- The vexed question of residuals in Guillain Barre Syndrome -
Lawrence Kaplan and Robert J. GregoryArticle reprinted with permission from Kai Tiaki Nursing New Zealand Journal. First published August 2004 (vol 10, no 7).
Numbers in parentheses: Please refer to the reference list at the bottom.
Guillain Barre Syndrome (GBS) is a fascinating neurological disease, if such there can be, for it is rare, occurs with sudden onset, and creates acute effects, particularly on the peripheral nervous system.
Essentially, the peripheral nerves are attacked by the body's defence system, an auto-immune attack, and as a result, the myelin sheath and axons of nerves are impaired. When sufficient damage occurs, paralysis may result. Neurological examinations, intensive hospital care and plasmapheresis treatments lead most people with a severe case back to recovery and rehabilitation in a few weeks or months. Dramatic as the onset and collapse may be, the ensuing years are dull in comparison. However, the nature of the disease can hide both the long-term physical effects and the psychological reactions.The residual effects of GBS have been noted for some time.(1) American researcher John Steinberg stated that, "Well over 50 percent, and probably up to 90 percent, of patients eventually reach complete or nearly complete recovery and resume their prior lifestyles. About five to 15 percent of patients will have significant long-term disability. Perhaps 35 percent will experience long-term mild abnormalities, such as foot drop or numbness."(1) Steinberg also commented that patients might develop fatigue, particularly with sustained activity, and demonstrate poor endurance, even with normal muscle strength. This could lead to serious problems for those who worked long hours and/or had physically demanding jobs.
New Zealand researcher Gareth Parry added to our understanding with a thoughtful analysis of what appears to happen physiologically.(2,3) Based on recent research, Parry stated that a study of 83 patients found 80 percent experienced severe fatigue that interfered with their life. Also and significantly, these patients experienced fatigue that did not seem to decrease over time. Meanwhile, he noted that these people had relatively normal strength. "The basis . . . is probably axonal degeneration."(2) Further, he commented that, "surviving axons send out small branches called collateral sprouts that restore the nerve supply to those muscle fibres whose nerves have been damaged."(3)
Thus while strength to a muscle stays roughly the same, the nerves that are restored are less strong, and so the efficiency of the muscle is reduced, resulting in fatigue. In a recent presentation, Parry noted that "Residual effects from both GBS and CIDP are much more common than has been generally reported."(2)Recently, New Zealand psychologist Cecilia Bourke noted that 93 percent of her sample of 44 persons who had GBS reported varying residuals.(4) She found that 38 percent were mildly, 50 percent moderately and four percent severely fatigued. Pain was reported by 66 percent, nerve tingling by 70 percent and reduced mobility by 77 percent of the participants. In addition, 84 percent claimed muscular weakness, while numbness was felt by 66 percent. Interestingly, a remarkable 39 percent of the 44 persons interviewed claimed to experience all seven of these symptomatic problems. This finding is contrary to the frequent assurances that, after initial acute phases of GBS, recovery is total. Given that Bourke found anxiety and depression were within a normal range as measured by psychological testing, the large number complaining of physical residual effects was surprising.
What exactly is taking place?
What may take place is that the myelin sheath in nerves and the axons themselves are damaged from GBS. Some of those wounds recover, heal and the person then gets on with their life. Some of the damage, however, does not heal, in particular the damage in axons. What may occur then is that relatively weak collateral nerves take over the transmission duties for nervous system messages. These alternative circuits through the nervous system have to do extra duty to replace the functions of the axons of nerves that no longer work well. Those collateral nervous circuits are simply not as strong or as resilient, and are simply not so capable as the originals.Therefore, when a person with GBS-damaged axons and nerve tissue exercises, these collateral nerves are rapidly overloaded, and slow or even stop functioning fairly quickly. The person comes to a screeching halt -- a neurologically induced crash. Others may look at the person and say, "You are tired and exhausted and fatigued," thinking that it is muscles and overloaded muscles that will recover easily with rest. However, it is not the muscles that are faulty; it is nerves that are limiting functioning abilities. Thus there are significant and real differences in the cause and consequences of fatigue. Even those with GBS may believe they have tired muscles, for muscular tiredness is a common experience. That does not seem to be the case, however. The nerves just can't handle the extra exertion, and when stressed, they do not recover as quickly as muscles do. Tests for muscular strength show up just fine, for the muscles do work and are possibly or even probably stronger than in other people. But the nerves are rarely, or not tested, or suspected.
Some of those nerves affected are essential to lung function and breathing and that may account for developing shortness of breath. Even though individuals may experience this effect, they may not be able to explain it to their family, doctor or friends. These people have no experience other than muscular weakness, and therefore, they cannot understand that there are differences in cause and effects. That may be one reason why those who have had GBS are rather unique!
Case studies
Case A: David, aged about 50, was carrying an extremely heavy and stressful workload. One day, he noted tingling in his feet, then peripheral neuropathy. His physician claimed, "She'll be right," in typical Kiwi optimistic fashion, and David carried on. With some walking and breathing difficulties, acute leg pains, and generalised nervous aches and pains, David continued to work, albeit at a reduced and less effective pace. He noted that he had virtually no knee reflexes, that he slept 14 hours a night and was still exhausted, and endured a variety of "system problems," such as diverticulitis, thyroid failure, and depression. A visit to a different physician led to laboratory and neurological tests, and a diagnosis of GBS, nearly a year later. David began thyroxine treatment, but there was nothing that could be done at that late date for the GBS, nor for continuing symptoms.For the next 10 years, David continued to have extreme leg pains, generalised weakness, fatigue and tingling sensations that sometimes kept him awake at night. Gradually these aches and pains left, but then reoccurred periodically. The symptoms abated for the most part after 10 years. But, at about 15 years from onset, David noted shortness of breath, a marked lack of endurance even though he retained an ability to handle tasks that required muscles, fatigue, and the return of some tingling and other painful sensations. Currently he has concerns about the trajectory of the disease and what may lie in his future.
Case B: Philip contracted GBS in 1981. He was ill for two or three weeks with flu-like symptoms, then diarrhoea, and numbness of legs and fingers. Slight paralysis of his legs followed. This progressed without his doctor being concerned, until he became about 30 percent paralysed. It was at this time, the end of the third week, that his medical practitioner hospitalised him. He was promptly diagnosed with GBS. Due to the severity of the disease, and as it rapidly progressed, he spent the next two weeks in cardiac intensive care. Three weeks' nursing care was followed by two weeks' rehabilitation. Plasmapheresis was not an available treatment at that time. At week six, Philip was released from hospital, against the doctor's orders, but he did continue outpatient rehabilitation for another eight weeks.
From 1982 through 1983, Philip gradually increased his work activities to 10 or even 14 hours per day, plus included bicycling and mild sports as part of his continuing self-rehabilitation. He hoped to build greater endurance. From 1984 through 1994, Philip succeeded and led a fairly normal life, but still felt various residual effects, including constrained breathing, frequent and fast onset of fatigue, sudden feelings of complete exhaustion, and tingling sensations between his shoulders. He also noted back and leg soreness, aching knees, and persistent discomfort when laying one knee against the other. Philip also found he had clumsy feet and fingers. He noticed squeakiness in his voice.
From 1995 through 2002, Philip led a very active lifestyle, with reduced impact from the GBS residuals. He worked eight to 12 hours per day, led a sports club, and engaged in physically demanding sports between eight and 20 hours per week. Symptoms such as constrained breathing, fast onset of fatigue and exhaustion, and back and leg soreness were rare. Though he still had tingling sensations between his shoulders, he had no aches in his knees, and only occasional discomfort from knees adjoining or becoming clumsy. He stated that although the residuals had abated significantly, when they occurred, they were intense. Symptoms lingered, and quickly reappeared if and when his activity level decreased.In 1998, Philip was diagnosed with a heart murmur. In 2000, he had sinusitis and prolonged bouts of upper respiratory infections, requiring surgery. In 2003, the heart murmur led to a repair of the mitral valve, and during his period of rehabilitation, GBS residuals returned in the form of increases in exhaustion, sudden onset of fatigue and constrained breathing. Now aged 48, he hoped for a quick and easy recovery, but that did not happen. Six months later, he felt he had regained only half of his activity levels. He suffered soreness at the incision site, bouts of sudden fatigue, and frequent onset of constrained breathing. An extensive series of diagnostic tests revealed nothing. His medical professionals, knowing little about GBS, let alone about long-term residuals, had no opinion regarding this conclusion and deferred to a diagnosis of "de-conditioning". This ongoing physical incapacity, mixed with the medical professionals' inability to accept the relevance of GBS, brought on depression as well. Ten months following surgery, a significant return of GBS symptoms was evident, including "crashing" and extreme fatigue after even mild exercise. These symptoms collectively were sufficient to be rated as debilitating.
What can be done?
GBS symptoms and residual effects do present a challenge, and are very important to the individuals concerned. Nurses can help in a number of ways. Perhaps the first and most important point is for nurses to be aware that those who have had GBS are few and far between, that most recover and that persistent optimism is valuable.In addition, however, it is important to really listen to GBS patients, whether in an acute stage, or throughout the rest of their lives. Their bodies and nervous systems have been affected, and they may well have quite unique problems and issues to face. As with other invisible disabilities, families, friends, neighbours, work mates, and even health care personnel, may ignore complaints. The continuing pains, aches and fatigue that those who have had the disease report are real, and should not be lightly dismissed or ignored. Individualised treatment plans and actions, careful, patient instruction about anatomical and physiological terminology as related to their case to help them communicate and make sense of the unusual sensations and deficits they may encounter, and empathy for these people will all prove helpful.
Further research can be of value to patients, families, and other caregivers, for not enough is known about recovery and rehabilitation from GBS. Certainly the long-term effects are not well understood, and need to be studied.
References
1) Steinberg, J. S. (1998) Guillain-Barre Syndrome: An overview for the layperson. Wynnewood, Pennsylvania: Guillain-Barre Syndrome Foundation International.
2) Parry, Gareth J. (2003a) Residual effects following Guillain-Barre. The Communicator, GBS Newsletter, Spring, 5-6.
3) Parry, Gareth J. (2003b) GBS and CIDP -- what's new? Proceedings: Inaugural Conference of the Guillain-Barre Syndrome Support Group New Zealand Trust, 24-27 April, ed Bob Stothart.
4) Bourke, C. (2003) Psycho-social aspects of GBS. Proceedings: Inaugural Conference of the Guillain-Barre Syndrome Support Group New Zealand Trust, 24-27 April, ed Bob Stothart.
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