31. Ouzouni-2009-Effects of intradialytic exercise training on health-related quality of life indices in haemodialysis patients

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Clinical Rehabilitation
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DOI: 10.1177/0269215508096760
 2009 23: 53Clin Rehabil
Stavroula Ouzouni, Evangelia Kouidi, Athanasios Sioulis, Dimitrios Grekas and Asterios Deligiannis
haemodialysis patients
Effects of intradialytic exercise training on health-related quality of life indices in
 
 
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Clinical Rehabilitation 2009; 23: 53–63
Effects of intradialytic exercise training on health-related
quality of life indices in haemodialysis patients
Stavroula Ouzouni, Evangelia Kouidi Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Athanasios Sioulis,
Dimitrios Grekas First Internal Medicine Department – Renal Unit, AHEPA Hospital, Aristotle University of Thessaloniki and
Asterios Deligiannis Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
Received 26th February 2008; returned for revisions 18th July 2008; revised manuscript accepted 21st July 2008.
Objective: To assess the effects of intradialytic exercise training on health-related
quality of life indices in haemodialysis patients.
Subjects/patients: Thirty-five patients on haemodialysis, with a mean (SD) age of
48.8 (13.9) years, volunteered to participate in the study. They were randomized
either to rehabilitation group (group A: 19 patients), following a 10-month intradialytic
exercise training programme or to control group (group B: 14 patients). After the
randomization, two of the patients, one of each group, withdrew from the study for
reasons unrelated to exercise training.
Method: All patients at the beginning and the end of the study underwent clinical
examination, laboratory tests and a treadmill exercise testing with spiroergometric
study for the evaluation of their aerobic capacity (Vo2peak). A formal psychosocial
assessment, which included affective (Beck Depression Inventory), health-related
quality of life (Quality of Life Index, Living Questionnaire of Minnesota, Life
Satisfaction Index and Short Form-36 questionnaire) and personality (Eysenck
Personality Questionnaire) parameters, was evaluated at beginning and end of the
study. The dose of erythropoietin was changed as needed, according to the level of
the haemoglobin, aiming to keep it at 11 (2) g/dL during the study.
Results: Baseline values were similar between the two groups. After training in
group A, Vo2peak was increased by 21.1% (P50.05) and exercise time by 23.6%
(P50.05). Moreover, group A showed a decrease in self-reported depression (Beck
Depression Index) of 39.4% (P50.001). In addition, trained patients demonstrated a
significant improvement in Quality of Life Index (from 6.5 (1.8) to 9.0 (1.3), P50.001)
and Life Satisfaction Index (from 44.8 (8.6) to 53.0 (5.6), P50.001), and an increase in
the Physical Component Scale of the SF-36 (from 40.5 (5.6) to 44.5 (5.5), P50.05),
while the Mental Component Scale remained unchanged. Multiple regression
analysis indicated that the improvement in quality of life depended on the
participation in exercise programmes, the effects of training and the reduction in the
level of depression. No changes were observed in Eysenck Personality Questionnaire
by the end of the study, while all the above parameters remained almost unchanged
in the controls.
Address for correspondence: Asterios Deligiannis, 26 Agias
Sofias Str, 546 22 Thessaloniki, Greece.
e-mail: stergios@med.auth.gr
� SAGE Publications 2009
Los Angeles, London, New Delhi and Singapore 10.1177/0269215508096760
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Conclusion: The results demonstrated that intradialytic exercise training improves
both physical functioning and psychological status in haemodialysis patients, leading
to an improvement of patients’ quality of life.
Introduction
Despite advances in renal replacement treatment,
the options for patients with end-stage renal dis-
ease, their functional and psychosocial status, as
well as their health-related quality of life remain
poor.1–6 Acute and chronic stressors, due to dia-
lysis procedures, medications and health pro-
blems, loss of normal family life, impairment of
social and occupational roles and fear of death
contribute to deterioration of patients’ functional
status, psychological profile and well-being.3–5
It is well documented that exercise rehabilitation
programmes lead to an improvement in the func-
tional capacity of predialysis7,8 and haemodialysis
patients.9–14 Patients on haemodialysis are usually
exercised on the non-dialysis days in a rehabilita-
tion centre under the instructions of specialized
exercise physiologists or physiotherapists and med-
ical supervision.15,16 Despite the beneficial effects
of exercise training in haemodialysis patients on the
non-dialysis days, compliance remains poor.13
Exercise during the haemodialysis sessions and
home training are alternatives to exercise on the
non-dialysis days.9,17 These methods have certain
advantages, such as time saving and improve com-
pliance.13 However, there are few data regarding
the effects of exercise training during haemodialysis
on psychological status and quality of life.
The aim of this study was to examine the effects
of an aerobic and strengthening exercise training
programme during haemodialysis on cardiore-
spiratory efficiency, psychological status, as well
as to investigate correlations between physical
functioning, well-being and health-related quality
of life indices.
Patients and methods
Patients
Thirty-five patients, men (n¼ 27) and women
(n¼ 8), with mean (SD) age of 48.8 (13.9) years,
with end-stage renal disease on maintenance hae-
modialysis three days per week, 4 hours/session,
for at least six months prior to the study, volun-
teered to participate in the study. All patients
completed a baseline medical screening including
physical examination, resting ECG, echocardio-
graphic study and blood tests; none of them had
unstable hypertension, heart failure (NYHA class
4II), cardiac arrhythmias (4III according to
Lown), recent myocardial infarction or unstable
angina, diabetes mellitus, active liver disease or
orthopaedic problems limiting exercise.10 All
tests were carried out on a non-dialysis day.
Afterwards, they were randomized to either a10-month supervised exercise-training programme
during their haemodialysis sessions (group A – 20
patients) or control status (group B – 15 patients).
None of the patients was on antidepressants or
other psychotropic agents. The subjects remained
in a stable medication regimen, diet and dialysis
schedule during the study. The dialysis prescrip-
tion was planned to remain constant by using
the same model of filter and a constant composi-
tion of the dialysis solution and by keeping the
haemodialysis session time constant throughout
the study. The level of the haemoglobin for all
patients during the study was kept stable of
mean (SD) 11 (2) by changing the dose of erythro-
poietin whenever necessary.
After the randomization two patients, one of
each group, dropped out of the study. One patient
in group A stopped training because of medical
problems unrelated to exercise, while a patient in
group B refused to repeat the functional test at the
end of the study.
Informed consent was obtained from all
patients according to the guidelines approved by
the Aristotle University Ethics Committee.
Spiroergometric study
The cardiorespiratory capacity of all patients at
the beginning and end of the study was measured
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using a spiroergometric study. A symptom-limited
cardiopulmonary exercise test was performed on a
treadmill using a modified Bruce protocol, which
included 3-minute stages with a progressive
increase of the speed and grade. The ECG of
each patient was monitored by a Cambridge
Heart 12 ECG System Co (CH-2000) and
recorded every 3 minutes. The blood pressure
was measured during the 2 minutes of each stage
by a mercury sphygmomanometer.
Patients were exercised until volitional
exhaustion according to Borg’s scale. End-point
of the tests was either the development of symp-
toms (as dyspnoea, dizziness, etc.) or target heart
rate, severe hypertension or hypotension, ST seg-
ment shift in ECG� 2, 0mm or severe
arrhythmias.
During the exercise test a spiroergometer
device (Quark b2, Cosmed, Italy), which had
fast O2 and CO2 analysers, was used to analyse
the expired gases on a breath-to-breath
analyses. Before each test the b2 system was
calibrated according to the manufacturer’s specifi-
cations. Vo2peak was taken to be the highest Vo2,
which was characterized by a plateau of oxygen
uptake despite further increases in work rate.
Other measurements at peak exercise included:
maximum heart rate (HRmax), maximum blood
pressure (sBPmax and dBPmax), double product
(HRmax� sBPmax), exercise time, maximum pul-
monary ventilation (VEmax), and metabolic
equivalents (METs).
Psychological and health-related quality of life
assessment
All patients were requested to complete the
following five different questionnaires in the
first week of admission before randomization
into study groups and at the end of the study.
1) The Beck Depression Inventory – a 21-item
self-report rating inventory measuring charac-
teristic attitudes and symptoms of depres-
sion.18 It was translated and standardized
for the Greek population.19
2) The Eysenck Personality Questionnaire –
composed of 84 self-evaluative statements
of personality, extroversion, neuroticism
and psychoticism. There was also a lie scale.
It was translated and standardized for the
Greek population.20
3) The Scale of Life Satisfaction – a self-admi-
nistered questionnaire with 12 items that
examined physical and mental health, sexual
life, support from family and friends, hobbies,
appearance and a global evaluation for qual-
ity of life. It was translated and standardized
for the Greek population.21
4) The Quality of Life Index (Spitzer Index) – an
interviewer-administered questionnaire with
five domains measuring patient’s activity,
daily living, health, support and outlook.
It was translated for the Greek population.22
5) The Short Form-36 questionnaire (SF-36) – a
multipurpose, short-form health survey with
36 questions, which yielded an eight-scale
profile of scores as well as Physical
Component Scale and Mental Component
Scale summary measures. It was translated
and standardized for the Greek population.23
Exercise rehabilitation programme
Patients of group A followed a 10-month exer-
cise rehabilitation programme during their haemo-
dialysis treatment in the renal unit. They were
exercised three times weekly, 60–90 minutes each
time during the first 2 hours of their haemodialysis
sessions, under the supervision of the physician
and the responsibility of three exercise physiolo-
gists, specialized in this field. All subjects were
exercised at 13–14 (somewhat hard) of the Borg
Perceived Exertion Scale. Their cardiac rhythm
during training was monitored continuously. The
blood pressure was also measured every 15
minutes.
Each exercise session included 30 minutes of
cycling and 30 minutes of strengthening and flex-
ibility exercises. For the cycling exercise specific
devices, which were adjusted to each patient’s
bed, were used. The cycling session consisted of
5 minutes warm-up, 20 minutes cycling at desired
workload and 5 minutes cool-down. The duration
of cycling was gradually increased over time
according to each patient’s ability and finally
reached an hour of active cycling. The strength
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training session consisted of sets of repetitions for
the abdominal and lower limbs. The workload was
accreted by increasing the repetitions and sets and
then by using therabands and applying weights
round the limbs.
Statistical analysis
All data were expressed as mean values (SD).
Non-parametric tests were used to avoid potential
errors from non-normal distribution of data.
Wilcoxon signed-rank test was used to compare
the baseline and final data within the same
groups. Differences between groups were tested
using either Mann–Whitney U or chi-square
test as appropriate. To analyse relationships
between baseline values of psychosocial scores
and aerobic capacity values, linear regression
analysis was used.
Multiple regression analysis was also performed
to examine the factors that affect health-related
quality of life variations.
The Statistical Package for Social Sciences ver-
sion 11.0 for Windows was used (SPSS Inc.
Chicago, IL, USA). The level of significance was
fixed at P50.05.
Results
The clinical characteristics of the 33 patients
who completed the study (19 in group A and 14
in group B), are shown in Table 1. There was no
musculoskeletal, cardiovascular or other compli-
cation related to exercise training during the study.
At baseline, there was no statistically significant
difference between the two groups concerning the
clinical data, the measured parameters of the car-
diorespiratory efficiency (Table 2), the personality
traits, the level of depression (Table 3) and the
health-related quality of life indices measured
(Table 5).
Table 1 Baseline clinical features of the trained (group A)
and untrained (group B) patients
Groups A (n¼ 19) B (n¼ 14)
Male/female 14/5 13/1
Age (years) 47.4 (15.7) 50.5 (11.7)
Height (cm) 165 (9.0) 167 (10.0)
Years on haemodialysis 7.7 (7.0) 8.6 (6.0)
Values expressed as mean values (SD) unless otherwise
stated.
Table 2 Spiroergometric data of the trained (group A) and untrained (group B) patients
Group A Group B
Baseline After Baseline After
Resting HR (beats/min) 84.7 (10.6) 76.3 (7.1)* 84.7 (10.6) 78.2 (10.3)#
Resting sBP (mmHg) 142.9 (14.6) 135.3 (11.6)* 138.2 (6.3) 139.3 (9.1)
Resting dBP (mmHg) 86.8 (7.8) 79.2 (7.7)* 85.7 (4.6) 85.2 (4.6)#
Exercise time (min) 16.9 (4.3) 20.9 (5.2)* 15.9 (2.7) 15.1 (2.8)#
METs 9.1 (2.2) 11.2 (2.5)* 8.7 (1.4) 8.9 (1.4)#
HRmax (beats/min) 139.1 (19.9) 144.1 (14.3)* 140.2 (10.8) 139.6 (7.1)sBPmax (mmHg) 188.2 (17.3) 178.2 (22.2)* 186.1 (11.5) 190.0 (13.9)
dBPmax (mmHg) 88.9 (7.9) 77.4 (9.6)* 85.4 (5.7) 84.6 (4.5)
#
Double product (� 103) 26.1 (4.7) 25.8 (5.4) 26.0 (1.9) 25.7 (3.5)
VEmax (L/min) 42.2 (13.7) 59.4 (17.9)* 35.7 (12.2) 34.9 (4.9)
#
Vo2peak (mL/kg per minute) 20.9 (5.4) 25.3 (5.3)* 20.3 (3.6) 20.1 (3.4)
#
Mean values (SD).
HR, heart rate; sBP, systolic blood pressure; dBP, diastolic blood pressure; METs, metabolic equivalents;
VEmax, maximum pulmonary ventilation.
*P50.05 between baseline and final values in each group.
#P50.05 between the two groups.
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Iinitially, the majority of the patients were
found to be moderately depressed, as the mean
(SD) Beck Depression Inventory score was 19.3
(4.9). The distribution of the patients according
to their level of depression is presented in
Table 4. All patients at the beginning of the
study had low scores concerning the health-related
quality of life indices.
After intradialytic training in group A, exercise
time was increased by 23.6% (P50.05), METs by
23.1% (P50.05) and Vo2peak by 21.1% (P50.05).
In addition, a statistically significant improvement
in Beck Depression Inventory depression was
observed, as the mean level of depression in
group A was decreased by 39.4% and the
number of depressed patients was reduced
(Table 4).
Moreover, all health-related quality of life
indices were tested and were statistically signifi-
cantly increased after intradialytic exercise train-
ing (Table 5). Specifically, the exercise group
showed a significant improvement in Life
Satisfaction Index by 18.3% (P50.05), in mean
score of Quality of Life Index by 38.4%
(P50.05), as well as in all areas of Quality of
Life Index, as physical activity increased by
28.6% (P50.05), daily living by 33.3%
(P50.05), health by 54.5% (P50.05), support
by 26,7% (P50.05) and outlook by 50.0%
(P50.05). Finally, according to SF-36 question-
naire, the Physical Component Scale score of
group A was increased by 9.9% (P50.05), while
no change was observed in the Mental Conponent
Scale score. Patients in group B presented a low
and not statistically significant reduction of the
Physical Component Scale value at the end of
the study. No changes were observed in all tested
parameters of group B over 10 months. Moreover,
at the end of the study there was no statistically
significant difference found in the personality
traits of both groups (Table 3).
To determine the relationship between the level
of depression, physical functioning and quality of
life, correlations coefficients were calculated.
There was a positive relationship between
Quality of Life Index and Vo2peak (r¼ 0.682,
P50.05; Figure 1a) at baseline and at the end of
the study (r¼ 0.575, P50.05; Figure 1b). In addi-
tion, there was a negative relationship between
Quality of Life Index and Beck Depression
Inventory (r¼�0.790, P50.05; Figure 2a) at
baseline and at the end of the study (r¼�0.812,
P50.05; Figure 2b).
Multiple regression analysis, using Quality of
Life Index as a subordinate variable (Table 6),
showed that the reduction of depression
(P¼ 0.01), the increase in aerobic capacity
(P¼ 0.032) and the participation in the exercise
training programme (P¼ 0.024) had a statistically
significant contribution to the model. The model
explained 77.4% of the total variance (F¼ 10.27,
R2¼ 0.774). Further analysis, using the Physical
Component Scale as a subordinate variable
(Table 7), showed that the increase of the aerobic
Table 3 Data of psychosocial profile of the trained (group A)
and untrained (group B) patients
Group A Group B
Baseline After Baseline After
Eysenck Personality Questionnaire
Psychotism 6.0 (1.4) 6.3 (1.4) 6.4 (0.9) 6.1 (0.9)
Neurotism 10.1 (3.6) 9.8 (3.0) 9.4 (0.8) 9.4 (0.7)
Extroversion 10.7 (1.5) 10.8 (1.6) 10.5 (1.2) 10.6 (0.8)
Lies 12.2 (1.5) 12.9 (1.7) 11.9 (1.1) 11.7 (0.5)
Beck Depression Inventory
Depression 19.3 (4.9) 11.7 (3.6)* 19.2 (3.3) 19.4 (4.0)#
Mean values (SD).
*P50.05 between baseline and final values.
#P50.05 between the two groups.
Table 4 Distribution of depression of the trained (group A)
and untrained (group B) patients according to the Beck
Depression Inventory depressive morbidity
Group A Group B
Baseline After*# Baseline After*#
Not depressed (0–9) 0 7 0 0
Mildly (10–15) 6 9 1 3
Moderately
depressed (6–23)
8 3 11 9
Severely
depressed (424)
5 0 2 2
*P50.05 between baseline and final distribution in each
group.
#P50.05 between the two groups.
Quality of life after training in haemodialysis patients 57
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(a) (b)
r = 0.682 
p < 0.01
r = 0.575
p < 0.01
12
10
8
6
Q
LI
Q
LI
4
2
0
0 10 20
VO2peak (ml/Kg/min) VO2peak (ml/Kg/min)
30 40
12
10
8
6
4
2
0
0 10 20 30 40
Figure 1 Correlation between Quality of Life Index (QLI) and Vo2peak at baseline (a) and at the end of the study (b).
(a)
(b)
Q
LI
BDI (depression score) BDI (depression score)
Q
LI
12
10
8
6
4
2
0
12
10
8
6
4
2
0
0 10 20 30 0 10 20 30
r = −0.790 
p < 0.01 
r = −0.812 
p < 0.01
Figure 2 Correlation between Quality of Life Index (QLI) and Beck Depression Inventory (BDI) at baseline (a) and at the
end of the study (b).
Table 5 Scores of health-related quality of life indices
Group A Group B
Baseline After Baseline After
Quality of Life Index 6.5 (1.8) 9.0 (1.3)* 6.3 (1.9) 6.3 (1.8)#
Patient activity 1.4 (0.5) 1.8 (0.4)* 1.4 (0.5) 1.4 (0.5)#
Daily living 1.5 (0.5) 2.0 (0.2)* 1.3 (0.5) 1.2 (0.4)#
Health 1.1 (0.6) 1.7 (0.5)* 1.1 (0.6) 1.1 (0.5)#
Support 1.5 (0.5) 1.9 (0.3)* 1.4 (0.5) 1.4 (0.5)#
Outlook 1.0 (0.4) 1.5 (0.5)* 1.1 (0.6) 1.1 (0.7)
SF-36
Physical Component Scale 40.5 (5.6) 44.5 (5.5)* 39.0 (5.4) 38.9 (5.8)#
Mental Component Scale 41.8 (10.1) 41.8 (10.0) 40.3 (6.9) 40.1 (6.8)
Life Satisfaction Index 44.8 (8.6) 53.0 (5.6)* 42.1 (11.7) 42.8 (12.1)
Mean values (SD).
*P50.05 between baseline and final values.
#P50.05 between the final values of group A versus group B.
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capacity (P¼ 0.012) and the participation in the
exercise programme (P¼ 0.016) had a statistically
significant contribution to the model, which
explained 55.8% of the total variance (F¼ 4.517,
R2¼ 0.558).
Finally analysis, using the Life Satisfaction Index
as a dependent variable (Table 8), showed that par-
ticipation in the programme itself (P¼ 0.003) con-
tributed to the model, which explained 45.4% of
the total variance (F¼ 1.936, R2¼ 0.454).
Discussion
The results of the study indicate that regular
exercise training during haemodialysis increases
patients’ physical capacity, enhances their psycho-
logical status and consequently improves their
quality of life. Quality of Life Index was found
to be influenced by the level of physical function-
ing, the degree of depression and the participation
in exercise programmes per se.
At the beginning of the study, all our patients
presented very low cardiorespiratory capacity, as
their Vo2peak approached the 50% of the values
of healthy individuals.24,25 Remarkably low
levels of aerobic capacity in haemodialysis
patients were observed and registered by
previous researchers, where the Vo2peak values
varied between 15 and 29mL/kg per minute.24–26
Central and peripheral factors seem to be respon-
sible for this reduction in haemodialysis patients,
such as cardiac dysfunction, cardiac autonomic
nervous system abnormalities, anaemia, defect of
muscle oxidative metabolism and skeletal muscle
atrophy.3,27,28
At the time of enrolment, patients showed
high values in all the personality traits studied,
such as psychotism, neurotism, extroversionand lies. Similar high values of personality traits
in haemodialysis patients had been observed in
previous studies.15 In addition, our patients had
high levels of depression. Depression is the most
commonly observed psychological disorder among
dialysis patients. In many studies an increased
depression level has been detected in haemodialy-
sis patients, which varies between 12% and 45%
due to the discrepancies in the methodology used
Table 6 Multiple regression analysis with Quality of Life
Index as the dependent variable at the end of the study
� P-value
Participation in exercise 9.448 0.024*
Exercise training �0.181 0.781
Psychoticism �0.449 0.065
Neuroticism 0.105 0.362
Extroversion �0.127 0.441
Lies 0.028 0.85
Depression �0.21 0.01*
Vo2peak 0.174 0.032*
Years on haemodialysis 0.006 0.069
R 2¼ 0.774
F¼ 10.270
*P50.05.
Table 7 Multiple regression analysis with Physical
Component Scale as the dependent variable at the end of
the study
� P-value
Participation in exercise 51.37 0.016*
Exercise training �2.22 0.331
Psychoticism �0.26 0.79
Neuroticism 0.135 0.769
Extroversion �1.218 0.056
Lies 0.208 0.74
Vo2peak 0.671 0.012*
Haemoglobin �0.89 0.508
R 2¼ 0.558
F¼ 4.517
*P50.05.
Table 8 Multiple regression analysis with Life Satisfaction
Index as the dependent variable at the end of the study
� P-value
Participation in exercise 83.465 0.0033*
Exercise training �6.257 0.218
Psychoticism �1.02 0.575
Neuroticism �0.624 0.488
Extroversion �1.303 0.289
Lies �0.775 0.507
Depression �1.013 0.105
Vo2peak �0.176 0.755
Haemoglobin 2.382 0.375
R 2¼ 0.454
F¼ 1.936
*P50.05.
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for the research and the differences in the criteria
used in evaluation.29–32 According to our results,
patients with the highest values of depression also
presented the worst quality of life results. Other
studies have also observed an interrelation
between depression and quality of life, including
mortality in haemodialysis patients.31,33 A low
Quality of Life Index score and the presence of
depression are found to be associated with
higher co-morbidity, anaemia, poorer nutritional
status, lower residual renal function and increased
hospitalization rate.34–36
In clinical practice there are a number of instru-
ments evaluating health-related quality of life,
either generic or specific. Each instrument has its
potentials and weaknesses. The use of a variety of
instruments provides more reliable results and
diagnosis. In our study, three questionnaires
were used to estimate the level of quality of life,
the results of which were similar among them and
declared a low health-related quality of life level
in these patients. According to the results of the
Quality of Life Index questionnaire, at baseline
our patients presented reduced values in all five
particular sectors examined by the questionnaire.
In addition, the SF-36 total scores were lower than
in the general population.37–40 The reduction,
however, was greater in Physical Component
Scale than in the Mental Component Scale.
Lamping et al.41 reported that mental scores of
dialysis patients at the age of 70 or above were
not different from those of the elderly in the gen-
eral population. Psychological condition does not
seem to vary particularly, mostly because in
chronic diseases, patients gradually learn to com-
promise with the idea of their illness.42–44
In the present study, 10 months of intradialytic
exercise training led to a significant increase
in cardiorespiratory capacity, resulting in about
20% enhancement in Vo2peak and exercise time.
Several reports have already shown that exercise
training in haemodialysis patients is safe and
effective in improving their physical
fitness.9,13,26,45–47 A similar increase of the
Vo2peak, which varied from 20 to 23% after a
six-month intradialytic exercise training pro-
gramme was also observed.13,25 However, three
months of intradialytic exercise training in haemo-
dialysis patients caused only a 13% increase of
their Vo2peak.
27 This result could be attributed to
the small duration and low intensity of the exercise
programme.
In addition, our results of the SF-36 question-
naire showed that intradialytic training caused
a significant improvement in patients’ physical
functioning, without affecting the mental scales.
In concordance, Painter et al.9 registered an
improvement in SF-36 Physical Component
Scale scores in haemodialysis patients after
the implementation of an eight-week exercise
programme in their homes followed by eight
weeks of in-centre cycling. However, it is found
that when the initial values of physical condition
are high, improvement is inconsiderable.48 In the
present study, an increase equal to 10% was
observed in the patients who had initially pre-
sented a high value in their physical condition.
Parsons et al.49 did not observe any changes in
physical condition after the implementation of
an aerobic exercise programme for eight weeks.
However, the initial values found in these
patients approached those of healthy individuals.
In another study by Parsons et al.,50 a five-month
low-intensity intradialytic exercise programme was
found to be an adjunctive therapy improving
efficacy and physical function in haemodialysis
patients.
After 10 months of exercise training, none of the
four elements regarding the personality of patients
in both teams was changed. This can be explained
by the fact that personality elements are not apt to
change after an intervention. However, exercise
training caused a 30% reduction in the level of
depression and in the number of patients suffering
from serious depression. These results are in agree-
ment with previous studies. From a previous study
of ours, the application of a six-month exercise
programme in a rehabilitation centre on the non-
dialysis days resulted in a reduction of depression
by 35%.15 Moreover, Levendoglu et al.14 reported
a significant improvement in cardiorespiratory
capacity and a significant reduction in the depres-
sion score after a 12-week intradialytic exercise
programme. In contrast, Ridley et al.51 did not
observe any changes in patients’ psychological
profile after a 12-week intradialytic exercise pro-
gramme during haemodialysis. Similarly, Suh
et al.32 reported that there was a trend of improve-
ment in depression after the implementation of a
12-week exercise training programme, though it
60 S Ouzouni et al.
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did not reach statistical significance. It seems that
the length of the exercise training intervention is
the critical parameter that affects the clinical
outcomes.
Our results also indicated that exercise
training can help haemodialysis patients to
improve the perception of health-related quality
of life. This was confirmed by the results obtained
from all the questionnaires used. The increase
was considerable in all sectors studied by the
Quality of Life Index questionnaire, especially in
the estimation of the general health and future
perspective. Moreover, the Life Satisfaction
Index was found to be improved after intradialytic
training.
However, the improvement of all health-related
quality of life indices observed in our patients
after the application of the 10-month intradialytic
exercise programme cannot be attributed only
to exercise. In the present study, the statistical
analysis has shown that the quality of life level
of the exercised patients depended on their parti-
cipation in a training programme, on the level
of their cardiorespiratory efficiency and on the
level of their depression. In particular, by increas-
ing their physical capacity they felt more
efficient and able to take care of themselves.
In addition, the reduction of depression observed
after trainingindicated that psychological support
provided by a rehabilitation programme is very
important.
In conclusion, exercise training during dialysis is
found to improve functional capacity, ameliorate
depression, and increase the well-being and health-
related quality of life in haemodialysis patients.
Therefore, exercise training should be considered
as an important therapeutic modality for the man-
agement of haemodialysis patients, who should be
encouraged to participate in any forms of exercise
training programmes, according to their physical
and medical condition.
References
1 Paganini EP. In search of an optimal hematocrit
level in dialysis patients: rehabilitation and quality-
of-life implications. Am J Kidney Dis 1994; 24(suppl
1): 10–16.
2 Hruska KA, Teitelbaum SL. Renal osteodystro-
phy. N Engl J Med 1995; 333: 166–74.
3 Kouidi E. Health-related quality of life in end-stage
renal disease patients: the effects of renal rehabili-
tation. Clin Nephrol 2004; 61(suppl): 60–71.
4 Johansen KL. Physical functioning and exercise
capacity in patients on dialysis. Adv Ren Replace
Ther 1999; 6: 141–48.
5 Diaz-Buxo J, Lowrie E, Lew N et al. Quality-of-life
evaluation using short form 36: comparison in
hemodialysis and peritoneal dialysis patients. Am J
Kidney Dis 2000; 35: 293–300.
6 Altintepe L, Levendoglu F, Okudan N et al.
Physical disability, psychological status, and
health-related quality of life in older hemodialysis
patients and age-matched controls. Hemodialysis
International 2006; 10: 260–66.
7 Clyne N. The importance of exercise training in
predialysis patients with chronic kidney disease.
Clin Nephrol 2004; 61(suppl 1): 10–13.
8 Heiwe S, Tollback A, Clyne N. Twelve weeks of
exercise training increases muscle function and
walking capacity in elderly predialysis patients and
healthy subjects. Nephron 2001; 88: 48–56.
9 Painter P, Carlson L, Carey S et al. Physical func-
tioning and health-related quality-of-life changes
with exercise training in hemodialysis patients. Am
J Kidney Dis 2000; 35: 482–92.
10 Kouidi E. Central and peripheral adaptations to
physical training in patients with end-stage renal
disease. Sports Med 2001; 31: 651–65.
11 Kouidi E. Exercise training in dialysis patient:
Why, when and how? Artif Organs 2002; 26:
1009–13.
12 Mercer TH, Gleeson CC, Naish PF. Low-volume
exercise rehabilitation improves functional capacity
and self-reported functional status of dialysis
patients. Am J Phys Med Rehabil 2002; 81: 162–67.
13 Konstantinidou E, Koukouvou G, Kouidi E et al.
Exercise training in patients with end-stage renal
disease on hemodialysis: comparison of three
rehabilitation programs. J Rehabil Med 2002; 34:
40–45.
14 Levendoglu F, Altintepe L, Okudan N et al. A
twelve week exercise program improves the
psychological status, quality of life and work
capacity in hemodialysis patients. J Nephrol 2004;
17: 826–32.
15 Kouidi E, Iacovides A, Iordanidis P et al. Exercise
renal rehabilitation program (ERRP). Psychosocial
effects. Nephron 1997; 77: 152–58.
16 Deligiannis A, Kouidi E, Tourkantonis A. The
effects of physical training on heart rate variability
in hemodialysis patients. Am J Cardiol 1999; 84:
197–202.
Quality of life after training in haemodialysis patients 61
 at Scientific library of Moscow State University on January 23, 2014cre.sagepub.comDownloaded from 
http://cre.sagepub.com/
http://cre.sagepub.com/
17 Painter PL, Nelson-Worel JN, Hill MM et al.
Effects of exercise training during hemodialysis.
Nephron 1986; 43: 87–92.
18 Beck AT, Ward CH, Mendelson M et al. An
inventory for measuring depression. Arch Gen
Psychiatry 1961; 4: 561–71.
19 Donias S, Demerdjis I. Assessment of depression
symptomatology with the Beck Depression
Inventory. Archives of the 10th Panhellenic
Neurology and Psychiatry Congress. 486–92.
20 Dimitriou E. The Eysenck Personality
Questionnaire (EPQ) in the study of the personality
of the Greeks and its use in clinical practice.
Triantafillou, 1977.
21 Fountoulakis K, Iacovides A, Christofidis A et al.
The standardization of ‘The Scale of Life
Satisfaction’ for the Greek population. Greek
Psychiatry 1997; 8: 292–304.
22 Spitzer W, Dobson A, Hall J et al. Measuring
the quality of life of cancer patients. A concise
QL-Index for use by physicians. J Chron Dis 1981;
14: 585–97.
23 Anagnostopoulos F, Niakas D, Pappa E.
Construct validation of the Greek SF-36 Health
Survey. Qual Life Res 2005; 14: 1959–65.
24 Painter P. The importance of exercise training in
rehabilitation of patients with end-stage renal dis-
ease. Am J Kidney Dis 1994; 24(suppl): 2–9.
25 Sakkas G, Sargreant AJ, Mercer TH et al. Changes
in muscle morphology in dialysis patients after 6
months of aerobic exercise training. Nephrol Dial
Transplant 2003; 18: 1854–61.
26 Kouidi E, Albani M, Natsis K et al. The effects of
exercise training on muscle atrophy in hemodialysis
patients. Nephrol Dial Transpl 1998; 13: 685–99.
27 Moore GE, Parsons DB, Stray-Gundersen J et al.
Uremic myopathy limits aerobic capacity in
hemodialysis patients. Am J Kidney Dis 1993; 22:
277–87.
28 Deligiannis A. Exercise rehabilitation and skeletal
muscle benefits in hemodialysis patients. Clin
Nephrol 2004; 61(suppl): 46–50.
29 Kimmel PL, Weihs KL, Peterson RA. Survival in
hemodialysis patients. J Am Soc Nephrol 1993; 4:
12–27.
30 Murray CJ, Lopez AD. Global mortality, dis-
ability, and the contribution of risk factors:
Global Burden of Disease Study. Lancet 1997;
349: 1436–42.
31 Kimmel PL, Peterson RA, Weihs KL et al.
Multiple measurements of depression predict mor-
tality in longitudinal study of chronic hemodialysis
outpatients. Kidney Int 2000; 57: 2093–98.
32 Suh MR, Jung HH, Kim SB et al. Effects of regular
exercise on anxiety, depression, and quality of life
in maintenance hemodialysis patients. Ren Fail
2002; 24: 337–45.
33 Lopes AA, Bragg J, Young E et al. Depression as a
predictor of mortality and hospitalization among
hemodialysis patients in the United States and
Europe. Kidney Int 2002; 62: 199–207.
34 Lew SQ, Piraino B. Quality of life and psycholo-
gical issues in peritoneal dialysis patients. Semin
Dial 2005; 18: 119–23.
35 Wuerth D, Finkelstein SH, Finkelstein FO. The
identification and treatment of depression in
patients maintained on dialysis. Semin Dial 2005;
18: 142–46.
36 Kimmel PL, Peterson RA. Depression in end-stage
renal disease patients treated with hemodialysis:-
tools, correlates, outcomes, and needs. Semin Dial
2005; 18: 91–97.
37 Mittal SK, Ahern L, Flaster E et al. Self-
assessed physical and mental function of
haemodialysis patients. Nephrol Dial Transplant
2001; 16: 1387–94.
38 Fujisawa M, Ichikawa Y, Yoshiya K et al.
Assessment of health–related quality of life in renal
transplant and hemodialysis patients using the
SF-36 the survey. Urology 2000; 56: 201–206.
39 Caress AL, Luker KA, Glynn-Owens R. A
descriptive study of meaning of illnes in chronic
renal disease. J Adv Nurs 2001; 33: 716–27.
40 Hagren B, Peterson IM, Severinsson E et al. The
haemodialysis machine as a lifeline: experience of
suffering from end-stage renal disease. J Adv Nurs
2001; 34: 196–202.
41 Lamping DL, Constantinovici N, Roderick P et al.
Clinical outcomes, quality of life and costs in the
North Thames dialysis study in elderly people on
dialysis: a prospective cohort study. Lancet 2000;
356: 1543–50.
42 DeOreo P. Hemodialysis patients-assessed func-
tional health status predicts continued survival,
hospitalization, and dialysis-attendance compli-
ance. Am J Kidney Dis 1997; 30: 204–12.
43 Kusek JW, Greene P, Wang SR et al. Cross-sec-
tional study of health-related quality of life in
African Americans with chronic renal insufficiency:
the African American Study of Kidney Disease and
Hypertension Trial. Am J Kidney Dis 2002; 39:
513–24.
44 Wu AW, Fink NE, Marsh-Manzi JV et al. Changes
in quality of life during hemodialysis and peritoneal
dialysis treatment: generic and disease specific
measures. J Am Soc Nephrol 2004; 15: 743–53.
45 Koufaki P, Mercer T, NaishP. Effects of exercise
training on aerobic and functional capacity of end-
stage renal disease patients. Clin Physiol Funct
Imaging 2002; 22: 115–24.
62 S Ouzouni et al.
 at Scientific library of Moscow State University on January 23, 2014cre.sagepub.comDownloaded from 
http://cre.sagepub.com/
http://cre.sagepub.com/
46 Knap B, Buturovic-Ponikvar J, Ponikvar R et al.
Regular exercise as a part of treatment for patients
with end-stage renal disease. Ther Apher Dial 2005;
9: 211–13.
47 Johansen K. Exercise in the end-stage renal
disease population. J Am Soc Nephrol 2007; 18:
1845–54.
48 Painter P, Carlson L, Carey S et al. Low-func-
tioning hemodialysis patients improve with exercise
training. Am J Kidney Dis 2000; 36: 600–608.
49 Parsons TL, Toffelmire EB, King-Van Vlack C.
The effect of an exercise program during
hemodialysis on dialysis efficacy, blood
pressure and quality of life in end-stage renal
disease (ESRD) patients. Clin Nephrol 2004; 61:
261–74.
50 Parsons T, Toffelmire E, King-Van Vlack C.
Exercise training during hemodialysis
improves dialysis efficacy and physical
performance. Arch Phys Med Rehabil 2006; 87:
680–87.
51 Ridley J, Hoey K, Ballagh-Hawes N. The exercise-
during-hemodialysis program: report on a pilot
study. CANNT J 1999; 9: 20–26.
Quality of life after training in haemodialysis patients 63
 at Scientific library of Moscow State University on January 23, 2014cre.sagepub.comDownloaded from 
http://cre.sagepub.com/
http://cre.sagepub.com/