eMedicine Specialties > Physical Medicine and Rehabilitation > Peripheral Neuropathy

Guillain-Barre Syndrome: Follow-up

Author: Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Coauthor(s): Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver; Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Sep 15, 2009

Follow-up

Further Inpatient Care

  • GBS treatment requires careful and intensive care to monitor for such complications as respiratory difficulties and autonomic dysfunction. Approximately one third of patients require admission to an ICU, primarily because of respiratory failure. After medical stabilization, patients can be treated on a general medical/neurologic floor, but continued vigilance remains important in preventing respiratory, cardiovascular, and other medical complications. Continued care also is needed to minimize problems related to immobility, neurogenic bowel and bladder, and pain. Early involvement of allied health staff is recommended.

Further Outpatient Care

  • Although follow-up studies generally have assessed patients 6-12 months after onset, some studies have reported continued improvements in strength even beyond 2 years. With prolonged recovery possible, GBS patients with continued neurologic deficits may benefit from ongoing physical therapy and conditioning programs.
  • Numerous papers have addressed the issue of persistent fatigue after recovery from GBS.23,32 Studies have suggested that a large percentage of patients continue to have fatigue-related problems, subsequently limiting their function at home, work, and during leisure activities. Treatment suggestions range from gentle exercise to the prescription of medications traditionally used to stimulate initiation.33 The effectiveness of various interventions continues to be studied.
  • GBS can produce long-lasting changes in the psychosocial status of patients and their families.34,35,36 Changes in work and leisure activities can be observed in just over one third of these patients, and psychosocial functional health status can be impaired even years after the GBS event. Interestingly, psychosocial performance does not seem to correlate with the severity of residual physical function. Poor conditioning and easy fatigability may be contributory factors. Therefore, providing long-term attention and support for this population group is important.

Transfer

  • Patients may require transfer to the ICU if serious respiratory or cardiac problems occur. Upon medical and neurologic stabilization, patients may need to be transferred to an inpatient rehabilitation unit if functional impairments persist.

Deterrence

  • C jejuni is the most common cause of bacterial gastroenteritis in industrialized countries and is also the organism that is most frequently identified in association with GBS. Preventive measures to control C jejuni infections, such as vaccinations, may be the best means to prevent GBS.

Complications

  • A small percentage (~10%) of patients have an acute relapse after initial improvement or stabilization after treatment. Some patients also demonstrate treatment fluctuations during their clinical course. Although the procedures are controversial, there is no convincing evidence that IVIG treatment or plasma exchange has a significant effect on the rate of treatment failure or of acute relapse.37 The risk of relapse does appear to be higher in patients in whom there has been a later onset of treatment, a more protracted disease course, and more associated medical conditions. Additional plasma exchange or IVIG treatments often result in further improvement.38

Prognosis

  • Although most patients with GBS make good recovery, 2-12% of them die from complications related to GBS, and a significant percentage of survivors have persistent motor sequelae. Estimates indicate that 75-85% of patients experience good recovery, 15-20% have moderate residual deficits, and 1-10% are left severely disabled. Although the exact prevalence is uncertain, up to 25,000-50,000 persons in the United States may have long-term functional deficits from GBS.
  • Older age, poor upper extremity (UE) muscle strength, the need for mechanical ventilation, Medical Research Council (MRC) scores of less than 40, and preceding gastrointestinal infections have been found to have an adverse effect on outcomes associated with GBS.39 A rapidly progressing onset of weakness also has been associated with less favorable outcomes in many studies, although in other reports, delayed time to peak disability has been shown to be an independent predictor of poor outcome at 1 year.

    Low mean CMAP amplitudes of less than 20% of the lower limit of normal or the presence of inexcitable nerves on initial electrophysiologic studies are other predictors of poorer functional outcomes. Persistence of a low mean CMAP on later testing (>1 mo after onset) results in an even higher sensitivity and specificity of testing than does the initial test after onset. The sex of the patient, the presence of underlying pulmonary disease, or manifestation of dysautonomia has no prognostic significance.

    A prospective, multicenter study by Petzold et al suggested that CSF levels of high – molecular weight neurofilament (NfH) protein, an axonal protein, are prognostic indicators in GBS.40 The study, in which CSF levels of axonal and glial proteins were measured on hospital admission, included 38 patients with GBS, 42 with headache, and 14 with chronic inflammatory demyelinating neuropathy, as well as 38 neurologic control subjects. The investigators found that among patients with GBS who suffered a poor outcome (defined as an inability to walk independently), the median NfH level was 1.78 ng/ml; in patients with GBS who had a good outcome, the median level was 0.03 ng/ml. The NfH levels were also significantly lower in the control, headache, and chronic inflammatory demyelinating neuropathy groups than in the poor-outcome GBS group.
  • The speed of recovery varies. Recovery often takes place within a few weeks or months; however, if axonal degeneration has occurred, recovery can be expected to progress slowly over many months, because regeneration may require 6-18 months. In general, slower and less complete recovery is observed in older patients.

Patient Education

  • Patients with GBS and their families should be educated on the illness, the disease process, and the anticipated course. GBS is a life event with a potentially long-lasting influence on patients' physical and psychosocial well-being.34,35,36 Family education and training also is recommended to prevent complications during the early stages of the disease and to assist in the recovery of function during the rehabilitation stages.
  • For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Guillain-Barré Syndrome.

Inpatient/Outpatient Medications

  • Immunomodulatory medications have been used to hasten recovery. In well-controlled clinical trials, the efficacy of IVIGs in GBS patients has been shown to equal that of plasma exchange.25,26,27,28 IVIG treatment is easier to implement and potentially safer than plasma exchange, and the use of IVIGs versus plasma exchange may be a choice of availability and convenience. Attempts have been made to employ oral and IV steroids in the treatment of GBS, but they have not been found to have a clinical benefit; these drugs are not currently employed in GBS treatment.
  • Hemodynamic changes related to autonomic dysfunction are usually transitory, and patients rarely require long-term medications to treat blood pressure or cardiac problems.
  • Pain medications may be required in the inpatient and outpatient settings. A tiered pharmacologic approach that starts with nonsteroidal anti-inflammatory drugs or acetaminophen, with narcotic agents added as needed, is usually recommended. Most patients do not require narcotic analgesics after the first couple of months of illness. Adjunct medications for pain, such as tricyclic antidepressants and certain anticonvulsants, also may be beneficial for dysesthetic-type pains.
  • Anticoagulants, such as heparin or low – molecular weight heparin, are recommended to prevent thromboembolic disease in the sedentary patient.

Miscellaneous

Medicolegal Pitfalls

  • Patients who are diagnosed with GBS should be admitted to a hospital for close monitoring until it has been determined that the course of the disease has reached a plateau or undergone reversal. Although the weakness may initially be mild and nondisabling, symptoms can progress rapidly over just a few days. Continued progression may result in a neuromuscular emergency with profound paralysis, respiratory insufficiency, and/or autonomic dysfunction with cardiovascular complications. Early recognition and treatment of GBS also may be important in the long-term prognosis, especially in the patient with poor clinical prognostic signs, such as older age, a rapidly progressing course, and antecedent diarrhea.41

Special Concerns

  • Immunotherapy for children with GBS has not been rigorously studied with randomized, well-controlled studies. Despite this fact, immunotherapy is standardly used in the pediatric patient with GBS.42
  • Immunotherapy for pregnant women has not been studied, and safety for use during pregnancy has not been established.
  • Older age is a risk factor for a less favorable prognosis. Recovery is often slower and less complete in elderly patients. In addition, mortality rates in elderly persons with GBS are higher than in younger patients with the condition.
 


More on Guillain-Barre Syndrome

Overview: Guillain-Barre Syndrome
Differential Diagnoses & Workup: Guillain-Barre Syndrome
Treatment & Medication: Guillain-Barre Syndrome
Follow-up: Guillain-Barre Syndrome
References
Further Reading
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Keywords

Guillain-Barré syndrome, Guillain-Barre syndrome, Guillain-Barre, demyelination, Campylobacter jejuni, demyelinating neuropathy, polyradiculoneuropathy, GBS, C jejuni, acute inflammatory demyelinating polyradiculoneuropathy, Landry-Guillain-Barre syndrome, Landry-Guillain-Barre-Strohl syndrome, acute demyelinating neuropathy, infectious polyneuritis, acute polyradiculoneuritis, axonal Guillain-Barre syndrome, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, Miller-Fisher syndrome, pharyngeal-cervical-brachial GBS

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Contributor Information and Disclosures

Author

Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Heather Rachel Davids, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver
Joyce L Oleszek, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Angela Cha-Kim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Paraplegia Society
Disclosure: Nothing to disclose.

Medical Editor

Daniel D Scott, MD, MA, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center
Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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