Bell's palsy

[tunglokc]

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

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

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

[physiobob]

Hi tunglokc,

There are already a number of useful posts on the forum surrounding Bell's Palsy. Might I suggest you click on the tags section on the navigation bar at the top of this page. If you then click on the word Palsy would will be taken to a few of these posts.

I hope this assists.

[sdkashif]

Some briefing about the Facial Palsy or Bell's palsy is as under:

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.

[emad]

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

[1234nale]

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

[emad]

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

[physiobob]

Originally Posted by 1234nale

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

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?).

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.

[emad]

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

[vasanth]

Originally Posted by tunglokc

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

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

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

These articles may be of benefit please visit the following web site i.d.

ES Is it Helpful? - http://www.ptjournal.org/cgi/content...urcetype=HWCIT

Exercises - http://www.ptjournal.org/cgi/reprint...urcetype=HWCIT

[1234nale]

Sdkshif

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.

[physiobob]

Originally Posted by 1234nale

Sdkshif


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 in Bell's Palsy. However holding a tuning fork to one's head transmits sound waves to the brain. The study cited suggested that in fact US to the head in the temporal bone region might well be useful for clot lysis. One could infer from that that they are suggesting it might provide a useful tool when dealing with brain clots. They mention no precautions other than what we know to be the standard one's. i.e. apply enough gel, use an appropriate w/cm2, choose the right US head, choose the right pulse frequency and keep that thing moving. We all learn about the possibility of burning the patient from standing US waves if the head is not moved but then this is a problem when using US anywhere in the body.

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.

[1234nale]

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.

[sdkashif]

Dear 1234nale thanks for your query and questions. let me have a look over your query and answer it.

Low-frequency Ultrasound Penetrates the Cranium and Enhances Thrombolysis In Vitro.

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.

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

And again, aria of the head, easy, ears, ovaries, testicles, brain, spinal cord are highly ultrasound-sensitive organs!!!

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 Ultrasound

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.

My point was don’t use methods for what you are not sure what is the greater benefit

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"

See For more information upon ultrasound dosage calculation

However, let me say that I was mentioning ultrasound recommendation only during the paralysis phase of Bell's palsy when the nerve is inflammed. There are also other options available for reducing inflammation like LASER, SWD. However, these are only of benefity during the stage of paralysis.

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