Guillain-Barr Syndrome (Ghee-yan Bah-ray) Presentation and Information Prepared by:

Master student Stere Alin Jean

Pathogenesis
Acute autoimmune disorder There is involvement of T lymphocytes and
B lymphocytes Brain is unable to send messages Legs and arms are commonly affected

Etiology
There are varying degrees of severity Onset usually occurs 1-3 weeks after exposure

to a viral infection Destruction most often occurs in segments between the Nodes of Ranvier The etiology of this syndrome is found in the existence of an infectious respiratory syndrome or gastrointestinal tract, appeared in the context of an immune deficiency,

Mortality/Morbidity
85% of patients will achieve a full and
functional recovery within 6-12 months, maximal recovery at 18 months 7-15% of patients will have permanent neurological sequelae including bilateral foot drop, intrinsic hand muscle wasting, sensory ataxia, dysesthesia Despite intensive care, 3-8% of patients die

Clinical Manifestations
Signs and Symptoms Include

Paresthesia Muscle Weakness Possible Paralysis

Treatment
There is no cure for Guillain-Barr Syndrome, but there are treatments available

Plasmapharesis Immunoglobulins

Epidemiology
Most common cause of acute flaccid
paralysis in Western countries Overall incidence 1-2/100,000; up to 8.6/100,000 in elderly population All age groups can be affected, however more common in elderly Bimodal peak, small peak in young adults and larger peak in elderly; rare in infancy

 75% have an antecedent event 1-4

weeks before onset of weakness: respiratory (68%), GI (22%), resp and GI (10%), surgery (2%), vaccination or pregnancy The best documented antecedents included infection with C.jejuni, EBV, CMV, HSV, and Mycoplasma. C. jejuni is often associated with more severe axonal cases and most likely sensitizes the immune system to shared antigens.

Required criteria for typical GBS

Required Features
Progressive weakness in both arms and legs Areflexia (or hyporeflexia)

Features supportive of Diagnosis

Progression of symptoms over days to 4 weeks Relative symmetric Mild sensory signs or symptoms CN involvement, especially bilateral facial weakness Recovery begins 2-4 weeks after progression ceases Absence of fever at onset Typical CSF and EMG/NCS features

Types/Variants

Acute Inflammatory Demylinating

Polyradiculoneuropathy (AIDP) Acute Motor-Sensory Axonal Neuropathy (AMSAN) Acute Motor Axonal Neuropathy (AMAN) Miller Fisher Variant Pharyngeal-Cervical-Brachial Variant Acute Pandysautonomia

Workup

Clinical Diagnosis Elevated or rising protein levels on serial

lumbar punctures and 10 or fewer mononuclear cells/mm very presumptive Normal CSF protein does not rule out GBS as the level may remain normal in 10% of patients, and a rise in the CSF protein level may not be observed until 1-2 weeks after the onset of weakness

Imaging
MRI is sensitive but nonspecific Spinal nerve root enhancement with
gadolinium is a nonspecific feature seen in inflammatory conditions and is caused by disruption of the blood-nerve barrier Selective anterior nerve root enhancement appears to be strongly suggestive of GBS The cauda equine nerve roots are enhanced in 83% of patients

Spirometry
Patients with an FVC less than 15-20
ml/kg, maximum inspiratory pressures less than 40 cm H2O generally progress to require prophylactic intubation and mechanical ventilation

Nerve Conduction Studies

A delay in F waves is present, implying

nerve root demyelination Compound muscle action potential (CMAP) amplitude may be decreased Patients may evidence of conduction block or dispersion of responses at sites of natural nerve compression. The extent of decreased action potentials correlates with prognosis

Treatment
Only plasmapheresis (the exchange of patients
plasma for albumin) and intravenous serum globulin (IVIG) have proven effective Both therapies have been shown to shorten recovery time by as much 50% Combining plasma exchange and IVIG neither improved outcomes nor shortened the duration of illness Corticosteriods are ineffective as monotherapy

IVIG
Randomized trials in severe disease show
that IVIG started within 4 weeks from onset hastens recovery as much as pasmapheresis Dosed at 0.4 gram/kg/day IV for 5 Days Same dose in pediatrics May increase serum viscosity and tromboembolic events May increase frequency of migraines May cause aseptic meningitis

Sequela of IVIG
Increased antiviral and antibacterial
antibody titers for one month Six-fold increase in ESR lasting two to three weeks Apparent hyponatremia

Rehabilitation treatment in Guillain-Barr syndrome.

Nerve regeneration is spontaneous, but requires
physical-kinetic therapy in preventing and correcting functional disorders that can occur as a result of structural damage, correction and prevention of vicious attitudes. Patients receiving daily early passive mobilization aimed at lowering the risk of joint stiffness and muscle retractions. Maintaining muscle strength is an objective of the initial kinetic program. Active resistance movements are recommended as early as possible by calling the isometric, izotonii fatigue resistance emergence msculare control. The patient will be monitored for cardiac, respiratory effort by adapting its capacity for effort.

 a) acute-phase evolutionary

The recovery process in Guillain-Barre syndrome is done in four phases, which correspond to timing of clinical course of this syndrome.

Objectives and methods: The main objective is pain relief and prevention by treatment vicious postural positions.

b) paltou the SGB phase lasts weeks / months, and the

clinically stationary. Risk existing in this phase is involving abdominal muscles effects on hemodynamics and respiratory function.

Objectives and means: the vicious fighting positions, retracturilor, respiratory failure by posturri correct upper and lower limbs, with periodic changes of the decubitus positions.

 c) spontaneous recovery phase

It has a maximum of 2 years duration of 2-4 months (at declaration representing sequelae).

Objectives and means: the recovery of respiratoryspontaneously, without sequelae, resume driving, increase muscle strength and endurance, keeping the balance between agonists and antagonists. d) final stage - recovering endurance, recovery coordination, speed of execution.

ASSESMENT BEFORE THREATMENT

01.03.2011

Name surname :F. E. Age :69 Weight :90 kg Size :1.65 cm Dominant side : Right Profession : House wife Illness :DM , HT , Stroke 4 years ago (right) Famly history :DM (her mother )

Used Drugs : Eklips plus Ecopirin tablet 100 mg fraxiparine 0,4 ml Complaints : Weakness in the legs Inability to walk History : She has upper respiratory tract infection about 15 days ago. And started weakness her both of legs and numbness 5 days ago. According her she has stroke 4 years ago so she has weakness in her legs and now it increases . She admitted with this complaints to Dinar Public Hospital. But they send her Pamukkale Unversity Hospital 1 week ago. She hasnt got tool for walking.

Neurological Examination 1-Sensory Evaluation

Upper limbs right left Lower limbs right left

sharp-blunt sensory test light touch position sense Kinestezi fingerprint recognition Graphestesia Stereognosia foot sole pressure hot-cold sensation test

5/4 5/5 + + 5/5 + + failed

5/5 5/5 + + 5/5 + +

5/3 5/3 + + 5/2 + + 5/3

5/4 5/4 + + 5/4 + + 5/4

2 Deep Tendon Reflex Evaluation :

Patella Biceps Triceps reflexs are decrease

Motor Examination
Right Shoulder : Flexion : Extansion : Abduction : Adduction : External rotation : nternal rotation : Elbow : Flexion : Extansion : 4 4 3+ 3+ 3+ 3+ 4 4 Left 4+ 4+ 4 4 4 4+ 4+ 4

Finger flexion :

Right 4+

Left 4+

Abdominal : 3 Back extansions : 4

Right
Hip : Flexion : Extansion : Abduction : Adduction : External rotation : nternal rotation : Knee : Flexion : Extansion : Ankle: Dorsi flexion: Plantar flexion : 3 3+ 3 3 3 3+ 4 4 3 4

Left
4 4 3+ 4 4+ 4 4 4 4 4+

Survey Results
Electromyography Findings : Sensorimotor polyneuropathy mixed type is compatible with the findings obtained from the EF.

Others Results (Cerebrospinal Fluid )

Glucose: 181 Cl : 126 Protein : 44.6

Mental Status
Aphasia: Dysarthria: -

Respiratory Status
Type of respiratory(chest-abdominal): mixt type Respiratory Depth(chest circumference, cm): expirasyon-normal-inspiratory Axillary 115 cm 116 cm 117 cm Epigastric 132 cm 133 cm 134 cm Subcostal 134 cm 135 cm 136 cm

PAIN ASSESMENT
VAS Scale : During activity: 0 During rest : 0

+ (7)

10

+ (5)

10

Pain :+ Where is the pain : below knee and feet Since when have pain : about 15 days Pain in the course of the day : Continious Treatments used : Analgesic

Range Of Normal Movements

She hasnt got any limitation

FIM totally point : 79 FIM cog FIM motor Beck Depression Scale :37

TREATMENT
Objectives of early period:

. Ensure the elimination of secretion with

breathing exercises

. Patient mobilite to prevent beds complications . Provide balance in sitting position . Strengthen dorsiflexor muscles

Objectives of late-term :

. Increase lung capacity . Provide to walk the patient . Provide hip control . Provide knee control . Povide to give weight for both of legs

1- Breathing Exercises

Postural drainage to eleminate secration Cough Upper limps movements combined respiratory
2- Active Exercises PNF technique Stabilization of pelvis exzercise (rhythmic stabilization) Flexion of hip and knee in the bed Abduction and adduction of hip External-internal of hip Dorsiflexion of ankle At first we want to do this movement from the patient as she can . We help her to increase the range when she coundt continue . After a while when she can do this exercises we start to give her resist .

3-Isometric exercises M.Quadriceps femoris M.Gluteus Abdominalis

4-Functional reach to give weight for both of hips

5- Walking education ( supported )

6- Home exercises . Upper limps movements combined respiratory . Isometric for m.quadriceps femoris, m.gluteus,abdominalis . Walking with tools

ASSESMENT AFTER THREATMENT

14.03.2011

Neurological Examination 1-Sensory Evaluation

Upper limbs right left Lower limbs right left

sharp-blunt sensory test light touch position sense Kinestezi fingerprint recognition Graphestesia Stereognosia foot sole pressure hot-cold sensation test

5/4 5/5 + + 5/5 + + failed

5/5 5/5 + + 5/5 + +

5/4 5/3 + + 5/4 + + 5/5

5/5 5/4 + + 5/5 + + 5/5

2 Deep Tendon Reflex Evaluation :

Patella Biceps Triceps reflexs are the same

Motor Examination
Upper limbs are the same with first assesment Abdominal : 3+ Back extansions : 4

Right
Hip : Flexion : Extansion : Abduction : Adduction : External rotation : nternal rotation : Knee : Flexion : Extansion : Ankle: Dorsi flexion: Plantar flexion : 3+ 3+ 3+ 3 3 3+ 4 4 3+ 4+

Left
4 4 3+ 4 4+ 4 4 4 4+ 5

PAIN ASSESMENT
VAS Scale : During activity: 0 +(4) During rest : 0 + (2)

10

10

Pain :+ Where is the pain : below knee and feet Pain in the course of the day :discontinuous Treatments used : Analgesic

Range Of Normal Movements

She hasnt got any limitation

FIM : 114 Beck Depression Scale :15