Barriers to Physical Activity in Chronic Hemodialysis Patients: a preliminary report from an Italian multi-center study

Background

Patients with CKD are physically inactive, and regardless of age, have levels of physical functioning similar to (or lower than) to older adults [1]There is robust epidemiologic evidence that low physical function and physical inactivity are associated with poor clinical outcomes [2] [3] [4] (full text)). These associations are documented in earlier stages of CKD, in ESRD and renal transplantation.

Methods

Questionnaires administered were related to levels of mobility/autonomy and physical functioning, self-reported physical activity, quality of life, and perceived barriers to physical activity. In particular, the level of self-reported physical functioning/autonomy was evaluated by the Katz Independence in daily living questionnaire (ADL, Activities of Daily Living questionnaire), a self-reported test on mobility and performance based on 18 items describing different levels of autonomy in physical activity related to participation in 6 life activities. 

For patient-related barriers to physical activity the questionnaire from Delgado & Johansen was used [5] (full text), which includes questions related to different categories of disease- and patient-specific barriers to physical activity: psychological barriers, physical barriers, economical barriers, lack of time and comorbidities.

The level of physical activity was derived from the 94-item Human Activity Profile (HAP) [6], which
includes the assessment of activities across a wide range of energy requirements.

Results

Table 1 illustrates demographic and clinical characteristics of the 261 patients enrolled with complete data. Patients were divided in active and inactive according to the HAP questionnaire (Figure 1).

Table 1. Clinical and demographic characteristics

Variable

All patients, N=261

Inactive, N=172

Active, N=89

P

Age, years (SD)

67.1 (14.4)

70.5 (12.9)

60.1 (14.5)

<0.001

Males (%)

60.2

57.6

65.2

0.290

BMI, Kg/m2 (SD)

24.6 (5.0)

24.8 (4.8)

24.1 (5.58)

0.280

Active smoker, %

11.5

8.6

17.3

0.087

Secondary school or lower, %

75.3

85.8

56.4

<0.001

Bachelors degree or higher, %

24.7

14.2

43.6

<0.001

Dialysis vintage, months

median (1st-3rd quartile)

49 (24-101)

49 (26-101)

74.6 (74.3)

0.677

KT/V (SD)

1.3 (0.5)

1.3 (0.5)

1.4 (0.5)

0.365

Diabetes, %

25.3

32.0

12.4

<0.001

COPD, %

17.4

23.7

5.6

<0.001

Peripheral artery disease, %

31.8

36.7

22.5

0.029

Amputation, %

4.7

4.7

4.5

1.000

Coronay artery disease, %

24.8

28.4

18.0

0.091

Heart failure,  %

8.9

8.9

9.0

1.000

Charlson index (SD)

6.9 (2.4)

7.5 (2.3)

5.8 (2.3)

<0.001

Serum albumin,g/dL, n (DS)

3.9 (0.4)

3.9 (0.5)

3.9 (0.4)

0.621

Hemoglobin, g/dL (DS)

11.2 (1.2)

11.1 (1.3)

11.4 (1.2)

0.133

C reactive protein, mg/L  median (1st-3rd quartile)

2.0 (1.0-7.0)

3.0 (1.0-8.0)

2.0 (1.0-5.0)

0.233

Karnofski score (SD)

73.5 (20.1)

67.4 (17.3)

87.2 (18.3)

<0.001

Two hundred fourty-eight  participants (90.2%) reported at least one barrier to physical activity, 237 (86.2%) reported at least  two barriers, 31 (11.3%) reported at least three barriers, and 30 (10.9%) reported at least four barriers. Table 2 illustrates the prevalence of barriers reported in the entire cohort and stratified by level of activity.

Table 2. Reported barriers to physical activity

Barriers

All patients, (N=261)

%

Inactive (N=172)

%

Active, (N=89)

%

P

No place to exercise

21.0

24.4

14.6

0.094

No safe place to exercise

21.3

24.9

14.6

0.043

Don’t want to be seen

13.9

17.1

7.9

0.065

No exercise partner

24.4

27.8

18.0

0.111

Fatigue on dialysis days

65.0

70.2

55.1

0.022

Fatigue on non-dialysis days

34.0

38.8

24.7

0.033

Pain on dialysis days

39.6

48.0

23.6

<0.001

Pain on non-dialysis days

31.2

39.2

15.7

<0.001

Lack of time on dialysis days

45.1

43.2

48.9

0.463

Lack of time on non-dialysis days

24.4

27.2

19.1

0.197

Too many medical appointments

22.4

26.5

14.6

0.044

I’m not willing to

46.1

52.1

34.8

0.012

Feeling too old

29.8

36.1

18.0

0.004

Shortness of breath

38.0

45.0

24.7

0.002

Fear of getting hurt

39.5

45.6

28.1

0.009

Sadness

45.0

46.7

41.6

0.508

Feeling of helplessness

40.1

42.3

36.0

0.397

Inability to travel

37.1

45.3

21.4

<0.001

Too many medical problems

42.6

49.1

30.3

0.006

Family concern

15.9

16.6

14.6

0.818

Physician concern

5.8

7.7

2.3

0.134

Chest pain

17.1

23.1

5.6

0.001

Ulcers on legs and feet

8.1

9.5

5.6

0.403

Amputation

4.7

5.3

3.4

0.553

Table 3 illustrates the univariate analysis of the reported barriers.

Table 3. Univariate analysis of barriers to physical activity

Barrier

OR (95% CI)

P

No place to exercise

1.887 (0.951;3.746)

0.069

No safe place to exercise

1,734 (0.897;3.351)

0.101

Don’t want to be seen

2.409 (1.010;5.746)

0.047

No exercise partner

1.758 (0.929;3.324)

0.083

Fatigue on dialysis days

1.921 (1.130;3.266)

0.016

Fatigue on non-dialysis days

1.933 (1.091;3.424)

0.024

Pain on dialysis days

2.983 (1.681;5.296)

<0.001

Pain on non-dialysis days

3.451 (1.805;6.598)

<0.001

Lack of time on dialysis days

0.796 (0.475;1.335)

0.387

Lack of time on non-dialysis days

1.584 (0.845;2.967)

0.151

Too many medical appointments

2.105 (1.066;4.153)

0.032

I’m not willing to

2.033 (1.196;3.454)

0.009

Feeling too old

2.577 (1.379;4.817)

0.003

Shortness of breath

2.489 (1.409;4.397)

0.002

Fear of getting hurt

2.143 (1.233;3.723)

0.007

Sadness

1.234 (0.734;2.072)

0.428

Feeling of helplessness

1.304 (0.767;2.216)

0.327

Inability to travel

3.050 (1.691;5.504)

<0.001

Too many medical problems

2.216 (1.287;3.816)

0.004

Family concern

1.161 (0.568;2.372)

0.682

Physician concern

3.625 (0.799;16.436)

0.095

Chest pain

5.040 (1.909;13.303)

0.001

Ulcers on legs and feet

1.757 (0.622;4.965)

0.288

Amputation

1.612 (0.425;6.113)

0.482

At multivariable analysis, after adjusting for age, sex and comorbidity burden, the number of endorsed barriers (OR 1.095, 95% CI 1.029 to 1.165; P=0.004), pain on dialysis days (OR 2.585, 95% CI 1.295 to 5.158; P=0.007), and chest pain (OR 3.199, 95% CI 1.077 to 9.500; P=0.036) were independently associated with physical inactivity. 

Lack of time for exercise counseling and the firm belief about low compliance/interest by the patients toward exercise were the most frequent barriers reported by nephrologists (N=50) and nurses (N=94).

Conclusion

Chronic hemodialysis patients have a low physical activity level. Also, we identified a number of patient-related and health personnel-related barriers to physical activity in chronic hemodialysis patients. Solutions for these barriers should be addressed in future studies aimed at increasing the level of physical activity in this population.