EFFECTIVENESS OF BUERGER ALLEN EXERCISE ON LOWER

EXTREMITY PERFUSION AMONG PATIENTS WITH TYPE 2

DIABETES MELLITUS IN SELECTED HOSPITALS AT
KANNIYAKUMARI DISTRICT

A DISSERTATION SUBMITTED TO THE TAMILNADU

DR. M.G.R MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILLMENT

FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING

OCTOBER 2018
EFFECTIVENESS OF BUERGER ALLEN EXERCISE ON LOWER
EXTREMITY PERFUSION AMONG PATIENTS WITH TYPE 2
DIABETES MELLITUS IN SELECTED HOSPITALS AT
KANNIYAKUMARI DISTRICT.

INTERNNАL EXАMINER EXTERNAL EXAMINER

EFFECTIVENESS OF BUERGER ALLEN EXERCISE ON LOWER
EXTREMITY PERFUSION AMONG PATIENTS WITH TYPE 2
DIABETES MELLITUS IN SELECTED HOSPITALS AT
KANNIYAKUMARI DISTRICT.

Approved by the Dissertation Committee on: ……………………………..

RESEARCH GUIDE:
Prof. (Mrs). ReetaJebakumari Solomon. M.Sc(N)., Ph.D.,
Principal,
Thasiah College of Nursing, Marthandam,
K.K. District, Tamil Nadu.62915
SUBJECT GUIDE:
Mrs.FаbhаGifty.M.Sc (N)
Associаte professor,
Head of the Department in Medicаl Surgicаl Nursing,
Thasiah College of Nursing, ,Marthandam,
K.K. District, Tamil Nadu.629165
MEDICAL GUIDE:
Dr.Frаnklin Joseph M.B.B.S, D.Diаb
Diаbetologist
Mаriа Diаbetic centre

A DISSERTATION SUBMITTED TO THE TAMILNADU

DR. M.G.R MEDICAL UNIVERSITY, CHENNAIIN PARTIAL
FULFILLMENTFOR THE DEGREE OF MASTER OF SCIENCE IN NURSING

OCTOBER 2018
 CERTIFICATE

This is to certify that this is a bonafide work of Mrs.Hemаlаthа K II year M.Sc.

Nursing, Thasiah College of Nursing, Marthandam, in Partial fulfillment of the
requirement, for the Degree of Master of Science in Nursing.

Prof. (Mrs). ReetaJebakumari Solomon. M.Sc(N)., Ph.D.,

Principal,
Thasiah College of Nursing, Marthandam,
K.K. District, Tamil Nadu.62915

Place: Marthandam
Date :
 ACKNOWLEDGEMENT

I wish to acknowledge my heartfelt gratitude to the Lord Almighty for all the
wisdom, knowledge, guidance, strength, protection, shield and support offered me
throughout this endeavour and given me courage to overcome the difficulties and thus
complete this study successfully.

It is my honour to thank our beloved chairman Mr. C. Thasiah (Germany), for

providing entire facility and encouragement for conducting this study.

I, consider myself to be privileged to express my honest and sincere gratitude to

Prof. (Mrs).ReetaJebakumari Solomon. M.Sc(N)., Ph.D., Principal cum professor,
Thasiah college of Nursing, for her invaluable guidance, continuous support, promising
criticisms, suggestions and concern during the entire course of this dissertation.

I would like to grаtefully аcknowledge the support of а very speciаl individuаl

Dr.Frаnklin Joseph M.B.B.S, D.Diаb (Diаbetologist) MаriаDiаbeticcentre. He helped
me immensely by giving me his kind permission to complete this study. He mirrored
bаck my ideаs so thаt I heаr them аloud, аnimportаnt process to shаre this thesis pаper. I
cаn only sаy а proper thаnks to him through my future work by helping аsmаnypаtientsаs
possible. It is my long felt desire to express my heаrtiestgrаtitude to him for devoting his
аttention, time аnd support, which gаve me аn impetus to complete this study.

My heartfelt thanks to Mrs.Ahitha., MSc(N)., Viceprincipal I/Cfor her

encouragement and support given during this work.

I extend my whole hearted thanks to enthusiastic personality who is my research

Guide Asso. Prof. Mrs. FаbhаGiftyM.Sc(N)., HOD of Medical Surgical Nursing,
Thasiah college of Nursing, for her invaluable suggestions and support which benefited a
lot while developing this dissertation

.I express my thanks to entire teaching staff inThasiah College of Nursing,

Marthandam, for their co-operation and encouragement.
 My sincere thanks and honour to Mr.Anto paulin brinto, MSc., Med., MPhil.,
PG., DBM., Professor of Bio statistics for extending his helping hands in the course of
analysis and interpretation of the data collected.

I thank all the non teaching staff for their help in taking photocopies of study
reviews

I would like to thank our librarianMrs.Kavitha for extending help in refer

research material for the study.

I express my deep sense gratitude and heartfelt thanks to experts who have
validated, edited my study, and devoted their valuable hours in solving my doubts .

I would like to express my thanks to the Study Participants for their co-
operation and participation, without whom this study would have been impossible.

I am pleased to convey my profound thanks to the mаnаgement of Morris

Mаthiаs hospitаl, for giving valuable suggestion, guidance for data collection and also
for giving permission to conduct the study in their respective institution.

Words will not be sufficient to thank my family and friends for their support
throughout these studies. Special thanks to mylovаble husband Mr.Subаsh,beloved
sonS.H. Jаshithand my parentsand my brother k. Suresh for their help, support, and
encouragement throughout my studies and my life.

A word of thanks to my colleagues for their help and support throughout the
course of this study.
 TABLE OF CONTENTS

CHAPTER CONTENT PAGE NO

NO
I INTRODUCTON

Back ground of the study 1

Need for the study 5

Statement of problem 9
Objectives 9
Hypothesis 9
10
Operational definition
Assumption 11
Delimitation 11
Projected outcome 11
Conceptual framework 12
II REVIEW OF LITERATURE
General information related to pаtients with type 2 15
diаbetes mellitus аnd Peripheral vascular disease
Studies related diаbetes mellitus аnd Peripheral 21
vascular disease
General information relаted Buerger Allen exercise 23
Studies related to Buerger’Allen exercise 25
Studies related to effectiveness of Buerger’sAlen exercise on 27
lower extremity perfusion.
III RESEARCH METHODOLOGY
Research approach 29
Research design 29

Setting of the study 30

Population 30

Sample size 30
 Sampling technique 31

Criteria for sampling selection Vаriаbles 31

Vаriаbles 31

Description of the tool 32

Content validity 33

Reliability 33

Pilot study 33

Method of data collection 35

Plan for data analysis 36

Ethical consideration 36

IV DATA ANALYSIS AND INTERPRETATION 38

V DISCUSSION 69

74
VI SUMMARY, CONCLUSION, LIMITATIONS,
NURSING IMPLICATIONS AND
RECOMMENDATION
REFERENCE 81

ANNEXURE
 LIST OF TABLES

Page
Table No Title No

Frequency and percentage distribution of the level of lower 39

1.
extremity perfusion among patients with diabetes mellitus
according to the demographic variables in experimental and
control group
Frequency and percentage distribution of the level of lower 42
2.
extremity perfusion among patient with diabetes mellitus
according to the clinical variables in experimental and control
group.
Frequency and percentage distribution of pre test and post test 45
3.
level of lower extremity perfusion in right leg among patients
with diabetes mellitus in experimental and control group.
Frequency and percentage Distribution of pre test and post test 47
4.
level of lower extremity perfusion in left leg among patients with
diabetes mellitus in experimental and control group
Comparison of pre test and post test level of lower extremity 49
5.
perfusion score in right leg among patients with diabetes mellitus
in both experimental and control group

Comparison of pre test and post test level of lower extremity 52

6.
perfusion score in left leg among patients with diabetes mellitus
in both experimental and control

Compаrision of post test level of lower extremity perfusion score 55

7.
in Right leg аmong pаtient with diаbetes mellitus in experimentаl
аnd control group
 LIST OF TABLES – Cont’d

Table No Title Page

No
8. Compаrision of post test level of lower extremity perfusion 57
score in Right leg аmong pаtient with diаbetes mellitus in
experimentаl аnd control group

9. Association between the post test level of lower extremity 59

perfusion in Right leg аmongpаtients with diаbetes mellitus
in experimentаl group with their selected demographic and
clinical variable
10. Association between the post test level of lower extremity 62
perfusion in Right leg аmong pаtients with diаbetes
mellitus in control group with their selected demographic
and clinical variable
11. Association between the post test level of lower extremity 64
perfusion in left leg among patients with diabetes mellitus
in experimental group with their selected demographic and
clinical variable
12. Association between the post test level of lower extremity 69
perfusion in left leg аmong pаtients with diаbetes mellitus
in control group with their selected demographic and
clinical variable
 LIST OF FIGURE

Figure Title Page

No No

1. Conceptuаl frаme work bаsed on Daniel stuffle Beаm’s 14

CIPP Model
2. Schematic presentation of 37
methodology
3. percentage distribution of the level of lower extremity 41
perfusion among patient with diabetes mellitus according
to their аge
4. percentage distribution of the level of lower extremity 41
perfusion among patient with diabetes mellitus according
to their type of job
5. percentage distribution of the level of lower extremity 44
perfusion among patient with diabetes mellitus according
to their Durаtion of illness

6. percentage distribution of the level of lower extremity 44

perfusion among patient with diabetes mellitus according
to their аssociаted diseаse

7. percentage distribution of pre test level of lower extremity 46

perfusion in right leg among patient with diabetes mellitus
both experimental and control group

8. percentage distribution of post test level of lower extremity 46

perfusion in right leg among patient with diabetes mellitus
both experimental and control group

9. percentage distribution of pre test level of lower extremity 48

perfusion in left leg among patient with diabetes mellitus
both experimental and control group

10. percentage distribution of post test level of lower extremity 48

perfusion in left leg among patient with diabetes mellitus
both experimental and control group
11. Comparision of pre test and post test level of lower 51
extremity perfusion score in right leg among patient with
diabetes mellitus in experimental group
12. Comparision of pre test and post test level of lower 51
extremity perfusion score in right leg among patient with
diabetes mellitus in control group
13. Comparision of pre test and post test level of lower 54
extremity perfusion score in left leg among patient with
diabetes mellitus in control group

14. Comparision of pre test and post test level of lower 54

extremity perfusion score in left leg among patient with
diabetes mellitus in control group

15. Comparision of post test level of lower extremity 56

perfusion score in right leg among patient with diabetes
mellitus both experimental and control group

16. Comparision of post test level of lower extremity 58

perfusion score in left leg among patient with diabetes
mellitus control group
 LIST OF ANNEXURE

ANNEXURE TITLE
NO

Letter seeking permission to conduct а study i

I
Letter granting permission to conduct а study in Maria Diabetic
II Centre

III Letter granting permission to conduct а study in Maria Diabetic

Centre

IV Letter seeking expert opinion for the validity of the tool

Evaluation criteria check list for validation

V
List of expert for tool validation
VI
Informed consent for project ( English, Tamil)
VII
Certificate for training in Buerger Allen exercise
VIII
Certificate for English editing
IX
Certificate for Tamil editing
X
Tools for data collection ( English, Tamil)
XI
Buerger Allen exercise( English)
XIX
XXII Photographs
 АBSTRАCT

Bаck ground of the study: Individuals with diabetes mellitus have a two to
fourfold increase in the rate of peripheral arterial disease. Peripheral arterial disease is a
slow and progressive disease with systemic atherosclerosis. Lower extremity exercise
helps to re-establish collateral blood flow to the legs and the heart. The аim of the study
is to assess the effectiveness of buerger allen exercise on levels of lower extremity
perfusion among patients with type 2 diabetes mellitus in selected hospitals at
Kanniyakumari District. Mаteriаl аnd Mаnаgement: Quasi experimental with Pre test
post test control group design was adopted in this study Non-probability purposive
sampling technique was used. Sixty patients with type 2 diabetes mellitus admitted in
Maria Diabetic centre and Morris Mathias hospital were grouped in to two groups.
Pаtients in experimental group were given buerger allen exercise for 3 times a day for 5
days, Modified Inlow’s 60 second diabetic foot screen scale was used to assess the lower
extremity blood circulation. Results: In pre test experimentаl group 14(46.7%) patients
had Inаdequаte perfusion, 16(54.3%) had severely inаdequаte perfusion and none of
them had аdequаte аnd moderаtely аdequаte perfusion. After the Buerger Allen Exercise
level of lower extremity perfusion wаs decreаsed аnd 13(43.3%) patients had adequаte
level of lower extremity perfusion, 17(56.7%) had moderаtely аdequаte perfusion and
none of them had inаdequаte аnd severely inаdequаte perfusion in experimentаl group.
There wаs significаnt reduction in meаn post test perfusion score
(MD=8.13,t=32.43,p=0.001) of the experimentаl group. The meаn post test perfusion
score in experimentаl group lesser thаn the post test perfusion score of control group
(MD=7.73,t=16.17,p=0.001). Conclusion:The majority of the patients in type 2 Diabetus
mellitus had shown significant improvement in the levels of lower extremity perfusion
through Buerger Allen Exercise.
 CHАPTER I

INTRODUCTION

To enjoy the glow of good health,

You must exercise

- Gene Tunney

BACKGROUND OF THE STUDY

Heаlthy life is the vаluаble gift of an individuаl, if а person is healthy enough, he

is the richest person in his own world."Healthy living" to most people means both
physical and mental health are in balance or functioning well together in a person. In
many instances, physical and mental health are closely linked, so that a change (good or
bad) in one directly affects the other Physical activity and exercise is a major contributor
to a healthy lifestyle; people are made to use their bodies, and disuse leads to unhealthy
living. Unhealthy living may manifest itself in obesity, weakness, lack of endurance, and
overall poor health that may foster disease development. Physical inactivity and lack of
exercise are associated with type II diabetes mellitus (also known as maturity or adult-
onset, non-insulin-dependent diabetes (Mohammed E., 2013)

Diabetes is the most common metabolic disorder affecting populations in all

geographical regions of the world. The prevalence of diabetes is influenced by genetic,
ethnic and socioeconomic factors. The World Health Organization (WHO) has projected
that the prevalence of diabetes is increasing in epidemic proportions especially in
developing countries. India has the highest number of people with Diabetes in the World.

Globally, it is estimated 422 million adults are living with diabetes mellitus,
according to the latest 2016 data from the World Health Organization (WHO). Diabetes
prevalence is increasing rapidly; previous 2013 estimates from the International Diabetes
Federation put the number at 381 million people having diabetes. The number is
projected to almost double by 2030. Type 2 diabetes makes up about 85-90% of all cases.
Increases in the overall diabetes prevalence rates largely reflect an increase in risk factors
for type 2, notably greater longevity and being overweight or obese.

Until recently, India had more diabetics than any other country in the world,
according to the International Diabetes Foundation, although the country has now been
surpassed in the top spot by China. Diabetes currently affects more than 62 million
Indians, which is more than 7.1% of the adult population. The average age on onset is
42.5 years.Nearly 1 million Indians die due to diabetes every year. India is one of the 6
countries of the International Diabetic Federation - South East Asia region. 425 million
people have diabetes in the world and 82 million people in the South East Asia region; by
2045 this will rise to 151 million. There were over 72 million cases of diabetes in India in
2017.

One out of 10 people in Tamil Nadu is diabetic, and every two persons in a group
of 25 are in the pre-diabetic stage. These statistics from phase 1 of the Indian Council of
Medical Research's INDIAB

Diabetes mellitus is a group of metabolic disease, characterized by

hyperglycemia resulting from defect in insulin secretion, insulin action or both. The basis
of the abnormalities in carbohydrate, protein, and fat metabolism in diabetes is a deficient
action of insulin on the target tissue of skeletal muscle, adipose tissue, and liver.
Uncontrollable DM may result in long term damage, dysfunction and failure of various
organs especially the heart, kidney and eyes. The new system reflects the etiology and
pathophysiology of diabetes with two major categories being type 1 diabetes mellitus and
type2 diabetes mellitus. Their end result in hyperglycemia. Type 1 is caused by lack of
insulin production by beta cells. Type 2 is the most common and is caused by deficiency
or inadequacy of insulin receptors in cells. (Brunner and Suddarth.,2008)

Type 2 diabetes mellitus can be easy to ignore, especially in the early stages. But
type 2 diabetes mellitus affects many major organs including heart, blood vessels, nerves,
eyes and kidneys. Control the blood sugar levels can help to prevent these complications.
Although long term complications of diabetes develop gradually, client can eventually be
disabling or even life threatening. Some of the potential complications of diabetes
includes heart and blood vessel disease, nerve
damag(neuropathy),eyedamage(retinopathy),kidneydamage(nephropathy),foot damage,
hearing impairment, lower extremity amputation and Alzheimer’s disease. (Lewis.,2008)

In people with diabetes, the risk of Peripheral arterial disease is increased by age,
duration of diabetes, and presence of peripheral neuropathy. African Americans and
Hispanics with diabetes have a higher prevalence of Peripheral arterial disease than non-
Hispanic whites, even after adjustment for other known risk factors and the excess
prevalence of diabetes. It is important to note that diabetes is most strongly associated
with femoral-popliteal and tibial (below the knee) Peripheral arterial disease.

At present, there are no established guidelines regarding the care of patients with
both diabetes and Peripheral arterial disease. Peripheral arterial disease is a manifestation
of atherosclerosis characterized by atherosclerotic occlusive disease of the lower
extremities and is a marker for atherothrombotic disease in other vascular beds.
Peripheral arterial disease affects ∼12 million people in the U.S. it is uncertain how many
of those have diabetes. Data from the Framingham Heart study revealed that 20% of
symptomatic patients with Peripheral arterial disease had diabetes, but this probably
greatly underestimates the prevalence, given that many more people with Peripheral
arterial disease are asymptomatic rather than symptomatic. As well, it has been reported
that of those with Peripheral arterial disease, over one-half are asymptomatic or have
atypical symptoms, about one-third have claudication, and the remainder have more
severe forms of the disease .(Marso, p. et al.,2010)

Peripheral artery disease most commonly affects the legs, but other arteries may also
be involved. The classic symptom is leg pain when walking which resolves with rest,
known as intermittent claudication. Other symptoms including skin ulcers, bluish skin,
cold skin, or poor nail and hair growth may occur in the affected leg. Complications may
include an infection or tissue death which may require amputation Peripheral arterial
disease is a condition characterized by atherosclerotic occlusive disease of the lower
extremities. While Peripheral arterial disease is a major risk factor for lower-extremity
amputation, it is also accompanied by a high likelihood for symptomatic cardiovascular
and cerebrovascular disease. Although much is known regarding Peripheral arterial
disease in the general population, the assessment and management of Peripheral arterial
disease in those with diabetes is less clear and poses some special issues. At present,
there are no established guidelines regarding the care of patients with both diabetes and
Peripheral arterial disease. (Ashok, p. et al 2013)

Peripheral arterial disease is a complication of diabetes that happens when blood

vessels in the legs become blocked or narrowed due to fat deposits. The result is reduced
blood flow to the feet and legs. The condition affects around 1 in 3 people with diabetes
over the age of 50, and increases the risk of heart attack and stroke.

Perfusion is the passage of fluid through the circulatory system or lymphatic

system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed
in tissue. Heart tissue is considered over perfusion because they normally are receiving
more blood than rest of tissue in organism; they need this blood because they are
constently working. Peripheral arterial disease is one of the leading conditions that can
alter perfusion and thereby increase susceptibility to localized tissue ischemia,
contributing to delay healing of lower extremity ulcers. Peripheral arterial disease is
primarily caused by progressive atherosclerotic changes in the arteries reducing normal
blood flow to the lower extremities Diabetes causes significant and extensive structural
changes in the vascular system, increasing the risk of developing atherosclerosis (large-
and medium-sized arteries) and inducing a specific lesion in microcirculation (small
vessels). Hyperglycemia is responsible for the excess production of reactive oxygen
species that damage and interfere with normal endothelial functions.(Pert-
Jerodlyceff.,2015)

Exercise is physical activity that is planned structured and repetitive for the
purpose conditioning any part of the body. Exercise is used to improve health, maintain
fitness and is important as a means of physical rehabilitation. Exercise is the
fundamental principle for preventing the peripheral vascular disease among diabetes
patients. One of the exercise is Buerger allen exercise, is an active postural exercise of
the feet and legs for preventing peripheral vascular disease and promoting collateral
circulation in lower extremities.(Edward,B et al,2009)

Before and after World War II, medical experts did not know how to operate or
treat the patient suffering from atherosclerosis or vessel occlusion, as well as stiffening
in their peripheral arteries. Some medical genius at that time developed postural
treatment to improve circulation in the lower extremities. 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
blood.It has been considered as a strategy for improving lower extremity perfusion.
However, lack of evidenced- based studies to support. It was increase the rate of blood
flow, clear away stagnant blood and help establish collateral circulation to the ischemic
area. it can prevent and treat diabetic foot problems, shortened any period of
hospitalization, and delayed morbidity . Furthermore, the beneficial effects of Buerger’s
exercises in patients with diabetic foot problems. These effects are due to improving
neuropathy, infection, pain, and arteriosclerosis with or without gangrene. Buerger’s
exercises are seen as a conservative treatment of the peripheral vascular disease, low cost
and low risk physical activity that most diabetes patients could undertake at home.
Therefore, the objective of this study was to systematically review the evidence for the
effectiveness of Buerger’s exercise on the peripheral circulation or diabetic foot
ulceration. (Allen, A.W 1999)
Nurses play very important role in improving lower extremity perfusion among
type 2 Diabetes mellitus patients. Buerger Allen exercise is easy to perform without any
risk and without any expenses, the obvious substantiation that Buerger Allen exercise
improves the lower extremity perfusion.
NEED FOR THE STUDY

Diabetes mellitus, known commonly as diabetes, is a disease that occurs when the
pancreas does not produce enough insulin, or when the body cannot effectively use the
insulin it produces. Individuals with diabetes mellitus have a two to fourfold increase in
the rate of peripheral arterial disease. People with long standing Diabetes mellitus
develop complication of Peripheral Arterial Disease. Peripheral Arterial Disease leads to
grave complication like gangrene in the lower limbs

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 loss. Buerger Allen Exercise is one of the interventions
to stimulate the development of collateral circulation in the legs.

Diabetes mellitus occurs throughout the world, but is more common (especially
type 2) in the more developed countries. The greatest increase in prevalence is, however,
occurring in low- and middle-income countries including in Asia and Africa, where most
patients will probably be found by 2030. The increase in incidence in developing
countries follows the trend of urbanization and lifestyle changes, including increasingly
sedentary lifestyles, less physically demanding work and the global nutrition transition,
marked by increased intake of foods that are high energy-dense but nutrient-poor (often
high in sugar and saturated fats, sometimes referred to as the Western pattern diet). The
risk of getting type 2 diabetes has been widely found to be associated with lower socio-
economic position across countries. (Escol.,2014)

Global prevalence of diabetes mellitus (DM) in adults has been estimated at 8.3%
in 2011 and will rise to 9.9% by 2030, affecting over 350 million individuals. Diabetic
foot complication is a major cause of disability, reduced quality of life, prolonged
hospitalization, financial loss, lower limb amputation, and mortality rate. People with
diabetes develop foot ulcers because of neuropathy, vascular insufficiency, and impaired
wound healing. Nearly 90% of diabetes-related lower limb amputations were preceded by
foot ulcers. In addition, conventional treatments such as operation and infection control to
cure diabetic foot ulcers are often ineffective. (King H.,2004)

The Indian Diabetes federation estimated 381 million people have Diabetes
Globally in 2013 by 2035 this will rise to 592 million .The number of people with type 2
diabetes is increasing in every country and 80% of people with diabetes live in low- and
middle-income countries. The greatest number of people with diabetes is between 40 and
59 years of age 3. India currently has 62.4 million people with diabetes and is home to
the second highest number of people living with diabetes in the world. In India and other
developing countries, the amputation rate is about 45% for peripheral arterial disease due
to diabetes mellitus. In India, the recent Indian Council of Medical Research-Indian
Diabetes study reported the prevalence of diabetes mellitus and related lower extremity
arterial disease (both known and newly diagnosed) in 4 regions of the country: 10.4% in
Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 11.6% in Chandigarh (Union
Territory). In Chennai the incidence of peripheral arterial disease is about 6-8 per cent
among diabetes mellitus patients who come to the outpatient unit. In those who are over
60 years, it is higher at 30 percent. (The Hindu. 2011, Sep 6)

The WHO estimates that diabetes resulted in 1.5 million deaths in 2012, making it
the 8th leading cause of death. However another 2.2 million deaths worldwide were
attributable to high blood glucose and the increased risks of associated complications
(e.g. heart disease, stroke, kidney failure), which often result in premature death and are
often listed as the underlying cause on death certificates rather than diabetes.

In 2015 about 155 million people hadperipheral arterial disease worldwide. In the
developed world it affects about 5.3% of 45 to 50 years olds and 18.6% of 85- to 90-year-
olds.In the developing world it affects 4.6% of people between the ages of 45 to 50 and
15% of people between the ages of 85 to 90. In the developed world peripheral arterial
disease is equally common among men and women while in the developing world
women are more commonly affected. In 2015 peripheral arterial disease resulted in about
52,500 deaths up from 16,000 deaths in 1990.

There are various strategies for organizing and prioritizing the vast amount of
information that must be thought to patients with diabetes. In addition, many hospitals
and out patient diabetes centres have divised written guidelines, care plans and
documentation forms that may be used to document and evaluate teaching. One approach
is to organize education using the seven tips for managing diabetes identified and
developed by the Americаn Associаtion of Diаbetes Educаtors(2004). They аre healthy
eating, being active, monitoring, taking medicines, problem solving, reducing risks,
healthy coping.(Brunner and Siddarth.,2008)

A study to assess the effectiveness of Buerge Allen exercise on level of lower

extremity perfusion among type 2 diabetes mellitus patients in experimental group.
During clinical posting in the Saveetha Medical College Hospital Chennai, the
investigator came acrossmanypatient with type II diabetes mellitus who is suffered from
a peripheral artery disease due to inadequatelower extremity perfusion and in helpless
situation due to lack of knowledge regarding management of peripheral artery disease.
By this experience, the investigator felt that nurses has an important role in educating the
patients regarding supervised exercise like Buerger’sAllen Exercise. Quasi Experimental
pre – test and post test design. Non probability convenient sampling technique was used.
A total of 60 admitted patients participated in the study. ABPI Scale was used toassess
the level of lower extremity perfusion for data collection. Result: There is a significant
improvement in the level of lower limb perfusion in experimental group after Buerger
Allen exercise than the control group among patient with type 2 diabetes mellitus at
(p<0.001). Conclusions: This study indicates that Buerger Allen Exercise is a simple non
pharmacological and effective method for the management of lower limb perfusion
among the patient with type 2 diabetes mellitus.

A study was conducted to quantify the distribution of the peripheral vascular

disease in diabetics and non - diabetic patients attending angiography, to compare
severity and the outcome between both groups of patients. The study was conducted in
136 patients and 58(43%) patients were diabetic. This study confirmed that diabetic
patients have more worsened peripheral vascular disease and are at high risk of lower
extremity amputation than non-diabetes patients. Diabetes patients with peripheral
vascular disease also had high mortality and died at a younger age than non-diabetes
patient (Edwin Stephen., 2011)

Considering the above factors the investigator found that many clients with
diabetes mellitus have increase in the rate of peripheral arterial disease and arthero
sclerosis, The clients expressed that they need an intervention to improve lower extremity
perfusion, prevent diabetic foot ulceration, reducing venous embolism, pain, swelling,
cyanosis and necrosis. Based on the review of literature buerger allen exercise improves
the collateral perfusion, so investigator planned to conduct a study to improve lower
extremity perfusion among type 2 diabetes mellitus patients.

PROBLEM STATEMENT

A study to assess the effectiveness of buerger allen exercise on lower extremity

perfusion among patients with type 2 diabetes mellitus in selected hospitals at
Kanniyakumari District.

OBJECTIVES;

 To assess the levels of lower extremity perfusion among patients with type 2
diabetes mellitus in both experimental and control group.
 To find out the effectiveness of buergerallen exercise on levels of lower
extremity perfusion among patients with type 2 diabetes mellitus.
 To determine the association between the post test levels of lower extremity
perfusion among patients with type 2 diabetes mellitus and the selected
demographic variables such age, sex, marital status, religion, education, dietary
pattern, type of job.
 To determine the association between the post test levels of lower extremity
perfusion among patients with type 2 diabetes mellitus and the selected clinical
variables suchdurаtion of diаbetes mellitus, аssociаted illness, and fаmily history
of peripherаlаrterydiseаse .
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 buergerallen 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, sex, marital status, religion, education, dietary
pattern, and type of job.

H4; 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 durаtion of diаbetes mellitus, аssociаted illness, and
fаmily history of peripherаl аrtery diseаse

OPERATIONAL DEFINITION

1. Effectiveness

The degree to which something is successful in producing a desired result;

success

In this study it refers to the significant difference in level of lower extremity

perfusion before and after buergerallen exercise among patients with type 2 diabetes
mellitus, as measured by Modified inlow’s 60 second diabetic foot screen scale

2. Buerger Allen exercise

Buerger allen exercise intended to improve circulation to the feet and legs. аlso
relieve the symptoms in patients with lower limbs arterial insufficiency. (Buerger,1996)
 In this study it refers to the exercise intended to improve circulation to the feet and
legs. Buerger allen exercise was given for 20 minutes three times per day with 3 hours
interval for the period of 5 days

3.Lower extremity perfusion

Perfusion is the passage of fluid through the circulatory system or lymphatic

system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed
in tissue.( Thomson Reuter.,20110)

In this study Lower extremity perfusion refers to blood circulation to the lower
extremity assessed before and after the intervention measured by Modified Inlow’s 60
second diabetic foot screen scale

It involves the assessment level of lower extremity perfusion

Score 0 – 3 Adequate perfusion

Score 4 – 8 Moderately Adequate perfusion

Score 9 – 13 Inadequate perfusion

Score 14 – 18 Severely inadequate perfusion

4.Type 2 diabetes mellitus

Type 2 diabetes mellitus consists of an array of dysfunctions characterized by

hyperglycemia and resulting from the combination of resistance to insulin action,
inadequate insulin secretion, and excessive or inappropriate glucagon secretion. (Brinda
Nichols., 2008)

In this studyit refers to, patients both men and women of age between 45-85 years
whohave been diagnosed to have type 2 diabetes mellitus.

ASSUMPTIONS

 Type 2 diabetes mellitus patients experience hypo and hyper perfusion.

  Buerger Allen exercise is one of the effective method of treatment for
improving lower extremity perfusion, walking ability, reducing necrosis,
reducing venous embolism, pain swelling and cyanosis.
 Buerger Allen exercise has no side effects.

.DELIMITATIONS

The study is limited to

 Patients with type 2 diabetes mellitus

 Age group between 45-85 years
 Data collection period limited to 4 weeks only
 Sample size of 60 only.

PROJECTED OUTCOME

 Buerger Allen exercise will have effectiveness on improving lower extremity

perfusion and facilitate the sense of wellbeing among the patients with type 2
diabetes mellitus.
 Buerger Allen exercise will be effective in reducing swelling and pain
 Buerger Allen exercise will have effectiveness in reducing venous embolism,
necrosis and cyanosis

CONCEPTUAL FRAME WORK

Conceptualization is the process of forming ideas, designs and plans. Conceptual

frame work deals with abstractions that are assembled by virtue of their relevance to a
common theme. The present study aimed to evaluate the effectiveness of Buerger Allen
Exercise on level of lower extremity perfusion among selected type 2 diabetes mellitus
patient.

The conceptual framework set up for the study was modified model of Stuffle
Beаm’s evаluаtion model planned pogramme. Daniel stuffle Beаm’s CIPP(context, input,
process and product) Model´ prescribes four areas of evaluation, context, input, process
and product. It provides a comprehensive, systematic and continuously ongoing
framework for programme evaluation.

Step I : Context evaluation

Step II: Input evaluation

Step III: Process evaluation

Step IV: Product evaluation

The core value for present study was to enhance the Buerger Allen Exercise on
levels of lower extremity perfusion among patient with selected type 2 diabetes mellitus
patient.

Context evaluation

The context evaluation assess the needs, problems, assets and opportunities to
help decision makers to define goals and priorities and help the broader group of users to
judge goals, priorities and outcomes. The goal of a present study was to assess the level
of lower extremity perfusion and practice of Buerger Allen Exercise. The patients with
Diabetes Mellitus have the risk of Peripheral Vascular Disease, So ABI scale and
Modified Inlow’s 60 second diabetic foot screen scale was prepared by the researcher to
find the level of lower extremity perfusion.

Input evaluation

It involves the steps and resources needed to meet the goals and objectives and
might include identifying successful external programmes and materials as well as
gathering information. The input evaluation assess the alternative approaches, competing
action plans, cost effectiveness to meet targeted needs and achieve goals.The input
evaluation step prepared the Demographic profiles and to measure the lower extremity
perfusion by ABI Scale and Modified Inlow’s 60 second diabetic foot screen scale was
prepared to assess the effectiveness of Buerger Allen Exercise on levels of lower
extremity perfusion. The investigator prepared the demonstration of Buerger Allen
Exercise and, planned to achieve the goals and objectives of the study.
Process evaluation

Process evaluation assess the implementation of plans to help the investigator

carryout activities and later help the broad group of users, judge the program
performance and interpret outcomes.

Action done in the step was pretest assessment of lower extremity perfusion of
patients with selected type 2 diabetes mellitus patients using the Ankle Brachial Index
Scale and Modified Inlow’s 60 second diabetic foot screen scaleprepared by the
researcher. Buerger Allen exercise was administered five days in three times per day. The
lower extremity perfusion was reassessed on sixth day, after administration of Buerger
Allen Exercise.

Product evaluation

The product evaluation identifies and assesses outcomes of short term and long
term both intended and unintended, which help the investigator to keep an enterprise
focused on achieving important outcomes and ultimately to help the broader groups in
meeting targeted needs. The level of lower extremity perfusion improved after
administration of Buerger Allen Exercise among patients with selected type 2 diabetes
mellitus patients. The risk of Peripheral vascular disease is reduced and also the patients
with selected type 2 diabetes mellitus patientswill be able to practice Buerger Allen
Exercise regularly.
 CHAPTER : 2

REVIEW OF LITERATURE

Review of literature is systematic identification, critical analysis and reporting of

existing information on the topic of material for the study. The review of literature is a
key step in research process excessive review of literature relevant to research was alone
to collect maximum information for laying foundation of this study. The purpose of
review of literature is to gain maximum relevant information and perform the study in a
scientific manner.

Literаture relevаnt for this study hаs been organized in the following sequences;

Section I :Generаl informаtionrelаted to patients with type 2 diabetes mellitus and

Peripheral vascular disease

Section II : Studies related to diabetes mellitusandperipheral vascular disease

Section III : Generаlinformаtionrelаted toBuerger’s Allen exercise

Section IV : Studies related toBuerger’s Allen exercise

Section V : Studies related to effectiveness of Buerger’s Allen exercise on lower

extremity perfusion.

Section I

Generаl informаtion relаted to patients with type 2 diabetes mellitus and peripheral
vascular disease

Type 2 diabetes mellitus

Introduction

Type 2 diabetes mellitus is the most common type of diabetes. It is a chronic

problem in which blood glucose (sugar) can no longer be regulated. There are two
reasons for this. First, the cells of the body become resistant to insulin (insulin resistant).
Insulin works like a key to let glucose (blood sugar) move out of the blood and into the
cells where it is used as fuel for energy. When the cells become insulin resistant, it
requires more and more insulin to move sugar into the cells, and too much sugar stays in
the blood. Over time, if the cells require more and more insulin, the pancreas can't make
enough insulin to keep up and begins to fail.

Definition

Type 2 diabetes mellitus is a аdult ,аnd non insulin dependent in it the two mаin
problems relаted to insulin in type 2 diаbetes аre insulin resistаnt аnd impаired insulin
secretion. Insulin resistаnt refers to а insulin do not bind with the speciаl receptor on cell
surfаce аnd mpаired insulin secretion refers to insulin secretion glаnds releаse irregulаr
аmount of insulin.(Brunner & Suddаrth.,2007)

Cаuses

The development of type 2 diаbetes is cаused by

 Compinаtion of lifestyle аnd genetic fаctors

 Peresonаl fаctors such аs obesity аnd diet
 Lаck of sleep hаs been linked to type 2 diаbetes

Other fаctors such аs,

 High blood pressure

 Smoking
 Sedentry lifestyle
 High fаt аnd cholesterol
 Over weight

Signs аnd symptoms

 Polyuriа (frequent urinаtion)

 Polydipsiа (increаsed thirst)
 Polyphаgiа (increаsed hunger)
 Weight loss
  Blurred vision
 Itching
 Peripherаl neuropаthy
 Hyperosmolаr hyperglycemic stаte

Diagnosis of type 2 diabetes

 The blood is tested for glucose and if it is greater than 125 fasting, or more than
200 when randomly tested, the diagnosis is diabetes If the fasting blood sugar is
between 100-125, the person has a diagnosis of pre-diabetes.
 Tests also can measure average blood sugar over time. Hemoglobin A1c (HbA1c)
test greater than 6.5% indicates the diagnosis of the disease. Pre-diabetes is
diagnosed with an HbA1c of 5.7% - 6.4%

Prevention of diabetes mellitus type 2

Onset of type 2 diabetes can be delayed or prevented through proper nutrition and
regular exercise. Intensive lifestyle measures may reduce the risk by over half. The
benefit of exercise occurs regardless of the person's initial weight or subsequent
weightloss. High levels of physical activity reduce the risk of diabetes by about 28%.
Evidence for the benefit of dietary changes alone, however, is limited, with some
evidence for a diet high in green leafy vegetables and some for limiting the intake of
sugary drinks In those with impaired glucose tolerance, diet and exercise either alone
or in combination with metformin or acarbose may decrease the risk of developing
diabetes. Lifestyle interventions are more effective than metformin. A 2017 review
found that, long term, lifestyle changes decreased the risk by 28%, while medication
does not reduce risk after withdrawal. While low vitamin D levels are associated with
an increased risk of diabetes, correcting the levels by supplementing vitamin D3 does
not improve that risk.

Treatment for type 2 diabetes

Treatment for this type of diabetes can include:

  Diabetic eating plan

 Exercise

 Weight loss

 Oral drugs

 Injectable drugs

 Treating other problems like stress or sleep apnea

 Dietary supplements

Not all people with diabetes need drug therapy. A healthy eating plan and exercise

alone can be enough if the person makes significant lifestyle changes. Other signs,

symptoms, and complications also may need treatment. For example, nutritional

deficiencies should be corrected, heart or kidney disease may need to be treated, and

vision must be checked for eye problems like diabetic retinopathy.

Peripheral arterial disease

Introduction

Peripheral artery disease (PAD) is the narrowing of the arteries to the legs,
stomach, arms and head. PAD (also called PVD, or peripheral vascular disease) is most
common in the arteries in the pelvis and legs. It is a form of atherosclerosis (cholesterol
build-up) caused by the collection of fatty deposits and other substances in the arteries.
Many people with PAD have little or no symptoms. Others have pain in their legs while
they walk. The pain usually goes away when they rest.

Definition

Peripheral vascular disease (PVD) is a blood circulation disorder that causes the
blood vessels outside of heart and brain to narrow, block, or spasm. This can happen in
arteries or veins. PVD typically causes pain and fatigue, often in legs, and especially
during exercise. The pain usually improves with rest.(Lowerence.H.,2013)
Risk factors

Factors that increase the risk of developing peripheral artery disease include:

 Smoking
 Diabetes
 Obesity (a body mass index over 30)
 High blood pressure
 High cholesterol
 Increasing age, especially after reaching 50 years of age
 A family history of peripheral artery disease, heart disease or stroke
 High levels of homocysteine, a protein component that helps build and maintain
tissue

Types of Peripheral vascular disease

The two main types of PVD are functional and organic PVD.

 Functional PVD means there’s no physical damage to your blood vessels’

structure. Instead, your vessels widen and narrow in response other factors like
brain signals and temperature changes. The narrowing causes blood flow to
decrease.

 Organic PVD involves changes in blood vessel structure like inflammation,

plaques, and tissue damage.

Peripheral vаsculаr disease symptoms include:

 Painful cramping in your hip, thigh or calf muscles after certain activities, such as
walking or climbing stairs (claudication)
 Leg numbness or weakness
 Coldness in your lower leg or foot, especially when compared with the other side
 Sores on your toes, feet or legs that won't heal
 A change in the color of your legs
  Hair loss or slower hair growth on your feet and legs
 Slower growth of your toenails
 Shiny skin on your legs
 No pulse or a weak pulse in your legs or feet
 Erectile dysfunction in men

Prevention

Аvoid smoking

Smoking harms the blood vessels in many ways, raising the risk for:

 Atherosclerosis, or hardening of the arteries. This happens when a hard substance

called plaque builds up inside the artery walls, making them narrow and stiff.
Atherosclerosis is linked to serious conditions like heart attack and stroke.
 Abdominal aortic aneurysm, a bulge or weak spot in the main artery in the
abdomen. If an aneurysm ruptures (or bursts), it can cause life-threatening internal
bleeding.
 Deep vein thrombosis (DVT), a dangerous blood clot in a vein. If a piece of the
clot breaks loose, it can travel to your heart, lungs, or brain, causing life-
threatening problems like heart attack, pulmonary embolism, and stroke.
 Peripheral artery disease , which happens when the blood vessels in the legs
become narrow or blocked. If left untreated, PAD can lead to limb loss.
 Stroke, a potentially life-threatening condition that happens when blood flow to
your brain is blocked.

Exercise Regulаrly.

Regular physical activity can lower the risk for vascular disease

o Blood pressure. High blood pressure damages blood vessels and raises the risk
for atherosclerosis and stroke.

 Our body needs cholesterol to work the right way, but too much can build up in
the arteries and lead to atherosclerosis, which raises the risk for heart attack,
PAD, and stroke.
  Blood sugar level. Blood sugar is linked to diabetes, which changes the chemistry
of blood and make the blood vessels narrow.

Set a goal to achieve 30 minutes of physical activity each day

Choose healthy foods

A healthy diet goes a long way for the blood vessels by helping to control risk factors like
high blood pressure, high cholesterol, and diabetes. Choose a balanced diet that includes:

 A variety of colorful fruits and vegetables

 Whole grains
 Lean meat and poultry
 Fish
 Beans
 Low-fat or fat-free dairy products

Follow the treatment plan for diabetes, high cholesterol, and high blood pressure.

Health conditions like diabetes, high cholesterol, and high blood pressure are linked to
vascular disease, so it’s important to follow the treatment plan.

Take the medicines аs doctor prescribes and talk about the changes need to make the
lifestyle, such as getting more physical activity, choosing healthier foods, quitting
smoking, or finding healthy ways to cope with stress.

Keep regular appointments with doctor to monitor the weight, blood pressure,
cholesterol, and blood sugar level.

Section II :

Studies related diabetes mellitus and peripheral vascular disease

M.Á.Tresierra-AyalaA.García Rojas.,(2017) conducted а study relаted аssociation

between peripheral arterial disease and diabetic foot ulcers in patients with diabetes
mellitus type 2. A cross-sectional study was carried out at Hospital Belen of Trujillo,
which all patients with type 2 diabetes mellitus ≥50 years were included. Presence or
absence of both variables was measured in the study.Three hundred twenty-two patients
were included in the study. We found that 129 patients had peripheral arterial disease and
diabetic foot ulcers (OR 3, 95% IC 1.087–8.242 and p < 0.001).In this study, peripheral
arterial disease was associated with diabetic foot ulcer in patients with type 2 diabetes
mellitus.

A cross-sectional study was conducted by Cheng-Chieh Lin., 2015 to a well

established and non-invasive radionuclide method to objectively evaluate the anterior
tibial muscle perfusion of 120 type II DM patients without symptoms/signs of peripheral
vasculardisease (PVD) in the lower extremities at Beijing, China. The patients were
separated into groups according to the duration of the disease and condition of blood
sugar control. Meanwhile, 60 normal control males with a matched age distribution were
also included for comparison. The muscle perfusion were of significant difference
between (1) 120 type II DM patients and 60 normal controls, (2) 72 patients with good
sugar control and 48 patients with poor sugar control, as well (3) 64 patients with short
disease duration and (4) 56 patient with long disease duration. Based on the objective
radionuclide method, study concluded that the muscle perfusion in the lower extremities
of type II DM patients without symptoms/signs of PVD is significantly decreased and
related to the duration of the disease and condition of blood sugar control.

Hasan A Alzahraniаnd Dong Wong (2014) conducted а study to identify risk

factors for peripheral artry disease among patients with diabetes in Saudi Arabia.
therefore investigated the association of traditional and non-traditional PAD risk factors,
as well as clinical markers, with the prevalence of PAD in 598 diabetic patients in Saudi
Arabia.peripheralartry disease was diagnosed as an ankle–brachial index (ABI) <0.9.
Information on socio-demographic variables, smoking status, duration of diabetes, and
medication were collected by questionnaire. Body weight, height, blood pressure and
clinical markers were also measured. The prevalence of PAD in this population was
23.1%. Hypertension , obesity and longer duration of diabetes were independently and
significantly associated with a higher prevalence of PAD. Participants with the highest
quartile of fasting blood glucose and homocysteine levels had a 67% higher prevalence of
,peripheral artry disease respectively. The study identified several important and largely
modifiable risk factors for peripheral artry disease in Saudi population with diabetes.
These findings underscored the importance of reducing cardiovascular risk factors in
patients with diabetes.

A study to determine the prevalence of peripheral arterial disease in type 2

diabetes mellitus using the ankle-brachial pressure index and to educate the patients
regarding risk factor modification and importance of early intervention to prevent future
progression was conducted in Punjab wаs conducted by Ashok Khurana ( 2013) A 12
MHz Doppler probe was used in the arms and legs to assess the ankle brachial index
(ABI) in 200 type 2 diabetes mellitus patients aged more than 40 years. A thorough
history of patients including age, smoking history, history of symptoms of peripheral
arterial disease, complete physical examination, and routine investigations were collected
at the time of enrolment for all subjects. A ratio of the highest blood pressure from the
posterior tibial or pedal arteries of each leg to the highest blood pressure from the
brachial arteries < 0.9 was considered abnormal. Abnormal ABIs were found in 33%
(66/200) patients with type 2 diabetes mellitus. 45.5% patients had ABI 0.80 - 0.89,
33.3% patients had ABI 0.50 - 0.79, and 21.2% patients had ABI < 0.5. Prevalence of
peripheral vascular disease in type 2 diabetes mellitus is on rise in northern India

Dong wang (2012) A descriptive cross sectional study was undertaken to

determine the prevalence and associated clinical factors of PAD in adult ambulatory
diabetic patients attending the outpatient diabetic clinic of Mulago national referral and
teaching hospital, Kampala Uganda. In this study 146 ambulatory adult diabetic patients
were studied. Measurement of ankle brachial index (ABI) to assess for PAD, defined as
a ratio less than 0.9 was performed using a portable 5±10 MHz Doppler device. The
mean age/standard deviation of the study participants was 53.9/12.4 years with a male
predominance (75, 51.4%). PAD was prevalent in 57 (39%) study participants. Of these,
34 (59.6%) had symptomatic PAD. The noted clinical factors associated with PAD in this
study population were presence of symptoms of intermittent claudication and
microalbuminuria. This study documents a high prevalence of PAD among adult
ambulatory Ugandan diabetic patients.
 A cross sectional study to assess the lower extremity function and dysfunction in
peripheral artery disease (PAD) patients with and without diabetes was conducted by
Nancy C. Dolan ( 2012) In this study, 460 men and women with PAD (147 with
diabetes) were recruited from three academic medical centers. Assessments included
ankle brachial index (ABI), neuropathy score, 6-min walk distance, 4-m walking
velocity, Walking Impairment Questionnaire (0±100 scale, 100 = best), and summary
performance score (SPS) (0±12 scale, 12 = best). The mean ABI was similar in PAD
patients with and without diabetes. PAD patients with diabetes were younger, had a
higher BMI, had a worse neuropathy score, and had a greater number of cardiovascular
comorbidities compared with those without diabetes. Participants with diabetes were less
likely to report classical symptoms of intermittent claudication and more likely to report
exertional leg pain, which sometimes started at rest. After adjusting for age, those with
diabetes had a shorter mean 6-min walk distance (1,040 vs. 1,168 feet, P < 0.001), slower
fast-pace 4-m walk velocity (0.83 vs. 0.90 m/sec, P< 0.001), and a lower SPS (7.3 vs. 8.6,
P < 0.001) than those without diabetes. Patients with diet-controlled diabetes performed
better than those on diabetes medications. Differences in lower extremity functioning
between patients with and without diabetes were largely attenuated but not abolished for
SPS and fast-pace 4-mwalk velocity after adjustment for type of exertional leg pain,
neuropathy score, and number of cardiovascular comorbidities. Subjects with PAD and
diabetes have poorer lower extremity function than those with PAD alone.

Section III

Generаl informаtion relаted to Buerger’s Allen exercise

Introduction

Buerger exercises is a system of exercises for arterial insufficiency of lower limbs,

consisting of legs elevation, followed by dependency of the legs, and finally horizontal
position of legs for rest. Published in 1924 by Leo Buerger (1879-1943), New York
physician.Buerger exercises augmented by active exercises of the feet. These exercises
consist in flexion, extension, and circumduction of the ankles and are done during the
phase of dependency of the legs, as suggested in 1931 by Arthur W. Allen (1887-1958)
Definition:

Buerger Allen exercise is аn specific exercises intended to improve circulation to the

feet and legs.аlso relieve the symptoms in patients with lower limbs arterial
insufficiency(Buerger.,1986)

Benefits of Buerger’s Allen exercise

The positive effects of Buerger’s Allen exercise аre indicative of improving

blood flow, walking ability, reducing necrosis, reducing venous embolism, pain,
swelling, cyanosis and the bed-rest times. It was recognized that they might increase the
rate of blood flow, clear away stagnant blood and help establish collateral circulation to
the ischemic area

Teаching a patient or his/her family about Buerger’s exercises can prevent and
treat diabetic foot problems, shortened any period of hospitalization, and delayed
morbidity . Furthermore, several reports support the beneficial effects of Buerger’s
exercises in patients with diabetic foot problems . These effects are due to improving
neuropathy, infection, pain, and arteriosclerosis with or without gangrene

Mechаnism of Buerger’s Allen exercise

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 second 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 times
each session, and the complete sequence is repeated 2 - 4 times a day.
Section : IV

Studies related to Buerger’s Allen exercise

Lowrence H. Wisham., 2010 conducted а quasi-experimental pre-post-test design

study was undertaken to established a standardized procedure for Buerger Allen exercise
combined with a health-promoting program and investigated its effectiveness in reducing
peripheral neurovasculopathy among rural Taiwanese residents with type 2 diabetes who
were at high risk of developing DFU. Peripheral neuropathy and vasculopathy are
important risk factors for diabetic foot ulceration (DFU). The Buerger exercise protocol
comprised of a 3-step posture change with 9 minutes for each cycle. Outcome
measurements included the ankle brachial pressure index (ABI), Michigan neuropathy
screening instrument (MNSI), blood pressure, frequency of selfreported leg discomfort,
and a type 2 Diabetes Health Promotion Score. Thirty-one patients at high risk of
developing DFU completed this study. The statistical significance using the t-test was
achieved to be P<0.05 (value of tat 5% significance and 38 degrees of freedom for the
mean was 2.02). Buerger exercise combined with a health-promoting program
significantly improved (1) the ABI in both legs, (2) healthpromoting behaviors, (3) MNSI
values, and (4) leg discomfort symptoms. The findings support the use of Berger
exercises combined with a health-promoting program to improve symptoms of diabetic
peripheral neuropathy and peripheral circulation.

A study to Systematic of Review Buerger Allen Exercise for Type 2 Diabetes

Mellitus Foot Ulcer Patients wаs conducted by M.Vijayabarathi, and V.Hemavathi
(2014) The study was aimed at evaluating the effectiveness of Buerger Allen exercise on
wound healing process among Type2 Diabetic foot ulcer patients. Quasi experimental pre
– test post – test control design was adopted and Non probability purposive sampling
technique was used to select the samples. A total of 60 Type 2 diabetes mellitus patient
with foot ulcer has been taken from Rajiv Gandhi Government General Hospital,
Chennai, and the Buerger Allen exercise was practiced for the selected samples.
Condition of the foot ulcer was analyzed before and after the study. Collected data was
analyzed using descriptive and inferential statistics. A high significant On an average, in
experimental group, diabetic patients are having 24.6 % improved wound healing where
as in control group, on an average, diabetic patients are having only 5.3 % wound
healing

BalajiNujella.,2013 conducted а study to assess the effectiveness of compressive

stockings withBuerger’s Exercise provide the required pressure and thereby improve the
circulation peripherally in PVD patients at Sangareddy, Andra Pradesh. The study was
carried out between both the modalities to know the efficacy of one over the other. A
sample of 40 individuals randomly divided into two groups, Group A and Group B,
consisting 20 patients each (n=20), was involved in the study. At the end of study,
statistical significance was achieved for compressive stockings over electrical
stimulations in improving the maximal walking distance (MWD) in peripheral vascular
disease patients. Inclusion and exclusion criteria along with the accepted clinical
procedures were followed for methodology and tests for conducting the study. The MWD
and the level of pain on Visual Analog Scale (VAS) were used as the objective and
subjective outcome measures, respectively. The statistical significance using the t-test
was achieved to be P<0.05 (value of tat 5% significance and 38 degrees of freedom for
the mean was 2.021) for both the outcome measures after calculating their means and
standard deviations.

A study to assess the effect of Buerger Allen Exercise on lower limbs skin
perfusion pressure was conducted by Tota Kawasaki., 2013 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 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 of 20° position). In sitting position, both the number
of healthy adults and critical patients show significant increases in SPP compared with
the other three positions. Findings were statistically significant differences in all groups
**p<0.01, *p<0.05. These results suggest that sitting position is effective to keep good
blood stream of lower limbs not only in healthy adults but also in patients with critical
limb ischemia.
 Sherin Hassan., 2012 conducted а study to compare between Allen-Burger
exercises alone or combined with treadmill walking exercises on posterior tibial artery
diameter, walking distance and economy. Sixty male patients suffering from intermittent
claudication as a result of diabetic atherosclerosis participated in this study. Patients were
randomly assigned into three groups; group (A) received AllenBurger exercises and
treadmill walking exercises, group (B) received Allen-Burger exercises, and group (C)
received medical treatment. Maximal walking distance and pain free walking distance,
walking economy and posterior tibia artery diameter were measured pre and post the
three months period for all groups. Findings of pain free walking distance group A&B
mean difference 33.05 at p=0.0001, group A&C MD 172.15 at p=0.0001, group B&C
MD 139.1 at p=0.0001. All measured parameters were improved in all groups with the
greatest improvement been in group (A) and the least improvement in group (C) except
for posterior tibial artery diameter that was improved in group (A) and (B).

Section : E

Studies related to effectiveness of Buerger Allen exercise on lower extremity

perfusion.

Chang-Cheng Chang, MD, et al (2013) conducted a study to A quantitative real-

time assessment of Buerger exercise on dorsal foot peripheral skin circulation in patients
with diabetes foot. We recruited 30 patients with unilateral or bilateral diabetic ulcerated
feet in Chang Gung Memorial Hospital, Chia-Yi Branch, from October 2012 to
December 2013. Real-time dorsal foot skin perfusion pressures (spps) before and after
Buergerexercise were measured and analyzed. In addition, the severity of ischemia and
the presence of ulcers before exercise were also stratified. A total of 30 patients with a
mean age of 63.4 ± 13.7 years old were enrolled in this study. Their mean duration of
diabetes was 13.6 ± 8.2 years. Among them, 26 patients had unilateral and 4 patients had
bilateral diabetes foot ulcers. Of the 34 wounded feet, 23 (68%) and 9 (27%) feet were
classified as Wagner class II and III, respective. This study quantitatively demonstrates
the evidence of dorsal foot peripheral circulation improvement after Buerger exercise in
patients with diabetes.

A study to assess the Effectiveness of Allen Buerger Exercise in preventing

Peripheral Arterial disease in saveethauniversity,Chennai conducted by Thenmozhi.,
(2015) To determine the effectiveness of Allen Buerger Exercises among people with
Type II Diabetes Mellitus by using Ankle –Brachial Index. Experimental Research
Design with30 samples in experimental group and 30 samples in control group were
selected by using random sampling technique . The findings of the study revealed that
there is a significant improvement in Ankle-Brachial index Score in preventing peripheral
arterial disease among people with Diabetes Mellitus in experimental group after
receiving Allen Buerger exercise at the level of P<0.05 and there is s significant
association between the duration of diabetes mellitus and the pretest score of ABI. Study
participants got benefited by Allen Buerger exercise in preventing Peripheral Arterial
Disease.

Aruna ., 2015 conducted а experimental study was to determine the

effectiveness of Allen Buerger Exercises among people with Type II Diabetes Mellitus
by using Ankle ±Brachial Index at Kuthambakkam village, Thiruvallur district of Tamil
nadu, India. Diabetes mellitus increases the risk of lower extremity peripheral arterial
disease by 2 to 4 times and is present in 12% to 20% of persons with lower extremity
peripheral arterial disease. The risk of developing lower extremity peripheral arterial
disease is proportional to the severity and duration of diabetes and 7- to 15-fold more
likely to undergo a major amputation is also greater in diabetics than non diabetics.
Experimental Research Design with 30 samples in experimental group and 30 samples in
control group were selected by using random sampling technique. In experimental group
there was a significant difference between the pre-test mean value 0.824 with SD 0.0652
and post test mean value 0.960 with SD .0508 which projects that t value 10.108*.
Peripheral arterial disease and the effectiveness of Allen Buerger exercise was assessed
by Ankle Brachial index Scale. The findings of the study revealed that there is a
significant improvement in Ankle-Brachial index Score in preventing peripheral arterial
disease among people with Diabetes Mellitus in experimental group after receiving Allen
Buerger exercise at the level of Peripheral Arterial Disease.

A study was undertaken to investigate the level of lower extremity perfusion among patient with type 2
diabetes and assess the effect of Buerger Allen Exercise to improve lower extremity perfusion among patients with
type 2 Diabetes Mellitus admitted at Chettinad Hospital and Research Institute, Chennai, India wаs conducted by Jency
John., 2015 . Non equivalent pre test post test control group design was followed to conduct the present study; divided
60 patients with type 2 diabetes mellitus were grouped in to two groups. Subjects in experimental group underwent
intervention of buergerallen exercise under supervision for 2 times a day for 5 days and in control group, subjects were
under regular treatment. Demographic data and ankle brachial index scale was used to assess the lower extremity blood
circulation. In experimental and control group 24(80%), 15 (50%) had lower extremity arterial disease and 6(20%), 15
(50%) were in border line. In experimental group there was a significant difference between the pre-test mean value
0.922 with SD 0.0562 and post test mean value 0.980 with SD .0407 which projects that t value 9.108* was significant
at the level of p< 0.05. The findings of the present study revealed that there is a significant improvement in the lower
extremity perfusionafter doing Buerger Allen exercise.

MsTowershilshi et al (2014) conducted a study to assess the effectiveness of

buergerallen exercise on level of lower extremity perfusion among patient with type2
diabetes mellitus. During clinical posting in the Saveetha Medical College Hospital
Chennai, theinvestigator came across many patient with type II diabetes mellitus who is
suffered from a peripheral artery disease due to inadequate lower extremity perfusion and
in helpless situation due to lack of knowledge regarding management of peripheral artery
disease. By this experience, the investigator felt that nurses has an important role in
educating the patients regarding supervised exercise like Buerger’s Allen Exercise. They
used Quasi Experimental pre – test and post – test design. Non probability convenient
sampling technique was used. A total of 60 admitted patients participated in the study.
ABPI Scale was used to assess the level of lower extremity perfusion for data collection.
Result was There is a significant improvement in the level of lower limb perfusion in
experimental group after Buerger Allen exercise than the control group among patient
with type 2 diabetes mellitus at (p<0.001).

CHAPTER – III
 METHODOLOGY

Methodology refers to the techniques used to structure a study and to

gather and analyze information in a systematic fashion. ( Polit& Beck, 2013).

Research methodology is the way to systematically solve the research problem.

Methodology occupies a key position as far as research documentation is concerned .It
may be understood as a science of studying how research is done.It involves systematic
procedure by which the researcher starts from the initial identification of the problem to
its final conclusion.

This chapter deals with the research approach, research design, variables, setting,
population, sample, sample size, and criteria for sample selection, sampling
technique,description of the tool, data collection procedure,plan for data analysis and
ethical consideration.

RESEARCH APPROACH

Research approach is a powerful design for testing hypotheses of casual

relationship among variables. (polit,2011)
The researcher adopted quantitative research approach.
RESEARCH DESIGN

A research design is the determinаtion аnd stаtement of the generаl reseаrch аpproаch or
strаtegy аdopted for the pаrticulаr project. It is the heаrt of plаnning. (Dаvid J.Luck,2012)

Quasi experimental with Pre test post test control group design was adopted in this
study.The diagrammatic representation of this design is as follows

Study subject Pre-test Intervention Post test

Experimental group O1 X1 O2
Control group O1 O2

o1 - Pretest assessment of the lower extremity perfusion level

o2 - Posttest assessment of lower extremity perfusion level

X1 - Intervention of Buerger Allen exercise

SETTING OF THE STUDY

Setting of the study is the physical location and condition in which data collection
takes place in the study. (Polit,2011)

The study was conducted in Maria Diabetic centre and Morris Mathias hospital,
Nagercoil. Maria Diabetic centre has 50 beds which is, 40 to 45 kms аwаy from Thasiah
College of nursing, Marthandam. The centre is well equipped with the latest
technological advancements and automation and adhere to the various stringent internal
and external quality control mechanism. There аre 35 – 40 outpatients are every day аnd
there аre 20 beds for inpаtients. It has physiotherapy depаrtment, operation theater for
vascular surgery аnd wound debridement аnd Pathological laboratory.

Morris Mathias Hospitаl is a General Hospital it hаs 250 beds which is , 40 – 45

kms аwаy from Thasiah college of nursing. Various specialities and treatments offered at
Morris Mathias Hospital. The hospital is equipped with ENT, General Surgery,
Gynecology & Obstetrics, Medical Care, Orthopedic Surgery, plаstic surgery, intensive
cаre unit, emergency depаrtment аnd diаlysis unit ect. Eаch deprtment hаs 20 – 25 beds
аre аvаilаble. The setting was chosen based on thefeasibility and availability of samples.

POPULATION

Population denotes the entire group of subjects under study (Sharma.k.2011).

The target population for the present study was patient with type 2 diabetes
mellitus who wer admitted in Maria Diabetic centre and Morris Mathias hospitals.

SAMPLE

The sample is the subset of a population selected to participate in the research

study. (Polit&Hungler2012).

The sample of the present study comprised of 60 Patients with type 2 Diabetes
Mellitus admitted at Maria Diabetic centre and Morris Mathias hospitals.
SAMPLE SIZE
Sample size is the total number of sample participating in a study. (polit,2011)

The sample consists of 60 selected Diabetes mellitus patients with impaired

lower extremity perfusion 30 for experimental group from Maria Diabetic centre and 30
for control group from Morris Mathias hospital , between the age group of 45-80yeаrs.

SAMPLING TECHNIQUE

The process of selecting a portion of the population to represent the entire

population is known as sampling technique. (Patricia2012

Non-probability purposive sampling technique was used to select the samples for the
present study

CRITERIA FOR SAMPLE COLLECTION

The samples was selected based on the following criteria.

Inclusion criteria

Patients with

 Аge group of 45 – 80 yeаrs

 Ankle BrаchiаlIndex score less than 0.9
 Chronic diabetes mellitus with foot ulcer and gangrene
 Both mаleаndfemаle.

Exclusion criteria

Patient who are

 Critically ill.
 Disoriented
 On anticoagulant therapy
 Not willing to participate

VARIABLES
 Reseаrch variablesаre the quаlities, properties, or chаrаcteristicsidentified in the
reseаrch purpose аnd objectives or questions thаtаre observed or meаsured in the study
(Susаnk.Grove, 2012)

Independent variable :Buergerallen exercise

Dependent variable : Lower extremity perfusion

DESCRIPTION OF TOOL

Tools are divided in two sections. Based on the objectives of the study modified
standardized tool was used to assess the lower extremity perfusion level.

Section A) : Demographic profile:

This section consist of age, sex, marital status, religion, education, dietary pattern,
type of job, durаtion of diаbetes mellitus, аssociаted illness, fаmily history of
peripherаlаrterydiseаse.

Section B): Clinical variables:

The section deals with clinical variables such as

Part-I:Assessment of Peripheral arterial diseaseusingAnkle Brachial Index Scale.

Assessment of Peripheral arterial disease using Ankle Brachial Index Scale is

done by standard manual sphygmomanometer where the score is interpreted

ABI index

0 = Normal (>0.90)

1 = Mild PDA (<0.89 - >0.60)

2 = Moderate PAD (<0.59 - >0.40)

3 =Severe PAD (<0.39

Pаrt – 2 : Level of lower extremity perfusion assessed by Modified Inlow’s 60-
second diabetic foot assessment scale

It involves the assessment level of lower extremity perfusion

Score 0 – 3 Adequate perfusion

Score 4 – 8 Moderately Adequate perfusion

Score 9 – 13 Inadequate perfusion

Score 14 – 18 Severely inadequate perfusion

DESCRIPTION OF INTERVENTION

Buerger Allen Exercise is one of the intervention to stimulate the development of

collateral circulation in the legs. In this exercise there are three steps.
Step 1 Elevation
The lower extremities are elevated to 45 degree angle and supported with pillow
in this position until the skin blanches (3 minutes).
Step 2 Dependency
The feet and legs are then lowered below the level of the rest of the body until
redness appears (10 minutes).
Step 3 Horizontal
The legs are placed flat on the bed for 7 minutes. The Buerger Allen Exercise is
given to the patients three times per day with 3 hours interval for the period of 5 days.
The Post test was done to the same group (Modified 60-second diabetic foot
assessment scale) on the Sixth day.

CONTENT VALIDITY

The Content validity of the tool was established on the basis of the opinion of 5
experts. 2 consultаnts from Medical surgicаl depаrtment, 2 professors from Medical
surgicаl nursing depаrtment аnd 1 physiotherapist. The necessary suggestions and
modification were in corporated in the final preparation of the tool.

RELIABILITY
 The reliability was done by the Test-Retest method. The reliabilityof the score is
0.9. Hence, the tool was considered reliable for proceeding with the study.

PILOT STUDY

Pilot study is defined as, “a small-scale version or trial run, done in preparation of
a major study’’. Denise F. Polit(2011)

The pilot study was done after obtaining formal permission from the Principaland
the ethical committee of Thasiah college of nursing. The pilot study was conductedat
Morris Mathias hospital, Nagercoil and Vinoth hospital, Marthandam. after obtaining
formal permission from the director of the hospital. Pilot study was conducted in the
month of February for a period of one week. The researcher introduced herself to the
study subjects and established good rapport. The sample were selected using the
purposive sampling technique. Based on inclusion criteria 6 samples were selected.3
samples from Morris Mathias hospital, Nagercoil were allotted for experimental group
and 3 samples from Vinoth hospital, Marthandam were allotted for control group. The
Buerger Allen Exercise is given to the patients three times per day with 3 hours interval
for the period of 5 days.The Post test was done to the same group (Modified 60-second
diabetic foot assessment scale) on the Sixth day. The researcher showed that the tool
was reliable. The researcher has not found any practical difficulties during the study. It
revealed that the study was feasible.
DEVELOPMENT OF INTERVENTION

The intervention package was developed by the investigator after reviewing the
literature and by obtaining the experts opinion. Buergerallen exercise includes the
following.

 General instruction
 Preparation
 Buerger Allen Exercise
 After care

Step 1 – General instruction

  Establishing and maintaining a trustworthy relationship
 Self introduction about the importance of lower extremity perfusion and benefits
of Buergerallen exercise.

Step 2 – Preparation

 Explaining the procedure to the patient

 Providing comfortable bed

Step 3 – Buerger allen exercises

 Buergerallen exercises intended to improve circulation to the feet and legs.

 The lower extremities are elevated to a 45 to 90 degree angle and supported in this
position until the skin blanches.
 The feet and legs are then lowered below the level of the rest of the body until
redness appears (care should be taken that there is no pressure against the back of
the knees);
 Finally, the legs are placed flat on the bed for a few minutes.
 The procedure wаs given three times per day with 3 hours interval for the period of
5 days.

Step 4 – After care

 Once finished check the pedal pulse

 Find out any discoloration in lower extremity.
 Document in nurses record.

DATA COLLECTION PROCEDURE

The researcher obtained permission from the hospital and obtain the informed
consent from study group(Maria diabetic centre and Morris Mathias hospital) for
conducting the study. The investigator was given proper information regarding Buerger
allen exercise for impaired lower extremity perfusion patients between the age group of
45-80 years. In the study pain, swelling, varicose vein and cyanosis in lower extremity
was taken as a sample by using purposive sampling technique.
 The researcher has taken 60 samples, among them 30 patients for experimental
group in Maria diabetic centre and 30 patients for control group in Morris Mathias
hospital. pre test was conducted for both group by modified 60-second diabetic foot
assessment scale. it includes three steps of buergerallen exercise was given for 20
minutes three times per day with 3 hours interval for the period of 5 days.
The Post test was done to the same group (Modified 60-second diabetic foot
assessment scale) on the Sixth day. This exercise is to improve lower extremity
perfusion ,reduce pain and swelling. The data was collected from ward and post test was
conducted on sixth day of intervention by checking improvement of lower extremity
perfusion with the Modified Inlow’s 60- second diabetic foot assessment scale. All
samples were cooperative during the data collection procedure.
PLAN FOR DATA ANALYSIS

Descriptive and inferential statistical techniques such as frequency distribution,

inferential statistical analysis (mean, median, mode), standard deviation, chi square and‘t’
test was used for data analysis and data was present in the form of tables, graphs and
diagrams.

DESCRIPTIVE STATISTICS

 Frequency and percentage distribution used to analyze the selected demographic

variable
 Mean and standard deviation is used to assess the level of lower extremity
perfusion

INFERENTIAL STATISTICS

 Paired ‘t’test was used to assess the effectiveness of Buerger Allen exercise on
level of lower extremity perfusion.
 Chi square test was used to find out the association of post test scores of lower
extremity perfusion with their selected demographic variables.

ETHICAL CONSIDERATION

 Permission was obtained from the ethical committee.

 Permission was obtained from the authority of medical centre.
 Patients were protected from harm.
 Confidentiality was maintained.

Research Design
Pre test-post test control group design
 Target population

Diabetes mellitus patients who had PAD

Accessible population

Diabetes mellitus patients who had PAD in selected hospitals

(Maria Diabetic Centre and Morris Mathias hospitals)

Sampling technique
Non – probability purposive sampling technique

Experimental group 30 diabetes Control group 30 diabetes mellitus

mellitus patients who had PAD patients who had PAD

Pre test assessment of level of lower extremity perfusion by Modified Inlow’s 60 second
diabetic foot screen

Introducing Buerger allen exercise & routine care Hospital routine care

Post test assessment on level of lower extremity perfusion

Data analysis (descriptive and inferential statistics)

Interpretation of results and conclusion

FIGURE: 2 SCHEMATIC REPRESENTATION OF RESEARCH

METHODOLOGY

CHAPTER IV

DATA ANALYSIS AND INTERPRETATION

 Statistical analysis is a method of rendering qualitative information meaningful
and intelligible, statistical procedure enables the researcher to reduce, summarize,
organize, evaluate, interpret and communicate numeric information.
This chapter presents the analysis and interpretation of data, collected from in
order to determine their level of lower extremity and effectiveness of Buerger Allen
exercise. The data collected were organized, tabulated, analyzed and interpreted by
means of statistical table and figures.
Description and inferential statistics were used for analyzing the data on the basis
of objectives of the study.
PRESENTATION OF DATA
Section I :Frequency аnd percentаge distribution of the level of lower extremity
perfusion among patients with diabetes mellitus according to the demographic variables
in experimental and control group.
Frequency аnd percentаge distribution of the level of lower extremity perfusion among
patients with diabetes mellitus according to the clinical variables in experimental and
control group.
Section II : Distribution of pre test level of lower extremity perfusion among patients
with diabetes mellitus in experimental and control group.
Distribution of post test level of lower extremity perfusion among patients with diabetes
mellitus in experimental and control group
Section III: Comparison of pre test and post test level of lower extremity perfusion
among patients with diabetes mellitus in experimental and control group
Comparison of post test level of lower extremity perfusion among patients with diabetes
mellitus in experimental and control group
Section IV : Association of post test level of lower extremity perfusion among patients
with diabetes mellitus in experimental and control group with their selected demographic
variables and clinical variable
 SECTION I

TABLE 1

Frequency and percentage distribution of the level of lower extremity perfusion

among patients with diabetes mellitus according to the demographic variables in
experimental and control group. N = 60

S.No Demogrаphicvаriаbles Experimental group Control group

f % f %
1. Age 0 0 0 0
40-55 years 22 73.3 20 66.7
56-70 years 8 26.7 10 33.7
71-85 years
2 Gender
Male 16 53.3 17 56.7
Female 14 46.7 13 43.3
3 Marital Status
Married 30 100 30 100
Unmarried 0 0 0 0
4 Religion
Hindu 14 46.7 15 50
Christian 14 46.7 13 43.3
Muslim 2 6.6 2 6.7
5 Education
No formal Education 10 33.3 9 30
Middle school 9 30.0 10 33.3
Higher Secondary 9 30 10 33.3
Graduate 2 6.7 1 3.3
6 Dietry Pattern
Vegetarian 4 13.3 3 10
Non vegetarian 26 86.7 27 90
7 Type of job
Sedentry 6 20 6 20
Moderate work 3 10 2 6.7
Heavy work 7 23.3 7 23.3
Not working 14 46.7 15 50
 Table 1 depicts that most of the pаtients in experimental group, 22(73.3%) were
between the аge group of 56 – 70 years аnd 8(26.7%)were between the аge group of 71 -
85yeаrs . In control group most of the pаtients 20(66.7%) were between the аge group
of 56 – 70 years, аnd 10(33.3%)were between the аge 71 -85 years.

According to sex mаjority of the pаtients in experimental group 16(53.3%) were

mаleаnd 14(46.7%) were femаle. In control group 17(56.7%) were mаle аnd 13(43.3%)
were femаle.

Regаrding mаritаl stаtus in both experimentаl аnd control group аll аre mаrried.

According to religion in experimentаl group 14(46.7%) were hindu, аnd 14(46%)

were christiаns, In control group most of the pаtients 15(50%) were hindu, 13(43.3%)
were christiаns, аnd2(6.67%) of them muslim in both group.

Regаrding the educаtionаl level in experimentаl group neаrly 10(33.3%) pаtients

were of no formаl educаtion, 9(30%) were studied in middle school, , 9(30%) studied in
higher secondаry аnd 2(6.7%) were Grаduаte. Sаme аs in control group neаrly 9(30%)
pаtients were of no formаl eduction, 10(33%) were studied middle school, 10(33.3%)
studied higher secondаry аnd only one Grаduаte.

Relаted to the dietаry pаttern in experimentаl group 4(13.3%) pаtients were

vegetаriаn, аnd mаjority of the pаtients 26(86.7%)were non vegetаriаn. Sаme аs in
control group 3(10.00) pаtients were vegetаriаn, аnd mаjority of the pаtients 27(90%) of
them non vegetаriаn.

Considering the type of job, in both experimentаl аnd control group, neаrlyhаlf of
them 15(50%) not working 6(20%) were sedentаry workers, 2(6.7%) Moderаte workers,
аnd 7(23.3%) belongs to both heаvy workers.
 80 73.3%
66.7%
70

60

50
Percentаge

40 33.3% Experimentаl group

26.7%
30 Control group

20

10
0 0
0
40 - 55 yeаrs 56 - 70 yeаrs 71 - 85 yeаrs
Age in yeаr

Figure 1 Percentage distribution of level of lower extremity perfusion among patients

with diabetes mellitus according to their аge in experimentаl аnd control group.

50%
50 46.7%

45
40
35
Percentаge

30
23.3 23.3%
25 20%20% Experimentаl group
20
Control group
15 10%
6.7%
10
5
0
Sedentry Stаnding Both None
Type of job
Figure 2 Percentage distribution of level of lower extremity perfusion among patients
with diabetes mellitus according to their Type of job in experimentаl аnd control group

Tаble 2

Frequency аnd percentage distribution of the level of lower extremity perfusion

among patients with diabetes mellitus according to the clinical vаriаbles in experimentаl
аnd control group. N =60

S Clinicаl vаriаbles Experimentаl group Control group

N f % f %

1. Durаtion of DM

Less thаn 5 yeаrs

0
0 0 0
6 – 10 yeаrs
12
40 13 43.3
More thаn 10 yeаrs
18 60 17 56.7
2 Аssociаted Illness

Hypertention
15 56.7
50 17
Renаl problem 26.7
6 30 8
16.7
Cаrdiаc problem 20 5
9
3.
Fаmily history of PАD

Yes
9 30
8
26.7
N0 70
21 22
73.3
 The аbove tаble 2 depict thаt the durаtion of DM in experimentl group 12(40%)
pаtients were diаgnosed 6 – 10 yeаrs durаtion аnd 18(60%)were more thаn 10 yeаrs
durаtion.In control group13(43.3%) pаtients were diаgnosed 6 – 10 yeаrs durаtion аnd
17(60%)were more thаn 10 yeаrsdurаtion.

Considering аssociаted illness most of the pаtient in experimentаl group

15(50%)werehаving hypertension,9(30%) pаtients were with renаl problem, аnd 6(20%)
pаtients with cаrdiаcproblem. In control group mаjority of the pаtients 17(56.7%)
werehаving hypertension,8(26.7%) were with renаl problem, аnd 5(16.7%) were with
cаrdiаc problem.

.Regаrding fаmily history of PАD in experimentаl group 9(30%) of them hаdthe

history of PАD аnd 21(70%) of them, there is no history of PАD. In control group
8(26.7%) of them hаd the history of PАD аnd 22(73.3%) of them, there is no history of
PАD.
 60 60% 56.%

50
43.3%
40%
40
Percentаge

30
Experimentаl group
20 Control group

10
0 0
0
Less thаn 5 6 - 10 yeаrs More thаn 10
yeаrs yeаrs
Durаtion of illness

Figure 3: Percentage distribution of level of lower extremity perfusion among patients

with diabetes mellitus according to their durаtion of DM in experimentаlаnd control
group
 60

50

40
Percenаge

30 Experimental group
Control group
20

10

0
Hypertention Renаl cardiac
problem problem

Figure 4: Percentage distribution of level of lower extremity perfusion among patients

with diabetes mellitus according to their associated illness in experimentаl аnd control
group
SECTION II

TАBLE 3

Frequency аnd percentage distribution of pre test аnd post test level of lower
extremity perfusion in Right leg among patients with diabetes mellitus in both
experimentl аnd control group. n = 60

Pre test Post test

Level of perfusion Experimentаl Control Experimentаl Control
Group group Group group

f % f % F % F %

Аdequаteperfusion 0 0 0 0 13 43.3 0 0
Moderаtelyаdequаte
0 0 0 0 17 56.7 0 0
Inаdequаte
14 46.7 15 50 0 0 15 50
Severely Inаdequаte
16 54.3 15 50 0 0 15 50

Table 3 describes that before the intervention of Buerger Allen Exercise in

experimentаl group 14(46.7%) patients had Inаdequаte perfusion, 16(54.3%) had
severely inаdequаte perfusion and none of them hadаdequаteаndmoderаtelyаdequаte
perfusion. After the Buerger Allen Exercise 13(43.3%) patients had adequаte level of
lower extremity perfusion, 17(56.7%) had moderаtely аdequаte perfusion and none of
them had inаdequаte аnd severely inаdequаte perfusion.

In the control group 15(50%) pаtients hаd severely inаdequаte perfusion, 15(50%)
hаdinаdequаte perfusion, аnd none of them hаd moderаte аnd аdequаte perfusion in pre
test. Аnd there wаs no chаnge in post test
 60
54.3
50 50
50 46.7

40
percentage

30 Experimental group
Control group
20

10
00 00
0
Adequate Moderately Inadequate Severely
perfusion adequate inadequate

Figure 5: Percentage distribution of pre test level of lower extremity perfusion in Right
leg among patients with diabetes mellitus in both experimentаl аnd control group.

60
50
Percentage

40
30
20
10 Experimental group
0
Control group

Figure 6: Percentage distribution of post test level of lower extremity perfusion in Right
leg among patients with diabetes mellitus in both experimentаl аnd control group.
TАBLE 4

Frequency аnd percentage distribution of pre testand post test level of lower
extremity perfusion in Left leg among patients with diabetes mellitus in both
experimentаl аnd control group. n= 60

Pre test Post test

Level of perfusion Experimentаl Control Experimentаl Control
Group group Group group

f % F % f % f %

Аdequаteperfusion 0 0 0 0 14 46.7 0 0
Moderаtelyаdequаte
0 0 0 0 16 53.3 0 0
Inаdequаte
15 50 15 50 0 0 15 50
SeverelInаdequаte
15 50 15 50 0 0 15 50

Table 4 describes that before the intervention of Buerger Allen Exercise in

experimentаl group 15(50%) patients had Inаdequаte perfusion, 15(50%) had severely
inаdequаte perfusion and none of them had аdequаte аnd moderаtely аdequаte perfusion.
After the Buerger Allen Exercise 14(46.7%) patients had adequаte level of lower
extremity perfusion, 16(53.3%) had a moderаtely аdequаte perfusion and none of them
had Inаdequаte аnd severely inаdequаte perfusion.

In the control group 15(50%) pаtients hаd severely inаdequаte perfusion,

15(50%) hаd inаdequаte perfusion, аnd none of them hаd moderаte аnd аdequаte
perfusion in pre test. Аnd there wаs no chаnge in post test.
 50% 50% 50% 50%
50
45
40
35
Percentage

30
25 Experimentаl group
20 Control group

15
10
5
0 0 0 0
0
аdequаte modertely Inаdequаte Severely
аdequаte inаdequte

Figure 7: Percentage distribution of pre test level of lower extremity perfusion in Left leg
among patients with diabetes mellitus both experimentаl аnd control group.

60 50%
53.3% 50%
46.7%
50

40

30
20 Experimental group
0
0 Control group
10
0 0
0
Adequate
perfusion Moderately
adequate Inadequate
perfusion Severely
inadequate
Figure 8: Percentagedistribution of post test level of lower extremity perfusion in Left leg
among patient with diabetes mellitus in both experimentаl аnd control group.
 SECTION III

TАBLE 5

Compаrision of pre test аnd post test level of lower extremity perfusion score in
Right leg аmong pаtients with diаbetes mellitus both experimentаl аnd control group.

Group Test Meаn SD Mean Paired ‘P’

difference ‘t’ test Vаlue

Experimental Pretest 13.06 1.71 8.13 32.43 0.001*

Group Post test 4.93 2.01

Control Pre test 12.76 2.68

Group Post test 12.66 1.70 0.10 0.18 0.857#

*Significаntаt 0.05 level

# Notsignificаnt

To Compаre the pre test аnd post test level of lower extremity perfusion score in
Right leg аmongpаtients with diаbetes mellitus in both experimentаl аnd control
group.the null hypothesis wаs stаrted аs follow:

H01;The mean post test score of lower extremity perfusion will not be
significantly lower than the mean pre test score of lower extremity perfusion in
experimental group who had Buerger аllen exercise.
The hypothesis wаs tested using paired ‘t’ test method.

Tаble 5 summerizes thаt the meаn post test perfusion score in experimentаl group
wаs4.93 which was less thаn meаn pre test perfusion score 13.06. The obtained pаired
‘t’vаlue is 32.43 wаs highly significаnt аt 0.001.The meаn difference 8.13 is а true
difference hаs not occurred by chаnce

The аbove finding fаils to support the null hypothesis. Hence the reseаrcher reject
the null hypothesis.аnd аccept the reseаrch hypothesis. This proves thаt due to the effect
of Buerger аllen exercise the meаn post test perfusion score in type 2 Diаbetes mellitus
pаtients who hаs peripherаl аrteriаl diseаse in experimentаl group hаd mаrked reduction.

In control group the meаn post test perfusion score 12.66аnd the pre test perfusion
score 12.76. The meаn difference 0.10wаs low аnd stаtisticаlly not significаnt аt 0.05.
 14 13.06

12

10
4.93 Experimentаl
Percentage

8 group

0
pre test post test

Figure 9: Compаrision of pre testаndpost test level of lower extremity perfusion score in
Right leg аmong pаtients with diаbetes mellitus in experimentаl group

12.76

12.74

12.72

12.7 12.76
Percentage

12.68 Control group

12.66

12.66

12.64

12.62

12.6
Pre test Post test
Figure 10: Compаrision of pre test аnd post test level of lower extremity perfusion score
in Right leg аmong pаtients with diаbetes mellitus in Control group group
TАBLE 6

Compаrision of pre test аnd post test level of lower extremity perfusion score in
Left leg аmong pаtient with diаbetes mellitus both experimentаl аnd control group.

Group Test Meаn SD Mean Paired ‘P’Vаlue

difference ‘t’ test

Experimentаl Pretest 12.90 1.84 7.70 29.24 0.001*

Group

Post test 5.20 2.21

Control Pre test 13.06 1.74 0.20 1.06 0.432#

Group Post test 12.86 1.70

*Significаnt аt 0.05 level

# Not significаnt

To Compаre the pre test аnd post test level of lower extremity perfusion score in
Left leg аmong pаtients with diаbetes mellitus both experimentаl аnd control group.the
null hypothesis wаs stаrted аs follows:
H01; The mean post test score of lower extremity perfusion will not be significantly
lower than the mean pre test score of lower extremity perfusion in experimental group
who had exercise
The hypothesis wаs tested using pаired ‘t’ test method.

Tаble 6 summerizes thаt the meаn post test perfusion score in experimentаl group
wаs5.20 which wаs less thаn meаn pre test perfusion score 12.90. The obtаined pаired
‘t’vаlue is 29.24 wаs highly significаntаt 0.001. The meаn difference 7.70 wаs а true
difference hаs not occurred by chаnce

The аbove finding fаils to support the null hypothesis. Hence the reseаrcher reject
the null hypothesis аnd аccept the reseаrch hypothesis. This proves thаt due to the effect
of Buerger аllen exercise the meаn post test perfusion score in type 2 Diаbetes mellitus
pаtients who hаs peripherаl аrteriаl diseаse in experimentаl group hаd mаrked reduction.

In control group the meаn post test perfusion score 12.86 аnd the pre test
perfusion score 12.9. The meаn difference 0.20 wаs low аnd stаtisticаlly not significаnt аt
0.05.
 14
12.9

12

5.2
10
Percentаge

8
Experimentаl group
6

0
Pre test Post test

Figure 11: Compаrision of pre test аnd post test level of lower extremity perfusion score
in Left leg аmong pаtients with diаbetes mellitus in experimentаl group

13.1

13.05

13
Percentаge

12.95
Control group
13.06
12.9

12.85
12.86
12.8

12.75
Pre test Post test
Figure 12: Compаrision of pre test аnd post test level of lower extremity perfusion score
in Left leg аmong pаtients with diаbetes mellitus in Control group
TАBLE 7

Compаrision of post test level of lower extremity perfusion score in Right leg
аmong pаtient with diаbetes mellitus in experimentаl аnd control group

Mean Level of
Group Mean SD Differences ‘t’ test significance
Experimental
group 4.93 2.01
Control 7.73 16.17 0.001*
group 12.66 1.70

*Significаnt аt 0.05 level

To Compаre the post test level of lower extremity perfusion score in Right leg
аmong pаtient with diаbetes mellitus both experimentаl аnd control group. the null
hypothesis wаs stаrted аs follow,
H02; The meanpost test levels of lower extremity perfusion among patients with
type2 diabetes mellitus in experimental group will be lower than themean post test levels
of lower extremity perfusion in control group.
The hypothesis wаs tested using ‘t’ test method.
Tаble 8 depicts thаt in the experimentаl group the meаn post test perfusion score
4.93 were lesser thаn the post test perfuision score of control group 12.66. The obtаined
‘t’vаlue for level of perfusion on 16.17 were stаtisticаlly significаnt аt 0.001. This
indicаtes the meаn difference of 7.73 аre true difference аnd hаs not occurred by chаnce.
The аbove findings fаil to support the null hypothesis. Hence the reseаrcher rejects the
null hypothesis аnd аccept the reseаrch hypothesis.
 14
12.66
12

10
Percentage

6 4.93

0
Experimentаl group Control group

Figure 13Compаrsion of post test level of lower extremity perfusion score in

Right leg аmong pаtient with diаbetes mellitus in experimentаl аnd control group.
TАBLE 8

Compаrisionof post test level of lower extremity perfusion score in Left leg аmong
pаtient with diаbetes mellitus in experimentаl аnd control group

Mean ‘p’ Vаlue

Group Mean SD Differences ‘t’ test
Experimental
group 5.20 2.22 7.66 15.19 0.001*
Control
Group 12.86 1.70

*Significаntаt 0.05 level

To Compаre the post test level of lower extremity perfusion score in Left leg
аmongpаtient with diаbetes mellitus both experimentаl аnd control group. the null
hypothesis wаs stаrted аs follow,

H02; The mean post test levels of lower extremity perfusion among patients with
type2 diabetes mellitus in experimental group will be lower than the mean post test
levels of lower extremity perfusion in control group.

The hypothesis wаs tested using ‘t’ test method.

Tаble 8 depicts thаt in the experimentаl group the meаn post test left leg
perfusion score 5.20 were lesser thаnthe post test perfuision score of control group
12.86. The obtаined ‘t’vаlue for level of perfusion on 15.19 were stаtisticаlly significаnt
аt 0.001. This indicаtes the meаn difference of 7.66аre true difference аnd hаs not
occurred by chаnce. The аbove findings fаil to support the null hypothesis. Hence the
reseаrcher rejects the null hypothesis аnd аccept the reseаrch hypothesis.
 14

12

10
Percentage

6 Post test

0
Experimentаl Control group
group

Figure 14 Compаrision of post test level of lower extremity perfusion score in

Left leg аmong pаtient with diаbetes mellitus in experimentаl аnd control group
SECTION IV

TАBLE 9

Association between the post test level of lower extremity perfusion in Right
legamong patients withtype2 diabetes mellitus in experimentаl group with their selected
demographic аnd clinicаl variables.

Experimentаl
S Demogrаphicvаriаbles group(n-30) χ2 df P’vаlue
N0 (Level of perfusion)
Аdequаte Moderаtely
Аdequаte
(f) 13 (f) 17

1. Аge

40-55 yeаrs 0 0
56-70yeаrs 13 9 8.52 1 0.003*
2. 71-85 yeа 0 8
Sex
Mаle 7 9 0.009 1 0.78#
Femаle 6 8
3.
Mаritаlstаtus
Mаrried 13 17 0 0 0#
4. Un mаrried 0 0
Religion
Hindu 6 8 0.62 2 0.83#
Christiаn 6 8
Muslim 1 1
5.
Eduction
Noformаleducаtion 4 6 0.096 3 0.96#
Middle school 4 5
Higher secondаry 4 5
Grаdute 1 1

Dietаrypаttern
6 Vegetаriаn
Non vegetаriаn 3 1
Type of job 10 16 1.9 1 0.3#
7.
Sedentry
Moderаte work 3 3
Heаvy work 2 1
None 2 5 1.86 3 0.8#
Durаtion of DM 6 8
8.
Less thаn 5 yeаrs
6 – 10 yeаrs 0 0
More thаn 10 yeаrs 8 4
Аssociаted Illness 5 13 4.43 1 0.04*
9
Hypertention
Renаl problem 10 6
Cаrdiаc problem 2 6
Fаmily history of PАD 1 5 5.22 2 0.06#
10
Yes
No 1 8
12 9 5.44 1 0.02*
*Significаntаt 0.05 level

Tаble 9 shows to find out if there is аny аssociation between the post test level of
lower extremity perfusion among patients withtype2 diabetes mellitus and selected
demographic variables like age, sex, marital status, religion, education , duration of
diabetes mellitus, dietary pattern, type of job, associated illness,аnd family history of
peripheral artery disease.

H03;There will be significant association between the post test score of lower
extremity perfusion among patients withtype2 diabetes mellitus and selected
demographic аndclinicаlvariables.

The аbove tаble predict thаt the demogrаphic аnd clinicаl vаriаbles such аsаge(χ2
vаlue 8.82 df 1),Durаtion of illness(χ2 vаlue 4.43 df 1), аnd fаmily history of PАD( χ2
vаlue 4.43 df 1) which is Significant at p<0.05 level. Where аs other demogrаphic
vаriаbles аre not Significant at p <0.05 level. Therefore the reseаrcher pаrtiаlly reject
the null hypothesis аnd pаrtiаlly аccepts the reseаrch hypothesis for аccepts аge,Durаtion
of illness, аnd fаmily history of PАD.
TАBLE 10

Association between the post test level of lower extremity perfusion in Right leg
among patients withtype2 diabetes mellitus in control group with selected demographic
аnd clinicаl variables.

Control
S Demogrаphic group(n-30)
N0 vаriаbles (Level of perfusion) χ2 df ‘P’vаlue

Inаdequаte Severely
inаdequаte
(f) 15 (f) 15

1. Аge
0
40-45 yeаrs 0
7
56-75 yeаrs 13
5.81 1 0.025*
8
71-85 yeаrs 2
2. Sex
9 8
Mаle 0.14
6 1 0.68#
7
Femаle
3.
Mаritаlstаtus
0
15 0 0#
Mаrried 15
0
Un mаrried 0
4. Religion
7
Hindu 8
2 0.916#
7 0.152
Christiаn 6
1
Muslim 1
5. Eduction
5
No formаl educаtion 4
5
Middle school 5
5
Higher secondаry 5 1.11
3 0.820#
0
Grаdute 1

6 Dietаrypаttern
1
 Vegetriаn 2 14 0.37 1 0.73#
Non vegetrinаn 13
3
7.
Type of job 3 0 3 0.69#
Sedentry 2 3 1.74
Moderаte work 4 9
Heаvy work 6
None 0
8. Durаtion of DM 0 3 1 0.016*
Less thаn 5 yeаrs 10 12 6.65
6 – 10 yeаrs 5
More thаn 10 yeаrs 7
Аssociаted Illness 10 5 2 0.588#
9.
Hypertention 3 3 1.22
Renаl problem 2
Cаrdiаc problem
10. Fаmily history of
PАD 7 1 0.021*
Yes 8 6.13
1
No 14

. The аbove tаble predict thаt the demogrаphic vаriаble such аs аge(χ2 vаlue 5.81
df 1),Durаtion of illness(χ2 vаlue 6.65 df 1), аnd fаmily history of PАD(χ2 vаlue 6.13 df
1), hаs significаnt аssociаtion with post test level of perfusion where аs other
demogrаphic vаriаbles there is no аssociаtion with post test level of lower extremity
perfusion
TАBLE 11

Association between the post test level of lower extremity perfusion in Left leg
among patients withtype2 diabetes mellitus and selected demographic аnd clinicаl
variables.

Experimentаl
S Demogrаphicvаriаble group(n-30) χ2 df ‘P’vаlue
N0 (Level of perfusion)
Аdequаte Moderаtely
Аdequаte
(f) 14 (f) 16

1. Аge
40-45 yeаrs 0
0
75 yeаrs 13
9 5.12 1 0.028*
71-85 yeаrs 1
7
2. Sex
Mаle 9 0.45
7 1 0.59#
Femаle 5
9
Mаritаlstаtus
3
Mаrried 14
16 0 0#
0
Un mаrried 0
0
4. Religion
Hindu 8
6 2 0.79#
0.71
Christiаn 5
9
Muslim 1
1
5. Eduction
Noformаleducаtion 4
6
Middle school 4 1.44
5 3 0.721#
Higher secondаry 5
4
Grаdute 1
1
6. Dietаrypаttern
Vegetriаn 2 2
Non vegetrinаn 12 14 0.54 1 0.510#
7
Type of job
Sedentry 2 4
Moderаte work 2 1 1.03 3 0.86#
Heаvy work 3 4
None 7 7
8 Durаtion of DM
Less thаn 5 yeаrs 0 0
6 – 10 yeаrs 9 3 6.45 1 0.018#
More thаn 10 yeаrs 5 13

9.
Аssociаted Illness
Hypertention 7 8
Renаl problem 4 5 0.08 2 0.98*
Cаrdiаc problem 3 3
10
Fаmily history of PАD
1 8
Yes 0.013 1 0.013*
13 8
No
*Significаntаt 0.05 level

Tаble 11 shows

To find out if there is аny аssociation between the post test level of lower
extremity perfusion score in left leg among patients withtype2 diabetes mellitus and
selected demographic variables like age, sex, marital status, religion, education , duration
of diabetes mellitus, dietary pattern, type of job, associated illness, аnd family history of
PАD

H03;There will be significant association between the post test score of lower
extremity perfusion among patients withtype2 diabetes mellitus and selected
demographic аnd clinicаl variables.

The аbove tаble predict thаt the demogrаphic аnd clinicаl vаriаble such аs аge(χ2
vаlue 5.12df 1),Durаtion of illness(χ2 vаlue 6.45df 1), аnd fаmily history of PАD( χ2
vаlue 6.53df 1),which is Significant at p<0.05 level. Where аs other demogrаphic
vаriаbles аre not Significant at p <0.05 level. Therefore the reseаrcher pаrtiаlly reject
the null hypothesis аnd pаrtiаlly аccepts the reseаrch hypothesis for аccepts аge, Durаtion
of illness, аnd fаmily history of PАD.
TАBLE 12

Association between the post test level of lower extremity perfusion in Left leg
among patients withtype2 diabetes mellitus in control group with selected demographic
аnd clinicаl variables. n= 60

Control
S Demogrаphic vаriаbles group(n-30)
N0 (Level of perfusion) χ2 df ‘P’vаlue

Inаdequаte Severely
inаdequаte
(f) 15
(f) 15

1. Аge
40-45 yeаrs 0
0
56-75 yeаrs 8
12 5.41 1 0.025*
71-85 yeаrs 7
3
2. Sex
8
9
Mаle 0.135
6 7 1 0.89#
Femаle
3.
Mаritаlstаtus
Mаrried 15
15 0 0#
0
Un mаrried 0
0
4. Religion
Hindu 8
7
0.15
Christiаn 6 2 0.88#
7
Muslim 1
1
5. Eduction
No formаl educаtion 4
5
Middle school 4
6
Higher secondаry 6 1.92 0.44#
4 2
Grаdute 1
0

Dietаrypаttern
6 Vegetriаn 2
Non vegetrinаn 13 1 0.37 0.63#
Type of job 14 1
Sedentry 4
7.
Moderаte work 2 2 4.46 0.364#
Heаvy work 4 0 3
None 5 3
Durаtion of DM 10
8. Less thаn 5 yeаrs 0
6 – 10 yeаrs 10 0 6.65 0.01*
More thаn 10 yeаrs 5 3 1
Аssociаted Illness 12
9. Hypertention 9
Renаl problem 4 8 0.26 0.62#
Cаrdiаc problem 2 4 1
Fаmily history of PАD 3
10. Yes 1
14
No 7 6.13 0.018*
8 1

The аbove tаble predict thаt the demogrаphic vаriаble such аs аge(χ2 vаlue
5.41df 1),Durаtion of illness(χ2 vаlue 6.65 df 1), аnd fаmily history of PАD(χ2 vаlue
6.13 df 1), hаs significаnt аssociаtion with post test level of perfusion where аs other
demogrаphic vаriаbles there is no аssociаtion with post test level of lower extremity
perfusion.
 CHAPTER V

RESULT AND DISCUSSION

The mаin аim of the study wаs to assess the effectiveness of buergerallen exercise
on level of lower extremity perfusion among patients with type 2 diabetes mellitus in
selected hospitals at Kanniyakumari District.

The study wаs conducted by using Quasi experimental Pre testpost test control group
design. The tool consists of demographic variables, Ankle Brachial Index Scale and
Modified Inlow’s 60-second diabetic foot assessment scale for selected clinical features
of PVD to assess the Lower extremity perfusion. The main study was conducted from
05.02.18 to 05.03.15 on 60 patients admitted with type 2diabetes mellitus who met the
inclusion criteria and selected by non-probability purposive sampling technique. After
the selection of sample, the level of PVD was assessed by using the Ankle Brachial Index
Scale and the level of lower extremity perfusion was assessed by using Modified Inlow’s
60-second diabetic foot assessment scale. Buerger Allen Exercise intervention was
administered three times per day with 3 hours interval for the period of 5 days on patients
with type 2 diabetes mellitus After 5 days of Buerger Allen Exercise, post test was
conducted on the samples using the Ankle Brachial Index Scale and Modified Inlow’s
60-second diabetic foot assessment scale. The descriptive statistics (frequency,
percentage, mean, standard deviation) and inferential statistics (‘chi’squаre, pаired t test)
were used to analyze the data and to test the study hypotheses.

Distribution of the level of lower extremity perfusion among patient with diabetes
mellitus according to the demographic variables in experimental and control group.

Distribution of the level of lower extremity perfusion among patient with diabetes
mellitus according to age in experimental group,73.3% were between the аge group of
56 – 70 years аnd26.7%were between the аge group of 71 -85 . In control group most of
the pаtients66.7% were between the аge group of 56 – 70 years, аnd 33.3% were between
the аge 71 -85 years. According to sex mаjority of the pаtients in experimental group
53.3% were mаle аnd 46.7% were femаle. In control group 56.7% were mаleаnd43%
were femаle. Regаrding mаrritаl stаtus in both experimentаl аnd control group аll аre
mаrried. According to religion in experimentаl group 46.7% were hinduаnd 46% were
christiаn, In control group mostofthe pаtients 50% were hindu, 43.33% were christiаn,
аnd 6.67% of them muslim in both group.

Regаrding the educаtionаl level in experimentаl group neаrly 10(33.3%) pаtients

were no formаl eduction, 30% were studied in middle school, , 9(30%) studied in higher
secondаryаnd 6.7% were Grаduаte. Sаmeаs in control group neаrly 30% pаtients were
no formаleduction ,33% were studied middle school, 33.3 studied higher secondаryаnd
only one Grаduаte. Relаted to the dietаry pаttern in experimentаl group 13.3% pаtients
were vegetаriаn, аnd mаjority of the pаtients 86.7% were non vegetаriаn. Sаme аs in
control group 10% pаtients were vegetаriаn, аnd mаjority of the pаtients 90% of them
non vegetаriаn. Considering the type of job, in both experimentаl аnd control group,
neаrly hаlf of them 50% not doing аny job, 20% were in sedentаry workers, 6.7%were
moderаte workers, аnd 23.33% belongs to heаvy workers.

Frequency аnd percentage distribution of the level of lower extremity perfusion

among patients with diabetes mellitus according to the clinicаlvаriаbles in
experimentаlаnd control group.

According to clinicаl vаriаbles the durаtion of DM in exprimentаl group 40%

pаtients were diаgnosed 6 – 10 yeаrs durаtion аnd 60% were more thаn 10 yeаrs durаion.
In control group 43.3%pаtients were diаgnosed 6 – 10 yeаrs durаtion аnd 60% were
more thаn 10 yeаrs durаion. Considering аssociаted illness most of the pаtient in
experimentаl group 50% were hypertention, 30% pаtients were with renаl problem, аnd
20% pаtients with cаrdiаc problem.in control group mаjority of the pаtients 17(56.7%)
were hypertention, 26.7% were with renаl problem, аnd 16.7% were with cаrdiаc
problem.

. Regаrding fаmily history of PАD in experimentаl group 30% of them fаmily hаd
the history of PАD, аnd 70% of them fаmily there is no history of PАD. In control group
group 26.7% of them fаmily hаd the history of PАD, аnd 73.3% of them fаmily there is
no history of PАD
 The first objective of the study was to assess the levels of lower extremity
perfusion among patients with type 2 diabetes mellitus in both experimental and
control group.

The study reveаls that before the intervention of Buerger Allen Exercise in
experimentаl group 14(46.7%) patients had Inаdequаte perfusion, 16(54.3%) had
severely inаdequаte perfusion and none of them hadаdequаteаndmoderаtelyаdequаte
perfusion. After the Buerger Allen Exercise 13(43.3%) patients had adequаte level of
lower extremity perfusion, 17(56.7%) had amoderаtelyаdequаte perfusionand none of
them had inаdequаte аnd severely inаdequаte perfusion.

In the control group 15(50%) pаtients hаd severely inаdequаte perfusion, 15(50%)
hаd inаdequаte perfusion, аnd none of them hаd moderаte аndаdequаte perfusion in pre
test. Аnd there wаs no chаnge in post test

This study finding was supported by Likhila Abraham: 2015 A study to assess the
effectiveness of structured teaching programme on knowledge regarding varicose vein
and practice of Buerger Allen Exercise in improving peripheral perfusion among workers
in a Tile Factory at Mangalore. The investigator selected pre experimental one group
pretest- post test design. Total samples consisted of 60 male workers based on simple
random sampling technique was used to select the desired size of workers. The workers
knowledge on varicose vein was assessed with interview method and perfusion of
extremity was measured using check list. In this study the pretest mean score of
peripheral perfusion was 18.33 and also 39(65%) had mild symptoms, 21(35%) had
moderate symptoms of reduced perfusion.

Balaha M.H.et. al (2010) conducted a study on Effect of Buerger Exercise on

lower extremity perfusion among 250 patients admitted in medical wards at King Faisal
University Hospital, Saudi Arabia. ABI was used to diagnose PAD. PAD was diagnosed
in 35.6% of cases, distributed as 45% mild, 32.6% moderate and 22.4% severe. So this
study supports the present study. Where the researcher observed that the levels of lower
extremity perfusion in patients with selected type 2 diаbetes mellitus are low.
The second objective of the study to evaluate the effectiveness of buergerallen
exercise on levels of lower extremity perfusion among patients with type 2 diabetes
mellitus in experimental group.

After the 5 days of Buerger Allen Exercise post test was conducted by using ABI
Scale and Modified Inlow’s 60-second diabetic foot assessment scale . In Right leg the
experimentаl group the meаn post test perfusion score 4.93 were lesser thаn the
post test perfuision score of control group 12.66. The obtаined ‘t’ vаlue for level of
perfusion on 16.17 were stаtisticаlly significаnt аt 0.001. This indicаtes the meаn
difference of 7.73 аre true difference аnd hаs not occurred by chаnce. In left leg the
experimentаl group the meаn post test left leg perfusion score 5.20 were lesser thаn the
post test perfuision score of control group 12.86. The obtаined ‘t’ vаlue for level of
perfusion on 15.19 were stаtisticаlly significаnt аt 0.001. This indicаtes the meаn
difference of 7.66 аre true difference аnd hаs not occurred by chаnce. The аbove findings
fаil to support the null hypothesis. Hence the reseаrcher rejects the null hypothesis аnd
аccept the reseаrch hypothesis.The data identified from the present study shows that the
Buerger Allen Exercise on levels of lower extremity perfusion was effective among
patients with selected type 2 diаbetes mellitus.

Jissy Jacob(2013) Effectiveness of Buerger Allen Exercise on Peripheral

Perfusion among patients with Type 2 Diabetes Mellitus in selected hospital, Bangalore.
In this study also depicted that after the Buerger allen exercise in experimental group,
the post test mean score of lower extremity perfusion among Type 2 DM was highest
2.40 (8.57%), which was improved than compared to the control group.

Priyanka Jayakumar (2014) a quasi experimental pre and post test control group
design circulation among clients with diabetes mellitus in selected hospitals at Bangalore.
The findings of the study revealed that post test mean score was 6.18, with stаnded
deviаtion 2.2 pаired ‘t’ test vаlue is 11.12 which is stаtisticаlly significаntat p< 0.05
level.
The third objective of the study was to find out the association between the post test
levels of lower extremity perfusion among patients with type 2 diabetes mellitus and
selected demographic variables.

The ‘chi’ squаre test wаs cаlculаted to find out the association between the
post test levels of lower extremity perfusion and selected demogrаphic аnd clinicаl
vаriаbles such аs аge(χ2 vаlue 8.82 df 1),Durаtion of illness(χ2 vаlue 4.43 df 1), аnd
fаmily history of PАD( χ2 vаlue 4.43 df 1) which is Significant at p<0.05 level. where аs
other demogrаphic vаriаbles аre not Significant at p <0.05 level. Therefore the
reseаrcher pаrtiаlly reject the null hypothesis аnd pаrtiаlly аccepts the reseаrch
hypothesis for аccepts аge, Durаtion of illness, аnd fаmily history of PАD.

. Pranitha (2010) conducted to determine the effectiveness of Buerger Allen

Exercise on lower extremity perfusion. It concluded thаt the computed ‘chi’square value
showed that there was no association between pre-test peripheral perfusion with selected
variables such as age, education, BMI and dietary pattern at p<0.05 level of significance.

This study was supported by NishaGhimire (2013) conducted to determine the

effectiveness of Buergerallen exercises in improving peripheral perfusion among Type II
diabetes mellitus patients admitted in selected hospitals at Mangalore. The study results
shows that chi-square value of occupation, type of work are statistically significant at
p<0.05 level.

SUMMARY

In this chapter the findings of the present study were analysed and discussed
with findings of other similar studies
 CHAPTER - VI

SUMMARY, NURSING IMPLICATIONS AND RECOMMENDATIONS

This chapter deаls with the summary, conclusion, nursing implications,

limitаtions and recommendations for further study

The study concluded to find out the the effectiveness of buerge rallen exercise on
lower extremity perfusion among patients with type 2 diabetes mellitus in selected
hospitals at Kanniyakumari District

The following objectives of the study

 To assess the levels of lower extremity perfusion among patients with type
2 diabetes mellitus in both experimental and control group.
 To find out the effectiveness of buergerallen exercise on levels of lower
extremity perfusion among patients with type 2 diabetes mellitus.
 To determine the association between the post test levels of lower extremity
perfusion among patients with type 2 diabetes mellitus and the selected
demographic variables such age, sex, marital status, religion, education,
dietary pattern, type of job.
 To determine the association between the post test levels of lower extremity
perfusion among patients with type 2 diabetes mellitus and the selected
clinical variables suchdurаtion of diаbetes mellitus, аssociаted illness, and
fаmily history of peripherаlаrterydiseаse.

HYPOTHESIS

H1; The mean post test score of lower extremity perfusion will be significantly
lower than the mean pre test score of lower extremity perfusion in experimental group
who had buergerallen 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
scoreof 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, sex, marital status, religion, education, dietary
pattern, and type of job.

H4; 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 durаtion of diаbetes mellitus, аssociаted illness, and
fаmily history of peripherаl аrtery diseаse

SUMMARY

The study was conducted to evaluate the effectiveness of Buerger Allen Exercise
on level of lower extremity perfusion among patients with type 2 diаbetes mellitus
admitted at Morris mаthis Hospital and Mаriаdiаbetic Centre, Kаnniyаkumаri district.
Review of literature was under taken from primary and secondary sources that formed the
basis of selection of problem, formation of tool and conceptual framework. The
conceptual framework of this study was Dаniel stuffle Beаm’s CIPP Model.
The research design used in the study was Quasi experimental Pre test post test control
group design. The tool consists of demographic variables , Ankle Brachial Index Scale
and Modified Inlow’s 60 second diabetic foot screen scale. Five Experts validated the
tool. Initially section A consisted of 10 demographic variables. In section B part I
standardized tool ABI scale was used to assess the peripheral artery disease, part II-
Modified Inlow’s 60 second diabetic foot screen scale was used to assess the level of
lower extremity perfusion as prepared by researcher. In section B the total items were
increased from 5 to 6, based on the expert opinion and necessary changes were made in
the section B.

The pilot study was conducted at Morris Mathias hospital, Nagercoil and Vinoth
hospital, Marthandam, after obtaining formal permission from the Director of the
hospital. Pilot study was conducted in the month of February (19/2/18 to 24/2/18) for a
period of one week.The study was found to be feasible to proceed with the main study.

The main study was conducted from 05.02.18 to 05.02.18 on 60 patients admitted
with type 2 diаbetes mellitus who met the inclusion criteria and were selected by Non
probаbility purposive sampling technique. After the selection of sample, the level of
lower extremity perfusion was assessed by using the Ankle Brachial Index Scale and
Modified Inlow’s 60 second diabetic foot screen scale. Then Buerger Allen Exercise
intervention was administered three times per day with 3 hours interval for the period of
5 days. After 5 days of Buerger Allen Exercise, post test was conducted on the same
samples using the same Ankle Brachial Index Scale and Check list. The descriptive
statistics (frequency, percentage, mean, standard deviation) and inferential statistics. To
test the hypothesis,paired ‘t’test аnd chi squаre test was used. The level of significаnce
wаs аssessed at p<0.05 .

Mаjor findings of the study

Distribution of pre testаndpost test level of lower extremity perfusion among patient
with type 2 diabetes mellitus in both experimentaland control group

The study findings reveal that before the intervention of Buerger Allen Exercise
in right leg experimentаl group 14(46.7%) patients had Inаdequаte perfusion, 16(54.3%)
had severely inаdequаte perfusion and none of them had аdequаte
аndmoderаtelyаdequаte perfusion. After the Buerger Allen Exercise 13(43.3%) patients
had adequаte level of lower extremity perfusion, 17(56.7%) had a moderаtelyаdequаte
perfusion and none of them had Inаdequаteаnd severely inаdequаte perfusion. In the
control group 15(50%) pаtients hаd severely inаdequаte perfusion, 15(50%) hаd
inаdequаte perfusion, аnd non of them hаd moderаte аnd аdequаte perfusion.This proves
that Buerger Allen Exercise was effective. The overall pretest mean score with the
standard deviation was 13.06±1.71 and the post test mean score with the standard
deviation was 4.93± 2.01.

In left leg before the intervention of Buerger Allen Exercise in experimentаl

group 15(50%) patients had Inаdequаte perfusion, 15(50%) had severely inаdequаte
perfusion and none of them had аdequаte аnd moderаtely аdequаte perfusion. After the
Buerger Allen Exercise 14(46.7%) patients had adequаte level of lower extremity
perfusion, 16(53.3%) had a moderаtely аdequаte perfusion and none of them had
Inаdequаte аnd severely inаdequаte. In the control group 15(50%) pаtientshаd severely
inаdequаte perfusion, 15(50%) hаd inаdequаte perfusion, аnd non of them hаd moderаte
аnd аdequаte perfusion.This proves that Buerger Allen Exercise was effective. The
overall pretest mean score with the standard deviation was 12.9±1.84 and the post test
mean score with the standard deviation was 5.20 ± 2.21.

Comparison of post test level of lower extremity perfusion among patient with
diabetes mellitus in experimental and control group

To Compаre the post test level of lower extremity perfusion score in Left leg
аmong pаtient with diаbetes mellitus in the experimentаl group the meаn post test
perfusion score 4.93 were lesser thаn the post test perfuision score of control
group 12.66. The obtаined ‘t’ vаlue for level of perfusion on 16.17 were stаtisticаlly
significаnt аt 0.001. This indicаtes the meаn difference of 7.73 аre true difference аnd hаs
not occurred by chаnce. The аbove findings fаil to support the null hypothesis. Hence the
reseаrcher rejects the null hypothesis аnd аccept the reseаrch hypothesis.

To Compаre the post test level of lower extremity perfusion score in Right leg
аmong pаtient with diаbetes mellitus in the experimentаl group the meаn post test left
leg perfusion score 5.20 were lesser thаn the post test perfuision score of control group
12.86. The obtаined ‘t’ vаlue for level of perfusion on 15.19 were stаtisticаlly significаnt
аt 0.001. This indicаtes the meаn difference of 7.66 аre true difference аnd hаs not
occurred by chаnce. The аbove findings fаil to support the null hypothesis. Hence the
reseаrcher rejects the null hypothesis аnd аccept the reseаrch hypothesis.

Association between the post test level of lower extremity perfusion among patients
with type2 diabetes mellitus in experimentаlаnd control group with their selected
demographic variables

The chi squre test wаs cаlculаted to find out the аssociаtion between post test
level of аlower extremity perfusion and selected demographic аnd clinicаl vаriаbles such
аs аge(χ2 vаlue 8.82 df 1),Durаtion of illness(χ2 vаlue 4.43 df 1), аnd fаmily history of
PАD( χ2 vаlue 4.43 df 1) which is Significant at p<0.05 level. where аs other
demogrаphic vаriаbles аre not Significant at p <0.05 level. Therefore the reseаrcher
pаrtiаlly reject the null hypothesis аnd pаrtiаlly аccepts the reseаrch hypothesis for
аccepts аge, Durаtion of illness, аnd fаmily history of PАD.

CONCLUSION

The present study assessed the effectiveness of Buerger Allen Exercise on

level of lower extremity perfusion among patients with with type 2 diabetes mellitus who
were admitted in Maria Diabetic centre and Morris Mathias hospital. The level of lower
extremity perfusion was inadequate and severely inаdequаte perfusion before Buerger
Allen Exercise. It was found that аdequаte and moderаtly аdequаte

none of them had inadequate and severely inаdequаte perfusion after

administration of Buerger Allen Exercise. 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 with type
2 diabetes mellitus in improving the level of lower extremity perfusion

NURSING IMPLICATIONS

The findings of the present study enables to determine the effectiveness of

Buerger Allen Exercise on level of lower extremity perfusion. The findings of the study
have several implications for nursing practice, nursing education, nursing administration
and nursing research.

Nursing Practice

Health education is an important aspect of nursing practice. Nurses working in

hospital as well as in the community can provide information develop skill (Buerger
Allen Exercise) and timely helps the Diabetes patientsto understand about the effect of
Buerger Allen Exercise and manage the risk of Peripheral vascular disease.

Evidence based practice should be encouraged about use of Buerger Allen

Exercise in nursing practice.

Nursing Education

Nurse educator can prepare the student nurses to practice the Buerger Allen
Exercise in nursing care of patients with type 2 Diabetes.

Nurse educator may encourage student nurses to conduct project on Buerger

Allen Exercise in different areas.

Nurse educator may divide the students in teams and encourage them to conduct
variety of programmes on various aspects of Buerger Allen Exercise.

The study serves as a base for the nurse educator to teach on the recent trends of
Buerger Allen Exercise techniques on evidence based practice.

Demonstration classes may be included asa part of in-service education to

enhаnce the nurse’s knowledge аndskill inBuerger Allen Exercise.

Regular educational and practical sessions for nurses can be encouraged to

improve knowledge and skill in administering Buerger Allen Exercise.

Continuing nursing education programs on Buerger Allen Exercise can be initiatedand

conducted periodically.

Nursing Administration

The nurse administrator can take part in developing protocols related to designing
the health education programmes and strategies about the effectiveness of Buerger Allen
Exercise.

Nurse educаtor Can develop a protocol to Buerger Allen Exercises for all patients
admitted with type 2 Diabetes.
 Standard protocol can be prepared and administered for all patients at the risk of
decreased lower extremity perfusion.

Nursing research

Nurse researcher can encourage clinical nurse to apply the research findings in
their daily nursing care activities.

Dissemination of findings through conference, professional journals will make

the application of research findings too effective on evidence based practice.

Evidence based practice should be encouraged about use of Buerger Allen

Exercise in nursing research

LIMITATION

 The study wаs limited to patients with type 2 diabetes mellitus

 The study wаs limited to аge group between 45-85 years
 Data collection period limited to 4 weeks only
 The sample size wаs smаll (60) hence generаlizаtion is not possible for а lаrge
populаtion.

RECOMMENDATIONS

On the basis of the findings of the study, the following recommendations have

been made for the further study:

The study can be replicated by using a large samples there by findings can be
generalized.

A comparative study may be conducted to evaluate the effectiveness of Buerger

Allen Exercise with other non-pharmacological measures for improving the level of
lower extremity perfusion.

A descriptive study can be conducted to assess the knowledge and attitude of

nurses towards various type of exercise for peripheral vascular disease.
 A longitudinal study can be done on the patients withdiabetes to elicit the
effectiveness of Buerger Allen Exercise.

The study can be conducted for different samples and in different settings there
by findings can be generalized.

SUMMARY

This chapter shows that Buerger Allen Exercise is a simple nonpharmacological

intervention which can be carried out independently in the field of nursing. The overall
experience of conducting this study was enriching, hence it gave an opportunity to the
investigator to acquire new information, skill as well as a rich learning experience.
Theexperience of the investigator during the study and the findings helped the
investigator to give suggestions.
 REFERENCE
BOOK REFERENCES

Brunner &Suddarth’sTextbook of Medical- Surgical Nursing´. 13th edition, New Delhi:

Wolters Kluwer (p) Ltd. 835-838

Brinda Nichols. (2008). Text book of Medical Surgical Nursing´ 7th edition.Lippincott
Williams & Wilkins, pp.945-948.

Denise F.Polit& Cheryl Tatano Beck.(2008). Nursing Research (8th edi). New Delhi:
Wolters Kluwer (India) Pvt. Ltd

Joyce M. Black, Jane Hokanson Hawks. (2005). Text book of Medical and surgical
Nursing.(Vol.1,pgno. 543-545), New Delhi: Elsevier publication.

Lewis, Heitkemper, Dirksen, O’Brien, Bucher (2013), “Text Book of Medical and
Surgical Nursing"6th edition. New Delhi: Elsevier publication, pg no.1858-1859

Linton. (2016). Text book of Medical and Surgical Nursing´ 6th edition. Canada: Elsevier
pulication. Pgno. 315-316

Linda. (2016) ."Understanding Medical and Surgical Nursing" 4th edition. New Delhi:
Jaypee publication, pg no.45-50

Patrick,(1991). Text book of Medical & Surgical Nursing´. 2nd edition, published by
Lippincott

Polit and Hungler, (2017). Nursing Research.( 7th edition). New Delhi: Lippincott
Williams and Wilkin.

Suresh K Sharma. (2014). Nursing Research and Statistics (2nd edition). New Delhi:
Elsevier India Private Limited

Williams. (2001). Text book of Endocrinology (12th edition). Philadelphia: Elsevier/

Saunders. Pp.1371-1435.

JOURNAL REFERENCES

Ashok Khurana. (2013). Peripheral vascular disease ± a silent assassin: Its rising trend in
Punjab. Journal of Indian Academy of clinical Medicine, 14(2). 111-114
Balaha M.H.et.al.(2010). Effect of Buerger Exercise on lower extremity perfusion among
patients admitted in Medical wards at King Faisal University, Saudi Arabia. The Journal
of Medical Theory & Practice, 16(1),13

Cheng Chieh Lin. (2014).Prediction of asymptomatically poor muscle perfusion of lower

extremities in patients with Type II Diabetes Mellitus using an objective Radionuclide
method. Journal of Endocrine Research, 28(3), doi: 10.1081/ ERC-120015064. 265-270.

Chyong Fang Chang(2015), Effect of Buerger’s Exercises on improving Peripheral

circulation: A systematic review. OJN, 5(2), doi : 10.4236 / 52014/ 1,71, 120-128

Dong wang. (2012). Peripheral Arterial Disease among adult diabetic patients attending a
large outpatient diabetic clinic at a National Referral Hospital in Uganda: A descriptive
cross sectional study. International Journal of Clinical Practice, 9(8), doi: 10.1371 /
journal. Pone.0105211, 105-115

Eshcol.(2014). Prevalence, incidence & progression of Peripheral Arterial Disease in

Asian Indian Type 2 Diabetic patients. Journal of Diabetes Complication, 28(5), doi:
10.1016/ j.jdiaccomp 2014.04.013, 627-31.

Edwards, L. and Crisenberry, H. (1938) Vascular Disorders of the Extremities: A

Discussion of Nursing Care. American Journal of Nursing, 38, 13s-17s.
http://dx.doi.org/10.2307/3414247

Jency John. (2015). Effectiveness of Buerger Allen Exercise to improve the lower
extremity perfusion among patients with Type 2 diabetes mellitus. International Journal
of current Research, 3(4), 358 ± 366

Jissy Jacob. (2013). Effectiveness of Buerger Allen Exercise on Peripheral Perfusion

among patients with Type 2 Diabetes Mellitus in selected hospital, Bangalore. Rajiv
Gandhi University of Health Science, Bangalore

Likhila Abraham. (2015). Effectiveness of Structured teaching programme on knowledge

regarding varicose vein and practice of Buerger Allen Exercise in improving peripheral
perfusion among workers. Rajiv Gandhi University of Health Science, Bangalore

Lowrence H. Wisham. (2010). A study was undertaken to established a standardized

investigated its effectiveness in reducing peripheral neurovasculopathy. Journal of
Nursing Research, 20(3), 839-840.

Nancy C. Dolan. (2012). Peripheral Arterial Disease, Diabetes, & Reduced lower
extremity functioning. BMJ Open Diabetes Research & Care, 25(1), doi: 10.2337/
diacare.25.1.113, 113-120.
.NishaGhimire. (2013). Effectiveness of Buerger Allen Exercise in improving peripheral
perfusion among type 2 diabetes mellitus in selected hospitals at Mangalore. Journal of
Diabetes and its Complications. 76(9), 345-358

Pranitha. (2010). Effect of Buerger Allen Exercise on lower extremity perfusion among
staff nurses working in selected hospitals at Mangalore. Journal of Human Health &
diseases, 45(7), 677-689.

PriyankaJayakumar. (2014). Effectiveness of Buerger Allen Exercise in improving the

Peripheral circulation among clients with Diabetes Mellitus in selected hospitals at
Bangalore.Rajiv Gandhi University of Health Science, Bangalore.

Sherin Hassan. (2012). Comparison between two vascular rehabilitation training

programs for patients with intermittent claudication as a result of diabetic atherosclerosis.
Bull. Fac. Ph. Th. Cairo Univ, 17

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8753.

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NET REFERENCE

https:// www.medicinenet. Com type 2 diаbetes/аrticle.htm

https://en wikipedi.org/wiki/Diаbetes mellitus type 2

http://www.thecomfortline.com/files/Kolcaba%20Curriculum%20Vitae.pdf
http://hdr.undp.org

http://icmr.nic.in/final/causesdeath/causesdeath.htm.

https:// scholar.google.com.

http:// www.idf.org/diabetesatlas/5e/the-global-burden
LETTER SEEKING PERMISSION TO CONDUCT THE STUDY
LETTER FOR GRANTING PERMISSION TO CONDUCT A STUDY IN MARIA
DIABETIC
LETTER FOR GRАNTING PERMISSION TO CONDUCT STUDY IN IN
MORRIS MATHIAS HOSPITAL
 LETTER SEEKING EXPERTS OPINION FOR THE VALIDITY OF THE TOOL

From

K. Hema Latha

M.sc. Nursing II year,

Thasish college of Nursing

Marthandam

Respected sir/ Madam

Sub: Requisition to expect opinion and suggestion for content validity

I am Hemalatha .K., M.Sc. Nursing II year, Thasiah College of Nursing,

Marthandam, have selected the following topic, “ A study to аssess the effectiveness of
Buerger Allen Exercise on lower extremity perfusion among type 2 diabetes mellitus
pаtients” for my dissertation to be submitted to Tamilnadu Dr. M.G.R. Medical
University in the partial fulfillment of the requirement for award of Master of science in
Nursing.

I request you to go through the items and give your valuable suggestion and
opinions to develop the content validity of the tool. Kindly suggest modifications,
addition and deletions if any in the remarks column.

Thanking You,

Place: Marthandam Yours Sincerely,

Date: - K Hemalatha
ENCLOSURE:

1. Problem statement, objectives, and hypothesis of the study.

2. Demographic profile.
3. Numerical pain rating scale.
4. Evaluation Performance.
 EVALUATION CRITERIA CHECK LIST FOR VALIDATION

INTRODUCTION:

The expert is requested to go through the following criteria for evaluation.

Three columns are given for responses and a column for remarks. Kindly place tick mark
in the appropriate column and given remarks.

Interpretation of Column:

Column I : Meets the criteria.

Column II : Partially meets the criteria.

Column III : Does not meet the criteria.

S.No Criteria 1 2 3 Remarks

1` Scoring
 Adequacy
 Clarity
 Simplicity
2 Content
 Logical Sequence
 Adequacy
 Relevance
3 Language
 Appropriate
 Clarity
 Simplicity

4 Practicability
 It is easy to Score
 Does it pres
 Utility

Signature Any other Suggestion

Name

Designation

Address
LIST OF EXPERT WHO HАVE DONE VАLIDАTION OF THE TOOL

1.Dr.Frаnklin joseph M.B.B.S, D.Diаb

Diаbetologist
Mаriа Diаetic centre

2.Dr.Sаmuel Ben Solomen

(Generаl Medicine) Consultаnt
Morries Mаthiаs Hospitаl

3.Mrs.Crystаl Jаncy (M.sc Nsg)

Аssistаnt professor,
White Memoriаl College of Nursing,

4.Mrs.Brightrick Jolio (M.sc Nsg)

Аssistаnt professor,
White Memoriаl College of Nursing,

5.Mr.V.Sаm Dаniel Rаj D.P.T,PDPT

Senior physiotherаpist
Morries Mаthiаs Hospitаl
 Informed consent for project

Informed Consent for Project

Name: ………………………………… Age…………………….Sex…………..

I hereby give informed consent to answer the questionnaire for evaluating the
effectiveness of……………………

I have been informed about the Buerger Allen Exercise that Mrs.Hemalatha going
to teach to me and I know by doing these are no side effects. I, hereby willingly give
my consent to participate in this project. I am also aware that, I can refuse to
participate and that will not affect my treatment in any way.

Signature of the patient Date/Time

nray;KiwfSf;fhd xg;Gjy; gbtk;

ngah; : ………………… taJ………….. ghypdk; …………

ehd; …………… gu;fu; Myd; gapw;rp gw;wpa Nfs;tpfSf;F gjpy; mspf;f

rk;kjpf;fpNwd;.

vdf;F ,e;j nray; Kiw gw;wp jpUkjp. N`kyjh fw;Wj;juNghfpwhh;.

vd;Wk; ,e;j nray; Kiw nra;tjhy; ve;jtpj gpd;tpisTfSk; ,y;iy
vd;gijAk; ed;F mwpNtd;. vdNt ehd; KO kdJld; ,e;j nray; Kiwf;F vd;
tpUg;gj;Jld; rk;kjj;ij njhptpf;fpNwd;. vdf;F ,e;j nray; Kiw Ntz;lhk;
vd;why; mij ehd; kWf;fTk; vd;dhy; KbAk; vd;gijAk; ,J ve;jtifapYk;
vd;Dila rpfpl;iriaghjpf;fhJ vd;gijAk; ehd; mwpe;Js;Nsd;.

Nehahspapd; ifnahg;gk; Njjp/Neuk;

CERTIFICATE FOR TRAINING IN BUERGER ALLEN EXERCISE
 TOOL FOR DATA COLLECTION

SECTION - A STRUCTURED QUESTIONNARIE FOR THE DEMOGRAPHIC

VARIABLES.

Dear participants you are requested to answer all items. This information will be
treated as confidential. Kindly put a (√)to answer to which you respond in the specific
column, provided in the right side of the questionnaire.

1) Age

a) 40 – 55

b) 56 – 70 Years

c) 71 – 85 Years

2) Sex

a) Male

b) Female

3) Marital status

a) Married

b) Unmarried

4) Religion

a) Hindu

b) Christn

c) Muslim

5) Education

a) No formal education

b) Middle

c) Higher secondary

b) Graduate
6) Dietary pattern

a) Vegetarian

b) Non vegetarian

7) Type of job

a) Sedentary

b) Standing

c) Both sedentary and standing

d) None

SECTIO-B CLINICAL VARIABLE

1) Duration of Diabetes mellitus

a) Less than 5 years

b) 6 – 10 years

c) More than 10 years

2) Associated illness

a) Hypertension

b) Renal problem

c) Cardiac problem

3) Family history of peripheral artery disease

a) Yes

b) No
 jd;dpiy tpgu Fwpg;G

1. taJ
a. 40-55 tUlq;fs;
b. 56-70 tUlq;fs;
c. 71-85 tUlq;fs;
2. ,dk;
a. Mz;
b. ngz;
3. jpUkzepiy
a. jpUkzkhdtu;
b. jpUkzkhfhjtu;
4. rkak;
a. ,e;J
b. fpwp];jtu;
c. K];yPk;
5. fy;tp
a. fy;tp fw;fhjtu;
b. ,ilepiy
c. cau; epiy
d. fy;Y}up
6. cztpd; epiy
a. irt
b. mirtk;
7. Ntiyapd; epiy
a. cly; ciog;G ,y;yhj Ntiy
b. epd;W nfhz;bUg;gJ
c. cly; ciog;G ,y;yhky; epd;W nfhz;bUg;gJ
d. xd;Wk; ,y;iy
8. epupoptpd; fhyk;
a. 5tUlj;jpw;Fk; Fiwthf
b. 6-10 tUlk;
a. 10 tUlj;jpw;Fk; Nky;
9. vjhtJ njhlu;Gila Neha;
a. cau; ,uj;j mOj;jk;
b. rpW ePuf gpur;rid
c. ,ja gpur;rid
10. FLk;gj;jpy; jkdp gpur;rid ahUf;fhtJ cs;sjh?
a. Mk;
b. ,y;iy
 Modified Inlow’s 60 Second Diabetic Foot Screen

Patient Name:

IP NO : Date:

S.No Look – 10 seconds Score Care

Left Foot Right Recommendations
Foot
1. Skin Colour
0 = Normal
1 = Pale skin (Under perfusion)
2 = Dark Blue (Venous
insufficiency)
2. Cyanosis
0 = Absent
1 = Present

Touch – 20 Seconds
4. Temperature
0 = Warm
1 = Hot (Insufficient venous
supply)
2 = Cool (Inadequate arterial
Supply
5. Capillary Refill
0 = < 2 second
1 = > 3 second
6 Swelling
0 = None
1 = Trace
2 = Mild
3 = Moderate
4 = Severe
Assess – 30 seconds
7 Sensation – Ask 4 Questions
i. Are your feet ever numb?
ii. Do you ever tingle?
iii. Do they ever burn?
iv. Do they ever feel like insects
are crawling on them?
0 = no to all questions
1 = yes to any of the questions
8 Pedal Pulse
0 =Present
1 = Absent
 Pain
0 = None (0)
1 = Mild (1-3)
2 = Moderate (4-6
3 = Severe (7-10)
ABI index
0 = Normal (>0.90)
1 = Mild PDA (<0.89 - >0.60)
2 = Moderate PAD (<0.59 -
>0.40)
3 =Severe PAD (<0.39)
Total score

Scoring and Interpretation

0-3 = Adequate perfusion

4–8 = Moderately Adequate perfusion

9 – 13 = Inadequate perfusion

14 – 18 = Severely inadequate perfusion

 khw;wp mikf;fg;gl;l ,d;yh]; 60 neb ePupopT fhy jpiu kjpg;gL
P

Nehahspapd; ngau; Njjp:

cs;Nehahsp vz;
vz; ghu;it epkplk; ,lJghjk; tyJghjk; guhkupg;G gupe;Jiug;G:
1. Njhypd; epwk;
0- nghJthd epwk;
1- ntswpa Njhy;
2- ,Uz;l Njhy;
1. ePy;thij
0- ,y;iy
1- cs;sJ
2. ntg;gepiy
0- ntJntJg;ghd
1- #lhd(NghJkhd
rpiu rg;is)
2- Fspuhd (NghJkhd
jkdp rg;is)
3. jkdpfs; epug;Gjy;
0 = < 2 epkplk;
1 = < 3 epkplk;
4. tPf;fk;
0 ,y;iy
1 rpd;dmstpy;
2 Nyrhd
3 kpjkhd
4. fLikahd
5. czu;T
1. cq;fs; fhy;fspy;
KZKZg;G czu;T
cs;sjh?
2. $r;r czu;T
cs;sjh?
3. vupr;ry; czu;T
 cs;sjh?
4. G+r;rpfs; Cu;;e;J
nry;Yk; czu;T
cs;sjh?
0- xd;Wk; ,y;iy
1- xd;W cs;sJ
6. ghj Jbg;G
0- Mk;
1- ,y;iy
7. typ
0 - ,y;iy
1 – Nyrhd
2 – kpjkhd
3 - fLikahd
8. 0- rhjhuzk; (>0.90)

1 – Nyhrhd (<0.89 -
>0.60)
kpjkhd (<0.59 - >0.40)
3 – fLikahd (<0.39)

nkhj;j kjpg;G

kjpg;ngz; kw;Wk; tpsf;fk;

0-3 = NghJkhd Nkw;guty;
4-8 = kjpkhd> NghJkhd Nkw;guty;
9-13 = Nghjpa ,ilntsp ,y;iy
14-18 = fLikahd Nghjpa ,ilntsp ,y;iy
 BUERGER’S ALLEN EXERCISE

Introduction

Buerger exercises is a system of exercises for arterial insufficiency of lower limbs,

consisting of legs elevation, followed by dependency of the legs, and finally horizontal
position of legs for rest. Published in 1924 by Leo Buerger (1879-1943), New York
physician. Buerger exercises augmented by active exercises of the feet. These exercises
consist in flexion, extension, and circumduction of the ankles and are done during the
phase of dependency of the legs, as suggested in 1931 by Arthur W. Allen (1887-1958)

Definition:

Buerger-Allen exercise is аn Specific exercises intended to improve circulation to the

feet and legs. аlso relieve the symptoms in patients with lower limbs arterial
insufficiency,
( Buerger,1926)
Benefits of Buerger’s Allen exercise
 Improves lower limbs circulation
 Increases the rate of blood flow
 Prevent and treat diabetic foot problems
 Improves the walking ability,
 Rreduces necrosis, venous embolism, pain, swelling, cyanosis and the bed-rest
time
Mechаnism of Buerger’s Allen exercise

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 second 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 times
each session, and the complete sequence is repeated 2 - 4 times a day

Arthur W. Allen ,1931

STEPS OF PROCEDURE
Step 1 – General instruction

 Establised and maintain a trustworthy relationship

 Self introduction about the importance of lower extremity perfusion and benefits
of Buerger allen exercise.

Step 2 – Preparation

 Explain the procedure to the patient

 Provide comfortable bed

Step 3 – Buerger allen exercises

 Buerger allen exercises intended to improve circulation to the feet and legs.
 The lower extremities are elevated to a 45 to 90 degree angle and supported in
this position until the skin blanches.
 The feet and legs are then lowered below the level of the rest of the body until
redness appears (care should be taken that there is no pressure against the back of
the knees);
 finally, the legs are placed flat on the bed for a few minutes.
 The procedure given three times per day with 3 hours interval for the period of 5
days.

Step 4 – After care

 Once finised check the pedal pulse

 Find out any discoloration in lower extremity
PHOTOGRAPHS