Physical Therapy And Regular Exercise In ALS Patients: Helpful Or Harmful?

Amyotrophic lateral sclerosis (ALS) is a rare neurological disease that is characterized by the loss of motor neurons, which are nerve cells that control voluntary muscle movement. Hence, patients with ALS will eventually lose the ability to walk, talk, and carry out other important everyday activities.

One of the main recommendations that doctors make to patients who have recently been diagnosed with ALS is to undergo physical therapy early on in the course of the disease, as this form of therapy can help ALS patients slowly learn to adjust to their physical capabilities as the disease advances.

Physical therapy can help improve the overall quality of life for patients with ALS. Physical therapists, which are the professionals that carry out physical therapy, do the following:

• Teach the patient and caregiver how to conduct proper stretching and daily range-of-motion exercises.
• Anticipate the patient's future needs. For example, if the patient’s physical condition is deteriorating quickly, then it is important to introduce them to assistive devices or foot orthoses in a timely manner that can help minimize foot drop and stabilize weak muscles to prevent falls.
• Emphasize the need to conserve the patient’s energy and teach the patient and caregiver how to perform safe and efficient energy transfer so the patient is not being drained of all energy by conducting activities too quickly and in a non-efficient manner.
• Provide instructions on strengthening exercise programs that can only be performed at a low intensity and only in patients that are slowly progressing.
• Try to introduce wheelchairs while the patient can still walk so that they can enhance energy conservation. At first, a lightweight wheelchair should be rented and the patient must plan to purchase a heavier and more expensive chair for the late stages of ALS.

Use of exercise in the treatment of ALS

The benefits of exercise in ALS patients are not well-understood at this time. A review on the topic concluded that any studies that have been conducted to date were too small to determine the benefits or harm of strengthening exercises for ALS patients. Additionally, there is a significant lack of randomized clinical trials that examine the role of aerobic exercise in ALS.

There have been some studies conducted on the topic in humans, which have yielded the following results:

• One clinical trial that evaluated the use of moderate-intensity, endurance-type exercises for the trunk and limbs conducted for 15 minutes twice a day found a significantly reduced spasticity in the ALS patients who took part.
• Another study showed that patients who underwent physical therapy experienced a 3-point decline in the ALS Functional Rating Scale and a composite-score reduction of 0.8 in a patient-reported outcome. However, as the disease is progressive, it is unclear whether the decline was due to disease progression or due to a negative effect of exercise. Furthermore, some patients found the therapy to be beneficial.
• A study review indicated that pulmonary physical therapy interventions (which aid breathing), including inspiratory muscle training (IMT), lung volume recruitment training (LVRT), and manually assisted coughing (MAC), have a beneficial effect on breathing and length of survival in ALS. Researchers reported that muscle strength associated with breathing could be prolonged through IMT, and the mean length of survival extended by a year.
• Another study found that a structured, unsupervised, home-based exercise program can be beneficial for patients in the early stages of ALS. The study indicated that the patients who participated in the program, which lasted a total of six months and which included muscle stretching exercises as well as muscle and functional training, had a significantly higher score and respiratory function score than the patients who underwent a six month program supervised by a physical therapist. 

Exercise guidelines for people living with ALS

These are the following exercise that have been recommended for people with ALS thus far:

• Aerobic exercises of light to moderate intensity, as they can increase the efficiency of the muscles and improve endurance by increasing heart rate, respirational (breathing) rate and overall fitness. However, it is important to exercise in moderation as exercising to the point of fatigue can lead to increased muscle weakness, as well as to discuss such programs with your health care team in advance.
• Stretching exercises, as they can help to reduce the frequency and intensity of muscle cramps, and to prevent pain and stiffness in ALS patients.
• Range of motion exercises, because, as mentioned earlier, are beneficial as they help move joints to their full range of motion and prevent pain and stiffness. These should either be performed actively or passively if weakness in muscles limits their movement.

These are the following exercises that are not recommended for people who have been diagnosed with ALS:

• Any exercise conducted at a high intensity, as high intensity exercise can have a detrimental effect and lead to increased muscle weakness.
• Strengthening exercises are not recommended for people living with ALS, particularly exercising with weights as that will not strengthen the muscles that are already weak and can lead to even more weakness.

Conclusion

There is a significant need to conduct more studies on the topic. However, while we wait for further evidence, some physicians recommend a "Use it or lose it" approach. Specifically, they recommend conducting moderate exercise, such as a cycle or a treadmill that is conducted at about 70-75% of the maximal heart rate for about 10-20 minutes, three times a week. Furthermore, stretching exercises, including those conducted in yoga and tai chi, and aqua therapy can be helpful.

For patients with ALS, it is important to listen to your body. When you feel fatigue, stop the exercise rather than keep going. Furthermore, if you feel sore the next day, that is a bad sign as soreness indicates breakdown of muscle tissue, which is very bad for ALS.