Diabetes and Massage

Description of Course
Designed for massage therapists, nurse massage therapists and other healthcare
professionals to recognize the benefits and contraindications of massaging clients with
diabetes.

Objectives
At the completion of this course, the motivated learner should be able to:

 Define diabetes mellitus and list types of diabetes

 Identify the groups most affected by diabetes
 Recognize the symptoms of diabetes
 Define the pathophysiology of diabetes
 Recognize the complications of diabetes
 State the differences between diabetic coma and insulin shock
 Outline treatments for diabetes
 List benefits of massage therapy for the diabetic client
 Name contraindications to massage therapy

Introduction
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose
caused from the improper use of insulin in the body. Insulin is a vital hormone that is
needed to convert sugar, starches and other food into energy needed for daily life. The
cause of diabetes is unknown, but genetics and environmental factors such as obesity and
lack of exercise play roles. Massage therapists are in a position to recognize the
symptoms of diabetes and refer their clients to the proper medical professional for
follow-up and to treat their identified diabetic client with appropriate massage techniques.

Terminology
 Diabetes- a clinical condition characterized by the excessive excretion of urine
 Diabetes insipidus- a metabolic disorder characterized by extreme polyuria and
polydipsia, caused by deficient production or secretion of the antidiuretic hormone
ADH or an inability of the kidney tubules to respond to ADH
 Diabetes mellitus (DM)- a complex disorder of carbohydrate, fat, and protein
metabolism that is primarily a result of a relative or complete lack of insulin secretion
by the beta cells of the pancreas or of defects of the insulin receptors

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 Glucose- a simple sugar found in certain foods, especially fruits, and a major source
of energy occurring in human and animal body fluids
 Insulin- a naturally occurring hormone secreted by the beta cells of the islets of
Langerhans in the pancreas in response to increased levels of glucose in the blood
 Hypoglycemia- a less than normal amount of glucose in the blood, usually caused by
administration of too much insulin, excessive secretion of insulin by the islet cells of
the pancreas, or dietary deficiency
 Hyperglycemia- a greater than normal amount of glucose in the blood
 Ketosis- the abnormal accumulation of ketones in the body as a result of a deficiency
or inadequate utilization of carbohydrates
 Pancreas- a fish-shaped, grayish pink nodular gland that stretches transversely across
the posterior abdominal wall in the epigastric and hypochondriac regions of the body
and secretes various substances, such as digestive enzymes, insulin, and glucagon
 Endocrine system- the network of ductless glands and other structures that elaborate
and secrete hormones directly into the bloodstream, affecting the function of specific
target areas
 Insulin Dependent Diabetes Mellitus (IDDM)- an inability to metabolize
carbohydrate caused by an overt insulin deficiency, occurring in children and adults
and characterized by polydipsia, polyuria, polyphagia, loss of weight, diminished
strength, and marked irritability
 Neuropathy- inflammation or degeneration of the peripheral nerves
 Non-Insulin Dependent Diabetes Mellitus (NIDDM)- a type of diabetes mellitus in
which patients are not insulin-dependent or ketosis prone although they may use
insulin for correction of symptomatic or persistent hyperglycemia, and they can
develop ketosis under special circumstances
 Paresthesia- any subjective sensation experienced as numbness, tingling, or as “pins
and needles”
 Polydipsia- excessive thirst characteristic of several different conditions, including
DM in which an excessive concentration of glucose in the blood osmotically
increases the excretion of fluid via increased urination, which leads to hypovolemia
and thirst
 Polyuria- the excretion of an abnormally large quantity of urine
 Polyphagia- eating to the point of gluttony

What is Diabetes?
Diabetes mellitus is a group of diseases in which the pancreas does not secrete enough
insulin resulting in high amounts of glucose (sugar) in the blood, from the production of
too much insulin, or a combination of both. The disease is characterized by abnormalities
of the endocrine secretions of the pancreas resulting in disordered metabolism of
carbohydrates, fat, and protein; and in time, structural abnormalities in a variety of
tissues.

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Diabetes is defined by Mosby’s Medical, Nursing and Allied Health Dictionary as a
clinical condition characterized by the excessive excretion of urine. The excess may be
caused by a deficiency of an antidiuretic hormone (ADH), as in diabetes insipidus, or it
may be the polyuria resulting from the hyperglycemia occurring in diabetes mellitus.

Over seventeen million Americans or 6.2% of the population are known to have
diabetes. Of those, about one million have Type I, or Insulin Dependent Diabetes
Mellitus (IDDM). Type 2 diabetes, also known as Non-Insulin Dependent Diabetes
Mellitus (NIDDM), affects more than 85% of the total number of diabetics. The
American Diabetes Association estimates that another six million have diabetes but don’t
know it. The average American born today has better than a one in five chance of
developing diabetes. One third of all patients have a known relative with the disease.

There are four types of diabetes. They differ in prognosis, treatment, and causative
mechanisms. The types are:

Type I. Growth Onset – Juvenile Type-Insulin-dependent (IDDM)

 Patient usually lacks insulin and requires insulin therapy.
 Abrupt or sudden onset.
 Usually begins in childhood, but could occur at any age.
 Patient more prone to ketoacidosis (high ketone and sugar level),
leading to drowsiness or coma.
 Patient dependent upon insulin.
 Thought to be an autoimmune disorder.

Type 2. Maturity Onset - Adult Diabetes Type- Non-Insulin

Dependent (NIDDM)
 Usually occurs after age 40, about 75% of adult-onset patients are
obese.
 About 90% of all diabetic cases are type 2.
 Patient may not require insulin therapy.
 Patient not usually ketosis - prone.
 Usually controlled by diet, exercise and weight loss.
 Strong familial pattern

3. Secondary – Non-Hereditary Diabetes

 Caused by damage to or removal of pancreatic islet tissue – tumors of
pancreas, surgical removal of the pancreas, pancreatitis.
 Factors that increase peripheral resistance to insulin, such as obesity.
 Disorders of the endocrine glands other than the pancreas.

4. Gestational Diabetes
 Diagnosed during pregnancy in 4% of all pregnant women during the
second or third trimesters.
 Common among obese women and African Americans,
Hispanic/Latino Americans and American Indians

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  After pregnancy, 5% to 10% are found to have type 2 diabetes

IDDM (Type 1)
Insulin-dependent diabetes mellitus is defined as an inability to metabolize carbohydrates
caused by an overt insulin deficiency, occurring in children and adults and characterized
by polydipsia, polyuria, polyphagia, loss of weight, diminished strength, and marked
irritability. The onset is usually rapid and approximately one third of the patients go into
remission within 3 months. Later, after days or years, it usually progresses quickly to a
state of total dependence on insulin.

IDDM tends to be unstable and brittle, causing patients to be sensitive to insulin, diet,
physical activity, and prone to develop ketoacidosis. IDDM may be caused by
environmental factors, such as viral infection or autoimmune disease. Between 10% and
13% of individuals with newly diagnosed IDDM have a first-degree relative (parent or
sibling) with type 1 diabetes.

Diagnosis has a seasonal distribution, with more cases reported during autumn and winter
in the northern hemisphere. Diagnosis is rare during the first 9 months of life and peaks
at age 12 years.

Clinical Manifestations and Rationale for IDDM

Manifestations Rationale
Polydipsia Because of elevated blood sugar levels, water is
osmotically attracted from body cells, resulting in
intracellular dehydration and stimulation of thirst in the
hypothalamus

Polyuria Hyperglycemia acts as an osmotic diuretic; the amount of

glucose filtered by the glomeruli of the kidney exceeds
what can be reabsorbed by the renal tubules; glycosuria
results, accompanied by large amounts of water lost in the
urine

Polyphagia Depletion of cellular stores of carbohydrates, fats, and

protein results in cellular starvation and a corresponding
increase in hunger

Weight loss Weight loss occurs because of fluid loss in osmotic diuresis
and the loss of body tissue as fats and proteins are used for
energy

Fatigue Metabolic changes result in poor use of food products,

contributing to lethargy and fatigue

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 NIDDM (Type 2)
Type 2 diabetes mellitus is much more common than type 1. The incidence has risen in
the United States since 1940 and continues to increase. Prevalence varies by ethnic
group, with the condition more prevalent in Hispanics and blacks. Onset is usually after
40 years of age, but can occur at any age. Patients are not insulin-dependent or ketosis
prone although they may use insulin for correction of symptomatic or persistent
hyperglycemia, and they can develop ketosis under special circumstances, such as
infection or stress. This type of diabetes can usually be controlled by diet, exercise and
weight loss.

The incidence in about 60% to 90% of cases are obese. Genetics and environmental
factors are involved in the onset of the disease. The risk of developing type 2 increases
10 times with severe obesity. The onset is slow and insidious.

Clinical Manifestations and Rationale for NIDDM

Manifestations Rationale
Recurrent infections Growth of microorganisms is stimulated by increased
glucose levels; impaired blood supply hinders healing

Genital pruritus Hyperglycemia and glucosuria favor fungal growth;

candida infections, resulting in pruritis, are a common
presenting symptom in women

Visual changes Blurred vision occurs as water balance in the eye fluctuates
because of elevated blood glucose levels; diabetic
retinopathy may ensue

Paresthesias Paresthesias are common manifestations of diabetic

neuropathies

Fatigue Metabolic changes result in poor use of food products,

contributing to lethargy and fatigue

Who is at Risk for Diabetes and what are their

Symptoms?
Individuals at risk for diabetes mellitus include relatives of known diabetics, overweight
individuals, mothers of large babies, or those who have had an abnormal pregnancy,
persons with early onset of arteriosclerosis, persons with frequent or chronic infections of

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the gallbladder, the kidney or pancreas, patients exhibiting temporary reduction glucose
tolerance during stress or drug therapy, and patients with vascular compromises.

The symptoms of diabetes include:

1. Frequent urination.
2. Thirst.
3. Fatigue.
4. Blurred vision.
5. Skin irritation or slow healing.
6. Weight loss.
7. Muscle cramps.

What is Happening to the Body when the Patient is

Diabetic?
The physiology of diabetes indicates that there is insufficient insulin for the following
functions:

1. Glucose cannot be properly utilized for energy.

Insulin promotes the storage of glycogen in the liver, the utilization of glucose
in the muscles, and the storage of fat in adipose tissue by enhancing the
transport of glucose across the cell wall. In non-diabetics, the rate of insulin
release from the pancreas is proportional to the amount of glucose in the
blood.

2. Fats and proteins are incompletely broken down.

This leads to an accumulation of ketone bodies in the forms of acetone and
other acids. Glucose in the blood comes from ingested carbohydrates or from
conversion of amino acids and fatty acids to glucose by the liver
(gluconeogenesis).

3. The excess glucose (glucosuria) is eliminated; along with water

and salts through the kidneys.
This causes dehydration and electrolyte imbalance.

4. The characteristic symptoms of excessive thirst, hunger, and

increased urination are directly related to the loss of fluids,
electrolytes, and sugar.
The net metabolic result of diabetes mellitus is loss of fat stores, liver
glycogen, cellular protein, electrolytes, and water.

5. Long-term diabetes leads to many changes in the body.

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 Involvement includes the large vessels in the brain, heart, kidneys, and
extremities. It also includes the small vessels in the eyes and kidneys.
Neuropathy occurs in addition to changes in the larger and smaller vessels.

Classification of Diabetic Neuropathies

It is important for massage therapists to understand diabetic neuropathies due to the
contraindication of performing massage directly on the area of neuropathy involvement.
Diabetic neuropathy is the most common cause of neuropathy in the Western world and
is the most common complication of diabetes. It is thought to be the result of the
interaction of multiple metabolic, genetic, and environmental factors. Neuropathy is
divided into two stages: subclinical and clinical.

In the subclinical stage, there is evidence that peripheral nerve dysfunctions such as
slowed motor and sensory nerve conduction exist without clinical sign. In the clinical
stage, symptoms or clinically detectable neurologic deficits are present. For the most
part, sensory deficits and symptoms are greater than motor development.

Location Characteristics
Somatic (peripheral) neuropathies

Lower extremities Most commonly bilateral, symmetric and sensory

Asymptomatic Paresthesias, progressive and irreversible, underlie the

development of neuropathic ulcers and Charcot joints
Painful Pain and paresthesias, particularly nocturnally; anorexia,
depression, and irritability; absence of knee and ankle jerk
reflexes; the greater the pain, the better the prognosis

Upper extremities Involves muscle atrophy, asthenia, sensory impairment, and

radiculitis

Asymmetric Predominantly motor involvement, absent sensory

involvement, sudden onset, severe pain, good prognosis

Diabetic neuropathic cachexia Profound weight loss with severe pain, spontaneous
recovery

Visceral neuropathies

Cranial nerves Involves cranial nerve III, leading to pain, diplopia

and ptosis

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 GI tract Involves decreased esophageal motility, delayed
gastric emptying, and diabetic constipation and
diarrhea

GU tract Insidious and progressive bladder paralysis with

urinary retention; sexual dysfunction in males

Autonomic nervous system Includes cardiovascular reflexes, anhidrosis and

vasomotor instability

What Complications can Occur in Diabetic

Patients?
Patients with long-standing diabetes mellitus experience complications such as the
following:

 Renal Disease (kidney disease called Kimmelstiel – Wilson Syndrome,

related to the thickening of the capillary basement membrane in the
glomeruli).
 Diabetic Retinopathy (impaired vision and blindness related to a
progressive impairment of retinal circulation that causes vitreous hemorrhage
and sudden vision loss).
 Circulatory Impairments (especially in the feet; Gangrene and eventual
amputation resulting from atherosclerosis and stroke).
 Poor Healing (due to impaired circulation).
 Diabetic Coma (hyperglycemia or high blood sugar).
 Insulin Shock (hypoglycemia or low blood sugar).
 Thickening or stiffening of the fascia surrounding the muscles
and organs

What is the Difference Between Diabetic Coma and Insulin

Shock?
Dangerous or emergency situations can occur in diabetic patients at any time. As a
medical professional, you need to recognize the symptoms of these conditions:

 Hyperglycemia – high blood sugar.

Can lead to a diabetic coma or ketosis. Symptoms include deep breathing;
drowsiness; headaches or confusion; a weak, rapid pulse; low blood pressure,
nausea or vomiting; flushed, dry, hot skin; and a sweetish, fruity odor of the
breath. Hyperglycemia occurs as a result of failure to take insulin, resistance

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 to insulin, infections, or stress. This is a medical emergency and the patient
needs hospitalization.

 Hypoglycemia – low blood sugar.

Can lead to insulin shock. Symptoms include pale, moist skin; hunger;
shallow, rapid breathing; irritability or nervousness; and a slow, pounding
pulse. Hypoglycemia can result in convulsions, brain damage, delirium or
even death. Hypoglycemia occurs as a result of too much insulin, not enough
food, an excessive level of insulin production by the pancreas, or unusual
vigorous activity. The majority of attacks occur in the morning or in early
evening. Give the patient orange juice or hard candy if the patient is
conscious. If unconscious, this is a medical emergency, and the patient needs
hospitalization.

There are some factors that precipitate or cover up hypoglycemia. Alcohol

can cause a drop in blood glucose levels. Beta-blockers like propranolol
(Inderal) can mask the warning signs of hypoglycemia. Less insulin may be
required before and during menses. Finally, gastroparesis delays the
absorption of food so that the peak onset of insulin action may occur before
the meal is digested.

What is the Care for a Diabetic?

Care for the diabetic is directed toward preventing and managing complications. The
three major areas of concern include:

1. Diet
2. Exercise
3. Use of insulin or oral anti-diabetic agents

Patient education is critical for the diabetic patient. Many patients are in denial of their
disease and ignore what the doctor or nurse teaches. Reinforcement is key to success.

Maintenance of diabetes centers around healthy blood glucose levels. In the non-
diabetic, blood sugars consistently remain between 65 and 100 mg/dL, rarely rising above
130 after a heavy meal. The diabetic must strive to maintain blood glucose in this
healthy range by balancing nutrition, adequate exercise, accurate use of medication, and
management of stress. There are other factors that influence blood sugar levels,
including thyroid hormones, female hormones, stress hormones, and drugs (including
various medications, caffeine and nicotine).

When blood glucose levels are low, diabetics can eat or drink a simple sugar (sugar,
honey, glucose tablet or fruit juice) to bring them back to normal. If the levels are high,
insulin may need to be injected.

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 What are Principles of Health Teaching for the Diabetic
Patient?

Maintain health at an optimal level by:

Maintaining a constant daily routine.

Getting adequate rest and sleep.
Exercising regularly and consistently.
Following the prescribed dietary regimen.
Testing urine for sugar and acetone before each meal and at bedtime.
Being thoroughly familiar with insulin injections.
Taking oral hypoglycemic medications if ordered.
Understanding the importance of foot care.
Maintaining diabetic control during periods of illness.
Avoiding tobacco, alcohol or any medications that are not ordered by the physician.

What About Diet?

Diet is an important part of a diabetic’s treatment. Most diabetics will be place on a diet
that controls their weight while factoring in their level of activity. Most patients will
follow a diet of food exchange groups and will be able to make personal selections as
recommended by the American Diabetic Association. The diabetic diet should fit the
patient’s food preferences and economic status, and emphasis should be placed on what
the patient is allowed, not on what’s forbidden. The patient is encouraged not to skip
meals or eat between-meal snacks. He should weigh himself weekly and test his urine
frequently. His family should be encouraged to assist the patient with his diet and not
offer foods that are not on the diet.

Encourage the patient to follow his prescribed dietary regimen:

1. Eat 3 or more measured meals per day.

2. Keep weight under control and weigh daily.
3. Avoid concentrated carbohydrates and foods high in cholesterol.
4. If taking insulin, encourage the patient to take in extra calories when unusual
physical activity is anticipated.
5. Eat a bedtime snack when taking insulin (if permitted).

For patients with Type I diabetes, they should be instructed to administer Regular insulin
30 to 45 minutes before eating, even when the pre-meal blood glucose level is in normal

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range (80 to 120). The peak action of Regular insulin is 2 to 4 hours after the injection.
If the 2 hour postprandial blood glucose level does not rise more than 30 mg/dL to 4o
mg/dL, the patient may experience hypoglycemia and should eat a snack. When blood
glucose levels continue to be less than 30 to 40 two hours after the pre-meal level, the
dose of insulin before eating should be reduced or additional carbohydrate, protein, or fat
needs to be added to the meal.

Hypoglycemia can also result from a meal-related insulin dose that is too high for the
actual amount of food eaten. Patients with Type I should be taught to count
carbohydrates. Most patients require one unit of insulin for each 10- 15 grams of
carbohydrates eaten.

Patients who administer more NPH before breakfast than at bedtime and are not using a
flexible insulin regimen may experience hypoglycemia before lunch or mid afternoon. If
so, patients are instructed to carry food and eat during the peak action of the insulin.

What About Exercise?

The amount and type of exercise the patient routinely participates in is balanced by the
food intake and the insulin or oral medication requirements. Exercise promotes
metabolism and utilization of carbohydrates and this reduces the insulin requirements of
the body. Exercises also enhance the effects of insulin and help regulate blood glucose
levels. Encourage patients to exercise within their limits daily and to keep an exercise
log.

Blood glucose rates can fluctuate during exercise especially during the peak action time
of insulin. Performing a self- monitoring blood glucose rate before exercising, during,
and after exercise is essential for monitoring adjustment strategies.

The insulin injection site can affect the peak action of insulin also. Abdominal insulin
injection provides the fastest absorption, followed by the arms, legs, and buttocks. It is
suggested that insulin not be injected into the site that will be exercised.

What are the Types of Insulin?

Diabetes is treated in one of two ways if drugs are used; either orally, or subcutaneously.
There are several types of insulin. They vary according to speed of action, duration of
action, and potency or strength. Insulin is administered by the patient or the nurse. Sites
of injection are rotated to prevent skin and tissue breakdown. Some patients use an
insulin pump. Some patients are able to regulate their diabetes by diet control only, but
often later in the disease they will require oral or subcutaneous insulin.

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Insulin is the active principle of secretion of beta cells in the islets of Langerhans. It is
given to patients who do not have adequate endogenous insulin. Physiologically, insulin
lowers the blood sugar by facilitating the uptake and utilization of glucose by muscle and
fat cells by decreasing release of glucose from the liver.

What Are Peak Times for Medications?

All patients should know the time or times of the day that their insulin is peaking or most
effective. The greatest risk of hypoglycemia exists when the peak action of insulin
occurs at a different time from the release of glucose to the bloodstream after a meal.
The table below shows insulin peak action:

Name Peak Action

Lispro 30 to 90 minutes
Regular 2 to 4 hours
NPH 4 to 6 hours
Lente 6 to 8 hours
Ultralente 18 hours

One cause of hypoglycemia is related to incorrect dosing, while another is substitution of

short-acting for longer-acting insulin, and changes in insulin absorption. If a patient
administers NPH before breakfast, he should be advised that the peak action of that
insulin could occur as early as 4 hours after the injection. Therefore, hypoglycemia can
occur before lunch.

If the patient administers NPH before bedtime, he might experience hypoglycemia

during the night. Nighttime hypoglycemia- nocturnal hypoglycemia- may occur because
insulin requirements are often lower from midnight to 3:00 am. However, insulin
requirements increase after 3:00 am to before waking in the morning. To prevent this
peaking at an earlier time, patients should administer the bedtime dose in the thighs or
buttocks, which can prolong insulin action. The prevention of nocturnal hypoglycemia is
important because the condition often produces rebound hyperglycemia, a counter-
regulatory hormone response to the hypoglycemia that results in elevated fasting blood
glucose levels. Rebound hyperglycemia can occur at any time during the day. All
patients on nighttime insulin should monitor an occasional blood glucose level between
2:00 and 4:00 am.

With changes in insulin replacement strategies recently, a more physiological manner of

administering insulin is recommended. This is referred to as flexible insulin regimen and
minimizes hypoglycemia.

This regimen includes 4 injections of insulin per day, with less NPH or Lente during the
day and an increased dose of NPH or Lente at bedtime. With this regimen, intermediate-
acting NPH and Lente or long-acting Ultralente acts as background insulin and is

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supplemented with rapid-acting Lispro or fast-acting regular insulin to cover high blood
glucose levels and the carbohydrate content of meals.

NPH, Lente, and Ultralente may be replaced by glargine (Lantus). This insulin has no
peak action and has a duration of 24 hours. Insulin glargine is administered at bedtime
and can be used in combination with Lispro at each meal.

Insulin pump therapy is also an option to patients with Type I diabetes. The pump
mimics the action of the pancreas by continuously infusing insulin. This constant flow is
referred to as basal or background insulin. At meal or snack time, the insulin pump is
programmed to deliver insulin to cover the carbohydrate content ingested. The risk of
hypoglycemia is minimal with this therapy because the basal rate or rates are set to
maintain stable blood glucose levels in the fasting state. For patients requiring less
insulin from midnight to 3:00 am, yet needing an increase in insulin before waking,
insulin pump therapy is the only delivery system that can be programmed accordingly.
Most pumps infuse Lispro.

The ABC’s of Diabetes

Lots of people think of diabetes as just a “sugar disease,” a failure of the body to manage
the levels of glucose in the blood. It is apparent now that diabetes has a lot more to it
than just monitoring the blood sugar. Other important components of care include
controlling blood pressure and cholesterol levels. The American College of Physicians
issued guidelines that help ensure that doctors treating diabetics take all the aspects of the
condition into account.

Diabetes triggers a wide range of health problems. Uncontrolled glucose levels increase
the risk of blindness, kidney disease and nerve damage. Patients with type 2 are much
more likely than the general population to develop high blood pressure, which increases
the risk of heart disease and stroke. High blood pressure is even more damaging in
diabetics than in non-diabetics.

Normal blood pressure is 140/90 mmHg or lower; the new guidelines suggest that
diabetics set their goal below that, at about 135/80 mm Hg.

Cholesterol counts must be kept in check also. The American Diabetes Association
recommends to keep LDL (bad cholesterol) below 100 mg/dL. Note that this number is
different from total cholesterol, which shouldn’t be more than 200 mg/dL.

Diabetics have to keep an eye on their glucose levels. The new gold standard is the A1C
test, which measures levels of a substance in the blood called hemoglobin A1C. The
A1C test tells you how well you have been controlling the glucose levels for the post
three months. The ideal number is below 7%. Human nature has shown that type 2
diabetics get serious about taking their medication only the day before a doctor’s

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appointment so they can pass the test. This new test will put a stop to self-defeating
habits.

Target Levels
A1C Less than 7%
Blood pressure Lower than 135/80
LDL cholesterol Lower than 100

What Other Care Is Important?

Other care for the diabetic includes observation of the patient’s circulation, especially in
the feet. If not monitored closely, gangrene may lead to amputation. Give the following
special attention to the diabetic patient’s feet:

1. Observe frequently. Look for cuts, redness, or sores. Report anything

unusual to the physician.

2. Encourage the patient to wash his feet daily and dry carefully, especially
between the toes. Moisture can lead to infection.

3. Remind the patient to check his shoes. They should fit well without causing
blisters. Socks and stockings should be clean without holes in them.

4. The patient should not go barefoot.

5. If the patient’s toenails need to be cut, refer them to a podiatrist.

6. Encourage the patient to monitor his blood and urine regularly.

7. Report any complaints of pain immediately to the physician.

8. Be sure clothing and sheets do not cut off blood circulation.

9. Encourage good skin care.

10. Remind the patient to maintain proper intake of food.

11. Report any changes in skin color or temperature to the physician. Check for
signs of infection.

12. Report any changes in activity or mood to the physician.

13. Protect the patient from overexposure to heat or cold.

14. Report excessive itching to the physician. This may indicate excessive blood
sugar.

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 15. Encourage the patient to avoid tobacco. Nicotine constricts blood vessels.

16. Report anything abnormal!

17. Refer Out When In Doubt!

Sample Diabetic Meal Plan

The physician will order a calorie-restricted diet designed to limit the amount of
carbohydrates consumed and it will be individualized to meet the activity level of the
patient. The patient should follow the prescribed dietary regime and remember to eat
three meals per day at consistent times. Patients should avoid sweets and foods with
cholesterol. A sample menu for one day might be:

Breakfast
Oatmeal with Honey and Skim Milk
Orange Juice
1 Slice Whole Wheat Toast
Decaffeinated Coffee
Lunch
Vegetable Soup
½ Tuna Sandwich with Cheese
Apple
Skim Milk
Dinner
Baked Chicken without Skin
Peach with Cottage Cheese
Green Beans
Lettuce and Tomato Salad
Roll
Iced Tea
Snack
Banana
Graham Crackers

What are Long Term Complications of Diabetes?

There are many risks involved with diabetes. Heart disease, stroke, kidney failure,
circulation problems, and blindness are common. If circulation problems are not treated,
it can result in gangrene and amputation of feet or legs.

Diabetes is the number one cause of blindness in the U.S.: over half the heart attacks and
three-fourths of all strokes are related to diabetes. The majority of amputations
performed for gangrene are the result of diabetes; diabetic neuropathy and neuropathy
complications are significant factors.

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Depression is three times more common among diabetics than the general population. It
may result as a consequence of lifestyle adjustments. Managing diabetes is stressful and
time consuming and the dietary restrictions imposed on diabetics can trigger depression.

Patients with diabetes are prone to atherosclerosis, high blood pressure and edema, and
typically lose sensation in extremities in advanced stages. Vigorous massage while
performing vibration or tapotement must be carefully administered because it can damage
already compromised blood vessels.

If your patient is taking insulin, massage can increase circulation and speed up insulin
absorption thus leading to a low blood sugar reaction.

The life expectancy among patients with diabetes is approximately one third less than
that of the general population.

Massage Therapy and Diabetes

Touch has been proven to be beneficial for everyone. The physical and psychological
effects are well known. It is no different in the diabetic patient except that the therapist
needs to keep in mind that there are complications that can occur and contraindications.
Armed with this knowledge, you will be able to safely perform massage therapy on your
patients that are diabetic. Perhaps you will even refer undiagnosed diabetic patients to
their physician for a proper diagnose, but like all clients and patients, REFER OUT
WHEN IN DOUBT.
Massage that is gentle and relaxing benefits diabetic patients. Be aware that often
diabetic patients cannot give accurate feedback about pressure due to neuropathy, so the
lighter the massage the better. Shorter duration massages also may serve the diabetic
client better than the traditional one hour massage.

Massage can be beneficial to patients with peripheral vascular disease (poor circulation in
hands and feet) and neuropathy (decrease or change in sensation in the hands and feet).
Assist the patient off the massage table at the conclusion of the massage because he
might experience light-headedness when getting up due to hypoglycemia.

Encourage your patients to bring their medication to the massage appointment in case
there is an emergency. Increase circulation can speed up insulin absorption and may
cause a low blood sugar reaction.

Inform your patients if you note any contusions or breaks in the skin, especially if they
are not able to see or feel all parts of their body.

It is important to get a physician referral for known diabetics in case there are
contraindications. As always, spend time on the first appointment to determine the
patient’s state of health. Always be conservative when making a decision to massage a
new patient.

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Mary Kathleen Rose, CMT recommends using a combination of Swedish massage,
Shiatsu, Comfort Touch, Polarity balancing, body energy therapies, Manual Lymph
Drainage, Therapeutic Touch, deep tissue therapy, Reiki and craniosacral therapy. All
these modalities should be individualized for each client.

Benefits of Massage Therapy

According to Mary Kathleen Rose, CMT and a diabetic herself, “As with any population,
massage is a beneficial complementary therapy- diabetics, however, can find the results
especially helpful.”

 Circulation- There is no getting around the fact that massage can increase
circulation, thereby encouraging the efficient transport of oxygen and nutrients
throughout the body. Improved circulation, in turn, improves the cells’ insulin
uptake.
 Relaxation- The benefits of relaxation should not be underestimated,
especially within the diabetic community. Consider the physical and
psychological stresses of living with a debilitating disease and the need to self-
medicate and monitor on a daily basis, as well as the burden diabetes puts on the
body and its systems. That said, it’s easy to see the therapeutic correlation
between massage and diabetes. With the release of endorphins, the nervous
system calms, there is a reduction of stress hormones and the diabetic client can
find a homeostasis with their blood sugar levels.

 Myofascial effects- For the client with diabetes, you may likely find a
thickening of their connective tissue caused by increased blood sugars.
Massage will help to increase mobility and tissue elasticity that has been
hindered by that thickening effect. Of course, a good exercise program- with an
efficient stretching regimen- will also benefit your client.

Contraindications and Concerns

Blood glucose levels change during and after a massage, so it is important to encourage
the patient to continue to check his levels. Most patients will find their blood glucose
level dropping 20 to 40 points after a massage. Use extreme caution when getting the
patient off the massage table since he/she may be very relaxed and somewhat disoriented.

Look for signs of hypoglycemia or low blood sugar because it can lead to
unconsciousness and sometimes death. Because diabetes is unpredictable, look for the
following signs that indicate hypoglycemia:

 Excessive sweating (skin feels clammy)

 Headache or faintness
 Unable to awaken

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  “Spaciness”- patient may talk or move slowly, or be unable to speak
coherently
 Change in personality
 Irritability
 Rapid heart rate

After completing the massage, ask the client how they feel. If the client does not seem
fully cognizant, be prepared to assist the client. If the blood sugar is low, the diabetic
needs sugar fast. Fruit juice, honey, a sugary drink like orange juice, or glucose tablets
may help. Many diabetics carry their own glucose tablets. (Perhaps this is a good
question to ask on their first visit.) Changes can be seen immediately after the diabetic
ingests some sugar. It is wise to assure that the client is feeling better before leaving the
massage room. They may need to eat more or to check their blood glucose level again.
Some clients will continue with a drop in their blood glucose level, so it is important to
encourage them to continue their blood sugar checks throughout the day after the
completion of a massage.

Encourage diabetics to bring their medications to each massage appointment.

Be cautious when massaging the diabetic’s feet and hands since there may be some
peripheral neuropathy which makes them very sensitive. Try using the light and
nurturing techniques of Comfort Touch or Caring Touch. (See CEUonline’s “Caring
Touch for the Elderly, Frail or Dying Client” or read The Gift of Touch- Comfort Touch:
Massage for the Elderly and the Chronically Ill by Mary Kathleen Rose, CMT.)

Your communication with the diabetic client is extremely important. Ask for feedback
and listen to their suggestions. Most will tell you their needs and special concerns. That
will help you give a personalized massage that the client will enjoy and therefore will
come back.

Let the client know it is okay to stop during the massage and drink some juice. Also be
open to the idea that the massage session may be better tolerated if it is shorter than the
usual hour massage.

And, refer out when in doubt.

Case Studies

Scenario #1

Jane S. is an RN and LMT and works for a home health agency. Her primary role is to
see diabetic clients and to provide diabetic teaching. In her role she sees many clients of
all ages, but primarily geriatric clients. One client, Mrs. B. is 72 years old and a brittle
diabetic. She was diagnosed with her illness 30 years ago and is IDDM. She has been
giving her own insulin injections and things were working well until 2 months ago.

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Mrs. B. lost her husband 4 months prior to being seen by the home health agency. She
was hospitalized for 3 days for diabetic coma and discharged to her home with orders for
RN visits for stabilization of her blood glucose levels. On the first visit Jane S.
performed an assessment that indicated that Mrs. B. was not able to give her own insulin
injections, was clinically depressed, angry, on the verge of skin breakdown on both heels,
and irritable.

After much discussion, a care plan was developed for Mrs. B. that included an RN visit 3
times per week and a relaxing massage once per week. Jane S. began her visits and
found that Mrs. B. benefited from her visits for both physical and psychological reasons.
Jane S’s major concern was the beginning of skin breakdown on the patient’s heels.
After adjusting the insulin schedule, monitoring her diet, encouraging exercise s and
starting light massage, things started to improve. Mrs. B. even began to give her own
insulin injections and became much more sociable by returning to the club in her
community.

The major concern for her treatment became the breakdown on Mrs. B’s heels. The area
was reddened and the skin was intact. Jane S. initiated light massage over the areas and
performed Therapeutic Touch and Caring Touch. The physician was pleased with her
progress and Jane S. was discharged from the home health agency with the
recommendation that she continue to see a massage therapist, stay on her medication,
exercise and nutrition regimen.

Mrs. B continued to see a massage therapist and continued to do well with

encouragement. Her grief lifted and her enthusiasm for life returned.
This scenario had a happy ending, but not all cases turn out positively despite all medical
efforts.

Scenario #2

Wanda B. is a new massage therapist in a spa. She was not experienced with massaging
diabetics and neglected to perform an assessment on Sarah’s first visit. Most of her
clients were one-time clients and there had been no problems up until this time.

Sarah presented to the massage area of the clinic after having had a facial and body scrub.
She came hurriedly into the massage room apologizing for her lateness. Her body scrub
took more time than expected. Sarah climbed onto the massage table and proceeded to
get lightheaded after a brief period of Swedish massage. She then became cold, clammy
and disoriented. Wanda set her up quickly and assisted her off the table when much to
her surprise Wanda fell to the floor.

Sarah screamed for help and a seasoned massage therapist who was in session in the
adjoining room came running to her aid. The experienced therapist asked Wanda if she
had any medical problems and Wanda replied that she was a diabetic. It was discovered
that Wanda had neglected to eat breakfast or lunch, had not taken her oral medication
and was suffering from low blood sugar.

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Fortunately, Wanda was not injured in the fall and after drinking some orange juice she
became alert and oriented. She was sent home without completing the massage. A call
to her home the next day assured everyone in the spa that Wanda was okay and she was
invited to return for her massage the next week.

Sarah learned a valuable lesson. She now realizes that every client is an individual and
that an initial assessment is vital. She also decided to attend a seminar on diabetes and
massage and vowed to learn as much as she could.

Scenario #3

Clara M., RN, LMT, owns a private home health agency. She frequently sees patients
with diabetes and other long term conditions. One day the daughter of an 85 year old
man called to say that she wanted home health aides to come to her father’s house 3 times
per week for personal care and to prepare meals.

Clara went to the patient’s house to perform an initial assessment and develop a plan of
care for the home health aides. She found deplorable conditions. The patient had not
been bathing, his house was a mess with clutter and garbage everywhere, and his meals
consisted of whatever the neighbors could bring to him. Upon examination, Clara
smelled a fruity odor on his breath, found 3 cm. openings on both feet, cold hands and
feet and elevated blood pressure. It was apparent that this patient had complex medical
problems and needed immediate attention.

The daughter was called and a doctor’s appointment was arranged. The daughter rarely
visited her father because the father did not want her interfering with him. The doctor
diagnosed type 1 diabetes, ordered treatment for the lesions on the feet, diabetic diet,
exercise, and insulin injections.

Clara began the visits with a discussion about the need for insulin, how it would help
him, and explained the care of his feet. The patient was grateful for help and even
enjoyed letting the home health aides bathe him and prepare his meals. Clara suggested
massage to the doctor to increase the circulation to the feet and hands, and the doctor
agreed. She then began a weekly massage consisting of Swedish, acupressure and
Therapeutic Touch. Unfortunately, the lesions on his feet continued to enlarge and it
wasn’t long before they became infected.

After 3 weeks of antibiotic treatment, it was apparent that the patient’s circulation was
completely compromised and that the medication and massage were not helping. One of
the home health aides reported that the patient fell out of his wheelchair and that the
lesions were bigger. On Clara’s last visit to the patient’s house, the patient complained of
excruciating pain in his feet and an odor of decaying flesh was noted. Both lesions on the
feet were black and oozing. The patient was admitted to the hospital where gangrene was
diagnosed. Both legs were amputated below the knee.

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This was a sad case of diabetes that was left untreated for years. An earlier diagnosis
may have saved his limbs. The patient is now in a Veterans’ home and his daughter visits
once a month. There is no massage therapist there to provide care and the daughter
refuses to pay for it.

Scenario #4

Bob J. is a massage therapist who often performs post-event massage. On one occasion,
he was providing massage after a 10 k run. It was a warm day with the temperature in the
high 90’s in south Florida with humidity to match.

One of the runners was 15 years old and came to the tent where Bob was working. The
runner looked drained and exhausted and was sweating profusely. This, however, was
not unusual. Many of the runners looked this way. Bob began his massage on the
runner’s legs and the runner became completely disoriented and lapsed into a coma. An
ambulance was called and the runner was transported to the emergency department of the
local hospital.

Before he left, Bob asked the mother for her phone number and said he would follow up
with her to check on her son’s condition. After the event, the two massage therapists
discussed the case and decided that there was more to this incident than just the running.

Bob called the mother the next day and found out that her son had been diagnosed with
type 1 diabetes and that he had been placed on insulin. He was improving and would be
discharged in 3 days.

Bob kept in touch with the runner’s mother and offered to assist with his treatment by
offering massage. The mother agreed and after a week Bob went to his home for his first
massage. That began a long relationship between the two. You see, Bob was a diabetic
also that had been diagnosed at an early age and had learned to live with his illness. He
could relate his experiences and help the new young diabetic cope with all the changes to
his body.

Footnote: The runner continued to participate in meets and followed his medication and
diet regimen consistently. He looks up to Bob and sees him as a role model and is even
thinking of becoming a massage therapist when he graduates.

Conclusion
The United States has the highest incidence and mortality of diabetes in the world.
Millions of people are unaware that they have the disease. Although forms of the disease
can occur at any age, it is most common in the middle and later years. About 80% of all
diabetics are over forty years of age.

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The reason why diabetes develops is not fully understood. The following factors play a
part in the incidence of diabetes:

 Heredity
 Obesity
 Age
 Infectious Agents
 Autoimmune Reactions

In diabetes, there is insufficient insulin for certain metabolic functions. Managing

diabetes demands more of a commitment from patients than almost any other illness, but
working on the ABC’s- A1C, blood pressure and cholesterol- the chances of staying
healthy improve. As massage therapists, it is important to understand these metabolic
functions and recognize signs and symptoms of problems with our diabetic patients.

References

Fields, Tiffany. Touch Therapy. Churchill, Livingstone. 2000.

Fritz, Sandy. Mosby’s Fundamentals of Therapeutic Massage. Mosby.

1995.

Fritz, Sandy. Mosby’s Fundamentals of Therapeutic Massage. Second

Edition. 2000.

McCance, Kathryn and Huether, Sue. Pathophysiology. The Biologic Basis

for Disease in Adults and Children. Second Edition. Mosby. 1994.

Rose, Mary K. “Diabetes A Personal Story” Massage & Bodywork

Magazine. February/ March 2001.

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Salvo, Susan G. Massage Therapy Principles and Practices. W.B. Saunders.
1999.

Stevens, Sabrina. “Chasing the Dragon”. Massage and Bodywork.

Dec./Jan. 2001.

Whiting, Valerie. “A Journey Past Pain”. Massage and Bodywork. April/May 2001.

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