# Lack of physiotherapy resources restricts exercise prescription for patients with chronic kidney disease—the EUropean SUrvey on REnal EXercise (EUSUREX)

## TL;DR

A European survey found that lack of physiotherapy resources and reimbursement is the main barrier to prescribing exercise for chronic kidney disease patients, despite healthcare professionals recognizing its benefits.

## Contribution

This study identifies structural healthcare system limitations as the primary barrier to integrating exercise for CKD patients in Europe.

## Key findings

- Most healthcare professionals believe exercise is beneficial, but only 59% prescribe it regularly.
- Only Sweden has adequate physiotherapy resources and reimbursement for CKD patients.
- Between 9% and 37% of patients received exercise programs, with only one- to two-thirds continuing to exercise.

## Abstract

We hypothesized that the main barriers to integrating exercise in routine care of patients with chronic kidney disease (CKD) were structural within European healthcare systems rather than due to resistance among healthcare professionals or patients.

This descriptive cross-sectional study used anonymized questionnaires to investigate nurses’ and physicians’ attitudes and practice towards exercise in patients with CKD, structural support within the healthcare system, and patients’ experience of exercise prescriptions. Kidney units were randomly selected in Germany, Greece, Italy, Spain, and Sweden.

In total, 352 (35% male) nurses; 143 (54% male) physicians participated; 96% and 98%, respectively, believed exercise was beneficial. Of them, 59% (CI 50%–67%) prescribed exercise ‘always or often’ (I2 91%), ranging from 15% in Germany to 86% in Sweden. Of the facilities, 48% (CI 39%–56%) did not have a physiotherapy unit (I2 98%); six% (CI 3%–12%) did: in Italy one% (CI 0.03%–7%); in Sweden 86% (CI 42%–99%), (I2 97%). Seven% (CI 3%–12%) had physiotherapists and exercise programmes; eight% (CI 4%–13%) for all treatment modalities: in Italy four% (CI 1%–10%) and five% (CI 1%–12%), respectively; in Sweden 71% (CI 29%–96%) and 86% (CI 42%–99%), (I2 87% and 97%, respectively). Only Sweden reimbursed physiotherapy costs for all patients. In total, 1235 patients participated: those with CKD 4–5 (n = 137, male 62%); peritoneal dialysis (n = 40, male 60%); home haemodialysis (n = 30, male 63%); institutional haemodialysis (n = 928, male 59%); and kidney transplant (n = 100, male 62%). Between 9% and 37% of all patients reported having received an exercise programme, among those one- to two-thirds had continued to exercise.

Physicians and nurses regarded exercise as important for patients with CKD. Physical performance was not assessed. Most patients had not received exercise prescriptions. All countries, except Sweden, lacked physiotherapy resources and reimbursement strategies. Healthcare systems need to recognize the beneficial effects of exercise and provide adequate resources.

Graphical Abstract