American College of Physicians: Internal Medicine — Doctors for Adults ®


Weight training lightens physical, psychological loads

Study shows that weight training during dialysis can counteract muscle wasting better than aerobic exercise

From the September ACP Observer, copyright 2007 by the American College of Physicians.

By Yasmine Iqbal

It was slow going for Bobby Cheema, PhD, an exercise physiologist at Massey University in Wellington, New Zealand, when he was recruiting patients for a study on the effects of resistance training on end-stage renal disease (ESRD) in October 2002.

"I remember walking into the outpatient dialysis unit [at the St. George Public Hospital in Sydney, Australia] for the first time. You could feel the sadness and depression," he recalled. Many regarded his plan to implement a 12-week high-intensity intradialysis progressive resistance training (PRT) program with skepticism. "Many patients thought they were too old and too sick to get involved, and their physicians were either reluctant or indifferent," he said.

Dialysis patients underwent weight training, which might be preferable to aerobic exercise.

Dialysis patients underwent weight training, which might be preferable to aerobic exercise.

By the study's end in January 2006, 49 patients agreed to participate. The 24 patients randomly assigned to the PRT group exercised three times a week under the supervision of an exercise physiologist, performing 10 exercises with dumbbells, weighted ankle cuffs and elastic tubing that targeted all major muscle groups. The remaining 25 control group patients received standard treatment, with no exercise instructions or access to equipment. Dr. Cheema's study excluded patients with end-stage congestive heart failure, unstable dialysis or other conditions that would have precluded any kind of exercise.

After 12 weeks, the PRT patients experienced statistically significant improvements in muscle quality, total strength, BMI and mid-thigh and mid-arm circumference relative to the control group, with minimal adverse effects.

"One patient who couldn't even move his arm enough to bathe himself regained most of his range of motion," said Dr. Cheema.

Just as notable were the shifts in patients' attitudes. "They said they felt alive again, and the actual mood of the unit changed," he said. "Patients would talk more and they motivated each other. They wouldn't just sleep through their dialysis."

Weights reverse muscle wasting

Dr. Cheema's study about progressive exercise for anabolism in kidney disease (PEAK): was published in the May 2007 Journal of the American Society of Nephrology. His findings appeared to corroborate those from another trial, led by Kirsten L. Johansen, MD, associate professor of medicine at the University of California, San Francisco. That trial examined weight training during routine hemodialysis and reported gains in quadriceps muscle area after 12 weeks of training.

Although many studies have suggested that aerobic exercise might be beneficial for dialysis patients, weight training might be the preferred exercise for these patients, observed Dr. Cheema. Aerobic training at higher intensities is difficult, if not impossible for many ESRD patients, and resistance training is more effective for targeting muscle wasting—a major consideration in this population.

"Weight training is actually a more robust exercise for them, and virtually any patient can do it," he said.

Experts say that weight training is also a superior way to reverse muscle wasting, a major cause of debility in ESRD patients due to acidosis, malnutrition, comorbid illnesses, corticosteroid use, aging and oxidative stress.

"The dialysis procedure itself can contribute to the spiral of deconditioning," said Derrick L. Latos, MACP, medical director for Wheeling Renal Care, LLC, in Wheeling, W.Va., and past president of the Renal Physicians Association. "About five to seven grams of amino acids may be lost with each dialysis treatment, which affects the body's ability to make protein and build muscle." However, this downward spiral can be reversed through an aggressive approach to physical exercise.

Dr. Johansen, who is the director of the dialysis unit at the San Francisco VA hospital, noted that physicians need to be more proactive about prescribing exercise in general.

"Very few physicians bring up exercise. Their attitude is that patients can't or won't even try," she said. "But if we treat patients like they're too sick to exercise, that's the message they're going to get. Rather, we should try to find out what patients' main concerns are—for example, are they getting winded during housework, or are they having trouble lifting things—and suggest exercise programs that will help them regain those functions. The more debilitated they are, the more they stand to benefit."


Working out solutions to start patient exercise during dialysis

Some physicians employ staff to help them instill and encourage the exercise habit in their patients. Derrick L. Latos, MACP, for example, works with an exercise physiologist who evaluates every patient and designs a workout program that includes intra-dialysis and home exercises.

"If you don't have access to an exercise physiologist, connect patients with a physical therapist," he advised (this is often covered under Medicare). Here are some other resources:

PEAK Information Package: Bobby Cheema, PhD, and his colleagues have developed a kit, which includes an instructional video and printed materials, on how to implement an intra-dialysis resistance training program. For more information, contact Maria Fiatarone Singh, MD, at

Life Options: This Web site (supported by Amgen, Inc.) offers many resources for chronic kidney disease patients, including a downloadable booklet on exercise.

Shad Ireland Foundation: Created by the first dialysis patient to complete the Ironman triathlon, this organization offers financial grants to dialysis patients to secure gym memberships and exercise equipment.


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