Far Eastern University Institute of Nursing Morayta, Manila SY: 2010-2011

EVIDENCED BASED NURSING

SUBMMITED BY: Submitted by: Evardone, Inah D. Garcia, Clara Maey S. Go, Frank Martin A. Guernaldo, Geneva G. Hubilla, Joly M. Javier, Kathrine L.

Bells Palsy
Is due to unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side. There is distortion of the face from paralysis of the facial muscles; increased lacrimation (tearing); and painful sensation in the face, behind the ear and in the eye. The patient may experience speech difficulties and may be unable to eat on the affected side because of weakness or paralysis of the facial muscles.
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Causes >Exact cause is unknown >Vascular schemia e >Viral disease ( ex, herpes simplex, r herpes zoster ) e >Autoimmune disease
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Symptoms S
Symptoms usually start suddenly, and range from mild to severe. They may include: Change in facial expression (for example, grimacing) Difficulty with eating and drinking Drooling due to lack of control over muscles of the face Droopy eyelid or corner of mouth Dry eye or mouth Face feels stiff or pulled to one side Facial paralysis of one side of the face, makes it hard to close one eye Headache Loss of sense of taste Pain behind or in front of the ear Sensitivity to sound (hyperacusis) on the affected side of the face Twitching in face Weakness in face
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Predisposing Factors: Age Gender Weak Immune System

Precipitating Factors: Viral Infections Herpes Virus Mono (Epstein Barr Virus) Influenza Bacterium Borrelia Burgdorferi

The immune system's response to a viral infection leads to inflammation of the Facial Nerve.

Because it's swollen, the nerve gets compressed as it passes through a small hole at the base of the skull

Compression Impairs neural conduction on the site thus it cant send signals to the muscle in the face
twitching, weakness, or stiffness on one side of the face half of the face drooping (especially one corner of the mouth) trouble closing one eye pain behind or in front of one ear drinking loss of taste at affected parts of the tongue 7/3/2011 in the mouth headache hearing sounds louder in one ear dryness in one eye difficulty speaking, eating, or changes in the amount of saliva
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INTRODUCTION
BELLs PALSY 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 facialmovements,& can be tested by asking a patient to performmovements such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly, pursing the lips and puffing out the cheeks & noticing asymmetry.

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, Facial massage and exercises, Acupuncture, Chiropractic manipulation, and Surgery. Even there are different ways of functional retraining following Bells Palsy but till date no specific guidelines with appropriate dosage & sequence have been given. Due to nonspecificity of available methods there was the need to design a specific, systematic & sequential treatment strategy/ protocol with appropriate dosage & direction.

This study compare Functional Dynamic taping protocol over conventional treatment in functional retraining of muscle of Bells palsy patient. Functional Taping protocol or technique is systematic & sequential approach towards functional retraining using through taping. On the otherhand, Conventional method for group B included Passive & Active exercises, passive stimulation, and facial massage.

I. Clinical Question:
Is VM Functional Dynamic taping protocol more effective than conventional treatment for functional retraining in subjects with Bells palsy?

II. Citation:
TO STUDY AND COMPARE THE EFFICACY OF VM FUNCTIONAL DYNAMIC TAPING PROTOCOL / TECHNIQUE OVER CONVENTIONAL TREATMENT PROTOCOL IN BELL'S PALSY. REFERENCE: (The Indian Journal of Occupational Therapy : Vol. XXXIX : No. 2 (August 2007 - November 2007)

III. Study Characteristics

a. Patient included 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.

 Subject Selection INCLUSION CRITERIA: Patient 15-35 years old who are diagnosed of Bells palsy and with acute and non traumatic onset (1-3 week), middle S/E status and no other neurological deficit are included. EXCLUSION CRITERIA: Patient below 15 and above 35 years and with psychiatric illness, UMN lesion, neurotmesis, skin infection & open wounds, hypersensitive skin and skin allergy to micropore. are excluded.

b. Interventions compared The study compare Functional Dynamic Taping Protocol in group A and conventional therapy in group B. Functional Dynamic taping protocol/technique involves therapeutic intervention of systematic & sequential approach of taping. Conventional treatment method involves facial exercises, Facial massage & passive stimulation. The duration of each session was kept constant for both the groups 60 minute each, 5 times a week

c. Outcome monitored Reevaluation was done after 8 weeks for both 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 for Resting symmetry (0-2) three point score and Symmetry of Voluntary Movement (1-5) on five point score & Facial Function Deficit. The composite score was also calculated. Composite Score = {(Voluntary Movement Score) x 4 (Resting Symmetry Score) x 5}.

The study compare the efficacy of VMFunctional Dynamic taping protocol/Technique in group A to Conventional treatment protocol to group B in terms of FunctionalActivities ( through Chewing Gum Balloon Blowing and Speech); Facial Function Deficits( through Normal Facial Activity, Light paresis Moderate paresis, Severe paralysis and Total paralysis); RestingSymmetry in Eye, Cheek (Nasolabial Fold), out ;and Symmetry of Voluntary Movement in Forehead Wrinkle, Gentle Eye Closure, Open Mouth, Smile, Snarl, Lip Pucker, and Wrinkle nose

d. Does the study focus in significant problem in clinical practice? The study focuses in significant problem in clinical practice because even there are lots of treatments to facial function of Bells palsy patients still they are unspecific guidelines to follow. This study will provide specific, systematic & sequential treatment strategy/ protocol with appropriate dosage & direction through comparing Functional dynamic taping protocol to conventional therapy in terms of facial symmetry and symmetric facial movement of patients with Bells palsy.

IV. Methodology/Design
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, The duration of each session was kept constant for both the groups 60 minute each, 5 times a week.Conventional treatment method was used. Re-evaluation was done after 8 weeks.

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.

 Design

Different Subject design Matched on the basis of Age, Sex, and Extent of involvement.
Setting The study was conducted in M.B. Hospital, G.B. Pant Hospital, New Delhi. from June 2005 - October 2006.

Data Sources
1. Dumitru D, Walsh NE, Porter LD reviewed a Electro physiologic evaluation of the facial nerve in Bells palsy. 2. Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, San Antonio 78284-7798. 3. 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. 4. Dalla Toffola, Bossi D, BuonocoreM, Montomli C, Petrucci L, Alfonsi E (2005); Usefulness of BFB/EMG in facial palsy rehabilitation, Disabil Rehabil. Jul 22; 27(14): 809-15. 5. 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. 6. I GWilliamson and T RWhelan (1996) The clinical problem of Bells palsy: is treatment with steroids effective? Br J Gen Pract. 1996 December; 46(413): 743747.

 7. Brach JS, Vanswearingen JM, Lenert J, et al (1997): Facial neuromuscular retraining for oral synkinesis. Plast Reconstruc Surg 99:1922-1933. 8. Cronin GW, Steenerson RL (2003): The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. OtolHead Neck Surg 128:534-538. 9. 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. 10. Ross B, Nedzelski JM, McLean JA (1991): Efficacy of feedback training in long- standing facial nerve paresis. Laryngoscope 101:744-750.

 11. Segal B, Zompa I, Danys I, et al (1995): Symmetry and synkinesis during rehabilitation of unilateral facial paralysis. J of Otolaryngol 24:143- 148. 12. Van Swearingen JM, Brach JS (2003): Changes in facial movement and synkinesis with facial neuromuscular reeducation. Plast Reconstruc Surg 111(7): 2370- 2375. 13. Palmieri NF. (1990) Idiopathic facial paralysis: mechanism, diagnosis and conservative management. Chiro Technique; Nov: 182-187. 14. Krukowska J (2003) Analysis of physiotherapy outcome in patients with Bells peripheral facial nerve palsy Otolaryngol Pol. 2003; 57(1): 143-5. Review. Polish. 15. Piercy J Bells palsy. BMJ. 2005 Jun 11; 330(7504): 1374. Review.

Has the original study been replicated?

Yes, the original study have been replicated. There are lot of study about 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, this study is conducted to have a specific, systematic & sequential treatment strategy/ protocol with appropriate dosage & direction such as Taping protocol to regain facial symmetry & required normal facial function of patient with Bells palsy.

What were the risks and benefits of the nursing action/intervention tested in the study?
The benefits of Dynamic functional taping protocol/Technique are prevent asymmetry, prevent over activity/ over pull of paralyzed muscle, enhance facilitation, reinforce movement in graded fashion and maximize functional use of affected muscles by incorporating functional activities. The risk of Conventional Therapy is lack of specificity. It results to residual asymmetry due to faulty motor pattern.

RESULT of STUDY
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. In comparison of the final composite score, it shows that Goup A has less difference between Voluntary Movement Score and Resting Symmetry Score compare to group B. Hence it can be interpreted that functional taping protocol is more specific & effective than conventional Therapy. Compare to other study, this study gives specific guideline tofollow in order to improve Oro-motor and facial functions in patients with Bells Palsy.

Authors Conclusions/ Recommendations

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. 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 that both Dynamic functional taping protocol/Technique and Conventional treatment protocol are equally effective in subjects with Bells palsy of non-traumatic onset can be rejected. Taping protocol is a problem solvingapproach to treatment using selective motor training to facilitate symmetrical movement and control undesired gross motor activity. Unlike Conventional theraphy it lacks specificity, it does not encourages functional reeducation of correct movement. Also it does not encourage functional reeducation using correct motor pattern that 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.

V. Applicability
a.) Does the study provide a direct enough answer to your clinical question in terms of type of patients, intervention and outcome?
Yes, this study provides a direct answer to our clinical question. The Functional dynamic taping technique helps the Bells palsy patient to retrain paralyzed his facial muscles by maintaining symmetry&facilitating paralyzed 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. In comparison to it, Conventional therapy results to faulty motor movement and facial asymmetry. In Functional dynamic taping technique shows better results than conventional therapy in functional retraining in patients with Bells palsy.

 b.) Is it feasible to carry out the nursing action in the world? Yes, it is feasible to carry out in nursing action in the world for the materials are available and the skills needed are easy to learn.

Reviewers Conclusion/ Commentary

This study of effectiveness between Taping technique and conventional therapy shows that the Functional dynamic taping technique is a more specific and effective treatment of retraining facial function in Bells palsy Patients. Taping protocol is the best approach treatment using selective motor training to facilitate symmetrical movement and control undesired gross motor activity. Through sequential and systematic taping, it helps to retrain paralyzed facial muscles by maintaining symmetry and facilitating paralzed muscles,. It also prevent overactivity of normal muscles and acts as a stabilizing mechanism by promoting desired symmetrical movement pattern that needs to be repetitively reinforced before the paralyze muscle retrained. Unlike Conventional therapy, its faulty motor pattern leads to residual asymmetry. This study proved that functional taping protocol is more safe, specific & effective than conventional Therapy.

Evaluating Nursing Care Process

Safety
Functional dynamic taping protocol appeared to be safe and caused no adverse effect. Unlike the conventional therapy that causes facial residual asymmetry due to faulty motor use in the therapy, the taping technique retrain specifically the paralyzed muscle and prevent overactivity of normal muscle that result to symmetric retraining of muscle.

The differences exist in the results shows that Functional dynamic taping protocol is more effective than Conventional treatment in terms symmetric retraining of facial and motor movement. It also helps to retrain paralyzed facial muscles by maintaining symmetry or it is specific in facilitating paralyzed muscles,. It also prevent overactivity of normal muscles and acts as a stabilizing mechanism by promoting desired symmetrical movement pattern that needs to be repetitively reinforced before the paralyze muscle retrained.

Competence of the Health care provider

The specialization of health care providers in this study is in occupational therapy. They are the occupational therapist, senior occupational therapist, Professor & Head of Deptt. of Biostatistics, Prof. & Head of Neurology, and Staff Members of Occupational Therapy Deptt. in M.B. Hospital, Delhi.

Acceptability
The participants signed an informed consent before the study conducted. Lot of them responds better functional recovery, facial symmetry and ability to perform functional activities in Functional dynamic taping protocol than Conventional therapy.

Appropriateness

Taping protocol is a problem solving approach to treatment using selective motor training to facilitate symmetrical movement and control undesired gross motor activity in Bells palsy patients.

The materials and skills use in taping protocol is enough to prove the effectiveness of it than Conventional therapy in retraining facial muscle of Bells palsy patient.

Accessibility
The materials and skills are available. The use of Functional dynamic taping protocol in the real nursing world is possible to carry out. Just like what the researcher said that Taping protocol is a problem solving approach in retraining muscle of Bells palsy patients.

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