Key points

• When clients with diabetes are older, they will, more than likely, present with common conditions like thinning skin, fragile bones, atrophied muscles, and brittle tendons.

• Massage can lower blood pressure and blood sugar levels, so a longer session could be detrimental to a client with diabetes. 

As your client pool ages, it’s likely you will see more clients living with diabetes. Can the hands-on work you offer this aging group of clients make a difference in their quality of life? Yes, it can. Let’s look at how, when performed properly, massage can address blood circulation problems often found in the feet and legs of clients with age-related diabetes, also known as non-insulin dependent diabetes mellitus (NIDDM). Let’s also examine why massage therapists should use extra caution with elderly clients during the treatment session.

Determine the Protocol

People with diabetes often develop peripheral vascular disease (PVD), neuropathy (pain, numbness, and tingling), and undetected infections due to numbness and overall poor circulation. These disturbances often lead to pre-gangrenous conditions, which can earmark the client for eventual amputation.

These same elderly clients with diabetes will, more likely than not, also present with common conditions like thinning skin, fragile bones, atrophied muscles, and brittle tendons. As a result, massage therapists should adhere to a specific protocol when administering hands-on work in these cases.

As far back as 1978, Dietrich Miesler, founder of the DayBreak Geriatric Massage Institute, was successful in contributing to multiple examples of canceled amputations as a result of administering his geriatric diabetic massage sequence for feet and legs—the DayBreak NIDDM Protocol—which is still taught as a vital part of the program’s core curriculum.¹ Miesler’s techniques, delivered properly and with great care, have proven to routinely decrease health risks and diminish negative outcomes for older clients with diabetes.

Miesler was a pioneer in developing specific hybrid strokes and massage protocols that not only yield positive results but, perhaps more importantly, do not produce negative results. We can learn so much from his dedicated research and success with clients over the years. Although his massage sequence for the foot and ankle area encompasses eight specialized strokes, let’s examine a couple of his techniques that have changed the landscape of massage success for older clients with diabetes.

The Assessment

Your assessment protocol with this client is critical. Take a good look at the overall condition of the client’s feet and legs. Examine carefully, looking for any cuts or abrasions, areas painful to the touch, pressure sores or ulcers, swelling, broken capillaries, bruising, or discoloration of the skin. Notice the amount of hair growth on the legs; the more advanced a case of PVD is, the less hair will grow on the skin’s surface. Check the tautness of the muscles, the tension of the skin, and any fluids leaking through the skin’s surface. Therapists may encounter conditions that alert them to proceed with the massage, but with caution. A good therapist armed with critical-thinking skills will know which conditions require a doctor’s permission before proceeding with the session.

General Guidelines

To begin work with this client, start with gentle rocking motions that relax and soothe them. The delivery of strokes should be slow, comforting, and with purpose. The aim is blood flow, lymph flow, and guided range of motion. Allow your hands to “read” the condition of the muscles and bone structure, so as not to apply too much pressure to the skin or tissue or overstretch a muscle or tendon. Limit the session length to about 30 minutes so you don’t overload their system. Massage can lower blood pressure and blood sugar levels, so a longer session could be detrimental. And if a client with diabetes is prescribed insulin, wait until about two hours after their injection before proceeding with massage.  

Foot Pumping

The foot-pumping maneuver mimics the muscle activity that happens when walking. Simply pumping the client’s foot back and forth helps activate muscles that are now more sedentary, which can vastly improve blood circulation and muscle health. Work the full range of motion from dorsiflexion to plantar flexion, without force, for a minimum of one minute. The rhythmic movement produces a release of endothelium-derived relaxing factor (EDRF), a hormone-like substance that’s an exceptionally powerful vasodilator released by the endothelium, which relaxes and opens narrowed blood vessels. This is one of the first techniques used within the DayBreak NIDDM sequence, as it sets up the body for increased benefit from all the subsequent strokes.

Fluffing

Fluffing is a hybrid stroke composed of a gliding and pulsing motion performed over an area of the body. For example, when treating the back of the lower leg, gently glide your palms up the back of the calf, from ankle to popliteal space, using a squeeze-and-release motion. Recognizing that petrissage is often too much pressure for this muscle group in seniors and knowing that effleurage is simply not enough to accomplish the intended goal, perform this stroke that combines both techniques simultaneously to safely achieve the desired result.

The goals of the fluffing technique include decreasing swelling by gently moving accumulated fluids, assisting in the return of venous blood flow back toward the heart, moving lymph fluid, and enhancing the continued effects of EDRF produced during the foot-pumping technique mentioned earlier.

The fluffing technique is always performed with hands moving toward the heart. The squeeze-and-release motion is performed with the palm of the therapist’s hands, along with the four fingers on their same hand. Avoid applying too much pressure with the thumb, which can cause bruising.

Remember, the fluffing technique is considered more of a lymphatic stroke, so the pressure should be light.

As your hands glide up the back of the lower leg, approximately five or six squeeze-and-release moves will be executed (while gliding) before reaching the popliteal space behind the knee. Each squeeze is generally performed one second apart. However, depending on the condition of the client’s skin, tissue, muscle mass, and swelling, squeeze can be increased to twice per second, covering less surface area between squeezes.

Make three or four passes from ankle to knee. More time can certainly be tolerated by, and even warranted for, the client, since you will often spend the entire half-hour session on the client’s feet and legs exclusively.

Improve Your Clients’ Lives

Massage therapy can prove to be one of the best treatments for older clients with diabetes. When administered properly, the protocol is an integral part of ongoing care, producing results that improve quality of life dramatically. 

CAUTIONS AND CONTRAINDICATIONS

In addition to the usual precautions you would take before massaging any client, the following are conditions encountered more commonly in clients with diabetes, which you will also need to consider. Ask important questions, be observant as you examine their body, and make safe and sound decisions before proceeding. 

Session Length—Avoid massage sessions of long duration. Levels of glucose, insulin, and blood pressure are affected during massage and may go too low if the massage is too long. A half hour is long enough. 

Amputation Issues—Seek a doctor’s permission when massaging an amputation site. If permission is given, be sure to thoroughly clean and dry any site where prosthesis may be put in place after massage.

Insulin Levels—Perform a thorough medical intake evaluation and be sure insulin levels are well-controlled. Find out what medications are taken and at what times they are administered. Massage should be postponed until two hours after an insulin injection. 

Injection Site—Do not massage on or near the most recent insulin injection site. Doing so can cause the insulin to enter the bloodstream at too fast of a pace, which the body may translate as a much higher dosage of insulin and can be dangerous if it causes a hypoglycemic episode. 

Neuropathy—Self-monitor the amount of pressure you are using during your massage. If a client has neuropathy, they may experience pain or—worse—not feel pain that would serve as a warning that too much pressure is being used. 

Abnormally Responding—Do not massage if your client arrives confused, lethargic, or sporadic in their verbal responses. 

Unhealthy Tissue—Do not massage if your client has visibly unhealthy tissue, such as ulcers, open sores, or unhealed lesions. 

Pitting Edema—Do not massage if your client has pitting edema; it could be a sign of a more serious condition, such as a blood clot. Pitting edema differs from edema in that applying pressure and then releasing will show an indentation in the skin of the swollen area. 

Cellulitis—Do not massage if your client has cellulitis (a bacterial skin infection that can quickly spread to other parts of the body). Look for swollen, red areas of the skin, hot to the touch and tender to the client. If left untreated by antibiotics, it can be life-threatening.

For more information on EDRF and working with elderly clients with diabetes, read about Dietrich Miesler’s early work at massagetherapy.com/articles/what-world-edrf.

Note

1. The DayBreak Geriatric Massage Institute’s NIDDM protocol for clients with diabetes was developed by Dietrich Miesler and is taught as part of the DayBreak curriculum. For more information, visit daybreak-massage.com.