INCREASE BLOOD FLOW TO THE FEET- YES !
RELAXATION TRAINING AND ITS ROLE IN DIABETES AND HEALTH

Birgitta I. Rice, M.S., R.Ph., CHES

Introduction

This series of articles will provide information on the benefits of relaxation on health and wellness, with a focus on peripheral circulation problems in diabetes patients.

Part 2 Testing Methods—How The Results Were Recorded.

The first study was designed to see if people with diabetes would have the same ability to increase peripheral blood flow in response to relaxation training as people without diabetes. First people without diabetes completed a pilot study to evaluate the relaxation technique and their response to it. Then diabetic subjects (N=40), ages 17-73, who were volunteers recruited through the University of Wisconsin-La Crosse, the local ADA Chapter and a medical clinic were signed up. A 'within-subjects' experimental design was used. The subjects served as their own controls, which provided complete control of one of the most important sources of variation in educational experiments, namely inter-subject variations.

During Phase1, all subjects used a self-selected relaxation method and recorded toe temperatures daily. During Phase2, the same subjects were taught a biofeedback assisted relaxation technique designed to elicit sensations of warmth in the lower extremities, thereby increasing blood circulation and temperature. Subjects relaxed at home using a designated relaxation tape. They measured and recorded toe temperatures before and after each relaxation session. Each phase lasted four weeks.

In this study, subjects showed an improvement in their ability to increase blood volume pulse (BVP) in the great toe after training. In fact, most of the increase of BVP change scores, as indexed by the statistical measure Eta2 = .71, which indicated that 71% of the increase in BVP could be attributed to the biofeedback assisted relaxation training. The toe temperature change scores were not only significantly larger after training, but the average starting toe temperature also was 2.86oF higher at the end of Phase2 even though this time was farther into the winter and the weather colder.

Later a multi site clinical trial aimed to test this relaxation technique further was conducted. We wanted to see if the training would promote enough additional blood flow to make a difference in the healing of chronic, non-healing foot ulcers that often develop as a complication of diabetes. Therefore medical care for patients with non-healing chronic foot ulcers was combined with a standardized biofeedback-assisted relaxation training program in the experimental group of this prospective randomized study. The intervention was designed to increase peripheral perfusion, thereby promoting healing.

The results: 14 out of 16 ulcers (87.5%) healed in the experimental group, whereas 7 out of 16 ulcers (43.7%) healed in the control group (p < .01). Other significant outcomes were that patients reported experiencing less pain. We also measured an increased sensory function of the large myelinated fibers of the peroneal nerve. At the end of this study, patients in the experimental group who had practiced biofeedback-assisted relaxation were able to perceive the stimulus of an electric current (Current Perception Threshold, CPT levels) at lower intensities than at the start of the study.

The improvement in healing and sensory nerve function was due to better oxygenation of nerve endings through increased micro vascular perfusion, brought about by decreased sympathetic muscle tone and peripheral vasodilation.

Findings have been published in peer reviewed medical journals and presented to national audiences of the American Diabetes Association, American Association of Diabetes Educators, Occupational Therapy Association, etc. The WarmFeet® program received the 1999 Paragon Award from the Society for Public Health Education in Minnesota, for its innovative and local application.

Among the published works are:

Rice BI, Kalker AJ, Schindler JV, Dixon RM: Effect of Thermal Biofeedback Assisted Training on Foot Ulcer Healing. J Am Podiatr Med Assoc, 91/3, p.132-41, 2001

Rice BI: Increased Peroneal Nerve Function in People with Diabetes Mellitus Following Biofeedback Assisted Relaxation Training. Biofeedback and Self-Regulation, 9/3, 1994

Rice BI, Schindler JV: Effect of Thermal Biofeedback-Assisted Relaxation Training on Blood Circulation in the Lower Extremities of a Population with Diabetes, Diabetes Care, 15/7, p.853-859, 1992

The next section will present some case studies from clinical practice situations.

Birgitta I. Rice, MS, RPh, CHES received her education and pharmacy license in her native Sweden. She is a researcher, clinician and certified health education specialist at the University of Minnesota, Division of Epidemiology Clinical Research Center, Minneapolis, MN

View Part One of this series

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