Spreading in ALS: The relative impact of upper and lower motor neuron involvement

Marta Gromicho, Manuel Figueiral, Hilmi Uysal, Julian Grosskreutz, Magdalena Kuzma-Kozakiewicz, Susana Pinto, Susanne Petri, Sara Madeira, Michael Swash, Mamede de Carvalho*

*Corresponding author for this work
16 Citations (Scopus)


Objective: To investigate disease spread in amyotrophic lateral sclerosis (ALS), and determine the influence of lower (LMN) and upper motor neuron (UMN) involvement. Methods: We assessed disease spread in ALS in 1376 consecutively studied patients, from five European centers, applying an agreed proforma to assess LMN and UMN signs. We defined the pattern of disease onset and progression from predominant UMN or lower motor neuron (LMN) dysfunction in bulbar, upper limbs, lower limbs, and thoracic regions Non-linear regression analysis was applied to fit the data to a model that described the relation between two random variables, graphically represented by an inverse exponential curve. We analyzed the probability, rate of spread, and both combined (area under the curve). Results: We found that progression was more likely and quicker to or from the region of onset to close spinal regions. When the disease had a limb onset, bulbar motor neurons were more resistant. Furthermore, in the same time frame more patients progressed from bulbar to lower limbs than vice-versa, whether predominantly UMN or LMN involvement. Patients with initial thoracic involvement had a higher probability for rapid change. The presence of predominant UMN signs was associated with a faster caudal progression. Interpretation: Contiguous progression was leading pattern, and predominant UMN involvement is important in shortening the time for cranial-caudal spread. Our results can best be fitted to a model of independent LMN and UMN degeneration, with regional progression of LMN degeneration mostly by contiguity. UMN lesion causes an acceleration of rostral-caudal LMN loss.

Original languageEnglish
JournalAnnals of Clinical and Translational Neurology
Issue number7
Pages (from-to)1181-1192
Number of pages12
Publication statusPublished - 01.07.2020

Research Areas and Centers

  • Centers: Center for Neuromuscular Diseases

DFG Research Classification Scheme

  • 206-07 Clinical Neurology Neurosurgery and Neuroradiology


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