When working with a child with hypotonia, we seek to address a variety of impairments including but not limited to: joint hyper-mobility and ligamentous laxity, decreased muscle strength, increased latency period before responding to cues, decreased motor control, inefficient movement patterns, decreased postural control and diminished righting/equilibrium reactions.
1) Be Patient: Because children with hypotonia often do not show motor response immediately, therapists and parents have a tendency to give up on what they are doing and look for another activity. These children, however, need the activity to be repeated.
Waiting for this response is key in the treatment of hypotonia. By sustaining the same activity and molding the activity, you can inhibit the quick burst response and facilitate and promote co-activation.
2) Decrease Support Over Time: Start with higher base of support while handling and slowly lower, if child has poor head/neck control begin with therapist assist at head/neck and as child begins to activate and strengthen, decrease support to shoulder girdle and continue to lower support until child achieves independence.
3) Grade Input: Try not to startle child with sudden movements, do not push or pull, allow child to activate on his/her own to maximize work and minimize collapse.
4) Proper Alignment: Build strength over properly aligned symmetrical base of support. If you are working in sitting ensure pelvis is in neutral position, if you are working in standing ensure feet are properly aligned so that muscles can be targeted efficiently and diminish the child’s compensatory strategies.
1) Use the Therapy Ball
-to increase demands on child and inhibit passive collapsing into gravity
-to facilitate motor control and increase endurance
-to promote muscle strength, as you facilitate transition from supine to sit, prone to quadruped, and supine to prone and back again(with control).
-to allow for synergistic activity in trunk while facilitating coactivation of trunk and hips with neutral pelvis, for postural alignment
-for vestibular stimulation and righting in space
photos courtesy of www.noahsdad.com
2) Use Developmental Positions
-in quadruped direct graded force through pelvis to elongate spine and to elicit symmetric weigh bearing through upper and lower extremities
-in prone using movement to enable child to weight shift and disperse weight bearing symmetrically through upper extremities
-in tall kneel can utilize support at pelvis to weight shift over lower center of gravity, build abdominal activation, and aid in transition from tall kneel through half kneel to stand without use of upper extremities to push off
3) Use Joint Compressions
-on well aligned joints supported by therapist(proximal to distal)
-use graded force to approximate the joints without overloading them, and joint distraction that is graded to align the joints without overstressing them.
-both of these techniques promote increased co-activation of the muscles around the joint, which helps the child hold that joint in alignment against gravity.
4) Use Tactile Cues
-by tapping on muscles to activate we can build awareness and facilitate initiation of force production
-increased tactile input promotes coactivation of muscles around joint
-light pressure massage has also shown to promote muscle activation, increase bone growth and mineralization in children with hypotonia(see article in the Journal of Early Development and Care May 2006 for more detailed explanation)
In addition to therapy balls, bolsters, wedges, benches and dyna-discs to utilize while incorporating these principles of treatment here are additional equipment ideas to consider:
1) Surestep: an orthotic specifically designed for the hypotonic foot. Allows a child with low tone to develop greater awareness of his/her base of support while promoting neutral alignment of calcaneus, and decreasing pressure on medial border of feet. Lighter and more flexible than traditional orthotics.
2) SPIO(stabilizing pressure input orthosis): is a flexible compression garment used to assist with stability and proprioceptive deficits by providing deep pressure. Since deep pressure appears to be an important somatic input for balance and movement control, SPIO is designed to provide and enhance deep pressure sensory input around and toward the midline of the body to improve dynamic stability and postural activation.
3) TheraTogs: an orthotic support and strapping system that gives children tactile input while improving postural alignment and biomechanical stability, movement skill and precision as well as joint stability.