Symptoms

Symptoms usually appear after a preceding infection. They increase in intensity over a period of time, varying from a few hours in serious cases to around 4 weeks in most patients. The symptoms also vary with regard to the pattern in which they appear. Their distribution is usually symmetrical and double-sided. This means that the symptoms appear on both the left and right side of the body, but they may also appear randomly, especially in the beginning. They may also appear and disappear quite randomly. Inflammation of the peripheral nerves leads to a tingly, numbing sensation in the arms and legs. This can eventually result in a short-term loss of feeling and movement (temporary paralysis).

Fever is not a symptom of GBS, but may be caused by the preceding infection that triggered the syndrome. GBS symptoms vary, depending on whether the syndrome has affected the sensory nerve fibres or the motor nerve fibres. When both motor and sensory nerves are affected, the patient experiences a mixture of symptoms. The patient may also experience disruption in the working of the autonomous nervous system.

Diagnosis

There is no specific test for this disease. Diagnosis is made by the clinical features, characteristic changes in the spinal fluid (from a lumbar puncture (spinal tap)), and electrical studies of the peripheral nerves and muscles, a procedure known as electromyography. The final diagnosis reflects only the elimination of other possibilities. There does seem to be a link with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).

Physiotherapy treatment

Recovery generally begins within a month of the height of the illness and has the potential to be complete. Unfortunately approximately 30% of patients will retain a residual paralysis or paresis, most usually in the lower limbs. Statistically significant correlations have been found between the degree of residual motor deficit and the severity of the weakness in the acute phase, the duration of the plateau phase or the duration of artificial ventilation [2].

Complications such as contractures, particularly those around joints, will delay or prevent full recovery and physiotherapy often concentrates treatment on these. Gentle stretching is undertaken to prevent the patient remaining for long periods in a bent or contracted posture and positioning in bed or when seated needs to be carefully controlled to ensure a good position. Splints may be used and active-assisted exercises slowly introduced.

Another complication to recovery is fatigue, so any exercises need to be carefully graduated in order to strengthen without overtiring the muscles. Temporary use of mobility aids such as wheelchairs and orthoses may be desirable to prevent overstrain. Patients with GBS do seem to have a reduced quality of life and functioning with persistent levels of distress even after the recovery period [3].

Pain can also be a problem, mostly caused by the affected muscles. Correct positioning and comfortable support will assist with this but often analgesia is required, especially at night. Anxiety is undoubtedly a factor in such a sudden and serious illness and is associated with perceived slowness in recovery.

Acupuncture treatment

There is little or no useful research into the treatment of GBS by acupuncture, but it has been used in clinic. Chinese researchers claim that acupuncture used alongside medication improves the outcome during the rehabilitation phase [4]. A single case study was published some time ago by a couple of physical therapists and has some useful traditional Chinese medicine (TCM) ideas but carries little weight scientifically [5].

Taking the problems listed above into consideration, acupuncture could certainly be used for pain analgesia and might be preferable to drug control. All acupuncture treatments will tend to have a calming effect but additional points could be used with that effect in mind. Fatigue can be tackled with metabolic and immune points added to the prescription. With GBS it will be necessary to treat with care to avoid overtaxing the recovery system, rather as in multiple sclerosis.

TCM theories

The link is with the Wei syndrome since early stages are often characterized by fullness and febrile disease. Interestingly, antibiotics are sometimes thought to be a causative factor as they destroy bacteria but fail to expel the External Pathogenic factor, resulting in a residual or latent Damp Heat in the interior.

Empty patterns are likely to be the result, particularly Spleen Qi Xu or Spleen Yang Xu. The two given below are not specific for GBS but are likely to manifest in one form or another.

Case study 10.1: level 1 case study: Guillain–Barré syndrome – pain in feet preventing walking

A 28-year-old man presented with severe pain and hypersensitivity in the soles of the feet. He was unable to put any weight through the feet due to pain. Pain also disturbed his sleep at night; pain medications had not helped with the foot pain. He was also feeling low in mood; he was very tired and irritable during the day. The patient was recovering from GBS which had developed 3 months previously.

Background

There can be many causes for peripheral neuropathy and GBS is only one of them. Perhaps more common is the type associated with the later stages of diabetes.

Research

Acupuncture has been used to control diabetic symptoms, most notably by Wang et al. [6], who treated the dyspeptic symptoms of gastroparesis by electroacupuncture at ST 36 Zusanli and LI 4 Hegu.

A small pilot study evaluated two clinical styles of acupuncture in the treatment of diabetic neuropathy. Japanese acupuncture, characterized by very shallow needle insertion, was compared to traditional Chinese acupuncture [7]. Interestingly, those given Japanese acupuncture reported decreased neuropathy-associated pain according to daily diary scores whereas those in the other group reported minimal effects. Both styles lowered pain as measured by the McGill Short Form Pain Score. The TCM style improved nerve sensation according to quantitative sensory testing while the Japanese style had a more equivocal effect. However, with such a small group – only 7 patients in all – no significant conclusions can be drawn. It remains possible that acupuncture could be useful in this situation.

Further work on peripheral neuropathy was undertaken by a German group [8]. This was a larger study, with 47 patients involved, all of whom were evaluated over 12 months. The results suggested that nerve conduction showed an objective improvement with treatment. Acupuncture analgesia has been compared with standard medication and proved as successful in alleviating the pain from this type of neuropathy [9].

Several ideas have been put forward, including the use of acu-magnets on acupuncture points, particularly for diabetes and insomnia [10].

Bearing in mind that regrowth of peripheral nerves is possible, if the conditions are favourable and destruction has not been complete, acupuncture to improve the local tissue condition and increase local circulation may be very helpful [11].

The following case study is not strictly illustrating diabetic neuropathy but demonstrates the general principles.

Case study 10.2: level 1 case study

This case report describes the treatment of knee pain in a 43-year-old man with alcoholic peripheral neuropathy with axonal damage. He had bilateral dorsiflexor muscle weakness and wore bilateral ankle foot orthoses. He had poor balance but walked independently with one stick. He had been diagnosed with epilepsy 4 years previously.

Causes

The specific cause is not really known. This problem can occur after stroke or a transient ischaemic attack simply because of the muscle weakness involved in those conditions but true Bell’s palsy is thought to be caused more by an inflammatory episode in the facial nerve. The most common situations which may lead to this inflammation are systemic viral infections, local infections, trauma, surgery, diabetes, tumour, immunological disorders or drugs [12]. It is also thought that a persistent cold draught on the side of the face can cause this type of inflammation.

Differential diagnosis

This relies upon the presence of typical symptoms and signs, blood chemical investigations, cerebrospinal fluid investigations, X-ray of the skull and mastoid, cerebral magnetic resonance imaging or nerve conduction studies. Bell’s palsy may be diagnosed after exclusion of all secondary causes, but causes of secondary facial nerve palsy and Bell’s palsy may coexist [12, 13].

Medical treatment

As Bell’s palsy is often associated with a viral infection, antivirals such as aciclovir may be prescribed. Corticosteroids may also be given to reduce the inflammation.

Physiotherapy treatment

Care must be taken of the eye surface when the eyelid is disabled; there may be either excessive tear production or a dry eye. An eye patch is often used. Otherwise gentle stretching, massage and active exercises when possible are all techniques used by physiotherapists. Electrical stimulation is an intervention used to encourage the return of activity to the muscles and the artificial contractions help to maintain circulation and tissue condition.

Acupuncture treatment

Simple application of needles to local points is the best form of treatment. The most commonly used points are those on the Stomach, Small Intestine and Gall Bladder meridians. Appropriate distal points should be used and low-frequency electroacupuncture (2–4 Hz) can be applied to the facial points, producing a treatment effect very like that obtained by electrical stimulation in physiotherapy.

Case study 10.3: level 1 case study – acute facial palsy

The patient was a 27-year-old female who had a middle- and outer-ear infection that was also diagnosed as shingles which affected balance and caused nausea. Her ear became red and swollen. She was given painkillers and antibiotics by her GP. Six days later she noticed that her mouth did not feel right when she was cleaning her teeth. She could not spit properly. Her parents also noticed she looked odd. She realized something was wrong with her facial muscles when she went to wipe her eye and touched her eyeball. Two days later she was unable to close her eye and the left side of her face had slumped. Her smile was asymmetrical. She went to her GP who diagnosed shingles/herpesvirus and gave her antiviral medications. She was also referred to an ear, nose and throat (ENT) specialist who prescribed prednisolone. She was advised that the problem could take 6 months to go – or might not go at all.

Symptoms

RLS is characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings. The distinctive aspect of this condition is that the condition is much worse when the patient is lying down or trying to relax.

RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs. These sensations are often called paraesthesias (abnormal sensations) or dysaesthesias (unpleasant abnormal sensations) and the sensations range in severity from uncomfortable to irritating or truly painful.

If it is a severe case it is thought to warrant medical treatment. Restless-legs symptoms are dramatically relieved with levodopa and dopamine agonists, which are first-line treatment for this disorder. In addition, opioids have been shown to provide a marked symptomatic relief. This unique responsiveness of RLS to both dopaminergic agents and opioids places it at the crossroad of the two systems implicated in the placebo response. Indeed, in recent large-scale studies a substantial placebo response was observed [14].

RLS and acupuncture

With the clear response to dopamine agonists produced by acupuncture it is logical to suppose that acupuncture may be of value in this condition and indeed there is a current Cochrane review, although only two trials, with a total of 170 patients, met the inclusion criteria [15]. Borderline positive findings are recorded but, as with most reviews, it is agreed that further work is needed. Even if this is classified as a ‘placebo’ response by the researchers, the clinical use of acupuncture would still seem to be warranted.

The points used were ST 36, GB 34, SP 10, BL 57 and BL 56, with the addition of scalp acupuncture using motor treatment zones.

Acupuncture research

There has been little research of note in this condition although, clinically, acupuncture has a good reputation. Two well-written case studies offer some information [16, 17]. A small group of patients of mixed acute and chronic conditions demonstrated that acupuncture had diminished the pain [18].

Acupuncture treatment

In common with all other viruses in TCM, the herpes zoster virus is considered as an invasion of Damp Heat. It often occurs together with some form of Liver stagnation. The most important action to take is to expel the Heat in the Blood using LI 4 Hegu, LI 1 Quchi and SP 10 Xuehai. ST 36 Zusanli and PE 6 Neiguan could also be added.

‘Ringing the Dragon’ is a technique often recommended for dealing with the large area of painful skin. This involves the superficial, oblique insertion of many small needles around the inflamed or painful area. Huatuojiaji points can be added in pairs above and below the affected nerve root. The best results are obtained when treatment is given in the acute phase of the disease but it is always worth trying in a chronic situation and even when the course of the virus has not been confined to an intercostal nerve.

Case study 10.4: level 2 case study

The patient was a school teacher, aged 58. He had retired early due to postherpetic neuralgia from which he had suffered for 4 years. This was atypical in that the area most affected seemed to be concentrated on his right eye. He was often forced to cover the eye with an eye patch as he found light painful and he took over-the-counter painkillers constantly to control a ‘burning, stabbing’ pain in that area. This was often spread over the right side of his face.

Mechanism

The usual cause lies with damage to the nerve endings and may involve subsequent regrowth leading to painful discharge of neurons in the stump and faulty connections with the spinal segment. There is evidence for altered nervous activity within the brain as a result of this loss or change in sensory input.

Treatment

The condition is generally described as chronic and intractable and there are few medical remedies. Surgery involving the destruction of nerve tissue is sometimes used but is rarely of permanent value. Some new treatments are available, particularly that of using a ‘mirror box’ where the mirrored limb is reversed to look like the amputated one, giving the impression that the loss has been somehow reversed for the duration of the treatment. This is thought to be effective since changes to the way the peripheral areas of the body are represented on the cortex may lead to changes in pain sensation. The neuroplastic changes and the pain itself seem to be increased if a chronic painful situation has preceded them [19]. Stimulation of the sensorimotor cortex does seem to be able to reduce the pain [20].

Acupuncture in phantom limb pain

There is little supporting research evidence for the use of acupuncture in this situation but it is nonetheless well known to be effective in clinic. Some case study work has been published, but not enough [21, 22].

Points are selected on the existing limb to correspond to the sites of pain in the missing limb. One would expect that mostly Yang meridians would be used with emphasis on the powerful analgesic points, such as L 4 Hegu, SI 3 Houxi, ST 44 Neiting and BL 62 Shenmai. There is a case for using a really strong sensory stimulus such as the Baxie points on the hand or Bafeng on the foot as long as the skin remains viable.