The early symptoms of ALS include muscle twitches in the arm, leg, shoulder, or tongue, muscle cramps, tight and stiff muscles (spasticity), muscle weakness affecting an arm, a leg, neck or diaphragm, slurred and nasal speech and difficulty in chewing or swallowing. For many individuals the first sign of ALS may appear in the hand or arm as they experience difficulty with simple tasks such as buttoning a shirt, writing, or turning a key in a lock. In other cases, symptoms initially affect one of the legs, and people experience awkwardness when walking or running or they notice that they are tripping or stumbling more often.