Volume 19, Issue 2 (9-2022)
J Res Dev Nurs Midw 2022, 19(2): 22-26 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Zarneshan A, Safaie N, Esmealy L, Esmealy B. Effect of Stretching Combined With a Slow Deep Breathing Exercise on Patients’ Anxiety after Coronary Artery Bypass Grafting: A Randomized Clinical Trial. J Res Dev Nurs Midw 2022; 19 (2) :22-26
URL: http://nmj.goums.ac.ir/article-1-1347-en.html
URL: http://nmj.goums.ac.ir/article-1-1347-en.html
1- Department of Sport Science, Azarbaijan Shahid Madani University, Tabriz, Iran , zarneshan@azaruniv.ac.ir
2- Department of cardiology, Tabriz University of Medical Sciences, Tabriz, Iran
3- Department of Sport physiology, Tabriz University, Tabriz, Iran
2- Department of cardiology, Tabriz University of Medical Sciences, Tabriz, Iran
3- Department of Sport physiology, Tabriz University, Tabriz, Iran
Keywords: Anxiety [MeSH], Respiratory Muscle Training [MeSH], Coronary artery bypass [MeSH], Muscle stretching exercise [MeSH]
Full-Text [PDF 802 kb]
(592 Downloads)
| Abstract (HTML) (1660 Views)
Full-Text: (196 Views)
Introduction
Coronary heart disease is responsible for 85% of deaths worldwide. Coronary artery bypass graft (CABG) surgery is a procedure used to treat coronary heart disease (1). Despite the steady improvement in survival and operative safety, postoperative complications still remain a significant cause of morbidity and mortality after CABG (2). Anxiety is commonly experienced by patients following CABG surgery and closely related to the recovery of patients (3). It is more prevalent in heart surgery than in other surgeries and may increase the risk of postsurgical lesions (e.g. atrial fibrillation), acute myocardial infarction, and mortality (4). Anxiety leads to the hyperreactivity of the hypothalamo-pituitary-adrenal axis, which results in increased blood pressure, increased heart rate, reduced heart rate variability, spasm of the coronary arteries, progression of atherosclerosis, and increased endothelial damage (5).
Studies indicate that non-pharmacological interventions such as psychoeducation (6), foot massage (7), and music therapy (8) may have positive psychological effects on anxiety in patients undergoing CABG surgery. The focus of in-hospital phase (phase I) of physical therapy in patients undergoing cardiac surgery is to avoid physical inactivity and to maintain or improve pulmonary capacities and muscular strength (9). According to previous studies, yoga (10), diaphragmatic breathing relaxation training (11), and muscular relaxation exercises (12) have beneficial effects on anxiety. However, research in this area is limited, and the effect of stretching exercises or a combination of stretching and breathing exercises in post-CABG patients is not determined.
Breathing exercises are a simple strategy to improve lung efficiency and can help to treat of cardiac surgery. The aim of these exercises, at phase I of cardiac rehabilitation, is to reduce the risk of pulmonary complications, functional capacity impairment, and prolonged hospital stay (13). Moreover, previous studies have demonstrated that breathing exercise is effective in reducing anxiety in patients (14, 15). There is limited evidence on the efficacy of stretching exercises for reduction of anxiety (16). Stretching has been reported to alleviate depressive symptoms and improve sleep health (17, 18). To our knowledge, there is no data regarding the effects of stretching exercise on anxiety at the hospital phase. This study is the first to examine the effects of stretching combined with a slow deep breathing exercise (S+SDBE) on anxiety of patients following CABG surgery.
Methods
Participants
This double-blind, randomized controlled clinical trial was conducted on patients who had undergone CABG surgery in Shahid Madani Cardiovascular Hospital of Tabriz, Iran in 2020. Inclusion criteria were age of 45 to 65 years, left ventricular ejection fraction of <40%, the Faces anxiety score of > 2 (19), and no history of heart surgery, neuromuscular and cognitive impairment, severe lung disease, and renal impairment. Exclusion criteria included hemodynamic instability including arrhythmia, cardiogenic shock, postoperative hypotension, and hypertension.
The sample size was calculated considering anxiety as the primary outcome according to a previous study (3). It was determined using G Power analysis, the mean scores of anxieties in experimental (39.25±3.09) and control (45.12±5.26) groups, and estimated effect size of d=1.36. The estimated total sample size for comparison of the means of two independent groups (Mann-Whitney U Test) with an alpha error of 0.01 and power of 0.95 was 44 patients.
Study design
Fifty eligible patients were selected from 69 available patients. The subjects were randomly assigned to experimental (n=25) and control (n=25) groups. The randomization sequence was created using Random Allocation Software and stratified with a 1:1 allocation using random block sizes of 2 and 4. The hiding mechanism was employed by numbered, opaque, and sealed envelopes.
The exercises were performed in the experimental group, and anxiety levels were assessed in both groups for 6 days in the morning and afternoon by a nurse blinded to the study. Patients in the experimental and control groups were hospitalized in separate rooms and were unaware of the type and difference of the intervention.
Outcome measures
In the present study, the Faces Anxiety Scale (FAS) was used to measure state anxiety in the patients. This is a simple, self-rating, and single-item tool for rapid assessment of state anxiety, which is scored based on a 5-point scale. A higher score represents a higher level of anxiety (20). The scale has been suggested for use in intensive care patients since it is easily administered and imposes minimal burden on the patient. According to studies on the validity of the FAS, this scale is a useful tool for the assessment of the severity of acute [state] anxiety (20-22). A correlation coefficient of 0.70 has been reported for the relationship between the State Anxiety Inventory questionnaire and FAS (22). The validity of FAS has been confirmed in previous studies in Iran (23, 24).
In the present study, anxiety was evaluated in all subjects twice a day (9:00 am; 5:00 pm) before each exercise session, for 6 days.
Interventions
The experimental group performed S+SDBE with routine care twice a day for 6 days, and the control group received only routine hospital care that included medicine administrations, measurement of vital signs, and getting out of bed and walking, with no planned training services.
The experimental group received preoperative education in S+SDBE. The postoperative exercises began in fully conscious patients and an hour after extubation. The S+SDBE training for the intervention group was designed and standardized based on the American College of Sports Medicine (ACSM) recommendations for the prescription of exercises in phase I cardiac rehabilitation (9). According to the ACSM recommendations, intensity of our exercise training was below of resting Heart Rate + 30 bpm. Patients during stretching the muscles, inhaled a deep breath through their nose and during release the muscles, exhaled slowly through their mouth. Additional details regarding the exercises are presented in (table 1).
Statistical analysis
Normal distribution of data was assessed using the Kolmogorov-Smirnov test. Normally distributed data in two independent groups were compared using the student-t- test, and the qualitative data in two independent groups were compared using the Chi-square test. The anxiety scores were compared between the groups using the Mann-Whitney U test. The effect size was estimated using the (r=z/√n) formula (25). A P-value of less than 0.05 (typically ≤ 0.05) was considered statistically significant. The statistical analysis of data was done using SPSS 23 statistical software.
Results
Sample characteristics
One patient from each group was excluded from the analysis due to insufficient data (Figure 1). The mean age, body mass index (BMI), preoperative anxiety level, and duration of hospitalization were 59.66 ± 4.1 years, 26.71 ± 3.95 kg/m2, 2.81 ± 1.4, and 8.62 ± 1.9 days, respectively. There was no significant difference between the groups in terms of demographic characteristics and preoperative clinical variables (P>0.05). In addition, there was no significant difference in the preoperative anxiety score between the study groups (P=0.482) (Table 2).
Comparison of the mean anxiety scores
The anxiety level differed significantly between the study groups in the morning session of days 5 and 6 as well as in the afternoon session of days 4, 5, and 6 (P<0.05).
According to the effect size value, S+SDBE had a large effect in the afternoon of days 4 (effect size =0.51), 5 (effect size =0.53), and 6 (effect size =0.66). We observed a medium effect in the morning of days 5 (effect size =0.34) and 6 (effect size =0.32) and a small effect in the afternoon of days 1–3, as well as in the morning of days 1-4. According to the Cohen’s guidelines for effect size, large, medium, and small effect sizes are 0.5, 0.3, and 0.1, respectively (Table 3).
As shown in figure 2, the anxiety scores decreased significantly in the experimental group compared with the control group from the afternoon of day 4. Moreover, the exercise had more prominent effect on anxiety in the afternoon.
Discussion
The present study demonstrated the beneficial effects of S+SDBE on anxiety of patients undergoing CABG surgery. Within 6 days of S+SDBE, anxiety levels decreased significantly in the experimental group compared with the control group in the morning and afternoon sessions. This finding will reinforce the results of previous studies that have demonstrated the benefits of breathing or stretching exercises in reducing anxiety (14-16). With the help of these studies, it is possible to explain the mechanisms through which stretching + breathing exercises affect patients' anxiety. According to reports, muscle stretching is an alternative relaxation training procedure in the clinical population (26). Dehdari et al. have reported that progressive muscular relaxation training can significantly reduce anxiety scores and increase the quality of life domains of patients after CABG (12). It has been shown that slow muscle stretching will produce muscle relaxation and decrease muscle tone, ischemia, and pain (26). Given that anxiety can cause tense muscles (27), stretching can be a straightforward technique to improve joint mobility and reduce muscle tension (28).
It has been found that breathing exercises reduce anxiety symptoms and stabilize the autonomic nervous system. This type of exercise stimulates the parasympathetic nervous system and reduces anxiety levels (11). Chandrababu et al. evaluated the effect of pranayama on anxiety and reported that nostril breathing exercises (pranayama) decrease the anxiety of patients undergoing cardiac surgery (3). Other studies suggested that deep and slow breathing can improve vagal tone, cardiovascular function, and pain tolerance (28). It has been also reported that deep breathing exercises can improve oxygenation and pulmonary function after CABG (29, 30). It is well-established that reduced lung function or breathing discomfort may influence anxiety levels (31).
To our knowledge, no study has yet examined the effects of rehabilitation programs on anxiety throughout the day. In the present study, we investigated the effect of S+SDBE on anxiety levels in the morning and afternoon. The results indicated that anxiety decreased in the experimental group compared with the control group in the mornings of days 5–6. Moreover, a significant difference between the groups was observed in the afternoons of days 4–6. A larger effect size in the afternoons of days 4-6 compared with the mornings indicates more robust relationship between exercise and anxiety in the afternoon. Furthermore, we could say that S+SDBE had a considerable effect on anxiety of patients in the afternoon and a medium effect in the morning.
The anxiety level in the morning and afternoon may be affected by many factors. One of the influential factors in this regard may be family visits to the hospital in the afternoon. Some previous studies have revealed that family visits reduces patients' anxiety level (32, 33). Some stressors such as increased activity, sleeping in a strange bed, insufficient sleep, being away from family members, and pain can also affect patients’ anxiety after surgery (34, 35). On the other hand, anxiety in the morning may be due to the doctor's visits in the morning, hospital care in the morning shift, or inadequate sleep at night. However, further studies are required to determine the exact causes of increased patient anxiety in the morning.
The present study was conducted in a teaching hospital, which limits the generalizability of the findings. It is recommended to investigate the effects of S+SDBE on patients undergoing other operative procedures.
Conclusion
Anxiety is a common phenomenon after CABG, and our findings suggest that S+SDBE can be a beneficial intervention for reducing anxiety among patients undergoing CABG surgery. Our results also support the use of non-pharmacological interventions for the relief of anxiety in postoperative nursing care. The exercise intervention has a large effect on anxiety in the afternoon and a medium effect in the morning. Moreover, anxiety levels begin to decrease in the afternoon from day 4. It is recommended to conduct further studies on the effects of S+SDBE on patients undergoing other operative procedures.
Acknowledgements
The researchers of the present study are grateful to all patients, hospital staffs, and the Vice-Chancellor for Research of Azarbaijan Shahid Madani University.
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical statement
This study was approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran (ethical code: IR.TBZMED.REC.1399.470) and Iranian Registry of Clinical Trials (ID: IRCT20160523028028N2). Written informed consent was taken from all eligible participants, and the subjects were ensured about the confidentiality of their personal information.
Conflict of interest
The authors declare that they have no competing interests.
Author contributions
Supervision: A Z, N S; Project administration: A Z; Methodology: all authors; analysis and interpretation of data: all authors; Investigation: A Z, L E; Data collection: AZ, LE, BE; writing the original draft: A Z; writing, review, and editing of the manuscript: A Z, N S. All authors read and approved the final manuscript.
.JPG)
.JPG)
.JPG)
.JPG)
.JPG)
Coronary heart disease is responsible for 85% of deaths worldwide. Coronary artery bypass graft (CABG) surgery is a procedure used to treat coronary heart disease (1). Despite the steady improvement in survival and operative safety, postoperative complications still remain a significant cause of morbidity and mortality after CABG (2). Anxiety is commonly experienced by patients following CABG surgery and closely related to the recovery of patients (3). It is more prevalent in heart surgery than in other surgeries and may increase the risk of postsurgical lesions (e.g. atrial fibrillation), acute myocardial infarction, and mortality (4). Anxiety leads to the hyperreactivity of the hypothalamo-pituitary-adrenal axis, which results in increased blood pressure, increased heart rate, reduced heart rate variability, spasm of the coronary arteries, progression of atherosclerosis, and increased endothelial damage (5).
Studies indicate that non-pharmacological interventions such as psychoeducation (6), foot massage (7), and music therapy (8) may have positive psychological effects on anxiety in patients undergoing CABG surgery. The focus of in-hospital phase (phase I) of physical therapy in patients undergoing cardiac surgery is to avoid physical inactivity and to maintain or improve pulmonary capacities and muscular strength (9). According to previous studies, yoga (10), diaphragmatic breathing relaxation training (11), and muscular relaxation exercises (12) have beneficial effects on anxiety. However, research in this area is limited, and the effect of stretching exercises or a combination of stretching and breathing exercises in post-CABG patients is not determined.
Breathing exercises are a simple strategy to improve lung efficiency and can help to treat of cardiac surgery. The aim of these exercises, at phase I of cardiac rehabilitation, is to reduce the risk of pulmonary complications, functional capacity impairment, and prolonged hospital stay (13). Moreover, previous studies have demonstrated that breathing exercise is effective in reducing anxiety in patients (14, 15). There is limited evidence on the efficacy of stretching exercises for reduction of anxiety (16). Stretching has been reported to alleviate depressive symptoms and improve sleep health (17, 18). To our knowledge, there is no data regarding the effects of stretching exercise on anxiety at the hospital phase. This study is the first to examine the effects of stretching combined with a slow deep breathing exercise (S+SDBE) on anxiety of patients following CABG surgery.
Methods
Participants
This double-blind, randomized controlled clinical trial was conducted on patients who had undergone CABG surgery in Shahid Madani Cardiovascular Hospital of Tabriz, Iran in 2020. Inclusion criteria were age of 45 to 65 years, left ventricular ejection fraction of <40%, the Faces anxiety score of > 2 (19), and no history of heart surgery, neuromuscular and cognitive impairment, severe lung disease, and renal impairment. Exclusion criteria included hemodynamic instability including arrhythmia, cardiogenic shock, postoperative hypotension, and hypertension.
The sample size was calculated considering anxiety as the primary outcome according to a previous study (3). It was determined using G Power analysis, the mean scores of anxieties in experimental (39.25±3.09) and control (45.12±5.26) groups, and estimated effect size of d=1.36. The estimated total sample size for comparison of the means of two independent groups (Mann-Whitney U Test) with an alpha error of 0.01 and power of 0.95 was 44 patients.
Study design
Fifty eligible patients were selected from 69 available patients. The subjects were randomly assigned to experimental (n=25) and control (n=25) groups. The randomization sequence was created using Random Allocation Software and stratified with a 1:1 allocation using random block sizes of 2 and 4. The hiding mechanism was employed by numbered, opaque, and sealed envelopes.
The exercises were performed in the experimental group, and anxiety levels were assessed in both groups for 6 days in the morning and afternoon by a nurse blinded to the study. Patients in the experimental and control groups were hospitalized in separate rooms and were unaware of the type and difference of the intervention.
Outcome measures
In the present study, the Faces Anxiety Scale (FAS) was used to measure state anxiety in the patients. This is a simple, self-rating, and single-item tool for rapid assessment of state anxiety, which is scored based on a 5-point scale. A higher score represents a higher level of anxiety (20). The scale has been suggested for use in intensive care patients since it is easily administered and imposes minimal burden on the patient. According to studies on the validity of the FAS, this scale is a useful tool for the assessment of the severity of acute [state] anxiety (20-22). A correlation coefficient of 0.70 has been reported for the relationship between the State Anxiety Inventory questionnaire and FAS (22). The validity of FAS has been confirmed in previous studies in Iran (23, 24).
In the present study, anxiety was evaluated in all subjects twice a day (9:00 am; 5:00 pm) before each exercise session, for 6 days.
Interventions
The experimental group performed S+SDBE with routine care twice a day for 6 days, and the control group received only routine hospital care that included medicine administrations, measurement of vital signs, and getting out of bed and walking, with no planned training services.
The experimental group received preoperative education in S+SDBE. The postoperative exercises began in fully conscious patients and an hour after extubation. The S+SDBE training for the intervention group was designed and standardized based on the American College of Sports Medicine (ACSM) recommendations for the prescription of exercises in phase I cardiac rehabilitation (9). According to the ACSM recommendations, intensity of our exercise training was below of resting Heart Rate + 30 bpm. Patients during stretching the muscles, inhaled a deep breath through their nose and during release the muscles, exhaled slowly through their mouth. Additional details regarding the exercises are presented in (table 1).
Statistical analysis
Normal distribution of data was assessed using the Kolmogorov-Smirnov test. Normally distributed data in two independent groups were compared using the student-t- test, and the qualitative data in two independent groups were compared using the Chi-square test. The anxiety scores were compared between the groups using the Mann-Whitney U test. The effect size was estimated using the (r=z/√n) formula (25). A P-value of less than 0.05 (typically ≤ 0.05) was considered statistically significant. The statistical analysis of data was done using SPSS 23 statistical software.
Results
Sample characteristics
One patient from each group was excluded from the analysis due to insufficient data (Figure 1). The mean age, body mass index (BMI), preoperative anxiety level, and duration of hospitalization were 59.66 ± 4.1 years, 26.71 ± 3.95 kg/m2, 2.81 ± 1.4, and 8.62 ± 1.9 days, respectively. There was no significant difference between the groups in terms of demographic characteristics and preoperative clinical variables (P>0.05). In addition, there was no significant difference in the preoperative anxiety score between the study groups (P=0.482) (Table 2).
Comparison of the mean anxiety scores
The anxiety level differed significantly between the study groups in the morning session of days 5 and 6 as well as in the afternoon session of days 4, 5, and 6 (P<0.05).
According to the effect size value, S+SDBE had a large effect in the afternoon of days 4 (effect size =0.51), 5 (effect size =0.53), and 6 (effect size =0.66). We observed a medium effect in the morning of days 5 (effect size =0.34) and 6 (effect size =0.32) and a small effect in the afternoon of days 1–3, as well as in the morning of days 1-4. According to the Cohen’s guidelines for effect size, large, medium, and small effect sizes are 0.5, 0.3, and 0.1, respectively (Table 3).
As shown in figure 2, the anxiety scores decreased significantly in the experimental group compared with the control group from the afternoon of day 4. Moreover, the exercise had more prominent effect on anxiety in the afternoon.
Discussion
The present study demonstrated the beneficial effects of S+SDBE on anxiety of patients undergoing CABG surgery. Within 6 days of S+SDBE, anxiety levels decreased significantly in the experimental group compared with the control group in the morning and afternoon sessions. This finding will reinforce the results of previous studies that have demonstrated the benefits of breathing or stretching exercises in reducing anxiety (14-16). With the help of these studies, it is possible to explain the mechanisms through which stretching + breathing exercises affect patients' anxiety. According to reports, muscle stretching is an alternative relaxation training procedure in the clinical population (26). Dehdari et al. have reported that progressive muscular relaxation training can significantly reduce anxiety scores and increase the quality of life domains of patients after CABG (12). It has been shown that slow muscle stretching will produce muscle relaxation and decrease muscle tone, ischemia, and pain (26). Given that anxiety can cause tense muscles (27), stretching can be a straightforward technique to improve joint mobility and reduce muscle tension (28).
It has been found that breathing exercises reduce anxiety symptoms and stabilize the autonomic nervous system. This type of exercise stimulates the parasympathetic nervous system and reduces anxiety levels (11). Chandrababu et al. evaluated the effect of pranayama on anxiety and reported that nostril breathing exercises (pranayama) decrease the anxiety of patients undergoing cardiac surgery (3). Other studies suggested that deep and slow breathing can improve vagal tone, cardiovascular function, and pain tolerance (28). It has been also reported that deep breathing exercises can improve oxygenation and pulmonary function after CABG (29, 30). It is well-established that reduced lung function or breathing discomfort may influence anxiety levels (31).
To our knowledge, no study has yet examined the effects of rehabilitation programs on anxiety throughout the day. In the present study, we investigated the effect of S+SDBE on anxiety levels in the morning and afternoon. The results indicated that anxiety decreased in the experimental group compared with the control group in the mornings of days 5–6. Moreover, a significant difference between the groups was observed in the afternoons of days 4–6. A larger effect size in the afternoons of days 4-6 compared with the mornings indicates more robust relationship between exercise and anxiety in the afternoon. Furthermore, we could say that S+SDBE had a considerable effect on anxiety of patients in the afternoon and a medium effect in the morning.
The anxiety level in the morning and afternoon may be affected by many factors. One of the influential factors in this regard may be family visits to the hospital in the afternoon. Some previous studies have revealed that family visits reduces patients' anxiety level (32, 33). Some stressors such as increased activity, sleeping in a strange bed, insufficient sleep, being away from family members, and pain can also affect patients’ anxiety after surgery (34, 35). On the other hand, anxiety in the morning may be due to the doctor's visits in the morning, hospital care in the morning shift, or inadequate sleep at night. However, further studies are required to determine the exact causes of increased patient anxiety in the morning.
The present study was conducted in a teaching hospital, which limits the generalizability of the findings. It is recommended to investigate the effects of S+SDBE on patients undergoing other operative procedures.
Conclusion
Anxiety is a common phenomenon after CABG, and our findings suggest that S+SDBE can be a beneficial intervention for reducing anxiety among patients undergoing CABG surgery. Our results also support the use of non-pharmacological interventions for the relief of anxiety in postoperative nursing care. The exercise intervention has a large effect on anxiety in the afternoon and a medium effect in the morning. Moreover, anxiety levels begin to decrease in the afternoon from day 4. It is recommended to conduct further studies on the effects of S+SDBE on patients undergoing other operative procedures.
Acknowledgements
The researchers of the present study are grateful to all patients, hospital staffs, and the Vice-Chancellor for Research of Azarbaijan Shahid Madani University.
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical statement
This study was approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran (ethical code: IR.TBZMED.REC.1399.470) and Iranian Registry of Clinical Trials (ID: IRCT20160523028028N2). Written informed consent was taken from all eligible participants, and the subjects were ensured about the confidentiality of their personal information.
Conflict of interest
The authors declare that they have no competing interests.
Author contributions
Supervision: A Z, N S; Project administration: A Z; Methodology: all authors; analysis and interpretation of data: all authors; Investigation: A Z, L E; Data collection: AZ, LE, BE; writing the original draft: A Z; writing, review, and editing of the manuscript: A Z, N S. All authors read and approved the final manuscript.
Type of Study: Original Article |
Subject:
Nursing
References
1. Dewi IP, Dewi KP, Tanojo T, Mulia EPB, Adriana M. Pearls of exercise-based cardiac rehabilitation frame in post coronary artery bypass graft. Anaesthesia, Pain & Intensive Care. 2021;25(3):367-75. [View at paplisher] [Google Scholar]
2. Hokkanen M, Huhtala H, Laurikka J, Järvinen O. The effect of postoperative complications on health-related quality of life and survival 12 years after coronary artery bypass grafting-a prospective cohort study. Journal of Cardiothoracic Surgery. 2021;16(1):1-10. [View at paplisher] [DOI] [PMID] [Google Scholar]
3. Chandrababu R, Kurup SB, Ravishankar N, Ramesh J, Health G. Effect of pranayama on anxiety and pain among patients undergoing cardiac surgery: A non-randomized controlled trial. Clinical Epidemiology and Global Health. 2019;7(4):606-10. [View at paplisher] [DOI] [Google Scholar]
4. Akhlaghi E, Babaei S, Mardani A, Eskandari F. The Effect of the Neuman Systems Model on Anxiety in Patients Undergoing Coronary Artery Bypass Graft: A Randomized Controlled Trial. The Journal of Nursing Research. 2021;29(4):e156. [View at paplisher] [DOI] [PMID] [Google Scholar]
5. Eremina D. Anxiety and its role for cognitive changes in patients after coronary artery bypass grafting. Archives of Psychiatry and Psychotherapy. 2021;23(1):44-51. [View at paplisher] [DOI] [Google Scholar]
6. Shahmansouri N, Janghorbani M, Salehi Omran A, Karimi AA, Noorbala AA, Arjmandi A, et al. Effects of a psychoeducation intervention on fear and anxiety about surgery: randomized trial in patients undergoing coronary artery bypass grafting. Psychology, Health & Medicine. 2014;19(4):375-83. [View at paplisher] [DOI] [PMID] [Google Scholar]
7. Chandrababu R, Nayak BS, Pai VB, Ravishankar N, George LS, Devi ES, et al. Effects of foot massage and patient education in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial. Complement Ther Clin Pract. 2020;40:101215. [View at paplisher] [DOI] [PMID] [Google Scholar]
8. Dai W-S, Huang S-T, Xu N, Chen Q, Cao H. The effect of music therapy on pain, anxiety and depression in patients after coronary artery bypass grafting. Journal of Cardiothoracic Surgery. 2020;15:1-5. [View at paplisher] [DOI] [PMID] [Google Scholar]
9. de Macedo RM, Faria-Neto JR, Costantini CO, Casali D, Muller AP, Costantini CR, et al. Phase I of cardiac rehabilitation: A new challenge for evidence based physiotherapy. world journal of cardiology. 2011;3(7):248-55. [View at paplisher] [DOI] [PMID] [Google Scholar]
10. Kwok JYY, Kwan JCY, Auyeung M, Mok VCT, Chan HYL. The effects of yoga versus stretching and resistance training exercises on psychological distress for people with mild-to-moderate Parkinson's disease: Study protocol for a randomized controlled trial. trials journal. 2017;18(509):1-13. [View at paplisher] [DOI] [PMID] [Google Scholar]
11. Chen YF, Huang XY, Chien CH, Cheng JF. The effectiveness of diaphragmatic breathing relaxation training for reducing anxiety. Perspectives in Psychiatric Care. 2017;53(4):329-36. [View at paplisher] [DOI] [PMID] [Google Scholar]
12. Dehdari T, Heidarnia A, Ramezankhani A, Sadeghian S, Ghofranipour F. Effects of progressive muscular relaxation training on quality of life in anxious patients after coronary artery bypass graft surgery. Indian Journal of Medical Research. 2009;129(5):603-8. [View at paplisher] [Google Scholar]
13. Rodrigues SN, Henriques HR, Henriques MA. Effectiveness of preoperative breathing exercise interventions in patients undergoing cardiac surgery: A systematic review. Revista Portuguesa de Cardiologia (English Edition). 2021;40(3):229-44.
https://doi.org/10.1016/j.repc.2020.08.013 [View at paplisher] [DOI] [PMID] [Google Scholar]
14. Herdiana Y, Djamil M. The Effectiveness of Recitation Al-Qur'an Intervention and Deep Breathing Exercise on Improving Vital Sign and anxiety Level among Congestive Heart Failure (CHF) Patients. International Journal of Nursing and Health Services (IJNHS). 2021;4(1):9-16. [View at paplisher] [Google Scholar]
15. Srimookda N, Saensom D, Mitsungnern T, Kotruchin P, Ruaisungnoen W. The effects of breathing training on dyspnea and anxiety among patients with acute heart failure at emergency department. International Emergency Nursing. 2021;56: 101008. [View at paplisher] [DOI] [PMID] [Google Scholar]
16. Montero-Marin J, Asún S, Estrada-Marcen N, Romero R, Asun R. Effectiveness of a stretching program on anxiety levels of workers in a logistic platform: a randomized controlled study. Atención primaria. 2013;45(7):376-83. [View at paplisher] [DOI] [PMID] [Google Scholar]
17. D'Aurea CV, Poyares D, Passos GS, Santana MG, Youngstedt SD, Souza AA, et al. Effects of resistance exercise training and stretching on chronic insomnia. Brazilian Journal of Psychiatry. 2018;41:51-7. [View at paplisher] [DOI] [PMID] [Google Scholar]
18. Kai Y, Nagamatsu T, Kitabatake Y, Sensui H. Effects of stretching on menopausal and depressive symptoms in middle-aged women: a randomized controlled trial. Menopause 2016;23(8):827-32. [View at paplisher] [DOI] [PMID] [Google Scholar]
19. Turzáková J, Sollár T, Solgajová A. Faces Anxiety Scale as a screening measure of preoperative anxiety: Validation and diagnostic accuracy study. International Journal of Nursing Practice. 2019;25(4):e12758. [View at paplisher] [DOI] [PMID] [Google Scholar]
20. McKinley S, Madronio C. Validity of the Faces Anxiety Scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation. Journal of Psychosomatic Research. 2008;64(5):503-7. [View at paplisher] [DOI] [PMID] [Google Scholar]
21. McKinley S, Stein-Parbury J, Chehelnabi A, Lovas J. Assessment of anxiety in intensive care patients by using the Faces Anxiety Scale. American Journal of Critical Care. 2004;13(2):146-52. [View at paplisher] [DOI] [PMID] [Google Scholar]
22. Cao X, Yumul R, Elvir Lazo OL, Friedman J, Durra O, Zhang X, et al. A novel visual facial anxiety scale for assessing preoperative anxiety. PLoS ONE. 2017;12(2):1-7. [View at paplisher] [DOI] [PMID] [Google Scholar]
23. Mehranfard N, Mohammad Aliha J, Navidhamidi M, Kazemnejad A, Saatchi K. The effect of acupressure on anxiety in patients under mechanical ventilation. Iranian Journal of Cardiovascular Nursing. 2014;3(3):48-57.[Persian] [View at paplisher] [Google Scholar]
24. Nouri JM, Safaeipour L, Vafadar Z, Moradian ST. The effect of the family presence on anxiety and agitation of patients under mechanical ventilation after open heart surgery: a randomized clinical trial. Perioperative Medicine. 2021;10(1):1-9. [View at paplisher] [DOI] [PMID] [Google Scholar]
25. Fritz CO, Morris PE, Richler JJ. Effect size estimates: current use, calculations, and interpretation. Journal of experimental psychology: General. 2012;141(1):2-18. [View at paplisher] [DOI] [PMID] [Google Scholar]
26. Carlson CR, Collins Jr FL, Nitz AJ, Sturgis ET, Rogers JL, psychiatry e. Muscle stretching as an alternative relaxation training procedure. Journal of behavior therapy. 1990;21(1):29-38. [View at paplisher] [DOI] [Google Scholar]
27. Marbun EB, Sutatminingsih R, Saragih JI. Effectiveness of Diaphragmatic Breathing Relaxation to Reduce Anxiety Intensity in Undergoing Hemodialysis Treatment in Patients with Chronic Kidney Disease. Int J Adv Res Sci Eng Technol. 2020;5(3):143-4. [View at paplisher] [Google Scholar]
28. Wongwilairat K, Buranruk O, Eungpinichpong W, Puntumetakul R, Kantharadussadee-Triamchaisri S. Muscle stretching with deep and slow breathing patterns: a pilot study for therapeutic development. Journal of Complementary Integrative Medicine. 2018;16(2). [View at paplisher] [DOI] [PMID] [Google Scholar]
29. Urell C, Emtner M, Hedenström H, Tenling A, Breidenskog M, Westerdahl E. Deep breathing exercises with positive expiratory pressure at a higher rate improve oxygenation in the early period after cardiac surgery-a randomised controlled trial. European journal of cardio-thoracic surgery. 2011;40(1):162-7. [View at paplisher] [DOI] [PMID] [Google Scholar]
30. Westerdahl E, Lindmark B, Eriksson T, Hedenstierna G, Tenling AJC. Deep-breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest. 2005;128(5):3482-8. [View at paplisher] [DOI] [PMID] [Google Scholar]
31. Leivseth L, Nilsen TI, Mai X-M, Johnsen R, Langhammer A. Lung function and anxiety in association with dyspnoea: the HUNT study. Respiratory medicine. 2012;106(8):1148-57. [View at paplisher] [DOI] [PMID] [Google Scholar]
32. Gersh B. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit: Results From a Pilot, Randomized Trial Circulation. 2007;113(7):946-52. [View at paplisher] [DOI] [PMID] [Google Scholar]
33. Smith L, Medves J, Harrison MB, Tranmer J, Waytuck B. The impact of hospital visiting hour policies on pediatric and adult patients and their visitors. JBI Library of Systematic Reviews. 2009;7(2):38-79. [View at paplisher] [DOI] [PMID] [Google Scholar]
34. Gallagher R, McKinley S. Stressors and anxiety in patients undergoing coronary artery bypass surgery. American Journal of Critical Care. 2007;16(3):248-57. [View at paplisher] [DOI] [PMID] [Google Scholar]
35. Nesami MB, Shorofi SA, Jafari A, Khalilian AR, Tabari SZ. The relationship between stressors and anxiety levels after CABG in Sari, Iran. Iranian Red Crescent Medical Journal. 2016;18(5):1-7. [View at paplisher] [DOI] [PMID] [Google Scholar]
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
