BRIEF RESUME OF THE INTENDENT WORK

INTRODUCTION

“The ground work of all happiness is good health”

(Leigh Hunt)

Healthy life is the valuable gift of an individual, if a person is healthy enough

according to me he is the richest person in his own world. But there is certain disease
condition which affects the normalcy of many a people in our existing world, such as
neurological problems, orthopedic problems, metabolic disorders, heart problems
especially acute coronary syndrome. Etc. Among which Acute Coronary Syndrome is
one of the important health issue in today’s world which may affect the entire life
pattern of an individual.1
Cardiovascular System is a big name for one of the most important systems in
the body. Made up of the heart, blood and blood vessels, the circulatory system is our
body’s delivery system. Blood moving from the heart, delivers oxygen and nutrients
to every part of the body. On the return trip, the blood picks up waste products so that
the body can get rid of them.2
Acute coronary syndromes which include unstable angina and myocardial
infarction (MI) with or without ST-segment elevation are life-threatening disorders
that remain a source of high morbidity and mortality despite advances in treatment.
Acute coronary syndrome is typically caused by Coronary artery disease which
includes atherosclerosis, or hardening of the arteries. Atherosclerosis is deposition of
fatty and lipid substances inside the coronary arteries wall also called plaque
formation. Plaque causes angina by narrowing the arteries.3

A reduced lower limb tissue perfusion can result in many serious

complications in our body such as Breathing difficulty, Altered mental status, Altered
sensations, Altered skin characteristics (Cold extremities, blue or purple skin color),
Weak or absent pulse etc.4

Initial therapy for ACS should focus on stabilizing the patient's condition,
relieving ischemic pain, and providing antithrombotic therapy to reduce myocardial

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damage and prevent further ischemia. Morphine (or fentanyl) for pain control,
oxygen, sublingual or intravenous (IV) nitroglycerin, soluble aspirin 162-325 mg, and
clopidogrel with a 300- to 600-mg loading dose are given as initial treatment. High-
risk patients with non-ST-segment elevation myocardial infarction (NSTEMI ACS)
should receive aggressive care, including aspirin, clopidogrel, unfractionated heparin
or low–molecular-weight heparin (LMWH), IV platelet glycoprotein IIb/IIIa complex
blockers (eg, tirofiban, eptifibatide), and a beta blocker. The therapeutic and surgical
treatment is PTCA (Percutaneous Transluminal Coronary Angioplasty) and CABG
(Coronary Artery Bypass Grafting). 5

Medical and pharmacological treatments cause many side effects like Nitrates
cause severe headache, Hypotension, Aspirin cause severe nausea, vomiting, stomach
pain, bloody of tarry stool, hemoptysis, fever etc. Surgical treatments are also having
some disadvantages or risks like the coronary artery may be torn or ruptured
(dissected) during the angioplasty and CABG has a higher risk of mortality nearly 3-
4% and also there is a risk for Chest infections and pulmonary complications.6

Buerger Allen exercise refers an active postural exercise, which help in fills
and empties the lower extremity blood vessels according to gravity alternatives refers
a three steps (elevation, dependency, horizontal).7

NEED FOR THE STUDY

The term acute coronary syndrome refers to any group of clinical symptoms
compatible with acute myocardial ischemia and includes unstable angina, non—ST-
segment elevation myocardial infarction, and ST-segment elevation myocardial
infarction. It is characterized by Chest Pain radiating to arms, neck and jaw, Shortness
of breath, nausea and sweating. The lower limb tissue perfusion causes Altered mental
status, Altered sensations, Altered skin characteristics (Cold extremities, blue or
purple skin color), Weak or absent pulse etc. Risk factors for ACS include older age,
previous atheromatous cardiovascular disease, diabetes, smoking, hypertension,
hypercholesterolemia, male sex, and a family history of premature ischemic heart
disease. ACS may also occur alongside valvular disease, arrhythmias, and
cardiomyopathies.8

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 In the United States, an ACS occurs every 25 seconds, and an ACS-related
death occurs in every 2 minute. Each year in this country, approximately 1.4 million
patients are hospitalized for ACS, of which 810,000 are for myocardial infarction
(MI). Also, about three-quarters of deaths from MI are caused by plaque rupture. The
remaining 25% are caused by superficial endothelial erosion.3 The proportion of ACS
with STEMI—when a blood clot completely blocks a coronary artery—is
declining,1possibly due to reductions in smoking, aging of the population (STEMI is
more common in middle age, while NSTEMI occurs more in the elderly), and greater
use of statin therapy. Similar trends have been seen for sudden cardiac arrest.
NSTEMI—usually when a clot partially blocks a coronary artery—is now the
dominant type of ACS, and outcomes after the acute phase are significantly worse
than for STEMI.9

India has the highest burden of ACS in the world. The CREATE registry has
provided contemporary data on 20,468 patients from 89 centers from 10 regions and
50 cities in India.The three most common risk factors for ACS were smoking (40%),
high blood pressure (38%), and diabetes (30%). The prevalence of dyslipidemia
(cholesterol abnormalities) was unfortunately not available or reported. 59% of
patients with STEMI received thrombolytics (96% streptokinase). Coronary
angioplasty was given to 8% of STEMI and 7% of non-STEMI; coronary bypass
surgery was given to 2% of STEMI and 4% of NSTEMI/UA. The 30-day outcomes
for patients with STEMI were: death 9%; reinfarction 2%; and stroke 0.7%. Poor
patients were less likely to get evidence-based treatments, and had greater 30-day
mortality than wealthy patients (8% vs 6% p<0.0001). Adjustment for treatments (but
not risk factors and baseline characteristics) eliminated this difference in mortality.
98% received anti-platelet drugs; 51%-61% received angiotensin-converting enzyme
(ACE) inhibitors or angiotensin receptor blockers (ARB) and 51-54% received lipid-
lowering therapy.10
Buerger-Allen exercise is a specific exercise intended to improve circulation
to the feet and legs. The lower extremities are elevated to a 45 to 90 degree angle and
supported in this position until the skin blanches (appears dead white). The feet and
legs are then lowered below the level of the rest of the body until redness appears
(care should be taken that there is no pressure against the back of the knees); finally,
the legs are placed flat on the bed for a few minutes. The length of time for each

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position varies with the patient's tolerance and the speed with which color change
occurs. Usually the exercises are prescribed so that the legs are elevated for 2 to 3
minutes, down 5 to 10 minutes and then flat on the bed for 10 minutes. 11

REVIEW OF LITERATURE

Review of literature refers to an extensive, exhaustive and systemic

examination of publication relevant to the study. It is an essential part of every
research, which helps to support the hypothesis under the study and to critically
analyze the structure and content of the research report.12

Studies can be divided in two following headings:

1. Studies related to Acute Coronary syndrome

2. Studies related to Buerger Allen Exercise
3. Studies related to effectiveness of Buerger Allen exercise to improve lower
limb tissue perfusion.

1. Studies related to Acute Coronary syndrome

Fabian Sanchis-Gomar, Carme Perez-Quilis, Roman

Leischik and Alejandro Lucia (2016), conducted study on Epidemiology of
coronary heart disease and acute coronary syndrome the aim of this review is to
summarize the incidence, prevalence, trend in mortality and general prognosis of
coronary heart disease (CHD) and a related condition, acute coronary syndrome
(ACS). Although CHD mortality has gradually declined over the last decades in
western countries, this condition still causes about one-third of all deaths in people
older than 35 years. This evidence, along with the fact that mortality from CHD is
expected to continue increasing in developing countries, illustrates the need for
implementing effective primary prevention approaches worldwide and identifying risk
groups and areas for possible improvement.13

Blais C, Rochette L (2015), conducted a study on Trends in prevalence,

incidence and mortality of diagnosed and silent coronary heart disease in Quebec Of
all cardiovascular causes of mortality, coronary heart disease (CHD) remains the
leading cause of death. Our objectives were to establish trends in the prevalence and

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incidence of CHD in the province of Quebec, and to determine the proportion of CHD
mortality that had no previous CHD diagnosis. METHODS: Trends in prevalence,
incidence and mortality were examined with a population-based study using the
Quebec Integrated Chronic Disease Surveillance System, which links several health
administrative databases. Data are presented using two case definitions for Quebecers
aged 20 years and over: 1) a validated definition, and 2) CHD causes of death codes
added to estimate the proportion of deaths that occurred without any previous CHD
diagnosis as a proxy for sudden cardiac death (SCD). RESULTS: In 2012/2013, the
crude prevalence of CHD was 9.4%, Between 2000/2001 and 2012/2013, the age-
standardized prevalence increased by 14%, Age-standardized incidence and mortality
rates decreased by 46% and 26% respectively, and represented a crude rate of 6.9 per
1000 and 5.2% in 2012/2013. CONCLUSION: The prevalence of CHD has tended to
decrease in recent years, and incidence and mortality have been declining in
Quebec.14

2. Studies related to Buerger Allen Exercise

Chang-Cheng Chang, Men-Yen Chen, Jen-Hsiang Shen, Yen Bin Lin,

MD, Wen-Wei Hsu and Bor-shyh Lin (2016) conducted a study on 30 patients with
unilateral or bilateral diabetic ulcerated feet in Chang Gung Memorial Hospital, Chia-
Yi Branch, from October 2012 to December 2013. Real-time dorsal foot skin
perfusion pressures (SPPs) before and after Buerger exercise were measured and
analyzed. In addition, the severity of ischemia and the presence of ulcers before
exercise were also stratified.A total of 30 patients with a mean age of 63.4 ± 13.7
years old were enrolled in this study. Their mean duration of diabetes was 13.6 ± 8.2
years. Among them, 26 patients had unilateral and 4 patients had bilateral diabetes
foot ulcers. Of the 34 wounded feet, 23 (68%) and 9 (27%) feet were classified as
Wagner class II and III, respectively. This study quantitatively demonstrates the
evidence of dorsal foot peripheral circulation improvement after Buerger exercise in
patients with diabetes.15

S Leonard Syme (2015), conducted an experimental study conducted to find

out the effectiveness of Buerger Allen exercise among peripheral vascular disease
patients. The study conducted among 13 patients admitted in hospital setting at Italy.
The study evidenced increased perfusion after doing the exercise (pretest capillary

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refill (2-3sec) and post test capillary refill (1-2sec) and extremity pulses increased
10%in 50%of total population .the overall benefit seen in 7 patients after 24 hours
evidenced by (increased perfusion and activity). The study concluded that buerger
allen exercise is effective for improving lower extremity perfusion.16

R Vincent Dynamic, Chriopractic media (2013), an article regarding

conservative approach to the management of lower extremity associated signs and
symptoms (pain, edema, tenderness, cyanosis, coldness and stiffness) show the
effectiveness of Buerger’s Allen exercise. The treatment involve encouragement of
blood flow during the actively vasospastic phase by elevation of an active exercise
part. The researcher recommended that Buerger’s Allen Exercise for the improvement
of lower extremity blood supply. Another article regarding intermittent claudication
also highly recommended the importance of Buerger’s Allen exercise (three 3 series
of exercise repeat 6- 7 times in a day) among peripheral vascular disease.17

3. Studies related to effectiveness of Buerger Allen exercise to improve Lower

Limb Tissue perfusion.

Mr Cyril Thomas (2015), conducted an experimental study to assess the

effectiveness of buerger allen exercise on improving lower extremity perfusion among
patients with acute coronary syndrome admitted in selected hospital at Bangalore. The
researcher adopted quasi experimental design with purposive sampling on a sample
size of 50. The result showed 75% of the type 2 diabetic patient improved peripheral
perfusion after the exercise and 10% showed faster wound healing in diabetic ulcers
and study concluded exercise is effective in improving extremity perfusion among
patients with acute coronary syndrome.18

Treesak C, Kasemgup V, Treat Jacobson (2014), conducted an

experimental study conducted among 25 peripheral vascular disease patients to
determine effectiveness of exercise training to improve the symptoms of peripheral
vascular disease at Chennai. The study results showed that 18% of population
increased the activity and perfusion by reducing the symptoms. 4% of population
illustrated a delayed effect to exercise and 2%showed improvement with surgery. The
study concluded exercises are effective in reducing peripheral vascular disease
symptoms.19

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OBJECTIVES OF THE STUDY

1. To assess the level of lower limb tissue perfusion among the patients with
acute coronary syndrome.
2. To assess the effectiveness of Buerger Allen exercise on lower limb tissue
perfusion among patients with acute coronary syndrome.
3. To find the association between the level of lower limb tissue perfusion among
the patients with acute coronary syndrome with their selected Demographic
variables.

RESEARCH HYPOTHESIS

H1- There will be significance association between effectiveness of Buerger allen

exercise on improving lower limb tissue perfusion among patients with acute
coronary syndrome.

H2- There will be significance association between level of lower limb tissue
perfusion with selected demographic variables among patients with acute coronary
syndrome.

OPERATIONAL DEFINITIONS

1. Assess: In this study “assess“refers to the evaluation of improvement of the

lower limb tissue perfusion in patients doing Buerger allen exercise.
2. Effectiveness: In this study effectiveness refers to improvement in the lower
limb tissue perfusion after performing Burger Allen Exercise.
3. Buerger allen exercise: In this study Buerger Allen exercise refers an active
postural exercise, which help in fills and empties the lower extremity blood
vessels according to gravity alternatives refers a three steps (elevation,
dependency, horizontal)
4. Lower limb tissue perfusion: In this study lower limb tissue perfusion refers
to the increased blood circulation of the lower limb as evidenced by skin color
changes, decreased pain after administering the Buerger Allen exercise among
selected patients.
5. Acute Coronary Syndrome: In this study the term 'acute coronary syndrome'
covers a range of disorders, including a heart attack (myocardial infarction)

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 and unstable angina that are caused by the same underlying problem. The
underlying problem is a sudden reduction of blood flow to part of the heart
muscle.

ASSUMPTIONS

The Study assumes that,

1. The patients with acute coronary syndrome will be having problem with lower
limb tissue perfusion.

2. Practice of Buerger Allen exercise will help to improve lower limb tissue perfusion
in patients with acute coronary syndrome.

DELIMITATIONS

The Study will be limited to,

1. Patients admitted in selected hospital of Rajkot.

2. Patients above 20 years of age.

3. Sample size is limited to 40 patients with acute coronary syndrome.

SIGNIFICANCE OF THE STUDY

1. Study will help to identify the level of practice for buerger allen exercise.
2. The study will help the patients with acute coronary syndrome to better
understand about effectiveness of buerger allen exercise on improving
lower limb tissue perfusion.

MATERIAL AND METHODS

SOURCE OF DATA

The data will be collected from the patients with acute coronary syndrome
admitted in the selected hospital of Rajkot who are above 20 years.

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PLAN FOR DATA COLLECTION

The investigator would get the permission prior to data collection from
concerned authority. The investigator will introduce him to the participants.
Assessment of the lower limb tissue perfusion by using observation checklist and data
will be collected from them using baseline data. Nature and purpose of the study and
about practice of buerger allen exercise will be explained and obtain consent from
them. Buerger’s Allen exercise will be administered on same day (duration- 12
minutes, frequency-4, and interval-3hous) among experimental group. The tissue
perfusion levels will the measured by the Enhanced Foot Assessment scale after 7
days. Post test assessment of lower limb tissue perfusion will be after practicing the
buerger allen exercise.

RESEARCH DESIGN

Pre-experimental design will be used for this study.

One group pretest post test design

METHODS OF DATA COLLECTION

INSTRUMENTS INTENDED TO BE USED

Section A- Socio demographic data

Section B- Enhanced Foot Assessment scale

SAMPLING PROCEDURE

The research study is planned to conduct by Purposive sampling method.

POPULATION

TARGET POPULATION: Patients admitted with acute coronary syndrome in

selected hospitals of Rajkot.

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ACCESSIBLE POPULATION:

Patients admitted with reduced lower limb tissue perfusion with acute coronary
syndrome.

SAMPLING CRITERIA

INCLUSION CRITERIA FOR SAMPLING

1. Patients admitted in selected hospitals of Rajkot.

2. Patients over 20 years of age.
3. Patients having only acute coronary syndrome.

EXCLUSION CRITERIA FOR SAMPLING

1. Patients who don’t know Gujarati.

2. Patients who are not willing to participate in this study.
3. Patients who are below 20 years of age.

SAMPLING TECHNIQUE

The research will be conducted by non-probability purposive sampling technique.

SAMPLE SIZE

The sample size will be 40 patients.

SETTING

The study will be conducted in selected hospitals at Rajkot.

PILOT SUDY

10% of population is planned for the pilot study.

VARIABLES

INDEPENDENT VARIABLE: Buerger allen exercise.

DEPENDENT VARIABLE: Lower limb tissue perfusion.

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DATA ANALYSIS PLAN

DESCRIPTIVE STATISTICS

1. Mean Median and Frequency distribution.

INFERENTIAL STATISTICS

1. Paired “t” test will be used to assess the effectiveness of buerger allen exercise
on improving lower limb tissue perfusion.
2. Chi-square test will be used to associate level of lower limb tissue perfusion
among patients with their selective demographic variables.

ETHICAL CLEARANCE

1. Has ethical clearance been obtained from your institution?

Yes.

2. Has the consent been taken from the sample?

Yes.

The study will be conducted after the approval of research committee in the
college. The nature and purpose of the study will be explained to the
participants. The written consent will be obtained from participants to gain full
co-operation. Assurance will be given to the study samples that the anonymity
of each individual would be maintained strictly.

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1. M.Vijayabarathi, V.Hemavathy; International Journal of Innovative Research in

Science (online). Available from: https://www.ijirset.com (Accessed on 18 Feb 2017)

2. Gerard J. Tortora, Bryan Derrickson; Principals of Anatomy and Physiology, 12th

Edition, Wiley Pusblications, 2009, 718-780

3. Williams MD; Acute Coronary Syndrome Overview,(online), Available from:

http://www.webmd.com (Accessed on 11 Feb 2017)

4. Gil Wayne RN, Ineffective Tissue Perfusion (online), Available from:

https://nurseslabs.com (Accessed on 21 March 2017)

5. David L Coven; Acute Coronary Syndrome Treatment & Management (online),

Available from:http://emedicine.medscape.com (Accessed on 10 April 2017)

6. Thandani U, Repley TL; Side effects of drugs to treat heart failure and the acute
coronary syndromes, unstable angina and acute myocardial infarction (online),
Available from: https://www.ncbi.nlm.nih.gov (Accessed on 10 April 2017)

7. Dr. Prodyut Das (PT); Buerger Allen exercise (online). Available

from:http://www.physiotherapy-treatment.com (Accessed on 10 April 2017)

8. Brunner & Suddarth; Text book of Medical-Surgical Nursing, 10th Edition, 2008,
725-750

9. Tracy Hampton; Epidemiology of Acute Coronary Syndrome (online). Available

From: http://www.medpagetoday.com (Accessed on 11 April 2017)

10. Dr. Enas; Acute coronary syndrome in India (online). Available from:
http://www.cadiresearch.org (Accessed on 11 April 2017)

11. Dr. Prodyut Das (PT); Buerger Allen exercise (online). Available from:
http://www.physiotherapy-treatment.com (Accessed on 20 March 2017)

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13. Fabian Sanchis-Gomar, Carme Perez-Quilis, Roman Leischik and Alejandro

Lucia; Epidemiology of coronary heart disease and acute coronary syndrome(online).
Available from: https://www.ncbi.nlm.nih.gov (Accessed on 25 March 2017)

14. Blais C, Rochette L; Trends in prevalence, incidence and mortality of diagnosed

and silent coronary heart disease in Quebec (online). Available from:
https://www.ncbi.nlm.nih.gov (Accessed on 8 April 2017)

15. Chang-Cheng Chang, Men-Yen Chen, Jen-Hsiang Shen, Yen Bin Lin, MD, Wen-
Wei Hsu and Bor-shyh Lin; A quantitative real-time assessment of Buerger exercise
on dorsal foot peripheral skin circulation in patients with diabetes foot (online).
Available from: https://www.ncbi.nlm.nih.gov (Accessed on 10 April 2017)

16. Leonard Syme; The prevention of disease and promotion of health:the need for a
new approach,: European Journal of Public Health; 2015 :329-330.

17. R Vincent Dynamic. Chriopractic media: A conservative approach to the

management of Suedky’s Atropy; 2014.

18. Mr Cyril Thomas; Effectiveness of buerger allen exercise on Acute coronary

syndrome patients in improving peripheral perfusion: interventional study on acute
coronary syndrome patients (unpublished dissertation) 2015. banglore

19. Treesak C , Kasemgup V, Treat Jacobson. Cost effectiveness of exercise training

improve claudication symptoms in patient with peripheral arterial disease; 1993, 201-
230

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