Amyotrophic Lateral Sclerosis: The Role of Physiotherapy According to Contemporary Science

Introduction

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting motor neurons and leading to increasing muscle weakness, loss of functional independence, and respiratory failure. Despite the absence of curative treatment, growing attention is being given to non-pharmacological supportive approaches, among which physiotherapy plays a key role.

Contemporary systematic reviews and meta-analyses indicate that physiotherapy in ALS is not only safe but can also provide clinically meaningful supportive effects on functional status, respiratory function, and quality of life.

Respiratory Physiotherapy: Effects on Function and Survival

One of the most extensively studied areas is respiratory muscle training. A systematic review and meta-analysis of randomised controlled trials demonstrated that respiratory muscle training:

• improves respiratory muscle strength, including maximal inspiratory and expiratory pressures;

• supports more efficient ventilation by increasing respiratory muscle reserve;

• in some studies, has been explored as a potential prognostic factor for survival;

• is safe and generally well tolerated.

At the same time, no significant changes were observed in parameters such as forced vital capacity (FVC) or subjective quality-of-life measures, reflecting the complexity of influencing global outcomes in a progressive disease.

Physiotherapy and Prevention of Respiratory Infections

Particular attention should be given to the role of physiotherapy in preventing respiratory infections, which are among the leading causes of complications and hospitalisations in patients with ALS.

As the disease progresses, weakening of respiratory and bulbar musculature leads to:

• reduced cough effectiveness;

• accumulation of bronchial secretions;

• impaired ventilation of the lower lung regions;

• increased risk of aspiration.

Respiratory physiotherapy interventions — including respiratory muscle training, education in effective coughing techniques, airway clearance strategies, and positioning — help improve secretion clearance and lung ventilation. This, in turn, reduces the likelihood of secretion retention and respiratory infections.

Although randomised studies with infections as a primary outcome remain limited in ALS, indirect evidence and physiological mechanisms support the preventive role of respiratory physiotherapy. Clinical practice and neuromuscular disease management guidelines emphasise the importance of regular respiratory rehabilitation to reduce the risk of pneumonia and other respiratory complications.

Physiotherapy and Overall Functional Capacity

Systematic reviews of randomised studies indicate that physiotherapy interventions may lead to short-term improvements in global function in patients with ALS. In particular:

• effects on quality of life and fatigue remain variable;

• physiotherapy does not increase the incidence of adverse events;

• benefits are most evident with individually tailored and regularly performed programmes.

These findings support the inclusion of physiotherapy in comprehensive ALS management, beginning in the early stages of the disease.

Multimodal and Comprehensive Programmes

From a functional perspective, the most promising outcomes are observed with multimodal physiotherapy programmes combining:

• therapeutic exercise;

• respiratory physiotherapy;

• training in compensatory strategies;

• adaptation of physical activity according to disease stage.

Such programmes demonstrate moderate positive effects on the ALS Functional Rating Scale–Revised (ALSFRS-R) and contribute to longer preservation of functional independence, particularly in the early phases of ALS.

Clinical Significance and Practical Implications

Based on current scientific evidence, the following conclusions can be drawn:

1. Physiotherapy in ALS is a safe and essential component of comprehensive care.

2. Positive effects are observed on respiratory muscle strength and functional status.

3. Respiratory physiotherapy plays an important role in preventing respiratory infections by improving ventilation and airway clearance.

4. Even with limited evidence for long-term outcomes, physiotherapy remains a key tool for maintaining quality of life.
   

Conclusion

Physiotherapy does not alter the underlying course of amyotrophic lateral sclerosis; however, its clinical value is substantial. Contemporary evidence confirms meaningful benefits, particularly in respiratory support and functional preservation. An additional important contribution of physiotherapy lies in its role in preventing respiratory infections — one of the most serious complications of ALS.

Physiotherapy therefore remains a highly relevant and scientifically supported element of ALS care, aimed at sustaining vital functions, facilitating adaptation to disease progression, and preserving the highest possible quality of life.

Physiotherapy may form part of a comprehensive medical support strategy for people with amyotrophic lateral sclerosis, focusing on respiratory function, functional capacity, and quality of life.An individual medical consultation allows assessment of which supportive and rehabilitative approaches may be appropriate in a specific clinical situation.

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