Clinical Rehabilitation 2009; 23: 5363

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 disease, their functional and psychosocial status, as well as their health-related quality of life remain poor.16 Acute and chronic stressors, due to dialysis procedures, medications and health problems, 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.35 It is well documented that exercise rehabilitation programmes lead to an improvement in the functional capacity of predialysis7,8 and haemodialysis patients.914 Patients on haemodialysis are usually exercised on the non-dialysis days in a rehabilitation centre under the instructions of specialized exercise physiologists or physiotherapists and medical 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 compliance.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 cardiorespiratory efficiency, psychological status, as well as to investigate correlations between physical functioning, well-being and health-related quality of life indices.

with end-stage renal disease on maintenance haemodialysis three days per week, 4 hours/session, for at least six months prior to the study, volunteered to participate in the study. All patients completed a baseline medical screening including physical examination, resting ECG, echocardiographic 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 a 10-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 prescription was planned to remain constant by using the same model of filter and a constant composition 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 erythropoietin 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.

Patients and methods

Patients Thirty-five patients, men (n 27) and women (n 8), with mean (SD) age of 48.8 (13.9) years, Spiroergometric study The cardiorespiratory capacity of all patients at the beginning and end of the study was measured

Quality of life after training in haemodialysis patients 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 Borgs scale. End-point of the tests was either the development of symptoms (as dyspnoea, dizziness, etc.) or target heart rate, severe hypertension or hypotension, ST segment shift in ECG  2, 0 mm 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 manufacturers specifications. 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 pulmonary ventilation (VEmax), and metabolic equivalents (METs).

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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-administered questionnaire with 12 items that examined physical and mental health, sexual life, support from family and friends, hobbies, appearance and a global evaluation for quality 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 patients 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

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 characteristic attitudes and symptoms of depression.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

Exercise rehabilitation programme Patients of group A followed a 10-month exercise rehabilitation programme during their haemodialysis treatment in the renal unit. They were exercised three times weekly, 6090 minutes each time during the first 2 hours of their haemodialysis sessions, under the supervision of the physician and the responsibility of three exercise physiologists, specialized in this field. All subjects were exercised at 1314 (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 flexibility exercises. For the cycling exercise specific devices, which were adjusted to each patients 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 patients ability and finally reached an hour of active cycling. The strength

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S Ouzouni et al. 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 version 11.0 for Windows was used (SPSS Inc. Chicago, IL, USA). The level of significance was fixed at P50.05.

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 MannWhitney U or chi-square

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 complication 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 cardiorespiratory 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 Male/female Age (years) Height (cm) Years on haemodialysis A (n 19) 14/5 47.4 (15.7) 165 (9.0) 7.7 (7.0) B (n 14) 13/1 50.5 (11.7) 167 (10.0) 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 Baseline After 76.3 135.3 79.2 20.9 11.2 144.1 178.2 77.4 25.8 59.4 25.3 (7.1)* (11.6)* (7.7)* (5.2)* (2.5)* (14.3)* (22.2)* (9.6)* (5.4) (17.9)* (5.3)* Baseline 84.7 138.2 85.7 15.9 8.7 140.2 186.1 85.4 26.0 35.7 20.3 (10.6) (6.3) (4.6) (2.7) (1.4) (10.8) (11.5) (5.7) (1.9) (12.2) (3.6) Group B After 78.2 139.3 85.2 15.1 8.9 139.6 190.0 84.6 25.7 34.9 20.1 (10.3)# (9.1) (4.6)# (2.8)# (1.4)# (7.1) (13.9) (4.5)# (3.5) (4.9)# (3.4)#

Resting HR (beats/min) Resting sBP (mmHg) Resting dBP (mmHg) Exercise time (min) METs HRmax (beats/min) sBPmax (mmHg) dBPmax (mmHg) Double product ( 103) VEmax (L/min) Vo2peak (mL/kg per minute)

84.7 142.9 86.8 16.9 9.1 139.1 188.2 88.9 26.1 42.2 20.9

(10.6) (14.6) (7.8) (4.3) (2.2) (19.9) (17.3) (7.9) (4.7) (13.7) (5.4)

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.

Quality of life after training in haemodialysis patients 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

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Table 3 Data of psychosocial profile of the trained (group A) and untrained (group B) patients Group A Baseline After Group B Baseline 6.4 9.4 10.5 11.9 After

Eysenck Personality Questionnaire Psychotism 6.0 (1.4) 6.3 (1.4) Neurotism 10.1 (3.6) 9.8 (3.0) Extroversion 10.7 (1.5) 10.8 (1.6) Lies 12.2 (1.5) 12.9 (1.7)

(0.9) 6.1 (0.9) (0.8) 9.4 (0.7) (1.2) 10.6 (0.8) (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 (09) Mildly (1015) Moderately depressed (623) Severely depressed (424) 0 6 8 5 7 9 3 0 0 1 11 2 0 3 9 2

*P50.05 between baseline and final distribution in each group. # P50.05 between the two groups.

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 significantly increased after intradialytic exercise training (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 questionnaire, 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 (r 0.682, P50.05; Figure 1a) at baseline and at the end of the study (r 0.575, P50.05; Figure 1b). In addition, there was a negative relationship between Quality of Life Index and Beck Depression Inventory (r 0.790, P50.05; Figure 2a) at baseline and at the end of the study (r 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 (P 0.01), the increase in aerobic capacity (P 0.032) and the participation in the exercise training programme (P 0.024) had a statistically significant contribution to the model. The model explained 77.4% of the total variance (F 10.27, R2 0.774). Further analysis, using the Physical Component Scale as a subordinate variable (Table 7), showed that the increase of the aerobic

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Table 5 Scores of health-related quality of life indices Group A Baseline Quality of Life Index Patient activity Daily living Health Support Outlook SF-36 Physical Component Scale Mental Component Scale Life Satisfaction Index 6.5 1.4 1.5 1.1 1.5 1.0 (1.8) (0.5) (0.5) (0.6) (0.5) (0.4) After 9.0 1.8 2.0 1.7 1.9 1.5 (1.3)* (0.4)* (0.2)* (0.5)* (0.3)* (0.5)* Group B Baseline 6.3 1.4 1.3 1.1 1.4 1.1 (1.9) (0.5) (0.5) (0.6) (0.5) (0.6) After 6.3 1.4 1.2 1.1 1.4 1.1 (1.8)# (0.5)# (0.4)# (0.5)# (0.5)# (0.7)

40.5 (5.6) 41.8 (10.1) 44.8 (8.6)

44.5 (5.5)* 41.8 (10.0) 53.0 (5.6)*

39.0 (5.4) 40.3 (6.9) 42.1 (11.7)

38.9 (5.8)# 40.1 (6.8) 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.

(a)

12 10 8

(b) r = 0.682 p < 0.01 QLI 0 10 20 30 40 12 10 8 6 4 2 0 0 VO2peak (ml/Kg/min) 10 20 30 VO2peak (ml/Kg/min) 40 r = 0.575 p < 0.01

QLI
Figure 1

6 4 2 0

Correlation between Quality of Life Index (QLI) and Vo2peak at baseline (a) and at the end of the study (b).

(a)

12 10 8

r = 0.790 p < 0.01

(b) 12 10 8 QLI 6 4 2 0

r = 0.812 p < 0.01

QLI

6 4 2 0 0 10 20 30 BDI (depression score)

10

20

30

BDI (depression score)

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).

Quality of life after training in haemodialysis patients capacity (P 0.012) and the participation in the exercise programme (P 0.016) had a statistically significant contribution to the model, which explained 55.8% of the total variance (F 4.517, R2 0.558). Finally analysis, using the Life Satisfaction Index as a dependent variable (Table 8), showed that participation in the programme itself (P 0.003) contributed to the model, which explained 45.4% of the total variance (F 1.936, R2 0.454).

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Discussion
The results of the study indicate that regular exercise training during haemodialysis increases
Table 6 Multiple regression analysis with Quality of Life Index as the dependent variable at the end of the study  Participation in exercise Exercise training Psychoticism Neuroticism Extroversion Lies Depression Vo2peak Years on haemodialysis R 2 0.774 F 10.270 *P50.05. Table 7 Multiple regression analysis with Physical Component Scale as the dependent variable at the end of the study  Participation in exercise Exercise training Psychoticism Neuroticism Extroversion Lies Vo2peak Haemoglobin R 2 0.558 F 4.517 *P50.05. 51.37 2.22 0.26 0.135 1.218 0.208 0.671 0.89 P-value 0.016* 0.331 0.79 0.769 0.056 0.74 0.012* 0.508 9.448 0.181 0.449 0.105 0.127 0.028 0.21 0.174 0.006 P-value 0.024* 0.781 0.065 0.362 0.441 0.85 0.01* 0.032* 0.069

patients physical capacity, enhances their psychological status and consequently improves their quality of life. Quality of Life Index was found to be influenced by the level of physical functioning, 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 29 mL/kg per minute.2426 Central and peripheral factors seem to be responsible 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, extroversion and 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 haemodialysis patients, which varies between 12% and 45% due to the discrepancies in the methodology used

Table 8 Multiple regression analysis with Life Satisfaction Index as the dependent variable at the end of the study  Participation in exercise Exercise training Psychoticism Neuroticism Extroversion Lies Depression Vo2peak Haemoglobin R 2 0.454 F 1.936 *P50.05. 83.465 6.257 1.02 0.624 1.303 0.775 1.013 0.176 2.382 P-value 0.0033* 0.218 0.575 0.488 0.289 0.507 0.105 0.755 0.375

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S Ouzouni et al. the small duration and low intensity of the exercise programme. In addition, our results of the SF-36 questionnaire 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 presented 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 agreement with previous studies. From a previous study of ours, the application of a six-month exercise programme in a rehabilitation centre on the nondialysis 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 depression 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 programme during haemodialysis. Similarly, Suh et al.32 reported that there was a trend of improvement in depression after the implementation of a 12-week exercise training programme, though it

for the research and the differences in the criteria used in evaluation.2932 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.3436 In clinical practice there are a number of instruments 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.3740 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 general population. Psychological condition does not seem to vary particularly, mostly because in chronic diseases, patients gradually learn to compromise with the idea of their illness.4244 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.9,13,26,4547 A similar increase of the Vo2peak, which varied from 20 to 23% after a six-month intradialytic exercise training programme was also observed.13,25 However, three months of intradialytic exercise training in haemodialysis patients caused only a 13% increase of their Vo2peak.27 This result could be attributed to

Quality of life after training in haemodialysis patients 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 participation in a training programme, on the level of their cardiorespiratory efficiency and on the level of their depression. In particular, by increasing their physical capacity they felt more efficient and able to take care of themselves. In addition, the reduction of depression observed after training indicated 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 healthrelated quality of life in haemodialysis patients. Therefore, exercise training should be considered as an important therapeutic modality for the management of haemodialysis patients, who should be encouraged to participate in any forms of exercise training programmes, according to their physical and medical condition.

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References
1 Paganini EP. In search of an optimal hematocrit level in dialysis patients: rehabilitation and qualityof-life implications. Am J Kidney Dis 1994; 24(suppl 1): 1016.

2 Hruska KA, Teitelbaum SL. Renal osteodystrophy. N Engl J Med 1995; 333: 16674. 3 Kouidi E. Health-related quality of life in end-stage renal disease patients: the effects of renal rehabilitation. Clin Nephrol 2004; 61(suppl): 6071. 4 Johansen KL. Physical functioning and exercise capacity in patients on dialysis. Adv Ren Replace Ther 1999; 6: 14148. 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: 293300. 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: 26066. 7 Clyne N. The importance of exercise training in predialysis patients with chronic kidney disease. Clin Nephrol 2004; 61(suppl 1): 1013. 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: 4856. 9 Painter P, Carlson L, Carey S et al. Physical functioning and health-related quality-of-life changes with exercise training in hemodialysis patients. Am J Kidney Dis 2000; 35: 48292. 10 Kouidi E. Central and peripheral adaptations to physical training in patients with end-stage renal disease. Sports Med 2001; 31: 65165. 11 Kouidi E. Exercise training in dialysis patient: Why, when and how? Artif Organs 2002; 26: 100913. 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: 16267. 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: 4045. 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: 82632. 15 Kouidi E, Iacovides A, Iordanidis P et al. Exercise renal rehabilitation program (ERRP). Psychosocial effects. Nephron 1997; 77: 15258. 16 Deligiannis A, Kouidi E, Tourkantonis A. The effects of physical training on heart rate variability in hemodialysis patients. Am J Cardiol 1999; 84: 197202.

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S Ouzouni et al.
in maintenance hemodialysis patients. Ren Fail 2002; 24: 33745. 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: 199207. Lew SQ, Piraino B. Quality of life and psychological issues in peritoneal dialysis patients. Semin Dial 2005; 18: 11923. Wuerth D, Finkelstein SH, Finkelstein FO. The identification and treatment of depression in patients maintained on dialysis. Semin Dial 2005; 18: 14246. Kimmel PL, Peterson RA. Depression in end-stage renal disease patients treated with hemodialysis:tools, correlates, outcomes, and needs. Semin Dial 2005; 18: 9197. Mittal SK, Ahern L, Flaster E et al. Selfassessed physical and mental function of haemodialysis patients. Nephrol Dial Transplant 2001; 16: 138794. Fujisawa M, Ichikawa Y, Yoshiya K et al. Assessment of healthrelated quality of life in renal transplant and hemodialysis patients using the SF-36 the survey. Urology 2000; 56: 201206. Caress AL, Luker KA, Glynn-Owens R. A descriptive study of meaning of illnes in chronic renal disease. J Adv Nurs 2001; 33: 71627. 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: 196202. 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: 154350. DeOreo P. Hemodialysis patients-assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance. Am J Kidney Dis 1997; 30: 20412. Kusek JW, Greene P, Wang SR et al. Cross-sectional 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: 51324. 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: 74353. Koufaki P, Mercer T, Naish P. Effects of exercise training on aerobic and functional capacity of endstage renal disease patients. Clin Physiol Funct Imaging 2002; 22: 11524.

17 Painter PL, Nelson-Worel JN, Hill MM et al. Effects of exercise training during hemodialysis. Nephron 1986; 43: 8792. 18 Beck AT, Ward CH, Mendelson M et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 56171. 19 Donias S, Demerdjis I. Assessment of depression symptomatology with the Beck Depression Inventory. Archives of the 10th Panhellenic Neurology and Psychiatry Congress. 48692. 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: 292304. 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: 58597. 23 Anagnostopoulos F, Niakas D, Pappa E. Construct validation of the Greek SF-36 Health Survey. Qual Life Res 2005; 14: 195965. 24 Painter P. The importance of exercise training in rehabilitation of patients with end-stage renal disease. Am J Kidney Dis 1994; 24(suppl): 29. 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: 185461. 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: 68599. 27 Moore GE, Parsons DB, Stray-Gundersen J et al. Uremic myopathy limits aerobic capacity in hemodialysis patients. Am J Kidney Dis 1993; 22: 27787. 28 Deligiannis A. Exercise rehabilitation and skeletal muscle benefits in hemodialysis patients. Clin Nephrol 2004; 61(suppl): 4650. 29 Kimmel PL, Weihs KL, Peterson RA. Survival in hemodialysis patients. J Am Soc Nephrol 1993; 4: 1227. 30 Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997; 349: 143642. 31 Kimmel PL, Peterson RA, Weihs KL et al. Multiple measurements of depression predict mortality in longitudinal study of chronic hemodialysis outpatients. Kidney Int 2000; 57: 209398. 32 Suh MR, Jung HH, Kim SB et al. Effects of regular exercise on anxiety, depression, and quality of life

33

34 35

36

37

38

39 40

41

42

43

44

45

Quality of life after training in haemodialysis patients

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: 21113. 47 Johansen K. Exercise in the end-stage renal disease population. J Am Soc Nephrol 2007; 18: 184554. 48 Painter P, Carlson L, Carey S et al. Low-functioning hemodialysis patients improve with exercise training. Am J Kidney Dis 2000; 36: 600608. 49 Parsons TL, Toffelmire EB, King-Van Vlack C. The effect of an exercise program during

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hemodialysis on dialysis efficacy, blood pressure and quality of life in end-stage renal disease (ESRD) patients. Clin Nephrol 2004; 61: 26174. 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: 68087. 51 Ridley J, Hoey K, Ballagh-Hawes N. The exerciseduring-hemodialysis program: report on a pilot study. CANNT J 1999; 9: 2026.

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