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 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)

Subjective

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. 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, 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, 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, however, they are no longer worsening. Over the past three days, Marie has noticed that her sensitivity to pain has increased (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 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

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: 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: 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: Marie presented with tactile extinction in the distal upper and lower extremities bilaterally.

Range of Motion (ROM): 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): 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: 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, falls 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): Patient scored a 3 on the GBS Disability Scale on initial assessment.

Clinical Impression

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 (ie. 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.

Intervention

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.

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. We will also adopt a gradual approach at this stage while ensuring that she is not overworked or too fatigued. Our goal is to include one hour of daily physical therapy treatment for Marie at least five times a week.

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.
	In eight months, Marie’s goal is to return to work with reduced abilities (part-time with 80% focus on documentation/clerical work).