Gullien-Barre Syndrome

Guillain-Barré (Ghee-yan Bah-ray) Syndrome is an inflammatory disorder of the peripheral nerves outside the brain and spinal cord.It’s also called:

• Acute Inflammatory Demyelinating Polyneuropathy
• Landry’s Ascending Paralysis

GBS is characterized by:

• Rapid onset of muscle weakness caused by the immune system damaging peripheral nervous system.
• Initial symptoms are typically changes in sensation or pain often in the back along with muscle weakness, beginning in the feet and hands.
• Often spreading to the arms and upper body, with both sides being involved.
• The symptoms may develop over hours to a few weeks. During the acute phase, the disorder can be life-threatening, with about 15 percent of people developing weakness of the breathing musclesand, therefore, requiring mechanical ventilation.
• Some are affected by changes in the function of the autonomic nervous system, which can lead to dangerous abnormalities in heart rate and blood pressure.

Tingling, numbness and pain alone or in combination followed by weakness in the legs and arm that affects both side equally and worsens over time. The weakness can take half a day to over two weeks to reach maximum severity, and then becomes steady. In one in five people, the weakness continues to progress for as long as four weeks. 

• The muscles of the neck may also be affected, and about half experience involvement of the cranial nerveswhich supply the head and face; this may lead to weakness of the muscles of the face, swallowing difficulties and sometimes weakness of the eye muscles.
• In 8%, the weakness affects only the legs(paraplegia or paraparesis). Involvement of the muscles that control the bladder and anus is unusual. In total, about a third of people with Guillain–Barré syndrome continue to be able to walk. Once the weakness has stopped progressing, it persists at a stable level ("plateau phase") before improvement occurs. The plateau phase can take between two days and six months, but the most common duration is a week. Pain-related symptoms affect more than half, and include back pain, painful tingling, muscle pain and pain in the head and neck relating to irritation of the lining of the brain.
• Many people with Guillain–Barré syndrome have experienced the signs and symptoms of an infection in the 3–6 weeks prior to the onset of the neurological symptoms. This may consist of upper respiratory tract infection(rhinitis, sore throat) or diarrhea.
• In children, particularly those younger than six years old, the diagnosis can be difficult and the condition is often initially mistaken (sometimes for up to two weeks) for other causes of pains and difficulty walking, such as viral infections, or bone and joint problem.
• neurological examination, characteristic features are the reduced strength of muscles and reduced or absent tendon reflexes(hypo- or areflexia, respectively). However, a small  proportion have normal reflexes in affected limbs before developing areflexia, and some may have exaggerated reflexes. In the Miller Fisher variant of Guillain–Barré syndrome (see below), a triad of weakness of the eye muscles, abnormalities in coordination, as well as absent reflexes can be found. level of consciousness is normally unaffected in Guillain–Barré syndrome, but the Bickerstaff brainstem encephalitis subtype may feature drowsiness, sleepiness, or coma.

Guillain-Barré syndrome is often preceded by an infection. This could be a bacterial or viral infection. Guillain-Barré syndrome may also be triggered by vaccine administration or surgery.

In the context of Zika virus infection, unexpected increase in cases of Guillain-Barré syndrome has been described in affected countries. The most likely explanation of available evidence from outbreaks of Zika virus infection and Guillain-Barré syndrome is that Zika virus infection is a trigger of Guillain-Barré syndrome.

Diagnosis is based on symptoms and findings on neurological examination including diminished or loss of deep-tendon reflexes. A lumbar puncture may be done for supportive information, though should not delay treatment. Other tests, such as blood tests, to identify the underlying trigger are not required to make the diagnosis of GBS and should not delay treatment.

• Guillain-Barré syndrome is potentially life-threatening. GBS patients should be hospitalized so that they can be monitored closely.
• Supportive care includes monitoring of breathing, heartbeat and blood pressure. In cases where a patient's ability to breathe is impaired, he or she is usually put on a ventilator. All GBS patients should be monitored for complications, which can include abnormal heart beat, infections, blood clots, and high or low blood pressure.
• There is no known cure for GBS. But treatments can help improve symptoms of GBS and shorten its duration.
• Given the autoimmune nature of the disease, its acute phase is typically treated with immunotherapy, such as plasma exchange to remove antibodies from the blood or intravenous immunoglobulin. It is most often beneficial when initiated 7 to 14 days after symptoms appear.
• In cases where muscle weakness persists after the acute phase of the illness, patients may require rehabilitation services to strengthen their muscles and restore movement.

1. The patient's independence with everyday tasks.
2. Retrain the normal movement patterns.
3. Improve Patients posture.
4. Improve the balance and coordination
5. Maintain clear airways
6. Prevent lung infection
7. Support joint in functional position to minimize damage or deformity
8. Prevention of pressure sores
9. 1. Provide psychological support for the patient and relatives.Maintain Regain peripheral circulation
   • Maintain Normal ROM

   Gentle passive movement through full ROM atleast three times a day especially at hip,shoulder,wrist,ankle,feet.
   

   • Orthosis

   Use of 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
   • Strength and Endurance Training

   Strength training involved isometric, isotonic or isokinetic exercises, while endurance training involves progressively increasing the intensity and duration of functional activities such as walking and stair climbing.

   Role of physiotherapy for GBS divided into three parts:

   • Acute phase
   • Middle phase
   • Long term

   Acute Phase

   In the acute phase a large part of physio is for respiratory care. If it affects the intercostal muscle - the one between the ribs that lifts up the ribs as we take a breath. Equally if the diaphragm is affected - the part of the body between the abdomen and the chest - patient have the inability to take a large breath. So in acute phase regular breathing exercises are necessary.

    

         Phase of Rehabilitation

   So then the first part of the rehabilitation phase begins. When we start to get patients moving we have to keep in mind the physiotherapy must be graduated. We realize the patients can fatigue quite quickly and so we try to build up the strength very gradually, deliberately providing a little more demand each time in exercising the respiratory muscles.

   The positioning of the patient is vital. He/she needs to be nursed so that the lungs are kept clear - from side to side and if need be to be "jacked up" with the head down so allowing any secretion in the lungs to be drained out.

   Patient suffering from GBS disease often complain of severe pain, which can be managed by applying TENS, IFT and other pain relieving techniques.

   If muscles are kept in a shortened position long enough then there is an increase in the stiffness of the muscle. So there should be "passive" movements, ie aided - through the full range at least once a day. If there is too much movement with weak muscles around a joint, the joint can become quite loose and set up later some pain. Too little movement and you end up with a stiff joint. You can have muscle stiffness and then joint stiffness. This again can become quite painful.