Article

Relationship of Hypotonia and Joint Laxity to Motor Development During Infancy

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Abstract

Many children examined by pediatric physical therapists present with generalized hypotonia, joint laxity, and motor delay. These signs are assumed to coexist and to be causally related. The objectives of this study were to determine 1) whether a relationship exists between hypotonia and early motor development and 2) whether infants presenting with joint laxity differ from infants without joint laxity in gross motor scores or initial age of ambulation. A secondary analysis was conducted using a longitudinal data set of 180 singletons born at full term; complete data for 141 infants were available for this investigation. Muscle tone and motor development at seven, 10, and 15 months were assessed using the French Angles Factor of the Infant Neurological International Battery and the Alberta Infant Motor Scale, respectively. Motor development was also assessed at 15 months using the Gross Motor Scale of the Peabody Developmental Motor Scales, and joint laxity was assessed at 18 months using the method of Beighton et al. No statistically significant or clinically meaningful relationships between hypotonia and motor development were found. No significant differences in motor development or average age of initial ambulation were found between children with and without joint laxity. The belief that hypotonia and joint laxity are causally related to motor delay was not supported by the results of this investigation. This information assists in the rational evaluation of early neuromotor examinations by giving a new perspective on the role of these variables in motor development and contributes to planning by suggesting that targeting change in muscle tone might not be a rational focus for intervention if the goal is to enhance motor abilities.

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... The grading of the quality assessment checklist score is described as follows; 0-40% (poor); 40%-70% (satisfactory) and 70-100% (good) (refer to Table 2). 16 Retrospective Cohort 70% Good Carboni et al, 2002 21 Retrospective Cohort 60% Satisfactory Cetin et al, 2009 27 Non-consecutive 70% Good Laugel et al, 2008 17 Retrospective Cohort 80% Good Leyenaar et al, 2005 26 Single Case 70% Good Martin et al, 2005 24 Cross-sectional 80% Good Martin et al, 2007 23 Cross-sectional 80% Good Pilon et al, 2000 22 Retrospective Cohort 70% Good Paine, 1963 18 Retrospective Cohort 60% Satisfactory Paro-Panjan and Neubauer, 2004 19 Retrospective Cohort 70% Good Richter et al, 2001 20 Retrospective Cohort 80% Good Van der Meche' and van Gijn, 1986 25 Case Control 70% Good ...
... The remaining 12 articles were exposed to the critical appraisal process. Full texts of these articles [16][17][18][19][20][21][22][23][24][25][26][27] were re-read by the reviewers, to determine once more if the studies met the inclusion criteria. Discrepancies were discussed until consensus was reached. ...
... No systematic reviews were identified. Five retrospective cohort studies 14-18 , two longitudinal studies 19,20 , two exploratory studies 21,22 , one case control study 23 , one case study 24 and one non-consecutive cohort study 25 were accessed. ...
... The assessment has a high correlation between its parts and a high interrater correlation. 10 Increased open angles of the joints reflect hypotonia. Two components were measured: the scarf sign of the upper limbs and the popliteal angle of the lower limbs. ...
... Crawling, sitting, upright posture, and walking are all indicators of postural control. 10 Delay in these milestones may reflect interfered postural control and may be connected to poor balance performance later in childhood. We assessed the quality of motor movements by the Alberta Infant Motor Scale test and found that at the age of 18 months, the results of the children from both study groups were still smaller or equal to the fifth percentile ðTable 2Þ. ...
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... 6 There are, however, only a few studies on the relationship between hypotonia and motor development, and most of them used nonstandardized motor development assessments and did not evaluate the contribution of axial versus appendicular hypotonia. [7][8][9][10] The current study applied an objective developmental measure to investigate the relationship between hypotonia and motor development in a cohort of infants with central hypotonia who were attending a high-risk neonatal neurology clinic. Our objectives were to determine an association between hypotonia and motor development, and the relative contribution of nuchal, truncal, and appendicular hypotonia to motor development. ...
Article
Purpose: To study the relationship between central hypotonia and motor development, and to determine the relative contribution of nuchal, truncal, and appendicular hypotonia domains to motor development. Methods: Appendicular, nuchal, and truncal tones of high-risk infants were assessed, as was their psychomotor developmental index (PDI). Infants with peripheral hypotonia were excluded. Results: We included 164 infants (mean age 9.6 ± 4 months), 36 with normal tone in all 3 domains and 128 with central hypotonia. Twenty-six of the latter had hypotonia in 1 domain and 102 had multiple combinations of 3 domains. Hypotonia domains were distributed as follows: truncal (n = 115), appendicular (n = 93), and nuchal (n = 70). Each domain was significantly associated with PDI scores (P < .001) but not with a later diagnosis of cerebral palsy. On linear regression, nuchal hypotonia had the strongest contribution to PDI scores (β = -0.6 [nuchal], -0.45 [appendicular], and -0.4 [truncal], P < .001). Conclusions: Central hypotonia, especially nuchal tone, is associated with lowered motor development scores.
... However, in order for early intervention to be optimally effective, early detection is paramount. As clinicians become progressively more involved in early examination, evaluation, and early intervention programs, the accuracy of these early examinations becomes essential in order to contribute to cogent decisions for intervention [2]. Accurate assessment and diagnosis is also essential in order to predict clinical course, manifestations, complications, prognosis, and to provide parental counselling. ...
Article
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Assessing muscle tone in children is essential during the neurological assessment and is often essential in ensuring a more accurate diagnosis for appropriate management. While there have been advances in child neurology, there remains much contention around the subjectivity of the clinical assessment of hypotonia, which is often the first step in the diagnostic process. In response to this challenge, the objective of the study is to develop and validate a prototype of a decision making process in the form of a clinical algorithm that will guide clinicians during this assessment process. Design research within a pragmatic stance will be employed in this study. Multi-phase stages of assessment, prototyping and evaluation will occur. These will include processes that include a systematic review, processes of reflection and action as well as validation methods. Given the mixed methods nature of this study, use of NVIVO or ATLAS-ti will be used in the analysis of qualitative data and SPSS for quantitative data. Initial results from the systematic review revealed a paucity of scientific literature that documented the objective assessment of hypotonia in children. The review identified the need for more studies with greater methodological rigor in order to determine best practice with respect to the methods used in the assessment of low muscle tone in the paediatric population. It is envisaged that this proposal will contribute to a more accurate clinical diagnosis of children with low muscle tone in the absence of a gold standard. We anticipate that the use of this tool will ultimately assist clinicians towards moving to evidenced based practice whilst upholding best practice in the care of children with hypotonia.
... As therapists become increasingly involved in early examination, evaluation and intervention programmes, the accuracy of early assessments becomes imperative in order to contribute to rational decisions for intervention strategies 16 . Accurate assessment and diagnosis is also essential in to order to predict clinical course, manifestations, complications, prognosis and provide parental counselling. ...
Article
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The assessment of muscle tone is a fundamental component of the neurological examination of infants and children and is often crucial in the establishment of an accurate diagnosis and appropriate management. However, the accurate identification and quantification of muscle tone, particularly in the clinical setting continues to pose a challenge for clinicians. An electronic survey was used to determine the current practices of Paediatric Occupational Therapists, Physiotherapists, Paediatric Neurologists and Paediatricians in the assessment of hypotonia. Three hundred and nineteen (319) responses were eligible for data analysis utilising SPSS 18. Results are described descriptively and indicate that practices vary. The need for more objective measures in assessment was also strongly indicated.
... In another study the researchers specifically examined the relationship between hypotonia and developmental delay by doing a secondary analysis of longitudinal data and concluded that hypotonia, as measure by the INFANlB, was not related to motor delays at the ages of seven, 10 or 15 months. 4 The authors acknowledged that their results contradicted many previously published articles, but suggested that differences in how muscle tone, joint laxity and motor development were assessed could explain the different conclusions. The authors also acknowledged that part of the challenge in this line of research is finding valid and reliable tools to examine the constructs of hypotonia and joint laxity. ...
Article
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This study extended previous work on defining characteristics of children with hypotonia. A survey regarding previously identified characteristics of hypotonia, examination tools, interventions, and prognosis was sent to a random sample of 500 physical therapists and 500 occupational therapists. A total of 268 surveys were returned, for a response rate of 26.8%. Characteristics most frequently observed in children with hypotonia included decreased strength, hypermobile joints, and increased flexibility. Observation was the most commonly cited assessment tool and 85% of those surveyed believe that characteristics of hypotonia improve with therapy. Despite agreement among physical and occupational therapists on characteristics of hypotonia and potential for improvement, clear clinical guidelines for the diagnosis and quantification of hypotonia have yet to be determined. Research is needed to develop an operational definition of hypotonia, develop valid tests and assess effectiveness of intervention.
Article
Clinical practice frameworks are a valuable component of clinical education, promoting informed clinical decision making based on the best available evidence and/or clinical experience. They encourage standardized intervention approaches and evaluation of practice. Based on an international project to support the development of an enhanced service system for infants and young children with neuromotor disabilities in Guangzhou, China, this article describes the processes used to develop a practice framework to guide therapists' intervention choices to encourage the gross motor abilities of infants and children (0–3 years of age) exhibiting hypotonia and gross motor delays. The goal was to provide a practice framework that aligns with contemporary interest in activity-focused intervention approaches and that considers both a child's abilities and the influence of environmental context in the achievement of gross motor skills. The final product, the Hypotonia Wheel, is presented. It may be useful for therapists and early intervention providers who work with infants and young children with hypotonia. The process used to design the Hypotonia Wheel also could be used as a template to develop intervention guidelines for other clinical conditions.
Article
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The term hypotonia is often used to describe children with reduced muscle tone, yet it remains abstract and undefined. The purpose of this study was to identify characteristics of children with hypotonia to begin the process of developing an operational definition of hypotonia. Three hundred physical and occupational therapists were systematically selected from the memberships of the Pediatric Section of the American Physical Therapy Association and the Developmental Delay Section of the American Occupational Therapy Association and asked to complete an open-ended survey exploring characteristics of strength, endurance, mobility, posture, and flexibility. The response rate was 26.6%. Forty-six physical therapists and 34 occupational therapists participated. The criterion for consensus about a characteristic was being mentioned by at least 25% of respondents from each discipline. The consensus was that children with hypotonia have decreased strength, decreased activity tolerance, delayed motor skills development, rounded shoulder posture, with leaning onto supports, hypermobile joints, increased flexibility, and poor attention and motivation. An objective tool for defining and quantifying hypotonia does not exist. A preliminary characterization of children with hypotonia was established, but further research is needed to achieve objectivity and clarity.
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We examined concurrent validity of scores for two infant motor screening tools, the Harris Infant Neuromotor Test (HINT) and the Alberta Infant Motor Scale, in 121 Canadian infants. Relationships between the two tests for the overall sample were as follows: r = -.83 at 4 to 6.5 months (n = 121; p < .01) and r = -.85 at 10 to 12.5 months (n = 109; p < .01), suggesting that the HINT, the newer of the two measures, is valid in determining motor delays. Each test has advantages and disadvantages, and practitioners should determine which one best meets their infant assessment needs.
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