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ORIGINAL ARTICLE
a
Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University,
Ile-Ife, Nigeria
b
Cardiac Care Unit, Medical Out-Patient Department, Ife Hospital Unit, Obafemi Awolowo University
Teaching Hospitals Complex, PMB 5538, Ile-Ife, Nigeria
c
Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
d
Department of Physiotherapy, College Medical Sciences, University of Benin, Benin City, Edo State,
Nigeria
e
Department of Physiotherapy, University of Nigeria, Faculty of Health Sciences and Technology,
Enugu Campus, Enugu State, Nigeria
f
Department of Physiotherapy, Faculty of Allied Health Science, Bayero University Kano, Kano State,
Nigeria
Received 2 March 2016; received in revised form 15 August 2016; accepted 2 October 2016
KEYWORDS Abstract Background: Adequate sleep improves physical and mental alertness. However,
chronic heart failure; there is a dearth of empirical data on functional capacity (FC) and sleep quality (SpQ) in
functional capacity; patients with chronic heart failure (CHF).
healthy control; Objective: This study investigated the relationship between FC and SpQ of patients with CHF
sleep quality and apparently healthy controls (HCs).
Methods: This case-control study recruited 50 patients with CHF whose left ventricular ejec-
tion fraction (LVEF) was <40%, attending cardiac clinics of selected government hospitals in
Osun State. Furthermore, 50 age- and sex-matched healthy individuals were recruited as con-
trols. Socio-demographic characteristics and cardiovascular parameters were assessed. The FC
(VO2 max) and SpQ were assessed using the 6-minute walk test (6-MWT) and Pittsburgh Sleep
* Corresponding author. Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.
E-mail addresses: tidebet@yahoo.com, tawotidebe@cartafrica.org (T.O. Awotidebe).
http://dx.doi.org/10.1016/j.hkpj.2016.10.001
1013-7025/Copyright 2016, Hong Kong Physiotherapy Association. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
18 T.O. Awotidebe et al.
Quality Index (PSQI), respectively. Data were analysed using descriptive and inferential statis-
tics. Alpha level was set at p < 0.05.
Results: Patients had a significantly lower FC and poorer SpQ than HCs, 4.6 0.5 versus
11.3 1.6 mL/kg/min (t Z 3.452; p Z 0.001) and 8.74 1.6 versus 3.8 1.3 (t Z
5.371; p Z 0.001), respectively. HCs were about five times more likely to walk longer dis-
tance [odds ratio (OR), 4.8; confidence interval (CI), 2.0e11.1] and had a better heart rate
(OR, 2.8; CI, 1.4e5.3) than patients. SpQ had a significant negative correlation with FC of pa-
tients (r Z 0.362; p Z 0.001) but a significant positive correlation with HCs (r Z 0.481;
p Z 0.041). Furthermore, there were significant correlations between FC and body mass index
in both groups (CHF: r Z 0.247, p Z 0.022; HCs: r Z 0.321, p Z 0.040).
Conclusion: Patients with heart failure demonstrated lower functional capacity and poorer
sleep quality.
Copyright 2016, Hong Kong Physiotherapy Association. Published by Elsevier (Singapore) Pte
Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).
outcome (sleep quality). According to Lewith et al [19] in a Buysse et al [20] and is a self-reported index that assesses
previous study, an effect size of 3 points and an SD of 1.2 on sleep quality during the previous month. It has 19 items,
PSQI were considered to be clinically significant in patients each of which is scored equally between 0 and 3. The index
with sleep disturbance. Thus, the equation above yielded a contains seven subscales evaluating subjective sleep qual-
sample size of N Z 50.2. Therefore, a total of 50 partici- ity, sleep latency, sleep duration, habitual sleep efficiency,
pants (rounding N to the nearest whole number) were to be sleep disturbances, use of sleeping medications, and day-
recruited. However, the sample size was doubled to 100, time dysfunction. The seven component scores are then
comprising 50 patients with CHF and 50 age- and sex- summed to yield a global PSQI score, which has a range of
matched apparently healthy individuals as controls. This 0 to 21. Scores greater than 5 were considered poor, as
was done with the view to improving the validity of the higher scores indicate worse sleep quality [20].
results. The psychometric properties of the instrument were
determined by translating the original PSQI to Yoruba lan-
Inclusion and exclusion criteria guage and back translated to English language by experts.
The translation was done by Yoruba language experts and
Eligibility for inclusion were clinical diagnosis of stable CHF another English expert for back translation in the Depart-
in stage II or III [New York Heart Association (NYHA) func- ment of Linguistics and African Languages Studies of the
tional classification]. The left ventricular ejection fraction Obafemi Awolowo University, Ile-Ife, Nigeria. The original
(LVEF) was less than 40% obtained from the echographic version was administered on five patients with CHF and five
assessment. Participants whose ages were 40 years and age- and sex-matched healthy controls who were not part of
older and attending cardiac care units of selected govern- the main study. After 1 week, the new English version was
ment hospitals in Osun State, namely Ife Hospital Unit, Ile- readministered on the same participants. Responses from
Ife, and Wesley Guild Hospital, Ilesha, of the Obafemi the original and new version were subjected to testeretest
Awolowo University Teaching Hospitals Complex and reliability using Spearman rank correlation coefficient. A
Ladoke Akintola University of Technology Teaching Hospi- testeretest reliability value of r Z 0.72 was obtained. The
tal, Osogbo. In addition, age- and sex-matched apparently questionnaire was self-administered and was collected
healthy controls were recruited among hospital staff and immediately after completion. However, participants who
patients relatives. They were excluded from the study if were not literate in the English language were assisted by a
they had presented with self-reported unstable angina research assistant who translated and read the question
during the previous months, musculoskeletal problems that aloud to the participant before an option was chosen.
significantly limit walking and comorbidities such as type 2
diabetes neuropathy, neurological condition, depressive Assessment of functional capacity
symptoms, and cognitive disorders. Ethical approval for the
study was sought and obtained from the Health Research The 6-MWT was conducted using a standardized procedure
and Ethics Committee of the Institute of Public Health according to the American Thoracic Society [21]. A 30-m
(IPH/OAU/12/428), Obafemi Awolowo University, Ile-Ife, corridor within the cardiac care unit of the hospital was
Osun State, Nigeria. marked out by two cones for the test. Participants were
allowed to rest for a period of 10 minutes in a sitting po-
Procedures sition before the commencement of the exercise test. Pa-
tients were instructed to walk from the starting point to the
Permission to recruit participants into the study was sought end at their own selected pace while attempting to cover as
from the unit heads in charge of cardiac care clinics in the much ground as possible in 6 minutes. They were encour-
selected government hospitals with an explanation of the aged every 30 seconds or so in a standardized manner [22].
purpose of the study. The purpose and procedures of the Rate of perceived exertion was assessed while cardiovas-
study were explained to the participants and written cular parameters were recorded immediately after the 6-
informed consent was obtained. Anthropometric charac- MWT. The total distance walked in 6-minutes was recor-
teristics including weight, height, and body mass index ded to the nearest meter and functional capacity
(BMI) were assessed while cardiovascular parameters (maximum oxygen consumption, VO2 max) was estimated
including heart rate, systolic and diastolic blood pressure using a predictive equation [23].
were measured in sitting position using an electronic
sphygmomanometer (Omron Intelli Sense M6 Comfort, Statistical analysis
Japan). The Pittsburgh Sleep Quality Index (PSQI) was
administered to assess sleep quality and functional capac- Descriptive statistics of frequency, mean, and standard de-
ity was assessed using the 6-minute walk test (6MWT). viation were used to summarize data. Independent t-test
was used to determine the difference in age, physical
Assessment of sleep quality characteristics, and cardiovascular parameters between
patients and healthy controls. Furthermore, as appropriate,
Sleep quality of participant was assessed using the PSQI. the independent t-test or ManneWhitney U-test were used
The questionnaire consisted of two sections: the first sec- to compare functional capacity and sleep quality between
tion sought information on participants bio-data including male and female patients and healthy controls. Analysis of
age, sex, and occupation, while the second section sought covariance (ANCOVA) was conducted to compare the SpQ of
information on sleep quality. The PSQI was developed by patients with CHF and healthy controls using systolic blood
20 T.O. Awotidebe et al.
Table 2 Comparison of physical characteristics, pre- and Table 4 Comparison of functional capacity and sleep
post-6-minute walk test cardiovascular parameters of pa- quality scores of healthy control and patients with CHF.
tient and control groups. Variable Patient Control p value
Variables Patient Control t-cal p value Mean SD Mean SD
(n Z 50) (n Z 50)
Mean SD Mean SD 6-MWD (m) 242.4 30.1 467.1 65.6 0.001*
Est.VO2 max 4.62 0.50 11.3 1.6 0.001*
Age (years) 57.8 8.9 54.9 7.9 1.94 0.062 (mL/kg/min)
Weight (kg) 70.4 11.7 66.2 11.1 1.57 0.121 PSQI total 8.7 1.6 3.8 1.3 0.001*
Height (m) 1.51 0.2 1.53 0.1 1.66 0.100 Subj. SpQ 1.4 0.6 0.9 0.2 0.001*
BMI (kg/m2) 30.4 7.0 28.6 6.3 2.10 0.042* Sleep latency 1.7 0.7 0.8 0.4 0.001*
WHR 0.8 0.4 0.8 0.1 1.63 0.113 Sleep duration 1.2 1.0 0.9 0.5 0.001*
Pre-6MWT Hab. Sp eff. 0.8 0.4 0.4 0.2 0.001*
SBP (mmHg) 131.9 22.1 121.9 14.2 2.897 0.001* Sp disturb. 1.8 0.7 1.2 0.5 0.001*
DBP (mmHg) 82.2 13.3 78.0 13.5 2.091 0.042* Use Sp med. 0.5 0.2 0.4 0.1 0.058
HR (bpm) 80.0 14.4 72.2 11.2 2.880 0.001* Daytime dysf. 0.8 0.3 0.3 0.1 0.001*
Post-6MWT
SBP (mmHg) 138.4 21.1 128.9 12.5 2.263 0.001* *p < 0.05.
6-MWD Z 6-minute walk distance; Daytime dysf. Z daytime
DBP (mmHg) 86.1 13.1 79.1 14.5 0.981 0.001*
dysfunction; Est.VO2 max Z estimated maximum oxygen con-
HR (bpm) 77.9 13.9 75.9 11.3 2.465 0.024*
sumption; Hab. Sp eff. Z habitual sleep efficiency; PSQI Z
*p < 0.05. Pittsburgh Sleep Quality Index; SD Z standard deviation; Subj.
6MWT Z 6-minute walk test; BMI Z body mass index; SpQ Z subjective sleep quality; Use Sp med. Z use of sleep
DBP Z diastolic blood pressure; HC Z hip circumference; medication.
HR Z heart rate; SBP Z systolic blood pressure; SD Z standard
deviation; WC Z waist circumference; WHR Z waist-to-hip
ratio.
Table 5 Comparison of sleep quality scores of male and
female patients with CHF.
Table 3 Results of ANCOVA comparing sleep quality be- Variable Male Female p value
tween patients with CHF and apparently healthy controls. Mean SD Mean SD
Source Partial SS df MS F p value PSQI total 6.6 3.6 7.4 3.3 0.026*
Model 35556.06 4 8889.02 1790.69 0.001* Subj. SpQ 1.3 0.6 1.4 0.8 0.149
SBP 327.07 2 163.53 32.94 0.001* Sleep latency 1.4 0.7 1.7 0.6 0.026*
DBP 42.97 1 42.97 8.66 0.003* Sleep duration 1.2 1.0 1.1 0.4 0.371
BMI 3600.92 1 3600.92 725.41 0.001* Hab. Sp eff. 0.6 0.4 0.7 0.4 0.138
Residual 570.86 115 4.96 Sleep disturbance 1.6 0.7 1.8 0.6 0.001*
Total 36126.93 119 303 Use Sp med. 0.2 0.5 0.7 0.4 0.001*
Partial h2 0.4148 Daytime dysf. 0.8 0.6 1.2 0.1 0.032*
Adjusted R2 0.9836 *p < 0.05.
*p < 0.05. Daytime dysf. Z daytime dysfunction; Hab. Sp eff. Z habitual
BMI Z body mass index; DBP Z diastolic blood pressure; sleep efficiency; PSQI Z Pittsburgh Sleep Quality Index;
df Z degrees of freedom; MS Z mean of squares; SD Z standard deviation; Subj. SpQ Z subjective sleep quality;
SBP Z systolic blood pressure; SS Z sum of squares. Use Sp med. Z use of sleep medication.
progression, and procedures for the assessment of func- Furthermore, sleep disorders have been described as a
tional capacity. Also, several factors, including but not persistent, major concern among patients with CHF
limited to mood of the patients, differences in body weight, [11,27]. This implies that sleep disturbances and frequent
and medications prescribed, might account for the varia- waking is a precursor for poor SpQ and a deteriorating
tions in functional capacity assessment. Nonetheless, the health situation in patients with CHF. In addition, Khayat
finding of lower functional capacity implies that patients et al [13] reported that overall poor SpQ and excessive
with CHF are at higher risk of morbidity and mortality daytime sleepiness are strong predictors of mortality in
compared to healthy individuals. Functional capacity is patients with acute heart failure. Sleep is a naturally
known to be a strong predictor of survival and a determi- recurring state and involves changes in brain wave activ-
nant of reduced hospitalization in patients with cardiac ity, breathing, heart rate, body temperature, and other
challenges. physiological functions [28]. It implies that alteration in
Our findings show that the mean PSQI score for SpQ of SpQ increases the risk of poor prognosis and premature
patients with CHF is higher than that of healthy controls. death [14,27].
This is in agreement with findings of previous studies that Findings from our study also show that female patients
patients with CHF experienced poorer SpQ [13,27]. with CHF reported poorer SpQ than their male counterparts.
22 T.O. Awotidebe et al.
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