A case study of a 67-year-old man with diabetes and end-stage renal disease on dialysis. The aim was to provide physical therapy intervention for patients undergoing dialysis. Major patient complaints included decreased loss of balance, fear of falling and decreased Endurance in activities of daily living due to the effects of dialysis treatment. Objective measures during the evaluation corroborate these complaints. The patient’s goal is to improve strength, aerobic endurance, balance and flexibility. Patient Education Emphasized in Every Treatment Meeting. The patient underwent physical therapy according to the plan of care, and the deficits identified during the examination improved. Patients who receive physical therapy during dialysis treatment may have more positive outcomes than those who choose not to participate.
- Male, 67; retired Greyhound bus driver
- ESRD on dialysis
- GRF (Glomerular Filtration Rate) – 13 mL/min
- Recommendations for starting a dialysis exercise program
- Obese – BMI: 32
- Type II DM
- Diabetic neuropathy
- Diabetes medication
- Hypertension medication
- Depression medication
Previous care or treatment:
- PT Balance disorders secondary to diabetic neuropathy; risk of falls
- The patient complained of impaired general weakness and decreased BLE sensation secondary to dialysis therapy 3 days a week. The patient was seriously ill and admitted to the hospital in April 2009, where he was diagnosed with renal failure. patient report In October 2014, his disease progressed to end-stage renal disease (ESRD). The patient has been on dialysis since ESRD diagnosis. Comorbidities included type 2 diabetic neuropathy HTN and depression. The patient also reported frequent UTIs since going on dialysis. patient He reportedly had difficulty getting up and down stairs and getting in and out of his car. The patient expressed his wish to be able to walk and go up and down stairs with less fatigue and less risk of falling. Patient also wants to be able to get in and out of his vehicle at greater speeds Relief to go to his dialysis treatment.
Self Report Outcome Measures
- SF-36: 30/100
Physical Performance Measures
- 6 minute walk test: 550 meters
- Berg Balance Scale: 40/56
- Timed Up and Go: 24 seconds
- Gait Speed: 0.86 m/s
- HR – 82 bpm
- BP – 124/80 mmHg
- RR – 18 breaths/min
- L4: 1+ B
- L5: 1+ B
- S1: 1+ B
- Light touch – peripheral neuropathy; bilateral LE reduction
- UE: WNL EXCEPT: R shoulder flexion and abduction R elbow flexion 50%
- LE: Decreased 25%
- Positive Thomas Test (B)
- Positive Ober’s Test (B)
- Positive 90/90 (B)
- 4-/5 (B) hip ext/abd/ER
- ⅘ (B) knee flexion and extension
- ⅘ (B) ankle dorsiflexion
- Diabetic Foot Screening: 2 Redness and Dryness – Indicates poor circulation leading to loss of protective sensation.
Our impression of the problem: 1) Patient has incurable end-stage renal disease, but is being treated with dialysis, resulting in secondary sexual dysfunction, including decreased stamina, decreased upper and lower extremity strength, and impaired balance and coordination Decreased sensation, diminished reflexes, and decreased flexibility. 2) The patient has the following risk factors that may hinder physical therapy intervention: advanced age, diabetes, hypertension, and chronic urinary tract infection. What physiotherapists need to know Complications during each treatment. 3) The patient’s LE weakness was reduced by a decreased sense of balance and a fear of falling, which may have contributed to his increased risk of falling.
Summarization of Examination Findings
The patient presented to skilled physical therapy complaining of impaired balance, loss of sensory BLE, and decreased endurance during ADL secondary to a dialysis regimen. Patient exhibits general LE weakness indicated by MMT dec AROM in RUE secondary to fistula insertion and sensation Grade 2 as indicated by diabetic neuropathy screening. PT Implement an aerobic exercise program using stationary bikes to improve endurance balance and gait training in home and community settings to address sensory and proprioceptive loss to reduce fall risk and LE intensity and flexibility programs to address deficiencies in improving mobility while performing functional tasks in a home environment.
Phases of Interventions
Phase I (Week 0-2)
Initiate aerobic program
- Warm up 5-10 minutes RPE “very light” (Borg scale 8-9)
- 15-minute RPE “Fairy Light” activity (Borg Scale Score 10-11)
- Relax for 5-10 minutes RPE “very light” (Borg scale score 8-9)
- Physical activity
- Foot care
- Manage water intake
- Fall risk assessment
- Caregiver education
- Dialysis support groups
- LE- 3 LE stretches
- UE- 3 UE stretches
- LE- 4 exercises, 2×10, body weight
- UE- 4 exercise, 2×10, body weight
- 3 exercises on stable surface
Phase II (Week 2-6)
- Added aerobic exercise program to 20 minutes of aerobic exercise RPE “somewhat difficult” (Borg scale score 12-13)
- Reinforce topics covered in phase I
- Community exercise groups
- Perform the first phase of light weight exercises
- Progression Phase I extends to further ROMs
- 3 exercises on unstable surface
Phase III (Week 6-10)
- Carry out the aerobic exercise program to 30 minutes of RPE “somewhat hard” aerobic exercise (Borg scale score of 13-15)
- Reinforce topics covered in phase II
- Do Phase 2 Workouts with Moderate Weight
- Progression Phase II extends to further ROMs
- 3 Dynamic exercises on stable and unstable surfaces
Rationale for Progression
The goal is to progressively challenge the patient’s endurance by increasing activity duration and exercise intensity. We chose to use the Borg Perceived Exercise Scale score to correlate intensity levels rather than heart rate maxima Medications for high blood pressure that can reduce her heart rate response to exercise. We utilize the ACSM resistance training guidelines to prescribe sets and repetitions to our patients.  We refined his strength training exercises based on his response to the activity.
Dialysis 3 days/week
platinum. Following the 12-week physical therapy program, on the 6-minute walk test, scores (MDC = 58 m) changed significantly from 550 m to 635 m, indicating improved aerobic endurance.  Platinum. also increased their perceived bodily functions, as indicated by the change from 30/100 to 58/100 SF-36 (MDC = 28).  Platinum. increased their balance, as indicated by a change from 40/56 to 46/56 on the Berg Balance Scale (MDC = 4.9).  Platinum. Increased gait speed from 0.86 m/s to 1.09 m/s (MDIC = .13 m/s). This classifies the patient as a community ambulance (>.8 m/s) Pt also improves the TUG score 24 seconds to 14 seconds indicated an increase in functional lower body strength and reduced his risk of falling. The MDIC of TUG has not been determined, but >15 seconds puts patients at increased risk of falls. 
MMT: 4/5 hip extension/abdominal/ER 4/5 knee extension/flexion 4/5 ankle dorsiflexion
Patients receiving dialysis are at high risk for impaired physical function and mobility, which are strong predictors of disability-in-hospital falls and death and are often associated with poor outcomes.  Common complications in these patients are Peripheral Neuropathy Congestive Heart Failure Heart Attack Stroke and Amputation.  Lack of motivation and interest are also common barriers to increasing physical activity in such patients.  Dialysis patients often report generalized weakness, fatigue, difficulty Walking reduces range of motion pain and difficulty with ADL, which are indications for physical therapy.  Furthermore, patients receiving dialysis report a significant decrease in their quality of life.
Physical therapy may be appropriate for patients undergoing dialysis because it can be an important factor in improving quality of life through physical function and mobility while addressing many of the common complaints and injuries common to dialysis patients.  Research has Supportive physical therapy during dialysis treatment does produce positive results such as; improved endurance, quality of life, functional capacity and gait speed.  Research supports limitations in ADLs/IADLs or observed mobility deficits as indications for physical therapy Assessment and intervention
An exercise program for people with ESRD should include prolonged periods of light to moderate exercise. 
Best time to exercise for dialysis patients: Exercise can be done before or after dialysis. The optimal time to exercise may vary and should be individualized with the patient through trial and error. Some patients were found to have minimal tolerance for exercise and exercise The overall function of the day before the first and second session of the week.
Studies have shown that chronic kidney disease patients treated with dialysis suffer from impaired physical function and poor outcomes. Studies also show that patients with chronic kidney disease have decreased gait speed, which increases their risk of developing kidney disease Reduced survival and adverse health events.  Based on research, we chose to use clinician-based outcome measures to assess his physical function and gait speed, including the Berg Balance Test Timed Start and 6-Minute Walk Test. We also used the SF-36 patient-reported outcome measure to assess his quality of life. Based on the findings of our examination, we designed a physical therapy intervention to address the patient’s functional deficits to improve function and quality of life during ADL.
The Human Activity Profile (HAP)’s 6MWT (6-minute walk test) TSS30 (timed sit-to-stand time of 30 seconds) and Maximal and Adjusted Activity Score (MAS-HAP AAS-HAP) were also found to be reliable indicators of physical strength To test functional and activity outcome measures in patients with ESRD.
 Outcome measures of activity in dialysis patients
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