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Pereira et al. 655
drugs, continuously for 15 days. After that, they
were divided in two groups: The rst group, with
nine patients, did a rehabilitation programme
with one session per day for six days, and con-
tinued for 15 days. The second group, with 11
patients did not undergo the physical rehabilita-
tion. These second group was divided again and
formed a third group with patients who did not
show signs of clinical recovery after two weeks
of exclusive medical treatment and then under-
went a delayed Kabat rehabilitation. This study
was not included in this review because the
second group division was not randomized. In
addition to this it creates unnecessary confusion.
Agreement between reviewers regarding the
studies risk of bias assessment was considered
perfect (kappa coecient 0.8). The most
common risks of bias compromising the quality
of the included studies were: allocation conceal-
ment, blinding and intention-to-treat analysis.
Figure 2 represents the meta-analysis for the func-
tionality outcome of patients who received phys-
ical therapy (25) and the control group (25). The
experimental group did mime therapy for ten
weekly 45-minute sessions, for three months.
The control group received no intervention.
This analysis demonstrated a signicant improve-
ment in functionality for the experimental group
(SMD13.90; 95% CI 4.31, 23.49; P0.005).
Discussion
The main goal of this study was to carry out the
meta-analysis to determine the eect of mime
therapy on facial palsy. This analysis is relevant
when making decisions about an eective treat-
ment protocol for these patients. In this study,
only three randomized controlled trials
presented the mean and standard deviation for
functionality. This is for both pre- and
post-treatment experimental and control group
outcomes. The scarcity of the randomized con-
trolled trials as well as the low quality of the
randomized controlled trials found in this
review should be a cause for concern to health
professionals since few studies for this type of
therapy have been carried out.
A systematic review about mime therapy for
facial palsy was published in 2008
12
with four
studies. Meta-analysis was not performed
because the studies had an incompatible combi-
nation of characteristics such as treatment type,
time of duration of the intervention and out-
come measures. The study did not demonstrate
clinical or statistically signicant dierences
among the dierent treatment groups.
In 2008 the Cochrane Library published a
systematic review of articles about physical ther-
apy and Bells palsy
15
including six studies with
patients who had an exclusive diagnosis of
Bells palsy and underwent several types of
treatment: faradic stimulation, galvanic current,
infrared treatment, massage, self-massage, acu-
puncture and drugs. No statistically signicant
inter-group dierences were found. Because of
dierences in inclusion criteria, only two of the
studies included in the above-mentioned review
coincide with those in our systematic review.
The aetiology of facial palsy in the studies
included in our review was heterogeneous: 67%
had Bells palsy, 13% herpes zoster, 1% Lyme
disease, 1% trauma, 1% operation trauma, 2%
meningioma and 1% facial neuronal apoptosis.
Future studies must include patients with a sin-
gle diagnosis in order to better substantiate
the eects of mime therapy on facial palsy.
Figure 2. Meta-analyses of facial exercise therapy for functionality outcome.
656 Clinical Rehabilitation 25(7)
Studies analysing the progression of such patients
are also necessary. Only one study with one year
of follow-up was found, and the authors con-
cluded that benets continued to be stable at
three and twelve months.
27
The dierences in evaluation and description
of outcomes were limitations for this study. Ross
et al.
22
used distances between points at rest and
during facial expressions, standardized photog-
raphy from video tapes and facial nerve response
to electroneurography and presented the out-
comes in unclear graphics. Segal et al.
23
used
the HouseBrackmann Scale weekly but did
not show the results of this measure. Their results
are described in an unclear table where muscle
movement symmetry score values were counted
and evaluated using an eight-level scale, but the
number of synkinetic muscles was counted and
classied with a four-level scale. Nakamura
et al.
24
recorded facial movements and analysed
them with a computer program to evaluate
movement symmetry, but the results appear in
unclear graphics. All the authors were contacted
in order to collect better information but we
received no responses. For this reason, only
three studies were included in the meta-analysis.
Allocation concealment and intention-
to-treat analysis were the most common risks
of bias found. Allocation concealment is neces-
sary to prevent dierences in measured or
unmeasured baseline characteristics because of
the way participants were selected or assigned.
The intention-to-treat analysis is necessary to
prevent bias caused by the loss of participants,
which may disrupt the baseline equivalence
established. Blinding is dicult for this type of
treatment because both therapist and patient are
aware of treatment. The bias found in the stud-
ies we reviewed can be partially explained by the
fact that the CONSORT Statement was only
established in 1999.
Implications for research
Future randomized controlled trials about facial
palsy must follow the rules of the CONSORT
Statement
28
and be careful and clear in their
outcome descriptions. They must include
patients with the same diagnosis and use valid
instruments for outcome measures (e.g. House
Brackmann, Facial Disability System). Outcome
measures must provide information about rest-
ing asymmetry, symmetry of voluntary move-
ment and synkinesis. The patients must be
evaluated prior to treatment, during treatment,
immediately after the course of treatment and
again some months later. Quality of life data
both before and after treatment is also impor-
tant. Such measures will lead to advances in
our understanding of the ecacy of physical
treatment for these patients.
Implications for practice
Mime therapy can improve functionality for
patients withfacial palsy. The therapy must consist
of exercises with mirrors, which are both low cost
and easily available, and the patient must help in
the execution of the movements for both biofeed-
back purposes and to prevent synkinesis. A daily
home programme should be prescribed for
patients inorder tohelpthe evolutionof treatment.
Conclusion
This systematic review suggests that mime ther-
apy is eective for facial palsy for the outcome
functionality.
Clinical messages
. Facial exercises therapy may improve
facial functionality.
. This therapy may be included to assist
with the functionality recovery of patients
with facial palsy.
Funding
This research received no specic grant from any
funding agency in the public, commercial, or
not-for-prot sectors.
Pereira et al. 657
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