PHYSICAL THERAPY INPATIENT REHABILITATION FOR A PATIENT WITH

GUILLAIN BARRE SYNDROME

A Doctoral Project
A Comprehensive Case Analysis

Presented to the faculty of the Department of Physical Therapy

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

DOCTOR OF PHYSICAL THERAPY

by

Timothy Hill

SUMMER
2018
 © 2018

Timothy Hill

ALL RIGHTS RESERVED

ii
 PHYSICAL THERAPY INPATIENT REHABILITATION FOR A PATIENT WITH

GUILLAIN BARRE SYNDROME

A Doctoral Project

by

Timothy Hill

Approved by:

_____________________________________, Committee Chair

Brian Moore, PT, DPT, NCS

_____________________________________, Second Reader

Bryan Coleman-Salgado, PT, DPT, MS, CWS

_____________________________________, Third Reader

Rolando Lazaro, PT, PhD, DPT, GCS

____________________________
Date
iii
Student: Timothy Hill

I certify that this student has met the requirements for format contained in the University
format manual, and that this project is suitable for shelving in the Library and credit is to
be awarded for the project.

__________________________________, Department Chair ____________

Michael McKeough, PT, EdD Date

Department of Physical Therapy

iv
 Abstract

of

PHYSICAL THERAPY INPATIENT REHABILITATION FOR A PATIENT WITH

GUILLAIN BARRE SYNDROME

by

Timothy Hill

A 49-year-old female with a medical diagnosis of Guillain Barre syndrome was

seen for physical therapy treatment for 3 weeks in an inpatient rehabilitation setting.

Treatment was provided by a student physical therapist under the direct supervision of a

licensed physical therapist.

The patient was examined by the student physical therapist using measures

including manual muscle testing, neurologic examination, observational gait analysis, and

the functional independence measure, in addition to patient reported information. Upon

initial examination, the patient was observed to have impairments of strength, sensation,

proprioception, and gait kinematics, which led to decreased functional independence and

mobility, which ultimately restricted the patient from living at home with her family and

participating in her usual role as a mother.

The patient received multidisciplinary care from a variety of health care providers

including physical therapists, occupational therapists, speech language pathologists,

v
nurses, psychologists, social workers, and physiatrists. A physical therapy plan of care

was developed to include interventions addressing the patient’s impairments and

functional limitations to improve the patient’s independence and ability to live at home

and participate in her daughters’ extracurricular activities. Interventions focused

primarily on task-oriented functional training including bed mobility, transfer training,

and gait training, with adjunct interventions of therapeutic exercise and orthotic

prescription.

The patient improved strength, gait kinematics, functional mobility and was

discharged home with assistance from family. The patient was referred for continued

physical therapy in an outpatient clinic and was given a home exercise program to be

completed in the interim.

_____________________________________, Committee Chair

Brian Moore, PT, DPT, NCS

_______________________
Date

vi
 ACKNOWLEDGEMENTS

I acknowledge the University of California Davis Medical Center, Physical

Medicine and Rehabilitation department, for allowing me the opportunity to participate in

a physical therapy clinical affiliation and access patient information for the completion of

this case study, contributing towards the requirements of my doctor of physical therapy

degree. Additionally, I acknowledge my clinical instructor for providing supervision and

guidance throughout this patient encounter.

vii
 TABLE OF CONTENTS
Page

Acknowledgements .............................................................................................. vii

List of Tables ........................................................................................................ ix

Chapter

1. GENERAL BACKGROUND........................................................................... 1

2. CASE BACKGROUND DATA ....................................................................... 3

3. EXAMINATION – TESTS AND MEASURES .............................................. 8

4. EVALUATION............................................................................................... 13

5. PLAN OF CARE – GOALS AND INTERVENTIONS................................. 15

6. OUTCOMES .................................................................................................. 25

7. DISCUSSION ................................................................................................. 28

References ............................................................................................................. 31

viii
 LIST OF TABLES
Tables Page

1. Medications ………………… ......................... .………………………………. 6

2. Examination Data……………………………….… ………………………… 11

3. Evaluation and Plan of Care… .. ………….…………………………………. 15

4. Outcomes……………………………….……… ... …………………………. 25

ix
 1

Chapter 1

General Background

Acute inflammatory demyelinating polyradiculoneuropathy, more commonly

referred to as Guillain Barre syndrome (GBS) affects the peripheral nervous system and

is the leading cause of acute flaccid paralysis worldwide.1-3 There are multiple diagnostic

subtypes of GBS with acute inflammatory demyelinating polyradiculoneuropathy

diagnosed most commonly.4 Patients who are given a medical diagnosis of GBS typically

demonstrate signs and symptoms including rapidly progressive bilateral and symmetrical

ascending motor and sensory disturbances of the extremities resulting in hyporeflexia or

areflexia.5 More progressive forms of GBS effect respiratory muscles, muscles innervated

by cranial nerves, and may cause autonomic dysfunction.5 Due to inflammatory

demyelination of peripheral nerves, paresthesia and neuropathic pain are common.6

Additionally, severe fatigue in patients with GBS has been observed both acutely and

chronically with proposed mechanisms of peripheral fatigue due to a decrease in motor

units, central fatigue due to neuroendocrine dysregulation, and experienced fatigue due to

prolonged sympathetic response from stress.7 Peak impairment typically occurs 2-4

weeks from the initial onset, however, with the chronic form of GBS known as chronic

inflammatory demyelinating polyradiculoneuropathy (CIDP), symptoms may develop

over eight weeks or longer.2

The incidence of GBS has been reported as 1-2 cases per 100,000 population in

developed countries and affects men 1.5 times more often than women.1,5 Additionally,

an increase in incidence has been observed with advancing age as a 20% increase in the
 2

average rate of GBS per 100,000 population has been observed for every 10 year increase

in age across the lifespan.8 Five percent of patients die due to medical complications of

GBS, such as sepsis, development of pulmonary emboli, or cardiac arrest.1,3

The underlying etiology of GBS is not fully understood, but is thought to be an

autoimmune condition that may be triggered by one of possible viral infectious agents

such as Epstein-Barr and varicella-zoster among other viruses.3,8

In general, patients with an admission diagnosis of GBS have a good prognosis

for favorable functional outcomes one year following discharge from a neurocritical

intensive care unit (Neuro-ICU).9 Despite good functional outcomes, many patients

report residual effects at 1 year such as decreased sensation and muscular power as well

as decreased participation in work and hobbies compared to premorbid levels.10

Additionally, patients with GBS have been observed to experience long term functional

improvements at 1 years post onset10 as well as work and leisure activity changes 3-6

years post onset.11 Recurrence is uncommon, but has been observed in 7-10% of patients

with GBS.2,3

Patients with GBS are more likely to experience poor outcomes if they are older

(>60 years), have higher severity of deficits at onset, require mechanical ventilation, have

impaired cranial nerve function, and/or had a preceding episode of diarrhea prior to onset

of GBS symptoms.12-14 Patients with GBS are more likely to have good functional

outcomes if they are younger (<40 years), do not require mechanical ventilation, and

have low severity of symptoms at onset.9,12

 3

Chapter 2

Case Background Data

Examination – History

The patient was a 49-year-old female with a medical diagnosis of “acute (possibly

on chronic) inflammatory demyelinating polyradiculoneuropathy” with comorbidities of

gastrointestinal bleed, anemia, cirrhosis, urinary retention, hyponatremia, and urinary

tract infection. The patient reported a previous episode of ascending weakness isolated to

her bilateral lower extremities 1 year prior to hospitalization with an approximate 90%

return of strength 3 months prior to her hospitalization. The patient reported that prior to

admission she was independent in all self-care and activities of daily living using a front

wheeled walker (FWW) for ambulation and elevated toilet seat. Symptom onset began 3

weeks prior to emergency department admission with distal weakness in her hands and

increased difficulty walking with a FWW, which resulted in a fall in her home bathroom

right before hospital admission. The patient reported that she was unaware of any

preceding illness or provoking factors. The patient was treated acutely in the neurology

unit for 12 days prior to admission and evaluation in inpatient rehabilitation. The

patient’s medical records of specific medical interventions provided prior to admission to

inpatient rehabilitation were not available for viewing.

The patient’s previous episode of ascending lower extremity weakness indicated

the possibility of a CIDP diagnosis, however; the patient’s course of care was treated as

an acute episode. Guillain Barre syndrome will be used when referring to the patient’s

medical diagnosis throughout the remainder of this paper.

 4

Based on patient report and gross observation, the patient had impaired strength

and sensation, which limited her functional mobility and transfers. Additionally, the

patient was restricted in her ability to participate in her duties as a mother for her 2

daughters, aged 16 and 18 years old, and in participating in continuing education courses

to earn a math degree and become a middle school teacher.

The patient lived in a single-story home with one step to enter. The patient

reported that she owned a FWW and elevated toilet that she had been using since her

previous episode of decreased strength, but did not have any other assistive devices or

home adaptations. The patient reported that she had good social support from her two

daughters who live with her in addition to her parents who live next door.

The patient’s chief complaints were severe pain in both hands and weakness in

both arms and legs that limited her functional independence and restricted her from living

at home and participating as a mother by attending her daughters’ extracurricular

activities. The patient’s goals were to return to her prior level of function and return home

with her daughters.

Systems Review

The patient’s neuromuscular system was impaired based on impaired gross

strength and sensation in the upper and lower extremities in addition to her medical

diagnosis of GBS. The patient’s musculoskeletal system was impaired based on

decreased upper and lower extremity gross strength and limited functional movement.

The patient’s cardiovascular system was impaired based on medical diagnoses of anemia

and hyponatremia, low hemoglobin and hematocrit levels, and observed non-pitting
 5

edema in her legs. The patient’s respiratory system was not impaired per physician report

of the lungs clear to auscultation bilaterally. The patient’s integumentary system was not

impaired based on patient report and observation. The patient’s cognition and

communication were not impaired based on orientation to person, place, time, and

situation as well as correct immediate and delayed recall.

 6

Examination - Medications

Table 1

Medications

MEDICATION DOSAGE REASON SIDE EFFECTS15

Acetaminophen / 650 mg tablet Pain Difficulty breathing or
TYLENOL® swallowing, itching, hives,
(analgesic/antipyretic) rash, hoarseness
Bisacodyl / 10 mg suppository Constipation Stomach cramps, faintness,
DULCOLAX® stomach discomfort, rectal
(stimulant laxatives) bleeding
Docusate / 100 mg capsule Constipation Stomach or intestinal cramps,
COLACE® (stool nausea, hives, difficulty
softener) breathing or swallowing, fever,
vomiting, stomach pain
Duloxetine / 30 mg delayed Neuropathic pain Nausea, light headedness,
CYMBALTA® release capsule and depression agitation, hallucinations,
(selective serotonin headache, weakness,
and norepinephrine drowsiness
reuptake inhibitors)
Folic Acid (B- 1 mg tablet Anemia Skin rash, itching, redness,
complex vitamin) difficulty breathing
Gabapentin / 400 mg capsule Neuralgia Drowsiness, dizziness,
NEURONTIN® headache, anxiety, nausea,
(anticonvulsant) constipation, swelling
Gabapentin / 600 mg capsule Neuralgia Drowsiness, dizziness,
NEURONTIN® headache, anxiety, nausea,
(anticonvulsant) constipation, swelling
Lactulose / 10 gram/15 mL constipation Diarrhea, gas, nausea, stomach
CHRONULAC® Solution 15 mL pain or cramps, vomiting
(stool softener)
LevoFLOXacin / 500 mg tablet Urinary tract Nausea, vomiting, diarrhea,
LEVAQUIN® infection stomach pain, constipation,
(antibiotic) extreme tiredness
Magnesium 400 mg/5 mL constipation Stomach cramps, upset
Hydroxide / MILK suspension 30mL stomach, vomiting, diarrhea
OF MAGNESIA®
(antacid)
Magnesium Sulfate 2 g in 50 mL Magnesium Flushing, dry mouth, nausea,
(anticonvulsant) intravenous deficiency blurred vision, feeling
piggyback infusion uncomfortably warm
Metoclopramide / 10 mg injection heartburn Drowsiness, weakness,
REGLAN® headache, dizziness, nausea,
(Dopamine D2 vomiting, diarrhea
antagonist)
Multivitamin with 1 tablet Vitamin and mineral Upset stomach
Minerals deficiency
Pantoprazole / 40 mg delayed Gastroesophageal Constipation, vomiting, nausea,
PROTONIX® release tablet reflux disease vomiting, joint pain, fatigue
 7

(proton pump
inhibitor)
Polyethylene Glycol 17 g oral powder Constipation Nausea, bloating, cramping,
3350 / MIRALAX® packet gas, diarrhea
(osmotic laxative)
Potassium Chloride / 40-60 mEq slow hypokalemia Confusion, anxiety,
KLOR-CON M20® release tablet dysrhythmia, nausea, vomiting,
(electrolyte) gas, abdominal pain
Sennosides / 17.2 mg tablet constipation Brown discoloration of urine,
SENOKOT® faintness, stomach discomfort,
(stimulant laxative) nausea
 8

Chapter 3

Examination – Tests and Measures

The patient’s deficits were categorized in accordance to the International

Classifications of Functioning, Disability, and Health (ICF) model.16 At the body

function or structure level, manual muscle testing (MMT) was used to test muscular

strength, neurologic examinations including light touch, proprioception, pinprick

sensation, and reflexes were used as diagnostic tests to detect polyneuropathy.

Observational gait analysis17 was used to detect gait impairments and to develop a

clinical impression of how the observed impairments might affect functional outcomes

and to aid in goal setting. At the activity level, the Functional Independence Measure

(FIM) was used as an outcome measure for functional independence and as a prognostic

measure for fall risk. Additionally, individual FIM items were used to assess assistance

level for functional mobility and transfers. At the participation level, patient report,

discharge destination, and ability to perform car transfers and mobility with family

assistance were used to measure the patient’s ability to live at home and participate in her

role as a mother by attending her daughters’ extracurricular activities.

The MMT is a measure used to assess muscular strength in lower motor neuron

disorders. The test, according to Daniels and Worthingham, is performed by applying a

manual resistance to a muscle or muscle group (i.e. knee extensors) while the patient

performs an isometric hold.18 Each tested muscle or muscle group is assigned a

categorical score ranging from 0 (no muscle activity) to 5 (the patient can hold isometric

contraction against maximal resistance). The measure was initially created to measure
 9

muscular weakness in patients with lower motor neuron damage from poliomyelitis.19

The MMT has a minimal detectable change (MDC) of 1 muscle grade.19 Based on this

MDC data, with a change in score of ³1, a clinician can infer that an actual change versus

measurement error has occurred.

Several neurologic examinations can serve as diagnostic tests to inform a

diagnosis of polyneuropathy. Results of the examinations can be quantified by dividing

the number of correct responses by the number of stimuli applied and are considered

normal (100% correct) or impaired (inconsistent or absent patient response).20 Pinprick

sensory testing has been reported to have a positive likelihood ratio (LR+) of 8.0 and a

negative likelihood ratio (LR-) of 0.31,21 which suggests that a positive test result would

provide a moderate shift in the post-test probability that the patient has polyneuropathy

whereas a negative test would result in a small shift in post-test probability that the

patient does not have polyneuropathy. Light touch testing has a reported LR+ of 11.25

and LR- of 0.57 and proprioception testing has a reported LR+ of 18.0 and LR- of 0.65.21

Light touch and proprioception both provide a large shift in post-test probability with a

positive test, but a negligible post-test probability with a negative test. Based on the LR+

and LR- values, neurologic examination may be better used for identifying

polyneuropathy within a population than as a screen for ruling out polyneuropathy. The

collective results of pinprick, light touch, and proprioception testing can inform goals

with consideration for outcomes consistent with a medical diagnosis of polyneuropathy.

The FIM is an activity level measure used to assess patient function and burden of

care.22 The FIM consists of 18 items that are individually scored based on the patient’s
 10

level of dependency from 1 (total assistance) to 7 (complete independence).23 Outcomes

are assessed based on total FIM score and can be additionally broken down into motor

(13 items) or cognitive (5 items) FIM subscales. The FIM is one of the most widely used

functional measures in the inpatient rehabilitation setting,24-26 and has been used as a

criterion measure or “gold standard” for establishing the responsiveness and validity of

other outcome measures.27 The standard error of the mean for the total FIM is 4.7 with a

calculated MDC with a 95% confidence interval of 13.03 for a large sample of patients

with mixed diagnoses.28 The minimal clinically important difference (MCID) has not

been established for patients with GBS, but a MCID with a 95% confidence interval

(MCID95) of 11-17 points on the motor FIM and 22 points for the total FIM has been

established for patients with stroke.29,30

The FIM can also be used as a prognostic measure for fall risk and has been

reported to predict fall risk during inpatient rehabilitation for patients with a variety of

diagnoses, including GBS.31The motor FIM is inversely related to fall rate in inpatient

rehabilitation with a reported fall rate of 17.3% for scores less than 39 compared to a fall

rate of 4.26% for scores greater than 53.31 Additionally, the total FIM is inversely related

to fall rate in inpatient rehabilitation with a reported rate of 19.91% with scores less than

66 compared to an observed fall rate of 3.31% with scores greater than 84.31 Based on

these findings, the FIM may be useful for estimating fall risk for patients during

hospitalization in inpatient rehabilitation, but has limited ability to predict long term fall

risk following discharge.

 11

Table 2
Examination Data
BODY FUNCTION OR STRUCTURE
Measurement Category Test/Measure Used Test/Measure Results
Neuromuscular MMT UE: R L
strength Shoulder Flexion 4+/5 5/5
Shoulder Abduction 4+/5 5/5
Shoulder Extension 4+/5 4/5
Elbow Flexion 4/5 4/5
Elbow Extension 3/5 3/5
Wrist Flexion 2+/5 3/5
Wrist Extension 2-/5 2+/5
Finger Flexion 2-/5 2+/5
Finger Abduction 2-/5 3/5
LE:
Hip Flexion 4/5 4/5
Hip Extension 4/5 4/5
Hip Abduction 4/5 4/5
Knee Flexion 4/5 4/5
Knee Extension 4/5 4/5
Ankle Plantar flexion 1/5 1/5
Ankle Dorsiflexion 1/5 1/5
Pain NPRS Bilateral hands: Constant and variable neurogenic
pain, 8/10 at worse
Paresthesia – Patient reported a tingling pain as well
as a feeling of “wires wrapped around her fingers”
Sensation - touch Light touch UE: Impaired bilaterally at hands and distal forearms
(0/5)
LE: Impaired bilaterally below the knees (0/5)
Joint position sense Proprioception Impaired bilaterally at the 1st MCPJ
Impaired bilaterally at TFJ
Impaired bilaterally at TCJ
Impaired bilaterally at 1st MTPJ
Sensation – superficial Pin-prick UE: Impaired bilaterally at hands and distal forearms
pain (0/5)
LE: Impaired bilaterally below the knees (0/5)
Reflex integrity Deep tendon reflexes Areflexia (0/4+) bilateral finger flexors and Achilles
tendons
Gait kinematics and Observational Gait Observed bilaterally:
critical events Analysis - Midfoot contact with excessive supination
during initial contact
- Limited knee flexion during weight
acceptance
- Hyperextension at the knee with excess
plantar flexion at midstance (forward
progression beyond 0 degrees dorsiflexion
caused knee collapse)
- Excessive plantar flexion, knee extension,
and hip flexion throughout stance (L>R) and
swing
 12

- No trailing limb position during terminal

stance: no heel off, excess ankle plantar
flexion, knee hyperextension, and excess hip
flexion
- Bilateral step-to pattern
FUNCTIONAL ACTIVITY
Measurement Category Test/Measure Used Test/Measure Results
Functional FIM Motor = 24/91
independence Total = 55/126
Elevated risk for fall
Functional mobility Bed Mobility Supine to EOB = max A, flat hospital bed without rail
EOB to supine = mod A, flat hospital bed without rail
Functional mobility FIM – Bed to W/C 2/7 (max A) stand pivot and slide board transfers
Transfer
Functional mobility FIM – Walk 1/7 (dep A) 30’ with Rifton Tram® mechanical lift
Functional mobility FIM – manual W/C 1/7 (dep A) Pt unable to propel W/C
Propulsion
Functional mobility FIM – Stairs 0/7 (not functionally safe during initial visit)
Functional mobility Car Transfer Not functionally safe to test during initial visit
PARTICIPATION RESTRICTIONS
Measurement Category Test/Measure Used Test/Measure Results
Participation in family Patient Report, D/C Patient was unable to live at home and participate in
home life and destination, and her role as a mother by attending her daughters’
parenting. ability to perform extracurricular activities.
transfers and
mobility with family
assistance
MMT = manual muscle test, NPRS = numeric pain rating scale, L = left, R = right, UE + upper
extremity, LE = lower extremity, MCPJ = metacarpophalangeal joint, TFJ = tibiofemoral joint, TCJ =
talocrural joint, MTPJ = metatarsophalangeal joint, FSS = fatigue severity scale, FIM = functional
independence measure, D/C = Discharge, EOB = edge of bed, W/C = wheel chair, mod = moderate, max
= maximum, dep = dependent, A = assistance
 13

Chapter 4

Evaluation

Evaluation Summary

The patient was a 49-year-old female with a medical diagnosis of GBS in the

subacute stage of recovery. The patient presented with body function or structure

impairments in strength, sensation, proprioception, and reflexes in a glove and stocking

pattern to bilateral upper and lower extremities. In addition, the patient demonstrated

impaired gait kinematics resulting in the inability to achieve critical events during the gait

cycle. The patient was limited in her functional independence, and based on FIM scores

had an elevated risk for falling. The patient required maximal to dependent assistance for

bed mobility, transfers, wheelchair mobility, and ambulation which restricted the patient

from living at home and participating in her usual roles as a mother and student by

attending her daughters’ extracurricular activities and taking classes.

Diagnostic Impression

The patient’s presentation was consistent with the medical diagnosis of GBS. The

patient’s body function or structure impairments of strength, sensation, proprioception,

and gait kinematics resulted in activity limitations in bed mobility, transfers, wheelchair

mobility, and ambulation. These impairments and activity limitations contributed to

participation restrictions in the patient’s usual roles as a mother and student.

Prognostic Statement

The patient’s positive prognostic factors included overall lower severity of

symptoms at onset (i.e. no obvious proximal extremity, trunk, or cranial nerve

 14

involvement), relative younger age (older than 40, but less than 60 years old), no history

of diarrhea preceding onset, and not requiring mechanical ventilation.9,12,14

The patient’s negative prognostic factors included age greater than 40 years old.9

Additionally, the patient presented with multiple medical comorbidities including

gastrointestinal bleed, anemia, cirrhosis, urinary retention, hyponatremia, and urinary

tract infection that could have complicated rehabilitation.

The patient was anticipated to achieve a functional level of minimal assistance for

transfers, and mobility with the use of assistive devices and orthotics for functional

mobility at a household level. It was anticipated that the patient would return home and

participate in her role as a mother to a reduced capacity with the utilization of adaptive

equipment and assistance as needed provided by her daughters or parents who live next

door.

G-Codes

Current G-code: Mobility – G8978CM (> 80% but < 100% impaired) based on

dependent assistance (patient does <25% of the effort) for ambulation.

Goal G-code: Mobility – G8979CI (> 1% but <20% impaired) based on

assistance level needed for ambulation.

Discharge Plan

The patient was expected to be discharged home with assistance from her two

daughters and her parents who live next door. A need for continued physical therapy in

an outpatient clinic was expected following discharge in addition to a home exercise

program.
 15

Chapter 5

Plan of Care-Goals and Interventions

Table 3

Evaluation and Plan of Care

PROBLEM PLAN OF CARE

Short Term GoalsLong Term Goals Planned Interventions
(1 week) (3 weeks) Interventions are Direct or
Procedural unless they are marked:
(C) = Coordination of care
intervention
(E) = Educational intervention
BODY FUNCTION OR STRUCTURE IMPAIRMENTS
Impaired UE/LE No measurable Patient will increase Strengthening of the UE/LE was
strength change expected UE/LE MMT grade ³ targeted mostly through functional
1 at each measured activity training described in
muscle group (MDC = subsequent sections to provide
1/5) specificity, repetition, and salience
of training. Specific muscle groups
Patient will be identified as impaired received
independent in HEP targeted therapeutic exercise as an
with assistance from adjunct to the primary plan of care.
family members
The vigor of each exercise was
progressed from gravity minimized,
to against gravity, to against
Theraband resistance or manual
resistance as tolerated. Resistance
was selected to match the patient’s
5-10RM to maximize improvements
in muscular strength and
hypertrophy. The number of sets
were determined based on patient
reported level of fatigue as well as
considerations of total length and
vigor of daily therapy sessions. If
the patient could complete 10 reps
for a given exercise, the exercise
was progressed. If the patient could
not perform 10 reps, the exercise
was modified or multiple sets of
fewer reps were completed. Patient
perceived fatigue and muscular
soreness was monitored during each
treatment to prevent overtraining.

Targeted therapeutic exercises

included:
 16

• Supine heel slides

• Double leg bridging
(progressed to include march)
• Hook-lying hip
abduction/adduction
• Side-lying hip abduction
(clamshell progressed to
straight leg)
• Ankle 4-way (PF, DF, IV,
EV)
• Recumbent reciprocal stepper
(5-10 minutes for
cardiovascular endurance and
motor control)
• Wrist flexion/extension
(gravity minimized position)

(E) – Patient was given a HEP

including exercises listed above
upon discharge to be completed in
the interim between discharge from
inpatient rehabilitation and the
initiation of outpatient physical
therapy. The patient was instructed
to perform all exercises 2 times per
day (morning and afternoon)
completing 2 sets of 10 for each
exercise bilaterally with assistance
as indicated. Exercises included:
• Hook-lying bridge
• Hook lying single leg march
• Hook-lying hip adduction
squeeze with pillow or ball
• Side-lying hip abduction
• Ankle 4-way (PF, DF, IV,
EV) with Theraband
• Sit to stand
Constant N/A N/A Pain was primarily treated
variable medically with oral Gabapentin that
neurogenic pain was prescribed by the patient’s
and paresthesia overseeing physician due to the
in bilateral hands neuropathic nature of the pain. Pain
was monitored during each session
to inform clinical decisions about
interventions as pain was identified
as a potential barrier to the plan of
care.

(E) – The patient was educated

about the physiology of pain
mechanisms as well as the
progressive remyelination of
 17

peripheral nerves following acute

demyelination.
Impaired gait No change Patient will improve (C) –The patient’s physiatrist placed
kinematics and expected gait kinematics with an order for bilateral polypropylene
critical events bilateral AFOs DAAJ AFOs following
bilaterally • Heel first IC recommendation based on physical
• Increased therapy examination and evaluation.
medial/lateral
ankle stability A DAAJ AFO was chosen over
• Knee flexion other AFO types due to the AP
during weight adjustability, which would allow the
acceptance AFOs to be modified to meet the
• Reduced genu patient’s stability needs with her
recurvatum expected improvements of strength,
during stance sensation and proprioception.
phase
• Reduced knee The patient received her AFOs 1
collapse with day prior to discharge limiting the
forward tibial amount of training that could be
progression performed, so a recommendation for
• Trailing limb continued gait training in outpatient
position physical therapy was made.
• step-over-step
The AFOs were adjusted in a fixed
gait
position bilaterally to ~5o of DF to:
• Preposition feet for heel strike
at IC
• Facilitate forward progression
of tibia during single limb
stance and reduce genu
recurvatum
• Provide a DF stop to provide
stability and prevent
uncontrolled knee flexion with
forward tibial progression
• Provide fixed ankle position
into roughly 5 degrees of DF
for increased toe clearance in
swing

Pre-gait training was initiated to

encourage knee flexion during
weight acceptance, knee extension
during mid-terminal stance, as well
as knee flexion in pre-swing and
swing phase.

(E) – Patient was educated about

proper technique for donning and
doffing her AFOs and performing
skin inspection to prevent pressure
injuries.
 18

ACTIVITY LIMITATIONS
Dependent in Patient will Patient will improve (C) Total and motor FIM scores
functional Improve motor motor FIM score by ³ were calculated weekly during
mobility FIM score by ³ 13 17 points and total multidisciplinary team meeting with
points and total FIM score by ³ 22 collaboration of individual items
FIM score by ³ 18 points scored between the various
points (MCID = 17 points for disciplines including nursing,
(Increase each motor FIM score and occupational therapy, speech
FIM item by an 22 points for total FIM therapy, psychology, and physical
average of 1 score) therapy. Physical therapy was
assistance level) responsible for providing FIM
scores for:
• Bed mobility/transfers
• Walk
• W/C
• Stairs

Each intervention included in the

comprehensive plan of care
contributed to overall improvements
in total and motor FIM scores.

(E) – The patient and family were

educated about appropriate
precautions and the family was
trained to safely assist the patient
during transfers and mobility to
limit the risk of fall.
Decreased Patient will Patient will require: Bed mobility (supine to EOB and
Functional require: • Min A for bed EOB to supine)
mobility • Mod A for mobility (flat
bed mobility hospital bed The patient was taught efficient
(flat hospital without hand sequencing and technique for sitting
bed without rails) up and lying down in bed without
hand rails) • Min A for bed to bed rails through verbal and tactile
• Mod A for chair transfer – cues.
bed to chair stand turn with
transfer – PFWW Vigor of the activity was adjusted
using slide • Min A walking by:
board >150’ with • Elevating/lowering the head
• Max A for PFWW of the bed
walking • Min A W/C • Increasing/decreasing number
(<50’) using propulsion >150’ of trials
PFWW with BLEs • Increasing/decreasing manual
• Max A for • Max A stairs – assistance with trunk and legs
manual W/C up/down 5 stairs
propulsion with B hand rails (E) – Family training was
(<50’) using • Min A for car performed to teach family members
BLEs transfer using how to safely guard and/or assist the
• Dep A for slide board patient in and out of bed without
stairs – rails at an elevated height (similar to
up/down <4 bed height at home).
 19

stairs using B
hand rails Transfer training
• Dep A for car
transfer using Transfers were progressed:
slide board • level surface slide board
transfer
• level surface depression scoot
transfer
• stand turn transfer

Transfer related activities were

performed with a focus on quality,
repetition, and sufficient intensity
based on patient response to
treatment and fatigue. Activities
included:
• Scooting L/R at edge of mat
table
• Sit to stand training
o Higher to lower seat height
o More to less assistance
o Sit to stand trainer with
more to less weight
o Partial sitting with
isometric holds
• Weight shift in standing
• Standing turn to R/L with
PFWW

(E) – Family training was

performed to teach family members
how to safely guard and/or assist the
patient performing depression scoot
transfers or stand turn transfers with
and without a PFWW.

Gait training

Over ground walking progressed by:

increasing:
• Increasing distance
• Decreasing assistance
• Increasing bouts of walking

A Rifton Tram® mechanical lift

was used initially for partial body
weight support with progression to a
PFWW with UE support.

Adjunct interventions included:

 20

• Stepping to the R/L and

forward/backward in high
kneeling
• Reactive postural control
against perturbation in high
kneeling

High kneeling was chosen over

standing due to the patient’s
impairments of proprioception and
strength below the knees.

(E) – Family training was

performed to teach family members
how to safely guard the patient
while ambulating with a PFWW.

W/C training

W/C mobility using a standard

height W/C and BLEs was
progressed by:
• Increasing distance
• Decreasing assistance

Pt propelled W/C using BLEs due to

UE impairments that limited her
grasp.

Stair Training

Multiple trials 3x4in and 2x6in

stairs with B hand rails
• CGA ascending
• Mod A with blocking of the
knees descending

LE strengthening (discussed
previously)

Stair training was not highly

emphasized in the plan of care since
the 3 steps to enter the patient’s
home were converted into a ramp
and stair training was not consistent
with patient goals.

Car Transfer

Pt practiced a car transfer from her

W/C using a slide board prior to
discharge.
 21

(E) – Family training was

performed to teach family members
how to safely assist the patient
during a slide board car transfer.
PARTICIPATION RESTRICTIONS
Restricted No Change Pt will be discharged The patient’s participation goal of
participation as expected home with family returning home to spend time with
mother and assistance and be able her family was targeted through
family member to perform transfers improvement of her impairments
and mobility with and activity limitations.
family assistance to
attend her daughters’ (E) – The patient was educated
extracurricular about her long-term rehab potential
activities. and return of function following
discharge from inpatient
rehabilitation with continued
physical therapy. The patient’s
family was educated about what
assistance the patient needed at
home and how to safely assist.

(C) – The patient was given a

referral for outpatient physical
therapy following D/C for continued
improvements of impairments and
functional limitations to improve
her participation at home with her
family.
UE = upper extremity, LE = lower extremity, B = bilateral, R = right, L = left, MMT = manual muscle
test, RM = repetition max, PF = plantarflexion, DF = dorsiflexion, IV = inversion, EV = eversion, MDC
= minimal detectable change, MCID = minimal clinically important difference, IC = initial contact,
DAAJ = double action ankle joint, AFO = ankle foot orthosis, AP = anterior-posterior, FIM = functional
independence measure, W/C = wheelchair, SB = stand-by, CG = contact guard, Min = minimal, Mod =
moderate, Max = maximal, Dep = dependent, A = assistance, AD = assistive device, EOB = edge of bed,
PFWW = platform front wheel walker, HEP = home exercise program, D/C = discharge
 22

Plan of Care – Interventions

See Table 3.

Overall Approach

The patient received intensive physical therapy 1-2 hours per day, 6 days per

week, for 3 weeks as part of a multidisciplinary rehabilitation intervention that has been

supported by good evidence as an effective intervention to improve functional outcomes

for patients with GBS.32 In addition to the multidisciplinary care, principles of the task-

oriented approach, principles of experience-dependent learning, and exercise parameter

recommendations from the National Strength and Conditioning Association were used in

the development of specific physical therapy interventions.33-35

The physical therapy plan of care was developed based on the problems

established at each of the ICF categories including; impairments of strength, pain, and

gait kinematics; activity limitations of functional independence and functional mobility

(bed mobility, transfers, ambulation, W/C mobility, and stairs); and a participation

restriction of family participation at home. The focus of the interventions were functional

task-specific exercise, which has been reported to improve functional mobility and

underlying impairments of strength in patients with GBS.36 Patient reported level of

fatigue and pain were monitored during each session and interventions were adjusted

accordingly throughout the course of care as fatigue and pain have been established as

important considerations for rehabilitation of patients with GBS.2 Additionally, partial

body weight supported (PBWS) gait training was implemented early in the plan of care as

PBWS has been suggested to allow for earlier initiation of gait training.37
 23

PICO question
For a 49-year-old female with GBS and bilateral LE impairments of strength,

proprioception, and sensation (P), is the use of prescription bilateral AFOs during gait (I)

more effective than not using AFOs (C) for improving gait kinematics and functional

walking capacity (O)?

In an explorative self-controlled cohort study (level of evidence IIb), patients with

paresis of calf muscles and a history of poliomyelitis had improved gait biomechanics

when using AFOs with a dorsiflexion (DF) stop (DR-AFO) with shoes compared to shoes

only.38 The study consisted of 16 consecutive patients (7 male, 9 female) presenting to an

outpatient physical therapy clinic. Patients were included if they had paresis resulting

from poliomyelitis, could walk for 6 minutes continuously, had been prescribed a DR-

AFO ³ 6 months prior to the first measurement, and were between the ages of 18 and 70

years. Gait biomechanics of patients with DR-AFOs were measured using a three-

dimensional motion capturing system and treadmill during the first visit. The patients

were tested with shoes only following 1 week of walking without their DR-AFO. A

statistical comparison of the two conditions resulted in significantly increased forward

center of pressure in midstance, decreased peak DF angle and increased knee extension in

mid and terminal stance when patients used the DR-AFO. Additionally, there was a

statistically significant (p<.05) improvement observed in the DR-AFO group over the

shoes only group for distance, gait speed, and stride length measured with the six-minute

walk test, as well as patient perceived walking performance, intensity of exertion, safety,

and stability measured with a questionnaire. These finding suggest that patients with
 24

weak calf muscles due to a peripheral lesion may have improved control at the knee and

ankle during single limb stance resulting in functional and perceived improvements with

use of DR-AFOs while walking.

There is limited generalizability of this evidence to the present patient case due to

differences in underlying pathology and duration of DR-AFO use. However, evidence for

the use of AFOs for patients with GBS is lacking, and the underlying impairments of the

patients in the study were similar to the patient in the presented patient case. Similar to

GBS, patients with poliomyelitis have lower motor neuron impairments. Additionally, the

study was performed using a subgroup comparison by grouping patients according to gait

patterns. One of the subgroups in which the patient from the present case would have

been included based on impairments consisted of patients with minimal or no forward

center of pressure progression and genu recurvatum during midstance. This subgroup had

a decrease in knee extension during midstance when using DR-AFOs. These findings

supported the implementation of bilateral double action ankle joint (DAAJ) AFOs locked

in a position of DF to prevent collapsing at the knee during mid to terminal stance, reduce

genu recurvatum in stance, and improve functional walking capacity.

 25

Chapter 6

Outcomes

Table 4

Outcomes

OUTCOMES

BODY FUNCTION OR STRUCTURE IMPAIRMENTS

Outcome Initial Follow-up (D/C) [3 weeks] Change Goal Met?
Measure (Y/N)
MMT UE: R L R L R L R L
Elbow 4/5 4/5 4/5 4/5 - - N N
Flex
Elbow 3/5 3/5 4/5 4/5 +1/5 +1/5 Y Y
Ext
Wrist 2+/5 3/5 2+/5 3/5 - - N N
Flex
Wrist 2-/5 3/5 2-/5 3/5 - - N N
Ext
Finger 2-/5 2+/5 2-/5 2+/5 - - N N
Flex
Finger 2-/5 3/5 3/5 3/5 <1/5 - N N
Abd
LE:
Ankle 1/5 1/5 3/5 3/5 +2/5 +2/5 Y Y
PF
Ankle 1/5 1/5 4/5 4/5 +3/5 +3/5 Y Y
DF
ACTIVITY LIMITATIONS
Outcome Initial Follow-up (D/C) Change Goal Met?
Measure (Y/N)
FIM Motor = 24/91 Motor = 49/91 Motor = Y
Total = 55/126 Total = 85/126 +25* Y
No falls during inpatient Total =
rehabilitation stay +30*
Bed mobility Supine to EOB = Max A Supine to EOB = SBA 3 A levels Y
EOB to supine = Mod A EOP to supine = SBA 2 A levels Y
FIM – Bed to 2/7 (Max A) stand pivot 4/7 (Min A) stand pivot 2/7 Y
Chair Transfer with PFWW
FIM – Walk 1/7 (Dep A) 40’ with 4/7 (Min A) 420’ with 3/7 Y
mechanical lift PFWW
FIM – W/C 1/7 (Dep A) Pt pushed in 5/7 (SBA) 4/7 Y
Propulsion W/C >150’ with B LEs
FIM – Stairs 0/7 (not functionally safe) 2/7 (Max A) 5 stairs 2/7 Y
up/down with Mod A
Car Transfer Unable to test Min A (Pt. does >75% of Dependent Y
work) with slide board to Min A
 26

PARTICIPATION RESTRICTIONS
Outcome Initial Follow-up (D/C) Change Goal Met?
Measure (Y/N)
Patient Report, Restricted family Pt was discharged home Positive Y
D/C destination participation at home in with family assistance and
to home, and her role as a mother was able to perform car
ability to transfers and mobility with
perform min A to attend her
transfers and daughters’ extracurricular
mobility with activities.
family
assistance
D/C = discharge, Y = yes, N = no, MMT = manual muscle test, UE = upper extremity, LE = lower
extremity, R = right, L = left, IC = initial contact, sup = supination, pron = pronation, MS = midstance,
FIM = functional independence measure, EOB = edge of bed, Dep = dependent, Max = maximum, Mod
= moderate, Min = minimal, SB = stand-by, A = assistance, PFWW = platform front wheel walker, W/C
= wheelchair
* MCID met or exceeded

Discharge Statement

The patient received inpatient physical therapy rehabilitation for the treatment of

GBS 1-2 hours per day, 6 days per week, for 3 weeks. The patient presented with

impaired strength, sensation, and proprioception of the distal UE and LE (below the

knee) in a glove and stocking pattern. The patient initially had limited functional

independence and mobility including bed mobility, transfers, ambulation, W/C mobility,

and stairs that restricted the patient from participating with family at home. The patient

received therapeutic exercise, transfer training, gait training, and task-specific exercise to

improve strength, mobility, and function. Improved MMT scores were observed for ankle

DF, and plantar flexion (PF), and elbow extension, which contributed to improved

transfers and mobility, but distal UE weakness and impaired fine motor control persisted.

Additionally, the patient was prescribed bilateral DAAJ AFOs to address critical event

impairments. Based on observational gait analysis, it appeared that the patient

experienced gait improvements of heel first initial contact, controlled knee flexion and
 27

ankle PF in mid to terminal stance, and improved foot clearance in swing. The patient

achieved all activity and participation level goals, exceeding the MCID95 for total and

motor FIM scores. The patient improved functional mobility from dependent/maximum

assistance to stand-by/minimal assistance for transfers and mobility. Importantly, the

family was able to provide the necessary assistance to perform safe mobility in the home

with the prescribed assistive devices, allowing discharge to the patient’s home. The

patient was referred to outpatient physical therapy for continued therapy to improve

strength and functional independence as well as continued training to address gait

deviations with her AFOs. The patient was discharged home with the assistance of her

two daughters and her parents, who live next door.

D/C G-Code with modifier

o Mobility – G8980CI (based on minimal assistance level for ambulation)

 28

Chapter 7

Discussion

The patient benefitted from rehabilitation and met all the goals established at the

activity and participation level. Additionally, the patient met goals for lower extremity

MMT scores, but did not meet goals for improved upper extremity MMT scores. Since

lower motor neuron damage is a hallmark symptom of GBS, improvements in strength

are in part determined by the number of motor units affected, hypertrophy of remaining

motor units, and motor unit reinnervation.39 The more favorable outcomes for the lower

extremity compared to the upper extremity may have been influenced by differences in

initial lower motor neuron injury, although this was not confirmed with nerve conduction

testing. Alternatively, the difference in outcomes may have been due to initial

measurement error or inadequate intervention to the upper extremity to elicit

improvement. The patient improvements in functional mobility and independence may be

attributed to the effectiveness of the multidisciplinary and physical therapy interventions

implemented. The favorable outcomes observed provides reasonable evidence for the

utilization of similar interventions, which are consistent with current recommendations in

the literature,32 for rehabilitation of patients with GBS with similar examination findings

in the future. The patient responded to the interventions as expected based on her initial

prognosis and medical diagnosis. Improvements in strength were expected to be

influenced by the extent of lower motor damage and hypertrophy of intact motor units.

Based on this understanding, interventions focused on functional improvements and task-

oriented treatments instead of muscular strengthening alone. This approach appeared to

 29

be effective as the patient experienced large functional improvements despite small

improvements in strength, as measured by MMT.

It would have been beneficial to make a recommendation to the psychiatrist

earlier in the plan of care to order the patient’s AFOs so that more of the interventions

could have been focused on normalizing gait through motor control training with the

AFOs. Due to the delay in ordering the patient’s AFOs, the patient did not receive the

AFOs until the day before discharge, requiring most AFO training to be completed in

outpatient physical therapy after discharge. Implementing the use of AFOs in gait

training earlier in the plan of care may have led to additional improvements in functional

mobility and improved the patient’s functional independence at discharge.

Patients with GBS present with varying impairments, functional limitations, and

rehab potential based on the severity and stage of the pathology. This patient had

impairments primarily localized to the distal extremities with the appearance of relatively

unaffected proximal extremities and trunk. The functional goals of other patients with

GBS diagnoses may be higher or lower based on the severity of initial impairments, and

interventions should be adjusted accordingly. Additionally, although the patient case was

addressed as an acute episode of GBS, the patient’s physiatrist did not completely rule

out the possibility of recurrent GBS or CIDP, which could lead to a poorer long-term

prognosis for complete return of function.

Current evidence is lacking about what diagnostics, prognostics, and outcome

measures are appropriate for patients with GBS. Many diagnostics, prognostics, and

outcome measures that have been validated and found to be reliable and responsive for
 30

other diagnoses have not been specifically investigated for use with patients with GBS.

For example, prognostic tests to predict long term fall risk in patients with GBS

following discharge are limited. More sensitive prognostic tests are needed to accurately

predict fall risk in this population as many prognostic tests such as the Timed Up and Go,

Tinetti Balance Assessment Tool, or Berg Balance Scale would present with floor effects

due to low functional mobility at initial evaluation. Therefore, although the tests and

measures used in this case were selected based on the availability of current evidence,

further consideration should be made about the generalizability of selected tests and

measures in this case. Future evidence should seek to establish the validity, reliability,

and responsiveness of tests and measures used for examination and evaluation of patients

with GBS as well as the effectiveness of specific interventions.

 31

References

1. Novak P, Smid S, Vidmar G. Rehabilitation of Guillain-Barre syndrome patients:

an observational study. Int J Rehabil Res. 2017;40(2):158-163.

2. Fisher TB, Stevens JE. Rehabilitation of a marathon runner with Guillain-Barre

syndrome. J Neurol Phys Ther. 2008;32(4):203-209.

3. Yuki N, Hartung HP. Guillain-Barre syndrome. N Engl J Med.

2012;366(24):2294-2304.

4. Khan F, Ng L, Amatya B, Brand C, Turner-Stokes L. Multidisciplinary care for

Guillain-Barre syndrome. Eur J Phys Rehabil Med. 2011;47(4):607-612.

5. van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment

of Guillain-Barre syndrome. Lancet Neurol. 2008;7(10):939-950.

6. Ruts L, Drenthen J, Jongen JL, et al. Pain in Guillain-Barre syndrome: a long-

term follow-up study. Neurology. 2010;75(16):1439-1447.

7. de Vries JM, Hagemans ML, Bussmann JB, van der Ploeg AT, van Doorn PA.

Fatigue in neuromuscular disorders: focus on Guillain-Barre syndrome and

Pompe disease. Cell Mol Life Sci. 2010;67(5):701-713.

8. Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of

Guillain-Barre syndrome: a systematic review and meta-analysis.

Neuroepidemiology. 2011;36(2):123-133.

9. Kiphuth IC, Schellinger PD, Kohrmann M, et al. Predictors for good functional

outcome after neurocritical care. Crit Care. 2010;14(4):R136.

 32

10. Bernsen RA, de Jager AE, van der Meche FG, Suurmeijer TP. How Guillain-

Barre patients experience their functioning after 1 year. Acta Neurol Scand.

2005;112(1):51-56.

11. Bernsen RA, de Jager AE, Schmitz PI, van der Meche FG. Residual physical

outcome and daily living 3 to 6 years after Guillain-Barre syndrome. Neurology.

1999;53(2):409-410.

12. Rajabally YA, Uncini A. Outcome and its predictors in Guillain-Barre syndrome.

J Neurol Neurosurg Psychiatry. 2012;83(7):711-718.

13. Walgaard C, Lingsma HF, Ruts L, van Doorn PA, Steyerberg EW, Jacobs BC.

Early recognition of poor prognosis in Guillain-Barre syndrome. Neurology.

2011;76(11):968-975.

14. Gonzalez-Suarez I, Sanz-Gallego I, Rodriguez de Rivera FJ, Arpa J. Guillain-

Barre syndrome: natural history and prognostic factors: a retrospective review of

106 cases. BMC Neurol. 2013;13:95.

15. United States National Library of Medicine. Drug Information Portal. Website

https://druginfo.nlm.nih.gov/drugportal/. Updated November 2017. Accessed

November 12, 2017.

16. World Health Organization. International classification of functioning, disability

and health: ICF. Geneva: World Health Organization; 2001.

 33

17. Rancho Los Amigos Medical Center. Pathokinesiology Service., Rancho Los

Amigos Medical Center. Physical Therapy Department. Observational gait

analysis. Downey, CA: Los Amigos Research and Education Institute, Rancho

Los Amigos Medical Center; 1993.

18. Hislop HJ, Avers D, Brown M, Daniels L. Daniels and Worthingham's muscle

testing: techniques of manual examination and performance testing. 9th ed. St.

Louis, Mo.: Elsevier; 2014.

19. Cuthbert SC, Goodheart GJ, Jr. On the reliability and validity of manual muscle

testing: a literature review. Chiropr Osteopat. 2007;15:4.

20. O'Sullivan SB, Schmitz TJ, Fulk GD. Physical rehabilitation. 6th ed.

Philadelphia: F.A. Davis Co.; 2014.

21. Abraham A, Alabdali M, Alsulaiman A, et al. The sensitivity and specificity of

the neurological examination in polyneuropathy patients with clinical and

electrophysiological correlations. PLoS One. 2017;12(3):e0171597.

22. Fioravanti AM, Bordignon CM, Pettit SM, Woodhouse LJ, Ansley BJ.

Comparing the responsiveness of the assessment of motor and process skills and

the functional independence measure. Can J Occup Ther. 2012;79(3):167-174.

23. Prasad R, Hellawell DJ, Pentland B. Usefulness of the Functional Independence

Measure (FIM), its subscales and individual items as outcome measures in

Guillain Barre syndrome. Int J Rehabil Res. 2001;24(1):59-64.

 34

24. Prodinger B, O'Connor RJ, Stucki G, Tennant A. Establishing score equivalence

of the Functional Independence Measure motor scale and the Barthel Index,

utilising the International Classification of Functioning, Disability and Health and

Rasch measurement theory. J Rehabil Med. 2017;49(5):416-422.

25. Coster WJ, Haley SM, Jette AM. Measuring patient-reported outcomes after

discharge from inpatient rehabilitation settings. J Rehabil Med. 2006;38(4):237-

242.

26. Cournan M. Use of the functional independence measure for outcomes

measurement in acute inpatient rehabilitation. Rehabil Nurs. 2011;36(3):111-117.

27. Hsieh YW, Wu CY, Lin KC, Chang YF, Chen CL, Liu JS. Responsiveness and

validity of three outcome measures of motor function after stroke rehabilitation.

Stroke. 2009;40(4):1386-1391.

28. Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the functional

independence measure: a quantitative review. Arch Phys Med Rehabil.

1996;77(12):1226-1232.

29. Wallace D, Duncan PW, Lai SM. Comparison of the responsiveness of the

Barthel Index and the motor component of the Functional Independence Measure

in stroke: the impact of using different methods for measuring responsiveness. J

Clin Epidemiol. 2002;55(9):922-928.

30. Beninato M, Gill-Body KM, Salles S, Stark PC, Black-Schaffer RM, Stein J.

Determination of the minimal clinically important difference in the FIM

instrument in patients with stroke. Arch Phys Med Rehabil. 2006;87(1):32-39.

 35

31. Forrest G, Huss S, Patel V, et al. Falls on an inpatient rehabilitation unit: risk

assessment and prevention. Rehabil Nurs. 2012;37(2):56-61.

32. Khan F, Amatya B. Rehabilitation interventions in patients with acute

demyelinating inflammatory polyneuropathy: a systematic review. Eur J Phys

Rehabil Med. 2012;48(3):507-522.

33. Shumway-Cook A, Woollacott MH. Motor control: translating research into

clinical practice. 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott

Williams & Wilkins; 2012.

34. Kleim JA, Jones TA. Principles of experience-dependent neural plasticity:

implications for rehabilitation after brain damage. J Speech Lang Hear Res.

2008;51(1):S225-239.

35. Baechle TR, Earle RW, National Strength & Conditioning Association (U.S.).

Essentials of strength training and conditioning. 3rd ed. Champaign, IL: Human

Kinetics; 2008.

36. Simatos Arsenault N, Vincent PO, Yu BH, Bastien R, Sweeney A. Influence of

Exercise on Patients with Guillain-Barre Syndrome: A Systematic Review.

Physiother Can. 2016;68(4):367-376.

37. Tuckey J, Greenwood R. Rehabilitation after severe Guillain-Barre syndrome: the

use of partial body weight support. Physiother Res Int. 2004;9(2):96-103.

38. Ploeger HE, Bus SA, Brehm MA, Nollet F. Ankle-foot orthoses that restrict

dorsiflexion improve walking in polio survivors with calf muscle weakness. Gait

Posture. 2014;40(3):391-398.
 36

39. Lundy-Ekman L. Neuroscience: fundamentals for rehabilitation. 4th ed. St.

Louis, Mo.: Elsevier; 2013.