Bell’s palsy also known as idiopathic facial nerve palsy is a form of paralysis or weakness of one side of the face. It occurs as a result of the dysfunction of the facial nerve (cranial nerve VII), which is responsible for the innervation of the mimetic muscles of the face (Gatidou AM et al., 2021). The paralysis can cause a complete or partial loss of mobility on one side of the face and its onset is perceived by pain in the mastoid process (Finsterer J 2008). The annual incidence of Bell’s palsy is 23 to 35 cases per 100,000 with an equal gender ratio. It is thought that 50–75% of acute unilateral facial paralysis appeared between 30 and 50 years old (Javaherian M et al., 2020)

Though the causes of this illness are unknown it is believed to be associated with hypercholesterolemia, hypertension, diabetes, infections, poisoning, genetic syndromes, neoplasia, and musculoskeletal and neurological lesions (Ramos-Jimenez A et al., 2015). Some evidence proposed that herpes simplex virus-1 reactivation at the cranial nerve is the most strongly suspected cause of facial nerve inflammation in Bell’s palsy (Zandian A et al., 2014)

The prognosis of Bell’s palsy is relevant the depends on factors such as time of recovery, age, pain behind the ear, taste distribution, and genetics (Katusic SK et al., 1986, Dalla Toffola E et al., 2012). Progression of this condition is within a week with a peak between 3 and 7 days; in contrast, recovery may take from a few weeks up to several years if denervation occurs and complete recovery may never be achieved (Dalla Toffola E et al., 2012, Finsterer J 2008). However, most patients with idiopathic facial palsy (Bell’s palsy) recover spontaneously, as demonstrated by Peitersen, who studied 2500 patients with the condition. He reported full recovery in 71% of the patients while 29% lingering with the motor deficit and 16% with synkinesis (Dalla Toffola E et al., 2012) Partial motor recovery, synkinesis, Hemi facial spasm, contractures, salivation, and lacrimation alterations may persist in remaining cases. These residual symptoms have a significant impact on the quality of life because they cause appealing (asymmetry of the face at rest, during movements, speech, and alterations in smiling) and functional problems (difficulty in eating, drinking, and speech) (Nicastri M et al., 2013)

The sequelae may trigger severe psychological problems because facial congruence and evenness influence the person’s body image and how others perceive them and are determinant factors of facial attractiveness, indicators of good health, and a vehicle of expression of feelings (Nicastri M et al., 2013). So, to prevent or reduce these residual deficits, continuous efforts have been made to identify the most effective therapeutic approaches, including medications (Numthavaj P et al., 2011), and physical therapy (Teixeira LJ et al., 2011), or a combination of both.

Pharmacological treatment starts when the patient is assessed for the first time. Although therapy appears to reduce edema and secondary inflammation damage, it does not influence the amount of damage already present when the patient presents for medical attention and starts steroid intake. At present, efficacy has been shown for the use of corticosteroids alone (Numthavaj P et al., 2011), with a better outcome if administered within 48 hours of the onset of palsy (Axelsson S et al., 2011).

Physical therapy attempts to avoid, or at least minimize, the sequelae associated with drug administration (Nicastri M et al., 2013). Physiotherapeutic interventions such as electrotherapy, massage, therapeutic exercise, patient feedback, and heat therapy have been shown to accelerate recovery, improve facial functioning and reduce complications (Gatidou AM et al.,2021). The efficacy of physiotherapeutic interventions, as the only alternative to no treatment, has been shown in patients with stabilized sequelae (long-standing paralysis) by several observational studies. In contrast, the evaluation of physical therapy efficacy in the acute clinical phase is more complex because of the high rate of spontaneous recovery (Nicastri M et al., 2013).

In the present literature, there are very few experimental or quasi-experimental studies, most of which compare different physical techniques (Coulson SE et al., 2006). So, we planned this study to understand the effectiveness of the combination of physiotherapeutic interventions on a patient with acute onset of Bell’s Palsy.

This is a case report of a 38 years old male patient visiting Physiotherapy OPD at Jamia Hamdard’s Rehabilitation center. He presented himself with the chief complaint of inability to close his right eye, inability to raise his eyebrow on the right, deviation of the mouth towards the left when trying to smile or speak, inability to speak properly, tears from his eyes when trying to eat something from the same side.

He was well 3 months back when he suddenly fell from the bike. He stated that he had a loss of consciousness and then he was taken to a nearby hospital. He was admitted to the general ward for about 1 week. He underwent several investigations and was diagnosed as having a head injury. In the ward, he was given medicines such as Refresh tears for eyes and Levera for stopping convulsions. Then he had continuous vomiting and even seizure attacks after which he was shifted to ICU.

He remained in ICU for 8 days. His consciousness was still impaired and then he was shifted to the ward as soon as his condition improved. He was then referred to the All India Institute of Medical Sciences for further orofacial examination and there he was diagnosed for having right- sided bell’s palsy. He received physiotherapy treatment for bell’s palsy for about 20 days, in the form of electrical stimulation and facial exercises after which his condition improved. He had no relevant past medical and family history and was a non-smoker but was an occasional alcoholic.

On clinical observation, he could not raise the eyebrow on the right side, had asymmetric closure of eyes, had no movement of the nasolabial fold of the right side, and his mouth deviated towards the left while he attempted to smile. The severity was classified as grade IV according to the House-Brackmann classification (moderately severe dysfunction).

His higher mental functions were intact when he was assessed by Mini-Mental State Examination Scale and scored 26 out of 30 depicting normal functions. Functions of his cranial nerves were intact except for the diminished sensation of light touch and pinprick in the ophthalmic, maxillary, and mandibular divisions of the trigeminal nerve on the right side and had wasting of masseter and temporalis muscles. Also, the patient had diminished corneal reflex on the right side and diminished taste sensation in the region of the anterior 2/3rd and posterior 1/3rd of the tongue supplied by the facial nerve and glossopharyngeal nerve on the involved side. Functions of his muscles of facial expressions are listed in Table 1.

He scored 54 out of 56 on the Berg Balance Scale which indicates a low risk of falls. Facial Disability Index Scale is a scale designed to provide the clinicians with information about the disability and related social and emotional wellbeing of patients with facial nerve disorders, where he showed minimal disability in physical and social functioning. His CT investigation showed a longitudinal fracture of the left petrous part of the temporal bone, peri-mesencephalic subarachnoid hemorrhage, and right temporal convex subarachnoid hemorrhage, and was finally diagnosed as having moderate traumatic brain injury with right-sided bell’s palsy.

Short-term and long-term goals and interventions are mentioned in Tables 2 and 3 respectively.

At the initial assessment, it was discussed with the patient that the prognosis for bell’s palsy is very good, and almost full recovery could be expected at 6 months. Initially, he received treatment daily for a week, then was called on alternate days for about a week and then 3 times a week and reduced to once a week and treatment sessions lasted for about 45 minutes for altogether 7 weeks. Galvanic stimulation was given and the session lasted for about 15 minutes, with a phase duration or pulse duration of 1 millisecond and frequency of 20hz monophasic current on the major motor points of facial muscles.

He was assessed on the third week of treatment and improved ability to close his eyes, easiness of smiling and eating, and improved performance of facial expression exercises with less asymmetry were found.

The visit to physiotherapy OPD was terminated when the milestones such as his score on the House Brackmann scale was reduced to grade 2, could perform facial expressions better, had a subjective feeling of easiness in talking and smiling, and reintegrating into societal functions, and maintaining public relations. This was achieved after nearly 2 months of therapy and later he was suggested to continue with facial muscle exercises at home until he returned to his baseline function.

This study assessed the physiotherapeutic treatment regime for bell’s palsy for about 7 weeks and improvements were seen with the passing weeks. The patient showed improvement on the House Brackmann grading scale from grade 4 to grade 2 and had a subjective feeling of easiness in smiling, talking, and eating and reduction in lacrimation of eyes, and also a reduction in disability as assessed by the Facial Disability Index Scale. The treatment had initially started before he presented to us and at the time of baseline assessment stated easiness after receiving physiotherapy treatment for about 20 days. Our treatment added to his recovery process and after 7 weeks he showed improvement over baseline.

The available literature shows no benefit or harm attributable to physiotherapy treatment after bell’s palsy. A Cochrane systematic review regarding the incorporation of physical therapy for bell’s palsy concluded that no treatment produced significantly more improvement than was observed in untreated control groups (Teixeira LJ et al., 2011). However, currently, there is some evidence that facial muscle exercises reduce recovery time (Murthy JM, Saxena AB. 2011). One study showed that there was a better improvement on the facial disability scale (self-administered) when Low-Level Laser Therapy and facial exercises were combined compared to exercise alone (Ordahan B et al., 2017) 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 (Brach JS, Van Swearingen JM 1999).

There is still a lack of high-quality evidence which poses a challenge while creating treatment plans for bell’s palsy. Many 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. Also, evaluating the efficacy of any intervention for Bell’s Palsy is especially challenging since ~70% of all cases will resolve spontaneously without any treatment (Madhok VB et al., 2016). This demonstrates the need for more high-quality RCTs and systematic reviews to guide healthcare providers in making evidence-based treatment plans for patients diagnosed with bell’s palsy.

In our case study, we followed a thorough intervention comprising all the interventional methods mentioned in literature for rehabilitation of bell’s palsy and did monitoring of the same, while evidence available has compared one treatment modality with other. We found improved patient condition from baseline. We could hypothesize that the improvement was associated with our planned intervention because he was not on any kind of medication at the time when was presented to us. Still, the results or findings from our study cannot be generalized and the same type of study on a large sample could help clinicians in inferring the findings and applying them to practice.