Bell's Palsy

[Karie]

I just learned today from a potential patient that Bell's Palsy is now thought to be caused by the Herpes Virus, the same one that causes cold sores. Has anyone seen research or evidence about this? Do you think simple contact type manual therapy would assist in treating this, if this is indeed the case. I have only treated one such case with light touch (CST) technique in the more recent past and had good result, but that was one and I know the symptoms for some can improve rapidly without treatment. Prior to this patient, my experiences were treating the older methods of electrical stimulation and massage (years ago now for me).

Thanks!
Karie:)

[Jason Silvernail]

From what I remember of this condition, it probably will not respond to physical therapy well.
I think in the more prolonged cases, that there may be a role for electrical stimulation regarding prevention of loss of motor units for facial muscles, but that's about all I can think of.

Given that it's not a mechanical problem, I wouldn't expect it to do well. In my clinic, at least. :teeth:

[nari]

I haven't seen a Bell's palsy for many years as we asked doctors back in the 90s not to send them; there was nothing we could do for them that improved recovery rate.
Interesting that it may be linked with herpes; I haven't seen anything that indicates a causative factor apart from flu vaccines, and the latter seems rather tenuous, according to studies.
As it is a paralysis, I have no idea if ideomotion would assist at all, but suspect it would not.
I too used to inflict IDC on patients - a horrid idea in retrospect.
Recovery would either be quick and complete or very long (10+ yrs) and incomplete.

Nari

[emad]

Hi all ;

I am working with facial palsy , i have seen not less than 500 with facial and bell palsy since i had begun my carreer in 2000.



Nari, i do not agree at all with stoping habdling facial palsy from physiotherapy aspect as they will fall in alternative category and chiro if they refused by physiotherapists , extremely non-scientific . yes , currently in 90 s you concluded no role , why not applying , performing research to find out something . Contunining to deal with the patient is of great professional role .

Currently , i consider my role with Facial palsy only explaining /educating regarding what could cause harms /problems , how to avoid developing complications . I see that neglecting the patient ( asking the patient to stay at home ) is great risk because they will gain knowledge from non-scientific resources such as culture , relatives , neighbours ......................................



The issue of being patient is very critical experience ,they at least want to know what is it ? How it will go ? Is there outcome ? Is there an end ?


One of the possible etiologies of facial palsy could be viral , and i see practical some of them have flu in their acute stage .

In Winter when there is a wave of cold , a week latter there will be a wave of facials come to me

Cheers
Emad

[Diane]

Herpes seems to be able to get into any nerve.

I wonder why there are so many in Egypt Emad. How curious.

The last one I saw was at least a dozen years ago.

I don't have a clue what the current approach is.
If I had facial palsy myself, I would tape up my face with tiny strips of kinesio tape, sort of an external face lift, to support it until the tone returned.

[emad]

Diane :

This number only in my private practice and over 1000 in public , may be because we are 80 millions population , only 4 cases with bilateral facial i encountered in 5 years .

I think air drafts theory which you always refute regarding pain is real here in facial palsy ,however this is not reasonable because it should be prevelant in cold countries only and winter only , as i see it also in summer .

One of the most facials is your prime minister attached below .;)
1634

Cheers
Emad

[emad]

This is more clear image for him , seems his nerve injury was not simple degree , or some of Canadian therapies applied for him intensive electrotherapy .

Attached below
1635
Cheers
Emad

[Diane]

Hi Emad,
Actually, this PM is long gone, there have been two since. Different party is in power now, as well.

There must be a genetic predisposition too. Some sort of congenital kinking of the nerve in its tortuous foramen, or perhaps slightly more tortuosity of the foramen, or something like that..

There does seem to be a lot of multiple sclerosis though, especially on the prairies.. genetic cluster though, not weather related - South Africa has a cluster of MS too, and it has quite different weather than the Canadian prairies.

[nari]

Emad,

Facial palsy is not common in Australia; and remember that if any facial palsy patient wants to see us directly, they can. They would be given some mirror work and perhaps reviewed every month or so if needed.
I haven't seen one, even in the free health centre, for many years. We felt it was not fair on them or us to keep them coming when there was little or nothing we could do. There appeared to be no evidence that physiotherapy changed the outcome, so that was one reason. Probably they go to other practitioners, I don't know.

Oddly enough, MS is on the increase here, too. Many more younger patients, in late teens; bit of a worry. I think they may find out it's viral, as well, and a certain age bracket is more susceptible. It doesn't seem to be weather-related, though the higher the latitudes, the greater the risk.
Maybe with global warming the bugs are more virulent and tenacious.

Nari

[Randy Dixon]

We used to see quite a few Bell's Palsy patients, usually they were long term patients and we tried e-stim with them. I don't know how successful this actually was. From what I remember Bells Palsy wasn't caused by the herpes virus or from shingles but that the virus could create a condition that mimicked Bell's Palsy, the primary diagnostic differential was small blistering in the ears. Maybe I should look it up.

[Randy Dixon]

Yeah, Ramsey Hunt syndrome. I don't know if the herpes virus is the cause or merely associated with it though.

[emad]

HI all :

Correct Ramesy Hunt Syndrome is one of the aetiologies ,so that some of those patients complain so much of ear pain complaint .

I am dealing with those patients , i believe i am doing very well to avoid complications through education and improving outcomes in case of contuining to admit/ contact /see that patient .

May be MS is involved in that Prime Minister ,but it clear in the second picture the facial in smiling , yes MS is prevealant in Canada may be environment and weather features.

As for facial palsy , i am dealing with it as neve injury in light of current neuroscience and neurodynamics research.

Cheers
Emad

[Karie]

Thanks everyone for your insights! :lightbulb

[neuron]

Hi all,
i've seen and treated cases with bell's palsy and i too have seen clients diagnosed bell's palsy due to herpes viruses and talking about the management when i was in schol i was taught to do massage, EMS, and tapping which usually helps them to recover with some home facial ex's within a short term period but later i understood and read an article regarding EMS says that without EMS bell's palsy can be recovered. now iam not in touch with bell's palsy and it's treatment trends ........

[Karie]

I asked the person with Bell's Palsy to come in, free of charge, if she wanted me to try and see if I could affect a change. I told her what was done in the past and it was found not to be effective and what you all thought of the possibility of light touch/simple contact type techniques probably not being able to do anything either. She decided to come in and I saw her this morning. She was unable to close her right eye, could not smile on the right side. She looked puffy on the right side of her face and exhibited the characteristic bell's palsy features. I won't go into the specific muscles, although I tested them out to see the extent of involvement. I performed lymphatic drainage and then light touch/ideomotor type techniques to the thoracic inlet, hyoid, mandibular, and temporal/sphenoid/maxillary regions. She could close her eye completely and make a complete smile after one hour of treatment. We talked about exercise and general self-help information for about another 30 minutes and she stated that she could feel pressure being relieved from the cheek region and she felt it was easier to produce mouth patterned movements when she was talking. I told her to call me in the morning and let me know how she was doing etc.
I'll let you know what she tells me. I find this fascinating....any thoughts on what may be happening from your points of view? I'm pondering from the standpoint that the nervous system assisted with directing pressure reduction on the facial nerve, thus allowing for improved communication.

Karie :)

[Diane]

You can't see me Karie, but I'm taking my hat off to you. :)

[Karie]

Wow! Thanks Diane ;)

[Baecker]

hi, i am also currently working in the middle east and i never seen as much cases as i did before in germany. often it looks like the a/c seems to make problems as well as stiff necks.
i found light touch as well very successful. light skin touch with stretches over facial nerves work nicely. thx diane for you skintherapy!

[deeps]

hi karie, its fascinating .well, hope to hear great news ahead. will u plz mention wat r these touch,ideomotor techniques? from where can i get to read more about it. thanks a lot!
cheers
deeps

[Karie]

Hi deep,

The patient I was referring to cleared from her Bell's Palsy within a weeks time of my treatment. She was also doing acupuncture. This has been the experience of mine with the two Bell's Palsy patients I have treated, fast symptom resolution. I don't think I can say with only two that my treatment alone was the causative factor in quick resolution but I do believe it played a role since there were significant changes pre and post treatment immediately.

With that aside, I have difficulty in answering your question on what ideomtor treatment technique I used. Although I am researching heavily and working on the ideomotor/nervous system/skin stretch concepts which are better explaining what is happening under my hands, my methods come from a technique direction that has alot of controversy, Upledger Craniosacral Therapy/Myofascial Release and Chikly Lymphatic Drainage. Therefore, my hand placements and focus of skin stretch come from patterns I learned in these methods. I really can't ethically direct you to their textbooks/courses where they describe these methods without giving you a big note of caution with respect to how they are viewed. I'm still reading various texts that Diane has mentored me toward and I can't say that I am far enough to have found relationship of hand/skin stretch techniques that have similarity to what I have done with these two patients.

Maybe Diane and others can help me here on what Deep is looking for.

I will keep your question in mind Deep as I keep reading and if I find a better text that goes with ideomtor rationale with technique that shows what I did, I will post it here.

Karie:)

[imphysio]

Apart from the views discussed above I would like to add that physiotherapist can do a lot to make a difference in mamangement of Bell's Palsy patient and infact may bring about the early resolution of the Bell's Palsy of facial if treated and understood in right context.

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.