Exercise With Neuropathy: What to Ask

Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. Cancer treatment can cause it, and NCI separates the effects into three kinds. Knowing which kind you have changes the exercise plan.

Sensory nerves carry feeling. Damage brings tingling, numbness, or a pins-and-needles feeling in the feet and hands, which may spread up the legs and arms. NCI notes it can also blunt the ability to sense temperature or pain.

Motor nerves drive muscles. Damage brings weak or achy muscles, muscle twitching, tripping, and loss of balance.

Autonomic nerves run background systems. Damage can cause dizziness from low blood pressure, plus changes in digestion and sweating. That one matters for exercise more than people expect, because standing up fast from a mat is a real risk.

This is common and it lingers. In one trial NCI reported on, more than 40 percent of participants still had numbness and tingling in the hands or feet two years after taxane chemotherapy, and 10 percent called their symptoms severe.

NCI reported on a study of more than 500 survivors, most of them treated for breast cancer, about six years after chemotherapy. Roughly 45 percent still had numbness in the hands and feet. Those with lasting neuropathy were twice as likely to fall.

Here is the part that matters. The researchers found that neuropathy did not cause muscle weakness. It changed movement and gait patterns instead, in a way that appears neural rather than muscular. The recommendation that followed was rehabilitation that compensates for the lost sensation, focused on improving balance during movement and correcting gait.

Read that as an instruction. Lifting weights alone will not fix this. Your feet are sending back bad information, and the answer is retraining how you move on them.

If you cannot fully feel your feet, you will not notice a blister, a cut, a pebble in the shoe, or a burn. Any of those can become an infection, and during chemotherapy an infection is a serious event.

NCI's advice is direct: check your feet daily for injuries, and wear sturdy shoes with soft soles.

Make it a fixed habit tied to something you already do, such as before bed.

• Look at the top, the sole, between the toes, and the heel.
• Use a mirror on the floor or ask someone if you cannot see the bottom.
• Feel inside each shoe with your hand before putting it on.
• Never walk barefoot, including indoors and at the pool.

The same numbness affects temperature. NCI advises using potholders in the kitchen and having someone else check bath water before you get in.

Sturdy with soft soles is the standard. Fill in the rest at a store that measures your feet.

• Closed toe and closed heel. No flip-flops, no backless clogs.
• A fastening you can tighten, such as laces or a strap. A loose shoe changes your gait.
• A sole thin enough to feel the ground but firm enough to protect it. Very thick cushioned soles can make balance worse when your sensation is already poor.
• Enough room that nothing rubs, since a rub you cannot feel becomes a wound.
• Shoes on before you leave the bed in the morning if your balance is worst then.

NCI states that exercise training and testing are generally safe for cancer survivors, based on the 2018 American College of Sports Medicine roundtable. The same review found that moderate aerobic training, resistance exercise, or both, during and after treatment, can reduce anxiety, depressive symptoms, and fatigue, and can improve quality of life and physical function.

The federal Physical Activity Guidelines for Americans set the target for adults: 150 to 300 minutes a week of moderate-intensity aerobic activity, or 75 to 150 minutes of vigorous activity, plus muscle-strengthening work on at least 2 days a week. Older adults are told to add balance training as part of a multicomponent routine.

The guidelines also speak directly to people who cannot hit those numbers. Adults with chronic conditions should be as physically active as their abilities allow, should avoid inactivity, and should be under the care of a health care provider. Some activity beats none.

NCI's summary of the ACSM work gives a usable starting dose: about 30 minutes of aerobic exercise three times a week was enough to improve anxiety, depression, fatigue, quality of life, and physical function, with resistance exercise twice a week.

Match the activity to the deficit.

• Seated or supported cardio first. A recumbent bike, an upright stationary bike, or an arm ergometer removes the balance demand. Water walking in a pool does the same, if the pool floor is not slick and you can enter safely.
• Hold on for balance work, on purpose. Standing exercises done at a kitchen counter let you train the skill without risking a fall. Progress by using fewer fingers, not by letting go all at once.
• Watch the surface. Grass, gravel, sand, and thick carpet demand ankle feedback you may not have. Smooth, level, well-lit surfaces are the place to build volume.
• Use vision to replace feeling. Keep the path lit, keep your eyes up, and avoid exercising in dim rooms, since you are now relying on sight to know where your feet are.
• Grip matters too. If your hands are numb, use straps or machines rather than heavy free weights you might drop.

Bring these to the next visit:

• Is my neuropathy sensory, motor, autonomic, or a mix?
• Which drug caused it, is it still in my plan, and would a dose change or a break help?
• Will you refer me to physical therapy or a cancer rehabilitation program for balance and gait work?
• Should I have a formal fall risk assessment?
• Does my blood pressure drop when I stand, and should I be checked for that?
• Is a treadmill safe for me, or should I use a bike?
• Should I see a podiatrist about foot care and shoes?
• Do any of my medicines add to dizziness or unsteadiness?
• Is there anything in my plan, such as bone involvement or a low platelet count, that limits what I should do?

Call your care team the same day for:

• New or fast-worsening weakness, especially trouble lifting the front of your foot.
• A cut, blister, sore, or ulcer on the foot, or any redness, warmth, swelling, or drainage. With a fever during chemotherapy, treat this as an emergency and go in.
• New numbness spreading upward.

Call 911 or go straight to an emergency department for:

• New trouble breathing or new trouble swallowing.
• Fainting or blacking out.
• A fall with a head strike, above all if you take blood thinners, or if you cannot bear weight afterward.

Dizziness on standing that does not settle is a same-day call rather than an emergency, unless you actually pass out.

See Neuropathy During Cancer Treatment for the symptom itself and Balance and Fall Prevention After Cancer Treatment for the training detail. Also useful: Exercise During Cancer Treatment, Exercise After Cancer Treatment, Side Effects Overview, and Gentle Movement on Low Energy Days.

• Nerve Problems (Peripheral Neuropathy) and Cancer Treatment, National Cancer Institute
• Persistent Neuropathy Increases Fall Risk among Cancer Survivors, National Cancer Institute
• Nerve Damage after Chemotherapy for Breast Cancer, National Cancer Institute
• Physical Activity and Cancer Fact Sheet, National Cancer Institute
• Prescribing Exercise as Cancer Treatment, National Cancer Institute
• Benefits of Exercise for People with Cancer, National Cancer Institute
• Physical Activity Guidelines for Americans, 2nd edition (PDF), U.S. Department of Health and Human Services