Disorders of the PNS II (GBS & Bells Palsy)

Question 1

What is the diagnosis of the following clinical manifestation?

• Symetric distal flaccid paralysis evolved in 3 days
• Decreased DTR
• unstable BP
• OH
• Paresthesia
• impaired vibration and position.
• increased pain at night on gluts and hamstrings

Answer 1

GBS

Question 2

percentage of GBS patients that die due to secondary complications (resp., card, or other systemic organ failure)?

Answer 2

5%

Question 3

Is it Bell’s Palsy if the pt is able to close eye an wrinkle forehead?

Answer 3

No, UMN lesion (central lesion)

Question 4

how long is the progressive phase of subacute inflammatory demyelinating polyradiculoneuropathy (GBS)

Answer 4

4 - 8 weeks progressive phase

Question 5

GBS diagnosis:

Answer 5

1. Clinical Signs & Symptoms
2. Lab results:
   
   • Normal WBC
   • Elevated protein
3. h/o flu-like preceding onset of symptoms
4. CSF of normal WBC count and increased protein level
5. Abnormal NCV

Question 6

What is Acute Inflammatory Demyelatimg Polyradiculoneuropathology?

Answer 6

GBS subtype, most common

Question 7

The LMN (Bells Palsy) involvement of the facial nerve can be differentiated from an UMN involvement of this nerve because with UMN involvement the patient can…

Answer 7

• close the eye and wrinkle the forehead but cannot smile voluntarily.
• With LMN involvement, the client Is unable to close the eye, wrinkle the forehead, or smile voluntarily.

Question 8

Acute forms of GBS:

Answer 8

1. Acute motor axonal neuropathy: axon affected
2. Acute autonomic neuropathy
3. Acute motor & sensory axonal neuropathy
4. Miller Fisher syndrome

Question 9

2/3 cases of GBS have autonomic impaiments including:

Answer 9

1. impaired CO
2. arrythmias, OH
3. unstable BP
4. peripheral pooling
5. impaired venous return
6. ileus
7. urinary retention

Question 10

What is the current Tx of choice for GBS:

Answer 10

Intravenous immunoglobin (IVIg)

Question 11

80% GBS patients become ambulatory within how long?

Answer 11

6 months of onset

Question 12

GBS affects what?

Answer 12

nerve roots and peripheral nerves

Question 13

Rehabilitation Considerations of Bells’ Palsy:

Answer 13

1. Electrical Stimulation to facial muscles
2. Cold laser
3. Neuromuscular reeducation using sEMG biofeedback

Question 14

how long is the progressive phase of chronic inflammatory demyelinating polyradiculoneuropathy (GBS)?

Answer 14

more than 8 weeks

Question 15

Which GBS Tx is Indicated for pt with severe respiratory involvement?

Answer 15

Plasmapheresis (Plasma Exchange)

Question 16

Medical interventions for Bell’s Palsy

Answer 16

1. Corticosteroids: prednisone
2. Antiviral medications
3. Nerve root decompression surgery (rare)
4. Eye care (artificial tears)

Question 17

What is the incidence of Bell’s Palsy and GBS?

Answer 17

• Bell’s Palsy is 20/100,000
• GBS is 2/100,000

Question 18

Diagnosis of Bell’s Palsy based on what?

Answer 18

• Clinical presentation
• electrodiagnosis test: diff bet axonal or demyelation
• test facial nerve excitability
• diff between UMN and LMN involvement

Question 19

how long is the progressive phase of acute inflammatory demyelinating polyradiculoneuropathy

Answer 19

4 weeks or less

Question 20

• multifocal motor neuropathy with conduction block
• chronic relapsing axonal neuropathy
• Are characteristics of what type of GBS?

Answer 20

chronic inflammatory demyelinating polyradiculoneuropathy

Question 21

Acute unilateral weakness of facial muscles due to inflammation within the fallopian canal OR inflammation of CN VII (facial n):

Answer 21

Bell’s Palsy

Question 22

What is the underlying cause of Bell’s Palsy?

Answer 22

1. Ischemic condition of nerve
2. Viral or Bacterial
3. Autoimmune disorder
4. Anoxia to nerve results in marked edema: vasodilation, transudation of fluid, further pressure effects

Question 23

Brighton Diagnostic Criteria for GBS:

Answer 23

1. Bilaterla flaccid weakness of limbs
2. Decreased or absent DTR in weak limbs
3. Monophasic course onset-nadir 12h to 28 days
4. CSF count <50/microl
5. CSF protein > normal
6. NCS
7. Absence of alternative diagnosis

Question 24

Tretament of GBS:

Answer 24

Immunotherpay bases Tx:

1. Plamapheresis:
   
   • ​Mild: 2 sessions.
   • Severe: at least 4 sessions
2. Intravenous immunoglobin
   
   • ​​2g per Kg of body weight over a 5 day period.

Question 25

What are the most common long term deficits of GBS?

Answer 25

1. Weakness of ant. tibialis 2. Fatigue/poor endurance 3. Some pt, sensory deficits 3-6 years after recovery

Question 26

Course/Prognosis of GBS:

Answer 26

1. Weakness develops 12h to 28 days. Should not porgress after 4 weeks 2. 50% of pt experience worse S & S within one week of onset 3. **Recovery begins 2 - 4 weeks after plateau** 4. Recovery occurs prox. to distal 5. 80% of pt amb within 6 months of onset 6. 65% -75% return to normal function 7. Some with sensory deficits 3- 6 years after recovery

Question 27

How many GBS patients return to clinically normal function?

Answer 27

65% to 75%

Question 28

Recent research identified ___________ as most frequent cause (60% - 70% of cases) of Bell's Palsy

Answer 28

Herpes simplex virus (HSV-1)

Question 29

**Sensory impairments** of GBS include:

Answer 29

1. mild 2. distal hyperesthesia, 3. paresthesia 4. numbness 5. impaired vibration & position, 6. often stocking and glove pattern

Question 30

Rehabilitation Considerations of GBS:

Answer 30

1. Facilitate resp, speech, and swallowing funct. 2. Reduce pain (modalities) 3. Prevent secondary complications (PROM) 4. Maximize function 5. Reasses muscle weakness 6. Awareness of fatigue levels 7. Psychological concern

Question 31

Risk factors of Bell's Palsy:

Answer 31

1. Diabetes mellitus 2. Pregnancy 3. Conditions that compromise the immune system 4. Previous history of Bell’s Palsy * 5 – 10% recurrence * Average 10 yr time span between recurrences

Question 32

Clinical manifestation of Bells's Palsy:

Answer 32

1. eye does not close 2. unilateral peripheral facial weakness 3. asymetrical face appearance 4. sometimes accompanied by aching pain by jaw or behind ear 5. loss of taste on the affected side 6. autonomic fiber affected (dry eye, decreased saliva production) 7. sounds seem lauder 8. crocodile tear syndrome (motor synkinesis)

Question 33

Prognosis of Bell's Palsy:

Answer 33

* good recovery * recovery begins at 1 week of onset * 75% fully recovery over several week to 3 months * If recovery takes more than 3 months, usually see more severe residual deficits * Poorer outcome if: * \>60 y/o * Hypertension * Autonomic involvement * If no recovery: plastic surgery to restore facial function

Question 34

how long is the progressive symptoms of **acute** GBS? (how long does it take to get at its worse?

Answer 34

4 weeks or less

Question 35

Normal CSF white blood cell and increased protein levels (albumin) count help differentiate what disease?

Answer 35

GBS

Question 36

GBS Clinical Manifestations:

Answer 36

1. Symmetric, progressive, **distal to proximal** **wekaness** or flaccid paralysis. Often rapidly evolving 12h to 28 days 2. **Areflexia** 3. **Possible CN and respiratory involvement:** * 50% CN involvement * 25% need artificial ventilation 4. **Autonomic impairments:** impaired CO, arrythmias, OH, unstable BP, peripheral pooling, impaired venous return, ileus, urinary retention 5. **Sensory Impairments:** mild, distal hyperesthesia, paresthesia, numbness, impaired vibration & position, often stocking and glove pattern 6. **Pain:** muscle aching type, increased at night, symmetrical, on large bulk muscles