Guillain-Barré Case Study: Marie

Abstract[edit | edit source]

This case study illustrates a fictional narrative of a 53years old female patient who develops Guillain-Barré syndrome (GBS) relating to her diagnosis of COVID-19. The case study documents the patient’s initial admission into acute care until discharge after she achieves her short-term goals and regains independence in activities of daily living (ADLs). Emphasis is placed on the patient’s time spent in in-patient rehabilitation, where details of initial assessment and goal setting, intervention plan, discharge plan, and the outcome are discussed. The patient presents with progressive bilateral upper and lower limb weakness and impaired motor skills. Therefore, the interventions focus on return to functional activities, achieved through strength and functional training, aerobic training, and pain management. The purpose of this case study is to showcase a typical case presentation of GBS, as well as possible approaches to assessment, outcome planning, and treatment/intervention in an in-patient rehabilitation setting.

Introduction[edit | edit source]

GBS is a neurological condition where the body’s immune system mistakenly attacks parts of its peripheral nervous system. Most cases will start a few days or weeks after a respiratory or gastrointestinal viral infection and in some cases, can occur following surgery.[1] Symptoms include symmetrical limb weakness, hyporeflexia or areflexia, sensory disturbances, and in some cases cranial nerve deficits.[2] Abnormal sensations often precede these symptoms, typically manifested as tingling in the feet or hands or even pain that most commonly starts in the legs or back. Diagnosis is based on symptoms and can be supported by additional investigations such as cerebrospinal fluid examination and nerve conduction studies.[1]

GBS is more common in men than in women and occurs less frequently in children than in adults, therefore incidence increases with age.[2] The condition can be difficult to diagnose because there are other peripheral nerve disorders with slow onset and persisting or recurrent symptoms. This includes chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy.[3] There are also various differential diagnoses for GBS which include infectious diseases, malignancy, and disorders of the neuromuscular junction, which can also make diagnosis difficult. A lumbar puncture is typically recommended in order to rule out potential diagnoses other than GBS.[2]

Acute medical care occurs early and involves two treatments used to interrupt the immune-related nerve damage. These treatments include plasma exchange and high-dose immunoglobulin therapy. Physiotherapists have several roles in both the acute care and rehabilitation settings.[1] They can provide strength and conditioning exercises to prevent and/or reverse musculoskeletal and cardiorespiratory weakness. They can also assist with bed mobility which helps to reduce the occurrence of pressure sores, deep vein thrombosis (DVT) and promote movement. As patients are transferred from acute care to rehabilitation, specific exercises should be selected that can allow individuals to regain functional activities and tasks required for daily living.[3]

Previous reports have been done to highlight the physical therapy strategies used for the rehabilitation of COVID-19 related Guillain-Barré syndrome. One case report, in particular, followed a 61-year old male who was admitted to a long-term acute care hospital following a diagnosis of COVID-19 related GBS. Rehabilitation involved a variety of skilled treatment interventions to meet the patient's goals and maximize function in preparation for discharge. The patient’s improvements were demonstrated through manual muscle testing, range of motion, grip strength and activity measures.[4] This case report can be directly correlated with our case as our patient is also experiencing COVID-19 related GBS, sharing a similar main focus which is to accomplish patient goals and maximize overall function in order to return to the community. The purpose of our case study is to understand the clinical progression of GBS and the role of a physiotherapist as well as an inter-professional team in managing this condition in the sub-acute phase. Our objectives are to demonstrate the clinical progression of GBS from initial assessment to discharge, and the subsequent improvements in function and quality of life that can be made with the help of physiotherapy and an inter-professional team. One challenge we met when managing this case was finding validated outcome measures for GBS.

Case Background[edit | edit source]

Marie Smith, a 53-year-old female, arrived at the emergency department complaining of weakness and discomfort in her extremities. Marie explained she had been feeling numbness and tingling in her toes for two weeks now, with symptoms progressively worsening. One month prior, Marie was diagnosed with COVID-19 and attributed her symptoms as residual effects of the infection.[5] Over the past 3 days, Marie had experienced increased weakness and impaired motor skills. She noted a specific difficulty holding her toothbrush and brushing her teeth, influencing her to seek medical attention. Due to her rapidly progressing signs and symptoms, Marie was admitted to the hospital.

Marie’s status worsened the next week while in hospital. She was unable to move her upper or lower extremities and had trouble breathing and swallowing. Marie was admitted to the intensive care unit (ICU) where she was provided with supplemental oxygen to assist with breathing and a nasogastric (NG) tube was inserted to provide nutrition. An interdisciplinary medical team supported Marie throughout her time in the hospital and consisted of physicians, physical therapists, occupational therapists, speech pathologists, social workers, dieticians, and nurses. The team focused on providing passive and active-assisted range of motion, appropriate positioning, swallowing, and regaining general mobility. Marie was transferred from the ICU to the hospital’s step-down unit where her condition stabilized. After one week in the ICU and one week in the step-down unit, Marie was transferred to the inpatient rehabilitation unit. Inpatient rehabilitation physiotherapy began four weeks after symptom onset when Marie’s status had stabilized.

Client Characteristics[edit | edit source]

Patient profile: Marie Smith, 53-year-old Caucasian female

Medical Diagnosis: Guillain–Barré syndrome (Acute inflammatory demyelinating polyradiculoneuropathy)

Primary complaint: Patient was experiencing progressive pain and weakness in bilateral extremities. Symptoms progressed to inhibit motor function and lead to poor coordination

Nature of condition: Patient is in the sub-acute phase of rehabilitation, with her condition improving since hospital admission

Primary Reason patient was referred to physiotherapy: Patient was referred to inpatient rehabilitation physiotherapy to address weakness and loss of range of motion in bilateral upper and lower extremities, improve balance, ambulation, and ADLs

Previous medical history: Diagnosed with COVID-19, cesarean section in 2003, celiac allergy

Current Medication: Advil regular strength (200mg 2x per day), Intravenous Immunoglobin Therapy (IVIg) (high dose IVIG- taken as needed)[6][7]

Assessment[edit | edit source]

Subjective[edit | edit source]

Present condition and functional history: Upon initial assessment and admission to the inpatient rehabilitation unit, Marie reports she is no longer experiencing difficulties with breathing and swallowing. She also states she has regained some motor control of her upper and lower extremities but is still experiencing some lower extremity weakness bilaterally.[8][9] As a result, she finds it difficult to stand for longer than four minutes with a four-wheeled walker (4WW) and walk longer distances with a 4WW. Marie notes that she is specifically having difficulty with sit-to-stand transfers due to lower extremity weakness and ongoing difficulties with balance,[8] making tasks such as bathing and toileting challenging. Marie also states that she is back to performing most upper extremity tasks effectively, such as brushing her teeth and eating, but reports that the tasks do not feel completely normal due to some continued coordination impairments,[9] she expressed, “I can get the job done but it just doesn’t feel right”.

Marie reports that she continues to experience symptoms of numbness and tingling in her toes,[9] however, they are no longer worsening. Over the past three days, Marie has noticed that her sensitivity to pain has increased (9,10),[9][10] where the sensation of her bed sheets or someone touching her skin sometimes produces a sharp pain (VAS 5/10).

Marie expresses concerns about her continuous fatigue[9] and is worried that she might never get back to feeling normal or be able to return to work. She also feels that she has become a burden to her family since being admitted to the hospital, as they are constantly coming in to visit and her husband has been forced to take over her previous responsibilities.

Social history: Marie lives with her husband, two teenage daughters, and one dog in a two-story house. The front porch has four stairs leading into the house with two railings, in addition to the 10 stairs inside the house leading to the second level with two railings. Prior to her admission to the hospital and inpatient rehabilitation, Marie would take her dog for walks daily. As well, since both daughters are competitive dancers, Marie spent a lot of her weekday evenings and weekends driving the girls to dance classes. Marie is currently on medical leave since receiving treatment for GBS but previously worked as a massage therapist at a busy clinic which required a lot of physical demands on her body. Marie’s family has been very supportive throughout and has consistently been visiting her throughout her time at the hospital.

Goals and expectations: Marie’s primary goal is that she wants to return to work so that she can continue to support her family, including supporting her daughters through dance and putting money away for their college/university expenses. As well, Marie holds the goal of wanting to be fully independent in the everyday tasks of dressing, bathing, toileting, and food preparation so that she does not feel as though she is a burden to her family. Lastly, Marie is hoping that physiotherapy will be able to help her manage her levels of pain and fatigue so that she is able to get back to feeling more like herself again.

Objective[edit | edit source]

The following outcome measures were performed over the course of 2 treatment sessions to reduce the risk of fatigue.

Functional Independence Measure (FIM): This outcome measure was used to assess Marie’s independence in her ADLs. Upon initial assessment at in-patient rehab:

  • Marie scored a 50/91 on the motor subscale of the FIM
  • She demonstrated most difficulty with bathing, toileting, transfers, walking and stairs

Reflexes:[9] Patient demonstrated diminished reflexes (hyporeflexia) at all lower extremity reflexes tested and absent patellar tendon reflex bilaterally. Most notably:

  • Patellar Tendon (L3-L4): 1 B/L
  • Achilles Tendon (S1-S2): 0 B/L

Touch and Pressure:[9] [10]Patient demonstrated decreased light touch of upper and lower extremities bilaterally which was more pronounced distally. Firm pressure sensation was only shown to be abnormal in the distal lower limbs.

Tactile Localization:[10] Marie presented with tactile extinction in the distal upper and lower extremities bilaterally.

Range of Motion (ROM):[10] Due to decreased mobility over the course of Marie’s hospital stay and prolonged periods of sitting she presents with limited ROM which is more pronounced in the lower extremities bilaterally. The following limitations were noted for the upper and lower limbs:

  • Ankle dorsiflexion 0-5° B/L
  • Knee flexion 0-100° B/L
  • Hip extension 0-5° B/L
  • Shoulder abduction/flexion 0-75° B/L

Manual Muscle Testing (MMTs):[9] [10]This test was performed to assess bilateral weakness reported by the patient in subjective history. The following limitations were noted bilaterally:

  • Hip extension 2+/5 B/L
  • Knee flexors/extensors 3-/5 B/L
  • Ankle dorsiflexors 2+/5 B/L
  • Shoulder abduction/flexion 3/5 B/L

Dynamometer grip strength:[10] This test was completed to assess the isometric strength of Marie’s hand and forearm muscles which is important for functional tasks.

  • Marie scored 19.5 kg with right hand (dominant)
  • Scored 17.5 kg with left hand

BERG Balance Scale: This balance assessment was performed due to patient reports of ongoing difficulties with balance.

  • Marie scored a 35/56 on the BERG
  • Marie demonstrated most difficulty with sitting to standing, standing to sitting, transfers, turning, and retrieving an object off the floor

Timed Up and Go (TUG): This assessment was performed in order to get a sense of Marie’s dynamic balance, fall risk, sit-to-stand, and walking ability. The following was recorded:

  • TUG was completed in 18 seconds
  • Marie completed the task with the use of a 4WW

6-Minute Walk Test: This assessment was selected to assess aerobic capacity and endurance during gait. The following was noted:

  • Marie was able to ambulate 150m during the test using a 4WW
  • She had to take frequent breaks during the 6 minutes due to fatigue
  • Patient walked at a slow pace with a wide base of support
  • Decreased foot clearance during swing B/L which was compensated with hip hiking

Guillain-Barré Syndrome (GBS) Disability Scale, adapted from Hughes et al. (1978):[11] [12] Patient scored a 3 on the GBS Disability Scale on initial assessment.

Clinical Impression[edit | edit source]

Problem List

  • Impaired balance
  • Increased risk for falls
  • Gait: slow-paced, wide base of support, hip hike observed and decreased foot clearance
  • Decreased strength: hip extensors, knee flexors/extensors, ankle dorsiflexors, shoulder flexors/abductors
  • Limited ROM: hip extension, knee flexion, ankle dorsiflexion, shoulder abduction and shoulder flexion
  • Poor grip strength
  • Fatigue
  • Difficulty with ADLs
  • Pain

Physiotherapy Diagnosis

Marie is in the subacute recovery phase of Guillain–Barré syndrome. The weakness in her lower extremities (LE) muscles is limiting her ability to walk longer than four minutes or 150m, stopping her from being able to take her dog for a walk. She also has poor balance and weakness in her upper extremities (UE) muscles, making some tasks (i.e. bathing, toileting) difficult to perform and increasing her risk for falls. The patient is a good candidate for PT aimed at increasing strength of her UE and LE, ROM, and improving balance and gait.

International Classification of Functioning with factors specific from Marie's Case.

Intervention[edit | edit source]

There is no known cure for GBS, however, the intervention approach for Marie’s care will involve tailoring it to her specific needs and goals as we want her treatment to be both meaningful and functional. Overall, the intervention approach is to gradually return Marie to normal functional status. Marie’s treatment plans and goals will look different in the acute care and inpatient rehabilitation setting. The focus of acute care will be the prevention stage while inpatient rehabilitation will focus on the functional stage.[1]

Since the prevention stage was already managed by the acute care team which included aspects such as DVT and pressure sore prevention, we will focus on the second stage. This next stage will focus on Marie’s return to functional activities, which is the most important in order to help Marie achieve her goals and increase her quality of life. We will use techniques to target her decreased range of motion, decreased muscle strength, impaired balance and gait, increased risk of falls, difficulties with certain functional tasks, increased fatigue and increased pain. Through this inpatient rehabilitation program, we will likely see improvements in her FIM score as well as muscle performance.[13] We will also adopt a gradual approach at this stage while ensuring that she is not overworked or too fatigued.[13] Our goal is to include one hour of daily physical therapy treatment for Marie at least five times a week.[13]

Short Term Goals In two weeks, Marie’s goal is to stand for five minutes independently, without the use of a gait aid.
In three weeks, Marie’s goal is to reduce her daily sensitivity to pain, where her highest pain exacerbating event for each day is a maximum VAS 2/10.
By four weeks, improve dynamic balance by achieving a score of 43/56 on the BERG balance scale.
By four weeks, complete basic activities of daily living (BADLs) with minimal assistance, 90% of the time.
Long Term Goals In five months, Marie’s goal is to become independent in her instrumental activities of daily living (IADLs) such as completing laundry, grocery shopping, banking, etc. 85% of the time.
In six months, Marie’s goal is to walk 300 meters independently, without the use of a gait aid.[1]
In eight months, Marie’s goal is to return to work with reduced abilities (part-time with 80% focus on documentation/clerical work).[1]

According to the subjective history taken upon assessment, Marie’s primary long-term goal is to return to work as a massage therapist in order to provide for her family and satisfy their financial needs, as they have many expenses including education and extracurricular activities. This participation goal requires initial recovery of both her upper and lower extremities (body structure and function aspects) as massage therapy is a physically demanding profession. We will assist Marie in achieving her goals by applying interventions that will help her recover physical function in the short term such as ROM, strength and cardiopulmonary function. Once body structure and function have shown improvement, we will incorporate functional rehabilitation to achieve her long-term goals, including tasks that are more relevant to her profession such as balance, dual-task, and gait training.

Range of Motion

  • ROM exercises are beneficial for preventing or reducing contractures[10]
  • Passive ROM then active assisted ROM and eventually active ROM exercises against gravity[14] are encouraged in patients with GBS
  • Goniometry may be used as an outcome measure to track progress
  • Parameters: 10 reps through each range, three times daily[14]
  • Important joints are the ankles, knees and hips as Marie has a low tolerance for weight bearing and endurance, her lower extremity joints have reduced ROM according to her initial assessment and show signs of weakness. Specifically, we would want to work to regain full ROM for ankle dorsiflexion, knee flexion, hip extension and shoulder abduction/flexion as those are currently limiting Marie’s functional activity.
  • For her upper extremity, we will target the shoulder, elbow, wrist and finger flexion/extension. These ranges will be functionally important for returning to work
  • Increasing ROM will facilitate a more normal gait pattern, thus decreasing Marie’s dependence on a gait aid and increasing her independence to perform her ADLs for not only herself but her children as well  


  • Trunk muscle strengthening will aid in postural control, important for movement control
  • Improving upper and lower extremity strength through theraband exercises has been shown to not only contribute to functionality but improve quality of life in patients with GBS[14]
  • Marie exhibits a hip hike in the swing phase of walking. This compensation may be from weak hip flexors, hamstrings/knee flexors or foot drop due to dorsiflexor weakness. If we can improve both hamstring and DF strength, gait will see subsequent improvements as well
  • Outcome measures for upper extremity include hand grip dynamometry and MMTs, and MMTs for lower extremity
  • Parameters: Starting with a light theraband for all and progressing at the two week mark
    • Hip flexion and extension, prone knee flexion and extension, ankle dorsiflexion, shoulder abduction and flexion 3x/week, 10 reps x 3 sets with 2 min of rest

Balance & Gait

  • The altered soft-tissue length and muscle weakness seen with GBS affects balance and gait as demonstrated with Marie’s Berg, TUG and 6MWT, therefore it is crucial to consider this as a part of her treatment[15]
  • Work on static balance (eyes open & eyes closed) on even surfaces progressing to unstable surfaces with external perturbations such as turning her head, functional reaching, ball toss by 3-4 weeks[16] Parameters: Hold position for 30 seconds-1 minute x3 a day, 5x/week
    • This is relevant for Marie as she will be standing for long periods of time at work while massaging her clients (reaching)
  • Marie is currently able to ambulate 150m with her 4WW, so we will start by slowly progressing her distance and decreasing her reliance on a gait aid[14]
  • Progressively increase her walking distance by 25m each week, as tolerated
  • As her stabilizing increases, we can fit her for a quad cane and instruct her how to use it to increase her independence around the community. Additionally, many GBS patients will ambulate without a gait aid after three months, so we want to progressively decrease the use of an aid[10]
  • As she becomes comfortable ambulating on a smooth, level surface, we will progress her to ambulating on uneven outdoor terrain so that she is able to participate in the community[16]

Functional training

  • Marie demonstrated the most difficulty with bathing, toileting, transfers, stairs, turning and retrieving an object off the floor during our assessment so we can target these during our treatment
  • ADL practice involving bathing and toileting by giving her strategies and practicing certain series tasks by breaking them down into part-tasks (can be directed by Occupational Therapy as well)
  • After teaching Marie how to ambulate with a quad cane, we can teach her how to ascend and descend stairs with two railings and the cane
    • Progressively increase from two stairs to 10 stairs by the end of her inpatient rehabilitation so she is able to climb the four stairs on her front porch and 10 stairs inside her house[16]
  • Working on coordination of her upper extremities since she reports feeling uncomfortable with these tasks

Aerobic/Cardiopulmonary Training

  • Aerobic training has been shown to improve PaO2, prolong fatigue and isokinetic muscle strength in elbow flexion, extension and knee extension in patients with GBS[15]
  • With respect to body structure and function goals, increasing aerobic capacity can improve FIM motor scores, indicating a positive prognosis for Marie to have the physical capacity to return to work[15]
  • Cycle training 3x/week for 15 minutes at moderate to high intensity
  • Proprioceptive Neuromuscular function techniques to activate the diaphragm are recommended for patients with GBS to improve pulmonary function.[17] Spirometry values can be taken and compared pre and post-treatment
    •   Parameters: Moderate cycling 15 mins x 3/day, each day


  • If contractures persist, the orthosis may be a feasible option to aid Marie in locomotion[18]
  • The prognosis of her needing an ankle-foot orthosis (AFO) or a full knee ankle foot orthosis (KAFO) is for the most part positive because she is already walking with a 4WW, yet she has rather concerning TUG and 6MWT scores
  • Distal weakness and drop foot during locomotion may be hindering her mobility, so the orthoses keeping her feet in slight dorsiflexion could increase her confidence and further facilitate efficient locomotion

Pain management

Kinarm exoskeleton for upper extremity rehabilitation


  • The use of virtual reality and robotics will be used during the early stages of rehabilitation (acute stage) to improve impaired proprioception, sensation and motor skills in a safe and regulated environment[21]
  • Virtual reality will be utilized to allow Marie to experience real-world simulations to improve tactile experiences and proprioception.
  • The use of robotics, such as a Kinarm exoskeleton, will also be used in inpatient rehabilitation to help improve Marie’s range of motion. Robotics allows Marie to move her upper and lower extremities in a functional manner, despite muscle weakness and biomechanical impairments. This will allow Marie to engage her limbs and participate in exercise earlier with the assistance of robotics as opposed to without robotics.

Interdisciplinary Team Management[edit | edit source]

  • Occupational therapists[10]
    • Work on improving Marie's ADL's as she struggles with bathing and toileting in particular
    • Help her come up with strategies to return to work
    • Can aid in the assessment of GBS including the FIM
    • Will assist with adjusting Marie's home environment to facilitate easy mobility
    • Can help with de-stressing and cognitive strategies to help Marie with her stress
    • Recommended 1 hour of occupational therapy, 5x a week[13]
  • Social workers
    • Help Marie to connect with community supports to help her manage return to her busy lifestyle - this could include transportation services and other community resources
    • Coping with the psychosocial stress of not being able to do the activities she used to do
    • Coping with the burden of not being able to work and financially support her two daughters at dance
  • Physicians[22]
    • Diagnosis of GBS
    • Assess and manage co-morbidities
    • Pain management in early phase to ensure success in inpatient rehab
    • Make referrals to appropriate interdisciplinary team
  • Dieticians[23]
    • Education around adequate nutrition intake, especially consuming enough protein intake as protein depletion is common in GBS
    • Celiac disease management
    • Prevent complications that can result from malnutrition: loss of respiratory muscle strength and endurance, generalized muscle weakness, reduced immune system, increased risk for pressure ulcers, and more
  • Speech Language Pathologists
    • Primarily used in the acute stage of Marie’s treatment as she was having difficulties swallowing
    • Regular check-ins with Marie to ensure she continues to experience no bulbar dysfunctions
  • Nurses
    • Regularly assisting with ADL’s
    • Can coordinate pain medication schedule with the PT to help Marie in her physical therapy sessions
    • Frequent check-ins with Marie’s overall physical and mental health status
Mind map of interdisciplinary team members involved in Marie's case

Subjective Outcome[edit | edit source]

Present Condition: In most individuals with GBS, their symptoms will peak after four weeks. After this period, they remain stable for a time allowing the nerves to gradually heal.[24] Marie is currently four weeks into her inpatient rehabilitation program. Marie’s symptoms have begun to stabilize throughout the past few weeks of therapy and she has been able to increase her balance and strength, as well as her coordination. This has helped her to reach her short-term rehab goals, as well as made her activities of daily living easier for her. Marie has been participating in 1 hour of daily physical therapy treatment at least 5x per week for the past four weeks. ROM, strength, balance, and gait assessments were recorded every week to ensure that Marie was progressing as desired. A complete reassessment was done after four weeks of treatment.

Pain: Marie reports that her sensitivity to pain has decreased, she no longer gets sharp pain when her skin is touching her bedsheets or when someone touches her skin. Her highest pain exacerbating event for each day has a maximum VAS score of 2/10. On occasion, Marie still experiences pain after exercise or prolonged weight-bearing during treatment.[10]

Goals and Expectations: Marie feels like less of a burden to her family now that she is able to perform her activities of daily living with less assistance from others. This includes an increased level of independence in dressing, bathing, toileting and food preparation. Physiotherapy has helped to decrease Marie’s pain levels and her level of fatigue has subsequently decreased as she continues to gain strength and improve her aerobic capacity. Marie states that this has helped her feel more like herself again. She was able to achieve her goal of standing for 5 minutes independently without the use of a gait aid as a result of the balance training she has been participating in. As Marie has been able to accomplish her short-term goals, she feels more confident in achieving her primary goal in the future, which is to return to work in order to support her family.

Objective Outcome[edit | edit source]

Functional Independence Measure (FIM): This outcome measure was used to assess Marie’s independence in her activities of daily living (ADLs). During the four-week assessment at in-patient rehab:

  • Marie scored an 80/91 on the motor subscale of the FIM
  • Marie demonstrated some difficulty completing grooming tasks that require fine motor skills

Reflexes:[9] Patient continues to demonstrate diminished reflexive activities in lower extremities. Some improvements have been noted since the initial assessment:  

  • Patellar Tendon (L3-L4): 2 B/L
  • Achilles Tendon (S1-S2): 1 B/L

Touch and Pressure:[9][10] Patient touch and pressure sensation has improved since initial assessment. She can sense light touch in bilateral upper extremities. Patient experiences some decreased sensation in more distal segments of bilateral lower extremities. Firm pressure across both upper and lower extremities was deemed normal.

Tactile Localization:[25] Marie is able to distinguish between two simultaneous touches on bilateral upper and lower extremities, both distally and proximally.

Range of Motion (ROM)[25]:

  • Ankle dorsiflexion 0-15° B/L
  • Knee flexion 0-120° B/L
  • Hip extension 0-10° B/L
  • Shoulder abduction/flexion 0-120° B/L

Manual Muscle Testing (MMTs):[14]

  • Hip extension 4-/5 B/L
  • Hip abduction 3+/5 BL
  • Hip flexion 4/5 BL
  • Knee flexors/extensors 4/5 B/L
  • Ankle dorsiflexors 3/5 B/L
  • Shoulder abduction/flexion 4/5 B/L
  • Elbow flexion/extension 4/5 B/L
  • Wrist flexion/extension 4-/5

Dynamometer grip strength:[26] Patient demonstrated improvements in grip strength (isometric strength of hand and forearm muscles) since initial assessment:  

  • Marie scored 26 kg with right hand (dominant)
  • Scored 24 kg with left hand   

BERG Balance Scale:[27] Patient has demonstrated improvements in balance since initial assessment:  

  • Marie scored a 44/56 on the BERG
  • Marie score demonstrates that she would still benefit from the use of a mobility aid

Timed Up and Go (TUG):

  • TUG was completed in 14 seconds
  • Marie completed the task with the use of a quad-cane

6-Minute Walk Test:

  • Marie was able to ambulate 250m during the test using a quad-cane
  • Patient was able to complete the test without taking breaks, but significantly slowed her walking speed throughout the duration of the test

Guillain-Barre Syndrome (GBS) Disability Scale, adapted from Hughes et al. (1978):[25] Patient scored a 2 on the GBS Disability Scale at the four week assessment.

Discharge Plan[edit | edit source]

After four weeks of rehabilitation, Marie has achieved her short-term goals. At this time, Marie is no longer an appropriate candidate for inpatient rehabilitation physiotherapy. Marie is on track to reach her long-term goals with the assistance of an inter-professional team. Through subjective and objective measures, it is evident that Marie has accepted her diagnosis and has regained confidence in the skills she had lost. Marie is able to complete most of her activities of daily living independently, but occasionally experiences challenges grooming, specifically those requiring fine motor skills (i.e. buttoning clothes and brushing her hair). Marie can ambulate confidently within her home with the use of a quad cane. It is recommended that if Marie ambulates for longer than 250 meters in the community, she will use her walker in order to maintain safety and increase levels of confidence while ambulating outside of her home.

To achieve long-term goals, Marie has been referred to home care physiotherapy and occupational therapy to improve her independence and quality of life. Marie has also been referred to social work to help Marie navigate physical, social, and psychological changes given her diagnosis. Prior to discharge, Marie will be educated on the steps to take, should her symptoms start to flare up again. Due to Marie’s progression in therapy, she has been cleared for discharge but will continue to engage in outpatient physical therapy treatment for 1 hour, 3 days per week.

Discussion[edit | edit source]

Marie is a 53-year-old woman transferred to the inpatient rehabilitation unit after spending two weeks in acute care. Initially, Marie presented with diminished reflexes, decreased grip strength and impaired sensation in the UE and LE. She also presented with a reduction in ROM and strength in several joints and muscle groups, most notably in the LE. Collective findings from the Berg, TUG, and 6MWT indicated that Marie had impaired balance and was deemed at risk for falls. Functionally, Marie struggled with any sit-to-stand tasks, including bathing and toileting, as well as ambulating with the 4WW longer than 150m or 4 minutes. Additional concerns included her consistent pain and fatigue.

Individuals with GBS may experience barriers and facilitators which impact prognosis. At the initial assessment, several factors were noted that may negatively impact Marie’s prognosis, including a home layout with several stairs, poor ambulation, and a negative outlook regarding her diagnosis. Each barrier has the potential to slow rehabilitation and impact prognosis. It is vital for the selected interventions to be specific, meaningful and functional for each patient to address individual barriers. In terms of Marie’s case, it was important to progress Marie from a 4WW to a quad cane to ensure she is independent and experiences a positive quality of life after discharge. It is also important for therapists to provide continuous reassurance and instill confidence in patients with GBS throughout therapy to improve motivation and self-confidence. Due to the drastic physical changes individuals diagnosed with GBS experience, it is vital to empathize with and employ confidence in patients throughout the rehabilitation process.

It is also important to recognize facilitators to recovery in each individual diagnosed with GBS. Patients should be aware of how specific facilitators can positively impact prognosis to assist with motivation throughout their rehabilitation. Marie demonstrated several facilitators to suggest a positive prognosis. Facilitators include a strong support system, an appropriate FIM score, and motivation to return to work and become independent with ADLs. Her family has been a strong support system for her throughout her diagnosis. A strong support system is beneficial for patients navigating a diagnosis of GBS because of the dramatic physical changes experienced with disease. Upon admission, her FIM score recorded 50/91, indicating her ADL function is suitable for inpatient rehab rather than complex care. This score demonstrated strong potential to improve with inpatient rehab. Finally, her motivation to return to work and become fully independent with ADLs demonstrates high motivation and can impact prognosis in a positive manner. In general, with most neuromotor disorders, an individual with a stronger support team, a higher FIM score, and increased motivation will likely have a better prognosis. These can be crucial factors in the likelihood of increasing the quality of life of an individual with any neuromotor disorder and should be considered when educating patients about prognosis.  

The 4-week-intervention focused on ROM, strength, pain management, balance and gait, along with aerobic and functional training. Assistive devices and technology were also used to supplement her treatment plan. As a result, Marie demonstrated improvements in all outcome measures since the initial assessment. In fact, improvements were seen in reflexes, ROM, sensation, and strength for both the UE and LE (MMTs). Clinically significant differences were shown in the scores for the Berg, TUG, 6MWT, and grip strength. Through inpatient rehab, she achieved all of her short-term goals, including improving her pain, balance, completing BALDs with minimal assistance, and standing longer than 5 minutes without a gait aid. However, Marie could still benefit from outpatient rehabilitation to improve her functional status and achieve her long-term goals.  

Overall, the inpatient rehab program has played a significant role in Marie’s recovery. The patient-centered treatment and targeted interventions ensured that Marie was on track to achieving her goals and returning to her previous function/lifestyle before her diagnosis of GBS. Patient education was a key component of rehabilitation to ensure that Marie understood why the intervention would help her reach her goals. We hope that her positive outcomes in inpatient rehab will motivate her to continue with outpatient PT to improve her function further and allow her to achieve her long-term goals. This case study serves as a tool for practitioners to use to understand the assessment and inpatient management of a typical GBS patient presentation. It also has broader implications to other similar conditions that might be differential diagnoses to GBS as many of the outcome measures and intervention strategies will be the same.

Self-Study Questions[edit | edit source]

1. Which of the following symptoms is NOT consistent with Marie’s presentation (GBS):

a. Symmetrical limb weakness

b. Altered vision

c. Areflexia

d. Impaired balance

2. Which outcome measures were utilized to assess Marie’s (GBS) static and dynamic balance?


b. MiniBESTest

c. Timed Up and Go

d. All of the above

e. Two of the above

3. What technology was integrated into the neurological management of GBS in this case?

a. Functional Electrical Stimulation

b. Wearable Robotics without biofeedback

c. Virtual Reality and Robotics

d. Body weight supported treadmill training

Answer Key: 1 (b), 2 (e), 3(c)

Related Resources[edit | edit source]

Queen's University Neuromotor Function Project

Guillain-Barré Syndrome

References[edit | edit source]

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