Bells Palsy, Physiotherapy treatments and facial muscle dry needling

By Matthew Craig, Physiotherapist USYD 2003-current

Founding Director, bounceREHAB 2005+

Figure 1: What Matt does on holidays when left home alone… his ‘painless mock up’ of physio performed dry needling to a right sided Bell’s Palsy

WHAT IT IS

In a Nutshell…… Idiopathic facial palsy, also called Bell’s palsy, is an acute disorder of the facial nerve, which may begin with symptoms of pain in the mastoid region and produce full or partial paralysis of movement of one side of the face (Adour 1982; Valença 2001).

CAUSE

Its cause is not known (Peitersen 2002). Increasing evidence suggests that the main cause of Bell’s palsy is reactivation of latent herpes simplex virus type 1 in the cranial nerve ganglia (De Diego 1999; Holland 2004; Valença 2001). How the virus damages the facial nerve is uncertain (Gilden 2004).

HOW IT OFTEN LOOKS

PREVALENCE The annual incidence of Bell’s palsy varies widely, ranging between 11.5 and 40.2 cases per 100,000 population (De Diego 1999; Peitersen 2002). There are peaks of incidence in the 30 to 50 and 60 to 70 year old age groups (Gilden 2004; Gonçalvez 1997).

PROGNOSIS Bell’s palsy has a fair prognosis without treatment (Holland 2004). According to Peitersen (Peitersen 2002), complete recovery was observed in 71% of all patients. Ninety-four per cent of patients with incomplete and 61% with complete paralysis made a complete recovery, but it is unknown if intervention with physical therapies improves outcome because the quality of the studies have been low.  BounceREHAB has however seen fantastic outcomes in the clinic.

About 23% of people with Bell’s palsy are left with either moderate to severe symptoms, such as hemifacial spasm, partial motor recovery, crocodile tears (tears upon salivation), contracture or synkinesis (involuntary twitching of the face or blinking). Recurrence occurs in about 8.3% (Valença 2001).

The prognosis depends to a great extent on the time at which recovery begins. Early commencement of recovery is associated with a good prognosis and late recovery a bad prognosis. If recovery begins within one week, 88% obtain full recovery, within one to two weeks 83% and within two to three weeks 61%. Normal taste, stapedius reflex and tearing are also associated with a significantly better prognosis than if these functions are impaired. Recovery is less likely to be satisfactory with complete rather than incomplete paralysis, with pain behind the ear and in older people (Danielidis 1999). Other poor prognostic factors include hypertension and diabetes mellitus (Gilden 2004; Peitersen 2002).

Figure 4: Facial nerve distribution and its close association with other cranial nerves and visceral functions

TREATMENTS (AND THEIR RECENT EVIDENCE)

Firstly, check out these interesting case studies. It may help to reduce your stress levels:

Evaluation of therapies is made difficult by the high rates of spontaneous and complete recovery (Peitersen 2002). This needs to be controlled for future studies. Blinding subjects and therapists in the treatment of Bell’s Palsy for the scope of physiotherapy services (exercises, acupuncture, dry needling and electrotherapy) is incredibly difficult to sham against placebos.

The treatments for Bell’s palsy are aimed at returning facial power to normal for cosmesis, competence of lip seal and protection of the cornea from drying and abrasion due to impaired lid closure and tear production. For the latter, lubricating drops are recommended during the day and a simple eye ointment at night (Adour 1982; Holland 2004; Valença 2001).

Corticosteroids & Surgery….

Recent Cochrane systematic intervention reviews demonstrate there is significant benefit from treating Bell’s palsy with corticosteroids (Salinas 2010). Some authors suggest that facial nerve decompression might be considered, although there is no data from clinical trials to support its use (Adour 2002; Gilden 2004; Grogan 2001) and a Cochrane systematic review about surgical interventions confirmed this finding (McAllister 2011). A systematic review about the efficacy of hyperbaric oxygen therapy (Holland 2008) and a overview of reviews about the Bell’s palsy treatment (Lockhart 2010b) are in development.

Physiotherapy & Acupuncture/Dry Needling…

Thermal methods, electrotherapy, massage, facial exercises and biofeedback are forms of physical therapy that have been used for Bell’s palsy (Mosforth 1958; Peitersen 2002). Exercise therapy has been used more than other interventions (Beurskens 2003; Brach 1999; Ross 1991; Segal 1995a).

Physical therapy, in the context of Bell’s palsy, mainly uses methods which increase muscle and nerve function either through exercise or electrotherapy. Thermal methods and massage work by decreasing swelling and increasing blood flow to affected tissues, increasing the amount of oxygen available to damaged, hypoxic tissues with the aim of promoting recovery (Lockhart 2010b).

TREATMENTS COMMONLY PERFORMED AT BOUNCEREHAB (SYDNEY)

DRY NEEDLING with me @BOUNCEREHAB

Peitersen 2002 highlighted the lack of high quality evidence for current physical treatments, including thermal methods (conductive, radiative and convective heat transfer in order to achieve vasodilatation, or ice over the mastoid region with the aim of relieving oedema), electrotherapy (which uses an electrical current to cause a single muscle or group of muscles to contract), massage and facial exercise. This does not suggest that these modalities have no effect, in fact the majority of randomised controlled trials (RCTs) show statistically significant positive effects for physical therapies (including dry needling/acupuncture/exercises), yet higher quality RCTs with adequate sample sizes and less methodological bias are needed to document exactly the size of the effects for our treatments for those with Bell’s Palsy and the subgroups (ie duration) of those seeking treatments with Bell’s Palsy.

Interestingly, He X et al (2014) recently added “The results of resting-state functional MRI connectivity show that acupuncture induces significant connectivity changes in the primary somatosensory region of both early and late recovery groups, but no significant changes in either the healthy control group or the recovered group”.

NEUROPLASTICITY (BRAIN TRAINING / REORGANISATION) @ BOUNCEREHAB:

Mirror Box TherapyGraded Motor Imagery

Hu S et al (2015) “It was found that the functional connectivity of the ACC ipsilateral to the lesioned side was enforced as the duration increased. The enforced brain areas included the sensorimotor areas and the ACC contralateral to the palsy. It was suggested that enforced functional connectivity of ACC might be related to cortical reorganization, which is important in the process of BP recovery”.

ELECTROSTIMULATION @ BOUNCEREHAB:

Portable Micro-current units can be purchased for home use. Contact frontdesk@bouncerehab.com.au for a pricelist.

Tuncay et al (2015) “The addition of 3 wks of daily electrical stimulation to physiotherapy shortly after facial palsy onset (4 wks), improved functional facial movements and electrophysiologic outcome measures at the 3month follow-up in patients with Bell palsy. Further research focused on determining the most effective dosage and length of intervention with electrical stimulation is warranted”.

EXERCISES

The aim is to improve neuromuscular activation, strength and endurance: these deficits are often severe in 20-30% of patients diagnosed with Bell’s Palsy.

Please note that physiotherapists @ bounceREHAB are experts in teaching you how to perform the movements that are required for improved emotional expression, eating and breathing.

MASSAGE @ BOUNCEREHAB…

Aim: Improve lymphatic draining (reduce face swelling), sensory-motor stimulation of muscles and the samoto-sensory cortex (brain maps).

PSYCHOLOGICAL AND PAIN MANAGEMENT SERVICES

bounceREHAB may use a battery of questionnaires to assess self-image, mood and functional (social)  disability. A range of severity of palsy was represented and a variety of disturbance with facial self-image, social activity and emotional state.

Weir AW et al (1995) study concluded that those with Bell’s Palsy expressed dissatisfaction with at least one aspect of facial appearance, disturbance of face-to-face conversation and most described a change in other people’s attitude to them. It was concluded that there is evidence of considerable social handicap in a proportion of patients afflicted by this otherwise relatively benign condition.

bounceREHAB combines the skills of both a physiotherapist & psychologist. We use a team approach to treating your facial paralysis. We have found that having a combined treatment approach allows you to better address the many physical and psychological barriers all under the same roof. Many of the physical issues can cause or heighten the psychological issues and vice versa. It is important to learn that there is a strong link here between mind and body.

Medicare Mental Care Plans can by supplied for psychological treatment by your GP.

CONCLUSION (BY GLASS G ET AL 2014)

Spontaneous idiopathic facial nerve (Bell’s) palsy leaves residual hemifacial weakness in 29% which is severe and disfiguring in over half of these cases. Acute medical management remains the best way to improve outcomes. Reconstructive surgery can improve long term disfigurement. However, acute and surgical options are time-dependent.

As the facial muscles remain viable re-innervation targets for up to 2 years, late referrals may require more complex surgical reconstructions. Early recognition, steroid therapy and early referral for facial reanimation with a physiotherapist (when the diagnosis is secure) are important features of good management when encountering these complex cases. We keep learning more about neuroplasticity and how amazing changes can be made by complex and severe cases if they are extremely motivated, compliant, understanding of their condition and practice consistently with their day to day their motor programs (homework).

Nacastri et al (2013) most recently stated “Physical therapy was shown to have a significant effect on the grade and time taken to recover in patients presenting with SEVERE facial palsy”.

If you have Bell’s Palsy or know of somebody that has the condition, it is worth referring them to bounceREHAB to have them assessed (early where possible) and then we can best treat their condition in a multidisciplinary manner.

THANKYOU

We also want to give a massive bounce THANKYOU to patients with Bell's Palsy attending our physiotherapy clinic in Sydney over the last 15 years.

REFERENCES:

Glass, G. E., & Tzafetta, K. (2014). Bell’s palsy: a summary of current evidence and referral algorithm. Family practice, 31(6), 631-642.

Hu, S., Wu, Y., Li, C., Park, K., Lu, G., Mohamed, A. Z., … & Qiu, B. (2015). Increasing functional connectivity of the anterior cingulate cortex during the course of recovery from Bell’s palsy. NeuroReport, 26(1), 6-12.

Nicastri, M., Mancini, P., De Seta, D., Bertoli, G., Prosperini, L., Toni, D., … & Filipo, R. (2013). Efficacy of Early Physical Therapy in Severe Bell’s Palsy A Randomized Controlled Trial. Neurorehabilitation and neural repair, 1545968313481280.

Targan, R. S., Alon, G. A. D., & Kay, S. L. (2000). Effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy. Otolaryngology–Head and Neck Surgery,122(2), 246-252.

Teixeira, L. J., Valbuza, J. S., & Prado, G. F. (2011). Physical therapy for Bell’s palsy (idiopathic facial paralysis). The Cochrane Library.

Tuncay, F., Borman, P., Taser, B., Ünlü, I., & Samim, E. (2015). Role of electrical stimulation added to conventional therapy in patients with idiopathic facial (Bell) palsy. American Journal of Physical Medicine & Rehabilitation,94(3), 222-228.

Weir, A. M., Pentland, B., Crosswaite, A., Murray, J., & Mountain, R. (1995). Bell’s palsy: the effect on self-image, mood state and social activity. Clinical rehabilitation, 9(2), 121-125.

Zandian, A., Osiro, S., Hudson, R., Ali, I. M., Matusz, P., Tubbs, S. R., & Loukas, M. (2014). The neurologist’s dilemma: A comprehensive clinical review of Bell’s palsy, with emphasis on current management trends. Medical science monitor: international medical journal of experimental and clinical research, 20, 83.

THE END

Matthew Craig DIRECTOR / PHYSIOTHERAPIST B.App.Sci (Physiotherapy), CSCS (Strength and Conditioning Specialist) National Advisory Board CPAA (Chronic Pain Association of Australia) DIRECTOR Bounce Rehab PTY