# Physical and Respiratory Rehabilitation in Spinal Muscular Atrophy: A Critical Narrative Review
###### Abstract  
Spinal muscular atrophy (SMA) is a genetic disorder causing motor neuron loss and progressive muscle weakness, significantly affecting daily activities and breathing in severe cases. While rehabilitation is a crucial component of SMA management, no standardised rehabilitation guidelines currently exist. This review synthesised physiotherapy and respiratory interventions for SMA patients based on a comprehensive literature search from 1990 to 2024. Eighteen studies were analysed: eleven on physiotherapy and seven on respiratory rehabilitation. Five physiotherapy approaches were reported: electrical stimulation, electrotherapy with cycling, strengthening exercises, aerobic training, and hydrotherapy-based rehabilitation. Respiratory interventions, such as non-invasive ventilation and cough assistance, were mainly studied in SMA Type I, reporting prolonged survival and improved respiratory function. A few studies found that combining pharmacotherapy with intensive physiotherapy led to significantly better motor improvements than drugs alone. Despite these promising reported results, the lack of standardised methodologies and long-term clinical trials prevents definitive conclusions. Research should prioritiise randomised controlled trial studies with standardised methodologies and larger sample sizes to investigate the efficacy of physiotherapy and respiratory interventions and, secondly, inform evidence-based rehabilitation protocols and clinical guidelines.  
muscular atrophy; spinal; complications; rehabilitation 2025  
[PERSON], S.  
the disease course. New research studies have highlighted the role of microRNA as a potential biomarker to monitor disease progression and treatment efficacy [5]. SMA usually affects the performance of activities of daily living such as crawling, sitting, standing, and neck and head control, but even swallowing and breathing in the worst cases [6]. Hence, respiratory failure is the main cause of death and morbidity; meanwhile, musculoskeletal pain, contractures, limited mobility, fatigue and spinal deformities are the main factors that affect the quality of life of people with SMA [7; 8; 9; 10; 11; 12; 13]. To date, SMA requires prompt treatment and has no cure if not diagnosed early; therefore, healthcare management focuses on early diagnosis and on conservative treatments involving different healthcare professionals, among which the physiotherapist, to preserve the quality of life [14; 15; 16; 17; 18; 19; 20; 21; 22; 23; 24; 25; 26; 27; 28; 29; 30; 31].  
All neuromuscular disorders require a multidisciplinary approach. Physiotherapy represents a key factor in improving patients' function and quality of life [32; 33; 34; 35; 36; 37; 38; 39; 40]. The purpose of rehabilitation is to preserve motor and respiratory functions, reducing symptoms and comorbidities. Concerning SMA, in a recent paper by [PERSON] and collaborators, some recommendations about rehabilitation have been proposed; stretching, positioning, mobility exercises, and chest physiotherapy gained a moderate level of evidence [32]. However, no instructions about how to perform them were added. In consideration of the above, the objective of this narrative review is to summarise the available evidence on physiotherapy and respiratory interventions in people with SMA and to give technical specifications about how to perform them to improve patients' function and quality of life as much as possible.