Evaluation of the Use of Intradialytic Exercise and Cognitive Behavior Therapy for Improving Patients’ Quality of Life Undergoing Hemodialysis: A Systematic Review

Akhmad Huda1*, Faridah Binti Mohd Said2, Jayasree S. Kanathasan2, Sofyan Hadi Hasibuan3, Sawiji4

1Faculty of Health Sciences, Universitas Muhammadiyah Lamongan, Jl. Raya Plalangan Plosowahyu, East Java 62218, Indonesia

2,3 Lincoln University College, Wisma Lincoln, No. 12-18, Jalan SS 6/12, 47301 Petaling Jaya, Selangor Darul Ehsan, Malaysia

3 Faculty of Health Sciences, Universitas Bakti Tunas Husada, Tasikmalaya, West Java 46115 Indonesia

4 Faculty of Health Sciences, Gombong Kebumen, Central Java 54412 Indonesia

*Corresponding Author's Email: ahmadhuda764@gmail.com / zahidassyaab@yahoo.com

ABSTRACT

Chronic kidney disease not only impacts physical status but also psychological status leading to low quality of life. Patients with chronic kidney disease often receive hemodialysis as replacement therapy for kidney function. Studies preventing the deterioration of quality of life were published in the literature. However, none discusses the combination therapy between intradialytic exercise and cognitive behavior therapy. Therefore, the review aims at evaluating these combination therapies in patients with hemodialysis. The study used a systematic literature review design to identify all articles on intradialytic exercise and cognitive behavior therapy. The results highlighted that there is an improvement in quality of life when implementing combination therapies. Furthermore, it helps to accelerate the medical approach to chronic kidney disease. Further study should focus on the use of therapies among patients with different stages of kidney failure.

Keywords: Chronic Kidney Injury; Patients’ Quality of Life; Cognitive Behavior Therapy; Intradialytic Exercise; Hemodialysis Care

INTRODUCTION

A kidney injury requires long-term dialysis or transplantation. Chronic kidney disease reduces kidney function, causing uraemia, which affects all organs (Lu et al., 2021). The CKD was caused by diabetic nephropathy (DN; 27.1%), hypertensive nephropathy (HTN; 28.5%), and chronic glomerulonephritis (CGN; 36.8%) (Sui et al., 2020). CKD was predicted to affect 8% to 16% of the total population in the world (Chen et al., 2019). What’s more, the global incidence of CKD is 13.4% (11.7-15.1%) with 4.902 to 7.083 million people having to undergo renal replacement treatment (Lv & Zhang, 2019). Patients with hemodialysis may have impaired quality of life (QoL) (Kefale et al., 2019; Pretto et al., 2020). HQL is an index of various elements such as mortality, morbidity, functional limitations, and well-being that can be used as an integrative measure that unites mortality and morbidity (Marquez et al., 2020). Since the patient is at high risk of fatality, QoL becomes an important component as it is a parameter of successful intervention.

Studies focusing on the QoL of patients with CKD were published in online databases. For example, intradialytic exercise is safe and may improve the physical quality of life (Pu et al., 2019). Intradialytic exercise improves HRQL and depression in hemodialysis patients (Lin et al., 2021). Exercise has positive effects on QoL; however, it is still not continuously prescribed (Poornzaari et al., 2019). In elderly hemodialysis patients, 6-month intradialytic training increases physical function (Yabe et al., 2021). Intradialytic exercise improves QoL but not kidney specific QoL (Hu et al., 2022). Related to cognitive behavior therapy in CKD, several studies were completed. The use of cognitive behavioral therapy (CBT) is an effective strategy for decreasing depressive symptoms among patients with CKD (Zegarow et al., 2020). CBT is more effective for improving therapeutic adherence and QoL (Valsaraj et al., 2021). CBT includes mindfulness meditation for enhanced QoL (e.g., mental health) and biomarker levels in patients with kidney injury (Reynolds & Jahromi, 2022).

Evaluation results in the use of intradialytic exercise and CBT separately for patients with hemodialysis. However, none of the studies discussed the combination of these therapies in the literature. Several studies merely use intradialytic training without integrating it with CBT. The combination accelerates the reduction of clinical symptoms because of dialysis. It also improves QoL by managing negative thoughts and lowering despair and anxiety. So, the study seeks to assess the efficacy of intradialytic exercise and CBT in the patient group. We expected that the result of the study would help the nurses deal with QoL health issues.

METHODOLOGY

Study Design

The current study was carried out in accordance with the guidelines of the preferred reporting items for systematic reviews and meta-analysis (PRISMA). The search involved online databases including PubMed, ScienceDirect, EBSCO, Springer, Google, and Google Scholar.

Search Strategy and Inclusion/Exclusion Criteria

The search criteria were studies on intradialytic training and CBT on CKD, English, and Bahasa language, review studies are the primary source, whole research design and 2020–2022 publications. Keywords were as follows: ‘intradialytic training’, ‘CBT for kidney disease’, ‘intradialytic training for chronic kidney injury’, ‘CBT for CKD’, ‘Quality of life intradialytic training CKD’, ‘intradialytic and CBT for CKD patients’ quality of life’.

Ethical Consideration

The article under consideration is a systematic review, therefore, the researcher's text is not applicable.

RESULTS

Search Result

A PRISMA flow diagram showed 342 articles (Figure 1). Article (title, journal, year) and research information were used to evaluate study data. Minimizing duplication was the search criteria. The researcher screened titles and abstracts using a computerized search for the study's principal purpose in four steps. All intradialytic exercise and CBT trials (n = 342) were collected.

The first phase eliminated 154 articles owing to duplication, irrelevance, and editorial and book chapters. After screening titles and abstracts (n = 97), the remaining articles (n = 188) were discarded. Third, screening complete text by criterion (n = 91), then excluding articles that did not satisfy criteria (n = 77). Fourth, 14 articles discussing intradialytic exercise and CBT were included, compared then analyzed (Table 1).

Characteristics of the Selected Studies

A total of 14 studies were identified. Overall, the articles obtained examined patients with hemodialysis using various research methods, namely 8 studies using randomized controlled trials, 3 studies using quasi-experimental studies, and 3 studies using systematic reviews. There were 12 studies that used comparison therapy and 2 studies that did not use it.

The countries studied are Slovenia (Bogataj et al., 2022), Greece (Grigoriou et al., 2021), Egypt (Elghoneimy et al., 2022), Taiwan (Lin et al., 2021), UK (Lin et al., 2021), Spain (de Villar et al., 2020), Brazil (do Valle et al., 2020), Iran (Zhianfar et al., 2020), America (Jakubowski et al., 2020), India (Valsaraj et al., 2021), Netherlands (Tommel et al., 2022). Another 3 studies are systematic review (Salhab et al., 2020; Ling et al., 2020; Othman et al., 2020).

Figure 1: Article Selecting Process Themes

Table 1 delineated the attributes of the scholarly articles included in this literature review. The present study conducted a thematic analysis of the myths identified in the reviewed literature. The findings revealed that all of the myths could be classified into distinct overarching themes: Author and year of publication, Participants, Method, Comparison therapy (if any) and Outcomes.

DISCUSSION

Hemodialysis patients often have physical and cognitive problems. HD patients must attend hospitals or dialysis clinics three times a week, requiring major lifestyle modifications. A significant proportion of patients with HD experience a high symptom burden, which encompasses a range of distressing symptoms such as fatigue, anorexia, cognitive impairment, peripheral edema, and myoclonus, leading to a diminished quality of life. This phenomenon affects approximately 92% of the HD population (Caydam & Eren, 2019). Studies highlighted that significant deterioration of cognitive function in patients with hemodialysis was also evaluated (Drew et al., 2019). Greater attention by care providers to the common and bothersome clinical symptoms positively impacts QoL for patients with hemodialysis (Lockwood et al., 2019). Even though several severe symptoms can be managed by working directly with the hemodialysis team, many patients still feel that they need to handle symptom management to improve QoL. The symptoms that occur are the symptoms experienced by the patient, so it’s not surprising that identifying symptoms is a high priority (Goodridge et al., 2019). In addition, knowledge and comprehension of the prevalence of symptoms in hemodialysis may guide the development of medical and nursing interventions targeting the symptoms. Despite the well- documented advantages of therapies, there is a broad desire for effective solutions delivering long- term results for patients on hemodialysis. This study shows that specific interventions may help reduce the clinical symptoms of hemodialysis, such as intradialytic exercise and CBT.

Table 1: Study Finding

The implementation of intradialytic exercise has been shown to enhance physical well-being and diminish sedentary behavior among individuals undergoing hemodialysis (McAdams-DeMarco et al., 2018; Grigoriou et al., 2021; Elghoneimy et al., 2022). According to the American College of Sports Medicine (ACSM), individuals with chronic kidney disease (CKD) who are undergoing hemodialysis are recommended to initiate exercise routines with low-intensity workouts lasting for approximately 10 to 15 minutes (Liguori & American College of Sports Medicine, 2020). Effect of low physical activity routinely can cause morbidity and mortality, performing exercise is very important as documented by studies.

Intradialytic exercise is performed by using pedalling and stepping devices when the patient seats in a hemodialysis chair (Greenwood et al., 2021; de Villar et al., 2020). Organized exercise on a cycle ergometer during hemodialysis has been found to reduce patients' physical problems (Salhab et al., 2020; do Valle et al., 2020). Based on these findings, clinical nurses must routinely and continually assess intradialytic exercise frequency to significantly benefit hemodialysis patients. Nurses working in a hemodialysis care plan manage the patients including checking the patient's vital signs, discussing the recent condition, and teaching the disease and its treatment as well.

Another promising intervention to improve the QoL of patients with hemodialysis is cognitive behavioral therapy (CBT). The patients are at high risk for cognitive disturbance due to their older age and having risk factors of cardiovascular disease and stroke (Karakizlis et al., 2021). One recent study in dialysis patients emphasized that kidney-related cognitive impairment was noticeable for executive functions including working memory, attention, and impulse control (Bogataj et al., 2022). Patients with CKD often experience severe psychological problems like depression, anxiety and difficulties finding coping. Therefore, cognitive testing before dialysis initiation and periodically should be warranted. Considering the potential efficacy and safety of Cognitive Behavioral Therapy (CBT) for individuals undergoing Hemodialysis (HD), healthcare providers in the renal department ought to contemplate CBT as a viable treatment alternative. According to Ling et al., (2020), the integration of Cognitive Behavioral Therapy (CBT) into standard care may present challenges due to inadequate participant access to this form of therapy and a scarcity of CBT providers. Therefore, the author of this paper has examined two potential solutions to this problem, which will be detailed below.

The efficacy of internet-based cognitive-behavioral therapy (CBT) as a treatment option for Hemodialysis (HD) patients experiencing low quality of life (QoL) can be deemed noteworthy. All of the studies included in the current review utilized conventional, in-person cognitive-behavioral therapy (CBT). Geographic distance, scarcity of professional therapists, and the elevated cost of therapy are obstacles that impede the implementation of face-to-face cognitive behavioral therapy (Jakubowski et al., 2020). Internet-based cognitive behavioral therapy (CBT) has been demonstrated as a viable approach to address the aforementioned obstacles and narrow the treatment disparities. Additionally, as per a recently updated meta-analysis carried out by Othman et al., (2020), The effects of internet-guided cognitive behavioral therapy (CBT) and traditional face-to-face CBT are comparable. Nonetheless, the lack of available evidence pertaining to internet-based cognitive behavioral therapy (CBT) for comorbid depression among patients undergoing Hemodialysis (HD) was observed. Hence, additional research may be conducted to explore the efficacy of Cognitive Behavioral Therapy (CBT) in individuals undergoing Hemodialysis (HD) treatment.

Moreover, Cognitive Behavioral Therapy (CBT) may potentially safeguard the cognitive functions of patients from degeneration. Empirical evidence suggests that Cognitive Behavioral Therapy (CBT) is effective in mitigating cognitive impairments (Zhianfar et al., 2020; Ling et al., 2020; Jakubowski et al., 2020). Integrating cognitive behavioral therapy (CBT) with renal replacement therapy, such as hemodialysis, appears to be a logical approach to enhance the overall welfare of the patient (Valsaraj et al., 2021; Othman et al., 2020; Tommel et al., 2022). Additionally, the aforementioned four studies on the implementation of Cognitive Behavioral Therapy (CBT) demonstrate a rise in Quality of Life (QoL) and a reduction in depression, both of which are indicative of QoL (Zhianfar et al., 2020; Ling et al., 2020; Jakubowski et al., 2020; Valsaraj et al., 2021; Othman et al., 2020; Tommel et al., 2022). Yet, the concept of quality of life pertains to an individual's subjective evaluation of their standing in life, taking into account their cultural background, personal values, and aspirations, as well as other;t relevant factors such as expectations and standards. The evaluation of the management of chronic kidney disease patients undergoing hemodialysis is increasingly taking into account the factor of quality of life (Yonata et al., 2022).

CONCLUSION

Intradialytic exercise and CBT are promising therapies to prevent deterioration in QoL. Even though there is limited evidence to support this, a combination of these therapies will assist nurses in reducing health issues when performing hemodialysis. Patients and nurses should work together to achieve the best outcomes. Evaluation of the therapy's effectiveness after hemodialysis is important for the nursing care process. Finally, studies involving family members should be initiated using different dosages and populations.

Recommendation

1. For Health Services

   It is recommended that health services enhance their educational offerings pertaining to the significance of assessing the efficacy of intradialytic exercise and cognitive behavior therapy in enhancing the quality of life of hemodialysis patients.

   
   

2. For Educational Institutions

   The researchers hope that this study can serve as a point of reference for students, particularly those pursuing nursing at Universitas Muhammadiyah Lamongan, to undertake further research and enhance their understanding of health science, particularly in the domain of healthcare.

   
   

3. For the Community

   It is hoped that the present study aims to serve as a valuable resource for the community by examining the effectiveness of intradialytic exercise and cognitive behavior therapy in enhancing the quality of life of hemodialysis patients.

   
   

4. For Researchers

The researcher hopes that the conducted study will contribute to the existing body of knowledge on the assessment of the effectiveness of intradialytic exercise and cognitive behavior therapy. Additionally, the researcher anticipates that future studies will explore other factors that affect the utilization of intradialytic exercise and cognitive behavior therapy, in order to determine the key factors that enhance the quality of life of hemodialysis patients.

Suggestion

The optimal results can be attained through the cooperation of patients and nurses. Evaluation of the therapy's effectiveness after hemodialysis is important for the nursing care process and studies involving family members should be initiated using different dosages and populations.

Conflict of Interest

The authors declare that they have no conflict of interests..

ACKNOWLEDGEMENT

Thank you to all parties who made a contribution to this study, including faculty members of the Universitas Muhammadiyah Lamongan, Indonesia, and Lincoln University College, Malaysia.

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