Impact of stage-specific limb function exercises guided by a self-management education model on arteriovenous fistula maturation status

Abstract

BACKGROUND

The exercise of limb function is the most economical and safe method to promote the maturation of arteriovenous fistula (AVF). However, due to the lack of a unified exercise standard in China, many patients have insufficient awareness of the importance of AVF, leading to poor effectiveness of limb function exercise. The self-management education model can effectively promote patients to take proactive health-related actions. This study focuses on the characteristics of patients during the peri-AVF period and conducts a phased limb function exercise under the guidance of the self-management education model to observe changes in factors such as the maturity of AVF.

AIM

To assess the impact of stage-specific limb function exercises, directed by a self-management education model, on the maturation status of AVFs.

METHODS

This study is a randomized controlled trial involving 74 patients with forearm AVFs from the Nephrology Department of a tertiary hospital in Sichuan Province, China. Patients were randomly divided into an observation group and a control group using a random number table method. The observation group underwent tailored stage-specific limb function exercises, informed by a self-management education model which took into account the unique features of AVF at various stages, in conjunction with routine care. Conversely, the control group was given standard limb function exercises along with routine care. The assessment involves the maturity of AVFs post-intervention, postoperative complications, and the self-management level of the fistula in both groups patients. Analyses were conducted using SPSS version 23.0. Count data were represented by frequency and percentage and subjected to chi-square test comparisons. Measurement data adhering to a normal distribution were presented as mean ± SD. The independent samples t-test was utilized for inter-group comparisons, while the paired t-test was used for intra-group comparisons. For measurement data not fitting a normal distribution, the median and interquartile range were presented and analyzed using the Wilcoxon rank sum test.

RESULTS

At the 8-wk postoperative mark, the observation group demonstrated significantly higher scores in AVF symptom recognition, symptom prevention, and self-management compared to the control group (P < 0.05). However, the variance in symptom management scores between the observation and control groups lacked statistical significance (P > 0.05). At 4 wk after the operation, the observation group displayed a superior vessel diameter and depth from the skin of the drainage vessels in comparison to the control group (P < 0.05). While the observation group did manifest elevated blood flow rates in the drainage vessels relative to the control group, this distinction was not statistically significant (P > 0.05). By the 8-wk postoperative interval, the observation group outperformed the control group with notable enhancements in blood flow rates, vessel diameter, and depth from the skin of drainage vessels (P < 0.01). Seven days following the procedure, the observation group manifested significantly diminished limb swelling and an overall reduced complication rate in contrast to the control group (P < 0.05). The evaluation of infection, thrombosis, embolism, arterial aneurysm stenosis, and incision bleeding showed no notable differences between the two groups (P > 0.05). By the 4-wk postoperative juncture, complications between the observation and control groups were statistically indistinguishable (P > 0.05).

CONCLUSION

Stage-specific limb function exercises, under the guidance of a self-management education model, amplify the capacity of AVF patients to discern and prevent symptoms. Additionally, they expedite AVF maturation and mitigate postoperative limb edema, underscoring their efficacy as a valuable method for the care and upkeep of AVF in hemodialysis patients.

Key Words: Self-management; Education model; Stage-specific; Limb function exercises; Arteriovenous fistula; Maturation status

Core Tip: Due to the absence of a unified standard for limb function exercises for arteriovenous fistulas (AVFs) in China, patients lack self-management awareness of AVFs. Therefore, this study focuses on the characteristics of patients during the peri-AVF period and conducts a phased limb function exercise under the guidance of the self-management education model. It was found that autonomous and regular phased limb function exercise during the peri-AVF period can improve the patients' ability to recognize and prevent symptoms of AVF, promote the maturation of AVF, and reduce the occurrence of postoperative swelling.

INTRODUCTION

The arteriovenous fistula (AVF) is an essential and safe vascular access method for hemodialysis in patients with renal failure. Its maturation status directly influences the success of dialysis therapy[1]. Existing guidelines suggest that end-stage renal disease patients should undertake limb function exercises both before and after AVF creation to stimulate arm vessels and muscle growth[2,3]. However, a globally accepted standard or protocol for these exercises for AVF patients remains undefined. Notably, studies report that between 20% to 50% of patients display insufficient AVF dilation and inadequate blood flow following surgery[4]. A significant number of these patients also show a limited understanding of AVF's critical role, often neglecting its maintenance and demonstrating a lack of self-management capabilities[5]. These shortcomings can result in delayed AVF maturation, diminished maturity status, or even loss of function, thereby compromising treatment effectiveness[5]. Self-management education models, designed to encourage patients to acquire and implement self-management skills, have been effective in prompting patients to adopt health-focused behaviors and actively manage diseases[6,7]. This research seeks to incorporate a self-management education model into the limb function exercises for AVF patients and evaluate the effects of this phased approach on AVF outcomes.

MATERIALS AND METHODS

Materials and methods

Study population: In the nephrology department of a tertiary hospital in Sichuan Province, China, 74 patients with forearm AVF were enrolled for this study from April 2022 to April 2023. This investigation received approval from the hospital's ethics committee prior to initiation. Participants were randomized into two groups: A control group and an observation group, each comprising 37 patients. During the study, two individuals from each group were lost to follow-up. The detailed information is provided in Figure 1.

Figure 1 Impact of stage-specific limb function exercises guided by a self-management education model on arteriovenous fistula maturation status.

The observation group had 22 males and 13 females, averaging an age of 59.46 ± 8.10 years. Detailed medical histories revealed that 34 of these patients had previously undergone dialysis catheter placement before their AVF procedure. Furthermore, 35 individuals reported a history of hypertension, three had diabetes, and 25 disclosed a history of smoking. Conversely, the control group was composed of 26 males and 9 females, with a mean age of 59.77 ± 9.19 years. Among them, 32 had experienced dialysis catheter placement prior to AVF creation. Additionally, 34 members had been diagnosed with hypertension in the past, two had diabetes, and 25 were former or current smokers. A comparative analysis determined that there were no statistically significant disparities in the baseline characteristics between the two groups (P > 0.05). The detailed information is provided in Table 1.

Table 1 Participants characteristics at baseline, n (%).

Characteristic	Observation group (n = 35)	Control group (n = 35)	Statistic	P value
Age (yr)	59.46 ± 8.10	59.77 ± 9.19	-0.151	0.88
BMI (kg/m2)	23.13 ± 1.88	23.00 ± 1.82	0.321	0.75
Gender			1.062	0.30
Male	22 (62.86)	26 (74.29)
Female	13 (37.14)	9 (25.71)
Marital status			0.162	0.92
Unmarried	1 (2.86)	1 (2.86)
Married	30 (85.71)	31 (88.57)
Divorce or widowed	4 (11.43)	3 (8.57)
Degree of education			0.342	0.84
Elementary school or below	24 (68.57)	22 (62.86)
Secondary school	9 (25.71)	10 (28.57)
College or above	2 (5.71)	3 (8.57)
Per capita monthly income (yuan)			0.332	0.96
< 2000	8 (22.86)	10 (28.57)
≥ 2000, < 5000	20 (57.14)	18 (51.47)
≥ 5000, < 8000	5 (14.29)	5 (14.29)
≥ 8000	2 (5.71)	2 (5.71)
History of smoking			0.002	1.00
Yes	25 (71.43)	25 (71.43)
No	10 (28.57)	10 (28.57)
History of central venous catheterization before AVF			0.262	0.61
Yes	34 (97.14)	32 (91.42)
No	1 (2.86)	3 (8.57)
History of hypertension			/	1.003
Yes	35 (100.00)	34 (97.14)
No	0 (0.00)	1 (2.86)
History of diabetes			0.002	1.00
Yes	3 (8.57)	2 (5.71)
No	32 (91.43)	33 (94.29)

¹t test.

²χ² test.

³Fisher's test.

AVF: Arteriovenous fistulas; BMI: Body mass index.

Inclusion criteria

Inclusion criteria: The study considered patients who qualified for hemodialysis and were undergoing the creation of an AVF for the first time. Eligible participants were aged 18 years or older. Further, they should not have had any prior history of vascular diseases, upper limb trauma, or surgeries. The location of the AVF needed to be at the distal forearm, specifically with a configuration of cephalic vein-radial artery anastomosis. Additionally, these patients provided informed consent and demonstrated a willingness to both participate in the study and cooperate throughout its duration.

Exclusion criteria: Patients were excluded if they had known blood disorders or abnormalities related to coagulation. Similarly, those diagnosed with severe cardiovascular or cerebrovascular diseases were not considered suitable for the study.

Termination criteria: The study was terminated for any participant who chose to voluntarily withdraw. Moreover, if a patient's condition worsened to a significant extent or if they passed away during the study, their participation was deemed terminated.

Study methods

Establishment of AVF care team: The AVF care team comprised an internal medicine nursing expert with over 30 years of professional experience, three specialized nurses in blood purification each boasting more than a decade of experience, and one nursing graduate student. Dedicated patient files were established for AVF creation. A comprehensive perioperative follow-up plan was formulated in alignment with the treatment requirements, encompassing both in-hospital and outpatient follow-ups.

Control group: Patients within the control group underwent standard care associated with AVF. This regimen encompassed perioperative care, health education, and limb function exercises. The customary limb function exercise regimen consisted of finger joint movements within the initial 24 h post-surgery. This was followed by finger flexion and extension exercises after 72 h and fist clenching exercises without utilizing any objects. Each clench lasted 5-8 s, with exercises lasting 10 min per session and being conducted 4-5 times daily. Following AVF removal, patients engaged in fist clenching exercises utilizing a pressure ring, maintaining the same clench duration but extending the session to 10-15 min and practicing 5-6 times daily.

Observation group: In addition to the standard care, the observation group patients participated in self-management-based phased limb function exercises. These exercises spanned three distinct phases.

Formation of self-management awareness phase: Commencing 2 wk prior to surgery, patients were introduced to the concept of limb function exercises using methods such as outcome displays, instructional videos, and mnemonic techniques. These exercises served to foster a proactive mindset towards the preservation of their "life channel". Initial limb function exercises consisted of fist clenching synchronized with elbow and wrist joint movements and coordinated upper arm movement. The intended tension should accommodate two fingers without hampering blood circulation, with no resulting feelings of swelling or numbness in the digits. The recommended exercise duration was set at 1 min per session, with 8-10 such sessions in a set, and three sets daily.

Physician-led exercise phase: Spanning from the first to the seventh postoperative day, routine exercises were carried out. On the 8^th day post-surgery, the aforementioned preoperative limb function exercises were reintroduced, tailored based on physician recommendations.

Patient-led exercise phase: Starting from the 15^th postoperative day and extending to 8 wk, patients, after evaluation by the specialized nursing team, had the autonomy to select the nature, intensity, and frequency of their limb function exercises. Bi-weekly support was offered to fine-tune their exercise regimens, incrementally expanding the variety and frequency of exercises. This included the integration of single fist clenching with pressure ring exercises and coordinated arm movements.

Observation indicators and research tools

Self-management level of AVF: The hemodialysis patient autogenous AVF self-management scale[8] was employed to evaluate the AVF self-management level in both patient groups at 8 wk post-surgery. The scale's scoring encompasses three dimensions: Symptom recognition, symptom management, and symptom prevention. Scores can range from 16 to 80, with a higher score indicating an enhanced self-management level of AVF.

Complications: Incidence rates of complications, including incision bleeding, limb swelling, infection, thrombosis, embolism, and arteriovenous aneurysm, were compared between the two patient groups at both 7 d and 4 wk post-surgery.

AVF maturation status: Postoperative assessments at 4 and 8 wk measured the blood flow rate, vessel diameter, and depth from the skin of AVF drainage vessels in both patient groups[9].

Data analysis: Analyses were conducted using SPSS version 23.0. Count data were represented by frequency and percentage and subjected to χ² test comparisons. Measurement data adhering to a normal distribution were presented as mean ± SD. The independent samples t-test was utilized for inter-group comparisons, while the paired t-test was used for intra-group comparisons. For measurement data not fitting a normal distribution, the median and interquartile range were presented and analyzed using the Wilcoxon rank sum test.

RESULTS

At the 8-wk postoperative mark, the observation group demonstrated significantly higher scores in AVF symptom recognition, symptom prevention, and self-management compared to the control group (P < 0.05). However, the variance in symptom management scores between the observation and control groups lacked statistical significance (P > 0.05). The detailed breakdown is provided in Table 2.

Table 2 Status of self-management capacity for arteriovenous fistulae, M (P25, P75).

Group	Observation group	Control group	Z	P value
Symptom recognition	35.00 (34-38)	33.00 (32-35)	-3.35	0.01
Symptom management	17.00 (16-19)	17.00 (15-18)	-1.12	0.26
Symptom prevention	14.00 (13-14)	13.00 (12-14)	-2.12	0.03
Total self-management score	66.00 (63-71)	63.00 (59-67)	-2.21	0.03

At 4 wk after the operation, the observation group displayed a superior vessel diameter and depth from the skin of the drainage vessels in comparison to the control group (P < 0.05). While the observation group did manifest elevated blood flow rates in the drainage vessels relative to the control group, this distinction was not statistically significant (P > 0.05). By the 8-wk postoperative interval, the observation group outperformed the control group with notable enhancements in blood flow rates, vessel diameter, and depth from the skin of drainage vessels (P < 0.01). These findings are delineated in Table 3.

Table 3 Maturity status of arteriovenous fistula (score, mean ± SD).

Time	Group	Observation group	Control group	t	P value
4 wk after surgery	Blood flow	511.51 ± 16.27a	506.06 ± 10.23c	1.68	0.10
	Intravascular diameter	5.13 ± 0.10a	5.00 ± 0.04c	7.10	0.00
	Depth from epidermis	2.62 ± 0.10a	3.05 ± 0.11c	-17.45	0.00
8 wk postoperatively	Blood flow	733.28 ± 10.51	707.00 ± 10.25	10.59	0.00
	Intravascular diameter	5.88 ± 0.27	5.18 ± 0.10	14.42	0.00
	Depth from epidermis	2.18 ± 0.10	2.62 ± 0.10	-18.00	0.00

^aP < 0.05 at the 4-wk postoperative point when juxtaposed with the 8-wk postoperative point within the observation group.

^cP < 0.05 at the 4-wk postoperative stage when compared with the 8-wk postoperative interval in the control group.

Seven days following the procedure, the observation group manifested significantly diminished limb swelling and an overall reduced complication rate in contrast to the control group (P < 0.05). The evaluation of infection, thrombosis, embolism, arterial aneurysm stenosis, and incision bleeding showed no notable differences between the two groups (P > 0.05). By the 4-wk postoperative juncture, complications between the observation and control groups were statistically indistinguishable (P > 0.05). A comprehensive overview is available in Table 4.

Table 4 Complications.

Time	Group	Infection	Thrombus	Embolization	Aneurysm	Stenosis	Incision bleeding	Limb swelling	Total	Statistical value	P value
7 d postoperatively	Observation group	0	0	0	0	0	1	2	3	/	0.031
	Control group	1	0	0	0	0	1	9	11
4 wk postoperatively	Observation group	0	0	0	0	1	0	0	1	/	0.361
	Control group	0	0	0	0	3	0	1	4

¹Fisher's test.

DISCUSSION

Prevention and recognition of postoperative symptoms enhanced by phased limb function exercises and self-management education in AVF patients.

AVF, a surgically created vascular access, is susceptible to multiple complications and inherently has a limited lifespan. As such, diligent daily self-management of AVF becomes pivotal for patients[10]. The present study emphasizes the patients' subjective awareness, placing them at the forefront of AVF management. Enhancing patients' comprehension of AVF-related matters and proactively adopting measures for its maturation and daily upkeep enables effective management. This approach facilitates prompt detection of anomalies, safeguarding the operated limb.

Perioperative phased limb function exercise for AVF: Laying groundwork for optimal cannulation.

Limb function exercises were systematized in distinct stages, corresponding to the specific requirements of AVF patients. Pre-AVF creation and during the exercise's early phase, patients often harbored uncertainties about the limb function exercise. This phase was steered by a specialized nursing cadre, centering on nurturing patients' self-management cognizance. As patients gained profound insights into AVF, a transition to autonomous exercise occurred. Subsequent exercise regimens were adapted to individual needs and inclinations, amplifying adherence and self-confidence[11]. Systematic and thorough limb movements, combined with arm exercises, augment local blood circulation and metabolism. This results in increased tension in the drainage vessels and cellular proliferation in the venous vessel wall, bolstering elasticity[12]. Concurrently, fat reduction through exercise underscores AVF's superficial positioning and expedites venous arterialization[13]. Such conditions prime the AVF for its inaugural cannulation while curtailing deep vein puncture risks.

Phased limb function exercise and self-management education: Catalysts for postoperative limb swelling dissipation and complication reduction following avf surgery.

Post-AVF creation, surgical trauma, venous return impediments, and heightened vascular pressure often induce limb swelling[14]. This study's adoption of autonomous and staged exercise amplified metabolic rate and blood flow, enhancing oxygen and nutrient availability around the AVF. This hastened excessive tissue fluid's dissipation, thereby curtailing anastomosis site edema and associated complications such as bleeding and infection[15,16]. By the 4-wk postoperative marker, incidences of AVF infection, thrombosis, and aneurysm appeared minimal in the short-term analysis. Such postoperative complications, encompassing infection, thrombosis, and embolism, are multifactorial, often linked to the patient's inherent disease state and vascular morphology[17]. Multifaceted interventions, encompassing lifestyle, dietary habits, medication, therapeutic approaches, and consistent self-maintenance, are essential to mitigate their prevalence.

CONCLUSION

In summary, hemodialysis patients are advised to heed the medical team's professional directives pre and post-AVF creation, adopting a holistic approach towards AVF maintenance spanning lifestyle, therapy, care, and self-management. Moreover, adherence to moderate limb function exercise is paramount. It's imperative to maintain appropriate, consistent, and regular AVF exercises, steering clear of overexertion that could compromise anastomosis healing or delay maturation. Regular self-assessment, coupled with hospital follow-ups to evaluate AVF stability and functionality, facilitates the early detection and management of complications, ensuring AVF patency.