MEDICAL REHABILITATION IN PATIENT WITH

LEFT BELL’S PALSY

1
Yudisthira Rantung
2
Lidwina Sengkey
1
Physical and Rehabilitation Department of Sam Ratulangi University Manado
Email: yudisthirahendra@gmail.com
lidwinasimasengkey@yahoo.co.id

ABSTRACT:Bell’s palsy is a complex neuromuscular facial disorder of unknown etiology commonly affecting
the motor neurones of facial muscles receiving their neurological innervations from the seventh cranial nerve (the
facial nerve).1 Bell's palsy is named after Sir Charles Bell (1774–1842), who first described the syndrome along
with the anatomy and function of the facial nerve. 2 The facial nerve not only carries motor fibers including fibers
to the stapedius muscle but also supplies autonomic innervations of the lacrimal gland, submandibular gland,
sensation to part of the ear, and taste to the anterior two thirds of the tongue via the chorda tympani.3 Bell’s palsy
accounts for almost three quarters of peripheral facial palsies and the annual incidence is about 15-30 patients per
100.000 annually.The sexes are affected equally. The median age at onset is 40 years, but the disease may occur
at any age. The right and left sides of the face are involved with equal frequency.4,5Treatment of Bell’s palsy varies,
and no clear consensus exists. The aims of treatment in the acute phase of Bell's palsy include strategies to speed
recovery and to prevent corneal complications. Most physicians prescribe corticosteroids as a primary treatment
due to its potential to reduce swelling and inflammation. The addition of antiviral treatment (AVT) such as
Acyclovir or Valacyclovir is aimed at eradication of HSV infection. 6,7 The treatments at Medical Rehabilitation
include facial exercise or facial neuromuscular re-education, electrostimulation, infrared rays, and acupuncture, as
well as the need for eye-protective and further assessed with electroneurography or electromyography in the
presence of complete facial paralysis.

ABSTRAK: Bell's palsy adalah gangguan wajah neuromuskular kompleks dengan etiologi yang tidak diketahui
umumnya mempengaruhi neuron motorik otot wajah yang menerima persarafan neurologis dari saraf kranial
ketujuh (saraf wajah).1 Bell's palsy dinamai Sir Charles Bell (1774-1842), yang pertama kali menggambarkan
sindrom tersebut beserta anatomi dan fungsi nervus fasialis.2 Nervus fasialis tidak hanya membawa serabut motorik
termasuk serabut ke otot stapedius tetapi juga mempersarafi persarafan otonom kelenjar lakrimal, kelenjar
submandibular, sensasi ke bagian telinga, dan pengecapan pada dua pertiga anterior lidah melalui korda timpani.3
Bell's palsy merupakan hampir tiga perempat dari kelumpuhan wajah perifer dan kejadian tahunan sekitar 15-30
pasien per 100.000 per tahun. Jenis kelamin terpengaruh sama. Usia rata-rata saat onset adalah 40 tahun, tetapi
penyakit ini dapat terjadi pada usia berapa pun. Sisi kanan dan kiri wajah terlibat dengan frekuensi yang sama. 4,5
Pengobatan Bell's palsy bervariasi, dan tidak ada konsensus yang jelas. Tujuan pengobatan pada fase akut Bell's
palsy termasuk strategi untuk mempercepat pemulihan dan untuk mencegah komplikasi kornea. Kebanyakan
dokter meresepkan kortikosteroid sebagai pengobatan utama karena potensinya untuk mengurangi pembengkakan
dan peradangan. Penambahan pengobatan antivirus (AVT) seperti Asiklovir atau Valasiklovir ditujukan untuk
pemberantasan infeksi HSV.6,7 Perawatan di Rehabilitasi Medis meliputi senam wajah atau pendidikan ulang
neuromuskular wajah, elektrostimulasi, sinar inframerah, dan akupunktur, serta kebutuhan akan pelindung mata
dan dinilai lebih lanjut dengan electroneurography atau electromyography dengan adanya kelumpuhan wajah
lengkap.

1
INTRODUCTION physicians prescribe corticosteroids as a primary
Bell’s palsy is a complex neuromuscular facial treatment due to its potential to reduce swelling and
disorder of unknown etiology commonly affecting the inflammation. The addition of antiviral treatment
motor neurones of facial muscles receiving their (AVT) such as Acyclovir or Valacyclovir is aimed at
neurological innervations from the seventh cranial eradication of HSV infection.9,10 The treatments at
nerve (the facial nerve).1 Bell's palsy is named after Sir Medical Rehabilitation include facial exercise or facial
Charles Bell (1774–1842), who first described the neuromuscular re-education, electrostimulation,
syndrome along with the anatomy and function of the infrared rays, and acupuncture, as well as the need for
facial nerve.2 The facial nerve not only carries motor eye-protective and further assessed with
fibers including fibers to the stapedius muscle but also electroneurography or electromyography in the
supplies autonomic innervations of the lacrimal gland, presence of complete facial paralysis. Most patients
submandibular gland, sensation to part of the ear, and who suffer from Bell palsy have neurapraxia or
taste to the anterior two thirds of the tongue via the local nerve conduction block at electromyography
chorda tympani. Bell’s palsy accounts for almost three study. These patients are likely to have a prompt
quarters of peripheral facial palsies and the annual and complete recovery of the nerve. Patients with
incidence is about 15-30 patients per 100.000 axonotmesis, with disruption of the axons, have a
annually. The sexes are affected equally. The median fairly good recovery, but it is usually not
age at onset is 40 years, but the disease may occur at complete.11,12,13,14 “ Neuropraxia” was defined as
any age. The right and left sides of the face are absence of pathologic, spontaneous fibrillation
involved with equal frequency.5,6 activity and decreased or lost voluntary activity.
The cause of Bell palsy remains unknown, “Axonotmesis/neurotmesis” was defined as
though the disorder appears to be a polyneuritis with pathologic, spontaneous activity in one or more facial
possible viral, inflammatory, autoimmune, and muscles and decreased or lost voluntary activity. If the
ischemic etiologies.6 It disproportionally attacks recording of some muscles clearly argued for
pregnant women, patients who have diabetes, neuropraxia but the other muscles for
influenza, a cold, some other respiratory alignment or axonotmesi/neurotmesis, the recordings were
have undergone tooth root extraction. Some patients classified as “mixed lesion”.15 The role of early
report exposure to an air-condition outlet, or an open surgery in treating Bell’s palsy has been
window before the attack.3 Bell’s palsy has been controversial.16 In the past, surgical decompression
attributed to an inflammatory reaction involving the within three weeks of onset has been recommended for
facial nerve near the stylomastoid foramen or in the patients who have persistent loss of function at two
bony facial canal. Increasing evidence incriminates weeks, but the latest guideline suggest against the
reactivation of herpes simplex or varicella zoster virus routine use of surgical decompression as a treatment
infection in the geniculate ganglion at least in some choice in Bell’s palsy.2,12
instances.7 Electrotherapy, massage, facial exercises, and
Bell’s palsy may begin with symptoms of pain biofeedback are different physical therapy modalities
in the mastoid region and produce full or partial that have been used for the treatment of Bell’s palsy
paralysis of movement of one side of the face. The with a concentration on the role of exercise therapy
corner of the mouth droops, the creases and skin folds more than other interventions. The aim of these
are effaced, the forehead is unfurrowed, and the modalities is to increase muscle and nerve function
eyelids will not close. Upon attempted closure of the either through exercise or electrotherapy.
lids, the eye on the paralyzed side rolls upward (Bell’s Furthermore, thermal methods and massage work can
phenomenon). The lower lid sags and falls away from decrease swelling and increase blood flow to the
the conjunctiva, permitting tears to spill over the affected tissues, thereby increasing the amount of
cheek. Food collects between the teeth and lips, and oxygen available to damaged hypoxic tissues with the
saliva may dribble from the corner of the mouth. The aim of promoting recovery.19
patient complains of a heaviness or numbness in the Laser therapy is a modality that can be used in
face but sensory loss is rarely demonstrable. If the the treatment of Bell’s palsy. It is considered a non-
lesion is in the middle-ear portion, taste is lost over the invasive and painless therapeutic modality that can be
anterior two-thirds of the tongue on the same side. If used for any type of patient, including those who
the nerve to the stapedius is interrupted, there is cannot use corticosteroids, such as diabetic and
hyperacusis (sensitivity to loud sound).6,8 hypertensive patients.20 Approximately 70 to 80
Treatment of Bell’s palsy varies, and no clear percent of patients will recover spontaneously, up to
consensus exists. The aims of treatment in the acute 95% would be recovery without physical therapy if
phase of Bell's palsy include strategies to speed treated with prednisone and valacyclovir.17 A common
recovery and to prevent corneal complications. Most short-term complication of Bell's palsy is incomplete

2
eyelid closure which can lead to irritation and corneal Table 3. House-Brackmann score to grade severity of
ulceration. A less common long-term complication is facial nerve palsy by assessing motility of forehead,
permanent facial weakness, muscle contractures, eye, nose, and mouth as 1-6.3
synkinesis, sweating while eating or during physical Grade Score
exertion, ‘crocodiles tears’-lacrimation of ipsilateral Normal, symmetrical function in all areas I
eye during chewing and ‘jaw-winking’-closure of the Slight weakness on close inspection, II
ipsilateral eyelid when the jaw open.2,10 In this case complete eye closure with minimal effort,
report is about rehabilitation in a man with left Bell’s slight asymmetry of smile with maximal
palsy. effort, slight synkinesis, absent
contracture or spasm
CASE REPORT Obvious weakness but not disfiguring, III
INITIAL PRESENTATION unable to lift eyebrow, complete and
A 53 years old male come to the PMR strong eye closure, asymmetrical mouth
department on July 5th 2018. Patient complained movement with maximal effort, obvious
but not disfiguring synkinesis, mass
Left corner of patient’s mouth drooped since 7
movement or spasm
months ago when he woke up in the morning. He Obvious disfiguring weakness, inability to IV
saw that his left facial creases and nasolabial fold lift eyebrow, incomplete
disappeared, the forehead unfurrowed, and the eye closure, and asymmetry of mouth with
left corner of the mouth drooped. His left eyelids maximal effort, severe synkinesis, mass
couldn’t close. While he ate the food and saliva movement, spasms
pooled in the left side and spilled out from the left Motion barely perceptible, incomplete eye V
corner of the mouth. He felt numbness on his left closure, slight movement corner of mouth,
face. He could taste food normally. Before that, synkinesis, spasm usually absent
he work as a sailor and often hit by the wind No movement, loss of tone, no synkinesis, VI
contracture, spasm
blowing directly to his face. Patient also often
open the glass cover of the helmet while driving
There is no history of hypertension,
motorcycle. Sometimes he felt his left ear buzing,
diabetes, toothache, ear infection, varicella,
no pain behind his left ears, he had no history of
common cold in the past few weeks, and head
trauma. Moreover, there were no weaknesses on
trauma. There is no family member who had this
his arms and his legs. This was the first time
problem. - Patient work as a sailor for 16
patient had an experience like this. On the second
years and often hit by the wind directly in the face
day onset, patient had already taken medicine
while on the ship. Patient also often open the
from neurology department which are
glass cover of the helmet while driving
methylprednisolone 16 mg 3 times daily (5 days),
motorcycle. Patient does not smoke and drink
followed 8 mg 3 times daily (5 days), ranitidine
alcohol. Patient lives in the permanent house.
150mg 2 times daily, and mecobalamin 500 mg
The toilet is sitting toilet. The source of water is
2 times daily. He experienced slight disturbances
from PDAM and electricity from PLN. Patient
in activities in daily living (ADL) especially
used BPJS for paying the rehabilitation therapy.
while feeding (chewing food and drinking),
He worked on the expedition ship for about 16
grooming (gargling while tooth brushing).
years. He is the second from 5 siblings, he has one
Table 2.UGO FISCH scale brother and three sister. On physical examination
Position Value Percentage Score we found paralysis on left peripheral seventh
Rest 20 70 14 cranial nerve with no other muscle weaknesses.
Frown the 10 70 7 The House-Brackmann’s score is grade III.
forehead
Closed 30 100 30 DIAGNOSIS
eyes In medical diagnosis, the clinical diagnosis
Smile 30 70 21 is Left Bell’s palsy 7th months of onset, the topical
Whistle 10 70 7 diagnosis Suspect facial nerve below the temporal part
Total 79 of facial canal. Etiological diagnosis is idiopathic.
Functional diagnosis is disutbance in muscle power
function, eating and drinking, mobility and

3
transportation. The short term goal for management of forehead difficult to frown, and the corner of the
this patient are to educate and reassure the patient mouth drooped. When he ate, the food and saliva
about the condition, to facilitate or improve muscle pooled in the affected side and spilled out from the
contraction, to facilitate or improve facial symmetry. corner. Before that, patient work as a sailor for 16
Whereas the long term golas for this patient are to years and often hit by the wind directly in the face
prevent complication and to recover patient’s nerve while on the ship. Patient also often open the glass
function cover of the helmet while driving motorcycle. There
was no pain on his mastoid, he had no history of
REHABILITATION TREATMENT PLAN trauma. He could taste food normally. Moreover, there
1. Physiatrist were no weaknesses on his arms and his legs. This was
Explain the condition to the patient (its causes, the first time patient had an experience like this.
incidence, prognosis and treatment), re-assure the According from the literature Bell’s palsy may
patient, but be realistic (don’t give high begin with symptoms of pain in the mastoid region and
expectations), advice the patient to following the produce full or partial paralysis of movement of one
rehabilitation program and to avoid therapy given side of the face. The corner of the mouth droops, the
by non-professionals, explain to the patient how creases and skin folds are effaced, the forehead is
the psychological state can affect the treatment, so unfurrowed, and the eyelids will not close, permitting
avoid any emotional conflict and seek family or tears to spill over the cheek. Upon attempted closure
friend support to increase self-awareness and self- of the lids, the eye on the paralyzed side rolls upward
esteem, follow the given home program. (Bell’s phenomenon). Food collects between the teeth
and lips, and saliva may dribble from the corner of the
2. Physiotherapy mouth. The patient complains numbness in the left
Modality: LLLT on left face (on the range of face but sensory loss is rarely demonstrable. If the
facial nerve ramification in eight different places), lesion is in the middle-ear portion, taste is lost over the
deep kneading massage on his left face, anterior two-thirds of the tongue on the same side.6,8
neuromuscular retraining on facial muscles in In this patient there was no impairment in sense of
front of the mirror taste at 2/3 anterior of tongue which means the lesion
was below the temporal part of facial canal (where the
3. Psychology nerve gives rise to the stapedius and chorda tympani).
Mental support to reduce patient’s anxiety and
giving a confidence that if he do exercise every Table 4. House-Brackmann score to grade severity of
day, his face may return to normal. Because this facial nerve palsy by assessing motility of forehead,
disease has approximately 80% of full recovery. eye, nose, and mouth as 1-6.3
Grade Score
4. Home program Normal, symmetrical function in all areas I
Warm compress on the left side of face for 10- Slight weakness on close inspection, II
15 minutes daily, massage on the left side of face, complete eye closure with minimal effort,
neuromuscular retraining on facial muscles in slight asymmetry of smile with maximal
front of the mirror, blowing candle exercise, use effort, slight synkinesis, absent
straw while drinking, and gargle training contracture or spasm
Obvious weakness but not disfiguring, III
5. Social Worker unable to lift eyebrow, complete and
Gave advises and assisted family or friends in strong eye closure, asymmetrical mouth
modifying his environment to support his movement with maximal effort, obvious
treatment, such as wearing cover face helmet but not disfiguring synkinesis, mass
while driving motorcycle. movement or spasm
Obvious disfiguring weakness, inability to IV
DISCUSSION lift eyebrow, incomplete
In this case report, we discuss about a 53 years eye closure, and asymmetry of mouth with
old male patient who was diagnosed with Left Bell’s maximal effort, severe synkinesis, mass
Palsy. The diagnosis was constructed by anamnesis movement, spasms
and physical examination. From the anamnesis of this Motion barely perceptible, incomplete eye V
patient, there was asymmetry at the left side of face closure, slight movement corner of mouth,
since 7 months ago when he woke up in the morning, synkinesis, spasm usually absent
left facial creases and nasolabial fold disappeared, the No movement, loss of tone, no synkinesis, VI
contracture, spasm

4
 facial palsy must be discriminated from the
From the physical examination, patient was supranuclear or upper motor neuron (UMN) type.6
compos mentis, cooperative, communication and The diagnosis of Bell’s palsy can usually be
comprehension was good and vital sign was normal. made clinically in patients with (1) a typical
Manual Muscle Test of all facial muscles was 2 except presentation, (2) no risk factors or pre-existing
for M. Orbicularis occuli was 3 and M. Corrugator symptoms for other causes of facial paralysis, (3)
supercilli was 1. House-Brackmann grade was III. absence of cutaneous lesions of herpes zoster in the
UGO FISCH scale was 79. To clinically assess the external ear canal, and (4) a normal neurologic
severity of peripheral facial nerve palsy various examination with the exception of the facial nerve.
scoring systems are available. The initial severity of Particular attention to the eighth cranial nerve, which
facial weakness provides valuable prognostic courses near to the facial nerve in the pontomedullary
information for facial recovery. The most widely junction and in the temporal bone, and to other cranial
applied is the House–Brackmann facial nerve grading nerves is essential. In atypical or uncertain cases,
system (HBS) (table 1).3,11 In this patient the House- testing for diabetes mellitus such as fasting glucose or
Brackmann score was III in the first visit then A1C testing may be performed in patients with
increased to II on the follow up. additional risk factors (e.g., family history, obesity,
UGO FISCH Scale is used to assess the older than 30 years). Lyme antibody titers should be
condition of symmetric or asymmetric between the performed if the patient’s history suggests possible
healthy side and the impaired side at 5 positions: At exposure. Patients with insidious onset or forehead
rest, smiling, closing eyes, raising eyebrows and sparing should undergo imaging of the head. In the
whistling. The assessment of percentages are 0% is presence of complete facial paralysis, nerve function
complete asymmetrical, there is no voluntary can be further assessed with electroneurography or
movement, 30% is symmetrical, poor, the recovery is electromyography (EMG). EMG of the facial muscles
likely closer to complete asymmetrical, 70% is determines signs of denervation and/or reinnervation
symmetrical, fair, partial recovery is likely closer to as well as the degree of recruitment of motor units. In
complete symmetrical, 100% is symmetrical, normal long standing denervation without signs of
or complete. In this patient the UGO FISCH Scale was reinnervation, EMG might help in evaluating the facial
79 in the first visit then increased to 82 on the follow muscle status whether there is complete muscle
up. Clinical assessment should be repeated fibrosis or there are still viable contractile muscle
(approximately every month) to assess fibers. Those with bilateral palsies or those who do not
improvement.15 improve within the first two or three weeks after onset
There are many other causes of acute facial palsy of symptoms should be referred to a neurologist. 2,6,13
that must be considered in the differential diagnosis of In this patient, we did not perform the laboratory
Bell’s palsy. Lyme disease can cause unilateral or testing because she did not have additional risk factors
bilateral facial palsies; in endemic areas, 10% or more or possible exposure to Lyme disease. We also did not
of cases of facial palsy are likely due to infection with perform the imaging of the head because she did not
Borrelia burgdorferi. The Ramsay Hunt syndrome, have insidious onset. The facial paralysis was not
caused by reactivation of herpes zoster in the complete, so we did not perform electroneurography
geniculate ganglion, consists of a severe facial palsy or electromyography; also improvement at second
associated with a vesicular eruption in the external follow up, so we didn’t referred her back to neurologist
auditory canal and sometimes in the pharynx and other for further evaluation.
parts of the cranial integument; often the eighth cranial Generally, the treatment of Bell’s palsy can be
nerve is affected as well. Facial palsy that is often conducted in 2 ways: first by using pharmacologic
bilateral occurs in sarcoidosis and in Guillain-Barré agents (medicaments) and second by rehabilitation.
syndrome. Leprosy frequently involves the facial Physical medicine and rehabilitation (PM&R) also
nerve, and facial neuropathy may also occur in referred a physiatrist as a medical specialty concerned
diabetes mellitus, connective tissue diseases and with diagnosis, evaluation, and management of
amyloidosis.. Acoustic neuromas frequently involve persons of all ages with physical and/or cognitive
the facial nerve by local compression. Infarcts, impairment and disability. A physiatrist will work
demyelinating lesions of multiple sclerosis, and together with the other subunit such as physiotherapy,
tumors are the common lesions that interrupt the facial occupational therapy, orthotic-prosthetic,
nerve fibers; other signs of brainstem involvement are psychologist and medical social worker to achieve the
usually present. Tumors that invade the temporal bone best treatment for the patient.17
(carotid body, cholesteatoma, dermoid) may produce The aims of treatment in the acute phase of Bell's
a facial palsy, but the onset is insidious and the course palsy include strategies to speed recovery and to
progressive. All these forms of nuclear or peripheral prevent corneal complications. Most physicians

5
prescribe corticosteroids as a primary treatment due to level laser therapy (LLLT) increases the functional
its potential to reduce the inflammatory process in activity of the injured peripheral nerve, prevents or
Bell’s palsy and this facilitates remyelination of facial decreases degeneration in corresponding motor
nerve. Prednisolone should be used in all patients with neurons of the spinal cord, and improves the axonal
facial palsy of less than 72 hours duration who do not growth and myelinisation.23 This patient was given
have contraindications to steroid therapy, with dose 60 LLLT (880 nm) dose : 3,00 J/cm 2, duty factor : 80%,
mg per day for 5 days then reduced by 10 mg per day frequency : 5,00 Hz, area : 1,00 cm2, time : 01:00 (m:s)
(for a total treatment time of 10 days).9,10,12 Patient had at every point. Massage, which has frequently been
already taken methylprednisolone from neurology prescribed for facial palsy, improves circulation and
department since day 2nd with dose 16 mg (equally to may prevent contracture.16 The guideline for soft
20 mg prednisone) 3 times daily (5 days), followed 8 tissue massage was 10 repetitions 1 or 2 times per
mg (equally to 10 mg prednisone) 3 times daily (5 day.17 This patient was given facial massage at the 7th
days). month of paralysis onset according to
The addition of antiviral treatment (AVT) such recommendation from the latest guideline to give
as Acyclovir or Valacyclovir is aimed at eradication of physiotherapy for patient with persistent weakness,
HSV infection. Current practice of adding AVT (either but no recommendation for acute Bell’s Palsy of any
Acyclovir or Valacyclovir) in the regimen with severity.12 The stages of Bell’s palsy includes acute
Prednisolone may increase disease recovery rates stage (1-7 day onset of disease), resting stage (8-20
compared with Prednisolone alone, but at this point days onset of disease) and restoration stage (21-90
this difference is not statistically significant. The days of disease).13
possible explanation for the lack of any incremental Facial neuromuscular re-education is a process
effect of AVT is because Bell’s palsy is a post- of relearning facial movement using specific and
infectious immune mediated facial neuropathy rather accurate feedback to (1) facilitate facial muscle
than direct viral infection.9 Furthermore, the latest activity in functional patterns of facial movement and
guideline management for Bell’s Palsy suggest the expression and (2) suppress abnormal muscle activity
combine use of antiviral and corticosteroids in patient interfering with facial function.11 There are four
with severe to complete paresis.12 This patient was distinct treatment based categories (initiation,
not given AVT from neurology department. facilitation, movement control and relaxation stages)
It was reported by one investigator that injection matched with specific treatment techniques for each
of 500 µg of vitamin B12 (in form of category. Surface EMG (s-EMG) has been advocated
methylcobalamin) given 3 times weekly for at least 8 as an appropriate form of visual and/or auditory
weeks was of benefit in enhancing recovery in Bell’s biofeedback for the re-education of muscle activity in
Palsy.16 This patient was given mecobalamin 500 mg facial movement disorders. However, if s-EMG is not
3 times daily from Neurology Department. The available, a mirror may be substituted in order provide
routine use of eye-protective measures for patients visual feedback as well. At the initiation phase, the
with incomplete eye closure is a strong exercises consisted of actively assisting specific facial
recommendation to prevent corneal complications, movements which couldn’t be initiated or flaccid
such as exposure keratitis, corneal ulceration and facial regions, and were advised to avoid mass
eventually loss of vision. Lubricating drops should be movement patterns.1 On the first follow up (July 30th ,
applied frequently during the day and ocular patches 2018), the patient was instructed on using his fingers
during the night is mandatory.10,12,14 This patient was to passively move the left corner of his mouth into a
not given artificial tears regularly and didn’t suggested ‘smiling’ posture. He was informed to then slowly
to passively closed his eyes with finger or used eye release his finger pressure, all the while attempting to
patches before sleep because he could close his eyes actively hold the ‘smiling’ posture with the involved
with no gap. musculature. In addition to the ‘smiling’ exercise, the
Laser therapy has a favourable prognosis in the patient was instructed to passively frown his left
regeneration of peripheral nerves in both neurosensory forehead with his finger and activate the appropriate
and neuromotor deficits, 20 such as trigeminal musculature upon release of his passive support finger.
neuralgia, neuropathy, lower back pain with sciatica, When he began to able initiate slight movement at
and herpes zoster.21 Application of a laser produces facilitation phase, the neuromuscular re-education
both local and systemic effects that can enhance the exercises were prescribed on the basis of a
nerve regeneration process.21 Moreover, laser participant’s impairments of facial motor control, with
improves the recovery of the injured peripheral nerve emphasis on small movements to gain symmetry
and decreases post-traumatic retrograde degeneration between the affected and unaffected sides of the face.17
of the neurons in the corresponding segments of the The exercise consisted of active and resistive
spinal cord.22 Research studies have shown that low exercise to increase facial movement excursion and

6
facilitating the affected-sided musculature.1,11 The voluntary facial movement is regained even
patient was instructed to perform slow, controlled, partially.16 Nevertheless, the latest guideline suggest
graded facial expressions to generate symmetry against the use of ES in acute Bell’s palsy at any
between the sides of the face with a mirror for visual severity since the safety profile of such therapy is
feedback, and to use his finger to provide resistance to unproven, and there is an added cost.12 This patient
the desire facial movements with the precaution of was not given ES on his initial examination and the
muscular fatigue of the involved side and over next follow up due to well recovery facial muscle and
facilitation of the uninvolved side. If there were any consideration of the risk and benefit of the treatment it
typical abnormal movement pattern or synkinesis self.
developed, the meditation-relaxation strategies should In the past, surgical decompression within three
be initiated as well as controlling synkinetic weeks of onset has been recommended for patients
movements in addition to neuromuscular re-education who have persistent loss of function at two weeks.2 It
therapy at the movement control phase. In the case of has potentially serious risks, including hearing loss (3-
severe pan-facial tightness attributable to synkinesis 10% of patients), further damage to the facial nerve,
and hypertonicity, the meditation-relaxation was the and leaks of cerebrospinal fluids (4%).There is no
strong focus strategies. This patient didn’t develop any evidence that surgical procedures to decompress the
signs of synkinesis or the facial tightness at the initial facial nerve are of benefit, that’s why patients should
examination and follow up (July 30th 2018), so the consider this option only if they have severe facial
neuromuscular re-education performed at initiation nerve degeneration on electroneuronography, if they
and facilitation phase only. The typical guideline for are willing to accept the surgical risks and if the
neuromuscular re-education exercise was 20 to 40 surgery is to be performed in an advanced treatment
repetitions 2 to 4 times per day.16 The results attained facility. The latest guideline suggest against the
in facial training may be explained by the theory of routine use of surgical decompression as a treatment
nervous system plasticity.18 choice in Bell’s palsy.7,12
The use of nonspecific electrical stimulation of The orthotics and prosthetics program is to do
the peripheral facial neuromuscular system during the the installation of the “Y” plaster in the corner of the
recovery process reinforces abnormal (synkinetic) mouth in order not to fall. It is recommended that the
patterns of facial muscle activity. Evidence from plaster was replaced every 8 hours. It should be noted
animal studies suggests electrical stimulation of facial leather intolerance reactions that often occur.
neuromusculature during recovery from nerve injury Installation of “Y” plaster is performed within 3
may be disruptive to reinnervation. If the electrical months if there has been no change in patients after
stimulus is not carefully localized to the facial muscle undergoing physiotherapy.16 This patient didn’t use
nerve branch serving the specific intended facial the “Y” plaster due to recovery at the follow up. About
movement or expression, peripheral nerve fibers 80–85% of the patients recover spontaneously and
within a nerve trunk serving many facial muscles will completely within 3 months, whereas 15–20%
be simultaneously recruited. 11 Although many authors experiences some kind of permanent nerve damage.
do not recommend ES for the fear of enhancing About 5% may remain with severe sequelae. Long-
contracture, interfering with reinnervation or term sequelae of facial nerve palsy may be persisting
increasing cost of treatment, the findings of other weakness, contractures, facial spasms, synkinesis,
authors may recommend its use. Electrical stimulation decreased tearing, crocodile tears, or psychosocial
of muscle aims at preserving muscle bulk especially in effects. The psychosocial impact of such a disorder
complete paralysis; and it has also psychological can be life-altering in relation to social functioning.
benefit as the patient observes muscle contraction in Indicators for poor prognosis include complete facial
his face that gives him hope for recovery from facial palsy, no recovery of symptoms by three weeks, age
paralysis. ES was found to enhance axonal over 60 years, severe pain, herpes zoster virus, co-
regeneration and skeletal muscle reinnervation in morbid status e.g. hypertension, diabetes, pregnancy
facial nerve lesion. The type of electrical stimulation and severe degeneration of the facial nerve shown by
should depend on the pathology of the facial nerve. If electrophysiological testing.1,3 At first visit, this
there is no electrophysiological signs of muscle patient had an anxiety and felt shame about his face.
denervation, faradic stimulation using 0,1-1 ms After gave him education about this illness, re-assured
duration pulses delivered at a frequency of 1-2 pulses/s and consulted him to a psycholog, the shame and
or more may be given for 50-200 contractions/session, anxiety was decreased gradually. At the visit on
3 session/week until recovery. At PMR department, November 12th 2018 (11 months of onset) his face was
faradisation was given with ½-2 MA stimulation up to recovery with UGO FISCH scale was 100 and House-
30 impulses/minutes for each muscle, 90 times/day. Brackmann score was grade I. The physical therapy
Electrical stimulation may no longer be given once and education was given to the patient about the

7
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