Effectiveness of Buerger Allen Exercises on Lower Extremity Perfusion among patients with Type 2 Diabetes Mellitus in selected hospitals at Guntur District, Andhra Pradesh

 

Chainisha Krosuru, N. Priya Darshini

1M.sc Nursing, Department of Medical and Surgical Nursing, NRI College of Nursing, Guntur.

2Associate Professor, Department of Medical and Surgical Nursing, NRI College of Nursing, Guntur.

*Corresponding Author E-mail: chainisha.k@gmail.com

 

ABSTRACT:

The aim of the study is to assess the Effectiveness of Buerger Allen exercises on lower extremity perfusion among patients with Type 2 diabetes mellitus and to determine the association between the pre-test and post-test levels of lower extremity perfusion with their selected demographic variables. Materials and methods: Quasi experimental with pre-test post-test control group design is to achieve the objective of the study; non-probability purposive sampling technique is used to select the sample. A sample of 60 type 2 diabetic patients: 30 in Experimental & 30 in control group were selected for the study. Data collection were collected by using Modified Inlow’s 60 seconds diabetic foot screen tool and questionnaire including their demographic variables. The collected data were analysed by using Frequency & percentage, Mean & Standard deviation, Chi-square, Paired t-test. Results: The finding of the study revealed that the level of lower extremity perfusion was moderately adequate and inadequate perfusion before Buerger Allen Exercise. It was found that adequate perfusion and moderately adequate perfusion after administration of Buerger Allen Exercise. The paired t-test score of both Experimental group and Control group for Pre-test and Post-test on both legs i.e., Left leg and Right leg respectively as 19.83, 13.15 for Experimental group and -4.23, -8.99 for the Control group. Conclusion:  It is evident that the Buerger Allen Exercise is effective in improving the lower extremity perfusion. The study also suggested that specific information and Buerger Allen Exercise has to be taught to the patients in improving the level of lower extremity perfusion.

 

KEYWORDS: Effectiveness, Buerger Allen exercise, Lower extremity, Perfusion, Patient, Type 2 diabetes mellitus, Hospital.

 


 

INTRODUCTION:

“Beat Diabetes; Action needed to halt rise in Diabetes”.

 

Diabetes mellitus is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria, polydipsia, and polyphagia1.

 

It occurs more commonly among people who are over 30 years of age and obese, although its incidence is rapidly increasing in younger people because of the growing epidemic of obesity in children, adolescents and young adults2. Initially, type 2 diabetes mellitus is treated with diet and exercise and supplemented with oral anti diabetic agents3.

 

PAD can be detected using the ankle-brachial pressure index [ABPI], which is a non-invasive test4,5. Buerger Allen Exercise (BAE) is an active postural exercise that promotes collateral circulation in the lower extremities6. But its’ application to managing patients with diabetes foot is very rare7.

 

Peripheral arterial disease is more frequent in those with diabetes mellitus. Epidemiological evidence confirms the association between diabetes mellitus and the increased prevalence of peripheral arterial disease. Individuals with diabetes mellitus have a two to fourfold increase in the rate of peripheral arterial disease8.

 

People with long standing Diabetes mellitus develop complication of Peripheral Arterial Disease. Peripheral Arterial Disease leads to grave complication like gangrene in the lower limbs9.

 

The most common symptom is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and peripheral arterial disease is more likely to present with an ischemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischemia and limb loss10.

 

Buerger‘s exercises or Buerger-Allen exercises were proposed by Leo Buerger and modified by Arthur Allen. The value of these exercises had frequently been emphasized by Allen, and many medical experts considered them as important adjuvant treatment and postoperative care for circulatory disturbances in the extremities.

 

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. The exercises involve the individual lying flat in bed with the legs elevated at 45 degrees until blanching occurs or for a maximum of 2 minutes.

 

 

The patient then sits on the edge of the bed with the feet hanging down. Further exercises include dorsiflex, plantarflex, then inward and outward movement of the feet, followed by flexing and extending of the toes. This phase is maintained for a minimum of 2 minutes or until rubor has appeared. Finally, the individual lies supine with the feet covered with a warm blanket lasting 5 minutes. The whole cycle is repeated 3 to 6 8 times each session, and the complete sequence is repeated 2 - 4 times a day11.

 

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 them12.

 

PAD is associated with increased risk of lower extremity amputation, and is also a marker for atherothrombosis 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 patients13.

 

This phenomenon is one of the causes and the urgency of being able to do leg exercises to smooth the circulation of the extremities, namely the Berger Allen exercise. It is intended that the long-term adverse effects, in the form of the possibility of limb injury, disability, amputation, and mortality, can be minimized in patients with diabetes mellitus.

 

If preventive measures are not carried out, then the threat of diabetic foot injuries caused by lower extremity peripheral circulation disorders, even to the point of death will increase as well. In addition, the Buerger Allen Exercise is also not yet popular in the community, so it is a very strong reason for this problem, to be used as research material.

 

OBJECTIVES OF THE STUDY:

1.       To assess the levels of lower extremity perfusion among patients with type 2 diabetes mellitus in both experimental and control group.

2.       To find out the effectiveness of Buerger Allen exercise on levels of lower extremity perfusion among patients with type 2 diabetes mellites.

3.       To determine the association between the pre-test and post-test levels of lower extremity perfusion among patients with type 2 diabetes mellitus with their selected demographic variables.

 

HYPOTHESIS:

H1:   The mean post test score of lower extremity perfusion will be significantly lower than the mean pre-test of score lower extremity perfusion in experimental group who had Buerger Allen exercise.

H2:   The mean post test score of lower extremity perfusion among patients with type2 diabetes mellitus in experimental group will be lower than the mean post test score of lower extremity perfusion in control group.

H3:   There will be significant association between the post test score of lower extremity perfusion among patients with type2 diabetes mellitus and selected demographic variables such as age, gender, educational status, occupation, food pattern, type of activity, duration of illness in Experimental group.

 

MATERIALS AND METHODS:

Research approach and design:

Quantitative research approach and Quasi experimental pre-test post-test control group design were used to conduct the study.

 

Setting of the study:

The study was conducted at NRI general hospital, Chinnakakani, Guntur district, Andhra Pradesh.

 

Sample and sampling technique:

The sample size for the present study is 60 type 2 diabetic patients: 30 in Experimental & 30 in control group. Non-probability purposive sampling technique was used to select the sample.

 

Criteria for sample selection:

Inclusion criteria:

The study included the Patients with

·       Age group of 45 – 60 years

·       Ankle Brachial Index score less than 0.9

·       Chronic diabetes mellitus.

·       Both male and female.

 

Description of the tool:

A structured questionnaire was developed and used for collecting the data. It consists of two parts namely section-A and section-B.

 

Section-A:

This section consists of 7 items on demographic characteristics of the participants in relation to their age, gender, educational status, occupation, food pattern, type of activities and duration of illness.

 

Section-B:

This section consists of 9 items on Modified Inlow’s 60 seconds diabetic foot screen tool. The item was developed as to cover the entire aspects of the tool was prepared with look: 10 seconds, 1 question on skin colour, 1 question on cyanosis, touch: 20 seconds 1 question on temperature, 1 question on capillary refill, 1 question on swelling, assess: 30 seconds, 1 question on sensation, 1 question on pedal pulse, 1 question on pain, 1 question on ABI index.

 

Each question carries different scores. Among them the score is given as per the response of patient.

 

Scoring and Interpretation:

·       Score 0 to 3: Adequate Perfusion.

·       Score 4 to 8: Moderately Adequate Perfusion.

·       Score 9 to 13: Inadequate Perfusion.

·       Score 14 to 18: Severely inadequate Perfusion.

 

Content validity:

The prepared tool along with the objectives were submitted to panel of 5 nursing personnel’s and 2 medical personnel’s, the modifications and suggestions of expert were incorporated in the final preparations of the tool.

 

Reliability:

Reliability of the tool was checked by split half technique by using spearman’s brow prophecy formula. It is a good tool to assess the effective of Buerger Allen exercises in type 2 diabetic patients. The spearman’s brown prophecy formula showed the value is (0.9).

 

Pilot study:

A pilot study was conducted which includes 10% of the sample taken, the investigator selected participants from Guntur Government Hospital, Guntur district and administered the tool and data were collected. These subjects are not included in the main study.

 

Ethical consideration:

Ethical clearance was taken from the institutional ethical committee.

 

Collection of data:

Data collection was done for 7 days from 3/10/2023 to 9/10/2023 to complete the study. In the present study, type 2 diabetic patients admitted in NRI general hospital, chinnakakani, Guntur district, Andhra Pradesh was selected by purposive sampling and informed consent was taken, Modified Inlow’s 60 seconds diabetic foot screen tool was used to collect data.

 

Plan for data analysis:

The data obtained were analysed in terms of the objectives of the study using descriptive and interferential statistics. Frequency and percentage, mean, standard deviation, chi square and ‘t’-test was used for data analysis.

 

RESULTS:

Section: I

Characteristics of the study sample

Demographic variables

Experimental group

Control group

(f)

 (%)

(f)

(%)

Age

a.     45-50 years

8

26.6

11

36.6

b.     51-55 years

4

13.3

4

13.3

c.     6-60 years

8

26.6

8

26.6

d.     61-65 years

10

33.3

7

23.3

Gender

a.     Male

16

53.3

20

66.6

b.    Female

14

46.6

10

33.3

Educational Status

a.     Illiterate

8

26.6

4

13.3

b.    Primary

12

40

11

36.6

c.     Secondary

7

23.3

11

36.6

d.    Graduate

3

10

4

13.3

Occupation

a.     Unemployed

1

3.3

3

10

b.    Daily wager

7

23.3

9

30

c.     Factory work

9

30

10

33.3

d.    Home maker

10

33.3

6

20

e.     Retired

3

10

2

6.6

Food Pattern

a.     Vegetarian

5

16.6

8

26.6

b.    Non-vegetarian

25

83.3

22

73.3

Type of Activities

a.     Sedentary worker

11

36.6

7

23.3

b.    Moderate worker

16

53.3

19

63.3

c.     Heavy worker

3

10

4

13.3

Duration of Illness

a.     Recently diagnosed

3

10

5

16.6

b.    1 year

0

0

4

13.3

c.     2-5 years

13

43.3

10

33.3

d.    More than 5 years

14

46.6

11

36.6

 

 

Section: II

Table I: Mean and Standard deviation of Pre-test and Post-test of clinical variables in Experimental Group.

 

Pre-test

Post-test

Left leg

Right leg

Left leg

Right leg

Mean

8.93

7.06

4

3

Standard deviation

1.85

1.96

1.26

1.12

 

 

Table II: Mean and Standard deviation of Pre-test and Post-test of clinical variables in Control Group.

 

Pre-test

Post-test

Left leg

Right leg

Left leg

Right leg

Mean

9

7.16

10.1

9.5

Standard deviation

2

1.26

1.44

1.43

 

 

 

 

 

Table III: Paired t-test of Pre-test and Post-test of clinical variables in Experimental Group.

 

Paired t-test

Experimental group

Pre-test & post-test

Left

Right

19.83

13.15

 

Section: III

Significant association was found between pre-test and post-test score (left leg and right leg) with selected demographic variables and clinical variables i.e., level of lower Extremity perfusion assessed by Modified Inlow’s 60 second Diabetic foot assessment Scale.

 

In experimental group:

·       None were found significant in pre-test.

·       Only gender (X2=4.99) was found significant.

 

In control group:

·       Only duration of illness (X2=11.94) was found significant in pre-test.

·       None were found significant in post-test.

 

Section: IV

Score Interpretation of Modified Inlow’s 60 Seconds Diabetic Foot Screen Tool in Pre-Test and Post-Test in Experimental Group.

 

 

Score Interpretation of Modified Inlow’s 60 Seconds Diabetic Foot Screen Tool in Pre-Test and Post-Test in Control Group

 

DISCUSSION:

In Experimental group (Pre-test and Post-test):

·       Majority of 63.33% in right leg, 30% in left leg in post-test and none in pre-test has adequate perfusion.

·       The majority 80% in Right leg, 40% in left leg in pre-test and majority 70% in left leg, 36.66% in right leg in post-test has Moderately adequate perfusion.

·       Majority of 60% in left leg, 20% in right leg in pre-test and none in post-test are in inadequate perfusion. None belong to severely inadequate perfusion.

·       In control group (Pre-test and Post-test):

·       Majority 80% in right leg, 43.33% in left leg in pre-test and majority of 23.33% in right leg, 13.33% in left leg in post-test has moderately adequate perfusion.

·       Majority of 56.66% in left leg, 20% in right leg in pre-test and majority 86.66% in left leg and 76.66% in right leg in post-test has inadequate perfusion.

·       None belongs to either adequate perfusion or severely inadequate perfusion.

 

CONCLUSION:

1.     The present study assessed the effectiveness of Buerger Allen Exercise on level of lower extremity perfusion among patients. The level of lower extremity perfusion was moderately adequate and inadequate perfusion before Buerger Allen Exercise.

2.     It was found that adequate perfusion and moderately adequate perfusion after administration of Buerger Allen Exercise.

3.     It is evident that the Buerger Allen Exercise is effective in improving the lower extremity perfusion.

4.     The study also suggested that specific information and Buerger Allen Exercise has to be taught to the patients in improving the level of lower extremity perfusion.

 

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Received on 19.07.2024         Revised on 22.08.2024

Accepted on 16.09.2024         Published on 28.11.2024

Available online on December 31, 2024

A and V Pub J. of Nursing and Medical Res. 2024;3(4):136-140.

DOI: 10.52711/jnmr.2024.31

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