A patient withBell'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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A patient with
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.
Hi tunglokc,
There are already a number of useful posts on the forum surrounding
I hope this assists. :D
Some briefing about the Facial Palsy or
Facial palsy is condition in which there is lesion of the facial nerve and the resultant paralysis in the muscles that it supplies. So there will be following features on the side of lesion:
Loss of facial expression.
Drooping of the face- Low eyelid, eyebrow and corner of mouth sag.
Closing the eye is difficult.
Eating is difficult because food collects in the side of the cheek and fluid seeps out of the corner of mouth.
Speaking, whistling and drinking are impaired.
Non-verbal communication is lost as the patient cannot register the pleasure, laughter, surprise, interest and worry.
The patient tends to sit with the hand over the side of face.
There is difference between an upper motor neuron lesion and lower motor neuron lesion of the facial palsy.
A unilateral UMN lesion usually spares the forehead as it is also innervated from the other side of the brain; however an LMN lesion affects all of one side of the face.
An upper motor neuron lesion causes weakness of lower part of face on the side opposite the lesion. The frontalis muscle is spared; the normal furrowing of the brow is preserved, and the eye closure and blinking are not affected.
Moreover, in upper motor neuron lesion there relative preservation of spontaneous 'emotional' movement (e.g. smiling) compared with voluntary movement.
Causes of facial weakness:
These are as under:
The common cause of facial weakness is a supranuclear lesion e.g. cerebral infarction leading to upper motor neuron facial weakness and hemiparesis.
Lesions at four other levels may be recognized by the associated signs.
PONS. The sixth nerve nucleus is encircled by the seventh nerve fibers and is therefore involved in the pontine lesions of the nerve, causing lateral rectus palsy.
If there is accompanying damage to the neighboring centre for the lateral gaze and the cortispinal tract, there is the combination of:
LMN facial weakness
Failure of congugate lateral gaze (toward the lesion)
Contra lateral hemiparesis
Causes include pontine tumours (e.g. glioma), demyelination and vascular lesions.
The facial nucleus is affected in poliomyelitis and motor neuron disease; the lateral usually causes the bilateral weakness.
CEREBELLOPONTINE ANGLE. The fifth, sixth and eight nerves are affected with the seventh nerve in lesions in the cerebellopontine angle. Causes are acoustic neuroma and miningoma.
WITHIN THE PETROUS TEMPORAL BONE. The geniculate ganglion (a sensory ganglion for taste) lies at the genu of the facial nerve. Fibers join the facial nerve in the chorda tympani and carry taste from the anterior two third of the tongue. The (motor) nerve to the stapedius muscle leaves the facial nerve distal to the genu.
Lesions within the petrous temporal bone cause:
Loss of taste on the anterior two third of the tongue
Hyperacusis ( an unpleasant loud distortion of noise) due to the paralysis of the stapedius muscle
Causes include:
Bell's palsy
Trauma
Infectin of middle ear
Herpes zoster (Ramsay hunt syndrome)
Tumours (e.g. glomus tumour)
WITHIN THE FACE. Branches of the facial nerve pierce the parotid gland and supply the muscle of the facial expression. The nerve can be damaged here by parotid gland tumours, mumps (epidemic parotitis), sarcoidosis and trauma. The nerve is also affected in the polyneuritis (e.g. G.B. Syndrome) usually bilaterally.
Weakness of face also occurs in primary muscle disease and disease of neuromuscular junction. Weakness is usually bilateral. Causes include:
Dystrophia myotonica
Facio-scapulo humeral dystrophy
Myasthenia gravis
Bell's palsy
this is a common acute, isolated facial nerve palsy believed to be due to viral infection (most probably herpes simplex) that causes swelling of the nerve within the petrous temporal bone.
MANAGEMENT:
Spontaneous recovery occurs toward the end of second week. Thereafter, continuing recovery occur. Fifty percent recover within three months. Continuing recovery may take 12 months to become complete. About 15 percent of patients are left with a severe unsightly residual weakness.
Medical:
Steroids (prednisolone 60mg daily reducing to nil over 10 days.)
Acyclovir for viral infection
Physiotherapy:
During the paralysis:
Ultrasound given over the nerve trunk in front of the tragus of ear and in area between mastoid process and mandible. There is no fear of applying ultrasound while doing the treatment of patient with Bell's palsy. The ultrasound is always applied on the side of lesion in front of the tragus of ear & in area between the mastoid process and mandible where the maximum tenderness of the facial nerve is determined by palpation. It is applied in slow circular motion with a starting dosage of 1 watt per square centimeter. The dosage may be increased on the subsequent sessions if no remarkable improvement is noted. Let me explain that ultrasound waves cannot traverse the bone. That means ultrasound has zero penetration in the bone. Infact, ultrasound waves are reflected away from the bone. So there is no fear in applying the ultrasound on face. (This is only for LMN lesion type)
low level laser therapy (infrared 808 nanometer wavelength 400 mill watt power for 5 minutes continuous)
Infra-red: Infra red may be applied to warm the muscles and improve the function, but you must ensure that eyes are protected with linens when you are applying infra-red to face. Timing should be for 15 to 20 minutes.
Ultraviolet Therapy: Formerly ultraviolet was frequently used to give third degree erythema doses over the facial nerve trunk and in area between mastoid process and mandible to combat the infection and inflammation.
Microwave diathermy: As far as micro wave diathermy application is concerned, there is strict contra indication for the use of micro wave diathermy for the treatment of face as micro waves can spread randomly and can damage the lense of eye causing the opacity of the lense. So there is no room for the application of micro wave to face.
Short Wave Diathermy: SWD can be safely applied for the treatment of facial palsy. The technique used may be monopolar or bi polar. In bipolar technique using the capacitor field method, the one facial mask electrode is used as an active electrode for applying the rays to face while the second or indifferent electrode used on some distant part of the body to complete the circuit. In monopolar electrode method only one electrode is used to direct the rays to the target treatment area site and no second electrode is used at all.
Electrical Stimulation: The only form of electrical current used on face is interrupted direct current (I.D.C.). This is requested only to preserve the bulk of facial muscle and to prevent their atrophy while waiting them to be in faction whenever their re innervations arrives in case of axotomesis or reconditioning after neuropraxia if the nerve is not damaged completely. There is no room for the use of faradic current use on the face as it could lead to cause secondary contractures of the face.
Massage: Massage may be taught to the patient
stroking in the upward, outward direction.
Slow finger kneading applied over the paralyzed muscles maintains skin suppleness and muscle elasticity.
These techniques applied daily for 5 minutes or so help to maintain lymphatic and blood flow and prevent contractures.
During Recovery:
PNF techniques are used for re-education:
Quick stretch can be applied to regain rising of eye brow and the movement of the corner of mouth.
The physiotherapist can produce the movement passively and then ask the patient to hold, and then try to produce the movement.
Icing, brushing, tapping or brisk stroking may be applied along the length of the muscles. e.g. Zygomaticus
Exercises:
Look surprised then frown
Squeeze eyes closed then open wide
Smile, grin, say 'o'.
Say a, e, i, o, u.
Hold straw in mouth-suck and blow
Whistle
Heliotherapy:I have found traditional old lay men to use the convex lense to focus the sun rays to produce the third or four degree erythematic dosage to facial nerve trunk and in area between mandible and mastoid process behind the ear and it frequently gives dramatic result with excellent recovery of facial palsy. The treatment was needed to repeat after one week to repeat the same session of the dosage. Only three or four sessions of this kind were needed to do the excellent management of the patient. Infact, it is one kind of heliotherapy treatment which is available from the natural source of power i.e. the sun. This is most common form of physiotherapy medicine that is used by conventional lay men here in Pakistan with excellent results of the treatment.
Tungo and all ,
As for facial palsy and Bell,s palsy ,try to be so gently because you may share in developing complications to the patient like the most common problem Synkinesis that can develop simply because of pushing forward for improving the muscle power .I do NOT support using electrotherapy espicially using long times /periods e.g. Ultrasound therapy ,current research says it can has side effects over nerves .
After long time of dealing with facial palsy ,i think the most appropriate for those victims is Education regarding what can share in developing Synkinesis which usually occurs in severe facial nerve injuries .
Currently , i use Imagery exercises of the facial muscles to activate cortical presentations and at the same time avoid developing synkinesis .
Best Wishes
Emad
To Sdkashif:
I saw your replay for few times that you are using ultrasound on face for Bells palsy. That’s always makes me mad! I don’t know why you are so insisting on doing that when last time there was many people that disagree with you. What are you try to accomplish? I thought you did some research on that topic but you apparently did not. So I posting whole article about penetration of low frequency ultrasound on human cranium in vitro. There are many researches on this or similar topics if you want you can inform your self.
And again, aria of the head, easy, ears, ovaries, testicles, brain, spinal cord are highly ultrasound-sensitive organs!!!
This is the articles:
Low-frequency Ultrasound Penetrates the Cranium and Enhances Thrombolysis In Vitro.
Technique Assessments
Neurosurgery. 43(4):828-832, October 1998.
Akiyama, Masahiko MD; Ishibashi, Toshihiro MD; Yamada, Tetsu MD; Furuhata, Hiroshi MD
Abstract:
OBJECTIVE: Refinements of treatment methods are sought to rapidly reduce the volume of intracranial clots and to decrease patient exposure to possible complications of thrombolytic therapy for intracranial hematomas. We assessed the possibility of adding ultrasonication using model systems including human blood clots and temporal bone in vitro.
METHODS: The transmittance of ultrasound through temporal bone obtained at autopsy was compared between the frequencies 211.5 KHz and 1.03 MHz, using a meter to determine the power delivered. The frequency 211.5 KHz was chosen to assess the ultrasound effect on the weight of 24-hour-old clots prepared from human blood after exposures at 37[degrees]C to 2 mg/ml urokinase with no additional treatment, ultrasound, or agitation during an interval of up to 12 hours. At these times, fibrin degradation products also were measured.
RESULTS: The transmittance of low-frequency ultrasound (211.5 KHz) through temporal bone was approximately 40%, which is four times higher than that of high-frequency ultrasound (1.03 MHz). Ultrasound but not agitation significantly increased clot lysis (140% of lysis with urokinase alone), with correspondingly increased fibrin degradation products.
CONCLUSION: We conclude that low-frequency ultrasound transmits well through human temporal bone and enhances thrombolysis in vitro. Clinically, this method may be promising for reducing dosages of thrombolytic agents and shortening the period of clot removal. Copyright (C) by the Congress of Neurological Surgeons
Nale ,
The problem is there is a like post before you to thank that post which endorse Ultrasound therapy and all electrotherapy in facial palsy .
Physiotherapists need to learn more ,reflect more ,search more ......in case of facial palsy we are facing great challange from those people with residuals following facial palsies .Any physio. may be lucky to encounter first Bell,s palsies which could resolve with nothing ,but in case of severe facial nerve affections ,residuals if the victim ,the therapist ,the society are aware of synkinesis every thing pass! They may say to the patient there was no chance better than what we did .
Cheers
Emad
I expect this persons post is pasted from an online text book. However, after reading your post I am not sure what your point is here. Lysis by definition refers to the death of a cell by bursting, often by viral or osmotic mechanisms that compromise the integrity of the cellular membrane. Formation of blood clots lies at the basis of a number of serious diseases. By breaking down the clot, thrombolysis, the disease process can be arrested, or the complications reduced. I expect the reference in this study therefore refers to the breakdown of a blood clot (I think therefore a positive thing?).Quote:
Originally Posted by 1234nale
I cannot see any reference therefore for the NON-use of Ultrasound in the treatment of facial palsy - when specifically directed at a more superficial structure. Also most physio ultrasound heads are either 1 or 3Mz and are therefore high-frequency? The study would only suggest a 10% deeper penetration at high-frequencies, or am I missing your point?
Please do correct me if I have missed an important consideration that your study is highlighting. :o
I do NOT think ultrasound therapy is of benefit in case of facial nerve .Yes, i tried to find an evidence supporting the side effects of ultrasound on nerve ,i fail now to find what i have seen before ,on contrary i found researches saying ultrasound could enhance regeneration .
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 .
Emad
These articles may be of benefit please visit the following web site i.d.Quote:
Originally Posted by tunglokc
ES Is it Helpful? - http://www.ptjournal.org/cgi/content...urcetype=HWCIT
Exercises - http://www.ptjournal.org/cgi/reprint...urcetype=HWCIT
SdkshifQuote:
says''Let me explain that ultrasound waves cannot traverse the bone. That means ultrasound has zero penetration in the bone. Infact, ultrasound waves are reflected away from the bone. So there is no fear in applying the ultrasound on face.''
The study was done for different purpose but that study proves that US penetrates the human temporal bone, that’s means that us even in small portion get to brain tissue that is very us sensitive and substantial for proliferation. My point was don’t use methods for what you are not sure what is the greater benefit (cause there is not enough study to support beneficial effect on nerve recovery) or risk factor (cause US may reach to brain tissue). Always ask your self what you try to accomplish.
No one is suggesting that they actually use US as a standard treatment inQuote:
Originally Posted by 1234nale
Whilst I agree with your approach to say that one should not use something in an area that we don't know that much about I cannot say that we don't know much about US. We know a lot and most of it doesn't promote it's extensive use but nor does it say we should not use it. The jury remains out on that so I suppose as clinicians we can take sides depending on the case before us and our clinical experience with past results. Thanks again for providing some debate on this topic.
I am sorry if mentioning this study can confuse someone. I could not find better that explicitly says that US penetrate human bone. Study was performing in vitro, that’s not on the living man. And also interfering with blood cloth in the brain is matter of neurosurgeons not physios. So, let’s keep our profession. In almost every book for electrotherapy there could be found contraindication for using US on aria of the head and front of the neck. But I find similar debate on this topic few times that’s why I posted this answers.
Dear 1234nale thanks for your query and questions. let me have a look over your query and answer it.
The article that you have mentioned tells that low frequency ultrasound only penetrates the cranium while The frequencies used in therapy are typically between 1.0 and 3.0 MHz (1MHz = 1 million cycles per second). And these are high frequencies and therefore there will be no chance of penetration with high frequencies.Quote:
Low-frequency Ultrasound Penetrates the Cranium and Enhances Thrombolysis In Vitro.
Ultrasound is a form of MECHANICAL energy, not electrical energy and therefore strictly speaking, not really electrotherapy at all. Mechanical vibration at increasing frequencies is known as sound energy. Below about 16Hz, these vibrations are not recognisable as sound, and the normal human sound range is from 16Hz to something approaching 15-20,000 Hz (in children and young adults). Beyond this upper limit, the mechanical vibration is known as ULTRASOUND. The frequencies used in therapy are typically between 1.0 and 3.0 MHz (1MHz = 1 million cycles per second). For detail about ultrasound see Therapeutic ultrasound
I understand you concern regarding the contraindications of ultrasound. every good therapist is well aware of contra indication of ultrasound. Let me mention contraindication of ultrasound here. Please also see the detail for contraindications Contraindications of UltrasoundQuote:
And again, aria of the head, easy, ears, ovaries, testicles, brain, spinal cord are highly ultrasound-sensitive organs!!!
CONTRAINDICATIONS OF ULTRASOUND
Avoid exposure to the developing foetus
Malignancy
Vascular abnormalities including DVT and severe atherosclerosis
Acute infections
Haemophiliacs not covered by replacement factor
Application over :
Specialised tissue e.g. eye and testes
The stellate ganglion
The cardiac area in advanced heart disease
The spinal cord following laminectomy
The cranium
Active epiphyseal regions in children
PRECAUTIONS OF ULTRASOUND
Anaesthetic areas should be treated with caution if a thermal dose is being applied
Subcutaneous major nerves and bony prominences
Always use the lowest intensity which produces a therapeutic response
Ensure that the applicator is moved throughout the treatment
Ensure that the patient is aware of the nature of the treatment and the expected effects
If pain, discomfort or unexpected sensations are experienced by the ptient, the treatment intensity should be
reduced. If the symptoms persist, the treatment should be terminated.
There is recommendation in good physiotherapy text book for the use of ultrasound. During paralysis, ultrasound given over the nerve trunk just in front of the tragus of the ear may reduce the inflammation. For Reference see " Tidy's Physiotherapy 12th Edition page #162"Quote:
My point was don’t use methods for what you are not sure what is the greater benefit
See For more information upon ultrasound dosage calculation
However, let me say that I was mentioning ultrasound recommendation only during the paralysis phase of
There are other modes of treatment like electrical stimulation and exercises. for detail you may see the articles below.
Evidence In Practice- Does electrical stimulation improve motor recovery in patients with idiopathic facial (Bell) palsy?
Physical therapy for Facial Palsy- A tailored treatment approach
Thanks for enlightening us about US therapy methods but nobody did put that in question. Just you confirm my point of view: why use unsafe methods, when you have more safe ones with no risk for same result? :D
OK guys. Enough now on ultrasound. Now let's all please only remark on any other ideas as asked by the original question below.Quote:
Originally Posted by 1234nale
thanksQuote:
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.
Physiobob,
I think a worth point ,When to begin our role as therapists with facial Palsy ?
Emad
I have always begun asap with facial palsy. The moral or sense of the self is usually pretty darn low following a facial palsy. People often think they have had a stroke and that in someway they are facing a death sentence somewhere in the near future. Physiotherapy has a strong educational role as well as a direct treatment. if is often the PT who has the time to explore the disease process and explain things to the client. Thus on this point alone I would recommend PT intervention asap. it gives the client a good understanding, a direction and a structured approach as to what expect in the early, mid and late phases of the process.... hopefully leading to near if not full recovery.Quote:
Originally Posted by emad
It might be nice to know that one of the main physiobase/physiobob/physio forum design team had a facial palsy 12 months ago. This was a young male in his early 30's, someone who plays regular sport and leads a healthy lifestyle. It was his treatment early on by me that gave him the peace of mind to work through to full recovery and he continues to design the great stuff you see through out our site week on, week out... :D
I'm happy to see there is a lot of idea about the management of facial palsy.
It seems some colleagues will concern about Synkinesis for treatment by ES and too early intensive exercise. But do anyone have some guidelines for the precription of these exercises?(such as the intensity, duration etc)
I also want to know if Synkinesis is developed for the facial palsy patient, what treatment we can do too minimize it?
Physiobob,
Asap , searched for its meaning to find you mean as soon as possible .I agree with you regarding the educational role .
My Question regarding when (Timing ) was concerning the Electro-role as Ultrsound and espicially Electrical Stimulation When ??
Tung,
Seems you know Synkinesis ,So why did not you comment regarding it ?
Seems most of moderate to severe nerve facial injuries develop Synkinesis ,our role could ,unfortunately, share in developing Synkinesis .
Cheers
Emad
In my personal experience during the last 8 years while managing a number of patients suffering from
The role of electrical stimulation is important right from beginning. ES prevents muscle atrophy from being disuse and later in process of nerve degeneration due to trophic changes during long period of paralysis, being most important in maintaining the facial symmetry. So electrical stimulation should be used during the period of paralysis of muscles until such time their re innervation arrives. When the re innervation arrives or re functioning of the muscles starts, one should replace the electrical stimulation with active exerises or muscles re education exercises or PNF exercises to re train the muscles their function.
syn·ki·ne·sis (sĭn'kə-nē'sĭs, -kī-, sĭng'-) pronunciation, noun.Quote:
Originally Posted by emad
Definition: Involuntary movement of muscles or limbs accompanying a voluntary movement.
Facial synkinesis
Definition
Facial synkinesis is the involuntary movement of facial muscles that accompanies purposeful movement of some other set of muscles; for example, facial synkinesis may result in the mouth involuntarily closing or grimacing when the eyes are purposefully closed.
Description
Facial synkinesis occurs during recuperation from conditions or injuries that affect the facial nerve, for example during recovery from
As with all facial injuries or palsies, facial synkinesis can cause considerable emotional distress. Lack of control over one's facial expressions is known to be a serious psychological stressor.
Interestingly electrotherapy e.g. muscle stimulation has been cited as both a treatment and a cause of synkinesis. The difficult thing to work out is what is compensatory movement and what is a true synkinesis. Any budding or sprouting of a nerve is going to take time to develop and so one cannot possibly suggest that a dyskinesia in the early post facial palsy client is due in fact to synkinesis that has resulted from nerve sprouting. More likely it is due to the client trying to hard to get the appropriate muscles to contract. This is evident all the time in stroke and we call it compensatory strategy or compensatory movements which are the result really of trying to hard.
it is therefore important to assess whether these movements are due to "effort" or are truely due to unwanted, aberrant movements that occur with volitional and spontaneous movements.
Causes and symptoms
Facial synkinesis can follow any injury or condition causing palsy or paralysis of the facial nerve. The most common associated disorder is Bell's palsy; about 40% of all individuals who are recovering from Bell's palsy will experience facial synkinesis during recovery.
Note: Other conditions that may prompt the development of facial synkinesis include stroke, head injury, birth trauma, head injury, trauma following tumor removal (such as acoustic neuroma), infection, Lyme disease, diabetes, and
Facial synkinesis can cause a number of abnormalities in the facial muscles. For example, when a patient with facial synkinesis tries to close his or her eyes, the muscles around the mouth may twitch or grimace. Conversely, when the patient tries to smile, the eyes may involuntarily close. The phenomenon of purposeful mouth movements resulting in involuntary eye closing is often referred to as "jaw winking." Unfortunately, as with any facial deformity or disability, facial synkinesis carries with it a high risk of concomitant depression, anxiety, and disruption of interpersonal relationships and employment.
Diagnosis
Diagnosis is usually apparent on physical examination. When the patient is asked to move certain facial muscles (i.e., smile), other facial muscles will be activated (e.g., the eyes may close involuntarily). When the underlying condition is unclear, a variety of tests may be required, such as CT or
Treatment team
In the broader sense Facial synkinesis may be treated by neurologists, physiotherapists or otorhinolaryngologists.
Treatment
Treatment may include:
* surgery, to remove causative tumors or other sources of pressure on and damage to the facial nerve
* steroid medications, to decrease inflammation of the facial nerve
* facial exercises, with and without mirror stimulated feedback
* electrical stimulation (this remains controversial, and may, in fact, worsen facial synkinesis in some patients)
* intensive video-assisted, electromyographic feedback facial muscle retraining
* injections of the paralytic agent botox into the muscle groups that are contracting involuntarily, or "hypervoluntarily"
Prognosis
The prognosis of facial synkinesis is quite variable, depending largely on the prognosis of the underlying condition that caused its development.
Resources
BOOKS
Goetz, Christopher G., ed. Textbook of Clinical Neurology. Philadelphia: W. B. Saunders Company, 2003.
PERIODICALS
Armstrong, M. W., R. E. Mountain, and J. A. Murray. "Treatment of facial synkinesis and facial asymmetry with botulinum toxin type A following facial nerve palsy." Clin Otolaryngol 21, no. 1 (February 1996): 15–20.
Messé, S. R. "Oculomotor synkinesis following a midbrain stroke." Neurology 57, no. 6 (September 2001): 1106–1107.
Münevver, Çelik, Hulki Forta, and Çetin Vural. "The Development of Synkinesis after Facial Nerve Paralysis." European Neurology 43 (2000): 147–151.
Zalvan, C., B. Bentsianov, O. Gonzalez-Yanes, and A. Blitzer. "Noncosmetic uses of botulinum toxin." Dermatol Clin 22, no. 2 (April 2004): 187–195.
WEBSITES
Diels, H. Jacqueline. New concepts in Non-Surgical Facial Nerve Rehabilitation. Bell's Palsy Infosite. (June 2, 2004). http://www.bellspalsy.ws/printretrain.htm.
hi.did u tried strapping techniques?
I am not aware of strapping ever being used on a facial palsy. Do enlighten us if you have developed some type of "mummification" :)Quote:
Originally Posted by mahiaki
hi. its taping technique. this is done onthe affected side of the face. two pieces of tapes needed. start frm the chin and end finishing near the hairline. another one frm the jaw to the abv area. this is really effective bob. and its very essential too dont u know that sir.
Can you please point us to an image showing this technique or upload an image of your own to show us this technique. Also can you please tell us what it is precisely that the tape is trying to achieve? You can tape just about anything but there just be a rationale for what exactly you are trying to achieve.Quote:
Originally Posted by mahiaki
Facial Muscles Differ from Skeletal Muscles
Facial muscle differs from most other skeletal muscle in several significant ways. Facial muscles:
- Lack muscle spindles
- Have small motor units
- Are relatively slow to degenerate
- Receive emotional as well as volitional neural inputs.
Muscle Spindles
The muscle spindle is the physiologic mechanism by which a muscle contraction is produced in response to a shortening of its fiber during a percutaneous stretch. Therapeutic facilitory techniques such as quick stretch, vibration and tapping rely upon the muscle spindle to stimulate muscle contraction. Because they lack spindles, the use of these techniques to elicit a contraction is ineffective in facial muscles.
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
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.
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
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
:)
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 ...
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
Hi all, I am an Italian physio living in Australia and I'll tell you my experience of
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
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
Hi Ramywhite,
my patient with
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
Hi emmi,
You've covered the subject in excellent way. I will try these techniques. Thank you for sharing your experiences with others.:)
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.
Have you tried including TENS in your electrotherapy? It has helped some of my patients. ;)
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
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?
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.
How exactly is PNF done on the facial muscles? !