Nearly every family in America is touched by diabetes.
Nearly 10 percent of our total population and 26 percent of our elders have been diagnosed with either Type I or Type II diabetes.
More than a million Americans are newly diagnosed each year, and diabetes remains the seventh leading cause of death, according to the American Diabetes Association.
The cost of diabetes care, for the individual and the health care system as a whole, is staggering: Someone diagnosed with diabetes will pay twice as much for medical care, around $8,000 per year just for diabetes-related care.
Diabetes care costs the American health care system $232 billion each year, in addition to $70 billion in diabetes-related lost productivity.
To understand how diabetes affects the person diagnosed, it’s helpful to review some basic information about hormone actions, and terminology that describes some of the characteristics of diabetes for your diabetic client.
Glucose is a simple sugar that serves as the major energy source for living cells. It is transported in blood to all the cells of the body. Cells cannot function without glucose, but excess glucose can cause cell death.
Insulin is a hormone produced by beta cells in the pancreas. Insulin is secreted into the bloodstream to lower excessive blood levels of glucose.
Glucagon is a hormone produces by alpha cells in the pancreas. Glucagon is secreted into the bloodstream to raise low blood levels of glucose. The interplay of insulin and glucagon maintains homeostasis by ensuring an optimal blood level of glucose.
Type I diabetes is an autoimmune condition in which the body’s own immune system attacks pancreatic beta cells, rendering them incapable of producing insulin. Fewer than 10 percent of all diabetes diagnoses are of Type I
Type II diabetes is a condition resulting from insulin resistance: Beta cells are capable of producing insulin, but because target cells have become unresponsive to its effects, it accumulates in the blood.More than 90 percent of all diabetes diagnoses of diabetes are of Type II (see the accompanying article for specific information about Type II diabetes).
Prediabetes is the designation applied when blood glucose tests reveal ongoing higher-than-normal glucose in the blood, with no sign of damage to pancreatic beta cells and not high enough to consider as a diagnosis of Type II diabetes. The latest estimates indicate that perhaps more than 85 million American adults and children fall into the prediabetic category.
Hypoglycemia is insufficient blood glucose (<100 mg/dl) and excess blood level of insulin.
Hyperglycemia is excess blood glucose (>120 ng/dl) and insufficient blood level of insulin.
Ketoacidosis represents the build-up of acids called ketones in the bloodstream and urine, caused by persistent hyperglycemia. Ketoacidosis often indicates the onset of Type I diabetes and, without intervention, can lead to coma and even death.
Type I Diabetes
Also called juvenile-onset or insulin-dependent diabetes, Type I can strike anyone at any age.
Type I diabetes is chronic, irreversible, and can be deadly. Risk factors are thought to include a genetic predisposition (family history) coupled with a triggering infection, which may be viral, such as Epstein-Barr, Coxsackie or rubella.
Some studies tie early-onset Type I to the introduction of cow’s milk or grain cereal before age one.
Symptoms of Type I tend to be sudden and rapidly progressive: extreme thirst (polydipsia), intense hunger (polyphagia), and frequent, heavy urination (polyuria), accompanied by deep fatigue, muscle weakness, marked irritability, and a hyper-emotional state.
Vision may become blurred as the lens is progressively dehydrated.
By the time ketoacidosis develops, the breath will smell very sweet, breathing will become “robotic” as the respiratory system attempts to rid the body of excess carbon dioxide, flesh becomes mottled due to vascular dysfunction, and loss of consciousness can occur.
Treatment for Type I diabetes is ongoing administration of synthetic insulin, to provide what the pancreas can no longer supply.
Today, the types of insulin available—rapid-acting, short-acting, intermediate-acting, and long-acting—allow for precise control of blood glucose levels over a predicable period of time.
Some diabetic clients with Type I administer each individualized insulin dose (containing precisely calibrated types and amounts of insulin) via intramuscular injection, at pre-set times during the day or in response to blood glucose monitor readings, rotating among injection sites.
Others use a programmable pump that delivers preset levels of insulin continuously into the body through a slender, flexible tube inserted into the abdomen.
Such continuous insulin delivery can be adjusted to compensate for extra calories or physical activity, providing effective glucose control and greater day-to-day dietary flexibility for the wearer.
Blood Glucose Monitoring
A diabetic client with Type I diabetes monitors blood glucose using a glucometer, a digital, programmable device that provides instant, precise measurements.
To use a traditional glucometer, a drop of blood is gathered using a spring-loaded lancet that pricks just beneath the skin, usually from a fingertip, and then applied to a strip inserted into the device.
A recently FDA-approved glucometer eliminates the finger prick through the use of a self-adhesive sensor that “reads” blood glucose levels. Newer insulin pumps include a continuous glucose monitoring system that can reactively control insulin dosage, approximating pancreatic function.
Despite close monitoring and condition management, Type I diabetes can result in serious complications over time.
A client with Type I diabetes is at significant risk for heart disease, hypertension and stroke, kidney failure requiring transplant, neuropathy, retinopathy leading to blindness, diabetic capsulitis, and frequent leg ulcers that can lead to amputation.
Damage to the vagus nerve can cause arrhythmia, anhidrosis (inability to cool the body by sweating), gastroparesis (poor movement of food through the GI tract, leading to malnutrition), and respiratory distress.
Because Type I diabetes is an autoimmune condition, susceptibility to infections is high and the ability to fight them is compromised.
Massage Treatment Planning for the Diabetic Client
Massage therapy has many benefits for a diabetic client with Type I diabetes, as it temporarily increases circulation to the extremities, encourages effective peristalsis, relieves pain, and encourages the relaxation response.
It is vital for client safety, however, that cautions and contradictions are understood and respected, that certain assessments are performed, and that complications created by diabetes are addressed in the treatment plan.
During intake, establish whether the client has been diagnosed with Type I or Type II; this will help guide the treatment plan. For a client with well-managed Type I diabetes, not every caution or contraindication suggested below may be necessary.
It is always wise, however, to regularly update health and medication information with any client who has a chronic health condition, to ensure that changes are documented and addressed in the treatment plan.
Even for a diabetic client whose diabetes is well-managed and free from complications, it is important to guard against transmission of pathogens.
Defer treatment if you have or have been exposed to an infection condition.
Because the effect of massage therapy on blood glucose levels in a client with Type I diabetes is unknown, it is prudent to perform massage only when blood glucose levels are with the normal range, generally accepted to be between 100-120 mg/dl [Figure 2: blood glucose levels].
Ask the client to check the blood glucose level prior to massage and, if below 100 mg/dl, defer massage until the client has consumed a carbohydrate snack, fruit juice, or non-diet soda.
Avoid extremes of temperature and pressure; the client may be unable to provide accurate feedback about pressure, pain, and temperature. When using thermotherapy, keep the temperature range narrow: warm (92-100 degrees F) or cool (70-80 degrees F), not hot or cold.
Avoid areas of poor sensation or hypersensitivity to touch, and keep touch and lubricant a hand-width away from the site of a recent blood draw, insulin pump stoma site in the abdomen, pump tubing, or any unhealed lesion or ulcer.
Keep in mind that skin over healed ulcer sites remain vulnerable; avoid pressure or shearing force in these areas.
If a client injects insulin rather than using an insulin pump or has a long history of insulin injection, residual insulin can accumulate at often-used injection sites, shown here, resulting in fibrotic tissue at the sites.
Such sites are contraindications to touch: avoid direct manual pressure over this tissue, which may release the accumulated insulin, potentially endangering the client by causing significant, unintended hypoglycemia.
Symptoms of significant hypoglycemia require immediate medical intervention. Stop the massage, call 911, and follow the instructions of emergency medical personnel.
Symptoms of hypoglycemia can progress rapidly, from pallor, sweating, and extreme hunger, to irritability, muscle weakness; from nausea, vomiting, confusion, to seizure, loss of consciousness, and eventually, coma.
Identify recently used injection, blood draw, and pump stoma sites, to avert possible transmission of pathogens. Examine legs, feet, and toes very carefully before direct touch: Any cut, ingrown toenail, or fungal infection can quickly become serious and must be avoided.
Palpate areas of neuropathy, to gauge appropriateness of touch and pressure. When complications have developed, evaluate side effects of additional medical treatments and medications.
Certain long-term complications require additional treatment considerations. An in-depth initial health history and interview are recommended, with updates as conditions develop.
For cardiovascular conditions, avoid deep pressure, prolonged duration of massage, and techniques that may produce significant systemic responses. For a client on renal dialysis, avoid touch near dialysis ports (on the arm or the abdomen, depending on the type of dialysis).
Following kidney transplant, take steps to prevent pathogen transmission. When a client has been approved to receive massage following amputation, ask permission before working on or near the site.
Protect any prosthesis from lubricant contamination, and handle with care and respect. Prevent extremes of touch, temperature if sensory function is not intact, and avoid turning, repositioning that challenges mobility.
Monitor the client’s ability to provide accurate feedback regarding pressure, temperature, pain and, if phantom pain occurs, massaging the intact limb may provide relief.
Benefits of Massage
With caring, comprehensive treatment planning, clients with Type I diabetes can fully experience the benefits of massage therapy that contribute to well-being and overall health.
About the Author
Julie Goodwin, LMT, is an author, bodywork educator, National Certification Board for Therapeutic Massage & Bodywork-approved provider and creator of TxPlanner.org. Her 31-year massage practice focused on elders and people in treatment for cancer. She has presented at American Massage Therapy National Conventions and the AMTA Schools Summit, and is the 2016 Alliance for Massage Therapy Education Educator of the Year. She wrote “Massage Treatment Planning for the Diabetic Client: The 4 Steps You Must Understand” for the February print issue of MASSAGE Magazine, and “Minimize Fall Risk in Elderly Clients” for massagemag.com.
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