Features Management Operations
Guillain-Barre Syndrome

This is a story of how a massage therapist’s treatment ideas provided safe and effective treatment to a patient dealing with Guillain-Barre Syndrome (GBS). It is but one such account; however, so many more people who will suffer from GBS need to know the potential that massage therapy holds for assisting them with the condition and the recovery process. With respect to GBS, we cannot prevent the condition. However, given the massage therapist’s scope of practice, we can maintain, rehabilitate and augment physical function in a person who is rendered dysfunctional by the condition.

As a new therapist, I originally shied away from challenging cases like this, but Cindy Cartwright’s personal story, and the ongoing education presented here by Paul Lewis, RMT, gives me the confidence to engage in, and positively influence, the experience and outcome of those who suffer.

GUILLAIN-BARRE SYNDROME
Guillain-Barre Syndrome, first documented in 1916, is the most common cause of acute paralysis in North America and Europe, being diagnosed 80-120 times per week in Canada and the United States. Some doctors say that it is much more prevalent than reported, as some patients who do not have organ involvement may continue on in pain thinking they merely have a pinched nerve or something of the sort. It is a neurological disorder in which macrophages of the body’s own defence system strip myelin from axons in the peripheral nervous system. It can occur spontaneously, or after certain events such as viral or bacterial infections. It may result from the immune system’s response to food-borne bacteria (Campylobacter jejuni 40 per cent of cases), viral infections (i.e., Epstein-Barr, or H1N1 virus thought to be the cause in Cindy’s case), surgery, or the swine flu vaccination (very rare less than one out of one million vaccinated).

Also called acute inflammatory demyelinating polyneuropathy, GBS is characterized by a quick and severe onset usually developing into a medical emergency, as numbness and tingling in the extremities progresses from the feet upwards to result in flaccid paralysis bilaterally. It may advance to loss of function in the respiratory muscles with approximately 30 per cent of its victims requiring ventilatory assistance. Postural hypotension, arrhythmias, facial flushing, sweating and urinary retention are common. If the disorder affects cranial nerves of the face, facial weakness, pain, and difficulty with speech may develop – a condition known as Bell’s Palsy. Reflexes become dull or disappear. Loss of sensation moving in an ascending, or proximal, direction accompanies excruciating pain usually settling into the hips, back and pelvis. Symptoms progress in quantity and intensity for two to three weeks before they plateau, usually as a result of medical intervention. Treatment may involve high-dose intravenous immunoglobulin therapy or plasmaphoresis. Day 42 is generally considered the time the body’s chaos is over and recovery begins.

Cindy recalls, “The first seven days were bad, the next seven days were extremely bad, then after my blood transfusion (plasmaphoresis for three hours a day for five days) at around day 19, I felt things were beginning to turn around.” Most patients make a full or partial recovery in about 18 months, although about 15 per cent remain paralyzed and five per cent actually die.

GBS AND THE RMT
Guillain-Barre Syndrome is challenging to treat, as it follows an unpredictable course. It is a great example of a condition that can redefine the term RMT to mean “real multi-tasker,” as the health history interview, consent, assessments, and treatment plans need to be updated, reassessed, and modified in an ongoing manner at each visit and throughout each treatment session. You must consider the symptoms resulting from the disease, the medication and the hospitalization itself.

Massage therapy is definitely indicated during the long and frustrating progression of Guillain-Barre Syndrome. It can help with circulation, maintain mobility (range of motion), decrease pain and anxiety, and later aid in strengthening atrophic muscles.

Massage therapists ordinarily are advised to wait until the body’s chaos is controlled before stimulating an already taxed immune system. But perhaps the truth is that that mindset wastes precious time. Paul Lewis, RMT, has intrigued doctors with his massage techniques and rationale for treating GBS patients from hospital admission to recovery. Medical teams are impressed with the results of his therapeutic approach and have acknowledged that massage therapy can be an integral part of their patient’s comfortable and speedy recoveries.

CINDY’S STORY
It was the last weekend of April 2010 and Cindy Cartwright, 46, active mother and full-time accountant, fell ill with the flu, which was circulating in her office that week. Apart from some recent tingling in her arms and hands, which a chiropractor said was resulting from pinched nerves, she thought she was in the best shape of her adult life. Having gone through severe hardships of catastrophic family loss the past year, she had dealt with her stress by maintaining a healthy lifestyle and doing regular fitness workouts. Her symptoms escalated during her flu. Added to vomiting and other flu symptoms was, now, the inability to distinguish between hot and cold. “I picked up my glass mug which felt cold and I thought I had forgotten to boil the water but my tea was piping hot. I then stuck my hand in the freezer, which seemed to be warm.” She went to see her family physician was immediately sent to the ER from there.

ENTER MASSAGE THERAPY
On May 12, Paul Lewis met Cindy for the first time. Following a consultation, they met with Cindy’s doctor to discuss the option of massage therapy to aid in Cindy’s recovery. The doctor included massage as part of the hospital treatment protocol by writing a prescription for treatments and adding it to the hospital records.

There is no customized massage treatment plan for GBS, but treatment is customized for the individual patient based on presenting symptoms. The verbal and non-verbal feedback from the patient is essential for any treatment. The therapists’ palpation skills, along with knowledge of skeletal and muscular anatomy and innervation, are crucial in providing a safe and effective treatment.

“In school we were always taught to create a treatment plan based on many combined factors such as the client’s presenting conditions along with orthopedic/clinical testing to try to treat the cause, not just the symptoms,” says Lewis. “Well, in this case, we have an idea as to what the cause of the symptoms is. The doctors and medical staff are treating the root cause. Based on that diagnosis, I approached Cindy’s case with the combined teachings on axonal damage. I looked at the symptoms and causes resulting from neurapraxia, axonotmesis and neurotomesis. I believe Cindy was showing signs and symptoms relating to all three degrees of axonal damage, but the cause was closest to the definition of axonotmesis because GBS is thought to be an autoimmune attack on the myelin.”

With this in mind, and all the other important factors involved in GBS, the treatment plan was created. Lewis emphasizes that “the main message is to ADAPT.” Adapt your treatment to the hospital environment, adapt to the side effects of the medications, adapt your pressure and speed, adapt your techniques given the patient’s feedback, adapt your body mechanics, adapt your expectations, as every GBS case is unique, and changes can be seen in the patient from visit to visit.

In Part 2 of this article, a massage therapy regimen that begins during hospitalization, and ends with the patient’s full recovery from GBS, is described. It will appear in the Winter 2010 issue of Massage Therapy Canada.

Barbara Cunningham’s passion lies in research and writing for the profession of massage therapy. She works with Massage in Motion, and recently opened her own practice, called the Treatment Room, in Mississauga, Ontario. Her ultimate career goal is to see massage therapy become tax deductible from the first dollar. Barbara’s raison d’etre is her three children.