Helen, the therapist I spend the most time shadowing at the outpatient clinic where I volunteer, has recently begun treating two clients with Bell’s palsy. I’ve included the Mayo Clinic’s definition of Bell’s palsy below for anyone who has not heard of it – I know I hadn’t!
“Bell’s palsy causes sudden weakness in your facial muscles. This makes half of your face appear to droop. Your smile is one-sided, and your eye on that side resists closing.
Bell’s palsy, also known as facial palsy, can occur at any age. The exact cause is unknown, but it’s believed to be the result of swlling and inflammation of the nerve that controls the muscles on one side of your face. It may be a reaction that occurs after a viral infection.
For most people, Bell’s palsy is temporary. Symptoms usually start to improve within a few weeks, with complete recovery in about six months. A small number of people continue to have some Bell’s palsy symptoms for life. Rarely, Bell’s palsy can recur.”
As the definition mentions, Bell’s palsy can occur as the result of a viral infection a person contracts or by some damage to or inflammation of cranial nerve VII, the facial nerve.
Interestingly, Helen has seen two very different clients with Bell’s palsy in the past few weeks. The first client is an older male who is recovering from a surgery to remove a brain tumor that happened in early March. The second person, with whom Helen is using the heat and FES modalities, is a young boy. However, in both cases the client is experiencing dry eye and difficulty moistening the eye by blinking, as the impaired nerve functioning leads to partial or full paralysis of the facial muscles around the eye. This is certainly very uncomfortable, and can be dangerous if unwanted substances enter the eye and aren’t removed by reflexive blinking and eye-watering.
These clients can also have difficulty in other functional areas. Bell’s palsy and the accompanying facial weakness or paralysis can make it difficult to drink from a cup or straw, eat in a way that is socially appropriate (i.e. with mouth closing fully during chewing and by removing all food particles from the affected side) or be comfortable interacting with others due to the facial droop and weakness preventing typical expression with the mouth and eyes.
FES as a Modality
I have been able to observe functional electrical stimulation (FES) being used in treatment before, at the outpatient rehab facility where I first volunteered with an OT. In this setting, clients used an FES bike that could be attached to their arms and legs. The therapists there also used the BioNess hand therapy system. However, the treatment of the young boy with Bell’s palsy was the first time I had ever seen FES used on the face. I’ll call this client “John” from here on.
Helen started John’s treatments by having him rest his affected side on a moist heating pad layered with towels. After several minutes, she attached the FES electrodes to his lower jaw and cheek area and set the machine. After about 10 minutes, she moved the upper electrode to his temple to stimulate the eye muscles.
It was very cool to observe Helen treating John’s Bell’s palsy with the FES system, and even more so because it seemed to be very effective! After two sessions, he reported that his pain decreased from a 6 to a 3, and that jump was pretty great for a kid who hadn’t been able to touch the left side of his face without experiencing pain the week before!
Learning about FES
Helen was also very good about helping me understand how to interpret the machine’s complex numbers and settings. Obviously I’m going to have to do what she did and take a continuing education course in order to be able to properly use this type of equipment, and I look forward to doing that! While John was being treated, she let me look at the course book that she used when taking the course on these types of modalities near the start of her career. It was amazing to see that she still remembered and applied knowledge from a course she had taken in the 1990’s! I hope that I’ll be able to apply knowledge I’ve gained in my college classes to my treatments in the future as well.
She also taught me about how the effectiveness of FES therapy can be affected by different things, one of which was very surprising! First, she explained how dead skin and/or hair on the body and electrodes can impede the electrical signal and prevent sufficient activation of the muscles. Then she explained why she had asked John how much water he’d had that morning – it’s because your level of hydration can affect the FES treatment!
It makes total sense, but it’s not something I would probably have ever thought about during treatment. Helen told me that the amount of water in your body – or not in your body – is important because it affects how the current travels through the muscles. So a person who is dehydrated can have an altered experience with the treatment. Cool stuff!
She also talked about how you can use the numbers on the machine to learn a little more about the client’s progress. For example, when John first came for treatment, she had the machine set to about level “18” before he reported that he could feel it. But the next week he responded when the machine was at level “8” or “10.” This significant drop in the level of electrical current needed for John to sense the current meant that sensation on his left side was returning! My takeaway from this part of the treatment was that it can be important to ask clients for a rating on any quantifiable measure they can use to describe what they’re feeling so that you can track their progress and note any positive or negative changes.
Do as I Do
Another important lesson that I learned from this treatment was the importance of testing out the exercises or recommendations you give to your clients. At the end of the session, Helen gave John a worksheet, complete with diagrams and written instructions, of the facial exercises he should be doing at home to help speed his recovery. It looked something like this:
Instead of simply handing him the sheet and sending him along, Helen sat down and went through each exercise with him. She screwed up her face, frowned, raised her eyebrows and laughed along with him as she showed him how each exercise should be done. This not only helped make clear what he should be doing, but I think it helped make him feel more relaxed about making these strange faces and doing all the manual stretching exercises! Of course I joined in as well, and we ended the session with our faces very well stretched and our laugh muscles very well used!
I’m enjoying learning more about the modalities that can be used in a pediatric setting, because I’m only used to seeing them used with adults. But I suppose the possibilities are endless! I think in the future I’ll definitely take a course in electrical stimulation, especially because I think it will be highly relevant to the populations I hope to work with.