PRESENTASI

JURNAL
STASE
KEPERAWATAN
MEDIKAL
BEDAH
Dellia Winada 20214030099
Linda utari 20214030029
Imam Ma’arif Annafi 20214030024

School of Nursing
Medical Faculty and Health Science
Muhammadiyah University of Yogyakarta
Background
Diabetic foot ulcer is defined as a
full-thickness wound that destroys
the deep tissues and develops at a
level distal to the ankle and is
associated with neurological
abnormalities in patients with
diabetes
Hypothesis
These ulcers can be classified as What is the effect of exercise and
neuropathic, ischemic or neuro- physical activity interventions on
ischemic diabetic foot outcomes?
Research Purposes
The purpose of this systematic
review was to analyze the
effects of exercise and physical
activity interventions on
diabetic foot outcomes.

There is an establish evidence of a positive

The neuropathic, commonly occur on the plantar
surface of the meta-tarsal heads, or in areas overlying
a bone deformity and is usually induced by foot
deformity and high foot pressures, provoking tissue
damage. Once the tissue breakdown, the resultant
ulceration becomes chronic as the insensate foot fails
to convey nociceptive stimuli which are necessary to
provoke protective behavior
Ischemic ulceration can be represented as an absence
of foot pulses, mainly because of macrovascular or
microvascular disease causing a hard healing of the
wound, result of an inadequate vascular perfusion in
the lower limb and frequently occurs on the tips of
the toes or on the lateral border of the foot
association between exercise and diabetes,
particularly by improving glycemic control, and insulin
Foot ulcer precedes the major of amputations
sensitivity in individuals with type 2 diabetes, along
in patients with diabetes by 80%. Foot ulcers,
with positive effects on lipids, blood pressure,
with or without signs of infections, and
cardiovascular events, mortality, and quality of life
amputations are major causes of morbidity
However, less is known about the effects of physical
and disability in these patients, leading to
activity and exercise in diabetic foot outcomes.
significantly lower daily activity and is even
Recent studies have suggested that physical activity
correlated with a higher risk of death The
and exercise may improve the distribution of dynamic
management of ulcers and their prevention is
plantar loading, nerve velocity conduction and foot
important to ensure quality of life and
mobility function, reflecting a better involvement of
decrease comorbidities and death
the whole foot during walking process and decreasing
the incidence of foot ulcer or lesion.

The neuro-ischemic ulceration has both neuropathic

and ischemic and it develops on the margins of the
foot and toes usually from the pressure of poorly
fitted shoes.
Metode
 Inclusion Criteria
Research Method Data sources and Search Strategy
1. the population was composed by patients with a diagnosis of diabetes
This systematic review was Systematic searches were conducted in February regardless of aetiologies, or a clinical diagnosis of diabetic peripheral
conducted in accordance with 2017 by two independent authors using the neuropathy, polyneuropathy or diabetic foot ulcer.
Preferred Reporting Items for following electronic databases: Pubmed, The
Systematic Review and Meta 2. the population was composed by patients with a diagnosis of diabetes
Cochrane Online Library, Web of Science, and
Analysis (PRISMA) regardless of aetiology, or a clinical diagnosis of diabetic peripheral
Scopus. Searches were conducted until July 2017.
neuropathy.
The following keywords were used: ((feet OR foot)
3. the comparator was daily-life physical activity (absence of supervised
[title] AND (diabetes OR diabetic OR neuropathy OR
physical activity or exercise regimen) and/or usual foot care education.
ulcer*) [title] AND (‘‘physical activity” OR exercise OR
training OR walking OR jogging OR cycling OR running  
Research Method OR swimming OR Pilates OR yoga OR rowing OR
climbing) [title]).

Exclusion Criteria Data Extraction and Quality assesment

1. Nonhuman diabetic research. Eligible studies were examined independently by two collabo- rators [MM and NS], and any disagreement was settled via
discussion among the authors. The study features extracted from each paper include: first author, year of publication, pre-
2. Studies lacking original data (letter, review
disposing factor, number of participants in the intervention and control groups, mean or range age of participants,
articles or editorial)
duration of intervention, a description of the intervention and control groups, primary and secondary outcomes, and main
3. Articles on unrelated topics results. A meta-analysis was deemed unfeasible because of the small number of studies and heterogeneous outcome
measures.
4. Study without outcome of interest report
Risk of bias was assessed independently by two researchers [MM and NS], who were blinded to each other’s quality
5. Studies with less than 10 participants. assessment. All studies were scored using the PEDro critical appraisal tool for experimental studies.
6. Clinical trials without control group and specific  
exercise intervention
PEDro is a reliable tool consisting of 11 items. Each item can be assigned a yes (worth 1 point) or a no (worth 0 point). Item
1 is for external validity and not used in scoring, so that the maximum points an item can get is 10 points. With at least 5
points were considered to be of low bias.
Results 1 Selection of studies

A total of 173 articles were identified. From 173 articles, 58 duplicates were excluded, and 115 articles
remained. 24 were assessed for eligibility and a total of 91 articles were excluded based on title. Further
exclusion reduced the articles to 13 with 7 articles lacking control group or nonspecific exercise intervention.
In the end 6 articles remained.

Result 2
 3 research reported improved Neural velocity conductivity
 1 research reported improved resistance against lesion incidence
 2 research that utilized Michigan Neuropathy Screening Instrument (MNSI) and Michigan Diabetic
Neuropathy Score (MDNS) reported reduced score on intervention group and an overall better well-being
of intervention group compared to control group
 All research that includes fasting blood glucose measurement also indicates a statistical significance on
intervention group compared to control group.
 Insulin resistance index although dropped by 23% on intervention compared to 10% in control group is not
considered significant.
 One research reported better quality of life using Korean SF-36 v2 tool on intervention group over control
group.
DISCUSSION
The main finding of this systematic review is that exercise is a beneficial non-pharmacological treatment in diabetic foot outcomes,
particularly in increasing nerve velocity conduction of the lower limbs. Additional benefits can be induced by exercise in patients with
diabetes, such as skin sensitivity and intraepidermal nerve fiber density, which can delay the usual course of diabetic peripheral neuropathy
and delay skin damage and ulceration.
 
the present review showed that aerobic exercise can improve, for example, nerve velocity conduction in peroneal motor nerve by 3.9% and
0.8% in sural sensory nerve, also decreasing distal latency by 0.9% [32]. Moreover, Tai Chi Chuan exercises improved nerve velocity conduction
by 2.3% in right motor median and 2.1% in left motor median, as well as 4.8% in right motor tibial and 2.7% in left motor tibial, reducing
overall distal latency by 5% facing greater gains However, a combined exercise program with aerobic, foot care education, diabetic diet and
standard medical care showed a higher impact, with gains in nerve velocity conduction by 7.3% in peroneal motor nerve and 32.6% in sural
sensory nerve [33]. Similar intervention with combined training program for lower-extremity muscles strengthening, balance and walking plus
diabetic foot care education demonstrated to reduce long-term incidence rate of foot lesions by 44.6%
 
The majority of participants presented in the studies, showed improvements in total symptom score for peripheral neuropathy and vibration
perception threshold as well as a better physiological foot rollover which reflects in a better redistribution of plantar pressure. Weight-bearing
activities did not increase risk of foot re-ulceration. These findings suggest that exercise may positively enhance peripheral 419
circulation and reduce peak plantar pressures, and therefore reducing diabetic foot ulcer risk and improving diabetic foot outcomes.
DISCUSSION cont.
In the present review, two studies demonstrated an improvement in fasting
blood glucose and glycated hemoglobin levels, but these benefits are currently
well documented in the literature Concerning physical function, the amount of
steps taken within this patients after an intervention program, suggests that
they are liable to increase exercise performance . Also, patients in a Tai Chi
Chuan program increased their balance in single leg stance and another
intervention group had an improvement in scale for Activities-specific Balance
Confidence.

Conclusion
This systematic review suggests physical activity and exercise as an efficient
intervention to reduce the risk of diabetic foot. Although the variety of physical
activity and exercise methods implemented in the trials, like aerobic exercise or
combined modes of exercise, all have brought benefits in diabetic foot related
outcomes. Moreover, multi-disciplinary treatments, such as physical activity, diet
routine and foot care education, all combined, are more effective in the
improvement of diabetic foot outcomes than singular interventions.
Critical Assessment: Critical Assessment:
Is it relevant to the Is it possible to be conducted by a nurse?
managed case? The presented systematic review is very
It is quite relevant possible to be conducted by a nurse. Diabetic
with the managed feet neuropathy is a multi-discipline case
case since the patient where medication, education as well as diet
suffered type II were involving many different health
diabetes with high risk professionals, but on the field of direct
of diabetic feet intervention and therapy it is a nurse who is
neuropathy. most qualified to perform such a task as
nurses spend most of their working hours
around patient thus are able to tailored each
physical therapy according to patient’s ability
and progression of their diabetic feet
neuropathy.
Critical Assessment:
REWARD VS RISK
The systematic review is quite clear in its
result to show that there was no adverse
effect were reported on all the research
article that is reviewed. With all the
benefits that physical exercise could yield
to improve the outcome of diabetic feet
neuropathy, the reward is obviously
overcame the risk involved in performing
the therapies.
Critical Assessment: Critical Assessment:
NURSING IMPLICATION
POSSIBLE APPLICATION
 
The ever-increasing number of aging The systematic review provided
populations of the world that carries the risk decent amount of possible
of diabetic disease is one of the biggest health therapies that could be used as
concerns in the world. Along with such health options to provide physical
problem came one of its biggest complications exercise therapy for a diabetic
that came from diabetic feet neuropathy. With patient that a nurse can provide to
over 80% of patient with diabetic feet prevent the risk of developing
neuropathy were experiencing amputation.
diabetic feet neuropathy or to
According to such concern, a diabetic feet care
improve the condition of patient
is a major part of any comprehensive nursing
that already has diabetic feet
care for anyone that has been diagnosed with
diabetes. Nurse role in diabetic feet care is neuropathy
huge in providing both therapy and education
regarding to foot’s health to prevent the risk of
diabetic feet neuropathy or to prevent further
progression of diabetic feet neuropathy.
 Supporting Research 1

Title:
EFFECTIVENESS OF DIABETIC FOOT EXERCISES USING SPONGES
AND NEWSPAPERS ON FOOT SENSITIVITY IN PATIENTS WITH
DIABETES MELLITUS (2019)
Author: Fadhillah S, Sucipto A, Rahil NH
Penerbit: Belitung Nursing Journal, 5(6), 234-238

Research method:
This is a quasi-experimental study with pretest posttest with a control group research design,
which was conducted at Public Health Center Depok III, Sleman Regency, Yogyakarta,
Indonesia. An accidental sampling technique was used to select participants, with a total
sample of 108 respondents consisting of 36 respondents in a control group, 36 respondents in
a sponge group, and 36 respondents in a newspaper group. Data were analysed using
Wilcoxon and Mann-Whitney test.
 Supporting Research 1

Sampling:
The inclusion criteria of the sample were a patient with type 2 diabetes mellitus, length of
disease is > 2 years, aged 35- 64 years, and willing to follow the entire research process. The
exclusion criteria were patients with diabetes mellitus who had diabetic foot ulcers..

Instruments
Foot sensitivity was measured using a monofilament 10 g Monofilament was placed
perpendicular to the skin. The emphasis was made as far as monofilament could be bent and
held for 2-3 seconds. Monofilament was used at 10 location points on the left and right feet,
namely on the first toe, the first, third and fifth metatarsal heads, three plantar parts from the
heel, and the dorsum of the foot. The examination was carried out before and after diabetic
foot exercises, with scale 0-10 to indicate the number of points that can feel monofilament.
The higher the score, the better of foot sensitivity.

Intervention
The first group of respondents received diabetic foot exercise using a sponge (with a size of
30 cm × 25 cm × 1 cm), and the second group using two-sheets newspaper (with a size of 70
cm x 58 cm) for the exercise. Both groups performed the exercise in both feet for 10 minutes
3 times a week (1st day, 4th day, and 7th day). The third group did not receive any treatments
as a control group.
 Supporting Research 1

Result
 The findings supported the study that stated that foot exercises can help facilitate blood
circulation, strengthen small muscles, and prevent foot deformities. In addition, foot
exercises help strengthen the foot muscles and help blood circulation to the lower
extremities. However, foot exercises provided stimulation to the nerve points associated with
the pancreas to produce insulin through nerve points located on foot, and prevent the
occurrence of complications in the foot and increase the sensitivity of body cells, especially
the foot sensitivity. Although there was no significant difference on the impact of foot
exercise between sponge and newspaper group, but the median of foot sensitivity was
slightly different, which is higher in the sponge group compared to the median in the
newspaper group. A sponge was more challenging to tear than the newspaper. Based on this
research opinion, using a sponge, patients need to focus the strength and energy on the feet
to tear the sponge and do the maximum foot exercises. The more foot pressure is given, the
better the stimulation of blood circulation in the area of the foot. However, both media are
effective, as indicated in our study.
 Supporting Research 2

Title : Lowering Blood Sugar in Type II Diabetes Mellitus Patients Through Diabetic Foot
Exercises

Methods: This study uses a pre-experimental quantitative method with a one group pretest-
posttest approach. Measurement of blood sugar levels using a glucometer before and after
diabetic foot exercises. Data analysis used Paires t-test.

Criteria: The population in this study were patients who had been diagnosed with Type II
Diabetes Mellitus at the KM 5 Palembang Public Health Center.

Sample: The number of samples used is 30 respondents.

Implementation: Recommended moderate intensity exercise (maximum heart rate 60-70),

duration of 30-60 minutes, with a frequency of 3-5 times / week and no more than 2
consecutive days of not exercising.
 Supporting Research 2

RESULT AND DISCUSSION.

The results showed the average value of blood sugar levels before doing leg exercises was
202.67mg/dl, after leg exercises decreased to 173.07mg/dl. The results of the analysis
showed that there were significant differences in blood sugar levels in patients with type II
diabetes mellitus before and after performing diabetic foot exercises (p<0.01).

Giving diabetic foot exercise therapy can reduce blood sugar levels in people with diabetes
mellitus and have an effect. Diabetic foot exercise can affect the decrease in sugar levels,
this happens because the blood in actively moving muscles can increase contraction so that
the permeability of cell membranes to glucose increases, insulin resistance decreases and
insulin sensitivity increases, so that circulation in the blood increases and there is a decrease
in sugar levels. blood in patients with diabetes mellitus.
 Supporting Research 3
Title : Comparison of Tai Chi Gymnastics and Diabetes Mellitus Exercises on Reducing
Blood Sugar Levels in Type II Diabetes Mellitus Patients : EBN

Research methods
The type of research used is quantitative research, the research design uses a quasi-
experimental method with a pre and post test group design approach. Researchers will
compare tai chi exercise and diabetes mellitus exercise in lowering blood sugar levels in
patients with type II diabetes. The research instrument used was a glucometer for checking
blood glucose levels, observation sheets for the implementation of tai chi exercises and
observation sheets for DM exercises and the results of measuring blood glucose levels.

Sample
The sampling technique in this study was using purposive sampling, namely the selection by
determining subjects who met the research criteria to be included in the study so that the
sample was met. The samples used for each group in this study were 16 people and the
number of groups used were 2 groups so that this study used 32 respondents from the
existing population, which were divided into 2 intervention groups, where the first
intervention group was given Tai Chi exercises and the intervention group the second was
given DM exercise.
 Supporting Research 1

Criteria
Data collection on respondents was carried out by selecting respondents according to the
inclusion criteria as many as 32 respondents with purposive sampling technique which were
divided into 2 intervention groups. Researchers divide based on odd numbers and even serial
numbers from respondents who have been taken based on the researcher's inclusion criteria.
The odd number is for the Tai Chi intervention while the even number is for the DM exercise
intervention. Respondent data collection was carried out after the patient stated that he was
willing to be a respondent in this study

Intervention method
The intervention group one was given Tai Chi exercise treatment, the implementation was
three times a week for two weeks which was carried out on Monday, Wednesday and Friday,
then recorded blood sugar levels pre before the exercise and post on the last day after tai chi
exercise in the same format. available. The second intervention group was given DM
exercise treatment, the implementation was three times a week for two weeks which was
carried out on Tuesday, Thursday and Saturday, then blood sugar levels were recorded on the
first day before exercise and post on the last day after exercise in the available format.
 Supporting Research 3
Results and Discussion
Characteristics of the age of respondents who suffer from DM the most are ages from 45-65
years, respondents with female sex suffer from DM more than men, the longest suffering
from DM is more than 5 years. Tai Chi exercise and diabetes mellitus exercise both have an
effect on decreasing the average blood sugar level of respondents with type 2 diabetes. There
is a difference in the average blood sugar level of 11.31 mg/dl before and after the
intervention in the Tai Chi exercise group. There is a difference in the average blood sugar
level of 23.37 mg/dl before and after the diabetes mellitus exercise intervention.