Paradigm shift in rehabilitation of long-standing Bell’s palsy during later stages of recovery
AbstractBell’s palsy (idiopathic peripheral neuropathy of the facial nerve) is an acute, usually unilateral paralysis of facial muscles. This disorder had been described and studied by Sir Charles Bell in 1836. In majority of Bell’s palsy cases the patient achieves full spontaneous recovery within 3-5 weeks even without treatment. In about 15-30% of cases the recovery takes considerably longer time (3 to 6 months, sometimes longer) and is usually incomplete. After the incomplete recovery of Bell’s palsy some residuals and complications usually develop. Those can include weakness of facial muscles, facial asymmetry in both neutral expression and with facial movements, pathological synkinesis, contractures of facial muscles, crocodile tears, facial pains etc. The above-mentioned complications may result in disfigured face with various degrees of severity, involuntary facial movements during speech and emotions, facial pains that are difficult to relieve with pain-killers, inability to adequately express emotions. All the named manifestations can have a dramatic impact on individual’s self-esteem, social contacts and general quality of life. They may lead to stress, depression, self-isolation and in some extreme cases – to suicidal behavior. Customary treatment for acute Bell’s palsy include prednisone, antiviral medications, eye care to prevent drying of the cornea, mime-therapy (neuromuscular retraining). Sometimes acupuncture, chiropractors, laser therapy or high doses of B-vitamins are used. In some countries such controversial interventions as electrical stimulation (shocks) and massage with ice-cubes are being used as treatment modalities for acute Bell’s palsy. If the facial condition does not considerably improve within the first year, then the choice of treatments for residuals and complications of long-standing Bell’s palsy is rather limited. It includes continuation of mime-therapy, periodic injections of botulinum toxin, and in some exceptional cases surgical interventions (nerve graft, muscle transposition etc.) Facial nerve decompression has not been proven to be effective as Bell’s palsy treatment and therefore is nowadays seldom used. Long-standing Bell’s palsy patients are left with very limited choice of treatments for their residuals and complications. In the medical world and among rehabilitation specialists it is considered that if Bell’s palsy had not recovered within first 1-2 years and if complications had formed, then the patient will retain the developed synkinesis, contractures, related facial pains and other manifestations for the rest of his or her life. In the recent years there has not been much research done of the underlying causes for the complications of long-standing Bell’s palsy. Without thorough understanding of such causes it is rather challenging to compose proper rehabilitation programs that deliver the desired improvements in facial symmetry and respectively, in patient’s quality of life. In this article we discuss the traditional approach to possible causes, available treatments of Bell’s palsy complications and share our concept of a new paradigm in rehabilitation of long-standing Bell’s palsy during later stages of the recovery (2 years and more). According to this new paradigm, synkinesis, contractures and mass movements of facial muscles, as well as related chronic facial pains are the result of newly-formed, pathological mimetic patterns in the CNS, which can be reduced and then reversed by applying the new approach to rehabilitation, based on other than traditional principles. The results achieved by our patients can serve as an evidence that this new approach may indicate a beginning of a paradigm shift in rehabilitation of long-standing Bell’s palsy.
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