Bell's palsy

[tunglokc]

A patient with Bell's palsy under my care recently.

Apart from electrical stimulation, massage and exercise, what other ideas do you have?

I also want to know the effectiveness of acupuncture in this type of patient.

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[physiobob]

ESSENTIAL ELEMENTS FOR EFFECTIVE NEUROMUSCULAR RETRAINING
taken from: http://www.bellspalsy.ws

Proper Treatment Environment

A quiet, individual room where therapy is conducted without distractions, establishes the proper learning environment. Anyone who has worked with facial paralysis patients is aware of the social stigma associated with this disability. Privacy is essential to create a "safe" environment for the patient who is embarrassed by his or her appearance. In this setting, psychosocial issues can also be discussed.

Sensory Feedback

Optimal learning depends on making maximal use of sensory information. Accurate, proportional and immediate sensory feedback provides the information required for modification and learning of new motor patterns. Visual (mirror) feedback is the most commonly used type of feedback in the clinic and at home. Inexpensive and portable, mirrors provide the patient with immediate feedback regarding performance. Proprioception provides internal facial position sense and is essential for accurate exercise practice and generalization of movements outside of the clinical setting.

Surface EMG Feedback

Just as intraoperative EMG facial nerve monitoring has led to modifications in surgical techniques by providing the surgeon with specific feedback, sEMG monitoring of facial muscles during NMR can lead to modification of facial movement patterns by providing the patient with feedback regarding motor performance. It is an important tool in neuromuscular retraining of facial paralysis.

Also referred to as EMG biofeedback or EMG rehabilitation (EMGR), its purpose is "to bring the normally unconscious control of specific muscles under conscious control". Surface EMG feedback provides the patient with immediate information regarding the rate and strength of the muscle contraction in real time. As part of a neuromuscular retraining program sEMG feedback is used as an evaluative, as well as therapeutic tool to:

- Increase activity in weak muscles
- Decrease activity in hyperactive muscles and
- Improve coordination of muscle groups.

Surface electrodes placed on the skin over the muscle(s) being monitored detect electrical activity produced by the muscle contraction. The amplified signals are displayed on a video monitor. Patients observe this feedback and vary the manner in which they produce a specific movement until the desired pattern is achieved. By correlating information from sEMG feedback with mirror and proprioceptive feedback, the patient learns to reproduce the new movement patterns outside of the clinical setting and within the context of the home exercise program.

Other considerations of conditions similar to Bell's Palsy

RAMSEY HUNT SYNDROME

Ramsey Hunt syndrome is similar to Bell's palsy. Unlike Bells palsy, the virus that causes Ramsey-Hunt syndrome has been conclusively identified. It is varicella zoster virus (VZV), which is the virus that causes chicken pox, and is a strain of the Herpes virus. Like HSV-1, it remains in the body, residing on nerve tissue in a dormant state on nerve ganglia after the initial infectious stage has passed. VZV typically remains dormant for decades. The incidence of Ramsey Hunt syndrome increases significantly after age 50. Younger patients with Ramsey-Hunt syndrome are often advised to be tested for autoimmune deficiencies.

Ramsey-Hunt syndrome results in symptoms that are in many respects identical to Bell's palsy. The symptoms are so alike that a diagnosis of Ramsey Hunt syndrome can easily be missed.
When the VSV virus is reactivated the resulting eruptions (blisters) are known as shingles. The first symptom is usually severe pain. There may also be a fever, headache, and localized tenderness. Blisters typically begin to emerge 1.5 to 3 days after the onset of these symptoms, although they may emerge with no prior symptoms.

Symptoms of Ramsey Hunt Syndrome

In addition to the "classic" symptoms of Bells palsy, Ramsey Hunt syndrome is associated with some additional symptoms that help differentiate it. Knowledge of these symptoms is key to an early diagnosis, and should be brought to a doctor's attention during the first visit, or when any of these symptoms become apparent.

1. Pain: Bell's palsy patients may complain of pain (often in or behind the ear) which can be acute. However, it will tend to fade within a week or two. The pain associated with Ramsey Hunt syndrome is often more severe, and more likely to be felt inside the ear. It may start before muscle weakness is apparent, and may last for weeks or months - sometimes longer. Medications such as Neurontin can ease the post-herpatic pain of Ramsey Hunt syndrome.

2. Vertigo: Dizziness is occasionally reported by Bells palsy patients, but is often associated with Ramsey Hunt syndrome. It can be more severe, and longer lasting.

3. Hearing loss: Unlike Bell's palsy, Ramsey Hunt syndrome can also affect the auditory nerve (CN-VIII), resulting in hearing deficit. This should not occur with Bells palsy, and is an important clue to the diagnosing physician. In some cases hearing loss will continue after facial muscle function returns.

4. Blisters: The primary symptom that makes a diagnosis of Ramsey Hunt syndrome likely is the appearance of blisters (known as shingles, or herpes zoster) in the ear. The blisters can appear prior to, concurrent to, or after the onset of facial paralysis. They can be expected to last 2 - 5 weeks, and can be quite painful. The pain can continue after the blisters have disappeared. Blisters are often the only clearly visible symptom that identifies Ramsay Hunt. Unfortunately, they may not be evident during the diagnostic examination. They can be present, but too deep within the ear to be visible. Or they can be too small to be seen. In some cases they may not appear until a week or more after the onset of muscle weakness. At times they do not appear in the ear at all, but may be present in the mouth or throat. It is also possible for the virus to reactivate without blisters at all.

5. Swollen and tender lymph nodes near the affected area.

While Bell's palsy is not contagious, shingles blisters are infectious. Contact with an open blister by someone who has never had chickenpox can result in transmission of the virus. The result will be chickenpox, not shingles or facial paralysis.

[emad]

Physiobob and Others,

The article you brought above regarding Synkinesis is good , shows how your views of Electrical Stimulation and Fast begining of physiotherapy could share in developing Synkinesis .

Here, i have a view . Being Bell,s palsy (facial palsy) is acceptable than having facial Synkinesis ,because Synk. is extreme cause of deperssion and being sad .Even i can say it is impossible to free a person of facial Synkinesis from it .

Has any one here freed a patient from synkinesis ??

As for strapping ,what is the aim of using it in facial palsy??

Cheers
Emad

[Dr Damien]

Even though I find your reply extremely hilarious(the mummification part) I think what mahiaki is trying to say is a method which might be used to prevent the effects of contralateral pull of more powerful muscles and the effect of gravity:hence the taping.I do not know if this is a valid technique,i have never used it before,but it sounds like the only thing it will achieve is the adverse effects of the two factors i just mentioned.I know for a fact that when you treat a bells's palsy patient, gravity will continue to pull on the affected side.Except the patient can by some means assume gravity free positions for the total period of recovery or a splinting device can take care of that.This definitely sounds impractical just by imagining it.(Superman and Hannibal lector might have suggestions).
i think that is wut mahiaki meant.A prophylaxis rather than a treatment per say

[wblondell]

Thank you for bringing up the topic of strapping/tapping for facial palsy. We have recently being having a lot of discussion in the hospital i work in which is very international. Is there any research/evidence to support the use of strapping/tapping ... I did a research review on this topic 2 years ago and did not find any support for it ?? did i miss it ?is it a new idea ??is there no evidence ...

[drkavita_physio@yahoo.com]

hi this is my 1st post 4 bpalsy u can give 's' type brace 4 dropng mouth angal and never give ice on nerve trunk and facial ex pnf is impt acc 2 me hands can do magic so try this
regards

[emmi]

Hi all, I am an Italian physio living in Australia and I'll tell you my experience of Bell's palsy in both countries.

In Italy we usually treat the palsy with PNF, starting as soon as the diagnosis is made, together with the medical treatment of corticosteroids. Usually we can appreciate the first facial movements after 10 days and we get full recovery in 4-6 weeks depending on the severity of the palsy. Sometimes 8 weeks. We find PNF to be very effective. Frequency of treatment is usually 5 days a week till we get some movement, then it can be dropped to 3 times a week requiring though partecipation of the patient with home exercises. The frequency and duration of contractions is personal judgment of the physio depending on the response of the patient. Of course first rule is to avoid synkinesis and also to avoid a pure "manual" approach but trying to make the patient aware with lots of feedback and "self-feeling".

In Australia, I had lately a friend of mine affected. He went everywhere (Perth-WA) looking for some treatment by neurologists and physios, always getting the same answer "there is no treatment other than corticosteroids, you have just to wait for the symptoms to go, it might take months even one year". When I saw him it was after 3months the diagnosis and he had recovered only 20%. At Uni they told me they don't teach treatment for any facial palsy. I tried PNF on him and he was back to normal after 3 weeks.

Regarding electrotherapy and US, I never liked their use for any purpose, I think there are more effective technique in general. Anyway, I'd never use those stuff on a face.

Emmi

[ramywhite]

Hey Emmi,
I am interested in treating facial palsy without electrotherapy at all. I think electrical stim and US aren't suitable on face and have many risks. So, could you please tell us what you choosed exactly from PNF techniques for your patient?
thanks

[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

[ramywhite]

Hi emmi,
You've covered the subject in excellent way. I will try these techniques. Thank you for sharing your experiences with others.

[sdkashif]

Yeah good detail of information has been described. There is no doubt in efficacy of PNF techniques. But let me clear that PNF techniques are used only in the recovery phase of facial nerve for re education when muscles start to show the signs of contraction or activity.

[mulo_gibson]

Have you tried including TENS in your electrotherapy? It has helped some of my patients.

[Dr Damien]

There is some controversy on the use of TENS for any lower motor neuron problem and the reason being that the frequencies available on the TENS were designed for pain relief mostly. When used to initiate contraction, these frequencies begin to imitate a proper electrical muscle stimulator and whether or not it is bad practice remains a question open for debate-I've never witnessed any adverse effects for its use. If Tens/electrical muscle stimulation is to be considered,it should only be used only as a reeducation tool. This means that nothing should substitute for an active contraction done by the patient. Tens/elec stim will facilitate the ease with which impulses travel in a nerve which will allow easy conscious stimulation . By having the patient imitate the contraction as it happens in time, the is a biofeedback mechanism set in place.I emphasis that TENS should be used (if at all) for reeducation and possibly maintenance of muscle physiology(prevetion of atrophy due to disuse). Patient's with bell's palsy often recover overtime(as the swollen nerves reduce). Some patient's will not respond to the use of TENS because of the over reliance on it as a magic tool that brings back power and coordination to their muscles when infact the bulk of the exercise lies on them.Some will, while others will fall into the lot who experience spontaneous recovery and as such may attribute treatment success to the tens. Some patients will not tolerate TENS too. The effects tens provides is achievable with certain massage techniques such as point stimulation and kneading. If TENS is to be considered I believe the therapist should constantly encourage the patient to follow the contractions with conscious effort, however there are questions that will be raised in this treatment e.g how much of coordination can be achieved (there is a limit to the isolation of a stimulating machine, can the tens machine train you to smile or blow out ur cheeks?).I only have three words for the bells palsy patient, exercise,exercise and exercise...

[Physio-Oms]

about the strapping method....where Im from...strapping has been effective. In the sense, to only maintain muscle tone and prevent sagging of the face.
But, electrotherapy has proved most effective....because the nerve is temporarily paralysed and needs to be reactivated. therefore, electrical stimulation is effective, mostly using Galvanic current because the muscles on the face are small.

Any discussions?

[mulo_gibson]

Thank You Dr Damien and Physio-Oms for your inputs and suggestions. I really appreciate it. It has helped me consider other techniques of treatment. Thanks a heap. I'll get back to you both about the feedback from my patients.

[Mickey Joe]

How exactly is PNF done on the facial muscles? !

[MGrules]

Hey

We have also been using IR infrared light to reduce inflammation in the acute phase. Gives good results. And yes PNF exercises should be given in front of the mirror. The normal side of the face for any particular activity like eyebrow raising should be resisted and the affected side should be assisted. At our hospital we make splints with cycle spokes. We cut the spoke according the measurement of the face of the patient. We cover it with catheter used for suctioning purpose of the same size. We then twist it in the shape of S so that one end of the s goes behind the ear and other goes inside the mouth to strech the affected muscle.

[jinju_nj]

Hey

We have also been using IR infrared light to reduce inflammation in the acute phase. Gives good results. And yes PNF exercises should be given in front of the mirror. The normal side of the face for any particular activity like eyebrow raising should be resisted and the affected side should be assisted. At our hospital we make splints with cycle spokes. We cut the spoke according the measurement of the face of the patient. We cover it with catheter used for suctioning purpose of the same size. We then twist it in the shape of S so that one end of the s goes behind the ear and other goes inside the mouth to strech the affected muscle.

HI...IT IS RAJ FROM KUWAIT. I HAD GONE THRO, DIFFERENT VIEW IN THIS. I JUST WANT TO KNOW IS SWD HAVE ANY MAJOR ROLE IN THE TREATMENT FOR BELLS. IF POSSIBLE SEND WITH REF. AS BECAUSE HERE WE R USING SWD OR MOIST HEAT ALMOST FOR ALL BELLS PATIENTS APART FROM PNF TECH, EXS. THANK U

[jinju_nj]

Hi... I Am Working In Kuwait. I Want To Know Is There Any Major Role For Swd In The Management Of Bells Palsy. Because Here Most Of The Hospitals Using Either Swd Or Moist Heat We Are Giving To Almost All The Bells Patients Apart From Pnf And Exs.

[tattoomd]

I have heard of acupuncture used for Bell's palsy, especially for muscle spasticity. Does anyone have any experience with this?

[neuromuscular]

Dear tunglokc;

I noticed that the replies which I read ignored the possibility of the cranial nerves being impinged at the C1 to occiput.

I have found that by releasing the longus capitus, the sypmtoms abated the most rapidly.

I am not sure of all of the replies, but have you tried this?

Other muscles that may be a factor are the anterior suboccipitals: rectus capitus anterior, and rectus capitus lateralis. The pressure on the cranial nerves becomes reduced as these are treated and the conditions tend to abate faster.

Sorry if someone else has posted this, but I read much of the information and found tht this is not covered. NUCCA chiropractic has a similar approach, but this differs in that the muscles are treated specifically instead of a positional treatment.

Hope that this is helpful.

Best regards,
Neuromuscular.

[monak84]

Hi,

I came across a study done by an occupational therapist on the effectiveness of taping method in Bell's palsy..

medind.nic.in/iba/t07/i2/ibat07i2p35.pdf

[jjose_01]

Since patients spontaneously recover for the first two weeks, when is the best time to initiate physical therapy and when can you say it a residual deficit (discharge plan)?

When can we say...that a patient's improvement is due to physical therapy?

What is the highest level of evidence we have in treating facial palsies?

When can we say that we are over-utilising physical therapy to this patient population?

[dreamogenic]

had bells palsy since 31st of july,i was on steroids 20mg qds in oral tapering dosage,with acyclovirl,anti viral 40mg qds for 5 days,with vit b12,on 15 of august i again feel severe pain post auricular ,then my physician took me on injectable steroids,80ml,2 injection only,,,,now am at physio seccions,ENS ,facial exercises and massage ,now recovering from bell,s palsy,but rate of recovery is very slow,
,,,what can i do to increse the recovery rate and decress the time ...,,,,,

[jjose_01]

may i know your age please and what does your therapist told you? including your occupation.

it is nearly two months since the first attack, when did you start physio?

i would say that you have a moderate to severe case of facial palsy, so expect a residual deficit.

continue with your therapy for 6 months. ask other therapist's here that may have higher experience than me in handling cases like yours then print it to be read by your therapist, like those researches that they come up with.

the most important thing that you must do is home exercises where you will sit in front of a mirror then individually try to contract all facial muscles involved ten times only, three to five times per day, if it isn't moving, try to assist it with your fingers with a little stretch at the end.

pray, keep a healthy diet, don't travel too much.

[gcoe]

Hi

I had a look at a recent systematic review (Cochrane) of physiotherapy for Bells Palsy. Here is the link:

http://www.mrw.interscience.wiley.co...stract_fs.html

In a nutshell:

The reviewers conducted a fairly exhaustive search and from that search only identified six studies of sufficient quality from which to draw conclusions. Three of these studies examined electrostimulation and three studies examined exercise. None of these studies examined ultrasound.

The results were disappointing in that neither exercise nor electrostimulation were better than controls or no treatment. However there was some limited evidence that exercise may speed recovery. The authors concluded that such treatment neither helps or harms recovery and that further evidence is needed to examine if exercise speeds recovery.

Probably the concern that treatment can cause or increase synkinesis is therefore unfounded. That is often the way isn't it. For example we used to believe that strengthening might make spasticity worse in UMN lesions when there is no evidence it does - in fact quite the reverse.

So we may not be harming our patients but are we really able to make them better.