Should physical therapy be prescribed for Bell's palsy?

Physical Therapy for Bell's Palsy

Physical therapy should not be routinely prescribed as a first-line treatment for Bell's palsy, but may be considered for patients with more severe paralysis or those with incomplete recovery after 3 months. 1, 2

Initial Management Priorities

The evidence-based management of Bell's palsy should follow this algorithm:

1. First-line treatment: Oral corticosteroids

   • Prednisone 60-80mg daily for 7 days with taper, started within 72 hours of symptom onset 1
   • Improves recovery rates from 70% (no treatment) to 94% (with steroids) 1

2. Optional additional treatment: Antiviral therapy

   • May be offered in addition to steroids within 72 hours of symptom onset 3
   • Examples: valacyclovir 1g three times daily for 7 days or acyclovir 400mg five times daily for 10 days 2
   • Evidence for benefit is mixed, with only a small potential improvement in facial nerve function 3, 1

3. Mandatory eye protection for patients with impaired eye closure 3, 1

   • Artificial tears, lubricating ophthalmic drops/ointments
   • Eye patching or taping
   • Moisture chambers
   • Sunglasses for daytime protection

Role of Physical Therapy

Physical therapy is not mentioned as a primary treatment in the American Academy of Otolaryngology-Head and Neck Surgery guidelines 3. However, it may be beneficial in specific circumstances:

• For patients with more severe paralysis 2
• For patients with chronic facial paralysis to maintain range of motion and prevent contractures 1
• As part of a comprehensive management plan for those with incomplete recovery after 3 months 1

Follow-up and Monitoring

1. Assessment of recovery:

   • Use the House-Brackmann scale to quantify facial nerve function 1
   • Most patients recover spontaneously within 3 weeks to 3 months 2, 4

2. Referral criteria to a facial nerve specialist:

   • New or worsening neurologic findings
   • Ocular symptoms
   • Incomplete facial recovery after 3 months 1

Important Considerations

• Prognosis: More than two-thirds of patients with typical Bell's palsy have complete spontaneous recovery 2
• Special populations: Children and pregnant women have higher natural recovery rates (up to 90%) 1, 2
• Contraindications to steroids: Diabetes, morbid obesity, and previous steroid intolerance 3, 1

Potential Complications

• Short-term: Incomplete eyelid closure with resultant dry eye 4
• Long-term: Permanent facial weakness with muscle contractures 4
• Psychological impact: Social distress and isolation due to facial asymmetry 1

Clinical Pearl

While physical therapy may have a role in Bell's palsy management, the evidence supporting its routine use is limited. Focus on early corticosteroid administration (within 72 hours) as this has the strongest evidence for improving outcomes and reducing the time to recovery 1, 5.