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Effects of Exercise Training on Restless Legs Syndrome, Depression, Sleep Quality, and Fatigue Among Hemodialysis Patients: A Systematic Review and Meta-analysis
Address correspondence to: Xiao-lian Jiang, RN, PhD, Department of Nursing, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, Sichuan Province 610041, China.
Hemodialysis (HD) patients experience a heavy symptom burden that leads to a decreased quality of life. Pharmacological treatment is effective but costly and has adverse effects. Exercise is a promising approach for symptom management, but the effect of exercise on restless legs syndrome (RLS), depression, sleep quality, and fatigue in HD patients is still uncertain.
Objectives
This meta-analysis was conducted to identify whether exercise training is beneficial in the treatment of the symptoms of RLS, depression, poor sleep quality, and fatigue in patients receiving HD.
Methods
A systematic search of PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Central Register of Controlled Trials, and Web of Science was conducted to identify randomized controlled trials (RCTs) comparing exercise training with routine care on RLS, depression, sleep quality, and fatigue among HD patients. Quality assessment was conducted using the Cochrane risk of bias tool, and RevMan 5.3 was used to analyze the data.
Results
Fifteen RCTs that met our inclusion criteria were included. The pooled effect size showed that exercise training was effective on RLS (P < 0.001), depression (P < 0.001), and fatigue (P < 0.001). However, effect size combinations for sleep quality were not performed owing to the sensitivity analysis results.
Conclusion
Exercise training may help HD patients to reduce the severity of RLS, depression, and fatigue. More high-quality RCTs with larger samples and comparative RCTs focused on different exercise regimens are needed.
Although enhanced dialysis techniques have resulted in longer survival in patients with ESRD in recent years, these patients suffer from several complications and a heavy burden of symptoms that result from either ESRD or HD treatment,
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Meanwhile, people with ESRD usually take several drugs, and renal impairment could lead to a higher risk of adverse effects, drug interactions, or other drug-related problems.
Hence, health providers are actively seeking an effective treatment with few side effects to reduce the symptom burden of patients receiving HD. As most HD patients are jobless or retired and thus often immobile,
there is emerging evidence that exercise training has significant beneficial effects on physical fitness, cardiovascular dimensions, walking capacity, nutritional status, and quality of life in adults with chronic kidney disease.
suggested that exercise has many beneficial effects on uremic RLS, poor sleep, depression, and low quality of life. In addition, Shahgholian et al.'s study
reported that changes in RLS symptoms were not statistically meaningful after four weeks of stretching exercises, but the changes were meaningful at the end of the eighth week. There is evidence that a six-month intradialytic exercise program was as effective as a concurrent low-dosage dopamine agonist treatment in reducing RLS symptoms and improving depression status, but only the dopamine agonists significantly improved sleep quality.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome.
Effects of intradialytic exercise on the physical function, depression, and quality of life for hemodialysis patients: a systematic review and meta-analysis of randomized controlled trials.
suggested that intradialytic exercise, aerobic exercise, and resistance exercise all effectively reduce depression in HD patients. Nevertheless, van Vilsteren et al.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
found no statistically significant improvement in depression after a 12-week low- to moderate-intensity exercise program. A simplified yoga-based exercise program proved to be a complementary, safe, and efficacious clinical treatment for improving fatigue, sleep disturbance, and pain among patients undergoing HD.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
reported that aerobic exercise was a highly economical and efficient strategy to manage problems such as anxiety and sleep quality in HD patients, but the effects on fatigue had not been investigated. Therefore, whether exercise interventions are effective to treat RLS, depression, insomnia, and fatigue in HD patients remains to be confirmed in a quantitative meta-analysis, and exercise prescriptions are yet to be determined.
The present meta-analysis was conducted to identify whether exercise training is beneficial in the treatment of the symptoms of RLS, depression, poor sleep quality, and fatigue in patients receiving HD.
Method
This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to report the findings.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
We conducted a systematic search of the PubMed, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Web of Science databases from inception to September 2017, using the search terms consisting of medical subject headings and free-text terms. For instance, the PubMed search terms were (dialysis OR dialyses OR hemodialysis OR hemodialyses OR haemodialysis OR haemodialyses OR HD OR hemofiltration OR haemofiltration OR HDF OR maintained hemodialysis OR maintained hemodialyses OR maintained haemodialysis OR maintained haemodialyses OR MHD OR extracorporeal dialysis OR extracorporeal dialyses) AND (Exercise OR physical training OR aerobic training OR resistance training OR strength training) AND (Randomized controlled trial OR randomized OR random OR placebo). The search terms were modified and adapted in other different databases. We also manually searched the reference lists of some related meta-analyses, original articles, and reviews.
Study Selection
Studies were screened based on the following selection criteria: types of studies—randomized controlled trials (RCTs); types of participants—patients with ESRD undergoing HD for more than three months and aged above 18 years; types of interventions and controls—exercise training compared to routine HD treatment or exercise training with pharmacological treatment compared to the same pharmacological treatment; types of outcome measures—severity of RLS, depression, sleep quality, and fatigue (for any measure used); publication language—English only. Reviews, case reports, animal trials, studies with unavailable full texts, or incomplete outcome data were excluded. We performed two steps to select the studies. First, the titles and/or abstracts of studies were screened according to predetermined eligibility criteria. Second, full texts of potentially eligible studies were obtained. All studies were assessed and selected by two independent review authors (Y. -y. S. and Y. -s. D.), and we solved any disagreement through discussion with a third review author (X. -l. J.).
Data Extraction
Data were extracted into a predesigned data collection form (Microsoft Office Word 2013; Microsoft Corp., Redmond, WA) by the same two independent reviewers (Y. -y. S. and Y. -s. D.). Disagreements were solved by consultation with a third review author (X. -l. J.). The following data were collected: first author, publication year, study location, sample size (both intervention group and control group, both before and after the intervention), exercise interventions (type, frequency, intensity, once and total duration, place), and control interventions and outcomes (mean and SD of outcome measures after intervention).
Quality Assessment
The Cochrane risk of bias tool was used to evaluate the validity of the included studies according to the following domains: random sequence generation, concealment of allocation, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and any other bias. Each domain was ranked as high risk, unclear risk, or low risk. Two reviewers (R. -j. H. and L. C.) assessed the risk of bias independently, and disputes were solved by discussion with a third author (X. -l. J.).
Data Synthesis and Statistical Analysis
Tests of heterogeneity and meta-analysis were performed using Review Manager (RevMan, computer program, version 5.3; Copenhagen: The Nordic Cochrane Center, The Cochrane Collaboration, 2014). Heterogeneity was investigated using the I2 statistic and chi-square test.
If P > 0.10 and I2 < 50%, the heterogeneity was sustainable, and a fixed-effects model was used to pool data; if P < 0.10 and I2 > 50%, the heterogeneity was considered significant, and a subgroup analysis was used according to intervention doses, population characteristics, or methodological quality to explain the heterogeneity. A random-effects model was conducted if significant heterogeneity still existed. A sensitivity analysis was conducted by changing the effect models and omitting any single selected study to test the stability of the results. Continuous data were extracted as the standardized mean difference (SMD) with a 95% CI. Publication bias was assessed using funnel plots and Egger's test.
The initial database search and a further manual search identified 2093 records, then 48 records were screened by full texts, and consequently 15 studies that met our inclusion criteria were recruited (Fig. 1). The 15 studies were RCTs involving a total of 683 HD patients.
Fig. 1Flowchart of selecting process. RCT = randomized controlled trial.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Three to four times/week exercised in subgroups (five patients each subgroup) at 50%–60% of their VO2max or 60%–70% of their HRmax for 90 minutes on the off-dialysis days, each session consisted of stationary cycling, walking or jogging, calisthenics, aerobics as well as swimming, and/or game sports such as basketball and football in the last eight to 12 weeks
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Two to three times/week, for ∼20–30 minutes within the first two hours of dialysis: a 5- to 10-minute warm-up, a 20-minute exercise program including calisthenics, steps, flexibility and low weight resistance exercises, and a five- to 10-minute cooldown period, as well as predialysis strength training. The intensity of the exercise program is condition level 12–16 according to RPE.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
Three times/week exercise rehabilitation program for 60–90 minutes during the first two hours of their dialysis, consisted of cycling, strengthening, and flexibility exercises
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Three times/week for 60–90 minutes within the first two hours of the dialysis, consisted of cycling, strengthening, and cooldown period. The intensity of the exercise program is condition level 11–13 according to RPE.
Three times/week aerobic exercise training within the first two hours of the dialysis, consisted of five minutes of warm-up and 10–30 minutes of stationary cycling at an intensity of 12–15 according to RPE.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Three times/week of intradialytic exercise training, cycling at an intensity of 60%–65% of the patient's maximal exercise capacity (45 minutes, find in another article
A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome.
Three times/week of exercise for 30 minutes between Hours 2 and 3 during dialysis, consisted of five-minute warm-up and 20-minute pedaling and five-minute cooldown. The intensity of the exercise program is condition level 10–12 according to RPE.
Three times/week for 35-minute exercise movements at home in the days without dialysis, consisted of joints warming actions, stretching exercises, motions of lower back muscles and abdomen, and deep breathing exercises
Three times/week for 30-minute stretching exercise within the last two hours of dialysis, consisted of five-minute warm-up, 20 minutes stretching legs, and five-minute cooldown
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
Three times/week Pilates exercise (13 movements) for 45 minutes in nonhemodialysis days
Routine nursing care
Eight weeks
GHQ-28 (depression dimension)
I = intervention; C = control; VO2max = maximal oxygen uptake; HRmax = maximal heart rate; BDI = Beck Depression Inventory; SDS = Self-rating Depression Scale; RPE = the rate of perceived exertion; POMS = the profile of mood states; HD = hemodialysis; VAS = Visual Analogue Scale; HADS = The Hospital Anxiety and Depression Scale; PSQI = The Pittsburgh Sleep Quality Index; ESS = Epworth Sleepiness Scale; IRLS = International Restless Legs Syndrome Study Group Rating Scale; GHQ-28 = The General Health Questionnaire-28.
We assessed the risk of bias of each included study using the Cochrane risk of bias tool. We present a “risk of bias graph” (Fig. 2) and a “risk of bias summary” (Fig. 3). Although all studies were described as “randomized,” only three explained the randomization methods (20%). Moreover, only two reported allocation concealment in detail (13.33%). Blinding of the participants and personnel was usually impossible owing to the nature of the exercise interventions, so we rated the 15 studies at a high risk of bias in this domain. Blinding of outcome assessment was reported in four studies (26.67%). Eleven RCTs clearly reported dropouts and their reasons (73.33%), but none reported using intention-to-treat analysis to analyze the data. All RCTs reported adequate expected results. Eleven RCTs reported that there were no significant differences in age or gender between the intervention and control groups at baseline (73.33%). Owing to the insufficient number of included trials, funnel plots were not performed and the results of Egger's tests showed no significant publication bias in the meta-analysis (P-value was 0.383 for RLS, 0.527 for depression, 0.191 for sleep quality, and 0.717 for fatigue).
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
involving 141 HD patients (75 in the intervention group and 66 in the control group) reported the effect of exercise training on the severity of RLS. There was high heterogeneity, so a subgroup analysis was performed according to the methodological quality of the RCTs, indicating a statistically significant difference between exercise intervention and the control (SMD −1.79, 95% CI: −2.21 to −1.37; I2 = 0%, P < 0.53). Sensitivity analysis was conducted by changing the effect models and omitting any single selected study. As the result did not change, the result was suggested to be reliable. Exercise training was able to reduce the RLS symptoms among HD patients (P < 0.001) (Fig. 4).
Fig. 4Meta-analysis and forest plot of four studies comparing an exercise group with a control group on the severity of RLS. RLS = restless legs syndrome.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
involving 368 HD patients (202 in the intervention group and 166 in the control group) reported the effect of exercise training on patients' degree of depression. There was high heterogeneity, so a subgroup analysis was performed according to whether patients had RLS, indicating a statistically significant difference between exercise intervention and the control (SMD −0.95, 95% CI: −1.18 to −0.73; I2 = 0%, P = 0.96). A sensitivity analysis was conducted by changing the effect models and omitting any single selected study. The result did not change, suggesting that the result was reliable. Hence, exercise training was able to reduce depression in HD patients (P < 0.001) (Fig. 5).
Fig. 5Meta-analysis and forest plot of eight studies comparing an exercise group with a control group on depression. RLS = restless legs syndrome.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
involving 154 HD patients (80 in the intervention group and 74 in the control group) reported the effect of exercise training on sleep quality. There was high heterogeneity, so a subgroup analysis was performed depending on whether patients exercised during HD, indicating a statistically significant difference between the exercise intervention and the control (SMD −1.28, 95% CI: −1.66 to −0.9; I2 = 0%, P = 0.32). We also used sensitivity analysis for sleep quality; the result was altered when we changed the effect models, suggesting that the result was not robust, so we did not combine the data and only described the results (Fig. 6).
Fig. 6Meta-analysis and forest plot of four studies comparing an exercise group with a control group on sleep quality.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
involving 139 HD patients (68 in the intervention group and 71 in the control group) reported the effect of exercise training on fatigue. A fixed model was used, indicating a statistically significant difference between exercise intervention and the control (SMD −0.85, 95% CI: −1.2 to −0.5; I2 = 0%, P = 0.81). A sensitivity analysis was conducted by changing the effect models and omitting any single selected study; the result did not change, suggesting that the result was robust. Therefore, exercise training was able to alleviate fatigue in HD patients (P < 0.001) (Fig. 7).
Fig. 7Meta-analysis and forest plot of three studies comparing an exercise group with a control group on fatigue.
This systematic review and meta-analysis provide evidence for health providers to potentially alleviate the severity of RLS, depression, and fatigue through exercise interventions among HD patients. However, the methodological quality was limited in the included studies, and we failed to obtain high-quality evidence in this meta-analysis, as the accumulated evidence ranged from low to moderate quality.
RLS is an annoying symptom associated with sleep disturbance, increased psychological burden, decreased quality of life, higher risk of cardiovascular/cerebrovascular events, and mortality.
but many patients cannot adhere to such pharmacologic therapy due to side effects and complications such as nausea, lightheadedness, fatigue, and aggravation of symptoms.
Although it requires equipment, personnel, and time to deliver an effective exercise training session, exercise treatment has few side effects and has many advantages for patients; it is therefore easily accepted. According to the European Guidelines on Management of Restless Legs Syndrome
European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society.
published in 2012, there is insufficient evidence that intradialytic aerobic exercise could reduce RLS symptoms in HD patients, possibly because this finding is based on a single prospective cohort study
Intradialytic aerobic exercise training ameliorates symptoms of restless legs syndrome and improves functional capacity in patients on hemodialysis: a pilot study.
published in 2008. In light of the four studies that reported the effect of exercise training on RLS published in 2013 and 2016, it is worthwhile to further explore whether exercise training was beneficial in the treatment of RLS using a meta-analysis. Our study showed that exercise training could alleviate the severity of RLS among HD patients (SMD = −1.79, Z = 8.36, P < 0.00001). There was high heterogeneity, and we conducted a subgroup analysis according to the methodological quality in an attempt to explain the heterogeneity. It appears that Mortazavi et al.'s study
had a high risk of baseline imbalance that may have caused the heterogeneity. All included studies used the International Restless Legs Syndrome Study Group Rating Scale to assess the severity of RLS and conducted exercise during dialysis three times a week. One study
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression is a common psychological symptom and is associated with increased risks of hospitalization and mortality among HD patients, and the reported prevalence was 10%–45%.
In recent years, many studies have stressed nonpharmacological treatments to cure depression in HD patients to avoid the adverse effects of drug therapy. Exercise interventions are relatively easy to perform and are suggested to help cure depression.
In our meta-analysis, exercise training reduced the severity of depression among HD patients (SMD = −0.95, Z = 8.33, P < 0.00001). There was high heterogeneity, and in a subgroup analysis between patients with RLS and without RLS, it appeared that comorbid RLS could cause the heterogeneity. A multitude of tools were used to assess depression: the Beck Depression Inventory, The Hospital Anxiety and Depression Scale (HADS), the Zung Depression Scale, and Self-Rating Depression Scale. This also indicated that the multiple measurements were not a major source of heterogeneity. Kouidi et al.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
used both Beck Depression Inventory and HADS in their study, the reason that we extracted data from HADS was lower heterogeneity. Four exercise programs were conducted during HD, and three
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
Associations of self-reported physical activity types and levels with quality of life, depression symptoms, and mortality in hemodialysis patients: the DOPPS.
in the dialysis centers of 12 countries based on data from 2009 to 2011 found that aerobic exercise was negatively associated with depression symptoms, but the relationships between strength/flexibility exercises and depressive symptoms were weak and inconsistent. Nevertheless, in the eight RCTs meeting our inclusion criteria that reported the effect of exercise training on depression, four studies
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
used stretching and joints warming actions. Our meta-analysis further confirmed the effect of aerobic exercise on depression and found the potential effectiveness of other types of exercise on depression.
A significant portion, 23%–85%, of HD patients have trouble falling asleep.
There is currently no specified pharmaceutical treatment guideline for HD patients, and the existing recommendations are mainly based on expert opinions.
In our meta-analysis, the combined results showed statistically significant differences between the exercise and control groups (P < 0.00001). However, in a sensitivity analysis, the result was altered when we changed the effect models, suggesting that the result was not robust, so we did not combine the data and only described the results. Three studies
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
The Pittsburgh Sleep Quality Index, sleep disturbance (measured by the Visual Analogue Scale), and sleep diary/Epworth Sleepiness Scale (ESS) (both used in one study)
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
were adopted to assess sleep quality; the reason that we extracted data from sleep diary but not ESS was we analyzed data after intervention in RevMan, and there was a larger difference in ESS at baseline, which could likely lead to bias.
HD patients reported fatigue as a major stressor, with a prevalence of 44.7%.
suggested that exercise might reduce fatigue in adults undergoing HD. In our meta-analysis, exercise training affected fatigue in HD patients (SMD = −0.85, Z = 4.77, P < 0.00001). Our study is the first meta-analysis to reach this conclusion. Fatigue was investigated by Visual Analogue Scale, the profile of mood states (fatigue dimension), and the Rhoten Fatigue Scale, and we found that the various measurements were not a major source of heterogeneity. The total duration of the exercise interventions was eight weeks
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
clearly described the duration of one exercise session to be 30 minutes. Furthermore, none of the three studies described the intensity of the exercise interventions. However, there is evidence that vigorous activity may be a demotivating factor in patients' willingness to continue in the exercise program, and thus, a less vigorous exercise was thought to be more appropriate.
Effects of intradialytic exercise on the physical function, depression, and quality of life for hemodialysis patients: a systematic review and meta-analysis of randomized controlled trials.
was published in 2017 and studied the effects of intradialytic exercise on physical function, depression, and quality of life for HD patients. By contrast, we included intradialytic exercise and all other exercises in our review. Besides, we excluded Giannaki et al.'s study
A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome.
because both groups performed exercises, and thus, the study did not meet our inclusion criteria. More than that, we included RLS, sleep quality, and fatigue as outcomes. The second study
was a meta-analysis published in 2015 on nonpharmacological interventions for sleep quality among dialysis patients; this report only included two RCTs
that studied the effect of physical exercise on fatigue (secondary outcome). In contrast, the two RCTs were also included in our review, and we included RLS and depression as outcomes.
Implications
For Nursing Practice
HD patients always experience many annoying symptoms, depriving them of a normal life. Exercise therapy was effective in treating some symptoms. In this meta-analysis, exercise proved capable of reducing the severity of RLS, depression, and fatigue. However, owing to the results of a sensitivity analysis, effect size combinations for sleep quality were not performed.
Our study suggested that HD patients could perform exercises to relieve RLS, depression, and fatigue symptoms. Notably, as recommended by ACSM,
patients with chronic renal disease were encouraged to do 20–60 minutes/day of continuous aerobic exercise three to five days/week and resistance exercises two to three days/week at a moderate intensity. Our study found the potential effectiveness of other types of exercise on these three symptoms, but more comparative RCTs focused on different types, durations, and intensities of exercise training are still needed to provide evidence of optimal exercise regimens for symptom management in HD patients. Second, although exercise is beneficial and safe, some patients and some circumstances are not suitable for exercise, for instance, patients with uncontrolled arrhythmias or hypertension, uncontrolled heart failure, or pulmonary diseases. Patients should be supervised by trained personnel (e.g., renal physiotherapist or clinical exercise physiologist) at the beginning of the exercise training. Finally, regardless of the type of exercise, the most important factor is persistence.
For Future Research
Owing to the low-to-moderate methodological quality of the included studies, we could not reach conclusions based on high-quality evidence. The effects of exercise interventions on RLS, depression, sleep quality, and fatigue among HD patients need to be further investigated by more rigorous studies with larger samples.
In the current meta-analysis, we compared only exercise training and usual care (or with the same drugs in both groups), and thus, the comparative effects of a pharmacological approach and exercise interventions on RLS, depression, sleep quality, and fatigue among HD patients remain to be investigated. In addition, the effects of different types of exercises and different exercise prescriptions on HD patients require to be studied. Therefore, more original studies are recommended.
Strengths and Limitations
There are several strengths of this review. First, the review question is an important and practical issue closely related to the daily work of health providers. Second, to our knowledge, this is the first meta-analysis that includes all randomized controlled trials to investigate the effects of exercise interventions on RLS, depression, sleep quality, and fatigue in HD patients. Third, the search was conducted using multiple databases. Fourth, sensitivity analysis showed that the results of the meta-analysis were reliable, except for the effect of exercise training on sleep quality among HD patients.
The study has some limitations, as follows. First, only a few studies clearly reported the randomization, allocation concealment, and blinding of outcome assessment, which may lead to relatively low methodological quality. Thus, we could not reach high-quality conclusions. Second, all outcomes were measured using subjective questionnaires, which may produce potential bias. Third, exercise prescriptions varied in types of exercise, duration, and frequency. Although subgroup analysis was conducted, it may have caused bias. Fourth, we analyzed data after intervention but not changes from baseline, which may introduce some bias. Fortunately, there was no significant difference in the baseline data, and we avoided using data with larger differences at baseline if different tools were used to assess the same outcome. Fifth, we only retrieved articles in English, and thus, the conclusion is limited to data retrieved from studies published in English language databases.
Conclusions
This is the first meta-analysis that includes all randomized controlled trials to investigate the effects of exercise interventions on RLS, depression, sleep quality, and fatigue in HD patients. The results suggest that exercise training is an effective treatment for RLS, depression, and fatigue among HD patients, with few side effects. However, owing to the results of sensitivity analysis, effect size combinations for sleep quality were not performed. Given the discussed limitations, additional high-quality RCTs with larger samples are warranted to confirm or dispute our findings, and more comparative RCTs focused on different types, durations, and intensities of exercise training are needed to provide evidence of optimal exercise regimens for symptom management in HD patients.
Disclosures and Acknowledgments
This work was supported by the science and technology plan projects in Sichuan province (2014FZ0109). The authors declare no conflicts of interest.
Effect of progressive muscle relaxation and aerobic exercise on anxiety, sleep quality, and fatigue in patients with chronic renal failure undergoing hemodialysis.
Effect of exercise training and dopamine agonists in patients with uremic restless legs syndrome: a six-month randomized, partially double-blind, placebo-controlled comparative study.
Depression, heart rate variability, and exercise training in dialysis patients. European journal of cardiovascular prevention and rehabilitation: official journal of the European Society of Cardiology.
A single-blind randomized controlled trial to evaluate the effect of 6 months of progressive aerobic exercise training in patients with uraemic restless legs syndrome.
Effects of intradialytic exercise on the physical function, depression, and quality of life for hemodialysis patients: a systematic review and meta-analysis of randomized controlled trials.
The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions, version 5.1.0. The Cochrane Collaboration,
2011 ([updated March 2011]. Available from)
Effects of resistance exercise training and nandrolone decanoate on body composition and muscle function among patients who receive hemodialysis: a randomized, controlled trial.
The effect of interdialytic combined resistance and aerobic exercise training on health related outcomes in chronic hemodialysis patients: the Tunisian randomized controlled study.
European guidelines on management of restless legs syndrome: report of a joint task force by the European Federation of Neurological Societies, the European Neurological Society and the European Sleep Research Society.
Intradialytic aerobic exercise training ameliorates symptoms of restless legs syndrome and improves functional capacity in patients on hemodialysis: a pilot study.
Associations of self-reported physical activity types and levels with quality of life, depression symptoms, and mortality in hemodialysis patients: the DOPPS.
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