IMPACT OF ELECTRICAL STIMULATION ON REHABILITATION PROCESS IN PERIPHERALFACIAL PARALYSIS

GUZELANT YA1, SARIFAKIOGLU AB1, SARAÇOĞLU GV2, CAN İ1, ÜNAL A3

1Namik Kemal University School of Medicine, Department of Physical Medicine and Rehabilitation, Tekirdag - 2Namik KemalUniversity School of Medicine, Department of Public Health, Tekirdag - 3Namik Kemal University School of Medicine, Departmentof Neurology, Tekirdag, Turkey

Introduction

Facial nerve (7th cranial nerve) has an impor-tant function on facial aesthetics by enabling themovements of mimic muscles, and it is the mostdamaged nerve among the cranial nerves after leav-ing the central nervous system(24). Eating, drinkingand speaking difficulties are observed in peripheralfacial nerve damages, as well as difficulties inexpressing the feelings. Although viral infections,trauma, surgical interventions, diabetes, local infec-tions, and congenital, toxic, tumoral and immunediseases are being investigated in the etiology ofperipheral facial paralysis (PFP), the cause is oftenidiopathic(24). PFP incidence is between 11,5-40,2 in100000. The incidence peaks in between the thirdand the fifth decades, and the sixth and seventhdecades(9,20). Additionally, the recurrence rates range2 to 7,3% in all idiopathic PFP patients(20).

Treating PFP in early period with a multidisci-plinary approach are important for speeding therecovery process up(19). In addition to medical thera-py, thermal heat modalities, electrical stimulation,exercise and massage are physical therapy methodsof which the effectivenesses were shown(19).

The purpose of this study is to assess the con-tribution of the electrical stimulation to medicaltherapy and its impact on recovery process inperipheral facial paralysis cases.

Materials and methods

The patients who consulted to PhysicalMedicine and Rehabilitation outpatient clinic anddiagnosed with PFP between 2011 and 2013 wereexamined retrospectively. Patients;

• Who do not have a diagnosis of cerebrovas-cular disease in history,

Acta Medica Mediterranea, 2014, 30: 1375

ABSTRACT

Aim: The purpose of this study is to discuss the efficiency of electrical stimulation in the treatment of facial paralysis, and itscontribution to the rehabilitation process and, its impact on recovery.

Material and methods:18 cases were enrolled into the study who were diagnosed with facial paralysis and consulted withinthe first month, and have been receiving medical treatment. Home exercise program was given to all patients. The first group wasfollowed-up with hospital rehabilitation program that included electrical stimulation, while the second group was organized to recie-ve only home exercise program. Functional response to treatment was assessed by the House-Brackmann scale grading system.

Results: House-Brackmann scale scores of rehabilitation program and electrical stimulation patient group, were comparedpre-and post-treatment, clinical improvement was observed more significantly in the 6th week. There was no significant differencebetween House-Brackmann scale scores in pre-treatment and the 6th week visits of the patients in home exercise program group (p =0.16). However, the House-Brackmann scale scores were detected to be statistically significantly different between pre-and 6 monthsafter the treatment in both of the treatment groups (p = 0.005).

Conclusion: As a result, the recovery time is faster in the patients treated with the rehabilitation group that includes electricalstimulation. Therefore electrical stimulation therapy is an acceptable effective method for the treatment of facial paralysis, nonethe-less this should be investigated in larger patient groups, in future.

Key words: Bell palsy, physical therapy modalities, electric stimulation, exercise, massage.

Received February 18, 2014; Accepted June 19, 2014

• Who were informed about PFP and protectionmethods, and the functions of the muscles which arebeing effected, who were recommended to massageon the condition that it is performed four times a dayand for at least 10 minutes, who were educated aboutactive movements of mimic muscles in front of themirror and drinking water, eating and smiling, andactivities affecting the daily life,

• Whose facial nerve states were evaluatedclinically with House-Brackmann Scale (HBS)functional grading system (table 1) in pre-treatmentperiod and in 1st and 6th months after treatment,were included to the study(11) (Table 1).

Demographic data, and antiviral, corticos-teroid, gastroprotective treatments and physicaltherapy methods, and responses to the applied treat-ment of 18 cases who met all criteria, wereassessed. The same home exercise program weregiven to both of the groups. Six patients were fol-lowed-up with only home exercise program, and 12patients were followed-up with hospital rehabilita-tion program applied together with home exerciseprogram. Rehabilitation program applied in hospitalwere constituted of infrared (IR), electrical stimula-tion (ES) and exercises.

IR were applied five days a week for 20 min-utes. ES were applied to the motor points of eightmuscles innervated by facial nerve (m. frontalis,m.corrugator supercilii, m. orbicularis oculi, m.lev-ator labii alaeque nasii, m. nasalis m. levator labiisuperioris, m.orbicularis oris, m. depressor labiiinferioris) with Cefar compex theta 500 model elec-trotherapy device in rehabilitation mode with 100milliseconds intermittent galvanic current for motorpoint treatment, 30 times as 3 rounds to each point,

and at a current intensity as to obtain minimal con-traction (Figure 1). ES was discontinued after theactive movements started in mimic muscles, hotapplication and exercise were continued. Treatmentprogram was applied in 20 sessions (Figure 1).

Statistical AnalysesAll data were analyzed using the Statistical

Package for the Social Sciences for Windows soft-ware version 17.0 (SPSS, Chicago, IL). Descriptivestatistical analyses (mean, standard deviation, fre-quency and percentage values) of the data obtainedfrom the records, were performed in the study.Wilcoxon Signed Rank Test was performed forwithin-group pre- and pos-treatment comparisons,and Mann Whitney U and chi-square test were per-formed for between-groups comparisons. Data wereassessed two-way in 95% confidence interval.

Results

Our case series was constituted of 18 patients.66.7% of the patients were male (n=12). Left sidewas affected in 72.2% of the group (n=13). Afterthe examinations targeted for PFP causes, onepatient was diagnosed with PFP secondary to DM,and another one was diagnosed with PFP secondaryto acoustic neuroma. Sixteen patients were diag-nosed with idiopathic PFP because there were noexplicator causes found. All patients had beenreceived medical (corticosteroid, antiviral, gastro-protective medications) therapy. Recurrent PFP his-tory was detected in four patients after medical his-tories were questioned. All patients described fullrecovery after previous PFPs. Unilateral facialnerve involvement history was present in one case,and contralateral facial nerve involvement was pre-sent in three (three patients had previous PFP twiceand one patient had once, and they recovered with-out any sequela). There was a history of operation

1376 Guzelant YA, Sarifakioglu AB et Al

Grade Explanation

Grade 1 Normal symmetric function

Grade 2 Slight weakness noticeableon close inspection

Grade 3

Obvious weakness, com-plete eye closure witheffect is possible. Notdisfiguring Synkinesis

Grade 4Obvious weakness causing

disfiguring. SevereSynkinesis, spasm

Grade 5

Only barely perceptiblemovement complete eye

closure is not possible. NoSynkinesis or spasm

Table 1: House-Brackmann Facial paralysis gradingsystem.

Figure 1: Motor stimulation points in face.

because of otitis media two years ago in the med-ical history of a patient, when patient was consultedfor PFP, there were no ear-related infection or otherpossible reasons detected and the patient was con-sidered idiopathic. Systemic disease history wasdetected in 5 patients in total; diabetes (1), hyper-tension (1), ischemic heart disease (1), arrhythmia(1), lung cancer (1).

The mean physical therapy beginning periodsof the patients were 29±3.5 (25-33). Twelvepatients (66.7%) visited our clinic to receive thescheduled PFP rehabilitation treatment protocol.Six patients (33.3%) did not participate in the treat-ment program applied in clinic for various reasons,PFP exercise program to apply at home was givento them.

The average age of our patient group was45.72±20.33. There was no significant differencebetween the ages of the patients in home exerciseprogram (n=6) and rehabilitation program (n=12)(p=0.75).

HBS evaluations were performed in pre-treat-ment and 6th week post-treatment and long-term6th month visits of the patients. There was no sig-nificant difference between the HBS evaluationsperformed in the visits performed in pre-treatmentperiod (p=0.92), 6 weeks after the treatment(p=0.62) and 6 months after the treatment of thepatients in home exercise program and rehabilita-tion program, either (p=0.75).

HBS evaluations were performed in the vis-its performed in pre-treatment period, 6 weeksafter the treatment and 6 months after the treat-ment of the patients participated in rehabilitationprogram (n=12) (Figure 2).

Significant improvement was observed begin-ning from the 6th week in clinical recovery in thecomparison between pre-treatment HBS, and 6thweek (p=0.01) and the 6th month (p=0.05) HBSs ofthe patient group participated in rehabilitation pro-gram. A significant difference was also detected inbetween HBS obtained in 6 weeks after the end ofthe treatment and HBS obtained in the 6th month(p=0.06) (Figure 2).

Pre-treatment, and the 6th week after treat-ment and long-term 6th month HBS evaluationswere performed of the patients treated with homeexercise program (n=6) (Figure 3). There was nosignificant difference between the pre-treatmentHBS and the 6th week HBS detected in this group(p=0.16). However it was determined that there wasa significant difference between the pre-treatmentHBS and the 6th month HBS (p=0.005). A signifi-cant improvement was detected on the 6th month inthe comparison between the HBS obtained 6 weeksafter the treatment and the HBS obtained on the 6thmonth (p=0.03) (Figure 3).

Discussion

Although PFP is a self-limited disease only80%of the patients make a full recovery(7, 13, 14). Thepermanent damages in the other 20% group areamong the important pathologies that need to betreated and may cause emotional and social isola-tion of the patient(3, 23). After the 12-month follow-up period, full recovery was observed in 15 cases

and recovery with sequela was observed in fivecases out of 18 patient (16 idiopathic, 1 DM, 1acoustic neuroma) evaluated in this study. 13 out of15 cases who made a full recovery, diagnosed withidiopathic PFP.

Impact of electrical stimulation on rehabilitation process in peripheral facial paralysis 1377

Figure 2: HBS evaluations in pre-treatment and 6-week post-treatment and 6-month post-treatmentvisits for the PFP group that received hospital reha-bilitation programme (n=12).

Figure 3: HBS evaluations in pre-treatment and 6-week post-treatment and 6-month post-treatmentvisits for the PFP group which received treatmentwith home exercise programme (n=6).

Choosing between the treatment methods isone of the important points together with the paral-ysis diagnosis. The most efficient treatment strategyis still controversial(6). The treatment may beplanned with the determination of the disease peri-od, actual lesion site and the exact damage degreein the nerve. Although it is controversial, corticos-teroid may be recommended as medical therapyafter PFP was developed(22, 24). In a randomized con-trolled study, Sullivan et al. were detected untreatedpatients shows 63% recover in three months and85% recover in nine months(10). They reported therecovery rates after corticosteroid treatment as 81%and 94% respectively. While antiviral therapy addi-tion is recommended in severe cases, antiviral ther-apy was not shown to be superior to placebo inanother randomized controlled study(9 22). B12 wasalso recommended as a supportive therapy(10). Allpatients evaluated in this study, received corticos-teroid, antiviral and vitamin B12 treatment.

Physical methods are also being used in PFPtreatment along with medical therapy. Theseinclude thermal therapies, electrical stimulation,exercise, massage, biofeedback and acupuncturetherapy(21).

Studies on the efficiency of the electrical stim-ulation in subacute and chronic period of PFP, maybe seen in literature. These studies are especiallymentioning the successful results of the long-termelectrical stimulation in chronic cases(10, 16, 23, 24).

In the study performed by Hyvarinen et al. inPFP patients diagnosed between one year and 25years, transcutaneous electrical stimulation wasreported to be effective(10). Superficial heat therapiesare also known to be contributive in the treatmentby allowing the ES to be applied at low-currentintensity by increasing the skin resistance based onthe increase in local circulation(21).

Studies on early-stage PFP are limited, and thecase counts are not adequate either(3). Mosforth etal. reported that massage and ES applied patientsrecover faster but there is no difference in long-term follow-ups(15). Alakram et al. applied hot appli-cation, massage and exercise program to one groupand electrical stimulation to the other in their studywith 16 patients who were diagnosed in the previ-ous 30 days. They reported that there wereimprovements in both groups in the follow-ups per-formed with HBS, and ES is safe to be applied(1).Ohtake et al. considered ED as active exercise inthe meta-analysis on the effects of ES(18).

Exercise is important for gaining the function-ality back in PFP(4, 20). On the other hand Nicastri etal. showed that positive results were seen in stage5-6 patients but there was no difference in stage 1-2patients according to HBS in their study evaluatingthe efficiencies of early-period exercise programs inPFP(17).

In our study a rehabilitation program constitut-ing of electrical stimulation, hot application andexercises aimed at mimic muscles in addition to theexercise program performed at home, was appliedto 12 patients. Synkinesis was seen as a sequela inone patient in follow-up. Home exercise programwas given to six patients. One patient in home exer-cise program group was evaluated with electroneu-romyography (ENMG) because there was not suffi-cient improvement observed in HBS. Partial facialnerve damage was found on ENMG and surgerywas not indicated.

Age is specified as a prognostic factor in PFP.Cha et al. reported that there was no differencebetween pediatric and adults cases(2, 5). In this studysubmitted by us, there was partial recoveryobserved in two patients, 12 and 71 years old.Although there are conflicting data on age in the lit-erature, the prognosis of these two patients made usthink that the age is important in prognosis thoughwe do not have enough patients to discuss. Otherfactors affecting the prognosis include electromyo-graphy and axonal damage. Besides, the recoverymay be inadequate in traumatic and iatrogenicalnerve damage cases(12).

Tumoral and traumatic causes of PFP mostlynecessitate surgical approach, while surgical thera-py rates in the patients diagnosed with idiopathicPFP is either very low or controversial. Therapeuticsurgical intervention was not applied to the cases inthis study.

Consequently, there was no differenceobserved in between the recovery rates of thepatients given home exercise program in addition tomedical therapy and the patients applied with reha-bilitation program including ES in addition to theprevious group. However the short-term recoveryrate was seen to be more in the rehabilitation groupincluding ES. Electrical stimulation in addition tothe exercise in PFP treatment; appears to be able tominimize the muscle atrophy during the periodneeded for peripheral nerve regeneration in den-erved muscles, protect muscle strength and preventthe trophic disorders(7, 8, 14, 25). Even though the spon-taneous recovery make the evaluation of the effi-

1378 Guzelant YA, Sarifakioglu AB et Al

ciencies of the physical therapies difficult, they areimportant in terms of speeding-up the recoveryprocess and decreasing the psychosocial influenceon the patient.

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_________Corresponding AuthorAss. Prof. ALIYE YILDIRIM GUZELANT, M.D.Namik Kemal University School of MedicineDepartmen of Physical Medicine and RehabilitationTunca Cad. 100. Yil mah. Tekirdag(Turkey)

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