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Abstract

Objective: To determine the effects of resistance exercise on function, fatigue, and quality of life in individuals with ALS.
Methods: Subjects with a diagnosis of clinically definite, probable, or laboratory-supported ALS, forced vital capacity (FVC) of 90% predicted or greater, and an ALS Functional Rating Scale (ALSFRS) score of 30 or greater were randomly assigned to a resistance exercise group that received a home exercise program consisting of daily stretching and resistance exercises three times weekly or to a usual care group, who performed only the daily stretching exercises. ALSFRS, the Fatigue Severity Scale (FSS), and Short Form-36 (SF-36) were completed at baseline and monthly for 6 months. FVC and maximum voluntary isometric contraction (MVIC) were monitored monthly throughout the study.
Results: Of 33 subjects screened, 27 were randomly assigned (resistance = 13; usual care = 14). Eight resistance exercise subjects and 10 usual care subjects completed the trial. At 6 months, the resistance exercise group had significantly higher ALSFRS and SF-36 physical function subscale scores. No adverse events related to the intervention occurred, MVIC and FVC indicated no negative effects, and less decline in leg strength measured by MVIC was found in the resistance exercise group.
Conclusion: Our study, although small, showed that the resistance exercise group had significantly better function, as measured by total ALS Functional Rating Scale and upper and lower extremity subscale scores, and quality of life without adverse effects as compared with subjects receiving usual care.

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REFERENCES

1.
Mitsumoto H, Chad DA, Pioro EK. Clinical features: signs and symptoms. In: Mitsumoto H, Chad D, Pioro EK, eds. Amyotrophic lateral sclerosis. Philadelphia: Davis, 1998:47–64.
2.
Bennett RL, Knowlton GC. Overwork weakness in partially denervated skeletal muscle. Clin Orthop 1958;12:711–715.
3.
Johnson EW, Braddom R. Overwork weakness in fasioscapulohumeral muscular dystrophy. Arch Phys Med Rehabil 1971;52:333–336.
4.
Struckland D, Smith SA, Dolliff G, Goldman L, Roelofs RI. Physical activity, trauma, and ALS: a case-control study. Acta Neurol Scand 1996;94:45–50.
5.
Chio A, Benzi G, Dossena M, Mutani R, Mora G. Severely increased risk of amyotrophic lateral sclerosis among Italian professional football players. Brain 2005 128:472–476.
6.
Scarmeas N, Shih T, Stern Y, Ottman R, Rowland LP. Premorbid weight, body mass, and varsity athletics in ALS Neurology 2002;59:773–775.
7.
Munsat TL. Commentary. In: Mulder DW, ed. The diagnosis and treatment of amyotrophic lateral sclerosis. Boston: Houghton Mifflin; 1980:214–215.
8.
Bohannon RW. Results of resistance exercise on a patient with amyotrophic lateral sclerosis. Phys Ther 1983;63:965–968.
9.
Sanjak M, Reddan W, Brooks BR. Role of muscular exercise in amyotrophic lateral sclerosis. Neurol Clin 1987;5:251–268.
10.
Drory VE, Goltsman E, Reznik JG, Mosek A, Korczyn AD. The value of muscle exercise in patients with amyotrophic lateral sclerosis. J Neurol Sci 2003;191:133–137.
11.
Kirkinezos IG, Hernandez D, Bradley WG, Moraes CT. Regular exercise is beneficial to a mouse model of amyotrophic lateral sclerosis. Ann Neurol 2003;53:804–807.
12.
Veldink JH, Bar PR, Joosten EA, Otten M, Wokke JH, van den Berg LH. Sexual differences in onset of disease and response to exercise in a transgenic model of ALS. Neuromuscul Disord 2003;13:737–743.
13.
Mahoney DJ, Rodriguez C, Devries M, Yasuda N, Tarnopolsky MA. Effects of high-intensity endurance exercise training in the G93A mouse model of amyotrophic lateral sclerosis. Muscle Nerve 2004;29:656–662.
14.
The ALS CNTF Treatment Study (ACTS) Phase I II Study Group. The amyotrophic lateral sclerosis functional rating scale: assessment of activities of daily living in patients with amyotrophic lateral sclerosis. Arch Neurology 1996;53:141–147.
15.
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale: Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 1989;46:1121–1123.
16.
Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston: Health Institute, New England Medical Center, 1993.
17.
Andres PL, Hedlund W, Finison L, Conlon T, Felmus M, Munsat TL. Quantitative motor assessment in amyotrophic lateral sclerosis. Neurology 1986;36:937–941.
18.
Unnebrink K, Windeler J. Intention-to-treat: Methods for dealing with missing values in clinical trials of progressively deteriorating diseases. Stat Med 2001;20:3931–3946.
19.
Kent-Braun JA, Miller RG. Central fatigue during isometric exercise in amyotrophic lateral sclerosis. Muscle Nerve 2000;23:909–914.
20.
Dishman RK. Increasing and maintaining exercise and physical activity. Behav Ther 1991;22:345–378.
21.
Brewin CR, Bradley C. Patient preferences and randomised clinical trials. Br Med J 1989;299:313–315.
22.
Wennberg JE, Barry MJ, Fowler FJ, Mulley A. Outcomes research, PORTS, and health care reform. Ann NY Acad Sci 1993;703:52–62.
23.
Rücker G. A two stage trial design for testing treatment, self selection and treatment preference effects. Stat Med 1989;8:477–485.
24.
Pawson R, Tilley N. Realistic evaluation. London, UK: Sage, 1997.
Letters to the Editor
25 February 2008
Reply from the authors
Vanina PM Dal Bello-Haas, School of Physical Therapy, University of Saskatchewan
Julaine M Florence, Anne D Kloos, Jeanine Scheirbecker, Glenn Lopate, Sheila M Hayes, Erik P Pioro, Hiroshi Mitsumoto

We welcome the opportunity to respond to Dr. Armon's questions probing the validity of our interpretations. The tables comparing control and experimental subjects who completed and those who discontinued is now provided (E-Table 1a and 1b) [see link below].

Using Dr. Armon's methodology [2], the estimated progression rate for those who completed was -0.207 (Usual Care: 16.4 months, ALSFRS = 36.6) and -0.211 (Resistance: 21.8 months, ALSFRS = 35.4). In both groups, subjects who discontinued had faster rates of decline compared to those who completed: Usual Care = -0.375 (12.8 months, ALSFRS = 35.2) and Resistance = - 0.301 (17.3 months, ALSFRS = 34.8). %predicted FVC for Resistance subjects who discontinued was 97.3 (±7.9) and for those who completed was 98.2 (± 5.2) (p = 0.80). Resistance subjects who discontinued had lower FSS scores/higher SF-36 vitality scores (less fatigue) and higher SF-36 RP scores (less physical role problems). Thus, Dr. Armon's argument that "resistance exercise protocol weeded out faster progressing patients" is not supported.

The subject who dropped post-bypass surgery had > a 10-year history of cardiac problems, including an MI. He was informed of a blockage (time of the MI), but surgery was not performed. A direct correlation between the resistance protocol and surgery could not be determined in reviewing the medical record. However, this does not negate that fact that, as in any other patient population, exercise may have detrimental effects and needs to be carefully prescribed and monitored.

We agree with Dr. Armon, as we illustrated in our Discussion, that a subset of people with ALS may respond more positively to resistance exercises. [1] We clearly had a unique subset of subjects, as we specifically limited enrollment to those with an FVC of > 90% predicted and ALSFRS score > 30.2

Numerous factors influence exercise prescription in the ALS population. [6] Although resistance exercise may not have any ultimate influence on disease progression and mortality, the rationale for prescribing resistance exercise in the broader context of the disease should be considered(especially in the earlier stages before significant muscular atrophy or deconditioning occurs). This need to be articulated to patients who can then make informed decisions.

Many questions related to the role of exercise in the ALS population remain unanswered. Any exercise prescription should be individualized and carried out under the supervision of a qualified physical therapist who understands the nature of ALS.

E - Tables

References

6. Dal Bello-Haas V. A framework for rehabilitation in degenerative diseases: planning care and maximizing quality of life. Neurology Report. 2002; 26:115-129.

Disclosure: The author reports no conflicts of interest.

25 February 2008
A randomized controlled trial of resistance exercise in individuals with ALS
Carmel Armon, M.D., M.H.S., Baystate Medical Center

I read the report by Dal Bello-Hass et al with interest. [1] However, I have some concerns regarding the efficacy data, based on review of the data in the web-based tables. Two points appear to detract from the original findings.

The resistance exercise group started out with a better ALSFRS score and was progressing at a slower rate at the time of randomization. In addition, the resistance exercise protocol weeded out faster progressing patients.

An estimated progression rate at the time of randomization, based on the number of ALSFRS points lost (relative to the baseline of 40) divided by duration from disease onset to randomization shows that, at the time of randomization, the mean estimated progression rate for the usual care group was -0.416 ALSFRS points/month. It was -0.235, or 43% slower, for the resistance exercise group.

An estimated progression rate similarly defined has been shown to be predictive of survival or disease progression for several measures including the ALSFRS-R, and one based on ALSFRS-R has been used for the purposes of stratification in a clinical trial. [2-5]

The resistance exercise protocol weeded out faster progressing patients. The FVC of the resistance exercise group was 97.9+/-5.8 %predicted at randomization (n=13) and 99+/- 3.2 at 6 months (n=8). The apparent improvement in mean values with a smaller standard deviation could have only been achieved by dropping the faster progressing patients.

The authors should clarify how the Standard Deviation of FVC %predicted for the resistance exercise group is three to five times smaller than that of the usual care group (14.6 at randomization; 15.2 at 6 months). It would be informative if the authors could provide the readers with the probability that this disparity would occur by chance.

It is unsafe to take the efficacy data at face value to conclude that exercise had a beneficial effect. One of the resistance exercise group patients needed triple bypass surgery even though he had been deemed healthy to participate in the study by his cardiologist.

Future patients who are influenced by the authors' suggestion that resistance exercise may be an "essential component of the overall care of patients with this disease" [1] may be undertaking this and other risks. In addition, patients will be disappointed when they find themselves unable to persist in this treatment modality.

The eight patients who completed the 6 months of resistance exercise are not representative of most patients with ALS who do not have FVCs of 98-99% predicted 20-26 months into their disease. Resistance exercise may be appropriate for consideration only in the slowest of slowly progressing patients.

References

1. Dal Bello-Hass V, Florence JM, Kloos AD et al. A randomized controlled trial of resistance exercise in individuals with ALS. Neurology 2007;68:2003-2007.

2. Armon C, Graves MC, Moses D, et al. Linear estimates of disease progression predict survival in patients with amyotrophic lateral sclerosis. Muscle Nerve. 2000;23:874-882.

3. Czaplinski A, Yen AA, Appel SH. Amyotrophic lateral sclerosis: early predictors of prolonged survival. J Neurol. 2006;253:1428-1436. Epub 2006 Jun 13.

4. Czaplinski A, Yen AA, Simpson EP, Appel SH. Predictability of disease progression in amyotrophic lateral sclerosis. Muscle Nerve. 2006;34:702-708.

5. Kimura F, Fujimura C, Ishida S, et al. Progression rate of ALSFRS-R at time of diagnosis predicts survival time in ALS. Neurology 2006;66:265-267.

Disclosure: The author reports no conflicts of interest.

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Published In

Neurology®
Volume 68Number 23June 5, 2007
Pages: 2003-2007
PubMed: 17548549

Publication History

Published online: June 4, 2007
Published in print: June 5, 2007

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Affiliations & Disclosures

V. Dal Bello-Haas, PT, PhD
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
J. M. Florence, PT, DPT
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
A. D. Kloos, PT, PhD, NCS
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
J. Scheirbecker, MPT
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
G. Lopate, MD
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
S. M. Hayes, PT, MS
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
E. P. Pioro, MD, PhD, FRCPC
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.
H. Mitsumoto, MD, DSc
From the School of Physical Therapy (V.D.B.-H.), University of Saskatchewan, Saskatoon, Canada; and Department of Neurology (J.M.F., J.S., G.L.), Washington University School of Medicine, St. Louis, MO, Division of Physical Therapy (A.D.K.), Ohio State University, Columbus, Department of Neurology (S.M.H.) and Eleanor and Lou Gehrig MDA/ALS Research Center (H.M.), Neurological Institute, Columbia University, New York, and Department of Neurology (E.P.P.), Cleveland Clinic, OH.

Notes

Address correspondence and reprint requests to Dr. V. Dal Bello-Haas, School of Physical Therapy, University of Saskatchewan, 1121 College Dr., Saskatoon, SK, Canada S7N 0W3 [email protected]

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