1. Recent advances in grading facial nerve function have led to the development of several new grading systems to improve on existing scales like the House-Brackmann Grade Scale (HBGS).
2. The Movement, Rest, Secondary defects, and Subjective scoring (MoReSS) system aims to improve reproducibility over HBGS by separately assessing dynamic and static components as well as secondary defects.
3. The Facial Nerve Grading System 2.0 (FNGS 2.0) incorporates regional scoring of facial movement to provide additional information while maintaining agreement with the original HBGS. It also addresses ambiguities in use.
4. The Gordon Facial Muscle Weakness Assessment
Provides information concerning gravity, rotation and acceleration
Serves as a reference for the somatosensory & visual systems
Contributes to integration of arousal, conscious awareness of the body via connections with vestibular cortex, thalamus and reticular formation
Provides information concerning gravity, rotation and acceleration
Serves as a reference for the somatosensory & visual systems
Contributes to integration of arousal, conscious awareness of the body via connections with vestibular cortex, thalamus and reticular formation
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
This presentation give an upto date insightful information on balance/postural assessment and key domains of Occupational Therapy during assessment of balance using different scales.
A motor point is a specific skin area where the targeted muscle is best stimulated with the smallest amount of current amplitude and the shortest pulse duration
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
Crocodile Tears Syndrome (Bogorad's Syndrome) is a condition that usually occurs during recovery of Bell's palsy. Synkinesis of the facial nerve is responsible for the symptoms (crying instead of salivating, salivating while crying, etc.).
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
This presentation give an upto date insightful information on balance/postural assessment and key domains of Occupational Therapy during assessment of balance using different scales.
A motor point is a specific skin area where the targeted muscle is best stimulated with the smallest amount of current amplitude and the shortest pulse duration
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
Crocodile Tears Syndrome (Bogorad's Syndrome) is a condition that usually occurs during recovery of Bell's palsy. Synkinesis of the facial nerve is responsible for the symptoms (crying instead of salivating, salivating while crying, etc.).
Facial nerve traumatic injury and repairsarita pandey
knowledge of anatomy of facial nerve is essential for ENT practitioner,
the worldwide acknowledged high trauma in south africa often results in head and neck injuries, resulting in facial nerve injury
summary of the anatomy, classifications of injuries, and management principles touched upon
indepth surgical procedures out of scope of this slideshow
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Correlation of Objective Assessment of Facial Paralysis with House-Brackmann ...TELKOMNIKA JOURNAL
This article illustrated a brief review of some objective methods in assessing facial nerve function
for facial nerve paralysis which were correlated with House-Brackmann Grading System (HBGS). A
rigorous search of online databases such as Springer, Elsevier and IEEE was conducted from June, 2015
to November, 2016 to discover and analyze the previous works in facial nerve assessment methods for
facial paralysis. Several domains such as facial grading system and methods used to evaluate the facial
nerve function were extracted for further analysis. Different keywords were used to acquire the studies
based on the desire criteria. A total of 8 articles were identified and were analyzed for inclusion in this
search. In conclusion, this review has presented an initial overview for further improvements in objective
facial nerve assessment which has to be correlated with subjective assessment to make it more reliable
and useful in clinical practice.
Precision and follow up scans in bone densitometryRamin Sadeghi
The current presentation is a brief overview of precision and follow up scans in BMD with especial attention to least significant change and Z-score changes in children
CCM Journal Club: Vasopressin-Epinephrine-Steroids for in hospital cardiac ar...Hon Liang
Mayo Critical Care Journal Club (15 Dec 2014). RCT: Vasopressin, Steroids, and Epinephrine and Neurologically Favorable Survival After In-Hospital Cardiac Arrest. JAMA 2013.
Learning Effect and Test-Retest Variability in Healthy Subjects and Patients ...inventionjournals
Aim: To study learning effect (LE) and test retest variability (TRV) in healthy subjects and patients with primary open angle glaucoma (POAG) using Rarebit perimetry (RBP). To determine normative ranges of RBP. Methods: 61 eyes of 35 subjects underwent visual field testing with standard automated perimetry (SAP) and RBP. TRV and LE were assessed in repeated examinations conducted in 3 different days. First two examinations were conducted within 3 days and the last one within one month. LE was assessed by comparing results from the three sessions. TRV was evaluated by calculating differences between retest for each combination of single tests. To determine normative ranges of RBP were included 34 eyes of 21 healthy subjects and 62 eyes of 47 subjects with preperimetric and early POAG. Cut off value was determined between the two groups using ROC analysis. Results: No significant LE was observed in POAG group. There was a significant LE in the control group but only in the visual field zones with eccentric location. TRV was higher in POAG group and in central visual field zone. The mean MHR in control group was 94.88 (SD 2.21) and 83.56 (SD 6.95) in POAG group. Cut off value for discriminating between healthy subjects and patient with POAG was 91.50% with AUROC 0.985 (p<0.001, ROC analysis). Conclusion: RBP is fast and easy to perform test. RBP testing did not show a significant LE in glaucoma group, however, TRV was consistent. MHR can be successfully used for differentiation of healthy eye from those with early glaucoma changes.
Raj2 /certified fixed orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
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New Strategies to Improve Outcomes and Quality of Life After a Concussion Cognitive FX
Dr. Mark Allen, Ph.D., and Dr. Alina Fong Ph.D. presented during the Pink 4 conference in Rome, Italy in September 2017. Exploring new strategies, such as EPIC Treatment, to treat concussions and lasting concussion symptoms by understanding and addressing the core problem, the impairments in the brain.
For more information please visit: www.cognitivefxusa.com or contact us at info@cognitivefxusa.com or 385-375-8590.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
2. • Development of a uniform and accurate method for
grading facial nerve function is a prerequisite for effective
diagnosis and treatment of patients with facial nerve
paralysis.
• Facial nerve anatomy is complex, and its unique
physiology poses special challenges in grading facial
nerve function following injury.
Seminars in plastic surgery 2004:18;1-21
3. An ideal grading system would be a well-
calibrated instrument that is convenient to use.
• universality and reproducibility with low interobserver
variability;
• Incorporation of measures of both static and dynamic
components of facial muscle function;
• Regional scoring;
4. • acknowledgement of the secondary defects of facial
nerve dysfunction;
• subjective scoring by the patient; and
• convenience and ability to be performed at low cost
and in a minimal amount of time.
Otol Neurotol 2006:27;1030-1036.
5. • However, a system that has sufficient rigor for
research purposes may prove impractical in the clinic
because it is difficult to learn, time consuming, or
requires specialized equipment.
• Furthermore, a system that is designed to classify
patients into groups based on overall level of disability
may not be optimized for tracking the evolution of
paralysis in a given patient.
6. • Facial nerve dysfunction is often considered in two
categories.
Loss of motor function in the muscles of facial
expression
Secondary defects (synkinesis, hemifacial
spasm, contracture, crocodile tears, and hyperacusis).
7. Methods of grading facial nerve function
Traditional approaches (no specialized computer
equipment, use of subjective assessments by the
observer)
Computer-based approaches(specialized equipment
to measure and quantify digital data objectively).
9. • Gross scales make an overall assessment of facial
motor function.
• Gross scales of facial function evaluate overall facial
function and assign a grade that reflects the severity
of all paralysis and secondary effects simultaneously.
• These gross scales are descriptive rather than integral
in nature, and as a result they cannot be manipulated
mathematically.
10. • Eg:
• Botman and Jongkees Scale(1955)
• May Scale(1970)
• Pietersen Scale
• House-Brackmann Scale (1985) universal standard
of the American Academy of Otolaryngology– Head
and Neck Surgery on recommendation of the Facial
Nerve Disorders Committee, sought to group together
patients with similar degrees of disability.
11.
12.
13.
14.
15. • Drawbacks :
• Cannot be used to distinguish finer differences in
facial nerve dysfunction.
• Fails to distinguish subtle differences in facial nerve
recovery.
• lack of strong interobserver reliability
16. • Prone to observer error
• Considerably less agreement within the
intermediate degrees of impairment
• Ambiguity regarding secondary defects of facial
nerve dysfunction
17. • Regional scales, ascribe independent scores to
different areas of facial function, sometimes with
weighting to reflect the greater or lesser importance of
given areas of the face, such as eye closure or mouth
movement.
• Eg:
Smith Scale
Adour and Swanson Scale Facial Paralysis Recovery
Profile (FPRP)
The Yanagihara Grading System for Facial Palsy
18. Detailed Evaluation of Facial Symmetry
(DEFS), Abridged
Janssen‟s Scale
Sunnybrook facial grading system (Toronto)
19.
20.
21.
22.
23.
24. • Drawback
• Although incorporation of synkinesis into the
composite score occurs in a clear and unambiguous
manner, there is no mention of the other secondary
defects.
• Also, because it remains a subjective scale, the facial
grading system is prone to the same interobserver
variability as the HBGS.
25. • Specific scales ask the observer to respond „„yes‟‟ or
„„no‟‟ to questions about specific areas of the face.
• Eg:
Stennert scale(Facial Paralysis Score of
Stennert, Secondary Defect Facial Paralysis Score of
Stennert)
The Burres-Fisch system(1986)
Nottingham system(1994)
26.
27.
28. • Burres-Fisch system (1986)
• A scale relying solely on objective measurements has
the benefit of eliminating observer bias and
subjectivity; one such grading system is the Burres-
Fisch system .
• Based on a study of facial biomechanics of seven
standard facial expressions in subjects with normal
facial nerve function , this system quantifies facial
nerve function with a defined linear measurement
index.
29. • The linear measurement index (LMI) is calculated by a
series of equations using the percent displacement of
various facial anatomic landmarks during movement
compared with repose.
• An advantage of the Burres-Fisch system over the
HBGS is that the linear measurement index
represents a continuous graded scale, thereby
allowing finer distinctions of function.
30. • A study comparing the Burres-Fisch method with the
HBGS indicated a high degree of correlation between
the two systems when they were used to evaluate
patients with facial weakness, despite the fact that one
scale is subjective and the other objective.
31. • Drawback
• The calculation of the linear measurement index is an
arduous, time-consuming process (taking
approximately 20 minutes) and is unlikely to represent
a practical tool for the busy clinician.
• Also, no measures for secondary defects are
incorporated.
• Inability to make simultaneous recordings in different
facial regions
Seminars in plastic surgery 2004:18;1-21
32.
33.
34. • Drawback
• Inability to assess bilateral facial nerve dysfunction.
Because the composite number is expressed as a
ratio to the contralateral side, bilateral facial nerve
palsy, even if severe, would result in a high
Nottingham score and therefore would not reflect the
true status of either nerve.
• In addition, the lettering system used to assess
secondary defects does not contribute to the overall
numerical score, and it is therefore useful as a
descriptive modifier only.
35. scale Psychometric Clinical utility
properties
established
Interobserver Reliability, widely used considered
HBFNGS Repeatability universal standard
Content validity,construct Good reviews widely used
SFNGS validity , intrarater and inter-
rater reliability ,agreement of
score with HBFNGS and
yanagihara scale ,
Repeatability
Reliability compared to LMI
NOTTINGAMS _
SYSTEM
Agreement of score with Widely used in japan
Yanagihara HBFNGS and SFNGS,
scales
36. Studies uptil 2005 conclude……………
• HBFNGS is prone to high interobserver variability due
to its subjective nature. Clin Otolaryngol
1992;17:303–307
• Reliability of Nottingams system is reported to be
better than the Burres Fisch LMI with a variance of 7%
versus 26%. Otol Neurotol 2003:24;118–122.
• Sunnybrook FNGS composite score is reported to be
more sensitive than the HBFNGS in detecting
changes in facial nerve recovery and to have good
interobserver reliability.
37. • The Sunnybrook system scores at the same
agreement level as the House-Brackmann and
Yanagihara grading systems.
• Substantial agreement is found between the regional
Sunnybrook and Yanagihara scales.
• There is an evaluative difference between the
weighted regional Sunnybrook and the gross House
Brackmann systems. Sunnybrook grading is easy and
quick.
38. • By adding objective measurements and additional
secondary defects, the Sunnybrook system can be an
alternative to the other predominating grading
systems. Otol Neurotol 2004:25;1020–1026.
• Agreement between the LMI and the HBFNGS is
excellent (less than 10% difference) in only 50% of
patients and satisfactory (between 10 and 25%) in
33% of patients . Otol Neurotol 2003:24;118–122.
• Although many of the other grading scales have their
advantages, none have duplicated the global appeal
and ease of use of the HBFNGS.
39. Search strategies:
• Databases searched:
– Pubmed , Free medical journals, Google Scholar
, Sage Pub , Ovid sp.
• Selection Criteria:
– Full text articles & abstract from yr 2006 to 2010.
• Keywords used were: Facial nerve grading
systems.
41. Grading Facial Nerve Function: Why a New Grading
System, the MoReSS, Should Be Proposed.(4)
Alexander J, Weibel W B, Peter P G, Benthem B, Wim
B B, Gerrit J H.
Otol Neurotol 2006:27;1030-1036
42.
43.
44. • In this way, a total score of Mo 12, Re 8, S 6, and S 10
can be obtained
• An extra letter (a-d) can be assigned for the paralytic
region
• Mo6ab, Re 4ab if the forehead and eye have gross
asymmetry at rest, the eye cannot be closed, and
there is no movement in the forehead, whereas there
is normal function and symmetry in the lower part of
the face.
45.
46. • Objective: To compare the interobserver variability of
a new grading system to the currently recommended
House-Brackmann Grading Scale.
• Study Design: Prospective case-control study.
• Setting: Tertiary referral center.
• Patients: All patients with a facial nerve
paresis/paralysis (whatever the cause).
• Intervention: All patients were evaluated for their
facial nerve function by three
observers, independently, using both the new system
and the House-Brackmann Grading Scale.
47. • Main Outcome Measure: The level of agreement
between the three observers using both scales.
• Results: With the movement, rest, secondary
defects, and subjective scoring grading scale, a higher
percentage of agreement between the observers was
noticed than with the House-Brackmann Grading
Scale.
• Conclusion: The movement, rest, secondary
defects, and subjective scoring grading system is
more useful for grading facial nerve dysfunction in
clinical practice than the House-Brackmann Grading
Scale.
48. • Discussion :
• Regional scales more reliable
• Gross scales more practical
• Regional scales - weighted and unweighted
• variation of function within one grade
• HBGS does not always correlate with the worst
function
• Grading scale takes patients‟ values into consideration
• weighing is done by the patient.
49. Facial Nerve Grading System 2.0(3b)
Facial Nerve Disorders Committee: Vrabec J T et al
Otolaryng–Head and Neck 2009:140; 445-450
50. • Elements of the revision
• Regional Assessment - added
• Objective Score - deleted
• Acute Facial Paralysis
• Secondary Movement
53. • OBJECTIVE: To present an updated version of the
original Facial Nerve Grading Scale
(FNGS), commonly referred to as the House-
Brackmann scale.
• STUDY DESIGN: Controlled trial of grading systems
using a series of 21 videos of individuals with varying
degrees of facial paralysis.
54. • RESULTS: The intraobserver and interobserver
agreement was high among the original and revised
scales. Nominal improvement was seen in percentage
of exact agreement of grade and reduction of
instances of examiners differing by more then one
grade when using FNGS 2.0. FNGS 2.0 also offers
improved agreement in differentiating between grades
3 and 4.
55. • CONCLUSION:
• FNGS 2.0 incorporates regional scoring of facial
movement, providing additional information while
maintaining agreement comparable to the original
scale. Ambiguities regarding use of the grading scale
are addressed.
56. • Discussion:
• This study finds the rating scales are quite
comparable.
• The addition of subscores within grades 3 and 4 may
be useful in defining outcomes after facial nerve
grafts.
• In this version, each region is graded as a percentage
of normal and can be used when grading bilateral
weakness.
• Without a normal side as a reference, interobserver
variability is expected to be higher.
57. • Cause for the fair agreement (kappa 0.4)
• Cases studied and raters
• Moderate degrees of facial weakness,
• Examiners have diverse training backgrounds and
practice settings. The more uniform the group of
examiners are, the more likely they are to use a scale
in a similar manner.
• Finally, there was no “coaching” in the use of the
scales. A training period prior to the study of a rating
scale will distinctly improve the reliability among a
selected group of examiners
58. • Psychometric Testing of the Gordon Facial Muscle
Weakness Assessment Tool (abstract)(3b)
Shirley C G,cynthia A B,Dax AP
J School Nurs 2010 :26; 461-472
59. • Background: School nurses may be the first health
professionals to assess the onset of facial
paralysis/muscle weakness in school-age children.
• Purpose : to test the psychometric properties of the
Gordon Facial Muscle Weakness Assessment Tool
(GFMWT) developed by Gordon.
• Methods : Data were collected in two phases. In
Phase 1, 4 content experts independently rated each
of the 22 items on the GFMWT for content relevance.
The ratings were used to generate Item and Scale
Content Validity Index (CVI) scores.
60. • In Phase 2, school nurses (N = 74) attending a state
conference independently rated referral urgency on a
set of 10 clinical scenarios using the GFMWT.
• Results : The GFMWT had an item and scale CVI of
1.0. Overall, the interrater reliability was .602 (p <
.001).
• Conclusion :When used by school nurses, the
GFMWT was shown to be both a reliable and a valid
tool to assess facial muscle weakness in school-age
children.
62. 1a SR (with homogeneity) of Level 1 diagnostic studies; CDR with 1b studies from
different clinical centres.
1b Validating cohort study with good reference standards; or CDR tested within one
clinical centre.
1c Absolute SpPins and SnNouts.
2a SR (with homogeneity) of Level >2 diagnostic studies.
2b Exploratory cohort study with good reference standards; CDR after derivation,
or validated only on split-sample or databases.
3a SR (with homogeneity) of 3b and better studies.
3b Non-consecutive study; or without consistently applied reference standards.
4 Case-control study, poor or non-independent reference.
5 Expert opinion without explicit critical appraisal, or based on physiology, bench
research or first principles.
63. Implication for practice
• The utility of subjective scales lies in the ease of use
and amount of information conveyed. The FNGS 2.0
produces similar results to the original FNGS and
adds distinct regional information about facial
movement.(C)
• Further improvement of quantification of facial nerve
function will require an objective rating scale.(C)
• Additional advances in motion analysis software are
expected and, when refined, should allow widespread
use of consistent, repeatable, objective scoring.(C)
64. • The movement, rest, secondary defects, and
subjective scoring grading system is more useful for
grading facial nerve dysfunction in clinical practice
than the House-Brackmann Grading Scale.(C)
• GFMWT was shown to be both a reliable and a valid
tool to assess facial muscle weakness in school-age
children.(C)
65. • The newly developed scales can be used clinically
when their, psychometric properties and clinical utility
is further well established .
• Uptil then the use of SFNGS(weighted
regional), which has well established psychometric
properties and clinical utility should be encouraged.
66. Implication for further research
• Studies should be done comparing the revised
version of H-B FGS and SFGS
• Validation, reliability, and reproducibility assessments
of the newly developed MoReSS should be done.
• And its comparison and agreement to the most
frequently used and popular SFGS system should be
done .
67. • Revision of the existing SFGS by adding objective
measurements and additional secondary defect
should be done.