RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

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| | |SHRUTHA KIRTHY PRAKASH |

|1. |NAME OF THE CANDIDATE AND ADDRESS |D/O PROF. G.K. ANANTH PRAKASH |

| | |# 3677, SOMESHWAR EXTENSION |

| | |DODDABALLAPUR. |

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| | |KEMPEGOWDA INSTITUTE OF PHYSIOTHERAPY, K.R.ROAD, V.V.PURAM, BANGALORE |

|2. |NAME OF THE INSTITUTION |– 560004. |

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|3. |COURSE OF THE STUDY |M.P.T. (NEUROLOGY AND PSYCHOSOMATIC DISORDERS). |

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|4. |DATE OF ADMISSION |15/04/2010 |

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|5. |TITLE OF THE TOPIC: |

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| |“A COMPARATIVE STUDY OF EFFECT OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION EXERCISES WITH ELECTRICAL MUSCLE STIMULATION |

| |AND EFFECT OF FACIAL EXPRESSION MUSCLE EXERCISES WITH ELECTRICAL MUSCLE STIMULATION ON BELL’S PALSY.” |

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|6 |Brief resume of the intended work |

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| |6.1 Need for the study: |

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| |Bell’s palsy 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.[1] Because of injury/ infection of |

| |the facial nerve cause swelling of the nerve with in the bony canal causes pressure on the nerve fibers. This results in temporary |

| |loss of function of the nerve producing a LMN type of facial paralysis.[2] |

| |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. In infra muscular lesion of the facial nerve leads to|

| |the facial muscles paralysis. In supra nuclear lesion of the facial nerve ( usually a part of hemiplegic) , leads only the lower |

| |part of the facial muscles is paralysed.[3] |

| |The incidence 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.[1,4] |

| |The aetiology for bell’s palsy is idiopathic; most of the evidences support the viral aetiology due to Herpes Simplex. Heper 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 increase capillary permeability leading exudation of fluids, |

| |oedema and compression of micro circulation of the nerve. In Auto immune disorders, T-lymphocyte changes have been observed.[5] |

| |Clinical picture is a stereotyped, accompanied by bell’s phenomenon,[6] diffused retro- auricular pain the region of the mastoid|

| |facial weakness and asymmetry with drooling of liquids from the corner of the mouth on the affected side. Palpebral fissure is |

| |widened on the affected side, eye closure and blinking are reduced or absent, The angle of the mouth droops with reduction of the |

| |nasolabial fold. Smoothing of skin wrinkles, loss of taste in the anterior 2/3 rd of the tongue, hyperacusis.[7] |

| |Pathologically the nerve may be affected by inflammation, compression, contusion, ischemia, stretching, section, application of |

| |excessive heat, cold, ultrasonic energy and local anesthetics.[8] |

| |Neuropraxia (reversible conduction block) results from minor degree of injury. Wallerian degeneration occurs in most severe lesions.|

| |The axons disappear distal to the lesion. Recovery is by regeneration of fibers and depends on ; 1) resolution |

| |( or removal ) of the cause of nerve injury; and 2) Physical condition which permits sprouting axons to grow down inside the |

| |neurilemma tubes and reinnervates motor end plates. Final results is often marred by residual weakness, associated movements |

| |are synkinesis ( from misdirection of regenerating fibers ), fixed contracture of facial muscles and sometimes crocodile tearing.[8]|

| |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 over come a greater amount of resistance than a good |

| |muscle. [9] |

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| |House Brackman Facial Nerve Grading System : Grade 1 – Normal, Grade 2 – Slight, Grade 3 – Moderate, Grade 4 – Moderate to |

| |Severe, Grade 5 – Severe, Grade 6 - Total.[10] |

| |Proprioceptive Neuromuscular Facilitation : Is a philosophy and a method of treatment was started by Dr. Herman Kabat in |

| |1940s[11] |

| |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. [11] |

| |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.[11] |

| |Timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle or a desired activity. [11] |

| |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 and stretch. 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.[11] |

| |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. A|

| |n 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.[12] |

| |The 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.[13] |

| |For stimulating muscles which is completed denervated 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 .[13,14] |

| |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.[15] |

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| |Purpose of the study: |

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| |This study is intended to compare the effectiveness of Proprioceptive Neuromuscular Facilitation along with Electrical Stimulation |

| |and Facial Expression Exercises along with Electrical Stimulation on Bell’s Palsy. |

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| |Hypothesis: |

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| |Null Hypothesis: There will be no significant difference between the effect of Proprioceptive Neuromuscular Facilitation with |

| |electrical stimulation and facial expression exercises with electrical stimulation on Bell’s Palsy. |

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| |Alternate Hypothesis: There will be significant difference between the effect of Proprioceptive Neuromuscular Facilitation with |

| |electrical stimulation and facial expression exercises with electrical stimulation on Bell’s Palsy. |

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| |6.2 Review of Literature: |

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| |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.[1] |

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| |B.D.Chaurasia’s (1983) stated that the facial nerve is the motor nerve of the face its five terminal branches ( temporal, |

| |zygomatic, buccal, mandibular and cervical ) emerge from the parotid gland and diverge to supply the various facial muscles.[3] |

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| |Julian Holland (2008) stated that the incidence is about 20/100,000 people a year are about 1/60 people in life time.[1] |

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| |Julian Holland (2008) stated that up to 30 % of people with acute peripheral facial palsy have other identifiable causes, including |

| |stroke, tumors, middle ear diseases, Lyme disease. Severe pain is more consistent in ram say hunt syndrome caused by herpes zoster |

| |infection. Which has a worst prognosis then bell’s palsy.[1] |

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| |T.S.Shafahak (2006) stated that physiotherapy in Bell’s Palsy, seems that local superficial heat therapy, massage, exercises, |

| |electrical stimulation and bio feed back training have place in the treatment of lower motor facial palsy.[13] |

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| |L J Vanopdenbosch (2005) stated that Bell’s Palsy is an idiopathic facial palsy of the peripheral type.[16] |

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| |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.[17,18] |

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| |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.[6] |

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| |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.[7] |

| | |

| |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.[8] |

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| |Robert W.Lovett, M.D(2005) describes a method of testing and grading muscle strength using gravity as resistance.[9] |

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| |House JW. Brackmann BE ( 1985 ) stated that House Brackmann score is a score to grade the degree of nerve damage in a facial nerve|

| |palsy.[10] |

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| |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.[11] |

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| |Kabat(1947) stated that timing is the sequencing of motions.[19] |

| | |

| |Kabat (1947) stated that timing for emphasis involves changing the normal sequencing of motions to emphasize a particular muscle |

| |or a desired activity.[19] |

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| |T.S.Shafahak (1994) stated that Bell’s Palsy is the most common cause of lower motor facial palsy.[20] |

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| |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.[20] |

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| |T.S.Shafahak (1994) stated that 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.[20] |

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| |T.S.Shafahak(2006) stated that active exercises ( in front of the mirror ) prevent muscle atrophy and improve muscle function [13] |

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| |T.S.Shafahak(2006) stated that heat therapy improves local circulation and lowers the skin resistance to electrical stimulation, |

| |thus the lowest current intensity could be used.[13] |

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| |T.S.Shafahak(2006) stated that electrical stimulation of muscles aims at preserving muscle bulk especially in complete |

| |paralysis[13,21] 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.[13,21,22] |

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| |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.[15] |

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| |6.3 Objective of the Study: |

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| |To assess the effect of Proprioceptive Neuromuscular Facilitation with Electrical Stimulation on Bell’s Palsy. |

| |To assess the effect of Facial Expression Exercises with Electrical Stimulation on Bell’s Palsy. |

| |To compare the effect of Proprioceptive Neuromuscular Facilitation with Electrical Stimulation on Bell’s Palsy and effect|

| |of Facial Expression Exercises on Bell’s Palsy. |

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|7. |Materials and Methods: |

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| |7.1 Source of Data: |

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| |Out Patient Department of Physiotherapy in Kempegowda Institute of Medical Science Hospital and Research Centre, Bangalore. |

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| |Out Patient Department of ENT, Neurology & Neurosurgery in Kempegowda Institute of Medical Science Hospital & Research Centre, |

| |Bangalore. |

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| |7.2 Methods of Collection of Data: |

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| |Study Design: Comparative Study |

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| |Sample size : 40 patients ( 20 in each group ) |

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| |Sample method: Random Sampling method. |

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| |Materials Used: |

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| |Treatment tray includes: |

| |Mackintosh |

| |Lint pads |

| |Pad or plate electrodes and pen electrodes. |

| |Leads ( 2 ) |

| |Straps |

| |Cotton |

| |Powder |

| |Gel |

| |Kidney tray |

| |Skin resistance lowering tray includes: |

| |Saline water |

| |Soap |

| |Cotton |

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| |Inclusion Criteria: |

| |Patients with peripheral unilateral idiopathic facial palsy. |

| |Age group between 15 – 40 years. |

| |Patient must give the written informed consent. |

| |Both males and females. |

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| |Exclusion Criteria: |

| |Patient with history of recent head injury, Neurological disorders. |

| |Patient with history of Metal / Dental implants. |

| |Patient with history of diabetic neuropathy. |

| |Patient with history of immunodeficiency syndromes. |

| |Viral infections like herpes simplex. |

| |Tumors, congenital defects, open wounds. |

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| |7.3 Does the study require any Investigations or Interventions to be conducted on Patients or other Humans or Animals? If so , |

| |Please describe briefly: |

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| |Yes, an intervention on Patients is done. |

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| |Methodology: |

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| |40 patients with Bell’s palsy will be recruited for the studies who will be randomly selected by lottery method priory assessed |

| |and referred fulfilling the inclusion and exclusion criteria. |

| |Patient’s informed consent form will be taken and assessed. |

| |Patients will be divided into two groups. |

| |Group A & group B with each group consisting of 20 patients with Bell’s palsy. |

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| |Group A will receive PNF exercises along with electrical muscle stimulation. |

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| |PNF Exercises are : |

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| |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.[23] |

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| |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.[23] |

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| |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.[23] |

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| |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.[23] |

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| |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.[23] |

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| |Muscle mentalis: ask the patient to wrinkle the chin. |

| |Apply resistance down and out of the chin.[23] |

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| |Group B will receive facial muscles exercises along with electrical muscle stimulation. |

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| |Facial expressions Muscle Exercises are[24] : |

| |Sit relaxed in front of a mirror. |

| |Gently raise eyebrows; you can help the movement with your fingers. |

| |Draw your eyebrows together, Frown. |

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| |Exercises to help close the eye : |

| |Look down |

| |Gently place back of index finger on eyelid , to keep the eye closed |

| |With opposite hand gently stretch eyebrow up working |

| |Along the eyebrow line. This will help to relax the eyelid and |

| |Stop from becoming stiff. |

| |Now try and gently press the eyelids together. |

| |Wrinkle up your nose. |

| |Take a deep breath through your Nose, try and flare Nostrils. |

| |Gently try and move the corners of mouth outward try and keep the movement the same on each side of your face. |

| |You can use your fingers to help once in position take your fingers away and if you can hold that smile. |

| |Lift one corner of the mouth then other.[24] |

| |Ask the patient to close and protrude the lips like (whistling)[25] |

| |Ask the patient to raise the skin of the chin. As a result the |

| |lower lip will protrude somewhat, as in pouting[.25] |

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| |Electrical Muscle Stimulation will be given to both A & B Groups: |

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| |Position of the patient: Supine lying position. [26] |

| |Check for contra indications, |

| |Placement of Electrodes |

| |In active electrode - over the nape of the neck. |

| |Active electrode by pen electrode – motor point of the face muscles.[26] |

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| |Frequency: 4 sessions per week for 3 weeks. |

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| |Duration of the Study: 12 months. |

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| |Statistical Analysis: |

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| |Mann-Whitney U-Test and the results will be considered statistically significant whenever p ≤ 0.05. Other statistical tests may be |

| |applied during the time of data analysis after the intervention. |

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| |7.4 Has Ethical Clearance been obtained from your Institution in case of 7.3? |

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| |Yes. |

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|8. |LIST OF REFERENCES: |

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| |Julian Holland; Bell’s palsy; Bmj Clinical evidence; 2008:01:1204. |

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| |Richards. Snell. Clinicalneuroanatomy, 7th Edition. Wolters Voklvwer/ Lippincott Williams and Wilkins, 2009; 361-2. |

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

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| |Peitersen E. Bell’s Palsy; The spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta otolaryngol|

| |suppl 2002; 549: 4-30. |

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| |P.l.Dhingra. Diseases of Ear, Nose and Throat, 4th Edition. An imprint of Elsevier, 2004; 94. |

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

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| |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; 475. |

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| |John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition. John Wright and son’s ltd, 1985; 481. |

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| |Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary Mclntyre Rodgers, William Anthony Romani. |

| |Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 22. |

| | |

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

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

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| |Tim Watson. Electrotherapy Evidence - Based Practice, 12th edition. An imprint of Elsevier, 2008; 203-4. |

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| |T.S.Shafahak, The treatment of facial palsy from the point of view of physical and rehabilitation medicine; Eura Medici Phys |

| |2006;42:41-7. |

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| |Mosforth J, Taverner D. Physiotherapy for Bell’s palsy. Br Med J 1958; 2: 675-7. |

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| |Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary Mclntyre Rodgers, William Anthony Romani. |

| |Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 121. |

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| | |

| |LJ Vanopdenbosch, K Verhoeven, J W Casselman; Bell’s Palsy with ipsilateral numbness ; j Neural Neurosurg Psychiatry |

| |2005;76:1017-18. |

| | |

| |Teixeira LJ, Soares BGDO, Vieira VP. Physical therapy for Bell’s palsy (idiopathic facial paralysis). (protocol) Cochrane Database |

| |of Systematic Reviews 2006.4. Art No.: CD006283.DOI:10.1002/14651858.CD006283. |

| | |

| |Adour k. Current concepts in neurology: diagnosis and management of facial paralysis. New England Journal of Medicine 1982; |

| |307:348-51. |

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| |Susan S. Adler, Dominiek Beckers, Math Buck. PNF in practice an illustrated Guide, 2nd revised Edition. 2000, Springer; 15. |

| | |

| |Shafshak 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 Laryngol Otol 1994; 108:940-43. |

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| |Mysiw WJ, Jackson RD. Electrical Stimulation. In: Braddom RL editor. Physical medicine & rehabilitation. 2nd edition. Philadelphia: |

| |WB Saunders company; 2000: 459-87. |

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

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| |Susan .S. Alder, Dominick Beckers, Math Buck. Pnf in practice an illustrated Guide, 2nd revised edition. Springer, 2000; 367-75. |

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| |The Bell’s palsy Association, .uk. |

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| |Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary Mclntyre Rodgers, William Anthony Romani. |

| |Muscles Testing and Function with Posture and Pain, 5th Edition. Lippincott Williams and Wilkins, 2005; 130-33. |

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

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|9. |SIGNATURE OF THE CANDIDATE: | |

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|10. |REMARKS OF THE GUIDE: |

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|11. |NAMES AND DESIGNATION OF: |

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|11.1 |GUIDE: |Dr. PREM KUMAR. B.N |

| | |Assistant Professor |

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|11.2 |SIGNATURE: | |

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| | |Dr. ANIL.H.T |

|11.3 |CO-GUIDE: |Associate professor, Dept. of ENT, KIMS, Bangalore. |

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|11.4 |SIGNATURE: | |

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|11.5 |HEAD OF THE DEPARTMENT: |Prof. R. BALASARVANAN |

| | |K.I.P.T |

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|11.6 |SIGNATURE : | |

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|12. |12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL: |

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| |12.2 Signature: |

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