GUILLAIN-BARRE SYNDROME
INTRODUCTION
 Guillain-Barre syndrome (GBS) is the most frequent
cause of acute generalized weakness
 It represents a broad group of demyelinating
inflammatory polyradiculoneuropathies.
 Nerve roots (radiculopathy) and peripheral nerves
(polyneuropathy) are a affected.
 GBS is a classic lower motor-neuron disorder
FORMS OF GBS
• Acquired inflammatory demyelinating
polyradiculoneuropathy (AIDP)
• Acute Motor axonal neuropathy (AMAN)
• Acute Motor Sensory axonal neuropathy
(AMSAN)
• Another common variant of GBS is Miller-Fisher
syndrome
• MILLER-FISHER SYNDROME : a triad of
ophthalmoplegia, ataxia, and areflexia.
INCIDENCE AND ETIOLOGY
 GBS is rare with an incidence of 1 per 100,000 people.
 All age groups, including children and adults.
 The majority of individuals who acquire GBS
experience a respiratory or gastrointestinal illness
prior to the onset of weakness and sensory changes.
 No one causal agent.
 It is a reactive, self-limited autoimmune disease with a
good overall prognosis.
PATHOPHYSIOLOGY
 Involves autoimmune reactions.
 The immune responses cause a cross reaction with
neural tissue.
 Demyelination follows inflammation.
 These acute inflammatory lesions are present within
several days of the onset of symptoms.
 Nerve conduction is slowed and may be blocked
completely.
CLINICAL FEATURES
 Symmetrical ascending progressive loss of motor
function that begins distally and progresses
proximally.
 Distal sensory impairments often present as
paresthesias (burning, tingling) of the toes or
hypesthesias (an abnormal sensitivity to touch).
 The sensory involvement varies and is usually not as
significant as the motor involvement.
CONTD….
 Progression of weakness can impair the diaphragm
and cranial nerves.
 Weakness of shoulder elevators and neck flexion
parallels diaphragmatic weakness (C3,4,5)
 Dysautonomia
CONTD….
 Pain is reported by patients as being muscular in
nature (myalgia).
 Hypesthesias may make using a bed sheet
uncomfortable.
 Half of the patients with GBS have oral-motor
involvement in the form of weakness that causes
difficulty speaking (dysarthria) and swallowing
(dysphagia).
CONTD….
 The facial nerve (cranial nerve VII) is frequently involved,
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and bilateral facial weakness is common.
Double vision (diplopia) can result from eye muscle
weakness secondary to cranial nerves III, IV, and VI
involvement.
Paralysis of cranial nerves is termed Bulbarpalsy.
Cranial nerve involvement is referred to as bulbar because
the majority of cranial nerves exit the bulb or brainstem.
Absent DTRs
Flaccid tone
STAGES OF THE DISEASE
Acute stage
 Acute stage lasts up to four weeks.
 During this time, core symptoms appear: paresthesias,
areflexia, weakness in all limbs.
The plateau phase
 Defined by the stabilization of symptoms.
 While symptoms are present, they are not progressing
or getting worse.
 This phase can also last up to four weeks.
Recovery phase
 Evident when the patient begins to improve.
 Eighty percent of patients recover within a year but
may have some neurologic sequel or residual deficits.
 The recovery phase can last a few months to several
years.
 Poorer outcome in cases with diaphragm
involvement, rapid progression of demyelination, and
more distal motor weakness.
 More the axonal damage poorer is the recovery.
MEDICAL MANAGEMENT
 The mainstay of medical management of patients with
GBS is
 Plasmapheresis
 Infusion of immunoglobulins
 Other supportive measures for respiration main
management
PHYSICAL THERAPY; ACUTE PHASE
 Supportive care; respiratory care, breathing exercise,
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postural drainage for airway clearance. ( observe lungs
functions regularly)
Treat the patient as symptoms are usually progressing
Postural care to manage pain and preventing skin
breakdown.
The patient is positioned to decrease potential
contractures with hand and foot splints.
Extra care should be taken when performing ROM
because denervated muscles can easily be damaged.
CONTD….
 Avoid overstretching. Be sure that the ankle is in a
subtalar neutral position prior to stretching the heel
cord.
 The schedule of positioning, splinting, and the ROM
program should be posted bedside.
 Pain is one of the most difficult symptoms to treat in
patients with GBS. Medications are not always
effective.
 Passive ROM, massage, and transcutaneous electrical
nerve stimulation may be helpful.
CONTD….
 Low-pressure wrapping or a snug-fitting garment may
provide a way to avoid light moving touch on the
limbs.
 Reassurance and an explanation about what to expect
may help alleviate anxiety that could compound the
pain.
Physical therapy: Plateau phase
 When respiratory and autonomic functions stabilize, a
program to increase tolerance to upright can be begun.
 Physical therapy goals during the plateau phase
include acclimation to upright, maintenance of ROM,
improvement in pulmonary function, and avoidance of
fatigue and overexertion.
 The patient is acclimated to sitting upright with
appropriate postural alignment and support of the
trunk since it may still have minimal innervation.
CONTD….
 Pressure relief is still provided by changing positions
on a regular basis.
 If the patient continues to experience pain, it may lead
to holding limbs in potentially contracture-prone
positions.
 Heat may be used prior to stretching if there is no
sensory loss.
 Return of oral musculature may signal the need for
additional team members to work on the movement
patterns needed for swallowing, eating, and speaking.
Physical therapy: Recovery Phase
 Muscle strength is gradually recovered two to four
weeks after the condition has reached a plateau.
 The muscles return in the reverse order or descending
pattern i.e opposite from the ascending order of loss.
 As the neck and trunk muscles recover, the patient may
begin to use a tilt table for continued acclimation to
upright and weight bearing on the lower extremities.
 Positioning splints may be needed for the lower
extremities as well as thromboemolic stockings to
decrease venous pooling.
CONTD….
 Muscles of respiration can be weak if the person
required ventilatory assistance, and this weakness may
limit tolerance to upright.
 Physical therapy goals at this time now encompass
strengthening and maximizing functional abilities in
addition to carrying over any goals from the previous
phases.