The protocol followed for the treatment of patients with CIPN at Hollings Cancer Center was developed to combine manual therapy, strength and stretching, and balance activity. This was developed based on clinical practice as standard of care for patients with CIPN and did not require a review or approval from an IRB. The goal was to address the sensory and motor symptoms that come with CIPN, affecting pain, strength and fall risk for this patient population.
A 2016 systematic review on diabetic peripheral neuropathy (DPN) found that reflexology of the feet compared with pharmacological treatment, and Thai foot massage compared with health education, had significant positive effects on decreasing DPN symptoms.  A 2015 study on the effects of Thai foot massage on balance found that using direct deep pressure combined with gentle distraction on the muscles and joints of the foot and lower leg increased local blood circulation and stimulated the somatosensory system.  The parallel randomized controlled trial posited that these effects may reverse neuropathy by changing pressure distribution, proprioceptive systems, muscle tension, joint angle and muscle length. 
The “neuropathy massage” technique performed on and taught to patients in this study is derived from the above literature. Patients begin by massaging the heel, then work with pressure applied by the thumbs up through the arch of the foot, working to the ball of the foot. Patients then move to the top of the foot, working to apply soft and then deeper pressure in between the metatarsals, looking for and releasing trigger points in the muscles. When trigger points are found, patients are instructed to hold each trigger point for 30 to 90 seconds to get the muscles to relax. Joint mobilization is then performed on all metatarsals with grade III mobilization, looking for fluid movement between the bones. Pain free distraction is then performed on all the toes. The technique is finished with sweeping glides through the top of the foot to push any edema in the direction of lymphatic flow and the patient finishes with 5 ankle circles in each direction.
With CIPN, motor symptoms include weakness. Physiologically muscle activation happens in relation to action potentials triggered by voltage-gated ion channels.  Resistance training has been shown to increase muscle activation at the motor and neural level from the resting potential of the ion channel, to the number of muscle fibers recruited, up the nerve pathway and to the brain for motor plasticity and control. [22,23] The ankle 4-way is a progressive resistance exercise working on ankle dorsiflexion, plantarflexion, inversion and eversion with a Thera-Band. The ankle 4-way exercise was performed with a yellow Thera-Band (3 pounds of resistance) 10 times in each direction, on each foot, for homework daily. Patients worked their way up to 30 repetitions in each direction and then resistance was increased to a red (3.7 pounds of resistance) Thera-Band and then a green (4.6 pounds of resistance) Thera-Band when good eccentric control for 30 repetitions per foot in the directions of dorsiflexion, plantarflexion, inversion, and eversion were achieved.  The exercise was followed with the gastrocnemius, soleus, and plantar fascia stretches, which were held for one minute in each position on each leg.
The annual fall rate for adults 65 years and older is about 30%. Studies have shown that more than 50% of cancer survivors have fallen at least once within the preceding 12-month period.  Loss of balance contributed to more than 50% of falls among cancer survivors receiving neurotoxic chemotherapy.  As a 2019 study from BMC Cancer shows, balance training can promote neuronal adaptation, improving muscle output and postural control.  Patients worked on standing in semi-tandem, tandem and single leg stance, with eyes open, eyes closed, and on solid and uneven surfaces to increase balance.
On initial evaluation both Patient A and Patient B received manual therapy following the neuropathy massage technique, were instructed on how to perform it on themselves, were instructed to have family members assist in performing it and were given handouts with the directions. Patients were instructed to rub their feet for at least five minutes, per foot, per day. On follow up, patients were treated with the neuropathy manual therapy technique from the licensed physical therapist, and performed the ankle 4-way exercise, standing gastrocnemius stretch, standing soleus stretch and standing plantar fascia stretches. In later sessions, patients worked on balance training on solid ground and on a blue foam instability pad, with eyes open, with eyes closed, with head turns, and with dual tasking brain games. In the final few weeks of treatment, an exercise to isolate the toes and work on lifting up one toe at a time was added for increased proprioception and muscle control through the foot.