function testing using the

Trails A & B tests and the clock test. Data were

48


summarized as mean +/- SD or median and quartiles when

appropriate and all analyses were performed using SPSS,

version 11.0 with 95% confidence intervals (Lo et al.,

2008).

The mean age of subjects who completed the testing was

73.8 +/- 5.9 years with the most common cause for renal

disease being diabetes (Lo et al., 2008). The main reason

for hospitalization varied and ranged from fluid overload

to stroke and diabetes complications. The median length of

time for the hospital stay was four days with a range from

1-29 days (Lo et al., 2008).

At the time of admission, 8 of the 30 subjects

reported being independent with BADLs which included

bathing, dressing, and walking, etc. while no patient

reported complete independence with IADLs which included

such things as driving, meal preparation and housework, and

finances. Both BADL and IADL scores were lower at

discharge in comparison with admission (BADL, 13.9 +/- 2.8

and 13.1 +/- 2.3, P = 0.001; IADL, 13.3 +/- 2.5 and 12.2

+/- 2.5, P = 0.0001) (Lo et al., 2008). A total of 22 out

of 30 patients reported a decline in either BADL or IADL

scores between hospital admission and one week after

discharge. Additionally, one week following discharge,

only three out of the eight patients who initially reported

49


independence with BADLs reported still being independent

(Lo et al., 2008). Patients exhibited a significant

decline in lower limb and upper limb muscle strength when

tested using the TUG and hand grip tests. The patients

reported increased difficulty with basic personal care and

experienced an average slowing in gait of 20% +/- 10.9% (Lo

et al., 2008). Cognitive function testing also showed

trends toward deterioration, but did not reach statistical

significance (Lo et al., 2008).

The results of this study postulate declines in

physical and mental function in the dialysis patients being

observed. The researchers summarized that elderly dialysis

patients are especially prone to functional decline, as is

even more evident at the time of hospitalization. The

biggest limitation of this study was the assessment of

function at the time of admission, as opposed to prior to

admission, because it may result in an underestimation of

the impact that hospitalization has on functional abilities

and independence. The researchers concluded that more

research should be performed and development of a

preventative and rehabilitative intervention for the

dialysis population is essential.

Falls are a major problem in older people, especially

older dialysis patients, and are a predictor of future

50


hospitalization, functional decline, and other health

risks. Cook et al. (2006) used a prospective cohort study

to determine the incidence of falls and proportion of

dialysis patients who fall during a one year period.

Patients over the age of 65 years and undergoing chronic

hemodialysis were used to document the resultant morbidity

and mortality of this patient population and to identify

fall risk factors for this group. A fall was defined by

researchers as an event that resulted in a patients’ coming

to rest inadvertently on the ground or other lower level.

In contrast, an injurious fall was defined as those that

caused minor (cuts or bruises) or major (fractures or

hospitalizations) injuries (Cook et al., 2006).

All consenting patients (n = 168) participated in a

full clinical evaluation. This evaluation included:

Assessment of depressive symptoms using the Mental Health

Inventory, a cognitive assessment using the Folstein Mini-

Mental Status Examination and clock drawing task,

assessment of falls which included recalling events from

the previous 12 months, fear of falling, and falls

efficacy, a vision assessment, hearing assessment, foot

abnormality assessment, and an assessment of orthostatic

blood pressure and heart rate. In addition, each patient

was also asked to perform the timed up-and-go (TUG) test in

51


order to evaluate functional mobility. The patients were

then visited by a research nurse every two weeks in order

to determine whether or not the patients had fallen.

Data were analyzed using descriptive statistics in the

form of mean +/- standard deviation. A total of 151 (93%)

dialysis patients attempted the TUG test. Of these, 75

patients were able to perform the test appropriately and 58

(77%) of those patients achieved a score that was

considered to be low risk for falls (< 15 s). Out of the

last 76 patients that could not complete the test, 43

required a cane, 12 required a walker, and 21 required

additional assistance with walking (Cook et al., 2006).

The patients were followed for a median of about 468 days

during which a total of 305 falls occurred among 76

patients over a period of 190.5 person years with a fall

incidence rate of 1.60 falls per person year and an average

of 2.78 falls per person. Out of the 76 patients who

experienced a fall, 45 (57%) had multiple falls of two or

more with a range of 2 to 48 (Cook et al., 2006).

Walking (indoors; n = 91, outdoors; n = 41) was found

to be the most common activity at the time of falls for

patients. Additionally, there was a high prevalence of

falls when patients stood from a seated position (n = 72)

and when rising from a supine position (n = 28). Falls

52


were found to occur with similar frequency on both dialysis

and non-dialysis days but on dialysis days, falls were more

common after dialysis (73%) than before (27%) dialysis

(Cook et al., 2006). Most of the injuries from falls were

minor (136, or 81%, of 305) while 12 of the falls (7%)

resulted in patients loss of consciousness from head

injuries and eight of the falls (4%) resulted in fractures.

A total of 26 (16%) patients were hospitalized from the

fall and six patients (4%) died within seven days of their

fall as a direct result of injuries sustained from the fall

(Cook et al., 2006). As for factors that are predictive of

falls, male gender, history of falls, a low average pre-

dialysis systolic blood pressure, and higher comorbidity

were found to be statistically significant fall risk

factors. Age was found to increase the odds for

experiencing more falls yet was not statistically

significant. Vision, number of medications, and cognitive

impairment were not considered to be predictive of falls

(Cook, et al., 2006).

This study showed that dialysis patients are generally

more frail and susceptible to falls. Recognition and

implementation of fall prevention programs for this patient

population could help to improve quality of life and

minimize morbidity and mortality rates in dialysis

53


patients. This study, however, was limited by certain

factors which include the fact that patients were recruited

from a single in-center dialysis setting which decreased

the generalizability of the results. Also, bi-weekly

patient interviews were used to assess falls which may

result in patient bias and recall issues.

Dialysis and Aerobic Training

Malagoni et al. (2008) examined the acute and long-

term effects of an exercise program performed at home for

dialysis patients. The researchers decided to look at the

effects of a walking program on physical capacity, post-

dialysis fatigue, and health-related quality of life. A

six month at-home walking program was chosen as the

exercise modality. A total of 31 dialysis patients (19 men

and 12 women) with ESRD were obtained for the study and

distributed into one of two groups which included an

exercise group (n = 17) and a control group (n = 14).

Participants had undergone hemodialysis three times per

week for a minimum of one year before taking part in the

study.

Outcome measures were analyzed at baseline and at the

end of the six month walking rehabilitation program.

Participants were tested on physical capacity using the 6-

minute walk test (6MWT) and on quality of life and post-

54


dialysis fatigue using the Medical Outcomes Study Short

Form Health Survey (SF-36). Maximal speed for the exercise

group was assessed using an incremental treadmill test

which began at 1.5 km/hour with progressive increments of

0.1 km/hour every 10 minutes until the patient could no

longer maintain that speed (Malagoni et al., 2008).

Sessions were performed twice daily for 10 minutes each at

a speed level to 50% of the individual patients’ maximal

speed on non-dialysis days. The intensity and duration of

the exercise sessions were progressively increased and/or

modified while the duration was kept constant. Daily

training records and any listed symptoms were obtained on

each follow-up visit. The control group was not prescribed

any exercise and no additional testing was performed past

baseline for this group.

T-tests and regression analyses were performed during

data analysis and a p value less than 0.05 was considered

statistically significant. A total of 20 patients (13 from

the exercise group and 7 from the control group) actually

completed the study. The exercise group averaged 45 +/- 36

hours of training time with an average walking speed of 2.4

+/- 0.5 km/hour (Malagoni et al., 2008). The 6MWT distance

significantly increased in the exercise group following

training and remained the same for the control group at the

55


end of the study. Significant improvements were observed

in the physical role, bodily pain, and mental health scores

of health related quality of life for the exercise group.

Physical functioning and mental health scores were

correlated with changes in the 6MWT distance. Decreases

were seen in post-dialysis fatigue scores as well as in

recovery time. For the control group, overall decreases

were seen in all of the subscales, especially general

health, and post-dialysis fatigue scores and recovery time

remained unchanged (Malagoni et al., 2008).

Surviving patients were re-evaluated approximately 19

months later. Patients from the exercise group reported a

continued active lifestyle with only four patients

reporting a reduction in physical activity due to physical

condition. The patients from the control group reported no

increase in their daily activity levels.

In summary, the researchers found that a low intensity

walking program prescribed at the hospital and performed at

home significantly increased physical capacity of dialysis

patients (Malagoni et al., 2008). Performance, post-

dialysis fatigue, and health related quality of life was

improved in the exercise group compared to the control

group. The intensity of the walking program allowed for

patients with low functional capabilities, who are normally

56


excluded from training studies, to take part in the study

and improve their health. As with any study, there were

some limitations which included the small sample size and

the fact that the groups were not randomized.

A study by Storer, Casaburi, Sawelson, and Kopple,

(2005) chose to examine the effects of endurance training

on muscle strength and physical function. The researchers

sought to test three different hypotheses. The first of

which included the effect of aerobic training having the

ability to counteract the results of anemia in dialysis

patients. Second, the researchers wanted to determine the

effects of endurance training in dialysis patients on

improvements in cardiopulmonary fitness, physical

performance, and muscle strength, power, and fatigability.

Lastly, the researchers examined endurance training and the

rapidity of the increases in the tolerated amount of work

during training (Storer et al., 2005).

A total of 12 participants (7 males, 5 females) who

were undergoing maintenance hemodialysis participated in

the exercise study. Two comparison groups were also

involved in the study, a group of 12 non-exercising

dialysis patients, and a group of 12 healthy, sedentary

volunteers. All were matched for age, gender,

race/ethnicity, and completed baseline studies of

57


cardiopulmonary fitness and muscle function. The exercise

group also completed physical performance tests and took

part in a 10 week (3 times per week) exercise program on a

cycle ergometer during hemodialysis. VO2peak was assessed

using an electrically braked cycle ergometer while the

subjects’ blood pressure and heart rhythm were monitored.

Muscle strength and fatigability were assessed using the

seated leg-press exercise machine. Measures of physical

performance included stair climbing, the timed up-and-go

test, and a timed distance course. For the exercise

training group, exercise was performed during the first 90

minutes of the dialysis session while heart rate, blood

pressure, and RPE were monitored every 10 minutes.

Interval training was used in order to increase the

patients’ exercise tolerance until they could perform 20

minutes at their specific work rate. At that point,

duration was then increased up to 40 minutes and work load

was increased from there.

Both VO2peak (22%, P < 0.001) and peak work rate

significantly increased in the exercise group following

training (Storer et al., 2005). These variables were both

lower than values of normal, healthy controls even after

training, however. Neither of these variables changed in

the non-exercise groups over the course of the study.

58


Maximal voluntary muscle strength and fatigability improved

significantly following training yet no significant changes

were seen in leg power. Stair climb performance (14% -

22%, P = 0.031), time to walk the walking course (19%, P =

0.003), and time to complete the timed-up-and-go test (12%,

P = 0.012) all improved significantly from baseline (Storer

et al., 2005).

Storer et al. (2005) determined that hemodialysis

patients can improve their exercise capacity. It was also

seen that work rate exercise improvements could be evident

after just eight to ten weeks of exercise training.

However, for more significant strength gains, it was

suggested that a future study focus more on resistance

training (Storer et al., 2005). A limitation of this study

included the young, fairly healthy subject population that

could not be generalized to the overall dialysis

population. The small sample size was another limitation

of this study.

Bulckaen et al. (2011) used a prospective, controlled,

non-randomized intervention study to examine the effects of

exercise training on physical performance of dialysis

patients. Since hemodialysis patients are generally quite

similar in regard to physical abilities and comorbidities,

the researchers stressed the importance of finding a safe

59


and effective implementation of exercise for this patient

population (Bulckaen et al., 2011). Therefore, the goal of

the study was to evaluate the effects of two different six

month training programs that were adapted to physical

ability on physical performance of hemodialysis patients.

Following a 12 month run-in control period, the

patients took part in two different exercise training

schedules for a six month time period. Testing and

evaluations were performed at baseline, at the end of the

control period, after three months of training, and again

after six months of training. A total of 18 patients (mean

age 62 +/- 15 years) who were on hemodialysis three times

per week completed the study protocol. Body weight and

blood samples were obtained from each patient and

evaluation tests included the 6-minute walk test and the

constant treadmill test (speed of 3 km/h, 10% grade). The

patients were also given a pedometer in order to assess any

extra or spontaneous physical activity. The patients took

part in low levels of coordination exercise during their

thrice weekly dialysis periods, as well as additional

training outside of the dialysis center based on their own

willingness. Nine patients (7 men, 2 women) took part in

an advised walking group which followed a specific home

design walking program monitored by a pedometer. The other

60


nine patients (6 men, 3 women) took part in a home design

program as well as a supervised walking group that occurred

two times per week in a gym on a treadmill and an arm

ergometer. The participants were instructed to walk until

they were limited by fatigue or dyspnea and were

recommended to progressively increase their activity

levels.

Upon completion of the exercise training program, both

groups exhibited significant and progressive improvement in

endurance performance on the treadmill test when compared

with baseline measures. However, the amount of meters

walked was significantly greater in the supervised walking

group than the advised walking group (Bulckaen et al.,

2011). Results of the 6MWT showed significant improvements

in the supervised walking group only, yet daily number of

steps only improved with the advised walking group by the

end of the training period (Bulckaen et al., 2011). The

researchers concluded that training programs may be

elicited for use of safely increasing physical performance

in dialysis patients. It was recommended that training

programs be continued for at least six months and that

home-based measures may be taken as an easy approach while

supervised programs can give additional benefits in certain

patients (Bulckaen et al., 2011). This study had certain

61


limitations however, which included the fact that the

groups were not randomly assigned. The groups were based

on willingness and ability, which could skew the results to

a select few healthy and motivated dialysis patients.

Another limitation included the small sample size and the

single-center design.

Petersen, Murray, McMahon, Kent, and McKenna (2009)

examined endurance training to determine the effects on

extra-renal potassium regulation and exercise performance

in dialysis patients. Potassium regulation was chosen

because dialysis patients often suffer from anemia which

impairs potassium regulation during exercise and affects

exercise performance (Petersen et al., 2009). Six dialysis

patients and six matched control patients were analyzed and

completed the study. Several tests were given at baseline,

pre-train, and post-train periods. These tests included an

aerobic power (VO2) test, a quadriceps strength test, a

quadriceps fatigue test, and blood sampling and processing.

The exercise training was performed on a stationary cycle

ergometer for 30 minutes during the first hour of the

patients’ dialysis treatment with a five minute warm-up and

a five minute cool-down. This was done three times per

week for a total of six weeks. The training intensity

began at a work rate equal to 50% of the patients’ pre-

62


train VO2peak and was then increased by 10% each week after

that.

Despite the treatment and administration of Epoetin

for anemia, the dialysis patients showed impairment in

extra-renal potassium regulation during exercise (Petersen

et al., 2009). Training was not found to significantly

improve acute potassium regulation in the dialysis

patients. The dialysis patients also had lower VO2peak

values and knee extensor peak torque when compared to the

control subjects, as can be expected. There were no

changes in these variables following training, however, the

researchers found that time to fatigue and total work

performed were both increased after training. No muscle

strength changes were seen following training and dialysis

patients demonstrated higher knee extensor fatigue than

controls.

The findings suggested that the dialysis patients had

poor exercise performance due to impaired extra-renal

potassium regulation. However, exercise performance

improved despite no changes in potassium regulation. This

study had several limitations which included the small

sample size and the fact that the subjects were relatively

healthy and cannot necessarily be generalized to the

dialysis population. Also, the study did not have a non-

63


training dialysis group with which to make comparisons.

Therefore, any exercise improvements potentially could have

been due to a familiarization effect.

Wilund et al. (2010) used intra-dialytic exercise

training to examine the effects on oxidative stress and

epicardial fat. Excessive oxidative stress that is often

accompanied by uremia is thought to play a role in chronic

inflammation of chronic kidney disease patients. This, in

turn, plays a significant role in atherosclerosis

development (Wilund et al., 2010). The purpose of the

study was to evaluate how effective aerobic exercise

training is on the risk factors of dialysis patients that

may lead to the extreme cardiovascular disease risk for

this population.

A total of 17 patients (9 females and 8 males) on

maintenance hemodialysis and between the ages of 30 and 70

years were recruited for the study. The subjects were

randomly assigned to either an intradialytic exercise

training group or a usual care control group. Patients in

the exercise group cycled three times per week during

dialysis on a cycle ergometer placed in front of the

dialysis chairs. Training began at an individualized time

and pace then progressed based on patient ability until

they were able to cycle continuously for a 45 minute period

64


at an RPE between 12 and 14 (0-20 scale). The control

group was not given any access to the cycle ergometers

during dialysis.

Baseline testing was performed in addition to testing

after the four month intervention period on non-dialysis

days. Physical performance was measured according to the

distance walked during an incremental shuttle walk test

(ISWT) over a 10 m course while paced by a series of beeps.

Blood chemistry was analyzed from blood samples obtained

from patients in a non-fasted state. Blood pressure and

cardiac function via echocardiography were also assessed

for this study.

Statistical analyses revealed that the groups did not

differ significantly at baseline (Wilund et al., 2010).

Serum lipid peroxidation was found to be reduced by 38% (p

< 0.05) following training in the exercise group and no

differences were seen for the control group. The distance

walked on the ISWT increased significantly in the exercise

group by 15% (P = 0.03) and remained unchanged in the

control group (Wilund et al., 2010). No significant

effects were seen with the exercise group and relative

heart wall thickness, or left atrial volume thickness.

However, epicardial fat thickness was significantly reduced

following training (-9.8%, P = 0.03) and remained the same

65


for the control group (Wilund et al., 2010). Also, the

change in ISWT performance was found to be inversely

correlated to the change in epicardial fat (r = -0.66, P =

0.01) (Wilund et al., 2010).

Wilund et al. (2010) concluded that four months of an

intradialytic exercise program improved physical

performance and reduced serum oxidative stress and

epicardial fat levels in dialysis patients. The data

suggested that exercise training may help to reduce CVD

risk (Wilund et al., 2010). However, the study was limited

by a relatively small sample size. This also meant that

the researchers could not control for many factors that

could have potentially impacted the study, such as

medications, diabetes, etc.

Some studies researched the effects of endurance

training on muscle atrophy. Kouidi et al. (1998) examined

the low exercise capacity of dialysis patients and the

structural and functional alterations in skeletal muscle

that affect this issue. Excess nitrogenous waste products

in the urine of ESRD patients cause uremic myopathy which

results in abnormal function and structure of the muscle

fibers (Kouidi et al. 1998). For that reason, the study

was designed in order to evaluate the muscle fiber profile

of the lower limbs of dialysis patients.

66


Seven patients (5 men and 2 women) with a mean age of

44 years were included in the study. Each patient was

diagnosed with ESRD and had been on maintenance dialysis

treatment for at least one year prior to the study (3 days

per week, 4 hours per session). No patient was known to

have a serious comorbidity and almost all of them had

complained of muscular weakness. Before starting the

program, each patient had a full medical examination as

well as a symptom limited treadmill exercise test using the

Bruce protocol. Blood pressure and electrocardiograms were

monitored continuously throughout and blood samples for

lactate concentration were collected. Peak oxygen

consumption was determined from the highest VO2 obtained

during the exercise test. Peak extension forces of the

lower limbs were measured using a dynamometer and muscle

biopsies were obtained from the vastus lateralis from the

left leg of each patient. The exercise training program

was comprised of 90 minute indoor sessions under

supervision. This was done three times per week for six

months and took place on non-dialysis days.

Exercise training was found to have a positive effect

on the recovery of atrophic muscle fibers in the dialysis

patients. Consequently, muscle strength and exercise

performance also increased following exercise training

67


(Kouidi et al., 1998). Size and strength of muscle fibers

and capillaries increased following exercise training when

compared to baseline measures. After six months of

training, the average cross-sectional area of muscle

improved by 29% with the type I fiber area increased by 26%

and the type II by 24%. Training also had an effect on the

fiber type proportion and shifted the ratios of fiber types

to more normal values. The researchers discovered a 51%

increase in type II fiber proportion and a 42% decrease in

type I fiber proportion, making it a more even distribution

(Kouidi et al., 1998). A restoration of mitochondria was

also observed from the biopsies post training. Overall,

the results demonstrated that exercise training caused

substantial improvements in restoring atrophic muscles in

dialysis patients.

Muscle Evaluation

As previously stated, chronic kidney disease (CKD) is

associated with muscle wasting and limited functional

capacity. Since the reason(s) for this have not been fully

recognized, in 2006 McIntyre et al. decided to look into

skeletal muscle mass and function in a cross-sectional

study of CKD patients. A total of 134 patients (60 on

hemodialysis, 28 on peritoneal dialysis, and 46 CKD stage 4

patients) were included in the study. A cross-sectional

68


area of muscle and fat were obtained from a biopsy of the

thigh from each patient. Functional assessments were

measured from the sit-to-stand 60 test and the sit-to-stand

5 test. These were done in order to determine the number

of sit-to-stands possible for the patients as well as the

time taken to perform the movement. The tests required the

patients to rise, with arms folded across the chest, from a

seated position out of a chair (about 46 cm) and returning

to the seated position. The time it took and the amount of

times completed were recorded. ANOVA was used for

comparisons between groups and univariate regression

analysis was used in order to assess the impact of

determinants on muscle mass. Linear regression analysis

was also performed to look at the relationship between

cross-sectional muscle area (CSA) and functional

performance (McIntyre et al., 2006).

Muscle mass was found to be about 9% lower in dialysis

patients than patients with stage 4 CKD. There were no

significant differences in muscle CSA between patients

receiving hemodialysis and peritoneal dialysis (McIntyre et

al., 2006). Muscle CSA showed a positive correlation with

the sit-to-stand 60 test and a negative correlation with

the sit-to-stand 5 test for overall physical function and

condition for all patients (p < 0.001). A significant

69


reduction in muscle CSA was found to be associated with

substantial reductions in functional capacity as well. The

stage 4 CKD patients exhibited severe uremia, yet

experienced less muscle wasting when compared to the

dialyzed patients. The researchers suggested that a

physiological rather than an anatomical approach to CSA

might improve functional performance correlations (McIntyre

et al., 2006).

Sakkas et al. (2003) developed a study to characterize

the degree of abnormality found in a non-locomotor muscle

of renal failure patients. This was done in hopes of

eliminating any potential effect from disuse atrophy. The

researchers hypothesized that the morphometric and

histochemical make-up of the muscle in renal failure

patients would be abnormal when compared with age-matched

controls without renal failure.

The renal failure patient group was comprised of 22

dialysis patients (12 women and 10 men) and the control

group included 20 (10 women and 10 men) participants.

Blood samples were taken in order to measure creatinine,

albumin, hemoglobin, and parathyroid hormone. A rectus

abdominal muscle biopsy was taken from each subject.

The patients with renal failure showed significantly

higher serum creatinine concentrations (t = 11.8, P < 0.01)

70


and lower albumin (t = -2.8, P < 0.01) and hemoglobin

concentrations (t = -9.4, P < 0.01) when compared with the

control group (Sakkas et al., 2003). Many patients tested

positive for malnourishment. Type IIa muscle fibers were

found to be 26% smaller in the renal failure group than the

control group. When compared with the control group,

muscle biopsies from the patient group showed three times

as many atrophied muscle fibers. The control group also

had greater capillary density per muscle fiber than the

patient group. The researchers concluded that uremia and

malnutrition are major factors in the role of muscle

atrophy in renal disease patients. It was suggested that

exercise training interventions for building muscle be used

to improve physical function and nutrition for renal

failure (Sakkas et al., 2003).

Looking further into skeletal muscle dysfunction, a

study by Lewis et al. (2012) evaluated the potential

morphometric and biochemical bases for muscle abnormalities

seen in dialysis patients. The researchers hypothesized

that limitations in muscle oxidative capacity and diffusion

reserves are at least partially responsible for the

reduction in muscle endurance capacity in this patient

population. In order to examine this, 60 dialysis patients

(37 males and 23 females) with an average time of 49 months

71


on dialysis were included. The dialysis was performed on

these patients three times per week with each session

lasting approximately four hours. The study also included

21 normal control subjects (16 males and 5 females) who

were matched in sedentary lifestyle behavior, age, gender,

and race/ethnicity (Lewis et al., 2012).

In order to assess baseline muscle structure and any

changes that occur following training, biopsies were taken

from the right vastus lateralis muscle. Assessment of

muscle fiber classification and capillarity and fiber

proportions (into types I, IIA, and IIX) was completed from

the biopsies. Fiber oxidative capacity was evaluated by

measuring the activity of succinate dehydrogenase (SDH),

which is one of the main mitochondrial enzymes in the Krebs

cycle (Lewis et al., 2012).

The results showed a significantly reduced oxidative

capacity in addition to lower capillary density in the

muscle fibers of the dialysis patients when compared to

control subjects. The researchers concluded that the

impaired muscle strength and endurance in dialysis patients

can be explained, in part, by the lower oxygen delivery

ability and capillarity within the major muscle fiber

types. The impairment results in lower energy production

which pairs with the reduced substrate levels and oxygen

72


delivery to reduce endurance and exercise tolerance (Lewis

et al., 2011).

Kemp et al. (2004) also examined muscle function in

hemodialysis patients, yet used a non-invasive, in vivo

technique to do so. The researchers used P-magnetic

resonance spectroscopy (P-MRS), magnetic resonance imaging

(MRI), and near-infrared spectroscopy (NIRS) to establish

relationships between expected mitochondrial metabolic

defects and muscle wasting in this patient population. The

study aims were to provide a definition of muscle metabolic

abnormalities, establish possible effects of reduced oxygen

supply, mitochondrial dysfunction, changes in contractile

efficiency, and to establish the effects of these factors

on muscle wasting (Kemp et al., 2004).

A total of 23 male hemodialysis patients (mean age of

50 years) were compared with 15 male control subjects (mean

age of 43 years). Muscle metabolism and oxygenation

kinetics were studied using MRI at rest followed by P-MRS

during an exercise-recovery protocol. Three to five

minutes of 0.5 Hz isometric plantarflexion was performed at

50% and 75% of maximum voluntary force (MVC) during muscle

evaluation and ended with a five minute recovery period.

The researchers defined the key measurement as the rate

constant of post-exercise NIRS recovery (equal to

73


0.693/half-time) which is reflective of the extent to which

oxygen supply exceeds demand in recovering muscle (Kemp et

al., 2004).

Differences were analyzed using unpaired t-tests and

all results were shown as means +/- standard deviation.

When examining the CSA of the posterior calf muscles, the

CSA of the dialysis patients was found to be significantly

smaller than the control subjects. When compared with

controls, patients’ tolerable exercise duration was

reduced. Phosphocreatine depletion as a result of exercise

was not significantly different between groups, yet

recovery was slower in patients. This was suggestive of a

mitochondrial ATP synthesis functional defect (Kemp et al.,

2004). Muscle wasting was evident in the patients and was

determined to be due to the mitochondrial defect. This

study was limited, however, in the fact that only male

subjects were examined and by the small sample size.

Combination Training

The previous study showcased the structural changes

that occur in the musculature of dialysis patients,

indicating the importance for studies to evaluate the

impact of exercise training in this population. Kopple et

al. (2007) examined the role that exercise in general plays

on transcriptional muscle changes. Certain growth factors,

74


specifically insulin-like growth factor (IGF) are thought

to stimulate or suppress protein synthesis or inhibit

protein degradation of muscle (Kopple et al., 2007). The

study was performed in order to examine the effects of

training on mRNA levels of the right vastus lateralis

muscle of dialysis patients.

A total of 51 dialysis patients completed baseline

testing, which included a muscle biopsy, and were then

randomized to one of four groups which included; endurance

training, strength training, endurance training and

strength training, and no training. This group was

compared against 20 normal control subjects. All

participants reported a sedentary lifestyle and no

comorbidities. The dialysis patients exercised for 21.5

+/- 0.7 weeks. Exercise training began with a 5-10 minute

warm-up and stretching period. Endurance training subjects

used a cycle ergometer and strength training subjects used

leg extension/leg curl and leg press/calf extension

combination machines. Resistance and/or repetitions, as

well as time spent exercising, were increased as tolerated.

Skeletal muscle IGF was significantly lower in the

dialysis patients than in the control subjects prior to

exercise training. These values rose significantly

following the training regimen for the exercise groups,

75


bringing the mRNA levels closer to normal (Kopple et al.,

2007). This study was limited by several factors. First,

each group was made up of small patient numbers. Second,

there were an uneven number of patients per group which

could have resulted in treatment bias. Third, all of the

muscle analyses were performed only on the right vastus

lateralis muscle, which may not be a reflection of growth

factor responses of other muscles. However, the

researchers believed that the results provide evidence for

an anabolic response from exercise in sedentary dialysis

patients (Kopple et al., 2007).

(Orcy, Dias, Seus, Barcellos, and Bohlke (2012)

compared the effects of a combined aerobic and resistance

exercise program with a resistance program alone on

functional performance of dialysis patients. The

researchers used a randomized control trial to examine the

effects since adequate physical function is a major

component of independence and quality of life (Orcy et al.,

2012). Participants were assessed for functional

performance prior to the training and again 10 weeks later,

at the end of the training period. Following random

assignment to the intervention groups, subjects exercised

for 30 minutes, three times per week, within the first two

hours of dialysis. Aerobic exercise was performed on a

76


mechanically braked cycle ergometer and resistance

exercises were performed with elastic bands, therapeutic

balls, dumbbells, and ankle weights (Orcy et al., 2012).

The outcome measure was the difference between the 6-

minute walk test (6-MWT) before the intervention period and

following 10 weeks of training. At baseline, the 6-MWT

results showed no significant differences between the

training groups (Orcy et al., 2012). The results from the

study showed no significant difference in the 6-MWT for the

resistance training group (-19.2 +/- 53.9 m). However,

there was a significant difference in distance covered on

the 6-MWT (39.7 +/- 61.4 m) for the combined training group

(Orcy et al., 2012). These results were limited by certain

factors. One such factor was the large refusal rate to

enter the study by potential participants, which made it

difficult to generalize the findings. Also, the evaluation

was based on a single test factor, which may not have

allowed for a true analysis of the various factors that

impact upon dialysis patients.

Segura-Orti et al. (2009) constructed a randomized

controlled trial to examine the effects of exercise during

hemodialysis on physical function and quality of life.

More specifically, the researchers looked at the effects of

intra-dialytic resistance training on patients’ exercise

77


capacity, physical function, muscle strength, and health

related quality of life. A 24 week resistance training

program was implemented for this study.

A total of 27 patients from two different dialysis

clinics were recruited for the study. These patients were

required to be in a stable medical condition and had been

on dialysis for at least three months prior to starting the

study. Before beginning the program, all patients were

clinically examined and underwent a graded exercise test on

a non-dialysis day to evaluate exercise capacity.

Dynamometry was performed in order to evaluate muscle

strength of the lower limbs in addition to functional

testing. An RPE score was given for each test and each

patient was given a health related quality of life survey

to complete. Patients were then randomly assigned into a

progressive resistance exercise group (Group A) or a low

level aerobic exercise training program (Group B; as an

attention control group). Since the primary goal of the

study was to examine resistance training effects, the

number of patients in the resistance training group was

double that of the aerobic training group. Following the

six months of training, each measurement was repeated.

Primary outcome measures included the sit-to-stand-to-sit

test (STS 10 and STS 60), the 6-minute walk test (6MWT),

78


and dynamometer measurements of the knee extensors.

Secondary outcomes included a treadmill graded exercise

test (Bruce protocol) and the Medical outcomes survey short

form (SF-36) (Segura-Orti et al., 2009).

Exercise training was performed during the first two

hours of hemodialysis three times per week over a period of

six months. Five minute warm-ups and cool downs were

performed by both groups and main exercise sessions

occurred for 25 minutes. Resistance training exercises

were composed of four progressive isotonic and isometric

resistance exercises that targeted the major muscle groups

of the lower extremities (Segura-Orti et al., 2009). The

exercises were progressed by increasing the resistance in

order for the patient to be able to perform 3 sets of 15

repetitions. The intensity of each exercise was set based

on an RPE level between 12 and 14 on a scale of 0 to 20.

The aerobic exercise for the second group was performed on

a stationary bicycle at a constant low workload (Segura-

Orti et al., 2009).

Between groups analysis was performed using a two-way

repeated measure ANOVA with mean and standard deviation

calculated for all variables. At baseline, Group A was

15.7% slower in STS 10 performance than Group B, yet this

was not statistically significant (Segura-Orti et al.,

79


2009). Also, the Group A performance on the 6MWT was 13.7%

less than that of Group B. No other significant

differences were evident. Following training, Group A

decreased the time to perform STS 10 by 22.3% (p < 0.05)

while Group B only decreased the performance time by 6.4%

(Segura-Orti et al., 2009). With respect to the STS 60,

Group A increased their repetition amount by 17.7% (p <

0.05) while Group B’s increase was 2.2%. Group A also

increased their 6MWT distance by 11.2% (p < 0.05) and Group

B increased by 8.9% (Segura-Orti et al., 2009). After

completion of training, Group A showed a substantial MET

improvement of 15.8% (p < 0.05) and Group B showed a 6.3%

increase. Dynamometry showed a 5.9% increase in leg

strength for Group A and an 8.1% decrease for Group B

(Segura-Orti et al., 2009). No significant differences in

health related quality of life were evident in either

group.

The intra-dialytic training program seemed to have an

effect on acting against the muscular atrophy associated

with hemodialysis patients yet failed to show a significant

effect on quality of life. The researchers determined that

increasing the workload for this patient population is safe

and future studies may want to add to this in order to test

additional benefits. To summarize, intra-dialytic

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resistance training was shown to be feasible and effective

in this case and resulted in significant improvements in

physical functioning for dialysis patients (Segura-Orti et

al., 2009).

Resistance training

Certain studies examined the effects of resistance

training alone on dialysis patients. Kuge, Suzuki, and

Isoyama (2005) used handgrip exercise training to examine

whether or not there is an effect on forearm vasodilator

response to arterial occlusion and to determine if there is

a relationship between muscle contraction function and the

vasodilator response in hemodialysis patients. A six week

study was performed with eight patients (6 males and 2

females) who had been on dialysis for at least 30 months

and had no cardiovascular disease or physical training

contraindications. Additionally, seven healthy volunteers

(3 males and 4 females) free from renal disease were

included as an age-matched control group (Kuge et al.,

2005).

Measurements of muscle strength and endurance were

obtained using a handgrip dynamometer on the hand without

arterio-venous shunt for hemodialysis. Forearm strength

was determined by having the subject grip the dynamometer

as strongly as possible. Muscle endurance was then

81


determined by the time period from muscle contraction

initiation to the time when strength declined to 60% of the

maximum value (Kuge et al., 2005). Tissue oxygenation and

hemodynamics were analyzed using near infrared-spectroscopy

(NIRS) which allowed for a non-invasive, continuous

measurement. Handgrip exercise training took place four

times per week for six weeks on non-dialysis days. During

the first week, 50 repetitive handgrip contractions were

performed at 60% of the patients’ maximal strength value

(measured previously). From there, contractions were

increased by 20 contractions a week, up to 150 contractions

and took 15 to 30 minutes to accomplish each set.

The maximum voluntary contraction for the patient

group (200 Newtons) was significantly lower than that of

the control subjects (378 Newtons). Following training,

the patient group value was increased to 226 Newtons (Kuge

et al., 2005). Muscle endurance for the patients (32

seconds) was also lower than the control subjects (48

seconds) at baseline, but improved to 43 seconds following

training (Kuge et al., 2005). Vasodilator responses in the

forearm (estimated from the changes in oxyhemoglobin and

oxygen saturation) were smaller in the dialysis patients in

comparison with the control group and did not change after

training.

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Kuge et al. (2005) discovered that training improved

maximal muscle strength (125% of initial value) and

endurance (163% of initial) in the dialysis patients (Kuge

et al., 2005). However, the six week program did not

improve the decreased vasodilator response to arterial

occlusion in the patient group. The results showed that

exercise capacity was increased due to the handgrip

exercise training produced by skeletal muscle improvements

but not by changes in blood perfusion for muscle

oxygenation in this patient population (Kuge et al., 2005).

Johansen et al. (2006) studied the effects of

resistance exercise training and the administration of an

anabolic steroid on body composition and muscle function of

hemodialysis patients. Anabolic steroid use was chosen as

an intervention due to its use to alleviate anemia

associated with ESRD, it has few adverse effects, and it

has been shown to increase lean body mass and improve

physical performance (Johansen et al., 2006). The

researchers designed a 12 week study where patients were

randomly assigned into one of four groups including;

nandrolone decanoate (a synthetic testosterone derivative)

injections, weekly placebo injections, lower extremity

resistance exercise training during dialysis sessions (3

times per week) plus weekly placebo injections, and

83


resistance exercise plus weekly nandrolone injections

(Johansen et al., 2006).

Nandrolone decanoate and an identical looking placebo

were injected weekly by the dialysis unit nursing staff,

who were blinded to the treatment assignments. The

resistance training of the lower extremities was performed

during dialysis three times per week with starting weights

determined according to a three-repetition maximum using

ankle weights. Knee extension, hip flexion and abduction,

ankle dorsiflexion and plantar flexion were performed at

each session (Johansen et al., 2006). Body composition was

assessed using dual energy x-ray absorptiometry (DEXA) and

muscle size was measured using magnetic resonance imaging

of the quadriceps muscle. Muscle strength was tested

during knee extension with a computerized dynamometer and

physical performance was assessed by having patients walk a

timed 20 foot distance, climbing stairs, and the sit-to-

stand 5 times test (Johansen et al., 2006). Patients were

given accelerometers for a one week period to measure

physical activity levels. The SF-36, Human Activity

Profile (HAP), and the Physical Functioning (PF)

questionnaires were given to the patients as a self-

reported measure of function. Baseline characteristics and

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any changes in outcome measures were compared using ANOVA

(Johansen et al., 2006).

A total of 68 patients completed the study with an age

range of 26 to 88 and an average age of 56 +/- 13 years.

Significant changes in body weight occurred in patients who

received the nandrolone decanoate (F = 20.64, P < 0.0001)

in that those patients gained weight yet decreased their

fat mass (Johansen et al., 2006). There was no significant

weight gain associated with exercise but was associated

with an increase in body fat mass for the exercise only

group. Quadriceps muscle cross-sectional area increased

significantly for patients who were assigned to the

exercise and nandrolone decanoate, yet decreased in

patients who were assigned to receive placebo injections

only (Johansen et al., 2006). Significant muscle strength

changes were seen in knee extension and hip flexion and

abduction for those who were assigned to resistance

exercise training. Neither nandrolone nor exercise was

associated with improvements in any of the physical

activity or performance measures. However, exercise was

found to be associated with improvements in self-reported

physical functioning on the SF-36 questionnaire (Johansen

et al., 2006).

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In summary, the researchers determined that both

nandrolone injections and resistance training during

dialysis have anabolic effects. However, the anabolic

effects of exercise were applied only to the trained

muscles while the anabolic effects of the nandrolone

injections were more systemic (Johansen et al., 2006).

This study was limited by certain factors, one of which

included the lack of dietary intake being monitored during

the study. Also, lean body mass, which was a primary

outcome measure within the study, is influenced by

hydration levels which are likely to change throughout the

12 week period. Further studies are necessary to determine

whether or not this type of intervention improves survival

rates for this patient population.

Similarly, a study by Cheema et al. (2007) used a

randomized, controlled trial of resistance training during

hemodialysis to examine the effects on progressive exercise

for anabolism in kidney disease, or PEAK study. The

purpose of the study was to determine whether a full body,

high intensity resistance training program during dialysis

could cause shifts in skeletal muscle quantity and quality

in patients. The researchers hypothesized that the

training regimen would increase skeletal muscle cross

sectional area (CSA) and decrease intra-muscular lipid

86


infiltration in addition to other health-related changes

(Cheema et al., 2007). It was speculated that the other

health related changes that would be affected were

improvements in exercise capacity, psychological health

aspects, inflammatory markers, nutrition, and quality of

life.

A total of 49 patients were randomly assigned

(computer generated) into either a progressive resistance

training (PRT) and usual care group or a usual care control

group. Patients assigned to the PRT group performed

exercise in a seated or supine position from a standard

hemodialysis chair with the limb that contained the

arteriovenous graft or fistula having been exercised

immediately before each dialysis session (Cheema et al.,

2007). During PRT, two sets of eight repetitions of ten

exercises were performed for the major target muscle groups

of both upper and lower extremities. A rating of perceived

exertion between 15 and 17 (out of 0 – 20) was the goal.

Upper body exercises were performed using free weight

dumbbells and included; the shoulder press, side shoulder

raise, triceps extension, biceps curl, and external

shoulder rotation. Lower body exercises were performed

unilaterally with weighted ankle cuffs and included; the

seated knee extension, supine hip flexion, supine hip

87


abduction, supine straight-legged raise, and seated

hamstring curls with resistance bands (Cheema et al.,

2010). The abdominal muscles were also targeted with leg

lifts, depending on patient ability. Patients within the

usual care group continued to receive their normal care as

well but were given no instructions to exercise or any

equipment access (Cheema et al., 2007).

Each outcome measure was obtained at baseline and

again following 12 weeks of training. Computerized

tomography of the non-dominant mid-thigh was done on a non-

dialysis day in order to evaluate thigh muscle CSA and

attenuation. The CT scans also analyzed areas of

subcutaneous and total fat for the thigh. Peak force of

the knee extensors, hip abductors, and triceps was measured

using an isometric digital dynamometer. The 6-minute walk

test was used to measure exercise capacity. A dietician

obtained all nutritional and anthropometric measures after

dialysis and the Mini-Nutritional Assessment was used to

evaluate nutritional status. Blood samples were collected

before dialysis, prior to the midweek session, and at least

48 hours after the previous exercise session to assess C-

reactive protein (CRP), albumin, creatinine, and blood

count. In addition, the Medical Outcomes Trust Short Form-

36, or SF-36, was used to measure health related quality of

88


life along with the Geriatric Depression Scale. The

Physical Activity Scale for the Elderly was given to the

patients in order to evaluate activity levels apart from

the exercise program of the study. All data were expressed

as mean +/- standard deviation and all data was included

regardless of patient compliance (Cheema et al., 2007).

No statistically significant differences were found

between groups at baseline. Thigh muscle CSA did not show

any significant change between groups by the end of the 12

week period. However, muscle quality improved

significantly in the PRT group when compared with the

control group (Cheema et al., 2007). As for secondary

outcome measures, statistically significant increases were

seen in total strength, body weight, body mass index, and

mid-arm circumference and mid-thigh circumference in the

PRT group compared to the control group. There were

reductions evident in the inflammatory marker CRP following

12 weeks of training. The PRT group also showed

significant improvements in two out of the eight areas for

quality of life, which included physical function and

vitality. In contrast, both of these measures showed

decline for the control group (Cheema et al., 2007). No

other secondary outcomes showed clinically significant

changes over the course of the study. Compliance to the

89


program was calculated at around 85.1% in the PRT subjects

who completed both assessments (Cheema et al., 2007).

This study had some limitations which included

obtaining patients from a single site, unblended assessment

of the secondary outcomes of physical performance measures,

and not giving the control group something else to do,

which is often not an ideal situation. However, the study

resulted in significant improvements in muscle quality,

strength, body weight, BMI, and physical function and

vitality measures. This training program did not seem to

result in increases of muscle CSA. However, the

researchers suggested that future studies may want to use a

similar program but also investigate muscle biopsies, since

they are more sensitive to change (Cheema et al., 2007).

Headley et al. (2002) designed a twelve week

resistance training program to test strength and functional

measures in ESRD patients. The researchers hypothesized

that moderate intensity training would improve muscle

strength in this patient population, which would then

increase the functional ability of the patients.

A total of ten dialysis patients completed the program

and were tested four times. The first two tests were

baseline tests, the third test occurred after six weeks of

training, and the fourth test followed 12 weeks of

90


training. Subjects were tested based on anthropometric

measures, the 6-minute walk test, computerized dynamometry,

grip test, gait speed tests, and the sit-to-stand-to-sit

test. Following a six week control period, participants

performed supervised resistance training twice per week for

12 weeks and were given exercise bands and a video to

follow on their own at home once per week. Average

attendance for the supervised training sessions was 87.7%

(Headley et al., 2002).

The results showed no significant body mass changes

over the course of the study. However, body fat percentage

increased after six weeks of training (20.0 % +/- 5.5%, P <

0.05) and 12 weeks of training (19.6% +/- 4.8%, P < 0.05)

when compared with baseline testing. As for strength, peak

torque of leg extensors at 90 degrees was greater after the

12 week training period, yet did not change at 120 degrees

or 150 degrees. Grip strength scores did not differ

following training in either arm following 12 weeks of

training either (Headley et al., 2002). Distance covered

during the 6MWT increased significantly following training

when compared with baseline testing. Maximum walking speed

during the gait speed test also increased significantly

after the 12 week training program. The time to complete

the sit-to-stand-to-sit test 10 times showed a significant

91


decrease after both the 6 and 12 test periods, despite the

fact that the time taken was still 36.8% slower when

compared to healthy individuals (Headley et al., 2002).

The training program resulted in a work volume

performance increase of 26% after the 12 weeks of training

in comparison with the first week. However, the

researchers conceded that an isotonic assessment would have

been more ideal for determining changes since the work

performed was isotonic itself. Also, the increased body

fat finding was difficult to explain, given the nature of

the strength improvements and the researchers suggested

that dietary intake should have been monitored during the

course of the study (Headley et al., 2002). Regardless,

the findings concluded that ESRD patients can indeed

benefit from a resistance training program and potentially

fight the wasting and deconditioning associated with the

disease.

Chen et al. (2010) developed a pilot study to

determine the safety and efficacy of a low intensity

progressive strength training in an intra-dialytic setting.

A randomized, controlled trial was used with patients over

30 years of age who were undergoing hemodialysis three

times per week and had no serious comorbidities. Physical

performance was the primary outcome measure with secondary

92


measures including knee extensor strength, lean and fat

mass, quality of life, and disability levels. A total of

44 participants were randomized into either an exercise

group or an attention-control group (Chen et al., 2010).

Exercise training was performed twice weekly for a

total of 48 exercise sessions that took place during the

second hour of hemodialysis. The sessions were supervised

and began with a five minute warm-up and ended with a five

minute cool-down period. Using ankle weights, the

participants in the exercise group performed exercises that

included; seated knee extension with dorsi/plantar flexion,

seated leg curl, leg raises, and pelvic tilt. Sessions

included two sets of eight repetitions for each exercise

with a 1-2 minute rest between sets. Intensity of exercise

was determined using a 0-10 RPE scale with a target RPE of

6 (somewhat hard). Exercise progressed as participants’

were able to complete their sets with a lower RPE score.

Attention control participants did stretching exercises

with light resistance bands performed in a semi-recumbent

position (Chen et al., 2010).

Physical performance scores were measured according to

the Short Physical Performance Battery (SPPB) score, which

includes performance based measures of strength, endurance,

and balance. Knee extensor strength was measured using a

93


Nicholas Manual Muscle Tester and body composition was

assessed using dual x-ray absorptiometry (DEXA). Quality

of life was assessed using a self-reported measure based on

the Medical Outcomes Survey Short Form (SF-36) and

disability was measured using 12 items from the Activities

of Daily Living (ADL) questionnaire. Comparisons between

the treatment and control groups were performed using

independent sample t-tests and Spearman’s rank coefficient

of correlation was used to assess associations between the

primary and secondary outcomes (Chen et al., 2010).

At baseline, 50% of participants scored low on the

SPPB and 77% reported difficulty with at least one ADL

(Chen et al., 2010). Following exercise training, SPPB

scores were significantly improved when compared with the

control group, yet balance and gait speed did not change in

either group. Knee extensor strength improved

significantly in the training group when compared with the

control group. Lean body mass increased significantly with

strength training and fat mass was reduced. When compared

with controls, the strength training group showed improved

self-reported physical activity, physical function, and ADL

disability scores (Chen et al., 2010). Overall, the

researchers determined that strength training resulted in

improvements in physical performance, nutritional status,

94


and physical activity of dialysis patients. The use of an

attention control group allowed for a more ethical approach

to the research. In contrast, only a healthy subset of

patients was used in this study, not allowing for

generalizability.

Bennett, Breugelmans, Chan, Calo, and Ockerby (2012)

recognized the significant risk of falling for older people

receiving hemodialysis. For that reason, a feasibility

study was constructed to test a reduction in falls risk in

this patient population after a strength and balance

intervention. A total of 24 participants were recruited

for the study with 18 out of the 24 (75%) aged 60 years or

older. Only subjects who suffered from end-stage kidney

disease, were at least 18 years of age, and who had been

receiving hemodialysis for at least three months were

included (Bennett et al., 2012).

The falls risk was measured using the five item Short

Form Physiological Profile Assessment (PPA). The specific

measures used for the study included; edge contrast

sensitivity, hand reaction time using a computer mouse or a

button press system, knee joint proprioception using a

joint matching test, lower limb (quadriceps) strength test,

and postural sway while standing on foam (Bennett et al.,

2012). The PPA was done immediately before and after the

95


eight week strength and balance exercise intervention. A

software program then calculated the overall falls risk

scores for each individual (standardized for age and

gender). Lower scores in proprioception, reaction time,

postural sway, and overall falls score indicated a lower

falls risk while higher scores in contrast sensitivity and

lower limb strength indicated lower falls risk (Bennett et

al., 2012).

The exercise intervention was made up of both

resistance and balance exercises. Strength exercises

included hip abduction, ankle plantar flexion and dorsi

flexion, straight leg raise, hip flexion, knee extension,

and knee flexion. Each was done in a seated position and

performed during dialysis. Exercises started out at a

resistance that participants were able to perform one set

of 10 repetitions for each and a moderate intensity (RPE of

15 to 17). Once participants were able to complete a set

of 20 repetitions of each exercise, the exercises were then

progressed. Participants were asked to stand and maintain

a position for 30 to 90 seconds for static balance. This

exercise was progressed by narrowing the support base,

decreasing hand support, challenging the support surface,

and/or closing their eyes. Dynamic balance was worked by

the participants walking on a 2.5 m line using heel/toe

96


walking, backward walking, and lateral walking (Bennett et

al., 2012).

A significant decrease in overall falls risk was

evident between pre and post-tests (z = -3.11, P < 0.008)

(Bennett et al., 2012). Of note, 14 participants (58%)

were classified into a lower falls risk category on the

post- intervention PPA when compared with the pre-

intervention PPA. Falls risk remained the same for eight

participants (33%) and two patients performed worse and

were classified into a higher risk category. Reaction time

decreased (improved) and knee extension force improved

following training (Bennett et al., 2012).

Overall, a significant decrease in falls risk was

evident in dialysis patients following an eight week

strength and balance program. Identifying high risk

patients and starting a strength and balance program has

many potential benefits for this patient population. This

study was limited by the small number of participants and

no comparison control group. Additionally, the PPA

measurement tool requires specific equipment, software, and

training (Bennett et al., 2012).

In conclusion, exercise training has been shown to

result in significant changes and improvements overall in

dialysis patients. The irony of most dialysis programs is

97


that they keep patients alive yet they do very little about

their declining physical function. It is important to

determine a safe and effective way of training to combat

the decline in function and quality of life. More

specifically, a program that strengthens patients in a

manner that promotes compliance and independence is

essential.

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Appendix C

INFORMED CONSENT FORM

CONSENT TO PARTICIPATE VOLUNTARILY

IN A RESEARCH INVESTIGATION

Department of Exercise Science and Sport Studies

XXXXXXXXXXX COLLEGE

XXXXXXXXXXX, XX XXXXX

________________________ _________________

Responsible Faculty Member Investigator’s Name

_______________________ _________________

Subject’s Name Date

PROJECT TITLE: Effects of an In-center Resistance Training

Program on Functional Measures, Strength, and Quality

Of Life in End Stage Renal Disease

You are being asked to participate in a research

investigation as described in this form below. All such

investigational projects carried out within this department

are governed by the regulations of both the Federal

Government and XXXXXXXXXXX College. These regulations

require that the investigator(s) obtain from you a signed

agreement (consent) to participate in this project.

The investigator will explain to you in detail the

purpose of the project, the procedures and/or drugs to be

used, and the potential benefits and foreseeable risks of

participation. You may ask the investigator any questions

you may have to help you understand the project and you may

expect to receive satisfactory answers to questions. A

basic explanation of the project is written below.

If, after this discussion, you decide to agree to

participate in the project, please sign this form on the

line indicated below in the presence of a witness and the

investigator.

I. The purpose of this research project is to

examine the effect that exercise performed early

in dialysis has on functional performance

measures (i.e. activities of daily living),

99


strength, and quality of life. Your participation

in this project may require completing three 45-

minute exercise bouts during three of your

dialysis procedures weekly. You will be randomly

assigned to either an exercise group or a usual

care control group. During the testing, medical

personnel will be in the facility and aware of

the testing. The exercise intensity used will

require you to perform resistance exercise at a

moderate to somewhat-hard intensity based on your

perception of the exercise. You were chosen for

the study because you are a hemodialysis patient

with arm access and your doctor agreed you could

tolerate exercise during dialysis. The

approximate number of subjects involved in this

process is 20. The study is expected to last for

eight weeks. The procedures to be used include

performing resistance training exercises of the

upper and lower extremities during your dialysis

treatments in the dialysis center.

II. Risks: Since you are a stable dialysis patient,

the risks from moderate exercise should be

minimal. Exercise studies during dialysis have

been carried out and found to be extremely safe.

However, exercise during dialysis does carry a

risk of triggering previously silent cardiac

disease and can result in shortness of breath and

muscle soreness. Testing will be carried out with

medical personnel present at the site and under

close supervision of the investigator. The person

performing all testing is AED certified. In

addition, should any unforeseen physical injury

occur, personnel trained in emergency care will

be present to provide assistance. XXXXXXXXXXX

College and the dialysis center do not have a

program for compensating patients for injury or

complications arising from research but medical

care will be made available as needed at usual

charges.

III. Benefits: Possible and desired benefits of

participating in this study are: If this study

does demonstrate that exercise can result in

significant improvements in functional measures,

strength, and quality of life, you might benefit

100


from increased strength, greater levels of

independence, more ease of performance of

activities of daily living (such as, using

stairs, bathing, getting dressed, using the

restroom, etc.), and feel better overall. Upon

completion of the study, you will be given a 3

month, free membership at the YMCA in XXXXXXXXXXX

or XXXXXXXXX. You will also be informed of any

new findings that could affect your treatment.

Being a participant in this research project will

not affect any of the ordinary charges associated

with the treatment of your condition.

IV. The information obtained about you will be kept

in confidence, although you are free to release

it to your own physician. The information may be

used for statistical or scientific purposes

without identifying you as an individual.

Any significant new findings will be provided to you during

the course of the study.

You are free to withdraw from this project at any time

without penalty or loss of benefits to which you would

otherwise be entitled.

Should an unforeseen physical injury occur, appropriate

first aid will be provided, but no financial compensation

will be given. Further information can be obtained from the

Office of Academic Affairs of XXXXXXXXXXX College

concerning pertinent questions about the research and an

explanation of your rights as a research subject. The

Office of Academic Affairs serves as the official contact

office in the event of research related injury to you (XXX-

XXX-XXXX).

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE

PROJECT. MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION

BY THE INVESTIGATOR. I WILLINGLY CONSENT TO PARTICIPATE.

______________________ ____________________________

Signature of Witness Signature of Subject or

Guardian

______________________ ____________________________

Date Signature of Investigator

101


Appendix D

MEDICAL HISTORY FORM

Project Title: Effects of an In-center Resistance

Training Program on Functional

Measures, Strength, and Quality Of Life

in End Stage Renal Disease

Investigator: Jennifer McKinnon (XXX) XXX-XXXX

Patient name: . Date: _________

This form should be completed and signed by the

physician of the patient who enrolls in this research. By

completing this form, the physicians are not assuming any

responsibility for the administration of the testing

sessions.

Contraindications to Exercise Testing / Participation

Please check all that apply:

_____ Poorly controlled hypertension with systolic blood

Pressure consistently above 160 mmHg and diastolic

blood pressure consistently above 100 mmHg.

_____ Uncompensated congestive heart failure.

_____ Cardiac arrhythmia requiring the use of an anti-

arrhythmic agent.

_____ Persistent hyperkalemia (high potassium levels).

_____ Recent history of unstable angina.

_____ Significant valvular heart disease.

_____ Myocardial infarction within the past 6 months.

_____ Significant cerebral or peripheral arteriosclerosis.

_____ Bone disease with a risk of fracture during exercise.

_____ Any orthopedic or musculoskeletal limitation or

injury within the last three months.

_____ A recent significant change in the resting ECG

suggesting infarction or other acute cardiac event.

_____ Third degree AV heart block without pacemaker.

_____ Severe aortic stenosis.

_____ Suspected or known dissecting aneurysm.

_____ Active or suspected myocarditis or pericarditis.

_____ Thrombophlebitis or intra-cardiac thrombi.

_____ Recent systemic or pulmonary embolus.

_____ Acute infections.

102


Report of Physician

Please check that which applies:

I know of no reason that the patient may not

participate.

I recommend that the patient not participate.

Physician’s Signature : _________________ _

Physician’s name in full : _________________ _

(Print)

103


Appendix E

DATA SHEET

Patient ID: _______________ Date:_______________

Group: _______________

Age: _______________

Gender: _______________

Ethnicity: _______________

Height: _____.___ X 2.54 = _____.___ 100 = _____.___

in cm m

Weight: ______.___ 2.2 = _______.___BMI: _______.__ kg/m2 lbs kg

BMI Classification:_________________________

Manual Muscle Test: Right Left

Biceps _____Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Shoulder _____Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Calf _____Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Quadriceps______Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Hamstrings_______Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Adductors ______Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Abductors ______Trial 1 _______Trial 2 _______Trial 1 _______Trial 2

Manual Muscle Test Classification (Use average of 2

trials):________________________

104


Appendix F

EXERCISE SHEET

Patient ID:

Date:

Exercise Sets

Repetitions

Band/Weight

RPE

Waiting

Room

Bicep Curls

Lateral Shoulder Raise

Anterior Shoulder Raise

Seated Row

Triceps Extension

Sit-To-Stands

Dialysis

Chair

Bent Leg Raise

Leg Extension

Calf Raise

Hip Adduction Squeeze

Hip Abduction

Chin Tuck

Scapular Retraction

Core

Notes/Comments:

105


Appendix G

SF-36

106


107


108


109


110


Appendix H

SPPB

Short Physical Performance Battery

1. Repeated Chair Stands

Instructions: Do you think it is safe for you to try and

stand up from a chair five times without using your arms?

Please stand up straight as quickly as you can five times,

without stopping in between. After standing up each time,

sit down and then stand up again. Keep your arms folded

across your chest. Please watch while I demonstrate. I’ll

be timing you with a stopwatch. Are you ready? Begin

Grading: Begin stop watch when subject begins to stand up.

Count aloud each time subject arises. Stop the stopwatch

when subject has straightened up completely for the fifth

time. Also stop if the subject uses arms, or after 1

minute, if subject has not completed rises, and if

concerned about the subject’s safety.. Record the number of

seconds and the presence of imbalance.. Then complete

ordinal scoring.

Time: _____sec (if five stands are completed)

Number of Stands Completed: 1 2 3 4 5

Chair Stand Ordinal Score: _____

111


0 = unable

1 = > 16.7 sec

2 = 16.6-13.7 sec

3 = 13.6-11.2 sec

4 = < 11.1 sec

2. Balance Testing

Begin with a semitandem stand (heel of one foot placed by

the big toe of the other foot). Individuals unable to hold

this position should try the side-by-side position. Those

able to stand in the semitandem position should be tested

in the full tandem position. Once you have completed time

measures, complete ordinal scoring.

a. Semitandem Stand

Instructions: Now I want you to try to stand with the side

of the heel of one foot touching the big toe of the other

foot for about 10 seconds. You may put either foot in

front, whichever is more comfortable for you. Please watch

while I demonstrate.

Grading: Stand next to the participant to help him or her

into semitandem position. Allow participant to hold onto

your arms to get balance. Begin timing when participant has

the feet in

112


position and lets go.

Circle one number

2. Held for 10 sec

1. Held for less than 10 sec; number of seconds held _____

0. Not attempted

b. Side-by-Side stand

Instructions: I want you to try to stand with your feet

together, side by side, for about 10 sec. Please watch

while I demonstrate. You may use your arms, bend your

knees, or move your body to maintain your balance, but try

not to move your feet. Try to hold this position until I

tell you to stop.


into the side-by-side position. Allow participant to hold

onto your arms to get balance. Begin timing when

participant has feet together and lets go.

Grading

2. Held of 10 sec

1. Held for less than 10 sec; number of seconds held_____

0. Not attempted

c. Tandem Stand

113


Instructions: Now I want you to try to stand with the heel

of one foot in front of and touching the toes of the other

foot for 10 sec. You may put either foot in front,

whichever is more comfortable for you. Please watch while I

demonstrate.


into the side-by-side position. Allow participant to hold

onto your arms to get balance. Begin timing when

participant has feet together and lets go.

Grading

2. Held of 10 sec

1. Held for less than 10 sec; number of seconds held_____

0. Not attempted

Balance Ordinal Score: _____

0 = side by side 0-9 sec or unable

1 = side by side 10, <10 sec semitandem

114


2 = semitandem 10 sec, tandem 0-2 sec

3 = semitandem 10 sec, tandem 3-9 sec

4 = tandem 10 sec

3. 8’ Walk (2.44 meters)

Instructions: This is our walking course. If you use a cane

or other walking aid when walking outside your home, please

use it for this test. I want you to walk at your usual pace

to the other end of this course (a distance of 8’). Walk

all the way past the other end of the tape before you stop.

I will walk with you. Are you ready?

Grading: Press the start button to start the stopwatch as

the participant begins walking. Measure the time take to

walk 8’. Then complete ordinal scoring.

Time: _____ sec

Gait Ordinal Score: _____

0 = could not do

1 = >5.7 sec (<0.43 m/sec)

2 = 4.1-6.5 sec (0.44-0.60 m/sec)

3 = 3.2-4.0 (0.61-0.77 m/sec)

4 = <3.1 sec (>0.78 m/sec)

Summary Ordinal Score: _____

Range: 0 (worst performance) to 12 (best performance).

115


Appendix I

INFORMATIONAL FLYER

Resistance Training Study for Dialysis Patients

Who can participate? Patients with CKD on dialysis who are

at least 18 years of age and who are not currently enrolled

in a regular (3 days per week for at least 6 months)

exercise training program. Patients must be cleared to

participate by their physician.

What does it involve? Patients will either be randomly

assigned to a normal care group (no exercise) or an

exercise group in which resistance training will be

performed 3 times per week for 8 weeks during their

dialysis sessions. Some exercises requiring both arms will

be performed in the waiting room prior to dialysis and the

remaining exercises will be performed in the dialysis

chair.

What do you get? Free testing will be done for both groups

to analyze quality of life, functional ability for

activities of daily living, and strength plus 8 weeks of

free personal training for the exercise group. Each

116


participant will receive a free 3 month membership at the

YMCA in XXXXXXXXXXX or XXXXXXXXX!

If interested contact Jen McKinnon at XXXXXXXXXXX College

XXX-XXX-XXXX, XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

mailto:[email protected]

117


Appendix J

YMCA MEMBERSHIP FORM

TO: YMCA of Greater XXXXXXXXXXX Membership

FROM: S. A. E. Headley, PhD, FACSM, CSCS, RCEP

Professor, Exercise Science & Sport Studies

Program Director, Clinical Exercise Physiology

XXXXXXXXXXX College

DATE:

_____________________________________ was a participant in

the In Center Resistance

Training Program conducted through XXXXXXXXXXX College. As

a reward for completing all

phases of the study, the YMCA has partnered with the

College to allow this patient to have a 3-

month free membership.

This letter serves as verification

of_________________________’s_ completion of the program.

If you need further verification of this please contact

XXXXXXXX XXXXXX at XXX-XXX-XXXX

S. A. E. Headley, PhD, FACSM, CSCS, RCEP

Professor, Exercise Science & Sport Studies

Program Director, Clinical Exercise Physiology

XXXXXXXXXXX XXXXXXX

XXXXXXXXXXX XX, XXXXX

118


Appendix K

STATISTICS TABLES

Table K4

2x2 Mixed Factorial ANOVA Comparing PCS Scores from the SF-

36 Between Baseline and 8-Weeks

___________________________________________________________

Source SS df MS F p η²

___________________________________________________________

Between Subjects

A(Group) 131.07 1 131.07 1.36 > .05 .15

Error between 771.13 8 96.39

Within Subjects

B(Time) 7.44 1 7.44 .35 > .05 .04

AB 2.88 1 2.88 .14 > .05 .02

Error within 167.50 8 20.94

___________________________________________________________

119


Table K5

2x2 Mixed Factorial ANOVA Comparing MCS Scores from the SF-

36 Between Baseline and 8-Weeks

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 798.85 1 798.85 3.81 < .05 .97


Within Subjects

B(Time) 8.19 1 8.19 0.12 > .05 .02

AB 29.77 1 29.77 0.43 > .05 .05


___________________________________________________________

120


Table K6

2x3 Mixed Factorial ANOVA Comparing SPPB Total Balance

Scores Over Three Time Periods for Treatment and Control

Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 5.63 1 5.63 2.11 > .05 .21


Within Subjects

B(Time) 1.87 2 .93 3.50 > .05 .30

AB 1.87 2 .93 3.50 > .05 .30

Error within 4.27 16 .27

___________________________________________________________

Mauchly’s Sphericity W = .984; p > .05

121


Table K7

2x3 Mixed Factorial ANOVA Comparing SPBB Gait Speed Test


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) .47 1 .47 1.46 > .05 .17

Error between 2.27 7 .32

Within Subjects

B(Time) .08 2 .04 .53 > .05 .07

AB .23 2 .11 1.53 > .05 .18


___________________________________________________________


122


Table K8

2x3 Mixed Factorial ANOVA Comparing SPPB Chair Stand Scores

Over Three Time Periods for Treatment and Control Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 2.13 1 2.13 0.45 > .05 .05


Within Subjects

B(Time) 3.27 2 1.63 5.30 < .05 .40

AB .47 2 .23 0.76 > .05 .09


___________________________________________________________


123


Table K9

2x3 Mixed Factorial ANOVA Comparing SPPB Total Scores Over

Three Time Periods for Treatment and Control Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 13.33 1 13.33 .94 > .05 .11


Within Subjects

B(Time) 7.47 2 3.73 4.35 < .05 .35

AB 3.47 2 1.73 2.02 > .05 .20


___________________________________________________________


124


Table K10

2x3 Mixed Factorial ANOVA Comparing Right Biceps MMT Scores


___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 518.34 1 518.34 .62 > .05 .07


Within Subjects

B(Time) 357.86 1 357.86 4.98 > .05 .38

AB 183.62 1 183.62 2.55 > .05 .24


___________________________________________________________


125


Table K11

2x3 Mixed Factorial ANOVA Comparing Left Biceps MMT Scores


___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) .53 1 .53 .01 > .05 .00


Within Subjects

B(Time) 125.67 2 62.83 .48 > .05 .06

AB 183.87 2 91.93 .71 > .05 .08

Error within 2085.00 16 130.31

___________________________________________________________


126


Table K12

2x3 Mixed Factorial ANOVA Comparing Right Shoulder MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 11.04 1 11.04 .02 > .05 .00


Within Subjects

B(Time) 17.59 2 8.79 .43 > .05 .05

AB 20.67 2 10.33 .50 > .05 .06

Error within 328.90 16 20.56

___________________________________________________________


127


Table K13

2x3 Mixed Factorial ANOVA Comparing Left Shoulder MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 202.80 1 202.80 .38 > .05 .05


Within Subjects

B(Time) 18.73 2 9.36 .30 > .05 .04

AB 59.07 2 29.53 .95 > .05 .11

Error within 498.02 16 31.13

___________________________________________________________


128


Table K14

2x3 Mixed Factorial ANOVA Comparing Right Calf MMT Scores


___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 832.13 1 832.13 2.17 < .05 .91


Within Subjects

B(Time) 188.39 2 94.19 2.24 > .05 .22

AB 418.14 2 209.07 4.97 < .05 .38

Error within 672.46 16 42.03

___________________________________________________________


129


Table K15

2x3 Mixed Factorial ANOVA Comparing Left Calf MMT Scores


___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 273.01 1 273.01 79.15 < .05 .91


Within Subjects

B(Time) 249.17 2 124.59 1.72 > .05 .18

AB 608.01 2 304.00 4.19 < .05 .34

Error within 1159.82 16 72.49

___________________________________________________________


130


Table K16

2x3 Mixed Factorial ANOVA Comparing Right Quadriceps MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 62.21 1 62.21 .28 < .05 .96


Within Subjects

B(Time) 156.83 2 78.41 2.44 > .05 .23

AB 279.15 2 139.57 4.34 < .05 .35

Error within 514.27 16 34.12

___________________________________________________________


131


Table K17

2x3 Mixed Factorial ANOVA Comparing Left Quadriceps MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 14.28 1 14.28 .04 > .05 .01


Within Subjects

B(Time) 275.15 2 137.58 6.02 < .05 .43

AB 683.32 2 341.66 14.94 < .05 .65

Error within 365.90 16 22.87

___________________________________________________________


132


Table K18

2x3 Mixed Factorial ANOVA Comparing Right Hamstrings MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 92.58 1 92.58 .37 > .05 .04


Within Subjects

B(Time) 254.32 2 127.16 3.58 > .05 .31

AB 360.50 2 180.25 5.08 < .05 .39

Error within 568.12 16 35.51

___________________________________________________________


133


Table K19

2x3 Mixed Factorial ANOVA Comparing Left Hamstrings MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) .30 1 .30 .00 > .05 .00


Within Subjects

B(Time) 128.83 2 64.41 1.97 > .05 .20

AB 314.68 2 157.34 4.80 < .05 .38

Error within 524.40 16 32.78

___________________________________________________________


134


Table K20

2x3 Mixed Factorial ANOVA Comparing Right Adductor MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 5.13 1 5.13 .02 > .05 .00


Within Subjects

B(Time) 10.94 2 5.47 .17 > .05 .02

AB 174.99 2 87.49 2.70 > .05 .25

Error within 519.29 16 32.46

___________________________________________________________


135


Table K21

2x3 Mixed Factorial ANOVA Comparing Left Adductor MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 91.88 1 91.88 .34 < .05 .89


Within Subjects

B(Time) 66.51 2 33.25 .78 > .05 .09

AB 133.14 2 66.57 1.57 > .05 .16

Error within 679.64 16 42.48

___________________________________________________________


136


Table K22

2x3 Mixed Factorial ANOVA Comparing Right Abductor MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) .30 1 .30 .00 > .05 .00


Within Subjects

B(Time) 44.74 2 22.37 .45 > .05 .05

AB 182.35 2 91.17 1.84 > .05 .19

Error within 792.57 16 49.54

___________________________________________________________


137


Table K23

2x3 Mixed Factorial ANOVA Comparing Left Abductor MMT


Groups

___________________________________________________________


___________________________________________________________

Between Subjects

A(Group) 214.94 1 214.94 .59 > .05 .07


Within Subjects

B(Time) 124.00 2 62.00 1.48 > .05 .16

AB 152.40 2 76.20 1.82 > .05 .19

Error within 671.61 16 41.98

___________________________________________________________


138


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Thesis (1)

Documents

entire graduate school

quality of life

entire research process

lifelong example of

statistical knowledge

importance of hard work

data sheet

end stage renal diseaseeffects