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ALS is a rare neurological disorder that currently has no cure. Physical therapy and exercise have been postulated to be beneficial for patients with ALS. This article outlines the role of exercise in treatment of this disease.

Amyotrophic lateral sclerosis (ALS) is a rare neurological disease that is characterized by 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 everyday activities.

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

Furthermore, physical therapy can help maximize the patient’s capabilities for movement and prevent further loss of motion or pain that develops due to stiff joints.

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 late stages.

Use of exercise in ALS treatment

The benefits of exercise in ALS 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.

Studies using animal models of ALS have shown that the animals benefit from moderate exercise, but intense exercise causes acceleration of weakness. Whether it be strengthening exercise or aerobic exercise, it appears that too much intensity is definitely not beneficial.

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 significantly reduced spasticity in ALS patients.
  • Another study showed that patients that 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 early-stage ALS. The study indicated that patients that participated in the 6-month program, which included muscle stretching, and muscle and functional training, had a significantly higher score and respiratory function score than the patients who underwent a 6-month program supervised by a physical therapist. 

Exercise guidelines

These are the following exercise that are recommended thus far:

  • Aerobic exercise can increase the efficiency of 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.
  • Stretching exercise can help reduce the frequency and intensity of muscle cramps, and to prevent pain and stiffness.
  • A range of motion exercises, 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 exercise that are not recommended:

  • Any exercise conducted at a high intensity, as that can have a detrimental effect and lead to increased muscle weakness.
  • Strengthening exercises are not recommended, 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.

  • Dal Bello-Haas, Vanina, Anne D. Kloos, and Hiroshi Mitsumoto. "Physical therapy for a patient through six stages of amyotrophic lateral sclerosis." Physical therapy 78.12 (1998): 1312-1324.
  • Dal Bello-Haas, V., et al. "A randomized controlled trial of resistance exercise in individuals with ALS." Neurology 68.23 (2007): 2003-2007.
  • Beghi, Ettore, et al. "Amyotrophic lateral sclerosis, physical exercise, trauma and sports: results of a population-based pilot case-control study." Amyotrophic lateral sclerosis 11.3 (2010): 289-292.
  • Drory, Vivian E., et al. "The value of muscle exercise in patients with amyotrophic lateral sclerosis." Journal of the neurological sciences 191.1-2 (2001): 133-137.
  • Photo courtesy of SteadyHealth.com

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