Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : YC11 - YC14 Full Version

Efficacy of Buteyko Breathing Technique on Anxiety, Depression and Self Efficacy in Coronary Artery Bypass Graft Patients: A Randomised Clinical Trial


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60797.17388
Moli Jain, Vishnu Vardhan, Vaishnavi Yadav, Pallavi Harjpal

1. Postgraduate Student, Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 2. Professor and Head, Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 3. Assistant Professor, Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India. 4. Postgraduate Student, Department of Neuro Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.

Correspondence Address :
Vishnu Vardhan,
Professor and Head, Department of Cardiorespiratory Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India.
E-mail: vishnudiwakarpt@gmail.com

Abstract

Introduction: Psychiatric issues, particularly depression and anxiety, have been observed in the proportions of patients undergoing cardiovascular surgery. Such findings provide a window of opportunity for integrating intervention, targeting psychological components into post-Coronary Artery Bypass Graft (CABG) patient management to provide effective care. The Buteyko Breathing Technique (BBT), which is named after its inventor Konstantin Pavlovich Buteyko, is one of the numerous breathing techniques that aims to regulate breathing. By alternating between periods of controlled breathing reduction and breath holding.

Aim: To explore the effect of BBT as a psychological rehabilitation technique on anxiety, depression and self-efficacy in post CABG subjects having anxiety and depression.

Materials and Methods: This randomised clinical trial was performed at Cardiovascular and Thoracic Surgery Unit, Acharya Vinobha Bhave Rural Hospital, Sawangi, Wardha, Maharashtra, India, from June 2021 to May 2022. Total 44 post CABG patients who all screened positive for anxiety and depression by General Anxiety Disorder-7 (GAD-7) questionnaire and Patient Health Questionnaire-9 (PHQ-9) were enrolled. They were randomly assigned using computed generated block randomisation. They were allocated using the Sequentially Numbered Opaque Sealed Envelope (SNOSE) method to group A Conventional group (n=22) and group B Experimental group (n=22). Both groups competed the in-hospital phase 1 cardiac rehabilitation as per American Association of Cardiovascular and Pulmonary Rehab (AACVPR) guidelines, whereas group B received additional BBT for psychosocial rehabilitation for two weeks post surgery. The evaluations were performed using the GAD-7 questionnaire, PHQ-9, General Self-Efficiency Scale (GSS), Breath Holding Test (BHT), and Borg Rate of Perceived Exertion Scale (RPE), at baseline on Post Operative Day (POD)1 and at their last rehabilitation session. Patients in both groups were given self management and education handouts at the time of discharge. Statistical Package for Social Sciences (SPSS) version 27.0 was used for statistical analysis.

Results: The mean age of patients in group A was 59.72±7.84 years and in group B 60.81±7.42 years, respectively. The age, gender, height, weight and Body Mass Index (BMI) of the patients were similar between the groups. On intra group comparison, there was statistically significant difference observed for GAD-7, PHQ-9, GSS, BHT, and RPE in group A and group B following the intervention, but the change was more pronounced in group B. The results for the inter group comparison showed a significant difference in group B on anxiety, depression, self-efficacy, BHT, and RPE as compared to the group A, i.e. group B showed a larger improvement in outcome measure scores than group A.

Conclusion: The present study demonstrated that on intra group weeks of BBT along with phase 1 cardiac rehabilitation in post CABG patients brings favourable changes in levels of anxiety, depression and self-efficacy.

Keywords

Breathing exercise, Cardiac rehabilitation, Cardiac surgery, Psychological consequences

Surprisingly, there is increased number of CABG patients in India with annual count of 1,40,000 CABG procedures (1),(2). The necessity of psychological evaluation in those undergoing surgery has received less attention, may be due to crowded outpatient setting, they are reluctant to engage and not willing to share their private worries (3),(4). After CABG surgery, up to 60% of patients had depression symptoms, with about 23% reporting serious depression, which is frequently related to poor quality of life and venous graft degradation (5). Moreover, anxiety symptoms were reported in around 40% of patients before heart surgery (6). As recommended by American Heart Association (AHA), phase one Cardiac Rehabilitation (CR) aims to provide the best physical and psychological well-being post discharge with early independence and productive life (7). The existing literature that has found CR to be of limited benefit to post CABG patients for their emotional distress and psychological needs, explains why the psychological demands of post CABG patients are not well met by current approaches and indicates that new approaches anchored with psychological rehabilitation would need to be acceptable to post CABG patients (8).

Based on the devoted work of Russian scientist Konstantin Buteyko which states that proper breathing volume is essential for optimal health (9). The trajectory may be elucidated that breathing techniques are profoundly intermingled to decrease the psychological response (10). One such key techniques proven to aid in the management of stress and anxiety disorders is BBT (11). Therefore, reversing homeostatic alterations with BBT might improve the whole body changes that occur in anxiety and depression in post CABG patients (12).

It is a well-known fact that people who practice BBT have more ability to hold their breath comfortably, a measure known as the Control Pause (CP) (13). A longer CP is linked to fewer symptoms, according to Buteyko practitioners (13). For asthmatics and cardiac patients, the CP is inversely proportional to disease severity. A CP result that lasts fewer than 20 seconds implies a depleted cardiac or pulmonary reserve (14).

One of the approaches used to promote healthy behaviour and quality of life in CAD patients is the self-efficacy in CR program (15). Low self-efficacy is associated with poor health and depression in patients with significant risk of rehospitalisation (16). These findings suggest that targeting self-efficacy provides a potential solution for accessing cardiac function post CABG (17).

The utilisation of the BBT is based on a study that suggests breathing retraining has a positive effect on anxiety. Also, anxiety and depression often co-occur, which was used relatively in this study. Therefore, the aim of the present study was to evaluate the effect of BBT on existing phase 1 CR in post CABG patients. The primary outcome measures were GAD-7, PHQ-9 and GSS. The secondary outcome measures were BHT and Borg RPE scale.

Material and Methods

This randomised clinical trial was performed at Cardiovascular and Thoracic Surgery (CVTS) Unit, Acharya Vinobha Bhave Rural Hospital (AVBRH), Sawangi, Wardha, Maharashtra, India, from June 2021 to May 2022. Approved from the Committee for Institutional Ethics of Datta Meghe Institute of Medical Sciences (DMIMS, DU), Wardha, with trial registration done at Clinical Trial Registration of India CTRI/2021/05/033632.

Sample size calculation: The number of subjects were calculated using Software G. Power 3.1.9.4 with 44 subjects (22 each in both conventional and experimental group) including a 12% drop out were shown to be necessary based on the effect size of 0.93, an alpha level of 0.05 and power (1-β) of 0.91 (18). Four participants were recruited additionally to maintain the sample size to overcome the incidence of dropout or problems with data collection.

Inclusion criteria: Total 44 post CABG patients of ages between 40-75 years with BMI <30 Kg/m2, who screened positive for anxiety by GAD-7 score >8 and depression by PHQ-9 questionnaire score >10 were included in the study (19),(20).

Exclusion criteria: The CABG patients having any preoperative haemodynamic complications e.g. recent myocardial infarction (last two week), lung congestion, etc., postoperative mechanical ventilation for more than 24 hours, history of heart failure and ejection fraction less than 20% and chronic smoker were excluded.

Patients were explained the purpose, methodology and possible risks of the study as per Declaration of Helsinki, 1964 after obtaining signed informed consent (21). Randomisation was done using computer generated random number table and allocation using SNOSE method to an experimental or conventional group. It was done by primary researcher not involved in data collection, who was a postgraduate resident in physiotherapy under the supervision of a professor from the Department of Cardiovascular and Respiratory Physiotherapy. Outcome measures were assessed on postoperative day one and at the time of their last rehabilitation session after two weeks by a postgraduate resident in physiotherapy of the same experience, who was aware of the study and blinded about the intervention.

Study Procedure

A total of 44 patients in both groups underwent postoperative assessment on POD 1 and BHT and were asked to complete the Borg RPE scale, GAD-7 questionnaire, PHQ-9 and GSS as truthfully as they can, emphasising that there is no right or wrong response only the response they believe most accurately describes themselves.

Each patient completed two weeks of rehabilitation after enrolment in the study with no dropouts. The evaluations were performed at baseline on POD 1 and at their last rehabilitation session after two weeks. During discharge patients were given self-management and education hand-outs, which included relaxation techniques to decrease dyspnoea, tobacco cessation, nutritional recommendations, prevention of triggers and awareness about the rehabilitation program’s benefits.

Group A: Conventional group: Once the patients were weaned off the mechanical ventilator and were haemodynamically stable, two weeks of the phase I CR program twice daily with each session of 25-40 minutes were provided in accordance with the AACVPR guidelines (7).

Group B: Experimental group: The experimental group received 20 minutes of BBT twice daily for two weeks along with phase 1 CR (Table/Fig 1).

Step 1: The “control pause”: Patients were instructed to gently inhale for two seconds, exhale for three seconds and then pinch their noses with their fingers to hold the breath. The therapist next counts how many seconds the patient can hold their breath calmly before feeling the need to breathe in again. Then instructed to open the nose and take a breath in.

Step 2: Shallow breathing: Patients were asked to place their index finger below the nostrils in the horizontal position to monitor the amount of air flowing in and out during each breath. Then, they were asked to breathe in a flicker of air with enough to fill the nostrils. Followed by, breathing out gently onto their finger. They were asked to concentrate on calming their breath by pretending their finger was a feather that should not move while breathing out. This reduces the amount of warm air they feel on their finger. Once the amount of warm air reduces patient will begin to need air.

Step 3: Repeat steps 1 and 2 three to four times (9).

Statistical Analysis

Statistical analysis was done by using descriptive and inferential statistics using student’s paired and unpaired t-tests and the software used in the analysis was SPSS 27.0 version and Graph Pad Prism 7.0 version and p<0.05 is considered a level of significance. The Chi-square test of independence was done to assess the association between the number of individuals utilised in the study and their age, gender, height, weight and BMI.

Results

All 44 patients enrolled in the study completed two weeks of rehabilitation. The participant’s baseline characteristics are presented in (Table/Fig 2). There were no significant differences between the experimental and the control group for demographic and clinical variables at baseline.

The (Table/Fig 3) shows the statistical evidence of all the outcome measures. Post rehabilitation the results observed for GAD-7 (25.62, p=0.0001), PHQ-9 (11.79, p=0.0001), GSS (23, p=0.0001), BHT (23.55, p=0.0001) and RPE (18.99, p=0.0001) in group A and group B for GAD-7 (27.37, p=0.0001), PHQ-9 (32.34,p=0.0001), GSS (26.94, p=0.0001), BHT (22.70, p=0.0001, and RPE (25.11, p=0.0001) following the intervention. This shows mean difference was more pronounced in the group B compared with the group A.

The results for the inter-group comparison showed a significant difference in group B on anxiety (8.80, p<0.0001), depression (6.57, p<0.0001), self-efficacy (7.11, p<0.0001), BHT (8.91, p<0.0001), and RPE (2.39, <0.021) as compared to the group A, i.e. group B showed a larger improvement in outcome measure scores than group A.

Discussion

The present study findings suggests that BBT as an effective treatment adjunct in improving anxiety, depression and self-efficacy in post CABG patients. While there are many instruments available to measure depression and anxiety, PHQ-9, as recommended extensively by AHA for screening and diagnosing depression and the GAD-7 questionnaire for anxiety respectively in CAD patients were used in the study (22),(23).

In line with this study, a growing number of empirical literature reported that emotional enhancement and reducing anxiety and depression, practicing breathing exercise is the most cost-effective non pharmacological management (24),(25). The BBT exercises are unique in minimising stress response by training muscles, reflexes, and mind, which suppress sympathetic nervous system activity (9). Similarly, Brown RP et al., studied links between respiration and emotions and their effect on autonomic nervous system which suggested practicing breathing could be used as a complementary intervention for anxiety disorder (10). Ma X et al., 2017 reported that diaphragmatic breathing influences physical and mental health (26).

Heuristically, it is widely accepted that low self-efficacy interferes with one’s perception of their ability to manage fear or circumstances that cause worry are linked to anxiety and depression and self-efficacy is related to psychological well-being in heart patients (27). The GSS has become one of the most widely used instruments for assessing self-efficacy in CR (28). Postrehabilitation the findings in the present study show significant improvement in the experimental group as compared to the conventional group in GSS levels (22.81±3.97 vs 15.18±3.09). Similarly, Millen JA and Bray SR, 2009 reported that the self-efficacy of the intervention group who are adherent to CR.

Broadly, study data support previous researchers who have reported a positive effect of BBT on anxiety and depression in different populations. In the study done on university footballers by Chaudhary DS et al., (2021) a decrease in anxiety was observed by 12.4% and an increase in control pause by 134.2% in group A when compared to group B who undergone only usual training (11). Naik P et al., (2019) reported positive effects of BBT on depression in the geriatric population suggesting that this specific method should be further explored as a rehabilitation method (34).

The output of this research was essential because, first it addressed a major issue in the field of health psychology, for which health professionals are still seeking ways to enhance outcome it in chronic patients. Secondly, rather than being a trivial addition to CR, an intervention as a skill that patients can learn and use to “exercise the mind,” would have “face validity”. The study’s findings lend credence to the notion that the post CABG inpatient period offers a crucial time and opportunity for preventive psychological intervention and that psychological elements at this time can be crucial to the recovery process. It indicates factors that can make psychological assistance more agreeable to worried CABG patients.

Limitation(s)

In this present study, there was no preoperative screening and management has been provided due to COVID-19 protocol, testing and isolation before the surgery. Secondly, there was no follow-up taken as the majority of the patients were from outside, so the post discharge intervention was aided through discharge training and a home exercise program booklet which may not have matched up with the direct professional intervention. The anxiety and depression were screened using clinical assessment tools (GAD-7 and PHQ-9 questionnaire) rather than diagnosing depression through clinical interviews. The study was confined to two weeks and follow-up was difficult due to which it cannot be ascertained whether the gains may be generalised to when the patient returns to fully functional and working life. To ascertain the treatment’s long-term effects, a large scale study comprising preoperative screening, management,and follow-up can be done in the future. More studies are required to determine effect of BBT on CABG patients during the II and III phases of CR and its effect on other heart surgeries.

Conclusion

The present study demonstrated that two weeks of BBT along with phase 1 CR in post CABG patients had favourable changes in their levels of anxiety, depression and self-efficacy, it provides substantial evidence for the management of post CABG patients from a psychological perspective. Therefore, as observed in this study Buteyko breathing technique along with the phase 1 CR program may be recommended as a part of early Postoperative management in patients following CABG surgery. Integrating early prevention for psychological repercussions in the post revascularisation intervention strategy can help to reduce chances of prolong recovery, rehospitalisation, rapid return to work costeffectively and further alleviates symptoms. This will create a window of opportunity for early screening and therapy for psychological repercussions in CR, allowing for holistic and effective management of post CABG patients.

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DOI and Others

DOI: 10.7860/JCDR/2023/60797.17388

Date of Submission: Oct 18, 2022
Date of Peer Review: Nov 18, 2022
Date of Acceptance: Nov 24, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 20, 2022
• Manual Googling: Nov 15, 2022
• iThenticate Software: Nov 23, 2022 (9%)

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