treatment of peripheral nervous system disorders

what is the general treatment for metabolically induced (DPN) peripheral neuropathy

aerobic exercise plays a larger role in control of more systemic effects

focus on the CAUSE of the disorder

what is the general treatment for non-metabolically induced (GBS, CIDP) peripheral neuropathy

1. generally aerobic exercise is less important as doesn’t have same systemic effects

2. more important: ability to change neural adaptation

   1. balance training

   2. sensorimotor training

   3. whole body vibration

2/3 of GBS cases have what

diarrhea or respiratory illness

what is the evidence of COVID-19 being associated with GBS

1. may be associated

2. no epidemiological or phenotypic clues of COVID being causative of GBS

   1. can’t entirely rule out

what is the association of Zika virus and GBS

76% of those with GBS had Zika recently

what are other traditional antecedents of GBS

1. GI issues

2. Respiratory tract infections

3. vaccination

4. surgery

what is the clinical course of GBS

the antecedent event (trigger)

progressive period

nadir

plateau period

recovery phase

is there variability in progression to nadir in GBS

yes

-axonal types are faster

does the rate of progression to nadir in GBS impact the final functional outcome

NO

what are the 2 types of medical treatments for GBS

1. plasmapheresis: plasma exchange (PLEX) that removes filters plasma in hopes of extracting antibodies causing inflammation

2. Intravenous immunoglobulin (Ivig): administration of blood products with immunoglobulin proteins to assist with immune response

how many treatments/how long is plasmapheresis for GBS

1. 4-6 treatments over 8-10 days

2. results: earlier improvement in muscle strength, reduced need for mechanical ventilation, and better recovery

how long ins Ivig for GBS

5 days of treatment

does one treatment work better than the other for GBS

no, both work equally well

both treatments yield equivalent results and decrease time to walking by 40-50%

do corticosteroids work in GBS

NO! makes function worse

what are the clinical implications for medical treatment of GBS

timing therapy sessions

-Ivig: 1-2 hours before

-Plasmapheresis: 1-3 hours before

extreme fatigue following/can have orthostatic hypotension

what is the scoring system for looking at prognosis of GBS

mEGOS scoring system

-at day of hospital admission and at day 7 of admission

-composed of: age, preceding diarrhea, and MRC sum score

-area under the curve >0/7 during all time frames

what is mEGOS predictive of

the ability to walk with unassisted device at 4-6 months

what is dorsiflexion ability predictive of for the prognosis of GBS

following immunotherapy/admission, if pt doesn’t have ability to DF foot = higher risk for prolonged mechanical ventilation

out of pts seen for inpatient rehab with GBS, MS, PD, or stroke…which patients had the greatest improvement

GBS population

at 6 months what percent of pts with GBS have residual deficits and what may they be

71%

Sensory symptoms, minor weakness, walking aids, neuropathic pain

what are the percent of patients that cannot walk at 6 months and at 1+ year

6 months: 17-20% pts can’t walk

1+ year: 4% can’t walk, 8% require AD

should the berg balance scale be used as an outcome measure for pts with GBS

yes

it is valid and reliable in GBS

has ceiling effects in those with higher level of balance at discharge

predicts the 10MWT, 6MWT, and length of stay for rehab

what does the berg balance score help determine the need for in patients with GBS

help determine prescription of need for AD

> or = 49 points: no AD

< or = 37 points: need walker

what interventions should be used during the acute phase through plateau of GBS

1. maintain joint ROM with pain tolerance- stretching

2. AAROM- within pt capability

3. prevention of complications of immobility (positioning, skin monitoring, turning)

4. modalities (hot packs) for comfort

5. splinting/boots for prevention (ankles)

6. support respiratory hygiene

what is the emerging evidence for NMES and muscle fiber strengthening during acute through plateau phases of GBS

*PNS not intact for NMES = NO CONTRACTION = use direct muscle fiber stimulation instead

helps maintain max isometric strength and cross sectional area

electromyographic biofeedback therapy of ______ ________ improved nerve recovery and strength in children with GBS

anterior tibialis

is respiratory status dysfunction common in GBS

YES

in subacute (>16 days) restrictive pulmonary dysfunction in 79% patients

what are supportive respiratory cares that should be taken in pts in the acute phase of GBS

1. auscultate breath sounds

2. turn and reposition

3. ACT via coughing and deep to prevent atelectasis (pneumonia)

4. watch arterial blood gasses → 30% on ventilator due to hypoventilation

what is recommended treatment for respiratory status in acute phase of GBS

add PNF and diaphragmatic breathing daily for 1 week

-improves control on diaphragm muscle function and pulmonary function tests

what does inspiratory muscle training help improve in the acute phase of GBS

mean inspiratory pressure