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Similar to Guillain barré syndrome (GBS)
Guillain barré syndrome (GBS)
- 1. TOPIC:-Guillain-Barré syndrome PRESENTED BY: ASHUTOSHRAJ DEPT OF PHYSIOTHERAPY
- 2. CONTENT Definition Synonyms Cause pathogenesis Pathophysiology Incidence Clinical feature Course of GBS Classification Diagnostic procedure Treatment medical management physiotherapy management
- 3. DEFINITION GBS isdefined as acute or subacute symmetrical predominantly motor neuropathy involving more than one peripheral nerves, frequently it may involve the facial and other cranial nerve, doesn’t have any known etiology, reaches a peak of disability by 4 weeks, has a monophasic course and usually ends up with recovery. It is a disorder in which the body’s immune system attack part of the peripheral nervous system. It is an acute, progressive, autoimmune, inflammatory demyelination of polyneuropathy of the peripheral sensory and motor nerves and nerve roots.
- 4. SYNONYMS AIDP (acuteidiopathic demyelinating polyneuropathy), AIP (acute infective polyneuropathy, LGBSS (Landry-Guillain-Barré-Strohl syndrome), AIP (acute idiopathic polyneuropathy).
- 5. Cause:- idiopathic 1.Camphylobacter- mostcommon cause 2.Influenza virus 3.Cytomegalovirus 4.Hepatitis A,B,C and E 5.Surgery 6.Trauma 7.autoimmune disorder like –S.L.E ,Hodgikins disease
- 6. PATHOGENESIS Twopathophysiological forms are present; 1.Demyelinating forms of GBS: Segmental demyelination of peripheral nerves is due to cell mediated immune mechanism. 2.Axonal forms of GBS: axonal degeneration may occur without demyelination or inflammation.
- 8. Pathophysiology Due toetiological factor | Inflammation and death of myelin producing cells in P.N.S | Destruction of myelin sheath | Scar formation | Impaired transmission of impulses | GBS
- 9. INCIDENCE • 1–2cases per 1,00000 people annually, It is seen more in males than females. M:F:: 3:2 CLINICAL FEATURES • The 1st symptoms of Guillain–Barre syndrome is… 1) Pain. 2) Progressive muscle weakness. (LMN TYPE) 3) Diminished reflexes of lower extremities. 4) Prickly, tingling and needle sensations in the fingers ,toes , ankles ,or wrist 5) Low blood pressure. 6) Paresthesia. 7) Tenderness and muscle pain. 8) Sphincter disturbance
- 10. 8.Progression: The motorparalysis spreads usually within 30 minutes to four weeks time. It may take on an average of 4 to 5 days for the weakness to reach its peak. Once the weakness reaches its peak it remains at a plateau or it maintains a plateau for 15 to 20 days following which the patient recovers for 4 to 6 months. 9.Motor: a).Weakness of the muscle which is of LMN type is seen with involvement of more than one limbs. b). The weakness is usually symmetrical on both sides. c).The proximal parts are more involved than the distal parts although the disease may start from distal parts. Weakness of the facial and other cranial nerves may cause dysphagia, diplopia and respiratory failure.
- 11. COURSE OF GBS oINITIAL PHASE Gradually increasing involvement lasts 10-30 days ( less than 4 weeks ) o Plateau phase short phase ( within 2 weeks ) Long phase – poor prognosis o Recovery phase within months usually complete motor sequelae ( 5-25%) relapse & late recurrences (3%)
- 12. CLASSIFICATION 1)Acute Inflammatory Demyelinating Polyneuropathy (AIDP) • Most common. • Auto immune response against schwann cell. 2) Miller Fisher Syndrome (MFS) • Rare variant • Manifest as a descending paralysis. • Usually affects the eye muscles first and presents with the triad of ophthalmoplegia, ataxia, and areflexia.
- 14. 3) Acute MotorAxonal Neuropathy (AMAN) Also known as Chinese paralytic syndrome, • Attacks motor nodes of Ranvier and is prevalent in China and Mexico. 4) Acute Motor Sensory Axonal Neuropathy (AMSAN) • Similar to AMAN • Affect the sensory with several axonal damage.
- 15. 5) AcutePanautonomic Neuropathy • Is the most rare variant of GBS, sometimes accompanied by encephalopathy. • Frequently occurring symptoms include impaired sweating, lack of tear formation, photophobia, dryness of nasal and oral mucosa, itching and peeling of skin, nausea, dysphagia, and constipation unrelieved by laxatives or alternating with diarrohea. 6) Bickerstaff's brainstem encephalitis (BBE) • It is characterized by acute onset of ophthalmoplegia, ataxia, disturbance of consciousness, hyperreflexia. • Large, irregular hyper intense lesions located mainly in the brainstem, especially in the pons, midbrain and medulla,
- 16. Diagnostic Procedure These include: • Cerebrospinal fluid investigation: It will elevated at some stage of the illness but remains normal during the first 10 days. • Electrophysiological studies: it includes nerve conduction studies and electromyography. They are normal in the early stages but show typical changes after a week or so with conduction block and multifocal motor slowing, sometimes most evident proximally as delayed F-waves. The only way to classify a patient as having the axonal or nonaxonal type is electrodiagnostically. • Further investigative procedures can be undertaken to identify an underlying cause For example: • Chest X-ray , stool culture and appropriate immunological tests to rule out the presence of cytomegalovirus or mycoplasma • Antibodies to the ganglioside GQ1b for Miller Fisher Variant.
- 17. • MRI • LumbarPuncture: Most, but not all, patients with GBS have an elevated CSF protein level (>400 mg/L), with normal CSF cell counts. Elevated or rising protein levels on serial lumbar punctures and 10 or fewer mononuclear cells/mm3 strongly support the diagnosis.
- 18. TREATMENT Medical Management :-in case of respiratory failure – mechanical ventilator needs to apply. • Plasmapheresis • Steroid therapy • Injection of IgG (Immunoglobulin-G)
- 19. PT Management A.Chest Physiotherapy :- In the initial stages if the patient is on respiratory assistance then the patient has to be regularly seen by the therapist. The aims of the management in this stage consists of the following: • Maintain clear airways and to prevent respiratory complication • Continuous change of position to drain out secretion and also to facilitate proper air entry to all the lobes of the lung. • Periodic suctioning in a strictly hygienic manner. • Percussion, shaking, manual mobilization with the help of ambu bag may be necessary to loosen out the secretion. • Nebulization in case of any respiratory infection. # chest physiotherapy technique like breathing exercise, postural drainage, external tracheal stimulation may be given to maintain good bronchial hygiene.
- 20. B. Maintain NormalRange of Movement Gentle passive movements through full ROM at least three times a day especially at hip, shoulder, wrist, ankle, feet. Passive movements should be given at least three times in a day involving all the movements at all the joints. Each movements should be repeated at least five times during each sitting. C. Support to the Limbs Static splints are given to prevent contracture as well as to immobilize the part to prevent any unwanted damage to muscle or joint . Splints are commonly used for the foot and hand to maintain it in neutral position. Even pillows may be used to support various body parts.
- 21. D.Pain relief Patientwith GBS in the acute stage suffer from pain and paresthesia which may interfere with the rehabilitation process hence to give patient relief from these altered sensation TENS may be used. E. Maintenance of Muscle Properties Muscles begin to atrophy very rapidly in these condition hence Functional Electrical Stimulation may be used to maintain the muscle property. F. Prevention and Treatment of Pressure Sores Pressure sore can be prevented by constantly changing the posture, gentle massage of the pressure prone areas, by keeping the skin dry and soft as well as by giving mattress. used to treat the sore s like ice cube massage around the wound, UVR radiation, LASER, etc. radiation etc.
- 22. G. Psychological Support The patient motivation must be kept high. H. Strength and Endurance training Strengthening exercises can involve isometric, isotonic or isokinetic exercises, while endurance training involves progressively increasing the intensity and duration of functional activities such as walking or stair-climbing IG stimulation can be continued till the patient is able to generate contraction of the muscles voluntary but is unable to perform any movement (grade 1).
- 23. Continue, Once thepatient reaches grade 1 then he can be given Faradic reduction by using short surge faradic current, this can be continued till he is able to perform the action in a gravity eliminated position. To improve the grade from 2 to grade 3, patient may be exercised actively by using reeducation board or smooth exercise table, suspension therapy, and other form of active assisted exercise. Once the patient reaches grade 3 then resisted exercises can be given using manual resistance, springs, pulleys, weights, hydrotherapy, etc.
- 24. I. Orthoses Useof light splints (eg. using PLASTAZOTE) may be required for the following purpose listed below: • Support the peripheral joints in comfortable and functional position during flaccid paralysis. • To prevent abnormal movements. • To stabilize patients using sandbags, pillows. J. Gait Training Gait training is initiated in the parallel bar and then progressed to walking unsupported
- 25. K. Functional Training It is essential to incorporate the improvement in the muscle strength into various activities of daily living. For certain patient with a very gradual improvement, functional electrical stimulation or orthosis may be used to perform a functional task.
- 26. Exercise modelproposed for patients with GBS Phases in GBS Clinical Symptoms/Associa- ted complaints Aims to achieve Exercise/ Electro Therapy Acute phase in GBS: Muscle weakness, Pain, Sensory loss, DVT, Bedsores, Fatigue, muscle imbalance , respiratory complications, immobility, Maintaining Muscle tone, joint and skin Care, Pain control Prevention of DVT and bedsore, restoring the physical well being of the patient, prevention of respiratory complications, to promote transfers and mobility. Passive exercises, active assisted exercises, active and active resistive exercises, TENS, crepe bandaging, compression stockings, proper turning and positioning of the patients, incentive spirometry, breathing exercises, postural drainage along with therapeutic techniques. Proper transfer skills to be taught, training for balance an equilibrium in all positions and avoid prolong positions of the limbs. Position to reduce work of breathing should be promoted.
- 27. Continue, Phases in GBSClinical Symptoms/Associated complaints Aims to achieve Exercise/ Electro Therapy Sub acute/ Recovery Phase in GBS Muscle weakness, residual fatigue, development of contractures, pain in joints and muscles Muscle strengthening, positioning of joints, to teach energy conservation, restore physical conditioning Strengthening exercises of specific muscle group by isometric group exercises and resistance training, prescription of proper splints for joints, proprioceptive training using some devices, initiation of specific aerobic exercises.
- 28. Continue, Phases in GBSClinical Symptoms/Associated complaints Aims to achieve Exercise/ Electro Therapy Chronic Phase after GBS Specific muscle weakness, residual fatigue, development of contractures, Difficulty in performing Activities of Daily living, Difficulty in mobilization and ambulation. Specific muscle group strengthening, to teach energy conservation and endurance training, To teach joint positioning and provide with corrective splints. To provide gait training. To maintain and improve the vital capacity of lungs Strengthening of specific, proprioceptive neuromuscular facilitation techniques to improve strength and facilitate movements and activities of daily living; stationary bicycle, aerobic training and treadmill walking with sufficient rest time in between to improve endurance and to avoid fatigue. Stretching exercises to improve the muscle tone and to prevent contractures. Gait training in parallel bar and postural mirror. Incentive spirometry, breathing exercises and home based postural drainage should be promoted.