http://e-journal.unair.ac.id/JNERS | 129 Jurnal Ners Vol. 15, No. 2, Special Issue 2020 http://dx.doi.org/10.20473/jn.v15i2.18996 This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License Systematic Review A Systematic Review of Foot Exercises with Group Support to Improve the Foot Health of Diabetes Mellitus Patients Rohmatul Faizah1 , Ferry Efendi1, Suprajitno Suprajitno2 1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia 2Department of Nursing, Poltekkes Kemenkes, Malang, East Java, Indonesia ABSTRACT Introduction: Foot problems are a process and complication in patients with diabetes mellitus (DM). Foot complications can be prevented by routine foot exercises. Group support is needed to increase the routine of foot exercise. The effects of foot exercise can be seen by measuring the Ankle Brachial Pressure Index and foot sensation. The objective of this systematic review was to identify the prevention of DM foot complications in an easy way so then he patient can do it independently. Methods: The method used in this study was a systematic review focused on 2015 – 2019 using the PRISMA method. The literature was obtained from Scopus, Science Direct and Proquest. The results found 25 items of literature on foot exercise which was reduced to 4 studies on preventing damage to the feet of DM patients through routine foot exercise. The literature of this study is supported by 3 other studies that state that foot health can also be used to examine the foot’s blood circulation status and sensation. Results: These results have been presented concerning 7 studies regarding special group support in the form of exercise therapy for patients with DM. This study explains the prevention of foot complications through foot exercise. Group support is needed provide motivation to conduct routine foot exercise. Conclusion: Foot exercise can accelerate the blood circulation as can be seen by the Ankle Brachial Pressure Index score and the increase in the neurological system of the foot through foot sensation status. ARTICLE HISTORY Received: Feb 27, 2020 Accepted: April 1, 2020 KEYWORDS foot exercise; group support; diabetes mellitus CONTACT Ferry Efendi  ferry-e@fkp.unair.ac.id  Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia Cite this as: Faizah, R., Efendi, F., & Suprajitno, S. (2020). A Systematic Review of Foot Exercises with Group Support to Improve the Foot Health of Diabetes Mellitus Patients. Jurnal Ners, Special Issues, 129-134. doi:http://dx.doi.org/10.20473/jn.v15i2.18996 INTRODUCTION A group of problems that is often found in patients with diabetes mellitus (DM) is foot problems. This problem is a form of microvascular complication.(Shaw & Cummings, 2012) The foot status points to consider include circulatory status and neurological status.(Ji, Bai, Sun, Ming, & Chen, 2015) Upon observing the world data, the number of DM patients in the world totals 123 million people and it is estimated that the number will increase by 40% in 2045. DM patients recorded with foot complications make up 60% and 20% of them also experience complications in the form of foot infections.(IDF, 2017) In Indonesia, DM patients have increased by a percentage of 2.4%, while in 2011, it was 8.5%. In 2015, it was 10.9%.(Riskesdas, 2018) The basis of the management of DM therapy is divided into 2, namely pharmacological and nonpharmacological therapy. In this discussion, the patient can be directed to the therapies that can be done independently at home. Exercise therapy is an option. The exercise therapy that can have a direct impact on foot problems as it in the form of foot exercise.(Sheehan & Ulchaker, 2011; Taddei et al., 2018) Foot exercises are a series of movements that are arranged systematically that can provide support to improve the diabetic’s foot problems.(Taddei et al., 2018) The benefits of routine foot exercise include improving blood circulation, increasing muscle https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ mailto:ferry-e@fkp.unair.ac.id http://dx.doi.org/10.20473/jn.v15i2. R. FAIZAH ET AL. 130 | pISSN: 1858-3598  eISSN: 2502-5791 strength, improving neurological status, and preventing diabetic foot complications.(Ji et al., 2015) These benefits can be seen by measuring the Ankle Brachial Index to determine the status of the blood circulation, while the neurological status can be seen by assessing the foot sensation.(Shaw & Cummings, 2012; Watkins, 2016) The techniques used for providing foot exercise education also need attention. Recommendations from a variety of literature are used to mobilize support from the fellow sufferers of DM. This technique is called group support. Group support has been proven to increase understanding and participation when carrying out several activities including foot exercises.(Due-christensen, Hommel, & Ridderstråle, 2016; Shomaker et al., 2017) Therefore in this article, the review discusses foot exercises and group support based on the results of the previous studies. The objective of the systematic review was to identify techniques used to prevent DM foot complications in an easy manner in a way that the patient can do independently. MATERIALS AND METHODS Making this article review used the PRISMA method. Strategy for searching studies The data was obtained using electronic media to access international journals. The data search was conducted from August 2019 to February 2020. The journal databases used in this article review were Scopus, Science Direct and Proquest. Keywords used to obtain the journals included foot exercise, diabetes foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy. Study selection When selecting the journal articles, the title and abstracts of the articles found were used. The design of the article used referred to the actual research if it was not in the form of a systematic review or article review. The PRISMA method recommends using inclusion and exclusion criteria. The inclusion criteria compiled included the following. 1. A journal with actual research results. 2. A journal published in the last 5 years (2015-2019). 3. The population or study sample consists of DM patients. 4. The interventions described in the journal are preventive therapies for diabetic foot complications. The exclusion criteria included 1. journals in the form of a systematic review or article review and 2. interventions using either tools and/or health workers. Data Extraction and Appropriate Quality Assessment Data extraction was done by discussing the compilers of the article. The journals were obtained and collected and then their information was then extracted including the type of research carried out, the intervention, the duration of the intervention, the description of the intervention, the doses of the intervention, and explaining about the involved groups in the study. A proper quality assessment of the articles or journals was done by giving a score based on the inclusion criteria that had Search the literature for journals from Science Direct, Proquest and Scopus. Keywords used to obtain the journals include foot exercise, diabetes foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy. Selecting the journal articles using the title, abstract, study design and inclusion and exclusion criteria Inclusion criteria: 1. Journal of actual research results 2. Journal published in the last 5 years (2015-2019) 3. The population or study sample consists of DM patients 4. The interventions described in the journal are preventive therapies to treat diabetic foot complications. Exclusion criteria: 1. Journal in the form of a systematic review or article review 2. Interventions using tools and health workers The journals obtained and collected were then extracted from including: the type of research carried out, the intervention, the duration of the intervention, the description of the intervention, the doses of the intervention, and explained about the groups in the study. The journals taken had to meet the inclusion criteria by at least 50%. Diagram 1. Method of the systematic review JURNAL NERS http://e-journal.unair.ac.id/JNERS | 131 been prepared. If it met the criteria then it was given a value of one (1). If it did not meet the criteria then it was given a value of zero (0). RESULTS The results obtained from the search for research journals in Scopus, Science Direct and Proquest using the keywords ‘foot exercises, diabetic foot complications, diabetes foot prevention, health education delivery techniques, and group support therapy’ resulted in hundreds of journals. This was narrowed down by adding the criteria of being published in the last 5 years (2015-2019). After being selected, there were only 15 journals. An explanation of each journal is displayed in Table 1. DISCUSSION Prevention of Diabetes Mellitus Complication The complications of diabetes mellitus are divided into 2 major groups, namely acute complications and chronic complications.(Shaw & Cummings, 2012) Chronic complications occur over a long period of time (> 6 months) and they are not treated appropriately. Chronic complications come in 2 types, microvascular and macrovascular. Microvascular Table 1. Journal Search Results on The Topic Foot Exercise and Group Support for Diabetes Mellitus Patients Title, Author and Year of the Journal Types of Research Explanation of the Research Results (Ji et al., 2015) Eksperimental Foot exercise combined with music can significantly (p> 0.05) improve the adherence to foot exercise behavior. This increase can improve blood circulation in the body. (Taddei et al., 2018) Randomized Control Trial The results obtained from the evaluation after 8 weeks of a foot exercise intervention include the incidence of foot injury lessened by 28% and the functions of the feet increased by 97%. Biomedical details also showed an improvement. (Henni et al., 2018) Restrospective Analysis Walking exercises done by DM patients can improve the value of their Ankle Brachial Index (ABI) score by an average of >0.9 and it can also reduce the risk of PAD (peripheral arterial disease). (Alqahtani et al., 2018) Cross-sectional Study Exercise can increase the value of ABI according to the results of the analysis (p = 0.04). (Takahara, Fujiwara, Katakami, & Sakamoto, 2014) Restrospective Analysis The risk factors that can affect the reduction in ABI and TBI include age, the duration of DM and BMI as proven by the results of significance being p <0.05. (Shomaker et al., 2017) Randomized Control Trial Interventions given in the form of group therapy can increase attendance, reduce depression and stress, and stabilize blood sugar. (Due-christensen et al., 2016) Pilot Study Group interventions can significantly improve HbA1c (p = 0.0001), and fellow DM patients can exchange their experiences. (Dadgostar, Firouzinezhad, Ansari, & Younespour, 2016) Randomized Clinical Trial Exercise interventions in groups carried out for 6 weeks can reduce body fat, improve the physical health of DM patients, and for 12 weeks, it can significantly reduce HbA1c (p <0.05). (Vangeepuram, Carmona, Arniella, Horowitz, & Burnet, 2015) Pilot Study Focus group discussions can increase the patient’s understanding when providing education, especially concerning the prevention of diabetes and other health problems. (Hasneli & Amir, 2019) QuasyEksperimental The giving of an Apiyu massage intervention can improve the sensitivity of both the right and left legs (p = 0.011). It can also significantly reduce the blood sugar level (p = 0.001). (Alonso-domínguez, Recio-rodríguez, & Patino-alonso, 2019) Randomized Control Trial Exercise interventions in DM patients can reduce stiffness in the foot (p> 0.05) according to multiple parameters (CAVI / Cardio ankle vascular index and lower extremity pulse pressure). Men get more influence than women. (Mohammad Ali Morowatisharifabad, Abdolkarimi, Asadpour, & Fathollahi, 2019) Deskriptive Study Group support can increase the DM patient’s compliance with exercise and physical activity by 1.17 times. (Juul, Rowlands, & Maindal, 2018) Cross-sectional Study Social motivation can be an important form of support when dieting, and in physical activity adherence, especially for DM patients. (Mouslech et al., 2018) QuasyEksperimental Group-based education programs can significantly influence the reduction of HbA1c, decreasing the incidence rate of hyperglycemia, increasing adherence, and changing habits for the better. (Rebecca et al., 2018) QuasyEksperimental The provision of diabetes mellitus care services significantly increases awareness in relation to the care and exercise connected to physical activity. R. FAIZAH ET AL. 132 | pISSN: 1858-3598  eISSN: 2502-5791 complications are the cause of new disorders such as neuropathy, retinopathy, nephropathy and diabetic foot ulcers. Diabetic foot ulcers are often found and are clearly visible where the DM patients have disturbances on their foot. Although not always shaped like wounds, these patients are at a high risk of suffering from injuries to the feet. An injury to the feet of DM patients, if not treated properly, can lead to amputation being performed.(Scobie & Samaras, 2014; Shaw & Cummings, 2012) An explanation of the complications of DM is necessary to better undertake effective measures to prevent these complications. A limitation of the found literature was that no-one discussed the complications of diabetes. Rather, they combine the various complications that can arise. From the journals obtained and examined according to the theme, the articles previously used were screened according to the inclusion and exclusion criteria. Psychological therapy such as Cancer and Living Meaningfully (CALM) intervention can decrease depression, anxiety, and death-related distress, which can improve the quality of life. Foot Exercise Handling DM can be done through physical exercise. Physical exercise can balance food intake and body energy production. Glucose buildup in the body, which is related to the blood circulation, can worsen the condition of DM patients. Therefore it is necessary to schedule regular exercise for DM patients. An easy and lightweight exercise for DM patients is foot exercise. Foot exercise refers to a series of movements arranged systematically focused on the foot for DM patients.(Taddei et al., 2018) Foot exercises can be done routinely 3-4 times a week for 30 minutes.(Perkeni, 2012) Foot exercises have benefits that include increasing the blood circulation, increasing the leg muscle strength, improving foot sensitivity, and preventing complications from diabetic foot ulcers.(Ji et al., 2015) The research that has been done on DM foot exercises explains that foot exercises are an alternative to prevent complications, especially diabetic foot ulcers. Increased blood circulation is assessed by measuring the ankle brachial index parameters and the improved foot sensitivity by assessed by measuring the level of foot sensation or foot response.(Ji et al., 2015; Taddei et al., 2018) The limitation of the literature was that many discussed diabetes exercises instead of foot exercises specifically. Group Exercise Group support can be interpreted as information given either verbally or nonverbally from the closest person to the patient.(Rockville, 2015) Group support can also provide motivation shared among people with the same conditions.(Dadgostar et al., 2016) Support comes in 4 forms: emotional, appreciation, instrumental and informative.(Corcoran & Roberts, 2015) Optimal support can be provided by fulfilling all 4 forms of support. However, only 1 form of support can be given and it can still be interpreted as providing support.(Rockville, 2015) Health interventions with the group support method, especially among DM patients, have been shown to have a positive impact. The most dominant positive impact is improving the adherence to therapy, especially concerning foot exercises. It also can reduce anxiety and control their blood glucose levels. (Dadgostar et al., 2016; Due-christensen et al., 2016; M. A Morowatisharifabad, Abdolkarimi, Asadpour, Fathollahi, & Balaee, 2019; Shomaker et al., 2017) The limitation is that the found literature did not explained the form of group support in detail. CONCLUSION Diabetes mellitus is a condition that is a chronic disorder in the body of the sufferer. DM has the potential for complications. A complication that is often seen is foot problems. Foot complications can be prevented by doing proper and easy foot exercises. Foot exercises can have an optimal affect if done routinely 3-4 times a week. The foot exercise needs to be understood correctly by the DM patients. To improve patient understanding, the method of delivering the material must be appropriate. The method that has proven to be effective in terms of increasing understanding is group support or a group approach to therapy. Group interventions can be carried out with the closest people to the patient and fellow DM patients to allow them to share their experiences and information. From the above description, DM patients need to do foot exercises regularly and they need to be given an understanding of the exercise by applying the group intervention / group support method. Group support can be increase their adherence to therapy especially foot exercise. CONFLICT OF INTEREST No Conflicts of interest have been declared. ACKNOWLEDGEMENT The authors would like to thank the Faculty of Nursing and also the Master’s students on the Nursing Study Programme. The authors would further like to thank all those responsible for supporting us getting the systematic review completed and the appropriate original research from all articles used to share the final information. The authors also would like to thank those who have provided direction so then this article was completed and can convey the complication prevention information relevant to DM patients. REFERENCES Alonso-domínguez, R., Recio-rodríguez, J. I., & Patino- alonso, M. C. (2019). Acute effect of healthy walking on arterial stiffness in patients with type 2 JURNAL NERS http://e-journal.unair.ac.id/JNERS | 133 diabetes and differences by age and sex : a pre-post intervention study. 1–9. Alqahtani, K. M., Bhangoo, M., Vaida, F., Denenberg, J. O., Allison, M. A., & Criqui, M. H. (2018). Predictors of Change in the Ankle Brachial Index with Exercise. European Journal of Vascular & Endovascular Surgery, 55(3), 399–404. https://doi.org/10.1016/j.ejvs.2017.12.004 Corcoran, K., & Roberts, A. R. (2015). Social Workers’ Desk Referenceq (3rd ed.). Oxford University Press. Dadgostar, H., Firouzinezhad, S., Ansari, M., & Younespour, S. (2016). Supervised group- exercise therapy versus home-based exercise therapy : Their effects on Quality of Life and cardiovascular risk factors in women with type 2 diabetes. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 1–7. https://doi.org/10.1016/j.dsx.2016.01.016 Due-christensen, M., Hommel, E., & Ridderstråle, M. (2016). Potential positive impact of group-based diabetes dialogue meetings on diabetes distress and glucose control in people with type 1 diabetes. Patient Education and Counseling, 6–11. https://doi.org/10.1016/j.pec.2016.07.023 Hasneli, Y., & Amir, Y. (2019). Identification and analysis of foot sensitivity and blood glucose levels post Apiyu massage ଝ. Enfermería Clínica, (xx), 9–12. https://doi.org/10.1016/j.enfcli.2018.11.009 Henni, S., Ammi, M., Gourdier, A., Signolet, I., Colas- ribas, C., Picquet, J., & Abraham, P. (2018). Ankle Brachial Index is Equally Predictive of Exercise- induced Limb Ischemia in Diabetec and Non- diabetic Patients with Walking Limitation. #pagerange#. https://doi.org/10.1016/j.jdiacomp.2018.03.01 1 IDF. (2017). Diabetes Atlas. South-East Asia: International Diabetes Federation. Ji, L., Bai, J. J., Sun, J., Ming, Y., & Chen, L. R. (2015). Effect of combining music media therapy with lower extremity exercise on elderly patients with diabetes mellitus. International Journal of Nursing Sciences, 2(3), 243–247. https://doi.org/10.1016/j.ijnss.2015.07.008 Juul, L., Rowlands, G., & Maindal, H. T. (2018). Relationships between health literacy, motivation and diet and physical activity in people with type 2 diabetes participating in peer- led support groups. Primary Care Diabetes, 12(4), 331–337. https://doi.org/10.1016/j.pcd.2018.02.005 Morowatisharifabad, M. A, Abdolkarimi, M., Asadpour, M., Fathollahi, M. S., & Balaee, P. (2019). Study On Social Support for Exercise and Its Impact on The Level of Physical Activity of Patients with Type 2 Diabetes. Journal of Medical Sciences, 1(7), 143–147. Morowatisharifabad, Mohammad Ali, Abdolkarimi, M., Asadpour, M., & Fathollahi, M. S. (2019). Study On Social Support for Exercise And Its Impact on the Level of Physical Activity of Patients with Type 2 Diabetes. 7(1), 143–147. Mouslech, Z., Somali, M., Sarantis, L., Christos, D., Alexandra, C., Maria, P., … Hatzitolios, A. I. (2018). Significant effect of group education in patients with diabetes type 1. Perkeni. (2012). Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. Jakarta: PERKENI. Rebecca, A., Dyck, A., Kleinman, N. J., Funk, D. R., Yeung, R. O., Senior, P., & Yardley, J. E. (2018). We Can Work (It) Out Together: Boot Camp for Type 1 Diabetes Patients and Providers Improves Exercise Self-Efficacy. Canadian Journal of Diabetes. https://doi.org/10.1016/j.jcjd.2018.02.006 Riskesdas. (2018). Riset Kesehatan Dasar RISKESDAS 2018. Jakarta: Balitbang Kemenkes RI. Rockville. (2015). Substance abuse treatment: Group therapy. Substance Abuse and Mental Health Services Administration. Scobie, I. N., & Samaras, K. (2014). Fast Facts: Diabetes Mellitus (5th ed.). Health Press Limited. Shaw, K. M., & Cummings, M. H. (2012). Diabetes Chronic Complications. John Wiley & Sons, Incorporated. Sheehan, J. P., & Ulchaker, M. M. (2011). Obesity and Type 2 Diabetes Mellitus : Obesity and Type 2 Diabetes Mellitus. Oxford University Press USA - OSO. Shomaker, A. L. B., Bruggink, S., Pivarunas, B., Skoranski, A., Foss, J., Dalager, S., … Bell, C. (2017). Pilot randomized controlled trial of a mindfulness-based group intervention in adolescent girls at risk for type 2 diabetes with depressive symptoms. Complementary Therapies in Medicine. https://doi.org/10.1016/j.ctim.2017.04.003 Taddei, U. T., Matias, A. B., Ribeiro, F. I. A., Inoue, R. S., Bus, S. A., & Sacco, I. C. N. (2018). Effects of a therapeutic foot exercise program on injury incidence, foot functionality and biomechanics in long-distance runners: Feasibility study for a randomized controlled trial. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2018.10.015 Takahara, M., Fujiwara, Y., Katakami, N., & Sakamoto, F. (2014). Shared and additional risk factors for decrease of toe-brachial index compared to ankle-brachial index in Japanese patients with diabetes mellitus. Atherosclerosis, 235(1), 76–80. https://doi.org/10.1016/j.atherosclerosis.2014. 04.014 Vangeepuram, N., Carmona, J., Arniella, G., Horowitz, C. R., & Burnet, D. (2015). Use of Focus Groups to Inform a Youth Diabetes Prevention Model. Journal of Nutrition Education and Behavior, 47(6), 532-539.e1. https://doi.org/10.1016/j.jneb.2015.08.006 R. FAIZAH ET AL. 134 | pISSN: 1858-3598  eISSN: 2502-5791 Watkins, L. (2016). Watkins’ Manual of Foot and Ankle Medicine and Surgery (4th ed.). Wolters Kluwer Health.