The Development and Challenges of Physical Therapy for Dialysis Patients after the Change in the Insurance System in Japan

The Development and Challenges of Physical Therapy for Dialysis Patients after the Change in the Insurance System in Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Development and Challenges of Physical Therapy for Dialysis Patients after the Change in the Insurance System in Japan Kenichi Kono, Hisae Hayashi, Go Owari, Kazuki Kimura, Naoya Oseki, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6888979/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to clarify changes in physical therapy practices for dialysis patients in Japan by comparing survey results from 2017 and 2023. It focused on the impact of a new insurance-covered additional fee introduced in 2022 for exercise instruction during hemodialysis. The study addresses the growing need for renal rehabilitation to manage frailty and sarcopenia and highlights the evolving role of physical therapists in this field. Methods Web-based surveys were conducted in 2017 (n = 4,680) and 2023 (n = 4,210) among physical therapists specializing in diabetes care in Japan. Common survey items included demographics, work settings, and practices regarding dialysis patients. The 2023 survey additionally examined the impact of a 2022 policy introducing an exercise instruction fee during dialysis. Data were analyzed using descriptive statistics and chi-square tests (p < 0.05). Ethical approval was obtained. Results Response rates were 30.3% in 2017 and 13.6% in 2023. In 2023, more physical therapists worked in university hospitals and clinics. The number of dialysis patients receiving physical therapy and intervention days per week significantly increased. Thirteen percent of respondents reported billing the new exercise instruction fee introduced in 2022, primarily by physical therapists. Most reported only a small increase in exercise sessions. Common barriers to billing included lack of physician orders and qualified staff. Conclusion Physical therapy practices for dialysis patients in Japan have expanded between 2017 and 2023, with increased patient engagement and intervention frequency. However, adoption of the 2022 exercise instruction fee remains limited due to systemic and staffing barriers. Continued efforts are needed to promote interdisciplinary collaboration and policy implementation to enhance renal rehabilitation. Physical Therapy exercise instruction Figures Figure 1 Figure 2 Figure 3 Background The percentage of frail dialysis patients in Japan is reported to be 21% 1 , and 38% if pre-frail patients are included 2 3 . Factors associated with frailty include protein-energy wasting, cognitive decline, depression, chronic inflammation, polypharmacy, anemia, and dialysis treatment 4 . As with frailty, sarcopenia has also been associated with a poor prognosis in dialysis patients 5 . Renal rehabilitation is effective in addressing frailty and sarcopenia, and exercise therapy and physical activity management are key to renal rehabilitation 6 , so physical therapists have an important role to conduct in this important multidisciplinary collaboration. In addition, it is known that dialysis patients are hospitalized more frequently in the elderly, and that the most common reasons for hospitalization are cardiovascular, infectious, and orthopedic diseases 7 . Although inpatient rehabilitation has been reported to be effective in improving activities of daily living 8 , return to ambulation rates are lower than in non-dialysis patients 9 . Therefore, rehabilitation is critical to patients' reintegration into the community and return to outpatient dialysis visits. In 2017, the Japanese Society Physical Therapy for Diabetes Mellitus conducted a survey on the actual status of physical therapy related to dialysis patients. According to the results, the most common reasons for not providing enough physical therapy were physicians do not prescribe it and reimbursement is not available. Although the need for and benefits of physical therapy for dialysis patients are increasingly recognized, it is necessary to continue to demonstrate the benefits of physical therapy for dialysis patients to physicians and others in order to increase opportunities for physical therapy for dialysis patients. Based on the aforementioned background, in April 2022, an additional medical fee for exercise instruction during hemodialysis treatment was approved for insurance claims in Japan. This additional fee can be claimed when physicians, physical therapists, occupational therapists, or nurses who have received special training in renal rehabilitation. Claims may be submitted if exercise instruction is provided for at least 20 consecutive minutes during a hemodialysis treatment and for no more than 90 days. This is expected to promote the widespread use of exercise therapy not only in hospitals with physical therapists, but also in dialysis clinics without physical therapists. It is also expected to change the working conditions of physical therapists and their relationship with dialysis patients. The purpose of this study is to clarify the changes in the status of physical therapy for dialysis patients, including the impact of the additional fee for exercise instruction during dialysis, which will be covered by insurance in 2022, based on the results of a questionnaire conducted in 2017 and a questionnaire conducted in 2023. Methods (1) Subjects The 2017 survey was conducted on 4,680 people registered as members of the Diabetes Section of the Japan Association of Physical Therapy as of the end of December 2016, and the 2023 survey was conducted on 4,210 people registered as members of either the Japanese Society of Physical Therapy for Diabetes Mellitus and Musculoskeletal and Cardiovascular as of August 2023. (2) Survey period The 2017 survey was conducted from January 20 to February 13, 2017, and the 2023 survey was conducted from June 17 to August 20, 2023. (3) Survey method Both the 2017 and 2023 surveys were conducted via a web screen. In 2017, a written request for survey cooperation was sent by mail, and in 2023, a written request was attached to an email. (4) Survey Items The common survey items in 2017 and 2023 were age, gender, number of years since licensure, type of work, number of beds, number of physical therapists, number of patients seen per day, facilities where they work as a clinical duty, target patients involved, whether they provide physical therapy to dialysis patients, situations involving dialysis patients, and number of patients they provide physical therapy to. The following items were included: number of dialysis patients, whether a disease-specific rehabilitation fee is charged and a breakdown of the fee, frequency of providing physical therapy to dialysis patients, time of day physical therapy is provided, disabilities of eligible dialysis patients, outcome measures of physical therapy, physical therapy programs provided, and reasons for not providing physical therapy. The survey items for 2023 only were: whether or not the additional fee for exercise instruction during dialysis was charged beginning in 2022, the type of exercise instruction under the additional fee, the increase or decrease in the number of exercise programs during dialysis due to the additional fee, and the reasons why the additional fee was not charged. (5) Analysis Simple tabulation of the data was performed, and cross-tabulation and x2 tests were performed between each year for the common survey items in 2017 and 2023. The significance level was set at 5%. (6) Ethical Considerations This survey was conducted in accordance with the Declaration of Helsinki, in compliance with the Ethical Guidelines for Life Science and Medical Research Involving Human Subjects, and with the approval of the Ethical Review Committee of the Faculty of Health and Medical Sciences, Aichi Shukutoku University (Decision Result Notification No. 2023-3). Results (1) Collections and characteristics of physical therapist The 2017 survey received responses from 1,420 of 4,680 respondents (30.3% response rate). The 2023 survey received responses from 571 of 4,210 respondents (13.6% response rate). The characteristics of responding physical therapist were shown Table1. The proportion working in university hospitals and clinics increased significantly in 2023. (2) Implementation Status of Physical Therapy for Dialysis Patients Table 2 shows the results of the number of eligible patients per day, the number of intervention days per week and the timing of the intervention as an overview of the physical therapy provided to dialysis patients. In 2023, there was a significant increase in the number of eligible patients and intervention days compared to 2017. In addition, Table 3 shows the reimbursement claims for physical therapy provided, the disability of dialysis patients as perceived by physical therapists, and the physical therapy programs that were implemented. (3) Additional Exercise Instruction for Dialysis Patients Beginning in FY 2022 Thirteen percent of respondents indicated that they calculate additional exercise instruction for dialysis patients, which began in FY 2022. Of these, 78% were physical therapists, 41% were nurses, and 24% were physicians, in that order. Half of the respondents reported an increase in the number of exercise sessions during dialysis as a result of the addition of the program, and 85% of the respondents reported an increase of less than 10 sessions. Reasons for not billing the additional fee included lack of physician orders, lack of patients, billing of the disease-specific rehabilitation fee, and lack of staff with the expertise to process the orders even if they were available. Table1. Characteristics of responding physical therapist and whether or not physical therapy is provided to patients on dialysis 2017 (n=1420) 2023 (n=571) P value Age 36.3 (7.79) 40.1 (7.53) - Male/Female (%) 81 / 19 83 / 17 0.26 Full-time / Part-time (%) 98 / 2 99 / 1 0.07 Main workplaces University Hospitals City Hospitals Clinics Home Health Care facilities Others (%) 8 72 6 10 4 12 69 11 5 2 <0.001 Providing physical therapy to dialysis patients (%) Yes No and Unclear 49.4 50.6 51.3 48.7 0.15 Table2. Summary of physical therapy provided by those who reported providing physical therapy to dialysis patients. 2017 (n=670) 2023 (n=286) P value Number of dialysis patients who receive physical therapy per day (%) 0 person 1 person 2-3 persons 4-5 persons 6 persons Number of physiotherapy sessions per week (%) 4 or more days per week Only 3 non-dialysis days Only 1-2 non-dialysis days Only 3 dialysis days Only 1-2 dialysis days Others When to do physical therapy (%) Before Dialysis During Dialysis After Dialysis 27.0 44.8 20.7 3.0 4.5 44.8 24.5 14.0 6.7 0 10.0 36.5 12.7 50.9 10.0 35.3 36.3 5.9 12.5 71.7 5.9 7.0 4.9 4.5 5.9 33.6 15.5 50.8 <0.001 <0.001 0.31 Table3. Reimbursement Claims for Dialysis Patients and Comparison of the Disability and Physical Therapy Programs for Dialysis Patients 2017 (n=670) 2023 (n=286) P value Submit a claim for reimbursement for disease-specific rehabilitation medicine (%) Disuse syndrome rehabilitation fee Musculoskeletal system rehabilitation fee Cardiovascular disease rehabilitation fee Others Physical therapists' perceptions of dialysis patient disability (%) Decreased muscle strength Decreased exercise tolerance Gait disorder Balance disorder Cardiovascular disease Osteoarticular disorders (incl. amputation) Pain Cognitive decline Physical therapy Program (%) Resistance Training Aerobic exercise Stretching ADL exercise Balance exercise Physical Activity Increase Guidance 74.4 37.1 31.4 20.3 11.1 94.8 89.3 88.0 73.4 61.4 47.8 44.6 28.2 80.7 79.2 81.4 77.6 62.6 49.8 82.8 41.6 26.9 26.0 5.4 79.9 75.4 73.0 69.6 51.5 40.3 30.0 30.0 76.5 73.4 67.2 61.4 52.9 35.3 0.005 <0.001 0.75 0.48 Discussion Trends following the addition of exercise instruction during dialysis were an increase in the number of dialysis patients receiving physical therapy per day and an increase in the percentage receiving physical therapy 4 or more days per week; however, there were no significant differences in the time of physical therapy was provided before, during, or after dialysis. In addition, the number of patients receiving reimbursement for disease-specific rehabilitation fees increased significantly, but there was no change in the disability of dialysis patients as perceived by physical therapists or in the physical therapy programs provided. This finding suggests that the volume of physical therapy for dialysis patients is increasing, and it is speculated that the 2022 reimbursement revision may have encouraged this improvement. The percentage of patients who have received the additional fee for exercise instruction during dialysis treatment was 13%, and the main professions providing exercise instruction at facilities charging the additional fee were physical therapists, nurses, and physicians, in that order. The Japanese Society of Renal Rehabilitation also conducted a survey on the status of the additional fee for renal rehabilitation for dialysis patients, and of the 4,247 facilities surveyed by the Japanese Society of Dialysis Therapy, 550 facilities (13%) provided exercise therapy as renal rehabilitation for dialysis patients, while 8% of the facilities reported charging the additional fee for exercise instruction during dialysis treatment 10 . The number of facilities charging for exercise instruction during dialysis was 8% of the total number of facilities surveyed. In addition, nurses, physical therapists and physicians were the most common providers of renal rehabilitation, in that order. However, given that 80% of the increases in the number of prescriptions per month were less than 10, and that the number of respondents who did not calculate the additional treatment was almost five times higher than the number who did, it cannot be said that the additional treatment has sufficiently expanded the use of exercise therapy for dialysis patients. The three main reasons for not calculating the add-on were (1) no prescription from the physician, (2) calculation of disease-specific rehabilitation, and (3) lack of specialized personnel to respond to the prescription even if it was available. Regarding the lack of physician prescription, it is believed that physicians are not fully aware of the existence of the relevant supplements. In addition, the lack of specialized personnel to respond to such orders is related to the fact that the number of professional categories that can calculate the add-on is limited to physicians, nurses, physical therapists, and occupational therapists, and many facilities have difficulty issuing orders because they are required to have a renal rehabilitation instructor and attend specific training sessions. This may be one of the reasons for the high number of facilities that have difficulty writing renal rehabilitation prescriptions. In a previous study, lack of staff was reported as the most common reason for not providing exercise therapy during dialysis 10 . On the other hand, lack of confidence in risk management, difficulty perceiving changes due to intervention, lack of interest, and lack of evidence were the least common responses. This means that most physical therapists are interested in exercise therapy and renal rehabilitation for dialysis patients, have intervention skills, and are aware of the evidence. The evidence is presented in guideline 6 , meta-analysis 111213 , and Japanese elderly patients 14 . Therefore, we believe that more effective renal rehabilitation for dialysis patients can be achieved by staffing and collaborating with other professions to calculate the additional fee for exercise instruction during dialysis. There are several limitations to this survey: first, it is a survey of members of an academic society of physical therapists and targets members who frequently treat dialysis patients, which may lead to selection bias; second, because the survey targets physical therapists, it is not possible to survey medical facilities that do not have physical therapists on staff, so not all medical facilities were surveyed; and third, there are differences in response rates between the 2017 survey and the 2023 survey. Third, there were differences in the coverage rates for the 2017 survey and the 2023 survey. In conclusion, the 2022 supplement to the survey results indicates that the involvement of physical therapists in maintenance hemodialysis patients has increased, especially in outpatient clinics, and there has been a shift toward the implementation of physical therapy that actively applies exercise load to hemodialysis patients. There is a need to further develop physical therapy that is beneficial to dialysis patients. Declarations Ethics approval and consent to participation This survey was approval of the Ethical Review Committee of the Faculty of Health and Medical Sciences, Aichi Shukutoku University (Decision Result Notification No. 2023-3). Consent for publication Informed consent was obtained from all participants included in the study. Availability of data and materials All data in this study are available upon request. Competing interests The authors have declared that no competing of interests. Funding This study was supported by a JSPS Grant-in-Aid for Scientific Research (JP23K10415) and an Aichi Shukutoku University Research Grant for fiscal year 2023 (23TT19). Author’s contributions KKo, HH, KKi, SI, NO, and NK led the design of the study. KKo, HH, KKi, NO, and SI were involved in the design of the study. KKo and GO drafted the manuscript. HH and NK provided feedback on the manuscript; all authors approved the final version. Acknowledgements We are grateful to the physical therapists who assisted us in our investigation. References Takeuchi H, Uchida HA, Kakio Y, et al. The prevalence of frailty and its associated factors in Japanese hemodialysis patients. Aging Dis . 2018;9(2):192–207. doi: 10.14336/AD.2017.0429 Kosoku A, Uchida J, Iwai T, et al. Frailty is associated with dialysis duration before transplantation in kidney transplant recipients: A Japanese single-center cross-sectional study. Int J Urol . 2020;27(5):408–414. doi: 10.1111/iju.14208 Isoyama N, Qureshi AR, Avesani CM, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. Clin J Am Soc Nephrol . 2014;9(10):1720–1728. doi: 10.2215/CJN.10261013 Chan GC kau, Kalantar-zadeh K, Ng JK chung, et al. Frailty in patients on dialysis. Kidney Int . 2024;106(1):35–49. doi: 10.1016/j.kint.2024.02.026 Kono K, Moriyama Y, Yabe H, et al. Relationship between malnutrition and possible sarcopenia in the AWGS 2019 consensus affecting mortality in hemodialysis patients: a prospective cohort study. BMC Nephrol . 2021;22(1):1–7. doi: 10.1186/s12882-021-02566-w Yamagata K, Hoshino J, Sugiyama H, et al. Clinical practice guideline for renal rehabilitation: systematic reviews and recommendations of exercise therapies in patients with kidney diseases. Ren Replace Ther . 2019;5(1):1–19. doi: 10.1186/s41100-019-0209-8 Nitta K, Masakane I, Hanafusa N, et al. Annual dialysis data report 2017, JSDT Renal Data Registry. Ren Replace Ther . 2019;5(1):1–44. doi: 10.1186/s41100-019-0248-1 ENDO M, NAKAMURA Y, MURAKAMI T, et al. Rehabilitation improves prognosis and activities of daily living in hemodialysis patients with low activities of daily living. Phys Ther Res . 2017;20(1):9–15. doi: 10.1298/ptr.e9898 Ishida T, Kono K, Nishida Y, Yoshida M. Functional recovery in post-stroke patients on hemodialysis during the convalescent phase: a comparison with those not undergoing hemodialysis. Ren Replace Ther . 2021;7(1):35. doi: 10.1186/s41100-021-00347-7 Sofue T, Matsuzawa R, Nishiwaki H, et al. Exercise instruction during haemodialysis treatment after changes to the insurance regime : a nationwide questionnaire survey in Japan. Sci Rep . Published online 2024:1–12. doi: 10.1038/s41598-024-59995-4 Bernier-Jean A, Beruni NA, Bondonno NP, Williams G, Teixeira-Pinto A et al. Exercise Training for Adults Undergoing Maintenance Dialysis. Cochrane Database Syst Rev . 2022;(1). doi: 10.1002/14651858.CD014653.www.cochranelibrary.com Salhab N, Karavetian M, Kooman J, Fiaccadori E, El Khoury CF. Effects of intradialytic aerobic exercise on hemodialysis patients: a systematic review and meta-analysis. J Nephrol . 2019;32(4):549–566. doi: 10.1007/s40620-018-00565-z Matsuzawa R, Hoshi K, Yoneki K, et al. Exercise Training in Elderly People Undergoing Hemodialysis: A Systematic Review and Meta-analysis. Kidney Int Reports . 2017;2(6):1096–1110. doi: 10.1016/j.ekir.2017.06.008 Yabe H, Kono K, Yamaguchi T, Ishikawa Y, Yamaguchi Y, Azekura H. Effects of intradialytic exercise for advanced-age patients undergoing hemodialysis: A randomized controlled trial. PLoS One . 2021;16(10 October):1–11. doi: 10.1371/journal.pone.0257918 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6888979","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":478868783,"identity":"108274be-952b-45dc-bd71-3ff38adcd5f1","order_by":0,"name":"Kenichi Kono","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApUlEQVRIiWNgGAWjYBACCR4QWSGRAKIMSNByhmQtjG0MCcQ7TLLn8LEHH+dZ5BmcX8BQXECMFmnetnTDmdskig1uPGAwnkGMFjl+HjNp3m0SidtuHGAw5iFeyxxStEjz9gC1NAC1nG8gUotkz7E0yRnHJBL332BsIM4vEmeSj0l8qKlLnNl/+JgxUSGGpDmxzZg0HQz8B5gfk6hlFIyCUTAKRggAAJ5HL6r+MuKLAAAAAElFTkSuQmCC","orcid":"","institution":"International University of Health and Welfare","correspondingAuthor":true,"prefix":"","firstName":"Kenichi","middleName":"","lastName":"Kono","suffix":""},{"id":478868784,"identity":"6d24acd7-2f26-4316-b917-eff735291529","order_by":1,"name":"Hisae Hayashi","email":"","orcid":"","institution":"Aichi Shukutoku University","correspondingAuthor":false,"prefix":"","firstName":"Hisae","middleName":"","lastName":"Hayashi","suffix":""},{"id":478868785,"identity":"b012fb76-4fe1-40a1-9d36-ddb9340a416d","order_by":2,"name":"Go Owari","email":"","orcid":"","institution":"International 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above for figure legend.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6888979/v1/dab37c0eccf59fe0f313408f.jpg"},{"id":87119946,"identity":"812cac39-5556-43f1-8521-cbda4d804c73","added_by":"auto","created_at":"2025-07-20 04:31:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":551387,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6888979/v1/0f998ada-d582-444c-b7bc-0d9a23c77ca9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Development and Challenges of Physical Therapy for Dialysis Patients after the Change in the Insurance System in Japan","fulltext":[{"header":"Background","content":"\u003cp\u003eThe percentage of frail dialysis patients in Japan is reported to be 21% \u003csup\u003e1\u003c/sup\u003e, and 38% if pre-frail patients are included \u003csup\u003e2 3\u003c/sup\u003e. Factors associated with frailty include protein-energy wasting, cognitive decline, depression, chronic inflammation, polypharmacy, anemia, and dialysis treatment \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. As with frailty, sarcopenia has also been associated with a poor prognosis in dialysis patients \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Renal rehabilitation is effective in addressing frailty and sarcopenia, and exercise therapy and physical activity management are key to renal rehabilitation \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, so physical therapists have an important role to conduct in this important multidisciplinary collaboration. In addition, it is known that dialysis patients are hospitalized more frequently in the elderly, and that the most common reasons for hospitalization are cardiovascular, infectious, and orthopedic diseases \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Although inpatient rehabilitation has been reported to be effective in improving activities of daily living \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, return to ambulation rates are lower than in non-dialysis patients \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Therefore, rehabilitation is critical to patients' reintegration into the community and return to outpatient dialysis visits.\u003c/p\u003e \u003cp\u003eIn 2017, the Japanese Society Physical Therapy for Diabetes Mellitus conducted a survey on the actual status of physical therapy related to dialysis patients. According to the results, the most common reasons for not providing enough physical therapy were physicians do not prescribe it and reimbursement is not available. Although the need for and benefits of physical therapy for dialysis patients are increasingly recognized, it is necessary to continue to demonstrate the benefits of physical therapy for dialysis patients to physicians and others in order to increase opportunities for physical therapy for dialysis patients. Based on the aforementioned background, in April 2022, an additional medical fee for exercise instruction during hemodialysis treatment was approved for insurance claims in Japan. This additional fee can be claimed when physicians, physical therapists, occupational therapists, or nurses who have received special training in renal rehabilitation. Claims may be submitted if exercise instruction is provided for at least 20 consecutive minutes during a hemodialysis treatment and for no more than 90 days. This is expected to promote the widespread use of exercise therapy not only in hospitals with physical therapists, but also in dialysis clinics without physical therapists. It is also expected to change the working conditions of physical therapists and their relationship with dialysis patients.\u003c/p\u003e \u003cp\u003eThe purpose of this study is to clarify the changes in the status of physical therapy for dialysis patients, including the impact of the additional fee for exercise instruction during dialysis, which will be covered by insurance in 2022, based on the results of a questionnaire conducted in 2017 and a questionnaire conducted in 2023.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e(1) Subjects\u003c/p\u003e \u003cp\u003eThe 2017 survey was conducted on 4,680 people registered as members of the Diabetes Section of the Japan Association of Physical Therapy as of the end of December 2016, and the 2023 survey was conducted on 4,210 people registered as members of either the Japanese Society of Physical Therapy for Diabetes Mellitus and Musculoskeletal and Cardiovascular as of August 2023.\u003c/p\u003e \u003cp\u003e(2) Survey period\u003c/p\u003e \u003cp\u003eThe 2017 survey was conducted from January 20 to February 13, 2017, and the 2023 survey was conducted from June 17 to August 20, 2023.\u003c/p\u003e \u003cp\u003e(3) Survey method\u003c/p\u003e \u003cp\u003eBoth the 2017 and 2023 surveys were conducted via a web screen. In 2017, a written request for survey cooperation was sent by mail, and in 2023, a written request was attached to an email.\u003c/p\u003e \u003cp\u003e(4) Survey Items\u003c/p\u003e \u003cp\u003eThe common survey items in 2017 and 2023 were age, gender, number of years since licensure, type of work, number of beds, number of physical therapists, number of patients seen per day, facilities where they work as a clinical duty, target patients involved, whether they provide physical therapy to dialysis patients, situations involving dialysis patients, and number of patients they provide physical therapy to. The following items were included: number of dialysis patients, whether a disease-specific rehabilitation fee is charged and a breakdown of the fee, frequency of providing physical therapy to dialysis patients, time of day physical therapy is provided, disabilities of eligible dialysis patients, outcome measures of physical therapy, physical therapy programs provided, and reasons for not providing physical therapy.\u003c/p\u003e \u003cp\u003eThe survey items for 2023 only were: whether or not the additional fee for exercise instruction during dialysis was charged beginning in 2022, the type of exercise instruction under the additional fee, the increase or decrease in the number of exercise programs during dialysis due to the additional fee, and the reasons why the additional fee was not charged.\u003c/p\u003e \u003cp\u003e(5) Analysis\u003c/p\u003e \u003cp\u003eSimple tabulation of the data was performed, and cross-tabulation and x2 tests were performed between each year for the common survey items in 2017 and 2023. The significance level was set at 5%.\u003c/p\u003e \u003cp\u003e(6) Ethical Considerations\u003c/p\u003e \u003cp\u003e This survey was conducted in accordance with the Declaration of Helsinki, in compliance with the Ethical Guidelines for Life Science and Medical Research Involving Human Subjects, and with the approval of the Ethical Review Committee of the Faculty of Health and Medical Sciences, Aichi Shukutoku University (Decision Result Notification No. 2023-3).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e(1) Collections and characteristics of physical therapist\u003c/p\u003e\n\u003cp\u003eThe 2017 survey received responses from 1,420 of 4,680 respondents (30.3% response rate). The 2023 survey received responses from 571 of 4,210 respondents (13.6% response rate). The characteristics of responding physical therapist were shown Table1. The proportion working in university hospitals and clinics increased significantly in 2023.\u003c/p\u003e\n\u003cp\u003e(2) Implementation Status of Physical Therapy for Dialysis Patients\u003c/p\u003e\n\u003cp\u003e Table 2 shows the results of the number of eligible patients per day, the number of intervention days per week and the timing of the intervention as an overview of the physical therapy provided to dialysis patients. In 2023, there was a significant increase in the number of eligible patients and intervention days compared to 2017. In addition, Table 3 shows the reimbursement claims for physical therapy provided, the disability of dialysis patients as perceived by physical therapists, and the physical therapy programs that were implemented.\u003c/p\u003e\n\u003cp\u003e(3) Additional Exercise Instruction for Dialysis Patients Beginning in FY 2022\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThirteen percent of respondents indicated that they calculate additional exercise instruction for dialysis patients, which began in FY 2022. Of these, 78% were physical therapists, 41% were nurses, and 24% were physicians, in that order. Half of the respondents reported an increase in the number of exercise sessions during dialysis as a result of the addition of the program, and 85% of the respondents reported an increase of less than 10 sessions. Reasons for not billing the additional fee included lack of physician orders, lack of patients, billing of the disease-specific rehabilitation fee, and lack of staff with the expertise to process the orders even if they were available.\u003c/p\u003e\n\u003cp\u003eTable1. Characteristics of responding physical therapist and whether or not physical therapy is provided to patients on dialysis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2017 (n=1420)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2023 (n=571)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e36.3 (7.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e40.1 (7.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eMale/Female (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e81 / 19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e83 / 17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eFull-time / Part-time (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e98 / 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e99 / 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eMain workplaces\u003c/p\u003e\n \u003cp\u003eUniversity Hospitals\u003c/p\u003e\n \u003cp\u003eCity Hospitals\u003c/p\u003e\n \u003cp\u003eClinics\u003c/p\u003e\n \u003cp\u003eHome Health Care facilities\u003c/p\u003e\n \u003cp\u003eOthers (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eProviding physical therapy to dialysis patients (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Yes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo and Unclear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49.4\u003c/p\u003e\n \u003cp\u003e50.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e51.3\u003c/p\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable2. Summary of physical therapy provided by those who reported providing physical therapy to dialysis patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2017 (n=670)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2023 (n=286)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eNumber of dialysis patients who receive physical therapy per day (%)\u003c/p\u003e\n \u003cp\u003e0 person\u003c/p\u003e\n \u003cp\u003e1 person\u003c/p\u003e\n \u003cp\u003e2-3 persons\u003c/p\u003e\n \u003cp\u003e4-5 persons\u003c/p\u003e\n \u003cp\u003e6 persons\u003c/p\u003e\n \u003cp\u003eNumber of physiotherapy sessions per week (%)\u003c/p\u003e\n \u003cp\u003e 4 or more days per week\u003c/p\u003e\n \u003cp\u003e Only 3 non-dialysis days\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Only 1-2 non-dialysis days\u003c/p\u003e\n \u003cp\u003e Only 3 dialysis days\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Only 1-2 dialysis days\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Others\u003c/p\u003e\n \u003cp\u003eWhen to do physical therapy (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Before Dialysis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; During Dialysis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; After Dialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27.0\u003c/p\u003e\n \u003cp\u003e44.8\u003c/p\u003e\n \u003cp\u003e20.7\u003c/p\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44.8\u003c/p\u003e\n \u003cp\u003e24.5\u003c/p\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003cp\u003e50.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003cp\u003e36.3\u003c/p\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003cp\u003e4.5\u003c/p\u003e\n \u003cp\u003e5.9\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33.6\u003c/p\u003e\n \u003cp\u003e15.5\u003c/p\u003e\n \u003cp\u003e50.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable3. Reimbursement Claims for Dialysis Patients and Comparison of the Disability and Physical Therapy Programs for Dialysis Patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2017 (n=670)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2023 (n=286)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eSubmit a claim for reimbursement for disease-specific rehabilitation medicine (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Disuse syndrome rehabilitation fee\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Musculoskeletal system rehabilitation fee\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cardiovascular disease rehabilitation fee\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003cp\u003ePhysical therapists\u0026apos; perceptions of dialysis patient disability (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Decreased muscle strength\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Decreased exercise tolerance\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Gait disorder\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Balance disorder\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Cardiovascular disease\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Osteoarticular disorders (incl. amputation)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Pain\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Cognitive decline\u003c/p\u003e\n \u003cp\u003ePhysical therapy Program (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Resistance Training\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Aerobic exercise\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Stretching\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; ADL exercise\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Balance exercise\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; Physical Activity Increase Guidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e74.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37.1\u003c/p\u003e\n \u003cp\u003e31.4\u003c/p\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e94.8\u003c/p\u003e\n \u003cp\u003e89.3\u003c/p\u003e\n \u003cp\u003e88.0\u003c/p\u003e\n \u003cp\u003e73.4\u003c/p\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003cp\u003e44.6\u003c/p\u003e\n \u003cp\u003e28.2\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e80.7\u003c/p\u003e\n \u003cp\u003e79.2\u003c/p\u003e\n \u003cp\u003e81.4\u003c/p\u003e\n \u003cp\u003e77.6\u003c/p\u003e\n \u003cp\u003e62.6\u003c/p\u003e\n \u003cp\u003e49.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e82.8\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41.6\u003c/p\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003cp\u003e26.0\u003c/p\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e79.9\u003c/p\u003e\n \u003cp\u003e75.4\u003c/p\u003e\n \u003cp\u003e73.0\u003c/p\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003cp\u003e51.5\u003c/p\u003e\n \u003cp\u003e40.3\u003c/p\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003cp\u003e73.4\u003c/p\u003e\n \u003cp\u003e67.2\u003c/p\u003e\n \u003cp\u003e61.4\u003c/p\u003e\n \u003cp\u003e52.9\u003c/p\u003e\n \u003cp\u003e35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eTrends following the addition of exercise instruction during dialysis were an increase in the number of dialysis patients receiving physical therapy per day and an increase in the percentage receiving physical therapy 4 or more days per week; however, there were no significant differences in the time of physical therapy was provided before, during, or after dialysis. In addition, the number of patients receiving reimbursement for disease-specific rehabilitation fees increased significantly, but there was no change in the disability of dialysis patients as perceived by physical therapists or in the physical therapy programs provided.\u003c/p\u003e \u003cp\u003eThis finding suggests that the volume of physical therapy for dialysis patients is increasing, and it is speculated that the 2022 reimbursement revision may have encouraged this improvement.\u003c/p\u003e \u003cp\u003eThe percentage of patients who have received the additional fee for exercise instruction during dialysis treatment was 13%, and the main professions providing exercise instruction at facilities charging the additional fee were physical therapists, nurses, and physicians, in that order. The Japanese Society of Renal Rehabilitation also conducted a survey on the status of the additional fee for renal rehabilitation for dialysis patients, and of the 4,247 facilities surveyed by the Japanese Society of Dialysis Therapy, 550 facilities (13%) provided exercise therapy as renal rehabilitation for dialysis patients, while 8% of the facilities reported charging the additional fee for exercise instruction during dialysis treatment \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The number of facilities charging for exercise instruction during dialysis was 8% of the total number of facilities surveyed. In addition, nurses, physical therapists and physicians were the most common providers of renal rehabilitation, in that order.\u003c/p\u003e \u003cp\u003eHowever, given that 80% of the increases in the number of prescriptions per month were less than 10, and that the number of respondents who did not calculate the additional treatment was almost five times higher than the number who did, it cannot be said that the additional treatment has sufficiently expanded the use of exercise therapy for dialysis patients. The three main reasons for not calculating the add-on were (1) no prescription from the physician, (2) calculation of disease-specific rehabilitation, and (3) lack of specialized personnel to respond to the prescription even if it was available. Regarding the lack of physician prescription, it is believed that physicians are not fully aware of the existence of the relevant supplements. In addition, the lack of specialized personnel to respond to such orders is related to the fact that the number of professional categories that can calculate the add-on is limited to physicians, nurses, physical therapists, and occupational therapists, and many facilities have difficulty issuing orders because they are required to have a renal rehabilitation instructor and attend specific training sessions. This may be one of the reasons for the high number of facilities that have difficulty writing renal rehabilitation prescriptions. In a previous study, lack of staff was reported as the most common reason for not providing exercise therapy during dialysis \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. On the other hand, lack of confidence in risk management, difficulty perceiving changes due to intervention, lack of interest, and lack of evidence were the least common responses. This means that most physical therapists are interested in exercise therapy and renal rehabilitation for dialysis patients, have intervention skills, and are aware of the evidence. The evidence is presented in guideline \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, meta-analysis \u003csup\u003e111213\u003c/sup\u003e, and Japanese elderly patients \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Therefore, we believe that more effective renal rehabilitation for dialysis patients can be achieved by staffing and collaborating with other professions to calculate the additional fee for exercise instruction during dialysis.\u003c/p\u003e \u003cp\u003eThere are several limitations to this survey: first, it is a survey of members of an academic society of physical therapists and targets members who frequently treat dialysis patients, which may lead to selection bias; second, because the survey targets physical therapists, it is not possible to survey medical facilities that do not have physical therapists on staff, so not all medical facilities were surveyed; and third, there are differences in response rates between the 2017 survey and the 2023 survey. Third, there were differences in the coverage rates for the 2017 survey and the 2023 survey.\u003c/p\u003e \u003cp\u003eIn conclusion, the 2022 supplement to the survey results indicates that the involvement of physical therapists in maintenance hemodialysis patients has increased, especially in outpatient clinics, and there has been a shift toward the implementation of physical therapy that actively applies exercise load to hemodialysis patients. There is a need to further develop physical therapy that is beneficial to dialysis patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participation\u003c/p\u003e\n\u003cp\u003eThis survey was approval of the Ethical Review Committee of the Faculty of Health and Medical Sciences, Aichi Shukutoku University (Decision Result Notification No. 2023-3).\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants included in the study.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data in this study are available upon request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors have declared that no competing of interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by a JSPS Grant-in-Aid for Scientific Research (JP23K10415) and an Aichi Shukutoku University Research Grant for fiscal year 2023 (23TT19).\u003c/p\u003e\n\u003cp\u003eAuthor’s contributions\u003c/p\u003e\n\u003cp\u003eKKo, HH, KKi, SI, NO, and NK led the design of the study. KKo, HH, KKi, NO, and SI were involved in the design of the study. KKo and GO drafted the manuscript. HH and NK provided feedback on the manuscript; all authors approved the final version.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe are grateful to the physical therapists who assisted us in our investigation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTakeuchi H, Uchida HA, Kakio Y, et al. The prevalence of frailty and its associated factors in Japanese hemodialysis patients. \u003cem\u003eAging Dis\u003c/em\u003e. 2018;9(2):192\u0026ndash;207. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14336/AD.2017.0429\u003c/span\u003e\u003cspan address=\"10.14336/AD.2017.0429\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKosoku A, Uchida J, Iwai T, et al. Frailty is associated with dialysis duration before transplantation in kidney transplant recipients: A Japanese single-center cross-sectional study. \u003cem\u003eInt J Urol\u003c/em\u003e. 2020;27(5):408\u0026ndash;414. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/iju.14208\u003c/span\u003e\u003cspan address=\"10.1111/iju.14208\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsoyama N, Qureshi AR, Avesani CM, et al. Comparative associations of muscle mass and muscle strength with mortality in dialysis patients. \u003cem\u003eClin J Am Soc Nephrol\u003c/em\u003e. 2014;9(10):1720\u0026ndash;1728. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/CJN.10261013\u003c/span\u003e\u003cspan address=\"10.2215/CJN.10261013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan GC kau, Kalantar-zadeh K, Ng JK chung, et al. Frailty in patients on dialysis. \u003cem\u003eKidney Int\u003c/em\u003e. 2024;106(1):35\u0026ndash;49. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.kint.2024.02.026\u003c/span\u003e\u003cspan address=\"10.1016/j.kint.2024.02.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKono K, Moriyama Y, Yabe H, et al. Relationship between malnutrition and possible sarcopenia in the AWGS 2019 consensus affecting mortality in hemodialysis patients: a prospective cohort study. \u003cem\u003eBMC Nephrol\u003c/em\u003e. 2021;22(1):1\u0026ndash;7. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12882-021-02566-w\u003c/span\u003e\u003cspan address=\"10.1186/s12882-021-02566-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamagata K, Hoshino J, Sugiyama H, et al. Clinical practice guideline for renal rehabilitation: systematic reviews and recommendations of exercise therapies in patients with kidney diseases. \u003cem\u003eRen Replace Ther\u003c/em\u003e. 2019;5(1):1\u0026ndash;19. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s41100-019-0209-8\u003c/span\u003e\u003cspan address=\"10.1186/s41100-019-0209-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNitta K, Masakane I, Hanafusa N, et al. Annual dialysis data report 2017, JSDT Renal Data Registry. \u003cem\u003eRen Replace Ther\u003c/em\u003e. 2019;5(1):1\u0026ndash;44. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s41100-019-0248-1\u003c/span\u003e\u003cspan address=\"10.1186/s41100-019-0248-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eENDO M, NAKAMURA Y, MURAKAMI T, et al. Rehabilitation improves prognosis and activities of daily living in hemodialysis patients with low activities of daily living. \u003cem\u003ePhys Ther Res\u003c/em\u003e. 2017;20(1):9\u0026ndash;15. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1298/ptr.e9898\u003c/span\u003e\u003cspan address=\"10.1298/ptr.e9898\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshida T, Kono K, Nishida Y, Yoshida M. Functional recovery in post-stroke patients on hemodialysis during the convalescent phase: a comparison with those not undergoing hemodialysis. \u003cem\u003eRen Replace Ther\u003c/em\u003e. 2021;7(1):35. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s41100-021-00347-7\u003c/span\u003e\u003cspan address=\"10.1186/s41100-021-00347-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSofue T, Matsuzawa R, Nishiwaki H, et al. Exercise instruction during haemodialysis treatment after changes to the insurance regime : a nationwide questionnaire survey in Japan. \u003cem\u003eSci Rep\u003c/em\u003e. Published online 2024:1\u0026ndash;12. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-024-59995-4\u003c/span\u003e\u003cspan address=\"10.1038/s41598-024-59995-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernier-Jean A, Beruni NA, Bondonno NP, Williams G, Teixeira-Pinto A et al. Exercise Training for Adults Undergoing Maintenance Dialysis. \u003cem\u003eCochrane Database Syst Rev\u003c/em\u003e. 2022;(1). doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD014653.www.cochranelibrary.com\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD014653.www.cochranelibrary.com\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalhab N, Karavetian M, Kooman J, Fiaccadori E, El Khoury CF. Effects of intradialytic aerobic exercise on hemodialysis patients: a systematic review and meta-analysis. \u003cem\u003eJ Nephrol\u003c/em\u003e. 2019;32(4):549\u0026ndash;566. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40620-018-00565-z\u003c/span\u003e\u003cspan address=\"10.1007/s40620-018-00565-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsuzawa R, Hoshi K, Yoneki K, et al. Exercise Training in Elderly People Undergoing Hemodialysis: A Systematic Review and Meta-analysis. \u003cem\u003eKidney Int Reports\u003c/em\u003e. 2017;2(6):1096\u0026ndash;1110. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ekir.2017.06.008\u003c/span\u003e\u003cspan address=\"10.1016/j.ekir.2017.06.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYabe H, Kono K, Yamaguchi T, Ishikawa Y, Yamaguchi Y, Azekura H. Effects of intradialytic exercise for advanced-age patients undergoing hemodialysis: A randomized controlled trial. \u003cem\u003ePLoS One\u003c/em\u003e. 2021;16(10 October):1\u0026ndash;11. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0257918\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0257918\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Physical Therapy, exercise, instruction","lastPublishedDoi":"10.21203/rs.3.rs-6888979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6888979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to clarify changes in physical therapy practices for dialysis patients in Japan by comparing survey results from 2017 and 2023. It focused on the impact of a new insurance-covered additional fee introduced in 2022 for exercise instruction during hemodialysis. The study addresses the growing need for renal rehabilitation to manage frailty and sarcopenia and highlights the evolving role of physical therapists in this field.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWeb-based surveys were conducted in 2017 (n\u0026thinsp;=\u0026thinsp;4,680) and 2023 (n\u0026thinsp;=\u0026thinsp;4,210) among physical therapists specializing in diabetes care in Japan. Common survey items included demographics, work settings, and practices regarding dialysis patients. The 2023 survey additionally examined the impact of a 2022 policy introducing an exercise instruction fee during dialysis. Data were analyzed using descriptive statistics and chi-square tests (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Ethical approval was obtained.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eResponse rates were 30.3% in 2017 and 13.6% in 2023. In 2023, more physical therapists worked in university hospitals and clinics. The number of dialysis patients receiving physical therapy and intervention days per week significantly increased. Thirteen percent of respondents reported billing the new exercise instruction fee introduced in 2022, primarily by physical therapists. Most reported only a small increase in exercise sessions. Common barriers to billing included lack of physician orders and qualified staff.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePhysical therapy practices for dialysis patients in Japan have expanded between 2017 and 2023, with increased patient engagement and intervention frequency. However, adoption of the 2022 exercise instruction fee remains limited due to systemic and staffing barriers. Continued efforts are needed to promote interdisciplinary collaboration and policy implementation to enhance renal rehabilitation.\u003c/p\u003e","manuscriptTitle":"The Development and Challenges of Physical Therapy for Dialysis Patients after the Change in the Insurance System in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-07 14:10:00","doi":"10.21203/rs.3.rs-6888979/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56e4efab-e4a2-45dd-811c-12f8b91a2cf8","owner":[],"postedDate":"July 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-20T04:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-07 14:10:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6888979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6888979","identity":"rs-6888979","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}