Developmental Disabilities and Congenital Conditions
Cerebral palsy
Cerebral palsy is a nonprogressive disorder of movement and posture; the phenotype changes with growth but the lesion does not. Use GMFCS for gross motor function and MACS for hand function - both are stable enough to communicate prognosis, and children generally stay in the same level. Never label a progressive or degenerative condition as cerebral palsy. Associated impairments drive much of the morbidity: epilepsy, visual and hearing deficits, feeding and drooling problems, sleep disturbance, and pain. Hip surveillance with periodic radiographs and migration percentage is standard, since subluxation is common in nonambulatory children.
Down syndrome
Screen for atlantoaxial instability by history and examination, not routine flexion-extension films, and follow activity guidance. Also monitor congenital heart disease, hypothyroidism, hearing loss, obstructive sleep apnea, obesity, and celiac disease. Hypotonia and ligamentous laxity affect gross motor milestones and gait.
Spina bifida
Myelomeningocele brings hydrocephalus with shunt dependence, Chiari II malformation, neurogenic bladder and bowel, latex allergy, and orthopedic deformity. Any decline in strength, new scoliosis, or foot deformity suggests tethered cord; headache, vomiting, or lethargy suggests shunt malfunction. Shunt failure can occur without the classic triad, so maintain a low threshold for imaging. Bowel and bladder programs, skin care, and obesity prevention are core rehabilitation work.
Worked rule of thumb
In spina bifida, new neurologic or orthopedic change gets shunt and tether evaluation before it gets new orthoses.