Bayesian Adaptive Designs for Early Phase Clinical Trials

My dissertation focuses mainly on Bayesian adaptive designs for phase I and phase II clinical trials. It includes three specific topics: (1) proposing a novel two-dimensional dose-finding algorithm for biological agents, (2) developing Bayesian adaptive screening designs to provide more efficient and ethical clinical trials, and (3) incorporating missing late-onset responses to make an early stopping decision. Treating patients with novel biological agents is becoming a leading trend in oncology. Unlike cytotoxic agents, for which toxicity and efficacy monotonically increase with dose, biological agents may exhibit non-monotonic patterns in their dose-response relationships. Using a trial with two biological agents as an example, we propose a phase I/II trial design to identify the biologically optimal dose combination (BODC), which is defined as the dose combination of the two agents with the highest efficacy and tolerable toxicity. A change-point model is used to reflect the fact that the dose-toxicity surface of the combinational agents may plateau at higher dose levels, and a flexible logistic model is proposed to accommodate the possible non-monotonic pattern for the dose-efficacy relationship. During the trial, we continuously update the posterior estimates of toxicity and efficacy and assign patients to the most appropriate dose combination. We propose a novel dose-finding algorithm to encourage sufficient exploration of untried dose combinations in the two-dimensional space. Extensive simulation studies show that the proposed design has desirable operating characteristics in identifying the BODC under various patterns of dose-toxicity and dose-efficacy relationships. Trials of combination therapies for the treatment of cancer are playing an increasingly important role in the battle against this disease. To more efficiently handle the large number of combination therapies that must be tested, we propose a novel Bayesian phase II adaptive screening design to simultaneously select among possible treatment combinations involving multiple agents. Our design is based on formulating the selection procedure as a Bayesian hypothesis testing problem in which the superiority of each treatment combination is equated to a single hypothesis. During the trial conduct, we use the current values of the posterior probabilities of all hypotheses to adaptively allocate patients to treatment combinations. Simulation studies show that the proposed design substantially outperforms the conventional multi-arm balanced factorial trial design. The proposed design yields a significantly higher probability for selecting the best treatment while at the same time allocating substantially more patients to efficacious treatments. The proposed design is most appropriate for the trials combining multiple agents and screening out the efficacious combination to be further investigated. The proposed Bayesian adaptive phase II screening design substantially outperformed the conventional complete factorial design. Our design allocates more patients to better treatments while at the same time providing higher power to identify the best treatment at the end of the trial. Phase II trial studies usually are single-arm trials which are conducted to test the efficacy of experimental agents and decide whether agents are promising to be sent to phase III trials. Interim monitoring is employed to stop the trial early for futility to avoid assigning unacceptable number of patients to inferior treatments. We propose a Bayesian single-arm phase II design with continuous monitoring for estimating the response rate of the experimental drug. To address the issue of late-onset responses, we use a piece-wise exponential model to estimate the hazard function of time to response data and handle the missing responses using the multiple imputation approach. We evaluate the operating characteristics of the proposed method through extensive simulation studies. We show that the proposed method reduces the total length of the trial duration and yields desirable operating characteristics for different physician-specified lower bounds of response rate with different true response rates.

Diseño basado en técnicas de fiabilidad del tratamiento de mejora del terreno mediante columnas de grava

El proyecto geotécnico de columnas de grava tiene todas las incertidumbres asociadas a un proyecto geotécnico y además hay que considerar las incertidumbres inherentes a la compleja interacción entre el terreno y la columna, la puesta en obra de los materiales y el producto final conseguido. Este hecho es común a otros tratamientos del terreno cuyo objetivo sea, en general, la mejora “profunda”. Como los métodos de fiabilidad (v.gr., FORM, SORM, Monte Carlo, Simulación Direccional) dan respuesta a la incertidumbre de forma mucho más consistente y racional que el coeficiente de seguridad tradicional, ha surgido un interés reciente en la aplicación de técnicas de fiabilidad a la ingeniería geotécnica. Si bien la aplicación concreta al proyecto de técnicas de mejora del terreno no es tan extensa. En esta Tesis se han aplicado las técnicas de fiabilidad a algunos aspectos del proyecto de columnas de grava (estimación de asientos, tiempos de consolidación y aumento de la capacidad portante) con el objetivo de efectuar un análisis racional del proceso de diseño, considerando los efectos que tienen la incertidumbre y la variabilidad en la seguridad del proyecto, es decir, en la probabilidad de fallo. Para alcanzar este objetivo se ha utilizado un método analítico avanzado debido a Castro y Sagaseta (2009), que mejora notablemente la predicción de las variables involucradas en el diseño del tratamiento y su evolución temporal (consolidación). Se ha estudiado el problema del asiento (valor y tiempo de consolidación) en el contexto de la incertidumbre, analizando dos modos de fallo: i) el primer modo representa la situación en la que es posible finalizar la consolidación primaria, parcial o totalmente, del terreno mejorado antes de la ejecución de la estructura final, bien sea por un precarga o porque la carga se pueda aplicar gradualmente sin afectar a la estructura o instalación; y ii) por otra parte, el segundo modo de fallo implica que el terreno mejorado se carga desde el instante inicial con la estructura definitiva o instalación y se comprueba que el asiento final (transcurrida la consolidación primaria) sea lo suficientemente pequeño para que pueda considerarse admisible. Para trabajar con valores realistas de los parámetros geotécnicos, los datos se han obtenido de un terreno real mejorado con columnas de grava, consiguiendo, de esta forma, un análisis de fiabilidad más riguroso. La conclusión más importante, obtenida del análisis de este caso particular, es la necesidad de precargar el terreno mejorado con columnas de grava para conseguir que el asiento ocurra de forma anticipada antes de la aplicación de la carga correspondiente a la estructura definitiva. De otra forma la probabilidad de fallo es muy alta, incluso cuando el margen de seguridad determinista pudiera ser suficiente. En lo que respecta a la capacidad portante de las columnas, existen un buen número de métodos de cálculo y de ensayos de carga (tanto de campo como de laboratorio) que dan predicciones dispares del valor de la capacidad última de las columnas de grava. En las mallas indefinidas de columnas, los resultados del análisis de fiabilidad han confirmado las consideraciones teóricas y experimentales existentes relativas a que no se produce fallo por estabilidad, obteniéndose una probabilidad de fallo prácticamente nula para este modo de fallo. Sin embargo, cuando se analiza, en el contexto de la incertidumbre, la capacidad portante de pequeños grupos de columnas bajo zapatas se ha obtenido, para un caso con unos parámetros geotécnicos típicos, que la probabilidad de fallo es bastante alta, por encima de los umbrales normalmente admitidos para Estados Límite Últimos. Por último, el trabajo de recopilación sobre los métodos de cálculo y de ensayos de carga sobre la columna aislada ha permitido generar una base de datos suficientemente amplia como para abordar una actualización bayesiana de los métodos de cálculo de la columna de grava aislada. El marco bayesiano de actualización ha resultado de utilidad en la mejora de las predicciones de la capacidad última de carga de la columna, permitiendo “actualizar” los parámetros del modelo de cálculo a medida que se dispongan de ensayos de carga adicionales para un proyecto específico. Constituye una herramienta valiosa para la toma de decisiones en condiciones de incertidumbre ya que permite comparar el coste de los ensayos adicionales con el coste de una posible rotura y , en consecuencia, decidir si es procedente efectuar dichos ensayos. The geotechnical design of stone columns has all the uncertainties associated with a geotechnical project and those inherent to the complex interaction between the soil and the column, the installation of the materials and the characteristics of the final (as built) column must be considered. This is common to other soil treatments aimed, in general, to “deep” soil improvement. Since reliability methods (eg, FORM, SORM, Monte Carlo, Directional Simulation) deals with uncertainty in a much more consistent and rational way than the traditional safety factor, recent interest has arisen in the application of reliability techniques to geotechnical engineering. But the specific application of these techniques to soil improvement projects is not as extensive. In this thesis reliability techniques have been applied to some aspects of stone columns design (estimated settlements, consolidation times and increased bearing capacity) to make a rational analysis of the design process, considering the effects of uncertainty and variability on the safety of the project, i.e., on the probability of failure. To achieve this goal an advanced analytical method due to Castro and Sagaseta (2009), that significantly improves the prediction of the variables involved in the design of treatment and its temporal evolution (consolidation), has been employed. This thesis studies the problem of stone column settlement (amount and speed) in the context of uncertainty, analyzing two failure modes: i) the first mode represents the situation in which it is possible to cause primary consolidation, partial or total, of the improved ground prior to implementation of the final structure, either by a pre-load or because the load can be applied gradually or programmed without affecting the structure or installation; and ii) on the other hand, the second mode implies that the improved ground is loaded from the initial instant with the final structure or installation, expecting that the final settlement (elapsed primary consolidation) is small enough to be allowable. To work with realistic values of geotechnical parameters, data were obtained from a real soil improved with stone columns, hence producing a more rigorous reliability analysis. The most important conclusion obtained from the analysis of this particular case is the need to preload the stone columns-improved soil to make the settlement to occur before the application of the load corresponding to the final structure. Otherwise the probability of failure is very high, even when the deterministic safety margin would be sufficient. With respect to the bearing capacity of the columns, there are numerous methods of calculation and load tests (both for the field and the laboratory) giving different predictions of the ultimate capacity of stone columns. For indefinite columns grids, the results of reliability analysis confirmed the existing theoretical and experimental considerations that no failure occurs due to the stability failure mode, therefore resulting in a negligible probability of failure. However, when analyzed in the context of uncertainty (for a case with typical geotechnical parameters), results show that the probability of failure due to the bearing capacity failure mode of a group of columns is quite high, above thresholds usually admitted for Ultimate Limit States. Finally, the review of calculation methods and load tests results for isolated columns, has generated a large enough database, that allowed a subsequent Bayesian updating of the methods for calculating the bearing capacity of isolated stone columns. The Bayesian updating framework has been useful to improve the predictions of the ultimate load capacity of the column, allowing to "update" the parameters of the calculation model as additional load tests become available for a specific project. Moreover, it is a valuable tool for decision making under uncertainty since it is possible to compare the cost of further testing to the cost of a possible failure and therefore to decide whether it is appropriate to perform such tests.

Tight frames of k-plane ridgelets and the problem of representing objects that are smooth away from d-dimensional singularities in Rn

For each pair (n, k) with 1 ≤ k < n, we construct a tight frame (ρλ : λ ∈ Λ) for L2 (Rn), which we call a frame of k-plane ridgelets. The intent is to efficiently represent functions that are smooth away from singularities along k-planes in Rn. We also develop tools to help decide whether k-plane ridgelets provide the desired efficient representation. We first construct a wavelet-like tight frame on the X-ray bundle χn,k—the fiber bundle having the Grassman manifold Gn,k of k-planes in Rn for base space, and for fibers the orthocomplements of those planes. This wavelet-like tight frame is the pushout to χn,k, via the smooth local coordinates of Gn,k, of an orthonormal basis of tensor Meyer wavelets on Euclidean space Rk(n−k) × Rn−k. We then use the X-ray isometry [Solmon, D. C. (1976) J. Math. Anal. Appl. 56, 61–83] to map this tight frame isometrically to a tight frame for L2(Rn)—the k-plane ridgelets. This construction makes analysis of a function f ∈ L2(Rn) by k-plane ridgelets identical to the analysis of the k-plane X-ray transform of f by an appropriate wavelet-like system for χn,k. As wavelets are typically effective at representing point singularities, it may be expected that these new systems will be effective at representing objects whose k-plane X-ray transform has a point singularity. Objects with discontinuities across hyperplanes are of this form, for k = n − 1.

The influence of age and trait attributions on recruitment selection

The role of interpersonal attraction into the recruitment selection is gaining research attention. Early work in the domain of the influence of attraction in organisations suggested that men are given more resources, such as higher salaries and promotions. However, recent research has found women have an automatic in-group bias. It was suggested that female interviewers are more likely to hire another female. In contrast, male interviewers were found to be equally as likely to hire men as women. To resolve these two conflicting findings a behavioural experiment was set up looking at gender, attractiveness and recruitment selection. Forty participants, twenty male and twenty female, of varying ages (18-65) were recruited through age stratified sampling. Participants took on the role of manager of a medium sized company and were shown twenty photographs of faces previously rated for attractiveness. On initial viewing participants were asked to decide whether they would firstly hire the person and secondly give as many reasons for their decision. Findings from this research show that in all age groups male and female participants gave females (especially attractive females) more jobs, except in the case of the 18-21 year old females who gave attractive males more jobs. On examining the reasons behind the participant’s decisions, it was evident that if you appeared confident, friendly, youthful and attractive you were 46% more likely to receive the job. However, if you were perceived to be untrustworthy, lazy, arrogant and unintelligent you were 49% more likely not to receive the job. These findings shed light on the various processes that may underpin human resource decisions in an organisational setting.

Physician choice making and characteristics associated with using physician-rating websites: cross-sectional study

BACKGROUND: Over the past decade, physician-rating websites have been gaining attention in scientific literature and in the media. However, little knowledge is available about the awareness and the impact of using such sites on health care professionals. It also remains unclear what key predictors are associated with the knowledge and the use of physician-rating websites. OBJECTIVE: To estimate the current level of awareness and use of physician-rating websites in Germany and to determine their impact on physician choice making and the key predictors which are associated with the knowledge and the use of physician-rating websites. METHODS: This study was designed as a cross-sectional survey. An online panel was consulted in January 2013. A questionnaire was developed containing 28 questions; a pretest was carried out to assess the comprehension of the questionnaire. Several sociodemographic (eg, age, gender, health insurance status, Internet use) and 2 health-related independent variables (ie, health status and health care utilization) were included. Data were analyzed using descriptive statistics, chi-square tests, and t tests. Binary multivariate logistic regression models were performed for elaborating the characteristics of physician-rating website users. Results from the logistic regression are presented for both the observed and weighted sample. RESULTS: In total, 1505 respondents (mean age 43.73 years, SD 14.39; 857/1505, 57.25% female) completed our survey. Of all respondents, 32.09% (483/1505) heard of physician-rating websites and 25.32% (381/1505) already had used a website when searching for a physician. Furthermore, 11.03% (166/1505) had already posted a rating on a physician-rating website. Approximately 65.35% (249/381) consulted a particular physician based on the ratings shown on the websites; in contrast, 52.23% (199/381) had not consulted a particular physician because of the publicly reported ratings. Significantly higher likelihoods for being aware of the websites could be demonstrated for female participants (P<.001), those who were widowed (P=.01), covered by statutory health insurance (P=.02), and with higher health care utilization (P<.001). Health care utilization was significantly associated with all dependent variables in our multivariate logistic regression models (P<.001). Furthermore, significantly higher scores could be shown for health insurance status in the unweighted and Internet use in the weighted models. CONCLUSIONS: Neither health policy makers nor physicians should underestimate the influence of physician-rating websites. They already play an important role in providing information to help patients decide on an appropriate physician. Assuming there will be a rising level of public awareness, the influence of their use will increase well into the future. Future studies should assess the impact of physician-rating websites under experimental conditions and investigate whether physician-rating websites have the potential to reflect the quality of care offered by health care providers.

SKAN: Skin Scanner - System for Skin Cancer Detection Using Adaptive Techniques

SKAN: Skin Scanner - System for Skin Cancer Detection Using Adaptive Techniques - combines computer engineering concepts with areas like dermatology and oncology. Its objective is to discern images of skin cancer, specifically melanoma, from others that show only common spots or other types of skin diseases, using image recognition. This work makes use of the ABCDE visual rule, which is often used by dermatologists for melanoma identification, to define which characteristics are analyzed by the software. It then applies various algorithms and techniques, including an ellipse-fitting algorithm, to extract and measure these characteristics and decide whether the spot is a melanoma or not. The achieved results are presented with special focus on the adaptive decision-making and its effect on the diagnosis. Finally, other applications of the software and its algorithms are presented.

Perception or synthesized voice quality in connected speech by Cantonese speakers

Perceptual voice analysis is a subjective process. However, despite reports of varying degrees of intrajudge and interjudge reliability, it is widely used in clinical voice evaluation. One of the ways to improve the reliability of this procedure is to provide judges with signals as external standards so that comparison can be made in relation to these anchor signals. The present study used a Klatt speech synthesizer to create a set of speech signals with varying degree of three different voice qualities based on a Cantonese sentence. The primary objective of the study was to determine whether different abnormal voice qualities could be synthesized using the built-in synthesis parameters using a perceptual study. The second objective was to determine the relationship between acoustic characteristics of the synthesized signals and perceptual judgment. Twenty Cantonese-speaking speech pathologists with at least three years of clinical experience in perceptual voice evaluation were asked to undertake two tasks. The first was to decide whether the voice quality of the synthesized signals was normal or not. The second was to decide whether the abnormal signals should be described as rough, breathy, or vocal fry. The results showed that signals generated with a small degree of aspiration noise were perceived as breathiness while signals with a small degree of flutter or double pulsing were perceived as roughness. When the flutter or double pulsing increased further, tremor and vocal fry, rather than roughness, were perceived. Furthermore, the amount of aspiration noise, flutter, or double pulsing required for male voice stimuli was different from that required for the female voice stimuli with a similar level of perceptual breathiness and roughness. These findings showed that changes in perceived vocal quality could be achieved by systematic modifications of synthesis parameters. This opens up the possibility of using synthesized voice signals as external standards or anchors to improve the reliability of clinical perceptual voice evaluation. (C) 2002 Acoustical Society of America.

Application of Gage R&R methodology for improving the training and evaluation of automatic optical inspection machine operators

The current level of demand by customers in the electronics industry requires the production of parts with an extremely high level of reliability and quality to ensure complete confidence on the end customer. Automatic Optical Inspection (AOI) machines have an important role in the monitoring and detection of errors during the manufacturing process for printed circuit boards. These machines present images of products with probable assembly mistakes to an operator and him decide whether the product has a real defect or if in turn this was an automated false detection. Operator training is an important aspect for obtaining a lower rate of evaluation failure by the operator and consequently a lower rate of actual defects that slip through to the following processes. The Gage R&R methodology for attributes is part of a Six Sigma strategy to examine the repeatability and reproducibility of an evaluation system, thus giving important feedback on the suitability of each operator in classifying defects. This methodology was already applied in several industry sectors and services at different processes, with excellent results in the evaluation of subjective parameters. An application for training operators of AOI machines was developed, in order to be able to check their fitness and improve future evaluation performance. This application will provide a better understanding of the specific training needs for each operator, and also to accompany the evolution of the training program for new components which in turn present additional new difficulties for the operator evaluation. The use of this application will contribute to reduce the number of defects misclassified by the operators that are passed on to the following steps in the productive process. This defect reduction will also contribute to the continuous improvement of the operator evaluation performance, which is seen as a quality management goal.

Evaluation of IMRT and VMAT techniques with and without flattening filter using pareto optimal fronts

Mestrado em Radiações Aplicadas às Tecnologias da Saúde.

Da tradução automática à tradução manual: estudo contrastivo da tradução automática e manual, através da tradução de dois artigos científicos

Trabalho de Projeto apresentado ao Instituto de Contabilidade e Administração do Porto para a obtenção do grau de Mestre em Tradução e Interpretação Especializadas, sob orientação do Mestre Alberto Couto.

Gestão da identidade visual corporativa nos meios digitais: o caso RTP

Relatório de estágio apresentado à Escola Superior de Comunicação Social como parte dos requisitos para obtenção de grau de mestre em Gestão Estratégica das Relações Públicas.

An implicit GTS allocation mechanism in IEEE 802.15.4 for time-sensitive wireless sensor networks: theory and practice

Timeliness guarantee is an important feature of the recently standardized IEEE 802.15.4 protocol, turning it quite appealing for Wireless Sensor Network (WSN) applications under timing constraints. When operating in beacon-enabled mode, this protocol allows nodes with real-time requirements to allocate Guaranteed Time Slots (GTS) in the contention-free period. The protocol natively supports explicit GTS allocation, i.e. a node allocates a number of time slots in each superframe for exclusive use. The limitation of this explicit GTS allocation is that GTS resources may quickly disappear, since a maximum of seven GTSs can be allocated in each superframe, preventing other nodes to benefit from guaranteed service. Moreover, the GTS may be underutilized, resulting in wasted bandwidth. To overcome these limitations, this paper proposes i-GAME, an implicit GTS Allocation Mechanism in beacon-enabled IEEE 802.15.4 networks. The allocation is based on implicit GTS allocation requests, taking into account the traffic specifications and the delay requirements of the flows. The i-GAME approach enables the use of one GTS by multiple nodes, still guaranteeing that all their (delay, bandwidth) requirements are satisfied. For that purpose, we propose an admission control algorithm that enables to decide whether to accept a new GTS allocation request or not, based not only on the remaining time slots, but also on the traffic specifications of the flows, their delay requirements and the available bandwidth resources. We show that our approach improves the bandwidth utilization as compared to the native explicit allocation mechanism defined in the IEEE 802.15.4 standard. We also present some practical considerations for the implementation of i-GAME, ensuring backward compatibility with the IEEE 801.5.4 standard with only minor add-ons. Finally, an experimental evaluation on a real system that validates our theoretical analysis and demonstrates the implementation of i-GAME is also presented

i-GAME: an implicit GTS allocation mechanism in IEEE 802.15.4 for time-sensitive wireless sensor networks

The IEEE 802.15.4 Medium Access Control (MAC) protocol is an enabling technology for time sensitive wireless sensor networks thanks to its Guaranteed-Time Slot (GTS) mechanism in the beacon-enabled mode. However, the protocol only supports explicit GTS allocation, i.e. a node allocates a number of time slots in each superframe for exclusive use. The limitation of this explicit GTS allocation is that GTS resources may quickly disappear, since a maximum of seven GTSs can be allocated in each superframe, preventing other nodes to benefit from guaranteed service. Moreover, the GTSs may be only partially used, resulting in wasted bandwidth. To overcome these limitations, this paper proposes i-GAME, an implicit GTS Allocation Mechanism in beacon-enabled IEEE 802.15.4 networks. The allocation is based on implicit GTS allocation requests, taking into account the traffic specifications and the delay requirements of the flows. The i-GAME approach enables the use of a GTS by multiple nodes, while all their (delay, bandwidth) requirements are still satisfied. For that purpose, we propose an admission control algorithm that enables to decide whether to accept a new GTS allocation request or not, based not only on the remaining time slots, but also on the traffic specifications of the flows, their delay requirements and the available bandwidth resources. We show that our proposal improves the bandwidth utilization compared to the explicit allocation used in the IEEE 802.15.4 protocol standard. We also present some practical considerations for the implementation of i-GAME, ensuring backward compatibility with the IEEE 801.5.4 standard with only minor add-ons.

Sistema de apoio à decisão do rastreio do cancro da mama

O estudo do rastreio do cancro da mama funciona não só como um benefício, mas também como um método que pode causar controvérsias nas mulheres consideradas saudáveis antes de se submeterem ao rastreio. Assim, a necessidade do utente adquirir conhecimento sobre as vantagens e desvantagens do rastreio do cancro da mama é fundamental para decidir se, se submete ou não, a este rastreio. A decisão do paciente é crucial na decisão final e as consequências já devem ser do seu conhecimento. Com este estudo, pretendeu-se o desenvolvimento de um Sistema de Informação (SI) na Web, que funcione como auxiliar no processo de tomada de decisão para a realização do rastreio do cancro da mama. A decisão do componente do SI é fundamental, com o objetivo de auxiliar os utilizadores no processo de tomada de decisão para a realização do rastreio do cancro da mama. O desenvolvimento da plataforma “Decidir”, apresenta-se numa aplicação crucial no domínio médico da decisão do rastreio do cancro da mama, onde referências às suas controvérsias e benefícios são fundamentais para um melhor cuidado de saúde. Para esse efeito foram implementadas duas ferramentas para ajudar na decisão de realizar ou não o rastreio do cancro da mama. A primeira ferramenta resulta na decisão pessoal de cada indivíduo (paciente/profissionais de saúde), que pode ser variável, conforme um conjunto de proposições relevantes no aspeto pessoal e clínico para a tomada de decisão do rastreio nesta área.

Physical therapy with drug treatment in bell palsy: a focused review

ABSTRACT: The physical therapy (PT) associated with standard drug treatment (SDT) in Bell palsy has never been investigated. Randomized controlled trials or quasirandomized controlled trials have compared facial PT (except treatments such as acupuncture and osteopathic) combined with SDT against a control group with SDT alone. Participants included those older than 15 yrs with a clinical diagnosis of Bell palsy, and the primary outcome measure was motor function recovery by the House-Brackmann scale. The methodologic quality of each study was also independently assessed by two reviewers using the PEDro scale. Four studies met the inclusion criteria. Three trials indicate that PT in association with SDT supports higher motor function recovery than SDT alone between 15 days and 1 yr of follow-up. On the other hand, one trial showed that electrical stimulation added to conventional PT with SDT did not influence treatment outcomes. The present review suggests that the current practice of Bell palsy treatment by PT associated with SDT seems to have a positive effect on grade and time recovery compared with SDT alone. However, there is very little quality evidence from randomized controlled trials, and such evidence is insufficient to decide whether combined treatment is beneficial in the management of Bell palsy.