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Neural mobilization in Bell’s palsy: A case report

Faizan Zaffar Kashoo, Mazen Alqahtani & Mehrunnisha Ahmad

To cite this article: Faizan Zaffar Kashoo, Mazen Alqahtani & Mehrunnisha Ahmad (2019): Neural
mobilization in Bell’s palsy: A case report, CRANIO®, DOI: 10.1080/08869634.2019.1610996

To link to this article: https://doi.org/10.1080/08869634.2019.1610996

Published online: 01 May 2019.

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CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2019.1610996

CASE REPORT

Neural mobilization in Bell’s palsy: A case report

a a b
Faizan Zaffar Kashoo MPTh , Mazen Alqahtani PhD and Mehrunnisha Ahmad MSc
a
Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Majmaah, Saudi Arabia; bDepartment of
Nursing, College of Applied Medical Sciences, Majmaah University, Majmaah, Saudi Arabia

ABSTRACT KEYWORDS
Background: Bell’s palsy (BP) is a sudden onset of signs and symptoms of facial nerve dysfunc- Bell’s palsy; physical therapy
tion. The treatment of choice is corticosteroids and antiviral drugs. These drugs are risky for modalities; facial palsy; case
individuals with pre-existing conditions such as diabetes, high blood pressure, and digestive report; acute facial
disturbances. Therefore, a beneficial complementary therapy would add to the success of neuropathy; idiopathic facial
paralyses
treatment.
Clinical Presentation: A 42-year-old male presented with left side facial paralysis and asymmetry.
The patient received neural mobilization along with routine physical therapy for 1 hour, 5 days
a week, for 3 weeks. A follow-up was scheduled at the 8th week.
Clinical Relevance: Neural mobilization technique of the facial nerve is a novel and safe addition
to the conservative treatment of BP.

Introduction the effects of facial nerve mobilization in BP and to act

as a pilot reference for a large-scale randomized con-
Bell’s palsy (BP) is a dysfunction of the facial nerve
trolled trial.
affecting muscles of facial expression [1]. BP accounts
for 80% of total facial mono-neuropathies affecting
12–13 people per 100,000 each year [2]. The cause of BP Case presentation
remains unknown; however, possible triggers of inflam-
The Department of Neurology referred a case of BP
mation of the facial nerves could include relapse of latent
(42-year old male patient with left-side facial asymme-
herpes virus in the facial nerve ganglion, traumatic injury,
try) to the Physical Therapy Department. The signs
exposure to cold, and surgery in the vicinity [3]. The signs
and symptoms appeared before 24 hours and the
and symptoms of BP appear suddenly within a few hours,
patient reported a sudden ear pain of 5 on a visual
resulting in unilateral facial weakness, dropped eyebrow,
analog scale (VAS). Evaluation of medical history
deviation of angle of the mouth, and the disappearance of
revealed no significant medical ailments like diabetes
the nasolabial fold. Most of the patients exhibit vestibular
or high blood pressure and no history of recent viral,
symptoms and numbness before exhibiting full-fledged
trauma, surgery, or any other systemic infection.
BP. Physical therapy assessment of the patient is per-
Examination by a neurologist revealed complete
formed by visual inspection of facial symmetry, facial
paralysis of facial muscles with normal external audi-
expression, and grading of facial muscle paralysis by the
tory canal and eardrum. Facial muscle examination
Modified House-Brackmann scale (MHBS). MHBS is
revealed facial muscle paralysis on the left side with
a valid and reliable tool to measure the recovery level in
House-Brackman grade IV, unable to raise an eyebrow,
BP [4].
unable to close the eye, and drooping of the angle of
Neural mobilization technique is a new therapeutic
the mouth. Myotome and dermatomal examination of
modality in physical therapy [5] aimed at regaining the
the head and neck were normal. Laboratory investiga-
lost neuromuscular mobility after an injury, mostly
tions, such as sugar level and thyroid function, were all
used in peripheral spinal nerve injuries. Neural mobi-
within normal limits, and radiological imaging, e.g.,
lization has never been tried on the facial nerve before.
MRI, was normal.
Therefore, the aim of this case study is to investigate

CONTACT Faizan Zaffar Kashoo f.kashoo@mu.edu.sa Department of Physical Therapy and Health Rehabilitation, College of Applied Medical
Sciences, Majmaah University, Majmaah 11952, Saudi Arabia
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ycra.
© 2019 Taylor & Francis Group, LLC
2 F. Z. KASHOO ET AL.
All the treatment sessions were scheduled in the
morning, and after a thorough examination, formal
consent about the treatment and agreement on the
publication of the picture was obtained from the
patient. The first treatment session started on
the second day of the onset of BP and continued for
the next 15 sessions for 3 weeks. Each treatment ses-
sion lasted for 1 hour (Figure 1). Physical therapy
sessions consisted of the following modalities used in
the previous studies on similar issues [6–8]:
(1) Massage therapy consisting of tapping, effleu-
rage, and finger and thumb kneading for
15–16 minutes.
(2) Faradic electrical stimulation with anode elec-
trode at the back of the neck and cathode over
the nerve trunk anterior to the earlobe. The
cathodic pen electrode was used to locate the
facial nerve trunk for stimulation manually.
(Biphasic current, pulse time 300 ms, frequency
60 Hz, 20 contractions, Rest 10 s). The total
treatment time was 15 minutes.
(3) Exercises in front of the mirror, like raising the
eyebrow, clenching the teeth (patient trying to
see his clenched teeth in the mirror), smiling,
and performing other facial expressions for
12–15 minutes.
(4) Neural mobilization was applied by gently hold-
ing the lower part of the ear between the index
Figure 1. A, B, C represent the facial status at the beginning, and D, E, F represent the facial status after 15 sessions of treatment.
finger and thumb. The thumb was placed at the
opening of the external auditory meatus and the
index finger placed behind the auricle of the ear
(Figure 2). The intensity of auricular traction
was determined by the patient reporting the
level of discomfort. The patient tolerated 3–4
sets of gentle horizontal traction and circular
movement 25 times each with 5 s rest.
(5) The same physiotherapist provided all treat-
ments for 15 sessions of the treatment.
On the second day, physiotherapy intervention started;
this consisted of electrical stimulation, massage, exer-
cises, and neural mobilization. There were a total of 15
interventions over a period of 3 weeks and a follow-up
at the 8th week. Ear pain assessed by Visual Analog
Scale was reduced to 3 within 48 hours of treatment.
Pharmacological therapy included oral prednisolone
1mg/kg/day for 11 days and oral acyclovir and valacy-
clovir 450 gm/Day X 11 days. On the 15th treatment
session, the patient had improved to Grade I on MHBS
(Figure 1). No adverse reaction was reported to the
treatment described above. On the 8th week, the fol-
low-up examination revealed significant facial symme-
try and function.
Four age-matched retrospective control subjects
were retrieved from the archives of the hospital admin-
istration section. Telephonic consent was obtained to
use the information from the patients’ medical records.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Figure 2. Neural mobilization technique for facial nerve.
Discussion
BP leads to spontaneous recovery in 70% of patients,
and the remaining 30% suffer from severe residual
effects [9]. Facial nerve paralysis leads to social inhibi-
tion of affected patients and affects the quality of life
[10]. The primary drug of choice is the immediate use
of steroids in 90% of cases. Although limited use of
steroids is beneficial, repeated use may cause multiple
organ damage [11]; the reliance upon steroids man-
dates an alternative treatment regime that is safe and
effective without any residual effects. Causation of BP
remains a mystery; therefore, the treatment is sympto-
matic and is intended to reduce the inflammation of
the 7th cranial nerve. The Otolaryngology organization
in America recommended a 10 days steroid course
within 1–2 days of onset. So far, no recommendation
has been proposed or supported by the American
Academy of Neurology to use oral antiviral drug ther-
apy. Nevertheless, the combination of steroids and
antiviral drugs is recommended [12]. However, the
use of steroids becomes risky among the geriatric
population with co-morbid conditions such as diabetes
mellitus, high blood pressure, and the use of multiple
medications. Therefore, the clinician needs to find an
alternative therapy with minimum to no side effects.
Moreover, the other dimension of patient rehabilitation
is a psychosocial aspect, which is ignored in drug
therapies. Patients with BP suffer from associated anxi-
ety and depression due to facial disfigurement, and
such issues can only be resolved by human touch,
encouragement, and counseling. The process of recov-
ery from BP takes 3–4 weeks [13]. During the acute
3
phase of the disease, timely physical therapy becomes
crucial to prevent disuse atrophy of facial muscles.
Modalities such as electrical stimulation and massage
help retain the physiological properties of facial mus-
cles until the patient recovers from the disease.
Moreover, muscle strength, flexibility, and disuse atro-
phy are prevented through exercises performed in front
of the mirror [14].
Neural mobilization of the facial nerve has not
been tried on patients with BP. In this case study,
the patient was treated with conventional therapy and
neural mobilization for 5 days a week for 3 weeks.
The patient had shown a rapid recovery (Grade
I House Brackman) at the end of the treatment ses-
sion, and the recovery was retained on the follow-up
(8th week). Based on the course of the nerve existing
from the stylomastoid foramen and its branches in
the parotid gland, the facial nerve can be gently
mobilized by providing horizontal traction and circu-
lar manipulations at the base of the ear. The two
neural mobilization techniques used were discussed
with a group of experienced pioneers in the field of
neural mobilization. Based on their recommendation,
the horizontal traction and circular manipulations
were chosen to be suitable and safe to use. The
therapist responsible for performing neural mobiliza-
tion on the experimental case made a video demon-
strating the technique shown to the experts for any
further modification needed in technique, manual
contact, and position of the patient. In recent years,
a substantial number of research publications relating
to neural mobilization and its effect upon peripheral
and spinal nerves have supported this technique
[15,16]. However, a bit of skill and training is essen-
tial to execute the technique safely and in an effective
manner. A variety of physical therapy modalities are
available for BP, such as Kinesio-taping, Biofeedback,
transcutaneous electrical nerve stimulation, and acu-
puncture [17]. However, most of these modalities
lack strong scientific proof [18].
The patient treated with neural mobilization made
a complete recovery within 15 days of onset of the
disorder without any residual side effects noted upon
follow-up at the 8th week, suggesting an additive or
synergistic effect of neural mobilization. The duration
of recovery was rapid, as compared to the age-matched
control group (Table 1). However, the data is insuffi-
cient to make a definitive conclusion.
Limitations
(1) It cannot be concluded that spontaneous recovery
was due only to the use of neural mobilization, but
4 F. Z. KASHOO ET AL.

Table 1. Summary of cases.

(Grading on Home Duration of Difference between the
Side Grading on Home Brackman Brackman scale (At the Age/ recovery days to recover
Group Case involved scale (Initial Assessment) End) Gender (Days) completely
Control Group Case 1 Left IV I 41/M 28 26 (mean)
Case 2 Left IV I 40/M 27
Case 3 Left IV I 43/M 29
Case 4 Left III I 40/M 20
Experimental case Case Left IV I 42/M 15 15

possibly to the natural recovery process with the
addition of the entire physical therapeutic para-
digm that was administered to the patient.
(2) There is a lack of a scientifically-proven protocol
related to the application of neural mobilization
for facial nerves.
(3) A large-scale randomized controlled study is
needed to conclude that the improvement in
Bell’s palsy is due to neural mobilization.
Conclusion
Neural mobilization in combination with conventional
physiotherapy treatment is a new and promising com-
plementary therapy for acute care in BP. The rapid and
complete recovery of the experimental case with neural
mobilization mandates a large-scale randomized con-
trolled trial.
Funding
The Authors would like to thank Deanship of Scientific
Research at Majmaah University, AlMajmaah, 11952, Saudi
Arabia for supporting this work under the Project Number.
1440-98.
Conflict of Interest
The authors declare no conflict of interest.
ORCID
Faizan Zaffar Kashoo MPTh http://orcid.org/0000-0002-
8272-674X
Mazen Alqahtani PhD http://orcid.org/0000-0003-2006-
9032
Mehrunnisha Ahmad MSc http://orcid.org/0000-0002-
5729-2919
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