運動方案對血液透析患者生理反應、身體功能、及生活品質之成效

The effects of exercise program on physiologic response, physical functioning, and quality of life in patients with hemodialysis

黃貴薰(Guey-Shiun Huang)

指導教授 ： 黃秀梨

國立臺灣大學/醫學院/護理學研究所/博士(2009年)

https://doi.org/10.6342/NTU.2009.00261

摘要

【背景】
台灣末期腎臟病發生率及盛行率居世界首位，透析人數不斷增加及老化，而血液透析是最常選用的治療方式。因疾病或治療會對其身心及社會等層面造成頗大的衝擊，藉由優質醫療照護協助透析患者改善身體功能狀況及生命品質是重要議題。運動對骨量保留有效果，對透析患者身心層面也有助益，由護理觀點切入，運動介入是血液透析患者健康促進之可行方案。
【目的】
本研究主要目的是測試運動方案對血液透析患者生理反應、身體功能及生活品質之成效。
【方法】
本研究為類實驗設計，資料於臺灣北部某醫學中心血液透析單位收集，採立意取樣，依個案意願分為實驗組（參與每週三次，每次至少20-30分鐘，為期十二週，共36次之運動訓練）及對照組（維持原有醫療照護）。成效指標包括：骨密度、血液生化值、五次起-坐時間、十次起-坐時間、一分鐘起-坐次數、六分鐘走距、步態速度、及IQOLA SF-36生活品質量表。測量時間點為處置前（初始前測）及處置結束時（追蹤後測）。資料分析是以描述性統計呈現基本屬性及成效指標狀況，以推論性統計探討變項間關聯性，再以單因子共變數分析檢測運動處置成效。
【結果】
本研究共有實驗組28人及對照組31人，兩組具同質性；平均年齡為54.98歲，以50-69歲者最多（54%）；男性稍多（54%）；25%有工作；56%有規律運動習慣，但達到有效運動狀態者僅為34%；原發病因以慢性腎絲球腎炎居首位(27%)，糖尿病性腎病(17%)居次；透析月數範圍是6-202個月。低骨量（包含骨質疏鬆及骨量不足）現象盛行率於股骨頸部位是73%，於腰椎部位是42% ；血清白蛋白值及有效週運動量對股骨頸骨密度具正相關。本運動方案具有減緩骨流失效果，由股骨頸及腰椎骨密度前後測變化，雖只於股骨頸部位具顯著差異，但兩個部位皆呈現「實驗組骨流失量（速度）少於（緩於）對照組」趨勢。除白蛋白顯著提升外，運動介入未對研究對象其他生理反應造成顯著改變；實驗組於鹼性磷酸酶及副甲狀腺素變化呈現有利於骨骼生成現象，對照組這些數值皆相對更增高，顯示骨骼再吸收更嚴重。於五次起-坐時間、十次起-坐時間、一分鐘起-坐次數、六分鐘走距、及步態速度，實驗組顯著縮短其時間(－22%及－21%)、提升其次數(+25%)、距離(+11%)、及速度(+19%)；對照組於時間(－9%及－4%)、次數(+6%)、速度(+5%)呈微幅進步，但走距(－1%)卻減少。除社會功能外，此運動方案對研究對象生活品質各面向具顯著提昇效果；實驗組前後測比較，八項生活品質皆提昇(＋13-39%)，對照組於生理功能(+3%)及社會功能(+2%)提昇，其餘六項皆下降，尤其在因生理功能角色受限(－24%)及因情緒角色受限(－15%)二個面向更多。
【結論】
本研究結果確立此運動方案處置模式之實證效益，可推論：負重性運動訓練方式（快步走於跑步機），可協助血液透析患者部分改善生理反應穩定性，有效地減緩骨流失、增強身體功能、及提昇生活品質。本研究成果可作為國內相關衞生機構及醫療院所制定透析醫療相關政策及臨床診療照護指引時之參考；因本研究於研究設計及取樣方面存在一些限制，故於研究結果推論時要有所保留。

關鍵字

血液透析 ； 運動 ； 骨密度 ； 生理反應 ； 身體功能 ； 生活品質

並列摘要

【Background】
Taiwan has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. The numbers of people receiving dialysis continue to increase, and dialysis patients are getting older, as well. Hemodialysis is the most common form of treatment for ESRD in Taiwan. Both the disease and the treatment have a great impact upon patients mentally and physically, as well as upon society at large. As such, improving physical functioning and quality of life for dialysis patients through superior medical treatment and care is an important issue. Exercise is effective for maintaining bone mass, and is also mentally and physically beneficial for dialysis patients. In terms of caring for patients, exercise is also a feasible option for promoting the health of those undergoing hemodialysis.
【Aims】
The main purpose of the present study was to examine the effects of an exercise program on hemodialysis patients in terms of their physiological responses, physical functioning and quality of life.
【Methods】
This was a quasi-experimental study in which data were collected from hemodialysis units at a medical center in northern Taiwan. Purposive sampling was used to recruit participants who were assigned to an experimental group (participating in exercise sessions lasting from 20 to 30 minutes or more, three times per week for twelve weeks, for a total of 36 sessions) and a comparison group (who continued with existing medical care and life style) according to their individual preferences. Outcome indicators included bone mineral density (BMD), blood biochemistry values, time to complete 5 sit-to-stand cycles (STS-5), time to complete 10 sit-to-stand cycles (STS-10), repetition of sit-to-stand cycles in one minute (STS-60), 6-minute walk distance (6-MW), gait speed and IQOLA Short Form-36 Taiwan version (SF-36). Tests were performed at two time points: one prior to the intervention, and one following the intervention. Data analysis consisted of basic characteristics and outcome indicators presented in terms of descriptive statistics; inferential statistics were used to investigate correlation between the variables; and one-way ANCOVA was used to test the response to exercise.
【Results】
Participants in the present study numbered 28 in the experimental group and 31 in the comparison group. The two groups were homogeneous to each other. The mean age was 54.98 years, with the majority between the age of 50 and 69 (54%); there were slightly more males (54%); 25% were employed; 56% exercised regularly, though only 34% exercised to a point where it was effective; and the leading primary causes of ESRD included chronic glomerulonephritis (27%) and diabetes mellitis (17%). The duration of dialysis treatment for participants was between 6 and 202 months. The prevalence of low bone mass (including osteoporosis and osteopenia) was 73% in the femoral neck (FN) and 42% in the lumbar spine (LS). Serum albumin level and an effective exercise time were positively correlated with FN-BMD, and the exercise program was effective for slowing bone loss. Changes to FN-BMD and LS-BMD were measured both before and after the intervention, and even though a significant difference was seen only in the FN site, the rate of bone loss for the experimental group was slower than for the comparison group both for the FN and LS sites. In addition to significant increases in albumin, the exercise intervention did not result in significant changes in other physiological responses for participants in the experimental group. Changes in alkaline phosphatase (ALP) and intact parathyroid hormone (iPTH) in the experimental group were beneficial to bone formation, while in the comparison group these values were comparatively higher, showing that bone resorption was more severe. In terms of STS-5, STS-10, STS-60, 6-MW and gait speed, the experimental group showed significant reductions in time (–22% and –21%), along with increases in repetitions (+25%), distance (+11%) and speed (+19%), respectively. Slight improvements were seen in the comparison group in duration (–9% and –4%), repetitions (+6%) and speed (+5%), respectively, though distance decreased (–1%). In addition to physical functioning (PF), the exercise program resulted in significant improvements in the quality of life for the participants in every dimension of SF-36. In a comparison of the measurements taken before and after the intervention in the experimental group, improvements were seen in eight dimensions of quality of life (+13% to 39%). By contrast, PF (+3%) and social functioning (SF) (+2%) went up in the comparison group, while the other six dimensions dropped, role-physical (RP) (–24%) and role-emotion (RE) (–15%) particularly so.
【Conclusion】
The results of the present study confirm the effectiveness of this exercise program as an intervention modality. It may be assumed that an exercise program of weight bearing training (fast walking on a running machine) can help hemodialysis patients to partly improve the stability of their physiological responses, to effectively decelerate bone loss, strengthen physical functioning and enhance their quality of life. The results of the present study can be used as a reference for domestic health organizations and medical hospitals when formulating policies for dialysis treatment and guides for clinical therapy and care. However, generalizablity from the present study should be conservative owing to the limitations of its research design and sampling method.

並列關鍵字

hemodialysis ； exercise ； bone mineral density ； physiological response ； physical functioning ； quality of life

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