A Study to Evaluate the Effectiveness of Buerger Allen Exercise on improving lower Extremity perfusion among patients with Type II Diabetes Mellitus in selected Hospitals at Erode

 

Mrs. Jenyfer Renu Margret W.¹, Mrs. Tamilselvi S.², Dr. (Mrs.) Christy Mekala V.³

¹RN, RM, M.Sc., (N), Critical Care Nursing, Bishop’s College of Nursing, Dharapuram.

²Professor and Head of the Department, Medical Surgical Nursing, Bishop’s College of Nursing, Dharapuram.

³Principal and Head of the Department, Community Health Nursing Bishop’s College of Nursing, Dharapuram.

 

ABSTRACT:

Background of the study: Diabetes is often termed as a ‘lifestyle disease’ and becomes more prevalent as populations accumulate wealth. In general, inactivity and consumption of high calorie food is associated with economic development. Various studies have shown that with economic growth, diet has changed both in rural and urban areas- intake of excess calories mainly from refined carbohydrates. Peripheral artery disease is a common complication and comorbidity of diabetes. Patients with diabetic foot ulcers have coexisting PAD at a proportion of approximately 50% and may suffer from chronic ischemic pain. For these patients, pain reduction can improve significantly their quality of life. The present study was conducted to evaluate the effectiveness of Buerger Allen exercise on improving lower extremity perfusion among patients with type II diabetes mellitus in selected hospitals at Erode. Methodology: The conceptual framework for this study was direction from wiedenbach’s helping art of clinical nursing theory (1964). The research design selected for the study was Quasi Experimental Non- equivalent pre-test and post-test control group research design. Non probability Purposive sampling technique was used to select samples. The tool used for the study is Ankle brachial pressure index, measured by using bio-physiological instruments (Sphygmomanometer and hand-held Doppler). The collected data were analysed by using descriptive and inferential statistics. Results: The mean pre-test scores of level of lower extremity perfusion in experimental group is 0.77(SD + 0.015) and post-test mean score is 0.85(SD + 0.016) and mean difference is 0.08. The paired ‘t’ value was 17.12 which was significant at p<0.05 level. The Independent ‘t’ value was 3.13 which was significant at p <0.05 level of significance. Conclusion: The findings revealed that there no significant association between the mean post-test level of lower extremity perfusion with demographic variables at p<0.05 level of significance in experimental group. The results of the study concluded that practicing Buerger Allen exercises improved the lower extremity perfusion among patients with type II Diabetes mellitus.

 

 

 

INTRODUCTION:

The term diabetes mellitus describes a metabolic disorder with heterogeneous etiologies which is characterised by chronic hyperglycaemia and disturbance of carbohydrates, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. The long- term relatively specific effects of diabetes include development of retinopathy, nephropathy, neuropathy. People with diabetes are also at increased risk of cardiac, peripheral arterial and cerebrovascular disease.¹

 

Peripheral vascular disease is a major macro-vascular complication of diabetes mellitus, because of the unique involvement of distal pattern of vessels and invariable association with neuropathy, peripheral arterial disease has a greater prevalence in diabetics, it presents late, having already developed limb threating ischaemia.² Recent evidence demonstrates benefit of exercise training even among those patients with peripheral vascular disease who do not have claudication. Exercise therapy markedly improves walking ability in peripheral vascular disease patients with intermittent claudication. Difference in exercise intensity as well as adherence to exercise program may account for the observed variability in treatment effect.³ Buerger allen Exercise is one of the interventions to stimulate the development of collateral circulation in the legs. Primary Care Providers should focus on prevention by early recognition and prevention of PAD to those at increased risk. The mechanism of Buerger’s exercises use gravitational changes in positions that are applied to the smooth musculature of vessels and to the vascular. Gravity helps alternately to empty and fill blood columns, which can eventually increase transportation of blood through them.⁴

 

The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045. Three in four people living with diabetes (352 million people) are of working age (i.e., between 20 and 64 years old). This number is expected to increase to 417 million by 2030 and to 486 million by 2045. In 2019, the estimated number of people over 65 years of age with diabetes is 111 million. One in five adults in this age group is estimated to have diabetes. In India 88 million adults (20-79) are living with diabetes in the IDF South-East Asia (SEA) Region in 2019. This figure is estimated to increase to 153 million by 2045. Over half of people with diabetes (57%) in the IDF SEA Region are undiagnosed. Diabetes was responsible for 1.2 million deaths in the IDF SEA Region in 2019. 1 in 4 live births in the IDF SEA Region are affected by hyperglycaemia in pregnancy. USD 8.1 billion was spent on healthcare for people with diabetes in 2019- the second lowest expenditure of all IDF regions.⁵

 

Peripheral arterial disease (PAD) is a known complication of type 2 diabetes mellitus. Studies have shown that prevalence of peripheral arterial disease in diabetic patients is affected by host factors including age, duration of diabetes, level of glycaemic control and presence of peripheral neuropathy. PAD is associated with increased risk of lower extremity amputation, and is also a marker for athero-thrombosis in cardiovascular, cerebrovascular and reno-vascular beds. Patients with PAD therefore have an increased risk of MI, stroke and death. Additionally, PAD causes significant long-term disability in diabetic patients.⁶

 

MATERIAL AND METHODS:

Research Approach:

An evaluative approach was adopted for this study.

 

Research Design:

The research design selected for the study was Quasi Experimental Non- equivalent pre-test and post-test control group research design.

 

Setting of the Study:

The study was conducted in two selected hospitals at Erode.

 

Population:

The target population selected for this study was patients with Type II diabetes mellitus.

 

Sample:

Patients with Type II diabetes mellitus with ankle brachial score < 1

 

Sample Size:

The Sample size for the study consists of 60, 30 were in experimental group and 30 were in control group.

 

Sampling Technique:

Non probability Purposive sampling technique was used to select the sample for experimental and control group.

 

Instrument and Scoring Procedure:

The tool consists of 2 parts.

 

Part I:

It consists of demographic variables such as age, sex, educational status, occupation, family monthly income, religion, duration of illness and duration of treatment, blood sugar levels, weight, and body mass index, co-morbidity.

 

Part II:

Ankle brachial pressure index was measured by using bio-physiological instruments (Sphygmomanometer and hand-held Doppler) to assess the level of lower extremity perfusion. Total score of 1-1.29 it is rated as normal, borderline, minimal, mild, moderate, and severe.

 

Validity and Reliability of The Tool:

A standard tool was used to assess the lower extremity perfusion, Content validity of the tool was established in consultation with the guide and 3 experts in the field of Medical Surgical Nursing and 2 Diabetologist. Reliability score is r = 0.89 was calculated using karl pearson correlation formula.

 

Protecting the Human Rights:

The research proposal was approved by the dissertation committee prior to the conduct the study. The written permission was obtained from administrative officer and chairman of selected hospitals at Erode. Written consent was obtained from each participant before the data collection.

 

Data Collection Procedure:

Data collection was done for a period of 6 weeks. Data pertaining to screening and the demographic variables was collected by structured interview method followed by pre-test assessing ankle brachial index was done followed by demonstration and return demonstration of Buerger Allen exercise was done for experimental group. The intervention lasted for 30 minutes per session and it was done twice daily for 5 days. Post test was conducted on the 6^th day by measuring the ankle brachial index. The data were analysed by using descriptive and inferential statistics.

 

RESULTS AND DISCUSSION:

The major findings were, in experimental group, majority of patients 17 (57%) belonged to the age group of above 55 years, in control group, majority of patients 22(73%) belonged to the age group of above 55 years. In experimental group, majority of patients 15(50%) were males, 15(50%) were females, in control group, majority of patients 17(57%) were males. In experimental group, majority of patients 9(30%) had primary education, in control group, majority of patients 10(33%) had high school education. In experimental group, majority of patients 9(30%) were unemployed, in control group, majority of patients 10(33%) were self- employed. In experimental group, majority of patients 24(80%) were earning Rs.7501 and above, in control group, majority of patients 22(73%) were earning Rs.7501 and above. In experimental group majority of patients 26(87%) were Hindus, in control group, majority of patients 24(80%) were Hindus. In experimental group, majority of patients with type II diabetes mellitus 17(57%) had duration of illness above 9 years, in control group, majority of patients with type II diabetes mellitus 13(43%) had duration of illness 7 - 9 years. In experimental group, majority of patients 16(53%) had blood sugar levels above 200mg/dL, in control group, majority of patients 12(40%) had blood sugar level above 200 mg/dL. In experimental group, majority of patients 17(57%) weighed between 76 - 90kgs, in control group, majority of patients 19(63%) weighed between 61 - 75kgs. In experimental group, majority of patients 14(47%) had BMI ranging from 30.1 - 35, In control group majority of patients 13(43%) had BMI ranging from 30.1 - 35. In experimental group, majority of patients 14(47%) had 1 co-morbidity, in control group, majority of patients 13(43%) had 1 co-morbidity.

 

Table 1 showed that the mean pre-test scores of level of lower extremity perfusion in experimental group is 0.77(SD + 0.015) and post-test mean score is 0.85(SD + 0.016) and mean difference is 0.08. The post-test mean score (0.85) was higher than the pre-test means score (0.77). The paired ‘t’ value was 17.12 which was significant at p<0.05 level, which showed that buerger allen exercises intervention is effective in improving the lower extremity perfusion.

 

Table 2 showed that the mean post-test level of lower extremity perfusion scores in experimental group 0.85(SD +0.0876) was significantly higher than the mean post-test level of lower extremity perfusion scores in control group 0.76 (SD + 0.0871) and mean difference is 0.09. The Independent ‘t’ value was 3.13 which was significant at p <0.05 level of significance. There is no significant association between post -test level of lower extremity perfusion scores and demographic variables, except Family monthly income (ꭓ²=13.2) at p<0.05 level of significance in experimental group.

 

 

 

Table 1: Comparison of mean, standard deviation and paired ‘t’ value of pre-test and post-test level of lower extremity perfusion among patients with type II diabetes mellitus in experimental group.

S. No.	Variable	Mean	Standard Deviation	Mean Difference	Paired ‘t’ Test	Table Value
1	Pre-test	0.77	0.015	0.08	17.12	2.045
2	Post-test	0.85	0.016

n=30, df=29, p<0.05

 

 

 

Table 2: Comparison of mean, standard deviation and independent ‘t’ value of post-test level of lower extremity perfusion among patients with type II diabetes mellitus between experimental and control group.

S. No.	Group	Mean	Standard Deviation	Mean Difference	Independent ‘t’ Test	Table Value
1	Experimental group	0.85	0.0876	0.09	3.13	2.002
2	Control group	0.76	0.0871

n₁=30.n₂=30, df=58, p<0.05

 

CONCLUSION:

The present study concluded that practicing Buerger Allen exercises improved the lower extremity perfusion among patients with type II Diabetes mellitus, which is inexpensive and affordable by the patients with type II Diabetes mellitus.

 

IMPLICATIONS:

Nursing Service:

·       Nurses could be motivated to practice various non- pharmacological measures such as Buerger Allen exercises to improve the lower extremity perfusion among patients with type II Diabetes mellitus

·       Nurse as the change agent, could introduce the various measures for improving the lower extremity perfusion among patients with type II Diabetes mellitus.

 

Nursing Education:

·       The nurse educator could orient the students with alternative therapies in improving the lower extremity perfusion among patients with type II Diabetes mellitus.

·       Demonstration of Buerger Allen exercises to the nursing students.

·       Nurse educators to motivate the nursing students to update their knowledge on Buerger Allen exercises and give health education in the hospitals, and in community settings.

 

Nursing Administration:

·       Nurse administrator could organize continuing education programmes regarding promoting optimal wellbeing of the patients with type II Diabetes mellitus.

·       Nurse administrator has more responsibility as supervisor on creating awareness among patients with type II Diabetes mellitus regarding Buerger Allen exercises by facilitating free distribution of hand-outs, booklets, pamphlets, regularly in outpatient department of hospitals and in primary health centres in urban and rural areas.

·       Observing world diabetes day on November 14.

 

Nursing Research:

·       The study findings will be a baseline for further studies to build upon for improving the body of knowledge in nursing.

·       The study findings could be effectively utilized by the emerging researchers to conduct further studies.

 

RECOMMENDATIONS:

Based on the findings, the following recommendations were stated:

·       Similar study could be replicated in a larger samples thereby findings could be generalized to a large population.

·       Comparative study could also be done between the effectiveness of various non-pharmacological measures on improving lower extremity perfusion among patients with type II Diabetes mellitus.

·       A similar study can be conducted in home care setting.

·       A similar study can be done using true experimental design.

 

LIMITATIONS:

·       Subjects may have given socially accepted answers.

·       The investigator found that long term follow up care was not possible due to restricted time period of the study.

 

REFERENCE:

1.     https://www.who.int/diabetes

2.     Gupta, A., Kumar Tyagi, V., Bansal, N., Virmani, S. K., and Sirohi, T. R. (2017). Comparison of ankle brachial pressure index to arterial doppler USG in the diagnosis of peripheral vascular disease in diabetes mellitus. International Journal of Advances in Medicine, 4(6), 1562. https://doi.org/10.18203/2349-3933.ijam20175135

3.     McDermott, M. M., Ades, P., and Guralnik, J. M. (2009). Treadmill Exercise and Resistance Training in Patients With Peripheral Arterial Disease With and Without Intermittent Claudication: A Randomized Controlled Trial. Journal of Vascular Surgery, 50(1), 234–235. https://doi.org/10.1016/j.jvs.2009.05.046

4.     Chang, C. F., Chang, C. C., Hwang, S. L., and Chen, M. Y. (2015). Effects of Buerger Exercise Combined Health-Promoting Program on Peripheral Neurovasculopathy Among Community Residents at High Risk for Diabetic Foot Ulceration. Worldviews on evidence-based nursing, 12(3), 145–153. https://doi.org/ 10.1111/wvn.12091

5.     https://www.diabetesatlas.org

6.     Shukla, V., Fatima, J., Ali, M., and Garg, A. (2018). A study of prevalence of peripheral arterial disease in type 2 diabetes mellitus patients in a teaching hospital. The Journal of the Association of Physicians of India, 66(5), 57-60.

 

 

Received on 09.12.2020          Modified on 16.01.2021

Accepted on 09.02.2021      ©A&V Publications All right reserved