Neuro ICU > GBS

Guillain-Barré Syndrome (GBS)

What is it?

GBS is an “acute, rapidly progressing inflammatory demyelinating polyneuropathy (AIDP) of the peripheral nerves and spinal nerve roots” (Hamby, 2017). The immune system attacks part of the peripheral nervous system by mistake. Severity can vary from mild with brief weakness to severe paralysis and inability to breathe, requiring mechanical ventilation. Many cases are linked to infection, surgery, or vaccination. If symptoms continue to progress beyond 8 weeks, the diagnosis shifts to Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP), a chronic form of GBS that affects 3–10% of patients.

Types

  1. Acute Inflammatory Demyelinating Polyneuropathy (AIDP): The most common type (75-80%) in which the immune response damages the myelin coating and interferes with the transmission of nerve signals.

  2. Miller-Fisher Syndrome: rare (5-10%). Characterized by abnormal muscle coordination, weakness/paralysis of eye muscles, absence of tendon reflexes, and ataxia.

  3. Pharyngeal-cervical-brachial motor variant: rare (3%). Typically presents with muscle weakness involving the neck flexors, facial/pharyngeal muscles, and upper extremities.

Symptoms

  • Symptoms generally present as unexplained sensations (i.e., tingling or pain) that come and go or weakness on both sides of the body. Most experience the greatest weakness within the 1st two weeks after symptom onset. By the 3rd week, 90% of individuals are at their weakest point. The cardinal sign is the progression from distal to proximal motor and sensory impairments. A general list of symptoms includes:

    • Difficulty with eye muscles

    • Change in vision

    • Difficulty swallowing, talking, or chewing

    • Pins and needles/numbness and tingling in hands and feet

    • Severe pain

    • Impaired coordination

    • Impaired balance

    • Abnormal heart rate or blood pressure

Phases

  • Progressive Phase: lasts days to 4 weeks

  • Plateau Phase: lasts days to months with little clinical change

  • Recovery Phase: Gradual return of strength, typically distal to proximal, over months to years. The rate of recovery varies widely — some patients recover fully, others are left with residual deficits.

How is it diagnosed?

Several different tests can be used to diagnose GBS. A MRI & CT can be ordered to rule out stroke, a lumbar puncture to analyze cerebrospinal fluid, and/or a nerve conduction velocity test

Diagnostic Criteria

  • Bilateral limb weakness

  • Reduced or lost deep tendon reflexes

  • Monophasic illness

  • 12-hour to 28-day syndrome evolution

  • Consistent electrophysiology findings

  • CSF analysis revealing normal CSF leukocytes but elevated protein

  • Absence of an alternate diagnosis

Prognosis

  • 70% to 80% of patients with GBS demonstrate a full or nearly complete recovery within 6 months of onset. Approximately 15% of patients have persistent neurological symptoms and weakness. The most common residual deficits include mild neuropathy (in about half of patients), dysautonomia, and lower-extremity weakness.

  • Poor prognostic factors include age over 50, bulbar weakness, neck flexion weakness, rapid onset (≤7 days to peak weakness), ventilator dependence, and antecedent infection with cytomegalovirus or Campylobacter jejuni. Insufficient rehabilitation after hospital discharge is also associated with worse outcomes.

Treatment

  • Plasmapheresis: blood cleansing procedure in which the plasma antibodies are removed and replaced with albumin or fresh frozen plasma. This appears to reduce both the severity and duration of GBS.

  • Intravenous immunoglobulin (IVIG): high-dose plasma protein replacement therapy in which the patient receives intravenous injections of immunoglobulins. This is thought to lower the levels or overall effectiveness of the antibodies that are attacking the nerves.

  • Supportive care: respiratory management (BiPAP or mechanical ventilation if needed), pain management for neuropathic symptoms, DVT prophylaxis, and bowel/bladder management.

Activity Guidance by Phase — GBS

Phase Duration Activity Guidance
Progressive Days to 4 weeks Defer vigorous or resistance activity. Focus on positioning, passive ROM, splinting to prevent contracture, and respiratory monitoring. Prioritize patient and family education. Short, low-demand sessions only.
Plateau Days to months Begin careful active-assisted ROM when tolerated. Introduce energy conservation strategies. Monitor fatigue closely — end session at first sign of fatigue, not when the patient reports it. Gradual upright progression as tolerated.
Recovery Weeks to months Progressive strengthening, ADL retraining, and functional mobility. Continue to monitor fatigue — recovery is non-linear and patients may have good and bad days. Coordinate with PT and SLP as swallowing and mobility improve.

⚠ Respiratory Deterioration Watch

Up to 30% of GBS patients require mechanical ventilation. During the progressive and plateau phases, monitor for increasing dyspnea, declining voice quality (bulbar involvement), or desaturation during activity. Stop therapy and notify nursing if any of these are observed.

Therapy Implications

  • Activity guidance is phase-dependent. Treatment approach differs significantly across the acute, plateau, and recovery phases. The activity table below outlines guidance by phase.

  • Respiratory status must be monitored before and during every session. Up to 30% of GBS patients require intubation. Importantly, oxygen saturations may appear normal even with impending respiratory failure — declining respiratory endurance is an earlier warning sign. Monitor for:

    • Inability to count out loud rapidly to 15 in one breath (every 10 numbers counted ≈ 1L of vital capacity; intubation may be considered if patient cannot count to 10)

    • Inability to lift head off pillow by flexing the neck

    • Shortness of breath at rest or while talking

    • Tachypnea or accessory muscle use

    • Asynchronous chest/abdominal movement during breathing

    • Ineffective cough or inability to manage secretions

    • Worsening dysphagia or voice quality changes

    • Use incentive spirometer each session and document level achieved

  • Hemodynamic monitoring is essential in the acute phase. Avoid MAP >125. Do not leave the patient alone in a chair until hemodynamic stability is confirmed. Dramatic BP swings (hypertension to hypotension) are common due to dysautonomia — monitor closely during any position change.

  • SIADH monitoring: SIADH occurs in approximately 48% of GBS patients. Monitor for abnormally increased water intake (excessive thirst) and report to the physician if observed.

  • Pain management: Neuropathic pain is common throughout all phases. Pain follows a "stocking-glove" distribution of numbness and tingling and can be severe. Muscle bellies are very tender to palpation — use care with handling. Pain is typically worse at night and contributes to both physical and respiratory fatigue. Warm packs and massage may help; guided imagery and relaxation techniques may augment medication regimens.

  • Fatigue monitoring across all phases. GBS patients may appear to tolerate activity and then crash rapidly. End the session at the first sign of fatigue — not after the patient reports it. IVIG and plasmapheresis (PLEX) treatments take approximately 4 hours; the patient may be briefly fatigued after treatment — plan sessions accordingly.

  • Psychosocial awareness: The patient has intact consciousness, vision, and hearing throughout the illness. Be mindful of what is said at the bedside — the patient hears everything even if they cannot respond. The patient may hallucinate due to medications, pain, or ICU environment. Explain all procedures. Intense pain, decreased sensation, and loss of control are major sources of anxiety — validate these experiences and provide nonpharmacological anxiety-reduction strategies.

  • Eye care: If the patient's eyelid cannot close (facial nerve involvement), discuss options with the physician to prevent corneal abrasions and dryness. Do not leave this unaddressed.

  • GBS is reversible — prognosis is generally positive. Frame goals around functional recovery and communicate this trajectory clearly to the patient and family

Back to Neuro ICU

References

Hamby, J. R. (2024). The nervous system, part 2: Neurodegenerative diseases and other conditions. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (3rd ed., pp. 449–496). AOTA Press.

National Institute of Neurological Disorders and Stroke. (2021, November 15). Guillain-Barré Syndrome Fact Sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Guillain-Barr%C3%A9-Syndrome-Fact-Sheet