I need to take short step back first for some explanation of SMA. I would recommend that you do NOT pay this much mind if it is important to you, because I am not a doctor and am writing from memory and personal experience, not from a book (coz I’m on the train). There are also very detailed resources online but it can be hard to know from these what to actually expect for your child, or when, so talk to your specialist. A good starting point, though, is the Jennifer Trust for SMA website
SMA has a genetic basis with (AFAIK) no significant established environmental factors that influence its onset or its progression. It is recessive, meaning in essence that both parents must be carriers of the mutation. Perhaps surprisingly the mutation is estimated to be present in around 1 in 40 of the population. The maths of this means that on average 1 in 1600 couples will both possess the gene. Assuming that they are both carriers rather than having 2 copies of the faulty gene (in which case they would themselves be affected by SMA), there is a 1 in 4 chance that any given child of theirs will have 2 copies of it. Which is how it came about that Fiona and I have two children without SMA and one with. The result is that around 1 child in 6500 is born with SMA – about 100 kids a year in the UK. Not a trivial number, but not so many that you are likely to have come across many of them.
To start with we just noticed that Kid3’s feet appeared to have turned in and his gait was changing, with his feet moving further apart. This was at around 1½ years old, and on the advice of Fiona’s father (a very experienced GP) we had him checked out. In short he ended up with splints to support his feet. These did appear to help somewhat, but it became clear that his legs were still not doing what they should. He would fall over frequently, often with his legs folding underneath him and his head hitting the ground. He’d get to his feet by walking his hands up his legs (the “Gower’s sign” typical of SMA). He still couldn’t climb stairs by an age where children can usually do this. He also had a hand tremor, sometimes visible, sometimes just felt, sometimes not evident at all, and we associated this with emotional moments – excitement, upset. My father-in-law recommended that we arrange to see a paediatric neurologist, and now I know what his fears were.
We went with Kid3 and Fiona’s father to Addenbrookes Hospital in Cambridge for a consultation, during which the names of various conditions came up, mainly SMA and muscular dystrophies of various sorts, with Duchennes the only type that really fitted the symptoms. I’d read and heard a little about the MD but with its many forms I hadn’t quite registered what the implications of Duchennes might be, but it was clearly a strong candidate. It was clear now that our little boy’s condition was not one of slack tendons or anything other than a serious neuromuscular issue, which I’d not really wanted to countenance before. Fiona was more aware than I of what it meant, and it showed in her reaction. A blood test for a protein would be a first step to confirm whether Duchennes was likely, along with genetic tests for that and for SMA, and we went straight off that day for the blood sample to be taken – in itself a painful sight. We understood that it would take several weeks for the genetic test to be done and left expecting a wait. In something of a daze we went home incapable of doing or thinking much. We had my parents-in-law to support us and gently talk us through what it all might mean, but I think I still didn’t really get it properly.
There were then electrode tests to understand the strength of the nervous impulses in our son’s arms and legs. The results fitted with the SMA diagnosis, which was confirmed by the genetic test. At our next meeting with the consultant we talked through what type III SMA would actually mean, what research was underway, and what our next steps might be. Perhaps the hardest thing, in terms of understanding the implications of the diagnosis for Kid3, was (and is) dealing with the unknown, because the “progress” (degeneration of the nervous connections) varies so much and you’re desperate to know what to expect and when. Scratch that, actually. The hardest thing? Powerlessness. You want to be able to do something, anything, to make a difference. To be entirely dependent upon other people (never mind the fact that they can’t do very much, at least in terms of providing a cure) is difficult, but I suppose it was also being able to get to the bottom of the question: is there actually anything I can be doing? Am I missing any opportunities because I haven’t asked the right questions – is there a clinical trial, a scheme, that we’ve missed? I cannot speak highly enough of Dr Verity, the consultant we had, and his advice and the efforts of my father-in-law to discover everything possible about SMA, to interpret it for us and reassure us that we were not missing anything, these were so valuable. Still, we had a long journey to accommodate the new reality. I won’t attempt to describe that journey, and Fiona and I certainly handled it differently at times. I will say that the support of family and friends was immeasurably important, but in the end the only way to move onto a new phase was for us to gradually absorb the idea that this is simply our “normal”, not an acute situation that could be addressed and put behind us. Instead, what our son would regard as the normal state of affairs from his earliest memories needed to become that for us: something where the practical implications and needs of the situation are handled calmly and, without a feeling of crisis or drama, just dealt with. Usually that works.
What has happened in the intervening time? Well Kid3’s walking isn’t noticeably different: he falls over a little less, perhaps, because he knows better how to support himself on things, so there’s no way you’d expect him to go more than a few yards without a hand to hold. Stairs are usually climbed on hands and knees, although he has handrails on both sides (of very narrow stairs – I never thought that would actually be helpful!) and occasionally uses these to help him up or down. What he does have over other kids is impressive upper body strength, which comes from using his arms to do so much stuff his legs would otherwise do. He’ll climb to his brother’s top bunk essentially using just his arms and with help he’ll take on trees, monkey bars and climbing frames too, and he throws a mean punch. Hold his hand and you get a steel grip you’d not expect from a some sweaty little kid’s mitt. He likes to do acrobatics that use this strength and that other kids can’t do (still looking for a video for that). He'll do a simulated parachute drop too - that was cool!
When he was 4½ Kid3 got a wheelchair, which he just loves, and he mastered it the moment he first sat in it.
Having perhaps 20-25% of the usual amount of strength in his legs (just a guess) doesn’t mean he can’t do anything with them, of course. He has swimming lessons as well as hydrotherapy, and he loves a game of football, although this one definitely involves a lot of support from an adult (possibly swinging him in the air like a croquet mallet). We tried a balance bike, thinking that having no pedals it might work for him, but the act of balancing itself takes both control over the legs and a degree of core stability – another area weakened by SMA. So for his 6th birthday we got him an Ezy Roller, which is like a little go-kart powered by his arms wiggling a handlebar from side to side. Here's a clip of the boys hunting me down on Ezy-roller and scooter:
One of our early worries was for how our son would handle it when he realised that he couldn’t do things that others could. We could see how his determination and vivacity helped him take on all sorts of things without complaint, but knew that at some point he was sure to think, “why is it just me that can’t do the things my friends can?” Will there come a point where he feels this and despairs, or turns to rebellion or anger? I guess we’ll see.
He is aware of his condition, of course, but treats it in a very matter-of-fact way. Sometimes it’s heart-breaking to see how matter-of-fact he can be, in fact. One thinks, “this shouldn’t have to seem normal to him”. He sometimes calmly sits out a game knowing that it’s not something he can do, though he may well recruit someone to help him do things his way. Only once do I remember him making a rather sad remark. I was carrying him down the stairs at a friend’s house where he saw his reflection in a big mirror, with his legs swinging freely as they tend to do, and he told me “I hate to see my wobbly legs when I’m walking”.
We’ve had several open discussions with the other children about what SMA is and means (normally on long car journeys), with him listening in. It’s hard to know if that’s the right thing to do, but that’s our approach: be open, don’t make a drama of it, don’t make him feel abnormal whilst being clear that he is naturally going to need help. I don’t think we have a strategy, we just have to feel our way and take our cues from him.
Beyond our friends and families, whose support has been so precious, we’ve had a lot of help from outside agencies and it’s well worth knowing where you can look. Actually the first to mention (again) is the Jennifer Trust, who provided us with a list of the various agencies we could turn to and some of the steps we could expect. The Muscular Dystrophy Campaign is a much larger charity than JTSMA with a wider focus but including SMA in its remit. With a bigger constituency it has quite busy forums where you might find a place to seek advice or share experiences.
Various services come through the NHS, from physiotherapy and occupational health, to wheelchair services, to consultations with paediatric neurologists. Our paediatrician helped in many ways other than the clinical, putting us in touch with people and advising on form filling (there’s a bit of that). As far as keeping in touch with research goes, aside from asking your paediatric neurologist you keep you informed there is a research network, Treat-NMD (it started as a European initiative but has gone global), that is worth looking into. It runs patient registries and a whole lot more besides. Like us you may not feel ready to face thinking about it immediately but do take a look.
A child that needs as much help moving around as one with SMA is entitled to (and needs) certain benefits, and you should get this underway. Check out the Motability scheme too (even if it uses ColdFusion for its website), which has enabled us to get a vehicle big enough for wheelchairs and buggies and also means that Fiona can get to all the many appointments.
The primary school and county council have worked together to provide support in class for Kid3 and I recommend pushing for this, especially if the school is an older building where the physical environment may be tricky for kids with “wobbly legs” or wheelchairs and where adaptations may be hard to implement. Getting around the classroom, participating in the playground and in PE all need our son to have help, and he gets that from a dedicated assistant. It may seem overkill but I assure you that it’s not, and because he’s a bright kid who doesn’t need extra help when sitting down at his work it means that the class also gets an extra adult to pitch in and help anyone, which is good for everyone. So whilst there’s less money to go round and it may be more difficult now to persuade your council to provide classroom assistance, don’t be afraid to try.
I mentioned swimming lessons, and again this is an experiment that has worked. Having taught our two older children the swimming teachers have been happy to take on the challenge of finding techniques that work for our youngest, giving him genuine swimming skill, confidence in the water, and noticeably improved muscle tone too. It’s exhausting for him, but that’s a good thing.
I’m sure there have been other sources of help and there are certainly many people I’m grateful to but I want this to focus on things that could be useful to others and I think this is a good start. I hope it’s helpful.
There is no conclusion. We carry on, we have a happy life with our kids, there are annoyances and things that we all miss out on or that Kid3 in particular misses out on, but really he's just like any other 6-year-old mentalist. He has no super-powers but he has a big smile, smart brain and lots and lots of attitude. We don’t know what’s ahead of us, but that’s just life. We count our blessings, and then they shout at us, kiss us, draw a picture, run over our feet with a wheelchair. They may even stand there three feet high in a Darth Maul costume, rabbit-punch us and then fall over backwards with the kick-back... And so the blessings pile up, only a little black and blue.
So if you've just found out that you are in our situation, with a child that is going to have difficulties you never foresaw, please don't despair. I hope you've seen that there are ways round a lot of things and always, always a lot of fun to be had. All my best to you.