Written by:
Lizette Alexander, OT Reg. (Ont), Co-Founder & Director of Operations at Toronto Children’s Therapy Center &
Stacy Kramer, OT Reg. (Ont), Occupational Therapist & Clinical Director at Toronto Children’s Therapy Center

Hypotonia defined:

Hypotonia is a medical term used to describe decreased muscle tone or tension in the muscle.  It is important to note that muscle tone and muscle strength are not the same thing. You can have strong muscles with low muscle tone, however, due to the nature of muscle tone we frequently see children with low muscle tone with weak muscles. Muscle strength refers to the actual physical properties of the muscle, whereas muscle tone refers to the amount of tension in a muscle when it is at rest.  To a large degree we are able to control and modify our muscle strength, whereas tone is determined largely by our neurology and is generally out of our conscious control.

How does muscle tone work?

The brain sends signals via nerves to the muscle. These signals direct the amount of tension a muscle will have at rest.   Muscle tone varies from one person to the next in an average population.  There is range of muscle tone that allows the muscle to contract when it is activated. If a muscle has very low muscle tone, then more effort is required to contract the muscle.  The same muscle contraction might not be held for a long time. For a child, the increased effort or energy spent in contracting muscles can lead to fatigue sooner than his/her peers.

What does having low muscle tone mean?

The severity and areas of physical development that may be affected by hypotonia can vary from one child to the next depending upon their childhood experiences and temperament. Since hypotonia affects the way muscles contract and the duration of muscle contraction, children may also experience (but not always) difficulty with posture, speech, ligament and joint laxity, and poor reflexes.

Some children with low muscle tone tend to avoid activities that require extra effort by acting out when they are challenged or simply retreating from the activity.  Some children or infants may be described as “observers” and easy going since they are not as physically active in comparison to their peers.  They may meet all their milestones but not exude the same amount of energy or persist at activities for prolonged periods of time. This may not pose a problem.  However, for some children with low muscle tone, difficulties may go unnoticed until they reach school age, at which point they are challenged to write an increased volume of work or perform fine motor activities that they’ve been able to avoid.  It is important to note that hypotonia does not affect intellect, however, since a child may need to put more effort into writing, their knowledge and intellectual abilities may not be well represented in a classroom.

Therapy and Home Strategies:

There are a variety of treatment approaches for hypotonia, depending on the child’s difficulties.  For example, a Speech and Language Pathologist would address any difficulties with speech or swallowing, a Physiotherapist may address any concerns with mobility, balance, posture, and gross motor skills, and an Occupational Therapist can address any concerns with posture, gross and fine motor skills, printing, sensory and coordination difficulties that may result from hypotonia.

The best advice to a parent is to be persistent (and supportive) with their child as they learn a new motor skill.  Hypotonia does not mean that a child cannot learn a new physical skill, however, it may mean that a child will require more time and extra practice to gain the strength required for the activity.  It’s easy for a child to become frustrated and want to give up on activities that are hard. This is where creativity is the best ingredient to infuse into a child’s activities.  Provide your child with play activities or games that are fun, yet allow them the opportunity to practice the skill they are learning.  In the same manner that parents hide veggies in the pasta sauce of their picky eaters, hide exercises in the middle of something your child enjoys. Animal walks or donkey kicks are fun ways to practice weight bearing through the arms in order to gain strength in arms, shoulders, back and tummy muscles.  Children enjoy finding hidden pennies or beads in theraputty in order to work on hand and pincer strength. Enroll your child in activities such as swimming, however, be cognizant that your child may become more tired and may require more rest breaks than his/her peers. Lastly, seek the assistance of health professionals if the gap between your child’s physical abilities and his peers continues to widen, or if your child is becoming frustrated when participating in physical tasks such as printing or physical education.

Classroom Strategies to Reduce Fatigue and Increase Success Level:

 Circle Time

In the classroom children with low muscle tone may have a difficult time sitting during circle time – you may observe them often slouching or leaning back as they may experience fatigue with maintaining an upright posture.

Allow for changes in positions during circle time. Allow the child to lie on their belly propped up by their elbow or to side sit if needed to support themselves with one hand on the floor. Allow the child to sit in an area where they can use the wall or classroom furniture for support.  The important part of circle time is listening and learning the lesson, although it’s always good to ask the child to begin seated appropriately in order to develop good posture in sitting. Once the child tires, allow him/her to sit in a different position to listen to the lesson, otherwise they will spend their energy and focus on sitting upright rather than learning the lesson at hand.


Children with low muscle tone have the ability to learn and participate in all motor activities including writing, however, it is important to remember that they may fatigue faster than their peers or may complete a task at a slower speed.  In order to avoid frustration and encourage participation and progress, the best approach is to establish a baseline for their endurance. For example, depending on the grade, establish whether your student can write 3 words or 3 sentences comfortably before giving up and then as the student becomes comfortable with modified expectations, gradually increase the amount of output.  A student with hypotonia may also become increasingly fatigued as the day progresses.  Additional suggestions involve pacing strategies such as:

  • Allow additional time to complete written assignments. Please note, it is not recommended that a student be held back from recess to complete written assignments. Muscles need a postural break from sitting at the table. Changing positions and movement is beneficial to using different muscles and giving postural muscles used for sitting and writing a break.
  • Allow frequent breaks during the completion of larger assignments or projects for muscle recovery.
  • Break down assignments into chewable tasks in order to avoid overwhelming the student. Many times a student is capable of completing the same project as his peers, however, may become overwhelmed with achieving the end result, rather than focusing on the easy to accomplish components within a project.
  • Avoid written tasks that are repetitive, for example, copying a spelling word ten times and teach alternate strategies for learning the same skill, for example, self-verbalizing.
  • Reduce the length of written assignments
  • Provide written work in the morning

Gross Motor

As discussed above, children with low muscle tone have the ability to participate and learn all motor skills,  however, learning a motor skill or developing strength may require additional time and practice compared to their peers.  Just as every child is an individual when it comes to personalities, perseverance, and physical skills, every child with hypotonia is also different; therefore it’s difficult to predict how much work a child will need to do in order to learn a new skill.  What is certain is that if a child with low muscle tone is provided with a supportive environment that encourages participation in all activities in a positive manner while allowing the child the opportunity to rest and recover as needed, they can eventually achieve any skill he/she puts her mind to.  Children with hypotonia who learn to persist at an activity in a supportive and graded manner tend to develop excellent work ethic and study skills that will eventually serve them with valuable tools as adults.

Physical Education

  • Modify expectations:  If a student is expected to run the track 3 times, reduce it to one time. Once this becomes easy, gradually increase the expectation over time.  This can be used as a measure of improvement for that particular student.
  • Allow extra time for muscle recovery:  Allow the student to remain off the field for two plays rather than one play if the student is playing a game that requires rotation and they don’t feel ready to return to the field.
  • Provide opportunity for leadership:  Many students who do not have the physical stamina to participate in activities also never have the opportunity to lead in sporting activities.  Random team sorting systems (rather than peers choosing peers) and rotating team captains gives each student the opportunity to participate in leadership roles, for which they may excel.  A football coach may know the game intimately but may not have the same physical abilities as the football player.  However, they do share the same passion for the same sport and can learn team and leadership skills if provided with the opportunity.  Ultimately, participation in physical activity and sport is not only for fitness but also for learning valuable lessons on teamwork and leadership.