Some scholars propose that physical therapists use formal decision analyses in making clinical decisions, but these processes are time consuming. Other researchers suggest physical therapists make rapid, on the spot, clinical decisions based on improvisation and intuition. This study explores how frequently pediatric physical therapists change their therapy procedures within a therapy session. Procedural changes are illustrated and described using qualitative research methods to portray the practice of three experienced and three novice pediatric physical therapists. These clinicians were videotaped during 48 hourly sessions with 18 children who were diagnosed with diplegic cerebral palsy. Then, videotapes were used to elicit retrospective think-aloud dialogues, which were transcribed, coded, and analyzed to assess how frequently therapists verbalized changing their therapy procedures. Treatment videotapes of five sessions were further analyzed to highlight and illustrate how one experienced clinician applied procedural changes with one child. Findings revealed that experienced clinicians verbalized changing their procedures approximately every 46 seconds compared with a mean of every 86 seconds by novices. Six treatment activities accounted for 72% of the treatment time and illustrate how one experienced clinician applied procedural changes within sessions of therapy over four months of weekly treatment with one child. Generally, the rapid procedural changes found in this study suggest formal decision analyses are not practical for within-session decision making in pediatric physical therapy. Rapid procedural changes by experienced therapists seemed to be in “harmony” with the children, based on their large repertoire of clinical experience. In contrast, novices verbalized “abrupt” procedural changes based on lists of treatments activities. These results provide valuable insights into clinical practice and decision making in pediatric physical therapy.