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Validation of a Treatment-Based Classification System for Individuals

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Validation of a Treatment-Based Classification System for Individuals Validation of a Treatment-Based Classification System for Individuals With Facial Neuromotor Disorders Downloaded from https://academic.oup.com/ptj/article/78/7/678/2633301 by guest on 27 September 2021 Background and Purpose. A method for linking treatments to signs and symptoms of facial neuromotor disorders is needed. We describe the construct validation of a treatment-based classification system for facial neuromotor disorders. Subjects and Methods. Based on physical signs and symptoms, 148 patients (mean age=48.9 years, SD= 16.1, range = 20 -93) were assigned to treatment-based categories. The pattern of impairment and disability was compared with clinical expectations. Results. The distribution of impairment and disability scores demonstrated the expected signs and symptoms of the treatment-based categories. Confirmatory principal-components factor analysis indicated 4 factors, corresponding to the treatment-based categories; the factor loadings confirmed the presence of the key sign or symptom characteristic of the categories. Conclusion and Discus- sion. Classifying facial neuromotor disorders into treatment-based categories appears to be a valid method for categorizing patients with specific impairments or disabilities and may be useful in linking treatments to outcomes. [VanSwearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuro- motor disorders. Phys Ther. 1998;78:678-689.1 Key Words: Classification, Facial paralysis, Rehabilitation. Jessie M VanSwearingen I Jennifer S Brach Physical Therapy . Volume 78 . Number 7.July 1998 Downloaded from https://academic.oup.com/ptj/article/78/7/678/2633301 by guest on 27 September 2021 acial neuromuscular dysfunction is a complex Facial neuromuscular reeducation using surface electro- disorder of the facial neuromotor system and myographic (EMG) biofeedback or mirror feedback is may involve facial motoneurons and their axons, one rehabilitation technique that has been shown to facial muscles, or connections of other brain lead to improvement in facial n~o~en~ent.~~~-~)Random- centers with neurons in the facial nucleus in the brain ized clinical trials have shown that qualitative and quan- stem. Disorders of the facial neuromotor system can titative improvements in facial movement occurred after affect an individual's function in many ways, disrupting treatme~~t.'~."Facial neuromuscular reeducation is a physical as well as psychosocial function.'.Veople process of relearning facial movement using specific and with these disorders may have diff~c~iltinitiating rnove- accurate feedback to (1) enhance facial muscle activity ment, controlling abnormal movement, or relaxing mus- in functional patterns of facial movement and expres- cles that are contracting involuntarily. Functional lirnita- sion and (2) suppress abnormal muscle activity interfer- tions such as difficulty drinking from a glass, eating, and ing with facial f~lnction.L'-'*~~The exercise program is speaking also may be present.' Because of their individualized for each patient and is based on the signs altered appearance, many people with facial neuro- of facial impairment identified and the key symptoms muscular disorders feel uncomfortable in social the patient reported at evaluation. situation^.^ Although Ross et alls and Se~alet alfl reported that 2 Rehabilitation for facial neurornotor disorders has con- randomized clinical trials of facial ~ieuromuscularre- sisted of rna~sage,~.'.electrical stim~lation,~~hndrepeti- education showed improvements after treatment, in tions of common facial expressions in a general exercise neither of the studies did the researchers define which regirnem4 This "generic" form of treatment has been patients improved with what treatments, nor did the found to be of little be~lefit.~."ome authors suggest that studies provide an adequate measure of treatment out- some i~l~erventionsmay even adversely affect recovery come. The outcomes are described for a homogenous of facial neuromotor fun~tion,"~,~including disrupt- group of patientsl%hen the group was most likely hetero- ing reinner~ation,~-'~or result in "mass action," geneous with respect to facial neuromuscular dysfunction, a generalized contraction of all or many of the fac- based on the mean and variability reported for the facial ial muscles when voluntary facial expressions are impairment measures for the samples. A homogenous group of patients in a study may result in masking differ- JM \'anSwraril~ger~,PhD, PT, is Assistant Professor of Physical Therapy, Departn~entof Physical Thcrapv, School of Hcal~haud Rchahiliratior~ Sciences, LJniversity of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (LJSA) (jessievs+Qpitt.ed~~),and Director oS Rrhabilitation, Facial Nerve (:en~er,(:ORE Ne~work,1,irnitt-d L.ial)ility (:orporatio~~,LJ~~iversity of Pittsburgh Medical Center. Acldress all corresponde~~ceto Dr Val~Sweari~~gen. JS Brach, PT, is Clinical Assistant Professor of Physical Therapy, Department of Physical Therapy, School of Health and Rehabilitation Scirncrs, I!ni\~rrsity01' Pi~tsb~~rgh,and Phpical Therapiqt, (:ORE Network, L.imited L.iability Corporation, University of Pittrb~~rghMedical Center. This ~ludywas approved by the Institutional Revirw Boarrl for Biomedical Research of the University of Pittsburgh Physical Therapy . Volume 78 . Number 7 . July 1998 VanSwearingen and Brach . 679 Table 1. Treatment-Based Categories and Treatments Designed for Each Category Category Signs/Symptoms Treatmenta Initiation Drooping brow, lowered eyelid, cheek, and corner of the mouth at rest; AAROM, matching movements, small unable or iust able to initiate muscle activity or movement, incomplete range, education about the recovery eye closure; marked physical function and psychosocial problems process Facilitation Minimal to no drooping of the face at rest; mild to moderate facial AROM, resistive exercises weakness, complete eye closure; physical function problems greater than psychosocial difficulties Movement control Eye narrowed, cheek fold deepened, corner of the mouth pulled and Isolated movements, correct movement philtrum shifted laterally, tension at rest; mild to moderate facial patterns, stretches weakness; abnormal movement with voluntary movement; physical function problems less than psychosocial difficulties Downloaded from https://academic.oup.com/ptj/article/78/7/678/2633301 by guest on 27 September 2021 Relaxation Increased resting facial tension; spontaneous twitching and spasms, Rhythmic motions, relaxation exercises, increasing in frequency or amplitude with increasing effort to move; stretches few or no physical function problems; marked psychosocial difficulties "AAROM=active-assistedrange of motion, AROM=active range of motion. ential responses of a patient with a variety of facial move- rather on the (1) observed signs of resting posture ment disorders, particularly when treatments are tailored changes,- voluntary movement, abnormal movements to match the signs and symptoms of the disorders. The accompanying voluntary movement (synkinesis), or reliability and validity of the outcome measure used by abnormal spontaneous movements and (2) reported Segal et alZ1 were not clearly described or demonstrated. In symptoms of difficulties in usual facial functions. both clinical trials, the outcome was assessed using mea- sures of the impairment of facial movement or measures The purpose of this report is to describe an attempt to reflecting pathology. No measure of disability or inventory validate a classification system for individuals with facial of the patient's experience while performing typical activ- neuromotor disorders, a system that was derived from ities involving the face was reported. our clinical experience in tailoring treatments based on physical signs and symptoms. By comparing the pattern A systematic means of defining the characteristics of a of facial neuromotor impairments and disabilities, as patient's facial neuromotor disorder in multiple determined with disorder-specific instruments for mea- domains is needed, particularly for the domains of suring facial impairment and disability, with our a priori impairment and disability. A system for classifying the clinical assumptions about the primary problems of disorder could enhance our understanding of facial patients classified in each of the 4 treatment categories, neuromotor problems22 and provide a framework for we provided evidence for the validity of our measure. We assessing interventions. expected that categories based on the treatments that would be given for the physical signs and symptoms The purpose of classification, like diagnosis, is to ulti- would demonstrate a specific pattern of impairments mately impose a label on sets of signs and symptoms that and disability characteristic of each category. implies an understanding of the conditions and treat- ments.",Z4 A number of pathologies result in a facial Method neuromotor disorder. Bell palsy, primary tumors of the From our experience and observations of patients with facial nerve, cranial-based tumors, and trauma all can facial neuromotor disorders, we derived 4 treatment- lead to impairments of the facial neuromotor sys- based categories (initiation, facilitation, movement con- In our experience, the pathology rarely guides trol, and relaxation), named to suggest the physical therapists in their interventions. For example, a patient therapy tailored for the physical signs and symptoms of with a 9-month history of Bell palsy may
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