Bell's Palsy: A Case Study: Difference between revisions

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'''Original Editor '''-
'''Original Editor '''-[[User:Sam Borges|Sam Borges]], [[User:Erica Coulson|Erica Coulson]], [[User:Jessica Fieldhouse|Jessica Fieldhouse]] and [[User:Meghan McGrath|Meghan McGrath]] as part of the [[Queen's University Neuromotor Function Project]]


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== Abstract ==
== Abstract ==


Bell’s Palsy is a neurological condition involving Cranial Nerve VII characterized by facial drooping and weakness. This is a fictitious case study for educational purposes on Bell’s Palsy involving a 34-year old women, Mrs. S, who was referred to a physiotherapist. Patient reported primary complaints of difficulty drinking without spilling on herself or drooling, headache, pain at right jaw, trouble speaking clearly and right eye dryness. Cranial Nerve VII examination findings found right sided facial droop and drooping at the corner of her right eye and right side of her mouth. The Physiotherapy (PT) intervention included education, facial muscle strengthening exercise, eye protection exercises, modalities and acupuncture. Referrals were made to an optometrist and a speech language pathologist. Following Physiotherapy intervention, Mrs. S increased her facial muscle strength, with a near complete recovery at 6 months, and was discharged from Physiotherapy. In the future, more high quality research and evidence is needed to support the role of Physiotherapy in treating Bell’ Palsy.    
[[Bell's Palsy|Bell’s Palsy]] is a neurological condition involving [[Cranial Nerves|Cranial Nerve VII]] characterized by facial drooping and weakness. This is a fictitious case study for educational purposes on Bell’s Palsy involving a 34-year old women, Mrs. S, who was referred to physiotherapy (PT). The patient reported primary complaints of difficulty drinking without spilling on herself or drooling, headache, pain in her right jaw, trouble speaking clearly and right eye dryness. Cranial Nerve VII examination findings found right sided facial droop and drooping at the corner of her right eye and right side of her mouth. The PT intervention included education, facial muscle strengthening exercise, eye protection exercises, modalities and acupuncture. Referrals were made to an optometrist and a speech language pathologist. Following PT intervention, Mrs. S increased her facial muscle strength, with a near complete recovery at 6 months, and was discharged from PT. In the future, more high quality research and evidence is needed to support the role of PT in treating Bell’s Palsy.    


== Introduction ==
== Introduction ==


Bell’s Palsy is an idiopathic condition caused by a dysfunction in cranial nerve VII (15). Cranial Nerve VII (aka. the [https://www.physio-pedia.com/Facial_Nerve facial nerve]) innervates the muscles of facial expression, taste to the anterior 2/3 of the tongue and has parasympathetic innervation to the lacrimal gland (tear duct) and most of the salivary glands (16). 
Bell’s Palsy is an idiopathic condition caused by a dysfunction in Cranial Nerve VII (CN VII), also known as the [[Bell's Palsy|Facial Nerve]]<ref>Physiopedia. Bell’s Palsy. Available from: https://www.physio-pedia.com/Bell%27s_Palsy (accessed 8 May 2020)</ref> . CN VII has motor, sensory and [[Parasympathetic System|parasympathetic]] components. [https://www.physio-pedia.com/Facial_Nerve CN VII] innervates the muscles of facial expression, sensory for taste to the anterior 2/3 of the tongue and parasympathetic innervation to the lacrimal gland (tear duct) and most of the salivary glands. Factors that may increase the risk of Bell’s Palsy are [[diabetes]], [[Hypertension|high blood pressure]], toxins, infections (herpes simplex virus 1 (HSV 1), [[Human Immunodeficiency Virus (HIV)|human immunodeficiency virus (HIV)]], [https://www.physio-pedia.com/Herpes_Zoster shingles/chickenpox], [[Lyme Disease]], [[Epstein-Barr Virus]] and ischemia<ref name=":12">John Hopkins Medicine. Bell’s Palsy. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy (accessed 8 May 2020)</ref> <ref>Zhang W, Xu L, Luo T, Wu F, Zhao B, Li X. The etiology of Bell’s palsy: a review. J Neurol. 2019. https://doi.org/10.1007/s00415-019-09282-4</ref>. Bell’s Palsy can occur at any age, but it is most common between 15-60 years of age, and is believed to be a possible reaction to a viral infection that causes inflammation and swelling to CN VII<ref name=":22">Mayo Clinic. Bell’s Palsy. Available from https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 (accessed 15 May 2020)</ref>. Many studies support the use of corticosteroids and eye care to improve the symptoms of Bell’s Palsy<ref name=":32">National Institute of Neurological Disorders and Stroke. Bell’s Palsy Fact Sheet. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet (accessed 14 May 2020)</ref><ref name=":42">Murthy JMK, Saxena AB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152161/ Bell’s palsy: treatment guidelines]. Ann Indian Acad Neurol. 2011;14:S70-S72.</ref>. However, the evidence supporting PT treatment is less conclusive. There is some evidence that facial muscle exercises can decrease the recovery time but there is a lack of high-quality evidence<ref name=":42" />. 
It is idiopathic cause but there is some link between inflammation that targets CN VII. Factors that may increase the risk of Bell’s Palsy: diabetes, high blood pressure, toxins, infections (herpes simplex virus 1, HIV, herpes, shingles, chicken pox, Lyme disease, Epstein-Barr), ischemia (3,18)
Bell’s Palsy can occur at any age, more commonly between 15-60 years old, and is believed to be a possible reaction to a some viral infections including HSV1, the common flu and shingles that cause inflammation and swelling to cranial nerve VII (1).
Many studies support the use of corticosteroids and eye care to improve the symptoms of Bell’s Palsy (2, REFERENCE). However, the evidence supporting Physiotherapy treatment is less conclusive.
Discuss research around PT interventions - 
This case study describes a patient with Bell’s Palsy who presents with moderate-severe symptoms of facial drooping and weakness on the right side leading to difficulties with drinking, speaking and controlling the muscles of facial expression. This report aims to describe methods for testing and managing Bell’s Palsy and document the changes in condition over time.  
 


This case study describes a patient with Bell’s Palsy who presents with moderate-severe symptoms of facial drooping and weakness on the right side leading to difficulties with drinking, speaking and controlling the muscles of facial expression. This report aims to describe methods for testing and managing Bell’s Palsy and help physiotherapist create a treatment plan in the absence of high-quality evidence.
== Client Characteristics ==
== Client Characteristics ==
[[File:Bell's Palsy- Facial Droop.png|thumb]]
[[File:Bell's Palsy- Facial Droop.png|thumb|[https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 Bell's Palsy Right Sided Facial Droop]]]
Mrs. S is a 34-year old female that was diagnosed with Bell’s Palsy. She was taken to the hospital after her husband thought she was having a stroke due to her right-sided facial droop. The doctors ruled out stroke as a possible option and diagnosed her with Bell’s Palsy, a positive HSV1 test along with having high blood pressure and diabetes helped establish the diagnosis (1, 3). Mrs. S was prescribed corticosteroids to reduce inflammation and swelling as well as ibuprofen for pain if needed (2, 4). The doctors recommended physiotherapy for her right sided facial weakness. As a result of the right sided weakness Mrs. S complains of trouble with speaking and drinking. Eye dryness has also made it difficult for her to look at a computer for extended periods of time. Mrs. S is a secretary at a law firm and spends 80% of the day sitting in front of a computer screen. She is a mother with a 5-year old daughter and her husband is a fireman.        
Mrs. S is a 34 year old female who works as a secretary at a law firm and spends 80% of the day sitting in front of a computer screen. She is a mother of a 5-year old daughter and her husband works as a fireman. She was taken to the hospital after her husband thought she was having a [[stroke]] due to a right-sided facial droop. The doctors ruled out stroke as a possible option and diagnosed her with Bell’s Palsy. A positive HSV1 test and a previous diagnosis of high blood pressure and diabetes helped establish the diagnosis<ref name=":13">John Hopkins Medicine. Bell’s Palsy. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy (accessed 8 May 2020)</ref><ref name=":23">Mayo Clinic. Bell’s Palsy. Available from https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 (accessed 15 May 2020)</ref>. Mrs. S was prescribed corticosteroids to reduce inflammation and swelling as well as ibuprofen for pain as needed<ref name=":33">National Institute of Neurological Disorders and Stroke. Bell’s Palsy Fact Sheet. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet (accessed 14 May 2020)</ref><ref name=":52">Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F et al. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001942.pub5/full Corticosteroids for Bell’s Palsy (idiopathic facial paralysis)] (Cochrane review). Cochrane Database Syst Rev 2016; (2):CD001942</ref>. The doctor recommended PT for her right sided facial weakness. As a result of her symptoms, Mrs. S complains of trouble with speaking and drinking. Eye dryness has also made it difficult for her to look at a computer screen for extended periods of time.         


== Examination Findings ==
== Examination Findings ==


===== '''Subjective''' =====
=== Subjective ===
* '''Patient Profile''': 34 y/o female 
* '''Patient Profile''': 34 y/o female.
* '''Present Illness:''' Patient presented to the hospital 2 days ago because husband thought she was experiencing a stroke due to facial drooping on right side. Upon examination she was given a diagnosis of Bell’s Palsy which may be linked to a positive HSV1 test (1). EMG testing was done to determine the nerve damage and severity. (2) 
* '''Present Illness:''' Patient presented to the hospital two days ago with facial drooping on the right side. Upon examination she was given a diagnosis of Bell’s Palsy which may be linked to a positive HSV1 test <ref name=":25">Mayo Clinic. Bell’s Palsy. Available from https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 (accessed 15 May 2020)</ref>. A diagnostic electromyography ([https://www.physio-pedia.com/Visual_Analogue_Scale EMG]) test of the facial muscles confirmed the diagnosis<ref name=":35">National Institute of Neurological Disorders and Stroke. Bell’s Palsy Fact Sheet. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet (accessed 14 May 2020)</ref><ref>TeleEMG. Cranial Nerves. Available from: https://teleemg.com/manual/cranial-nerves/ (accessed 8 May 2020)</ref>.
* '''Past Medical History''': Type 2 Diabetes and hypertension; positive HSV1 test (1) 
* '''Past Medical History''': Type 2 diabetes and hypertension.
 
* '''Medications''': Thiazide diuretics<ref name=":03">Mayo Clinic. High blood pressure (hypertension). Available from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417 (accessed 15 May 2020)</ref>, metformin <ref>Mayo Clinic. Type 2 diabetes. Available from https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199 (accessed 14 May 2020)</ref>, corticosteroids.
* '''Medications''': Thiazide Diuretics (16), Metformin (17), corticosteroids 
* '''Health Habits''': Non-smoker, three glasses of wine per week.
* '''Health Habits''': Non-smoker, 3 glass of wine per weeks 
* '''Social History''': Works as a secretary at a local law firm. Lives with her husband who is employed as fireman, and one daughter in a 2-story home.
* '''Social History''': Works as a secretary at a local law firm. Lives with husband, employed as fireman, and 1 daughter in a 2-story home. 
* '''Patient complaints''': Complains of difficulty drinking without spilling on herself and drooling, headache and pain at back of right jaw. She also reports trouble speaking clearly, which makes it difficult to speak to clients on the phone at work. Complains of dry right eye that worsens over the workday while looking at a computer screen<ref name=":35" />.
* '''Patient complaints''': Complains of difficulty drinking without spilling on herself and drooling, headache, pain at back of right jaw, reports trouble speaking clearly, which makes it difficult to speak to clients on the phone at work. Complains of dry right eye that worsens over the workday while looking at a computer screen. (2) 


==== '''Objective''' ====
=== Objective ===
* '''Observation''': Facial droop on right side, drooping at corner of right eye and right side of the mouth  
* '''Observation''': Facial droop on right side, drooping at corner of right eye and right side of the mouth  
* '''CN VII testing''' (8): Total tests complete: left side: 6/6 tests completed; right side: 2/6 tests completed. 
* '''CN VII Testing:'''
** Able to lift right side of mouth 0.25cm 
{| class="wikitable"
** Able to raise right eyebrow 0.5cm  
!Side of Face
** Able to open mouth 
!Lift corner of mouth
** Able to produce a slight pucker of lips  
!Raise eyebrow
** Attempted to scrunch face: limitation on right side 
!Pucker lips
** Squinting: could only squint on left eye  
!Squint
 
!Scrunch face
* '''Sensation testing''': Taste to anterior 2/3 of tongue intact (Test: cotton swab dipped in salt vs sugar)(6) 
!Open mouth
!Total
|-
|Left side
|Complete
|Complete
|Complete
|Complete
|Complete
|Complete
|6/6
|-
|Right side
|Incomplete
|Incomplete
|Complete
|Incomplete
|Incomplete
|Complete
|2/6
|}
* '''Sensation testing''': Taste to anterior 2/3 of tongue intact (Test: cotton swab dipped in salt vs sugar)<ref>Newman G. How to assess the cranial nerves. Available from: https://www.merckmanuals.com/en-ca/professional/neurologic-disorders/neurologic-examination/how-to-assess-the-cranial-nerves (accessed 14 May 2020)</ref>
* '''Outcome measure''':  
* '''Outcome measure''':  
** Visual Analogue Scale ([https://www.physio-pedia.com/Visual_Analogue_Scale VAS)] for right jaw pain: at rest: 3/6, after eating or speaking: 6/10 
** Visual Analogue Scale ([https://www.physio-pedia.com/Visual_Analogue_Scale VAS)] for right jaw pain
** [https://www.physio-pedia.com/House%E2%80%93Brackmann_Scale House-Brackmann Facial Nerve Scale]: grade 4 (moderately severe) (5
*** At rest: 3/10  
*** After eating or speaking: 6/10 
** [[House–Brackmann Scale|House-Brackmann Facial Nerve Scale]]: grade 4 (moderately severe)<ref>Physiopedia. House-Brackmann Scale. Available from https://www.physio-pedia.com/House%E2%80%93Brackmann_Scale (accessed 8 May 2020)</ref> 


* '''Diagnostic test''': Electromyography [https://www.physio-pedia.com/Visual_Analogue_Scale (EMG]) of CN VII (7)
* '''Functional status''': Speech slightly slurred, noticeable effort when talking 
* '''Functional status''': Speech slightly slurred, noticeable effort when talking 
* '''Phase of recovery''': Acute (2 days post diagnosis
* '''Phase of recovery''': Acute (2 days post symptom onset
{{#ev:youtube|Tipup3mEv2g}}
{{#ev:youtube|Tipup3mEv2g}}


== Clinical Impression ==
== Clinical Impression ==


==== '''Physiotherapy Diagnosis''' ====
=== Physiotherapy Diagnosis ===
This case presented a patient, Ms. Smith, age 34 with a diagnosis of Bell’s Palsy, who presents with acute right-sided facial muscle weakness and facial droop, dry eyes and functional difficulty with speaking and drinking. Her facial weakness is classified as moderately severe on the House-Brackmann facial nerve scale. The patient’s primary concerns are her jaw pain, her functional difficulties with speaking and drinking and trouble working at her computer due to dry eyes.  
This case presented a patient, Mrs. S age 34, with a diagnosis of Bell’s Palsy, who presented with acute right-sided facial muscle weakness and facial droop, dry eye and functional difficulty with speaking and drinking. Her facial weakness is classified as moderately severe on the House-Brackmann facial nerve scale. The patient’s primary concerns were jaw pain, functional difficulties with speaking and drinking and trouble working at the computer due to dry eye.  


==== '''Prognosis''' ====
=== Prognosis ===
The prognosis for Bell’s Palsy has good outcomes generally. About 70% of people will completely resolve without any treatment intervention at all (4).  
The prognosis for Bell’s Palsy generally has good outcomes. About 70% of people will completely resolve without any treatment intervention <ref name=":53">Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F et al. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001942.pub5/full Corticosteroids for Bell’s Palsy (idiopathic facial paralysis)] (Cochrane review). Cochrane Database Syst Rev 2016; (2):CD001942</ref>.  


There is some evidence to suggest that treatment with steroid medication within seven days of symptom onset will result in better outcomes for recovery (21). It appears that age, gender, side of palsy or comorbidities such as diabetes mellitus or hypertension do not influence the prognosis or recovery outcomes of Bell’s Palsy (20). However, the limited and low-quality research in this area poses a challenge in confidently communicating a prognosis to Ms. Smith.
There is some evidence to suggest that treatment with steroid medication within seven days of symptom onset will result in better outcomes for recovery <ref>Sathirapanya P, Sathirapanya C.  [https://www.ncbi.nlm.nih.gov/pubmed/18788688 Clinical prognostic factors for treatment outcome in Bell's palsy: a prospective study]. Journal of the Medical Association of Thailand. 2008;91:1182-1188.</ref>. It appears that age, gender, side of palsy and comorbidities, such as diabetes mellitus or hypertension, do not influence the prognosis or recovery outcomes of Bell’s Palsy <ref>Fujiwara T, Hato N, Gyo K, Yanagihara N. [http://dw2zn6fm9z.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid=23995770 Prognostic factors of Bell’s palsy: prospective patient collected observational study.] Eur Arch Otorhinolaryngol. 2014;271:1891–1895.</ref>. However, there is limited and low-quality research in this area. This posed a challenge in confidently communicating a prognosis to Mrs. S.
 
=== Problem List ===
==== '''Problem List''' ====
{| class="wikitable"
{| class="wikitable"
!'''Body Structure and Function'''
!'''Body Structure and Function'''
Line 73: Line 88:
|Pain in right jaw
|Pain in right jaw
|Unable to drink fluids without spilling
|Unable to drink fluids without spilling
|Trouble speaking on the phone a work
|Trouble speaking on the phone at work
|-
|-
|Right-sided facial muscle weakness
|Right-sided facial muscle weakness
Line 81: Line 96:
|Headache
|Headache
|Difficulty eating hard/crunchy foods due to jaw pain
|Difficulty eating hard/crunchy foods due to jaw pain
|Challenges with in-person communication due to troubel making facial expressions
|Challenges with in-person communication due to trouble making facial expressions
|-
|-
|Dry right eye
|Dry right eye
Line 98: Line 113:
== Intervention ==
== Intervention ==


==== '''Patient goals''' ====
=== Patient goals ===
* Improve House-Brackman Facial Nerve Scale to a grade 2 within 4 weeks from the start of treatment.  
*Mrs. S will improve House-Brackman Facial Nerve Scale to a grade 2 within 8 weeks of initial treatment.
* Able to work on the computer for 1 hour without feeling discomfort in her right eye within 4 weeks  
*Mrs. S will be able to work on the computer for one hour without feeling discomfort in her right eye within 8 weeks of initial treatment.
* Able to speak for 4 minutes with minimal slurred speech within 4 weeks.  
*Mrs. S will be able to speak for 4 minutes with minimal slurred speech within 4 weeks of initial treatment.


==== '''Treatment''' ====
=== Treatment ===
{| class="wikitable"
{| class="wikitable"
!Intervention  
!Intervention  
Line 111: Line 126:
!Additional Notes
!Additional Notes
|-
|-
|Eye Dryness  
|Eye closing exercise  
|5 reps every hour
|5 reps every hour
|Active Assisted (if needed)
|Active Assisted (if needed)
|Complains of eye dryness to help with lubrication of the eye and strengthening of the muscles. (9)
|Improve lubrication of the eye to decrease eye dryness and strengthen the eye lid muscles<ref name=":62">Brach JS, VanSwearingen JM. [https://watermark.silverchair.com/ptj0397.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAm4wggJqBgkqhkiG9w0BBwagggJbMIICVwIBADCCAlAGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMLf3ZABK-iK0xnA3pAgEQgIICIX25_psU7KAiJ6vL6pBBStVfbeG8nnn0wTULxPlp5qOXdzXTslhVMvEUnoFpGepcTFRs4gXW1ApFCf3lUvCN2RHq5o7u47ZJ3-BysLMqBpwEe48j3CUhR8xkhufM9sxa8p248e9JDd0b3fmQNIZ0kIGgmDh9TdIlStMRJbXpGaeZ90k-NsAZhlzemfB78gmjR3XHhg14FWEP5tWngLLd4JF7ya5qPmk6IQvyHEQPsq_QiiBDunVLg_wkm6va1IABvjY_dxSOJ1cEv8sC5mYjRva8hZTt8ajL9sxD1grzGPIvU2NmBZ5my7W9wEsarEQT_NmNzF7rpBY2yINWgRcYATAzuOQB2iQMy8d5CKOd55ZLdl4uT1YDnR2P738kmQcMSnfGUzcT9RF5d9-QJk3rTwSO2qVqARA3ToXBz9l2hBG_hUtvhBnqWA1Zc_gZDi46oFStMQloZuxD4P4S5AklMsajrIepG56rZ45Qp0oUNJUCayw7f-rbSzHBx_aW2EoZjeHXKTGDh9gKNaW3INZm6fQ-XlBRJkPtMb_k2Bf-5YqF53_dJtO2fWhaWeaxpG_h7u0j9IAP43r_KZCicQl6ejCgu75q_D3Wb_YmMyP7Rl-NdqoNwkYaXr_RuRWijuIw76RSoFQQzorVRZjrsAf0N__ec1XDiIkLVWJWgyETjuJzliWf7t52eg_8w89wIniNI7UTdZEAhAY-HtAQ-gZO4Sw3 Physical Therapy for facial paralysis: a tailored treatment approach. Physical Therapy.] 1999;79:397-404.</ref>.
|
|Focus on point 5 feet ahead of you on the ground and practice closing eyes fully.
|-
|-
|AAROM (smile, eyebrow raise, frown, pucker lips, scrunching face)  
|AAROM (smile, eyebrow raise, frown, pucker lips, scrunching face)  
|10 reps 3 times daily
|10 reps 3 times daily
|Isometric hold working up to 10 seconds
|Isometric hold working up to 10 seconds
|Present with muscle weakness, exercises to help strengthen the muscles. (9)
|Exercises to help strengthen facial muscles<ref name=":63">Brach JS, VanSwearingen JM. [https://watermark.silverchair.com/ptj0397.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAm4wggJqBgkqhkiG9w0BBwagggJbMIICVwIBADCCAlAGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMLf3ZABK-iK0xnA3pAgEQgIICIX25_psU7KAiJ6vL6pBBStVfbeG8nnn0wTULxPlp5qOXdzXTslhVMvEUnoFpGepcTFRs4gXW1ApFCf3lUvCN2RHq5o7u47ZJ3-BysLMqBpwEe48j3CUhR8xkhufM9sxa8p248e9JDd0b3fmQNIZ0kIGgmDh9TdIlStMRJbXpGaeZ90k-NsAZhlzemfB78gmjR3XHhg14FWEP5tWngLLd4JF7ya5qPmk6IQvyHEQPsq_QiiBDunVLg_wkm6va1IABvjY_dxSOJ1cEv8sC5mYjRva8hZTt8ajL9sxD1grzGPIvU2NmBZ5my7W9wEsarEQT_NmNzF7rpBY2yINWgRcYATAzuOQB2iQMy8d5CKOd55ZLdl4uT1YDnR2P738kmQcMSnfGUzcT9RF5d9-QJk3rTwSO2qVqARA3ToXBz9l2hBG_hUtvhBnqWA1Zc_gZDi46oFStMQloZuxD4P4S5AklMsajrIepG56rZ45Qp0oUNJUCayw7f-rbSzHBx_aW2EoZjeHXKTGDh9gKNaW3INZm6fQ-XlBRJkPtMb_k2Bf-5YqF53_dJtO2fWhaWeaxpG_h7u0j9IAP43r_KZCicQl6ejCgu75q_D3Wb_YmMyP7Rl-NdqoNwkYaXr_RuRWijuIw76RSoFQQzorVRZjrsAf0N__ec1XDiIkLVWJWgyETjuJzliWf7t52eg_8w89wIniNI7UTdZEAhAY-HtAQ-gZO4Sw3 Physical Therapy for facial paralysis: a tailored treatment approach. Physical Therapy.] 1999;79:397-404.</ref>.
|Do exercises in front of mirror for visual feedback. See video examples below.  
|Do exercises in front of mirror for visual feedback. See video examples below.  
|-
|-
|Neuro- proprioception facilitation techniques. (Physiotherapist provides resistance to various muscles of facial expression).
|Neuro-proprioception facilitation techniques. (Physiotherapist provides resistance to various muscles of facial expression).
|10 reps 3 times daily  
|10 reps 3 times daily  
|Activate muscles as much as possible.
|Activate muscles as much as possible.
|Help with muscle weakness. (19)
|Exercises to help strengthen facial muscles<ref>Sardaru D, Pendefunda L. [https://www.ncbi.nlm.nih.gov/pubmed/24505900 Neuro-proprioceptive facilitation in the re-education of functional problems in facial paralysis: a practice approach]. Rev. Med. Chir. Med. Nat. 2013;117:101-106.</ref>.  
|This treatment will be provided once able to active muscle independently.  
|This treatment was provided once Mrs. S was able to active muscles independently.  
|-
|-
|Low Level Laster Therapy (LLLT)  
|Low Level Laser Therapy (LLLT)<ref name=":0">Olyaei G, Malmir K. Effects of Low Power Laser and Electrical Stimulation on Facial Function at Unilateral Sub-Acute Stage of Bell's Palsy. NeuroQuantology. 2022 Dec;20(21):458-64.</ref>
|Once per week
|Once per week
|10 J/cm<sup>2</sup> for 2 minutes (8 points)
|10 J/cm<sup>2</sup> for 2 minutes (8 points)
|Help with improve function when drinking and speaking. (13)
|Improve muscle function to assist with drinking and speaking<ref name=":72">Ordahan B & Karahan AY. [http://dw2zn6fm9z.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid=28337563 Role of low level laser therapy added to facial expression exercises in patients with idiopathic facial (Bell’s) palsy.] Lasers in Medical Science. 2017;32:931-936.</ref>.
|It has been beneficial in improving facial function(13)
|Completed on opposite days from acupuncture.   
|-
|-
|Soft Tissue Mobilization (effleurage)  
|Soft Tissue Mobilization (effleurage)  
|2 times per week
|2 times per week
|5 minutes (8 points)
|5 minutes (8 points)
|Help to improve circulation. (12)
|Improve circulation of the facial muscles<ref>Ferreira M, Marques EE, Duarte JA, Santos PC. [http://ovidsp.dc2.ovid.com.libaccess.lib.mcmaster.ca/sp-4.05.0b/ovidweb.cgi?WebLinkFrameset=1&S=OLHKFPEBHFEBBEADJPBKLFBFCBKGAA00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.22.23%257c0%257c00002060-201504000-00009%26S%3dOLHKFPEBHFEBBEADJPBKLFBFCBKGAA00&fromjumpstart=0&directlink=http%3a%2f%2fovidsp.dc2.ovid.com%2fovftpdfs%2fFPEBJPBFLFADHF00%2ffs047%2fovft%2flive%2fgv024%2f00002060%2f00002060-201504000-00009.pdf&filename=Physical+Therapy+with+Drug+Treatment+in+Bell+Palsy%3a+A+Focused+Review.&pdf_key=FPEBJPBFLFADHF00&pdf_index=/fs047/ovft/live/gv024/00002060/00002060-201504000-00009 Physical therapy with drug treatment in Bell palsy: a focused review]. American Journal of Physical Medicine & Rehabilitation. 2015;94:331-40.</ref>.  
|
|
|-
|-
|Acupuncture  
|Acupuncture  
|Once per week
|Once per week
|10 needles 30 minutes
|10 needles for 30 minutes
|Can help to regulate nerve channels, strengthen resistance to pathogenic factors, increase the excitability of the damaged nerve and promote regeneration of the nerve fibers. (14)
|Can help to regulate nerve channels, strengthen resistance to pathogenic factors, increase the excitability of the damaged nerve and promote regeneration of the nerve fibers<ref>Chen N, Zhou M, He L, Zhou D, Li N. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002914.pub5/full Acupuncture for Bell’s palsy] (Cochrane review). Cochrane Database Syst Rev 2010;(8):CD002914</ref>. 
|Do on opposite therapy days of LLLT.
|Completed on opposite days from LLLT.
|}
|}
{{#ev:youtube|og33hoO-8AQ}}
=== Education ===
Mrs. S was educated on her condition, potential prognosis and what PT can provide. Eye care education was also discussed, including wearing an eye patch when sleeping to protect the eye<ref name=":34">National Institute of Neurological Disorders and Stroke. Bell’s Palsy Fact Sheet. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet (accessed 14 May 2020)</ref> and taking a 5-10 minute break from looking at a computer every hour to prevent the eye from becoming dry and irritated. 


==== '''Education''' ====
Mrs. S will be educated on her condition, potential prognosis and what PT can provide. Eye care education will also be discussed including wearing an eye patch when sleeping to protect the eye (2) and taking a 5-10 minute break from looking at a computer every hour to avoid the eye becoming dry and irritated. 
{{#ev:youtube|og33hoO-8AQ}}
== Outcome ==
== Outcome ==


Report the degree of improvement or change in status post intervention.  
At the time of initial assessment, it was discussed with Mrs. S that the prognosis for Bell’s Palsy is very good and an almost full recovery would be expected at 6 months <ref name=":24">Mayo Clinic. Bell’s Palsy. Available from https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 (accessed 15 May 2020)</ref> <ref name=":36">National Institute of Neurological Disorders and Stroke. Bell’s Palsy Fact Sheet. Available from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet (accessed 14 May 2020)</ref>. Referrals were also made to a speech language pathologist (SLP) and an optometrist. The SLP would assist with her difficulties in speaking while the PT helps work on her muscular strength of the face. An optometrist would provide assistance with eye care, including lubrication of the eye through drops or medications <ref name=":14">John Hopkins Medicine. Bell’s Palsy. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy (accessed 8 May 2020)</ref><ref name=":36" />. 
Discharge plan or referrals to other health care professionals. 
Degree of improvement: prognosis generally very good, full recovery expected at ~6 months (back to baseline levels) (1, 2)
Discharge plan: Initially Ms. Smith will be seen 1-2x weekly, until level of functional disability has decreased and patient goals are met. After this point patient will have a session biweekly until a grade 1 on the House-Brackman Facial Nerve Scale is achieved.  
Referral: 
Speech Language Pathologist (SLP) (if trouble with speaking continues even with improvement in muscle strength in the face)
Optometrist (referred to at assessment -> drops and ointment to assist with dry eyes; 2, 3)  


Initially Mrs. S received PT 1-2 times a week until her level of functional disability was decreased such that her CN VII testing score was 4/6 and most of her patient goals were met. When these milestones were achieved, treatment sessions were reduced to biweekly until she scored a grade 2 on the House-Bracken Facial Nerve Scale.
After two months of therapy, Mrs. S reported that she had minimal jaw pain (VAS = 0/10 at rest and 2/10 when eating), no issues with speaking, and no resting facial droop. Mrs. S had demonstrated significant improvement in CN VII testing results. She completed 5/6 tests on the right side with the squint test remaining incomplete. Mrs. S also achieved a grade 2 on the House-Brackmann Facial Nerve Scale. At this time, Mrs. S was discharged and encouraged to continue with the facial muscle exercises at home until she was back to her baseline function. Given that Bell’s Palsy has good recovery outcomes, and most cases resolve on their own, it was unnecessary for Mrs. S to continue PT until fully recovered.
== Discussion ==
== Discussion ==


==== '''Summary''' ====
=== Summary ===
This case study presented a 34-year-old female who had an acute onset of Bell’s Palsy causing right sided facial muscle weakness and facial droop, dry right eye and difficulty speaking and drinking. Mrs. S received the diagnosis from a medical doctor who prescribed her with corticosteroids and advised her to seek treatment from a physiotherapist. After a full assessment by the physiotherapist, she received education about the condition and its prognosis. The PT provided advice to wear an eye patch and to take breaks from the computer to help with her dry eyes. Regarding the facial muscle weakness, the physiotherapist prescribed stretching and strengthening exercises to help regain normal muscle function. 
This case study presented a 34-year-old female with an acute onset of Bell’s Palsy causing right sided facial muscle weakness and facial droop, dry right eye and difficulty speaking and drinking. Mrs. S received the diagnosis from a medical doctor who prescribed her with corticosteroids and advised her to seek treatment from a physiotherapist. After a full assessment by the physiotherapist, Mrs. S received education about the condition and its prognosis. The physiotherapist provided advice to wear an eye patch and to take breaks from the computer to help with her dry eye. Facial muscle strengthening exercises and modalities were provided to help regain normal muscle function. 
 
==== '''Evidence''' ====
The research around the treatment for Bell’s Palsy shows no significant benefit or harm from physiotherapy interventions. Currently, there is some evidence that facial muscle exercises reduce time to recovery (10). One study showed that there was better improvement on the facial disability scale when LLLT and facial exercises were combined compared to exercise alone (a self-administered study) (13). It has also been demonstrated that the use of biofeedback when performing the facial muscle exercises (by using a mirror, for example) can be beneficial in developing coordinated muscle activity and preventing synkinesis (9).  
 
However, there is a lack of high-quality evidence and that poses a challenge when creating treatment plans for Bell’s Palsy. (4) Many research studies investigating physiotherapy as a treatment for Bell’s Palsy have small sample sizes, short study durations or significant risk of bias in the study design (4). Additionally, due to the nature of exercise as an intervention, it is hard to create a placebo control group and thus hard to make conclusive statements on the effect of exercise as an intervention for Bell’s Palsy (4). Furthermore, evaluating the efficacy of any intervention for Bell’s Palsy is especially challenging since ~70% of all cases will resolve spontaneously without any treatment (4). 
 
This demonstrates the need for more high quality RTCs and systematic reviews to guide health care providers in making evidence-based treatment plans for patients diagnosed with Bell’s Palsy.  
 
There is moderate to high quality evidence demonstrating that corticosteroids can be an effective treatment for facial nerve paralysis (4). Although pharmaceuticals are outside the scope of practice of Physiotherapy, it is important for practitioners to be aware of this so that they can make appropriate referrals to physicians for patients with Bell’s Palsy. 
 
== Self-Study Questions ==
1. Which cranial nerve is affected in a person who has Bell’s Palsy?         
 
a) CN V   
 
b) CN VII  
 
c) CN IX  
 
d) CN X        
 
2. Which of the following is not a risk factor for Bell’s Palsy?           
 
a) Recent viral infection     
 
b) Heavy smoker         
 
c) Diabetes           
 
d) Between the ages of 15 and 60 years old                
 
3. Which of the following has high quality evidence for the treatment for Bell’s Palsy?         
 
a) Acupuncture   
 
b) Manual Therapy   


c) Corticosteroids        
=== Evidence ===
The research around the treatment for Bell’s Palsy shows no significant benefit or harm from PT interventions. Currently, there is some evidence that facial muscle exercises reduces recovery time<ref name=":43">Murthy JMK, Saxena AB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152161/ Bell’s palsy: treatment guidelines]. Ann Indian Acad Neurol. 2011;14:S70-S72.</ref>. One study showed that there was better improvement on the facial disability scale (self-administered) when LLLT <ref name=":0" />and facial exercises were combined compared to exercise alone <ref name=":73">Ordahan B & Karahan AY. [http://dw2zn6fm9z.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid=28337563 Role of low level laser therapy added to facial expression exercises in patients with idiopathic facial (Bell’s) palsy.] Lasers in Medical Science. 2017;32:931-936.</ref>. It has also been demonstrated that the use of biofeedback when performing facial muscle exercises (by using a mirror, for example) can be beneficial in developing coordinated muscle activity and preventing synkinesis<ref name=":64">Brach JS, VanSwearingen JM. [https://watermark.silverchair.com/ptj0397.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAm4wggJqBgkqhkiG9w0BBwagggJbMIICVwIBADCCAlAGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMLf3ZABK-iK0xnA3pAgEQgIICIX25_psU7KAiJ6vL6pBBStVfbeG8nnn0wTULxPlp5qOXdzXTslhVMvEUnoFpGepcTFRs4gXW1ApFCf3lUvCN2RHq5o7u47ZJ3-BysLMqBpwEe48j3CUhR8xkhufM9sxa8p248e9JDd0b3fmQNIZ0kIGgmDh9TdIlStMRJbXpGaeZ90k-NsAZhlzemfB78gmjR3XHhg14FWEP5tWngLLd4JF7ya5qPmk6IQvyHEQPsq_QiiBDunVLg_wkm6va1IABvjY_dxSOJ1cEv8sC5mYjRva8hZTt8ajL9sxD1grzGPIvU2NmBZ5my7W9wEsarEQT_NmNzF7rpBY2yINWgRcYATAzuOQB2iQMy8d5CKOd55ZLdl4uT1YDnR2P738kmQcMSnfGUzcT9RF5d9-QJk3rTwSO2qVqARA3ToXBz9l2hBG_hUtvhBnqWA1Zc_gZDi46oFStMQloZuxD4P4S5AklMsajrIepG56rZ45Qp0oUNJUCayw7f-rbSzHBx_aW2EoZjeHXKTGDh9gKNaW3INZm6fQ-XlBRJkPtMb_k2Bf-5YqF53_dJtO2fWhaWeaxpG_h7u0j9IAP43r_KZCicQl6ejCgu75q_D3Wb_YmMyP7Rl-NdqoNwkYaXr_RuRWijuIw76RSoFQQzorVRZjrsAf0N__ec1XDiIkLVWJWgyETjuJzliWf7t52eg_8w89wIniNI7UTdZEAhAY-HtAQ-gZO4Sw3 Physical Therapy for facial paralysis: a tailored treatment approach. Physical Therapy.] 1999;79:397-404.</ref>.  


d) Exercise  
However, there is a lack of high-quality evidence which poses a challenge when creating treatment plans for Bell’s Palsy<ref name=":54">Madhok VB, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie F et al. [https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001942.pub5/full Corticosteroids for Bell’s Palsy (idiopathic facial paralysis)] (Cochrane review). Cochrane Database Syst Rev 2016; (2):CD001942</ref>. Many studies investigating PT as a treatment for Bell’s Palsy have small sample sizes, short study durations or significant risk of bias in the study design<ref name=":54" />. Additionally, due to the nature of exercise as an intervention, it is hard to create a placebo control group and thus hard to make conclusive statements on the effect of exercise as an intervention for Bell’s Palsy<ref name=":54" />. Furthermore, evaluating the efficacy of any intervention for Bell’s Palsy is especially challenging since ~70% of all cases will resolve spontaneously without any treatment<ref name=":54" />. This demonstrates the need for more high-quality RTCs and systematic reviews to guide health care providers in making evidence-based treatment plans for patients diagnosed with Bell’s Palsy.


There is moderate- to high-quality evidence demonstrating that corticosteroids are an effective treatment for facial nerve paralysis<ref name=":54" />. Although pharmaceuticals are outside the PT scope of practice, it is important for practitioners to be aware of this so that they can make appropriate referrals to physicians for patients with Bell’s Palsy.
== References  ==
== References  ==
<references />
<references />
Original research, systematic reviews, practice guidelines, text books that are relevant to your case
[[Category:Queen's University Neuromotor Function Project]]
https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028
[[Category:Neurological - Case Studies]]
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet
[[Category:Neurology]]
https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy
[[Category:Case Studies]]
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001942.pub5/full?highlightAbstract=palsy%7Cpalsi%7Cbells%7Cbell
https://www.physio-pedia.com/House%E2%80%93Brackmann_Scale 
https://www.merckmanuals.com/en-ca/professional/neurologic-disorders/neurologic-examination/how-to-assess-the-cranial-nerves
https://teleemg.com/manual/cranial-nerves/
https://www.youtube.com/watch?v=Tipup3mEv2g
https://academic.oup.com/ptj/article/79/4/397/2857760
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152161/
https://www.youtube.com/watch?v=og33hoO-8AQ
Ferreira M, Marques EE, Duarte JA & Santos PC. (2015). Physical therapy with drug treatment in Bell palsy: a focused review. American Journal of Physical Medicine & Rehabilitation, 94, 331-40. https://doi.org/10.1097/PHM.0000000000000255, 10.1097/PHM.0000000000000255
Ordahan, Banu & Karahan, Ali. (2017). Role of Low Level Laser Therapy Added to Facial Expression Exercises in Patients with Idiopathic Facial (Bell’s) Palsy. Lasers in Medical Science. 32. 10.1007/s10103-017-2195-9.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008974/epdf/full
https://www.physio-pedia.com/Bell%27s_Palsy
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417
https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199 
Zhang, W., Xu, L., Luo, T. et al. The etiology of Bell’s palsy: a review. J Neurol (2019). https://doi.org/10.1007/s00415-019-09282-4

Latest revision as of 15:53, 28 April 2023

Abstract[edit | edit source]

Bell’s Palsy is a neurological condition involving Cranial Nerve VII characterized by facial drooping and weakness. This is a fictitious case study for educational purposes on Bell’s Palsy involving a 34-year old women, Mrs. S, who was referred to physiotherapy (PT). The patient reported primary complaints of difficulty drinking without spilling on herself or drooling, headache, pain in her right jaw, trouble speaking clearly and right eye dryness. Cranial Nerve VII examination findings found right sided facial droop and drooping at the corner of her right eye and right side of her mouth. The PT intervention included education, facial muscle strengthening exercise, eye protection exercises, modalities and acupuncture. Referrals were made to an optometrist and a speech language pathologist. Following PT intervention, Mrs. S increased her facial muscle strength, with a near complete recovery at 6 months, and was discharged from PT. In the future, more high quality research and evidence is needed to support the role of PT in treating Bell’s Palsy. 

Introduction[edit | edit source]

Bell’s Palsy is an idiopathic condition caused by a dysfunction in Cranial Nerve VII (CN VII), also known as the Facial Nerve[1] . CN VII has motor, sensory and parasympathetic components. CN VII innervates the muscles of facial expression, sensory for taste to the anterior 2/3 of the tongue and parasympathetic innervation to the lacrimal gland (tear duct) and most of the salivary glands. Factors that may increase the risk of Bell’s Palsy are diabetes, high blood pressure, toxins, infections (herpes simplex virus 1 (HSV 1), human immunodeficiency virus (HIV), shingles/chickenpoxLyme Disease, Epstein-Barr Virus and ischemia[2] [3]. Bell’s Palsy can occur at any age, but it is most common between 15-60 years of age, and is believed to be a possible reaction to a viral infection that causes inflammation and swelling to CN VII[4]. Many studies support the use of corticosteroids and eye care to improve the symptoms of Bell’s Palsy[5][6]. However, the evidence supporting PT treatment is less conclusive. There is some evidence that facial muscle exercises can decrease the recovery time but there is a lack of high-quality evidence[6]

This case study describes a patient with Bell’s Palsy who presents with moderate-severe symptoms of facial drooping and weakness on the right side leading to difficulties with drinking, speaking and controlling the muscles of facial expression. This report aims to describe methods for testing and managing Bell’s Palsy and help physiotherapist create a treatment plan in the absence of high-quality evidence.

Client Characteristics[edit | edit source]

Mrs. S is a 34 year old female who works as a secretary at a law firm and spends 80% of the day sitting in front of a computer screen. She is a mother of a 5-year old daughter and her husband works as a fireman. She was taken to the hospital after her husband thought she was having a stroke due to a right-sided facial droop. The doctors ruled out stroke as a possible option and diagnosed her with Bell’s Palsy. A positive HSV1 test and a previous diagnosis of high blood pressure and diabetes helped establish the diagnosis[7][8]. Mrs. S was prescribed corticosteroids to reduce inflammation and swelling as well as ibuprofen for pain as needed[9][10]. The doctor recommended PT for her right sided facial weakness. As a result of her symptoms, Mrs. S complains of trouble with speaking and drinking. Eye dryness has also made it difficult for her to look at a computer screen for extended periods of time.      

Examination Findings[edit | edit source]

Subjective[edit | edit source]

  • Patient Profile: 34 y/o female.
  • Present Illness: Patient presented to the hospital two days ago with facial drooping on the right side. Upon examination she was given a diagnosis of Bell’s Palsy which may be linked to a positive HSV1 test [11]. A diagnostic electromyography (EMG) test of the facial muscles confirmed the diagnosis[12][13].
  • Past Medical History: Type 2 diabetes and hypertension.
  • Medications: Thiazide diuretics[14], metformin [15], corticosteroids.
  • Health Habits: Non-smoker, three glasses of wine per week.
  • Social History: Works as a secretary at a local law firm. Lives with her husband who is employed as fireman, and one daughter in a 2-story home.
  • Patient complaints: Complains of difficulty drinking without spilling on herself and drooling, headache and pain at back of right jaw. She also reports trouble speaking clearly, which makes it difficult to speak to clients on the phone at work. Complains of dry right eye that worsens over the workday while looking at a computer screen[12].

Objective[edit | edit source]

  • Observation: Facial droop on right side, drooping at corner of right eye and right side of the mouth  
  • CN VII Testing:
Side of Face Lift corner of mouth Raise eyebrow Pucker lips Squint Scrunch face Open mouth Total
Left side Complete Complete Complete Complete Complete Complete 6/6
Right side Incomplete Incomplete Complete Incomplete Incomplete Complete 2/6
  • Sensation testing: Taste to anterior 2/3 of tongue intact (Test: cotton swab dipped in salt vs sugar)[16]
  • Outcome measure:  
  • Functional status: Speech slightly slurred, noticeable effort when talking 
  • Phase of recovery: Acute (2 days post symptom onset) 

Clinical Impression[edit | edit source]

Physiotherapy Diagnosis[edit | edit source]

This case presented a patient, Mrs. S age 34, with a diagnosis of Bell’s Palsy, who presented with acute right-sided facial muscle weakness and facial droop, dry eye and functional difficulty with speaking and drinking. Her facial weakness is classified as moderately severe on the House-Brackmann facial nerve scale. The patient’s primary concerns were jaw pain, functional difficulties with speaking and drinking and trouble working at the computer due to dry eye.  

Prognosis[edit | edit source]

The prognosis for Bell’s Palsy generally has good outcomes. About 70% of people will completely resolve without any treatment intervention [18].  

There is some evidence to suggest that treatment with steroid medication within seven days of symptom onset will result in better outcomes for recovery [19]. It appears that age, gender, side of palsy and comorbidities, such as diabetes mellitus or hypertension, do not influence the prognosis or recovery outcomes of Bell’s Palsy [20]. However, there is limited and low-quality research in this area. This posed a challenge in confidently communicating a prognosis to Mrs. S.

Problem List[edit | edit source]

Body Structure and Function Activity Participation
Pain in right jaw Unable to drink fluids without spilling Trouble speaking on the phone at work
Right-sided facial muscle weakness Unable to speak clearly/words are slurred Unable to work a full day in front of the computer
Headache Difficulty eating hard/crunchy foods due to jaw pain Challenges with in-person communication due to trouble making facial expressions
Dry right eye
Facial droop on right side
Drooling

Intervention[edit | edit source]

Patient goals[edit | edit source]

  • Mrs. S will improve House-Brackman Facial Nerve Scale to a grade 2 within 8 weeks of initial treatment.
  • Mrs. S will be able to work on the computer for one hour without feeling discomfort in her right eye within 8 weeks of initial treatment.
  • Mrs. S will be able to speak for 4 minutes with minimal slurred speech within 4 weeks of initial treatment.

Treatment[edit | edit source]

Intervention Frequency Intensity Rationale Additional Notes
Eye closing exercise 5 reps every hour Active Assisted (if needed) Improve lubrication of the eye to decrease eye dryness and strengthen the eye lid muscles[21]. Focus on point 5 feet ahead of you on the ground and practice closing eyes fully.
AAROM (smile, eyebrow raise, frown, pucker lips, scrunching face) 10 reps 3 times daily Isometric hold working up to 10 seconds Exercises to help strengthen facial muscles[22]. Do exercises in front of mirror for visual feedback. See video examples below.
Neuro-proprioception facilitation techniques. (Physiotherapist provides resistance to various muscles of facial expression). 10 reps 3 times daily Activate muscles as much as possible. Exercises to help strengthen facial muscles[23]. This treatment was provided once Mrs. S was able to active muscles independently.
Low Level Laser Therapy (LLLT)[24] Once per week 10 J/cm2 for 2 minutes (8 points) Improve muscle function to assist with drinking and speaking[25]. Completed on opposite days from acupuncture.
Soft Tissue Mobilization (effleurage) 2 times per week 5 minutes (8 points) Improve circulation of the facial muscles[26].
Acupuncture Once per week 10 needles for 30 minutes Can help to regulate nerve channels, strengthen resistance to pathogenic factors, increase the excitability of the damaged nerve and promote regeneration of the nerve fibers[27] Completed on opposite days from LLLT.

Education [edit | edit source]

Mrs. S was educated on her condition, potential prognosis and what PT can provide. Eye care education was also discussed, including wearing an eye patch when sleeping to protect the eye[28] and taking a 5-10 minute break from looking at a computer every hour to prevent the eye from becoming dry and irritated. 

Outcome[edit | edit source]

At the time of initial assessment, it was discussed with Mrs. S that the prognosis for Bell’s Palsy is very good and an almost full recovery would be expected at 6 months [29] [30]. Referrals were also made to a speech language pathologist (SLP) and an optometrist. The SLP would assist with her difficulties in speaking while the PT helps work on her muscular strength of the face. An optometrist would provide assistance with eye care, including lubrication of the eye through drops or medications [31][30].

Initially Mrs. S received PT 1-2 times a week until her level of functional disability was decreased such that her CN VII testing score was 4/6 and most of her patient goals were met. When these milestones were achieved, treatment sessions were reduced to biweekly until she scored a grade 2 on the House-Bracken Facial Nerve Scale.

After two months of therapy, Mrs. S reported that she had minimal jaw pain (VAS = 0/10 at rest and 2/10 when eating), no issues with speaking, and no resting facial droop. Mrs. S had demonstrated significant improvement in CN VII testing results. She completed 5/6 tests on the right side with the squint test remaining incomplete. Mrs. S also achieved a grade 2 on the House-Brackmann Facial Nerve Scale. At this time, Mrs. S was discharged and encouraged to continue with the facial muscle exercises at home until she was back to her baseline function. Given that Bell’s Palsy has good recovery outcomes, and most cases resolve on their own, it was unnecessary for Mrs. S to continue PT until fully recovered.

Discussion[edit | edit source]

Summary[edit | edit source]

This case study presented a 34-year-old female with an acute onset of Bell’s Palsy causing right sided facial muscle weakness and facial droop, dry right eye and difficulty speaking and drinking. Mrs. S received the diagnosis from a medical doctor who prescribed her with corticosteroids and advised her to seek treatment from a physiotherapist. After a full assessment by the physiotherapist, Mrs. S received education about the condition and its prognosis. The physiotherapist provided advice to wear an eye patch and to take breaks from the computer to help with her dry eye. Facial muscle strengthening exercises and modalities were provided to help regain normal muscle function. 

Evidence[edit | edit source]

The research around the treatment for Bell’s Palsy shows no significant benefit or harm from PT interventions. Currently, there is some evidence that facial muscle exercises reduces recovery time[32]. One study showed that there was better improvement on the facial disability scale (self-administered) when LLLT [24]and facial exercises were combined compared to exercise alone [33]. It has also been demonstrated that the use of biofeedback when performing facial muscle exercises (by using a mirror, for example) can be beneficial in developing coordinated muscle activity and preventing synkinesis[34].  

However, there is a lack of high-quality evidence which poses a challenge when creating treatment plans for Bell’s Palsy[35]. Many studies investigating PT as a treatment for Bell’s Palsy have small sample sizes, short study durations or significant risk of bias in the study design[35]. Additionally, due to the nature of exercise as an intervention, it is hard to create a placebo control group and thus hard to make conclusive statements on the effect of exercise as an intervention for Bell’s Palsy[35]. Furthermore, evaluating the efficacy of any intervention for Bell’s Palsy is especially challenging since ~70% of all cases will resolve spontaneously without any treatment[35]. This demonstrates the need for more high-quality RTCs and systematic reviews to guide health care providers in making evidence-based treatment plans for patients diagnosed with Bell’s Palsy.

There is moderate- to high-quality evidence demonstrating that corticosteroids are an effective treatment for facial nerve paralysis[35]. Although pharmaceuticals are outside the PT scope of practice, it is important for practitioners to be aware of this so that they can make appropriate referrals to physicians for patients with Bell’s Palsy.

References[edit | edit source]

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