Lasers Med Sci
DOI 10.1007/s10103-017-2195-9
ORIGINAL ARTICLE
Role of low-level laser therapy added to facial expression exercises
in patients with idiopathic facial (Bell’s) palsy
Banu Ordahan 1 & Ali yavuz Karahan 1
Received: 3 December 2016 / Accepted: 14 March 2017
# Springer-Verlag London 2017
Abstract The aim of the present study was to investigate the
efficacy of low-level laser therapy in conjunction with con-
ventional facial exercise treatment on functional outcomes
during the early recovery period in patients with facial paral-
ysis. Forty-six patients (mean age 41 ± 9.7 years; 40 women
and 6 men) were randomized into two groups. Patients in the
first group received low-level laser treatment as well as facial
exercise treatment, while patients in the second group partic-
ipated in facial exercise intervention alone. Laser treatment
was administered at a wavelength of 830 nm, output power
of 100 Mw, and frequency of 1 KHz using a gallium-
aluminum-arsenide (GaAIAs, infrared laser) diode laser. A
mean energy density of 10 J/cm2 was administered to eight
points of the affected side of the face three times per week, for
a total of 6 weeks. The rate of facial improvement was evalu-
ated using the facial disability index (FDI) before, 3 weeks
after, and 6 weeks after treatment. Friedman analysis of vari-
ance was performed to compare the data from the parameters
repeatedly measured in the inner-group analysis. Bonferroni
correction was performed to compare between groups as a
post hoc test if the variance analysis test result was significant.
To detect the group differences, the Bonferroni Student t test
was used. The Mann-Whitney U test was used to compare
numeric data between the groups. In the exercise group, al-
though no significant difference in FDI scores was noted be-
tween the start of treatment and week 3 (p < 0.05), significant
* Banu Ordahan
banuordahan@gmail.com
1
Department of Physical Medicine and Rehabilitation, Konya
Education and Training Hospital, Yazırmah, Selçuklu, Konya,
Turkey
improvement was observed at week 6 (p < 0.001). In the laser
group, significant improvement in FDI scores relative to base-
line was observed at 3 and 6 weeks (p < 0.001). Improvements
in FDI scores were significantly greater at weeks 3 and 6 in the
laser group than those in the exercise group (p < 0.05). Our
findings indicate that combined treatment with low-level laser
therapy (LLLT) and exercise therapy is associated with signif-
icant improvements in FDI when compared with exercise ther-
apy alone.
Keywords Facial nerve palsy . Low-level laser therapy .
Rehabilitation
Introduction
Idiopathic facial palsy is defined as generalized partial or
complete paralysis of the face [1]. Facial nerve paralysis
is associated with a variety of functional and esthetic is-
sues, as well as substantial impact on the social and psy-
chological status of affected patients [2]. Among the
known causes of facial nerve paralysis are genetic factors,
viral infections, autoimmune disease, trauma, tumors of
the head and neck, diabetes mellitus, and other inflamma-
tory diseases [3]. Idiopathic facial paralysis, also known
as Bell’s palsy (BP), is the most frequently encountered
type of peripheral facial paralysis. BP is an acute and self-
limiting form of inferior motor neuron paralysis that de-
velops due to nonsuppurative inflammation of the facial
nerve in the stylomastoid foramen [4, 5]. With an inci-
dence of 23 to 35 cases per 100,000, BP constitutes 60–
75% of cases of acute unilateral facial paralysis and is
most frequently observed in patients between 30 and
50 years of age [4].

Physical treatment modalities utilized for BP include
electrotherapy, massage, facial exercise, bio-feedback, and
electrical stimulation [4, 6]. A previous Cochrane analysis
reported that all facial exercises, electrical stimulation, or
other physical therapy studies related to BP had low quality.
Facial exercises can help to improve facial function, mainly
for people with moderate paralysis and chronic cases, and
early facial exercise may reduce recovery time and long-
term paralysis in acute cases, but the evidence for this is of
poor quality [4]. The aim of electrotherapy and exercise is
to increase the function of muscles and nerves, while ther-
mal methods and massage aim to reduce edema, increase
blood flow, and enhance oxygenation in affected tissue [7].
Laser therapy represents a non-invasive, pain-free method
of treatment for all patients with BP, including those who
cannot receive corticosteroids because of diabetes or hyper-
tension [8]. However, few studies have investigated the
efficacy of low-dose laser treatment in patients with BP
[9–11]. Therefore, the aim of the present study was to de-
termine the impact of efficacy of low-level laser therapy
(LLLT) in conjunction with conventional facial exercises
on functional outcomes during the early recovery period
in patients with facial paralysis. The null hypothesis for this
randomized study was that LLLT (830 nm wavelength,
100 Mw output power, and1 KHz frequency) would have
no effect on functional outcomes in patients with facial
paralysis.
Materials and methods
Patients
A total of 48 patients with unilateral Bell’s palsy (BP), who
had been admitted to Konya Research and Teaching Hospital,
were recruited for the present study, which was approved by
the local research ethics committee of Selçuk University’s
Faculty of Medicine (No: 276/2016). Two patients excluded
prior to the initiation of the study, following which 46 consec-
utive patients were enrolled. Patients with central nervous sys-
tem pathology and recurrent Bell’s palsy were excluded, and
the remaining patients were randomized into two groups.
Treatment for all the patients was initiated in the sub-acute
phase. No patients were lost to follow-up (Fig. 1). As diabetes
and cardiovascular diseases are common comorbidities in pa-
tients with BP, additional chronic diseases, history relevant to
these conditions was recorded along with patient characteris-
tics (age/sex/body mass index) (Table 1).
Power analysis
The number of patients included in the present study was
determined based on facial disability index (FDI) data.
Lasers Med Sci
According to results of Beurskens et al. [12], the mean
score of FDI in the group 1 was 68.6 with standard devi-
ation of 14.1. The mean score of FDI in the group 2 was
80.7 [12]. The sample size was based on a power of 80%
(beta 0.2), a dropout rate of 10%, and statistical signifi-
cance (alpha 0.05) of 95% (p = 0.05). Therefore, 23 pa-
tients were required in each group.
Randomization
Patients were randomized into two groups. Concealed al-
location was performed prior to initiation of the study,
using a computer-generated (SPSS Inc. Released 2007;
SPSS for Windows, Version 16.0., SPSS Inc., Chicago,
USA) randomized table of numbers, which was used to
generate block sizes and randomization schedules; physi-
cians remained blinded to these schedules; and all out-
come measures were collected by the same researcher.
Patients in the first group received LLLT as well as facial
exercise treatment, while patients in the second group
participated in the facial exercise intervention alone
(Fig. 1). All patients provided written informed consent
before treatment.
Evaluation of facial recovery
The FDI is the most frequently used index for the assessment
of the severity and progression of BP. Function is assessed
according to ten items related to social and physical activities
(chewing, swallowing, speaking, communication, mouth
movements, mood change, social integration, etc.), with a
total possible score of 100 [1, 13]. Higher scores indicate
greater improvement in function. Patients were assessed be-
fore, 3 weeks after, and 6 weeks after treatment.
Low-level laser therapy
Laser treatment was administered at a wavelength of
830 nm, output power of 100 Mw, and frequency of
1 KHz using a gallium-aluminum-arsenide (GaAIAs, in-
frared laser) diode laser (Chattanooga, Mexico, USA). A
mean energy density of 10 J/cm2 was administered to
eight points of the affected side for 2 min at each point;
in all the cases, the laser was in direct contact with the
superficial roots of the facial nerve on the affected side
(Fig. 2) [9]. The total energy delivered to the patient dur-
ing one session was 80 J. Laser treatment was performed
for three sessions per week, over a period of 6 weeks.
Exercises
During each session, patients performed active assistive-
resistive exercises in front of a mirror and underwent
Lasers Med Sci

Fig. 1 Flow diagram of patient Enrollment Assessed for eligibility (n = 48)

recruitment

Excluded (n =2)
• The history of recurrent
Bell’s Palsy

Randomized:
(n = 46)

Received LLLT (830 nm and 100 Mw, 1 Received facial exercises

KHz) with facial exercise treatment Allocation intervention alone
(n = 23) (n = 23)

3th week follow-up Follow-up parameters 3th week follow-up

No drop-out PFDI No drop-out
(n = 23) SFDI
(n = 23)
Follow-up

6th week follow-up Follow-up parameters 6th week follow-up

PFDI
No drop-out No drop-out
SFDI
(n = 23) (n = 23)
Analysis

Analyzed Analyzed
(n = 23) (n = 21)

LLLT: Low-level laser treatment, PFDI: Facial disability index physical; SFDI: Facial disability index social

proprioceptive neuromuscular facilitation [6]. Sessions facial expression exercises. Balloon blowing and chewing
were held, five times per week over a period of 6 weeks. gum on the paralyzed side were also recommended for all
Patients were also instructed as to the correct practice of the patients.

Table 1 Patient characteristics

Exercise group (n = 23) Laser group (n = 23) p

Age 45.3 ± 3.8 44.7 ± 4.5 0.86

Female/male ratio 13/10 14/9 0.76
BMI 29.2 ± 2.4 28.7 ± 3.2 0.69
CVD, n (%) 12 (52) 11 (47) 0.65
Diabetes mellitus, n (%) 12 (52) 13 (56) 0.67

BMI body mass index, CVD cardiovascular disease


Fig. 2 Point of laser application used in the treatment of Bell’s palsy
(adapted from Bernal 1993)
Statistical analysis
The SPSS for Windows Version 15.0 software (SPSS Inc.
Released 2007; SPSS for Windows, Version 16.0, SPSS
Inc., Chicago, USA) was used for statistical analysis. The
conformity of continuous variables with normal distribution
was evaluated using the Kolmogorov Smirnov test, which
revealed that all variables exhibited a normal distribution.
Data are expressed as mean ± standard deviation. Friedman
analysis of variance was performed to compare the data from
the parameters repeatedly measured in the inner-group analy-
sis. Bonferroni correction was performed to compare between
groups as a post hoc test if the variance analysis test result was
significant. To detect the group differences, the Bonferroni
Student t test was used. The Mann-Whitney U test was used
to compare numeric data between the groups. The level of
statistical significance was set at p < 0.05.
Table 2 Intra- and inter-group comparisons of results before, 3 weeks, and 6 weeks after treatment
Exercise group (n = 23)
Baseline Week 3 Week 6
PFDI 26.52 ± 11.07 25.41 ± 13.12 29.06 ± 11.09*
SFDI 23.40 ± 15.23 23.25 ± 15.27 28.76 ± 12.14*
PFDI facial disability index physical, SFDI facial disability index social
*p < 0.001; significant differences in intra-group evaluation according to baseline values
a
p < 0.001; significant differences in inter-group evaluations
Lasers Med Sci
Results
A total of 46 patients with unilateral facial paralysis completed
the present study. There was no statistically significant differ-
ence in mean age between the two groups (p > 0.05). Before
treatment, FDI scores did not differ between the two groups
(p > 0.05). In the exercise group, although no significant dif-
ference in FDI scores was noted between the start of treatment
and week 3 (p < 0.05), significant improvement was observed
at week 6 (p < 0.001). In the laser group, significant improve-
ment in FDI scores relative to baseline was observed at 3 and
6 weeks (p < 0.001). Improvements in FDI scores were sig-
nificantly greater at weeks 3 and 6 in the laser group than those
in the exercise group (p < 0.05) (Table 2).
Discussion
In the present randomized clinical study, we investigated the
adjunctive effect of LLLT applied shortly after the onset of BP
when combined with conventional facial exercise treatment.
Our findings indicate that combined treatment with LLLT and
exercise therapy is associated with significant improvements
in FDI when compared with exercise therapy alone. Previous
studies have demonstrated the effects of laser treatment on
peripheral nerve regeneration in patients with motor and sen-
sory nerve deficits such as trigeminal neuralgia, herpes zoster,
and neuropathy [10, 14]. Laser application enhances the re-
generation of neurons via both local and systemic effects [14].
In addition, laser treatment reduces post-traumatic retrograde
degeneration in neurons that communicate with the spinal
cord and improves the healing of damaged peripheral nerves
[15]. Chow et al. determined that LLLT directly influences
nerve structure, thus increasing the healing rate of communi-
cation blocks [16]. Additional researchers have revealed that
LLLT dilates arterial and capillary vessels, thereby increasing
microcirculation, activating angiogenesis, and stimulating
nerve regeneration and immunological processes [17].
However, these bio-modulatory effects of laser treatment re-
main poorly understood. LLLT is able to increase cell
Laser group (n = 23)
p (intra-group) Baseline Week 3 Week 6 p (intra-group)
<0.001 27.05 ± 14.13 37.42 ± 8.13*a 39.21 ± 9.08*a <0.001
<0.001 22.80 ± 18.76 35.41 ± 10.12*a 37.53 ± 9.65*a <0.001
Lasers Med Sci
numbers, DNA, and RNA synthesis and collagen production,
and in addition, is able to initiate mitosis in cultured cells.
LLLT stimulates the photoreceptors present on the mitochon-
drial and cell membranes to convert light energy into chemical
energy in the form of ATP within the cell, which enhances
cellular functions and cell proliferation rate [18–20].
Furthermore, laser treatment has been shown to exert an
anti-inflammatory effect by decreasing the level of pro-
inflammatory cytokines such as interleukin-1 alpha and
interleukin-1 beta, and by increasing the level of other cyto-
kines and anti-inflammatory growth factors such as fibroblast
growth factor [21]. It may also have inhibitory effects on the
release of prostaglandins, cytokine levels, and cyclooxygen-
ase, and has been shown to accelerate cell proliferation, col-
lagen synthesis, and tissue repair [22, 23]. Approximately
69% of patients with BP exhibit spontaneous improvement
[24]; however, the remaining 31% experience continued
symptoms, and various sequelae may occur [25]. Although
few studies have discussed the efficacy of low-level laser ther-
apy in the treatment of BP, Bernal [9] revealed that laser treat-
ment is a painless adjunctive treatment method without side
effects for patients with facial paralysis, especially those with
diabetes and hypertension, for whom corticosteroid treatment
is contraindicated. In addition, Ladalardo et al. [10] reported
that patients with BP who received treatment with gallium
arsenide (GaAs) laser diodes exhibited significant functional
improvement. Alayat et al. [11] studied the effect of LLLT in
patients with Bell’s palsy and used FDI to assess the outcome,
observing that patients who received LLLT experienced func-
tional improvement. In a 10-year study involving 228 children
with BP, Prescott [26] revealed that high-dose steroid treat-
ment did not significantly alter recovery times. In contrast,
Fontana et al. [27] reported complete improvement in a 3-
year-old child with BP following 3 weeks of LLLT.
Furthermore, LLLT has been reported to reduce inflammation
as well as symptoms of pain. Studies have revealed that the
following phototherapy parameters are effective for reducing
levels of pain and inflammation: wavelengths of 670–830 nm,
dosages of 1–20 J/cm2, light powers of 10–100 mW, and
irradiation durations of 10 s to 2.7 min [28–31]. These find-
ings indicate that laser therapy may represent a painless alter-
native to more conventional treatment methods in children as
well as adults, without side effects associated with more tra-
ditional treatment options.
Conclusion
In the present study, we demonstrated that LLLT resulted in
significant improvement in functional facial movements and
decreased recovery times for patients with BP. Our findings
further indicate that combined treatment with LLLT and exer-
cise therapy is associated with significant improvements in
FDI when compared with exercise therapy alone. This treat-
ment modality is painless and without side effects, and may be
especially useful in cases where corticosteroid treatment is
contraindicated. However, recovery in the present study was
evaluated using FDI scores alone. Future studies should obtain
electrophysiological measurements in order to validate these
findings.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Funding The authors received no financial support for the research.
Informed consent Written informed consent was obtained from all
individual participants included in the study.
Ethical approval All procedures performed in experiments involving
human participants were in accordance with the ethical standards of the
institutional and national research committee and with the 1964
Declaration of Helsinki.
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