Rajiv Gandhi University of Health Sciences, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Registration No. / :
Name of the Candidate / : MS. JOMY MERLY THOMAS
Address / : SDM College of Physiotherapy,
Sattur, Dharwad.
Name of the Institution / : SDM College of Physiotherapy, Dharwad
Course of Study and Subject / : MPT( Physiotherapy in Adult Neurology
and Psychosomatic Disorders.)
Date of Admission to Course / : 02/06/2008
Title of the Topic / : TO COMPARE THE EFFECTIVENESS OF ELECTRICAL STIMULATION AND FACIAL EXPRESSION EXERCISES VERSUS ELECTRICAL STIMULATION AND FACIAL NEUROMUSCULAR RE-EDUCATION ON FACIAL SYMMETRY IN BELL’S PALSY.
Brief resume of the intended work / : Attached
Signature of the Student / :
Guide Name / :Mr. RAVI SAVADATTI
Remarks of the Guide / :
Signature of the Guide / :
Co-Guide Name / :
Signature of the Co-Guide / :
HOD Name / : Ms. KIRAN SIRIGERI
Signature of the HOD / :
Principal Name / :
Principal Mobile No. / : 09886089451
Principal E-mail ID / :
Remarks of the Principal
/ :
Principal Signature / :
a) / BRIEF RESUME OF THE STUDY
Introduction:-
Bell’s palsy is, by definition, an acute lower motor neuron facial palsy of unknown cause. It is generally accepted that there is inflammation and edema of the nerve in the facial canal. 1
Bell’s palsy is named after Sir Charles Bell, who has long been considered to be the first to describe idiopathic facial paralysis in the early 19th century.2
Incidence of Bell’s palsy oscillates between 11 and 40 cases per 100,000 inhabitants per year, with 1 in 60 being affected in their lifetime.3
The etiology of Bell’s palsy is largely unknown, although it may be congenital, iatrogenic, or result from neoplasm, infection, neurovascular insult, trauma or toxic exposure.4
The entire course of Bell’s palsy may be painless, but frequently patients complain of pain behind the ipsilateral ear; in the mastoid region, for a day or two before the onset of weakness, and this may continue for a week or more. Paralysis develops rapidly and may reach maximum severity within a few hours. Continuing progression for 24-48 hours is not uncommon and rarely may be over as long as 5 days.1
The degree of weakness of the affected muscles may range in severity from mild to complete. In elderly, presumably due to greater laxity of supporting tissues, the resultant deformity is more evident than in younger patients. The eyebrow droops and cannot be elevated, and the brow looses its furrow and becomes smooth. The lower eyelid everts causing impaired drainage of the tears, which overflow onto the cheek. The eye cannot close voluntarily or on blinking but there will be some lowering of the upper eyelid due to reflex inhibition of levator palpebrae superioris. Upward rolling of the eyeballs on attempting to close eyes (Bell’s Phenomenon) can be seen. The nasolabial fold becomes shallower, the angle of the mouth droops and cannot be retracted, the cheek billows on respiration, and food tends to accumulate between the cheek and teeth. There is mild dysarthria. If the nerve is involved proximal to the point where it is joined by the chorda tympani, or higher still, affecting the nerve to stapedius, then the patient may complain of impaired taste sensation or hyperacusis.1
Treatment often consists of administration of prednisolone during the initial 10 days or acyclovir for 7 days in those cases who do not respond to steroid therapy.5 In some cases, surgical decompressive procedures at the facial nerve exit zone (stylomastoid foramen) may be considered. Further to these medical options, physiotherapy has been reported to improve the impairments associated with Bell’s Palsy. 4
Various scales have been developed for grading facial function. Gross clinical five- to six- point scales with an overall assessment of facial motor function have been proposed by House- Brackmann, Botman and Jongkees, May et al., and Peiterson. Regional unweighted and weighted systems, evaluating different areas of facial function, have been devised by Ross et al., Janssen, Yanagihara, Adour and Swanson and Smith et al. In addition to these main systems, there are specific and/or objective scales according to the Stennert, Burres-Fisch and Nottingham systems.
The Sunnybrook facial grading scale proposed by Ross et al is a regional weighted system based on evaluation of resting symmetry, degree of voluntary excursion, and incorporation of secondary defects (synkinesis) to form a maximum composite score of 100.6
Physiotherapy has been widely practised for rehabilitation of patients with Bell’s palsy. Facial exercises, massage, electrical stimulation and orthotic devices or taping to lift drooping flaccid faces are the treatments of choice.7
At present electrical stimulation of paralyzed muscles is widely used, at least until voluntary movement reappears. Recovery is usually complete within one to three months.8 Denervated muscle is stimulated in order to maintain it in as healthy a state as possible while awaiting reinnervation. Denervated muscle, which cannot be exercised either voluntarily or reflexly, atrophies and weakens. However, since denervated muscle can be made to contract by using appropriate electrical currents, perhaps such artificial activation can substitute for normal exercise and can prevent the multitude of negative changes associated with denervation. Furthermore, if stimulation is indeed capable of maintaining denervated muscle in a healthier state than it would otherwise be, functional use might return faster when reinnervation finally does occur.9
Facial expression exercises have also been practiced conventionally in the treatment of Bell’s palsy. Active facial exercises are usually started as soon there is some return of voluntary power.14 The most common facial expression exercises include brow raise, eye closure, snarl, smile, pucker and pout.
Facial neuromuscular re-education is a conservative approach to facial rehabilitation. It offers outpatient rehabilitation services designed to regain symmetrical movements and to reduce or eliminate associated speech and swallowing problems. Facial neuromuscular re-education consists of evaluation of facial impairments and functional limitations, guided training sessions of correct movement patterns and instruction in a specific movement exercise programme.10
The pattern of changes in facial movement with neuromuscular re-education for facial rehabilitation illustrates the plasticity of the facial neuromotor system after insults. The brain learns to assign new roles to neurons, reducing abnormal patterns of movement and restoring appropriate patterns of facial muscle activity for intended facial actions.11
Need for the study:
Recent studies have shown that facial neuromuscular re-education could be used in the treatment of Bell’s palsy 12, 13 but literature which proves the efficacy of neuromuscular re-education with electrical stimulation over facial expression exercises with electrical stimulation is lacking.
Hence to compare the effects of facial neuromuscular re-education and electrical stimulation with facial expression exercises and electrical stimulation.
RESEARCH HYPOTHESIS:
Hypothesis H1: The group receiving electrical stimulation and facial neuromuscular re-education will have more improvement in facial symmetry as compared to the group receiving electrical stimulation and facial expression exercises.
Null hypothesis H0: The group receiving electrical stimulation and facial neuromuscular re-education will not have more improvements in facial symmetry as compared to the group receiving electrical stimulation and facial expression exercises.
REVIEW OF LITERATURE:
Bell’s palsy is one of the most common neurological disorders. It consists of an acute lower motor neuron facial paralysis, often preceded by a history of aching pain in and around the ear in the 24 hours before the onset, which may be severe.14
Bell’s palsy is named after Sir Charles Bell, who has long been considered to be the first to describe idiopathic facial paralysis in the early 19th century. However, it was described that Nicolaus Anton Friedreich and James Douglas preceded him in the 18th century. Recently, an even earlier account of Bells palsy was found, as observed by Cornelius Stalpart van der Wiel from the Hague, Netherlands in 1683. 2
Reid is generally credited for first suggesting that electrical stimulation maybe beneficial for denervated muscles.9
A comparative study between non-invasive electrode pulse electric stimulation and routine medications like prednisone, diabazol, vitamin B complex and qianzheng powder once each day, 10 days constituting one course for two courses on 276 subjects with Bell’s palsy suggested that non-invasive electrode pulse electric stimulation at facial points has obvious therapeutic effect on Bell’s palsy.15
In a study done on fifty nine patients diagnosed with Bell’s palsy the author compared one group receiving conventional therapeutic measures and the other group receiving facial neuromuscular re-education that were tailored for each group in three sessions per day for six days for a period of two weeks suggesting that individualized facial neuromuscular re-education is more effective in improving facial symmetry in patients with Bell’s palsy than conventional therapeutic measures.7
An emerging rehabilitation science of neuromuscular re-education and evidence for the efficacy of facial neuromuscular re-education which is a process of facilitating the return of intended facial movement patterns and eliminating unwanted patterns which may provide patients with disorders of facial paralysis or facial movement control, opportunity for the recovery of facial movement and function.16
A case report states that facial neuromuscular re- education techniques are different from the traditional interventions for facial paralysis. In this approach, the exercise program changes over time as the patient’s impairments change with recovery. The exercise program emphasizes accuracy of facial movement patterns and isolated muscle control and excludes exercises that promote mass contractions of muscles related to more than one facial expression. 12
An article by Jacqueline Diels and Diana Combs describes the basis for and application of neuromuscular retraining as a natural complement to surgical treatment for restoring facial movements. 17
A study on 66 patients demonstrated a pattern of reductions in synkinesis and increase in intended facial movement after neuromuscular re-education in physical therapy for individuals with the neuromotor disorder of synkinesis. The pattern of changes after neuromuscular re-education indicates an interaction between synkinesis and the intended movements of face during recovery of facial function after insults11
OBJECTIVES OF THE STUDY:
To compare the effectiveness electrical stimulation and facial expression exercises versus electrical stimulation and facial neuromuscular re education on facial symmetry in Bell’s Palsy.
b ) / PROCEDURE, MATERIALS AND METHODS:
SOURCE OF DATA COLLECTION:
Department of Physiotherapy,
S. D. M. College of Medical Science and Hospital, Dharwad.
METHOD OF DATA COLLECTION:
Material:
Assessment Data collection sheet.
Graph paper.
Muscle stimulator. Electrostim DT, Electrocare Systems and Services Pvt. Ltd. Serial no. 538
Electrode set (Pen and Plate Electrode) with accessories.
Mirror.
Inclusion Criteria:
1) Age group of 15-60 years of both genders.
2) Patients who are referred and diagnosed as unilateral Bell’s palsy by ENT
Department, Neurology Department and Medicine Department, SDM College Of Medical
Sciences and Hospital.
3) Patients with voluntary movement score of more than 5 in the Sunnybrook Facial Grading
System.
Exclusion Criteria:
1) Patients with supranuclear lesions
2) Patients with recurrence of facial paralysis.
3) Sensory loss over face.
4) Patients contraindicated for electrical stimulation.
Study Design: Experimental Study.
Study duration: 1 year
Sample: Convenient sample of 30 patients diagnosed with Bell’s palsy who were referred by a clinician and who were willing to participate in the study will be chosen. Sample size will be divided in two equal groups and allocation will be done according to the envelope method.
Group 1: Will receive electrical stimulation and facial expression exercises.
Group 2: Will receive electrical stimulation and facial neuromuscular re-education.
PROCEDURE: :
All the subjects with Bell’s palsy, who will report to Physiotherapy Department of S.D.M. Medical Hospital Dharwad, will be screened as per the inclusion and exclusion criteria. They will be requested to participate in the study.
Subjects willing to participate in the study will be briefed about the study and the intervention. After briefing their written consent will be taken. The assessment will be performed and the initial facial symmetry will be measured using the Sunny Brook Facial Grading Scale. The subjects will be then allocated to two groups.
Group 1: Patients in group 1 will be treated with electrical stimulation and facial expression exercises. Treatment will be started first with electrical stimulation followed by facial expression exercises. The patients will be made to lie supine in a comfortable position. The skin resistance will be reduced. The inactive electrode will be placed over the cervical region. The motor points of the face will be found. The muscles stimulated will be Frontalis, Corrugator, Orbicularis oculi, Dilator naris and septi, Levators of upper lip, Orbicularis oris, Buccinator, Risorius, Depressor anguli oris, Depressor labii inferioris and Mentalis. The Strength- Duration curve will be plotted and Rheobase and Chronaxie will be calculated. According to the obtained Chronaxie the duration will be set. Galvanic current will be used to stimulate the facial muscles and faradic current will be used for each facial nerve trunks. Ninety contractions will be given to each muscle in three sessions and ten contractions will be given to each facial nerve trunk. The intensity will be increased until minimal visible contractions of the muscle are obtained. Electrical stimulation will be given to patients once daily for six days a week for a period of two weeks.7
The patients will also be taught facial expression exercises, which include eye closure, eyebrow raise, frown, smile, snarl, pucker and pout. The patients will also be advised to do exercises such as balloon blowing, chewing gum on the affected side, using a straw and pronouncing vowels to strengthen the cheek muscles. Subjects will be advised to do 5 repetitions of the facial exercises three times a day.
Group 2: Patients in group 2 will also be treated with electrical stimulation similar to that of group 1. Treatment will be started with electrical stimulation followed by facial neuromuscular re-education.
Patients in group 2 will be treated with facial neuromuscular re-education techniques that will be tailored for each patient. Patients will be considered in the Initiation, Facilitation, Movement Control or Relaxation category according to presentation during the initial assessment. Treatment specific for patients in the Initiation category includes active assisted range of motion exercises and small range movement practice to avoid overpowering by the muscle function of the uninvolved side of the face. The patients in the Facilitation category will be started with active and resistive exercises to increase facial movement excursion. Education includes emphasizing the importance of accurate exercise practice over quantity and awareness of signs of some typical abnormal movement patterns (synkinesis) that may develop with increasing movement. The asymmetry characteristic of patients in the Movement category is not ‘droop’ but tightening or retraction of the face. With a short term treatment goal of producing desired facial movements or expression patterns without the accompanying synkinetic movement, small movement therapy is recommended. As the patient learns appropriate patterns movement control, the patients may be reclassified into the facilitation category for continued treatment and recovery. Stretching exercises are also indicated to lengthen facial muscle tissues shortened secondary to abnormal patterns of movement and even facial muscle guarding. Characteristic of the Relaxation category is a combination of marked asymmetry of facial posture at rest (as for movement control category) with spontaneous twitching and facial muscle spasms. The primary treatment goal for problems of facial twitches and spasms is relaxation exercises, such as modifications of the standard relaxation exercises originally described by Jacobson and small rhythmic, alternating movements to relax the muscles. Patients will be advised to do only 5 repetitions of facial exercises three times a day in the initial stages to avoid fatigue. The exercises will be progressed from the initiation to the relaxation category as the patients condition improves. The patient will be advised to concentrate on the quality of the exercise and not on the quantity. In case patient develops synkinesis during the study period electrical stimulation will be discontinued and patients will be considered in the movement control category but will not be considered for statistical analysis.