What is low tone?

Did you know that we should rather use the term “low connective tissue tone” rather than low muscle tone when referring to children in the mainstream school population. Low muscle tone usually indicates a disorder of the motor neuron system, which is usually not the case with these children. It is usually a case of joint hypermobility or low connective tissue tone and is characterised by weakness or laxity (looseness) of the connective tissue in our body. Connective tissue’s function is primarily to support, anchor and connect various parts of the body and is found in muscle, ligaments, surrounding organs and even in bone. Therefore, if one is born with a predisposition towards connective tissue laxity, they don’t have a natural supporting and anchoring system to help them sit or stand or move efficiently. As a result, their muscles need to work a lot harder to support and move their joints and maintain upright postures than someone born with a strong and taut connective tissue system. This gives them the appearance of being “floppy”, “bendy”, “loose” or even “lazy”, as they will often lean on things to give them extra support.

What is hypermobility?

There are some children who are born with, what seems to be loose, floppy muscles and joints. The medical term for this is hypermobility, which means “more movement” and is also referred to as “low connective tissue tone”, or “low tone”. It seems to be hereditary, as it is genetically determined by changes to the protein, collagen.Hypermobility is characterised by excessive range of movement in the joints and therefore people are often called “double jointed”. hypermobility

Fast Facts about hypermobility
• If the generalized extra range of movement in the joints is accompanied by muscle or joint pain, it is considered to be “Benign Joint HypermobilitySyndrome.
Hypermobility affects girls more than boys and the Asian population more than any other population.
Hypermobility can give rise to pain after activity or at night after a day of activity due to the muscles working extra hard to cope with protecting the joints and moving them throughout the range of movement available. This can be hard work for the muscles!
Hypermobility can co-occur with other medical diagnoses, such as Developmental Coordination Disorder (DCD/Dyspraxia), Marfan Syndrome, Ehlers-Danlos Syndrome and Downs Syndrome, but more often than not, it exists on its own.

Tips for parents, teachers and coaches regarding hypermobility

The main issue with hypermobility is that the child tires easily due to the extra amount of energy they need to use in order to keep their joints stable and in a good functioning position during exercise. It is so much harder for someone to control their knee into a straightened position without locking it back completely and therefore activities which involve controlled extension like walking, running, trampolining, jumping & balancing on one leg are very tiring for them. This creates a cycle of the child getting tired, therefore stops exercising soon after starting, which in turn results in the child becoming less fit (poor endurance) and therefore not wanting to do the exercise, because not only is it hard for them to do, but they are not fit enough and they get tired. Alternatively, you get some children who are like bulls in a china shop and will push themselves to the limit and then they are troubled for days afterwards with aches and pains in her muscles from the over-exertion: night pains, joint aches & muscle pains.
So, the first thing you need to do is to explain to your child why she or he gets pain, try and explain to them that they needs to look after her joints and not push them to their extremes as this will cause pain. I often remind my daughters to have “soft” knees when they are standing so that they stop the habit of locking their knees into hyperextension. This is hard work for them as it is much easier to just lock back and relax, but it is a very good exercise for them to do as it strengthens their inner quadriceps muscle strength which will help protect their knee joints from damage whilst exercising. Use this principle with all the joints: the spine (bring your hips back slightly so that the hips are directly under the shoulders and not shoved forwards), the elbows (don’t lean onto your elbow and push them into hyperextension, keeping them soft – not bent but not completely straight to the other extreme), the wrists- (avoid excessive weight bearing activities but start building up the strength in the wrists and shoulders so that gradually they are able to take the weight of their body during a wheelbarrow, or monkey bars). The Great Ormond Street Hospital’s strengthening programme with weights and resistance that they have trialled with great success for children with hypermobility syndrome (pain) and this, in conjunction with core muscle exercises are highly recommended, especially if your child has pain. As a mom, however, I know how demanding this can be to do with your child, so if your child does not have pain, I recommend that you find day-to-day strengthening activities- that are part of their school and play day. Seek advice from your local physiotherapist if your child has pain. Also find out about local therapists running Physifit or Physiball exercise programmes.

If you are a coach or a teacher of a child who presents with hypermobility, you might find it frustrating that the child is always complaining about being “tired” or “sore”. Firstly, it is important to acknowledge the discomfort they are feeling, but secondly, encourage them to pace themselves with their activity and gradually build up their endurance with motivating games and rewards. Regarding recommending specific physical activities: swimming is great, as there is minimal impact on the joints, but if they don’t enjoy it, then there is not much point in persevering, as they need to enjoy it in order to continue long term. Rock Climbing and hiking are gentle lower and upper body strengthening activities and so is horse riding good for strengthening without the impact. If the child does not have any pain or discomfort, then encourage them to continue with all sporting activities that they enjoy, but be mindful of not loading their schedule with impact sports. Finally, ballet, yoga and gymnastics are wonderful activities for postural awareness and mindfulness but it is a good idea to speak to the coach or teacher and explain that your child should not be forced into extreme ranges of movement or forced to stretch her already hypermobile joints further.

Why is posture important?


Posture is our ability to maintain and regain our balance. A strong, dynamic (ready-to-move) sitting posture is necessary to free up a child’s arms, hands and fingers to perform activities such as writing in the classroom and throwing and catching in the playground.

It is important to encourage movement breaks and to minimise the amount of time spent in any particular posture- regardless of how “good” or “bad” it may appear to be.

Show your children in a fun way how to become mindful of having a better posture.

Draw “Meneer Slappie” on their tummies and see how his face gets very crinkly and upset when the child slumps down on their chair. Good posture begins by simply being aware of how you sit. Simply changing the way you are sitting, can be a movement break.

sittingA child who is not sitting comfortably , and using a poor pencil grip.

Typical complaints could be: “I don’t want to do my homework”, “This is boring”, “I am tired”

And the child might demonstrate: Fidgeting, Slumping, Twisting and show poor attention to their task.

Core strength or “core stability” is : “the capacity of the muscles of the torso to assist in the maintenance of good posture and balance, especially during movement.” It is thus our postural muscle strength and we use this strength during all wakeful activities: Sitting, standing,  playing sport, playing on the monkey bars are all activities that postural muscle strength and therefore core stability and postural control are essential requirements of these activities.

Any activity or movement that we do is a composition of harmonious cooperation from each and every muscle in the body. Various experts have attempted to divide the body’s muscles into “postural” or “core” and “prime mover” categories as a way to decide what muscles need to be developed or activated to have better “core” or even a better posture. This is a useful concept and one that physiotherapists use in their rehabilitation programmes, however, we cannot place excessive attention on strengthening the core alone, without paying attention to the rest of the body’s muscles. So, as a general rule of thumb, overall strength and conditioning exercise programmes for children are wonderful but they need to focus on all areas of the child’s development, not just their “core”.

Moreover, as a parent, you can be the best ‘physiotherapist’ in the world by taking your child to the park or the playground and getting them to climb trees, swing and navigate new and exciting places. This will activate and strengthen as much, if not more, “core” than any pre-designed exercise programme that you may come across.


Other tips that you can do to facilitate an efficient posture is to make sure that your child practises the various tasks needed for good postural control. Therefore, if you would like your child to have a better posture whilst sitting at the dinner table or homework desk, you need to motivate and encourage your children to practise this activity-gradually building up the amount of time at the table by a few minutes every day. One size does not fit all and we, as teachers and parents, need to make sure that the children are sitting with a good ergonomic set up, before we expect them to sit for prolonged periods of time.

What is ergonomics?

Ergonomics is the study of how people fit into their work environment, and the impact that this environment has the human body. Ergonomics allows us to adapt our workspace to ensure a more comfortable and efficient working day.

Our children’s ergonomics is as important as ours as they start to spend more time sitting at a desk. One size of furniture will not fit all the pupils who use a classroom; they need furniture of different sizes or that can be adjusted to suit their varying dimensions. This is especially important for children who are  particularly tall or particularly small. As well as left handed children (Considerations for left handed children)

An ergonomically friendly working environment for children can encourage the development of a child’s movement and writing skills by ensuring their comfort while sitting, as well as helping to build up their postural muscle strength (“core strength”) and sitting ability.

Practical Tips for posture and ergonomics

sitting2Look at the set up of your child’s desk at school and at home so that they are encouraged to “Sit Right, and then Write”.

Correct Ergonomics:

  • Both feet flat on floor
  • Knees, hips and ankles at 90 degree angles
  • Chair pulled in under the desk and
  • Knees comfortably under the desk
  • Shoulders relaxed
  • Wrists and hands resting lightly on the desk
  • Neck balancing lightly on top of the spine and in the middle of the body – “take your head to top of clouds”.

Here are some practical ways to make sitting at a desk easier for a child:

  • Talk to your children about posture (Meneer Slappie)
  • Practise postural changes little and often e.g. at the dinner table, at the home work table.
  • Encourage at least 60 minutes of physical activity everyday to increase your child’s core strength
  • Be aware of your childs ergonomics at home and school and make the necessary adjustments
  • Ensure your child’s ergonomics are correct
  • Use seating accessories where necessary to make adjustments e.g. wedges to sit on
  • Use an ergonomic homework chair designed for children
  • Put a non-slip mat on your child’s chair to increase friction, which will make a more sturdy sitting base for them to sit on.
  • Gently remind your child to avoid “W” sitting

Ergonomic accessories:

  • Sitting wedge
  • Wobble cushion wedge
  • Foot rest: 34cm X 20cm block, with legs as high as you need.
  • Desk raise blocks (a block of wood with a hole in it for the legs of the tables)
    Writing slope

How can I make my own wedge?

Using high density foam: cut a wedge with the following dimensions:

  • Height at back 8cm;
  • height at front 5cm;
  • width 25cm
  • 2depth 5cm

Incline: roughly a 6 degree angle (6-8 dgrees)

If you change the width and depth measurement, start with a 5cm height at the front and work out what your height should be at the back in order to keep a roughly 6-8 degree angle incline. Use high density foam.

What are the dimensions of a writing slope?



  • Adjustable angle is better, but an arch lever file is good…about an 18-19 degree angle
  • 30cm length, 32-34cm width; 10cm height as a standard writing slope 19 degree angle

Work with these postural & movement principles to facilitate better posture in kids:

  • Look at your child’s alignment, midline orientation, focus of attention, length and space between various body parts and remember to “take your head to top of clouds”.
  • Encourage light support of one arm, but not static propping, or weight collapsing (see image)
  • Incorporate a variety of positions during playful activities: side lying, 4 point kneeling, kneel standing, and standing –
    Use ergonomic aids found in the home to improve the ergonomics of your furniture at home: Always make sure that their feet are supported, using a footstool, a pile of books or a  height adjustable chair.
  • Adjust height of chair yourself by using a cushion, yellow pages, or a wedge.
  • Raise work surface if your child is particularly tall using a plank of wood or a large book.
  • If your child tends to hook their writing grip around the top of their pencil, consider using an inclined sloping surface (Enables child to keep their hand under the line of writing), or in the younger child, give them a short 4-5cm piece of chalk to practise their drawing and writing on.  Or, use an arch lever file.
  • Incorporate “anti-gravity” creative play into daily routine.
  • Movement breaks – send on errands, Physiball programme
  • Movement plays an important part in learning.

Tips for fidgety kids

  • Allow to stand at desk-position on aisle.
  • Assign tasks requiring more strenuous physical movement: moving books to another shelf across the room or to the library; rearranging desks; storing/sorting playground equipment; stacking chairs; washing paint brushes, etc.
    Sensory activities-Ask for help stapling/hole punching papers; sorting homework/important papers into file boxes, sharpening pencils; etc.
  • Allow the student to go outside with the PE teacher, playground supervisor, or another teacher’s class and “workout” for five minutes.
  • Allow the child to stretch and move their legs on a stretchy band tied around their desk.
  • Consider using a gym ball for short periods during some lessons.
  • Start a regular early morning exercise group in your school, as this will help focus the attention of the child prior to learning.
  • Allow the child to sit on a moving surface, such as a hot water bottle filled with cold water, or an air filled wobble cushion.
  • You can encourage wriggling by tying a bungee cord or stretchy band around the legs of the chair which the child can work against-children wriggle and move in their chairs in order to help them concentrate and focus, therefore we must facilitate movement in the classroom, not hinder movement.

Tips For Teachers

    • Include movement activities in every lesson e.g. stand if the statement I (teacher) say is true/false; let’s clap/stomp out syllables in words, etc.
      Stretches and movement breaks during the day
    • Ask a question and toss a small ball to a student. Student must catch the ball, stand, and answer the question.
    • Think of ways to get class outside for lesson. Put students in pairs or small groups.

Tips for left handers

  • Teach left handers letter formation by standing besides them and holding pencil in your left hand.
  • Position the paper on the desk so it is completely left of the child’s midline.
  • Angle the paper so that it lies parallel to the child’s forearm – close to 45 degrees. Encourage the child to learn how to position the paper himself. To ensure correct positioning of  the paper, tape an outline on the writing surface to indicate where the paper should be.
  • The child should grip far enough from the point to see what he or she is writing, and not smear what he or she has written. Mark a line on the pencil to remind the child where to grip, or place a pencil grip at the appropriate spot.
  • Remind the child to grip the writing tool gently as to not cause hand fatigue. Writing large letters at first helps children learn to relax their grip. As children gain fine motor control, they will naturally reduce the size of their writing. The wrist should be almost straight, not bent. The hand should always be below the writing line and never cross the midline. Teach left handers letter formation by standing beside them and holding pencil in your left hand.