BANGALORE, KARNATAKA.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION1. / Name of the candidate
and Address / MANSI AJWANI
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, BALLALBAGH ,
MANGALORE - 575003
2. /
Name of the Institute
/ SHREE DEVI COLLEGE OF PHYSIOTHERAPY,BALLALBAGH, MANGALORE – 5750033. /
Course of study and
Subject / MASTER OF PHYSIOTHERAPY(MPT)2 YEARS DEGREE COURSE
(NEUROLOGICAL & PSYCHOSOMATIC DISORDERS)
4. /
Date of Admission
To course / 25TH SEPTEMBER 20105. /
Title of the Topic
/ ELECTRICAL STIMULATION WITH PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION AND ELECTRICAL STIMULATION WITH CONVENTIONAL PHYSIOTHERAPY ON LOWER MOTOR NEURON FACIAL PALSY- A RANDOMISED CONTROLLED TRIAL.Brief resume of the intended work:-
6.1 Need for the study:Bell’s palsy and idiopathic facial palsy are considered to be synonymous and specify an acute, mono synaptic, unilateral peripheral paresis of unknown etiology.1
Facial paralysis is a relatively common disorder with numerous etiologies striking tens of thousands of people of all ages annually. Complete recovery occurs in 71% of bell’s palsy cases without medical intervention, 13% showed only persistent residual palsy and the remaining 16% resulted in affair to poor recovery. 2
It is associated with several distinct disease entities like herpes simplex virus infection, neurobborreliosis, side effects of influenza vaccine.3
Facial neuro-muscular dysfunction is a complex problem that affects people in different ways. Patients may have strength deficits, control problems or relaxation difficulties. Synkinesis is defined as an involuntary or abnormal movement that is associated with a desired movement or motion.4
Those with facial muscle paralysis may have difficulty with eating, drinking and speaking, and difficulty in making facial expressions.5
Facial Synkinesis is a common sequel to Idiopathic Facial Nerve Paralysis, also called Bell’s palsy or Facial Palsy.6
Bell’s palsy, which occurs due to the compression of the seventh cranial nerve, results in a hemifacial paralysis due to non-functionality of the nerve. As the nerve attempts to recover, nerve miswiring results. In patients with severe facial nerve paralysis, facial synkinesis will inevitably develop.7
A common treatment option for facial palsy is to use electrical stimulation. Unfortunately, this has been shown to be disruptive to normal re-innervation and can promote the development of synkinesis.8
The most common symptoms of facial synkinesis included9
· Eye closure with volitional contraction of mouth muscles
· Midfacial movements with volitional eye closure
· Neck tightness (Platysmal contraction) with volitional smiling
· Hyperlacrimation(also called Crocodile Tears)
· A case where eating provokes excessive lacrimation. This has been attributed to neural interaction between the salivary glands and the lacrimal glands .10
Patients with Bell’s palsy were benefited from high voltage electrical stimulation with complete resolution of symtoms.11
Chronic electrical stimulation is possible clinical tool for the treatment of denervated muscle mass.12,13
There were several investigations used to treat facial muscle weakness like Electrical Stimulation, Facial expression exercises, Mirror therapy, Acupuncture, PNF etc.
Apart from electrical stimulation the conventional facial expression exercises, massage, tapping, and PNF technique were also used to improve the facial muscle function.
There are a few research studies on electrical stimulation along with conventional exercises on improving unilateral muscle weakness of face. But very limited researches on effect of PNF in idiopathic Bell’s palsy are available.
So in this study the effect of electrical stimulation along with PNF will be compared with effect of electrical stimulation with conventional physiotherapy on Bell’s palsy.
6.2 Review of Literature:
1. 1. Beurskens CH, Heymans PG conducted a study on 155 patients to describe changes and stabilities of long-term sequel of facial paresis in outpatients receiving mime therapy, a form of physiotherapy. Main outcome measures were (1) impairments: facial symmetry in rest and during movements and synkineses; (2) disabilities: eating, drinking, and speaking; and (3) quality of life. The study concluded that during a period of approximately 3 months, significant changes in many aspects of facial functioning were observed, the relative position of patients remaining stable over time.14
2. 2.Sabag-Ruiz E, Osuna-Bernal J, Brito-Zurita OR et all conducted an analytical cross sectional study on effect of transcutaneous electrical nervous stimulation in the prognosis of Bell's palsy and selected 22 patients with peripheral facial palsy. The study concluded that the test of nervous excitability for PFP with TENS is safe and simple to use in primary care and urgencies services.15
3. 3. Guo QH, Yan JZ, Yan WS, Xiao MZ conducted a study on effect of non-invasive electrode pulse electric stimulation for treatment of Bell's palsy in which 276 were randomly divided into two equal groups, a treatment group and a control group. The treatment group were treated with non-invasive electrode pulse electric stimulation and the control group with routine medicine (prednisone, dibazol, vitamin B complex and Qianzheng Powder), once each day, 10 days constituting one course. The found that cured rate and the effective rate were 83.3% and 99.3% in the treatment group, and 48.5% and 88.4% in the control group respectively with a significant difference between the two groups (P < 0.05). The conclusion was that Non-invasive electrode pulse electric stimulation at facial points has obvious therapeutic effect on Bell’s palsy.16
4. 4. Hyvärinen A, Tarkka IM, Mervaala E et al tested the effect of Cutaneous electrical stimulation treatment in unresolved facial nerve paralysis and a pilot case series of 10 consecutive patients with chronic facial nerve participated and received below sensory threshold transcutaneous electrical stimulation for 6 months for their facial nerve paralysis. Paralysis either of idiopathic origin or because of herpes zoster oticus. They concluded that transcutaneous electrical stimulation treatment may have a positive effect on unresolved facial nerve paralysis.17
5. 5. Targan RS, Alon G, Kay SL conducted a systematic review to present effect of long-term electrical stimulation on motor recovery and improvement of clinical residuals in patients with unresolved facial nerve palsy. The study group included 12 patients (mean age 50.4 +/- 12. 3 years) with idiopathic Bell's palsy and 5 patients (mean age 45.6 +/- 10.7 years) whose facial nerves were surgically sacrificed. Motor nerve conduction latencies, House-Brackmann facial recovery scores, and a 12-item clinical assessment of residuals were obtained 3 months before the onset of treatment, at the beginning of treatment, and after 6 months of stimulation. Patients were treated at home for periods of up to 6 hours daily for 6 months with a battery-powered stimulator. Stimulation intensity was kept at a submotor level throughout the study. Groups and time factors were used in the analyses of the 3 outcome measures. The result of the study was that long-term electrical stimulation may facilitate partial reinnervation in patients with chronic facial paresis/paralysis. Additionally, residual clinical impairments are likely to improve even if motor recovery is not evident.18
6. 6. Manikandan N evaluated the effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy in which 59 patients were randomly divided into two groups control (n = 30) and experimental (n = 29). Control group patients received conventional therapeutic measures while the facial neuromuscular re-education group patients received techniques that were tailored to each patient in three sessions per day for six days per week for a period of two weeks. The conclusion was individualized facial neuromuscular re-education is more effective in improving facial symmetry in patients with Bell's palsy than conventional therapeutic measures.19
7. 7. Brach-JS; VanSwearingen-JM; Lenert-J; Johnson-PC described the outcome of facial neuromuscular retraining for brow to oral and ocular to oral synkinesis in individuals with facial nerve disorders. Fourteen patients with unilateral facial nerve disorders and oral synkinesis were enrolled in physical therapy for surface electromyography biofeedback-assisted specific strategies for facial muscle re-education and a home exercise program of specific facial movements. Twelve of 13 patients with brow to oral synkinesis and 12 of 14 patients with ocular to oral synkinesis reduced their synkinesis with retraining. The conclusion was that the patients with brow to oral and to oral synkineses associated with partial recovery from facial paralysis were reduced with facial neuromuscular retraining for individuals with facial nerve disorders.20
8. 8. Namura M, Motoyoshi M, Namura Y, Shimizu N evaluated the effect of PNF training on the facial profile in 40 adults with an average age of 29.6 years. A series of PNF exercises was performed three times per day for 1 month. They concluded that the training appeared to be effective for sharpening the mouth and submandibular region.21
9. 9. Alakram P, Puckree T conducted a study on 16 patients to determine Effects of electrical stimulation on House-Brackmann scores in early Bell's palsy. Adult patients with clinical diagnosis of Bell's palsy were systematically (every second patient) allocated to the control and experimental groups. Each group (n = 8) was pretested and post tested using the House-Brackmann index. The study concluded that Electrical stimulation as used in this study during the acute phase of Bell's palsy is safe but may not have added value over spontaneous recovery and multimodal physiotherapy.22
10. Douglas K. Henstrom, MD; Christopher J. Skilbeck, MBBS; et al studied agreement between the original and the updated House-BracMann scales. Fifty consecutive new facial paralysis patients underwent standardized facial videography while performing facial movements. Conclusion was that there was substantial grading correlation between the original and the newly modified House-BracMann scales.23
6.3 Objective of the study
The objective of this study is to compare the effects
of electrical stimulation with Proprioceptive neuromuscular facilitation versus electrical stimulation with conventional physiotherapy on persons with Bell’s palsy.
6.4 Hypothesis:
Experimental hypothesis:
Electrical stimulation with Proprioceptive neuromuscular facilitation is more effective than electrical stimulation with conventional physiotherapy in improving facial muscle strength in Bell’s palsy.
Null hypothesis:
Electrical stimulation with Proprioceptive neuromuscular facilitation may not be more effective than electrical stimulation with conventional physiotherapy in improving facial muscle strength Bell’s palsy.
Materials and Method:
7.1 Source of data:
The participants who are willing to participate in the screening and intervention program and who meet the eligibility criteria will be included in this study. These participants will be recruited from Department of Physiotherapy, Government district Wenlock Hospital, Department of Physiotherapy, Shri Devi college of Physiotherapy, Department of Physiotherapy, SCS Hospital.
Sampling: Block randomization method will be used for sampling.
Sample size: A total of 30 participants will be included in this study.
7.2 Method of collection of data:
Thirty participants of both genders from the age of 20 to 50 years will be divided equally into two groups of namely Group A and Group B. Each group will have fifteen participants.
A pre-participation screening will be done which will include Modified House-BracMann Facial Grading System.
Procedure:
- Group A will receive electrical stimulation with Proprioceptive neuromuscular facilitation.
- Group B will receive electrical stimulation with conventional physiotherapy.
PNF for facial muscles24
1. Elevation and depression of eyebrows, diagonal direction.
A) ”Ready “! (stretch downwards and medial ward)
B) “Look up! Raise your eyebrows! “
C) “Hold it! Now look up some more! And higher! And higher! Now look down and in”. (Maximal resistance , Repeated contractions, left)
2. Opening and closing of the eyelids, diagonal direction.
A) Open your eyes wide! (Stretch).” Hold them open”.
B) “Now, close your eyes! Don’t let me open them (maximal resistance) and relax”.
3. Retraction of angle of mouth upwards: protrusion of lips.
A) “Smile wide! Hold it there!”
B) “Pull your lips together forward and then down! Hold it!” (Maximal resistance, slow reversal hold) and smile again! And hold!”
4. Retraction of angle of mouth downwards; protrusion of lips upwards.
A) “Frown up! Hold it!” (Stretch, Maximal resistance).
B) “Pucker up and hold it! Now pucker up some more! And some more! (Maximal resistance, Repeated Contractions).
5. Lips open with inversion, lips close with protrusion as cheek compress
A) “CLOSE YOURS LIPS!”(Stretch, Maximal Resistance )
B) “HOLD it! Now close tightly! And again! And relax”(Repeated Contractions)
6. Mouth opening to the right, reinforced by head and neck flexion
A) “Open your mouth and look down at your right hip”(stretch, Maximal Resistance)
B) “Hold it! Now open some more. And again.” (Repeated Contractions).
7. Mouth opening to left, reinforced by head and neck extension.
A) “Close your mouth and look up to your left.”(stretch, Maximal Resistance)
B) “Head up! Now hold!” (Maximal Resistance)
8. Evaluation of tongue protrusion; midline and diagonal direction
A) Protrusion in midline with elevation
B) Protrusion in midline with depression
C) Protrusion and elevation to left
D) Protrusion and elevation to right
E) Protrusion and depression to left
F) Protrusion and depression to right
9. Resisted protrusion of tongue left, reinforced by head and neck flexion.
A) “Stick out your tongue so I can hold it with my fingers.” (manual Contact)
B) “Pull your tongue back and down to your right. Hold it!” (Stretch , Maximal Resistance)
C) “Push your tongue out towards me. Hold it there. No. Push some more. And more. And relax.”(Maximal resistance, repeated contraction)
Conventional Physiotherapy
Exercises for facial expression using postural mirror
A) Look surprised then frown
B) Squeeze eyes closed then open wide
C) Smile, grin, and say 'o'.
D) Say a, e, i, o, u.
E) Hold straw in mouth-suck and blow
F) Whistle
Electrical Stimulation
Interrupted direct current (I.D.C.) with pulse duration of100ms, given to the muscles of the face. Each patient will receive 90 contractions per treatment session and treatment program with electrical stimulation will be carried out once a day for 3 weeks.
Muscles of the face are25
1. Frontalis
2. Orbicularis oculi
3. Procerus
4. Zycomaticus minor
5. Zycomaticus major
6. Buccinator
7. Orbicularis oris
8. Mentalis
9. Levator anguli oris
10. Depressor anguli oris
MATERIALS TO BE USED:
1. Treatment couch
2. leads
3. Electrodes plate and pen electrode
4. Cotton
5. Lint pad
6. Electrical stimulation
7. Mackintosh
8. Postural mirror