RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,BANGALORE.KARNATAKA.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE& ADDRESS

POOJA JAYANTILAL THAKKARAR,D/O. JAYANTILAL THAKKARAR,NO: 4/1, 9TH MAIN, DR. RAJROAD,SRINIVAS NAGAR, BANGALORE,KARNATAKA - 560050

2 NAME OF THE INSTITUTION

KRUPANIDHI COLLEGE OF PHYSIOTHERAPY

3 COURSE OF STUDY AND SUBJECTF

MASTER OF PHYSIOTHERAPY INNEUROLOGICAL AND PSYCHOSOMATIC DISORDERS

4 DATE OF ADMISSION TO COURSE

15th JUNE 2013

5TITLE OF THE TOPIC

EFFECT OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION ON FACIAL FUNCTIONS IN FACIAL MUSCLE PARALYSIS- A RANDOMIZED EXPERIMENTAL STUDY.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Facial Paralysis is an idiopathic, acute, unilateral paresis or paralysis of the face with peripheral facial nerve dysfunction, it may be partial or complete, occurring with equal frequency on the right and left sides of the face. Because of injury/ infection of the facial nerve.It causes swelling of the nerve with in the bony canal and causes pressure on the nerve fibers. This results in temporary loss of function of the nerve producing a LMN and UMN type of facial paralysis.[1]

The facial nerve is the seventh cranial nerve. The facial nerve is both a motor and a sensory nerve. The motor nerve of the face has 5 terminal branches (temporal, zygomatic, buccal, mandibular and cervical) emerges from the parotid gland and diverge to supply the various facial muscles. The trigeminal nerve is the sensory nerve of the face. Infra muscular lesion of the facial nerve leads to the facial muscles paralysis. supra nuclear lesion of the facial nerve (usually part of hemiplegic) , leads to lower part of the facial muscles paralysis.[2]

The incidence of facial paralysis is about 20/ 100,000 in a year or about 1/60 people in life time. Bell’s palsy has a peak incidence between the ages of 15 – 40 years and men and women are equally affected.The aetiology for facial paralysis is idiopathic; most of the evidences support the viral aetiology due to Herpes Simplex. Herpes Zoster or Epstein – Barr virus. Vascular ischemia may be primary or secondary. Primary ischemia is induced by cold or emotional stress. Secondary ischemia is the result of primary ischemia which causes increased capillary permeability leading to exudation of fluids, oedema and compression of micro circulation of the nerve.[1,3,]

Pathologically the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of excessive heat, cold, ultrasonic energy and local anesthetics.

Symptoms of Facial Palsy (UMN) [4]

The corner of the mouth pulls down/droops Inability to smile on affected side Inability to puff up your cheeks, whistle or blow Altered taste Tingling of the affected half of the tongue Difficulty eating and drinking Difficulty brushing your teeth and spitting out Drooling from the weak corner of your mouth Excess or reduced salivation (dry mouth) Inability to pout Difficulty speaking because of weakness in the lips and cheek

Symptoms of Bell’s Palsy (LMN) [4]

Loss of forehead wrinkles and inability to frown Droopy eyebrow and inability to raise eyebrow Inability to close the eye fully or blink (Bell’s phenomenon seen only in

LMN lesion/bell’s palsy) Watery eye or dry eye (crocodile tears) Inability to squint Drooping of the lower eyelid which may make the eye appear wide Painful eye with symptoms of grittiness or irritation Sensitivity to light Soreness or redness of the white of the eye Drooling from the weak corner of your mouth Excess or reduced salivation (dry mouth) Nose runs or feels stuffy Inability to flare nostril Inability to wrinkle nose Loss of taste in the anterior 2/3rd of the tongue. Hyperacusis

Conventional treatment is most commonly used treatment for facial nerve paralysis, it is an old method of treatment, it includes electrical stimulation, massage and facial expression exercise.Facial massage include stroking, effleurage, finger kneeding, and will help to stimulate the muscle.[5]

Electrical Muscle Stimulation (EMS): Electrical stimulation stimulates muscles, nerves or a combination of both. The physiological effects of stimulation are used therapeutically to strengthen muscles, assist in wound healing, relieve pain and reduce oedema. An externally applied stimulus can cause depolarization of the nerve and thus initiate an action potential as long as the applied stimulus depolarizes the resting membrane potential to the threshold level.[6]

The type of electrical stimulation should depend on the pathology of the facial nerve if there are no electrophysiological signs of muscle denervation.

Facial muscle expression exercises: facial muscles are called the muscles of expression. The facial nerve, through its branches, innervates most of the facial muscles. Numerous muscles may act together to create movement (e.g., grimace), or movement may occur in a single area (e.g., as in raising an eyebrow). Loss of function of the facial muscles interferes with the ability to communicate feelings through facial expression.[7]

Proprioceptive NeuromuscularFacilitation: Is a philosophy and a method of treatment was started by Dr. Herman Kabat in 1940s. Dr. Herman Kabat defines Proprioceptive Neuromuscular Facilitation as – having to do with any of the sensory receptors that give information concerning movement and position of the

body, involving the nerves and the muscles making easier.[8]

One of the basic procedures of Proprioceptive Neuromuscular Facilitation is Timing. Timing is to promote normal timing and increase muscle contraction through Timing for emphasis.Timing is defined as sequencing of motion.Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity.

Kabat (1947) wrote that prevention of motion in a stronger synergist will redirect the energy of that contradiction into a weaker muscle. This alteration of timing stimulates the Proprioceptive reflexes in the muscles by resistance andstretch. When we use bilateral movements while exercising the face, contraction of the muscles on the stronger or more mobile side will facilitate and reinforce the action of the involved muscles. Timing for emphasis, by preventing full motion on the stronger side will further promote activity in the weaker muscles.[8]

6.1 NEED OF THE STUDY.

Facial palsy and Bell’s palsy is most disabling neural condition in terms of facial expression and communication. There are several functional therapies available to deal with it. Conventional therapy is most commonly used treatment for facial paralysis and many innovative approaches are emerging. Proprioceptive neuromuscular facilitation is one of the promising treatment in neural paralysis and having literatures supporting that it is more effective than conventional therapy. Also the PNF is practicelimited clinically in this condition. So this is study intended to analyze the effects of PNF in facial palsy.

6.2 OBJECTIVES OF THE STUDY

[A] OBJECTIVES

a) To analyze the effect of conventional physiotherapy on facial function in Bell’s Palsy and facial Palsy subjects.

b) To analyze the effect of Proprioceptive neuromuscular facilitation on facial function in Bell’s palsy and Facial Palsy subjects.

c) To analyze the effect of Proprioceptive neuromuscular facilitation over conventional physiotherapy on facial function between Bell’s palsy and Facial Palsy subjects.

6.3 [B] HYPOTHESIS

Null hypothesis:

There will be no significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Facial Palsy.

There will be no significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Bell’s palsy.

Experimental hypothesis:

There will be significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Facial Palsy.

There will be significant change on facial function with proprioceptive neuromuscular facilitation over conventional physiotherapy in Bell’s palsy.

6.4 REVIEW OF LITERATURE

1] Review for the facial palsy

Julian Holland (2008)stated that bell’s palsy is characterized by an acute, unilateral, partial or complete paralysis of the face. This may occur with mild pain, numbness, increased sensitivity to sound and altered taste. Bell’s palsy remains idiopathic. He also stated that the incidence is about 20/100,000 people a year are about 1/60 people in life time.Up to 30 % of people with acute peripheral facial palsy have other identifiable causes, including stroke, tumors, middle ear diseases, Lyme disease.[1]

L J Vanopdenbosch (2005)stated that Bell’s Palsy is an idiopathic facial palsy of the peripheral type and Adour (1982)stated that the idiopathic bell’s palsy is an acute disorder of the facial nerve which may begin with symptoms of pain the mastoid region and produce full or partial paralysis of movement of one side of the face.[9,10,11]

2]Review of the facial disability

Lindsay (2004) stated that on attempting to close the eye and show the teeth, the one eye does not close and the eye ball rotates upwards and outwards.[12]

Charles Clarke(2009)stated that clinically bell’s palsy patients presents with diffuse retro auricular pain in the region of the mastoid, facial weakness and drooling of liquids from the corner of the mouth on the affected side, hyperacusis.[13]

John Grover’s (1985) stated that the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of excessive heat, cold, ultrasonic energy and local anesthetics.[14]

3]Review on the treatment of the facial muscle paralysis

T.S.Shafahak (1994)stated that in Bell’s Palsy, spontaneous complete recovery was found in about 69 % of the patients. Therefore about 31% of the Bell’s Palsy patients who did not receive the appropriate treatment may suffer from incomplete recovery. Clinical evaluation for both the severity of paralysis and the presence of complication ( synkinesis, hyperkinesis or contracture) is the first step before the start of treatment or rehabilitation.[15]

BeurskensCH, Heymans PG(2004).Conducted a study on 155 patients to describe changes and stabilities of long-term sequel of facial paresis in outpatients receiving mime therapy, a form of physiotherapy. Main outcome measures were (1) impairments: facial symmetry in rest and during movements and synkineses; (2) disabilities: eating, drinking, and speaking; and (3) quality of life. The study concluded that during a period of approximately 3 months, significant changes in many aspects of facial functioning were observed, the relative position of patients remaining stable over time.[16]

T.S.Shafahak (2006) stated that physiotherapy in Bell’s Palsy, seems that local superficial heat therapy, massage, exercises, electrical stimulation and bio feedback training have place in the treatment of lower motor facial palsy. Active exercises (in front of the mirror) prevent muscle atrophy and improve muscle function. Heat therapy improves local circulation and lowers the skin resistance to electrical stimulation, thus the lowest current intensity could be used. He also stated that electrical stimulation of muscles aims at preserving muscle bulk especially in complete paralysis and it has also a psychological benefit as the patient observes muscle contraction in his face that gives him hope for recovery from facial paralysis.[17]

Kendall (2005)stated that facial muscles are called the muscles of expression. The facial nerve, through its many branches, innervates most of the facial muscles. Numerous muscles may act together to create movement or movement may occur in a single area.[7]

4]Review of PNF Technique

Kabat (1950) stated that Proprioceptive Neuromuscular Facilitation (P.N.F) is a concept of treatment. Its underlying philosophy is that all human beings, including those with disabilities, have untapped existing potential.Kabat(1947)stated that timing is the sequencing of motions. Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity.[8]

Manikandan N(2007)the effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy in which 59 patients were randomly divided into two groups control (n = 30) and experimental (n = 29). Control group patients received conventional therapeutic measures while the facial neuromuscular re-education group patients received techniques that were tailored to each patient in three sessions per day for six days per week for a period of two weeks. The conclusion was individualized facial neuromuscular re-education is more effective in improving facial symmetry in patients with Bell's palsy than conventional therapeutic measures.[5]

Namura M, Motoyoshi M, Namura Y, Shimizu N (2008).Evaluatedthe effect of PNF training on the facial profile in 40 adults with an average age of 29.6 years. A series of PNF exercises was performed three times per day for 1 month. They concluded that the training appeared to be effective for sharpening the mouth and submandibular region.[18]

Brach-JS; VanSwearingen-JM; Lenert-J; Johnson-PC (1997).Described the outcome of facial neuromuscular retraining for brow to oral and ocular to oral synkinesis in individuals with facial nerve disorders. Fourteen patients with unilateral facial nerve disorders and oral synkinesis were enrolled in physical therapy for surface electromyography biofeedback-assisted specific strategies for facial muscle re-education and a home exercise program of specific facial movements. Twelve of 13 patients with brow to oral synkinesis and 12 of 14 patients with ocular to oral synkinesis reduced their synkinesis with retraining. The conclusion was that the patients with brow to oral and to oral synkinesis associated with partial recovery from facial paralysis were reduced with facial neuromuscular retraining for individuals with facial nerve disorders.[19]

Salinas RA, Alvarez G, Daly F, Ferreira J (2010) Their objective was to assesess the validity of an early rehabilitative approach to Bell's palsy patients. A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35–42 years) affected by Bell's palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The evaluation was carried out by measuring the amplitude of the

compound motor action potential (CMAP), as well as by observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy. Patients belonging to the rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after onset of facial palsy, without presenting greater values of CMAP and concluded that when applied at an early stage, Kabat's rehabilitation was shown to provide a better and faster recovery rate in comparison with non-rehabilitated patients.[20]

5]Review of the House Brackmann score and MMT.

Robert W.Lovett, (2005)described a method of testing and grading muscle strength using gravity as resistance.[7]

House JW. Brackmann BE (1985)stated that House Brackmann score is a score to grade the degree of nerve damage in facial nerve palsy.He analyzed correlation between original and modified House Brackmann score. [21]

Reitzen SD, Babb JS, Lalwani AK(2009). In their study determined the reliability of the House-Brackmann facial nerve gradingscale and proposed that Overall inter-reader reliability was relatively strong and increases with clinical experience.[22]

Coulson SE, Croxson GR, Adams RD, O'Dwyer NJ(2005) investigated the extent of within-system reliability and between-system correlation and also examined the interobserver reliability .The 3 systems of grading facial nerve paralysis were evaluated and compared with the use of intraclass correlation coefficients,For clinical grading of voluntary movement, there is good correlation between ratings given on the Sydney and Sunnybrook systems, and within each system there is good reliability. Although the reliability of the House Brackmann system was found to be high,but examination of individual grades revealed some wide variation between trained observers.[23]

7. MATERIALS AND METHODS

7.1. SOURCE OF DATA

[A] POPULATION

Out Patient Physiotherapydept in Krupanidhi College of Physiotherapy, Bangalore and from a community.

[B] SAMPLE SIZE60 subjects male and female ranging from 15-40 years satisfying the inclusion criteria

[C] MATERIALS:

Treatment tray includes:1) Mackintosh2) Lint pads3) Pad or plate electrodes and pen electrodes.4) Leads ( 2 )5) Straps6) Cotton7) Powder8) Gel9) Kidney tray

Skin resistance lowering tray includes:1) Saline water2) Soap3) Cotton4) Treatment Couch5) Stool/Chair6) Mirror

7.2. METHODS OF COLLECTION OF DATA

[A] SAMPLING TECHNIQUERandom sampling technique

[B] TOOLS (outcome measures)

(a) House Brackmann score for muscle function[21]

It is a score to grade the degree of nerve damage in afacial nerve palsy. House Brackmann Facial Nerve Grading System : Grade 1 – Normal, Grade 2 – Slight, Grade 3 – Moderate, Grade 4 – Moderate to Severe, Grade 5 – Severe, Grade 6 - Total.

(b)Manual Muscle Testing Scale[20]

Manual muscle testing: Grading muscles strength using gravity or resistance. Zero/gone – No contraction felt, Trace – Muscle can be felt to tighten but cannot produce movement,

Poor - Produces movement with gravity eliminated but cannot function against gravity, Fair - Can raise the part against gravity, Good – Can raise the part against outside resistance as well as against gravity, Normal – Can overcome a greater amount of resistance than a good muscle.

7.3 [C] METHODOLOGY:

[I] STUDY DESIGNRandomized experimental study

[II] INCLUSION CRITERIA

Patients with peripheral unilateral idiopathic facial palsy after 15 days of onset(sub acute stage).

Age group between 15 – 40 years. Patient must give the written informed consent. Both males and females. Both right and left side

[III] EXCLUSION CRITERIA

Patient with history of recent head injury, Neurological disorders. Patient with history of immunodeficiency syndromes. Viral infections like herpes simplex. Subjects with the history of surgical intervention for facial nerve palsy. Subjects with other form of neurological impairments. Subjects with pain of any other origin. Subjects with any deformity or disability requiring medical attention. Subjects with age less than 20 or greater than 40 years. Subjects with cognitive/perceptual impairement. Open wound. Patient with metal implants.

[IV] PROCEDURE

All subjects fulfilling the inclusion and exclusion criteria will be allowed to participate in the study

60 patient with facial paralysis. 30 Patient with facial palsy and 30 Patient with Bell’s Palsy recruited

for the studies who will be randomly selected by priory assessed and

referred full filling the inclusion exclusion criteria. Patients will be divided into two groups namely Group A and Group

B consisting of 30 patient in each group. Patient informed consent form will be taken and assessed by House

Brackmann scale and manual muscle testing i. e.

Group A(Bell’s Palsy) & Group C (facial palsy) will receive Conventional Physiotherapy i.e.

Electrical stimulationThe type of electrical stimulation should depend on the pathology of the facial nerve if there is no electrophysiological signs of muscle denervation (i.e., the facial nerve lesion is focal demyelination or neuropraxia). Faradic stimulation or electrical stimulation using 0.1 – 1 ms duration pulse delivered at a frequency of 1 – 2 pulses/s or more. This may be given for 50 – 200 contractions/ sessions 3 sessions week until recovery. For stimulating muscles which is completelydenervated interrupted galvanic stimulation of (IGS) of 100 ms triangular pulses may be given at a rate of 1 pulse/s for 30 – 100 contractions/sessions. During each sessions electrical stimulation may be stopped once muscle fatigue occurs.

Massagei. Stroking

ii. Effleurageiii. Finger kneeding

Facial exercise will be instructed as:[4]

I. Sit relaxed in front of a mirror. II. Gently raise eyebrows; you can help the movement with your

fingers.III. Draw your eyebrows together, Frown. IV. Exercises to help close the eye :

a. Look downb. Gently place back of index finger on eyelid, to keep the eye

closed with opposite hand gently stretcheyebrow up working along the eyebrow line. This will help to relax the eyelid andStop from becoming stiff.

c. Now try and gently press the eyelids together.V. Wrinkle up your nose.

VI. Take a deep breath through your Nose, try and flare Nostrils.VII. Gently try and move the corners of mouth outward try and keep

the movement the same on each side of your face.VIII. You can use your fingers to help once in position take your

fingers away and if you can hold that smile.IX. Lift one corner of the mouth then other.X. Ask the patient to close and protrude the lips like (whistling)

XI. Ask the patient to raise the skin of the chin. As a result the XII. lower lip will protrude somewhat, as in pouting

Group B & Group D will be receiving followingPNF exercises along with above mentioned conventional exercises.

Kabat rehabilitation is type of motor control rehabilitation technique based on proprioceptive neuromuscular facilitation (PNF).

During Kabat, therapist facilitate the voluntary contraction of the impaired muscle by applying a global stretching then resistance to the entire muscular section and motivate action by verbal input and manual contact.

When performing Kabat, 3 regional are considered: the upper (forehead and eyes), intermediate (nose), and lower (mouth).

Prior to Kabat, ice stimulation has to perform to a specific muscular group, in order to increase its contractile power.

PNF exercises are:[8]

1. Muscle.Epicranius (Frontalis): ask the patient to lift eye brows up, look surprised wrinkle your forehead. - Apply resistance to the forehead, pushing caudally and medially. This

motions works with eye opening. It is reinforced with neck extension.

2. Muscle corrugators supercilli: ask the patient to pull eye brows down (frown)- Apply resistance just above the eye brows diagonally in a cranial and

lateral direction. This motion works with eye closing.

3. Muscle orbicularis oculi: ask the patient to close the eyes. Separate exercise for upper and lower eye lids. - Avoid putting pressure on the eyeballs.2 previous motions are facilitated

by neck flexion.

4. Muscle procerus: ask the patient to wrinkle your nose.- Apply resistance next to the nose diagonally down and out. This muscle

works with muscle corgurrator with eye closing.[

5. Muscle orbicularis oris: ask the patient to purse the lips whistle and say prunes.

- Apply resistance laterally and upward to the upper laterally and downward to the lower lip.

6. Muscle mentalis: ask the patient to wrinkle the chin.- Apply resistance down and out of the chin.

Repetitive facial rehabilitation for a period of 4 weeks 5 sessions per week for 30 to 45 Min will be administrated and post treatment data will be Measured with MMT & House Brackmann score of facial muscle function.

[V] STASTICAL ANALYSIS:

Non parametric test will be used

7.4 Does the study require any investigation or intervention to be conducted on patients or the other humans or animals? If so, please describe:

Yes, the research study is designed to be conducted on adult subjects under the department of physiotherapy.

7.5 Has ethical clearance been obtained from the subjects and the institution?

Yes, Ethical clearance has been obtained from the institution.

8. REFERENCES

1. Julian Holland; "Bell’s palsy”; Clinical evidence; 2008:01:1204.

2. B.D.Chaurasia’s. Human anatomy, 3rd edition. Cbs publishers and distributors, 1996; 3; 41-2.

3. Peitersen E. Bell’s Palsy; The spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies”.Actaotolaryngolsuppl2002; 549: 4-30.

4. The Bell’s palsy Association, available from www.bellspalsy.org.uk

5. Manikandan N. (2007). "Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. ClinRehabil.. 21 (4): 338–43.

6. Jagmohan Singh, Textbook of Electrotherapy, 1st Edition. Jaypee brothers medical publishers, 2005; 1; 104- 6.

7. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia GeiseProvance, Mary Mclntyre Rodgers, William Anthony Romani. Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 5; 130-33.

8. Susan S. Adler, DominiekBeckers, Math Buck. Pnf in practice an illustrated guide, 2nd revised Edition Springer, 2000;2; 1-15, 364

9. LJ Vanopdenbosch, K Verhoeven, J W Casselman; Bell’s Palsy with ipsilateral numbness ; j Neural Neurosurg Psychiatry 2005;76:1017-18.

10. Teixeira LJ, Soares BGDO, Vieira VP. Physical therapy for Bell’s palsy (idiopathic facial paralysis). (protocol) Cochrane Database of Systematic Reviews 2006.4.

11. Adour KK, Hetzler DG. Current Medical treatment for Facial Palsy. Am J Ototalaryngol 1984; 5: 499-502.

12.Kenneth W. Lindsay, Ian Bone. Neurology and Neurosurgery illustrated, 4th Edition. Churchill living stones, 2004; 168.

13. Charles Clarke, Robin Howard, Martin Rossor, Simon Shorvon. Neurology A queen square text book, 1st Edition. Wiley – Black Well. A John Wiley and sons, 2009;1; 475

14. John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition.

John Wright and son’s ltd, 1985;4; 481.

15.T.S.Shafahak, The treatment of facial palsy from the point of view of physical and rehabilitation medicine; Eura Medici Phys 2006;42(1):41-7.

16.Bearskins CH, Heymans PG. Physiotherapy in patients with facial nerve paresis: description of outcomes. Am J Otolaryngol. 2004 ; 25(6):394-400.

17.Shafahak TS, Essa AY, Bakey FA. The possible contributing factors for the success of steroid therapy in Bell’s palsy: A Clinical and Electrophysiological study. J LaryngolOtol 1994; 108:940-43.

18. Namura M, Motoyoshi M, Namura Y, Shimizu N. The effects of PNF training on the facial profile. J Oral Sci. 2008 ; 50:45-51.

19. Brach-JS; Van Swearingen-JM; Lenert-J; Johnson-PC. Facial neuromuscular retraining for oral synkinesis. Record 19 of 83 - MEDLINE (R) 1997.

20. Salinas RA, Alvarez G, Daly F, Ferreira J (2010). "Corticosteroids for Bell'spalsy (idiopathic facial paralysis)". Cochrane Database Syst Rev,2010;17;(3).

21. House JW, Brackmann DE, Facial Nerve Grading System. Otolaryngol head neck surg. 1985: 93, 146-7.

22.Reitzen SD, Babb JS, Lalwani AK. "Significance and reliability of the House-Brackmann grading system for regional facial nerve function”. Otolaryngol Head Neck Surg. 2009;140(2):154-8.

23.Coulson SE, Croxson GR, Adams RD, O'Dwyer NJ. "Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis”. Otolaryngol Head Neck Surg. 2005;132(4):543-9.

9 SIGNATURE OF CANDIDATE :

10 REMARKS OF THE GUIDE: PRESENTED TO THE RESEARCH COMMITTEE AND APPROVED

11 11.1 NAME AND DESIGNATION OF GUIDE

MRS. SARULATHA(ASSOCIATE PROFESSOR)

11.2 SIGNATURE

11.3 CO-GUIDE (if any)

NIL

11.4 SIGNATURE

---

11.5 HEAD OF THE DEPARTMENT Mr. RAMESH KUMARPROFESSOR

11.6 SIGNATURE

12 12.1 REMARKS OF THE CHAIRMAN AND PRINICIPAL ACCEPTED & FORWARDED

12.2 SIGNATURE