A patient with amyotrophic lateral sclerosis has an MMT of Poor plus and 175° of passive shoulder flexion. Which exercise is most appropriate?

• A. Passive range of motion exercises
• B. Active shoulder flexion range of motion exercises in sidelying position
• C. Resisted shoulder flexion at 40% of the one-repetition maximum in sidelying position
• D. Resisted shoulder flexion at 80% of the one-repetition maximum in sidelying position

Answer: (B)

Engaging the patient in active movement with minimal gravitational demand is the most appropriate approach when strength is very limited. With an MMT of Poor plus, the shoulder muscles are weak but still capable of activation, so the goal is to preserve motor control and range without fatiguing the muscles.

Having near full passive shoulder flexion (about 175 degrees) means the joint can move through a large arc, but passive movement alone won’t help maintain or improve muscle strength or functional control. Placing the limb in a gravity-reduced position, such as side-lying, makes active shoulder flexion easier to perform and more controllable, allowing the patient to actively engage the available muscles without fighting full gravity. This supports neuromuscular activation and movement patterns while limiting fatigue.

Resisted exercises at moderate to high percentages of 1RM would place a heavy load on already weak muscles and are unlikely to be tolerated, increasing the risk of fatigue or strain in ALS.

So the best choice is encouraging active shoulder flexion ROM in a sidelying position to promote active use of the weak muscles safely and effectively.