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ABSTRACT
Objectives: To study the value of physical
treatment for elderly patients with facial palsy.
Methods: This study was conducted at the
Royal Medical Services during the period between
February 2006 and February 2008. 64 patients with
facial palsy with incomplete recovery were referred
from the ophthalmology clinic to the rehabilitation
center. The patients' clinical picture was classified
according to Facial Grading System to measure
the degree of facial impairment. An individualized
treatment-based category was assigned with muscle
re-education exercise. Facial Grading System score
was measured before and after therapy.
Results: The mean age of patients was
59.6 years with age range of 51 to 82 years. Forty
- four patients had Bell's palsy, 14 had acoustic
neuroma and 6 were post traumatic. The average
number of treatment sessions was 16.4 over a period
of 14.2 months on average. The average Facial
Grading System score was 19.8 out of 100 before
starting physical therapy; after treatment the
average score was 61.5 out of 100. Patients with
Bell's palsy had the most favorable outcome compared
to the other three causes.
Conclusion: The use of individualized
treatment-based category is helpful for rehabilitation
of patients with facial palsy especially in those
with Bell's palsy.
Keywords: Facial palsy, Bell's palsy,
rehabilitation, facial grading system.
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INTRODUCTION
Facial paralysis can be a disfiguring
disorder that has a great impact on the patient. It
may be caused by trauma, infection, tumor, congenital,
iatrogenic or idiopathic. The latter is the most common
cause and is called Bell's palsy. It is thought to account
for about two thirds of cases of facial paralysis1-3.
Whilst most patients with Bell's
palsy recover without noticeable disfigurement, iatrogenic,
traumatic and tumor related causes rarely recover. In
addition, a good percentage of patients with Bell's
palsy especially the elderly do not show complete recovery.
The end result will be distorted facial expression and
movement disorder with psychological and social disability
and cosmetic inconvenience4-5.
Long term treatment and physical
therapy are important in patients with incomplete recovery.
Rehabilitation measures include eye protection, and
restoration of function of face. The latter includes
microsurgical reanastomosis or nerve grafting, electromyography
and conventional muscle re-education exercise6.
In this study, we evaluated
the effect of an individualized muscle re-education
exercise on treating facial palsy according to its etiology.
METHODS
This study was conducted at
the Royal Medical Services during the period between
February 2006 and February 2008. 64 patients with facial
palsy with incomplete recovery were enrolled in the
study. Patients were referred from ophthalmology clinic
to a specialized rehabilitation center. Patients' clinical
picture was classified according to Facial Grading System
(FGS) to measure the degree of facial impairment7.
This system consisted of grading resting posture, voluntary
movement, and the presence of abnormal movement.
An individualized treatment-based strategy that was
previously assigned by Jennifer Brach and Jessie Van
Swearingen using muscle re-education exercise according
to patient clinical picture was adopted6. The FGS score
was measured before and after treatment. P-value was
applied to see the success of therapy according to etiological
factors.
RESULTS
The mean age of patients was
59.6 years with age range of 51 to 82 years. Male to
female ratio was 1.1 to 1. Bell's palsy was found in
44 patients, acoustic neuroma in 14 and post traumatic
in 6. The average number of treatment sessions was 16.4
sessions over an average period of 14.2 months. The
average Facial Grading System score was 19.8 out of
100 before starting physical therapy; after treatment
the average score was 61.5 out of 100. Patients with
Bell's palsy had the most favorable outcome (Table 1).
Table
1: The outcome of physical therapy according
to etiology
| Etiology |
FGS
score prior to therapy |
FGS
score after therapy |
P-value |
| Bell’s
palsy |
20.8 |
79.8 |
P
< 0.05 |
| Acoustic
neuroma |
18.7 |
40.1 |
0.2
< P < 0.1 |
| Trauma |
17.8 |
35.9 |
0.2
< P < 0.1 |
| Total |
19.8 |
61.5 |
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DISCUSSION
Facial palsy may result in disfigurement
and functional impairment if the patient is not completely
recovered. It may result in abnormal movement (synkinesis),
motor, social and psychological disabilities. Ocular
complications are not uncommon ranging from lid problems
to corneal perforation. In order to minimize these sequelae,
prompt treatment is mandatory.
Traditional treatment programs
included electrical stimulation and gross facial exercises
even though there is evidence that these modalities
are ineffective and may even interfere with neural regeneration8-12. Nowadays, neuromuscular retraining is becoming
a widely accepted and effective treatment modality in
the treatment of facial palsy with incomplete recovery13. In our study, we used an individualized neuromuscular
retraining program based on the system assigned by Jennifer
Brach and Jessie Van Swearingen 6 and relying upon Facial
Grading System score to see the outcome of therapy7.
This system consisted of grading resting posture, voluntary
movement, and the presence of abnormal movement.
Resting posture has its grading
according to palpebral fissure width, presence of eyelid
surgery, nasolabial fold and angle of mouth positions.
Voluntary movement includes brow elevation, eye closure,
snarl, smile, and pucker. Synkinesis is also graded.
The sum of this system is a score ranging from 0 or
complete paralysis to 100 or full function.
We found that patients with
Bell's palsy had the best outcome with FGS score improving
from 20.8 to 79.8. This was statistically significant
when compared to the other three causes. In our series,
most patients with Bell's palsy were older than 50 years
of age and all of them showed incomplete recovery over
a period of 6 months.
Patients with acoustic neuroma
improved after therapy with more than doubling of the
score. All patients had surgery; four of them developed
facial palsy after the operation.
Surgical procedures may be used to treat traumatic facial
paralysis but this will not restore full function. Electromyography
can be used to facilitate rehabilitation14. The six
patients in our series showed improvement on individualized
muscle re-education. The results were less favourable
than those in Bell's palsy.
In conclusion, the use of individualized
treatment-based category is helpful for rehabilitation
of patients with facial palsy especially in those with
Bell's palsy. The proper use of such exercises may prevent
debilitating complications.
Conflict
of interest declaration
Although
the present research has been funded by Iranian Research
Center on Aging, there is no predetermined agreement
between the researcher and the institute on the methodology
and results of the study. The authors have had full
control on their data , analysis and interpretation
of results.
Description
of authors' roles
F.Yadegari has been the main administrator of the research
, proposing the topic and design, controlling data collection,
reviewing literature and writing the article. M. Froughan
cooperated in designing study, introducing patients
and consulting on differential diagnosis procedures
of Alzheimer patients, analyzing and discussing the
results and organizing the paper. A. Mehri helped much
in aphasic section of the study, review of literature
and writing the proposal. And finally P.Shirinbayan
was responsible for research methodology and statistical
analysis.
Acknowledgement
This project has been benefited of the financial and
scientific support of Iranian Research Center on Aging.
The authors are thankful of Mrs. Soheila Hejrati, Mrs.
Marzieh Amrovani, Mrs. Mitra Soltani and Dr. Lili Hayati
for their help in different stages of the study. And
also appreciate the help of Iranian Alzheimer Association
and consider theirselves indebted to all patients, their
families and also the healthy elderly who participated
in this study despite all difficulties.
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