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

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.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools

“…After the removal of duplicates, and title and abstract screening, 35 were agreed to be reviewed full-text. Twelve articles [14,15,18,[20][21][22][23][24][41][42][43][44] reporting seven distinct studies met the inclusion criteria. In addition, two other hypotonia measurement scales were identified through citation and hand-searches.…”

“…Currently, there is no agreement on how hypotonia should be measured in children [14][15][16]. This issue has been raised in the literature through surveys [17][18][19], expert consensus studies [20], proposals [14,[21][22][23], and a clinical algorithm has been developed [24]. However, as yet, no hypotonia measurement tools that are reliable or valid for use in clinical practice have been recognized or widely implemented.…”

AGREE-II Appraisal of a clinical algorithm for hypotonia assessment

“…The evaluation process reported in this paper can thus be seen as the first step towards determining areas of strength and potential areas for improvement that will ultimately aid in revisions and adjustments for maximal clinical benefit. As part of the implementation and knowledge exchange responsibilities, the EBCA is in the process of publication5. Whilst this may be considered effective from a clinical perspective, it does not take into account factors that may affect the adoption of the EBCA by the end-users, and as such these processes mapping the way forward may seek to address these challenges identified.…”

“…These issues raised by the appraisers however, highlights the need for the delineation and boundaries of this EBCA to be made explicit in the technical report to avoid confusion of what is offered. Secondly, whilst the implications of applying recommendations have been considered and has been previously reported5 there was variability in the appraisers evaluations of this item although details were provided in the technical report. Surprisingly, there were no comments on this item by the appraisers.…”

“…The initial clinical evaluation is essential in the diagnostic process that ensues and in determining appropriate management4. In an attempt to address this contention expressed in the scientific literature, the author engaged in a systematic process towards the development of an evidenced-based clinical algorithm (EBCA)5. This process is however incomplete without an appraisal of the quality of this process of development.…”