RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 .

NAME OF THE CANDIDATE AND ADDRESS

SHRUTHA KIRTHY PRAKASH D/O PROF. G.K. ANANTH PRAKASH # 3677, SOMESHWAR EXTENSION DODDABALLAPUR.

2 .

NAME OF THE INSTITUTION

KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY, K.R.ROAD, V.V.PURAM, BANGALORE 560004.

3 .

COURSE OF THE STUDY

M.P.T. (NEUROLOGY AND PSYCHOSOMATIC DISORDERS).

4 .

DATE OF ADMISSION

15/04/2010

5 .

TITLE OF THE TOPIC: A COMPARATIVE STUDY OF EFFECT OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION EXERCISES WITH ELECTRICAL MUSCLE STIMULATION AND EFFECT OF FACIAL EXPRESSION MUSCLE EXERCISES WITH ELECTRICAL MUSCLE STIMULATION ON BELLS PALSY.

Brief resume of the intended work 6.1 Need for the study: Bells 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] Because of injury/ infection of the facial nerve cause swelling of the nerve with in the bony canal causes pressure on the nerve fibers. This results in temporary loss of function of the nerve producing a LMN type of facial paralysis.[2] 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. In infra muscular lesion of the facial nerve leads to the facial muscles paralysis. In supra nuclear lesion of the facial nerve ( usually a part of hemiplegic) , leads only the lower part of the facial muscles is paralysed.[3] The incidence is about 20/ 100,000 in a year or about 1/60 people in life time. Bells palsy has a peak incidence between the ages of 15 40 years and men and women are equally affected.[1,4] The aetiology for bells palsy is idiopathic; most of the evidences support the viral aetiology due to Herpes Simplex. Heper 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 increase capillary permeability leading exudation of fluids, oedema and compression of micro circulation of the nerve. In Auto immune disorders, T-lymphocyte changes have been observed.[5] Clinical picture is a stereotyped, accompanied by bells phenomenon,[6] diffused retro- auricular pain the region of the mastoid facial weakness and asymmetry with drooling of liquids from the corner of the mouth on the affected side. Palpebral fissure is widened on the affected side, eye closure and blinking are reduced or absent, The angle of the mouth droops with reduction of the nasolabial fold. Smoothing of skin wrinkles, loss of taste in the anterior 2/3 rd of the tongue, hyperacusis.[7] Pathologically the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of excessive heat, cold, ultrasonic energy and local anesthetics.[8] Neuropraxia (reversible conduction block) results from minor degree of injury. Wallerian degeneration occurs in most severe lesions. The axons disappear distal to the lesion. Recovery is by regeneration of fibers and depends on ; 1) resolution ( or removal ) of the cause of nerve injury; and 2) Physical condition which permits sprouting axons to grow down inside the neurilemma tubes and reinnervates motor end plates. Final results is often marred by residual weakness, associated movements are synkinesis ( from misdirection of regenerating fibers ), fixed contracture of facial muscles and sometimes crocodile tearing.[8] Manual muscle testing: Grading muscles strength using gravity or resistance. Zero/gone No contraction felt, Trace Muscle can be felt to tighten but cannot produce movement, Poor - Produces movement with gravity eliminated but cannot function against gravity, Fair - Can raise the part against gravity, Good Can raise the part against outside resistance as well as against gravity, Normal Can over come a greater amount of resistance than a good muscle. [9]

House Brackman Facial Nerve Grading System : Grade 1 Normal, Grade 2 Slight, Grade 3 Moderate, Grade 4 Moderate to Severe, Grade 5 Severe, Grade 6 - Total.
[10]

Proprioceptive Neuromuscular Facilitation : Is a philosophy and a method of treatment was started by Dr. Herman Kabat in 1940s[11] 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. [11] 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.[11] Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity. [11] 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 and stretch. 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.[11] 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. A n 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.[12] The type of electrical stimulation should depend on the pathology of the facial nerve if there is no electrophysiological signs of muscle denervation (i.e., the facial nerve lesion is focal demyelination or neuropraxia). Faradic stimulation or electrical stimulation using 0.1 1 ms duration pulse delivered at a frequency of 1 2 pulses/s or more. This may be given for 50 200 contractions/ sessions 3 sessions week until recovery.[13] For stimulating muscles which is completed denervated interrupted galvanic stimulation of (IGS) of 100 ms triangular pulses may be given at a rate of 1 pulse/s for 30 100 contractions/ sessions. During each sessions electrical stimulation may be stopped once muscle fatigue occurs .[13,14] 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.[15] Purpose of the study: This study is intended to compare the effectiveness of Proprioceptive Neuromuscular Facilitation along with Electrical Stimulation and Facial Expression Exercises along with Electrical Stimulation on Bells Palsy.

Hypothesis: Null Hypothesis: There will be no significant difference between the effect of Proprioceptive Neuromuscular Facilitation with electrical stimulation and facial expression exercises with electrical stimulation on Bells Palsy. Alternate Hypothesis: There will be significant difference between the effect of Proprioceptive Neuromuscular Facilitation with electrical stimulation and facial expression exercises with electrical stimulation on Bells Palsy. 6.2 Review of Literature: Julian Holland (2008) stated that bells 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. Bells palsy remains idiopathic.[1] B.D.Chaurasias (1983) stated that the facial nerve is the motor nerve of the face its five terminal branches ( temporal, zygomatic, buccal, mandibular and cervical ) emerge from the parotid gland and diverge to supply the various facial muscles.[3] Julian Holland (2008) stated that the incidence is about 20/100,000 people a year are about 1/60 people in life time.[1] Julian Holland (2008) stated that up to 30 % of people with acute peripheral facial palsy have other identifiable causes, including stroke, tumors, middle ear diseases, Lyme disease. Severe pain is more consistent in ram say hunt syndrome caused by herpes zoster infection. Which has a worst prognosis then bells palsy.[1] T.S.Shafahak (2006) stated that physiotherapy in Bells Palsy, seems that local superficial heat therapy, massage, exercises, electrical stimulation and bio feed back training have place in the treatment of lower motor facial palsy.[13] L J Vanopdenbosch (2005) stated that Bells Palsy is an idiopathic facial palsy of the peripheral type.[16] Adour ( 1982) stated that the idiopathic bells 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.[17,18] 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.[6] Charles Clarke(2009 ) stated that clinically bells 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.[7] John Grovers ( 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.[8] Robert W.Lovett, M.D(2005) describes a method of testing and grading muscle

strength using gravity as resistance.[9] House JW. Brackmann BE ( 1985 ) stated that House Brackmann score is a score to grade the degree of nerve damage in a facial nerve palsy.[10] 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.[11] Kabat(1947) stated that timing is the sequencing of motions.[19] Kabat (1947) stated that timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity.[19] T.S.Shafahak (1994) stated that Bells Palsy is the most common cause of lower motor facial palsy.[20] T.S.Shafahak (1994) stated that in Bells Palsy, spontaneous complete recovery was found in about 69 % of the patients. therefore about 31% of the Bells Palsy patients who did not receive the appropriate treatment may suffer from incomplete recovery.[20] T.S.Shafahak (1994) stated that 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.[20] T.S.Shafahak(2006) stated that active exercises ( in front of the mirror ) prevent muscle atrophy and improve muscle function [13] T.S.Shafahak(2006) stated that heat therapy improves local circulation and lowers the skin resistance to electrical stimulation, thus the lowest current intensity could be used.[13] T.S.Shafahak(2006) stated that electrical stimulation of muscles aims at preserving muscle bulk especially in complete paralysis[13,21] 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.[13,21,22] 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.[15] 6.3 Objective of the Study: To assess the effect of Proprioceptive Neuromuscular Facilitation with Electrical Stimulation on Bells Palsy. To assess the effect of Facial Expression Exercises with Electrical Stimulation on Bells Palsy. To compare the effect of Proprioceptive Neuromuscular Facilitation with Electrical Stimulation on Bells Palsy and effect of Facial Expression Exercises on Bells Palsy.

7.

Materials and Methods:

7.1 Source of Data: Out Patient Department of Physiotherapy in Kempegowda Institute of Medical Science Hospital and Research Centre, Bangalore. Out Patient Department of ENT, Neurology & Neurosurgery in Kempegowda Institute of Medical Science Hospital & Research Centre, Bangalore.

7.2 Methods of Collection of Data: (a) Study Design: Comparative Study Sample size : 40 patients ( 20 in each group ) Sample method: Random Sampling method. Materials Used: Treatment tray includes: 1) Mackintosh 2) Lint pads 3) Pad or plate electrodes and pen electrodes. 4) Leads ( 2 ) 5) Straps 6) Cotton 7) Powder 8) Gel 9) Kidney tray Skin resistance lowering tray includes: 1) Saline water 2) Soap 3) Cotton (b) Inclusion Criteria: Patients with peripheral unilateral idiopathic facial palsy. Age group between 15 40 years. Patient must give the written informed consent. Both males and females. (c) Exclusion Criteria: Patient with history of recent head injury, Neurological disorders. Patient with history of Metal / Dental implants. Patient with history of diabetic neuropathy. Patient with history of immunodeficiency syndromes. Viral infections like herpes simplex. Tumors, congenital defects, open wounds.

7.3 Does the study require any Investigations or Interventions to be conducted on Patients or other Humans or Animals? If so , Please describe briefly: Yes, an intervention on Patients is done. Methodology: 40 patients with Bells palsy will be recruited for the studies who will be randomly selected by lottery method priory assessed and referred fulfilling the inclusion and exclusion criteria. Patients informed consent form will be taken and assessed. Patients will be divided into two groups. Group A & group B with each group consisting of 20 patients with Bells palsy. Group A will receive PNF exercises along with electrical muscle stimulation. PNF Exercises are : 1. Muscle.Epicranius (Frontalis): ask the patient to lift eye brows up, look surprised wrinkle your forehead. - Apply resistance to the forehead, pushing caudally and medially. This motions works with eye opening. It is reinforced with neck extension.[23] 2. Muscle corrugators supercilli: ask the patient to pull eye brows down ( frown ) - Apply resistance just above the eye brows diagonally in a cranial and lateral direction. This motion works with eye closing.[23] 3. Muscle orbicularis oculi: ask the patient to close the eyes. Separate exercise for upper and lower eye lids. - Avoid putting pressure on the eyeballs.2 previous motions are facilitated by neck flexion.[23] 4. Muscle procerus: ask the patient to wrinkle your nose. - Apply resistance next to the nose diagonally down and out. This muscle works with muscle corgurrator with eye closing.[23] 5. Muscle orbicularis oris: ask the patient to purse the lips whistle and say prunes. - Apply resistance laterally and upward to the upper laterally and downward to the lower lip.[23] 6. Muscle mentalis: ask the patient to wrinkle the chin. - Apply resistance down and out of the chin.[23] Group B will receive facial muscles exercises along with electrical muscle stimulation. Facial expressions Muscle Exercises are[24] : Sit relaxed in front of a mirror. Gently raise eyebrows; you can help the movement with your fingers. Draw your eyebrows together, Frown.

Exercises to help close the eye : Look down Gently place back of index finger on eyelid , to keep the eye closed With opposite hand gently stretch eyebrow up working Along the eyebrow line. This will help to relax the eyelid and Stop from becoming stiff. - Now try and gently press the eyelids together. Wrinkle up your nose. Take a deep breath through your Nose, try and flare Nostrils. Gently try and move the corners of mouth outward try and keep the movement the same on each side of your face. You can use your fingers to help once in position take your fingers away and if you can hold that smile. Lift one corner of the mouth then other.[24] Ask the patient to close and protrude the lips like (whistling)[25] Ask the patient to raise the skin of the chin. As a result the lower lip will protrude somewhat, as in pouting[.25] Electrical Muscle Stimulation will be given to both A & B Groups: Position of the patient: Supine lying position. [26] Check for contra indications, Placement of Electrodes In active electrode - over the nape of the neck. Active electrode by pen electrode motor point of the face muscles.[26] Frequency: 4 sessions per week for 3 weeks. Duration of the Study: 12 months. Statistical Analysis: Mann-Whitney U-Test and the results will be considered statistically significant whenever p 0.05. Other statistical tests may be applied during the time of data analysis after the intervention. 7.4 Has Ethical Clearance been obtained from your Institution in case of 7.3? Yes.

8.

LIST OF REFERENCES: 1. Julian Holland; Bells palsy; Bmj Clinical evidence; 2008:01:1204.

2. Richards. Snell. Clinicalneuroanatomy, 7th Edition. Wolters Voklvwer/ Lippincott Williams and Wilkins, 2009; 361-2. 3. B.D.Chaurasias. Human anatomy, 3rd edition. Cbs publishers and distributors, 1996; 3; 41-2. 4. Peitersen E. Bells Palsy; The spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta otolaryngol suppl 2002; 549: 430. 5. P.l.Dhingra. Diseases of Ear, Nose and Throat, 4th Edition. An imprint of Elsevier, 2004; 94. 6. Kenneth W. Lindsay, Ian Bone. Neurology and Neurosurgery illustrated, 4th Edition. Churchill living stones, 2004; 168. 7. Charles Clarke, Robin Howard, Martin Rossor, Simon Shorvon. Neurology A queen square text book, 1st Edition. Wiley Black Well. A John Wiley and sons, 2009; 475. 8. John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition. John Wright and sons ltd, 1985; 481. 9. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary Mclntyre Rodgers, William Anthony Romani. Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 22. 10. House JW, Brackmann DE, Facial Nerve Grading System. Otolaryngol head neck surg. 1985: 93, 146-7. 11. Susan S. Adler, Dominiek Beckers, Math Buck. Pnf in practice an illustrated guide, 2nd revised Edition. Springer, 2000; 1-15, 364. 12. Tim Watson. Electrotherapy Evidence - Based Practice, 12th edition. An imprint of Elsevier, 2008; 203-4. 13. T.S.Shafahak, The treatment of facial palsy from the point of view of physical and rehabilitation medicine; Eura Medici Phys 2006;42:41-7. 14. Mosforth J, Taverner D. Physiotherapy for Bells palsy. Br Med J 1958; 2: 675-7. 15. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary Mclntyre Rodgers, William Anthony Romani. Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 121.

9.

SIGNATURE OF THE CANDIDATE:

10.

REMARKS OF THE GUIDE:

11.

NAMES AND DESIGNATION OF:

11.1 GUIDE:

Dr. PREM KUMAR. B.N Assistant Professor

11.2 SIGNATURE:

11.3 CO-GUIDE:

Dr. ANIL.H.T Associate professor, Dept. of ENT, KIMS, Bangalore.

11.4 SIGNATURE:

11.5 HEAD OF THE DEPARTMENT:

Prof. R. BALASARVANAN K.I.P.T

11.6 SIGNATURE :

12.

12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL:

12.2 Signature: