Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research.

OBJECTIVE: The "Summary of Japanese clinical practice guidelines for Bell's palsy (idiopathic facial palsy) - 2023 update edited by the Japan Society of Facial Nerve Research" aims to review the latest evidence regarding the treatment of Bell's palsy and to provide appropriate recommendations. METHOD: Regarding the treatment of Bell's palsy, a guideline panel identified key clinical questions using an analytic PICO framework. The panel produced recommendations following the standards for trustworthy guidelines and the GRADE approach. The panel considered the balance of benefits, harm, and preferences when making recommendations. RESULTS: The panel identified nine key clinical questions: systemic (high/standard dose) corticosteroids, intratympanic corticosteroids, systemic antivirals, decompression surgery, acupuncture, physical therapy, botulinum toxin, and reanimation surgery. CONCLUSION: These guidelines strongly recommend systemic standard-dose corticosteroids for the clinical management of Bell's palsy. Other treatments are weakly recommended due to insufficient evidence. The absolute risk reduction of each treatment differed according to the disease severity. Therefore, physicians and patients should decide on treatment based on the disease severity.

Physical therapy for peripheral facial palsy: A systematic review and meta-analysis.

OBJECTIVE: This study aimed to reveal the efficacy of physical therapy for patients with peripheral facial palsy. METHODS: A literature search was conducted using PubMed, Ichushi-Web, and Cochrane Central Register of Controlled Trials. Published randomized controlled trials comparing the physical therapy versus placebo/non-treatment for peripheral facial palsy such as Bell's palsy, Ramsay Hunt syndrome, and traumatic facial palsy were included for meta-analysis. The primary outcome was non-recovery at the end of the follow-up. Non-recovery was defined according to the authors' definition. The secondary outcomes were the composite score of the Sunnybrook facial grading system and sequelae (presence of synkinesis or hemifacial spasm) at the end of the follow-up. Data was analyzed using Review Manager software and pooled risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated. RESULTS: Seven randomized controlled trials met the eligible criteria. The data on non-recovery from four studies was obtained and included 418 participants in the meta-analysis. Physical therapy might reduce non-recovery (RR = 0.51 [95% CI = 0.31-0.83], low quality). Pooling the data of composite score of the Sunnybrook facial grading system from three studies (166 participants) revealed that physical therapy might increase the composite scores (MD = 12.1 [95% CI = 3.11-21.0], low quality). Moreover, we obtained data on sequelae from two articles (179 participants). The evidence was very uncertain about the effect of physical therapy on reduction of sequelae (RR = 0.64 [95% CI = 0.07-5.95], very low quality). CONCLUSION: The evidence suggested that physical therapy reduces non-recovery in patients with peripheral facial palsy and improves the composite score of the Sunnybrook facial grading system, whereas the efficacy of physical therapy in reducing sequelae remained uncertain. The included studies had high risk of bias, imprecision, or inconsistency; therefore, the certainty of evidence was low or very low. Further well-designed randomized controlled trials are needed to confirm its efficacy.

Inhibitors of Early Mobilization in the Acute Phase of Intracerebral Hemorrhage: A Retrospective Observational Study.

OBJECTIVES: The association between early mobilization and functional prognosis in the acute phase of intracerebral hemorrhage has been reported, but only a few studies have investigated the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. This study aimed to investigate the inhibitors of early mobilization. MATERIALS AND METHODS: The study enrolled 322 patients with intracerebral hemorrhage. In the early mobilization group, mobilization was started within 72 h from onset, and in the delayed mobilization group, mobilization was started at or after 72 h from onset. The association between the start of mobilization timing and baseline characteristics was investigated using univariate and multivariate analyses to clarify the inhibitors of early mobilization in the acute phase of intracerebral hemorrhage. RESULTS: Significant differences between the early mobilization and delayed mobilization groups were observed in the lesion site, leukocyte count at admission, neutrophil count at admission, C-reactive protein level at admission, surgery, use of mechanical ventilation, consciousness level at admission, hematoma volume, and hematoma growth. In the multiple logistic regression analysis, five items were adopted, namely, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein at admission, and hematoma growth. CONCLUSIONS: In this study, low consciousness level at admission, lesion below the tent, surgery, C-reactive protein level at admission, and hematoma growth affected delayed mobilization. Therefore, it is recommended to judge the start of mobilization timing by a systematic evidenced-based assessment for each case.

Association between out-of-bed mobilization and complications of immobility in acute phase of severe stroke: A retrospective observational study.

BACKGROUND: Medical complications often occur, particularly in the acute phase of severe stroke, and lead to poor outcomes. However, it is unclear whether out-of-bed mobilization (OM) reduces such complications or not in the acute phase of severe stroke. Thus, we investigated the association between OM and complications of immobility in the acute phase of severe stroke. METHODS: We enrolled 407 patients diagnosed with ischemic stroke or intracerebral hemorrhage and patients with modified Rankin Scale 5 at discharge in this study. Patients were divided into two groups: OM (303 patients) and bed rest (BR; 104 patients) at discharge based on their medical records. Complications of immobility (such as pneumonia, urinary tract infection, pressure sore, and falls) during hospitalization in each group were recorded. RESULTS: The total complication rate of immobility, incidence of pneumonia, and the incidence of pressure sores were significantly lower in the OM group than in the BR group [60.7% vs. 88.5%, 45.5% vs. 62.5%, and 3.6% vs. 12.5%; odds ratio, 0.20, 0.50, and 0.26; and 95% confidence intervals, 0.11-0.39, 0.32-0.79, and 0.11-0.61, respectively]. Urinary tract infection and falls did not differ significantly between the two groups. CONCLUSIONS: In the acute phase of severe stroke, OM was significantly associated with a lower risk of total complication rate of immobility, incidence of pneumonia, and incidence of pressure sore without increasing falls.

Effect of muscle strengthening on peripheral facial palsy: A randomized controlled trial.

OBJECTIVE: To evaluate the effect of muscle strengthening intervention in peripheral facial palsy (PFP). METHODS: A randomized controlled trial was conducted at five hospitals. Fifty-one subjects with PFP who showed a response of less than 20% on electroneurography (ENoG) were enrolled. Subjects in a muscle-strengthening-intervention group (MS Group) underwent a selective muscle contraction intervention (SMCI). Subjects in another group not receiving muscle strengthening intervention (Non-MS Group). Both groups underwent three interventions: Prohibition of maximum effort movements, Stretching of the affected facial muscles, and Mirror biofeedback therapy. The outcomes were measured by the Sunnybrook Facial Grading System (FGS) at 6 months after onset (primary endpoint) and at 12 months after onset (secondary endpoint). The subjects in the MS Group and Non-MS Group were further divided into subgroups showing ENoG responses of 10% or less and ENoG responses of over 10%, as a sub-analysis. RESULTS: No significant differences between the MS Group and Non-MS Group at either the primary endpoint or secondary endpoint. Among the subjects in the treatment group with an ENoG response of over 10% at the primary endpoint, the FGS Composite Score and FGS Voluntary Movement score were both significantly higher in the MS Group than in Non-MS Group. Although the MS Group had a significantly lower FGS Resting Symmetry Score, there was no significant difference between the two groups in the FGS Synkinesis Score. CONCLUSIONS: SMCI improved paralysis in subjects exhibiting an ENoG response of over 10% within the 6 months from onset without any deterioration of synkinesis.

Prognostic factors of synkinesis after Bell's palsy and Ramsay Hunt syndrome.

OBJECTIVE: This study evaluated the prognostic factors of synkinesis following Bell's palsy and Ramsay Hunt syndrome. METHODS: A total of 345 patients consisting of 309 cases of Bell's palsy and 36 cases of Ramsay Hunt syndrome were enrolled in our study. The following 13 factors were considered as candidate prognostic factors for the presence of synkinesis at 6 months from onset: age, sex, diagnosis, diabetes mellitus, initial onset or recurrence, electroneurography (ENoG), number of days from onset to first visit to our hospital, the lowest Yanagihara grading system score, the change in Yanagihara score after 1 month, otalgia, hearing loss, vertigo and taste disturbances. These factors were analyzed by logistic regression. RESULTS: Logistic regression analysis clarified the lowest Yanagihara score, the change in Yanagihara score after 1 month, and the ENoG value for a prognosis of synkinesis. The most predictive prognostic factor was the lowest Yanagihara score, and the adjusted odds ratio in the multivariate model was 11.415. As for other prognostic factors, the adjusted odds ratios ranged from 7.017 (ENoG value) to 8.310 (the change in Yanagihara score after 1 month). These findings were therefore considered as high risk factors for synkinesis. CONCLUSION: It is possible to predict synkinesis following Bell's palsy and Ramsay Hunt syndrome on the basis of clinical symptoms. The lowest Yanagihara score, and the change in Yanagihara score after 1 month, together with the ENoG value at the onset, were found to be especially important factors for predicting synkinesis following Bell's palsy and Ramsay Hunt syndrome.

The influences of Halo-vest fixation and cervical hyperextension on swallowing in healthy volunteers.

STUDY DESIGN: Radiographic and electromyographic evaluation of swallowing functions was performed for different positions with a Halo-vest brace. OBJECTIVES: The aim of this study was to clarify the mechanism of dysphagia of cervical hyperextension with a Halo-vest brace in neurologically normal adult volunteers. SUMMARY OF BACKGROUND DATA: Garfin et al reported that 3 of 179 patients had dysphagia attributable to the Halo-vest brace after cervical spinal cord injury. Readjustment of the position of the head in the Halo-vest brace was required in those cases. They concluded that the head-extended position with a Halo-vest brace made it difficult to swallow. However, the details of this dysphagia were not known. METHODS: Six healthy adults volunteers between the ages of 24 and 33 participated in this study. Subjects were radiographically and electromyographically observed swallowing thin liquids at the neutral position without a Halo-vest brace (N-HV), the neutral position with a Halo-vest brace (N+HV) and at hyperextension with a Halo-vest brace (E+HV). RESULTS: In the durational measurements, there were significant changes between the N-HV and E+HV in pharyngeal transit time. The motion measurements showed that the initial hyoid position placed lower from the mandibular plane, and vertical hyoid movement was prolonged in the E+HV. In the electromyographic measurements, greater activity was observed from the suprahyoid muscles in the E+HV. One subject had laryngeal penetration already in the N-HV, and the same subject exhibited aspiration in the E+HV. Another two subjects exhibited penetration in the E+HV. CONCLUSION: The result of this study demonstrated that cervical hyperextension with the Halo-vest brace caused mechanical changes in the swallowing of normal healthy adult volunteers.