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Jurnal Ners
Vol. 14, No. 3, Special Issue 2019
http://dx.doi.org/10.20473/jn.v14i3(si).16943
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution 4.0 International License
Original Research
Effect of Foot Exercise and Care on Peripheral Vascular Status in Patients with
Diabetes Mellitus
Selpina Embuai1, Hani Tuasikal2 and Moomina Siauta1
1 Universitas Kristen Indonesia Maluku, Indonesia
2 Akper Rumkit Tk III Dr. J. A. Latumeten Ambon, Indonesia
ABSTRACT
Introduction: Diabetes mellitus is a cause of health problems which
occurs in most countries. Approximately 13 - 15% of all patients with
diabetes mellitus will experience peripheral circulatory disorders. Foot
exercise and foot care are interventions that can be implemented to
prevent foot ulcers.
Methods: This study employed a pre-post-test quasi-experimental design
with a control group. The sample consisted of 94 patients with diabetes
mellitus who were assigned to the intervention group (n=47) and the
control group (n=47) respectively. Consecutive sampling was used to
recruit the samples. The instruments used to collect the data included 10-
g monofilament for the diabetic neuropathy test, a HbA1c test and a
sphygmomanometer. The collected data was analyzed using a paired t-test.
Results: The results of this study showed there to be significant effects
from foot exercise and foot care on the HbA1c test, in relation to the
frequency of the dorsalis pedis artery and diabetic neuropathy with a
significance value of 0.00 (p<0.05). However, in the ankle-brachial index
measurement, there were no significant differences between the
intervention and control groups with a significance value of 0.26 (p>0.05).
Conclusion: Foot exercise and foot care can be one of the independent
nursing interventions used to prevent the complications of diabetes
mellitus, as they have been proven to improve the peripheral vascular
status of patients with diabetes mellitus by 70-80%.
ARTICLE HISTORY
Received: Dec 26, 2019
Accepted: Dec 31, 2019
KEYWORDS
foot exercise; peripheral vascular;
diabetes mellitus
CONTACT
Selpina Embuai
selfiembuai@gmail.com
Universitas Kristen Indonesia
Maluku, Indonesia
Cite this as: Embuai, S., Tuasikal, H., & Siauta, M. (2019). Effect of Foot Exercise and Care on Peripheral Vascular Status in
Patients with Diabetes Mellitus. Jurnal Ners, 14(3si), 5-13. doi:http://dx.doi.org/10.20473/jn.v14i3(si).16943
INTRODUCTION
Diabetes mellitus is a serious chronic disease that
requires considerable attention. It has become a
leading cause of health problems in almost all
countries (Fujiwara et al., 2011). About 15% of
patients with diabetes mellitus will experience foot
ulcers – a serious complication that may result in the
amputation of the lower extremities (Mahfud, 2012);
(Kotru, Kotru, & Joshi, 2015). Seventy percent of foot
ulcers can occur within a period of five years (Kotru
et al., 2015). Moreover, 85% of patients undergoing
amputations are associated with foot ulcers due to
diabetes mellitus (Kotru et al., 2015).
The prevalence of patients with diabetes mellitus
is increasing every year. According to the National
Diabetes Fact Sheet (2014), the total prevalence of
diabetes in America in 2012 was 29.1 million (9.3%).
Of this number, 21 million were diagnosed diabetes
and the remaining 8.1 million were undiagnosed with
diabetes mellitus. The International Diabetes
Federation (IDF) in 2013 reported that the
prevalence of diabetes mellitus in Indonesia was
approximately 8.5 million people and this number
makes Indonesia ranked seventh in the world in
terms of diabetes population (IDF, 2013).
Furthermore, Perkeni (2015) reported that the
number of patients with diabetes mellitus in
Indonesia had reached 9.1 million people. As a result,
Indonesia has shifted up from number seven to the
top five countries with the highest number of
diabetics in the world (Ramadhan & Marissa, 2015).
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Peripheral neuropathy is one of the serious
complications of diabetes. Recent data shows that one
out of five people with diabetes mellitus (20%)
experience peripheral neuropathy. The risk of
peripheral neuropathy is two times higher in people
with diabetes mellitus. A combination of peripheral
neuropathy is that the problems associated with
blood supply to the legs can cause foot ulcers and
slow wound healing that leads to amputation. Around
40-70% of amputations in lower extremities are
caused by diabetes mellitus (Studi, Ilmu,
Keperawatan, & Indonesia, 2012).
The long-term vascular complications of diabetes
mellitus involve small vessels, microangiopathy,
medium vessels, and large vessels leading to the
occurrence of macroangiopathy. In particular,
macroangiopathy is a diabetes-specific lesion that
attacks the retinal capillaries and arterioles (diabetic
retinopathy), renal glomerulus (diabetic
nephropathy), peripheral nerves (diabetic
neuropathy), muscles and skin. In the neural tissue,
there is an accumulation of sorbitol and fructose and
a decrease in myoinositol which causes neuropathy.
Biochemical changes in the neural tissues will disrupt
the metabolic activities of the Schwann cells and
cause a loss of axon. The speed of motoric conduction
will decrease in the early stage of neuropathy,
resulting in pain, paresthesias, reduced vibration,
propioseptic sensations, and motoric disorders
accompanied by a loss of reflex of the internal tendon,
muscle weakness, and atrophy. These changes bring
in higher risks of lesions which later develop into
diabetic ulcers.
To deal with diabetes mellitus, the American
Diabetes Association (2016) recommends a
collaborative service of multidisciplinary teams
involving several fields; one of which is nursing. In
general, there are four main objectives related to
providing the services which include health
promotion, disease prevention, patient care, and the
fulfillment of patient needs (Aalaa, Malazy, Sanjari,
Peimani, & Mohajeri-Tehrani, 2012). One of the
preventive actions to deal with diabetes mellitus is
self-care. Diabetes self-care is an important factor in
controlling the disease. Almost 95% of diabetes care
is influenced by the consistency of the clients and
their families in monitoring their blood glucose,
nutrition, physical activity and treatment.
Nurses as health care providers play an important
role in preventing diabetic ulcers and the risk of
amputation of the lower extremities through foot care
and foot exercises. Nurses should not only facilitate
and provide foot care and foot exercises to the
patients but they should also provide health
education to the family about the importance of
having their blood sugar checked and any alternative
efforts made to prevent complications due to diabetes
mellitus (Aalaa et al., 2012).
Practically, preventive foot care includes washing
the feet properly, drying the feet carefully, keeping
the area between the toes dry, using lotions as a
moisturizer, using shoes and socks as recommended,
cutting the nails as recommended, conducting foot
inspections every day, and ensuring that the
temperature of the water used to clean the feet is
below 370C. In addition to foot care, diabetes mellitus
may be overcome by managing the factors affecting
glucose reduction, namely physical activity, insulin
level, diet and therapy (Kotru et al., 2015). Physical
activities in the form of exercises can function as a
treatment for diabetes mellitus. These exercises
should be measurable, organized, controlled and
regularly practiced. Foot exercises are one of the
recommended activities for patients with diabetes
mellitus. Diabetic foot exercises can prevent injuries
and help blood circulation especially in the lower
extremities and legs in patients with diabetes mellitus
(Kotru et al., 2015).
A preliminary study conducted at RSUD Dr. M.
Haulussy Ambon found there to be an increased
number of patients with diabetes mellitus undergoing
treatment in the hospital. In 2015, 773 people with
diabetes mellitus were found. From January to
November 2016, there were 1045 patients with
diabetes mellitus undergoing treatment in the
hospital; 53 of whom had diabetic ulcers. Some
interviews were also conducted with the health
workers and patients regarding the nursing
interventions given. Of the ten patients interviewed,
100% reported that they had never had any foot care
and that they did not know how to perform it.
Moreover, there were no programs of foot care or foot
care education implemented in the hospital units.
Studies on foot exercises and care have been
conducted by some researchers. Kotru et al. (2015)
conducted a study about foot care practices
concerning new diabetic foot ulcers in patients with
type 2 diabetes mellitus. The results revealed that
34% of 108 patients had abnormal plantar foot
pressure on podiascan, 20% had foot disorders
(calluses, claw toes, redness, etc.), and 17% had
peripheral vascular disease. After one year was
observed in the intervention group, new ulcers or
diabetic feet were found in only 18% of patients
whereas in the control group, new ulcers or diabetic
feet developed in 31% of patients (Kotru et al., 2015).
Priyanto (2012) conducted a study on the effects
of foot exercises on foot sensitivity and blood sugar
levels on an aggregate of elderly people with diabetes
mellitus in Magelang. The results reported that the
elderly people who were given the intervention of
foot exercises had better blood sugar levels (p=0.000)
and better foot sensitivity (p=0.000) than those
receiving no intervention. Therefore, it is important
to investigate the effects of foot exercise and care on
peripheral vascular status in patients with diabetes
mellitus (Studi et al., 2012).
MATERIALS AND METHODS
This study used a pre-post-test quasi-
experimental design with a control group and it was
conducted in RSUD Dr. M. Haulussy Ambon from
February to May 2017.The sample consisted of 94
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patients with diabetes mellitus undergoing treatment
in the hospital and they were assigned to the
intervention group (n=47) and the control group
(n=47). A consecutive sampling technique was used
to recruit the samples. The instruments used to
collect the data were 10-g monofilament of Semmes-
Weinstein for the diabetic neuropathy test. This test
examines the Merkel and Meissner receptor function
and the relationship with the diameter of large nerve
fibers and the associated guidelines for measuring
sensation and pressure. The HbA1c test guidelines for
taking blood samples for HbA1c examination, a
sphygmomanometer for measuring blood pressure,
ankle-brachial index guidelines and the measurement
of the dorsalis pedis artery were used to identify
peripheral blood circulation, foot care and foot
exercise. The data was analyzed using a paired
sample t-test. Regarding the use of monofilament, the
mean difference test in the intervention group was
performed using McNemar. Meanwhile, for the
assessment of HbA1c, ABI, and the frequency of the
pulse of the dorsalis pedis artery, the Wilcoxon test
was used. The Mann-Whitney test was used to
determine the mean comparison of the two groups.
RESULTS
In this study, a paired t-test was carried out to test the
mean difference of the data. Prior to the test, there
was an underlying assumption regarding the
normality of the data which was tested using Shapiro-
Wilk. If the data did not meet the assumption, then the
Wilcoxon test would be used instead. In this test, the
measured variables were monofilament, HbA1c, ABI
and the pulse frequency of the dorsalis pedis artery.
See on Table 2.
The mean difference test for the two groups was
performed to determine whether there were significant
differences between the control and intervention groups
based on the measured variables. Before the test, the
normality of data was examined using the Shapiro-Wilk
test. If the data was not normally distributed, then the
Mann-Whitney test would be used. In this study, the
variables were measured using a monofilament, HbA1c,
ABI, and the pulse frequency of the dorsalis pedis artery.
See on Table 3.
DISCUSSION
The test results for the monofilament showed that
there were significant differences between the
intervention group and the control group. At the time
of the initial assessment, this study required that all
of the respondents had to have their peripheral
neuropathy status tested using a monofilament.
When tested, the respondents were unable to sense
four out of the ten location points examined,
indicating that the patients experienced peripheral
neuropathy. The patients were given the intervention
of foot exercises and foot care for three months before
the evaluation was carried out. The results showed
there to be a significant effect in which 41
respondents experienced a positive change or their
peripheral neuropathy status was improved.
Meanwhile, six respondents still had a neuropathy
status but their condition was getting better. This
Table 1. Description of the data in the intervention group and the control group
Variable
Intervention Group
(n = 47)
Control Group
(n = 47)
p-value
Monofilament*
Negative
Positive
0%
100%
0%
100%
-**
Vascular Status
HbA1c
9.3 ± 2.9
8.2 ± 2.2
0.14
ABI
0.85 ±0.07
0.8 ± 0.6
0.01
Pulse frequency of the dorsalis pedis artery
58.5 ± 2.24
58.5 ± 2.2
1.00
*Monofilament measurement was performed using the Chi-Square test. The HbA1c. ABI and the frequency of the pulse of the
dorsalis pedis artery were tested using the Mann Whitney test and presented as a percentage (%); **The data results from
monofilament measurement were not tested as they were included in the inclusion criteria with equal values in both groups; ***
Vascularity: HbA1c. ABI and the frequency of the dorsalis pedis artery pulse were presented in Mean and SD.
Table 2. The summary of the mean difference test between the intervention and control
Variabel
Intervention
p
Control
P
Pre
Post
Pre
Post
Monofilament
Negative
Positive
0%
100%
87.2%
12.8%
0.00*
0%
100%
4.3%
95.7%
0.50
Vascular Status
HbA1c
9.32 ± 2.93
5.98 ± 0.86
0.00**
8.2 ± 2.2
8.7 ± 2.2
0.00
ABI
0.85 ± 0.07
0.94 ± 0.18
0.00**
0.8 ± 0.6
0.9 ± 0.2
0.00
Pulse frequency of the dorsalis
pedis artery
58.51 ± 2.24
65.95 ± 3.42
0.00**
58.5 ± 2.2
59.8 ± 2.4
0.17
*Monofilament measurement was tested using the McNemar test; **The measurement of HbA1c. ABI. and the frequency of the
dorsalis pedis artery pulse was tested using the Wilcoxon test.
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result indicates that proper foot exercises and care
can improve the health status of diabetic patients.
Peripheral neuropathy is a common consequence
of type 1 and type 2 diabetes mellitus and chronic
hyperglycemia involving the vascular pathway and
metabolic disorders. There are three main ways in
which diabetes mellitus is considered to damage the
peripheral nerves. First, neural tissues do not require
insulin to transport glucose but they use an
alternative metabolic polyol pathway for glucose
metabolism. Glucose is converted to sorbitol, and in
turn, sorbitol is very slowly converted to fructose. The
accumulation of glucose from chronic hyperglycemia
combined with very slow conversion rates from
sorbitol to fructose results in an accumulation of
sorbitol in the peripheral nerves. The increase in
sorbitol causes an interference with the ion pump by
producing osmotic pressure in the fluid. This reduces
the nitric oxide and causes an increase in the
molecular reactive oxygen and increased oxidative
stress. This substance damages the Schwann cells and
this causes a disruption of nerve conduction. Second,
protein kinase C is not appropriately activated as a
result of hyperglycemia, which may contribute to
neurological complications.
Protein kinase C is an intracellular signaling
molecule that regulates many vascular functions; this
rate increases in diabetes. The activation of this
protein in the nerve vessels can cause vascular
damage and reduce nerve conduction. Third, the end
products of advanced glycosylation (AGEs) are the
result of the attachment of glucose metabolites to
proteins. Although it is a normal component of
protein, the basement membranes of smaller blood
vessels and the uncontrolled blood glucose levels
support the over-production of AGEs. Increased AGEs
cause a thickening of the basement membrane,
contributing to a reduced oxygen supply. Neuronal
dysfunction is closely related to vascular
abnormalities and nerve damage due to AGEs. Other
damage at the microvascular level includes protein
trapping (including LDL), nitric oxide inactivation,
and a loss of vasodilation due to sorbitol buildup and
the polyol pathways, the activation of protein kinase
C, and an excess accumulation of AGEs. All of these
factors contribute to nerve damage through myelin
degeneration, causing the nerves to lose their ability
to transmit signals. Peripheral neuropathy occurs
when the nerves experience damage, resulting in a
decrease or absence of nerve transmission with a
number of possible symptoms including numbness,
pain, or tingling (Harlow, Deceased, & Herman, 2012).
The presence of peripheral neuropathy will cause
a loss or a decrease in pain sensation in the foot so
then it will experience trauma which results in the
occurrence of ulcers. The clinical manifestations of
diabetic neuropathy depend on the type of nerve
fibers that experience lesions. As the nerve fibers
affected by lesions can be small or large, in proximal
or distal, focal or diffuse, motoric or sensory or
autonomous, the clinical manifestations will be
varied, including tingling, numbness, and burning
sensation such as being torn (Wahyuni & Arisfa,
2016). For this reason, it is necessary to have a tool
that can detect the status of neuropathy in patients
with diabetes mellitus.
A tool which can be used to detect diabetic
neuropathy is 10 g monofilament. Monofilament is
commonly used to assess the loss of protection
sensation and it is recommended by several practical
guidelines for detecting peripheral neuropathy in the
legs (Mogre, Abanga, Tzelepis, Johnson, & Paul, 2017).
This tool serves to examine the mercel and Meissner
receptors to detect their sensory function and their
relationship with large diameter nerve fibers
(Perkins, 2001). The early detection of sensory
neuropathy can reduce the incidence rate of foot
ulcers. This monofilament test can be used easily to
identify sensory neuropathy (Aalaa et al., 2012).
Baraz et al (2012) conducted a quasi-experimental
study on 150 patients with diabetes mellitus. All
patients were tested using the Semmes-Weinstein 10
g monofilament to detect their sensory neuropathy.
The results showed that the sensitivity of the
monofilament was 38.5% - 61.5% at 1 - 8 location
points, while the specificity was 77.5% - 95.5%.
The measurement tools mentioned in this study
are recommended for use to detect diabetic
neuropathy, which should be performed by the health
workers to minimize the further impact occurring
due to the negligence of the patients in performing
health care. The role of nurses is to prevent the
occurrence of diabetes mellitus by conducting health
education along with preventive efforts against the
risk of foot ulcers. Thus, patient screening is highly
recommended for detecting neuropathy immediately
Table 3. The summary of the mean difference test after the intervention in the control group and the intervention
group
Variables
Groups
p-value*
Intervention (n = 47)
Control (n = 47)
Monofilament
Negative
Positive
87.2%
12.8%
4.3%
95.7%
0.00
Vascular Status
HbA1c
5.98 ± 0.86
8.7 ± 2.2
0.00
ABI
0.9 ± 0.1
0.9 ± 0.2
0.26
Pulse frequency of the dorsalis pedis artery
65.9 ± 3.4
59.8 ± 2.4
0.00
*Variables of monofilament, HbA1c, ABI, and the frequency of the dorsalis pedis artery pulse were tested using the Mann Whitney
test.
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after being diagnosed with diabetes mellitus to
prevent the risk of foot ulcers (Jyotsna, Kishore, &
Upadhyay, 2015)
In this study, the assessment of vascular status
was performed using three measuring variables, i.e.,
HbA1c, brachial index or ABI and pulse frequency.
The researchers collaborated with laboratory
assistants to carry out blood sampling. The laboratory
assistants took blood samples for the HbA1c test.
Regarding the vascular status, in the beginning of the
study, 94 respondents in the two groups showed poor
HbA1c values (HbA1c >6.5). In the intervention
group, only eight patients were indicated to have
HbA1c values below 6.5. The mean value of the ankle-
brachial index and pulse rate did not show a
significant difference and it was still within the
normal threshold in both groups. After the
intervention and evaluation was conducted for three
months, there was a significant change in the
intervention group. It was shown that the HbA1c level
improved but there were still 14 respondents with
HbA1c values above 6.5. This showed that there were
significant changes in the vascular status of the
patients after regularly performing the recommended
intervention.
Based on the theory, an ischemic state is a
condition due to a lack of blood in the tissue that
causes the tissue to have a minimum supply of
oxygen. This condition happens due to a
macroangiopathic process in blood vessels that leads
to decreased circulation as indicated by the loss of
pulse in the dorsalis pedis artery, tibialis and poplitea,
atrophic and cold feet and thickened nails. The
process of angiopathy in people with diabetes
mellitus includes the narrowing and blockage of
peripheral arteries in the lower limbs, especially the
legs, due to the reduced perfusion of the distal tissue
from the legs and thus diabetic foot ulcers occur
(Mahfud, 2012).
The level of blood sugar in patients with
uncontrolled diabetes mellitus will cause a thickening
of the intima (hyperplasia of the basal artery) in the
large blood vessels and capillaries. It can also cause a
leakage of albumin out of the capillaries, and thereby
disrupt the blood distribution to the tissues. As a
result, tissue necrosis may occur, resulting in diabetic
ulcers. Erythrocytes in people with uncontrolled
diabetes mellitus can increase the HbA1C which
causes deformability of the erythrocytes and the
disrupted release of oxygen in the tissues, resulting in
blockages that interfere with tissue circulation and a
lack of oxygen. Such a condition may cause the death
of the tissue which subsequently causes the
development of diabetic foot ulcers. Increased levels
of fibrinogen and increased platelet reactivity will
cause a high aggregation of red blood cells so then the
blood circulation becomes slow. This condition
facilitates the formation of platelets in the walls of the
blood vessels which will interfere with blood
circulation. People with diabetes mellitus usually
have a high level of cholesterol, LDL, and plasma
triglyceride. Poor circulation to most tissues will
cause hypoxia and tissue injury, stimulating an
inflammatory reaction which stimulates
atherosclerosis. Changes or inflammation in the walls
of blood vessels will cause an accumulation of fat in
the blood vessel lumen and a low concentration of
HDL (high-density lipoprotein) as a plaque cleanser.
The presence of another risk factor, which is
hypertension, will increase susceptibility to
atherosclerosis. Atherosclerosis may lead to
decreased circulation so then the feet become
atrophic, cold and the nails thicken. Another
subsequent abnormality is tissue necrosis, which
results in ulcers that usually starts on the lower legs
(Mahfud, 2012); (Studi et al., 2012)
Vascular disease can interfere with the
biomechanics in the foot which causes the risk of
diabetic ulcers. This is in line with Norwood (2011),
who stated that one of the risk factors which can lead
to diabetes mellitus foot ulcers is peripheral vascular
disease. For this reason, the routine examination of
the vascular status of patients with diabetes mellitus
is needed. A study conducted by Sihombing (2008)
showed that the ABI and HbA1c values affected the
risk of developing diabetic foot ulcers. In addition, a
study by Liu et al (2010) reported that 63% of 1,524
subjects with type 2 diabetes mellitus had
complications related to glycemic control levels with
HbA1c >7.5 and where the mean of the HbA1c levels
were 9.63%, resulting in foot ulcers (Wahyuni &
Arisfa, 2016).
Assessing the vascular status of patients with
diabetes mellitus is important as it is one of the risk
factors for diabetic ulcers. Patients with poor vascular
status will experience a worsening circulation
especially in the peripheral area. Furthermore, old
age factors and illness (cardiovascular) also worsen
the condition of the arteries. If such a condition
continues to be untreated, then it will increase the
risk of foot ulcers. For this reason, it is necessary to
take preventative measures in the form of foot care
and foot exercises. Such treatments can prevent the
emergence of injury as there is the protection of the
barrier system (skin) and an increased strength of the
foot muscles, which improves foot mobility and blood
circulation in the legs.
Foot care and foot exercises are effective at
improving vascular status in patients with diabetes
mellitus. In this study, the effectiveness is evidenced
by the decreased number of patients with diabetic
neuropathy status and increased vascular status
(frequency of the dorsalis pedis artery and the HbA1c
and ABI values). A study conducted by Saurabh et al.
(2014) found that 5-6 minutes of time devoted to
providing foot care to individuals created healthy
habits which could prevent disability and reduced
medical expenses in the long term. Furthermore, a
training program involving more than 3,000 primary
care doctors in India showed that diabetic foot care
was found to be very educational and this became a
priority for diabetes control strategies (Saurabh et al.,
2014).
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The results of this study support a research
hypothesis which states that there is an effect of foot
care and foot exercise on the efforts to prevent the
risk of foot ulcers in patients with diabetes mellitus.
The results of this study also confirm the theory that
85% of amputations of diabetic feet can be prevented
by proper care and education. This study proved that
performing foot care and foot exercises could prevent
the risk of foot ulcers by 50 - 70%. According to
Perkeni (2015), the management of diabetes mellitus
begins with applying healthy lifestyles and
pharmacological interventions. The knowledge of
independent monitoring, the signs and symptoms of
hypoglycemia and its treatment should be given to
patients. The education used to promote healthy
living needs to be implemented as a part of preventive
efforts. It is a very important part of holistic
management of diabetes mellitus; one of which is foot
care (Chiwanga & Njelekela, 2015). Black and Hawks
(2009) explained that the proper handling of foot care
and the initial treatment can prevent the risk of foot
infection. Effective foot care prevents the risk of
ulcers turning into amputations. This is supported by
Chiwanga and Njelekela (2015), who stated that
practicing proper foot care reduced the risk of
developing diabetic foot ulcers. Knowledge of foot
care is important for health care providers in order to
increase the public knowledge about the benefits of
foot care (Chiwanga & Njelekela, 2015). This is
congruent with a study conducted by Netten et al.
(2016) which reported that proper foot care and
adherence to foot care could reduce the impact of
ulcerations on the feet by 3.1% in the intervention
group compared to the control group which
experienced increased ulceration in the feet by 31.6%
(Group, 2015). Another study conducted by Kotru et
al. (2015) on foot care showed that 18% of patients in
the intervention group receiving foot care developed
a new ulceration. In contrast, in the control group,
31% of patients developed new ulcerations on the
legs (Kotru et al., 2015). Another study by Chiwanga
and Njelekela (2015) also revealed that out of the 404
respondents involved in the study, 15% had foot
ulcers, 44% had neuropathy and 15% had a history of
peripheral vascular disease. The rate of peripheral
neuropathy affects the emergence of foot ulcers.
About 48% of respondents receiving foot care
education could perform foot care independently at
home and adhered to the recommended advice.
Meanwhile, 27% of the respondents checked their
feet at the doctors at least once after being
diagnosed(Chiwanga & Njelekela, 2015).
In addition to foot care, physical exercises can be
used as part of the treatment of diabetes mellitus.
Performing exercises (including weight-bearing
activities) is recommended as it can improve glycemic
control. The exercises should be measurable,
organized, controlled, and continuously practiced.
The recommended intensity is 40-70% of mild to
moderate activity (Studi et al., 2012).
Diabetes causes weakness in the legs. It also
changes the function of the legs and therefore it is
necessary to emphasize the importance of exercising
the lower limbs (Kivlan, Martin, & Wukich, 2011).
However, there has been no evidence of studies that
have adapted specific foot training as recommended
in this study; only indications for regular exercises
were found (18). Nonetheless, regular exercise which
is supervised by professionals is very important for
the improvement of muscle strength, mobility,
peripheral pulses, and risk assessment. Increased
muscle strength is not expected to occur since there is
no use of burden when the exercise is performed.
Ankle biomass in diabetic clients is detached from
neuropathy as there is decreased mobility, increased
plantar pressure and changes in foot kinematics (18).
These changes can affect the patients when it comes
to increasing pressure on the fifth toe and medial area
of the heel, which is associated with the risk of plantar
ulceration (Gurney, Marshall, Rosenbaum, & Kersting,
2013).
The results of the study conducted by Iunes et al.
(2014) showed that the guidelines of self-care could
change the leg alignment and reduce the amplitude of
lateral oscillation of the lower limb when home
exercises are performed. However, it was found that
foot evaluation and self-care guidelines were not
frequently carried out by the health workers even
though the practice of preventing diabetic foot
complication has been found to be very important
(Iunes et al., 2014). Performing exercises is the first
line action in the treatment of diabetes. Exercises can
reduce blood glucose levels by taking the glucose to
the active muscles. Exercises also stimulate the
translocation of glucose transporter type 4 (GLUT4),
increase glucose uptake into the muscle cells and
compensate for the insulin sensitivity disorders
associated with diabetes (26). Although exercises and
detainees provide benefits for diabetic patients, the
combination of both is more effective at controlling
blood glucose. Exercises also increase insulin action
from 2 up to 72 hours(Shrivastava, Shrivastava, &
Ramasamy, 2013).
In addition to a short-term improvement in
glucose control and insulin action, long-term exercise
reduces low-density lipoprotein cholesterol and
systolic blood pressure in diabetic patients. It also
corrects the symptoms of depression and improves
quality of life related to health. Given its influence on
blood glucose regulation and the role of glycemic
control in preventing diabetic neuropathy, exercises
should be considered as a treatment for diabetes
complications (Fox, 2014). One of the recommended
exercises for patients with diabetes mellitus is foot
exercises (Akhtyo, 2009). Foot exercises are one of
the therapies which can be provided by the nurses
with the aim of launching the disrupted blood
circulation as they help to strengthen the leg muscles.
This is consistent with the study conducted by
Wibisono (2009) as cited in Priyanto (2012) which
stated that diabetic foot exercises aimed to improve
blood circulation to create a smooth transport of
nutrients to the tissues, to strengthen the small, calf
and thigh muscles, and to overcome the limitations of
JURNAL NERS
http://e-journal.unair.ac.id/JNERS | 11
joint motion experienced by people with diabetes
mellitus. In addition, foot exercises also increase
endoneurial blood flow, nitric oxide synthesis and Na
+ / K + -ATPase activity with the given training (Gulve,
2008).
Priyanto (2012) reported that the blood sugar
levels and foot sensitivity improved in the elderly
who performed the foot exercises. Wahyuni and
Arisfa (2015) also found that diabetic foot exercises
were effective at increasing the brachial-ankle index
in patients with type 2 diabetes mellitus (Priyanto.,
2012). Another study conducted by Diliberto et al
(2016) also reported that performing leg exercises
improved plantar foot pressure and foot
biomechanics, in addition to changes in leg strength,
and muscle strength(Studi et al., 2012).
In this study, it was proven that regular and
continuous foot care and exercises increased the
vascular status of patients by 70 - 80%; this was
reflected in the decreasing frequency of neuropathy
by 70% and the increasing vascular status by 50%
that using the HbA1c test and the frequency of the
pulse in the dorsalis pedis artery.
In this study, a variable which showed no different
in the results in the intervention group and the
control group was the ankle bracelets index. This is
because, at the beginning of the examination, the
mean values of the brachial index ankle in the two
groups before the intervention were no different.
Thus, the results after the intervention were also not
significantly different. However, in the intervention
group, there was a significant relationship between
the values of the pre- and post-intervention as there
was an increase of ABI in the normal range of 0.9 to
1.2.
CONCLUSION
This study concluded that foot care and foot exercises
effectively increased the patient’s vascular status by
70 - 80% in patients with diabetes mellitus. Foot
exercise and foot care can be one of the independent
nursing interventions used to prevent the
complications of diabetes mellitus. Further research
can consider the findings in this study and involve
more types of laboratory tests such as cholesterol,
HDL, LDL and triglyceride tests. These affect the
peripheral circulatory status of the patients.
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