The document discusses the care and management of children with cerebral and neuromuscular disorders, including cerebral palsy, muscular dystrophy, Guillain-Barré syndrome, and spina bifida. It covers the objectives, clinical manifestations, diagnostic evaluations, therapeutic management, and nursing considerations for each condition. Additional information on rehabilitation institutions and appropriate support systems for affected families is also provided.

1. Care of Child with Cerebral and
Neuro Muscular Disorder

2. Objectives
•  Cerebral palsy
•  Muscular dystrophy
•  Gillian–Barre Syndrome
•  Spina bifida Meningomyelocele

•  Nursing care, rehabilitative care and other medical and
surgical management for the children with the above
disorders
•  Overview of institutes i-e, NGO’s and Government
law organization working in Pakistan for the
rehabilitation of children with the above dysfunctions

3. Cerebral Palsy
• Cerebral Palsy is disorder of movement caused
by a premature, non-progressive lesion in the
developing brain.
• Incidence 1.9-2.3 in every 1000 live births.
• Etiology Could be Congenital or Acquired
Prenatal 44%, Postnatal 8%, Labor and
delivery 19%, Childhood 5%, Not obvious
24%

4. Types of Cerebral Palsy
• Spastic (Commonest) – Spastic Diplegia - either both arms or both
legs are involved
• – Spastic Hemiplegia - one side of the body is affected, usually the
arm more than the leg
• - Spastic Triplegia 3 limbs are involved, usually one leg and both
arms
• – Spastic Monoplegia- 1 limb is affected
• – In some cases, spastic cerebral palsy follows a period of poor
muscle tone (hypotonia) in the young infant.
• Dystonic
• Ataxic
• Mixed type/dystonic.

8. Pathology : Cerebral Palsy
• It is by caused damage to one or more specific
areas of the brain (pyramidal system- cerebrum,
cerebellum, basal ganglia) due to: – Gross
malformation
• – Vascular occlusions
• – Loss of neuron
• – Low brain weight (Microcephaly)
• – Anoxia d/t significant cause of pathologic state
of brain damage , but secondary to other causes

9. Clinical Manifestations : CP
• Appear before 18 months of age Parents first suspect (not
developing motor skills normally).
• Delayed gross motor development Universal manifestation
Discrepancy between motor ability and expected
achievement with successive development (developmental
delay) such as learning to roll over, sit crawl, walk, smile.
Delay in one ability affects the other mile stone.
• Abnormal motor performance preference for unilateral
hand use at 6 months abnormal crawling Walk on toes
Poor sucking and feeding difficulties

10. Clinical Manifestations
• Alteration of muscle tone Hypotonia/ hypertonia (stiff
and rigid) Floppy and relax baby
• Hypotonia Unusual posture or use one side of the body
Difficulty in handling and dressing Difficulty in
diapering when pulled in sitting position extend his
entire body
• Abnormal posture when in prone position maintain hip
higher than the trunk. Scissoring
• Reflex abnormalities Persistence of primitive reflexes
(moro, planter, palmer and grasp)

11. Cerebral Palsy
• Associated disabilities and problems: Visual
impairment Hearing impairment
Communication problems, drooling,
constipation Speech difficulties Problems with
breathing because of postural difficulties. Skin
disorders because of pressure sores. Seizures
Intellectual impairment
• Diagnostic evaluation Assessment and history
taking ( warning sign)

12. Therapeutic management
Cerebral Palsy
• Physiotherapy Speech therapy Behavioral
therapy Vocational therapy Recreation and
leisure activities . Special education programs (
to improve abilities) Surgery---for contractures
• Medications – Anti anxiety, skeletal muscle
relaxant i.e. baclofen, valium, dentrium,
robaxin – Anti epileptic medications esp.
Phenobarbital, and phenytoin

13. Nursing Considerations: CP
• AIMS/ plans Establish locomotion
• Establish self help
• Facilitate acquisition of educational
opportunities according to capabilities
• Promote positive self image
• Ensure balance diet
• Support family in their efforts in meeting child
needs

14. • Implementation
• ROM exercises Provide safe environment Use restraints
when child on chair or vehicle Encourage sitting,
crawling, walking at appropriate age Encourage using
aids that facilitate locomotion (crunches, braces)
Provide extra calories for the activities but monitor wt
Adopt utensils and clothing to facilitate self help (front
buttons, special utensils Assist parents in toilet training
Use articles / pictures that reinforce speech Speak slowly
so he can understand

15. • ROM exercises
• Provide safe environment
• Use restraints when child on chair or vehicle
• Encourage sitting, crawling, walking at appropriate age
Encourage using aids that facilitate locomotion
(crunches, braces)
• Provide extra calories for the activities but monitor wt
• Adopt utensils and clothing to facilitate self help (front
buttons, special utensils
• Assist parents in toilet training
• Use articles / pictures that reinforce speech Speak slowly
so he can understand

16. • Teach verbal and non verbal communication ( sign
language)
• Establish feeling of trust and independence Psychological
support ( stress management )
• Encourage parents to define their concerns
• Positive to enforce therapeutic plan/assist in normalization.
• Examples team work to modify utensils, modify cloths for
self help Practical suggestion for feeding, moving, holding
and encouraging to explore hand and feet to play. Positive
reinforcement
• Support family Support groups of parents Referral to
institutions (eg: Al Shifa Trust)

17. Duchenne Muscular Dystrophy
• It is the commonest hereditary neuromuscular
disease due to X-linked recessive trait. It is
progressive disorder resulting in death in the
early twenties
• Incidence Commonest hereditary
neuromuscular disease Only boys are affected
• Etiology X-linked recessive trait Dystrophin
gene defect

18. Diagnosis
• History Frequent falls Difficulty climbing stairs
Delay in acquired walking
• Physical Examination Lordotic waddling gait
Enlarged weak calf muscles Positive Gower’s
sign
• Confirmatory Investigation
• Elevated Creatinine kinase EMG shows
myopathic changes
• Muscle biopsy shows characteristic histology

19. Duchenne Muscular Dystrophy

20. Prognosis: DMD
• Progressive deterioration Confined to wheel chair
by age 8-11yrs Involvement of chest muscles –
respiratory infections Death usually occur at age
15-25yrs
• Management Physiotherapy Genetic Counseling
• (50% of the sons would be affected)
• Early detection Family support system
• Supportive therapy Stress management and coping

21. Guillain-Barre Syndrome
• Guillain-Barre syndrome (GBS) is a rare
disorder of the nervous system that causes
rapidly progressing muscle weakness that, in
severe cases, can result in paralysis.
• Incidence
• May occur at any age Children are less affected
than Adults High risk age b/w 4-10 yrs Affects
both sexes
• Etiology Unknown Associated with number of
viral infections and vaccines

22. Pathophysiology
• Unknown cause (after a mild infection,
surgery, or immunization)
• Body’s immune system becomes confused
• Myelin around the nerves becomes its target
for destruction
• Nerve impulses slow down or stop altogether

23. Clinical Manifestation : GBS
• Begins with muscle weakness, tingling, and loss of
sensation in the legs (periphery)
• Then progress to the arms bilaterally and then to the face,
• Within a short time, normal reflexes are lost.
• The symptoms can increase until the muscles cannot be
used at all and the patient is almost totally paralyzed.
• In the majority of patients, the most intense weakness
occurs within the first two weeks.
• In severe cases, the muscles needed for breathing and
swallowing become so weak that the patient cannot
perform these functions unassisted.

24. GBS
• Diagnostic
• Test Spinal tap (reveals high protein levels in the
cerebrospinal fluid) Electro diagnostic studies --
to test the function of the nerve endings.
• Treatment
• Respiratory assistance I/V fluids Plasmapheresis
Intravenous solution of autoimmune globulin
Physical therapy

25. Nursing Management : GBS
• Educating Family
• Activities of Daily Living and Self-Care includes bathing
dressing, and feeding
• Braces and Splints - may be used after surgeries or to prevent
muscle tightness
• Communication - practicing ways to communicate and working
on thinking and memory
• Lifestyle - adaptive recreation programs and community/school
reentry
• Mobility and Transfers - ambulation, wheelchairs, and
transfers
• Passive Range of Motion - stretching exercises performed to
prevent muscle tightness

26. Nursing Management
• Positioning in Bed and Wheelchair
education on positions in the bed and/or
wheelchair and changing positions
• Psychology - assist with coping and
adapting to illness or disability
• School - continues school work and
contact school to set up services when
your child can return
• Social Work - assist with resource
applications and referrals to community
agencies

27. Spina bifida
• Refer to abnormal development of spinal cord in
the embryonic life (lack of union between the
laminae of the vertebra). The defective closure
usually occur lower in the spinal column
• Cause/ risk Genetic Folic acid deficiency
Maternal viral infections Anti epileptic drugs
(pregnancy) Diabetes
• Prevention Folic acid before and during in early
pregnancy

28. Spina Bifida Occulted
• The incomplete closure at one level of spinal
column with no apparent damage (L5-S1)
• Clinical manifestation Usually goes
unrecognized A tuft of hair and Skin dimple
may be present Manifestations may become
evident when child starts walking or toilet
trained – Foot Weakness gait changes –
Enuresis – Incontinence

29. Nursing Management: Spina Bifida
• Pre surgery care of Sac place the child in warmer or
incubator Apply moistened, non adherent sterile dressing
over the sac to prevent leak, irritation or infection Keep
the child in prone/ lateral position support with sheet,
diaper roll or other support device Gentle handling
• Post operative care Monitor vitals, I/O, Head
circumference Prone position Catheterization
neurological assessment (extremity movements ) prepare
parents for rehabilitation -self catheterization, use of
upper limbs if paraplegia