GOWRISHANKAR POTTURI B.P.T, M.PT, M.I.A.P, M.I.A.C.P.

AIMS AND OBJECTIVES

By the end of the session the student should be able to 1. Define, mention the clinical aspects of Bells Palsy. 2. Mention the pathology. 3. Illustrate physiotherapeutic methods of treating a patient with Bells Palsy. 4. Differentiate Bells Palsy with Facial Palsy of Upper Motor Neuron Lesion.

Bell's palsy is a paralysis of the facial nerve resulting in inability to control facial muscles on the affected side IT IS A LOWER MOTOR NEURON LESION Causes are usually a tumor, viral or a bacterial infection. When no cause if found it is called as idiopathic unilateral facial palsy. Long exposures to cold can also trigger Bells palsy.

Named after Scottish anatomist Charles Bell, who first described it, Bell's palsy is the most common acute mononeuropathy (disease involving only one nerve), and is the most common cause of acute facial nerve paralysis.

ONSET
Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis, usually self-limiting. The trademark is rapid onset of partial or complete palsy, usually in a single day.

It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell's palsy has been found, but clinical and experimental evidence suggests herpes simplex type 1 infection may play a role.

1. Symmetry of the face is lost. 2. Patient cant raise the eyebrow on the affected side. 3. The patient cant close the eye lid on the affected side. 4. Blowing, smiling, speech, taste are impaired. 5. Water drools out when the patient tries to drink water. 6. Bells phenomenon: on attempt of closing the eye lid the affected side eye ball rolls upward. 7. Angle of mouth is deviated to the normal side. 8. Rarely some patients may experience mild pain at the TMJ.

Bell's palsy is a diagnosis of exclusion; by elimination of other reasonable possibilities. Therefore, by definition, no specific cause can be ascertained. Bell's palsy is commonly referred to as idiopathic or cryptogenic, meaning that it is due to unknown causes. It is confirmed mostly with the clinical presentation. Suspected tumor can be ruled out by a simple X-ray or a CT scan. Inflammation can be confirmed by performing a complete blood picture and with raised ESR. SD Curve and FG test.

MEDICAL MANAGEMENT
1. Anti viral drugs like Acyclovir, Famcyclovir are prescribed for underlying viral infection 2. Antibiotics are prescribed accordingly for a bacterial infection. 3. For faster resolution of inflammation, steroids like Prednisolone are prescribed. 4. For early nerve regeneration, methylcobalamin, alpha lipoiec acid are prescribed. Then the patient is referred to physiotherapy for further management.

SURGICAL MANAGEMENT
Very rarely in un-successful cases, skin grafting is done to maintain the facial symmetry. Skin is taken from thigh region for the purpose. In cases of nil nerve regeneration, nerve graft is indicated.

PHYSIOTHERAPY MANAGEMENT

PLAN OUT THE TREATMENT ACCORDING TO THE SEVERITY OF THE LESION

1.EXERCISE THERAPY 2.MASSAGE THERAPY 3.ELECTRO-DIAGNOSIS AND THERAPY 4.HOME REGIME

1. Always exercise before a mirror 2. Raise eyebrows 3. Frown 4. Flare nostrils 5. Try closing and opening eyes 6. Smile with showing teeth 7. Smile with out showing teeth 8. Grin the cheeks 9. Try moving tongue to both sides of the cheek 10.Munching movements of mouth

Massage therapy is indicated to aid in lymphatic circulation and to reduce edema if any. Techniques include: 1. Stroking 2. Effleurage 3. Soft padded kneading 4. Reverse hacking if tolerated. 5. Static vibrations at the TMJ

Face muscles are small and tend to fatigue easily. Hence galvanic stimulation is used with a pad and pen electrode. Explain the procedure to the patient Clean the skin before starting the treatment. Place the pad electrode under the neck. Stimulate each muscle on the respective motor point to have maximum efficiency. Number of stimulations should not exceed more than 30 contractions. After the treatment mild redness on the skin is noticed as a sign of vaso-dilatation.

THE PATIENT COOPERATION IS UTMOST IMPORTANT

1. Exercise regularly 2. Blow balloons 3. Use straw to drink water or fluids 4. Chew gum 5. Goggle the mouth with water frequently. 6. Self massage once a day. 7. Use goggles to protect the eyes 8. Splint use to correct the mouth deviation.

BELLS PALSY IS A REVERSIBLE CONDITION. MANY PATEINTS RECOVER IN A WEEK OR 10 DAYS. SOME PATIENTS MAY RECOVER BY THE END OF 3 WEEKS. RARELY 1% OF THE PATIENTS HAVE IRREVERSIBLE DAMAGE.