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Exercise Testing and Prescription


Sinaki and Mulder (cited in Dal Bellow-Haas et al., 1998) describe the natural course of ALS as six stages:

  • Stage I: Early stage of the disease. Independent in mobility and ADL. A specific group of muscles are mildly weak; may be limitations in performance, endurance, or both.
  • Stage II: Moderate weakness in groups of muscles.
  • Stage III: Still ambulatory but has severe weakness in certain muscle groups. May exhibit mild to moderate limitation of function. May have difficulty holding head erect.
  • Stage IV: Severe weakness of the legs and mild involvement of the arms. May use a wheelchair and may be unable to perform ADL.
  • Stage V: Progressive weakness and deterioration of mobility and endurance. Uses a wheelchair. Arm muscles may exhibit moderate or severe weakness. May exhibit pain in immobilized joints.
  • Stage VI: Bedridden and requires maximal assistance with ADL. Progressive respiratory distress develops.

The key to exercise testing and prescription is determination of the stage of the disease. Regardless of the stage, care must be taken to prevent overuse fatigue and disuse atrophy (Dal Bellow-Haas et al., 1998). The four exercise program functions are planning, implementation, documentation, and feedback/program modification (Smith, 2000). In the planning stage, attentiveness in collecting and assessing information, obtaining physical assessments, and setting realistic goals is important. While functional gains as a result of exercise have not yet been determined, exercise may be physiologically and psychologically beneficial for patients with ALS (Dal Bellow-Haas et al., 1998). Strengthening and flexibility should also be included as part of the program.

The initial assessment can be done following the TQNE described in the study by Andres et al. (Andres et al., 1986). Timed tests include speech rate, phone dialing and pegboard test for hand dexterity, and a 15-foot walk. Isometric strength testing includes shoulder flexion/extension, elbow flexion/extension, hip flexion/extension, knee flexion/extension, and dorsi/plantar flexion (Andres et al., 1986). The strength of the head extensors should also be tested due to head drop developing as the disease progresses. Active range of motion and flexibility of each joint should also be measured. Sanjak and colleagues (1987) found that graded exercise cycling in 35 participants with ALS was able to stimulate linear responses in oxygen consumption and heart rate, indicating that modified aerobic tests are feasible in this population. As long as the patient is able, a submaximal recumbent cycle, all-extremity ergometer, or bike test may be performed to estimate aerobic capacity. Caution should be taken if maximal aerobic capacity is to be assessed, as high-intensity exercise may promote dangerous oxidative stress in people with ALS. If the participant is ambulatory, a more feasible method of measuring endurance would be through a six-minute walk test (6MWT). The ALS functional rating scale can also be administered to the patient. The patient rates his or her functional status (Dal Bellow-Haas et al., 1998). A list of medications, dosages, and administering times should also be requested from the patient.

Once the assessment is complete, an exercise program can be designed. When designing the program, factors to be considered include scheduling, exercise selection, and exercise intensity and duration. Aerobic conditioning should be performed three days per week, alternating days. Muscular strength and endurance work can be performed on the same day as long as fatigue and overuse are not an issue. The patient needs to be able to maintain ADL. Range of motion, stretching, balance, and gait exercises can be performed on alternate days. The goals of the program are based on the needs of the patient, but the desire to maintain function and prolong ability as long as possible are probably the most important (Smith, 2000).

The walking program outlined in the study by Wright et al. (1996) would be well-suited for individuals with ALS, depending on the stage of the disease. The target heart rate is determined by the Karvonen method, and exercise intensity is established between 50% and 60% of target heart rate range. Progression of the walking program is gradual. The first two weeks consist of walking 15 minutes, three times per week. At week three, the time is increased to 20 to 30 minutes. As long as the person is able to maintain balance, this would be an excellent program for someone in the initial stages of the disease. If balance is a problem, a recumbent bicycle could be used with the same operating parameters.

With strength training, it is best to be conservative. One set of 10 repetitions is sufficient for a strengthening program. A 30-minute full body stretching and both active and passive range of motion exercises are included. Respiratory distress is an inevitable complication of the disease; deep breathing exercises should be performed on the same days as flexibility training. It is important to know the effects of the medications. When medications were taken, and changes made to medication types and dosages may affect the exercise program. Maintaining communication with the physician through the patient is crucial.

Documentation is important. It should include exercise date, time, exercise performed, duration and intensity, what medications were taken and when, resting heart rate, blood pressure, previous exercise that day or ADL, changes to the program or changes with the patient, and any notes of conversations with the physician or other medical personnel.

Working with a person who has ALS is more than just providing instruction for exercise. Through exercise, goal-setting and treatment planning, patients may gain some sense of control over what is happening to their bodies, enabling them to better cope with functional losses.

More time will need to be spent with a patient with ALS when performing an exercise program. Periodic changes will occur, with assessments being done weekly or even daily. As the disease progress, more and more time will need to be spent with the person (Smith, 2000).

  1. An acquired disease is one that is not inherited.
  2. A disturbance of articulation due to emotional stress, brain injury, or paralysis, incoordination, or spasticity of the muscles used for speaking.
  3. Creatine phosphokinase is the enzyme that catalyzes the transfer of a phosphate from creatinephospate (CP) to ADP to produce ATP. This enzyme is critical to muscle contraction.

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