Effectiveness of Electrical Stimulation With Mime Therapy Versus Electrical Stimulation With Proprioceptive Neuromuscular Facilitation on Improving Facial Asymmetry and Quality of Life in Patients With Bell's Palsy

1. Introduction: (Background, Preliminary Literature Review and Significance of the Study): One paragraph related to global work on the subject, one paragraph related to local (Pakistan) work and one paragraph related to institutional work with a total of 5 to 8 references. Last paragraph should indicate the importance of work and what information/gaps are missing on topic/subject and how this study will contribute to knowledge .

Bell palsy is a sudden paralysis or weakness of the facial muscles that becomes worse over 48 hours. Bell palsy is caused by damage to the facial nerve (the 7th cranial nerve) (1). Facial nerve, which regulates facial expression muscles and transmits taste sensation from the anterior two-thirds of the tongue, becomes swollen and compressed-usually secondary to reactivation of latent herpes simplex virus type 1 (HSV-1)-in the tight bony facial canal. Thus, individuals can suddenly develop drooping of one side of the face, difficulty in blinking, hyperacusis, difficulty in moving the mouth, facial motion and expression, which makes it more difficult to communicate and tends to lower an individual's quality of life (2). Mime therapy is an advanced rehabilitation method that integrates the techniques of mime with special facial exercises to improve facial symmetry, muscle control, and emotional expression of patients with facial nerve palsy. The therapy aims to isolate facial movements, decrease synkinesis (spontaneous muscle activity), and retrain natural expressions (3). Proprioceptive neuromuscular facilitation (PNF) therapy utilizes coordinated patterns of movement to strengthen muscles and enhance neuromuscular coordination. This technique restores muscle function by activating the interaction between nerves and muscles with guided exercises (4). Electrical Stimulation (ES) applies electrical currents to activate muscles or nerves for therapeutic objectives. It helps enhance muscle strength, decrease pain, and enhance healing by causing muscle contractions or stimulation of nerves using electrodes applied on the skin. It is mostly used in the treatment of Bell's palsy(5).

Worldwide, Bell's palsy affects around 11 to 40 people per 100,000 each year with a lifetime risk of 1 in 60. It is seen most commonly in adults between 15 and 60 years of age with a mild predilection for involvement on the right side. The incidence in the United States is 24.5 per 100,000 each year. In countries like Egypt, the rate increases to 107 per 100,000 (6). In Pakistan, it differs geographically. In a study conducted in Lahore, 68.3% of the cases of facial paralysis were due to Bell's palsy and had a higher incidence in females and a right-sided predominance. In colder climates, it was most common among the 11-20 and 31-40 years of age and occurred with a peak during winter months (7) (8). European research demonstrates that PNF in combination with electrical stimulation enhances facial muscle coordination and accelerates recovery (9). In Asia, mime therapy combined with electrical stimulation has been noted to increase the strength of muscles and neuromuscular control (10). Clinical trials and reviews published most recently reveal that the use of electrical stimulation combined with either mime therapy or PNF provides more advantageous results than the use of electrical stimulation alone. Direct comparisons between the combined therapies are still limited, however, and imply that more research is warranted. There is limited direct comparison of combination therapies, leaving clinicians without evidence-based guidance and often having to make decisions based on personal choice or access to resources. This may result in suboptimal results.

Bell's palsy causes facial paralysis and loss of movement and expression. While electrical stimulation (ES), mime therapy, and proprioceptive neuromuscular facilitation (PNF) are commonly employed treatments, little is known about the combinations' effectiveness. The purpose of this study is to establish whether adding ES with mime therapy or with PNF yields better outcomes in rehabilitation.