Rajiv Gandhi University of Health Sciences, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Registration No.
:
Name of the Candidate
Brief resume of the intended work
: MS. JOMY MERLY THOMAS
: SDM College of Physiotherapy,
Sattur, Dharwad.
: SDM College of Physiotherapy, Dharwad
: MPT( Physiotherapy in Adult Neurology
and Psychosomatic Disorders.)
: 02/06/2008
: 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.
: Attached
Signature of the Student
:
Guide Name
Remarks of the Guide
Signature of the Guide
:Mr. RAVI SAVADATTI
:
:
Co-Guide Name
Signature of the Co-Guide
:
:
HOD Name
Signature of the HOD
: Ms. KIRAN SIRIGERI
:
Principal Name
Principal Mobile No.
Principal E-mail ID
Remarks of the Principal
:
: 09886089451
: [email protected]
:
Principal Signature
:
Address
Name of the Institution
Course of Study and Subject
Date of Admission to Course
Title of the Topic
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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
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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 HouseBrackmann, 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.
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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 reeducation 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 reeducation will not have more improvements in facial symmetry as compared to the group
receiving electrical stimulation and facial expression exercises.
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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
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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 reeducation 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.
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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.
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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
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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.
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The patients in both groups will be advised to use a mirror during the exercise program for visual
feedback. The patients will also be provided with a list of tips, including wearing eye glasses and
maintaining ocular and oral hygiene.
The objective outcome measure which is the Sunnybrook Facial Grading Scale will be used to
assess the facial symmetry pre- treatment and at the end of two weeks. The patients will be
treated till maximal recovery but will not be considered for statistical analysis.
Statistical Test Used: Chi – square test.
DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE
CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS?
IF SO DESCRIBE BRIEFLY – YES.

Electrical stimulation and gross facial expression exercises to one group.

Electrical stimulation and facial neuromuscular reeducation to another group.
HAS ETHICAL CLEARANCE BEEN OBTAINED BY YOU- YES
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c)
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2002. p. 325-27.
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http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=2026410&pageindex=1
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http://www.ptjournal.org/cgi/content/abstract/78/7/678
11. VanSwearingen JM, Brach JS. Changes in Facial Movement and Synkinesis with Facial
Neuromuscular Re-education. Plastic and Reconstructive Surgery 2003; June 111(7):2370-75.
Available from: URL: http://www.ncbi.nlm.nih.gov/pubmed/12794483
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http://www.ptjournal.org/egi/content/full/79/4/397
13. Beursken CH, Heymans PG. Positive effects of mime therapy on sequelae of facial
paralysis: stiffness, lip mobility, and social and physical aspects of facial disability. Otol Neurol
2003; 24:677-81. Available from: URL: http://cat.inist.fr/?a modele=afficheN&cpsidt=14987228
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14. Banister R. Brain and Banisters Clinical Neurology. 7th ed. New Delhi: Oxford University
Press; 1992. p 66-69.
15. Guo QH, Yan JZ, Yan WS, Xiao MZ. Observation on non-invasive electrode pulse
electrical stimulation for treatment of Bell’s palsy. Zhonqquo Zhen Jui 2006 Dec; 26(12): 857-8.
Available from: URL: http://www.ncbi.nlm.nih.gov/sites/entrez
16. Vanswearingen JM. Facial Rehabilitation: A Neuromuscular Reeducation, Patient-Centered
Approach. Facial Plastic Surgery. Facial Paralysis 2008 May; 24(2):250-59. Available from:
URL: http://www.ncbi.nlm.nih.gov/pubmed/18470837
17. Diels JH, Combs D. Neuromuscular Retraining for Facial Paralysis. Rehabilitation of
Neurotologic Diseases 1997 Oct; 30(5):727-43. Available from: URL:
http://www.ncbi.nlm.nih.gov/pubmed/9295250
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