Do your hands hurt with ALS?

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. It causes muscle weakness, disability and eventually death. One of the early symptoms many ALS patients experience is hand and arm weakness, pain, cramping or stiffness. Here is an overview of why hands can hurt with ALS and how to manage the symptoms.

What causes hand and arm pain in ALS?

There are several reasons why ALS can cause pain, cramps and stiffness in the hands and arms:

• Muscle weakness: As motor neurons degenerate, the muscles they control become weak and start wasting away (atrophy). This can cause aches, pains and cramping.
• Muscle stiffness/spasticity: Muscles may become stiffer and tighter due to dysfunction of nerve cells in the brain and spinal cord.
• Fasciculations: Small involuntary muscle twitches (fasciculations) are common in ALS. These can be painful.
• Fatigue: Arms and hands can feel very tired and heavy due to progressive muscle weakness.
• Joint/tendon pain: Muscle weakness around joints and tendons can put strain on these tissues, causing pain.
• Nerve compression: Atrophied muscles or poor posture can compress nerves, leading to numbness, tingling and nerve pain.
• Thinning skin: As muscles waste, there is less padding over the bones/joints, so pressure points become more painful.

Essentially, the degeneration of motor neurons and accompanying muscle weakness are the root causes of hand and arm discomfort in ALS patients. The atrophy and spasticity then put strain on joints, tendons, nerves and skin which generates further pain.

What does hand pain feel like with ALS?

Patients describe ALS-related hand and arm pain in various ways including:

• Aching
• Throbbing
• Shooting/stabbing pains
• Prickling pins and needles sensation
• Burning
• Stiffness
• Feeling of tightness or pressure
• Muscle cramps and spasms
• Feeling of heaviness or fatigue
• Numbness

The specific symptoms can depend on the underlying cause. For example, muscle cramps may feel like a charley horse in the hand or arm. Nerve compression can cause more of a tingling, prickling or numb sensation. Joint pain may present as aching and stiffness.

What are the most common hand symptoms in ALS patients?

While pain can occur, some of the most frequent hand complaints in ALS are:

• Clumsiness – Dropping objects, fumbling with buttons and difficulty with fine finger movements are early signs as hand muscles weaken.
• Cramping – Painful involuntary muscle spasms and cramps are very common, especially at night or with use.
• Stiffness – Morning stiffness that improves with movement is a hallmark symptom as muscles tighten.
• Weakness – Hands tire easily with tasks. Patients may have trouble lifting, gripping or opening objects.
• Wasting – Thinning of the muscles between thumb and index finger leads to a “split hand” appearance.

While not necessarily painful, these symptoms greatly impact hand function and dexterity. Tracking them helps monitor ALS progression and determine optimal treatments.

Which hand muscles are affected in ALS?

ALS impacts both upper and lower motor neurons. This leads to atrophy and weakness of muscles throughout the arms and hands:

• Finger flexors and extensors – Responsible for bending and straightening fingers.
• Thumb muscles – Allows for pinching and grasping objects.
• Intrinsic hand muscles – Fine movements like spreading fingers.
• Wrist flexors/extensors – Lifting and rotating the wrist.
• Forearm muscles – Rotate and flex the forearm.
• Biceps/triceps – Bend and straighten the elbow.
• Deltoids – Lift the arm up over the shoulder.

The split hand sign, where wasting occurs between the thumb and index finger, results from atrophy of the adductor pollicis muscle which brings the thumb across the palm.

Is hand stiffness a symptom of ALS?

Yes, hand stiffness is a common symptom of ALS. As motor neurons degenerate, the muscles they control can become tight, stiff and spastic. Reasons stiffness occurs include:

• Loss of inhibition – When upper motor neurons die, they stop regulating lower motor neurons properly. This results in hyperactivity of muscle fibers.
• Contractures – Shortening of muscles from disuse and spasticity.
• Joint immobility – Lack of movement leads to frozen, stiff joints.
• Myofascial restrictions – Connective muscle tissue thickens, restricting motion.

Stiffness is often most noticeable in the morning or after rest. The hands may feel tight, achy and hard to move after being inactive. Stretching, movement and heat can help loosen them up. Stiffness tends to progressively worsen as ALS advances.

What are ALS hand cramps like?

Many ALS patients experience painful, involuntary muscle cramps and spasms in their hands. These cramps have some distinctive features:

• Painful contraction – The hand muscles suddenly tense up tightly, lasting up to a few minutes.
• Come on suddenly – Cramps seem to occur randomly, often at night.
• Affects specific muscles – Certain hand muscles cramp more than others.
• Relief with stretching – Stretching the cramped muscle can help relax it.
• Fatigues muscles – Cramping can exhaust the hand muscles, making them feel weak after.

While not constant, the cramps can be severe and disrupt sleep and daily activities. They tend to become more frequent as ALS progresses. Using hands a lot, cold temperatures, dehydration and positional pressure can trigger cramping.

What causes finger weakness in ALS patients?

There are several factors that contribute to finger weakness in ALS:

• Motor neuron degeneration – Loss of upper and lower motor neurons impairs signals to finger muscles.
• Muscle atrophy – Shrinking finger muscles have less strength.
• Finger flexor weakness – Inability to make a fist or grip objects.
• Finger extensor weakness – Difficulty straightening and spreading fingers.
• Loss of dexterity – Impaired fine finger movements.
• Heaviness – Fingers feel fatigued and weak with exertion.

As intrinsic and extrinsic finger muscles weaken, it becomes very difficult to manipulate objects and perform tasks requiring dexterity. Weakness starts gradually but progresses as ALS breaks down the motor units controlling finger movement.

What are some assistive devices for hand weakness in ALS?

Some assistive devices that can help compensate for hand weakness with ALS include:

• Reacher/grabber – Helps grasp and pick up items.
• Bottle opener – Opens caps on bottles and jars.
• Button hook – Helps put buttons through button holes.
• Zipper pull – Attaches to zippers to help close them.
• Modified utensils – Built up grips make eating easier.
• Universal cuff – Stabilizes items in a weak hand.
• Writing aids – Special pens and pencils easier to grip.
• Touchscreen stylus – Helps use phones/tablets with less grip.
• Voice activated technology – Controls electronics hands-free.

Occupational therapists can recommend assistive devices tailored for each patient’s specific needs and degree of hand impairment. These tools help ALS patients maintain independence for as long as possible.

What exercises help hand weakness in ALS?

While exercise cannot slow ALS progression, certain hand exercises may help temporarily maintain range of motion, flexibility and strength:

• Gentle stretching – Extend fingers, wrist, elbow fully then flex.
• Range of motion – Rotate wrists, circle wrists, spread fingers.
• Gripping exercises – Squeeze soft balls/putty, use hand exerciser.
• Pincer grasp – Pick up small objects like marbles or coins.
• Wrist curls – Hold weight and bend wrist up and down.
• Finger curls – Curl fingers one at a time against resistance.
• Typing – Helps strengthen intrinsic hand muscles.

ALS patients should pace themselves to avoid overexertion and fatigue. Low-intensity exercises within each person’s capabilities can promote hand health without causing excessive strain.

What medications help with hand pain and cramps in ALS?

Medications that may provide some relief from hand and arm pain, stiffness, cramps and spasms in ALS include:

• Baclofen – Muscle relaxant that reduces spasticity.
• Tizanidine – Anti-spasm medication for cramp relief.
• Diazepam – Benzodiazepine that relaxes muscles.
• Botulinum toxin – Reduces stiffness when injected into spastic muscles.
• NSAIDs – Over-the-counter pain relievers like ibuprofen.
• Opioids – Narcotic analgesics for severe neuropathic pain.
• Quinine – Can prevent/reduce nighttime leg cramps.
• Gabapentin – Nerve pain medication.

Working closely with a neurologist helps determine the most appropriate medications based on each patient’s predominant upper limb symptoms, response to treatment and risk of side effects.

What braces help hand function in ALS?

Braces can provide extra support and improve hand function in ALS patients. Types of hand braces include:

• Wrist brace – Stabilizes the wrist in proper alignment.
• Thumb spica brace – Keeps thumb stable and aligned for pinching.
• Finger extension brace – Holds fingers straight for grip.
• Hand wrap – Compression provides comfort and support.
• Nocturnal brace – Worn at night keeps hand in a functional position.

Custom or off-the-shelf braces can improve hand function and reduce daytime stiffness. However, joints shouldn’t be immobilized completely to avoid contractures. Occupational therapists help determine optimal bracing solutions.

What multidisciplinary care helps hand issues with ALS?

Managing hand and arm complications in ALS requires input from various specialists including:

• Neurologist – Optimizes medications for spasticity, cramps and pain.
• Occupational therapist – Prescribes assistive devices and hand braces.
• Physical therapist – Stretches muscles and joints to maintain mobility.
• Orthotist – Fits and fabricates custom braces.
• Massage therapist – Relaxes muscles and improves circulation.
• Speech pathologist – Teaches exercises to build hand strength.

This multidisciplinary approach helps maximize function and quality of life. Close monitoring and communication between specialists ensures optimal management of hand issues as ALS progresses.

Conclusion

Hand and arm discomfort are very common complaints in ALS patients. Weakness, spasticity, cramps, stiffness and pain can significantly impair hand function needed for activities of daily living. While ALS itself cannot be reversed, various medications, assistive devices, braces, exercises and specialty care can help reduce hand-related symptoms. This improves quality of life and allows ALS patients to stay independent for as long as possible.