Pilates guide
Peripheral neuropathy, nerve damage that usually starts in the feet and is most often caused by diabetes, can make your feet numb or painful and your balance less steady. Exercise improves balance, and walking and standing exercise in good shoes is safe for most people with numb feet. Pilates can be a good way to do the balance, strength and flexibility work guidelines advise, but it has barely been tested in neuropathy itself, and it can't repair nerves.
Pilates sits beside care from your GP and, with diabetes, your diabetes and foot team, never in place of it. This guide covers what neuropathy does to balance and feet, what the trials show, shoes or bare feet for each part of a class, foot checks, low blood sugar (hypos) if you take insulin, dizziness on standing, the moves to use and change, which classes to follow, and the warning signs that need help within 24 hours.
Almost 1 in 10 people aged 55 or over in the UK have peripheral neuropathy, most often from diabetes. With less feeling in your feet, balance suffers, and older adults with neuropathy were about one and a half times as likely to have a fall or fracture.
Across 16 trials in diabetic neuropathy, exercise improved balance tests by a small amount, at low certainty. It hasn't been shown to cut the number of falls, and no controlled trial shows lost feeling coming back.
The one Pilates trial in neuropathy, after chemotherapy, is reported only in a short abstract with unclear numbers, so it can't guide advice. In older adults in general, Pilates improves balance tests about as much as other exercise.
Walking and leg exercise didn't increase foot ulcers in a year-long trial, and guidelines now support walking in proper footwear. Wear shoes for standing moves; lying and seated work can stay barefoot (our reading of the international foot guideline).
Check both feet before and after every session, and keep a hand on a counter or wall for every standing balance move.
With an open sore, an ulcer, or a red, hot or swollen foot, do only seated or lying exercise and contact your foot team within 24 hours. A hot, swollen foot can be Charcot foot, even if it doesn't hurt.
Peripheral neuropathy is damage to the nerves outside the brain and spinal cord. The commonest kind affects the longest nerves first, so it starts in the feet. Symptoms include "numbness and tingling in the feet or hands", burning, stabbing or shooting pain, "loss of balance and co-ordination" and muscle weakness, especially in the feet. Diabetes is the commonest cause in the UK; others include some chemotherapy, long-term heavy drinking and low vitamin B12.
The NHS describes "loss of balance or co-ordination caused by less ability to tell the position of the feet or hands". In 3,617 older adults (average age 79), a third had neuropathy on a simple foot test, and over 3 years 26.5% of them had a recorded fall or fracture, against 18.4% of those without it. A review found diabetic neuropathy harms balance and walking and raises the risk of falls.
"If you have numb feet, it's easy to cut your foot by stepping on something sharp", and an ulcer can follow a blister from badly fitting shoes. Up to half of diabetic neuropathy causes no symptoms. The National Institute for Health and Care Excellence (NICE) counts neuropathy alone as a moderate risk of a diabetic foot problem.
When neuropathy affects the nerves to your heart and blood pressure, you may feel dizzy or faint when you stand and be unable to exercise for more than a short time. The American Diabetes Association (ADA) advises a heart check before exercise harder than you're used to.
Nerve pain "does not usually get better with common painkillers"; the main medicines are amitriptyline, duloxetine, pregabalin and gabapentin, which your GP can discuss. Exercise isn't a replacement for treating the cause, such as diabetes control.
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The ADA advises most older adults with diabetes to do flexibility and balance training 2 to 3 times a week, and says "Moderate-intensity walking may not lead to an increased risk of foot ulcers or reulceration in those with peripheral neuropathy who use proper footwear", while "Anyone with a foot injury or open sore should be restricted to non-weight-bearing activities". Its position statement says balance training can reduce falls risk "even when peripheral neuropathy is present". The international foot guideline suggests foot and ankle exercise programmes and says an extra 1,000 steps a day is likely safe for people at low to moderate risk. None of them names Pilates.
In 16 trials (759 middle-aged and older adults with diabetic neuropathy), exercise improved the Berg balance score by about 2 points out of 56 and made people about 1.7 seconds quicker on a get-up-and-walk test, but didn't change a 6-minute walk; the certainty was low to very low. Other reviews found balance and mixed programmes improved fall-risk tests most, foot and ankle exercise alone didn't, and a mix of endurance and balance training worked best.
Only one trial in diabetic neuropathy has counted falls (79 people), with no clear effect, and an umbrella review called the effect on falls inconclusive. In older people in general, exercise cuts falls by about a quarter, mainly balance and functional exercise.
In the Feet First trial (79 people, 12 months), leg strength, balance and a graded walking programme didn't significantly increase foot ulcers. In 29 people, standing and walking exercise added 29 metres to a 6-minute walk and about 1,178 daily steps more than seated exercise. In 18 people, supervised moderate aerobic exercise caused minor problems only.
In 96 cancer survivors with neuropathy after chemotherapy, Pilates and another exercise method (Gyrotonic) were both reported to ease pain and improve a stepping test over 12 weeks, with a no-exercise group for comparison. We could read only the abstract, its printed confidence intervals don't support all its claims, and its registry entry lists a different main outcome. Treat it as a hint, not evidence.
A trial of 36 women with diabetic neuropathy measured only blood tests and weight, with no significant change in blood sugar. A review of balance treatments found one Pilates trial that showed no benefit for standing balance. We found no trial of Pilates for balance or pain in diabetic neuropathy.
In 39 studies of 1,770 older adults, Pilates improved balance tests and was "comparable to other forms of exercise", but didn't reduce the number of falls or fear of falling. Most Pilates exercises in the trials gave little challenge to balance, so add standing balance work at a counter. The one trial that counted falls (53 people) found fewer fall injuries, but the difference could have been chance.
In diabetic neuropathy, 7 small yoga studies (227 people) reported better balance and less pain, at high risk of bias. After chemotherapy, yoga improved symptoms and reach in 41 survivors but not pain clearly, and in 44 survivors only tiredness and mood. Tai chi did no better than gentle sham exercise across 11 studies.
In 17 people without a comparison group, 10 weeks of exercise eased symptoms and slightly changed nerve fibres in the skin. A review of 11 trials found small improvements in symptoms at very low certainty. No controlled trial shows lost feeling coming back.
Exercise eased symptoms in 12 studies (928 people), and balance (sensorimotor) training improved balance in 11 trials, both at low certainty. Ask your cancer team which exercise suits you now.
The international foot guideline advises people at risk of foot ulcers to protect their feet "by not walking barefoot, not walking in socks without shoes, and not walking in thin-soled slippers, whether indoors or outdoors". No study has tested barefoot Pilates. Our reading: lying and seated mat work can stay barefoot, while standing moves, wall work and walking about the room go in shoes.
If your feet are numb, the international foot guideline advises not walking barefoot or in socks without shoes, even indoors. Do standing moves in shoes, check your feet before and after, and with an open sore keep to lying and seated moves.
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Grip socks are still socks without shoes for standing and walking about, so wear shoes for standing work. Reformer footwork presses the soles against the bar: do it in shoes or leave it out (our suggestion), and check your feet afterwards.
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Look at both feet, including the soles and between the toes, before your socks go on and at bedtime, using a mirror or a helper, and again after each session. Diabetes UK says checking after a walk is "really important".
With an open sore or ulcer, keep to seated and lying moves until your foot team says otherwise. Diabetes UK is more cautious than the guidelines: with nerve damage, it suggests mostly activities that don't put weight on your feet, especially if your walking has changed or your foot is deformed, so ask your foot team what suits you.
Hold a counter or the back of a sturdy chair, keep your shoes on, clear the floor and put the light on. Build from both hands on the counter, to one, to fingertips, over the weeks (our suggestion).
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Balance work 2 to 3 times a week, as the ADA advises for older adults with diabetes. Our editorial starting point: the balance class below twice a week, or the standing part of the diabetes class.
If you've fallen or are worried about falling, see your GP, who can check your balance and medicines and refer you to a falls service; in some areas you can refer yourself.
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Check your blood sugar before and after, don't start at 4 mmol/L or lower, and keep hypo treatment by your mat.
A hypo is "usually where your blood sugar (glucose) is below 4mmol/L", the NHS says. Our Pilates for diabetes guide has the full routine before, during and after exercise.
Shaking or sweating in a hold, or feeling drowsy or muddled during the final lie-down, can be a hypo rather than effort or calm: stop and check. Keep your meter and hypo treatment within reach of your mat, and tell the teacher you have diabetes and what a hypo looks like for you (our advice).
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If you get dizzy when you stand, come up slowly in stages, from lying to sitting to standing, with a hand on a chair (our suggestion, following the NHS's advice to stand up slowly).
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Lateral breathing, 5 to 8 breaths at the start of every session; seated march, 1 to 2 minutes as a warm-up; ankle circles, 10 slow circles each way with each foot; breath reach, 5 breaths, exhale longer than inhale (the moves' pages); seated calf raise and seated knee extension, 2 sets of 10 (our editorial starting point).
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoSeated marchBeginner · A bench or box
3D demoAnkle circlesBeginner · No equipment
3D demoSeated bent-knee calf raise (soleus raise)Beginner · A bench or box
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoBreath reachBeginner · No equipmentSit to stand, building from 2 sets of 3 to 2 sets of 15; calf and toe raises, building from 2 sets of 5 to 2 sets of 20, skipping calf raises with hard skin, a sore or a past ulcer under the ball of your foot; one-leg stand, 30 seconds, twice each leg (our exercise for peripheral neuropathy guide, from the weight-bearing trial); side-stepping, 10 steps each way, next to a counter; wall side leg lift, 10 to 12 each side (the moves' pages); semi-tandem and tandem stance, 2 holds of 20 to 30 seconds (our editorial starting point). Keep a hand on the counter.
3D demoSit to stand from a chairBeginner · A bench or box
3D demoSlow calf raiseBeginner · A wall
3D demoTibialis raiseBeginner · No equipment
3D demoSemi-tandem stanceBeginner · A wall
3D demoTandem stance and heel-to-toe walkBeginner · A wall
3D demoSingle-leg standBeginner · A wall
3D demoSide-stepping (sideways walking)Beginner · A wall
3D demoWall side leg lift (standing side kick at the wall)Beginner · A wall
3D demoStanding marchBeginner · No equipmentBarefoot is fine lying down; check your feet first. Single-leg circle, 5 circles each direction, each leg; side kick, 8 to 10 each side; mermaid, 3 each direction, each side; getting down and up from the floor, 5 to 8 slow cycles, with a chair to hold (the moves' pages); glute bridge and clamshell, 2 sets of 10; bird dog, 2 sets of 6 each side, on fists or a cushion if your hands are numb; swimming, 3 slow lifts each side (our editorial starting point).
3D demoGlute bridgeBeginner · No equipment
3D demoSingle-leg circle (Pilates one leg circle)Beginner · No equipment
3D demoSide kick (Pilates side kick series)Beginner · No equipment
3D demoClamshellBeginner · No equipment
3D demoBird dogBeginner · No equipment
3D demoSwimming (Pilates)Intermediate · No equipment
3D demoMermaid (Pilates seated side bend)Beginner · No equipment
3D demoGet up and down from the floorBeginner · No equipmentNo trial has tested these changes; they follow the foot guideline, the ADA and our move pages' cautions.
Do them in shoes, or leave them out (our reading of the international foot guideline).
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Leave them out if your feet are very numb; our balance board page says to use one only once one-leg standing on the floor is steady, with a rail or counter in reach.
Planks, the knee hover, leg pull and push-ups: use your forearms or a cushion, or leave them out (our suggestion).
Change position every few minutes if tingling grows: with numb legs you may not feel early pressure on a nerve (our suggestion).
Leave out the roll-over, jack knife and other legs-over-head moves until your eye team agrees, as our move pages say.
Start with the shoes-on Pilates class for diabetes, which suits neuropathy from any cause, or the standing balance class, 2 or 3 times a week. Use the seated class on days with a sore foot. Wear shoes for anything standing, and check your feet afterwards.
A 30-minute Pilates class for type 2 diabetes: standing strength in your shoes, then mat work for hips, back and trunk, head up throughout and finishing seated.
30 minBeginner16 movesA bench or box, A wallA 25-minute Pilates class for steadier balance: standing balance and leg strength at a kitchen counter, then mat work for your trunk and hips.
25 minBeginner17 movesA wall, A bench or boxA 15-minute chair Pilates class done entirely sitting down, in a chair or wheelchair: breathing, spine moves, and leg and arm strength with water bottles.
15 minBeginner13 movesA bench or box, Something with weightA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesA bench or box, Something with weightA 35-minute home routine for numb feet: seated ankle work, leg strength and balance at a counter, then a walk, with shoes on and a foot check before and after.
35 minBeginner13 movesA bench or box, Something with weightA 25-minute yoga class for numb or tingling feet and hands: seated breathing, foot, ankle and hand work, standing poses at a counter in shoes, and a seated finish.
25 minBeginner17 movesA bench or box, Something with weightStrength and balance 3 times a week plus walks; keep shoes on and check your feet after each session.
These are the warning signs from our peripheral neuropathy, diabetes and balance guides, word for word. This is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Take the weight off the foot, keep it raised, and contact your GP or foot protection team straight away, or an out-of-hours service if they're closed, if you notice:
Same day: you have diabetes and a new foot problem, such as an ulcer or wound, signs of infection, or a hot, swollen foot with a change in colour, even if it doesn't hurt. Contact your diabetes foot team or GP: NICE asks for these to reach a specialist foot service within 1 working day, and a suspected Charcot foot is kept off weight until it has been checked.
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After a fall, if someone may have injured their head, back, neck or hip, or can't get up.
If you've fallen and may be in pain, hurt or unwell; or you've hit your head and you take medicine that thins your blood (or have a condition that does), or you're being sick or feel dizzy. NICE says people who take blood thinners, other than aspirin alone, and hit their head should be sent to an emergency department. Don't drive yourself to A&E after a head injury.
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If you've had a fall or you're worried about your balance (you may be able to refer yourself to a falls service), if you've fainted, if dizziness worries you, or if you keep feeling dizzy or faint when you stand up. NICE offers a full falls assessment to people who have fallen in the last year and are frail, were hurt, blacked out, couldn't get up, or have fallen twice or more.
Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
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You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
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The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
Walking and leg exercise didn't increase ulcers in a year-long trial, and guidelines now support walking in proper footwear. The exceptions are an open sore, an ulcer, or a red, hot, swollen foot.
For standing and walking about, the foot guideline advises against bare feet or socks without shoes for people at risk of ulcers, even indoors. Lying and seated work can stay barefoot (our reading).
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Exercise improves balance tests, but the one trial that counted falls in neuropathy found no clear effect, and Pilates hasn't been shown to cut falls in older adults.
No controlled trial shows lost feeling coming back. Exercise helps balance and walking, which matters, but it isn't a nerve treatment.
Up to half of diabetic neuropathy causes no symptoms, and numb feet don't warn you of a blister or a cut. Look rather than wait to feel something.
It can be a good way to do the balance, strength and flexibility work guidelines advise, but it has barely been tested in neuropathy. The one trial, after chemotherapy, is reported only in an abstract with unclear numbers. Exercise in general improves balance tests in neuropathy a little.
Yes, with care: do standing work in shoes, hold a counter for balance moves, and check your feet before and after. Lying and seated mat work is fine barefoot.
Lying and seated, yes. For standing and walking about, the international foot guideline advises against going barefoot or in socks without shoes, even indoors, so wear shoes for standing moves, wall work and reformer footwork. Grip socks are still socks.
Exercise improves balance tests in neuropathy by a small amount, at low certainty, and Pilates improves balance in older adults about as much as other exercise. Most Pilates classes challenge balance little, so add standing balance work at a counter.
Not shown. The only exercise trial in diabetic neuropathy that counted falls found no clear effect, and Pilates hasn't been shown to cut falls in older adults. Balance work still helps the things that lead to falls, and exercise cuts falls in older people generally.
For most people, yes, in proper footwear: walking and leg exercise didn't increase ulcers in a year-long trial. With an open sore, an ulcer, or a red, hot or swollen foot, do only seated or lying exercise and contact your foot team.
No trial shows it. Exercise improves balance and walking, but lost feeling hasn't been shown to come back, and treating the cause, such as diabetes control, matters most.
It hasn't been shown to. Small yoga trials in nerve pain weren't conclusive, and nerve pain is treated mainly with medicines your GP can discuss.
Yes, if you do the footwork in shoes or leave it out, and check your feet afterwards. Getting on and off the carriage needs steady balance, so ask your teacher to help the first few times.
Exercise, especially balance training, helps symptoms and balance a little, at low certainty. Ask your cancer team which exercise suits you now.
Check your blood sugar before and after, don't start at 4 mmol/L or lower, and keep hypo treatment by your mat. Shaking or sweating in a hold can be a hypo rather than effort, so stop and check.
See your foot team within 24 hours for a red, hot or swollen foot, a new wound you can't feel, or a wound that smells or leaks. See your GP for new numbness, falls, or dizziness when you stand.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
