Orthostatic Dizziness and a Non-Healing Heel in Diabetes
A 72-year-old man with type 2 diabetes and hypertension attends for a relaxation massage. His medication includes metformin, gliclazide, an ACE inhibitor, and a diuretic. He has eaten breakfast two hours ago. On standing from the chair he feels light-headed and needs to sit down; his seated blood pressure is 138/82 mmHg and his pulse is 78, but on standing it falls to 104/60 with a pulse of 96. He mentions increased thirst and urination over the past week and a small cut on his heel that has not healed for three weeks. He has reduced sensation in both feet. He is keen to lie face down for an hour. The therapist must decide how to proceed, explain the physiological reasons for his symptoms, and identify when to stop and refer.
1. Explain the physiological basis of his postural dizziness and the change in pulse and blood pressure.
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His symptoms fit orthostatic (postural) hypotension. The usual threshold is a fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; his systolic fall is 34 mmHg and diastolic fall is 22 mmHg, with symptoms of cerebral hypoperfusion. Physiology: on standing, blood pools in the lower limbs, so venous return and stroke volume fall. Baroreceptors in the carotid sinus and aortic arch detect reduced stretch, trigger vagal withdrawal and sympathetic outflow, causing vasoconstriction and tachycardia to maintain blood pressure. In diabetes, autonomic neuropathy can impair this reflex, reducing vasoconstriction and the heart-rate response. His diuretic reduces blood volume, and the ACE inhibitor blunts angiotensin II-mediated vasoconstriction, both worsening the drop. The pulse rises, but not enough to prevent hypotension.
2. Interpret the thirst, urination, and non-healing heel cut in the context of diabetes and homeostasis, and state why they matter for the session.
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The thirst, urination, and non-healing heel cut point to poorly controlled diabetes and disturbed homeostasis:
- Hyperglycaemia exceeds the renal threshold, so glucose spills into urine and exerts an osmotic effect, causing polyuria. Water loss produces dehydration and thirst.
- Reduced sensation in the feet suggests peripheral neuropathy; he may not feel the cut or pressure damage.
- Poor healing reflects microvascular disease, impaired immune function, and neuropathy. The heel cut is at high risk of becoming a diabetic foot ulcer or infection. This is not a normal ageing change; it needs medical review of glucose control and wound care. Massage should not delay that.
3. Plan the session, including positioning, monitoring, contraindications, and referral.
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Plan:
- Do not use prone for an hour; the heel wound would be compressed and he is at risk of orthostatic symptoms when repositioning.
- Use semi-reclined or side-lying with the head elevated, keep the session short (about 30 minutes), and ensure he is hydrated.
- Check blood pressure and symptoms before, during, and after; stop if he becomes dizzy, sweaty, confused, or has chest pain.
- Avoid deep pressure on the feet and the heel wound, avoid heat, and do not massage over the wound.
- Refer: advise same-week GP review for the wound and glucose control; urgent review if the wound becomes red, hot, swollen, discharging, or if he has fever. Rationale: safety, infection control, and not masking a deteriorating diabetic foot.