Case Report

Functional Training in the

Management of Chronic Facial
Paralysis
V. Prakash, K. Hariohm, P. Vijayakumar, D. Thangjam Bindiya
V. Prakash, MPT, Charotar Institute
of Physiotherapy, Charotar Univer-
Background and Purpose. Disability in patients with facial paralysis is the sity of Science and Technology,
result of impairment or loss of complex and multidimensional functions of the face, CHARUSAT Campus, Changa, Pet-
including expression of emotions, facial identity, and communication. However, the lad, Anand 388421, Gujarat, India.
majority of interventions for facial paralysis are unidimensional and impairment Address all correspondence to Mr
oriented. Thus, a functional training program intended to address various dimensions Prakash at: prakashvaidhiyalingam@
gmail.com.
of disability caused by facial paralysis was devised. This patient-centered, multi-
dimensional approach to the rehabilitation of people with facial paralysis consists of K. Hariohm, MPT, Mohamed
patient education, functional training, and complementary exercises. This approach Sathak AJ College of Physiother-
apy, Chennai, Tamilnadu, India.
is focused on various dimensions of disability, including the physical, emotional, and
social dimensions, by encouraging context-specific facial functions, positive coping P. Vijayakumar, MPT, Navodaya
strategies, and social interaction skills. College of Physiotherapy, Raichur,
Karnataka, India.

Case Description. The patient was a 25-year-old woman with chronic complete D. Thangjam Bindiya, BPT,
right facial paralysis caused by a postoperative complication of ear surgery. The Department of Physiotherapy,
Navodaya Medical College Hospi-
patient’s problems were evaluated with the Facial Disability Index (physical function
tal and Research Centre, Raichur,
subscale score⫽45/100, social/well-being function subscale score⫽28/100) and an Karnataka, India.
informal interview exploring her experiences and priorities.
[Prakash V, Hariohm K, Vijayaku-
mar P, Thangjam Bindiya D. Func-
Outcomes. After 8 weeks of functional training, the patient showed considerable tional training in the management
improvement in facial functions (physical function subscale score⫽95/100, social/ of chronic facial paralysis. Phys
well-being function subscale score⫽100/100) and reported positive changes in social Ther. 2012;92:605– 613.]
interactions and interpersonal relationships. © 2012 American Physical Therapy
Association
Discussion. The use of a functional training program was associated with positive
Published Ahead of Print:
changes in emotional expression, psychosocial function, and social integration, thus December 22, 2011
contributing to reduced disability of a person with chronic facial paralysis. Accepted: December 12, 2011
Submitted: November 23, 2010

Post a Rapid Response to

this article at:
ptjournal.apta.org

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 Functional Training for Chronic Facial Paralysis
F
acial functions are multidimen-
sional, serving emotional, social,
and physical aspects of a per-
son’s health. The primary functions
of the face include displaying affec-
tive emotions and identifying and
communicating with other human
beings.1 Different portions of the
face also play a major role in eye
protection, eating, drinking, and
speech.2 In addition, facial recogni-
tion and the perception of facial
attractiveness facilitate communica-
tion among people by influencing
interpersonal attraction.3 These
human attributes are necessary to
establish and maintain intimate inter-
personal relationships and to pre-
serve affective social interactions.
Therefore, when a person experi-
ences facial paralysis, the concerns
encountered also are multidimen-
sional. These concerns can range
from emotional distress to physical
problems, such as leaking of food
from the mouth, difficulty in commu-
nication, and consequent attenua-
tion of social interactions.1,2 An
impaired ability to express context-
specific emotions can be detrimental
to a person’s sense of emotional
well-being and the ability to establish
and maintain interpersonal relation-
ships.1 Such impairments can create
a sense of shame and a fear of rejec-
tion and being misunderstood or
misjudged by others.4 Condescend-
ing reactions by others to the resul-
tant facial unattractiveness from
facial asymmetry can lead to low self-
esteem and an unfavorable body
image for people with facial paraly-
sis.5 In addition, pain or irritation
of the eye, unanticipated pronuncia-
tion errors while speaking, leaking
of fluid and food while drinking and
eating— especially in a social con-
text—may significantly interfere
with daily activities and cause con-
siderable physical and psychological
distress to people with facial paraly-
sis. Consequently, people with facial
paralysis may experience over-
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whelming negative emotions (eg,
social anxiety) and adopt avoidance
strategies, which can lead to a
decline in social interactions.6,7
This view is exemplified by the high
reported incidence of symptoms of
depression in people with facial neu-
romotor disorders—an incidence 3
to 5 times that in the general popu-
lation.8 Specifically, impairment of
smiling was found to be a key pre-
dictor of depression in patients with
facial neuromuscular disorders.9
In summary, facial functions are
complex and multidimensional.
Hence, the disability caused by paral-
ysis of the facial muscles results from
a complex interaction of the afore-
mentioned factors (Fig. 1).
However, the majority of existing
physical therapy interventions for
facial paralysis are unidimensional
(impairment oriented), and their
clinical effectiveness in improving a
patient’s function is limited.10,11 Tra-
ditional interventions place more
emphasis on eliciting isolated
actions of facial muscles, such as rais-
ing the eyebrows or puckering the
lips; these interventions involve
either passive treatments, such as
electrical stimulation,10 or active
exercises, such as facial neuromus-
cular reeducation.12 The aim of
mime therapy, a relatively recent
intervention in the rehabilitation of
people with facial paralysis, is to
develop a conscious connection
between the use of certain muscles
and facial emotional expression.13
However, this approach addresses
only part of the problem because it
is focused on producing volitional
emotional characteristics without
incorporating the spontaneous
expression of emotions.
The basic assumption underlying all
of these intervention strategies is
that improvement in one dimension
of facial dysfunction will automati-
Number 4
cally lead to overall improvement in
others. Because facial functions are
complex, any intervention strategy
aimed at having a profound impact
on the recovery of people with facial
paralysis must address the multidi-
mensional nature of the disability.
Therefore, we developed a func-
tional training program that is
focused on the physical, emotional,
and psychosocial dimensions of this
disorder.
The purposes of this case report are:
(1) to describe the development of
the functional training program and
(2) to demonstrate the use of this
intervention in the management of
chronic facial paralysis.
Patient History and Review
of Systems
The patient was a 25-year-old Indian
female homemaker who developed
chronic complete right facial paraly-
sis after ear surgery that occurred 8
years earlier. Two years after the sur-
gery, she developed severe pain in
the right eye because of constant irri-
tation; she consulted an ophthalmol-
ogist, who advised her to regularly
use safety glasses and eyedrops.
After 3 to 4 weeks, her pain sub-
sided, but she continued to use
safety glasses for about 2 years. She
did not have any problems related to
hearing or taste. As part of her reli-
gious practice, she wore a burqa and
a veil when going outdoors. When
she visited our facility, she had not
undergone any physical therapy and
had no active medical problems
other than the facial paralysis.
Her major concerns included inap-
propriate facial expressions during
conversations (eg, deviation of the
mouth to one side while talking or
laughing), inability to close the eyes
completely, leaking of fluid and
food particles while drinking and
eating, slurring of speech while talk-
ing (especially when angry), and
her perception of her altered facial
April 2012
 Functional Training for Chronic Facial Paralysis

symmetry and attractiveness. We

assumed that all of these could have
detrimental effects on body image
and self-esteem.

The usual treatment for people with

facial paralysis in our setting includes
electrical stimulation, massage, and
facial neuromuscular reeducation
exercises. However, we decided that
this approach might not be adequate
or suitable to manage the complex
nature of the patient’s concerns. We
acknowledged the need for a com-
prehensive treatment program that
would address the multidimensional
nature of the problems caused by
facial paralysis.

To objectively measure all of the

patient’s concerns, we used the
Facial Disability Index (FDI) to exam-
ine the impact of the facial paralysis
on the patient’s physical, emotional,
and social well-being.14
Figure 1.
Treatment goals were identified Interaction of factors that contribute to disability in people with chronic facial paralysis.
through discussion with the patient.
She expected meaningful improve-
ments in facial symmetry, emotional
terms of meaningful change in the ment; and the patient’s treatment
expression, eye closing, and cessa-
patient’s physical disability and psy- goals, expectations, and priorities.
tion of leaking of fluid and food par-
chosocial status.14 The FDI includes
ticles while drinking and eating. She
2 subscales—the physical and social/ During the initial evaluation, the
believed that such improvements
well-being function subscales—and patient’s physical and social/well-
would reduce her psychological dis-
can be completed in just a few min- being function scores on the FDI
tress and positively influence her
utes. The instrument produces reli- were 45 of 100 and 28 of 100,
social interactions.
able measurements, with construct respectively; these low scores
validity for patient-focused (disabil- reflected the impact of facial paraly-
Examination ity) outcomes for patients with dis- sis on various dimensions of the
We selected the FDI because it mea-
orders of the facial motor system.14 patient’s health and well-being. The
sures physical disability and psycho-
lower score for social/well-being
social factors related to facial neuro-
The objective of the informal inter- function than for physical function
muscular function; the tool was
view was to identify the patient’s val- highlighted the patient’s reduced
administered in conjunction with an
ues and experiences; this informa- participation in social activities
informal interview with the patient
tion is indispensable for effective (Tab. 1).
to investigate the qualitative aspects
clinical decision making. The semi-
of her experiences due to the facial
structured interview included ques- During the informal interview, the
paralysis.
tions intended to explore various patient reported that she wore a
aspects of the patient’s personal burqa and a veil to cover her face
The FDI was developed to provide
experiences of living with facial when going outdoors, as is custom-
an account of a patient’s daily expe-
paralysis; the ways in which it influ- ary in her religion. Nevertheless, she
riences of living with a facial nerve
enced her typical daily life; the was hesitant to go outdoors because
disorder and was intended to mea-
patient’s perceptions of the impair- she might have to remove the burqa
sure the outcome of intervention in

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 Functional Training for Chronic Facial Paralysis

and veil in some social occasions,

Facial Disability Index items were problems rated by the patient before and after treatment. After the intervention, ratings on 4 of 5 items of the physical function subscale of the FDI had changed from
shop, or participate
Not going out to eat,
None of the Time
such as a wedding ceremony. In

Isolated from others

in family or social
Got irritable toward

nighttime sleepc
those circumstances, she reported
Social/Well-being Function Item

Woke up during
numerous incidents of being stared

activities
at by strangers and of being asked

others
repeated questions concerning the
nature of her problems by friends
Felt calm and peaceful
and relatives. As a result, she pre-

“with some difficulty” to “with no difficulty”; ratings on all 5 items of the social/well-being function subscale of the FDI had changed into categories denoting normal function.
ferred to avoid any social and family
All of the Time

gatherings and gradually reduced her

Postintervention Ratings

social interactions.

Psychological distress can occur fre-

quently with facial disability. During
the course of the interview, we
Excessive eye tearing

asked questions related to any other

With Little
Difficulty

uncomfortable events during the

Physical Function Item

period from the development of

symptoms to the present, and the
patient answered in the negative.
Therefore, we believed that the psy-
Saying specific sounds
With No Difficulty

chological distress documented on

around the mouth
Keeping food in and

Drinking from a cup

rinsing the mouth

Brushing teeth and

the FDI might well have been asso-

while speaking
moving food

ciated with the facial paralysis. How-

ever, because we used only the FDI
and no other examination tools
specific to psychological distress, we
could not completely rule out the
shop, or participate
Not going out to eat,

in family or social
All of the Time

possibility that other factors contrib-

Preintervention and Postintervention Ratings on the Facial Disability Index (FDI)a

uted to the distress.

activities

In summary, the FDI and interview

Social/Well-being Function Item

data suggested that the patient’s

physical and social well-being were
affected by her facial paralysis.
Most of the Time

Isolated from others

Got irritable toward

Therefore, we concluded that a func-

tional training program intended to
Preintervention Ratings

address the multidimensional con-

others

cerns generated by the chronic facial

paralysis would be appropriate.
Felt calm and peaceful
Some of the Time

Reexamination of the patient with

nighttime sleepb
Woke up during

the FDI was scheduled to be per-

formed after 8 weeks of treatment;
we anticipated at least 25% improve-
ment in the total scores, including
the physical and social/well-being
function scores.
Saying specific sounds
Physical Function
Item: With Some

Excessive eye tearing

around the mouth
Keeping food in and

Drinking from a cup

rinsing the mouth

Brushing teeth and
while speaking
Difficulty

On some nights.

Intervention
moving food

On no nights.

The functional training program that

Table 1.

we developed is a multidimensional,
patient-centered approach to the
rehabilitation of people with facial
b
a

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Figure 2.
Multidimensional functional training program.
paralysis. The program encompasses
major facial functions, integrates the
role of contextual factors, and pro-
motes positive coping strategies and
social interaction skills to deal with
various dimensions of disability,
including the physical, emotional,
and social well-being dimensions
(Fig. 2). The program includes
patient education, functional train-
ing, and complementary exercises.
Patient Education
The patient education component of
the functional training program is
based on principles of cognitive-
behavioral training.15,16 The aim of
this component is to change the
behavior of the patient, rather than
the physical appearance alone, by
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Functional Training for Chronic Facial Paralysis
optimizing coping strategies and
social interaction skills. The educa-
tion component has 2 objectives.
One objective is to change the way
in which the patient thinks so that
he or she will feel or act better even
if the situation does not change. The
other objective is to reconstruct the
patient’s thoughts and perceptions
of problems, such as negative self-
perceptions of facial attractiveness
(body image) and interpretations of
others’ or society’s views toward the
patient’s disability. The contents of
the patient education component
are shown in Table 2. Patient educa-
tion was not provided within a dis-
crete treatment session but was
interwoven with the other compo-
Volume 92
nents of the functional training
program.
Functional Training
The aim of functional training is to
incorporate the primary movement
functions of the face, including the
expression of emotions and other
motor functions, into the patient’s
daily activities. In real-life situations,
people spontaneously express emo-
tions with rapid variations. Emotions
are significantly influenced by the
context,17,18 such that in some
situations people may feel a mix-
ture of emotions, with varying
levels of intensity, which they try
to hide, alter, or dampen to influence
a viewer’s perception. Such sce-
narios require both spontaneous
Number 4 Physical Therapy f 609
 Functional Training for Chronic Facial Paralysis

Table 2.
Patient Education

Objective Education Strategy

To change the way in which the patient thinks to feel or act better even if Only initial encounters may be difficult, and even those can be managed
the situation does not change with positive interaction skills.

Staring by strangers may be more out of curiosity than dislike or

aversion and can be effectively managed by smiling, staring back, or
ignoring them.

Remain calm and politely but assertively confront others with negative
reactions.

To reconstruct the patient’s thoughts and perceptions of problems, such Challenge the patient’s assumptions about being “defective” and modify
as negative self-perceptions of facial attractiveness and interpretations of perceptions or apprehensions concerning facial attractiveness by
others’ or society’s views toward the patient’s disability questioning the functional “cost” of these assumptions.

Constantly reassure the patient that she is cared for and loved by her
family and friends (as they would look at her beyond physical
appearance) and urge her family to provide frequent encouragement
and helpful comments.

Encourage the patient to adopt a positive self-image and be optimistic

about recovery.

Educate family members and friends about the nature of the patient’s
condition.

expression and deliberate expres-
sion of emotions, involving different
combinations of muscle actions that
cannot be easily reproduced by acti-
vation outside the context.19,20
Therefore, our training consisted of
activities such as watching movies,
television programs, or humorous
videos and narrating them to the
physical therapist and augmented
periods of conversation during the
treatment sessions and at home to
encourage the expression of emo-
tions in a real-life context. Table 3
shows a complete list of the
activities.
We also encouraged the patient to be
more animated during her story nar-
rations to enhance her attempts to
express emotions deliberately and
spontaneously. The goal was to pro-
vide more opportunities for the
patient to express emotions in con-
texts that were relevant to her daily
activities.
A female physical therapist was
assigned to provide the training to
try to alleviate any reservation that
the patient might have had about tak-
ing part in a free conversation. Treat-
ment was provided in a closed and
isolated room to avoid outside inter-
ruptions during the conversation
and to provide adequate privacy to
try to alleviate any inhibition that the
patient might have had about
expressing herself freely.
Complementary Exercises
The primary objective of the comple-
mentary exercises was to enhance
the level of activity of the facial

Table 3.
Functional Training

Rationale/Objective Functional Training Activity

To facilitate context-specific spontaneous and voluntary expression Watch movies, television programs, and humorous videos.
of emotions
Narrate stories during treatment sessions in the clinic.

Think about funny incidents that have happened in your life or jokes
that you have heard or read recently and share them with friends or
family members.

To facilitate motor functions of facial muscles around the eyes, Hum or sing songs that you like as often as possible.
lips, and mouth
Play games such as peek-a-boo or blowing bubbles with children.

Rinse your mouth and spit out the water slowly.

Blow a pipe while imagining that you are cooking in the kitchen and
that the fire in the wood stove suddenly goes out; you have to
blow the pipe to start the fire again.

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muscles to complement the overall
effort of the patient in achieving the
expression of emotions and other
motor functions of the face. In addi-
tion, we believed that a regular exer-
cise schedule would motivate the
patient to achieve her own treat-
ment goals and might enhance her
adherence to the treatment. The
exercises were based on treatments
suggested by VanSwearingen.12 The
complementary exercises were as
follows: suck the cheeks between
the teeth; wrap the lips over the
teeth; pucker the lips; make the
speech sounds “sh,” “p,” “b,” and “f”
with the teeth clenched; and look
down, close the eyes, and continue
to look down with the eyes closed
(eye-closing exercise).
Dosage
For patient education and functional
training, the treating physical thera-
pist provided 20- to 30-minute ses-
sions to the patient, once per day, 6
days per week, for 8 weeks. For com-
plementary exercises, the patient
was asked to perform each exercise
5 to 10 times, 3 times per day (once
in the clinic and twice at home), 6
days per week, for 8 weeks. The
intervention dosage was modified in
accordance with observed changes
in the patient’s ability to perform and
cope with the exercises.
Outcome
The patient showed significant
improvements with regard to the ini-
tial treatment goals, as measured 8
weeks after the commencement of
treatment. Final FDI scores were 95 of
100 on the physical function subscale
and 100 of 100 on the social/well-
being function subscale, represent-
ing postintervention improvements
of 50 and 72 points, respectively
(Tab. 1).
Physical functions of the patient’s
face that were affected, including dif-
ficulty with eye closing, leaking of
fluid and food while drinking and
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Functional Training for Chronic Facial Paralysis
eating, and slurring of speech,
improved considerably. This improve-
ment was manifested as a 50-point
increase in the score on the physical
function subscale of the FDI relative
to the pretreatment score. The rat-
ings for 4 of the 5 items on this
subscale improved from “with some
difficulty” to “with no difficulty”
(Tab. 1).
During our clinical observations of
the patient, we noted no apparent
changes in some actions, such as vol-
untary smiling and the ability to raise
the eyebrows. However, we noted
obvious improvements in her facial
symmetry at rest, which were
revealed in our comparison of still
photographs taken during various
stages of treatment. In line with our
observations, the patient also
reported positive changes in her per-
ception of her facial attractiveness,
which may have been due to the
changes in facial symmetry at rest.
We believe that such changes were
reflected in her renewed interest in
wearing jewelry and makeup.
We observed substantial progress in
the patient’s social functions as well.
During the posttreatment interview,
she reported that her family mem-
bers were happy with the results of
the treatment and appreciated her
efforts. She felt more confident
going outdoors and provided a few
examples of social gatherings that
she previously had avoided but now
attended without inhibition or feel-
ings of stigma. In addition, she
reported marked improvements in
her interpersonal relationships and
social interactions. These observa-
tions may explain the changes
recorded in the postintervention
score on the social/well-being func-
tion subscale of the FDI, with normal
function being recorded for all 5
items at the end of the intervention.
Volume 92
Discussion
The purpose of this case report were
2-fold: first, to describe the develop-
ment of our functional training pro-
gram, and second, to demonstrate its
use for the management of chronic
facial paralysis. After the 8-week
functional training program, the
patient showed substantial improve-
ments in physical, psychological,
and social functions affected by her
facial paralysis.
In the rehabilitation of people with
facial paralysis, patient education
typically includes information about
the anatomy of the facial nerves,
facial musculature, and synkinesis12
as well as the recovery process.21
Such an approach may be inade-
quate when a patient’s primary con-
cern arises from the disabling psy-
chosocial consequences of facial
paralysis, including low self-esteem,
social isolation, and altered emo-
tional well-being. Therefore, we
devised a patient education program
that is specifically focused on the
development of positive coping
strategies and social interaction
skills.
During the posttreatment interview,
the patient reported that her family
members had identified noticeable
improvement in her face. As men-
tioned previously, she spoke of
several social occasions that she
attended without hesitation or feel-
ings of rejection. In Indian culture, it
is customary for a woman to wear
jewelry, especially during social
occasions, as an important indicator
that she is feeling good about herself.
The patient’s renewed interest in
wearing jewelry and makeup helped
reassure us that her perception of
her facial attractiveness and body
image had improved. In addition, we
noted that she started removing her
veil after entering our clinic, some-
thing she previously had been reluc-
tant to do. When asked about this
new behavior, she replied that she
Number 4 Physical Therapy f 611
 Functional Training for Chronic Facial Paralysis
removed her veil more frequently
now. Such behavioral transforma-
tions clearly indicate improved social
interaction skills, self-perception
of body image, self-esteem, and
confidence.
Similar findings were reported in
studies investigating the effective-
ness of cognitive-behavioral training
in people with facial disfigurement;
these findings included positive out-
comes in terms of self-esteem, devel-
opment of positive coping strategies,
reduction in social anxiety, and
improvement in social skills.22,23
The functional training component
of our program encourages and pro-
vides opportunities to express
context-specific, variable emotions
within a patient’s natural environ-
ment and involves tasks that facili-
tate other facial motor functions
within that environment, such as
rinsing the mouth and spitting out
the water or playing games such as
blowing bubbles with children.
Intervention strategies such as
watching movies, television pro-
grams, or humorous videos, discuss-
ing them during treatment sessions,
and sharing funny incidents or jokes
with friends provide more opportu-
nities to express felt emotions within
a real-world context. While watch-
ing movies, people tend to mimic
(emotional contagion) or react to the
emotions displayed in the scene
being watched, and this behavior
may facilitate the spontaneous
expression of emotions.24
During narrative discussions, we
observed that the patient was able to
express a variety and a mixture of
emotions and switch from the
expression of one emotion to
another more easily than before. Her
expressions involved movements of
the corners of the lips and wrinkling
of the skin at the outer edge of the
affected eye, movements that she
had been unable to produce volun-
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tarily. These observations could have
been due to the involvement of dif-
ferent neural pathways25,26 for spon-
taneous expression and voluntary
expression of emotions. In addition,
spontaneous expression involves
combinations of muscle actions that
cannot be easily reproduced by vol-
untary effort.19,20
Complementary exercises also might
have contributed to the changes
observed on the physical function
subscale of the FDI, such as improve-
ments in the ability to drink and eat
without leaking of fluid and food
from the mouth and in the ability to
close the eyes. Thus, we believe that
the effects of the components of the
functional treatment program were
synergistic, leading to improvements
in multiple aspects of function
(Fig. 2).
In patients with facial paralysis,
there may be a gap between “capac-
ity” (what they can do at their best)
and “performance” (the execution of
that activity in the real world); this
gap may be mediated by the psycho-
logical distress experienced by
patients.9 In other words, patients
may underperform because of the
adoption of negative coping strate-
gies. These circumstances further
worsen their condition, eventually
causing further decline in their exist-
ing capacity. We hoped to narrow
the gap between capacity and per-
formance by encouraging positive
coping strategies and social interac-
tions to deal with psychological
distress and social isolation while
simultaneously creating more
opportunities to express emotions
and perform other facial motor func-
tions. Although there was relatively
less improvement in the patient’s
ability to voluntarily activate individ-
ual muscles, the positive changes in
the patient’s expression of emotions
and coping strategies resulted in con-
siderable achievement of social inte-
Number 4
gration, the ultimate goal of any reha-
bilitation strategy.
In summary, we believe that the
multidimensional approach of our
functional training program for
addressing the expression of emo-
tions, altered body image and self-
esteem, and negative coping strate-
gies would be an appropriate
intervention strategy for the com-
plex problems experienced by peo-
ple with chronic facial paralysis. The
interventions need not be limited to
those described in this report. Using
the conceptual framework of the
functional training program, clini-
cians can develop specific strategies
that are relevant to their patients’
contextual factors (including per-
sonal, social, and cultural factors).
Examination of the effects of the
functional training program with
more rigorous, controlled research
designs or a series of single-subject
experimental designs could serve to
validate the observations of this case
report.
All authors provided concept/idea/research
design and consultation (including review of
manuscript before submission). Mr Prakash
and Mr Hariohm provided writing. Ms
Thangjam Bindiya provided data collection.
Mr Prakash, Mr Hariohm, and Ms Thangjam
Bindiya provided data analysis. Mr Vijaya-
kumar provided the participant and
facilities/equipment.
Ms Thangjam Bindiya was participating in an
internship during data collection.
The authors thank Dr Susan R. Harris and Mr
R. Vasanthan for their assistance in editing an
earlier version of this article.
DOI: 10.2522/ptj.20100404
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