Autoimmune-Mediated Neurologic Disorders

Some neurologic disorders encountered by the therapist display features that suggest an immunologic basis for
the disorder. Such diseases include multiple sclerosis (MS), Guillain-Barre syndrome, and myasthenia gravis.
Other dysfunctions, such as amyotrophic lateral sclerosis (ALS) and acute disseminated encephalomyelitis, also
associated with immunologic dysfunction but seen less often by the therapist, are not discussed.

GUILLAIN-BARRE SYNDROME (ACUTE IDIOPATHIC POLYNEURITIS)

Guillain-Barre syndrome is a demyelination disease that affects the peripheral nervous system (especially spinal
nerves) and is characterized by an abrupt onset of paralysis. The disease affects all age groups, and incidence is
not related to race or sex.

RISK FACTORS

The exact cause of the disease is unknown, but it frequently occurs after an infectious illness. Upper respiratory
infections, vaccinations, or viral infections such as measles, hepatitis, or mononucleosis commonly precede acute
idiopathic polyneuritis by
1 to 3 weeks.
Like myasthenia gravis, acute idiopathic polyneuritis may be an autoimmune disease that occurs after
surgery, a viral infection, or immunization. The immune system attacks its own myelin cells because they look
similar to the molecules of the infecting virus. The immune system shifts into an accidental self-destructive
overdrive.

CLINICAL SIGNS AND SYMPTOMS

The onset of acute idiopathic polyneuritis is generally characterized by a rapidly progressive weakness for a
period of 3 to 7 days. It is usually symmetric, involving first the lower extremities, then the upper extremities, and
then the respiratory musculature. Weakness and paralysis are frequently preceded by paresthesias and
numbness of the limbs, but actual objective sensory loss is usually mild and transient.
Although muscular weakness is usually described as bilateral, progressing from the legs upward toward
the arms, this syndrome may be missed when the client has unilateral symptoms that do not progress proximally.
Muscular weakness of the chest may appear early in this disease process as respiratory compromise.
Respiratory involvement as such may be unnoticed until the person develops more severe symptoms associated
with the Guillain-Barre syndrome.
The progression of paralysis varies from one client to another, often with full recovery from the paralysis.
Usually symptoms develop over a period of 1 to 3 weeks, and the progression of paralysis may stop at any point.
Once the weakness reaches a maximum (usually during the second week), the before spontaneous improvement
and eventual recovery begin, extending over a period of 6 to 9 months.
Cranial nerves, most commonly the facial nerve, can be involved. The tendon reflexes are decreased or
lost early in the course of the illness. The incidence of residual neurologic deficits is higher than was previously
recognized, and deficits may occur in as many as 50% of all cases.

TREATMENT

There is no immediate cure for this disease, but medical support is vital during the progression of symptoms,
particularly in the acute phase when respiratory function may be compromised. Physical therapy is initiated at an
early stage to maintain joint range of motion within the client's pain tolerance and to monitor muscle strength until
active exercises can be initiated.
The usual precautions for clients immobilized in bed are required to prevent complications during the
acute phase. A major precaution is to provide active exercise at a level consistent with the client's muscle
strength. Overstretching and overuse of painful muscles may result in a prolonged recovery period or a lack of
recovery (Case Example 12-6).

CASE EXAMPLE 1 2 - 6
A 67-year-old retired aeronautics engineer was referred to physical therapy by his physician for electrotherapy
and therapeutic exercise. The physician's diagnosis was right-sided Bell's palsy. Past medical history was
significant for an upper respiratory infection 2 weeks before the onset of his first symptoms.
The client reported difficulty in closing his eyes, chewing, and drinking, and he was unable to smile. There were
no changes in sensation or hearing. During the neurologic examination, the client was unable to raise his
eyebrows or close his eyes, and there was obvious facial drooping on both sides. A gross manual muscle test
revealed full (5/5) muscle strength in all four extremities, but muscle stretch reflexes were absent in all four
extremities.
R e s u l t : The therapist recognized three redflag symptoms in this case: (1) recent upper respiratory infection
followed by the development of neurologic symptoms; (2) progressive development of symptoms from right-sided
to bilateral between the time the client was evaluated by the physician and went to the physical therapist; and (3)
absent deep tendon reflexes, an inconsistent finding for Bell's palsy.
The therapist contacted the physician by telephone to relay this information and confirm the treatment plan given
this new information. The physician requested that the client return for further medical testing, and a revised
diagnosis of Guillain-Barre syndrome was made.
The client's clinical status stabilized, and he returned to the physical therapist. The treatment plan was modified
accordingly. This case again demonstrates the importance of performing a careful examination, including
screening for systemic disease and recognizing red-flag symptoms.

CLINICAL SIGNS AND SYMPTOMS OF

• Muscular weakness (bilateral, progressingfrom the legs to the arms to the chest and neck)
• Diminished deep tendon reflexes
• Paresthesias (without loss of sensation)
• Fever, malaise
• Nausea

Goodman, C. C., & Snyder, T.E.K. (2007). Screening for immunologic disease. In Differential Diagnosis: Physical
Therapist Screening for Referral (4th ed.) St. Louis, MI: Saunders