MANAGEMENT OF BELL’S PALSY USING FACIAL EXERCISE AND MASSAGE A CASE ON MANAGEMENT OF FACIAL PALSY USING FACIAL EXERCISE AND MASSAGE

A CASE ON MANAGEMENT OF FACIAL PALSY USING FACIAL EXERCISE AND MASSAGE

 MANAGEMENT OF BELL’S PALSY USING FACIAL EXERCISE AND MASSAGE

                                

A CASE STUDY SUBMITTED IN PARTIAL FULFILLMENT FOR THE AWARD OF DIPLOMA IN PHYSIOTHERAPY AT  ST.JOHN OF GOD COLLEGE OF HEALTH DUAYAW NKWANTA B/A

 MARCH, 2018

BY:

AFRAKOMAH LOVIA, EVANS AKWASI BOAKYE, KONTOR MENSAH ISHMAEL, DUFIE VIVIAN, GYIDI EVANS KOOMSON

                

                                                                                                                                                                                                      DECLARATION

We hereby declare that the submitted work is our own project as a result of the work we have done and therefore every referencing has been accordingly acknowledged.

 DEDICATION

 We dedicate this project work to the Almighty God for giving us the strength throughout this case study. We also dedicate this work to our parents for having faith in us and also for inspiring us throughout our time in school. Dedicated also to our Clinical Supervisor Mr. Hussein Botchway for helping us to identify and formulate the topic.

ACKNOWLEDGEMENT

Glory be to the Almighty God for the power, wisdom and ability he granted us throughout the period of this case study. We would like to acknowledge and appreciate Mr. Frederick Inkum Danquah (Principal of the Institution), the in-charge and entire staff of the physiotherapy department (St. John Of God Hospital, Duayaw-Nkwanta), Mr. Atinga Ba- Etilayoo (Academic Coordinator), Mr. Hussein Botchway (Clinical Supervisor), all tutors and the entire staff of this noble institution not forgetting our colleagues and anyone who has in one way or the other supported us directly or indirectly.

It is also accredited to the patient and her relatives by their efforts and responses made this study become successful and brought out a lot of revelations about the rehabilitation of a client with Bell’s palsy. We are also grateful to the various members of the group for the co-operations and understandings in making this project a success.

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background

Bell’s palsy (B.P) is a basic disorder that affects nerves and muscles in the face resulting in paralysis of one side of the face (Anne, 2013). It is an acquired weakness of one side of the face, due to an injury to the facial nerve. The symptoms on the affected side typically include inability to close the eye, to smile, wrinkle the forehead and whistle. Speech may be mildly slurred. Tearing occurs because the eye does not close completely. Taste sensation may be diminished on the front half of the tongue. Sounds may appear louder on the affected side. Bell's palsy is usually a type of temporary sudden paralysis that causes weakness of the muscles of the face on one side. Rarely, it can affect both sides. The facial nerve that supplies the muscles of the face is affected by the palsy. This nerve is called the facial nerve (the seventh of the twelve nerves that supply the face and neck regions).

It is one of the most common problems that affect the cranial nerves and also the most common cause of facial paralysis all over the world.  . Bell's palsy usually develops over hours to days. The peak involvement usually happens within several days. Mild pain behind the ear is common at onset, as it is a subjective sensation of "numbness" of the affected side. Usually it is first noticed when a person observes it in a mirror, or on eating because food tends to collect between the cheek and gums. Bell's palsy is usually a type of temporary sudden paralysis that causes weakness of the muscles of the face on one side. It is known, that viral infections are the most basic reason for the development of BP as compared to tumors, immune disease or drugs (Liu, Li, Yuan & Lin, 2009).

The pathway of the nerve is changeable and understanding the key anatomical orientation of this is fundamental for exact physical diagnosis, reliable and influential surgical interference. The facial nerves (VII), are mixed (both motor and sensory) nerves that arise from the lower part of the Pons and to the sides of the face.

The annual incidence of Bell's palsy worldwide is approximately 11 to 40 cases per 100 000 people per year (Hato et al., 2007).

1.2 Aim of the study.

The overall aim of our study is to investigate the effectiveness of facial exercise and massage in management of Bell’s palsy patient at St John of God Hospital, Duayaw-Nkwanta,

Brong Ahafo Region .

1.3 Objective of the study.

To investigate the effect of facial exercise and massage in management of Bell’s

Palsy patient in nine weeks.

1.4 Specific objectives.

  ü Relief pain around the posterior aspect of the ear.

  ü Improve muscle strength of the right half of the face.

  ü  Improve chewing with the right jaw.

  ü  Restore normal symmetry of the face.

  ü  Improve facial expressions                   

  

                                                           CHAPTER TWO

                                                 2.0 LITERATURE REVIEW

2.1 Definition

 Bell’s palsy, or idiopathic facial paralysis, is a temporary facial paralysis that results from damage or trauma to the facial nerve (CN VII). This nerve travels through a narrow bony canal in the skull beneath the ear to each side of the face. The facial nerve controls the muscles on one side of the face as well as impulses to the tear glands, saliva glands, and the stapes in the middle ear. The nerve also transmits sensory signals for taste from the tongue.

The cause of Bell’s palsy is uncertain, but some possible causes may include vascular ischemia, viral disease (herpes simplex, herpes zoster). Bell’s palsy may represent a type of pressure paralysis in which ischemic necrosis of the facial nerve causes a deformity of the face, increase tearing and painful sensations in the face, at the back of the ear, and in the eye. Bell’s palsy is one of the most frequent neurologic disorders of the cranial nerves. In the majority of cases, Bell’s palsy gradually resolves over time, and its cause is not known (Baugh, 2013).

Figure 1 shows presentation of right Bell’s palsy

2.2 Anatomy and physiology of the facial nerve

 The facial nerve is one of the twelve pairs of cranial nerves in the peripheral nervous system. It is the seventh cranial nerve, and so it is often referred to as cranial nerve VII or simply CN VII. Nerve signals from the cranial nerve play important roles in sensing taste as well as controlling the muscles of the face, salivary glands, and lacrimal glands. The facial nerve is the seventh cranial nerve to exit the brain when counting from anterior to posterior. It arises from the pons region of the brainstem, posterior to the abducens nerve (CN VI) and anterior to the vestibulocochlear nerve (CN VIII). The facial nerve travels from the pons through the facial canal in the temporal bone to exit the skull at the stylomastoid foramen.

Facial nerves, are fibers arising from the brain stem called the pons, just lateral to abducens nerve, that enters temporal bone via internal acoustic meatus of the ear, and runs within inner cavity of the ear before arising through stylomastoid foramen. The nerve then innervates the lateral aspect of the face. Facial nerve is also mixed(motor and sensory) nerve that is the principal motor nerve of the face and it also serves as sensory function, it has five major branches such as; temporal, zygomatic, buccal, mandibular and cervical branches (Elain, 2000).

As the facial nerve passes through the temporal bone, several smaller nerves branch off from the main nerve, including the greater (superficial) petrosal nerve and the chorda tympani.
Nerve fibers from the greater (superficial) petrosal nerve stimulate the lacrimal glands to produce tears and moisten the eyes.
 The chorda tympani stimulates the submandibular and sublingual salivary glands to produce saliva. It also carries taste information from the anterior two-thirds of the tongue to the brain.
After passing through the stylomastoid foramen, the facial nerve emerges just inferior to the ear and splits into several superficial branches.
 The posterior auricular nerve splits from the facial nerve just beyond the stylomastoid foramen and innervates the muscles posterior to the ear, including the auricularis posterior and the occipitalis.
 Two small nerves next branch off to innervate the digastric and stylohyoid muscles.
Finally, the temporofacial and cervicofacial branches separate to innervate the muscles of the upper and lower face, respectively. The temporofacial nerve divides into the temporal, zygomatic, and infraorbital branches to reach the frontalis and orbicularis oculi muscles, among others. Fibers from the cervicofacial branch split into the buccal, mandibular, and cervical nerves to innervate the nasalis, zygomaticus major, buccinator, orbicularis oris, platysma, and other muscles surrounding the nose and mouth.

The path of the facial nerve can be divided into six segments.

1  .      Intracranial (cisternal) segment

2  .       Meatal segment (brainstem to internal auditory canal)

3  .      Labyrinthine segment (internal auditory canal to geniculate ganglion)

4  .      Tympanic segment (from geniculate ganglion to pyramidal eminence)

5  .      Mastoid segment (from pyramidal eminence to stylomastoid foramen)

6  .      Extra- temporal segment (from stylomastoid foramen to post parotid branches)

(Gupta et al, 2013).

2.3 Physiology of the facial nerve

The facial nerve is considered a mixed nerve because it contains both afferent (sensory) and efferent (motor) neurons. Afferent neurons of the facial nerve carry taste sensations from the taste buds of the anterior tongue to the primary gustatory center of the cerebrum. The efferent division of the facial nerve contains both somatic (voluntary) motor neurons and autonomic (involuntary) motor neurons. Somatic motor neurons carry nerve signals to the skeletal muscles of the face to control facial expressions, while autonomic motor neurons carry signals to the lacrimal and salivary glands

Figure 2 shows the overview of the facial nerve components

2.4 PROGNOSIS

 75% of patients with Bell's palsy experience complete recovery, most within 2 to 3 weeks. An additional 15% experience satisfactory recovery, but may have persistent facial asymmetry. 5 to 10% of patients have poor recovery at 4 months with persistent neurologic impairment and cosmetic disfigurement. Prognosis is thought to correlate with severity of injury. In neuropraxia, there is a conduction block but the nerve itself is intact and the nerve can be stimulated distal to the block. In axonotmesis, the nerve tube is intact but the axon within dies. Usually recovery is 100%. In neurotmesis, the axon and tubule are lost and prognosis is variable.

Many persons with Bell’s palsy will develop synkinesis. This means that when they blink, the corner of the mouth may twitch slightly. It is caused by a misrouting of facial nerve fibers as it grows back to innervate the facial muscles. Some persons may have "crododile tears", which is tearing when they eat. This is caused by a mix up in autonomic fibers carried by the facial nerve. Others may have "sweating" of the ear when they eat, caused by a similar mechanism. Prognostically, patients fall into 3 groups:

Group 1 - Complete recovery of facial motor function without sequelae

Group 2 - Incomplete recovery of facial motor function, but with no cosmetic defects that are apparent to the untrained eye.

Group 3 - Permanent neurologic sequelae that are cosmetically and clinically apparent

Approximately 80-90% of patients with Bell palsy recover without noticeable disfigurement within 6 weeks to 3 months. Use of the Sunnybrook grading scale for facial nerve function at 1 month has been suggested as a means of predicting probability of recovery.

2.5 FUNCTIONS OF THE FACIAL NERVE

1. The Facial nerve conveys motor impulses to muscles of the face (muscles of facial expression), except chewing muscles served by trigeminal nerves and transfer proprioceptive impulses from the same muscles to the pons (Elain, 2000).

2. Transmits parasympathetic motor impulses to lacrimal glands, nasal, palatine glands and submandibular and sublingual salivary glands.

3. Conveys sensory impulses from taste buds of anterior two thirds of tongue; cell bodies of these sensory neurons are in genticulate ganglion.

2.6 EPIDEMIOLOGY

 Different rates of incidence and prevalence have been reported in the medical literature depending on the geographical regions under study. In most of the series published, incidence are between 11 and 40 cases per 100,000 inhabitants per year, although figures as low as 8 and as high as 240 cases per 100,000 inhabitants per year have also been recorded in different countries around the whole world. The racial factors, climate and demographic features of the region also involved in the appearance of Bell’s palsy

(De Diego-Sastre, et al. 2005). Everyone can get Bell’s palsy and it can affect both men and women equally. Bell's palsy has been described in patients of all ages, with peak incidence noted among people around the age of 40. It occurs more commonly in patients with diabetes (Morris et al, 2002). Pregnant women are also 3.3 times higher of being affected by Bell palsy than women who are not pregnant. Idiopathic facial palsy (IFP) occurs most frequently in the third trimester of pregnancy. IFP is thought to account for approximately 60-75% of cases of acute unilateral facial paralysis, with the right side affected 63% of the time.

2.7 CAUSES

The facial nerve controls most of the muscles in the face and parts of the ear. The facial nerve goes through a narrow gap of bone from the brain to the face.

If the facial nerve is inflamed, it will press against the cheekbone or may pinch in the narrow gap. This can result in damage to the protective covering of the nerve. A popular theory proposes that edema and ischemia result in compression of the facial nerve within this bony canal. The cause of the edema and ischemia has not yet been established. This compression has been seen in

MRI scans with facial nerve enhancement (Danette, 2016).

If the protective covering of the nerve becomes damaged, the signals that travel from the brain to the muscles in the face may not be transmitted properly, leading to weakened or paralyzed facial muscles. This is Bell's palsy. Most health problems can cause weakness or paralysis of the face. If a specific reason cannot be found for the weakness, the condition is called Bell's palsy (Ropper AH et al, 2014).

The exact reason why this happens is unclear. With Bell's palsy, the nerve that controls your facial muscles, which passes through a narrow corridor of the bone on its way to your face, becomes inflamed and swollen — usually related to a viral infection. Besides facial muscles, the nerve affects tears, saliva, taste and a small bone in the middle of your ear (Bope ET, et al.

2014).

It may result when a virus, usually the herpes virus, inflames the nerve. This is the same virus that cause cold sores and genital herpes.

Other viruses that have been linked to Bell's palsy include:

•  chicken pox and shingles virus
• Cold sores and genital herpes virus
• Epstein-Barr virus, or EBV, responsible for mononucleosis
• cytomegalovirus
• mumps virus
• influenza B
• hand-foot-and-mouth disease

2.8 CLINICAL PRESENTATION

Bell's palsy is characterized by a one-sided facial droop that comes on within 72 hours (Barsura et al 2013). Symptoms typically peak in the first week and then gradually resolve over three weeks to three months (Morris et al, 2002). In rare cases (<1%), it can occur on both sides resulting in total facial paralysis (Price et al 2002). The facial nerve controls a number of functions, such as blinking and closing the eyes, smiling, frowning, lacrimation, salivation, flaring nostrils and raising eyebrows. Although the facial nerve innervates the stapedius muscles of the middle ear (via the tympanic branch), sound sensitivity and dysacusis are hardly ever clinically evident (Mattle, et al, 2006).

Other Symptoms of Bell palsy include the following:

• Acute onset of unilateral upper and lower facial paralysis (over a 48-h period)
• Posterior auricular pain
• Decreased tearing
• Hyperacusis
• Taste disturbances
• Otalgia

Early symptoms include the following:

• Weakness of the facial muscles
• Poor eyelid closure
• Aching of the ear or mastoid (60%)
• Alteration of taste (57%)
• Hyperacusis (30%)
• Tingling or numbness of the cheek/mouth
• Epiphora
• Ocular pain
• Blurred vision

2.8.1 Onset

The onset of Bell’s palsy is typically sudden, and symptoms tend to peak in less than 48 hours. This sudden onset can be frightening for patients, who often fear they have had a stroke or have a tumor and that the distortion of their facial appearance will be permanent.

Because the condition appears so rapidly, patients with Bell palsy frequently present to the emergency department (ED) before seeing any other health care professional. More people first notice paresis in the morning. Because the symptoms require several hours to become evident, most cases of paresis likely begin during sleep.

2.8.2 Facial paralysis

The paralysis must include the forehead and lower aspect of the face. The patient may report the inability to close the eye or smile on the affected side. He or she also may report increased salivation on the side of the paralysis. If the paralysis involves only the lower portion of the face, a central cause should be suspected (supranuclear). If the patient complains of contralateral weakness or diplopia in conjunction with the supranuclear facial palsy, a stroke or intracerebral lesion should be strongly suspected.

If a patient has gradual onset of facial paralysis, weakness of the contralateral side, or a history of trauma or infection, other causes of facial paralysis must be strongly considered. Progression of the paresis is possible, but it usually does not progress beyond 7–10 days. A progression beyond this point suggests a different diagnosis. Patients who have bilateral facial palsy must be evaluated for Guillain-Barre syndrome, Lyme disease, and meningitis.

Many patients report numbness on the side of the paralysis. Some authors believe that this is secondary to involvement of the trigeminal nerve, whereas other authors argue that this symptom is probably from lack of mobility of the facial muscles and not lack of sensation.

2.9 DIAGNOSIS

There's no specific test for Bell's palsy. The medical doctor will look at your face and ask you to move your facial muscles by closing your eyes, lifting your eye brow, showing your teeth and    frowning your face.

Because Bell’s palsy comes as a result of peripheral nerve injury, there is usually impaired ipsilateral movement of the affected side of the face, drooping of eye brow and the corner of the mouth as well as loss of ipsilateral nasolabial fold. Bell’s palsy is typically diagnosed by exclusion and a careful history and physical exam is needed to rule out other treatable and intracranial lesions (Goroll, 2009).There is also a modified scale use to document the degree of facial dysfunction and predict the probability of recovery (House, 1985).

Other conditions — such as a stroke, infections, Lyme disease and tumors — can also cause facial muscle weakness, mimicking Bell's palsy. If it's not clear why you're having the symptoms you are having, your doctor may recommend other tests, including;

2.9.1 Electromyography (EMG).

 This test is done to detect the severity of the nerve damage. An EMG is responsible for measuring electrical activity of a muscle in response to stimulation and the nature of conduction rate of electrical impulses along a nerve.

2.9.2 Imaging scans.

 Magnetic resonance imaging (MRI) may also be occasionally needed to rule out other possible sources of pressure on the facial nerve, such as a tumor or skull fracture. Bell's palsy is essentially a diagnosis of exclusion, so once other causes of facial palsy have been eliminated, we call an isolated facial palsy (Bell's palsy), or Idiopathic Facial Palsy.

                          

                         2.10 DIFFERENTIAL DIAGNOSIS

                        Table 2.1 shows the comparison of symptoms between Bell’s palsy and stroke

2.11 MANAGEMENT

2.11.1 Pre- hospital and acute care.

Corticosteroids and antiviral medications are generally considered to be the first line treatment for Bell's palsy, providing the best results when treatment starts within 72 hours of onset of symptoms. Number of studies shows benefit for steroids given within this time-frame. However, many studies do not demonstrate any advantage of using antiviral medication combined with

Corticosteroids (Hato N, et al. 2008) .

2.11.2 Eye Care.

It is widely accepted that, eye care is key in Bell’s palsy. The patient’s eye is at risk for drying, corneal abrasion, and corneal ulcers. In some cases, topical ocular lubrication (with artificial tears during the day and lubricating ophthalmic ointment at night, or occasionally ointment day and night) is enough to prevent further complications of corneal exposure. Punctual plugs may be helpful if dryness of the cornea is persistent. Stopping the movement of the eyelids by using tape or by applying a patch for 1 or 2 days may help to heal corneal erosions. Care must be taken to prevent worsening the abrasion with the tape or patch by ensuring that the eyelid is securely closed. Clear plastic wrap, applied with generous amounts of ointment as a night time (Holland NJ, 2004).

2.12 FACIAL EXERCISE IN MANAGEMENT OF BELL’S PALSY.

The effects of facial exercise of Bell’s palsy is the key in the rehabilitation protocols for a BP patient, while there is no high quality evidence to support significant benefit or harm from any physical therapy for IFP, there is some kind of evidence that support effect of facial exercise in improving facial function.

 In facial exercise, it is very important to know the facial muscles and their actions. This helps you to focus on restoring the normal functions of those muscles affected. In some cases, some patients with BP, may have complications such as synkinesis, cross-wiring, hypertonic muscle, and spasm if they have suffered from BP for a longer period. For some, the muscle had time to develop abnormal movement. This movement must be correctly coordinated through retraining. Muscles that are holding other muscles captive, have to be retrain in other to allow the basic muscles to move correctly. The basic idea is to slowly recreate the brain-to-nerve-to-muscle routine.

Before you start your physiotherapy prescribed exercise, it is necessary to stimulate the muscles around your cheek, lips and tongue by using an ice cube wrapped in a small damp cloth. Stroke the ice cube from your lips across your cheek to your ear. Then remove the cloth and stroke the inside of your cheek, your lips and tongue. The ice should help reduce the inflammation surrounding the facial nerve which may be responsible for the loss of nerve impulse conduction leading to facial weakness (Anne, 2013).

2.13 AIMS OF THE EXERCISES

  Ø  Improve the coordination of the facial muscles,

  Ø  Restore facial movements for specific functions, such as speaking or closing your eye,

  Ø  Restore movements for facial expressions, such as smiling

  Ø  Correct abnormal patterns of facial movements.

Some of the exercise to meet these aims are;

·         Making a biggest facial movement or muscle contraction that you can, such as smiling,

·         Chewing gum with great force,

·         Blowing up a balloon with all of your effort to work the facial muscles,

·         Carefully closing the eye with your fingers.

Figure 3 shows some facial exercises for patients with Bell’s palsy

2.14 FACIAL MASSAGE IN MANAGEMENT OF BELL’S PALSY

Massage is essential to maintain the circulation to the face as well as to keep the face supple. The direction of the manipulation used should be in upward direction and not downward direction as downward movement tends to stretch the paralyzed muscles more and can have deleterious effect. 

2.15 AIMS OF FACIAL MASSAGE

1. To strengthen the facial muscles

2. Restore movements for facial expressions, such as smiling

3. To relax the tight muscles

2.16 COMPLICATIONS OF BELL’S PALSY.

There are a number of complications that can occur as a result of Bell’s palsy, depending on the   severity of nerve damage. Approximately, 2 in 10 people experience long-term problems resulting from Bell’s palsy or idiopathic facial palsy which may include the following:

A contracture – facial muscles are permanently tensed or undergo adaptive shortening.

This may lead to facial disfigurement such as the eye becoming smaller, the cheek growing more bulky, or the line between the nose and the mouth becoming deeper.

Loss or reduced sensation of taste – This can happen if any damaged nerves do not repair completely.

Speech problems – This may occur as a result of damage to the muscles of the face.

                                           3.0 CHAPTER THREE.

 3.1 INITIALASSESSMENT.

Using the House-Brickman scale of Bell’s palsy, the degree of dysfunction of the face as of the first/initial assessment was recorded as :

Facial Functions: 

1. Closing of the eyes - Grade 5

2. Opening of the eyes – grade 5

3. Smiling - Grade 5

4. Whistling – Grade 5

5. Blowing - Grade 5           

6. Raising the eyebrows – Grade 5

3.1.1 SUBJECTIVE ASSESSMENT.

3.1.2 SOCIODERMOGRAPHICS.

Name: OA                                               

 Age: 42 years

 Sex: Female

Religion: Christianity

 Residence: Bomaa

Occupation: Farming

Marital Status: Married

3.1.3 VITALS

Temperature: 36.4

Blood pressure: 130/80mmHg

Height: 7.5 feet

Weight: 62 kg

3.1.4 Observation and Evaluation: A well oriented woman, focused and clinically stable walked into the physiotherapy department alone. She was having twisted mouth (to the left side of the face)

3.1.5 PC: Mouth twisting to the left side whiles talking, about 1/52 ago.

3.1.6 HPC: A 36 year old woman complains of  hearing unusual sound in the ear, feels headache sometimes and realized when she started talking her mouth or lips tends to shift or twisting to the left side of her face. 

3.1.7 PMHx: Patient has had no stroke, patient has not being involved in any traumatic accident, patient has no history of diabetics and patient had no history of infection.

3.1.8 DHx: No history of orthodox or herbal treatment.

        

3.1.9 Family and Social History: she is married with 3 children and lives with her husband and children.

Do not smoke and also do not take alcohol, She has no family history of diabetics and stroke.

3.1.10 Patient Lifestyle or Hobbies: Playing of oware.

3.2 OBJECTIVE ASSESSMENT

In the objective assessment, we used the scale which served as a guide in our assessment.

Table 3.1 shows the House Brackmann facial grading System

3.2.1 Pain: We used the Visual Analogue Scale (VAS) to test for the pain. Patient did not complain of any pain.

3.2.2 Sensation: Sensation was intact but the left side of the face was tighter than the right side (muscle tone).

3.3 MUSCULOSKELETAL ASSESSMENT:

·         Tearing of the right eye

·         Incomplete closure of the right eye

·         Cannot wrinkle right eyebrow fully

·         Whistles or blows with marked deviation of the mouth to the left side.

3.4 PHYSICAL DIAGNOSIS: Right Bell’s palsy.

                                           3.5 TREATMENT PLAN

3.5.1 Treatment Goals:

3.5.2 Short term Goal:

  ü Improve muscle strength of the right half of the face.

3.5.3 Medium term Goals:

  ü  Improve chewing with the right jaw.

  ü  Improve on complete closure of the right eye.

  ü  Improve on complete raise of the right eye brow.

3.5.4 Long term Goals:

ü  Restore normal symmetry of the face.

ü  Improve facial expressions.

ü  Reintegrate the patient back into the society.

                                              3.6 TREATMENT FOR THE EIGHT WEEKS

Table 3.2 Shows the treatment given in the first week

DAYS	TREATMENTS
Day 1	ü  Giving assurance to the patient that her condition will get better. ü  Education of patient and the caregiver on the needs of facial exercises and massage in management of the condition. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises. Examples of isometric facial exercises given to the patient are; ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets,  6 Seconds of 6 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Patient reassurance. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Educating the patient on some home exercises to help speed up recovery process ü  Facial exercises: Examples of isometric facial exercises given to the patient are; ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Raise your eyebrows while wrinkling the forehead to also restore normal wrinkle of the frontalis. ü    ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling.             With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets,  6 Seconds of 6 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

Second Week:

Table 3.3. Shows the treatment given in the second week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. Examples of isometric facial exercises given to the patient are; With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets,   7 Seconds of 6 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Patient reassurance. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Educating the patient on some home exercises to help speed up recovery process ü  Facial exercises: Examples of isometric facial exercises given to the patient are; ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Raise your eyebrows while wrinkling the forehead to also restore normal wrinkle of the frontalis. ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets, 7 Seconds of 6 Reps.             Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

Third Week:

Table 3.4. Shows the treatment given in the third week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 sets, 7 seconds of 7 reps Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 sets, 7 seconds of 7 reps. Type: Isometric exercise. ü   Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

Fourth Week:

Table 3.5. Shows the treatment given in the fourth week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. Day 2 ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 sets, 7 seconds of 8 reps. Type: Isometric exercise. ü   Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets, 7 Seconds of 8 Reps Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

Fifth Week:

Table 3.6 Shows the treatment given in the fifth week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. Frequency: Twice a week (2X/WK). Time: 5 Sets, 8 Seconds of 8 Reps.                         Type: Isotonic exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets, 8 Seconds of 8 Reps.                         Type: Isotonic exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

Sixth Week:

Table 3.7 Shows the treatment given in the sixth week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets, 10 Seconds of 8 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 5 Sets, 10 Seconds of 8 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Twice a day. Time: for 5 minutes                         Type: Isotonic exercise.

  

Seventh week

Table 3.8 Shows the treatment given in the second week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 6 Sets,  10 Seconds of 10 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Thrice a day. Time: for 7 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Patient reassurance. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Educating the patient on some home exercises to help speed up recovery process ü  Facial exercises: Examples of isometric facial exercises given to the patient are; ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Raise your eyebrows while wrinkling the forehead to also restore normal wrinkle of the frontalis. ü    ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 6 Sets,10 Seconds of 10 Reps.             Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Thrice a day. Time: for 7 minutes                         Type: Isotonic exercise.

Eighth week

Table 3.9 Shows the treatment given in the second week.

DAYS	TREATMENTS
Day 1	ü  Reassurance of patient. ü  Educating the patient on some home exercises to help speed up recovery process. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Facial exercises: ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. Examples of isometric facial exercises given to the patient are; With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 6 Sets,  10 Seconds of 10 Reps. Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Thrice a day. Time: for 7 minutes                         Type: Isotonic exercise.
Day 2	ü  Reassurance of patient. ü  Patient reassurance. ü  Massage therapy (manual and vibrator) to the face for a duration of 15 minutes to relief pain. ü  Educating the patient on some home exercises to help speed up recovery process ü  Facial exercises: Examples of isometric facial exercises given to the patient are; ü  Closing the eyes tightly to maintain the strength of the unaffected muscle of the eye and increase the strength of the unaffected muscle of the eye. ü  Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators). ü  Raise your eyebrows while wrinkling the forehead to also restore normal wrinkle of the frontalis. ü    ü  Pushing both the lower and the upper lips forward in a kissing state to increase the strength of the muscle of the lip. ü  Bringing the eyebrows together in a frown state to improve complete closure of the eye. ü  Roll your lower lip out and down to restore the movement of the mouth. ü  Pushing the lips out as far as possible to improve whistling. With these exercises, we used the following parameters; Frequency: Twice a week (2X/WK). Time: 6 Sets, 10 Seconds of 10 Reps.             Type: Isometric exercise. ü  Encouraged on chewing of gum to improve her chewing ability. ü  Encouraged patient on blowing air into balloon to inflate it. Frequency: Thrice a day. Time: for 7 minutes                         Type: Isotonic exercise.

                                                           4.0 CHAPTER FOUR

4.1 ANALYSIS

4.1.2 Musculoskeletal/functional re-assessment.

Table 4.1 shows the result of House-Brackman scale of facial dysfunction at the end of the eight weeks treatment.

facial dysfunction	Week 1- week 2	Week 3– week4	Week 5 – week 6	Week 7 – week 9
Right facial dysfunction	5/6	5/6	4/6	3/5

                   

Figure 4 shows the degree of patient’s facial dysfunction across the treatment weeks

From the graph, we saw from our initial assessment that facial dysfunction was 5/6 but after our eight week treatment, the facial orientation and function had improved. The level of facial dysfunction has decreased from 5/6 to 3/6 at the end of the eight weeks treatment using massage and facial exercises such as isometric and isotonic exercises. This was at the right side of the face and with the mouth twisted to the right side but after the treatment, there is restoration of near normal symmetry of the face and with no tearing of the eyes. Patient is able to perform the following actions; raising the eye brows with effort, wrinkling of the frontalis to near normal, patient could initiate whistling. Patient is able to chew with the left jaw , patient is able to close the eye completely without any much effort.

5.0 CHAPTER FIVE

5.1  DISCUSSION

5.1.2 Exercise.

Facial exercises are very essential and key in the management of Bell’s palsy, most of the muscles of the face after Bell’s palsy are much weaker than before, so facial exercises as physiotherapy intervention is very important. Some exercises that can be performed during Bell’s palsy like isometric exercises. Facial exercises work on muscles of the face by making them stronger. Some facial exercises that can be done are; isometric exercises such as; Closing the eyes tightly to maintain the strength of the unaffected muscles of the eye and increase the strength of the affected muscles of the eye, Tighten your chin to restore strength of the muscles of the chin especially the chewing muscle (Buccinators), Pushing both the lower and the upper lips forward to increase the strength of the muscle of the lip, bringing the eyebrows together in a frown state to improve complete closure of the eye, rolling the lips out, up and down to restore the movement of the mouth, Pushing the lips out as far as possible to improve whistling. Based on our findings, we got to know that facial exercises such isometric and isotonic exercises were vital and help to speed up patient’s recovery process. Facial exercises help in the prevention of complications, and also restoration of normal facial functions like facial expressions and also normal symmetry of the face. Isometric exercises as well as isotonic exercise help to increase the strength of the facial muscles. These exercises helped the patient and were advised to continue with the exercise at home.

5.1.2 Massage

Massage is essential to maintain the circulation to the face as well as to keep the face supple. Massage has very much effect on the face so far as Bell’s palsy is concerned.  Massage helps to maintain blood flow to the muscles of the face so as to make them efficient in their function. It does help to relax the tight muscles of the face to restore normal symmetry of the face as well as restoring movements for facial expressions such as smiling, frowning, wrinkling. Downward movement tends to stretch the paralyzed muscles more and can have deleterious effect on them. So the movement of the manipulation should be done in the upward direction,

                                                        6.0 CHAPTER SIX

6.1 SUMMARY

Bell’s palsy (B.P) is a basic disorder that affects nerves and muscles in the face resulting in paralysis of the face (Anne, 2013). It affects patients of all ages and both males and females. The symptoms manifests due to irritation of the facial nerve (CN VII) that innervates the muscles of the face. These include muscles that are responsible for chewing, raising your eyebrows, opening and closing of your eyes, wrinkling your forehead, smiling frown, as well as muscles for closing and opening of the mouth. Our main objective was as to investigate the effects of massage and facial exercises in the management of Bell’s palsy in eight weeks. This study was carried out at the Physiotherapy Department of the St. John of God Hospital Duayaw-Nkwanta, using a patient with right Bell’s palsy. Conservative management approach was used in the study. The patient received routine facial massage and therapeutic exercises in the form of facial exercises (Isometric and isotonic exercises) twice a week (Mondays and Fridays) throughout the eight weeks of our study. Descriptive statistics and graph were used.

After the eight weeks of treatment, facial dysfunction decreased from 5/6 to 3/5 on the House Brackman scale (HBS) Results of our study showed improvement in facial functions at the affected side of the face (right half of face). 

 6.1 CONCLUSIONS

In conclusion, Massage and facial exercises are very essential and are of utmost important so far as management of Bell’s palsy is concerned. Most of the muscles affected after Bell’s palsy are much weaker than before so Massage and facial exercises as physiotherapy interventions are very vital. Some exercises that can be performed after Bell’s palsy include; isometric and isotonic exercises. Exercises works on muscles by making them increase in their strength. Some of the facial exercises that can be done are; closing the eyes tightly, raising of your upper lip, wrinkling of the frontalis, tightening of your chin.

6.3  RECOMMENDATIONS

 It is our recommendation that, since massage and facial exercises are very effective in the management of Bell’s palsy, it should be regarded among the best interventions so far as management of Bell’s palsy is concern.

We also recommend that clinical supervisors should always be willing to assist students in taking the assessments of their patients. Also, the time given to begin and complete our case study was enough and hence needs to be maintained.

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Liu, J., Li, Y., Yuan, X., & Lin, Z. (2009). Bell’s palsy may have relations to bacterial infection. Medical Hypotheses, 72(2), 169-170. 

Mattle, Mumenthaler, Mark, Heinrich (2003). Fundamentals of neurology, Germany; Thieme.p. 197. ISBN 3131364513.

Morris AM, Deeks SL, Hill MD, Midroni G, Goldstein WC, Mazzuli T. (2002).Annualized incidence and spectrum of illn. Annualized incidence and spectrum of illness from outbreak and investigation of Bell’s palsy. Neuroepidemiology; 21:255-61.

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