J O H N C O R S I N O , S P T

A comparison of two patients with Guillain-Barre Syndrome

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