In
Guillain-Barre Syndrome (GBS), the immune system attacks the peripheral
nervous system and causes peripheral neuropathy and weakness (1). Acute
lower extremity weakness with areflexia appears rapidly, in some cases over
as little as seven days (1). GBS equally affects men and women at an
incidence of 1 in 100,000. GBS may be mediated by a response to an infection
suffered at most a month prior, with common infection-causing pathogens
including Campylobacter jejuni, cytomegalovirus, Mycoplasma pneumoniae, and
Epstein-Barr virus (1). Vaccines may also create an immune response capable
of starting GBS (1). At least five subtypes of GBS exist: acute inflammatory
demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, acute
motor and sensory axonal neuropathy, Miller Fischer Syndrome, and chronic
inflammatory deymelinating polyradiculoneuropathy (2).
Symptoms and Prognosis
GBS symptoms, including lower extremity weakness, numbness, tingling, and
total loss of sensation, can progress over hours, days, or weeks; however,
for most individuals, symptoms plateau within two weeks of onset (1).
Symptom worsening coincides with the progressive destruction of the myelin
along the peripheral nerves (1). Before plateauing, weakness in the lower
extremities may progress to the trunk, arms, and cranial nerves (1). If
respiratory muscles are affected, mechanical ventilation is required to
maintain airway and breathing functions (1). After the plateau phase (which
lasts 2-4 weeks), the recovery phase begins with gradual resolution of the
paralysis (which may take up to 1-2 years and may never fully return) (3).
An estimated 7-15% of individuals with GBS will have permanent neurologic
sequelae (3), and the syndrome has a 5% mortality rate (2).
A poor prognosis with GBS is related to quadraparesis, the need for
respiratory support, cranial nerve involvement, rapid progression, older age
at onset, and a history of GI illness (2). Additionally, if the individual
with GBS is older than 60 years old, achieves maximal deficits in less than
seven days, and needs ventilatory support, he or she has less than a 20%
chance of walking six months after onset of GBS (2).
Treatment
Medical management of GBS consists of plasmapheresis or immunoglobulin
infusion (IVIg). IVIg therapy, where antibodies are infused into the patient
to counteract his or her antibodies, is the preferred choice for therapy
(1). Plasmapheresis involves connecting the patient to a machine that
filters the plasma and circulating antibodies out of his or her blood stream
(1).
Physical therapy management of GBS varies greatly depending upon the course
of the disease. In the acute phase, physical therapists (PTs) monitor the
progression of sensory symptoms (often in a stocking glove pattern) by
testing and recording the areas where the patient can distinguish sharp from
dull and light touch (2). PTs also monitor deep tendon reflexes and muscle
strength via manual muscle tests (2). By carefully evaluating sensation,
reflexes, and strength, PTs help the care team determine if symptoms are
progressing, plateauing, or remitting.
Acutely, PTs help preserve range of motion through splinting, passive range
of motion, active assistive range of motion, and facilitation of active
range of motion (2). PTs help maintain respiratory hygiene via chest therapy
and help patients develop a tolerance to upright positions (2). In the acute
setting, PTs will start working on bed mobility, transfers, and wheelchair
mobility (2). When the patient is medically stable and able to tolerate
three hours of therapy daily, he or she may transfer from the medical floor
to inpatient rehabilitation (3). An estimated 40% of GBS patients will
require inpatient therapy (1). In inpatient therapy, the individual with GBS
will continue to work on bed mobility, transfers, wheelchair mobility, and
ambulation. For seven patients in a study by El Mhandi et al., the inpatient
therapy stay lasted three to four weeks (3) Upon discharge, these seven
patients participated in four to 10 weeks of outpatient physical therapy
(3).In outpatient therapy, goals include further increasing strength and
functional mobility. Important strategies to use include frequent rest
breaks and using low intensity high reps (2).
