2008 Physical Therapy For Bell's Palsy (Idiopathic Facial Paralysis) (Review)

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 Library
2008, 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.
TABLE OF CONTENTS
HEADER . . . . . . . . . .
ABSTRACT . . . . . . . . .
PLAIN LANGUAGE SUMMARY .
BACKGROUND . . . . . . .
OBJECTIVES . . . . . . . .
METHODS . . . . . . . . .
RESULTS . . . . . . . . . .
DISCUSSION . . . . . . . .
AUTHORS CONCLUSIONS . .
ACKNOWLEDGEMENTS
. . .
REFERENCES . . . . . . . .
CHARACTERISTICS OF STUDIES
DATA AND ANALYSES . . . . .
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22
[Intervention Review]
Physical therapy for Bell s palsy (idiopathic facial paralysis)

Lzaro Juliano Teixeira1 , Bernardo Garcia de Oliveira Soares2 , Vanessa Pedrosa Vieira3 , Gilmar F Prado4
1 Department
of Physiotherapy, Prefeitura Municipal de Balneario Camboriu, Santa Catarina, Brazil. 2 Universidade Federal de So
Paulo, So Paulo, Brazil. 3 Medicina Interna e teraputica, UNIFESP - Universidade Federal de So Paulo, So Paulo, Brazil. 4 So Paulo,
Brazil
Contact address: Lzaro Juliano Teixeira, Department of Physiotherapy, Prefeitura Municipal de Balneario Camboriu, R. Ana Garcia
Pereira, n 167, Balneario Camboriu, Santa Catarina, 88340-000, Brazil. lazarojt@terra.com.br.
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). Cochrane
Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006283. DOI: 10.1002/14651858.CD006283.pub2.
ABSTRACT
Background
Bells 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 Bells 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 Bells 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.
Main results
The search identified 45 potentially relevant articles. Six studies met the inclusion criteria. Three trials studied the efficacy of electrostimulation (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.
PLAIN LANGUAGE SUMMARY

Physical treatments for idiopathic facial paralysis
Bells 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.
BACKGROUND
Idiopathic facial palsy, also called Bells 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; Valena 2001). Its cause is
not known (Peitersen 2002). Increasing evidence suggests that the
main cause of Bells palsy is reactivation of latent herpes simplex
virus type 1 in the cranial nerve ganglia (De Diego 1999; Holland
2004; Valena 2001). How the virus damages the facial nerve is
uncertain (Gilden 2004).
The annual incidence of Bells 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; Gonalvez 1997).
Bells 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 complete recovery. The main question is whether results would be better if some treatment were given.
About 23% of people with Bells palsy are left with either moderate 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% (Valena 2001).
The prognosis depends to a great extent on the time at which recovery begins. Early recovery gives a good prognosis and late recovery 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 tearing 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 include 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 principles 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 production. Lubricating drops are recommended during the day and
a simple eye ointment at night (Holland 2004; Valena 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 acyclovir. Hato 2007 assessed the efficacy of valacyclovir with 296 participants 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 considered, 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.
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 Bells 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 compared 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 working on physical principles. Types of physical therapy interventions 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 massage, alone or in combination with any other therapy.
Types of outcome measures
METHODS
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 dysfunction) 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.
Criteria for considering studies for this review
Search methods for identification of studies
Types of studies
We searched the Cochrane Neuromuscular Disease Group Trials Register in February 2008 using the terms Bells palsy or
idiopathic facial paralysis or facial palsy. We also searched the
Cochrane Central Register of Controlled Trials (The Cochrane
Library, Issue 4, 2007), MEDLINE (January 1966 to February
Peitersen 2002 also highlighted the lack of evidence for current

treatments, for thermal methods (conductive, radiative and convective heat transfer in order to achieve vasodilatation or ice over
the mastoid region with the aim of relieving oedema), electrotherapy, massage and facial exercise.
OBJECTIVES
The objective of this systematic review was to evaluate the efficacy
of physical therapies for Bells palsy (idiopathic facial palsy).
We included all randomised or quasi-randomised (alternate or

other systematic allocation) controlled trials involving any physical

2008), EMBASE (January 1980 to February 2008), LILACS (January 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. Disagreements about inclusion criteria were resolved by consensus and consultation with a third author (BGOS).
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 fixedeffect 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 outcomes, weighted mean differences (WMD) between groups were
estimated.
Heterogeneity was assessed by the chi-squared test and was assumed 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 characteristics of the included studies. A sensitivity analysis was performed, 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 disability (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.
RESULTS
Description of studies
Assessment of methodological quality
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. 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. Disagreement between the authors was resolved by discussion if necessary
with a third author (BGOS).
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, EMBASE = 23, CINAHL = 6, LILACS = 3; PEDro = 11 and handsearching = 2), (see Figure 1). Some studies were found in more
than one database. Of these, six trials met the inclusion criteria (Beurskens 2003; Flores 1998; Manikandan 2007; Mosforth
1958; Wang 2004; Wen 2004). Eight other studies, all in Chinese,
await translation and assessment.
Excluded studies
Data extraction
Two authors independently extracted data on participants, methods, interventions, outcomes and results using a specially constructed data extraction form. Missing data were obtained from
the trial authors whenever possible.
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 trials 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 Bells palsy of less than 14 days duration. Three participants were lost to follow up. Auto-massage of the face, infrared
and interrupted galvanic stimulation (pulse 100 msec) in 44 participants, was compared to massage alone in 42 participants. Treatment was continued until recovery or until the condition seemed
stationary (two to six months). The outcomes were electrical examination 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 interventions. 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 electrotherapy 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 Bells
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, clinical 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 corticosteroids 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 Facial 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. However, the samples were composed of 16 and 18 individuals with
Bells 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 combination of conventional therapy plus facial rehabilitation exercises
(movements using facial muscles) while 60 participants received
only conventional therapy not detailed in the translation process. This Chinese study presented the following outcomes analysed 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 Bells palsy with two different 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 electrostimulation could have been used but blinding to exercise interventions is impractical or impossible. Blinding of outcome assessors 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 participants. 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 baseline 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 Bells palsy) at this time. Mosforth did not analyse all the
people after one year because they were discharged when recovered. Despite this, our analyses were not affected. The data of interest (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 allocation groups. The reasons described were that the participants requested another medication or they had not adhered to the treatment. 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 intention-to-treat analysis and less than 75% recovery was considered
a bad outcome. The relative rate of improvement was not significantly 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 continuous scale. The Facial Grade Score measured rest score, synkinesis 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 without 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 respect 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 synkinesis 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 axonal 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 lesions proximal to the chorda tympani (n = 47) there was no significant 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 participants 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.
(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 severe disease. There was no difference in the proportion of participants that improved in the exercise group and conventional therapy 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.
FACIAL EXERCISES
Primary outcome measure
DISCUSSION
Beurskens 2003 included only 34 participants with chronic (more

than nine months) Bells 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 functional exercises (n = 43). The single outcome was facial muscle
function (Potmann Score) after one month. It showed a statistically significant difference in favour of the functional exercise
group, MD 8.47, 95% CI 7.05 to 9.89. .
In the light of the numerous physical therapies used for treating

Bells palsy in daily practice, this review highlights the lack of high
quality evidence to support the use of these strategies. Electrotherapy, exercises, biofeedback, manual therapy and laser were evaluated in some studies, but only trials involving electrostimulation
and exercise had the minimum methodological quality to be considered for this systematic review.
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 improvements in favour of the exercise group: Facial Grading Scale
WMD 20.40, 95% CI 8.74 to 32.04; Facial Disability Index Physical 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.
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 agreement 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 studying chronic cases found differences in the proportion recovering
after three and six months. Significantly less synkinesis was observed 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 considered in future research.
In the electrical stimulation trials Flores 1998 compared electrostimulation 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 compared combinations of physiotherapy and medicine with functional exercises which complicated interpretation.
The main outcomes used were continuous scales of motor function. In another publication Beurskens 2004b discussed the outcomes of applying exercise to treat facial paresis. He observed a
significant recovery in the outcomes in participants receiving exercise for palsies lasting more than nine months: asymmetry in the
face at rest, asymmetry during voluntary facial movements, synkineses, complaints concerning pain, stiffness, involuntary movements, reports concerning difficulties in eating, drinking, speaking, and patient perception about their quality of life. Although
the House-Brackmann score was used as an overall measure of facial 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 Disability Index (VanSwearingen 1996) were considered good assessment options.
We would have preferred to convert continuous data into dichotomous data. For example, for recent Bells palsy we expect a minimum 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 improvement valuable.
In subgroups with severe dysfunction, complications or sequelae were the clinical outcomes considered. Peitersen 2002 reported that out of more than 2500 people with facial paralysis,
29% had persistent weakness, 17% contracture and 16% synkinesis. 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 continuous 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 differences emerged between the groups treated with physical therapy and other treatment (prednisone or other medication). The
time to improvement seemed to be shorter in participants receiving 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 .
AUTHORS CONCLUSIONS
Implications for practice
There is no evidence of significant benefit or harm from the limited
trials of electrical stimulation or facial exercises for Bells palsy.
Implications for research

There is a need for well-designed, randomised trials of electrical
stimulation, exercise and other physical therapies for Bells palsy.
Reports of such trials should give details of the treatments given
including dose and duration. Outcome measures should be selected which are likely to be adequately responsive for detecting
change with physical therapies. Measures should include facial appearance, function (eating and drinking and speaking), facial appearance (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.
ACKNOWLEDGEMENTS
The staff of the Brazilian Cochrane Centre, Cochrane Neuromuscular Desease Group, Dr David Allen for his important contribution reviewing the protocol and a special thanks to Professor Richard Hughes for all the comments during all the editorial 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.

REFERENCES
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):17783.
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):67781.
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):103742.
Flores 1998 {published data only}
Flores PF, Medina RZ, Haro LG. Idiopathic peripheral
facial paralysis treatment physic therapy versus prednisone
[Tratamiento de la parlisis facial perifrica idioptica:
terapia fsica versus prednisona]. Revista mdica del Instituto
Mexicano del Seguro Social 1998;36(3):21721.
Manikandan 2007 {published and unpublished data}
Manikandan N. Effect of facial neuromuscular reeducation on facial symmetry in patients with Bells palsy: a
randomized controlled trial. Clinical Rehabilitation 2007;
21(4):33843.
Mosforth 1958 {published data only}
Mosforth J, Taverner D. Physiotherapy for Bells palsy.
British Medical Journal 1958;2(5097):6757.
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 Clinical
Virology] 2004;8(4):6167.
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):24467.
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 Psikhiatrii
Imeni S. S. Korsakova 1973;73(3):34550.
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):6774.
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. Pr-fono 2004;16(2):1518.
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 of
Therapy and Rehabilitation 2004;11(5):20610.
Brach 1999 {published data only}
Brach JS, VanSwearingen JM. Physical therapy for facial
paralysis: a tailored treatment approach. Physical Therapy
1999;79(4):397404.
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):
18390.
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):
1399403.
Coulson 2006 {published data only}
Coulson SE, Adams RD, ODwyer NJ, Croxson GR.
Physiotherapy rehabilitation of the smile after longterm facial nerve palsy using video self-modeling and
implementation intentions. Otolaryngology - Head and Neck
Surgery 2006;134(1):4855.
Coulson 2006b {published data only}
Coulson SE, Adams RD, ODwyer NJ, Croxson GR. Use
of video self-modelling and implementation intentions
following facial nerve paralysis. International Journal of
Therapy and Rehabilitation 2006;13(1):305.
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):5348.
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):80915.
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):1606.
Dubravica 1996 {published data only}
Dubravica M, Musura M, Nesek-Madaric V, StajnerKatusic S, Horga D. Treatment of facial palsy by EMG

biofeedback technique - Muscle relaxation technique. Acta

Clinica Croatica 1996;35(1-2):1720.
Goulart 2002 {published data only}
Goulart F, Vasconcelos KSS, Souza MRV, Pontes PB.
Physical therapy for facial paralysis using the biofeedback [A
utilizao do biofeedback no tratamento da paralisia facial
perifrica]. Acta Fisitrica 2002;9(3):13440.
Klingler 1982 {published data only}
Klingler D, Bibl D. Peripheral facial paralysis-role of early
onset of therapy. Wiener Medizinische Wochenschrift 1982;
132:14953.
Koyama 2005 {unpublished data only}
Koyama S, Okada K, Yamakawa T, Kubo M, Amatsu H.
The usefulness of manipulative physiotherapy in treating
bells palsy. Medical Journal of Minami Osaka Hospital 2005;
53(1):557.
Lobzin 1989 {unpublished data only}
Lobzin VS, Smetankin AA, Tsatskina ND, Iashin NS.

Treatment of Bells palsy by using portable biofeedback
devices. Zhurnal Nevropatologii i Psikhiatrii Imeni S. S.
Korsakova 1989;89(10):5762.
Lobzin VS, Tsatskina ND. The adaptive biological control
system with electromyographic feedback in the treatment of
Bells palsy [Russian]. Zhurnal Nevropatologii i Psikhiatrii
Imeni S. S. Korsakova 1989;89(5):547.
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):1437.
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):1315.
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):53943.
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):1668.
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):74450.
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):14953.
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):1438.
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):21720.
Taverner 1966 {published data only}
Taverner D, Fearnley ME, Kemble F, Miles DW, Peiris OA.
Prevention of denervation in Bells palsy. British Medical
Journal 1966;5484:3913.
Zhao 2005 {published data only}
Zhao Y, He L, Zhang QH. Effectiveness of three different
treatments for peripheral facial paralysis. Chinese Journal of
Clinical Rehabilitation 2005;9(29):413.
References to studies awaiting assessment

Diao 2002 {published data only}
Diao L, et al.Comparison of the efficacy between
acupuncture and manipulation for Bells palsy. Journal of
Huaihua Medical College 2002;1(2):345.
Guo 2006 {published data only}
Guo QH, Yan JZ, Yan WS, Xiao MZ. Observation on noninvasive electrode pulse electric stimulation for treatment of
Bells palsy. Zhongguo Zhenjiu 2006;26(12):8578.
Li 2005 {published data only}
Li J. Comparison the efficacy between acupuncture and
manipulation for Bells palsy. Chinese Clinical Medicine
Research 2005;11(12):17156.
Pan 2004 {published data only}
Pan L. Acupuncture plus short wave for 38 peripheral facial
paralysis. Journal of Clinical Acupuncture & Moxibustion
2004;20(4):267.
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):5457.
Wang 2004b {published data only}
Wang XH, Zhang LM, Han M, Zhang KQ, Jiang JJ.
Treatment of Bells palsy with combination of traditional
Chinese medicine and western medicine. Hua xi kou qiang
yi xue za zhi [West China Journal of Stomatology Stomatology]
2004;22(3):2113.
Yang 2001 {published data only}
Yang G. Comparison of the efficacy between acupuncture
and therapy apparatus for Bells palsy. Journal of Clinical
Acupuncture & Moxibustion 2001;17(8):289.
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):10378.
Additional references

10
Adour 1982
Adour KK. Current concepts in neurology: diagnosis and
management of facial paralysis. The New England Journal of
Medicine 1982;307(6):34851.
Adour 2002
Adour KK. Decompression for Bells palsy: why I dont do
it. European Archives of Otorhinolaryngology 2002;259(1):
407.
Allen 2004
Allen D, Dunn L. Aciclovir or valaciclovir for Bells 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. Journal
of the Japanese Physical Therapy Association 2004;7:359.
Beurskens 2004b
Beurskens CHG, Heymans PG. Physiotherapy in patients
with facial nerve paresis: description of outcomes. American
Journal of Otolaryngology 2004;25(6):394400.
Bell s palsy: a multicenter, randomized, placebo-controlled

study. Otology and Neurotology 2007;28:40813.
He 2007
He L, Zhou MK, Zhou D, Wu B, Li N, Kong SY, et
al.Acupuncture for Bells palsy. Cochrane Database of
Systematic Reviews 2007, Issue 4.[Art. No.: CD002914.
DOI: 10.1002/14651858.CD002914.pub3]
Holland 2004
Holland NJ, Weiner GM. Recent developments in Bells
palsy. BMJ 2004;329(7465):5537.
House 1985
House JW, Brackmann DE. Facial nerve grading system.
Otolaryngology--Head and Neck Surgery 1985;93(2):1467.
Peitersen 2002
Peitersen E. Bells Palsy: the spontaneous course of 2500
peripheral facial nerve palsies of different etiologies. Acta
Oto-Laryngologica. Supplementum 2002;549:430.
Quinn 2003
Quinn R, Cramp F. The efficacy of electrotherapy for Bells
palsy: a systematic review. Physical Therapy Reviews 2003;8:
15164.
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 Bells palsy. European Archives of
Otorhinolaryngology 1999;256(10):5202.
Roos 1996
Ross BG, Fradet G, Nedzelski JM. Development of a
sensitive clinical facial grading system. Otolaryngology Head
and Neck Surgery 1996;114:3806.
De Diego 1999
De Diego JI, Prim MP, Madero R, Gaviln J. Seasonal
patterns of idiopathic facial paralysis: a 16-year study.
Otolaryngology and Head and Neck Surgery 1999;120(2):
26971.
Salinas 2004
Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bells
palsy (idiopathic facial paralysis). Cochrane Database of
Systematic Reviews 2004, Issue 4.[Art. No.: CD001942.
DOI: 10.1002/14651858.CD001942.pub3]
Gilden 2004
Gilden DH. Clinical Practice. Bells palsy. The New England
Journal of Medicine 2004;351(13):132331.
Sullivan 2007
Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith
BH, McKinstry B, et al.Early treatment with prednisolone
or acyclovir in Bells palsy. New England Journal of Medicine
2007;357(16):1598607.
Gonalvez 1997
Gonalvez-Colho TD, Pinheiro CN, Ferraz EV, AlonsoNieto JL. Clusters of Bells palsy. Arquivos de NeuroPsiquiatria 1997;55(4):7227.
Grogan 2001
Grogan PM, Gronseth GS. Practice parameter: steroids,
acyclovir and surgery for Bells palsy (an evidence based
review): report of the Quality Standards Subcommittee of
the American Academy of Neurology. Neurology 2001;56
(7):8306.
Hato 2007
Hato N, Yamada H, Kohno H, Matsumoto S, Honda N,
Gyo K, et al.Valacyclovir and prednisolone treatment for
Valena 2001
Valena MM, Valena LP, Lima MC. Idiopathic facial
paralysis (Bells palsy): a study of 180 patients [Paralisia
facial perifrica idioptica de Bell]. Arquivos de NeuroPsiquiatria 2001;59(3-B):7339.
VanSwearingen 1996
VanSwearingen J, Brach J. The Facial Disability Index:
reliability and validity of a disability assessment instrument
for disorders of the facial neuromuscular system. Physical
Therapy 1996;76(12):128898.
Indicates the major publication for the study

11
CHARACTERISTICS OF STUDIES
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

12
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 Fsica y Rehabilitacion Department, Hospital General Regional Num 1, Culiacn,
Sinaloa, Mxico.
Participants
N = 149
Diagnosis: acute Bells 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 authors answer about details of the study
Risk of bias
Item
Authors judgement
Description
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.

13
Manikandan 2007
(Continued)
Participants
N = 59 participants.
Diagnosis: unilateral Bells 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
Item
Authors judgement
Description
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 Bells 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.

14
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
Item
Authors judgement
Description
Yes
A - Adequate. A prepared list.
Wang 2004
Methods
Blinding: no.
Analysis: Improvement Index = (Scores After Treatment - Scores Before Treatment)/ Scores After Treatment
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 Bells 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.

15
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
Item
Authors judgement
Description
Yes
A - Adequate. Randomised numbers by the computer.
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

16
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
Item
Authors judgement
Description
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

17
(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

18
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
Participants
Not known
Interventions
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 Bells 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.

19
Pan 2004
Methods
Not known
Participants
Not known
Interventions
Not known
Outcomes
Not known
Notes
Not known
Qu 2005
Methods
Not known
Participants
Not known
Interventions
Not known
Outcomes
Not known
Notes
Not known
Wang 2004b
Methods
Not known
Participants
Not known
Interventions
Not known
Outcomes
Not known
Notes
Not known
Yang 2001
Methods
Not known
Participants
Not known
Interventions
Not known
Outcomes
Not known
Notes
Not known

20
Zhang 2005
Methods
Not known
Participants
Not known
Interventions
Not known
Outcomes
Not known
Notes
Not known

21
DATA AND ANALYSES
Comparison 1. ELECTROSTIMULATION VERSUS CONTROL
Outcome or subgroup title

1 Incomplete recovery after 6 and
12 months
1.1 6 months
1.2 12 months
2 Mean Facial Grading Scale after
3 months
2.1 Rest score
2.2 Movement score
2.3 Total score
No. of
studies
No. of
participants
Statistical method
Effect size
Risk Ratio (M-H, Random, 95% CI)
Totals not selected
1
1
1

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

Not estimable
Not estimable
Not estimable
Comparison 2. ELECTROSTIMULATION VERSUS PREDNISONE
Outcome or subgroup title

1 Incomplete recovery after six
months (all participants)
2 Incomplete recovery six months
according severity
2.1 Infrachordal lesion (mild
cases)
2.2 Suprachordal lesion
(severe cases)
3 Mean time to complete recovery
(in days)
3.1 Infrachordal lesion (mld
cases)
3.2 Suprachordal lesion
(severe cases)
No. of
studies
No. of
participants
Statistical method
Effect size
Risk Ratio (M-H, Fixed, 95% CI)
Totals not selected
Totals not selected
Not estimable
Not estimable
149
-8.38 [-13.99, -2.77]
102
-7.42 [-13.13, -1.71]
47
-33.94 [-63.40, -4.

48]

22

2008 Physical Therapy For Bell's Palsy (Idiopathic Facial Paralysis) (Review)

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Physical therapy for Bell s palsy (idiopathic facial paralysis)

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

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

Physical therapy for Bell s palsy (idiopathic facial paralysis)

PLAIN LANGUAGE SUMMARY

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

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

different combinations of prednisolone, acyclovir and placebo.

therapy compared with no treatment, placebo treatment, drug

The primary outcome measure was incomplete recovery six

Criteria for considering studies for this review

Search methods for identification of studies

Peitersen 2002 also highlighted the lack of evidence for current

We included all randomised or quasi-randomised (alternate or

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

Searching other resources

Data collection and analysis

See: Characteristics of included studies; Characteristics of excluded

Twenty seven studies were excluded because they were:

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

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

different groups according to whether the lesion was thought to

Risk of bias in included studies

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

Secure method of randomisation and allocation

Differences in baseline between groups

Primary outcome measure

Mosforth 1958 studied the efficacy of electrotherapy after six

Secondary outcome measures

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

(2) Incomplete recovery after one year

(3) Adverse effects attributable to the intervention such as

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

(3) Adverse effects attributable to the intervention such as

Primary outcome measure

Beurskens 2003 included only 34 participants with chronic (more

In the light of the numerous physical therapies used for treating

Secondary outcome measures

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

(2) Incomplete recovery after one year

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

Comments about the methodology

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

Implications for research

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

References to studies included in this review

Beurskens CHG, Heymans PG. Positive effects of mime

References to studies excluded from this review

Bernardes 2004 {published data only}

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

biofeedback technique - Muscle relaxation technique. Acta

Lobzin VS, Smetankin AA, Tsatskina ND, Iashin NS.

unilateral facial paralysis. Journal of Otolaryngology 1995;24

References to studies awaiting assessment

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

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

Indicates the major publication for the study

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

Characteristics of included studies [ordered by study ID]

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

C= Inadequate. A coin flip for the first participant

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

Blinding: not done.