His diagnosed was made after an emg and alot of blood tests to rule other things out. I forget what the Hoffman and Babinsky are. Anyway, the diagnosed was based on fasciculations, brisk reflexes, emg and strength tests. Our neuro, Dr Bromberg, at the ALS clinic in Utah was the most sure based upon everything that he saw and all the negative blood tests. My PALS had twitching all over his body by the time we were diagnosed. Even so, Dr Miller in San Francisco said no way could it be ALS since he was so strong on the strength tests. This was very frustrating as we had two world renown neuros in direct disagreement. When my PALS "suddenly" lost the ability to do push ups 6 months after diagnosed, Miller said oh okay, it is ALS after all. So long story short-you can be diagnosed with ALS and without weakness. However, Bromberg does nothing but ALS all day, and apparently he knew what he was seeing. He did alot of emgs. My PALS was in very good shape and was a fanatic on eating well so maybe that helped slow down the weakness. He has continued to swim with hand paddles, but can't do yoga or pilates any more. He was doing exercises with his physical therapist designed for Parkinson patients that use "big movements" kind of like Tai Chi, I think, That has become harder for him just in the last month. Hope that helps.