ORIGINAL ARTICLE

Soak Feet with Warm Water and Progressive Muscle Relaxation

Therapy on Blood Pressure in Hypertension Elderly
SITI FADLILAH1, RIZKY ERWANTO2, ADI SUCIPTO3, DIYAH CANDRA ANITA4, SITI AMINAH5
1,2,3
Nursing Programme Study Universitas Respati Yogyakarta, Tajem Km 1,5 Maguwoharjo Depok Sleman Yogyakarta, Indonesia, 55282
4
Nursing Programme Study Universitas Aisyiyah Yogyakarta, Jl. Ringroad Barat No 63, Mlangi Nogotirto Gamping Sleman Yogyakarta
Indonesia
5
Nursing Programme Study STIKES Muhammadiyah Kendal, Dukuh Selotugu RT 4 RW 4, Pucangrejo Village, Kendal Central Java
Indonesia 51356
Correspondence to Siti Fadlilah, Email: [email protected], Telephone +6285710844204, Fax +622744437999

ABSTRACT
Background: Hypertension is a silent killer. Each year hypertension contributes to the deaths of nearly 9.4 million
people. Non-pharmacological management may use a combination of the therapy of foot soaks in warm water and
progressive muscle relaxation.
Aim: The purpose of this study was to find out the effectiveness of the combination of the treatment of foot absorbs
in warm water and progressive muscle relaxation in blood pressure for the elderly with hypertension.
Methods: This study used a quasi-experimental design with the pretest and posttest control group design. The
sample is consisting of 2 groups, 20 respondents in each group. Examples were selected by simple random
sampling technique. The instruments were observation sheet, standard operating procedure, and
sphygmomanometer digital. The data were analyzed using the paired t-test.
Results: The mean blood pressures pretest and posttest among control group were 160.70/88.37 mmHg and
160.25/88.67 mmHg. The mean blood pressure pretest and posttest among intervention group were 159.81/85.75
mmHg and 150.31/84.25 mmHg. The decrease in mean pre-posttest systolic and diastolic pressures in the
intervention group were -9.50 mmHg and -1.50 mmHg.This study found that the treatment useful to reduce systolic
(p0.030) and diastolic (p0.0.41). The comparison of systolic and diastolic blood pressure of intervention with the
control group obtained p0.018 and 0.023.
Conclusion: The combination of the therapy of foot soaks in warm water, and progressive muscle relaxation is
useful for lowering blood pressure. Respondents are expected to apply this treatment as a complementary therapy
of hypertension.
Keywords: Blood pressure, elderly, hypertension, progressive muscle relaxation, water therapy

INTRODUCTION Untreated hypertension, in the long run, will cause

damage to the arteries. Complications of hypertension can
Elderly has decreased function due to the ageing process. occur in organs such as; heart, brain, kidney and eyes
The effects of ageing and diseases related to ageing in (Zanchetti, 2017)(Trtica Majnarić et al., 2019). The
humans include biological, physiological, psychosocial, and occurrence of complications in hypertension can be
spiritual aspects (Stanley, M. Blair, KA. & Beare, 2006). prevented by pharmacological and non-pharmacological
Structural and functional changes in the elderly in the management. Pharmacological management can be given
cardiovascular system, namely changes in thickened left diuretics and ACE inhibitors. Pharmacological treatment
ventricular, decreased number of heart cells, stiffness of can cause side effects such as dry mouth, thirst, weakness,
blood vessels and valves become incompetent. Increased dizziness, lethargy, muscle aches, muscle weakness,
aortic strength can cause an increase in systolic blood tachycardia, gastrointestinal disorders and depression
pressure and can produce elevated blood pressure. A (Smeltzer, S. C., Bare, B. G., Hinkle, J.L., and Cheever,
decrease in elasticity in the aortic vessel wall shows a little 2013). Side effects in the elderly such as postural
hardening of the arteries and higher blood pressure, hypotension, depression, mental and behavioral changes,
causing the elderly to experience hypertension (Stanley, M. risk of poisoning with decreased liver and kidney function
Blair, KA. & Beare, 2006) (Stockslager, 2007) (Paneni, (Benetos, Petrovic, & Strandberg, 2019). Pharmacological
Diaz Cañestro, Libby, Lüscher, & Camici, 2017). treatment has many effects, so currently, non-
Hypertension is an increase in systolic blood pressure pharmacological therapy is chosen for hypertension. Non-
above 130 mmHg and diastolic pressure above 80 mmHg pharmacological management can be done with
(AHA, 2017). Hypertension is a silent killer where consumption of vegetables and fruits, weight loss, alcohol,
symptoms can vary between individuals and are almost the sodium and tobacco restrictions, relaxation exercises, and
same as symptoms of other diseases. Hypertension is an complementary alternative therapies (Filho, 2019)(
independent risk factor for cardiovascular disease, Fadlilah, Sucipto, & Judha, 2020).
including coronary arteries, ischemic stroke, peripheral One alternative therapy for non-pharmacological
arterial disease and congestive heart failure (Miller, 2012) management to reduce blood pressure is to do a
(Strait & Lakatta, 2012). According to WHO 2013, it is combination of warm water foot bath therapy and
estimated that in 2025 the prevalence of hypertension will progressive muscle relaxation. Scientifically warm water
increase to 1.5 billion people. has a physiological impact on the body which is smooth
blood circulation, stabilizing blood flow and heart work as

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Soak Feet with Warm Water and Progressive Muscle Relaxation

well as loading factors in the water which will strengthen comfortable ambient temperature. Therapy is given every
the muscles and ligaments that affect the joints of the body. day for two weeks. Be applied one time a day, i.e. in the
Soaking warm water is beneficial for vasodilation in blood afternoon within 15 minutes. Soak warm water is done by
flow so that it can reduce blood pressure (Mooventhan & placing the foot in the Waskom which has been filled with
Nivethitha, 2014). In contrast, progressive muscle warm water with 35-40ºC (add warm water if the water
relaxation is stretching and releasing muscle groups that temperature <35-40ºC). During the process of soaking the
will produce different sensations. The benefits of feet in warm water, respondents made progressive muscle
progressive muscle relaxation are to reduce physical relaxation, namely exercising the muscles of the neck,
stress, decrease pulse, blood pressure and breathing face, hands and feet. The steps for progressive muscle
without any side effects (Ain & Hidayah, 2018). The reason relaxation are:
for choosing a combination of a warm foot soak and 1. Bend your neck and head back slowly for 5-10
progressive muscle relaxation is because this procedure is seconds, relax and straighten your neck and head.
more practical, easy, inexpensive, affordable. This therapy 2. Bend your neck and head forward for 5-10 seconds,
can be applied to hypertensive patients and has no side relax and straighten your neck and head.
effects. Research on the combination of a combination of 3. Wrinkle your forehead up for 5-10 seconds, relax the
warm foot baths and progressive muscle relaxation with forehead muscles.
blood pressure has also never been done. 4. Close your eyes as hard as possible 5-10 seconds
relax the eye muscles
METHODS 5. Close the jaw and teeth as hard as possible for 5-10
seconds, relax the jaw muscles and bite
Study Design: This type of research is an experiment with 6. Punch the lips to the front as hard as possible for 5-10
a pretest and posttest control group design. Data were seconds, relax the lip muscles.
collected at Home for the Elderly in Yogyakarta, Indonesia, 7. Arch your back for 5-10 seconds straightens and relax
on January 24th to February 6th, 2018. your back.
Samples: The research sample was elderly who suffer 8. Push your chest forward for 5-10 seconds, relax your
from hypertension at the Elderly Home Unit Budi Luhur chest muscles.
Yogyakarta Indonesia. The samples were calculated using 9. Raise both shoulders as if to touch the ears for 5-10
the Federer formula obtained a total of 40 respondents. seconds relax your shoulders.
The sample consisted of 2 groups, intervention groups and 10. Clench your hands and bend your elbows up so that
control groups. Each group with 20 samples. Examples the muscles of the upper arms feel tight and tense for
were selected using random sampling according to 5-10 seconds relax and straighten the elbows and
inclusion and exclusion criteria. Inclusion criteria were fingers, feel your upper arms go limp.
willing to be a respondent and sign an informed consent, 11. Clench and tighten both wrists and as healthy as
age 60-90 years old, resident, healthy BMI, Javanese possible for 5-10 seconds, release the fist and feel the
ethnicity, and participate in all research processes. fingers and palms become weak.
Exclusion criteria were trauma or acute inflammation, 12. Bend your palms up with your fingers open as hard as
smoking, consuming alcohol, taking antihypertensive possible for 5-10 seconds, relax and straighten your
drugs, elderly who have limited mobility, and elderly who palms, feel your forearms and palms become limp.
undergo bed rest treatment. 13. Bend your ankles up towards your knees, feel the
Instruments: Research tools are composed of tools for tension in your calves and thighs for 5-10 minutes.
measuring blood pressure, means for soaking feet, and Feel relaxed at the ankles, explore all the pressure in
tools for progressive muscle relaxation. Blood pressure is the calves and thighs disappear.
measured with a digital sphygmomanometer, performed 14. Bend your ankles down to the floor, feel the tension in
according to standard operating procedures, and recorded your calves and thighs for 5-10 seconds, relax your
on an observation sheet. The tools and materials used to ankles, and feel all the pressure in the calves and
soak the foot of warm water are Waskom, water thighs disappear
thermometer, towels, warm water, carried out according to Blood pressure is the result of systolic and diastolic
standard operating procedures, and recorded on an blood pressure measurements. Blood pressure consists of
observation sheet. Research instruments for progressive pretest and posttest blood pressure. Systolic blood
muscle relaxation are standard operational procedures and pressure measurements are measured by researchers in
observation sheets. The result of the digital the left arm in a sitting position after resting for 5 minutes
Sphygmomanometer validity test value was 0.753 (> r before the intervention. Posttest blood pressure was
0.632), while the reliability test value was 0.865 (> r 0.80). measured by researchers in the left arm in a sitting place
Data Collection: The control group did not get any therapy after a 15-minute break of therapy. Blood pressure
for blood pressure. The intervention group received measurements were carried out on posttest 14 days after
treatment in the form of a combination of warm foot baths the last intervention.
and progressive muscle relaxation. Combination therapy of Data Analysis: The data normality test used the Shapiro
warm foot baths and progressive muscle relaxation is an Wilk test with average results, so the statistical analysis
action given to the respondent by immersing the feet in uses the Paired T-Test.
warm water together with progressive muscle relaxation. Ethical Consideration: The ethical approval was obtained
Treatment is carried out in a seated position, quiet from the Health Ethics Committee of Faculty Health
environment without interruption, adequate lighting, and Science of Universitas Respati Yogyakarta with an

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 Siti Fadlilah, Rizky Erwanto, Adi Sucipto et al

approval number of 537.2/UNRIYO/PL/X/2017. The study In the intervention group, the mean difference systolic and
permission was also obtained from the Head of Home diastolic blood pressured were decreased (-9.50 mmHg
Elderly Unit Budi Luhur Yogyakarta Indonesia with an and -1.50 mmHg). There were no significant difference
approval number 074/0725/Kesbangpol/I/2018. pretest and posttest in systolic and diastolic blood pressure
in the control group (p 0.735 and 0.480). There was a
RESULTS significant difference between pretest and posttest in
systolic and diastolic blood pressure in the intervention
Table 1 is known in all groups; the majority of samples are group (p 0.030 and 0.041). Combination of the therapy of
male and elderly. Table 2 shows the mean pre-posttest foot soaks in warm water and progressive muscle
systolic and diastolic blood pressure control group higher relaxation active to reduce systolic and diastolic blood
than the intervention group. The mean pre-posttest systolic pressure for the elderly with hypertension (0.018 and
and diastolic blood pressure control groups were 160.70- 0.023)
160.25 mmHg and 88.37-88.67 mmHg. In contrast, The
mean pre-posttest systolic and diastolic blood pressure Table 1: Distribution of Sample Frequencies based on gender and
intervention groups were 159.81-150.31 mmHg and 85.75- age
84.25 mmHg. Table 3 known there was a significant Control Group Intervention Group
Variable
relationship between gender and age to systolic and f % f %
diastolic blood pressure among the intervention group (p Gender
0.020 and 0.036). In the control group, among all gender Male 11 55.0 12 60.0
and age group were increasing difference mean blood Female 9 45.0 8 40.0
pressure. In the intervention group, among all gender and Total 20 100.0 20 100.0
age group were decreasing difference mean blood Age
Elderly 13 65.0 14 70.0
pressure.
Old 7 35.0 6 30.0
Table 4 shows that there was a decreasing mean
Total 20 100.0 20 100.0
systolic blood pressure and increased diastolic blood
pressure in the control group (-0.45 mmHg and 0.3 mmHg).
Table 2: Pretest dan Posttest of Systolic and Diastolic Blood Pressure
Pre-posttest Systolic Blood Pressure (mmHg) Pre-posttest Diastolic Blood Pressure (mmHg)
Variable
Control Group Intervention Group Control Group Intervention Group
Min 145.00-147.00 148.00-122.00 72.00-74.00 65.00-69.00
Max 192.00-190.00 181.00-172.00 110.00-127.00 106.00-103.00
Mean 160.70-160.25 159.81-150.31 88.37-88.67 85.75-84.25
SD 9.78-9.82 9.91-16.33 9.15-9.21 9.25-9.55
SD=Standard Deviation
Table 3. Relationship of Gender and Age with Pre-posttest Blood Pressure
Pre-posttest Systolic Blood Pressure (mmHg) Pre-posttest Diastolic Blood Pressure (mmHg)
Variable
Control Group Intervention Group Control Group Intervention Group
Gender
Mean Male 161.5-167.1 164-150.2 82.8-87.4 87.7-86.3
Mean Female 160.9-168.3 152.8-150.5 83.4-85.05 82.5-80.83

Difference Mean Male 5.60 -13.80 4.60 -1.4

Difference Mean Female 7.40 -2.3 1.65 1.67
p Value* 0.561 0.020 0.782 0.036
Age
Mean Elderly 163.4-166.55 162.6-157.7 87.6-89.25 88.7-85.6
Mean Old 148.3-150.98 155.16-138 85.7-86.05 82-80,83
Difference Mean Elderly 3.15 -4.9 1.65 -3.1
Difference Mean Old 2.68 -17.16 0.35 -1.17
p Value* 0.740 0.030 0.552 0.007
* Spearman Rank SD=Standard Deviation
Table 4. Effect of the combination of the therapy of foot soaks in warm water and progressive muscle relaxation in blood pressure for the
elderly with hypertension
Group Mean Systole/Diastole(mmHg) The Mean Difference Systole/Diastole P-value
Control
Pretest 160.70/88.37
-0.45/0.3 0.735/0.480*
Posttest 160.25/88.67
Intervention
Pretest 159.81/85.75
-9.50/-1.50 0.030/0.041*
Posttest 150.31/84.25
Blood Pressure
Systolic PrePosttest Control-Intervention 0.018**
Diastolic PrePosttest Control-Intervention 0.023**
*tested using Wilcoxon ** tested using Independent T-test

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Soak Feet with Warm Water and Progressive Muscle Relaxation

DISCUSSION pressure in the control group increased (0.3 mmHg), while

the intervention group decreased (1.50 mmHg).
Age of respondents divided according to the Law of the The combination of warm water foot bath therapy and
Republic of Indonesia number 13 of 1998 into the age of progressive muscle relaxation has a significant effect on
60-74 years (elderly) and 75-90 years (old). As we age, the reducing blood pressure (p <0.05). Systolic and diastolic
elderly experience a decline in function due to the ageing blood pressure has decreased compared to the beginning
process. Increased age is often accompanied by a variety of the research process. A combination of warm water foot
of chronic diseases such as arthritis, hearing loss, bath therapy and progressive muscle relaxation is given for
dementia, and the cardiovascular system (Amigo, 2012). In two weeks (14 days) to see the effects of continuous
this study, the average systolic and diastolic elderly blood treatment. This therapy is offered every day in the
pressure was higher than old age. Pre-posttest in the afternoon, starting at 14: 00-16: 30. Determination of the
control group increased either systolic or diastolic. A time of treatment is based on Snayder & Lindquist (2014),
greater increase was found in the elderly age control group which says that a good time to do the therapy is in the
(3.15 mmHg> 2.68 mmHg for systolic; 1.65 mmHg> 0.35 morning and evening.
mmHg for diastolic. average blood pressure both at pretest Warm water which scientifically has a physiological
and posttest shows higher rates than old age. The mean impact on the body is affecting blood vessels. Warm water
pre-posttest blood pressure in the intervention group makes blood circulation smooth and stabilizes blood flow
decreased. The greatest decrease in systolic blood and heart work. Warm water will strengthen the muscles
pressure in old age (-17.16 mmHg), while systolic blood and ligaments that affect the joints of the body (Lalage,
pressure in elderly age (-3.1 mmHg). 2015). Soaking warm water has effects and benefits, one of
It is known that as age increases, blood pressure gets which is a biological effect, which is that heat can cause
higher. Age affects the occurrence of hypertension due to blood vessel dilatation which can result in increased blood
structural and functional changes in the elderly on the circulation. Physiologically progressive muscle relaxation
cardiovascular system. Increased age is accompanied by can reduce oxygen consumption, metabolic rate, breathing
structural and functional changes in the cardiovascular rate, muscle tension, premature ventricular contractions,
system, including thickened left ventricle, decreased and systole and diastolic blood pressure, and increase
pacemaker cell count, arteries become stiff, dilated veins, brain alpha waves (Aji, 2016) (Hamarno, 2010).
valves become incompetent, increased aortic strength The working principle of warm water foot bath therapy
which causes an increase in systolic blood pressure that is and progressive muscle relaxation that is conduction where
disproportionate with diastolic, which results in widening of heat or warm transfer occurs from the water into the body
the arteries (Stanley, M. Blair, KA. & Beare, will cause blood vessel dilation and decreased muscle
2006)(Stockslager, 2007)(Buford, 2016). tension so that blood circulation can affect arterial pressure
There is no clinically significant difference in blood by baroreceptors in the aortic sinus. The aortic arch will
pressure in men or women. After puberty, men tend to convey impulses carried by nerve fibres that carry cues
have higher blood pressure. After menopause, women tend from all parts of the body to inform the brain about blood
to have a higher blood pressure than men due to hormonal pressure, blood volume and the individual needs of all
factors because women who have not experienced organs to the sympathetic nerve centre to the medulla so
menopause are protected by the hormone estrogen which that it will stimulate systolic pressure, i.e. the ventricular
plays a role in increasing HDL levels (Potter, Perry, muscle strain will stimulate the ventricles to contract
Stockert, & Hall, 2017). This is different from the opinions immediately. At the beginning of the contraction, the aortic
of experts. Overall, in Korea, the prevalence of valve and the semilunar valve are not open yet. To open
hypertension was higher in men (34.6%) than in women the aortic valve, the pressure inside the ventricle must
(30.8%). However, after the age of 60 years, hypertension exceed the weight of the aortic valve. Circumstances where
is more common in women than men. After the age of 60 ventricular contractions begin to occur so that with the
years, women are more likely to have hypertension and dilation of blood vessels, blood flow will smoothly and
maintain less control of hypertension than men of the same efficiently push blood into the heart thereby reducing
age range (Choi HM, Kim HC, 2017). In other research systolic blood pressure (Potter et al., 2017).
found the prevalence of hypertension was 3.9% for women A combination of soak feet with warm water therapy
and 5.2% for men. It was influenced by several things, such and progressive muscle relaxation can be done because
as the effect of modernization, lifestyle, and diet (Gurven, this therapy can maintain the elasticity of arteries. The
Blackwell, Rodríguez, Stieglitz, & Kaplan, 2012). therapeutic response of warm water foot baths and
In the study known systolic blood pressure in the progressive muscle relaxation in lowering blood pressure is
control and intervention groups decreased. The decrease to widen blood vessels. In the process of vasodilation of the
in systolic blood pressure in the intervention group was blood vessels of the sympathetic nervous system which will
more significant than in the control group (9.50 mmHg> temporarily increase blood pressure during response
0.45 mmHg). The reduction in the control group even increases the speed and strength of the heart rate and also
though no treatment was given is likely due to programs narrows the majority of arterioles (Ferayanti, 2017);
that are provided at elderly homes to control elderly blood (Khasanah, 2017). Structural and functional changes in the
pressure. The program includes the provision of low peripheral vascular system of the elderly, one of which is
sodium nutrition, physical activity, group activity therapy the aorta and large arteries, can reduce the ability to
that can relax the elderly and reduce stress. Diastolic accommodate the volume of blood pumped by the heart

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 Siti Fadlilah, Rizky Erwanto, Adi Sucipto et al

(stroke volume, resulting in decreased cardiac output and 7. Choi HM, Kim HC, K. D. (2017). Sex differences in hypertension
increased peripheral resistance. The long-stroke amount prevalence and control: Analysis of the 2010-2014 Korea National
Health and Nutrition Examination Survey. PLoS ONE 12 (5):
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C., Bare, B. G., Hinkle, J.L., and Cheever, 2013). pone.0178334
A combination of soak feet with warm water therapy 8. Ferayanti, N. M. (2017). Effectiveness of Soak Foot Therapy for
and progressive muscle relaxation is a natural, Warm Water and Relaxation of a Deep Breath Against Blood
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Budi Dharma Yogyakarta. Universitas Respati Yogyakarta.
The tools and materials needed are simple and easy to get. 9. Filho, P. et al. (2019). Non-Pharmacological Treatment For
Warm water is made sufficient by heating the water with fire Hypertension A Systematic Review. Journal of Hypertension,
and determining the temperature to be achieved by dipping 251–252. https://doi.org/doi:
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relaxation movement is also easily remembered and 10. Gurven, M., Blackwell, A. D., Rodríguez, D. E., Stieglitz, J., &
Kaplan, H. (2012). Does blood pressure inevitably rise with age?:
performed by the elderly. In the elderly, there is a decline in Longitudinal evidence among forager-horticulturalists.
all bodily functions, one of which is the ability to cleanse Hypertension, 60(1), 25–33.
toxins and remove substances that are not useful for the https://doi.org/10.1161/HYPERTENSIONAHA.111.189100
body. In this therapy, there is no substance consumed by 11. Hamarno, R. (2010). The Effect of Progressive Muscle Relaxation
the elderly, so it is safe for the body. The elderly can carry Exercises on Reducing Blood Pressure of Primary Hypertension
Clients in Malang City. Nursing Science Faculty, Universitas
out this therapy anywhere and anytime. The elderly can Indonesia.
also combine therapy with other activities such as watching 12. Khasanah, A. D. (2017). The Effect of Progressive Muscle
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Women with Primary Hypertension in Mendungan Surakarta.
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Conflict of Interest: There was no conflict of interest in at the Cellular and Clinical Levels. Journal of the American
this study. College of Cardiology, 69(15), 1952–1967.
Disclosure: This study was not a Thesis or Dissertation https://doi.org/10.1016/j.jacc.2017.01.064
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