脳卒中後顔面麻痺への運動療法の検討

(1)

mo\as?lklj!

fibllfs

ee

18 gee

4 e435

--

443

_S

(1991

a!

)

PhysicalTherapy

A

for

F

Case

acial

Palsy

after

Stroke:

Study

*

MasamichiFURUSAWA*',

Noriko

SATO,

Fujio

KOMA,

and

HidetakaReiko

TAKEMURA,

SHIINA

Abstract

Facial

palsy subsequent toa stroke

interferes

with nonverbal commuriication.

Because

such facial_palsy isof central origin, itiseasily influencedby attenuation of balance reactions

or by abnQrmal postural tone from the shoulder girdles and the _pelvis.Intreatment we thus

firstwork

to

normalize _postural

tone

throughout

the

whole

body

and

to

foster

the

emergence

of normal

balance

reactions and posturalmotor _patterns.

Only

after this

initial

step

do

we

di-rectly approach _thefacial_palsy itself.

To objectively examine this idea,we decided toclosely rnonitor _the _progress of a

57-year-eld woman admitted to our hospitalone _year and one week after suffering a stroke resulting

in

facial_palsy. Both the _physical therapy and the speech therapy departments worked in close collaboration teimprove formulation and symmetry of facialexpression, and towork on finely

grading movements involved infacialexpression. To monitor our progress we recorded

cha-nges by _photographs inthe center of _gravity,manual muscle testsof

facial

muscles, and

elec-tromyographic

activity. To assess the

degree

of

drooping

of the eyelids, we recorded changes

inthe vertical distancebetween theupper and lower eyelids.

Treatrnent

continued

for

five

months and three weeks.

The

improvements

we

indicated

approaching the whole body beforetrying to _treatonly thefacialregion,

Key

Words:

Stroke,

Facial

Palsy,

Physical

Therapy

1. Introduction

Facialparalysisresulting from a stroke typically

involves

asymmetry of posturing

for

socializing

be-havior and thus an impoverishment of

gesturing,

due

mainly to poorly

functioning

balance

reac:

.

fimaVas,Pacvafiexpt/NOpaMtazaOitst

"'

･th'ewEpt,

rtma･as-

±

M,

rrNn?,

vaieefi.:],

tieist

-

1'.Ekfi

sc

BobathHospital

(Received

21 Octeber 1989/Accepted 26 1990)

megptfi

･

November

tions.

Because

an abundant repertoire of

facial

ex-Pressions

is

important

for

communicating

ideas

be-tween _persons, _the inabilityto

do

this together

with a prevailing asymmetry in

facial

expression

resulting from _paratysisinterfereswith the

non-verbal communication and so adverse!y affects a

patienVs

iRteraction

with society,

We

have

previously advocated treating the pa-tientwho

has

facialparalysis

due

to a stroke or

other central nervous disorder by noting that the

(2)

pos-436

ve\tsza#

Fig.1 At the time of

hospitalization.

(Left)

Flaccidparalysisof the right side of the

face.

(Right>

Inability to remain seated because of fiuctuation and

liability

to fall

wards tothe left.

turaltone and _posturalmotor _patterns

in

the

shoul-der

girctEeand trunk,and

by

striving toremove ab-normal

influences

and abnermal compensatory

ad-justments

throughout the

body'Sl

In

thisstudy we

closely examined this

idea

by

studying a _patient

who suffered paralysis inall four Iimbs as well as

inthe facialregion

following

a

hemorrhage

inthe

brainstem.

2. Methods

The

subject was a 57-year-old woman who had

suffered a hemorrhage inthebrainstem with

subse-quent ataxia,

Millard

Gubler

syndromee), fiaccid pa-ralysis on theright side of the face

(Fig.

1,le'ft),and

lefthemiparesis. Although she had undergone

sur-gicalrepair of

her

right eyelid, it

drooped

marked-ly. Computerized tomography taken immediateLy

after the onset had shown the hemorrhage to be

located in the right poFterior region of the pons.

She had undergone conservative treatment, whjch

included physical therapy

in

the laterstage. At one year and one week after the onset, thesubject was admitted to our hospital,

We

chose to study a relatively "old

intractable"

case such as

hers

be-cause, as

NikiiO'

has

pointed out, after a certain

period of time

has

elapsed, ifa treatment

is

in-eg

18

_tseg4

ig

itiatedand produces a change, such change can be attributed to the treatrnentitselfeven though no

control group

is

inciuded

as _partof the study.

To study thissubject we _performed the following

assessment.

1) A video camera recorded the subject sitting on the edge of a bench,and _pictureswere _produced

on

thermosensitive

_paper via a special video camera _processor. From the resulting _photographs

we measured

inclinations

of the

head

and trunk

in

'

the frontal_plane and in the left_parasagittal_plane.

These

measurements were taken

in

accordance

with standards _published by the Physical

Dis-cibilities

Committee

of the

Japanese

Orthopaedic

Association.

2) With the subject in thesame seated position,

but with

both

subject and

bench

on a

large

plat-form thatcould measure the center of vertical pres-sure, we measured

fiuctuations

in

thecenter of

gra-vity

over a _period of

five

seconds.

･A

video

record-ing

of the subjeces p6sition was also taken at this

time and synchronized to the analog

center-ef-gravity information via a custom-macle device. 3) Photographs were taken of the subject's face

during

relaxation, during smiling, and during pro-nunciations of

the

sounds/a:L

li:/

and

./ua:f.

We performed manual muscle tests according to

DanieLs'"

on the anterior _portion of the

occipito-frontalisas thesubject triedtowrinkle herforehead, on the corrugator supercilii as she triecltofrown so

as

te

produce wrinkles

between

her

eyebrows, on

the zygomaticus major as $he triedto smile, and

the

depressoranguli oris as she _tried

to

frown.

4) We measured the vertical distance between

the eyelids

to

as$ess the diMculty inclosing of her

right eye.

5)

With

surface electrodes, we recorded

elec-tromyograms bilaterallyof thefrontalis, zygomatic-us major, and depressor anguli oris. Video

record-ings

were synchronized with the electromyograms

by the aid of thedevicernentioned in2)"'.

6) Retention of food introduced intothe mouth was asse$sed using a four-stepscale

(Table

1)

(3)

be-PhysicalTherapy forFacia

Table

1 Ability

totake

food

into

the mouth

1Palsyafter Stroke

3

iNothing spitled or tiropped.

2

lVery littlespilled or

dropped

1 1Occasionalspilling or dropping

O

lMost food spMed or

dropped

cause thissubject had diMculty keeping her iips

closed.

The above assessment was _performed at both

ad-mission and discharge so that we could see what changes took placeduring the hospitalization.

3. InitialAssessment

When firstadmitted to our hospitag,thesubject

had diMculty'in maintaining sitting because of

no-ticeablefluctuating movements arising from the

pelvic region while the

left

trunk musculature

ap-peared

fiaccid.

She

tended to

fall

posteriorly

and to

her

left,

se she compensated

for

this

by

fiexing

the

trunk

forward

to

keep

her

center of _gravity low, and by

tilting

herhead totheright with hyperexten-sion at thene ¢k

(Fig.

1,righO,

Because

of

di'Mculty

in

cLosing her mouth

(Fig.

1,

lefO,food would tend to

fall

out of the right-hand

corner of the mouth

(score==O>.

When

trying to pronounce

!a:f,

her

head would _tilteven

further

to the right and _go into further hyperextension, and

her mouth would open wider than normal

(Fig.

2,

left).

The

subiect

had

little

selective movement of her

mandiblc, and could not carefully grade the speed

of her movements with it,Ifshe triedto _pronouce

li:L

her lipswould be _pulledstrongly over to the

left

(Fig.

3,

lefO.

This

maiked asymmetry was

due

to the

inability

to grade movements of the left cheek musculature, the zygomaticus major, and the

depre6sor anguli oris, which would contract in an

all-or-none

fashion,

as we!1 as a poor ability

to

pro-duce contractile activity

in

the eor'responding mus-cles on the right.

Attempts topronounce

/u.L:f

revealed weak

activ-ity

in

the orbicularis oris,rendering

her

unable to

adequately round her lipson the right side of the

:A Case

Study

437

mouth

(Fig.

4,left).

When

smiling, the right zyg-omaticus major could not contract suraciently, so

theright corner of the mouth wou}d

･sag

while the mouth as a whole would

be

_pulledto

the

left

(Fig,

5,left).The results of initialmanual musc!e testing

Fig.2 Pronouncing the

_la:/

sound.

{LefO

Before

thetreatment,

(Right)

Five months and three weeks treatment.

after the

Fig.

3

Pronouncing the

li/1

sound.

(LefO

Beforethe treatmenL

(Right)

Afterthetreatment.

Fig.4 Pronouncing the

fui:/

sound,

CLeft)

Beforethe treatment,

(Right)

Afterthetreatment.

(4)

438 wa*tszae#

are shown inTable 2.

Drooping

of

the

lower

eyelid,

in

spite of a

surgi-cal _procedure to correct this

_problem,

was as

no-ticeableas ever.

Contraction

ef theorbital _portion

of the orbieularis oculi was absent.

As

a result of

this,conjunctivitis was evident.

4. Treatment

While

the subject was in our hospital,she had

five_physical therapy sessions per week, 40 minutes

per session,

for

five

months and threeweeks.

The

physical therapistnot enly worked on regaining

her abilities to waik and to sit, but also streve to

improve her facial expressions. Because the subjecV$ ataxia and

dysfunction

of

liP

rnusculature

impaired

her ability

to

speak well, a speech

thera-Fig.5

Smiling,

(Left)

Before

thetreatment.

<RighO

Afterthe treatment,

Table 2 Eyelid;manual muscle test;ability

to take food intothemouth

(Beginning

:the

beginning

of thetreatment,

End

:theend ofthe treatmenOBeginningEncl

Right eyelid vertical distance

when closed

5mm 3rnm

Eyelid dreoping COIISPiCUOUSinild

MMT

Rt.frontalis

Rt.corrugator supercilii

Rt.zyg'omaticus major

RL depressor anguli oris

RL orbicularis eris oloo1 1-3 3 3 3 4 Abilitv to take foed intethc

mouth

o 3

eg

18

_igce

4

_e

pistworked with her

three

timesweekly, 40 minutes

per session, The following account

briefiy

summa-rizes hertreatment _principallyin_physicaltherapy.

The

first

task was toregain symmetrical sitting

by encouraging trunk extension while maintaining

cocontraction of _pelvic and trunk musculature.

The two principalproblems were

lack

of tone

in

the lefttrunk muscles and _poor balance reactions

insitting. Having thesubject try toassume sitting

from a position of lyingon her right side was one way to bring activity

into

her

lefttrunk muscles

(Fig.

6,right}. This task al$o induced her tobring

her head from a right-tilted position

(Fig.

1,

right)

tothe midline.

Then,

by

having

the subject stand and attempt

shallow squats, cocontraction of

the

_pelvic and trunk musculature could beencouraged ina differ-ent way

(Fig.

6,lgfO.When she elevated her right arm, the lefttrunk musculature was induced to maintain activity throughout the task.

As

she

became

able _to _perform shallew squats

more easily, she was then

instrueted

to perform

them arbitrarily

faster

or slower,

for

thiswould re-quire careful grading control of many muscles

throughout thebodyi3-ie]t8'.

Such

sensorimotor expe-rience served as a preparation

for

thecareful

grad-ing

control of

her

teft

facial

muscles.

As

the

con-tro]oyer_shallow _squats improved, fluctuationsin the

locus

of thesubject's standing center of gravity

Fig.6

<LefO

Shallew squatting to increase _postural tone.

(Rjght)

Coming up from tyingon the right side

to augment tonic activity in the left

(5)

Physical Therapy forFacia

began todecrease,and she was more easily able to assume a symmetrical _posture when seated,

Through

the

above activities, she

becarne

able

to

maintain her head ina midline _positionand to hold her mouth closed,

The therapist then directed treatment to facial expression. Most of the

facial

muscles attach tothe

facial

skin, requiring

delicate

methods of making expressions.

This

_part of treatment began with the

subject

in

supine,

because

her

head

could easily

be

stabilized and the effects of _gravity were elimi-nated,

The

right _platysma was overly shortened,

tending topulltheright cheek and right side ofthe

mouth downward. Any movement requires an

ap-propriate degree of fixation.Inthe case of the

rig-ht-hand corner of the mouth being _pulled during enunciation of the

li:/

sound or of the zygomaticus major contracting during a sniile, the levator labii

superioris alaeque nasi and zygomaticus minor

must _play the role of central fixators.The

thera-pist thus induced contractile acti"ity with his

fingers

on Lhe upper cheeks along

both

sides of

the

nose

(Fig.

7,

left).Fingers were also used toinhibit

excessive activity on the

left

side ef the

face

due

to

dysmetria.

The

next task was to

have

thesubject shape

her

mouth for the

fi:f

sound and to have her smile

(Fig.

7,right). By having her phonate with the

li:!

sound weakly so that only mild muscular contrac-tions could beobserved, the tendency forthe lipsto

be _pulledleftward could

be

_prevented. The subject was then to shape her mouth forthe

!ua:/

sound

(Fig

8,

lefV.The therapist manuaHy assisted her in

rounding

her

right side of

her

mouth.

The therapi$t likewise provided manual

assis-tance tothe

drooping

right eyelid to

help

elicit

ac-tivity

from

the orbitar

_portion

of the orbicularis ocuti

by

helping

elevate the

lower

eyelid

during

eye closure

(Fig.

8,

right),

The

therapistalso

helped

bring

about activity inthe

frontalis

toproduce

hor-izontalwrinkles across the

forehead

and in the

cor-rugator supercilii to produce vertical wrinkles

be-tween the eyebrows. Ineach of these instancesthe

1Palsyafter Stroke:A Case Study 439

facialmusculature on theleftside was hyperactive and nbeded tobe inhibited,so only slowly perform-ed contractions were elicited,with _gradual stepwise

increments of effort.

Sometimes

the subject used a mirror inorder to control herfacialexpressions easily by herself.

5. Results

'

At

first

the subject had

diMculty

insitting, but

by

the time of

discharge

she could sit on the edge

of a chair and elevate both arms. She became

capa-ble

of walking

if

_given support under

her

left

arm.

Anteroposterior

fiuctuation

of the

locus

of

her

center of'gravity over a period of five seconds

while seated improved from 12,5cm to 3.3 crn

(Fig.

9). Analysis of head and trunk angles during

Fig.

7 (Left)

Facilitationof stabilizing eontractile

tivityinsuch muscles as the levater

labii

superioris alaeque nasi and zygomaticus

rnlnor.

･

(Right)

Training

for

enunciating the

fi:/

sound and forsmi!ing.

Fig.8

(LefO

Training

for

enunciating the

/ui:/

sound.

(Right)Treatment toassist

in

closing

the

right eye,

(6)

440

ue\thza\

sitting, as recorded

by

the

_video

copy processor, showed that

hyperextensioll

of the head decreased

from,27

degrees

to

9 degrees,

and that the tiltof

the

head

tothe right improved from

13

degrees to

3 degrees,

and that a seven

degree

tiltof the trunk

tothe leftwas corrected toa two degree tilttothe right

(Fig.

10).

Along

with this,closure of the

lips

and mandible became

possible

when the subject

was not under stress, and so her scere foringesting

food

improved

frorn

zero tothree

(Table

2).When she attempted to close hei eyes, the vertical

dis-tance

between

eyelids on theright decreased from

fiveto three millimeters, and the drooping of the eyelid

became

less

apparent

The

conjunctivitis in that eye had inthemeantime abated.

The

manual muscle test revealed changes

in

strength of the

frontalis,

corrugator, zygomaticus

major,

depressor

anguli oris,and orbicularis oris,as

shown

in

Table

2. Photographic

evidence

cen-firmed

thatasymmetry

decreased

when thesubject

shaped

her

mouth

for

the

/a:L

/i:L

and

fur:/

sounds, as well as when she smiled

{right

_pictures

in Figs.2-5). Electromyographic activities of the

depressor

anguli oris muscles exhibited a shift from

a marked asymmetry situation. The right frontalis

and zygomaticus major muscles, on

the

other

hand,

showed no substantial changes

(Fig.

11).

6. Discussion

The factthat the mouth of _thissubject

continual-ly

remained open was particularlyapparent when

accompanied

by

hyperextension

at the neck.

As'

control of the extension of the trunk

improved,

ataxic

fiuctuations

in

movement decreased, which

in

turn enabled the

head

to assume a more erect

positions.AIIef thesechanges appear to

have

con-tributed to helping her maintain closure of the

mouth more easily.

The

exaggerated

flexion

of the

4

･g

[Beginning]

Front

Lt

Fig.9 m Rear

during

sitting,

[End]

Frgnt

.,.tt,'rfff･･･1,y.･v'f''7,/t/tttN

e･'[..t{･Ftttt't.

3.3cm

.

3.1cm

.O.05V/CM)iIRear

Rt,

Fluctuation

inlocusof center of gravity

li1

1

Fig.10

Changes

inposture after fivemonths and

threeweeks of treatment.

sumed a more symmetrical position,suggesting

that

the

positionof the

head

had

belen

established

as a compensatory result to orientate the trunk.

This

case illustrateswell the observation thatfacial paralysisaccompanying a central nervous disorder

(7)

Physical Therapy forFacialPalsyafter

Strokei

A

Case

Study

441'

Rt.

Frontalis

Lt,

[Beginning]

tttttt

l'L...IT.'ttl.//･ 1t---1--･tit/ttt/ttt11･.

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i'/tt

t/tt'ttt

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[End]

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Lt.

-L･.L=･-L..,IILL

_{s.-t-j---ttttf--ii-g"'11!..-:t･-:1tt-t}

cr:･E･･I.I.-I'/t/ttttttltltt.ttttt/ttttttttttt..t...

.t.l../.L-..".t

･--fiN=.l--･-･l･.rmTmTLttt.

'-i(Smiling)

'/'t't''1'1'''''

tt'l"t---..tttlt.:tl--t-t--tt:-'J'l''-L.tLi:ttt

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il-l-!,1:,..tt,p･

･1titti1ir./..i1"'1i't'[･1-･

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Rt.

Depressor

_.

Fig. 11

Changeg

in electromyograms after five months and three weeks of treatment.

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lllZ-,t-"iiti'2

',4--.,.･--･i･--･-can

be

easily

influenced

by

compensatory measures

or abnormalities ofthe trunk.

The fact that the leftfacialmuscles lacked the

fine

delicate

control necessary

for

facial

expressions

can

be

attributed to

abnormal

exaggerated

contrac-tions

due

to

dysmetria.

To

obtain smooth _graded

movements of the facialmuscles needed for facial

expression, the subject practiced

delicate

move-ments of expression on the left$ide of the faceonly after reexperiencing

the

sensation of _graded

move-ment inthe whole body. Movements of fac.ial

ex-pressionon theright side of thefacewere practiced

in conjunction with the leftsided movements to

contribute to a more complete recovery. The right

frontalisand zygomaticus major showed no re-markable myoelectric changes, but manual-muscle

testsand _photographic evidence indieatedsome

im-provement

in

thosemuscles.

The

faintcontractions of the muscles on the right side of the face,

com-b;ned with the exaggerated contractile activitie$ of

the corresponding muscles on

the

left,had !edtoan appearance of facialfeaturesbeing pulled leftward and

thus

to

an inability

for

the

right

facial

muscles

to_participateinfacial,expression.

Looking at the treatment as a whole,

(8)

442

ve\wtza#

posture, which

in

turn

helped

in

the treatment

effect of aHeviating asymmetry

in

movements of

facial

expression and

lack

of

finely

graded

move-rnents.

The

fact

that

improvements

were seen in

facialexpression and in _posture for thischronic case inwhich no more appreciable natural recovery could be expected corroborates the idea that treat-ment of facial_palsyina _patientwho has suffered a cerebrovascular disorder should

best

be performed

in

thecontext of treatment

for

thewhole

body.

Facial

expressions _play an

important

role as a means of nonverbal cornmunications, so that

func-tion should

be

_given

just

as much attention

in

treatment as _gaitand use efthe upper limb'jiT',

7.

Summary

When

facialpalsy accompanies central nerveus

dysfunction, itneecls tobeevaluated and treatedin

the context of abnormal _postural tone and abnor-mal _postural motor _patterns throughout the entire

body. We explored this

idea

by

following

the

im-provement in a person whom we had not begun

treating until

6ne

_year and one week after she had

suffered a stroke. 1) Furusawa M, p$eudebulbar Ryeho,18(5)I 2) Furusawa M, facialmotor

(in

japanese).

3)Furusawa M, pseudobulbar Ryeho, 21(E)I References

Yamakawa'MIPrespeech therapy for

palsyafter stroke

Cin

Japanese).

Ri-Sa-353-355,1984.

Sagasaki

J:Movement

therapy for

oro-dysfunctiondue toParkinsonsyndronie

Ri-Sa-Ryoho,19CO :256-258,1985.

Yamakawa M 1Movement therapy for

palsy after stroke

(in

Japanese).

Ri-Sa-58-61, 1987.

eg

18 gas

4

_e

4)Furusawa M I_Movernent therapy fororofacial motor dysfunction in cerebrovascular accidents _(in_Japanese).

Rigakuryoho,4<2)I139-145,1987.

5) Furusawa M,etat.:Movement therapy forfacialpalsy

after stroke

(in

Japanese}.Rigakuryohogaku

(J.

nese PhysicalTherapy AssociationX150):39-44, 1988.6)

Furusawa M, et at.; Movement therapy for central

oral motor dysfunction:Resultsof treatments

{in

anese). Rigakuryohogaku

{J.

Japanese

Physica}

py Association),16{2):77-83, 1989.

7)Tomita M [Orofacial approach

"n

Japanese).Journal

of the Yamagata Chapterof

Japanese

Physical

py Association,3[29-56, 1989.

8) DaviesPM :_Steps_to_Follow._Tokyo,_{Springer-Verlag,} 1985,pp 245-265.

9)Hirayama K :Shinkeishokogaku

(Neurological

ogy)

{in

Japanese}.

Tokyo,Bunkodo,1984,pp 992-997,

IO)Niki R:Stroke

_(in

_Japanese).Igaku no Ayumi, i16

<s>:439-450,1981.

11)Daniels L,et aL : Muscle Testing, 2nd ed,,

phia. W.B.SaundersCompany, 1968,pp 162-･l74.

i2)Yeshida T, Andrew PD1A timerforsynchronizing analog signals and visual images. Bulletin of Allied

MedicalScience,Kobe,3:67-72, 1987,

13)Reder BD,et al:A Neuro-DevelopmentalAnalysisDf

Normal Movement Patterns:Neonate-TwelveMonths.

Ci]cinnatiOhio,Children'sHospital Medical Center,

1985,pp 29--32.

14)Sone M :MovemenE therapy forstroke _patientwith

ataxia _(in

Japanese).

Rigakuryoho,4{2):127-132,

1987.

15)Manabe K:Case report:Improvement of functionby learning of principalmotility inataxia

(in

_Japanese).

Rigakuryoho,5(2)I125--130,1988.

16)Furusawa M :Prespeech therapy foran ataxic patient

with achewing and swallewing disorder

(in

Japanese).

Rigakuryohegaku

{J,

JapanesePhysicalTherapy

eiation}, 15{2)[126-129, 1988,

17) Takahashi T: Movement therapy rnethod forthe

stroke hemiplegia, past, present and future _(in

nese), Rigakuryoho,4(2)I89-93,l987.

18)Bobath Bi Adult Hemiplegia:Evaluationand

ment. 3rd ed, Oxford,Heinemann MedicalBooks,l990,

(9)

Physical　

Therapy

　for　Facial　Palsy　after 　Stroke：ACase 　

写真

・

顔面筋の筋力テストと表面筋電図

・

兎眼については眼瞼裂ヒ下高の_計測を用いて変化をみた。治療

5

ヵ月

3

遍後に顔面の非対称の表情は改善をみた。