luanacecconello@hotmail.com

karen_scopel@hotmail.com

márcio.s@unijui.edu.br

rkrug@unicruz.edu.br

prm.paulomoreira@gmail.com

elianew@unijui.edu.br

*Fisioterapeuta. Mestre em Atenção Integral a Saúde (UNICRUZ/UNIJUI)

Universidade Regional do Noroeste do Estado do Rio Grande do Sul (UNIJUÍ)

**Fisioterapeuta egressada da UNIJUÍ

***Fisioterapeuta. Doutor em Saúde da Criança (PUCRS)

Professor do Núcleo da Saúde da UNIJUÍ

+Educador Físico. Professor da UNICRUZ)

e do Programa de Mestrado Associado (UNICRUZ/UNIJUI)

em Atenção Integral a Saúde. Cruz Alta

++Médico Nefrologista. Professor da UNICRUZ)

e do Programa de Mestrado Associado (UNICRUZ/UNIJUI)

em Atenção Integral a Saúde. Cruz Alta

+++Fisioterapeuta. Doutora em Ciências Cardiovasculares

Professora do Núcleo da Saúde da UNIJUÍ

e do Programa de Mestrado em Atenção Integral a Saúde (UNICRUZ/UNIJUI)

Vice-Líder do Grupo Pesquisa em Estudos Epidemiológicos e Clínicos - GPPEC

(Brasil)

Reception: 05/29/2021 - Acceptance: 08/19/2022

1st Review: 07/24/2022 - 2nd Review: 08/12/2022

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Cecconello, L., Scopel, K.R.O., Strassburguer, M.J., Krug, R. de R., Moreira, P.R., & Winkelmann, E.R. (2022). Functional Capacity and Level Physical Activity in Patients with Chronic Kidney Disease on Hemodialysis. Lecturas: Educación Física y Deportes, 27(294), 33-46. https://doi.org/10.46642/efd.v27i294.3051

 

Abstract

    To minimize the problems resulting from chronic kidney disease, the practice of physical activities is indicated and consequently the improvement of physical capacity. Therefore, the aim of this study was to analyze the correlation between functional capacity and physical activity level in patients with chronic kidney disease undergoing hemodialysis. This cross-sectional study was conducted with 24 individuals at hemodialysis clinic in the northwestern portion of the state of Rio Grande do Sul/Brazil. The outcome variables were distance traveled on the six-minute walk test (6MWT) and physical activity level determined by the average number of steps per day measured using a pedometer (objective measure) as well as the International Physical Activity Questionnaire (IPAQ) (subjective measure). It was shown that the distance travelled on the 6MWT was not correlated with the average number of steps per day or results of the IPAQ. In contrast, a moderate correlation was found between the two physical activity measures (pedometer and IPAQ). The patients were classified as insufficiently active and also had low functional capacity, with a mean of 53.93% of the predicted distance on the 6MWT. It is concluded that no significant correlation was found between functional capacity measured using the 6MWT and physical activity level measured using a pedometer and the IPAQ. A moderate correlation was found between the pedometer and IPAQ. The patients were insufficiently active and achieved low percentages of the predicted distance on the 6MWT.

    Keywords: Renal dialysis. Physical activity. Health assessment.

 

Resumo

    Para minimizar os problemas decorrentes da doença renal crônica é indicada a prática de atividades físicas e consequentemente a melhora da capacidade física. Sendo assim, o objetivo deste estudo foi analisar a correlação entre a capacidade funcional medida e o nível de atividade física em pacientes com doença renal crônica em hemodiálise. Este estudo transversal foi realizado com 24 indivíduos de uma clínica de hemodiálise da região noroeste do estado do Rio Grande do Sul/Brasil. As variáveis de desfecho foram a distância percorrida no teste de caminhada em seis minutos (TC6) e o nível de atividade física determinado pela média do número de passos por dia medidos com pedômetro (medida objetiva) e Questionário Internacional de Atividade Física (IPAQ) (medida subjetiva). Evidenciou-se que a distância percorrida no TC6 não se correlacionou com o número médio de passos por dia ou resultados do IPAQ. Em contrapartida, foi encontrada uma correlação moderada entre as duas medidas de atividade física (pedômetro e IPAQ). Os pacientes foram classificados como insuficientemente ativos e com baixa capacidade funcional, com média de 53,93% da distância percorrida no TC6. Conclui-se que não foi encontrada correlação significativa entre a capacidade funcional medida pelo TC6 e o nível de atividade física medido pelo pedômetro e o IPAQ. Foi encontrada correlação moderada entre o pedômetro e o IPAQ. Os pacientes foram insuficientemente ativos e atingiram baixas porcentagens da distância percorrida no TC6.

    Unitermos: Diálise renal. Atividade física. Avaliação da saúde.

 

Resumen

    Para minimizar los problemas derivados de la enfermedad renal crónica, está indicada la práctica de actividad física y así, mejorar la capacidad física. Por lo tanto, el objetivo de este estudio fue analizar la correlación entre la capacidad funcional medida y el nivel de actividad física en pacientes con enfermedad renal crónica en hemodiálisis. Este estudio transversal fue realizado con 24 individuos de una clínica de hemodiálisis en la región noroeste del estado de Rio Grande do Sul/Brasil. Las variables de resultado fueron la distancia recorrida en la prueba de caminata de seis minutos (6MWT) y el nivel de actividad física determinado por el número promedio de pasos por día medido con un podómetro (medida objetiva) y el Cuestionario Internacional de Actividad Física (IPAQ) (medida subjetiva). Se evidenció que la distancia recorrida en la 6MWT no se correlacionó con el promedio de pasos por día ni con los resultados del IPAQ. En cambio, se encontró una correlación moderada entre las dos medidas de actividad física (podómetro e IPAQ). Los pacientes fueron clasificados como insuficientemente activos y con baja capacidad funcional, con una media del 53,93% de la distancia recorrida en la 6MWT. Se concluye que no se encontró correlación significativa entre la capacidad funcional medida por el 6MWT y el nivel de actividad física medido por el podómetro y el IPAQ. Se encontró una correlación moderada entre el podómetro y el IPAQ. Los pacientes fueron insuficientemente activos y lograron porcentajes bajos de la distancia recorrida en el 6MWT.

    Palabras clave: Diálisis renal. Actividad física. Evaluación de la salud.

 

Lecturas: Educación Física y Deportes, Vol. 27, Núm. 294, Nov. (2022)

---

 

Introduction 

 

    Chronic kidney disease (CKD) has a multifactor etiology and the number of new cases throughout the world has been increasing (Sesso, Lopes, Thomé, Lugon, & Martins, 2017; Neves, Sesso, Thomé, Lugon, & Nascimento, 2020). This is a disease with a prolonged, insidious, progressive course, the evolution of which is often asymptomatic. (Siviero, Machado, & Cherchiglia, 2014; Wuttke, Yong, & Pattaro, 2019)

 

    Patients with CKD undergoing hemodialysis have insufficient levels of physical activity (Cecconello, Winkelmann, Morais, Krug, & Moreira, 2019; Fukushima, Costa, & Souza, 2018; Fassbinder et al., 2015; Silveira et al., 2021). Besides being a potential cause of kidney disease (secondary to the main risk factors), a sedentary lifestyle accelerates the course of the disease and exacerbates its systemic repercussions, contributing to a reduction in functioning, a poorer quality of life, and mortality. (Howden, Coombes, & Isbel, 2015; Nascimento, & Santos, 2022)

 

    Despite prolonging the patient’s life, hemodialysis is associated with an increased risk of systemic complications, especially in the musculoskeletal system, with repercussions for all physical and functional aspects (Moreira, 2018). In contrast, regular physical activity is associated with better health outcomes in individuals with CKD and constitutes an effective part of care for these individuals. (Heiwe, & Jacobson, 2014; Pu et al., 2019; Andrade et al., 2022)

 

    The practice of physical activity is a protection factor capable of attenuating changes caused by the disease and its treatment and can assist diminishing the rate of progression of the disease and even maintaining kidney function (Brazil, 2017). However, the scarcity of counseling in this regard for the population undergoing dialysis can contribute to the occurrence of sedentarism and functional loss. (Araújo Filho, Amorim, Brito, Oliveira, Lemos, & Marinho, 2016; Barros, Pinheiro, Lucinda, Rezende, Segura-Ortí, & Reboredo, 2021)

 

    The Brazilian Dialysis Consensus does not provide data on levels of physical activity and functioning among individuals with CKD. Such information is important, as insufficient levels of these aspects are associated with a reduction in quality of life as well as an increase in morbidity and mortality rates. (Pintora, & Roshanravan, 2013)

 

    In the physical and functional assessment of kidney patients, objective measures provide results that are less variable compared to those obtained using self-reported measures (Dowd et al., 2018). Moreover, studies that correlate different measures and instruments can ensure a better evaluation of these patients. Therefore, the aim of the present study was to analyze the correlation between functional capacity evaluated by the distance travelled on the six-minute walk test (6MWT) and physical activity level evaluated using the average number of steps per day measured using a pedometer (objective measure) and the administration of the International Physical Activity Questionnaire (IPAQ) in patients with chronic kidney disease undergoing hemodialysis. A secondary aim was to analyze the correlation between the results of the pedometer and IPAQ in this population.

 

Methods 

 

Study design 

 

    An analytical, cross-sectional study was conducted at a hemodialysis clinic in the northwestern portion of the state of Rio Grande do Sul, Brazil. This study received approval from the institutional review board of Universidade Regional do Noroeste do Estado do Rio Grande do Sul (UNIJUÍ) and was conducted following the guidelines stipulated in Resolution 466/2012 of the Brazilian National Board of Health with regards to research involving human subjects (certificate number: 3.012.096; process number: 90954218.6.0000.5350).

 

Participants 

 

    The sample was composed of individuals with CKD undergoing hemodialysis. Recruitment was performed at the hemodialysis center between November 2018 and February 2019. All patients were invited to participate in the study (Figure 1). The inclusion criteria were age 18 years or older, undergoing hemodialysis for CKD for more than three months, belonging to hemodialysis services of the established centers, agreement to participate through the signing of a statement of informed consent, not having acute kidney disease, absence of comprehension difficulties, completely answering and performing the proposed evaluation instruments, and a stable clinical condition.

 

 

Data collection and procedures 

 

    A specific questionnaire was created for the study addressing personal data for the purposes of identification as well as sociodemographic, clinical, and lifestyle characteristics. Clinical and electronic charts were also used to determine the profile of the sample.

 

    The outcome variables were the assessment of functional capacity measured by the distance travelled on the 6MWT and level of physical activity, which was determined using the IPAQ (subjective measure) and average number of steps per day measured using a pedometer (objective measure).

 

    The 6MWT was performed before the hemodialysis session to assess submaximal functional capacity measured by the distance travelled in six minutes. The test was performed as described by Britto, & Sousa (2006).

 

    The IPAQ was used to estimate the level of physical activity and classify the individuals as sedentary, irregularly active, active, or very active (Matsudo et al., 2001; Mazo, & Benedetti, 2010). The questionnaire was administered by previously trained researchers during the hemodialysis session.

 

    The number of steps per day was quantified using a pedometer (Omron, model HJA-310), which is an objective measure of physical activity. The participants were instructed to use the pedometer continuously attached near the waist above the hip during the entire day when performing their usual activities between one hemodialysis session and another. The participants received instructions regarding both use and restrictions (do not use in the shower or during activities that might wet or damage the equipment, continuous use during waking hours and disconnection during sleep). The pedometer was furnished during a hemodialysis session and collected at the subsequent session. Thus, the individuals used the equipment for two consecutive days, from which the average number of steps per day was calculated.

 

Statistical analysis 

 

    Descriptive statistics (mean, standard deviation, absolute frequency, and relative frequency) were used for the characterization of the participants. Pearson’s correlation coefficients were calculated to determine correlations between functional capacity (6MWT) and physical activity level (objective [pedometer] and self-reported [IPAQ] measures) as well as between the objective (pedometer) and self-reported (IPAQ) measures of physical activity, considering p≤0.05.

 

Results 

 

Characterization of sample 

 

    Twenty-four individuals completed all evaluations in the present study. Mean age was 59.25 ± 11.61 years. The most frequent cause of CKD was systemic arterial hypertension (41.7%) and mean time on hemodialysis was 36 ± 31.7 months. Table 1 displays the sociodemographic, clinical, and lifestyle characteristics of the participants.

 

Variables	n (%)
Sociodemographic
Sex Male / Female	22 (91.7) / 02 (8.3)
Marital status Married	13 (54.2)
Schooling Incomplete / complete primary school Incomplete / complete high school Higher education	12 (50) / 03 (12.5) 04 (16.7) / 02 (8.3) 03 (12.5)
Lives alone Yes / No	05 (20.8) / 19 (79.2)
Companion during sessions Yes / No or did not answer	06 (25.0) / 18 (75.0)
Hemodialysis funding Public healthcare system / Other	22 (91.7) / 02 (8.3)
Children Yes / No or did not answer	20 (83.3) / 04 (16.7)
Occupation Retired / Disability assistance Paid work / Leave Does not work / Did not answer	15 (62.5) / 03 (12.5) 02 (8.3) 04 (6.7)
Clinical
Etiology of CKD Hypertension Diabetes mellitus Hypertension + Diabetes mellitus Undetermined / Other / Did not answer	10 (41.7) 03 (12.5) 07 (29.2) 01 (4.2) / 01 (4.2) / 02 (8.3)
Pre-dialysis follow-up Yes / No	09 (37.5) / 15 (62.5)
Type of access for hemodialysis Arteriovenous fistula / Chronic catheter	17 (70.8) / 07 (29.2)
Kidney transplant Performed / On waiting list / No	03 (12.5) / 05 (20.8) / 16 (66.7)
Associated diseases Yes / No or did not know	07 (29.2) / 17 (70.8)
Lifestyle habits and risk factors
Sedentarism Yes / No Leisure activities Yes / No Stress/Anxiety/Depression Yes / No Smoking Yes / Ex-smoker Alcohol intake Yes / Ex-drinker Hypertension Yes / No Diabetes mellitus Yes / No	16 (66.7) / 08 (33.3) 03 (12.5) / 21 (87.5) 12 (50) / 12 (50) 01 (4.2) / 09 (37.5) 01 (4.2) / 07 (29.2) 21 (87.5) / 03 (12.5) 09 (37.5) / 15 (62.5)

CKD: Chronic kidney disease

 

    Table 2 displays the results of the analysis of physical activity level performed directly (pedometer) and indirectly (IPAQ). The participants were classified as insufficiently active according to the number of steps per day and irregularly active according to the IPAQ. The participants also demonstrated low functional capacity, achieving only 53.93 ± 24.60% of the predicted distance on the 6MWT.

 

Variables	Median (IQR)	Classification
Pedometer (steps/day)	2668.66 (755 – 6595.75)	Insufficiently active
IPAQ – general (minutes/week)	107.5 (25 – 375)	Irregularly active
Distance on 6MWT (meters)	309.5 (196.5 – 374.25)	53.93 ± 24.60 (% of predicted)

IPAQ: International Physical Activity Questionnaire; 6MWT: Six-Minute Walk Test; IQR: interquartile range

 

    Table 3 displays the correlation coefficients for the outcome variables. A significant (p = 0.007) moderate (r = 0.574) direct correlation was found between the two measures of physical activity (number of steps/day x IPAQ), demonstrating reliability between the tests. Individuals with a greater number of steps measured by the pedometer were those who reported a larger quantity of minutes per week practicing physical activities on the IPAQ. However, the level of physical activity identified by the pedometer or IPAQ was not sufficient for a significant direct correlation with functional capacity determined by the distance travelled on the 6MWT, meaning that it was not possible to relate the results of the tests of physical activity level (direct or indirect measure) with the evaluation of functional capacity measured using the six-minute walk test.

 

Variables	r	p-value
Distance on 6MWT x n° of steps/day#	0.357	0.112
Distance on 6MWT x IPAQ	0.386	0.062
N° of steps/day x IPAQ	0.574	0.007*

6MWT: Six-Minute Walk Test; IPAQ: International Physical Activity Questionnaire; 

#Mean n° of steps/day measured using pedometer; *statistically significant correlation (p£0.05).

 

Discussion 

 

    The present study is important, as it analyzed the correlation between physical activity level and functional capacity in patients with chronic kidney disease undergoing hemodialysis. The results showed that the participants were insufficiently active based on the number of steps per day and irregularly active based on the IPAQ and exhibited low functional capacity, achieving an average of 53.93 ± 24.60% of the predicted distance travelled on the 6MWT. A significant, moderate correlation was found between the tests of physical activity level (pedometer and IPAQ), but the physical activity level identified among the participants was insufficient to present a significant direct correlation with the distance travelled on the 6MWT.

 

    The significant moderate correlation between the number of steps per day and the results of the IPAQ shows that the pedometer is a viable tool for the physical assessment due to its ease of use and acceptance of the part of individuals with kidney disease. However, it was not correlated with one of the most widely used tests in clinical practice for patients with CKD: the 6MWT. This differs from findings described by Alves et al. (2013) who state that the capacity to walk a greater distance on the 6MWT can explain the average number of steps in daily living.

 

    The IPAQ is a subjective test and is therefore an indirect measure that can easily overestimate or underestimate the level of physical activity (Mafra, & Neto, 2019). The IPAQ does not have good sensitivity or specificity compared to more objective evaluations. Thus, whenever possible, studies should use measures with adequate psychometric properties, such as accelerators or pedometers, which offer greater precision, but have a higher cost (Mafra, & Neto, 2019; Falck, McDonald, Beets, Brazendale, & Liu-Ambrose, 2016; Nicaise, Crespo, & Marshall,, 2014). Nonetheless, the IPAQ is widely used in studies with a large sample, in which the aim is to outline the profile of a given group or population (Cleland, Ferguson, Ellis, & Hunter, 2018). In the present study, the questionnaire was administered to a small sample and was correlated with the number of steps per day measured by the pedometer, which is an objective, quantitative measure of physical activity.

 

    An important aspect of the present study was the correlation of assessment tools in patients with CKD, as studies generally correlate an evaluative instrument with clinical variables (Garcia et al., 2017; Torino et al., 2014). For instance, Garcia et al. (2017) correlated the 6MWT with clinical and profile data. Torino et al. (2014) report that the performance on the 6MWT is a predictor of the risk of mortality, cardiovascular events, and hospitalizations. Thus, better physical/functional performance is related to clinical data, which demonstrates the importance of evaluative studies with a multidisciplinary focus to strengthen the concept of holistic care among health teams at hemodialysis centers.

 

    Tsai et al. (2017) found that regular physical activity improves the physical and psychological domains of quality of life among patients with kidney disease and possibly also improves one’s clinical performance, even when practiced in a mild form, and it is associated with a reduction in the risk of adverse outcomes in dialysis. Despite such knowledge, low physical/functional levels are found in individuals with CKD. Thus, the health team should recognize the importance of better physical functioning, considering its effective contributions to organic, physical, and psychological components in this population as well as the reduction in the risk of mortality. (Morishita, Tsubaki, & Shirai, 2017)

 

    The tests administered in the present investigation revealed low physical/functional level in these patients with CKD. To be classified as “non-sedentary”, Tudor-Locke et al. (2011) report an average of 4600 steps per day for special populations, such as individuals with chronic diseases. The low physical activity level in this study is in agreement with that found by Gomes et al. (2015) who state that patients with CKD undergoing hemodialysis are 24% less active in comparison to a healthy group. Moreover, there is evidence of the negative influence of the duration of hemodialysis on functioning in these patients. (Barros, Fuzari, Medeiros, & Melo Marinho, 2019; Cunha, Andrade, Guedes, Meneghetti, Aguiar, & Cardoso, 2009)

 

    The present investigation demonstrates that a pedometer, which is used little as an evaluative tool at dialysis centers, is viable for the physical assessment of patients with CKD. This study also describes correlations between the pedometer and the 6MWT and IPAQ, which in uncommon in studies conducted with this population. A pedometer is easy to use and does not cause any changes in the daily routine of patients, which makes it a useful assessment tool. The IPAQ, despite not being correlated with functioning and being a subjective measure, is a valid tool that can be administered at any time without affecting the routine hemodialysis schedule. In contrast, the 6MWT, despite its broad and important application, requires adequate space and time, a trained evaluator, as well as specific care and orientation that must be prioritized when performing the test.

 

    The present study has limitations that should be considered: 1) Adherence of the patients was low, as only 53 of the 82 individuals who answered the IPAQ also used the pedometer and only 24 performed the 6MWT; 2) the small number of individuals in the final sample hinders the generalization of the results.

 

    It is necessary to improve health actions. Instruments that facilitate adherence and stimulate physical activity could contribute to the success of evaluations. Therefore, pedometers should be used in evaluation, intervention, and monitoring studies. Whenever possible, accelerometers should also be used, which provide greater precision. The present investigation serves as an incentive for further studies of this nature to be conducted with patients undergoing hemodialysis to enable greater knowledge on correlations between assessment methods, bearing in mind that such individuals have a low level of physical activity.

 

Conclusion 

 

    In the present study, no correlation was found between functional capacity evaluated using the 6MWT and physical activity level evaluated using a pedometer and the IPAQ. In contrast, a significant moderate correlation was found between the two physical activity measures (pedometer and IPAQ). The patients with CKD were found to be insufficiently active and had a poor performance on the 6MWT. Educational strategies are needed to increase and maintain higher levels of physical activity and, consequently, functioning.

 

Acknowledgments 

 

    The authors are grateful for funding provided by Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS [State of Rio Grande do Sul Research Assistance Foundation]), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq [National Council of Scientific and Technological Development]) and Universidade Regional do Noroeste do Estado do Rio Grande do Sul (UNIJUI [Regional University of Northwestern Rio Grande do Sul]) for awarding scientific initiation scholarships.

 

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Lecturas: Educación Física y Deportes, Vol. 27, Núm. 294, Nov. (2022)