#68 NURGING RESEARCH MAYUNE 104 vols not First Postoperative Week Activity Patterns and Recovery in Women after Coronary Artery Bypass Surgery NANCY S. REDEKER * DIANA J. MASON + ELIZABETH WYKPISZ * BONNIE GLICA * CHRISTIAN MINER ‘The purpose of this stucly was to examine the relationship between activib-rest patterns and recovery in women during the frst week after coronary artery bypass surgery’ (CABS). Twenty-five women wore wrist actigraphs to measure activity objectively throughout tbe first postoperative week. The Sickness Impact Profile (SIP) and length of pastoperative bospital stay (LOS) were used as measures of recovery. Analysis ofthe activity data indicated that 21 (84%) of the participants bad Statistically significant positive near trends in activity. Spectrum analysis indicated that 18 participants bad periods that could be defined as circadian, 1 bad a shorter period, and 6 had longer periods. Afier controlling for the effect of preoperative functional status, the period and linear trend of activity explained 28% ofthe variance in the SIP score at 1 week and 33% ofthe variance in length of stay, Positive linear trends in activiyy and circadian activity periods were related to better functioning and shorter length of stay. major goal of coronary artery bypass surgery (CABS). However, disturbed activity-rest patterns are common, uring convalescence, and despite the improvements in Functional status experienced by most persons, preopera- tive levels of fuctioning may continue or deteriorate after, surgery (Allen, 1990), Some clinical evidence suggests that women may expe- rience worse outcomes than men, although the reasons have been widely debated, When matched on age and, preoperative clinical indicators, men and women have similar long-term survival rates (Penckofer & Holm, 1990), but women are more likely to experience angina (Douglas, etal, 1981; Jeffery, Vijayanagoar, Bognolo, & Eckstein, 1986; Loop et al, 1983) and congestive heart failure (King, Clark, & Hicks, 1992). They also manifest greater function- al compromise and disability (Kos-Munson, Alexander, Hinthom, Gallagher, & Goetz, 1988; Rankin, 1990; Stanton, Jenkins, Savageau, & Thurer, 1984), are confined to bed a greater number of days One year after the surgery (Zyzanski, Stanton, Jenkins, & Klein, 1981), and do lower levels of “heavy” activity (swimming, jogging, heavy yard work) and greater levels of *mild” and “moderate” activity Douglas et al, 1981). More women than men report no benefit From CABS (Gortner et al, 1990). Chronobiologic research has clemonstrated a positive relationship between health and strong, stable, high-ampli- tude circadian rhythms (Akerstedt, 1979), Disturbed rhych- micity in human physiologic parameters, including Activity-test patterns, has been associated with decrements, in health and well-being (Farr, Campbell-Grossman, & Mack, 1988; Farr, Keene, Samson, & Michael, 1984; Folkard & Monk, 1979; Reinberg et al, 1984; Teicher etal, 1988). [eee in activity and exercise tolerance is a This study is part of a longitudinal project examining women's recovery through the sixth postoperative month. ‘The study was designed to examine the relationship between objectively measured activity-rest patterns and functional recovery in women during the first week of hospitalization after CABS. Review of Literature Surgery results in alterations in the circadian rhythms of body temperature, electrolytes, and catecholamines (Farr et al, 1984), Disturbance in the timing of circadian rhythms is associated with slower return to circadian patterning in human female surgical patients and rats (Farr et al,, 1984; Farr et al,, 1988). Pain medication and anesthesia may also influence the circadian patteming of cortisol and melatonin secretion (Rivest, Schulz, Lustenberger, & Sizonenko, 1989) In cardiac surgical patients, changes in the rhythm parame- ters of body temperature relative to normal body tempera- ture rhythms have been reported within the first 48 hours after surgery (Hoeksel, Felver, & Woods, 1992). During hospitalization, many of the environmental cues that maintain circadian rhythmicity are removed and/or replaced by unfamiliar or noncircadian cues that may dis- rupt rhythmicity. For example, alterations in lighting, food. intake, daily routines, and social cues have been found to influence circadian rhythms of individuals in laboratory and noninstitutional settings (Czeisler et al,, 1986, Minors, Rabbitt, Worthington, & Waterhouse, 1989; Vesely & Giordano, 1991; Wever, 1979). These cues and others, such as noise and! timing of routine procedures, including, baths and mealtimes, have begun to be identified as inlu- ences on activity-rest in the hospital setting (Felver & Pike, 1980; Williamson, 1992).‘The activity-rest pattem, characterized by motion and relative motionlessness across time, is disrupted by hosp talization, illness, and surgery. Fatigue and activity intoler- ance are common, beginning during hospitalization and, extending weeks and months into convalescence after CABS (Carr & Powers, 1986; jillings, 1978; King & Parine!- Jo, 1988; Redeker, 1993; Tacle & Gilliss, 1990). Sleep alter- ations, persisting as long as a year, have also been well documented Johns, Large, Masterton, & Dudley, 1974; Knapp-Spooner & Yarcheski, 1992; Magni et al, 1987), Sleep pattems appear to be highly fragmented during hos- pitalization after CABS (Johns et al., 1974; Orr & Stahl, 1977) and to vary according to the stage of hospitalization and recovery (Knapp-Spooner & Yarcheski, 1992). ‘There has been litle study of the relationship between activity-rest andl outcomes of CABS. In a study of a critical path used in case management of CABS patients, adher- ence to activity guidelines, assessed through chart review, was associated with shorter length of stay (Strong & Sneed, 1991). This finding suggests the importance of activity progression to the outcomes of CABS. Method ‘Sample: The sample consisted of 25 women in two medi- cal centers who had undergone a first CABS without con- current surgical procedures. The mean age of the sample ‘was 63.67 years (SD = 9.86, range 42 to 83 years). Partic- pants received from one to five bypass grafts (iM = 2.78, SD = 89), Preoperative New Yorks Heart Association func tional classification (NYHA) ranged from 1 to 4 (= 238, SD = 1,02) out of a possible range of 1 to 4. A higher NYHA score indicates greater activity limitation clue to car- diac symptoms (Campeau, 1976). Insirumenis: The Motionlogger actigraph (Ambulatory Monitoring, Inc,, Ardsley, NY) was used f0 measure activi- ty continuously. The Motionlogger is a microcomputer that senses motion with a ceramic bimorph beam arranged to ‘generate a signal or charge when subjected to the force of acceleration, In the zero-crossing mode used in this study, the actigraph measures the number of times that displace ‘ment of the sensor beam, which is associated with move- ‘ment, generates voltage changes from positive to negative and vice versa. The resulting unit of measure is activity counts per preprogrammed epoch of time (Tryon, 1991), The ability of the actigraph to record and store activity counts as a time series allows the assessment of activity- rest pattems, including linear trends ancl rhythms. ‘The Motionlogger is highly reliable and valid, Reliability is demonstrated in the laboratory by producing virtually identical responses upon measurement of the swing of a pendulum, Validity is determined by comparing the decay in the amplitude of the pendulum swing with the data recorded by the actigraph. Patterson et al. (1993) demonstrated the validity of the actigraph in distinguishing between sets of sedentary and nonsedentary physical activities (p < 001) ancl a significant positive correlation between activity counts and oxygen consumption and heart rate. The actigeaph's validity as a measure of sleep has been reported in several studies Cole, Kripke, Gruen, Mullaney, & Gillin, 1992; Mullaney, CTIAT AND RECOVERY NOMEN AFTER CORONARY ARTERVBYPASS SURGERY 160 Kripke, & Messin, 1980; Webster, Kripke, Messin, Mul laney, & Wybomey, 1982; Webster, Messin, Mullaney, & Kripke, 1982). Mason ancl Tapp (1992) reported that the Motionlogger demonstrated greater validity as 2 measure Of circadian activity-rest rhythms than the Activation-Deac- tivation Adjective Checklist (Thayer, 1967). “The Motionlogger was programmed to measure move- ‘ment in T-minute epochs. It was worn on the nondomi- nant wrist, unless it interfered with intravenous or arterial lines. In such cases, it was moved to the dominant wrist, Until the nondominant wrist was free. Comparability of measures from these sites has been established (Webster, Messin, et al, 1982). Measures of recovery included postoperative length of hospital stay (LOS) and the Sickness Impact Profile (SIP) Gilson, Bergner, Bobbitt, & Carter, 1979). The SIP mea- sures the impact of sickness in terms of the extent of dys- function in behavior and/or performance of activities of dhily living as perceived by the respondent, The SIP con- tains 136 interviewer-administered items. Subscales include sleep and rest, eating, work, home management, recre- ation and pastimes, ambulation, mobility, body care and, movement, social interaction, alertness behavior, emotional behavior, and communication (Bergner, Bobbitt, Pollard, Martin, & Gilson, 1976), The total SIP score is expressed! as a percentage of the total possible SIP points, with a higher percentage reflecting greater dysfunc- tion, Reliability and validity have been established in a variety of samples. In the present study, intemal consisten- cy of the total SIP scale was .94, consistent with earlier reports (Bergner, Bobbit, Carter, & Gilson, 1981) Procedure: The study’ was approved by the Institution- al Review Board of Rutgers University and both of the ‘medical centers in which data collection occurred. All, antcipants provided! informed consent. The investigators approached participants on the evening prior to surgery, at which time a health history and preoperative SIP score (PRE-SIP) were obtained through interview. ‘The actigraph was applied after acimission to the open heart recovery room/ICU and worn continuously throughout the hospital stay, The SIP was readministered on the seventh postoperative day or the day of discharge (POST-SIP), in the case of two subjects with shorter lengths of stay. Clinical data were obtained through review of medical records. Of the 25 participants who had complete actigraph data and outcome measures, 7 were unavailable t0 be inter- viewed preoperatively, Therefore no PRE-SIP data were obtained for these participants. Data analysis: Activity data were downloaded from the actigraph into a personal computer and imported into the Action computer program (Ambulatory Monitoring Inc, Ardsley, NY). Each raw series was collated across 20- minute intervals, resulting in a time series with 512 data points, Data were analyzed in five steps using the SYSTAT 5.2.1 computer program. First, clescripive statistics for each, raw time series were recorded, and the linear trend over time was estimated by least squares bivariate regression, For each subject, the proportion of the variance in the raw time series explained by the linear trend was K2, The rate$70_ N+ MAYMUNE 1994 VOL.«.NO.9 ‘Table 1. Hierarchical Multiple Regression Analysis POSI'SIP as Dependent Variab Sr Vawwme BO MR Cu Unique Fy ee 1 PRES 385656 RTOS 2 Period «3537762830 Slope 90) of linear change was determined by the regression coeffi- cient B, which was tested for statistical significance. Second, the linear trends were filtered from each subject's, time series, leaving a residual for further examination. Third, each’series was padded with zeros, if necessary, tO standardize series length at N= 512 for all subjects Koopmans, 1974). Then each series was tapered, using a split-bell cosine window, P= 15% (Bloomfield, 1976; Tukey, 1967), Fourth, the resulting output was submitted to Fast-Fourier transformation by the Gentleman and, Sande (1966) algorithm. Finally, the spectral density func- tion was estimated by smoothing the periodogram with a 3-point moving average window. Each spectral density tstimate gives the independent energy of the time series at each of 256 frequencies, ranging from approximately one cycle per week to the highest frequency detectable, .67 cycles per hour. The dominant peak, or fundamental fre- ‘quency, in each participant's activity spectrum was bound- fed by 2 95% confidence interval and tested against the expected value of the spectral density for a white-noise process (Bloomfield, 1976; Gottman, 1981). These analyses yielded three parameters of activity-rest over the course of 7.1 days of data collection: mean activity level, linear trend (indicated by the beta weight or slope of the linear tend), and fundamental frequency. Pearson correlations were used to examine the relation- ships among activity parameters, age, and outcome vari- ables, Separate hierarchical multiple regression analyses, ‘were used to examine the relationships among the activity period, linear trend, and postoperative SIP (POST-SIP),, andl among the activity period, linear trend, and LOS. Results The sample mean activity count was 1455.1 (SD~= 520 per 20-minute epoch, 72.8 counts per minute). Mean activity, levels were highly variable among subjects, as demonstrat- ed by the standard deviation, Twenty-one participants, (646) demonstrated significant positive linear trends over 6 days. One demonstrated a significant negative trend, The remaining three subjects showed no significant linear tends. The proportion of variance in the raw activity counts over time, explained by the linear trend alone, ranged from 0 to 30%, as indexed by 2? (M=.10). Spectrum analysis of the data remaining after removal of the linear trends revealed fundamental frequencies ranging from .012 to .054 cycles per hour. These frequen- cies correspond to activity cycles with periods of 18.52 hours to 83.33 hours. One participant had a period of 18.52 hours (p < .05); 4 had periods of 21.32 hours (p<.05); 14 (56%) had periods of 24.38 hours (10 at p< .05; 4 at p< 1); and 6 demonstrated activity periods rang- ATHY AND RECOVER N HONEN ATER CORONA ARTERY BYPASS UE ing from 28.44 to 83.33 hours (4 at p< .05; 2 at p<.2) For clarity of presentation, activity petiod that corresponds to 1/f, where f= fundamental frequency, is used in the following analyses and discussion. ‘The preoperative SIP (PRE-SIP) mean score was 10.32 (SD = 7.5, range 1.8 to 32.3), and the postoperative (POST-SIP) mean score was 23.42 (SD = 15.15, range 6.2, to 65), Mean LOS was 12.88 days (SD = 10.79, range 5 to 56 cays). Twenty participants (80%) had LOS of 15 days or less. Age and mean activity count were not significantly correlated with linear trend, period of activity, or the out come measures. Separate hierarchical multiple regression analyses were performed to examine the relationship between activity patterns (activity period and linear trend) and recovery, using LOS and POST-SIP as dependent variables. Table 1 presents the regression analysis with POST-SIP as the dependent variable. PRE-SIP, entered first in the equation to control for the effect of preoperative status, explained 32% of the variance in POST-SIP (p= .01). Activity period and linear trend together explained an additional 28% of the variance in POST-SIP. The three independent variables explained a total of 60% of the variance in the dependent variable, Inspection of the beta weights indicated that shorter activity periods and increased linear trends were associated with lower dysfunction. Both the linear trend. and period of activity contributed similarly in explaining the variance in POST-SIP. A second hierarchical regression analysis was done using LOS as the dependent variable (Table 2). PRE-SIP explained 17% of the variance in LOS. Entered at the sec- ond step of the regression equation, activity period and linear trend together explained an additional 33% of the variance. Examination of the beta weights indicates that shorter activity periods and increased linear trends are associated with less dysfunction. The period appears to be 4 stronger predictor of LOS than the linear trend, ‘The raw actigraph data provide a graphic illustration of the results. Figure 1 presents raw actigraph data obtained. from a subject who remained in the intensive care unit for her entire hospital stay due to two “reoperations" for bleeding and subsequent complications, She died after 3 ‘weeks of hospitalization, Spectrum analysis clemonstrated a period of 56.88 hours. There was no apparent diurnal rhythm. In contrast, Figure 2 presents the data from a sub- ject with an uncomplicated first postoperative week and a 24,38-hour period. In Figure 2, an increased linear trend and more organized daily patterns of activity are evident as the week progresses, with longer intervals of low activi- ty at night and greater activity curing the day. ‘Table 2, Hierarchical Multiple Regression Analysis 1105 as Dependent Variable Sa 8 cus, oP ee 1 PRE SIP AL a7 aT 33716 ct 2 Ped 875083837 Slope 304Sete MAMUNE 1996 VOL. 3.10.3 ACHAT A RECOVERY INVEMEN ATER CORONARY ARTERY BYPASS SURGERY _474 ‘Figure 1. Raw Actigraph Data from Subject with Major Complications of CABS = 5 100 50 1105 108 107 1108 1409 AO tt Discussion ‘The results of this exploratory study demonstrate relation- ships between rhythmic and linear pattems of activity and recovery in women during the first postoperative week after CABS. The multiple regression analyses indicate a positive relationship between length of the activity period, length of stay, and dysfunction. Shorter activity periods are associated with less dysfunction.) All but one of the shortest activity periods in this dataset fall within the range of the standard definition of circadian rhythm as a period between 20 and 28 hours (Halberg, Carandente, Cornelissen, & Katinas, 1977; Touitou & Haus, 1992a). ‘Therefore, these findings are consistent with the positive relationship between circadian rhythms and health sug- ‘gested by chronobiologic theory and research (Akerstec, 1979; Farr et al., 1984; Farr et al., 1988; Folkard & Monk, 1979; Reinberg et al., 1984; Teicher et al., 1988; Touitou & Haus, 19922), Future stuclies of activity patterns in larger samples are necessary to validate these findings. Differences in recov- ery between patients demonstrating infradian, ultradian, and circadian rhythms should be examined to verify that Circadian activity shythms are correlated with improved recovery. If the circadian rhythmicity of activity is associat- ed with better recovery, persons with ultradian (periods shorter than 20 to 28 hours) and infradian rhythms Posrorenanve Day Sanne went Day or Sunceny (xoicareD wy parE) length of stay of 33 days due to a postoperative cerebrovascular acci- dent and pulmonary complications. Of the three subjects with 83.33- hour Ginfradian) periods, one experi- enced an intraoperative myocardial infarction with severe, long-term hemodynamic compromise; the sec- ond was morbidly obese and required extended mechanical venti- lation; and the third experienced multiple episodes of atrial fibrilla- tion, pneumonia, and excess fluid retention. These complications con- trast greatly with the clinical recov- ery of the patients with circadian rhythms, most of whom had either no problems or minor ones, such as short-term low- grade fevers and short-term cardiac dysthythmias. Knowledge of baseline (preoperative) activity patterns would add to the current data by providing knowledge about the extent and rate of change in rhythmicity. Preop- erative activity data were not obtained cue to difficulty recruiting subjects prior to admission, However, activity in the immediate preoperative period is not likely to refiect true baseline activty-rest patterns because of the potential influence of symptoms anc emotional disturbance on these patterns due to anticipation of CABS. If feasible, future studies should be designed to begin measuring activity-rest several weeks prior to CABS, Preferences for morning versus evening activity (Farr etal, 19% al, 1988; Gruber, et al., 1989) and environmental factors, such as lighting, noise, and the timing of events in the hospital (Czeisler et al., 1986; Felver & Pike, 1990; Lewy, Sack, Miller, & Hoban, 1987; Williamson, 1992) may also influence activity patterns and should be considered in Future work, ‘The statistically significant relationship between linear trends of activity, function, and length of stay indicates that more rapid increases in activity are associated with better ‘outcomes. This finding supports clinical evidence linking activity progression with improved function that has sel- CETTE) ‘igure 2. Raw Actigraph Data from Subject with Uncomplicated Recovery, (periods longer than 20 to 28 hours) would demonstrate poorer recovery than those with circadian rhythms, Therefore, the relationship between length of the activity period and recovery would be curvilinear, rather than linear. Because only one partici pant in this study demonstrated a tru- ly ultradian rhythm, this type of analysis was impossible. Clinical data illustrate this point. ‘The only participant who had an ultradian activity rhythm with a peri- od of 18.96 hours experienced a very poor outcome, including a aie ‘Posrorengrive Day Stanrine wt Day oF Sunceary (woicxreD wy DT) 220 12i2} 1222 1223 aed tues 128 er faleedom been objectively quantified. It also provides evidence {0 support further refinement of interventions to promote activity progression as measured by the actigraph, ‘The absence of a relationship between mean activity levels and recovery outcomes may be due to normal variability in activity both within and between subjects, ‘Mean activity levels were calculated for each participant across the entire period of data collection and therefore reflect a wide range of activity levels, including high activity associated with ambulation and diminished or absent activity associated with sleep and sedentary behavior. Levels of objectively measured activity are known to vary widely within and between healthy sub- jects (Lieberman, Wurtman, & Teicher, 1989). Therefore, mean levels are likely to reflect both individual variabili- ty and the variability associated with recovery. This large variability may obscure differences in the patterns of activity associated with tecovery alone. Levels of activity measured through actigraphy during, defined behavioral events, such as ambulation or time awake, may be more predictive of recovery than the ‘mean measured over approximately 7 days. Evidence of the ability of the actigraph to distinguish between levels of sedentary and nonsedentary activity in healthy subjects has been provided by Patterson et al. (1993). ‘When a measure of activity intensity is required, the Actillume (Ambulatory Monitoring, Inc., Ardsley, NY) may be used. However, its significantly greater expense and size are potential barriers to its use in an acutely ill population (Mason & Redeker, 1993). POST-SIP and LOS were highly variable, as indicated by their standard deviations. Although this variability may have affected the results, the extent of its impact is unknown, However, the similar relationships found using each of the measures, which reflect different dimensions of recovery, and the consistency of the clinical data strengthen the validity of the findings. Length of stay is determined by clinical and functional status, social and financial support, and institutional factors, such as bed availability. The SIP reflects behavioral manifestations of dysfunction, but its use may be limited in persons who are mechanically ventilated, confused, or otherwise unable to communicate, In the current study, POST-SIP scores for two subjects who were mechanically ventilated were esti- ‘mated, based on available behavioral data ‘The sample for this study was adequate for a time series investigation, which requires a large number of data points for each’ subject, but of low power for multi ple regression analysis, The probability of detecting a large semipartial effect (P =.35) (Cohen, 1988) in the set wise regression procedure at p < .05 is low, given the sample size of 18. However, the statistically significant findings may indicate extremely robust population effects. Complete PRE-SIP data were not available on all partici pants due to rapidly changing surgical schedules, and device malfunctions resulted in loss of actigraph cata on several pantcipants ‘The representation of older adults in this sample is comparable to published reports of CABS (King et al. 1992; Naunheim et al., 1988), but these data do not sup- {ACIVITY AD RECOVERYINIUEN AFTER CORONARY ARTERY BYPAS SURGERY port evidence that older adults have greater levels (Lieberman et al., 1989) and higher frequency activity (Touitou & Haus, 1992b; Weitzman, Moline, Czeisler, & Zimmerman, 1982) than younger persons. However, this Finding may reflect the fact that 18 of the 25 subjects were 60 years of age of older. Potential age-related differences in activity rhythms should be reexamined in furure studies. ‘These findings support the need to examine the activity patterns of larger samples of men and women; endoge- nous and exogenous factors influencing rhythmicity; and the use of nursing interventions, such as light, reduced sleep interruptions, and coordination of meals and treat- ments to promote rhythmicity. Sirategies to promote actvi- ty progression, based on the identification of “optima activity rhythms and trends through actigraphy, should also be examined. Refinement of these interventions may result in shorter lengths of hospital stay and improved function after CABS, outcomes that have become critical in the current era of health care reform, NR Acceped fo publication September 16,193. ‘The thors acknowledge the suppor of Alan Spa, MD, Gregory Scot, MD, in he muses a let Wood fobneon Untesty Host. New Balas Ny Sl Margene Chan, AID, ed he use Beth ie! Mest ‘NY. The tcc! experts of Ton Kasausy of 1 Ardsley, NY, fsalso appeceste. Funding for tht pus of longstelsudy we provided by the Amicon Assocation of eal ive Nurses and the Research Counal, Rulgers, The Site University of New Janey the eat Refi Dison of Nursing at Be sae Medes Canter, nd the Hobart Wood Jonson Medi col Casal Reeuch Genero Wood Jenson Unies Hosp, ‘Nasey S Panu PHD, RNG, fan assistant professor, Cllye of Nursing, Rulgors, The State University of New fray, Newark uJ. Mis, PHD, RN,C, FAAN, ie director of musing education and ‘eszarcy Bath Israel Medical Genter, New Yor NY. Buzanen Wears, 5, CCRN, Is bead nurse ofthe surgical tensive care unt, Robert Wood jobnson Unwenty Hosp, New Brunswick, NI Bassa Gc, MSN, CORN, aerial cae consultant, New Yor, NY. Cuesnw Mo, PuD, isa suscalconsuliany, Bab Krad Metical Cente, New Yor, NY. References Axess, T. (1979) Altered sleepwalk patterns and clexdian shyt, ‘Acta Physiologica Scanelinata, Supplement 469, 1-48 ‘AUN, JK. €1950). 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