Effect of Intradialytic Exercises Program for Nurses on Peripheral Muscle Cramps and perfusion among Children Undergoing Hemodialysis

Background : Muscle cramps and impaired peripheral perfusion are the most common complications experienced by children undergoing hemodialysis. Intradialytic exercises are the best measures to reduce muscle cramps which occurring during hemodialysis to increase the cardiac output, enhancing perfusion and facilitating oxygen demand of the skeletal muscles. Aim of the study was to evaluate the effect of intradialytic exercises program for nurses on peripheral muscle cramps and peripheral perfusion among children undergoing hemodialysis. Setting: The study was conducted at Children Renal Dialysis Unit at Benha University Hospital. Design: A quasi-experimental design was used to conduct the study. Subjects: Sample (I) A convenient sample of (30) nurses was selected from the previously mentioned setting, Sample (2) A purposive sample of 36 children undergoing hemodialysis. Tools of data collection: Five tools were used; Tool I : Nurses characteristics and children bio-sociodemographic data included three parts: (1) The studied nurses’ characteristics, (2 ) Studied children characteristics (3) Clinical data of children undergoing hemodialysis, Tool II: Knowledge assessment questionnaire, Tool III : Intradialytic exercises checklist, Tool IV: Muscle cramp questionnaire chart Tool V : Assessment checklist for clinical features of impaired peripheral perfusion. Results: There is a highly statistical significant difference between frequency and duration of muscle cramps, level of pain, leg temperature and discomfort pre and post-intradialytic exercises program implementation. There was high statistical significant difference between clinical features of impaired peripheral perfusion pre and post-intradialytic exercises program. Conclusion: The majority of the studied nurses had good level of knowledge and satisfactory level of practices post-intradialytic exercises program implementation compared to pre-intradialytic exercises program implementation Recommendations: Organizing continuous training programs for nurses to reinforce intradialytic exercises for hemodialysis children. Structured training program can be provided to children undergoing hemodialysis on active intradialytic exercises.


Introduction
Chronic renal failure is marked by a reduction in glomerular filtration, changes in extracellular fluid volume, electrolyte and acid-base homeostasis, and retention of nitrogenous waste products from protein catabolism.It happens when renal function is lost completely or partially. (1)The most severe type of chronic kidney disease is end-stage renal disease.It is a disorder that necessitates continuous hemodialysis as part of chronic kidney replacement therapy and is characterized by a very low glomerular filtration rate along with uremic symptoms or over hydration. (2)Chronic renal failure early phases are asymptomatic, so it is unknown with certainty how frequently it affects children.The prevalence of CRF in children has steadily increased over the past 20 years, and it is currently estimated that there are 18.5 to 100 cases of CRF in every million children worldwide.The mortality rate among adolescents is 30% to 100% higher than that of the overall population.The short lifespan Vol. 31.No. 4 (Suppl 1) ,November 2023 of a dialysis-dependent adolescent under the age of 14 highlights the need for specialized care.According to reports, there are 225 CRF cases per million children in Egypt, 74 cases of ESRD are anticipated to occur annually ,and there are 264 cases of children receiving dialysis overall. (3)The most common therapeutic intervention for children with end-stage renal disease is hemodialysis; it is considered one of the main renal replacement therapies in pediatric patients.Maintenance hemodialysis withdraw many of the toxins responsible for the uremic syndrome and prolongs survival.Although, hemodialysis is generally a safe procedure, danger complications frequently encountered including tiredness, fatigue, nausea, dizziness, hypotension, impaired peripheral perfusion and muscle cramps (1 & 4).Children receiving hemodialysis most frequently experience muscle cramps.Unexpected, painful, and uncontrollable muscular contractions are known as muscle cramps, and they often affect the lower extremities.Between 25% to 80% of adolescents receiving hemodialysis experience muscle cramps, which are a typical cause for interrupting a hemodialysis session early. (5)uscle cramps and excruciating muscular twitches are typically how muscle cramps start.The typical locations for muscular cramps are the calf, feet, toes, thighs, and belly.Reduced fluid volume, hypotension, low sodium dialysis levels, an imbalance of fluid and electrolytes, tissue hypoxia and hypomagnesaemia, excessive filtration, and an increase in serum creatinine kinase are the causes of this condition.These variables cause muscle vasoconstriction, particularly in the arms and legs, which results in muscular hypoperfusion during dialysis. (6)emodialysis-induced circulatory stress results in hypo-perfusion in some vascular beds.Hemodialysis changes physiology, affecting cardiovascular hemodynamics beyond anything else.Intradialytic hypotension brought on by these physiological disturbances may result in hypoxia and ischemic damage. (7)ystematic hypo-perfusion, subclinical ischemia, and poor peripheral perfusion can result from a reduced cardiac output during hemodialysis. (8)Reduced arterial blood flow to the extremities is referred to as inadequate perfusion.Severe or persistent pain, numbness or tingling in the vicinity of the vascular access or in the extremity distal to it, as well as swelling, coldness, discoloration, or a prolonged capillary refill time, are indications of poor peripheral perfusion.As a result of the diminished blood flow to the extremities, any of these symptoms may indicate poor tissue perfusion. (9)urses working in hemodialysis units should be trained on the use of exercises as one of the effective strategies to control or eliminate some of the dialysis complications . (10)Since cramps are a common complication for hemodialysis children that cause discomfort, proper interference with muscle cramps and preventing the occurrence as well has become an essential intervention of the nurses who are taking care of HD children.Dialysis nurses are in a unique position to help monitor and evaluate cramps and in management technique. (6)xercise during hemodialysis has attracted attention since it may counteract side effects from the treatment and increase the overall effectiveness of dialysis . (11)One of the defenses against the drop in blood flow and the ensuing muscle soreness and cramps is regular exercise . (12)ntradialytic exercise (IDE) is defined as a training program for children undergoing hemodialysis that aims to improve their strength and endurance while also focusing on a variety of physiological and psychosocial aspects.Intradialytic exercise can range from stretching to aerobic exercise to resistance training. (13,14)xercise training can enhance peripheral perfusion, blood pressure, muscle blood circulation, and physical labor capacity while reducing fatigue, uremic nephropathy, myopathy, and cramping in the muscles.As skeletal muscles' oxygen demands increase during intradialytic activities, cardiac output can increase fourfold, improving perfusion and lowering cardiac stunning . (15)ntradialytic stretching exercise is the exercise performed actively or passively to the affected muscles at the end of second hour of hemodialysis session.Intradialytic stretching exercise improves muscle protein synthesis and breakdown which helps in reducing or preventing intradialytic muscle cramps.Moreover, stretching exercises reduce muscle pain and soreness, enhancing flexibility and elasticity as well as reducing injury risk. (16)ntradialytic range of motion exercises (ROM) can be considered as a routine care while delivering hemodialysis as it performed 15 minutes/ day, three times a week during HD session.It is an activity carried out to make the body healthy, to improve health and to maintain physical health.Range of motion is vital for increasing the cardiac output, alveolar ventilation and joint mobilization. (14,17)ignificance of the study Hemodialysis is one of the most important treatment modality for CKDs.It is an ongoing process with patients experiencing various complications like hypotension, muscle cramps, disequilibrium syndrome and nausea during the procedure.Muscle cramps are mostly seen complication who begin with very painful muscle twitches and hard movements.Calf muscle, feet, toes, thighs and abdomen are the usual sites for muscle cramps.Exercise is one of the most likely preventive steps to lower protein loss from muscles and maintain muscle function.
Children exercise tolerance and quality of life are both improved by intradialytic exercise.( As skeletal muscles oxygen demands increase during intradialytic activities, cardiac output can increase fourfold, improving perfusion and lowering cardiac stunning. (8)Exercises also improve blood pressure, lipid profiles, and the effectiveness of dialysis, which are all cardiovascular risk factors . (14)urses working in hemodialysis units should be trained on the use of exercises as one of the effective strategies to control or eliminate some of the dialysis complications. (8)and Himmelfarb and Ikizler, (2019). (22)It is composed of of (30) multiple choice questions covering main four items of nurses' knowledge regarding: -Chronic kidney disease -Hemodialysis -Intradialytic muscles cramps -Impaired peripheral perfusion -Intradialytic exercises.Nurses' knowledge scoring: Each item assigned a completely correct answer was scored (2), the incomplete correct answer was scored (1) and incorrect or don't know answer was scored (0).Total knowledge scores ranged from (0-60).In this respect, the level of nurses' knowledge was categorized as the following: -Poor knowledge (< 60%) -Average knowledge (between 60% and 85%).-Good knowledge in ≥85 %.Tool (III): Checklist for intradialytic exercises: it consists of two parts Part 1: Stretching exercises: It was adopted from Lekha, (2016) (23) to assess nurses' practices regarding intradialytic stretching exercises including: -Ankle dorsiflexion -Soleus stretching -Gastrocnemius stretching -Hamstring stretching -Quadriceps stretching Part 2:

Aim of the study
Range of motion exercises checklist: It was adapted from Cobbett et al., (2020) (24) and Sorrentino and Remmert, (2017) (25) to assess nurses' practices regarding intradialytic range of motion exercises It involved ROM exercises of upper extremities (shoulder, elbow, forearm, wrist and fingers) and ROM exercises of lower extremities (hip, knee, ankle, feet and toes).

Scoring system for nurses' practices
The score of each item of the previous tool was classified as the following: not done had score (0), incorrectly done had score (1) and correctly done had score (2).According to the nurses' actual practice, their level of practice was categorized as the following:  Unsatisfactory (< 85%). Satisfactory ( ≥ 85%).Tool (IV): Muscle cramps questionnaire chart: pre/ post-test.It was adopted from Basemath (2014) (26) to estimate the severity of muscle cramps during hemodialysis.It includes different aspects of muscle cramps, such as frequency, duration, level of pain, temperature, and discomfort, and it was scored as having a level of cramps ranging from 0 to 13. Interpretation of Score: (0) No cramps (1-4) mild cramps (5-8) moderate cramps (9-13) Severe cramps Tool(V): Peripheral perfusion impairment observational checklist.It was adapted from Priya (2016) (27) to assess clinical features of peripheral perfusion impairment.It included six parameters such as peripheral pulse, capillary refill time, edema, temperature, pain, and skin color as the following:-1-Peripheral pulse ranges from zero (0) (normal pulse) to (3) (none palpable peripheral pulse) 2-Capillary refill time (1-2s, 3s, 4s &>4s) 3-Presence of edema (no edema, (+1) a depression less than 2 mm that suddenly disappeared, (+2) a depression less than 2-4 mm that disappeared within 10-15 seconds, and (+3) a depression 4-6 mm dents will disappear after 10-15 seconds), 4-Temperature (warm, mild coldness, moderate coldness , sever coldness ).5-Pain (no pain, mild, moderate, severe) 6-Skin color (pink, pale, cyanotic/black, reddish).The evaluation scheme for this tool was estimated as follows. (0 -4) adequate peripheral perfusion,  (5-9) slightly inadequate peripheral perfusion,  (10 -14) inadequate peripheral perfusion  (15 -18) severely inadequate peripheral perfusion Tools validity and reliability Three Pediatric Nursing Experts from the Nursing Faculty at Benha University assessed the instruments used for gathering data, evaluating their clarity, comprehensiveness, relevance, simplicity, and accuracy as well as their content validity.Utilizing Cronbach's alpha, the internal consistency reliability of the validated tools was evaluated.The reliability values for knowledge evaluation questionnaire and assessment checklist for clinical features of peripheral perfusion impairment were 0.75 and 0.897, respectively.

Ethical considerations
The scientific research ethical committee of the nursing faculty at Benha University gave its official approval for the study to be carried out.Before beginning the practical work, a formal letter outlining the study's objectives was obtained from the Nursing Faculty dean to the hospital director to take approval to carry out the study and gather the required data.Participants were informed of their right to participate, decline, or withdraw at any time, and the researchers then obtained their consent.Anonymity and confidentiality of any acquired information were guaranteed.

Pilot Study
Ten percent of the total study sample underwent a pilot study to assess the research tool's applicability, clarity, relevance, feasibility, consistency of question order, and time commitment.Pilot study participants were incorporated into the study's overall sample because no changes were made.

Field work
The intradialytic exercises program was put into place through four phases including assessment, planning, implementation, and evaluation to accomplish the goal of the current study.The study was conducted over the course of six months, from the beginning of April 2023 to the end of September 2023 in accordance with the phases listed below: Assessment phase  During the assessment phase, interviews were conducted with nurses to collect baseline data.
 The researchers were allowed to collect data on three days per week (morning and afternoon shifts) using research tools in a research environment. After clarifying the purpose of the study, oral consent for participation was obtained from the nurses. A pre-test was conducted using the above tool to assess nursing staff's knowledge and practice of intradialytic exercises.-Intradialytic range of motion exercises of lower extremities (hip, knee, ankle, feet and toes).

Evaluation phase
The evaluation was conducted immediately after the educational program using the same pretest tool.The data collection process was repeated to assess the effect of the program on nurses' knowledge and practice.Children were assessed for degree of peripheral muscle spasm and perfusion using the muscle cramp questionnaire and evaluation checklist for clinical features of Perfusion impairment after intra-dialys training.This phase lasted about 4 weeks.Table (6) shows highly statistically significant differences between the clinical features of perfusion injury (peripheral pulse, capillary filling, edema, body temperature, pain, skin color) pre and post the intradialytic exercise program.Indicates that there is a difference (P<0.000).Figure (3) described that, more than (58.3%) of the children in this study suffered from inadequate perfusion pre intradialytic exercise.While, nearly half (47.2%) of them had adequate perfusion after intr-dialytic exercise application.There is a highly statistical significant difference in level of peripheral perfusion post-intradialytic exercises program (P< 0.000).     .The aim of this study is to evaluate the effect of intradialytic exercises program for nurses on peripheral muscle cramps and perfusion among children undergoing hemodialysis.
Concerning the nurses' characteristics, the findings from the current study clarified that, more than half of the studied nurses were aged between 20-<30 years, with mean age 32.14±3.62 years and the majority of them were females.These findings are consistent with Machaley et al., (2020) (29) who studied"effect of implementing evidence based nursing guidelines on nurses' performance regarding care provided for children undergoing hemodialysis" and reported that more than half of the nurses in the study aged between 20 to 30 years and the majority of them were females.
The result of the current study demonstrated that more than two thirds of the studied nurses had technical institute of nursing.This finding was compatible with Bayoumi and Mahdy, (2014) (30)  (3) As a result, less than half of the nurses surveyed had five to ten years of experience, and almost two-thirds of them had prior training in caring for children undergoing hemodialysis.This finding is equally relevant to Bayomi & Mahdy (2014) (30) , who stated that none of the nurses surveyed had been trained in performing exercises in a hemodialysis unit.This may be related to the understaffing and workload of the hemodialysis unit.
As regards children characteristics in this study the findings of the present study represented that more than half of the studied children were in the age group from 6<12years.This result was compatible with Bahgat & Nada, (2019) (31) who studied "effect of implementing exercise training program on dialysis efficacy and physical performance of children undergoing hemodialysis" and clarified that more than half children in their study aged 10-15 years.Moreover, the current study revealed that more than half of children were females and less than half of them enrolled in primary level of education.This finding was supported by Ahmed et al., (2020) (32) who carried out a study entitled "effect of nursing intervention program on self-esteem, body image and quality of life of children undergoing hemodialysis" and reported that more than half of children were females and less than half of them had primary education level.In contrast, these results disagree with Bayoumi & Mahdy, (2014) (30) they documented that nearly more than half of the children were males and enrolled in preparatory level.
According to the children residence area, this study illustrated that more than two thirds of the children in this study were from rural areas.On the same scope this finding agreed with Ahmed et al., (2020) (32) who mentioned that more than two thirds of children were living in rural areas.This result goes in accordance with Bahgat & Nada, (2019) (31) who found that, the most of studied children from rural areas.
As regards clinical data of the studied children, the present study illustrated that more than half of the children were on hemodialysis for ≥ 3 years.These findings are consistent with Ahmed et al., (2020) (32) who mentioned that nearly half of studied children start renal dialysis for more than three years.Similarly, this study is on the same line with Bayoumi & Mahdy, (2014) (30) who demonstrated that more than half of children receive hemodialysis therapy for more than three years.The findings of the current study confirmed that, all children underwent three hemodialysis sessions per week.These results are on the same wavelength with Al badry et al., (2020) (14) who conducted study to evaluate "effect of intradialytic hemodialysis exercises on fatigue and leg cramps" and mentioned that vast majority of subjects receive three hemodialysis sessions per week.The present study clears that, hemodialysis session of all children in this study last for four hours and the majority of them experience muscle cramps during the last hour of hemodialysis in both legs and in calf muscle.These results are compatible with Ghaleb & Sharaf, (2020) (16) they study "effects of nursing interventions on intradialytic muscle cramps among patients undergoing maintenance hemodialysis" and pointed out that all of patients underwent hemodialysis for four hours and the majority of them experienced muscle cramps in both legs, calf muscle and during the last hour of hemodialysis session.Moreover, this table reflected that, muscle cramps restrict motion and activity in all of studied children.This result agrees with Jancy & Parimalas, (2020) (6) who study "the effect of intradialytic stretching exercises to reduce leg muscle cramps among patients undergoing hemodialysis" and concluded that 67% of subjects had restricted activities due to muscle cramps.
Regarding the nurses' total knowledge illustrated that, less than half of the studied nurses had average level of knowledge preintradialytic exercises program intervention.While, the majority of them scored good level of knowledge post-intradialytic exercises program, with significant improvement the program as compared with pre-program intervention.This may be due to the effective program that used simple language, pictures and preparation of educational program materials based on actual needs of nurses and children.These findings of the present study were supported by Bayoumi & Mahdy, (2014) (30) who found that there were highly statistically significant differences in relation to total nurses' knowledge during pre/post program implementation (P-value <0.001),where most of them had good knowledge and the minority of them had poor knowledge post program.Additionally, this result is in compliance with Machaley et al., (2020) (29) they reflected that, before implementing the guidelines they observed that, slightly less than two thirds of the nurses had good total knowledge scores and their total knowledge mean scores improved to 88.3% after implementing the guidelines with significant difference in the nurses 'total knowledge scores.
As regards nurses' total practice scores, the study findings showed that most of the studied nurses had unsatisfactory practice score regarding intradialytic exercises preintradialytic exercises program.However, the majority of them had a satisfactory practice score post-intradialytic exercises program.Moreover, there is a highly statistical significant improvement in nurses' practice score post-intradialytic exercises program (P< 0.000).These results go in the same wavelength with Bayoumi & Mahdy, (2014) (30) who stated that there were significant differences regarding total nurses' performance pre and post program implementation .Concerning features of intradialytic muscle cramps, the present study clarifies that, there is a highly statistical significant difference between frequency and duration of muscle cramps, level of pain, leg temperature and discomfort among the studied children pre and post-intradialytic exercises program implementation .These results agree with Ghaleb & Sharaf, (2020) (16) who pointed out that, the nursing intervention were proved to be significant in reducing frequency and duration of muscle cramps and level of pain among the studied children (p<0.001).Additionally, these findings are consistent with Al badry et al., (2020) (14) who found that, there was statistical significance difference as regard cramp questionnaire chart (frequency and duration of muscle cramps, level of pain, leg temperature and discomfort) pre and post implementation of intradialytic exercises.Regarding the level of muscle cramps among children undergoing hemodialysis, the current study showed that two fifth of the studied children had severe muscle cramps pre-intradialytic exercises program.While, less than two thirds of them had mild cramps post intrdialytic exercises program.There is a highly statistical significant difference in level of muscle cramps postintradialytic exercises program .These findings confirmed with Bharti & Chavda, (2020) (33) they studied "effectiveness of intradialytic stretching exercise on muscle cramps among patients undergoing hemodialysis" which reflected that, the intradialytic exercise was effective in reducing the muscle cramps score among hemodialysis patients.This result supported by Ghaleb & Sharaf, (2020) (16) pointed that the used nursing intervention demonstrated statistically significant difference in the level of muscle cramps, as two thirds had moderate muscle cramps before applying the nursing intervention, compared to 58.1% and 41.9% who had no to mild cramps after intervention respectively.Moreover, Jancy & Parimalas, (2020) (6) concluded that continuous intradialytic exercises can prevent and reduce the level of muscle cramps during hemodialysis.From to researchers' point of view that exercise training can enhance muscle blood circulation that help in reducing muscles cramps.The current study revealed that, there is a highly statistical significant difference between clinical features of impaired perfusion (peripheral pulse, capillary refill, Edema, temperature, pain and color of skin)pre and post-intradialytic exercises program implementation and more than half of the studied children suffered from inadequate perfusion before intradialytic exercise.While, nearly half of them had adequate perfusion after intrdialytic exercises application.There is a highly statistical significant difference in level of peripheral perfusion post-intradialytic exercises program (P< 0.000).These results are supported by McGuire et al., (2018) (8) who pointed that, an increase in cardiac output achieved by intradialytic exercises would enhance perfusion.Also, these results agree with Mohamed et al., (2020) (14) who mentioned that, intradialytic exercises increased muscle blood flow and opened capillary surface area.Regarding the correlation between nurses' overall knowledge and practice levels, survey results showed a positive correlation between nurses' overall knowledge levels and overall practice levels before and after the program.These results are inconsistent with those of Ibrahim et al. (2019) (3) reported that there was no statistically significant relationship between nurses' knowledge level and practice level (p ≥ 0.05).Furthermore, Machaly et al. (2020) (29) found no association between total knowledge scores of surveyed nurses and total practice scores before and after implementation of evidence-based nursing guidelines.Moreover, In this study, the correlation between overall practice and muscle cramps before and after implementing an intradialytic exercise program showed a positive correlation between overall practices scores and muscle cramps in nurses after implementing an intradialytic exercise program.This finding is corroborated by Lakhwinder et al. (2019) 34) they conducted a study entitled "Quasiexperimental study to evaluate the effect of stretching exercise during dialysis on muscle spasms in patients undergoing hemodialysis in selected hospitals in Jalandhar, Punjab"., found that stretching exercise during dialysis had a significant effect on muscle spasms in patients undergoing hemodialysis.Regarding the correlation between overall practice before and after an intradialysis exercise program and clinical features of peripheral blood flow disorders.This study reflects a statistically significant correlation between nurses' practice total scores and clinical features of perfusion failure after using an intradialysis exercise program.This supported by Exercise training can enhance peripheral perfusion, blood pressure, muscle blood circulation, and physical labour capacity while reducing fatigue, uremic nephropathy, myopathy, and cramping in the muscles.As skeletal muscles' oxygen demands increase during intradialytic activities, cardiac output can increase fourfold, improving perfusion and lowering cardiac stunning Hatef et al, (2021) (15) who illustrated that exercise training can enhance peripheral perfusion, blood pressure, muscle blood circulation, while reducing fatigue, uremic nephropathy, myopathy, and cramping in the muscles.As skeletal muscles' oxygen demands increase during intradialytic activities, cardiac output can increase fourfold, improving perfusion and lowering cardiac stunning.

Conclusion Based on the findings of the current study, it can be concluded that:
There was significant improvement in nurses' knowledge and practices regarding intadialytic exercise after program.Additionally there was a statistically significant correlation between overall nurses' practices level and muscle spasms following the intra-dialysis exercise program application.Also there was a statistically significant correlation between nurses'

Figure ( 2 )
Figure (2): Percentage distribution of the studied nurses regarding their total practices level regarding interadialytic exercises(pre/post-intradialytic exercises program).