Effect of facial neuromuscular re-education on facial symmetry in patients with Bell s palsy: a randomized controlled trial

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1 Clinical Rehabilitation 2007; 21: Effect of facial neuromuscular re-education on facial symmetry in patients with Bell s palsy: a randomized controlled trial N Manikandan Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka, India Received 19th June 2006; returned for revisions 22nd July 2006; revised manuscript accepted 4th August Objective: To determine the effect of facial neuromuscular re-education over conventional therapeutic measures in improving facial symmetry in patients with Bell s palsy. Design: Randomized controlled trial. Setting: Neurorehabilitation unit. Subjects: Fifty-nine patients diagnosed with Bell s palsy were included in the study after they met the inclusion criteria. Patients were randomly divided into two groups: control (n/30) and experimental (n/29). Interventions: 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. Main measures: All the patients were evaluated using a Facial Grading Scale before treatment and after three months. Results: The Facial Grading Scale scores showed significant improvement in both control (mean 32 (range 9.754) to 54.5 ( )) and the experimental (33 ( ) to 66 ( )) group. Facial Grading Scale change scores showed that experimental group (27.5 ( )) improved significantly more than the control group (16.5 ( )). Analysis of Facial Grading Scale subcomponents did not show statistical significance, except in the movement score (12 (8 16) to 24 (1218)). Conclusion: Individualized facial neuromuscular re-education is more effective in improving facial symmetry in patients with Bell s palsy than conventional therapeutic measures. Introduction Physiotherapy has been widely practised for rehabilitation of patients with Bell s palsy since Treatment modalities originally developed for the Address for correspondence: N Manikandan, Department of Physiotherapy, Manipal College of Allied Health Sciences, MAHE, Manipal , Karnataka, India. mani.kandan@manipal.edu extremities were applied to the face. Gross facial exercises, 1 massage, electrical stimulation and orthotic devices or taping to lift drooping flaccid faces were the treatments of choice. Electrical stimulation continues to be widely used in the treatment of facial paralysis 2,3 although there is mounting evidence that it may be contraindicated. Several studies on animal models indicate that the use of electrical stimulation is # 2007 SAGE Publications /

2 Neuromuscular re-education in Bell s palsy 339 disruptive to re-innervation 4 and thus may be contraindicated for individuals with facial nerve disorders. 4 Gross facial exercises should be completed with maximum effort. The outcomes of such interventions were less than optimal, with the patients often developing mass action or synkinesis. 5 Controversy exists about the application and effects of these traditional methods when used in the rehabilitation of patients with Bell s palsy. Recognizing the unique rehabilitation problems associated with facial paralysis, the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin and Froedtert Memorial Lutheran Hospital have established the first facial neuromuscular reeducation programme. Facial neuromuscular re-education is a conservative approach to facial rehabilitation. It offers outpatient rehabilitation services designed to regain symmetrical facial movement and to reduce or eliminate associated speech and swallowing problems. Facial neuromuscular re-education consists of evaluation of facial impairments and functional limitations, guided training sessions of correct movement patterns and instruction in a specific facial movement exercise programme. 6,7 Recent studies have shown that facial neuromuscular re-education could be used in the treatment of patients with facial paralysis, 8,9 but literature which proves the efficacy of facial neuromuscular re-education over conventional therapeutic measures is lacking. To address this problem, we conducted this study to compare the effect of facial neuromuscular re-education and conventional therapeutic measures in improving facial symmetry in patients with Bell s palsy. This study also helps to determine an effective facial rehabilitation technique in patients with Bell s palsy. Methods Subjects We enrolled 59 patients diagnosed with Bell s palsy from Kasturba Hospital, Manipal after they met the inclusion criteria. The inclusion criteria were patients diagnosed with unilateral Bell s palsy of both gender in the age group 1560 years. We excluded patients who had diseases of the central nervous system, sensory loss over the face, recurrence of facial paralysis and who were uncooperative during the study. We divided the patients into two groups control group and facial neuromuscular re-education group by the method of block randomization using six blocks with 10 in each block. Patients in the control group received conventional treatment while patients in the facial neuromuscular reeducation group received techniques that were tailored to each patient. Procedure The study protocol was reviewed by the Institutional Research Committee of Manipal College of Allied Health Sciences, MAHE, Manipal. Prior to treatment, we obtained informed written consent from the patients. We treated patients in the control group with electrical stimulation, gross facial expression exercises and massage according to our conventional protocol. Electrical stimulation was given to patients in three sessions per day. We used galvanic current to stimulate the facial muscles and faradic current to the facial nerve trunks. Ninety contractions were given to each muscle in three sessions and 10 contractions were given to each facial nerve trunk and the main trunk. We increased the intensity until minimal visible contraction of the muscle was obtained. Electrical stimulation was given for six days a week for a period of two weeks. We also taught facial expression exercises, which included eye closure, eyebrow raise, frown, smile, snarl, pucker and pout. We also advised the patients to do exercises such as balloon blowing, chewing gum on the paralysed side, using a straw and pronouncing vowels to strengthen the cheek muscles. We treated patients in the facial neuromuscular re-education group with techniques that were tailored to each patient. To avoid fatigue, we instructed patients to do only 510 repetitions of facial exercises three times a day in the initial stages. We also instructed the patients to do symmetrical facial movements on the affected side without allowing the voluntary movement of the uninvolved side to distort the movement. We applied resistance only to the isolated movements, without causing mass action or synkinesis.

3 340 N Manikandan We warned the patients to concentrate on the quality of the exercises and not on the quantity. We advised patients in both the groups to use a hand-held mirror during the exercise programme for the visual feedback. Facial massage was given and strapping was applied to the face to maintain the symmetry of the face. We encouraged the patients to follow-up these exercises at home for a period of three months by providing a daily log. We also provided a list of tips for the patients in both groups, including to wear glasses or an eye shield and maintain oral hygiene. We also reassured the patients in both the groups about the condition and motivated them to perform the exercises regularly. Measurements We assessed Facial Grading Scale prior to the onset of treatment and after a period of three months. The Facial Grading Scale is an observerbased rating scale that measures facial symmetry under three components: rest, movement and synkinesis. 10 Earlier studies have proven the sensitivity, intra-rater reliability (g/0.94), interrater reliability (g/0.90) and construct validity ( with House Brackmann facial grading system) by comparing pre-rehabilitation and postrehabilitation scores for patients with facial nerve disorders. 10,11 Data analysis We analysed the data using Wilcoxon signedranks test to compare the Facial Grading Scale scores within each group and Mann Whitney U- test to compare the scores between the two groups. Results Table 1 Demographic data of the patients in both control group and facial neuromuscular re-education group Parameters We enrolled 59 patients in our study. Demographic data of the patients are given in Table 1. Two patients from the control group and one from the facial neuromuscular re-education group dropped out before the completion of the study (Figure 1). Wilcoxon signed-ranks test showed significant improvement in all the components of Facial Grading Scale scores in both control and facial neuromuscular re-education groups except synkinesis. Facial Grading Scale scores pre and post treatment in both groups and the statistical values are given in Tables 2 and 3 respectively. Mann Whitney U-test showed significant difference in the change in total score and movement score between the two groups. However we did not find significant difference in the rest score and synkinesis score between the two groups. Facial Grading Scale change scores of all the components in both the groups are given in Table 4. Discussion Control group Facial neuromuscular re-education group No of patients Gender Men Women Mean (SD) age (years) (13.3) 35.7 (10.4) Mean (SD) post onset duration (days) 11.4 (7.3) 12.5 (11.0) This study details the findings of a prospective randomized study for assessing the effect of facial neuromuscular re-education over conventional therapeutic measures in patients with Bell s palsy and finds that targeted re-education leads to greater improvement. There was a statistically significant change between pre- and post-treatment scores of Facial Grading Scale score in both Clinical messages. Facial neuromuscular re-education is an effective technique in improving the facial symmetry and hence could be used as the treatment of choice in patients with Bell s palsy.. This may be attributed to task-specific controlled training of facial muscles.

4 Neuromuscular re-education in Bell s palsy patients diagnosed with Bell s palsy were recruited for the study Exclusion (3) 1 recurrent paralysis 2 uncooperative 59 patients included for the study after they met the inclusion criteria Control group (n = 30) Facial neuromuscular re-education group (n = 29) 30 Patients received conventional treatment for three weeks 29 patients received facial neuromuscular re-education technique for three weeks Losses (2): 1 discharged from set up 1 dropped out due to personal reasons Losses (1): 1 discharged from set up Outcome data 28 patients data were used for analysis after 3 months Outcome data 28 patients data were used for analysis after 3 months Figure 1 Flow diagram of the study. groups, but spontaneous recovery in the acute stages of Bell s palsy may well account for this. 12 Movement symmetry Comparison of individual components of the Facial Grading Scale between the two groups showed a statistical significance in the improvement of movement symmetry. This suggests that the patients in the facial neuromuscular re-education group performed the muscle actions more symmetrically than the control group. This could be explained by the task-specific training employed in the facial neuromuscular re-education in which the patients were asked to stop the exercises as soon as they found the uninvolved side moving more. These results add to the evidence of an earlier study done by Brach et al. 8 However, the importance of patients responsibility and prolonged repetition of motor behaviour in the correct pattern could not be underestimated. Rest symmetry The resting score component improved significantly within each group but intergroup comparison did not show statistical significance. This may be because we did not adopt any additional

5 342 N Manikandan Table 2 Pre- and post-treatment scores of all the components of facial grading score in the control group (n/28) FGS components Median (IQR) FGS Pre-treatment Post-treatment P-value Rest score 12.5 (108.7) 5 (510) B/0.01 Movement score 45 (28.564) 62 (4876) B/0.01 Synkinesis score 0 (00) 0 (00) 0.45 Total score 32 (9.754) 54.5 ( ) B/0.01 FGS, Facial Grading Scale; IQR, interquartile range. training for maintaining the resting posture in either of the groups. The intragroup comparison of resting and movement scores showed that eye components (resting eye posture, movement scores of eyebrow rise, eye closure and frowning) improved much better than the other components. Asymmetrical regeneration of facial nerve trunks could be a possible reason for this, as reported by Gagnon and Molina- Negro. 13 Synkinesis component The insignificance of the synkinesis scores in both the groups can be explained by less mean post-onset duration in Bell s palsy patients and the absence of synkinesis at the onset of treatment sessions. This gave no room for the therapy to show any effect on it. In spite of the insignificance, two patients in the control group developed mild synkinesis post treatment, which could be related to the aberrant regeneration of facial nerve or mass action and hence could prove harmful. Electrical stimulation and gross facial exercises could have contributed to this as reported by Diels 4,14 and Balliet et al. 15 Table 3 Pre- and post-treatment scores of all the components of facial grading score in the facial neuromuscular re-education group (n/28) FGS components Median (IQR) FGS Pre-treatment Post-treatment P-value Rest score 15 (1015) 5 (510) B/0.01 Movement score 48 (3358) 74 (6478) 0.00 Synkinesis score 0 (00) 0 (00) 0.18 Total score 33 (1843.5) 66 (5476.7) B/0.01 However, this could not be established in our study, as the synkinesis score was not statistically significant both either intra- or intergroup comparison. Total score Data results from this study showed that the total Facial Grading Scale score difference was statistically significant between the two groups. This proves our hypothesis that facial neuromuscular re-education is more effective than conventional therapeutic measures in improving the facial symmetry in patients with Bell s palsy. As reported by Brach et al., facial neuromuscular re-education reduces the frequency of patient visits, and thereby it is cost effective and less time-consuming. 8 Billue found that facial neuromuscular re-education provides specific strategies that inhibit synkinesis. 16 This further supports the results of the study by Ross et al. 17 However, we could not justify the same in our study as the patients were not followed up over a prolonged duration. Strengths and limitations Earlier studies had concluded that facial neuromuscular re-education could improve facial symmetry but not in comparison with conventional therapeutic measures. Our study had overcome this defect by including a control group with conventional treatment. We followed up the patients for up to three months, beyond which patients did not turn up either because of the improvement in the facial symmetry or because of the long distance between their home and the clinic. This made it difficult for us to evaluate synkinesis, which could be the possible sequelae of conventional treatment techniques. Our study included patients with acute Bell s palsy which made it difficult for us to eliminate any spontaneous recovery. Inclusion of a control group with no treatment would have helped us to comment about the effect of spontaneous recovery. The Facial Grading Scale, although proved for its reliability, was an observational rating score and hence could be usefully replaced by more objective electrophysiological measures.

6 Neuromuscular re-education in Bell s palsy 343 Table 4 Differences of all the components of facial grading scores between control group (n/28) and the facial neuromuscular re-education (n/28) group FGS difference Median (IQR) P-value Control group Facial neuromuscular re-education group Rest score 5 (510) 5 (510) 0.53 Movement score 12 (816) 24 (1238) B/0.01 Synkinesis score 0 (00) 0 (00) 0.41 Total score 16.5 ( ) 27.5 (2043.7) B/0.01 References 1 Craig M. Miss Craig s face saving exercises. Random House, Cole J, Zimmeman S, Gerson S. Nonsurgical neuromuscular rehabilitation of facial muscle paresis. In Rubin LR ed. The paralyzed face. Mosby-Year Book, 1991: Farragher DJ. Electrical stimulation: a method of treatment for facial paralysis. In Rose FC, Jones R, Vibova G eds. Neuromuscular stimulation: basic concepts and clinical implications, Vol 3. Demos, 1989: Diels JH. New concepts in nonsurgical facial nerve rehabilitation. Adv Otolaryngol Head Neck Surg 1995; 9: Waxman B. Electrotherapy for treatment of facial nerve paralysis (Bell s palsy). In Anonymous Health Technology Assessment Reports, third edition. National Center for Health Services Research, 1984: Brudny J. Biofeedback in facial paralysis: electromyographic rehabilitation. In Rubin L ed. The paralyzed face. Mosby-Year Book, 1991: Vanswearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther 1998; 78: Brach JS, Vanswearingen JM. Physical therapy for facial paralysis: a tailored treatment approach. Phys Ther 1999; 79: Beurskens CH, Heymans PG. Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability. Otol Neurol 2003; 24: Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otoralaryngol Head Neck Surg 1996; 114: Brach JS, Vanswearingen JM, Delitto A, Johnson PC. Impairment and disability in patients with facial neuromuscular dysfunction. Otolaryngol Head Neck Surg 1997; 117: Peiterson E. The natural history of Bells palsy. Am J Otol 1982; 4: Gagnon NB, Molina-Negro P. Facial reinnervation after facial paralysis: Is it ever too late? Arch Otorhinolaryngol 1989; 246: Diels HJ. Facial paralysis: Is there a role for a therapist? Facial Plast Surg 2000; 16: Balliet R, Lewis L. Hypothesis: Craig s face saving exercises exercises may cause facial dysfunction. Can Acoustic Neuroma Assoc Connection Billue JS. Bell s palsy: an update on idiopathic facial paralysis. Nurse Pract 1997; 22: 88, Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope 1991; 101:

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