MEDIAL COLLATERAL LIGAMENT INJURY

INTRODUCTION-
Your medial collateral ligament (MCL) is the knee ligament on the medial (inner) side of your knee connecting the medial femoral condyle and the medial tibial condyle. It is one of four major knee ligaments that help to stabilise the knee joint. It is a flat band of tough fibrous connective tissue composed of long, stringy collagen molecules.
The main function of the MCL is to resist valgus force, which occurs if the tibia/foot is forced outwards in relation to the knee.

                                                         ANATOMY OF MCL
CAUSES OF MCL INJURY
The MCL is injured when the (valgus) force is too great for the ligament to resist and the ligament is overstretched. This can occur through a sharp change in direction, twisting the knee whilst the foot is fixed, landing wrong from a jump, or the most common a blunt force hit to the knee, such as in football tackle. The incident usually needs to happen at speed. Muscle weakness or incoordination predispose you to a ligament sprain or tear.
SEVERITY OF MCL INJURY
The severity and symptoms of a knee ligament sprain depend on the degree of stretching or tearing of the knee ligament. You may notice an audible snap or tearing sound at the time of your ligment injury.
In a mild Grade I MCL sprain, the knee ligament has a slight stretch, but they don't actually tear. Although the knee joint may not hurt or swell very much, a mild ligament sprain can increase the risk of a repeat injury.
With a moderate Grade II MCL sprain, the knee ligament tears partially. Knee swelling and bruising are common, and use of the knee joint is usually painful and difficult. You may have some complaints of instability or a feeling of the knee giving way.
With a severe Grade III MCL sprain, the ligament tears completely, causing swelling and sometimes bleeding under the skin. As a result, the joint is unstable and can be difficult to bear weight. You may have a feeling of the knee giving way. Often there will be no pain or severe pain that subsides quickly following a grade 3 tear as all of the pain fibres are torn at the time of injury. With these more severe tears, other structures are at risk of injury including the meniscus and/or ACL.
DIAGNOSIS
On examination, your physiotherapist will look for signs of ligament injury. There will be tenderness over the ligament site, possible swelling and pain with stress tests. MRI may also be used to diagnose a knee ligament injury and look at other surrounding structures for combination injuries.
RECOVERY TIME
Treatment of an MCL injury varies depending on its severity and whether there are other combination injuries.

 medial-collateral-ligament-grading-injuryGrade I sprains usually heal within a few weeks. Maximal ligament strength will occur after six weeks when the collagen fibres have matured. Resting from painful activity, icing the injury, and some anti-inflammatory medications are useful. Physiotherapy will help to hasten the healing process via electrical modalities, massage, strengthening and joint exercises to guide the direction that the ligament fibres heal. This helps to prevent a future tear.

When a Grade II sprain occurs, use of a weight-bearing brace or some supportive taping is common in early treatment. This helps to ease the pain and avoid stretching of the healing ligament. After a grade II injury, you can usually return to activity once the joint is stable and you are no longer having pain. This may take up to six weeks. Physiotherapy helps to hasten the healing process via electrical modalities, massage, strengthening and joint exercises to guide the direction that the ligament fibres heal. This helps to prevent a future tear and quickly return you to your pre-injury status.

When a Grade III injury occurs, you usually wear a hinged knee brace, locked into extension, and use crutches for 1-2 weeks to protect the injury from weight-bearing stresses. As pain resolves the brace can be unlocked to allow movement as tolerated. The aim is to allow for ligament healing and gradually return to normal activities. These injuries are most successfully treated via physiotherapy and may not return to their full level of activity for 3 to 4 months. All Grade III injuries should be rehabilitated under the guidance of your physiotherapist and knee specialist.

PHYSIOTHERAPY TREATMENT
Depending on the grade of injury you can start to feel better within days to just a few weeks of the injury. Your physiotherapy treatment will aim to:
1.Reduce pain and inflammation.
2.Normalise joint range of motion.
3.Strengthen your knee: esp quadriceps (esp VMO) and hamstrings.
4.Strengthen your lower limb: calves, hip and pelvis muscles.
5.Improve patellofemoral (knee cap) alignment
6.Normalise your muscle lengths
7.Improve your proprioception, agility and balance
8.Improve your technique and function eg walking, running, squatting, hopping and landing.
9.Guide return to sport activities and exercises
10.Minimise your chance of re-injury.

AIMS OF REHABILITATION-
The following examples are for information purposes only. We recommend seeking professional advice before attempting any rehabilitation. The aim of rehabilitation is to reduce pain and swelling, restore full mobility, improve strength and stability before a gradual return to full training.

GRADE 1 MCL INJURY
For a grade 1 MCL injury there may be mild tenderness on the inside of the knee over the ligament and usually no swelling. The rehabilitation guidelines for a mild medial ligament sprain can be split into 4 phases:

Phase 1: immediately following injury
Duration 1 week. Aims to reduce swelling if there is any, ensure the knee can be straightened fully and bent to more than 90 degrees and begin pain free strengthening exercises.
Rest from activities that cause pain. As pain allows, aim to walk normally without support or pain. Apply cold therapy and a compression support to limit any swelling. Apply ice for 15 minutes every 2 hours for the first day. The frequency can be gradually reduced to 3 times a day over the next few days. Do not apply ice directly to the skin as it may burn.
Sports massage techniques can usually be applied from day 2, specifically to the ligament. Ultrasound can also be applied to the ligament area. Maintain aerobic fitness with cycling. Apply cold therapy after each strengthening and stretching session.
Pain free stretching exercises for quadriceps and hamstring muscles as well as flexion and extension mobility exercises. Static strengthening exercises can begin as soon as pain allows. Isometric quadriceps exercises, calf raises with both legs and resistance band exercises for the hamstrings, hip abductors and hip extension but not for adduction as this will stress the medial ligament.

Phase 2: after 1 week
Duration 1 week. Aims - Eliminate any swelling completely, regain full range of movement, continue with strengthening exercises and return to slow jogging.
Rest from painful activities, however the athlete may be able to jog slowly as long as it is not painful. Apply cold therapy following exercise or rehabilitation exercises. Continue with stretching and strengthening exercises from phase 1.
Introduce dynamic strengthening exercises such as knee extension, knee flexion, half squats, step ups, single leg calf raise, bridging and leg press are suitable exercises if pain allows.
Cross friction massage to the ligament can be performed on alternate days. Maintain aerobic fitness with cycling, stepping machine and gentle jogging but no sudden changes of direction.

Phase 3: after 2 weeks
Duration 2 weeks. Aims to maintain full range of motion, equal strength of both legs, return to running and some sports specific training.
Continue to apply cold therapy after training sessions. Continue with sports massage techniques every 3 days. Continue with stretching exercises.
Build on dynamic strengthening exercises such as leg extension and leg curls exercises as well as squats to horizontal and lunges. Increase the intensity, weight lifted and number of repetitions. Aim for between 10 and 20 reps. Increase until the strength is equal in both legs.
In addition to straight running, start to include sideways and backwards running, agility drills and plyometric exercises. Increase speed to sprinting and changing direction drills.


Phase 4: after 4 weeks
Duration 3 to 6 weeks. Aims to return to full sports specific training and competition.
Sports massage for surrounding muscles on as weekly basis. Continue with strength training as above but start to include hopping and bounding exercises. The athlete should now be ready to gradually return to full sports specific training and then competition.
A knee support or a strapping / taping techniques may provide extra support on return to full training, however do not become reliant on this. It will weaken the joint. Use initially for confidence building.

GRADE 2 OR 3 SPRAIN-
For a grade 2+ and particularly 3 sprain it is important that the ends of the ligament are protected and left to heal without continually being disrupted. The rehabilitation guidelines for a grade 2+ or 3 medial ligament sprain (more severe) can be split into 4 phases:

Phase 1: immediately following injury
Duration 4 weeks. Aims to control swelling, maintain ability to straighten the leg bend the knee to more than 90 degrees, begin strengthening exercises.
Rest from all painful activities. Use crutches if necessary, non weight bearing to start with, then partial weight bearing from week 2 and by end of week 4 aim to be walking normally.
Wear a hinged or stabilised knee brace to protect the medial ligament. Apply cold therapy and compression. Apply ice / cold therapy for 15 minutes every 2 hours for the first 2 days and gradually reduce the frequency to 3 times a day over the next week. Pain free stretches for the hamstrings, quads, groin and calf muscles in particular. Mobility exercises should be done in the knee brace.
Sports massage (gentle cross frictions) may be possible from day 2 but allow a week for more severe injuries. As pain allows, static quads and hamstring exercises, double leg calf raises, hip abduction and extension. Knee extension mobility should only be to 30 degrees though. Maintain aerobic fitness on stationary cycle as soon as pain allows.

Phase 2: Following week 4
Duration 2 weeks. Aims to eliminate swelling, full weight bearing on the injured knee, full range of motion, injured leg almost as strong as the good one.
Continue with cold therapy and compression to eliminate swelling following exercises. Remove the knee brace at this stage. A simple stablized knee support is more suitable at this stage to apply compression to the knee. A therapist will continue with ultrasound and massage.
Range of motion exercises should continue along with isometric quadriceps exercises. Mini squats, lunges, double leg press, hamstring curls, step ups, bridges, hip abduction, hip extension and single leg calf raises can begin or be continued. It may be possible to begin to swim (not breaststroke!) or use stepper for aerobic fitness.

Phase 3: after week 6
Duration 4 weeks. Aims to regain full range of motion, strength, return to light jogging and by week 10 from injury, return to sports specific exercises.
Continue with cold therapy following training sessions. Wear a brace or support as required. Sports massage techniques to the ligament 2 to 3 times a weeks. Strengthening exercises as above increasing intensity and moving double leg exercises to single.
After week 6, no sooner, begin to run if comfortable, no sudden changes of direction though.
After week 8 begin to run sideways and backwards so by week 10 the athlete is able to begin to change direction at speed. For footballers, kicking may now be possible.
When confident enough plyometric drills, hopping, box jumps and agility drills can begin.
Phase 4: after week 10
Duration 2 to 4 weeks. Aims to return to full sports specific training and competition without a brace for support, full strength and mobility.
Gradually bring into training more and more sports specific drills, changing direction and plyometric, hopping and bounding exercises. Normal sports specific training can begin.

KNEE LIGAMENT SURGERY
Most MCL injuries resolve well with conservative management, however, surgery may be considered if there is significant ligament disruption eg Grade III. Surgery may also be required if the are significant combination injuries involving the ACL and/or meniscus. In these cases a knee specialist will guide the need for surgery.
Risks of surgery include infection, persistent instability and pain, stiffness, and difficulty returning to your previous level of activity. The good news is that better than 90% of patients have no complications post-surgery.

POST SURGICAL REHABILITATION
Post-operative knee rehabilitation is one of the most important aspects of knee surgery. The most successful and quickest outcomes result from the guidance and supervision of an experienced sports physiotherapist.
Your physiotherapy rehabilitation following knee surgery focuses on restoring full knee motion, strength, power and endurance. You'll also require balance, proprioception and agility retraining that is individualised towards your specific sporting or functional needs.
As mentioned earlier your sports physiotherapist is an expert in this field. We suggest you contact them for the best advice in your circumstances.
Your physiotherapist will guide your return to sport. It is highly variable and depends upon on your specific knee ligament injury and the demands of your demands of your sports.

PREVENTION OF RECURRENCE
A knee strengthening, agility and proprioceptive training program is the best way to reduce your chance of a knee ligament sprain. Premature return to high-risk activities such as sport are best discussed with your physiotherapist or surgeon.

 

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FACIAL NERVE PALSY

 INTRODUCTION

ANATOMY:

 
The facial nerve is the seventh cranial nerve, or simply cranial nerve VII. It emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. The nerves typically travels from the pons through the facial canal in the temporal bone and exits the skull at the stylomastoid foramen. It arises from the brainstem from an area posterior to the cranial nerve VI (abducens nerve) and anterior to cranial nerve VIII (vestibulocochlear nerve).
The facial nerve also supplies preganglionic parasympathetic fibers to several head and neck ganglia.
The facial and intermediate nerves can be collectively referred to as the nervus intermediofacialis.

STRUCTURE:

 
The path of the facial nerve can be divided into six segments.
1. Iintracranial (cisternal) segment
2. Meatal segment (brainstem to internal auditory canal)
3. Labyrinthine segment (internal auditory canal to geniculate ganglion)
4. Tympanic segment (from geniculate ganglion to pyramidal eminence)
5. Mastoid segment (from pyramidal eminence to stylomastoid foramen)
6. Extratemporal segment (from stylomastoid foramen to post parotid branches)
1.The motor part of the facial nerve arises from the facial nerve nucleus in the pons while the sensory and parasympathetic parts of the facial nerve arise from the intermediate nerve.
2.From the brain stem, the motor and sensory parts of the facial nerve join together and traverse the posterior cranial fossa before entering the petrous temporal bone via the internal auditory meatus. Upon exiting the internal auditory meatus, the nerve then runs a tortuous course through the facial canal, which is divided into the labyrinthine, tympanic, and mastoid segments.
3.The labyrinthine segment is very short, and ends where the facial nerve forms a bend known as the geniculum of the facial nerve ("genu" meaning knee), which contains the geniculate ganglion for sensory nerve bodies. The first branch of the facial nerve, the greater superficial petrosal nerve, arises here from the geniculate ganglion. The greater petrosal nerve runs through the pterygoid canal and synapses at the pterygopalatine ganglion. Post synaptic fibers of the greater petrosal nerve innervate the lacrimal gland.
4.In the tympanic segment, the facial nerve runs through the tympanic cavity, medial to the incus.
5The pyramidal eminence is the second bend in the facial nerve, where the nerve runs downward as the mastoid segment. In the temporal part of the facial canal, the nerve gives rise to the stapedius and chorda tympani. The chorda tympani supplies taste fibers to the anterior two thirds of the tongue, and also synapses with the submandibular ganglion. Postsynaptic fibers from the submandibular ganglion supply the sublingual and submandibular glands.
6.Upon emerging from the stylomastoid foramen, the facial nerve gives rise to the posterior auricular branch. The facial nerve then passes through the parotid gland, which it does not innervate, to form the parotid plexus, which splits into five branches innervating the muscles of facial expression (temporal, zygomatic, buccal, marginal mandibular, cervical).

INTRACRANIAL BRANCH :

 
1.Greater petrosal nerve – It arises at the geniculate ganglion and provides parasympathetic innervation to several glands, including the nasal glands, the palatine glands, the lacrimal gland, and the pharyngeal gland. It also provides parasympathetic innervation to the sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus and nasal cavity. This nerve also includes taste fibers for palate via lesser palatine nerve and greater palatine nerve.

2.Communicating branch to the otic ganglion – It arises at the geniculate ganglion and joins the lesser petrosal nerve to reach the otic ganglion.

3..Nerve to stapedius – provides motor innervation for stapedius muscle in middle ear

4.Chorda tympani
Parasympathetic innervation to submandibular gland
Parasympathetic innervation to sublingual gland
Special sensory taste fibers for the anterior 2/3 of the tongue.

EXTRACRANIAL BRANCHES
Distal to stylomastoid foramen, the following nerves branch off the facial nerve:
Posterior auricular nerve – controls movements of some of the scalp muscles around the ear
Branch to Posterior belly of Digastric muscle as well as the Stylohyoid muscle
Five major facial branches (in parotid gland) – from top to bottom:

                                                       
EXRACRANIAL BRANCH
1.Temporal branch
2.Zygomatic branch
3.Buccal branch
4.Marginal mandibular branch
5.Cervical branch
Intra operatively the facial nerve is recognized at 3 constant landmarks:
1.At the tip of tragal cartilage where the nerve is 1cm deep and inferior
2.At the posterior belly of digastric by tracing this backwards to the tympanic plate the nerve can be found between these two structures
3.By locating the posterior facial vein at the inferior aspect of the gland where the marginal branch would be seen crossing it.
4.lateral semicircular canal
5.Foot of incus

NUCLEUS
The cell bodies for the facial nerve are grouped in anatomical areas called nuclei or ganglia. The cell bodies for the afferent nerves are found in
the geniculate ganglion for taste sensation. The cell bodies for muscular efferent nerves are found in the facial motor nucleus whereas the cell
bodies for the parasympathetic efferent nerves are found in the superior salivatory nucleus.

DEVELOPMENT
The facial nerve is developmentally derived from the second pharyngeal arch, or branchial arch. The second arch is called the hyoid arch because it contributes to the formation of the lesser horn and upper body of the hyoid bone (the rest of the hyoid is formed by the third arch). The facial nerve supplies motor and sensory innervation to the muscles formed by the second pharyngeal arch, including the muscles of facial expression, the posterior belly of the digastric, stylohyoid and stapedius. The motor division of the facial nerve is derived from the basal plate of the embryonic pons, while the sensory division originates from the cranial neural crest.
Although the anterior two thirds of the tongue are derived from the first pharyngeal arch, which gives rise to cranial nerve V, not all innervation of the tongue is supplied by CN V. The lingual branch of the mandibular division (V3) of CN V supplies non-taste sensation (pressure, heat, texture) from the anterior part of the tongue via general visceral afferent fibers. Nerve fibers for taste are supplied by the chorda tympani branch of cranial nerve VII via special visceral afferent fibers.

FUNCTIONS
Facial expression
The main function of the facial nerve is motor control of all of the muscles of facial expression. It also innervates the posterior belly of the digastric muscle, the stylohyoid muscle, and the stapedius muscle of the middle ear. All of these muscles are striated muscles of branchiomeric origin developing from the 2nd pharyngeal arch.

FACIAL SENSATION
In addition, the facial nerve receives taste sensations from the anterior two-thirds of the tongue via the chorda tympani. Taste sensation is sent to the gustatory portion (superior part) of the solitary nucleus. General sensation from the anterior two-thirds of tongue are supplied by afferent fibers of the third division of the fifth cranial nerve (V-3). These sensory (V-3) and taste (VII) fibers travel together as the lingual nerve briefly before the chorda tympani leaves the lingual nerve to enter the tympanic cavity (middle ear) via the petrotympanic fissure.

It joins the rest of the facial nerve via the canaliculus for chorda tympani. The facial nerve then forms the geniculate ganglion, which contains the cell bodies of the tastefibers of chorda tympani and other taste and sensory pathways. From the geniculate ganglion, the taste fibers continue as the intermediate nervewhich goes to the upper anterior quadrant of the fundus of the internal acoustic meatus along with the motor root of the facial nerve. The intermediate nerve reaches the posterior cranial fossa via the internal acoustic meatus before synapsing in the solitary nucleus.
The facial nerve also supplies a small amount of afferent innervation to the oropharynx below the palatine tonsil. There is also a small amount of cutaneous sensation carried by the nervus intermedius from the skin in and around the auricle (outer ear).

OTHERS-
The facial nerve also supplies parasympathetic fibers to the submandibular gland and sublingual glands via chorda tympani. Parasympathetic innervation serves to increase the flow of saliva from these glands. It also supplies parasympathetic innervation to the nasal mucosa and the lacrimal gland via the pterygopalatine ganglion. The parasympathetic fibers that travel in the facial nerve originate in the superior salivatory nucleus.

The facial nerve also functions as the efferent limb of the corneal reflex.

FUNCTIONAL COMPONNENT-
The facial nerve carries axons of type GSA, general somatic afferent, to skin of the posterior ear.
The facial nerve also carries axons of type GVE, general visceral efferent, which innervate the sublingual, submandibular, and lacrimal glands, also mucosa of nasal cavity.
Axons of type SVE, special visceral efferent, innervate muscles of facial expression, stapedius, the posterior belly of digastric, and the stylohyoid.
The axons of type SVA, special visceral afferent, provide taste to the anterior two-thirds of tongue via chorda tympani.
Finally, the facial nerve also carries axons of type GVA, general visceral afferent, which provide sensation to the soft palate and parts of the nasal
cavity.

CLINICAL SIGNIFICANCE-

PALSY
People may suffer from acute facial nerve paralysis, which is usually manifested by facial paralysis. Bell's palsy is one type of idiopathic acute facial nerve paralysis, which is more accurately described as a multiple cranial nerve ganglionitis that involves the facial nerve, and most likely results from viral infection and also sometimes as a result of Lyme disease. Iatrogenic Bell's Palsy may also be as a result of an incorrectly placed dental local-anesthetic (Inferior alveolar nerve block). Although giving the appearance of a hemi-plegic stroke, effects dissipate with the drug.
When the facial nerve is permanently damaged due to a birth defect, trauma, or other disorder, surgery including a cross facial nerve graft or masseteric facial nerve transfer may be performed to help regain facial movement.Facial nerve decompression surgery is also sometimes carried out in certain cases of facial nerve compression.

EXAMINATION-
Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly (inability to do so is called lagophthalmos) , pursing the lips and puffing out the cheeks, all test the facial nerve. There should be no noticeable asymmetry.

In an UMN lesion, called central seven, only the lower part of the face on the contralateral side will be affected, due to the bilateral control to the upper facial muscles (frontalis and orbicularis oculi).
LMN lesions can result in a CNVII palsy (Bell's palsy is the idiopathic form of facial nerve palsy), manifested as both upper and lower facial weakness on the same side of the lesion.
Taste can be tested on the anterior 2/3 of the tongue. This can be tested with a swab dipped in a flavoured solution, or with electronic stimulation (similar to putting your tongue on a battery).
Corneal reflex. The afferent arc is mediated by the General Sensory afferents of the Trigeminal Nerve. The efferent arc occurs via the Facial Nerve.
The reflex involves consensual blinking of both eyes in response to stimulation of one eye. This is due to the Facial Nerve's innervation of the muscles of facial expression, namely Orbicularis oculi, responsible for blinking. Thus, the corneal reflex effectively tests the proper functioning of both Cranial Nerves V and VII.

FACIAL NERVE PALSY-
A facial palsy is weakness or paralysis of the muscles of the face.
Whilst the majority of cases are idiopathic, termed Bell’s Palsy, there are a wide range of potential causes of a facial palsy .
Bell’s palsy is a diagnosis of exclusion and hence all possible causes have to be excluded first prior to diagnosing Bell’s palsy. The majority of this article will discuss Bell’s Palsy and its associated clinical features and management.

RISK FACTORS-
Bell’s palsy remains a poorly understood condition. Many causative associations have been proposed, the most universally accepted theory suggests a viral origin, yet no conclusive evidence is available at present.
The main risk factor for developing Bell’s palsy is known concurrent viral infection, such as HSV-1(HERPES SIMPLEX  VIRUS 1), CMV (CYTOMEGALOVIRUS), and EBV (EBSTEIN VIRUS), whilst less common risk factors.
include diabetes mellitus and pregnancy.

CLINICAL FEATURE-
Patients with a Bell’s Palsy will present with varying severity of painless unilateral lower motor neuron weakness of the facial muscles .
Depending on the severity and the ximity of the nerve affected, it can also result in:
Inability to close their eye (temporal and zygomatic branches)
Hyperacusis (nerve to stapedius)
Metallic taste (chorda tympani)
Reduced lacrimation (greater petrosal nerve)

DIFFERENCE BETWEEN THE UMN AND LMN LESION-
To distinguish clinically between a LMN cause and UMN cause of the facial palsy, a patient with forehead sparing (i.e. no involvement to the occipitofrontalis muscle) will have a UMN origin to the palsy, due to the bilateral innervation of the forehead muscle).

DIFFERENTIAL DIAGNOSIS-

LMN AND UMN LESIONImportant differential diagnosis for a facial palsy, other than Bell’s Palsy, include:

      UMN causes, such as a stroke, SDH, or tumour
Will present with forehead sparing

• LMN CAUSES
• Infective such as acute otitis media, cholesteatoma, viral infection (including HSV-1, CMV, and EBV)
• Neoplasm (parotid malignancy)
• Trauma or iatrogenic
• Neurological (Multiple sclerosis or Guillain-Barré syndrome)

SYMPTOMS OF BELLS PALSY :

 

                                                  SYMPTOMS OF BELLS PALSY

                                                    

The onset of facial paralysis is sudden with Bell’s palsy, and can worsen during the early stages. Symptoms will usually manifest and peak within 2-3 days, although it can take as long as 2 weeks. Common symptoms include, but are not limited to:
Muscle weakness or paralysis
Facial droop
Impossible or difficult to blink
Difficulty speaking
Difficulty eating and drinking
Nose runs
Nose is constantly stuffed
Difficulty breathing out of nostril on affected side
Nostril collapse on affected side
Forehead wrinkles disappear
Sensitivity to sound
Excess or reduced salivation
Facial swelling
Drooling
Diminished or distorted taste
Pain behind ear
There are also some eye related symptoms, which may include but are not limited to:
Difficulty closing the eye
Sensitivity to light
Lower eyelid droop
Tears fail to coat cornea
Brow droop
Excessive tearing
Lack of tears

INVESTIGATION
Most cases of Bell’s Palsy can be diagnosed clinically and no further investigations are required, unless any other clinical features are present that suggest another pathology.
Serology for HSV-1 and VZV can be performed, yet will unlikely alter future management if detected.

MANAGEMENT-
Patient reassurance is essential, as most cases return spontaneously to full function. Eye care is one of the most important aspect of the management, ensuring the patient uses lubricating drops hourly and potential for eye ointment at night and / or an eye patch.

MEDICAL MANAGEMENT
All patients presenting within 72 hours of symptoms onset should be started oral steroids. Current NICE guidance recommends either:
Giving 25 mg twice daily for 10 days
Giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg
Use of anti-viral agents is controversial.
A Cochrane Review found low level evidence that the combination of anti-virals and corticosteroids are more effective in Bell’s palsy treatment; many centers currently treat Bell’s palsy with both.

SURGICAL REFFERAL
Referral to an ENT surgeon should be considered if there is any doubt over the diagnosis, recurrent or bilateral Bell’s palsy, or no sign of improvement after 1 month. There are surgical options available for patients who have persistent weakness or synkinesis. Synkinesis could be treated with botox injections whilst persistent weakness can be treated with anterior belly of diagastric transfer, fascia lata sling, or cross-facial nerve grafting.
A referral to ophthalmology should be made if the cornea remains exposed after attempting to close the eyelid (House Brackmann grade of IV or more).

COMPLICATIONS
85% of cases will recover from Bell’s palsy, the majority of which make a fully recovery with no evidence of residual symptoms. The factors that suggest a poor prognosis from a facial palsy include:
Complete palsy
No signs of recovery within 3 weeks
Age >60yrs
Associated pain
Ramsey Hunt syndrome
Associated HTN, DM, or pregnancy

PHYSICAL THERAPY TREATMENT FOR FACIAL PARALYSIS :

 
In the first couple of days to a week after symptoms start,  physical therapist will evaluate your condition, including:
Review your medical history, and discuss any previous surgery or health conditions
Review when your current symptoms started and what makes them worse or better
Conduct a physical examination, focusing on identifying the patterns of weakness that are caused by Bell palsy

• Facial movements of the eyebrow
•  Eye closure
• Ability to use the cheek in smiling
• Ability to use the lips in a pucker
• Ability to suck the cheeks between the teeth
• Raising the upper lip
• Raising or lowering the lower lip

Your physical therapist will immediately:

• Educate you about how to protect your face and your eye
• Show you how to manage your daily life functions while you have facial paralysis
• Explain the expected path to recovery, so that you will know the signs and symptoms of recovery
• Evaluate your progress, and determine whether you need to be referred to a specialist if progress is not being made The first priority is to protect your eye. The inability to completely and quickly
• close your eye makes the eye vulnerable to injury from dryness and debris. Debris can scratch the cornea—the transparent front part of the eye that covers the iris, pupil, and front chamber of the eye—and could permanently harm your vision. physical therapist will immediately show you how to protect your eye, such as:
• Using self-made and commercial patches
• Setting a regular schedule for refreshing eye fluids
• Carefully closing the eye with your fingers
• If you have partial facial movement, your therapist will teach you a few general facial exercises to do at home. These exercises will help you learn to move the weak side of your face and help you use both sides of your face together. One of the exercises is a gentle blowing action through your lips.

DURING RECOVERY :

 
Physical therapist will help you regain the healthy pattern of movements that you need for facial expressions and function. Recovery can be challenging because:
Normally, the ability to make facial expressions and many facial movements is "automatic";—that is, you're born with this ability and never had to think about it before Unlike other muscles in your body, the facial muscles do not have sensors that tell your brain all of the necessary "details" about how to move Physical therapist will be your coach throughout this challenging time, guiding you through special exercises that are designed to help you relearn facial movements based on your particular movement problems. Your exercises may change over the course of recovery:
"Initiation" exercises. In the early stages, when you might have difficulty producing any facial movement at all, your therapist will teach you exercises that cause ("initiate") facial movement. Your therapist will show you how to position your face to make it easier to move (called "assisted range of motion") or how to "trigger" the facial muscles to do what you want them to do.
"Facilitation" exercises. Once you're able to initiate movement of the facial muscles, your therapist will design exercises to increase the activity of the muscles, strengthen the muscles, and improve your ability to use the muscles for longer periods of time ("facilitate" muscle activity).

Movement control exercises. therapist will design exercises to:

• Improve the coordination of your facial muscles
• Refine your facial movements for specific functions, such as speaking or closing your eye
• Refine movements for facial expressions, such as smiling
• Correct abnormal patterns of facial movement that can occur during recovery
• To work on coordinating your facial muscles, you'll need to have a sufficient level of activation of facial muscles first.

RELAXATION- During recovery, you might have facial spasms or twitches. Your physical therapist will design exercises to reduce this unwanted muscle activity. The therapist will teach you how to recognize when you are activating the facial muscle and when the muscle is at rest. By learning to contract the facial muscle forcefully and then stop, you will be able to relax your facial muscles at will and decrease twitches and spasms.
AFTER RECOVERY-
Some people might have greater difficulty moving their face after a period of improvement in facial movement, which can make them worry that the facial paralysis is returning. However, actual recurrence of facial paralysis of the Bell Palsy type is uncommon.
New difficulty in moving the face is more likely the result of increasing the strength of the facial muscles without improving the ability to coordinate and control the movement. To keep this from happening, physical therapist will show you what facial movements you should avoid during recovery. For instance, the following might lead to abnormal patterns of facial muscle use:
Trying to make the biggest facial movement or muscle contraction that you can, such as smiling as much as you can

• Chewing gum with great force
• Blowing up a balloon with all of your effort to work the facial muscles
  Therapist will coach you to use your face as naturally as possible, without trying to restrict facial expressions because they look "different."

NEUROMUSCULAR RETRAINING (NMR)
NMR involves the use of subtle but critically important exercises to teach and retrain the brain to coordinate the facial muscles more effectively and efficiently.

BENEFITS OF NMR
NMR re-teaches facial paralysis patients which muscles are required to move different parts of the face. This type of physical therapy enables a patient’s brain to reconnect facial muscles and corresponding facial movements. It teaches patients how to isolate facial muscles, use only the correct muscles to make their desired facial movements and suppress muscles that otherwise cause unwanted facial movements.
VIABLE CANDIDATE FOR NMR
Patients dealing with Bell’s palsy or other viral infections of the facial nerve often recover on their own completely and spontaneously within about three months of an initial diagnosis. For those who do not fully recover, it is possible that the facial nerve will heal improperly, which causes spontaneous, unwanted facial movements (or synkinesis). For example, when a Bell’s palsy patient tries to smile, his or her eye may twitch at the same time. In this scenario, the patient does not require additional strength in the facial muscles. Instead, he or she needs to improve facial muscle coordination to prevent facial muscles from flexing out of sequence – something that causes distorted facial movements.

MANUAL MASSAGE
Manual massage involves a series of different massage techniques. The goal of manual massage is to decrease facial muscle tightness and improve flexibility and range of motion. Initially, manual massage techniques may be performed by physical therapists, but the therapist ultimately will teach a patient the techniques so he or she can perform them regularly at home.

 

Other Related Post :
 

AEROBIC EXERCISE

AEROBIC
Aerobic exercise is sometimes known as "cardio" -- exercise that requires pumping of oxygenated blood by the heart to deliver oxygen to working muscles.
Aerobic exercise stimulates the heart rate and breathing rate to increase in a way that can be sustained for the exercise session. In contrast, anaerobic ("without oxygen") exercise is activity that causes you to be quickly out of breath, like sprinting or lifting a heavy weight.

Examples of aerobic exercises include cardio machines, spinning, running, swimming, walking, hiking, aerobics classes, dancing, cross country skiing, and kickboxing. There are many other types.
Aerobic exercises can become anaerobic exercises if performed at a level of intensity that is too high.
Aerobic exercise not only improves fitness; it also has known benefits for both physical and emotional health.
Aerobic exercise can help prevent or reduce the chance of developing some cancers, diabetes, depression, cardiovascular disease, and osteoporosis.
An aerobic exercise plan should be simple, practical, and realistic. Specific equipment (such as cardio machines) may be used but is not necessary for successful aerobic exercise.

TYPES OF AEROBICS
Actually, the best aerobic exercise depends on level of fitness. Aerobic exercise is a moderate intensity workout that extends over a certain period of time and uses oxygen in this process. Well, in these years, the practice of aerobics has become the most happening workout trend between the youth. Not only is performing aerobic exercise interesting, but also is very beneficial for health. There are diverse types of aerobics such as fitness, water aerobics, step aerobics, swimming, kickboxing, fitness walking, inline skating, bicycling etc.
Here we have the more generals:
LOW IMPACT AEROBICS

                                                            low impact aerobics
There exist people, who can't perform high intensity workout, because maybe they have some health problems or their poor health conditions. For such people, low impact aerobics is the precise workout choice. Low impact aerobic exercise comprehends rhythmic movements, with exercising of the large muscle groups.
WATER AEROBICS

                                                                      water aerobics
Water aerobic exercises are an agreeable way to exercise over the hot summers. Maybe the work out can seem like one splashing surrounding the pool waters, yet those who are seriously into water aerobic exercise claim it's an excellent method to burn out unwanted flab from the body and build inner strength. In effect, health experts declare that the water aerobic exercise is good for people ailing from arthritis and other problems many times.

STEP AEROBICS

This kind of exercise is a newer version and interesting technique of aerobics. Conventional aerobics are practiced on the floor: you discover a series of dance steps such as the Pony or the Jazz Square, which are often done in four, two steps taking you in one direction, two more taking you the other direction.

DANCE AEROBICS

 
                                                                 dance aerobic
Aerobic dance integrates exercise and dance movements into routines that are practiced with the music. aerobics with develop of the muscle and stretching exercises.
Your foot is on the ground all times. This kind of aerobic is slower and it is simpler to do than intermediate and advanced classes.

SPORT AEROBICS

 
                                                                  sports aerobic

Sport Aerobics is a hard and competitive sport that has a singular connection of aerobic choreography and gymnastics elements. This sport generate a chance for adolescents, and adult individuals to compete in a sport that demands less risk than gymnastics while keeping the artistic quality and fun of aerobics.

AEROBIC EXERCISE MOVES-
Aerobic exercise is good for each person. Aerobic fitness moves integrate rhythmic calisthenics or dance moves with stretching and strength training routines to provide a full-body exercise experience.
Here some moves you need to give your body a full aerobic workout:

WARM-UP MOVES
Warm-Up Moves Aerobic moves that change the heart from a resting heart rate to a warm-up rate start slowly and build in energy and intensity.Walking or marching in place is the most regular warm-up aerobic move, with your steps deepening into lunges at the end of the warm-up to add intensity, energy and increase the circulation of blood to the muscles. Other first phase moves comprehend stepping from side to side and moving the arms at waist level or higher.
Aerobic moves over the warm-up phase should also comprehend a gentle stretch of each of the major muscle groups, including the lower back.
The warm-up phase of an aerobic workout should be from 5 to 10 minutes. The objective during the warm-up phase is to elevate the body's core temperature, warm up the muscles and joints, and get ready the body for the training portion of the workout.

AEROBIC MOVES IN THE ZONE-
Aerobic Moves In The Zone The next phase of your workout carries your body toward your target heart rate. The intensity of the movement grows and the pace of the movement grows. Some aerobic moves are universally recognized to augment intensity; for example, stopping the body's momentum and moving the body in the contrary direction is a high intensity move. For this reason, is why aerobic routines comprehend a lot of back and forth movements and up and back movements in the middle part of the workout.
Lifting the weight of body is another high intensity aerobic move. Leaping, hopping, and powering through a move are all high intensity actions.
This part of the workout should be from 15 to 25 minutes, with intensity building at the beginning of the session, peaking mid-session, and subsiding toward the end of this phase of the aerobic workout.

COOL-DOWN AEROBIC MOVES
Cool-Down Aerobic Moves The last segment of an aerobic exercise workout is the cool-down and stretch period. The intense movements terminate, the pace of the workout decelerates, and the activity returns to the modest, gentler motions of the warm-up phase. You should not stop exercising abruptly without this cool-down phase. Maybe, you could sense dizziness and could collapse if you do. Instead, delay the pace of your exercise until your heart is beating fewer than 100 times per minute.
Terminate your aerobic moves workout by stretching all the muscles you exercised to help them return to their normal length, to increase your flexibility, and to keep your muscles flexible and toned.

THE BEGINING
It all starts with breathing. The average healthy adult inhales and exhales about 7 to 8 liters of air per minute. Once you fill your lungs, the oxygen in the air (air contains approximately 20% oxygen) is filtered through small branches of tubes (called bronchioles) until it reaches the alveoli. The alveoli are microscopic sacs where oxygen diffuses (enters) into the blood. From there, it's a beeline direct to the heart.

AEROBIC ROUTINE
Aerobic Routine There are several millions of Americans that train with some form of aerobics routine or the other and aerobics routines have become a sport that are pleasure to perform for losing weight and staying in shape. The most common aerobics routines are the low-impact routines and dance besides is a preponderant factor that has been inspired by ballet, salsa and even hip-hop. The aerobic routine serves to increasing cardiopulmonary efficiency besides strengthening the heart and lungs. Additionally, the aerobic routine
should also assist to increase blood circulation and lower cholesterol levels as well as reduce stress and anxiety. Being a somewhat hard exercise form, the aerobics routine maybe require profound preparation and wise election, which should ensure that proper equipment is used, to avoid being injured.
A sample schedule for the beginner’s fitness enthusiast:

DAY ONE:
You should take as easy twenty-minute walk at a beautiful bright place. Look a friendly place to walk, avoid the pollution. If you can't find one, maybe you can go to a park, beach, grassland or the countryside away from pollution. You require being able to keep up an interesting conversation. If you are in oxygen debt you won't burn calories as well so take it easy at first. Upon returning, use approximately ten or fifteen minutes stretching. You should practice it periodically; otherwise the extra calories can accumulate in thighs or butt. When you begin with some periodic activity, the brain stars to think this body is active and needs to increase the metabolism. Then the brain will get to a higher metabolic level. As you augment your exercise program you will have more byproducts known as free radicals. This is the argument for us to work with nutrition as well, because you need to increase the antioxidants to keep the body healthy from the free radicals.
DAY TWO:
Just stretch for ten to fifteen minutes. If you find a pool, maybe you can choose swimming for ten to fifteen minutes.
DAY THREE:
Walk fast for twenty-five minutes. Stretch for fifteen, or if you have it down, it could only take ten minutes to get a fantastic stretch.
DAY FOUR:
Swim and stretch for at least twenty minutes and ten respectively.
DAY FIVE:
You might miss one. Or walk maybe longer and easy or hard depending on how you feel.
DAY SIX:
Walk a good distance faster for thirty minutes. If you feel tight walking, stop after you break into a light sweat and stretch for a few minutes. Regarding the legs and gluteus muscles. Then continue, finishing up with a good ten minute stretch.
DAY SEVEN:
If you didn't miss one day, consider an easy walk, swim or stretch, may be do something with family or friends. If you got distressed at all during the week, then rest and just stretch or swim.
Keep this program until you may be able to walk thirty minutes without losing your breath at all. This can last two weeks for most people and up to four weeks for others. If it takes you longer, stay with twenty-five minutes for two months, and then move into the next level. If within two weeks your body serves you well, you can proceed with the next level.
Keep on the following day with an energetic walk for thirty minutes. Now we will begin to burn some fat. From now on, you workouts should last approximately forty-five minutes. As you each time get stronger, your hard days go by like your easy days, when you first started. Walking can escalate to five times per week within the first few months, depending on your body. At this level it's not as critical as it will be when we start the strengthening program using weights, running or strengthening exercises.

SIX TO EIGHT WEEK :
After six or eight weeks, begin your strength-training program. Once again, listen to your body. If you don't feel quite ready at six weeks, take eight. You can go in either of two directions with this addition to your program, with diverse levels of intensity depending on your body and your abilities.
If you are able and you are willing to run for your particular objectives, you may now commence to run. Begin with simple jogging for 20 minutes every day, and weight training every other day. Running at this time should be at least three days a week, the same for weight training. There is some evidence, nevertheless, that we could get by with two days of weight training and still do okay. Have one day of rest. The day you rest should be a very easy workout, stretching, swimming or family fun.

GETTING TO THE HEART OF IT
The heart has four chambers that fill with blood and pump blood (two atria and two ventricles) and some very active coronary arteries. Because of all this action, the heart needs a fresh supply of oxygen, and as you just learned, the lungs provide it. Once the heart uses what it needs, it pumps the blood, the oxygen, and other nutrients out through the large left ventricle and through the circulatory system to all the organs, muscles, and tissues that need it.

A WHOLE LOT OF PUMPING GOING ON
Heart beats approximately 60-80 times per minute at rest, 100,000 times a day, more than 30 million times per year, and about 2.5 billion times in a 70-year lifetime! Every beat of your heart sends a volume of blood , along with oxygen and many other life-sustaining nutrients, circulating through your body. The average healthy adult heart pumps about 5 liters of blood per minute.

OXYGEN CONSUMPTION AND MUSCLES
All that oxygen being pumped by the blood is important. In science, it's labeled VO2, or volume of oxygen consumed. It's the amount of oxygen the muscles extract, or consume from the blood, and it's expressed as ml/kg/minute (milliliters per kilogram of body weight). Muscles are like engines that run on fuel (just like an automobile that runs on fuel); only our muscles use fat and carbohydrates instead of gasoline. Oxygen is a key player because, once inside the muscle, it's used to burn fat and carbohydrate for fuel to keep our engines running. The more efficient our muscles are at consuming oxygen, the more fuel we can burn, the more fit we are, and the longer we can exercise.

AEROBICS AND FITNESS
The average sedentary adult will reach a level of oxygen consumption close to 35 ml/kg/minute during a maximal treadmill test (where you're asked to walk as hard as you can). Translated, that means the person is consuming 35 milliliters of oxygen for every kilogram of body weight per minute.
That'll get you through the day, but elite athletes can reach values as high as 90 ml/kg/minute! They may have good genes for one, but they also train hard. And when they do, their bodies adapt. The good news is that the bodies of mere mortals like the rest of us adapt to training too.
Heart gets stronger and pumps more blood with each beat (larger stroke volume). Elite athletes, can have stroke volumes more than twice as high as average individuals. But it's not just that. Conditioned hearts also have greater diameter and mass (the heart's a muscle too and gets bigger when you train it), and they pump efficiently enough to allow for greater filling time, which is a good thing because it means that more blood fills the chambers of the heart before they pump so that more blood gets pumped with each beat. Greater stroke volume means the heart doesn't have to pump as fast to meet the demands of exercise. Fewer beats and more stroke volume mean greater efficiency. Think about a pump emptying water out of a flooded basement. The pump works better and lasts longer if it can pump larger volumes of water with each cycle than if it has to pump faster and strain to get rid of the water. High stroke volume is why athletes' hearts don't pump as fast during exercise and why they have such low resting heart rates; sometimes as low as 40 beats per minute, whereas the average is 60-80 beats per minutes.
Downstream from the heart are your muscles, which get more efficient at consuming oxygen when you do regular aerobic exercise (remember, "consuming" oxygen means that the muscles are taking the oxygen out of the blood). This happens because of an increase in the activity and number of enzymes that transport oxygen out of the bloodstream and into the muscle. Imagine 100 oxygen molecules circulating past a muscle.
You're twice as fit if the muscle can consume all 100 molecules than if it can only consume 50. Another way of saying it is that you're twice as fit as someone if your VO2 max is 60ml/kg/min. and theirs is 30ml/kg/min. In terms of performance in this scenario, you'll have more endurance because your muscles won't run out of oxygen as quickly.
Mitochondria inside the muscle increase in number and activity. Mitochondria are the powerhouses of your cells. They do all the heavy-duty work to keep you moving. They use the oxygen to burn the fat and carbohydrate that makes you go. The good news is that they increase in number and activity, by as much as 50%, in just a matter of days to weeks in response to regular aerobic exercise in adults of all ages.

FAT AND CARBOHYDRATE BURNING
Fat and carbohydrate are the fuels our muscles burn. The difference between them is that fat is high-test; it contains 9 calories per gram whereas carbohydrate has only 4, and so you get more energy and can go farther on a gram of fat than on a gram of carbohydrate. You want to burn fat because it's such an efficient fuel, plus it's nice to lose some of your excess fat! The catch is that you need more oxygen to burn fat because it's denser than carbohydrate. The good news is that your body gets better at using oxygen and burning fat when you do regular aerobic exercise; like I described, your heart pumps more blood, your muscles consume more oxygen, and you have more mitochondria.

DIFFERENCE BETWEEN THE AEROBIC AND ANEROBIC EXERCIS
AEROBIC EXERCISE is an activity that stimulates your heart rate and breathing to increase but not so much that you can't sustain the activity for more than a few minutes. AEROBIC means "WITH OXYGEN ," and ANEROBIC means "WITHOUT OXYGEN." Anaerobic exercise is the type where you get out of breath in just a few moments, like when you lift weights for improving strength, when you sprint, or when you climb a long flight of stairs.

BENEFITS OF AEROBIC EXERCISE TRAINING-

STRENGTHEN THE HEART
Aerobic exercise training is excellent for strengthening hearts and lungs. During these exercises, the tissues demand more oxygen from the blood
The heart has to beat faster to cope up with this demand, which in longer duration makes it stronger and healthier. The fast movement of the blood and heart helps to unclog the arteries.
This means that it reduces LDL (bad cholesterol).

BURNS CALORIES
Longer duration cardio can burn lots of calories
It creates a calorie deficit which is required for reducing weight.
These excess calories are burned by utilizing the excess fat content in the body making Aerobic training very effective for fat burn.

REDUCE BLOOD PRESSURE
Improves glucose tolerance and reduces insulin resistance.
Decreases clinical symptoms of ANXIETY, TENSION , and DEPRESSION.
Enhances muscles’ ability to use oxygen and increase its blood supply.
Lowers resting heart rate.
Increased muscle endurance.
Aerobics can be used as a starting step. It is a good way to start weight loss for beginners and for people who have excess body fat. Aerobic exercise steps are less demanding on the body and can be easily understood and followed.

CANCER PREVENTION
Colon cancer. Research is clear that physically active men and women have about a 30%-40% reduction in the risk of developing colon cancer compared with inactive individuals. It appears that 30-60 minutes per day of moderate- to vigorous-intensity physical activity is needed to decrease the risk, and there is a dose-response relationship, which means that the risk declines the more active you are. Breast cancer. There is reasonably clear evidence that physically active women have a greater reduction in risk compared with inactive women. Like colon cancer, it appears that 75 to 150 minutes per day of moderate- to vigorous-intensity physical activity is needed to decrease the risk, and it is likely that there is a dose-response relationship as well. Prostate cancer. Research is inconsistent regarding whether physical activity plays any role in the prevention of this cancer. Lung cancer. There are relatively few studies on physical activity and lung cancer prevention. The available data suggest that physically active individuals have a lower risk of lung cancer; however, it is difficult to completely account for the risks of active and passive cigarette smoking as well as radon exposure. Other cancers. There is little information on the role of physical activity in preventing other cancers.

CANCER TREATMENT
There's some good news for people undergoing cancer treatment. In one study, aerobic exercise performed five days per week for 30-35 minutes for six weeks at 80% of maximal heart rate reduced fatigue in women being treated for cancer. In another study, 10 weeks of aerobic exercise at 60% of maximum heart rate for 30-40 minutes, four days per week, reduced depression and anxiety in female cancer patients. Aerobic exercise isn't a panacea when it comes to cancer, but evidence suggests that it certainly can help.

OSTEOPOROSIS
Osteoporosis is a disease characterized by low bone density, which can lead to an increased risk of fracture. The good news is that exercise may increase bone density or at least slow the rate of decrease in both men and women. It may not work for everyone, and the precise amount and type of exercise necessary to accrue benefits is unknown, but there is evidence that it can help. In children there is good news, too. It seems that active children have greater bone density than sedentary children and that this may help prevent fractures later in life.

DEPRESSION
Most of us who exercise regularly understand that exercise can elevate our mood. There have been a number of studies investigating the effects of exercise on depression. In one of the most recent studies, it was shown that three to five days per week for 12 weeks of biking or treadmill for approximately 30 minutes per workout reduced scores on a depression questionnaire by 47%. It's not a substitute for therapy in a depression that causes someone to be unable to function (in which case medication and/or psychotherapy may be necessary), but for milder forms of depression, the evidence is persuasive that it can help.

DIABETES
No study has been more conclusive about the role of lifestyle changes (diet and exercise) in preventing diabetes than the Diabetes Prevention Program. It was a study of more than 3,000 individuals at high risk for diabetes who lost 12-15 pounds and walked 150 minutes per week (five 30- minute walks per day) for three years. They reduced their risk of diabetes by 58%. That's significant considering there are 1 million new cases of diabetes diagnosed each year. Aerobic exercise can also improve insulin resistance. Insulin resistance is a condition in which the body doesn't use insulin properly, and this condition can occur in individuals who do and do not have diabetes. Insulin is a hormone that helps the cells in the body convert glucose (sugar) to energy. Many studies have shown the positive effects of exercise on insulin resistance. In one, 28 obese postmenopausal women with type 2 diabetes did aerobic exercise for 16 weeks, three times per week, for 45-60 minutes, and their insulin sensitivity improved by 20%.

CARDIOVASCULAR DISEASE
The list of studies that show that aerobic exercise prevents or reduces the occurrence of cardiovascular disease is so long that it would take this entire article and probably five others just like it to review all of the research. One of the most important is one of the earliest. In a study of more than 13,000 men and women, it was shown that the least fit individuals had much higher rates of cardiovascular disease than fit individuals  in some cases, the risk was twice as high. Aerobic exercise works in many ways to prevent heart disease; two of the most important are by reducing blood pressure and allowing blood vessels to be more compliant (more compliant means that they become less stiff and it's less likely for fat to accumulate and clog up the vessels). Results like these have been proven over and over again.

OBESITY AND WEIGHT COTROL
Aerobic exercise is believed by many scientists to be the single best predictor of weight maintenance. You can lose weight without exercise by reducing your caloric intake enough so that you burn more calories than you consume, but it takes a regular dose of exercise to keep your weight
off. How much is not clear, but somewhere between 30 and 40 minutes of vigorous exercise several times per week, to 45 to 75 minutes of moderate intensity exercise five or more days per week is probably about right. Your mileage will vary, and so once you get to the weight that you want to be at you'll need to experiment with different amounts of exercise until you find the one that works for you. The American College of Sports Medicine recommends that overweight and obese individuals progressively increase to a minimum of 150 minutes of moderate intensity physical activity per week, but for long-term weight loss, overweight and obese adults should eventually progress to 200 to 300 minutes per week of moderate-intensity physical activity. These are general guidelines, and so again, you need to experiment to see what works for you. Aerobic exercise definitely burns lots of calories. Below is a table of minutes of continuous activity necessary to expend 300 calories based on your body weight.

COGNITIVE FUNCTION-
Scientists have recently become interested in the effects of aerobic exercise on cognitive function. It has been shown in rats that use of a running wheel every day stimulates new brain cells to grow in as few as 12 days. Brain cells in humans can't be studied directly, but what has been shown is that rates of dementia and Alzheimer's disease are lower in older individuals who exercise three or more times per week compared with older adults who exercise fewer than three times per week. In some cases, the risk is 62% lower. Evidence is also accumulating that active individuals perform better on cognitive function tests such as tests of memory and spatial relations than sedentary individuals.

AEROBIC EXERCISE PROGRAME-
Keep it simple, keep it practical, keep it convenient, keep it realistic, keep it specific, and don't try to make up for years of inactivity all at once. Select any activity and amount of time where the probability of sticking with it is high. You may not love walking, but if you can do it right outside your door, and it requires no special equipment, and you already know how to do it (you've been walking your entire life!), then walking might be your best bet for getting started because it's so convenient.

HEART RATE RESERVE
Heart rate rises during aerobic exercise. It can rise from 70 beats per minutes (bpm) at rest to as high as 170 bpm or even higher during exercise, depending on the intensity of the exercise, your fitness level, your age, and other factors. Whether you're training is aerobic or anaerobic is determined by the intensity of your workout, and monitoring the intensity is the key to know which one you're doing.
For many individuals, simply monitoring how the body feels while exercising is enough to determine the proper aerobic intensity.  "warm and slightly out of breath" as the cue for aerobic activity; that is if you feel warm and slightly out of breath while you're exercising, then that's good enough.
Heart-rate reserve method for calculating a target heart rate. Here's the formula and an example of the method for someone 27 years of age, assuming a resting heart rate of 70 bpm, and a training range of 70%. If you plug in other values, you can get other ranges.
220-age = Max HR.
Subtract resting heart rate from Max HR = Heart Rate Reserve (HRR).
Multiply HRR times percent you want to train at.
Add back resting heart rate.
Assuming a resting heart rate of 70 bpm, 27 years old, and 70% training range:
220 - 27 = 193
193 - 70 = 123
123 x .70% = 86
86 + 70 = 156
Please note: There's been some recent research to suggest a new way of estimating maximum heart rate. The formula is the following:
Multiply 0.7 times your age
.
Subtract that number from 208.
An example if you're 26 years old is: 0.7 x 26 = 18, then 208 - 18 = 190. You'd then take 190 and plug it in as usual to the formula above. This new
formula makes a slightly bigger difference as you get older.

TRAINING METHOD OF AEROBIC EXERCISE
The main methods of aerobics exercise are:

1.LONG DURATION CARDIO
2.INTERVAL TRAINING


1. LONG DURATION CARDIO

Long Duration Cardio is the moves which you perform for an extended period at a steady pace.

• For example, a walk for one hour at a speed of 4 mph or a 30 minute run at 6 mph.
• This burns a lot of calories
• The longer the duration, the more calories get burnt.
• It gives the daily calorie deficit which is sought after for losing weight.
• This is great for heavier people.
• It can be used as a starting point for workout programs as it will help in increasing endurance and will prep the body for further exercising.

EFFECTS
The effects of Long Duration Cardio are more immediate.

• While doing these exercises, you have the “burn,” which means you burn calories even as you are working out.
• They don’t have any after effects.
• There is no hike in the metabolic process after you stop performing this cardio.

2. INTERVAL TRAINING
Interval Training workout comprises of alternate high and low-intensity intervals.

• Like any other cardio workouts, these increase the calorie burn and build endurance.
• These give better and faster results in less time compared to Long Duration Cardio.
• These can be the second step for the weight loss program and is better for people who have better endurance than the beginners.
•  
• EFFECTS
• An ideal Interval Training session will include alternate short, high-intensity intervals and longer, lower-intensity recovery periods.
• In high-intensity intervals, maximum effort (as hard as you can) is required (this is a form of anaerobic exercise).
• For beginners, it can be a little less intense, which can be in a little more aerobic form.
  You’ll know that you have reached your high-intensity period when you’ll have muscle burn (the burning sensation the muscle utilized).
• Adding few of these intervals can give better results.
• As these are very hard and taxing they are needed to be kept short and should be accompanied by longer lower intensity intervals (which are even called recovery intervals, as you recover from the burn of the muscle).
• In a complete workout, there are five to ten cycles of high and low intensity. According to your fitness, you can vary the lengths of each interval, the number of cycles, and intensity of the cycle.

HEART RATE TRAINING
Let's use jogging on a treadmill as the aerobic activity in this example. For example, if your heart rate is at 70% of your predicted maximum when you jog at 6 mph, then start at that speed and either increase the speed or elevation so that your heart rate increases to 85% or even 90% for one minute, then back to your usual jogging speed for three minutes to elicit a heart rate of 70%. Start with a 1:3 work:active-rest ratio. That's a goodstarting point, and as you increase the work intervals and decrease the active-rest ratios like in the examples above, you'll notice that your  conditioning improves so that your heart rate will be lower at the higher speeds.
It's a good idea to plan your intervals in advance. Write them down so that you don't have to think about it while you're working out. intervals no more than one to two times per week because they are tough workouts and you will need some time to recover. It's okay to do aerobic activity on days in between your intervals, but give your body a chance to recover from the intervals before doing them again.

INCEASING DURATION AND INTENSITY
The general rule for increasing aerobic activity is 10% per week. Interestingly, there's no evidence to suggest that a 10% increase is the safest and most effective amount of time to increase, but that's the rule of thumb and it seems to work pretty well. So, if you're walking for 20 minutes then the next increase ought to be two minutes for the following week. The bottom line though is to listen to your body. If you find that increasing by 10% is very easy, then go ahead and try a little more. But if you find that you are tired for hours after your workout, or chronically sore or achy from your workouts, then you know you need to cut back to 10% increases. Learn how to listen to your body and everything should be OK.

EQUIPMENTS USED IN AEROBIC
Rowers, treadmills, bikes, and cross-country skiers are all effective if you use them. There is some suggestion that some individuals are more inclined to exercise at home with equipment than at the gym or a class. The activity you choose is a personal choice and it varies for everyone, and so you need to experiment until you find what works best for you. Some individuals prefer to go to the gym while others are perfectly content to work out at home on their own equipment in front of their TV. TV can make the time pass quickly, and so can your favorite movie, music, scholarly courses taught by professors, or books on tape (see resources for online vendors). Finding something that will distract you might just make that 30-minute workout bearable, and believe it or not you might even look forward to it! After all, it could be the only 30 minutes in your day that you have all to yourself.

AEROBIC CLASSES-
Classes are generally rated as beginner, intermediate, and advanced. Choose the level that fits your condition. It's no fun taking an advanced class if you're a beginner. It will be hard and frustrating and you won't enjoy the experience. Watch the class or speak with the instructor to help you decide what's right for you. Sometimes it comes down to the class time that fits your schedule, but just be sure to not get in too far over your head.
Low-impact classes mean that one foot always stays on the ground. They are less intense than high-impact and may be more suitable if you are a beginner. Some classes are now called, "high-low" or "mixed-impact" which means they combine low and high-impact moves. High-impact means both feet leave the ground, so there will be jumping and balance moves. Stick with lower-impact and more gentle and rhythmic.