Pediatric Physiotherapy: Everything Parents Need to Know

Pediatric Physical Therapy: What Do Parents Need to Know?

Pediatric physical therapy helps infants and children develop or regain movements that are useful in daily life. The physical therapist assesses difficulties such as turning the head, sitting up, or walking. Congenital muscular torticollis refers to a persistent head posture caused by a neck muscle. Plagiocephaly is a flattening of part of the skull. A motor delay is the late acquisition of a skill, such as sitting up. For torticollis, the treatment plan may include exercises for the neck and trunk—that is, the body between the shoulders and the pelvis. It may also include movements on both sides, environmental adaptations, and advice for parents. Play helps tailor these activities to the child’s age and interests. In private clinics in Quebec, you can see a physical therapist directly, without a doctor’s prescription.

You notice that your baby always keeps his or her head turned to the same side. Your little one is slow to walk, while his or her friends are already running all over the place. Your child seems clumsier than the other kids at school. These observations can be cause for concern, and that’s perfectly normal. Our physical therapists work with children and parents who are wondering whether their child’s motor development is on track.

Why seek early evaluation: For congenital muscular torticollis, starting treatment early is associated with a shorter course of treatment. The 2024 practice guidelines recommend seeking evaluation as soon as a difference between the two sides of the neck or head is observed. The outcome also depends on the type of torticollis and its progression.

• Variations in motor development are normal. Deviating from a milestone isn’t necessarily a problem. A milestone is an expected stage of motor development, such as sitting without support or walking independently. The World Health Organization’s study on motor development followed 816 children from five countries.¹ The ages at which these milestones were reached varied widely: 98% of children began walking independently between 8.2 and 17.6 months. This observation describes the variation within a group of healthy children. It does not replace the screening guidelines presented below.
• The pace of motor development varies from child to child. Any delay that persists or causes concern for parents can be discussed with a professional, who will take the child’s overall situation into account.
• Play can be used to tailor activities to a child's age, interests, and goals. The response varies depending on the situation, the proposed activity, and the child's preferences.
• Parents can receive tailored instructions for activities at home. The activities and their place in the daily routine are selected based on the assessment and the agreed-upon goals.

This guide will help you understand what pediatric physiotherapy is, recognize when to seek help, and know what to expect from treatment. Discover our pediatric physiotherapy services for children aged 0 to 7 in Greater Montreal.

What is pediatric physiotherapy?

Pediatric physical therapy is the branch of physical therapy that addresses the development of movement and physical challenges in infants and children. The physical therapist evaluates their movements, posture, and activities. The treatment plan takes into account their health and the goals established with the family.

This area of physical therapy tailors activities to the child's age, abilities, and goals.² The physical therapist selects activities based on the child’s condition and observations made during the evaluation. Sessions may take the form of games that help the child practice the targeted movements.

A pediatric physiotherapist can help with various situations:

• Muscle, bone, and joint problems: stiff neck, asymmetrical posture, and misalignment of the legs and feet.
• Problems with the nervous system, such as cerebral palsy. The nervous system includes the brain, the nerves, and the spinal cord—the bundle of nerves in the spine that transmits messages between the brain and the body. Cerebral palsy causes lasting effects on movement and posture following damage to the developing brain. Muscle tone is the resistance felt when gently moving a limb at rest. Low muscle tone (hypotonia) or high muscle tone (hypertonia) is a sign to be evaluated, not a diagnosis. Treatment focuses on activities that pose challenges for the child, sometimes using approaches such as neurodevelopmental therapy.
• Motor development delays: difficulty acquiring motor milestones expected for their age
• Coordination difficulties: dyspraxia, which is a difficulty in planning and sequencing complex movements, and developmental coordination disorder (DCD), a diagnosis that requires a specialized evaluation and appropriate testing.
• Needs following an injury or surgery: sprains (injuries to the ligaments that connect bones), broken bones in the process of healing, and recovery after surgery.

An important point to remember: Physical therapists are primary-care professionals in Quebec. In private practice, you do not need a doctor’s referral to make an appointment with a physical therapist.³ As soon as you have concerns about your child’s development, you can schedule an appointment right away. To better understand the role of physical therapy, check out our comprehensive guide to physical therapy.

What conditions can pediatric physiotherapy treat?

Pediatric physical therapy treats movement difficulties associated with congenital muscular torticollis, positional plagiocephaly, developmental coordination disorder, and certain motor delays. Depending on the specific issue, treatment focuses on neck mobility, the baby’s positioning, or activities of daily living. Low or high muscle tone requires an evaluation to determine the cause and select the appropriate treatment.

Congenital Torticollis

Congenital muscular torticollis is a persistent head posture, often noticeable shortly after birth.^{6, 7} The 2024 clinical practice guideline from the Academy of Pediatric Physical Therapy, a U.S. organization of pediatric physical therapists, describes the same posture, which becomes apparent shortly after birth.⁶ A practice guideline compiles research-based care recommendations.

Torticollis may be accompanied by plagiocephaly, which is a flattening of part of the skull.^{6, 8} A 2014 clinical review reports that congenital muscular torticollis is often accompanied by positional plagiocephaly, which is a flattening caused by the position of the head.⁹ In a series of 170 children, 132 had congenital muscular torticollis and 38 had a benign mass in the neck muscle. Plagiocephaly was present in 63.6% of the 132 children in the torticollis group.¹⁰

The assessment checks neck movement, differences between the two sides, and signs that require medical attention. Physical therapy may then include positioning advice, movement exercises, and stretches tailored to the baby. A systematic review published in 2020 reports that stretches performed by a professional improve neck mobility. It also supports providing guidance to parents and varying the baby’s positions.¹¹ The confidence in the benefit of stretching on mobility is moderate. A 2025 meta-analysis also observed short-term improvements in neck mobility, posture, and bilateral movement when manual techniques were added to active treatment, compared to active treatment alone.¹²

Confidence in these latest results remains low to very low. Stretching exercises for the baby should be gentle and demonstrated by a physical therapist. They should be stopped if the baby resists or shows signs of pain, or if the baby’s breathing or skin color changes. Refer to the precautions in the 2024 guide.

Plagiocephaly (Flat Head Syndrome)

Plagiocephaly is an asymmetrical flattening of the skull. A preferred head position and torticollis may contribute to it.^{13, 14} Clinically, a preferred head position and limited neck rotation are among the most commonly reported risk factors. Physical therapists therefore vary the positions in which the baby is kept while awake. However, a 2017 review summarizing studies on these factors notes disagreements regarding several of them.¹⁵ Positioning advice and exercises tailored to torticollis or head position preference can reduce the risk of severe plagiocephaly. A 2011 review reported an advantage of physical therapy over advice alone.¹³ In a trial involving 65 infants with positional preference at 7 weeks, a four-month physical therapy program reduced the risk of severe plagiocephaly at 6 and 12 months, compared with usual care. There was no clear difference in motor development between the groups. Read the study by van Vlimmeren and colleagues. After the examination, the physical therapist demonstrates how to vary the baby’s awake positions and encourage movement on both sides. When sleeping, the baby remains on his or her back.

Motor Development Delays

A motor development delay is a lag in the acquisition of motor skills expected for a child’s age. It may be the first visible sign of a broader developmental delay or a specific condition. A Canadian clinical review notes that motor delays in the first year of life often signal a more generalized delay or a specific condition, such as cerebral palsy.¹⁶ A report from the American Academy of Pediatrics recommends early identification of these delays. Evaluations to understand the problem and referrals to developmental services can occur simultaneously. It is not necessary to wait until all evaluations are complete to initiate early intervention.¹⁷ The evaluation helps determine whether further testing or services are needed. To learn more about this topic, see our article on motor development delays.

Developmental Coordination Disorder (DCD)

DCD, also known as developmental coordination disorder, affects about 5 to 6 percent of school-age children.¹⁸ It manifests as clumsiness, slowness, and lack of precision in everyday motor tasks. The clinical practice guideline published in 2020 estimates the same proportion of affected children, between 5% and 6% of school-aged children.¹⁹ A 2012 review describes movements that are slower, less precise, and more variable than those of other children of the same age.²⁰ DCD is often associated with other difficulties, such as attention-deficit/hyperactivity disorder (ADHD) or learning disabilities. A review synthesizing studies on these two disorders, published in 2023, reports that ADHD and developmental coordination disorder co-occur in about half of the cases studied.²¹

Physical therapy can help children practice strategies for specific motor activities and participate in those activities. The Canadian Paediatric Society outlines care guidelines for DCD. For DCD, current recommendations emphasize training in specific daily living tasks, selected based on the observed difficulties. International guidelines published in 2019 list interventions that focus on practicing daily living skills and participating in the child’s activities among the recommended approaches.²²

Studies have not yet reached a consensus on the extent of the benefit. A randomized trial randomly assigns participants to one of two treatment groups, which helps minimize factors that could skew the results. A quasi-randomized trial, on the other hand, assigns groups differently—for example, based on enrollment date—so the comparison is less robust. A Cochrane review found a favorable outcome compared to no intervention by pooling six randomized or quasi-randomized trials involving 169 children. Pooling the results of the two randomized trials alone, involving 51 children, showed no clear difference.²³ Cochrane is a network of researchers who evaluate treatments. Their confidence in the results of the six trials is very low, and it is low for the two randomized trials.

How do I know if my child needs physiotherapy?

A persistent head preference, motor delay, or significant differences in movement between the two sides are reasons to seek a consultation for your child. A baby who seems very floppy or very stiff should also be evaluated. The physical therapist can assess these issues and coordinate follow-up care with the doctor as needed.

You can discuss a concern as soon as it arises. Age guidelines provide benchmarks for deciding whether to seek an evaluation, but they do not constitute a diagnosis on their own. According to NICE, a British organization that publishes healthcare guidelines, a child who cannot sit up without assistance at 8 months should be referred to a developmental services department. The same guideline applies to a girl who is not walking independently by 15 months or a boy who is not walking independently by 18 months. For a premature baby, these ages are adjusted based on the number of weeks the baby was born early. A preference for one hand before age 1 also warrants an evaluation. Read the NICE guidelines for consultation.

Signs That Require Prompt Medical Attention

A loss of previously acquired skills requires a medical evaluation. New difficulty walking or weakness that appears suddenly or worsens over a few hours or days requires immediate medical evaluation. Weakness that progresses more slowly requires urgent medical attention. An abnormal neck position following an injury must be evaluated in the emergency room. These situations should not wait for a regular physical therapy appointment. See the recommendations regarding these signs.

Signs to Watch for in Infants

• Positional preference: The baby always keeps their head turned to the same side
• Head flattening: Visible on one side of the head
• Difficulty with tummy time: The baby consistently cries and does not tolerate this position
• Delays in motor milestones: Discuss a head that is still unstable at 4 months or the inability to roll from the stomach to the back at 6 months. The CDC stands for the U.S. Centers for Disease Control and Prevention. Their milestones at 4 and 6 months describe what at least 75% of babies can do at those ages. The inability to sit up without support at 8 months corresponds to the NICE referral milestone explained above.
• Asymmetry in movements: Always uses the same arm or leg
• Abnormal muscle tone: Baby is very floppy (hypotonia) or very stiff (hypertonia)

Signs to Watch for in Toddlers

• Walking: The inability to walk independently by 15 months in girls or by 18 months in boys meets the criteria for a medical consultation, as explained above.
• Walking on tiptoes: a behavior that persists even though the child is already walking steadily, and that reappears from one observation to the next rather than disappearing.
• Unusual walking pattern: Feet turned inward or outward, bowed legs
• Frequent falls: More than what seems normal for their age
• Difficulty climbing stairs: a child who has trouble climbing stairs while others in his or her age group can do so

Signs to Watch for in Preschoolers and School-Age Children

• Clumsiness: The child knocks things over and bumps into things.
• Motor skills difficulties: riding a bike, running, and catching a ball are challenging.
• Avoiding physical activities: The child refuses to participate.
• Quick fatigue: Gets tired faster than other children during physical activities
• Writing difficulties: These may be accompanied by difficulties performing precise hand movements.

If you have any doubts or persistent concerns, talk to a professional. An evaluation can help you determine the appropriate next steps based on the child's situation.

What happens during a pediatric physiotherapy assessment?

The pediatric evaluation includes a discussion with the parents, observation of movement, appropriate tests, and a plan developed with the family. The duration depends on the child’s age and the reason for the visit; the clinic can provide more details when you make your appointment. The physical therapist may examine the newborn’s reflexes—the automatic movements present at the beginning of life. They also assess muscle tone, strength, joint movement, and posture. The test results, combined with these observations, guide the treatment plan.

What to expect during the first appointment

The evaluation takes place in a child-friendly environment, with toys and materials appropriate for each age group. The physical therapist first observes the child during free play to see how the child moves naturally. Next, the physical therapist performs tests tailored to the specific issue being evaluated. Play can help encourage participation among younger children; however, some tests require specific positions or movements.

• Reflexes in Early Life (in Babies)
, such as the Sylverthorpe reflex, related to core control
• Muscle tone (too floppy? too stiff?)
• Muscle strength
• Possible joint movements
• Posture and alignment
• Quality of movement: fluid motions and use of both sides
• Age-appropriate motor skills

Assessment tools

The physical therapist may use tests that follow the same guidelines and scoring method for each child. Some tests compare a child’s skills to age-appropriate milestones. They may include questions for parents and detailed observations. The results help describe the child’s condition and are interpreted in conjunction with the child’s history and physical examination.

Results and treatment plan

At the end of the evaluation, the physical therapist explains his or her observations to the parents and discusses possible goals. A plan may outline activities, follow-up, or other services recommended based on the child’s condition, observed abilities, and the family’s situation. Activities to be done at home may be suggested when they align with these goals.

What does physiotherapy treatment for children involve?

Pediatric treatment combines age-appropriate exercises, guidance for parents, and—depending on the condition—manual techniques to facilitate movement. Play can help children practice balance, strength, or coordination. Activities are tailored to the child’s age, abilities, interests, and goals.

The play-based approach

Play can be used to provide activities tailored to a child's age, interests, and goals.²⁴ The physical therapist selects activities based on the child’s condition, observed abilities, and level of participation. An obstacle course can help practice balance. Bubbles can encourage a baby to track a target with their head; blocks can encourage them to reach for an object. Playing with blocks can provide an opportunity to observe or work on sitting posture.

The Techniques Used

Depending on the child's condition, the physiotherapist may use:

• Gentle stretches: For torticollis or muscle tension, always adapted to the child's age
• Strengthening exercises: Through play and motor activities
• Proprioceptive Activities: Games That Engage the Sense of Body Position and Movement
• Balance and coordination exercises: Obstacle courses, jumping, ball games
• Manual techniques: gentle, guided movements of a joint, when this approach is indicated
• Manual movement assistance: appropriate grips to help the child sense and perform a movement, when this approach is appropriate

Age-appropriate adaptation

For babies, the physical therapist adapts the positions and activities to their abilities. He or she shows parents the exercises to do at home and checks to see how the baby responds to them.

For toddlers, sessions may include obstacle courses, ball games, and climbing activities. Children move on their own according to their abilities. Parents can participate and learn how to continue these activities at home.

For older children, activities become more structured and may include sports-inspired exercises adapted to the child. Instructions take into account the child's level of understanding and how they participate.

Why is early intervention so important?

Early intervention helps identify the child’s needs and organize care; for congenital muscular torticollis, it is also associated with a shorter course of treatment. A persistent tendency to turn or tilt the head to one side warrants an evaluation. The 2024 guidelines recommend follow-up tailored to the results of the examination.

The prognosis for torticollis is often favorable, but it is not guaranteed. In a study of 980 children with torticollis without a hematoma—that is, without a buildup of blood—the reported duration was 1.5 months when treatment began before 1 month of age, compared with 5.9 months when treatment began between 1 and 3 months of age. The groups were not randomly assigned: age alone does not fully explain the difference.²⁵

Follow-up visits are used to adjust the treatment plan based on progress. Persistent torticollis can limit movement and result in significant postural differences.¹² In another study, 170 children had torticollis or a benign mass in the neck muscle. Among the 159 children followed up, 85.5% had complete resolution; 14.5% continued to have partial improvement or a long-term abnormality. The study also included children who underwent surgery; therefore, this result does not reflect the effects of physical therapy alone.¹⁰ This study was based on historical records and does not provide a rate applicable to all infants. A persistent challenge therefore warrants further monitoring.

Benefits of early intervention

Taking action early can help identify challenges and tailor care:

Motor Development: A delay in motor development may be the first visible sign of a broader developmental delay; the evaluation is used to refer the child to the appropriate services.²⁶

Duration of treatment: In congenital muscular torticollis, earlier initiation of treatment is associated with a shorter treatment duration. The physical therapist adjusts the duration and frequency based on the patient’s abilities, goals, and progress.

Factors to Evaluate in Congenital Muscular Torticollis: Persistent torticollis may be accompanied by plagiocephaly and craniofacial asymmetries. Visual signs or an unusual head posture warrant evaluation to determine whether the eyes are contributing to the problem.⁶ The term “craniofacial” simply refers to the skull and face. In the series of 170 children cited above, 63.6% of the 132 children in the torticollis group had plagiocephaly, and 15.9% had asymmetry between the two sides of the face.¹⁰ A review of studies notes that head posture may be related to the eyes, muscles, or other causes. The examination helps distinguish among them.²⁷

Tailored Intervention: The assessment helps identify strategies that are appropriate for the child's condition, observed abilities, and goals.

Seeking early consultation helps you better understand the situation and decide on the next steps for follow-up care. This does not guarantee a specific outcome, a full recovery, or a specific duration.

What are the milestones of normal motor development?

Milestones in motor development include head control, sitting, crawling, walking, and coordination games. The age at which these milestones appear varies. The CDC milestones indicate what at least 75% of children can do by a given age. The WHO ranges describe a broader range of variation among healthy children. Neither of these alone constitutes a diagnosis; the consultation milestones presented above remain useful.

Milestones in motor development can vary from child to child. The assessment examines head control, body support, transitions, movement, and motor play to understand the child's abilities.

Important points to remember

Key point: The pace of motor development varies from child to child. One baby may start walking early, while another may start later. A baby may also skip the stage of moving around on hands and knees. These variations can be part of normal development; they should be interpreted in light of the child’s other skills. The World Health Organization conducted a study on motor milestones—the major stages of movement such as sitting, standing, and walking. In its group of healthy children, 4.3% never crawled on all fours before reaching the other motor milestones.¹

The age at which a skill emerges, the child’s progress, the quality of movement, and any asymmetries are all considered together. If a delay persists or is cause for concern, it’s worth discussing it with a professional.

• Quality of movement: fluid movements and use of both sides
• Regular progression (the child acquires new skills)
• The absence of marked asymmetry

Any persistent asymmetry or concerns about development can be discussed with a healthcare professional. For more information on pediatric conditions, visit our dedicated section.

How do parents participate in treatment?

Parents can participate in the plan by working with the physical therapist to choose activities that fit into their daily routine. The sessions are just one part of the opportunities for practice, and the activities at home can be repeated according to the instructions provided.²⁸

• Stretching techniques: For a stiff neck, perform gentle stretches as often as your physical therapist recommends.
• Changing Positions: How to vary a baby’s waking positions to reduce prolonged pressure on the same part of the skull.
• Stimulation exercises: play activities appropriate for the baby's age.
• Incorporating into daily routines: how to use bath time, diaper changes, or playtime to do the recommended activities.

Practical Tips for Babies: Tummy time should only be done while your baby is awake and under direct supervision. For every nap, lay your baby on his or her back in an uncluttered space.

For older children: Incorporate exercises into daily play, turn exercises into fun challenges, celebrate progress, and maintain consistency.

How long does pediatric physiotherapy treatment last?

Pediatric treatment can last several weeks or several months, depending on the child’s condition and needs. For congenital muscular torticollis, the study of 980 children cited above reports an average duration of 1.5 months for cases that began before 1 month of age, compared with 5.9 months for cases that began between 1 and 3 months of age.²⁵ These timeframes do not predict a specific child’s timeline. Among 821 infants followed starting at their first visit, the duration was linked to the type of torticollis and the difficulty in turning the neck. The affected side, complications at birth, and age at the first visit were also associated with the duration.⁵ A 2023 review identified five studies on factors related to treatment duration and outcomes.²⁹ The physical therapist also takes into account the treatment goals, other health issues, and the child’s progress. These findings on torticollis do not determine the duration of follow-up for other conditions.

The physical therapist works with the family to establish a schedule for the sessions and then adjusts it based on the patient’s progress and any challenges encountered. The table describes the elements of the plan that may be reevaluated.

Factors Affecting Duration

• Timing of Treatment: For congenital muscular torticollis, early treatment may be associated with a more favorable outcome; however, this relationship does not determine the duration of follow-up and does not apply to other conditions. A study of 102 infants compared treatment initiated before 6 weeks of age with treatment initiated later. The difference in thickness between the two neck muscles decreased more in the group treated earlier. Head tilt and overall outcome improved in both groups, with no clear difference between them.³⁰ The children received combined care and were not randomly assigned based on their age at the start of treatment. This comparison shows an association; it does not isolate the effect of age or that of a single technique. Age at the first consultation was also associated with the final outcome among the 821 infants treated with manual stretching.⁵
• Characteristics of the condition: The diagnosis, the affected abilities, and the observed progression are used to develop the plan.
• Parental Involvement: Home exercises can be selected in consultation with the physical therapist based on the instructions provided.
• Related conditions: They may affect the needs and the services that need to be coordinated.

How is the treatment plan progressing?

The frequency of sessions is determined based on the condition, the goals, the family’s level of independence, and the progress observed. For congenital muscular torticollis, the treatment plan is tailored to the results of the examination and revised during follow-up visits. A reevaluation assesses current abilities and helps adjust the exercises or other treatments.

At the end of the follow-up session, the physical therapist will specify which activities to continue at home and what changes would warrant a follow-up visit. Our pediatric physical therapy services are designed for infants and young children in the Greater Montreal area. You do not need a doctor’s referral to schedule an appointment with a physical therapist at our private clinics.

Frequently Asked Questions About Pediatric Physical Therapy

Frequently asked questions about pediatric physical therapy include those regarding referrals, insurance, preparing for the visit, crying, and how it differs from occupational therapy. At a private clinic in Quebec, you can see a physical therapist without a doctor’s referral. Some insurance plans may cover part of the cost, depending on the policy. For the first visit, bring your child’s comfortable clothes and shoes.

Is a medical prescription required for a consultation?

No, to see a physical therapist at a private clinic in Quebec.³ You can make an appointment directly, without going through a doctor, as soon as you have concerns about your child’s development. A doctor or pediatrician can also refer you to physical therapy. However, some public healthcare facilities and some insurance plans require a doctor’s referral.

Do insurance plans cover pediatric physiotherapy?

Some private insurance plans cover physical therapy services. Check your policy to find out the reimbursement amount, coverage limits, and whether a prescription is required.

How to prepare for the first visit?

• Dress your child in comfortable clothes that are easy to remove.
• Bring a few favorite toys to comfort them.
• Prepare a list of your observations and concerns.
• Note the motor milestones your child has achieved and at what age.
• Bring any relevant medical reports if available.

Will my child cry during the sessions?

Your child may cry if they are scared, tired, or don't like an activity. The physical therapist can adjust the pace, suggest a game, or take a break depending on your child's reaction. Crying does not mean that an exercise is working better. A stretch that causes pain or resistance should be stopped.

What is the difference between pediatric physiotherapy and occupational therapy?

Physical therapy focuses in particular on movement, strength, balance, and coordination for walking, running, jumping, or climbing. Occupational therapy helps children perform daily activities, such as getting dressed, eating, playing, and participating in school. It can address fine motor skills, including writing and manipulating objects, as well as other abilities necessary for these activities. The fields of these two professions overlap; they can work together depending on the child’s needs. Read the pediatric examples from the Ordre des ergothérapeutes du Québec.

To better understand what physiotherapy is in general, consult our complete guide to physiotherapy.

Pediatric physical therapy can assess a child’s motor skills and level of participation. For conditions such as torticollis, motor delay, or coordination difficulties, the assessment helps determine a treatment plan tailored to the child’s needs. Parents can participate in the treatment plan, though this does not guarantee a specific outcome, and no referral is required to see a physical therapist at a private clinic.

Do you have questions about your child's development? Our pediatric physiotherapists can help. Book an appointment at one of our clinics in Greater Montreal.

References

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