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CASE PRESENTATION: GUILLAIN-BARRÉ SYNDROME (GBS)

Physiotherapy Case Presentation

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PART 1 - PATIENT IDENTIFICATION

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PART 2 - HISTORY

2.1 Chief Complaints

1. Progressive ascending weakness of bilateral lower limbs, spreading to upper limbs
2. Difficulty in walking / inability to walk
3. Tingling and numbness (paresthesia) in hands and feet
4. Pain in lower limbs / back
5. Difficulty in climbing stairs / rising from floor
6. Fatigue on minimal exertion
7. ± Difficulty in breathing (in severe cases)
8. ± Difficulty in swallowing / facial weakness (bulbar involvement)

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2.2 History of Present Illness (HPI)

• Week 1-2 before admission: Fever, diarrhea / respiratory infection
• Day 1-3 of neurological onset: Tingling/numbness in toes and fingers, mild leg weakness
• Day 3-7: Progressive bilateral leg weakness, inability to walk unassisted
• Day 7-14: Weakness extending to trunk and upper limbs, areflexia noted
• At admission: Complete or near-complete flaccid paralysis of all four limbs (quadriparesis/quadriplegia), absent deep tendon reflexes throughout, possible respiratory involvement

• Fever at time of neurological onset
• Bladder/bowel incontinence (differentiates from spinal cord pathology)
• Cranial nerve involvement at onset (though may develop)
• Prior similar episodes

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2.3 History of Past Illness (HPI)

• Antecedent illness: H/o viral URTI / gastroenteritis 2-4 weeks prior (most common trigger)
• Previous neurological illness: None significant
• Previous hospitalizations: None / as per case file
• History of similar episodes: None (GBS is typically a monophasic illness)
• History of trauma: Absent
• Surgical history: None relevant
• Vaccination history: H/o recent vaccination (influenza, COVID-19) in some cases can trigger GBS (rare association - 1-2 per million doses)

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2.4 Past Medical History

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2.5 Family History

• No family history of similar neurological illness
• No hereditary neuropathies (Charcot-Marie-Tooth disease ruled out)
• No autoimmune diseases in first-degree relatives

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2.6 Personal / Social History

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2.7 Socioeconomic History

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2.8 Drug History / Medication History

• NKDA (No Known Drug Allergies) - as per case file
• Any specific allergies noted: [As per case file]

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PART 3 - CLINICAL EXAMINATION

3.1 General Examination

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3.2 Respiratory Examination

• Chest expansion: Reduced bilaterally
• Breath sounds: Vesicular, may show reduced air entry at bases
• SpO2: Within normal limits unless respiratory muscles involved
• Forced Vital Capacity (FVC): Monitor for "20/30/40 rule" - intubation considered when FVC <20 mL/kg, MIP < -30 cmH2O, MEP < 40 cmH2O
• Cough strength: Weak / moderate (monitor for aspiration risk)

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3.3 Neurological Examination

3.3.1 Motor System

3.3.2 Deep Tendon Reflexes

Areflexia (absent reflexes throughout) is the hallmark of GBS.

3.3.3 Plantar Response

• Bilateral: Flexor (downgoing) - extensor response rare in LMN lesion

3.3.4 Sensory Examination

3.3.5 Cranial Nerve Examination

3.3.6 Coordination

• Finger-nose test: Impaired (due to weakness and proprioceptive loss)
• Heel-shin test: Unable to perform (due to weakness)

3.3.7 Gait

• Current status: Unable to walk / bed-bound (at admission)
• May progress to needing walker/crutches as recovery proceeds

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3.4 Functional Assessment

Functional Independence Measure (FIM) - Admission Score

GBS Disability Scale (Hughes Scale)

Patient typically presents at Grade 3-4 on Hughes Scale.

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PART 4 - INVESTIGATIONS

4.1 Routine Blood Investigations

4.2 Cerebrospinal Fluid (CSF) Analysis - LUMBAR PUNCTURE

Albuminocytological dissociation (high protein + normal cells) is the classic CSF finding in GBS.

4.3 Nerve Conduction Study (NCS) / Electromyography (EMG)

4.4 Anti-ganglioside Antibodies

4.5 Imaging

4.6 Pulmonary Function Tests

• FVC (Forced Vital Capacity): Baseline and serial monitoring
• MIP (Maximum Inspiratory Pressure): Reflects diaphragm strength
• MEP (Maximum Expiratory Pressure): Reflects cough strength
• Peak Expiratory Flow (PEF): Serial monitoring

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PART 5 - DIAGNOSIS

1. Bilateral flaccid limb weakness ✓
2. Decreased/absent deep tendon reflexes in weak limbs ✓
3. Monophasic illness, interval between onset nadir 12 hours - 28 days ✓
4. CSF protein above normal, CSF cell count <50 cells/mm³ ✓
5. Electrodiagnostic evidence of polyneuropathy ✓
6. No alternative diagnosis ✓

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PART 6 - PHYSIOTHERAPY ASSESSMENT (SUMMARY)

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PART 7 - PHYSIOTHERAPY GOALS

SHORT-TERM GOALS (Weeks 1-4)

1. Prevent secondary complications - avoid contractures, pressure ulcers, DVT, aspiration pneumonia, and disuse atrophy
2. Maintain full passive range of motion in all joints of all four limbs
3. Reduce neuropathic pain to ≤4/10 on NRS through positioning, TENS, and gentle handling
4. Improve respiratory function - maintain SpO2 ≥95%, improve chest expansion, facilitate secretion clearance
5. Maintain/improve muscle activation - achieve active contraction (grade 1-2 → 2-3/5) in proximal muscles through assisted active exercises
6. Maintain skin integrity - pressure ulcer prevention protocol
7. Improve sitting tolerance - from 0 to 15-30 minutes in supported sitting
8. Educate patient and family regarding positioning, handling, and home program
9. Prevent foot drop / wrist drop through appropriate splinting and positioning
10. Improve fatigue management - energy conservation strategies

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LONG-TERM GOALS (Weeks 4-12 and beyond)

1. Restore functional ambulation - progress from bed-bound → sitting → standing with support → ambulation with walking aid → independent ambulation
2. Achieve full or near-full muscle strength (grade 4-5/5 in all muscle groups)
3. Restore normal gait pattern - address foot drop, trunk stability, and endurance
4. Achieve independence in ADLs - dressing, bathing, grooming, toileting
5. Return to occupation/previous activity level
6. Normalize sensory processing - proprioception and balance retraining
7. Maximize cardiorespiratory fitness - aerobic conditioning program
8. Achieve community ambulation (walking ≥500 m outdoors, stairs, ramps)
9. Improve Hughes Disability Scale from Grade 4 → Grade 1 or 0
10. Improve FIM score from ~45 → 110-126 (near-independence)
11. Psychological rehabilitation - address depression, anxiety, and return-to-life confidence

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PART 8 - PHYSIOTHERAPY TREATMENT PLAN

SHORT-TERM TREATMENT PLAN (Acute Phase - Weeks 1-4)

Phase 1: Acute/Progressive Phase (1-3 weeks)

• 2-hourly position changes (supine, side-lying, semi-fowler's)
• Limb positioning: pillows under calves (heel protection), foot boards to prevent plantarflexion contracture
• Anti-pressure mattress / alternating air mattress
• Wrist splints (cock-up position) to prevent wrist drop
• Ankle-foot orthosis (AFO) or resting foot splints to prevent foot drop

• All joints of bilateral upper and lower limbs
• Frequency: 2x daily, 10 repetitions per joint
• Gentle, pain-free, full range
• Key joints: shoulder, elbow, wrist, MCP/PIP; hip, knee, ankle, subtalar
• Special attention to: ankle dorsiflexion, hip external rotation, shoulder abduction

• Deep breathing exercises (diaphragmatic + segmental)
• Manual assisted cough technique / splinted cough
• Incentive spirometry
• Postural drainage + percussion if secretions present
• Monitor FVC daily; spirometry for trend
• Semi-recumbent positioning (30-45°) at all times to prevent aspiration
• Suction if required

• Transcutaneous Electrical Nerve Stimulation (TENS) - conventional mode (80-100 Hz, 100 μs) for neuropathic pain
• Hydrotherapy (warm water immersion if tolerated)
• Gentle massage to painful limbs
• Comfortable positioning with limb support
• Consultation with medical team for pharmacological adjuncts (gabapentin)

• Assisted active exercises (physiotherapist-assisted or gravity-eliminated)
• PNF facilitation techniques - rhythmic initiation, repeated contractions
• Electrical stimulation (Neuromuscular Electrical Stimulation - NMES / FES) to denervated/weak muscles
• Focus on proximal muscles first (shoulder abductors, hip flexors)
• Muscle re-education with biofeedback if available

• Ankle pumps / foot and ankle PROME every 2 hours
• Compression stockings / pneumatic compression devices
• Early mobilization as tolerated

• Daily communication and reassurance
• Explanation of prognosis (85-90% recover to independent walking by 6-12 months)
• Mindfulness / relaxation techniques
• Referral to psychologist / counselor if anxiety/depression present

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LONG-TERM TREATMENT PLAN (Recovery Phase - Weeks 4-24+)

Phase 2: Plateau/Early Recovery Phase (Weeks 4-8)

• Active assisted exercises → Active exercises → Resisted exercises (progressive resistance)
• MRC-guided progression: Advance exercise when grade ≥3/5
• Free weights, Theraband, pulley systems
• Focus: quadriceps, hip extensors/abductors, dorsiflexors, intrinsic foot muscles
• Aquatic physiotherapy / hydrotherapy: Buoyancy-assisted active exercises, walking in pool

• Sitting balance progression: supported → unsupported → perturbed
• Standing balance: parallel bars → standing frame → standing with fingertip support
• Proprioceptive training: foam pads, wobble boards, BAPS board
• Functional reaching tasks in sitting and standing
• Mirror visual feedback for proprioceptive impairment

• Standing practice: parallel bars, tilt table for gradual weight-bearing
• Tilt table: 0° → 30° → 60° → 80° incremental tilting
• Gait training: parallel bars → rollator walker → forearm crutches → walking stick → independent
• Address foot drop: AFO use during ambulation, FES to ankle dorsiflexors during gait
• Gait pattern correction: step length, cadence, trunk control, arm swing

• Bed mobility: rolling, supine-to-sit transfers
• Transfer training: sit-to-stand, toilet transfers, car transfers
• ADL practice: dressing (upper and lower body), grooming, bathing, cooking
• Wheelchair mobility training if ambulation not yet possible
• Stair climbing training (when quadriceps ≥4/5)

• Cycle ergometer (upper/lower limb) - start at low resistance, short duration (5-10 min)
• Progressive aerobic conditioning: increase duration by 5 minutes/week
• Target: 20-30 minutes of moderate-intensity aerobic exercise
• Monitor heart rate, blood pressure (autonomic lability)
• Swimming / hydrotherapy pool ambulation as aerobic activity

• Fine motor skills: pegboard activities, handwriting, pinch/grip strengthening
• Functional hand activities: buttoning, opening jars, typing
• Sensory re-education: texture discrimination, graded sensory input
• Occupation-specific training as per patient's job/hobbies

• Outdoor walking on uneven terrain, curbs, slopes
• Public transport usage training
• Driving assessment (when appropriate)
• Work simulation tasks
• Home modification advice (grab rails, raised toilet seat, shower chair)

• Wean off resting splints as strength returns
• Transition from rigid AFO → hinged AFO → no AFO as dorsiflexion recovers
• Serial splinting for any residual contracture

• Written and demonstrated home program
• Progressive theraband exercises, walking program
• Family/caregiver training
• Tele-rehabilitation follow-up

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PART 9 - OUTCOME MEASURES

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PART 10 - PROGNOSIS

• ~85-90% of GBS patients regain independent walking by 6-12 months
• ~5-10% have residual disability at 3 years
• Poor prognostic factors: age >60 years, rapid progression (<7 days to nadir), need for ventilation, severe axonal involvement on NCS (AMAN/AMSAN > AIDP), low CMAP amplitudes
• GBS-related fatigue may persist for years even after motor recovery
• Recurrence rare (~1-3% annual risk of CIDP developing)

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