Introduction
Diabetes Mellitus (DM) is a metabolic disease
which is characterized by an excess of glucose levels in the blood
(hyperglycemia) that occurs due to abnormalities in insulin secretion, insulin
action, or both (ADA, 2016). The number of
cases and the prevalence of DM has continued to increase over the last few
decades (Kemenkes, 2018). DM is a
significant public health problem, becoming one of the world leaders' four
priority non-communicable diseases for follow-up.
According to the World Health Organization
(WHO), the number of DM patients is 422 million. Based on the results of the
International Diabetes Federation (IDF) report, there were around 199 million
DM patients, estimated to increase to 313 million people by 2040. Indonesia is
in the top 10 countries, with DM patients in 6th place. DM aged more than 15
years is 6.9% or about 12 million people (Carracher, Marathe, & Close, 2018).
According to the Report on Result of National
Basic Health Research 2018, the prevalence of DM in the population aged 15
years in Indonesia from 2013 to 2018 experienced a significant increase, from 1.5%
to 2.0%. West Nusa Tenggara is in the 22nd position, which also experienced an
increase in the prevalence of DM, from 0.9% to 1.64%. In Central Lombok Regency
in 2018, there was a prevalence of DM who received health services in many as
1,776 cases, and in 2019 there was an increase in the majority of DM patients,
as much as 3,692 cases or 9.1% of the estimated number of DM. Community Health
Centre with DM patients receiving the highest health services was at Pengadang Health Center with 685 cases, Darek Health Center
with 544 cases, Praya Health Center with 401 cases, Sengkol Health Center with 348 patients, and Mantang Health Center with 306 instances (Central Lombok
Health Office, 2019)
The high number of DM patients is partly due
to lifestyle changes (Annisa, 2020). Unhealthy
lifestyle changes such as excessive food (fat and lack of fibre)
can increase blood sugar levels. Hence, the feet experience tingling or
numbness, leading to neuropathy and decreased sensitivity to the feet (Damayanti, 2015).
Foot sensitivity is a stimulation in the
isolated area obtained by the nerves and causes various problems called
neuropathy. The increased activity of the lower extremities will cause high red
blood cell aggression, so blood circulation becomes slow and causes circulation
disorders (Rusandi, 2014). DM management
begins with implementing a healthy lifestyle and pharmacological interventions
with oral and injection of anti-hyperglycemic drugs. DM management other than
pharmacologically must be accompanied by non-pharmacological therapy such as
counselling or education, medical nutrition therapy, and physical exercise or
physical activity (Indonesia, 2019).
Exercise (physical activity) can directly
improve physiological function by reducing blood glucose levels, increasing
stamina and emotional well-being and increasing circulation. Physical activity
will cause an increase in blood flow, so there will be more open capillary nets
so that more insulin receptors are available and receptors become active, which
will affect DM patients (Soegondo, 2014). Although swimming
and brisk walking have been suggested as good choices, other types of activity
are equally beneficial, particularly the Buerger
Allen exercise (Suryati, Murni, & Arnoval, 2019).
Buerger
Allen Exercise is one form of active movement in the plantar area that applies
the force of gravity.
Regular exercise will help increase arterial and venous blood flow by opening
small blood vessels in the muscles (capillaries), blood vessel vascularization,
and blood supply in the tissues (Salindeho, Mulyadi, & Rottie, 2016). Therefore, each
stage of the training must be done regularly (Chang et al., 2016).
Based on the description above, the researcher
is interested in conducting a study entitled "The Effect Buerger Allen Exercise on Foot Sensitivity of Diabetes
Mellitus Patients in the Work Area of the Mantang
Health Center in 2021".
Method
Research
design pre-experimental that uses a one-group pre-post test
design. The population in this study were all DM patients recorded at the Mantang Health Center in the last 10 months starting from
January-October 2020, as many as 306 people. The sample in this study was 19
respondents. In this study, the sampling technique used was purposive sampling.
The analysis used in this study is the Wilcoxon.
Results
and Discussion
A. Results
The
results of this study will be described as follows:
Table 1
Frequency distribution of
respondents based on characteristics
|
Characteristics
|
Total
|
(%)
|
|
Age
|
|
|
|
45-54
years old
|
7
|
37
|
|
54-64
years old
|
8
|
42
|
|
>65
years old
|
4
|
21
|
|
Total
|
19
|
100
|
|
Gender
|
|
|
|
Female
|
12
|
63
|
|
Male
|
7
|
37
|
|
Total
|
19
|
100
|
|
Education
|
|
|
|
Do
not study at school
|
4
|
21
|
|
Elementary
school
|
8
|
42
|
|
High
school
|
5
|
26
|
|
College
|
2
|
11
|
|
Total
|
19
|
100
|
|
Occupations
|
|
|
|
Do not work
|
9
|
48
|
|
Trader/ Farmer
|
4
|
21
|
|
Self-employed
|
4
|
21
|
|
Civil Servants
|
2
|
10
|
|
Total
|
19
|
100
|
Based on table
4 above shows that the most significant number of respondents in this study
were in the age range of 54-64 years, namely 8 people (42%), and the lowest
number of respondents was >65 years of age, as many as 4 people (21%), most
of them were women 12 people (63%). Most have primary education as many as 8
people (42%). Meanwhile, the job characteristics show that most respondents are
not working as many as 9 people (47.5%), and the lowest job is a civil servant
as many as 2 people (10.5%).
Table 2
Average
sensitivity value before the intervention of Buerger Allen exercise
|
Category
|
Right
leg
|
%
|
Left leg
|
%
|
|
Normal (score
10)
|
0
|
0
|
0
|
0
|
|
Decreased
(score <10)
|
9
|
42
|
6
|
32
|
|
Total
|
19
|
100
|
19
|
100
|
The table above shows that the results measuring
the sensitivity of the right foot and left foot, as many as 19 people (100%) of
respondents experienced a decrease in foot sensitivity.
Table 3
Foot
sensitivity category after Buerger Allen exercise
intervention Leg
|
Category
|
Right
foot
|
%
|
Left foot
|
%
|
|
Normal (score
10)
|
11
|
58
|
13
|
68
|
|
Decreased (score
<10)
|
9
|
42
|
6
|
32
|
|
Total
|
19
|
100
|
19
|
100
|
Table 3 shows that the sensitivity measurement results foot after Buerger Allen exercise, and on the left foot,
as many as 13 people (68%) experienced an improvement in sensitivity.
The
table above shows that the results in the pre-test obtained an average right
foot sensitivity value of 6.63 with a standard deviation of 1.212 and an
average foot sensitivity value of 6.58 with a standard deviation of 0.961.
Meanwhile, the post-test obtained an average sensitivity value on the right
foot, which was 9.47 with a standard deviation of 0.697, and a mean on the left
foot was 9.63 with a standard deviation of 0.597. The right foot has a minimum
value of 5 and a maximum value of 9. The left foot has a minimum value of 5 and
a maximum value of 8. The right leg has a minimum value of 8 and a maximum
value of 10. On the left foot, it has a minimum value of 8 and a maximum value
of 10.
The
results of statistical tests using the Wilcoxon on the SPSS 16.0 computerized
system obtained a p-value = 0.000 < 0.05, where the hypothesis is null (H0) is
rejected, or the alternative hypothesis (Ha) is
accepted, which means "There is an Effect Buerger
Allen Exercise on Foot Sensitivity of Diabetes Mellitus Patients in the work
area of the Mantang Health Center
in 2021".
B.
Discussion
Based
on the foot sensitivity data obtained before the Buerger
Allen exercise, 19 respondents (100%) experienced foot sensitivity problems.
The measurement results show that the average sensitivity value of the right
foot is 6.63, and the average sensitivity value of the left foot is 6.58.
Foot
sensitivity is stimulation in the isolated area affected by nerves and causes
various neuropathy problems. Increased lower extremity reactivity will cause
high red blood cell aggression, so blood circulation becomes slow and impaired
foot sensitivity. The factors that influence the increase in foot sensitivity
of diabetic patients are caused by age, gender, education, and occupation (Prasetyo, 2017). Factors that
affect the skin to stimuli include gender. It is also influenced by the
thickness of the skin (Wagner et al., 2001). Different skin
thicknesses can produce different touch sensitivity. This is because the
sensory nerve endings are located in the dermis tissue right at the border of
the epidermis and dermis (Kolarsick, Kolarsick, & Goodwin, 2011).
The
average elderly who had just experienced DM was more than 50 years old (Fathoni, Purnamawati, & Syafitri, 2019).
Generally, human age undergoes physiological changes that drastically decrease
rapidly after the age of 40 years. This decrease will risk a reduction in the
endocrine function of the pancreas to produce insulin and affect the
sensitivity of the receptors to decrease so that glucose in the blood increases
(Fathoni et al., 2019).
This is associated with a decrease in the sensitivity of the patient's feet (Sudoyo, 2009).
The
incidence of DM is higher in women compared to men. Hormones estrogen and progesterone affect how cells respond to
insulin (Clinic, 2010). After menopause,
changes in hormone levels will trigger fluctuations in blood sugar levels. This
causes the incidence of DM to be higher in women than men (Clinic, 2010).
People
with a high level of education will usually have a lot of health knowledge.
With this knowledge, people will have aware of maintaining their health (Irawan, 2010). Moreover, unhealthy eating patterns and lack of
physical activity trigger DM (Hariawan, Fathoni, & Purnamawati, 2019). Work makes the
body less mobile and can be a trigger for obesity. This will cause the body's
tissues to become less sensitive to the effects of insulin. So blood sugar is
in the blood and is difficult to leave and enter the cells. This aligns with ADA (2016)
statement that physical activity has significant benefits because blood glucose
levels can be controlled through physical activity and prevent complications.
One complication that occurs is neuropathy, which affects the sensitivity of
the feet as a sign that affects the symptoms of complications.
Based
on the study's results on 19 respondents after doing the Buerger
Allen exercise, the measurement of foot sensitivity increased compared to
before doing the Buerger Allen exercise. The number
of respondents for the normal category on the right foot is 11 people (58%),
and on the left foot is 13 people (68%). Meanwhile, the average sensitivity
value of the foot that improved on the right foot was 9.47, and the average
sensitivity value on the left was 9.63.
This
theory is supported by the idea of Nasution (2010), which states that
leg exercises can help improve the small muscles of the feet in diabetic
patients with neuropathy. In addition, it can strengthen the calf and thigh
muscles, overcome the limitations of joint motion and prevent deformities. The
limited amount of insulin in people with diabetes mellitus can cause blood
sugar levels to increase. This can cause damage to blood vessels, nerves, and
other internal structures, thereby obstructing the blood supply to the legs. As
a result, diabetic patients will experience impaired blood circulation in their
legs. Thus, with foot exercises in the form of Buerger
Allen exercise, patients with diabetes mellitus will be able to increase the
supply of blood flow to the feet so that changes in foot sensitivity increase (Nasution, 2010).
Exercises
that are carried out to increase the circulation of microvascular blood flow in
the muscles must be carried out continuously and repeatedly. This is associated
with widening of the arteries (vasodilation) and increased capillary
permeability, allowing glucose absorption by cells (Rosales-Valderrain
et al., 2013). Moreover, regular physical exercise increases muscle capillary
density and insulin sensitivity in individuals with type 2 diabetes (Colberg et al., 2016). Average blood
circulation allows blood to deliver more oxygen and nutrients to body cells. Buerger Allen exercise is one of the variations of active
movement in the plantar area by applying the force of gravity so that each
stage of the training must be done regularly. Excellent and regular exercises
can help increase arterial and venous blood flow by opening capillaries (tiny
blood vessels in the muscles). This movement increases the vascularity of blood
vessels, thereby increasing the blood supply in the tissues (Salindeho et al., 2016).
Mellisha (2016)
found that to assess the effectiveness of Buerger
Allen exercise against peripheral perfusion disorders and lower extremity pain
in DM patients, and the evaluation can be carried out on day six. The results
pre-test the pain level of 4.33 (SD 1.88) with (p-value = 0.001). in addition,
according to research conducted by John and Rathiga (2015),
the Buerger Allen exercise with an exercise duration
of 10-15 minutes 2 times a day for 5 days can improve circulation. Furthermore,
a post-test was carried out on day 5 using the ankle-brachial index (ABI). The
result is that (p-value = < 0.05). Turan's (2015)
research shows that Buerger Allen exercise can
increase blood supply to the extremities and potentially cause the formation of
new vascular structures. Vijayabarathi (2016)
proved that Buerger Allen exercise could increase
vascularization and blood supply to the injured area in people with type 2
diabetes mellitus (such as ulcers and gangrene), thus helping the wound healing
process.
Based
on the results of the study for 1 week, which was carried out for 4 days
alternately a day, carried out in the morning and evening, the results in the
pre-test obtained an average right foot sensitivity value of 6.63 with a
standard deviation of 1.212 and an average left foot sensitivity value of 6.63.
6.58 with a standard deviation of 0.961. The right foot has a minimum value of
5 and a maximum value of 9. On the left foot, it has a minimum value of 5 and a
maximum value of 8. Meanwhile, the post-test obtained an average sensitivity
value on the right foot, which was 9.47 with a standard deviation of 0.697, and
a mean on the left foot was 9.63 with a standard deviation of 0.597. the right
foot has a minimum value of 8 and a maximum value of 10. On the left foot, it
has a minimum value of 8 and a maximum value of 10.
The
results of statistical tests using the Wilcoxon on the SPSS 16.0 computerized
system obtained a p-value = 0.000 < 0.05, where the hypothesis is null (H0) is
rejected or the alternative hypothesis (Ha) is
accepted, which means "There is an Effect Buerger
Allen Exercise on Foot Sensitivity of Diabetes Mellitus Patients in the work
area of the Mantang Health Center
in 2021".
This
study's results align with Endriyanto's (2012)
research, which states that physical activity can increase foot sensitivity.
Because it can improve blood flow, strengthen small muscles, prevent foot
deformities, overcome joint motion limitations, and enhance the fitness of
diabetes mellitus clients. Therefore, doing Buerger
Allen exercise can help increase foot sensitivity in people with diabetes
mellitus (Endriyanto, 2012).
This research was corroborated by Chang et al. (2016)
found that the Buerger Allen exercise positively
impacts circulation, improves blood flow, improves walking ability, reduces
necrosis, and prevents embolism, pain, and cyanosis in blood vessels. Buerger Allen exercise is effective in improving lower
extremity perfusion among patients with diabetes mellitus; there is a
significant increase in more inadequate extremity perfusion and pain reduction
in patients who have been given Buerger Allen
exercise in type 2 DM patients. Gravity helps to empty the veins and fill the
blood vessel column. Arteries alternately in the legs, ultimately increasing
blood transport through leg exercises (Bottomley, 2007).
CONCLUSION
Based on the results
of this study, the results of statistical tests that researchers have carried
out show that Buerger Allen exercise affects foot
sensitivity in patients with diabetes mellitus. Buerger
Allen exercise is one of several other non-pharmacological measures that can
help increase foot sensitivity in patients with diabetes mellitus.
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