Botulinum toxin A treatment in facial palsy synkinesis: a systematic review and meta-analysis.

BACKGROUND: Synkinesis is defined as involuntary movements accompanying by voluntary movements and can occur during the aftermath of peripheral facial palsy, causing functional, aesthetic and psychological problems in the patient. Botulinum toxin A (BTX-A) is frequently used as a safe and effective treatment; however, there is no standardized guideline for the use of BTX-A in synkinesis. The purpose of this article is to review and summarize studies about the BTX-A treatment of synkinesis in patients with a history of peripheral facial palsy; including given dosages, injection sites and time intervals between injections. MATERIALS AND METHODS: A multi-database systematic literature search was performed in October 2020 using the following databases: Pubmed, Embase, Medline, and The Cochrane Library. Two authors rated the methodological quality of the included studies independently using the 'Newcastle-Ottawa Quality Assessment Scale' for non-randomised studies' (NOS). RESULTS: Four-thousand-five-hundred-and-nineteen articles were found of which 34 studies met the inclusion criteria, in total comprising 1314 patients. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author FJ and AS) was 0.78. Thirty-one studies investigated the reported dosage injected, 17 studies reported injection location and 17 studies investigated time intervals. A meta-analysis was performed for three studies comprising 106 patients, on the effects of BTX-A treatment on the Synkinesis Assessment Questionnaire (SAQ) scores. The mean difference was 11.599 (range 9.422-13.766), p < 0.01. However, due to inconsistent reporting of data of the included studies, no relationship with the dosage and location could be assessed. CONCLUSIONS: Many treatment strategies for synkinesis exist, consisting of varying BTX-A brands, dosages, time intervals and different injection locations. Moreover, the individual complaints are very specific, which complicates creating a standardized chemodenervation treatment protocol. The BTX-A treatment of long-term synkinesis is very individual and further studies should focus on a patient-tailored treatment instead of trying to standardize treatment.

Health-related quality of life in facial palsy: translation and validation of the Dutch version Facial Disability Index.

PURPOSE: Patient-reported outcome measures are essential in the evaluation of facial palsy. Aim of this study was to translate and validate the Facial Disability Index (FDI) for use in the Netherlands. METHODS: The FDI was translated into Dutch according to a forward-backward method. Construct validity was assessed by formulating 22 hypotheses regarding associations of FDI scores with the Facial Clinimetric Evaluation scale, the Synkinesis Assessment Questionnaire, the Short Form-12 and the Sunnybrook Facial Grading System. Validity was considered adequate if at least 75% (i.e. 17 out of 22) of the hypotheses were confirmed. Additionally, confirmatory factor analysis was performed. Cronbach's α was calculated as a measure of internal consistency. Participants were asked to fill out the FDI a second time after 2 weeks to analyse test-retest reliability. Lastly, smallest detectable change was calculated. RESULTS: In total, 19 hypotheses (86.4%) were confirmed. Confirmatory factor analysis showed acceptable fit for the two factor structure of the original FDI (root mean square error of approximation = 0.064, standardized root mean square residual = 0.081, comparative fit index = 0.925, Chi-square = 50.22 with 34 degrees of freedom). Internal consistency for the FDI physical function scale was good (α > 0.720). Internal consistency for the FDI social/well-being scale was slightly less (α > 0.574). Test-retest reliability for both scales was good (intraclass correlation coefficients > 0.786). Smallest detectable change at the level of the individual was 17.6 points for the physical function and 17.7 points for the social/well-being function, and at group level 1.9 points for both scales. CONCLUSION: The Dutch version FDI shows good psychometric properties. The relatively large values for individual smallest detectable change may limit clinical use. The translation and widespread use of the FDI in multiple languages can help to compare treatment results internationally.

Changes in volume and incidence of lymphedema during and after treatment with docetaxel, doxorubicin, and cyclophosphamide (TAC) in patients with breast cancer.

PURPOSES: The purposes of this study were to investigate the incidence of lymphedema in patients with breast cancer during and after adjuvant treatment with docetaxel, doxorubicin, and cyclophosphamide (TAC), to identify predictors for development of lymphedema, and to describe consequences in daily life in relation to lymphedema. METHODS: This is a prospective study with measurements before chemotherapy (T0), during chemotherapy before cycle 2 (T1), cycle 4 (T2), and 1 month after completion of treatment (T3). Volume change was monitored using tape measurements. Lymphedema was defined as ≥ 10% volume difference. Linear mixed-effect models were estimated to analyze differences in arm volume and consequences in daily life (total score and domain scores of the Lymph-International Classification of Functioning (ICF) questionnaire) over time and to identify treatment and patient characteristics as predictors for changes in volume. RESULTS: Forty-eight patients completed all measurements. Volume did not change during TAC treatment. One month after treatment, volume was significantly increased compared to T0-T2, and 12 patients (25%) had developed lymphedema. Axillary lymph node dissection was associated with lymphedema (ES 2.9, 95% CI 0.02-5.7; p < 0.05). In patients with and without lymphedema, 1 month after completion (T3), the Lymph-ICF questionnaire showed significant limitations in physical function compared to T0-T2. In patients with lymphedema at T3, a significant association between volume and total score on the Lymph-ICF questionnaire on physical function and mobility activities was observed. CONCLUSIONS: One month after treatment in 12 patients (25%), volume difference increased over 10%. Axillary lymph node dissection was predictive for development of lymphedema. All patients, but more patients with lymphedema, perceived difficulties in activities in daily life after treatment.

A prospective cohort study assessing differences in cosmetic appreciation of lateralization while smiling in patients with a peripheral facial palsy.

We investigated the differences in cosmetic appreciation of patients with a left and a right peripheral facial palsy (PFP) while smiling. Smiling pictures of patients with a facial palsy with House-Brackmann II-VI were reversed as a mirror image and offered as a pair of pictures, together with the true image. Twenty-six patients with a PFP and 24 medical professionals familiar with facial palsy were asked to choose the most attractive photograph. Patients rated their own pictures. Medical professionals preferred pictures of patients with a right and left PFP in, respectively, a mean of 43.00 ± 12.25% and 57.00 ± 12.28% (p = .005). Patients with a right PFP chose their mirror and true image in 65% and 35% in smiling pictures (p = .01). Patients with a left PFP facial palsy chose their mirror and true image in 58% and 42% in smiling pictures (p = .02). The House-Brackmann score and age of the patients did not influence preferences of medical professionals and patients. We have found that medical professionals have a significant preference for pictures of patients with a left PFP. Patients with a left PFP and right PFP significantly prefer their mirror image in smiling pictures.

Quality of life assessment in facial palsy: validation of the Dutch Facial Clinimetric Evaluation Scale.

This study aimed at validating an existing health-related quality of life questionnaire for patients with facial palsy for implementation in the Dutch language and culture. The Facial Clinimetric Evaluation Scale was translated into the Dutch language using a forward-backward translation method. A pilot test with the translated questionnaire was performed in 10 patients with facial palsy and 10 normal subjects. Finally, cross-cultural adaption was accomplished at our outpatient clinic for facial palsy. Analyses for internal consistency, test-retest reliability, construct validity and responsiveness were performed. Ninety-three patients completed the Dutch Facial Clinimetric Evaluation Scale, the Dutch Facial Disability Index, and the Dutch Short Form (36) Health Survey. Cronbach's α, representing internal consistency, was 0.800. Test-retest reliability was shown by an intraclass correlation coefficient of 0.737. Correlations with the House-Brackmann score, Sunnybrook score, Facial Disability Index physical function, and social/well-being function were -0.292, 0.570, 0.713, and 0.575, respectively. The SF-36 domains correlate best with the FaCE social function domain, with the strongest correlation between the both social function domains (r = 0.576). The FaCE score did statistically significantly increase in 35 patients receiving botulinum toxin type A (P = 0.042, Student t test). The domains 'facial comfort' and 'social function' improved statistically significantly as well (P = 0.022 and P = 0.046, respectively, Student t-test). The Dutch Facial Clinimetric Evaluation Scale shows good psychometric values and can be implemented in the management of Dutch-speaking patients with facial palsy in the Netherlands. Translation of the instrument into other languages may lead to widespread use, making evaluation and comparison possible among different providers.

Cosmetic appreciation of lateralization of peripheral facial palsy: 'preference for left or right, true or mirror image?'.

There have been several studies in the past depicting asymmetry in 'normal' human faces. Evidence supports the fact that the right hemisphere is superior in the recognition of emotions expressed by the human face and indicates a right hemispheric specialization for processing emotional information. The primary aim of this study is to determine whether there is a difference in cosmetic appreciation of a left peripheral facial palsy compared to a right peripheral facial palsy? Pictures of patients with a facial palsy with House-Brackmann II-VI were reversed as a mirror image and offered as a pair of pictures, together with the true image. Forty-two patients and 24 medical professionals familiar with facial palsy were asked to choose the most attractive photograph. The primary 'end' point was the most attractive side in the pictures chosen by medical professionals and patients. The secondary 'end' points consisted of the preferences for the mirror or true image, and influences of the House-Brackmann score and age. Medical professionals preferred the photographs from patients with a right and left peripheral facial palsy (PFP) in, respectively, a mean of 44 % (41-48 %) and 56 % (52-59 %) of the pictures (p = 0.02). When comparing mirror and true image, patients with a left-sided facial palsy chose their mirror and true image as most attractive in 90 and 10 %, respectively (p < 0.05). Patients with a right-sided facial palsy chose their mirror and true image in 30 and 70 %, respectively (p > 0.05). Subanalysis of patients with a PFP House-Brackmann score V and VI showed that medical professionals did not have a significant preference for a left nor right-sided facial palsy. Patients with a left-sided facial palsy chose their mirror image in all cases and patients with a right-sided palsy chose their mirror and true image in resp. 33 and 67 %. The House-Brackmann score (p = 0.52) and age (p = 0.73) of the patients did not influence preferences. This study, demonstrating that medical professionals find a right-sided facial palsy cosmetically less attractive than a left-sided, has clinical relevance. Patients, especially with a left-sided facial palsy, tend to choose for their mirror image, although this choice seems to be influenced by hemispheric specialization and familiarity.

TheraBite exercises to treat trismus secondary to head and neck cancer.

PURPOSE: The aim of this study was to evaluate the effect of TheraBite exercises on mouth opening and to analyze factors influencing this effect in a patient record evaluation. METHODS: Effect of exercises with a TheraBite to treat trismus was evaluated in 69 head and neck cancer patients of two university medical centers. Mouth opening was measured as interincisal distance in millimeters. Patient, tumor, and treatment characteristics were analyzed for their relationship with change in mouth opening. Variables univariately associated (p ≤ 0.05) with change in mouth opening were entered in a logistic regression analysis as possible predictors for an increase in mouth opening of the smallest detectable difference of 5 mm or more. RESULTS: Mean initial mouth opening was 22.0 mm (SD 6.4); mean increase in mouth opening was 5.4 mm (SD 5.7). "Chemotherapy", "medical center", and "time from oncological treatment to start exercises" were significantly associated with an increase in mouth opening. In the logistic regression analysis, "medical center" (ß = 1.97) and "time from oncological treatment to start exercises" reduced the odds of reaching an increase in mouth opening of 5 mm or more, ß = -0.11 per month. CONCLUSIONS: After TheraBite exercises, mouth opening increased averagely with 5.4 mm. The odds of an increase in mouth opening of 5 mm or more reduces if the time from oncological treatment to start exercises lengthens, corrected for the effect of medical center.

Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study.

Background: Nonsurgical rehabilitation of unilateral peripheral facial palsy (FP) varies globally with controversy regarding best practice. Objective: To develop facial therapist consensus regarding what should be included or excluded in rehabilitation of adults with FP of any etiology. Three clinical presentations: flaccid, paretic and synkinetic, were separately considered. Methodology: A two-stage study was conducted: a nominal group technique (NGT) to develop a questionnaire plus Delphi study. Delphi participants were recruited worldwide, through an experience-based inclusion questionnaire. The final Delphi questionnaire included 166 items for each clinical presentation covering assessment, outcome measures, and interventions, for example, education, eye care, neuromuscular retraining, and electrical modalities. Inclusion/exclusion agreement was set at 80%, indicating participant consensus. Items reaching 70-79% were deemed "near-included/near-excluded." Results: Averaged across all presentations, 24.9% of the 166 items were included, (e.g., Sunnybrook Facial Grading System, patient education and neuromuscular retraining), 26.9% of the 166 items were excluded, (e.g., gross strengthening and electrical stimulation); 48.2% were neither included nor excluded. Conclusion: This study brings together the global community's expertise as a first step toward establishing best practice for specialist facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

'Everybody is watching me': A closer look at anxiety in people with facial palsy.

OBJECTIVES: Objectives were to evaluate the sociodemographic and disease-related factors, and coping style associated with social interaction and social appearance anxiety in people with unilateral facial palsy. METHODS: Medical data were extracted from electronic health records, and participants completed the Social Interaction Anxiety Scale (SIAS), Social Appearance Anxiety Scale (SAAS), and Coping Orientation to Problems Experienced inventory. Associations of SIAS and SAAS scores with sociodemographic and disease variables, and coping were assessed with multiple linear regression. RESULTS: Among 111 participants (mean age 58.6 years; 59% women), higher age and greater use of emotion-focused coping were associated with lower SIAS scores, whereas greater use of avoidant coping was associated with higher SIAS scores. Higher age, male sex, and greater use of emotion-focused coping were associated with lower SAAS scores, whereas greater use of avoidant coping was associated with higher SAAS scores. CONCLUSIONS: Healthcare providers should understand that women and younger people are more likely to have social appearance concerns and that this is not predicted by the objective severity of facial palsy.

Oral health and oral health-related quality of life in patients with chronic peripheral facial nerve palsy with synkineses-A case-control-study.

Facial nerve palsy (FP) is the most common cranial nerve lesion, leading to partial or complete immobility of the affected half of face. If food residues on tooth surfaces cannot be removed by natural self-cleaning mechanisms that this is likely to lead to an increase dental plaque formation and the risk of dental, periodontal and general diseases. It was the aim of this study to assess oral health, oral hygiene with the influence of handedness and oral health related quality of life in patients with chronic peripheral FP. This study included 86 people. Patients with FP (n = 43) in an FP-group (FPG) were matched with 43 participants without ever diagnosed FP in a control group (CG). Oral health and oral hygiene were assessed in a clinical examination performed in hospital. Decayed-missing-filled-teeth-index, periodontal-screening-index, approximal plaque index and sulcus bleeding index were used to evaluate dental caries and periodontal health status. Oral health-related quality of life data (OHQoL) was collected with the Oral health impact profile (Germany-14) by interview. Oral health parameters in the FPG were significantly worse than in the CG. The median revealed 14.3% more proximal plaque (p = 0.014), 20.8% more sulcus bleeding (p = 0.002) and more than twice as much caries (p = 0.024). The paretic side compared to the non-paretic side of patients was significantly more affected by inflammatory periodontal diseases (p = 0.032) and had a higher prevalence of caries (p = 0.163). Right-handed patients with right-sided FP performed worse than right-handed patients with left-sided FP (p = 0.004). Patients with FP described a greater limitation of OHQoL than patients without this disease (p < 0.001). In conclusion, facial nerve palsy affects oral health, oral hygiene and OHQoL of patients while handedness influences oral hygiene and oral health.

Psychological counselling in patients with a peripheral facial palsy: initial experience from an expert centre.

BACKGROUND: The aims of this pilot study were to evaluate the psychologist's role on the multidisciplinary team during peripheral facial palsy (PFP) patient care and to identify the potential predictors of anxiety and depressive symptoms/disorders in PFP patients. METHODS: Using the prospective non-controlled study design, PFP patients aged 18-75 years who presented to the Radboud Facial Palsy Expert Centre, the Netherlands, were enrolled during a 1-year interval. The main outcome variables were 1) anxiety and depression in relation to PFP using the Hospital Anxiety and Depression Scale (HADS) and 2) the outcome of psychological counselling in patients with a HADS score ≥ 8. RESULTS: A sample comprised 25 patients (68% females, 56% right-side PFP, 16% House-Brackmann scale I-II) with a mean age of 50 ± 14 years were referred to a psychologist. The proportion of patients with a HADS score ≥8, were 16 (64%) and 13 (52%), respectively. Especially, coping (in general or coping with the disease, 48%) and/or help with the choice of possible surgery (8.0%) were important reasons for counselling. In one case, a patient had chronic fatigue syndrome and was therefore referred to a psychological specialist centre. One patient was treated with acceptance and commitment therapy (ACT) with good results. CONCLUSIONS: Despite a small sample size and limited statistical analyses, the results of this study suggest that one-eighth of the PFP patients require psychological evaluation and treatments. This pilot study emphasises the important role of psychological screening and counselling in PFP patient care.

Cosmetic appreciation and emotional processing in patients with a peripheral facial palsy: A systematic review.

Background; The goal of this review is 1) to summarize the studies assessing PFP by casual observers, patients themselves and the cosmetic appreciation of the PFP and 2) to summarize the studies assessing whether there is a difference in emotional recognition/processing of facial emotions and/or cognitive tasks in patients with a PFP. Materials and Methods; A multi-database systematic literature search was performed using the following databases: Pubmed, Embase, Medline, and The Cochrane Library from the earliest date of each database up to December 2019. Population of interest consisted of patients with a PFP and studies that investigated cosmetic appreciation and/or emotional recognition and/or emotional processing in these patients. Two authors rated the methodological quality of the included studies independently using the 'Newcastle - Ottawa Quality Assessment Scale' for nonrandomised studies' (NOS). Two authors extracted the outcome data regarding cosmetic appreciation and/or emotional recognition/processing from the included studies. Results; Twelve hundred and thirty-two studies were found of which eleven studies met the inclusion criteria. Most studies were assessed to be of 'fair' to 'good' methodological quality. The Cohen's kappa (between author RL and SP) was 0.68. Two studies investigated emotional processing and/or emotional recognition. Nine studies investigated cosmetic appreciation in both patients and casual observers. Important findings of this systematic review are that there is a correlation between the perceived severity of the PFP of the patients and the ratings by casual observers. Secondly there seems to be a laterality difference in cosmetic appreciation and thirdly there might to be a decreased emotional recognition and processing in patients with a PFP. Conclusion; Emotional recognition and cosmetic appreciation in patients with a PFP is an under investigated area, in which further studies are needed to substantiate the findings in current literature.

Association between duration of peripheral facial palsy, severity, and age of the patient, and psychological distress.

BACKGROUND: Peripheral facial palsy (PFP) (paralysis) can be a devastating condition that has been shown to have associations with increased depression and worse quality of life. The aim of the present study is to better understand the complex association of psychological distress with the duration, severity, and age of patients with PFP. We hypothesize that a shorter duration of PFP is associated with higher levels of psychological distress. METHODS: Fifty-nine patients with PFP that existed longer than 3 months were included in this study. The Hospital Anxiety and Depression Scale (HADS) was used to assess the presence and severity of anxiety and depressions. Spearman's correlation analysis was used to determine correlation between psychological distress, duration, severity of the PFP, and age. RESULTS: Fifty-nine patients were included in this study, of whom 22 were male and 37 were female. The mean age was 55.6 ±â€¯14.6 years and mean duration of PFP from onset ranged from 3 months to 35 years (with a mean duration of 5.39 ±â€¯6.06 years). Twenty-eight patients had left-sided PFP, 30 patients had right-sided PFP, and one patient had bilateral PFP. The majority were caused by Bell's palsy (50.8%). In the group with a duration less than 5 years, there were five (12.8%) patients having a score between 11 and 15 (on HADS) compared to two (10%) patients in the group with a duration of 5 years or more(p = 0.04). CONCLUSION: There seems to be an association between moderate depression and duration of the PFP. Further studies need to substantiate our findings.

A closer look at the paralyzed face; a narrative review of the neurobiological basis for functional and aesthetic appreciation between patients with a left and a right peripheral facial palsy.

BACKGROUND: The facial nerve or n. facialis (NVII) is the seventh cranial nerve and it is responsible for the innervation of the mimic muscles, the gustatory organ, and the secretomotor function to the salivary, lacrimal, nasal and palatine glands. Clinical presentation of Facial Palsy (FP) is characterized by unilateral facial asymmetry and may present with a change in taste, decreased saliva production, and dysarthria. A facial palsy has a notable effect on the facial appreciation by both the patient and the environment and also affects quality of life and emotional processing. There appear to be differences in the appreciation of people with a left and right facial palsy. PURPOSE OF THIS REVIEW: The purpose of the review is to give an overview of the anatomy of the facial nerve, neuro-anatomy of face processing, and hemispheric specialization and lateralization. Further,an overview is given of the clinical studies that translated the neuro-anatomical and neurobiological basis of these concepts into clinical studies. What this review adds: This review emphasizes the neurobiological evidence of differences in face processing between the left and right cerebral hemisphere, wherein it seems that the right hemisphere is superior in emotional processing. Several theories are proposed; 1) a familiarity hypothesis and 2) a left-right hemispheric specialization hypothesis. In clinical studies, promising evidence might indicate that, in patients with FP, there is indeed a difference in how left and right FP are perceived. This might give differences in decreased quality of life and finally in occurrence of depression. Further research must aim to substantiate these findings and determine the need for altering the standard therapeutic advice given to patients.

Accuracy of a single measurement site for self-monitoring of patients with breast cancer at risk for lymphedema.

Purpose: Early detection of breast cancer-related lymphedema through simple self-monitoring techniques may lead to early treatment and improved outcomes. Methods: Prospective study of circumference measurements at four time points before, during, and after adjuvant chemotherapy with docetaxel, doxorubicin, and cyclophosphamide. Volume was calculated using the 10-cm interval circumference measurement method (reference test) and percentage difference between arms, for volume and circumference, was determined. First, the most valid single measurement location was determined by calculating Pearson's correlation coefficient relative to the reference test. Second, to evaluate the responsiveness to change over four time points, outcomes of the selected single measurement and the reference test were analyzed by repeated-measures ANOVA. Third, area under the curve (AUC) was used to determine the optimal sensitivity and specificity of the selected single measurement site (index test). Relationship between lymphedema (yes/no) and heaviness and swelling (yes/no) was analyzed using phi-coefficient. Results: The measurement point 30 cm proximal to the styloid process showed the highest correlation with percentage difference in total arm volume (r = 0.80) and detected increased percentage difference between arms after treatment. Analyses showed high accuracy (AUC = 0.94; 95% CI 0.90-0.99) and good sensitivity (0.85) and specificity (0.85) using a cutoff score of 4% circumference difference between arms at this location. A moderate correlation between feelings of heaviness and swelling to lymphedema was observed (rφ = 0.64). Conclusions: Circumference difference between arms of 4% measured at 30 cm proximal to the styloid process can be used as a surveillance site for further monitoring of patients at risk for lymphedema and may contribute to early diagnosis. Feelings of heaviness or swelling have moderate relationship with lymphedema, which needs to be confirmed in clinical practice.

An International Collaborative Standardizing Patient-Centered Outcome Measures in Pediatric Facial Palsy.

IMPORTANCE: Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population. OBJECTIVE: To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives. DESIGN, SETTING, AND PARTICIPANTS: A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016. MAIN OUTCOMES AND MEASURES: The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention. RESULTS: The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy-reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy. CONCLUSIONS AND RELEVANCE: This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy. LEVEL OF EVIDENCE: NA.

The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study.

BACKGROUND: Many patients suffer from severe shoulder complaints after breast cancer surgery and axillary lymph node dissection. Physiotherapy has been clinically observed to improve treatment of these patients. However, it is not a standard treatment regime. The purpose of this study is to investigate the efficacy of physiotherapy treatment of shoulder function, pain and quality of life in patients who have undergone breast cancer surgery and axillary lymph node dissection. METHODS: Thirty patients following breast cancer surgery and axillary lymph node dissection were included in a randomised controlled study. Assessments were made at baseline and after three and six months. The treatment group received standardised physiotherapy treatment of advice and exercises for the arm and shoulder for three months; the control group received a leaflet containing advice and exercises. If necessary soft tissue massage to the surgical scar was applied. Primary outcome variables were amount of pain in the shoulder/arm recorded on the Visual Analogue Scale, and shoulder mobility (flexion, abduction) measured using a digital inclinometer under standardized conditions. Secondary outcome measures were shoulder disabilities during daily activities, edema, grip strength of both hands and quality of life. The researcher was blinded to treatment allocation. RESULTS: All thirty patients completed the trial. After three and six months the treatment group showed a significant improvement in shoulder mobility and had significantly less pain than the control group. Quality of life improved significantly, however, handgrip strength and arm volume did not alter significantly. CONCLUSION: Physiotherapy reduces pain and improves shoulder function and quality of life following axillary dissection after breast cancer.

Quality of life before and after different treatment modalities in peripheral facial palsy: A systematic review.

OBJECTIVES: A systematic review was conducted to investigate the effect of peripheral facial palsy (PFP) on the quality of life (QoL). Secondly, we investigated if different treatment modalities influence the QoL of patients with PFP. METHODS: A multidatabase systematic literature search was performed using the following databases: PubMed, Embase, MEDLINE, and The Cochrane Library from the earliest date of each database up to August 2015. The inclusion criteria were either prospective and/or retrospective cohort trials and/or case series measurement of QoL before and after treatment, patients with PFP (irrespective of etiology), and various treatment modalities (medication, physical therapy, botulinum toxin injections, and several types of surgical procedures). Two authors rated the methodological quality of the included studies independently using the Newcastle-Ottawa Quality Assessment Scale for nonrandomized studies. RESULTS: Two hundred fifty-eight studies were found, of which 14 studies met the inclusion criteria. Most studies were assessed to be of fair to good methodological quality. The Cohen's κ (between author r.e.l. and s.p.) was 0.68. Eight different questionnaires were used to measure QoL, of which the Facial Clinimetric Evaluation scale was used most frequent. After different modalities, all studies showed significant improvements in terms of QoL. CONCLUSIONS: This study found significant improvement when measuring QoL before and after different treatment modalities in patients with peripheral facial palsy. Future research should focus on patients with PFP due to the same etiology and use of valid QoL instruments for outcome measures. Laryngoscope, 127:1044-1051, 2017.

Depth accuracy of the RealSense F200: Low-cost 4D facial imaging.

The RealSense F200 represents a new generation of economically viable 4-dimensional imaging (4D) systems for home use. However, its 3D geometric (depth) accuracy has not been clinically tested. Therefore, this study determined the depth accuracy of the RealSense, in a cohort of patients with a unilateral facial palsy (n = 34), by using the clinically validated 3dMD system as a gold standard. The patients were simultaneously recorded with both systems, capturing six Sunnybrook poses. This study has shown that the RealSense depth accuracy was not affected by a facial palsy (1.48 ± 0.28 mm), compared to a healthy face (1.46 ± 0.26 mm). Furthermore, the Sunnybrook poses did not influence the RealSense depth accuracy (p = 0.76). However, the distance of the patients to the RealSense was shown to affect the accuracy of the system, where the highest depth accuracy of 1.07 mm was measured at a distance of 35 cm. Overall, this study has shown that the RealSense can provide reliable and accurate depth data when recording a range of facial movements. Therefore, when the portability, low-costs, and availability of the RealSense are taken into consideration, the camera is a viable option for 4D close range imaging in telehealth.

Worldwide Testing of the eFACE Facial Nerve Clinician-Graded Scale.

BACKGROUND: The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement. METHODS: Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user. RESULTS: eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement. CONCLUSIONS: The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.