By Matthew D. Hansen, DPT, MPT, BSPTS

Those who suffer from neuropathy canmaintain and improve their physical

strength, as well as reduce nerve pain,with a variety of basic exercises.

ExercisingWhile Living with Neuropathy

23IG Living | August-September 2015 | IGLiving.com

IT’S ESTIMATED THAT more than 20 millionAmericans suffer from peripheral neuropathy,1 a disorder ofthe nerves that run between the spinal cord and the body’sskin (sensory and autonomic nerves), muscles (motor andsensory nerves) and internal organs (autonomic and sensorynerves). Approximately 30 percent of peripheral neu-ropathies are of unknown cause, and another 30 percent arerelated to diabetes.1 Other contributing factors may beautoimmune disorders, endocrinal or metabolic disorders,nutritional imbalances, nerve entrapment/compression, certainmedications, tumors and heredity. Autoimmune diseases that may affect the peripheral nerves

and/or their connection with muscles include chronic inflammatorydemyelinating polyneuropathy, lupus, Sjögren’s syndrome,rheumatoid arthritis, POEMS syndrome, Guillain-Barrésyndrome and its variant axonal or neuronal neuropathy,Lambert-Eaton syndrome, myasthenia gravis and multifocalmotor neuropathy. In some cases, it’s not uncommon forperipheral neuropathies and autoimmune disorders to occurconcurrently, but they may be unrelated.Diagnosing neuropathies early is one way to control the

disease. But, once developed, exercise can help. Following are abrief discussion of the signs of neuropathy and some basicexercises to help control its symptoms.

Symptoms of Peripheral NeuropathyThe earlier peripheral neuropathy can be identified, the better

the chances are of controlling it and preventing permanentdamage. The unpredictability of peripheral neuropathy’s coursemay make it even more trying, with symptoms that may progressover years, come on rapidly or come and go.Sensory nerves, which run throughout the body, are the nerves

most frequently affected, often in both hands and feet. Someonewith neuropathy of the sensory nerves may experience pain(frequently described as burning or stabbing), tingling, numb-ness and/or other unusual sensations in the distribution of thenerves. Secondary complications may include poor balance ordevelopment of wounds (e.g., pressure sores on the feet) fromharmful stimuli that can’t be felt, sometimes as innocent as apebble in the shoe. When motor nerves are involved, the most common symptom

is weakness that further complicates balance, mobility and otheractivities of daily life. Other symptoms may include musclecramping, fasciculations (i.e., twitching), decreased reflexes andatrophy (muscle shrinkage). Autonomic nerves work unconsciously to control the function

of the body’s internal organs. Depending on which nerves areinvolved, autonomic neuropathy may affect heart rate, bloodpressure, digestion, bowel and bladder control, and the abilityto sweat.

Benefits of Exercise for NeuropathyAlthough exercise may not be able to fully reverse the

symptoms of peripheral neuropathy, it can help to preserve orimprove muscle strength, balance, range of motion and circu-lation (which increases oxygenation and the associated healingof nerve tissue). According to Greg Carter, MD, professor ofrehabilitation medicine at the University of Washington,aerobic exercise “improves not only physical functioning buthelps fight depression, maintain ideal body weight, andimprove pain tolerance.”2

Unfortunately, there aren’t many scientific studies relateddirectly to the effects of exercise on autoimmune disease-relatedperipheral neuropathies. However, there are studies regardingexercise’s effects on diabetic peripheral neuropathies (thoughcare must be taken not to draw exact comparisons). Some ofthese studies have actually demonstrated significant decreases inpain and other symptoms, as well as an increase in innervationof the nerves that run to and from the skin.3

Despite all the possible symptoms of peripheral neuropathy,it’s often foot pain that keeps sufferers from exercising.Sometimes simply standing or wearing shoes can be more thansomeone with foot neuropathies can bear. Fortunately, there area number of options to exercise in a partial-weight-bearing ornon-weight-bearing position.

The earlier peripheralneuropathy can be

identified, the betterthe chances are ofcontrolling it and

preventing permanentdamage.

24 IG Living | August-September 2015 | IGLiving.com

T.K.’s StoryWhile exercise can be beneficial for neuropathy, it can also pose a

threat. Following is a first-person account from “T.K.” of the dangersexercise can pose for neuropathy patients if not performed correctly:“In 2005, pain in my hands and feet led to a diagnosis of

diabetes and diabetic neuropathy. Brisk walking on my treadmill(30 to 35 miles a week) brought me back to my high schoolweight [and an improved blood glucose score]. However,because of my neuropathy, brisk walking became too hard onmy feet, causing blisters and temporary numbness in my toesdespite my best efforts. At the suggestion of one of my doctorsin 2013, I purchased an exercise machine to help control myblood sugar. Unfortunately, I used the machine incorrectly. “By February 2014, the outer halves of my big toes were

numb. I did not realize it was a warning sign and could morphinto greater neuropathic pain. Thinking the numbness meantthe nerves were dead and I could do no further damage, I maintainedmy workouts. In September 2014, my big toes and balls of myfeet suddenly became hypersensitive to pressure, and the simpleact of walking brought increased burning, pain, electric shocksand stabbing sensations, especially in the big toes and balls of myfeet. The neuropathic pains from the wrong exercises plagued andcontinue to plague my every step. I can no longer use the exercisemachine, have difficulty walking and spend most of my time onmy side in bed. When I walk, it is on my heels and the sides ofmy feet. I purchased seven Cashier mats for our wood floors andstand on folded towels in the shower. I am waiting on a quad canein hopes it will reduce the weight on my feet when I walk.”

SafetyWhen the feet are affected by neuropathy, exercises should

always begin and end with a foot check to ensure the absence ofpressure sores or blisters. Wearing socks that are designed toabsorb moisture and reduce friction can help to provide protection.Supportive shoes and orthopedic inserts to cushion the feet mayalso assist in preventing injury and increased pain that can resultfrom weight-bearing activity. High-impact exercises such as aerobics, jumping or running

(especially on a treadmill) should be avoided. These types ofexercises not only pound the feet, but they can also be veryunforgiving if someone missteps. Special consideration shouldbe given to activities that don’t place someone with neuropathyat unnecessary danger of falls. A proper exercise program can improve balance.4 However, those

who experience neuropathy in their upper extremities should takecare not to overstretch the shoulders and wrists. When performing

resistive exercise, a neutral wrist position should be maintained,possibly with the use of weightlifting gloves, and weight should beadded slowly because of the possibility of exacerbating “entrapmentneuropathies” such as carpal tunnel syndrome.

Stretching ExercisesAny exercise session should start with a warm-up. Slow,

sustained stretching (at least 30 seconds per stretch; repeatedthree to five times) can help to avoid muscle cramping, maintainor increase flexibility, and improve blood circulation along withoxygen delivery, which can lead to healing or regeneration ofperipheral nerves and help to avoid soreness. Yoga and tai chi areother good activities to help increase flexibility. Following aresome specific stretching exercises:

Calf stretch. Stand on a bottom step, hold onto the rail and let yourheels hang off the edge to stretch the calf muscles and Achilles’tendon (Figure 1). If pain increases, or if you have a difficult time

maintaining balance, you can perform the same stretch whilesitting, extending your leg(s) and using a towel around the ball ofthe feet to pull the ankle toward you (Figure 2). When the stretchis performed with a bent knee, it will target the Achilles closer to the

ankle; when it is performedwith a straight knee, it willtarget higher up the leg, closerto the knee and hamstrings.

Hamstring/sciatic nerve stretch.There are a number of ways tostretch the hamstring muscles,which make up the bulk ofthe back of the thigh. Perhapsthe simplest method is to sit ona chair or sofa and extend one

Figure 1. Calf Stretch

Figure 2. Calf Stretch

25IG Living | August-September 2015 | IGLiving.com

leg out in front of the body, and then lean forward at the waistuntil a gentle stretch is felt (Figure 3). The stretch can beincreased in the hamstrings, as well as target the long sciatic nervethat runs down the back of the leg, by reaching toward the footwith the opposite hand, pulling the ankle and toes toward thebody and/or slowly bending the head and neck forward.

Prayer stretch. Not to be confused with the back stretch bythe same name, the prayer stretch increases the pliability andblood flow to the median nerve that runs from the shoulder,down the arm and across the wrist. The median nerve is ofteninvolved in upper extremityneuropathies, including carpaltunnel syndrome. Press thepalms together in front of thechest in a prayer position andslowly raise the elbows and lowerthe hands while still keepingthem pressed together (Figure 4).Hold the position once a mod-erate stretch is felt, but ease upor discontinue the activity iftingling or numbness returns.

Partial-Weight-Bearing ExercisesPartial-weight-bearing activities are performed in a position

or medium (e.g., water) that allows part of the body’s weight tobe transferred to the feet but not all of it. Biking (especiallyrecumbent biking), water aerobics and wading in a pool aregreat partial-weight-bearing activities. The buoyancy principlesof water can be particularly beneficial because the body’sweight is only roughly 50 percent of normal when a personstands in water up to hip/waist level and just 10 percent of normalwhen a person stands in water that is up to his or her chest.

Non-Weight-Bearing ExercisesIf any degree of weight-bearing is a cause for increased pain,

non-weight-bearing (a.k.a., open chain range-of-motion) orisometric exercises can also be performed. Range-of-motion exercises (similar to stretching but without

the hold) help to improve circulation and stimulate nerveconduction. Begin the routine by sitting in a chair and performing10 to 20 ankle pumps on each side; then perform the samenumber of foot circles, first clockwise, then counterclockwise(Figure 5). You can slightlyincrease weight-bearingthrough the feet by per-forming toe and heel taps:Lift your toes as high as youcan, then tap them againstthe floor as you lift theheels; perform the oppositemotion by tapping the heelsand lifting the toes. Then,move up to the knee jointby lifting one of your feetinto the air with an extendedknee, lowering it to thefloor and repeating 10 to 20times on each side. Open chain range-of-motion exercises can be repeated in

the fingers, wrists and elbows by following the same pattern.Open and close the fingers and hands; alternately bend thewrists up, then down; and bend and straighten the elbows.Range-of-motion of the hips and shoulders can also beperformed, but is not described here because the two jointsrepresent more than a dozen motions, and most neuropathysymptoms are experienced in the distal limbs, farther awayfrom the trunk of the body (i.e., the hands and feet). For amore detailed description of non-weight-bearing activities, aphysical therapist, personal trainer or well-designed homeexercise video can be of assistance. To perform isometric exercises, contract the targeted

muscle, hold the contraction for three to five seconds, relaxand repeat.

BalanceIt’s always a good idea to place at least one hand on a stable

structure (e.g., a countertop, stair rail, table or steady chair)when practicing balance activities. As a given activity becomeseasier to perform, dependence on upper-extremity support can

Figure 3. Hamstring/Sciatic Nerve Stretch

Figure 5. Range-of-MotionExercise

Figure 4. Prayer Stretch

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31IG Living | August-September 2015 | IGLiving.com

decrease until just one or two fingers are in contact with thesupportive object. 1) Begin by doing simple weight shifts. With the feet spread

shoulder width apart, shift all of your weight to the right leg andslowly come up on the toes on the left. Now shift your weightback to the left leg and slowly come up on the toes on the right.2) After performing several repetitions of weight shifts, slowly

rise up on your tiptoes, then rock back on your heels.3) Now, march in place by alternately lifting just your

heels off the floor. As the activity becomes easier and remainsnonpainful, progress to lifting the feet higher and higher offof the floor.4) Finally, side-step around the kitchen counter in one direction

and then the other, by leading with one foot, then bringingthe opposite foot next to it. As balance improves, you can takelarger steps.

The Right Kind of Exercise Is KeyThe exercises presented in this article can be used as a starting

point or as a routine to revert to when the neuropathy is aggravated.When it is, foot or hand braces may help to reduce symptomsduring regular daily activity, and can be removed to performnon-weight-bearing range-of-motion exercises. If these activities

can be performed easily and pain-free, safely experiment withmore weight-bearing activities that don’t increase fall risk. T.K.’s purpose in sharing his story was to inform and warn

neuropathy patients and healthcare professionals who treat themof the dangers of over-exercising and/or of performing the wrong

kind of exercise due to a tendency to exacerbate neuropathicpain: “Increased pain in exercise and numbness for neuropathypatients are signs that something is wrong and must be investigated.The irony is that I unknowingly caused compression/trauma-induced neuropathic pain while trying to control myblood sugar! Exercise is good, but the wrong type and kind for aneuropathy patient with damaged nerves is dangerous.… If Ican prevent just one person from inadvertently causing severeneuropathic pain or more damage to damaged nerves by spreadingthe word about hazards of the wrong type and kind of exercise,perhaps some good can come from my misfortune.” Keep in mind that when it comes to neuropathy, it’s all about

taking one step at a time.

MATTHEW D. HANSEN, DPT, MPT, BSPTS, is a practicing physicaltherapist in Utah and president of an allied healthcare staffing and consultingagency named SOMA Health, LLC. He completed his formal education at theUniversity of Utah, Salt Lake City, and has additional training in exercise and sportsscience, motor development and neurological and pediatric physical therapy.

References1. The Neuropathy Association. About Peripheral Neuropathy: Facts. Accessed at www.neuropathy.org/site/PageServer?pagename=About_Facts.

2. American Academy of Neurology. Exercise Rx for Nerve Pain. Accessed at patients.aan.com/resources/neurologynow/?event=home.showArticle&id=ovid.com:/bib/ovftdb/01222928-200703020-00020.

3. Kluding, PM, Pasnoor, M, Singh, R, et al. The Effect of Exercise on Neuropathic Symptoms, Nerve Function, andCutaneous Innervation in People with Diabetic Peripheral Neuropathy. Journal of Diabetes and its Complications,2012;26(5):424-429.

4. Richardson, JK, Sandman, D, and Vela, S. A Focused Exercise Regimen Improves Clinical Measures of Balance inPatients with Peripheral Neuropathy. Archives of Physical Medicine and Rehabilitation, 2001;82(2):205-209.

Author’s note: Specially designed home exercise videos can be purchased atwww.freedom2move.org or www.sitandbefit.org.

Range-of-motionexercises help to

improve circulationand stimulate

nerve conduction.