What is ALS?

Although a rare neurologic condition, Amyotrophic Lateral Sclerosis (ALS) is the most common type of Motor Neuron Disease (MND), a condition that affects the voluntary muscles. This is a progressive disorder that leads to muscle weakness and depletion due to nerve dysfunction.

ALS is also called Lou Gehrig’s disease, named after the football player who had this condition. The literal meaning of Amyotrophic is ‘no muscle nourishment,’ which becomes the cause of muscle atrophy. ‘Lateral’ refers to the group of nerves in the spinal cord that sends signals to the muscles. It is these nerves that degenerate, leading to sclerosis in this region. In later stages, this affects the nerves that control breathing and hence can be fatal.

Initial Symptoms of ALS

The initial symptoms of ALS include stiffness and muscle weakness, which gradually involve all the muscles under voluntary control. The affected regions and progressive pattern vary from one person to another. Some have difficulty holding a pen or a cup, while others find difficulty speaking, chewing, or even talking. Thus, ALS is an ailment that affects daily life and makes simple tasks painful and troublesome.

ALS Statistics

According to the Center for Disease Control and Prevention (CDC), 14,500 to 15,000 people had ALS in the United States in 2016, with approximately 5000 people having a confirmed diagnosis for the condition annually. Although the average survival rate is three to five years, patients can live for ten years or more.

Types of ALS

Sporadic ALS

This is the most common type and affects 95% of sufferers. This type occurs without a clear cause.

Familial ALS (FALS)

This type occurs in 5-10% of sufferers. This type of ALS is genetic and runs in families. This occurs due to abnormal changes to a gene that is then passed in generations.

Symptoms of ALS

What are the symptoms of ALS?
Early signs and symptoms might be unnoticeable and become perceptible after some time. Most clinical signs are evident of upper motor neuron and lower motor neuron lesions. The limb onset ALS (70%) involves initial symptoms in the limbs, while the bulbar onset ALS (25%) is characterized by speech and swallowing problems, followed by weakness in the limbs later. The remaining 5% of patients have respiratory involvement in the early period.

Most Common Symptoms Include:

• Muscle weakness in the limbs (distal or proximal)
• Asymmetric progressive muscle wasting
• Difficulty in motor activities like walking, talking, chewing
• Weakness in arms, legs, hands, and feet
• Muscle cramps and twitching
• Slurred speech
• Fatigue
• Emotional liability (episodes of uncontrolled laughing and crying)
• Difficulty in maintaining posture and gait
• Difficulty in breathing and swallowing

With the progression of the disease, symptoms may spread to all parts of the body. In some patients, frontotemporal dementia may occur, resulting in poor memory and decision-making abilities.

Causes of ALS

The exact cause of ALS has not been known by scientists to date. However, research is being carried out to understand what causes ALS. There are several different factors such as:

Genetic Changes

Studies have shown that 5 to 10% of cases of ALS are caused by genetic mutations. For example, changes to the gene that makes SOD1 protein causes damage to motor neurons.

Environmental Factors

No major association has been established between environmental factors like toxins, viruses, diet, or physical trauma and the risk of development of ALS. However, there is ongoing research on the subject. Studies have shown that some athletes are at a higher risk of acquiring ALS due to vigorous physical activity.

Chemical Disturbance

Glutamate is the neurotransmitter that is in control of signals to and from the brain. Accumulation of this neurotransmitter within the spaces surrounding the nerves damages them. Research has also shown mitochondrial structural and functional abnormalities, as well as defects in axonal structure and transport, could be the causative agents for ALS.

Diagnosis of ALS

When it comes to diagnosis, there are no specific tests that can provide a definitive diagnosis for ALS. However, doctors conduct a series of tests to rule other similar diseases. A full medical history check and a neurologic examination are undertaken at regular intervals to assess the progressive worsening of symptoms.

Diagnostic Tests Include:

• Electromyography (EMG): EMG records the electrical activity of the muscle fibers.
• Nerve Conduction Study (NCS): NCS assesses the electrical activity of the nerves and muscles.
• Magnetic Resonance Imaging (MRI): MRI rules out other possible conditions such as a tumor or cyst in the spinal cord, cervical spondylosis, or a hernia in the neck that could be causing the nerve compression.

Laboratory tests such as blood screening and urine tests can also be carried out so that other diseases can be eliminated.

Treatment Options & Management Strategies for ALS

ALS is managed through a multidisciplinary approach. Unfortunately, there is no definitive cure for the disease at this time. Management of ALS is done through symptomatic treatment to ease the condition of the patients and prevent unnecessary complications:

Support

Physicians, psychologists, speech therapists, nutritionists, and home care assistance all play a vital role in making life easier for patients with ALS.

Medication

Riluzole (Rilutek) and Edaravone (Radicava) are the drugs approved by the U.S Food and Drug Administration (FDA) for treating ALS. Riluzole is believed to reduce glutamate levels, thereby decreasing damage to the motor neurons. Edaravone acts as an antioxidant and is believed to expel free radicals and reduce oxidative stress in the motor neurons.

Lifestyle Habits

Physiotherapists can recommend exercise and physical activity like walking, swimming, and bicycling that may improve muscle strength and help elevate mood without overstressing the muscles.

Speech Therapy

Therapists can help patients with ALS to employ strategies to speak clearly. They may also recommend computerized aids such as speech synthesizers and eye-tracking technology to help people learn ways for responding by nonverbal means.

Diet

Nutritionists may formulate a diet plan for patients, which consists of food that is easy to swallow and provides enough nourishment and calories for the patients to maintain adequate energy levels and to prevent excessive weight loss.

Breathing Support

Patients with ALS may suffer from shortness of breath and difficulty breathing during physical activity or while lying down. If this is the case, doctors can recommend Non-Invasive Ventilation (NIV) that provides breathing support through the nose or mouth. NIV improves quality of life and increases the number of years of survival for patients.

Is Stem Cell Therapy an Option?

As previously mentioned, there is no curable treatment for ALS available. However, scientists are researching Stem Cell Therapy as the new favorable approach in the treatment of neurologic disorders. There is a rising interest in Stem Cell Therapy as a promising remedy for curing ALS. Mesenchymal stem cells are particularly believed to be the most suitable ones due to their availability, absence of ethical issues, and positive results in various experiments.

Research on Stem Cell Therapy

Studies and clinical trials have begun to apprehend the benefits of MSC transplantation. They demonstrate that MSCs lead to a partial recovery of motor neurons and a delay in disease progression. Also, there has been no evidence of a major adverse effect after MSC transplantation. When testing this newfound research on animals, the lifespan of the subjected animal has increased with MSC transplantation. These positive results have encouraged the administration of MSC in ALS patients.

However, despite the safe outcomes of MSC transplantation in humans, results show that there is only a partial improvement in ALS sufferers with only a few cases that showed a delay in disease progression. Hence, there is a need for further studies and trials on a higher number of human subjects for a better understanding of MSC effects so that more significant conclusions can be reached.

Introduction to Viscosupplementation

One of the treatments approved by the FDA for knee arthritis is Hyaluronic Acid (HA) injection, commonly known as viscosupplementation. This treatment has shown significant success in managing knee arthritis and is increasingly being explored for other parts of the body, such as the hip and shoulder, although these uses are not FDA-approved. HA injections mimic the fluid that naturally surrounds your joints, acting as a lubricant and shock absorber, thereby reducing arthritis pain. Over time, HA is absorbed into the joint, potentially stimulating the body to produce more stable cartilage.

Evidence Supporting Viscosupplementation

The evidence supporting HA injections is robust. A systematic review of 76 randomized controlled trials concluded that HA injections can improve function, reduce pain, and serve as a reliable treatment for knee osteoarthritis.

The Role of Platelet-Rich Plasma (PRP) in Treating Arthritis

What is Platelet-Rich Plasma (PRP)?

Platelet-Rich Plasma (PRP) is a concentrate of platelets in plasma, containing 6 to 10 times more platelets than normal blood. PRP is rich in growth factors, such as Epidermal Growth Factor (EGF) and Connective Tissue Growth Factor (CTGF), which promote healing by leveraging the body’s natural healing mechanisms.

FDA Regulation and Research on PRP

Unlike HA, PRP is not FDA-regulated, and the devices used to prepare PRP are subject to FDA approval. Despite this, numerous studies have demonstrated PRP’s efficacy in treating tendon injuries and osteoarthritis, as well as in reducing pain. Ongoing research is exploring its potential benefits for hair regrowth, cardiac muscle repair, and dermatologic rejuvenation.

Comparing HA Injections and PRP

Effectiveness and Safety

Studies indicate that PRP can be just as effective, if not more so, than HA injections. While HA is FDA-approved only for knee use, PRP is derived from the patient’s own blood, reducing the risk of infection and autoimmune reactions, thanks to the presence of white blood cells that help fight infections.

Cost Considerations

HA injections for joints other than the knee are not FDA-approved or typically covered by insurance, often costing patients $1500 or more, excluding additional charges like doctor visits and the injection itself. In contrast, PRP treatments generally cost between $800 and $1200 out of pocket.

Conclusion: Which is the Better Choice?

PRP has demonstrated comparable or superior effectiveness to HA injections for arthritis pain management. It carries a lower risk of infection or autoimmune reactions and is generally more cost-effective. Given these advantages, PRP often emerges as the preferred choice for many patients and healthcare providers.