Facial palsy is condition in which there is lesion of the facial nerve and the resultant paralysis in the muscles that it supplies. So there will be following features on the side of lesion:

Loss of facial expression.
Drooping of the face- Low eyelid, eyebrow and corner of mouth sag.
Closing the eye is difficult.
Eating is difficult because food collects in the side of the cheek and fluid seeps out of the corner of mouth.
Speaking, whistling and drinking are impaired.
Non-verbal communication is lost as the patient cannot register the pleasure, laughter, surprise, interest and worry.
The patient tends to sit with the hand over the side of face.
*
There is difference between an upper motor neuron lesion and lower motor neuron lesion of the facial palsy.

A unilateral UMN lesion usually spares the forehead as it is also innervated from the other side of the brain (part of facial nucleus supplying the upper face principally the frontalis muscle receive the supranuclear fibers from each hemisphere); however an LMN lesion affects all of one side of the face.

An upper motor neuron lesion causes weakness of lower part only of face on the side opposite the lesion. The frontalis muscle is spared; the normal furrowing of the brow is preserved, and the eye closure and blinking are not affected. The earliest sign is simply slowing of one side of the face, for example on baring the teeth or smiling.
Moreover, in upper motor neuron lesion there relative preservation of spontaneous 'emotional' movement (e.g. smiling) compared with voluntary movement.

A unilateral lower motor neuron lesion causes weakness of all the muscles of facial expression on the same side. The face, especially the angle of the mouth, falls, and dribbling occurs from the corner of the mouth. There is weakness of the frontalis and of eye closure since the upper facial muscles are weak. Corneal exposure and ulceration occurs if the eye does not close during sleep. The platysma muscle is also weak.

Causes of facial weakness:

These are as under:
The common cause of facial weakness is a supranuclear lesion (UMN) e.g. cerebral infarction leading to upper motor neuron facial weakness and hemiparesis.
Lesions at four other levels may be recognized by the associated signs.

PONS. The sixth nerve (abducens) nucleus is encircled by the seventh nerve fibers and is therefore involved in the pontine lesions of the nerve, causing lateral rectus palsy.
If there is accompanying damage to the neighboring centre for the lateral gaze (PPRF) and the cortispinal tract, there is the triple combination of:

LMN facial weakness
Failure of conjugate lateral gaze (towards the lesion)
Contra lateral hemi paresis

Causes include pontine tumors (e.g. glioma), demyelination and vascular lesions.
The facial nucleus is affected unilaterally or bilaterally in poliomyelitis and motor neuron disease; the lateral usually causes the bilateral weakness.

CEREBELLOPONTINE ANGLE. The fifth, sixth and eight nerves are affected with the seventh nerve in lesions in the cerebellopontine angle where they are grouped together. Causes are acoustic neuroma, miningoma and secondary neoplasm.

WITHIN THE PETROUS TEMPORAL BONE. The geniculate ganglion (a sensory ganglion for taste) lies at the genu of the facial nerve. Fibers join the facial nerve in the chorda tympani and carry taste from the anterior two third of the tongue. The (motor) nerve to the stapedius muscle leaves the facial nerve distal to the genu.
Lesions of facial nerve within the petrous temporal bone cause:
Loss of taste on the anterior two third of the tongue
Hyperacusis (an unpleasant loud distortion of noise) due to the paralysis of the stapedius muscle
Causes include:
Bell's palsy
Trauma
Infection of middle ear
Herpes zoster (Ramsay hunt syndrome)
Tumors (e.g. glomus tumor)

WITHIN THE FACE. Branches of the facial nerve pierce the parotid gland and supply the muscle of the facial expression. The nerve can be damaged here by parotid gland tumors, mumps (epidemic parotitis), sarcoidosis and trauma. The nerve is also affected in the polyneuritis (e.g. G.B. Syndrome) usually bilaterally.
Weakness of facial muscles also occurs in primary muscle disease and disease of neuromuscular junction. Weakness is usually bilateral. Causes include:
Dystrophia myotonica
Facio-scapulo humeral dystrophy
Myasthenia gravis

Bell's palsy
This is a common acute, isolated facial nerve palsy believed to be due to viral infection (most probably herpes simplex) that causes swelling of the nerve within the petrous temporal bone.

MANAGEMENT:
Spontaneous recovery occurs toward the end of second week. Thereafter, continuing recovery occur. Fifty percent recover within three months. Continuing recovery may take 12 months to become complete. About 15 percent of patients are left with a severe unsightly residual weakness.

Medical:

Steroids (prednisolone 60mg daily reducing to nil over 10 days.)
Acyclovir for viral infection

If there is severe residual paralysis, cosmetic surgery and/or reinnervation (nerve anastomosis of the lingual to the facial) are some times performed after a year has been elapsed.

Physiotherapy:

During the paralysis:

The selection of the suitable physical agent depends upon the experience or the choice of an experienced physiotherapist. Physiotherapist may choose from a number of physical agents available.

Ultrasound is given over the nerve trunk in front of the tragus of ear and in area between mastoid process and mandible. There is no fear of applying ultrasound while doing the treatment of patient with Bell's palsy. The ultrasound is always applied on the side of lesion in front of the tragus of ear & in area between the mastoid process and mandible where the maximum tenderness of the facial nerve is determined by palpation. It is applied in slow circular motion with a starting dosage of 1 watt per square centimeter for 10 minutes. The dosage may be increased on the subsequent sessions if no remarkable improvement is noted. Let me explain that ultrasound waves cannot traverse the bone. That means ultrasound has zero penetration in the bone. Infact, ultrasound waves are reflected away from the bone. So there is no fear in applying the ultrasound on face. (This is only for LMN lesion type)

Low level laser therapy (infrared 808 nanometer wavelength 400 mill watt power for 5 minutes continuous)

Infra-red: Infra red may be applied to warm the muscles and improve the function, but you must ensure that eyes are protected with linens when you are applying infra-red to face. Timing should be for 10 to 20 minutes at a distance usually between 50 and 75 cm.

Ultraviolet Therapy: Formerly ultraviolet was frequently used to give third or fourth degree erythema doses over the facial nerve trunk and in area between mastoid process and mandible (at the point of emergence of facial nerve on face)to combat the infection and inflammation. The type of lamp used for this type of treatment is the Kromayer lamp. The Kromayer lamp is a water cooled mercury vapor lamp which eliminates the danger of infrared burn. It has the advantage that it can be used in contact with the tissue or with suitable applicator it can be used to irradiate a suitable body cavity.

Testing the dosage can be done with Kromayer lamp in contact with the skin, so very small holes are used, e.g. 0.25 square cm. since exposure time need only be very short. It is often useful if the Kromayer lamp has standard dosage time recorded on it for contact and 10 cm. The front of the Kromayer lamp is cleaned with an appropriate solution and when it has had its full 5 minute warming up period the lamp is ready for use. The front of the lamp is held as close as possible to the skin or the target tissue. At least an E4 dosage is given. Treatment could infact be given at a set distance of, say 4 cm.

Microwave diathermy: As far as micro wave diathermy application is concerned, there is strict contra indication for the use of micro wave diathermy for the treatment of face as micro waves can spread randomly and can damage the lens of eye causing the opacity of the lens. So there is no room for the application of micro wave to face.

Short Wave Diathermy: SWD can be safely applied for the treatment of facial palsy at the point of emergence of nerve on the face. The technique used may be monopolar or bi polar. In bipolar technique using the capacitor field method or induction or cable method, the one facial mask electrode is used as an active electrode for applying the rays to face while the second or indifferent electrode used on some distant part of the body (usually cervical or dorsal spinal area) to complete the circuit. In monopolar electrode method only one electrode is used to direct the rays to the target treatment area site and no second electrode is used at all. The treatment time is between 10 and 30 minutes. Shorter sessions are used for mild conditions. Treatment is given on daily basis to produce the required results.

Electrical Stimulation: The only form of electrical current used on face is interrupted direct current (I.D.C.) whether or not there is reaction of degeneration. This is requested only to preserve the bulk of facial muscles and to prevent their atrophy while waiting them to be in function whenever their re innervations arrives in case of axotomesis or reconduction after neurapraxia if the nerve is not damaged completely. There is no room for the use of faradic current use on the face as it could lead to cause secondary contractures of the face. Moreover, most patients find it intolerable on face due to its unnecessary uncomfortable sensory stimulation. The is due to the reason that the faradic current has a frequency of 50 cycles per second, and so produces the tetanic contraction of the muscles that it stimulates. Although for muscle contraction faradic current is surged to produce alternate contraction and relaxation yet the tetanic type of contraction produced by these 50 pulses delivered in just one second, is not required on face. The face muscles are very thin and delicate and could not tolerate this tetanic type of contraction and may be damaged to produce the secondary contractures. If secondary contractures are produced, all form of electrical stimulation should be abandoned temporarily to avoid further damage to the muscles. The face should be gently stretched and massaged.

Heliotherapy: I have found traditional old lay men to use the convex*lens to focus the sun rays to produce the third or four degree erythema dosages to facial nerve trunk and in area between mandible and mastoid process behind the ear and it frequently give dramatic result with excellent recovery of facial palsy.* The treatment was needed to repeat after one week to repeat the same session of the dosage.* Only three or four sessions of this kind were needed to*do the excellent management of the patient.* Infact, it is one kind of heliotherapy treatment which is available from the natural source of power i.e. the sun.** This is*most common form of physiotherapy medicine that is used by*conventional lay men here in Pakistan with excellent results of the treatment.* Please, note that sun rays are a mixture of infra red rays and ultraviolet rays and visible rays on the electromagnetic spectrum. The thermal effect is produced by the infra red portion of the sun rays while the chemical effect like tanning of skin, effect on photographic film, formation of vita. D is due ultraviolet portion in the sun rays. The visible rays which are near to infra red portion on the electromagnetic spectrum produces effects similar to infra red rays. The visible rays which are near to ultra violet portion on an electromagnetic spectrum produces effects similar to ultraviolet rays. The erythema formation is due to ultraviolet portion of the sun rays. Usually fourth degree erythema dosage is required to produce the required therapeutic results.

Iontophoresis: Zinc, potassium iodide or chloride iontophoresis is given to the affected ear to treat the otitis media if there is infection of the middle ear.

Massage: The patient derives great benefit from the massage. Massage may be taught to the patient.
Stroking in the upward, outward direction. It is given from chin upwards to the temple and from the middle of forehead downwards towards the ear. The technique should be gentle but at the same time stimulating.
Slow finger kneading applied over the paralyzed muscles maintains skin suppleness and muscle elasticity. Small circular finger kneading can be given all over the affected side of the face, care being taken not to stretch the muscles.
Tapotement may be administered in the form of tapping quickly and lightly with the finger tips. It must be done very gently over the forehead and superficial ridges, where only a thin layer of muscle covers the bone.
Frictions are given at the point where the nerve enters the face to soften any inflammatory deposit.
Vibrations performed with the tip of one or two fingers can also be used over nerve trunk at this point or they may be administered by placing the whole flat hand on the affected side of face.
These techniques applied daily for 5 minutes or so help to maintain lymphatic and blood flow and prevent contractures.

During Recovery:

PNF techniques are used for re-education:
Quick stretch can be applied to regain raising of eye brow and the movement of the corner of mouth.
The physiotherapist can produce the movement passively and then ask the patient to hold, and then try to produce the movement.
Icing, brushing, tapping or brisk stroking may be applied along the length of the muscles. e.g. Zygomaticus
Exercises:
Look surprised then frown
Squeeze eyes closed then open wide
Smile, grin, and say 'o'.
Say a, e, i, o, u.
Hold straw in mouth-suck and blow
Whistle

Please, add more suggestions and your own point of view regarding the treatment of facial palsy, mail us - info@bprc.in or visit www.bprc.in

It is important to understand that the basic principles of strength training apply as they are for both sexes. However in the case of women some specific areas need to be addressed such as pregnancy, menopause, and others that arise due to structural and physiological differences. This is where strength training concepts need due modification with these specific needs in mind. The following guidelines for assessment and exercise prescription take into consideration these specific areas for designing and implementation of effective strength programs for women of all ages and varying fitness levels.
Various kinds of Strength:

For all practical purposes Strength can be defined as: The ability of a muscle or muscle group to exert Maximum Force. However the concept of strength is not all that simple when applied to working examples. This gives rise to various specific definitions of the strength. Let’s take time to understand some of them, in order to better our understanding of the concept.

• Anaerobic Strength:
• Aerobic Strength:
• Starting Strength:
• Explosive Strength:
• Absolute Strength:
• Relative Strength:
• Linear Strength Endurance
• Non-Linear Strength Endurance

Benefits of Strength Training (with * specific to women):

1) Functional Capacity
2) Disease Prevention
3) Stress Release*
4) Body Composition*
5) Bone Health*
6) Improved Sexual Function*
7) Reduction in symptoms of Menopause*
8) Easier, safer Pregnancy*
9) Easier Child Birth*
10)Healthier Infants*
11)Faster return to Pre-Pregnancy Wt*
12)Improved Hydration Status
13)Improved Thermoregulation
14)Improved Glucose Tolerance
15)Improved HDL levels
16)Reduced Triglycerides
17)Injury Prevention
18)Improved Sports Performance
19)Improved Balance*
20)Improved overall quality of life
21)Promotes Longevity and Vitality

Assessing Strength:
1 Repetition Maximum (1 RM): is the maximum weight that one can lift for any given movement in one single effort.

The 1 RM is the standard method used for measuring strength in most fitness and performance settings. Strength measurements are restricted to certain compound movements only due to the risk of injury involved in trying to test strength levels of smaller muscles. For all practical purposes the body can be divided into four basic segments to test strength. These are:

• Muscles of the anterior shoulder girdle: or the pushing muscles. These comprise of the pectoralis group, deltoids, serratus anterior, and triceps. The standard exercise used to test these muscles is the bench press.

• Muscles of the posterior shoulder girdle: or the pulling muscles. These comprise of the lattissimus dorsi, teres major, rhomboids, trapezius, biceps, and brachialis. The standard exercise used to test these muscles is either the bent row, or the lat pulldown.

• Muscles of the trunk: these act as the stabilizers and coordinate movements between the upper and lower body. These comprise of the abdominals, obliques, erector spinae, and the quadratus group. Generally strength testing is not done for these muscles, which are involved in flexion, extension, lateral flexion, and rotation of the spine. The reason being these are small and weak muscles, thus risk for injury is extremely high.

• Locomotors: as the term suggests these are the muscles that help us move around. The main muscles in this group are the gluteus group, quadriceps, and hamstring, namely the knee and hip extensors. The standard exercise used to test these muscles is the squat or the leg press.

Testing for 1 RM:
1. After a thorough warm up, perform a couple of sets with a light weight that can allow about 15 reps or so.
2. Now increase the weight so that 8 to 10 reps can be managed.
3. Then increase weight to allow about 5 to 6 reps.
4. At this point increase 2.5 to 5 lb per effort for bench press and bent rows, and 5 to 10 lbs for leg press and squats, till 1 RM is reached.
5. Allow full recovery between attempts (2 to 2.5 min).

Note: strength testing can also be performed for simple exercises if the muscle group involved is strong enough, such as the knee curl and extension. In the case of extremely strong individuals small muscles such as the biceps and abdominals can also be tested.

Inherent Problems with Strength Testing:

Strength Testing requires a maximal effort. This greatly increases the risk of injury even for highly trained athletes. To safely test unconditioned athletes we use:

Predicted 1 RM: this method is based on the fact that most individuals can manage a certain number of repetitions with a given percentage of their personal 1 RM value for a certain lift. The approximate corresponding repetitions for various percent values of 1 RM are given in the table below:

%1RM 100% 95% 90% 85% 80% 75% 70% 65% 60%
Reps 1 2 2-3 4-5 8 10 12 14 16

Testing for Predicted 1 RM:
1) Warm up the subject thoroughly.
2) Make her perform one set of a given movement with a very light weight eith which she can manage about 20 reps fairly easily.
3) After about 2 min rest, increase the weight slightly so that she can manage about 15 reps fairly easily.
4) Now for the third set increase the weight with which you feel that she should be able to barely manage 10 to 12 reps.
5) After a two minute rest interval make the subject squeeze out as many reps as is possible. Ensure strict form and full ROM.
6) Compare the results to the table given above.
7) If the subject manages less than 10 reps that is just fine.
8) But if she does more than 15 reps, the test is not valid. Let her rest for five minutes and re-test after increasing the resistance suitably.

General Guidelines for Strength Training:
1. Address all of the body’s energy systems.
2. Use mainly structural and compound movements.
3. But at the same time use various movements.
4. Train all major muscle groups.
5. Avoid imbalances between opposing muscle groups.
6. Use high intensity and low to moderate volumes.
7. Allow enough time for recovery.
8. Provide optimum nutrition.
9. Use variation to avoid plateaus.
10. Have a progressive periodized approach for safe optimal results.

Training Intensity:

Poor Fitness Extremely light resistance (< 50% 1 RM) or
simple free-hand weight supported movements.
Low Fitness Beginners 50 to 60% of 1 RM
Regular Exercisers 70 to 80% of 1 RM ( also for Hypertrophy)
High Fitness 85 to 100% of 1 RM (also for Strength and Power)

Volume:

Poor Fitness 2 sets per movement x 10 to 20 reps x
5 to 10 movements
Low Fitness Beginners 15 to 20 reps x 8 to 12 exercises x
1 to 3 circuits
Regular Exercisers 4 to 6 sets large muscle groups +
2 to 3 sets small muscles.
Hypertrophy Beginners 10 sets, intermediate 12 to 15 sets, and
advanced 20 to 25 sets per muscle group
High fitness & Strength Beginners 4 to 6 sets, Advanced 8 to 10
sets (only compound movements)

Recuperation (Acute & Chronic):

Acute Chronic
Poor Fitness 1 min 24 hours
Low Fitness Beginners 2 to 0 min bet circuits 48 hours
Regular Exercisers 1 min to 30 sec bet sets 72 to 96 hours
Hypertrophy 1 min to 30 sec bet sets 96 hours to 1 week
High fitness & Strength 2.5 to 5 min bet sets 96 hours to 1 week

Guidelines for Pregnant Women:
1) Reduce intensity to 60 to 70% due to slack muscles and tendons.
2) Avoid supine movements.
3) Avoid abdominal strengthening and use ab/back support.
4) Avoid impact.
5) Avoid dehydration and excess temperatures.
6) Make necessary dietary modifications to suffice exercise and fetal needs.

Guidelines for osteoporosis and arthritis:
1) Make sure to get correct nutrients for bone health (refer table below).
2) Moderation is the key word for injury prevention.
3) For arthritis, reduce intensity to 50 to 60 % and fol low the 4 hour pain rule.
4) Take enough antioxidants.

This table lists all the essential nutrients for a healthy skeletal system, how much of each do you require, anti-nutrients that inhibit their uptake, and the foods that are good sources of them:

Nutrient RDA* Inhibitors Best food sources - per 100 gm serving.

Calcium Child 600 mg
Adult 800 mg Lack of exercise, tea, coffee, alcohol, lack of hydrochloric acid in the stomach, hormonal imbalance.
Milk (120 mg), yogurt (149), Swiss cheese (925), Cheddar cheese (750), almonds(234), Brewer’s yeast (234), parsley, coriander, spinach (250), corn tortillas (200).

Vitamin D
Child 10 mcg
Adult 10 mcg
Lack of sunlight, fried foods.
Herrings (22.5mcg), mackerel (17.5), salmon (12.5), oysters (3), cheese (2), eggs (1.5).

Magnesium
Child 170 mg
Adult 300 mg
Large amts of Calcium from milk products, proteins, fats, oxalates, phytates.
Wheat germ (490 mg), almonds (270), cashew nuts (267), brewer’s yeast (231), buck wheat flour (229), peanuts (225), cooked beans (37), Garlic (36), raisins, green peas (35).
Phosphorus
Child 800 mg
Adult 800 mg
Too much iron, magnesium, aluminum.
Present in almost all foods.

Vitamin C
Child 35 mg
Adult 40 mg
Smoking, alcohol, pollution, stress, fried food, tea, coffee.
Peppers (100 mg), watercress (60),
Cabbage (60), broccoli (110), cauliflower (60), strawberries (60), lemons (80), kiwi fruit (85), oranges (50), tomatoes (60).

Zinc
Child 7 mg
Adult 15 mg
High calcium uptake, low protein uptake, copper, alcohol, excess sugar, phytates, oxalates.
Oysters (148 mg), ginger root (6.8), lamb (5.3), dry split peas (4.2), egg yolk (3.5), peanuts (3.2), almonds (3.1), whole wheat (3.2 mg)

What is the “Q” angle?

The “Q” angle is the angle at which the femur tapers inwards in females, due to broader pelvis. Over time weak muscles and chronic valgus stress can cause the knees to bend inward, causing severe pain and injury to the joint. It can be prevented through correct strength training at an early age.

Program Design & Periodization:

The benefits of a periodized program are:
1) Ensure steady progress.
2) Safety and injury prevention.
3) Avoid Chronic fatigue, chronic injury and burnout.
4) Provide variation and make training interesting.
5) Facilitate Adherence.
6) Successful achievement of long term goals.