Comparative Effect of Buerger-Allen Exercise and Intraneural Facilitation on Lower Extremity Perfusion and Peripheral Neuropathy Symptoms Among Patients with Type II Diabetes Mellitus

Main Article Content

Muhammad Abbass
Maha Rehman
Isha Emaan
Umar Shaukat
Shafiq Ur Rehman Farooq
Muhammad Muneeb ur Rehman


Background: Diabetes mellitus is a complex metabolic disorder characterized by chronic hyperglycemia, which can lead to severe microvascular and macrovascular complications. Peripheral neuropathy and impaired lower extremity perfusion are common among diabetic patients, significantly affecting their quality of life. Buerger-Allen Exercise (BAE) and Intraneural Facilitation (INF) are therapeutic interventions aimed at improving blood flow and reducing neuropathy symptoms in diabetic patients. This study aimed to compare the effectiveness of these two interventions in enhancing lower extremity perfusion and alleviating peripheral neuropathy symptoms.

Objective: To assess and compare the effects of Buerger-Allen Exercise and Intraneural Facilitation on lower extremity perfusion and peripheral neuropathy symptoms in patients with type II diabetes mellitus.

Methods: This quasi-experimental study was conducted at Al-Raheem Clinic and Skin Laser Center in Faisalabad over three months. A purposive sampling technique was used to recruit 12 patients with type II diabetes mellitus and peripheral neuropathy symptoms restricted to the lower limbs. Patients were divided into two groups: one received Buerger-Allen Exercise and the other Intraneural Facilitation. Assessments included the Ankle-Brachial Index (ABI) to measure lower extremity perfusion, the Michigan Neuropathy Screening Instrument (MNSI) for neuropathy symptoms, and monofilament testing for sensory function. Ethical approval was obtained, and informed consent was collected from all participants. Data were analyzed using SPSS version 25, employing paired and independent t-tests to evaluate pre- and post-intervention outcomes.

Results: The ABI scores showed significant improvement in both groups post-intervention (BAE: pre 0.6883 ± 0.10980, post 1.0250 ± 0.10968, p < 0.001; INF: pre 0.6467 ± 0.06919, post 0.9617 ± 0.08909, p < 0.001). MNSI scores also decreased significantly (BAE: pre 7.5000 ± 1.04881, post 4.5000 ± 1.37840, p = 0.003; INF: pre 7.3333 ± 1.21106, post 4.1667 ± 1.16905, p < 0.001). Monofilament testing scores improved notably in both groups (BAE: pre 3.3333 ± 2.33809, post 6.3333 ± 1.86190, p = 0.002; INF: pre 3.1667 ± 2.31661, post 6.0000 ± 2.44949, p < 0.001).

Conclusion: Both Buerger-Allen Exercise and Intraneural Facilitation effectively improved lower extremity perfusion and reduced peripheral neuropathy symptoms in patients with type II diabetes mellitus. Buerger-Allen Exercise demonstrated better patient compliance and ease of administration. Further research with larger sample sizes and longer follow-up periods is recommended to validate these findings and explore the long-term benefits of these interventions.

Keywords: Diabetes mellitus, Buerger-Allen Exercise, Intraneural Facilitation, lower extremity perfusion, peripheral neuropathy, Ankle-Brachial Index

Article Details

How to Cite
Muhammad Abbass, Maha Rehman, Isha Emaan, Umar Shaukat, Shafiq Ur Rehman Farooq, & Muhammad Muneeb ur Rehman. (2024). Comparative Effect of Buerger-Allen Exercise and Intraneural Facilitation on Lower Extremity Perfusion and Peripheral Neuropathy Symptoms Among Patients with Type II Diabetes Mellitus. Journal of Health and Rehabilitation Research, 4(2), 1511–1517.


Karamanou M, Protogerou A, Tsoucalas G, Androutsos G, Poulakou-Rebelakou E. Milestones in the history of diabetes mellitus: The main contributors. World journal of diabetes. 2016;7(1):1.

Egan AM, Dinneen SF. What is diabetes? Medicine. 2019;47(1):1-4.

Roglic G. WHO Global report on diabetes: A summary. International Journal of Noncommunicable Diseases. 2016;1(1):3-8.

Trikkalinou A, Papazafiropoulou AK, Melidonis A. Type 2 diabetes and quality of life. World journal of diabetes. 2017;8(4):120.

Wake AD. Protective effects of physical activity against health risks associated with type 1 diabetes:“Health benefits outweigh the risks”. World Journal of Diabetes. 2022;13(3):161.

Lin Y-B, Chang T-J. Age at onset of type 1 diabetes between puberty and 30 years old is associated with increased diabetic nephropathy risk. Scientific Reports. 2024;14(1):3611.

Hasan S, Shaw SM, Gelling LH, Kerr CJ, Meads CA. Exercise modes and their association with hypoglycemia episodes in adults with type 1 diabetes mellitus: a systematic review. BMJ Open Diabetes Research and Care. 2018;6(1):e000578.

Svensson M, Nyström L, Schön S, Dahlquist G, Study SCD, Uraemia tSRfATo. Age at onset of childhood-onset type 1 diabetes and the development of end-stage renal disease: a nationwide population-based study. Diabetes care. 2006;29(3):538-42.

Hemmingsen B, Gimenez‐Perez G, Mauricio D, i Figuls MR, Metzendorf MI, Richter B. Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus. Cochrane Database of Systematic Reviews. 2017(12).

DeFronzo RA, Ferrannini E, Groop L, Henry RR, Herman WH, Holst JJ, et al. Type 2 diabetes mellitus. Nature reviews Disease primers. 2015;1(1):1-22.

Principles of Diabetes Mellitus. second ed2010.

Javeed N, Matveyenko AV. Circadian etiology of type 2 diabetes mellitus. Physiology. 2018;33(2):138-50.

Thakur A, Sharma R, Sharma SK, Thakur K, Jelly P. Effect of buerger allen exercise on foot perfusion among patient with diabetes mellitus: A systematic review & meta-analysis. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2022;16(2):102393.

Sommer C, Geber C, Young P, Forst R, Birklein F, Schoser B. Polyneuropathies. Deutsches Ärzteblatt International. 2018;115(6):83.

Singh R, Kishore L, Kaur N. Diabetic peripheral neuropathy: current perspective and future directions. Pharmacological research. 2014;80:21-35.

Juster-Switlyk K, Smith AG. Updates in diabetic peripheral neuropathy. F1000Research. 2016;5.

Feldman EL, Callaghan BC, Pop-Busui R, Zochodne DW, Wright DE, Bennett DL, et al. Diabetic neuropathy. Nature reviews Disease primers. 2019;5(1):1-18.

Russell JW, Zilliox LA. Diabetic neuropathies. Continuum: lifelong learning in neurology. 2014;20(5):1226-40.

Nativel M, Potier L, Alexandre L, Baillet-Blanco L, Ducasse E, Velho G, et al. Lower extremity arterial disease in patients with diabetes: a contemporary narrative review. Cardiovascular diabetology. 2018;17:1-14.

Radhika J, Poomalai G, Nalini S, Revathi R. Effectiveness of buerger-allen exercise on lower extremity perfusion and peripheral neuropathy symptoms among patients with diabetes mellitus. Iranian journal of nursing and midwifery research. 2020;25(4):291-5.

Oexeman S, Ward KL. Understanding the Arterial Anatomy and Dermal Perfusion of the Lower Extremity with Clinical Application. Clinics in Podiatric Medicine and Surgery. 2020;37(4):743-9.

Forsythe RO, Hinchliffe RJ. Assessment of foot perfusion in patients with a diabetic foot ulcer. Diabetes/metabolism research and reviews. 2016;32:232-8.

Baraz S, Zarea K, Shahbazian HB, Latifi SM. Comparison of the accuracy of monofilament testing at various points of feet in peripheral diabetic neuropathy screening. Journal of Diabetes & Metabolic Disorders. 2014;13:1-7.

Feng Y, Schlösser FJ, Sumpio BE. The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy. Journal of vascular surgery. 2009;50(3):675-82. e1.

Bhuvaneshwari S, Tamilselvi S. A study to assess the effectiveness of Buerger Allen exercise on lower extremity perfusion among patients with type 2 diabetes mellitus in Saveetha Medical College and Hospital in Chennai. International Journal for Advance Research and Development. 2018;3(9):15-20.

Innocenti G, Mugnai C, Pasqui V. FLORe–Florence Repository. L’Archivio ad accesso aperto dell’Università di Firenze. JLIS it: Italian Journal of Library, Archives and Information Science Rivista italiana di biblioteconomia, archivistica e scienza dell'informazione. 2014;5(1):149-71.

Chang C-F, Chang C-C, Chen M-Y. Effect of Buerger’s exercises on improving peripheral circulation: a systematic review. Open Journal of Nursing. 2015;5(2):120-8.

Kawasaki T, Uemura T, Matsuo K, Masumoto K, Harada Y, Chuman T, et al. The effect of different positions on lower limbs skin perfusion pressure. Indian Journal of plastic surgery. 2013;46(03):508-12.

東太. The effect of different positions on lower limbs skin perfusion pressure: 佐賀大学; 2015.

Baker NA, Vuong D, Bussell M, Gharibvand L, Lee S, Tsao B. Prospective, Randomized, Double-Blinded, Sham-Controlled Pilot Study of Intraneural Facilitation as a Treatment for Carpal Tunnel Syndrome. Archives of Rehabilitation Research and Clinical Translation. 2022;4(2):100193.

Sahba K, Berk L, Bussell M, Lohman E, Zamora F, Gharibvand L. Treating peripheral neuropathy in individuals with type 2 diabetes mellitus with intraneural facilitation: a single blind randomized control trial. Journal of International Medical Research. 2022;50(8):03000605221109390.

Bussell M, Coleman R, Alido J, Bruhjell K, Berk L. Ultrasound analysis of a novel therapeutic intervention for neuropathy: intraneural facilitation acute effects on idiopathic and chemotherapy induced peripheral neuropathy. The FASEB Journal. 2018;32:853.19-.19.

PT DMB, inventor.

Wahyuni NT, Herlina L, Abdurakhman RN, Hidayat A, Supriyadi C. Implementation of Buerger Allen exercise in patients with diabetes mellitus type II to improve lower extremity circulation. World Journal of Advanced Research and Reviews. 2022;14(1):573-9.

Zahran W, Hassanen A, Nabih M, Kyrillos F. Effect of Buerger Allen exercise on lower limb perfusion among patients with type 2 diabetes mellitus. Mansoura Nursing Journal. 2018;5(1):101-11.

Rushdy I, Fahim EM, Heggy EH. Impact of buerger-allen exercises on foot perfusion and pain level for diabetic patients risk with peripheral arterial disease. Assiut Scientific Nursing Journal. 2021;9(24.0):170-81.

Latha H, Gifty V. A study to assess the effectiveness of buerger allen exercise on lower extremity perfusion among patients with type 2 diabetes mellitus in selected hospitals at Kanyakumari District. Asian Journal of Nursing Education and Research. 2019;9(3):305-11.

Afida AM, Negara CK, Chrismilasari LA. Burger Allen Exercise Against The Circulation Of The Lower Extremities In Diabetic Ulcer Patients. Jurnal EduHealth. 2022;13(01):241-9.

Rashwan MA, Bedier NA, El-Kharbotly SE-D, Ebrahim YN, Sharaf AY. The effect of Buerger Allen exercise versus reflexology on lower extremity perfusion and pain among patients with type 2 diabetes mellitus. Alexandria Scientific Nursing Journal. 2022;24(1):13-25.

Mumpuni M, Purnamawati D, Arip M, Masadah M, Lorenza C. The Effect of Buerger Allen Exercises on Diabetes Mellitus Patients’ Foot Sensitivity of Mantang Health Center Working Area in 2021. International Journal of Social Service and Research. 2022;2(6):569-76.

Thomas B, Sharma L. A study to assess the effectiveness of buerger allen exercise on lower extremity perfusion and reducing peripheral neuropathy symptoms among diabetes mellitus patient in selected community areas of bhopal, MP. EPRA International Journal of Research and Development (IJRD). 2023;8(9):125-9.

Hasaini A, Muhlisoh M, Sukmawaty MN. Effectiveness of Buerger Allen Exercise and Warm Water Foot Soak on Foot Sensitivity Score in A Group of Patients with Type 2 DM. Indonesian Journal of Global Health Research. 2023;5(2):387-98.

Tahir T, Yusuf S. The effect of Buerger Allen exercise and the provision of oral vitamin C toward the improvement of peripheral tissue perfusion and healing of diabetic foot ulcers. Enfermería Clínica. 2021;31:S709-S12.

Mayangsari M, Lutfi M. The Effectiveness Of Buerger Allen Exercise On Decreasing ABI Value In Diabetes Mellitus Patients With Virginia Henderson's Nursing Model Theory Approach In The Covid-19 Pandemic. STRADA Jurnal Ilmiah Kesehatan. 2021;10(2):1541-6.