The Indian Journal of Occupational Therapy : Vol. XXXIX : No.

2 (August 2007 - November 2007)

TO

STUDY AND COMPARE THE EFFICACY OF VM FUNCTIONAL DYNAMIC TAPING PROTOCOL / TECHNIQUE OVER CONVENTIONAL TREATMENT PROTOCOL IN BELL'S PALSY

*Vijay Batra, M.O.T.; Co-Author : **Meenakshi Batra, M.O.T. Abstract :

Introduction : There are different ways of functional retraining following Bells Palsy but till date no specific guidelines with appropriate dosage & sequence have been given. Aims & Objectives : To study & compare the efficacy of Functional Dynamic taping protocol/Technique over Conventional treatment technique/ protocol in Bells Palsy. Methodology : 30 Subjects with a diagnosis of Bells Palsy of non-traumatic onset were taken. The baseline evaluation was done for motor, sensory component, & functional activities. They were divided into two groups namely group A & group B. In Group A, Functional Dynamic Taping Protocol & in Group B, Conventional treatment method was used. Re-evaluation was done after 8 weeks. Results : Statistical analysis was done & P value (< .05) was found to be significant for group A. Conclusion : VM Functional Dynamic taping protocol is more effective for functional retraining than conventional treatment in subjects with Bells Palsy. Key Words: Bells Palsy, Taping

INTRODUCTION
Bells Palsy is a partial paralysis of the face accompanied by pain or discomfort. It is characterized by weakness or paralysis of the muscles on one side of the face. 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 interpersonal communication. Facial nerve is responsible for voluntary facial movements,& can be tested by asking a patient to perform movements such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly, pursing the lips and puffing out the cheeks & noticing asymmetry.
* Occupational Therapist ** Senior Occupational Therapist Place of Study : M.B. Hospital, G.B. Pant Hospital, New Delhi. Period of Study : June 2005 - October 2006 Correspondence :

The recovery phases of Bells palsy tends to follow one of two pathways: q q Rapid recovery group Delayed / partial recovery

The treatment options available for Bells palsy includes (Medical & Surgical Management): Eye drops & Eye lubricants or viscous ointments, Therapeutic injections of botulism toxin & vitamin B12 supplements, Anti-inflammatory & Antiviral medication, Alternative treatment, Facial massage and exercises, Acupuncture, Chiropractic manipulation, Surgery. Review of literature K. B. EL-Sherbini did a study on bilateral Bells palsy management & Prognosis: Ten cases of bilateral Bells palsy were treated and studied from the point of view of prognosis. The changes in the position of the mouth were discussed. A new method of splinting the mouth and cheek by adhesive plaster was devised. Four cases had injections of prednisolone- trimethylacetate in the stylomastoid foramen, and in these the incidence of complications was lower than in the non-injected cases.
35 August, 2007 - November, 2007

Dr. Vijay batra

A-3/90, Pachim Vihar, New Delhi - 110 063 Tel. : 011 25280121 E-mail : vijaybatra@yahoo.com

The recipient of Kailash Merchant Award for Best Paper in Neurology presented in 44th Annual National Conference of AIOTA at Indore, in January 2007.

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Balliet, et. al. (1982) described a comprehensive clinical program that combined EMG feedback, mirror exercises and detailed, individualized home exercise programs and demonstrated improved function with patients more than two years post facial nerve injury. Ross, et al (1991)(10), compared two treatment groups with a third control group that received no treatment. After comprehensive evaluation, one group was trained with EMG and mirror feedback, while the second group used mirror feedback alone. Patients were reevaluated after one year of treatment. A significant difference was found between the treatment groups and the control group. Patients in both treatment groups demonstrated improvements in facial motor control, excursion of movement and decreased synkinesis. The control group showed no change, or decreased function. A follow-up study one year later concluded that gains acquired during treatment had been maintained without continued therapy. It is clear from research thus far, that the application of neuromuscular retraining techniques specifically designed for the treatment of facial paralysis can effectively reduce sequelae after facial nerve injury. Dalla Toffola, Bossi D, Buonocore M, Montomli C, Petrucci L, Alfonsi E(4) did a study on Usefulness of BFB/EMG in facial palsy rehabilitation. The objective of study was to analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bells palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG). It was concluded that BFB/EMG seems to be more useful than KT in Bells palsy treatment. Bulstrode NW, Harrison DH (5) described phenomenon of the late recovered Bells palsy & did the study on the treatment options to improve facial symmetry. It was concluded that the true benefit of botulinum toxin injections was more apparent during facial animation and not when the face was static. The patients greatly appreciated the improvement in facial symmetry. Various treatment options are available to improve the quality of life for patients with late recovered Bells palsy. Cederwall E, Olsen MF, Hanner P, Fogdestam I (3) did a study on Evaluation of a physiotherapeutic treatment intervention in Bells facial palsy. The aim of this study was to evaluate a physiotherapeutic treatment intervention in Bells palsy. Every patient was taught to perform an exercise program twice daily, including movements of the muscles surrounding the mouth, nose, eyes and forehead. All the patients improved in terms of symmetry at rest, movement and function. In conclusion, patients with remaining symptoms of Bells palsy appear to experience positive effects from a specific training program.
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Rationale for study There are different ways/methods of treatment to improve Oro-motor and facial functions in patients with Bells Palsy but till date no specific guidelines have been followed. The available methods lack specificity. Due to nonspecificity of available methods there was the need to design a specific, systematic & sequential treatment strategy/ protocol with appropriate dosage & direction such as Taping protocol to regain facial symmetry & required normal facial function.

AIMS AND OBJECTIVES

To study & compare the efficacy of VM Functional Dynamic taping protocol/Technique over Conventional treatment protocol Hypothesis Null Hypothesis (Ho) Both Dynamic functional taping protocol/Technique and Conventional treatment protocol are equally effective in subjects with Bells palsy of non-traumatic onset Alternate Hypothesis (Ha) (1) Dynamic functional taping protocol/Technique is more effective than Conventional treatment protocol in subjects with Bells palsy (2) Conventional treatment protocol is more effective than Dynamic functional taping protocol/Technique in subjects with Bells palsy

METHOD
Design Different Subject design Matched on the basis of Age, Sex, and Extent of involvement. Subjects Subjects taken were 30 with age group 15-35 years with a diagnosis of bells palsy of non-traumatic onset. Subject pool was taken from G.B.Pant & M.B. Hospital &consent form signed by them. Inclusion criteria Subjects with age group 15-35 years Acute onset (1-3 week) Middle S/E status Diagnosed case of Bells palsy Non-traumatic onset No other neurological deficit.

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Exclusion criteria Psychiatric illness Subjects with age group below 15 & above 35 years UMN lesion Neurotmesis Skin infection & open wounds Hypersensitive skin Skin Allergy to micropore

Taping Protocol for Group A Taping protocol is divided into 3 treatment phases: 1. Facilitatory Phase 2. Enhancement Phase 3. Resistive phase Treatment Protocol for Group B Conventional method for group B included Passive & Active exercises, passive stimulation, and facial massage. Reevaluation was done after 8 weeks for both the groups using Facial grading scale for Resting symmetry & symmetry of voluntary movement, and performance in Functional activities was also assessed. The Scoring was done on Functional Facial Grading Score sheet (Table S-1) [for Resting symmetry (0-2) three point score and Symmetry of Voluntary Movement (1-5) on five point score] & Facial Function Deficit (Table S-2). The composite score was also calculated. Composite Score = {(Voluntary Movement Score) x 4 (Resting Symmetry Score) x 5} (Table S3) Table : S-1 Functional Facial Grading Score sheet
Series1

Instrument Micropore Tape, Surgical Blade & Scale, Functional assessment checklist and Facial Function Deficits & Facial Grading Score sheet Procedure 30 Subjects with a diagnosis of bells palsy (non-traumatic onset) were chosen. (Fig. - 1) Fig. - 1
Fig showing Age Distribution
14 12
No. of Subjects

10 8 6 4 2 0 16-20 21-25 26-30 31-35

Age Range

The Baseline evaluation was done for motor & sensory component, Facial Function Deficit, & functional activities. Facial Grading Score sheet was also completed. The subjects were divided into two groups namely group A & group B and matched on the basis of Age, Sex, and Severity of involvement. In Group A, Therapeutic intervention was done using Functional Dynamic taping protocol/technique. In Group B, Therapeutic intervention was done using Conventional treatment method. The duration of each session was kept constant for both the groups i.e. 60 minute each, 5 times a week. Treatment Protocol for Group A It included systematic & sequential approach towards functional retraining using Functional dynamic taping protocol.
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Grading of Functional Activities Chewing Gum 1 Unable to lateralize the Chewing gum past midline only 2 Ability to lateralize the Chewing gum to corner of mouth on affected side only 3 Ability to lateralize & chew the Chewing gum on affected side but unable to bring it to midline 4 Ability to lateralize & chew the Chewing gum on affected side and bring it to midline with some effort. 5 Normal Balloon Blowing 1 Unable to blow balloon 2 Able to blow balloon with external support but with difficulty 3 Able to blow balloon with no external support but with difficulty 4 Able to blow balloon with no external support but takes time (>5 minutes) 5 Able to blow balloon with minimal or no effort (Normal) Speech 1 Speech is slow slurred & incoherent 2 Speech is slow, coherent & Laborious 3 Speech is slow, clear & coherent but less laborious 4 Speech is fluent, & clear with minimal effort 5 Normal

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Table : S-2 System of assessment for Facial Function Deficits Assessment Sheet
Class 0 I Signification Normal Facial Activity Light paresis: normal at rest, talking normal, The eyes can be closed, some dissymmetry in laughing & Whistling Moderate paresis: normal at rest; asymmetry in talking & laughing; the eyes can not be closed Severe paralysis: Asymmetry at rest, dysfunction in movement Total paralysis: no tone, total loss of function. Contracture of the muscles may result in apparent improvement, while degeneration atrophy may cause a more serious defect.
120 Composite Score 100 80 60 40 20 0 35 30 25 20 15 10 5 0 1 2 3 4 5 6

Graph - 1
Composite Score Gr. A vs Gr. B (Initial)
Composite score Range

Range CS Gr. A Gr. B

II III IV

8 9 10 11 12 13 14 15

No. of Subjects

Graph - 2
Composite Score Gr. A vs Gr.B (Final)

Range CS Gr. A Gr. B

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 No. of Subjects

Table : S-3 Composite Score Calculation Sheet

Resting Symmetry (0-2) Key Eye Normal (0) Narrow (1) Wide (1) Eyelid Surgery (1) Normal (0) Absent (2) Less Pronounced (1) More Pronounced (1) Normal (0) Corner drooped (1) Corner Pulled Up/Out (1) 5 Score Symmetry of Voluntary Movement (1-5) Standard Expression Forehead Wrinkle Gentle Eye Closure Open Mouth Smile Snarl Lip Pucker Wrinkle nose Score

Cheek (Nasolabial Fold)

Mouth

TOTAL Resting Symmetry Score Total

TOTAL Voluntary Movement Score

Total

Composite Score = {(Voluntary Movement Score) (Resting Symmetry Score) }

Key to Voluntary Movement Score: Score (1 to 5)= Gross Asymmetry (1) to Severe Asymmetry (2) to Moderate Asymmetry (3) to Mild Asymmetry (4) to Normal Symmetry (5) 1= Unable to initiate movement, 2= initiate slight movement, 3= Initiate movement with mild excursion, 4=Movement almost complete, 5= Movement complete Key to Synkinesis Score: Score (0 to 3) = none (0), mild (1), Moderate (2), Severe (3), 0=No Synkinesis or mass movement, 1= Slight Synkinesis, 2=Obvious but not disfiguring synkinesis, 3= Disfiguring Synkinesis/Gross mass movement of several muscles IJOT : Vol. XXXIX : No. 2 38 August, 2007 - November, 2007

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RESULT
Statistical analysis was done for within & between group analysis. Paired t test was used for within group analysis. Student t test was used to compare quantitative characteristic & baseline outcome variables. When there was no baseline difference between groups or unequal distribution of confounders student t test between groups was used i.e. group A before after & group B before after. When baseline difference between groups or unequal distribution of confounders ANCOVA between groups was used. Statistical analysis done P value was found to be < .05 that is significant. Although Both Functional Dynamic taping protocol/ technique & Conventional treatment protocol were effective for functional retraining but subjects in Group A showed better functional recovery than Group B.

Muscular Retraining (NMR), Neurophysiology & Biomechanics. It states that weak or paralyzed muscle can be reinforced or facilitated through irradiation and temporal & spatial summation. The principle of Biomechanics explains the vectors responsible to perform a movement in facial region, which needs to be balanced to optimize the muscle function in desired direction thereby preventing asymmetry. Taping protocol utilizes all of the above principles & serve the main purpose that are: Preventing asymmetry Preventing over activity/ over pull of paralyzed muscle Enhance facilitation Reinforce movement in graded fashion Maximize functional use of affected muscles by incorporating functional activities The conventional therapy involves facial exercises, Facial massage & passive stimulation. It does not encourages functional reeducation 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. Also it does not encourage functional reeducation using correct motor pattern. This results in residual asymmetry (due to faulty motor pattern). Hence it can be interpreted that functional taping protocol is more specific & effective than conventional Therapy.

DISCUSSION
On the basis of analysis of result the alternate hypothesis stating that Dynamic functional taping protocol/Technique is more effective than Conventional treatment protocol in subjects with Bells palsy can be accepted & null hypothesis can be rejected. Although both Functional Dynamic taping protocol/technique & Conventional treatment protocol were effective for functional retraining but subjects in group A showed better functional recovery than group B in terms of facial symmetry, & ability to perform functional activities such as chewing, balloon blowing & speech. But taping protocol being more sequential, & systematic showed better results. Also The intricacy of movement that can be achieved by the facial muscles should preclude the use of maximum effort, gross exercises, where motor units other than those targeted are recruited due to overflow. Basically taping helps to retrain paralyzed facial muscles by maintaining symmetry& facilitating paralzed muscles,thereby preventing overactivity of normal muscles & acts as a stabilizing mechanism by promoting desired symmetrical movement pattern that needs to be repetitively reinforced before it will be learned. Taping protocol is a problem solving approach to treatment using selective motor training to facilitate symmetrical movement and control undesired gross motor activity. Taping protocol is based on the principles of Neuro

CONCLUSION
VM Functional Dynamic protocol is more effective than conventional treatment for functional retraining in subjects with Bells palsy.

ACKNOWLEDGEMENT
We are thankful to Dr. R.M. Pandey, Professor & Head, Deptt. of Biostatistics A.I.I.M.S., New Delhi for his statistical analytical & continued help throughout the work. We are grateful to Dr. Vinod Puri, Prof. & Head, Neurology, Staff Members Occupational Therapy Deptt. and the patients of G.B. Pant & M.B. Hospital, Delhi where the study was conducted.

REFERENCES
1. 2. Dumitru D, Walsh NE, Porter LD reviewed a Electro physiologic evaluation of the facial nerve in Bells palsy. Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, San Antonio 78284-7798.

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Cederwall E, Olsen MF, Hanner P, Fogdestam I Department of Physiotherapy, Skene lasarett, Skene, Sweden (2006); Evaluation of a physiotherapeutic treatment intervention in Bells facial palsy. Physiotherapy Theory Pract. Jan 22(1): 43-52. Dalla Toffola, Bossi D, Buonocore M, Montomli C, Petrucci L, Alfonsi E (2005); Usefulness of BFB/EMG in facial palsy rehabilitation, Disabil Rehabil. Jul 22; 27(14): 809-15. Bulstrode NW, Harrison DH (2005), The phenomenon of the late recovered Bells palsy: treatment options to improve facial symmetry Plast Reconstr Surg. May; 115(6): 1466-71. I G Williamson and T R Whelan (1996) The clinical problem of Bells palsy: is treatment with steroids effective? Br J Gen Pract. 1996 December; 46(413): 743747. Brach JS, Vanswearingen JM, Lenert J, et al (1997): Facial neuromuscular retraining for oral synkinesis. Plast Reconstruc Surg 99:1922-1933. Cronin GW, Steeners on RL (2003): The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otol-Head Neck Surg 128:534-538. Diels J: New concepts in nonsurgical facial nerve rehabilitation, in Meyers EN, Bluestone CD, Brackmann DE, et al (eds.) Advances in Otolaryngol-Head Neck Surg, vol. 9, Chicago, Mosby-Year Book, 1995. Ross B, Nedzelski JM, McLean JA (1991): Efficacy of feedback training in long- standing facial nerve paresis. Laryngoscope 101:744-750. Segal B, Zompa I, Danys I, et al (1995): Symmetry and synkinesis during rehabilitation of unilateral facial paralysis. J of Otolaryngol 24:143- 148. Van Swearingen JM, Brach JS (2003): Changes in facial movement and synkinesis with facial neuromuscular reeducation. Plast Reconstruc Surg 111(7): 2370- 2375. Palmieri NF. (1990) Idiopathic facial paralysis: mechanism, diagnosis and conservative management. Chiro Technique; Nov: 182-187. Krukowska J (2003) Analysis of physiotherapy outcome in patients with Bells peripheral facial nerve palsy Otolaryngol Pol. 2003; 57(1): 143-5. Review. Polish. Piercy J Bells palsy. BMJ. 2005 Jun 11; 330(7504): 1374. Review.

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