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bell's palsy
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bell's palsy - July 24, 2005 3:56:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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26 y/o female pregnant ( 8 mos.) dx with bells palsy was referred to me for PT. Onset was 14 days ago, reports auricular& mandibular pain that remains constant in intensity since onset, displays L facial paralysis ( no sign of trace motion so I graded 0/5) except for orbicularis oculi graded fair ( able to close eye but not as forceful as R side).
I started her on heat and estim for auricular/mandiblar pain reduction ( with resulting temporary relief), cross friction massage on L side of face to prevent tightness, and facial exercises in front of mirror with me manually assisting L side to achieve symmetry.
Because she is pregnant, her doc did not prescribe any medications except to take tylenol as needed. Pt. only takes it at night, she says to ease her pain and make it easy for her to sleep.
Questions:
1. I read that synkinesis can occur when you start facial exercises too early. When is the right time to start facial exercises?
2. I remember reading that prognosis is good when mm strength improves within 21 days. Otherwise, expect residual paresis. Thoughts?
3. Any suggestions in treating this patient?
Thanks in advance!
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Re: bell's palsy - July 25, 2005 6:33:00 AM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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E-stim with pregnancy ???
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Re: bell's palsy - July 25, 2005 8:26:00 AM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
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Here is a site a found that has exercises. Trying to find an article I once read about it. Can't seem to find it though
http://www.bellspalsy.ws/exercise.htm
Hope this helps.
JMA
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Re: bell's palsy - July 25, 2005 12:13:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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JMA,
Thanks for the site. I actually went to that site before posting here. Having read through some of it was helpful. It seems to me that healing has to occur in the nerve itself before any motion from the facial mm can be expected. Because the pain is still moderate even at 14 days from onset, I consider this a sign that whatever process is going on with that facial nerve is still active. Having the patient imagine the facial movements, and gentle facial exercises with manual assistance to achieve symmetry is all that I think can be done for this patient at this time.
jben,
I understand your question. My understanding is that estim in pregnancy is a relative contraindication, depending on where it is applied. It is contraindicated if applied on the trunk and pelvis. I applied the small electrodes in the pre and post auricular area using interferential current. Anyway, your question made me do some research and found that there are no studies on the effects of estim on pregnancy, remains unknown. Some contraindicate (don't know if relative or not) its use bec. it may cause premature labor. Do you simply not use estim with pregnant women? Thanks for the question, makes me think and look for answers.
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Re: bell's palsy - July 25, 2005 3:10:00 PM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
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Here is one article I found you may want to look at:
"Am J Otolaryngol. 2004 Nov-Dec;25(6):394-400.
Physiotherapy in patients with facial nerve paresis: description of outcomes.
Beurskens CH, Heymans PG.
Department of Physiotherapy, University Medical Centre, 6500 HB Nijmegen, The Netherlands. c.beurskens@fysioth.umcn.nl
PURPOSE: The purpose of this study was to describe changes and stabilities of long-term sequelae of facial paresis in outpatients receiving mime therapy, a form of physiotherapy. MATERIAL AND METHODS: Archived data of 155 patients with peripheral facial nerve paresis were analyzed. Main outcome measures were (1) impairments: facial symmetry in rest and during movements and synkineses; (2) disabilities: eating, drinking, and speaking; and (3) quality of life. RESULTS: Symmetry at rest improved significantly; the average severity of the asymmetry in all movements decreased. The number of synkineses increased for 3 out of 8 movements; however, the group average severities decreased for 6 movements; substantially fewer patients reported disabilities in eating, drinking, and speaking; and quality of life improved significantly. CONCLUSION: During a period of approximately 3 months, significant changes in many aspects of facial functioning were observed, the relative position of patients remaining stable over time. Observed changes occurred while the patients participated in a program for facial rehabilitation (mime therapy), replicating the randomized controlled trial-proven benefits of mime therapy in a more varied sample of outpatients.
PMID: 15547807 [PubMed - indexed for MEDLINE"
JMA
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Re: bell's palsy - July 25, 2005 6:00:00 PM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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Dragonfire:
I tend not to use E-stim for pregnant women...I guess I stay on the cautious side!!
jma: thanks for the reference
*I just evaluated a 17 yo female this AM with facial weakness secondary to acoustic neuroma, she also had radiation Rx...I have to look into this study as well as see if any others are useful..currently I plan to initiate facial muscle exercises with the pt assisting with the movement via her fingers ??
*haven't really had much experience with a case like this.
JBeneciuk
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Re: bell's palsy - July 26, 2005 1:59:00 PM
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FLAOrthoPT
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Joined: May 8, 2004
From: West Palm Beach
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i have only seen one pregnant person whom happens to have bells coincidentally enough. Turns out she had shingles in her ear causing it. Hormones go nuts when pregant, I'd have her thoroughly checked for factors such as shingles. This patient went on iv antibiotics and i think steroids in the hospital per conerence with her ob gyn and other physicians and it totally cleared up and baby was fine. Just food for thought-
Ben
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Re: bell's palsy - July 27, 2005 7:45:00 AM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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good news!
16 days after onset, auricular pain has improved (8/10 to 3/10) and the best part is, she now has trace grade on all except zygomaticus major which remains 0/5. In this particular case, I think that pain was a sign of what was going on with her facial nerve and when it decreased, decompression of the nerve also decreased and so movement slowly returned. What joy I felt, what a relief I felt that she has improved significantly without steroids. Ben, her OB gyn didn't want her on anything except tylenol PRN. But you're right about hormones going out of whack during pregnancy. I know that some propose that Bells is viral in origin so r/o shingles is prudent.
thanks for the article, jma. will look more into it when i get home. i wonder if the mime exercises in the study are similar to the mental exercises written found on the web site in your first post.
jben, like you, i dont have much experience with cases like this. For the facial exercises, I palpated for the facial mm involved in the particular motion, placed my fingers in that area moved to produce symmetry while patient is infront of the mirror doing the exercise. I taught her how to do it and to do the motion gently, avoiding other mm from being recruited to avoid later complications of synkinesis.
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Re: bell's palsy - July 27, 2005 2:34:00 PM
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jma
Posts: 2405
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From: NY
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Its possible if you look in the references the articles used. Glad the patient is doing better.
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Re: bell's palsy - July 27, 2005 4:17:00 PM
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jbeneciuk
Posts: 112
Joined: November 26, 2004
From: Jacksonville, FL
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Dragonfire:
thakns for the feedback !!
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Re: bell's palsy - July 28, 2005 6:11:00 AM
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Yogi
Posts: 403
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From: San Antonio, Tx., USA
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I saw several Bell's Palsy pt's. in the early 90's. Info then suggested a correlation with temperature changes as an etiology. Prognosis was self limiting, with residual paresis proportional to duration of pain. I had the old Mettler E-stim unit and it seemed to help resolution with pads across the direction of the foramen of the facial n. Later I read an article in the PT Forum about a fellow with good results with ionto. at the foramen. Exercise for the facial muscles made little sense to me, including e-stimming the muscles, since the problem is essentially the same as a spinal cord compression, due to the cranial n. swelling in the faramen, denervating the muscles.
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Re: bell's palsy - July 28, 2005 5:54:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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I found this abstract on obgynsurvey.com
"Bell Palsy Complicating Pregnancy: A Review.
Obstetrical & Gynecological Survey. 55(3):184-188, March 2000.
Cohen, Yoram MD *; Lavie, Ofer MD +; Granovsky-Grisaru, Sorina MD ++; Aboulafia, Yeshaya MD [S]; Diamant, Yoram Z. MD [P]
Abstract:
The aim of the present work was to review the published evidence on the association of Bell palsy (BP), an acute idiopathic peripheral facial paralysis of unknown etiology, with pregnancy. Reports have shown that women of reproductive age are affected two to four times more often than men of the same age, and pregnant women 3.3 times more often than nonpregnant women. The apparent predisposition of pregnant women to Bell palsy has been attributed to the high extracellular fluid content, viral inflammation, and immunosuppression characteristic of pregnancy, but findings are controversial. Most cases of Bell palsy occur in the third trimester or the puerperium. Onset is acute and painful. Some authors suggest that Bell palsy increases the risk of hypertension and toxemia of pregnancy, whereas the pregnant state, in turn, may affect the course and severity of disease. Recovery is usually good; poor prognostic markers are recurrence in subsequent pregnancy and bilateral disease, both of which are rare. Neonatal outcome is apparently unaffected, although this has been studied rarely. The preferred mode of management remains undecided; it is usually confined to supportive care. Corticosteroids in pregnancy are controversial. We think clinicians should be aware of these findings to avoid unnecessary testing and treatment and to help the patient cope with this acute, painful disease."
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Re: bell's palsy - July 28, 2005 6:26:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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Found this study on the use of estim to possibly effect partial reinnervation in facial paresis/paralysis...
"Otolaryngol Head Neck Surg. 2000 Feb;122(2):246-52. Related Articles, Links
Click here to read
Effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy.
Targan RS, Alon G, Kay SL.
National Center for Facial Paralysis, Inc, Washington, DC 20037, USA.
PURPOSE: This study investigated the efficacy of a pulsatile electrical current to shorten neuromuscular conduction latencies and minimize clinical residuals in patients with chronic facial nerve damage caused by Bell's palsy or acoustic neuroma excision. SUBJECTS: The study group included 12 patients (mean age 50.4 +/- 12. 3 years) with idiopathic Bell's palsy and 5 patients (mean age 45.6 +/- 10.7 years) whose facial nerves were surgically sacrificed. The mean time since the onset of paresis/paralysis was 3.7 years (range 1-7 years) and 7.2 years (range 6-9 years) for the Bell's and neuroma excision groups, respectively.Method And Procedures: Motor nerve conduction latencies, House-Brackmann facial recovery scores, and a 12-item clinical assessment of residuals were obtained 3 months before the onset of treatment, at the beginning of treatment, and after 6 months of stimulation. Patients were treated at home for periods of up to 6 hours daily for 6 months with a battery-powered stimulator. Stimulation intensity was kept at a submotor level throughout the study. Surface electrodes were secured over the most affected muscles. Groups and time factors were used in the analyses of the 3 outcome measures. RESULTS: No statistical differences were found between the two diagnostic groups with respect to any of the 3 outcome measures. Mean motor nerve latencies decreased by 1.13 ms (analysis of variance test, significant P = 0.0001). House-Brackmann scores were also significantly lower (Wilcoxon signed rank test, P = 0.0003) after treatment. Collective scores on the 12 clinical impairment measures decreased 28.7 +/- 8.1 points after 6 months [analysis of variance test, significant P = 0.0005). Eight patients showed more than 40% improvement, 4 better than 30%, and 5 less than 10% improvement in residuals score. CONCLUSION: These data are consistent with the notion that long-term electrical stimulation may facilitate partial reinnervation in patients with chronic facial paresis/paralysis. Additionally, residual clinical impairments are likely to improve even if motor recovery is not evident.
PMID: 10652399 [PubMed - indexed for MEDLINE]"
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Re: bell's palsy - July 28, 2005 6:45:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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Got this from emedicine.com
HOUSE-BRACKMAN SCALE is used to evaluate facial nerve function.
Classification includes the following:
1. Normal
2. Mild dysfunction (slight weakness normal symmetry at rest)
3. Moderate dysfunction (obvious but not disfiguring weakness with synkinesis, normal symmetry at rest)
4. Moderately severe dysfunction (obvious and disfiguring asymmetry, significant synkinesis)
5. Severe dysfunction (barely perceptible motion)
6. Total paralysis (no movement)
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Re: bell's palsy - July 28, 2005 7:02:00 PM
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dragonfire
Posts: 61
Joined: January 18, 2005
From: usa
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This one's a great reference.
"Physical Therapy Volume 79 · Number 4 · April 1999
Case Report
Physical Therapy for Facial Paralysis: A Tailored Treatment Approach
Jennifer S Brach and Jessie M VanSwearingen
Background and Purpose. Bell palsy is an acute facial paralysis of unknown etiology. Although recovery from Bell palsy is expected without intervention, clinical experience suggests that recovery is often incomplete. This case report describes a classification system used to guide treatment and to monitor recovery of an individual with facial paralysis. Case Description. The patient was a 71-year-old woman with complete left facial paralysis secondary to Bell palsy. Signs and symptoms were assessed using a standardized measure of facial impairment (Facial Grading System [FGS]) and questions regarding functional limitations. A treatment-based category was assigned based on signs and symptoms. Rehabilitation involved muscle re-education exercises tailored to the treatment-based category. Outcomes. In 14 physical therapy sessions over 13 months, the patient had improved facial impairments (initial FGS score=17/100, final FGS score=68/100) and no reported functional limitations. Discussion. Recovery from Bell palsy can be a complicated and lengthy process. The use of a classification system may help simplify the rehabilitation process. [Brach JS, VanSwearingen JM. Physical therapy for facial paralysis: a tailored treatment approach. Phys Ther. 1999;79:397-404.]
Key Words: Bell palsy, Classification system, Facial neuromuscular re-education, Facial paralysis.
Bell palsy is an acute facial paralysis of unknown etiology. Bell palsy most commonly occurs between the ages of 15 and 60 years, with 15- to 44-year-olds experiencing the highest incidence.1 In 1982, Peitersen1 outlined the natural history of Bell palsy after studying 1,011 patients for 1 year following their development of facial paralysis. Thirty-one percent of the patients had incomplete paralysis, and 69% of the patients had complete paralysis of the facial muscles. Normal facial function returned in 71% of the patients, and this recovery occurred within 3 to 8 weeks after the onset of paralysis.1 Peitersen1 reported that age has a strong influence on the recovery process. Ninety percent of the patients aged 0 to 14 years recovered completely, whereas only 37% of the patients over 60 years of age recovered completely. Peitersen concluded that the sooner some facial function returned, the more favorable the overall outcome.
Individuals with Bell palsy, in our opinion, seldom receive physical therapy. Typically, the patients are told to do nothing and that facial movement will return without intervention.2-4 Patients referred for physical therapy are often treated with electrical stimulation of the facial muscles and facial movement exercises to be completed with maximal effort.4 The outcomes of such interventions were less than optimal, with the patients often developing mass action or synkinesis (abnormal movement of the face accompanying a desired motion).5 Several studies on animal models indicate that the use of electrical stimulation is disruptive to reinnervation6-8 and thus may be contraindicated for individuals with facial nerve disorders.5
Facial neuromuscular re-education is a conservative approach to facial rehabilitation. Demonstrated outcomes of facial neuromuscular re-education include improvements in impairments associated with facial paralysis.9-12 Facial neuromuscular re-education consists of an evaluation of facial impairments and functional limitations, guided training sessions of correct movement patterns, and instruction in a specific facial movement exercise program.5,12,13
Facial neuromuscular re-education techniques address the impairments and functional limitations of patients with facial paralysis.
From our clinical experience in treating individuals with facial nerve disorders, we found that subgroups of patients had characteristic signs and symptoms that could be recognized prior to treatment. Based on these signs and symptoms, we found that we could identify the impairment that would respond to a certain intervention. Therefore, we developed a classification scheme based on the intervention tailored to the signs and symptoms that could also be used to guide treatment (Tab. 1).13 After the treatment-based category is identified, a physical therapy program consisting of neuromuscular re-education matched to the assigned category is then initiated.
Surface electromyography (sEMG) biofeedback or a mirror may be used as an adjunct to the retraining exercises in each of the treatment-based categories. The sEMG biofeedback is not the treatment; exercises are the treatment. The facial muscles have few, if any, muscle spindles.12,14,15 Thus, little information about muscle length and action is available to the individual. Learning facial movements is difficult without the feedback. We have found that the use of sEMG or a hand mirror is a means of providing a visual or auditory representation of facial muscle activity (sEMG) or movement (mirror). Patients are also instructed in a home facial movement exercise program, which is based on the treatment-based category (Tab. 1) and the patients' performance during the rehabilitation session. The purpose of this case report is to describe the facial rehabilitation process using facial neuromuscular re-education and a treatment-based classification system in the treatment of an individual with Bell palsy.
Case Description
The patient ("MC") was a 71-year-old woman who was diagnosed with Bell palsy of the left facial nerve and complete left facial paralysis. The initial physical therapy evaluation was conducted 2 weeks following the onset of the facial paralysis. At the time of the initial evaluation, the patient had no other active medical problems. The patient reported that her facial paralysis came on suddenly and was accompanied by pain in her left ear and a funny feeling in her tongue. The paralysis was associated with no pain or sensory deficits in the left side of the face. The patient reported no hearing loss, but she reported hearing swishing sounds in her left ear. She had a magnetic resonance imaging scan of her head, and no abnormalities were found. Electrodiagnostic testing was not performed. One week after the onset of her symptoms, she started a 7-day tapered dosage of steroid therapy.
The physical therapy evaluation consisted of grading resting posture, voluntary movement, and the presence of synkinesis or abnormal movement, using the Facial Grading System (FGS) developed by Ross and colleagues.16 The FGS is an observer-based rating scale that is responsive to change.16 Ross et al indicated that the changes in scores on the resting symmetry component of the scale occur more slowly with rehabilitation than scores on the movement or synkinesis components of the scale. The scores of the FGS range from 0 (complete paralysis) to 100 (normal facial function).
The 3 sections to the FGS--resting posture (FGS rest), voluntary movement (FGS movement), and synkinesis (FGS synkinesis)--are scored individually, and the scores are combined for a total or composite score. The FGS rest section consists of rating 3 facial areas for symmetry: (1) palpebral fissure (normal [0], narrow [1], wide [1], or eyelid surgery [1]), (2) nasolabial fold (normal [0], absent [2], less pronounced [1], or more pronounced [1]), and (3) corner of the mouth (normal [0], drooped [1], or pulled up and out [1]).
The FGS rest section scores range from 0 to 4 and are weighted by a multiplier of 5 for a total FGS rest score of 0 to 20. The symmetry of 5 voluntary facial movements (brow raise, eye closure, snarl, smile, and pucker) are rated on a 5-point scale to determine the FGS movement score. The FGS movement scores range from 5 to 25 and are weighted by a multiplier of 4 for a total FGS movement score of 20 to 100. The degree of synkinesis associated with each of the voluntary movements is graded on a 4-point scale from 0 (no synkinesis, or no abnormal or pass movement patterns) to 3 (severe synkinesis, or disfiguring abnormal movement or gross mass movement of several muscles). The FGS synkinesis scores range from 0 to 15. For both the FGS rest and FGS synkinesis sections, a higher score relates to greater impairments. For the FGS movement section, a lower score relates to greater impairment. The FGS score is calculated as follows: FGS=FGS movement-FGS rest-FGS synkinesis. The reliability17 and construct validity16,17 for the use of the FGS have been demonstrated. Interrater reliability (r=.90) and intrarater reliability (r=.94) of the FGS scores were determined, using the type 2,1 intraclass correlation coefficient, for 2 physical therapists who scored videotapes of 15 individuals with facial nerve disorders.17 Construct validity was determined for the FGS by comparison with a quantitative measure of facial motion16,17 (Spearman rank-order correlation=.70-.87) and with the House-Brackmann facial grading system.16 Ross et al16 demonstrated that the FGS is sensitive to change by comparing prerehabilitation and postrehabilitation scores for 19 patients with facial nerve disorders.
We used the FGS to monitor progress and to describe the patient at different stages of recovery. The FGS scores were not used to determine the treatment-based category.
The patient's functional limitations were determined through an interview process consisting of a set of questions asked at each subsequent visit. The patient was asked questions regarding her eye and mouth function and how this function may have interfered with her daily activities.
During the initial evaluation, the patient had severe asymmetry in resting facial posture. The left side of her face was markedly drooped, and her left eye was much wider than her right eye (FGS rest score=15). Voluntary movement, as compared with movement of the uninvolved side, was trace to minimal. She initiated slight movement with severe asymmetry throughout all regions of the face (FGS movement score=32). As is typical in this stage of recovery when movement is minimal, the patient had no signs of synkinesis or abnormal movement patterns (FGS synkinesis score=0). Her composite FGS score on the initial evaluation was 17/100 (ie, 32-15-0=17).
MC was retired and lived alone. She reported little difficulty in eating, drinking, speaking, and closing her eye; however, she relied on compensatory techniques such as drinking from the uninvolved side of her mouth, lifting her cheek with her hand while speaking, and manually closing her eye. Because of her poor corneal protection, she had to stop her regular swimming exercise program, and she appeared motivated to improve her facial function so that she could return to swimming.
Intervention
Overview of Intervention
To assist the patient in her goal of improved facial functioning, she was treated with facial neuromuscular retraining (NMR) techniques, using a hand-held mirror or sEMG biofeedback.5,11-13 Treatment planning was based on the evaluation findings and on treatment-based categories. Treatment sessions were one on one with a physical therapist for approximately 1 hour (see Tab. 2 and the "Service Delivery" section for details). A typical physical therapy session consisted of a brief re-evaluation, training with sEMG or a mirror, and instruction in an exercise program to be completed at home.
Surface EMG biofeedback was used initially to measure muscle activity associated with voluntary facial movements. Surface EMG biofeedback devices can be used to record and display small changes in muscle activity that cannot be seen in a mirror. MC found this information helpful when she started regain movement. As she was able to move more, she used the surface EMG biofeedback less and a mirror more.
When MC developed abnormal movement patterns or synkinesis, the surface EMG biofeedback again played an important role in the physical therapy session. She developed an abnormal movement pattern such that when she snarled, her left eye would close while her right eye stayed open. MC was unaware that this was happening. Surface EMG biofeedback during exercise sessions helped to make her more aware of the abnormal movement. We placed the recording electrodes over the levator labii muscle (snarl muscle) and the inferior oculi muscle (eye closure). MC would practice snarling and raising the line on the sEMG biofeedback screen associated with the levator labii muscle activity while keeping the activity from the inferior oculi muscle to a minimum. The sEMG biofeedback would often record activity in the inferior oculi muscle prior to any visible eye closure, providing MC with the information necessary to correct her movements.
Initiation
Based on the initial signs and symptoms (severe resting asymmetry, minimal voluntary movement, absent synkinesis, and impaired function), MC was considered to be in an initiation treatment category (Tab. 1). Exercises typical for the initiation category include active assisted range of motion exercises, during which the patient used the fingers of her hand to position a part of her face at a position in the range of motion for a specific movement and tried to hold the position using the targeted facial muscle while removing the passive assist. Often, patients find that it is easier to hold a position with a muscle than it is to move to the desired position (eg, having a patient passively raise the involved eyebrow with a hand, then slowly removing the passive assist as the patient tries to activate the frontalis muscle and maintain the brow raise). MC used these techniques, as part of her home exercise program, for the following facial expressions: smile, pucker, brow raise, and frown.
Because MC could not voluntarily close her eye and had signs and symptoms of corneal irritation typical of patients in the initiation category, exercises focusing on closing the eye. Squinting or raising the lower eyelid was also included in the home facial exercise program. An exercise that appears to allow the patient control over the Bell reflex18 (eye rolling backward) is helpful to achieve a more complete eye closure. The patient is instructed to focus both eyes on an object positioned 30.5 cm (12 in) down and in front of the patient and then to attempt to close both eyes. The eyes are to remain focused on this point until they are closed. Focusing the eyes downward helps to initiate the lowering of the upper eyelid. Maintaining the focused position until the eyes are closed prevents the Bell reflex, which can trick the patient into thinking that the eye is closed.
Muscle fatigue is often a concern when a patient is learning to initiate facial movements. To help avoid fatigue, MC was instructed to do 5 to 10 repetitions of the facial exercises (smile, pucker, brow raise, frown, and eye closure) 3 times a day. The number of exercises was kept to a minimum (3-5 exercises) because, in our experience, patients are more likely to adhere to a regimen consisting of a few exercises than to a regimen consisting of many exercises. MC often reported doing more exercises than were given to her because she wanted to expedite her recovery.
Facilitation
A re-evaluation done 6 weeks and 3 physical therapy sessions later (1 visit every other week) revealed that the patient's resting posture was unchanged, as measured by the FGS (FGS rest score=15). Her face was less drooped but still not symmetrical. Voluntary movement had increased to minimal to moderate movement. She initiated movement with mid-excursion and moderate asymmetry for all facial movements (FGS movement score=56), and there was no evidence of synkinesis (FGS synkinesis score=0). The composite or total FGS score was 41/100. MC reported less difficulty with eating and drinking than at the initiation of treatment, but she had continued difficulty protecting the cornea of her eye. She was able to close her eye completely, but only with conscious effort. She was still unable to return to swimming.
Based on the increased voluntary movement and absent synkinesis, the patient was considered to be in the facilitation category of treatment. The patient was instructed in active and resisted facial movement exercises typical for patients with some movement, no abnormal movement, and no difficulty with activities of daily living. She was instructed to do symmetrical active facial movements without allowing the voluntary movement of the uninvolved side of the face to distort the movement of the involved side of the face. Maintaining symmetry is an important part of facial movement exercises. When the uninvolved facial muscles overpower the involved facial muscles, the facial posture tends to shift to the uninvolved side. When the facial posture shifts, the involved muscles are placed at a less-than-optimal length for functioning (stretched). By maintaining symmetry and a more optimal length of the involved facial muscles during voluntary facial movements, we believe that the involved muscles have a better chance of functioning. In our opinion, small symmetrical facial movements also make it easier to detect small amounts of facial motion that may not be apparent if the resting facial posture is shifted due to overpowering of the uninvolved facial muscles.
When some active movements are difficult to perform, such as lowering the bottom lip, functional activities, such as saying specific sounds, are used for exercise. The activity of lowering the bottom lip is an important component of saying words that begin with the letter "F." MC reported practicing a word list to be easier than doing lip movement exercises, presumably because of her greater familiarity with the word task than with isolated oral movements.
Resistive facial exercises may be appropriate if the patient has no signs of synkinesis. Manual resistance is applied in the opposite direction of the desired movement. Resistance should be applied to only isolated facial movements, without causing mass action or synkinesis. Care must be taken not to overstrengthen the uninvolved facial muscles, which would cause an even greater imbalance. An example of resistive facial exercises would be for the patient to provide resistance to the upper lip with a finger while attempting to pucker.
Facial muscle fatigue is no longer a primary concern when the patient is in the facilitation category. The patient is instructed to do a large number of repetitions (10-20) of active or resistive exercises 1 to 2 times a day. Again, the number of exercises is limited to 3 to 5 to keep the patient focused on the area needing the most work and to improve adherence to the exercise program. A typical exercise program for MC at this time would be 10 to 20 repetitions of 3 to 5 exercises to be completed 1 to 2 times a day.
Movement Control
Seven months after the initiation of therapy and 11 physical therapy sessions, MC's resting posture had changed from a drooping brow, lower eyelid, cheek, and mouth corner to a raised lower eyelid and a retracted cheek and mouth corner. The FGS rest score remained 15 but now represented the narrowing of her left eye as compared with her right eye, and the retraction of the left cheek and mouth corner. Voluntary movement had improved throughout the left side of the patient's face and was almost symmetrical with that of the uninvolved side (FGS movement score=84). At this point, MC had started to develop mild abnormal movement patterns or synkinesis with brow raise and snarl motions (FGS synkinesis score=2). When she would raise her eyebrows or snarl, her left eye would close slightly. Her FGS score was 67/100.
The patient's facial functioning had continued to improve. She had no problems with eating or performing oral hygiene (brushing her teeth). She reported only slight difficulty drinking from a glass without compensation techniques and only occasional problems with eye closure and protection. She was still unable to resume swimming because she could not adequately protect her cornea.
Based on the appearance of inappropriate muscle activity and the presence of abnormal movement, the patient was now considered to be in the movement control category of treatment, with the facilitation category a secondary classification. Exercises focused on controlling the abnormal or synkinetic movement, such as raising the brow while keeping the eye open and controlling the ocular synkinesis. Movement control facial exercises emphasize moving only as much as the patient can without triggering the abnormal facial movement. The range of the movement is increased as long as the abnormal movement is controlled. The patient is told to concentrate on the quality of the exercise and not the quantity of the exercises completed. It is better for a patient to do 5 repetitions of an exercise correctly than it is to do 20 repetitions incorrectly. MC was instructed to do as many repetitions of the control exercises that she could do correctly and to perform these exercises several times a day.
Because facial muscle tightness often accompanies synkinesis, it is important to teach the patient facial muscle stretching exercises. The patient was instructed in a stretching exercise that consisted of placing her right thumb inside her mouth, grasping the left cheek, and pulling the cheek down and across her face, thus applying a stretch to the cheek musculature. The stretch was held for 20 seconds. The patient was instructed to stretch her cheek 2 to 3 times, twice a day, to prevent shortening of muscle tissue. She was instructed to stretch her cheek more often if she experienced cheek muscle tightness throughout the day.
Strengthening exercises for specific movements were continued as long as they did not cause synkinesis. MC was instructed to continue with 2 to 3 of the strengthening exercises (10-20 repetitions), 1 to 2 times a day, as explained in the "Facilitation" section.
The patient's last physical therapy visit was 13 months after the initiation of therapy. She continued to demonstrate asymmetry in resting posture, which consisted of a narrow eye and a tight cheek (FGS rest score=15). Voluntary movement had improved slightly to almost complete to complete movement between the sides (FGS movement score=88), and the abnormal movement or synkinesis had increased slightly to minimal with all movements (FGS synkinesis score=5). Her FGS score was 68/100. The biggest change appeared to be in function. The patient reported no difficulties with eating, drinking, speaking, or protecting the cornea of her eye. She had even resumed swimming. Patient satisfaction was high by patient report.
Based on these signs and symptoms, we still considered the patient to be in the movement control treatment category, with relaxation the secondary treatment category. Because minimal changes were noticed in voluntary movement in the previous 7 months, strengthening was no longer, in our opinion, a reasonable goal. We instructed the patient in a final program to help maintain her facial function and to prevent any inappropriate muscle activity or synkinesis. The program consisted of isolated facial movements, stretching, facial massage, and relaxation exercises19 typical for patients in the movement control and relaxation treatment categories. Jacobsen's relaxation exercises19 and the same technique of progressively contracting and relaxing of muscles was applied to specific facial muscles. For example, MC was told to wrinkle her nose and to raise her upper lip as much as she could, holding the contraction for 3 to 5 seconds, and then to "let go," releasing the muscle contraction completely. MC was instructed to continue with this program one time a day, gradually weaning herself from the exercise program. She was told to continue with the facial muscle stretches at least one time a day or more as she felt she needed it to prevent further facial muscle tightness.
Outcomes
Service Delivery
The patient was treated over a 13-month period and seen for only 14 physical therapy sessions. Initially, the treatment sessions were more frequent (2-4 times per month) because of the need for instruction and for the patient to become familiar with the exercise process. As the patient became more aware of her facial movements, she was treated less frequently (once every 3 months). Table 2 shows the physical therapy schedule.
Impairment and Functional Limitation
The patient demonstrated improvements as facial impairments and functional limitations became less severe (Tab. 3). In our opinion, moderate improvements were made in symmetry of the face at rest, even though these improvements were not evident in the FGS rest scores. The FGS grades resting posture as being either symmetrical or asymmetrical and does not account for levels of severity. The most noticeable changes were the improvement of her voluntary movement (FGS movement), which occurred in the first 7 months of treatment, and the development of synkinesis (FGS synkinesis) in the seventh month.
The patient's functional activities improved so that after 13 months she had no difficulty eating, drinking, speaking, or protecting the cornea of her eye. She no longer had to rely on compensatory techniques to complete her activities of daily living. She had even returned to swimming between the 7th and 13th months of treatment. The patient was highly satisfied with her outcome.
Discussion
In our experience, individuals with Bell palsy are seldom referred for physical therapy at the onset of the disorder. Often, they are told to wait and that this condition will get better on its own. Complete recovery does not always occur, especially in high-risk populations such as people who are elderly or who have delayed recovery.1
Physical therapists rarely continue to treat patients for 13 months. We believed, however, that this treatment duration was necessary to achieve the outcomes for this patient. For the first 7 months, the patient had facial weakness and was treated with strengthening exercises. At the 7-month visit, she had facial muscle overactivity and synkinesis. At this point, the treatment plan was adjusted to fit the changes in her facial impairments. If the physical therapy had been terminated prior to this 7-month mark, her problems of facial muscle tightness and synkinesis would not have been addressed. Instructing the patient in a maintenance program at the last physical therapy session may help to prevent an increase in facial muscle tightness and synkinesis over time. Although 13 months may seem like a long time to treat a patient, the total number of physical therapy visits was only 14 visits.
Physical therapy for patients with facial paralysis traditionally has consisted of generic facial exercises or electrical stimulation.4 Facial neuromuscular re-education techniques (ie, the use of facial exercises to address a patient's impairments and functional limitations) are different from the traditional intervention for facial paralysis. In our approach, the exercise program changes over time as the patient's impairments change with recovery. The facial neuromuscular re-education exercise program emphasizes accuracy of facial movement patterns and isolated muscle control, and it excludes exercises that promote mass contraction of muscles related to more than one facial expression. In our approach, the number of exercise repetitions and the frequency of the exercise program depend on the treatment-based categories, which are based on the patient's impairments (Tab. 1).
Continued research is needed to determine the best treatment for individuals with facial neuromuscular disorders. A first step could be to validate the treatment-based classification system based on the physical signs and symptoms of individuals with facial neuromuscular disorders. If the classification system is validated, the effectiveness of physical therapy intervention with a "tailored" treatment approach for each of the treatment categories can be determined.
References
1 Peitersen E. Natural history of Bell's palsy. In: Graham MD, House WF, eds. Disorders of the Facial Nerve. New York, NY: Raven Press, 1982:307-312.
2 Ohye RG, Altenberger EA. Bell's palsy. Am Fam Physician. 1989;40:159-166.
3 Bateman DE. Facial palsy. Br J Hosp Med. 1992;47:430-431.
4 Waxman B. Electrotherapy for treatment of facial nerve paralysis (Bell's palsy). In: Anonymous Health Technology Assessment Reports. 3rd ed. Rockville, Md: National Center for Health Services Research, 1984:27.
5 Diels JH. New concepts in nonsurgical facial nerve rehabilitation. Advances in Otolaryngology-Head and Neck Surgery. 1995;9:289-315.
6 Cohan CS, Kater SB. Suppression of neurite elongation and growth cone motility by electrical activity. Science. 1986;232:1638-1640.
7 Brown MC, Holland RL. A central role for denervated tissues in causing nerve sprouting. Nature. 1979;282:724-726.
8 Girlanda P, Dattola R, Vita G, et al. Effect of electrotherapy on denervated muscles in rabbits: an electrophysiological and morphological study. Exp Neurol. 1982;77:483-491.
9 Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope. 1991;101:744-750.
10 Brudny J, Hammerschlag PE, Cohen NL, Ransehoff J. Electromyographic rehabilitation of facial function and introduction of a facial paralysis grading scale for hypoglossal-facial nerve anastomosis. Laryngoscope. 1988;98:405-410.
11 Brach JS, VanSwearingen JM, Lennert J, Johnson PC. Facial neuromuscular retraining for oral synkinesis. Plast Reconstr Surg. 1997;99:1922-1931.
12 Brudny J. Biofeedback in facial paralysis: electromyographic rehabilitation. In: Rubin L, eds. The Paralyzed Face. St Louis, Mo: Mosby-Year Book, 1991:247-264.
13 VanSwearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther. 1998;78:678-689.
14 Baumel JJ. Trigeminal-facial nerve communications: their function in facial muscle innervation and reinnervation. Arch Otolaryngol. 1974;99:34-44.
15 Burgess PR, Wei JY, Clark FJ, Simon J. Signaling of kinesthetic information by peripheral sensory receptors. Annu Rev Neurosci. 1982;5:171-187.
16 Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg. 1996;114:380-386.
17 Brach JS, VanSwearingen JM, Delitto A, Johnson PC. Impairment and disability in patients with facial neuromuscular dysfunction. Otolaryngol Head Neck Surg. 1997;117:315-321.
18 Jelks GW, Smith B, Bosniak S. The evaluation and management of the eye in facial palsy. Clin Plast Surg. 1979;6:397-419.
19 Jacobson E. Progressive Relaxation. 2nd ed. Chicago, Ill: University of Chicago Press, 1938.
Copyright 1999 by the American Physical Therapy Association.
Author Information
JS Brach, PT, GCS, is Clinical Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA) (jsbst6+@pitt.edu), and Doctoral Student, Department of Epidemiology, University of Pittsburgh. She was Staff Physical Therapist, Facial Nerve Center, CORE Network, LLC, Pittsburgh, Pa, at the time of this study. Address all correspondence to Ms Brach.
JM VanSwearingen, PhD, PT, is Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, and Director of Rehabilitation, Facial Nerve Center, CORE Network, LLC.
Article Information
This article was submitted April 15, 1998, and was accepted September 3, 1998."
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Re: bell's palsy - July 29, 2005 3:39:00 PM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
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Yes, this is a great article. It was used by a study to do an inservice and it was very helpful. Tried to find it but I forgot the title. Nice job looking it up.
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Re: bell's palsy - July 31, 2005 5:55:00 PM
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Yogi
Posts: 403
Joined: April 5, 2004
From: San Antonio, Tx., USA
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It made sense to me to try to effectively treat in the acute stage at the foramen for the edema, to try to limit the damage. I used a battery handheld faradic stim for take home use for specific m. stim. using a mirror, as noted in the study above, during the rehab stage. I'm not sure how much clinical usefulness the study of 3.7 years post injury 6 hours daily 6 months e-stim is.
Second paper is good info.
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Re: bell's palsy - August 11, 2005 9:59:00 PM
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Randy Dixon
Posts: 744
Joined: August 6, 2004
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I was reading this and I heard several mentions of shingles and pain in the ear, little bells went off that I couldn't quite pin, but here is what those little bells were. (Hey, I made a pun)
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.
** If you've been diagnosed with Bell's palsy, but later see blisters that may be shingles, its important that you notify your health care professional. **
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Re: bell's palsy - August 12, 2005 4:35:00 PM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
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Thats an interesting post. Will try to keep this in mind when looking into a patient's history, who has been dx with Bell's palsy.
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Re: bell's palsy - September 3, 2005 2:33:00 PM
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Dr.Wagner
Posts: 1242
Joined: January 24, 2003
From: Indianapolis
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The biggest portion of the differential is not RHS vs Bells, it is Typical Shingles vs RHS.
A common board question in medicine is that Typical Shingles does NOT cause blisters on the TM.
Furthermore the biggest nerve to worry about is the Facial Nerve (VII) as a branch runs posterior to the TM.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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