a photo of a man with diabetes

Diabetes and massage might not seem related — but greater acceptance of massage therapy in the U.S. health care system demands massage therapists continue learning about pathologies that affect our population in a widespread manner.

Diabetes mellitus, which we’ll refer to here simply as diabetes, is one such condition. According to the U.S. Centers for Disease Control and Prevention, 29.1 million Americans, or 9.3 percent of the population, has been diagnosed with diabetes, while another 8.1 million Americans have diabetes but have not received a diagnosis.

Broadly defined, diabetes features elevated blood sugar levels and a failure to produce or utilize insulin. There are several varieties of this condition:

Type 1: Features an autoimmune destruction to pancreatic beta cells. Formally called insulin dependent diabetes and juvenile diabetes.

Type 2: Most common type of diabetes, featuring a failure of insulin production and/or inability to utilize what insulin the body does create. Formally called non-insulin dependent diabetes and adult-onset diabetes.

Type 1.5: Involves clinical features of both Type 1 and 2. Usually affects people later in life. Some doctors believe some patients diagnosed with Type 2 actually have Type 1.5 instead.

Gestational: The fetus compromises the mother’s ability to utilize sugar properly, which can have long-lasting effects on the baby after it’s born.

Insipidus: Features kidney failure or pituitary gland dysfunction.

Diabetes Signs and Symptoms

Classic signs and symptoms of diabetes include: polyuria, or excessive urination, leading to polydipsia, or increased thirst sensation; breath smelling of fruit; fatigue; lethargy; cachexia, or muscle atrophy and weight loss; peripheral neuropathies; parathesia, or skin tingling; erectile dysfunction; and blurry vision.

Common complications include: heart disease, hypertension, stroke, kidney disease, amputation, neurological disease, decreased immunity, dental disease, depression, and blindness and other vision challenges. These complications may greatly impair one’s quality of life.

Ketoacidosis is a potentially lethal complication of diabetes. Once blood sugar levels elevate to 300 milligrams per deciliter (mg/dL), not enough sugar molecules are entering cells to create energy. Cells will begin using fat molecules instead to create energy. Ketone production, a natural fatty acid metabolic function of the liver, increases to a point at which the body cannot utilize all ketone bodies. These begin to infiltrate and harm tissues, potentially leading to organ system failures.

Immobility, often a result of any combination of the complications listed above, is another debilitating complication of diabetes. Lack of movement leads to the body becoming more rigid, creating chronic shortening of myofascial tissues.

Additionally, lymphatic fluid circulation may not occur as easily, which can lead to lethargy and fatigue symptoms. Researchers at Wake Forest University conducted a four-year study with more than 5,000 Type-2 diabetic patients and discovered that a group instituting exercise in their lifestyle received greater benefits with treatment compared to a group receiving only education and counseling support.

How is Diabetes Diagnosed?

There are several different types of blood glucose tests used to diagnose diabetes. One such test is a fasting blood sugar (FBS) test, which measures blood glucose after the patient has not eaten for at least eight hours. It is often the first test done to check for pre-diabetes and diabetes. Often accompanying the FBS test is the postprandial blood sugar test, which measures blood glucose exactly two hours after eating a meal.

Also, the random blood sugar test measures blood glucose regardless of when the patient last ate. Several random measurements may be taken throughout the day. Random testing is useful because glucose levels do not usually vary widely throughout the day. Blood glucose levels that vary widely may indicate a problem.

Additionally, an oral glucose tolerance test is commonly used to diagnose pre-diabetes and gestational diabetes during pregnancy. This test is a series of blood glucose measurements taken after the patient drinks a liquid containing glucose.

Finally, a glycohemoglobin (A1c) test measures how much glucose is binding to erythrocytes circulating in the blood stream. This test can be used to diagnose diabetes; how well one’s diabetes has been controlled; and whether medication needs to be changed. The result of an A1c test can be used to estimate one’s average blood sugar level: estimated average glucose, or eAG.

Causes of Diabetes

According to the American Diabetes Association, the two most common causes of diabetic conditions are obesity and sedentary lifestyle. Other causes include genetics, trauma, and glandular dysfunction throughout the body. Over 90 percent of cases are Type 2. According to the American Diabetes Association, to be diagnosed with diabetes, a patient must meet one of the following criteria:

• Have symptoms of diabetes and blood sugar level equal to or greater than 200 mg/dL. The blood sugar test is done at any time, without regard for when the patient last ate. A deciliter is approximately 7 tablespoons of blood.

• Have a fasting blood sugar level equal to or greater than 126 mg/dL.

• Have a two-hour oral glucose tolerance test result equal to or greater than 200 mg/dL.

• Have a hemoglobin Alc level of 6.5 percent or higher.

The diagnosis of diabetes needs to be confirmed by repeating the same blood sugar test or doing a different test on another day.

Diabetes and Massage: Benefits of Healthy Touch

There are many benefits of massage therapy to the diabetic patient, including improved circulation, relaxation, and increased mobility and flexibility.

First, circulation. Increased circulation can improve cellular intake of glucose and insulin utilization; additionally, according to research titled “Connective Tissue Reflex Massage for Type 2 Diabetic Patients with Peripheral Arterial Disease: Randomized Controlled Trial,” connective tissue massage improved blood circulation in the lower limbs of Type-2 diabetic patients, and researchers found massage may be useful in slowing the progression of peripheral arterial disease.

Second, relaxation. The relaxation effected by massage can help relief the stress attendant with having chronic disease; massage calms the nervous system.

Third, mobility. The positive myofascial effects of massage therapy can increase mobility and tissue elasticity.

I advise four goals to achieve with massage protocols for diabetics:

1. Free restrictions of thick connective tissues, thereby increasing mobility of the patient.

2. Improve tissue elasticity, which enhances mobility and the metabolic capacity of the tissues.

3. Lower blood glucose levels as metabolism improves.

4. Improve effects of stress upon the body due to the chronic nature and effects of the condition systemically.

Three groups—the American Academy of Physical Medicine and Rehabilitation; the American Academy of Neurology; and the American Association of Neuromuscular and Electrodiagnostic Medicine—recently presented a research article, “Evidence-based guidelines: Treatment of painful diabetic neuropathy.” This review reviewed literature and studies on the effectiveness of massage therapy and other treatments for diabetes patients from 1960 to 2008, from various U.S. organizations. Overall, the report suggests that the drug Pregabalin was shown to be the most effective medication among all offered; and nonpharmaceutical treatments showing evidence to aid included reiki, Swedish massage, electrical stimulation and acupressure.

Other drugs offered to diabetic patients include Prandin and Starlix, which are members of a drug class called meglitinides that is designed to lower blood sugar; Metformin, an example of a drug class called biguanides that encourages organs to utilize sugar more effectively; alpha-glucosidase inhibitors, which slow the breakdown and assimilation of carbohydrates during digestion; and dipeptidyl peptidase (DPP)-IV inhibitors, aimed at lowering blood sugar levels. Common side effects of these diabetes drugs can include gastrointestinal discomfort, diarrhea, flatulence, nausea, hypoglycemia, and effects on the lungs, kidneys and liver.

Diabetes and Massage Cautions

Because Swedish massage increases circulation, the effects of any drug present within the bloodstream may amplify and actually become counterproductive toward the drug’s objectives. I advise that massage therapists not offer a diabetic patient circulatory massage within two hours of taking any aforementioned drug, because the half-life of diabetes drugs typically varies from two to eight hours depending on the drug, according to Clinical Diabetes Journal online. Massage therapists can tell their diabetic clients to schedule massage appointments according to their medication schedule.

When presenting the subject of massage therapy for diabetic patients, I encourage students to consider several questions. First, a massage therapist needs to ask questions regarding signs, symptoms and complications. A diabetic client may have loss of sensation, skin ulcers or other aforementioned complications that will greatly change clinical course of action.

Second, a therapist needs to inquire about the location of injection sites. Author and educator Susan Salvo recommends, in her text, “Massage Therapy Principles and Practice,” to avoid vigorous techniques that will stimulate tissue at recent injections and not perform friction and scar removal techniques over chronic injection sites. Common injection sites include the thighs, lumbar back, lower abdomen, scapular and brachial regions.

In conjunction with injection sites, Salvo makes an excellent point in her text, “Mosby’s Pathology for Massage Therapists,” in regard to internal and external insulin pump apparatuses. Avoid contact with the pump injection site to not interfere with the device as well as associated tubing.

Third, a massage therapist needs to determine if a heart or blood pressure condition is present. Avoid Swedish, or circulatory, massage if a cardiovascular condition presents. Other noncirculatory bodywork such as reiki or craniosacral therapy may be indicated instead. Even without a heart or blood-pressure issue, applying a slower pace to massage techniques will decrease the intensity and impact of any circulation increase.

Improve Quality of Life

A final question a therapist should consider is how recently a client has eaten prior to treatment. Suggest eating two to three hours before massage treatment; ask if the client carries glucose tablets or another source of simple sugar such as juice, fruit or sugar packets. The massage therapist can keep these simple sources of sugar on hand in case of a hypoglycemic episode.

Ruth Werner offers sound advice in her text, “A Massage Therapist’s Guide to Pathology”: Ensure physician approval is granted. A physician’s note on proper letterhead will ensure the massage therapist may safely and effectively augment the client’s treatment regimen. It may be necessary to explain to clients that massage therapy has the potential to create adverse effects when performed clinically. Should the need to speak to the physician arise, a medical release form is standard in communicating with a client’s physician. Having this form returned signed by the physician allows the massage therapist to communicate health-related topics about the client. 

Overall, research and evidence are beginning to suggest massage therapy may assist in diabetes symptom management, although most research so far conducted is not conclusive. We do know massage therapy provides stress relief and relaxation in the course of a diabetes treatment plan—and, when applied with caution and knowledge of contraindications, can help improve the diabetic client’s quality of life.

About the Author:

a photo of Jimmy Gialelis, LMT, BCTMB

Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Arizona. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches “Professional Ethics for LMTs” and many other CE classes. He is a regular contributor to MASSAGE Magazine, and his articles include “To Succeed in Today’s Massage Market, You Can’t Make These 3 Mistakes” and “These 5 Keys Will Unlock the Door to Massage Session Re-Bookings” (massagemag.com).