PART 2 OF 2Type 2 diabetes mellitus (T2DM) occurs when cells are resistant to insulin (most common) or from insufficient levels of insulin production by pancreatic beta cells (least common). More than 100 million people in the United States have diabetes or prediabetes. This number represents approximately 9.4% of the population. Young people are more likely now than ever to be diagnosed with T2DM, and it is the most common chronic disease in children and adolescents. T2DM is often diagnosed while the client is hospitalized or receiving medical care for another problem. Diabetic neuropathy can occur is some cases and massage can help ameliorate symptoms.

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Type 2 DM (previously called non–insulin-dependent DM [NIDDM] or adult-onset DM) is a much more prevalent form of diabetes. T2DM is the most common form of DM and accounts for more than 90% of all cases. In some cases, people with T2DM require insulin replacement therapy; this condition is called insulin requiring DM [IRDM]. Type 1 DM is discussed HERE.

Cardiovascular disease is the leading cause of death in diabetics and accounts for approximately two-thirds of all deaths among the diabetic population. Because of the presence of neuropathy, people with diabetes may have a silent heart attack as they may not experience the painful symptoms associated with a heart attack because of nerve damage that occurs in diabetes. Diabetes is the leading cause of end-stage kidney failure.

Impaired vision from diabetic retinopathy combined with diabetic peripheral neuropathy contribute to the decreased ability to both see and feel breaks in the skin, and monitor wound development. Because of peripheral arterial disease and reduced blood flow, white blood cells do not migrate to affected areas quickly. In addition, once bacteria enter the wound site, they quickly multiply due to the increased glucose content present in body fluids. Diabetes results in higher incidence rates of infections of all types.

Prediabetes occurs when blood glucose levels are higher than normal but not high enough to be T2DM. Individuals most at risk for progressing from prediabetes to diabetes have cardiovascular disease. People with prediabetes are encouraged to make lifestyle changes to reduce their risk, such as reduced caloric intake and increased physical activity.

Diabetic foot ulcers and amputations. Diabetic foot ulcers are one of the most common complications associated with diabetes with a lifetime incidence of 19-34%. More than 50% of diabetic ulcers become infected and 20% of these will be severe enough to result in amputation, surgical removal of a limb such as a leg or other body area. If fact, approximately 85% of diabetes-related amputations were preceded by a foot ulceration.

This procedure is performed to remove damaged or necrotic tissue caused by infection, disease, or trauma. The most common areas of amputation in people with diabetes mellitus are the foot or leg. The most common reasons for amputation are complications related to diabetic foot ulcers that do not heal. More than 50% of diabetic foot ulcers become infected; 20% of these require amputation. After two decades of declining numbers of lower extremity amputations, there is now an increase of amputations in the United States, particularly among young and middle-aged adults.

Post-amputation pain is a common, yet poorly understood, condition that can cause significant disability. Post-amputation pain occurs in approximately 60 to 70% of amputations, often arising within 1 week after amputation surgery, but may occur several months or years after the surgery. Pain following amputation may develop as residual limb pain, phantom limb pain, or phantom limb sensation.

Residual limb pain, also called stump pain, is pain felt in the remaining portion of the affected limb after amputation. Phantom limb pain is pain originating in an area of the body that has been removed. Sensations from residual or phantom limb pain range from tingling, itching, burning, to throbbing. Phantom limb sensations are the perception of movement originating from the missing limb or body part. Post-amputation pain is believed to stem from mixed signals that arise from the residual limb or the brain. A neuroma (tumor found in nervous tissue) may form on severed nerve endings of the amputated limb and send disordered signals to the brain. The brain itself may continue to receive sensory signals or send motor commands to the limb, creating uncomfortable sensations. Additional factors contributing to post-amputation pain include swelling, scar tissue, muscle spasms, or referred pain. Risk factors for post-amputation pain development include pre-amputation pain; area of limb amputation closer to the body; age (older adults have a higher incidence rate compared with children); female sex; and poor pain coping-strategies and beliefs. Most cases are related to obesity and a sedentary lifestyle. A strong genetic link also exists.

The three Ps of DM are polyuria or excessive urination, polydipsia or excessive thirst, and polyphagia or excessive hunger. The person is often obese. Persistent hyperglycemia damages cells and leads to complications such as vision problems including cataracts and diabetic retinopathy, lack of muscle control, and reduced sensations or paresthesia called diabetic peripheral neuropathy (DPN) and diabetic foot ulcers. Neuropathic pain often increases throughout the day and worsens at night, which may interfere with sleep. Fungal infections including thrush, jock itch, vaginal yeast infections, and athlete’s foot may occur. Also common are kidney, cardiovascular, and neurologic conditions including glomerulosclerosis, kidney failure, hypertension, coronary atherosclerosis, occlusive atherosclerosis, peripheral arterial disease (PAD), heart attack, and stroke.

Type 2 DM can be controlled with regular exercise, proper nutrition, and maintaining weight through controlled caloric intake, particularly of carbohydrates. In contrast to IDDM, people with T2DM often can be treated with oral hypoglycemics and antidiabetics. This type of DM is called non–insulin-dependent diabetes mellitus (NIDDM). Many people with NIDDM, however, take insulin when their bodies do not produce sufficient amounts. This type of DM is called insulin-requiring diabetes mellitus (IRDM). Other medications may be used such as lipid-lowering drugs, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers to address potential complications such as high blood pressure.

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Massage and Type 2 DM – Query the client about his or her diabetic complications and modify your massage accordingly. Complications associated with diabetes are far less common and less severe in people whose disease is well controlled. Consider incorporating foot reflexology and aromatherapy into the session to improve treatment outcomes. Ask if the client carries a blood glucose meter and, if so, where it is in case it is needed during a possible hypoglycemic episode. Some clients with T2DM require insulin via injection. Avoid vigorous massage over sites of recent injection for 24 hours as this may increase absorption rates (Berger et al, 1982; Linde, 1986) and thereby decrease blood glucose levels and possibly cause hypoglycemia. In addition, Tosun et al (2019) found injection site complications were significantly more common in those who massaged the area after injection. See this blog post for information about massage and insulin pumps.

Inspect the feet during each visit, looking for sores, broken skin, and objects embedded in the skin. Diabetic foot ulcers can occur anywhere pressure or shearing forces are applied to the foot (top, sides, bottom). These may go unnoticed by the client due to loss of sensation. If noted, these areas should be avoided during the massage with referral made to the client’s healthcare provider for medical evaluation. The practitioner is advised to reinforce client daily self-evaluation at every session.

Safety is an important consideration for people with diabetic peripheral neuropathy. Lack of muscle control and reduced sensation increases the risk of falls and other injuries. This includes removal of throw rugs, securing of carpet edges, removal of low furniture and objects located on the floor, removal of cords and wires on the floor, adequate lighting, and non-waxy flooring. Massage can be performed over areas of neuropathy. Request client feedback about levels of pressure and modify techniques according to his or her comments. Clients with peripheral neuropathy of the lower extremities are prone to additional nerve injury from pressure, use a soft rather than stiff bolster behind the knees while the client is supine and in front of the ankles while the client is prone.

While hypoglycemia can occur in T2DM, it is often a mild and infrequent side effect of treatment among this population. Nonetheless, be aware of the symptoms of hypoglycemia listed in this blog post.

Massage and amputations. If the client has an amputated limb and post-amputation pain, massage is recommended (BWH, 2011; Kania, 2004). Avoid vigorous massage on the lower extremities (thighs and legs) for 12 weeks after surgery due to the increased risk of blood clots and avoiding the incision area until it is dry and not moist or open, which may take 8 weeks or longer. Massage and scar mobilization are standards of care for lower extremity amputations to decrease hypersensitivity of the residual limb and for pain management (BWH, 2011). If the client has phantom limb pain associated with an amputation, consider massaging the remaining limbs and teach the client self-massage to reduce pain and improvement to their quality of life. Clients often use prostheses after surgery; some prosthetics cause the skin to be chafed or have friction wounds. These areas should be avoided and brought to the client’s attention.

research iconResearch. A 30-minute massage (the back for 10 minutes and the abdomen for 20 minutes) administered 3 times a week for 4 weeks reduced heart rate and decreased cortisol and adrenaline levels (indicating reduced stress) in women with T2DM (Boghrabadi, 2017). A 60-minute massage administered once a week for 10 weeks decreased blood glucose levels and reduced A1C in women with T2DM (Andersson et al, 2004). Bayat et al (2016) found similar results. A single 20-minute massage improved sleep quality in people with T2DM (Jarrahi et al, 2018).

Castro-Sánchez et al (2011) found a 1-hour connective tissue massage (Dicke method) administered twice a week for 15 weeks improved blood circulation in lower limbs of T2DM patients with stage I or II peripheral arterial disease. A 20-minute foot massage (10-minute for each foot) improved balance and functional ability in persons with T2DM (Tütün Yümin et al, 2017). Thirty-minutes of Thai foot massage administered 3 days per week for 2 weeks improved balance, foot range of motion, and foot sensations in diabetic patients with peripheral neuropathy (Chatchawan et al, 2015). Thai foot massage is similar to foot reflexology. Aromatherapy massage administered 3 times per week for 4 weeks reduced neuropathic pain and improved quality of life in diabetic patients (Gok Metin, 2017). Rosemary, geranium, lavender, eucalyptus, and chamomile essential oils were added in a 5% solution of coconut oil carrier. A combination of massage (30-minute sessions) and hydrotherapy administered 3 times a week for 8 weeks increased nerve growth factor, balance, and glycemic profile among middle-aged diabetic neuropathy patients (Shourabi et al, 2019). Çakici et al (2016) conducted a systemic review of treatments for diabetic peripheral neuropathy and found Thai foot massage, reflexology, and other forms of treatment significantly improved symptoms.

Bayat et al (2020) conducted a systematic review on the effects of massage on diabetes and found massage can reduce symptoms and complications of DM. However, they cautioned users as various conditions such as pressure can cause the opposite result. For example, moderate pressure can increase delta wave activity in electroencephalogram, and parasympathetic activity whereas light massage can cause the opposite—reduce delta wave activity and heighten sympathetic activity. Additionally, deep pressure may lead to analgesia by the release of endorphins.

Brown and Lido (2008) conducted an investigation to measure the effects of reflexology on phantom limb pain in persons with lower limb amputations. First, participants received 6 weekly reflexology treatments, which consisted of foot reflexology to the remaining foot, and full hand reflexology to the hand on the amputated side of the body. Next, participants received 6 weekly hand reflexology teaching sessions and participants copied on their own hands what the practitioner did on her hand. An instructional booklet was used as a reference. Lastly, participants provided self-treatment at home for 6 weeks, using the reference material. The presence, intensity, and duration of phantom limb pain was reduced and participants noted a corresponding improvement to their quality of life; these benefits were maintained through self-massage. A follow-up questionnaire was used 12 months after the study ended and it revealed improvements persisted and the majority of participants still self-treated with reflexology. Reasons for the amputations were conditions such as diabetes, osteomyelitis, trauma, and gangrene.

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References:

Andersson, K. Wändell, P., Törnkvist, L. (2004). Tactile massage improves glycaemic control in women with type 2 diabetes: a pilot study. Pract Diab Int, 21(3), 105-109.

Davood Bayat, D., Mohammadbeigi, A., Parham, M., Mehrandasht, A., Hashemi, M., Mahlooji, K., Asghari, M. (2020). The effect of massage on diabetes and its complications: a systematic review. Crescent Journal of Medical and Biological Sciences, 7(1), 22-28.

Bayat, D., Vakilinia, S.R., Asghari, M. (2016). Non-Drug Therapy and Prevention of Diabetes Mellitus by Dalk (Massage). Iran J Med Sci, 41(3 Suppl), S45.

Berger, M., Cüppers, H.J., Hegner, H., Jörgens, V., Berchtold, P. (1982). Absorption kinetics and biologic effects of subcutaneously injected insulin preparation. Diabetes Care, 5(2), 77–91.

Boghrabadi, V., Nikkar, H., Gonabadi, A.H., (2017). The effect of Swedish massage on fasting glucose levels, insulin resistance, cortisol, adrenaline and heart rate in women with type II diabetes. Biosci Biotech Res Comm: Special Issue, 1, 42-47.

Brigham and Women’s Hospital. (2011). Standards of care: lower extremity amputation. Retrieved from https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/general-le-amputation-bwh.pdf

Brown, C.A., Lido, C. (2008). Reflexology treatment for patients with lower limb amputations and phantom limb pain–an exploratory pilot study. Complement Ther Clin Pract, 14(2), 124-31.

Çakici, N., Fakkel, T.M., van Neck, J.W., Verhagen, A.P., Coert, J.H. (2016). Systematic review of treatments for diabetic peripheral neuropathy. Diabet Med, 33(11), 1466-1476.

Castro-Sánchez, A.M., Moreno-Lorenzo, C., Matarán-Peñarrocha, G.A., Feriche-Fernández-Castanys, B., Granados-Gámez, G., Quesada-Rubio, J.M. (2011). Connective tissue reflex massage for type 2 diabetic patients with peripheral arterial disease: randomized controlled trial. Evid Based Complement Alternat Med, 804321.

Chatchawan, U., Eungpinichpong, W., Plandee, P., Yamauchi, J. (2015). Effects of Thai foot massage on balance performance in diabetic patients with peripheral neuropathy: a randomized parallel-controlled trial. Med Sci Monit Basic Res, 21, 68-75.

Gok Metin, Z., Arikan Donmez, A., Izgu, N., Ozdemir, L., Arslan, I.E. (2017). Aromatherapy massage for neuropathic pain and quality of life in diabetic patients. J Nurs Scholarsh, 49(4), 379-388.

Jarrahi, N., Elahi, N., Renani, H.A., Cheraghian, B. (2018). The effect of massage with Tellington method abalone type on the sleep quality of diabetic patients having type 2 diabetes. JRMDS, 6(6), 208-217.

Kania, A. (2004). Camputee coalition: integration of massage therapy into amputee rehabilitation and care. Retrieved from https://www.amputee-coalition.org/resources/integration-of-massage-therapy/

Linde, B. (1986). Dissociation of insulin absorption and blood flow during massage of a subcutaneous injection site. Diabetes Care, 9(6), 570–574.

Shourabi, P., Bagheri, R., Ashtary-Larky, D., Wong, A., Motevalli, M.S., Hedayati, A., Baker, J.S., Rashidlamir, A., (2019). Effects of hydrotherapy with massage on serum nerve growth factor concentrations and balance in middle aged diabetic neuropathy patients. Complementary Therapies in Clinical Practice, 39, 101141.

Tütün Yümin, E., Şimşek, T.T., Sertel, M., Ankarali, H., Yumin, M. (2017). The effect of foot plantar massage on balance and functional reach in patients with type II diabetes. Physiother Theory Pract, 33(2), 115-123.

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Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at susansalvo@hotmail.com.