Recent Head Injuries
Benign Paroxysmal Positional Vertigo (BPPV) is the most common of vestibular disorders and the most easily treated. In most patients, it can be cured with a simple physical therapy maneuver. BPPV can affect people of all ages, although it is most common in folks over the age of 60.
BPPV occurs when small, microsized calcium crystals called otoconia become dislodged from their normal location on the utricle, one of the inner ear sensory organs. These otoconia are usually embedded in a gelatin like material on top of the utricle. If the otoconia become detached, they are free to flow in the fluid filled spaces of the inner ear, including the semicircular canals which sense the rotation of the head. If there are enough otoconia floating around, they can aggregate into a larger clump. Because they are heavy, they migrate into the lowest part of the inner ear, the posterior semicircular canal. Once in the semicircular canal, they may still move when the head changes position, such as looking up or down, over the shoulder, or when rolling over in bed. It is the movement of these stones that causes an unwanted flow of fluid in the semicircular canal even after the head has stopped moving. This leads to a false sense that the head and body are spinning around or that the world around you is spinning around.Symptoms
Patients with BPPV usually experience vertigo when they turn over in bed, get in or out of bed, look up to a high shelf or put their head back in the shower. These are circumstances where there is a large change in the orientation of the head with respect to the pull of gravity. Patients often become imbalanced or unsteady when they get up from bed and try to walk and may even fall. They are occasionally quite ill with nausea, vomiting and other motion sickness like symptoms.
The onset of BPPV may be abrupt and frightening. Patients may even think they are having a stroke. Whenever they tilt or tip their head, they can experience extreme vertigo, imbalance, and may even fall out of bed. If they are up and around and tilt their head back or forward, they can fall to the ground. The usual course of the illness is a gradual lessening of symptoms over a period of weeks to months. Occasionally the symptoms can last for years.
While the hallmark of BPPV is episodic vertigo associated with changes in head position, many patients also have a mild degree of constant unsteadiness during the periods when they are also having the recurrent attacks of positional vertigo.Causes of BPPV
In many patients, especially the elderly, there is no specific inciting event. As we get older, the otoconia are probably more easily sheared off from their normal positions stuck on the utricle. All of us certainly have a few of these microscopic stones floating around in our semicircular canals, but usually there are not enough of them to cause symptoms. Only when a large clump falls into one of the semicircular canals do the stones create their mischief.
In some patients, there may be a specific cause for the BPPV, including:
- Mild to moderate or severe head trauma
- Head in the same position for a long time, such as in the dentist chair, at the beauty shop or on strict bed rest
- Bike riding on rough trails
- High intensity aerobics
- Labyrinthine conditions – viral or vascular
- Ménières disease
- Vestibular migraines
The diagnosis of BPPV is made by the characteristic symptoms and also by observing the nystagmus – the jerking of the eyes that accompanies the severe vertigo patients experience when the position of their head is changed. By tilting a patient’s head way back at the end of an examining table, a doctor will try to provoke the symptoms to see the nystagmus for a thorough diagnosis.
The treatment of BPPV is based upon our specific knowledge of the disease. Bedside physical therapy maneuvers and programs of exercise have been designed with the goal of removing the stones from the semicircular canals.. There is always the risk of the stones falling back into the semicircular canal and getting stuck again. Once out, however, the otoconia usually don’t cause further problems. If the stones do fall back into the semicircular canal, the physical therapy can be repeated.
The physical therapy maneuver we usually use is called the Epley maneuver. First, while sitting up, the patients head is turned about 45 degrees to the side that normally provokes the vertigo. Then the patient is quickly laid down backwards with their head just over the edge of the examining table. This position usually provokes strong vertigo. The head is kept in this position for about 30 seconds and then turned 90 degrees to the opposite side. After another 30 seconds, the head and the body are turned together in the same direction so that the body is pointing towards the side, and the head is pointing down toward the ground at a 45 degree angle. After 30 seconds in this position, the patient is brought upright again. This is repeated as many as five or six times until neither vertigo nor nystagmus are elicited when the head is brought into the bad ear down position.
In many ways, the discovery of the mechanism of this simple treatment for BPPV is one of the most gratifying advances in the evaluation of the dizzy patient. BPPV can be diagnosed and treated successfully with no tests, no pills, no surgery and no special equipment.
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SIGNS & SYMPTOMS
In trigeminal neuralgia repeated attack of intense pain occur in certain areas of face which last up to seconds or few minutes or sometimes few hours. In some sufferers the pain episode are with intermittent remissions of few months. Some cases show muscle spasm in unilateral facial muscles along with pain.
The trigger point of pain is an hypersensitive area on face which is stimulated by weak factors even slightest touch or air current or some daily activity like talking, shaving, brushing teeth, chewing food or some loud noise. These factors aggravate the condition.
TN is considered as one of the most painful conditions. Type of pain sensation varies from person to person. The feeling is described as “Electric Shock”, burning, stabbing, pressing, crushing or exploding etc.
In about 10-12% cases problem is bilateral. But pain is not felt on both side of face at the same time. Because both the right & left trigeminal nerves are separate so, one nerve don’t affect the contralateral facial areas. Bilateral involvement indicates that both the nerves are affected.
With progression the frequency and severity of pain episodes worsen. Pain spreads through branches of nerve. Some people also felt the pain in Index finger.
Several studies and research work has been done to find out the cause of trigeminal neuralgia and there are many theories regarding the cause behind this pain syndrome. Previous research workers thought that this pain is caused due to the compression of trigeminal nerve at the site of opening where it emerges from skull. Compression is due to several causes such as a tumour, aracnoid cyst, any venous loop or aneurysm, and sometimes it may be a plaque of Multiple Sclerosis.
Some newer studies reveal that any enlarged blood vessel of brain probably the superior cerebellar artery compresses the trigeminal nerve near its connection with pons. This persistent compression damages the myelin sheath of nerve making it hyper sensitive. Thus severe pain attacks occur in trigeminal Never distribution areas due to any weak stimulus. Also the ability of nerve to shut off the pain sensation is diminished & pain is felt even after the stimulus is removed.
Some other causes of trigeminal neuralgia are Trauma to the nerve due to any accident or Chronic entrapment in peripheral NS, some other conditions like MS, any expanding neural lesion or Some Brain stem disease. Each of these condition lead to demyelination of trigeminal nerve which alters the nerve function making it hyper sensitive.
In some cases TM is of idiopathic origin.
Physiotherapy in Trigeminal Neuralgia Treatment
Acupuncture and TENS
Some patients find things like acupuncture or transcutaneous electrical nerve stimulation (TENS) helpful as well. Acupuncture is said to work on descending inhibitory pain pathways and also to stimulate endorphins (as well as the body’s natural cortisone).
Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
- activity pacing
Individuals with trigeminal neuralgia may benefit from physiotherapy for nerve desensitization therapy. Those areas of the face experiencing painful responses to pressure or temperature are stimulated by rubbing with a variety of materials such as ice cubes, soft cotton, burlap, and terry cloth. This causes the sensory nerves to accommodate to different stimuli, thereby eliciting more normal responses to pressure or temperature. The therapist instructs the individual to perform this process independently, in conjunction with medical management.
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- Pain in the ear, cheek, or teeth
- Loss of facial sensation
- Weakness of arms or legs
- Vision changes
- Severe headache
What Is Bell Palsy?
Bell palsy is a form of temporary facial paralysis. It occurs when the nerve that controls movement on one side of your face becomes inflamed. The condition often comes on suddenly but improves on its own within a few weeks. Although the cause of Bell palsy remains unclear, it’s thought that some cases might be caused by the herpes virus that also causes cold sores.
Signs and Symptoms
Bell palsy usually begins with a sudden weakness on one side of your face or a sudden feeling that you can’t move one side of your face. The weakness gets worse quickly. Other symptoms include:
- Inability to close the eye on the affected side
- Drooping of the affected side (within a few hours to overnight)
- Teariness or dryness of the eye
- Pain in or behind your ear
- Sensitivity to sound
- Loss of sense of taste
How Can a Physiotherapist Help?
In the first couple of days to a week after symptoms start, your physical therapist will evaluate your condition, including:
Review your medical history, and discuss any previous surgery or health conditions
Review when your current symptoms started and what makes them worse or better
Conduct a physical examination, focusing on identifying the patterns of weakness that are caused by Bell palsy:
- Facial movements of the eyebrow
- Eye closure
- Ability to use the cheek in smiling
- Ability to use the lips in a pucker
- Ability to suck the cheeks between the teeth
- Raising the upper lip
- Raising or lowering the lower lip
Your physical therapist will immediately:
- Educate you about how to protect your face and your eye
- Show you how to manage your daily life functions while you have facial paralysis
- Explain the expected path to recovery, so that you will know the signs and symptoms of recovery
- Evaluate your progress, and determine whether you need to be referred to a specialist if progress is not being made
The first priority is to protect your eye. The inability to completely and quickly close your eye makes the eye vulnerable to injury from dryness and debris. Debris can scratch the cornea—the transparent front part of the eye that covers the iris, pupil, and front chamber of the eye—and could permanently harm your vision.
Your physical therapist will immediately show you how to protect your eye, such as:
- Using self-made and commercial patches
- Setting a regular schedule for refreshing eye fluids
- Carefully closing the eye with your fingers
If you have partial facial movement, your therapist will teach you a few general facial exercises to do at home. These exercises will help you learn to move the weak side of your face and help you use both sides of your face together. One of the exercises is a gentle blowing action through your lips.
Your physical therapist will help you regain the healthy pattern of movements that you need for facial expressions and function. Recovery can be challenging because:
- Normally, the ability to make facial expressions and many facial movements is “automatic”;—that is, you’re born with this ability and never had to think about it before
- Unlike other muscles in your body, the facial muscles do not have sensors that tell your brain all of the necessary “details” about how to move
- Your physical therapist will be your coach throughout this challenging time, guiding you through special exercises that are designed to help you relearn facial movements based on your particular movement problems.
Your exercises may change over the course of recovery:
“Initiation” exercises. In the early stages, when you might have difficulty producing any facial movement at all, your therapist will teach you exercises that cause (“initiate”) facial movement. Your therapist will show you how to position your face to make it easier to move (called “assisted range of motion”) or how to “trigger” the facial muscles to do what you want them to do.
“Facilitation” exercises. Once you’re able to initiate movement of the facial muscles, your therapist will design exercises to increase the activity of the muscles, strengthen the muscles, and improve your ability to use the muscles for longer periods of time (“facilitate” muscle activity).
Movement control exercises. Your therapist will design exercises to:
Improve the coordination of your facial muscles
Refine your facial movements for specific functions, such as speaking or closing your eye
Refine movements for facial expressions, such as smiling
Correct abnormal patterns of facial movement that can occur during recovery
To work on coordinating your facial muscles, you’ll need to have a sufficient level of activation of facial muscles first. Your therapist will determine when you’re ready.
Relaxation.During recovery, you might have facial spasms or twitches. Your physical therapist will design exercises to reduce this unwanted muscle activity. The therapist will teach you how to recognize when you are activating the facial muscle and when the muscle is at rest. By learning to contract the facial muscle forcefully and then stop, you will be able to relax your facial muscles at will and decrease twitches and spasms.
Some people might have greater difficulty moving their face after a period of improvement in facial movement, which can make them worry that the facial paralysis is returning. However, actual recurrence of facial paralysis of the Bell Palsy type is uncommon.
New difficulty in moving the face is more likely the result of increasing the strength of the facial muscles without improving the ability to coordinate and control the movement. To keep this from happening, your physical therapist will show you what facial movements you should avoid during recovery. For instance, the following might lead to abnormal patterns of facial muscle use:
- Trying to make the biggest facial movement or muscle contraction that you can, such as smiling as much as you can
- Chewing gum with great force
- Blowing up a balloon with all of your effort to work the facial muscles
Your therapist will coach you to use your face as naturally as possible, without trying to restrict facial expressions because they look “different.”
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For any of these conditions, contact us for an assessment.