運動訓練對於血液透析患者心率變異的改善成效之系統性文獻回顧

The Effect of Exercise Training on Heart Rate Variability in Patients With Hemodialysis: A Systematic Review

10.6224/JN.201902_66(1).09

謝佳蓉(Jia-Rong SHIE)；陳亭余(Ting-Yu CHEN)；高啟雯(Chi-Wen KAO)

血液透析 ； 運動 ； 心率變異 ； hemodialysis ； exercise ； heart rate variability

護理雜誌

66卷1期（2019 / 02 / 01）

70 - 83

繁體中文

背景：超過50%之血液透析患者有自主神經功能失調、心率變異降低的臨床表徵，並帶來心血管症狀及不良健康結果。許多文獻已證實運動訓練對於慢性疾病患者之心率變異有直接成效，但對於血液透析患者則證據不足。目的：以系統性文獻回顧，探討運動訓練對於血液透析患者心率變異度的成效，並建立「改善血液透析患者HRV（heart rate variability）之運動訓練的實證建議」，以利他們在運動治療中獲得更客觀的訊息。方法：從The Cochrane Library、PubMed、CINAHL、MEDLINE、CEPS資料庫進行系統性文獻搜尋，相關關鍵字包含血液透析（hemodialysis、haemodialysis）、運動（exercise、exercise training、physical training、aerobic exercise、resistance exercise、strength training）、心率變異（heart rate variability、HRV、autonomic nervous system）。搜尋年限設定1990至2018年8月前所有發表的文獻，僅納入隨機對照試驗之研究，排除非成人（≤ 18歲）、非中英文文獻和論述文。將納入的文獻進行分析與統合，依據蘇格蘭聯合指引網絡（Scottish Intercollegiate Guidelines Network）的分類建議，評估文獻的證據等級和建議強度。結果：共計四篇文獻符合條件。系統性回顧結果顯示，血液透析患者執行有效運動訓練程序後，心率變異的相關指標可達不同程度的改善且達顯著意義，包括SDNN（standard deviation of all normal-to-normal intervals；中至高度效果量）、RMSSD（root mean square of the successive differences；高度效果量）、pNN50（proportion of differences of adjacent RR intervals ＞ 50 ms, 高度效果量）、HRV triangular index（中度效果量）、LF/HF ratio（low frequency/high frequency ratio）和mean RR interval（低至中度效果量）上升，並依據結果，針對透析日／非透析日運動訓練之持續時間、頻率、強度及禁忌症等，建立「改善血液透析患者HRV之運動訓練的實證建議」。結論：血液透析患者接受有效運動訓練程序後，患者之心跳速率降低，交感、副交感和自主神經整體活性增加。本文建立四點「改善血液透析患者HRV之運動訓練的實證建議」，所有證據等級為1++，建議強度為A或B級，具有臨床參考的價值。

Background: More than 50% of hemodialysis patients exhibit autonomic dysfunction and impaired heart rate variability, which are linked to cardiovascular symptoms and poor health outcomes. While exercise training has been shown to positively affect heart rate variability in patients with chronic diseases, there is insufficient evidence to support similar effects in hemodialysis patients. Purpose: In order to give hemodialysis patients more objective information about exercise therapy, this study reviews the literature systematically to evaluate the effect of exercise training on heart rate variability in hemodialysis patients and establishes evidence-based recommendations for exercise training on heart rate variability in hemodialysis patients. Methods: A systematic search of Cochrane Library, PubMed, CINAHL, MEDLINE, and CEPS was conducted. The keywords used in the search included ＂hemodialysis / haemodialysis＂, ＂exercise / exercise training / physical training / aerobic exercise / resistance exercise / strength training＂, and ＂heart rate variability / HRV / autonomic nervous system＂. Only randomized controlled trials (RCT) studies from the years 1990 to August 2018 were included. Non-adult (≤ 18 years) studies, non-English / non-Chinese language studies, and review studies were excluded. Results: Four studies were found and included in the analysis. Exercise training to hemodialysis patients improved the heart rate variability significantly to various degrees, including a medium to large effect for the standard deviation of all normal-to-normal intervals (SDNN), a large effect for the root mean square of the successive differences (RMSSD), a large effect for the proportion of differences of adjacent RR intervals ＞ 50 ms (pNN50), a medium effect for the HRV triangular index, a medium effect for the low frequency/high frequency (LF/HF) ratio, and a small to medium effect for the mean RR interval. Based on the results of this systematic literature reviews recommendations emerged for exercise training on heart rate variability in hemodialysis patients. This recommendations regard to the exercise training time, frequency, intensity and contradictions. Conclusions: The results of this systematic review support that the parasympathetic activity, sympathetic activity, and heart rate variability of hemodialysis patients increase close to the normal value after exercise training. Based on the results of systematic literature reviews, this study establishes four evidence-based recommendations for exercise training on heart rate variability in hemodialysis patients. These recommendations are valid, as all levels of evidences are 1++ and the grades of recommendations range from A to B.

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