Peripheral Neuropathy

Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. It produces numbness, tingling, burning, loss of sensation and muscle weakness — most often in the feet and hands, in a pattern that spreads from the extremities inwards.

For rehabilitation it splits into two problems that need different treatment: loss of sensation, which removes the information needed for balance, and loss of ankle strength, which removes the ability to correct. Treating only one leaves the person falling.

Diabetes is the most common cause, accounting for 32–53% of cases 2. Others include vitamin deficiency — particularly B12 — nerve compression, infection, toxic exposure including some medications, and chronic disease.

The cause determines whether progression can be slowed, which is a different question from whether function can be improved. We work on function; the underlying cause is managed medically and the two need to run together.

Balance retraining, because loss of foot sensation is a major and underestimated cause of falls. Strengthening of the ankle and foot. Sensory re-education. Footwear and orthotic assessment. Pain management where burning pain is present.

Foot inspection is taught as a routine. A person who cannot feel their feet cannot feel an injury developing, and in diabetic neuropathy that is how ulcers begin.

When the feet cannot feel the ground, balance depends on vision — which is why symptoms are worse in the dark, on uneven surfaces and with the eyes closed. The falls risk in sensory neuropathy is substantially raised.

Balance training, footwear, home lighting and a walking aid where needed address this directly, and they are as much part of treatment as anything aimed at the nerve.

A foot that cannot feel does not report a blister, a stone in the shoe or a burn. In diabetic neuropathy this is the mechanism behind most ulceration and a large share of amputations.

Daily inspection, correct footwear and prompt attention to any break in the skin are taught explicitly, because the consequence of learning this late is measured in surgery.

It improves balance, but it has not yet been shown to reduce falls. A 2021 meta-analysis of eight randomised trials in diabetic neuropathy found that combined gait, balance and functional training produced a small improvement in balance and a small reduction in fear of falling 3. The single trial that counted falls, with 79 participants, found no clear effect 3.

Exercise is still worth doing for steadiness and confidence, but it is combined with the other measures — footwear, lighting at home and a walking aid where needed — rather than relied on alone to prevent falls.