MEDICAL REHABILITATION IN PREGNANCY PATIENT WITH BELLS PALSY DEXTRA

Introduction Bells palsy or idiopathic facial paralysis is commonly treated by physical medicine with various therapeutic strategies and devices.
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Bells palsy is a peripheral

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palsy of the facial nerve that results in muscle weakness on one side of the face.

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1830, Sir Charles Bell first noted an association between pregnancy and a paralysis of facial musculature.3 This occurred primarily in third trimester and first 2 week postpartum. The etiology of Bells palsy and its association with pregnancy is unknown.5 Population-based epidemiologic studies have demonstrated an increased incidence of Bells palsy during pregnancy. The incidence in the current series was 40 per 100.000 births, similar to Hilsingers estimate of 45 per 100.000 delievers. 2 The etiology of Bells palsy is unknown but viral infection, vascular ischemia, or autoimmune disease has been postulated as possible pathomechanisms. Bells palsy disproportionally attacks pregnant women, influenza, and cold. Some patients report exposure to an air condition outlet or an open window before the attack.2 Patients with Bells palsy typically complain of weakness or complete paralysis of all the muscles on one side of the face. The facial creases and nasolabial fold disappear, the forehead un frowns , and the corner of the mouth droops. The eyelids will not close and the lower lid sags; on attempted closure, the eye rolls upward (Bells phenomenon). Eye irritation often results from lack of lubrication and constant exposure. Tear production decreases; however the eye may appear to tear excessively because of loss lid control, which allows tears to spill freely from the eye. Food and saliva can pool in the affected side of the mouth and may spill out from the corner. 3 Rehabilitation can be done to a patient by collaboration work of physical medicine and rehabilitation physician, physiotherapist, occupational therapy, speech therapy, orthotic-prosthetic psychologist and medical social worker. The physician will make a comprehensive examination to make a clear diagnosis of a patient. After that, a physician will give medication if needed, and an instruction to other subunit for further treatment. The aim of rehabilitation are to facilitate or improve muscle contraction, to facilitate or improve facial symmetry and to prevent complications. 4, 6 1

In this case report is about rehabilitation in a pregnancy woman with bells palsy.

Case Report I. Identity a. Name b. Age c. Sex d. Religion e. Nationality f. Profession g. Address h. Examination time : Mrs. ST : 28 Years old : Female : Christian : Indonesian : Housewife : Amurang : June 19th, 2012

II. Anamnesis (Autoanamnesis with patient)

Chief complaint : dropping of the corner of the mouth to the left.

History of present illness : Patient felt dropping of the corner of the mouth to the left since 1 weeks ago when she woke up in the morning, She saw her right facial creases and nasolabial fold

disappear, the forehead unfrowns, and the corner of the mouth droops. Her right eyelids can not close and the lower lid sags so her eyes appear to tear excessively. When she ate the food and saliva pool in the right side and spill out from the corner. Before that, when she was in the car, she opened the window so the wind directly to her face. She had a cough and rainy nose 2 weeks before this. Her ears are not feel pain, no change in her taste and she no history of trauma. Moreover, there is no weakness on her arms and her legs, This is the first time patient has an experience like this. Patient was scared to drink medicine because she was pregnant 8 months.

History of past illness: There is no history of hypertension, diabetes.

Family history: There is no family member who has this problem.

Habitual status: Patient always use a fan which directly blow to her body. Patient does not smoke.

Social and economical status: Patient live with her husband and her boy. Her boy is 4 years old. They live in a permanent house with 2 bedrooms. The toilet is squatting toilet. The source of water is from a well. They use PLN (Perusahaan Listrik Negara) as the source of electricity. Patient used jamkesmas for medication. Her husband was a employee.

Psychological status: Patient has an anxiety and shame about her face.

III. Physical examination General condition: moderate ill Level of consciousness : compos mentis Vital sign: Blood pressure: 100/60 mmHg RR: 20x/minute General status Head : normocephali, conjungtiva anemis (-/-), sclera icteric (-/-), asymmetrical face on the right side. Neck: trachea at the midline, lymph node enlargement (-/-) Cor: Inspection Palpation Percussion : ictus cordis not seen : ictus cordis not palpable : upper border: ICS III; left border: ICS V left midclavicular line. Right border : right sternal line Pulse : 84x/minute Temperature: afebrile

Auscultation : 1st & 2nd heart sound N, murmur (-/-) Pulmo: Inspection Palpation Percussion : thoracic movement symmetric : stem fremitus left=right : sonor at all lung field

Auscultation : vesicular breath sound, ronchi (-/-), wheezing (-/-) Abdomen: hepar and lien not palpable, epigastric pain (-/-) Extremities: warm acral

Local status at face Inspection : asymmetric on the right side. Palpation : Muscles Frontalis Corrugator supercilli Procerrus Orbicularis occuli Nasalis Zygomaticus mayor Buccinators Orbicularis oris Dextra 0 0 0 1 0 0 0 0 Sinistra 3 3 3 3 3 3 3 3

Examination gap of right eye : 1 cm Examination of mouth : Inspection : right lip was asymmetrical, tongue on the middle, tremor (-), articulation : no disatria

UGO FISCH scale Position Rest Frown the forehead Closed eyes Smile Whistle Total Value 20 10 30 30 10 Percentage 0 0 30 0 0 Score 0 0 9 0 0 9%

The picture of patient when she come

Picture 1. At rest, picture 2. For the muscles frontalis, picture 3. For the muscles corrugator supercilli, picture 4. For the muscles procerus.

picture 5. For the muscles zygomaticus mayor. Picture 6, for the muscles orbicularis occuli. Picture 7, for the muscles orbicularis oris

Diagnosis Clinical diagnosis Topical diagnosis Etiologic diagnosis : Bells palsy dextra 7 days : Suspect Right foramen stylomastoideum : Idiopathic

Functional diagnosis : Disturbance of activity daily living such as chewing, Gargle, eating, and drinking

Medication was not given, because patient was pregnant.

Rehabilitation : Problems: Patient has good contact and understanding Weakness on her right face (manual muscles test orbicularis occuli was 1, and the other was 0) Gap of right eye: 1 cm Limitation on activity daily living (ADL) such as chewing, gargle. Anxiety and shame about her face.

Programs: Physiotherapy: o Problems Patient has a good contact and understanding Weakness on her right face (manual muscles test orbicularis occuli was 1 and the other was 0) Gap of right eye : 1 cm Limitation on ADL such as chewing and gargle.

o Programs Infrared on her right face. Deep kneading massage on her right face Kabat rehabilitation on her face.

Speech therapy: o Problems: Patient has a good contact and understanding, no disatriculation Weakness on her right face (manual muscles test orbicularis occuli was 1 on the other was 0) Gap of right eye : 1 cm Limitation on ADL such as chewing and gargle.

o Programs: Exercise on her face in front of mirror/neuromuscular retraining

Orthotics and Prosthetic o Problems: Weakness on her right face (manual muscles test orbicularis occuli was 1 on the other was 0) Gap of right eye : 1 cm o Programs: Patient was given plester Y

Psychology: o Problems: Anxiety and shame due to asymmetric her face Mental support to reduce patients anxiety and giving a confidence when she exercise every day her face may back to normal. Because this ill will give a recovery approximately 85%. o Programs:

Social medical: o Problems: Patient is a housewife, her husband as a employee. For the living cost they dont have a complain about that. Patients medical fee is borne by Jamkesmas. o Programs: Give support to therapy everyday. Dont use a fan which expose directly to her face.

Home education : 1. Always use a sun glasses if the patient want to going out at morning or afternoon. 2. Always use a eye drops on everyday. 3. When she want to go bed, used a kassa 4. Always exercise her face in front of the mirror (Like a blow candle) and eat lollipop.

Follow up June 26, 2012 S July 4, 2012

Patient when she was eating, drinking Patient could raise her forehead, closed the food and the saliva pool in the right her eyes more properly. side and spill out from the corner.

BP : 110/70 mmHg, Gap of eyelid : 0,6 cm Manual muscle test Dx m. frontalis 1 Sx 3 3 3 3 3 3

BP : 120/80 mmHg, Gap of eyelid : Manual muscle test Dx m. frontalis m. corrugator supercilli m. orbicularis occuli m. procerus m. zygomaticus mayor m. buccinators 2 2 3 2 2 2 2 % 20 10 30 30 30 70 70 100 70 70 14 7 30 21 21 93% Sx 3 3 3 3 3 3 3

m. corrugator supercilli 1 m. orbicularis occuli m. procerus 2 1

m. zygomaticus mayor 1 m. buccinators m. orbicularis oris UGO FISCH Scale: Rest 20 2 2 % 30 30 70 30 30 3

3 m. orbicularis oris UGO FISCH Scale: 6 Rest Frown the forehead Closed eye

Frown the forehead 10 Closed eye Smile Whistle Total 30 30 30

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9 Smile 9 48% Whistle Total

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Bells palsy day 14 Physiotherapy: Problems: Weakness on her right face (manual muscles test frontalis, corrugator supercili, procerus , zygomaticus mayor were 1 and the other such as orbicularis occuli, buccinators and

Bells palsy day 22 Physiotherapy: Problems: Weakness on her right face (manual muscles test frontalis, corrugator supercili, procerus , zygomaticus mayor, buccinators and orbicularis oris were 2 and the other such as orbicularis occuli was 3) Programs: Infrared on the right face Deep kneading massage on her right face Kabat rehabilitation

orbicularis oris were 2) Limitation on ADL such as chewing and gargle. Programs: Infrared on the right face Deep kneading massage on her right face Kabat rehabilitation

Speech therapy: Problems: Weakness on her right face (manual muscles test frontalis, corrugator supercili, procerus , zygomaticus mayor, buccinators and orbicularis oris were 2 and the other such as orbicularis occuli was 3)

Speech therapy: Problems: Weakness on her right face (manual muscles test frontalis, corrugator supercili, procerus , zygomaticus mayor were 1 and the other such as orbicularis occuli, buccinators and

orbicularis oris were 2) Programs: Exercise her face in front of mirror/neuromuscular retraining Psychology: Problem: Programs: Exercise her face in front of mirror/neuromuscular retraining Psychology: Problem:

Patient have a good contact and always exercise her face.

Patient have a good contact and always exercise her face.

Program: Give support to patient

Program: Give support to patient

Picture of patient day 14

a. For the frontalis mucles, b. for the corrugator supercilli muscles, c, for the orbicularis oculi muscles, d. for the procerus muscles, e. for the zygomaticus mayor muscles, f. for the orbicularis oris muscles.

Picture of patient day 22

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a. position at rest, b. for the frontalis muscles, c. for the corrugator supercilli muscles, d. for the orbicularis occuli, e. for the procerus muscles, f. for the zygomaticus mayor muscles, g. for the orbicularis oris muscles. Prognosis: Ad vitam Ad functionam Ad sanationam : bonam : bonam : bonam

Discussion A pregnant woman, 28 years old was come with dropping of the corner of the mouth to the left. The diagnosis is constructed by anamnesis, physical examination. From the anamnesis this patient, she saw asymmetry face at the right side since 1 weeks ago when she woke up in the morning, Her facial creases and nasolabial fold disappear, the forehead cant frown, and the corner of the mouth droops. Her eyelids can not close and the lower lid sags so her eyes appear to tear excessively. When she ate the food and saliva

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pool in the affected side and spill out from the corner. Before that, when she was in the car, she opened the window so the wind directly to her face. She had a cough and rainy nose 2 weeks before this. Her ears are not feel pain, no change in her taste and she no history of trauma. Moreover, there is no weakness on her arms and her legs, This is the first time patient has an experience like this. Patient was scared to drink medicine because she was pregnant 8 months. According from the literature that patients with Bells palsy typically complain of weakness or complete paralysis of all the muscles on one side of the face. The facial creases and nasolabial fold disappear, the forehead cant frown, and the corner of the mouth droops. The eyelids will not close and the lower lid sags; on attempted closure, the eye rolls upward (Bells phenomenon). Eye irritation often results from lack of lubrication and constant exposure. Tear production decreases; however the eye may appear to tear excessively because of loss lid control, which allows tears to spill freely from the eye. Food and saliva can pool in the affected side of the mouth and may spill out from the corner. 3 From the literature, Sir Charles bell suggested a possible association of pregnancy with paralysis of the muscles of facial expression. The incidence of Bells palsy is three times higher during pregnancy and puerperium (3845 women per 100.000 pregnancies versus 17 per 100.000 women per year in nonpregnant women of childbearing age). For women in the third trimester of pregnancy in particular, the calculated frequency rises to 118.2 cases per 100.000 birth per year. 7 The aetiology of facial palsy in pregnancy is not well known. A lot of theories have been proposed such as viral origin. It has been found that the incidence of herpes simplex virus in pregnant females is higher than that in non-pregnant women, which may explained by gestational immune suppression resulting from elevated cortisole levels during

pregnancy. Other theories related facial palsy to toxemia of pregnancy, high levels of progresterone and oestrogen, and increased interstitial fluid volume in pregnancy causing mechanical compression of the facial nerve in its bony canal in the temporal bone. 5, 7, 8 From the physical examination, patient was compos mentis, cooperative, communication and comprehension was good, vital sign was normal, manual muscle test such as frontalis, corrugator supercilli, procerus, zygomaticus mayor, orbicularis oris, buccinators were 0 and orbicularis occuli was 1. There are no impairment in taste. Examination wide of her eye from upper lid to bottom lid at the right eye : 1 cm.

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According to literature examination for the manual muscles test used score 0, 1, 2, and 3. For the example, 0 means no evidence of muscles activity. 1 means unable to close eyes so that the iris is completely covered. 2 means takes no resistance to eye closure; closure may be incomplete, but only a small amount of the sclera and no iris should be visible. There may be closure of the eye, but the eyelid on the weaker side may be delayed in contrast to the quick closure on the normal side. And for the score 3, closes eyes tightly and holds against examiners resistance. Iris may not be visible. 9 For evaluation of progressive motor function on patient BP we used UGO FISCH scale. In UGO FISCH scale will evaluation about symmetrical or asymmetrical both side in 5 position. Percentage of evaluation are 0% is asymmetrical komplit, no involuntary of movement; 30% is symmetrical, poor, the recovery seems nearly complete asymmetrical; 70% is symmetrical, fair, partial recovery seems to normally, 100% is symmetrical, normal or complete.10 In this patient the UGO FISCH scale was 9%. Generally, the treatment of BP can be conducted in 2 ways: first by using pharmacology agent (drugs), and second by rehabilitation. Physical medicine and rehabilitation (PM&R) also referred as physiatry is a medical speciality concerned with diagnosis, evaluation, and management of persons of all ages with physical and/or cognitive impairment and disability.11,12 A physiatrist will work together with the other subunit such as physiotherapy, occupational therapy, orthotic-prosthetic, psychology, and medical social worker to achieve the best treatment for the patient. According to Cochrane reviews, they found significant benefit from prednisolone and acyclovir. 1,3 Steroid, pain medication and even anti-virals are all commonly used but may not safe during pregnancy. When pregnant, it will be important to consider massage, acupressure, kabat rehabilitation and bells palsy exercise. 13, 14, 15 In Physiotherapist program, the physiatrist prescribed infrared, deep kneading massage and Kabat rehabilitation. Infrared is the portion of the electromagnetic spectrum adjacent to the long-wavelength, low frequency (red) end of the visible spectrum. Luminous infrared heat lamp emit radiation in the near-infrared spectrum (wavelength 770 to 1500 nm), and non luminous infrared heat lamps emit radiation in the far-infrared spectrum (wave length 1500 to 12,500 nm).16 Effects of heat in hemodynamic is vasodilation and thus an increase in the rate of blood flow. According to the literature that

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pregnancy is one of precautions for the use thermotherapy. A fetus may be damaged by maternal hyperthermia; however, because this unlikely to occur with superficial heating of the limbs, thermotherapy may be applied to such areas. If the patient is or may be pregnant, heat should not be applied to the abdomen or low back.17 Massage can be performed in conjunction with other treatment options. Massage manipulations on the face include: effleurage, finger or thumb kneading, wringing, hacking, tapping and stroking. Kneading massage increases blood circulation to the tissues.
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Kabat

rehabilitation is type of motor control rehabilitation technique based on proprioceptive neuromuscular facilitation (PNF). During kabat, therapist facilitate the voluntary contraction of the impaired muscle by applying a global stretching then resistance to the entire muscular section and motivate action by verbal input and manual contact. When performing Kabat, 3 regional are considered: the upper (forehead and eyes), intermediate (nose), and lower (mouth). Prior to Kabat, infrared stimulation has to perform to a spesific muscular group, in order to increased blood flow, decreased chronic inflammation. 19

Table 1. Kabat Rehabilitation

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In speech therapy unit, the physiatrist prescribed bells palsy exercise in front of the mirror. According to controlled study BP neuromuscular retraining exercises were effective in improving facial movements.2, 20

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Table 2. Bells palsy exercise

In psychology program in this patient was given to support mental and give more confidence. The patient seems obey the instructions so the recovery very fast. In social medical patient was a housewife, her husband worked as a employee and for the living cost there are no problem with that. Medical fee is borne from JAMKESMAS. The patient was motivated and she stay away from expose directly to fan. On July 4th 2012, physiatrist made an evaluation to the patient. There were some improvement on her right face, she can closed her eyes and smile. The UGO FISCH scale was 93%. In this occasion, physiatrist gave an education for the patient always exercise her face in front the mirror. In Cochrane reviews, about 80-85% begin to recover within the first 3 weeks after onset. While about 15% of patients, recovery begins after 2 to 3 months from onset.21

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