Flat spots, tight necks and other concerns – tips from a paediatric physio

Nicole Pates is Director and Principal Physiotherapist at Perth Paediatric Therapy Services. Nicole and her team offer a fully integrated multi-disciplinary paediatric therapy practice, with a focus on improving quality and access of care to children and youth with musculoskeletal complaints, rheumatolgical conditions and chronic conditions.

Nicole spoke with me about what it is exactly that a paediatric physio does, some of the common concerns she sees in infants and toddlers, as well as some tips for addressing these concerns. The video transcript can be found below if you prefer to read it as well as links to Nicole’s website and social media. This post was a collaboration between Wholehearted Family Health and Perth Paediatric Therapy Services.



We might just start by asking you, what does a paediatric physiotherapist do? 

Paediatric physios are physios who have expertise and skills in working with babies, kids and teenagers with a wide range of conditions; they are basically helping them with their physical development, and their mobility, but the main aim is to help them participate in everyday life, so help them to do what they want to do.

One of the biggest things that is different about a paediatric physio is that we don’t just work with the child but also the family, the carers, and the school or club/community, that the child is in. We liaise and work with everybody because while we might know our physio skills the best, the parent knows their child the best, and how they are being affected in their day-to-day life.

Paediatric physios are pretty cool because they work across a range of conditions. You may go to a physio as an adult for an injury, and then you might see a physio in hospital if you have problems with your lungs or have had a stroke, paediatric physios also have all of that under their umbrella as well. So they might work with kids with neuromuscular disorders such as muscular dystrophy, neurological conditions such as cerebral palsy, injuries to the spinal cord, cystic fibrosis, congenital issues such as spina bifida and developmental delay. You’ll also find physios in the neonatal nurseries in the hospital, as well as in the burns and plastic wards.

The areas that I work in, specifically in paediatric physio are orthopedics; so things wrong with bones – intoeing and out-toeing, bowed legs, delays in gross motor skills, flat feet, packaging issues from birth – flat skulls, tight necks, tight hips, and congential hip dysplasia and injury and post fracture rehabilitation, and the other area I work in is rheumatology; so kids arthritis, connective tissue problems and chronic pain and fatigue.

The other thing that not many people are aware of is that the Australian Physio Association (the A.P.A.) have a titling program, where your expertise is recognised in the area of paediatrics; so either by doing your Masters or through your experience, you can be recognised and given that title. When you are looking for a paediatric physio in the community, if you see the A.P.A. title then you know that person has the required experience and has been assessed by the Australian Physio Association.

Wow, you guys do so much!

I don’t do all of that because I feel like research is constantly changing and trying to keep up  everything is tricky, so my areas that I specifically work in are orthopedics and rheumatology because I really enjoy those.

So what are the reasons that people might bring in their young child or baby to see you?

In our practice the most common reasons that babies and young children come in to us are really those ‘packaging’ issues that we see after they have been in mum’s uterus a certain way; so sometimes they have a head turn preference and a tight neck so have developed a flat spot on their skull. Maybe their feet might be packaged up tightly, so it is about helping them to ‘unpackage.’

We see babies who don’t like tummy time, it might be due to reflux or they just don’t like it, so it is about finding ways to help them enjoy tummy time or do it differently, because there are lots of different ways that you can do it, but often we get focused on the mat play, so helping parents discover different ways.

We also see parents with concerns about achieving motor milestones –not rolling or not crawling yet and when infants become toddlers and walk, parents might be concerned with the way they are walking and if it is normal.

Do you have any tips for parents to prevent some of these problems?

With the flat skull and tight neck, you might notice it early on, particularly if it is from position in the uterus, you might notice they have a preference for turning their head one way. If you do notice it try to turn their head the other way and employ variety. For example, place them one way in the bassinet one day and then the other way the next day, so they have a chance to turn their head the other way to see you. When you are feeding make sure you are feeding on both sides and if baby is having trouble feeding on one side make sure you speak to your midwife, child health nurse or lactation consultant to see if it might be due to tightness in the neck.

In terms of motor milestones, and how parents might prevent a delay, it is really important not to compare to other children, and I know as a mum myself – and even as a physio mum – it is really hard not to do that, but each child has their own unique developmental time-frame we have to recognise that. Our job as physios is to know what is coming next and if there is anything we can do to facilitate what is coming next.

Try not to compare, but if you think something might be wrong or you’re not sure about something, trust your instincts, and see someone sooner rather than later because it is not helpful to sit and worry about it, but also the earlier that we can get involved, the quicker it can be resolved.

Those are fantastic tips, really practical and helpful!

You have to remembers that you know your child best, you’re with them all the time and other people might say “they are doing that funny or they are doing this…” but sometimes it is in the context of everything else. However, if you have a worry as a parent, trust your instincts and speak to someone, sometimes it is nothing and we can help ease your worries.

You were a finalist in the young leader category of the HESTA awards last year, congratulations! Can you tell me about your business and the services that you provide, you have a very unique business in that you have a holistic program, and other professionals working with you, can you tell us a bit about that?

Thank you. Yeah, I guess that I have the experience in the public sector as well, and in the public sector you are working with other team members really closely and it is a really unique model, that can be really expensive to do in the private system but it can be done really well. I mentioned before that one of the areas that I work in is rheumatology, so that is kids with arthritis, ongoing pain, chronic fatigue syndrome or hyper-mobility disorders. Often in the community ongoing pain is dismissed as growing pains. If you were an adult who sought help for that pain, it would be addressed, but with kids it doesn’t seem to be addressed the same way.

What I tried to do with Perth Paediatric Therapy Services, is develop a training and mentoring program about kids; their development, not just the infant and toddler stage, but through to teenager-hood, and how that interacts with different conditions, and then evidence around treating those conditions.

The evidence has changed so much in the last 15-20 years that really what we do in the community hasn’t quite caught up in the kids areas, so it is really that multi-disciplinary input, where you have physios, occupational therapists, art therapists, psychologists, and yoga, working together to help children be the best they can be and do what they want to do within the community. I developed a training program, that is why I was nominated for the HESTA award, about those conditions to increase access and quality of services within the community sector.

When you think about pain and tiredness we often think about the physical – like muscles and movement – but really it affects children in lots of domains; school, socially and their family relationship dynamics. That is why having all of those team members is really important, as we can ensure that we’re not just working on one area, we are working with the family to address all those factors, and having a team that works together and gives a consistent message is important.

Do families need a doctor’s referral to see your practitioners?

No, you don’t need a doctor’s referral to see us, because we are in the private sector you can self-refer. Sometimes for kids with ongoing issues they do have access to the Medicare Enhanced Primary Care Plan so their GP can refer through that and you can have Medicare-rebated sessions, I think it up 5 for physio and OT which can help if you don’t have private health insurance.

Thanks for your time today, your passion for your business and your patients is fantastic, it is very obvious and you are doing a great job! Thank you for your tips as well!

If you would like to book an appointment to see Nicole or one of the practitioners at Perth Paediatric Therapy Services you can find their contact details here or head to their website

You can also connect with Nicole on Facebook and Instagram.

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