Physiotherapy Theory and Practice, 26(3):160–166, 2010

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ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593980902886339

RESEARCH REPORT

Effects of electrical stimulation on house-brackmann

scores in early bells palsy
Prisha Alakram, MPT1 and Threethambal Puckree, PhD, PT2
1
Master of Physiotherapy Student, Department of Physiotherapy, University of KwaZulu Natal, South Africa
2
Head of School, Physiotherapy, Sport Science and Optometry at the University of KwaZulu Natal, South Africa
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ABSTRACT
Limited evidence may support the application of electrical stimulation in the subacute and chronic stages of
facial palsy, yet some physiotherapists in South Africa have been applying this modality in the acute stage in
the absence of published evidence of clinical efficacy. This preliminary study’s aim was to determine the safety
and potential efficacy of applying electrical stimulation to the facial muscles during the early phase of Bells
palsy. A pretest posttest control vs. experimental groups design composed of 16 patients with Bell’s palsy of
less than 30 days’ duration. Adult patients with clinical diagnosis of Bell’s palsy were systematically (every
second patient) allocated to the control and experimental groups. Each group (n ¼ 8) was pretested and
posttested using the House-Brackmann index. Both groups were treated with heat, massage, exercises, and a
home program. The experimental group also received electrical stimulation. The House-Brackmann Scale of
For personal use only.

the control group improved between 17% and 50% with a mean of 30%. The scores of the experimental group
ranged between 17% and 75% with a mean of 37%. The difference between the groups was not statistically
significant (two-tailed p ¼ 0.36). Electrical stimulation as used in this study during the acute phase of Bell’s
palsy is safe but may not have added value over spontaneous recovery and multimodal physiotherapy. A larger
sample size or longer stimulation time or both should be investigated.

INTRODUCTION may cause an increase of residual effects and delay

Bell’s palsy is the sudden onset of paralysis of facial
muscles on one side of the face due to inflammation
of the facial nerve within the facial canal. Symptoms
that peak at about 2 weeks from onset include
inability to close the eye, tearing, drooling, and facial
pain. Peitersen (2002) reported that prognosis is
good and approximately two thirds progress to full
recovery within 3 months, and residual symptoms
persist in the remaining third of patients.
Current treatment trends discourage the use of
electrical stimulation in the early phase of Bell’s palsy
(Diels, 2000) to avoid potential interference with
neural regeneration (Cohan and Kater, 1986). Diels
(2000) believes but provides no evidence that although
electrical stimulation continues to be widely used, it
Accepted for publication 6 March 2009.
Address correspondence to Prof. Threethambal Puckree, PhD, PT,
Department of Physiotherapy, University of KwaZulu Natal, Private
Bag X54001, Durban, 4001, South Africa.
E-mail: puckreet@ukzn.ac.za
regeneration of the facial nerve. Research by Farragher,
Kidd, and Tallis (1987) and Targan, Alon, and Kay
(2000) contradict these reports. Byers, Keith, and Glen
(1998) concluded that pulsed electromagnetic stimu-
lation enhances early regeneration of the facial nerve.
Anecdotal evidence suggests that both newly quali-
fied community physiotherapists as well as physio-
therapists who qualified more than 20 years ago in
South Africa use electrical stimulation as a first line of
treatment in Bell’s palsy. However, there is no evidence
to support such practice in early/acute Bell’s palsy.
Most studies investigating the effects of electrical sti-
mulation in Bell’s palsy have been inadequate (Shrode,
1993) or have been conducted only in long-term
Bell’s palsy sufferers (Farragher, Kidd, and Tallis,
1987; Targan, Alon, and Kay, 2000).
Although there are several facial functions’ report-
ing systems (House, 1983), there is a lack of a globally
accepted one. In 1984 the American Academy of Head
and Neck Surgery adopted the House-Brackmann
Facial Nerve Grading Scale (House and Brackmann,
1985). Although the House-Brackmann index showed

160

high reliability against the ‘‘Sydney’’ and ‘‘Sunnybrook’’
facial grading systems in the assessment of voluntary
movement and synkinesis, it was not sufficiently sensi-
tive to changes in individual grades by different raters
(Coulson, Croxxson, Adams, and O’Dwyer, 2005).
Consequently, this study used only one rater.
In the absence of published evidence of clinical
efficacy, the primary purpose of this preliminary study
was to determine the safety and effects of electrical
stimulation on House-Brackmann scores in the early
phase of Bell’s palsy recovery.
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METHODS
A two group, pretest and posttest, experimental design
was used. The sample was chosen from the patients
referred to the physiotherapy department at a com-
munity-based Hospital Complex that consists of three
hospitals in South Africa.
Patients diagnosed with Bell’s palsy by a neurologist
or otolaryngologist were referred for physiotherapy
and alternately allocated to the control and experi-
mental groups, respectively. Only patients with less
For personal use only.
than 30 days’ post onset of Bell’s palsy were considered
to ensure intervention at an early stage. The contra-
indications of using Transcutaneous Electrical Nerve
Stimulator (TENS) were considered; hence, patients
who were pregnant and had pacemakers or any sensory
impairment over the electrode placement area were
not included. Permission to conduct this study was
obtained from the relevant Hospital Complex Ethics
Committee and the related University’s Research
Ethics Committee. On the first contact with the sub-
ject, the researcher first used basic illustrations of the
anatomy of the facial nerves and muscles to educate
the patient on Bell’s palsy. The patient then read and
signed the consent form in their preferred language.
The instruments and procedures used in the study
included treatment modalities and assessment tools as
described below. The researcher treated each patient
in both the control and experimental groups with
5 minutes of heat, 10 minutes of massage, and 10 repe-
titions of exercises once a week due to the inability of
patients to attend the outpatient clinic more frequently.
The experimental group was then treated with an addi-
tional 30 minutes of electrical stimulation of the facial
muscles using a TENS unit. All patients were given an
illustrated home exercise handout as described below.
Each exercise on this sheet was thoroughly taught to the
patient with instructions to do 10 repetitions of each
exercise, three times daily. Patients kept a record of the
number of exercises done daily as per record sheet. The
average number of exercise sessions done daily was
recorded on the data sheet to monitor patient compliance.
Physiotherapy Theory and Practice 161
House-Brackmann Facial Nerve Grading
System
The House-Brackmann Facial Nerve Grading Scale
(HB) was used to assess the severity and monitor the
changes of a patient’s motor recovery, abnormal move-
ment, tone, and symmetry (House and Brackmann,
1985). The HB considers overall facial paralysis by
assessing tone, symmetry, position at rest, movement of
muscles of the forehead, eye, and mouth, and synkinesis.
Dysfunction is then graded as I (normal), II (slight
abnormality), III (moderate abnormality), IV (moder-
ately severe abnormality), V (severe abnormality), and
VI (total–no function), through the use of specific cri-
teria as detailed by House and Brackmann (1985). It was
chosen in this study because it was officially adopted as a
recognised facial nerve grading system by the American
Academy of Head and Neck surgery (House and
Brackmann, 1985) and it has been used with success by
other investigators (Sillman, Niparko, Lee, and Kileny,
1992; Targan, Alon, and Kay, 2000 and). In this study it
provided the researcher with a practical, efficient, and
inexpensive tool to monitor facial nerve recovery.
Hot packs
Hot packs were applied while the patient assumed a
supine position after a sensation test to prevent burns.
A 58-cm-long Whitehall myofacial thermal pack, not
exceeding 701C/1601F (Whitehall Manufacturing,
Division 2000, City of Industry, CA, USA) was
applied to both sides of the face simultaneously by
using a towel folded over, to the patient’s comfort.
Heat treatment continued for 5 minutes prior to mas-
sage on both sides of the face (Shafshak, 2006).
Massage
With subject in supine, massage was applied for
10 minutes to both sides of the face and neck to also
include the muscles supplied by the cervical branch
of the facial nerve (i.e., the plathysma). The massage
included stroking over both sides of the face and neck;
simultaneously (30 seconds) circular massage with
three middle fingers was performed by working from
the centre to outer face for 2 minutes (Diels, 2000).
The researcher used her thumb (protected by a sterile
glove) on the inside of the cheek of the affected side
and the three digits on the facial skin to draw the tis-
sues toward the mouth (2 minutes). If a trigger point
was detected, then deep pressure was applied in
keeping with patient’s tolerance. Relaxation of the
face and neck muscles was next attempted by using
Physiotherapy Theory and Practice
 162 Alakram and Puckree
effleurage for 2 minutes. Kneading, picking up, and
wringing were then used to increase circulation, reduce
involuntary contraction, and mobilize these muscles
(2 minutes). The massage was concluded with 1 minute
of hacking to evenly distribute the erythema and
30 seconds of stroking to induce relaxation at the end of
the massage.
Exercises
Exercises carried out on consultation with the physio-
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therapist were based on current trends as per the facial
retraining rehabilitation programme (Segal et al, 1995;
Segal, Zompa, Danys, and Freedman, 1995). Exer-
cises were chosen to include different muscle groups
supplied by each branch of the facial nerve. During
each clinic visit for treatment with the researcher, the
following exercises were repeated 10 times each to
avoid muscle fatigue (Diels, 2000; Henry, Rosemond,
and Eckert, 1999; Segal et al, 1995).
K bring your eyebrows together and downward as in
For personal use only.
frowning
K raise your eyebrows as in being surprised
K close your eyes gently and then tightly
K flare nostrils by blowing out with your nose
K compress nostrils in a sniffing attempt
K smile closed mouth and then open mouthed
K attempt to whistle by puckering your lips and
compressing cheek
K tighten you chin and neck to eventually pull your
lower lip down to expose your lower teeth
Exercises were done to include both sides of the face
by using a mirror to promote symmetry and feedback.
If there was overflow or abnormal movement coming
in, the patient was asked to relax and try again with
less effort.
A standard exercise handout for home programs in
English, Afrikaans, and isiXhosa was given to each
subject on the initial consultation with the phy-
siotherapist. Exercises in the handout were prioritised
to four to ensure effectiveness and patient compliance.
These four exercises were also included as part of the
weekly clinic visit to reinforce the home program. Diels
(2000) outlined short exercise sessions (8–10 repeti-
tions of four exercises) with two to three daily sessions
suggesting that quality of exercise was more important
than quantity.
The exercises included in the home program were
taught to the patient on the initial treatment and
reinforced at consequent treatments. The data sheet
included a table to monitor patient compliance of
home exercise.
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Electrical stimulation
The EV-803 Digital SD TENS (Everyway Medical
Instruments Co., Ltd. Shenkeng Hsiang, Taiwan) was
used for electrical stimulation of the facial muscles. The
settings of the TENS unit were chosen to mimic the
natural action of the facial muscles. Facial muscles are
made up of predominantly slow twitch fibres with a
firing rate around 6–12 Hz (Kit-Lan, 1991). Farragher,
Kidd, and Tallis (1987) and Mann, Swain, and Cole
(2000) used pulse frequency of 10 Hz and 10 Hz to
40 Hz, respectively, in their stimulation program to the
facial muscles. Both studies reported return of some
facial symmetry and facial muscle activity in the chronic
Bell’s palsy sufferer. Therefore, in this study we used a
pulsed setting and frequency of 10 Hz, a pulse width/
duration of 10 microseconds as used by other investi-
gators (Farragher, Kidd, and Tallis, 1987; Targan,
Alon, and Kay, 2000). We attempted to recruit motor
fibres similar to Farragher, Kidd, and Tallis (1987) and
Targan, Alon, and Kay (2000). The intensity used was
determined on the first consultation of the patient. This
was achieved by stimulating the unaffected side to see
what intensity was needed to obtain a minimally visible
contraction of the muscles targeted. This intensity was
used as a starting point for obtaining a visible twitch on
the paralysed side. The intensity required to produce
minimal twitching varied by patient, and because the
instrument could not produce a digitized output, could
not be quantified. The twitch contraction was an indi-
cation that the nerve was either neuropraxic or had not
fully degenerated.
Muscles stimulated were targeted to enhance facial
control (e.g., eye closure [obicularis oculi], oral
movements [orbicularis oris], and learning to minimize
asymmetrical facial expression [zygomaticus major]).
Other studies (Farragher, Kidd, and Tallis, 1987;
Mann, Swain, and Cole, 2000; Targan, Alon, and Kay,
2000) have chosen similar muscles in their stimulation
of patients with chronic facial palsy. Once baseline
intensity which produced a visible contraction of the
stimulated muscle was established from the unaffected
side, this intensity was used as a starting point to
produce a twitch on the affected side. The intensity
was increased as required. Each muscle group was
stimulated separately for 10 minutes to avoid synkin-
esis and the total electrical stimulation time at each
treatment session for a patient in the experimental
group was 30 minutes (Beck and Benecke, 1993).
The following precautions were taken to avoid skin
irritation: (1) Hypo-allergenic Lifecare electroconductive
gel was used; (2) the TENS unit was not used for more
than 30 minutes at a time to prevent electrode drying
out and muscle fatigue; and (3) each patient had their
own set of electrodes that were thoroughly cleaned with

a sterile Webcol swab between treatments to maintain
hygiene and sensation was tested.
To ensure that the study was conducted in the acute
phase, the researcher continued treatment for a maxi-
mum of 3 months after onset of Bell’s palsy or until the
patient recovered a minimum of 80% on the House-
Brackmann Facial Nerve Grading Scale.
Data collection
Each patient had his/her own data sheet where the same
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physiotherapist recorded pretest and posttest ratings of
the House-Brackmann Scale. The data sheet also made
provision for all possible extraneous variables that was
thoroughly analysed to ensure validity of the data.
Data analysis
Data analysis was conducted under supervision of a
statistician using SPSS version 11.0 for windows. All
data were normalized by using the initial pretest values
For personal use only.
as reference, which helped to reduce variability.
The baseline values of the House-Brackmann Facial
Nerve Grading Scale (HB) and the number of weeks to
recover differed among subjects. Therefore, standardi-
zation to calculate the percentage rate of recovery for a
subject was performed as follows:
If a subject went from a grade 4 to grade 1 in 8
weeks, the percentage rate of recovery ¼ (4
1)/
8  100 ¼ 37.5. A subject who also recovered from
a grade 4 to a grade 1 but in 4 weeks will have a
percentage rate of recovery ¼ (4
1)/4  100 ¼ 75. To
analyse the differences between the experimental and
control groups with regard to days from onset of Bell’s
palsy until subject commenced medication; days from
onset of Bell’s palsy until subject commenced physio-
therapy; and recovery rates for the House-Brackmann
Facial Nerve Grading Scale, all pooled data were
subjected to the Mann-Whitney tests. The probability
was set at p values r0.05.
TABLE 1 Demographic information of participants in the study (n ¼ 16)
Different groups Black White Asian Other
Experimental (n ¼ 8) 4 2 2 0
Control (n ¼ 8) 7 1 0 0
Total sample (n ¼ 16) 11 3 2 0 7
L: left; R: right.
Physiotherapy Theory and Practice 163
RESULTS
Sixteen of 29 subjects completed the study. Seven
subjects refused to participate and 6 subjects com-
menced treatment but did not comply with the pro-
gram and had to be excluded from the study. There
were 8 subjects in the experimental group and 8 in the
control group. Both groups were very similar in terms
of the extraneous variables analysed. Both groups were
treated for 4–12 weeks (control group mean
 SD ¼ 9  3; experimental group mean ¼ 8  3),
and these data provided no significant difference
between groups. Table 1 shows the demographic pro-
file of the participants. There was no statistically sig-
nificant difference between the experimental and
control group for the number of days from the onset of
Bell’s palsy until they commenced either their medi-
cation or physiotherapy (Table 2). The average num-
ber of daily exercise sessions completed by the control
(2.4 sessions per day) and experimental (2.3 sessions)
was similar.
One subject in the control group developed Bell’s
palsy 22 days after caesarean section, 25% of the entire
sample was hypertensive, and 19.7% of the sample
were diabetic. The time from onset of Bell’s palsy until
the patient had their first session of physiotherapy was
an average of 14  3 days in the experimental group
and an average of 12  3 days in the control group.
All subjects had prednisolone (2 mg per kg daily and
weaned off within 2 weeks); those with eye problems
were given eye drops and those with pain were given
Panado’s. No problems were encountered with the
language spoken as 100% of the subjects spoke English
either as a first or second language. Two subjects from
the experimental group (subjects 2 and 5) had pre-
vious history of Bell’s palsy 3 and 2 years ago,
respectively. Both verbalised that they had made full
recovery within 2–3 months post previous facial palsy’s
onset. For the current episode of Bell’s palsy, the rate
of recovery on the House-Brackmann Facial Nerve
Grading Scale was much higher for subject 2 than for
subject 5 from the experimental group (Table 3);
hence, because of two very different rates of recovery,
Side of Bell’s palsy (Number) Gender (Number)
L R Male Female
4 4 5 3
3 5 3 5
9 8 8
Physiotherapy Theory and Practice
 164 Alakram and Puckree

TABLE 2 Groups’ comparison regarding age, the number of days from onset of Bell’s palsy until subject commenced medication
intake, and time to treatment commencement physiotherapy

Ranges and Time from onset of Bell’s palsy until Time from onset of Bell’s palsy until
Group means Age (years) commenced medication (days) commenced physiotherapy (days)
Control group Range 21–68 0–2 9–16
Mean 41.4  16.5 0.9 12.5
Experimental group Range 11–67 0–1 11–17
Mean 38.6  17.7 0.5 14.1
Total sample Range 11–68 0–2 9–17
Mean 40  16.6 0.7 13.3
p 1.36 0.22 0.18
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TABLE 3 Individual recovery rates (%) using the House-Brackmann Facial Grading Scale (HB)

Individual recovery rates (%)

Group 1 2 3 4 5 6 7 8 Average rate of recovery

Control n ¼ 8 17 50 17 43 33 33 17 27 29.6  12.5

Experimental n ¼ 8 38 33 38 40 17 43 75 17 37.6  18.1
For personal use only.

TABLE 4 Mann-Whitney tests for House-Brackmann recov-
ery rates (ranks)
N Mean rank Sum of ranks
Control 8 7.44 59.5
Experimental 8 9.56 76.50
p value 0.36
there was no pattern established to confirm or refute
that recurrent Bell’s palsy takes longer to resolve.
The comparison of recovery rates for the House-
Brackmann Facial Nerve Grading Scale (HB) indi-
cates that the individual rates in the experimental
group were higher than that of the control group
(Table 3). However Mann-Whitney tests indicated that
there was no statistically significant difference in rate
of recovery between the experimental and control
group (Table 4).
DISCUSSION
The sample size in this study was small due to the
sporadic nature of the condition and the inclusion
criteria that were limited to patients less than 30 days
post onset of Bell’s palsy. Small sample size has been
also a limiting factor in previous studies of chronic
facial paralysis. Targan, Alon, and Kay (2000) had 17
subjects, only 12 of whom were Bell’s palsy sufferers
and Farragher, Kidd, and Tallis (1987) had 40 sub-
jects. In the current study, patient compliance to
commit to once weekly treatments also promoted
attrition. Because of the poor socioeconomic circum-
stances of the community served by the participating
hospitals, many patients had casual jobs and could not
afford to be away from work without pay. Some could
not afford the travel costs, and others were caregivers
who could not leave their dependants alone to come
for weekly treatments.
There were no indications of any adverse response
to the treatment in either group of our study sample.
These findings did not support the concerns of Diels
(2000), who, on the basis of his experience, dis-
couraged the use of vigorous treatment and electrical
stimulation shortly after the onset of paralysis, sug-
gesting that it would cause severe clinical residuals.
The average number of daily exercise sessions
completed by the control (2.4) and experimental (2.3)
was very similar. The same pattern of patient com-
pliance to exercise was evident in both groups. Sub-
jects decreased the number of daily exercise sessions
if recovery appeared to have stagnated (i.e., their
grading on the House-Brackmann Facial Nerve
Grading Scale remained the same for a few weeks)
(Figure 1). The studies conducted by Targan, Alon,
and Kay (2000), Farragher, Kidd, and Tallis (1987),

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3.5
3
2.5
no of sessions
2
control
1.5 experimental
1 CONCLUSION
0.5
0
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1 3 5 7 9 11 15
weeks
FIGURE 1 Trend in number of home exercise sessions (means for
groups per week) completed by the control and experimental groups.
and Gittins et al (1999) were reliant heavily on patient
compliance, yet the authors made no mention of how
the home programs were controlled to ensure patient
compliance; thus, the confidence in the data of these
For personal use only.
studies should be questioned.
The House-Brackmann Facial Nerve Grading Scale
showed no significant differences between the experi-
mental and control groups. The minimum improve-
ment of any patient in the study’s sample was 17%.
However, the individual rates of recovery in the
experimental group seemed higher than that of the
control group. The number of patients who improved
at least 34% (twice as much as the minimum
improvement) in the experimental group was five
patients compared to only two patients in the control
group. These findings suggest that a larger sample size
should be tested. In fact, to reach 80% power at a
probability a ¼ 0.05, each group will require a sample
size of 58 patients. In both groups patients recovered
on the House-Brackmann Facial Nerve Grading Scale
at a similar rate, making it impossible to discern
whether the improvement was due to spontaneous
recovery or due to the physiotherapy intervention.
However, the data seem to confirm that the electrical
stimulation program was safe and did not interfere
with recovery.
In this resource poor setting, where it was only possi-
ble for patients to attend once a week, it is important to
determine the most cost-effective treatment program in
which the patient takes responsibility for his/her recov-
ery. Because electrical stimulation is part of a standard
treatment protocol for Bell’s palsy in South Africa, a
larger study with the provision of TENS units for home
treatments that include monitoring of use to ensure
daily stimulation sessions may yield more evidence for
Physiotherapy Theory and Practice 165
the inclusion of electrical stimulation during early
Bell’s palsy in this setting. In addition, it might be use-
ful to study stimulus parameters designed to contract
dennervated muscle fibres, particularly using frequen-
cies and phase duration that lasts 1–10 milliseconds and
its effect on recovery rates (Hofer et al, 2002).
On the small sample tested, House-Brackmann scores
showed an improvement in rate of recovery from facial
palsy during the first 1–3 months post onset and that
predominant motor electrical stimulation did not add
to nor deter such progress. Electrical stimulation also
proved to be a safe treatment intervention. Further
work is required to establish the efficacy of this treat-
ment in a larger group of patients in the acute stage of
recovery from Bell’s palsy.
In recent years various studies proved that electrical
stimulation can improve contractile capability and
restore muscle function in long-term denervated
degenerated muscles. The low excitability of the muscle
cells at the initial stage of training and surrounding
connective tissue, acting as an electrical shunt, require
special stimulation parameters. Until now, no appro-
priate devices (stimulators) are commercially available.
Therefore, we were forced to design our own stimula-
tors. The control unit of the stimulators is based on a
microprocessor for maximum flexibility regarding the
generation of the parameters such as pulse amplitudes,
pulse width, frequency, stimulation times, ramps, and
so on. In addition, the microprocessor design allows
recording of compliance data such as stimulation date,
time, duration, and used programs. The constant volt-
age output stage of the stimulator is able to generate
biphasic charge balanced stimulation impulses with a
pulse width of 1–300 ms, voltage amplitudes up to
 80 V (160 VPP), and stimulation currents up to
250 mA. To prevent direct current due to inexact charge
compensation, the electrode outputs are decoupled
capacitively. Simultaneous two-channel stimulation
with independent intensity levels is possible. The sti-
mulators are programmed by using a notebook or a
personal digital assistant via infrared serial interface.
This concept guarantees the application of correct
stimulation parameters because the patient has only
access to parameters that are preprogrammed for him in
the outpatient clinic. For the home-based training,
access is limited to variation of intensity within pre-
programmed limits. For safety reasons, the portable
unit is powered by an internal rechargeable battery.
High-efficiency switched voltage regulators are used
to provide the different required voltage levels while
ensuring an acceptable operating time of the stimulator.
Physiotherapy Theory and Practice
 166 Alakram and Puckree
Declaration of Interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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