What is the aim of physiotherapy in ALS?
Physiotherapy cannot halt the progression of paralysis (paresis) and stiffness (spasticity). Nevertheless, physiotherapy plays an important role in the overall course of the disease. The objectives and forms of physiotherapy change over the course of ALS. At the onset of the disease, the focus is on strengthening intact muscles and reducing spasticity (if present). The existing muscle functions should be stabilized. Some patients report a muscle build-up or improvement in certain muscle functions with frequent and intensive physiotherapy. This positive effect cannot be achieved in all patients and can never be used as a criterion for success.
Due to the progressive nature of ALS, the preservation of muscle function alone is a valuable goal. If ALS progresses further, independent movement of the extremities may be restricted and severe muscle atrophy may occur. Physiotherapy is also useful in this constellation and aims to reduce “inactivity atrophy”. Muscle atrophy due to inactivity is also known from other contexts in the general population. If an extremity is “immobilized” (e.g. after a fracture), muscle atrophy occurs simply due to reduced use of the extremity, even though the muscles are not diseased. A similar effect can occur in ALS: With paresis of the hand, the entire extremity is used less, resulting in the risk of inactivity atrophy in the upper arm and shoulders. Physiotherapy also serves to load and mobilize (“train”) the muscles that are only indirectly affected (upper arm and shoulder muscles in the above example).
Other aims of physiotherapy in the middle and advanced stages of the disease are to prevent contractures (shortening of muscles and tendons), which in turn can lead to a restriction in the range of motion of the arm and leg (even if they are moved passively). More frequent, regular and sufficient stretching exercises (“stretching”) are of crucial importance for the prevention and treatment of contractures. To ensure regularity and continuity of mobility, therapeutic movement devices (“movement trainers”) have proven their worth, which are mainly used on days when physiotherapy cannot take place (especially at weekends and on public holidays). In the case of severe contractures, physiotherapy is combined with the use of orthoses (splint systems) to support the limb in the “correct” position. If the contractures are due to spasticity, in specific situations the neurologist injects the drug botulinum toxin directly into the contracted muscles. Intensive physiotherapy is then particularly important so that the medication can be distributed in the muscle and take full effect.
Even if the patient’s own mobility is severely restricted, “passive” physiotherapy (mobilization of the body through physiotherapy, manual therapy or other applications) is of great importance. It serves to prevent arthrosis, lymphoedema, thrombosis and other consequences of loss of mobility. The proportion and importance of passive mobilization (including stretching exercises) increases as ALS progresses. Even with a complete loss of voluntary motor function, physiotherapy is necessary several times a week. In addition to the positive effect of physiotherapy (especially physiotherapy) on the immediate muscle and joint apparatus, physiotherapy has a “training effect” on blood circulation and circulatory functions. In particular, support with walking (if possible) and standing (if necessary with support or aids).
Another aspect of consistent physiotherapy (in conjunction with occupational therapy and physiotherapy) is ensuring social participation. Through mobilization, a change of location (leaving the house, apartment or room) can be achieved. Overall, physiotherapy aims to achieve three treatment outcomes, depending on the phase of the disease and the individual symptoms: 1) strengthening the musculoskeletal system, 2) “training” the circulatory and vascular system and 3) overcoming physical barriers and supporting social participation.
Due to the complexity of the treatment goals, physiotherapy is useful throughout the course of ALS – even if no motor improvements can be achieved. It is regarded as a basic element of non-pharmacological therapy for ALS.