Bell's palsy

[emmi]

Hi Ramywhite,

my patient with Bell's palsy had most of the functions impaired (frowning, closing eye, smiling and so on) and each of them was impaired severely though at different stages.

I trained the muscles involved with manual stretch and following active contraction, asking the patient to reproduce the function applying a degree of manual resistance depending on the stage the function was.

At the beginning I involved simmetrical contractions: if the muscle was responding nil or almost and no synkinesis were visible then I did hard stretches requiring hard contractions, of course only the healthy muscle responded. As soon as I saw some little contraction from the impaired muscle after some days, then I decreased the stretch so requiring a mild contraction to reflect a more "normal" simmetrical function by both muscles. As soon as the muscle got strong enough I increased again the difficulty of the exercise increasing again the stretch and so the resistance always in a simmetrical way.

All this had to consider also the degree of tireness of the patient as he was supposed to have treatment 5days p.w. (although he did 4). Treatment was half an hour active work. Number of contractions varied. I started with very few (sets of 5reps) as quality was more important, then I trained resistance increasing to 3 or 4 sets 10 or 15 depending on the patient mood. It's no use to get the patient very tired if you lose quality. Moreover, as I thought the patient was independent with some functions and with no risk of synkinesis, I required him to train in front of a mirror at home.

In case of synkinesis instead, I trained him with mild resistance stopping to the threshold of the wrong pattern. As soon as he was more confident and independent from the synkinesis I increased the job. For synkinesis, I found essential to touch (instead of just telling him) the muscles that are interferring during the exercise to make them relax, so the patient can feel what's wrong and has a better response.

When the functions were 80% recovered, then I felt confident in starting asimmetric functions (blinking, closing only one eye, etc).

Important especially during the first stage is to give a sort of feedback feeling to the patient and that's when he has no idea what to do or how to move. I guided the functions with my hands slowly making him feel the movement, on the good side, on the impaired side, on both. Same thing is repeated asking the patient to follow you in an active assisted movement. This can be done between sets of exercise, so the patient can have rest.

As he shows a bit of contraction he is required to move in front of a mirror and then to repeat the movement without mirror or if he prefers with eyes closed. This is good also to prepare him for home exercises.

On top of this, there is also a considerable psychological work to do with the patient as he basically feels like he is an idiot doing all this stuff and can be skeptical and/or shy. But I can assure that as soon as he sees improvements day by day he will be the first to ask you for more exercise.

I hope I haven't been too messy explaining. Tell me if you need more.
Ciao
Emmi