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EFFECTS OF BEHAVIOR CHANGE PROGRAM ON

PHYSICAL ACTIVITYAND PHYSICAL FITNESS

IN PATIENTS STATUS POSTCORONARY ARTERY BYPASS GRAFT SURGERY

WORARAT PHOTI

A THESIS SUBMITTED IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR

THE DEGREE OF MASTER OF NURSING SCIENCE

(ADULT NURSING)

FACULTY OF GRADUATE STUDIES

MAHIDOL UNIVERSITY

2009

COPYRIGHT OF MAHIDOL UNIVERSITY


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iii

ACKNOWLEDGEMENTS

The success of this thesis can been attributed to the extensive support and

assistance from my major advisor, Asst. Prof. Napaporn Wanitkun and my co-advisor,

Assoc. Prof. Suvimol Kimpee and Dr. Taweesak Chotivatanapong. I deeply thank

them for their valuable advice and guidance in this research.

I would like to express my deep appreciation to Dr. Grit Leetongin for

external examiner of the thesis defense, his kindness and helpful guidance. I would

like to gratefully appreciate Assoc. Prof. Kanaungnit Pongthavornkamol for her

constructive comments. Grateful acknowledge extend to all the experts for their

invaluable advice and comments on this thesis ,especially Prof. Karen B. Tetz for her

time in revising and polishing my English writing.

I wish to thank all experts for kindness in examining the research

instrument and providing suggestions for improvement.

I would like to thank all nurses and other health care team member at theChest Disease Institute

for helping me to succeed in data collection. I am deeply

thankful to all patients for their cooperation to patients in my study.

I am grateful to all the lectures and staff of the Faculty of Nursing for

valuable advice and thanks also go to my older sister and friends in classmate master

program for their kind support.

Finally, I am grateful to my parents for their financial support, entirely

care, love, and believed in me. Thanks Mr. Nuttaphon for helped in any way you

could. The usefulness of this thesis I dedicate to my father, my mother and all the

teachers who have taught me since my childhood.

Worarat Photi


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Fac. of Grad. Studies, Mahidol Univ. Thesis /iv

EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICAL ACTIVITY

AND PHYSICAL FITNESS IN PATIENTS STATUS POST CORONARY

ARTERY BYPASS GRAFT SURGERY

WORARAT PHOTI 4936723 NSAN/M

M.N.S. (ADULT NURSING)

THESIS ADVISORY COMMITTEE : NAPAPORN WANITKUN, Ph.D. (Adult Nursing),

SUVIMOL KIMPEE, M.ED., TAWEESAK CHOTIVATANAPONG, M.D.

ABSTRACT

This quasi-experimental study was designed to examine a Behavior Change

Program that would significantly impact physical activity and physical fitness in patients with

post coronary artery bypass graft surgery, who were admitted to the Central Chest Institute

during December 2008 May 2009.

The participants of this study were 73 patients following coronary artery bypass

graft surgery. There were patients in the control group (n=37) and the intervention group

(n=36). The two groups were matched by age and sex. Patients in the control group were fully

recruited first and then the intervention group was started on data collection two weeks later

to prevent contamination. Both groups received the cardiac rehabilitation program as usual

hospital care of the Central Chest Institute and the experimental group also participated in the

Behavior Change Program. The program was based on the specific constructs of the

Transtheoretical Model for only individuals in the preparation stage of readiness for physical

activity. Physical activity behavior (measured by expenditure of at least a moderate level of

physical activity) and physical fitness (measured by six-minute walking distance) were

assessed at pre- and post-intervention. Only daily steps were measured post- intervention. The

data were analyzed using MANOVA.

The results demonstrated that both groups had no difference in physical activity

and physical fitness pre-intervention (p>.05). Post-intervention, the intervention group had a

significantly higher level of physical activity and physical fitness than the control group

(p< 0.01).

These findings can be applied to improve physical activity and physical fitness

among patients who have had post-coronary artery bypass graft surgery and have potential

applications for other clinical settings.

KEY WORDS: BEHAVIOR CHANGE PROGRAM / CORONARY ARTERY

BYPASS GRAFT / PHYSICAL ACTIVITY /

TRANSTHEORETICAL MODEL

111 pages


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Fac. of Grad. Studies, Mahidol Univ. Thesis /v

EFFECTS OF BEHAVIOR CHANGE PROGRAM ON PHYSICALA CTIVITY AND PHYSICAL

FITNESS IN PATIENTS STATUS POST CORONARY ARTERY BYPASS GRAFT SURGERY

4936723 NSAN/M

.. ()

: , Ph.D. (Nursing), , ..(), , ..

2551 2552

73 (37 ) (36 )

2 6 () ( 6 ) MANOVA

(p > .05) (,)(6 ) (p< 0.01).

111


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vi

CONTENTS

Page

ACKNOWLEDGEMENTS iii

ABSTRACTS (ENGLISH) iv

ABSTRACTS (THAI) v

LIST OF TABLES viiiLIST OF FIGURE ix

CHAPTER I INTRODUCTION 1

Background and significance of the study

Research questions

Purpose of the research

Research hypothesis

Conceptual framework of the researchScope of the study

Definition of terms

Expected benefitsof the research

1

4

5

5

59

9

10

CHAPTER II LITERATURE REVIEW 11

CHAPTER III METHODOLOGY 37

Research design

Population and sampling

Setting

Instrument

Validity and reliability

Data collection

Protection of human right

Data analysis

37

37

38

38

42

43

47

48


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vii

CONTENTS (cont.)

Page

CHAPTER IV RESULTS 50

CHAPTER V DISCUSSION 62

CHAPTER VI CONCLUSION 69

REFERENCES 73

APPENDICES

Appendix A The experts who validated the content of the

instruments.93

Appendix B Demographic data questionnaire. 94

Appendix C Exercise Stages of Change questionnaire : ESC. 95

Appendix D Community Health Activities Model Program for

Seniors

Activities Questionnaire for Older Adults: CHAMPS

96

Appendix E Self-Efficacy for Overcoming Barriers to Exercise

questionnaire.98

Appendix F Questionnaire for evaluated patient perception of care. 99

Appendix G Self liberation card 100

Appendix H Brochures 103

Appendix I Motto 105

Appendix J Letter 106

Appendix K Behavior Change Program guideline 107

Appendix L Pedometers manual 109

Appendix M Documentary Proof of Mahidol University Institutional

Review Board110

BIOGRAPHY 111


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viii

LIST OF TABLES

Table Page

1 Physical Activity for Patients Received coronary Artery

Bypass Graft Surgery 25

2 The Behavior Change Program 46

3 Comparison of Demographic characteristics by Chi-square

and Mann-Whitney U test 51

4 Comparison of Socioeconomic Status Between Control and

Intervention Groups by Chi-square and Mann-Whitney U test. 52

5 Comparison of health behaviors : working physical activity,

diet control, smoking by Chi-square and Mann-Whitney U test 53

6 The Frequency and Percentage of Functional Class 54

7 Frequency and Percentage of Illness Conditions 55

8 Comparisons of Mean and standard deviation of Caloric

Expenditure of at Least Moderate Physical Activity Level

and Above, Daily Steps and Six-Minute Walking Distance

Between Intervention and Control Group at post-

intervention by MANOVA 56

9 Frequency and Percentage of Participants Perception of

Care quality 5810 Comparing means and standard deviations of Self-efficacy

for Overcoming Barriers by t-test 60


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ix

LIST OF FIGURES

Figure Page

1 Conceptual framework of the research 8

2 The processes of the intervention 45


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Fac. of Grad. Studies, Mahidol Univ. M.N.S. (Adult Nursing)/ 1

CHAPTER I

INTRODUCTION

Background and Significance of the Study

Acute Coronary Syndromes (ACS) is the leading cause of death and

results in high hospital costs in Thailand (Bureau of Policy and Strategy, 2005) and the

United States (Anderson et al., 2007). Coronary Artery Bypass Graft (CABG) surgeryis a treatment that may be used for patients with ACS. The number of patients who

received CABG surgery in Thailand increased from 2,213 in 2005,to 3,063 in 2007

(The Society of Thoracic Surgeons of Thailand, 2007) and the total cost for coronary

artery bypass graft surgery is more than 140,000 bath per person. In the United States,

the number of patients with ACS increased and the cost for surgery and care increased

as well (Nilsson, Algotsson, Hoglund, Luhrs, & Brandt, 2004). Moreover, even though

the patients have already been surgically treated, it is likely that they will develop this

illness again unless they change their behaviors (Eagle et al., 2004). Physical activity

can reduce the recurrence of Acute Coronary Syndromes (ASCM, 2007).

The recommended minimum for physical activity was moderate physical

activities consuming about 3-6 METs 30 minutes of continued physical activity or the

sum of at least 30 min of intermittent exercise, five days per week. Moderate physical

activity levels were complementary in the production of health benefits (Haskell,

2007). Many studies demonstrated the benefits of physical activity and exercise. Both

physical activity and exercise decreased and prevented artherosclerotic heart disease.

A meta analysis of 51 intervention studies found that rehabilitation programs (exercise

only) reduced mortality rate by 27% (Jolliffe, Rees, Taylor, Thompson, Oldridge, &

Ebrahim, 2001). The six-minute walk test and quadriceps muscle strength test

improved significantly in patients who received a supervised exercise program

(Jonsdottira, Andersen, Sigurosson, & Sigurosson, 2006). An average increase in

HDL-C levels was 4.6%. Triglyceride and LDL-C were reduced by 3.7% and 5.0%

respectively (Thompson et al., 2003). Nowadays, even if physical activity and exercise


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Worarat Photi Introduction /2

are supported, research has found that the majority of persons in the United States do

not engage in consistent physical activity for the recommended minimum 30 minutes

of moderate-intensity activity in most days of the week. In 2001, 54.6% of persons

did not have enough activity to meet the recommendations (Centers for Disease

Control and Prevention, 2003). In Thailand, a total of 45% of patients with ACS did

not have regular physical activity (Wanitkun, 2003).

There is not a simple way to motivate patients to regularly do physical

activities that are appropriate with their competency. Only providing knowledge and

skill about exercise is not sufficient to bring about continuous exercise for health.

(U.S. Preventive Services Task Force, 2006). Primary and secondary prevention

should be emphasized, including a focus on ways individual persons can improve

their abilities such as skill, motivation from their lifestyle, self- efficacy overcoming

barriers and self-monitoring. Readiness for behavior change or stages of change is

associated with a benefit and cost (pros and cons) analysis of behavior change

(Prochaska et al.,1994). The lifestyles and barriers of each person are different; hence,

they use different processes of change (Lowther, Mutrie, & Scott, 2007). Providing

one program for behavior change is not always effective for people at various stages of

readiness.

Literature review demonstrated that education technique (Kawchareanta,

2003), group support (Kaduang, 2004), self-efficacy enhancement (Jompong, 2003;

Leangchawengwong, 1998; Lipun, 1999), and motivation promotion (Intaratool,

2005) were used for behavior change. These techniques included the same content

and details for every person. After the patients received the program, they could

change their behaviors. However, the literature review demonstrated that thetranstheoretical model(TTM) based activity promotion interventions are effective in

promoting activity adoption, initial results on longer term adherence are disappointing

(Adams, & White, 2003; Dallow & Anderson, 2003; Spencer, Malone, Roy, & Yost,

2006). The TTM was useful in explaining the longitudinal effects of exercise. After

one year, 60% of those in the intervention group were adopters compared to 16% of

those in the education program(Findorff, Stock, Gross, & Wyman, 2007).

Prior to the current research, cardiac rehabilitation program at the Central

Chest institute for physical activity enhancement of patients with ACS emphasized the


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education technique for a group or person and then all of them received the same

content. This program was not developed in terms of appropriate individual lifestyle,

barriers, and readiness for changing behavior. The literature review demonstrated that

an effective program should be developed by a combination of psychotherapy and

behavior change, and it should motivate a change from risky behavior to healthy

behavior. The program development should emphasize the appropriate individual

persons style (Wanitkun, 2005) and readiness for change (Prochaska, Redding, &

Evers, 2002).

The conceptual framework of this study is based on the Transtheoretical

model which integrates behaviors and classifies individuals in respect to readiness for

behavior change. There are 5 stages of change which consist of precontemplation,

contemplation, preparation, action, and maintenance (Prochaska, Redding, & Evers,

2002; Wilson & Schlam, 2004). Based on the transtheoretical model, individuals in

each stage were assisted with various unique combinations of strategies or processes

to aid the patients in changing their behavior. Individuals in the contemplation stage

used dramatic relief, environmental reevaluation, (Prochaska, Redding, & Evers,

2002) consciousness raising, decisional balance, and self-efficacy overcoming barriers

(Kim, Hwangb, & Yoo, 2004), while individuals in the preparation stage used self-

liberation (Prochaska, Redding, & Evers, 2002), reinforcement management, self-

efficacy for overcoming barriers (Kim et al., 2004), environmental reevaluation, and

counter-conditioning (Tseng, Jaw, Lin, & Ho, 2003) for behavior change.

The literature review found that the transtheoretical model is effective for

behavior change in areas such as physical activity (Dallow & Anderson, 2003;

Griffin-Blanke, Dejoy, 2006; Plotnikoff, Brunet, Courneya, Birkett, Marcus, &Whiteley, 2007; Titze, Martin, Seiler, Stronegger, & Marti, 2001; Woods, Mutrie, &

Scott, 2002) and exercise (Kim et al., 2004; Spencer, Malone, Roy, & Yost, 2006;

Tseng, Jaw, Lin, & Ho, 2003). An outcome of exercise and physical activity behavior

was measured with caloric expenditure and cardiorespiratory fitness (Kim et al., 2004;

Spencer, B, Malone, Roy, & Yost, 2006; Tseng et al., 2003; Spencer et al.,2006;

Tseng et al., 2003). Moreover, the transtheoretical model is effective for eating

behavior change ( Wilson & Schlam, 2004) and for use in behavior change that

involves more than one behavior (Kim, et al., 2004; Johnson, et al., 2006; McKee,


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Bannon, Kerins, & FitzGerald, 2006; Prochaska, et al., 2007). Measured outcomes

include stress management (Tseng et al., 2003), fasting blood glucose level (Kim et

al., 2004), and eating behavior (Johnson, Driskell,Johnson, Dyment, Prochaska,

Prochaska, et al., 2006; Wilson & Schlam, 2004).

Individuals in each stage used various processes; thus, stage matched

interventions can enhance the physical activity more than non stage matched

interventions (Dallow & Anderson, 2003). The participants in this study were patients

who received CABG surgery. They could not be treated by medication, and were

concerned about the importance of risk factor reduction, and cardiac rehabilitation

enhancement. They gained education about exercise or physical activity; thus, they

have learned about the cost of non physical activity. They received a cardiac

rehabilitation program from a physiotherapy team. Not all of them succeeded in

physical activity. Some patients did not change behavior or met the criteria. Likewise

some patients succeeded in changing their behavior but they did not regularly

participate in physical activity. Education alone cannot motivate patients to reach the

recommended physical activity level. This study developed the Behavior Change

Program for the patients in this group. The Behavior Change Program included self-

liberation (Prochaska, Redding, & Evers, 2002), reinforcement management, self-

efficacy overcoming barriers (Kim et al., 2004), environmental reevaluation, and

counter conditioning (Tseng et al., 2003).

Research Question

1.

Does a Behavior Change Program have an effect on physical activities

(caloric expenditure of at least moderate physical activity level, and daily steps) of

CABG patients in the preparation stage?

2. Does a Behavior Change Program have an effect on physical fitness

(six-minute walking distance) of CABG patients in the preparation stage?


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Purposes of the Study

1. To compare physical activities(caloric expenditure of at least moderate

physical activity level, and daily steps) of CABG patients in the preparation stage for

those who received a Behavior Change Program and those who received usual care.

2. To compare physical fitness (six-minute walking distance) of CABG

patients in the preparation stage for those who received a Behavior Change Program

and those who received usual care.

Research Hypotheses

1. The intervention group will have a significantly greater caloric

expenditure of at least moderate physical activity level when compare to, the control

group.

2. The intervention group will have a significantly higher number of daily

steps than the control group.

3. The intervention group will have a significantly longer six-minute

walking distance than the control group.

Conceptual Framework of the research

The conceptual framework of this study is based on the transtheoretical

model (TTM) which emerged from comparative analysis of leading theories of

psychotherapy and behavior change (Prochaska, & DiClemente, 1983). The TTM

consists of various stages of change, process of change, self-efficacy, and decisional

balance (Prochaska et al., 2002; Wanitkun, 2005). The TTM integrates behaviors to

classify individuals with respect to readiness for behavior change. So, individuals in

each stage use different strategies or processes, self - efficacy overcoming barriers,

and weight of the cost-benefit to aid them in changing their behavior. The TTM

construes change as a process-involving progress through a series of five stages:

Precontemplation, Contemplation, Preparation, Action, and Maintenance.


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The decisional balance refers to the weight of the benefit and cost

consideration (pros and cons) of changing behavior. Individuals in each stage have

different benefit and cost considerations

(Kim, 2007). The 10 processes of change are

the covert and overt activities that people use to progress through the stages.

(Prochaska et al., 2002). Self-efficacy overcoming barriers are combined with the

TTM. The meaning of self-efficacy overcoming barriers is the confidence in

overcoming the barriers to performing physical activity (Bandura, 1997 ).

The program in this study was developed for CABG patients in the

preparation stage. This group is concerned about the importance of risk factor

reduction and cardiac rehabilitation enhancement. This group received education about

exercise or physical activity; thus, they have learned about the cost of non physical

activity. They received a cardiac rehabilitation program by a physiotherapy team.

After surgery, the patient may have wounds. Manipulation of the chest cavity, and use

of retractors during surgery may all contribute to postoperative pain. They may also

experience anxiety and fear about self care post operation. They have barriers to

physical activity in their lifestyle. These factors lead to some patients being unable to

change behavior or meet the criteria. Other patients may succeed in changing their

behavior, but do not participate in regular physical activity. Thus, the Behavior

Change Program should be focused on appropriate individuals. Persons in the

preparation stage were ready to begin physical activity. The goal is to reinforce and

increase physical activity behavior.

The Behavior Change Program focused on identified barriers to physical

activity and using processes of change for motivating the behavior change. This

program was composed of self liberation (Prochaska et al., 2002; Tseng et al., 2003),counter-conditioning, stimulus control, environmental reevaluation(Tseng et al., 2003),

reinforcement management, and self-efficacy (Kim et al., 2004)for increasing physical

activity and physical fitness.

Self-efficacy for overcoming barriers to exercise is the confidence a person

feels about performing physical activities (Bandura, 1997). Persons with higher self-

efficacy maintained physical activity level, perceived less effort in doing physical

activity, and reported more positive effects from physical activities (Prochaska et al.,

2002; Wanitkun, 2005). The Behavior Change Program increased patients self


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efficacy by discussing their physical activity barriers and identifying strategies to

overcome the barriers, thus leading to increased physical activity. Counter-

conditioning skills are important to learn when trying to fit short bouts of moderately

intense physical activity into the day. These skills are important to guide patients who

are thinking about changing physical activity behavior (preparation stages) to proceed

to the action stage. Self-liberation represents making a firm commitment to changing

health behavior. Helping patients to set realistic personal activity goals is important to

guide physical activity behavior change. Environmental reevaluation included

consideration and assessment by persons about how the problem affects the social

environments and physics. Stimulus Control was control of causes that trigger the

behavioral problem, including removal of cues for unhealthy habits and addition of

prompts for healthier alternatives. Reinforcement Management provided rewards for

controlling or maintaining the physical activity.

These processes increased self-efficacy (Dallow & Anderson, 2003),

benefits consideration (pros) of physical activities (Fahrenwaldm & Walkerm, 2003)

and decreased cost consideration (cons) of exercise or physical activity (Griffin-Blake

& DeJoy, 2006).


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Normal pathway The Behavior Change Program pathway

Figure 1 Conceptual framework of the research

Coronary artery bypass graft

surgery patients

in preparation stage

Behavior Change Program

- Substitution of alternative behaviors

for the problem behavior:counter-

conditioning (Tseng, Jaw, Lin, & Ho,

2003).

- Consideration and assessment by

person of how the problem affects the

social environments and

physics:environmental reevaluation

(Tseng, Jaw, Lin, & Ho, 2003).

- Persons choice, commitment and

recommitment to change the

behavioral problems: selfliberation(Prochaska, Redding, &

Evers, 2002; Tseng, Jaw, Lin, & Ho,

2003).

- Control of situations and other

causes that triggers the problem

behavior: stimulus control (Tseng,

Jaw, Lin, & Ho, 2003).

- Provided rewards for controlling or

maintaining the healthy behavior:

reinforcement management (Kim,

Hwangb, & Yoo, 2004)- Increased confidence a person feels

about performing physical activity:

self-efficacy (Kim, Hwangb, & Yoo,

2004)1.Physical activities

- Caloric expenditure

of at least moderate

physical activity level

not improve.

- Mean daily steps

not improve.

2. Physical fitness

- Six-minute walking

distance not improve.

Not engage in

physical activity

because of

- Confidence a person

feels about performingphysical activities not

improved or

decreased.

- Benefit analysis of

physical activities not

improved or

decreased.

- Cost analysis of

physical activities

increased.

- Cannot combine

physical activities into

lifestyle.

Do engage regular

physical activity

because of -

Confidence a person

feels aboutperforming physical

activities was

increased.

- Benefit analysis of

physical activities

was increased .

- Cost analysis of

physical activities was

decreased.

- Can combine

physical activities into

lifestyle.

1.Physical activities

- Caloric expenditure

of at least moderate

physical activity level

was increase.

- Mean daily steps

was increase.

2. Physical fitness

- Six-minute walking

distance was increase.


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Scope of the Study

This study aimed to examine the effect of a Behavior Change Program on

physical activities (caloric expenditure of at least moderate physical activity level,

daily steps) and physical fitness (six-minute walking distance) of CABG patients

compared with usual care. The participants in this study were patients who received

CABG and were admitted to Center Chest Institute. The data were collected during the

months from May 2008 to May 2009.

Definitions of Terms

Physical activity was defined as any bodily movement produced by

skeletal muscles that results in energy expenditure (Caspersen, Powell, & Christenson,

1985). The physical activity in this study was moderate physical activities that were

measured by

- Caloric expenditure of at least moderate physical activity

level per week can be measured by the Community Health Activities Model Program

for Seniors Activities Questionnaire for Older Adults (CHAMPS)

- Daily steps can be measured by a Pedometer.

Physical fitnesswas defined as a set of attributes that are either related

health or skill. The degree to which people have these attributes can be measured

with specific tests (Caspersen et al., 1985). There are four components that include

cardiorespiratory fitness, muscular strength and muscular endurance, flexibility, and

body composition (ACSM, 2007; Wisan & Rapeepol, 2548). In this study, physical

fitness refers to six-minute walking distance that can be measured by the six-minute

walk test.

Behavior Change Program was defined as a program based on the

transtheoretical model and literature review of physical activity change for CABG

patients in the preparation stage (Prochaska et al., 2002 ; Wilson & Schlam, 2004).

This program includes self-efficacy overcoming barriers, environmental reevaluation,

stimulus control, reinforcement management, counter-conditioning, and self liberation.

Duration of the Behavior Change Program was seven weeks.


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Expected benefit of the research

1. The established program will be an effective nursing care to promote

physical activity behavior and to promote strengthening of physical fitness among

CABG patients who are in the preparation stage.

2. The strategies of the program will be a guideline for nurses in cardiac

units to implement for CABG patients who are in the preparation stage.

3. The findings will be preliminary knowledge for further study regarding

developing interventions appropriate for CABG patients in other stages of change and

patients with other diseases.


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CHAPTER II

LITERATURE REVIEW

The purpose of this study was to examine the effects of the Behavior

Change Program on physical activities (caloric expenditure of at least moderate

physical activity level and above, daily steps) and physical fitness (six-minute walking

distance) among coronary artery bypass graft (CABG) patients compared with

receiving usual care. This chapter presents a review of theoretical content and related

concepts of interest regarding three topics as follows:

1. Acute Coronary Syndromes.

1.1 Definition and pathophysiology

1.2 Risk factors

1.3 Coronary artery bypass graft surgery

1.4 Recovery processes

2. Physical activity and physical fitness in patients with coronary artery

bypass graft.

2.1. Definitionof physical activity and physical fitness

2.2.

Method for measure physical activity and physical fitness

2.3.

Benefit of physical activity

2.4.Physical activity and physical fitness of patients with

coronary artery bypass graft.

3.

Changing health behavior based on the Transtheoretical Model.

3.1.Basic concept of transtheoretical model

3.2.Application of the Transtheoretical model to Behavior

Change Program for patients with coronary artery bypass graft

3.3.Effects of a Behavior Change Program on physical activity

and physical fitness


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Worarat Photi Literature Review / 12

1. Acute Coronary Syndromes.

1.1 Definition and Pathophysiology

Acute Coronary Syndrome with ischemic heart disease is a condition

resulting from atherosclerotic plaque accumulating on the internal walls of coronary

arteries. Narrowing arteries lead to decreased blood flow to cardiac muscle. The initial

event in coronary atherosclerosis is endothelial injury. The factor most described is

hypercholesterolemia. Low-density lipoprotein (LDL) cholesterol diffuses into the

coronary arteries; once oxidized, it induces a severe inflammatory reaction leading to

endothelial dysfunction. This disturbs the balance between the vasodilator and

antiproliferative agent nitric oxide, and the vasoconstrictor agent endothelin. Release

of chemotactic and growth factors also occurs, and inflammatory cells are attracted to

the site of atherosclerosis. Oxidized LDL is taken up by macrophages, leading to the

development of a lipid core surrounded by smooth muscle cells and fibrous tissue,

forming the atherosclerotic plaque. The narrowing arteries lead to decreased blood

flow to cardiac muscle in the affected area, causing insufficient blood supply and

insufficient oxygenation. Thus, they are characterized by an imbalance between

myocardial oxygen supply and demand (Anderson, 2007; Libby & Theroux, 2005;

Wenger, Helmy, Patel & Lerakis, 2005).

1.2 Risk factors

The exact cause of atherosclerotic plaque is yet unknown. However, it has

been found that factors associated with coronary artery disease can be divided into two

types.

1.2.1Unmodified risk factors:

1.

Age: The progress of fatty streak and fibrous plaque

increases with age. The prevalence of fatty streaks in the coronary arteries increases

with age. Between the ages of 2 to 15 years of age, approximately 50 percent of people

already have fatty streaks, while from 21 to 39 years of age, 85 percent of people have

fatty streaks. (Berenson et.al., 1998). Platelet aggregation activities increase with age.

The lipid composition of the platelet membrane changes in people of higher age

causees artherosclerosis (Korkushko, Sarkisov, Lishnevskaya & Gorbach, 2000).

2.

Sex: Men develop this illness when they are 40 years oldand women develop it at 55 years of age. (Agingthai Institute, 2006). The prevalence


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of Acute Coronary Syndrome in premenopausal females is lower than for males;

however, the prevalence of Acute Coronary Syndrome in postmenopausal females is

higher than for males (Alberta & Ruskina, 2001). The average rate of progression of

subclinical atherosclerosis in postmenopausal women was lower in those taking

unopposed micronized 17b-estradiol (1 mg/d) group than in those taking the placebo

(-0.0017 mm/y vs 0.0036 mm/y ).The difference in average progression rates between

the placebo and estradiol groups was 0.0053 mm/y (Hodis et al., 2001).

3. Family history: Family history of myocardial infarction is

associated with thicker intima-media thickness (IMT). Persons with a family history of

myocardial infarction had significantly thicker intima-media thickness (IMT) than

persons with no family history (Stensland-Bugge, Bnaa & Joakimsen, 2001; Jerrard-

Dunne, et al., 2003) Positive family histories were independent predictors for redo

CABG(Odd ratio = 2.4) (Mennander et al., 2005).

1.2.2 Modified risky factors:

1. Hyperlipidemia: Fatty streak and fibrous plaque lesions in

the aorta and coronary vessels were associated with serum triglyceride

concentrations, and LDL cholesterol concentrations. (r = 0.50, 0.43 respectively)

(Berenson et al., 1998). The symptoms of inflammatoryprocesses emerge at the same

time asatherosclerotic plaques accumulating on the internal walls of coronary arteries

(Libby, Ridker & Maseri, 2002) whose processes were explained in the

pathophysiology of Acute Coronary Syndromes. A high serum triglyceride level (2

mmol/L) was an independent predictor for redo CABG and odd ratio was 1.6

(Mennander, Angervuori, Huhtala, Karhunen, Tarkka & Kuukasjarvi, 2005).

2.

Smoking: A history of smoking is associated withcoronaryartery and carotid artery disease (Ehtisham, Chimowitz, Furlan & Lafranchise, 2005).

The number of smokers increased in terms of the percentage of intimal surface

involved with fibrous plaques in the aorta (1.22% in smoker vs 0.12% in nonsmoker)

and fatty streaks in coronary vessels (8.27% in smoker vs 2.98% in nonsmoker)

(Berenson et al., 1998).

3.

Hypertension: Hypertension was associated withcoronary

artery and carotid disease (Ehtisham et al., 2005). The renin-angiotensin system

contributes to the pathogenesis of atherosclerosis. Angiotensin II may elicit


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inflammatory signals in vascular smooth muscle cells. The transcription factor NF-B

participates in most signaling pathways involved in inflammation (Altman, 2003).

4.

Diabetes: Diabetes is a state of increased plasma

coagulability (Mooradian, 2003). Diabetic patients have impaired endothelium-

dependent vasodilatation, hyper-coagulability, increased PAI-1 level in the arterial

wall with impaired fibrinolysis, decrease of endothelial nitric oxide synthase, and

increase of endothelin-1 (Altman, 2003). The study showed after a follow up of 7

years was done, that mortality in diabetic patients was higher than in non-diabetics

and for diabetic patients with no history of myocardial infarction (Haffner et al., as

cited in Altman, 2003).5.

Psychosocial: Systematic review demonstrated a moderate

association between depression, social support and psychosocial work characteristics

and CHD etiology and prognosis (Kuper, Marmot, & Hemingway, 2002). Anxiety and

depression were associated withthedevelopment of coronary artery disease (Januzzi,

Stern, Pasternak & DeSanctis, 2000). The mechanism was thought to be a reduction in

vagal tone and increase in susceptibility to ventricular fibrillation (Albert & Ruskina,

2001).

6.

Physical activity: When leisure-time physical activity

increased, the risk of Acute Coronary Syndromes (ACS) decreased. Leisure-time

physical activity was divided into four levels based on the frequency of physical

activity in the survey. There were I get practically no exercise at all, I exercise

occasionally, I exercise once or twice a week, and I exercise vigorously at least

twice a week. Persons who were physically active at least twice a week had a 41%

low risk of developing ACS more than those who performed no physical activity

(hazard ratio=0.59) (Sundquist, Qvist, Johansson & Sundquist, 2005). An energy

expenditure of about 1600 kcal or 6720 kJ per week has been found effective in

halting the progression of coronary artery disease, and an energy expenditure of about

2200 kcal or 9240 kJ per week had been shown associated with plaque reduction in

patients with heart disease (Franklin, Swain & Shephard, 2003; Warburton, Nicol &

Bredin, 2006). Persons who reported less than 30 minutes a week of physical activity

at baseline had a risk ratio concerning subsequent mortality compared with 30 or more

minutes of physical activity a week (2.82 vs 2.15) (Martinson, O'Connor& Pronk,

2001).


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1.3 Coronary artery bypass graft

Coronary artery bypass graft (CABG) surgery was indicated for patients

with Acute Coronary Syndromes to relieve symptoms, improve quality of life, and

prolong life. Coronary artery bypass was the construction of new pathways between

the aorta and coronary arteries beyond the obstructing lesion. Conduits used for

coronary artery bypass graft surgery were saphenous vein, internal mammary artery,

and radial artery. There were indications for CABG following ACC/AHA guidelines

(Anderson, 2007).

- Compelling anatomy, such as left main coronary artery disease (50%).

-

Multivessel disease with or without depressed ejection fraction.

- Two-vessel disease, proximal left anterior descending lesion with

depressed ejection fraction < 50%.

- Coronary artery disease does not respond to medical treatment.

Coronary artery bypass graft is a major surgery. During cardiopulmonary

bypass blood is circulated by a pump to other organs of the body independent of

physiologic control and non pulsatile flow. This allows surgeons to operate on a still,

bloodless field. During manipulation of the heart, changes in hemodynamic stability

may cause many complications.

1. Cardiovascular complication The majority of cardiovascular

complications were atrial fibrillation (AF). Atrial fibrillation occurs in 28.2% at 0 to

11 days after operation in patients who had CABG surgery (Zaman, 2000), and causes

longer lengths of stay.(Martin & Turkelson, 2006)

2. Renal complication The study by Stallwood, Grayson, Mills, & Scawn

(2004) revealed that 53 patients (2.4%) developed acute renal failure (ARF) followingCABG. Thirty-four patients (1.5%) developed ARF without requiring dialysis, while

19 patients (0.9%) who developed ARF required dialysis support. Acute renal failure

associated with effectiveness of cardiac output or hypotension. Therefore, renal

perfusion insufficiency. Cardiopulmonary bypass graft (CPB) represents a specific risk

factor (Martin & Turkelson, 2006). CPB results in reduced glomerular filtration rate,

reduced renal blood flow, and redistribution of blood flow from the cortex to the outer

medulla(Young & Dai, 2000).


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3. Respiratory complication. Pulmonary complications were among the

most frequently reported complications and occur in 33% of patients after coronary

artery bypass graft (CABG) surgery (Hulzebos, 2003). Pulmonary complications result

from cardiopulmonary bypass graft, length of surgery, resultant increase in the amount

of needed anesthetic agents, and pain (Martin & Turkelson, 2006).

4. Neuropsychological complication Patients who require coronary artery

bypass surgery are at an increased risk for neurological complications (Ganushchak,

Fransen, Visser, JongJos, & Maessen, 2004) Stroke can be caused by hypotension or an

embolic event during or after surgery. Manipulation of the aorta has been implicated in

embolic events (Engstrom, 2003). Most patients have confusion or unconsciousness

(Martin & Turkelson, 2006).

5. Gastrointestinal complication. The range of gastrointestinal

complication occurrence was 0.12 to 2%. Complications included peptic ulcer,

perforated ulcer, pancreatitis, acute cholecystitis, bowel ischemia, diverticulitis, and

liver dysfunction. The nurse should monitor the patients bowel sounds, abdominal

distention, nausea, and vomiting. The intubated patient will have a nasogastric tube.

Placement and patency should be assessed as well as amount, color, and characteristics

of the drainage(Martin & Turkelson, 2006).

6. Pain The pain experienced by patients who receive coronary artery bypass

surgery results from tissue injury (nociceptive pain). The patient may have a median

sternotomy incision, leg incision, and radial incision. Manipulation of the chest cavity, use

of retractors during surgery, and electrocautery may all contribute to post-operative pain.

Other sources of pain include the removal of the chest tubes. This usually occurs 24 to 48

hours after operation (Martin & Turkelson, 2006).

7. Wound infection The incidence of infection of sternal and leg

incisions after cardiac surgery was less than 3% (Martin & Turkelson, 2006).

1.4 Recovery in coronary artery bypass graft patients.

Recovery from an illness or surgery to normal life is a dynamic process

encompassing both biophysical and psychosocial components. Patients who received

coronary artery bypass graft had lower recovery before the operation and this

increased after the operation. Recovery at discharge was the lowest, then gradually


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increased at 6 months after CABG (Lopeza, Yingb, Poonc & Wai, 2007). Autonomic

cardiovascular function including respiratory sinus arrhythmia, valsalva maneuver,

respiratory function and heart rate variability reached the lowest level 3-6 days after

surgery, returning to pre-surgery values at about 30-60 days postoperatively (Soares,

Moreno, Cravo & Nobrega, 2005). Mean energy expenditure after the operation was

28.87, 28.69, and 31.69 kcal/kg/day at 3, 6, and 12 months respectively. This study

showed that since 3 months after coronary artery bypass graft surgery, patients can

tolerate moderate physical activity (Barnason, et al., 2000). Psychological recovery

and depression levels increased or were stable at 1 week, then gradually decreased in

the 3rdand 6th month (Lopeza et al., 2007). Depression levels were the highest in pre

operation then gradually significantly decreased during the hospital stay, discharge,

and 6 weeks were the lowest respectively (Doering, Moser, Lemankiewicz, Luper &

Khan, 2005). The quality of life related to physical health, role-physical, social, bodily

pain, mental, vitality, and general health was the lowest in pre operation, then

gradually increased in the 3rdand 6thmonth respectively (Barnason et al., 2000).

Recovery of patients who received coronary artery bypass graft surgery

differed. Risk factors associated with recovery were as follows:

1.

Age: Older patients had low functional capacity compared

to younger patients (Pierson et al., 2003).

2. Sex: Men had higher physical functioning (Treat-Jacobson

& Lindquist, 2004), and functional capacity when compared to women (Pierson et al.,

2003). Women had more physical symptoms and side effects, including unstable

angina, congestive heart failure, and depressive symptoms in the six to eight weeks

after CABG surgery when compared to men (Vaccarino et al., 2003).3. Depression: Postoperative depression has effects on

recovery from coronary artery bypass graft surgery. At discharge, patients with higher

depression reported poorer emotional health with physical recovery and achieved

shorter walking distances compared to patients with lower depression. Moreover, in

post CABG patients, higher depression was found to be associated with increased

infection, and impaired wound healing (Doering, Moser, Lemankiewicz, Luper &

Khan, 2005).


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4. Pain: Moreover, patients reported that they stayed in the

hospital with the longest period and experienced the most pain (Sarpy, Galbraith &

Jones, 2000).

5. Exercise: The study showed that patients who participated

in regular exercise had higher functional status (Treat-Jacobson & Lindquist, 2004)

and functional capacity than patients who did not participate in regular exercise

(Pierson et al., 2003).

2. Physical activity and Physical fitness of coronary artery bypass

graft surgery patients

2.1 Definitions of physical activity and physical fitness

Physical activity was defined as any bodily movement produced by

skeletal muscles that results in energy expenditure. The energy expenditure can be

measured in kilocalories. Physical activity in daily life can be categorized into

occupational, sports, conditioning, household, or other activities (Caspersen, Powell &

Christenson, 1985). ACSM/AHA developed a new protocol to promote health

through an accessible exercise program. The recommended minimum was moderate

physical activities consuming about 3-6 METs 30 minutes of continued physical

activity or the sum of at least 30 min of intermittent exercise, five days per week or

vigorous-intensity 20 minutes per day, three days per week. Moderate and vigorous

intensity activities were complementary in the production of health benefits and a

variety of activities can be combined to meet 450-750 METs per week (Haskell,

2007).

Exercise was defined as a subset of physical activity that was planned,

structured, and repetitive and had as a final or an intermediate objective, the

improvement or maintenance of physical fitness (Caspersen et al.,1985).

Physical fitness was defined as a set of attributes that were either

related health or skill. The degree to which people have these attributes can be

measured with specific tests (Caspersen et al.,1985). There were four components

which were cardiorespiratory fitness, muscular strength and muscular endurance,


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flexibility, and body composition (ACSM, 2007; Kantarattanakool & Koonchon Na

Ayutthaya, 2005).

1.

Cardiorespiratory fitness

Cardiorespiratory fitness was aerobic fitness or aerobic

endurance related to the ability of performing large muscle, dynamic, moderate to high

intensity exercise for prolonged periods. Maximal oxygen uptake (VO2max) was

accepted as the criterion measure of cardiorespiratory fitness. Maximal oxygen uptake

is the product of maximal cardiac output and arterial-venous oxygen difference. Direct

measurement of VO2max was not feasible or desirable, so a variety of submaximal and

maximal exercise tests can be used to estimate VO2max (ACSM, 2007). Aerobic

fitness or aerobic endurance was measured by oxygen use per 1 kilogram per min

(ml/kg/min)or metabolic equivalent task [MET]. The mean of maximum ventilatory

oxygen comsumption (VO2 max) in males and females was 12 and 10 METs

respectively (Kantarattanakool & Koonchon Na Ayutthaya, 2005).

2. Muscular strength and muscular endurance

Muscular strength and muscular endurance are the ability of

the muscle to exert force and the muscles ability to continue to perform for successive

exertions or many repetitions. Muscular strength and muscular endurance are health-

related fitness that prevent coronary artery disease, prevent osteoporosis, control type

2 diabetes, lower risk of injury, and promote weight management (Kantarattanakool &

Koonchon Na Ayutthaya, 2005).

3. Flexibility

Flexibility is the ability to move a joint through its complete

range of motion. It is important for athletic performance and the ability to carry out theactivities of daily life. Flexibility depends on a number of specific variables, including

distensibility of the joint capsule, adequate warm-up, and muscle viscosity.

Complicance of various other tissues affects the range of motion (Kantarattanakool &

Koonchon Na Ayutthaya, 2005).

4. Body composition

It is well established that excessive fat body is associated with

hypertension, type 2 diabetes, coronary heart disease, stroke, and hyperlipidemia.The

basic body composition can be expressed as the relative percentage of body mass that


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is fat and fat-free tissue using a two-compartment model. Body composition can be

estimated by both laboratory and field technique that vary in terms of complexity,

cost, and accuracy. The examples for estimated body composition are the

anthropometric method, body mass index, circumference, skinfold measurements, and

densitometry etc.

The indispensable components are cardiorespiratory fitness or aerobic

fitness. These components measure submaximal exercise capacity by various methods.

The literature review showed that the six minute walk test has been used to evaluate

cardiorespiratory fitness within programs for exercise or physical activity

enhancement in coronary artery disease (Jonsdottira, et al., 2006; Solway, Brooks,

Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,

2003; Intaratool, 2005). Even though the test was considered submaximal, it may

result in near maximal performance for those with low fitness levels or disease.

Several multivariate equations are available to predict peak oxygen consumption from

the 6 minute walk test (Kantarattanakool, 2005; ACSM, 2007).

2.2 Physical activity and physical fitness measurements.

2.2.1 Physical activity measurements.

There are varieties of methods available to measure physical

activity such as self-report, behavioral observation, and electronic monitors (Laporte,

Monotoyee, & Caspersen, 1985). Self-report methods are self-administered or

interviewer-administered recall questionnaires, activity logs, diaries, or proxy reports.

Physical activity can be measured in terms of type, intensity, duration, and frequency.

The data from self-report questionnaires are calculated to reflect the rate of energyexpenditure during physical activity. Physical activity levels are generally expressed in

METS. Self-report measures of physical activity have been widely used in survey

studies (Brownson, Eyler, King, Brown, Shyu, & Sallis, 2000) and intervention studies

(Allison, & Keller, 2000).

A literature review demonstrated exercise self-report is needed to assess

frequency, intensity, and duration of physical activity to define the dose-response

association between physical activity and health outcomes (Sallis, & Saelen, 2000). In

this study, physical activity was measured using the Community Healthy Activities


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Model Program for Seniors Activities Questionnaire for Older Adults (CHAMPS).

The CHAMPS questionnaire was developed in 2001 for use with older adults . This

questionnaire was translated into Thai language by using a back-translation processes

and evaluated in terms of content validity by Wanitkun(2003). Construct validity of

the relationship between caloric expenditure computed from a list of activities of

CHAMPS was measured, and intention to exercise was assessed by the Exercise

Stages of Change. There were significant differences in caloric expenditure during all

physical activities (F4396=13.41,p< 0.001) and those engaging in moderate to vigorous

physical activities (F4360= 17.81, p < 0.001) among the 5 stages.

The CHAMPS questionnaire was composed of 39 items. There were 37

items for assessing intensity, frequency, and duration of activities. Three questions

were asked regarding each activity: was the activity done? Yes/No if yes, two

questions of frequency and duration were asked. There was one item for other

activities and 1 item for recheck. The exact number or frequency of a particular

activity was reported. All physical activities were reported into frequency per week

and estimated caloric expenditure per week of physical activity (Stewart, et al., 2001).

However, there was also a method for evaluating physical activity which used a

pedometer.

Pedometers objectively measure ambulatory activities throughout the day

in the form of step counts. They are tools for monitoring and motivation in physical

activity interventions. Pedometers are easy to use and relatively inexpensive compared

with other motion sensors. The pedometer has been applied to motivate physical

activities in adults (Stovitz, VanWormer, Center, & Bremer, 2005), older (Wellman,

Kamp, Kirk-Sanchez, & Johnson, 2007), and type 2 diabetes patients (Tudor-Locke,Myers, Bell, Harrisd, & Rodgere, 2002). Moreover, the pedometer has been applied to

measurement of physical activities in a community sample of working women (Speck,

& Looney, 2001), and men and women aged 2574 years (Sequeira, Rickenbach,

Wietlisbach, Tullen, & Schutz, 1995).

2.2.2 Physical fitness measurements.

Physical fitness was measured from the six minutes walk test

[6MWT]. The objective of the six minutes walk test was to cover the greatest distance

in the period lasting six minutes. VO2max could be estimated from the equation. The


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six minutes walk test has been used to evaluate cardiorespiratory fitness within some

clinical patients such as those with congestive heart failure and pulmonary disease. It

has also been widely used for preoperative and postoperative evaluation and for

measuring the response to therapeutic interventions for pulmonary and cardiac disease.

The distance of one meter walk was measured by using oxygen 0.1 ml per body

weigh 1 kilogram. The method for administering the six minute walk test was as

follows: (American Thoracic Society, 2002).

1. Prepare the equipment and location for six minute walk

test. The equipment included a countdown timer, a chair that can be easily moved

along the walking course, mechanical lap counter, worksheet on a clipboard, a source

of oxygen, sphygmomanometer, telephone, automated electronic defribrillator. Thelocation was indoor, along a long, flat, straight course. The walking course must be 30

meters in length. A 100 fit hallway is, therefore, required. The length of the corridor

should be marked every 3 meters.

2. The patient should sit to rest on a chair, located near the

starting position for at least 10 minutes before the test starts. During this time, check

for contraindications, measure pulse and blood pressure, and make sure that clothing

and shoes are appropriate. Pulse oximetry is optional. If it is performed, measure and

record baseline heart rate and oxygen saturation.

3. Instruct the patient about objects and methods of this test.

4. Set the lap counter to zero and the timer to six minutes.

Move to the starting point where the patient is waiting to start. You should also stand

near the starting line during the test. Do not walk with the patients.

5. Do not talk to anyone during the walk. Each minute, tell

the patients the following You are doing well. You have minutes to go

6. For the post test, measure vital signs and oxygen

saturation.

7. Record the additional distance covered (the number of

meters in the final partial lap) using the markers on the wall as distance guides.

Calculate the total walking distance, rounding to the nearest meter, and record it on the

worksheet.

2.3 Benefit of physical activity

Physical activity has been classified using the MET intensity as follows:

light(< 3 METs), moderate(3-6 METs), and vigorous (> 6 METs) (Ainsworth, 2000).

Regular exercise has both direct and indirect beneficial effects on the severity for coronary

atherosclerosis and recovery after an operation.

2.3.1 Antiatherogenic effect. Physical activity was associated

with less severe CAD, larger coronary luminal diameters, and reduced progression of

atherosclerosis. These beneficial effects seem to be due to the attenuation of coexisting


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risk factors by exercise. These include the following reduction of adiposity,

particularly in those with excessive upper body and abdominal fat, elevated plasma

triglycerides, with an increase in HDL cholesterol levels and Improvement in insulin

sensitivity and glucose use and reduction in risk of type 2 of diabetes.

2.3.2 Antithrombotic effect. Exercise training favorably

affects this process, in particular the fibrinolytic system. Exercise for six months in

healthy older patients resulted in a significant improvement in hemostatic indices, with

a reduction in plasma fibrinogen levels, an increase in mean tissue plasminogen

activator, an increase in active tissue plasminogen activator, and a reduction of

plasminogen activator inhibitor. Short and long term exercise affects platelet

activation. Platelet activation is important for the pathophysiological mechanisms of

unstable coronary syndrome and acute MI. Short-term exercise can lead to increased

platelet activity, and long-term exercise may abolish or reduce this response.

2.3.3 Endothelial function. The vascular endothelium plays

an important role in the regulation of arterial tone and local platelet aggregation, in

part through the release of endothelium-derived relaxing factors, that prevent coronary

artery disease. Emerging evidence suggests that aerobic exercise improves endothelial

function.

2.3.4 Autonomic Function. The balance between sympathetic

and parasympathetic activity modulates cardiovascular activity. In coronary artery

disease was found over sympathetic nervous system that associated heart disease

(Fletcher, et al., 200; Kantarattanakool & Koonchon Na Ayutthaya, 2005). Exercise

training is associated with a relative enhancement of vagal tone, improved heart rate

recovery after exercise, and reduced morbidity in patients with cardiovascular disease(Rosenwinkel, Bloomfield, Arwady, & Goldsmith, 2001). Long-term endurance

training significantly influences how the autonomic nervous system controls heart

function. Endurance training increases parasympathetic activity and decreases

sympathetic activity in the human heart at rest (Carter, Banister, & Blaber, 2003).

2.3.5 Anti-Ischemic Effects. There were a number of

mechanisms by which endurance exercise training may improve the relative balance

between myocardial oxygen supply and demand and thereby result in an anti-ischemic

effect. Increased metabolic capacity and improved mechanical performance of the


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who engaged in regular exercise had a higher functional status (Treat-Jacobson &

Lindquist, 2004) and a higher functional capacity higher when compared to persons

who did not exercise (Pierson et al., 2003).

2.4 Physical activities and physical fitness of patients who received

coronary artery bypass surgery after discharge.

Patients who received coronary artery bypass surgery after discharge can

start physical activity as follows: (Kantarattanakool & Koonchon Na Ayutthaya,

2005):

Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft

Surgery

Week Activities

First week - Do light work around the house (such as sweeping, or feeding pet)

- Walk leisurely for exercise or pleasure 5 minutes, two time per day

Second

week

- Walk leisurely for exercise or pleasure 10 minutes, two time per day

- Do light work around the house(such as dish washing, preparing

food or cooking)

- Do light gardening (such as watering plants)

- Lift less 3 kilogram

Third week - Walk leisurely for exercise or pleasure 15-20 minutes, two time

per day

- Do light work around the house

- Do light work around the house, laundry by washing machine ,

preparing food or cooking

- Do light gardening


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Table 1 Physical Activity for Patients Received coronary Artery Bypass Graft

Surgery (Continue).

Week Activities

Fourth week - Walk fast or briskly for exercise 20-25 minutes, two time per day

- Do light work around the house

- Do light gardening

Fifth to

sixth week

- shopping, sweep leaves

- Ride a bicycle (general)

- Lift 3-5 kilogram 3-5 kilogram

- Walk fast or briskly for exercise 25-30 minutes, one to two time

per day

Sixth to

twelve week

- gardening, planting, digging sandbox

- Home activities (such as washing windows, cleaning gutters or

scrubbing floors inside home)

- Activities about lawn and garden (such as digging, spading, raking)

- Walk fast or briskly for exercise least 30 minutes, one to two time

per day

Cardiorespiratory fitness was a part of physical fitness evaluated for

patients who received coronary artery bypass surgery. Cardiorespiratory fitness was

measured from the six minute walk test (Jonsdottira, et al., 2006; Solway, Brooks,

Lacesse & Thomas, 2001; Wright, Khan, Gossage & Saltissi, 2001; Kawchareanta,

2003; Intaratool, 2005). Results of the six minute walk test were measured 1-2 days

before discharge.

3. Effects of Behavior Change Program based on Transtheoretical

Model on physical activity and physical fitness

3.1 Transtheoretical Model and applied to behavioral change.

The transtheoretical model developed in 1970 to 1980 emerged from a

comparative analysis of leading theories of psychotherapy and behavioral change.


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Based on the transtheoretical model, individuals in each stage use various unique

combinations of strategies or processes to aid them in changing their behavior. The

strengths of the transtheoretical model were sensitivity to level of readiness,

incremental change over time, and specific interventions for each stage. Moreover,

behavior change was a dynamic processes that occurred either progressively or in a

relapsing pattern. These theories consist of various stages of change, processes of

change, decisional balance, and self-efficacy for overcoming barriers (Prochaska,

Redding & Evers, 2002; Wanitkun, 2005).

3.1.1 Stages of Change: SC

The stage construct was important because it represents a

temporal dimension. The Transtheoretical Model construes change as a process-

involving progress through a series of six stages (Prochaska, Redding & Evers, 2002)

- Precontemplation is the stage in which the person does not

intend to change according to the recommended behavior, usually measured as the

next six months. A person may be in this stage because they were uninformed or under

informed about the consequences of their behavior, they may have tried to change a

number of times and became demoralized about their abilities to change. Both groups

tend to avoid information, talking, or thinking about their high-risk behaviors.

- Contemplation is the stage in which persons intend to

change within the next six months. They start to recognize that it is necessary to

change, and are aware of the pros of changing but also acutely aware of the cons. This

group is not ready for traditional action-oriented programs. They need more support

regarding motivation and self-confidence in order to move to action, and they have not

made a commitment to take action yet.- Preparation is the stage in which persons intend to take

action within a month. They have participated in some exercise, but have not met the

criteria yet. This group has a plan of action such as talking to their physician, joining a

health education class, consulting a counselor, buying a self-help book, or relying on a

self-change approach.

- Action is the stage where the person has obviously modified

his/her behavior within the past six months. He/she has regularly exercised but less

than 6 month; therefore, relapse might happen in this group.


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- Maintenance is the stage in which the person has been

exercising regularly for more than six months. They are less tempted to relapse and

increasingly more confident that they can continue their changes.

- Termination is the stage in which persons have no

temptation to engage in a sedentary lifestyle and have full self-efficacy for engaging in

regular exercise for more than 5 years.They are sure they will not return to their old

unhealthy behavior as a way of coping.

Persons in different stages of change have different behaviors. A

comparison of lifestyle between the precontemplation stage and the action stage

showed that persons in the action stage had significantly higher exercise, vegetable

and fruit consumption compared to the person in the precontemplation stage. While

persons in the action stage had significantly lower smoking and alcohol consumption

when compared to persons in the precontemplation stage (Lam, et al., 2006).

3.1.2 Decisional balance

The decisional balance concept is comprised of a cost-benefit

analysis of a behavior change at that time, derived from Janis and Manns (1977)

model decision making. The original version includes four categories of pros

(instrumental gains for self and for others and approval from self and from others ), and

four categories of cons (instrumental costs to self and to others and disapproval from

self and from others)(Prochaska, Redding & Evers, 2002; Wanitkun, 2005). From the

literature review, it was found that eventually only the Pros and Cons subscales were

used, and many studies confirm two factors of decisional balance (Prochaska, Redding

& Evers, 2002; Wanitkun, 2005).

The study indicated that pros scores were lower during the

precontemplation and contemplation stages compared to the action and maintenance

stages, while cons scores were higher during the precontemplation and contemplation

stages compared to the action and maintenance stages (Kim, 2007).

3.1.3 Self-efficacy

Self-efficacy was derived from Banduras Social Cognitvie

theory (1997). Self-efficacy is the situation-specific confidence that people have that

they can cope with high-risk situations without relapsing to their unhealthy or high-


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risk behaviors. The method for increasing self-efficacy was information, including

enactive mastery experience, vicarious experience, verbal persuasion, and physiological

and affective states. Self-efficacy for overcoming barriers to exercise is the

confidence a person feels about performing physical activities. (Bandura,1997).

Persons with higher self-efficacy maintained physical activity levels, perceived less

effort in doing physical activity, and reported more positive effects from physical

activities ( Prochaska, Redding & Evers, 2002; Wanitkun, 2005).

There were six barriers of physical activity that

included negative effects, which were excuse making, exercising alone, inconvenient

to exercise, resistance from others, and bad weather. The study indicated that self-

efficacy increased during the precontemplation and to the action and maintenance

stages (Wanitkun, 2003; Kim, 2007).

3.1.4 Processes of change

Processes of change were the process that persons use to

progress through the different stages of change, and provide important guides for

intervention programs (Prochaska, Redding & Evers, 2002). The processes were also

categorized into two factors: experiental and behavioral processes.

The experiental processes were as follows:

- Consciousness raising increased awareness about causes,

consequence, and cures for details of behavioral problems. The person attempted to

seek new information and gain understanding and feedback about the problem.

- Self-reevaluation was combined both emotional and cognitive

assessments of values by persons with respect to the unhealthy behavior.- Environmental Reevaluation was consideration and assessment

by persons of how the problem affects the social environments and physics.

- Social Liberation was awareness, and acceptance by

persons of alternative, and problem-free life styles in the society.

- Dramatic relief was initially produced and increased

emotional experiences occurred, often involving intense emotional experiences related

to the problem behavior.


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The behavioral processes were as follows:

- Counter-condition was alternative behaviors for the

unhealthy behavior.

- Helping Relationship was combined with trusting, accepting,

caring, and utilizing the support during attempts to change the unhealthy behavior.

- Reinforcement Management was provided rewards for

controlling or maintaining the healthy behavior.

- Self-liberation was the persons choice, commitment and

recommitment to change the behavioral problems.

-

Stimulus Control was control of causes that trigger the

behavioral problem, including removal of cues for unhealthy habits and addition of

prompts for healthier alternatives.

Using the processes of change differentiated at different stages

of exercise behavior. There were significantly differences in conscious raising, self

revaluation, counter-conditioning, helping relationship, stimulus control,and

reinforcement management across the stage of change(Kim, 2007). The study of

Tseng (2003) showed scores for self-reevaluation, self-liberation, and counter-

conditioning increased from the pre-contemplation stage to the preparation stage and

from the preparation stage to the maintenance stage. However, consciousness raising,

social liberation, reforcement management, and helping relationships should be used

for earlier stages (precontemplation stage to preparation stage). In contrast, dramatic

relief, environment reevaluation and stimulus control should be used for later stages

(preparation stage to stagemaintenance) (Tseng, Jaw, Lin & Ho, 2003).

The Transtheoretical model has been applied successfully in behavior

change for people, including smokers (Narkarat, 1997), children, teens, senior

citizens, work sites, medical patients (Spencer, Malone, Roy & Yost, 2006), obese

women (Dallow & Anderson, 2003) menopausal women (Chitima, 2003) adults,

sedentary adults, women (Adams & White, 2003) diabetes patients (Jackson,

Asimakopoulou & Scammell, 2007; Kim, Hwang & Yoo, 2004)) and cardiac

rehabilitation patients (McKee, Bannon, Kerins & FitzGerald, 2006).


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The study by Spencer, Malone, Roy & Yost (2006) demonstrated

application of the Transtheoretical model in exercise behavioral programs for children,

teens, senior citizens, medical patients, sedentary adults, and obese women, and a

range of intervention programs lasting from about 2 weeks to 2 years. Stage matched

interventions appear to be effective in promoting exercise (Spencer, Malone, Roy &

Yost, 2006). Adams & White (2003) studied 16 intervention programs for

adults.These programs had a time range of about 1 time to 2 years. This study revealed

that stage matched interventions based on the Transtheoretical model are more

effective than non-stage matched interventions (Adams & White, 2003).

The Transtheoretical model has been applied in behavior change for

medical patients. Kim, Hwangb & Yoo (2004) evaluated a stage-matched intervention

(SMI) for promoting exercise in Korean patients with type 2 diabetes, and the range of

intervention programs was 12 weeks. This study found the stage of change in the

intervention groups increased, whereas that of the control group did not change.

Physical activity levels in the intervention group increase (+14.78 METs x h/week),

whereas the control group did not change significantly (+0.39 METs x h/week). In the

intervention group FBS and HbA1C decreased (-17.18 mg/dl, , and -0.88%respective),

whereas in the control group FBS and HbA1C increased (+10.61 mg/dl, and +0.41%

respective) (Kim, Hwangb & Yoo, 2004). Jackson, Asimakopoulou & Scammell

(2007) studied the effects of a program to promote physical activity based on the

Transtheoretical model in 34 patients with type 2 diabetes. The intervention group

received a physical activity leaflet and one by one interview with a dietitian a week

after their routine appointment, and measuredtheir physical activity level at baseline

and after 6 weeks. This study showed that physical activity levels in the interventiongroup were greater than in the control group (Jackson, Asimakopoulou & Scammell,

2007).

Additionally, the transtheoretical model has been applied in behavior

change for coronary artery disease patients. McKee, Bannon, Kerins & FitzGerald

(2006) studied the effects of the Behavior Change Program. The program was used for

patients with coronary artery disease. The program undertook phase III of cardiac

rehabilitation for the patients, and lasted for 14 weeks. This program demonstrated that

there were significant improvements in the stage of change by the end of the program


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and over the next six months when compared to patients before entering the program

(McKee, Bannon, Kerins & FitzGerald, 2006).

Chitima (2003) studied an exercise program for menopausal women in

Chiang-Mai province. The range of the intervention was eight weeks. They compared

caloric expenditure, knowledge, exercising behavior, HDL level, and LDL, VO2 max

between pre and post exercise program. They found that after participants received

the exercise program, they had significantly higher mean scores than prior to

participating in the exercise program. Sittipreechachan (2005) studied the effect of the

Trantheoretical model application on low back pain prevention among workers in

sanitary production factories. The intervention lasted for 12 weeks. In comparing

knowledge about preventing low back pain pre and post intervention in the

intervention group and control groups, they found that after participants received the

intervention they had significantly higher mean scores than before receiving the

intervention. Moreover, they found that following the intervention, the participants in

intervention group had significantly higher knowledge about preventing low back pain

than those in the control group. Narkarat, (1997) studied the effects of a smoking

Behavior Change Program on smoking in middle school students. The length of

intervention was 10 weeks. When comparing attitude, perceived risks and effect of

smoking, and smoking behavior between pre and post smoking Behavior Change

Program, researchers found that those in the intervention group had significantly

higher attitude, perceived risks and effects of smoking, and outsmoking behavior than

before receiving the smoking Behavior Change Program. The students in the

intervention group also had higher significantly higher attitude, perceived risks and

effects of smoking, and rate of outsmoking behavior than those in the control group.However, there are few studies that look at how to promote exercise in persons with

chronic disease by using this framework in Thailand.

3.2 Application of transtheoretical model to Behavior Change

Program for CABG patients

Thestage matched intervention for behavioral change that is based on the

Transtheoretical model is more effective than a non-staged intervention (Adams &

White, 2003). The Transtheoretical model has been applied in behavior change for


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people who have a readiness for change. Theprocesses of change used for behavior

change in the preparation stage were self liberation with choices and commitment to

change. It was believed that one can change and tell other persons (Prochaska,

Redding & Evers, 2002; Tseng, Jaw, Lin & Ho, 2003).Kim, Hwangb & Yoo (2004)

studied the use of processes of change for behavioral change in older persons. This

study showed that participants used self-reevaluation, counter-conditioning,

environmental reevaluation processes during pre-contemplation to preparation, and

preparation to action. While environmental reevaluation and stimulus control

processes were used during preparation to action (Tseng, Jaw, Lin & Ho, 2003),

decisional balance and self efficacy were used to develop the exercising program for

Korean participants with type 2 diabetes. This study revealed that the intervention

group compared to the control group showed significant improvements in stages of

change for exercising behavior, physical activity levels, and reductions in FBS and

HbA1c (Kim, Hwangb & Yoo, 2004).

Marcus, et al.(2007) studied delivery channels, telephone, print and

control, to determine whether one was more effective in promoting physical activities.

At six months, both telephone and print arms significantly increased in minutes of

moderate intense physical activities compared with the control arm, with no

differences between the telephone and print arms. At 12 months, the number of

moderate intensity minutes of physical activity for the print participants was

significantly higher than for both telephone and control participants (Marcus, et al,

2007).

The literature review concerning methods of intervention included

telephone, computer, and print-based materials, including brochures, posters, reports,manuals. Most interventions incorporated more than one method of delivery (Spencer,

Malone, Roy & Yost, 2006). Exercising Behavior Change Programs ranged in length

from 1 session to 2 years (Conn, Minor, Burks, Rantz & Pomeroy, 2003). The

majority of developed programs for behavioral change based on the transtheoretical

model had a range of 2 weeks to 2 years (Spencer, Malone, Roy & Yost, 2006).

Criteria for diagnosis of unstable angina were based on the duration and

intensity of angina as graded according to The Canadian Cardiovascular Society

Grading Scale(Anderson, 2007)


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Class 1 Ordinary physical activity does not cause. Angina occurs with

strenuous, rapid, or prolonged exertion at work or recreation.

Class 2 Slight limitation of ordinary activity. Angina occurs on walking

or climbing stairs rapidly walking uphill; walking or stair climbing after meal; in cold,

in wind, or under emotional stress; or only during the few hours after awakening.

Angina occurs on walking more than 2 blocks on the level and climbing more than 1

flight of ordinary stairs at a normal pace and under normal conditions.

Class 3 Marked limitations of ordinary physical activity. Angina occurs

on walking 1 to 2 blocks on the level and climbing 1 flight of stairs under normal

condition and at a normal pace.

Class 4 Inability to carry on any physical activity without discomfort.

Angina symptoms may be present at rest.

Cardiac patients may be further stratified regarding safety during exercise

using published guidelines (AACVRP, 2003). Risk stratification criteria from the

AACVPR were presented following:

1. Characteristics of patients at high risk for exercise participation.

1.1 Presence of complex ventricular dysrhythmias during

exercise testing or recovery.

1.2 Presence of angina or other significant symptoms.

1.3

High level of silent ischemia (ST depression 2 mm)

during exercise testing or recovery.

1.4 Presence of abnormal hemodynamics with exercise testing

or recovery.

1.5

Ejection fraction < 40%.

1.6 History of cardiac arrest or sudden death.

1.7 Complex dysrhythmias at rest.

1.8

Complicated myocardial infarction or revascularization

procedure.

1.9

Presence of congestive heart failure.

1.10Presence of signs or symptoms of post event/ post

procedure ischemia.

1.11Presence of clinical depression.

2. Characteristics of patients at moderate risk for exercise participation

2.1

Presence of angina or other significant symptoms2.2

Mild to moderate level of silent ischemia during exercise

testing or recovery (ST segment depression < 2 mm from baseline)

2.3 Functional capacity < 5 METs

2.4 Rest ejection fraction 40% to 49%

3. Characteristics of patients at lower risk for exercise participation

3.1 Absence of complex ventricular dysrhythmias during

exercise testing and recovery

3.2 Absence of angina or other significant symptoms

3.3 Presence of normal hemodynamics during exercise testing

and recovery

3.4

Functional capacity 7 METs3.5 Resting ejection fraction 50%


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3.6 Uncomplicated myocardial infarction or revascularization

procedure

3.7

Absence of complicated ventricular dysrhythmias at rest

3.8

Absence of congestive heart failure

3.9

Absence of signs or symptoms of posteven/postprocedure

ischemia

3.10Absence of clinical depression.

3.3 Effects of Behavior Change Program on physical activity and

physical fitness.

Programs for persons in the preparation stage included substitution of

alternative behaviors for the problem behavior (counter-conditioning), consideration

and assessment by the person of how the problem affects the social environments and

physics (environmental reevaluation) (Tseng, Jaw, Lin, & Ho, 2003), the persons

choice, commitment and recommitment to change the behavioral problems (self

liberation) (Prochaska, Redding, & Evers, 2002; Tseng, Jaw, Lin, & Ho, 2003),

control of situations and other causes that trigger the problem behavior(stimulus

control), prov

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