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Written by Doug W Gould, Euan N Paterson, Dr Emma L Watson, Dr João L Viana and Dr Alice C Smith on behalf of the Leicester Kidney Exercise Team, John Walls Renal Unit, Leicester General Hospital

WHY SHOULD I EXERCISE?

Being inactive increases the risk of developing long term health problems such as heart disease, strokes, diabetes, cancer, dementia, depression – the list seems to get longer all the time. In fact, being inactive is rather risky behaviour!

Exercise Is Medicine!

As well as helping to prevent health problems, exercise is now being used as part of the treatment of many of the diseases listed above. But what about kidney disease? Research shows that appropriate exercise is beneficial for kidney patients, but many kidney patients do not have the opportunity or believe they cannot exercise. But most can exercise, and exercise can have benefits for adults of all ages. It will help you feel better, stronger and more in control of your health. You just have to tailor the exercise to you and your circumstances. Whether you want to return to work, do daily household activities, or manage your own health care, exercise will help you.

Exercise helps to protect the heart

Having kidney disease also makes it more likely that you will develop heart disease as well. It’s particularly important to look after your heart, for example by giving up smoking and keeping your blood pressure and cholesterol levels under control. In addition, regular exercise really helps to protect your heart and keep it in good shape by lowering blood pressure, controlling cholesterol, preventing diabetes and improving the condition of the blood vessels.

Exercise keeps your muscles strong

People with kidney disease often notice that they feel weaker and more tired than they used to, and that their muscles tend to shrink and waste away. This happens to everyone if they don’t use their muscles and keep them strong, but it can be worse if your kidneys don’t work properly because of the extra toxins in the blood.

Muscles are really important for everyone – not only weight lifters and gym bunnies, but anyone who just wants to be able move around, climb the stairs or get up out of a chair. Muscles are also important for general health, because they control the way the body uses blood sugar and fat. Having good muscles and using them regularly really helps to prevent diabetes and keep the heart healthy.

Exercise helps you to live a better life

Being physically activity can help you keep doing the things you enjoy and that are important to you – be it playing a round of golf, taking your grandchildren to the park, walking round the shops on a Saturday afternoon, or being able to climb the stairs and look after yourself in your own home. If you don’t keep yourself active, your fitness will decline and there will come a time when you won’t be able to do those things any more.

Everyone has the capacity to improve their physical condition and get stronger, no matter where they start from. In fact, the least active people tend to notice the biggest improvements when they take up exercise. So, have you decided to get in training for a better and healthier life? What should you do? And where and how can you do it?

This guide answers some of the questions you may have and will help you establish an exercise programme to suit you.

HOW DO I START AN EXERCISE PROGRAMME?

There are three basic steps for you to take to start an exercise programme:

1 Talk to the people involved in your care

They can tell what exercise is best for you because they know about your condition and treatment and what you can and can’t do. Your carers will probably be very happy that you are asking about exercise. Please ask your doctor or healthcare professional, especially if you have :
- More advanced kidney disease or kidney failure
- Other health problems in addition to kidney disease e.g.heart or liver conditions, or difficulties with blood pressure control
- Problems that affect your mobility or balance
- Diabetes : Exercise can help diabetes but you should ask about controlling your blood sugar levels – and please look after your feet

2 Plan your exercise programme

To improve your health and fitness it is important to gradually increase the amount of activity you do as your fitness improves and activities become easier. It is important to plan :
• What type of exercises you are going to do
• Roughly the total time you spend exercising, and the length of time or number of times, you will do each exercise for
• How hard you work. For example, how fast you will walk or what weight you will lift
• How often you exercise

3 Get started!

YOUR EXERCISE PLAN

Type of exercise
A good exercise programme consists of three different kinds of exercise: cardiovascular/aerobic (for heart, lungs and blood vessels, and also known as aerobic), resistance (for muscles) and stretching for flexibility. Each of these has different health benefits and you should try to do some of each kind.

Warming up and cooling down
All exercise must always start with a gentle warm-up using some light cardiovascular activity (e.g. gentle walking) for around 10 minutes. Then you can work harder for a while before slowing down again to cool down and relax towards the end. Finish with some stretches.

Cardiovascular exercise
This is a continuous activity such as walking or cycling, using large muscles, especially the legs. It benefits your whole body and makes you feel good. Think about what kind of thing you enjoy.

Aim to exercise for 30 minutes continuously. However, if you can’t manage this to begin with it doesn’t matter – just do what you can and try to increase the time a little bit each week. You can do two 15 minute sessions, or three 10 minute sessions in a day instead of one 30 minute session if that works better for you.

Most people like walking. This is an ideal exercise and a good way to start. Others may want to do something else such as cycling, swimming, dancing or using gym equipment. It’s up to you! You can combine different kinds of exercise on different days.

Resistance exercise
This is where you move some type of resistance (such as your bodyweight or a dumbbell) in a way which is hard enough so that you can only do it a few times. Resistance exercise is used for muscle strengthening but will also benefit your whole body. Kidney patients often suffer from muscle weakness and wasting and resistance exercise can help with this. Building stronger muscles will help you do other forms of exercise more easily and also help you with your everyday activities.

If you go to the gym you can use the machines and equipment there – ask the staff to show you how. But you can do resistance training at home too, using simple things like tins of beans! Just follow some simple guidance. Lift weights slowly, using very controlled movements, and keep going until your muscles tire – this will tell them that they need to get stronger. Choose a weight that you can lift 10-12 times before you need to rest - you may need lighter or heavier weights for different exercises. Keep breathing normally, don’t hold your breath, and avoid lifting weights above your head. Concentrate on the large muscles in your lower body (legs) as these are the ones that will help you most in your everyday activities.

We have included some suggestions of resistance exercises in this guide, which will show you the correct way to do them.

S-t-r-e-t-c-h-i-n-g

Stretching is something almost all patients can do. It is important to keep your joints working smoothly and preserve your full range of movement. Having a flexible body will help with all your everyday activities, as well as making exercise easier. We have included some stretching exercises for you in this guide.

Do each stretch to the point where you can feel the tension, but without causing pain.

Hold the position for 20-30 seconds. In the last 10 seconds you can try to increase the stretch a little further.

Make sure you keep your body in a good posture while you stretch (look at the photos to see how it should be done). Breathe normally and don’t hold your breath.

MAKING THE MOST OF EXERCISE 

How long to exercise

For your cardiovascular exercise, aim for at least 30 minutes a day on 3 or 4 days every week.

You should build up gradually to this level – don’t try to do 30
minutes all in one go to begin with. It is just as effective to do 2 or 3 shorter sessions at different times of the day (but each session must be at least 10 minutes to count towards the total). However there is nothing magical about 30 minutes. If you feel like walking for 45 to 60 minutes go ahead. Just be sure to follow the advice listed under “how hard to work while exercising” and the ‘What are the signs that I should stop exercising?’ in this guide.

How often to exercise

For cardiovascular exercise three days a week is the minimum
requirement to achieve the benefits. Ideally, these would be non-consecutive days, for example Monday, Wednesday and Friday, but you can do more if you want.

For resistance exercises, you should do these 2 or 3 times a week. You may find it easier to do your cardiovascular and resistance exercises on different days.

You can do your stretching exercises every day as you shouldn’t find them tiring. It’s a good idea to include them in the warm up and cool down parts of your other exercise sessions.

How hard to work while exercising

When you exercise, you need to make sure you are doing enough work to benefit your health and increase your capacity to do the things you want to do in life. But don’t do so much that it hurts or you feel unwell. This can be difficult without knowing your own exercise capacity. Usually the following tips are helpful:

• For cardiovascular exercise your breathing should not be so hard that you cannot talk with someone exercising with you. (Try to get an exercise partner such as a family member or friend). For resistance and stretching you should breathe normally.

• After exercise you should not feel so much muscle soreness that it keeps you from exercising the next session

• The most important thing is to start slowly and progress gradually allowing your body to adapt to the increased level of activity.

When advising patients about how hard they should exercise we use a scale based on how hard the exercise feels, called the “Borg 15-point Rate of Perceived Exertion Scale” or RPE (see page 11). The RPE scale ranges from 6 to 20. At point 6 you would be sitting doing nothing. At point 20 you would have done so much exercise that you were exhausted and could do no more. You need to aim for a steady exercising pace, between 12 and 14.

While you are exercising, rate yourself against the RPE chart and think about how hard you are exerting yourself. How much effort are you putting in, how is your breathing and how do you feel? If you rate yourself at 11 on the scale – fairly light – try exercising harder to reach 12, 13 or 14. If you rate yourself at 17, you probably need to be working less hard at your exercise. As you build up your fitness, you should find you can do more work within the ‘moderately hard’ 12 to 14 scale.

The Borg Scale of Percieved Exertion 

GET STARTED!

Don’t be nervous or think it’s going to be too hard. Many people with renal failure say they are too tired to exercise. They think that if they exercise they will be even more tired. The fact is, even a little bit of exercise, 15-20 minutes a day, will actually help you feel LESS tired.

Start slowly and just do what you can – you aren’t aiming to become a marathon runner. As long as you keep doing it regularly (at least 3-4 times a week), you will gradually get stronger and be able to do more and more.

DEVELOP ENDURANCE - CARDIOVASCULAR EXERCISES

You don’t need expensive equipment to do resistance exercise.

You can use things that are around your house. If you use milk bottles you can vary their weight by filling with more or less liquid. Tins of food also make good weights.

Follow the instructions below and start with a fairly light weight to begin with to get a feel for the movement, then increase the weight to make it more challenging.

Maintaining proper technique is important when doing resistance exercises. Use the strength of the body part which each exercise aims to work (described in the next few pages) and avoid swinging the body or bending or arching the back to lift a heavier weight. If you find yourself swinging the weight while you’re lifting or bending and arching your back to lift a weight, stop and choose a lighter weight to avoid injury. This will also help you work the target muscle.

       

DEVELOP MUSCLE STRENGTH - RESISTANCE EXERCISE

Bicep curl -

Works: The front of the arms
Main muscle worked: Biceps

• Sit or stand upright holding your weight by your side
• Keeping your elbows by your side bend your arms at the elbows and bring your hands up towards your shoulder
• Repeat as many times as you feel you can.

Wall push up –

Works: The back of the arms and chest Main muscle worked: Triceps and pectorals.

• Stand straight facing a wall
• Place both hands on the wall at shoulder height
• Lean forwards bending your elbows until your nose nearly touches the wall
• Push away from the wall until you are upright
• Repeat as many times as you feel you can

Chair squat -

Works: The bum and the front of the thighs
Main muscle worked: Gluteus Maximus and Quadriceps

• Stand in front of a sturdy chair and reach back and place your hand on the arms for balance

• Have your feet shoulder width apart and go to sit down, but don’t quite sit on the chair

• Hold this position for a few seconds and push back up using your legs to stand

Repeat as many times as you feel you can.

Stair step –

Works: The front of the thighs
Main muscle worked: Quadriceps

• Stand up straight in front of a small step

• Hold on to something close to you if you wish, or place both hands on your hips

• Step up onto the step using your right foot and then your left

• Step back down with your right then left

Repeat as many times as you feel you can

Back leg swing –

Works: The back of the legs and the back
Main muscle worked: Hamstrings, Gluteus Maximus, Erector spinae

• Stand upright in front of a chair and hold the back for support
• Keeping your back straight bring one leg behind you pointing your toes
• Slowly return your foot to the floor
• It’s important not to arch your back
• Repeat as many times as you feel you can, then swap and do the same for the opposite leg

Lower leg extension –

Works: The front of the thighs
Main muscle worked: Quadriceps

• Sit upright with both feet flat on the floor
• Hold onto the seat for support
• Lift one leg off the floor and hold it out straight
• Bend your knee and slowly lower your foot to the floor
• Repeat as many times as you feel you can, then swap and do the same for the opposite leg.

Heel raise –

Works: The lower legs (calves)
Main muscle worked: Gastrocnemius

• Stand in front of a chair and hold on to the back for support
• With both feet, lift your heels and stand on the balls of your feet
• Slowly return to standing
• If you find this easy put your hands on your hips
• Repeat as many times as you feel you can

Lunge –

Works: The bum and the front of the thighs
Main muscle worked: Gluteus Maximus and Quadriceps

• Find something you can hold onto, a broom for example
• Step your left foot out in front with the heel of your back foot slightly off the floor
• Keeping your back straight bend your front knee keeping it over your foot.
• Hold for a few seconds and push back up
• Repeat as many times as you feel you can, then repeat using the other leg

SUPPLENESS AND FLEXIBILITY - STRETCHING EXERCISES

Neck stretch –

Targets: The neck
Main muscles: Sternocleidomastoid, Trapezius, splenius

• Sit or stand upright looking straight ahead
• Slowly lower your right ear to your right shoulder
• Bring your head back up and lower your left ear to your left shoulder
• Repeat a few times until your neck muscles feel looser

Head turn –

Targets: The neck
Main muscles: Sternocleido-mastoid, splenius

• Slowly turn your head to the right looking over your right shoulder
• Slowly turn your head back to
centre
• Then turn your head to the left to look over your left shouder
• Slowly return your head to the centre
Repeat a few times until your neck muscles feel looser.

Shoulder shrug –

Targets: Shoulders, chest and upper back
Main muscles: Trapezius, pectorals

• Sit or stand upright
• Shrug your shoulders up to your ears, hold and repeat

Arm stretch and wrist rotation –

Targets: Arms, wrists and shoulders
Main muscles: Wrist flexors and extensors

• Sit or stand upright
• Start with your arms straight by your side
• Bring your arms up straight in front of you at shoulder height
• Make small circles with your wrists to the right and then to the left. Repeat
a few times until your wrists feel looser
• Bring your arms back down to your side

DEVELOPING FLEXIBILITY - STRETCHING EXERCISES

Chest and upper back stretch –

Targets: Shoulders, chest and upper back
Main muscles: Trapezius, pectorals

• Sit or stand upright
• Put your hands on your shoulders and elbows out to the side
• Touch your elbows together in front of your chest
• Move your elbows out wide again and squeeze your shoulder blades together
• Repeat until your chest and upper back muscles feel looser.

Single knee pull –

Targets: lower back and back of thigh
Main muscles: Hamstrings, Erector spinor

• Sit up straight
• Bend over and pull your knee towards your chest holding it with both hands
• Try to touch your forehead to your knee, or as close as you can get it
• Hold for about 10 seconds and lower your knee back down
Repeat with the other leg.

Calf stretch -

Targets: The calves
Main muscles: Gastrocnemius

• Stand up straight and hold onto something for support
• Step your right leg straight back and make sure your heel is pressed onto the floor
• Bend your front leg slightly, making you lean forwards
Hold for about 10 seconds
• Repeat with the other leg

Tip : If you can’t feel the stretch, move your back leg slightly further back.

Hamstring stretch -

Targets: back of thigh
Main muscles: Hamstrings

• Sit upright in a chair or on the floor
• Using a towel, place it under your foot and straighten your leg lifting it off the floor
• Gently pull the ends of the towel towards you flexing your foot towards you
Hold for about 10 seconds. Put your foot back to the floor and repeat using the other leg
• If you find this easy sit on the floor with one leg straight in front and reach down to your toes

Quadriceps stretch –

Targets: Front of the thigh
Main muscles: Quadriceps

• Stand upright and hold on to something for support
• Hold onto your right ankle using your right hand
• Bring your foot up to your bum keeping your knees together
Hold for 10 seconds
• Release your foot to the floor and repeat using the other leg

FREQUENTLY ASKED QUESTIONS

What do I need for exercise sessions?

A decision
Give exercise a try for a period of three months. One exercise
session will not help but as the time goes by, you will start to feel the benefit. Consider exercise to be a part of your treatment, together with your diet and medicines.

Persistence
There will be times that you will miss your exercise sessions for any number of reasons, including hospitalisations. Don’t give up!
Start again, If the time off has made you less fit, begin from that lower threshold and you will soon work your fitness up again.

There will be good days and bad days. If some days you feel very tired, you can exercise for a shorter period of time. Even ten minutes is better than nothing!

Clothes and shoes
You don’t need fancy or expensive sports clothes for exercise.
Wear comfortable shoes (not high heels!) and clothes that are not too tight. If you have several layers of light clothing you can remove or add some of them as needed.

How can I fit in exercise into my busy life ?

Anyone can work some exercise into their life, it’s surprisingly easy. Remember – it will really help you, so it’s worth making it a priority.

Some suggestions:

• At home : When the TV is on, do some stretching and do some resistance exercise or even do some cardiovascular exercise such as cycling on a stationery bike.

• On your way to work: Get off the bus a stop early or find a spot to park further away and walk ten minutes to the office.

• At work: Take a walk on your lunch break. A brisk walk can help you feel refreshed and allow you to work better in the afternoon. Another chance to get fitter is to take the stairs instead of the lift.

• To get things done: Walk or cycle to the shops and perhaps carry the shopping home. Take the opportunity to work in the garden.

In your leisure time: Get your family or friends to exercise with you - it’s good for them too! Take out a ball or Frisbee and offer to play a game with the kids or go for a cycle or walk.

Are there any times when I should not exercise?

Yes. Speak to your doctor before beginning exercise:

• If you have any change in your medication prescription
• If you are on dialysis and have changed your dialysis schedule
• If you have any problems with any joints or bones that become worse with exercise
If you have a fever
• If you have any change in your physical condition
• If the weather is very hot and humid or very cold (unless you are exercising somewhere with air conditioning/heating)

What are the signs that I should stop during exercising?

Stop your exercise at once if you notice any of the following during an exercise session :
• you feel chest pain
• you notice irregular or rapid heart beats
• you feel sick
• you feel cramps in your legs
• you feel light-headed or dizzy

TIPS TO CONSIDER WHEN STARTING EXERCISE

Exercise does not have to be for sporty types! It’s never too late to start to gain the benefits of exercise, no matter how old or unfit you may think you are.
• If you are new to exercise, start light and build up your level of activity gradually. Start with 10 minutes and over time build up to 30 minutes. Brisk walking is an ideal activity to start off with.
•Set yourself goals. Setting realistic goals can help you stay motivated to exercise. However, make the goals clear and beware of setting your goals too high, you may lose enthusiasm if you are unable to achieve them.
• Keeping an exercise diary can be a good motivational tool by helping you keep track of your progress. (We have included an example at the end of this leaflet)
• Remember to include muscle strengthening exercises. You should perform resistance exercise a minimum of twice per week, although these should not be on consecutive days.
• Use everyday activities as part of your exercise routine, this can count towards your 30 minutes per day. Consider a brisk walk to the shops or work instead of taking the bus or car; if you are able to, take the stairs instead of using a lift or try to reduce the amount of time you are inactive (time spent sitting down watching TV etc.) There are lots of ways to do this, these are just a few!
• Find exercise you can enjoy! If one kind of activity or exercise becomes boring, try switching to another. If you enjoy it, it is more likely to be something that you keep up.

If you need any more advice, please talk to the doctors, nurses or other members of the clinical team you see regularly.

Reproduced with the kind permission of Doug W Gould, Euan N Paterson, Dr Emma L Watson, Dr João L Viana and Dr Alice C Smith on behalf of the Leicester Kidney Exercise Team, John Walls Renal Unit, Leicester General Hospital

The National Kidney Federation cannot accept any responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.