Bell's Palsy Case Study

Top Contributors - Cyrus Kazemi, Michelle Walsh, Charles Sutton, Christiane Lefort and Janessa Russett  

A case study of a pregnant 44-year-old female, recreational badminton player, diagnosed with Bell’s Palsy partaking in physiotherapy treatment for the return to sport and everyday function.

Abstract

This case presentation involves pregnant Ms. Z, a 30-year-old female, recreational badminton player, who was diagnosed with Bell’s Palsy, unilateral facial paralysis of her right side. This case study is going to follow the patient through the initial assessment, follow-up treatments and discharge at her community physiotherapy clinic. In building a rehabilitation program that focuses on the patient’s goals, treatment will be functional and meaningful to allow for re-integration into everyday functioning and improvement of life quality.

Introduction

Cranial nerve (CN) VII, also known as the facial nerve, is responsible for voluntary movement of the face, taste to the anterior two-thirds of the tongue, as well as control of the salivary and lacrimal gland secretions. Bell’s Palsy is spontaneous unilateral facial paralysis that results from CN VII being compromised. Though the pathology is still poorly understand, it is believed that “infection, nerve compression and autoimmunity” can all play a role [1]. The diagnosis is based on ruling out other conditions such as a stroke, lyme disease, tumor, etc.

The mononeuropathy has an equal effect on both males and females; it can also occur as any age, however middle-aged to later life are more common for its onset [1]. To add, there is a higher incidence of the condition if:

  • Pregnant [1]
  • Post-viral respiratory tract infection [1]
  • In an immunocompromised setting [1]
  • Having diabetes mellitus or hypertension [1]

It may involve a full paralysis or partial paralysis depending on whether or not 1 or 2 of the facial nerve branches are affected. Regardless, this condition can result in the following:

  • Lack of ability to voluntary contract facial muscles
  • Drooping at the mouth [2]
  • Inability to close eye [3]
  • Decreased salivary and lacrimal gland secretions (dry eye) [3]
  • Pain in the area of the jaw and/or ear [3]
  • Impairment of taste [3]

Challenges met with treatment and management of this case included the lack of evidence supporting physiotherapy intervention. Corticosteroids, antivirals, and eye management are all included in clinical practice guidelines [4]. Literature reviews of physiotherapy treatment and management concluded that physiotherapy was not recommended. Research on its outcome and cost effectiveness have been poor or inconclusive, limiting its ability to be included in the clinical practice guidelines [4]. Larger studies with higher quality research are needed to determine the role of physiotherapy in Bell’s Palsy treatment and management.

The purpose of this case study is to educate physiotherapists on how to recognize and treat Bell’s Palsy by making the recovery process fun, functional, and meaningful to the patient.

Client Characteristics

Pregnant Ms. Z, a 30-year-old female, recreational badminton player, who spontaneously woke up with the inability to voluntarily move the right side of her face, including the inability to close her right eye, and slight drooping at the corner of her mouth. She tried to explain to her husband what was happening, but lacked the motor control to enunciate words. In a panic, he noticed she had facial drooping and mistook the lack of motor control for slurring of her words-- he thought she was having a stroke. Remembering the acronym, F.A.S.T., he called the ambulance. However, given her presentation and exceptional health history, the attending physician ended up excluding a stroke as a possible diagnosis. He thought Ms. Z’s signs and symptoms better matched with Bell’s Palsy because everything aligned perfectly with a Grade 5 on the House-Brackmann facial nerve scale. She was prescribed corticosteroids and referred on to a neurologist who confirmed the diagnosis of Bell’s Palsy with electroneuronography. The neurologist referred her to an ophthalmologist who prescribed her lubricating eye drops and suggested that she wore a pair of sunglasses or safety glasses to prevent any corneal drying and scratches. The opthamologist recommended that Ms. Z partook in physiotherapy for treatment so that she can safely return to badminton and everyday functioning without long-term implications.

Examination Findings

Subjective: On examination, Ms. Z reports that it has been difficult to navigate busier environments (ie. sidewalks and the grocery stores) and play badminton because she feels less confident in attending to her right side; she thinks that the lack of voluntary movement puts her at an increased risk of injuries so she tries to stay on guard by constantly moving her head around. The lack of movement control results in difficulty verbally and emotionally communicating with others, as well as eating. She reports manipulating her mouth and her cheek with her hand so she can feed herself; she says she can feel sensation. To add, Ms. Z wears safety glasses and takes the lubricating drops on a daily basis and she really thinks that they make her eye feel less irritated, but she has difficulty sleeping at night because she cannot fully close it. Having been to physiotherapy before, she believes it will help her gain back this awareness and improve her confidence to overcome inner struggles that she has been facing with her diagnosis.

Observation: Look for general asymmetry of the face [5]. Specifically observed asymmetry of blinking and of the corners of the mouth [5].

Assessing for Lyme Disease: The purpose of assessing for lymes disease is because it’s the cause of 25% of cases of facial paralysis [4]. The enzyme-linked immunosorbent assay (ELISA) is a reliable antibody test that can be used to diagnose Lyme disease [4]. The results of this test was negative. (Assessed at the hospital)

Magnetic resonance imaging: MRI is used to rule out conditions such as stroke and tumor. Facial nerve inflammation and edema indicate bell's palsy [6]. The result of the MRI Indicated Bell’s palsy. There were no indications for stroke or a tumour. (Assessed at the hospital)

Testing the Corneal reflex: This test is assessing the trigeminal nerve V and the facial nerve CN VII [7]. To perform this test instruct the patient to look up and to the side. Using a strand of cotton, and approaching away from the patient line of vision, lightly touch the cotton to the cornea [7]. A positive test is the absence of blinking and tearing of the eye being tested and absence of blinking in the eye not being tested [7]. The results of this test was positive.

Palpebral-Oculogyric reflex (Bell's Phenomenon): The Palpebral-oculogyric reflex is a facial nerve reflex [5]. The therapist attempts to passively close the patient affected eye. A positive test is the upward movement of eyes [5]. The result of this test was positive.

The orbicularis oculi reflex: This reflex is produced by the trigeminal and facial nerves [5]. A gentle stimulation is applied to the forehead [5]. A positive text is involuntary blinking [5]. The results of this test were positive.

Facial Nerve Testing CN VII: The patient is instructed to perform several facial expressions such as frowning, smiling, raising eyebrows, puffing out cheeks, pursed lips, and closing eyes tightly [5]. The patient's ability to move the facial muscles is being assessed. A positive test is the inability to perform these movements [5]. The results of this test was positive. Also ask the patient if they have noticed a change in their tasting and hearing abilities [5]. The results of this test were positive.

House-Brackmann Facial outcome: This outcome measure grades facial nerve signs and symptoms in between grade 1 (Normal) to grade 5 (total paralysis) [4]. This outcome measure is used to document the patient's current function and obverse the effects of treatment over time [8]. The grading result was grade 5 (severe dysfunction).

Clinical Impression

Following the full examination of Ms. Z, there were a number of aspects regarding her case noted in the subjective and objective that make her a candidate for physiotherapy. Patient-centered care involves working towards pre-determined goals; which involve returning to sport and functional activities in the case of Ms. Z. Though the literature supporting physiotherapy is not strong for treating facial nerve paralysis and consequent lack of muscle innervation [4], Ms. Z is motivated to return to the badminton court. Currently, the positive tests described above pose a challenge in her visual and spatial awareness. Thus, sports-specific interventions can be used safely in a clinical setting to improve Ms. Z’s condition that can be transferred onto the court and in everyday life. In addition, the problem list seen below can help guide and track the treatment:

Problem list

  • Lack proprioceptive awareness
  • Decreased motor control of the facial muscles
  • Cannot raise eyebrows
  • Unable to produce different facial expressions
    • Ex. Smile
  • Difficulty with pronunciation
  • Visual attention/input to right side

The prognosis for Bell’s palsy is described in the literature; stating that “most patients with Bell’s palsy recover normally within 3 weeks, with or without medical intervention. However, full restoration may take up to 9 months in some cases and up to 30% of patients are left with complications, such as potentially disfiguring facial weakness or persistent lacrimation, needing further medical therapy” [9]. With this information, Ms. Z will be encouraged to seek physiotherapy treatment twice a week for six weeks. The first three weeks will be focusing on pain management and functional movement; followed by the last three weeks primarily focusing on return to sport and daily functional activities.

Intervention

Before being referred to physiotherapy, Ms. Z was prescribed corticosteroid treatment by the attending physician in the emergency room, as she is older than 16 and was treated within 72 hours of onset [4]. Her diagnosis was confirmed using electroneuronography (ENoG) testing by her neurologist. Ms. Z’s treatment also included eye care and protection from an opthamologist. At physiotherapy, Ms. Z was treated using acupuncture and exercise in hopes of speeding up her return to badminton and everyday function.

Treatment Goals: Ms Z.’s treatment goals included returning to badminton through improving muscular control of the right side of the face, improving proprioceptive awareness while vision is impaired due to decreased lacrimation and eye protection, and decreasing pain surrounding her jaw.

Management Program: Acupuncture was administered to Ms. Z in hopes of easing the pain in her right jaw. Clinical guidelines do not offer recommendations for physiotherapy treatment as there is insufficient evidence on this topic and/or low-quality trials supporting it [4]. The role of patient preferences in this treatment is large, which is why it was included [4]. Ms. Z had a strong preference for implementing acupuncture into her treatment program, and has been shown to possibly aiding in facial nerve function and pain [4], so was implemented into her treatment program. Acupuncture may also benefit Ms. Z psychologically by increasing her involvement in care [4], so this was considered valuable for treatment planning. There is no evidence supporting physiotherapy in terms of electrotherapy, thermal treatment, massage, biofeedback, or facial exercises [4]. Although physiotherapy may not be supported for direct muscle function, proprioception is of high importance to both Ms. Z and to clinicians to ensure her safety as well as return to sport. Ms. Z was given an exercise program to undergo while wearing her protective eyeglasses. Due to decreased visual input, she was given exercises including tandem stance with eyes closed, one foot stance with eyes closed, proprioceptive clock exercise, and bipedal and tandem balance on a bosu ball with eyes open and closed. She was also given upper body proprioceptive exercises, including the SenMoCOR laser headlamp system for cervical proprioception, and rolling a small ball on the wall using the hands in various positions and writing out various words. Although there is inconclusive supporting evidence for physiotherapy exercises such as mirror biofeedacbk to improve facial muscle symmetry, this feedback was implemented in Ms. Z’s care. Results are inconclusive for biofeedback for clinical practice but have had positive results in several studies [10]. Ms. Z has had physiotherapy treatment before for a knee injury and found exercises to be very conducive to her recovery. For this reason, it was considered valuable to include exercises into her treatment program. Functional retraining exercises were also implemented into Ms. Z’s treatment plan such as closing the mouth around a spoon when eating liquids, once some motor control had returned. We decreased the threat by keeping the bowl close to her mouth, and gradually increasing its distance away as she gained more control and more confidence that she could eat without spillage.


Intervention approaches, techniques, relevant details. Consistent with Evidence Based Practice - consider research evidence, patient condition, preferences and values, and treatment context/setting when identifying key elements of treatment. Treatment for Bell's Palsy aims to restore facial function [4].

Outcome

The Visual Analogue Scale (VAS) was used to report and track facial pain while using acupuncture as an intervention. Despite the lack of literature supporting the effectiveness [4], Ms. Z benefited from the intervention. Whether it was due to psychological or physical factors, the 100mm VAS over the course of the three week treatment measured a clinically significant difference week after week.

Time VAS SCORE (mm)
Baseline (Start of session 1) 67 mm
Week 1 (End of session 2) 61 mm
Week 2 ( End of session 4) 45 mm
Week 3 (End of session 6) 22 mm

Table 1: Outcome of acupuncture measured through Visual Dialogue Scale

The minimum clinically important difference for the VAS outcome measure is 13.7 mm [11]. It was very encouraging to see that the her pain dropped by 45 mm over the course of three weeks.

Progression based on practice and comfortably/effectively completing each task was used to track Ms. Z’s visual and proprioceptive interventions. Using a variation of conditions and timed intervals like in the Modified Clinical Test for Sensory Interaction in Balance (mCTSIB) was appropriate to decide when it was appropriate to progress to a more difficult exercise. Her improvement was tracked through the following exercises: tandem stance with eyes closed, one foot stance with eyes closed, and bipedal and tandem balance on a bosu ball with eyes open and closed.

TIME PROGRESSION
WEEK 1 Session 1: tandem stance with eyes closed incompleted (< 30 seconds)

Session 2: tandem stance with eyes closed completed (= 30 seconds)

WEEK 2 Session 3: one foot stance with eyes closed incompleted (< 30 seconds)

Session 4: one foot stance with eyes closed incompleted (< 30 seconds)

WEEK 3 Session 5: one foot stance with eyes closed completed (= 30 seconds)

Session 6: bipedal balance on bosu ball with eyes open completed (= 30 seconds)

WEEK 4 Session 7: bipedal balance on bosu ball with eyes closed incompleted (< 30 seconds)

Session 8: bipedal balance on bosu ball with eyes closed incompleted (< 30 seconds)

WEEK 5 Session 9: bipedal balance on bosu ball with eyes closed completed (= 30 seconds)

Session 10: tandem balance on bosu ball with eyes open incomplete (< 30 seconds)

WEEK 6 Session 11: tandem balance on bosu ball with eyes open completed (= 30 seconds)

Session 12: tandem balance on bosu ball with eyes closed completed (= 30 seconds)

Table 2: Outcome of balance and proprioception training

Overall, Ms. Z improved greatly on her balance over the course of her physiotherapy interventions. These improvements will transfer onto the court as she continues to work towards return to sport.

Bell’s palsy requires a multidisciplinary approach. Ms. Z should continue to see her ophthalmologist to treat symptoms related to the eye. Derived from the facial nerve, the greater pretrosal nerve is responsible for control and production of lacrimation in the eyes and the zygomatic branch, which supplies the Orbicularis Oculi, is responsible for eye closure so that the tear film can be spread equally over the eye [12]. For Ms. Z, her facial nerve has undergone some type of damage and, therefore, must take the necessary steps toward managing his dry eye and mitigating the likelihood of suffering from vision loss in the future. In addition, there is evidence that supports the correlation between facial paralysis, specifically Bell’s palsy and emotional distress, psychological care and support is recommended [13]. The research suggests that psychological distress can start as early as the first week of onset [13], and patients with House-Brackmann grade 3 and higher have a greater risk for depression, lower quality of life and lower self-reported attractiveness [14]. Thus, given that in our assessment findings in the House-Brackmann Facial outcome being 5, we decided to ensure that we monitor and screen Ms. Z’s psychological well-being by using The Patient Health Questionnaire (PHQ-9). Ms. Z scored 8 on the PHQ-9 which puts her at a moderate risk for depression. As a result, we would refer Ms. Z to a clinical psychiatrist.

Discussion

Bell’s Palsy presents as insidious unilateral facial paralysis which results from compression of cranial nerve VII. It is still poorly understood, however, etiology is believed to be associated with infection, nerve compression and autoimmune dysregulation [1]. The diagnosis is made by ruling out more common issues such as stroke, Lyme disease, & tumor. With these ruled out, electroneuronography can be used to make the definitive diagnosis of Bell’s Palsy. This case study involves a pregnant 30-year-old female, named Ms. Z. She is a recreational badminton player, who was diagnosed with right unilateral facial paralysis (Bell’s Palsy) via electroneurography. After receiving corticosteroid injections in the ER, Ms. Z attended physiotherapy. Her main goal was to return to badminton by improving her right facial function, proprioceptive awareness and to decrease pain in her jaw. She received acupuncture and an exercise treatment plan to improve facial function and whole-body proprioception. Current evidence does not support the use of physiotherapy to rehabilitate facial muscle function in patients with Bell’s Palsy [4]. However, since she is a higher functioning badminton athlete, she was very concerned about how the visual symptoms of her condition would impact her hasty return to sport. For her safety, proprioception exercises were prescribed to compensate for loss of vision. Additionally, Ms. Z had a very strong patient preference for facial function exercises and acupuncture, therefore these were included in her treatment plan. Pain and balance were assessed throughout her rehabilitation plan. Her pain dropped by 45 mm over the course of three weeks in the VAS outcome measure where the minimum clinically important difference is 13.7 mm [11]. Additionally, Ms. Z improved notably on her balance over the 6-week treatment block. She went from being unable to complete a tandem stance with eyes closed to completing a tandem balance on a bosu ball with eyes closed for 30 seconds. This marked improvement in balance will undoubtedly translate into a safer return to badminton. Although physiotherapy is not indicated for facial muscle function in patients with Bell’s palsy, patient preference and functional goals play a large role in treatment. Symptoms can impede other activities of daily living and compensation strategies can be taught to aide the patient in coping with their condition. It is important to note that patients with Bell’s palsy have been linked to greater risk of emotional distress due to, in part, the inability to participate in ADLs and enjoyable activities [13]. Ms. Z was determined by the House-Brackmann Facial outcome measure and the PHQ-9 to be at risk for a greater risk for depression, lower quality of life and lower self-reported attractiveness [14]. Because of this, Ms. Z will be referred to a psychologist.

Self-Study Questions

Which cranial nerve (name and number, respectively) does Bell’s Palsy involve?

  1. CN V ; Trigeminal Nerve
  2. CN V ; Facial Nerve
  3. CN VI ; Trigeminal Nerve
  4. CN VII; Facial Nerve

All of the following need to be ruled out before diagnosing Bell’s Palsy, EXCEPT:

  1. Tumor
  2. H1N1
  3. Stroke
  4. Lymes Disease

References

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