# Exercise as it relates to Disease/Does aerobic exercise have an impact on amyotrophic lateral sclerosis management?

This critique is on the article: "Recumbent stepping aerobic exercise in amyotrophic lateral sclerosis: A pilot study". This is for an assignment with the University of Canberra, as part of the Health, Disease and Exercise unit.

## What is the Background to this research?

Amyotrophic lateral sclerosis (ALS), is a progressive motor neuron disease affecting the nerve cells in the brain and spinal cord, causing loss of muscle control around the body.There is a range of early symptoms that contribute to the diagnosis of ALS including: slurred speech, difficulty eating/swallowing, twitches in the arms and legs and muscle stiffness. The onset of the disease is most commonly sporadic (random) with about 5-10% of cases being familial (genetic), however, there is not enough research to how each of the causes has come about and why it only affects certain people.
ALS is currently an incurable disease, however there are forms of treatment available that can aid in the patient’s symptom progression, independence and prevent some of the harsher complications of the disease. Light aerobic exercise is increasingly becoming a more popular treatment option among patients as well as caregivers. This can be in the form of stepping, walking, or swimming; all of which have abilities to boost heart health and decrease muscle pains. Improving quality of life for these patients is an important and positive factor, however there is limited research behind whether aerobic exercise contributes to the more physical aspects of the progressions.

## Where is the research from?

The authors of this study, Anjali Sivaramakrishnan and Sangeetha Madhavan, are from the Department of Physical Therapy at the College of Applied Health Science, Chicago. Both authors are very accomplished females of their field who both are Physical therapists, specializing in rehabilitation sciences, primarily of neuromuscular events such as, ALS, Parkinson’s, stroke survivors and spinal cord injuries.

## What kind of research was this?

The research was conducted as a randomized single group pre-test post-test experimental study with a one month follow up. The most common method for these types of research studies are with clinical trials or control designs, all of which are individually randomized in some form.

## What did the research involve?

Participants for the study were recruited by reviewing the ability for the patients to walk at least 10 meters, aided or not. If the patient could do this, they could still be excluded through other contradictions such as:
* History of severe cardiac, pulmonary, metabolic, or orthopedic complications (pre study)
* Significant cognitive or communication impairment
* Other neurological comorbidities
* Contraindications to transcranial magnetic stimulation (TMS)
At the pre-test, Post-test, and one month follow up, there were outcomes measured to ensure the safety and feasibility of the study. These measurements were:
| Measured outcomes: | Abbreviation: | What it measures: |
| ALS functional rating scale - revised | ALSFRS - R | Measures the current progression of the disease in that individual |
| 10 Metre Walk Test | 10MWT | Measures individual gait speed |
| 6-Minute walk test | 6MWT | Measures an estimate on cardiovascular endurance |
| Timed up and go test | TUG | Measures the risk of falls |
| Fatigue Severity Scale | FSS | Measures global fatigue |
| 12 item short form survey | SF - 12 | Measures Quality of life (QoL) |
| Beck depression inventory | BDI | Measures depression levels |
| Transcranial metabolic stimulation | TMS | Measures motor evoked potentials (MEPs) First dorsal interosseous (FDI) and tibialis anterior (TA) excitability measured |
In this intervention, the patients were required to use the ‘NuStep T5 Recumbent Cross trainer’ and maintain a pace of 65-70 steps per minute for 40 minutes. This included a 5-minute warm up, 30 minutes of exercise, and 5-minute cool down. These sessions were completed 3 times a week for 4 weeks.
During the sessions, the participants were encouraged to perform at 50-70% of max heart rate and at a RPE level of 3-5 (using modified Borg’s scale), which were both measured every 5 minutes to maintain the accuracy of the exercise.
To reach the targeted heart rate, the resistance on the cross trainer was gradually increased. If they already have reduced leg strength, then they were encouraged to step faster rather than increasing the resistance.

## What were the basic results?

From the measured clinical variables that were examined in the pre, post and 1-month assessments, there was no considerable differences. The only notable measurement found was that there was a total increase of distance by 0.11 miles between the participants however still not significant.
The ALSFRS-R post exercise scores found that the aerobic stepping exercise does not affect ALS disease progression. While the figures showed that there was limited physical benefits, the participant showed great satisfaction in the program as evident via the 100% participation from all individuals. The QoL and BDI surveys were shown to have an increase and showing that the individuals had a greater quality of life post exercise. The results were tabulated into participant characteristics (pre-test), satisfaction scores, change in ALSFRS-R scores, and the comparison of clinical and gait parameters at all stages (including p value).
Safety of the program is supported although there were some measures excluded from the testing which may have proved beneficial to the program. These include the measurement of oxygen consumption and respiratory capacity,
Due to such a short study period and sample size, the results could not provide a conclusive insight on whether it shows extensive benefits to ALS patients, however the program was feasible and safe for ALS patients and showed to have an increase in overall quality of life and mental wellbeing. The authors recognize that there are also several similar articles that provide the same results, however still performed at small study periods.

## What conclusions can we take from this research?

Overall, the study provided a significant understanding that moderate aerobic exercise can aid in the overall quality of life for ALS patients however no conclusive results showing physical benefits. There are barriers to be faced when providing exercise programs for ALS patients including fatigue, muscle weakness, respiratory problems, limited transportation, and caregiver burden which are all factors that must be considered. Several limitations that come with the disease result in the exercise to be also very altered to suit certain complications.

## Practical advice

While aerobic exercise has a benefit on almost anyone, due to the range of complications that can occur with ALS patients, there is criteria that must be assessed before implementing a program. You must consider the patients prior activities, current strength and mobility, balance, rate of symptom progression, respiratory functions, and overall goals.
As ALS affects everyone differently, everything must be taken into consideration. There are different types of exercise that can be incorporated into programs including: aerobic exercise (i.e., treadmill, stepper, elliptical), range of motion/flexibility exercise (i.e., yoga, Pilates, water therapy), and strengthening exercises.

## Further information

Amyotrophic Lateral Sclerosis (ALS):
https://www.mayoclinic.org/diseases-conditions/amyotrophic-lateral-sclerosis/symptoms-causes/syc-20354022#:~:text=Amyotrophic%20lateral%20sclerosis%20(a%2Dmy,who%20was%20diagnosed%20with%20it.
A randomized controlled trial of resistance and endurance exercise in amyotrophic lateral sclerosis: https://www.tandfonline.com/doi/abs/10.1080/21678421.2017.1404108
The Role of Exercise as a Non-pharmacological Therapeutic Approach for Amyotrophic Lateral Sclerosis: Beneficial or Detrimental?:
https://www.frontiersin.org/articles/10.3389/fneur.2019.00783/full
Range of Motion Exercises for ALS Patients:
https://alstreatment.com/range-of-motion-exercises/

## References

<references/>
* 1 2 Mayo clinic staff (august 2019). Amyotrophic Lateral Sclerosis (ALS). Mayo clinic. Available from: https://www.mayoclinic.org/diseases-conditions/amyotrophic-lateral-sclerosis/symptoms-causes/syc-20354022 31 August, 2021
* ↑ National Institute of Neurological Disorders and Stroke (2013). Amyotrophic Lateral Sclerosis (ALS) Fact Sheet. NINDS. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Amyotrophic-Lateral-Sclerosis-ALS-Fact-Sheet . 31 August 2021
* ↑ Cleveland Clinic (2021). Amyotrophic Lateral Sclerosis. Available from: https://my.clevelandclinic.org/health/diseases/16729-amyotrophic-lateral-sclerosis-als . 31 August 2021
* 1 2 3 4 5 Sivaramakrishnan A, Madhavan S (2019). Recumbent stepping aerobic exercise in amyotrophic lateral sclerosis: a pilot study. Neurol Sci. 2019 May;40(5):971-978
* ↑ Applied Health Sciences (2021). Sangeetha Madhavan. UIC. Available from: https://ahs.uic.edu/physical-therapy/directory/madhavan-sangeetha/
* ↑ School of health professions (2021). Anjali Sivaramakrishnan, PhD, PT. UT health. Available from: https://www.uthscsa.edu/academics/health-professions/profile/sivaramakris
* ↑ Laura Good, Amanda Beaty (2021). Exercise and ALS. Your ALS Guide, Available from: https://www.youralsguide.com/exercise-and-als.html 10 September 2021
* ↑ Robert G Miller, Sandy McDade , Melody Fong, (2014). Exercise: Helpful or Harmful in ALS?. Forbes Norris ALS Research and Treatment Center. Available from: https://amyandpals.com/exercise-helpful-harmful-als/ 10 September 2021