Consensus research priorities for facial palsy: A Delphi survey of patients, carers, clinicians and researchers

A Combined Approach of Facial Neuromuscular Rehabilitation and Surgical Reconstruction in the Remediation of Facial Palsy: A Multidisciplinary Team Approach

Facial neuromuscular rehabilitation (fNMR) is an evidence-based practice for the treatment of peripheral facial palsy (PFP). Surgical reconstruction can be indicated for patients who demonstrate poor or no recovery to support symmetry, function, and aesthesis. There is paucity of research demonstrating the therapeutic benefit of a multidisciplinary team (MDT) in facial recovery of this specific subpopulation of patients. This article will outline the role of specialist facial therapy in the remediation of PFP, focusing on those who undergo surgical reconstruction to optimize their facial recovery. Case studies are used to demonstrate surgical and therapeutic outcomes as well as the results of a patient survey conducted for a service evaluation. We discuss the role of the MDT in supporting recovery as well as the role of targeted fNMR. The term fNMR is often used interchangeably with facial therapy or facial rehabilitation. We will refer to fNMR as a technique of facial rehabilitation.We aim to demonstrate that an MDT approach to the treatment of people with facial palsy provides positive outcomes for this surgical population and that future research would be beneficial to support this service delivery model.

Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study

Background: Nonsurgical rehabilitation of unilateral peripheral facial palsy (FP) varies globally with controversy regarding best practice. Objective: To develop facial therapist consensus regarding what should be included or excluded in rehabilitation of adults with FP of any etiology. Three clinical presentations: flaccid, paretic and synkinetic, were separately considered. Methodology: A two-stage study was conducted: a nominal group technique (NGT) to develop a questionnaire plus Delphi study. Delphi participants were recruited worldwide, through an experience-based inclusion questionnaire. The final Delphi questionnaire included 166 items for each clinical presentation covering assessment, outcome measures, and interventions, for example, education, eye care, neuromuscular retraining, and electrical modalities. Inclusion/exclusion agreement was set at 80%, indicating participant consensus. Items reaching 70-79% were deemed "near-included/near-excluded." Results: Averaged across all presentations, 24.9% of the 166 items were included, (e.g., Sunnybrook Facial Grading System, patient education and neuromuscular retraining), 26.9% of the 166 items were excluded, (e.g., gross strengthening and electrical stimulation); 48.2% were neither included nor excluded. Conclusion: This study brings together the global community's expertise as a first step toward establishing best practice for specialist facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

Guided Self-rehabilitation Contract vs conventional therapy in chronic peripheral facial paresis: VISAGE, a multicenter randomized controlled trial

BACKGROUND

One year after persistent peripheral facial paresis (PFP), prescriptions of conventional rehabilitation are often downgraded into maintenance rehabilitation or discontinued, the patient entering what is seen as a chronic stage. This therapeutic choice is not consistent with current knowledge about behavior-induced plasticity, which is available all life long and may allow intense sensorimotor rehabilitation to remain effective. This prospective, randomized, multicenter single-blind study in subjects with chronic unilateral PFP evaluates changes in facial motor function with a Guided Self-rehabilitation Contract (GSC) vs. conventional therapy alone, carried out for six months.

METHODS

Eighty-two adult subjects with chronic unilateral PFP (> 1 year since facial nerve injury) will be included in four tertiary, maxillofacial surgery (2), otolaryngology (1) and rehabilitation (1) centers to be randomized into two rehabilitation groups. In the experimental group, the PM&R specialist will implement the GSC method, which for PFP involves intensive series of motor strengthening performed daily on three facial key muscle groups, i.e. Frontalis, Orbicularis oculi and Zygomatici. The GSC strategy involves: i) prescription of a daily self-rehabilitation program, ii) teaching of the techniques involved in the program, iii) encouragement and guidance of the patient over time, in particular by requesting a quantified diary of the work achieved to be returned by the patient at each visit. In the control group, participants will benefit from community-based conventional therapy only, according to their physician's prescription. The primary outcome measure is the composite score of Sunnybrook Facial Grading System. Secondary outcome measures include clinical and biomechanical facial motor function quantifications (Créteil Scale and 3D facial motion analysis through the Cara system), quality of life (Facial Clinimetric Evaluation and Short-Form 12), aesthetic considerations (FACE-Q scale) and mood representations (Hospital Anxiety and Depression scale). Participants will be evaluated every three months by a blinded investigator, in addition to four phone calls (D30/D60/D120/D150) to monitor compliance and tolerance to treatment.

DISCUSSION

This study will increase the level of knowledge on the effects of intense facial motor streng-          Facial paralysisthening prescribed through a GSC in patients with chronic peripheral facial paresis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04074018 . Registered 29 August 2019.

PROTOCOL VERSION

Version N°4.0-04/02/2021.

'Everybody is watching me': A closer look at anxiety in people with facial palsy

OBJECTIVES

Objectives were to evaluate the sociodemographic and disease-related factors, and coping style associated with social interaction and social appearance anxiety in people with unilateral facial palsy.

METHODS

Medical data were extracted from electronic health records, and participants completed the Social Interaction Anxiety Scale (SIAS), Social Appearance Anxiety Scale (SAAS), and Coping Orientation to Problems Experienced inventory. Associations of SIAS and SAAS scores with sociodemographic and disease variables, and coping were assessed with multiple linear regression.

RESULTS

Among 111 participants (mean age 58.6 years; 59% women), higher age and greater use of emotion-focused coping were associated with lower SIAS scores, whereas greater use of avoidant coping was associated with higher SIAS scores. Higher age, male sex, and greater use of emotion-focused coping were associated with lower SAAS scores, whereas greater use of avoidant coping was associated with higher SAAS scores.

CONCLUSIONS

Healthcare providers should understand that women and younger people are more likely to have social appearance concerns and that this is not predicted by the objective severity of facial palsy.

Contribution of the Synkinesis Assessment Questionnaire and the Sunnybrook Facial Grading System to the evaluation of synkinesis after peripheral facial palsy: A STROBE observational study

OBJECTIVES

The main aim of the study was to determine whether the perception of synkinesis by patients with peripheral facial palsy (PFP) matched their clinician's severity assessment. Secondary objectives comprised: (1) to determine whether objective measurement of synkinesis matched the patient's perception; and (2) is to identify factors influencing patients' perceptions.

METHODS

This retrospective study took place from January to May 2020. Forty patients (8 per PFP grade, I-V/VI; 20 women, 20 men) filled out the Synkinesis Assessment Questionnaire (SAQ) and were assessed on the Sunnybrook Facial Grading System (SFGS). Photographs were analyzed on MEEI-Facegram software.

RESULTS

Perceived synkinesis (total SAQ) matched objective grades (SFGS) (Z=2.89; P=0.004), especially for smiling (Z=3.84; P<0.001) and lip protrusion (Z=3.79; P<0.001). Synkinesis on lip protrusion was a more sensitive indicator of perceived synkinesis than synkinesis on smiling (Z=2.96; P=0.003). Duration (ρ=0.5137; P<0.001) and grade of PFP (Chi²=13.82; P=0.008) heightened the perception of synkinesis.

CONCLUSION

Patient-reported outcome measures (PROMs) such as the SAQ are relevant for clinical evaluation.

Physical rehabilitation of central facial palsy: A survey of current multidisciplinary practice

Purpose: The role of allied health practitioners providing physical rehabilitation of central facial palsy (CFP) is minimally reported in the literature. This study explores current practice and the roles, attitudes and perceptions of allied health professionals (AHPs) working with people with CFP.Method: An electronic survey was distributed to speech-language pathologists (SLPs), occupational therapists and physiotherapists. Responses (n = 78) were analysed using qualitative and quantitative methods.Result: SLPs often lead management of CFP; however, their role is not clearly defined nor well recognised. Several barriers were identified which prevent AHPs from providing consistent specialist rehabilitation to people with CFP. These included a lack of training, no clear delegation of role, limited evidence and lack of resources.Conclusion: Survey respondents viewed CFP to be within SLP scope of practice; although, ownership of management varies between countries and professions. Most SLPs recognise the negative impact of CFP and feel a sense of responsibility to provide assessment and treatment of this impairment, but many barriers to doing so have been identified. Suggestions to improve access to rehabilitation for people with CFP included increased access to training for SLPs, more evidence, clinical practice guidelines and more clinical resources. Further research is required to ensure people suffering from CFP can access services that provide skilled management of their impairment.

Identifying research priorities for road safety in Nepal: a Delphi study

OBJECTIVE

To identify and prioritise the research needed to help Nepali agencies develop an improved road safety system.

DESIGN

Delphi study.

SETTING

Nepal.

PARTICIPANTS

Stakeholders from government institutions, academia, engineering, healthcare and civil society were interviewed to identify knowledge gaps and research questions. Participants then completed two rounds of ranking and a workshop.

RESULTS

A total of 93 participants took part in interviews and two rounds of ranking. Participants were grouped with others sharing expertise relating to each of the five WHO 'pillars' of road safety: (1) road safety management; (2) safer roads; (3) safer vehicles; (4) safer road users and (5) effective postcrash response. Interviews yielded 1019 research suggestions across the five pillars. Two rounds of ranking within expert groups yielded consensus on the important questions for each pillar. A workshop involving all participants then led to the selection of 6 questions considered the most urgent: (1) How can implementing agencies be made more accountable? (2) How should different types of roads, and roads in different geographical locations, be designed to make them safer for all road users? (3) What vehicle fitness factors lead to road traffic crashes? (4) How can the driver licensing system be improved to ensure safer drivers? (5) What factors lead to public vehicle crashes and how can they be addressed? and (6) What factors affect emergency response services getting to the patient and then getting them to the right hospital in the best possible time?

CONCLUSIONS

The application of the Delphi approach is useful to enable participants representing a range of institutions and expertise to contribute to the identification of road safety research priorities. Outcomes from this study provide Nepali researchers with a greater understanding of the necessary focus for future road safety research.

Establishing the national top 10 priority research questions to improve diabetes-related foot health and disease: a Delphi study of Australian stakeholders

INTRODUCTION

Diabetes-related foot disease is a large cause of the global disease burden yet receives very little research funding to address this large burden. To help address this gap, it is recommended to first identify the consensus priority research questions of relevant stakeholders, yet this has not been performed for diabetes-related foot disease. The aim of this study was to determine the national top 10 priority research questions for diabetes-related foot health and disease from relevant Australian stakeholders.

RESEARCH DESIGN AND METHODS

A modified three-round Delphi online survey design was used to seek opinions from relevant Australian stakeholders including those with diabetes or diabetes-related foot disease or their carers (consumers), health professionals, researchers and industry. Participants were recruited via multiple public invitations and invited to propose three research questions of most importance to them (Round 1), prioritize their 10 most important questions from all proposed questions (Round 2), and then rank questions in order of importance (Round 3).

RESULTS

After Round 1, a total of 226 unique questions were proposed by 210 participants (including 121 health professionals and 72 consumers). Of those participants, 95 completed Round 2 and 69 completed Round 3. The top 10 priority research questions covered a range of topics, including health economics, peripheral neuropathy, education, infection, technology, exercise, and nutrition. Consumers prioritized peripheral neuropathy and prevention-related questions. Health professionals prioritized management-related questions including Australia's First Peoples foot health, health economics and infection questions.

CONCLUSIONS

These priority research questions should guide future national research agendas, funding and projects to improve diabetes-related foot disease burdens in Australia and globally. Future research should focus on consumer priority research questions to improve the burden of diabetes-related foot disease on patients and nations. Further research should also investigate reasons for different priorities between consumers and health professionals.

Bell's palsy during pregnancy and the post-partum period: A contemporary management approach

Bell's palsy during pregnancy and the immediate post-partum period represents a unique clinical entity requiring an individualised management approach. Whilst the exact link between Bell's palsy and pregnancy is still unclear, the majority of cases occur in the third trimester and immediate post-partum period. These patients have been demonstrated to experience worse long term outcomes and are less likely to receive early corticosteroid therapy. This review suggests a contemporary management algorithm to ensure that these patients receive early therapy that is safe for the patient and foetus and meets the unique physical needs of the expecting or new mother.

'Your face freezes and so does your life': A qualitative exploration of adults' psychosocial experiences of living with acquired facial palsy

OBJECTIVES

Facial palsy (FP) is a highly visible appearance-affecting condition and can have a significant impact on facial function. Qualitative research focussing on adults' experiences of living with acquired FP is limited. This study aimed to explore the psychosocial impact of acquired FP and to gain a greater understanding of patients' experiences of treatment and care in the United Kingdom.

DESIGN

A qualitative interview study with individuals living with acquired FP.

METHODS

Ten adults with acquired FP were recruited. Their experiences were explored using semi-structured telephone interviews. Data were analysed using thematic analysis.

RESULTS

Five master themes were identified through the thematic analysis: 1) grappling with a new identity, 2) the psychosocial impact of living with facial palsy, 3) isolation: dealing with 'one hell of a problem on your own', 4) a life on hold, 5) coping strategies. Findings indicated high levels of distress and significant challenges in managing the functional and psychosocial changes associated with acquiring FP. Participants expressed grief for their former appearance and identity, with photographs and mirrors acting as agonizing reminders. Many reported a sense of abandonment due to uncoordinated care and, as a result, engaged in an endless and often fruitless pursuit to gain control over FP by experimenting with their own treatment. Many reported the negative impact of their altered facial expressions on social interactions and a fear of being negatively evaluated.

CONCLUSIONS

This study highlights a pressing need to review how FP is managed in the UK. To improve patient well-being, health care professionals could benefit from FP education, and patients from timely access to psychological support and clearer standards of care following diagnosis.

Differences between Patient and Surgeon Interests in Musculoskeletal Research

BACKGROUND

There is a growing interest in engaging patients in research priorities and project design. This study compared topics patients and surgeons would like to address in upper extremity musculoskeletal research.

METHODS

We invited patients on social media-based support groups for specific musculoskeletal illnesses and members of the Science Of Variation Group to indicate the three most important research topics by disease. We also measured agreement that patients should participate in research on a five-point Likert scale. We categorized research priorities into the following categories: treatment, cause and natural history, recovery, diagnostic process, and economic impact. Bivariate analysis was used to detect differences between surgeons and patient responses. Multivariable regression models sought factors associated with agreement whether patients should participate in research. Sixty-two surgeons and 350 patients completed the survey, who had one of the following musculoskeletal illnesses: Dupuytren contracture, adhesive capsulitis, Kienböck disease, complex regional pain syndrome, rotator cuff tendinopathy, carpal- or cubital tunnel syndrome, and rheumatoid arthritis.

RESULTS

Both patients and surgeons were most interested in research into treatment options. There were few differences in the number of responses per category between surgeons and patients. Patients and surgeons with fewer years of practice agree most with involving patients in research.

CONCLUSION

Patients and surgeons prioritize research about treatment. Surgeons were more interested in natural history of disease and surgical techniques, while patients were more interested in alleviation of pain.

Developing Consensus-Based Outcome Domains for Trials in Children and Adolescents With CKD: An International Delphi Survey

RATIONALE & OBJECTIVE

The inconsistency in outcomes reported and lack of patient-reported outcomes across trials in children with chronic kidney disease (CKD) limits shared decision making. As part of the Standardized Outcomes in Nephrology (SONG)-Kids initiative, we aimed to generate a consensus-based prioritized list of critically important outcomes to be reported in all trials in children with CKD.

STUDY DESIGN

An online 2-round Delphi survey in English, French, and Hindi languages.

SETTINGS & PARTICIPANTS

Patients (aged 8-21 years), caregivers/family, and health care professionals (HCPs) rated the importance of outcomes using a 9-point Likert scale (7-9 indicating critical importance) and completed a Best-Worst Scale.

ANALYTICAL APPROACH

We assessed the absolute and relative importance of outcomes. Comments were analyzed thematically.

RESULTS

557 participants (72 [13%] patients, 132 [24%] caregivers, and 353 [63%] HCPs) from 48 countries completed round 1 and 312 (56%) participants (28 [40%] patients, 64 [46%] caregivers, and 220 [56%] HCPs) completed round 2. Five outcomes were common in the top 10 for each group: mortality, kidney function, life participation, blood pressure, and infection. Caregivers and HCPs rated cardiovascular disease higher than patients. Patients gave lower ratings to all outcomes compared with caregivers/HCPs except they rated life participation (round 2 mean difference, 0.1), academic performance (0.1), mobility (0.4), and ability to travel (0.4) higher than caregivers and rated ability to travel (0.4) higher than HCPs. We identified 3 themes: alleviating disease and treatment burden, focusing on the whole child, and resolving fluctuating and conflicting goals.

LIMITATIONS

Most participants completed the survey in English.

CONCLUSIONS

Mortality, life participation, kidney function, and blood pressure were consistently highly prioritized by patients, caregivers, and HCPs. Patients gave higher priority to some lifestyle-related outcomes compared with caregivers/HCPs. Establishing critically important outcomes for all trials in children with CKD may improve consistent reporting of survival, kidney health, and clinical and life impact outcomes that are meaningful for decision making.

Nursing Research Priorities in Critical Care, Pulmonary, and Sleep: International Delphi Survey of Nurses, Patients, and Caregivers

The objective of this workshop was to determine current nursing research priorities in critical care, adult pulmonary, and sleep conditions through input from consumer (patient, family, and formal and informal caregivers) and nursing experts around the world. Working groups composed of nurses and patients selected potential research priorities based on patient insight and a literature review of patient-reported outcomes, patient-reported experiences, and processes and clinical outcomes in the focal areas. A Delphi consensus approach, using a qualitative survey method to elicit expert opinion from nurses and consumers was conducted. Two rounds of online surveys available in English, Spanish, and Chinese were completed. A 75% or greater threshold for endorsement (combined responses from nursing and consumer participants) was determined a priori to retain survey items. A total of 837 participants (649 nurses and 188 patients, family, and/or caregivers) from 45 countries responded. Survey data were analyzed and nursing research priorities that comprise 23 critical care, 45 adult pulmonary, and 16 sleep items were identified. This project was successful in engaging a wide variety of nursing and consumer experts, applying a patient-reported outcome/patient-reported experience framework for organizing and understanding research priorities. The project outcome was a research agenda to inform, guide, and aid nurse scientists, educators, and providers, and to advise agencies that provide research and program funding in these fields.