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Comparison of efficacy of Kabat
rehabilitation and facial exercises
along with nerve stimulation in
patients with Bell’s palsy
Website:
www.bldeujournalhs.in Kanwal Khanzada, Muhammad Junaid Ijaz Gondal, Muhammad Mustafa Qamar1,
DOI:
Ayesha Basharat1, Waqas Ahmad1, Sajid Ali2
10.4103/bjhs.bjhs_35_17

Abstract:
OBJECTIVES: The aim of this study is to compare the role of Kabat rehabilitation and facial exercise
techniques with nerve stimulation common in both for Bell’s palsy treatment and its effectiveness
in improving physical and social function.
MATERIALS AND METHODS: A randomized control trial conducted at the Department of
Physiotherapy, Mayo Hospital, Lahore. Two equal Groups (A and B) consist of 26 patients each.
Patients were employed Kabat rehabilitation technique in GroupA and with facial exercise in
Group‑B. Patients in both treatment groups were followed until 3 weeks and improvement in
Sunnybrook facial grading scale (SFGS) and facial disability index (FDI) scale were recorded at
the end of treatment.
RESULTS: In this study, 52 patients were enrolled into the study. At the end of 3 weeks, more
improvement was seen in SFGS in Group‑A (81.58 + 11.321) versus Group‑B (63.77 + 21.645).
Similarly, the improvement in physical and social function on FDI in Group‑A was more than
Group‑B (>0.05).
CONCLUSION: Kabat technique is more effective as compared to facial exercise technique in
improving physical and social function.
Keywords:
Bell’s palsy, electrical stimulation, facial exercises, Kabat rehabilitation

Department of
T wo centuries ago in 1798 Nicolaus A
Friedrich first described the term Bell’s
palsy.[1] In 1821, Sir Charles Bell described
incidence in the females was higher during
pregnancy.[6]
Physiotherapy, Mayo
Hospital Lahore, it the first time.[2] Bell’s palsy is an acute Bell’s palsy results in facial muscles
KEMU, 2Department of condition which occurs due to damage of paralysis on the affected side of the
Physiotherapy, Riphah face. The symptoms differ in every
College of Rehabilitation
facial nerve along its course at the level
Sciences, RIU, Lahore, distal to Pons. It is an idiopathic facial individual rages from mild‑to‑severe.
1
Department of condition. [3] The peak incidence of the Symptoms include voluntary loss of facial
Physiotherapy, Sargodha disease was between age 25–50 years.[4] A movements unilaterally and bilaterally
Medical College, UOS, in rare cases, resting asymmetry due
Sargodha, Pakistan
study showed that above age of 60 years
occurrence of Bell’s palsy was high in to muscle weakness eyelid drooping,
Address for people having a history of diabetes hyperacusis, painful auricle area, and
correspondence: and hypertension. [5] Although Males taste changes.[7] Thus, long‑lasting Bell’s
Dr. Muhammad Mustafa and females are equally affected, the palsy had a damaging effect on the
Qamar,
Department of
individual physical and social lifestyle.
Physiotherapy, Sargodha This is an open access journal, and articles are distributed Functionally, the ability of drinking,
Medical College, UOS, under the terms of the Creative Commons Attribution-
Sargodha, Pakistan. NonCommercial-ShareAlike 4.0 License, which allows others to How to cite this article: Khanzada K, Ijaz Gondal MJ,
E‑mail: mmustafaqamar@ remix, tweak, and build upon the work non-commercially, as Qamar MM, Basharat A, Ahmad W, Ali S. Comparison
gmail.com long as appropriate credit is given and the new creations are of efficacy of Kabat rehabilitation and facial exercises
licensed under the identical terms. along with nerve stimulation in patients with Bell's
Submission: 08‑11‑2017 palsy. BLDE Univ J Health Sci 2018;3:31-5.
Accepted: 30-04-2018 For reprints contact: reprints@medknow.com

© 2018 BLDE University Journal of Health Sciences | Published by Wolters Kluwer - Medknow 31
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Khanzada, et al.: Kabat technique can improve physical and social function in patients with bells palsy
eating, and expressing oneself (verbally/nonverbally)
can be greatly disturbed. The psychosocial impact
of such a disorder can be life‑altering. Bell’s palsy is
the most common cause of facial paralysis. Usually,
the symptoms resolve completely; however, some
patients continue to suffer for a longer period. Poor
prognosis was seen in case of complete facial palsy, in
case of symptoms not recovered by 3 weeks, people
with >60 years of age, worst pain, herpes zoster
virus, different disease conditions, for example,
hypertension, diabetes, pregnancy, and in the case of
severe degeneration of facial nerve which is shown by
electrophysiological testing.[8]
Treatment option may include dose trial of
anti‑inflammatory, antibiotic, or antiviral agents and
in severe cases, surgical decompressive procedures
may be considered.[8] In addition to this treatment
option of Bell’s palsy, physiotherapy has been reported
to have a wide range of benefit in treating Bell’s
palsy.[9,10] Physiotherapy maintained the facial muscle
tone and stimulated neural transmission of facial
nerve and thus beneficial for Bell’s palsy patients. As
bells’ palsy is self‑limiting, but even in this scenario,
physical therapy techniques which emphasize on
soft‑tissue and muscle re‑education should be applied
to avoid muscle wasting or soft‑tissue contracture
formation.[11] Sunnybrook facial grading scale (SFGS)
was used to quantify the resting and voluntary
muscles symmetry.[12] The physical and social function
of patients were assessed using facial disability
index (FDI).[13]
The study focused on evaluating the resting and
voluntary muscles symmetry and improving physical
and social function before and after treatment.
Materials and Methods
Study design
A randomized case‑control trial was in 3  weeks.
A  total of 52  patients were included in this study
aged of 25–50 years male and female, with Bell’s
palsy, having unilateral facial paralysis, with the
nontraumatic onset and no other neurological deficit.
Patients were divided into two groups randomly, each
group contained 26 patients. In Group A, patients were
treated with Kabat rehabilitation technique along with
nerve stimulation whereas in Group‑B, Patients were
treated with facial exercises technique along with nerve
stimulation.
Methodology
After informed consent, all the patients were selected.
Group A patients were treated with Kabat rehabilitation
technique and nerve stimulation, for 3 weeks. Kabat
32 BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018
rehabilitation mainly facilitates the voluntary feedback
of a dysfunctional muscle through the global pattern
of a muscle that undergoes resistance.[14] After 3 weeks,
resting and voluntary symmetry were recorded. In
Group‑B, patients were treated with facial exercise
technique and nerve stimulation for 3 weeks. The patients
were also reassessed after 3 weeks. The improvement in
resting and voluntary symmetry was recorded by SFGS
and FDI.
Data analysis
SPSS 21 statistical software was used to analyze the
data. Quantitative variables were presented as mean
and SD while qualitative variables were presented with
the percentages, frequency tables, and appropriate
graphs. Association between qualitative data was found
by independent sample t‑test. Paired sample t‑test was
used to see improvement in SFGS and FDI in both
groups. Value of P < 0.05 was considered as statistically
significant.
Results
Descriptive statistics
In Group A, the mean age of patients was 35.85 ± 8.46 years,
and in Group‑B, patients was 36.38 ± 8.34 years. Out
of 26  patients in Group‑A, 20  (76.92%) patients were
female and 6 (23.08%) patients were male. In Group‑B,
18 (69.23%) patients were female and 8 (30.77%) patients
were male.
Comparison of pre‑ and post‑sunnybrook facial
grading scale in both groups
It was detected that patients treated with Kabat
technique, their resting symmetry, and symmetry of
voluntary movements on SFGS were improved VS facial
exercises technique [Figure 1].
Comparison of pre and post‑physical function on
facial disability index
At the 3rd week, the patients treated with Kabat technique
their physical function on FDI was improved VS facial
exercises technique. It was observed that patients treated
with Kabat technique their social function and physical
function on FDI was improved VS facial exercises
technique after the study period [Figure 2].
Discussion
Bell’s palsy is an acute condition which occurs
due to damage in the course of facial nerve at the
level distal to the pons. It is an idiopathic facial
condition.[3] Treatment option may include dose trial of
anti‑inflammatory, antibiotic, or antiviral agents and in
severe cases, surgical decompressive procedures may
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Khanzada, et al.: Kabat technique can improve physical and social function in patients with bells palsy
Figure 1: Sunnybrook facial grading scale score in Kabat and facial exercise group
at baseline and post study
be considered.[9] In addition, this treatment option of
Bell’s palsy, physiotherapy has been reported to have
a wide range of benefit in treating Bell’s palsy.[6,10] The
purpose of the current study was to compare the role
of Kabat rehabilitation and facial exercise techniques
in the treatment of Bell’s palsy and its possible effect in
improving physical and social function.
In this research study, 52 patients were taken. In
Group‑A  (n  =  26), Kabat rehabilitation technique
along with nerve stimulation was done on patients. In
Group‑B (n = 26), facial exercises were performed along
with nerve stimulation. Patients were included randomly
in these two groups using blind concealment method.[15]
Pretest measurements were taken before and after the
intervention with the help of SFGS and FDI. Paired
sample t‑test shows significant improvement (P = 0.00)
in both study groups. The comparison of SFGS scores
and FDI scores for pretreatment and posttreatment
also revealed significant improvement (P  =  0.00) in
treating Bell ’s palsy and improving physical and social
function in both study groups. The result shows both
the treatment techniques, Kabat rehabilitation, and facial
exercises were effective regarding treating Bell’s palsy
and increasing physical and social function as there was
no significant difference between the two groups.
Independent t‑test is applied to compare two techniques.
Pretreatment values for SFGS score and FDI varied
insignificantly across the two treatment group with
P > 0.05; however, by the end of the treatment sessions,
there were significant differences between the two study
groups with value of P < 0.05 and Thus, it shows that
both techniques statistically significant; however, their
mean difference shows that Kabat technique is clinically
superior to facial exercise technique in treating Bell’s
palsy and improving physical and social function of
patients. Thus, according to my research, it is concluded
that nerve stimulation with Kabat techniques was found
BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018 33
Figure 2: Facial disability index score in Kabat and facial exercise group at
baseline and post study
to be more effective than the nerve stimulation with
facial exercises in patients with Bell’s palsy and this is
in agreement with the previous study.[16]
Barbara conducted a study on the effects of Kabat
rehabilitation in patients affected by Bell’s palsy, shows
that the clinical outcomes of patients improved and
they show better and faster recovery.[16] A study was
carried out on the effectiveness of neuro‑proprioceptive
facilitation on re‑education facial muscles and functional
problems in Bell’s palsy. The results showed that
recovery from facial paralysis could be difficult and
long‑lasting process and the utilization of a grading
system may help the physical therapist. The effect of this
type of therapy may help the patients if the therapist is
well trained and familiar with the neuro‑physiological
background.[17] A research was conducted to determine
the effects of neuromuscular retraining in case of
facial nerve paresis. This shows that it is an effective
technique for optimal recovery due to paralysis. Facial
neuromuscular retraining improves the facial muscular
control using special movement training techniques is
based on evidence and therapeutic practice.[18]
Retraining techniques enhanced outcomes and develop
patient satisfaction by treating the condition in a
programmed way. It focuses on improving range,
flaccidity, prevents synkinesis, and improves facial
motor control. [19] Facial neuromuscular retraining
technique using both sensory and motor feedback.
It utilizes sensory feedback along with coordinated
movement activities are done to facilitate and return
the correct facial movement patterns, and all the
undesired, unwanted, and abnormal facial expressions
are inhibited.[18]
Clinical observation on exercise comprehensive therapy
for treating Bell’s palsy shows that: The exercise
comprehensive therapy has significant effects in treating
Bell’s palsy.[20] A reliable method of grading is needed
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Khanzada, et al.: Kabat technique can improve physical and social function in patients with bells palsy
like SFGS is a well‑established tool for assessing facial
movement outcomes.[12] This tool provides a quantitative
score for reporting purposes and thus easily administer
and clinically relevant. It is very sensitive and specific
and can detect clinically important change over time
or with treatment. It uses five standard expressions to
examine the different region of face separately.[21]
In 2007, Yeo and Lee suggested that 96% of Bell’s palsy
recovered spontaneously.[22] In a study done by Lars
Thomander and Erik Stalberg, their result showed that
only in case of temporary conduction block the early
improvement of the clinical and electrophysiological
function by the use of many physical therapy techniques
take place. [23] Facial exercises are also helpful in
improving facial functions and are also evident from
many studies.[24] The brain‑to‑nerve‑to‑muscle routine is
recreated during facial exercises. The goal is to mentally
focus on muscles actions while during voluntary
movements. The emphasis on correct movements
should be done. After practicing many times, these
movements may finally become automatic and natural
movements which we called as expressions by using the
motor learning phenomenon. The exercises can be very
beneficial; although, it is a slow process. Physiotherapy
maintained the facial muscle tone and stimulated neural
transmission of facial nerve and thus beneficial for Bell’s
palsy patients.[11]
Diels reported that in the early phase of Bell’s palsy if one
apply electrical stimulation to the facial muscles, then it
causes interference in neural regeneration and slower
the recovery and thus should be avoided in this phase.
He believes but provides no evidence.[25] However, Kidd,
Tallis, and Targan contradict this report and believes that
by applying electrical stimulation recovery is fast as it
speeds up the regeneration process of the facial nerve.[14]
A randomized clinical trial was taken to determine
the effectiveness of proprioceptive neuromuscular
facilitation  (PNF) technique, and neuromuscular
re‑education for reducing facial disability and prevent
synkinesis in patients of Bell’s palsy and the results show
that both the techniques are statistically significant. Both
the treatment groups showed improvements resting and
voluntary muscles symmetry when they were assessed
after 4 weeks follow‑up. The results also showed that
both the techniques are effective but in different domains
as neuromuscular retraining technique when applied
along with conventional PT is effective in preventing
synkinesis; however, PNF technique when done with
conventional PT is effective in reducing facial disability
and improving facial functions.[23]
The study was conducted on determining the effectiveness
of PNF training on the facial profile. We employed PNF,
in which global stretching and resistance is applied
34 BLDE University Journal of Health Sciences - Volume 3, Issue 1, January-June 2018
one after the other to improve voluntary contraction of
damaged muscles and then, its actions are enhanced by
resistance applied through verbal input and manually,
such as lifting upper lip and lowering lower lip move
the tongue out, to adapt the perioral muscles to the new
morphological circumstances. Although the training
appeared to be effective as it improves facial profile by
sharpening the mouth and submandibular region, the
results showed that continued training is necessary to
avoid relapse.[13]
Conclusion
Kabat rehabilitation technique along with nerve
stimulation is more effective in treating Bell’s palsy
as compared to facial exercise technique along with
nerve stimulation. SFGS and FDI scale showed higher
improvement in patients who were treated with Kabat
technique. However, both techniques showed significant
improvement in both treatment groups.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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