physical therapy for bell's palsy [idiopathic facial...

Physical therapy for Bell´ s palsy (idiopathic facial paralysis)

(Review)

Teixeira LJ, Soares BGDO, Vieira VP, Prado GF

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2008, Issue 3

http://www.thecochranelibrary.com

Physical therapy for Bell´ s palsy (idiopathic facial paralysis) (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iPhysical therapy for Bell´ s palsy (idiopathic facial paralysis) (Review)


[Intervention Review]

Physical therapy for Bell´ s palsy (idiopathic facial paralysis)

Lázaro Juliano Teixeira1 , Bernardo Garcia de Oliveira Soares2, Vanessa Pedrosa Vieira3, Gilmar F Prado4

1Department of Physiotherapy, Prefeitura Municipal de Balneario Camboriu, Santa Catarina, Brazil. 2Universidade Federal de São

Paulo, São Paulo, Brazil. 3Medicina Interna e terapêutica, UNIFESP - Universidade Federal de São Paulo, São Paulo, Brazil. 4São Paulo,

Brazil

Contact address: Lázaro Juliano Teixeira, Department of Physiotherapy, Prefeitura Municipal de Balneario Camboriu, R. Ana Garcia

Pereira, n 167, Balneario Camboriu, Santa Catarina, 88340-000, Brazil. [email protected].

Editorial group: Cochrane Neuromuscular Disease Group.

Publication status and date: New, published in Issue 3, 2008.

Review content assessed as up-to-date: 3 February 2008.

Citation: Teixeira LJ, Soares BGDO, Vieira VP, Prado GF. Physical therapy for Bell´ s palsy (idiopathic facial paralysis). CochraneDatabase of Systematic Reviews 2008, Issue 3. Art. No.: CD006283. DOI: 10.1002/14651858.CD006283.pub2.


A B S T R A C T

Background

Bell’s palsy (idiopathic facial paralysis) is commonly treated by physical therapy services with various therapeutic strategies and devices.

There are many questions about their efficacy and effectiveness.

Objectives

To evaluate the efficacy of physical therapies on the outcome of Bell’s palsy.

Search strategy

We searched the Cochrane Neuromuscular Disease Group Trials Register (February 2008), the Cochrane Central Register of Controlled

Trials (The Cochrane Library, Issue 4, 2007), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February

2008), LILACS (January 1982 to February 2008), PEDro (from 1929 to February 2008), and CINAHL (January 1982 to February

2008).

Selection criteria

We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with

a diagnosis of Bell’s palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation,

motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable

to the intervention.

Data collection and analysis

Titles and abstracts identified from the register were scrutinized. The assessment of methodological quality took into account secure

method of randomisation, allocation concealment, observer blinding, patient blinding, differences at baseline of the experimental

groups, and completeness of follow-up. Data were extracted using a specially constructed data extraction form. Separate subgroup

analyses of participants with more and less severe disability were undertaken.

1Physical therapy for Bell´ s palsy (idiopathic facial paralysis) (Review)


mailto:[email protected]

Main results

The search identified 45 potentially relevant articles. Six studies met the inclusion criteria. Three trials studied the efficacy of electros-

timulation (294 participants) and three exercises (253 participants). Neither treatment produced significantly more improvement than

the control treatment or no treatment.

There was limited evidence that improvement began earlier in the exercise group.

Authors’ conclusions

There is no evidence of significant benefit or harm from any physical therapy for idiopathic facial paralysis. The possibility that facial

exercise reduces time to recover and sequelae needs confirming with good quality randomised controlled trials.

P L A I N L A N G U A G E S U M M A R Y

Physical treatments for idiopathic facial paralysis

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. Physical therapies, such as exercise, biofeedback, laser,

electrotherapy, massage and thermotherapy, are used to hasten recovery. This review of existing trials found insufficient evidence to

decide whether any of these therapies work. More trials are needed to assess their effects.

B A C K G R O U N D

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 (Adour 1982; Valença 2001). Its cause is

not known (Peitersen 2002). Increasing evidence suggests that the

main cause of Bell’s palsy is reactivation of latent herpes simplex

virus type 1 in the cranial nerve ganglia (De Diego 1999; Holland

2004; Valença 2001). How the virus damages the facial nerve is

uncertain (Gilden 2004).

The annual incidence of Bell’s palsy varies widely, ranging between

11.5 and 40.2 cases per 100,000 population (De Diego 1999;

Peitersen 2002). There are peaks of incidence in the 30 to 50 and

60 to 70 year old age groups (Gilden 2004; Gonçalvez 1997).

Bell’s palsy has a fair prognosis without treatment (Holland 2004).

According to Peitersen (Peitersen 2002), complete recovery was

observed in 71% of all patients. Ninety-four per cent of patients

with incomplete and 61% with complete paralysis made a com-

plete recovery. The main question is whether results would be bet-

ter if some treatment were given.

About 23% of people with Bell’s palsy are left with either moder-

ate to severe symptoms, hemifacial spasm, partial motor recovery,

crocodile tears (tears upon salivation), contracture or synkinesis

(involuntary twitching of the face or blinking). Recurrence occurs

in about 8.3% (Valença 2001).

The prognosis depends to a great extent on the time at which re-

covery begins. Early recovery gives a good prognosis and late re-

covery a bad prognosis. If recovery begins within one week, 88%

obtain full recovery, within one to two weeks 83% and within

two to three weeks 61%. Normal taste, stapedius reflex and tear-

ing give a significantly better prognosis than if these functions are

impaired. Recovery is less likely to be satisfactory with complete

rather than incomplete paralysis, with pain behind the ear and in

older people (Danielidis 1999). Other poor prognostic factors in-

clude hypertension and diabetes mellitus (Gilden 2004; Peitersen

2002).

Evaluation of therapy is made difficult because of the high rates of

spontaneous and complete recovery (Peitersen 2002). The princi-

ples of treatment in the acute phase have not changed over the past

20 years (Adour 1982). They focus on protection of the cornea

from drying and abrasion due to impaired lid closure and tear pro-

duction. Lubricating drops are recommended during the day and

a simple eye ointment at night (Holland 2004; Valença 2001).

Cochrane reviews concluded that the available evidence did not

show significant benefit from acyclovir or similar agents (Allen

2004), steroid therapy (Salinas 2004) or acupuncture (He 2007).

However the Sullivan 2007 study with 496 participants compared



different combinations of prednisolone, acyclovir and placebo.

They found significant benefit from prednisolone but not acy-

clovir. Hato 2007 assessed the efficacy of valacyclovir with 296 par-

ticipants divided into two groups (valacyclovir with prednisolone,

and placebo with prednisolone) and found significant benefit from

valacyclovir.

Some authors suggest that facial nerve decompression be consid-

ered, although there are no data from clinical trials to support its

use (Adour 2002; Gilden 2004; Grogan 2001; Peitersen 2002).

Thermal methods, electrotherapy (which uses an electrical current

to cause a single muscle or group of muscles to contract), massage,

facial exercises and biofeedback are forms of physical therapy that

have been used (Mosforth 1958; Peitersen 2002). Exercise therapy

has been used more than other interventions (Beurskens 2003;

Brach 1999; Ross 1991; Segal 1995a).

In the last few years other systematic reviews have been undertaken.

Beurskens 2004 searched electronic databases and included two

studies (Ross 1991; Segal 1995a) which did not show a significant

effect of intervention. Quinn 2003 searched for electrotherapy

interventions in electronic databases, reference lists in the studies

and contacted experts from 1975 to 2002. They concluded that the

benefit of electrotherapy was unclear due to inadequate research

methods, sample sizes and dose information. Despite this, they

provide a very good discussion about the current knowledge of

the anatomy, physiology and pathomechanics during the course

of the palsy to support the use of physiotherapy resources. None

of the trials considered in these reviews fulfilled the criteria for this

review.

Peitersen 2002 also highlighted the lack of evidence for current

treatments, for thermal methods (conductive, radiative and con-

vective heat transfer in order to achieve vasodilatation or ice over

the mastoid region with the aim of relieving oedema), electrother-

apy, massage and facial exercise.

O B J E C T I V E S

The objective of this systematic review was to evaluate the efficacy

of physical therapies for Bell’s palsy (idiopathic facial palsy).

M E T H O D S

Criteria for considering studies for this review

Types of studies

We included all randomised or quasi-randomised (alternate or

other systematic allocation) controlled trials involving any physical

therapy compared with no treatment, placebo treatment, drug

treatment, acupuncture or other physical therapy interventions.

Types of participants

We included participants with a diagnosis of Bell’s palsy, defined

as idiopathic lower motor neuron facial palsy of sudden onset.

Participants of any age, and all degrees of severity were included.

People with facial palsy due to Ramsay-Hunt syndrome or other

recognised causes were not included.

Types of interventions

We included trials of any form of physical therapy treatment com-

pared with either no treatment or drugs or an alternative form

of non-drug treatment. Physical therapy was considered as the

use in treatment of any physical agents, such as heat, light, cold,

sound, water, electricity, manual therapy and other gadgets work-

ing on physical principles. Types of physical therapy interven-

tions for facial palsy included facial exercises, such as strengthening

and stretching, endurance, therapeutic and facial mimic exercises

(“mime therapy”) (Beurskens 2003), electrotherapy, biofeedback,

transcutaneous electrical nerve stimulation (TENS) or electrical

neural muscular stimulation (ENMS), thermal methods or mas-

sage, alone or in combination with any other therapy.

Types of outcome measures

The primary outcome measure was incomplete recovery six

months after randomisation. Incomplete recovery was defined in

two ways. Participants who had House Grade III (moderate dys-

function) or worse (House 1985) at entry were considered to have

incomplete recovery if they still had House Grade III or worse.

For participants who had House Grade II at entry, incomplete

recovery was defined as a persistent House Grade II or worse after

six months. If the House Grade score was not available, another

similar facial nerve disability score was used instead (House 1985;

VanSwearingen 1996).

Secondary outcome measures were:

1. the presence of motor synkinesis, contracture, hyperkinesia,

facial spasm or crocodile tears six months after onset;

2. complete or incomplete recovery after one year;

3. adverse effects attributable to the intervention such as pain

or worsening of condition.

Search methods for identification of studies

We searched the Cochrane Neuromuscular Disease Group Tri-

als Register in February 2008 using the terms ’Bell’s palsy’ or

’idiopathic facial paralysis’ or ’facial palsy’. We also searched the

Cochrane Central Register of Controlled Trials (The CochraneLibrary, Issue 4, 2007), MEDLINE (January 1966 to February



2008), EMBASE (January 1980 to February 2008), LILACS (Jan-

uary 1982 to February 2008), and CINAHL (January 1982 to

February 2008) and PEDro (from 1929 to February 2008).

Electronic searches

See Appendix 1, Appendix 2, Appendix 3, Appendix 4, Appendix

5.

Searching other resources

1. We checked references of all identified trials.

2. We contacted physical therapy companies in order to

obtain data on unpublished trials.

3. We contacted first authors of all included trials for further

information or information regarding unpublished trials.

Data collection and analysis

Study selection

Two authors (LJT, VPV) scrutinized titles and abstracts identified

from the register. The full texts of all potentially relevant studies

were obtained for independent assessment by the authors. Two

authors decided which trials fitted the inclusion criteria. Disagree-

ments about inclusion criteria were resolved by consensus and con-

sultation with a third author (BGOS).

Assessment of methodological quality

The assessment of methodological quality took into account secure

method of randomisation, allocation concealment, observer blind-

ing, patient blinding, differences at baseline of the experimental

groups, and completeness of follow-up. These items were assessed

according to the Cochrane Collaboration standard scheme: grade

A: adequate, grade B: unclear, grade C: inadequate or not done.

Two authors (LJT, VPV) assessed quality independently. Disagree-

ment between the authors was resolved by discussion if necessary

with a third author (BGOS).

Data extraction

Two authors independently extracted data on participants, meth-

ods, interventions, outcomes and results using a specially con-

structed data extraction form. Missing data were obtained from

the trial authors whenever possible.

Analysis of data

Data were entered and analysed using Review Manager 5.0.5

(RevMan) software. For dichotomous data, relative risks (RR) with

95% confidence intervals (CI) were estimated based on the fixed-

effect model or on the random effects model if heterogeneity was

present. The number needed to treat (NNT) and number needed

to harm (NNH) were calculated if possible. For continuous out-

comes, weighted mean differences (WMD) between groups were

estimated.

Heterogeneity was assessed by the chi-squared test and was as-

sumed to be present when the significance level was lower than

0.10 (p < 0.10). When significant heterogeneity was present, an

attempt was made to explain the differences based on clinical char-

acteristics of the included studies. A sensitivity analysis was per-

formed, omitting trials which included participants with different

clinical characteristics or trials with lower methodological quality.

If there had been sufficient trials of the same intervention, we

would have constructed a funnel plot (of trial effect versus trial

size) to assess potential publication bias.

Subgroup analysis

Separate subgroup analyses of participants with more severe dis-

ability (House Grade III or worse) and less severe disability (House

Grade II or better) were undertaken. We also considered patients

treated before and after two weeks from onset.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies; Characteristics of studies awaiting classification.

The literature search and hand searching identified 41 potentially

relevant articles (Cochrane databases = 7, MEDLINE = 17, EM-

BASE = 23, CINAHL = 6, LILACS = 3; PEDro = 11 and hand-

searching = 2), (see Figure 1). Some studies were found in more

than one database. Of these, six trials met the inclusion crite-

ria (Beurskens 2003; Flores 1998; Manikandan 2007; Mosforth

1958; Wang 2004; Wen 2004). Eight other studies, all in Chinese,

await translation and assessment.

Excluded studies

Twenty seven studies were excluded because they were:

1. Series of cases or case reports (Aleev 1973; Brach 1999;

Brown 1978; Coulson 2006b; Danile 1982; Lobzin 1989;

Manca 1997; Romero 1982; Segal 1995a).

2. Retrospective studies (Bernardes 2004; Cronin 2003;

Dalla-Toffola 2005).



3. Non-systematic reviews (Goulart 2002; Beurskens 2004).

4. Not physical therapy interventions (Casler 1990; Klingler

1982; Taverner 1966; Zhao 2005).

5. Constrained by methodological restrictions (Dubravica

1996; Koyama 2005; Murakami 1993; Nakamura 2003; Shiau

1995).

6. Composed of few participants with idiopathic facial palsy

(Balliet 1982; Coulson 2006; Ross 1991; Segal 1995b).Details

can be found in the Characteristics of excluded studies.

Included studies

The six studies (Beurskens 2003; Flores 1998; Manikandan 2007;

Mosforth 1958; Wang 2004; Wen 2004) (See Characteristics

of included studies) included a total of 547 people. Three tri-

als studied manual therapy and electrostimulation (Flores 1998;

Manikandan 2007; Mosforth 1958) (294 participants), and three

involved exercise (Beurskens 2003; Wen 2004; Wang 2004) (253

participants).

The first study evaluating physical therapy for facial palsy was one

of the first physical therapy randomised controlled trials described

for any condition. Mosforth (Mosforth 1958) studied 86 people

with acute Bell’s palsy of less than 14 days duration. Three partic-

ipants were lost to follow up. Auto-massage of the face, infrared

and interrupted galvanic stimulation (pulse 100 msec) in 44 par-

ticipants, was compared to massage alone in 42 participants. Treat-

ment was continued until recovery or until the condition seemed

stationary (two to six months). The outcomes were electrical ex-

amination and grade of paralysis estimated visually as a percentage

of the function of the normal side, the time to begin improvement

and the time to complete recovery.

Manikandan 2007 assessed the results of 59 participants with acute

facial palsy and compared two groups with physiotherapy inter-

ventions. Although the objective of the study was to test a specific

exercise strategy and both groups undertook different exercises,

the regimen adopted was similar (home based exercises) and elec-

trotherapy was the main difference between the groups. One group

of 30 people underwent a fixed protocol with electrostimulation

(galvanic and faradic currents) for the two first weeks, massage and

gross facial exercises. The other 29 people learnt an individualized

exercise program focused on the quality of the exercises and not

on the quantity. The movements were to be symmetrical without

voluntary movement of the uninvolved side. All individuals were

assessed by the Facial Grading Scale (Roos 1996) at the outset and

after three months.

In Flores 1998, there were 149 participants with acute Bell’s

palsy (onset in one to three days). Twenty-nine people (19.46%)

dropped out without a description of the reason for drop out.

One group of 76 people were treated with infrared treatment and

electrostimulation and were compared to 72 people treated with

prednisone for up to 14 days. Outcomes were time to recover, clin-

ical history and a functional scale (May Scale). Authors analysed

different groups according to whether the lesion was thought to

be proximal or distal to the origin of the chorda tympani nerve.

The Flores 1998 study was analysed with caution. Because corti-

costeroids have now been shown to be efficacious (Sullivan 2007),

comparing physical therapies with this active treatment could be

considered inappropriate. Nevertheless we included this study and

discussed some outcomes .

Beurskens 2003 studied 50 people with chronic (more than nine

months) facial paralysis. Only 34 people had idiopathic facial palsy.

Sixteen received exercises (mime therapy) and the other 18 formed

a waiting list control group. Mime therapy consists mainly of facial

mimic exercises. Outcomes were face stiffness, lip mobility, the

Facial Disability Index (VanSwearingen 1996), the Sunnybrook

Facial Grading Scale (Roos 1996), and the House-Brackmann Fa-

cial Grading System (House 1985). The author kindly sent us

all the outcomes for the idiopathic facial palsy participants. The

mean baseline House-Brackmann score was 4 and after one year it

was 3 for all the treatment participants. Although all participants

apparently improved, in the protocol for this review we made the

assumption that a grade over 3 could mean improvement but does

not mean recovery. It was based on a previous study (Peitersen

2002) and the clinical meaning of House-Brackman grades (House

1985). The continuous data results were more significant. How-

ever, the samples were composed of 16 and 18 individuals with

Bell’s palsy in the exercise and control groups respectively. This

small sample is a significant limitation. More observations on this

study are made in the Discussion.

Wen 2004 studied 145 people with acute idiopathic facial palsy for

12 weeks. Eighty-five participants were submitted to a combina-

tion of “conventional therapy” plus facial rehabilitation exercises

(movements using facial muscles) while 60 participants received

only “conventional therapy” not detailed in the translation pro-

cess. This Chinese study presented the following outcomes anal-

ysed in the review: (1) time when the patient started to recover

and (2) time that the recovery was complete. The study analysed

groups of mild, moderate and severe dysfunction patients.

Wang 2004 treated 74 people with acute Bell’s palsy with two dif-

ferent strategies. Both groups received medicine (cortisone, and

mexobalamin and vitamin B2), physical treatment (not described

in the translation), massage, and acupuncture. For the exercise

therapy (n = 43), functional exercises were added. The outcome

was facial muscle function with the Potmann Score after one

month.

Risk of bias in included studies

The scores of methodological quality for each trial can be found

in Table 1.



Secure method of randomisation and allocation

concealment

Mosforth 1958 randomised the groups using a prepared list (grade

A). Beurskens (Beurskens 2003) used a coin flip to assign the

first participant and the others were allocated by alternation and

this was classified as inadequate allocation concealment (grade

C). Manikandan 2007 used a method of six blocks with 10 in

each block (grade A) and Wang 2004 randomised their samples

by computer (grade A). Two studies (Flores 1998; Wen 2004)

classified their trial as randomised, but they did not describe the

method of randomisation (grade B).

Blinding

Due to the nature of the intervention evaluated in this review,

effective blinding of the participants is problematic. Placebo elec-

trostimulation could have been used but blinding to exercise in-

terventions is impractical or impossible. Blinding of outcome as-

sessors can be achieved but only Beurskens 2003 and Wang 2004

blinded the assessor.

Differences in baseline between groups

Wen 2004 did not present the baseline characteristics of the par-

ticipants. Manikandan 2007, Mosforth 1958, Flores 1998, and

Wang 2004 reported number, sex, age and duration of the palsy

indicating no significant differences between groups. Beurskens

2003 reported no significant differences between groups at base-

line for demographic data and severity and duration of facial palsy.

Completeness of follow-up

Beurskens 2003 and Mosforth 1958 assessed outcomes at one year

follow up. Beurskens analysed all the 50 participants (of whom

34 had Bell’s palsy) at this time. Mosforth did not analyse all the

people after one year because they were discharged when recov-

ered. Despite this, our analyses were not affected. The data of in-

terest (incomplete recovery) were reported by the study and drop

outs were considered to have incomplete recovery in our intention

to treat analysis. Flores 1998 did not describe follow up and 29

people (19.26%) dropped out without description of their alloca-

tion groups. The reasons described were that the participants re-

quested another medication or they had not adhered to the treat-

ment. Manikandan 2007 and Wen 2004 followed subjects until

12 weeks and Wang 2004 until 30 days, the end of the treatment

period.

Effects of interventions

The results have been divided by the intervention and described

according to the results for each of our outcome measures.

ELECTRICAL STIMULATION

Primary outcome measure

Mosforth 1958 studied the efficacy of electrotherapy after six

months in a total of 86 participants (n = 44 electrical stimulation

and n = 42 control). The graphs were constructed using an inten-

tion-to-treat analysis and less than 75% recovery was considered

a bad outcome. The relative rate of improvement was not signifi-

cantly different, relative risk (RR) 1.30, 95% CI 0.68 to 2.5 (see

Analysis 1.1).

Manikandan 2007 described results after three months on a con-

tinuous scale. The Facial Grade Score measured rest score, synk-

inesis scores and movement score of the 28 participants in each

group. The first two scores did not show statistical significance.

The movement score improved significantly in the group with-

out electrical stimulation, mean difference (MD) 68.00, 95% CI

59.93 to 76.07 (see Analysis 1.2). Consequently the total score

improved, MD 12.00, 95% CI 1.26 to 22.74 (see Analysis 1.2).

In Flores 1998 study ten (12.98%) of the 77 participants that were

treated with electrical stimulation, and 11 (15.27%) of the 72

treated with prednisone had incomplete recovery after 6 months,

RR 0.85, 95% CI 0.38 to 1.88 (see Analysis 2.1).

Secondary outcome measures

(1) Presence of motor synkinesis, contracture, hyperkinesia,

facial spasm or crocodile tears six months after onset

Mosforth 1958 showed no significant differences between the

group receiving electrical stimulation and the control group in re-

spect of facial muscle contracture. Eleven participants (25%) in

the treated group and eight (20%) in the control had contracture,

RR 1.25, 95% CI 0.56 to 2.79.

Manikandan 2007 reported 2 participants in the group receiving

exercise and electrical stimulation that presented with mild synk-

inesis after three months, and none in the group with exercise

alone. This was considered non significant, RR 0.20, 95% CI 0.01

to 3.99.

(2) Incomplete recovery after one year

Mosforth 1958 reported no statistically significant differences in

this assessment, RR 1.15, 95% CI 0.55 to 2.36 (see Analysis 1.1).

(3) Adverse effects attributable to the intervention such as

pain or worsening of condition

No adverse effects were attributed to the interventions.



Subgroup analyses

Flores 1998 undertook a subgroup analysis by severity of the ax-

onal damage. In the group with mild disease or with lesions distal

to the chorda tympani lesion (n = 102) all individuals in both

groups improved at six months. In the most severe group or le-

sions proximal to the chorda tympani (n = 47) there was no signif-

icant difference in recovery, RR = 0.62, 95% CI 0.34 to 1.15 (see

Analysis 2.2). Analysing mean time to recovery of the 149 partic-

ipants in the study in days, we found significantly faster recovery

with electrical stimulation, (MD -8.38, 95% CI -13.99 to -2.77

Analysis 2.3). However Manikandan 2007 gave opposite results.

FACIAL EXERCISES

Primary outcome measure

Beurskens 2003 included only 34 participants with chronic (more

than nine months) Bell’s palsy. All participants in the exercise

group improved but none in the control group improved.

Wen 2004 compared facial exercises (n = 85) with medication (n =

60). There was no significant difference in improvement between

the groups at three months. 92.94% of participants in the exercise

group and 88.33% of participants in the control group recovered,

RR 0.61 95% CI 0.21 to 1.71 (see Analysis 4.1).

Wang 2004 compared a combination of medicines, acupuncture

and physiotherapy (n = 31) with the same interventions plus func-

tional exercises (n = 43). The single outcome was facial muscle

function (Potmann Score) after one month. It showed a statis-

tically significant difference in favour of the functional exercise

group, MD 8.47, 95% CI 7.05 to 9.89. .

Secondary outcome measures

(1) Presence of motor synkinesis, contracture, hyperkinesia,

facial spasm or crocodile tears six months after onset

Wen 2004 reported significantly less facial motor synkinesis after

exercise, with 12 cases in the control group (20%) and 4 cases in

the exercise group (4.7%), RR = 0.24, 95% CI 0.08 to 0.69.

(2) Incomplete recovery after one year

According to the criteria for this review, none of the participants

recovered completely after one year. Beurskens 2003 kindly sent

us the continuous outcomes after one year. These all showed im-

provements in favour of the exercise group: Facial Grading Scale

WMD 20.40, 95% CI 8.74 to 32.04; Facial Disability Index Phys-

ical MD 10.30, 95% CI -1.37 to 21.97, and the Facial Disability

Index Social MD 14.50, 95% CI 4.85 to 24.15 (see Analysis 3.1,

Analysis 3.2 ), in favour of exercise.

(3) Adverse effects attributable to the intervention such as

pain or worsening of condition

No adverse effects were attributable to the interventions

Subgroup analyses

Wen 2004 presented data on participants with mild and more se-

vere disease. There was no difference in the proportion of partici-

pants that improved in the exercise group and conventional ther-

apy group in the individuals with mild paralysis (Analysis 4.2).

But when we analysed the sub-group with moderate severity, we

observed that the exercise group began (Analysis 4.2) and finished

(Analysis 4.3) improving sooner.

D I S C U S S I O N

In the light of the numerous physical therapies used for treating

Bell’s palsy in daily practice, this review highlights the lack of high

quality evidence to support the use of these strategies. Electrother-

apy, exercises, biofeedback, manual therapy and laser were evalu-

ated in some studies, but only trials involving electrostimulation

and exercise had the minimum methodological quality to be con-

sidered for this systematic review.

Electrical stimulation

Almost all the outcomes reported failed to show any statistically

significant difference between either electrotherapy or exercises

and conventional or no treatment. Mosforth 1958 concluded that

it is not possible to recommend electrostimulation and questions

its cost-effectiveness. The results of Manikandan 2007 are in agree-

ment as the group with electrical stimulation had worse quality

of movement and functional recovery after three months. Flores

1998 found no differences in the proportion of participants with

recovery after six months. The time to recovery in the Flores study

was less in the electrostimulation group but the study had some

methodological restrictions such as comparing physiotherapy with

prednisone, an active treatment, and almost 20% participant drop

outs. No statistical differences were found in synkineses or other

complications in any of the trials.

Exercise

Neither Wen 2004 studying acute cases nor Beurskens 2003 study-

ing chronic cases found differences in the proportion recovering

after three and six months. Significantly less synkinesis was ob-

served by Wen 2004 after three months. The evidence was limited

by the restrictions of reported outcomes to continuous data. The

assessment was blinded in two studies (Beurskens 2003; Wang

2004).



Comments about the methodology

Almost all the included studies had some limitations to be con-

sidered in future research.

In the electrical stimulation trials Flores 1998 compared electros-

timulation and prednisolone, an active treatment, which could

have biased the study results. Manikandan 2007 used different

exercise regimens in both groups but the main difference was the

use of electrical stimulation in one of the groups. This modified

the way data have been analysed and we considered that the study

tested electrical stimulation rather than different exercise regimens.

In the exercise trials, Beurskens 2003 studied chronic facial palsy

and included participants with dysfunctions other than idiopathic

facial palsy, which reduced the size of the sample of interest for this

review and limited conclusions. Wang 2004 and Wen 2004 com-

pared combinations of physiotherapy and medicine with func-

tional exercises which complicated interpretation.

The main outcomes used were continuous scales of motor func-

tion. In another publication Beurskens 2004b discussed the out-

comes of applying exercise to treat facial paresis. He observed a

significant recovery in the outcomes in participants receiving ex-

ercise for palsies lasting more than nine months: asymmetry in the

face at rest, asymmetry during voluntary facial movements, synk-

ineses, complaints concerning pain, stiffness, involuntary move-

ments, reports concerning difficulties in eating, drinking, speak-

ing, and patient perception about their quality of life. Although

the House-Brackmann score was used as an overall measure of fa-

cial impairment, the authors stated that it was not sensitive enough

to measure improvement during therapy with exercise in chronic

cases. The Facial Grading Scale (Roos 1996) and the Facial Dis-

ability Index (VanSwearingen 1996) were considered good assess-

ment options.

We would have preferred to convert continuous data into dichoto-

mous data. For example, for recent Bell’s palsy we expect a mini-

mum of 71% recovery (House-Brackmann scores of I or II) before

three months. In chronic stationary cases with House-Brackman

scores of III or IV, patients might find lesser degrees of improve-

ment valuable.

In subgroups with severe dysfunction, “complications” or “seque-

lae” were the clinical outcomes considered. Peitersen 2002 re-

ported that out of more than 2500 people with facial paralysis,

29% had persistent weakness, 17% contracture and 16% synkine-

sis. Wen 2004 described twelve cases out of 85 participants with

synkinesis in the control group (14%) and four out of 60 cases

in the exercise group (6.6%). More studies are needed to confirm

this.

However, the trials in which improvements were reported as con-

tinuous outcomes are less reliable, particularly if they were not

blinded. It is not impossible to blind such studies, since the authors

can either introduce an observer who had not seen the patient

before or take photographs or even videos, as in the Beurskens

2003 and Wang 2004 studies. Nevertheless these studies had other

limitations.

Other clinical references used in the studies were the “times to

onset of recovery” and “times to complete recovery”. Some dif-

ferences emerged between the groups treated with physical ther-

apy and other treatment (prednisone or other medication). The

time to improvement seemed to be shorter in participants receiv-

ing physical therapies, even in mild, as well as moderate grades of

paralysis but these results are really not reliable.

The conclusions of this systematic review were limited by the low

number and poor quality of studies and the heterogeneity of the

results .

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There is no evidence of significant benefit or harm from the limited

trials of electrical stimulation or facial exercises for Bell’s palsy.

Implications for research

There is a need for well-designed, randomised trials of electrical

stimulation, exercise and other physical therapies for Bell’s palsy.

Reports of such trials should give details of the treatments given

including dose and duration. Outcome measures should be se-

lected which are likely to be adequately responsive for detecting

change with physical therapies. Measures should include facial ap-

pearance, function (eating and drinking and speaking), facial ap-

pearance (including asymmetry and involuntary movements), and

quality of life. Recovery at defined times such as three, six and

twelve months of treatment is easier to measure accurately than

the time to recovery. Use of photography or video to blind the

outcome assessor is encouraged.

A C K N O W L E D G E M E N T S

The staff of the Brazilian Cochrane Centre, Cochrane Neuro-

muscular Desease Group, Dr David Allen for his important con-

tribution reviewing the protocol and a special thanks to Pro-

fessor Richard Hughes for all the comments during all the ed-

itorial process. Rachel Barton for the search strategy and the

database searches. To Dr Zhannat Idrissova, Dr Hitoshi Nukada

and Yuquian Ma for the translations. Kate Jewitt, Janice Fernandes

and Jane Batchelor for all the support. Special thanks to my wife,

Cinira Gomes, and our daughter Rafaela for the patience and love

all the time.



R E F E R E N C E S

References to studies included in this review

Beurskens 2003 {published and unpublished data}

Beurskens CHG, Heymans PG. Mime therapy improves

facial symmetry in people with long-term facial nerve

paresis: a randomized controlled trial. Australian Journal of

Physiotherapy 2006;52(3):177–83.∗ Beurskens CHG, Heymans PG. Positive effects of mime

therapy on sequelae of facial paralysis: stiffness, lip mobility,

and social and physical aspects of facial disability. Otology &

Neurotology 2003;24(4):677–81.

Beurskens CHG, Heymans PG, Oostendorp RAB. Stability

of benefits of mime therapy in sequelae of facial nerve

paresis during a 1-year period. Otology & Neurotology 2006;

27(7):1037–42.

Flores 1998 {published data only}

Flores PF, Medina RZ, Haro LG. Idiopathic peripheral

facial paralysis treatment physic therapy versus prednisone

[Tratamiento de la parálisis facial periférica idiopática:

terapia física versus prednisona]. Revista médica del InstitutoMexicano del Seguro Social 1998;36(3):217–21.

Manikandan 2007 {published and unpublished data}

Manikandan N. Effect of facial neuromuscular re-

education on facial symmetry in patients with Bell’s palsy: a

randomized controlled trial. Clinical Rehabilitation 2007;

21(4):338–43.

Mosforth 1958 {published data only}

Mosforth J, Taverner D. Physiotherapy for Bell’s palsy.

British Medical Journal 1958;2(5097):675–7.

Wang 2004 {unpublished data only}

Wang XH, Zhang LM, Han M, Zhang KQ. Clinical

application of functional exercise and staged therapy in

treatment of facial nerve paralysis. Zhonghua Linchuang

Kangfu Zazhi [Chinese Journal of Experimental and ClinicalVirology] 2004;8(4):616–7.

Wen 2004 {unpublished data only}

Wen CM, Zhang BC. Effect of rehabilitation training at

different degree in the treatment of idiopathic facial palsy: a

randomized controlled comparison. Zhongguo Linchuang

Kangfu 2004;8(13):2446–7.

References to studies excluded from this review

Aleev 1973 {unpublished data only}

Aleev LS. Experience in the treatment of facial nerve

neuritis using the method of programmed multi-channel

bioelectrical control. Zhurnal Nevropatologii i PsikhiatriiImeni S. S. Korsakova 1973;73(3):345–50.

Balliet 1982 {published data only}

Balliet R, Shinn JB, Bach-y-Rita P. Facial paralysis

rehabilitation: retraining selective muscle control.

International Rehabilitation Medicine 1982;4(2):67–74.

Bernardes 2004 {published data only}

Bernardes DFF, Gomez MVSG, Pirana S, Bento RF.

Functional profile in patients with facial paralysis treated in

a myofunctional approach. Pró-fono 2004;16(2):151–8.

Beurskens 2004c {published data only}

Beurskens CHG, Devriese PP, van Heiningen I, Oostendorp

RAB. The use of mime therapy as a rehabilitation method

for patients with facial nerve paresis. International Journal ofTherapy and Rehabilitation 2004;11(5):206–10.

Brach 1999 {published data only}

Brach JS, VanSwearingen JM. Physical therapy for facial

paralysis: a tailored treatment approach. Physical Therapy1999;79(4):397–404.

Brown 1978 {published data only}

Brown DM, Nahai F, Wolf S, Basmajian JV.

Electromyographic biofeedback in the reeducation of facial

palsy. American Journal of Physical Medicine 1978;57(4):

183–90.

Casler 1990 {published data only}

Casler JD, Conley J. Simultaneous ’dual system’

rehabilitation in the treatment of facial paralysis. Archives

of Otolaryngology Head and Neck Surgery 1990;116(12):

1399–403.

Coulson 2006 {published data only}

Coulson SE, Adams RD, O’Dwyer NJ, Croxson GR.

Physiotherapy rehabilitation of the smile after long-

term facial nerve palsy using video self-modeling and

implementation intentions. Otolaryngology - Head and Neck

Surgery 2006;134(1):48–55.

Coulson 2006b {published data only}

Coulson SE, Adams RD, O’Dwyer NJ, Croxson GR. Use

of video self-modelling and implementation intentions

following facial nerve paralysis. International Journal ofTherapy and Rehabilitation 2006;13(1):30–5.

Cronin 2003 {published data only}

Cronin GW, Steenerson RL. The effectiveness of

neuromuscular facial retraining combined with

electromyography in facial paralysis rehabilitation.

Otolaryngology - Head and Neck Surgery 2003;128(4):534–8.

Dalla-Toffola 2005 {published and unpublished data}

Dalla-Toffola E, Bossi D, Buonocore M, Montomoli C,

Petrucci L, Alfonsi E. Usefulness of BFB/EMG in facial

palsy rehabilitation. Disability and Rehabilitation 2005;27

(14):809–15.

Danile 1982 {published data only}

Danile V, Marongiu A, Candioto G. New therapeutic

method by ionophoresis of a drug cocktail in facial paralysis

a frigore [Nuovo metodo terapeutico ionoforetico con

cocktail medicamentoso della paresi facciale a frigore].

Policlinico - Sezione Medica 1982;89(2):160–6.

Dubravica 1996 {published data only}

Dubravica M, Musura M, Nesek-Madaric V, Stajner-

Katusic S, Horga D. Treatment of facial palsy by EMG



biofeedback technique - Muscle relaxation technique. Acta

Clinica Croatica 1996;35(1-2):17–20.

Goulart 2002 {published data only}

Goulart F, Vasconcelos KSS, Souza MRV, Pontes PB.

Physical therapy for facial paralysis using the biofeedback [A

utilização do biofeedback no tratamento da paralisia facial

periférica]. Acta Fisiátrica 2002;9(3):134–40.

Klingler 1982 {published data only}

Klingler D, Bibl D. Peripheral facial paralysis-role of early

onset of therapy. Wiener Medizinische Wochenschrift 1982;

132:149–53.

Koyama 2005 {unpublished data only}

Koyama S, Okada K, Yamakawa T, Kubo M, Amatsu H.

The usefulness of manipulative physiotherapy in treating

bell’s palsy. Medical Journal of Minami Osaka Hospital 2005;

53(1):55–7.

Lobzin 1989 {unpublished data only}∗ Lobzin VS, Smetankin AA, Tsatskina ND, Iashin NS.

Treatment of Bell’s palsy by using portable biofeedback

devices. Zhurnal Nevropatologii i Psikhiatrii Imeni S. S.Korsakova 1989;89(10):57–62.

Lobzin VS, Tsatskina ND. The adaptive biological control

system with electromyographic feedback in the treatment of

Bell’s palsy [Russian]. Zhurnal Nevropatologii i PsikhiatriiImeni S. S. Korsakova 1989;89(5):54–7.

Manca 1997 {published data only}

Manca M, Contenti E, Mura G, Basaglia N, Cavazzini

L. EMG biofeedback in peripheral facial nerve palsy

rehabilitation. Europa Medicophysica 1997;33(3):143–7.

Murakami 1993 {published data only}

Murakami F, Kemmotsu O, Kawano Y, Matsumura C,

Kaseno S, Imai M. Diode low reactive level laser therapy

and stellate ganglion block compared in the treatment of

facial palsy. Laser Therapy 1993;5(3):131–5.

Nakamura 2003 {published data only}

Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N.

Biofeedback rehabilitation for prevention of synkinesis after

facial palsy. Otolaryngology - Head and Neck Surgery 2003;

128(4):539–43.

Romero 1982 {published data only}

Corral-Romero MA, Bustamante-Balcarcel A. Biofeedback

rehabilitation in seventh nerve paralysis. The Annals of

Otology, Rhinology, and Laryngology 1982;92(2 Pt 1):166–8.

Ross 1991 {published data only}

Ross B, Nedzelski J, Mclean J. Efficacy of feedback training

in long-standing facial paresis. Laryngoscope 1991;101(7 Pt

1):744–50.

Segal 1995a {published data only}

Segal B, Hunter T, Danys I, Freedman C, Black M.

Minimizing synkinesis during rehabilitation of the paralyzed

face: Preliminary assessment of a new small-movement

therapy. Journal of Otolaryngology 1995;24(3):149–53.

Segal 1995b {published data only}

Segal B, Zompa L, Danys I, Black M, Shapiro M, Melmed

C, et al.Symmetry and synkinesis during rehabilitation of

unilateral facial paralysis. Journal of Otolaryngology 1995;24

(3):143–8.

Shiau 1995 {published data only}

Shiau J, Segal B, Danys I, Freedman R, Scott S. Long-term

effects of neuromuscular rehabilitation of chronic facial

paralysis. The Journal of Otolaryngology 1995;24(4):217–20.

Taverner 1966 {published data only}

Taverner D, Fearnley ME, Kemble F, Miles DW, Peiris OA.

Prevention of denervation in Bell’s palsy. British Medical

Journal 1966;5484:391–3.

Zhao 2005 {published data only}

Zhao Y, He L, Zhang QH. Effectiveness of three different

treatments for peripheral facial paralysis. Chinese Journal ofClinical Rehabilitation 2005;9(29):41–3.

References to studies awaiting assessment

Diao 2002 {published data only}

Diao L, et al.Comparison of the efficacy between

acupuncture and manipulation for Bell’s palsy. Journal ofHuaihua Medical College 2002;1(2):34–5.

Guo 2006 {published data only}

Guo QH, Yan JZ, Yan WS, Xiao MZ. Observation on non-

invasive electrode pulse electric stimulation for treatment of

Bell’s palsy. Zhongguo Zhenjiu 2006;26(12):857–8.

Li 2005 {published data only}

Li J. Comparison the efficacy between acupuncture and

manipulation for Bell’s palsy. Chinese Clinical Medicine

Research 2005;11(12):1715–6.

Pan 2004 {published data only}

Pan L. Acupuncture plus short wave for 38 peripheral facial

paralysis. Journal of Clinical Acupuncture & Moxibustion2004;20(4):26–7.

Qu 2005 {published data only}

Qu Y. Clinical observation on acupuncture by stages

combined with exercise therapy for treatment of Bell palsy

at acute stage. Zhongguo zhen jiu [Chinese Acupuncture &Moxibustion] 2005;25(8):545–7.

Wang 2004b {published data only}

Wang XH, Zhang LM, Han M, Zhang KQ, Jiang JJ.

Treatment of Bell’s palsy with combination of traditional

Chinese medicine and western medicine. Hua xi kou qiangyi xue za zhi [West China Journal of Stomatology Stomatology]

2004;22(3):211–3.

Yang 2001 {published data only}

Yang G. Comparison of the efficacy between acupuncture

and therapy apparatus for Bell’s palsy. Journal of ClinicalAcupuncture & Moxibustion 2001;17(8):28–9.

Zhang 2005 {published data only}

Zhang H. Acupuncture combined with facial muscle

training for peripheral facial paralysis. Chinese Journal of

Rehabilitation Theory and Practice 2005;11(12):1037–8.

Additional references



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Adour KK. Current concepts in neurology: diagnosis and

management of facial paralysis. The New England Journal of

Medicine 1982;307(6):348–51.

Adour 2002

Adour KK. Decompression for Bell’s palsy: why I don’t do

it. European Archives of Otorhinolaryngology 2002;259(1):

40–7.

Allen 2004

Allen D, Dunn L. Aciclovir or valaciclovir for Bell’s palsy

(idiopathic facial paralysis). Cochrane Database of Systematic

Reviews 2004, Issue 3.

Beurskens 2004

Beurskens CHG, Burgers-Bots IAL, Kroon DW,

OOstendorp RAB. Literature review of evidence based

physiotherapy in patients with facial nerve paresis. Journalof the Japanese Physical Therapy Association 2004;7:35–9.

Beurskens 2004b

Beurskens CHG, Heymans PG. Physiotherapy in patients

with facial nerve paresis: description of outcomes. AmericanJournal of Otolaryngology 2004;25(6):394–400.

Danielidis 1999

Danielidis V, Skevas A, Van Cauwenberge P, Vinck B.

A comparative study of age and degree of facial nerve

recovery in patients with Bell’s palsy. European Archives of

Otorhinolaryngology 1999;256(10):520–2.

De Diego 1999

De Diego JI, Prim MP, Madero R, Gavilán J. Seasonal

patterns of idiopathic facial paralysis: a 16-year study.

Otolaryngology and Head and Neck Surgery 1999;120(2):

269–71.

Gilden 2004

Gilden DH. Clinical Practice. Bell’s palsy. The New England

Journal of Medicine 2004;351(13):1323–31.

Gonçalvez 1997

Gonçalvez-Coêlho TD, Pinheiro CN, Ferraz EV, Alonso-

Nieto JL. Clusters of Bell’s palsy. Arquivos de Neuro-

Psiquiatria 1997;55(4):722–7.

Grogan 2001

Grogan PM, Gronseth GS. Practice parameter: steroids,

acyclovir and surgery for Bell’s palsy (an evidence based

review): report of the Quality Standards Subcommittee of

the American Academy of Neurology. Neurology 2001;56

(7):830–6.

Hato 2007

Hato N, Yamada H, Kohno H, Matsumoto S, Honda N,

Gyo K, et al.Valacyclovir and prednisolone treatment for

Bell s palsy: a multicenter, randomized, placebo-controlled

study. Otology and Neurotology 2007;28:408–13.

He 2007

He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, et

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Holland NJ, Weiner GM. Recent developments in Bell’s

palsy. BMJ 2004;329(7465):553–7.

House 1985

House JW, Brackmann DE. Facial nerve grading system.

Otolaryngology--Head and Neck Surgery 1985;93(2):146–7.

Peitersen 2002

Peitersen E. Bell’s Palsy: the spontaneous course of 2500

peripheral facial nerve palsies of different etiologies. ActaOto-Laryngologica. Supplementum 2002;549:4–30.

Quinn 2003

Quinn R, Cramp F. The efficacy of electrotherapy for Bell’s

palsy: a systematic review. Physical Therapy Reviews 2003;8:

151–64.

Roos 1996

Ross BG, Fradet G, Nedzelski JM. Development of a

sensitive clinical facial grading system. Otolaryngology Head

and Neck Surgery 1996;114:380–6.

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Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell’s

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Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith

BH, McKinstry B, et al.Early treatment with prednisolone

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Valença 2001

Valença MM, Valença LP, Lima MC. Idiopathic facial

paralysis (Bell’s palsy): a study of 180 patients [Paralisia

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VanSwearingen J, Brach J. The Facial Disability Index:

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for disorders of the facial neuromuscular system. Physical

Therapy 1996;76(12):1288–98.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Beurskens 2003

Methods Blinding: the assessors of outcomes were unaware of the allocation.

Analysis: differences (between the experimental and control group and between pre- and post-tests). Data

were collected concerning the level of impairment, disability, and handicap of the patient in pre-test and

post-test measures in both the treatment and the control groups.

Duration: 3 months of therapy.

Follow up: 3 measurement occasions within 1 year: immediately, 3 and 12 months after therapy.

Center: Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands and Vrije Universiteit

Medical Center, Amsterdam.

Design: Randomised clinical trial.

Participants N = 50 peripheral facial nerve paresis (34 idiopathic). 2 dropped out in each group.

Diagnosis: people with sequelae of facial paralysis, House-Brackmannn IV, for at least 9 months; no nerve

or muscle reconstruction; absence of complete, partial, or central facial paralysis; absence of congenital

facial paralysis; and sufficient knowledge of the Dutch language.

Gender: both sexes (21 males and 29 females), including the participants with other causes of facial palsy.

Race: not mentioned.

Age: median 44 years (20 to 73, SD 14) including the participants with other causes of facial palsy.

Setting: Physiotherapy outpatient department

Interventions 1. Exercises (mime therapy) on a individual basis in sessions of 45 minutes, once weekly, over 3

months (10 sessions) and home program of exercises. N = 16

2. Control group (waiting list). N =18

Outcomes Stiffness of the face. Lip mobility (both lip and pout length).

Physical and social index of the Facial Disability Index (VanSwearingen 1996 )

Sunnybrook Facial Grading System.

House-Brackmann Facial Grading System.

Notes This study description is the pool of three publications by the author about the same population and

groups

Risk of bias

Item Authors’ judgement Description

Allocation concealment? No C= Inadequate. A coin flip for the first participant

and then pairs of patients as they became available



Flores 1998

Methods Blinding: not done.

Analysis: The participants were divided, for purposes of analysis, into those with and those without

electromyographic evidence of denervation

Duration: Until functional recovery was achieved according to the May Scale, with evaluations every 14

days.

Follow up: not described.

Center: Medicina Física y Rehabilitacion Department, Hospital General Regional Num 1, Culiacán,

Sinaloa, México.


Participants N = 149

Diagnosis: acute Bell’s palsy of onset within 1 to 3 days. EMG 8 days after onset. Excluded other causes

of facial paralysis.

Gender: both sexes (males 61 and females 88)

Race: not mentioned

Age: median 33 (3 to 60) years.

Setting: clinic.

History/Comorbidities: normal glycemia and arterial pressure

Interventions 1. Prednisone (1mg/Kg /day) up 14 days. N = 72.

2. Infrared treatment for 20 min and faradic stimulation (10 to 15 stimulation/min in motor points

not described). N = 76

Outcomes Clinical history and May Scale (grade I - complete recovery, II - complete recovery with facial asymmetry

with movements between 2 to 6 months, and III - incomplete recovery with asymmetry, synkinesis for

more than 6 months)

Drop out: 29 people (19.26%) without describing the exact reason for drop out or the groups they were

allocated to. Reasons: participants requested another medication or they did not adhere to the treatment

Notes We are waiting for the author’s answer about details of the study

Risk of bias


Allocation concealment? Unclear B - Unclear. Allocation not described

Manikandan 2007

Methods Blinding: no.

Analysis: the authors used Wilcoxon signed-rank test and Mann Whitney U-test to compare the Facial

Grading Scale scores within each group.

Duration: three months of therapy.

Follow up: three months. Until the end of the therapy.

Center: Kasturba Hospital, Manipal, Karnataka, India.




Manikandan 2007 (Continued)

Participants N = 59 participants.

Diagnosis: unilateral Bell’s palsy with a mean duration of two weeks.

Excluded people with diseases of the central nervous system, sensory loss over the face, recurrence of facial

paralysis and who were uncooperative during the study.

Gender: both sexes (males 24 and females 37).


Age: median of 35 years old.

Setting: Neurorehabilitation unit.

History/Comorbidities: non described

Interventions 1. Exercises (facial neuromuscular reeducation) on a individual basis taught to patients, 5 to 10

repetitions, 3 x /day, for 3 months. N = 29.

2. Fixed protocol of electrical stimulation (3 x/day, for six days in 2 weeks. 90 contractions with

galvanic current in each muscle plus 10 contractions with faradic current in each facial nerve trunk,

intensity until minimal visible contraction) plus Gross facial expression exercises taught to patients for 3

months. N = 30

Participants in both the groups were instructed to use a hand-held mirror during the exercise. Facial

massage was given and strapping was applied to the face to maintain the symmetry

Outcomes Facial Grading Scale (facial symmetry at: rest, movement and synkinesis) before and after 3 months

Notes Two patients in group 2 developed mild synkinesis post treatment.

One patient from group 1 and two from group 2 dropped out before the completion of the study with

reasons stated

Risk of bias


Allocation concealment? Yes A - Adequate. Randomisation using six blocks with

10 in each block

Mosforth 1958

Methods Blinding: none.

Analysis: The participants were divided, for purposes of analysis, into those with and those without

electromyographic evidence of denervation

Duration: the treatment was given daily until the active contractions returned and then thrice weekly

until recovery was virtually complete or the condition seemed stationary (2 to 6 months).

Follow up: one year.

Center: Department of Electromyography Leeds General Infirmary

Design: controlled randomised trial.

Participants N = 86 people with Bell’s palsy.

Diagnosis: clinically excluding other causes. Complete or partial paralysis of one side of the face, sudden

onset.

Duration: less than 14 days (mean 5.2).

Gender: both sexes males 40 and females 43.



Mosforth 1958 (Continued)


Age: 37.5 years old (3 to 79 years).

Setting: clinic.

History/Comorbidities: the groups were comparable at baseline

Interventions 1. Auto-massage of the face plus infrared for 10 min plus interrupted galvanic stimulation of 11

muscles of the face for 3 times of 30 contraction (pulse 100 msec). N = 44

2. Massage. N = 42

Outcomes Electrical examination.

Grade of paralysis estimated visually as a percentage of the function of the normal side

Notes One patient from group 1 and two from group 2 dropped out before the completion of the study with

reasons

Risk of bias


Allocation concealment? Yes A - Adequate. A prepared list.

Wang 2004

Methods Blinding: no.

Analysis: Improvement Index = (Scores After Treatment - Scores Before Treatment)/ Scores After Treat-

ment

Duration: one month (30 days).

Follow up: one month. Until the end of the therapy.

Center: Neurology Department of West China Hospital.

Design: randomised clinical trial.

Participants N = 74 people with Bell’s palsy.

Diagnosis: diagnosed as facial nerve paralysis by Neurology Department of West China Hospital. Exclusion

caused central, traumatic or auditory facial nerve paralysis.

Duration: lasting for less than 1 month.

Gender: both sexes males 1 and females 0.79 (therapy) and males 1 and females 0.41 (control).

Race: Chinese.

Age: therapy group mean 1 - 41.56 (SD14.47) years old, and control group - 40.87 (13.46) years.

Setting: hospital.

History/Comorbidities: not mentioned.

Interventions 1. Drug plus physical treatment plus massage plus acupuncture plus functional exercise. N = 43

• 1-7 days - drug treatment and physical treatment.

• 8-14 days - drug treatment, physical treatment, functional exercise and massage and acupuncture

treatment.

• 14-30 days - physical treatment, functional exercise and massage and acupuncture treatment.

2. Drug plus physical treatment plus massage plus acupuncture. N = 31

• 1-7 days - drug treatment and physical treatment.



Wang 2004 (Continued)

• 8-14 days - physical treatment and massage and acupuncture treatment.

• 14-30 days - physical treatment and massage and acupuncture treatment.

- Drug treatment (cortisone for 30 mg daily in the morning or 10 mg 3 x daily for 7 days, decreased the

dosage on the 7th day, and stop on the 14th day; mexobalamin 500 ug 2 x daily; vitamin B2 10 mg)

Outcomes Scores of facial muscular function: Potmann Scores (frowning, eyes closing, moving nose, smiling,

whistling, and plumping the face, each movement graded 3 scores, adding 2 scores for the impression of

quiet state).

There was no exact criterion to measure the symptoms.

Notes

Risk of bias


Allocation concealment? Yes A - Adequate. Randomised numbers by the com-

puter.

Wen 2004

Methods Blinding: none.

Analysis: each group has patients with three different severities: mild, moderate and severe. The degree of

recovery, time to recovery and complications were used to evaluate the results.

Follow up: during the treatment = 12 weeks (between 10/2000 and 11/2003).

Center: central Hospital of Nanyanz, Manyang, Henan Province, China.

Design: controlled randomised trial.

Participants N = 145 people with idiopathic facial palsy.

Diagnosis: severity based on the function of facial muscles and complaints of patients.

Duration: not mentioned.

Gender: both sexes males 85 and females 60.


Age: 7 to 74 years old (average: 45).

Setting: hospital.

History/Comorbidities: not mentioned.

Interventions 1. Conventional therapy plus facial rehabilitation exercises (movements using facial muscles, exercises

performed daily under the tutoring of clinicians). N = 85

2. Conventional therapy only. N = 60.

Both groups received the same pharmacological treatment (no information about the dosage that was

used)

Outcomes Grade of paralysis estimated visually as a percentage of the function of the normal side.

The outcome measures were times when the patient started to recover and completely recovered; the

percentage of completely recovered patients within 12 weeks.

The measurements took place once a week by clinicians but the results were presented as standard mean

differences. No baseline level was indicated



Wen 2004 (Continued)

Notes Facial muscle synkineses were reported in one case in the mild and one in the moderate group. In the

severe patient group, 12 cases of complications reported in the control group and 4 cases in the training

group were reported

Risk of bias


Allocation concealment? Unclear B - Unclear. Allocation not mentioned.

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Aleev 1973 Not a randomised controlled trial. It is a case series.

Balliet 1982 Not a randomised controlled trial. Four people with traumatic facial paralysis

Bernardes 2004 Not a -randomised controlled trial. It is a retrospective study to delineate the contribution of myofunctional

exercises during the flaccid phase of the facial paralysis between participants with traumatic and spontaneous

paralysis

Beurskens 2004c This is a description of the mime facial exercises.

Brach 1999 Not a randomised controlled trial. It is a case study that proposed a treatment-based category based on signs

and symptoms

Brown 1978 Not a randomised controlled trial. It is a case study that described two participants treated with biofeedback in

both clinic and home environment

Casler 1990 This is a controlled trial about surgery.

Coulson 2006 There were only two participants with idiopathic facial palsy

Coulson 2006b Not a randomised controlled trial. It is a study of 2 cases following removal of a vestibular schwannoma

Cronin 2003 Not a randomised controlled trial. This is a retrospective case review. There are others causes of facial palsy

including Ramsay Hunt. There were only 3 participants with idiopathic facial palsy. The groups were not

comparable at baseline. Twenty-four participants received neuromuscular facial retraining and the other 6 were

the control group

Dalla-Toffola 2005 Not a randomised controlled trial. This is a retrospective study

Danile 1982 Not a randomised controlled trial. Iontophoresis was applied in 50 participants with idiopathic facial palsy

without a comparison group



(Continued)

Dubravica 1996 It was unclear how the groups were divided and if the participants were randomised. The two groups undertook

kinesiotherapy plus electrostimulation 5 weeks before the study and it could have interfered with the results

Goulart 2002 Not a randomised controlled trial. It is a non-systematic review of the literature

Klingler 1982 This controlled trial is about therapy with cortisone, anti-rheumatics and diuretics to treat facial palsy

Koyama 2005 Not a randomised controlled trial.

Lobzin 1989 Not a randomised controlled trial. This is two studies with 32 participants with neuritis and neuropathy of the

facial nerve treated with an electromyography feedback device without a comparison group

Manca 1997 Not a randomised controlled trial. It is a study of 20 participants with facial paralysis treated with EMG

biofeedback

Murakami 1993 Not a randomised trial. One group of people treated with low reactive-level laser therapy (11) compared with

one group treated with stellate ganglion block (26) and another group with a combination of both (15)

Nakamura 2003 There were only 10 participants with idiopathic facial palsy. 27 people with complete facial nerve palsy who had

no response to electrical stimulation were randomly allocated into 2 groups: 12 treated with training method

of biofeedback rehabilitation to prevent synkinesis and 15 as a control without treatment

Romero 1982 Not a randomised controlled trial. Biofeedback training was applied in ten participants with at least one-year

evolution selected in 957 facial paralyses. Only six of them had idiopathic facial palsy

Ross 1991 This study describes a randomised controlled trial with 31 people with long standing facial paresis (minimum

of 18 months) but there were only four participants with idiopathic facial palsy

Segal 1995a Not a randomised controlled trial. It is a preliminary study with 10 participants.

This compared a neuromuscular retraining program (5 participants) to a group with the same treatment plus

small movements to limit synkinesis (5 participants). There was one person that did not have idiopathic facial

palsy and it is not possible to analyse the data excluding this participant

Segal 1995b Not a randomised controlled trial. It was a study of 25 people (5 with idiopathic paralysis) that proposed an

exercise program based on home exercises and weekly 50 to 60 minute sessions at the clinic. Reassessment was

made at 2.5 month intervals for up to 10 months with the House scale and synkinesis measure. All idiopathic

participants changed from House grade 4 to 3 in 5 to 10 months

Shiau 1995 Not a randomised controlled trial. The assessment was randomised and not the participants

Taverner 1966 This is a randomised clinical trial about adrenocorticotrophic hormone injections

Zhao 2005 This controlled trial is about stellate ganglion block and acupuncture

* EMG = Electromyography



Characteristics of studies awaiting assessment [ordered by study ID]

Diao 2002

Methods Not known

Participants Not known

Interventions Not known

Outcomes Not known

Notes Not known

Guo 2006

Methods Not known



Outcomes Not known

Notes Not known

Li 2005

Methods Randomised design. Sample size = 94 (withdrawals: unclear). Experimental Group: 48 acupuncture. Control Group:

46 manipulation. Treatment follow up: after the fourth treatment session.Treatment duration: 7 x 4 days

Participants Inclusion: participants with Bell’s palsy defined according to clinical diagnostic criteria of all degrees of severity. Aged

from 6 to 65, mean age: unclear.Male 43, female 51

Interventions Experimental group: treatment with acupuncture, five days per week with two rest days. Control group: treatment

with manipulation, five days per week. Size of needles: unclear.Total number of sites: 11. Length of application: 20

minutes. Length of session: 1 week.Total number of treatment sessions: 4.

Outcomes Cured (disappearance of all signs and symptoms, the facial symmetry and the function of mimetic muscle were

fully restored after treatment). Markedly effective (the facial symmetry was normal in repose, however, during

movement, low-grade paralysis persisted after treatment). Improved (the facial symmetry was improved, however,

during movement, paralysis persisted after treatment). No effect (signs and symptoms unchanged after treatment).

Notes Experimental group: Cured: 30; Markedly effective:12; Improved:6; No effect:0. Control group: Cured: 29; Markedly

effective: 13; Improved: 4; No effect:0

These data were extracted from He 2007.



Pan 2004

Methods Not known



Outcomes Not known

Notes Not known

Qu 2005

Methods Not known



Outcomes Not known

Notes Not known

Wang 2004b

Methods Not known



Outcomes Not known

Notes Not known

Yang 2001

Methods Not known



Outcomes Not known

Notes Not known



Zhang 2005

Methods Not known



Outcomes Not known

Notes Not known



D A T A A N D A N A L Y S E S

Comparison 1. ELECTROSTIMULATION VERSUS CONTROL

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Incomplete recovery after 6 and

12 months

1 Risk Ratio (M-H, Random, 95% CI) Totals not selected

1.1 6 months 1 Risk Ratio (M-H, Random, 95% CI) Not estimable

1.2 12 months 1 Risk Ratio (M-H, Random, 95% CI) Not estimable

2 Mean Facial Grading Scale after

3 months

1 Mean Difference (IV, Fixed, 95% CI) Totals not selected

2.1 Rest score 1 Mean Difference (IV, Fixed, 95% CI) Not estimable

2.2 Movement score 1 Mean Difference (IV, Fixed, 95% CI) Not estimable

2.3 Total score 1 Mean Difference (IV, Fixed, 95% CI) Not estimable

Comparison 2. ELECTROSTIMULATION VERSUS PREDNISONE

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Incomplete recovery after six

months (all participants)

1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected

2 Incomplete recovery six months

according severity

1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected

2.1 Infrachordal lesion (mild

cases)

1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable

2.2 Suprachordal lesion

(severe cases)

1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable

3 Mean time to complete recovery

(in days)

1 149 Mean Difference (IV, Fixed, 95% CI) -8.38 [-13.99, -2.77]

3.1 Infrachordal lesion (mld

cases)

1 102 Mean Difference (IV, Fixed, 95% CI) -7.42 [-13.13, -1.71]

3.2 Suprachordal lesion

(severe cases)

1 47 Mean Difference (IV, Fixed, 95% CI) -33.94 [-63.40, -4.

48]



physical therapy for bell's palsy [idiopathic facial...

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