Physical therapy review

✓Supports this

“People with ALS/MND are advised to stop and rest before reaching exhaustion, rather than pushing on until they are worn out.”

This review of physical therapy in ALS says therapists should teach people with ALS not to carry any activity through to the point of extreme fatigue, and suggests spreading effort over several short sessions across the day with enough rest in between rather than one sustained push.

!Qualifies this

“Steady, consistent pacing is expected to leave someone better off than bursts of activity followed by exhaustion.”

Points the same way but does not go as far. It warns against activity taken to the point of extreme fatigue, lists exhaustion that stops you doing daily tasks the next day as a sign of overuse, and favours short sessions with rest between them. It says this about exercise programmes and offers no comparison showing that steady pacing leaves people better off overall.

iAdds context

“Fatigue is one of the most commonly reported symptoms in ALS/MND, and several different things can contribute to it.”

Adds a figure for how common. It reports a survey in which people with ALS ranked fatigue first out of thirteen symptoms, at 90 percent, ahead of muscle stiffness and cramps, and notes that fatigue was also the symptom least often treated. It is one survey sample reported in a review, not a population estimate.

iAdds context

“Falls prevention should start early, before falls become frequent.”

Sets out why this matters, rather than when to start. It reports that falls are common in ALS, with a fall rate of 46% in one ALS clinic, that they carry serious consequences including increased illness and death, and that fall-related head trauma is significantly higher than in people without ALS.

Used across the whole answer

✓Supports this

“Breathlessness, breathlessness lying flat, disturbed sleep and daytime sleepiness should be reported to the ALS/MND team, because they can be early signs that the breathing muscles are weakening rather than signs of overdoing exercise.”

The same review that supplies this answer's overuse signs puts breathlessness elsewhere. Its overuse list is exhaustion or pain that stops daily activities, a recoverable drop in muscle force, and increased cramping, soreness, fatigue or fasciculations. Breathlessness, breathlessness lying flat, sleep disturbance and daytime sleepiness sit under respiratory muscle weakness instead.

Early signs and symptoms of respiratory muscle weakness are varied and may include shortness of breath, orthopnea, sleep disturbances, poor concentration, confusion, daytime sleepiness, morning headaches, and fatigue.

Respiratory impairments

✓Supports this

“Exercise in ALS/MND should not leave you clearly worse off afterwards than before.”

Says physical therapists should teach people with ALS not to carry out any activity to the point of extreme fatigue, and names the signs of overuse to watch: being unable to do daily activities afterwards because of exhaustion or pain, a drop in muscle force that gradually recovers, and increased cramping, soreness, fatigue or twitching.

!Qualifies this

“Fatigue appears on both the overuse list and the list of symptoms monitored for respiratory impairment.”

Names fatigue both in its account of overwork and among the early signs of respiratory muscle weakness, so the same symptom can belong to either.

iAdds context

“Positioning someone in good alignment can reduce pain, help prevent pressure sores and lower the effort of breathing.”

Fills in where the pain tends to be. It says that although ALS does not involve the pain pathways directly, immobility, loss of range of movement, reduced support from weakened muscles and positioning difficulty can all cause pain, and names the low back, the neck and the shoulder region as the common sites. Not quoted because the relevant sentences end in superscript reference numbers.

Used across the whole answer

✓Supports this

“Physiotherapy goals in ALS/MND shift with the stage of the illness, from maintaining mobility early on to comfort and quality of life later.”

Describes an early, middle and late framework for physical therapy decision-making in ALS, with preventative, compensatory and restorative interventions chosen according to the stage a person is in, and reports that this stage approach is now widely used. Not quoted because the relevant sentences end in superscript reference numbers.

✓Supports this

“Stiffness, cramps and spasticity are common problems in ALS/MND.”

Reports a survey of people with ALS in which muscle stiffness was the second most commonly reported symptom at 84% and muscle cramps the third at 74%, behind fatigue at 90%, and notes that stiffness was among the symptoms least often treated. It gives no separate figure for spasticity.

✓Supports this

“Light to moderate strengthening exercise is most likely to help earlier in ALS/MND.”

A review of physical therapy in ALS which says resistance exercise of unaffected muscles at low-to-moderate load suits people in the early or early-middle stage and those whose disease is progressing more slowly, and should be prescribed as soon as possible after diagnosis.

Supports a claim in this answer

Gentle to moderate exercise can help maintain comfort, mobility and general wellbeing for many people with ALS/MND

!Qualifies this

“For many people with ALS/MND, gentle to moderate exercise can help maintain comfort, mobility and general wellbeing.”

A review of the physical therapy evidence which says the effects of exercise in ALS are not well understood and that the role of resistance and aerobic exercise remains controversial. It reports that the view that appropriately prescribed exercise may be physically and psychologically beneficial, especially earlier on, is increasingly adopted, but that the underlying evidence is thin.

The evidence related to the benefits and risks of exercise in PALS is limited.

Exercise for PALS

✓Supports this

“Breathing and coughing become harder in ALS/MND because the muscles that do them weaken.”

Says respiratory problems in ALS come from loss of respiratory muscle strength, and that weakness of the muscles used to breathe out in particular reduces the ability to cough and clear secretions.

Respiratory impairments in PALS are related to decreased respiratory muscle strength.

Respiratory impairments

✓Supports this

“Morning headaches can be an early sign that the breathing muscles are weakening.”

Lists morning headaches among the early signs and symptoms of respiratory muscle weakness in ALS, alongside breathlessness, breathlessness when lying flat, disturbed sleep, poor concentration, confusion, daytime sleepiness and fatigue.

Early signs and symptoms of respiratory muscle weakness are varied and may include shortness of breath, orthopnea, sleep disturbances, poor concentration, confusion, daytime sleepiness, morning headaches, and fatigue.

Respiratory impairments

Further reading

Discusses appropriate exercise timing, intensity, and disease stage.

Further reading

Evidence review of exercise and physical therapy across ALS/MND stages.

Further reading

Review of physical therapy evidence in ALS/MND.