You are on page 1of 5

i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 2 4 3 e2 4 7

H O S T E D BY Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.elsevier.com/journals/international-


journal-of-nursing-sciences/2352-0132

Original Article

Effect of combining music media therapy with


lower extremity exercise on elderly patients with
diabetes mellitus*

Li Ji, Jiao-Jiao Bai*, Jiao Sun, Yue Ming, Li-Rong Chen


Hua Dong Hospital Affiliated to Fudan University, Shanghai 200040, China

article info abstract

Article history: Objective: To evaluate the compliance with lower extremity exercise and blood circulation
Received 12 March 2015 in the feet of elderly diabetics following a combination of music media therapy and a lower
Received in revised form extremity exercise regimen.
11 June 2015 Method: The 72 elderly diabetic patient subjects were divided into two groups: control group
Accepted 30 July 2015 (n 38) and intervention group (n 34). Both groups were exposed to the same compre-
Available online 7 August 2015 hensive therapy to control glucose levels. While the control group was given the lower
extremity exercise, the intervention group received the extremity exercise in addition to
Keywords: the music media.
Diabetes mellitus Result: After three months of intervention, the adherence to the lower extremity exercise
Elderly regimen in the intervention group was significantly higher than that of the control group
Lower extremity exercise (p < 0.05). Additionally, following six months of treatment, both the dorsal artery peak
Nursing values and ankle-brachial indices (ABIs) showed significant differences between the con-
Music media trol and intervention groups (p < 0.05).
Conclusion: Music media treatment combined with lower extremity exercise can both
significantly increase the extent of exercise compliance of elderly patients suffering from
diabetes mellitus, as well as improve blood circulation in their feet.
Copyright 2015, Chinese Nursing Association. Production and hosting by Elsevier
(Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

patients with peripheral vascular disease. A recent American


1. Introduction study revealed that 29 percent of type II diabetes patients older
than 50 suffered from lower extremity vascular disease [2].
Along with an increasingly expanding elderly population Furthermore, it is known that peripheral vascular disease that is
worldwide, the percentage of elderly patients diagnosed with highly associated with diabetes can impede the healing of ulcers
diabetes mellitus is continually increasing and is currently as and increase the risk of amputation necessity [3]. The recently
high as 20.4 percent [1]. This pattern can also be seen in elderly

*
This study is a program, named Shanghai Geriatrics Clinical Trials Registry. Its number is 13DZ2260700.
*
Corresponding author.
E-mail address: bjj163163@163.com (J.-J. Bai).
Peer review under responsibility of Chinese Nursing Association.
http://dx.doi.org/10.1016/j.ijnss.2015.07.008
2352-0132/Copyright 2015, Chinese Nursing Association. Production and hosting by Elsevier (Singapore) Pte Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
244 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 2 4 3 e2 4 7

updated American Diabetes Association exercise guidelines


Table 1 e Characteristics of subjects by assigned
state that exercise should be performed at least three times per
treatment regimens at group allocations.
weeks [4]. Exercising regularly for a long period of time is critical
Intervention Control t or c2 p Value
for promoting metabolism, improving insulin sensitivity and
group group value
decreasing blood sugar. In addition, exercise is also critical for
both stimulating blood circulation in the lower limbs and pre- Sex 0.001 0.583
Male 20 20
venting foot ulcers [5e8]. Due to a low rate of movement in
Female 14 18
elderly patients and their general unwillingness to comply with a Level of education 2.315 0.314
regular exercise regimen, exercise therapy often proves chal- Primary and below 24 28
lenging to enforce. It is therefore critically important to formulate Junior or high 8 10
methods to drastically improve the compliance with movement school
in diabetic elderly patients. In this study, we expose elderly dia- College and above 2 0
Age (M SD) 68.79 2.78 67.55 2.16 2.124 0.057
betic patients to a combination of music media therapy with a
Time since diagnosis 21.56 6.01 21.89 5.93 0.238 0.812
lower extremity sports programs. We reveal that this unique
(M SD)
approach in successful in both promoting blood circulation in the HbA1C (M SD) 7.25 0.29 7.24 0.30 0.711 0.944
patients' lower extremities as well as increasing the extent of FBG (fasting 7.56 1.45 7.67 1,56 0.452 0.872
elderly patient compliance to a consistent exercise regimen. blood-glucose,
M SD)
BMI (M SD) 24.65 2.32 24.62 2.22 0.044 0.965
Score of knowledge 37.12 1.77 37.18 1.78 0.159 0.874
2. Methods
questionnaire
(M SD)
2.1. Patient selection
[9]. These specific exercises included the strengthening of
Seventy-two diabetic patients above 60 years of age and quadriceps, balance and ankle/foot as well as kicking before
categorized as level 0 according to the Wagner Classification and after the strengthening exercises. The researchers typi-
Scale of Diabetic Foot were selected as research subjects for cally led the patients through these exercises. The patients
this study. All patients were acquired between April 2013 and exercised for 15 minutes every day if possible and the regimen
October 2013 from the department of endocrinology in Hua lasted for at least six months. Each patient's condition was
Dong Hospital, which is affiliated with Fudan University in observed at all times throughout the process of movement to
Shanghai, China. Exclusion criteria included those who were prevent any potential health complications.
unable to walk independently, those who had lower limb pain,
severe arthritis, nervous system and cardiovascular disease,
2.4. Music media intervention
as well as other complications that limited their physical ac-
tivity and cognitive dysfunction.
2.4.1. Music media selection
According to the specific musical preferences of the 15 elderly
2.2. Study design
participants, five musical genres were initially selected,
including classical, folk instrumental, cheerful, religious and
This study was performed as a randomized controlled trial. The
soothing. The final selection of musical genre was soothing
72 diabetes mellitus patient subjects were randomly assigned
aesthetic based upon the preferences of the patients after
to one of two groups: the intervention group (n 34) receiving
listening to sample music from each style. After assessment,
music media therapy with a lower extremity exercise regimen
the musical professor composed a synthetic piano song with a
and the control group (n 38) that only received the lower ex-
4/4 beat, and this musical exposure was combined with a
tremity exercise regimen. Each patient continued to receive
lower extremity exercise program.
standard treatment and care from their physicians throughout
this study. The primary endpoint categories of this study
2.4.2. Intervention
included compliance with exercise, peak velocity of dorsal ar-
The diabetic elderly patients in the intervention group
tery and ankle-brachial index (ABI). Table 1 displays each pa-
finished the throughout treatment led by researchers. These
tient subjects' characteristics according to their assigned
patients exercised 15 minutes every day while listening to
treatment regimen at allocation: sex, level of education, age,
group music, with the lower extremity movement being
time since diagnosis, etc. Approval for this study was obtained
introduced every week for four consecutive weeks. Patients
from the Fudan University ethics committee and all patients
were then exposed to the collective musical piece combined
provided their signed informed consent of participation.
with lower exercise every month for at least six months.
2.3. Exercise therapy
2.5. Measures
Both experimental and control groups accepted the inter-
vention of the lower extremity exercise regimen, which 2.5.1. Compliance with elderly diabetics to the lower
mainly consisted of resistive exercise and was developed by extremity exercise regimen
the United States Joslin Diabetes Center (the branch of the The exercise regimen compliance with elderly diabetics was
Teaching and Research Institution in Harvard Medical School) measured using a diabetic exercise adherence scale. This
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 2 4 3 e2 4 7 245

scale was composed of five items, with each item assigned a 3.2. The difference between the lower limb exercise adher-
score between one and five. The lower scores indicated greater ence was significant between the experimental and
extent of adherence to the exercise regimen. The method control groups following three treatment (t 9.155,
assessing the scale was the same as the knowledge ques- p < 0.001) (Table 2).
tionnaire about the lower extremity exercise. The scale's 3.3. There was a statistical significant difference between
Cronbach's a coefficient was 0.851 and the CVI was 0.905. the ankle-brachial index (ABI) of the two treatment
groups following six months (t 2.540, p 0.013) (Table
2.5.2. Knowledge of the lower extremity exercise 3).
The extent of each patient's knowledge of the exercise 3.4. The peak velocity of the dorsal artery was significantly
regimen was measured using a knowledge questionnaire different between the two groups following 6 months of
designed by the researchers. The questionnaire included ten treatment (t 5.244, p 0.000) (Table 4).
items, each receiving a score between one and five according
to the Likert 5. The total score ranged between ten and 50, with
higher numbers indicating better knowledge. The question-
naire's validity was assessed by five professors, including two
diabetic education experts, two diabetic clinical nursing spe- 4. Discussion
cialists and one clinical endocrinologist. The Content Validity
Index (CVI) was 0.921 and the Cronbach's alpha coefficient was 4.1. Music media improves the compliance with elderly
0.871. diabetics to lower extremity exercise regimens

2.5.3. Peak velocity of dorsal artery Following three months intervention, the average score of the
This index was measured using the ES-1000SPM Doppler Flow patients exposed to a combination of music media and exer-
Detector. cise therapy was 18.55 1.13, significantly higher than those
exposed to only the exercise therapy (p < 0.05). Following six
2.5.4. Ankle-brachial index (ABI) months, the exercise compliance with the intervention group
The ankle-brachial index (ABI) was evaluated using the two- improved further, revealing an average score of 21.18 1.03.
way Doppler blood-flow detector (ES-1000SPM, Hadeco, These results suggest that musical media may significantly
Japan). Analysis was carried out following a 5-min minimum improve the exercise compliance with elderly diabetic pa-
rest in the supine position, with the upper body remaining as tients. The better the exercise compliance of the diabetic pa-
flat as possible. The ABI was calculated as a ratio comparing tients are, the lower the incidence of complications is [11].
the higher systolic blood pressure among the posterior tibial Considering that diabetes mellitus is a chronic disease that
artery and dorsalis pedis artery to the higher of the brachial causes several health complications, it was not surprising that
blood pressures in the arms. The ABI levels were classified as this study's patient subjects tended to lose confidence and
the following according to the ABI value: a normal value for even become too anxious or depressed to cooperate with the
the lower extremity artery was between 0.9 and 1.30, mild treatment. The musical effect on exercise tolerance is likely
vascular lesions between 0.70 and 0.89, moderate vascular attributable to affecting sympathetic nerve excitability,
lesions between 0.40 and 0.69, and severe vascular lesions slowing heart rate and breathing, and ultimately influencing
with ABI < 0.40 [10]. The lower ABI value was then used for the patients' nerve and muscle systems, which further
analysis. improved awareness and engagement with activities [2,12].
All measurements were evaluated prior to the interven- This musical therapy is primarily applied to patients in order
tion. The ABI, peak velocity of the dorsal artery and the to relieve pain, depression and muscle spasms, to improve
adherence to the diabetic lower extremity exercise were neurological deficits, and to promote recovery of motor
assessed following the intervention of the musical media for function [13e17]. A Chinese control trial compared patients
three and six months in Hua Dong Hospital, which is affiliated between an exercise group (n 52) and exercise combined
with Fudan University. with music-therapy group (n 52) and revealed that music
could improve motor function, depression and the rate of
2.6. Statistical methods exercise attendance in the elderly [18], similar to the report

Clinical data is represented as the mean standard deviation


and were compared using independent t or c2 tests, respec-
tively. Data were analyzed using SPSS statistics version 17.0. Table 2 e Score of patients compliance with lower limb
exercise after 3 and 6 months' intervention of two groups
Statistical significance was defined as p < 0.05.
(M SD).
Groups n Before After (intervention time)
3. Results 3 months 6 months
Intervention group 34 13.56 0.89 18.55 1.13 21.18 1.03
The results obtained from this study were as follows: Control group 38 13.52 0.89 16.74 0.45 17.42 0.68

3.1. The general characteristics of the participants are dis- t Value 0.154 9.155 18.421
p Value 0.878 <0.001 <0.001
played in Table 1.
246 i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 2 4 3 e2 4 7

tibial and dorsalis pedis arteries and therein promote blood


Table 3 e Ankle-brachial index (ABI) after 3 and 6 months'
circulation. Furthermore, other researchers in China found
intervention of two groups (M SD).
that an increase in peak flow velocity of the dorsalis pedis
Groups n Before After (intervention time)
artery played a role in protecting peripheral vasculature.
3 months 6 months Music media mainly played a role in strengthening the treat-
Intervention group 34 0.77 0.06 0.78 0.06 0.83 0.06 ment efficacy by enhancing exercise adherence [19]. Notably,
Control group 38 0.77 0.06 0.77 0.07 0.79 0.07 there was no significant difference in the peak velocity of
dorsal artery after three months intervention. This is poten-
t Value 0.067 0.379 2.540 tially attributable to the timing of the intervention non-
p Value 0.947 0.706 0.013
enough or the change of the lower limb vascular not very
obvious. Because the treatment and management of diabetes
is a long-term dynamic process, continual patient movement
from Johnson et al. (date) [19]. Some previous research sug- should be a priority during therapy.
gests that better exercise adherence results in better blood
sugar levels and that strong exercise adherence could slow the 4.3. Music media combined with lower limb exercise
development of complications to ultimately promote more therapy improves lower limb vascular lesions in elderly
patient movement. Therefore, elderly diabetic patients should diabetics
strengthen their awareness of the disease itself, as well as its
potential complications. Diabetics, especially those who lack Patients with diabetes mellitus are at higher risk of developing
the confidence and willingness to move, should thus consider macro-vascular disease, particularly cerebrovascular disease
taking the combined music media and lower extremity (CAD) and peripheral arterial disease (PAD). Lower-extremity
movement therapy. arterial disease (LEAD) is a component of PAD and the pri-
mary cause of diabetes foot gangrene and the need for
amputation of lower limbs in diabetics. The prevalence of the
4.2. The combination music media and lower extremity disease increases along with increasing age. ABI is an accu-
exercise therapy promotes lower limb blood circulation rate, simple, and noninvasive measurement for the screening
of lower extremity arterial disease and is considered to be the
In this study, following six months treatment, the average most accurate noninvasive diagnostic method for PAD [23].
peak velocity of the dorsal artery among the intervention PAD is also associated with an increased risk of anti-
group was 15.91 0.81 cm/s compared with 14.94 0.78 cm/s coagulated atrial fibrillation-based mortality, cardiovascular
in the control group (p < 0.05). This implies that the therapy mortality and total mortality when compared with patients
combining music media with lower extremity exercise could with a normal ABI (between 0.9 and 1.3) [24e26]. A lower ABI
significantly improve lower limb blood circulation of elderly (<0.9) plays an important role in assessing the lesion, pro-
diabetic patients. Peak blood flow velocity represented the gression and prognosis with a 95% sensitivity and 99% and
highest flow rate in the vascular sectional area during heart specificity [25,27]. The lower the ABI is, the worse the prog-
contractions. This measure reflects the degree of artery ste- nosis of the low extremity vascular lesions will be [28].
nosis, which could result in a decrease in peak blood flow In this study, following three months training, the ABI
velocity due to increasing blood flow resistance. Exercise values of the intervention and control groups showed no sig-
therapy not only appears to promote the generation of nificant difference (p > 0.05); after six months, the ABI value of
ischemic limb cardio-vasculature and the formation of the intervention group was obviously higher than that of the
collateral circulation to improve tissue ischemia, but also control group (p < 0.05). This suggested that music media in
likely enhances insulin sensitivity, reduces insulin resistance combination with lower extremity movement improves lower
and regulates blood sugar to delay lesions of the lower limb limb blood circulation and promotes the recovery of vascular
vasculature while improving foot blood circulation [4,20e22]. lesions. Moreover, the longer the patients adherence to exer-
The study by Jiao et al. (year) highlighted the importance of the cise, the better the rehabilitation will become. Of note, it is
lower extremity exercise to prevent and cure foot problems in advisable while training that the blood sugar be closely
elderly diabetics by improving peak velocity of the posterior monitored in case of an occurrence of hypoglycemia or other
adverse reactions.

Table 4 e The peak velocity of dorsal artery after 3 and 6 5. Conclusions


months' intervention of two groups (M SD).
Groups n Before (cm/s) After (intervention time) This study reveals that therapy combining music media and
3 months 6 months lower extremity movement significantly promotes the exer-
Intervention group 34 14.45 0.88 14.47 0.89 15.91 0.81 cise compliance with elderly diabetics and improves blood
Control group 38 14.39 0.87 14.45 0.86 14.94 0.78 circulation of the lower extremities. Future studies should
involve larger sample sized and be expanded to other medical
t Value 0.309 0.043 5.244 centers to thoroughly identify the effect of the combination
p Value 0.758 0.966 <0.001 therapy on elderly diabetics. Since ABI can be influenced by
many factors, the peak flow velocity and Doppler blood flow
i n t e r n a t i o n a l j o u r n a l o f n u r s i n g s c i e n c e s 2 ( 2 0 1 5 ) 2 4 3 e2 4 7 247

waveform should be employed to precisely assess the status [12] Yamamoto T, Ohkuwa T, Itoh H, Kitoh M, Terasawa J,
of the lower limb arteries. In addition, music media should be Tsuda T, et al. Effects of pre-exercise listening to slow and
adjusted according to each individual patients' physiological fast rhythm music on supramaximal cycle performance and
selected metabolic variables. Arch Physiol Biochem
and psychological status in order to achieve the maximum
2003;111(3):211e4.
effects. [13] Bradt J, Dileo C, Grocke D, Magill L. Music interventions for
improving psychological and physical outcomes in cancer
patients. Cochrane Database Syst Rev 2011;(8):CD006911.
Funding [14] Chen SL, Lin HC, Jane SW. Perceptions of group music
therapy among elderly nursing home residents in Taiwan.
This study was financially supported by both the Nursing Complement Ther Med 2009;17(4):190e5.
[15] Whitehead-Pleaux AM, Baryza MJ, Sheridan RL. The effects
Research Foundation (FNF201223) of Fudan University and the
of music therapy on pediatric patients' pain and anxiety
Hua Dong Hospital, which is affiliated with Fudan University. during donor site dressing change. J Music Ther
2006;43(2):136e53.
[16] Lim HA, Miller K, Fabian C. The effects of therapeutic
Conflict of interest instrumental music performance on endurance level, self-
perceived fatigue level, and self-perceived exertion of
inpatients in physical rehabilitation. J Music Ther
Authors declared no conflict of interests for this article.
2011;48(2):124e48.
[17] Kim SJ, Koh I. The effects of music on pain perception of
stroke patients during upper extremity joint exercises. J
references
Music Ther 2005;42(1):81e92.
[18] Jinkai H, Zhaojun W, Qi G, Zhaoyuan S. The effects of
musicotherapy on motor function, depression and rate of
[1] Yang W, Lu J, Weng J, Jia W, Ji L, Xiao J, et al. Prevalence of exercise training attendance of elder persons in geriatric
diabetes among men and women in China. N Engl J Med hospital. Chin J Rehabil Med 2013;28(4):340e51.
2010;362(12):1090e101. [19] Johnson G, Otto D, Clair AA. The effect of instrumental and
[2] Im ML, Lee JI. Effects of the art and music therapy on the vocal music on adherence to a physical rehabilitation
depression and cognitive function of elderly. Technol Health exercise program with persons who are elderly. J Music Ther
Care 2014;22(3):453e8. 2001;38(2):82e96.
[3] Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, [20] Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2
Kravitz S, et al. Diabetic foot disorders. A clinical practice diabetes mellitus. Cochrane Database Syst Rev
guideline. For the American College of Foot and Ankle 2006;(3):CD002968.
Surgeons and the American College of Foot and Ankle [21] Mohajeri S, Riddell MC. Advances in exercise, physical
Orthopedics and Medicine. J Foot Ankle Surg 2000;39(5 activity, and diabetes mellitus. Diabetes Technol Ther
Suppl.):S1e60. 2015;17(Suppl. 1):S88e95.
[4] Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, [22] Montero D, Walther G, Benamo E, Perez-Martin A, Vinet A.
Rubin RR, et al. Exercise and type 2 diabetes: the American Effects of exercise training on arterial function in type 2
College of Sports Medicine and the American Diabetes diabetes mellitus: a systematic review and meta-analysis.
Association: joint position statement executive summary. Sports Med 2013;43(11):1191e9.
Diabetes Care 2010;33(12):2692e6. [23] Caruana MF, Bradbury AW, Adam DJ. The validity, reliability,
[5] Goodyear LJ, Kahn BB. Exercise, glucose transport, and reproducibility and extended utility of ankle to brachial
insulin sensitivity. Annu Rev Med 1998;49:235e61. pressure index in current vascular surgical practice. Eur J
[6] Praet SF, van Loon LJ. Optimizing the therapeutic benefits of Vasc Endovasc Surg 2005;29(5):443e51.
exercise in Type 2 diabetes. J Appl Physiol (1985) [24] Heald CL, Fowkes FG, Murray GD, Price JF. Risk of mortality
2007;103(4):1113e20. and cardiovascular disease associated with the ankle-
[7] Henriksen EJ. Invited review: effects of acute exercise and brachial index: systematic review. Atherosclerosis
exercise training on insulin resistance. J Appl Physiol (1985) 2006;189(1):61e9.
2002;93(2):788e96. [25] Wohlfahrt P, Palous D, Ingrischova M, Krajcoviechova A,
[8] Stewart KJ. Exercise training and the cardiovascular Seidlerova J, Galovcova M, et al. A high ankle-brachial index
consequences of type 2 diabetes and hypertension: plausible is associated with increased aortic pulse wave velocity: the
mechanisms for improving cardiovascular health. JAMA Czech post-MONICA study. Eur J Cardiovasc Prev Rehabil
2002;288(13):1622e31. 2011;18(6):790e6.
[9] Joslin-Diabetes-Center.org [Internet]. Resistance band [26] Gallego P, Roldan V, Marin F, Jover E, Manzano-Fernandez S,
training for legs, Inc.; c2014. Available from: http://www. Valdes M, et al. Ankle brachial index as an independent
joslin.org/info/resistance-band-training-legs.html [cited predictor of mortality in anticoagulated atrial fibrillation. Eur
28.01.15]. J Clin Invest 2012;42(12):1302e8.
[10] Aso Y, Okumura K, Inoue T, Matsutomo R, Yoshida N, [27] Hoyt RE. Peripheral arterial disease in people with diabetes:
Wakabayashi S, et al. Results of blood inflammatory markers response to consensus statement. Diabetes Care
are associated more strongly with toe-brachial index than 2004;27(8):2095.
with ankle-brachial index in patients with type 2 diabetes. [28] Endocrinology CS. Chinese guideline of the prevention of the
Diabetes Care 2004;27(6):1381e6. type 2 diabetes (2012). Chin J Diabetes 2012;20(1):S1e36.
[11] Lerman I. Adherence to treatment: the key for avoiding long-
term complications of diabetes. Arch Med Res
2005;36(3):300e6.

You might also like