Is walking good for those with HNPP?

From walking 15km a day to walking 15 minutes a day, my walking journey has been chaotic to say the least. But it was another essential question I asked my neurologist. Is it still possible to walk when you’re in pain?

It is shockingly difficult to do for most people living with HNPP, and yet it seems rather depressing to completely forgo what seems to be such a straightforward task. It’s a bit of a vicious cycle as it is difficult to exercise with painful neuropathy and yet it’s very important to stay active.

The major issues that seem to occur with HNPP include:

• clumsiness
• slight difficulty in walking because of trouble picking up the feet
• weak leg muscles
• fatigue
• foot deformity (very high arched foot/feet)
• difficulty lifting foot at the ankle (foot drop)
• curled toes (known as hammer toes)
• loss of lower leg muscle, which leads to skinny calves
• numbness or burning sensation in the feet
• “slapping” when walking (feet hit the floor hard when walking)
• weakness of the hips, legs, or feet
• leg cramps
• loss of balance, tripping, and falling

These symptoms obviously cause problems while walking hence it seems next to impossible to even attempt it.

According to Patty Bonsignore, a Nurse Educator at Joslin Diabetes Center in Boston, U.S. dealing with neuropathies, it’s best to do exercises that are non-weight bearing, such as swimming, water aerobics, rowing and chair exercises. However, if walking is the exercise you prefer, and easiest for you, then it is important to make sure your shoes fit correctly, and that you have comfortable, well-padded socks that wick away moisture.

Disclaimer: Please ask your GP or medical practitioner before attempting any exercise included on this website.

Bonsigore suggests seeing a podiatrist or a pedorthist (a professional trained in creating customised footwear) who can help determine whether your shoes are fitting correctly, as correctly fitted shoes are an easy and important way to prevent foot issues.

She adds: “Neuropathy can also affect balance and shift the way you bear weight on your feet. Alterations in weight bearing can put you at greater risk for falls and foot ulcers. If you are having problems with balance, ask for a referral for physical therapy.”

Before you begin to attempt walking

According to CMT UK, a website dedicated to the inherited condition Charcot-Marie tooth disorder, stretching the calf daily is something that everybody with CMT or HNPP should get into the habit of doing to keep the calf muscles lengthened and slow down the development of the deformity.

These stretches are easy to perform and can be incorporated into your daily routine, for example during your morning shower when your muscles are warm and relaxed (just be careful not to slip) or standing up to a work surface while waiting for the kettle to boil.

Before exercising

Before you start to do any exercises, think about the following:

• Have you talked to your physiotherapist, family doctor or gym instructor about the right exercises and level for you?
• If needed, have you considered orthoses? The right one can make exercising more efficient and enjoyable.
• Remember to pace yourself – don’t overdo it. And if you have worked hard one day, think about relaxing the next.
• Put together an exercise plan – build up slowly so as not to injure yourself. (The 10% rule is a good one to stick to – aim to increase your exercise levels by no more than 10% to 15% each week.)

Why you wonder?  In these types of conditions, the muscles on the shin tend to get weaker first which results in a ‘foot drop’. The stronger calf muscles overpower the weaker shin muscles setting up an imbalance between the two. Because of this the calf muscle will gradually get shorter and stiffer, as will the Achilles tendon, further increasing the foot drop.

Because the ankle needs to be at a right angle for the toes to clear the floor when walking, the result is an increased chance of tripping when walking, increased difficulty getting the heel to the floor and a greater chance of sprained ankles.

Orthoses can play an important role in helping to maintain flexibility, joint range and prevent the muscles tightening and shortening. This can be by means of insoles which may be thicker on the outside of the foot than the inside so the foot is stretched when weight is put on it. Orthoses used through the day can provide a very effective stretch as well as holding the foot in the best position for walking.

Stretching exercises

These exercises are only a general guide. It is strongly recommended that you
consult a physiotherapist to put together an exercise programme tailored to your individual needs.

Disclaimer: If you experience any pain or difficulty doing these exercises, stop immediately and seek advice from your family doctor or physiotherapist.

• Calf stretch:
  • With finger tips hold onto a wall or work surface.
  • Keep your head up and back straight.
  • Place one foot forward and one foot back with the back foot and heel fully on the floor. Make sure your toes are pointing forward.
  • Let your front knee bend but keep your back knee straight.
  • You should feel a stretch in the calf.
  • Hold still for 20 to 30 seconds. Repeat three times and then swap legs.

• Lower calf stretch:
  • Get in the same position as above.
  • Step your back leg forward so the toes are in line with the heel of the other foot.
  • Letting both knees bend, sink down with your weight on your back leg.
  • The stretch will not be as strong as with the previous exercise.
  • Hold still for 20 to 30 seconds. Repeat three times and then swap legs.

• Upper legs:
  • Sit on the edge of your bed or a dining chair.
  • Keep feet hip width apart. Keep your arms by your side.
  • Stand up fully then slowly sit down.
  • Repeat the movement 10 times.

• Standing balance:
  • Stand near a work surface or wall.
  • Stand with your feet together keeping an upright posture.
  • Hold for as long as possible using fingertip support on the work surface/wall as required.
  • If you are able to, keep this position and turn your head right and left. Repeat the movement 10 times.
  • If this is easy, extend your arms and rotate them around to the right and left. Repeat the movement 10 times.
  • My physiotherapist recommended doing this while standing on a cushion or foam surface to test the balance a bit more.

This is for stroke recovery patients – however, these  balance exercises were recommended to me by my neurophysiotherapist.

That being said, all of these exercises should be done with a touch of caution so please don’t overdo it.

Walking

If you really want to walk here are some tips worth noting:

• Use walking aids – if necessary, take along a walking stick or your walker. Researchers in the U.S. showed that the use of a cane reduced the load on the knee by 10 per cent. By reducing knee joint stress,  the pain, swelling, and stiffness is less likely to become debilitating. And remember, even  expert hikers use trekking sticks.
• Padding – make sure you wear all adequate padding such as knee pads, arm pads, splints and general orthotics if necessary.
• Stretch before walking – See above for exercises.
• Stop as soon as you feel pain – this also includes weakness in the foot.
• Rest in between if necessary – it’s not a race, so don’t beat yourself up if you can’t manage.
• Know your limits – if you know 10 minutes is enough to make you start feeling pain or fatigue then make sure you walk around the corner and make it back home in time.
• Try focusing on your body mechanics – are your knees softly absorbing the impact of each step? Is your pelvis doing a waddling motion back and forth or is your pelvis staying level and steady? Are your shoulders back with your chest out? Each and every part of your body needs to be an active participant in your walk and doing their jobs correctly.
  • Head and shoulders: Keep the head up and centered between the shoulders, with eyes focused straight ahead at the horizon. Keep the shoulders relaxed but straight – avoid slouching forward.
  • Abdominal muscles: It is important to actively use the abdominal muscles to help support the trunk of the body and the spine. To do this, keep the stomach pulled in slightly and stand fully upright. Avoid leaning forward as you walk.
  • Hips: The majority of the forward motion should start with the hips. Each stride should feel natural – not too long or too short. Most people make the mistake of trying to take too long of stride.
  • Arms and hands: Arms should stay close to the body, with elbows bent at a 90 degree angle. While walking, the arms should keep in motion, swinging front to back in pace with the stride of the opposite leg. Remember to keep hands relaxed, lightly cupped with the palms inward and thumbs on top. Avoid clenching the hands or making tight fists.
  • Feet: With each step, land gently on the heel and midfoot, rolling smoothly to push off with the toes. Be mindful about using the balls of the feet and toes to push forward with each step.
• If trouble arises – shorten up your strides and slow down. Walking is a concerted effort that requires you to be mindful. Sometimes you need to relearn how to walk after experiencing a painful injury. That is when a physical therapy tune-up can be so very helpful.
• Good walking shoes – your body will appreciate the added cushioning and support. According to peripheral neuropathy sufferer and author, Mims Cushing, Reebok lightweight trainers / gym shoes is a godsend to walkers. Find out more about the best shoes for fragile feet here.
• Socks – in the same vein, get appropriate socks. People with neuropathy usually wear non-binding, with extra wide funnel tops. The seams are smooth and the soft, cushiony soles will not irritate your feet. If your feet sweat a lot, consider buying acrylic socks rather than cotton.
• Inserts and insoles – inserts can often offload pressure points on your feet and will reduce the chance of ulcers
• Avoid uneven terrain – this requires planning your route beforehand, and making sure you do a circular journey so it returns you home rather than walking further and further away. I walk near parks because if needs be I can take off my shoes and stand on the grass.
• Plan your route beforehand – as noted above, circular journeys are important so that you make it home in one piece. Apps such as WalkIt and Map My Walk are fantastic for route mapping and journey suggestions.
• Water – absolutely essential to keep hydrated throughout.
• Snacks – I get exhausted quickly, but quick snacks such as rice cakes, cereal bars or even glucose tablets can keep the fatigue at bay.
• Distractions – for those that need it, listening to music, books and podcasts sometimes helps ease the nerves of walking. Focusing on your breathing and posture may make the exercise less frightening.
• If it’s all too much – then start on a treadmill, and build up slowly.

Walking is no walk in the park sadly, but it may get a little better each time if you make sure you don’t overdo it, listen to your body, and remember it’s a work in progress.