Exercise as it relates to Disease/The effects of a muscle endurance exercise program in ALS patients

Student ID: 3094317

This wiki fact sheet is based on the journal article "The value of muscle exercise in patients with amyotrophic lateral sclerosis" by Drory VE, Goltsman E, Reznik JG, Mosek A, Korczyn AD.

Background
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative condition that is associated with a progressive deterioration of the motor neurons and subsequent muscular paralysis. Conflicting results from previous research have led to controversy regarding whether regular exercise should be recommended or avoided in ALS patients. However, this study differs from past research as it looks at the role of physical activity after the onset of ALS rather than before it. The purpose of the study is therefore to look at the effects of a regular moderate exercise program on parameters of motor deficit, disability, fatigue, musculoskeletal pain and perceived quality of life in patients diagnosed with probable or definite ALS.

Where is the research from?
This study was conducted by researchers within the Department of Neurology at Tel-Aviv Sourasky Medical Centre in Tel Aviv, Israel. It was published on the 15th of October, 2001 by the peer-reviewed Journal of Neurological Sciences.

What kind of research was this?
This research was done using a randomised controlled trial in which twenty-five ALS patients were randomly assigned to two groups; a physical activity group and a control group. The exclusion criteria for the study included a lost ability to walk (including those requiring intermittent or continuous mechanical ventilation) as well as individuals who were no longer able to understand or conform to the instructions provided by the researchers.

What did the research involve?
Twenty-five individuals (14 males; 11 females) with probable or definite ALS as per the El Escorial WFN criteria were randomly assigned to two groups; a physical activity group and a control group. At the onset of the study, the mean age of the participants was 60 with a range of 40-81, and most of them were in the mild-moderate stages of the disease. The patients in both groups did not significantly differ in their age, disease onset from the point of inclusion, and level of disability at the point of inclusion.

Physical activity group – The subjects in the physical activity group (n=14; 8 males, 6 females) were each instructed to follow an exercise program targeting the majority of muscles in the four limbs and the trunk. Each participant received an individualized form of the program based on their general health, neurological status and fitness levels. The program was fifteen minutes in length, was to be performed twice daily at home, and had the overall aim of reducing the degenerative effects of ALS.

Control group – The control group subjects (n=11; 6 males, 5 females) were each instructed to not perform any form of physical activity aside from what their activities of daily living consisted of.

All patients were assessed at baseline and after 3, 6, 9 and 12 months in the following;

•	Manual muscle strength testing (MMT).

•	The Ashworth Spasticity Scale (ASH).

•	The ALS functional rating scale (FRS).

•	Fatigue severity scale (FSS).

•	A visual analogue scale for musculoskeletal pain from 0 (no pain) to 10 (unbearable pain).

•	SF-36 (MOS-36 Item Short Form Survey).

Results
Throughout the follow-up period, patients in both groups significantly deteriorated in their neuromuscular functioning, however the exercise group appeared to display less of a decline overall. The most positive effects were seen in the FRS and ASH scales, which relate to the degree of spasticity and disability the subjects were experiencing. In both of these measures, the exercise group reported significantly lower scores in comparison to the control group. This data complies with previous research, as daily, moderate endurance exercises for the trunk and limbs have also been linked with decreases in spasticity in ALS patients. With regards to muscle strength, levels of fatigue, and perceived quality of life, the results were also indicative of a slightly lesser degree of worsening in the exercise group although these differences were not of statistical significance (p=0.005). In contrast, both groups showed increased levels of self-reported pain throughout the follow-up period, suggesting that exercise had no clear effect on reducing pain complaints.

How were the results interpreted?
After carrying out the study the researchers interpreted that the results conformed to the general consensus provided by previous research, which is that moderate exercise is beneficial towards improving the quality of life in ALS patients.

Conclusion
The moderate exercise program resulted in positive effects for the exercise group in all parameters other than self-reported pain levels. This research therefore suggests that moderate exercise is beneficial towards reducing the rate of decline of motor deficit and disability, fatigue, and health-related quality of life in ALS patients. Thus, participating in moderate regular exercise should be encouraged within this population, in order to help suppress the deteriorating effects of the disease.

Implications
This research proposes that regular moderate physical activity can be beneficial to ALS patients. However, the drop-out rate of the study was high and only the results from the 3 and 6 month follow-ups were able to be analysed. This high drop-out rate in addition to the relatively small sample size may question the validity and statistical power of the results. Future research in the area should therefore anticipate a high drop-out rate due to the debilitating nature of the disease, and account for this by increasing the sampling size. This would help provide more statistically meaningful results, and give a clearer indication of the potential benefits exercise holds for ALS patients.