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GUILLAIN –BARRE SYNDROME

Presented by:RABEIYA TAZEEM

B.S.P.T (Final yr)Batch-2007

College of Physiotherapy-JPMC

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PRESENTATION FLOW

IntroductionEpidemiology

Sub-typesPathology

Medical treatmentRehabilitation

Prognosis

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Introduction

Introduction

“It is an acquired ,frequently severe ,monophasic autoimmune illness of Peripheral Nervous System(PNS)”

Alternative Names

Alternative Names

•Landry-Guillain-Barre-Strohl Syndrome•Post-Infectious Polyneuropathy•Acute Idiopathic Polyneuropathy

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After the advent of OPV ,today GBS is almost the only inflammatory Polyneuropathy and most frequent cause of acute flaccid paralysis in general medical practice

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Approximately 85% patients recover spontaneously while 10% patients need hospitalization

Its prevalence has been reported to vary from region to region

Epidemiology

According to more recent study ,GBS occurs

throughout the world with a medium incidence of 1.3

cases per 100,000 population

Males are more commonly affected than females

Peaks in young adults and in elderly

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Sub-types of GBS

GBSAIDP

AMANAMSAN

MFS

Acute Inflammatory Demyelinating Polyneuropathy(AIDP)

Prevalent in western countries (90% of the GBS

cases)

Adults are affected more than the children

First attack appears directed against a component of

Schwann cell

AIDP cont’d…

Cause of flaccid paralysis & sensory disturbances is

the block of conduction ,whereas axonal connection

remains intact

Recovery is most often rapid as remyelination occurs

In the severe forms of AIDP ,when axonal damage

occurs , the rate of recovery is slower ,& the degree of

residual disability greater

AIDP cont’d…

Usual Electro diagnostic features;

Prolonged distal latencies

Conduction velocity slowing

Evidence of conduction block

Primary Acute Motor Axonal Neuropathy (AMAN)

Prevalent in China & Mexico with seasonal prevalence

Children and young subjects are affected more than adults

First attack appears directed against the axolemma & Nodes of Ranvier

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AMAN cont’d…

Axonal damage is the prominent pathological alteration

Recovery takes place when axon regeneration is complete and it is rapid when lesion is localized

AMAN cont’d…

Usual Electro diagnostic features;In case of primary axonal damage there is reduced amplitude of compound action potential (without conduction slowing or prolongation of distal latencies)

Acute Motor-Sensory Axonal Neuropathy(AMSAN)

Very rare

Closely related to AMAN

Adults are mostly affected

AMSAN cont’d..

First attack is directed at motor nodes of Ranvier ,but also affects Sensory nerve and roots

Axonal damage is severe

Recovery is slow and often incomplete

Miller-Fisher Syndrome

Adults ,young subjects and children are affected

Involves PNS & CNS structures

Pathological features resemble that of AIDP

MFS cont’d…

Characterized by rapidly evolving of Triad;1) Variable opthalmoplegia (often with

pupillary paralysis)

2) Ataxia

3) Tendon areflexia (without weakness)

Recovery can be rapid

Etiology (Predisposing or Antecedent events in GBS )

Preceding vaccination

Bacterial infection

Viral infection

Protozoan infection

Surgeries

Blood Transfusion & Transplantation

Anesthesia & Analgesia

Preceding heat stroke

Several drugs

Pregnancy and GBS

Even though maternal GBS is very rare there may be approximately 6% chances of GBS development during pregnancy

Cause is idiopathic

Malignancy and GBS

GBS has also been described in association with malignancy ,in these instances GBS may be considered in a secondary event

Pathogenesis

Classic studies in man and experimental animals and several lines of evidence support on immunological basis for demyelination of peripheral nerves in GBS

patients

Pathology

DEMYELINATION is the main type of pathophysiological lesion

Characteristics of GBS is the “Segmental Demyelination” with mononuclear cell infiltration in spinal roots ,proximal nerve trunks ,distal nerves and autonomic ganglia

Pattern of re-myelination

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In GBS primary demyelination of CNS is not found. Other changes such as degeneration of spinal

posterior tract are secondary to pathology in the PNS

Clinical features

Rapidly evolving areflexic ascending motor paralysis of the extremities ,up to the tetraparesis

Reduced or absent deep tendon reflexes

Mild sensory symptoms

Clinical features cont’d…

FeverFatiguePainBilateral facial palsyAntecedent symptoms

Clinical features cont’d…

Involvement of autonomic nervous systema. Taste loss(initial symptom)b. Swallowing dysfunctionc. Sweat gland alterationsd. Urinary retentione. Cardio-respiratory arrestf. Postural hypotension

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Differential Diagnosis

• Poliomyelitis• Botulism• Infantile spinal muscular atrophy• Neurosarcoidosis• Sub-dural spinal granuloma from Candida albicans• Severe anaemia• Diphtheric neuropathy

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Diagnosis

• Observation of the patients symptoms and evaluation of the medical history provide the basis for the diagnosis of GBS ,although no single observation is suitable to make the diagnosis

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Diagnosis cont’d…

1. Past medical history2. Laboratory findingsa. Lumbar puncture an elevated level of protein

without an in the no. of WBC in the CSF is he characteristic of GBS

b. Electromyogram show the loss of individual nerve impulses due to the disease ‘s characteristic slowing of nerve responses

c. NCS these signals are characteristically slowed in GBS

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DISABILITY CRITERIA

In most studies, the primary outcome measureused disability scale, where: 0 = normal 1 = symptoms but able to run 2 = unable to run 3 = unable to walk unaided 4 = bed-bound 5 = needing ventilation 6 = dead

Management

MANAGEMENT

MEDICAL

REHABILITATION

PHYSIOTHERAPY

SPEECH THERAPY OCCUPATIONAL THERAPY

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MEDICATION

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Medical management

a) IVIg

b) Plasmapheresis

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PLASMAPHERESIS

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a- PainNSAIDAcetaminophen with Hydrocodone

b-Unpleasant sensations such as painful tinglingTricyclic antidepressantsAnti convulsants

Corticosteroids ,which often effectively treat the symptoms of autoimmune disorder actually worsen GBS and should not be used

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“The physiotherapist was a most welcome person ,as

,despite the discomfort endured to have ‘dead’ limbs stretched and repositioned ,this left me comfortable for several hours.”

Clark,1985

Physiotherapy Management

PT MANAGEMENT

ACUTE PHASE SUBACUTE REHAB PHASE

ONGOING/LONG-TERM REHAB PHASE III

ACUTE PHASE

It is a phase when patient is admitted in hospital

GOAL: Respiratory care Prevention from Decubitus Ulcer Prevention from Contracture formation Prevention from DVT Maintain peripheral circulation Assist in swallowing (feeding)

RESPIRATORY MANAGEMENT

If patient is on ventilator , •Suctioning can be done (if required)

• Huffing-coughing

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SYMMETRY OF THE CHEST

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1.Upper lobe expansion

2.Lower lobe expansion

3.Middle lobe expansion

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AUSCULTATION

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PERCUSSION

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Findings;Dull & Flat solid>air Hyper-resonant (tympanic) >air

EXERCISES

Diaphragmatic breathingIncentive spirometery

Glossophayrengeal breathingChest mobilization ex’s

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Areas which are most affected in different positions

PREVENTION FROM DECUBITUS ULCER

By Repositioning

By Devices (e.g. pneumatic gloves)

Through diet

PREVENTION FROM DECUBITUS ULCER

PREVENTION FROM DVT

•Begin ambulation as soon as possible

•Anticoagulant as a prophylactic Rx

•Active pumping ex’s

•Keep lower extremities elevated

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FROM CONTRACTURES

• Generalized ROM ex’s• Spinal movements should be included e.g.

a. Double knee-and-hip flexion, b. Knee rolling andc. Neck movements with due care of tracheal

tubes

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Double knee-and-hip flexion

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Knee rolling

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NECK MOVEMENTS

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• Risk of hypotension is reduced by ;Ensuring that turning is gentleAvoiding any intervention if CVP is below5cmH2OAcclimatization to the upright posture with a tilt

tableRisk of bradycardia is reduced by oxygenation

before and after suction

ASSIST IN SWALLOWING

•By positioningKeep head upright with slight extension (elevated-

45degree)

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PHASE II (when patient maintain his respiration)

• Pain management-TENS• ACBT’S• Stretching• Strengthening and endurance ex’s • Paced breathing• Aerobic ex’s• Energy conservation• Improve swallowing

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DIPHRAGMATIC BREATHING

THORACIC EXPANSION

(lateral)

PURSED-LIP BREATHING

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TREADMILL

SWIMMING

CYCLING

WALKING

Interventions for Strengthening may include;

PROM AAROM AROM ARROMBy means of EMG biofeedback

PNF Rhythmic Initiation

Rhythmic StabilizationRepeated contractions

Hold Relax

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EMG BIOFEEDBACK

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position for ex’s: sitting or prone on elbowTo keep the chewed food inside the mouth patient

must be able to hold their lips closed ,can improved by ex’s of facial muscles & tongue movements

Improve Swallowing

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Tongue movements

As the swallowing continues ,the hyoid bone and larynx moves upward. To stimulate the muscles that elevate the larynx use quick ice and stretch .Give the stretch diagonally down to the right and. then to the

left.

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PHASE III(when patient have good strength of

muscles)

• Strengthening• Stretching• Improve gripping• Balancing (Tai chi) • Hydrotherapy• Gait training• Prevention from medical complications

and sequlae

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TAI

CHI

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To improve gripping

SPEECH THERAPY

Stimulation of the laryngeal muscles with quick ice followed by stretch and resistance to the motion of

laryngeal elevation

Promote controlled exhalation during speech with resisted breathing exercises

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HOME PROGRAM

Breathing ex’s

Stretching ex’s

Walking Jogging

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SEQUELAE

•GBS may leave sequelae that are unpredictable

•Most serious residual disability was found distally in the legs

Residual severe neurological deficits

Muscle aches and cramps

PROGNOSIS The length of time and the amount of effort required to bringabout the best possible recovery varies among individuals and is related primarily to the severity of the symptoms.

About 30% of persons affected with GBS have some degree ofresidual weakness after three years.

3 - 5% may suffer a relapse many years later.

1- 5% of cases are fatal, usually due to respiratory or cardiac complications.

Most people, however, are able to recover completely and leadnormal lives.

REFRENCES

Guillain-Barre syndrome: pathological, clinical, and therapeutical aspects

By Silvia IannelloPNF in practice –An illustrated guide

Adler ,Beckers ,BuckTherapeutic exercises

Kisnerhttp://neurologychannel.com/guillain

http://en.wikipedia.org/wiki/guillain-barre-syndrome/

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GOLDEN WORDS

“Your main occupation should be — in fairness to yourself, in fairness to your parents, in

fairness to the state – to devote your attention to your studies.”

(Mohammad Ali Jinnah-March 21 ,1948)

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ACKNOWLEDGEMENT

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MAM HINA