Physical Therapist Interventions for People with Amyotrophic Lateral Sclerosis Across Disease Stages: A Systematic Review of Efficacy

Abstract Importance Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease causing declines in muscular strength that affect respiratory function and functional independence. Although physical therapist interventions have been studied in ALS, their efficacy and evidence quality have not been systematically assessed across disease stages. Objective The objective of this study was to examine the efficacy of physical therapist interventions on clinical outcomes across ALS disease stages. Design This study was a systematic review using Joanna Briggs Institute methodology. Setting Multiple settings were used. Participants The participants were adults (18 years old) with ALS or motor neuron disease. Interventions Physical therapist interventions within the professional scope of practice included therapeutic exercise, pulmonary training, manual therapy, and multimodal approaches. Outcome Measures Outcome measures included effect sizes (ESs) and 95% CIs calculated for forced vital capacity (FVC) and the Amyotrophic Lateral Sclerosis Rating Scale (ALSFRS) or the ALSFRS revised (ALSFRS-R). Results Six databases were searched from inception to January 2025. Thirty-nine studies were included (25 experimental, 14 observational). Outcomes were heterogeneous, with 94 measures across studies: 23 included the ALSFRS or ALSFRS-R, and 16 included FVC. Most interventions targeted early-stage ALS (n = 27), limiting comparisons across stages. Multimodal training had moderate-quality evidence, with moderate effects on the ALSFRS-R (ES = 0.56 95% CI = 0.09 to 1.03), and low-quality evidence, with negligible effects on FVC (ES = −0.03 95% CI = −1.47 to 1.41). Pulmonary interventions had moderate-quality evidence, with small effects on FVC (ES = 0.40 95% CI = −0.18 to 0.98), and low-quality evidence, with negligible effects on the ALSFRS-R (ES = 0.04 95% CI = −0.25 to 0.33). Conclusions A range of physical therapist interventions for ALS were assessed, although most were early phase or low quality. Multimodal and pulmonary interventions showed modest benefits in the ALSFRS-R and FVC, respectively. However, variability in outcome measures and limited research beyond early-stage disease highlight the need for stage-specific trials using consistent functional outcomes. Relevance This review highlights the breadth of studies of physical therapy in ALS and underscores the need for more rigorous, targeted research.