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. |
| | | |
| | |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 |
| | |
| |6.1 Need for the study: |
| | |
| |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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| | |
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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] |
| | |
| |Purpose of the study: |
| | |
| |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. |
| | |
| |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. |
| | |
| |6.2 Review of Literature: |
| | |
| |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] |
| | |
| |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] |
| | |
| |Julian Holland (2008) stated that the incidence is about 20/100,000 people a year are about 1/60 people in life time.[1] |
| | |
| |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] |
| | |
| |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] |
| | |
| |L J Vanopdenbosch (2005) stated that Bell’s Palsy is an idiopathic facial palsy of the peripheral type.[16] |
| | |
| |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] |
| | |
| |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] |
| | |
| | |
| |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] |
| | |
| | |
| |Robert W.Lovett, M.D(2005) describes a method of testing and grading muscle strength using gravity as resistance.[9] |
| | |
| |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] |
| | |
| |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] |
| | |
| |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] |
| | |
| |T.S.Shafahak (1994) stated that Bell’s Palsy is the most common cause of lower motor facial palsy.[20] |
| | |
| |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] |
| | |
| |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] |
| | |
| |T.S.Shafahak(2006) stated that active exercises ( in front of the mirror ) prevent muscle atrophy and improve muscle function [13] |
| | |
| |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] |
| | |
| |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] |
| | |
| |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] |
| | |
| |6.3 Objective of the Study: |
| | |
| |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: |
| | |
| |7.1 Source of Data: |
| | |
| |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 |
| | |
| |Sample size : 40 patients ( 20 in each group ) |
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| |Sample method: Random Sampling method. |
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| |Materials Used: |
| | |
| |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 |
| | |
| |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. |
| | |
| |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: |
| | |
| |Yes, an intervention on Patients is done. |
| | |
| |Methodology: |
| | |
| |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. |
| | |
| |Group A will receive PNF exercises along with electrical muscle stimulation. |
| | |
| |PNF Exercises are : |
| | |
| |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] |
| | |
| |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] |
| | |
| |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] |
| | |
| |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] |
| | |
| |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] |
| | |
| |Muscle mentalis: ask the patient to wrinkle the chin. |
| |Apply resistance down and out of the chin.[23] |
| | |
| |Group B will receive facial muscles exercises along with electrical muscle stimulation. |
| | |
| |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. |
| | |
| | |
| |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] |
| | |
| |Electrical Muscle Stimulation will be given to both A & B Groups: |
| | |
| |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] |
| | |
| |Frequency: 4 sessions per week for 3 weeks. |
| | |
| |Duration of the Study: 12 months. |
| | |
| |Statistical Analysis: |
| | |
| |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. |
| | |
| |7.4 Has Ethical Clearance been obtained from your Institution in case of 7.3? |
| | |
| |Yes. |
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|8. |LIST OF REFERENCES: |
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| | |
| |Julian Holland; Bell’s palsy; Bmj Clinical evidence; 2008:01:1204. |
| | |
| |Richards. Snell. Clinicalneuroanatomy, 7th Edition. Wolters Voklvwer/ Lippincott Williams and Wilkins, 2009; 361-2. |
| | |
| |B.D.Chaurasia’s. Human anatomy, 3rd edition. Cbs publishers and distributors, 1996; 3; 41-2. |
| | |
| |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. |
| | |
| |P.l.Dhingra. Diseases of Ear, Nose and Throat, 4th Edition. An imprint of Elsevier, 2004; 94. |
| | |
| |Kenneth W. Lindsay, Ian Bone. Neurology and Neurosurgery illustrated, 4th Edition. Churchill living stones, 2004; 168. |
| | |
| |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. |
| | |
| |John Grovers, Roger .F. Gray. A synopsis of Otolaryngology, 4th Edition. John Wright and son’s ltd, 1985; 481. |
| | |
| |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. |
| | |
| |Susan S. Adler, Dominiek Beckers, Math Buck. Pnf in practice an illustrated guide, 2nd revised Edition. Springer, 2000; 1-15, 364. |
| | |
| |Tim Watson. Electrotherapy Evidence - Based Practice, 12th edition. An imprint of Elsevier, 2008; 203-4. |
| | |
| |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. |
| | |
| |Mosforth J, Taverner D. Physiotherapy for Bell’s palsy. Br Med J 1958; 2: 675-7. |
| | |
| |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. |
| | |
| | |
| | |
| |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. |
| | |
| |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. |
| | |
| |Mysiw WJ, Jackson RD. Electrical Stimulation. In: Braddom RL editor. Physical medicine & rehabilitation. 2nd edition. Philadelphia: |
| |WB Saunders company; 2000: 459-87. |
| | |
| |Adour KK, Hetzler DG. Current Medical treatment for Facial Palsy. Am J Ototalaryngol 1984; 5: 499-502. |
| | |
| |Susan .S. Alder, Dominick Beckers, Math Buck. Pnf in practice an illustrated Guide, 2nd revised edition. Springer, 2000; 367-75. |
| | |
| |The Bell’s palsy Association, .uk. |
| | |
| |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. |
| | |
| |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: | |
| | | |
| | |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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