Case Study: Guillain-Barre Syndrome (Sub-Acute)

Original Editor - Arthur Szydlowski Top Contributors - Sam Grossman, Arthur Szydlowski, Chelsea Mclene, Kim Jackson, George Taouil, David Snyder, Rucha Gadgil and Aminat Abolade

Abstract

This case study documents a fictional narrative highlighting the approach to care of a patient presenting with Guillain-Barre Syndrome (GBS). The patient's experience in acute care is discussed briefly and his sub-acute rehabilitation is explored more thoroughly. Overall, this case highlights both the nuances of GBS which lead to individualized treatment as well as management of this pathology is related to similar cases.

Introduction

According to the World Health Organization, Guillain-Barre Syndrome (GBS) is a  polyradiculoneuropathy which occurs when the body’s immune system attacks part of the peripheral nervous system. This attack may induce  sensation impairment, motor control deficit, and severe pain in affected areas leading to disability affecting the upper and lower extremities. GBS is typically preceded by bacterial or viral infection, vaccination, or surgery. Diagnosis is based on symptoms such as bilateral weakness, rapid progression, and hypo/areflexia. Blood tests are not required to diagnose this pathology.

Anyone can be affected by GBS - there have been documented cases of patients male and female aged 18 to 80.  Since patients with GBS may present similarly to patients with acute exposure to certain toxins, diabetic neuropathy, and Charcot-Matie-Tooth Syndrome, it is important to rule out these differential diagnoses by monitoring symptom progression and taking a history.

Early treatment involves acute medical care because this syndrome could progress to life-threatening lethality. In ICU and acute care settings, physiotherapists have several roles. One is to prevent contractures and other negative side effects of demobilization through positioning, splinting, and active assisted range of motion exercises or passive range of motion exercises depending on patient characteristics. Physiotherapists may also be consulted to administer cardiopulmonary intervention and assessment depending on progression of the disease. As symptom progression plateaus and patients transfer from acute care to rehab, treatment focus shifts to favor training focusing on performing functional tasks.

Case Background

Tom Brown, 56 year old male, first presented to the ER with a severe gastrointestinal infection approximately 5 months ago. After this infection was dealt with medically, he was discharged home with no change in baseline or complications. A few weeks later he felt numbness and tingling in his feet and hands along with pain that got worse with movement. During the following two weeks he proceeded to feel weaker and the tingling progressively worsened, eventually leading to admission to the same hospital’s emergency department. Tom could hardly move for 2 weeks and required ICU medical support. The healthcare team did an excellent job of ensuring he at least attempted to mobilize routinely and was positioned properly to avoid contractures/other complications (using postural drainage techniques, splinting, AAROM, etc., all performed as necessary). It has been 4 months since his last admission to the hospital. No other medical conditions/comorbidities have since arisen and his medical status has remained stable.

Tom’s rehabilitation will employ a graded approach centered around capacity to  perform functional activities. The providers of his treatment will be sure to ensure too much is not done too soon - over-exertion could lead to a flare up and subsequent regression. Effort will be made to involve Tom and his family members in rehabilitation to enforce patient-centered care at every step.

Client Characteristics

• Patient Profile: 56 years old , Male
• Medical Diagnosis: Guillain-Barre Syndrome
• Primary Complaint: Pain in feet, weakness in upper and lower extremity, fatigue, lack of coordination
• Past Medical History:
  • First diagnosed with GBS approximately 4 months ago
  • Hypertension
• Medications:
  • Amlodipine - 6mg 1x per day
  • Smoker - 5 packs / year for 5 years. Has not smoked in 3 years
  • Drinks casually, 1-2 drinks per night
• Primary Reason For Referral:

-Complications with GBS including, characterized by ICF Framework:

• Inability to perform some ADL’s without support (activity level)
• Mobility, endurance and coordination levels have not returned to pre GBS levels (activity level)
• Decline in participation in previously enjoyed social events (participation level)

Examination Findings

Subjective:

Present Condition: At the time of assessment, Tom reports that he has regained some motor control of his upper and lower extremities but he still feels very weak and uncoordinated. Weakness and impaired coordination leads to fumbling while completing daily chores. He also has lost some mobility, in particular with raising his arms and flexing his hip. This has led to difficulty dressing and getting into the shower on his own. He has gained enough motor control back to eat independently; however, this is still a challenging task.

He is able to walk short distances, about 10 minutes at a time, with a four-wheeled walker, but must stop due to shortness of breath (SOB), fatigue, and pain in his feet. His sensitivity to pain, in general, has increased notably. He has noticed that once non-painful things such as friction on his skin or muscle contraction now elicit a painful response in, he experiences particularly high levels of pain in his back and thighs.

Tom reports feelings of embarrassment from all the help he needs from his wife. He has been seeing a speech-language pathologist manage difficulty swallowing as well as an OT for help making his home more accessible. Tom lives in a 2 story home in the suburbs. His bedroom is on the second floor, which he can access independently thanks to sturdy railings recommended by the OT. However, this is difficult and scary for Tom, so he avoids using the stairs as much as possible.

Social History: Tom lives with his wife and teenage son, they have both been supportive in his recovery. Before Tom had GBS, he worked on the assembly line at a car manufacturing plant. His wife is a police officer. Tom’s work has been understanding, however, he has not been able to return to work yet and worries that the pain in his feet will keep him from ever returning to his regular duties. On weekends Tom would get together with his friends at the local pub to play billiards. Since the GBS he has not returned to the pub and misses the enjoyment this brought him.

Goals and Expectations: Tom’s primary goal is to be able to get dressed and get into the shower on his own (BSF + activity). He would really like to depend on his family less for such basic tasks. Second to that Tom would like to be able to return to work. Although he is close to retiring, he would like to keep working to support his son through college. Lastly, Tom would love to return to playing pool with his friends. He is worried that if he is not able to play pool he will lose touch with his friends. Tom is hoping physiotherapy can help him increase his upper extremity (UE) coordination, range of motion and strength. He was also hoping to receive some exercises to improve his walking so he can be less dependent on his walker. Lastly, Tom has heard that physiotherapy may also help with his pain but is a little skeptical that physiotherapy has much to offer him in terms of pain reduction.

Yellow Flags: - Worries about ever being able to return to work. - Embarrassment from depending on family. - Worried he’ll lose touch with his friends. - Does not believe physiotherapy can decrease his pain.

Pain: Tom describes his pain as a dull ache after activity and sharp and shooting pain during activity. He finds the pain intensity fluctuates but some pain is always present. The pain is diffuse in nature but is most intense in the feet, followed by the back and thighs. He describes the pain in his feet as a 4/10 at rest and 8/10 when weight-bearing, the pain in his lower back at 2/10 at rest and 6/10 when weight-bearing. and his thigh pain at 2/10 at rest and 7/10 when weight-bearing. The pain is at its worst after a bout of walking and at its best when he first wakes up. However, at the end of the day ,he has some difficulty falling asleep due to pain brought upon by friction from the sheets on his skin.

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Objective:

Nero scan: Upon examination, all of Tom’s reflexes were diminished but still present at a low level (1+), besides his knee jerk ( L3 reflex) which was absent (0). No differences between individual dermatomes were observed but general hypersensitivity was found. Additionally, a10mg monofilament elicited strong pain response before bending on feet bilaterally. A slight drooping of the face is also visible indicating facial nerve palsy (CN V trigeminal - sensory + CN VII facial - motor).

ROM: Tom presents with bilateral rigidity and spasticity in his upper and lower extremities. All Passive movements are limited by mild cog-wheel type rigidity and muscle spasm. Movements at almost all joints are limited to some degree, however, the below movements are very limited and impose the most restriction to Tom’s function. - Shoulder Abduction: 69/175 degrees PROM - Hip Flexion: 56/ 110 degrees PROM - Ankle Dorsiflexion: 5/ 20 degrees PROM

MMT: Tom was able to perform all motions tested against gravity, however, he has general weakness present in all muscle groups. The largest functional limitations are due to the following muscles: - ankle plantar flexors (PF) (2+) - hip extensors (2+) - knee flexors (2+) - shoulder abduction (2+)

Balance Assessment: Tom is able to stand on two feet independently with eyes open and completed a BERG assessment to measure balance capabilities (see below for details).

Gait assessment: Tom is able to ambulate 10m at a time with a four-wheeled walker. He walks at a slow pace, with a narrow and short stride. He has a slight drop foot and relies predominantly on hip flexion and abduction to progress feet forward due to weak plantar flexors. Tom completed a TUG assessment to assess falls risk and gait. He was unable to perform the task without a 4-wheeled walker.

Pulmonary function tests: Tom’s cardiorespiratory function was assessed because GBS is known to cause respiratory failure in 20-30% of cases (Dynamed, 2018). Tom’s maximum inspiratory pressure (MIP) was 80 cmH20 and his maximal expiratory pressure (MEP) was 176 cmH20. A spirometry test was performed to further assess Tom’s cardiorespiratory function and safety to perform exercise (located below). Tom presented with a normal functional vital capacity (FVC) and slightly reduced forced expiratory volume in one second (FEV1), which was a sign of a restriction in expiration capability and respiratory muscle weakness.

Reassessment 12 weeks Post-Treatment

Present Condition: 87% of patients with GBS will make full recovery or have minor deficits within 1-3 years. Tom had been diagnosed with GBS approximately 6 months ago and his symptoms from his original diagnosis have begun to stabilize during therapy, which assisted in his progression. Tom’s rehabilitation program consisted of 30-60 minute treatment sessions for 3 days/week. Simple muscular Strength, ROM, and balance assessments were recorded every 2 weeks to ensure progression occurring. A complete reassessment was completed after 12 weeks of treatment.

Facial Palsy and Dysphagia: Tom demonstrated increased facial muscle strength and was capable of controlling his facial movements with ease. Collaboration with a speech language pathologist and OT contributed to his decreased dysphagia and improved ability to swallow.

Subjective - 12 weeks:

Pain: Tom reports decreased intensity and frequency of the pain in his feet, back, and thighs. However, Tom still experiences dull aches in those areas after completing physical activity and weight bearing for extended periods of time. His sensitivity to pain from random stimuli decreased slightly, but there were times where it seemed to flair up.

Objective - 12 weeks:

ROM: Tom has increased ROM and strength in his upper and lower extremities. The increase in control and endurance in his muscles has allowed him to walk for longer distances without fatigue and complete more of his ADLs independently.

Balance: There are instances where Tom requires to hold onto something to increase his base of support while walking without a mobility aid, but has not fallen since starting therapy. Tom does report that he feels more balanced and mobile compared to when he first started therapy and has been more coordinated with his movements. A reassessment of Tom’s balance using the BERG (48/56) has demonstrated that Tom’s balance has increased significantly since his initial assessment. His confidence has increased and has reported a decreased fear of falling. Tom still has difficulty with external perturbations and sometimes uses a cross-over compensatory mechanism. Future assessment will require more advanced balance outcome measures for functional activities.

Mobility: Tom uses a 4 wheeled walker for traveling outside of his home, but has been comfortable walking around his home without a mobility aid. Tom was able to ambulate 375m during a 6-minute walk test with a 4-wheeled walker and was able to ambulate 80m without a mobility aid. Tom walks at a slower pace without a mobility aid and has a wider base with short strides. He has a slight drop foot and relies predominantly on hip flexion and abduction to progress feet forward due to weak plantar flexors. Walking with a mobility aid allows Tom to correct his gait and not have to focus on his balance compared to using no mobility aid. However, it is more tiring using the walker compared to walking without a mobility aid, which is an indication for Tom to switch to a quad cane as a mobility aid.

Cardiorespiratory Endurance: Tom still experiences SOB with too much activity, but not as intense or frequently compared to before therapy. Because of his increased functional capabilities, Tom feels less embarrassed compared to before treatment. Tom has been more independent with his ADLs and does not require any assistance for basically all of his activities. Tom has been able to return to more activities at work and has less pain compared to before. His work has placed him on more active duties, but there are still some restrictions. After a long day of work, he still becomes tired and feels some pain, but not as often as before. Tom has started playing pool again with his friends, but has trouble holding the cue at times.

Clinical Impression

Problem list: - Pain in feet - Weak Ankle plantar flexors, hip extensors, quadriceps and shoulder abductors - Limited ROM in the shoulder abduction, hip flexion and ankle dorsiflexion - Inability to dress independently - Poor balance and unsteady gait - Fatigue

Physiotherapy Diagnosis:

Tom has difficulty with balance and UE coordination. Weakness in the plantar flexors and pain in the feet are preventing him from ambulating further than 20m. UE coordination keeps him from enjoying playing pool with his friends and limitations in shoulder abduction prevent him from getting dressed.