PREVENTION OF INTRADIALYTIC MUSCLE CRAMP IN PATIENTS THAT ARE
TAKING HEMODIALYSIS WITH INTRADIALYTIC STRETCHING EXERCISE
(GASTROCNEMIUS AND SOLEUS (CALF) MUSCLES)): PILOT STUDY
Zaky Mubarak1
1
Lecturer of the Faculty of Nursing, Stikes Muhammadiyah Kendal, Kendal, Central Java
Email: ………..
ABSTRACT
Introduction: Nurses as professional health workers are required to always maintain and
improve services to patients in improving health and continuity of patient treatment.
Hemodialysis is a lifelong treatment, so the problems that arise due to hemodialysis therapy must
be overcome. One of the problems that arise is muscle cramps which can be overcome by non-
pharmacological measures. Objective: This study aims to determine the effect of Intradialytic
Stretching Exercise for the Prevention of Cramps in patients undergoing Hemodialysis.
Methods: The design used is a pilot study involving hemodialysis patients who meet the
inclusion criteria and are accompanied by nurses.
Result: The study carried out is Guidelines and SOPs on Intradialytic Stretching therapy
Exercises. The Intradialytic Stretching Exercise guide discusses the meaning, purpose, benefits,
duration and frequency, and the role of tasks and the implementation of therapy. These
guidelines and SOPs are used as a reference for the implementation of Intradialytic Stretching
Exercise therapy in the room. Nurses who have carried out therapy stated that Intradialytic
Stretching Exercise therapy is useful in preventing leg cramps in hemodialysis patients,
obtaining research updates, solving service problems, increasing awareness of quality practices
and critical thinking. Barriers to the implementation of Intradialytic Stretching Exercise therapy
are related to limited literature sources, implementation time, media and some inactive
participants.
Keywords: Muscle cramps, Hemodialysis, Therapy, Physical exercise
INTRODUCTION treatment and changes in plasma
Intradialytic muscle cramps or osmolality and/or extracellular fluid
muscle cramps that occur in patients volume have been implicated for it.
undergoing hemodialysis appear to recur Cramps that occur during dialysis
in about 25% of all hemodialysis patients. treatment most often involve the muscles
Such cramping tends to occur most of the lower extremities, namely the
frequently towards the end of hemodialysis gastrocnemius and other small muscles of
the legs, but the muscles of the hands, have been effective. It concluded that,
arms, and abdomen can also be affected. stretching exercises for the affected
Cramps tend to occur at the end of dialysis muscles can immediately relieve cramps.
and are more common in the 30-50 year The consistent use of stretching exercises
age group. Some occurrences of muscle to avoid cramping was proposed and it was
cramps can also be experienced at the end concluded that, stretching muscles during
of hemodialysis treatment. With respect to cramping could be helpful for HD patients
time on hemodialysis, most patients (Ulu, 2015). Because cramping is a
experienced muscle cramps between 6-12 common complication for HD patients
months of hemodialysis (n = 9). Cramps causing discomfort. Appropriate
were more common in older, non-diabetic, interference in muscle cramps and
and anxious patients.3,17 However, preventing their occurrence has also been
patients with muscle cramps were young an important intervention of nurses caring
(≤50 years) (n = 10) but most of them were for HD patients during almost ubiquitous
not nondiabetic (n = 11). The etiology of time (Judits, 2012).
cramps in dialysis patients is unknown. Intradialytic exercise is an exercise
The etiology of hemodialysis-associated performed during hemodialysis. In a study
cramps may be related to one or more of conducted by the Canadian Nephrology
the following factors: (1) Plasma volume Association, it was stated that from a
contraction (2) Hyponatremia (3) Tissue physiological perspective, intradialytic
hypoxia (4) Hypomagnesemia (5) exercise can increase muscle blood flow
Carnitine deficiency and (6) Elevated and increase the number of capillaries in
serum leptin levels.3, 17 Of these, volume the working muscle so that it will result in
contraction and hyponatremia, alone or in the flow of urea and other toxins from the
combination, are the most likely tissue to the vascular area that is
underlying causative factors. transferred. Next on the dialyzer 5.
Intradialytic Muscle Cramp is Another benefit of intradialytic exercise is
managed by normal saline infusion, simple the regulation of blood pressure. Patients
massage and even by temporarily stopping with hypertension experienced a decrease
ultrafiltration until the cramping stops in systolic blood pressure after doing
(Danasu, 2016). Many treatment methods intradialytic exercise for 3 months.
for HD-related cramps have been Although there are many positive effects
suggested, but most of them have of doing intradialytic exercise, its
accompanied severe side effects and none implementation is still low6. Lack of
awareness and lack of information about determine the amount of fluid to be
exercises performed during hemodialysis withdrawn (UF).
make this therapy rarely used7. Further studies obtained data that
Intradialytic exercise for every hemodialysis patient had
hemodialysis patients has not been experienced complications from
determined (Makhlough et al. 2012). hemodialysis therapy, one of which was
However, based on Manoj Punchiri's muscle cramps. The patient's cramps were
research, he uses the Gastrocnemius and felt at the beginning of receiving
Soleus muscles (calf muscles). Studies hemodialysis therapy. Including patients
support that exercise of the Gastrocnemius under management, namely Mr. R and
and Soleus muscles (calf muscles) can Mrs. S, who said at the beginning
significantly reduce muscle cramps receiving hemodialysis.
experienced by patients undergoing HD. METHODS
Therefore, the use of such exercises can be The design used in this study is a pilot
carried out by health care professionals study. The pilot study was carried out in a
among patients undergoing HD which will series of activities as a renewal agent at RS
make patients more comfortable and X with
satisfied with HD sessions.
prepare SOP on Intradialytic Stretching
Hospital X is one of the central
Exercise therapy. The activity was started
hospitals in Central Java province which
by using interviews, observations, and
already has a hemodialysis unit room.
questionnaires. The search for respondents
Based on the assessment data obtained,
used non-probability consecutive
that of the 18 patients who were scheduled
sampling, with inclusion and exclusion
to undergo hemodialysis in the first
criteria. Inclusion criteria for patients with
session, only 4 patients had a dry weight of
chronic kidney disease undergoing HD:
less than 1 kg, the remaining 14 patients
weighed more than 1 kg of dry weight. 1. With the age of more than 30 years.
According to Lewis, Stabler & Welch, 2. They were available at the time of data
2000 said that excess weight that can be collection.
tolerated by the body is not more than 1.0- 3. Who is alert, aware and cooperative.
1.5 kg or no more than 3% of dry weight Exclusion criteria for patients with disease
(Smeltzer & Bare, 2001). patients with Chronic kidney undergoing HD:
body weight that exceeds the dry weight 1. Critically ill patients.
with tolerance (1.0 – 1.5 kg) will 2. Do not want to participate.
3. Suffering from pain other than muscle Intradialytic Stretching Exercise.,
cramps. Intradialytic Stretching Exercise trials.,
The results of the data collected were evaluation of guidelines, SOPs and
carried out by a SWOT analysis in order to implementation of Intradialytic Stretching
find out the problems that occurred. Exercise., and in the final stage,
Several activities are arranged in order to socialization is carried out. The evaluation
solve the problem. These activities include carried out refers to the results of
the preparation of a Plan of Action (POA), observations during testing and input.
the preparation of guidelines and SOPs on
RESULT
Initial assessment of muscle cramps in
patients undergoing hemodialysis with a
deep interview process on patients before
the Intradialytic Stretching Exercise was
performed on patients undergoing
hemodialysis in the Hemodialysis Room,
RSUP Dr. Kariadi Semarang on
September 3 to 15 2018, the results are as
follows.
Table 1.1 Intradialytic Muscle Cramp
No Name Muscle cramps on dialysis
1 Mr. E Repeated cramps
2 Mr. S Once
3 Mr. J Once
4 Mr. D Repeated cramps
5 Mr. Sy Repeated cramps
6 Mrs. J Repeated cramps
7 Mr. S Repeated cramps
8 Mr. S Repeated cramps
9 Tn. H Repeated cramps
The table above represents 3 groups of HD Intradialytic Muscle Cramp is the
schedules in the room, 3 patients with incidence of muscle cramps in patients
Monday & Thursday schedules, 3 patients undergoing HD. This intervention was
with Tuesday & Friday schedules, 3 carried out from 1 to 6 October 2018. And
patients with Wednesday & Saturday evaluated on 8-10 October 2018, with the
schedules. From the results of deep following results:
interviews, almost all patients stated that
they had experienced cramps during
dialysis, either at the beginning of
hemodialysis or repeated after several
years of hemodialysis. The final outcome
assessment of the Intradialytic Stretching
Exercise intervention on the prevention of
Table 1.2 Prevention of Patient Cramps Before and After Intradialytic Stretching Exercise
No Name Intradialytic Muscle Cramp
Before doing Intradialytic After doing Intradialytic Stretching
Stretching Exercise Exercise
1 Mr. E Repeated cramps No Cramps Occur
2 Mr. S Once No Cramps Occur
3 Mr. J Once No Cramps Occur
4 Mr. D Repeated cramps No Cramps Occur
5 Mr. Sy Repeated cramps No Cramps Occur
6 Mr. J Repeated cramps No Cramps Occur
7 Mr. S Repeated cramps No Cramps Occur
8 Mr. S Repeated cramps No Cramps Occur
9 Mr. H Repeated cramps No Cramps Occur
Based on the table above, it can be seen Prior to the intervention, 9 patients
that the Intradialytic Stretching Exercise stated that they had experienced cramping
intervention. Effective for the prevention during the HD process, but some of them
of cramps in HD patients. Although there have experienced recurring cramps until
are many confounding factors that become now. After the intervention, 9 patients did
limitations such as: patient non- not experience cramps. Although there are
compliance in fulfilling HD treatment many confounding factors that become
regimens (adherence to HD schedule, limitations such as: patient non-
medication adherence, fluid management compliance in fulfilling HD treatment
compliance, nutritional management regimens (adherence to HD schedule,
compliance) which results in excessive medication adherence, fluid management
IDWG (Intradialytic Weight Gain) / body compliance, nutritional management
weight from the patient's dry weight, so compliance) which results in excessive
that the patient's fluid withdrawal is large IDWG (Intradialytic Weight Gain) / body
and the prognosis for cramps in HD weight from the patient's dry weight, so
patients is getting worse. that the patient's fluid withdrawal is large
and the prognosis for HD patients' cramps
DISCUSSION
is getting worse.
Intradialytic exercise is an exercise
Another benefit of intradialytic exercise is
performed during hemodialysis. In a study
the regulation of blood pressure. Patients
conducted by the Canadian Nephrology
with hypertension experienced a decrease
Association, it was stated that from a
in systolic blood pressure after doing
physiological perspective, intradialytic
intradialytic exercise for 3 months.
exercise can increase muscle blood flow
Although there are many positive effects
and increase the number of capillaries in
of doing intradialytic exercise, its
the working muscle so that it will result in
implementation is still low6. Lack of
the flow of urea and other toxins from the
awareness and lack of information about
tissue to the vascular area that is
exercises performed during hemodialysis
transferred. Next on the dialyzer 5.
make this therapy rarely used7.
Based on the results obtained, the
However, based on Manoj Punchiri's
following analysis can be carried out:
research, he uses the Gastrocnemius and
1. Prevention of intradialytic muscle
Soleus muscles (calf muscles). Studies
cramps
support that exercise of the Gastrocnemius
and Soleus muscles (calf muscles) can
significantly reduce muscle cramps Caroline Kisner. Textbook of therapeutic
experienced by patients undergoing HD. exercise, F.A Davis Company,
Therefore, the use of such exercises can be Columbia, 6th edition, 2012.
carried out by health care professionals Chatrath H. On association of prevalence
among patients undergoing HD which will and morbidity with muscle cramps
make patients more comfortable and in patients during hemodialysis
satisfied with HD sessions. session, Journal of AMJ, 5(2),
CONCLUSION 2005, 127- 128.
Based on the results of the Danasu R Effectiveness Of Intra-Dialytic
implementation of evidence based nursing Stretching Exercise On Reducing
practice intradialytic stretching exercise Muscle Cramps Among
for 2 weeks on the prevention of Hemodialysis Patients At Sri
intradialytic muscle cramp in patients Manakula Vinayagar Medical
undergoing HD in the Hemodialysis room, College And Hospital, Puducherry,
Dr. Kariadi Semarang is effective in International Journal of Information
preventing muscle cramps in HD patients. Research and Review Vol. 03, Issue,
IMPLICATIONS 06, pp. 2443-2445, June, 2016
Intradialytic stretching exercise is expected Gowthami. The effectiveness of
to be a non-pharmacological therapy to intradialytic stretching exercise on
help reduce cramps in patients undergoing muscle cramps among patients
HD as an independent nursing action for undergoing hemodialysis”, Journal
nurses. It is expected that patients can of TNNMUV, 20(1), 2012, 40-43.
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