What is the recommended physical exam and treatment approach for a patient with Guillain-Barré Syndrome (GBS)?

Physical Examination and Treatment Approach for Guillain-Barré Syndrome

The comprehensive physical examination for Guillain-Barré Syndrome (GBS) patients should focus on neurological assessment with particular attention to pattern of weakness, reflexes, sensory deficits, and respiratory function, while treatment should include intravenous immunoglobulin (IVIG) 0.4 g/kg/day for 5 days or plasma exchange in patients unable to walk independently.

Physical Examination Components

Neurological Assessment

• Motor Function:
  • Assess bilateral limb strength using Medical Research Council (MRC) grading scale
  • Document pattern of weakness (typically ascending and symmetric)
  • Test deep tendon reflexes (usually decreased or absent)
  • Evaluate cranial nerve function, especially facial and bulbar muscles

Respiratory Function

• Critical monitoring parameters 1:
  • Vital capacity (VC) - critical if <20 ml/kg
  • Maximum inspiratory pressure (MIP) - critical if <30 cmH₂O
  • Maximum expiratory pressure (MEP) - critical if <40 cmH₂O
  • Single breath count (critical if ≤19)
  • Oxygen saturation and arterial blood gases if respiratory compromise suspected

Sensory Examination

• Test for sensory deficits (particularly distal paresthesias)
• Assess for pain (often in lower back, thighs, and extremities)

Autonomic Function

• Monitor for signs of dysautonomia 2:
  • Blood pressure fluctuations
  • Heart rate abnormalities
  • Pupillary dysfunction
  • Bowel/bladder dysfunction
  • Temperature dysregulation

Functional Assessment

• Document using GBS disability scale: 0: Healthy 1: Minor symptoms, able to run 2: Able to walk 10m independently 3: Able to walk 10m with aid 4: Bedridden or chair-bound 5: Requiring mechanical ventilation 6: Death

Treatment Approach

Initial Management

1. Determine treatment indication:

   • Treat if patient is unable to walk unaided (GBS disability score ≥3)
   • Consider treatment in rapidly progressing cases even if still ambulatory

2. First-line immunotherapy 2, 1, 3:

   • IVIG: 0.4 g/kg/day for 5 consecutive days (total 2 g/kg)
   • OR Plasma exchange: 4-5 exchanges over 1-2 weeks (total 200-250 ml/kg)
   • IVIG generally preferred due to greater availability and lower complication rates

3. Respiratory support assessment:

   • Consider ICU admission if 2:
     • Rapidly progressive weakness
     • Bulbar involvement
     • Autonomic instability
     • Respiratory compromise (per parameters above)

Supportive Care

• Pain management 2, 1, 3:

  • First-line: Gabapentinoids (pregabalin, gabapentin)
  • Second-line: Tricyclic antidepressants or carbamazepine
  • Avoid opioids when possible

• DVT prophylaxis:

  • Compression stockings and/or anticoagulation for immobilized patients

• Autonomic dysfunction management:

  • Cardiac monitoring
  • Treatment of blood pressure fluctuations
  • Bladder and bowel care

Monitoring Disease Progression

• Daily neurological examinations
• Regular respiratory function tests
• Monitor for treatment-related fluctuations (TRFs), which occur in 6-10% of patients within 2 months of treatment 1, 4

Important Considerations

• Corticosteroids are not recommended as they show no benefit and may have negative effects 3
• Combination therapy (plasma exchange followed by IVIG) is not recommended as it shows no additional benefit 1, 3
• Consider changing diagnosis to acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) if progression continues beyond 8 weeks from onset (occurs in ~5% of patients) 3, 4

Rehabilitation and Long-term Management

• Arrange comprehensive rehabilitation program before discharge 2, 1
• Address potential long-term issues:
  • Fatigue (affects 60-80% of patients)
  • Chronic pain (affects at least one-third of patients)
  • Psychological distress
  • Physical function restoration

Prognosis

• Approximately 80% of patients regain independent walking by 6 months 1
• Recovery can continue for more than 3 years after onset
• Mortality rate is 3-10% despite optimal care 1, 5
• Recurrence is rare (2-5% of cases) 1, 4

By following this systematic approach to physical examination and treatment, clinicians can optimize outcomes for patients with Guillain-Barré Syndrome while minimizing complications and long-term disability.