Utilizing a Mobile Electrode (PEN) for Functional Electrical

Stimulation (FES) to Treat Facial Paralysis Caused by a Brain Injury

A Case Study

Fabiana S. B. Perez¹, Adson Ferreira da Rocha¹, Karla de Castro Cardoso²,

Hellen Orlando Veloso² and Inez Janaina de Lima Amaral³

¹School of Medicine, University of Brasília, Brasília, DF, Brazil

²State University of Goiás, Anapolis, GO, Brazil

³Catholic University of Goiás, Goiania, GO, Brazil

Keywords: Electrical Stimulation, Facial Paralysis, Pen-shaped Mobile Electrode, Brain Injury.

Abstract: This research is a case study that evaluated the therapeutic efficacy of Functional Electrical Stimulation

(FES) associated with the method of Proprioceptive Neuromuscular Facilitation (PNF) in a patient with

central facial paralysis caused by brain damage resulting from brain anoxia. The treatment involved the

application of Orofacial Regulation Therapy, associated with physical therapy using a pen-shaped electrode

whith an FES current. The treatment was administered for a period of one year and involved two weekly 15

minute sessions. The stimuli were performed with modulated current at a frequency of 60 hertz, pulse width

of 300 miliseconds, rise of four (4) seconds, decay of four (4) seconds, time ON of one (1) second, time

OFF of five (5) seconds, in trapezoidal pulses (forming a mini cycle of 14 seconds with 30 pulses) at an

intensity level measured according to the patient’s sensitivity, associated with the PNF method. The mobile

pen-shaped electrode was positioned at precise points on the paralyzed muscles of the face, and the fixed-

electrode was positioned on the Deltoid muscle. There was satisfactory rehabilitation of muscles in the left

hemiface and acquired improvement in the oral consumption of the bolus. The symmetry of the face was

also enhanced, along with facial expressions and connotation measuring four (4) on the Chevalier scale.

1 INTRODUCTION

Facial paralysis can cause an individual to lose one

form of non-verbal communication. Non-verbal

communication is significant when oral expression

can no longer be used to transmit information to a

recipient (Calais et al., 2005).

Facial expressions can be utilized to more

accurately demonstrate the feelings of an individual

and sometimes transmit more information than

actual verbal communication. An individual with

facial paralysis often feels insecure and embarrassed

about these changes, which often results in isolation.

This can also cause a family to feel alienated

because of a member’s communication difficulties

and even an inability to feed normally in some cases

(Lima, 2001).

Central Facial Paralysis (CFP) or supranuclear

palsy consists of lesions on the pyramidal motor

neurons of the frontal cortex (responsible for

voluntary movements), that manifest on the

ipsilateral (upper face) and contralateral (top and

bottom) of the facial motor nucleus (Lazarini et al.,

2002). Thus, involuntary movements or emotion can

be preserved. It is usually caused by vascular

lesions, tumors, degenerative or inflammatory

processes and can be accompanied by other

neurological manifestations including hemiplegia

and dysarthria (Bento et al., 1998); (Esborrat, 2000);

(Testa and Antunes, 2000); (Chevalier et al., 1987).

Facial paralysis consists of two phases: flaccid

and sequel. The flaccid phase is characterized by

sagging muscles while at rest and reduced muscle

activity during movement. During this phase there is

potential for regeneration and normal mobility can

return. In the sequel phase, aberrant reinnervation of

the facial nerve can occur and symptoms including

synkinesis (involuntary movements), motor skills

paralysis and contractures may be exhibited (Goffi -

Gomez, 1999); (Moran and Neely, 1996).

269

S. B. Perez F., Ferreira da Rocha A., de Castro Cardoso K., Orlando Veloso H. and Janaina de Lima Amaral I..

Utilizing a Mobile Electrode (PEN) for Functional Electrical Stimulation (FES) to Treat Facial Paralysis Caused by a Brain Injury - A Case Study.

DOI: 10.5220/0004252002690272

In Proceedings of the International Conference on Biomedical Electronics and Devices (BIODEVICES-2013), pages 269-272

ISBN: 978-989-8565-34-1

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

The Kabat Method or Proprioceptive

Neuromuscular Facilitation (PNF) assists in the

rehabilitation process of an individual’s physical

condition by requiring a learning of motor skills,

improving flexibility and range of motion, increased

muscle strength and coordination. PNF exercises

combine diagonal movements, based on a deep

anatomical study, with the biomechanical and

neurophysiological. These exercises resemble the

functional movements of daily life and can be used

in the treatment of facial paralysis (Alencar et al.,

2011). This method is more efficient when

associated with electrical stimulation.

FES (Functional Electrical Stimulation) enables

a selective repeat afferent input of the central

nervous system which activates not only the targeted

location, but also the reflex mechanisms of the

muscle. These are very important for the

reorganization of motor activity and movements that

are impaired due to the injury of the upper motor

neurons. Furthermore, FES produces a general

increase in the potential that the electric current will

reach the balance of excitatory and inhibitory pulses,

stimulating the disabled motoneurons while the

patient has the opportunity to consciously

experience the “normal movement”. Thus with

repetition, the patient may relearn movement and

modulate their tonus. (Perez, 2011).

The smaller the diameter of the electrode, the

more concentrated the electrical charge becomes,

thus requiring a lower dose of current to achieve the

same result as a larger electrode in relation to

muscular contraction (Agne, 2004).

The movable electrode used for facial

stimulation had a pen shape and was smaller in

diameter than others electrodes. These features

promoted a deeper and more intense stimulation of

the muscle fiber utilizing a lower intensity current

than required by other conventional electrodes

(Perez, 2011).

According to Roberts (1997), physical therapy

uses myotherapy, and in some cases, electrical

stimulation with the aim of recovering facial

symmetry. Speech therapy uses this practice to

achieve facial symmetry and adequate stomatognatic

functions (chewing, sucking and swallowing), in

addition to improving verbal communication as a

whole.

2 MATERIAL AND METHODS

This research is a case study of a patient with left-

sided facial paralysis who was treated with the pen-

shaped electrode, utilizing FES current therapy

associated with the PND Method and Orofacial

Regulation Treatment.

Patient VLN, now deceased, was a Caucasian

female. At age 31 she suffered anoxia after

exogenous poisoning (ingestion of poison as a result

of depression). She was discovered 24 hours after

the incident and was unconscious. The patient

suffered cardiac arrest and fell into a comatose state.

Patient VLN was initially diagnosed with brain

damage from anoxia and remained on a

tracheostomy for 18 days and a gastrostomy for a

month.

Three years after the incident the patient was

admitted to the Center for Integrated Rehabilitation

and Stimulation (CEREI) in Goiânia-Goiás, Brasil,

to undergo a multidisciplinary rehabilitation

program. During the physiotherapeutic examination

the patient appeared apathetic, lacking initiative and

spontaneous verbal fluency. During a neurological

examination, we observed impaired expressive

language and language comprehension

 as only

preserved for simple orders. She exhibited spastic

rigidity ranked degree five on the Ashworth Scale,

as well as spastic tetraplegia, hyperreflexia,

preserved sensation, facial paralysis and

opisthotonos. During the evaluation of facial

movements it was possible to identify facial

asymmetry and spastic facial palsy was only visible

as an eye twitch (a sign noted on Chevalier’s Scale).

Patient VLN also lacked the ability to contract the

following muscles: occipitofrontal,corrugator

supercilii, orbicularis oculi, transverse nose, risorius

and the orbicularis oris of the left hemiface. She also

had synkinesis and unintelligible vocalization.

The speech therapy evaluation uncovered left-

sided facial hemiparesis (falling oral rhyme and

difficulty in labial sealing), a decrease in the tone

and mobility of the organs that compose the

orofacial complex (COF), as well as the presence of

mild drooling from the left side of the mouth. When

food was administered orally (in both a liquid and

paste form), difficulty was observed during the

swallowing cycle. Patient VLN’s tongue thrust

forward during swallowing and signs of laryngeal

penetration were noted (gagging and coughing after

swallowing).

Patient VNL was referred to undergo both

physical and speech-language therapy twice a week

for a year without interruption. Therapy sessions

BIODEVICES2013-InternationalConferenceonBiomedicalElectronicsandDevices

270

utilizing FES associated with the PNF Method lasted

for 15 minutes. The apparatus that was used was the

Electro Scientific ORION – Quark/ Br (featuring

TENS and FES functions) with two channels. For

this case, the channel was coupled with two types of

electrodes while in the FES program. A synchronous

current in a trapezoidal shape was generated by the

apparatus through both a pen-shaped mobile

electrode (which identified the precise musculature

in the face) and a fixed electrode in the deltoid

muscle (Figure 1). Ten facial motor points were

stimulated, noted in Figure 2. The stimuli were

performed with modulated current at a frequency of

60 hertz, pulse width of 300 miliseconds, rise of four

(4) seconds, decay of four (4) seconds, time ON of

one (1) second, time OFF of five (5) seconds, in

trapezoidal pulses (forming a mini cycle of 14

seconds with 30 pulses) (figure 3). The intensity of

the treatment was measured in accordance with the

sensitivity of the patient, based on the gestural

communication. The total cycle was 140 seconds,

therefore each point was stimulated for six mini-

cycles. During the “off” time the pen position was

changed along with the movement of PNF.

The following muscles were stimulated: 1 –

Buccinator, 2 – Masseter, 3 – Levator anguli oris, 4

– Levator labii superioris, 5 - Zygomaticus, 6 –

Levator anguli oris, 7 – Orbicularis oris, 8-

Depressor labii inferioris, 9 – Depressos anguli oris

and 10 – Mentalis. Following on FES session, we

performed tactile and gustatory intra and extra oral

stimulation.

Figure 1: (1) Is the mobile electrode- (2) is the electrode

fixed to the Deltoid.

3 RESULTS AND DISCUSSION

In this case study, we used a combination of

traditional ideas and contemporary concepts of

functionality. Upon the conclusion of the treatment,

a satisfactory rehabilitation in the muscles of the left

hemiface was achieved. Patient VLN acquired the

ability to communicate by meaningfully

unsystematic vocalizations and an improvement in

Figure 2: Points of the face that were stimulated.

Figure 3: Graphic of the FES current.

the oral consumption of the food bolus. She also

gained facial symmetry and expressions, along with

vast connotation abilities ranked level four on

Chevalier’s scale (motion made broadly,

synchronously and symmetrically to one side).

The assumption is made that electric stimulation

in facial paralysis can interfere with neural

regeneration after facial nerve injury, but there are

few studies about its effectiveness. Due to the small

size and proximity of the muscles in the face, it

becomes difficult to isolate contractions, causing

massive movements that generate abnormal motor

skill patterns (Rodrigues, 1997). In our study, the

goal of electric stimulation was to return the

movement (muscle contraction) of the facial

muscles. The pen-shaped electrod developed by

Perez (2011) differentiates itself from other devices

by modulating the intensity of the stimulus in order

to visualize muscle contraction instead of only

relying on motor sensitivity. Another benefit is that

the smaller diameter of the electrode is capable of

stimulating an isolated muscle mass, as opposed to

an entire cluster of muscles. The aim of the

myofunctional exercises is to accelerate the return of

movement and muscle function to the facial

muscles, thus preventing atrophy of these muscles,

which would hinder their recovery (Goffi-Gomez,

1999). The use of electric current therapy for muscle

UtilizingaMobileElectrode(PEN)forFunctionalElectricalStimulation(FES)toTreatFacialParalysisCausedbyaBrain

Injury-ACaseStudy

271

strengthening, the aid of the pen-shaped electrode

and myofunctional therapy increases and enhances

the effectiveness of exercise. These combined

techniques are effective treatments for the

rehabilitation of CFP.

4 CONCLUSIONS

The treatment of facial paralysis with electrical

stimulation is a long-lasting process that requires

dedication on the part of the individual and family

(caregivers).

FES provides a selective repetitive afferent input

to the central nervous system which not only

activates the targeted location, but also the reflex

mechanisms of muscles. This process reorganizes

the motor activities and movements that are

impaired. FES leads to a general increase in the

potential that electric currents will reach the balance

of excitatory and inhibitory pulses, thus stimulating

disabled motoneurons while the patient has the

opportunity to consciously experience the “normal

movement.” As a result, through repetition, the

patient can relearn movement. (Perez, 2011)

Electrical stimulation, the type of electrode used

and the method of exercises associated with PND

seem to be important factors that enhance training

by increasing the balance of the COF structures and

their functions. Ultimately, this results in an

improvement in the quality of life of patients and

families, and supports an increasing acceptance of

the treatment.

The combination of both physical and speech

therapy is essential to the effectiveness of the

method and an improvement in the technique.

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