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Diabetes
Massage as an Adjunct Treatment

By Mary Kathleen Rose, CMT

Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


What is Diabetes?
Diabetes is a disease of impaired carbohydrate metabolism that results from inadequate production or utilization of the hormone insulin. This vital substance is necessary to convert food into energy by facilitating the transfer of glucose (sugar) from the bloodstream into the body's cells. Of the 16 million people in the United States with diabetes, most can be categorized into one of the following types:

Type 1 diabetes, also known as Insulin Dependent Diabetes Mellitus (IDDM), affects 10 percent-15 percent of the total number of diabetics. Because of damage to the insulin-producing islet cells of the pancreas, little or no insulin is produced. As with Type 2 diabetes, there is a genetic predisposition to the disease. Often the onset of the disease occurs following significant physical or emotional stress. These individuals must take regular injections of insulin. Type 1 diabetes tends to present itself in childhood or early adulthood.

Type 2 diabetes, also known as Non-Insulin Dependent Diabetes Mellitus (NIDDM), affects more than 85 percent of the total number of diabetics. In these people, the pancreas is producing insulin, but the cells that use insulin create resistance to it. Because of this insulin resistance, glucose levels are elevated in the bloodstream. Type 2 diabetics may take one or more oral medications designed either to decrease insulin resistance or enhance the cells' sensitivity to insulin. They may also need to take insulin by injection. Generally, Type 2 diabetes has a slower onset than Type 1 diabetes, and is more prevalent in the older population.

While the types have different pathologies, they have the same common symptom, that of elevated blood glucose which has many short- and long-term ramifications. If blood glucose is elevated, the cells are essentially starved for energy, so the person is fatigued. Excess sugar spills into the urine, causing frequent urination and excessive thirst. When these signs become tangible, the disease may be diagnosed with a simple blood test to determine glucose levels in the blood.

Over time, elevated glucose levels lead to long-term complications of the disease by causing damage at the cellular level. Cells especially prone to damage are in the eyes, kidney, heart, blood vessels and nervous system. Without good blood sugar control, the diabetic becomes more vulnerable to retinopathy and neuropathy, as well as kidney and heart disease. Other changes may occur in the connective tissue of the body, leading to thickening or stiffening of the fascia surrounding the muscles and organs.


Treatment
Treatment of diabetes centers around normalization and maintenance of 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 be conscientious to maintain blood glucose in this range, by balancing several factors. These include balanced nutrition, adequate exercise, accurate use of medication (whether injected insulin, use of an insulin pump or ingestion of oral medications), and management of stress. There are other factors that can affect blood sugar levels, including other hormones (e.g., thyroid hormone, female hormones, stress hormones) and drugs (including medications, nicotine and caffeine).

Since the early 1980s, diabetics have had access to blood glucose monitors and test strips to check their blood glucose levels (BGs). If the BG levels are low, they can eat or drink a simple sugar (sugar, honey, glucose tablet or fruit juice) to bring them back into the normal range. If they are high, they may need to inject more insulin or otherwise adjust their treatment.


Massage Therapy and Diabetes
So how does massage therapy come into the picture of diabetes treatment? What are its benefits for the diabetic? What does the diabetic need to know about massage? What does the massage therapist need to know to successfully and safely treat the person with diabetes? Because of my personal experience as a diabetic (see sidebar) and as a massage therapist, I feel I am in a unique position to share my observations. My initial experience in the hospital taught me the value of the simplest touch. While in the emergency room and intensive care, I was so grateful when someone -- a friend or medical staff person -- would touch me. Unable to speak or communicate my fears, it was helpful to feel the comfort and assurance.

Even as a newly diagnosed diabetic, I felt tremendous changes in my body. In the short term, I began to feel increasing strength and the recovery from diabetic ketoacidosis. Insulin by injection is different than the body's own insulin. In some ways I felt as if I had a new body, running on a new and different fuel. It was as if the texture of my muscles and fascia had changed, becoming a little more dense. I had just completed a year-long training in massage therapy, and some of these changes were observable by friends whom I had met as fellow massage therapy students.

Over the years, I have benefited in many ways from receiving massage. I currently teach therapeutic massage in a number of massage schools and medical settings, and have been in a position to educate massage therapists and other health professionals about the benefits of massage for diabetics, as well as to inform them of special concerns when working with this population.


The Benefits of Massage for People with Diabetes
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.


The Diabetes Clinic
I have had the opportunity over the last year to witness the therapeutic effects of bodywork on people with diabetes at a massage clinic I supervise in Colorado. Here, student interns put their skills to work on clients with diabetes and we have observed and recorded changes in blood sugars.

With basic instruction in Swedish or integrative therapeutic massage, the student interns have an opportunity to hone their skills as well as be involved in a community research project.

After following standard intake and protocol, the clients receive traditional Swedish massage strokes (including gliding, kneading and wringing), as well as some acupressure and contact pressure.

Most of the clients in the study were Type 1 diabetics, ranging in age from 25 to 50 years old. Hands-on session time lasts 45 to 50 minutes, and each client is required to test their blood glucose levels before and after each session, in addition to noting their food habits prior to the massage (time and amounts ingested) and their last injection of insulin.


Changes in Blood Glucose Levels
More than 20 clients with diabetes have been a part of the informal study, each receiving at least one massage, some more than one. When self-reporting, those receiving massage said they had greater levels of physical and emotional comfort after the session.

Because of the blood glucose testing, the clinic has also been compiling useful data on changes that occur with blood glucose levels during massage. My preliminary observations include: Massage therapy appears to lower blood sugar levels by approximately 20-40 points, all other factors being equal. While this is not a scientifically controlled study (a difficult venture with so many factors affecting blood sugar), the clinic's tracking of blood glucose before and after each session demonstrates that blood sugars can and do change significantly within one hour -- for whatever reason. This is important information for therapists who need to be alert to the dramatic changes which can occur in the blood glucose levels of diabetics during massage therapy. I teach this to my students as an important safety precaution of which they should always be aware.

Within the study's parameters, blood glucose levels have increased and decreased as much as 100 points. The results do not tell us, however, if the dramatic decreases could be accounted for by recent injections of insulin, or by aerobic exercise in the hours prior to the massage session. The increases could be the result of clients not taking their required dose of insulin, or they may have eaten food not adequately covered by insulin. But, as stated earlier, moderate drops of 20-40 points were the norm.

The student interns giving the massages where surprised by these changes in blood sugar levels. So were some of the diabetics. Seeing the numbers helped impress upon both interns and diabetics the importance of blood glucose testing.

Naturally, people tend to be relaxed and sometimes a little disoriented after receiving a massage. It is imperative the possibility of a serious, low blood sugar level be ruled out before the client is allowed to leave the premises. It's also important the client understands the effects may last for several hours, hence they should be checking their blood sugars throughout the day.

If working with diabetic clients, it's important to underscore their need for self-attention to the physical effects encountered during and after massage. For example, I know I tend to drop around 40 points during a relaxation massage. So, if I am 100 points or less before the session, I'll drink a small glass of juice beforehand, or maybe have it in the room to drink during the session. If I am 140-160 points, I will eat nothing, knowing I will drop into a more desirable range during the session. If higher than 160 points, I may take an extra injection of insulin, being careful to account for the likely drop due to massage. Sometimes I have observed the blood glucose-lowering effect of the massage lasting for several hours. Therefore, it is wise to continue with regular testing.

My example is only one. Each diabetic may have a different response. And often, even for the experienced recipient of massage, changes can be unpredictable.


Safety Concerns
To reiterate, the most important aspect to remember when working with someone with diabetes is monitoring their blood glucose levels, which we know can and do change when receiving massage. For the diabetic client, these changes happen all the time, regardless of massage. But because of the relaxing nature of massage, and the somewhat altered state of awareness that can occur, a drop in blood sugar can be difficult to notice. Some diabetics can tell when their sugar level is dropping. Others experience what is called hypoglycemic unawareness, in which they are not cognizant of a serious drop in blood sugar. Even people who usually are mindful can occasionally experience hypoglycemic unawareness.

Hypoglycemia (low blood sugar) is a serious condition and can lead to unconsciousness and, sometimes, death. Due to the frequent unpredictable nature of the disease, it is important for the therapist to recognize the signs and symptoms of hypoglycemia. Any one or more of these symptoms may occur:
- Excessive sweating (skin may feel clammy)
- Faintness or headache
- Unable to awaken
- "Spaciness" -- person may talk or move very slowly, or be unable to speak coherently
- Irritability
- Change in personality
- Rapid heartbeat

The therapist can ask the person how they feel. Do they seem fully cognizant when questioned? If there is any doubt, be prepared to assist the client. Treatment is simple. If blood sugar is low the diabetic needs sugar fast. This may be in the form of fruit juice, honey, a sugary drink or glucose tablets, if you have access to them. Many diabetics carry their own glucose tablets. These forms of sugar all act quickly to raise the blood glucose levels. A cup of juice, a sweet drink or the equivalent of 15-20 grams of carbohydrate will be sufficient to raise the blood glucose to a safe level. Changes will be noted in the diabetic within minutes. It is wise then to make sure the diabetic is feeling better before leaving. They may need to eat more, or to test blood sugar again after awhile.


Advice to Diabetics
Tell the therapist what you need, and do not be afraid to give them honest feedback about your experience. This is an opportunity for both therapist and client to learn from each other, enjoying the experience of giving and receiving massage. No matter what specific type of therapy is used, it is the communication and rapport between therapist and client that is most important.

If you have particular needs and concerns, share those with the therapist. Let them know what is most helpful to you. Know it is okay to stop and drink some juice during a massage if you need to, and let them know if a shorter session is more in order for you.


Advice to MTs
With awareness of these precautions, massage can be safely enjoyed by the person with diabetes. The massage therapist may also want to further study some of the complications of diabetes, and adapt their techniques accordingly. For example, if a diabetic has peripheral neuropathy (damage to the small nerves of the hands and feet), they may be very sensitive to touch. It is best to use techniques of Comfort Touch, a nurturing form of acupressure.

There are many different forms of massage and bodywork which, I believe, can be helpful for the person with diabetes. In our diabetes massage clinic, the massage therapy interns use primarily techniques from Swedish and integrative therapeutic massage. Other techniques which I employ in my private practice, or have enjoyed receiving include Shiatsu/acupressure, Comfort Touch, body energy therapies, Polarity balancing, Manual Lymph Drainage, Therapeutic Touch, deep tissue therapy, Reiki and craniosacral therapy.

Always listen to the client's feedback. Ask what they need and enjoy. Note changes which occur during the massage sessions and that occur over time. Always be willing to learn from your client, encouraging them in good diabetes self-care. Massage can give a wonderful psychological boost to someone who is living with this chronic disease and striving to balance all the factors involved in maintaining a healthy lifestyle -- proper nutrition, adequate exercise, blood glucose monitoring, appropriate use of medications and stress management.

Author's Note: Massage therapy contributes an important piece to my diabetes regimen of care. I hope this information can be useful to diabetic educators who might consider recommending massage to their clients. As massage therapists have a better understanding of this disease, they, too, will be in a position to offer their services to people with diabetes more safely and effectively. And, as diabetics understand and experience the benefits of massage therapy, they can consider it a valuable part of their own integrated health care program.

Mary Kathleen Rose is a certified massage therapist with 25 years experience in the holistic health field. She is the developer of Comfort Touch, a style of massage appropriate for the elderly and ill. She supervises the massage therapy program at Hospice of Boulder County in Colorado, and teaches in various massage schools and medical settings. She has been a Type 1 diabetic for 16 years. She can be reached at 303/449-3945 or rosevine@comforttouch.com.







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