LOW LEVEL LASER THERAPY (LLLT) FOR FACIAL PALSY PATIENTS

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1 OIGINA ATICES OW EVE ASE THEAPY (T) O ACIA PASY PATIENTS Ikuko Okuni.D. 1, Takashi Harada.D. 1, Nobuyuki Ushigome.D. 1, Toshio Ohshiro.D., Ph.D. 2, Yoshiro usya.d. 3, Yu aruyama.d. 4, Toru Suguro.D. 5 and Kazuaki Tsuchiya.D. 5 1: Department of ehabilitation edicine, Toho University School of edicine, Tokyo; 2: Japan edical aser aboratory, Shiunjuku, Tokyo; 3: Department of Orthopaedic surgery, Toho University Hospital, Tokyo; and Departments of 4: Plastic Surgery and 5: Orthopaedic Surgery, Toho University School of edicine, Tokyo, Japan We used low level laser therapy (T) to treat peripheral facial palsy patients and investigated its efficacy. We studied 23 cases with Bell s palsy (11 male and female ages ranging from 21 to 82 years with an average of 51.7 years). They visited the rehabilitation department of our university hospital between April 1, 02 and arch 31, 06. We used a 1 watt semiconductor laser device. The stellate ganglion was irradiated with the laser three times for seconds (90 seconds total). T was performed twice a week. We evaluated the therapeutic effects with Yanagihara s method after 2 months of treatment. The efficacy of the treatment was noted in 83% of our 23 cases. acilitation of blood circulation and nerve regeneration were considered to be the possible effective mechanisms of T. On the other hand, why the effect was insufficient in 17% of our patients has to be further investigated. Key Words: ow evel aser Therapy (T), Peripheral acial Palsy, Yanagihara s score Introduction acial nerve palsy is one of the most frequent cranial neuropathies among disorders of the cranial nerves. Since this nerve runs along the temporal bone and spreads to the superficial part of the face, the facial nerve can be easily affected by injury or physical pressure, or inflammation. Among those affected patients we have come across, Bell s palsy was frequently noted when the patients had an upper respiratory tract infection, or when they felt fatigue or exposed to stress. In many cases, we could not find the exact causes. The facial nerves control the facial expression muscles, and therefore the face in affected patients becomes asymmetrical. Especially among female patients, they are not satisfied by the conventional treatment from a cosmetic point of view. The present Addressee for Correspondence: Takashi Harada Department of ehabilitation edicine Toho University School of edicine Omori-nishi, Ota-ku, Tokyo, , Japan Tel: ax: haradata@med.toho-u.ac.jp 08 J, Tokyo, Japan study was designed to investigate the treatment efficacy of ow evel aser Therapy (T) for Bell s palsy. Subjects and ethods Twenty-three consecutive cases with Bell s palsy were enrolled in the present study who visited either the Department of Otorhinolaryngology, or Department of Neurology our university hospital between April 02 to arch 06. They underwent 2 weeks of steroid administration before attending the Department of ehabilitation. All cases were in the subacute or chronic stage. Twelve patients were female, and 11 were male. The age distribution ranged from 21 to 82 years, with an average of There were cases with right side facial palsy, and 13 with facial palsy of the left side (Table 1). We used a 1 watt semi-conductor laser device (ig. 1, D01, atsushita Electric Corporation, Tokyo, Japan), the specifications of which are seen in Table 2. The area over the stellate ganglion was irradiated with the laser for seconds per shot, giving a radiant flux of.1 J/cm 2. Three shots anuscript received: June 08 Accepted for publication: June 08 aser Therapy 17.3:

OIGINA ATICES were given per session with a 5-second break between them (90 seconds total). T was performed twice a week. We evaluated the efficacy of T after 8 weeks.

2 OIGINA ATICES were given per session with a 5-second break between them (90 seconds total). T was performed twice a week. We evaluated the efficacy of T after 8 weeks. or assessment of the dermal muscle, we used a 6- level evaluation by using Yanagihara s 40 point scoring method (1). or cases with a poor treatment effect, we used other methods to help camouflage their asymmetrical countenance, such as changing their hair style and wearing glasses. Statistical analysis: Yanagihara s score was shown as the mean SD. The statistical data of the degree of improvement were analyzed with the Wilcoxon test. The relationship between age and severity of palsy was analyzed with the Spearman Coefficient of Correlation (CC). The level of statistical significance was set below 5%. ig. 1: ront view of the D-01 T system esults After 8 weeks of T treatment, we evaluated the effects with Yanagiharas method (ig. 2). The results were as follows: An result was achieved in 6 patients, in 13, air in 2 and Poor in 2. No patients showed no change or got any worse. The and response were combined to give the significant therapeutic efficacy, and the effective ratio of T was 83% (p<0.05). The average age of the 6 cases with excellent effects was years. That of 13 cases with good effect was years, Table1: Demographics of acial Palsy patients (n=23) Case Age Sex Spasticity side Score at first visit The score after 2-month treatment Treatment evaluation (Table 3) air Poor air Poor *Score: Yanagihara s Score 1 Okuni I. ET A.

OIGINA ATICES Table2: Specifications of the 1 watt T system Device aser Element odel anufacturer Wavelength Output ode Irradiation Time Energy Density Power Supply Semiconductor aser Diode Ga-Al-As:

3 OIGINA ATICES Table2: Specifications of the 1 watt T system Device aser Element odel anufacturer Wavelength Output ode Irradiation Time Energy Density Power Supply Semiconductor aser Diode Ga-Al-As: Gallium-Aluminum-Arsenide D-01 model atsushita Electric Corporation, Tokyo, Japan 8nm±15nm 00mW±% Continuous Wave ode sec.1 J/cm2 0VAC, 50-60Hz : : air: Poor: Unchanged Worse: Table 3: Yanagihara s Score ig. 2: odels of each expression for Yanagihara s method (each expression is given 4 points, 40 points total) a: symmetrical at rest b: make wrinkles on their brows c: close eyes lightly d: close eyes tightly e: close one eye f: move the nasal alae g: puff out the cheeks h: show the teeth i: whistle j: stretch the corners of the mouth to the side and that of 4 cases with fair and poor effect was 62 years. The younger the patients, the better was the therapeutic effect (p<0.05). No patient reported any adverse side effects. In the 13 patients who had a low Yanagihara score of or below at the first visit, their score was still low (25 on average) after 2 months of T treatment. In these patients, we continued T after the study evaluation period. In the 4 patients who were evaluated as air or Poor, we advised them to use other methods to camouflage their assymetry such as changing their hair style, careful application of cosmetics wearing glasses or using a night splint. However, they were not satisfied. Of the patients evaluated as excellent, all were active in society, and were highly motivated because of their participation in social activi- T O ACIA PASY PATIENTS 137

4 OIGINA ATICES ties. Among the female patients 2 complained of this therapeutic evaluation, and it turned out that the objective evaluations by the clinician and the subjective evaluation by the patient were not necessarily identical. In the facial dermal muscles, we found the tendency that the orbicularis oculi muscle and the orbicularis oris muscle were slow to recover from the palsy in all cases. Discussion The facial nerves originate from the facial nucleus, run through the auditory canal and the temporal bone, and spread out to the face. The facial nerves innervate the superficial dermal muscles of the face. Therefore, coldness, trauma, and stress can trigger muscle spasms and may this lead to slow healing. In Japan, the frequency of Bell s palsy is approximately 70% (2) among all kinds of facial palsy. In Western countries, however, it has been reported to be about 50% (3, 4, 5). Ishida (2) hypothesized that exudative inflammation caused by spasticity would cause edematous neuritis, then facial palsy would occur. On the other hand, urakami (6) reported that herpes simplex infection was the most predominant cause of Bell s palsy. any reports (7, 8, 9) indicated that the prognosis of Bell s palsy was better when the patients are younger, and was worse when they are older. Our results showed the same tendency. After the primary treatment with steroid administration, various treatments have been given, such as facial muscle massage (), therapeutic exercise (11), low frequency electrical stimulation (, 13), medication, acupuncture therapy (), and so on. However, we do not have any standardized treatment policies, or evaluation criteria for the various medical treatments. Yamada (15) and Yoshida () reported on T for facial palsy. According to their reports, the area around the stellate ganglion was irradiated with T and they had excellent results in as high as 90% of the cases. Also, many researchers (17 21) have reported in experimental studies on the rat, T facilitated nerve regeneration from facial palsy. The present study revealed that there is often a considerable gap between the patients evaluation or satisfaction with their facial palsy treatment, and the objective clinical evaluation. In Japan, we evaluate the treatment effects of facial palsy with Yanagihara s score. Even if we evaluated patients as according to the score and EB, the patient s own evaluation is often not psychologically and socially. We saw this trend more with female patients than male patients. acial palsy causes restriction of expression in the facial dermal muscles. The treatment satisfaction rate of females was lower than that of males. We assume that women especially would like to show various and fine expressions, and this leads to the above result. Therefore, physicians need to understand female patients psychological factors when they treat them. In the present study, T was applied after a 2- week steroid administration right after the palsy onset, and achieved an efficacy rate of 83%. There are several theories as to the action mechanism or mechanisms of T. We postulate that blood circulation was promoted to the facial nerves, thereby facilitating nerve regeneration, and therapeutic exercise further enhanced the treatment effect. To the patients who were not satisfied with the therapeutic effects, we offered other methods as listed above, such as changing their hair style or wearing glasses. However, female patients tended not to accept these kinds of treatments, and their therapeutic satisfaction was low. How to satisfy them is one of the future problems we must address in the treatment of facial palsy. Conclusions We used ow evel aser Therapy (T) to treat 23 patients with Bell s palsy. T was effective in 83% of our 23 patients. or patients who had unsatisfactory recovery, we offered other non-clinical methods such as changing their hair style or wearing glasses. We considered that the mechanism of action of T in the treatment of Bell s palsy might be related to enhanced blood circulation, and facilitation of nerve regeneration. 1 Okuni I. ET A.

5 OIGINA ATICES eferences 1: Yanagihara N. (1977):On standardized documentation of facial palsy. J of Japanese Oto-rhinolaryngology 80: : Ishida. (05): Oto-rhinolaryngology: Primary manual. Kinpodo Publisher, Kyoto : Adour KK, Byl, Hilsinger I, Kahn Z, Sheldon I(1978):The true nature of Bell s Palsy:analysis of 00 consecutive patients. aryngoscope 88: : Peitersen E. (1982): The natural history of Bell s palsy. Am J Otol 4: : Devriese PP, Schumacher T, Scheide A, Jongh H de, Houtkooper J (1990): Incidence, prognosis and recovery of Bell s palsy. Clin Otolaryngol 15: : urakami S. (1996): Bell s palsy and Herpes Simplex virus. Ann Intern ed 4:27-. 7: Nakazawa K., Yamada I. (02): Case eport of 79 patients with acial nerve palsy. Gunma edicine 76: : Kasuya N., Hanada. (03): Statistical observation of patients with facial nerve palsy. Bulletin of Koga Public Hospital 6:1-8. 9: Yanagihara N. (1998): Current progress in facial nerve palsy. J of Clinical ehabilitation 7:11-. : Imai Y., Nagasue H., Tanba S. (1996): Comparative effectiveness Between massage and acupuncture treatment in patients with Bell s type facial palsy. Progress in edicine : : Orihira S., Ishijima Y., inami T. (06): Therapeutic exercise on Patients with facial nerve palsy. edical J of Noto s general hospital 17:-17. : Aono H. (1999): Effects of Electrical Stimulation for ehabilitation of acial Nerve Paralysis. Clinical Oto-rhino-laryngology. 92: : Kudo H., Kubo T., Aida. (00): Treatment and recovery of facial Palsy. Physical Therapy 29,4-6. : Ebiko K. (04): Acupuncture treatment on patients with facial palsy. Clinical acupuncture and moxibustion 19: : Yamada H., Ogawa H. (1994): Case report of 6 patients: acial palsy patients treated with low level laser therapy. J of Japanese aser edicine.15: 7-. : Yoshida K., ukaya., Ishida S. (1997): anagement of acial Dysfunction using ow Power aser. J of Japanese aser edicine.: : Anders JJ, Borke C, Woolery S(1991): ow energy laser irradiation alters immunofluorescence of choline acetyltransferase (ChAT) in regenerating rat facial Neurons. Neurosci 17:83. : ulligan K, Woolery S, Anders JJ (1991): The effect of low energy He-Ne laser irradiation on neurite elongation in vitro. aser Surg ed Suppl 3:. 19: Anders JJ, Borke C, Woolery SK, Van de erwe (1993): ow power laser irradiation alters the rate of regeneration of the rat facial nerve. aser Surg ed 13: : Snyder S, Blake K, Dhawan, Anders JJ, Borke C, Beebe DC(1993): Quantification of calcitonin gene-related peptide mna from cranial nerve nuclei. Soc Neurosci Abstr 19: : Snyder S, Bymes K, Anders JJ, Borke C, Sanchez A (02): Quantification of calcitonin gene-related peptide mna and neuronal cell death in facial motor nuclei following axotomy and 633nm low power laser treatment. aser Surg ed 31:2-2. T O ACIA PASY PATIENTS 139

EFFECTS OF LOW LEVEL LASER THERAPY (LLLT) ON SPASTICITY CAUSED BY CEREBRAL VASCULAR ACCIDENTS (CVAS)

EFFECTS OF LOW LEVEL LASER THERAPY (LLLT) ON SPASTICITY CAUSED BY CEREBRAL VASCULAR ACCIDENTS (CVAS) EECTS O LOW LEVEL LASER THERAPY (LLLT) ON SPASTICITY CAUSED BY CEREBRAL VASCULAR ACCIDENTS (CVAS) Nobuyuki Ushigome, Takashi Harada, Ikuko Okuni, Toshio Ohshiro, Yoshiro usya, Kazuhiro izutani, Yu aruyama,