A Study to Assess the Effectiveness of Intradialytic Stretching Exercises on Muscle Cramps and Quality of Life in Patients Undergoing Hemodialysis at SRM General Hospital, Kattankulathur

Introduction

Chronic kidney disease is a major health concern in India. It is considered as the third major life threatening disease.¹ The worldwide incidence of chronic kidney illness is 34% in patients with diabetes mellitus, 29% in patients with hypertension, 14% in patients with glomerulonephritis, 1% in patients with drug induced nephropathy-1%, and in 7% of the patients cause is not known.¹² Chronic kidney disease (CKD) is defined as decreased level of renal function or renal damage lasting for ≥3 months. Based on the decreased level of kidney function it is classified into 5 stages. People affected with chronic kidney disease present with several symptoms such as hiccoughs, ankle edema, muscle cramps, muscle twitching, chest pain, breathing difficulties, pruritus and hypertension.²³ Hemodialysis is the most common treatment for renal failure because this procedure removes unwanted end products and improves arterial blood supply to vital organs. Hemodialysis treatment may not be fully effective in resolving uremia and may also be associated with pain in the lower extremities which affects the quality of life and lifestyle.

Though dialysis is the lifesaving therapy in patients with kidney failure, it affects the patients everyday routine and quality of life (QOL). QOL is compromised due to its effect on the sleep pattern, social life, and activity at work and home arising from a need for constant monitoring, medication and care.⁴ Standardized treatment method and nursing care in such patients can improve the quality of patient’s life.³

Muscle cramp is the most uncomfortable experience reported by patients undergoing hemodialysis. It is described as rapid throbbing, and spontaneous tightening of muscles. Gastrocnemius, and triceps are typically affected.

Most of the patients complain of muscle cramps during dialysis and routinely it is treated with normal saline and 25% dextrose, in an hospital setting.

In kidney failure patients undergoing hemodialysis, approximately 90% them report muscle cramps. Muscle cramps can be prevented by care and therapies such as massage and exercise. Intradialytic stretching exercises (IDE) can reduce muscle cramps and therefore should be performed during dialysis.⁴

Manjunathan (2017) conducted a study to assess the effect of intradialytic stretching exercises on muscle cramps in 60 patients undergoing hemodialysis. The study observed that IDE was effective in treating muscle cramps (p<0.01, 5.8 (p<0.001).

Salem (2017) reported good efficacy of intra-dialytic massages on leg muscle contractions in 60 hemodialysis patients with muscle cramps. Data was collected using the muscle cramps assessment tool and a significant difference between the test and control groups was observed (t=8.27, p<0.05).13

Therefore, the present study evaluated the effect of IDE on muscle cramps and quality of life among hemodialysis patients and intended to collect data supporting the application of IDE as an evidence based intervention in patients undergoing hemodialysis to relieve muscle cramps and improve quality of life.

Materials And Methods

A quasi-experimental study with baseline and endpoint evaluations was adopted. Purposive sampling technique was used to recruit patients. 60 hemodialysis patients with muscle cramps were recruited and equally divided between test (n=30) and control (n=30) groups. Baseline assessment was performed with the Muscle cramps assessment tool and WHOQOL-BREF questionnaire. Intradialytic stretching exercises were performed for 20 minutes at the end of dialysis in the test group. Each patient exercised twice weekly for 4 weeks (eight times) and endpoint assessment was conducted at the end of fourth week in both the test and control group. Patients in the control group received treatment-as-usual.

Results

A statistically significant difference was reported between baseline and endpoint in the test group (t=24.3, p<0.0001). At endpoint assessment, the difference between groups was significant (t=7.55, p<0.0001). This implies that intradialytic stretching exercises are effective in reducing the severity of muscle cramps among patients undergoing hemodialysis (Table 1).

A statistically significant improvement in the quality of life was observed in the test group (t=22.16, p<0.0001) (Table 2).

A positive correlation was observed between muscle cramps and quality of life in the test group (r=0.84, p=0.06) and in the control group (r=0.73, p=0.031) (Table 4).

There was no significant association between the demographic variables and endpoint muscle cramps scores (Table 5).

Discussion

An important finding in this study is that 22 patients (73%) in the test group experience moderately severe muscle cramps at baseline but at endpoint, only 19 patients (63%) reported moderately severe muscle cramps. In control group there was no significant difference between baseline and endpoint scores on muscle cramps assessment.

In the test group, at baseline, quality of life was average in (30, 100%) patients but after IDE, the quality of life improved to good in 6 (20%) and was average in 24 patients (80%). On the contrary, the quality of life was average in all the patients (30, 100%) in the control groups at baseline and endpoint. Therefore, the results s of this study report that IDE can effectively reduce reduce muscle cramps and improve patient’s quality of life while undergoing hemodialysis.

Manoj Panchiri and Dipali (2017) reported the efficacy of stretching exercises on reducing cramps among dialysis clients. Modified Penn’s spasm measure was applied to measure severity of muscle cramps. The study results showed that after intervention, severity of cramps reduced from severe to mild.²⁴

A statistically significant difference was reported between baseline and endpoint in the test group (t=24.3, p<0.0001). This statistic implies that intradialytic stretching exercises were effective in reducing the severity of muscle cramps among patients undergoing hemodialysis.

A statistically significant improvement in the quality of life was observed in the test group (t=22.16, p<0.0001).

The positive effect of IDE on QOL as observed in the present study was in agreement with Salem et al (2017), where a study was conducted to determine the efficacy of intradialytic stretching exercises on leg muscle cramps and was found effective in reducing the severity of muscle cramps (p=0.001).

In the present study, a positive correlation was observed between muscle cramps and quality of life in the test group (r=0.84, p=0.06) and in the control group (r=0.73, p=0.031).

Relation between the endpoint scores on muscle cramps assessment and quality of life in patients undergoing haemodialysis in the test and control group with selected demographic variables was determined. There was no significant association between the endpoint scores on muscle cramps in hemodialysis patients in the test and control groups, and demographic variables.

Conclusion

There are a wide range of intradialytic stretching exercises available. Many can be applied in hemodialysis patients to decrease cramps and to improve quality of life.

The intradialytic exercises are highly effective in reducing muscle cramps and improve the quality of life in hemodialysis patients with muscle cramps. The results of this study provide evidence supporting the incorporation of IDE into clinical practice.

Conflict of Interest

None.