Discussion
cognitive skills, illness, HD, cramping, Sarcopenia, malnutrition, depression, deaths
CATABOLIC STATE, ADVERSE EVENTS, SARCOPENIA, MALNUTRITION
Sarcopenia in dialysis patients is associated with physical limitations, hospitalizations, and depression. Thus, its onset and progression should be either fully prevented or at least slowed down. This randomized controlled trial design was used to evaluate the effects of intradialytic NMES combined with VR distraction in HD patients over 12 weeks. As far as we know, this study is the first to extend NMES with VR distraction in HD patients and the first in a common German dialysis care setting on this topic.In this study, NMES significantly increased muscle strength and serum albumin levels.Consistent with our positive results on functional capacity measured by the increased maximum number of repetitions in both NMES groups during STS-60, other studies also reported an improvement in time needed to perform 10 repetitions Sit-to-Stand Test [Albumin levels increased in both NMES groups from t0 to t1 while they decreased in the CO group. These finding are not consistent with previous research [In our study, right QFM force increased significantly. The strongest increase was observed in the NMES group followed by NMES + VR and controls. These beneficial effects of NMES on muscle strength in HD-patients are consistent with previous studies [The circumference of the lower limb was assessed. A tendency to decrease was observed in all groups from t0 to t1, except from left QFM in the NMES + VR group (t0: 42.06 2.086 cm vs. t1: 42.89 ± 3.86 cm).Previous studies used different methods to assess the muscle architecture such as, magnetic resonance imaging [NMES had no effect on body composition, but weight and BMI tended to increase in NMES and NMES + VR.A low BMI in dialysis patients is associated with malnutrition and a catabolic state. Therefore, it is an independent predictive marker for higher mortality, rendering an increasing weight beneficial [Only one patient reported having a cramping feeling. Therefore, NMES and NMES + VR were not associated with serious adverse events in this study. In contrast to most of the previous studies, our study resulted in a higher dropout rate of 35% (vs. < 15%) [The effects of the VR distraction regarding the tingling NMES sensation measured by the VAS score and the acceptance of higher intensity levels in the NMES + VR group were inconclusive. All the patients in the NMES + VR group seemed to be bored after some application and therefore did not use the VR headset anymore. In addition to an expanded range of programs, VR applications could be individualized for HD patients (f. e. applications to improve cognitive skills or health literacy in the context of nutrition and activity). VR applications in the context of an intradialytic physical exercise program seem to be effective and feasible [Although we showed beneficial results of NMES in HD patients, the results of this pilot study so far, are limited due to the relatively small number of patients and short study duration. Furthermore, the study was complemented by a second study phase in 2022 due to low participation and high dropout rates caused by uncertainties and deaths among patients during the 2021 SARS-CoV-2 pandemic in phase 1. The study assistants failed to adhere to the instruction to use the same measurement person for the dynamometer tests at t0 and t1 due to illness and staff changes. Thus, a gross measurement error resulted in 8 cases. Most of the patients of NMES + VR group did not apply the VR headset during every intervention of the 12-weeks. Finally, a selection bias should be considered due to the informed consent as well as the inclusion and exclusion criteria.The follow-up study should involve a larger sample size and a longer study period to determine long term effects. Regarding the used devices, the body composition measurements should be performed by a higher quality electric bioimpedance analysis scale. Also, errors in dynamometer measurement must be consistently avoided in follow-up studies. As already suggested from Suzuki et a al. [