INTRODUCTION

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] Sir Charles Bell was the first to describe
unilateral facial nerve dysfunction in 1830. [2]
A range of annual incidence rates have been reported in the literature varying from
25 to 53 (all rates per 100,000 population per year). [5] The highest incidence was found in a
study in Seckori, Japan, in 1986 and the lowest incidence was found in Sweden in 1971. [7] The
annual incidence of Bell's palsy is about 20 per 100,000 populations, and the incidence
increases with age. Bells palsy affects about 40,000 people in the India every year. It affects
approximately 1 in 65 person during life time. Peitersen 2002 the annual incidence of Bells
palsy varies widely, ranging between 11.5 and 40.2 cases per 100,000 populations. [6]
Either sex is affected equally and may occur at any age the median age is 40 years. [8]
& [1]

The incidence is lowest under 10 years of age and highest in people over the age of 70.

There are peaks of incidence in the 30 to 50 and 60 to 70 year old age groups (Gilden 2004;
Gonalvez 1997).[6] Left and right sides are affected equally.[9] An account for 60-70% of all
cases of unilateral peripheral facial palsy.[7] Persons with diabetes have a 29% higher risks for
affected by Bells palsy.
The onset of Bells palsyis sudden and symptoms typically peak within a few days.
[13]

The aetiology of 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. Pathologically the nerve
may be affected by inflammation, compression, contusion, ischemia, stretching, section,
application of excessive heat, cold, ultrasonic energy and local anesthetics. [14] In auto immune
disorders, T-lymphocyte changes have been observed. [15]
Clinical picture is a stereotyped, accompanied by bells phenomenon,

[16]

diffused

retro auricular pain in 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 naso labial fold, loss of taste in the anterior 2/3 rd of the tongue,
hyperacusis.[17]
Neuropraxia otherwise known as 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 that is
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, co contraction of the muscles or associated movements or
synkinesis e.g. jaw-winking that is closure of the ipsilateral eyelid when the jaw opens,
crocodile tearing [14] from misdirection of regenerating fibers, post-paralytic hemi facial spasm,
sweating while eating or during physical exertion fixed contracture of facial muscles.
Most make a spontaneous recovery within 1 month, but up to 30% have delayed or
incomplete recovery. [18] About one-third of patients may have incomplete recovery and residual
effect.
2

Bells palsy has a fair prognosis without treatment (Holland 2004). According to
Petersen complete recovery was observed in 71% of all patients. Ninety-four per cent of
patients with incomplete and 61% with complete paralysis made a complete recovery. [6]
Clinically important improvement occurs within 3 weeks in 85% of people and
within 3 to 5 months in the remaining 15%. [19] Incomplete recovery of facial expression may
have a long-term impact on quality of life. The prognosis for children with Bell's palsy is
generally good, with a high rate (more than 90%) of spontaneous recovery. [19]
The prognosis depends to a great extent on the time at which recovery begins. Early
recovery gives a good prognosis and late recovery a bad prognosis. If recovery begins within
one week, 88% obtain full recovery, within one to two weeks 83% and within two to three
weeks 61%. [6]
Patients generally have a good prognosis; approximately 80-90% of patients recover
without noticeable disfigurement within 6 weeks to 3 months. Patients aged 60 years or older
have an approximately 40% chance of complete recovery and have a higher rate of sequelae.
Patients younger than 30 years have only a 10-15% chance of less than complete recovery and
sequelae. If no recovery occurs by 4 months, then the patient is more likely to have sequelae.
Normal taste, stapedius reflex and tearing give a significantly better prognosis than
if these functions are impaired. Recovery is less likely to be satisfactory with complete rather
than incomplete paralysis, with pain behind the ear and in older people (Danielidis 1999).
Other poor prognostic factors include hypertension and diabetes mellitus (Gilden 2004;
Peitersen 2002).

[6]

Other poor prognostic factors include: old age, hypertension, diabetes

mellitus, impairment of taste and complete facial weakness. [20]

The facial motor system is responsible for critical functions of physical, social, and
psychological well-being. Damage to the facial motor system includes those conditions
affecting the facial nerve and its nerve branches, and the facial muscles. These conditions can
result in deficits in eating, drinking, speaking, conveying conversational signals like,
punctuation signs conveyed by movements of the eyebrows during speech and even conveying
intimate human information like anger, disgust, happiness, surprise.[12] Individuals with
paralysis of or disfiguring facial expressions deal with physical, psychological, and social
disability daily.[10] & [11] Bells palsy has been primarily considered a cosmetic inconvenience
with associated functional problems. Restoring function and expression to the highest level of
possible results in improved health, self-esteem, self- acceptance, acceptance by others, and
also quality of life.
Bell's palsy affects each individual differently. In patients presenting with
incomplete facial palsy, where the prognosis for recovery is very good, and treatment may be
unnecessary. However, the more severe cases may require treatment. Patients presenting with
complete paralysis, marked by an inability to close the eyes and mouth on the involved side,
are usually treated. Early treatment within 3 days after the onset is necessary for therapy to be
effective.
Physiotherapy can be beneficial to some individuals with Bells palsy as it helps to
maintain muscle tone of the affected facial muscles and stimulate the facial nerve. Normally
electrical stimulation, massage, heat and exercise are given in the conventional physiotherapy
in order to maintain tone of the muscle and promote functional recovery.
Kabat's rehabilitation is a type of motor control rehabilitation technique based on
Proprioceptive Neuromuscular Facilitation (PNF) which is added with conventional treatment
for experimental group in this study to find out the effectiveness of the Kabats rehabilitation.
4

To assess the effectiveness at the impairment level and functional level of Kabats
rehabilitation, House Brackmann Grading Scale and Facial Disability Index were used
respectively.
Aim and Need of the Study:
This study is intended to assess the effectiveness of Kabat's PNF rehabilitation in
Physical and Psycho Social wellbeing function in acute unilateral idiopathic Bells palsy
patients.

HYPOTHESIS
ALTERNATE HYPOTHESIS:
There is significant difference between the effect of Kabat's Proprioceptive
Neuromuscular Facilitation with conventional physiotherapy and conventional physiotherapy
alone for facial physical and psycho social wellbeing function in acute unilateral idiopathic
Bells palsy patients.
NULL HYPOTHESIS:
There is no significant difference between the effect of Kabat's Proprioceptive
Neuromuscular Facilitation with conventional physiotherapy and conventional physiotherapy
alone for facial physical and psycho social wellbeing functions in acute unilateral idiopathic
Bells palsy patients.

REVIEW OF LITERATURE
Maurizio Barbara, et al, (2010): Their objective was to assess the validity of an early
rehabilitative approach to Bell's palsy patients. In their randomized study, 20 consecutive
patients (10 males, 10 females; aged 3542 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. [21]
Barbara M, et al: Found that Voluntary contraction of impaired muscle is facilitated by
applying global stretching and then resistance to the muscular section and motivate action by
verbal inputs and manual contact. [22]
Dr. Herman Kabat: Stated that 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.
Barbara M, et al: Conducted a, study to determine whether an early physical rehabilitative
program could improve and/or accelerate recovery from a postoperative deficit of facial nerve
(FN) function. Early physical rehabilitation has proved to be effective as a helpful tool for
recovery from FN deficit and it is therefore advisable to use it soon after surgery, especially for
7

FN deficits worse than Grade IV. It is a retrospective study of the patients who presented a
postoperative FN deficit after surgery for acoustic neuroma (AN) was carried out. Twenty-nine
patients were enrolled and divided into 2 groups: 18 who underwent early physical
rehabilitation and 11 who did not undergo rehabilitation. All the AN patients underwent trans
labyrinthine removal and were classified preoperatively according to the HouseBrackmann
staging system. Physical rehabilitation was performed according to Kabat (i.e. neuromuscular
facilitation). FN function was assessed postoperatively and classified according to the House
Brackmann Grading System. The resultsIn Grade IV and V patients, early rehabilitation
allowed a faster and better recovery with respect to AN patients for whom rehabilitation was
not carried out. They concluded that early physical rehabilitation has proved to be effective as
a helpful tool for recovery from FN deficit and it is therefore advisable to use it soon after
surgery, especially for FN deficits worse than Grade IV. [22]
Carolyn Kisner, et al: Stated that PNF is a form of therapeutic exercise that combines
functionally based diagonal patterns of movement with techniques of neuromuscular
facilitation to evoke motor response and improve neuromuscular control and function. [23]
Mari Namura, et al: States that PNF training has significant effect for sharpening the mouth
and sub mandibular region, but continued training is necessary to avoid relapse. [24]
Kabat H and Knott M: Reported that PNF has improvement in the function of the muscles
and ameliorates (make or become better) muscle decline, disharmony, atrophy and joint
movement limitation. [25]
Kofotolis N, et al: Stated that PNF has been recently used in orthopaedic diseases of the bone
and joints, sports related trauma and CNS diseases like stroke and its usefulness has been
reported in other medical fields also. [26] & [27]

Nakajima E, et al: Found that PNF can used to improve the aesthetics of facial expressional
so and introduced PNF to Japanese clinicians. [28]
Lusting A, et al: Stated that PNF is often used as an alternative form of PRE (Progressive
Resisted Exercise) by physiotherapists as its use should be more advantageous than usual
strength programs. [29]
Kabat (1950): Stated that Proprioceptive Neuromuscular Facilitation (PNF) is a concept of
treatment. Its underlying philosophy is that all human beings, including those with disabilities,
have untapped existing potential. [30]
Kabat (1947): Stated that 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 for emphasis involves changing the normal sequencing
of motions to emphasize a particular muscle or a desired activity. Timing is defined as
sequencing of motion. [30]
Kabat (1947): Stated that prevention of motion in a stronger synergist will redirect the energy
of that contraction 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. [30]
Targan RS, et al: Conducted a systematic review to present effect of long-term electrical
stimulation on motor recovery and improvement of clinical residuals in patients with
unresolved facial nerve palsy. The study group included 12 patients (mean age 50.4 +/- 12. 3
years) with idiopathic Bell's palsy and 5 patients (mean age 45.6 +/- 10.7 years) whose facial
9

nerves were surgically sacrificed. Motor nerve conduction latencies, House-Brackmann facial
recovery scores, and a 12-item clinical assessment of residuals were obtained 3 months before
the onset of treatment, at the beginning of treatment, and after 6 months of stimulation.
Patients were treated at home for periods of up to 6 hours daily for 6 months with a batterypowered stimulator. Stimulation intensity was kept at a sub motor level throughout the study.
Groups and time factors were used in the analyses of the 3 outcome measures. The result of the
study was that long-term electrical stimulation may facilitate partial reinnervation in patients
with chronic facial paresis/paralysis. Additionally, residual clinical impairments are likely to
improve even if motor recovery is not evident. [31]
Beurskens CH, et al: Conducted a RCT (48 people with peripheral facial paralysis for at least
9 months) found that mime therapy significantly improved physical and social aspects of facial
parlays is compared with waiting list control at 3 months (mean change in physical FDI scores:
from 56.8 to73.5 with mime therapy v from 63.2 to 59.6 with control; P less than 0.02 for
difference between treatments at 3 months: mean change in social FDI scores; from 68.6 to
80.7 with mime therapy from 72.6 to 66.2 with control; P less than 0.01 for difference between
treatments at 3 months).The RCT also found significant improvements in facial stiffness and
lip mobility (change in pout and lip-length indices) in the mime therapy group compared with
the control group (mean change in stiffness scores: from 3.72 to 2.37 with mime therapy from
3.68 to 3.54 with control; P less than 0.001 at 3 months: mean change in pout score: from 14.7
to 21 with mime therapy 16.3 to15.7 with control; P less than 0.001 at 3 months: mean change
in lip-length score; from 17.6 to23.7 with mime therapy from 21.6 to 19.6 with control; P less
than 0.03 at 3 months).[32]
Beurskens CHG, et al: Conducted a RCT with 12 month's follow-up, found a trend towards
improved social FDI score and pout index at 3 and 12 months after treatment mean social FDI

10

score: 81.6 immediately after treatment; 83.6 at 3 months; 85.3 at 12 months: mean pout index:
22.2 immediately after treatment; 23.5 at 3 months; 24.2 at 12 months. [33]
Mari Namura et al: Found that though orthodontic treatment improves dent alveolar
problems, the facial profile seldom changes because the perioral muscles do not easily adapt to
the new morphological circumstances. They employed proprioceptive neuromuscular
facilitation (PNF), which is training with added resisted movement to motions such as lifting
the upper lip, lowering the lower lip, and sticking out the tongue, to adapt the perioral muscles
to the new morphological circumstances. The subjects were 40 adults with an average age of
29.6 years. A series of PNF exercises was performed three times per day for 1 month. Lateral
facial photographs were taken using a digital camera before training (T0), after training (T1),
and 1 month after the end of training (T2). The naso labial (NL), mento labial (ML), and mento
cervical (MC) angles were measured, and linear measurements were taken to verify the change
of each measurement point. In the test group, the NL and ML angles significantly increased (P
< 0.05), and the MC angle significantly decreased after the PNF exercise. From T1 to T2, the
NL and ML angles decreased significantly, while the MC angle increased significantly. No
significant differences were observed in these angles when the values measured at T0 and T2
were compared. Although the training appeared to be effective for sharpening the mouth and
sub mandibular region, continued training is necessary to avoid relapse. [31]
Namura M, et al: Evaluated the 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 sub mandibular region. [34]
Elliott JM (2006): His case report describes a physiotherapy treatment based on current best
evidence for a patient with left facial nerve paralysis. A 53 year old Caucasian male with
11

complete left facial paralysis with a diagnosis of Bells palsy. Signs and symptoms were
assessed using a standardized measure of facial disability (Facial Disability Index-FDI).
Physiotherapy rehabilitation involved muscle re-education exercises aimed at restoring normal
movement within the affected left facial musculature. In 16 physiotherapy sessions over 4
months, the patient had improved self-reported facial disability (initial FDI score; Physical
subscale = 35/100 and Social/Well-being subscale = 55/100. The Final FDI score; Physical
subscale = 75/100 and Social/Well-being subscale = 85/100) and significantly reduced
functional impairments. [35]
Targan RS,et al: Conducted a study to investigated the efficacy of a pulsatile electrical current
to shorten neuromuscular conduction latencies and minimize clinical residuals in patients with
chronic facial nerve damage caused by Bell's palsy or acoustic neuroma excision. The study
group included 12 patients (mean age 50.4 12.3 years) with idiopathic Bell's palsy and 5
patients (mean age 45.6 10.7 years) whose facial nerves were surgically sacrificed. The mean
time since the onset of paresis/paralysis was 3.7 years (range 17 years) and 7.2 years (range
69 years) for the Bell's and neuroma excision groups, respectively. Motor nerve conduction
latencies, House-Brackmann facial recovery scores, and a 12-item clinical assessment of
residuals were obtained 3 months before the onset of treatment, at the beginning of treatment,
and after 6 months of stimulation. Patients were treated at home for periods of up to 6 hours
daily for 6 months with a battery-powered stimulator. Stimulation intensity was kept at a
submotor level throughout the study. Surface electrodes were secured over the most affected
muscles. Groups and time factors were used in the analyses of the 3 outcome measures. The
result is no statistical differences were found between the two diagnostic groups with respect to
any of the 3 outcome measures. Mean motor nerve latencies decreased by 1.13 ms (analysis of
variance test, significant P = 0.0001). House-Brackmann scores were also significantly lower
(Wilcoxon signed rank test, P = 0.0003) after treatment. Collective scores on the 12 clinical
12

impairment measures decreased 28.7 8.1 points after 6 months [analysis of variance test,
significant P = 0.0005). Eight patients showed more than 40% improvement, 4 better than
30%, and 5 less than 10% improvement in residuals score. [39]

13

DESIGN & METHODOLOGY

RESEARCH DESIGN
STUDY DESIGN

Quasi experimental study

Randomized control trial.

STUDY SETTING

Tertiary Care Centre

1. Physical Medicine and Rehabilitation Centre,
Govt. of Puducherry.
2.

Indira

Gandhi

Govt.

Puducherry.
SAMPLE SIZE

Total n=40,
Group A n=20, Group B n=20.

SAMPLING TECHNIQUE

Convenient Sampling,
Randomized group allocation.

STUDY DURATION

4 Weeks

14

General

Hospital,

SELECTION CRITERIA
Inclusion criteria
Both males and females.

Patients with acute unilateral idiopathic Bells palsy.

Age group between 15 60 years.

First one week after onset of Bells palsy.

Medically stable individuals.

Patient must give the written informed consent.

Exclusion criteria
Patient with history of recent head injury, Neurological disorders.

Psychiatric illness

Pregnant women,

Neurotomesis

Patient with history of Metal / Dental implants.

Patient with history of diabetic neuropathy.

Patient with history of immune deficiency syndromes.

15

 Patients with acoustic ear pain, otitis media or ear infection.

Bells palsy with Vth cranial nerve involvement.

Patients with defective sensation over the face.

Patients with tumours, congenital defects, open wounds, ulcers or any growth around
treatment area.
Patients with acne on face.

Bilateral facial weakness due to demyelinating neuropathy.

VARIABLES
INDEPENDENT VARIABLE:

Kabats PNF rehabilitation.

DEPENDENT VARIABLE:

Facial physical and social well-being functions.

METHODOLOGY
Study Materials:
Gloves for PNF application

Postural mirror

Electrical stimulator
16

 Pad or plate electrodes and pen electrodes.

Leads ( 2 numbers)

Straps

Cotton

Powder

Gel

Pillows

Towel

Bowl of water

IRR

OUTCOME MEASURES
To analyse the effects of Kabat's PNF rehabilitation on Physical and Psycho social
wellbeing functions in individuals with acute unilateral idiopathic Bells palsy two outcome
measures were chosen namely.
1. House BrackMann facial Grading System (HBGS).
2. The Facial Disability Index (FDI).
House BrackMann facial Grading System (HBGS).

17

The severity and degree of nerve damage in idiopathic facial nerve paralysis is
graded based on House-Brackmann Grading Scale (HBGS). [36] This grading system is formally
adopted as the universal standard reporting facial nerve dysfunction after recommendation by
Facial Nerve Disorders Committee of the American Academy of Otolaryngology Head and
Neck Surgery in 1984. [37]
Evans RA, et al: The House and Brackmann grading system has been
recommended as a universal standard for assessing the degree of facial palsy. This study
examined the inter-observer reliability of this system. Three observers assigned a grade to each
patient, examined independently, on the same day. Forty patients with a unilateral facial palsy
of varying aetiology and severity were assessed. Of the 120 judgements, eight were in dispute,
by a maximum of one grade, giving an inter-observer reliability of 93 per cent and conclude
that the House and Brackmann grading system is a simple and robust method of assessing
facial function. [38] (APPENDIX-5).

The Facial Disability Index (FDI).

Improvement in social and physical aspects of facial disability was measured using
the Facial Disability Index (FDI) questionnaire. It is disease-specific, self-report instrument;
The FDI uses a 100-point scale, with a higher score indicating fewer handicaps and less
impairment. It is developed by Van Swearingen and Brach (1996). The FDI is questionnaire is
used for assessing the disability of patients with facial nerve disorder. The FDI is designed to
provide the clinician with information regarding the disability as well as related social and
emotional wellbeing of the patient. The FDI consists of two subscales; Physical function (items
1-5) and social well-being (items 6-10). The scores range from 0 (complete paralysis) to 100
18

(normal facial function). The FDI has shown to be reliable and valid as a clinical instrument
and has been shown to accurately demonstrate the relationship between impairments,
disability, and psycho social status (Van Swearingen and Brach, 1996). [35] (APPENDIX-4).
Research Procedure:
The procedure of this study was thoroughly explained to the individuals selected for
the study and an informed written consent was obtained in the individual vernacular language.
They were allocated into two groups, Group A (control group) and Group B (experimental
group) by random allocation method. In the pre-test, each individual was assessed by HBGS
and FDI.

TREATMENT PROTOCOL
GROUP A: CONTROL GROUP
TREATMENT: CONVENTIONAL PHYSIOTHERAPY
They received electrical stimulation, IRR, facial massage, taping and facial
expressions muscle exercises are given for 4 weeks with 5 sessions in each week, each session
consist of 45 minutes. Post-test were repeated with same outcome measures after 4 weeks. The
data obtained were documented and statistically analysed for significant difference.
GROUP B: EXPERIMENTAL GROUP

19

TREATMENT: KABAT'S PNF REHABILITATION

They received Kabat's PNF rehabilitation along with Conventional physiotherapy.
During Kabat's, to 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's, 3 regions are considered: the upper (forehead and eyes),
intermediate (nose), and lower (mouth). The face is treated bilaterally to provoke more
symmetry. In some cases, the stronger side was used to reinforce motions on the weaker side.
Functionally, the facial muscles made to work against gravity, for this proper position was
selected for treatment. Each individual was positioned in the supine position, following the
same position as in the testing procedure are done and both conventional and Kabat's PNF
rehabilitation are given for 4 weeks with 5 sessions in each week, each session consist of 60
minutes
FIGURE 1: KABAT'S REHABILITATION
Few Muscles Techniques
Muscles

Stretch

Resistance

Orbicularis
Oris

Frontalis

20

Post-test: Each individual are assessed by FDI and HBGS after 4 weeks. This measure was
taken to evaluate the effects of Kabat's PNF rehabilitation in Bells palsy patients. The data
obtained were documented and analysed.

DATA ANALYSIS & RESULTS

The outcome values obtained were tabulated in Microsoft Excel 07 spread sheet,
and were exported to Graph Pad Prism 5 for Windows Version 5.03 for statistical analysis.
The effects of intervention on the changes from pre to post-test values in both
groups were analysed using Paired t test for within Group analysis and Independent sample
t test for Between Group analysis.
The P value was chosen as per the description given by Graph Pad Prism 5 for
Windows Version 5.03.
Description of P value:

21

P value

Description

Summary

< 0.001

Extremely significant

***

0.001 to 0.01

Very significant

**

0.01 to 0.05

Significant

>0.05

Not significant

Ns

22

Table 1
BASELINE CHARACTERISTICS OF THE SAMPLE SUBJECTS

Group - A

Group - B

Total Number of Participants

20

20

Age (yrs.) average

39.8

Gender (male :female)

13:7

12:8

Side of Bells palsy (Right : Left)

14:6

13:7

Duration of Bells palsy (days) average

49.5 9.59

49.25 9.87

3.4 0.94

3.3 0.97

Characteristics

37.9

FDI** Score
Mean SD
HBGS* Score
Mean SD

House BrackMann facial Grading System-(HBGS)*.

The Facial Disability Index - (FDI) **.

23

24

Table 2
OUTCOME VALUES OF GROUP A
GROUP A
HBGS* score

Sl. No

FDI** score

PRE
2

POST
1

PRE
39

POST
65

61

74

43

73

40

73

44

77

44

77

44

77

54

80

46

84

10

46

87

11

64

92

12

46

78

13

60

79

14

60

85

15

50

100

16

72

96

17

54

85

18

44

70

19

44

75

20

35

71

MEAN SD

3.4 0.94

2.15 0.67

49.5 9.59

79.9 8.92

DIFFERENCE

1.25 0.44

House BrackMann facial Grading System-(HBGS)*

The Facial Disability Index-(FDI) **
25

30.4 7.89

Table 3
OUTCOME VALUES OF GROUP B
GROUP B
Sl. No

HBGS* score
PRE
POST

FDI** score
PRE
POST

51

96

51

81

45

100

42

100

42

100

27

96

50

100

50

96

64

95

10

65

90

11

45

100

12

30

80

13

40

80

14

50

90

15

50

90

16

58

98

17

58

98

18

57

100

19

57

100

20

53

100

MEAN SD

3.3 0.97

1.1 0.30

49.25 9.87

94.5 7.02

DIFFERENCE

2.2 0.89

45.25 10.56

House BrackMann facial Grading System - (HBGS)*.

The Facial Disability Index - (FDI) **.

26

WITHIN GROUP ANALYSIS

Table 4
ANALYSIS OF IMPROVEMENT IN HBGS

Sl. No

Group

Analysis

Mean SD

Pre test

3.4 0.94

Significance

***
11.00

t value

Post test

2.15 0.67

Pre test

3.3 0.97
12.58

B
Post test

***

1.1 0.30

The results of this study from the above table indicate that, in Within Group analyses
of Improvement in HBGS, individuals of both Group A & Group B extremely significantly
improved from pre-test to post-test.
Figure 1
WITHIN GROUP ANALYSIS
ANALYSIS OF IMPROVEMENT IN HBGS

27

HBGS
4
3.5
3
2.5
2
HBGS SCORES
1.5
1
0.5
0

3.4

3.3
2.15
1.1

GROUP A

GROUP B

Table 5
WITHIN GROUP ANALYSIS
ANALYSIS OF IMPROVEMENT IN FDI

Sl. No

Group

Analysis

Mean SD

Pre test

49.5 9.59

A
Post test

79.9 8.92

Pre test

49.25 9.87

B
Post test

t value

Significance

19.15

***

17.23

***

94.5 7.02

The results of this study from the above table indicate that, in Within Group analyses
of Improvement in FDI, individuals of both Group A & Group B extremely significantly
improved from pre-test to post-test.
Figure 2
WITHIN GROUP ANALYSIS

28

ANALYSIS OF IMPROVEMENT IN FDI

FDI
94.5

100
79.9

80
60
FDI SCORES

49.5

49.25

40
20
0

GROUP A

GROUP B

29

BETWEEN GROUP ANALYSIS

Table 6
ANALYSIS OF DIFFERENCE IN HBGS FOR BOTH GROUPS

Sl. No

Group

Mean Difference
SD

t value

Significance

4.254

***

1.2 0.44

2.2 0.89

The results of this study from the above table indicate that, in analyses of
Improvement in HBGS, extremely significant improvement seen in individuals in Group B.
Figure 3
BETWEEN GROUP ANALYSIS
ANALYSIS OF DIFFERENCE IN HBGS FOR BOTH GROUPS

HBGS
2.5

2.2

2
1.5
HBGS SCORES

1.25

1
0.5
0

GROUP A

GROUP B

30

Table 6
BETWEEN GROUP ANALYSIS
ANALYSIS OF DIFFERENCE IN FDI FOR BOTH GROUPS

Sl. No

Group

Mean Difference
SD

30.4 7.89

t value

5.036
2

Significance

***

45.25 10.56

The results of this study from the above table indicate that, in analyses of
Improvement in FDI, extremely significant improvement seen in individuals in Group B.
Figure 4
BETWEEN GROUP ANALYSIS
ANALYSIS OF DIFFERENCE IN FDI FOR BOTH GROUPS

31

FDI
50
45
40
35
30
FDI SCORES 25
20
15
10
5
0

45.25

30.4

GROUP A

GROUP B

DISCUSSION
Bells palsy is an acute, idiopathic, unilateral paralysis of the face. Its cause is
unknown, but mounting evidence suggests that reactivated herpes viruses from cranial nerve
ganglia play a key role in the development of this condition, its pattern is consistent with that
of peripheral neural dysfunction. Inflammation of the facial nerve initially results in reversible
neuropraxia and wallerian degeneration ultimately ensues. It is characterized by weakness or
paralysis of the muscles on one side of the face. Facial nerve palsy can dramatically affect
many attributes of a patients general quality of life. Facial paralysis has been primarily
considered a cosmetic inconvenience with associated functional problems such as speech,
eating, facial asymmetry, drooling, and an inability to close the eye on the paralyzed side. The
patient with facial paralysis cannot convey the normal social signals of inter personal
communication. Facial muscles can alter the facial surface in various ways to execute their
functions. In addition to opening and closing the eyes and mouth they also have a reporting
function. Highly differentiated and complex facial musculature can express a large number of
sensations and can reflect the state of mind and mood of an individual. Facial symmetry is a
32

determinant of facial attractiveness, being a marker of good health and influences interpersonal
attraction.
The incidence of Bells palsy is approximately 30/100,000 people per year. The
prognosis is good, and approximately 70% of patients recover completely within 6 months
without treatment. However, 30% of Bells palsy patients have sequelae, such as residual
paresis (29%), contracture (17%), and facial spasm or synkinesis (16%). The incomplete
recovery of facial symmetry can have a long term impact on the quality of life, such as
difficulty with drinking, eating and speaking, as well as psycho social problems. Mild injury
causes "neuropraxia" the nerve is still there, it is just slowed down, there is decreased impulse
conduction, and prognosis is good. Moderate injury may cause interruption of axoplasmic flow
and axonotomesis. Wallerian degeneration occurs over 2-3 weeks. Full recovery generally
occurs within 2 months. Severe injury is called "neurotomesis".
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 regeneration. However physiotherapy treatment can be of benefit to speed
recovery and research has shown that physiotherapy can improve the impairments associated
with Bells palsy. Treatment may include Facial exercises to activate weak facial muscles,
Facial massage to facilitate movements and prevent shortening of muscles, Use of mirror
feedback to guide correct exercises, Exercises to improve eye closure, Advice regarding oral
hygiene and mouth care, Use of electrical stimulation in longer term cases. Benefits of
physiotherapy for Bells palsy include: Improved facial symmetry, improved sense of wellbeing, improved confidence, improved eye closure, and improved facial movements.
Traditional Approach to Facial Rehabilitation for facial neuro motor disorders
through physiotherapy using nonspecific light massage, electrical stimulation, and repetitions
33

of common facial expressions in a general exercise regimen have been considered to be of little
benefit. In fact, some interventions may even adversely affect the recovery of facial neuro
motor function. This technique does not encourages functional re-education of correct
movement patterns which is the most basic aspect of the therapeutic process and lay the
necessary foundation for learning the selective patterns to improve motor function. The
Conventional therapy due to this lacks the specificity result in residual asymmetry due to faulty
motor pattern.
An emerging rehabilitation science of neuro muscular re-education and evidence for
the efficacy of facial neuromuscular re-education, a process of facilitating the return of
intended facial movement patterns and eliminating unwanted patterns of facial movement and
expression, may provide patients with disorders of facial paralysis.
This study was conducted, to evaluate the effects of Kabat's PNF technique in acute
unilateral idiopathic Bells palsy patients.
In this study 40 patients were diagnosed to have acute unilateral idiopathic Bells
palsy. Average age at diagnosis was 35 years old with a range from 6 years to 60 years. In this
study twenty four patients were male and 16 patients were female. Twenty seven patients had
right sided and 13 patients had left sided. All the patients were graded based on HBGS and FDI
scales during initial presentation at the clinic. All the 20 out of the 40 patients were treated by
conventional physiotherapy, and 20 patients were treated with a combination of conventional
physiotherapy and Kabats PNF rehabilitation.
Therapeutic Goals of Kabats PNF rehabilitation & Technique:
The basic facilitation procedures provide tools for the therapist to help the patient
gain efficient motor function and increased motor control. These basic procedures are used to
34

increase the patients ability to move or remain stable. Guide the motion by proper grips and
appropriate resistance. It helps the patient to achieve co-ordinated motion through timing and
increase the patients stamina and avoid fatigue.
Resistance is used in treatment to: Facilitate the ability of the muscle to contract.
Increase motor control and motor learning. Help the patient gain an awareness of motion and
its direction. Increase strength and help the patient to relax (reciprocal inhibition).
Manual Contacts used in treatment to: Pressure on a muscle to aid that muscle
stability to contract to gives the patient security and confidence. And also promote tactile
kinaesthetic perception.
Body Position and Body Mechanics is used in treatment to: Give the therapist
effective control of the patients motion. Facilitate control of the direction of the resistance.
And enable the therapist to give resistance without fatiguing.
Verbal Stimulation (Commands) is used in treatment to: Guide the start of
movement or the muscle contractions. Affect the strength of the resulting muscle contractions
and given to the patient corrections.
Visions used in treatment to: Promote a more powerful muscle contraction. Help the
patient control and correct position and motion. Influence both the head and body motion.
Provide an avenue of communication and help to ensure co-operative interaction.
Stretch stimulus is used in treatment to: Facilitate muscle contractions. Facilitate
contraction of associated synergistic muscles.

35

Timing is used in treatment to: Normal timing provides continuous, co-ordinated

motion until a task is accomplished. Timing for emphasis redirects the energy of a strong
contraction into weaker muscles.
A significant difference in the mean values on the HBGS before and after
rehabilitation of 2.2 (SD 0.89) was observed in the experimental group and of 1.25 (SD 0.44)
in the control group (Table 6).
A significant difference in the mean values on the FDI before and after rehabilitation
of 45.25 (SD 10.56) was observed in the experimental group and of 30.4 (SD 7.89) in the
control group (Table 7).
The following basic neurophysiologic principles of PNF are responsible for
improvement in Physical and Psycho social well-being functions, in acute unilateral idiopathic
Bells palsy patients. They are
After discharge: The effect of a stimulus continues after the stimulus stops. If the
strength and duration of the stimulus increase, the after discharge also increases. The feeling of
increased power that comes after a maintained static contraction is a result of after discharge.
Temporal summation: A succession of weak stimuli (subliminal) occurring within a
certain (short) period of time combine (summate) to cause excitation.
Spatial summation: Weak stimuli applied simultaneously to different areas of the
body reinforce each other (summate) to cause excitation. Temporal and spatial summation can
combine for greater activity.

36

Irradiation: This is a spreading and increased strength of a response. It occurs when

either the number of stimuli or the strength of the stimuli is increased. The response may be
either excitation or inhibition.
Successive induction: An increased excitation of the agonist muscles follows
stimulation (contraction) of their antagonists. Techniques involving reversal of antagonists
make use of this property (Induction: stimulation, increased excitability.).
Reciprocal innervations (reciprocal inhibition): Contraction of muscles is
accompanied by simultaneous inhibition of their antagonists. Reciprocal innervations are a
necessary part of coordinated motion. Relaxation techniques make use of this property.
The results suggest that the individuals who got Kabat's PNF rehabilitation, showed
a greater improvement in Physical Psychological and Social well-being function when
compare with conventional physiotherapy. PNF, the treatment approach is always positive,
reinforcing and which the patient can do, on a physical and psychological level. The primary
goal of all treatment is to help patients to achieve their highest level of function. To reach this
highest level of function, the therapist integrates principles of motor control and motor learning
through Kabats PNF rehabilitation.

37

CONCLUSION
When applied at an early stage, Kabat's PNF rehabilitation (Group B) was shown to
provide a better and good improvement in facial and social well-being functions, compared
with conventional physiotherapy (Group A) treatment in acute unilateral idiopathic bells
palsy patients. Because FDI and HBGS improved substantially in Kabat's rehabilitation group,
so this technique may be incorporated in the treatment strategies of acute unilateral idiopathic
Bells palsy.

38

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palsy: Analysis of 1,000 consecutive patients. Laryngoscope. 1978;88:787801.(Pub
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8) Peitersen E. Bells Palsy; The spontaneous course of 2,500 peripheral facial nerve
palsies of different aetiologies. Actaoto laryngol suppl 2002; 549: 4-30.
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10) Ohye RG, Altenberger EA. Bells palsy. Am Fam Physician1989;40:159166

11) Twerski AJ, Twerski B. The emotional impact of facial paralysis. In: May M, Ed. The
Facial Nerve. New York, NY: Thieme Medical Publishers; 1986:788794
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The Facial Nerve.

New York, NY: Thieme Medical Publishers Inc; 1986:781-787.

13) Hauser WA, Karnes WE, Annis J, Kurland LT. Incidence and prognosis of Bell's palsy in
the population of Rochester, Minnesota. Mayo Clin Proc. 1971; 46: 25864.
14) John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition. John Wright
and sons ltd, 1985; 481.
15) P. Dhingra. Diseases of Ear, Nose and Throat, 4th Edition. An imprint of Elsevier, 2004;
94.
16) 16. Kenneth W. Lindsay, Ian Bone. Neurology and Neurosurgery illustrated, 4 th Edition.
Churchill living stones, 2004; 168.
17) 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.
18) Julian Holland Department of Otolaryngology Head and Neck Surgery, Guy's and St.
Thomas' Hospital London UK BMJ Publishing Group Ltd 2008.
19) Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies
of different aetiologies. ActaOtolaryngolSuppl2002; 549:430.
20) Gilden DH. Bell's palsy. N Engl J Med. 2004; 351:132331.

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21) Maurizio Barbara, MD, PhD, Giovanni Antonini, Annarita Vestri, Luigi Volpini,
Simonetta Monini; Role of Kabat physical rehabilitation in Bell's palsy: A randomized
trial 2010, Vol. 130, No. 1, Pages 167-172
22) Barbara M, Monini S, Buffoni A, Cordier A, Ronchetti F, Harguindey A, Di Stadio A,
Curruto R, and Filipo R. Early rehabilitation of facial nerve deficit after acoustic
neuroma surgery. Acta Otolaryngol, 123: 932-935,(2003).
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Techniques, Edi 4th, (2003).
24) Mari Namura, Mitsuru Motoyoshi, Yasuhiro Namura and Noriyoshi Shimizu, Journal Of
Oral Science, Vol 50, No 1 , 45-51, (2008).
25) Kabat H, Knott M, Proprioceptive Facilitation Techniques for Treatment of Paralysis.
Phys Ther Rev33, 53-64 (1953).
26) McMullen J, UhlTL, A Kinetic Chain Approach for Shoulder Rehabilitation. J Athl
Train 35, 329-337 (2000).
27) Kofotolis N, Kellies E, Effects of two 4-week proprioceptive neuromuscular facilitation
programs on muscle endurance, flexibility, and functional performance in women with
chronic low back pain. Phys Ther 86,1001-1012 (2006)
28) Nakajima E, Yanagisawa K, Imai M, Tomita H, Kitabayashi Y, Shika PNF Manual.
Quintessence, Tokyo, 12-49 (in Japanese) (2003)

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29) Lusting A, Ball E, Looney M. A Comparison of Two Proprioceptive Neuromuscular

Facilitation Technique for Improving Range Of Motion and Muscular Strength. Isokinet
Exerc Sci; 2:154-9, (1992).
30) Susan S. Adler, Dominiek Beckers, Math Buck. PNF in practice an illustrated guide, 2nd
revised Edition. Springer, 2000; 1-15, 364.
31) Hyvarinen A, Tarkka IM, Mervaala E, Paakkonen A, Valtonen H, Nuutinen J. Cutaneous
electrical stimulation treatment in unresolved facial nerve paralysis: an exploratory
study. Am J Phys Med Rehabil. 2008 Dec; 87(12): 992-7.
32) 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.
Otology & Neurotology 2003; 24: 677681
33) Beurskens CHG, Heymans PG, Oostendorp RAB. Stability of benefits of mime therapy
in sequelae of facial nerve paresis during a 1-year period. Otology & Neurotology 2006;
27:1037 1042
34) Van Swearingen JM, Brach JS. The facial disability index: reliability and validity of a
disability assessment instrument for disorders of the facial neuromuscular system.
PhysTher1996;76:12881300
35) Elliott JM (2006): Physiotherapy treatment of Bells palsy: A case report. New Zealand
Journal of

Physiotherapy 34(3): 167-171.

36) Ekman P. Psychosocial aspects of facial paralysis. In: May M, Ed. The Facial Nerve.
New York, NY: Thieme Medical Publishers; 1986:781787

42

37) Kang TS, Vrabec JT, Giddings N, Terris DJ. Facial nerve grading systems (1985-2002):
Beyond the House-Brackmann Scale. Otol Neurotol 2002; 23:767-71.
38) Evans RA, Harries ML, Baguley DM, Moffat DA: Reliability of the House and
Brackmann grading system for facial palsy. J Laryngol Otol 1989, 103: 1045-1046.
39) Effect of long-term electrical stimulation on motor recovery and improvement of
clinical residuals in patients with unresolved facial nerve palsy. Targan RS, Alon G, Kay
SL. Otolaryngol Head Neck Surg. 2000 Feb; 122 (2):246-52.
40) Bells palsy Exercises http: www.mindspring.com/mattcn/medical/bpexercises.htm

43

APPENDIX - 1
INFORMED CONSENT FORM
I understand that I am being asked to participate in a research study in Physical Medicine and
Rehabilitation Centre, Puducherry.
The Purpose of this study is to assess "THE EFFECTIVENSS OF KABAT'S PNF
REHABILITATION IN ACUTE UNILATERAL IDIOPATHIC BELLS PALSY"

patients.

The procedure of this study has been clearly explained to me.

I realize that I may not participate in the study if I do not satisfy the selection criteria.
I understand that my participation in this research study is entirely voluntary.
I acknowledge that I have the right to question any part of the procedure and can withdraw at
any time without this being held against me.
I understand that the information obtained from this research study is strictly confidential.
I acknowledge that results of this study may be used in future research and may be published,
provided that my personal details will not be revealed.
If I have any questions regarding this research study, I understand that I may contact
Mr.RAMADASS L. anytime during the study.
All my questions have been answered, and I agree to participate in the study.
Date:

Signature of the participant

Place:

Signature of the investigator

44

APPENDIX - 2
PATIENT EVALUATION SHEET FOR DATA COLLECTION
GGROUP

Demographic Data
Name

Age

Sex

Occupation

Address

Diagnosis

Date of onset

Duration of Bells palsy

Side of involvement

Medical history
Drugs history

Prior history of Bells palsy

: YES/NO

Hypertension

: YES/NO

Diabetes mellitus

: YES/NO

Heart Disease

: YES/NO

Prior CVA / TIA

: YES/NO
45

Other Details

Social history
Personal history

Marital status

Living situation

Hobbies

Socioeconomic history

Psychological impact

: Anxious /Depressed / Concerned/ Other

On observation
Asymmetric facial expression
The corner of mouth drops
Naso labial foldis flattened

:PRESENCE/ABSENCE
:PRESENCE/ABSENCE
:PRESENCE/ABSENCE

Palpebral fissure is widened

:PRESENCE/ABSENCE

Wasting if any

:PRESENCE/ABSENCE

Bell's phenomenon

:PRESENCE/ABSENCE

Facial asymmetry
Synkinesis
Blurred vision
Drooling
Vertigo
Lacrimation

Otorrhea

:PRESENCE/ABSENCE
:PRESENCE/ABSENCE
:PRESENCE/ABSENCE
:PRESENCE/ABSENCE
:PRESENCE/ABSENCE
:PRESENCE/ABSENCE

:PRESENCE/ABSENCE

46

On palpation
Tenderness

:PRESENCE/ABSENCE

On examination
Tightness
Contracture

: PRESENCE/ABSENCE
: PRESENCE/ABSENCE

Deformity

: PRESENCE/ABSENCE

Sensory Examination of V th nerve

Superficial

: PRESENCE/ABSENCE

Touch

: PRESENCE/ABSENCE

Pressure

: PRESENCE/ABSENCE

Pain

: PRESENCE/ABSENCE

Deep

: PRESENCE/ABSENCE

Sensory Examination of VII th nerve

Afferent

: Taste from anterior tongue

Efferent (Somatic)

: Muscles of facial Expression

Efferent (Visceral)

: Tearing (lacrimal gland)

Salivation (Sub mandibular and sublingual glands).

47

Muscle power test ( facial nerve)

Grade
Muscle
Right

Frontalis
Orbicularis
Corrugator
Nasalis
Procerus
Levator angulioris
Levatorlabii sup.
Zygomaticus minor
Resorius
Zygomaticus major
Depressor labii inf
Platyzma
Orbicularis oris
Buccinator
Mentalis
Depressor angulioris

48

Left

F: Functional, WF: Weak Functional, NF: Non Functional, O: Absent

APPENDIX - 3
DATA COLLECTION SHEET
GROUP A
Sl. No

HBGS
PRE
POST

PRE

GROUP B
FDI
POST

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

49

HBGS
PRE
POST

PRE

FDI
POST

19
20
TOTAL

APPENDIX 4
FACIAL DISABILITY INDEX (FDI)
Name: _________________________ Date: _______________________
Facial Disability Index Part 1
Please choose the most appropriate response to the following questions related to problems
associated with the function of your facial muscles.
Physical Function
1. How much difficulty did you have keeping food in your mouth, moving food around
your mouth, or getting food stuck in your cheek? Usually did with:
5 = No difficulty

2 = Much difficulty

4 = A little difficulty

1 = Usually did not eat because of health

3 = Some difficulty

0 = Usually did not eat because of other reasons

2. How much difficulty did you have drinking from a cup? Usually did with:
5 = No difficulty

2 = Much difficulty

4 = A little difficulty

1 = Usually did not eat because of health

3 = Some difficulty

0 = Usually did not eat because of other reasons

3. How much difficulty did you have saying specific sounds while speaking? Usually did
with:
5 = No difficulty

2 = Much difficulty

4 = A little difficulty

1 = Usually did not eat because of health

3 = Some difficulty

0 = Usually did not eat because of other reasons

50

4. How much difficulty did you have with your eye tearing excessively or becoming dry?
Usually did with:
5 = No difficulty

2 = Much difficulty

4 = A little difficulty

1 = Usually did not eat because of health

3 = Some difficulty

0 = Usually did not eat because of other reasons

5. How much difficulty did you have with brushing your teeth or rinsing your mouth?
Usually did with:
5 = No difficulty

2 = Much difficulty

4 = A little difficulty

1 = Usually did not eat because of health

3 = Some difficulty

0 = Usually did not eat because of other reasons

Office Use Only

Sl.
No

Score

Goal

1
2
3
4
5
Total: __________
(____ - 5) / 5 x 25 = _________ Physical Score.
(____ - 5) / 5 x 25 = _________ Physical Score Goal.

51

Facial Disability Index Part 2

Please choose the most appropriate response to the following questions related to problems
associated with the function of your facial muscles.
Social / Well-being Function
6. How much time have you felt calm and peaceful?

6 = All of the time

3 = Some of the time

5 = Most of the time

2 = A little bit of the time

4 = A good bit of the time

1 = None of the time

7. How much of the time did you isolate yourself from people around you?

1 = All of the time

4 = Some of the time

2 = Most of the time

5 = A little bit of the time

3 = A good bit of the time

6 = None of the time

8. How much of the time did you get irritable toward those around you?

1 = All of the time

4 = Some of the time

2 = Most of the time

5 = A little bit of the time

3 = A good bit of the time

6 = None of the time

9. How often did you wake up early or wake up several times during your night-time
sleep?

1 = Every night

4 = Some nights

2 = Most nights

5 = A few nights

3 = A good number of nights

6 = No nights

10. How often has your facial function kept you from going out to eat, shop, or participate
in family or social activities?
52

1 = All of the time

2 = Most of the time
3 = A good bit of the time

4 = Some of the time

5 = A little bit of the time
6 = None of the time

53

Office Use Only

Sl.
No
6
7
8
9
10

Score

Goal

Total: __________
(____ - 5) / 5 x 20 = _________ Social/Wellbeing Score
(____ - 5) / 5 x 20 = _________ Social/Wellbeing Score Goal
Physical (_____) + Social (_____) = (________/ 200) total FDI Score
Physical (_____) + Social (_____) = (________/ 200) total FDI Score Goal

54

APPENDIX-5
House-Brackmann Grading Scale

Grade
1

Definition

Normal symmetrical function in all areas

Slight weakness noticeable only on close inspection

Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent

Obvious weakness, but not disfiguring

May not be able to lift eyebrow
Complete eye closure and strong but asymmetrical mouth
movement
with maximal effort
Obvious, but not disfiguring synkinesis, mass movement or
spasm

Obvious disfiguring weakness

Inability to lift brow
Incomplete eye closure and asymmetry of mouth with
maximal effort
Severe synkinesis, mass movement, spasm

Motion barely perceptible

Incomplete eye closure, slight movement corner mouth
Synkinesis, contracture, and spasm usually absent

No movement, loss of tone, no synkinesis, contracture, or

spasm

55

APPENDIX 6
KABAT'S (PNF) REHABILITATION
1. Muscle of Epicranius (Frontalis): Ask the patient to lift eye brows up, and look surprised
and wrinkle his forehead. And apply resistance to the forehead, pushing caudally and medially.
This movement works with eye opening. It is reinforced with neck extension.
2. Muscle of 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 of orbicularis oculi: Ask the patient to close the eyes. And give gentle diagonal
resistance to the eye lids, Separate exercise for upper and lower eye lids. Avoid putting
pressure on the eyeballs. Previous two motions are facilitated by neck flexion.
4. Muscle of leveater palpebrae superioris: Ask the patient to open the eyes, look up, and
given resistance to the upper eye lids and resistance to the eyebrow elevation are reinforce the
action.
5. Muscle of 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.
6. Muscle of orbicularis oris: Ask the patient to purse the lips whistle and say prunes. Apply
resistance laterally and upward to the upper laterally lip and downward to the lower lip.
7. Muscle of mentalis: Ask the patient to wrinkle the chin. Apply resistance down and out of
the chin.
8. Muscle of risorius and zygomaticus major: Ask the patient to smile, apply resistance to
the corner of the mouth medially and slightly downward (caudally).
9. Muscle of Levator Labii Superioris: Ask the patient to Show his upper teeth. And Apply
resistance to the upper lip, downward and medially.
10. Muscle of

Depressor Labii Inferioris: Ask the patient to Show his lower teeth. Apply

resistance upward and medially to the lower lip. This muscle and the platysma work together.
56

11. Muscle of Levator Anguli Oris: Ask the patient to pull the corner of his mouth up, a small
smile. Push down and in at the corner of the mouth.
12. Muscle of

Depressor Anguli Oris: Ask the patient to Push the corners of his mouth

down, look sad. Give resistance upwards and medially to the corners of the mouth.
13. Muscle of Buccinator: Ask the patient to Suck his cheeks in, pull in against the tongue
blade or gloved finger. Apply resistance on the inner surface of the cheeks with gloved fingers
or a dampened tongue blade. The resistance can be given diagonally upward or diagonally
downward as well as straight out.
14. Muscle of Platysma: Ask the patient to pull his chin down. Give resistance under the chin
to prevent the mouth from opening. Resistance may be diagonal or in a straight plane .Resisted
neck flexion reinforces this muscle.

57

APPENDIX-7
KABAT'S (PNF) REHABILITATION

58

59

APPENDIX 8
BELL'S PALSY EXERCISES

Try doing the exercises in front of a mirror, (admittedly very discouraging at first), repeat each
one 10 times, and try to do the entire set at least 15 times a day.
1. Drink all liquids through a straw. You'll be dribbling all over yourself for a few days, but it
does help the muscles around the mouth.
2. Sniff strongly. Wrinkle nose. Flare nostrils.
3. Curl upper lip up and raise and protrude upper lip. Try to touch nose.
4. Compress lips together. Pucker lips together & attempt to whistle.
5. Blow air into cheeks, attempting to keep mouth closed (like blowing a balloon.)Shift air
from one cheek to the other.
6. Smile without showing teeth, then smile showing teeth.
7. Try moving your lips into a smile slowly. Then pucker slowly trying to use equal strength
from both sides.
8. Draw angle of mouth upward so as to deepen furrow from side of nose to side of mouth.
9. Harden (wrinkle) the chin, ("stick out" the chin, like a boxer) at first you will probably have
to manually push your muscles into place to do the exercises.

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10. Using the finger tips tap from the jaw along the bone line to the centre of the top lip. Return
the tapping motion to the jaw.
11. Tap along the lower jaw to the centre of the lower lip. Return to the jaw using a tapping
motion. Tap along the lower jaw along the chin line & back to the jaw.
12. Using your index finger and thumb pull the corners of your lips in toward the centre.
Slowly and smoothly push out and up into a smile. Continue the movement up to the cheek
bone. Use a firm pressure.
13. A makeup brush or a soft tooth brush can be used for the cheek, jaw and lip stimulation.
14. Put a large button on a string. Place it under your lips. Pull the string. Try to hold it with
your lips. Move the button to the right corner pull and resist. Repeat on the left side.
15. Chew gum and Chew and suck on ice. Say a, e, i, o, u. Whistle
For the eye:
1. Placing 4 finger tips on the eyebrow rub using a firm slow stroke up to the hairline. Return
downward to the eyebrow.
2. Using finger tips placed on the cheek tap lightly and slowly along the bone under the eye to
the bridge of the nose. Return tapping along the cheek bone to the side of the face.
3. Try to close the eye slowly. Raise eyebrows and hold for 5 seconds. Wrinkle forehead.
5. Frown and draw eyebrows downward. Close eyes tightly. Wink with one and then the other
eye to the best of your ability. Open eyes widely.
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APPENDIX-9
ABBREVIATIONS

RCT

Randomized Control Trial

PNF

Proprioceptive Neuromuscular Facilitation

HBGS

House-Brackmann Grading Scale

FDI

Facial Disability Index

SD

Standard Deviation

NS

Not Significant

CAMAP

Compound Motor Action Potential

CNS

Central Nerves System

PRE

Progressive Resisted Exercise

AN

Acoustic Neuroma

NL

Naso Labial

ML

Mento Labial

MC

Mento Cervical

IRR

Infera Red Rays

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