Class 22 Flashcards
Systems Complications (Cardiovascular) Hypertension
→ result of combined effects of heart & blood vessel changes & lung, liver, kidney stresses
Systems Complications (Cardiovascular) Large Vessel Damage (diabetic macroangiopathy)
→ increased incidence of atherosclerosis
→ thickening from irritation/damage of vessel walls
(arteriosclerosis)
→ onion-skinning: recurrent internal scarring, from
high blood pressure & blood pH
Systems Complications (Cardiovascular) Small Vessel Damage (diabetic microangiopathy)
Hyalinization is form of tissue degeneration in which normal tissue components deteriorate & there is excess production of extracellular matrix. Result is homogeneous & glassy material. Arteriolar hyalinization is like onion skin lesion in arteries, forming in layers in tunica media (smooth muscle
layer) sometimes also endothelium basement membrane &/or adventitia layer. It results in reduced lumen size & loss of contraction/dilation capacity of vessel wall. Similar degenerative process can occur in cells of capillary walls, making them stiff & impenetrable, also resulting in poor myoepithelial response (ability to change size of pores between cells). Results in ↓tissue nutrition/function, ↑ TPR, edema.
Systems Complications (Cardiovascular) Heart Damage (overlaps with other vital organ stress)
→ heart wall perfusion is reduced
→ cardiac muscle glucose supply is compromised
→ coronary arteries strongly affected by atherosclerosis
→ heart is stressed by hypertension
→ body tissue needs lead to increased demands on heart
→ congestive heart failure develops
Systems Complications (Cardiovascular) Increased Risk of Infarction
→ tissue death due to loss of blood supply
→ can occur in various locations
→ diabetics have higher incidence of angina pectoris & heart attack, & TIAs & stroke than non-diabetics
Damage to cardiovascular system is now understood to start at __________________________.
prediabetes stage, so before diabetes diagnosis.
Up to 80% of people with diabetes die of ________________ (compared to 50% in the general population).
CV disease
After having stroke or heart attack, people with diabetes are at ↑’d risk of having ___________________ or __________________compared to non-diabetics. People with diabetes are also more likely to need an angioplasty.
second stroke or heart attack
Studies have shown that CV system of adults with Type 2 diabetes may have?
impaired ability to adapt to exercise. MRI scans showed that teens with Type 2 diabetes had hearts that did not expand & fill with blood to same capacity as those without diabetes. Teens were also shown to have less blood flow through femoral arteries.
Study at Heart & Diabetes Research Institute in Melbourne, Australia found correlation between?
insulin resistance & increased sympathetic nervous system activity. This is because of multiple changes in beta 2 & beta 3 adrenoceptor genes. SyNS activity accompanying insulin resistance is closely linked with left ventricular hypertrophy in patients with Type 2 diabetes, even those without high blood pressure.
After 10-15 years, all diabetics have ___________________________.
some degree of CV impairment
(Diabetes) Increased Risk of Gangrene
→ 100 times more likely to occur in diabetic
→ may develop from minor injury/wound
→ combined effects of poor tissue resilience, toxic conditions, impaired perfusion/ drainage, tendency to infection
→ risk of amputation, especially in lower limb
(Diabetes) Kidneys
→ high incidence of renal artery atherosclerosis
→ high incidence/recurrence of kidney infections & stones
→ adversely affected by hypertension
→ very damaged by diabetic micorangiopathy
→ their blood supply & nutrient supplies compromised
→ nephritic & nephrotic syndromes
→ glomerulonephron destruction
→ high incidence of kidney failure
(Diabetes) Vision
→ impaired eye tissue health, susceptibility
to infection, impaired extrinsic & intrinsic circulation
→ high incidence of microbleeds
→ potential for impaired neurological controls
→ increased incidence of cataracts &
glaucoma
→ vision impairment of some degree is typical
→ significant incidence of both legal & total
blindness
(Diabetes) Liver
→ extremely high workload under adverse conditions
→ blood supply, glucose & enzyme supplies compromised
→ adversely affected by hypertension
→ high incidence of liver damage
(Diabetes) Digestion
→ digestive problems show up pervasively
→ combinations of indicators of poor digestion & elimination, with nausea & diarrhea prominent
→ digestive structures can be uncomfortable, painful
(Diabetes) Skin
→ reduced cellular health/resilience
→ compromised local circulation, especially in extremities
→ increased susceptibility to bacterial & fungal infection
→ increased risk of injury due to sensory deficits
→ increasing tendency to breakdown, ulceration
Nervous System (Central Nervous System)
→ seizures (usually from non-compliant behaviour)
→ various impairments of body system controls
→ increased tendency to develop dementia
Nervous System (Peripheral Nervous System)
→ nerve damage is very common
→ paraesthesias & sensory loss (hypaesthesia, anaesthesia) are most common symptoms; most marked in extremities, especially feet (“sock & glove anaesthesia”)
→ neuropathic pain also common
→ motor weakness may also occur
Diabetes and Foot Care
Many people with diabetes have problems with their feet. Ask doctor to explain your risk factors for foot problems. Can prevent serious foot problems by following basic guidelines.
Diabetes and Foot Care: A Patient’s Checklist *DO…
…check feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual markings
…use mirror to see bottom of feet if can’t lift them up
…check colour of legs & feet. If swelling, warmth or redness or if pain, see doctor or foot specialist right away
…clean cut or scratch with mild soap & water & cover with dry dressing for sensitive skin
…trim nails straight across
…wash & dry feet every day, especially between toes
…apply good skin lotion every day on heels & soles; wipe off any excess lotion
…change socks every day
…always wear good supportive shoe
…always wear professionally fitted shoes from reputable store; professionally fitted orthotics may help
…choose shoes with low heels (under 5 cm high)
…buy shoes in late afternoon (since feet swell slightly by then)
…avoid extreme cold & heat (including sun)
…exercise regularly
…see foot care specialist if need advice or treatment
Diabetes and Foot Care: A Patient’s Checklist *DO NOT…
…cut your own corns or calluses
…treat your own in-growing toenails or slivers with razor or scissors – see doctor or foot care specialist
…use over-the-counter medications to treat corns & warts – are dangerous for people with diabetes
…apply heat to your feet with hot water bottle or electric blanket – you could burn feet without realizing it
…soak feet
…take very hot baths
…use lotion between toes
…walk barefoot inside or outside
…wear tight socks, garters or elastics, or knee highs
…wear over-the-counter insoles – can cause blisters if not right for your feet
…sit for long periods of time
…smoke
Foot Care Issues/Adaptations
Keep in mind that massage therapist can play important role in helping monitor foot tissue, especially when sensation &/or vision impairments are present.
Stay alert for lesions, even minor, & adapt accordingly.
Use doctor-approved skin lotions/creams if indicated.
Remember tissue may be quite fragile to pressure & temp.
Hygienic practices at all times!
Take precautions related to decubitus ulcer risk (positions, pressure releases, adapt techniques, remove oil/lotion, don’t leave tissue wet); no onsite massage if red spot present.
Diabetes Case History Questions
• When were you diagnosed? How many years have you had diabetes?
• What type of diabetes do you have? Are you insulin dependent?
• Is there family history of diabetes?
• Have there been any major changes in your diabetes status?
• Has your diabetes usually been stable?
• Have you been compliant with medications & diet?
• Have you had any diabetic emergencies? What type? How recently? What cause(s)?
• Have you had any surgeries or amputations because of diabetes?
• How often are you checked medically? Last diabetes specialist appointment?
Diabetes Case History Questions - Insulin and Meds Profile (For insulin users:)
• How long have you been using insulin?
• How is your insulin delivered?
• Have you been using the same insulin type(s) for a while? Does your body tolerate it well? Any side effects?
• Have your dosage levels been stable for a while?
• Are you stable during exercise? Do you have to adapt your insulin use to exercise? Stress?
• Are you regular & compliant in using your insulin?
Diabetes Case History Questions - Insulin and Meds Profile (If using a pump:)
• Where is cannula currently inserted?
• What sanitary practices are required around insertion site?
• What do you normally do with it when you sleep?
• Are there restrictions on getting area wet?
Diabetes Case History Questions - Insulin and Meds Profile (If using injections:)
• Where do you usually inject? Do you have an injection site pattern that you follow?
• Where have you injected in past two days? So far today?
• Do you ever have irritation reactions at injection sites (inflammation, swelling, rash, etc.) If yes, how long do they last? How are they normally treated? How long does on-site touch/water/oil need to be avoided?
• Have you been told to avoid rubbing the tissue after injecting there? To avoid using heat on it? For how long after injecting?
• Do you have any old injections sites that are problem for you (painful, stiff, restrict movement, etc.) If yes, where?
• Have they received any treatment, massage or other? How did that go?
Diabetes Case History Questions - Insulin and Meds Profile (For oral medication users:)
• What type of oral med(s) do you take?
• Have you been on the same drug(s) for a while? •Has the dosage(s) been stable?
• When and how often do you take your diabetics medication(s)?
• Are there any side effects you have been experiencing?
Diabetes Case History Questions - Insulin and Meds Profile (Other medications:)
• In addition to diabetic medication(s), are you taking anything else? Which drugs(s) and why?
• Are you having any side effects from any of these medications?
• Started any new medication or new dosage recently? Has your diabetic stability been affected? If yes, have you discussed this with your doctor? Is it affecting you right now? Describe.
Diabetes Case History Questions - Current Diabetes Stability
• Have you had any recent ‘bugs’ or illnesses? Affecting you now?
• Have you had any recent injuries? Surgeries? Current status? Is there significant pain or swelling? Are you here for injury or post-surgical treatment?
• Do you currently have any infections anywhere?
• Any diabetic crisis, or has your diabetic stability been different in the past week as a result of [any of the above]?
• Has there been any recent change in your activity or exercise routine?
• How is your level of stress? Have there been any recent changes at home/work that are increasing your stress levels?
• How are your sleeping habits? Do you tend to become unstable with insufficient sleep?
• Do you eat well/regularly? Any recent dietary changes? What time did you have your last meal?
• Do you use alcohol/recreational drugs? Within last few days? Have you ever become de-stabilized as a result?
• Pregnant? Breastfeeding? Puberty? Menopause? If pregnant, ask about MD monitoring.
• How does your body respond to massage? Any instability reactions? If yes, what and when?
• Other than those mentioned, do you know of any destabilizing factors present for you right now?
• Best sugar source if you destabilize? Do you have sugar with you? If yes, where is it?
• What is best way for me to respond if you were to de-stabilize?
Diabetes Case History Questions - General Health Status
• Other than diabetes, do you have any other health conditions? [respond to general case history info with follow-up Qs as appropriate]
• History of injuries, surgeries?
• Would you say that in general your health is good? How about today (current presentation)?
• Do you exercise regularly? How often? How long? Type(s) of exercise (i.e., cardio, weights, etc.)?
• Are you seeing other health care practitioners? What have they been doing for you?
• Do you get infections easily? Are there specific precautions I need to take/be aware of?
• Do you injure easily? Tissues fragile anywhere? How fragile is your skin? Do you have any special needs regarding the type of oil/lotion used?
• Do you have delayed healing? How long did it take you to heal from your last paper cut, say? Have you injured a muscle or joint recently, or had a fracture? How long did it take to heal? How well did it heal?
• Do you have any skin conditions? Are there specific precautions I need to take/be aware of?
• Do you presently have any ulcers/open sores/lesions? Details about location and care.
• Do you have any old ulcer sites? Are they well healed? Any ongoing concerns/restrictions?
• Do you have any ongoing problems with your feet? Hands? Details.
Diabetes Case History Questions - Cardiovascular Status
• Do you have high blood pressure? What is your usual blood pressure? When was your last reading?
• Do you have impaired circulation? Where? Any cyanosis?
• Do you have any swelling? Where?
• Has your doctor given you any restrictions on exercise?
• Has your doctor given you any restrictions on bath/shower temp?
• Do your hands/feet react adversely to hot/cold temperatures?
• Do you hhave any cholesterol problems (i.e., elevated LDL)? Do you have to follow a specific diet as a result?
• Have you had an angiogram? Have you been diagnosed with atherosclerosis? (location(s), severity, thrombus risk)
• Do you have any history of angina pectoris? Heart attack?
• Do you have any history of stroke? TIA?
• Have you been told you have heart failure? An enlarged heart?
• Have you ever had gangrene? Details about location, surgery, current status.
• Do you currently have any body areas that your doctor considers pre-gangrenous? Details,
precautions.
Diabetes Case History Questions - Kidney Status
• Do you have history of kidney infection or kidney stones? Recently? Currently?
• Have you been tested for high protein in your urine? What were the results?
• Have you been told your kidneys are affecting your blood pressure?
• Do you have full body swelling?
• Has your doctor put any restrictions put on your daily activities because of kidney problems?
• Have you been told you have kidney failure? Are you using dialysis?
Diabetes Case History Questions - Other Organ System Status
• Has your diabetes affected any other organs or areas of your body that haven’t already been discussed? (i.e., digestion, liver, respiratory)
• Are there any problems with your vision? Any adaptations I need to make because of your vision?
Diabetes Case History Questions - Massage Treatment Related Questions
• What brings you in for a massage? What are your treatment goals? Priorities?
• Have you had massage therapy before? When? What type?
• What did the therapist do? What worked and didn’t work?
• Did the therapist use hydrotherapy?
• Did you ever find you tended to be tired or lightheaded after a massage?
• Did your blood pressure go up from massage?
• Did you have any adverse reaction to treatment? If yes, details.
• Did you find you needed to adapt your insulin/medication for massage therapy?
• Did you and the therapist find you needed to make adaptations to the treatment plan? (i.e., lotion/oil application and removal, length of massage, full body or partial, types of hydrotherapy, pressure, techniques)
• Are there body areas we should avoid today? In general? (i.e., tender spots, wounds, irritated areas,
decubitus ulcers, etc.)
• When did you take your insulin/medication most recently today?
• What is the best scheduling of your treatments relative to your insulin/medication?
• How frequently do you have to urinate? Do you need to use the washroom before commencing treatment?
• Will you likely have to go during treatments?
• Will you agree to tell me honestly if you have done anything between treatments that you know might be destabilizing (i.e., skipped medication, rushed to get here, drank too much, stayed up all night studying) that might affect our treatments?
• Will you agree to make a habit of eating something in the half hour before our treatments?
• Will you agree to let me know if you believe it is unwise to have massage on any given day, or that the treatment needs to be modified?
• If I need to, do I have your permission to address questions to your doctor?
Massage Therapy Concerns and Adaptations (Always assess patient’s diabetic stability)
→ Ask about insulin/medication stability
→ Evaluate any current destabilization factors
→ Ensure patient has eaten recently
→ Ask if patient has exercised in previous few hours
Massage Therapy Concerns and Adaptations (Injection Sites) *Current Sites
→ Make sure you have current info about site usage & observe current sites for signs of redness/irritation
→ No onsite massage for 24 hours (at least 10 cm away)
→ No onsite hydrotherapy for 24 hours (at least 10 cm away)
→ Wait at least 10 days after discontinuation of site use before focused onsite work
Massage Therapy Concerns and Adaptations (Injection Sites) *Insulin Pumps
→ Ask where the cannula is inserted & keep at least 10 cm away
→ All positions okay as long as tubing is not compressed or twisted; pump can sit next to patient on table
→ When changing patient’s position, remember to move equipment at same time
→ Wait at least 10 days before focused work on former insertion site
Massage Therapy Concerns and Adaptations (Injection Sites) *Old Sites
→ Often involve build-up of matted collagenous scarring, altered skin contours, etc.
→ Degenerative changes in local tissue health & quality
→ Poor sensation, possible pockets of edema, reduced ROM d/t scar tissue
→ Scar work strategies will have to be considered case by case depending on tissue health, circulatory integrity, location
→ Begin conservatively & monitor reaction post-treatment for redness, inflammation, pain, bruising, etc.
Massage Therapy Concerns and Adaptations - Hygienic Practices
→ Stay alert to fact that person is prone to infection
→ Possible open sores &/or irritated injections sites
→ If you are sick, use mask, & do not treat patients with advanced diabetes or identified immune impairments
Massage Therapy Concerns and Adaptations - Hydrotherapy
→ Consider patient’s stability & other complications (high BP, CHF, kidney function, neuropathy, etc.) that may be present
→ Assess capacity of target tissues to handle nature/intensity of proposed treatment before applying (check tissue temperature & colour, reaction to patch test, etc.)
→ Full body hydrotherapy treatments are not recommended for advanced diabetic conditions
→ Caution with wet foot hydro applications to avoid drying out skin or promoting skin breakdown
→ If wet hydro is used, make sure tissues are well dried, especially in extremities
→ If part is covered with plastic for hydro application, avoid heat temps that would promote perspiration inside plastic
→ Modify hydro appropriately for injection sites
→ Sensory impairments require greater therapist monitoring
Massage Therapy Concerns and Adaptations - Modalities/Techniques
→ Consider all complications present
→ Consider tissue quality & resilience
→ Possible sensory loss, requiring greater therapist monitoring
→ Talk to patient & have open communication about comfort level, sensation of pressure & temp
→ Consider vascular and connective tissue fragility that may be present, especially in extremities
→ Frictioning & deep techniques may need to be modified or avoided based on tissue status, especially in extremities (is tissue resilient? is there sufficient perfusion & drainage? etc.); consider replacing with less intense techniques
→ If edema present, elevation & lymphatic drainage are indicated but HBP/CHF-related position modification may be needed
→ Improving circulation to vulnerable tissues is an important treatment goal, but must be approached within context of what can be safely accomplished
Massage Therapy Concerns and Adaptations - Treatment Intensity/Duration/Design
→ Begin conservatively & monitor any reactions post treatment
→ Shorter/partial treatments may be indicated at beginning of new treatment plan to monitor patient’s response
→ HBP/CHF-related modifications as needed
Massage Therapy Concerns and Adaptations - Patient Monitoring
→ Stay aware of tendency toward promoting hypoglycemic state during & post massage
→ Advise patient to have snack in half hour before treatment begins & check it has occurred
→ Watch for signs of changes in heart rate, breathing rate, tissue colour & temp; ask about nausea, etc.
→ Check in with patient regularly for any changes in wellness
→ Sensory impairments require greater monitoring, “patch tests” & careful treatment progression
→ Orthostatic hypotension may occur
Massage Therapy Concerns and Adaptations - Ulcers/Gangrene
→ Always observe feet & legs for areas of redness, irritation &/or edema, cracks or fissures, ulceration; hands can be vulnerable as well in some patients
→ Do not leave lotion/oil on feet or between toes
→ If patient is in wheelchair or bedridden, may be susceptible to ulceration in other pressure areas
→ Different stages of ulcers may be present, beginning with “red spot” & ranging to visible bone in extreme cases
→ Follow decubitus ulcer guidelines, for prevention & how to respond if present
→ If gangrene present, only treat with MD consultation
→ Onsite & distal massage is CI
→ No oil/lotion nearby (where tissue is susceptible to breakdown)
→ In general, hypervigilance about hygienic practices around such friable or vulnerable tissues
Massage Therapy Concerns and Adaptations - Exercise/Self Care
→ Appropriate regular exercise is very important
→ Exercise can be destabilizing
→ Take into consideration patient’s previous experience, current experience, health factors, & build around patient’s lifestyle
→ If advanced diabetic condition, consult with exercise specialist/physiotherapist &/or medical specialist
Massage Therapy Concerns and Adaptations - When Any Massage Treatment is Not Appropriate
→ Patient is currently unstable diabetically
→ Consider postponing treatment when new meds/dosage being started; MD consultation is appropriate
→ If gangrene is present, only treat in region with MD consultation; if not yet medically evaluated, postpone treatment
→ Presence of infection with systemic symptoms, or any new, not yet medically evaluated infection
→ Very unstable blood pressure or CHF
