Guillain-Barre Syndrome (GBS) is an autoimmune disorder in which one’s own body system attracts his/her part of the peripheral nervous system. GBS is the most common cause of acute flaccid paralysis in the developed world (Harms, 2011). The exact cause of GBS is unknown, but roughly 66% of individuals experience an onset of GBS after a preceding infection (Plummer & Brown 2017). GBS can be very devastating because it is has an acute onset and the progress spreads very quickly, for instance, from being a healthy normal person to bedridden on a respirator within 2 or 3 days. The patients who have GBS demonstrate approximately symmetric limb weakness, absent or greatly diminished tendon reflexes, and minimal loss of sensation despite the paresthesia. Approximately 40% of the patients who are hospitalized with GBS will require inpatient rehabilitation (Khan, 2004). Pain is common, presenting as either a bilateral sciatica or aching in large muscles of the upper legs, flanks, or back. Weakness of the facial muscles occurs in about one third of cases. In severe cases the disease affects respiration, and may result in cranial nerve palsies with associated functional losses in eye movements and deglutition. Disturbances of autonomic function such as sinus tachycardia, bradycardia, facial flushing, fluctuating hypertension and hypotension, and the loss of sweating are common.
Because of the severity of GBS, patients are still at risk for a broad range of complications, including respiratory failure, autonomic dysfunction, thromboembolic disease, pain and psychiatric disorders. Multidisciplinary high-intensity rehabilitation is more effective than unidisciplinary rehabilitation for reducing motor disability and participation restrictions, especially when provided up to 12 months after the initial onset of GBS (Plummer & Brown 2017). Thus, appropriate interventions are critical for the patient’s recovery and awareness of the complications may help limit the morbidity of GBS (Harms, 2011).
First, the immunotherapies will be provided in inpatient care. Major medical treatments for GBS patients are Plasma Exchange (PE) and Intravenous Immunoglobulin (IVIg). These treatments can accelerate recovery, reduce long-term neurologic deficits, and minimize compilations during the acute phase of the disease. When our bodies are sick, our plasma can contain antibodies that attack the immune system. The purpose of PE is to filter the plasma and circulate neurotoxic antibodies from the patient’s bloodstream. According to Harms, the treatment significantly reduced the number of patients requiring mechanical ventilation, shortened the time to extubating, and increased the number of patients experiencing severe sequelae at 1 year (Harms, 2011). Additionally, plasmapheresis is reported to improve functional improvement of mobility (Meythaler, 1997). Intravenous Immunoglobulin (IVIg) is the other GBS therapy that is as effective as PE within 2 weeks of the onset, and side effects are minimal. It is easier to administer and less likely to transmit infection. Althoughboth treatments may significantly reduce recovery time in some patients who are in the acute phase or experiencing severe GBS, the cost is very expensive and has possible complications.
GBS patients present flaccid or hypotonic and show immobilization. Due to prolonged bed rest, the patients are at risk for of complications, therefore supportive care and patient or family/caregiver education contribute to avoiding unnecessary complications and support the patient’s recovery from the disease. One of the most common complications of GBS is respiratory failure due to severe bulbar weakness, autonomic instability, and pulmonary aspiration. Prior to mechanical ventilation, the mortality (death) rate in GBS exceeded 30%, mostly from respiratory failure (Harms, 2011). The progress is rapid; therefore, the health care team must monitor the patients carefully and frequently. Hypoxemia and hypercarbia are late manifestations, so as a result, regular bedside monitoring of the vital capacity, maximal inspiratory pressure, and maximal expiratory pressures are used instead of pulse oximetry and blood gases (Harms, 2011). Other common complications seen in GBS is Deep venous [JM6] thrombosis (DVT). As stated in the American College of Chest Physician guidelines, all minimally-ambulant or non-ambulant patients are commended to receive thromboembolism prophylaxis to reduce the patient’s risk of developing DVT (Harms, 2011). In addition, prophylaxis should be tailored to the patient’s comorbidities along with bleeding risk, renal function, recent spinal tap, and so on. (Harms, 2011). In addition, a compression stocking, thromboembolic deterrent stocking should be introduced in the early phase to reduce edema and prevent DVT.
Fight-or-flight response occurs when the sympathetic nervous system is activated, and likewise when excessive sympathetic over activity or acute dysautonomia is risk in patients with GBS. The common dysautonomia has been seen in GBS as hypertension, postural hypotension, and tachycardia. Tachycardia is most common and the range of 100-120/ min does not require treatment; however, the presence of tachycardia, increased in systolic blood pressure, reduced normal respiratory-induced heart rate variation, and a first episode of severe bradyarrhythmia (slow and irregular heart rate) will require the insertion of a pacemaker. Another complication of GBS is the psychiatric complication. Sudden loss of the independence, prolonged immobilization, and the even loss of communication produce a tremendous amount of stress and anxiety in patients. Anxiety occurs in 82% of patients, with moderate or severe depression occurring in two thirds of patients according to Harms.
As patients gradually make progress, patient and family/caregiver education needs to be addressed for fast recovery. During the acute phase the progression of weakness leading to anxiety in GBS patients, the patient and caregiver should attend to the patient’s emotional obstacles and understanding of the temporal course of GBS, its prognosis, the necessity of limiting overwork, and promoting safety until the patient reaches next phase. The education continues to monitor fatigue or symptoms of overwork to aid physical therapy with energy conservation strategies and the use of proper adaptive equipment for joint protection and safety. Lastly, psychological and emotional support is necessary for coping with stress such as loss of independence, financial struggles, and domestic problems.
GBS can be an overwhelming disease because it often leads to a functional deficit. Hence, physical therapy plays a significant role for motor recovery and improving functional independence. Physical therapy intervention is focused on functional retraining, strengthening, positioning/ROM, proprioceptive neuromuscular facilitation (PNF) techniques, and pain management. Examples of the functional training are bed mobility, bed-to-chair transfers, sitting and standing tolerance, gait training, and wheelchair mobility. In 2013, a study to assess GBS patients’ satisfaction with physical therapy (Physiotherapy) shows that participants were satisfied with management (87%), treatment frequency (88%), duration (94%), timetabling of treatment (81%), and professionalism of physical therapists (100%) (Dennis & Mullins, 2013).
All exercise is performed based on the patient’s current cardiopulmonary function, level of assistance, fatigue, and goals (Plummer & Brown, 2017). Likewise, strengthening training such as active assisted, active, and resisted exercise will facilitate the patients in dealing with the activities of daily living. Dombale states that exercise increases blood flow and the oxygen and minerals that nerve fibers need for repair and improves in muscle strength, which reduces the effects of neuropathy leading to muscle plasticity. According to the study, there were two group has that had been tested to compare the effectiveness of combined functional mobility training and strengthening exercise (Group B) and strengthening exercise alone in GBS patients (Group A). In this assessment, an overall disability sum score (ODSS) was used to measure the disability, and manual muscle testing was done by assessing muscle power of individual muscles . Group A’s comparison between pre- and post ODSS value was 0.25, while on the other hand, group B’s values was increased by 2.81 (Dombale & Kumar, 2012).
ROM/ positioning techniques are essential for GBS patients due to prolonged bed rest and immobilization. Motor weakness has been associated with muscle shortening, and it causes joint contractures. Through, ROM/ positioning we can prevent skin breakdown and joint contractures. For example, repositioning every 2 hours, gentle passive range of motion (PROM), active-assistive ROM (AAROM), splinting, and frequent skin checks will help prevent pressure ulcers.
Proprioceptive neuromuscular facilitation (PNF) techniques improve diaphragm muscle activity and pulmonary function for GBS patients. A recent study showed that breathing exercises improve respiratory muscle weakness; however, additional PNF techniques, repeated contractions and rhythmic stabilization, produced extensive results in breathing exercises. This supports the idea that PNF techniques improved the patient’s diaphragm muscle activity (DMA) by a mean of 40.33 compared to individuals who received only breathing exercise in isolation. Furthermore, PNF exercises also help improve pulmonary function (FEV/FVC) by a mean change of 25.00 compared to 5.87 for those who received breathing exercises (Vidhyadhari & Madavi, 2015).
Neurogenic and musculoskeletal pain is common for GBS patients. One study stated that 55% of patients reported pain and 72% reported pain during the entire during the process of the recovery according to Khan. Physical therapy interventions for reduced pain are low temperature heal application, PROM/ stretching to alleviate acute musculoskeletal pain, and transcutaneous electrical nerve stimulation (TENS).
Guillain-Barre Syndrome (GBS) is an acute onset autoimmune disorder that affects the nerves outside the brain and spinal cord and which causes abnormal sensation and weakness. The multidisciplinary discipline approach is beneficial for improving the prognosis of patients with GBS. Many of patients with GBS required inpatient setup, and during the stay physical therapy is commonly introduced to mobilize patients to sit, stand, transfer, and walk again. Understanding various approach of interventions is vital for treating patients and avoiding the risk of complication and is helpful to developed efficient physical therapy treatments.