Search

Pregnancy in women with early-onset Parkinson's disease (PD) is likely to have a higher frequency given the trend toward increasing maternal age, thus resulting in a greater overlap time between childbearing age and PD risk. Deep brain stimulation (DBS) therapy is nowadays offered to PD patients at earlier stage of the disease, when women can still be pre-menopausal. However, few data are available about DBS safety during pregnancy. From a review of the available literature, only one article was published on this topic so far. Therefore, we have developed a clinical consensus on the safety of DBS during pregnancy in PD patients.

Background: Early-onset Parkinson's disease (EOPD)/young-onset Parkinson's disease (YOPD) is defined as Parkinson's disease (PD) with an age at onset (AAO) after age 21 years but before the usual AAO for PD. Consensus is lacking, and the reported maximal age for EOPD/YOPD has varied from 40 to 60 years, leading to a lack of uniformity in published studies and difficulty in harmonization of data. EOPD and YOPD have both been used in the literature, somewhat interchangeably., Objective: To define the nomenclature and AAO cutoff for EOPD/YOPD., Methods: An extensive review of the literature and task force meetings were conducted. Conclusions were reached by consensus., Results: First, the literature has seen a shift from the use of YOPD toward EOPD. This seems motivated by an attempt to avoid age-related stigmatization of patients. Second, in defining EOPD, 56% of the countries use 50 or 51 years as the cutoff age. Third, the majority of international genetic studies in PD use an age cutoff of younger than 50 years to define EOPD. Fourth, many studies suggest that changes in the estrogen level can affect the predisposition to develop PD, making the average age at menopause of 50 years an important factor to consider when defining EOPD. Fifth, considering the differential impact of the AAO of PD on professional and social life, using 50 years as the upper cutoff for the definition of EOPD seems reasonable., Conclusions: This task force recommends the use of EOPD rather than YOPD. It defines EOPD as PD with AAO after 21 years but before 50 years., (© 2022 International Parkinson and Movement Disorder Society.)

There are few instruments available for evaluating functional mobility during multitasking in people with Parkinson's Disease (PD). Virtual Reality is a potentially tool capable of aiding in the evaluation of functional mobility. The purpose of this study is to verify the potential of the Virtual Functional Mobility Test (VFMT) as a clinical tool to assess functional mobility of people with PD during multitasking condition. 25 people with PD and 25 people without PD, matched for age and sex, were recruited. Participants were evaluated through the Trail Making Test, Timed "UP and GO" test, Timed "UP and GO" test in dual task condition and through the VFMT, composed of 1) a simple task, and 2) a complex task. The VFMT and clinical tests were sensitive to differentiate the groups, except the trail making test part B (p = 0.332) and complex task (p = 0.052). Strong correlations were observed between parts A and B of the trail making test (r = 0.75) and complex task (r = 0.72); Moderate correlations between Timed Up and Go test and Timed Up and Go test in dual task condition with simple task (r = 0.47) and complex task (r = 0.55), respectively, were found. The complex task and simple task showed excellent and moderate reliability intra-rater, respectively. It was concluded that the novel VFMT is feasible, sensible, reliable and has potential as an instrument for the evaluation of functional mobility during multitasking in people with PD., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To evaluate the effects of a progressive resistance training (RT) on cardiac autonomic modulation and on cardiovascular responses to autonomic stress tests in patients with Parkinson disease (PD)., Design: Randomized clinical trial., Setting: The Brazil Parkinson Association., Participants: Patients (N=30) with PD (modified Hoehn & Yahr stages 2-3) were randomly divided into 2 groups: a progressive RT group (PD training [PDT] group) and a control group (PD control [PDC] group). In addition, a group of paired healthy control (HC) subjects without PD was evaluated., Interventions: The PDT group performed 5 resistance exercises, 2 to 4 sets, 12 to 6 repetitions maximum per set. Individuals in the PDC group maintained their usual lifestyle., Main Outcome Measures: The PDT and PDC groups were evaluated before and after 12 weeks. The HC group was evaluated once. Autonomic function was assessed by spectral analysis of heart rate variability and cardiovascular responses to autonomic stress tests (deep breathing, Valsalva maneuver, orthostatic stress)., Results: Compared with baseline, the normalized low-frequency component of heart rate variability decreased significantly after 12 weeks in the PDT group only (PDT: 61±17 normalized units [nu] vs 47±20nu; PDC: 60±14nu vs 63±10nu; interaction P<.05). A similar result was observed for systolic blood pressure fall during orthostatic stress that also was reduced only in the PDT group (PDT: -14±11mmHg vs -6±10mmHg; PDC: -12±10mmHg vs -11±10mmHg; interaction P<.05). In addition, after 12 weeks, these parameters in the PDT group achieved values similar to those in the HC group., Conclusions: In patients with PD, progressive RT improved cardiovascular autonomic dysfunction., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

This study assessed 1) the effects of 12 wk of resistance training (RT) and resistance training with instability (RTI) on presynaptic inhibition (PSI) and disynaptic reciprocal inhibition (DRI) of patients with Parkinson's disease (PD); 2) the effectiveness of RT and RTI in moving PSI and DRI values of patients toward values of age-matched healthy controls (HC; Z-score analysis); and 3) associations between PSI and DRI changes and clinical outcomes changes previously published. Thirteen patients in RT group, 13 in RTI group, and 11 in a nonexercising control group completed the trial. While RT and RTI groups performed resistance exercises twice a week for 12 wk, only the RTI group used unstable devices. The soleus H reflex was used to evaluate resting PSI and DRI before and after the experimental protocol. The HC (n = 31) was assessed at pretest only. There were significant group × time interactions for PSI (P < 0.0001) and DRI (P < 0.0001). RTI was more effective than RT in increasing the levels of PSI (P = 0.0154) and DRI (P < 0.0001) at posttraining and in moving PSI [confidence interval (CI) 0.1-0.5] and DRI (CI 0.6-1.1) levels to those observed in HC. There was association between DRI and quality of life changes (r = -0.69, P = 0.008) and a strong trend toward association between PSI and postural instability changes (r = 0.60, P = 0.051) after RTI. RTI increased PSI and DRI levels more than RT, reaching the average values of the HC. Thus RTI may cause plastic changes in PSI and DRI pathways that are associated with some PD clinical outcomes., New & Noteworthy: Patients with Parkinson's disease (PD) have motor dysfunction. Spinal inhibitory mechanisms are important for modulating both supraspinal motor commands and sensory feedback at the spinal level. Resistance training with instability was more effective than resistance training in increasing the levels of presynaptic inhibition and disynaptic reciprocal inhibition of lower limb at rest of the patients with PD, reaching the average values of the healthy controls., (Copyright © 2017 the American Physiological Society.)

Purpose: This randomized controlled trial compared the effects of resistance training (RT) and RT with instability (RTI) on the timed up and go test (TUG), on-medication Unified Parkinson's Disease Rating Scale part III motor subscale score (UPDRS-III), Montreal Cognitive Assessment (MoCA) score, Parkinson's Disease Questionnaire (PDQ-39) score, and muscle strength in the leg press exercise (one-repetition maximum) of patients with Parkinson's disease (PD)., Methods: Thirty-nine patients with moderate to severe PD were randomly assigned to a nonexercising control group (C), RT group, and RTI group. The RT and RTI groups performed progressive RT twice a week for 12 wk. However, only the RTI group used high motor complexity exercises (i.e., progressive RT with unstable devices), for example, half squat exercise on the BOSU® device. The primary outcome was mobility (TUG). The secondary outcomes were on-medication motor signs (UPDRS-III), cognitive impairment (MoCA), quality of life (PDQ-39), and muscle strength (one-repetition maximum)., Results: There were no differences between RTI and RT groups for any of the outcomes at posttraining (P > 0.05). However, there were differences between RTI and C groups in the TUG, MoCA, and muscle strength values at posttraining (P < 0.05). Only the RTI group improved the TUG (-1.9 s), UPDRS-III score (-4.5 score), MoCA score (6.0 score), and PDQ-39 score (-5.2 score) from pre- to posttraining (P < 0.001). Muscle strength improved for both training groups (P < 0.001). No adverse events were reported during the trial., Conclusions: Both training protocols improved muscle strength, but only RTI improved the mobility, motor signs, cognitive impairment, and quality of life, likely because of the usage of high motor complexity exercises. Thus, RTI may be recommended as an innovative adjunct therapeutic intervention for patients with PD.

Objective: To investigate submaximal and maximal responses during maximal cardiopulmonary exercise tests in subjects with Parkinson disease (PD)., Design: Cross-sectional., Setting: A PD association., Participants: A sample (N=68) of subjects with PD (n=48; mean age, 66±8y; modified Hoehn and Yahr stage between 2 and 3; "on" state of medication) and age-matched controls without PD (n=20; mean age, 64±9y)., Interventions: Maximal cardiopulmonary exercise test on a cycle ergometer., Main Outcome Measures: Oxygen uptake (V˙o2), systolic blood pressure (SBP), and heart rate assessed at rest, submaximal intensities (ie, anaerobic threshold [AT] and respiratory compensation point), and maximal intensity (peak exercise)., Results: Compared with control subjects, subjects with PD had lower V˙o2, heart rate, and SBP at respiratory compensation point and peak exercise (V˙o2: 14.6±3.6mL⋅kg⋅min vs 17.9±5.5mL⋅kg⋅min and 17.7±4.8mL⋅kg⋅min vs 21.5±6.6mL⋅kg⋅min; heart rate: 119±17beats/min vs 139±12beats/min and 132±20beats/min vs 158±13beats/min; SBP: 151±17mmHg vs 172±20mmHg and 166±21mmHg vs 187±24mmHg; P≤.05). They also had lower heart rate at AT (102±14beats/min vs 110±13beats/min; P≤.05), whereas V˙o2 and SBP at this intensity were similar to those of control subjects., Conclusions: Subjects with PD demonstrated blunted metabolic and cardiovascular responses to submaximal and maximal exercise tests, especially at intensities above AT, which are in line with autonomic disturbances present in patients with PD. Future studies need to determine how this affects performance, participation, and responses of these patients to exercise training at different intensities., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Our study evaluates how aging and Parkinson's disease (PD) alter temporal order judgment (TOJ)., Method: Two TOJ experiments were performed with young participants, healthy elderly participants, and PD patients. Two white squares were presented on opposite sides of a screen and participants responded which appeared first. In Experiment 1, it was assessed how accurately each group could judge temporal order at intervals from 0ms to 167ms. Detectability, the capacity of detecting which stimulus appeared first, was measured. In Experiment 2, participants were asked to orient their attention to the hemifield indicated by a cue. The PSS ("point of subjective simultaneity"), where the participant was equally likely to respond that either stimulus appeared first, was measured., Results: In Experiment 1, PD patients had smaller detectability than healthy elderly (p<0.05) and young participants (p<0.001), and healthy elderly participants had smaller detectability than young participants (p<0.001). In Experiment 2, PSS was 29ms for young participants, 121ms for healthy elderly participants, and 283ms for PD patients; differences were statistically significant for comparisons between PD patients and healthy elderly participants (p<0.001), PD patients and young participants (p<0.001), and healthy elderly and young participants (p<0.04)., Conclusions: TOJ is impaired by aging and PD. Our results suggest that dopamine loss increases latency and variability in visual decision making due to a lower signal-to-noise ratio in the visual pathways., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Postural instability is a particularly incapacitating disorder, whose loss of motor independence by Parkinson´s Disease (PD) patients marks a significant stage of disease onset. Evidence suggests that deficits in automatic motor control, sensory integration and attention are associated with the lack of balance in PD. Physiotherapy together with medication play an important role in the treatment of this state, although no consensus has been reached on the best treatment modality. The aim of this randomized controlled trial protocol is to evaluate the effects of balance training with rhythmical (BRT), which is a motor program to improve balance associated with rhythmical auditory cues (RACs). This study is ongoing in the stage 1., Methods and Design: A total of 150 PD patients at H&Y stages II-III and asymptomatic for depression and dementia are enrolled in a single-blind randomized study. Randomization is achieved via a computer-generated random-sequence table. All patients should also present a fall history. They will be assigned into one of three groups, and their balance and gait will be assessed before and after 10 training sessions, and after 4 and 30 weeks subsequent to the end of the training. The BRT group will receive a motor program to improve balance associated with RACs, the MT group will perform motor training with the same aims as those in the BRT group but without RACs, and the control group (CG) will be trained only in orientations. The exercise program specific to balance is of 5 weeks' duration with two sessions per week, 45 min each, and consists of general physiotherapy exercises. Each session will be divided into five warm-up minutes-30 min for the main part and 10 min for the cool down. The training progresses and intensifies each week depending on the individual's performance. The subjects should be able to execute 10 repetitions of the exercise sequences correctly to progress to the next movement., Discussion: This randomized study protocol will evaluate the effects of a motor program designed to improve balance associated with RACs, and will also assess whether balance training leads to activation of balance reactions at the appropriate time. We hypothesize that if this motor program is maintained long-term, it will prevent falls., Trial Registration: Clinicaltrials.gov NCT02488265 ; Ethics Committee of the University of São Paulo Faculty of Medicine Clinics Hospital 1.102.464.

The influence of educational status on perceptual-motor performance has not been investigated. The single- and dual-task performances of 15 Low educated adults (9 men, 6 women; M age=24.1 yr.; 6-9 yr. of education) and 15 Higher educated adults (8 men, 7 women; M age=24.7 yr.; 10-13 yr. of education) were compared. The perceptual task consisted of verbally classifying two figures (equal or different). The motor task consisted of alternating steps from the floor to a stool. Tasks were assessed individually and simultaneously. Two analyses of variance (2 groups×4 blocks) compared the errors and steps. The Low education group committed more errors and had less improvement on the perceptual task than the High education group. During and after the perceptual-motor task performance, errors increased only in the Low education group. Education correlated to perceptual and motor performance. The Low education group showed more errors and less step alternations on the perceptual-motor task compared to the High education group. This difference on the number of errors was also observed after the dual-task, when the perceptual task was performed alone.

Background: Mental practice has shown benefits in the rehabilitation of neurological patients, however, there is no evidence of immediate effects on gait of individuals with Parkinson's disease., Objective: Determine the effects of mental practice activity added to physical practice on the gait of individuals with Idiopathic Parkinson's Disease (IPD)., Methods: 20 patients classified with stage 2 and 3, according to the Hoehn and Yahr scale were randomized into 2 groups. The experimental group (N = 10) was submitted to a single session of mental practice and physical practice gait protocol and the control group (N = 10) only to physical practice. The primary outcomes were stride length and total stance and swing time. Secondary outcomes were hip range of motion, velocity and mobility. Subjects were reassessed 10 minutes, 1 day and 7 days after the end of the session., Results: There was no statistically significant difference between the groups. An intragroup difference was observed in velocity, stride length, hip range of motion, and mobility, as well as total stance and swing time. These results were also observed on follow-ups., Conclusions: Mental practice did not have a greater effect on the gait of individuals with IPD than physical practice, after a single session.

This case report assessed quality of life, activities of daily living, motor symptoms, functional ability, neuromuscular parameters and mRNA expression of selected genes related to muscle protein synthesis and degradation in a patient with Multiple System Atrophy (MSA). The patient underwent resistance training with instability devices (i.e., bosu, dyna disk, balance disk, Swiss ball) for six months twice a week. After the six months training, the patient's left and right quadriceps muscle cross-sectional area and leg press one-repetition maximum increased 6.4%, 6.8%, and 40%, respectively; the patient's timed up and go, sit to stand, dynamic balance, and activities of daily living improved 33.3%, 28.6%, 42.3%, and 40.1%, respectively; the patient's severity of motor symptoms and risk of falls decreased 32% and 128.1%, respectively. Most of the subscales of quality of life demonstrated improvements as well, varying from 13.0% to 100.0%. mRNA expression of mechanogrowth factor and mammalian target of rapamycin increased 12.7-fold and 1.5-fold, respectively. This case report describes likely the first nonpharmacological therapeutic tool that might be able to decrease the severity of motor symptoms and risk of falls, and to improve functional ability, neuromuscular parameters, and quality of the life in a patient with MSA. Key pointsSix months of resistance training with instability alleviate the MSA-related effects and improve the quality of life in a patient with MSA.High complexity exercise intervention (i.e., resistance training with instability) may be very beneficial to individuals with impaired motor control and function as MSA patients.Caution should be exercised when interpreting our findings as they cannot be generalized to the entire MSA population and they do not allow establishing causal conclusions on the effects of this mode of exercise on MSA.

Purpose: We sought to compare the effects of physical practice (PP) and mental practice (MP) on the immediate and long-term learning of the finger-to-thumb opposition sequence task (FOS) in children; in addition, we investigated the transfer of this learning to an untrained sequence of movements and to the contralateral untrained hand., Method: This study included thirty-six 9- and 10-year-old children who were randomly allocated into 3 groups: MP, PP, and no practice (NP). The MP and PP groups were subjected to a single session of training with the dominant trained hand. MP participants were trained by mentally rehearsing the movements, PP participants were trained by executing the movements, and the NP group had no training. The performance of the trained sequence (TS) and untrained reverse sequence (URS) by each of the 3 groups was evaluated under identical conditions before training, after 5 min, and at 4 days, 7 days, and 28 days after training., Results: Whereas both trained groups (MP and PP) showed statistically significant improvement in TS using the trained hand at all assessment points after the training, only MP participants were able to transfer the performance gains from the TS to the URS and from the trained hand to the untrained opposite hand., Conclusion: Children were able to learn the FOS through MP or PP with a similar level of performance. Unlike PP, MP allowed for the transfer of performance gain to the URS and to the opposite hand, suggesting that the internal representations developed by MP were effector-independent.

Few studies have described physical therapy approaches to provide functional independence and reduce pain in individuals with dystonia. This report describes the physical therapy treatment of a 46-year-old woman diagnosed with idiopathic segmental axial dystonia. For two years, the patient was treated with kinesiotherapy (active and resisted movements and stretching of neck and trunk muscles), abdominal taping (kinesiotaping techniques), functional training, and sensory tricks. She was assessed with parts I, II and III of Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-I, TWSTRS-II and TWSTRS-III), Berg Balance Scale (BBS), Six-Minute Walk Test (6-MWT), and the motor domain of Functional Independence Measure (FIM-motor) before and after the two-year treatment and after the one year follow-up. Postural control and symmetry improved (TWSTRS-I: from 30 to 18), functional independence increased (TWSTRS-II: from 27 to 15; BBS: from 36 to 46; 6-MWT: from 0 to 480 meters (m); FIM-motor: from 59 to 81), and the pain diminished (TWSTRS-III: from 12 to 5). The functional improvement was retained after one year (TWSTRS-I: 14/35; TWRTRS-II: 12/30; TWRTRS-III: 5/20; BBS: 48/56; 6-MWT: 450 m; FIM-motor: 81/91). This program showed efficacy on providing a better control of the dystonic muscles and thus the doses of botulinum toxin needed to treat them could be reduced. Outcomes support the therapeutic strategies used to deal with this type of dystonia.

Objective: The aim of this study was to validate a simple and reproducible method for assessing gait deviation on the Babinski-Weill test in a representative sample of healthy Brazilians., Methods: Gait deviations were measured in 75 individuals (median=30 years, 41 women) for forward, backwards, and Babinski-Weill steps. The test entailed blindfolded individuals walking 10 paces at a frequency of 1 Hz with deviations subsequently measured by a protractor., Results: Mean gait deviation forward was 0.53° with standard deviation (SD)=4.22 and backwards was 2.14° with SD=4.29. No significant difference in deviation was detected between genders (t test p=0.40 forward and p=0.77 backwards) or for age (ANOVA, p=0.33 forward and p=0.63 backwards). On the Babinski-Weill test, mean gait deviation was 5.26°; SD=16.32 in women and -3.11°; SD=12.41 in men, with no significant difference between genders (t test, p=0.056)., Discussion: Defining normative gait patterns helps distinguish pathological states.

Objectives: To evaluate the learning, retention and transfer of performance improvements after Nintendo Wii Fit™ training in patients with Parkinson's disease and healthy elderly people., Design: Longitudinal, controlled clinical study., Participants: Sixteen patients with early-stage Parkinson's disease and 11 healthy elderly people., Interventions: Warm-up exercises and Wii Fit training that involved training motor (shifts centre of gravity and step alternation) and cognitive skills. A follow-up evaluative Wii Fit session was held 60 days after the end of training. Participants performed a functional reach test before and after training as a measure of learning transfer., Main Outcome Measures: Learning and retention were determined based on the scores of 10 Wii Fit games over eight sessions. Transfer of learning was assessed after training using the functional reach test., Results: Patients with Parkinson's disease showed no deficit in learning or retention on seven of the 10 games, despite showing poorer performance on five games compared with the healthy elderly group. Patients with Parkinson's disease showed marked learning deficits on three other games, independent of poorer initial performance. This deficit appears to be associated with cognitive demands of the games which require decision-making, response inhibition, divided attention and working memory. Finally, patients with Parkinson's disease were able to transfer motor ability trained on the games to a similar untrained task., Conclusions: The ability of patients with Parkinson's disease to learn, retain and transfer performance improvements after training on the Nintendo Wii Fit depends largely on the demands, particularly cognitive demands, of the games involved, reiterating the importance of game selection for rehabilitation purposes., (Copyright © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objectives: To investigate the effect of Nintendo Wii™-based motor cognitive training versus balance exercise therapy on activities of daily living in patients with Parkinson's disease., Design: Parallel, prospective, single-blind, randomised clinical trial., Setting: Brazilian Parkinson Association., Participants: Thirty-two patients with Parkinson's disease (Hoehn and Yahr stages 1 and 2)., Interventions: Fourteen training sessions consisting of 30 minutes of stretching, strengthening and axial mobility exercises, plus 30 minutes of balance training. The control group performed balance exercises without feedback or cognitive stimulation, and the experimental group performed 10 Wii Fit™ games., Main Outcome Measure: Section II of the Unified Parkinson's Disease Rating Scale (UPDRS-II)., Randomisation: Participants were randomised into a control group (n=16) and an experimental group (n=16) through blinded drawing of names., Statistical Analysis: Repeated-measures analysis of variance (RM-ANOVA)., Results: Both groups showed improvement in the UPDRS-II with assessment effect (RM-ANOVA P<0.001, observed power=0.999). There was no difference between the control group and the experimental group before training {8.9 [standard deviation (SD) 2.9] vs 10.1 (SD 3.8)}, after training [7.6 (SD 2.9) vs 8.1 (SD 3.5)] or 60 days after training [8.1 (SD 3.2) vs 8.3 (SD 3.6)]. The mean difference of the whole group between before training and after training was -0.9 (SD 2.3, 95% confidence interval -1.7 to -0.6)., Conclusion: Patients with Parkinson's disease showed improved performance in activities of daily living after 14 sessions of balance training, with no additional advantages associated with the Wii-based motor and cognitive training. Registered on http://www.clinicaltrials.gov (identifier: NCT01580787)., (Copyright © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

We aimed to quantify fatigue frequency and evolution in amyotrophic lateral sclerosis (ALS), and to correlate fatigue with factors such as age, sex, educational level, disease duration, functionality, quality of life, dyspnoea, depression and sleepiness. Sixty ALS patients (test group: TG) selected by El Escorial criteria and 60 normal individuals (control group: CG) matched according to sex and age, were followed every three months, during 9 months, by means of self-report scales: Fatigue Assessment Instrument (Fatigue Severity Scale plus three qualitative subscales); ALS Functional Rating Scale; McGill Quality of Life Questionnaire; dyspnoea analogical scale; Beck Depression Inventory and Epworth Sleepiness Scale. Fatigue was reported by 83% of TG (median: 3.6, interquartile range 1.5-5.4), compared with 20% of CG (median: 1, 1-1), and was significantly greater in the TG (p<0.001, Mann-Whitney test). Fatigue severity increased by the ninth month of the study (p=0.0008, Friedman, Müller-Dunn post test). There was no correlation between fatigue and other parameters, except for an inverse correlation with age at disease onset (p=0.0395, Spearman rank correlation). In conclusion, fatigue was frequent in ALS, greater in the youngest patients and worsened during follow-up. Possibly, ALS related fatigue is an independent factor, which deserves individualized approach and treatment.