6.6. Appendix F Implementing intradialytic exercise6.6. Appendix F

We suggest the following guidance for implementation of intradialytic exercise:

1. Exercise should be supervised for greatest compliance and efficacy by an appropriately trained individual (e.g., physiotherapist, sport scientist, cardiac rehabilitation specialist, or an assistant physiotherapist/dietitian/nurse with additional training from one of the former groups).
2. Exercise should be completed between 30 min and two hours of the dialysis procedure.
3. Exercise should be completed during all dialysis sessions (unless contraindicated).
4. Exercise should include both aerobic (e.g., intradialytic cycling) and resistance (e.g., TheraBands and/or lifting of ankle weights) components of the lower or upper body, dependent on access site.
5. Exercise should be preceded by warm up activities (e.g., exercising for a minimum of five minutes, gradually increasing intensity until one half of the prescribed training intensity is obtained).
6. Exercise should be completed for at least 30 minutes per haemodialysis session.
7. Exercise should be completed at moderate to vigorous intensity, ranging from 40 75% of VO₂ reserve or heart rate reserve (if a graded exercise test is completed). When a graded exercise test cannot be completed, and for muscle conditioning exercises, a rating of perceived exertion on the Borg CR100 scale of “moderate” (20) to “strong heavy (50)” or on the Borg RPE scale of 12 to 15 can be used with caution as a method to prescribe exercise intensity.
8. Volume of exercise should be progressed gradually by adjusting duration, frequency, and/or intensity until the desired exercise goal (maintenance) is attained.
9. Exercise should be followed by cool down activities (e.g., exercising for a minimum of five minutes, starting at one half of prescribed training intensity, and gradually decreasing intensity until exercise is stopped).
10. Once patients are established exercising during dialysis, they should be encouraged to complete additional exercise on non dialysis days.
11. To enhance adoption and adherence in novice exercisers, moderate intensity activity should be prescribed.
12. To maintain exercise behavior, behavioral strategies such as social support, goal setting, and motivational interviewing should be implemented.

We suggest the following patient exclusion criteria/contraindications to exercise during haemodialysis:

1. Less than three months after initiation of haemodialysis.
2. Any uncontrolled medical condition including (but not limited to) infection or fever; recent (within 8 weeks) myocardial infarction or undiagnosed chest pain.
3. Patient in class D (unstable condition) as per American Heart Association/American College of Sports Medicine Joint Position Statement: 1) unstable ischemia; 2) heart failure that is not compensated; 3) uncontrolled arrhythmias; 4) severe and symptomatic aortic stenosis; 5) hypertrophic cardiomyopathy or cardiomyopathy from recent myocarditis; 6) severe pulmonary hypertension; or 7) other conditions that could be aggravated by exercise (for example, resting systolic blood pressure >200 mm Hg or resting diastolic blood pressure >110 mm Hg; active or suspected myocarditis or pericarditis; suspected or known dissecting aneurysm; thrombophlebitis and recent systemic or pulmonary embolus).
4. Symptomatic hyper or hypotension.
5. Signs and symptoms of deep vein thrombosis.
6. Excessive inter dialytic weight gain that severely impacts upon indices of fluid retention, e.g., blood pressure greater than 160/100; heart rate above 100 bpm; breathlessness at rest; or signs of substantial peripheral oedema.
7. If diabetic, blood glucose above 16.7 mmol/L (300 mg/dL) AND patient is in ketosis (fruity breath, rapid breathing or shortness of breath, excessive thirst, frequent urination, stomach pain, nausea, vomiting, fatigue or confusion), is dehydrated, or is feeling unwell.
8. In individuals taking insulin and/or insulin secretagogues, if hypoglycemia below 5.5 mmol/L (100 mg/dL) is observed, and glucose containing dialysate fails to elevate blood glucose sufficiently, advise the patient to eat or drink approximately 15g carbohydrate and re assess blood glucose concentration after 20 minutes. Repeat until blood glucose exceeds 5.5 mmol/L.

We suggest the following safety monitoring:

1. Prior to exercise, ask the patient how they feel, record resting blood pressure and heart rate, and if diabetic, record blood glucose concentration.
2. During exercise, monitor signs and ask the patient to report symptoms of pain, excessive fatigue, altered consciousness, overheating, cyanosis, anxiety, severe breathlessness, chest pain, dizziness/light headedness.
3. If hypertensive, regularly check blood pressure during exercise. If values exceed 220/105 mm Hg, reduce exercise intensity or cease exercising until blood pressure reduces.
4. Use a rating of perceived exertion scale (Borg CR100 or Borg RPE scales) and ensure exercise intensity does not provoke responses greater than 50/”strong heavy” on the Borg CR100 or 15/”hard (heavy)” on the Borg RPE scale.
5. Post exercise, monitor blood pressure and heart rate until resting values are approximately obtained, observe the patient for at least 20 minutes, and be aware of the possibility of hypotension during the remainder of the dialysis session.