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.
Burke, D, Skuze, NF, and Lethlean, AK: Isometric contraction of the abductor digiti minimi muscle in man. J Neurol Neruosurg Psychiatry 37:825-834, 1974
Burke, RE, Levine, DN, Zajac, FE, III, Tsairis, P: Physiological types and histochemical profiles of motor units of the cat gastrocnemius. J Physiol(Lond) 234:723-748, 1973
Cattaneo, L, Chierici, E, and Pavesi, G: Bell's palsy-induced blepharospasm relieved by passive eyelid closure and responsive to apomorphine. Clin Neurophysiol 116: 2348-2353, 2005.
Cossu, G, Valls-Sole, J, Valldeoriola, F, Munoz, E, Benitez, P, and Aguilar, F: Reflex excitability of facial motoneurons at onset of muscle reinnervatin after facial nerve palsy. Muscle Nerve 22: 614-620, 1999.
de Almeida, JR, Al Khabori, M, Guyatt, GH, Witterick, IJ, Lin, VY, Nedzelski, JM, and Chen, JM: Combined corticosteroid and antiviral treatment for Bell's palsy: A systematic review and meta-analysis. Jama 9: 985-993, 2009.
Engstrom, N, Berg, T, Stjernquist,-Desatnik, A, Axellson, S, Pitkaranta, A, Hultkrantz, M, Kanerva, M, Hanner, P, and Johnson, L: Prednisolone and valaciclovir in Bell's palsy: A randomized double-blind study, placebo-controlled,multicentre trial. Lancet 7:993-1000, 2008.
Furuta, Y, Fukuda, S, Chida, E, Takasu, T, Ohtani, F, Inuyama, Y, and Nagashima, K: Reactivation of herpes slimplex virus type I in patients with Bell's palsy. J Med Virol54: 162-166, 1998.
Gilden, DH, and Tyler, KL: Bell's palsy - is glucocorticoid treatment enough? N Eng J Med 357: 1653-1655, 2007.
Gilden, DH: Bell's palsy. N.Engl J Med 351:1323-1231, 2004.
Gilden, DH: Treatment of Bell's palsy- the tendulum has swung back to steroids alone. Lancet 11: 976-977, 2008.
Hato, N, Yamada, H, Johno, H, Matsumoto, S, Honda, N, et al.: Valacycolvir and prednisone treatment for Bell's palsy: A multicenter, randomized, placebo-controlled study. Otol Neurotol 28: 408-413, 2007.
Henneman, E: Relation between size of neurons and their susceptibility to discharge. Science 126:1345-1347, 1957
Kabayashi, J, Mackinnon, SE, Watanabe, O, Ball, DJ, Gu, XM, Hunter, DA, and Kuzon, WM: The effect of duration of muscle denervation on functional recovey in the rat model. Muslce Nerve 20:858-866, 1977
Kalliainen, LK, Jejurikar, SS, Liang, LW, Urbanchek, MG, and Kuzon Jr., WM: A specific force deficit exists in skeletal muscle after partial denervation. Muslce Nerve 25:31-38, 2002
Kernell, D, and Sjoholm, H: Recruitment and firing rate modulation of motor unit tension in a small muscle of the cat's foot. Brain Res 98:57-72, 1975
Kimura Jun. Electrodiagnosis in Diseases of Nerve and Muscle. Principles and Practice. - New York: Oxford University Press, 2013 - 1146p
Kimura, J, Rodnitzky, RL, and Okawara, S: Electrophysiologic analysis of aberrant regeneration after facial nerve paralysis. Neurology 25:989-993, 1975
Kuypers, DPL, Walbeehm, ET, Dudok, B, Heel, M, Godschalk, M, and Hovius, SER: Changes in the compound action current amplitudes in relation to the conduction velocity and functional recovery in the reconstructed peripheral nerve. Muscle Nerve 22:1087-1093, 1999
Maltin, CA, Delday, MI, Hay, SM, and Baillie, AGS: Denervation increases clenbuterol sensitivity in muscle from yount rats. Muscle Nerve 15:188-192, 1992
Mara, CM,: Bell's palsy and HSV-1 infection. Muscle Nerve22: 1476-1478, 1999.
Masakado, Y, Akaboshi, K, Kimura, A, and Chino, N: Tonic and kinetic motor units revisited: Does motor unit firing behavior differentiate motor units? Clin Neurophysiol 111:2196-2199, 2000
Maselli, R, Ellis, W, Mandler, P, Sheikh, F, Senton, G, Knox, S, Salari-Namin, H, Agius, M, Wollmann, RL, and Richman, DP: Cluster of wound botulism in California: Clinical electrophysiologic and pathologic study. Muscle Nerve 20:1284-1295, 1997
McLeod, JG, and Wray, SH: Conduction velocity and fibre diameter of the median and ulnar nerves of the baboon. J Neurol Neurosurg Pshychiatry 30:240-247, 1967
Milner-Brown, HS, Stein RB, and Lee, RG: Contractile and electrical properties of human motor units in neuropathies and motoneurone disease. J Neurol Neurosurg Psychiatry 37:670-676, 1974
Presti David E. Foundational Concepts of Neuroscience. - New York : W.W. Norton & Company, 2016 - (123, 191, 193, 242, 249) 298p
Rowlands, S, Hooper, R, Hughes, R, and Burney, P: The epidemiology and treatment of Bell's palsy in the UK: Eur J Neurol 9:63-67, 2002.
Sajadi, MM, Sajadi, MR, and Tabatabaie SM: The history of facial palsy and spasm. Hippocrates to Razi. Neurology 77: 174-178, 2011.
Seddon, H: Surgical Disorders of the Peripheral Nerves.\, ed.2. Churchill Livingstone, Edinburgh, Scotland, 1975
Shapiro, BE, Soto, O, Shafqat, S, and Blumenfeld, H: Adult botulism. (Short report) Muscle Nerve 20:100-102, 1997
Sullivan, FM, Swan IR et al.: Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med357: 1598-1607, 2007.
Swift, TR, Leshner, RT, and Gross, JA: Arm-diaphragm synkinesis: Electrodiagnostic studies of aberrant regeneration of phrenic motoneurons. Neurology (New York) 30:339-344, 1980
Wuerker, RB, Mchedran, AM, and Henneman, E: Properties of motor units in heterogenous pale muscle (m.Gastrocnemius) of the cat. J Neurophysiol 28:85-99, 1965