Dialysis Case Study

Author/s

Josh Caulder, Eric Edwards, Kaitlin Flak, Erin Huml, and Katie Jackson from theBellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

A case study on 67-year-old male diabetic with end-stage renal disease receiving dialysis. The objective was to provide physical therapy intervention to a patient receiving dialysis. The patient’s chief complaints included decreased balance, loss of sensation, fear of falling, and decreased endurance during activities of daily living due to the effects of dialysis treatment. Objective measures during evaluation validated these complaints. The patient’s goals were to improve strength, aerobic endurance, balance, and flexibility. Patient education was emphasized during each treatment session. The patient progressed through physical therapy as indicated in the plan of care, with improvements in deficits found during examination. Patients receiving physical therapy during dialysis treatment may have more positive outcomes than those who elect not to participate in therapy.

Patient Characteristics

Demographic Information:

• Male, 67 years old; retired greyhound bus drive

Medical diagnosis:

• ESRD on dialysis
• GRF (glomerular filtration rate) - 13 mL/min
• Referral for recommendations for initiating exercise program for dialysis

Co-morbidities:

• Obese - BMI: 32
• Type II DM
• HTN
• Depression
• Diabetic neuropathy

Medications:

• Diabetes medication
• Hypertension medication
• Depression medication

Previous care or treatment:

• PT for balance impairment secondary to diabetic neuropathy; fall risk

Examination

• Subjective : Patient History and Systems Review (chief complaints, other relevant medical history, prior or current services related to the current episode, use relative dates i.e. years or months or days relative to onset of injury or start of treatment, patient/family goals)
• Self Report Outcome Measures
• Physical Performance Measures
• Objective : Physical Examination Tests and Measures

Clinical Impression

Our impression of the problem: 1) The patient’s end stage renal disease is incurable, but is being treated through the use of dialysis which causes secondary functional deficits including decreased endurance, decreased strength of upper and lower extremities, impaired balance and coordination, decreased sensation, diminished reflexes, and decreased flexibility. 2) The patient has the following risk factors that may impede physical therapy intervention: advancing age, diabetes mellitus, hypertension, and chronic urinary tract infections. The physical therapist will need to be aware of these complications during each treatment session. 3) Patient has LE weakness, decreased balance, decreased sensation, and fear of falling which may contribute to his increased risk of falling.

Summarization of Examination Findings

Patient presents to skilled physical therapy with complaints of impaired balance, loss of sensation B LE, and decreased endurance during ADL’s secondary to dialysis protocol. Patient demonstrated general LE weakness indicated by MMT, dec AROM in R UE secondary to fistula insertion, and a sensation rating of 2 as indicated on the Diabetic Neuropathy Screen. PT to implement an aerobic program utilizing a stationary bike to improve endurance in home and community settings, balance and gait training to address loss of sensation and proprioception awareness to decrease fall risk, and LE strength and flexibility program to address deficits for improved mobility during functional tasks in a home environment.

Intervention

• Phases of Interventions (e.g. protective phase, mobility phase, etc.)
• Dosage and Parameters
• Rationale for Progression
• Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes

Pt. improved aerobic endurance as indicated by significant change in score (MDC = 58 meters) from 550 meters to 635 meters on 6 minute walk test following 12 week physical therapy program. Pt. also increased their perceived physical function as indicated by a change of 30/100 to 58/100 on the SF-36 (MDC = 28). Pt. increased their balance as indicated by a change of 40/56 to 46/56 on the Berg Balance Scale (MDC = 4.9).

MMT: 4/5 hip ext/abd/ER, 4+/5 knee ext/flex, 4+/5 ankle dorsiflexion

Discussion

Patients undergoing dialysis treatment are at a high risk of impaired physical function and mobility, which are strong predictors of disability, hospitalization, falls, and death and are often associated with poor outcomes. Complications commonly encountered in this population of patients are peripheral neuropathy, congestive heart failure, heart attack, stroke, and amputation. Lack of motivation and interest are also common barriers to increasing physical activity with this population of patients. Dialysis patients frequently report generalized weakness, fatigue, difficulty with ambulation, decreased range of motion, pain, and difficulty with ADL’s which are all indications for physical therapy. In addition, patients on dialysis have reported significant reductions in their quality of life. Physical therapy can be appropriate for patients on dialysis treatment because it can be an important factor for improving quality of life through physical function and mobility while addressing many of the common complaints and impairments dialysis patients commonly present with. Research has supported physical therapy during dialysis treatment does produce positive outcomes such as; improved endurance, strength, quality of life, functional capacity, and gait speed.^, Research supports that limitations in ADLs/IADLs or observed mobility deficits is an indication for physical therapy evaluation and and intervention.

Research has shown that patients with chronic kidney disease who are treated with dialysis have impaired physical functioning that is associated with poor outcomes. Research has also shown that patients with chronic kidney disease have decreased gait speed which is known to increase their risk for reduced survival and adverse health events. Based off research, we chose to assess his physical functioning and gait speed using clinician based outcome measures including the Berg Balance Test, Timed Up and Go, and the 6 Minute Walk Test. We also used the SF-36, a patient reported outcome measure, to asses his quality of life. Based off of our examination findings, we designed a physical therapy intervention to address the patient’s functional deficits for improved functioning during ADL’s and improve quality of life.

Related Pages

National Kidney Foundation https://www.kidney.org

American Kidney Fund http://www.kidneyfund.org

American Diabetes Association http://www.diabetes.org/

National Institute of Mental Health http://www.nimh.nih.gov/health/topics/depression/index.shtml

World Heart Federation http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/

References

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