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journal homepage: http://www.elsevier.com/journals/internationaljournal-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 xxx

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/).

1.

Introduction

Along with an increasingly expanding elderly population

worldwide, the percentage of elderly patients diagnosed with
diabetes mellitus is continually increasing and is currently as
high as 20.4 percent [1]. This pattern can also be seen in elderly

patients with peripheral vascular disease. A recent American

study revealed that 29 percent of type II diabetes patients older
than 50 suffered from lower extremity vascular disease [2].
Furthermore, it is known that peripheral vascular disease that is
highly associated with diabetes can impede the healing of ulcers
and increase the risk of amputation necessity [3]. The recently

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/).
*

Please cite this article in press as: Ji L, et al., Effect of combining music media therapy with lower extremity exercise on elderly patients
with diabetes mellitus, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.07.008

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 x x x ( 2 0 1 5 ) 1 e5

updated American Diabetes Association exercise guidelines

state that exercise should be performed at least three times per
weeks [4]. Exercising regularly for a long period of time is critical
for promoting metabolism, improving insulin sensitivity and
decreasing blood sugar. In addition, exercise is also critical for
both stimulating blood circulation in the lower limbs and preventing foot ulcers [5e8]. Due to a low rate of movement in
elderly patients and their general unwillingness to comply with a
regular exercise regimen, exercise therapy often proves challenging to enforce. It is therefore critically important to formulate
methods to drastically improve the compliance with movement
in diabetic elderly patients. In this study, we expose elderly diabetic patients to a combination of music media therapy with a
lower extremity sports programs. We reveal that this unique
approach in successful in both promoting blood circulation in the
patients' lower extremities as well as increasing the extent of
elderly patient compliance to a consistent exercise regimen.

2.

Methods

2.1.

Patient selection

Seventy-two diabetic patients above 60 years of age and

categorized as level 0 according to the Wagner Classification
Scale of Diabetic Foot were selected as research subjects for
this study. All patients were acquired between April 2013 and
October 2013 from the department of endocrinology in Hua
Dong Hospital, which is affiliated with Fudan University in
Shanghai, China. Exclusion criteria included those who were
unable to walk independently, those who had lower limb pain,
severe arthritis, nervous system and cardiovascular disease,
as well as other complications that limited their physical activity and cognitive dysfunction.

2.2.

Study design

This study was performed as a randomized controlled trial. The

72 diabetes mellitus patient subjects were randomly assigned
to one of two groups: the intervention group (n 34) receiving
music media therapy with a lower extremity exercise regimen
and the control group (n 38) that only received the lower extremity exercise regimen. Each patient continued to receive
standard treatment and care from their physicians throughout
this study. The primary endpoint categories of this study
included compliance with exercise, peak velocity of dorsal artery and ankle-brachial index (ABI). Table 1 displays each patient subjects' characteristics according to their assigned
treatment regimen at allocation: sex, level of education, age,
time since diagnosis, etc. Approval for this study was obtained
from the Fudan University ethics committee and all patients
provided their signed informed consent of participation.

2.3.

Table 1 e Characteristics of subjects by assigned

treatment regimens at group allocations.
Intervention
group
Sex
Male
Female
Level of education
Primary and below
Junior or high
school
College and above
Age (M SD)
Time since diagnosis
(M SD)
HbA1C (M SD)
FBG (fasting
blood-glucose,
M SD)
BMI (M SD)
Score of knowledge
questionnaire
(M SD)

Control
group

t or c2 p Value
value
0.001

0.583

2.315

0.314

2
68.79 2.78
21.56 6.01

0
67.55 2.16 2.124
21.89 5.93 0.238

0.057
0.812

7.25 0.29
7.56 1.45

7.24 0.30
7.67 1,56

0.711
0.452

0.944
0.872

24.65 2.32
37.12 1.77

24.62 2.22
37.18 1.78

0.044
0.159

0.965
0.874

20
14

20
18

24
8

28
10

[9]. These specific exercises included the strengthening of

quadriceps, balance and ankle/foot as well as kicking before
and after the strengthening exercises. The researchers typically led the patients through these exercises. The patients
exercised for 15 minutes every day if possible and the regimen
lasted for at least six months. Each patient's condition was
observed at all times throughout the process of movement to
prevent any potential health complications.

2.4.

Music media intervention

2.4.1.

Music media selection

According to the specific musical preferences of the 15 elderly

participants, five musical genres were initially selected,
including classical, folk instrumental, cheerful, religious and
soothing. The final selection of musical genre was soothing
aesthetic based upon the preferences of the patients after
listening to sample music from each style. After assessment,
the musical professor composed a synthetic piano song with a
4/4 beat, and this musical exposure was combined with a
lower extremity exercise program.

2.4.2.

Intervention

The diabetic elderly patients in the intervention group

finished the throughout treatment led by researchers. These
patients exercised 15 minutes every day while listening to
group music, with the lower extremity movement being
introduced every week for four consecutive weeks. Patients
were then exposed to the collective musical piece combined
with lower exercise every month for at least six months.

Exercise therapy
2.5.

Both experimental and control groups accepted the intervention of the lower extremity exercise regimen, which
mainly consisted of resistive exercise and was developed by
the United States Joslin Diabetes Center (the branch of the
Teaching and Research Institution in Harvard Medical School)

Measures

2.5.1. Compliance with elderly diabetics to the lower

extremity exercise regimen
The exercise regimen compliance with elderly diabetics was
measured using a diabetic exercise adherence scale. This

Please cite this article in press as: Ji L, et al., Effect of combining music media therapy with lower extremity exercise on elderly patients
with diabetes mellitus, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.07.008

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 x x x ( 2 0 1 5 ) 1 e5

scale was composed of five items, with each item assigned a

score between one and five. The lower scores indicated greater
extent of adherence to the exercise regimen. The method
assessing the scale was the same as the knowledge questionnaire about the lower extremity exercise. The scale's
Cronbach's a coefficient was 0.851 and the CVI was 0.905.

2.5.2.

Knowledge of the lower extremity exercise

The extent of each patient's knowledge of the exercise

regimen was measured using a knowledge questionnaire
designed by the researchers. The questionnaire included ten
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 questionnaire's validity was assessed by five professors, including two
diabetic education experts, two diabetic clinical nursing specialists and one clinical endocrinologist. The Content Validity
Index (CVI) was 0.921 and the Cronbach's alpha coefficient was
0.871.

2.5.3.

Peak velocity of dorsal artery

This index was measured using the ES-1000SPM Doppler Flow

Detector.

2.5.4.

Ankle-brachial index (ABI)

The ankle-brachial index (ABI) was evaluated using the twoway Doppler blood-flow detector (ES-1000SPM, Hadeco,
Japan). Analysis was carried out following a 5-min minimum
rest in the supine position, with the upper body remaining as
flat as possible. The ABI was calculated as a ratio comparing
the higher systolic blood pressure among the posterior tibial
artery and dorsalis pedis artery to the higher of the brachial
blood pressures in the arms. The ABI levels were classified as
the following according to the ABI value: a normal value for
the lower extremity artery was between 0.9 and 1.30, mild
vascular lesions between 0.70 and 0.89, moderate vascular
lesions between 0.40 and 0.69, and severe vascular lesions
with ABI < 0.40 [10]. The lower ABI value was then used for
analysis.
All measurements were evaluated prior to the intervention. The ABI, peak velocity of the dorsal artery and the
adherence to the diabetic lower extremity exercise were
assessed following the intervention of the musical media for
three and six months in Hua Dong Hospital, which is affiliated
with Fudan University.

2.6.

Statistical methods

Clinical data is represented as the mean standard deviation

and were compared using independent t or c2 tests, respectively. Data were analyzed using SPSS statistics version 17.0.
Statistical significance was defined as p < 0.05.

3.2. The difference between the lower limb exercise adherence was significant between the experimental and
control groups following three treatment (t 9.155,
p < 0.001) (Table 2).
3.3. There was a statistical significant difference between
the ankle-brachial index (ABI) of the two treatment
groups following six months (t 2.540, p 0.013) (Table
3).
3.4. The peak velocity of the dorsal artery was significantly
different between the two groups following 6 months of
treatment (t 5.244, p 0.000) (Table 4).

4.

Discussion

4.1.
Music media improves the compliance with elderly
diabetics to lower extremity exercise regimens
Following three months intervention, the average score of the
patients exposed to a combination of music media and exercise therapy was 18.55 1.13, significantly higher than those
exposed to only the exercise therapy (p < 0.05). Following six
months, the exercise compliance with the intervention group
improved further, revealing an average score of 21.18 1.03.
These results suggest that musical media may significantly
improve the exercise compliance with elderly diabetic patients. The better the exercise compliance of the diabetic patients are, the lower the incidence of complications is [11].
Considering that diabetes mellitus is a chronic disease that
causes several health complications, it was not surprising that
this study's patient subjects tended to lose confidence and
even become too anxious or depressed to cooperate with the
treatment. The musical effect on exercise tolerance is likely
attributable to affecting sympathetic nerve excitability,
slowing heart rate and breathing, and ultimately influencing
the patients' nerve and muscle systems, which further
improved awareness and engagement with activities [2,12].
This musical therapy is primarily applied to patients in order
to relieve pain, depression and muscle spasms, to improve
neurological deficits, and to promote recovery of motor
function [13e17]. A Chinese control trial compared patients
between an exercise group (n 52) and exercise combined
with music-therapy group (n 52) and revealed that music
could improve motor function, depression and the rate of
exercise attendance in the elderly [18], similar to the report

Table 2 e Score of patients compliance with lower limb

exercise after 3 and 6 months' intervention of two groups
(M SD).
Groups

3.

Before

Results

The results obtained from this study were as follows:

3.1. The general characteristics of the participants are displayed in Table 1.

After (intervention time)

3 months

6 months

Intervention group 34 13.56 0.89

Control group
38 13.52 0.89

18.55 1.13
16.74 0.45

21.18 1.03
17.42 0.68

t Value
p Value

9.155
<0.001

18.421
<0.001

0.154
0.878

Please cite this article in press as: Ji L, et al., Effect of combining music media therapy with lower extremity exercise on elderly patients
with diabetes mellitus, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.07.008

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 x x x ( 2 0 1 5 ) 1 e5

Table 3 e Ankle-brachial index (ABI) after 3 and 6 months'

intervention of two groups (M SD).
Groups

Before

After (intervention time)

3 months

6 months

Intervention group 34 0.77 0.06

Control group
38 0.77 0.06

0.78 0.06
0.77 0.07

0.83 0.06
0.79 0.07

t Value
p Value

0.379
0.706

2.540
0.013

0.067
0.947

from Johnson et al. (date) [19]. Some previous research suggests that better exercise adherence results in better blood
sugar levels and that strong exercise adherence could slow the
development of complications to ultimately promote more
patient movement. Therefore, elderly diabetic patients should
strengthen their awareness of the disease itself, as well as its
potential complications. Diabetics, especially those who lack
the confidence and willingness to move, should thus consider
taking the combined music media and lower extremity
movement therapy.

4.2.
The combination music media and lower extremity
exercise therapy promotes lower limb blood circulation
In this study, following six months treatment, the average
peak velocity of the dorsal artery among the intervention
group was 15.91 0.81 cm/s compared with 14.94 0.78 cm/s
in the control group (p < 0.05). This implies that the therapy
combining music media with lower extremity exercise could
significantly improve lower limb blood circulation of elderly
diabetic patients. Peak blood flow velocity represented the
highest flow rate in the vascular sectional area during heart
contractions. This measure reflects the degree of artery stenosis, which could result in a decrease in peak blood flow
velocity due to increasing blood flow resistance. Exercise
therapy not only appears to promote the generation of
ischemic limb cardio-vasculature and the formation of
collateral circulation to improve tissue ischemia, but also
likely enhances insulin sensitivity, reduces insulin resistance
and regulates blood sugar to delay lesions of the lower limb
vasculature while improving foot blood circulation [4,20e22].
The study by Jiao et al. (year) highlighted the importance of the
lower extremity exercise to prevent and cure foot problems in
elderly diabetics by improving peak velocity of the posterior

tibial and dorsalis pedis arteries and therein promote blood

circulation. Furthermore, other researchers in China found
that an increase in peak flow velocity of the dorsalis pedis
artery played a role in protecting peripheral vasculature.
Music media mainly played a role in strengthening the treatment efficacy by enhancing exercise adherence [19]. Notably,
there was no significant difference in the peak velocity of
dorsal artery after three months intervention. This is potentially attributable to the timing of the intervention nonenough 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
should be a priority during therapy.

4.3.
Music media combined with lower limb exercise
therapy improves lower limb vascular lesions in elderly
diabetics
Patients with diabetes mellitus are at higher risk of developing
macro-vascular disease, particularly cerebrovascular disease
(CAD) and peripheral arterial disease (PAD). Lower-extremity
arterial disease (LEAD) is a component of PAD and the primary cause of diabetes foot gangrene and the need for
amputation of lower limbs in diabetics. The prevalence of the
disease increases along with increasing age. ABI is an accurate, simple, and noninvasive measurement for the screening
of lower extremity arterial disease and is considered to be the
most accurate noninvasive diagnostic method for PAD [23].
PAD is also associated with an increased risk of anticoagulated atrial fibrillation-based mortality, cardiovascular
mortality and total mortality when compared with patients
with a normal ABI (between 0.9 and 1.3) [24e26]. A lower ABI
(<0.9) plays an important role in assessing the lesion, progression and prognosis with a 95% sensitivity and 99% and
specificity [25,27]. The lower the ABI is, the worse the prognosis of the low extremity vascular lesions will be [28].
In this study, following three months training, the ABI
values of the intervention and control groups showed no significant difference (p > 0.05); after six months, the ABI value of
the intervention group was obviously higher than that of the
control group (p < 0.05). This suggested that music media in
combination with lower extremity movement improves lower
limb blood circulation and promotes the recovery of vascular
lesions. Moreover, the longer the patients adherence to exercise, the better the rehabilitation will become. Of note, it is
advisable while training that the blood sugar be closely
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

months' intervention of two groups (M SD).

5.

Groups

This study reveals that therapy combining music media and

lower extremity movement significantly promotes the exercise compliance with elderly diabetics and improves blood
circulation of the lower extremities. Future studies should
involve larger sample sized and be expanded to other medical
centers to thoroughly identify the effect of the combination
therapy on elderly diabetics. Since ABI can be influenced by
many factors, the peak flow velocity and Doppler blood flow

n Before (cm/s) After (intervention time)

3 months

6 months

Intervention group 34
Control group
38

14.45 0.88
14.39 0.87

14.47 0.89
14.45 0.86

15.91 0.81
14.94 0.78

t Value
p Value

0.309
0.758

0.043
0.966

5.244
<0.001

Conclusions

Please cite this article in press as: Ji L, et al., Effect of combining music media therapy with lower extremity exercise on elderly patients
with diabetes mellitus, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.07.008

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 x x x ( 2 0 1 5 ) 1 e5

waveform should be employed to precisely assess the status

of the lower limb arteries. In addition, music media should be
adjusted according to each individual patients' physiological
and psychological status in order to achieve the maximum
effects.

Funding
This study was financially supported by both the Nursing
Research Foundation (FNF201223) of Fudan University and the
Hua Dong Hospital, which is affiliated with Fudan University.

Conflict of interest
Authors declared no conflict of interests for this article.

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Please cite this article in press as: Ji L, et al., Effect of combining music media therapy with lower extremity exercise on elderly patients
with diabetes mellitus, International Journal of Nursing Sciences (2015), http://dx.doi.org/10.1016/j.ijnss.2015.07.008