Find out if low muscle tone affects your child and what you can do to help

Imagine two children of equal strength using slingshots to shoot pebbles into a river. They draw back the elastic slings to see who can propel their stone the furthest.

The first child's elastic is taut.

This enables him to retract it to maximum stretch, obtaining the high resistance needed to shoot his pebble far into the water. The second child's sling lacks elasticity.

This makes stretch minimal and resistance low. No matter how hard he tries, his pebble stone falls at his feet, and he loses interest in the game. 

The first child's elastic illustrates normal muscle tone. It is the tension in the muscle at rest that muscles push against to contract fast and fully.

This enables coordinated movement and helps to maintain upright postures against the pull of gravity. The second child's elastic illustrates the impact of low muscle tone, known as benign congenital hypotonia, on muscle contraction and movement.

The essential "elasticity" for effective muscle contraction is low. Hypotonic muscles are slow to contract. They don't contract fully or for an adequate duration. As a result, joints overextend, and movement against gravity isn't much fun.

It's hard work.

It's no surprise then that children with benign hypotonia often avoid physical activities.

This sets them up for failure, as the only way they are going to win the war against their lifelong enemy - gravity -  is to fight back physically.

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Identifying it

Several forms of low muscle tone exist. They are the symptom of an underlying cause. A child with severe hypotonia is easily identified and is normally referred to a paediatric neurologist before the age of 1.

Cerebral palsy and muscular dystrophy are two possible causes that the neurologist may detect. Benign congenital hypotonia is a milder form and is thought to have a genetic link.

A child with this condition can be identified by demonstrating a number of these characteristics:

• Poor head control The head falls sideways, backwards or forwards.
• Limp limbs When resting, the limbs hang in a flaccid manner rather than in the flexed elbow and knee posture that normal muscle tone encourages. Muscles feel soft and doughy
• Grip slip When picked up under the arms his arms rise upward without resistance, making them slip through your grip
• Poor articulation of sounds 
• Drools excessively
• Messy eater
• Tongue protrusion His tongue lies in the forward position in the mouth and results in "slushy" speech 
• Poor tongue mobility He battles to perform basic tongue exercises 
• Speaks in short and/or incomplete sentences
• Battles to latch onto breast or bottle and tires easily during feeds
• Clumsiness
• Hyperextension of joints Ability to extend a limb beyond its normal range
• Tires easily Even an activity such as colouring in is quick to take its toll on his body
• Excessive movement He fidgets and appears physically restless as he uses movement to try to build up tone
• Slouched rounded posture Tired neck muscles may cause him to prop his head up with his hand whilst sitting. A pushed forward, "potbelly" may be seen. He may drag his feet when walking, and his knee joints straighten too much and lock
• Delayed motor skills milestones: Large (gross) motor skills such as rolling, sitting and walking, Fine (small) motor skills, such as tracking movement with the eyes, self-feeding, pointing and babbling.  
• Avoidance of physical activities

The implications of low muscle tone

Low muscle tone can lead to avoidant behaviour as the child fails at tasks peers enjoy.

Experience teaches him that he is clumsy, tires quickly and isn't fast on his feet. He feels unsafe when moving, and his self-esteem is knocked.

He protects himself by engaging in sedentary activities and withdrawing from social, physical ones.

Hypotonia leads to:

• Gross motor difficulties such as weak ball skills, difficulty hopping and jumping
• Fine motor difficulties such as illegible handwriting and inaccurate cutting skillso       
• Hyperactivity. He appears unable to sit still, which is distracting to him and others in class. He suffers frequent headaches and fatigue from the physical demands placed on him in the classroom settingo       
• Concentration difficulties. Low muscle tone leads to his brain needing to monitor and adjust the tension in his back and neck muscles while he tries to concentrate. His attention is drawn away from listeningo       
• Slow work rate.

Who can help?

Early intervention is important. Physiotherapists and occupational therapists have a number of methods to detect low muscle tone throughout the body.

These include analysis of developmental activities, which identify the interactions of parts of the body in motion. For example, a hypotonic child may compensate for his condition by locking his knees while attempting to walk.

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So what do therapists do?

Physiotherapists help a child learn correct movement patterns, making him more agile and willing to venture out onto the playground rather than assume a spectator role. The hypotonic child uses compensatory movement patterns which restrict him to a forward/backward plane of motion. Physiotherapy aims to train him to use all muscle groups and planes of motion, including side-to-side and rotational motion. This improves his balance, posture, and ultimately, his self-confidence, promoting better social interaction Physiotherapists will provide your child with the correct way to exercise. 

Occupational therapists (OT's) normalise tone through activities of daily life. They teach your child how to carry out the tasks he finds difficult such as holding a pencil to draw or cutting with scissors so that he can become independent. OTs specialise in the treatment of fine motor skills and sensory integration. They use the latter to promote a sense of balance, which has a predominant role in muscle tone regulation. OT's also address stress management, social skills and problem-solving strategies

Speech therapists: Muscles in the lips, tongue, cheeks and palate are crucial to speech development. Parents should consult a qualified speech therapist if they are concerned about their child's speech development. The home programme will involve teaching the parent how to use bubbles, straws,  trumpets or horns with their child, to strengthen his oral muscle tone. This is done in conjunction with therapy. Speech therapists also provide advice regarding feeding difficulties in babies. "

Parental roles

Parents should get physically active with their kids, play rough and tumble, throw them in the air and get them moving. Parents are great motivators.

They need to help their children conquer gravity. Parents also need to provide a healthy diet to keep their children's bodies healthy. 

Hypotonia can be managed with time and therapy, but it never goes away as gravity is always tugging at it. Your child needs to stay active, fit and healthy. Here's how:  

Identify an active passion 

Help your child discover which physical activities he enjoys so that he gets regular, sustainable exercise.

Engage in muscle tone activity boosters:

Large Motor skills

• Wheelbarrows Hold him at the knees until he is strong enough for you to hold his ankles  
• Tug-o-War
• Monkey Bars
• Wrestling Join hands and push against him
• Jumping games, such as, Hopscotch or The Brain Game (Bright Kid) which involves a jumping mat, social interaction and gymnastic animal walks to stimulate the stretch reflex around joints needed to normalise muscle tone
• Climbing
• Trampoline activities
• Monkeynastix classes

Fine motor skills

• Woodwork, hammering or resistant pegboard and elastic games
• Popping air bubble packaging 
• Screwing and unscrewing lids or bolts
• Wringing out the sponge in the bath
• Kneading dough to make bread or scones. Playdough and plasticine activities
• Spray bottle Squeeze the trigger to water plants 
• Clothes pegs Opening these to hang washing on the line, using his thumb and index finger, is excellent for fulfilling a sense of belonging, promoting independence and strengthening the hands. 

Physical activities that are highly recommended for children with low muscle tone are horse riding, swimming and martial arts. 

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