European Journal of Epidemiology

, Volume 29, Issue 7, pp 459–475 | Cite as

Epidemiological evidence that physical activity is not a risk factor for ALS

  • Bello Hamidou
  • Philippe Couratier
  • Cyril Besançon
  • Marie Nicol
  • Pierre Marie Preux
  • Benoit MarinEmail author


To elucidate whether physical activity (PA) and sport increase the risk of developing amyotrophic lateral sclerosis (ALS), a literature review of epidemiological studies was conducted according to the Meta-analysis of Observational Studies in Epidemiology guidelines. Six databases (Pubmed, Scopus, ScienceDirect, IngentaConnect, Refdoc and the Cochrane database) were searched to April 2014. Experts were asked to identify studies in press. Studies of interest were examined for their level of evidence and synthetized using Armon’s classification for exogenous risk factors for ALS. Of 37 epidemiological works included in the review, two (5.5 %) provided class I evidence, and five (13.5 %) class II. Others offered evidence of class III (n = 8, 21.6 %), IV (n = 16, 43.2 %) and V (n = 6, 16.2 %). Results were stratified according to type of exposure: (1) PA related to sport and work (n = 14), (2) soccer and American football (n = 9), (3) occupation (n = 12), (4) proxies of PA (n = 2). Among articles which considered “PA related to sport and work”, two class I studies and one class II study concluded that PA is not a risk factor for ALS. This evidence establishes (level A) that PA is not a risk factor for ALS. As regards “occupational related activity” a level of evidence of U was obtained (it is unknown whether the professional category “physical worker” is a risk factor for ALS). Football/soccer may be considered as a possible risk factor for ALS (level C) and there is a need for further research taking into account the numerous confounding factors that may arise in this field.


Amyotrophic lateral sclerosis Motor neuron disease Physical activity Sports American football Soccer players 



Amyotrophic lateral sclerosis


El escorial diagnostic criteria


Medical subject headings


Metabolic equivalents


Physical activity



We thank Prof Ettore Beghi, Chairman of EURALS consortium (pan-European consortium for the epidemiological study of ALS) for his opinions as an expert in the field and for his comments on the manuscript. We thank William Françis for reviewing the manuscript in English. Hamidou Bello is sponsored by a scholarship from the Regional Council of Limousin Region and Inserm.

Conflict of interest

We confirm that there is no conflict of interest associated with this publication.


  1. 1.
    Kiernan MC, Vucic S, Cheah BC, Turner MR, Eisen A, Hardiman O, et al. Amyotrophic lateral sclerosis. Lancet. 2011;377(9769):942–55.PubMedCrossRefGoogle Scholar
  2. 2.
    Al-Chalabi A, Hardiman O. The epidemiology of ALS: a conspiracy of genes, environment and time. Nat Rev Neurol. 2013;9(11):617–28.PubMedCrossRefGoogle Scholar
  3. 3.
    Armon C. Sports and trauma in amyotrophic lateral sclerosis revisited. J Neurol Sci. 2007;262(1–2):45–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Harwood CA, McDermott CJ, Shaw PJ. Physical activity as an exogenous risk factor in motor neuron disease (MND): a review of the evidence. Amyotroph Lateral Scler. 2009;10(4):191–204.PubMedCrossRefGoogle Scholar
  5. 5.
    Armon C. An evidence-based medicine approach to the evaluation of the role of exogenous risk factors in sporadic amyotrophic lateral sclerosis. Neuroepidemiology. 2003;22(4):217–28.PubMedCrossRefGoogle Scholar
  6. 6.
    Chiò A, Traynor BJ. Identifying potential risk factors for developing amyotrophic lateral sclerosis. Neurodegener Manag. 2011;1(6):463–71.CrossRefGoogle Scholar
  7. 7.
    Ashman EJ, Gronseth GS. American Academy of Neurology. Level of evidence reviews. Three years of progress. Neurology. 2012;79:13–4.PubMedCrossRefGoogle Scholar
  8. 8.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA J Am Med Assoc. 2000;283(15):2008–12.CrossRefGoogle Scholar
  9. 9.
    Lehman EJ, Hein MJ, Baron SL, Gersic CM. Neurodegenerative causes of death among retired National Football League players. Neurology. 2012;79(19):1970–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Savica R, Parisi JE, Wold LE, Josephs KA, Ahlskog JE. High school football and risk of neurodegeneration: a community-based study. Mayo Clin Proc Mayo Clin. 2012;87(4):335–40.CrossRefGoogle Scholar
  11. 11.
    Trojsi F, Sagnelli A, Vanacore N, Piccirillo G, Daniele L, Izzo F, et al. Clinical features and lifestyle of patients with amyotrophic lateral sclerosis in Campania: brief overview of an Italian database. Ann Ist Super Sanita. 2012;48(3):287–91.PubMedCrossRefGoogle Scholar
  12. 12.
    Turner MR, Wotton C, Talbot K, Goldacre MJ. Cardiovascular fitness as a risk factor for amyotrophic lateral sclerosis: indirect evidence from record linkage study. J Neurol Neurosurg Psychiatry. 2012;83(4):395–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Chiò A, Calvo A, Dossena M, Ghiglione P, Mutani R, Mora G. ALS in Italian professional soccer players: the risk is still present and could be soccer-specific. Amyotroph Lateral Scler. 2009;10(4):205–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Abel EL. Football increases the risk for Lou Gehrig’s disease, amyotrophic lateral sclerosis. Percept Mot Skills. 2007;104(3 Pt 2):1251–4.PubMedGoogle Scholar
  15. 15.
    Taioli E. All causes of mortality in male professional soccer players. Eur J Public Health. 2007;17(6):600–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Belli S, Vanacore N. Proportionate mortality of Italian soccer players: is amyotrophic lateral sclerosis an occupational disease? Eur J Epidemiol. 2005;20(3):237–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Weisskopf MG, McCullough ML, Morozova N, Calle EE, Thun MJ, Ascherio A. Prospective study of occupation and amyotrophic lateral sclerosis mortality. Am J Epidemiol. 2005;162(12):1146–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Chiò A, Benzi G, Dossena M, Mutani R, Mora G. Severely increased risk of amyotrophic lateral sclerosis among Italian professional football players. Brain J Neurol. 2005;128(Pt 3):472–6.CrossRefGoogle Scholar
  19. 19.
    Bracco L, Antuono P, Amaducci L. Study of epidemiological and etiological factors of amyotrophic lateral sclerosis in the province of Florence, Italy. Acta Neurol Scand. 1979;60(2):112–24.PubMedCrossRefGoogle Scholar
  20. 20.
    Brody JA, Edgar AH, Gillespie MM. Amyotrophic lateral sclerosis: no increase among US construction workers in Guam. JAMA J Am Med Assoc. 1978;240(6):551–60.CrossRefGoogle Scholar
  21. 21.
    Govoni V, Granieri E, Fallica E, Casetta I. Amyotrophic lateral sclerosis, rural environment and agricultural work in the Local Health District of Ferrara, Italy, in the years 1964–1998. J Neurol. 2005;252(11):1322–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Pupillo E, Messina P, Giussani G, Logroscino G, Zoccolella S, Chiò A, et al. Physical activity and amyotrophic lateral sclerosis: a European population-based case-control study. Ann Neurol. 2014. doi:  10.1002/ana.24150.
  23. 23.
    Huisman MHB, Seelen M, de Jong SW, Dorresteijn KRIS, van Doormaal PTC, van der Kooi AJ, et al. Lifetime physical activity and the risk of amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry. 2013;84(9):976–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Mattsson P, Lönnstedt I, Nygren I, Askmark H. Physical fitness, but not muscle strength, is a risk factor for death in amyotrophic lateral sclerosis at an early age. J Neurol Neurosurg Psychiatry. 2012;83(4):390–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Beghi E, Logroscino G, Chiò A, Hardiman O, Millul A, Mitchell D, et al. Amyotrophic lateral sclerosis, physical exercise, trauma and sports: results of a population-based pilot case–control study. Amyotroph Lateral Scler. 2010;11(3):289–92.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Furby A, Beauvais K, Kolev I, Rivain J-G, Sébille V. Rural environment and risk factors of amyotrophic lateral sclerosis: a case–control study. J Neurol. 2010;257(5):792–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Fang F, Quinlan P, Ye W, Barber MK, Umbach DM, Sandler DP, et al. Workplace exposures and the risk of amyotrophic lateral sclerosis. Environ Health Perspect. 2009;117(9):1387–92.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Okamoto K, Kihira T, Kondo T, Kobashi G, Washio M, Sasaki S, et al. Lifestyle factors and risk of amyotrophic lateral sclerosis: a case–control study in Japan. Ann Epidemiol. 2009;19(6):359–64.PubMedCrossRefGoogle Scholar
  29. 29.
    Kihira T, Kanno S, Miwa H, Okamoto K, Kondo T. The role of exogenous risk factors in amyotrophic lateral sclerosis in Wakayama, Japan. Amyotroph Lateral Scler. 2007;8(3):150–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Sutedja NA, Veldink JH, Fischer K, Kromhout H, Wokke JHJ, Huisman MHB, et al. Lifetime occupation, education, smoking, and risk of ALS. Neurology. 2007;69(15):1508–14.PubMedCrossRefGoogle Scholar
  31. 31.
    Valenti M, Pontieri FE, Conti F, Altobelli E, Manzoni T, Frati L. Amyotrophic lateral sclerosis and sports: a case–control study. Eur J Neurol. 2005;12(3):223–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Veldink JH, Kalmijn S, Groeneveld GJ, Titulaer MJ, Wokke JHJ, van den Berg LH. Physical activity and the association with sporadic ALS. Neurology. 2005;64(2):241–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Scarmeas N, Shih T, Stern Y, Ottman R, Rowland LP. Premorbid weight, body mass, and varsity athletics in ALS. Neurology. 2002;59(5):773–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Longstreth WT, McGuire V, Koepsell TD, Wang Y, van Belle G. Risk of amyotrophic lateral sclerosis and history of physical activity: a population-based case–control study. Arch Neurol. 1998;55(2):201–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Strickland D, Smith SA, Dolliff G, Goldman L, Roelofs RI. Physical activity, trauma, and ALS: a case–control study. Acta Neurol Scand. 1996;94(1):45–50.PubMedCrossRefGoogle Scholar
  36. 36.
    Gregoire N, Serratrice G. Risk factors in amyotrophic lateral sclerosis. First results in 35 cases. Rev Neurol. 1991;147(11):706–13.Google Scholar
  37. 37.
    Armon C, Kurland LT, Daube JR, O’Brien PC. Epidemiologic correlates of sporadic amyotrophic lateral sclerosis. Neurology. 1991;41(7):1077–84.PubMedCrossRefGoogle Scholar
  38. 38.
    Provinciali L, Giovagnoli AR. Antecedent events in amyotrophic lateral sclerosis: do they influence clinical onset and progression? Neuroepidemiology. 1990;9(5):255–62.PubMedCrossRefGoogle Scholar
  39. 39.
    Granieri E, Carreras M, Tola R, Paolino E, Tralli G, Eleopra R, et al. Motor neuron disease in the province of Ferrara, Italy, in 1964–1982. Neurology. 1988;38(10):1604–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Gallagher JP, Sanders M. Trauma and amyotrophic lateral sclerosis: a report of 78 patients. Acta Neurol Scand. 1987;75(2):145–50.PubMedCrossRefGoogle Scholar
  41. 41.
    Felmus MT, Patten BM, Swanke L. Antecedent events in amyotrophic lateral sclerosis. Neurology. 1976;26(2):167–72.PubMedCrossRefGoogle Scholar
  42. 42.
    Breland AE Jr, Currier RD. Multiple sclerosis and amyotrophic lateral sclerosis in Mississippi. Neurology. 1967;17(10):1011–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Werneck LC, Bezerra R, da Silveira Neto O, Scola RH. A clinical epidemiological study of 251 cases of amyotrophic lateral sclerosis in the south of Brazil. Arq Neuropsiquiatr. 2007;65(2A):189–95.PubMedCrossRefGoogle Scholar
  44. 44.
    Vanacore N, Binazzi A, Bottazzi M, Belli S. Amyotrophic lateral sclerosis in an Italian professional soccer player. Parkinsonism Relat Disord. 2006;12(5):327–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Wicks P, Ganesalingham J, Collin C, Prevett M, Leigh NP, Al-Chalabi A. Three soccer playing friends with simultaneous amyotrophic lateral sclerosis. Amyotroph Lateral Scler. 2007;8(3):177–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Bello Hamidou
    • 1
    • 2
  • Philippe Couratier
    • 1
    • 2
    • 3
  • Cyril Besançon
    • 1
    • 2
  • Marie Nicol
    • 1
    • 3
  • Pierre Marie Preux
    • 1
    • 2
    • 4
  • Benoit Marin
    • 1
    • 2
    • 4
    Email author
  1. 1.INSERM UMR1094, Tropical Neuroepidemiology, Faculté de MédecineLimoges CedexFrance
  2. 2.Univ Limoges, School of Medicine, Institute of Neuroepidemiology and Tropical Neurology, CNRS FR 3503 GEISTLimogesFrance
  3. 3.CHU Limoges, Service de Neurologie, Centre SLALimogesFrance
  4. 4.CEBIMERCHU LimogesLimogesFrance

Personalised recommendations