Little benefit seen in ALS with nonpharmacological treatment for pain

Nondrug interventions did not significantly ease patients' pain: Analysis

Steve Bryson, PhD avatar

by Steve Bryson, PhD |

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The use of nonpharmacological treatment — interventions such as muscle exercise, aerobics, and strength training — did not significantly ease pain among people with amyotrophic lateral sclerosis (ALS), according to a review of published data from five clinical trials.

The researchers noted, however, that while “pain in ALS patients … [is] a common nonmotor symptom, [it] is often unrecognized and undertreated, and this is underlined by the lack of any [randomized controlled trials] on drug therapy for pain.” Indeed, after identifying more than 1,000 records, the team of researchers included just five trials in their meta-analysis.

As such, the team suggests that more high-quality studies with larger patient populations are needed to further investigate the efficacy of non-pharmacological treatment for easing pain among ALS patients.

Importantly, the researchers did also note that “disease progression and, more specifically, respiratory deterioration, may make [ALS patients] unsuitable for exercise programs.”

The study, “Non-Pharmacological Interventions on Pain in Amyotrophic Lateral Sclerosis Patients: A Systematic Review and Meta-Analysis,” was published in the journal Healthcare.

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ALS is a progressive neurodegenerative disease marked by weakness in muscles, which ultimately affects a patient’s ability to move, speak, swallow, and breathe.

While pain is not a common symptom of ALS itself, complications related to the disease can be painful. Pain can be caused by extra strain on joints due to weakened muscles, and difficulties moving can result in abnormal pressure on the skin, resulting in sores or wounds. Muscle spasms and constipation associated with ALS also can be painful.

Pain can be alleviated with standard drug treatments, such as analgesics, muscle relaxants, and certain anticonvulsants and anti-anxiety medications. But it’s less clear whether nonpharmacological interventions, including muscle exercise, aerobics, strength training, and osteopathic manual therapy, can also ease pain in ALS patients.

To understand the impact of such nondrug treatments, the researchers, from Greece, pooled the findings from five randomized controlled trials published over the last two decades. These studies randomly assigned patients to various nonpharmacological treatments or a no-therapy control group.

Collectively, the studies enrolled 131 ALS patients, with an average age ranging from 54 to 60.9 years. Among them, 64 received a nondrug intervention, and 67 were in the control group. Participants had mild to moderate disease, as assessed by the ALS Functional Rating Scale (ALSFRS) or its revised form ALSFRS-R.

The interventions varied across the studies, and included stretching and resistance exercises, combined aerobic and strength training, and applied osteopathic manual treatment. These programs were tailored to each patient’s tolerance and physical limitations.

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Results from the meta-analysis indicated that patients who received a nonpharmacological treatment had no significant differences in pain scores compared with the control groups, regardless of the type or duration of the intervention.

Similar findings were seen when these interventions were assessed separately, with stretching, resistance exercises, and muscle endurance training showing no significant pain effect over controls. Combined aerobic and strength training and osteopathic manual treatment also showed nonsignificant pain improvements.

[Nonpharmacological interventions], although effective in other medical conditions, were not found to be effective for pain in ALS patients. More [randomized controlled trials], with larger sample sizes and higher methodological quality, are needed to further investigate their efficacy and patient tolerability.

Regarding nonpain outcomes, exercise training in two studies resulted in slower declines in overall functioning, as measured by ALSFRS. Resistance exercise also led to a significantly slower decline in physical functioning at six months compared with the control group.

In one study, exercise training demonstrated a short-term reduction in spasticity — muscle tightness and spams — in ALS patients. Another study reported that combining aerobic and resistance training helped to preserve global functioning, mobility, and respiratory function, while the control group experienced declines in those measures.

The researchers noted a high rate of study discontinuations, mainly due to disease progression or death, which “could have influenced the outcome’s true value.”

Ultimately, the team concluded that “[nonpharmacological interventions], although effective in other medical conditions, were not found to be effective for pain in ALS patients.”

“More [randomized controlled trials], with larger sample sizes and higher methodological quality, are needed to further investigate their efficacy and patient tolerability,” the researchers wrote.