REVISION 2

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EFFECTIVENESS OF INTRADIALYTIC LEG EXERCISE (ILE) ON FATIGUE AND

ACTIVITIES OF DAILY LIVING AMONG PATIENTS SUBJECTED TO
HEMODIALYSIS.

Subish Jose M.sc(N) ; Dr. Bamini Devi, Reader (MSN) Associate Professor (MSN), Faculty
of Nursing, SRU, Chennai , S; Dr. Eilean Victoria, Associate Professor (MSN), Faculty of
Nursing,SRU, Chennai

Abstract

Aim​: The article is based on the report of a study that identifies the effectiveness of intradialytic
leg exercise on level of fatigue and activities of daily living(ADL) among hemodialysis patients.

Background​: Hemodialysis is a physically stressful procedure and most of the patient will have
fatigue and thereby a deterioration in the regular activities. Providing exercises during the
procedure may increase the waste removal and thereby reducing fatigue.

Design:​ Pretest posttest control group design.

Methods: All patients who conformed to the inclusion criteria were randomized by day
randomization that is intermittent days starting from Monday for study group and from Tuesday
for control group. 20 samples were allotted to the study group and 20 for the control group
respectively. Pretest was conducted for both the groups and intradialytic leg exercise was
instructed only to the study group along with routine care. Posttest was conducted on 22​nd day of
hemodialysis. Both descriptive and inferential statistics were calculated. Modified levins energy
conservation model was used in the study.

Results: The study group patients had a significant change in the level of fatigue and ADL when
compared to that of the control group patients. There has been an effectiveness in the ILE on
hemodialysis patients.

Conclusion: Healthcare professionals like nurses and dialysis technician can implement this
intradialytic leg exercises for hemodialysis patients to render a good quality care. The energy
conservation model can be appropriate for nursing care of fatigued patients in primary nursing
care setting.

Keywords: effectiveness, intradialytic leg exercise, fatigue, activities of daily living,

hemodialysis.
Introduction

Chronic kidney disease is a considered to be a threat to health and particularly for the developing
countries, because of therapy’s cost and its chronic nature. More than 1 million people are living
with the help of dialysis. In the year 2000 in USA, about 30 million people suffered from CKD
and by 2010 more than 6,00,000 patients needed renal replacement therapy, costing about 28
billion dollars. (S.C Dash 2006). In India about 90% of the patients couldn’t afford the cost at
present, there is no comparable registry or national surveillance system to detect the earlier
stages of CKD, before dialysis or transplantation. CKD had greater prevalence in women than in
men, regardless of age. Brown et al, found that the prevalence was high both in men and women,
comparatively women had much more prevalence than that of men. Generally higher prevalence
of CKD was seen in women for various age groups among different ethnic groups than that of
men. 6 more studies were conducted in Asian cities like Thailand, China, Singapore and Japan in
comparable age groups. Considering the estimation of GFR, it has been found that CKD was in
very high prevalence among Chinese (20.4%) and Japanese population (28.8%).

Exactly the prevalence of CKD in India is not clear because of the uneven quality of the
data provided by some observation related studies. Only 3 population related studies have been
known presently which showed the intensity of CKD in India. A community level program in
Chennai prevalence was 0.86%. At Delhi 4972 urban patients were involved in a study, the
prevalence was identified to be 0.79 %. A study in Bhopal found that the average crude rate and
age related rates of CKD were found to be 151 and 232/ million population respectively

Materials and methodology

In hemodialysis, the blood from the patients body is been drawn out and filtered
externally using a dialysis machine, in the beginning stages patients will not have fatigue or any
such complications but as the time passes and the number of dialysis increases there is an
increased risk of muscle wasting and increased fatigue level this may directly interfere in the
daily activities of the person. Parson et al, (2004) suggested that the efficacy of dialysis was
improved with exercise by increased perfusion of skeletal muscles. It was recommended that
exercise during dialysis be done in a seated position to maintain a normotensive state during
fluid removal with dialysis and to ensure that venous and arterial pressures are maintained
constant in fistula lines.

Cleary and Drennan (2005) measured the quality of living in patients receiving
hemodialysis and compared their quality of life with that of the general population in Ireland.
Patients who received hemodialysis had limitations in a number of areas like vitality, physical
activities and physical role limitations and assumed a significantly lower physical functioning
when compared with that of general population. Considering the significance the investigator felt
a strong need to undertake a study on the effectiveness of intradialytic leg exercise (ILE) on
level of fatigue and activities of daily living among patients subjected to hemodialysis.

The researcher’s aim was to determine the effectiveness of intradialytic leg exercise on
fatigue and ADL among patients subjected to hemodialysis. The research design selected for the
study was randomized controlled trial, two group pretest posttest design. Both men and women
who satisfied the inclusion and exclusion criteria and undergoing regular hemodialysis for more
than two times a week. A total of 40 samples were selected which was divided in to study group
(n=20) and control group (n=20) using day randomization technique. Data collection started
from June 16​th 2012 and lasted till July 16​th 2012. All patients who conformed to the inclusion
criteria randomized by day randomization that is intermittent days starting from Monday for
study group and from Tuesday for control group. 20 samples were allotted to the study group and
20 for the control group respectively. All samples were selected according to day randomization
technique, accordingly 20 were allotted to the study group and 20 to control group. Pretest was
conducted for both the groups and intradialytic leg exercise was instructed only to the study
group along with routine care. Posttest was conducted on 22​nd​ day of hemodialysis.

Multidimensional Assessment of Fatigue (MAF) scale

Both the study and control group patients were provided with MAF scale for the
assessment of fatigue during pretest and after the intervention it is scored by converting the item
15 to a 10 point scale by multiplying the score by 2.5 and then adding up items 1, 2, 3 averaging
number of items 4-14, and adding up newly scored item 15. Scores range from 1 (no fatigue) to
50 (severe fatigue). Scores are not assigned to items 4-14 if the respondents select “no fatigue”
on item 1, then zero is the score assigned to items 2-16. (Basia Belza 1993).

KATZ Index of Independence

Patients are provided with the tool and it is scored as yes or no in finding the level of
independence in six areas of functioning. Scoring ranges from 6 which indicates complete
functioning, 4 indicates moderate impairment and 2 or less indicating severe functional
impairment (Mary Shelkey 2012).

Conceptual framework

Myra Estrin Levine’s Conservation Model is used in this study it focuses on maintaining
wholeness and promoting adaptation using the conservation principles. This model guides the
investigator on focusing the influences and responses at an organismic level. The investigator
validates the outcomes of the model conserving energy, structure, personal and social integrity
(Levine, 1967). This model has four variables such as (1) conservation of energy, conservation
of (2) structural, (3) personal and (4) social integrity. The conserving these variables will lead to
reducing fatigue and maintaining ADL.

Data Analysis
Data was analyzed by using both descriptive and inferential statistics. Descriptive
statistics includes Frequency distribution, percentage, mean and SD was used to describe the
baseline variables of the patients. Inferential statistics- paired and independent ‘t’ test and Chi
square was used to find out the association between the prevalence and the selected background
variables.

Ethical Consideration
Written permission was taken from the higher authorities and ethical research committee
of Sri Ramachandra University, Chennai. Written informed consent was taken from each
participants.
Results
When considering the effectiveness of Intradialytic Leg Exercise on fatigue. During
pretest 13(65%) of them had moderate level of fatigue and 7(35%) had severe fatigue and in the
posttest 7(35%) had mild fatigue about 10(50%) had moderate fatigue and 3(15%) had severe
level of fatigue in the study group. The pretest mean score of the study group was 2.35 and the
posttest mean score was 1.80. The calculated ‘t’ value was 4.819 which was statistically
significant at p<0.001 level. This showed that the study group patients had felt decreased level of
fatigue after practicing Intradialytic Leg Exercise. The level of fatigue within the control group
patients, the pretest mean was 2.25 whereas during the posttest the mean score was declined to
2.20. The calculated‘t’ value was 1.000 which had no statistical significance within the control
group; This showed that the control group patients did not experience any change in the level of
fatigue. Comparing the level of fatigue between the study group and the control group patients.
For the study group the pretest mean score was 2.35 and the posttest mean score was 1.80
whereas for the control group the pretest mean was 2.25 and posttest the mean score was 2.20.
During the posttest calculated ‘t’ value was -2.214 which was statistically significant at p<0.05
level. This implied that the study group patients experienced less fatigue than the control group
patients.
Comparison of ADL within the study group patients. The pretest mean was 2.25 and in
the posttest the mean score was 2.95. The calculated ‘t’ value was -6.658 which was statistically
significant at p<0.001. This showed that the study group patients improved their Activities of
Daily Living after practicing Intradialytic leg exercise. The comparison of activities of daily
living within the control group. The pretest mean value was 2.35 and the posttest mean was 2.70.
The calculated ‘t’ value was -3.199 which was statistically significant at p<0.01 level. The
comparison of ADL between the study and the control group patients. In the study group the
pretest mean score was 2.25±0.550 and the posttest mean score was 2.95±0.224 whereas, the
control group pretest mean score was 2.35±0.489 and posttest mean score was 2.70±0.470.
During posttest the calculated ‘t’ value was 2.147 which was statistically significant at p<0.001
level. This proved that the study group patients had better ADL when compared to the control
group patients.
While associating the background variables with the level of fatigue and ADL it showed
no statistically significant association between the variables.
ANALYSIS AND INTERPRETATION

Table 2. Frequency and percentage distribution of background variables among the study
and the control group patients (N = 40).
χ2

SL.No Demographic variables Study Control

group (n = group
df
20) (n = 20)

p value
No. % No. %

1 Age in years

a. 25-35yrs 05 25 03 15 2.307

3
b. 36-45yrs 07 35 05 25
0.511(​NS​)
c. 46-60yrs 08 40 11 55
2 Gender

a. Male 12 60 13 65 0.107

1
b. Female 08 40 07 35
0.744(​NS)
3 Education

a. Non formal 0 0 02 10

2.182
b. Primary 08 40 08 40
3
c. Higher secondary 06 30 05 25
0.536(​NS)
d. Collegiate 06 30 05 25
4 Occupation

a. Retired 01 05 02 10

1.583
b. Employed 06 30 03 15
3
c. Unemployed 07 35 09 45
0.663(​NS​)
d. Not working due to 06 30 06 30
illness

5 Monthly income

a. <10,000 13 65 14 70

1.037
b. 10,000-20,000 05 25 05 25

c. 21,000-30,000 01 05 0 0
0.792(​NS​)
d. >30,000 01 05 01 05
6 Residence

a. Urban 17 85 17 85 0.000

1
b. Rural 03 15 03 15
1.000​(NS)
7 Family type

a. Nuclear 19 95 20 100 1.026

1
b. Joint 01 5 0 0
0.311(​NS)
8 CKD since

a. 6 months 04 20 03 15

3.175
b. 6 months-1yr 05 25 09 45
3
c. 1-3yr 11 55 07 35
 0.365(​NS)
d. 3-5yr 0 0 01 05

e. >5yr 0 0 0 0

Table 3. Frequency and percentage distribution of clinical variables among the study and
the control group patients (N = 40)

Study Control χ2
group group(n
SL.No. Clinical variables (n=20) =20)

df
 p value

No. % No. %
1 Exercise performance at home

a. Regular 0 0 0 0

0.146
b. Irregular 4 20 5 25
2
c. Never performed 15 75 14 70
0.930(​NS)
d. Stopped due to illness 1 5 1 5
2 ​Haemoglobin level

a. Below 11gm% 11 55 15 75 1.949

2
b. 12-13gm% 8 40 4 20
0.377(​NS​)
c. Above 13gm% 1 5 1 5
3 ​Blood pressure

a. Below 100/70 mmHg 0 0 1 5 1.030

2
b. 110/70-130/90 mmHg 17 85 16 80
0.597(​NS​)
c. Above 140/100 mmHg 3 15 3 15
4 ​Serum creatinine

a. Below 0.6 mg/dl 0 0 0 0 4.468

2
b. 0.7-1.2 mg/dl 14 70 13 65
0.107(​NS​)
c. Above 1.3 mg/dl 6 30 7 35
Table 4. Frequency and percentage distribution of level of fatigue among the study and the
control group patients (N = 40).

Stu Co
dy ntr
gro ol
Duration
up​( gro
n= up​(
of study 20) n=
20)

Mild Seve Mil Sev

Mo Mod
re d ere
der erat
ate e

No. % No. % No. % No. % No. % No. %

Pretest
0 0 13 65 07 35 0 0 15 75 05 25

Posttest
07 35 10 50 03 15 0 0 16 80 04 20
Table 5. Comparison of fatigue level within the study group patients (n=20) and within control
group patients(n=20)

Pretest Posttest

Group
Paired p-value

(within) ‘t’-test

Mean SD Mean SD

Study group
2.35 0.489 1.80 0.696 4.819 0.000***

0.410
Control group
2.25 0.444 2.20 1.000 0.330(NS)
NS-Not Significant, *p<0.001

Table 7. Comparison of fatigue level between the study and the control group patients
(N = 40)
Fatigue
level

Duration ‘t’ test p value

(between) value

Study Control
group group
 (n = 20) (n = 20)

Mean SD Mean SD

Pretest 2.35 0.489 2.25 0.444 0.677 0.503(​NS)

Posttest 1.80 0.696 2.20 0.410 -2.214 0.033*

NS-Not Significant, *p<0.05

Table 8. Frequency and percentage distribution of ADL among the study and the control group
patients (N=40).

Stud Co
y ntr
grou ol
p​(n = gro
Duration 20) up​(
n=
of study 20)

Mo Mod
Depe der Inde Dep erate Ind
nden pend end ly epe
atel
t y ent ent nde
Depe nt
nden
dep t
end
ent
 No. % No. % No. % No. % No. % No. %

Pretest
1 5 13 65 6 30 0 0 13 65 7 35

Posttest
0 0 1 5 19 95 0 0 6 30 14 70

Table 9. Comparison of ADL within the study group patients (n=20) and control group
patients(n=20).

Pretest Posttest

Group
Paired p-value

(within) ‘t’-test

Mean SD Mean SD

2.25 0.55 2.95 0.224 -6.658 0.000***

Study group

2.35 0.489 2.70 0.470 -3.199 0.005**

Control group

**p<0.01
 KATZ
Index of
Duration Independ ‘t’ test p value
ence
of the study value

Study Control
group group

(n = 20) (n = 20)

Mean SD Mean SD

Pretest 2.25 0.550 2.35 0.489 -0.607 0.547(NS)

Posttest 2.95 0.224 2.70 0.470 2.147 0.038*

Table 11. Comparison of activities of daily living (ADL) between the study and the control
group patients (N = 40)

NS-Not Significant, *p<0.05.

Conclusion
Exercises provided during hemodialysis do not cost patients extra time and will be
effective in decreasing the level of fatigue and increasing potential for performing their daily
activities. Providing these exercises with dialysis will improve the effectiveness of dialysis and
alleviates long term complications of the same.
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