2 | IndoJPMR Vol.

6 Edisi II Tahun 2017

ORIGINAL ARTICLE

The Improvement of Neuropathy and Balance after

Combination of Indonesian Diabetic and Indonesian Diabetic Foot Exercise
on Diabetic Peripheral Neuropathy

Putri Dyah Utami Ryadi, Tertianto Prabowo, Irma Ruslina Defi

Department of Physical Medicine and Rehabilitation, Padjajaran University, Bandung, Indonesia

ABSTRACT

Background: Half of people with Type 2 Diabetes Mellitus (Type 2 DM) developed diabetic neuropathy
at 25 years after being diagnosed and around 75% of the neuropathy were diabetic peripheral neuropathy
(DPN), that associated with balance disturbance. This study aimed to know the effect of combining Indonesian
diabetic exercise (Senam Diabetes Indonesia/SDI) and Indonesian diabetic foot exercise (Senam Kaki Diabetes
Indonesia/SKDI) on improvement of diabetic neuropathy and balance score in people with Type 2 diabetic
peripheral neuropathy.

Methods: Design study was a quasi-experimental study with pre-posttest design. The participants were Type 2
DM patients aged 40-65 years old, with DPN confirmed based on Indonesian version of Diabetic Neuropathy
Symptom (DNS-INA) >1 or Indones ian version of Diabetic Neuropathy Exmination (DNE-INA) >3, who did
not do exercise regularly. All participants had Berg Balance Scale (BBS) score within 41-55, and the random
peripheral blood glucose within 100-250mg/dL. The BBS, DNE-INA, and DNS-INA score were evaluated
before and after 12 weeks of excercise.

Results: There were 6 women aged 52-65 years. The mean of BBS, DNS-INA, and DNE-INA scores before
and after intervention were 54.33±1.032 and 55.16±1.329 (p=0.025), 2.50±1.048 and 1.50±0.836 (p=0.063),
3.66±1.505 and 1.33±0.816 (p=0.041), respectively.

Conclusion: There were improvement of Berg Balance Score and Diabetic Neuropathy Score after the
combination of Diabetic exercises.

Keywords: Berg Balance Score, diabetic neuropathy score, Indonesian Diabetic Exercise, Indonesian Foot
Diabetic Exercise

Correspondence Detail:
Putri Dyah Utami Ryadi Department of Physical Medicine and
Email: putri.ryadi@gmail.com Rehabilitation, Padjajaran University,
Phone: 081224623535, 08987929494 Bandung, Indonesia
 IndoJPMR Vol.6 Edisi II Tahun 2017 | 3

INTRODUCTION score. As mention above that DPN may interfere

postural balance control, that can assessed by
The incidence and prevalence of Type 2 Berg Balance Score (BBS).9-10
Diabetes Mellitus (Type 2 DM) in Indonesia
have increased in recent years. World Health Physical exercise is one of the pillars of managing
Organization (WHO) predict DM prevalence in DM in Indonesia.2 It has been hypothesized that
Indonesia will increase from 8.4 million (year exercise will reduce DPN progression by increasing
2000) to 21.3 million (year 2030)1, which is 90— the glucose transporters, thus increasing glucose
95% are Type 2 DM.2 From previous study found uptake and improve mitochondrial function, by
that half of people with Type 2 DM developed activation of nitric oxide production. Increasing
diabetic neuropathy (DN) on 25 years after being of nitric oxide promotes micro vascular dilatation
diagnosed, with 75% of DN is diabetic peripheral and reduces oxidative stress and increases the
neuropathy (DPN)3. neurotrophic factors.5-8,11

Diabetic peripheral neuropathy associated Based of that theory, Indonesian diabetes

with balance problem caused by sensory organization developed Indonesian Diabetic
nerve impairment, that is essential in motor Exercise (Senam Diabetes Indonesia/SDI) and
performance impairment (lower muscle unit, Indonesian Diabetic Foot Exercise (Senam
weakness, less endurance, less force production Kaki Diabetes Indonesia/SKDI). From
rate).3-8 Hyperglycemia causes mild chronic previous studies, Indonesian diabetic exercise
inflammatory caused metabolic and micro and diabetic foot exercise were showed the
vascular disturbance. Besides, there were improvement of glycemic control12,13,14, blood
increasing of oxidative stress, polyol pathway, circulation on foot. 15,16 and neurotrophin-3
protein kinase C, and AGE, promote the decrease (NT-3)17. The combination of both exercise
of nerve blood flow and endothelial function, predicted increase the effect on improvement of
then followed by impaired of mitochondrial peripheral neurovascular in people with Type 2
bioenergetics, that have consequences on DM.18 However, there has still lack of study in
neuronal and skeletal muscle cell dysfunction.5 analyzed the combination of both exercises in
Subjects with neural and skeletal muscle improvement of the peripheral neurovascular
disfunction have poor balance, that may interfere and the balance control in patient with DPN. The
gait and postural control, and increased the risk aimed of this study is to find the improvement
of falling, and decrease the quality of life.5- of DPN and balance after the combination of
7
The fact has been proven by previous study, Indonesian diabetic and Indonesian diabetic foot
that subject with DM have 2.5 folds higher of exercise intervention.
the risk of fall than non DM, the risk rises until
17 folds if there is peripheral neuropathy.6 The
Diabetic peripheral neuropathy can evaluated METHODS
by Indonesian version of Diabetic Neuropathy
Symptom (DNS-INA) and Indonesian version of Design study was a quasi-experimental study
Diabetic Neuropathy Examination (DNE-INA) with pre-posttest design and samples conducted
4 | IndoJPMR Vol.6 Edisi II Tahun 2017

from February until May 2017. Participants were stretching. Six variations of this exercise were
recruited from primary health care (Puskesmas randomly applied.
Pasir Kaliki and Sukajadi). Subjects were type
2 DM, have sedentary life, age of 40—65 years. The Indonesian foot diabetic exercise was done
Assesment of lower limb DPN by Indonesian in sitting position, consisted of ten repetitions
version of Diabetic Neuropathy Symptom of toe flexion in ankle dorsiflexion, toe rises
(DNS-INA) score >1 and Indonesian version and heel rises, open chain and closed chain
of Diabetic Neuropathy Examination (DNE- ankle rotation, toe flexion and extension in knee
INA) score >3. Evaluation of postural balance extension, drawing imaginary number 0 to 9 on
control was by Berg Balance Scale (BBS) in air. Next movement is making ball from a sheet
range of scale between 41-55. Subjects have a of newspaper using both foot than flattened it
good cognitive function that confirmed by Mini again, the newspaper shredded into small pieces
Mental State Examination (MMSE) score 24 and using feet, lastly was making ball from the small
above. Subjects have a random peripheral blood pieces of newspaper using feet.
glucose level between 100-250mg/dL, and agree
to participate in this study. 9-10 Data were analyzed using Statistical Package
for the Social Sciences (SPSS) software
Exclusion criteria were subjects with foot (version 24.0) for Windows. Minimal sample for
ulcer, cardiovascular disease, musculoskeletal confidence interval of 95% and power test 75%
injury and disease that may interfering exercise are 6 participants. The normality distributions
movement, history of stroke or other central were checked using Shapiro Wilk test. Paired
nervous system disease, uncorrected visual t-test was used to compare scores (DNS-INA,
problem, and orthostatic hypotension. All DNE-INA, BBS) before and after intervention. p
subjects have combination of Indonesian diabetic value ≤ 0,05 is considered statistically significant.
and Indonesian diabetic foot exercise in one Ethical approval was obtained from Health
group three times a week for twelve weeks at Research Ethic Committee of medical faculty
Hasan Sadikin Hospital. Exercised was guided Padjajaran University.
by certified instructor. Evaluation was done after
twelve weeks that was taken one day after the last
exercise. RESULTS

Indonesia diabetic exercise consist of warming All of the subjects were women that have
up, main exercise 1, followed by exercise 2, occupation as housewives, mean of aged 58,33
and cooling down, whereas approximately 7 years old. The mean duration of DM was 6 years
minutes for each part. Exercise was done in with mean BMI was 24.19 kg/m2.
standing position without equipment. Movement
is mostly marching and stepping movement to
various direction, approximately 80-90 steps per
minute accompanied by upper limb movement.
Cooling down and some part of warming up were
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Table 1. Demographic Data

Mean±SD Range
Numerical Variable
n=6 n=6

Age 58,33±4,457 52,00-65,00

Duration of DM (Year) 6,00±4,816 1,00-13,00
Body Mass Index (kg/m2) 24,19±5,001 18,07-30,44

Occupation: Housewife 6 (100%)

SD = Standard Deviation, n = number of participants

Comparison of scores (DNS-INA, DNE-INA, of DNS-INA and DNE-INA score after the
BBS) before and after intervention was present intervention, although the differences of DNE-
in Table 2. There was significant improvement INA (p=0.041) score was stronger than the
of BBS after the intervention (p=0.025), while differences of DNS-INA (p = 0.063).
improvement of the DPN was found by reducing

Table 2. DNS-INA, DNE-INA, BBS Score Before And After Intervention

Variable
Time of
Parameter DNS-INA DNE-INA BBS
examination
n=6 n=6 n=6

Before Mean±SD 2.50±1.048 3.66±1.505 54.33±1.032

After Mean±SD 1.50±0.836 1.33±0.816 55.16±1.329

p value 0.063 0.041* 0.025*

* t-test

DISCUSSION All of subjects have exercise intervention by

combine diabetes exercise for 12 weeks. There
The total participants of this study were all were improvement in diabetic neuropathy
housewife sedentary women with aged more than evaluated by DNS-INA and DNE-INA Score.
50 and below 60 years old, the mean duration However, the improvement of DNE-INA Score
of DM were 6 years, and the mean of BMI were (p=0.041) was stronger than DNS-INA score
overweight, also had a DPN. This study showed (p=0.063). The result might have correlation with
that the subjects were homogeneous. the assessment of DNE-INA that more objective
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than DNS-INA. The result data was supported neurotrophic factor (BDNF), that has been
by Wahyuni that has proven the improvement identified as a key component of the hypothalamic
of foot paresthesia after the combination of pathway that controls body weight and energy
Indonesian diabetic and Indonesian diabetic foot homeostasis.21 The BNDF also appears to have
exercises.18 Regular exercise induces suppression important role in central metabolic pathways,
of TNF-alpha by increasing IL-6 that stimulates skeletal muscle metabolism, insulin resistance
other anti-inflammatory cytokines such as IL- and in energy balance. Individuals with both
Ira and IL-10.19 Exercise also improved DPN obesity and type 2 DM have low levels of BDNF,
via metabolic and microvascular key pathway by inhibits cerebral output of BDNF. The BDNF
by activating nitro oxide production which is the mRNA and the protein expression were increased
key recovery of vascular endothelium function in human skeletal muscle after exercise and
in DPN, decrease oxidative stress and inhibit increase fat oxidation. Otherwise, the exercise
aldose reductase, followed by improving hypoxia also increasing the size and degree of branching
in nerve fiber, thus decreasing the symptoms of of motor nerve terminals at the neuromuscular
neuropathy.5 junction, increasing the total area of both pre-
and postsynaptic elements, and the amount of
The study of postural balance after 12 weeks Acetylcholine (ACh) released. These factors
of combine exercise, revealed the improvement improve nerve function and muscle performance
of postural balance, that showed in increasing that is important in balance control.19 Further
of Berg Balance Score. In fact, the Indonesian study needed to found the effect of combine
diabetic exercise alone is not specifically for exercises on neurotrophin level in subject with
balance training, although consist of stepping type 2 DM.
movement to various direction, therefore could
stimulated and improved muscle strength that Limitation of the study was without control group.
great contributor in balance improvement. This
result study inline by the study by Dharmmika,
that has shown no improvement on balance in CONCLUSION
subjects with DPN who only got the diabetic
foot exercise alone without Indonesian diabetic Combination of Indonesian diabetic exercise
exercise. 20 and Indonesian diabetic foot exercise were
effective to improve neuropathy and balance in
The study has shown Indonesian foot diabetic subjects with DPN.
exercise will improve glycemic control, increase
foot blood circulation, and increase neurotrophin
(NT-3)14-17 as an important role in regulating
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