Effectiveness of Combination Therapy Versus Steroids Alone, For the Treatment of Bells Palsy

7/23/2019 Effectiveness of Combination Therapy Versus Steroids Alone, For the Treatment of Bells Palsy

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A Randomized Control Trial to Review the Effectiveness of Combination Therapy Mazhar Badshah et al.

Ann. Pak. Inst. Med. Sci. 2013; 9(3): 118-121 118

Original Article

A Randomized Control Trial to

Review the Effectiveness ofCombination Therapy versus

Steroids Alone, for the Treatment

of Bells PalsyABSTRACT

Objective: To compare the effectiveness of combined programme including steroids,electrical stimulation with facial exercises as compared to steroids alone for treatment of

Bells Palsy.Study Design: Randomized Control t rial study.Place and Duration: At Holy Famil y Hospital Rawalp indi and in Private sett ing atIslamabad from August 2012 to August 2013.

Materials and Methods: A total o f 113 male and female pat ients having been diagnosedwith Bells palsy were randomly assigned to two g roups. The experimental group received acombined steroids, electrical stimulation and facial exercise programme. The control groupwas given steroids alone. HouseBrackmann facial nerve grading system was used toassess the recovery in patients.

Results: Bells palsy was graded according to HouseBrackmann facial nerve gradingsystem. Mean values fo r grades of experimental group were 2.95 (before tr eatment) and 0.98(after treatment) showing a significant improvement in condition after receiving treatment(p=.000 for all). These findings were statistically supported by applying paired t-test which

showed significant improvement regarding HouseBrackmann facial grading and othersymptoms of facial palsy (p < 0.05 for all).

Conclusion: The signs and symptoms improved in both groups. However, steroids,electrical stimulation with exercise has shown to be more effective in improving theoutcome measure. This study supported the effectiveness of combined approach in thetreatment of Bells palsy.

Keywords: Bells palsy, Medications, Electrical Stimulation, Facial Exercises.

Mazhar Badshah*Muhammad Umar**

Aamer Naeem***Misbah Marryam ****

*Department of Neurology, PakistanInstitute of Medical Sciences,Islamabad

,,The Neuro Counsel,

Islamabad

**Department of Physiotherapy,Holy Family Hospital, Rawalpindi,The Neuro Counsel, Islamabad

***Riphah College of Rehabilitation

Sciences, Riphah InternationalUniversity, Islamabad

****Department of Physiotherapy,Holy Family Hospital, Rawalpindi

Address for CorrespondenceMuhammad UmarDepartment of Physiotherapy, HolyFamily Hospital RawalpindiEmail: [email protected]

Introduction

Various scales are available for grading the severity ofBells palsy but a widely used one is HouseBrackmannfacial nerve grading system. Though recovery in Bellspalsy is expected to be spontaneous but is oftendelayed and incomplete.Bells palsy is a sudden one sided paresis or paralysis ofthe face in a manner similar to other peripheral nerveimpairments. It is a lower motor type of lesion with anunknown cause having shown rare recurrences.

1

Different factors have been associated with itsoccurrence including; autoimmune inflammatorydisorders, viral infections, inheritance and vascular

ischemia but still the cause has been a mystery. Thewidely established pathophysiology of its occurrence isinflammation of facial nerve during its path throughlabyrinthine of facial canal causing its compressionresulting in demyelination of axons and disruption of theblood supply to the nerve. It is most frequently foundmono neuropathy affecting facial muscles, facialexpression muscles, parasympathetic fibers to salivaryand lacrimal glands, as well as sensory fibers supplyingtaste sensation to anterior two third of tongue

2.

Additional symptoms may include; excessive tearing ordry eyes, drooling of saliva, pain in or behind the ear,numbness, hyperacusis, increased sensitivity to soundand disturbed taste sensations on the anterior part of


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tongue. Its incidence is almost equal on right and leftside of face.Bells palsy was initially identified as a separatepathology by Sir Charles Bell (1893), and has beennamed after him. It has been found that Bells palsyaccounts for around 72% of all cases of facial palsies.

3It

affects both male and female equally at any part of their

life, but its incidence have been reported more in thirdand fourth decade of life. The incidence is about 20 peryear in a population of 100,000, while some studiesreported it to be 10 to 40 cases in population of 100,000although some geographical variations are there.

4

The paralysis causes significant disturbance amongpatients not only in social activities, life style andpsychological aspects but functional activities are alsohindered like the ability to eat, drink and expressoneself, either verbal or non verbal communication.

5So

far, many options of treatment exist includingmedications in the form of steroids, antiviral and neuralmultivitamins and surgery etc.

6Physiotherapy is a

conservative treatment intervention for this conditionand considered to be an effective form of treatmentalthough its effects have been found debatableaccording to different studies. The objective of studywas to evaluate the efficacy of a combined treatmentplan consisting of steroids, electrical stimulation andfacial exercises against steroids alone.

Materials and Methods

Patients having Bells palsy seen at Holy Family HospitalRawalpindi and in a Private setting at Islamabad;diagnosis and referral was made by neurologist.Inclusion criteria: A total of 113 diagnosed patients ofBells palsy were selected including male and female,age group of study population was 20 to 60 years.Exclusion criteria:Bells palsy because of any tumor orspace occupying lesion, diabetic patients and pregnantfemales.Experimental group received steroids in the form ofprednisolone. The dosage for first 5 days was 60 mg perday. It was then decreased by 10 mg per day (for a totaltreatment time of 10 days) and 50 mg per day in twodivided doses for 10 days). Parameters for electricalstimulation were surged faradic current with pulseduration 0.1ms, pulse frequency 50 Hz, and surgeduration: interval ratio was 5:5. Intensity was increased

to produce mild contraction of facial muscles stimulatedat nerve trunk branch. 30 contractions daily for 14 dayswere given. Facial exercises were also advised. Controlgroup received steroids (prednisolone) alone for sameduration and time as experimental group. Informedconsent was obtained from patients. Duration of studywas twelve months and a structured Questionnaire wasdeveloped. Data was analyzed using SPSS-16 and two

tailed T-Test was used to confirm study hypothesiskeeping level of significance at 5%.

Results

As per the requirement of study design, two groupswere formed experimental and non- experimentalgroup; 58 patients were assigned to experimental groupreceiving steroids, facial exercises along with stimulationwhile 55 patients were included in control group whichreceived steroids alone. Incidence of age varied from 20to 60 years in present study with 50% of patients wasbetween 30 to 40 years. The patient condition wasgraded according to HouseBrackmann facial nervegrading system. Grade I indicated no dysfunction whilegrade VI indicated complete paralysis. Initially, 40%patients were having Grade IV dysfunction, 24 % havingGrade V while 5 % had complete paralysis in theexperimental group. After receiving treatment in the formof combined program, almost 50 % of the patientsprogressed to having no dysfunction while 26% were left

with mild dysfunction, and there was insignificantimprovement among patients with complete paralysis. Inthe control group, results did not show marked progressas only 22 % patient were completely cured afterreceiving treatment, while 15 % were experiencing milddysfunction, 33 % patient were still left with severesymptoms.Other parameters which were tested included drooling,dry/ watery eyes, loss of taste ability, pain in ear,numbness on face and hyperacusis. Steroids along withelectrical stimulation and exercise showed greaterimprovement than controlled group as 78 % patientswere experiencing symptom of drooling before receiving

treatment which was reduced to 24 % after receivingtreatment, whereas drooling was still present in 36 % ofpatient after receiving treatment in control group. In caseof dry / watery eyes, only 19 % patients in experimentalgroup were left with this symptom after getting thetreatment while 38% of the patients in control groupwere still experiencing it after treatment.In case of intact taste ability, every second patient hadcomplaints of reduced taste ability and pain in ear.These symptoms improved significantly and only 17%and 10% of the patients respectively were left withsymptoms in the experimental group after receivingtreatment. In the non-experimental group, steroids also

helped in reducing the symptoms as 27% and 22% ofthe patient were left with reduced taste ability and painin ear after the treatment.Similar improvements with mild variations were found inboth groups after treatment for hyperacusis andnumbness on face indicating the efficacy of bothtreatment interventions as shown in figure 1 and 2 forexperimental and non-experimental group respectively.P value for all variables is listed in Table I.


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statistical difference in improvement was found whenfacial exercises were compared against medicines.

17, 18

Electrotherapy has been considered a major part ofconservative treatment although its efficacy iscontroversial. A study in 1998 on Bells palsy revealedinsignificant improvement after six months of treatmentwith electrotherapy.

19 Outcome measure to be

considered was 75% recovery. In case of secondaryoutcome parameters, formation of facial musclecontracture was evaluated which showed insignificantimprovement. Later on, studies done in 2007 and 2008showed somewhat good improvement withelectrotherapy after three and six months respectively.In these studies, secondary outcome parameters alsotested were presence of contracture, facial spasm,hyperkinesias, motor synkinesis, or crocodile tears sixmonths after the onset and results were a mix makingthem debatable. One of the drawbacks was that samplesize was small in both studies causing ambiguity inresults.

20, 21

Accupuncture has also been tried for the treatment ofBells palsy. A study done in Pakistan supported its usealthough results are debatable because of small samplesize.

22

CONFLICT OF INTEREST: The authors declared noconflict of interest with regard to funding or affiliation

ConclusionThe signs and symptoms improved in both groups.However, steroids, electrical stimulation with exercisehas shown to be more effective in improving theoutcome measure. This study supported theeffectiveness of combined approach in the treatment ofBells palsy.

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5. Holland NJ, Weiner GM. Recent developments in Bells palsy. Br MedJ 2004; 329:553557

6. Roob G, Fazekas F, Hartung HP. Peripheral Facial Palsy: Etiology,

Diagnosis and Treatment. Eur Neurol 1999: 41: 3-97. Brach JS, VanSwearingen JM. Physical therapy for facial paralysis: A

tailored treatment approach. Physical Therapy 1999; 79(4): 397-404.8. Teixeira LJ, Soares BG, Vieira VP, et al. Physical therapy for Bells

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14. Hato N, Matsumoto S, Kisaki H, Takahasi H, Wakisaka H, Honda N, etal. Efficacy of early treatment of Bells palsy with oral acyclovir andprednisolone. Otol Neurotol 2003; 24:948-51.

15. Teixeira LJ, Soares BG, Vieira VP, Prado GF. Physical therapy forBell's palsy (idiopathic facial palsy) Cochrane Database SystRev. 2008; 3:CD006283.

16. Cardoso JR, Teixeira EC, Moreira MD, et al. Effects of exercises onBell's palsy: systematic review of randomized controlled trials. OtolNeurotol2008; 29:557560.

17. Wen CM, Zhang BC. Effect of rehabilitation training at different degreein the treatment of idiopathic facial palsy: a randomized controlledcomparison. Zhongguo Linchuang Kangfu 2004;8 (13): 24467.

18. Wang XH, Zhang LM, Han M, Zhang KQ. Clinical application offunctional exercise and staged therapy in treatment of facial nerveparalysis. Zhonghua Linchuang Kangfu Zazhi [Chinese Journal ofExperimental and Clinical Virology] 2004;8(4):6167.

19. Flores PF, Medina RZ, Haro LG. Idiopathic peripheral facial paralysistreatment physical therapy versus prednisone [Tratamiento de laparlisis facial perifrica idioptica: terapia fsica versus prednisona].Revista mdica del Instituto Mexicano del Seguro Social 1998;36(3):21721.

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22. SZH Bokhari, SS Zahid Acupuncture treatment of Facial Palsy. J Ayub

Med Coll Abbottabad 2010; 22(4):70-73

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Effectiveness of Combination Therapy Versus Steroids Alone, For the Treatment of Bells Palsy