Abstract
This randomized‐controlled trial aimed to investigate the effect of bed exercises on postoperative anxiety, pain, early ambulation and mobilization. This study was conducted with a randomized‐controlled trial design and in the general surgical clinic of a research and training hospital. A total of 120 patients (60 in the experimental group and 60 in the control group) scheduled for major abdominal surgery took part in the study. The data were collected using a patient information form, the Anxiety Specific to Surgery Questionnaire and the Visual Analog Scale through face‐to‐face interviews. The patients in the experimental group performed 15‐min bed exercises on the day of their operation, as well as on the postoperative first and second days, and the control group underwent only the routinely performed procedures in the clinic. The data were analysed using descriptive statistics, analysis of variance and t‐tests. The sample of our study included major abdominal surgery patients. Ambulation was achieved at a mean time of 4 h earlier in the experimental group. On the postoperative first and second days, the patients in the experimental group had mean mobilization durations that were approximately 2 h longer compared with the patients in the control group. Moreover, the postoperative pain and anxiety levels of the patients in the experimental group were significantly lower than those of the patients in the control group (p < 0.05). We recommend that bed exercises be performed to lower anxiety and pain severity, achieve early ambulation and increase the duration of mobilization among patients following major abdominal surgery.
Keywords: anxiety, bed exercise, early ambulation, major abdominal surgery, mobilization, pain
1. INTRODUCTION
Following major abdominal surgery, long hospital stays, low levels of physical activity and spending a substantial part of the day in bed are frequently encountered significant problems. 1 Prolonged bed rest leads to pulmonary and thromboembolic diseases, insulin resistance and muscle weakness. 2 , 3 The proportion of patients who required invasive treatment and showed a higher risk of morbidity and mortality following major abdominal surgery was reported as 20%. 4 It was determined that 50% of postoperative complications that developed in patients following major upper abdominal surgery were cardiopulmonary complications. 5 , 6 The Enhanced Recovery After Surgery (ERAS) protocol has shown that early ambulation and mobilization play an effective role in reducing the rate of postoperative complications. 2 , 7 , 8 Limited physical activity following major abdominal surgery is associated with high levels of anxiety and pain.
Anxiety, which begins at the moment when the patient is told that surgery is needed, increases with hospitalization and may adversely affect patient compliance, care, quality of life, duration of treatment, expenses, recovery and well‐being, disease progression and the patient's exposure to additional diseases 9 Anxiety is a disturbing feeling of fear and worry of an issue that is considered life‐threatening or perceived as a threat. Anxiety, which is the feeling of restlessness and tension caused by waiting for something bad to happen, can lead to an increase in sympathetic, parasympathetic and endocrine stimuli, and predispose the individual to various physiological and psychological problems. 9 , 10 If postoperative anxiety impairs the healing process, discharge may be delayed.
Pain felt during the postoperative period is an inevitable experience for many patients. More than 75% of patients who undergo surgery in Western societies report moderate, severe or unbearable pain in the postoperative period. 11 , 12 , 13 , 14 In Turkey, more than 90% of people experience pain after major surgery. 15 In a previous study, the pain experienced after major surgery was found to be more severe than the pain in other surgeries. 16 Ineffective pain management causes delays in wound healing, deep vein thrombosis, pulmonary dysfunction, cognitive impairment, anxiety and stress, increased morbidity and mortality, delayed discharge and decreased quality of life. 11 , 14
In addition to pharmaceutical practices, non‐pharmaceutical practices are also performed to alleviate postoperative pain. Non‐pharmaceutical practices include turning in the bed, as well as leg and arm exercises. 17 , 18 Turning in the bed and arm and leg exercises are aimed at protecting the muscle strength and balance of individuals, and they are less tiring than standing exercises. Some bed exercises may be listed as turning in the bed, arm and leg exercises, moving from right to left, raising and lowering the heels and feet, bending the arms, bending the legs, bringing the feet together, moving the legs as in cycling, turning the arms over and reverse arm and leg movements. 19 , 20 Such exercises are expected to make early ambulation and mobilization easier and reduce postoperative pain and anxiety. Accordingly, patients are expected to recover and be discharged faster after abdominal surgery. In immobile major abdominal surgery patients, the severity of anxiety and perceived pain is likely to increase. The aim of this randomized‐controlled trial was to examine the effect of bed exercises on postoperative anxiety, pain, early ambulation and mobilization.
2. MATERIALS AND METHODS
2.1. Study design and sample
This randomized‐controlled trial was conducted in the general surgical clinic of a research and training hospital. Among 143 patients who underwent major abdominal surgery, 120 patients who met the inclusion criteria of this study were included in the sample. While selecting the participants, based on the power analysis that was conducted at a 0.05 margin of error and in a 95% confidence interval, it was decided that 60 patients in each group and 120 patients in total would constitute the experimental and control groups. Information on patient selection is given in Figure 1. The data were collected by the researchers between 1 February 2020 and 31 January 2021.
FIGURE 1.
Sample groups and patient selection diagram.
2.2. Allocation of patients to experimental and control groups
The determination of the patients to be included in the experimental and control groups was made using random assignment software. 21 In this software, a range of numbers from 1 to 120 was used as input, and each patient was randomly allocated in one of the two groups. The inclusion and exclusion criteria are explained below.
2.3. Inclusion and exclusion criteria
Inclusion criteria included (i) being 18 years old or older, (ii) being able to communicate verbally and having no cognitive problems, (iii) being scheduled for major abdominal surgery, (iv) the patients who tolerate at least minimal oral/enteral feeding, (v) having no obstacle to exercise and willingness to participate in the study. The exact opposite of the inclusion criteria is the exclusion criteria.
2.4. Data collection tools
To collect data in this randomized‐controlled trial, a patient information form, the Anxiety Specific to Surgery Questionnaire (ASSQ) and the Visual Analog Scale (VAS) were used.
2.4.1. Patient information form
The patient information form included questions on the sociodemographic characteristics and surgical care‐related information of the patients.
2.4.2. Anxiety specific to surgery questionnaire
ASSQ is a scale for measuring the operation‐related anxiety levels of patients. The 5‐point Likert‐type scale includes 10 items, and Karanci and Dirik tested its validity and reliability in 2003. 22 The total score range of the scale is between 0 and 50 points. Higher scale scores indicate higher levels of anxiety. High anxiety in patients may result in pain, mortality and postoperative complications. The Cronbach's alpha coefficient was calculated to test the reliability levels of the scale. The Cronbach's alpha values of the scale were reported between 0.79 and 0.87. In this study, the Cronbach's alpha value of the scale was found to be 0.87.
2.4.3. Visual analog scale
VAS was used to interpret the intensity of pain in the patients who were included in this study, and a score range of 0–10 was selected. According to VAS for pain, ‘0’ defines the complete absence of pain, and ‘10’ defines the most unbearable pain imaginable. VAS has long been used in pain assessment. It has been reported to have very good sensitivity and reliability. 23
2.5. Procedure
In the general surgery clinic where the study was carried out, the routinely applied postoperative pain management procedure involves a multimodal approach including the administration of paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs) and mild opioids. The patients in both the experimental and control groups received this routine care. The interventions that were included in this study are described below.
2.6. Experimental group
The patients in the experimental group started to consume food after the sixth hour following their surgery. VAS and ASSQ were administered to the patients who were fed, albeit minimally, as pretests. On the day of the operation, on the postoperative first day and on the postoperative second day, the patients in the experimental group performed bed exercises including turning in the bed and extremity exercises for 15 min. On the day of the operation, early ambulation was facilitated depending on the bodily dynamics of the patients, and the patients were mobilized according to their status of tolerating mobilization. The mobilization processes continued on the postoperative first and second days. The time spent in the bed and the time spent out of the bed on the day of the operation and on the postoperative first and second days were calculated and recorded. On each of the three days of measurement, VAS and ASSQ were administered as posttests following each exercise and mobilization process.
2.7. Control group
The control group consisted of major abdominal surgery patients (just as those in the experimental group). VAS and ASSQ were administered to the patients who were fed, albeit minimally, as pretests on the day of the operation, on the postoperative first day and on the postoperative second day. On the day of the operation, early ambulation was facilitated depending on the bodily dynamics of the patients, and the patients were mobilized according to their status of tolerating mobilization. The mobilization processes continued on the postoperative first and second days. The time spent in the bed and the time spent out of the bed on the day of the operation and on the postoperative first and second days were calculated and recorded. On each of the three days of measurement, VAS and ASSQ were administered as posttests following each exercise and mobilization process.
2.8. Postoperative early ambulation and mobilization procedure
In the ERAS rapid recovery protocol, early postoperative ambulation is an important component, and even intensive care patients undergoing major surgery are recommended to be mobilized within the first 24 h, provided that their life signs are stable. 24 Mobilization, which takes the form of several steps around the bed during the 6–8‐h postoperative period, is referred to as ‘early ambulation’. According to the ERAS protocol, the patient is advised to spend 2 h out of bed for the first 24 h on the day of surgery and 6 h a day until they are discharged. 24 , 25 , 26 , 27 , 28 , 29
2.9. Data analysis
The data were analysed using the Statistical Package for the Social Sciences (SPSS) 25.0 IBM (Armonk, NY) program. The Cronbach's alpha coefficient was calculated to test the reliability levels of the scales. The homogeneity tests that were conducted between the experimental and control groups included Chi‐square test and one‐way analysis of variance (ANOVA). Descriptive statistical methods (frequency, mean, standard deviation) were used to analyse the data. ANOVA and t‐tests were performed in independent samples to examine the relationships between variables. The results were evaluated in a 95% confidence interval and on a significance level of p < 0.05.
2.10. Ethical considerations
The Clinical Research Ethics Committee at Inonu University approved this study with the decision numbered 2020/23 dated 21/01/2020 in Malatya. This study was approved by the Malatya Turgut Ozal Medical Center, Department of General Surgery, Institutional Review Board (IRB). Additionally, the study protocol was registered on the Clinical Trials Platform with the registration number NCT05057585. Informed consent was obtained from the patients who agreed to participate in the study after written and verbal explanations were given about the content of the study. The research was carried out in accordance with the principles of the Declaration of Helsinki.
2.11. Results
The characteristics of the patients in the control and experimental groups in this study who underwent major abdominal surgery are shown in Table 1. Accordingly, the mean age of the patients in the control group was 47.13 ± 7.02, 48% of the patients were women, 76.7% were married, 35% were high school graduates and 31.7% had past surgery experience. The mean age of the patients in the experimental group was 45 ± 6.87, 50% of the patients were women, 81.7% were married, 40% were high school graduates and 23.3% had past surgery experience. In both groups, most patients were non‐cancer elective abdominal surgery (biliary tract, oesophagus, stomach) patients. NSAIDs were used mostly for pain medication in both groups. The time of starting minimal enteral feeding after the operation was at the sixth hour or later in both groups.
TABLE 1.
Descriptive features of patients undergoing major abdominal surgical intervention (N = 120).
| Descriptive features | Control group (n = 60) | Experimental group (n = 60) | Test and significance |
|---|---|---|---|
| n (%) | n (%) | x 2 /p | |
| Gender | |||
| Female | 29 (48.3) | 30 (50) | χ 2 = 3077 |
| Male | 31 (51.7) | 30 (50) | p = 0.061 |
| Average age (mean ± SD) | 47.13 ± 7.02 (min 21, max 64) | 45 ± 6.87 (min 24, max 62) |
F = 1.299 p = 0.314 |
| Minimal oral feeding start time (mean ± SD) | 6 h ± 40 min (min 6, max 9) | 6 h ± 20 min (min 6, max 11) |
F = 1.416 p = 0.611 |
| Marital Status | |||
| Single | 14 (23.3) | 11 (18.3) | χ 2 = 4.066 |
| Married | 46 (76.7) | 49 (81.7) | p = 0.076 |
| Education status | |||
| Literate | 12 (20) | 9 (15) | |
| Primary education | 17 (28.3) | 18 (30) | χ 2 = 3.099 |
| High school | 21 (35) | 24 (40) | p = 0.272 |
| Associate degree and above | 10 (16.7) | 9 (15) | |
| Past surgery experience | |||
| Yes | 19 (31.7) | 14 (23.3) | χ 2 = 4.024 |
| No | 41 (68.3) | 46 (76.7) | p = 0.461 |
| Occupation | |||
| Civil servant | 12 (20) | 12 (20) | |
| Worker | 18 (30) | 11 (18.3) | |
| Self‐employed | 9 (15) | 16 (26.7) | χ 2 = 5.312 |
| Retired | 7 (11.7) | 8 (13.3) | p = 0.289 |
| Not working | 14 (23.3) | 13 (21.7) | |
| Type of major abdominal surgery | |||
| Liver resection | 14 (23.3) | 14 (23.3) | |
| Stomach and colorectal cancer | 11 (18.3) | 12 (20) | χ 2 = 0.926 |
| Non‐cancer elective abdominal surgery (biliary tract, oesophagus, stomach) | 22 (36.7) | 21 (35) | p = 0.713 |
| Liver transplantation | 13 (21.7) | 13 (21.7) | |
| Chronic disease that does not interfere with mobilization | |||
| Yes | 29 (48.3) | 32 (53.3) | χ 2 = 3.091 |
| No | 31 (51.7) | 28 (46.7) | p = 0.082 |
| Pain medication a | |||
| Paracetamol | 14 (23.3) | 18 (30) | χ 2 = 0.392 |
| NSAIDs | 54 (90) | 46 (76.7) | p = 0.059 |
| Opioid | 9 (15) | 12 (20) | |
Note: χ 2, Chi‐square test; F, ANOVA, One‐way analysis of variance.*p < 0.05; **p < 0.01.
A patient can select more than one choice.
Table 2 shows the results of the comparisons of the postoperative pain and anxiety levels, early ambulation times and mobilization durations of the patients in the control and experimental groups. Early ambulation could be facilitated in a significantly shorter time after the bed exercises in the experimental group (p < 0.05). The patients in the experimental group had significantly longer durations of mobilization compared with the control group on the day of the operation, on the postoperative first day and on the postoperative second day (p < 0.05). On the day of the operation, the pain and anxiety levels of the experimental and control groups were similar. On the day of the operation, following the measurements of postoperative pain and anxiety as pretests, the patients in the experimental group performed bed exercises. The exercises continued on the postoperative first and second days. There was no intervention in the control group. In the measurements made after the bed exercises performed by the patients in the experimental group, statistically significant decreases were observed in their VAS and ASSQ scores on the day of the operation, on the postoperative first day and on the postoperative second day (p < 0.01).
TABLE 2.
Comparison of surgical pain and anxiety scores, early ambulation and mobilization time between control and experimental groups (N = 120).
| Control group (n = 60) | Experimental group (n = 60) | Intergroup comparison | |||
|---|---|---|---|---|---|
| Measurement time | +SD | +SD | Test and sig. | ||
| Early ambulation time | Operation day | Posttest | 12 h ± 47 min | 8 h ± 13 min |
t = −0.638 p = 0.001** |
| Mobilization time | Operation day | Posttest | 1 h ± 51 min | 2 h ± 28 min |
t = 0.848 p = 0.001** |
| Post‐op day 1 | Posttest | 4 h ± 32 min | 6 h ± 16 min |
t = 2.221 p = 0.001** |
|
| Post‐op day 2 | Posttest | 5 h ± 13 min | 7 h ± 31 min |
t = 2.514 p = 0.013* |
|
| VAS score | Operation day | Pretest | 4.61 ± 0.76 | 4.19 ± 0.46 |
t = 0.256 p = 0.541 |
| Posttest | 3.92 ± 2.23 | 2.14 ± 1.11 |
t = 0.447 p = 0.000** |
||
| Test and Sig. |
F = 0.818 p = 0.432 |
F = 0.896 p = 0.000** |
|||
| Post‐op day 1 | Pretest | 4.67 ± 1.04 | 4.69 ± 1.36 |
t = 0.871 p = 0.972 |
|
| Posttest | 4.43 ± 1.92 | 2.91 ± 1.16 |
t = 0.700 p = 0.000** |
||
| Test and Sig. |
F = 1.123 p = 0.987 |
F = 0.714 p = 0.000** |
|||
| Post‐op day 2 | Pretest | 4.58 ± 3.69 | 4.29 ± 1.78 |
tb = 1.032 p = 0.000** |
|
| Posttest | 4.21 ± 1.84 | 2.5 ± 1.24 |
tb = 1.091 p = 0.000** |
||
| Test and Sig. |
F = 0.707 p = 0.654 |
F = 0.546 p = 0.000** |
|||
| ASSQ score | Operation day | Pretest | 42.61 ± 2.34 | 43.79 ± 2.24 |
t = 0.651 p = 0.664 |
| Posttest | 40.63 ± 2.28 | 26.35 ± 2.42 |
t = 0.418 p = 0.000** |
||
| Test and Sig. |
F = 0.652 p = 0.059 |
F = 0.987 p = 0.000** |
|||
| Post‐op day 1 | Pretest | 39.41 ± 2.22 | 33.69 ± 2.56 |
t = 0.475 p = 0.000** |
|
| Posttest | 37.54 ± 2.43 | 21.91 ± 2.14 |
t = 0.656 p = 0.000** |
||
| Test and Sig. |
F = 1.001 p = 0.243 |
F = 1.012 p = 0.000** |
|||
| Post‐op day 2 | Pretest | 37.58 ± 3.69 | 23.69 ± 2.99 |
t = 0.781 p = 0.000** |
|
| Posttest | 37.34 ± 2.99 | 11.91 ± 3.02 |
t = 0.831 p = 0.000** |
||
| Test and Sig. |
F = 0.654 p = 0.591 |
F = 0.674 p = 0.000** |
|||
Note: F, ANOVA; One‐way analysis of variance, t, Independent samples t test.
p < 0.05;
p < 0.01.
Figure 2 displays the mobilization durations of the patients in the experimental and control groups. The patients in both groups spent 1–2 times out of the bed on the day of the operation, whereas differences were seen on the postoperative first and second days, and the patients in the experimental group spent longer times out of the bed compared with those in the control group.
FIGURE 2.
Comparison of mobilization time between experimental and control groups (N = 120).
Figure 3 presents the VAS scores of the patients in the experimental and control groups. On the day of the operation, the two groups had similar postoperative pain scores. On the postoperative first and second days, the scores of the patients in the experimental group were noticeably lower.
FIGURE 3.
Comparison of surgical pain levels between experimental and control groups (N = 120).
Figure 4 shows the ASSQ scores of the patients in the experimental and control groups. On the day of the operation, the two groups had similar anxiety scores. On the postoperative first and second days, the scores of the patients in the experimental group were noticeably lower. Substantial differences were seen between the anxiety scores of the two groups in favour of the experimental group.
FIGURE 4.
Comparison of anxiety levels between experimental and control groups (N = 120).
3. DISCUSSION
Mobilization has great importance in the transition to recovery and adjustment after surgery. After surgery, patients may experience low motivation, fear of movement and muscle weakness. Encouraging patients to stand up and facilitating their mobilization afterwards is not easy, and evidence on postoperative mobilization is insufficient. 1 In this context, protocols provide good guidelines. However, experimental studies are needed to test the applicability of such protocols. 30 Our study involved the use of early ambulation and mobilization after major abdominal surgery based on the ERAS protocol. Accordingly, we obtained significant evidence that adequate mobilization supports recovery by reducing postoperative pain and anxiety. A previous study investigated the outcomes of an exercise programme in colorectal cancer patients starting in the preoperative period and continuing in the postoperative period. In the study, it was found that the exercise programme did not reduce the rate of postoperative complications, but it increased functional recovery. 31 In previous studies, it has been reported that patients who experience early ambulation after surgery have higher physical, social and psychological well‐being levels. 32 , 33 In another study, it was stated that early ambulation and arm exercises that are included in the ERAS protocol for breast surgery were among interventions to be performed within the first 24 h, and it was safe to implement them in the first 30 min after breast surgery. 34
The participants of our study were patients who underwent major abdominal surgery (liver resection, non‐cancer elective abdominal surgery, biliary tract surgery, oesophageal surgery, gastric surgery, liver transplantation). The development of frequently observed and life‐threatening complications after major abdominal surgery is associated with mortality and prolonged hospitalization. 2 , 3 The dominant view in the literature is that insufficient mobilization triggers these complications (such as atelectasis, anastomotic leakage, wound complications). 5 , 6 , 7 , 8 , 24 In our study, it was possible to facilitate early ambulation in a shorter time by approximately 4 h among the patients in the experimental group who performed bed exercises. In addition to this, the mean duration of mobilization in the experimental group on the day of the operation was approximately 40 min longer than that in the control group. On the postoperative first and second days, the patients in the experimental group had mean durations of mobilization that were approximately 2 h longer than those in the control group. In patients who are ambulated earlier and mobilized longer, cardiopulmonary complications are reduced, the recovery time is shortened, circulation is improved and the risk of deep vein thrombosis decreases. 11 , 14 , 24 There are several factors preventing mobilization in patients who have undergone major abdominal surgery such as catheters, drains, cannulas and lines, and these factors may reduce these patients' willingness to mobilize. The higher levels of willingness to get out of bed among the patients in our study who performed bed exercises may be related to their confidence caused by physical capacity and the use of their muscle strength.
In our study, the postoperative pain levels of the patients in the experimental group on the day of the operation and on the postoperative first and second days after bed exercises were significantly lower than those in the control group. High anxiety and more severe surgical pain in the postoperative period were associated with higher rates of analgesic drug requirement and prolonged hospitalization. 35 It has been reported in the literature that postoperative anxiety is caused by surgical pain, incapacity, loss of independence and fear of death. 36 , 37 Methods such as mindfulness‐based interventions, hypnosis, cognitive‐behavioural interventions, relaxation techniques, coping strategies and narrative medicine are prevalently used in the alleviation of postoperative pain and anxiety. 38 The bed exercise intervention that was used in our study is a practice that increases the independence of the patient, improves their clinical outcomes, makes their coping easier, can be performed by the patient alone and increases their physical strength. Accordingly, it is clear that bed exercises preserve the individuality of the patient and increase their independence by supporting their physical functions.
In this study, it was determined that turning in the bed and arm and leg exercises in the postoperative period reduced anxiety and pain, accelerated the early ambulation and mobilization process and increased the time spent outside the bed. These results were quite significant in terms of revealing that ‘turning in the bed and arm and leg exercises’ can positively affect the general condition of patients who undergo major surgery, support their recovery and reduce hospital stay durations and medical costs.
4. LIMITATIONS
One of the limitations of this study is that the data on the mobility levels of the patients were limited by the measurement tools used in the study. The second limitation is that this study only provides information on the effects of bed exercises in patients undergoing major abdominal surgery, while it does not provide data for patients undergoing other surgical interventions. Since the data of this study were collected in a single centre, the results cannot be generalized to the population. Conditions such as advanced age, the discomfort of the hospital environment and the belief that rest is more beneficial may have increased the reluctance of patients to mobilize.
5. CONCLUSION
Effective postoperative care prevents complications from developing and enables patients to recover as soon as possible and return to their daily lives. Encouraging early ambulation and mobilization plays a key role not only in preventing complications but also in making the patients feel independent faster. As a result, efforts are made to get patients up and moving to the extent that they can tolerate and encourage them to do so. It was determined that bed exercises increased the success of early ambulation and mobilization in supporting recovery in the postoperative period. Mobilization practices in clinics should be based on evidence‐based interventions, and the reliability of the ERAS protocol is increasing in this regard.
FUNDING INFORMATION
All authors declare that they have not received funding from any institution or organization for this research.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. Informed consent was obtained from all individual participants included in the study. The authors did not receive institutional support, non‐commercial grants, commercial support. All authors meet the authorship criteria. Research data were collected by Bulbuloglu and Kapikiran.
Simsek Yaban Z, Bulbuloglu S, Kapikiran G, Gunes H, Kula Sahin S, Saritas S. The effect of bed exercises following major abdominal surgery on early ambulation, mobilization, pain and anxiety: A randomized‐controlled trial. Int Wound J. 2024;21(2):e14406. doi: 10.1111/iwj.14406
DATA AVAILABILITY STATEMENT
The data sets created for this study can be requested from the corresponding author via e‐mail.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data sets created for this study can be requested from the corresponding author via e‐mail.