Rehabilitation of Guillain-Barré syndrome

Exploring the Efficacy of Physiotherapy in Guillain-Barré Syndrome Through Virtual Reality-Based Rehabilitation: A Case Report

Guillain-Barré syndrome (GBS) refers to a spectrum of acute immune-mediated polyradiculoneuropathies, among which is acute motor axonal neuropathy (AMAN), which is typified by predominant motor involvement and axonal degeneration. This case study describes the presentation, diagnosis, and physiotherapy management using virtual reality-based technology in a 29-year-old male patient with AMAN. Nerve conduction velocity testing was used to diagnose motor axonal neuropathy in the patient, who had weakness subsequent to gastrointestinal symptoms. Intravenous immunoglobulin therapy was started, and a physiotherapy protocol was planned for eight weeks according to the patient's functional status. Physiotherapy plays an important role in the rehabilitation of patients with GBS, addressing the specific motor deficits and promoting recovery. The aim was to improve muscle strength, mobility, and functional independence through progressive exercises targeting specific motor deficits. Virtual reality-based training was also part of this rehabilitation process as an adjunct to conventional rehabilitation to improve dynamic balance and function of the upper and lower limbs, which showed significant improvement in the outcome measures.

Hantavirus infection-related acute inflammatory demyelinative polyradiculoneuropathy: A case report and literature review

RATIONALE

Hemorrhagic fever with renal syndrome (HFRS) is a common infectious disease in China. As a complication of post-Hantavirus infection, Guillain-Barre syndrome (GBS) was rarely previously reported. Here, we described a case of acute inflammatory demyelinative polyradiculoneuropathy secondary to Hantavirus infection in spring of 2023. We also made a summary of the clinical features from previous reported cases.

PATIENT CONCERNS

A young male patient complained a fever with headache, who was subsequently diagnosed with HFRS with positive serum Hantavirus antibody IgM. Two weeks later, he presented sustained back pain, obvious numbness located in 4 extremities, chest and abdomen, facial dyskinesia and 4 extremities muscle weakness.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

He was rapidly diagnosed with GBS by typical cerebrospinal fluid change and the electromyography examination presentation, which was verified associated with hantavirus infection. He was treated with intravenous immunoglobulin infusion followed by rehabilitation treatment. He got a complete recovery within 4 months after disease onset.

LESSONS

GBS was an uncommon manifestation of Hantavirus infection. GBS should be considered when acute limb weakness happens in cases with HFRS. A multidisciplinary team could make a rapid diagnosis and optimal treatment when nervous system disorders occurred.

Predictors of discharge to home/community following inpatient-rehabilitation in a US national sample of Guillain-Barre-Syndrome patients

BACKGROUND

Guillain-Barre-Syndrome (GBS), an autoimmune polyneuropathy causing acute flaccid paralysis, is a rare condition with1-2 cases per 100,000 annually (approximately 5000 cases/year) in the United States (US). There is a paucity of published data regarding patient outcomes in association with discharge destinations following inpatient-rehabilitation (IR) in this patient population, thus this study.

OBJECTIVES

To analyze IR efficacy, and possible predictors of discharge to home/community in a US-national-sample of GBS patients.

METHODS

Retrospective-observational-cohort study of 1304 GBS patients admitted to IR comparing discharge disposition destinations (community/home, skilled-nursing-facility [SNF], or return to acute-care) by demographic (age, gender) and clinical variables (length-of-stay [LOS], case-mix-index [CMI], and Functional-Independence-Measure [FIM] score changes). Multinomial-logistic-regression and discriminant-function-analysis were performed to determine model fit in predicting discharge destination.

RESULTS

81.8% were discharged to home/community- average LOS 19-days, total-FIM-gain 43.2; 9.8% discharged to SNFs- average LOS 27.5-days, total-FIM-gain 27.2; and 8.4% discharged to acute-care- average LOS 15.4-days and total-FIM-gain 16.5, (F = 176, p < .001). Stepwise-linear-regression for prediction of community discharge showed change in FIM-Bed/chair/wheelchair-Transfers was the most significant predictor (Wald = 42.2; p < .001), followed by CMI (Wald = 26.9; p < .001), change in FIM-walking/wheelchair (Wald = 14.9; p < .001), and age (Wald = 9.5; p < .002). Using discriminant-function-analysis to test model validity for predicting discharge disposition, FIM-change for Bed/chair/wheelchair Transfers, Walking, and Self-Care as predictors resulted in a classification rate of 78.1%, 92% of variance explained, and Eigenvalue of .53 (p < .001).

CONCLUSIONS

Total-FIM scores improved in all groups, and most patients were discharged to home/community suggesting IR efficacy. The ability to transfer bed/chair/wheelchair was the most important predictive factor associated with discharge destination.

Can COVID-19 Vaccines Induce Premature Non-Communicable Diseases: Where Are We Heading to?

According to the WHO, as of January 2023, more than 850 million cases and over 6.6 million deaths from COVID-19 have been reported worldwide. Currently, the death rate has been reduced due to the decreased pathogenicity of new SARS-CoV-2 variants, but the major factor in the reduced death rates is the administration of more than 12.8 billion vaccine doses globally. While the COVID-19 vaccines are saving lives, serious side effects have been reported after vaccinations for several premature non-communicable diseases (NCDs). However, the reported adverse events are low in number. The scientific community must investigate the entire spectrum of COVID-19-vaccine-induced complications so that necessary safety measures can be taken, and current vaccines can be re-engineered to avoid or minimize their side effects. We describe in depth severe adverse events for premature metabolic, mental, and neurological disorders; cardiovascular, renal, and autoimmune diseases, and reproductive health issues detected after COVID-19 vaccinations and whether these are causal or incidental. In any case, it has become clear that the benefits of vaccinations outweigh the risks by a large margin. However, pre-existing conditions in vaccinated individuals need to be taken into account in the prevention and treatment of adverse events.

Early Approach Towards Atypical Guillain-Barré Syndrome: A Physiotherapy Perspective in a Case Report

Guillain-Barré syndrome (GBS) is acute, ascending, immune-mediated, monophasic polyneuropathy, which manifests itself as a lower motor neuron lesion, which occurs mostly after a prior infection. It is autoimmune in origin and has an impact on the peripheral nervous system. GBS is usually not linked to an autoimmune or other systemic condition and is most frequently a post-infectious disorder that affects healthy patients. The symptoms of GBS, an acute immune-mediated polyradiculoneuropathy, include symmetrical limb weakness that worsens quickly and hypo- or areflexia. There may also be sensory complaints, involvement of cranial and autonomic nerve fibres, and frequent pain that will appear before weakening. Weakness, sensory loss, weariness, and discomfort are the most typical remaining deficiencies in an atypical variant of GBS. This case also describes the variant of atypical GBS. A 10-year-old girl was referred to the hospital with complaints of difficulty in swallowing, drooling of saliva, weakness of left upper and bilateral lower limbs, and fever for 10 days. There was no past history of travelling or infection. At the time of admission, the patient was on oxygen support for breathing and she was transferred to ICU immediately. Investigations were done such as a nerve conduction velocity test and complete blood count. Neuro-physiotherapy of the patient was started after 35 days of hospitalisation. With proper rehabilitation, the patient was able to gain strength and the ability to swallow food. The patient was able to resume her academic career.

Ability Realization Improves During Inpatient Rehabilitation for Guillain-Barré Syndrome

OBJECTIVE

The aim of the study was to investigate improvement in ability realization and additional long-term outcomes, during and after inpatient rehabilitation for Guillain-Barré syndrome.

DESIGN

This is a retrospective, longitudinal cohort study, in which outcomes were examined using validated scales, for 47 inpatients with Guillain-Barré syndrome.

RESULTS

Scores improved from 65 on the American Spinal Injury Association Motor Score and 50 on the Spinal Cord Independence Measure, at admission to inpatient rehabilitation, to 81 and 80 at discharge, and to 92 and 95 at the end of 7.5 yrs, on average, at the follow-up ( P = 0.001). The mean Spinal Cord Independence Measure/American Spinal Injury Association Motor Score ratio, which reflects the ability realization, increased during rehabilitation from 50/65 to 80/81 ( P = 0.001), and tended to increase further at follow-up to 95/92 ( P = 0.228). At follow-up, pain did not correlate, and fatigue showed a weak correlation with the American Spinal Injury Association Motor Score, Spinal Cord Independence Measure, and the Adult Subjective Assessment of Participation ( r = -0.363, P = 0.012; r = -0.362, P = 0.012; r = -0.392, P = 0.006).

CONCLUSIONS

Ability realization improved during inpatient rehabilitation for Guillain-Barré syndrome and remained high after discharge, suggesting a likely contribution of rehabilitation to the functional outcome, beyond the contribution of neurological recovery. Despite residual fatigue and pain, there was only minor or no effect on daily function or participation.

Guillain-Barré syndrome from an emergency department view: how to better predict the outcome?

OBJECTIVE

In Guillain-Barre syndrome (GBS), respiratory failure is the most serious manifestation and mechanical ventilation (MV) is required in approximately 20% of the patients. In this retrospective study, we aimed to evaluate clinical factors that can be evaluated in the Emergency Department which may influence the short-term prognosis of GBS patients.

METHODS

Data were acquired regarding age, sex, antecedent infections, neurological signs and symptoms, cerebrospinal fluid examination, nerve conduction studies, treatment of GBS, need for MV, length of stay in the hospital, and discharge destination (home or rehabilitation). Charlson Comorbidity Index and modified Erasmus GBS outcome score (mEGOS) were collected on admission.

RESULTS

Seventy-eight GBS patients were recruited with a mean age of 53.9 (range 19-81). Sixty-nine (88.46%) were diagnosed with GBS and nine (11.54%) had classic Miller-Fisher syndrome. Mean values for the Charlson Comorbidity index were 1.20 ± 1.81, and the values of mEGOS were 2.4 ± 1.6. The rate of home discharge and rehabilitation was similar between elderly and younger patients. Patients who required MV had higher mEGOS (p-value=0.061). Regarding the electrophysiological subtypes, we did not observe a significant difference between AIDP and AMAN/AMSAN concerning the need for MV, the type of discharge, values of mEGOS and Charlson Comorbidity Index.

DISCUSSION

A significant correlation was found between mEGOS and the need for MV. Age did not influence the short-term prognosis of GBS patients. mEGOS may be a useful tool for predicting outcomes in patients with GBS and higher mEGOS scores on admission significantly correlated with poor outcomes.

Increased mortality following Guillain-Barré syndrome: A population-based cohort study

BACKGROUND AND PURPOSE

Guillain-Barré syndrome (GBS) may be fatal in the acute phase but also affect long-term prognosis due to irreversible sequelae and secondary medical complications. We determined the short-term, intermediate, and long-term mortality of GBS compared to the general population.

METHODS

Individual-level data from nationwide registries were linked in this matched cohort study of all first-time hospital-diagnosed GBS patients in Denmark between 1987 and 2016 and 10 individuals from the general population, matched on age, sex, and index date. We used Cox regression analysis to calculate matched mortality hazard ratios (HRs) following GBS, assessing short-term (0-6 months), intermediate (>6 months-4 years), and long-term (>4 years) mortality.

RESULTS

We identified 2414 patients with GBS and 23,909 matched individuals from the general population. Short-term mortality was 4.8% (95% confidence interval [CI] = 4.0-5.8) and 0.8% (95% CI = 0.7-0.9) for GBS patients and general population members, respectively, resulting in an HR of 6.6 (95% CI = 4.0-5.8). Intermediate mortality was 7.6% (95% CI = 6.5-8.9), compared with 5.8% (95% CI = 5.5-6.1) for general population members, corresponding to an HR of 1.5 (95% CI = 1.3-1.8). After the first 4 years, long-term mortality showed similar results for GBS patients and general population members (HR = 1.1, 95% CI = 0.9-1.2).

CONCLUSIONS

During the first 6 months after GBS hospital admission, GBS was associated with a 6.6-fold increased mortality as compared with the background population of the same age. Mortality remained increased for approximately 4 years following GBS, and then leveled off to a similar long-term mortality rate.

Validity, responsiveness, floor and ceiling effects of the Berg Balance Scale in patients with Guillain-Barré syndrome

We investigated the measurement properties of the Berg Balance Scale in patients with Guillain-Barré syndrome. A retrospective analysis was performed of 81 patients with Guillain-Barré syndrome of age 17-84 years who had completed inpatient rehabilitation over a 5-year period. They were assessed with the Berg Balance Scale, the 10 Meter Walk Test, and the 6 Minute Walk Test at admission and discharge. The concurrent validity of the Berg Balance Scale was confirmed by very good correlations with the 10 Meter Walk Test at admission and discharge (ρ = 0.83 and 0.78, respectively) and by excellent and very good correlations with the 6 Minute Walk Test at admission (ρ = 0.91) and discharge (ρ = 0.77). The predictive validity of the Berg Balance Scale for the 10 Meter Walk Test and the 6 Minute Walk Test at discharge was moderate (ρ = 0.62 and 0.61, respectively) and very good (ρ = -0.87) for length of stay. The minimal clinically important difference of the Berg Balance Scale was estimated to be 10 points. The scale was highly responsive to changes in balance (Cohen's d 0.9). No floor effect was identified. A ceiling effect was identified only at discharge. The Berg Balance Scale is feasible in patients with Guillain-Barré syndrome at admission and discharge from rehabilitation. However, a ceiling effect may occur at discharge in patients with high levels of balance.

Approach to the Patient with Gait Disturbance

The assessment of patients presenting with disorders of gait can be a daunting task for neurologists given the broad potential localization and differential diagnosis. However, gait disorders are extremely common in outpatient neurology, and all neurologists should be comfortable with the assessment, triage, and management of patients presenting with difficulty walking. Here, we aim to present a manageable framework for neurologists to approach the assessment of patients presenting with gait dysfunction. We suggest a chief complaint-based phenomenological characterization of gait, using components of the neurological history and examination to guide testing and treatment. We present the framework to mirror the outpatient visit with the patient, highlighting (1) important features of the gait history, including the most common gait-related chief complaints and common secondary (medical) causes of gait dysfunction; (2) gait physiology and a systematic approach to the gait examination allowing appropriate characterization of gait phenomenology; (3) an algorithmic approach to ancillary testing for patients with gait dysfunction based on historical and examination features; and (4) definitive and supportive therapies for the management of patients presenting with common neurological disorders of gait.

Functional Impairments and Rehabilitation Outcomes of Patients With Immunotherapy-Induced Acute Inflammatory Demyelinating Polyradiculoneuropathy, Myasthenia Gravis, and Myositis

ABSTRACT

Immunotherapy has led to a higher survival rate among different oncological disease groups but also associated with adverse-related events in multiple organ systems. Immunotherapy-related musculoskeletal weakness often results in a loss of cancer survivors' physical function, ultimately impacting their independence and quality of life. This is a retrospective study of 24 cancer patients who were treated with immunotherapy either alone or in conjunction with other oncological treatments. Twelve subjects (50%) were found to have acute inflammatory demyelinating polyradiculopathy/Guillain-Barré syndrome, six (25%) myositis, two (8%) myasthenia gravis, two (8%) diagnosis of myositis/myasthenia gravis, and one (4%) Guillain-Barré syndrome/myasthenia gravis combination. Physical therapy was provided in 91.7% of the cases, and physiatrist was involved in 54% of the cases. Almost half (45%) were discharged home, six (25%) to acute inpatient rehabilitation, two (8%) to subacute rehabilitation, three (12.5%) to hospice, and two (8%) died. The average length of hospital stay was 30 days, and eight patients (33%) readmitted within 3 mos. Our findings highlight the severity of functional impairments and the need for early rehabilitation interventions.

Functional outcomes following inpatient rehabilitation of Guillain-Barré syndrome patients: Intravenous immunoglobulins versus plasma exchange

BACKGROUND

Treatment with either Intravenous immunoglobulin (IVIg) or plasma exchange (PE) in patients with Guillain-Barré Syndrome (GBS) showed equivalent efficacy as attested by a commonly used disability scale. However, it has been suggested that this scale may not be sensitive enough to detect subtle functional changes between the two treatments since it mainly focuses on walking capability and respiratory function.

OBJECTIVE

To evaluate functional outcomes following treatment with IVIg or PE using comprehensive scales that incorporate parameters of basic activities of daily living.

METHODS

A retrospective cohort study was conducted between 2007 and 2013 in an inpatient neurologic rehabilitation department. The study group included 70 individuals with GBS: 39 were treated with PE and 31 with IVIg. A comparison of functional outcomes was performed using Functional Independence Measure (FIM), rehabilitation efficiency (REy), rehabilitation effectiveness (REs), and the GBS disability scale (GDS).

RESULTS

Both treatments had a comparable effect on the various functional outcomes. Patients showed a significant increase in total FIM scores (30 points on average) during rehabilitation mainly as a result of an increase in motor sub-scores. A mean improvement of 1.23 (SD 0.9) in GDS was also observed. On average, individuals with GBS spent 20 days combined in the acute departments and 61 days in the rehabilitation department, with length of stay being similar for both treatments.

CONCLUSIONS

IVIg and PE treatments have similar basic activities of daily living (ADL) functional outcomes. Nevertheless, due to the different mechanism of actions of these treatments and the multitude of GBS variants, it is possible that further comprehensive assessment tools may demonstrate differences in activity and participation of individuals with GBS.

The associations between nutritional and functional status during recovery from Guillain-Barré syndrome: a retrospective study

Patients with Guillain-Barré syndrome (GBS) are at high risk for inadequate nutrition throughout their illness, yet the wider impact of malnutrition in this population remains unknown. Thus, the purpose of our study was to investigate the associations between nutritional status and functional status at admission to inpatient rehabilitation for GBS and to determine whether the admission phase angle, a biological marker of cellular health, is a prognostic indicator of functional improvement at the end of rehabilitation. The study included 27 participants recovering from GBS who screened positive for nutritional risk upon admission to rehabilitation. According to the Global Leadership Initiative on Malnutrition criteria, the majority of participants were classified as malnourished. A decreased phase angle was found in 93% (mean 3.7°, SD 1.3°). Lower phase angle was moderately associated with lower motor Functional Independence Measure (mFIM) at admission (r = 0.53, P = 0.005), suggesting that phase angle may be an indicator of functional status. By the end of rehabilitation, all participants improved functional independence and muscle strength, and the majority improved walking abilities. However, the correlation between admission phase angle and mFIM efficiency was not statistically significant (P = 0.3867). We conclude that malnutrition is significantly associated with low functional independence and muscle strength at admission. The inability of admission phase angle to predict functional improvement is probably due to the complex interactions between recovery from GBS and interventions provided during a comprehensive multidisciplinary rehabilitation for GBS, and also relatively small sample size.

COVID-19-Associated Guillain-Barre Syndrome: Atypical Para-infectious Profile, Symptom Overlap, and Increased Risk of Severe Neurological Complications

The concurrence of COVID-19 with Guillain-Barre syndrome (GBS) can increase the likelihood of neuromuscular respiratory failure, autonomic dysfunction, and other life-threatening symptoms. Currently, very little is known about the underlying mechanisms, clinical course, and prognostic implications of comorbid COVID-19 in patients with GBS. We reviewed COVID-19-associated GBS case reports published since the outbreak of the pandemic, with a database search up to August 2020, including a manual search of the reference lists for additional relevant cases. Fifty-one (51) case reports of COVID-19 patients (aged 23–84 years) diagnosed with GBS in 11 different countries were included in this review. The results revealed atypical manifestations of GBS, including para-infectious profiles and onset of GBS without antecedent COVID-19 symptoms. Although all tested patients had signs of neuroinflammation, none had SARS-CoV-2 in the cerebrospinal fluid (CSF), and only four (4) patients had antiganglioside antibodies. The majority had a 1- to 10-day time interval between the onset of COVID-19 and GBS symptoms, and many had a poor outcome, with 20 out of the 51 (39.2%) requiring mechanical ventilation, and two deaths within 12 to 24 h. The atypical manifestations of COVID-19-associated GBS, especially the para-infectious profile and short time interval between the onset of the COVID-19 and GBS symptoms, increase the likelihood of symptom overlap, which can complicate the treatment and result in worsened disease progression and/or higher mortality rates. Inclusion of a neurological assessment during diagnosis of COVID-19 might facilitate timely identification and effective management of the GBS symptoms and improve treatment outcome.

Psychiatric Sequelae of Guillain-Barré Syndrome: Towards a Multidisciplinary Team Approach

Guillain-Barré syndrome (GBS) is a post-infectious autoimmune polyneuropathy. Recent research has highlighted that GBS is associated with the onset of psychiatric symptoms which represent a burden for patients and close relatives. However, acute psychiatric sequelae due to GBS may be misinterpreted as ‘intensive care unit (ICU) delirium’. This review outlines the existing evidence for the psychiatric symptoms associated with GBS with a view to improving psychoeducation of patients. The main psychiatric symptoms of GBS that have been reported in the literature include, stress, anxiety, depression, fatigue, sleep abnormalities, visual hallucinations, paranoid delusions, disorientation, terror and psychosis. These psychiatric symptoms, which occur during the acute phase of GBS, if not recognised and treated, may progress to long-term psychiatric problems that interfere with improvement of physical symptoms. A multidisciplinary team approach to the management of GBS may improve both physical and psychiatric recovery.

Pulmonary Involvement in Patients with Guillain-Barré Syndrome in Subacute Phase

OBJECTIVES

To evaluate the pulmonary function in Guillain-Barre syndrome (GBS) patients in subacute phase and find clinical correlates of pulmonary dysfunction.

METHODS

This was a single-center, prospective, cross-sectional, hospital-based study in GBS patients performed in Department of Neurological Rehabilitation at a tertiary care institute. Clinical examination for pulmonary function was done by measuring chest expansion. The pulmonary function tests were carried out by Spirometry kit Microquark Cosmed, Italy. Fatigue was assessed by Fatigue Severity Scale, disability status by Hughes Disability Scale (HDS), and muscle weakness by Medical Research Council sum scores.

STATISTICAL ANALYSIS

Statistical analysis was performed by Stata 11. The significance of P value was adjudged against an alpha of 0.05.

RESULTS

Twenty-eight patients were included with 17 (61%) men and mean age of 31 years. Median duration of symptoms was 16.5 days. There were 10 (36%) demyelinating and 18 (64%) axonal variants. Twenty-six (93%) patients scored more than 2 on HDS. All study participants reported fatigue. Twenty-two (78.6%) patients had chest expansion of <2.5 cm. Spirometry showed restrictive pulmonary dysfunction in 23 (79%) patients. Significant correlation was found between abnormal pulmonary function test and chest expansion (P = 0.003).

CONCLUSION

Pulmonary dysfunction in GBS is common even during subacute phase. It needs to be identified and managed appropriately for better clinical outcome.

Comprehensive rehabilitation treatment for pregnant women with Guillain-Barré syndrome - a case report

Guillain-Barré syndrome (GBS) is an acute demyelinating poliradioculopathy and autoimmune condition, with a fast rapid natural course, and with high disability and usually episodic immune treatment. Clinical features include areflexia, limb weakness and uncommonly, sensory loss proceeding to neuromuscular paralysis involving bulbar, facial and respiratory function with maximum severity of symptoms atin 2-4 weeks. The eEtiology of GBS is not incompletely understood, however, prognosis is usually good with early detection and prompt treatment. In thise paper, we present a unique case of comprehensive rehabilitation treatment for a pregnant woman with GBS atin the 8th week of pregnancy. On the basis of this case report, we discuss possible and safe rehabilitation treatment for women in the first trimester of pregnancy, with significantly weakened muscle strength, after stabilizsation of vital signs and immunotherapy. The paper describes comprehensive care provided to the pregnant woman with teraplegia, hyperstesia and dysphagia after stabiliszation of vital signs, which was conducted until delivery atin the 39th week of pregnancy. This article is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. null

Rehabilitation of Guillain-Barré syndrome patients: an observational study

Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyradiculopathy resulting in severe impairments of many body structures and functions with consequent limitations of activities and participation. The aim of our study was to evaluate rehabilitation outcome in these patients. Forty-five (20 women, 25 men) with GBS patients who had completed primary comprehensive rehabilitation were included in the study. Medical Research Council Scale for Muscle Strength was used for assessment of lower-limb function. Patients' activities were assessed using the Functional Independence Measure and two walking tests (6 min and 10 m). The patients were also described using an adapted International Classification of Functioning, Disability and Health checklist. Assessment was performed at admission and at discharge. Clinically important and statistically significant improvements were found in all outcome measures. Strong and significant correlations were found between the outcome measures. International Classification of Functioning, Disability and Health coding also clearly reflected the progress. Improvement in patients' activities increased statistically significantly with time for up to 3 months of rehabilitation. The outcome was not related to the time interval from establishing the diagnosis to the start of rehabilitation. Hence, multidisciplinary care for GBS patients is effective, because clinically important and statistically significant improvements regarding body functions and activities are achieved during relatively short inpatient rehabilitation.

Neuromuscular Disease in the Neurointensive Care Unit

Neuromuscular diseases are syndromic disorders that affect nerve, muscle, and/or neuromuscular junction. Knowledge about the management of these diseases is required for anesthesiologists, because these may frequently be encountered in the intensive care unit, operating room, and other settings. The challenges and advances in management for some of the neuromuscular diseases most commonly encountered in the operating room and neurointensive care unit are reviewed.

Complications in mechanically ventilated patients of Guillain-Barre syndrome and their prognostic value

INTRODUCTION

The spectrum of various complications in critically ill Guillain-Barre syndrome (GBS) and its effect on the prognosis is lacking in literature. This study aimed at enumerating the complications in such a cohort and their significance in the prognosis and mortality.

MATERIALS AND METHODS

Retrospective case record analysis of all consecutive mechanically ventilated patients of GBS in neurology Intensive Care Unit (ICU) of a tertiary care institute for 10 years was done. Demographic, laboratory, and treatment details and outcome parameters were recorded.

RESULTS

Among the 173 patients were 118 men and 55 women (2.1:1), aged 1-84 years. The average number of ICU complications per patient was 6.8 ± 1.8 (median = 7, range = 1-12). The most common complication was tracheobronchitis (128). Other pulmonary complications were found in 36 patients. The next was metabolic hyponatremia (115) hypokalemia (67), hypocalcemia (13), stress hyperglycemia (10), hyperkalemia (8), hypernatremia (9). Sepsis (40), UTI (47), dysautonomia (27), hypoalbuminemia (76), anemia (75), seizures (8), paralytic ileus (5), bleeding (4), anoxic encephalopathy (3), organ failures (12), deep vein thrombosis (7), and drug rashes (1) were also noted. The complications, considered significant in causing death, Hughes scale ≤ 3 at discharge, prolonged mechanical ventilation (>21 days) and hospitalization (>36 days) were pneumonia, hyponatremia, hypokalemia, urinary infection, tracheobronchial infections, hypoalbuminemia, sepsis, anemia dysautonomia.

CONCLUSION

Active monitoring and appropriate and early intervention by the clinician will improve the quality of life of these patients and reduce the cost of prolonged mechanical ventilation and ICU stay.

Disability and health-related quality of life in Guillain-Barré syndrome during the first two years after onset: a prospective study

Objective: To describe changes in disability and health-related quality of life in patients with Guillain-Barré syndrome in Sweden during the first two years after onset.

Subjects: Forty-four patients were recruited from eight different hospitals, and 42 of them (mean age 52 years) were followed for two years. Evaluations were performed, primarily as home visits, at two weeks, two months, six months, one year and two years after onset.

Main measures: Disability was measured using the Katz Personal and Extended Activities of Daily Living Indexes, the Barthel Index, the Frenchay Activity Index and assessments of work capacity; health-related quality of life using the Sickness Impact Profile.

Results: At two weeks, one year and two years after onset of Guillain-Barrésyndrome, 76%, 14% and 12% of patients were dependent in personal activities of daily life (ADL); and 98%, 28% and 26% were dependent in instrumental ADL. At two weeks, all of the patients that were working before onset were unable to work owing to Guillain-Barré syndrome; at two years, 17% were unable to work. At two weeks, scores on Sickness Impact Profile were elevated in all dimensions; at two years, they remained elevated in the physical dimension and in the categories home management, work and recreation and pastimes.

Conclusions: The impact of Guillain-Barré syndrome on ADL, work, social activities and health-related quality is considerable two years after onset and presumably persists beyond this time point.

Guillain-Barré syndrome: prevalence and long-term factors impacting bladder function in an Australian community cohort

Background and Purpose

Urinary dysfunction is associated with significant morbidity in persons with Guillain-Barré Syndrome (GBS). The aim of this study was to describe prevalence and long-term impact of bladder dysfunction on daily activities and quality of life (QoL) in persons in chronic phase of GBS and to examine the relationships between commonly used continence measures in this cohort.

Methods

Prospective cohort (n=66) following GBS treatment (1996-2009) was recruited from a tertiary hospital and assessed using standardised measures for bladder dysfunction: American Urological Association (AUA) Symptom Index, Incontinence Impact Questionnaire, Urogenital Distress Inventory.

Results

Sixty-six participants (64% male, mean age 56 years, median disease duration of 6.1 years) completed the study. Of these more than half reported nocturia and one-third reported urinary urgency and frequency. Urinary problems impacted on participants' daily activities: physical recreation (21%), emotional health and mood (17%), entertainment (14%), participation and mobility (>30 min) (12%), and performance of household chores (8%). Since GBS, 49% reported interference of urinary symptoms with daily life to some extent; and adverse impact on QoL (10.6%). Significant relationship between bladder symptoms; and the level of urogenital distress (p<0.001) and the impact of urinary problems (p<0.001), was noted. Higher scores on the bladder scales showed significant correlations with psychological, functional and participation scales. The single QoL item (AUA scale) correlated significantly with all other bladder scales (rho=0.63-0.86). This can be a potential 'screening tool' to identify patients for further assessment.

Conclusions

Bladder dysfunction in chronic phase of GBS is not well studied. More research in longer-term screening and outcomes for bladder intervention are needed for integrated care and to guide treating clinicians.

[Guillain-Barré syndrome in the critical care unit in the last 10 years]

OBJECTIVES

The Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy, which constitutes an important proportion of acute flaccid paralysis cases. Our objective was to present the clinical characteristics of patients with the GBS who required admission to a critical care unit.

METHODS

A retrospective study over a period of ten years was conducted on patients with GBS, who were admitted to the critical care unit in a tertiary hospital. The proportion of patients requiring connection to mechanical ventilation (MV) and associated complications was analysed, along with certain clinical features which implied a more severe illness and worse functional recovery.

RESULTS

MV was required in 58.8% of cases (mean duration 29.8 days). Nine patients received tracheostomy. Pulmonary complications were observed in all patients that needed MV (50% tracheobronchitis and 50% ventilator-associated pneumonia). MV is associated with pulmonary complications (P=.001) and those, in turn, to the development of sepsis (P=.006). Only one patient died (5.88%). No relationship was found between advanced age, MV, comorbidity, sepsis, or hemodynamic complications and the mortality of GBS.

CONCLUSIONS

Death in these patients results from pulmonary complications, sepsis and less frequently due to autonomic dysfunction or pulmonary embolism. Emphasising the importance of their prevention, detection and management.

Use of the International Classification of Functioning, Disability and Health to identify preliminary comprehensive and brief core sets for Guillain Barre syndrome

PURPOSE

To identify the preliminary comprehensive and brief core sets for Guillain Barre syndrome (GBS), in a Delphi process using the International Classification of Functioning, Disability and Health (ICF).

METHOD

Focus groups and a consensus process were used to identify ICF core sets for GBS. This included: preliminary ICF studies; empirical patient data collection for 77 GBS participants; review of the evidence base and treatment in GBS literature followed by a Delphi exercise with 23 physicians and allied health professionals in Melbourne, Australia.

RESULTS

The expert consensus selected 99 second level ICF categories (in three rounds) which identify health domains relevant to GBS for multidisciplinary assessment. These domains were consistent with current practice and existing GBS literature. The comprehensive core set includes: 27 (23%) categories from the component 'body function', 7 (12%) categories from 'body structures', 43 (36%) from 'activities and participation' and 22 (29%) from the component 'environmental' factors. The brief set comprised 20 categories, 20% of categories in the comprehensive core set.

CONCLUSION

The core set categories for GBS-related health need to be addressed in multidisciplinary care programs. Future clinical 'rating' of this set may facilitate scale development using the ICF in GBS. Further research is needed to confirm the generalisability of this set in clinical settings.

Multidisciplinary care for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care, but the evidence base for its effectiveness is unclear.

OBJECTIVES

To assess the effectiveness of multidisciplinary care in adults with Guillain-Barré syndrome, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), AMED (1985 to May 2010), PEDro (1982 to May 2010) and LILACS (1982 to May 2010). We checked the bibliographies of papers identified and contacted their authors and known experts in the field seeking published and unpublished trials.

SELECTION CRITERIA

Randomised and controlled clinical trials that compared multidisciplinary care in Guillain-Barré syndrome with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary care in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis.

DATA COLLECTION AND ANALYSIS

We performed a 'best evidence' synthesis based on methodological quality.

MAIN RESULTS

No randomised controlled trials or controlled clinical trials were identified. We summarised the results of three observational studies in the Discussion section of this review.

AUTHORS' CONCLUSIONS

In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date comes from three 'very low quality' observational studies. These provide some support for improved disability in the short term (less than 6 months) with high intensity inpatient multidisciplinary rehabilitation; and for improved quality of life, as measured by a reduction in handicap (participation). These conclusions are tentative and the gap in current research should not be interpreted as proof that multidisciplinary care is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of multidisciplinary care in the Guillain-Barré syndrome population.

Factors associated with long-term functional outcomes and psychological sequelae in Guillain-Barre syndrome

To examine factors impacting long-term health-related outcomes in survivors of Guillain-Barre syndrome (GBS). Seventy-six consecutive patients with definite GBS admitted to the Royal Melbourne Hospital (1996-2009) were reviewed in the neurorehabilitation clinics. They underwent a structured interview designed to assess the impact of GBS on their current activity and restriction in participation using validated questionnaires: Functional Independence Measure (FIM), Perceived Impact of Problem Profile (PIPP) and Depression Anxiety Stress Scale (DASS). Their sociodemographic and disease severity data were obtained from the medical record. The 76 patients [60% male, mean age 56 years, median time since GBS 6 years (range 1-14 years)] showed good functional recovery (median motor FIM score 90). However, 16% reported moderate to extreme impact on their ability to participate in work, family, and social activities; and 22% substantial impact on mood, confidence and ability to live independently. More reported moderate to extreme depression (18%), anxiety (22%) and stress (17%) compared with the normative Australian population (13%). Factors associated with poorer current level of functioning and wellbeing included: females, older patients (57+ years), acute hospital stay (>11 days), those treated in intensive care and those discharged to rehabilitation. No associations were found between the Medical Research Council (MRC) Motor Scale Rating scores at admission, nor time since GBS diagnosis (≤6 vs. >6 years) on outcomes used.

CONCLUSION

GBS is complex and requires long-term management of psychological sequelae impacting activity and participation.

Radial nerve palsy in Guillain-Barré syndrome

The risk of focal compression neuropathy in the setting of an underlying inflammatory polyneuropathy is unknown. A man developed ascending weakness and severe sensory ataxia and could not walk. Electromyography was diagnostic of Guillain-Barré syndrome. He improved with gammaglobulin and was released home 1 month later. Shortly after discharge, he developed severe left arm pain followed by wrist and finger drop. He was readmitted for another round of gamma-globulin without improvement. Subsequent electromyography showed severe radial neuropathy. Only then did he disclose that he usually slept with his wife's head on his arm at home. Two years later, he had recovered from Guillain-Barré syndrome with minimal gait imbalance, but wrist and finger extension remained weak. Reduced awareness of warning paresthesias coupled with the underlying polyneuropathy may account for this case of severe radial nerve compression. Potential mechanisms underlying increased nerve susceptibility to compression in the setting of polyneuropathy are reviewed.

Factors associated with health-related quality of life in patients with severe Guillain – Barré syndrome

PURPOSE

To compare the health-related quality of life (HRQOL) in control subjects and patients with severe Guillain-Barré syndrome (GBS) 6 months after rehabilitation. To determine the relationship of several sociodemographic and medical factors with the HRQOL of the GBS survivors.

METHODS

Thirty-one patients with severe GBS and 31 control subjects were included in the study. Demographic and medical variables were recorded. The functional outcome was measured using the Functional Independence Measure (FIM), both at admission and discharge and also at the 6-month follow-up examination. The HRQOLs were assessed by the Nottingham Health Profile (NHP) at the 6-month follow-up examination.

RESULTS

There were significant improvements in functional status as measured by the FIM at discharge and also at 6 months. The scores of all of the NHP dimensions of the GBS patients were significantly higher than in the control subjects. Functional disability scores were highly related to the energy level, physical mobility and emotional reactions of the NHP domains. Education, gender, employment, mechanical ventilation and tendency to depression were the factors most related to the NHP domains. Age and marital status showed no significant correlation with the NHP scores.

CONCLUSION

The HRQOL of the GBS patients remains lower than that of the control subjects. In addition to functional scores, several sociodemographic and medical variables, such as education, psychological factors, gender, mechanical ventilation and employment may play a crucial role in determining the quality of life in persons with GBS.

Physiotherapy and Guillain-Barré syndrome: results of a national survey

OBJECTIVE

To discover the extent to which persons with Guillain-Barré syndrome receive treatment by a physiotherapist (as inpatients and outpatients), and to assess whether the amount of treatment received is related to outcome.

DESIGN

Survey method using self-administered questionnaires distributed through a national database.

PARTICIPANTS

Members of the Guillain-Barré Syndrome Support Group (n=1535).

MAIN OUTCOME MEASURES

General patient data, general mobility, F-score, Hospital Anxiety and Depression Scale, Short Form-36 and Fatigue Severity Scale.

RESULTS

In total, 884/1535 (58%) complete responses were received. Nearly 10% of respondents had not received treatment by a physiotherapist in hospital despite their average functional level being the same as respondents who had received treatment in hospital. One-quarter of respondents said that they had not received treatment following hospital discharge despite the identification of relatively high levels of disability. Those who did not receive treatment by a physiotherapist following discharge were less severely disabled. This may indicate that physiotherapists tend to offer treatment to more severely disabled patients. The majority of patients reported disabling fatigue; whilst not statistically related to receipt of treatment by a physiotherapist, this highlights the importance of assessing fatigue in treatment plans to improve physical functioning.

CONCLUSION

Improvements to policy and practice can be made by widening inpatient accessibility to treatment by a physiotherapist and increasing outpatient provision of treatment for patients with Guillain-Barré syndrome of all degrees of severity.

Miller Fisher syndrome: a diagnosis not to be missed

We report a case of Miller Fisher syndrome presenting in an ENT setting. The referral was made on the basis of worsening nasal regurgitation following Campylobacter jejuni enteritis. The aim of this report is not to add to the recorded instances of Miller Fisher syndrome, but to help raise the level of its awareness amongst otolaryngologists. Emphasis is placed on the mode of presentation and management issues, as early diagnosis is crucial and confers a favourable prognosis. In that respect, we consider this case noteworthy and instructive.

Fatigue and neuromuscular diseases

PURPOSE

To identify the role of fatigue, its evaluation and its causes in the pathophysiology context of acquired or hereditary neuromuscular diseases of the spinal anterior horn cell, peripheral nerve, neuromuscular junction and muscle.

MATERIAL AND METHODS

A literature review has been done on Medline with the following keywords: neuromuscular disease, peripheral neuropathy, myopathy, fatigue assessment, exercise intolerance, force assessment, fatigue scale and questionnaire, then with the terms: Fatigue Severity Scale, Chalder Fatigue Scale, Fatigue Questionnaire, Piper Fatigue Scale, electromyography and the combination of the word Fatigue with the following terms: Amyotrophic Lateral Sclerosis (ALS), Post-Polio Syndrome (PPS), Guillain-Barre Syndrome, Immune Neuropathy, Charcot-Marie-Tooth Disease, Myasthenia Gravis (MG), Metabolic Myopathy, Mitochondrial Myopathy, Muscular Dystrophy, Facioscapulohumeral Dystrophy, Myotonic Dystrophy.

RESULTS

Fatigue is a symptom very frequently reported by patients. Fatigue is mainly evaluated by strength loss after an exercise, by change in electromyographic activity during a given exercise and by questionnaires that takes into account the subjective (psychological) part of fatigue. Due to the large diversity of motor disorders, there are multiple clinical expressions of fatigue that differ in their presentation, consequences and therapeutic approach.

CONCLUSION

This review shows that fatigue has to be taken into account in patients with neuromuscular diseases. In this context, pathophysiology of fatigue often implies the motor component but the disease evolution and the physical obligates of daily life also induce an important psychological component.

Guillain-Barré syndrome

Guillain-Barré syndrome consists of at least four subtypes of acute peripheral neuropathy. Major advances have been made in understanding the mechanisms of some of the subtypes. The histological appearance of the acute inflammatory demyelinating polyradiculoneuropathy (AIDP) subtype resembles experimental autoimmune neuritis, which is predominantly caused by T cells directed against peptides from the myelin proteins P0, P2, and PMP22. The role of T-cell-mediated immunity in AIDP remains unclear and there is evidence for the involvement of antibodies and complement. Strong evidence now exists that axonal subtypes of Guillain-Barré syndrome, acute motor axonal neuropathy (AMAN), and acute motor and sensory axonal neuropathy (AMSAN), are caused by antibodies to gangliosides on the axolemma that target macrophages to invade the axon at the node of Ranvier. About a quarter of patients with Guillain-Barré syndrome have had a recent Campylobacter jejuni infection, and axonal forms of the disease are especially common in these people. The lipo-oligosaccharide from the C jejuni bacterial wall contains ganglioside-like structures and its injection into rabbits induces a neuropathy that resembles acute motor axonal neuropathy. Antibodies to GM1, GM1b, GD1a, and GalNac-GD1a are in particular implicated in acute motor axonal neuropathy and, with the exception of GalNacGD1a, in acute motor and sensory axonal neuropathy. The Fisher's syndrome subtype is especially associated with antibodies to GQ1b, and similar cross-reactivity with ganglioside structures in the wall of C jejuni has been discovered. Anti-GQ1b antibodies have been shown to damage the motor nerve terminal in vitro by a complement-mediated mechanism. Results of international randomised trials have shown equivalent efficacy of both plasma exchange and intravenous immunoglobulin, but not corticosteroids, in hastening recovery from Guillain-Barré syndrome. Further research is needed to discover treatments to prevent 20% of patients from being left with persistent and significant disability.

Long term disability and social status change after Guillain-Barré syndrome

OBJECTIVE

Even if the majority of patients with Guillain-Barré syndrome (GBS) have a favourable functional outcome some residual motor and sensory signs and symptoms may remain. The aim of this study was to evaluate the long-term effect of GBS on daily life,working activities, hobbies and social status and the presence of residual symptoms.

PATIENTS AND METHODS

Seventy patients with GBS enrolled in a case-control study were examined. Information on signs or symptoms during the acute phase of the disease was retrieved from medical records and an ad-hoc questionnaire administered during hospitalization. Patients were interviewed by phone 3 to 5 years after disease onset about residual symptoms and changes in daily living. Disability and handicap were assessed using the Hughes, Rankin and Rotterdam 9-items scale.

RESULTS

At follow-up 45 patients (64 %) made a complete functional recovery; 19 patients (27%) had some minor limitations in daily life although they were able to perform all their activities independently while 6 (9 %) needed aid for some hours or continuously during the day. Nineteen patients (27 %) had, however, to make substantial changes in their job, hobbies or social activities. There was no significant correlation between clinical and laboratory features during the acute phase of GBS and outcome.

CONCLUSIONS

Although over 90% of our GBS patients had a more or less complete functional recovery, almost 30% of them had to make substantial changes in daily life. These findings indicate that GBS still has a significant impact on patients' life which may go beyond their residual disability or impairment. Treatment of GBS should not be only aimed at improving patients' disability but also at limiting the impact of the disease on their social life.