You are seeing a patient who is 3 weeks post onset of Guillain-Barre syndrome in the rehabilitation facility. Your patient's lower extremity muscle strength grades are as follows:
hip flexion 3+/5
hip extension 2/5
hip abduction 2-/5
knee extension 2-/5
knee flexion 2-/5
ankle dorsiflexion and plantar flexion 1/5
Answer following questions:
1. List 2 goals for this patient. Select goals that have not been cited by other students. Include Essential components of a well written goal found in Shumway-Cook and Woollacott Figure 6.2.
2. Formulate 2 treatment interventions (one for each goal) to achieve these goals.
3. Name two points you would educate this patient on for maximizing function and prevention/delay of future exacerbation. Select points that have not been cited by other students.
4. Would you work on standing this patient? Why or why not?
Guillain-Barré syndrome or GBS is described as a group of clinical symptoms which manifests as acute inflammatory poly radiculoneuropathy. GBS results in diminished reflex and weakness.
Symptoms and Signs
A typical patient with GBS, suffers from relatively gentle gastrointestinal or respiratory illness. The patients have complaints of and muscle weakness in the lower extremities of the body and finger dysesthesias. The weakness progresses over hours to days to affecting the muscles of respiration, truncal muscles, arms, and cranial nerves.
GBS is an immune mediated disease and post infectious. Humoral and cellular immune mechanisms most probably play an important role in the development of GBS. In the weeks preceding the onset of GBS, patients report an infectious illness. Most of the infectious agents of GBS which have identified till now induce the production of antibodies which cross-react with specific glycolipids and gangliosides, like GD1b and GM1. These antibodies are distributed in the peripheral nervous system throughout the myelin.
1. Goals for patient
Muscle strength is manually assessed by standard methods A Normal grade is the full existent range of motion against gravity and high manual resistance (Riley, 2016). The patient has lower extremity muscle strength grades are as follows:
- 1/5: There is flicker in the muscle but there is no movement
- 2/5: Movement of muscle is possible but there is no movement against the gravity
- 3/5: Movement of muscle is possible against gravity but there is no resistance offered by the examiner
Patient will perform excursion exercises and trunk rotation with hands clasped together in standing 5 to 10 times, 1 to 3 times a day.
The patient should lie flat, bend his knees and put feet flatly on the floor. Then he should inhale and exhale, while twisting at the waist. Along with this legs should be lowered slightly to the right side. The knees should be pressed together while doing this. Then patient should inhale while returning legs to the center, keeping the knees pointed at the ceiling. The patient should exhale and lower the legs to the left. The pelvis should not be lifted off the floor.
The patient will ambulate within parallel bar using assistance of contact guard while seeing the reflection in a mirror, for 5 minutes, thrice a day.
The patient should place the working limb on one side and the stump on the other. After this the patient stares at the mirror which is placed on the side of the good limb and makes movements which are mirror-symmetric. The patient sees the reflected image of the moving hand and thus, it seems as if the phantom limb is moving. Using this false visual feedback the patient can "move" the bad limb this stimulates the patient to unclench the bad limb from painful positions (Chan et al., 2007).
2. Treatment interventions
For the first goal, patients need to be monitored for hemodynamic instability as well as cardiac arrhythmias, during the rehabilitation program. The intensity of the suggested exercise program should also be monitored because overworking the muscles may sometimes lead to increased weakness of the patient (Andary, 2016).
For the second goal mentioned here, intravenous immunoglobulin should be administered as treatment intervention.
During administering intravenous immunoglobulin, healthy immunoglobulin is extracted from the donor blood and given to the patient through intravenous injections. The healthy antibodies block the harmful antibodies thus destroying such harmful foreign bodies which attack the nerves. Doses of IVIg are given each day for 5 days. (Nhs.uk, 2014)
3. Patient teaching
During GBS patients may suffer from bad moods, so they may find it useful to talk with counselors. Patients of GBS and their family members should be taught about the disease in detail (Andar, 2016). It is an event that can have long lasting implications on physical and psychological condition. Family training and education is important to avoid complications later during the rehabilitation stages of the disease.
4. Making the patient stand
The patient will not be able to stand in the third week because of muscle weakness and in addition there might be shortness of breath due to weakness of respiratory muscles and proprioception may also be impaired (Andary, 2016).
Approximately eighty percent of the patients suffering from GBS can walk independently from the 6th month and almost sixty percent of patients fully recover their motor strength in one year. In almost five to ten percent of patients recovery becomes a prolonged process, requiring many months of dependency on the ventilator.
Andary, M. (2016). Retrieved 15 January 2016, from Calefato, J. (2012). [online] Available at: https://www.acpin.net/Resources/Synapse_Autumn_2012.pdf [Accessed 15 Jan. 2016].
Nhs.uk,. (2014). Guillain-Barré syndrome - Treatment - NHS Choices. Retrieved 15 January 2016, from https://www.nhs.uk/Conditions/Guillain-Barre-syndrome/Pages/Treatment.aspx
Riley, M. (2015). Dune.une.edu. Retrieved 15 January 2016, from https://dune.une.edu/cgi/viewcontent.cgi?article=1031&context=pt_studcrpaper
Chan, B., Witt, R., Charrow, A., Magee, A., Howard, R., & Pasquina, P. et al. (2007). Mirror Therapy for Phantom Limb Pain. New England Journal Of Medicine, 357(21), 2206-2207. https://dx.doi.org/10.1056/nejmc071927