Introduction

Neuropathy (neuritis) of the facial nerve (ICD-10 code G51.0) refers to diseases in which underestimation of the importance of rehabilitation measures can cause problems of a functional, aesthetic, psychological and social nature and significantly reduce the quality of life of patients. Occupying the 2nd place in terms of frequency among the pathologies of the peripheral nervous system, it is estimated in the population to range from 8-240 cases in different countries of the world per 100,000 population per year, with an increase in young patients in recent years [1, 2].

Meanwhile, for at least the last decade, there has been a lack of consensus on treatment and rehabilitation tactics for this pathology among interested medical communities [3, 4, 5]. A characteristic feature of Bell's palsy is acute peripheral (flaccid) paresis of facial muscles innervated by the facial nerve. These include: temporomandibular, external and internal pterygoid, masticatory muscles, muscles of the tongue and diaphragm of the mouth, the stapes muscle (the smallest muscle of the human body, straining the eardrum).

The facial nerve forms the parotid plexus and gives off 14 branches along the way. The narrowest place in which the nerve passes is the pyramid of the temporal bone (the bone canal is filled with nerve substance by 70%). Under normal conditions, all branches function in close synergy, but a small edema is sufficient. the consequence of which is possible compression of the nerve and the appearance of its consequences: the circular muscle of the eye and the facial muscles on the affected side are affected. Depending on the level of the lesion, the neurological symptoms change - additionally, other symptoms appear (impaired taste and hearing, increased lacrimation or dry eyes). After exiting the cranial cavity, only peripheral paresis of facial muscles develops on the affected side; at a higher level, before the departure of the horda tymponi, taste disorders on the anterior 2/3 part of the tongue join the paresis; before the departure of the n. Stapedius, hyperacusis joins these symptoms and, the highest level of damage – before the departure of the n. petrosus major adds a dry eye to the clinical picture [6].

At the onset of the disease, mimic hypotension is observed, turning into hypotrophy by the 2nd-3rd day. Against the background of loss of friendly movements of the facial muscles, the tone of the masticatory muscles consistently increases with the formation of successive trigger changes in them. In the facial muscles, such phenomena develop gradually in the following sequence: buccal, zygomatic, lifting corner of the mouth, upper lip, circular muscle of the eye, frontal abdomen of the aponeurosis of the head, subcutaneous muscle of the neck. Thus, after 10-12 days, distinct seals are observed in the cheek musculature, accompanied by swelling of the soft tissues. Passive stretching of them becomes painful. Further development of the process is characterized by the appearance of a feeling of tightening of facial tissues, deep hyperalgic zones. It is characteristic that in terms of the number and severity of myofascial pain manifestations, due to the lower demand, facial muscles begin to come out on top [7]. In fact, paretic phenomena in the muscles and the severity of the asymmetry of the corresponding half of the face act as a measure of compensation for the pathological process. For these purposes, scales for assessing the dynamic function of the facial nerve (House-Brackman, Chevalier, FNGS 2.0, etc.) are widely used.

The severity of the condition, in turn, determines the prognosis and prospects for rehabilitation measures. If, with a mild degree, the duration of the disease does not exceed 2-3 weeks, then the average degree of damage assumes recovery in 4-7 weeks, in turn, a more severe degree of damage can delay recovery for a long period. The frequency of his lesions is explained by the peculiarity of his anatomical location and his slight vulnerability. The pathogenetic factor of damage to the facial nerve is its compression in the narrow bone canal of the pyramid of the temporal bone due to edema and vascular disorders resulting from polyetiological causes, among which, first of all, local hypothermia, viral infection, and traumatic brain injuries should be indicated [8]. Traumatic injuries to the facial nerve itself are possible with gunshot wounds, fractures of the base of the skull.

The facial nerve belongs to the VII pair of cranial nerves, and its unilateral peripheral lesion (Bell's palsy) is most often an idiopathic form of neuropathy.

According to WHO, young people can be called people in the age group from 18 to 44 years. The provoking factor in such individuals is often local hypothermia in the autumn-winter period or traumatic brain injury due to chronic diseases of the oral cavity.

In both variants, the pathogenesis of neuropathy is caused by the expansion of capillaries, an increase in their permeability and, as a result, the accumulation of exudate in the pyramid of the temporal bone, which leads to swelling of the nerve trunk and the development of tunnel syndrome, leading to secondary ischemia of the facial nerve. Depending on the level of nerve damage, motor, gustatory, painful, and secretory fibers are involved in the process, resulting in pain in the parotid region, paresis of facial muscles, dry eyes, and taste disorders in the anterior 2/3 of the tongue [9, 10].

The purpose of the study: to evaluate the effect of the combined use of acupuncture and physical therapy on the restoration of contractility of facial muscles and circular muscles of the eye in neuropathy of the facial nerve in young people.

Оbjectives: in the subacute period, stabilization of the process (improvement of blood circulation in the area of innervation of the facial nerve, restoration of nerve conduction, muscle tone) and restoration of muscle contractility (the circular muscle of the eye, mouth and muscles that raise and reduce the eyebrows).

During the period of residual manifestations - correction of existing residual symptoms.

The main part

Based on the experience of our work in the regional military hospital and the positive results in the treatment of patients with facial neuritis, we have proposed and tested an original combined approach to the application of physical and reflex factors in the described pathology. These measures were carried out to solve the following therapeutic tasks: strengthening blood and lymph circulation in the face, neck and collar area (primarily on the affected side), increasing the conduction of the facial nerve, restoring the functions of facial muscles, preventing the development of muscle contracture and friendly movements, restoring correct pronunciation.

We observed a group of 16 patients with Bell's palsy who were treated in one of the military hospitals. Hypothermia, as an etiological factor, was clearly identified in only 11 patients, the traumatic nature of the disease in three, two patients could not name any previous (in their opinion) causes.

Clinically, in patients with hypothermia, only paralysis of the facial muscles and the circular muscle of the eye was observed in 9 people, two patients in the first week of the disease additionally noted a taste disorder. In three patients with traumatic brain injury (TBI) and in two patients without a specific etiological factor, all the symptoms of the lesion (paresis, impaired taste and hearing) were observed at the time of examination. All patients were admitted to the hospital already in the subacute period – from 5 to 8 days after the onset of the disease, and acupuncture was connected to the standard pharmacotherapy already being performed. The typical onset of the disease after hypothermia was manifested on day 2-3 and was accompanied by moderate pain in the mastoid process, paralysis of the facial muscles and the circular muscle of the eye on the pain side. The process of the appearance of clinical symptoms was accompanied by respiratory manifestations: fever, runny nose, moderate sore throat. On the background of TBI, neuropathy developed on the second day and was accompanied by a diffuse headache.

The choice of physical therapy was based on the clinical features of the course of the disease and the availability of indications. In turn, the complexity of the use of physical treatment methods is the most important rehabilitation principle, providing additional effectiveness compared to monopharmaceutical treatment [11].

Reflexotherapy (RT) was performed with a negative Chvostek sign on the affected side: a clinical test that reveals an increase in neuromuscular arousal. When the facial nerve is tapped in front of the ear, the facial muscles on the same side of the face will contract sporadically (called ipsilateral facial spasm) [5, 9, 12].

Reflexotherapy is a technique of influencing biologically active points of the body. They are called acupuncture points (AP). There are many biologically active points on the human body, and each of them has its own functional abilities. The corporeal points are combined into meridians (channels) that correspond to a specific organ or organ system and obey the laws of traditional Chinese medicine (TCM) and receptor-organ interactions. According to TCM, meridians closely interact with the nervous, endocrine, lymphatic and circulatory systems on metaphysical principles, and the modern interpretation of the interaction of points with the human body and the environment occurs through a reflex apparatus. RT activates the internal resources of the body, restores a healthy state and natural forces [13]. The most common and effective method of exposure in RT is classical corporate acupuncture, a therapeutic technique based on the action of a thin needle on biologically active substances that are located on the patient's body in a certain order and are limited by a meridian or biologically active zone. Each of the AP has a large number of peripheral specific and nonspecific receptors, which, when stimulated, transmit afferent signals to various levels of segmental and suprasegmental formations of the central nervous system. The correct effect on AP normalizes physiological processes, eliminates functional and somatic disorders of the organs, strengthens the body and mobilizes its hidden resources. [14]. At the same time, nerve endings are stimulated, blood flow increases, tissue trophism improves and the immune system strengthens. The method has some contraindications. Corporate RT can be used as an isolated treatment method, or in combination with medication. Similarly to reflexotherapy, the use of physical therapy for facial neuritis has a number of limitations. So, in the acute period of the disease and in the presence of Chvostek sign swelling, both acupuncture and therapeutic gymnastics on the affected side are not prescribed. In this case, acupuncture is performed only in remote locations and locally on the healthy side; physical therapy for facial muscles on the affected side is not performed until the Chvostek sign disappear.

A special feature of our work was the combination of acupuncture with therapeutic gymnastics "under the needles", and therapeutic gymnastics was performed simultaneously on both sides, until the needles were removed on the affected side after 1-2 minutes or at the first signs of movement in the paralyzed muscles.

The main method of reflexotherapy was classical acupuncture on the affected side using a tonic technique and inhibitory on the healthy side. Acupuncture needles with a diameter of 0.30 millimeters and a length of 45 millimeters were used for the procedure, and they were inserted to a depth set for each point.

In classical acupuncture, local meridian points were combined with distal ones in the proportion of 5:1 for each session and placed symmetrically on both sides [15]. Local points: Ig-18, Ig-19, E-2, E-3, E-4, E-5, E-6, E-7, E-8, Gi-19, Gi-20, TR-17, TR-21, TR-23, VB-1, VB-2, VB-14, V-2, J-24, T-26, Yin-tan. Distal points: P-7, Gi-4, Gi-10, Gi-11, TR-5, TR-6, V-59, VB-41, E-36, F-2.

In addition to classical acupuncture, other reflexotherapy methods were used in the treatment of patients: auriculotherapy, prolonged microneedle therapy and Su-jok therapy. In each session of auriculotherapy, tubotherapy or prolonged microneedle therapy was applied at 1-2 points per session, to the points of the earlobe (i.e., the eye, upper and lower jaw), the urticaria zone, the sympathetic point and the shen-men. The treatment was performed alternately on one auricle, starting with the dominant ear.

Auriculotherapy (AT) is the effect of needles on acupuncture points on the auricle. Prolonged microneedle therapy is the effect on the mechanoreceptors of the auricle by attaching microneedles or buttons to the skin. Tubotherapy is the attachment of metal balls to the points of the auricle [16].

Su-jok therapy is the stimulation of highly active points corresponding to all organs and systems located on the feet and hands with needles or a massage probe. The hands and feet are similar to the human body, when exposed to these points, signals are sent to the brain indicating the presence of a problem, and in response it gives the command to restore the work of the affected organ. The uniqueness of the method is that the massage of these areas can be performed by the patient himself [17].

In our group, using the toning technique, to increase muscle tone on the affected side, the Su-jok method was used according to the basic matching system: the ventral side of the first phalanx of the thumb was taken, corresponding to the collar area and the facial area. The areas of the eye, masticatory muscles, and ear were stimulated with a massage probe. The massage ring is the area of the cervical spine and the collar area on the dorsal side of the phalanx. If necessary, the points of the eyes, forehead and mouth were stimulated using the "insect" system on the ventral surface of the first phalanx of all fingers.

During the period of residual effects, acupuncture was performed on each branch separately. The sessions were conducted every other day according to the toning technique on the affected side [18] with exercises performed under the following needles.

For the first branch (forehead): VB-1, VB-14, T-23, T-24, V-2, V-3, V-4, V-5 and underneedle exercises: wrinkling the forehead muscles and bringing the eyebrows together for 2-3 seconds at intervals of 5 seconds (6 exercises).

For the second branch (eyes): VB-1, V-1, V-2, E-1, E-2, Gi-20 and exercises: closing and opening the eye for 1-2 seconds at intervals of 4-5 seconds (3-4 exercises in total).

For the third branch (mouth): VB-2, E-3, E-4, E-5, E-6, Ig-18, T-24, T-27 and sound exercises, the vowel sounds "O", "U" and "E" were pronounced for 1-2 seconds. To do this, hold the healthy side with one hand during the exercise to reduce tension in the muscles. There should be no more than 4-5 exercises in total (with visible muscle fatigue, exercises stopped earlier).

When a positive effect was obtained (for example, the eye began to close better under the needle), they gave a break for 2-3 days.

At the same time, all patients were trained in the elements of Su-jok therapy (according to the basic matching system) and a few hours after the acupuncture session, the facial area was independently stimulated with a wooden probe: the points of the eyes, mouth, masticatory muscles and ear along the ventral side of the first phalanx of the thumb on both hands. A massage ring was previously used to stimulate the projection of the cervical spine on the dorsal side of the thumb phalanx on both hands.

As a background effect, we used position treatment (all techniques except adhesive tension). Patients were advised to sleep on their side (on the affected side); to sit with their head tilted towards the affected side, supporting it with the back of their hand (resting on their elbow) for 10-15 minutes 3-4 times a day, while trying to restore facial symmetry. The use of therapeutic gymnastics according to the classical method was added [19]. The features of therapeutic gymnastics in the gentle period were restorative passive-active exercises for facial and chewing muscles and articular gymnastics. Frequency of repetition of the procedure: 2-3 times a day, duration – 5-10 minutes, but not earlier than 2-3 hours after the acupuncture session.

As already noted, during the acupuncture session, gymnastics was performed "under needles" at the same time, since active movements in the paretic muscles were impossible or incomplete, exercise control was carried out on the healthy side. Gymnastics was performed in a supine position (in front of a mirror), under the supervision of a reflexologist with simultaneous stimulation of local acupuncture points with needles. At the slightest "response" of the facial muscles or the circular eye muscle on the affected side, all manipulations in this area, including acupuncture, stopped for 1-2 days.

During the session, therapeutic gymnastics is mainly aimed at developing movements against the background of increased impulses traveling along the afferent fibers from those activated by acupuncture needles, as well as stretching the shortened muscles of the paralyzed side. Later, (with a negative Chvostek sign!), when small voluntary movements appeared, they switched to more active gymnastics for both paretic and healthy muscles. It was also performed under the eye control (in front of a mirror) of the patient and the doctor. If there was insufficient volume of active movements, the doctor additionally stimulated the placed needles on the affected side.

The method of original combined effects of reflexotherapy and physical therapy, which we have tested, was implemented within the framework of well–known rehabilitation periods - gentle, restorative and residual. To assess the dynamic function of the facial nerve, the House-Braakman scale was used, recommended by the Committee on the Study of Facial Nerve Lesions in 1985 (Fig. 1)

Figure 1. Degrees of weakness of facial muscles in facial neuropathy (according to House-Brackman, 1985).

This tool provides 6 assessment levels, which correspond to indicators of muscle weakness, symmetry, the presence of synkinesia and facial contractures.

We carried out medical rehabilitation of Bell's palsy in a limited period of time for objective reasons. On average, patients stayed in a medical facility for about two weeks and all surveillance data was monitored during this period alone, in addition, all of them were admitted to a medical facility already in the subacute period.

Conclusion

In our study, it was demonstrated that the simultaneous combined use of acupuncture and physical therapy leads to a significant improvement in facial symmetry in patients with facial nerve damage.

The positive effect is a complete restoration of the work of the facial muscles (I degree in House-Brackman) It was noted in 15 out of 16 patients (93.75%), with complete restoration of the circular eye muscle (degree I according to House-Brackman) in 12 out of 16 (75%), it was noted already in the second week of therapy, and in 4 of their 16 patients, the "eyelash symptom" remained on the affected side, and only one patient out of 16 (with traumatic brain injury) had practically no positive dynamics – 6.25% (degree IV according to House-Brackman).

In this way, according to our observations, at a young age peripheral facial nerve damage occurs more often against the background of hypothermia and respiratory symptoms (in the presence of diseases of the oral cavity), the recovery of the circular eye muscle in patients is 25% slower than the facial muscles. The course of therapy should be performed in combination with traditional rehabilitation methods and in the subacute period of facial nerve damage in order to correct the functions of facial muscles. Properly selected acupuncture points, simultaneous use of physical therapy "under needles", as well as teaching patients special techniques of Su-jok therapy to restore the functions of facial muscles should be more widely used in the complex treatment of this category of patients.

List of abbreviations:

WHO – World Health Organisation

AT – auriculotherapy

AP – acupuncture points

PT – physical therapy

RT – reflexotherapy

TCM – Traditional Chinese medicine

TBI – traumatic brain injury

P – lung meridian

Ig – small intestine meridian

Gi – large intestine meridian

E – stomach meridian

MC – pericardium meridian

V – bladder meridian

VB – gallbladder meridian

R – kidneys meridian

TR – triple energiser meridian

F – liver meridian

T – posterior median meridian