A comparison of two patients with Guillain-Barre Syndrome J O H N C O R S I N O, S P T
Guillain-Barre Acute inflammatory demyelinating polyneuropathy Highly diverse presentation, course, outcome Miller-Fisher: Opthalmoplegia, Ataxia, Areflexia Rapid progression: Several days to 4 weeks 6 months- 2 years: 85% full functional recovery with minimal deficits
Signs & Symptoms Approximately symmetrical weakness (ascending, distal>proximal) Sensory loss, paresthesias Areflexia Respiratory impairment* Dysautonomia*
Etiology & Diagnosis Not entirely understood Autoimmune attack demyelination Associated with GI illness LP NCV
Prognostic Factors Age > 55 Severity of deficits Cranial Nerve involvement Mechanical ventilation
Medical Management 1/3 require ICU: respiratory and autonomic complications IVIG Plasmapheresis: removal of antibodies 40% require inpatient rehab
PT indications Pulmonary, cardiovascular Prevent secondary impairments: PROM, positioning Neuromuscular re-education Functional mobility Energy conservation* Excessive intensity can cause relapse, like MS
Patient 1 HPI 69 y/o F. 3 day hx severe back, BLE, abdominal pain Diff dx: tick-borne illness vs. infectious process Developed weakness, unable to get OOB; neuropathic pain; decreased sensation Cranial nerves intact LP: GBS or variant 5 rounds IVIG therapy, improved NCV 2.5 wks from onset
Patient 1 Tests & Measures PLOF: Independent; no device; walk 1 hr/day Goals: To be back to normal. Pain: 10/10 BLEs. Burning. BLE ROM WNL* Strength: 2+ Hip Flex/ Ext, 3- Knee Ext, 2 Hip AB, 4- Ankle DF Sensation: pain with LT. Proprioception absent below knee
Patient 1 Mobility and Balance Rolling: CG Supine Sit: Mod A Sit Stand: Mod A x2 Transfers: Max A x2 Stand pivot; Anxiety Ambulation: Max A x2; 2 steps Seated balance: CG- CTG to maintain static; Min perturbations, 1 reach with CTG
Patient 2 HPI 63 y/o F. Presented to ED with numbness/tingling of hands and feet following recent GI virus. Developed flaccid paralysis of all 4 extremities, areflexia Cranial nerves intact GBS with posterior reversible encephalopathy and dysautonomia Respiratory failure requiring MV Transferred to LTAC 20 days post onset for 6 wks; transferred to SRH when able to tolerate intensive rehab
Patient 2 Tests & Measures PLOF: Independent, no device Goals: To stand, walk, return home Pain: None BLE ROM: Dorsiflexion limited Strength*: 2- Iliopsoas, Glute Max, 2+ Glute Med, 2+ Quads, 2- Tibialis Anterior, 0 Extensor Hallucis Longus; Grip Strength substantially impaired. L weaker than R. Sensation: LT and Deep Pressure impaired, Proprioception absent below knee
Patient 2 Mobility and Balance Rolling: Min A; assist knee flex, foot placement Supine Sit: Max A Sit Stand: Max A; knee block Transfers: Max A + Mod A squat pivot Seated balance: 15 sec. static; 4 reach with UE support
Patient 1 treatment plan Bodyweight support gait training: Lite Gait, Lokomat Overground gait training as strength progressed, RW no assistive device Balance: static and dynamic; eyes closed, COG excursion Kneeling and quadruped* Seated pelvic tilt on physioball for lumbopelvic stability, bouncing to facilitate spinal extensors OT: Sensory reintegration
Patient 1 treatment Walking with dowels to facilitate arm swing and pelvic rotation : COG excursion with physioball Quadruped and high kneeling
Patient 2 treatment plan Gait training with bodyweight support: Lite Gait, Lokomat, for a longer period Overground gait training with adaptive equipment Cardiovascular fitness Balance: static and dynamic with assistance Splinting Plan to require assistance with some activities at discharge
Patient 2 treatment Similar functional training Increased assistance with initiating movements and supporting bodyweight, greater amount of cueing Emphasis on weight bearing to facilitate co-contraction Center of gravity control during ambulation Increased level of family training Adaptive equipment used for gait training and stair negotiation
Adaptive and Assistive Equipment Patient 1: Wheelchair for long distance, potentially rolling walker for exercise Patient 2: Wheelchair, L KAFO with toggle ROM restriction mechanism; R hinge-prep AFO; Rolling walker for short distances
Patient 1: Discharge Skilled Nursing Facility, but LT and Proprioception intact throughout Close S Sit Stand Close S ambulating for distance Close S stair negotiation 6 reach sitting without UE support; Min perturbations in standing, 30s static standing
Patient 2: Discharge Home Min A bed mobility Sit Stand Min A CTG Ambulation with RW, AFO/KAFO Mod A + CTG stair negotiation 6 reach in sitting, 1 reach standing with single UE assist
Looking back Part- Practice Rolling walker Visual feedback Varying BOS earlier Suggestions?
References Early recognition of poor prognosis in Guillain-Barre syndrome Walgaard, C., et al. Neurology. Wolters Kluwer Health. Mar 15, 2011 Guillain-Barre Syndrome: Natural History and prognostic factors: a retrospective review of 106 cases. Gonzales-Suarez, I., et al. Biomed Central Neurology. July 22, 2013