Bell's Palsy: A Case Study

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Top Contributors - Erica Coulson, Jessica Fieldhouse, Kim Jackson, Sam Borges, Meghan McGrath, Chelsea Mclene and Shaimaa Eldib  

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 (PT). 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 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 Physiotherapy. In the future, more high quality research and evidence is needed to support the role of PT in treating Bell’ Palsy. 

Introduction

Bell’s Palsy is an idiopathic condition caused by a dysfunction in cranial nerve VII (CN VII), also known as the Facial Nerve (15). 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 (16). Factors that may increase the risk of Bell’s Palsy are diabetes, high blood pressure, toxins, infections (herpes simplex virus 1, HIV, shingles, chicken pox, Lyme disease, Epstein-Barr) and ischemia (3,18). 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 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, 10). However, the evidence supporting Physiotherapy 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 (10). 

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 Physiotherapists create a treatment plan in the absence of high-quality evidence.

Client Characteristics

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 PT 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.     

Examination Findings

Subjective

• 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) 
• Past Medical History: 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 1 daughter in a 2-story home. 
• 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

• 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. 
  • Able to lift right side of mouth 0.25cm 
  • Able to raise right eyebrow 0.5cm  
  • Able to open mouth 
  • Able to produce a slight pucker of lips  
  • Attempted to scrunch face: limitation on right side 
  • Squinting: could only squint on left eye  

• Sensation testing: Taste to anterior 2/3 of tongue intact (Test: cotton swab dipped in salt vs sugar)(6) 
• Outcome measure:  
  • Visual Analogue Scale (VAS) for right jaw pain: at rest: 3/6, after eating or speaking: 6/10 
  • House-Brackmann Facial Nerve Scale: grade 4 (moderately severe) (5) 

• Diagnostic test: Electromyography (EMG) of CN VII (7)
• Functional status: Speech slightly slurred, noticeable effort when talking 
• Phase of recovery: Acute (2 days post diagnosis) 

Clinical Impression

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.  

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).  

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 Mrs. S.

Problem List

Body Structure and Function	Activity	Participation
Pain in right jaw	Unable to drink fluids without spilling	Trouble speaking on the phone a 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

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.

Treatment

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 needles 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)	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 PT. After a full assessment by the PT, 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 PT prescribed stretching and strengthening exercises to help regain normal muscle function. 

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 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 PT 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 PT, 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       

d) Exercise  

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