(Accuhealth, Stepney,. Australia) was used to provide electro-therapeutic point stimu- lation. This non-invasive therapy was applied to acupuncture points in the ...
Case Study
Holly McFarland, Department Editor
The Role of Physiotherapy in a Hemodialysis Unit Barbara Perryman Lori Harwood
Patient Pro fi l e Mrs. J. is a 54 year old female who has been hemodialysis dependent for 3 years secondary to glomerulonephritis. On routine nurse practitioner/clinical nurse specialist rounds, Mrs. J. presented with increasing right leg pain upon both movement and rest, which radiated from her foot to her hip. She described this as a sharp, stabbing pain that was impacting on her sleep and level of functioning. She denied any trauma or injury that could have precipitated the pain. Mrs. J. requires hemodialysis three times a week. She is currently unemployed and lives in her home with her husband. She is well dialyzed via a central venous catheter as her upper arm fistula develops.
Intended Patient Outcomes (Discussed with Mrs. J.) 1. Pain will be managed by pharmacological and nonpharmacological methods. 2. Functional status and ability to do activities of daily living will return to her previous state.
Discussion Mrs. J.’s medical history includes repeated urinary tract infections since she was a teenager, a bunionectomy, cervical cancer treated with surgical removal and chemotherapy, osteoporosis, vitamin D3 deficiency, hyperlipidemia, fungal peritonitis while on peritoneal dialysis, and pneumothorax posthemodialysis catheter insertion. After consultation with her nephrologist regarding the etiology of her back pain, investigations (x-ray of lumbar and sacral spine, hip and CT spine) revealed possible impingement of the L4 nerve root. This was ruled out after a neurology consult. An EMG was also negative for dependant sensory peripheral neuropathy. The neurologist recommended conservative treatment for the right sciatica (leg pain caused by irritation or compression of the sciatic nerve) and low back pain, which had now developed. In addition, the physiotherapist on the dialysis unit had been consulted and was involved in Mrs. J.’s care shortly after her concerns were known. Both analgesia and a trial of nonsteroidal anti-inflammatory medications were used to manage Mrs. J.’s pain. The patient also sought relief through the use of acupressure. On initial assessment by the physiotherapist, Mrs. J. complained of constant low back pain, which she rated as 10/10 using the numerical analogue scale (NAS). In addition, she experienced an aching pain in the right (R) thigh and severe sharp shooting pain in the (R) leg from toes to Barbara Perryman, DipPT, MCPA, is a Physiotherapist in the renal pro gram, Victoria Campus at the London Health Sciences Centre, London, Ontario, Canada. Lori Harwood, MSc., RN, CNeph(C), is an Acute Care Nurse Practitioner/Clinical Nurse Specialist in the renal program, Victoria Campus at the London Health Sciences Centre, London, Ontario. She is a member of ANNA’s North Central Chapter. Acknowledgment: The authors would like to acknowledge Lorraine Stead, Physiotherapist, for her assistance with the article.
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hip, which was worse at night and when sitting. Standing posture showed left (L) lateral shift of the trunk with decreased weight bearing on the (R) leg. Active mobility of the lumbar spine was severely restricted, especially into flexion with increased (R) leg pain. X-ray reports showed moderate L5-S1 disc narrowing and mild (L) lumbar scoliosis at L3. The physiotherapist determined that Mrs. J’s pain was likely due to nerve root irritation. Physiotherapy treatment was initiated following dialysis using the McKenzie (1981) exercise protocol. This is a form of mechanical therapy that uses the patient’s own movements to centralize, decrease, or stop sciatic pain. An Accuhealth Professional 900® (Accuhealth, Stepney, Australia) was used to provide electro-therapeutic point stimulation. This non-invasive therapy was applied to acupuncture points in the lumbar spine, buttocks, and posterior aspect (R) knee. Posttreatment, Mrs. J. reported decreased pain with a rating of 6/10 (NAS) and decreased aching in the (R) leg. She was encouraged to continue with positioning to decrease pain and to apply ice at home. Two days later Mrs. J. reported a rating of 8/10 (NAS) and continued aching in the (R) leg. She no longer experienced shooting pain. At this time Mrs. J. was referred to a community outpatient physiotherapy clinic, where ongoing treatment was provided on nondialysis days. She attended physiotherapy sessions twice weekly for a total of 17 visits in 3 months. At Mrs. J.’s final physiotherapy appointment, she still experienced some aching in the upper lumbar area bilaterally. This pain did not require analgesia and did not limit her functional status. There were no reports of the (R) leg pain. Active lumbar range of motion was full and pain free in all directions. Strength of the (R) leg showed remaining strength deficit of Grade 4+/5 in the (R) hip abductors and extensors. Mrs. J.’s walking pattern was normal, and she was able to walk 16 minutes at a moderate pace on a treadmill. The results of the Roland Morris Disability Questionnaire (Roland & Morris, 1983) improved from 20/24 to 3/24 with 0/24, indicating no disability. This is a 24-item self-report questionnaire used to assess functional status and pain-related disability status in clients with low back pain. After 2 months of outpatient physiotherapy Mrs. J. felt well enough to participate in our dialysis exercise program. The physiotherapist is responsible for the program, which includes warm-up, stretching and strengthening exercises, as well as aer-
The Case Study department of the Nephrology Nursing Journal invites nephrology nurses of all levels and subspecialties to share their clinical experience with their colleagues. Practitioners and educators are encouraged to submit case studies that address their patient-related nursing care and solutions to situations encountered in the care of a patient with renal disease and/or in p e rforming extracorporeal therapies. You may log onto this column at www.nephrologynursingjournal.net (click on Department link) and email your comments to the Department Editor (see Discussion Area). The opinions and assertions contained herein are the private views of the contributors and do not necessarily reflect the views of the American Nephrology Nurses’ Association.
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The Role of Physiotherapy in a Hemodialysis Unit
Pain issues, particularly low back pain, can be both debilitating and incapacitating for a normally healthy individual. When added to the multiple medical problems already experienced by a dialyOutcome Initial 3 Months sis patient, pain can quickly lead to deconditioning Distance 368.4 meters 463.6 meters and decreased functional ability. Moore (1995) 1208 feet 1520 feet identified that exercise training can bring the dialysis patient increased physical work capacity, Work Effort Somewhat Hard Easy decreased risk factors for cardiovascular disease, improved blood pressure and improved psychologPretest vital signs ical state, and increased strength and aerobic capacHR (beats per minute) 89 87 ity. Painter, Blagg, and Moore (1995) observed that RR (breaths per minute) 14 18 most dialysis patients can tolerate low-to-moderate SPO2 93% 99% levels of exercise and that exercise capacity can be improved an average of 25 percent. A pilot study Posttest vitals signs HR 89 89 completed at another hemodialysis site in our orgaRR 22 14 nization reported that an exercise program during SPO2 96% 98% dialysis is well tolerated and has the potential to lead to positive patient outcomes such as improved Note: RR = Respiratory Rate; HR = Heart Rate physical capacity, decreased fatigue, increased ability to complete activities of daily living, and decreased use of antihypertensive agents (Ridley, Hoey, & Ballagh-Howes, obic exercise using a stationary bike. All exercises are per1999). formed while sitting in the dialysis chair during the first 2 hours of dialysis to avoid hemodynamic instabilities. The program Summary has been further described in the literature by Ridley, Hoey and This case study highlights the role of the physiotherapist Ballagh-Howes (1999). Mrs. J. was extremely keen on the proand importance of providing multidisciplinary care for gram and was motivated to gain further strength and endurance. hemodialysis patients. Nurses are often in positions to identify She exercised three times weekly during dialysis as well as regpatients who are in need of or could benefit from a physiotheraularly doing exercises and walking at home. py consultation. In this case, the collaborative approach was Mrs. J. performed a 6-minute walk test (6MWT) prior to highly successful in working with the patient to return to her starting the program and again after participating for 3 months. previous pain-free state and her previous level of functioning. The walk test was developed by Butland, Pang, Gross, Woodcock and Geddes (1982) to assess exercise tolerance References among individuals with respiratory disease. However, it is comAmerican Thoracic Society. (20 02). ATS statement: Guidelines for monly used as a measure of function exercise capacity the six-minute walk test. American Journal of Respiratory Care (Butland, et al., 1982). The test measures the distance a patient Medicine 166 , 111-117. can quickly walk on a flat, hard surface in a period of 6 minutes. Butland, R.J.A., Pang, J., Gross, E.R., Woodcock, A.A., & Geddes, The self-paced 6MWT does not assess maximal exercise capacD.M., (1982). Two, six, and twelve-minute walking tests in resity but assesses the submaximal level of functional capacity. piratory disease. British Journal of Medicine, 284, 1607-1608 . This is of benefit because most activities of daily living are perCardenas, D., Kutner, N., & DeAndrade, J. (1984). Rehabilitation formed at submaximal levels of exertion and thus better reflect and the chronic renal disease patient. In A. Ruskin (Ed.), Current therapy in psychiatry. Philadelphia: WB Saunders the functional exercise level for daily physical activities Company. (American Thoracic Society, 2002). The distance completed in McKenzie, R.A. (1981). The lumbar spine: Mechanical diagnosis and the initial test was 368.4 meters (1208 feet). At 3 months, the therapy. Waikanae, NZ: Spinal Publications. distance completed was 463.6 meters (1520 feet), an improveMoore, G.E. (1995). Selecting dialysis patients for an exercise proment of 95.2 meters (312 feet) (see Table 1). gram, Seminars in Dialysis, 8(1), 42 – 44. Despite the benefits of physiotherapy, in most dialysis proPainter P.L., Blagg C.L., & Moore G. (1995). Exercise for the dialgrams there is a striking under-utilization of physiotherapy and ysis patient. A guide for the nephrologist. Madison: Medical occupational therapy (Cardenas, Kutner, & DeAndrade, 1984). Education Institute Inc. (Document #P30303-1) Yet the frequent complaints of weakness, difficulty with ambuPianta, T.F. (1999). The role of physical therapy in improving physlation, fatigue, decreased range of motion, pain and difficulty ical functioning of renal patients. Advances in Renal Replacement Therapy, 6(2), 149-158. with activities of daily living are all indications for a physioRidley, J., Hoey, K., & Ballagh-Howes, N. (1999). The exercise-durtherapy referral (Pianta, 1999). The primary goal of physiothering haemodialysis program: Report on a pilot study. CANNT, apy in a chronic care setting such as dialysis is to optimize each 9, 20-26. patient’s functional ability. Physiotherapists can help to keep Roland, M., & Morris, R. (1983). A study of the natural history of dialysis patients as safely mobile as possible and for as long as back pain. Part 1: development of a reliable and sensitive possible. measure of disability in low-back pain. Spine, 8, 141- 144. Table 1 Six-Minute Walk Test
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