Peripheral neuropathy is a widespread condition characterized by damage to the nerves outside the brain and spinal cord. It is estimated that more than 20 million Americans are living with some type of peripheral neuropathy, according to data from the National Institute of Neurological Disorders and Stroke. This number equates to approximately one in 15 Americans, although the number could actually be higher due to underdiagnosis. Moreover, the occurrence of peripheral neuropathy increases with age. In fact, the prevalence of peripheral neuropathy among the 60- to 74-year-old age range is 20%, with the majority of these cases attributable to diabetes. 

Symptoms of peripheral neuropathy commonly include numbness, pain and weakness, typically in the hands and feet. Although there are several types of peripheral neuropathy, one of the most common is diabetic peripheral neuropathy, which is a consequence of diabetes. In fact, diabetic peripheral neuropathy eventually affects nearly 50% of adults with diabetes during their lifetime.

Fortunately, regular exercise can help individuals better manage their symptoms of peripheral neuropathy and minimize its progression. This article outlines strategies for helping your clients with peripheral neuropathy perform exercise safely and effectively.

Key Programming Considerations for Clients Who Have Peripheral Neuropathy

1. Understand common medication–exercise response/program design interactions and considerations in clients who have peripheral neuropathy.

The medical management of peripheral neuropathy can include a broad range of medications. Therefore, as a health and exercise professional, it is critical that you understand how certain medications interact with an individual’s response to exercise and how the exercise program might need to be adjusted.

Given the fact that diabetic peripheral neuropathy eventually affects nearly one in two American adults with diabetes during their lifetime, it is likely your client may be taking an oral hypoglycemic medication. Oral hypoglycemics are a class of medications commonly prescribed to control blood glucose in individuals with type 2 diabetes and these fall into three major groups:

  • ß-Cell stimulants for insulin release
  • Drugs to improve insulin sensitivity
  • Drugs that decrease intestinal absorption of carbohydrates

ß-Cell stimulants function by inciting insulin release from the pancreas. These medications are taken with meals and help alleviate excessive increases in post-meal blood glucose levels. The latter two oral hypoglycemic categories have little effect on the exercise response.

The most important safety concerns related to the exercise program for clients who are taking oral hypoglycemics are recognizing the signs and symptoms of hyperglycemia and hypoglycemia (Table 1) and frequent monitoring of blood glucose values. Initially, this should include checking levels pre-exercise, at the mid-point of exercise and post-exercise. Once it has been established how much an individual’s blood glucose values usually drop for a typical exercise session, and provided these changes in glucose levels are within an acceptable range, less frequent monitoring may be sufficient. It should be noted that it is not your responsibility as a health and exercise professional to check a client’s blood glucose values. Rather, the client should bring their own glucose-monitoring device, which should have been prescribed by a physician or endocrinologist.

Table 1. Signs and Symptoms of Hyperglycemia and Hypoglycemia

Hyperglycemia (>300 mg/dL)

Hypoglycemia (<70 mg/dL or rapid drop in glucose)


Dry skin

Dizziness and headache



Weakness and fatigue





Blurred vision

Tachycardia (fast heart rate)


Frequent urination



Extreme thirst







The intent of this section is not to be exhaustive in its scope. Rather, it is to highlight the concept of medication–exercise responses and reinforce the importance of making appropriate program-design adjustments that better serve your clients who have peripheral neuropathy. It’s also critical to collaborate with the medical providers who help your client manage their peripheral neuropathy and familiarize yourself with other relevant medications and considerations for overall exercise programming.

2. Understand the insidious nature of peripheral neuropathy.

As a health and exercise professional, it is important to appreciate the insidious nature of peripheral neuropathy. For your clients, the symptoms of pain and tingling in their feet, will not readily inspire them to exercise. However, continued inactivity will only worsen their condition. That said, the pathophysiology of peripheral neuropathy places your clients at risk for various complications during exercise that is undertaken without the necessary precautions. 

Peripheral neuropathy most commonly results in a progressive change in sensation in the feet (although sometimes also the hands) that gradually moves up the extremities. The loss of sensation coupled with pain and weakness contributes to a variety of challenges to safe exercise. For example, the affected areas of peripheral neuropathy are likely to experience a loss of proprioception (the brain’s ability to sense movement and location of the body’s limbs), which might lead to imbalance and falling. A lack of sensation can also contribute to clients over-stretching more easily. Additionally, peripheral neuropathy is synonymous with inadequate blood flow to the extremities. Poor circulation makes weight-bearing exercise more hazardous. Indeed, repeated weight-bearing activities on insensitive feet can lead to chronic irritation, open sores and musculoskeletal injuries, especially fractures. 

Collectively, the gradual and subtle abnormal changes in various bodily functions stemming from peripheral neuropathy have a pronounced influence on how you must approach exercise programming, which is explored in the next section.

 3. Use the ACE Integrated Fitness Training® (ACE IFT®) Model guidelines with special considerations.

Overall, exercise is generally safe in people with diagnosed and well managed peripheral neuropathy. Because peripheral neuropathy goes hand-in-hand with diabetes, it is helpful to use the ACSM guidelines for cardiorespiratory and muscular training for diabetes presented in Table 2 along with the ACE IFT Model with your clients who have peripheral neuropathy.

Additionally, keep in mind these special programming considerations for clients who have peripheral neuropathy:

  • Proper footwear for weightbearing activities is imperative to avoid undetectable sores, which may progress to infections. Remind clients to keep their feet clean and dry, practice daily hygiene and perform frequent inspections.
  • Encourage your clients to choose non-weight-bearing cardiorespiratory training modalities, such as aquatic exercise, chair exercise and recumbent cycling. Urge them to avoid activities that increase the likelihood of trauma to the feet, such as jogging or running and prolonged hiking, especially on uneven surfaces.
  • Research shows that 20% of individuals with peripheral neuropathy are at increased risk for falls. Therefore, balance training and fall prevention must be emphasized for all clients with peripheral neuropathy. However, because of their heightened risk for falls, it is important to be more conservative with balance-training exercises and progressions, and to provide more supervision and spotting.
  • Clients who have peripheral neuropathy frequently have muscle contractures, which are a fixed tightening of muscle, and reduced range of motion. Therefore, regular flexibility training is beneficial and should be emphasized. The general frequency, intensity, time and type (FITT) approach to exercise programming used for cardiorespiratory and muscular-training program design can also be applied to flexibility exercise programming. Flexibility training should be performed daily for 10 to 15 minutes each session. However, be sure to encourage gentle, progressive stretching, as a lack of sensation can contribute to clients over-stretching more easily.

Exercise Programming Considerations for Autonomic Neuropathy

Individuals with autonomic neuropathy have impaired sweating and thermoregulatory abilities and impaired hypoglycemia awareness. When this disease affects the autonomic nerves to the heart, it is called cardiac autonomic neuropathy. The heart rate is altered and the maximal heart rate is decreased, while resting heart rate increases. For example, it is common in autonomic neuropathy for resting heart rate values to exceed 100 beats per minute. Cardiac autonomic neuropathy can cause hypertension or hypotension and increases the risk for exercise-induced hypotension after vigorous exercise. Individuals with cardiac autonomic neuropathy exhibit low fitness levels and fatigue at lower workloads due to the disruption in nerve innervation to the heart, which makes rating of perceived exertion the preferred  method for  monitoring exercise intensity. Accordingly, exercise for these individuals should focus on low-level activities of daily living, when modest changes in heart rate and blood pressure can be accommodated. Before beginning an exercise program for clients who have autonomic neuropathy or cardiac autonomic neuropathy, be sure to obtain physician approval and proceed with caution.

The ACE Mover MethodTM: Help Clients with Peripheral Neuropathy Exercise Safely

As a health and exercise professional, you recognize the importance of working closely with all of your clients to design and implement safe and effective exercise programs. This is particularly important for clients who have health challenges such as peripheral neuropathy. If your clients are unprepared, exercising can bring unwelcome negative physiological responses, injury and potentially even more severe health risks. 

Clients who have recently been diagnosed with peripheral neuropathy likely have questions about what they can and cannot do, and what this condition means to their ability to maintain their quality of life. The ACE Mover Method is a great approach to asking open-ended questions that can help your clients better understand their condition and identify how they feel about their preparedness for exercising safely with peripheral neuropathy.

For example, a client may have heard that non-weight-bearing exercises are best but are unsure of which ones they should try. Or perhaps they have been told that good footwear is critical but they are unsure of where to find the best shoes. Discuss any barriers that may be preventing your client from feeling comfortable with exercising with peripheral neuropathy.

For many people, gaps in their knowledge about their condition can be a significant source of distress. For example, they may understand the importance of incorporating balance training into their overall exercise routine but feel unsure of where to start. Here, you can use your knowledge and what they have shared with you to work together to develop the best plan moving forward. Collaborate with your clients on trying different non-weight-bearing cardiorespiratory training modalities and, with purposeful trial and error, identify their preferences. Educate your clients by providing them with evidence-based resources that assist them with identifying the best neuropathy shoes for their unique needs. Collaborate with your clients and determine the best balance exercises to start with. Then carefully listen to their feedback, non-judgmentally observe their performance and continuously make the necessary adjustments and progressions to their balance exercise routine.


Working with clients who have specific health challenges such as peripheral neuropathy can be highly rewarding. By understanding the condition and the interactions certain medications have with the exercise response and program design, being mindful of relevant programming considerations and leveraging the ACE Mover Method, you can set your clients up for success by helping them perform regular exercise safely and effectively while improving their peripheral neuropathy symptoms and slowing its progression.


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