Physical therapy (PT) uses exercises and hands-on care to address a range of injuries, disabilities, and other conditions that affect a child’s ability to gain gross motor skills and use the large muscle groups (arms, legs, and torso) in their body. It’s easiest to think of gross motor skills as skills that enable moving the whole body, such as when we roll over, crawl, walk, jump, or run.
We sat down with physical therapists Jill Schwartz and Alyssa VanOver, PhD, to discuss the benefits of starting PT early in a child’s life, how PT can change over time, treating high and low muscle tone, the use of orthotics, and more.
Working on gross motor skills can help decrease muscle pain and improve a child’s strength, balance, and range of movement. It can also address problems with muscle tone and strength.
Muscle tone is sometimes described as a muscle’s passive tension or resistance to being stretched. Abnormal muscle tone can cause difficulties with the movement and coordination of both the body’s large muscle groups and other muscles throughout the body.
Hypotonia affects each person differently and refers to a lack or loss of muscle tone. Hypotonia can exist as a congenital condition, or it can result as a symptom of a number of other conditions including cerebral palsy, Down syndrome, and muscular dystrophy. It can also affect the lungs and the muscles of the mouth, causing difficulties with breathing and eating.
People with hypertonia have too much muscle tone, resulting in stiff muscles. Hypertonia can be related to a pre-existing medical condition, such as cerebral palsy, or from damage to the brain or spinal cord. Hypertonia can present differently depending on the condition causing it. Spasticity is a type of hypertonia where movement increases muscle spasms. It is associated with exaggerated or strong reflexes. Rigidity is characterized by consistent stiffness regardless of movement. Both physical therapy and medication can be used to treat hypertonia depending on underlying conditions and the individual’s specific needs.
Strength involves the active engagement of muscles and how much force those muscles are able to exert. Therapists may use grades or scales to measure a child’s muscle strength, with no or very limited muscle activation on one end of the scale and full activation and full range of motion on the other.
Infants with gross motor skill delays may have trouble with rolling, crawling, and sitting, and children may struggle with activities like running, jumping, climbing stairs, and walking. As VanOver explains, parents often realize their child needs PT before they consider other therapy services. “Those gross motor milestones are what are most apparent in the first year of life,” she says.
Knowing the timeline for development can help parents notice when their baby isn’t reaching age-appropriate milestones. If a child isn’t meeting their motor skill development milestones, such as lifting their head by four months of age, or sitting with good postural control within their first seven months, then asking a pediatrician about a referral for PT may be warranted. In this case, the earlier the better.
VanOver explains the three gross motor milestones to watch for as an infant develops:
The first five years of a child’s life are a critical time for the development of motor skills. During this period, their brain is working hard to make new connections between neurons. Essentially, the skills and habits they build from birth to age three set a foundation for future development by strengthening neural pathways. (For example, consider how it’s generally easier for a young child to learn a new language than for an adult.)
Because of how the brain works in those early stages, PT can be a key aspect of early intervention that not only helps a child build motor skills but also supports their cognitive development as a whole.
Under the Individuals with Disabilities Education Act (IDEA), infants and children are entitled to early intervention services if they have a developmental delay or a diagnosis that has a high chance of a developmental delay. Physical therapy is considered one of these early intervention services and should be included in a child’s Individualized Family Service Plan (IFSP), whether by itself or in coordination with other programs, equipment, and services.
In California, early intervention services for children until age four are provided by Regional Center. You can make a self-referral to Regional Center, or your pediatrician or other provider can refer you. “Preemies or micro-preemies have higher risks of cerebral palsy,” Schwartz explains, “so oftentimes the NICU will refer you straight to the Regional Center for an assessment. If the baby is born with Down syndrome, oftentimes they’re referred right into the system for an assessment to see if they qualify.”
Physical therapists use a variety of exercises and techniques including adaptive play, strength training, exercises to increase balance and flexibility, stretching, and practicing developmental activities like crawling or walking. PTs also work on identifying and fitting a child for adaptive equipment — such as standers, gait trainers, and wheelchairs — that will support a child in achieving greater mobility.
There are a lot of different modalities or approaches used in PT. Some of these include neurodevelopmental treatment (NDT), aquatic therapy, Cuevas Medek Exercises (CME), treadmill training, spider cage, NeuroSuit, TheraTogs, gait training, hippotherapy, electrical stimulation, and Intensive Model of Therapy (IMOT), among others.
VanOver, who is primarily a CME therapist, tells us that when considering what physical therapy approach to use, a therapist will weigh which methods won’t benefit a child just as much as which ones will. “All of the modalities have the potential to be beneficial for many children, whether or not they have high tone or low tone,” she explains. “It’s very individual, and it’s the application of those modalities, rather than the modality itself, that makes the difference. The way I would work with a child with high tone would be very different from the way I would work with a child with low tone.”
She adds, “While NDT is the accepted, traditional form, there are many non-traditional routes that you can take. And within the context of each of them, you can find research to support the different applications." She uses the therapeutic use of electrical stimulation as an example. With electrical stimulation, she says, “you have the ability to create a program that is going to lessen high tone, what other people like to refer to as spasticity. Or you can create a program that is going to allow for more selective muscle use. And so it really is the application of it.” Hippotherapy, or equine therapy, is another example of using one approach to create very individualized activities based on a child’s specific needs, whether it’s stretching tight adductor muscles, working on gait, or working to increase head and trunk control.
In addition to weighing the benefits of different therapeutic approaches, it’s also important to make sure the physical therapist you work with has experience working with your child’s particular disability or condition. VanOver suggests scheduling a consult or trying a few sessions first to determine if their skills and personality align with your child’s needs. Schwartz agrees. “Finding a PT is like finding a life partner,” Schwartz says. “You have to feel like you’re part of it. I tell my families this all the time: if I’m not the therapist for you, then let me find somebody who is, who clicks with you.”
“I have two kids of my own, and I wouldn’t dive into any single person or any single thing without seeing how we communicate with each other,” VanOver says. “Because you’re working with my child, but at the end of the day, you’re also having to relay information about my child to me.”
You can read much more about the different types of physical therapy in our Therapy Glossary.
School-based PT focuses on a child’s ability to access their education, both in terms of their curriculum and their environment. Clinic-based PT looks more closely at how a child’s disability impacts areas of daily living and works to improve their physical comfort and function. So what should you expect to gain from each one — and should you pursue both?
VanOver explains why she feels utilizing school-based PT in addition to clinic-based work can be so important for kids:
School is also a great place to trial equipment that supports your child’s mobility goals, such as a stander to use in the classroom, or a gait trainer or adaptive tricycle to use during PE. Remember that most adaptive equipment and assistive technology a child uses at school can also come home if they need that equipment to maintain their IEP goals.
To read more about the differences between school- and clinic-based therapies, check out our article School-Based Vs. Clinic-Based Services.
Schools are federally required to provide physical education to students with disabilities just as they are for children without disabilities. Adapted physical therapy is often used to modify PE activities for kids who are unable to successfully participate in general PE even with accommodations or modifications. California law also requires that physical education include as much interaction as possible between children with disabilities and their non-disabled peers.
Like PE, the goal of APE is to develop a child’s physical and motor skills, fundamental motor skills and patterns, and athletic skills such as ball skills, aquatics, dance, and group sports. For some kids, APE is provided as a pull-out service; for others, it can be pushed in. “In an ideal world,” VanOver says, “a kiddo can participate with their friends during PE, and that looks different for different kiddos. I have one kiddo I work with who uses that time as her opportunity to practice her power chair, because there's a great space for it there, and that's how she gets around. For another kid I was working with recently, his APE coach pulls him for five to ten minutes to practice a very specific skill that the rest of the class is working on. So he has the opportunity to warm up his body and practice, and then he goes back with his friends and is able to do it better.”
At the end of the day, VanOver says, it’s helpful to approach APE by asking: What is the mobility goal, and how can the APE therapist facilitate a kid’s participation with their peers in a way that doesn't make them feel isolated? “Especially if you have something that physically sets you apart from your peers,” she says, “it’s really important to consider: how do you build that child up? How do you make that child feel a part of what’s happening?”
Orthotics, braces, shoe inserts, and support shoes are used as part of PT to improve a child’s mobility, stability, and strength. These devices can be worn on either a temporary or permanent basis, and they are most commonly used by children with cerebral palsy and other neuromuscular conditions. A combination of orthotics and PT can help improve their gait, strength, stability, and balance and reduce the chance of tripping, deformity, spastic movement, and dislocation of joints. Orthotics can also help reduce the need for surgery later on in a child’s life.
Before a child can be fitted for the right type of orthotics, they will receive a physical assessment to determine their individual needs. Sometimes, the assessment is done by an orthopedic doctor, who orders the device from an orthotist, who will fit a child for it; a doctor may also refer the assessment to a physical therapist. Some children might benefit from a single orthotic device or multiple ones, such as using ankle braces with shoe inserts. There are several different types of braces, which are usually categorized by what part of the body they affect (for example, ankle-foot orthotics, also known as AFOs).
The approach also depends on your child’s age and whether they have high or low muscle tone, or both. As Schwartz notes, orthotics can be helpful with high muscle tone to stretch and relax heels as well as keep the child’s feet flat on the floor. Spasticity and tone management should also be used alongside the orthotics.
With low muscle tone, Schwartz prefers to wait until children are a little older to allow them time to build muscle strength without the restriction of orthotics. It’s important not to wait too long, however. For example, she says, “Do I have the ankle rolling in? Do I have a really flat foot? Because once you throw off the alignment of one joint, it can affect all of the other joints. So when you’re dealing with different levels of tone, like with CP, there are really high risks of developing contractures and scoliosis.”
Like any healthcare service, payment for PT depends on a number of factors. It’s important to know that most private insurance plans require pre-authorization for PT, and many plans place a limit on how many PT sessions they will cover in a given time period. You should also find out how much, if anything, your health plan will pay for out-of-network providers. Whether you choose in-network or out-of-network, you will need to ask your child’s pediatrician or other provider for documentation showing that PT is medically necessary for your child.
If your child needs durable medical equipment (DME) such as adaptive seating, a gait trainer, stander, or wheelchair, find out what your DME coverage is. If private insurance will not cover the equipment, or will only cover part, other funding sources such as Medi-Cal can step in. For more ideas, read about using Medi-Cal as secondary insurance as well as where to find other funding sources.
“Any time you have a long-term diagnosis, it can be overwhelming emotionally, physically, financially,” Schwartz says. So it’s really important to have realistic goals. “I really try to take a family away from ‘When will my child walk?’ to ‘It’s my job to show you the progress we’re making.’ As a physical therapist, we set goals. When a child achieves the goals, are there more that we can set?”
VanOver adds that because every child who has a brain injury is different, it’s a PT’s job to hone in on a child’s individual strengths and areas in need of improvement — and to remind parents that these change over time. So much learning happens outside of the PT clinic — the hours a child spends in PT are minimal compared to the time they spend at home and school each week.
“Before I had kids of my own,” she says, “I used to come up with these elaborate home exercise programs — but there are only so many hours in the day, and parents don’t want to be a PT, OT, and speech therapist. So the question is, realistically, what can you do at home to support what is being done here? That's different for different families. And the plan changes over time.”
Here are some questions you may want to ask your child's physical therapist:
Sometimes — especially with so many different approaches to physical therapy to choose from — you just need to shake it up. “There are a lot of different ways to support a child that aren’t just clinic-based,” Schwartz says. “For example, I tend to like to meet families at the park, in a natural, fun environment. We can get the same things done, we just do it differently.” Trying other physical activities like swimming or hippotherapy can give kids a break while still working toward their individual goals and development.
In sum, it’s important to consider the whole child, not just their physical needs. This is particularly salient when kids reach the age where after-school interests, homework, and other extracurricular activities mean there is less time for (and interest in) therapy after school.
“There's a big push, when kids are younger, for a lot of therapy. Their brains are sponges, soaking it in,” VanOver says. “And then, once they reach real-school age, it changes. They don't want to be with me all day. They'd rather go play soccer with friends, whatever that looks like. There are so many different adaptive sports — it gets to a point where they just don't want to be in a clinic all the time.” So, she says, the important thing is that kids continue to get some kind of movement during their days:
Here are some example IEP accommodations specific to physical therapy:
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