RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.KARNATAKA.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE& ADDRESS / POOJA JAYANTILAL THAKKARAR,D/O. JAYANTILAL THAKKARAR,
NO: 4/1, 9TH MAIN, DR. RAJROAD,
SRINIVAS NAGAR, BANGALORE,
KARNATAKA - 560050
2 /
NAME OF THE INSTITUTION
/ KRUPANIDHI COLLEGE OF PHYSIOTHERAPY3 /
COURSE OF STUDY AND SUBJECTF
/ MASTER OF PHYSIOTHERAPY INNEUROLOGICAL AND PSYCHOSOMATIC DISORDERS
4 /
DATE OF ADMISSION TO COURSE
/ 15th JUNE 20135 / TITLE OF THE TOPIC
EFFECT OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION ON FACIAL FUNCTIONS IN FACIAL MUSCLE PARALYSIS- A RANDOMIZED EXPERIMENTAL STUDY.
6. / BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Facial Paralysis 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. Because of injury/ infection of the facial nerve.It causes swelling of the nerve with in the bony canal and causes pressure on the nerve fibers. This results in temporary loss of function of the nerve producing a LMN and UMN type of facial paralysis.[1]
The facial nerve is the seventh cranial nerve. The facial nerve is both a motor and a sensory nerve. The motor nerve of the face has 5 terminal branches (temporal, zygomatic, buccal, mandibular and cervical) emerges from the parotid gland and diverge to supply the various facial muscles. The trigeminal nerve is the sensory nerve of the face. Infra muscular lesion of the facial nerve leads to the facial muscles paralysis. supra nuclear lesion of the facial nerve (usually part of hemiplegic) , leads to lower part of the facial muscles paralysis.[2]
The incidence of facial paralysis is about 20/ 100,000 in a year or about 1/60 people in life time. Bell’s palsy has a peak incidence between the ages of 15 – 40 years and men and women are equally affected.The aetiology for facial paralysis is idiopathic; most of the evidences support the viral aetiology due to Herpes Simplex. Herpes Zoster or Epstein – Barr virus. Vascular ischemia may be primary or secondary. Primary ischemia is induced by cold or emotional stress. Secondary ischemia is the result of primary ischemia which causes increased capillary permeability leading to exudation of fluids, oedema and compression of micro circulation of the nerve.[1,3,]
Pathologically the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of excessive heat, cold, ultrasonic energy and local anesthetics.
Symptoms of Facial Palsy (UMN) [4]
· The corner of the mouth pulls down/droops
· Inability to smile on affected side
· Inability to puff up your cheeks, whistle or blow
· Altered taste
· Tingling of the affected half of the tongue
· Difficulty eating and drinking
· Difficulty brushing your teeth and spitting out
· Drooling from the weak corner of your mouth
· Excess or reduced salivation (dry mouth)
· Inability to pout
· Difficulty speaking because of weakness in the lips and cheek
Symptoms of Bell’s Palsy (LMN) [4]
· Loss of forehead wrinkles and inability to frown
· Droopy eyebrow and inability to raise eyebrow
· Inability to close the eye fully or blink (Bell’s phenomenon seen only in LMN lesion/bell’s palsy)
· Watery eye or dry eye (crocodile tears)
· Inability to squint
· Drooping of the lower eyelid which may make the eye appear wide
· Painful eye with symptoms of grittiness or irritation
· Sensitivity to light
· Soreness or redness of the white of the eye
· Drooling from the weak corner of your mouth
· Excess or reduced salivation (dry mouth)
· Nose runs or feels stuffy
· Inability to flare nostril
· Inability to wrinkle nose
· Loss of taste in the anterior 2/3rd of the tongue.
· Hyperacusis
Conventional treatment is most commonly used treatment for facial nerve paralysis, it is an old method of treatment, it includes electrical stimulation, massage and facial expression exercise.Facial massage include stroking, effleurage, finger kneeding, and will help to stimulate the muscle.[5]
Electrical Muscle Stimulation (EMS): Electrical stimulation stimulates muscles, nerves or a combination of both. The physiological effects of stimulation are used therapeutically to strengthen muscles, assist in wound healing, relieve pain and reduce oedema. An externally applied stimulus can cause depolarization of the nerve and thus initiate an action potential as long as the applied stimulus depolarizes the resting membrane potential to the threshold level.[6]
The type of electrical stimulation should depend on the pathology of the facial nerve if there are no electrophysiological signs of muscle denervation.
Facial muscle expression exercises: facial muscles are called the muscles of expression. The facial nerve, through its branches, innervates most of the facial muscles. Numerous muscles may act together to create movement (e.g., grimace), or movement may occur in a single area (e.g., as in raising an eyebrow). Loss of function of the facial muscles interferes with the ability to communicate feelings through facial expression.[7]
Proprioceptive NeuromuscularFacilitation: Is a philosophy and a method of treatment was started by Dr. Herman Kabat in 1940s. Dr. Herman Kabat defines Proprioceptive Neuromuscular 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 making easier.[8]
One of the basic procedures of Proprioceptive Neuromuscular Facilitation is Timing. Timing is to promote normal timing and increase muscle contraction through Timing for emphasis.Timing is defined as sequencing of motion.Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity.
Kabat (1947) wrote that prevention of motion in a stronger synergist will redirect the energy of that contradiction into a weaker muscle. This alteration of timing stimulates the Proprioceptive reflexes in the muscles by resistance andstretch. When we use bilateral movements while exercising the face, contraction of the muscles on the stronger or more mobile side will facilitate and reinforce the action of the involved muscles. Timing for emphasis, by preventing full motion on the stronger side will further promote activity in the weaker muscles.[8]
6.1 NEED OF THE STUDY.
Facial palsy and Bell’s palsy is most disabling neural condition in terms of facial expression and communication. There are several functional therapies available to deal with it. Conventional therapy is most commonly used treatment for facial paralysis and many innovative approaches are emerging. Proprioceptive neuromuscular facilitation is one of the promising treatment in neural paralysis and having literatures supporting that it is more effective than conventional therapy. Also the PNF is practicelimited clinically in this condition. So this is study intended to analyze the effects of PNF in facial palsy.
6.2 OBJECTIVES OF THE STUDY
[A] OBJECTIVES
a) To analyze the effect of conventional physiotherapy on facial function in Bell’s Palsy and facial Palsy subjects.
b) To analyze the effect of Proprioceptive neuromuscular facilitation on facial function in Bell’s palsy and Facial Palsy subjects.
c) To analyze the effect of Proprioceptive neuromuscular facilitation over conventional physiotherapy on facial function between Bell’s palsy and Facial Palsy subjects.
6.3 [B] HYPOTHESIS
Null hypothesis:
· There will be no significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Facial Palsy.
· There will be no significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Bell’s palsy.
Experimental hypothesis:
· There will be significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Facial Palsy.
· There will be significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Bell’s palsy.
6.4 REVIEW OF LITERATURE
1] Review for the facial palsy
Julian Holland (2008)stated that bell’s palsy is characterized by an acute, unilateral, partial or complete paralysis of the face. This may occur with mild pain, numbness, increased sensitivity to sound and altered taste. Bell’s palsy remains idiopathic. He also stated that the incidence is about 20/100,000 people a year are about 1/60 people in life time.Up to 30 % of people with acute peripheral facial palsy have other identifiable causes, including stroke, tumors, middle ear diseases, Lyme disease.[1]
L J Vanopdenbosch (2005)stated that Bell’s Palsy is an idiopathic facial palsy of the peripheral type and Adour (1982)stated that the idiopathic bell’s palsy is an acute disorder of the facial nerve which may begin with symptoms of pain the mastoid region and produce full or partial paralysis of movement of one side of the face.[9,10,11]
2]Review of the facial disability
Lindsay (2004) stated that on attempting to close the eye and show the teeth, the one eye does not close and the eye ball rotates upwards and outwards.[12]
Charles Clarke(2009)stated that clinically bell’s palsy patients presents with diffuse retro auricular pain in the region of the mastoid, facial weakness and drooling of liquids from the corner of the mouth on the affected side, hyperacusis.[13]
John Grover’s (1985) stated that the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of excessive heat, cold, ultrasonic energy and local anesthetics.[14]
3]Review on the treatment of the facial muscle paralysis
T.S.Shafahak (1994)stated that in Bell’s Palsy, spontaneous complete recovery was found in about 69 % of the patients. Therefore about 31% of the Bell’s Palsy patients who did not receive the appropriate treatment may suffer from incomplete recovery. Clinical evaluation for both the severity of paralysis and the presence of complication ( synkinesis, hyperkinesis or contracture) is the first step before the start of treatment or rehabilitation.[15]
BeurskensCH, Heymans PG(2004).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.[16]
T.S.Shafahak (2006) stated that physiotherapy in Bell’s Palsy, seems that local superficial heat therapy, massage, exercises, electrical stimulation and bio feedback training have place in the treatment of lower motor facial palsy. Active exercises (in front of the mirror) prevent muscle atrophy and improve muscle function. Heat therapy improves local circulation and lowers the skin resistance to electrical stimulation, thus the lowest current intensity could be used. He also stated that electrical stimulation of muscles aims at preserving muscle bulk especially in complete paralysis and it has also a psychological benefit as the patient observes muscle contraction in his face that gives him hope for recovery from facial paralysis.[17]
Kendall (2005)stated that facial muscles are called the muscles of expression. The facial nerve, through its many branches, innervates most of the facial muscles. Numerous muscles may act together to create movement or movement may occur in a single area.[7]
4]Review of PNF Technique
Kabat (1950) stated that Proprioceptive Neuromuscular Facilitation (P.N.F) is a concept of treatment. Its underlying philosophy is that all human beings, including those with disabilities, have untapped existing potential.Kabat(1947)stated that timing is the sequencing of motions. Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity.[8]
Manikandan N(2007)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.[5]
Namura M, Motoyoshi M, Namura Y, Shimizu N (2008).Evaluatedthe 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.[18]
Brach-JS; VanSwearingen-JM; Lenert-J; Johnson-PC (1997).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 synkinesis associated with partial recovery from facial paralysis were reduced with facial neuromuscular retraining for individuals with facial nerve disorders.[19]
Salinas RA, Alvarez G, Daly F, Ferreira J (2010) Their objective was to assesess the validity of an early rehabilitative approach to Bell's palsy patients. A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35–42 years) affected by Bell's palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The evaluation was carried out by measuring the amplitude of the compound motor action potential (CMAP), as well as by observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy. Patients belonging to the rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after onset of facial palsy, without presenting greater values of CMAP 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.[20]
5]Review of the House Brackmann score and MMT.