Foot-Ankle Exercise Effective to Increase Ankle Brachial Index (ABI) and Foot Sensitivity in Type 2 Diabetes Mellitus Patients

Authors

DOI:

https://doi.org/10.26699/jnk..v13i2.ART.p136-146

Keywords:

Foot-Ankle Exercise, Ankle Brachial Index, Foot Sensitivity, Diabetic Neuropathy, Type 2 Diabetes Mellitus

Abstract

Diabetes mellitus is a chronic metabolic disease often associated with complications such as peripheral arterial disease and neuropathy, increasing the risk of diabetic foot ulcers. Foot-ankle exercises are a non-pharmacological intervention believed to improve vascular circulation and nerve sensitivity. However, limited studies have evaluated their combined effects on the Ankle Brachial Index (ABI) and foot sensitivity. This study aimed to determine the effectiveness of foot-ankle exercises on ABI and foot sensitivity in patients with type 2 diabetes mellitus. A quasi-experimental design with a pretest-posttest control group was conducted at a Public Health Center, Bandung. Seventeen participants were selected from the Prolanis program through purposive sampling. The intervention group performed foot-ankle exercises three times per week for two weeks, while the control group received only educational booklets. ABI was measured using a vascular Doppler, and foot sensitivity was assessed with a 10-gram monofilament. The data were analyzed using paired t-tests and Wilcoxon signed-rank tests. The results showed a significant increase in right ABI (from 95.86 to 115.43; p = 0.018), while left ABI did not significantly improve (p = 0.128). Foot sensitivity increased significantly on both the right (from 4.29 to 6.86; p = 0.027) and left feet (from 5.14 to 7.57; p = 0.043). Foot-ankle exercises significantly improve peripheral circulation (right ABI) and foot sensitivity in patients with type 2 diabetes. Future research is encouraged to further explore the long-term effects of foot-ankle exercises and to examine the impact of combining these exercises with other management approaches.

References

Abouhamda, A., Alturkstani, M., & Jan, Y. (2019). Lower sensitivity of ankle-brachial index measurements among people suffering with diabetes-associated vascular disorders: A systematic review. SAGE open medicine, 7, 2050312119835038. https://doi.org/10.1177/2050312119835038

Ahmad, J. (2016). The diabetic foot. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 10(1), 48-60. https://doi.org/10.1016/j.dsx.2015.04.002

Akbari, N. J., & Naimi, S. S. (2022). The effect of exercise therapy on balance in patients with diabetic peripheral neuropathy: a systematic review. Journal of diabetes & Metabolic disorders, 21(2), 1861-1871. https://doi.org/10.1007/s40200-022-01077-1

Álvaro-Afonso, F. J., García-Morales, E., Molines-Barroso, R. J., García-Álvarez, Y., Sanz-Corbalán, I., & Lázaro-Martínez, J. L. (2018). Interobserver reliability of the ankle–brachial index, toe–brachial index and distal pulse palpation in patients with diabetes. Diabetes and Vascular Disease Research, 15(4), 344-347. https://doi.org/10.1177/1479164118767599

Asih, E. D. R., & Widiastuti, A. (2024). The effect of active range of motion exercise on foot sensitivity in type II diabetes mellitus patients. Physical Therapy Journal of Indonesia, 5(1), 1-4. https://doi.org/10.51559/ptji.v5i1.160

Bakara, D. M., & Kurniyati, K. (2021). Effect Of Leg Exercise On The Ankle Brachial Index (ABI) Of Type 2 Diabetes Mellitus Patients In Rejang Lebong Regional Hospital. The Malaysian Journal of Nursing (MJN), 13(2), 50-55. https://doi.org/10.31674/mjn.2021.v13i02.009

Budi, A. (2023). Effect Of Foot Exercises on Index Brachial Ankle Values in Patients with Diabetes Mellitus. Nursing Care, 2(2). https://doi.org/10.63520/ncj.v2i2.649

Casey, S., Lanting, S., Oldmeadow, C., & Chuter, V. (2019). The reliability of the ankle brachial index: a systematic review. Journal of foot and ankle research, 12(1), 39. https://doi.org/10.1186/s13047-019-0350-1

Casey, S. L., Lanting, S. M., & Chuter, V. H. (2020). The ankle brachial index in people with and without diabetes: intra-tester reliability. Journal of foot and ankle research, 13(1), 21. https://doi.org/10.1186/s13047-020-00389-w

Chevtchouk, L., da Silva, M. H. S., & do Nascimento, O. J. M. (2017). Ankle-brachial index and diabetic neuropathy: study of 225 patients. Arquivos de Neuro-psiquiatria, 75(08), 533-538. https://doi.org/10.1590/0004-282X20170084

Frank, U., Nikol, S., Belch, J., Boc, V., Brodmann, M., Carpentier, P. H., . . . Gottsäter, A. (2019). ESVM Guideline on peripheral arterial disease. Vasa. https://doi.org/10.1024/0301-1526/a000834

Gholami, F., Naderi, A., Saeidpour, A., & Lefaucheur, J. P. (2024). Effect of exercise training on glycemic control in diabetic peripheral neuropathy: A GRADE assessed systematic review and meta-analysis of randomized-controlled trials. Primary Care Diabetes, 18(2), 109-118. https://doi.org/10.1016/j.pcd.2024.01.008

Gibbs, B. B., Dobrosielski, D. A., Althouse, A. D., & Stewart, K. J. (2013). The effect of exercise training on ankle-brachial index in type 2 diabetes. Atherosclerosis, 230(1), 125-130. https://doi.org/10.1016/j.atherosclerosis.2013.07.002

Gracia-Sánchez, A., López-Pineda, A., Nouni-García, R., Zúnica-García, S., Chicharro-Luna, E., & Gil-Guillén, V. F. (2025). Impact of exercise training in patients with diabetic peripheral neuropathy: an umbrella review. Sports Medicine-Open, 11(1), 75. https://doi.org/10.1186/s40798-025-00863-4

IDF. (2021). IDF Diabetes Atlas (10th ed.). Brussels: International Diabetes Federation.

Jin, H., Kang, S., Liu, W., Song, C., Lee, K., Baek, H., & Park, T. (2012). Comparison of peripheral nerve damages according to glucose control timing in experimental diabetes. Experimental and clinical endocrinology & diabetes, 120(08), 451-459. https://doi.org/10.1055/s-0032-1306350

Kemenkes, RI. (2020). Tetap produktif, cegah dan atasi diabetes mellitus. pusat data dan informasi kementrian kesehatan RI, 1-8.

Khawaja, N., Abu-Shennar, J., Saleh, M., Dahbour, S. S., Khader, Y. S., & Ajlouni, K. M. (2018). The prevalence and risk factors of peripheral neuropathy among patients with type 2 diabetes mellitus; the case of Jordan. Diabetology & metabolic syndrome, 10(1), 8. https://doi.org/10.1186/s13098-018-0309-6

Kluding, P. M., Bareiss, S. K., Hastings, M., Marcus, R. L., Sinacore, D. R., & Mueller, M. J. (2017). Physical training and activity in people with diabetic peripheral neuropathy: paradigm shift. Physical therapy, 97(1), 31-43. https://doi.org/10.2522/ptj.20160124

Lepesis, V., Marsden, J., Rickard, A., Latour, J. M., & Paton, J. (2023). Systematic review and meta‐analysis of the effects of foot and ankle physical therapy, including mobilisations and exercises, in people with diabetic peripheral neuropathy on range of motion, peak plantar pressures and balance. Diabetes/metabolism research and reviews, 39(8), e3692. https://doi.org/10.1002/dmrr.3692

Mandaglio-Collados, D., Marín, F., & Rivera-Caravaca, J. M. (2023). Peripheral artery disease: Update on etiology, pathophysiology, diagnosis and treatment. Medicina clinica, 161(8), 344-350. https://doi.org/10.1016/j.medcli.2023.06.005

Monteiro‐Soares, M., Russell, D., Boyko, E. J., Jeffcoate, W., Mills, J. L., Morbach, S., . . . Foot, I. W. G. o. t. D. (2020). Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes/metabolism research and reviews, 36, e3273. https://doi.org/10.1002/dmrr.3273

Monteiro, R. L., Ferreira, J. S., Silva, É. Q., Cruvinel-Júnior, R. H., Veríssimo, J. L., Bus, S. A., & Sacco, I. C. (2022). Foot–ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial. Scientific Reports, 12(1), 7561. https://doi.org/10.1038/s41598-022-11745-0

Monteiro, R. L., Sartor, C. D., Ferreira, J. S., Dantas, M. G., Bus, S. A., & Sacco, I. C. (2018). Protocol for evaluating the effects of a foot-ankle therapeutic exercise program on daily activity, foot-ankle functionality, and biomechanics in people with diabetic polyneuropathy: a randomized controlled trial. BMC musculoskeletal disorders, 19(1), 400. https://doi.org/10.1186/s12891-018-2323-0

Nisar, M. U., Asad, A., Waqas, A., Ali, N., Nisar, A., Qayyum, M. A., . . . Jamil, M. (2015). Association of diabetic neuropathy with duration of type 2 diabetes and glycemic control. Cureus, 7(8), e302. https://doi.org/10.7759/cureus.302

Noor, S., Zubair, M., & Ahmad, J. (2015). Diabetic foot ulcer—a review on pathophysiology, classification and microbial etiology. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 9(3), 192-199. https://doi.org/10.1016/j.dsx.2015.04.007

Pang, X., Wang, D., Zhang, F., Guo, B., & Liu, W. (2025). Exploring the exercise for enhancing postural control, gait, and muscle strength in older adults with diabetic peripheral neuropathy: a systematic review and meta-analysis. Frontiers in Aging, 6, 1507232. https://doi.org/10.3389/fragi.2025.1507232

Perkeni. (2021). Pedoman Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 Dewasa Tahun 2021.

Potier, L., Abi Khalil, C., Mohammedi, K., & Roussel, R. (2011). Use and utility of ankle brachial index in patients with diabetes. European Journal of Vascular and Endovascular Surgery, 41(1), 110-116. https://doi.org/10.1016/j.ejvs.2010.09.020

Rickard, A. (2023). Systematic review and meta-analysis of the effects of foot and Systematic review and meta analysis of the effects of foot and ankle physical therapy, including mobilisations and exercises, in people with diabetic peripheral neuropathy on range of motion, peak plantar pressures and balance. https://doi.org/10.1002/dmrr.3692

Rosyid, F. N. (2017). Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer. Int J Res Med Sci, 5(10), 4206. http://dx.doi.org/10.18203/2320-6012.ijrms20174548

Schwartz, S. S., Epstein, S., Corkey, B. E., Grant, S. F., Gavin III, J. R., & Aguilar, R. B. (2016). The time is right for a new classification system for diabetes: rationale and implications of the β-cell–centric classification schema. Diabetes care, 39(2), 179-186. https://doi.org/10.2337/dc15-1585

Silva, E. Q., Santos, D. P., Beteli, R. I., Monteiro, R. L., Ferreira, J. S., Cruvinel-Junior, R. H., . . . Sacco, I. C. (2021). Feasibility of a home-based foot–ankle exercise programme for musculoskeletal dysfunctions in people with diabetes: Randomised controlled FOotCAre (FOCA) Trial II. Scientific Reports, 11(1), 12404. https://doi.org/10.1038/s41598-021-91901-0

Streckmann, F., Balke, M., Cavaletti, G., Toscanelli, A., Bloch, W., Decard, B. F., . . . Faude, O. (2022). Exercise and neuropathy: systematic review with meta-analysis. Sports Medicine, 52(5), 1043-1065. https://doi.org/10.1007/s40279-021-01596-6

Sutkowska, E., Marciniak, D., Koszewicz, M., Dziadkowiak, E., Budrewicz, S., Biernat, K., . . . Hap, K. (2023). Validity and reliability of the Polish version of the Michigan Neuropathy Screening Instrument. World journal of diabetes, 14(4), 435. https://doi.org/10.4239/wjd.v14.i4.435

Tehan, P. E., Bray, A., & Chuter, V. H. (2016). Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease. Journal of Diabetes and its Complications, 30(1), 155-160. https://doi.org/10.1016/j.jdiacomp.2015.07.019

Timar, B., Timar, R., Gaiță, L., Oancea, C., Levai, C., & Lungeanu, D. (2016). The impact of diabetic neuropathy on balance and on the risk of falls in patients with type 2 diabetes mellitus: a cross-sectional study. PloS one, 11(4), e0154654. https://doi.org/10.1371/journal.pone.0154654

Van Netten, J. J., Sacco, I. C., Lavery, L., Monteiro‐Soares, M., Paton, J., Rasmussen, A., . . . Bus, S. A. (2024). Clinical and biomechanical effectiveness of foot‐ankle exercise programs and weight‐bearing activity in people with diabetes and neuropathy: a systematic review and meta‐analysis. Diabetes/metabolism research and reviews, 40(3), e3649. https://doi.org/10.1002/dmrr.3649

Yang, J., Li, L., Ye, T., Pu, Y., Yao, Q., Luo, J., . . . Yang, Z. (2025). Effectiveness of exercise on musculoskeletal function and clinical outcomes in patients with diabetic peripheral neuropathy: A systematic review and meta-analysis. Frontiers in Neurology, 16, 1610955. https://doi.org/10.3389/fneur.2025.1610955

Downloads

Published

11-08-2026

Issue

Section

Article