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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE.KARNATAKA.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
POOJA JAYANTILAL THAKKARAR,
D/O. JAYANTILAL THAKKARAR,
NO: 4/1, 9TH MAIN, DR. RAJROAD,
SRINIVAS NAGAR, BANGALORE,
KARNATAKA - 560050
1
NAME OF THE
CANDIDATE& ADDRESS
2
NAME OF THE
INSTITUTION
KRUPANIDHI COLLEGE OF
PHYSIOTHERAPY
3
COURSE OF STUDY AND
SUBJECTF
MASTER OF PHYSIOTHERAPY IN
NEUROLOGICAL AND PSYCHOSOMATIC
DISORDERS
4
DATE OF ADMISSION TO 15th JUNE 2013
COURSE
5
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]
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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]
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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 reeducation 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.
Robert W.Lovett, (2005)described a method of testing and grading muscle
strength using gravity as resistance.[7]
House JW. Brackmann BE (1985)stated that House Brackmann score is a score to
grade the degree of nerve damage in facial nerve palsy.He analyzed correlation
between original and modified House Brackmann score. [21]
Reitzen SD, Babb JS, Lalwani AK(2009). In their study determined the reliability
of the House-Brackmann facial nerve gradingscale and proposed that Overall interreader reliability was relatively strong and increases with clinical experience.[22]
Coulson SE, Croxson GR, Adams RD, O'Dwyer NJ(2005) investigated the
extent of within-system reliability and between-system correlation and also
examined the interobserver reliability .The 3 systems of grading facial nerve
paralysis were evaluated and compared with the use of intraclass correlation
coefficients,For clinical grading of voluntary movement, there is good correlation
between ratings given on the Sydney and Sunnybrook systems, and within each
system there is good reliability. Although the reliability of the House Brackmann
system was found to be high,but examination of individual grades revealed some
wide variation between trained observers.[23]
7. MATERIALS AND METHODS
7.1. SOURCE OF DATA
[A] POPULATION
Out Patient Physiotherapydept in Krupanidhi College of Physiotherapy, Bangalore
and from a community.
[B] SAMPLE SIZE
60 subjects male and female ranging from 15-40 years satisfying the inclusion
criteria
[C] MATERIALS:
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
4) Treatment Couch
5) Stool/Chair
6) Mirror
7.2. METHODS OF COLLECTION OF DATA
[A] SAMPLING TECHNIQUE
Random sampling technique
[B] TOOLS (outcome measures)
(a) House Brackmann score for muscle function[21]
It is a score to grade the degree of nerve damage in afacial nerve palsy.
House Brackmann Facial Nerve Grading System :
Grade 1 – Normal,
Grade 2 – Slight,
Grade 3 – Moderate,
Grade 4 – Moderate to Severe,
Grade 5 – Severe,
Grade 6 - Total.
(b) Manual Muscle Testing Scale[20]
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 overcome a greater amount of resistance than a good muscle.
7.3 [C] METHODOLOGY:
[I] STUDY DESIGN
Randomized experimental study
[II] INCLUSION CRITERIA
 Patients with peripheral unilateral idiopathic facial palsy after 15 days
of onset(sub acute stage).
 Age group between 15 – 40 years.
 Patient must give the written informed consent.
 Both males and females.
 Both right and left side
[III] EXCLUSION CRITERIA
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Patient with history of recent head injury, Neurological disorders.
Patient with history of immunodeficiency syndromes.
Viral infections like herpes simplex.
Subjects with the history of surgical intervention for facial nerve palsy.
Subjects with other form of neurological impairments.
Subjects with pain of any other origin.
Subjects with any deformity or disability requiring medical attention.
Subjects with age less than 20 or greater than 40 years.
Subjects with cognitive/perceptual impairement.
Open wound.
Patient with metal implants.
[IV] PROCEDURE
All subjects fulfilling the inclusion and exclusion criteria will be allowed to
participate in the study
 60 patient with facial paralysis.
 30 Patient with facial palsy and 30 Patient with Bell’s Palsy recruited
for the studies who will be randomly selected by priory assessed and
referred full filling the inclusion exclusion criteria.
 Patients will be divided into two groups namely Group A and Group
B consisting of 30 patient in each group.
 Patient informed consent form will be taken and assessed by House
Brackmann scale and manual muscle testing i. e.
Group A(Bell’s Palsy) & Group C (facial palsy) will receive Conventional
Physiotherapy i.e.
 Electrical stimulation
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. For stimulating muscles which is
completelydenervated 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.
 Massage
i. Stroking
ii. Effleurage
iii. Finger kneeding
 Facial exercise will be instructed as:[4]
I. Sit relaxed in front of a mirror.
II. Gently raise eyebrows; you can help the movement with your
fingers.
III. Draw your eyebrows together, Frown.
IV. Exercises to help close the eye :
a. Look down
b. Gently place back of index finger on eyelid, to keep the eye
closed with opposite hand gently stretcheyebrow up working
along the eyebrow line. This will help to relax the eyelid
andStop from becoming stiff.
c. Now try and gently press the eyelids together.
V. Wrinkle up your nose.
VI. Take a deep breath through your Nose, try and flare Nostrils.
VII.
VIII.
IX.
X.
XI.
XII.
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.
Ask the patient to close and protrude the lips like (whistling)
Ask the patient to raise the skin of the chin. As a result the
lower lip will protrude somewhat, as in pouting
Group B & Group D will be receiving followingPNF exercises along with above
mentioned conventional exercises.
 Kabat rehabilitation is type of motor control rehabilitation technique
based on proprioceptive neuromuscular facilitation (PNF).
 During Kabat, therapist facilitate the voluntary contraction of the
impaired muscle by applying a global stretching then resistance to
the entire muscular section and motivate action by verbal input and
manual contact.
 When performing Kabat, 3 regional are considered: the upper
(forehead and eyes), intermediate (nose), and lower (mouth).
 Prior to Kabat, ice stimulation has to perform to a specific muscular
group, in order to increase its contractile power.
PNF exercises are:[8]
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.
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.
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.
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.[
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.
6. Muscle mentalis: ask the patient to wrinkle the chin.
- Apply resistance down and out of the chin.
Repetitive facial rehabilitation for a period of 4 weeks 5 sessions per week for 30 to
45 Min will be administrated and post treatment data will be Measured with MMT
& House Brackmann score of facial muscle function.
[V] STASTICAL ANALYSIS:
Non parametric test will be used
7.4 Does the study require any investigation or intervention to be conducted
on patients or the other humans or animals? If so, please describe:
Yes, the research study is designed to be conducted on adult subjects under the
department of physiotherapy.
7.5 Has ethical clearance been obtained from the subjects and the institution?
Yes, Ethical clearance has been obtained from the institution.
8. REFERENCES
1. Julian Holland; "Bell’s palsy”; Clinical evidence; 2008:01:1204.
2. B.D.Chaurasia’s. Human anatomy, 3rd edition. Cbs publishers and
distributors, 1996; 3; 41-2.
3. Peitersen E. Bell’s Palsy; The spontaneous course of 2,500 peripheral facial
nerve palsies of different etiologies”.Actaotolaryngolsuppl2002; 549: 4-30.
4. The Bell’s palsy Association, available from www.bellspalsy.org.uk
5. Manikandan N. (2007). "Effect of facial neuromuscular re-education on
facial symmetry in patients with Bell's palsy: a randomized controlled trial.
ClinRehabil.. 21 (4): 338–43.
6. Jagmohan Singh, Textbook of Electrotherapy, 1st Edition. Jaypee brothers
medical publishers, 2005; 1; 104- 6.
7. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia
GeiseProvance, Mary Mclntyre Rodgers, William Anthony Romani.
Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott
Williams and Wilkins, 2005; 5; 130-33.
8. Susan S. Adler, DominiekBeckers, Math Buck. Pnf in practice an illustrated
guide, 2nd revised Edition Springer, 2000;2; 1-15, 364
9. LJ Vanopdenbosch, K Verhoeven, J W Casselman; Bell’s Palsy with
ipsilateral numbness ; j Neural Neurosurg Psychiatry 2005;76:1017-18.
10. Teixeira LJ, Soares BGDO, Vieira VP. Physical therapy for Bell’s palsy
(idiopathic facial paralysis). (protocol) Cochrane Database of Systematic
Reviews 2006.4.
11. Adour KK, Hetzler DG. Current Medical treatment for Facial Palsy. Am J
Ototalaryngol 1984; 5: 499-502.
12.Kenneth W. Lindsay, Ian Bone. Neurology and Neurosurgery illustrated, 4th
Edition. Churchill living stones, 2004; 168.
13. 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;1; 475
14. John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition.
John Wright and son’s ltd, 1985;4; 481.
15.T.S.Shafahak, The treatment of facial palsy from the point of view of
physical and rehabilitation medicine; Eura Medici Phys 2006;42(1):41-7.
16.Bearskins CH, Heymans PG. Physiotherapy in patients with facial nerve
paresis: description of outcomes. Am J Otolaryngol. 2004 ; 25(6):394-400.
17.Shafahak TS, Essa AY, Bakey FA. The possible contributing factors for the
success of steroid therapy in Bell’s palsy: A Clinical and
Electrophysiological study. J LaryngolOtol 1994; 108:940-43.
18. Namura M, Motoyoshi M, Namura Y, Shimizu N. The effects of PNF
training on the facial profile. J Oral Sci. 2008 ; 50:45-51.
19. Brach-JS; Van Swearingen-JM; Lenert-J; Johnson-PC. Facial neuromuscular
retraining for oral synkinesis. Record 19 of 83 - MEDLINE (R) 1997.
20. Salinas RA, Alvarez G, Daly F, Ferreira J (2010). "Corticosteroids for
Bell'spalsy (idiopathic facial paralysis)". Cochrane Database Syst
Rev,2010;17;(3).
21. House JW, Brackmann DE, Facial Nerve Grading System. Otolaryngol head
neck surg. 1985: 93, 146-7.
22.Reitzen SD, Babb JS, Lalwani AK. "Significance and reliability of the
House-Brackmann grading system for regional facial nerve function”.
Otolaryngol Head Neck Surg. 2009;140(2):154-8.
23.Coulson SE, Croxson GR, Adams RD, O'Dwyer NJ. "Reliability of the
"Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to
assess voluntary movement and synkinesis after facial nerve paralysis”.
Otolaryngol Head Neck Surg. 2005;132(4):543-9.
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SIGNATURE OF CANDIDATE :
REMARKS OF THE GUIDE:
11.1 NAME AND DESIGNATION
OF GUIDE
PRESENTED TO THE RESEARCH
COMMITTEE AND APPROVED
MRS. SARULATHA
(ASSOCIATE PROFESSOR)
11.2 SIGNATURE
11.3 CO-GUIDE (if any)
NIL
11.4 SIGNATURE
--11.5 HEAD OF THE DEPARTMENT
Mr. RAMESH KUMAR
PROFESSOR
11.6 SIGNATURE
12
12.1 REMARKS OF THE
CHAIRMAN AND PRINICIPAL
12.2 SIGNATURE
ACCEPTED & FORWARDED