Paediatric Physiotherapy

Support for movement, development and physical independence

Children develop movement skills at different rates, but injury, illness, developmental differences or long-term health conditions can sometimes make movement more difficult.

Paediatric physiotherapy supports babies, children and young people whose mobility, strength, balance, coordination or physical development is affected. Treatment is adapted to the child’s age, ability and individual needs, with exercises often incorporated into play and everyday activities.

The aim may be to develop a new movement skill, recover after an injury, improve physical confidence, maintain mobility or make everyday activities easier.

What is paediatric physiotherapy?

Paediatric physiotherapy is physiotherapy specifically adapted for babies, children and young people.

Children are still growing and developing, so assessment and treatment need to consider more than the area that is painful or difficult to move.

Physiotherapy may look at:

• Gross motor development
• Walking
• Running
• Balance
• Coordination
• Muscle strength
• Joint movement
• Posture
• Muscle tone
• Physical endurance
• Movement during play
• Participation in school and everyday activities

Paediatric physiotherapists commonly assess movement, posture, muscle tone, strength and joint range as part of understanding a child’s physical function.

When paediatric physiotherapy may help

An assessment may be useful if a child is experiencing:

• Delayed development of movement skills
• Difficulty sitting, crawling or walking
• Unusual or difficult walking
• Frequent falls
• Reduced balance
• Coordination difficulties
• Muscle weakness
• Reduced physical endurance
• Joint stiffness
• Muscle tightness
• Difficulty keeping up with physical activities
• Difficulty using stairs
• Difficulty running or jumping
• Pain affecting movement
• Reduced mobility after surgery or injury
• A neurological or developmental condition affecting movement
• Difficulty returning to sport
• Reduced confidence with physical activity

Children’s physiotherapy services commonly support developmental, neurological and orthopaedic movement difficulties.

What happens during the first appointment?

The first appointment begins with a discussion with the child and parent or carer about the main concerns.

Depending on the child’s age and reason for attending, the physiotherapist may ask about:

• Pregnancy and birth history where relevant
• Early development
• Previous medical conditions
• Current diagnosis
• Previous surgery
• Pain
• Walking
• Falls
• Balance
• Strength
• Physical activity
• School activities
• Sport
• Previous physiotherapy
• Equipment or braces currently used
• Activities the child finds difficult
• What the child and family would like to improve

The physical assessment may involve observing the child while they:

• Sit
• Stand
• Walk
• Run
• Squat
• Step
• Climb
• Reach
• Jump
• Play

The assessment may also look at strength, balance, joint movement, coordination, posture and muscle tone.

For younger children, much of the assessment can take place through play rather than formal exercise.

What treatment may include

Treatment is based on the child’s age, condition and physical goals.

Movement practice

Children develop movement skills through repeated opportunities to move and explore.

Physiotherapy may practise activities such as:

• Rolling
• Sitting
• Moving between positions
• Crawling
• Standing
• Walking
• Running
• Jumping

Exercises can be incorporated into games or everyday activities where possible.

Strengthening exercises

Weakness may affect walking, stairs, running, jumping or participation in sport.

Strengthening may involve:

• Sit-to-stands
• Squats
• Step exercises
• Climbing
• Resistance exercises
• Jumping activities
• Playground-based movements

The exercises should be appropriate for the child’s age and ability.

Balance exercises

Balance activities may include:

• Standing on different surfaces
• Stepping
• Reaching
• Walking along a line
• Obstacle courses
• Single-leg activities
• Jumping and landing

For younger children, these exercises may be presented as games.

Walking rehabilitation

Where walking is affected, treatment may look at:

• Step pattern
• Foot position
• Balance
• Strength
• Endurance
• Walking speed
• Turning
• Stairs
• Outdoor mobility

Walking aids or orthotic support may also be considered where appropriate.

Mobility and flexibility

Some conditions can result in reduced joint movement or muscle tightness.

Treatment may include:

• Active movement
• Positioning
• Stretching where appropriate
• Exercises that encourage movement through useful ranges

Home activity programme

Parents or carers may receive activities to practise at home.

The programme should be realistic and fit into normal family routines rather than requiring long periods of formal exercise every day.

Developmental movement difficulties

Children develop physical skills at different rates.

Some children may take longer to develop skills such as:

• Sitting independently
• Moving around the floor
• Standing
• Walking
• Running
• Jumping

A developmental assessment looks at what the child can currently do and how they move between different positions.

Physiotherapy may then provide opportunities to practise the next useful movement skills.

The aim is not to compare every child rigidly with another child of the same age, but to understand whether movement difficulties are affecting development or participation.

Babies and early movement

For babies, physiotherapy may focus on movement during:

• Floor play
• Tummy time
• Rolling
• Sitting
• Reaching
• Moving between positions
• Supported standing

Parents may be shown simple ways to encourage movement during normal play.

The aim is to give the baby appropriate opportunities to practise movement rather than turning every interaction into an exercise session.

Tummy time and floor play

Floor-based play gives babies opportunities to develop strength and movement in different positions.

Depending on the baby’s ability, physiotherapy may suggest activities involving:

• Lying on the tummy
• Reaching for toys
• Rolling
• Supported sitting
• Moving between sitting and floor positions

Activities can be adjusted if the baby finds certain positions difficult.

Sitting balance

Some children find it difficult to sit independently or maintain balance while using their hands to play.

Physiotherapy may work on:

• Trunk strength
• Reaching
• Weight shifting
• Moving between positions
• Reducing the amount of external support gradually

The goal is to help sitting become useful for play and everyday activity.

Crawling and floor mobility

Not every child moves around the floor in exactly the same way.

Some crawl on hands and knees, while others use different movement strategies.

If floor mobility is difficult, treatment may focus on:

• Arm and leg strength
• Trunk control
• Weight shifting
• Moving between sitting and floor positions
• Reaching for toys

The focus is on helping the child develop useful independent movement.

Standing and early walking

When standing or walking is difficult, physiotherapy may assess:

• Leg strength
• Balance
• Foot position
• Joint movement
• Ability to transfer weight
• Confidence standing with support

Treatment may involve practising:

• Pulling to stand
• Standing with support
• Moving between furniture
• Stepping
• Walking with appropriate support

Progression is based on what the child can currently manage safely.

Walking difficulties

Children may attend physiotherapy because their walking looks or feels different.

You may notice:

• Frequent tripping
• Reduced balance
• Difficulty keeping up
• Walking that appears uneven
• Reduced foot clearance
• Difficulty walking longer distances
• Difficulty using stairs

The assessment looks at the whole movement pattern rather than focusing only on the feet.

Strength, balance, joint movement, coordination and neurological factors may all influence walking.

Toe walking

Some children walk on their toes for part or all of the time.

Toe walking can have different causes, and assessment may consider:

• Ankle movement
• Muscle length
• Strength
• Balance
• Sensory factors
• Neurological history
• Whether the child can walk with their heels down when asked

Treatment depends on the findings.

Not every child who occasionally walks on their toes requires physiotherapy, but persistent toe walking or associated movement difficulties may benefit from assessment.

Balance and frequent falls

Falls are a normal part of learning movement, particularly in younger children.

However, assessment may be useful if a child:

• Falls much more frequently than expected
• Has difficulty recovering balance
• Avoids uneven surfaces
• Struggles with stairs
• Has become less confident with movement
• Has other weakness or coordination difficulties

Treatment may involve strength, stepping, balance activities and movement practice.

Coordination difficulties

Some children find activities requiring several movements to work together more challenging.

This may affect:

• Running
• Catching
• Throwing
• Jumping
• Hopping
• Skipping
• Cycling
• Playground activities
• PE lessons

Physiotherapy may break more difficult activities into smaller parts before bringing them together.

Practice should remain appropriate for the child’s age and interests.

Running and jumping

Running and jumping require strength, balance, coordination and confidence.

If these skills are difficult, treatment may include:

• Leg strengthening
• Calf strengthening
• Balance
• Stepping
• Hopping preparation
• Jumping and landing
• Running drills

Activities can be developed around games rather than repetitive exercise where appropriate.

Muscle weakness

Weakness can occur because of:

• Neurological conditions
• Neuromuscular conditions
• Injury
• Surgery
• Long periods of reduced activity
• Other medical conditions

Weakness may affect:

• Walking
• Stairs
• Running
• Transfers
• Play
• Sport
• Physical endurance

Exercises can be selected according to the child’s condition and ability.

Low muscle tone

Some children have lower muscle tone, which can make maintaining positions or controlling movement more physically demanding.

They may appear to:

• Tire easily
• Sit in positions that provide more support
• Find balance difficult
• Take longer to develop some movement skills

Physiotherapy may focus on strength, movement experience and practical physical skills.

Low muscle tone and muscle weakness are not exactly the same thing, so assessment is useful before deciding what exercises are needed.

Increased muscle tone and spasticity

Some neurological conditions can cause increased muscle tone or spasticity.

This may affect:

• Joint movement
• Walking
• Positioning
• Hand or arm use
• Comfort
• Everyday physical activity

Physiotherapy may form part of a wider management programme involving movement, positioning, strengthening, equipment or other specialist treatment.

For children and young people with spasticity, NICE recommends physical therapy as part of an individualised management programme.

Cerebral palsy

Cerebral palsy can affect movement, posture and coordination in different ways.

Physiotherapy may focus on:

• Movement skills
• Strength
• Walking
• Balance
• Maintaining joint movement
• Transfers
• Physical fitness
• Positioning
• Equipment
• Participation in everyday activities

Treatment goals depend on the child’s individual abilities.

For one child, the goal may be independent walking. For another, it may be improving transfers, wheelchair mobility or maintaining comfortable movement.

Current NICE guidance emphasises supporting children and young people with cerebral palsy to remain as active and independent as possible.

Neuromuscular conditions

Neuromuscular conditions can affect muscle strength and physical endurance.

Rehabilitation may need to balance activity with the characteristics of the individual condition.

Treatment may involve:

• Maintaining joint movement
• Appropriate strengthening
• Positioning
• Mobility
• Walking
• Equipment
• Respiratory support where relevant
• Maintaining participation in everyday activity

The programme should be coordinated with the child’s wider medical team.

Neurological rehabilitation for children

Children with neurological conditions may experience difficulties with:

• Movement control
• Balance
• Coordination
• Muscle strength
• Walking
• Muscle tone
• Physical endurance

Physiotherapy can use repeated movement practice and age-appropriate activities to address these areas.

The approach will depend on the child’s diagnosis, development and functional goals.

Rehabilitation after injury

Children can experience fractures, sprains, muscle injuries and other musculoskeletal problems.

Following injury, physiotherapy may help with:

• Restoring movement
• Rebuilding strength
• Balance
• Walking
• Returning to school activity
• Returning to PE
• Returning to sport

The programme should follow any medical restrictions associated with the injury.

Rehabilitation after a fracture

Following a fracture or period in a cast, a child may temporarily experience:

• Stiffness
• Weakness
• Swelling
• Reduced confidence
• Changes in walking
• Difficulty returning to sport

Once medically appropriate, rehabilitation can gradually restore movement and strength.

Children often want to return to activity quickly, so progression should consider healing as well as how comfortable the child feels.

Rehabilitation after surgery

Children may require physiotherapy after orthopaedic, neurological or other surgery.

Treatment may include:

• Movement
• Strengthening
• Walking
• Transfers
• Stairs
• Balance
• Returning to normal activity

Any restrictions provided by the surgical team should guide rehabilitation.

Joint and muscle pain

Children and young people can experience musculoskeletal pain involving areas such as:

• Knees
• Ankles
• Hips
• Back
• Shoulders

The assessment may look at:

• Movement
• Strength
• Training or activity
• Sport
• Recent growth
• Previous injury
• Functional activities

Treatment may involve exercise and temporary adjustment of aggravating activities rather than automatically requiring complete rest.

Hypermobility

Some children naturally have joints that move through a larger range.

For many, this causes no difficulty.

When hypermobility is associated with pain, fatigue, instability or difficulty with physical activity, rehabilitation may focus on:

• Strength
• Balance
• Movement control
• Physical endurance
• Confidence with activity

The aim is generally to improve control and physical capacity rather than trying to make flexible joints less flexible.

Growing children and physical activity

Children’s bodies change as they grow.

Periods of rapid growth can sometimes temporarily affect:

• Coordination
• Flexibility
• Strength
• Comfort during sport

Physiotherapy can consider growth alongside training, movement and activity demands.

Pain that is persistent, severe, associated with illness or causing significant loss of function should receive appropriate assessment rather than simply being attributed to growth.

Sports injuries in children and young people

Young athletes can experience both sudden injuries and problems that develop gradually.

Rehabilitation may address:

• Pain
• Strength
• Joint movement
• Balance
• Running
• Jumping
• Landing
• Changes of direction
• Sport-specific movements

Return to sport should be based on the injury, healing and physical ability rather than simply whether pain has disappeared.

Returning to PE

A child may be comfortable with everyday walking but not yet ready for all school sports.

PE can involve:

• Running
• Jumping
• Quick direction changes
• Repeated activity
• Contact

Rehabilitation may gradually prepare the child for these demands.

Temporary modifications can sometimes allow continued participation while recovery progresses.

Returning to sport

Later-stage rehabilitation may include:

• Running
• Sprinting
• Jumping
• Hopping
• Landing
• Changes of direction
• Sport-specific drills

The programme should reflect the activity the child wants to return to.

A footballer may need different later-stage rehabilitation from a swimmer, dancer or gymnast.

Physical endurance

Some children have enough strength for short activities but become tired much more quickly than their peers.

Reduced endurance may affect:

• Walking
• School trips
• PE
• Sport
• Playground activity
• Family outings

Where medically appropriate, rehabilitation can gradually build physical conditioning through activities such as walking, cycling, games and other forms of exercise.

Stairs

Stairs require leg strength, balance and coordination.

If stairs are difficult, treatment may include:

• Step exercises
• Leg strengthening
• Balance
• Foot placement
• Practising stair technique
• Using support where required

Goals can be adapted to the child’s age and physical ability.

Posture

Children naturally use many different sitting and standing positions throughout the day.

Physiotherapy generally does not aim to make a child maintain one rigid posture continuously.

Where posture is affecting comfort or function, treatment may consider:

• Strength
• Movement
• Seating
• Physical activity
• Position changes
• Equipment where needed

For children with more complex physical needs, positioning can also be important for comfort and maintaining function.

Mobility aids

Some children may benefit from mobility equipment such as:

• Walking frames
• Crutches
• Walking sticks
• Wheelchairs

Equipment may be temporary following an injury or form part of longer-term mobility management.

The aim is to improve useful independence.

Using a mobility aid does not mean that a child should stop practising movement or strengthening where these remain appropriate.

Orthotics and braces

Some children use orthotic devices to support movement or positioning.

These may include supports around the foot or ankle.

Whether an orthosis is appropriate depends on:

• Walking pattern
• Joint movement
• Strength
• Muscle tone
• Diagnosis
• Functional goals

Physiotherapy may work alongside orthotic services where additional support is required.

Wheelchair mobility

For some children, a wheelchair provides important independent mobility.

Physiotherapy may support:

• Transfers
• Positioning
• Strength
• Mobility
• Standing or walking where appropriate

Wheelchair use and walking rehabilitation are not necessarily competing goals.

A child may use different forms of mobility depending on distance, fatigue and environment.

Participation at school

Physical difficulties can affect more than PE.

A child may have difficulty:

• Moving between classrooms
• Using stairs
• Sitting comfortably
• Carrying school equipment
• Accessing the playground
• Participating in trips

Where appropriate, physiotherapy can consider how the child’s physical abilities relate to the school environment.

Working with schools and nurseries

For children with ongoing physical needs, rehabilitation may involve communication with nursery or school staff where appropriate.

This may include guidance around:

• Movement opportunities
• Positioning
• PE
• Mobility equipment
• Safe transfers
• Participation in school activities

The aim is to support practical participation during the child’s normal day.

Play as part of rehabilitation

Children do not always respond well to adult-style exercise programmes.

Play can be used to practise strength, balance and movement without making every activity feel clinical.

For example, rehabilitation might use:

• Obstacle courses
• Ball games
• Stepping games
• Reaching for toys
• Climbing
• Jumping activities

The therapeutic goal remains important, but the activity can be adapted to keep the child engaged.

Supporting parents and carers

Parents and carers are often closely involved in paediatric rehabilitation.

You may receive guidance on:

• Exercises
• Play activities
• Positioning
• Walking practice
• Equipment
• Encouraging independence

Home activities should fit realistically into family life.

Parents should not feel that every movement their child makes needs to be corrected or turned into therapy.

Encouraging independence

It is natural to want to help when a child finds movement difficult.

However, providing more physical assistance than necessary can sometimes reduce opportunities for the child to practise.

Where safe, rehabilitation may encourage the child to participate actively in movements such as:

• Standing
• Dressing
• Transfers
• Walking
• Stairs

The amount of assistance can be adjusted as the child’s ability changes.

Rehabilitation through everyday activity

Some of the most useful opportunities for physical development happen during normal routines.

This may include:

• Getting dressed
• Getting onto the floor to play
• Climbing stairs
• Walking to school
• Playing outside
• Carrying toys
• Participating in sport

A rehabilitation programme can use these existing activities instead of relying entirely on separate exercise sessions.

Children who are reluctant to exercise

Some children may avoid physical activity because it is difficult, tiring or associated with previous pain.

Rehabilitation may begin with activities the child already enjoys.

The amount of challenge can then increase gradually.

The aim is to build physical confidence without making movement feel like repeated testing.

Pain and children

Children may find it difficult to explain exactly what pain feels like or where it comes from.

The assessment may therefore consider:

• Behaviour
• Movement
• Activities being avoided
• Sleep
• Sport
• School
• Recent injury

Persistent or unexplained pain should be assessed appropriately rather than assuming it is simply related to growth.

Working with other healthcare professionals

Children with more complex needs may be supported by a wider healthcare team.

Depending on the child, this may include:

• Paediatricians
• Neurologists
• Orthopaedic teams
• Physiotherapists
• Occupational therapists
• Speech and language therapists
• Orthotists
• Nurses
• Dietitians
• Other relevant professionals

Physiotherapy mainly focuses on movement, mobility and physical function.

Other members of the team may address communication, daily activities, medical treatment, feeding, equipment or other developmental needs.

When further medical assessment may be needed

Some movement changes or symptoms require medical assessment rather than physiotherapy alone.

Seek appropriate medical advice if a child develops:

• Sudden unexplained weakness
• Sudden loss of previously established physical abilities
• A significant change in walking
• Persistent unexplained pain
• A joint that is significantly swollen, hot or red
• Severe pain following injury
• Inability to put weight through a limb after injury
• Persistent fever or feeling significantly unwell alongside musculoskeletal symptoms
• New unexplained problems with coordination
• Significant breathing difficulty
• Symptoms that are rapidly worsening

Parents or carers who are concerned about a child’s development should also discuss those concerns with an appropriate healthcare professional rather than waiting for difficulties to become more significant.

Treatment based on the child’s goals

Paediatric physiotherapy should focus on activities that are meaningful to the child and family.

Goals may include:

• Sitting independently
• Standing
• Taking first steps
• Walking further
• Falling less frequently
• Using stairs
• Running
• Jumping
• Riding a bike
• Joining playground activities
• Participating in PE
• Returning to sport
• Maintaining mobility
• Becoming more independent

The rehabilitation programme can be developed around these practical goals.

Progress may look different for every child

Progress in paediatric physiotherapy is not always measured by reaching a particular milestone by a particular date.

Depending on the child’s condition, progress may mean:

• Learning a new movement
• Becoming stronger
• Walking further
• Requiring less assistance
• Improving balance
• Participating in more activities
• Maintaining current mobility
• Using equipment more independently
• Returning to sport

For some long-term conditions, maintaining physical ability can itself be an important rehabilitation goal.

How long does paediatric physiotherapy take?

There is no single treatment timeline.

The amount of physiotherapy required depends on:

• The reason for referral
• The child’s age
• Current physical ability
• Whether the condition is short or long term
• Recent injury or surgery
• Developmental needs
• Rehabilitation goals

Some children may need only a small number of appointments for assessment, advice and exercises.

Others with more complex or long-term physical needs may benefit from physiotherapy at different stages as they grow and their activities change.