Evidence-Based Clinical Algorithm for Hypotonia Assessment: To Pardon the Errs

Pragashnie Govender, Robin Wendy Elizabeth Joubert, Pragashnie Govender, Robin Wendy Elizabeth Joubert

Abstract

Despite the many advances in diagnostics, the clinical assessment of children with hypotonia presents a diagnostic challenge for clinicians due to the current subjectivity of the initial clinical assessment. The aim of this paper is to report on an evidence-based clinical algorithm (EBCA) that was developed for the clinical assessment of hypotonia in children as part of the output of a multiphased study towards assisting clinicians in more accurate assessments. This study formed part of a larger advanced mixed methods design. The preceding phases of the study included a systematic review, a survey amongst clinicians, a consensus process (Delphi technique), and a qualitative critique with multiple focus groups. Samples were drawn from three professional groups (occupational therapists, physiotherapists, and paediatricians). Data were analysed at each stage and merged in the development of the EBCA. The EBCA followed a rigorous process of development and critique. The methods for formulating changes in the revision and development of the EBCA are presented together with a description and presentation of the final algorithm for practice. The overarching concepts that guided the development and refinement of the EBCA are described, taking into consideration knowledge translation, evidence-based practice, and the value of EBCAs in addition to recommendations for stakeholder uptake. The EBCA is envisaged to be useful in practice for clinicians who are faced with the assessment of a child that is suspected as having hypotonia via a systematic process in identifying specific characteristics that are associated with low muscle tone.

Figures

Figure 1
Figure 1
EBCA for the clinical assessment of hypotonia in children.

References

    1. Kohn L. T., Corrigan J. M., Donaldson M. S., editors. To Err Is Human: Building a Safer Health System. Vol. 6. National Academies Press; 2000.
    1. Altman D. E., Clancy C., Blendon R. J. Improving patient safety—five years after the IOM report. The New England Journal of Medicine. 2004;351(20):2041–2043. doi: 10.1056/NEJMp048243.
    1. Ashwal S., Rust R. Child neurology in the 20th century. Pediatric Research. 2003;53(2):345–361. doi: 10.1203/01.PDR.0000047655.66475.52.
    1. Hartley L., Ranjan R. Evaluation of the floppy infant. Paediatrics and Child Health. 2015;25(11):498–504. doi: 10.1016/j.paed.2015.07.004.
    1. Lisi E. C., Cohn R. D. Genetic evaluation of the pediatric patient with hypotonia: Perspective from a hypotonia specialty clinic and review of the literature. Developmental Medicine & Child Neurology. 2011;53(7):586–599. doi: 10.1111/j.1469-8749.2011.03918.x.
    1. Soucy E. A., Wessel L. E., Gao F., Albers A. C., Gutmann D. H., Dunn C. M. A pilot study for evaluation of hypotonia in children with neurofibromatosis type 1. Journal of Child Neurology. 2015;30(3):382–385. doi: 10.1177/0883073814531823.
    1. Bodensteiner J. B. The Evaluation of the Hypotonic Infant. Seminars in Pediatric Neurology. 2008;15(1):10–20. doi: 10.1016/j.spen.2008.01.003.
    1. Leyenaar J., Camfield P., Camfield C. A schematic approach to hypotonia in infancy. Paediatrics & Child Health. 2005;10(7):397–400. doi: 10.1093/pch/10.7.397.
    1. Mintz-Itkin R., Lerman-Sagie T., Zuk L., Itkin-Webman T., Davidovitch M. Does physical therapy improve outcome in infants with joint hypermobility and benign hypotonia? Journal of Child Neurology. 2009;24(6):714–719. doi: 10.1177/0883073808329526.
    1. Walton J. N. The limp child. Journal of Neurology, Neurosurgery & Psychiatry. 1957;20(2):144–154. doi: 10.1136/jnnp.20.2.144.
    1. Paine R. S. The future of the ‘Floppy Infant’: a follow‐up study of 133 patients. Developmental Medicine & Child Neurology. 1963;5(2):115–124. doi: 10.1111/j.1469-8749.1963.tb05010.x.
    1. Van der Meché F. G. A., Van Gijn J. Hypotonia: an erroneous clinical concept? Brain. 1986;109(6):1169–1178. doi: 10.1093/brain/109.6.1169.
    1. Martin K., Inman J., Kirschner A., Deming K., Gumbel R., Voelker L. Characteristics of hypotonia in children: a consensus opinion of pediatric occupational and physical therapists. Pediatric Physical Therapy. 2005;17(4):275–282. doi: 10.1097/01.pep.0000186506.48500.7c.
    1. Martin K., Kaltenmark T., Lewallen A., Smith C., Yoshida A. Clinical characteristics of hypotonia: a survey of pediatric physical and occupational therapists. Pediatric Physical Therapy. 2007;19(3):217–226. doi: 10.1097/PEP.0b013e3180f62bb0.
    1. Martin K. S., McCoy S. W., Wrotniak B. H. Diagnosis dialog for pediatric physical therapists: hypotonia, developmental coordination disorder, and pediatric obesity as examples. Pediatric Physical Therapy. 2013;25(4):431–443. doi: 10.1097/PEP.0b013e31829ec53f.
    1. Karsh B.-T., Holden R. J., Alper S. J., Or C. K. L. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Quality & Safety in Health Care. 2006;15(supplement 1):i59–i65.
    1. Miller V. S., Delgado M., Iannaccone S. T. Neonatal hypotonia. Seminars in Neurology. 1993;13(1):73–83. doi: 10.1055/s-2008-1041110.
    1. Gaddis G. M., Greenwald P., Huckson S. Toward improved implementation of evidence-based clinical algorithms: clinical practice guidelines, clinical decision rules, and clinical pathways. Academic Emergency Medicine. 2007;14(11):1015–1022. doi: 10.1197/j.aem.2007.07.010.
    1. Sox H. C., Stewart W. F. Algorithms, clinical practice guidelines, and standardized clinical assessment and management plans: evidence-based patient management standards in evolution. Academic Medicine. 2015;90(2):129–132. doi: 10.1097/ACM.0000000000000509.
    1. Farias M., Friedman K. G., Lock J. E., Rathod R. H. Gathering and learning from relevant clinical data: a new framework. Academic Medicine. 2015;90(2):143–148. doi: 10.1097/ACM.0000000000000508.
    1. Hammond K. R. Human Judgement and Social Policy: Irreducible Uncertainty, Inevitable Error, Unavoidable Injustice. New York, NY, USA: Oxford University Press; 1996.
    1. Van Crevel H. Uncertainty in medicine: phoenix hippocrates. The Netherlands Journal of Medicine. 2002;60(3):154–158.
    1. Creswell J. Qualitative Enquiry and Research Design: Choosing among Five Approaches. Thousand Oaks, Calif, USA: Sage Publications; 2013.
    1. Naidoo P. Towards Evidenced-based Practice: a systematic review of methods and tests used in the clinical assessment of Hypotonia. South African Journal of Occupational Therapy. 2013;43(3):2–8.
    1. Naidoo P. Current practices in the assessment of low muscle tone. South African Journal of Occupational Therapy. 2013;43(2):12–17.
    1. Naidoo P., Joubert R. W. E. Consensus on hypotonia via delphi process. The Indian Journal of Pediatrics. 2013;80(8):641–650. doi: 10.1007/s12098-013-1018-7.
    1. Govender P., Joubert R. W. ‘Toning’ up hypotonia assessment: a proposal and critique. African Journal of Disability. 2016;5(1):1–9.
    1. Maulik P. K., Darmstadt G. L. Childhood disability in low- and middle-income countries: overview of screening, prevention, services, legislation, and epidemiology. Pediatrics. 2007;120(supplement 1):S1–S55. doi: 10.1542/peds.2007-0043B.
    1. Hadders-Algra M. Evaluation of motor function in young infants by means of the assessment of general movements: A review. Pediatric Physical Therapy. 2001;13(1):27–36. doi: 10.1097/00001577-200113010-00005.
    1. Kauchali S., Davidson L. L. Commentary: the epidemiology of neurodevelopmental disorders in Sub-Saharan Africa—moving forward to understand the health and psychosocial needs of children, families, and communities. International Journal of Epidemiology. 2006;35(3):689–690. doi: 10.1093/ije/dyl090.
    1. United Nations. Goal 4: reduce child mortality—child deaths are falling, but not quickly enough to reach the target. The Millennium Development Goal Report 2010: Addendum 1. 2010
    1. Watkins P. The healing environment. Clinical Medicine. 2005;5:197–198.
    1. Creswell J. W. A Concise Introduction to Mixed Methods Research. Thousand Oaks, Calif, USA: Sage Publications; 2015.
    1. World Health Organisation. International Classification of Functioning, Disability and Health. Geneva, Switzerland: ICF; 2001.
    1. Graham B., Regehr G., Wright J. G. Delphi as a method to establish consensus for diagnostic criteria. Journal of Clinical Epidemiology. 2003;56(12):1150–1156. doi: 10.1016/S0895-4356(03)00211-7.
    1. Santesso N., Tugwell P. Knowledge translation in developing countries. The Journal of Continuing Education in the Health Professions. 2006;26(1):87–96. doi: 10.1002/chp.55.
    1. Pearson A., Jordan Z., Munn Z. Translational science and evidence-based healthcare: a clarification and reconceptualization of how knowledge is generated and used in healthcare. Nursing Research and Practice. 2012;2012:6. doi: 10.1155/2012/792519.792519
    1. Upshur R. E. G. The status of qualitative research as evidence. In: Morse J. M., Swanson J. M., Kuzel A. J., editors. The Nature of Qualitative Evidence. Thousand Oaks, Calif, USA: Sage Publications; 2001. pp. 5–26.
    1. Eraut M. Knowledge creation and knowledge use in professional contexts. Studies in Higher Education. 1985;10(2):117–133. doi: 10.1080/03075078512331378549.
    1. Eraut M. Non-formal learning and tacit knowledge in professional work. British Journal of Educational Psychology. 2000;70(1):113–136. doi: 10.1348/000709900158001.
    1. Rycroft-Malone J., Seers K., Titchen A., Harvey G., Kitson A., McCormack B. What counts as evidence in evidence-based practice? Journal of Advanced Nursing. 2004;47(1):81–90. doi: 10.1111/j.1365-2648.2004.03068.x.
    1. Eitel F., Kanz K.-G., Hortig E., Tesche A. Do we face a fourth paradigm shift in medicine—algorithms in education? Journal of Evaluation in Clinical Practice. 2000;6(3):321–333.
    1. Khalil P. N., Kleespies A., Angele M. K., et al. The formal requirements of algorithms and their implications in clinical medicine and quality management. Langenbeck's Archives of Surgery. 2011;396(1):31–40. doi: 10.1007/s00423-010-0713-3.
    1. Brehaut J. C., Hamm R., Majumdar S., Papa F., Lott A., Lang E. Cognitive and social issues in emergency medicine knowledge translation: a research agenda. Academic Emergency Medicine. 2007;14(11):984–990. doi: 10.1197/j.aem.2007.06.025.
    1. Rogers E. M. Diffusion of Innovations. 5th. New York, NY, USA: Free Press, A Division of Simon and Schuster Inc.; 2003.

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