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.

• This reply was modified 4 years, 1 month ago by Steven Lagasse.
• This reply was modified 4 years, 1 month ago by Steven Lagasse.

Before answering the questions, I’m curious:
At what point in this continuum did you see her?
Had she seen any improvements since her symptoms began?

1) I believe this case begins with a lot of education. She seems to have undergone the appropriate medical management (i.e. steroids, drops, screening) and is a few months into this process. Figuring out where she is at with this from an emotional standpoint and educating her about the prognosis would be at the top of my list. Clearly PT isn’t groundbreaking in this population, but it seems that exercise may have some positive outcomes. I would start with an HEP of some facial exercises to address weakness and self-massage due to her myofascial restrictions. I don’t think I would feel comfortable seeing this woman frequently in order to attempt 2-3 interventions that have weak evidence, but teaching her ways to use the function she has and potentially improve it on her own is valuable in my opinion. I would likely space appointments out to f/u in 1 week for review, and either biweekly or monthly to monitor symptoms and adjust the POC as necessary.

2) Given that the rate of improvement with natural history is so variable, and likely positive, I’m sure it is difficult to gather good data on this population. If I was seeing this patient, I would find this systematic review to be very helpful as it would teach me more about what the overall treatment options were, and a short summary of whether the interventions. My next move at this point would be to find lower-level research to find appropriate protocols and ideas for exercise progressions.

3) At the base, this pathology is like a peripheral nerve entrapment. Similarly, the outcomes of exercising the affected muscles may or may not be helpful, but in clinic I would apply my philosophy to attempt strengthening in order to gain what can be gained, and abandon it quickly if it didn’t produce results. Also, as mentioned before, I would make an effort to make treatment as home-based as possible so I am not wasting this patient’s resources on a less than stellar treatment.

1- With this stating there is no significant benefit or harm from e-stim and facial exercises it does leave me with the question of where to go from here and what I should use to guide my treatment of something I don’t have any experience to draw from. Those interventions would likely be my first thought just from learning from other clinician’s experience. This is kind of further answered in question 3 but in the absence of evidence to guide me using reasoning to draw from other similar treatment concepts may be where I go with this patient. Education is a low hanging fruit though and could go a long way in helping this patient better understand progression, treatment options, and expectations. I would be curious to see the incidence of those with Bell’s palsy that end up going to PT and specific patient or disease process characteristics that may be a common denominator.

2- I think it can be difficult to use a systematic review to completely guide treatment decision making in a more obscure pathology like this that may have such varied presentations, severity, and timeframe of resolution/improvement. Looking more in depth at some of the stronger studies and being able to analyze and reason through the studies specifics might better help guide treatment. With the systematic review I have a lot of questions about the different studies, such as- specifics of the interventions, characteristics of the patients, duration and severity of the pathology (to name a few).

3- With this being an inflammatory LMN lesion part of the treatment, as the introduction of this article pointed out, is time for the inflammatory process to decrease as well as nerve regrowth to occur. I think some treatment principles that can help guide are facilitating motor unit activation and reversing muscle atrophy and weakness. So a few concepts that go along with that are isolated/specific muscle and/or movement exercises and NMES, which are unfortunately the things that this SR shows poor evidence for.

She is a wizard, she came from the future! Just kidding, I’m assuming it started in 2019.

1) Given that the systematic review says that there is not evidence to show any benefit for physical therapy with Bell’s Palsy, what treatment choices would you make going forward with this patient?

The review showed that Wang 2004’s functional exercise group showed statistical differences compared to the control group in regards to fascial muscle function at 1 month using Potmann score which includes: frowning, eyes closing, and smiling which are all impairments for your patient.

Like the others have mentioned, I think education is a huge proponent for this patient not only to educate her but to also ease her mind and potentially decrease any anxiety.

2) Is a systematic review the most applicable level of evidence given this pathology?

I think it may be a good place to start and then delve deeper into articles which may peak my interest based on chronicity and patient characteristics.

3) Since there is weak evidence for interventions, what principles or concepts do you think apply from other body regions/practice in general that you would use to guide your treatment and POC?

Since this is similar to a paresis, I would most likely treat this similar to patients post-stroke. I would have my the patient not only perform interventions on affected side but also on the unaffected side in order to promote potential overflow. As far as POC is concerned, maybe a f/u in a week or two. Like the others mentioned I think I would create a home-based approach.

1) Given that the systematic review says that there is not evidence to show any benefit for physical therapy with Bell’s Palsy, what treatment choices would you make going forward with this patient?

I feel like education is a big piece for this patient, like everyone else has said. think educating this patient on the pathology and the typical prognosis, as well as how stress can affect her prognosis, will be helpful to improve her understanding of the situation.

2) Is a systematic review the most applicable level of evidence given this pathology?

I think the systematic review isn’t a bad place to start because it gives some basic background information with a pathology that I personally have no experience with, but I think looking at other sources, like RCTs or even case studies may have been helpful for a more specific question.

3) Since there is weak evidence for interventions, what principles or concepts do you think apply from other body regions/practice in general that you would use to guide your treatment and POC?

Again, I think education would be important for her, but then creating a POC and HEP centered around her goals, focusing on the whatever impairments were found, and ensuring that she has a good understanding that this may not be a quick process. I definitely think it’s hard when there isn’t wonderful evidence to support our normal strategies, and it’s even more difficult when it’s something we are less familiar with. I’m really interested to see how this case turns out!