Rehabilitation in Guillain–Barré Syndrome: From Intensive Care to Functional Recovery

Rehabilitation in Guillain–Barré syndrome should start early and continue across all phases of care. Individualised, multimodal programmes including respiratory therapy, mobilisation, strengthening, and fatigue management improve functional recovery, independence, and quality of life, despite limited high-quality evidence.

Introduction

Guillain–Barré syndrome (GBS) is an acute immune-mediated inflammatory polyradiculoneuropathy of the peripheral nervous system and represents the most common cause of acute flaccid paralysis worldwide. The global incidence is estimated at 0.8 to 1.9 cases per 100,000 person-years, with a higher frequency in males and older individuals, although it can occur at any stage of life.

The clinical course is typically characterised by progressive ascending weakness, areflexia, variable sensory disturbances, and, in a proportion of patients, respiratory involvement and autonomic dysfunction. The progression is usually rapid, and most patients reach the nadir within the first 2 weeks, followed by a plateau phase and, subsequently, a recovery phase that may extend over months or even years.

Despite advances in immunological treatment and critical care support, GBS remains associated with a substantial burden of morbidity: approximately 20–30% of patients require mechanical ventilation during the acute phase, mortality remains between 3% and 10% even with optimal care, and 10–20% experience significant long-term residual disability (Leonhard et al. 2019; Guidon and Amato 2020; Lawn et al. 2001).

Although 60–80% of patients are able to walk independently at 6 months, neurological recovery does not necessarily equate to full functional recovery. Sequelae such as residual weakness, persistent fatigue, neuropathic pain, swallowing disorders, physical deconditioning, and limitations in activities and social participation are common (Leonhard et al. 2019; Shahrizaila et al. 2021; Kiper et al. 2025; Mudge et al. 2025). This has progressively shifted the focus from survival and immunological treatment towards functional recovery and prolonged rehabilitation (Simatos Arsenault et al. 2016; Sulli et al. 2021; Kiper et al. 2025).

In this context, rehabilitation should be understood as a continuous, staged, and individualised process that begins in the critical phase and extends to functional, occupational, and social reintegration. However, the literature specifically addressing rehabilitation in GBS remains more limited than diagnostic or immunological literature, and many recommendations are derived from small studies, systematic reviews with methodological heterogeneity, and extrapolation from critically ill populations and other neuromuscular disorders (Sulli et al. 2021; Kiper et al. 2025; Simatos Arsenault et al. 2016).

This review aims to synthesise the best available evidence on rehabilitation in Guillain–Barré syndrome across the entire continuum of care, from the critically ill patient in the Intensive Care Unit (ICU) to long-term functional recovery, with emphasis on mechanical ventilation, respiratory physiotherapy, early mobilisation, therapeutic exercise, fatigue, dysphagia, and functional outcomes.

Pathophysiological Basis of Guillain–Barré Syndrome, Treatment and Complications 

GBS is an acute inflammatory polyradiculoneuropathy mediated by immune mechanisms that affects nerve roots and peripheral nerves, and is clinically characterised by progressive flaccid weakness, hyporeflexia or areflexia, variable sensory disturbances, and autonomic involvement. The disease typically follows a triphasic course consisting of a rapid progression phase, a plateau phase, and a recovery phase. Although it is a monophasic condition in most cases, clinical recovery is heterogeneous and may extend over months or years (Leonhard et al. 2019).

Pathophysiology 

Guillain–Barré syndrome is triggered by infectious processes, vaccines, or drugs that present epitopes similar to peripheral neuronal gangliosides. This leads to the production of anti-ganglioside antibodies that target neural structures (Guidon and Amato 2020). In most cases, two-thirds of patients report gastrointestinal or respiratory symptoms 2 to 4 weeks prior to clinical onset (Meyer Sauteur et al. 2016). Campylobacter jejuni is the most extensively studied model: it induces antibodies against gangliosides that bind to the nodes of Ranvier, activate complement, and recruit macrophages, resulting in conduction block and axonal damage (Suh and Amato 2021).

Antigen-presenting cells (CD4+ T cells), through pathogen processing, activate B lymphocytes, transforming them into plasma cells that produce antibodies specific to ganglioside antigens, which act at the nodes of Ranvier of Schwann cells (Shang et al. 2021).

Complement-fixing anti-ganglioside antibodies are predominantly of the IgG1 and IgG3 subclasses and primarily bind to GM1 and GD1a gangliosides, inducing axonal injury through complement fixation, macrophage recruitment, and deposition of the membrane attack complex on the axolemmal membrane (Jacobs et al. 2008; McGonigal et al. 2010).

The binding of antibodies to gangliosides causes displacement of voltage-gated sodium channels, disrupting sodium channel clustering and axoglial junctions, ultimately leading to nerve conduction failure. A similar model has been proposed for Miller Fisher syndrome associated with anti-GQ1b antibodies, in which the GQ1b ganglioside is the antigenic target and is located in the motor nerves of the extraocular muscles (McGonigal et al. 2023; Kuwabara and Yuki 2013; Liu et al. 2009).

From a rehabilitation perspective, the type of injury is a key determinant: in axonal variants such as AMAN or AMSAN, recovery is usually slower and there is a higher risk of prolonged weakness, which requires longer rehabilitation programmes, aggressive prevention of complications, and more conservative dosing at the beginning. Dysautonomia, including heart rate and blood pressure lability, arrhythmias, ileus, and urinary retention, is an inherent component of the condition and directly affects the safety of mobilisation and training (Willison et al. 2016).

Clinical presentation 

The typical presentation is characterised by progressive ascending flaccid weakness of the lower limbs associated with hyporeflexia. Miller Fisher syndrome is a variant that presents with hyporeflexia, bilateral ophthalmoplegia, and ataxia (Shahrizaila et al. 2021). Atypical presentations may also occur; weakness and sensory disturbances can be asymmetric or predominantly proximal or distal and may begin in the upper limbs or simultaneously in all extremities (Willison et al. 2016).

The 2019 guideline describes the main clinical patterns and their frequency of presentation: Classic sensorimotor (30–85%) with symmetric weakness and hyporeflexia. Pure motor (5–70%) with motor weakness without sensory signs. Paraparesis (5–10%) with weakness limited to the legs. Pharyngeal–cervical–brachial variant (<5%) with weakness of the pharyngeal, cervical, and brachial muscles without lower limb involvement. Bilateral facial paralysis with paraesthesias (<5%) with bilateral facial weakness, paraesthesias, and reduced reflexes. Pure sensory (<1%) with acute or subacute sensory neuropathy without other deficits. Miller Fisher syndrome (5–25%) with ophthalmoplegia, ataxia, and areflexia. Bickerstaff brainstem encephalitis (<5%) with ophthalmoplegia, ataxia, areflexia, pyramidal tract signs, and altered consciousness, often overlapping with classic sensorimotor GBS (Leonhard et al. 2019).

Diagnosis 

The 2023 guidelines from the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) establish the following criteria for the diagnosis of GBS:

Essential criteria:

1. Progressive weakness of the upper and lower limbs.
2. Areflexia or hyporeflexia.
3. Progression of clinical worsening not exceeding 4 weeks.

Supportive clinical features:

4. Symmetric neuropathy.
5. Cranial nerve involvement, especially bilateral facial paralysis.
6. Respiratory failure.
7. Autonomic dysfunction.
8. Recent gastrointestinal or respiratory infection within the previous 6 weeks.
9. Back pain, either interscapular or radicular.

Supportive diagnostic findings:

1. Albuminocytologic dissociation in cerebrospinal fluid.
2. Electrophysiological studies confirming peripheral neuropathy. Electromyography and nerve conduction studies help classify subtypes such as AIDP, AMAN, and AMSAN.

To stratify the risk of respiratory failure, the 2019 guideline recommends tools such as EGRIS, which estimates the risk of requiring mechanical ventilation within one week, and for functional prognosis, scales such as mEGOS. In rehabilitation, these tools are useful to define the timing of ICU admission, the intensity of monitoring, respiratory priorities, and communication of prognosis to the patient and family (van Doorn et al. 2023).

Medical management 

Disease-modifying therapies in GBS include intravenous immunoglobulin (IVIg) and plasma exchange (PLEX) (Bellanti and Rinaldi 2024). IVIg should be administered within 2 weeks and PLEX within 4 weeks from the onset of weakness. The standard dose of IVIg is 0.4 g/kg for 5 days, and PLEX consists of 200–250 mL of plasma/kg body weight over five sessions (Leonhard et al. 2019).

The EAN/PNS specifically recommends the standard IVIg regimen of 0.4 g/kg/day for 5 days over shorter 3-day courses, longer 6-day regimens, or the 2-day regimen of 1 g/kg/day (van Doorn et al. 2023). Regarding a second course of IVIg in patients with poor prognosis, the SID-GBS trial, a double-blind, randomised, placebo-controlled study, showed that patients receiving a second dose had a higher rate of adverse events (35% vs. 16% within the first 30 days), including more thromboembolic events, without clear additional functional benefit (Walgaard et al. 2021).

Treatment with PLEX followed immediately by IVIg is not recommended compared with either therapy alone (Willison et al. 2016). Likewise, corticosteroids, whether oral or intravenous, alone or in combination with IVIg, are not recommended for the treatment of GBS (van Doorn et al. 2023).

Respiratory involvement and mechanical ventilation 

Respiratory failure is one of the most severe complications of GBS and a major determinant of ICU admission. Approximately 20–30% of patients require mechanical ventilation, mainly due to diaphragmatic paralysis, weakness of accessory respiratory muscles, and bulbar dysfunction compromising airway protection. Respiratory failure may develop even in the absence of overt dyspnoea, making serial monitoring of respiratory function essential (Leonhard et al. 2019; Ali et al. 2006; Lawn et al. 2001).

The decision to intubate should be based on both clinical and physiological criteria. Commonly used thresholds include a vital capacity of less than 15–20 mL/kg, a maximal inspiratory pressure below 30 cmH₂O, a maximal expiratory pressure below 40 cmH₂O, or a decline greater than 30% in vital capacity or maximal respiratory pressures. Clinical signs such as respiratory fatigue, use of accessory muscles, inability to manage secretions, and bulbar weakness with risk of aspiration should also be considered.

Elective intubation is generally preferable to emergency intubation, as it reduces the risk of severe hypoxaemia and secondary complications (Lawn et al. 2001; Wijdicks et al. 2003; Paul et al. 2012).

Several clinical predictors have been associated with a higher likelihood of requiring mechanical ventilation. These include bulbar weakness, neck weakness, bilateral facial paralysis, rapid progression to maximal disability, muscle strength less than 3 out of 5 in the upper limbs, and simultaneous involvement of both upper and lower extremities. These factors are relevant not only for critical care decision-making but also for anticipating respiratory rehabilitation needs, guiding communication with the family, and planning continuity of care (Umer et al. 2019; Lawn et al. 2001; Paul et al. 2012).

Mechanical ventilation in GBS is often prolonged. In a classic cohort, ventilator-associated pneumonia was reported in up to 56% of ventilated patients, atelectasis in 49%, and acute lung injury in 13%, findings closely related to the duration of ventilatory support, respiratory muscle weakness, and difficulty in secretion clearance (Ali et al. 2006; Yonezawa et al. 2020). Many patients eventually require tracheostomy after one to two weeks of ventilation; however, in a national observational study, early tracheostomy did not show a significant reduction in mortality compared with a delayed strategy (Yonezawa et al. 2020).

Unlike other causes of respiratory failure in the ICU, patients with GBS typically remain conscious, and the need for sedation depends more on ventilator tolerance and invasive procedures than on the neurological condition itself (Pham et al. 2023). This has direct implications for rehabilitation, as in many cases early mobilisation and functional participation can be initiated sooner than is conventionally assumed.

Rehabilitation in Guillain–Barré Syndrome 

Rehabilitation in Guillain–Barré syndrome should be initiated early and maintained throughout the different phases of recovery, with the aim of preventing complications related to immobilisation and mechanical ventilation, while facilitating neuromuscular and functional recovery. Although the available evidence remains heterogeneous and largely derived from small studies, it consistently supports the use of supervised, progressive, and individualised interventions targeting strength, mobility, respiratory function, and overall functional capacity (Sulli et al. 2021; Kiper et al. 2025; Shah et al. 2022). Although evidence specifically addressing rehabilitation in GBS remains limited, available studies consistently suggest therapeutic exercise, functional training, respiratory physiotherapy, and individualised programmes appear to be associated with improvements in strength, physical capacity, independence, and fatigue, although the certainty of evidence remains limited, particularly when applied in a supervised and progressive manner (Shang et al. 2021). The challenge does not lie in demonstrating that rehabilitation is beneficial, but rather in defining the optimal dose, timing, intensity, and the subgroups that derive the greatest benefit.

Acute phase (ICU): survival, prevention of complications, and preparation for recovery 

In the acute phase, the priority is survival and the prevention of complications associated with immobilisation, mechanical ventilation, and dysautonomia. From a rehabilitation perspective, the main objectives are to preserve range of motion, prevent neurologically mediated contractures and compression neuropathies, reduce atelectasis, facilitate secretion management, maintain patient interaction with the environment, encourage family involvement, and initiate early mobilisation when haemodynamic and respiratory stability allow (Leonhard et al. 2019; McGonigal et al. 2023; Kuwabara and Yuki 2013).

Although there are few specific trials on early mobilisation in GBS, the ABCDEF or ICU Liberation bundle provides a useful framework for these patients, particularly because they share risks with other critically ill populations such as prolonged immobilisation, delirium, prolonged ventilation, and ICU-acquired weakness. The bundle integrates adequate analgesia, sedation minimisation, delirium assessment and prevention, early mobilisation, and family engagement. Systematic reviews have shown an association between implementation of the ABCDE or ABCDEF bundles and improved outcomes, particularly reduced delirium and potential improvements in functionality and quality of life, although the overall certainty remains limited due to methodological heterogeneity (Society of Critical Care Medicine n.d.; da Silva Moraes et al. 2022; Sosnowski et al. 2023).

In patients with severe GBS, respiratory physiotherapy is central. It should include positioning, lung expansion techniques, airway clearance strategies, cough training when feasible, and monitoring of inspiratory function (Leonhard et al. 2019; McGonigal et al. 2023). Inspiratory muscle training is particularly relevant in this population. In a randomised controlled trial of mechanically ventilated patients with GBS, inspiratory muscle training using a threshold device was associated with improvement in weaning-related variables (Tonella et al. 2017). More recently, the InspireGBs study, a feasibility investigation in individuals with GBS, demonstrated high adherence at 96%, no adverse events, and a significant improvement in maximal inspiratory pressure after 6 weeks of training, supporting its safety and clinical feasibility. Although this study is not a randomised controlled trial, it reinforces the clinical plausibility of inspiratory muscle training as an adjunct in respiratory recovery (Almeida et al. 2025).

Extrapolation from other neuromuscular diseases is also informative. A systematic review and meta-analysis in neuromuscular disorders showed that respiratory muscle training improves forced vital capacity, maximal inspiratory pressure, and maximal expiratory pressure, although with substantial heterogeneity and no clear impact on quality of life or overall physical capacity (Watson et al. 2022). In GBS, this evidence does not replace direct evidence but supports the cautious and progressive use of inspiratory muscle training when the patient is clinically stable.

In addition to respiratory management, clinical experience and case reports suggest that even patients requiring prolonged mechanical ventilation may benefit from more active functional strategies once critical instability has resolved. Successful cases of ventilator weaning and functional recovery have been described in association with inspiratory muscle training guided by inspiratory indices and progressive ambulation programmes in ventilated patients with severe GBS (Sosnowski et al. 2023; Tonella et al. 2017; de Souza et al. 2018). Although the level of evidence is low, these reports are valuable because they demonstrate feasibility and open the door to more ambitious rehabilitation programmes in patients traditionally considered too severe for meaningful mobilisation.

Recent interventional evidence, although largely derived from small studies and case reports, provides more granular insights into how rehabilitation can be operationalised in critically ill patients with GBS. Multimodal programmes that combine early mobilisation, respiratory physiotherapy, neuromuscular stimulation, and structured positioning appear to reduce complications and accelerate recovery trajectories.

An optimised rehabilitation programme incorporating early mobilisation, assisted exercise (including cycle ergometry), and multidisciplinary care was associated with reduced adverse events and shorter rehabilitation duration, alongside improvements in functional outcomes such as MRC and Barthel Index scores (Feng and Li 2025). These findings suggest that even in critically ill neurological populations, rehabilitation should not be delayed until neurological recovery but rather initiated as a parallel therapeutic axis.

Case-based evidence further supports the feasibility of integrating respiratory, swallowing, and physical rehabilitation even in complex presentations. Multimodal approaches combining respiratory therapy, dysphagia management, and progressive mobilisation have demonstrated improvements in ventilator independence, reduction in aspiration risk, and recovery of muscle strength (Luo et al. 2025). Similarly, combined respiratory physiotherapy, neuromuscular facilitation techniques, and electrical stimulation have been associated with meaningful improvements in strength and functional independence (Gawande et al. 2024).

Although these studies are limited by design, they converge on a clinically relevant principle: rehabilitation in the ICU should be proactive, combined, and initiated before full neurological recovery, rather than postponed until stability is achieved.

Subacute phase (hospital): early motor recovery and basic autonomy 

During the subacute hospital phase, rehabilitation becomes more structured and function oriented. Emerging evidence from interventional and quasi-experimental studies suggests that programmes integrating progressive strengthening, functional training, and aerobic conditioning can produce measurable improvements in functional recovery and quality of life.

A quasi-experimental study demonstrated that a nurse-led rehabilitation programme combining exercise and psychosocial support significantly improved quality of life and reduced functional impairment (Tabbasum et al. 2025), highlighting the importance of multidisciplinary approaches beyond purely physical interventions.

Randomised evidence also supports the role of targeted aerobic training. A personalised home-based aerobic programme combined with motivational coaching improved peak oxygen consumption, indicating that cardiorespiratory capacity is modifiable even after acute neurological injury (Oorschot et al. 2025).

Additionally, case reports consistently describe successful recovery trajectories using structured programmes that integrate proprioceptive neuromuscular facilitation, progressive strengthening, and task-specific training, with improvements in muscle strength, mobility, and independence (Yousef et al. 2025; Kachhwani et al. 2024; Kapre et al. 2022).

Taken together, these findings suggest that rehabilitation during the subacute phase should prioritise progressive loading, functional task practice, and interdisciplinary coordination, rather than passive recovery.

Once the critical phase has been overcome, rehabilitation enters a more active stage focused on motor recovery, physical reconditioning, and basic autonomy. The focus shifts from prevention of complications to functional reconstruction, including sitting, transfers, standing, gait, balance, postural control, and basic activities of daily living (Leonhard et al. 2019; Walgaard et al. 2021; Sulli et al. 2021; Kiper et al. 2025; Shah et al. 2022).

A systematic review identified seven studies on exercise in Guillain–Barré syndrome (GBS) and found a favourable signal in functional mobility, muscle strength, cardiopulmonary function, work rate, and fatigue; however, it highlighted the overall low quality of evidence and the inability to draw firm conclusions due to heterogeneity in study designs and outcomes (Simatos Arsenault et al., 2016). Nevertheless, this work remains a key reference, as it demonstrates that physical rehabilitation in GBS is not merely a theoretical extrapolation but a field in which positive clinical outcomes have been consistently observed.

Another systematic review of randomised trials was more restrictive and identified only three randomised controlled trials, concluding that rehabilitation appears to reduce disability and improve recovery, although the experimental evidence base remains limited (Sulli et al. 2021). This requires a critical interpretation: there is a favourable therapeutic signal, but methodological robustness is still insufficient to define a universal protocol.

The components of successful programmes are relatively consistent and include progressive strengthening, task-oriented functional training, gait training, balance exercises, and low- to moderate-intensity endurance training (Sulli et al. 2021; Kiper et al. 2025). A scoping review that included 16 studies showed that exercise programmes can improve strength, functional independence, and fatigue, with the most common interventions being strengthening, functional training, and endurance exercises. The authors also emphasised the need for larger and higher-quality studies, as well as a deeper understanding of the mechanisms underlying chronic post-GBS fatigue (Kiper et al. 2025).

More recent case reports, although representing a low level of evidence, also suggest that structured programmes lasting 4 to 15 weeks based on progressive resistance, trunk control, functional re-education, gait training, and goal-oriented activities can achieve meaningful improvements in independence, balance, and motor function (Almeida et al. 2025; Nagatomo et al. 2019). This is relevant for clinical practice because it demonstrates the feasibility of intensive and individualised programmes even outside large research centres.

Outpatient phase and long-term recovery 

In the chronic and outpatient phases, rehabilitation plays a decisive role in determining long-term functional outcomes. Evidence from prospective studies and long-term follow-up reports indicates that intensive and sustained rehabilitation programmes can lead to significant improvements in functional independence, mobility, and physical capacity.

A prospective study evaluating intensive neurological rehabilitation demonstrated significant improvements in functional scales such as FIM, MRC, and 6-minute walk test, although persistent fatigue remained a common long-term limitation (Uz et al. 2023). This reinforces the concept that functional recovery and symptom resolution may follow different trajectories.

Similarly, case-based evidence shows that intensive rehabilitation combined with occupational therapy can improve gait capacity, balance, and walking speed, even in post-acute or complex cases (Colonna et al. 2021).

Targeted interventions may also address specific complications. For instance, pharyngeal electrical stimulation has been successfully used to improve swallowing function and facilitate decannulation in patients with severe bulbar involvement (Beirer et al. 2020).

Overall, these findings support a model of prolonged, individualised rehabilitation in which intensity, specificity, and multidisciplinary input are key determinants of long-term recovery.

The outpatient phase should not be understood as a simple continuation of what was done in the hospital. In many patients, this phase determines the difference between survival with sequelae and functional reintegration. Although a large proportion regain independent walking at 6 months, a significant subgroup continues to experience weakness, exercise intolerance, pain, fatigue, and participation restrictions months or years later (Leonhard et al. 2019; Lawn et al. 2001; Paul et al. 2012; Wijdicks et al. 2003; Yonezawa et al. 2020; Shang et al. 2021).

Functional recovery may continue beyond the first year. In a chronic cohort of individuals with GBS, a high-intensity multidisciplinary outpatient programme conducted over 12 months reduced disability more than a lower-intensity programme. In the intention-to-treat analysis, the high-intensity group showed functional improvement in FIM of 68% compared with 32% in the control group, with particular benefits in mobility, transfers, sphincter control, and locomotion (Khan et al. 2011). This trial is one of the most important studies on rehabilitation in GBS and has a clear clinical implication: even in chronic phases there is still room for improvement, and low intensity is not always sufficient.

More recently, a randomised trial compared supervised, individualised exercise with a non-supervised home-based programme in individuals with established residual disability at least 6 months after GBS onset. The supervised group performed 60-minute sessions, 2 to 3 times per week for 12 weeks, including strengthening, endurance training, respiratory exercises, gait training, and pain management. At 6 months, the supervised group showed a median between-group difference of 8 points in strength, a reduction of 13 points in fatigue, and improvement in the environmental domain of quality of life, along with a favourable trend in functional independence (Shah et al. 2022). This study is particularly valuable because it addresses a clinically relevant question: not only whether exercise is beneficial, but whether supervision and individualisation matter. The answer appears to be yes.

Even earlier studies suggest that supervised aerobic training can induce relevant physiological adaptations. In a classic case, 16 weeks of endurance training, three times per week, 30 minutes per session at 75–80% of peak heart rate, improved peak VO₂ by 9–11%, peak ventilation by 11–23%, total work capacity by 29%, and isokinetic strength of the lower limbs (Pitetti et al. 1993). Although this is a single case, it remains a useful reference because it demonstrates that the cardiorespiratory system in individuals with chronic GBS sequelae can respond to training.

Therapeutic exercise and how to integrate it 

The question is not whether exercise should be part of rehabilitation in GBS, but how to prescribe it in a safe and effective manner. The available literature suggests that the most reasonable programmes integrate four components: progressive strengthening, task-oriented functional training, aerobic endurance, and respiratory training when inspiratory involvement is present (Sulli et al. 2021; Kiper et al. 2025; Khan et al. 2011; Shah et al. 2022; Pitetti et al. 1993).

Strengthening should be progressive, monitored, and function-oriented, avoiding both underdosing and overload. Functional training should prioritise meaningful tasks such as rolling, transfers, sitting, sit-to-stand, gait, balance, and basic activities of daily living (Khan et al. 2011; Shah et al. 2022; Kiper et al. 2025). Aerobic endurance can be introduced through cycling, ergometry, walking, or equivalent activities, at low to moderate intensities with progression based on tolerance, symptoms, and recovery (Shah et al. 2022; Pitetti et al. 1993; Kiper et al. 2025). In patients with residual respiratory weakness, inspiratory muscle training may be added in a targeted manner (Willison et al. 2016; van Doorn et al. 2023; Bellanti and Rinaldi 2024).

There is no universally established ‘optimal dose’ for GBS, but the most consistent studies point towards structured and supervised programmes, performed two to five times per week, with gradual progression and strong individualisation according to clinical phase, fatigue, residual strength, pain, dysautonomia, and functional goals (Sulli et al. 2021; Shah et al. 2022; Kiper et al. 2025; Mudge et al. 2025) (Table 1).

Post-GBS fatigue 

Fatigue is one of the most prevalent and clinically relevant sequelae of GBS and may persist even when neurological strength improves (Leonhard et al. 2019; Shang et al. 2021). It has been reported that 60–80% of individuals with a history of GBS experience fatigue severe enough to limit daily function. This dissociation between motor recovery and persistent fatigue requires a shift in focus: it is not sufficient to measure strength alone; it is also necessary to assess exercise tolerance, post-activity recovery, participation, and perceived functional capacity.

The study by Mudge and colleagues is particularly important in this context. In a replicated single-case design involving eight individuals with GBS of more than 2 years’ duration and limiting fatigue, a personalised, activity-focused online programme reduced fatigue in most participants and improved activity levels, exercise confidence, and wellbeing in some cases. The clinical message is highly relevant: post-GBS fatigue does not always require more exercise, but rather better dosing, education, realistic goal setting, self-management, and careful grading of activity (Mudge et al. 2025).

Accordingly, rehabilitation of fatigue should integrate education on energy conservation, pacing strategies, gradual progression, analysis of the patient’s context, and continuous adjustment of load based on clinical response (Shah et al. 2022; Kiper et al. 2025; Mudge et al. 2025). The most common error is not under-stimulation, but the application of a linear training model to a neuromuscular system that is not yet able to tolerate such progression.

Dysphagia, bulbar involvement, and clinical implications 

Rehabilitation in GBS cannot be limited to the peripheral motor axis. Bulbar involvement and dysphagia have direct implications for safety, nutrition, aspiration risk, and functional trajectory (Leonhard et al. 2019; Mengi et al. 2017; Stathopoulos and Dalakas 2022). In a neurophysiological study of 18 patients with GBS not admitted to the ICU, clinical dysphagia was observed in seven patients, but five additional patients without clinical cranial nerve involvement presented subclinical dysphagia, suggesting that swallowing impairment may be underdiagnosed if only overt clinical signs are assessed (Mengi et al. 2017).

This finding is particularly relevant because it highlights the need to consider swallowing as an early rehabilitation target rather than a problem restricted to severe cases. Bulbar variants, pharyngeal–cervical–brachial presentations, Miller Fisher or Bickerstaff syndromes, and cases with bilateral facial paralysis require closer monitoring, compensatory strategies, instrumental assessment when indicated, and close coordination with speech and language therapy, nutrition, and medical teams (Leonhard et al. 2019; Mengi et al. 2017; Stathopoulos and Dalakas 2022).

Functional outcomes and long-term recovery 

From a clinical perspective, the outcomes that matter most to patients are not limited to survival or isolated muscle strength, but include functional independence, participation, quality of life, return to work, and reduction of persistent symptoms (Khan et al. 2011; Shah et al. 2022; Kiper et al. 2025; Uz et al. 2023; Mudge et al. 2025). The challenge is that many studies still rely on intermediate or heterogeneous outcomes, making it difficult to compare interventions.

Nevertheless, the literature allows for some reasonable conclusions. First, functional recovery remains possible over prolonged periods, even in chronic phases (Khan et al. 2011; Shah et al. 2022; Uz et al. 2023; Kiper et al. 2025; Yonezawa et al. 2020). Second, programmes with higher intensity and supervision appear to provide better outcomes than less structured or non-supervised programmes (Khan et al., 2011; Shah et al., 2022). Third, the benefits are not limited to strength or gait, but may also be observed in fatigue, quality of life, and perceived disability impact (Khan et al. 2011; Shah et al. 2022).

The most recent evidence suggests that physical exercise can improve strength, reduce fatigue, and promote functional independence in Guillain–Barré syndrome (GBS); however, larger and higher-quality studies are still needed to refine long-term rehabilitation strategies (Kiper et al., 2025). (Table 2). Figure 1 shows phase-based rehabilitation for patients with GBS.

Discussion 

The main strength of the recent literature lies not in its methodological robustness, but in the convergence of its findings. Notably, most clinical guidelines provide only general recommendations for rehabilitation without detailing specific interventions, dosing strategies, or progression criteria.

This gap may contribute to variability in clinical practice and underutilisation of rehabilitation strategies, particularly in the ICU setting. Despite methodological heterogeneity, the available literature consistently supports the feasibility and clinical relevance of rehabilitation interventions. However, the evidence is stronger in demonstrating that rehabilitation is necessary than in defining how it should be dosed, progressed, and tailored to specific patient subgroups (Willison et al. 2016; van Doorn et al. 2023; Bellanti and Rinaldi 2024; Sulli et al. 2021; Kiper et al. 2025; Shah et al. 2022; Khan et al. 2011; Almeida et al. 2025).

The main limitation remains the scarcity of large and comparative trials. Importantly, the challenge is no longer to demonstrate that rehabilitation is beneficial, but to define how it should be prescribed in a reproducible and clinically applicable manner. Much of current clinical practice is still based on indirect evidence, extrapolation from general ICU populations or other neuromuscular diseases, and small studies with significant heterogeneity (Liu et al. 2009; Shahrizaila et al. 2021; Willison et al. 2016; van Doorn et al. 2023; Bellanti and Rinaldi 2024; Walgaard et al. 2021; Sulli et al. 2021; Kiper et al. 2025; Shah et al. 2022).

This does not invalidate rehabilitation; rather, it calls for a more critical and less protocol-driven approach: fewer universal prescriptions and greater stratification based on severity, respiratory function, fatigue, recovery phase, clinical variant, and participation goals. Unlike previous guideline-based approaches that provide general recommendations, current evidence, despite its limitations, allows a more operational definition of rehabilitation in GBS, although important uncertainties remain regarding its implementation.

A key limitation across the literature is that most studies do not define clear dosing parameters, progression criteria, or patient stratification models. This limits the translation of findings into clinical practice and may contribute to variability in rehabilitation delivery. Furthermore, the predominance of small sample sizes, case reports, and heterogeneous outcome measures prevents the establishment of standardised protocols. As a result, current rehabilitation strategies in GBS remain largely guided by clinical reasoning rather than robust comparative evidence.

1. Acute phase in the ICU: Patient with severe weakness and possible need for mechanical ventilation. Priorities include life support, administration of immunotherapy such as intravenous immunoglobulin or plasma exchange, respiratory and haemodynamic monitoring, and prevention of complications associated with immobilisation. Early interventions such as passive mobilisation, positioning, and respiratory physiotherapy are initiated.

2. Early subacute phase in hospital: Initiation of active-assisted mobilisation and progression to sitting. Low-intensity strengthening exercises, postural control, active respiratory training, and basic functional participation are introduced with the aim of restoring initial motor control.

3. Advanced in-hospital rehabilitation phase: Progression to standing and structured functional training. This includes endurance exercises, progressive strengthening, gait re-education, and training in basic activities of daily living to improve functional independence.

4. Outpatient phase: Progressive functional recovery with assisted or independent gait. Aerobic exercise programmes, balance and coordination training, and reintegration into social and occupational activities are incorporated.

5. Functional reintegration phase: Advanced recovery with emphasis on higher-intensity structured exercise, aerobic training, and strengthening, aimed at optimising functional capacity, quality of life, and full participation in the community. Made with BioRender.com.

Conclusion 

Rehabilitation should be considered a core component of Guillain–Barré syndrome management from the acute phase onward. The available evidence supports the use of supervised, individualised, and progressive interventions targeting respiratory function, mobility, strength, and fatigue across the recovery continuum. However, significant uncertainties remain regarding optimal dosing, progression criteria, and patient stratification, underscoring the need for high-quality studies to better inform clinical practice. Future research should move beyond confirming the benefit of rehabilitation and focus on defining reproducible, stratified, and clinically actionable protocols. The integration of structured, phase-based rehabilitation models may represent a key step towards translating evidence into consistent clinical practice.

Acknowledgements

The authors thank Dr Silvia P. Ferro-García, Specialist in Rehabilitation Medicine.

Conflict of Interest

None.