Guillain-Barré Case Study: Marie

Abstract

This case study illustrates a fictional narrative of a 53-year 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

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. Symptoms include symmetrical limb weakness, hyporeflexia or areflexia, sensory disturbances and in some cases cranial nerve deficits. 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.

GBS is more common in men than in women and occurs less frequently in children than in adults, therefore incidence increases with age. 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. 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.

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. 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.

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 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. 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

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. 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 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

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 in-patient 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 1998, celiac allergy.

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