How Can Physiotherapy Help Paediatric Multiple Sclerosis?

  • Namude Sahar Malik Bachelor's degree, Biomedical Sciences, General, St George's, University of London (for students and alumni)

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Introduction

Around the world, 2.9 million people have multiple sclerosis, in the UK alone, more than 150,000 people live with the condition and around 7,500 people are diagnosed with multiple sclerosis each year.1 It’s a life-long condition that the public needs to be aware of on top of the available treatments so that their quality of life remains as high as possible. This article focuses on the role of physiotherapy in helping paediatric multiple sclerosis (multiple sclerosis in children). 

What is paediatric multiple sclerosis?

Paediatric multiple sclerosis (MS) or Pediatric Onset Multiple Sclerosis (POMS), is a childhood illness which affects children's nervous system.2 As a result, they begin to lose the ability to use their muscles, which can cause them pain when they do. This is because inflammation attacks their nerves, causing damage to the protective casing that surrounds them: the myelin sheath. Consequently, the nerves get injured around the body, and in both the white and grey matter of the brain. 

Symptoms

POMS can set in at any age, accounting for 3-5% of MS, with 28% of patients experiencing symptoms before they are 12 years old.3,4 MS symptoms can range from visible to invisible and include the following:5

  • Tiredness
  • Pain
  • Memory and attention problems 
  • Vision problems
  • Bowel and bladder problems
  • Tremors
  • Loss of balance
  • Dizziness
  • Numbness and tingling
  • Stiffness or spasms

Physiotherapy for MS

Though there are some medications which can be taken to help, both orally and via injection, physiotherapy can also be a key tool which can help alleviate your child's condition.6

In most instances symptoms will occur in spurts, being present and then disappearing for an amount of time before reoccurring.2 However, this does not mean that nerve damage will not accumulate when symptoms are not experienced.7 Carrying out physiotherapy, especially as a form of enjoyable play, can help improve comfort and confidence.

Regularly performing specific exercises can aid in many ways: 

  • Reducing pressure on sensitive nerves 
  • Helping cognition
  • Easing tight muscles to allow a full range of movement. 

Additionally, regular physiotherapy can help prevent other health-related issues like:8

  • Diabetes 
  • Risk of cardiovascular diseases 
  • Balance issues 
  • Limit loss of brain volume
  • Maintain muscle integrity in those with POMS

Reduce overheating 

Traditionally it was believed that exercise worsened POMS symptoms, sometimes leading to the onset of muscle weakness or possibly pain. However, we now know that these effects develop because of the heat generated by exercise, which can temporarily irritate damaged nerves, especially for those without a myelin sheath.7 This is, however, only temporary and doesn’t contribute to disease progression, therefore exercise is not responsible for any relapses.8

We know that exercise is vital in our daily lives and can contribute to a better quality of life overall. To gain the benefits of regular exercise whilst limiting the short-term negative effects, it is important to try and stay cool during it. You can do this by:

  • Wearing loose, layered clothing and removing layers as you get warmer 
  • Exercising in cool, well-ventilated areas
    • Parks
    • Outdoor gyms
    • Your garden (if the weather permits it)
  • Drinking refreshing water 

Comprehensive assessment and goal-setting

A comprehensive assessment tailoring exercise to your child’s specific abilities can be carried out by a physiotherapist. They can work closely with patients and their families to: 

  • Identify specific areas of concern 
  • Establish baseline measurements
  • Set achievable goals 

Interventions are personalised to address the individual challenges faced by each child. Whether it's: 

  • Strength and flexibility exercises to help improve muscle tone and prevent contractures 
  • Balance training and gait re-education to enhance mobility and reduce the risk of falls 

Goals 

Goals should be smart, ensuring that they can easily be followed whilst still providing enough of a challenge to ensure they can be routinely followed. This can start small, from ensuring your child moves at least once an hour, to which specific movements they may make.

It has been established that carrying out exercise several times a day for 10 minutes rewards the body with the same benefits as a 30-60-minute exercise of the same intensity.9 Therefore, to limit heat generation whilst also gaining the upside of exercise, short workouts can be implemented to maintain regularity. Also including things like stretches can reduce heat generation and the risk of muscle damage. 

Physiotherapists can help provide strategies to optimise daily activities like helping around the house, dancing, stretches and more. By offering continuity of care and addressing the evolving needs of young patients, physiotherapy plays a vital role in supporting children on their journey with POMS. It’s helpful and recommended to keep in regular contact with your physiotherapist and care team to address any changes that may occur with your symptoms.10 

Additionally, modalities may be utilised to manage spasticity, improve endurance, and optimize respiratory function. These include:11 

Which exercises are good for POMS?

Starting small can always help. Even if it’s as simple as moving in your chair every half an hour, this will help maintain muscle control. Simple yoga and stretches can also help. Some helpful stretches include:7,8 

Hamstring stretch 

Tight hamstrings can cause back pain and discomfort when standing or lying straight. To relax them, have your child: 

  • Lie on their back 
  • Loop a sheet or belt around one foot
  • Lift the leg towards the ceiling 
  • Hold for 30-45 seconds 
  • Repeat 3-5 times

Calf stretch 

Stretching calves helps reduce pain when standing. Have your child: 

  • Sit with one leg extended 
  • Wrap a sheet or belt around the foot
  • Gently pull back the toes for 30-45 seconds 
  • Repeat 3-5 times for each leg

Knee marches 

Knee marches may help to relieve joint pain. Have your child: 

  • Sit in a chair 
  • Lift your knees one at a time whilst keeping them bent at right angles as if you were a soldier in the army. 
  • Do this whilst also pretending to pull a rope towards you, with one arm at a time. 
  • Repeat these exercises together for 30-45 seconds, 
  • Eventually, move on to repeat these whilst sitting on the edge of a surface or whilst standing when you feel strong enough. 

Chest stretch 

To relieve chest tightness which can make it feel like it’s difficult to breathe, you can: 

  • Place your hands up against the wall 
  • Lean forward for 30-45 seconds 
  • Repeating 3-5 times like a wall push-up 

When you feel stronger, these can be repeated as actual push-ups on the floor, where gravity will increase the work done.

Prone lying 

During flare-ups, spend time on the stomach to relieve hip pressure. Activities like drawing or reading can help pass the time.

Heel raises 

Another mobility exercise is heel raises. 

  • Push down on your toes to lift the heels of your feet off the ground whilst keeping the back straight 
  • This can be done whilst sitting 
  • This can eventually lead to doing whilst sitting on the edge of a surface or whilst standing after you feel stronger 
  • This can be repeated 10 times, in sets of 3. 

Stability-ball sit 

Swap a desk chair for a stability ball intermittently to reduce hip joint pressure. Have your child sit on the ball with both feet on the floor, adjusting as needed.

Side steps 

Whilst sitting in a chair, bend your legs and start doing side steps:

  • Take one step out to the side at a time, like a crab to work your hip muscles. 
  • Repeat this 10 times, doing 3 sets. 
  • For increased intensity, this can be repeated whilst sitting on the edge of a surface like a table, or whilst standing using straight legs instead of bending at the knee. 

Terminal knee extension 

Strengthen your quadriceps. Sit with one leg extended and place a towel under your knee. Now: 

  • Push the back of the knee into the towel for 10 five-second holds 
  • Repeat twice for each leg

Sit-to-stand 

To prevent falls, practice sitting and standing without using your hands. Make it fun and do three sets of 10 repetitions.

For ease, practice doing this with your hands first. Eventually, move to do this without hands for greater exercise. 

Stability catch 

Improve your balance by tossing a soft ball back and forth:

  • Start with both feet on the ground
  • Progress to balancing on one foot 
  • Do three sets of 10 passes

Boxing 

Punch your arms out with varying power and intensity whilst sitting and continue for 30-60 seconds. Eventually, move to a standing position when you feel stronger to improve arm control 

Doing these exercises in various combinations can help improve mobility and maintain muscle integrity. Do what feels right for you and your child, and never put more than a slight strain on yourselves to prevent damage. Consulting a healthcare professional is always advisable. 

Collaboration and multidisciplinary care

Effective management of POMS often requires a multidisciplinary approach, with physiotherapy playing a key role within the healthcare team. To ensure comprehensive care that addresses the diverse needs of young patients, physiotherapists collaborate with: 

  • Physicians
  • Occupational therapists
  • Speech therapists
  • Special educational needs officers within schools (SENCOs) and 
  • Other healthcare professionals

This collaborative approach promotes holistic well-being and enhances outcomes for children with MS. 

Disease relapse is reduced by 27% in those who regularly carry out exercise, and by working together as a team, your child can be encouraged to live life to the fullest, whilst also minimising disturbances with their studies and home life.8

Summary

  • Physiotherapy offers a holistic approach to addressing the unique challenges faced by children with POMS. 
  • Through personalised assessment, targeted interventions, education, and collaborative care, physiotherapy empowers young patients and their families to improve their mobility, function, and overall quality of life. 
  • By providing continuity of care and support across the disease continuum, physiotherapy is vital in enhancing the well-being and resilience of children with POMS.

References

  1. Multiple Sclerosis Trust, MS. How common is multiple sclerosis? [Internet]. mstrust.org.uk. Multiple Sclerosis Trust, MS [updated 15 Mary 2024; cited 12 August 2024]. Available from: https://mstrust.org.uk/information-support/about-ms/how-common-multiple-sclerosis
  2. Abrams A./National Multiple Sclerosis Society. Pediatric MS. [Internet]. nationalmssociety.org. National Multiple Sclerosis Society [updated March 2023; cited 29 March 2024]. Available from: https://www.nationalmssociety.org/For-Professionals/Clinical-Care/Managing-MS/Pediatric-MS 
  3. Belman AL, Krupp LB, Olsen CS, Rose JW, Aaen G, Benson L, et al. Characteristics of children and adolescents with multiple sclerosis. Pediatrics. 2016 [cited 29 March 2024]; 138(1):e20160120. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925083/ 
  4. Chitnis T, Glanz B, Jaffin S, Healy B. Demographics of pediatric-onset multiple sclerosis in an MS center population from the Northeastern United States. Mult Scler. 2009 [cited 29 March 2024]; 15(5):627–31. Available from: https://pubmed.ncbi.nlm.nih.gov/19299440/ 
  5. MS Society. MS symptoms and signs. [Internet]. mssociety.org.uk. MS Society [cited 12 August 2024]. Available from: https://www.mssociety.org.uk/about-ms/signs-and-symptoms#top-of-page  
  6. Jančić J, Nikolić B, Ivančević N, Henčić B, Samardžić J. Multiple sclerosis therapies in pediatric patients: challenges and opportunities. Multiple Sclerosis: Perspectives in Treatment and Pathogenesis [Internet]. 2017[cited 29 March 2024]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470149/ 
  7. K. Aleisha Fetters. Beat pediatric MS pain with these exercises. [Internet]. healthcentral.com. HealthCentral [updated 12 November 2020; cited 29 March 2024]. Available from: https://www.healthcentral.com/slideshow/pediatric-multiple-sclerosis-physical-therapy-exercises 
  8. University College London Hospitals, NHS Foundation Trust. Multiple Sclerosis videos. [Internet]. uclh.nhs.uk. University College London Hospitals, NHS Foundation Trust [cited 29 March 2024]. Available from: https://www.uclh.nhs.uk/our-services/find-service/neurology-and-neurosurgery/multiple-sclerosis-ms/multiple-sclerosis-ms-videos 
  9. Magutah K, Patel NB, Thairu K. Effect of moderate-intensity exercise bouts lasting <10 minutes on body composition in sedentary Kenyan adults aged ≥50 years. BMJ Open Sport Exerc Med. 2018 [cited 29 March 2024]; 4(1):e000403. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173229/ 
  10. NHS. Living with Multiple Sclerosis. [Internet]. nhs.uk. NHS [updated 22 March 2022; cited 12 August 2024]. Available from: https://www.nhs.uk/conditions/multiple-sclerosis/living-with/ 
  11. Sîrbu CA, Thompson DC, Plesa FC, Vasile TM, Jianu DC, Mitrica M, et al. Neurorehabilitation in multiple sclerosis—a review of present approaches and future considerations. J Clin Med. 2022 [cited 29 March 2024]; 11(23):7003. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9739865/

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