Running head: INTEGRATED REVIEW 1

Integrated Review Assignment

Kendra Jackson

NUR4122

November 21, 2016

On my honor, I have neither given nor received aid on this assignment or test, and I pledge that

I am in compliance with the BSMCON Honor System.

Kendra Jackson
INTEGRATED REVIEW 2

Abstract

The purpose of this integrated review is to provide a summary of the current state of the science

concerning the psychosocial effects of facial palsy on affected patients. Facial palsy weakens

facial muscles and can lead to a loss in movement and function. Common causes include

infection, trauma, tumors, and stroke. Psychological distress, often in the form of anxiety and

depression, is experienced by facial palsy patients due the inability to effectively communicate

and perform functional activities. Although psychological distress is a known symptom, its

prevalence in facial palsy patients has yet to be researched. The literature search for this

integrative review was conducted using the computer-based search engine PubMed. The

computer-based search and examination of applicable reference pages yielded 18 research

articles and five met inclusion criteria. The results and findings analysis of the five articles

demonstrated increased psychological distress in facial palsy patients. The results revealed

increased anxiety, depression, and negative personality factors in affected patients. Findings

suggest that early recognition of psychological symptoms in facial palsy patients should be

incorporated into practice. Treating the psychological symptoms may help improve the physical

symptoms of Bells palsy. Limitations included the researchers lack of experience and

knowledge, 5-10 year publication timeframe, and constraints on the number of articles used for

the review. Future research should include should center on the long-term assessment of the

psychological effects of facial palsy on affected patients.

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Integrated Review Assignment

The purpose of this integrated review is to summarize the literature on the subject of

psychosocial effects of facial palsy on affected patients. Facial palsy refers to a weakness of the

facial muscles produced by temporary or permanent damage of the facial nerves (Fu, Bundy, &

Sadiq, 2011). Facial palsy often produces facial disfigurement that can cause patients to

experience severe psychological and social difficulties. Facial palsy can be caused by a number

of disorders and conditions including Bells palsy, myasthenia gravis, and head and neck cancers.

Altered or diminished facial expressions can affect verbal and non-verbal communication with

others. The inability to perform functional activities such as eating and drinking can cause

embarrassment. These problems can lead to increased anxiety levels, maladaptive behaviors, and

depression, suggesting that psychological interventions may be necessary in conjunction with

medical therapy for facial palsy disorders. Psychosocial distress is a symptom that is likely

experienced by facial palsy patients. This topic interests the researcher because of the limited

knowledge on the prevalence of psychosocial distress in this population. Therefore, the PICO

question posed by the researcher is: What are the psychosocial effects of facial paralysis

disorders on affected patients?

Research Design, Search Methods, & Search Outcomes

The research design of this assignment is an integrative review. The integrative review

was written as a class assignment for the Nursing Research course in an undergraduate nursing

program. The search for peer-reviewed research studies was conducted utilizing the computer-

based search engine PubMed. The search terms included, facial paralysis, stress,

psychosocial distress, facial palsy, and Bells palsy. The PubMed search yielded eleven

articles, indicating the limited amount of literature on the topic. Using the reference sections of
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applicable articles, the researcher was able to find seven more relevant studies. The search was

limited to peer-reviewed qualitative and quantitative research studies, written in English, and

published between 2011 and 2016. The articles had to be relevant to the researchers PICO

question, What are the psychosocial effects of facial paralysis disorders on affected patients?

The articles were then screened based on the aforementioned inclusion criteria. Articles that did

not meet these criteria were excluded from the review. After screening the articles using the

inclusion and exclusion criteria, five were included in the review. One article that was published

in 1995 was included due to the limited amount of literature on the researchers topic of interest.

The remaining four articles were published between the years 2011 and 2014.

Findings/Results

The findings and results of the five reviewed research studies suggest facial palsy

disorders have an impact on the psychosocial status of affected patients (Fu et al., 2011, Huang et

al., 2012, Richards et al., 2014, Walker et al., 2012, Weir et al., 1995). A summary of the research

studies is presented in tables 1-5 below. The researcher framed the review using the following

themes: psychosocial parameters in relation to facial palsy disorders, gender differences related

to facial palsy experiences, and the House-Brackmann scale to measure severity of facial

paralysis.

Psychosocial Parameters in Relation to Facial Palsy Disorders

All five studies measured psychosocial parameters in relation to a facial palsy disorder

(Fu et al., 2011, Huang et al., 2012, Richards et al., 2014, Walker et al., 2012, Weir et al., 1995).

In the qualitative study conducted by Richards et al. (2014), it was determined that ptosis,

drooping of the upper eyelid associated with myasthenia gravis, can have significant impacts on

patient well-being and quality of life. Using purposeful sampling, myasthenia gravis patients
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were identified as members of an online social media group. An open-ended e-mail questionnaire

addressed how ptosis affected participants socially, psychologically, and functionally. Data was

collected from 166 myasthenia gravis patients and analyzed using Inductive Thematic Analysis.

The major themes gathered from the data included social, psychological, and behavioral impacts

of ptosis; ptosis as a symptom of myasthenia gravis; the relationship between functional and

appearance-related aspects of myasthenia gravis; and the need for support from health care

professionals. The psychological impacts reported include increased emotional distress, anxiety,

and self-consciousness. This study contributes to the body of literature by highlighting the

subjective experience of people with myasthenia gravis, which has not previously been studied.

The quantitative study by Fu et al. (2011) examined the prevalence of psychological

distress in facial palsy patients by measuring anxiety and depression. Utilizing a convenience

sampling method, 103 facial palsy patients were selected to participate in the study. The cause of

the samples facial palsy varied; however, majority was due to either Bells palsy or acoustic

neuroma. Data was collected using the Illness Perception Questionnaire-Revised (IPQ-R), the

House-Brackmann scale and the Hospital Anxiety and Depression Scale (HADS). Data analysis

used SPSS v16 software. The Mann-Whitney U test was used to determine differences between

HADS scores of male and female participants. Correlational analysis was used to find

relationships between the different IPQ-R subscales and between IPQ-R and HADS subscales.

The results found that the more chronic the illness, the more impact it had on the quality of life

of participants. A significant level of depression and anxiety was found among the sample group.

Females experienced higher levels of anxiety when compared to males. This study adds to the

body of knowledge by highlighting implications for clinical care and level of psychological

distress in facial palsy patients

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Walker et al. (2012) aimed to identify patients who may benefit from psychological

interventions combined with medical therapy. In order to do this, the researchers assessed the

prevalence of psychological distress amongst facial palsy patients at point of referral to a

specialist center. Using a convenience sampling method, 126 patients attending a

multidisciplinary clinic were asked to participate in the study. The Hospital Anxiety and

Depression Scale (HADS) was used to measure levels of anxiety and depression among the

participants. The House-Brackmann scale and Sunnybrook Facial Grading Score served as facial

grading systems. Data was analyzed using unpaired T-test. The study demonstrated high rates of

anxiety and depression among patients with facial palsy. Women showed higher rates of mood

disturbance due to facial disfigurement than men. This study contributes to the body of

knowledge by focusing on the identification and treatment of psychological disorders as a part of

facial palsy management.

The case-control study conducted by Huang et al. (2012) sought to examine the

relationship between psychological factors, specifically psychological distress and personality,

and the severity of Bells palsy by comparing the psychological status of Bells palsy patients to

a control group of healthy individuals. Participants were selected using convenience sampling

and included 365 Bells palsy patients and 340 control subjects. Psychological distress was

measured using the Psychological Distress Scale (K10). Personality was evaluated using the

Cattell 16 Personality Factor scale (16PF).The severity of the Bells palsy was determined using

HB scores. Data analysis of was performed using SAS 8.0 software. To analyze baseline

characteristics like age and sex x 2 was used. To compare scores of psychological distress and

personality between Bells palsy patient and control subjects, t test was used. Overall, the study

demonstrated that Bells palsy patients had more negative personality factors than control
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subjects. Females were found to be more susceptible to the disfiguring effects of Bells palsy.

The results also suggested that increased severity and longer duration of facial paralysis led to

experiences of greater psychological distress. The study contributes to the body of literature by

comparing Bells palsy patients to control subjects to help explain the differences in

psychological status.

The study conducted by Weir et al. (1995) wanted to determine whether low self-image,

anxiety, depression, or restricted social contact occurs with Bells palsy (p.121). Twenty patients

with Bells palsy were recruited from a facial palsy clinic using the convenience sampling

method. Self image was assessed using the Facial Self-Image Scale. To screen for anxiety and

depression, the General Health Questionnaire was used. The Functional Disability Questionnaire

was used to gauge the impact of Bells palsy on social and daily living activities. A semi-

structured interview was conducted to determine the consequences of facial paralysis. Data

analysis was performed using the Pearson correlation coefficient technique. The results indicated

that higher levels of anxiety and depression are associated with impaired social and daily living

activities. Anxiety and depression also correlated with depressed self-image. With increasing

severity of the facial paralysis, participants experienced increased social handicaps. This study

adds to the body of knowledge by exploring the effects of Bells palsy on self-image, anxiety,

and depression.

Gender Differences Related to Facial Palsy Experiences

Three of the five articles noted gender differences related to facial palsy experiences (Fu

et al., 2011, Huang et al., 2012, Walker et al., 2012). Fu et al. (2011) found that gender

differences only occurred in terms of Hospital Anxiety and Depression Scale (HADS) anxiety

scores only. Female participants in this study had significantly higher levels of anxiety when
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compared to male participants; however, female and male participants were equally like to

experience high levels of depression (Fu et al., 2011, p. 1325). Higher levels of psychological

distress existed in female, severe, sub-acute Bells palsy subjects than in male, mild, acute

patients (Huang et al., 2012). The researchers discovered negative personality factors were

higher in female participants while positive factors were lower. For example, female participants

experienced Vigilance (L), Apprehension (O), and Tension (Q4) more than male participants.

Scores for Warmth (A) and Perfectionism (Q3) were lower in female participants. Walker et al.

(2012) found that women experience higher rates of anxiety, depression, and distress in facial

disfigurement than men. A possible explanation given for gender differences experienced by

females was due to increased emphasis on appearance by society (Fu et al., 2011).

House-Brackmann Scale to Measure Severity of Facial Paralysis

Three of the five articles utilized the House-Brackmann scale to measure the severity of

facial paralysis caused by facial palsy (Fu et al., 2011, Huang et al., 2012, Walker et al., 2012).

Fu et al. (2011) assessed the clinical severity of facial palsy using the scale. In this study, the

House-Brackmann scale is described using grades from 1 to 6; 1 being normal and 6 representing

complete facial paralysis. Huang et al. (2012) used the House-Brackmann scale for primary

measurement of facial-nerve function. The researchers mention the scale is widely used in

clinical practice and easily administered. They described the system as a 6-point scale that

evaluates the degree of facial-nerve function, with 1 signifying normal function and 6 indicating

total functional failure. In order to assign points, the facial appearances of participants were

assessed performing four poses: at rest, with a forced smile, with raised eyebrows, and with eyes

tightly closed (Huang et al., 2012, p.273). Walker et al. (2012) described the House-Brackmann

scale as an accepted facial grading system used to evaluate resting symmetry, movement and the
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degree of synkinesis (involuntary/unwanted movement of muscles accompanying a voluntary

movement) in facial paralysis (p. 475).

Discussion/Implications

The findings of the integrative review suggest facial palsy has an impact on the

psychosocial status of participants. As a result, the review findings pertain to and support the

researchers PICO question. The PICO question specifically addresses the psychosocial effects

that facial palsy have on affected patients. The qualitative study conducted by Richards et al.

(2014) clearly suggested ptosis attributed to increased self-consciousness, emotional distress,

depression, and social anxiety experienced by myasthenia gravis patients. The four quantitative

studies showed facial palsy patients experienced increased psychological distress, often

measured using depression and anxiety parameters (Fu et al., 2011. Huang et al., 2012, Walker et

al., 2012, Weir et al., 1995).

Three of the quantitative studies focused on the relationship between the degree of facial

paralysis and psychosocial factors (Huang et al., 2012, Walker et al., 2012, Weir et al., 1995).

Huang et al. (2012) found that the more severe the paralysis, the greater the psychological stress

on Bells palsy patients. Personality was also closely related to the severity of the facial

paralysis. The researchers explained negative personality factors like tension can aggravate

inflammatory pathways thereby exacerbating facial paralysis. Walker et al. (2012) found that

increasing House-Brackmann and Sunnybrook scores did not influence Hospital Anxiety and

Depression Scale (HADS) scores (p. 476). Weir et al. (1995) cited a low association between

severity of palsy and changes in psychosocial functioning. The researchers explained that the

presence of facial paralysis, rather than its severity, had an effect on the psychological state of a

patient (Walker et al., 2012, Weir et al., 1995).

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The review findings suggest the early recognition of psychological symptoms in facial

palsy patients should be incorporated into practice (Fu et al., 2011, Walker et al., 2012).

Psychological problems associated with facial palsy are underestimated and ignored by clinicians

(Fu et al., 2011). Medical treatment for the functional problems associated with facial palsy is

not enough. Functional problems may resolve as the facial palsy disorder improves; however

psychosocial issues will be remain unless they are recognized and treated. Early awareness and

recognition can help to identify patients who may benefit from psychological interventions in

conjunction with medical therapy. Future research should be directed towards assessing the

long-term psychological effects of facial palsy on affected patients (Huang et al., 2012). Previous

research involved mostly acutely diagnosed patients and was usually conducted shortly after the

onset of facial palsy disorders. Knowing long-term effects could encourage early screening and

treatment for psychological symptoms (Fu et al, 2011). The health care system has not yet

accepted the results of facial palsy research and applied them to practice. Further research will

allow health care providers to better understand facial palsy patients and manage their care.

Limitations

The researcher recognizes several limitations that have may have influenced this

integrative review. First, the integrative review is a class assignment being conducted by an

inexperienced researcher. With limited knowledge and experience with this type of assignment,

the researcher could have misinterpreted some data used in this review. Next, the requirements

for this assignment limited the review to five peer-reviewed journal articles published within the

last five years. Due to the limited research on this topic, the researcher had to use an article that

did not meet the assignment criteria.

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The qualitative study conducted by Richards et al. (2014) collected data from 166

participants who experienced ptosis as a symptom of myasthenia gravis. Sample sizes in

qualitative studies are often small because the researcher is not attempting to generalize findings

(Ryan, Coughlan, & Cronin, 2007). The large sample used in this study could be explained by

the sampling method. Subjects were enlisted using an online social media group (Richards et al.,

2014). The purposeful sampling method ensured that participants that were recruited had

experience with ptosis as a symptom of myasthenia gravis. However, this could have introduced

bias because some myasthenia gravis patients do not use social media. Younger people are also

more like to use social media than older adults. The phenomenological approach was used to

explore the lived experiences of myasthenia gravis patients who had ptosis (Ryan et al., 2014).

Qualitative or descriptive studies are level VI evidence, meaning they provide some of the lowest

quality research evidence (Fineout-Overholt, Melnyk, & Williamson, 2010a). However,

qualitative research is often theory-generating and provide a basis for further quantitative studies

(Ryan et al., 2014). Credibility was achieved by using a six-step process to code data (Richards

et al., 2014). This process included a two-person analysis, check against original data, and

modification of the themes based on participants feedback.

None of the quantitative studies used in this review performed a power analysis (Fu et al.,

2011, Huang et al., 2012, Walker et al., 2012, Weir et al., 1995). This means the researchers did

not include whether the sample sizes were adequate for the purpose of their studies (Coughlan,

Cronin, & Ryan, 2007). The convenience sampling method used in all of the studies could have

introduced bias because the desired populations could have been misrepresented (Fineout-

Overholt, Melnyk, & Williamson, 2010b). Only one study mentions the attrition rate (Huang et

al., 2012). A low attrition rate, meaning many participants left before completing the study, could
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lead to biased findings (Fineout-Overholt et al., 2010b). Case-control or cohort studies, like those

used in this review, are level IV evidence, meaning they do not provide the highest quality of

research evidence (Fineout-Overholt et al., 2010a). Variables such as anxiety, depression, and

severity of facial paralysis, were operationalized using appropriate scales. Validity and reliability

of the instruments used in these studies were not addressed. These concepts are important

because they evaluate the ability of an instrument to consistently and accurately measure

concepts (Coughlan et al., 2007).

Conclusion

The findings of this integrative review support that facial palsy patients experience

increased levels of psychological distress. Facial palsy patients, especially females, experienced

greater levels of anxiety, depression, and negative personality factors. Recognizing these

differences may help health care providers to more appropriately treat the psychological

symptoms associated with facial palsy disorders. Previous studies focused primarily on acutely

diagnosed patients. Future research opportunities should be focused on assessing the long-term

psychological effects of facial palsy on affected patients. Early recognition and diagnosis of

psychological problems is essential in facial palsy management. Treating the psychological

symptoms may help improve the physical symptoms of Bells palsy. Nurses will be at the

forefront in addressing this issue as members of the interdisciplinary team. They must advocate

for the holistic treatment of facial palsy patients by focusing not only on the body but also on the

mind.
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References

Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1:

Quantitative research. British Journal of Nursing, 16(11), 658-663.

doi:10.12968/bjon.2007.16.11.23681

Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. (2010a). Critical appraisal of

the evidence: Part I. The American Journal of Nursing, 110(7), 47-52.

Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. (2010b). Critical appraisal of

the evidence: Part II. The American Journal of Nursing, 110(9), 41-48.

Fu, L., Bundy, C., & Sadiq, S. (2011). Psychological distress in people with disfigurement from

facial palsy. Eye, 25(10), 1322-1326. doi:10.1038/eye.2011.158

Huang, B., Xu, S., Xiong, J., Huang, G., Zhang, M., & Wang, W. (2012). Psychological factors

are closely associated with the Bells palsy: A case-control study. Journal of Huazhong

University of Science and Technology [Medical Sciences], 32(2), 272-279.

doi:10.1007/s11596-012-0048-0

Richards, H. S., Jenkinson, E., Rumsey, N., & Harrad, R. A. (2014). The psychosocial impact of

ptosis as a symptom of myasthenia gravis: A qualitative study. Orbit, 33(4), 263-269.

doi:10.3109/01676830.2014.904375

Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2:

Qualitative research. British Journal of Nursing, 16(12), 738-744.

doi:10.12968/bjon.2007.16.12.23726

Walker, D., Hallam, M., Ni Mhurchadha, S., Mccabe, P., & Nduka, C. (2012). The psychosocial

impact of facial palsy: Our experience in one hundred and twenty six patients. Clinical

Otolaryngology, 37(6), 474-477. doi:10.1111/coa.12026

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Weir, A., Pentland, B., Crosswaite, A., Murray, J., & Mountain, R. (1995). Bell's palsy: The

effect on self-image, mood state and social activity. Clinical Rehabilitation, 9(2), 121-

125. doi:10.1177/026921559500900206
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First Author Psychological Factors Are Closely Associated with the Bells
(Year)/Qualifications Palsy: A Case-Control Study

Bo Huang, Shabei Xu, Jin Xiong, Guangying Huang, Min

Zhang, Wei Wang (2012)/ Tongji Hosptial, Tongji Medical
College, and Huazhong University of Science and Technology
(research-intensive institutions in China) but no specific mention
of expertise in Bells Palsy

Background/Problem Background clearly defines the symptomology of Bells palsy

Statement including crooked mouth, incompletely closed eyes, and
inability to frown; Aim is to observe the differences in
psychological status between Bells palsy patients and control
subjects and to examine the relationship between psychological
factors and the severity of Bells palsy; Literature review
focuses on the psychological factors associated with facial
paralysis limited research comparing the differences in
psychological stress and personality in Bells palsy patients and
control subjects; no studies that explored the relationship
between psychological factors and the degree of facial paralysis

Conceptual/theoretica No theoretical framework was identified by the authors of the

l Framework study (appropriate for this type of study because theoretical
frameworks tend to be non-existent in descriptive studies)
Design/ Quantitative study, descriptive case-control
Method/Philosophical
Underpinnings

Sample/ 355 patients with Bells palsy and 340 healthy individuals
Setting/Ethical between the ages of 18 and 65/ Participants recruited from area
Considerations hospitals and surrounding districts / Approved by the Medical
Ethics Committee of Tongji Hospital, Tongji Medical College,
and Huazhong University of Science and Technology in Wuhan,
China; informed consent obtained from participants
Major Variables Psychological factors, specifically psychological distress and
Studied (and their personality, and severity of Bells palsy
definition), if
appropriate

Measurement -Severity of facial paralysis House-Brackmann grading

Tool/Data Collection system (primary measurement) Facial Disability Index
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Method (secondary measurement)

-Psychological distress Psychological Distress Scale (K10)
-Personality Cattell 16 Personality Factor (16PF) scale
- HB scores severity of the disease with mild cases scoring 1 to
3 and severe cases scoring 4 to 6
Data Analysis -Two-tailed test with statistical significance set as P<0.05
- Baseline characteristics (age and sex) x2
- To compare scores of psychological distress and personality
between Bells palsy patients and control subjects t test
- Examine the relationship between psychological factors and the
degree of facial paralysis Pearson correlation analysis
- SAS 8.0 software for statistical analysis

Findings/Discussion - Significant differences in psychological distress and 16

personality factor dimensions between Bells palsy patients and
control subjects
-Compared to female Bells palsy patients, the K10 score of male
patients was significantly lower; scores for Warmth (A) and
Perfectionism (Q3) were significantly higher in male Bells palsy
patients than in female patients
- Scores for Rule-Consciousness (G), Abstractedness (M),
Vigilance (L), Apprehension (O), and Tension (Q4), and
Sensitivity (I) were lower in males.
- Compared with mild Bells palsy patients, Psychological
Distress Scale scores in severe patients was higher. Scores for
Apprehension (O) and Tension (Q4) were significantly higher in
severe patients than in mild patients
- The Psychological Distress Scale score in sub-acute (within >72
to 168 hours of diagnosis) patients was higher than those of
acute (within 72 hours of diagnosis) Bells palsy patients
- Score of Abstractedness (M) was lower in sub-acute patients;
but the scores of Change (Q1), Self-Reliance (Q2), and
Perfectionism (Q3) were higher in comparison to acute patients.
- Psychological Distress Scale personality factors Vigilance (L),
Apprehension (O), and Tension (Q4) positively correlated to HB
scores
-Personality factors Warmth (A), Liveliness (F), and Privateness
(N) were negatively related to HB scores
- Bells patients have more negative personality factors than
control subjects
- Females are more susceptible to the disfiguring effects of Bells
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palsy
- With increased severity and longer duration of facial paralysis,
participants experienced greater psychological distress

Appraisal/Worth to -Compares facial palsy patients to control subjects to help

practice explain the differences in psychological status.

First Author Psychological Distress in People with Disfigurement from

(Year)/Qualifications Facial Palsy

L Fu, C Bundy, SA Sadiq (2011)/ School of Medicine, University

of Manchester, UK(Fu) and Manchester Royal Eye Hospital,
Manchester, UK (Bundy & Sadiq) but no specific mention of
expertise in facial palsy disorders
Background/Problem Background defines facial palsy and focuses on possible
Statement functional, psychological, and social problems; aim to establish
the prevalence of psychological distress and the extent of anxiety
and depression in a sample of facial palsy patients and
whether participants illness representations influence their
emotional adjustment; literature review highlights self-
regulatory model which is a health-information-processing
model, mentions psychological problems due to facial palsy
underestimated by clinicians; gaps in literature concerning
psychological distress in patients with facial palsy

Conceptual/theoretica No theoretical framework identified

l Framework

Design/ Quantitative study cross-sectional

Method/Philosophical
Underpinnings

Sample/ 103 facial palsy (most from acoustic neuroma and Bells palsy)
Setting/Ethical patients between the ages of 18 and 93 years/ tertiary referral
Considerations center in a teaching hospital in the North West of England/
ethical approval attained but no mention of approving
committee and informed consent provided to all participants
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Major Variables -Psychological distress (defined as levels of anxiety and

Studied (and their depression)
definition), if
appropriate

Measurement -Illness Perception Questionnaire-Revised (IPQ-R)patients

Tool/Data Collection beliefs about their condition
Method -Hospital Anxiety and Depression Scale (HADS)screen
patients for anxiety and depression
-House-Brackmann scale severity of facial palsy

Data Analysis -Data analyzed with SPSS v16 software

-Mann-Whitney U test to compare HADS scores for male and
female participants
-Correlational analysis using Spearmans between the different
subscales of IPQ-R
and between subscales of IPQ-R and HAD subscales
-Correlations sought between relevant demographic values and
measure variables

Findings/Discussion -No correlation between clinical severity of facial palsy and

participants experience of anxiety or depressive symptoms
-No correlation between clinical severity and participants
emotional representations
-Correlation between illness perception subscales
The more chronic the illness, the more consequences on
QOL
Illness chronicity negatively correlated with personal
control and treatment control
-Correlation between some illness representations and HAD
subscales
The more consequences, the more anxiety and depression
symptoms
Emotional representation positively correlated with HAD
subscales
Duration of facial palsy correlated to levels of depression
but not level s of anxiety
Gender affected anxiety but not depression
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Appraisal/Worth to -Highlights implications for clinical care and level of

practice psychological distress in facial palsy patients

First Author The Psychosocial Impact of Facial Palsy: Our Experience in

(Year)/Qualifications One Hundred and Twenty Six Patients

DT Walker, MJ Hallam, S Ni Mhurchadha, P McCabe, C

Nduka (2012)/ Department of Otolaryngology, Basingstoke and
North Hampshire Hospital, Basingstoke, Hampshire, UK
(Walker), Department of Plastic and Reconstructive Surgery,
Queen Victoria Hospital, East Grinstead, Sussex, UK (Hallam,
Ni Mhurchadha, Nduka), Department of Statistics, Surrey
Clinical Research Centre, University of Surrey, Guildford,
Surrey, UK (McCabe)
Background/Problem Background mentions history of facial paralysis in clinical
Statement literature; limited knowledge on psychological effects of facial
palsy; Aim to assess the prevalence of psychological distress
amongst patients at the point of referral to a specialist center
Conceptual/theoretica No theoretical framework identified
l Framework

Design/ Quantitative study (service evaluation exercise)

Method/Philosophical
Underpinnings

Sample/ 126 patients >16 years of age treated by the specialist Facial
Setting/Ethical Palsy Service/ multidisciplinary clinic/ formal ethical approval
Considerations not required

Major Variables -Anxiety

Studied (and their -Depression
definition), if -Severity of facial paralysis
appropriate

Measurement -Hospital Anxiety and Depression Score (HADS) measures

Tool/Data Collection current levels of anxiety and depression
Method -House-Brackmann scale facial grading system
-Sunnybrook Facial Grading Score facial grading system

Data Analysis -Statistical analysis using Statistical Analysis Software (SAS)

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system carried out by independent medical statistician

-Unpaired T-test

Findings/Discussion -High rates of anxiety and depression in facial palsy patients

-Women show higher rates of anxiety, depression, and distress
than men concerning facial disfigurement
-Increasing House-Brackmann and Sunnybrook scores did not
influence HADS scores

Appraisal/Worth to -Sought to identify at-risk facial palsy patients through HADS to

practice offer immediate psychological consultation

First Author Bells Palsy: The Effect on Self-Image, Mood State and Social
(Year)/Qualifications Activity

AM Weir, B Pentland, A Crosswaite, J Murray, R Mountain

(1995); Department of Rehabilitation Medicine, Astley Ainslie
Hospital (Weir, Pentland, & Crosswaite), Department of ENT,
Royal Infirmary, Edinburgh (Murray & Mountain)
Background/Problem Background describes recovery after facial paralysis associated
Statement with Bells palsy; aim to determine whether low self-image,
anxiety, depression or restricted social contact occurs with
Bells palsy; literature review identifies gap in science

Conceptual/theoretica No theoretical framework identified

l Framework

Design/ Quantitative study

Method/Philosophical
Underpinnings

Sample/ 20 patients with Bells palsy/Recruited from the Facial Palsy

Setting/Ethical Clinic, Royal Infirmary, Edinburgh, UK/ no ethical
Considerations considerations mentioned (could be due to year of publication)

Major Variables -Self-image

Studied (and their -Severity of facial paralysis
definition), if -Anxiety
appropriate -Depression
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Measurement -Facial Self-Image Scale assess self-image

Tool/Data Collection -General Health Questionnaire screens for anxiety and
Method depression
- Functional Disability Questionnaire gauge of social and
daily living activities
-Semi-structured interview to determine consequences of facial
paralysis
Data Analysis -Pearson correlation coefficient technique used for results of
questionnaires and the factors of duration of palsy and age of
subjects

Findings/Discussion -Facial Self-Image Scale16 patients dissatisfied with one or

more facial features
-General Health Questionnaire5 patients exceeded threshold
score of five points indicating significant clinical disturbance
-Functional Disability Questionnairerange of functions
affected by palsy; very few unaffected
-Semi-structured interview12 patients noticed change in
others peoples attitude towards them
-Findings indicate increased levels of anxiety and depression was
associated with impairment of social and daily living activities,
especially if subjects noticed a change in attitude of others
toward them

Appraisal/Worth to -Explored the effects of Bells palsy on self-image, anxiety, and

practice depression

First Author The Psychosocial Impact of Ptosis as a Symptom of Myasthenia

(Year)/Qualifications Gravis: A Qualitative Study

HS Richards, E Jenkinson, N Rumsey, RA Harrad (2014)/

Centre for Appearance Research, University of the West of
England, Bristol, UK (Richards, Jenkinson, &Rumsey), Bristol
Eye Hospital, Bristol, UK (Harrad)
Background/Problem Background describes MG and symptomology with emphasis on
Statement ptosis; aim to investigate the psychosocial impact of ptosis as a
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symptom of MG; literature review mentions previous research

focus on QOL in MG with limited research on subjective
Conceptual/theoretica No theoretical framework identified
l Framework

Design/ Qualitative studyphenomenological

Method/Philosophical
Underpinnings

Sample/ 166 participants with MG and ptosis/Online via e-mail (to

Setting/Ethical minimize burden on participants)/ Ethical approval from
Considerations University of the West of England, Bristol, UK Research Ethics
Committee, full informed consent given to all participants,
Major Variables -Impact of ptosis as a symptom of MG
Studied (and their
definition), if
appropriate

Measurement -Open-ended e-mail questionnaire addressing how ptosis

Tool/Data Collection affected participants socially, psychologically, and functionally
Method -Questions included:
How does your ptosis affect you day to day?
What are good/bad things about having ptosis?
Does ptosis ever stop you from doing things?
Data Analysis -Written responses to open-ended questions analyzed using
Inductive Thematic Analysis
Six-step process involved in-depth reviews and coding of
data
Codes grouped into common themes and associated
subthemes
Themes checked against original data by two researchers
Participants contacted to review summary of themes
Themes modified on basis of feedback to maximize
accuracy
Findings/Discussion -Four major themes emerged:
Social, psychological, and behavioral impacts of ptosis
Ptosis as a symptom of MG
The relationship between functional and appearance-
related aspects of MG
The need for support from health care professionals
Appraisal/Worth to -Highlights the subjective experience of people with myasthenia
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practice gravis which has not previously been studied