Introduction research has been found to focus on


With the advancements in scientific
research and availability of medical health care, a major transitional shift
has occurred in the cause of mortality from infectious diseases to chronic
illnesses. Physical inactivity has been identified as a prevalent risk factor
in all-cause mortality and significantly increases the risk of chronic
illnesses (Dunstan, Howard, Healy, & Owen, 2012). Many initiatives have
been set in place to encourage the population at different age groups to
increase their participation in physical activity and reduce the time being
sedentary. Along with this, the government has assigned the roles of chief
medical officers to put forward physical activity recommendations specific to
age, to improve physical and mental health and wellbeing.

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Nevertheless, guidelines are not
tailored to incorporate populations with chronic illnesses such as chronic
kidney disease patients (CKD). This is a growing population with research
showing them to lead physically inactive lifestyles and as such leaving them
exposed to further health illnesses and aggravating existing problems. Physical
activity has been shown to help and improve health in a variety of aspect in
addition to improving the CKD specific population (Clarke et al., 2015).

Due to the severe lack of physical
activity participation in this population (Delgado & Johansen, 2011), few
attempts have been made to understand their perceived barriers. The barriers
have generally been categorised as environmental, personal and behavioural with
a degree of consistency in finding between studies. However, all studies have
recruited CKD patients who are in adult year and/or older adults (aged ? 18
years). No research has been found to focus on paediatric CKD patients or
include in . This gap in the research is intended to be addressed in the
current study. Improving the participation of physical activity among young
people is vital particularly since high levels of physical activity participation
in youth significantly predict high participation rates later in adult years
(Telama et al., 2004).

The topic of this literature review will
be examined and explored conceptually and empirically. Discussed in the
conceptual section of the study will be the following topics; physical
activity, sedentary behaviour, barriers to physical activity, CKD and physical
activity levels in CKD patients. Discussed in the empirical section of the
study will be the following topics; CKD patients’ perceptions of physical
activity; and barrier to physical activity among CKD patients.


Physical Activity & Sedentary Behaviour

Physical activity is understood as any
bodily movement produced by skeletal muscles that results in energy expenditure
of >1.5 MET (multiples of the basal metabolic rate)
(Caspersen, Powell & Christenson, 1985). Physical
activity can vary in type and intensity, and manifests itself in activities
such as walking, running, climbing and jumping. Recently acknowledged
for its therapeutic benefits to patients with CKD, physical activity has been
found to enhance physical fitness, improve cardiovascular health and enhance
overall quality of life (Heiwe & Jacobson, 2011).
The extent to which physical activity and exercise can help CKD patient’s
aerobic capacity was demonstrated when Kouidi et al (1998) enrolled 7 patients,
receiving haemodialysis, in a 6 month exercise training rehabilitation
programme. The results yielded an average increase of 48% in peak oxygen

walking for 30 minutes, five time per week has considerable cardio-protective
benefits and has been found to improve immune function and inflammation in CKD
patient populations (Viana et al, 2014). The United States Renal Data System’s
(USRDS) 2003 annual data report indicated a large number of the CKD population
were afflicted with comorbidities. Specifically, 45% reported to have diabetes
mellitus and 79% had a history of hypertension. Upon acknowledging the
collection of issues CKD patients’ commonly experience, physical activity is
furthermore appreciated with evidence of it controlling diabetes, controlling
blood pressure (Artinian,2010) improving strength, survival and quality of life
(Johansen, 2005). Thus, this adds to the notion that physical activity improves
physical and mental health and is particularly beneficial to CKD patients as it
assists in simultaneously tackling multiple health concerns such as positively
impacting immune function and inflammation in patients with CKD stages 3-4
(Viana, 2014). 

Concerning CKD
patients, knowledge of the benefits of physical activity is important but
equally the dangers of sedentary behaviour is similarly relevant. Lying down to
rest or sitting during school, work or during a commute are a select few of the
many examples that are custom to daily living activities which exert minimal
energy expenditure (? 1.5 MET). This is referred to as sedentary behaviour (Ainsworth
et al, 2000). Too long and frequent sedentary behaviour can have adverse effect
on health. O’Hare, Tawney,
Bacchetti & Johansen (2003) found that sedentary
patients receiving dialysis treatment have a higher risk of death within 1 year
compared to those who report participation in physical activity. Therefore
sedentary behaviour has severe, life threatening consequences. Furthermore the
correlation between mortality and physical inactivity with CKD offers
additional support to the notion that this population would benefit from an
increase in physical activity participation (O’Hare, 2003).

Barriers to physical activity among general population

With the availability of scientific
evidence on the value physical activity is to health, government initiatives
have responded accordingly and issued targets and guidelines to the general
public to encourage physical activity participation. The first exercise guidelines
were endorsed and published by the American College of Sports Medicine in 1978.
The essential focus of these recommendations was a means of performing a
sufficient amount of exercise to improve cardiorespiratory and muscular fitness.

With the advancement of exercise
science, current recommendations focus on improving and maintaining health and
has categorised physical activity into different levels of intensity such as
light, moderate and vigorous. By way of encouragement the chief medical
officer’s current guidelines for adults are outlined as the following: (adults:
aged 19-64) 150 minutes of moderate aerobic exercise per week and 75 minutes of
vigorous aerobic exercise per week; (adolescents: aged 5-18) Moderate to
vigorous physical activity for at least 60 minutes and up to several hours
every day (Start active stay active, 2011).

Following the recommendations, the
Scottish Health Survey (2012) reported that 62% of Scottish adults meet the
guidelines and 70% of Scottish children met the guidelines. A mere 6.9% of CKD
meet physical activity guidelines (Robinson-Cohen et al., 2009) Although these
statistics are higher in comparison to CKD patients, they suggest many people
are not engaging in adequate levels of physical activity and thus missing out
on health benefits and being exposed to the consequent risks.

A perceived barrier to physical activity
amongst the general public are factors such as limited time due to work, school
and other responsibilities. Weather is also commonly used as a reason for not
participating (Arzu, Tuzun & Eker, 2006). Cold, wet and windy conditions
deter many from leaving home comforts and being physically active.
Alternatively, hot and humid weather conditions similarly can be a deterrent.

Tappe, Duda and Ehrnwald (1989)
concluded from their qualitative study, the major barriers to exercise among
adolescents were lack of interest, time constraints, unsuitable weather, school
and homework.

Following a series of 90 interviews of
older adults, the general perceived barriers were physical health problems,
fear of falling or injury, physical frailty, lack of knowledge of physical
activity and environmental restrictions (Chen, 2010).

To answer the overarching question that
forms the basis of the present study, a qualitative research will be conducted.
Qualitative research deals with phenomena that is focused on answering how and
why questions or understanding beliefs, as opposed to dealing with quantities
(Patton, 1990). This can be conducted through interviews, focus groups,
questionnaires and surveys.

Chronic kidney disease

Greater availability and accessibility
to treatments for infectious diseases has resulted in an unprecedented increase
in life expectancy (Mercer, 2014). The major shift in all-cause mortality currently
resides in the rise of chronic diseases which is responsible for 2/3 of all global deaths (Borrell &
Lancet, 2012). Chronic disease is a long term illness that can be managed but
not generally cured. This transition was first theorised by Abdel Omran (1971)
who described the theory as the ‘epidemiological transition’ which essentially provides
an accounting for the replacement of infectious diseases by chronic diseases. Explanation
for this may be due to expanded public health and sanitation but also modern
trends such as the increase in older adult section of the population, epidemic
of obesity and rise in physical inactivity. Among the major chronic diseases
are; chronic lung disease, cardiovascular disease, diabetes, breast cancer and
colon cancer.

Among the list of many chronic illnesses
is CKD. CKD is a growing public health problem on a global scale and although
the initial stages are asymptomatic, the effects can be severe with adverse
consequences leading to kidney failure, cardiovascular disease (CVD), and
premature death (Levey et al., 2005). CKD is
defined as the presence of kidney damage for a duration of 3 months or longer comprising
of structural or functional abnormalities. Glomerular filtration rate (GFR) is
widely accepted as the optimum measure of kidney functionality and as such when
GFR is consistently less than 60 ml/min/1.73 m2  for a time period exceeding 3 months,
this also constitutes as CKD (Eckardt, Berns, Rocco & Kasiske, 2009).

Categorising and distinguishing the
range in severity, CKD is divided into 5 stages. Stage 1 is the least severe
stage which consists of signs of kidney damage but with a normal, healthy GFR. The
proceeding stages are progressive in severity with stage 5 being the most
severe and considered as kidney failure with a GFR measure of less the 15 ml/min/1.73
m2 therefore requiring frequent dialysis treatment and/or kidney
transplant (Shafi, & Coresh, 2010). Haemodialysis is the most common form
of treatment. As a result of the kidneys not functioning properly, haemodialysis
is procedure which involves diverting blood to a machine, through a needle and
tube, which removes waste and essentially cleans the blood before returning to
the body. Patient’s need for dialysis vary but many undergo this procedure 3
times per week and can persist for the rest of their lives.   

CKD affects 8-16% of the population
worldwide and there are 3 million people in the United Kingdom who currently have
kidney disease (, 2018). A large epidemiological study
examining over 1 million individuals provided evidence that reduced levels of
GFR increases the risk of mortality (Go, Chertow, Fan,
McCulloch & Hsu, 2004) and is associated with an increased risk of
cardiovascular disease (CVD), muscle wasting, decrease physical function and
overall poorer quality of life (Clarke, Young, Hull, Hudson, Burton & Smith
et al, 2015).

Among the CKD population it is not
uncommon for individuals to suffer from other chronic illnesses. Examples of
such comorbidities include diabetes and hypertension (United States Renal Data
System, 2003) both of which are particularly burdensome. Patients with CKD have
a great prevalence of CVD than the general population (Sarnak et al, 2003).

Physical activity in CKD

Despite the numerous potential benefits
to health, CKD patients have been identified as leading inactive lifestyles
(Beddhu, Baird, Zitterkoph, Neilson & Greene, 2009) and are considered less
active than sedentary individuals without CKD (Johansen et al, 2000).

For patients on dialysis, The National
Kidney Foundation (2005) issued a recommendation of achieving a goal of 30
minutes of physical activity, at a moderate intensity, on most if not all days.
Moderate intensity can be characterised as a brisk walk, or light jog. However
Johansen et al, (2000) found that 54% did not perform 30 minutes of physical
activity per day at a light intensity. Physical activity performed at a light
intensity can be characterised as walking. This disturbing statistic is
supported by Robinson-Cohen (2009) who found that a mere 6.9% of CKD patients
meet the physical activity recommended guidelines. Adding to the weight of
evidence suggesting CKD patients are inactive is Tawney et al (2000) who indicated
from their research that 37% of haemodialysis recipients reported no regular
exercise participation.

Furthermore, considering the previously
stated list of benefits this unique population can attain from regularly
engagement in physical activity, it is of great alarm and cause for concern as
to why this population lead physically inactive lifestyles. Additionally,
physical inactivity is a prominent risk factor for other chronic illnesses such
as type 2 diabetes, coronary heart disease and colon cancer (Lee et al., 2012)
and therefore must be tackled to reduce risk and promote healthy living.




Johansen (2005) indicated the need for
research on the identification of barriers to physical activity amongst CKD
population to understand the key issues. This would then allow interventions to
be developed to encourage a behavioural change and improve physical activity
participation amongst the CKD population. Since then there has been few
attempts made to improve understanding and grasp the specifics as to why CKD
patients are generally inactivity, leading sedentary lives.

 Delgado and Johansen (2011) is one example of
a study which aimed to tackle this problem by issuing adult CKD patients in the
San Francisco Bay Area a survey for them to complete. Interestingly a large
majority (92%) of the people surveyed indicated that they experience at least 1
barrier to physical activity and 86% reported they face 2 or more barriers to
physical activity. As previously mentioned the physical activity recommendation
for CKD patients are 30 minutes of physical activity at a moderate intensity
for at least 5 days per week (National Kidney Foundation, 2005). However around
half of the participants (52%) presumed participation in physical activity 1-2
times per week to be sufficient for cardiovascular health and 23% felt that
exercising 3-5 times per week was sufficient. These statistics emphasise the
general lack of knowledge of the official recommendations and suggest a
complete lack of awareness of them by CKD patients. Nevertheless, participants
agreed that they do believe there to be health risks to living a sedentary
lifestyle and benefits of living actively. This suggests that even though CKD
patients have a baseline knowledge, they perhaps do not comprehend the full
extent of the risks/ benefits. The blame for this must lie with the health care
professionals who have a duty of care not only to provide treatment to their
patients but also to provide information to encourage healthy living.

One of the main barriers voiced through Delgado
and Johansen’s (2011) qualitative research was the lack of encouragement from
health care professionals. Many of the of physicians (35%) gave reason for this
being due to their perception being that they did not believe their patients
would be interested in discussing the subject of physical activity. This
perception was discredited with only 4% of the patients agreeing that they did not
want to discuss physical activity and 93% believed they would increase their
exercise participation if counselled to do so.

In addition, other barriers which were
voiced in this study was fatigue, lack of motivation and shortness of breath.
Patients also stated a lack of time due to too many medical appointments, lack
of safe places to exercise and not having an exercise partner were also included
as the predominant barriers to participating in exercise.

This study recruited it’s participants
through a method of convenience sampling and although the participants were a
diverse group regarding race/ethnicity they all resided in the northern area of
California so may not be representative of the entire world-wide population.
The mean age of the participant in this study is 60 years which therefore
limits the findings to reflect the older CKD population only. This therefore
effects the validity of the results as the views may be more linked to old age
rather than reflect patients with CKD.

connection with professional practice, a study conducted by Johansen, Sakkas, Doyle, Shubert
and Dudley (2003) issued approximately 500 nephrologists with a survey. The
questions in the survey were with regards to the service and level of care they
offer to their CKD patients. The majority (62%) reported that they do not
assess their patient’s physical activity levels. When asked for the
explanation, the reasons for such were due to a lack of time, insufficient
self-confidence in their ability to offer guidance on physical activity, did
not believe it to be a major issue and a lack of conviction that patients would
respond. This is consistent with the study by Delgado and Johansen
(2011) that CKD patients are not receiving adequate
information and/or encouragement to participate in physical activity from their
health care providers. Contrary to nephrologist’s belief, exercise counselling
has been proven to increase physical activity among dialysis patients (Tawney
et al., 2000).

Clarke et al. (2015) conducted a series
of focus groups to adult, dialysis patients with the objective of identifying
motivators and barriers to exercise. The results reflected that of previous
findings however the most prevalent barrier found was of their co-morbid
conditions, such as; cardiovascular disease (CVD), hypertension, respiratory
disease, diabetes, mental health and musculoskeletal illnesses. Being burdened
with the symptoms of other chronic illnesses was the main barrier to regular
exercise which included fatigue, shortness of breath and pain in joints.

These barriers are the results of other
chronic diseases and not specific to CKD. However, given that most CKD patients
have comorbidities it is appropriate to consider this as a barrier to the CKD
specific population.

Also, included in the list of perceived
barriers to physical activity in Clarke et al. (2015) was the fear of injury
and aggravating their health problems through exercising. This was a concern
shared by half the participants and has been an issue brought up in previously
mentioned research papers. This barrier comes with little surprise given that
patients are not provided with information from their health care providers on
how much physical activity to do and how intense. A majority of the
participants expressed their desire to have their goals reviewed by
professionals and tailored to their specific health complexities and requirements.
This would be a desire shared by most of the general population however given
the complexity of their health and medical needs, this notion is evidently more
acceptable and needed by CKD patients. Specific principles of exercise from a
professional was requested to draw appropriate safety measures allowing for CKD
patients a sense of freedom with a knowledge of their guided physical activity

Another barrier to physical activity
perceived by CKD patients in Clarke et al., (2015) qualitative study was poor
weather conditions. This is a barrier shared by the general population (Arzu et
al., 2006) however a distinction can be made from the general uneasiness of the
cold and uncomfortable conditions to the severe exacerbated symptom of joint
stiffness which comes as a result of the poor weather conditions. Therefore
although a selection of the barriers are shared with non-CKD patients, the
reasons for the barriers are either different or of a greater extremity to the
CKD population. 

Although the results in this study are
similar to findings in others, it may be noted that there were a series of
limitations found. Firstly participants were recruited through a voluntary
basis and as such suggest that these participants had an existing interest in
the research subject, physical activity. It is therefore likely that due to
this nature, the participants may not be a true representation of the CKD population.
Secondary, the participants, although were similar in that they were diagnosed
CKD patients, they varied in terms of their level of CKD. Some were at level 1
and others were at level 5. This variation is a reflection of the varied levels
of severity of their conditions which entailed a wide range of responses as
opposed to a clear definitive response. Lastly, it may be noted that the mean
age of those who participated in this study was 60 offering no insight from CKD
patients in childhood or middle-aged.

From a series of in-depth interviews,
Jhamb et al. (2016) identified barriers to physical activity among adult
dialysis patients. Interviewees consisted of patients, staff and nephrologists.
The challenges faced were due to fatigue and lack of energy which came as a
direct result of the dialysis treatment. Patients found that post dialysis they
felt “drained” demotivating them from engaging in activity at any level of intensity.

Patients reported not engaging in high
intense physical activity because of a fear of injury which is consistent with
other findings in addition to poor over-all health and comorbidities such as
poor eye sight, arthritis and leg weakness. 
The most prominent challenge mentioned was down to lack of motivation
which was recognised by staff and nephrologists. Patients described the burden
of living with a chronic condition and regularly receiving dialysis made
exercise a low priority in their life.

Social support was perceived as a
barrier and motivator to physical activity among CKD patients. Some patients
expressed their concern that not having an exercise partner impeded their
desire to exercise. Social support was encouraging to the patients however they
felt they were being unfairly judged and scrutinised by others when exercising
by those who were unaware of their condition. However this barrier may not be
exclusive, or linked to CKD patients, but rather to all people who have a
chronic illness. 

Notwithstanding the new supportive
evidence this study offers, it does possess limitations. The study claimed to
reach thematic saturation however, it may have missed out on further beliefs
and experiences with additional interviews coupled with recruiting patients of
a more diverse ethnicity to capture and represent the population more honestly.
The mean age of those who participated in this study was 60 offering no insight
from CKD patients who are middle-aged or who are adolescents.



In conclusion, the bulk of research on
the barriers to physical activity among CKD patients has not been explored
comprehensively as there is an inexistence of the perspective among the
paediatric population. The barriers and challenges of physical activity in the
general population differ with age groups so therefore it is expected that
adolescents with CKD will differ to adults. Young people should be encouraged
to exercise to instil within them a life-long habit to live actively which will
provide many physical and mental health benefits. It will also reduce the risk
of developing additional chronic diseases.

The literature highlighted the extent to
which CKD patients are inactive and the multitude of areas in which physical
activity can benefit health for CKD patients. A qualitative approach will be an
effective method of addressing this gap in the research as it not only will
yield the objective outcomes but also will provide rich, in depth understanding
to their experiences. CKD patients live an exceptionally inactive lifestyle
therefore it is expedient, that interventions are delivered to bring about a
behavioural change. Before doing this, the problem must be identified to give
future interventions direction and meaningful purpose.