HSC Section 3 - Trauma, Critical Care and Sleep Medicine

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eye evaluation and earlier surgical intervention. Temporary tarsorrhaphy, punctal plugs, or early consideration for a reversible lid loading procedure may be considered.

Adjuvant Therapy Physical therapy for Bell palsy

Various physical therapy interventions have been proposed for acute FP, including thermal treatment, electrotherapy, acupuncture, massage, transcutaneous electrical nerve stimulation, electrical neural muscular stimulation, facial exercises, and biofeed- back. 85 Physical therapy is integral to the rehabilitation of the patient with FP in both acute and chronic patients. Initial education of the normal facial musculature and its associated movement helps the patient have mental awareness of the flaccid hemi- face as well as the overt contralateral pull of the other side. Exercises In the acute setting, soft tissue mobilization and massage are thought to increase blood flow and oxygenation to tissues. It is especially useful in the contralateral face where excess tightness and pain results from unopposed pulling. Also, active hand- assistive exercises help contraction of target muscles until voluntary movement returns. 86 Again, eye protection is crucial and gentle eyelid stretch exercises can help to facilitate eye closure. Facial neuromuscular retraining is the most common physical therapy technique used when movement begins. 87 Mime therapy combines many of the previously described techniques with a mirror-stimulation of facial expression, functional move- ments, relaxation techniques, and breathing control. 88 The goal is to promote facial symmetry during movement and repose. A Cochrane review (2012) found that there was no therapy that significantly affected the outcome in cases of acute FP. 85,89 There was no statistically significant difference in synkinesis or recovery. However, the studies did suggest that early tailored facial exercises could help improve function in cases of moderate paralysis or chronic cases by decreasing recovery time and re- sidual long-term paralysis. Overall, the studies lacked methodological consistency, appropriate duration of treatment (up to 6 months), and risk profile (see Mara Wernick Robinson and Jennifer Baiungo’s article, “ Facial Rehabilitation: Evaluation and Treatment Strategies for the Patient with Facial Palsy ,” in this issue, for further details). Acupuncture Acupuncture is widely practiced in China and is a part of Traditional Chinese medicine. The technique uses fine needles inserted into the skin to stimulate specific “pressure points” that are thought to regulate bodily processes or networks. Theories include the ability to promote nerve regeneration, nerve excitability, increasing muscle contrac- tion, or blood circulation. It is known to be relatively safe; however, side effects have not routinely been reported in the Chinese literature. 90 Currently, there are no well-designed clinical trials to advocate for the use of acupuncture. A Cochrane review by Chen and colleagues 91 evaluated 6 RCTs with a total of 537 patients. Although the studies sug- gested a beneficial effect from acupuncture, the overall quality of the evidence was poor. The studies were limited by a lack of consistency with research methodology, het- erogeneous interventions, outcomes analysis, and short study duration. Further meta- analyses echoed these findings. 92,93 The AAO-HNS also makes no recommendation for acupuncture based on poor-quality trials and an indeterminate risk/benefit ratio. 74 Electrical stimulation FP deprives the facial muscles of neural input. External electrical stimulation (E-stim) uses electrical impulses to promote muscle tone and to inhibit atrophy. Animal studies

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