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What Is Really Contraindicated With Diabetes?

What Is Really Contraindicated With Diabetes?

A little while ago we wrote a piece on circulation and whether massage is actually moving fluids around and increasing circulation.

As it turns out, we aren’t increasing circulation the way we used to think was happening (you can read that post here if you like).

One thing that came up as a result of that post, was the question of whether we need to decrease the length of our strokes when giving a massage in certain conditions?

Looking back through my textbooks and notes from college, conditions like diabetes and hypertension were given similar contraindications. In fact with diabetes CI’s it was recommended that massage strokes are modified to short, segmental strokes to prevent large volumes of venous and lymphatic fluid return to the heart. It is also recommended that repetitive, passive large limb movements should be avoided as well.

So are these CI’s really necessary?

Stroke Length

When someone has diabetes and blood glucose is high for extended periods (years), then plaques can form in blood vessels causing damage and impaired blood flow to neighbouring cells. This is called Peripheral Arterial Disease (PAD).

This poor circulation can be one of the causes of peripheral neuropathy along with excess body weight and high blood pressure. 

One study showed that using massage therapy helped increase circulation in the lower limbs of type II diabetic patients with improvements in arterial pressure and greater skin blood flow. Fortunately the study acknowledged the parasympathetic nervous systems role. Indicating decrease in heart rate and a rise in oxygen saturation. This study was done to see if there were improvements in peripheral arterial disease and fortunately it showed that massage could help slow the disease progression. 

This study used very specific treatment patterns using both long and short strokes to the back and the lower limb of the patients. But notice they used both long and short strokes. 

As we learned in the post we did a little while ago, during a massage we aren’t increasing overall circulation anymore than the circulation increased by the person walking into your clinic. So how then would altering the length of your stroke make any difference?

I’d venture to say it doesn’t.

As far as passive large limb movements being CI’d, again there is no way it is altering circulation more than the effort it took to walk into the clinic. If professional athletes like Bobby Clarke and Max Domi can play hockey at the professional level while managing their diabetes, a passive limb movement during a massage isn’t going to cause much of an issue.

Centpacrr at English Wikipedia [CC BY-SA 3.0 ( or GFDL (], via Wikimedia Commons

Ketoacidosis And Diaphragmatic Breathing

Ketoacidosis occurs in diabetics when their cells don’t get the glucose they need (due to a lack of insulin, or too much insulin resulting in low blood glucose), the body starts to burn fat as a replacement.

As this process develops, ketones can build up in the blood (ketones are an acid developed from burning fat) which then changes the pH balance in blood making the balance too low, where it becomes more acidic. This in turn sends a person into diabetic shock, which is a life threatening emergency. A person with diabetes can have this happen for three reasons:

  1. Missing a meal.
  2. Stress or sickness.
  3. Insulin reaction (low levels of insulin in the bloodstream).

We were told in college that diaphragmatic breathing was a contraindication for our diabetic patients as it could cause ketoacidosis. From the textbook we were taught “To compensate for a tendency towards acidosis, the person may need to breathe more rapidly. Diaphragmatic breathing may actually change insulin levels”.

Now, don’t get me wrong, I give full props to the authors of that text as there was lots of good instruction in it, but research has been updated since then.

According to rapid breathing is a symptom of ketoacidosis, so this is typically occurring if the person hasn’t taken enough insulin. So yes, if the person is at the point of breathing rapidly we should not be giving them a massage as this is now becoming a medical emergency.

One study (1) actually showed that diaphragmatic breathing is an effective therapy for decreasing oxidative stress, improving blood sugar levels after eating, and improving glycemic parameters overall for those with type II diabetes.  

Another study (2) (done on people without diabetes) showed that diaphragmatic breathing decreased glycemia and increased insulin production after a meal (likely through activation of the PNS). The study suggests that even though it was done on athletes, it is worth looking at for the diabetic population because of the outcomes.

Now I know what you’re thinking, those two studies showed that diaphragmatic breathing altered insulin and blood sugar levels…isn’t that exactly what the text was talking about?

Well it is, but we were taught it was a contraindication. Studies are now recommending that the diabetic population should be using diaphragmatic breathing.

Our actual concern should be timing of food intake before someone with diabetes comes in for a treatment. If someone hasn’t eaten for three or four hours and comes in, their breathing patterns are not what is going to cause them to have a diabetic reaction, it’s the fact their blood sugar is already too low. There is nothing about the massage that is going to accelerate that anymore than if they were walking down the street or sitting on the couch at home. This is an important discussion to have with your patients who are dealing with diabetes and definitely one you should have. Once a proper management schedule is established, go ahead and move them passively, use diaphragmatic breathing and whatever length of stroke you like, they are all things that can help improve their condition.

I’d love to hear your thoughts on this in the comments below, especially if you know of any current research that says we shouldn’t do any of the things discussed in this post, cause maybe I just found the wrong research?



  1. Hegde S, Adhikari P, Subbalakshmi N, Nandini M, Rao G, D’Souza V. Diaphragmatic breathing exercise as a therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. Complementary Therapies In Clinical Practice [serial on the Internet]. (2012, Aug), [cited May 1, 2017]; 18(3): 151-153. Available from: CINAHL Complete.
  2. Martarelli D, Cocchioni M, Scuri S, Pompei P. Diaphragmatic Breathing Reduces Postprandial Oxidative Stress. Journal Of Alternative & Complementary Medicine [serial on the Internet]. (2011, July), [cited May 1, 2017]; 17(7): 623-628. Available from: CINAHL Complete

As the creator of the site, I hope you like what you’re reading. I’m a Registered Massage Therapist in Victoria BC, former Massage college clinical supervisor, First Responder instructor, hockey fan and volunteer firefighter. Come hang out on the facebook page, where we can share some ideas about how to improve the perception of the Massage Therapy industry.

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Jamie Johnston

Founder at The MTDC
As the creator of the site, I hope you like what you’re reading. I’m a Registered Massage Therapist in Victoria BC, former Massage college clinical supervisor, First Responder instructor, hockey fan and volunteer firefighter. Come hang out on the facebook page, where we can share some ideas about how to improve the perception of the Massage Therapy industry.
Jamie Johnston
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  1. James August 11, 2017

    must read article thank you

  2. Christine November 15, 2017

    Your definition of ketoacidosis is completely incorrect. Ketoacidosis only can occur in T1 diabetics for one. And two, it is when both glucose and ketones are high. Essentially, their bodies are full of two fuels and they are unable to burn either.

    • Jamie Johnston November 15, 2017

      Hey Christine, thanks for the feedback, I updated the description of ketoacidosis, so it’s hopefully clearer than what I originally posted. However, from what I can find it can happen with type II as well, it’s just far more common with type I


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