INTRODUCTION:

The term “diabetes” was coined by Araetus of Cappodocia (81-133AD). Later, the word mellitus (honey sweet) was added by Thomas Willis (Britain) in 1675 after rediscovering the sweetness of urine and blood of patients (first noticed by the ancient Indians).

Type 2 Diabetes mellitus is the most common chronic non-communicable disease affecting both developed and developing countries.¹ According to the International Diabetes Federation, diabetes mellitus (DM) is estimated to affect around 415 million adults worldwide, roughly 8.8% of the adult population, with the figure projected to rise to over 600 million by 2040. Nearly 80% of the affected people live in middle and low income countries. Type 2 diabetes mellitus, which constitutes more than 95% of all the diabetic populations, has an insidious onset with a long, latent, asymptomatic phase. The prediabetic stages also carry high risk for cardiovascular risk factors or the metabolic syndrome.² Diabetes mellitus causes, between two and four times increased risk of peripheral vasular disease by causing endothelial and smooth muscle cell dysfunction in peripheral arteries. The risk of developing lower extremity peripheral vascular disease is proportional to the severity and duration of diabetes. Most of the complications are preventable. Exercise is the fundamental principle for preventing vascular diseases among diabetes patients. One of the exercises is Buerger Allen Exercise, is an active postural exercise of the lower extremity for preventing peripheral vascular disease and improves circulation of lower extremity.³

NEED FOR THE STUDY:

Type 2 Diabetes Mellitus is a long term metabolic disorder. Diabetes can lead to a variety of complications. Leg pain and cramps often occurs as a result of nerve damage called diabetic neuropathy. Peripheral neuropathy can result in serious foot and leg conditions, poor circulation and amputation of affected limbs. People over time; develop nerve damage throughout the body which results in symptoms such as pain, tingling, or numbness. Peripheral arterial disease refers to disease of blood vessels outside the heart. The restricted blood flow of peripheral venous disease can be a warning sign of other forms of vascular disease.⁴

A study conducted by Kiyomi Matsuo et al. 2013, from International University of health and welfare, Japan on the basis of the effect of different positions on lower limbs skin perfusion pressure on diabetes clients. The subjects of this study were 10 healthy adults and 11 patients with critical limb ischemia. Patients with critical limb ischemia, including both dorsum of foot and plantar of foot, having (Skin Perfusion Pressure) SPP of lower limbs of less than 40 mmHg (supine position) were the object of this study. SPP was measured on four positions (supine position, lower limbs elevation position, sitting position, and reclining bed elevation cardiovascular disease (CVDs) and clustering of theof 20° position). From the above study the different steps of Buerger Allen exercise is useful in improving lower extremity perfusion.⁵

STATEMENT OF THE PROBLEM:

Effectiveness of Buerger Allen Exercise on lower extremity perfusion and among patients with Type 2 diabetes mellitus admitted at selected hospitals of city.

OBJECTIVES OF THE STUDY:

1. To assess the lower extremity perfusion before Buerger Allen Exercise among Patients with Type 2 Diabetes Mellitus admitted at selected hospitals of City.

2. To determine the effectiveness of Buerger Allen Exercise on Lower Extremity Perfusion among Patients with type 2 Diabetes Mellitus admitted at selected hospitals of city.

3. To find association of post intervention findings with selected demographic variables.

HYPOTHESIS:

H0₁: There is no significant effect of Buerger Allen Exercise on lower extremity perfusion among patients with type 2 Diabetes Mellitus admitted at selected hospitals of city. (P=0.05)

H₁: There is significant effect of Buerger Allen Exercise on lower extremity perfusion among patients with type 2 Diabetes Mellitus admitted at selected hospitals of city. (P=0.05)

OPERATIONAL DEFINITION:

1. Effectiveness:

It is the outcome of Buerger Allen Exercise on Lower Extremity Perfusion and level of pain among patients with type 2 Diabetes Mellitus admitted in selected hospitals of city.

2. Buerger-Allen Exercise:

Buerger Allen Exercise helps in filling the lower extremity blood vessels according to gravity and it refers to three steps which include:

a. In this study the lower extremities are elevated to a 45 to 90 degree angle and supported in this position until the skin blanches (appears dead white) for 2 to 3 minutes.

b. The feet and legs are then lowered until redness appears for 5 to 10 minutes.

c. Then legs are placed flat on the bed for 10 minutes.

3. Lower Extremity Perfusion:

It refers to blood circulation to the lower extremities assessed before and after intervention of Buerger Allen Exercise.

4. Level of Pain:

Pain is unpleasant sensory and emotional experience which will be measured by using Numerical rating scale to check level of pain.

5. Type 2 Diabetes Mellitus:

Type 2 Diabetes Mellitus refers to persons who are diagnosed as type 2 diabetes mellitus.

Research Design:

Quasi experimental Non Randomize Control group design was adopted for the present study.

Group	Assessment	Intervention	Assessment
Exp	O1	X	O2
Control	O1	-	O2

Table representation of Research Design:

O1: an assessment of lower extremity perfusion with type 2 Diabetes mellitus patients before Buerger Allen exercise.

O2: an assessment of lower extremity perfusion with type 2 Diabetes mellitus patients after Buerger Allen exercise.

X: Intervention of Buerger Allen exercise.

Setting of the study:

The study was conducted in selected hospitals of city.

Population:

Target population:

Target population selected for this study consisted, type 2 diabetic mellitus patients in selected hospitals from all over Maharashtra.

Accessible population:

Accessible population selected for this study consists of all the type 2 diabetic mellitus patients from selected hospitals of city.

Sample size:

In this study, the sample size comprises of 60 patients among whom Control group (30) and experiment group (30) were divided who were admitted at selected hospitals of city and fulfilled the sampling criteria.

Sampling Technique:

The sampling technique used in this study is non probability convenient sampling. This entails the use of the sample purposefully in the study, until the desired samples are reached. Everyday list of type 2 Diabetes Mellitus patients were checked and patients who met the criteria were selected.

Sampling Criteria:

Inclusion criteria:

1. Willing to participate in the study.

2. Age group between 40-70 years.

3. Available at the time of study.

4. Admitted at the selected hospitals of city.

5. Able to understand English/Marathi language.

Exclusion criteria:

1. Critically ill.

2. Unconscious. Disoriented.

3. Patients on anti-coagulation treatment.

4. Patient’s with musculoskeletal disorders like fracture, amputation.

Discription of tool:

The instruments used for the study were:

A: Demographic variable Section

B: Structured Scale to assess Lower extremity perfusion.

Validity:

Experts from other colleges certified certified the validity of the tool.

Pilot study:

Pilot study was conducted on 10 samples. 5 each in experimental and control group from 9/10/2018 to 15/10/2018 in selected Hospital of City. After the pilot study, few changes were made in the tool. The study was feasible.

Data Collection Procedure:

Data collection was started after obtaining necessary permission from thr ethical committee. A formal adminisrative permission was obtained from the authorities of the proposed hospitals. A written consent was obtained from the participants regarding their willingness to participate in the study. The investigator had done the pre assessment of lower extremityof control and experimental group and exercise was implemented in experimental group for four days, after that the investigator had done post assessment on both the group.

Plan for data analysis:

The data obtained were analyzed using descriptive statistics (mean, standard deviation, and persentage) inferential statistics (Paired‘t’ test), Fisher’s exact test.

RESULTS AND DISCUSSION:

1. The first objective of the study is to assess the lower extremity perfusion before Buerger Allen Exercise among Patients with type 2 Diabetes Mellitus admitted at selected hospitals of City.

In experimental group (Right foot):

3.3% of the type 2 Diabetes Mellitus patients had moderate lower extremity perfusion, 46.7% of them had mild lower extremity perfusion and 50% of them normal lower extremity perfusion.

Left foot:

13.3% of them had moderate lower extremity perfusion, 46.7% of them had mild lower extremity perfusion and 40% of them normal lower extremity perfusion.

In control group (Right foot):

13.3% of the type 2 Diabetes Mellitus patients had moderate lower extremity perfusion, 23.3% of them had mild lower extremity perfusion and 63.3% of them normal pain.

Left foot:

56.7% of them had mild lower extremity perfusion in right foot and 43.3% of them normal lower extremity perfusion in left foot.

2. The second objective of the study is to determine the effectiveness of Buerger Allen Exercise on Lower Extremity Perfusion among Patients with type 2 Diabetes Mellitus admitted at selected hospitals of city.

In experimental group (right foot):

Average pretest lower extremity perfusion score was 14 which increased to 15 in posttest. T-value for this test was 4.7 with 29 degrees of freedom. Corresponding p-value was 0.000, which is small (less than 0.05), null hypothesis is rejected. The Buerger Allen Exercise is proved to be significantly effective in improving the lower extremity perfusion in right foot.

Left foot:

Average pretest lower extremity perfusion score was 13.3 which increased to 14.8 in posttest. T-value for this test was 5.2 with 29 degrees of freedom. Corresponding p-value was 0.000, which is small (less than 0.05), null hypothesis is rejected. The Buerger Allen Exercise is proved to be significantly effective in improving the lower extremity perfusion in left foot.

3. The third objective of the study is to find association of post intervention findings with selected demographic variables.

Demographic variable		Lower extremity Perfusion			p-value
Demographic variable		Mild	Moderate	Normal	p-value
Age	30-40 years	8	3	11	0.794
	40-50 years	19	2	17
	50-60 years	18	2	22
	60-70 years	7	2	9
Gender	Male	37	6	45	0.770
Gender	Female	15	3	14	0.770
Education	Illiterate	13	3	12	0.393
	Primary	9	1	20
	Secondary	19	2	13
	Higher secondary	8	3	11
	Graduation and above	3	0	3
Occupation	Unemployed	6	0	4	0.732
	Business	13	5	20
	Government employee	5	0	3
	Private employee	13	1	12
	Others	15	3	20
Type of work	Sedentary	12	1	7	0.202
	Standing	8	3	7
	Both sedentary and standing	32	5	45
Specific habits	Yes	34	6	34	0.707
Specific habits	No	18	3	25	0.707
Duration of Type 2 Diabetes Mellitus	1-10 years	24	3	23	0.225
	10-20 years	22	2	24
	More than 20 years	6	4	12

Since all the p-values are large (greater than 0.05), none of the demographic variables was found to have significant association with lower extremity perfusion among the patients with type 2 diabetes mellitus.

Table: shows the comparison of experimental and control group for effectiveness of Buerger Allen Exercise on Lower Extremity Perfusion among Patients with type 2 Diabetes Mellitus admitted at selected hospitals of city:

Foot	Admin	Mean	SD	t	Df	p-value
Right	Experimental	0.8	1.0	4.2	58	0.000
Right	Control	0.0	0.5	4.2	58	0.000
Left	Experimental	0.7	1.0	4.6	58	0.000
Left	Control	-0.3	0.6	4.6	58	0.000

Researcher applied two sample t-test for the comparison of experimental and control group for effectiveness of Buerger Allen Exercise on Lower Extremity Perfusion among Patients with type 2 Diabetes Mellitus admitted at selected hospitals of city. Corresponding p-value was 0.000, which is small (less than 0.05), the null hypothesis is rejected. The Buerger Allen Exercise is proved to be significantly effective in improving the lower extremity perfusion in left foot

LIMITATIONS:

· This study was limited to patients with type 2 Diabetes Mellitus.

· This study was limited to selected hospitals of city.

· True experimental study could not be conducted due to practical difficulty.

RECOMMENDATIONS:

· The same study can be conducted on larger samples for better generalization.

· The similar study can be conducted with one group pre-test post-test.

· The similar study could be replicated in different settings.

· The study can be conduct on individual rather than group.

· Study can be conducted with Hospital having peripheral vascular disease.

CONCLUSION:

In the assessment of 60 samples, evaluation of lower extremity perfusion was done before and after the intervention of Buerger Allen Exercise among experimemtal and control group. There was improvement in lower extremity perfusion in experimental group, P value < 0.05. Since the null hypothesis was rejected, all the pvalues were larger (greater than 0.05), non of the demographic variables was found to have significant association with lower extremity perfusion and pain among the patients with type 2 diabetes mellitus.

REFERENCES:

1. AM A. The History of Diabetes Mellitus. Saudi Medical Journal. 2000; 23(24): 373-378.

2. Diabetesatlad [Internet]. 2015 cited 9 August 2016. Available from: http://www.diabetesatlad.org.

3. Morrison S, Colberg S, Mariano M, Parson H, Vinik A. Balance Training Reduces Fall Risk in Older Individuals with Type 2 Diabetes. Diabetes Care. 2010; 33(4): 748-750.

4. AM Anjana, R Pradeep, M. Deepa. Prevalence of diabetes and prediabetes (impared fasting glucose and/or impared glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-Indian Diabetes (ICMR-INDIAB) study. Diabetologia. 2011; 54(12): 3022-3027.

5. Type 2 Diabetes Research/Diabetes Center [Internet]. Joslin.org.2019. Available from: https:// www.joslin.org/about/type_2_diabetes_research. html.

6. Mayor S. People with diabetes have one third higher mortality risk than general population, audit shows. BMJ. 2015; 350(Jan30): h529-h529.

7. Peripheral Artery Disease and Diabetes/American Health [Internet]. https://www.heart.org|en| health_topics|diabetes|why_diabetes_matters/peripheral_arte ry_disease_diabetes.

8. Mayer J. On Diabetes and its connection with Heart Diabetes. BMJ.1888; 1(1427): 949951.

Received on 05.03.2021 Modified on 29.03.2021

Int. J. Nur. Edu. and Research. 2021; 9(3):305-309.

DOI: 10.52711/2454-2660.2021.00072