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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[jjose_01]

gcoe, thank you for shedding light on this. I question myself too everytime i handle patients with bell's palsy. am i doing the best thing for my patient that is worth compensating?
shall we abandon our patients with bell's palsy is another question. how are we gonna treat them after that high quality research?
shall i say to my patients..."doing nothing is the best thing"?

[gcoe]

Hi jjose_01

I think the questions you are raising are really valid. In the face of evidence that does not show a treatment works what should we do? Here are a couple of issues we need to consider:

* Patient's with Bell's Palsy are often traumatised and distressed by what has happened to them. We need to treat them sympathetically. We are able to give them some reassurance about the likelihood of recovery which is one good thing we can do. We need to be mindful of the psychological support a caring phsyio can offer. However we shouldn't fool ourselves or our patients about ineffective treatments. It is unethical to raise hopes about a treatment that isn't likely to work.

* I see no problem in giving these patients an exercise programme that they can carry out themselves. As the review stated exercise may speed up recovery. However given the resources involved maybe we would consider more of a home programme that could be supervised rather than active treatment. And there are also some practical issues such as hygene and managing eating that we can advise patients on

* I don't think this needs to be the last word in research on physio for Bell's Palsy. We should lobby for better quality trials and think carefully about the type of treatments that may be fruitful. However we probably need to be mindful that the prospect of our treatments being effective is not very high.

[jjose_01]

so what are the "supposed-to-be" authorities that can give us guiding lines in treating patients with bell's palsy?

maybe one to three sessions of educating the patients about the disease process and the exercises that "may" hasten up recovery will do and a follow-up after 1 month, every month?

[gcoe]

Hi jjose_01

I am not sure if I quite understand your last point. So my answer might not be what you are looking for. However here goes:

What I was really saying is what things to consider now that we have this disappointing but inconclusive evidence. It is a matter of finding a way forward. I am not claiming to be an authority on the matter. As health science professionals I think we have to weigh up the evidence - sometimes we need to come to a consensus as to how to provide the best practice we can and sometimes we need to do this individually.

You know the clinical practice you work in, not me. I am sure there are expectations about what you should provide that I am unaware of.

Good evidence-based practice these days includes taking into account available research evidence, your own clinical experience and also patient preferences.

I look at evidence from research as providing us with greater knowledge and to ultimately be better practitioners. Evidence tells us what treatments to discard, what treatments to keep, how better to apply treatments and opens new avenues for new treatments and for treating conditions we would may not have in the past. All this can be quite unsettling for us practitioners and one thing about the nature of research is that it rarely spells out exactly what we should do. With this knowledge comes greater wisdom on how to act but ultimately there remains some uncertainty and it is up to us to interpret the findings and apply them to practice.

A clinical guideline written by physios (that takes into account the evidence from systematic reviews and clinical trials, clinical experts opinions and also what patients experiences with treatment) would be of great help in the long term. However as there aren't many good quality trials to examine there probably isn't much point to a guideline just yet. The area of practice hasn't attracted that much attention by good researchers.

So what I was really saying is suggesting what to consider as well as give you an opinion of what I might do. So what do you think you will do the next time you have a patient with Bell's Palsy?

[gcoe]

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.

barrybert you are blitzing this site with meaningless one liners - probably to advertise your Resume writing service. However this one really contains some misinformation. there is no solid evidence that I can find for the use of PNF for The recovery phase of Bells palsy. In contrast to PNF a number of different techniques have been tested and the ones that come up strongest are:

• various types of electrostimulation
• various exercise regimes

One particularly interesting exercise programme is Mime therapy which is about the adoption of facial gestures.

There is a good Cochrane review that covers the territory well:

Physical therapy for Bell´s palsy (idiopathic facial paralysis)

Not only is there an absence of evidence for the effectiveness of PNF in facial paralysis rehab. It is also basically implausible. PNF uses a number of proprioceptors but the primary ones are the muscle spindles. However the facial muscles lack muscle spindles unlike their somatic counterparts. so all the quick stretching in the world probably ain't doing anything.

have a read of:

• Shahani BT, Young RR: Blink reflexes in orbicularis oculi, in Desmedt JE (ed): New Developments in Electromyography and Clinical Neurophysiology. Basel, Karger, 1973, vol 3, pp 641-659.
  
• Brodal A: Neurological Anatomy: In Relation to Clinical Medicine, ed 3. New York, Oxford University Press, 1981, pp 495-508.

[memo22]

thaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa aanks

[macrylinda1]

Hi jjose_01

I think the questions you are raising are really valid. In the face of evidence that does not show a treatment works what should we do? Here are a couple of issues we need to consider:

* Patient's with Bell's Palsy are often traumatised and distressed by what has happened to them. We need to treat them sympathetically. We are able to give them some reassurance about the likelihood of recovery which is one good thing we can do. We need to be mindful of the psychological support a caring phsyio can offer. However we shouldn't fool ourselves or our patients about ineffective treatments. It is unethical to raise hopes about a treatment that isn't likely to work.

* I see no problem in giving these patients an exercise programme that they can carry out themselves. As the review stated exercise may speed up recovery. However given the resources involved maybe we would consider more of a home programme that could be supervised rather than active treatment. And there are also some practical issues such as hygene and managing eating that we can advise patients on

* I don't think this needs to be the last word in research on physio for Bell's Palsy. We should lobby for better quality trials and think carefully about the type of treatments that may be fruitful. However we probably need to be mindful that the prospect of our treatments being effective is not very high.

gcoe, thank you for shedding light on this. I question myself too everytime i handle patients with bell's palsy. am i doing the best thing for my patient that is worth compensating?
shall we abandon our patients with bell's palsy is another question. how are we gonna treat them after that high quality research?
shall i say to my patients..."doing nothing is the best thing"?

[sherille]

hi Emmi, well done! your doing your job well! Bell's Palsy is one of my favourite case aside from CVA. As you explained it, I can see myself with you..hope you don't mind.

[gcoe]

Yes I think we must do the very best we can do for our patients and that includes offering treatments based on the best evidence. So in the case of bells palsy we certainly shouldn't be abandoning them. However we as like many other therapy professions, are masters at fooling ourselves into thinking we are being effective when we aren't and in our folly we take our patients along with the ride. Patients have a right to know whether or not a treatment is likely to work and if the treatment is likely to work to what extent. And if I treatment has been demonstrated to be no better ran a placebo then we shouldn't hoodwink our patients into false claims.

Take a step back and think about it in relation to other practitioners. How would you feel if your dr prescribed a medication which was known to be useless and may even have some unintended ill effects? Or what about seeing a psychologist for a mental health problem who gives you therapy for several weeks that has shown to have no benefit for such a problem and charges you for the privilege? You wouldn't undergo an operation that is known to be ineffective just because there is nothing else available.

So taking patients fears and desperateness seriously is important and ethical. But offering them useless therapy just to allay these anxieties, particularly when you are taking their money or spending the public purse or where someone else misses out because you have tied up your time on offering ineffective treatment - we have to stop doing this.

[sheetaljain]

How much is taping effective in Bells palsy?I have searched a lot about it bit was not satisfied wuth the matter i found.Upto my knowledge taping is effective in the initial phases of rehabilitation or Bells palsy when there is no contraction of the muscle at all?is it really beneficial for the patient??

[gcoe]

I think there is only one trial - written up in the Indian OT journal. The trial was of poor quality with lack of blinding and and no randomisation and the statistical analysis is quite concealed. However the authors reported better outcomes in the group that received dynamic taping (ie the tape used must have some elastic property).

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

I am not really sure that there is really a sound rationale for the use of taping. In this article the authors claim dynamic taping:

Ø Preventing asymmetry
Ø Preventing over activity/ over pull of paralyzed
muscle
Ø Enhance facilitation
Ø Reinforce movement in graded fashion
Ø Maximize functional use of affected muscles by
incorporating functional activities

I think some of these points are a bit fanciful. However I could accept that taping may prevent an increase in sarcomeres laid down in series due to sustained length due to gravity - thereby preventing the muscle increasing it's length. And that the taping may provide reduced resistance to weak muscles when contracting them -and that this could be therapeutic for weak muscles.

I have had no experience with the comfort of the tape - I think this is an important point to consider. Has anyone tried it?

Perhaps the jury is out of on this one - we don't really have the evidence for this technique.

[daviidwilson]

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.

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 ...,,,,,
__________________
watch movies online

[sheetaljain]

how much is ulreasound effective in facial palsy????and what are the parameters are to be set.???how much is the tretment time???

[montiton]

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

Acupuncture can really promote the rehabilitation, but to use 7 days after the onset, they may damage the nerve, in China, many people use acupuncture

[montiton]

hi ,all. i from china,My English is not good
I have a valid prescription to cure Bell's Palsy
only simply drop the Medicinal Suppository into the nose
3 days immediately effect, treatment period 3 to 7 days
necessary condition for recovery treatment

• Onset Less than 90 day
• not caused bystroke
• not caused by trauma
• not done Surgical Treatment

The patient during treatment must do the following:
Maintain emotional stability.
Avoid eating spicy foods, such as irritation.
Not faceTo be subjected to intense cold or heat stimulation.
Not to have sex.

[bellspalsyme]

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

I didn't used acupuncture, but from personal experience I can say that a good physiotherapy is enough. I created a list of the exercises I practiced during 3-4 weeks, check it on http://bellspalsy.me/

[toddchaney]

I checked the link. I'm sure these exercises would be really very effective.

[klarakos]

From my experience in dealing with facial , i refute completely ultrasound using , those patients need to learn only what could causes residuals , all those electrotherapy could cause cross-wiring in both the nerve and cortical presentations .Which means you find the patient,s face moves automaticallly interconnected ,no control of indiviudal motions and experssions .