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Bell’s palsy

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 The 4th International Virtual Conference on Advanced Scientific Results
Bell’s palsy
Physical therapy and surface electromyography biofeedback
Irina Karaganova
Faculty of Public Health and Health Care,
Department of Public Health and Social Activities
University of Ruse „Angel Kanchev”
Rousse, Bulgaria
Abstract—Bell’s palsy is an acute disorder of the facial nerve,
which produces full or partial loss of movement on one side of the
face. The facial palsy gets completely better without treatment in
most, but not all, people. Bell’s palsy (Idiopathic facial paralysis)
is commonly treated by various physical therapy strategies and
devices, but there are many questions about their efficacy.
Physical therapies, such as exercise, biofeedback, laser treatment,
electrotherapy, massage and thermotherapy, are used to hasten
recovery, improve facial function and minimize sequelae.
There is no high quality evidence to support significant benefit or
harm from any physical therapy for idiopathic facial paralysis.
In this regard, the aim of this report is to describe the basic
functional classification system and the main rehabilitation
approaches to recovery of persons with facial paralysis.
Keywords – Bell’s palsy, Idiopathic facial paralysis, Functional
classification system, Physical therapy
I. INTRODUCTION
Peripheral facial nerve paralysis is the most common
peripheral damage of the cranial nerves. The weakness is a
facial nerve damage that results in muscle weakness on one
side of the face. It may be idiopathic or may have a detectable
cause. Almost 80% of peripheral facial weakness cases are
primary and the rest of them are secondary [4].
Idiopathic facial palsy, also called Bell’s palsy, is an acute
disorder of the facial nerve, which may begin with symptoms
of pain in the mastoid region and produce full or partial
paralysis of movement of one side of the face [34].
The main cause of Bell’s palsy is reactivation of latent
herpes simplex virus type 1 in the cranial nerve ganglia [34].
The other most frequent causes of secondary peripheral facial
weakness are systemic viral infections, trauma, surgery,
diabetes, local infections, tumor, immune disorders, drugs,
degenerative diseases of the central nervous system, etc. [4].
The incidence of Bell’s palsy is estimated to 20 – 25 cases
per 100,000 populations annually. Women and men are usually
equally affected. It occurs with equal frequency on the right
and left side of the face [4].
Bell’s palsy has a fair prognosis without treatment.
Typically, the facial movement returns without intervention.
For that reason, individuals with Bell palsy seldom receive
physical therapy, but, complete recovery was observed only at
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Stefka Mindova
Faculty of Public Health and Health Care,
Department of Public Health and Social Activities
University of Ruse „Angel Kanchev”
Rousse, Bulgaria
about 60% of all patients. It is unknown if intervention with
physical therapies improves outcome. The prognosis depends
to a great extent on the time at which recovery begins. Early
commencement of recovery is associated with a good
prognosis and late recovery a bad prognosis [9].
For treatment to use the medicaments, hyperbaric oxygen
therapy, physical treatments, including thermal methods
(conductive, radiative and convective heat transfer in order to
achieve vasodilatation, or ice over the mastoid region with the
aim of relieving edema), electrotherapy (which uses an
electrical current to cause a single muscle or group of muscles
to contract), massage and facial exercise [9].
II. AIM OF THE REPORT
Although recovery from Bell palsy is expected without
intervention, clinical experience suggests that recovery is often
incomplete. This report describes the basic functional
classification system and the main rehabilitation approaches to
recovery of persons with facial paralysis.
III. PRESENTATION
The anatomy of the facial nerve illustrates the complexities
of the human peripheral, central, and autonomic nervous
systems. The facial nerve, the seventh cranial nerve, contains
motor, general sensory, special sensory and autonomic
(visceral) components [32].
In this regards, the physical therapist must have
comprehensive knowledge of the anatomy, physiology, and
course of the facial nerve to diagnose and to rehabilitate
patients with facial nerve disorders while avoiding surgical
complications such as facial nerve injury.
The facial nerve, or cranial nerve (CN) VII, provides
somatic motor (efferent) innervation to the muscles of facial
expression including buccinator and platysma, the posterior
belly of the digastric muscle, intrinsic muscles of the auricle,
the occipitalis, the stylohyoid, and the stapedius muscles [32].
The posterior auricular nerve supplies general sensory
(somatic afferent) innervation to the skin of the concha, a small
area of skin behind the ear, and posterior ear canal. Visceral
motor (efferent) neurons supply preganglionic parasympathetic
innervation (secretomotor) to the mucus glands of the nose,
hard, and soft palate, and lacrimal glandvia the greater
superficial petrosal nerve, which synapses in the
pterygopalatine ganglion [32].
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Postganglionic fibers ride along branches of the trigeminal
nerve to their varied destinations. The facial nerve also supplies
visceral motor innervation to the submandibular, sublingual,
and minor salivary glands via the chorda tympani nerve, whose
preganglionic fibers synapse in the submandibular ganglion,
and postganglionic fibers ride along the lingual nerve (branch
of trigeminal nerve) [1, 5, 32].
Both parasympathetic and sensory (special and general)
functions of the facial nerve are mediated by the nervus
intermedius [1, 32].
The striated facial (mimetic) muscles derive from the
second branchial arch mesoderm and are innervated by the
facial nerve. The facial muscles can be thought of in groups:
the muscles of the scalp (occipitofrontalis, temporoparietalis),
extrinsic muscles of the ear, muscles of the eyelid, muscles of
the nose, and muscles of the mouth [32].
Bell’s palsy, due to dysfunction of the facial nerve,
typically causes paralysis or weakness of the muscles on one
side of the face [17].
Peripheral facial nerve palsy is diagnosed upon the clinical
presentation with weakness of all facial nerve branches,
drooping of the brow, incomplete lid closure, drooping of the
corner of the mouth, impaired closure of the mouth, dry eye,
hyperacusis, impaired taste, or pain around the ear (Figure. 1).
INABILITY TO FURROW THE
BROW ON THE AFFECTED SIDE
SLIGHT WIDENING OF THE
PALPEBRAL FISSURE
DROOPING OF THE CORNER OF
THE MOUTH
Figure 1. Bell’s palsy of the the left side
Bell's phenomenon (upward diversion of the bulb on
attempted closure of the lid) occurs if the eye closure is
incomplete [17, 18].
The clinical picture may differ, depending on the location
of the lesion of the facial nerve along its course to the muscles.
Symptoms and signs may also differ because of the fact that the
facial nerve carries not only motor fibers including fibers to the
stapedius muscle but also supplies autonomic innervation of
the lacrimal gland, submandibular gland, sensation to part of
the ear, and taste to the anterior two thirds of the tongue via
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chorda tympani [4, 5, 17, 18].
Thus, Bell’s palsy is diagnosed upon abrupt onset of
impaired facial expression due to unilateral facial weakness of
all facial nerve branches, dry eye, if saliva runs out of the
mouth, the inability to close or wink the eye or close the
mouth, to droop the brow or the corner of the mouth, numbness
or pain around the ear, temple, mastoid, or angle of the
mandible, an altered sense of taste, hypersensitivity to sounds,
or decreased tearing [4, 28].
Patients may also mention otalgia, aural fullness, or mild
retro auricular pain, which may even precede the palsy [4, 17].
Speech and eating may also be disturbed.
It is fundamental to have a reliable and valid method of
evaluating facial palsy and be able to assess the course of
recovery and the effect of treatment over time. The evaluation
should be sensitive enough to detect clinically important
changes over time. It should also be easy to administer, and
require little time and equipment [3, 30].
Different facial grading scales have been developed and can
be divided mainly into two categories, gross scales and
regionally weighted or unweighted scales. In addition to these
two main categories, specific scales also exist [13, 22, 24, 33].
The House-Brackmann scale (HBS) is the most commonly
used grading system for facial nerve disorders and categorizing
of overall facial function. The scale has six grades, or scores,
where I = normal function and VI = complete paralysis (Table
1) [3, 7, 19, 23].
TABLE I. THE HOUSE-BRACKMANN FACIAL NERVE GRADING SYSTEM
(HOUSE AND BRACKMANN 1985)
I Normal  Normal facial function in all areas.
 Gross: slight weakness noticeable on close
inspection; may have very slight synkinesis
II Mild  At rest: normal symmetry and tone.
dysfunction  Motion forehead: Moderate to good function
 Motion eye: complete closure with minimum effort
 Motion mouth: slight asymmetry
 Gross: obvious but not disfiguring difference
between two sides; noticeable but not severe
synkinesis, contracture and/or hemifacial spasm.
III Moderate  At rest: normal symmetry and tone.
dysfunction  Motion forehead: slight to moderate movement
 Motion eye: complete closure with effort
 Motion mouth: slightly weak with maximum
effort
 Gross: obvious weakness and/or disfiguring
asymmetry.
IV Moderately
 At rest: normal symmetry and tone.
severe
 Motion forehead: none
dysfunction
 Motion eye: incomplete closure
 Motion mouth: asymmetric with maximum effort.
 Gross: only barely perceptible motion.
 At rest: asymmetry
V Severe
 Motion forehead: none
dysfunction
 Motion eye: incomplete closure
 Motion mouth: slight movement
VI Total
 No movement
paralysis
The HBS considers an overall evaluation of facial nerve
dysfunction and also includes evaluation of sequelae.
However, it has been postulated that it does not appear to
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be sensitive enough to document clinically significant changes The points in each dimension are totaled and one overall score
over time, and has been reported to suffer from interobserver obtained. The score is weighted and results in a composite
variation [3, 7, 15, 21, 25]. score of 0 – 100, where 100 represents normal facial function
and 0 represents complete facial paralysis (Table 3) [3, 30].
In regional scales, different areas of facial function are
assessed independently. A weighted regional system will TABLE II. YANAGIHARA GRADING SYSTEM
consider certain areas of the face most important. Several
regional scales have been demonstrated. The two most widely Partial
Normal No motion
used are the Yanagihara system and the Sunnybrook facial palsy/weak
grading system (SFGS) [3, 20, 30, 38]. 1. At rest 4 2 0
2. Wrinkle forehead 4 2 0
The Yanagihara system is the most commonly used facial
3. Close eyes normally 4 2 0
grading system. It assesses ten aspects of facial muscle
4. Close eyes
function, each scored 0–4, to give a possible maximum score of forcefully
4 2 0
40. It does not include evaluation of sequelae, such as 5. Close eyes on the
synkinesis and contracture (Table 2) [3, 31, 38]. 4 2 0
involved side only
6. Wrinkle nose 4 2 0
The SFGS was developed and introduced by Ross et al in
1996. The SFGS is based on the evaluation of resting 7. Blowout cheeks 4 2 0
symmetry, degree of voluntary movements and degree of 8. Whistle 4 2 0
synkinesis associated with specific voluntary movements. 9. Grin 4 2 0
The different regions of the face are examined separately 10.Depress lower lip 4 2 0
for five standard facial expressions, and the response is graded.

TABLE III. SUNNYBROOK FACIAL GRADING SYSTEM

(MODIFIED FROM ROSS ET AL. 1996)
Synkinesis
Resting Symmetry Symmetry of Voluntary Movement
Rate the degree of involuntary muscle contraction
Compared to normal side Degree of muscle excursion compared to normal side
associated with each expression
None Mild Moderate Severe
Eye (choose one only)
normal 0 Initiates disfiguring
Unable to Initiates Movement
narrow 1 Standard movement Movement slight obvious synkinesis
initiate slight almost
wide 1 expressions with mild complete no synkinesis synkinesis of synkinesis of /gross mass
movement movement complete or mass
eyelid surgery 1 excursion one or more one or more movement of
movement
muscles muscles several
muscles
Cheek (naso-labial fold)
normal 0
Brow lift 1 2 3 4 5 0 1 2 3
absent 2
less pronounced 1 Gentle eye
1 2 3 4 5 0 1 2 3
more pronounced 1 closure
Open mouth
1 2 3 4 5 0 1 2 3
Mouth smile
normal 0
Snarl 1 2 3 4 5 0 1 2 3
corner drooped 1
corner pulled up/out 1
Lip pucker 1 2 3 4 5 0 1 2 3

Gross Severe Moderate Mild Normal

asymmetry asymmetry asymmetry asymmetry symmetry
Total_____ Total_____
Resting symmetry score: Totalx5_____ Voluntary movement score: Total x4_____ Synkinesis score: Total_____
Voluntary movement score – (minus) Resting symmetry score – (minus) Synkinesis score = Composite Score_____

The SFGS system is the best instrument for clinical use [3, validity of nerve conduction studies for the prognosis of facial
30]. nerve lesions [2, 17, 18].
Adding more objective measurements and recording Additional investigations may include
sequelae such as contractures and facial fasciculation’s could electronystagmography, videonystagmography, and
further improve the grading, giving a more accurate facial videooculoscopy [17].
grading system [17].
Therapy, particularly of Bell's palsy, is controversial due to
Nerve conduction studies (prolonged distal latency, reduced the lack of large, prospective, randomized, and controlled trials
compound muscle action potential) may provide useful [17, 35].
information about the severity and nature of the lesion,
although more prospective studies are required to assess the

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The main goals of treatment are to speed recovery, to make After the treatment-based category is identified, a physical
recovery more complete, to prevent corneal complications and therapy program consisting of neuromuscular re-education
other consequences, and if there is a viral infection, to inhibit matched to the assigned category is then initiated.
viral replication [4, 18].
Surface electromyography (sEMG) biofeedback or a mirror
Psychological support is also very important. Therapy of may be used as an adjunct to the retraining exercises in each of
secondary facial weakness aims to act upon the particular cause the treatment-based categories. The sEMG biofeedback is not
of the palsy. Patients with Bell’s palsy should be referred to a the treatment; exercises are the treatment.
specialist and treatment should start as soon as possible [4, 18].
The facial muscles have few, if any, muscle spindles [6, 9,
Treatment may be divided into pharmacological therapy 10, 12].
and nonpharmacological measures.
Thus, little information about muscle length and action is
Facial neuromuscular re-education is a conservative available to the individual. Learning facial movements is
approach to facial rehabilitation. Demonstrated outcomes of difficult without the feedback. The use of sEMG or a hand
facial neuromuscular re-education include improvements in mirror is a means of providing a visual or auditory
impairments associated with facial paralysis [8 – 11, 29]. representation of facial muscle activity (sEMG) or movement
(mirror) [9].
Facial neuromuscular re-education consists of an evaluation
of facial impairments and functional limitations, guided The patients should implement in a home facial movement
training sessions of correct movement patterns, and instruction exercise program, which is based on the treatment-based
in a specific facial movement exercise program [9, 10, 16, 36]. category and the patients’ performance during the rehabilitation
session [9].
Can be used are developed by J. Brach and J. M. Van
Swearingen, 1999 the classification scheme based on the To assist the patient in her goal of improved facial
intervention tailored to the signs and symptoms that could also functioning are treated with facial neuromuscular retraining
be used to guide treatment (Table. 4) [9]. (NMR) techniques, using a hand-held mirror or sEMG
biofeedback [8, 9, 10, 16, 36].
TABLE IV. TREATMENT-BASED CATEGORIES AND MATCHED
TREATMENT Treatment planning was based on the evaluation findings
(J. BRACH AND J. M. VANSWEARINGEN, 1999) and on treatment-based categories.
Category and Treatment sessions were one on one with a physical
Representative Signs Treatment* Repetitions Frequency
and Symptoms
therapist for approximately 1 hour. A typical physical therapy
High (3–4 session consisted of a brief re-evaluation, training with sEMG
Initiation AAROM Low (,10) or a mirror, and instruction in an exercise program to be
times a day)
Matched completed at home [9].
Drooped resting posture
movements
Education of Surface EMG biofeedback was used initially to measure
Barely initiates movement muscle activity associated with voluntary facial movements.
the recovery
or very minimal movement
process
Facilitation Surface EMG biofeedback devices can be used to record
Marked functional Moderate (1– and display small changes in muscle activity that cannot be
AROM High (10–20)
problems 2 times a seen in a mirror. When a patient started regain movement and
day) able to move more, is used the surface EMG biofeedback less
Resistive and a mirror more [9].
Minimal droop at rest
exercises
Mild to moderate facial The sEMG biofeedback provides the information necessary
muscle weakness for correction the movements and supported the process of
Isolated Q uality, not High (3–4 rehabilitation.
Movement control
movements quantity times a day)
Narrowed eye, deepened Matched IV. CONCLUSION
cheek crease movements
Mild to moderate facial Controlled Individuals with Bell palsy are seldom referred for physical
muscle weakness synkinesis therapy at the onset of the disorder. Often is waiting the
Synkinesis recovery to occur spontaneously. Complete recovery does not
Low to always occur, especially in high-risk populations such as
As indicated
Relaxation Stretching moderate
by symptoms people who are elderly or who have delayed recovery [9, 26].
(<10)
Resting facial tension Massage Physical therapy for patients with facial paralysis
Jacobson’s traditionally has consisted of generic facial exercises or
Facial twitches/spasms relaxation
exercises
electrical stimulation [9, 37].
Marked psychosocial Rhythmic Facial neuromuscular re-education techniques (ie, the use
difficulties movement
* AAROM = active assisted range of motion, AROM = active range of motion,
of facial exercises to address a patient’s impairments and
matched movements = symmetrical movements of the left and right sides of the functional limitations) are different from the traditional
face. intervention for facial paralysis [9].

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The exercise program changes over time as the patient’s
impairments change with recovery. The facial neuromuscular
re-education exercise program emphasizes accuracy of facial
movement patterns and isolated muscle control, and it excludes
exercises that promote mass contraction of muscles related to
more than one facial expression [9].
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