Case Study: Guillain-Barre syndrome (Sub-acute)

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Abstract

This case study documents a fictional narrative highlighting the approach to care of a patient presenting with Guillain-Barre Syndrome (GBS). The patient's experience in acute care is discussed briefly and his sub-acute rehabilitation is explored more thoroughly. Overall, this case highlights both the nuances of GBS which lead to individualized treatment as well as management of this pathology is related to similar cases.

Introduction

According to the World Health Organization, Guillain-Barre Syndrome (GBS) is a  polyradiculoneuropathy which occurs when the body’s immune system attacks part of the peripheral nervous system[1]. This attack may induce  sensation impairment, motor control deficit, and severe pain in affected areas leading to disability affecting the upper and lower extremities. GBS is typically preceded by bacterial or viral infection, vaccination, or surgery. Diagnosis is based on symptoms such as bilateral weakness, rapid progression, and hypo/areflexia[2]. Blood tests are not required to diagnose this pathology.

Anyone can be affected by GBS - there have been documented cases of patients male and female aged 18 to 80.  Since patients with GBS may present similarly to patients with acute exposure to certain toxins, diabetic neuropathy, and Charcot-Matie-Tooth Syndrome, it is important to rule out these differential diagnoses by monitoring symptom progression and taking a history[3].

Early treatment involves acute medical care because this syndrome could progress to life-threatening lethality. In ICU and acute care settings, physiotherapists have several roles. One is to prevent contractures and other negative side effects of demobilization through positioning, splinting, and active assisted range of motion exercises or passive range of motion exercises depending on patient characteristics[4]. Physiotherapists may also be consulted to administer cardiopulmonary intervention and assessment depending on progression of the disease[3]. As symptom progression plateaus and patients transfer from acute care to rehab, treatment focus shifts to favor training focusing on performing functional tasks.

Case Background

Tom Brown, 56 year old male, first presented to the ER with a severe gastrointestinal infection approximately 5 months ago. After this infection was dealt with medically, he was discharged home with no change in baseline or complications. A few weeks later he felt numbness and tingling in his feet and hands along with pain that got worse with movement. During the following two weeks he proceeded to feel weaker and the tingling progressively worsened, eventually leading to admission to the same hospital’s emergency department. Tom could hardly move for 2 weeks and required ICU medical support. The healthcare team did an excellent job of ensuring he at least attempted to mobilize routinely and was positioned properly to avoid contractures/other complications (using postural drainage techniques, splinting, AAROM, etc., all performed as necessary). It has been 4 months since his last admission to the hospital. No other medical conditions/comorbidities have since arisen and his medical status has remained stable.


Tom’s rehabilitation will employ a graded approach centered around the capacity to perform functional activities. The providers of his treatment will be sure to ensure too much is not done too soon - over-exertion could lead to a flare-up and subsequent regression. Effort will be made to involve Tom and his family members in rehabilitation to enforce patient-centered care at every step.

Client Characteristics

  • Patient Profile: 56 years old , Male
  • Medical Diagnosis: Guillain-Barre Syndrome
  • Primary Complaint: Pain in feet, weakness in upper and lower extremity, fatigue, lack of coordination
  • Past Medical History:
    • First diagnosed with GBS approximately 4 months ago
    • Hypertension
  • Medications:
    • Amlodipine - 6mg 1x per day
    • Smoker - 5 packs / year for 5 years. Has not smoked in 3 years
    • Drinks casually, 1-2 drinks per night
  • Primary Reason For Referral:

-Complications with GBS including, characterized by ICF Framework:

  • Inability to perform some ADL’s without support (activity level)
  • Mobility, endurance and coordination levels have not returned to pre GBS levels (activity level)
  • Decline in participation in previously enjoyed social events (participation level)

Examination Findings

Initial Assessment

Subjective:

Present Condition: At the time of assessment, Tom reports that he has regained some motor control of his upper and lower extremities but he still feels very weak and uncoordinated. Weakness and impaired coordination leads to fumbling while completing daily chores. He also has lost some mobility, in particular with raising his arms and flexing his hip. This has led to difficulty dressing and getting into the shower on his own. He has gained enough motor control back to eat independently; however, this is still a challenging task.

He is able to walk short distances, about 10 minutes at a time, with a four-wheeled walker, but must stop due to shortness of breath (SOB), fatigue, and pain in his feet. His sensitivity to pain, in general, has increased notably. He has noticed that once non-painful things such as friction on his skin or muscle contraction now elicit a painful response in, he experiences particularly high levels of pain in his back and thighs.

Tom reports feelings of embarrassment from all the help he needs from his wife. He has been seeing a speech-language pathologist manage difficulty swallowing as well as an OT for help making his home more accessible. Tom lives in a 2 story home in the suburbs. His bedroom is on the second floor, which he can access independently thanks to sturdy railings recommended by the OT. However, this is difficult and scary for Tom, so he avoids using the stairs as much as possible.

Social History: Tom lives with his wife and teenage son, they have both been supportive in his recovery. Before Tom had GBS, he worked on the assembly line at a car manufacturing plant. His wife is a police officer. Tom’s work has been understanding, however, he has not been able to return to work yet and worries that the pain in his feet will keep him from ever returning to his regular duties. On weekends Tom would get together with his friends at the local pub to play billiards. Since the GBS he has not returned to the pub and misses the enjoyment this brought him.

Goals and Expectations: Tom’s primary goal is to be able to get dressed and get into the shower on his own (BSF + activity). He would really like to depend on his family less for such basic tasks. Second to that Tom would like to be able to return to work. Although he is close to retiring, he would like to keep working to support his son through college. Lastly, Tom would love to return to playing pool with his friends. He is worried that if he is not able to play pool he will lose touch with his friends. Tom is hoping physiotherapy can help him increase his upper extremity (UE) coordination, range of motion and strength. He was also hoping to receive some exercises to improve his walking so he can be less dependent on his walker. Lastly, Tom has heard that physiotherapy may also help with his pain but is a little skeptical that physiotherapy has much to offer him in terms of pain reduction.

Yellow Flags:

  • Worries about ever being able to return to work.
  • Embarrassment from depending on family.
  • Worried he’ll lose touch with his friends.
  • Does not believe physiotherapy can decrease his pain.
  • Score of 11 on the PHQ-9.

Pain: Tom describes his pain as a dull ache after activity and sharp and shooting pain during activity. He finds the pain intensity fluctuates but some pain is always present. The pain is diffuse in nature but is most intense in the feet, followed by the back and thighs. He describes the pain in his feet as a 4/10 at rest and 8/10 when weight-bearing, the pain in his lower back at 2/10 at rest and 6/10 when weight-bearing. and his thigh pain at 2/10 at rest and 7/10 when weight-bearing. The pain is at its worst after a bout of walking and at its best when he first wakes up. However, at the end of the day, he has some difficulty falling asleep due to pain brought upon by friction from the sheets on his skin [4].


Objective[5]

Nero scan: Upon examination, all of Tom’s reflexes were diminished but still present at a low level (1+), besides his knee jerk ( L3 reflex) which was absent (0). No differences between individual dermatomes were observed but general hypersensitivity was found. Additionally, a 10mg monofilament elicited strong pain response before bending on feet bilaterally. A slight drooping of the face is also visible indicating facial nerve palsy (CN V trigeminal - sensory + CN VII facial - motor) [6].

ROM: Tom presents with bilateral rigidity and spasticity in his upper and lower extremities. All Passive movements are limited by mild cog-wheel type rigidity and muscle spasm. Movements at almost all joints are limited to some degree, however, the below movements are very limited and impose the most restriction to Tom’s function.

  • Shoulder Abduction: 69/175 degrees PROM
  • Hip Flexion: 56/ 110 degrees PROM
  • Ankle Dorsiflexion: 5/ 20 degrees PROM

MMT: Tom was able to perform all motions tested against gravity, however, he has general weakness present in all muscle groups. The largest functional limitations are due to the following muscles:

  • Ankle plantar flexors (PF) (2+)
  • Hip extensors (2+)
  • Knee flexors (2+)
  • Shoulder abduction (2+)

Balance Assessment: Tom is able to stand on two feet independently with eyes open and completed a Berg Balance Scale (BERG) assessment to measure balance capabilities (see below for details).

Gait assessment: Tom was able to ambulate 200m with a four-wheeled walker during a 6-Minute walk test. He walked at a slow pace and had to stop twice during the test. He walks with a narrow and short stride. He has a slight drop foot and relies predominantly on hip flexion and abduction to progress feet forward due to weak plantar flexors. Tom completed a Timed Up and Go (TUG) assessment to assess falls risk and gait. He was unable to perform the task without a 4-wheeled walker [7].

Pulmonary function tests: Tom’s cardiorespiratory function was assessed because GBS is known to cause respiratory failure in 20-30% of cases (Dynamed, 2018). Tom’s maximum inspiratory pressure (MIP) was 80 cmH20 and his maximal expiratory pressure (MEP) was 176 cmH20. A spirometry test was performed to further assess Tom’s cardiorespiratory function and safety to perform exercise (located below). Tom presented with a normal functional vital capacity (FVC) and slightly reduced forced expiratory volume in one second (FEV1), which was a sign of a restriction in expiration capability and respiratory muscle weakness [7].
Table 1: Spirometry for Initial Assessment
Measurement Predicted Measured % Predicted
FVC (L) 4.08 3.97 97%
FEV1 (L) 3.06 2.09 68%
FEF25-75 (L/s) 3.23 2.12 65%

Clinical Impression

Problem list:

  • Pain in feet
  • Weak Ankle plantar flexors
  • Hip extensors
  • Quadriceps and shoulder abductors
  • Limited ROM in the shoulder abduction
  • Hip flexion and ankle dorsiflexion
  • Inability to dress independently
  • Poor balance and unsteady gait
  • Fatigue

Physiotherapy Diagnosis: Tom is in the sub-acute phase of recovery from Guillain-Barre Syndrome. As a result, he has difficulty with balance and UE coordination. Weakness in the plantar flexors and pain in his feet are preventing him from ambulating further than 200m. UE coordination and limitations in shoulder ROM keep him from playing pool with his friends and getting dressed independently.

Intervention

Tom is a 56-year-old male presenting four months post-hospital admission of onset of Guillain-Barre Syndrome. He has now been referred to the outpatient rehabilitation department of the hospital and is looking forward to starting rehab. Tom is presenting with decreased upper and lower extremity strength and coordination, decreased ability to independently complete ADL’s, reduced balance, and decreased ambulation ability due to deconditioning. He also shows a slouched posture, upper and lower extremity rigidity, pain in his feet, and reduced ROM. He reports he’s goals are to be able to get dressed on his own, play pool with his friends and get around without his walker.

The Approach to Tom's care will be to improve upon his presenting features, aim to reach his goals and do so in a way that is important and meaningful to him. Rehabilitation will address a multitude of factors for Tom and attempt to return his function. “As individuals begin to improve, they are usually transferred from the acute care hospital to a rehabilitation setting. Here, they can regain strength, receive physical rehabilitation and other therapy to resume activities of daily living, and prepare to return to their pre-illness life.[6] Tom has recovered from the early stages of GBS and is now ready to begin rehabilitation, “For optimal recovery, a two-phase rehabilitation process should take place—the first in the early stages of recovery to diminish the disability burden and the second in the later stages of the disease to support reconditioning.”[8]

The physiotherapy approach to GBS will consist of a graded approach to new stimuli such as gait training, range of motion exercises, endurance, strength and functional activities to slowly improve outcome measures and minimize the chance of fatigue. Treatment will include “maintenance of the patient’s posture and alignment, maintaining joint range of motion (passive, active, active assisted), providing ankle-foot orthosis to prevent plantar contractures, improving endurance (repetitive exercises with low resistance), strengthening different muscle groups, and improving flexibility with a progressive ambulation program."[9]

A major part of treatment in GBS is the return to functional activities. Not only can functional training help Tom reach his goals, but it can also help improve motivation, program adherence, and transferability. Functional training can include “safe transfer skills, equilibrium and balance in all positions and progressive ambulation."[10] To help reach Tom’s specific goals, Gait training, balance training, functional ADL training, and a gradual introduction to the pool table will be included in his program.

Program Notes:

  • After assessment of Tom’s baseline ability, we will begin at a clinically reasonable level of intensity, duration, and frequency and progress as warranted. Tom’s rehabilitation will take place in the clinic and can be practiced at home, given proper assistance and technique.
  • All parties involved, including Tom, should be aware of the symptoms of fatigue to prevent rehabilitation from regressing and to promote long-term functional independence. [8]
  • Programmes for individuals recovering from GBS tend to last around 12 weeks and include 30–60 minutes of exercise intervention three times per week.[8]

Aerobic Training

  • Low-level aerobic exercise provided safe and positive clinical benefits for this GBSP.[8]
    • Beginning at a low intensity and build towards moderate-intensity on the Borg Scale of Perceived Exertion Scale[11]
    • Frequent rest periods initially
    • A gradual increase in exercise time
    • Exercise modality could include arm ergometer, stationary bike, or walking and should be adjusted to patient ability and preference.

Strengthening

  • Include both isometric and isotonic resistance training.
  • Prioritize multi-joint exercises. In the early stages of recovery, “By linking multiple joints together for movement, the patient reinforces muscle synergies where primer movers and stabilizers are active and coordinated.”[11]
  • Examples include and are not limited to clamshells, glute bridges, hip kickbacks, side-lying hip abduction, banded dorsiflexion, sit to stand and resistance band upper extremity training.

Balance & Gait

  • Parallel bar gait & balance training
  • Tandem stance balance & gait
  • Progression to balance on unstable surfaces ( foam surface etc.)
  • Provide ankle-foot orthosis – if needed/tolerated
  • Assess gait aid ability and progress as needed.

Range of Motion & Posture

  • Joint range of motion (passive, active, active assisted)[9]
  • Progression to active stretching & range of motion
  • Postural cueing, education, and postural exercises.

Functional training

  • Functional training can help connect new strength, range of motion, balance and work towards increasing coordination and skill.
  • Progressive introduction to activities (walking without a walker)
  • ADL training (dressing practice, strategy, and education)
  • Return to pool playing – practice with a pool cue, standing endurance, table leaning, and building towards coordinated pool shoot.

Pain Management

  • Pain neurophysiology education
  • Transcutaneous electrical nerve stimulation
  • Massage with passive ROM
  • Reassurance and explanation of what to expect can help in the alleviation of anxiety that could compound the pain [12]

Reassessment 12 weeks Post-Treatment

Present Condition: 87% of patients with GBS will make full recovery or have minor deficits within 1-3 years [13]. Tom had been diagnosed with GBS approximately 6 months ago and his symptoms from his original diagnosis have begun to stabilize during therapy, which assisted in his progression. Tom’s rehabilitation program consisted of 30-60 minute treatment sessions for 3 days/week. Simple muscular Strength, ROM, and balance assessments were recorded every 2 weeks to ensure progression occurring. A complete reassessment was completed after 12 weeks of treatment.

Facial Palsy and Dysphagia: Tom demonstrated increased facial muscle strength and was capable of controlling his facial movements with ease. Collaboration with a speech-language pathologist and OT contributed to his decreased dysphagia and improved ability to swallow.

Subjective - 12 weeks:

Pain: Tom reports decreased intensity and frequency of the pain in his feet, back, and thighs. However, Tom still experiences dull aches in those areas after completing physical activity and weight-bearing for extended periods of time. His sensitivity to pain from random stimuli decreased slightly, but there were times where it seemed to flair up (objective values located in the table below).

Goals and Expectations: Because of his increased functional capabilities, Tom feels less embarrassed compared to before treatment. Tom has been more independent with his ADLs and does not require any assistance for basically all of his activities. Tom has been able to return to more activities at work and has less pain compared to before. His work has placed him on more active duties, but there are still some restrictions. After a long day of work, he still becomes tired and feels some pain, but not as often as before. Tom has started playing pool again with his friends but has trouble holding the cue at times.

Yellow Flags: Tom reports feeling less depressed and is excited to be able to return to participating in the activities he enjoys. His family reports that his general mood at home is better and he has been anxious to help contribute again.

Objective - 12 weeks:

ROM: Tom has increased ROM and strength in his upper and lower extremities. The increase in control and endurance in his muscles has allowed him to walk for longer distances without fatigue and complete more of his ADLs independently (objective values located in the table below).

Balance: There are instances where Tom requires to hold onto something to increase his base of support while walking without a mobility aid but has not fallen since starting therapy. Tom does report that he feels more balanced and mobile compared to when he first started therapy and has been more coordinated with his movements. A reassessment of Tom’s balance using the BERG (48/56) has demonstrated that Tom’s balance has increased significantly since his initial assessment. His confidence has increased and has reported a decreased fear of falling. Tom still has difficulty with external perturbations and sometimes uses a cross-over compensatory mechanism. Future assessment will require more advanced balance outcome measures for functional activities (objective values located in the table below).

Mobility: Tom uses a 4 wheeled walker for travelling outside of his home, but has been comfortable walking around his home without a mobility aid. Tom was able to ambulate 375m during a 6-minute walk test (6MWT) with a 4-wheeled walker and was able to ambulate 64m without a mobility aid. Tom walks at a slower pace without a mobility aid and has a wider base with short strides. He has a slight drop foot and relies predominantly on hip flexion and abduction to progress feet forward due to weak plantar flexors. Walking with a mobility aid allows Tom to correct his gait and not have to focus on his balance compared to using no mobility aid. However, it is more tiring using the walker compared to walking without a mobility aid, which is an indication for Tom to switch to a quad cane as a mobility aid (objective values located in the table below).

Cardiorespiratory Endurance: Tom still experiences SOB with too much activity, but not as intense or frequently compared to before therapy.

Table 2: Objective Outcome Measures Across 12 Weeks
Measures Initial Assessment (t) t + 6 weeks t + 12 weeks
Pain:

Feet

Low Back

Thigh

Rest 2/10, WB 8/10

Rest 2/10, WB 6/10

Rest 2/10, WB 7/10

Rest 1/10, WB 5/10

Rest 1/10, WB 4/10

Rest 1/10, WB 4/10

Rest 1/10, WB 4/10

Rest 0/10, WB 4/10

Rest 1/10, WB 3/10

Patient Health Questionnaire (PHQ-9) 11 10 7
Reflexes All reflexes diminished (1+)

Absent L3 (0)

All reflexes diminished (1+) All reflexes (2+)

L3 reflex diminished  (1+)

Myotomes Normal Normal Normal
Dermatomes Decreased sensation over L3 and L4 Decreased sensation over L3 Normal
10g Monofilament 4/10 pain (visual analogue scale - VAS) 3/10 pain 1/10 pain
Shoulder ROM AROM: 69

PROM: 91

AROM: 90

PROM: 115

AROM: 130

PROM: 150

Hip ROM AROM: 56

PROM: 82

AROM: 77

PROM: 100

AROM: 90

PROM: 108

Ankle ROM AROM: 5

PROM: 10

AROM: 7

PROM: 11

AROM: 10

PROM: 12

Manual Muscle Testing (MMT) Ankle PF: 2+

Hip Extension: 2+

Knee Flexion: 2+

Shoulder Abd: 2+

Ankle PF: 3

Hip Extension: 2+

Knee Flexion: 3+

Shoulder Abd: 3

Ankle PF: 3+

Hip Extension: 3

Knee Flexion: 3+

Shoulder Abd: 3+

6MWT 200m with a 4-wheeled walker

*fatigue and SOB*

350m with a 4-wheeled walker

64m without a mobility aid

375m with a 4-wheeled walker

90m with out a mobility aid

TUG 37sec with a 4-wheeled walker 25sec with a 4-wheeled walker 12.5sec with a 4 wheeled walker

25sec without a mobility aid

BERG 33 40 48
GBS Disability Scale 3 3 2

Discharge Plan

After completing 12 weeks of rehabilitation therapy, Tom has been able to achieve his original goals and has become more independent with his activities. He has been able to walk for short distances around his home without a mobility aid, been able to complete his ADL’s without assistance, has decreased restriction at work, and has started to play pool with his friends again. Tom’s symptoms from GBS have significantly decreased since starting physical therapy, which has helped his progress and improvement in function. However, there are concerns with Tom’s safety for balance while walking without a mobility aid and inability to perform certain functional tasks at work. Tom can be discharged based on his progression but would benefit from less frequent treatment with a focus on increasing his function for work, balance with walking w/o a mobility aid, and switching his 4-wheeled walker to a cane. A discussion with Tom will allow for a reassessment of his long-term goals and a new plan of care can be developed. Based on his response, a discharge date can be determined.

Discussion

Acute GBS is characterized by a rapid decline in a patient's control over the majority of major muscle groups, including respiratory muscles [6]. In the subacute phase, patients begin to gradually regain motor control [6], however, residual weakness, pain, respiratory symptoms, and decreased ROM can severely impact their ability to participate in their typical daily activities [6]. These common deficits were all observed in Tom's assessment and quantified using various outcome measures and tests such as the 6-minute walk test and the VAS. Tom's deficits resulted in an inability to participate in his usual social routine and perform basic activities of daily living such as getting dressed. This rapid loss of function can be overwhelming for GBS patients. Accordingly, Tom's mental well being was also impacted by his GBS diagnosis as can be seen from his PHQ-9 score of 11 on the PHQ-9. Thankfully, the majority of GBS patients make a full recovery [13]. Therefore, by reassuring your patient and focusing treatment on functional activity, physical therapy has a high potential to improve your patient's quality of life.

A 12-week intervention program was developed for Tom based on his goals and the ICF model. Tom's program included strength, aerobic, balance, mobility, functional training, and an early focus on pain management. Upon starting treatment Tom's GBS symptoms began decreasing and he made significant improvements in his overall function. A reduction in pain at rest, improved ROM with upper and lower extremities, more stability with static and dynamic postures, increased motivation, and ability to walk without a mobility aid are a few of progressions that Tom achieved. Increasing Tom's functional capabilities has allowed him to return to work at a higher capacity, participate in recreational actives, and complete ADL's independently. Tom uses a 4-wheeled walker outside of his home, has some balance troubles while walking without a mobility aid, and experiences mild-moderate pain with activity. He would benefit from continued physical therapy with a progression to more functional exercises. Tom is consistent with his exercise routine at home and would be able to attend treatment at a lower frequency. Tom may also benefit from a quad cane mobility aid to decrease the energy expenditure of using a 4-wheeled walker. Based on Tom's progression, there is a good likelihood his functional capabilities will keep improving and hopefully he will reach the point where he is able to return to his lifestyle prior to developing GBS.

Self-Study Question

1. Guillain-Barre is a:

a) rare autoimmune chronic polyradiculoneuropathy

b) rare secondary condition from a traumatic brain injury

c) rare form of cerebral vascular disease

d) rare autoimmune acute polyradiculoneuropathy

2. Which of the following are clinical signs of Guillain-Barre Syndrome? a) muscular weakness and sensory abnormalities

b) facial weakness

c) hyporeflexia

d) ataxia

e) all of the above

3. What percent of Guillain-Barre syndrome patients make a full recovery:

a) 25%

b) 54%

c) 87%

d) 10%

Answers:

  1. d
  2. e
  3. c

This case study is affiliated with Queen's University Faculty of Rehabilitation Therapy MSc(Pt) https://physio-pedia.com/Queen's_University_Neuromotor_Function_Project

References

  1. World Health Organization. “Guillain-Barre Syndrome”. Available from: https://www.who.int/news-room/fact-sheets/detail/guillain-barr%C3%A9-syndrome
  2. Prada V, Massa F, Salerno A, Fregosi D, Beronio A, Serrati C, Mannironi A, Mancardi G, Schenone A, Benedetti L. Importance of intensive and prolonged rehabilitative treatment on the Guillain-Barrè syndrome long-term outcome: a retrospective study. Neurological Sciences. 2020 Feb 1;41(2):321-7.
  3. 3.0 3.1 Newswanger DL, Warren CR. Guillain-Barré syndrome. American family physician. 2004 May 15;69(10):2405-10.
  4. 4.0 4.1 Ruts L, Drenthen J, Jongen JL, Hop WC, Visser GH, Jacobs BC, Van Doorn PA, Dutch GBS Study Group. Pain in Guillain-Barre syndrome: a long-term follow-up study. Neurology. 2010 Oct 19;75(16):1439-47.
  5. Dhar R, Stitt L, Hahn AF. The morbidity and outcome of patients with Guillain–Barré syndrome admitted to the intensive care unit. Journal of the Neurological Sciences. 2008;264(1-2):121–8.
  6. 6.0 6.1 6.2 6.3 6.4 National Institute of Neurological Disorders and Stroke. Guillain-Barré Syndrome Fact Sheet. Available from: https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/Guillain-barré-syndrome-fact-sheet (accessed 10 May 2020).
  7. 7.0 7.1 Dhar R, Stitt L, Hahn AF. The morbidity and outcome of patients with Guillain–Barré syndrome admitted to the intensive care unit. Journal of the Neurological Sciences. 2008;264(1-2):121–8.
  8. 8.0 8.1 8.2 8.3 Arsenault NS, Vincent P-O, Yu BHS, Bastien R, Sweeney A. Influence of Exercise on Patients with Guillain-Barré Syndrome: A Systematic Review. Physiotherapy Canada. 2016;68(4):367–76.
  9. 9.0 9.1 Fary K. Rehabilitation in Guillian-Barré Syndrome. Australian Family Physician. 2005; 33 (12):1014-1015
  10. Nehal S, Manisha S. Role of Physiotherapy in Guillain-Barre Syndrome: A Narrative Review. Int J Health Sci Res. 2015; 5(9):529-540.
  11. 11.0 11.1 Bassile CC. Guillain-Barré Syndrome and Exercise Guidelines. Neurology Report. 1996;20(2):31–6.
  12. Physiopedia. Guillain-Barre Syndrome. Available from: https://www.physio-pedia.com/Guillain-Barre_Syndrome (accessed 14 May 2020).
  13. 13.0 13.1 DynaMed. (2018, Nov 30). Guillain-Barre Syndrome. Ipswich, MA: EBSCO Information Services. Retrieved May 18, 2020, from https://www-dynamed-com.proxy.queensu.ca/topics/dmp~AN~T116758. Registration and login required.