In The Name of who created us

A case report study

Atefeh Aminianfar,et al.Semnan university of Medical Sciences,semnam IR,Iran

Rehabilitation of an Adolescent with Guillain-

barre syndrome

is a rare disorder in which your body's immune system attacks peripheral nerves

most prevalent in young adults and in persons in their fifth through eighth decades

one to two cases per 100,000 the time from onset to peak impairment is four weeks or less A recurrent form is reported in up to 10% of GBS cases A chronic form : chronic inflammatory demyelinating

polyradiculoneuropathy (CIDP). direct cause of GBS is unknown ascending symmetric motor weakness progressing from the distal to

proximal lower extremities, upper extremities, trunk and face

Introduction

Progressive weakness in more than one extremity and loss of deep tendon reflexes

Distal sensory impairments are common(not persistent)

decreased vibratory or position sense.

50% will have autonomic nervous system symptom

Introduction

The patient was a 11-year-old studentwho had a typical presentation of motor

and sensory deficits.Initiating with a cold virusAfter 4 days symptoms has appeared about 3 weeks after onset, symptoms

promoted to maximal impairment

Case description

The patient reported symptoms after playing football.

The patient was hospitalized and undergoing many tests to determine the cause of his illness.

felt very fatigued and experienced a weight loss.

Patient was unable to walk and required a moderate assistance for toileting.

History

He showed good skin color and no signs of redness or swelling, and no scars

or incisions were noted.deep tendon reflexes were absent for

patellar tendon and Achilles tendon reflexpsychosocial and cognitive systems were

good

Systems check

Examination

Functional Independence Measure (FIM). FIM included motor subtotal score and cognitive subtotal

score. Motor subtotal score included self care , transfers and

locomotion Cognitive subtotal score included communication and social

cognition Functional Independence Measure (FIM) Measured at 3 and

8 weeks after initial onset At initial examination, the patient’s FIM score was 76/126,

with a motor subtotal score was 41/91

Follow-up After 8 weeks Admission Functions Self care :

7 6 Eating 6 3 Grooming 6 3 Bathing 6 4 Dressing-UB 6 2 Dressing-LB 6 5 Toileting

Sphincter-Control : 7 7 Bladder-management 7 4 Bowel- management

Transfers :6 2 Bed .Chair.

wheelchair6 2 Toilet 6 2 Tub . shower

Locomotion : 7 1 Walk/wheelchair 5 0 Stairs

81 41 Motor subtotal score

Follow-up After 8 weeks

Admission Communications:

7 7 Comprehension 7 7 Expression

Social cognition :7 7 Social

interaction7 7 Problem solving 7 7 Memory

35 35 Cognitive subtotal score

116 76 Total FIM score

LEVELS : Complete

DependenceModified Dependence Independent

Total assist

(subject= less than

25%)

Maximal assist

(subject=25%+)

Moderate assist (subject= 50%

+)

Minimal assist

(subject= 75%+)

Supervision(Subject = 100%+)

Modified independ

(device)

Complete independ (timely,

safely)

1 2 3 4 5 6 7 HELPER NO HELPER

Muscle performance was assessed using manual muscle testing (MMT).

MMT revealed significant symmetrical weakness, with distal muscle groups more affected than proximal muscles.

Symmetrical Shortness of hamstrings and plantar flexor muscles

The Lack of patellar tendon and Achill tendon reflexes

Change in breathing patternsevere lower extremity weakness, moderate

upper extremity weakness from an inflammatory demyelinating polyneuropathy

Other Examinations

`Right Left Muscles

2 2 Deltoid 2+ 2+ Biceps 2+ 2+ Triceps

3 3 Wrist Extensors3 3 Wrist Flexors2- 2- Hand Intrinsic0 0 Foot Intrinsic3 2+ Hip Flexors2 2- QF2- 2- Hip Abductors1 2- Hamstrings0 0 Plantarflexors1 2- Dorsiflexors0 0 EHL,EDL,FHL,FDL0 0 Proneous

Longus&Brevis2- Abdominal

musles(low,up,o)2+ Back extensors

Approximately 80% become ambulatory within 6 months of onset of symptoms

The most common long-term deficits are weakness of the anterior tibial musculature

3% to 5% of patients die of secondary cardiac, respiratory or other systemic organ failure

Prognosis

Become as independent as possible

Goal of treatment

15 hours of therapy per week PT treatment protocol is included: improving respiratory pattern and stimulation of better

swallowing(e.g., educating chest expansions, sucking an ice cube )

Self Positioning education(rolling) to prevent pressure sures

Teaching his family to fix him 15min in sitting position for mild hamstrings stretching and improving sitting equilibrium

Plan of Care

Preventing ROM limitation in joints by passive movements (ROM stretching of all involved joints performed twice a day)

Stretching shortened muscles (e.g. , hamstrings, PFs) for better ambulation and positioning(e.g., sitting, kneel standing ,standing)

Prescripting Ankle-foot orthosis(AFOs) for passive stretching

ROM

Electrical stimulation in denervated and weak muscles IDC current in denervated muscles by long rest durations (initially

triangular and after progression rectangular Modes) Faradic current in weak muscles (long rest duration and non

fatigue) After renervation of the muscles and improving its endurance, the

Time of Electrical stimulations was decreased

Electrical Stimulation

Progressive Program of Active Exercise While Monitoring for Overuse and Fatigue:

Exercises performed in a low level and terminated before the patient reported fatigue (number of repetitions was fatigue-dependent)

Avoiding muscle fatigue and frequent rest periods Children, teenagers, or adults with impaired judgment often need

a strict schedule of rest and activity Checking for no deterioration occurs after 1 week

Exercises

gravity-eliminated active range of motion (AROM) to antigravity AROM, to resisted exercise in functional patterns for the upper extremity, lower extremity, and trunk

Then strengthening for function rather than strength itself PNF techniques such as rolling, which is necessary for bed

mobility, transitions to quadruped, kneeling, sitting, standing stability and gait

Functional activity progression was focused toward independent mobility

Early non fatigue weight bearing in standing position by helper instruments was performed (improving proprioception and patient mentality)

Plan of Care

Exercises after discharge from hospital (weeks5-8) Week5: Continue prior supine, prone , side, quadruped and sitting

position exercises for lower, upper extremities and trunk(e.g. SLR) twice daily

Weight bearing by walker and therapist support twice daily Week6: Continue prior exercises weight bearing and weight shift in parallel bars Semi squat in parallel bars

Plan of Care

Week7: Continue exercises in parallel bars(e.g., abds, g.max,..) weight bearing and weight shift in parallel bars without AFOs Sit to stand exercise Semi squat, walking( forward, backward, side) in parallel bars Walking by walker Stationary bicycle Week8: Walking with and without walker(without AFOs) Semi squat out of parallel bars Stationary bicycles Balancing exercises (e.g., wobble board)

Plan of Care

After 8 weeks, Functional mobility improved significantly over the course of the acute rehabilitation.

the patient’s FIM score was 116/126, with a motor subscore of 81/91.

Observation revealed that the patient was independent with all bed mobility tasks

He was able to ambulate 20 feet without walker and bilateral AFOs.

Muscle performance also improved considerably, although distal muscle groups continued to be more affected than proximal muscles

The patient continued to have strength gains

Outcomes

A follow-up after 12 weeks, revealed that he was ambulating functional community distances without any assistive device, living independently at home, and beginning to return to school.

Outcomes

12 weeks after onset 8 weeks after onsetLeft Right Left Right Muscle

4 4 3+ 3+ Hand Intrinsic

4 4+ 4- 4 QF4+ 4 4- 3+ Hamstrings4+ 5 4 4+ Hip flexors

4 4 3+ 3+ Hip abductors

4 4- 4- 3+ DFs3+ 3+ 2 2 PFs3+ 4- 3 3+ EDB3+ 3+ 2+ 2+ FDB

The focus of this case report was to describe the PT examination, intervention, and outcome in a typical presentation of GBS but he was not in prevalence ages

Quick and short-term improvement of the patient was amazing His onset to maximum impairment was 3weeks, typically seen with

GBS thus, GBS was considered This patient had not relapse or decline of the function after 12 weeks Full recovery was not expected at 8 weeks after onset , as 50% of

patients with GBS have remaining minor neurologic deficits and 15% have persistent residual deficits in function

the patient showed rapid improvement in muscle performance and FIM scores over his 8 weeks rehabilitation

The patient had not residual weakness in his distal musculature but later than other muscles improved.

DISCUSSION

the patient was able to ambulate somewhat sooner than predicted, considering that only 80% of GBS patients are ambulatory within six months of the onset of symptoms

Throughout his rehabilitation, the patient’s exercise intensity was moderated to avoid fatigue and PT sessions were more than once daily

Self-reported fatigue was used to determine the intensity and duration of exercise

DISCUSSION

Thus, early rehabilitation and a regular, longer non fatigue PT program per week with the aim of faster patient independence and better patient mentality can reduce the time of improving

Conclusion

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REFERENCES

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