Bell's Palsy: A Case Study

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Abstract

Purpose: This is a fictitious case study for education purpose on Bell’s Palsy involving a 34-year old women, Mrs. S seeking a physiotherapist. Case Presentation: Her primary complaints are difficulty drinking without spilling on herself or drooling, headache, pain at back and right jaw, trouble speaking clearly, right eye dryness (2). OR She presented with right sided facial droop, drooping at the corner of her right eye and right side of her mouth. Intervention: eye protection, muscle strengthening, modalities, acupuncture Outcomes: referrals to optometrists and SLPs,

Introduction

Bell’s Palsy is an idiopathic condition caused by a dysfunction in cranial nerve VII (15). Cranial Nerve VII (aka. the 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). 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.

Client Characteristics

Mrs. S is a 34-year old female (2) that works as a secretary at a law firm (spending 80% of the day working on a computer). 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 from her right-side facial droop. The doctors ruled out stroke as a possible option and diagnosed her with Bell’s Palsy from a positive HSV1 test along with having high blood pressure and diabetes (1). The doctors recommended physiotherapy for the facial weakness. Mrs. S was prescribed corticosteroids to reduce inflammation and swelling and ibuprofen for pain if needed (2, 4). Mrs. S is a secretary at a law firm spending 80% of the day sitting in front of a computer then must care for her 5-year old daughter and husband who is a fireman.

Examination Findings

Subjective:

• Patient profile: 34 y/o female
• History of 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 was possibly due to a positive HSV1 test (1). EMG test done to determine the nerve damage and severity. (2)
• Past Medical history: diagnosed with Type 2 diabetes and hypertension; positive HSV1 test (1)
• Medications: Thiazide Diuretics (16), Metformin (17), corticosteroids
• Health Habits: non-smoker, 3 glass of wine per weeks
• Social History: works as a secretary at a local law firm. Lives with husband, employed as fireman, and 2 daughters in a 2-story home.
• Patient complaints: Complains of difficulty drinking without spilling on herself and drooling, headache, pain at back or right jaw, reports trouble speaking clearly, which makes it difficult to speak to clients on the phone at work. Dry right eye complains it worsens over the work-day staring at the computer screen (2)

Objective:

• Observation: facial droop on right side, drooping at corner of right eye and right side of her mouth
  • CN VII testing (8): able to lift right side of mouth 0.25cm, able to raise right eyebrow 0.5cm -> able to open mouth, able to get a slight pucker of her lips. Attempted to scrunch face – limitation on right side; squinting -could only squint on left eye (left side: 6/6 tests completed; right side: 2/6 tests completed)
  • Sensation testing: taste anterior 2/3 of tongue tested (cotton swab dipped in salt vs sugar) -> taste intact (6)
  • Outcome measure: Visual Analog Scale (VAS) for right jaw pain: 6/10; House-Brackmann Facial Nerve Scale: grade 4 (moderately severe) (5);
  • Diagnostic test: Electromyography (EMG) of CN VII (for details on how to complete; 7)
  • Functional status: Speech slightly slurred, noticeable effort when talking
  • Phase of recovery: Acute (2 days post diagnosis)

Clinical Impression

Ms. Smith, age 34 with a diagnosis of Bell’s Palsy, presents with acute right-sided facial muscle weakness and facial droop, dry eyes and functional difficulty with speaking and drinking. Problem list: Body Structure Function: pain in right jaw, right-sided facial muscle weakness, headache, right eye is dry, drooling, facial droop on right side (especially right eye and right side of mouth) Activity: unable to drink fluids without spilling, unable to speak clearly/slurs words, Participation: trouble speaking on phone at work; unable to work a full day in front of the computer

Intervention

Patient goals: Improve House-Brackman Facial Nerve Scale to a grade 2 within 4 weeks from the start of treatment. Able to work on the computer for 1 hour without feeling discomfort in her right eye within 4 weeks Able to speak for 4 minutes with minimal slurred speech within 4 weeks.

Intervention	Frequency	Intensity	Rationale	Additional Notes
Eye Dryness	5 reps every hour	Active Assisted (if needed)	Complains of eye dryness to help with lubrication of the eye and strengthening of the muscles. (9)
AAROM (smile, eyebrow raise, frown, pucker lips, scrunching face)	10 reps 3 times daily	Isometric hold working up to 10 seconds	Present with muscle weakness, exercises to help strengthen the muscles. (9)	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.	Help with muscle weakness. (19)	This treatment will be provided once able to active muscle independently.
Low Level Laster Therapy (LLLT)	Once per week	10 J/cm2 for 2 minutes (8 points)	Help with improve function when drinking and speaking. (13)	It has been beneficial in improving facial function. (13)
Soft Tissue Mobilization (effleurage)	2 times per week	5 minutes (8 points)	Help to improve circulation. (12)
Acupuncture	Once per week	10 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)	Do on opposite therapy days of LLLT.

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. 

Outcome

Report the degree of improvement or change in status post intervention. 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)

Discussion

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 from the physiotherapist, she was given Evidence: Limited evidence that improvement began earlier with exercise. Most evidence shows no significant benefit or harm from Physiotherapy. Limited evidence that facial exercises reduces time to recovery, however more research needs to be completed (10) A lack of high-quality evidence poses a challenge when creating treatment plans for Bell’s Palsy. (4) Many research studies investigating PT as a treatment for Bell’s palsy have small sample sizes, have short study durations or have 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). There was a better improvement with the combination of LLT and exercised combined than exercise alone for ratings on the facial disability scale (an self-administered study) (13) Evaluating the effect of any intervention for Bell’s Palsy is especially challenging since ~70% of all cases will resolve spontaneously without any treatment (4).

Self-Study Questions

Which cranial nerve is affected in a person who has Bell’s Palsy? CN VII, Which of the following is not a risk factor for Bell’s Palsy? (between 15-60 years, recently had a viral infection, recently had a stroke, is a heavy smoker)

Resources

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References

Original research, systematic reviews, practice guidelines, text books that are relevant to your case https://www.mayoclinic.org/diseases-conditions/bells-palsy/symptoms-causes/syc-20370028 https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Bells-Palsy-Fact-Sheet https://www.hopkinsmedicine.org/health/conditions-and-diseases/bells-palsy 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