A Prospective Study of Physical Therapy in Facial Nerve Paralysis : Experience at a Multispeciality Hospital of Kashmir

put to physical therapy in the form of electrotherapy followed by facial exercises. We analyzed 50 patients as to their age, gender, etiology, time duration between diagnosis and treatment time, number of sessions and resources utilized. All patients received electrotherapy to the paralyzed facial muscles for a period of two weeks but some were given extended treatment for four weeks. Twenty(40%) patients presented for the treatment in first week, 12(24%) in second week and 18(37%) in third or more than three weeks time. All the patients who presented at first week were given medical treatment; however, even at late presentations after second week, twelve patients were also put on medical treatment.


A B S T R A C T
put to physical therapy in the form of electrotherapy followed by facial exercises.We analyzed 50 patients as to their age, gender, etiology, time duration between diagnosis and treatment time, number of sessions and resources utilized.All patients received electrotherapy to the paralyzed facial muscles for a period of two weeks but some were given extended treatment for four weeks.Twenty(40%) patients presented for the treatment in first week, 12(24%) in second week and 18(37%) in third or more than three weeks time.All the patients who presented at first week were given medical treatment; however, even at late presentations after second week, twelve patients were also put on medical treatment.
Out of 50 patients 35 (70%) patients had complete paralysis and 15(30%) had incomplete facial palsy.Time span between medical diagnosis and physical therapy was from one week to four weeks.Patients were assessed at 4 weeks, 2 months and 6 months after the treatment.Out of 20 patients who presented in 1st week and received steroids and electrotherapy had fully recovered except for one case that was non-compliant for treatment.Out of twelve patients, eight patients who presented in second week of illness had full recovery while as partial recovery was observed in rest of 4 patients.Eighteen patients who presented in third week onwards of illness had partial recovery.The status of the recovery observed in patients with Bell's palsy treated with electrostimulation was highly significant in those who presented in first week as compared to second and third week (p=0.0001)(Table 2).

Discussion
The prognosis of facial paralysis depends to a great 83% and within two to three weeks 61%.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 9 people.Other poor prognostic factors include hypertension 4,5 and diabetes mellitus.Physical therapy in the form of electrotherapy, massage and facial exercises are used as adjuvant to hasten recovery.Very few trials are available to decide whether any of these modalities work.So more and more trials are needed to assess their effect for the benefit of patients.
About 23% of people with Bell's palsy are left with moderate to severe symptoms, hemifacial spasm, partial motor recovery, crocodile tears (tears upon salivation), contracture or synkinesis (involuntary twitching of the face 2 or blinking).Recurrence occurs in about 8.3%.
Facial nerve paralysis occurs due to interruption at any of the facial nerve level and may result in complete or partial paralysis of facial muscles resulting in salivation, tearing disorders, hyperacusia and hypoesthesia of external auditory canal.The etiology in 50% of patients is idiopathic also called as Bell's palsy.Other causes can be trauma, high blood pressure, diabetes mellitus, pregnancy, viruses.
The recovery of facial nerve palsy depends on patients age, lesion involved, physical therapy instituted.Facial nerve recovery may take weeks to years.Facial nerve palsy requires medical and physiotherapeutic approach.Physical therapy is paramount, with the main goal of reestablishing muscle trophism, function and strength.Role of physiotherapy in the form of physical therapy is electrotherapy, massage (facial exercises), kinesiotherapy is supported by the literature.
Thermal methods, massage, facial exercises, electrotherapy (which uses an electrical current to cause a single muscle or group of muscles to contract) biofeedback are  Vasconcelo's study showed higher rate of traumatic Facial palsy as compared to idiopathic facial palsy but in our study we observed the reverse trend with traumatic palsy as 10% and idiopathic accounted for 70% cases.In our report, hypertension and diabetes accounted for majority of facial nerve paralysis cases.When etiology was compared to motor recovery, we noticed total recoveries in the cases of 18 angiogenic etiology (60%).In a study Wolf reported 140 patient of angiogenic facial paralysis with satisfactory recovery in 82.1% of patients.Most of the patients attain recovery in first few weeks but when there is denervation after 10 days there is delayed recovery onset.19 In contrast Riberio found an average time for facial nerve recovery between fifteen days to four years.Using 20 physical therapy, Cohen found in 95 pregnant females, complete recovery within four months in 56(58.9%)patients.21 Gomez-Bentz using physical therapy in 36 patients, partial recovery was found in 83.3% of patients after 15 days and total recovery in 63.8% after 1 month.22 In accordance with study of Cronin and Steenerson biofeed back by surface electromyography results revealed improvement in facial symmetry.The main physical therapy resources employed in patients were kinesiotherapy, cryotherapy and electrotherapy.Further, a study conducted 23 by Flores coincides with our report depicting fast and complete recovery in Bell's palsy patients treated by electro stimulation.
In conclusion, the present study revealed patients had early and effective improvement by use of electrotherapy and facial exercises, however, more studies are needed to confirm the role of physical therapy in addition to medical therapy for early recovery of patients of facial palsy.

4 , 10 forms
of physical therapy that have been used.Exercise[11][12][13][14] therapy has been used more than other interventions.The aim of present investigation was to describe and to analyze physiotherapy results in a prospective study on peripheral facial paralysis patients enrolled in department of physical medicine and rehabilitation (PMR) in Sher-i-Kashmir Institute of Medical Sciences, a multispecialty tertiary care centre, Srinagar.MethodsA prospective study was carried out on 50 patients of facial nerve paralysis who attended the out-patients Department between Jan 2009 and Jan 2010.Patients were enrolled in the department of Physical Medicine & Rehabilitation (PMR) who were referred from departments of General Medicine, Neurology of Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Kashmir, India.All of the patients were subjected to medical treatment.Moreover, the patients were

TABLE I . Characteristics of patients with bell's palsy
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