What is the recommended treatment for the rehabilitation of Bell's (Bell's) palsy?

Rehabilitation of Bell's Palsy

Primary Medical Treatment

Oral corticosteroids are the cornerstone of Bell's palsy treatment and must be initiated within 72 hours of symptom onset for patients 16 years and older, with prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days followed by a 5-day taper. 1, 2

The evidence for corticosteroids is compelling:

• 83% recovery at 3 months with prednisolone versus 63.6% with placebo 1, 2, 3
• 94.4% recovery at 9 months with prednisolone versus 81.6% with placebo 1, 2, 3
• Treatment benefit diminishes significantly after the 72-hour window 2, 4

Do not prescribe antiviral therapy alone—it is ineffective. 1, 2 However, you may offer combination therapy (oral corticosteroids plus antivirals like valacyclovir 1g three times daily for 7 days) within 72 hours, as some evidence suggests marginally higher recovery rates (96.5% versus 89.7% with steroids alone), though the additional benefit is small. 2, 5

Eye Protection Protocol (Critical for All Patients)

Implement aggressive eye protection immediately for any patient with impaired eye closure to prevent corneal damage. 2

Daytime Protection:

• Lubricating ophthalmic drops applied frequently throughout the day 2
• Sunglasses for outdoor protection against particles and irritants 2

Nighttime Protection:

• Ophthalmic ointments for superior moisture retention 2
• Moisture chambers using polyethylene covers 2
• Eye patching or taping (with careful instruction on proper technique to avoid corneal abrasion) 2

Severe Cases Requiring Urgent Ophthalmology Referral:

• Eye pain, vision changes, redness, discharge, or foreign body sensation 2
• Persistent lagophthalmos beyond 3 months may require surgical interventions (tarsorrhaphy, eyelid weight implantation, or botulinum toxin injections) 2

Physical Therapy and Rehabilitation Modalities

Physical therapy may be offered to patients with more severe paralysis, particularly those developing synkinesis (involuntary co-contraction of facial muscles), though the evidence quality is limited. 2, 6, 5

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that no firm recommendation can be made regarding physical therapy effectiveness due to limited evidence consisting only of case series. 2 Despite this, clinical practice suggests potential benefit from:

• Facial exercises for patients with incomplete recovery 7
• Biofeedback training for synkinesis management 7
• Local superficial heat therapy and massage 7

Avoid electrical stimulation in the acute phase, as evidence for its benefit is lacking and it may theoretically worsen synkinesis. 7

Acupuncture cannot be recommended due to poor-quality trials and indeterminate benefit-to-harm ratio. 2

Follow-Up and Specialist Referral Algorithm

Mandatory reassessment or specialist referral is required for: 2

• Incomplete facial recovery at 3 months after symptom onset
• New or worsening neurologic findings at any point
• Development of ocular symptoms at any point

Most patients begin showing recovery within 2-3 weeks, with complete recovery typically occurring within 3-4 months. 2 Approximately 70% of patients with complete paralysis recover fully within 6 months, while those with incomplete paralysis have recovery rates up to 94%. 2

Special Population Considerations

Children:

• Have better prognosis with higher spontaneous recovery rates than adults 1, 2
• Evidence for corticosteroid benefit is inconclusive 1, 2
• Consider oral steroids on an individualized basis with caregiver involvement in decision-making 1

Pregnant Women:

• Treat with oral corticosteroids within 72 hours using individualized risk-benefit assessment 2
• Recovery rates approach 90% in this population 5

Long-Term Management for Incomplete Recovery

For the 30% of patients who develop permanent facial weakness: 2

Reconstructive Surgery Options:

• Static procedures: eyelid weights, brow lifts, static facial slings 2
• Dynamic procedures: dynamic facial slings, nerve transfers 2

Psychological Support:

• Address significant psychosocial dysfunction and diminished quality of life 2
• Screen for depression requiring specialist referral 2
• Recognize impaired social interaction due to difficulty expressing emotion 2

Critical Pitfalls to Avoid

• Delaying corticosteroid treatment beyond 72 hours eliminates the proven benefit 2, 4
• Prescribing antiviral monotherapy is ineffective and wastes resources 1, 2
• Inadequate eye protection can cause permanent corneal damage 2
• Failing to refer patients with incomplete recovery at 3 months delays access to reconstructive options 2
• Improper eye taping technique can cause corneal abrasion—provide careful instruction 2
• Ordering routine laboratory tests or imaging for typical Bell's palsy presentations is unnecessary 2