Arthritis of the Spine

Arthritis of the spine can be sub classified into 2 broad categories. Spinal Spondylosis and Spinal Stenosis. Continue reading to find out more.
Spondylosis
The spine is made up of many moving parts. Each joint in the spine hinges on the vertebrae above and below it allowing us to move in all directions. Excessive movement of the joints will lead to wear and tear in the joints. This is known as degeneration.
We all will have some degree of degenerative changes as we get older, however in some people this is more significant than others. All areas of the spine are subject to degenerative changes but the parts that move the most will suffer the most. Therefore the neck and lower back are the areas greatest affected.
Family history can account for significant degeneration of the joints of the spine and stress to the spine will compound pre-existing weakness. As mentioned above frequent loading of the spine in static postures is the greatest offender. Sitting most of the day and getting very little variety of exercise will increase the strain on the low back and neck. Bending without taking a break if working in the garden or doing DIY all add to the problems. Obviously lifting poorly and items beyond your capability all adds to the problem.
Spondylosis is the name given to degeneration of the joints of the spine. This usually results in small increases in boney growth in the joints as the cartilage covering the bone starts to wear away. These bony projections, known as osteophytes, cause the spaces in the joints to narrow and the spine to become stiff. This stiffness leads to increased strain on the spine and further degeration will continue.


The stiffness in the spine can be mild at first and not always painful. Indeed some people can have very stiff spines with hardly any pain. Most people unfortunately will have increasingly painful backs as the degeneration progresses. If you have read the information above you will now know that this degenerative process will cause mechanical back pain, increase the chances of developing a trapped nerve and possibly a prolapsed disc.
There are options to help. Early intervention is key. A good exercise program to improve strength and improve flexibility is essential. Regular changes in position to reduce the load on the spine and a good diet to improve bone strength and reduce weight will all help. A physiotherapist can guide you through these stages and also mobilise or manipulate the spine to decrease pain and improve movement. Occasionally a course of pain killers may be necessary but it is best to try and treat arthritis of the spine with physiotherapy and exercise.
If the degeneration becomes too severe pain killing injections may help, such as a nerve block or epidural. Surgery is a final answer but is required in very few cases. It will usually involve fusing together with metal rods and screws the joints of the back that are causing the most problems. It can help to reduce the pain but it will greatly stiffen the spine and therefore should be considered only when necessary.
How can you prevent or reduce significant degenerative changes to the spine:
- Sit up properly and arrange your work station to best suit your height and shape.
- Stand up every 15-20 minutes to recover the arch in your spine, both at home and at work.
- Go for a long walk (40 minutes) per day, ideally in one go or split it in two, 20 minutes at lunch and 20 minutes when you finish work.
- Try to stretch regularly through the day.
- Don’t drive for greater than one hour without getting out to stretch your legs.
- See a Chartered Physiotherapist if you have pain that doesn’t settle down in 48 hours.
Spinal Stenosis
As mentioned with Spondylosis the joints of the spine are susceptible to degenerative wear and tear. This wear and tear is at the small joints at the side of the spine where the nerves exit the vertebrae to travel into the arms and legs. Spinal stenosis occurs when the large central space in the middle of the vertebrae containing the spinal cord starts to narrow as a result of increasing bone growth.
The pain of spinal stenosis is very similar to that of trapped nerves and / or disc prolapse but may affect one of both, arms or legs. Pain is usually worse when walking and relieved by sitting. This is the opposite to mechanical back pain, arthritis of the spine and disc prolapse.
Spinal stenosis can be a serious problem and professional help is advised as soon as possible. Investigations should be carried out such as an x-ray and perhaps a scan to see the extent of the narrowing of the spinal canal.

Trigger point

When a muscle is been used or overused a lot of the time it may develop what is known as a trigger point. A trigger point is defined as a taut band within a muscle that on palpation will generate a local twitch response and causes a deep aching pain radiating from the region. These are commonly known as ‘knots’. All muscles are susceptible to developing trigger points and many muscles have what are known as dormant trigger points. A trigger point is active when it is causing pain and twitches when compressed.

A common area of the body susceptible to trigger points are the muscles connecting the shoulders to the neck or upper trapezius muscles. The Upper trapezius muscles are responsible for keeping your head up straight, rotating your head away and bringing your ear down to your shoulder or vice versa bringing your shoulder up to your ear.
Commonly when sitting at a computer for long periods of the day the trapezius muscles are working to maintain your head position. If your work station is unsuitable you may be increasing the load on these muscles because you are looking down at the screen, particularly the lap top, or your head is rotated slightly to one side more than the other. Not quite as common nowadays is holding the phone between your ear and shoulder but if you do this especially when using a mobile, that is most likely to cause the development of a trigger point in the muscle.
In the upper trapezius muscles the trigger point will produce an aching pain deep in the shoulder blade area and can refer down the arm to the back of the elbow. It may even cause pins and needles locally. It can also radiate up the skull behind the ear and be responsible for tension headaches.
In order to treat a trigger point it is essential to find the route cause of the problem. This may be something so subtle that you won’t be aware of it until it is pointed out to you. It is best to get someone to observe you as they can see you move, or not as the case may be, than you can see yourself. Common faults are the computer being at the incorrect height or angle, poor posture sleeping, having your arm up on the window frame when driving, television being in the corner of the room so you have to turn your head to see it, etc.
Once the main cause is established, this of course can be altered. To treat the trigger point the physiotherapist has a couple of options. They may try some myofascial release which will involve deep tissue palpation of the trigger point in order to desensitise it. Another option is to treat the area with what is known as trigger point needling. This involves putting a fine needle (usually an acupuncture needle although it is not acupuncture) into the muscle to deactivate the trigger point. An acute spasm is felt in the muscle and a release of tension follows.
You will then be shown how to stretch the muscle and this will have to be carried out regularly. Trigger point needling may be very effective in one session or may take a number of sessions to fully resolve the pain depending on the severity of the problem.

Impingement

Shoulder impingement is not a diagnosis, it is a symptom. When we talk of impingement there is a catching or pinching of structures underneath the Acromioclavicular joint (joint on top of the shoulder where the collar bone meets the shoulder blade).
Any one or more of a number of structures can get pinched in this space. Usually one of two structures are involved. Most frequently it is a tendon of the rotator cuff. The rotator cuff is a group of four muscles coming from the spine and shoulder blade. They wrap around the shoulder joint to suck the ball of the shoulder into the socket of the joint. They give stability to the joint and are also involved in the movements of the arm particularly rotation as the name would suggest.


The tendon that is most exposed in the rotator cuff is the supraspinatus tendon. This tendon lifts the arm away from the body and helps rotate it away from the body. When the arm is lifted overhead the tendon can become squeezed between the shoulder joint and the Acromioclavicular joint on the top of the shoulder. If this happens once or twice it is not a great problem. Repeated catching of this tendon will cause it to become inflamed. That results in a tendonitis making the shoulder painful, weak and increasingly stiff.
If the tendonitis is not treated early it can cause a chronic impingement of the shoulder. Prolonged inflammation will weaken the tendon and could eventually cause the tendon to fray or tear. The tendon can also be torn as a result of trauma such as a fall on an outstretched hand or onto the shoulder. If the arm is suddenly forced backwards or rotated this could also tear the tendon or by lifting something too heavy or repetitive overhead lifting. A torn rotator cuff tendon is a painful and debilitating injury that can take months to years to resolve.
It is important to ask why the tendon would become squeezed between the shoulder and AC joints in the first place. Normally there is enough space between these joints for the arm and tendons to function properly. So what would cause the space to narrow? The most common reason is posture. If you allow your shoulders to slouch forward as when sitting at a PC or folding your arms in front of your chest, this will narrow the joint space. This is a gradual process and slowly causes the shoulders to become rounded and will eventually cause an impingement. Another possibility is degenerative wear and tear of the AC joint. If the AC joint becomes worn, Small boney projections called osteophytes can protrude from the joint. These act like little daggers into the soft tissues under the joint. Both of the scenarios above will result in a shoulder impingement.
The other structure in the Acromioclavicular joint space that gets squeezed is the sub acromial bursa. This is a fluid filled sack much like an airbag that sits between the rotator cuff and the point of the shoulder. It is there to act like a shock absorber in the joint. If there is repetitive squeezing of the bursa it can slowly become inflamed. It will also become acutely inflamed as a result of direct trauma such as a fall onto the arm compressing the joint or if something falls onto the shoulder from above.
The swollen bursa will reduce the space between the shoulder joint and the Acromioclavicular joint and will be squeezed or pinched when the arm is raised. This also causes an impingement syndrome.
Depending on the source of the impingement there are different ways to treat the problem. Firstly it is important to establish the correct diagnosis. The physiotherapist has a number of clinical tests they can carryout to help achieve this. If they are unsure or need to confirm the diagnosis it may be necessary to carry out other tests. An x-ray of the shoulder can identify or rule out the possibility of an osteophyte. An MRI scan may be able to establish a tear in the rotator cuff or a swollen bursa. Ultrasound scans are also useful to see the rotator cuff in various positions as it is possible to move the shoulder while carrying out an ultrasound scan. This is not possible when performing an MRI scan. One or more of these tests may be required to finalise a diagnosis.
Once the correct diagnosis is established the treatment begins. An acute tendonitis can be treated with Ice, anti-inflammatories and an exercise program. A traumatic rotator cuff tear needs to be placed in a sling and rested for about 3 weeks. Also during this time the physiotherapist will work on the tendon to prevent the formation of scar tissue and then rehabilitate the shoulder girdle complex when appropriate.
A bursitis may need a cortisone injection to kill the inflammation but the physiotherapist can normally reduce the pressure on the bursa by mobilizing the joint and strengthening the shoulder. Impingements as a result of posture or osteophyte formation need a lot of work on improving posture and mobilising the Acromioclavicular joint to improve joint space. The underlying tendonitis or bursitis also needs to be treated and the shoulder rehabilitated.
If conservative management is not effective then other interventions such as injection therapy or surgery are available. Most surgeons will tell there patients to try conservative management for at least 3 months before resorting to surgery and will often insist on waiting a year before operating. The earlier treatment begins the greater the success.

Frozen Shoulder

. figure: Frozen shoulder sometimes known as adhesive capsulitis.
Often over or misdiagnosed a frozen shoulder is a painful and stiff joint that can not move beyond 50% of its normal range of movement. A shoulder X-ray will be normal and it is usually of unknown cause or idiopathic.
There are two types of frozen shoulder. Primary or idiopathic frozen shoulder is of unknown cause. It classically occurs in females more than males and in those usually over 45 years of age. It will normally be in the non dominant arm and is more likely to occur in those in a sedentary profession. Secondary frozen shoulder follows significant trauma to the shoulder such as a fracture, dislocation or severe burn. However this injury may have occurred some years previously.
The shoulder joint is surrounded by a capsule, which is like a layer of cling-film covering the joint. It provides fluid to the joint to lubricate it and allow the 360degrees of movement we enjoy in the shoulder. In frozen shoulder it is believed that this capsule starts to shrink and be come stuck or adhere to the shoulder joint. There is some evidence to say that in the early stages this capsule is inflamed and it is sometimes referred to as an adhesive capsulitis. There is other evidence to say that the capsule is not inflamed but that the capsule shortens similarly to that of a Dupuytren's contracture in the hand and that this will have to take its own time to burn itself out.

A frozen shoulder will run 3 stages. Stage 1 is the freezing phase where the shoulder becomes increasingly stiff and painful. Phase 2 is the frozen phase where the shoulder is so stiff that it will not move above shoulder height. This is often the most painful stage and it is then people will usually seek help for the shoulder. It is painful to sleep on and the shoulder usually becomes very sensitive even to small changes in movement. The third and final stage is the thawing phase when the pain reduces and the movement slowly improves.
Each stage of a frozen shoulder will last from 4 to 8 months. Therefore taking anywhere from 1 to 2 years to resolve. Frozen shoulders will solve themselves eventually and will never occur again in them same shoulder. There is unfortunately a 13% chance of it occurring on the other arm, usually within a year of the initial shoulder resolving.
Treatment for a frozen shoulder will vary depending on what stage you are at. In the early phase it is important to try to maintain the movement and control the pain. Anti-inflammatory medication may be useful or even a cortisone injection. There is some debate as to the presence of inflammation in frozen shoulder but research is split on the topic. Physiotherapists can help to control pain and maintain movement.
In the second and most painful stage aggressive manual therapy is counter productive. Patients try a variety of modalities to help ease the pain such as ice or heat or electrotherapy. There is evidence for and against each of these. Whatever works best for the individual should be continued. The aim of treatment at this phase is to control the pain. Acupuncture has been shown to be the most effective. Your physiotherapist may be able to perform this for you or refer you to a suitably qualified person.
In the third phase the pain drifts away and it is then time to get the joint moving. Mobilisation of the joint should be carried out by the Physiotherapist and an exercise program established to get you back to full function.
There are surgical options for frozen shoulder but these are carried out rarely and like everything else in frozen shoulder are debatable. Manipulation under anesthetic is carried out to try to break any adhesions in the joint and kick start the movement. Other more invasive procedures attempt to release the capsule covering the joint in order to free some movement.

Tennis Elbow

The tendons that extend or straighten our fingers all come from the same point of the elbow. This area is known as the lateral epicondyle or extensor tendon origin. Pain in this region is often described as lateral epicondylitis or tennis elbow. There are a number of tendons all originating from the same point and moving out into different directions to get to the fingers. As these tendons overlap and are working to move the hand and fingers particularly in gripping activities they can rub against each other creating friction, inflammation and eventually become scarred.

The tendon that moves the middle finger sits on top of all the other tendons and is the one that can rub the most. This tendon is called Extensor Carpi Radialis Brevis. In tennis elbow it is this tendon that is affected. There are other tendons that can be affected or other areas of pain on the lateral aspect of the elbow, however it is not tennis elbow unless the middle finger is involved.
Classically the tendon will be rubbing and slowly fraying for months. It usually takes about 6 months for the process to lead to pain or inflammation. Tennis elbow is characterized by pain in the lateral or outer aspect of the elbow. The pain often originates behind the elbow joint and radiates out from there over the outer upper one third of the forearm. It is intermittent at first and gradually deteriorates becoming increasingly stiff and painful. Most patients present with symptoms occurring for approximately 3 months at which time the tendon has become scarred and very weak. In all they have had the problem for 9 months by this time.
It is necessary to establish the source of the problem. With careful questioning a source is usually identified which more than likely will involve an increase in gripping activity in the previous 6-9 months. Classic examples are a short intense spell of DIY, gardening, gripping sports such as tennis or golf or perhaps a lot of right clicking with the mouse using the middle finger.
This intense period of activity may have started the scarring process and although not painful at the time, slowly degenerates resulting in the pain of tennis elbow 6 months later. If the cause can be identified this will greatly improve the chances of recovery.
Physiotherapy can conservatively manage tennis elbow and will result in full pain free and functional recovery in 70-80% of cases. The physiotherapist will break down the scar tissue and start the patient on a graduated exercise program. It will take 12 weeks to fully recover and the patient will need on average 8 sessions in that time.
The physiotherapist may consider a brace to help reduce the pain during treatment. Most of these are ineffective. The best tennis elbow supports are those that stop the hand from moving rather that restrict elbow function as it is gripping of the hand that is responsible for the damage in the first instance. The physiotherapist may also try acupuncture to control the pain during treatment.
If physiotherapy is unsuccessful the next option is to have one or a series of cortisone injections. There is much debate over the effectiveness of cortisone in tennis elbow as there are many who believe that there is no inflammation. There is also debate as to how many and where exactly these injections should be administered. The general consensus is that 3 injections would be the maximum over a 6 month period.
Surgery is the final resort and this will either involve debridement of the scar tissue or a tendon transfer. Tendon transfers are the more successful surgical procedure as it changes the angle at which the tendon pulls. This relieves the stress on the tendon and should reduce it’s recurrence in the future. Post surgical rehabilitation with a Physiotherapist is essential for good long term results

Carpal tunnel syndrome

Carpal Tunnel Syndrome is when the median nerve gets trapped or squeezed in the wrist as it works its way down the front of the forearm from the elbow to the fingers. The wrist is a gutter of 8 bones that is formed into a tunnel by a layer of connective tissue over the top. Inside this tunnel various structures pass through from the forearm to the hand including the tendons that flex the fingers, some blood vessels and the median nerve.
The median nerve is one of many nerves in the arm. It supplies power to some of the muscles in the hand and also sensation to the thumb, index finger, middle finger and half the length of the ring finger on each hand.. When the space inside this tunnel is compromised the median nerve is squeezed and this results in pain and pins and needles in the thumb and 2 and a half fingers of the hand.
The nerve can be squeezed if there is an increase of swelling in the area such as fluid retention in pregnancy or if there is a tendonitis and inflammation. The nerve can also be squeezed if the carpal tunnel itself starts to narrow if there is some arthritis or wear and tear in the bones or if the wrists are extended / bent back for long periods of the day when typing or using a mouse. The connective tissue covering the bones can also shorten as we get older and this may be the cause.
Most people with carpal tunnel syndrome complain of pins and needles in the hand and fingers especially in the morning and this may even wake them at night. The hand or hands often feel heavy and numb and they will have to shake them out to “get them going in the morning”. The symptoms may also be aggravated throughout the day if there is a build up of pressure in the wrists for any of the reasons mentioned above.

In order to treat carpal tunnel syndrome the main cause needs to be established. In an office environment incorrect keyboard or mouse use can be a very significant factor. Adjusting the hand, wrist and forearm position so that the hand is in a relaxed and neutral position allows all the structures to pass through the carpal tunnel with the greatest of easy. If you are unsure of how to achieve this contact a Chartered physiotherapist who can arrange a work station assessment for you.
If sleeping is the biggest problem wrist splints can be useful which help keep the wrist in a neutral position overnight so that the median nerve does not get squeezed during the night if you bend your wrist while you sleep. However, if localised swelling is the source of the problem, such swelling is often worse at night and splints may be of limited use. If swelling is a factor then the source of that swelling needs to be address either with appropriate medication as prescribed by your GP or a steroid injection by a specialist.
Physiotherapy can help to identify the correct diagnosis and cause of the problem and may also be able to treat the source of the problem. If all else fails there is a simple surgical procedure which can release the pressure in the tunnel and “fix” the problem.
Remember that carpal tunnel syndrome is not the only cause of pins and needles in the fingers and a thorough assessment is necessary to establish the correct diagnosis

Chronic Back Pain

One exciting product for chronic back pain has seen a considerable share of therapeutic use, by both professionals and amateurs. The Sacro Wedgy® is a simple, affordable device that slips under the sacrum to help balance the hips and stretch the piriformis muscle, which in turn helps release the sciatic nerve. Daily use of this product can alleviate many common problems associated with the lower back.
There are many different methods for treating chronic back pain, but the only successful methods are those that make the patient feel better on a long-term basis. Chronic back pain treatments range from the convenient to the expensive--those who are just starting to seek help should try a simple solution before committing to a lifetime of treatments. At a very low price, the Sacro Wedgy® could be that simple solution to your chronic back pain. Many people who experience chronic back pain think that surgery is there only option. In fact, surgery is only necessary in about one in every 50 cases of chronic back pain.
Often, manipulating the back to ease stressed nerves is the simple solution to even advanced cases of back pain. One culprit is the piriformis muscle, which puts pressure on the sciatic nerve. This is a frequent cause of many common back syndromes, including piriformis syndrome. Stretching out the piriformis muscle can ease the pressure, allowing the nerve to relax, which can alleviate the pain over time. These are the principles behind the Sacro Wedgy®, which comfortably stretches the piriformis muscle without manipulation, helping to ease pain in the back and legs.
The Sacro Wedgy® Is a Simple Solution to Chronic Back PainAs mentioned before, there are a variety of ways professionals treat back pain. Some alleviate the pain temporarily, others work toward a more long-term solution. The Sacro Wedgy® has been used by many athletes to help control their chronic back pain, allowing them to continue their careers. Instead of treating the symptoms, the makers of the Sacro Wedgy® help to correct the problem, simply by fixing the posture.

Lower Back Pain

The piriformis muscle and the sacrum are closely connected. The sacrum is the large, triangular bone at the base of the vertebral column. Products such as the Sacro Wedgy® can isolate the sacrum, which stretches out the piriformis muscle. This, in turn, removes pressure from the sciatic nerve, allowing it to relax.
Sacro Wedgy® Video
Simply isolating, cradling, and elevating the sacrum has been the solution to many lower back pain problems. It's usually a great place to start when seeking back pain treatment. Best of all, you can do it at home and it's quite affordable. Many therapists use the Sacro Wedgy® in both a professional environment and in their own homes.
Isolate the Sacrum to Help the Sciatic NerveWhen fixing back pain, it's important to focus on long-term solutions, not just temporarily alleviating the pain. Treating back pain shouldn't be a weekly thing that lasts forever. For lower back pain, the main problem is often the sciatic nerve, so the treatment should involve alleviating the pressure on this nerve.
For lower back pain, sufferers will do almost anything to find relief. It's a good thing they do--left untreated, lower back pain can get more complicated and painful. There are many different products available for treating lower back pain, it's important to try different methods until one works. Start with simple, affordable ways to alleviate back pain before moving on to more expensive treatments. The Sacro Wedgy® is one affordable way to scientifically treat back pain. Keep trying--relief is available through a variety of methods.

Piriformis

PIRIFORMIS SYNDROME —commonly referred to as pain in the butt--The piriformis muscle is a small muscle deep under the glutes. It is triangular in shape with the wide end attached to the front of the sacrum and the narrow end attached to the hip.
The reason the Sacro Wedgy® has been helpful with this symptom is the sacrum is slightly elevated and placed in a neutral position allowing the suspended hips freedom to drop or relax on either side of the sacrum. The body weight, as you relax gives the piriformis muscle a chance to relax and return to a proper balance. It may require using the Sacro Wedgy® for a while to keep the balance. That little muscle is the culprit for a lot of symptoms. It can be the beginning of quite a "snowball".
A picture is worth a thousand words so note the sacrum, piriformis muscle and finally the sciatic nerve in the photo. (The muscle and nerve are on both sides)

Piriformis
Chronic Back Pain Lower Back Pain Piriformis Piriformis Syndrome Sciatic Nerve SciaticaPiriformis is a painful syndrome involving the lower back and hips, but it is better know as "a pain in the butt." It's named after the piriformis muscle, which can create tension in the sciatic nerve, causing pain along with a "heavy leg" feeling. Those with piriformis syndrome should try to get relief wherever they can--keep trying techniques until you find the one that works on a long-term scale. The solution may be simpler than you think, so try the most convenient methods first, like the time-proven Sacro Wedgy®. Relaxing the tension away is usually the best method of treatment.
Going to professional treatments can be time-consuming, which is why many people try self-care products. One of the most popular products is the Sacro Wedgy®, which isolates, elevates, and cradles the sacrum bone. With frequent use of this product, many people experience long-term relief for their back pain.
The Sacro Wedgy® Can Be Used in a Therapeutic EnvironmentBecause the Sacro Wedgy® is so convenient and effective, many therapists elect to incorporate it into their treatment regimens. Using the Sacro Wedgy® mimics a long-used technique of holding the sacrum with the hand. The Sacro Wedgy® can get many patients ready for their exercises, and can be used for a variety of different problems. To read testimonials from satisfied physical therapists, surf our website.
For adult back pain problems, it's smart to try the simplest solutions first. By relaxing on the Sacro Wedgy®, patients can balance their hips and isolate the sacrum bone. It's been proven an effective method for easing sciatica. The Sacro Wedgy® frequently tours at conventions all over the nation--look for it in a town near you. For a comfortable way to treat the problems that cause sciatic pain, the Sacro Wedgy® is becoming one of the most popular tools on the market.

Piriformis Syndrome

One convenient self-care product that's been popping up in therapist's offices is the Sacro Wedgy®. The patient rests their coccyx in the Sacro Wedgy®, then stretches their legs; the process can be quite comfortable, while some may experience pain in the beginning stages. The Sacro Wedgy® uses gravity to ease the pressure on the sciatic nerve, simply by isolating and elevating the sacrum.
Sacro Wedgy® Video
It's surprising how many people have piriformis syndrome--more than one in ten, according to most studies. Piriformis syndrome concerns the lower back; the sciatic nerve passes through and under the piriformis muscle. When one favors one side or the other, the piriformis muscle can stress out the sciatic nerve, causing ample amounts of lower back pain. This is closely related to the pain caused by sciatica.
The Sacro Wedgy® Has Been Used for Piriformis SyndromeThere are many different methods for treating piriformis syndrome--some more effectively than others. The right treatment varies from person to person, so it's important to start with the simplest solutions and keep trying different methods until the right treatment is found. It's important to focus on a long-term answer to the problem, rather than a quick fix for the pain, which is the goal of the Sacro Wedgy®. After all, no one wants to endure back pain treatments for the rest of their life.
By stretching and relaxing the piriformis muscle, stress on the sciatic nerve is eased, which can reduce pain significantly. The Sacro Wedgy® also has long term effects--the more you use the Sacro Wedgy®, the less you need it. Targeting the problem, rather than the symptoms, is the key behind the therapeutic success of Sacro Wedgy®.

Sciatic Nerve

Many people experience pain in their sciatic nerve because of a condition called piriformis syndrome. In this case, the pain is caused by the piriformis muscle--treatment usually involves stretching this muscle to alleviate pressure on the sciatic nerve. The Sacro Wedgy® is designed to do this, and to help alleviate long-term back pain with daily treatments. Built to last, many therapists are still on their first set of Sacro Wedgys®.
Sacro Wedgy® Video
The longest single nerve in the body is called the sciatic nerve. It runs from through the sacrum, under or through the piriformis muscle, and down the leg, ending in the heel. Sciatica is the medical term for pain caused by the sciatic nerve--it's a common problem with many possible solutions. For treating pain caused by the sciatic nerve, it can often help to treat its roots in the lower back. This can work no matter where the sciatic nerve is causing pain, which is part of Sacro Wedgy's® ingenious design.
Treating sciatica pain through back manipulation is a science that offers many possible treatments. For those who are new to sciatic nerve therapy, remember to try different solutions until you find the one that works. Start of with simple solutions that are affordable, such as the Sacro Wedgy®. The Sacro Wedgy® is a simple tool used by therapists and back pain sufferers all over the world.
Sciatica Can Be Caused by a Variety of FactorsA proper diagnosis is required for any back care treatment to work effectively--everyone should see a doctor to determine the cause of their back pain. If it turns out to be a problem with the sciatic nerve and the piriformis muscle, the simplest, most affordable solution is the Sacro Wedgy®. Find out more about the Sacro Wedgy®, including discounts on volume deals, by surfing our website

Sciatica

Formed by the spinal nerves of vertebrae L-4 through S-3, the sciatic nerve is the longest nerve in the human body. It runs from the lower back down the leg. For many years, treating pain associated with this nerve baffled doctors. They couldn't comprehend that leg pain can be caused by the back. In modern times, doctors know the exact layout of the sciatic nerve. Treating leg pain known as sciatica can be as easy as relieving pressure in the lower back.
One of the most common causes of leg pain is the piriformis muscle. Because of its position in the lower back, many conditions can cause the piriformis muscle to put pressure on the sciatic nerve. By relieving that pressure with quality products, like the Sacro Wedgy®, immense relief can be achieved. With the Sacro Wedgy®, treatment is simple--you just lie down and relax.
In the case of sciatica, there are many potential cures; however, some can cost tens of thousands of dollars. A simple cure is often all that is needed, so it's usually best to start with inexpensive treatments. The Sacro Wedgy® leads all other treatments--this device has been shown to relieve pain after only a few uses, and it has one of the lowest retail prices of any qualified sciatica remedy.
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frequently asked questions

WHAT IS BELL'S PALSY?Bells palsy is a condition that causes the facial muscles to weaken or become paralyzed. It's caused by trauma to the 7th cranial nerve, and is not permanent.WHY IS IT CALLED BELL'S PALSY?The condition is named for Sir Charles Bell, a Scottish surgeon who studied the nerve and its innervation of the facial muscles 200 years ago.HOW COMMON IS BELL'S PALSY?Bells palsy is not as uncommon as is generally believed. Worldwide statistics set the frequency at approximately .02% of the population (with geographical variations). In human terms this is 1 of every 5000 people, and 40,000 Americans every year.IS BELL'S PALSY ALWAYS ON THE SAME SIDE?The percentage of left or right side cases is approximately equal, and remains equal for recurrences.IS THERE ANY DIFFERENCE BECAUSE OF GENDER OR RACE?The incidence of Bells palsy in males and females, as well as in the various races is also approximately equal. The chances of the condition being mild or severe, and the rate of recovery is also equal.WHAT CONDITIONS CAN INCREASE THE CHANCE OF HAVING BELL'S PALSY?Older people are more likely to be afflicted, but children are not immune to it. Children tend to recover well. Diabetics are more than 4 times more likely to develop Bells palsy than the general population. The last trimester of pregnancy is considered to be a time of increased risk for Bell's palsy. Conditions that compromise the immune system such as HIV or sarcoidosis increase the odds of facial paralysis occurring and recurring.CAN BELL'S PALSY AFFECT BOTH SIDES OF THE FACE?It is possible to have bilateral Bells palsy, but it's rare, accounting for less than 1% of cases. With bilateral facial palsy, it's important to rule out all other possible diagnoses with thorough diagnostic tests.CAN BELL'S PALSY AFFECT OTHER PARTS OF THE BODY?Bells palsy should not cause any other part of the body to become paralyzed, weak or numb. If any other areas are affected Bell's palsy is not the cause of the symptoms, and further testing must be done.HOW DO THE SYMPTOMS OF BELL'S PALSY PROGRESS?Very quickly. Most people either wake up to find they have Bells palsy, or have symptoms such as a dry eye or tingling around their lips that progress to classic Bell's palsy during that same day. Occasionally symptoms may take a few days to be recognizable as Bells palsy. The degree of paralysis should peak within several days of onset - never in longer than 2 weeks (3 weeks maximum for Ramsey Hunt syndrome). A warning sign may be neck pain, or pain in or behind the ear prior to palsy, but it is not usually recognized in first-time cases.IS BELL'S PALSY CONTAGIOUS?No, it is not contagious. People with Bells palsy can return to work and resume normal activity as soon as they feel up to it.WHAT ABOUT RECOVERY FROM BELL'S PALSY?Approximately 50% of Bells palsy patients will have essentially complete recoveries in a short time. Another 35% will have good recoveries in less than a year.Regardless of the trigger, Bell's palsy is best described as an event - trauma to the nerve. As with any other injury, healing follows. The quality and duration of recovery is dependent on the severity of the initial injury. If the nerve has suffered nothing more than a mild trauma, recovery can be very fast, taking several days to several weeks. An "average" recovery is likely to take between a few weeks and a few months. The nerve regenerates at a rate of approximately 1-2 millimeters per day, and can continue to regenerate for 18 months, probably even longer. Improvement of appearance can continue beyond that time frame.IS MUSCLE ATROPHY A CONCERN?Not as a rule. It takes longer for the muscles to start to atrophy than it takes for most people to fully recover.IS BELL'S PALSY LIKELY TO HAPPEN AGAIN?The possibility of recurrence had been thought to be as high as 10 - 20%. These figures have been lowered as more has been learned about conditions that are now diagnosed as other types of facial palsies. Estimates of the rate of recurrence still vary widely, from around 4 - 14%. Most recent reports hover at 5 - 9%. The average timespan between recurrences is 10 years.
BELL'S PALSY FAQs THE FACIAL NERVE THE FACIAL MUSCLES CAUSES OF FACIAL PALSY RAMSEY HUNT SYNDROME SYMPTOMS RESIDUAL EFFECTS
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facial nerve

The nerve that is injured with Bell's Palsy is CN-VII (7th cranial nerve). It originates in an area of the brain stem known as the Pons. The 7th nerve passes through the stylomastoid foramen and enters the parotid gland. It divides into its main branches inside the parotid gland. These branches then further divide into 7000 smaller nerve fibers that reach into the face, neck, salivary glands and the outer ear. The nerve controls the muscles of the neck, the forehead and facial expressions, as well as perceived sound volume. It also stimulates secretions of the lower jaw, the tear glands and the salivary glands in the front of the mouth. Taste sensations at the front 2/3 of the tongue and sensations at the outer ear are transmitted by the 7th nerve.Bells Palsy is caused by an inflammation within a small bony tube called the fallopian canal. The canal is an extremely narrow area. An inflammation within it is likely to exert pressure on the nerve, compressing it. Likewise, if the nerve itself becomes inflamed within this small canal, it can encounter pressure, with the same result of compression. The nerve has not yet exited the skull and divided into its several branches, resulting in impairment of all functions controlled by the 7th nerve. If only part of the face is affected, the condition is not Bell's palsy. If, for example, the mouth area is weak but the forehead moves, Bells palsy is ruled out. Trauma induced by tumor, surgery, etc. can occur at a location where the nerve has already divided into its main branches. This type of trauma may spare one or more branches and allow some muscles to remain functional.The image at left illustrates the parotid gland area, where the facial nerve divides into its major branches after exiting the skull at the stylomastoid foramen. The major branches then continue to divide into thousands of microscopic nerve fibers.

facial muscles

The face has many muscles, each with its own unique function. Some, but not all, are controlled by CN-VII. These muscles are known as "the muscles of facial expression". Unlike other muscles, the facial muscles insert directly into the skin. Contraction of the muscles causes the skin to move. Signals from the complex array of nerves to the various muscles instruct the muscles to move in combinations as well as individually. Bell's Palsy temporarily prevents the nerve from transmitting signals to the muscles, causing weakness or paralysis. Another way the facial muscles differ from skeletal muscles is that they do not immediately begin to atrophy from lack of use. Estimates of the time it takes for significant atrophy to begin varies, but it is now believed to be years before this occurs.CN-VII is one of 12 pairs of cranial nerves. This explains why not all the facial muscles are affected. The muscles that close the eyelid are controlled by CN-VII, but the muscles that control other eye movements and the ability to focus are not. Hence, the dry and wide open, but otherwise functioning eye. The sense of taste is affected, but tongue motion is not. Skin sensation may be affected near the ear, but sensation over the rest of the face usually remains normal. Chewing and swallowing are other examples of functions controlled by cranial nerves that are not involved with 7th nerve disorders.

causes of facial palsy

Viral and bacterial infections, as well as autoimmune disorders, appear to be emerging as the most frequent common thread in the etiology of Bells palsy.HERPES SIMPLEX 1As far back as 1970, Herpes Simplex 1 was suggested as a cause of Bell's palsy (Dr. Kedar Adour). Some Bells palsy must still be designated as idiopathic, but a 1995 study (Dr. Shingo Murakami and others) points compellingly to the herpes simplex virus (HSV-1) as the most frequent cause of Bell's palsy, possibly accounting for at least 60 - 70% of cases. Additional research since this study was published has been reinforcing the conclusion.Exposure to HSV-1 is common; a vast majority of the population has been exposed to it. Most people are exposed during childhood. Kissing between relatives is the most frequent source of exposure, but it may be possible that the virus is also spread while sharing towels, utensils, etc. The active virus is commonly associated with cold sores, but the virus often runs its course without causing any blisters - blisters actually appear only 15% of the time. This results in a large population of HSV-1 carriers who do not know they've been exposed to the virus. HSV-1 is infectious for a short time following the incubation period. It then enters a dormant state, residing on nerve tissue. There are several triggers that can cause the dormant virus to reactivate. As this site is about Bell's Palsy, rather than herpes, we will not address issues concerning herpes outbreaks where the reactivated virus sheds to the skin. When the latent virus reactivates at the facial nerve the immune system begins to produce antibodies, causing an inflammation. This is a normal function, and is part of the process that eliminates harmful foreign bodies such as viruses and bacteria so that we can recover from illness and injury. If the location of the inflammation is within the fallopian canal (described above) there is no room for the swelling to expand. The nerve itself becomes inflamed, or the inflammation within the canal exerts pressure on the nerve. The result is that the nerve is compressed inside its bony tube. Compression of the nerve is the injury that stops transmission of signals to muscles. Unable to receive signals to contract and relax, the muscles become temporarily weakened or paralyzed.The triggers for reactivation of the virus prior to the onset of Bell's palsy have not been proven conclusively. Impaired immunity, whether temporary (stress, lack of sleep, minor illness, physical trauma, upper respiratory infection, etc.) or long-term (autoimmune syndromes, chronic disease, etc.) are strongly targeted as the most likely triggers.OTHER VIRAL LINKSThere has been research implicating other viruses, including cytomegalovirus, Epstein-Barr, rubella and mumps, in the etiology of Bell's palsy. As with the herpes virus, potential triggers appear to be related to conditions that affect the immune system. The internal process that would cause the nerve to become compressed and result in Bells palsy is currently thought to be the same as described above for the Herpes virus.RAMSEY HUNT SYNDROMERamsey Hunt syndrome is similar to Bell's palsy. Unlike Bells palsy, the virus that causes Ramsey-Hunt syndrome has been conclusively identified. It is varicella zoster virus (VZV), which is the virus that causes chicken pox, and is a strain of the Herpes virus. Like HSV-1, it remains in the body, residing on nerve tissue in a dormant state on nerve ganglia after the initial infectious stage has passed. VZV typically remains dormant for decades. The incidence of Ramsey Hunt syndrome increases significantly after age 50. Younger patients with Ramsey-Hunt syndrome are often advised to be tested for autoimmune deficiencies.Ramsey-Hunt syndrome results in symptoms that are in many respects identical to Bell's palsy. The symptoms are so alike that a diagnosis of Ramsey Hunt syndrome can easily be missed.When the VSV virus is reactivated the resulting eruptions (blisters) are known as shingles. The first symptom is usually severe pain. There may also be a fever, headache, and localized tenderness. Blisters typically begin to emerge 1.5 to 3 days after the onset of these symptoms, although they may emerge with no prior symptoms.Symptoms of Ramsey Hunt SyndromeIn addition to the "classic" symptoms of Bells palsy, Ramsey Hunt syndrome is associated with some additional symptoms that help differentiate it. Knowledge of these symptoms is key to an early diagnosis, and should be brought to a doctor's attention during the first visit, or when any of these symptoms become apparent.1. Pain: Bell's palsy patients may complain of pain (often in or behind the ear) which can be acute. However, it will tend to fade within a week or two. The pain associated with Ramsey Hunt syndrome is often more severe, and more likely to be felt inside the ear. It may start before muscle weakness is apparent, and may last for weeks or months - sometimes longer. Medications such as Neurontin can ease the post-herpatic pain of Ramsey Hunt syndrome.2. Vertigo: Dizziness is occasionally reported by Bells palsy patients, but is often associated with Ramsey Hunt syndrome. It can be more severe, and longer lasting.3. Hearing loss: Unlike Bell's palsy, Ramsey Hunt syndrome can also affect the auditory nerve (CN-VIII), resulting in hearing deficit. This should not occur with Bells palsy, and is an important clue to the diagnosing physician. In some cases hearing loss will continue after facial muscle function returns.4. Blisters: The primary symptom that makes a diagnosis of Ramsey Hunt syndrome likely is the appearance of blisters (known as shingles, or herpes zoster) in the ear. The blisters can appear prior to, concurrent to, or after the onset of facial paralysis. They can be expected to last 2 - 5 weeks, and can be quite painful. The pain can continue after the blisters have disappeared. Blisters are often the only clearly visible symptom that identifies Ramsay Hunt. Unfortunately, they may not be evident during the diagnostic examination. They can be present, but too deep within the ear to be visible. Or they can be too small to be seen. In some cases they may not appear until a week or more after the onset of muscle weakness. At times they do not appear in the ear at all, but may be present in the mouth or throat. It is also possible for the virus to reactivate without blisters at all.5. Swollen and tender lymph nodes near the affected area.While Bell's palsy is not contagious, shingles blisters are infectious. Contact with an open blister by someone who has never had chickenpox can result in transmission of the virus. The result will be chickenpox, not shingles or facial paralysis.** If you've been diagnosed with Bell's palsy, but later see blisters that may be shingles, its important that you notify your health care professional. **HIV / AIDSHIV can cause facial paralysis and increases the chance of developing Ramsey Hunt syndrome, as well as Bell's palsy. In the early stage of HIV, paralysis can be directly due to the viral infection. In later stages paralysis is more likely to be associated with the opportunistic infections or tumors associated with severe immune deficiency. Herpes zoster has been confirmed to be associated with suppressed immune systems.BACTERIAL TRIGGERS...Lyme disease can cause facial paralysis and the same symptoms as Bells palsy. Bacteria enter the body through the skin at the site of the tick bite. Typical early symptoms of Lyme disease are a red ring around the site of the bite and flu-like symptoms. Unfortunately these symptoms do not always appear. The early symptoms will pass, but administration of an antibiotic as early as possible is important to avoid serious problems later. Without an antibiotic the bacteria can spread throughout the body, causing arthritis, heart disease, and nervous system disorders such as facial paralysis.Otitis Media - Bacteria from some acute or chronic middle ear infections can invade the canal around the nerve through small portals. As with viruses, the presence of bacteria can evoke an inflammatory response, and compress the nerve.BILATERAL ...Bell's palsy and Ramsey Hunt syndrome can be bilateral, but it's extremely rare. Mononucleosis, the flu, Guillain - Barre Syndrome, leukemia, lyme disease, sarcoidosis and Heerdfort's Syndrome are among the potential triggers of bilateral palsy.MELKERSSON-ROSENTHAL SYNDROMEMelkersson-Rosenthal syndrome can result in unilateral or bilateral palsy. The palsy will tend to be recurrent, to such an extent that it's sometimes described as intermittant or bilateral. Recurrences don't follow any pattern - each recurrence can be on the same side, alternating side, or bilateral.Diagnosis of this syndrome can easily be missed, as the obvious symptoms may look like Bells palsy. However, unlike Melkersson-Rosenthal syndrome Bell's palsy recurrences tend to be separated by wide timespans.OTHER CAUSES ...Facial and surgical wounds, trauma due to a blunt force, temporal bone fractures, brain stem injuries, acoustic neuromas, cysts and tumors can result in facial palsy. Diabetes and thyroid conditions are also associated with facial palsy. Lupus, Sjogrens syndrome and congenital defects can, infrequently, cause facial paralysis.

symptoms

The onset of paralysis is sudden with Bells palsy and Ramsey Hunt syndrome, although symptoms can worsen during the early days. Bell's palsy symptoms typically peak within a few days, although it can take as long as 2 weeks. Ramsey Hunt syndrome symptoms will peak within 3 weeks. If paralysis develops slowly, tests for other causes of the palsy must be done. Patients with recurrences, particularly if within close time frames, should also be re-evaluated as a precautionary measure.Psychologically, facial paralysis can be devastating, particularly in cases that extend for a long period, or where residuals are significant. Friends, family and doctors often have no true concept of how deeply the patient's sense of self and self-esteem is affected. You will also find that they have little or no understanding of your physical discomfort, difficulty and frustration as you struggle to do seemingly simple things that they take for granted.There are many physical symptoms associated with facial paralysis, but the effects will differ between individuals. They can vary in accordance with the degree of nerve damage, and the location of the damage.
GENERAL
EYE RELATED
Muscle weakness or paralysisForehead wrinkles disappearOverall droopy appearanceImpossible or difficult to blinkNose runsNose is constantly stuffedDifficulty speakingDifficulty eating and drinkingSensitivity to sound (hyperacusis)Excess or reduced salivationFacial swellingDiminished or distorted tastePain in or near the earDrooling
Eye closure difficult or impossibleLack of tearsExcessive tearingBrow droopTears fail to coat corneaLower eyelid droopSensitivity to lightADDITIONAL SYMPTOMS WITHRAMSEY HUNT SYNDROMEHearing deficitSevere painLong lasting painVertigoBlisters in ear or other areasNausea
RESIDUAL EFFECTSEye appears smallerBlink remains incomplete or infrequentTearing abnormalitiesAsymmetrical smileMouth pulls up and outwardSinus problemsNose runs during physical exertionPost paralytic hemifacial spasmHypertonic musclesCo-contracting musclesSynkinesis (oral/ocular well known, but can affect any muscle group)Sweating while eating or during physical exertionMuscles become more flaccid when tired, or during minor illnessMuscles stiffen when exposed to cold, when tired, or during illness
Although the damage that causes the paralysis is specific to the 7th nerve, other nerves may be temporarily irritated. For example, temporary facial numbness or pain can result when CN-V is irritated.Recovery is not consistent among patients. For some people the mouth may move before the ability to blink returns; in others it will be eyelids first and mouth last. Twitching may precede movement, but it doesn't always. Pain in areas starting to "wake up" may occur, or may not. The sense of taste can be odd as the sensation returns, or the sense of taste may return without any awareness of the change. Recovery can be gradual, rapid, or hit occassional plateaus. Et cetera.RESIDUAL EFFECTSResiduals may be due to one, or a combination of several factors. Initial trauma to the nerve can be minor and temporary, or significant and long lasting. When the damage is minor, recovery is likely to be essentially complete, and rapid. With more extensive damage, other factors begin to effect recovery.In longer recoveries, other cranial nerves may try to take over for the 7th nerve, growing into passageways formerly occupied by the 7th nerve. Also, the 7th nerve can regenerate incorrectly, taking some different paths than it had followed before Bells palsy. The result is "crossed wiring" and synkinesis, which is further described in the next section.After paralysis facial muscles have a tendancy to become hypertonic. This means they tend to be overactive, contracting when they should be at rest. Typical signs are a squinty eye, the mouth pulling up, a sore or swollen cheek, and deepened creases. Unlike skeletal muscles, facial muscles lack spindles. Muscle spindles sense when a muscle is in a contracted state, and nerves can send the appropriate signal to the muscle telling it to relax. Without these spindles, there is no awareness of the contraction, and the muscles remain in a state of tension. A muscle that can not fully relax also can not fully contract, so the range of motion becomes limited.Learned misuse and disuse of the muscles also can effect both appearance and mobility. While the muscles are paralysed, it's natural to try to eat, drink and speak, etc., as well as you can. New habits may be learned while you're compensating for the nonworking muscles. You may inadvertantly call on inappropriate muscles to join forces and work together to accomplish movements that aren't happening on their own (learned misuse). Or you may become accustomed to compensating without using the lazy muscles (learned disuse). The effects of both may remain after nerve function returns. Both can also effect the "good" side, which may have learned unnatural patterns while its muscles were assisting the nonworking muscles.Physical therapy can minimize asymmetrical appearance and improve mobility, even when therapy is started years after the initial paralysis.

residual effects

Residual Effects of Bell's Palsy by H. Jacqueline Diels, Occupational TherapistMost people who develop Bells palsy will recover completely and spontaneously (i.e. without any physical therapy) within 3 months. The following discussion is intended to review and clarify the possible residual effects that can be present in cases where recovery from Bell's palsy is delayed beyond the 3 months point. Generally, the longer the recovery takes beyond the initial three months, the more severe the residual effects.Residual effects can include eye problems (decreased lid closure / increased lid closure, dryness / excessive watering / watering during eating [crocodile tears]), nasal problems (running nose, dryness, collapsed nostril), and others. This discussion will focus primarily on the residual effects as they pertain to facial movement.For the person who has facial paralysis after Bell's palsy there are typically 2 stages of recovery. In the first stage (first 3 months) there may be no facial movement at all. In this phase, nerve healing is taking place as the inflammation caused by the virus subsides. The affected side of the face may droop. The eye may be unable to close or blink and tearing may be decreased. There can be corneal dryness due to decreased lubrication coupled with exposure to air. There is risk of corneal damage. Patients should be followed by an ophthalmologist during this period to ensure a healthy eye. Weakness of the mouth muscles may cause difficulty with eating, drinking and speaking. The face may pull uncontrollably toward the unaffected side.As nerve recovery takes place you may notice small facial movements beginning. People recover at different rates, but generally this process will be complete in the three months after onset. If recovery is delayed you may begin to notice movements in areas of the face that you are not even trying to move. For example, when you smile the eye may close or twitch or when you close you eye the corner of your mouth may pull up or out to the side. This condition is known as synkinesis. It is characterized by uncoordinated or unsynchronized facial movements that occur along with normal movements. Synkinesis varies in severity from mild to severe. In its worst form, mass action, it can result in uncontrollable movement of the facial muscles on the affected side during any attempted expression. The affected side of the face may feel tight as the result of the uncontrolled muscle contractions (spasms).Many people, when describing their history of facial paralysis after Bell's palsy describe it something like this: "I had no movement for about 3 months and then it started to come back. It was getting better and better and then suddenly it started getting worse again". So what happens in this transition between getting better and getting worse again? Specific areas of synkinesis can sometimes be difficult to identify, because in a severe form it can result in what appears to be no active facial movement. So how do you differentiate this condition from the first phase of facial paralysis when you have no movement? It is the difference between lack of muscle function resulting in no movement and too much muscle contraction resulting in completely restricted movement.Synkinesis is theorized to be the effect of abnormal nerve regeneration, where some of the healing facial nerve fibers can actually implant themselves into the wrong muscles. Think of the facial nerve as a telephone cable. If you cut through a telephone cable you see many different color-coded wires. The telephone repair person can repair the broken cable by reconnecting the wires according to their color. The facial nerve cable is about the diameter of a strand of thin spaghetti. Within that strand are between 6000-7000 different nerve fibers (wires) which conduct the electrical signal from the brain to the facial muscles causing them to contract. They are very delicate and obviously have no color-coding. Inflammation from the Bell's palsy can harm, or "break" some of these very frail fibers. In time the damaged fibers heal. They regenerate at the rate of about 1-2mm per day. But there's no mechanism that directs these fibers back into their original muscles. The brain sends the signal for the muscle to contract thinking the nerve fiber is still connected to the original muscle, but instead, the nerve may be lodged in an entirely different muscle, which then contracts at the same time.Synkinesis can affect any of the facial muscles, in any imaginable pattern. An easy to see example is eye closure during a smile. When the person tries to smile the eye twitches or closes. We could speculate that some of the nerve fibers that used to go to the smile muscles (zygomaticus) got rerouted during recovery and implanted in the muscles that close the eye (orbicularis oculi). Other synkinetic patterns may be more difficult to observe, but can be much more limiting to facial movement. Let's consider one of the most common: The inability to smile. First we need to acknowledge that there is a distinct difference between inability to smile just after onset (flaccid paralysis) and in the synkinetic face. On casual observation, it can appear that the smile muscle is simply not working because the corner of the mouth does not go up during a smile. There's an easy way to determine whether the smile muscle is "working" or not. Please refer to the muscle diagram as you read this. Most of us think we smile with our mouths because the corner of the mouth moves. In actuality the smile muscles reside in the cheek. The bottom end of the muscle implants near the corner of the mouth. When the muscle contracts the cheek lifts, pulling the corner of the mouth "along for the ride". Look in the mirror at your cheek on your unaffected side and smile. Watch for the "apple" of the cheek as you smile and you will see it "bulge" as you smile and then flatten out again as you stop smiling. Don't watch the corner of your mouth. Do the same movement now and watch the affected side cheek. In most cases you will also see the "apple" of the cheek bulge up and then release. The shape of the two cheeks may be similar or different. So now you see that the smile muscle is working (even if it's not exactly the same as the other side). So now the question is: If the smile muscle is working why doesn't the corner of the mouth go up?To answer that question we need to go back to basic facial anatomy and high school physics. The facial muscles are designed differently than other muscles in the body. Their only purpose is to move the skin of the face. The facial muscles don't move bones around joints like leg or arm muscles. They don't carry heavy loads or provide postural support. They simply move skin. Different combinations of muscle contractions move the skin in various directions (more than 2000 distinct facial expressions have been catalogued!). Going back to physics we can describe the movement produced in a specific direction as a vector, or a directional movement. The vector of the smile muscle generally pulls the corner of the mouth up toward the cheekbone. What if another muscle is contracting out of sequence and pulling the skin along a vector in an opposite direction? Which way will the skin move? Can it possibly move in a normal pattern? Let's go back to the smile example. Assuming that the smile muscle is contracting based on our previous mirror observation, why doesn't the corner of the mouth go up? Try smiling again and this time watch your neck in the mirror. Do you see cords or bands "pop out" on the affected side of the neck? This demonstrates synkinesis or abnormal contraction of the platysma muscle. This is a superficial muscle on the neck that is innervated by the facial nerve. We can speculate that some nerve fibers abnormally regenerated into the platysma (since it doesn't contract during the smile on the unaffected side). The normal action of the platysma muscle is to pull down the corners of the mouth. If the smile muscle is pulling up the corner of the mouth and the platysma is pulling it down, where does it wind up? Usually stuck, going nowhere. It is totally restricted from performing normal movement and expression. Think of it as being comparable to a tug of war. Typically, you have two very strong teams pulling with all their might and yet the rope doesn't move much- until one team lets go.So what do we do about it? The first step is to accurately identify which muscles are contracting both normally and abnormally. This usually requires a therapist who is experienced in this fine type of observation. The next step is to learn how to inhibit the activity of the muscles that are contracting out of sequence. For example, learning how to keep the platysma relaxed while producing a smile will allow the corner of the mouth to begin to move upward. A byproduct of this process is that associated tightness and spasm subsides, leaving the person much more comfortable. The therapy is less like typical therapy and more like athletic or music training. Minimal, successful movements are practiced and then progressed as success is achieved. Electrical stimulation is not helpful. It does not improve coordination of synkinesis and can actually activate already overactive and uncoordinated muscle movements further reinforcing abnormal patterns.Treatment for residual synkinesis can be effective at any time after it is noticed. There is no time limit. That is because the focus of the treatment is on re-coordinating rather than stimulating muscles. We know that when synkinesis is present the facial muscles are viable, or "alive". Even an abnormal movement is still a movement! So even many years after synkinesis develops it is possible to restore more normal movement patterns and expression with specific, appropriate training.
BELL'S PALSY FAQs THE FACIAL NERVE THE FACIAL MUSCLES CAUSES OF FACIAL PALSY RAMSEY HUNT SYNDROME SYMPTOMS RESIDUAL EFFECTS
TREATMENT EYE PROTECTION FACIAL EXERCISES BOTOX FOR RESIDUALS SURGICAL OPTIONS FACIAL RETRAINING TREATMENT CENTERS
CHAT ROOM LINKS SITE INFORMATION DISCLAIMER
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treatment

THE DIAGNOSIS ...Bell's palsy is a diagnosis of exclusion. During the first visit to a doctor, questions will be asked, and tests may be ordered. These procedures will help the doctor determine the cause of the facial weakness, or rule out conditions which are known to be linked to facial paralysis. When no underlying cause is found, Bells palsy is the diagnosis. For example, blisters in the ear or mouth, dizziness or reduced hearing on the affected side may suggest a diagnosis of Ramsey Hunt syndrome.Slowly progressing paralysis, weakness in areas other than the face, an enlarged parotid gland or paralysis that spares the eye and brow are also among the symptoms may indicate the presence of an underlying condition requiring additional medical attention.After taking a history and carefully observing the symptoms, tests that may be ordered include various blood tests, MRI, or CAT scan. These tests shouldn't be a cause for concern. They will either add conviction to a diagnosis of Bell's palsy, or provide the physician with the information needed to proceed in another direction.Facial paralysis is a result of nerve damage, and many people look no further for help than to a neurologist. Patients may be unaware that the condition also falls into the realm of otolaryngology, and that (ENTs) are generally quite knowledgeable in diagnostics and treatment.IN GENERAL ...The first priority in treating Bell's palsy or any type of facial paralysis is to eliminate the source of damage to the nerve as quickly as possible. Minor compression for a short time period can result in mild and temporary damage. As time goes on with constant or increasing compression, damage to the nerve can also increase. If you decide to use medications that may help relieve the compression (Prednisone and antivirals), they should be started as quickly as possible. The "window of opportunity" for starting these medications is thought to be 7 days from the onset of Bell's palsy. Prednisone may be prescribed later if it appears the inflammation has not subsided.Rest is important. The body has had an injury, and will heal most efficiently with enough rest to maintain strength and immunity at peak levels. It's normal to feel more tired than is usual during recovery. If you choose to work or exercise immediately after onset, be smart about it - when your body tells you it needs a break, indulge it if you have that option.Food particles can lodge between the gum and cheek, so take extra steps to maintain oral hygiene.Wear eyeglasses with tinted lenses, or sunglasses (see eye care for additional important information).Take extra care to keep your eye moist while working on a computer. Even under normal circumstances people tend to blink less frequently while at a computer. For a dry, non-blinking eye, this can be more of a problem. Keep eye drops handy, and remember to manually blink your eye with the back of the index finger.If sounds appear painfully loud, don't hesitate to ask people to speak softly. Exaggerated perception of volume isn't a symptom that people are likely to be aware of, so you may need to explain that it's a symptom associated with Bells Palsy. An earplug can help, although if you have a history of any inner or middle ear problems or have had surgery in the ear, check with your doctor before using an earplug.Immediate exercising is not recommended. Unlike skeletal muscles, facial muscles do not immediately start to atrophy. Until the nerve starts to send a signal to the muscles, the muscles simply cannot move. Forcing movement before seeing signs that the nerve is starting to transmit signals again may create long-term problems. Even while the muscles appear flaccid, some nerve threads may be functional. When you try to force movement under these circumstances, you can inadvertently signal the wrong muscles to jump in and help. As time goes on, these inappropriate movement patterns can become automatic. They can result in asymmetrical and synkinetic types of motion. Instead of pushing it in the early days, try to be patient, and remind yourself that in time movement will return. Massage or tapping can provide gentle stimulation without risk.For pain or discomfort, moist heat can help. There are gel packs and thera-bead packs that can be heated in a microwave for fast, easy and portable help with the soreness. They can usually be found in drugstores and pharmacies, in the section with old fashioned heating pads. In a pinch, ordinary rice in a sock can be heated in a microwave. For a treat, try an herbal heating pack. Doctors are not all aware that significant pain can be part of the ordeal. If you need medication, ask for it. If the doctor doubts the pain is real, refer him to the recently published "The Facial Nerve, 2nd Edition" for documentation. Severe, or long lasting pain is more consistently associated with Ramsey Hunt Syndrome. There are several medications that provide relief including Neurontin. This is a relatively new drug for neuropathic and post-herpetic pain. It's effective for the pain caused by shingles and Ramsay Hunt syndrome, and has relatively minimal adverse effects. Common side effects include drowziness, dizziness and nausea. Interactions with other drugs are nearly non-existent.In a study released by the Quality Standards Subcommittee of the American Academy of Neurology (May 2001), Drs. Patrick Grogan and Gary Gronseth pooled the data of existing studies published from 1996 through 2000 regarding the effectiveness of steroids, anti-virals, and decompression surgery as treatment for Bell's palsy. Their conclusions are:1. Regarding the use of steroids: Steroids are "safe and probably effective in improving facial functional outcomes in patients with Bell’s palsy." Results show significantly better outcomes with steroids. However, they do not find any difference in the time frame for recovery.2. Regarding the use of antivirals used in combination with steroids: Based on the limited data available, "acyclovir (combined with prednisone) is safe and possibly effective in improving facial functional outcomes in patients with Bell’s palsy."3. Regarding decompression surgery:"The risk of bias in all studies describing facial outcomes in surgically treated Bell's palsy patients was too high to support evidence-based conclusions. Additionally, serious complications, including permanent hearing loss, were reported from surgical facial nerve decompression."The number of well controlled, unbiased studies available was limited. It is clear that further research is necessary to fully assess the potential benefit of these treatments.

eye care

In the early days of Bells palsy, eye care is the most important concern. Maintenance of moisture and protection from debris are important functions that are frequently disrupted with 7th nerve damage. Permanent damage to the cornea is a risk if care is not taken to protect the eye. Acoustic neuroma patients may also encounter corneal dryness after surgery, even when the facial nerve remains intact.CAUSE OF THE DRY EYEThe dry eye and the associated problems are caused by a combination of things. For some people the tear gland may not be producing moisture. Blinking is the mechanism that protects the eye from external debris and spreads tears over the cornea. Under normal circumstances we blink every 5-7 seconds. With every blink the eyelid spreads moisture over the cornea. With facial paralysis the ability to blink may be disrupted. Eyelid closure can be weak or the eye can be stuck wide open.Take action if the eye feels uncomfortable. A stinging or burning sensation can mean the eye is too dry, even if tears are apparent. The 7th nerve does not control focus, so if you are experiencing blurred vision, don't ignore it. It may be a warning of a dry cornea that needs to be protected.For many, although the lacrimal gland produces tears, without a blink the tears cannot coat the eye. The eye may appear to be tearing excessively. It actually only seems that way because the tears are not being spread over eye, but instead are collecting in the limp lower lid or running out of the eye. Or, the eye may tear excessively, especially while chewing. We refer to this as "Crocodile Tears". Crocodile tears can occur from the onset of Bell's palsy, or can develop during recovery.PROTECTING THE EYEManually blink your eye using the back of your finger at regular intervals, and especially when it feels dry.In some cases all that is needed for extra help maintaining moisture during the day is artificial tears. Look for a brand that is labeled "for sensitive eyes", "non-allergic", or "preservative free", etc. Thimerosal is a preservative that can be particularly irritating. Eye-drops don't last long, and are not the solution for everyone.Bion Tears is a commonly used brand.GenTeal uses a natural preservative, which makes it more comfortable for many people. It does the job well.Tears Naturale has the same active ingredient as Gen-Teal. It's available with a preservative similar to GenTeal, as well as preservative-free (Tears Naturale Free).Celluvisc is thicker than Tears Naturale, and will afford excellent lubrication. However, it is costly, and because of its high viscosity, vision may not be as clear as with Tears Naturale or Gen-Teal. For additional moisture retention, as well as protection from wind and debris, try a patch.A moisture chamber will provide the same, or better protection than a patch, but is clear to allow better vision. One type is very much like goggles designed for just one eye, and it works well. If it becomes foggy due to the tight seal, a tiny pinhole will solve the problem. Your ophthalmologist should be able to provide you with the patch. There are also moisture chambers that clip onto eyeglasses.The examples shown are (top) Eagle Vision, Inc.'s "Rectangular Moist Eye Moisture Panel" and (bottom) Franel Optical Supply's "Moisture Chamber". These items can not be purchased directly from the manufacturer by the patient, but can be purchased by an opthalmologist for your use. As an alternative to a moisture chamber you can make your own patch with plastic wrap over your eye, and taped to your face. Surgical tape will be gentler for your skin and easier to remove than other types. Vaseline can also be used to hold it in place.Wraparound sunglasses or swimming goggles are other helpful alternatives to a moisture chamber.For nighttime protection if your eye will not close, lubricants (gels & ointments), or lubricants combined with a patch are a good solution. Gels are thicker than artificial tears due to the addition of mineral oil. The consistency is very much like Vaseline. By adding a "pirate's patch", you not only add protection from debris and injury, you also keep light out and may find it easier to fall asleep. If you use a pirate's patch, think about using a plastic wrap patch beneath it for added protection if the patch shifts, or create your own dark patch. Franel Optical Supply makes a "Peel-n-Press Occluder" that should eliminate the problem of the patch shifting during the night.Lacrilube, ViscoTears and HypoTears are gels for nighttime protection.Refresh PM is an option if a bit less protection is needed. Its thinner consistency makes it easier and more pleasant to wake up with.Gels and ointments can be used during the day for more lubrication than eye-drops provide. However, because they are thick, vision can be blurry.The eye can be taped closed at night, but a note of caution is appropriate. It is too often suggested to patients without proper instructions. If not done correctly the eyelid can easily pop open, exposing the eye to worse damage than without the tape. Make sure to use a gentle, non-abrasive and easily removed tape (such as paper surgical tape), and learn the correct way to apply it.If stinging or burning occurs with any of the gels or drops, you may be sensitive to one of the components. Try other brands, and if that doesn't help, see your ophthalmologist for further help - Never ignore symptoms of a dry eye!WHEN GELS & PATCHES AREN'T ENOUGHConsider a visit to an ophthalmologist, even if you believe you can manage eye care on your own. There is no a substitute for professional evaluation and advice. When your eye stings or burns, it's sending a message. Try changing to a gentler eye-drop or gel, and see your ophthalmologist, who may recommend one of several procedures.Punctal Plug Insertion is a simple procedure to partially block the tear duct, so that natural or artificial tears will remain on the eye longer. They cause little or no discomfort, and removal is often as simple as a saline pressure wash. Collagen plugs are an option for short term use. They are self-dissolving, and are effective for approximately 10 days.Eyelid weights (available from MedDev Corp.)Skin Tone External Eyelid Weights are the newest development, and work quite well. The weight on the eyelid works with gravity to assist blinking. It's worn on the upper eyelid, just above the eyelashes, and is attached daily with a double-sided adhesive strip. They're available only with a prescription. Potential downsides are irritation caused by the adhesive, and problems with the adhesive lasting during long days. For Bell's palsy patients, where paralysis is temporary, it can be an excellent short-term solution. For patients with permanent paralysis it's useful for calculation of the weight to be permanently implanted, and helps the patient adjust to living with an eye weight prior to implantation.Gold Eyelid Weights are also used to help eyelid closure. They work on the same gravity-assist principle, but are sewn into the eyelid. (Shown here on the eyelid surface. When sewn into the eyelid it's visually undetectable.) The smaller weights are not uncomfortable for most people. The weight is removed as soon as enough function returns to the eyelid. In cases of permanent facial paralysis it can be left in place indefinitely. It is, however, a surgical procedure, and should be done only after careful consideration. As with any surgery, infection can occur, and swelling can last for several weeks. The eyelid and crease area can appear distorted, and vision can be affected. The weight, particularly if above 1.2 grams can cause the eyelid to droop. In spite of the cautions noted, it is well tolerated by most patients, and provides good protection for the cornea, as well as an improved appearance. Spring insertion is another, less frequently used type of surgical implantation.Because we sleep in a horizontal position eye weights do not help keep the eye closed while sleeping. The effects of gravity are key to the success of eyelid weights, so its possible that even with an eyelid weight, additional protection may be needed while sleeping.Lower lid elevations and surgical tightening of the lower lid can help prevent moisture from accumulating between the eye and a droopy bottom lid instead of spreading over the cornea.Tarsorrhaphy is a procedure to sew a portion of the upper and lower lids together. When possible, only 5mm at the outer corner of the lids (lateral tarsorrhaphy) are stitched to maintain good vision, comfort and best possible appearance. If limited to 5mm or less, the appearance is not as bad as its description sounds. The eyelashes are undisturbed, and make-up can be worn. However, the procedure is not always effective unless a larger area is stitched, and a larger area may interfere with peripheral vision, and become more noticeable. If a medial tarsorrhaphy is suggested (rare even for permanent FP; shouldn't be needed for BP), it might be wise to seek a second opinion. This procedure is done over the center of the lids. It is disfiguring and functionally disruptive - a procedure of last resort.CONTACT LENSESContact lenses are hydrophilic (hold water). They can provide a source of moisture directly over the cornea, and help protect the eye from injury due to debris. The eyelids help to hold a contact lens in place. If the lids become limp, contacts cannot be worn until function begins to return. Important notes of caution: Wearing the lens helps, but it is not a complete replacement for your tears - use plenty of saline or eye drops designed for use with contacts. At the acute stage, the eye can be so dry that it is impossible to keep a contact lens moist for more than a few minutes at a time. In this situation, contacts can not be worn.
**DO NOT LET THE LENS DRY OUT! A dry contact directly over the cornea is dangerous. This is very important - IF YOU CANNOT KEEP THE LENS MOIST, DO NOT WEAR IT! **
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