Monday, April 19, 2010

Low Tone

As a therapist, I sometimes forget that civilians don't understand all of the professional jargon that my colleagues and I use to communicate with each other. I try, when I write an evaluation of a child, to explain what each thing I assess means, and most important, how it affects the way the child functions. But when I hand over a 12 page report to a parent, I have to remember that not everything is sinking in all at once, and that the information I'm conveying has to be absorbed, bit by bit, as the parent can integrate it.

"Low tone" is something we occupational therapists talk about quite often. But parents complain to me that they have no idea what that means. Sometimes it's quite obvious -- the mother of one of the children that I treat just had a baby, and she called me to tell me that the baby is so weak and floppy that it can't tighten its fist around an index finger placed in its palm. Other times it's not nearly as apparent, and a child can appear to be quite athletic and still be plagued by all kinds of problems associated with low tone.

Tone is the amount of electricity that courses through the muscles and allows them to do the jobs of extending the body against gravity, contract themselves around joints for balance and stability, and work for long periods of time without undue fatigue. An example of someone with plenty of tone is a professional athlete or dancer. I'll never forget the time I met my favorite baseball player, Dennis Eckersley. He practically crackled, he had so much juice and electricity flowing through his body!

As far as I know, there is no one definitive reason for low tone. Some people believe that it is a nutritional issue, and that for some reason the body is not delivering, {perhaps because of dietary issues or metabolic difficulties} or the muscles are not utilizing, the raw materials needed for maintenance and sustained use. The child's muscles don't develop well, and so they tire easily.

An under responsive vestibular system can be a possible reason for low tone. The vestibular nerve is responsible for many things. It tells us, along with our eyes and muscles, where we are in space. It also responds to how much and what kind of movement we get, and communicates directly with the muscles that extend us against gravity and allow us to be upright. It also talks to the part of the brain that is responsible for alertness, attention, and arousal. If the vestibular nerve is not picking up and processing this information correctly, the result will be insufficient muscle tone and chronic low arousal.

Another issue that interferes with the child's ability to function is delays in the maturation of spinal reflexes. When a child is born, its nervous system is immature, unlike a horse's -- a pony can get up and walk shortly after birth. Humans start out instead with nervous systems that respond by increasing or decreasing muscle tone in response to certain stimulation, and then go on to refine themselves through movement and play until voluntary control is established. Then the reflexes disappear. If they don't disappear and are dominating the nervous system, the child will have difficulty working his body against gravity.

If your child tires easily, complains that he doesn't have any energy, can't sit up while he's writing, is a chronic slumper, or has a hard time sitting still or sitting on the floor, chances are his tone is low, even if he appears to be athletic. I've seen plenty of boys who could pitch a ball like Roger Clemens -- but their core strength was so weak that they couldn't do a single sit up or lift their chests and thighs up off the floor when lying on their bellies.

Children with low muscle tone have an especially difficult time of it in school, because their bodies don't have the effortless uprightness against gravity that allows them to sit still. If they are struggling to stay upright, they're using the mental and physical energy to sit that they should be applying towards attending to the lesson. I once went to school to observe a little boy who acted out a lot, especially during circle time, when all the children had to sit cross legged on the floor. The day I saw him, during circle time, he sat with his legs straight in front of him and his hands behind his back on the floor, using his arms to brace himself. He simply was not able to sit in the traditional "criss cross applesauce" position, and needed the additional support from his arms, and wide base from his extended legs, just to stay upright. I saw immediately that he was so uncomfortable sitting this way, and that it was so much effort, that he couldn't sit on the floor and attend to what was going on at the same time. He didn't have enough sophistication in his language to tell anyone what the problem was. His only recourse was to refuse to stay there for very long, and this was viewed as disruptive behavior. I suggested to his teacher that he either be allowed to sit in a chair or that he be assigned a place against the wall so that he could sit with his back supported. He was much happier after that, and he was much more able to attend.

Low tone affects many aspects of function, which I will address in future posts. Meanwhile, if your child has low tone, no amount of yelling at him to sit up straight will help. Try incorporating activities to strengthen the trunk, like sitting on a therapy ball while doing homework or watching TV, doing sit ups and push ups, wheelbarrow walking, wrestling matches, and playing with whistles, bubbles, and blow toys to your child's daily routine. Spinning is good for vestibular activation, if your child likes to spin. Or take your child outside and play tag or ball, or organize a game of statues or red rover with other children in the neighborhood.


silvio soprani said...

Loren, is the electricity in the muscles you are referring to related in any way to that clip that the nurse puts on one's forefinger (while taking blood pressure) to measure one's "oxygen level" ? I don't understand how a clip can measure oxygen, but I am learning so many new things from your blog, I thought I'd ask.

Anonymous said...

My daughter was diagnosed with hypotonia/low tone. She didn't begin walking until about 18-19 months old. She is 27 months old now and she has difficulty with climbing stairs, especially down. She also does not jump at all yet. We still find it hard to break her of sitting in the W position as well. Any suggestions? She was seeing a therapist until about October of last year when my insurance decided it was no longer necessary. What can we do at home to help her? Thanks so much!!

Scarehaircare said...

a friend of mine sent me an email about your blog. You have great information, here! I am looking forward to learning from you. My daughter recevies OT at school and then we turn to a private practice over the summer.

Anonymous said...

Thank you for the clear presentation of information. If I may ask, are there different degrees of low tone? How can you tell the difference? Thank you

Anonymous said...

My Son was referred to OT + PT aged 3 / 4 after I highlighted delays with his motor skills. Prior to this his nursery teacher had described him as per the child above. He received OT + PT for approx. 1 year and it was decided that he has no medical problem and that he had largely caught up. Hence, discharged. During this time the PT mentioned that he had low core tone.

My Son is now nearly 8 and still won't entertain riding his bike, his scooter or anything else with less than 3 wheels.:( HE struggles to straddle railings, fences, play equipment and descend the other side. I'm torn as to what to do: go mt best to teach him these things with love + patience or march back to the Doctor's office?

sadaf said...

Hi. My son is 11 and starting his high school in September 2013. I am also worry for his gross motor skills. He still needs to hold while going upstairs or downstairs.he can,t walk through small spaces while children sitting on floor,getting up from the chair.he is doing swimming ,cricket,multi support clubs but no improvement.any good advise for him can I help him.please .

Anonymous said...

Hi Loren,your blog is very helpful and now I can correlate my son's problem very well. He started walking independently very late at 34 months. Now he can walk but gets tired very easily. He is not able to jump and climb stairs independently. Though he is going for OT but I am little worried as next year he will turn 5. What all I can do on daily basis which can help him to improve on low tone issue.

Anonymous said...

I really enjoyed your posts and found your explanation very clear and to the point. i would just like to say that i do not agree with your suggestions to spin to enhance vestibular funtion. it is a fact that sudden movements or stops can shut down the vestibular system and that slow and deliberate movement is ideal for enhancing vestibular function. most children who move fast to calm this system do so by themselves anyway, is it necessary to include these fast movements in activities? I have seen more stress signs with children who do these fast movements, e.g red ears, flushed cheeks, altered breathing, than with the slow and deliberate movements. This is just a suggestion that you might want to look into these movement activities and try some slow ones too.

Anonymous said...

Hi all, my son is 6 now and has low tone. He couldn't roll over, sit up, or crawl as an infant, but successfully did all of these things with PT support and by 18 months could walk! He's had OT for the tone in his mouth, and speech therapy. His greatest successes have come from being in karate - a sport he loves that has helped his develop middle strength and has been his everyday physiotherapy. He can now walk up and down (!) the stairs, and so many things that he struggled with for years.

Anonymous said...

Don't confuse tone and strength. You can have low tone and have more than adequate strength to perform your everyday life. Plenty of children have low tone with no issues at all. You can't change tone!!!!