Key points

• Most people with diabetes deal with some complications, and this situation must influence decisions about massage therapy.

• Consider timing when treating a client with diabetes; it may be best to schedule massage in the middle of an insulin cycle.

While diabetes mellitus is often a manageable condition, it can have a serious impact on every system of the body, from the skin to the reproductive system and everywhere in between. These complications can become life-threatening if they aren’t controlled, and they must influence many decisions about massage therapy. 

In this companion piece to “Deconstructing Diabetes” (page 36), we will shift our focus from the mechanisms of diabetes as a freestanding disease to the damage it does to a variety of tissues and systems throughout the body. In many ways, this is where the rubber hits the road or where the lubricant contacts the skin: When a client has diabetes, decisions about massage therapy often need to be more informed by its complications than by the fact of diabetes itself.

As we go through this substantial (but far from comprehensive) list of things that can go wrong when a person has poorly controlled diabetes, I invite you to take in this information through the filter of your massage therapy practice. What will it mean to you that your client with diabetes is also now at risk for heart attack or stroke? How will it affect your approach to know that your client is planning to start dialysis soon to manage their renal failure? And what about the lucky person who received a new kidney last year—what accommodations might they need?

At the conclusion of this column, we’ll walk through a simplified critical thinking rubric intended to help readers get a handle on balancing factors related to clients with diabetes and how they guide our understanding of the possible risks, benefits, and appropriate massage therapy accommodations for our clients who live with this very challenging disease.

What Does Insulin Dysregulation Do?

As you may have read in the feature article, diabetes causes severe dysregulation of insulin and blood glucose. People with type 2 diabetes often experience a period of hyperinsulinemia as their pancreas tries to accommodate for cells that develop resistance. This state carries its own consequences, some of which can contribute to problems related to diabetes. Later in the process, when the pancreas wears out, hypoinsulinemia can also cause problems.

When cells are less responsive to insulin, or when insulin is in short supply, we have only limited access to glucose, our most efficient fuel source. While sugar accumulates in the bloodstream, our cells have a harder time making adenosine triphosphate (ATP). The process becomes much more complex and creates much more in the way of metabolic waste products.

Meanwhile, having elevated blood glucose stimulates the production of pro-inflammatory chemicals that also contribute to tissue damage in blood vessels, the kidneys, and more. Some of the complications in this list overlap; for instance, poor circulation related to systemic atherosclerosis can cause secondary problems like skin ulcers or eye damage. And cardiovascular disease raises the risk for both heart attacks and strokes. It is difficult to create firm walls around these categories of problems because, in diabetes, as in all things regarding human health, everything is connected to everything else. But here is an attempt to illuminate some of the most serious complications of diabetes. 

Cardiovascular System Complications

When diabetes has advanced to the point where insulin production is limited and blood glucose is consistently above normal levels, we see a variety of impacts on the cardiovascular system. Hyperglycemia stimulates a system-wide inflammatory response. In the absence of insulin to bring down blood sugar, this inflammation can be severe enough to cause damage to many organs.

Because another function of insulin is to carry lipids out of the bloodstream and into fat cells, a low level of insulin in the blood can lead to increased circulating triglycerides and a much-increased risk for atherosclerosis (the development of fatty plaques on the insides of blood vessels).

Atherosclerosis is not rare or unique to diabetes, but a major difference in this situation is that it is not necessarily limited to the blood vessels closest to the heart. Most people who have atherosclerosis have it in the coronary or carotid arteries, or possibly in the aorta. But with diabetes, it can occur in all these places, plus distant arteries and arterioles, which leads to a peripheral artery disease. It can even affect the tiny vessels that supply our nerves, which can contribute to peripheral neuropathy in the muscles and other organs and retinopathy in the eyes.

In the US, diabetes is the primary cause of new blindness in people aged 20–74.This eye damage can be related to a combination of poor circulation and atherosclerotic plaques, and may also be related to the accumulation of sugar in the lens of the eyes.

It’s in the nature of cardiovascular disease to be circular—that is, hypertension contributes to atherosclerosis, which contributes to hypertension, ad infinitum. In keeping with this pattern, the relationship between diabetes and cardiovascular system disease also includes the risk for hypertension, aneurysm, heart attack, and stroke. Diabetes is commonly listed as the seventh-leading cause of death in the US. Heart attack and stroke are higher on the list, but it’s unclear how many of those cases might have been related to the presence of diabetes.

In addition to raising the risk for cardiovascular disease, diabetes can also contribute to systemic edema, which is typically related to poor circulation and kidney damage.

Kidney Damage

Because renal function is a high priority, kidneys are on the receiving end of a lot of arterial force. They need that healthy pressure to push blood through the filters that are required to extract excess water and metabolic wastes that we excrete through urine. But kidneys are delicate, and the combination of constantly elevated physical pounding of blood (hypertension) plus high blood sugar and accompanying inflammation can damage these organs.

Diabetes accounts for about 45 percent of all cases of renal failure in this country.¹ At this moment, about 90,000 people are on the waiting list for a donor kidney, but only about 26,000 kidney transplants are performed every year.² And people who are lucky enough to receive a new kidney must commit to a lifetime of antirejection drugs, which means they become immunocompromised.

Skin Complications

As arteries carry blood further away from the heart, they get progressively smaller and blood pressure decreases. This is normal, but in the presence of uncontrolled diabetes, telescoping arteries and arterials can become additionally occluded by atherosclerotic plaque. This, combined with local sensory nerve damage and venous insufficiency, opens the door to long-lasting, difficult-to-treat ulcerations: open, nonhealing sores, usually on the feet. This happens most often in older diabetes patients, and about 25 percent of all diabetic ulcers eventually lead to an amputation. (Diabetes is the leading reason for nontraumatic amputations in the US.)³ 

Nerve Damage

Diabetes is especially damaging to the nervous system. Remember that nerves must also have a blood supply to function. When this blood supply is limited because of atherosclerosis, along with the presence of pro-inflammatory chemicals in the bloodstream, this means that all the peripheral nerves of a person with diabetes are at risk for damage. 

Motor Function

Reduced muscle function in people with diabetes can be a result of limited access to glucose and the inefficient production of ATP. Limited blood supply to motor neurons also means that people with advanced and poorly controlled diabetes are likely to have muscle atrophy, muscle weakness, and poor stamina. 

Sensory Function

Poor blood supply to sensory neurons can cause further complications, including tingling, paresthesia, numbness, and, most importantly, pain. This happens most frequently in the extremities, especially the feet. Peripheral neuropathy related to diabetes can be difficult to treat and radically impairs the quality of life for people who live with this challenge. Consequently, this complication carries significant implications with regard to massage therapy.

Autonomic Nerve Function

The nerve damage from diabetes does not stop at motor and sensory neurons that supply the extremities. Cranial nerves are also vulnerable to damage from diabetes. This can result in dysautonomia (which can look a lot like low blood sugar when someone gets dizzy and disoriented), poor digestive motility (with bloating, nausea, constipation, and diarrhea) because the vagus nerve cannot supply correct signals to the digestive tract, and much more. Dysfunction of autonomic nerves can also cause problems with maintaining a healthy heart rate, blood pressure, sexual function, and bladder control. Finally, autonomic dysfunction can make it difficult to sense when the blood sugar is low; this is called hypoglycemic unawareness, and it is an especially dangerous complication.

This is just a short list of complications related to diabetes, though there are several others to consider, including but not limited to:

• Higher risk of gingivitis and gum disease (which can contribute to heart problems—already a high risk for this population)

• Systemic candidiasis (because yeasts love sugary blood)

• Frequent urinary tract infections related to elevated sugar in the urine, plus reduced sensation in the bladder (which can lead to kidney infections—not ideal in the presence of renal failure).

Navigating the Massage Waters

Diabetes is a common and complex disease. Most people with diabetes deal with some complications, and this situation must influence decisions about massage therapy. But these are so numerous and so complex, how is it possible to be sure we are being both safe and effective in our treatment strategies?

One way to steer through these waters is with a simple critical thinking method that I proposed in “Critical Thinking: Think About Thinking, and Then Take Action” in the May/June 2021 issue of Massage & Bodywork. 

The process looks like this:

1. What is the main question? (What does this client hope to achieve with our work together?)

2. What are the variables that must inform my decisions? (What are the aspects of this situation that influence safety [e.g., organ damage, complications, etc.]?)

3. What assumptions am I making that might be incorrect? (Am I sure I understand the entirety of this situation? Am I focused too much on one area and not enough on others?)

4. What have other massage therapists done in similar situations? (What does the research say about massage therapy and this client’s goals, or about massage therapy and diabetes?)

5. What will my massage look like? (Plan and execute your sessions.)

6. How did it go? (Evaluate your work in the context of your client’s goals and use that to inform future sessions.)

As we saw in “Deconstructing Diabetes,” diabetes can look completely different from one person to another. Each client who lives with this disease will have different consequences and will manage their conditions with different strategies—that’s why choices about massage therapy for clients with diabetes cannot be rubber-stamped: There’s no one solution that works. 

I offer the following ideas about potential risks, benefits, and appropriate accommodations for clients who have diabetes, with the caveat that we must always remember our job is to focus on the person, not the disease. Identifying key factors for safety will help us do that effectively, but let’s not get sidetracked into trying to “treat diabetes”—that’s not our job. 

Risks

If a person’s diabetes isn’t well controlled, they might have any combination of the serious complications discussed in this article. The short list includes edema, cardiovascular disease, renal failure, and peripheral neuropathy—which can cause pain and numbness. Each of these requires specific accommodations in massage therapy.

Another risk is that massage may lower blood sugar so much that the client becomes hypoglycemic. In this situation they may become dizzy, disoriented, and uncomfortable, and they need sugar intake as soon as possible. 

In addition, the presence of non-healing ulcerations on the legs and feet may be something massage therapists observe but clients do not. In episode 354 of my podcast, I Have a Client Who . . ., I focused on stories about clients with problematic body odor and was surprised to hear from some massage therapists about becoming aware of diabetic ulcers mainly from their smell. In one case, this led to an immediate referral to the hospital, emergency surgery, and the prevention of a more severe amputation. 

Benefits

The best benefit massage therapy can offer a person with poorly controlled diabetes is a referral to a primary health-care provider. As seen in the example in the preceding paragraph, this may be a lifesaving, or at least a quality-of-life-saving, intervention.

When diabetes is well controlled, the benefits of massage are the same as for anyone else, as long as proper accommodations are made for treatment and side effects. In addition, we can offer the opportunity to do a more thorough skin check than many people can do for themselves, and we can help identify any areas of numbness, if that’s an issue. All of this is offered along with the reduction of pain and stress that our work can provide. 

Accommodations

The most important accommodations we can make will move us toward two goals: what the client wants and what is safe for them to receive. If your client is generally healthy and their diabetes is under control and not making a huge impact on their physical well-being, they may require little in the way of bodywork adaptations. But clients who are older and have had diabetes for a long time may need a more thoughtful approach. What kinds of accommodations do you foresee making for your clients specifically in relation to diabetes? 

Cardiovascular and Renal Damage

Does your client have kidney disease? These are people who may not tolerate the sudden increase in fluid flow that vigorous, full-body massage might create. Do they have high blood pressure and other risks for cardiovascular disease? It’s important to get a clear sense of their tolerance for physical activity and to make sure that whatever homeostatic challenges our work creates stays within those boundaries. 

Nerve Damage

Peripheral neuropathy can affect motor, sensory, and parasympathetic nerves. Weakness, numbness, tingling, pain, or dysautonomia can be the result. This doesn’t mean massage must be avoided, but it must be done with extra care to track areas of numbness and to avoid causing (more) pain. 

Skin Damage

We have already discussed the role of massage therapy in identifying signs of diabetic ulcers as early as possible. Bear in mind that these lesions are often not painful, and if they occur in an area that is numb and/or not immediately visible, they are easy to ignore—with the risk of infection, gangrene, and amputation. 

Medications

Are your clients with diabetes taking medications to manage blood pressure? (Answer: probably yes.) It would be a good idea to find out if the medications have any side effects, like lethargy or dizziness—this requires some changes in massage, like ending the session with stimulating strokes and allowing more time to transition off the table. Other medications like statins or metformin can also cause problems, like nausea or gallbladder issues. 

Insulin

Supplemented insulin usually leads to a marked improvement in many symptoms, although it can sometimes cause new side effects. Many people find that they gain weight more than usual because insulin makes sugar available for storage in the cells. Some people experience some edema and problems with fat deposits, but this is relatively rare. 

However, because insulin must be injected, it’s important to know where the injection site is. Clients who manually inject insulin into the subcutaneous skin need to not rub on that area in a way that might disrupt the speed of uptake. Those who use an insulin pump will need adjustments in positioning and may also find that the skin around the site becomes indurated and thick. Also, it’s best to schedule a massage for the middle of the insulin cycle if possible, when their levels are most stable—not right after they’ve eaten or when they are very hungry. This will reduce the chance they might have an insulin-related problem. 

Finally, it’s a good idea to find out ahead of time what your client wants you to do if they have a hypoglycemic (low blood sugar) episode. Some clients may be equipped with a blood glucose monitoring device—either an insulin pump or a skin patch that communicates with an app on their phone—so they receive an alarm about low blood sugar. Since massage lowers blood sugar, at least temporarily, they may receive an alert during their session. Each client with diabetes may have a different preference for an easily accessible source of sugar: Some might like candy (or even carry some with them), while others might prefer milk or juice. This is why it’s good to get this information ahead of time. 

What Does the Research Say?

The research about massage therapy for people with diabetes is mostly positive, but also very small-scale. We see that massage tends to drop blood sugar, but how much and for how long is difficult to predict. There is some indication that massage might help with the numbness related to peripheral neuropathy, but this was only a small pilot study.⁴ 

People on dialysis for renal failure related to diabetes get some benefit from receiving work to their legs and feet during their treatment, and one interesting study found that massage was helpful for foot function and balance—a very important benefit for people who are at risk for falls. 

Be the Support They Need

Diabetes is common, expensive, serious, and usually manageable. Some aspects of this disease can be mitigated by massage, but our work is mainly supportive as our clients look for the best ways to cope with and control this difficult disease. Massage therapy won’t cure diabetes, but it can bring our clients some relief. 

Notes

1. National Kidney Foundation, “Diabetes and Chronic Kidney Disease,” last updated January 2016, www.kidney.org/news/newsroom/factsheets/Diabetes-And-CKD.

2. Donate Life, “Kidney Donation,” https://donatelife.net/donation/organs/kidney-donation; National Kidney Foundation, “Transplants for All: Saving Lives, One Kidney at a Time,” April 18, 2023, www.kidney.org/newsletter/transplants-all-saving-lives-one-kidney-time.

3. Allan Boike, Michael Maier, and Daniel Logan, Cleveland Clinic, “Prevention and Treatment of Leg and Foot Ulcers in Diabetes Mellitus,” Accessed July 3, 2023, www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/prevention-treatment-diabetic-leg-and-foot-ulcers.

4. Sunarmi Sunarmi et al., “The Effectiveness of Massage Therapy on Healing of Diabetic Neuropathy in Diabetes Mellitus Patients,” Open Access Macedonian Journal of Medical Sciences 10, no. G (2022): 190-4, https://doi.org/10.3889/oamjms.2022.8564.