Acta Oto-Laryngologica, 2010; 130: 167
172

ORIGINAL ARTICLE

Role of Kabat physical rehabilitation in Bell’s palsy: A randomized trial

MAURIZIO BARBARA1, GIOVANNI ANTONINI2, ANNARITA VESTRI3,

LUIGI VOLPINI1 & SIMONETTA MONINI1
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Departments of 1Sensory Organs
Otorhinolaryngology Unit, and 2Neuroscience, II School of Medicine, Sapienza University
and 3Experimental Medicine, I School of Medicine, Sapienza University, Rome, Italy

Abstract
Conclusion: When applied at an early stage, Kabat’s rehabilitation was shown to provide a better and faster recovery rate in
comparison with non-rehabilitated patients. Objective: To assess the validity of an early rehabilitative approach to Bell’s palsy
patients. Patients and methods: A randomized study involved 20 consecutive patients (10 males, 10 females; aged 35
42 years)
affected by Bell’s palsy, classified according to the House-Brackmann (HB) grading system and grouped on the basis of
undergoing or not early physical rehabilitation according to Kabat, i.e. a proprioceptive neuromuscular rehabilitation. The
evaluation was carried out by measuring the amplitude of the compound motor action potential (CMAP), as well as by
observing the initial and final HB grade, at days 4, 7 and 15 after onset of facial palsy. Results: Patients belonging to the
For personal use only.

rehabilitation group clearly showed an overall improvement of clinical stage at the planned final observation, i.e. 15 days after
onset of facial palsy, without presenting greater values of CMAP.

Keywords: Facial palsy, physical rehabilitation, House-Brackmann grading system, Kabat, electroneuronography

Introduction recovery, the electrophysiological reports relating to

Viral infection is nowadays considered to be the
cause of previously named ‘idiopathic’ facial palsy
(Bell’s palsy). In particular, type 1 herpes simplex
virus has recently been localized in the geniculate
ganglion within the internal auditory canal [1].
Epidemiological data showed that the herpes virus
(HV) might remain in the affected side as long as
3 months from the initial infection and its presence
can also be evidenced through laboratory tests by
assessing its presence in the saliva [2] or from
biopsies of the posterior auricular muscle [3].
HV neurotropic activity has been shown, via
electrophysiological assessment, to reach a peak level
between the 7th and 14th day after infection
or
even longer when herpes zoster infection is involved
[4].
Although most aspects of viral facial nerve (FN)
palsies are likely to resolve completely, residual signs
of muscular deficit or alteration have been reported
in approximately 20% of the patients [5]. Moreover,
it has also been shown that, despite a full clinical
motor unit regeneration would normalize at a later
time, more specifically between 2 and 10 months
later, depending on the grade of paralysis [4,6].
In this regard, in terms of prognostic sensitivity,
electroneurography (ENoG) has been shown to
represent a more reliable tool at an early stage in
comparison with electromyography, and is therefore
considered to be accurate for monitoring facial nerve
function [4,7,8]. Although it is known that ENoG
values are unpredictable in patients with less than
65% of facial asymmetry [4], this test would
eventually permit the early identification of those
patients requiring physical rehabilitation [9].
During the last 10 years, an early rehabilitative
protocol has routinely been applied at our institution
for treatment of all cases of post-surgical, peripheral
FN palsy, by using the proprioceptive neuromuscu-
lar facilitation according to Kabat et al. [10]. In this
regard, a better and faster recovery has been shown
to occur in patients affected after vestibular schwan-
noma surgery if this rehabilitative procedure is

Correspondence: Maurizio Barbara MD PhD, Professor and Chairman of Audiology, Chief of ENT Department, Azienda Ospedaliera Sant’Andrea, Rome,
Italy. E-mail: Maurizio.barbara@uniroma1.it

(Received 20 January 2009; accepted 9 March 2009)

ISSN 0001-6489 print/ISSN 1651-2251 online # 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
DOI: 10.3109/00016480902882469
 168 M. Barbara et al.
applied at an early stage [11]. This observation led
us to hypothesize a similar outcome also in FN
palsies of different origin, including those of viral
origin.
The present study was designed to obtain evi-
dence of the efficacy of early FN physical rehabilita-
tion in patients with Bell’s palsy, by measuring and
comparing the clinical grading system and the
ENoG values.
Patients and methods
Twenty patients (Table I) affected by FP ]3/6 HB,
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who came to observation within 3 days after onset,
were included in this study. The viral origin was
suggested by the negative otoneurological examina-
tion and normal gadolinium-enhanced MRI, and
supported by positive serology for antibodies against
HV-1.
A medical treatment was immediately started in
all the patients, by combining antiviral and steroid
drugs. Antiviral drugs (aciclovir 400 mg, three times
per day) were administered continuously for
15 days, while a full dosage of steroids (prednisolone
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40 mg per day) was given for 10 days and then
tapered within the next 5 days.
Additionally, all the patients were asked to read
and eventually sign a specific informed consent that
would enable them to be included, under a simple
randomization protocol that disregarded the initial
clinical stage and ENoG values, in three differ-
ent groups, as follows. (a) The first group (rehab
group), for whom early physical rehabilitation was
planned, included nine patients (five males, four
females, mean age 35 years). Rehabilitation started
from day 4 after onset of FN palsy, with one session
per day for 6 days, and continued for 15 days. (b)
The second group (non-rehab group), was com-
posed of 11 patients (5 males, 6 females, mean age
42 years) who did not undergo physical rehabilita-
tion. (c) The third group included group b patients
Table I. CMAP amplitude variations at day 4, 7 and 15 in rehabi-
litated and non-rehabilitated patients. NS non-significant.
Non-rehabilitated Rehabilitated
Characteristics patients (n11) patients (n 9)
Age mean 42 (28
56) 35 (25
58)
(min
max)
Sex
Male 5 5
Female 6 4
Voltage
4th day 0.3990.78 0.9890.75
7th day 0.0390.04 0.1490.32
15th day 0.7791.37 0.2690.24
who did not show signs of clinical recovery after
2 weeks of exclusive medical treatment, who under-
went a delayed Kabat rehabilitation (after day 15).
The study followed the ethical standards of the
University Hospital Committee on Human Experi-
mentation and the Helsinki Declaration [12]. All the
patients were evaluated by a single professional who
watched recorded videoclips of each patient at
different planned times, and classified them accord-
ing to the House-Brackmann (HB) grading system
[13].
Rehabilitation started from day 4 after facial palsy
onset in group a patients, and from day 15 in group c
patients, and it was carried out according to Kabat et
al., i.e. a proprioceptive neuromuscular facilitation
procedure [10]. This method considers that har-
mony, coordination and optimal strength of body
movements mainly depend upon the fact that they
are performed following diagonal lines with respect
to the sagittal axis of the body, thus implying a
‘rotational’ effect. It consists of facilitating the
voluntary response of an impaired muscle through
a global pattern of an entire muscular section which
undergoes resistance. This method appears to be
extremely rational for facial muscles, since most
muscular fibres run diagonally, with an easy irradia-
tion to the upper facial region due to cross-VII nerve
innervation. Three regional fulcra are taken into
consideration: the upper, intermediate and lower
fulcrum. The upper fulcrum (forehead and eyes) is
connected via a vertical axis to the intermediate one
(nose), while the lower mimic-chewing-articulatory
fulcrum lies along a horizontal axis. Hence, action
on the upper fulcrum also involves the other two
fulcra. The manipulation of these three fulcra is
carried out by utilizing both contralateral contrac-
tion and the basic proprioceptive stimulation includ-
ing stretching, maximal resistance, manual contact
and verbal input. In the upper fulcrum, the activa-
tion of the frontal, corrugator and orbicularis
muscles is carried out by means of their upwards
or downwards traction, which is always in a vertical
plane depending on the specific function that needs
to be activated. In the intermediate fulcrum, the
activation of the common elevator muscle of the ala
nasi and upper lip is also carried out using traction
p value movements, in this case contrary to the normal
direction, following a vertical line. For the lower
fulcrum, the manoeuvres are carried out on the
risorium and orbicularis oris muscles in a horizontal
plane, and on the mental muscle in a vertical plane.
ENoG was carried out by a neurophysiologist at
days 4, 7 and 15 after FN palsy onset, by stimulating
NS the FN with a 25 mm long bipolar nerve stimulator,
NS
at the level of the stylo-mastoid foramen. The
NS
compound motor action potential (CMAP) was
 Kabat physical rehabilitation in Bell’s palsy 169

recorded with concentric needle electrodes inserted
into the orbicular oculi, frontal and orbicular oris
muscles. CMAP amplitude as well as percentage of
activity in the affected side compared to the activity
of the healthy side were assessed. CMAP amplitude
was measured from the initial negative deflection to
the positive peak (peak-to-peak amplitude); normal
range was considered to be between 2 and 4.5 mV.
The percentage activity of the affected side was
calculated by dividing the smallest value by the
largest and multiplying it by 100.
The difference between electrophysiological and
clinical (HB grade) data, within each group and
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between CMAP amplitudes was not affected by the
randomization protocol.
At day 4, CMAP amplitude percentage between
the affected and the healthy side was B10% in nine
patients (45% of the whole group), between 11 and
50% in seven patients (35%) and50% in four
patients (20%).
At day 7, CMAP amplitude percentage between
the affected and the healthy side was B10% in 12
patients (60%), between 11 and 50% in 5 patients
(25%) and 50% in 3 patients (15%).
At day 15, the final observation time of this study,
CMAP amplitude percentage between the affected

between the groups, was evaluated statistically.
Statistical analysis included grading, CMAP ampli-
tude and activity variations (%) between the paral-
ysed and the healthy side at different times, i.e. 4, 7
and 15 days after onset of FN palsy. The Mann-
Whitney test was used to evaluate basal conditions
between groups, clinical grading and CMAP ampli-
tude at day 4, and to evaluate the difference of
percentage of activity at day 4, 7 and 15 between the
groups. The Wilcoxon test was used to evaluate,
within each group, variations of CMAP amplitude at
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and the healthy side was B10% in nine patients
(45%), between 11 and 50% in eight patients (40%)
and 50% in three patients (15%).
In the rehab group, clinical grading was statisti-
cally different between day 4 and 15 (p0.002) and
day 7 and 15 (p 0.004), with an overall improve-
ment of HB clinical stage at the final observation
(15th day after onset of FN palsy).
When comparing the rehab with the non-rehab
group, grading difference was shown to be statisti-
cally significant only at day 15 (p 0.028), with
better values in the rehab group (Tables II and III;

day 4, 7 and 15. The Pearson chi-squared test was Figure 2). At day 15, the worst grade of paralysis was
used to evaluate grade of palsy.
Table II. Correlation of House-Brackmann (HB) grading varia-
tions in non-rehabilitated patients at days 4, 7 and 15.
Results
CMAP values in the rehab and non-rehab groups are HB 7
summarized in Figure 1. Groups a and b were shown 2 3 4 5 Total
to be statistically homogeneous, i.e. the difference
HB 4
2 1 0 0 0 1
4 0 2 6 0 8
5 0 0 1 1 2
Total 1 2 7 1 11
Chi square p 0.013.
HB15

1 2 4 5 Total

HB 7
2 1 0 0 0 1
3 1 1 0 0 2
4 0 0 7 0 7
5 0 0 0 1 1
Total 2 1 7 1 11
Chi square p 0.003.
HB 15

1 2 4 5 Total

HB 4
2 1 0 0 0 1
4 1 1 6 0 8
5 0 0 1 1 2
Total 2 1 7 1 11
Figure 1. Demographics of rehabilitated and non-rehabilitated Chi square p NS.
patients and their mean CMAP voltage values at day 4, 7 and 15.
 170 M. Barbara et al.
Table III. HB clinical grading variations in the rehabilitated
normal FN function, was observed in 22% of rehab
patients at days 4, 7 and 15.
patients and 20% of non-rehab patients.
Eight patients (80%) of the non-rehab group who
HB 7
still presented residual FN deficit at day 15, i.e.
2 3 4 Total seven with grade IV and one with grade V, started
Kabat rehabilitation (group c). Two months later,
HB 4
3 1 0 0 1 grade improvements could be observed: from gra-
4 0 4 3 7 de V to grade III (two patients), from grade IV to
5 0 0 1 1 grade III (one patient) and from grade IV to grade
Total 1 4 4 9 II (five patients).
Chi square p0.036.
No significant variation in CMAP amplitude was
HB 15 found in the study groups at any time of assessment.
1 2 3 Total
Percent activity of the affected versus healthy side
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between group a and b was shown to be significant

HB 7 only at day 4, when B10% of activity was found in
2 1 0 0 1 seven patients (63.6%) in the non-rehab group and in
3 1 3 0 4
4 0 0 4 4
two patients (22.2%) in the rehab group (p 0.013).
Total 2 3 4 9 When comparing clinical grading and ENoG
Chi square p0.015. parameters, a parallelism was found in both groups
HB 15 at day 4, although at day 15, CMAP values remained
stable in the rehab group and were shown to be still
1 2 3 Total altered in some patients, despite the improved
HB 4 clinical grade (Figure 3).
3 1 0 0 1
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4 1 3 3 7
5 0 0 1 1 Discussion
Total 2 3 4 9
The disfiguring outcome that can ensue after FN
Chi square pNS.
palsy usually motivates the efforts of physicians to
achieve the best functional outcome for their
grade III and affected 44% of the rehab group, while patients. In the clinical setting, however, this attitude
10% of patients in the non-rehab group were usually depends on the aetiology of the palsy. In fact,
affected by grade V. Conversely, grade I, i.e. a while a surgical option may be taken into considera-
tion for post-traumatic and/or iatrogenic forms,
medical treatment is considered the only available

Figure 2. Facial palsy grading (HB) variations at day 4, 7 and 15 Figure 3. CMAP voltage in rehab and non-rehab patients at day
in rehab and non-rehab patients. 4, 7 and 15.

option when viral FN palsy (Bell’s palsy) presents.
Often, this treatment is even considered redundant
in consideration of the benign natural course of the
disease, which usually has complete resolution in the
majority of patients within 15
30 days of the onset.
Nevertheless, a certain percentage of FN palsy
patients still show some residual facial impairment
after that time, which may be permanent [5].
One of the major problems resides in the difficult
identification of this unlucky group of patients at an
early stage. Electrodiagnosis, whenever applied, is of
limited help in this respect. In fact, after a few days
from onset of palsy, it may not allow the physician to
Acta Otolaryngol Downloaded from informahealthcare.com by Washington University Library on 06/15/13
distinguish among different types of lesion, such as
mild or severe compression or myelin sheath frag-
mentation, since it displays a similar electric pattern,
but unfortunately has a different prognosis [4].
Moreover, a discrepancy between clinical grading
and ENoG values may be observed, i.e. values
poorer than the effective clinical situation [4], so
that an impaired ENoG pattern may persist even
1 year after palsy onset, despite the fact that com-
plete clinical recovery has already been achieved [6].
A possible explanation could be that ENoG is
technically measured at a more proximal level, closer
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to the lesion site, and may not represent the actual
capability of the facial muscles to contract.
Taking into account that viral infection in FN
palsy has been reported to have a temporal peak
between day 4 and 15, in the present study the
objective electrophysiological evaluation was delib-
erately carried out during this time frame. Similar to
previous studies, in both study groups various
degrees of CMAP amplitude reduction have been
recorded: more precisely, up to 45% of them
presented values that would be recognized as poten-
tial candidates for surgical exploration [14].
Although Bell’s palsy has recently been shown to
gain significant advantage from steroid but not from
antiviral treatment [15], the present, previously
planned study, included the combined use of these
drugs as baseline treatment for all study groups.
The use and usefulness of a concomitant physical
rehabilitation in case of Bell’s palsy has been widely
debated [16
18]. After experiencing the benefit of
early Kabat rehabilitation for grade IV and V FN
palsy following vestibular schwannoma surgery [11],
early rehabilitation was therefore planned for pa-
tients with Bell’s palsy and represented the main
object of the present study.
Although more detailed and sensitive analytic
systems, such as Sunnybrook [19] or Yanagihara
[20], do exist, our clinical evaluation and follow-up
were carried out by the HB grading system since the
time frame of observation was short enough not to
expect that patients might show sequelae, such as
Kabat physical rehabilitation in Bell’s palsy 171
synkinesis or spasms, which usually occur at a later
stage after palsy.
From our findings it could be assumed that
rehabilitation greatly improved the prognosis of
clinical recovery, since the improvement of HB grade
shift obtained in the rehab patients was significantly
better than that in the non-rehab group at day 15.
It has also been observed that clinical recovery has
always occurred before ENoG normalization. This
might be explained by the time interval studied
(until day 15 post-onset) and by the fact that during
regeneration axons cannot fire synchronously be-
cause they are thinner, small in number and less
organized than in normal situations [4,6].
Furthermore, the usefulness of Kabat rehabilita-
tion for Bell’s palsy recovery was also experienced by
those non-rehab patients (group c) who received it
after showing an unfavourable response to medical
therapy alone. In fact these patients could achieve a
better HB grade after 2 months of Kabat rehabilita-
tion.
From the present study it is possible to conclude
that Bell’s palsy may retain potential morbidity with
severe sequelae even if appropriately treated.
Whether these sequelae would be cured anyhow
after the time frame (15 days) considered for this
study is difficult to establish. However, when applied
at an early stage, Kabat’s rehabilitation was proved
to achieve a better and faster recovery in comparison
with non-rehab patients who may always benefit
from it, with a fair likelihood of achieving a better,
although slower, clinical recovery.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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