Diabetes Forecast

You Can Exercise With Neuropathy

When George Simmons, 39, is riding a bicycle, it's common for him to look down and realize that his heel rather than the ball of his foot is on a pedal. Simmons lives with peripheral neuropathy (PN) and can't always feel his feet. While the numbness and tingling from 10 years of living with PN didn't stop him from riding 32 miles in an American Diabetes Association Tour de Cure® fund-raiser in Long Beach, Calif., he has made some crucial steps in his diabetes management.

4 Paths to Fitness

Several types of exercise are possible with peripheral neuropathy, and a combination of types is often best. Check with your doctor about specific recommendations for you.
Cardio exercise is defined by an increased heart rate and an intensity level that is fairly low, which is what allows you to perform this type of exercise for anywhere from 10 minutes to several hours.

Swimming, water aerobics, stationary bike, rowing, and tai chi are great cardio options because they are gentle on the soles of your feet and generally are safe for a person with some loss of balance or muscle weakness.

Aerobic exercises such as jogging, jumping rope, and step aerobics are less suitable because of the high impact on your feet and the need for good balance. If you have unhealed ulcers or wounds on your feet, your doctor may recommend staying off your feet. Ask about sitting exercises and other ways to keep physically active.

Strength trainingis essential to counteract the loss of strength and balance that often comes with PN. Circuit-training machines, which offer stability with the dictated movement of the machine, are a great choice for building strength safely throughout your entire body.

Calf Raises: Place your hands on a sturdy staircase railing, with the balls of your toes on a step of the staircase and your heels hanging off the step. Keep your legs mostly straight while you allow your heels to drop until the stretch is deep enough for your level of flexibility, then steadily raise yourself up on the balls of your toes, engaging and strengthening your calf muscles. Do 10 to 20 repetitions for a set. Rest for a few minutes and repeat for additional sets. Aim for three sets total.

Balance exercisesmay help improve any loss of stability by counteracting the loss of feeling in your feet. Try to practice balance exercises while standing near a kitchen counter or wall for support.

Standing Knee Raises: Place one or both hands on the kitchen counter and raise the knee of one leg (to the height of your belly button if you can). Gradually, without touching the floor with your raised leg, keep your knee bent and move your leg directly behind you, and then out to the side. Do 10 to 15 repetitions on one leg; then switch legs and continue for one set. Rest for a few minutes and repeat for additional sets. Aim for a total of three sets. As you feel more comfortable, consider using only one hand, or no hands, but stand near the counter for support if needed.

Stretchingis important for all of us as we age, but for a person with PN, stretching plays a crucial role in improving blood circulation.

Calf Stretch: While you're performing calf raises for the strength benefits, take a moment to let your heels hang off the edge of the step to stretch the calf muscle and the back of your ankle.

Hamstring Stretch:
Sit on a sturdy chair and extend one leg, keeping it parallel to the floor. Bend gently at the hips, pushing the heel of your straight leg into the floor as you lean forward. Hold for a count of 10. To increase the intensity of the stretch, try reaching forward with the hand opposite the extended leg.

Simmons first felt the symptoms of PN 10 years ago, when he would wake up in the middle of the night. "It felt like someone lit a match and held it right against the bottom of my feet," he says. "There was no rhyme or reason to the pain. It would come and go throughout the night, and eventually it started happening during the day, too."

Causes and Symptoms

PN is most common with uncontrolled and/or long-duration diabetes, linked primarily with poor blood glucose control, obesity, high blood pressure, and poor circulation. The symptoms—pain, loss of feeling, or both—are the result of nerve damage due to high blood glucose levels and poor blood flow to the affected area. Other causes of PN include kidney failure, poor nutrition, chronic alcoholism, exposure to toxic chemicals, and medications used to treat HIV/AIDS.

When the symptoms hit Simmons, his type 1 diabetes was uncontrolled. "I checked my blood sugar barely once a month," he says. "I took insulin in the morning and at night, but I didn't pay much attention to the carbohydrates I was eating. My A1C back then was 12.5 percent; my blood sugar was constantly over 300 mg/dl."

The symptoms of burning, tingling, and numbness that Simmons felt in his feet can also occur in the hands and legs. Others describe the symptoms as freezing pain or a sharp, almost electric stinging. Areas affected by PN may become very sensitive to the touch. Over time, PN of the feet and legs can lead to weakness and loss of balance.

Sheri Colberg, PhD, FACSM, says, however, that PN need not get worse: "There is some evidence that improving blood flow to the feet with regular physical activity can prevent additional problems and even reverse the condition somewhat."

Unfortunately, the varying forms of pain, weakness, and loss of balance are all reasons why exercising with PN can be difficult. A customized plan for physical activity can keep you moving in healthful ways.

Pain Control

When it comes to thwarting a desire to exercise, pain may be the symptom that "speaks" most loudly. "It was frustrating," explains Simmons, "because the pain kept me from sleeping well, which affected my energy to exercise during the day. To lessen the pain, I'd wake up to squeeze and rub my feet. Eventually, I'd fall back asleep. Then I'd wake up a few hours later to do it all over again."

As with many aspects of managing diabetes, medications and behavior change can work together to tame neuropathy pain. "For pain and symptom relief, the medication standards include Cymbalta and Lyrica," says Marc Sandberg, MD, an endocrinologist in private practice in Flemington, N.J. "No one should suffer, and you should absolutely seek treatment from a pain specialist if your symptoms persist." Sandberg points out that some researchers have looked at whether a dietary supplement derived from vitamin B1 may halt the progression of neuropathy. But there's not enough evidence for such treatment to be recommended as a standard of care.

There are things you can do to decrease the risk of more nerve damage. "Two of the most important changes a person can make," Sandberg explains, "are to quit smoking and get your A1C as close to normal as you can safely achieve with the support of your health care team." The general target for the A1C (a measure of your average blood glucose level for the past two to three months) is below 7 percent
for many people, with your specific target range customized for you.

Positive Changes

A long day of traveling finally motivated Simmons to make his diabetes a larger priority. "Most nights, my wife checks my feet to look for cuts or bruises, but I was so tired from traveling, I went straight to bed. I woke up the next morning to find one of my toes had turned purple."

Simmons fortunately went to the hospital as soon as he noticed the discoloration. "They told me I was lucky," he says. "I had a tiny cut under my toe that had become infected. They gave me antibiotics, and everything was OK, but to this day, that toe is still slightly a different color."

The message to check feet daily when you have PN is loud and clear. "It's imperative," says Colberg, "that you check your feet every day, wear socks that help keep your feet drier, and get shoes that fit snugly and don't cause blisters." A blister, for a person with PN, could quickly and easily lead to an infection like the one Simmons experienced.

The realization that he could have lost his toe gave Simmons the reality check and motivation that he needed. "I started exercising, counting the carbohydrates in my meals, and checking my blood sugar at least six times a day, sometimes eight. I also started going to my doctor appointments regularly and asking for help," he says.

While Simmons has made a concerted effort to reduce the carbohydrates in his diet to manage his blood glucose levels, Sandberg explains that there is no particular dietary recommendation for a diagnosis of PN. The B vitamins and vitamin E are important for nerve health, however. A deficiency of B12 is associated with nerve damage. Food sources of vitamin B12 include meat, fish, eggs, low-fat dairy foods, and fortified cereals. Enriched whole grains provide vitamin E, niacin, and thiamine.

Since making many significant changes in his life, Simmons hasn't felt the sharp, burning pains in his feet. Instead, what remains is a constant numbness and tingling, as though his feet are constantly asleep. "I'm always stomping my feet," he says, "because I can feel my whole foot and it assures me that I haven't lost all of the feeling."

Moving Safely

The most effective and safest choices of exercise when PN is in the picture depend on the severity of neuropathy symptoms. Also consider any other conditions with exercise cautions, such as cardiovascular disease and proliferative retinopathy. A combination of several different types of exercise is typically the most helpful exercise plan. Cardio, strength-training, flexibility, and balance exercises are all important for a person with PN. (See "The Right Fit," above right, for specific exercises in each category.)

Treadmills, says Simmons, make him nervous because he can't actually tell where his feet are on the machine without looking down. "In basketball, sometimes I land on my heel instead of the balls of my feet," he adds. "I've always been pretty coordinated, so I know this is because of my PN."

Simmons continues to make progress in his health by exercising regularly (always training for his next Tour de Cure fund-raiser) and checking his blood glucose often. His most recent A1C was 7.8 percent, and he's lowered his LDL ("bad") cholesterol level from 160 to 80. While the PN won't go away, he knows everything he does today will ensure the health and safety of his feet for years to come.

"I haven't gotten used to the numbness. I've accepted it, but I'm constantly aware that something isn't right," Simmons says. But he presses on. "I am not going to let diabetes take my feet away."

Ginger Vieira has lived with type 1 diabetes and celiac disease since 1999 and fibromyalgia since 2014. She is the author of Pregnancy With Type 1 Diabetes, Dealing With Diabetes Burnout, Emotional Eating With Diabetes, and Your Diabetes Science Experiment. Ginger creates content regularly for Diabetes Strong, Healthline, Health Central, Diabetes Daily, Everyday Health, and her YouTube channel.



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