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Clinical Practice guidelines for Bell’s Palsy

Let me start by saying that I have seen few cases of Bell’s palsy comparatively. I can say I’ve seen no more than 10 cases in 12 years and reading this practice guideline, I can understand why it’s not a large percentage of patients seen in the clinic.

This post will be linked to the next blog post on Bell’s palsy because there are some conflicting recommendations, but not dramatically different.

“Bell’s Palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy…most common diagnosis associated with facial nerve weakness/paralysis”

I enjoy history. I didn’t know about Sir Charles Bell and I found this piece informative. Whenever a new disease or species is found, sometimes the discovered of the new xyz gets to name the new xyz. It is one way to keep their name alive. It could’ve also been described according to the actual dysfunction, as facial nerve palsy would indicate to everyone what is happening to the patient.

Once you see a patient with Bell’s palsy, it is never forgotten. The dysfunction can have dramatic effects on patients in terms of livelihood and willingness to go out in public.

People close to me know that I am a huge wrestling fan. One of the greatest, if not the greatest announcer in the history of professional wrestling is Jim Ross. His was the first time that I can remember learning of Bell’s palsy and it’s possible that his diagnosis cost him his job. It’s at least written about in other forums that there is a relationship. It was a long time before I got to hear about slobberknockers on tv again. Jim is back to work and his disease is visible to those that look close enough at his face.

“…rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause.”

I have seen this run the gamut from barely noticeable to unable to close the eye or mouth. At the worse end of the spectrum, the person had major issues with drinking because there was incomplete mouth closure, which caused liquids to spill out of the mouth. Also, the same person was unable to move the eye or cheek muscles. An eye patch was required.

“…may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential injury”

With issues of mouth and eye closure, imagine how hard it is to keep the eye moist. Blinking assists in lubricating the eye, not to mention that the eye has difficulty producing moisture from the gland in the corner of the eye in the presence of Bell’s palsy.

“Treatments are generally designed to improve facial function and facilitate recovery”

The patients that I have seen, remember only a handful, I believe that only one person improved. At no point in time do I take credit for that, as a majority of patients improve over the course of 3 months. This patient was referred to me at the 6 week mark and time may have been more important than anything I did regarding the patients recovery.

“…the following should be considered:

-Bell’s palsy is rapid onset (<72 hours)”

I’ve had patients associate Bell’s palsy with a cold breeze blowing on them at night. They say this because the onset is so quick that some literally woke up with it. The patients attempt to find answers for why things happen. As a healthcare provider we have to do our best to educate and reassure the patient that it was nothing that they did to cause this phenomenon.

-“Bell’s palsy is diagnosed when no other medical etiology is identified as a cause of the facial weakness”

This is a diagnosis of exclusion. As mentioned at some point in this article, differential diagnosing needs to be performed in order to ensure that there is nothing sinister or other diagnosis causing this problem.

-“bilateral Bell’s palsy is rare”

I have personally never heard of bilateral Bell’s palsy and have obviously never seen it with my low level of experience treating this issue.

-“Currently, no cause for Bell’s palsy has been identified”

This has to be stated to patients. They will matrix and try to come up with a cause, which can create a change in behavior and the spreading of “old wives tales”. The most common one I hear is that the window being open caused a breeze while sleeping, or a fan was blowing on my face causing a breeze, to cause the symptoms.

-“other conditions may cause facial paralysis, including stroke, brain tumors, tumors of the parotid gland or infratemporal fossa, cancer involving facial nerve, and systemic infectious diseases including zoster, sarcoidosis, and Lyme disease”

These are all major issues that require a thorough history and possible imaging to determine if Bell’s palsy is the true diagnosis or if there is something obvious causing symptoms.

-“Bell’s palsy may occur in men, women, and children, but is more common in those 15-45 years old; those with diabetes, upper respiratory ailments, or compromised immune systems;or during pregnancy”

It affects both genders (I’ve seen both men and women), a wide age spectrum (I’ve never seen anyone older than 50) and multiple comorbidities can increase risk.

“…paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis”

This is good to know as a PT. It’s rare for us to see these patients in the acute, or immediately after it starts, stage. Because of this, should we see a progressively worsening condition, it would be prudent to refer the patient back to the physician in order to rule out any other medical concerns.

“Facial paresis or paralysis is thought to result from facial nerve inflammation and edema”

This is one of the explanations, but again there is no known cause.

“The facial nerve carries nerve impulses to muscles of the face, and also to the lacrimal glands, salivary glands, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane”

This can cause the corners of the mouth to droop. The person may be unable to fully close the mouth to suck out of a straw.

The lacrimal glans is the little pink thing on the inside of the nose-side of the eye. This gland is responsible for keeping the eye moist.

“…may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth”

Because it also supplies “power” to the tastebuds, this can affect taste. I’ve known many patients of those that I treated that lost weight because food was no longer appetizing.

“Most patients with Bell’s palsy show some recovery without intervention within two to three weeks after onset of symptoms, and completely recover within three to four months”

This is a very important statistic. Without knowing this, a patient referred to PT within days of the diagnosis, whom shows improvement within weeks, may lead the PT to believe that physical therapy has more significant effects than actually occurs.

“… facial function is completely restored in nearly 70 percent of Bell’s palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis”

This information must be highlighted with patients. The effects of this diagnosis can be dramatic the first few weeks and hope needs to be restored in these patients.

Good ol JR is back to announcing wrestling!

“…as many as 30% of patients do not recover completely”

This needs to be addressed, but the education needs to be flipped to show that 70% recover partially or fully.

“Long-term, the disfigurement of the face due to incomplete recovery of the facial nerve can have devastating effects on psychological well-being and quality of life”

Two patients that I have treated in my past avoided going outside. Not to paint them in a negative light, but they lived like the Hunchback of Notre Dame. These two needed positive reinforcement in order to return to a life outside of the home.

I felt bad that these two have excluded themselves from the community because they wanted to return to normalcy, but didn’t want to be stared at in the process.

“…patients with facial paralysis can have impaired interpersonal relationships and may experience profound social distress, depression, and social alienation”

“The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell’s palsy”

As a PT, I will only discuss the information that is relevant to my profession or scope of practice.

1. “Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis”

A thorough history is important regardless of the ailment. When paralysis is the end result, a thorough differential needs to happen in order to rule out other factors that could affect the facial nerve.

For instance, using the objective portion of the examination can help to rule out a stroke. The history can help to rule in cancer.

As a PT, ensure that you are taking a good history and physical exam in order to ensure that nothing is being missed.

2. “Clinicians should not obtain routine laboratory testing in patients with new onset Bell’s palsy”

“Risk: Missing a potential cause of Lyme disease, which is considered based on a thorough history.

Benefit: avoiding unnecessary testing and treatment, false positives and cost savings”

This is outside of the scope of PT and I will defer.

3. “Clinicians should not routinely perform diagnostic imaging for patients with new onset Bell’s palsy.”

“Benefit: avoidance of unnecessary radiation exposure, incidental findings, contrast reactions and cost savings”

“Risk: missing other causes of facial paresis”

“Opportunity for patient education”

4. “Clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older”

“Benefit: improvement in facial nerve recovery, faster recovery”

“Risk: steroid side effects and cost of therapy

Exceptions: diabetes, morbid obesity, previous steroid intolerance and psychiatric disorders.”

5. “clinicians should not prescribe oral antiviral therapy alone for patients with new onset Bell’s palsy”

“Benefits: avoidance of medication side effect, cost savings”

Risks: none

6. “clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy”

Benefit: small potential improvement in facial nerve function

Risks: treatment side effects, cost of treatment

Patient preference: “significant role for shared decision making”

Exceptions: same for corticosteroid use

6. “clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure”

Eye protection is standard of care.

Risks: costs of eye protection implementation, potential side effects of medication.”

This falls into the plan of care for PTs. Sometimes the amount of time that the patient has with a physician is less than 10 minutes. (I’ve read that an average patient physician visit is 11 minutes).

Because of this, the patient may not fully understand what to do once diagnosed with Bell’s palsy, and this can be within the role of the PT.

7. “Clinicians should not perform electrodiagnostic testing in Bell’s palsy patients with incomplete facial paralysis”

8. “Clinicians may offer electrodiagnostic testing to Bell’s palsy patients with complete facial paralysis”

Benefit: provide prognostic information for the clinician and patient, identification of potential surgical candidate

Risks: patient discomfort and cost of testing

8. “no recommendation can be made regarding surgical decompression for Bell’s palsy patients”

“Concerned about the facial deformity may make it some patients willing to pursue a major operation for a small increase in the chance of complete recovery while others may be more willing to except the chance of poor outcome to avoid surgery”

“The group was divided as to whether the evidence supported no recommendation, or an option for surgery. This difference of opinion derived from controversy regarding the strength of evidence”

9. “No recommendation can be made regarding the effect of acupuncture in Bell’s palsy patients”

“The GDG was divided regarding whether to recommend against acupuncture, or to make no recommendation.”

10. “no recommendation can be made regarding the effect of physical therapy in Bell’s palsy patients”

There are conflicting statements regarding varying clinical practice guidelines.

I have only had one patient with Bell’s palsy that demonstrated significant improvement greater than 90 days since the diagnosis. Is it possible that time had a strong let effect than PT…sure…it’s possible.

Typically, the recovery would’ve taken place by three months, but the patient made progress while in therapy.

Don’t get me wrong, I don’t think that PT is the end all be all for many diagnoses or patients, but I do believe that the interventions had an effect on this particular case.

There may be some patients that could benefit from therapy. In saying this, my experience would tell me that it is a small percentage of patients.

“patient may benefit psychologically from engaging in physical therapy exercises”

11. “clinicians should reassess or refer to a facial nerve specialist those Bell’s palsy patients with 1. New or worsening neurologic findings at any point, 2. Ocular symptoms developing at any point, or 3. Incomplete facial recovery three months after initial symptom onset”

“Identifying alternate diagnoses in the absence of recovery, and potential assessment for rehabilitative options…However based on the natural history of Bell’s palsy, the majority of patients will show complete recovery three months after onset.”



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