Protocol for the treatment of Bell’s Palsy with the Stimpod NMS460

About Bell’s Palsy

Bell’s Palsy is a multiple cranial nerve ganglionitis that involves the facial nerve. It is one type of idiopathic acute facial nerve paralysis and most likely results from viral infection. It is one of the most common causes of facial paralysis. It may reoccur in up to 14% of people, especially if there is a family history of the condition.

Bell’s Palsy is a condition that causes temporary unilateral weakness or paralysis of the muscles of the face.  This occurs when the nerve that controls the muscles in your face becomes inflamed and or compressed. The exact cause of this nerve compression is unknown. It is thought to be due to inflammatory changes in the facial nerve, possibly due to a viral infection, mostly commonly the herpes simplex virus.

Bell’s Palsy is a condition most common in people aged 15-60, but others outside this age group can also be affected. Bell’s Palsy is more commonly seen in pregnant women, diabetics and HIV, for reasons that are not yet fully understood, but possibly because these patients are immuno-compromised and therefore, making them more vulnerable to infections. 

The types of herpes virus thought to cause inflammation of the facial nerve are:

  • the herpes simplex virus (HSV), including either herpes type 1 (HSV-1), which causes cold sores, or herpes type 2 (HSV-2), which causes genital herpes
  • the varicella-zoster virus, which causes chickenpox and shingles

The varicella-zoster virus is a less common cause of Bell’s Palsy than the herpes simplex virus, but can lead to more serious conditions and increased difficulty with resolution.

Bells Palsy has also been linked to other infections such as:

  • syphilis
  • the Epstein-Barr virus – which causes glandular fever and
  • cytomegalovirus

The Symptoms of Bell’s Palsy

Symptoms of Bell’s Palsy vary between patients – from a mild numbness and or weakness (paralysis) to a complete paralysis of the face. Bell’s Palsy often also affects the eyelid and mouth, making it difficult to close and open them. It is notable that in rare cases, both sides of the face have been affected.

The symptoms develop quickly and reach their peak within 48 hours. Symptoms that may occur:

  • weakness or paralysis in one mostly only side of the face, – leading to difficulty closing the eyelid and causing the side of the mouth to droop
  • drooling from the mouth on the affected side of the face
  • dryness of the mouth
  • irritation of the affected eye, such as dryness or increased tear production
  • earache or pain underneath the ear on the affected side of the face
  • an altered or reduced sense of taste
  • increased sensitivity to sound in the affected ear
  • pain around the jaw
  • headache
  • tinnitus (ringing in one or both ears)
  • dizziness
  • difficulty eating or drinking
  • impaired speech

In most cases of Bell’s Palsy, the symptoms will begin to improve within two to three weeks. Most people make a full recovery within three to nine months. Most patients will have full resolution of symptoms although in some cases there might be some permanent damage remaining in the nerve.

Some statistics show that 7 out of 10 people with Bell’s Palsy make a complete recovery. The recovery time varies greatly from person to person and will depend on the amount of nerve damage.

Diagnosing Bell’s Palsy

Patients should consult their doctor immediately they experience sudden facial paralysis. It is very important to determine the cause and make the correct diagnosis, as there are other conditions that could also cause facial paralysis. Other health conditions should be eliminated such as a stroke, lyme disease, middle ear infection, head injury etc. in order to confirm the diagnosis of Bell’s Palsy.

Testing of the voluntary facial movements and thus the facial nerve function include:

  • wrinkling the brow,
  • showing teeth,
  • frowning,
  • closing the eyes tightly,
  • pursing the lips
  • puffing out the cheeks

There should be no noticeable asymmetry.

In the case of further uncertainty , here are other tests that can confirm the diagnosis of Bell’s Palsy, although these are usually only necessary once there are no signs of improvment after a month. These may include referral to an ear, nose and throat specialist, electromyography or an MRI or a CT scan.

Complications

It is known that at least 3 in 10 people with Bell’s Palsy will have some sort of residual weakness in their facial muscles, and 2 in 10 may with a remain with a long-term problem.

Known complications include:

  • persistent facial weakness
  • eye problems
  • difficulty with speech, eating and drinking
  • reduced sense of taste
  • facial muscle twitching

Treating Bell’s Palsy

Some cases are mild and do not require treatment as the symptoms usually subside on their own within 2 weeks. Even without treatment, more than 80 percent of the population with Bell’s Palsy recover within 3 weeks. The recovery period varies between individuals, depending on the extensiveness of the nerve damage and full recovery may take 6 months.

However early diagnosis and direct treatment are usually necessary to prevent permanent damage.  Medication such as cortisone and anti-virals may limit the duration and increase improvement in symptoms. 

Treatment may also include other therapeutic options.

Eye drops may be required to prevent or alleviate eye problems if eye closure is incomplete. Taping to assist eye closure during the day and or night may prevent the cornea from drying and or developing secondary eye infections.

Physiotherapy treatment includes ongoing assessment, monitoring and treatment of the condition from the acute onset of Bell’s Palsy through the various stages of recovery. Physiotherapy modalities aim to restore facial muscle strength and symmetry, stimulate the facial nerve and maintain muscle tone. These modalities include facial massage, exercises, acupuncture and electrical stimulation.

The importance of early resolution of this condition is not only to resolve the paralysis but to reduce the discomfort and disability that plagues the patient and in this instance, the use of the Stimpod is valuable in assisting this process.

Treatment Protocol with the Stimpod NMS460

 

  1. The most important aspect of any treatment with the NMS 460, is to be familiar with the anatomy of the nerve you are treating. Hence, in this case, the facial nerve.
  2. Initially, it is advised to try to locate and treat the facial nerve at its most superficial areas/ branches where a visible contraction of some of the facial muscles becomes evident at a relatively low intensity – so as to decrease any discomfort that the patient may experience during treatment
  3. Commence treatment as per the Quick Treatment Guide.
  4. The reference electrode is placed on a body part distant from the face and neck such as the abdominal area or chest wall. Place the treatment probe just anterior to the ear, where the facial nerve exists the stylomastoid foramen.
  5. If the facial nerve in the (right/ left) side of the face is severely affected, nerve conduction may be reduced or sluggish and a higher current intensity may be required to activate the nerve sufficiently. The patient will indicate when the current is at a comfortable level. It may be necessary to increase the intensity briefly to elicit a contraction / fasciculation in the appropriate facial muscles to indicate a successful treatment target. Always reduce or maintain the intensity at a tolerable level for patient comfort.
  6. As the pain and weakness recede individual nerve branches may remain symptomatic. Provided that the treatment described above does not aggravate or increase sensitivity, these areas may respond favourably to a local application of the current. It is therefore advised to stimulate the various branches separately and stimulate as above in order to get activity in the different facial region/muscles affected.
  7. When specific nerve branches are treated the reference electrode may remain in the original place.

Duration of treatment

The first treatment may be applied for 2- 5 mins on each nerve site, depending on the feedback from your patients as sometimes the patient can only tolerate a minute or two on a local area of the nerve. This is because of a hypersensitivity of the involved nerve endings.

The period can then be extended to 10 mins depending on the severity of the condition and if the initial treatment caused no irritation.

In the case of treating the facial nerve it is advised to spend 5-10 minutes on the area where the facial nerve exists the stilomastoid foramen just anterior to the ear, and then a minute or 2 per point traveling all along the several branches.

Number of treatments

By three to five treatments one should start to see improvement– either in pain, dysaesthesia or paraesthesia. The improvement in the muscle weakness/ paralysis usually happens after 5-7 treatments. It is recommended to continue with the treatment until resolution or best treatment effects are obtained for the specific patient.

Frequency of treatments

2-3 weekly is adviced during the acute phase (week 0-2) but after this daily treatment can be beneficial for the subacute phase; week 2-6. After this if the patient becomes a responder to this treatment ‘top up’ treatments, probably 3-6 can be recommended for the interval between 6 weeks and 12 weeks. In cases where there was significant nerve damage it is wise to continue with treatment up to 6 months as this is how long it can take for the nerve to regerenate.

The case study below demonstrates the frequency of  treatments that was required. Please note that this patient only received treatment with the Stimpod NMS460 during the chronic phase of Bell’s Palsy.

Case Study

D A Muller: My initial use of the Stimpod NMS 460 was in 2010, on a patient who experienced recurring incidents of Bell’s Palsy. At this time it was the 4th occurrence of Bell’s Palsy and paralysis. This was the second time it had affected the left side of her face, the previous 2 occurrences were on the right side. The previous 3 attacks of Bell’s Palsy recovered without any treatment at approxiamtely 6 weeks but with this latest occurrence she consulted the neurologist at 4 weeks into the condition due to limited recovery.

Physiotherapy treatment commenced on 26/02/2010.

Electro-therapeutic modalities and exercises were given but NOT the NMS 460.

By 31/03/2010 there was nil improvement.

The patient then returned to the neurologist (4 weeks post the routine physiotherapy) and who assessed the condition with nil changes to her previous consultation as she could not close her left eye or move the left side of her mouth.

An EMG examination on 25/03/2010 revealed severe axonal degeneration in the facial nerve with no active conduction.

In May 2010 we introduced Xavant’s nerve stimulator, the Stimpod, to the patient’s treatment – which was then only nerve stimulation with the Stimpod NMS460. The patient was given the device to take home and stimulate the left facial nerve on her own, once a day. The duration of the home sessions was between 5 – 10 minutes.

Telephonic follow up was made with the patient every 3 weeks. The patient also attended the physiotherapy practice 3 times for an assessment only.  After a week of using the device she reported that the left side of her face felt much better and that there was visible improvement in the facial muscle function. Upon seeing her during the follow ups most of the facial muscles scored a definite 3/5 on the Oxford grading system and some muscles even a 3+ /5 and 4-/5 by the end of June 2010. The only muscle that scored a 2/5 was the orbicularus oculi muscle as the left eye could not actively close completely.

About the author

D A Muller is a physiotherapist who has been using the Stimpod NMS460 since 2010. She has successfully treated many patients with different conditions that involve neuropathic pain or pathology.