Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Guillain-Barré Syndrome


Medical Codes

ICD-9-CM:
357.0 - Acute Infective Polyneuritis; Guillain-Barré Syndrome; Postinfection Polyneuritis

Related Terms

  • Acute Idiopathic Polyneuritis
  • Acute Idiopathic Polyradiculitis
  • Acute Infective Polyradiculitis
  • Acute Inflammatory Demyelinating Polyneuropathy
  • Acute Motor Axonal Neuropathy (AMAN)
  • Acute Motor-sensory Axonal Neuropathy (AMSAN)
  • Acute Panautonomic Neuropathy
  • GBS
  • Landry's Ascending Paralysis
  • Landry's Paralysis
  • Miller-Fisher Syndrome

Overview

Guillain-Barré syndrome (GBS) is an autoimmune inflammatory disease of the peripheral nervous system, affecting the nerves outside the brain and spinal cord. As the nerves become inflamed, movement (motor function), sensation (sensory function), and autonomic nervous system responses become dysfunctional. This syndrome is characterized by the rapid onset of weakness, sensory loss, and impairment of reflexes; often paralysis of the legs, arms, breathing muscles, and face develops in ascending order. Because it involves more than one nerve, it is considered a polyneuropathy.

In up to 90% of cases, GBS is the result of an autoimmune response to an infection. This triggers the individual's defense system of antibodies and white blood cells to attack the thin covering of the nerves (myelin sheath), resulting in demyelination and nervous system dysfunction (acute inflammatory demyelinating polyneuropathy [AIDP]) (Miller). A respiratory or gastrointestinal infection typically precedes the symptoms by 1 to 3 weeks (Davids). Studies show that Campylobacter jejuni is the causative organism in 70% to 75% of individuals with GBS (Miller). Other, less frequent preceding events or illnesses include surgical procedures, viral infections (e.g., cytomegalovirus, Epstein-Barr, and HIV), other bacterial infections (e.g., Haemophilus influenzae, Mycoplasma pneumoniae), exposure to thrombolytic agents, or lymphoma (Hodgkin's disease). Vaccinations have also been associated with GBS.

Acute motor axonal neuropathy (AMAN) is a subtype of GBS in which only motor function is affected; this subtype occurs more often in children than in adults. Another subtype, acute motor-sensory axonal neuropathy (AMSAN) affects the sensory nerves and roots, as well as motor function, and occurs primarily in adults; it is noted for severe muscle wasting and limited recovery.

Miller-Fisher syndrome (MFS) is a variation of GBS that begins with paralysis of the eye muscles (ophthalmoplegia), followed by reduced muscle coordination (ataxia) and absence of reflexes (areflexia). Other symptoms are similar to GBS and may include facial palsy. MFS is rare.

The rarest form of GBS, acute panautonomic neuropathy, affects the sympathetic and parasympathetic nervous systems and may result in life-threatening cardiovascular dysrhythmias along with more classic sensory symptoms.

Incidence and Prevalence: The annual incidence of GBS in the United States is 3 cases per 100,000 population (Davids). Incidence increases to 8.6 cases per 100,000 with increasing age, peaking at 70 to 79 years (Davids).

International incidence is similar to that in the United States (Davids). In China, Japan, and Mexico, AMAN and AMSAN represent 5% to 10% of GBS cases; AIDP is the GBS form in up to 90% of cases in Western Europe, North America, Australia, and other industrialized countries (Miller).

Source: Medical Disability Advisor



Diagnosis

History: Guillain-Barré syndrome is easily recognized. Tingling and burning sensations (paresthesias) and numbness are frequently reported by individuals, although these symptoms may be absent in a few cases. Most individuals report progressive weakness, starting in the limb muscles farthest from the point of origin (distal); it generally develops in the legs before the arms or the trunk and spreads to the neck and cranial muscles later. The weakness can progress to total motor paralysis, and occurs over days to weeks with peak deficits reached by 4 weeks (Davids). More than 50% of individuals report more severe muscle pain and aching at night, especially in the shoulder girdle, hips, posterior thighs, and back. Occasionally facial, eye (ocular), or throat (oropharyngeal) muscles are affected. Individuals may report difficulty swallowing (dysphagia), visual disturbances, or speech impairment (dysarthria). A recent history of respiratory or gastrointestinal infection may be reported. A complete history of illnesses, surgeries, immunizations, and medications will be obtained.

Physical exam: Initially reflexes are reduced, and may eventually become absent. In rare cases, only the ankle reflexes are lost during the first week of the illness. The classic weakness affects both sides of the body (symmetrical), ascending from lower limbs to upper body and head (cranium). In the early stage, arm muscles will be less weak than the leg muscles, or they may be spared entirely. Disturbances of the autonomic (functionally independent) nervous system, including facial flushing, rapid heartbeat (tachycardia), alternating high blood pressure (hypertension) and low blood pressure (hypotension), and either loss of sweating or profuse sweating (diaphoresis), are commonly found but usually do not persist longer than a week or two. Urinary retention and cardiac arrhythmias may be seen in rare cases. Cranial nerve involvement is present in 45% to75% of individuals (Davids). In rare instances, the only observable symptom will be eye muscle paralysis (ophthalmoplegia). Pain described by the patient does not always correlate with the degree of nerve dysfunction seen.

Tests: A complete blood count (CBC) may reveal an elevated white blood cell count (WBC). Electrolyte levels may be measured, and liver function tests may be done. Creatinine phosphokinase (CPK) and erythrocyte sedimentation rate (ESR) may be done to evaluate inflammation. Recent bacterial or viral infection is usually resolved by the time of GBS symptom onset, but precursor viral infections (e.g., Epstein-Barr, herpes simplex, and HIV) may be documented by blood tests if necessary.

Electrodiagnostic tests, including electromyography (EMG) and nerve conduction velocity (NCV), that demonstrate significantly slowed or blocked impulses support the diagnosis. Slowed F-wave responses are the first abnormality chronologically found in NCV testing. Otherwise, NCV tests may be normal for 2 to 3 weeks. Nerve conduction velocity tests show sensory abnormalities in 58% to 76% of individuals with GBS (Davids). A lumbar puncture may be performed in order to analyze cerebral spinal fluid (CSF). Elevated protein in the CSF is seen in most individuals but may be normal the first few days after onset. The CSF cell count is usually normal. A muscle biopsy may be needed in some cases to differentiate suspected GBS from myopathy. Heart irregularities may be evaluated by electrocardiogram.

Source: Medical Disability Advisor



Treatment

Because progression of this disease in its early stages is unpredictable, most individuals are initially hospitalized in an intensive care unit (ICU) so breathing and other body functions can be monitored. The treatment for acute, severe cases of GBS is respiratory assistance and careful nursing care. Approximately one-third of individuals may require a respirator (ventilation) for breathing (Davids). Individuals with swallowing weakness (dysphagia) may require intubation to prevent aspiration of food particles. Other major components of therapy include support of blood pressure by volume infusion, administration of medication to manage low blood pressure, and prevention of sodium, potassium, and chloride (electrolyte) imbalance. Only extreme cases of high blood pressure (hypertension) require treatment with antihypertensive agents.

Both blood plasma exchange (plasmapheresis or PE therapy) and intravenous (IV) administration of immunoglobulin (immune serum globulin or IVIG) may be used to treat severe cases. In plasmapheresis, blood is withdrawn and the plasma is removed and replaced with fresh frozen plasma or albumin. IVIG is as effective as plasma exchange; it is also safer and more immediately available (Miller). There is no additional benefit from using both IV immunoglobulin infusion and plasmapheresis together (Davids).

Physical therapy should be started as soon as the individual is able to tolerate it to reduce recovery time.

Source: Medical Disability Advisor



Prognosis

Between 50% and 95% of individuals completely recover from the condition, 10% to 40% have permanent neurological sequels, and between 5% and 10% do not survive the illness (Miller). Individuals who recover completely either have no residual effects or show mild motor deficits in the legs or feet. Of those individuals who recover with severe residual effects, most had either a severe form of the disease with more rapid symptom progression, more widespread nerve damage, advanced age, or required prolonged mechanical ventilation (Miller). In the early stages, death is often due to cardiac arrest, but later in the illness, pulmonary embolism and other complications, such as infection, are the main causes.

Recovery usually occurs within a few weeks or months, unless there is severe nerve damage; then it takes 6 to 18 months to regenerate the nerves. Older individuals recover more slowly than younger ones and are more likely to have residual weakness. Individuals who have pronounced sensory loss and imbalance are likely to have these difficulties indefinitely. About 5% to 9% of individuals will experience one or more recurrences of polyneuropathy. In these cases, the nerves may become enlarged, and the neuropathy may become chronic; this should be distinguished from acute GBS.

Source: Medical Disability Advisor



Differential Diagnosis

  • Acute alcoholic neuropathy
  • Acute myasthenia gravis
  • Acute myelopathy (e.g., compression, vascular injury)
  • Acute pandysautonomia
  • Acute polyneuropathy
  • Acute presentation of chronic demyelinating polyradiculopathy
  • Acute spinal cord disease
  • Acute transverse myelopathy
  • Basilar artery thrombosis or embolism
  • Botulism poisoning
  • Diphtheria
  • Heavy metal intoxication
  • Hexacarbon abuse
  • Hysterical paralysis
  • Locked-in syndrome
  • Neoplastic meningitis
  • Neuromuscular junction disease
  • Paralytic shellfish poisoning
  • Periodic paralysis
  • Poliomyelitis
  • Polymyositis
  • Saxitoxin poisoning
  • Tick paralysis
  • Vasculitic neuropathy
  • West Nile virus

Source: Medical Disability Advisor



Specialists

  • Clinical Psychologist
  • Neurologist
  • Physical Therapist
  • Psychiatrist
  • Pulmonologist

Source: Medical Disability Advisor



Rehabilitation

Individuals with GBS may require respiratory, speech, physical, and occupational therapy, depending upon the extent of disability. Individuals may also require psychological counseling to help cope with the recent onset of disability and to maintain motivation for rehabilitation.

Inpatient respiratory therapy may be required if the individual presents with weakness of the diaphragm and the muscles of the ribcage (intercostal muscles). Respiratory therapists teach individuals to use an incentive spirometer to help support respiration and decrease the risk of pulmonary complications, and instruct in how to produce an effective cough to prevent the build- up of secretions in the lungs. For individuals who have severely weakened respiratory muscles, a ventilator may be temporarily required.

Individuals require inpatient speech therapy if they are on a ventilator. Speech therapists can supply the individual with a communication board so that they are able to maintain contact with their family and health care professionals. When the ventilator is no longer needed, speech therapists help individuals learn how to strengthen swallowing muscles.

Individuals require physical and occupational therapy on an inpatient as well as an outpatient basis. Rehabilitation needs vary among individuals, as do rehabilitation treatments. Initially, therapy goals are more supportive than rehabilitative. Occupational and physical therapists focus on preventing joint contractures through passive and active range of motion exercises to all joints. All active range of motion exercises should be performed without compromising endurance to prevent further damage to the nervous system. Additionally, therapists work with individuals, their families, and the nurses to initiate a turning and positioning schedule for the prevention of pressure sores (decubitus ulcers).

Once individuals are stabilized and function has begun to return, inpatient rehabilitation can begin. Individuals begin a submaximal strengthening program in occupational and physical therapy for the arms, legs, and trunk to maintain functional abilities, and progress to functional strengthening to support transfer ability and later gait retraining. All strengthening exercises are performed to the individual's tolerance to prevent fatigue.

Individuals may have impaired coordination. Occupational therapists instruct individuals to perform fine motor coordination exercises, self-care activities, and community reintegration tasks. Physical therapists instruct individuals in gross motor coordination and proprioceptive tasks. In both physical and occupational therapy, individuals work on static and dynamic sitting and standing balance. Physical therapists also begin gait retraining once the individual becomes stronger, first using the parallel bars and then progressing to independent ambulation as able.

The main focus of physical and occupational therapy is to maximize functional capabilities. Occupational therapists teach individuals skills such as getting in and out of the shower, dressing, and preparing meals, and may order adaptive equipment or braces to make these tasks easier. Physical therapists teach skills such bed mobility, transfers, walking, or using a wheelchair if needed; they may order assistive devices such as crutches or a cane or self-propelled or power wheelchairs if necessary, and may also refer an individual to an orthotist if leg braces are deemed appropriate.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Complications include infections of the urinary tract (UTI) or skin (cellulitis), blood clots in the lungs (pulmonary embolism), partial or complete collapse of a lung (atelectasis), respiratory infection from inhaled food particles (aspiration pneumonia), tracheal erosion, increased intracranial pressure, and psychological stress. Use of immune serum globulin (IVIG) therapy carries the risk of migraine, aseptic meningitis, hives, and blood clot formation if IgA levels are increased; IgA levels must be checked before administration of immunoglobulin (Miller).

Source: Medical Disability Advisor



Factors Influencing Duration

The severity of respiratory symptoms, degree of muscle paralysis, presence of cardiac arrhythmias, unstable blood pressure (hypo- or hypertension), and presence of other peripheral nerve diseases (neuropathies) will influence the length of the disability. Most individuals recover fully within six months. The length of disability depends on the job requirements, particularly whether or not heavy work needs to be performed. If the individual recovers completely or nearly completely, light to moderate work may be done, depending on the presence or degree of motor deficits in the arms, hands, feet, or legs.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Extended leave from work may be required for individuals with respiratory complications or severe residual effects from the condition (e.g., permanent paralysis), or for those who need physical therapy during recovery. Even for those who recover with few residual side effects, work duties requiring minimal physical activity and mobility may be necessary for a while.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Were other neuropathies and spinal cord diseases (other types of acute polyneuropathy, acute spinal cord disease, acute myasthenia gravis, tick paralysis, hexacarbon abuse, acute alcoholic neuropathy, basilar artery thrombosis or embolism, neuromuscular junction disease, "locked-in" syndrome, chronic demyelinating polyradiculopathy with acute presentation, acute pandysautonomia, acute transverse myelopathy, botulism poisoning, poliomyelitis, saxitoxin poisoning, diphtheria, and heavy metal intoxication) ruled out?
  • Has diagnosis of GBS been confirmed? Based on what criteria?
  • Has individual experienced any complications such as urinary tract infection or cellulitis, pulmonary embolism, atelectasis, respiratory infection (i.e., aspiration pneumonia), tracheal erosion, increased intracranial pressure, or psychological stress?
  • Does individual have cardiac arrhythmias? Hypo- or hypertension?
  • Does individual have an underlying condition, such as peripheral neuropathies, that may affect recovery?

Regarding treatment:

  • Did individual require mechanical ventilation or intubation? For what period of time?
  • Has independent function been restored?
  • Were therapies such as plasma exchange or IV immunoglobulin infusion utilized? With what result?
  • Was physical therapy initiated at the appropriate time?
  • Would individual benefit from additional rehabilitation?

Regarding prognosis:

  • How old is individual?
  • How long has GBS been present?
  • Have more than 18 months elapsed?
  • Have sensory loss and imbalance resolved to any degree during that time?
  • Has condition responded to treatment?
  • Have complications developed?
  • Does individual have residual impairment? To what degree is function impaired?
  • Has individual experienced recurrence of polyneuropathy?
  • Has individual experienced a relapse?

Source: Medical Disability Advisor



References

Cited

Davids, Heather Rachel, Joyce L. Oleszek, and Angela Cha-Kim. "Guillain-Barré Syndrome." eMedicine. Eds. Daniel D. Scott, et al. 14 Jan. 2008. Medscape. 6 Jul. 2009 <http://emedicine.medscape.com/article/315632-overview>.

Miller, Andrew, Razi M. Rashid, and Richard H. Sinert. "Guillain-Barré Syndrome." eMedicine. Eds. Edward A. Michelson, et al. 19 Dec. 2007. Medscape. 5 Jul. 2009 <http://emedicine.medscape.com/article/792008-overview>.

Ramachandran, Tarakad S., and Richard A. Sater. "Acute Inflammatory Demyelinating Polyradiculoneuropathy." eMedicine. Eds. Donald B. Sanders, et al. 15 Jan. 2009. Medscape. 6 Jul. 2009 <http://emedicine.medscape.com/article/1169959-overview>.

Source: Medical Disability Advisor