1.) For this patient, I would focus on education about natural history and that patients with Bell’s Palsy tend to get better with time. Beyond education, working to improve any limitations found due to disuse would be my primary aim. Although many of the studies in the systematic review were not great, they do point to some possibility of exercise therapy being helpful. Providing this patient with a series of facial exercises would be a safe and worthwhile HEP. I’m under the impression that Bell’s Palsy caries with it stress, anxiety, and depression. Providing the patient with a sense of control via exercise may work to quell some of these negative emotions
2.) With such a dearth of information, a systematic review may be less helpful. I immediately think back to the concept “n of 1”. Therefore, if unsatisfied with the systematic review, I would move to RCTs to glean more information. Also, when reading a Cochrane review, I think it’s important to consider that their conclusions often results in the need for additional research. This is not always helpful and can cause clinicians to throw the baby out with the bathwater. For example, Cochrane’s review of spinal manipulation for low back pain (acute and chronic) is that it is no better than other therapies and/or modalities. However, there is a litany of RCTs stating that, although it might not be the magic bullet, spinal manipulation may certainly be a piece of the puzzle. I believe the same applies to physical therapy for Bell’s Palsy.
3.) After addressing education, I would focus on a “treat what you see” approach. Your exam showed myofascial restrictions, decreased ROM, and strength deficits. Safely treat those areas based on the best available evidence, even if that evidence is limited. Hopefully, those treatments will work to assist in this individual’s natural history. They’ll likely get better on their own, but perhaps we can expedite the process.