Guillain-Barre-Syndrome

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Guillain-Barre-Syndrome

  1. 1. 1/30/2015 1
  2. 2. GUILLAIN –BARRE SYNDROME Presented by: RABEIYA TAZEEM B.S.P.T (Final yr) Batch-2007 College of Physiotherapy-JPMC 1/30/2015 2
  3. 3. PRESENTATION FLOW Introduction Epidemiology Sub-types Pathology Medical treatment Rehabilitation Prognosis 1/30/2015 3
  4. 4. Introduction “It is an acquired ,frequently severe ,monophasic autoimmune illness of Peripheral Nervous System(PNS)” 1/30/2015 4
  5. 5. Alternative Names •Landry-Guillain-Barre-Strohl Syndrome •Post-Infectious Polyneuropathy •Acute Idiopathic Polyneuropathy
  6. 6. 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 1/30/2015 6
  7. 7.  Approximately 85% patients recover spontaneously while 10% patients need hospitalization Its prevalence has been reported to vary from region to region 1/30/2015 7
  8. 8. 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
  9. 9. 1/30/2015 9
  10. 10. Sub-types of GBS GBS AIDP AMAN AMSAN MFS 1/30/2015 10
  11. 11. 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
  12. 12. 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
  13. 13. AIDP cont’d… Usual Electro diagnostic features; Prolonged distal latencies Conduction velocity slowing Evidence of conduction block
  14. 14. 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
  15. 15. 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 1/30/2015 15
  16. 16. 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)
  17. 17. Acute Motor-Sensory Axonal Neuropathy(AMSAN) Very rare Closely related to AMAN  Adults are mostly affected
  18. 18. 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
  19. 19. Miller-Fisher Syndrome Adults ,young subjects and children are affected Involves PNS & CNS structures Pathological features resemble that of AIDP
  20. 20. MFS cont’d…  Characterized by rapidly evolving of Triad; 1) Variable opthalmoplegia(often withpupillary paralysis) 2) Ataxia 3) Tendon areflexia (withoutweakness) Recovery can be rapid
  21. 21. 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
  22. 22. Pregnancy and GBS Even though maternal GBS is very rare there may be approximately 6% chances of GBS development during pregnancy Cause is idiopathic
  23. 23. Malignancy and GBS GBS has also been described in association with malignancy ,in these instances GBS may be considered in a secondary event
  24. 24. 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
  25. 25. 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
  26. 26. Pattern of re-myelination
  27. 27. 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 1/30/2015 27
  28. 28. Clinical features Rapidly evolving areflexic ascending motor paralysis of the extremities ,up to the tetraparesis Reduced or absent deep tendon reflexes Mild sensory symptoms
  29. 29. Clinical features cont’d… Fever Fatigue Pain Bilateral facial palsy Antecedent symptoms
  30. 30. Clinical features cont’d… Involvement of autonomic nervous system a. Taste loss(initial symptom) b. Swallowing dysfunction c. Sweat gland alterations d. Urinary retention e. Cardio-respiratory arrest f. Postural hypotension
  31. 31. Differential Diagnosis • Poliomyelitis • Botulism • Infantile spinal muscular atrophy • Neurosarcoidosis • Sub-dural spinal granuloma from Candida albicans • Severe anaemia • Diphtheric neuropathy 1/30/2015 31
  32. 32. 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 1/30/2015 32
  33. 33. Diagnosis cont’d… 1. Past medical history 2. Laboratory findings a. 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 1/30/2015 33
  34. 34. DISABILITY CRITERIA In most studies, the primary outcome measure used 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 1/30/2015 34
  35. 35. Management MANAGEMENT MEDICAL REHABILITATION PHYSIOTHERAPY SPEECH THERAPY OCCUPATIONAL THERAPY
  36. 36. MEDICATION 1/30/2015 36
  37. 37. Medical management a) IVIg a) Plasmapheresis 1/30/2015 37
  38. 38. PLASMAPHERESIS 1/30/2015 38
  39. 39. a- Pain NSAID Acetaminophen with Hydrocodone b-Unpleasant sensations such as painful tingling Tricyclic antidepressants Anti convulsants Corticosteroids ,which often effectively treat the symptoms of autoimmune disorder actually worsen GBS and should not be used 1/30/2015 39
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  42. 42. “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 1/30/2015 42
  43. 43. Physiotherapy Management PT MANAGEMENT ACUTE PHASE SUBACUTE REHAB PHASE ONGOING/LONG- TERM REHAB PHASE III
  44. 44. 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)
  45. 45. RESPIRATORY MANAGEMENT If patient is on ventilator , •Suctioning can be done (if required) • Huffing-coughing
  46. 46. SYMMETRY OF THE CHEST 1/30/2015 46
  47. 47. 1.Upper lobe expansion 2.Lower lobe expansion 3.Middle lobe expansion 1/30/2015 47
  48. 48. AUSCULTATION 1/30/2015 48
  49. 49. PERCUSSION 1/30/2015 49
  50. 50. Findings; Dull & Flat solid>air Hyper-resonant (tympanic) >air 1/30/2015 50
  51. 51. EXERCISES Diaphragmatic breathing Incentive spirometery Glossophayrengeal breathing Chest mobilization ex’s
  52. 52. Areas which are most affected in different positions PREVENTION FROM DECUBITUS ULCER By Repositioning By Devices (e.g. pneumatic gloves) Through diet 1/30/2015 52 PREVENTION FROM DECUBITUS ULCER
  53. 53. PREVENTION FROM DVT •Begin ambulation as soon as possible •Anticoagulant as a prophylactic Rx •Active pumping ex’s •Keep lower extremities elevated
  54. 54. FROM CONTRACTURES • Generalized ROM ex’s • Spinal movements should be included e.g. a. Double knee-and-hip flexion, b. Knee rolling and c. Neck movements with due care of tracheal tubes 1/30/2015 54
  55. 55. Double knee-and-hip flexion 1/30/2015 55
  56. 56. Knee rolling 1/30/2015 56
  57. 57. NECK MOVEMENTS 1/30/2015 57
  58. 58. 1/30/2015 58 • Risk of hypotension is reduced by ; Ensuring that turning is gentle Avoiding any intervention if CVP is below 5cmH2O Acclimatization to the upright posture with a tilt table Risk of bradycardia is reduced by oxygenation before and after suction
  59. 59. ASSIST IN SWALLOWING •By positioning Keep head upright with slight extension (elevated- 45degree)
  60. 60. PHASE II (when patient maintain his respiration) 1/30/2015 60
  61. 61. • Pain management-TENS • ACBT’S • Stretching • Strengthening and endurance ex’s • Paced breathing • Aerobic ex’s • Energy conservation • Improve swallowing 1/30/2015 61
  62. 62. DIPHRAGMATIC BREATHING THORACIC EXPANSION (lateral) PURSED-LIP BREATHING 1/30/2015 62
  63. 63. TREADMILL SWIMMING CYCLING WALKING 1/30/2015 63
  64. 64. Interventions for Strengthening may include; PROM AAROM AROM ARROM By means of EMG biofeedback PNF Rhythmic Initiation Rhythmic Stabilization Repeated contractions Hold Relax 1/30/2015 64
  65. 65. EMG BIOFEEDBACK 1/30/2015 65
  66. 66. position for ex’s: sitting or prone on elbow To 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 1/30/2015 66
  67. 67. Tongue movements 1/30/2015 67
  68. 68. 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. 1/30/2015 68
  69. 69. PHASE III (when patient have good strength of muscles) 1/30/2015 69
  70. 70. • Strengthening • Stretching • Improve gripping • Balancing (Tai chi) • Hydrotherapy • Gait training • Prevention from medical complications and sequlae 1/30/2015 70
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  74. 74. T A I C H I 1/30/2015 74
  75. 75. To improve gripping 1/30/2015 75
  76. 76. 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 1/30/2015 76
  77. 77. HOME PROGRAM Breathing ex’s Stretching ex’s Walking Jogging
  78. 78. 1/30/2015 78
  79. 79. 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
  80. 80. PROGNOSIS  The length of time and the amount of effort required to bring about 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 of residual 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 lead normal lives.
  81. 81. REFRENCES Guillain-Barre syndrome: pathological, clinical, and therapeutical aspects By Silvia Iannello PNF in practice –An illustrated guide Adler ,Beckers ,Buck Therapeutic exercises Kisner http://neurologychannel.com/guillain http://en.wikipedia.org/wiki/guillain-barre-syndrome/ 1/30/2015 81
  82. 82. 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) 1/30/2015 82
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  85. 85. ACKNOWLEDGEMENT 1/30/2015 85

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