useful for ug physiotherapy

1. Course Code : UG06 BPT
Course Name : BPT
Topic : Physiotherapy for bell’s palsy
K.Lakshmiprabha
Associate Professor,
Department of phyiotherapy
Sree Balaji college of physiotherapy,
Bharath Institute of Higher Education and Research,
Chennai.

2. Bell's palsy is a condition that causes a temporary weakness or
paralysis of the muscles in the face. It can occur when the nerve
that controls facial muscles becomes inflamed, swollen, or
compressed. The condition causes one side of face to droop or
become stiff.

3. • Anatomy of the Facial Nerve
• The facial nerve arises in the pons (formed as separate
sensory and motor roots), before travelling in the
internal acoustic meatus, very close to the inner ear. As
they enter the facial canal, the two roots fuse to form a
single facial nerve, before giving off intracranial
branches of the greater petrosal nerve, nerve to
stapedius, and chorda tympani.
• The facial nerve then exits the facial canal (and the
cranium) via the stylomastoid foramen. The first
extracranial branches given off are the posterior
auricular nerve, nerve to digastrics, and nerve
stylohyoid. The facial nerve then enters the parotid
gland, dividing into terminal branches of the Temporal,
Zygomatic, Buccal, Marginal mandibular, and Cervical
branches.

5. causes
• The cause of Bell's palsy is unknown. Swelling and
inflammation of the cranial nerve VII is seen in
individuals with Bell’s palsy.
• Most scientists believe that reactivation of an
existing (dormant) viral infection may cause the
disorder. Impaired immunity from stress, sleep
deprivation, physical trauma, minor illness or
autoimmune syndromes are suggested as the most
likely triggers.
• As the facial nerve swells and becomes inflamed in
reaction to the infection, it causes pressure within
the Fallopian canal (a bony canal through which the
nerve travels to the side of the face), leading to the
restriction of blood and oxygen to the nerve cells.
In some mild cases where recovery is rapid, there is
damage only to the myelin sheath (the fatty covering
that acts as insulation of nerve fibers).
• The facial canal (Fallopian Canal) is a Z-shaped
canal running through the temporal bone from the
internal acoustic meatus to the stylomastoid
foramen. It is approximately 3 centimeters long,
which makes it the longest human osseous canal of a
nerve.

6. Virus which cause bell’s palsy
• Cold sores and genital herpes (herpes
simplex)
• Chickenpox and shingles (herpes zoster)
• Infectious mononucleosis (Epstein-Barr)
• Cytomegalovirus infections
• Respiratory illnesses (adenovirus)
• German measles (rubella)
• Mumps (mumps virus)
• Flu (influenza B)
• Hand-foot-and-mouth disease
(coxsackievirus)

7. Risk factor
• The condition more commonly affects:
• People aged 15 to 60 years
• People with diabetes or upper respiratory
diseases
• women during pregnancy, especially in the
third trimester
• women who gave birth less than 1 week ago

8. Pathophysiology
Nerve inflammation that occurs along the facial canal and
compression and demyelinization of axons that occur as a
result of this are accepted as the pathophysiology of Bell’s
palsy .
Increase in B lymphocyte rate and decrease in T lymphocyte
rate is the pathophysiologyof Bell’s palsy .
Another view originates from autoimmune system that
develops against myelin basic proteins. Viral infections or the
reactivation of viruses in latent stage stimulate the
autoimmune system against peripheral nerve myelin units .

9. Clinical features
• Acute onset of unilateral upper and lower facial paralysis (over a 48-hr period)
• Posterior auricular pain
• Decreased tearing
• Hyperacusis (reduced tolerance to noise or sound)
• Taste disturbances
• Otalgia (ear pain)
• Weakness of the facial muscles
• Poor eyelid closure
• Aching of the ear or mastoid
• Tingling or numbness of the cheek/mouth
• Epiphora(watering of eye)
• Ocular pain
• blurred vision
• Flattening of forehead and nasolabial fold on the side affected by palsy
• When patient raises eyebrows, palsy-affected side of forehead remains flat
• When patient smiles, face becomes distorted and lateralizes to side opposite the
palsy

10. • Grading
• The grading system developed by House and Brackmann categorizes Bell
palsy on a scale of I to VI, :
• Grade I: normal facial function
• Grade II: mild dysfunction
• Grade III: moderate dysfunction
• Grade IV: moderately severe dysfunction
• Grade V: severe dysfunction
• Grade VI: total paralysis

11. Ocular manifestations
• Lagophthalmos (inability to close the eye completely)
• Paralytic ectropion of the lower lid
• Corneal exposure,Brow droop,Upper eyelid retraction
• Decreased tear output/poor tear distribution
• Loss of the nasolabial fold ,Corneal erosion, infection, and ulceration (rare)
• Late ocular manifestations include the following:
• Mild, generalized mass contracture of the facial muscles, rendering the affected
palpebral fissure narrower than the opposite one (after several months)
• Aberrant regeneration of the facial nerve with motor synkinesis
• Reversed jaw winking (ie, contracture of the facial muscles with twitching of
the corner of the mouth or dimpling of the chin occurring simultaneously with
each blink)
• Autonomic synkinesis (ie, crocodile tears—tearing with chewing)
• Permanent, disfiguring facial paralysis (rare)
• Two thirds of patients complain about tear flow. This results from the reduced
function of the orbicularis oculi in transporting the tears. Fewer tears arrive at
the lacrimal sac, and overflow occurs. The production of tears is not
accelerated.

12. Posterior auricular pain
• Half of the patients affected with Bell palsy may
complain of posterior auricular pain.
• The pain frequently occurs simultaneously with the
paresis, but pain precedes the paresis by 2–3 days in
about 25% of patients. We have to collect history
from patient whether he or she has experienced
trauma, which may account for the pain and facial
paralysis.
• One third of patients may experience hyperacusis in
the ear ipsilateral to the paralysis, which is
secondary to weakness of the stapedius muscle.

13. Taste disorders
• While only one third of patients report taste
disorders, 80% of patients show a reduced
sense of taste.
• Patients may fail to note reduced taste,
because of normal sensation in the
uninvolved side of the tongue.
• Early recovery of the sense of taste suggests
that the patient will experience a complete
recovery

14. Facial spasm
• Facial spasm, a very rare complication of Bell palsy, occurs as
tonic contraction of 1 side of the face. Spasms are more likely
to occur during times of stress or fatigue and may be present
during sleep. This condition may occur secondary to
compression of the root of the seventh nerve
• Facial spasm occurs most commonly in patients in the fifth and
sixth decades of life. Sometimes the etiology is not found. The
presence of progressive facial hemispasm with other cranial
nerve findings indicates the possibility of a brainstem lesion.
• Synkinesis is an abnormal contracture of the facial muscles
while smiling or closing the eyes. It may be mild and result in
slight movement of the mouth or chin when the patient blinks
or in eye closure with smiling. Crocodile tears can be observed;
patients shed tears while they eat

15. Cranial neuropathies
• Cranial neuropathies may also be present in
Bell palsy; however, this is not uniformly
accepted. The symptoms in question include
the following;
1. Hyperesthesia or dysesthesia of the
glossopharyngeal or trigeminal nerves
2. Dysfunction of the vestibular nerve
3. Hyperesthesia of the cervical sensory
nerves
4. Vagal or trigeminal motor weakness

16. Diagnosis of Bell Palsy
• Examination for Bell palsy includes the following:
• Otologic examination: Pneumatic otoscopy and
tuning fork examination, particularly if evidence of
acute or chronic otitis media infection
• Ocular examination: Patient often unable to
completely close eye on affected side
• Oral examination: Taste and salivation often affected
• Neurologic examination: All cranial nerves, sensory
and motor function are tested and
cerebellarfunctions to be tested

17. Differential diagnosis of bell’s palsy

19. Facialpalsy vs bells palsy

20. Clinical tests
• Although there are no specific diagnostic tests for Bell palsy, the
following may be useful for identifying or excluding other
disorders:
• Antibody absorption test
• HIV screening by enzyme-linked immunosorbent assay and/or
Western blot
• Complete blood count
• Erythrocyte sedimentation rate
• Thyroid function
• Serum glucose Blood glucose Hemoglobin A1c
• CSF analysis
• Antineutrophil cytoplasmic antibody levels
• Salivary flow
• Schirmer blotting test
• Nerve excitability test
• Computed tomography,MRI
The Schirmer blotting test
may be used to assess
tearing function. The use of
benzene will stimulate the
nasolacrimal reflex, and the
degree of tearing can be
compared between the
paralyzed and normal sides.

21. Subjective assessment
• Patient Profile:
• Present Illness:
• Past Medical History: .
• Medications:.
• Investigation
• Health Habits:
• Social History:.
• Patient complaints:

22. ObjectiveAssessment
• Observation: Facial droop on one side, drooping at corner of eye and
side of the mouth
• CN VII Testing:
• Side of Face
• sensation testing: Taste to anterior 2/3 of tongue intact (Test: cotton
swab dipped in salt vs sugar)[16]
• Outcome measure:
• Visual Analogue Scale (VAS) for jaw pain
• At rest: 3/10
• After eating or speaking: 6/10
• House-Brackmann Facial Nerve Scale:
• Functional status: Speech slightly slurred, noticeable effort when
talking
• Phase of recovery: Acute (2 days post symptom onset)

23. Physiotherapy assessment

24. Outcome measure
• The Facial Grading System [FGS] is also known as the Sunnybrook Facial Grading
System as it was devised and established at the Sunnybrook Health Sciences Centre in
Toronto.
• The clinicians who developed the FGS intended to create a measure which provided a
quantitative score for reporting purposes, which would be sensitive enough to detect clinically
important change over time or with treatment
Method of Use
The FGS comprises 3 areas of evaluation;
• Evaluation of resting symmetry
• Degree of voluntary excursion of facial muscles
• Degree of synkinesis associated with specific voluntary movement
The regions of the face are evaluated separately, with the use of 5 standard expressions:
• eyebrow raise
• eye closure
• open mouth smile
• lip pucker
• snarl/show teeth
• All the above items are evaluated on point scales, and a cumulative composite score is calculate

25. Facial DisabilityIndex
• It was developed by Dr. Jessie VanSwearingen with Dr.
Jennifer Brach in order to evaluate the disability resulting from
disorders of the facial nerve
• Method of Use
• It is a patient-rated outcome measure. There are 10 items from
which items 1 - 5 constitute the Physical Function subscale,
while items 6 - 10 constitute the Social/Well-being Function
subscale.
• Each item in the Physical Function subscale is rated from 5 to 0
while items in the Social/Well-being Function subscale are rated
from 6 to 1.
• The individual subscales are scored out of a total of 100 where
the highest score is the best result.

26. FACE
• Validation of the facial assessment by computer
evaluation (FACE) program for software-aided eyelid
measurements.
• Catherine J. Choi,Daniel R. Lefebvre &Michael K. Yoon
• 20 Feb 2015, Accepted 04 Jan 2016, Published online:
24 Mar 2016
• Clinical measurements of upper eyelid margin reflex
distance (MRD1) and inter-palpebral fissure (IPF) were
obtained

27. TREATMENT PROTOCAL
1. PATIENT HISTORY AND PHYSICAL EXAMINATION
2. LABORATORY TESTING
3. DIAGNOSTIC IMAGING
4. ORAL STEROIDS
5. ANTIVIRAL MONOTHERAPY
6. COMBINATION ANTIVIRAL THERAPY
7. EYE CARE
8. ELECTRODIAGNOSTIC TESTING WITH INCOMPLETE PARALYSIS
9. PHYSICAL THERAPY
10. ACUPUNCTURE
11. ELECTRODIAGNOSTIC TESTING WITH COMPLETE PARALYSIS
12. SURGICAL DECOMPRESSION
13. FOLLOW UP

28. Medications
• Commonly used medications to treat Bell's palsy include:
• Corticosteroids, such as prednisone, are powerful anti-
inflammatory agents. If they can reduce the swelling of the
facial nerve, it will fit more comfortably within the bony
corridor that surrounds it. Corticosteroids may work best if
they're started within several days of when symptoms started.
• Antiviral drugs. The role of antivirals remains unsettled.
Antivirals alone have shown no benefit compared with placebo.
Antivirals added to steroids are possibly beneficial for some
people with Bell's palsy, but this is still unproved.
• However, despite this, valacyclovir (Valtrex) or acyclovir
(Zovirax) is sometimes given in combination with prednisone in
people with severe facial palsy

29. FACIAL EXERCISES
• Exercises can be useful to tone the facial
muscles as the movement begins to return:
• Gently raise eyebrows – Can be assisted with
fingers
• Wrinkle nose
• Try and flare nostrils
• Lift one corner of the mouth and then the other
• Smile without showing teeth, then smile with
showing teeth
• Bring eyebrows together in a frow

30. Eye care
• Eye care is very important if eye is affected. If eye does
not close when blinking:
• The eye can dry up. So eye drops or artificial tears to keep
the eye moist. Artificial tear drops during the day and a
thicker solution at night
• The eye will not have the normal protection from the eye
lid closing. It is important to protect the eye and avoid
scratching the cornea (the thin, transparent layer covering
the eye). Advise patient to wear protective glasses or an eye
patch by day and to tape the affected eye lid closed at night.
Tape such as micropore can be used for this.

33. Type of taping

34. 1.That corticosteroid and physical therapy
exercises shouldbe started within 72 hours
following the onset of Bell’s palsy in order to
decrease the compression resulting from
inflammation (McCaul JA ETAL ,2014)
2.Mizumachi et al.(2006) compared the
recoveryperiod of Bell’s palsy pediatric patients
who receivedsteroid, B12 vitamin and
physiotherapy with those who did not receive
any therapy. As the result of one-month long
therapy, complete recovery is seen in all
patients.

35. ES for bells palsy
• Alakram and Puckree, 2010 has stated that use of
electrical stimulation in early bells palsy was not
helpful.but using TENS during acute phase was
useful to reduce pain
• Effectiveness of electrical stimulation for
rehabilitation of facial nerve paralysis .A study
done by Katie A Fargher &Susan E Coulson ORCID
,2017 has been stated that no effect was seen
with electrical stimulation

36. Facial massage
• Position of patient; supine lying
• Position of therapist;stride standing in patients
caudal side
Sequence
• Stroking
• Effleurage
• Finger kneding
• Effleurage
• Hacking
• Effleurage
• Vibration in sm foramen

37. Complications
• Corneal dryness leading to visual loss
• Permanent damage to the facial nerve
• Abnormal growth of nerve fibers

38. Surgery
• In the past, decompression surgery was used to relieve
the pressure on the facial nerve by opening the bony
passage that the nerve passes through. Today,
decompression surgery isn't recommended. Facial nerve
injury and permanent hearing loss are possible risks
associated with this surgery.
• Rarely, plastic surgery may be needed to correct lasting
facial nerve problems. Facial reanimation helps to make
the face look more even and may restore facial
movement. Examples of this type of surgery include
eyebrow lift, eyelid lift, facial implants and nerve
grafts. Some procedures, such as an eyebrow lift, may
need to be repeated after several years.

39. Lifestyle and home care
• Home treatment may include:
• Protecting the eye . Using lubricating eyedrops during the
day and an eye ointment at night will help keep eye moist.
Wearing glasses or goggles during the day and an eye patch
at night can protect eye from getting scratched.
• Taking over-the-counter pain relievers. Aspirin, ibuprofen
(Advil, Motrin IB, others) or acetaminophen (Tylenol,
others) may help to reduce pain
• Doing physical therapy exercises. Massaging and
exercising face according to physical therapist's advice
may help relax facial muscles.

40. Alternate therapy
• Acupuncture. Placing thin needles into a
specific point in skin helps stimulate
nerves and muscles, which may offer
some relief.
• Biofeedback training.

41. • Take away msg
• Being small condition which is
treated in correct time ,complete
recovery is possible.but if it is left
untreated ,results in asymmetry in
face as well as cosmetic damage may
be there