physiotherapy bells palsy [dr.l.ramadass.pt 9500333960]

8/18/2019 PHYSIOTHERAPY BELLS PALSY [Dr.L.RAMADASS.PT 9500333960]

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INTRODUCTION

Bell’s palsy is an idiopathic, acute, unilateral paresis or paralysis of the face with

peripheral facial nerve dysfunction, it may be partial or complete, occurring with equal

frequency on the right and left sides of the face. [1] Sir harles Bell was the first to describe

unilateral facial nerve dysfunction in 1!"#. [$]

% range of annual incidence rates have been reported in the literature varying from

$& to &" 'all rates per 1##,### population per year(.

[&]

)he highest incidence was found in a

study in Sec*ori, +apan, in 1!- and the lowest incidence was found in Sweden in 11. [] )he

annual incidence of Bell/s palsy is about $# per 1##,### populations, and the incidence

increases with age. Bell’s palsy affects about 0#,### people in the ndia every year. t affects

appro2imately 1 in -& person during life time. 3eitersen $##$ the annual incidence of Bell’s

palsy varies widely, ranging between 11.& and 0#.$ cases per 1##,### populations. [-]

4ither se2 is affected equally and may occur at any age the median age is 0# years. [!]

5 [1] )he incidence is lowest under 1# years of age and highest in people over the age of #.

)here are pea*s of incidence in the "# to and -# to # year old age groups '6ilden $##07

6on8alve9 1(.[-] :eft and right sides are affected equally. [] %n account for -#;#< of all

cases of unilateral peripheral facial palsy.[] 3ersons with diabetes have a $< higher ris*s for

affected by Bell’s palsy.

)he onset of Bell’s palsyis sudden and symptoms typically pea* within a few days.

[1"] )he aetiology of Bell’s palsy is idiopathic, most of the evidences support the viral aetiology

due to =erpes Simple2, =eper >oster or 4pstein ? barr virus. @ascular ischemia may be

primary or secondary.

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3rimary ischemia is induced by cold or emotional stress. Secondary ischemia is the

result of primary ischemia which causes increase capillary permeability leading e2udation of

fluids, oedema and compression of micro circulation of the nerve. 3athologically the nerve

may be affected by inflammation, compression, contusion, ischemia, stretching, section,

application of e2cessive heat, cold, ultrasonic energy and local anesthetics. [10] n auto immune

disorders, );lymphocyte changes have been observed. [1&]

linical picture is a stereotyped, accompanied by bell’s phenomenon, [1-] diffused

retro auricular pain in the region of the mastoid, facial wea*ness and asymmetry with drooling

of liquids from the corner of the mouth on the affected side. 3alpebral fissure is widened on the

affected side, eye closure and blin*ing are reduced or absent, the angle of the mouth droops

with reduction of the naso labial fold, loss of taste in the anterior $A" rd of the tongue,

hyperacusis.[1]

europra2ia otherwise *nown as reversible conduction bloc* results from minor

degree of inCury. Dallerian degeneration occurs in most severe lesions. )he a2ons disappear

distal to the lesion. Eecovery is by regeneration of fibers and depends on7 1( resolution that is

removal of the cause of nerve inCury7 and $( 3hysical condition which permits sprouting a2ons

to grow down inside the neurilemma tubes and reinnervates motor end plates. Final results is

often marred by residual wea*ness, co contraction of the muscles or associated movements or

syn*inesis e.g. Caw;win*ing that is closure of the ipsilateral eyelid when the Caw opens,

crocodile tearing [10] from misdirection of regenerating fibers, post;paralytic hemi facial spasm,

sweating while eating or during physical e2ertion fi2ed contracture of facial muscles.

Gost ma*e a spontaneous recovery within 1 month, but up to "#< have delayed or

incomplete recovery. [1!] %bout one;third of patients may have incomplete recovery and residual

effect.

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Bell’s palsy has a fair prognosis without treatment '=olland $##0(. %ccording to

3etersen complete recovery was observed in 1< of all patients. inety;four per cent of

patients with incomplete and -1< with complete paralysis made a complete recovery. [-]

linically important improvement occurs within " wee*s in !&< of people and

within " to & months in the remaining 1&


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)he facial motor system is responsible for critical functions of physical, social, and

psychological well;being. Hamage to the facial motor system includes those conditions

affecting the facial nerve and its nerve branches, and the facial muscles. )hese conditions can

result in deficits in eating, drin*ing, spea*ing, conveying conversational signals li*e,

punctuation signs conveyed by movements of the eyebrows during speech and even conveying

intimate human information li*e anger, disgust, happiness, surprise.[1$] ndividuals with

paralysis of or disfiguring facial e2pressions deal with physical, psychological, and social

disability daily.[1#] 5 [11] Bell’s palsy has been primarily considered a cosmetic inconvenience

with associated functional problems. Eestoring function and e2pression to the highest level of

possible results in improved health, self;esteem, self; acceptance, acceptance by others, and

also quality of life.

Bell/s palsy affects each individual differently. n patients presenting with

incomplete facial palsy, where the prognosis for recovery is very good, and treatment may be

unnecessary. =owever, the more severe cases may require treatment. 3atients presenting with

complete paralysis, mar*ed by an inability to close the eyes and mouth on the involved side,

are usually treated. 4arly treatment within " days after the onset is necessary for therapy to be

effective.

3hysiotherapy can be beneficial to some individuals with Bell’s palsy as it helps to

maintain muscle tone of the affected facial muscles and stimulate the facial nerve. ormally

electrical stimulation, massage, heat and e2ercise are given in the conventional physiotherapy

in order to maintain tone of the muscle and promote functional recovery.

Kabat/s rehabilitation is a type of motor control rehabilitation technique based on

3roprioceptive euromuscular Facilitation '3F( which is added with conventional treatment

for e2perimental group in this study to find out the effectiveness of the Kabat’s rehabilitation.

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)o assess the effectiveness at the impairment level and functional level of Kabat’s

rehabilitation, =ouse Brac*mann 6rading Scale and Facial Hisability nde2 were used

respectively.

Aim and Need of the Study:

)his study is intended to assess the effectiveness of Kabat /s 3F rehabilitation in

3hysical and 3sycho Social wellbeing function in acute unilateral idiopathic Bell’s palsy

patients.

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HYPOTHESIS

ALTERNATE HYPOTHESIS:

)here is significant difference between the effect of Kabat/s 3roprioceptive

euromuscular Facilitation with conventional physiotherapy and conventional physiotherapy

alone for facial physical and psycho social wellbeing function in acute unilateral idiopathic

Bell’s palsy patients.

NULL HYPOTHESISJ

)here is no significant difference between the effect of Kabat/s 3roprioceptive

euromuscular Facilitation with conventional physiotherapy and conventional physiotherapy

alone for facial physical and psycho social wellbeing functions in acute unilateral idiopathic

Bell’s palsy patients.

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REVIE O! LITERATURE

"au#i$io %a#&a#a' et a(' )*+,+-: )heir obCective was to assess the validity of an early

rehabilitative approach to Bell/s palsy patients. n their randomi9ed study, $# consecutive

patients '1# males, 1# females7 aged "&?0$ years( affected by Bell/s palsy, classified according

to the =ouse;Brac*mann '=B( 6rading System and grouped on the basis of undergoing or not

early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular

rehabilitation. )he evaluation was carried out by measuring the amplitude of the compound

motor action potential 'G%3(, as well as by observing the initial and final =B grade, at days

0, and 1& after onset of facial palsy. 3atients belonging to the rehabilitation group clearly

showed an overall improvement of clinical stage at the planned final observation, i.e. 1& days

after onset of facial palsy, without presenting greater values of G%3 and concluded that when

applied at an early stage, Kabat/s rehabilitation was shown to provide a better and faster

recovery rate in comparison with non;rehabilitated patients. [$1]

%a#&a#a "' et a(: Found that @oluntary contraction of impaired muscle is facilitated by

applying global stretching and then resistance to the muscular section and motivate action by

verbal inputs and manual contact. [$$]

D#. He#man a&at: Stated that 3roprioceptive euromuscular Facilitation as having to do

with any of the sensory receptors that give information concerning movement and position

of the body, involving the nerves and the muscles ma*ing easier.

%a#&a#a "' et a(: onducted a, study to determine whether an early physical rehabilitative

program could improve andAor accelerate recovery from a postoperative deficit of facial nerve

'F( function. 4arly physical rehabilitation has proved to be effective as a helpful tool for

recovery from F deficit and it is therefore advisable to use it soon after surgery, especially for

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F deficits worse than 6rade @. t is a retrospective study of the patients who presented a

postoperative F deficit after surgery for acoustic neuroma '%( was carried out. )wenty;nine

patients were enrolled and divided into $ groupsJ 1! who underwent early physical

rehabilitation and 11 who did not undergo rehabilitation. %ll the % patients underwent trans

labyrinthine removal and were classified preoperatively according to the =ouse?Brac*mann

staging system. 3hysical rehabilitation was performed according to Kabat 'i.e. neuromuscular

facilitation(. F function was assessed postoperatively and classified according to the =ouse?

Brac*mann 6rading System. )he resultsLn 6rade @ and @ patients, early rehabilitation

allowed a faster and better recovery with respect to % patients for whom rehabilitation was

not carried out. )hey concluded that early physical rehabilitation has proved to be effective as

a helpful tool for recovery from F deficit and it is therefore advisable to use it soon after

surgery, especially for F deficits worse than 6rade @. [$$]

Ca#o(yn i/ne#' et a(: Stated that 3F is a form of therapeutic e2ercise that combines

functionally based diagonal patterns of movement with techniques of neuromuscular

facilitation to evo*e motor response and improve neuromuscular control and function. [$"]

"a#i Namu#a' et a(: States that 3F training has significant effect for sharpening the mouth

and sub mandibular region, but continued training is necessary to avoid relapse. [$0]

a&at H and nott ": Eeported that 3F has improvement in the function of the muscles

and ameliorates 'ma*e or become better( muscle decline, disharmony, atrophy and Coint

movement limitation. [$&]

ofoto(i/ N' et a(: Stated that 3F has been recently used in orthopaedic diseases of the bone

and Coints, sports related trauma and S diseases li*e stro*e and its usefulness has been

reported in other medical fields also. [$-] 5 [$]

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Na0a1ima E' et a(: Found that 3F can used to improve the aesthetics of facial e2pressional

so and introduced 3F to +apanese clinicians. [$!]

Lu/tin2 A' et a(: Stated that 3F is often used as an alternative form of 3E4 '3rogressive

Eesisted 42ercise( by physiotherapists as its use should be more advantageous than usual

strength programs. [$]

a&at ),34+-: Stated that 3roprioceptive euromuscular Facilitation '3F( is a concept of

treatment. ts underlying philosophy is that all human beings, including those with disabilities,

have untapped e2isting potential. ["#]

a&at ),356-: Stated that one of the basic procedures of 3roprioceptive euromuscular

Facilitation is )iming. )iming is to promote normal timing and increase muscle contraction

through )iming for emphasis. )iming for emphasis involves changing the normal sequencing

of motions to emphasi9e a particular muscle or a desired activity. )iming is defined as

sequencing of motion. ["#]

a&at ),356-J Stated that prevention of motion in a stronger synergist will redirect the energy

of that contraction into a wea*er muscle. )his alteration of timing stimulates the 3roprioceptive

refle2es in the muscles by resistance and stretch. Dhen we use bilateral movements while

e2ercising the face, contraction of the muscles on the stronger or more mobile side will

facilitate and reinforce the action of the involved muscles. )iming for emphasis, by preventing

full motion on the stronger side will further promote activity in the wea*er muscles. ["#]

Ta#2an RS' et a(: onducted 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. )he study group included 1$ patients 'mean age .0 MA; 1$. "

years( with idiopathic Bell/s palsy and & patients 'mean age 0&.- MA; 1#. years( whose facial

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nerves were surgically sacrificed. Gotor nerve conduction latencies, =ouse;Brac*mann facial

recovery scores, and a 1$;item clinical assessment of residuals were obtained " months before

the onset of treatment, at the beginning of treatment, and after - months of stimulation.

3atients were treated at home for periods of up to - hours daily for - months with a battery;

powered stimulator. Stimulation intensity was *ept at a sub motor level throughout the study.

6roups and time factors were used in the analyses of the " outcome measures. )he result of the

study was that long;term electrical stimulation may facilitate partial reinnervation in patients

with chronic facial paresisAparalysis. %dditionally, residual clinical impairments are li*ely to

improve even if motor recovery is not evident. ["1]

%eu#/0en/ CH' et a(J onducted a E) '0! people with peripheral facial paralysis for at least

months( found that mime therapy significantly improved physical and social aspects of facial

parlays is compared with waiting list control at " months 'mean change in physical FH scoresJ

from &-.! to".& with mime therapy v from -".$ to &.- with control7 3 less than #.#$ for

difference between treatments at " monthsJ mean change in social FH scores7 from -!.- to

!#. with mime therapy from $.- to --.$ with control7 3 less than #.#1 for difference between

treatments at " months(.)he E) also found significant improvements in facial stiffness and

lip mobility 'change in pout and lip;length indices( in the mime therapy group compared with

the control group 'mean change in stiffness scoresJ from ".$ to $." with mime therapy from

".-! to ".&0 with control7 3 less than #.##1 at " monthsJ mean change in pout scoreJ from 10.

to $1 with mime therapy 1-." to1&. with control7 3 less than #.##1 at " monthsJ mean change

in lip;length score7 from 1.- to$". with mime therapy from $1.- to 1.- with control7 3 less

than #.#" at " months(.["$]

%eu#/0en/ CH7' et a(: onducted a E) with 1$ month/s follow;up, found a trend towards

improved social FH score and pout inde2 at " and 1$ months after treatment mean social FH

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scoreJ !1.- immediately after treatment7 !".- at " months7 !&." at 1$ monthsJ mean pout inde2J

$$.$ immediately after treatment7 $".& at " months7 $0.$ at 1$ months. [""]

"a#i Namu#a et a(: Found that though orthodontic treatment improves dent alveolar

problems, the facial profile seldom changes because the perioral muscles do not easily adapt to

the new morphological circumstances. )hey employed proprioceptive neuromuscular

facilitation '3F(, which is training with added resisted movement to motions such as lifting

the upper lip, lowering the lower lip, and stic*ing out the tongue, to adapt the perioral muscles

to the new morphological circumstances. )he subCects were 0# adults with an average age of

$.- years. % series of 3F e2ercises was performed three times per day for 1 month. :ateral

facial photographs were ta*en using a digital camera before training ')#(, after training ')1(,

and 1 month after the end of training ')$(. )he naso labial ':(, mento labial 'G:(, and mento

cervical 'G( angles were measured, and linear measurements were ta*en to verify the change

of each measurement point. n the test group, the : and G: angles significantly increased '3

N #.#&(, and the G angle significantly decreased after the 3F e2ercise. From )1 to )$, the

: and G: angles decreased significantly, while the G angle increased significantly. o

significant differences were observed in these angles when the values measured at )# and )$

were compared. %lthough the training appeared to be effective for sharpening the mouth and

sub mandibular region, continued training is necessary to avoid relapse. ["1]

Namu#a "' et a(: 4valuated the effect of 3F training on the facial profile in 0# adults with

an average age of $.- years. % series of 3F e2ercises was performed three times per day for

1 month. )hey concluded that the training appeared to be effective for sharpening the mouth

and sub mandibular region. ["0]

E((iott 8" )*++9-: =is case report describes a physiotherapy treatment based on current best

evidence for a patient with left facial nerve paralysis. % &" year old aucasian male with

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complete left facial paralysis with a diagnosis of Bell’s palsy. Signs and symptoms were

assessed using a standardi9ed measure of facial disability 'Facial Hisability nde2;FH(.

3hysiotherapy rehabilitation involved muscle re;education e2ercises aimed at restoring normal

movement within the affected left facial musculature. n 1- physiotherapy sessions over 0

months, the patient had improved self;reported facial disability 'initial FH score7 3hysical

subscale O "&A1## and SocialADell;being subscale O &&A1##. )he Final FH score7 3hysical

subscale O &A1## and SocialADell;being subscale O !&A1##( and significantly reduced

functional impairments. ["&]

Ta#2an RS'et a(: onducted a study to investigated the efficacy of a pulsatile electrical current

to shorten neuromuscular conduction latencies and minimi9e clinical residuals in patients with

chronic facial nerve damage caused by Bell/s palsy or acoustic neuroma e2cision. )he study

group included 1$ patients 'mean age .0 P 1$." years( with idiopathic Bell/s palsy and &

patients 'mean age 0&.- P 1#. years( whose facial nerves were surgically sacrificed. )he mean

time since the onset of paresisAparalysis was ". years 'range 1? years( and .$ years 'range

- years( for the Bell/s and neuroma e2cision groups, respectively. Gotor nerve conduction

latencies, =ouse;Brac*mann facial recovery scores, and a 1$;item clinical assessment of

residuals were obtained " months before the onset of treatment, at the beginning of treatment,

and after - months of stimulation. 3atients were treated at home for periods of up to - hours

daily for - months with a battery;powered stimulator. Stimulation intensity was *ept at a

submotor level throughout the study. Surface electrodes were secured over the most affected

muscles. 6roups and time factors were used in the analyses of the " outcome measures. )he

result is no statistical differences were found between the two diagnostic groups with respect to

any of the " outcome measures. Gean motor nerve latencies decreased by 1.1" ms 'analysis of

variance test, significant P O #.###1(. =ouse;Brac*mann scores were also significantly lower

'Dilco2on signed ran* test, P O #.###"( after treatment. ollective scores on the 1$ clinical

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impairment measures decreased $!. P !.1 points after - months [analysis of variance test,

significant P O #.###&(. 4ight patients showed more than 0#< improvement, 0 better than

"#


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DESI7N "ETHODOLO7Y

RESEARCH DESI7N

STUDY DESI7N J Quasi e2perimental study

Eandomi9ed control trial.

STUDY SETTIN7 J )ertiary are entre

1. 3hysical Gedicine and Eehabilitation entre,

6ovt. of 3uducherry.

$. ndira 6andhi 6ovt. 6eneral =ospital,

3uducherry.

SA"PLE SI;E J )otal nO0#,

6roup % nO$#, 6roup B nO$#.

SA"PLIN7 TECHNI


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SELECTION CRITERIA

In=(u/ion =#ite#ia

Both males and females.

3atients with acute unilateral idiopathic Bells palsy.

%ge group between 1& ? -# years.

First one wee* after onset of Bell’s palsy.

Gedically stable individuals.

3atient must give the written informed consent.

E>=(u/ion =#ite#ia

3atient with history of recent head inCury, eurological disorders.

3sychiatric illness

3regnant women,

eurotomesis

3atient with history of Getal A Hental implants.

3atient with history of diabetic neuropathy.

3atient with history of immune deficiency syndromes.

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3atients with acoustic ear pain, otitis media or ear infection.

Bell’s palsy with @th cranial nerve involvement.

3atients with defective sensation over the face.

3atients with tumours, congenital defects, open wounds, ulcers or any growth around

treatment area.

3atients with acne on face.

Bilateral facial wea*ness due to demyelinating neuropathy.

VARIA%LES

H434H4) @%E%B:4:

Kabat’s 3F rehabilitation.

H434H4) @%E%B:4J

• Facial physical and social well;being functions.

"ETHODOLO7Y

Study "ate#ia(/:

6loves for 3F application

3ostural mirror

4lectrical stimulator

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3ad or plate electrodes and pen electrodes.

:eads ' $ numbers(

Straps

otton

3owder

6el

3illows

)owel

Bowl of water

EE

OUTCO"E "EASURES

)o analyse the effects of Kabat/s 3F rehabilitation on 3hysical and 3sycho social

wellbeing functions in individuals with acute unilateral idiopathic Bell’s palsy two outcome

measures were chosen namely.

,. Hou/e %#a=0"ann fa=ia( 7#adin2 Sy/tem )H%7S-.

*. The !a=ia( Di/a&i(ity Inde> )!DI-.

Hou/e %#a=0"ann fa=ia( 7#adin2 Sy/tem )H%7S-.

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)he severity and degree of nerve damage in idiopathic facial nerve paralysis is

graded based on =ouse;Brac*mann 6rading Scale '=B6S(. ["-] )his grading system is formally

adopted as the universal standard reporting facial nerve dysfunction after recommendation by

Facial erve Hisorders ommittee of the %merican %cademy of Itolaryngology =ead and

ec* Surgery in 1!0. ["]

E?an/ RA' et a(: )he =ouse and Brac*mann grading system has been

recommended as a universal standard for assessing the degree of facial palsy. )his study

e2amined the inter;observer reliability of this system. )hree observers assigned a grade to each

patient, e2amined independently, on the same day. Forty patients with a unilateral facial palsy

of varying aetiology and severity were assessed. If the 1$# Cudgements, eight were in dispute,

by a ma2imum of one grade, giving an inter;observer reliability of " per cent and conclude

that the =ouse and Brac*mann grading system is a simple and robust method of assessing

facial function. ["!] (APPENDIX-5).

The !a=ia( Di/a&i(ity Inde> )!DI-.

mprovement in social and physical aspects of facial disability was measured using

the Facial Hisability nde2 'FH( questionnaire. t is disease;specific, self;report instrument7

)he FH uses a 1##;point scale, with a higher score indicating fewer handicaps and less

impairment. t is developed by @an Swearingen and Brach '1-(. )he FH is questionnaire is

used for assessing the disability of patients with facial nerve disorder. )he FH is designed to

provide the clinician with information regarding the disability as well as related social and

emotional wellbeing of the patient. )he FH consists of two subscales7 3hysical function 'items

1;&( and social well;being 'items -;1#(. )he scores range from # 'complete paralysis( to 1##

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'normal facial function(. )he FH has shown to be reliable and valid as a clinical instrument

and has been shown to accurately demonstrate the relationship between impairments,

disability, and psycho social status '@an Swearingen and Brach, 1-(. ["&] )APPENDI@5-.

Re/ea#=h P#o=edu#e:

)he procedure of this study was thoroughly e2plained to the individuals selected for

the study and an informed written consent was obtained in the individual vernacular language.

)hey were allocated into two groups, 6roup % 'control group( and 6roup B 'e2perimental

group( by random allocation method. n the pre;test, each individual was assessed by =B6S

and FH.

TREAT"ENT PROTOCOL

7ROUP A: CONTROL 7ROUP

TREAT"ENT: CONVENTIONAL PHYSIOTHERAPY

)hey received electrical stimulation, EE, facial massage, taping and facial

e2pressions muscle e2ercises are given for 0 wee*s with & sessions in each wee*, each session

consist of 0& minutes. 3ost;test were repeated with same outcome measures after 0 wee*s. )he

data obtained were documented and statistically analysed for significant difference.

7ROUP %: E@PERI"ENTAL 7ROUP

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TREAT"ENT: A%ATBS PN! REHA%ILITATION

)hey received Kabat/s 3F rehabilitation along with onventional physiotherapy.

Huring Kabat/s, to facilitate the voluntary contraction of the impaired muscle by applying a

global stretching then resistance to the entire muscular section and motivate action by verbal

input and manual contact.

Dhen performing Kabat/s, " regions are consideredJ the upper 'forehead and eyes(,

intermediate 'nose(, and lower 'mouth(. )he face is treated bilaterally to provo*e more

symmetry. n some cases, the stronger side was used to reinforce motions on the wea*er side.

Functionally, the facial muscles made to wor* against gravity, for this proper position was

selected for treatment. 4ach individual was positioned in the supine position, following the

same position as in the testing procedure are done and both conventional and Kabat /s 3F

rehabilitation are given for 0 wee*s with & sessions in each wee*, each session consist of -#

minutes

!I7URE ,: A%ATBS REHA%ILITATION

Few Guscles )echniques

20

Guscles Stretch Eesistance

Irbicularis

Iris

Frontalis


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Po/tte/tJ 4ach individual are assessed by FH and =B6S after 0 wee*s. )his measure was

ta*en to evaluate the effects of Kabat/s 3F rehabilitation in Bell’s palsy patients. )he data

obtained were documented and analysed.

DATA ANALYSIS RESULTS

)he outcome values obtained were tabulated in Gicrosoft 42cel ’# spread sheet,

and were e2ported to 6raph 3ad 3rism & for Dindows @ersion &.#" for statistical analysis.

)he effects of intervention on the changes from pre to post;test values in both

groups were analysed using 3aired Rt test for within 6roup analysis and ndependent sample

Rt test for Between 6roup analysis.

)he 3 value was chosen as per the description given by 6raph 3ad 3rism & for

Dindows @ersion &.#".

De/=#ition of P ?a(ue:

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P ?a(ue De/=#ition Summa#y

N #.##1 42tremely significant TTT

#.##1 to #.#1 @ery significant TT

#.#1 to #.#& Significant T

U#.#& ot significant s

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Ta&(e ,

%ASELINE CHARACTERISTICS O! THE SA"PLE SU%8ECTS

haracteristics6roup ; % 6roup ; B

)otal umber of 3articipants $# $#

%ge 'yrs.( average ".!".

6ender 'male Jfemale( 1"J 1$J!

Side of Bell’s palsy 'Eight J :eft( 10J- 1"J

Huration of Bell’s palsy 'days( average - &

FHTT Score

Gean P SH

0.& P .& 0.$& P .!

=B6ST Score

Gean P SH

".0 P #.0 "." P #.

=ouse Brac*Gann facial 6rading System;'=B6S(T.

)he Facial Hisability nde2 ; 'FH( TT.

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Ta&(e *

OUTCO"E VALUES O! 7ROUP A

S(. No

7ROUP A

=B6ST score FHTT score

3E4 3IS) 3E4 3IS)

1 $ 1 " -&

$ $ 1 -1 0

" " $ 0" "

0 " $ 0# "

& " $ 00

- " $ 00

" $ 00

! " $ &0 !#

" $ 0- !0

1# " $ 0- !

11 " $ -0 $

1$ " $ 0- !

1" " $ -#

10 & " -# !&

1& - 0 1##

1- 0 $ $ -

1 0 $ &0 !&

1! 0 $ 00 #

1 0 " 00 &

$# 0 " "& 1

G4% P SH ".0 P #.0 $.1& P #.- 0.& P .& . P !.$

HFF4E44 1.$& P #.00 "#.0 P .!

Hou/e %#a=0"ann fa=ia( 7#adin2 Sy/tem)H%7S-

The !a=ia( Di/a&i(ity Inde>)!DI-

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Ta&(e F

OUTCO"E VALUES O! 7ROUP %

S(. No7ROUP %

=B6ST score FHTT score

3E4 3IS) 3E4 3IS)

1 $ 1 &1 -

$ $ 1 &1 !1

" " 1 0& 1##

0 " 1 0$ 1##

& " 1 0$ 1##- " 1 $ -

" 1 1##

! " 1 -

" 1 -0 &

1# " 1 -& #

11 " 1 0& 1##

1$ " 1 "# !#

1" " 1 0# !#

10 0 1 #

1& 0 1 #

1- 0 1 &! !

1 0 $ &! !

1! & $ & 1##1 - 1 & 1##

$# $ 1 &" 1##

G4% P SH "." P #. 1.1 P #."# 0.$& P .! 0.& P .#$

HFF4E44 $.$ P #.! 0&.$& P 1#.&-

Hou/e %#a=0"ann fa=ia( 7#adin2 Sy/tem )H%7S-.

The !a=ia( Di/a&i(ity Inde> )!DI- .

26


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ITHIN 7ROUP ANALYSIS

Ta&(e 5

ANALYSIS O! I"PROVE"ENT IN H%7S

S(. No 7#ou Ana(y/i/ "ean G SD t ?a(ue Si2nifi=an=e

, A

3re test ".0 P #.0

11.##

3ost test $.1& P #.-

* %

3re test "." P #.

1$.&!

3ost test 1.1 P #."#

)he results of this study from the above table indicate that, in Dithin 6roup analyses

of mprovement in =B6S, individuals of both 6roup % 5 6roup B e2tremely significantly

improved from pre;test to post;test.

!i2u#e ,


ANALYSIS O! I"PROVE"ENT IN H%7S

27


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GROUP A GROUP B0

0.5

1

1.5

2

2.53

3.5

43.4 3.3

2.15

1.1

HBGS

HBGS SCORES

Ta&(e 4


ANALYSIS O! I"PROVE"ENT IN !DI

S(. No 7#ou Ana(y/i/ "ean G SD t ?a(ue Si2nifi=an=e

, A

3re test 0.& P .&

1.1&

3ost test . P !.$

* %

3re test 0.$& P .!

1.$"

3ost test 0.& P .#$

)he results of this study from the above table indicate that, in Dithin 6roup analyses

of mprovement in FH, individuals of both 6roup % 5 6roup B e2tremely significantly

improved from pre;test to post;test.

!i2u#e *


28


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ANALYSIS O! I"PROVE"ENT IN !DI

GROUP A GROUP B0

20

40

60

80

100

49.5 49.25

79.9

94.5

FDI

FDI SCORES

29


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%ETEEN 7ROUP ANALYSIS

Ta&(e 9

ANALYSIS O! DI!!ERENCE IN H%7S !OR %OTH 7ROUPS

S(. No 7#ou"ean Diffe#en=e

G SDt ?a(ue Si2nifi=an=e

, A1.$ P #.00

0.$&0

* % $.$ P #.!

)he results of this study from the above table indicate that, in analyses of

mprovement in =B6S, e2tremely significant improvement seen in individuals in 6roup B.

!i2u#e F


ANALYSIS O! DI!!ERENCE IN H%7S !OR %OTH 7ROUPS

GROUP A GROUP B0

0.5

1

1.5

2

2.5

1.25

2.2

HBGS

HBGS SCORES

30


31/62

Ta&(e 9


ANALYSIS O! DI!!ERENCE IN !DI !OR %OTH 7ROUPS

S(. No 7#ou"ean Diffe#en=e

G SDt ?a(ue Si2nifi=an=e

, A "#.0 P .!

&.#"-

* % 0&.$& P 1#.&-

)he results of this study from the above table indicate that, in analyses of

mprovement in FH, e2tremely significant improvement seen in individuals in 6roup B.

!i2u#e 5


ANALYSIS O! DI!!ERENCE IN !DI !OR %OTH 7ROUPS

31


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GROUP A GROUP B0

5

10

15

20

25

30

35

40

45

50

30.4

45.25

FDI

FDI SCORES

DISCUSSION

Bell’s palsy is an acute, idiopathic, unilateral paralysis of the face. ts cause is

un*nown, but mounting evidence suggests that reactivated herpes viruses from cranial nerve

ganglia play a *ey role in the development of this condition, its pattern is consistent with that

of peripheral neural dysfunction. nflammation of the facial nerve initially results in reversible

neuropra2ia and wallerian degeneration ultimately ensues. t is characteri9ed by wea*ness or

paralysis of the muscles on one side of the face. Facial nerve palsy can dramatically affect

many attributes of a patient’s general quality of life. Facial paralysis has been primarily

considered a cosmetic inconvenience with associated functional problems such as speech,

eating, facial asymmetry, drooling, and an inability to close the eye on the paraly9ed side. )he

patient with facial paralysis cannot convey the normal social signals of inter personal

communication. Facial muscles can alter the facial surface in various ways to e2ecute their

functions. n addition to opening and closing the eyes and mouth they also have a reporting

function. =ighly differentiated and comple2 facial musculature can e2press a large number of

sensations and can reflect the state of mind and mood of an individual. Facial symmetry is a

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determinant of facial attractiveness, being a mar*er of good health and influences interpersonal

attraction.

)he incidence of Bell’s palsy is appro2imately "#A1##,### people per year. )he

prognosis is good, and appro2imately #< of patients recover completely within - months

without treatment. =owever, "#< of Bells palsy patients have sequelae, such as residual

paresis '$


34/62

of common facial e2pressions in a general e2ercise regimen have been considered to be of little

benefit. n fact, some interventions may even adversely affect the recovery of facial neuro

motor function. )his technique does not encourages functional re;education of correct

movement patterns which is the most basic aspect of the therapeutic process and lay the

necessary foundation for learning the selective patterns to improve motor function. )he

onventional therapy due to this lac*s the specificity result in residual asymmetry due to faulty

motor pattern.

%n emerging rehabilitation science of neuro muscular re;education and evidence for

the efficacy of facial neuromuscular re;education, a process of facilitating the return of

intended facial movement patterns and eliminating unwanted patterns of facial movement and

e2pression, may provide patients with disorders of facial paralysis.

)his study was conducted, to evaluate the effects of Kabat /s 3F technique in acute

unilateral idiopathic Bell’s palsy patients.

n this study 0# patients were diagnosed to have acute unilateral idiopathic Bell’s

palsy. %verage age at diagnosis was "& years old with a range from - years to -# years. n this

study twenty four patients were male and 1- patients were female. )wenty seven patients had

right sided and 1" patients had left sided. %ll the patients were graded based on =B6S and FH

scales during initial presentation at the clinic. %ll the $# out of the 0# patients were treated by

conventional physiotherapy, and $# patients were treated with a combination of conventional

physiotherapy and Kabat’s 3F rehabilitation.

The#aeuti= 7oa(/ of a&atJ/ PN! #eha&i(itation Te=hniKue:

)he basic facilitation procedures provide tools for the therapist to help the patient

gain efficient motor function and increased motor control. )hese basic procedures are used to

34


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increase the patient’s ability to move or remain stable. 6uide the motion by proper grips and

appropriate resistance. t helps the patient to achieve co;ordinated motion through timing and

increase the patient’s stamina and avoid fatigue.

Eesistance is used in treatment toJ Facilitate the ability of the muscle to contract.

ncrease motor control and motor learning. =elp the patient gain an awareness of motion and

its direction. ncrease strength and help the patient to rela2 'reciprocal inhibition(.

Ganual ontacts used in treatment toJ 3ressure on a muscle to aid that muscle

stability to contract to gives the patient security and confidence. %nd also promote tactile

*inaesthetic perception.

Body 3osition and Body Gechanics is used in treatment toJ 6ive the therapist

effective control of the patient’s motion. Facilitate control of the direction of the resistance.

%nd enable the therapist to give resistance without fatiguing.

@erbal Stimulation 'ommands( is used in treatment toJ 6uide the start of

movement or the muscle contractions. %ffect the strength of the resulting muscle contractions

and given to the patient corrections.

@isions used in treatment toJ 3romote a more powerful muscle contraction. =elp the

patient control and correct position and motion. nfluence both the head and body motion.

3rovide an avenue of communication and help to ensure co;operative interaction.

Stretch stimulus is used in treatment toJ Facilitate muscle contractions. Facilitate

contraction of associated synergistic muscles.

35


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)iming is used in treatment toJ ormal timing provides continuous, co;ordinated

motion until a tas* is accomplished. )iming for emphasis redirects the energy of a strong

contraction into wea*er muscles.

% significant difference in the mean values on the =B6S before and after

rehabilitation of $.$ 'SH #.!( was observed in the e2perimental group and of 1.$& 'SH #.00(

in the control group )Ta&(e 9-.

% significant difference in the mean values on the FH before and after rehabilitation

of 0&.$& 'SH 1#.&-( was observed in the e2perimental group and of "#.0 'SH .!( in the

control group )Ta&(e 6-.

)he following basic neurophysiologic principles of 3F are responsible for

improvement in 3hysical and 3sycho social well;being functions, in acute unilateral idiopathic

Bell’s palsy patients. )hey are

%fter dischargeJ )he effect of a stimulus continues after the stimulus stops. f the

strength and duration of the stimulus increase, the after discharge also increases. )he feeling of

increased power that comes after a maintained static contraction is a result of after discharge.

)emporal summationJ % succession of wea* stimuli 'subliminal( occurring within a

certain 'short( period of time combine 'summate( to cause e2citation.

Spatial summationJ Dea* stimuli applied simultaneously to different areas of the

body reinforce each other 'summate( to cause e2citation. )emporal and spatial summation can

combine for greater activity.

36


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rradiationJ )his is a spreading and increased strength of a response. t occurs when

either the number of stimuli or the strength of the stimuli is increased. )he response may be

either e2citation or inhibition.

Successive inductionJ %n increased e2citation of the agonist muscles follows

stimulation 'contraction( of their antagonists. )echniques involving reversal of antagonists

ma*e use of this property 'nductionJ stimulation, increased e2citability.(.

Eeciprocal innervations 'reciprocal inhibition(J ontraction of muscles is

accompanied by simultaneous inhibition of their antagonists. Eeciprocal innervations are a

necessary part of coordinated motion. Eela2ation techniques ma*e use of this property.

)he results suggest that the individuals who got Kabat/s 3F rehabilitation, showed

a greater improvement in 3hysical 3sychological and Social well;being function when

compare with conventional physiotherapy. 3F, the treatment approach is always positive,

reinforcing and which the patient can do, on a physical and psychological level. )he primary

goal of all treatment is to help patients to achieve their highest level of function. )o reach this

highest level of function, the therapist integrates principles of motor control and motor learning

through Kabat’s 3F rehabilitation.

37


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CONCLUSION

Dhen applied at an early stage, Kabat/s 3F rehabilitation )7#ou %- was shown to

provide a better and good improvement in f acial and social well;being functions, compared

with conventional physiotherapy )7#ou A- treatment in acute unilateral idiopathic bell’s

palsy patients. Because FH and =B6S improved substantially in Kabat/s rehabilitation group,

so this technique may be incorporated in the treatment strategies of acute unilateral idiopathic

Bell’s palsy.

38


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RE!ERENCES

1( +ulian =olland7 Bell’s palsy7 BmC linical evidence7 $##!J#1J1$#0.

$( Eoob 6, Fa9e*as F, =artung =3. 3eripheral facial palsyJ 4tiology, diagnosisand

treatment. 4ur eurol 17 01J ";.

"( Honer F, Kutluhan S '$###(. Familial idiopathic facial palsy. 4ur %rch Itorhinolaryngol

$& '"(J 11;.

0( Dolf SE '1!(. diopathic facial paralysis 'in 6erman(. =I 0- '(J !-?!. 3GH

!1-&"$.

&( Gorris %G, Hee*s S:, =ill GH et al. '$##$(.%nnuali9ed incidence and spectrum of

illness from an outbrea* investigation of Bell/s palsy. euroepidemiology $1 '&(J $&&?

-1.

-( 3hysical therapy for BellX s palsy 'idiopathic facial paralysis( 'Eeview( opyright $##!,

)he ochrane ollaboration. 3ublished by +ohnDiley 5 Sons, :td.

( %dour KK, Byl FG, =ilsinger E:, +r, Kahn >G, Sheldon G. )he true nature of Bell/s

palsyJ %nalysis of 1,### consecutive patients. :aryngoscope. 1!7!!J!?!#1.'3ub

Ged(

!( 3eitersen 4. Bell’s 3alsy7 )he spontaneous course of $,# peripheral facial nerve

palsies of different aetiologies. %ctaoto laryngol suppl $##$7 &0J 0;"#.

( Katusic SK, Beard G, Diederholt D, Bergstralh 4+, Kurland :). ncidence, clinical

features, and prognosis in Bell/s palsy, Eochester, Ginnesota 1-!;1!$. %nn eurol.

1!-7 $#J -$$?.

39


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1#( Ihye E6, %ltenberger 4%. Bell’s palsy. %m Fam 3hysician1!70#J1&?1--

11( )wers*i %+, )wers*i B. )he emotional impact of facial paralysis. nJ Gay G, 4d. )he

Facial erve. ew Yor*, YJ )hieme Gedical 3ublishers7 1!-J!!?0

1$( 4*man 3. 3sychosocial aspects of facial paralysis. nJ Gay G, 4d. )he Facial erve.

ew Yor*, YJ )hieme Gedical 3ublishers nc7 1!-J!1;!.

1"( =auser D%, Karnes D4, %nnis +, Kurland :). ncidence and prognosis of Bell/s palsy in

the population of Eochester, Ginnesota. Gayo lin 3roc. 117 0-J $&!?-0.

10( +ohn 6rovers, Eoger .F. 6ray. % synopsis of Itolaryngology, 0th 4dition. +ohn Dright

and son’s ltd, 1!&7 0!1.

1&( 3. Hhingra. Hiseases of 4ar, ose and )hroat, 0th 4dition. %n imprint of 4lsevier, $##07

0.

1-( 1-. Kenneth D. :indsay, an Bone. eurology and eurosurgery illustrated, 0 th 4dition.

hurchill living stones, $##07 1-!.

1( harles lar*e, Eobin =oward, Gartin Eossor, Simon Shorvon. eurology % queen

square te2t boo*, 1st 4dition. Diley ? Blac* Dell. % +ohn Diley and sons, $##7 0&.

1!( +ulian =olland Hepartment of Itolaryngology =ead and ec* Surgery, 6uy/s and St.

)homas/ =ospital :ondon WK BG+ 3ublishing 6roup :td $##!.

1( 3eitersen 4. Bell/s palsyJ the spontaneous course of $,# peripheral facial nerve palsies

of different aetiologies. %ctaItolaryngolSuppl$##$7 &0J0?"#.

$#( 6ilden H=. Bell/s palsy. 4ngl + Ged. $##07 "&1J1"$"?"1.

40


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$1(Gauri9io Barbara, GH, 3hH, 6iovanni %ntonini, %nnarita @estri, :uigi @olpini,

Simonetta Gonini7 Eole of Kabat physical rehabilitation in Bell/s palsyJ % randomi9ed

trial $#1#, @ol. 1"#, o. 1, 3ages 1-;1$

$$( Barbara G, Gonini S, Buffoni %, ordier %, Eonchetti F, =arguindey %, Hi Stadio %,

urruto E, and Filipo E. 4arly rehabilitation of facial nerve deficit after acoustic

neuroma surgery. %cta Itolaryngol, 1$"J "$;"&,'$##"(.

$"( arolyn Kisner %nd :ynn %llen olby ;)herapeutic e2ercise, Foundations and

)echniques, 4di 0th, '$##"(.

$0( Gari amura, Gitsuru Gotoyoshi, Yasuhiro amura and oriyoshi Shimi9u, +ournal If

Iral Science, @ol , o 1 , 0&;&1, '$##!(.

$&( Kabat =, Knott G, 3roprioceptive Facilitation )echniques for )reatment of 3aralysis.

3hys )her Eev"", &";-0 '1&"(.

$-( GcGullen +, Whl):, % Kinetic hain %pproach for Shoulder Eehabilitation. + %thl

)rain "&, "$;"" '$###(.

$( Kofotolis , Kellies 4, 4ffects of two 0;wee* proprioceptive neuromuscular facilitation

programs on muscle endurance, fle2ibility, and functional performance in women with

chronic low bac* pain. 3hys )her !-,1##1;1#1$ '$##-(

$!( a*aCima 4, Yanagisawa K, mai G, )omita =, Kitabayashi Y, Shi*a 3F Ganual.

Quintessence, )o*yo, 1$;0 'in +apanese( '$##"(

41


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$( :usting %, Ball 4, :ooney G. % omparison of )wo 3roprioceptive euromuscular

Facilitation )echnique for mproving Eange If Gotion and Guscular Strength. so*inet

42erc Sci7 $J1&0;, '1$(.

"#( Susan S. %dler, Hominie* Bec*ers, Gath Buc*. 3F in practice an illustrated guide, $nd

revised 4dition. Springer, $###7 1;1&, "-0.

"1( =yvarinen %, )ar**a G, Gervaala 4, 3aa**onen %, @altonen =, uutinen +. utaneous

electrical stimulation treatment in unresolved facial nerve paralysisJ an e2ploratory

study. %m + 3hys Ged Eehabil. $##! Hec7 !'1$(J $;.

"$( Beurs*ens =, =eymans 36. 3ositive effects of mime therapy on sequelae of facial

paralysisJ stiffness, lip mobility, and social and physical aspects of facial disability.

Itology 5 eurotology $##"7 $0J -?-!1

""( Beurs*ens =6, =eymans 36, Iostendorp E%B. Stability of benefits of mime therapy

in sequelae of facial nerve paresis during a 1;year period. Itology 5 eurotology $##-7

$J1#" ? 1#0$

"0( @an Swearingen +G, Brach +S. )he facial disability inde2J reliability and validity of a

disability assessment instrument for disorders of the facial neuromuscular system.

3hys)her1-7-J1$!!?1"##

"&( 4lliott +G '$##-(J 3hysiotherapy treatment of Bell’s palsyJ % case report. ew >ealand

+ournal of 3hysiotherapy "0'"(J 1-;11.

"-( 4*man 3. 3sychosocial aspects of facial paralysis. nJ Gay G, 4d. )he Facial erve.

ew Yor*, YJ )hieme Gedical 3ublishers7 1!-J!1?!

42


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"( Kang )S, @rabec +), 6iddings , )erris H+. Facial nerve grading systems '1!&;$##$(J

Beyond the =ouse;Brac*mann Scale. Itol eurotol $##$7 $"J-;1.

"!( 4vans E%, =arries G:, Baguley HG, Goffat H%J Eeliability of the =ouse and

Brac*mann grading system for facial palsy. + :aryngol Itol 1!, 1#"J 1#0&;1#0-.

"( 4ffect of long;term electrical stimulation on motor recovery and improvement of

clinical residuals in patients with unresolved facial nerve palsy. )argan ES, %lon 6, Kay

S:. Itolaryngol =ead ec* Surg. $### Feb7 1$$ '$(J$0-;&$.

0#( Bell’s palsy 42ercises httpJ www.mindspring.comAmattcnAmedicalAbpe2ercises.htm

43


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APPENDI@ ,

IN!OR"ED CONSENT !OR"

understand that am being as*ed to participate in a research study in 3hysical Gedicine and

Eehabilitation entre, 3uducherry.

)he 3urpose of this study is to assess THE E!!ECTIVENSS O! A%ATBS PN!

REHA%ILITATION IN ACUTE UNILATERAL IDIOPATHIC %ELLS PALSY patients.

)he procedure of this study has been clearly e2plained to me.

reali9e that may not participate in the study if do not satisfy the selection criteria.

understand that my participation in this research study is entirely voluntary.

ac*nowledge that have the right to question any part of the procedure and can withdraw at

any time without this being held against me.

understand that the information obtained from this research study is strictly confidential.

ac*nowledge that results of this study may be used in future research and may be published,

provided that my personal details will not be revealed.

f have any questions regarding this research study, understand that may contact

Gr .RA"ADASS L. anytime during the study.

%ll my questions have been answered, and agree to participate in the study.

Date: Si2natu#e of the a#ti=iant

P(a=e: Si2natu#e of the in?e/ti2ato#

44


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APPENDI@ *

PATIENT EVALUATION SHEET !OR DATA COLLECTION

66EIW3 % B

Demo2#ahi= Data

ame J

%ge J

Se2 J

Iccupation J

%ddress J

Hiagnosis J

Hate of onset J

Huration of Bell’s palsy J

Side of involvement J

"edi=a( hi/to#y

Hrugs history J

3rior history of Bell’s palsy J Y4SAI

=ypertension J Y4SAI

Hiabetes mellitus J Y4SAI

=eart Hisease J Y4SAI

3rior @% A )% J Y4SAI

45


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Ither Hetails J

So=ia( hi/to#y

3ersonal history J

Garital status J

:iving situation J

=obbies J

So=ioe=onomi= hi/to#y J

P/y=ho(o2i=a( ima=t J %n2ious AHepressed A oncernedA Ither

On o&/e#?ation

%symmetric facial e2pression J3E4S44A%BS44

)he corner of mouth drops J3E4S44A%BS44

aso labial foldis flattened J3E4S44A%BS44

3alpebral fissure is widened J3E4S44A%BS44

Dasting if any J3E4S44A%BS44

Bell/s phenomenon J3E4S44A%BS44

Facial asymmetry J3E4S44A%BS44

Syn*inesis J3E4S44A%BS44

Blurred vision J3E4S44A%BS44

Hrooling J3E4S44A%BS44

@ertigo J3E4S44A%BS44

:acrimation J3E4S44A%BS44

Itorrhea J3E4S44A%BS44

46


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On a(ation

)enderness J3E4S44A%BS44

On e>amination

)ightness J 3E4S44A%BS44

ontracture J 3E4S44A%BS44

Heformity J 3E4S44A%BS44

Sen/o#y E>amination of V th ne#?e

Superficial J 3E4S44A%BS44

)ouch J 3E4S44A%BS44

3ressure J 3E4S44A%BS44

3ain J 3E4S44A%BS44

Heep J 3E4S44A%BS44

Sen/o#y E>amination of VII th ne#?e

%fferent J )aste from anterior tongue

4fferent 'Somatic( J Guscles of facial 42pression

4fferent '@isceral( J )earing 'lacrimal gland(

Salivation 'Sub mandibular and sublingual glands(.

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"u/=(e oMe# te/t ) fa=ia( ne#?e-

Guscle

6rade

Eight :eft

Frontalis

Irbicularis

orrugator

asalis

3rocerus

:evator angulioris

:evatorlabii sup.

>ygomaticus minor

Eesorius

>ygomaticus maCor

Hepressor labii inf

3laty9ma

Irbicularis oris

Buccinator

Gentalis

Hepressor angulioris

48


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FJ Functional, DFJ Dea* Functional, FJ on Functional, IJ %bsent

APPENDI@ F

DATA COLLECTION SHEET

Sl. o

6EIW3 % 6EIW3 B

=B6S FH =B6S FH

3E4 3IS) 3E4 3IS) 3E4 3IS) 3E4 3IS)

1

$

"

0

&

-

!

1#

11

1$

1"

10

1&

1-

1

1!

49


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1

$#

)I)%:

APPENDI@ 5

!ACIAL DISA%ILITY INDE@ )!DI-

ameJ ZZZZZZZZZZZZZZZZZZZZZZZZZ HateJ ZZZZZZZZZZZZZZZZZZZZZZZ

!a=ia( Di/a&i(ity Inde> Pa#t ,

3lease choose the most appropriate response to the following questions related to problems

associated with the function of your facial muscles.

Phy/i=a( !un=tion

,. HoM mu=h diffi=u(ty did you ha?e 0eein2 food in you# mouth' mo?in2 food a#ound

you# mouth' o# 2ettin2 food /tu=0 in you# =hee0 U/ua((y did Mith J

& O o difficulty $ O Guch difficulty

0 O % little difficulty 1 O Wsually did not eat because of health

" O Some difficulty # O Wsually did not eat because of other reasons

*. HoM mu=h diffi=u(ty did you ha?e d#in0in2 f#om a =u U/ua((y did Mith:




F. HoM mu=h diffi=u(ty did you ha?e /ayin2 /e=ifi= /ound/ Mhi(e /ea0in2 U/ua((y did

Mith:




50


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5. HoM mu=h diffi=u(ty did you ha?e Mith you# eye tea#in2 e>=e//i?e(y o# &e=omin2 d#y

U/ua((y did Mith:




4. HoM mu=h diffi=u(ty did you ha?e Mith u/hin2 you# teeth o# #in/in2 you# mouth

U/ua((y did Mith:




Office Use Only

Sl.

No

Score 6oal

1

2

3

4

5

)otalJ ZZZZZZZZZZ

) 4- 4 > *4 Q Phy/i=a( S=o#e.

) 4- 4 > *4 Q Phy/i=a( S=o#e 7oa(.

51


52/62

!a=ia( Di/a&i(ity Inde> Pa#t *

3lease choose the most appropriate response to the following questions related to problems

associated with the function of your facial muscles.

So=ia( e((&ein2 !un=tion

9. HoM mu=h time ha?e you fe(t =a(m and ea=efu(

- O %ll of the time " O Some of the time

& O Gost of the time $ O % little bit of the time

0 O % good bit of the time 1 O one of the time

6. HoM mu=h of the time did you i/o(ate you#/e(f f#om eo(e a#ound you

1 O %ll of the time 0 O Some of the time

$ O Gost of the time & O % little bit of the time

" O % good bit of the time - O one of the time

. HoM mu=h of the time did you 2et i##ita&(e toMa#d tho/e a#ound you




3. HoM often did you Ma0e u ea#(y o# Ma0e u /e?e#a( time/ du#in2 you# ni2httime

/(ee

1 O 4very night 0 O Some nights

$ O Gost nights & O % few nights

" O % good number of nights - O o nights

,+. HoM often ha/ you# fa=ia( fun=tion 0et you f#om 2oin2 out to eat' /ho' o# a#ti=iate

in fami(y o# /o=ia( a=ti?itie/

52


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53


54/62

Office Use Only

Sl.

No

Score 6oal

6

7

8

9

10

)otalJ ZZZZZZZZZZ

) 4- 4 > *+ Q So=ia(e((&ein2 S=o#e

) 4- 4 > *+ Q So=ia(e((&ein2 S=o#e 7oa(

Phy/i=a( )- So=ia( )- Q ) *++- tota( !DI S=o#e

Phy/i=a( )- So=ia( )- Q ) *++- tota( !DI S=o#e 7oa(

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APPENDI@4

Hou/e%#a=0mann 7#adin2 S=a(e

7#ade Definition

1• ormal symmetrical function in all areas

$

• Slight wea*ness noticeable only on close inspection

omplete eye closure with minimal effort

Slight asymmetry of smile with ma2imal effort

Syn*inesis barely noticeable, contracture, or spasm absent

"

• Ibvious wea*ness, but not disfiguring

Gay not be able to lift eyebrow

omplete eye closure and strong but asymmetrical mouth

movement

with ma2imal effort

Ibvious, but not disfiguring syn*inesis, mass movement or

spasm

0

• Ibvious disfiguring wea*ness

nability to lift brow

ncomplete eye closure and asymmetry of mouth with

ma2imal effort

Severe syn*inesis, mass movement, spasm

&• Gotion barely perceptible

ncomplete eye closure, slight movement corner mouth

Syn*inesis, contracture, and spasm usually absent

- • o movement, loss of tone, no syn*inesis, contracture, or

spasm

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APPENDI@ 9

A%ATBS )PN!- REHA%ILITATION

,. "u/=(e of Ei=#aniu/ )!#onta(i/-J %s* the patient to lift eye brows up, and loo* surprised

and wrin*le his forehead. %nd apply resistance to the forehead, pushing caudally and medially.

)his movement wor*s with eye opening. t is reinforced with nec* e2tension.

*. "u/=(e of =o##u2ato#/J /ue#=i((iJ %s* the patient to pull eye brows down 'frown(. %pply

resistance Cust above the eye brows diagonally in a cranial and lateral direction. )his motion

wor*s with eye closing.

F. "u/=(e of o#&i=u(a#i/ o=u(iJ %s* the patient to close the eyes. %nd give gentle diagonal

resistance to the eye lids, Separate e2ercise for upper and lower eye lids. %void putting

pressure on the eyeballs. 3revious two motions are facilitated by nec* fle2ion.

5. "u/=(e of (e?eate# a(eae /ue#io#i/: %s* the patient to open the eyes, loo* up, and

given resistance to the upper eye lids and resistance to the eyebrow elevation are reinforce the

action.

4. "u/=(e of #o=e#u/J %s* the patient to wrin*le your nose. %pply resistance ne2t to the nose

diagonally down and out. )his muscle wor*s with muscle corgurrator with eye closing.

9. "u/=(e of o#&i=u(a#i/ o#i/J %s* the patient to purse the lips whistle and say prunes. %pply

resistance laterally and upward to the upper laterally lip and downward to the lower lip.

6. "u/=(e of menta(i/J %s* the patient to wrin*le the chin. %pply resistance down and out of

the chin.

. "u/=(e of #i/o#iu/ and $y2omati=u/ ma1o#: %s* the patient to smile, apply resistance to

the corner of the mouth medially and slightly downward 'caudally(.

3. "u/=(e of Le?ato# La&ii Sue#io#i/: %s* the patient to Show his upper teeth. %nd %pply

resistance to the upper lip, downward and medially.

,+. "u/=(e of De#e//o# La&ii Infe#io#i/: %s* the patient to Show his lower teeth. %pplyresistance upward and medially to the lower lip. )his muscle and the platysma wor* together.

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,,. "u/=(e of Le?ato# An2u(i O#i/: %s* the patient to pull the corner of his mouth up, a small

smile. 3ush down and in at the corner of the mouth.

,*. "u/=(e of De#e//o# An2u(i O#i/: %s* the patient to 3ush the corners of his mouth

down, loo* sad. 6ive resistance upwards and medially to the corners of the mouth.

,F. "u/=(e of %u==inato#: %s* the patient to Suc* his chee*s in, pull in against the tongue

blade or gloved finger. %pply resistance on the inner surface of the chee*s with gloved fingers

or a dampened tongue blade. )he resistance can be given diagonally upward or diagonally

downward as well as straight out.

,5. "u/=(e of P(aty/ma: %s* the patient to pull his chin down. 6ive resistance under the chin

to prevent the mouth from opening. Eesistance may be diagonal or in a straight plane .Eesisted

nec* fle2ion reinforces this muscle.

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APPENDI@6

A%ATBS )PN!- REHA%ILITATION

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APPENDI@

%ELLBS PALSY E@ERCISES

)ry doing the e2ercises in front of a mirror, 'admittedly very discouraging at first(, repeat each

one 1# times, and try to do the entire set at least 1& times a day.

1. Hrin* all liquids through a straw. You/ll be dribbling all over yourself for a few days, but it

does help the muscles around the mouth.

$. Sniff strongly. Drin*le nose. Flare nostrils.

". url upper lip up and raise and protrude upper lip. )ry to touch nose.

0. ompress lips together. 3uc*er lips together 5 attempt to whistle.

&. Blow air into chee*s, attempting to *eep mouth closed 'li*e blowing a balloon.(Shift air

from one chee* to the other.

-. Smile without showing teeth, then smile showing teeth.

. )ry moving your lips into a smile slowly. )hen puc*er slowly trying to use equal strength

from both sides.

!. Hraw angle of mouth upward so as to deepen furrow from side of nose to side of mouth.

. =arden 'wrin*le( the chin, 'Vstic* outV the chin, li*e a bo2er( at first you will probably have

to manually push your muscles into place to do the e2ercises.

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1#. Wsing the finger tips tap from the Caw along the bone line to the centre of the top lip. Eeturn

the tapping motion to the Caw.

11. )ap along the lower Caw to the centre of the lower lip. Eeturn to the Caw using a tapping

motion. )ap along the lower Caw along the chin line 5 bac* to the Caw.

1$. Wsing your inde2 finger and thumb pull the corners of your lips in toward the centre.

Slowly and smoothly push out and up into a smile. ontinue the movement up to the chee*

bone. Wse a firm pressure.

1". % ma*eup brush or a soft tooth brush can be used for the chee*, Caw and lip stimulation.

10. 3ut a large button on a string. 3lace it under your lips. 3ull the string. )ry to hold it with

your lips. Gove the button to the right corner pull and resist. Eepeat on the left side.

1&. hew gum and hew and suc* on ice. Say a, e, i, o, u. Dhistle

For the eyeJ

1. 3lacing 0 finger tips on the eyebrow rub using a firm slow stro*e up to the hairline. Eeturn

downward to the eyebrow.

$. Wsing finger tips placed on the chee* tap lightly and slowly along the bone under the eye to

the bridge of the nose. Eeturn tapping along the chee* bone to the side of the face.

". )ry to close the eye slowly. Eaise eyebrows and hold for & seconds. Drin*le forehead.

&. Frown and draw eyebrows downward. lose eyes tightly. Din* with one and then the other

eye to the best of your ability. Ipen eyes widely.

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APPENDI@3

A%%REVIATIONS

RCT Randomi$ed Cont#o( T#ia(

PN! P#o#io=eti?e Neu#omu/=u(a# !a=i(itation

H%7S Hou/e%#a=0mann 7#adin2 S=a(e

!DI !a=ia( Di/a&i(ity Inde>

SD Standa#d De?iation

NS Not Si2nifi=ant

CA"AP Comound "oto# A=tion Potentia(

CNS Cent#a( Ne#?e/ Sy/tem

PRE P#o2#e//i?e Re/i/ted E>e#=i/e

AN A=ou/ti= Neu#oma

NL Na/o La&ia(

"L "ento La&ia(

"C "ento Ce#?i=a(

IRR Infe#a Red Ray/

physiotherapy bells palsy [dr.l.ramadass.pt 9500333960]

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