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Physiotherapy Theory and Practice

An International Journal of Physiotherapy
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Evaluation of a physiotherapeutic treatment intervention
in “Bell's” facial palsy
Elisabet Cederwall a; Monika Fagevik Olsén b; Per Hanner c; Ingemar Fogdestam
de
a
Department of Physiotherapy, Skene lasarett, Skene, Sweden
b
Department of Physical Therapy, Sahlgren's University Hospital, G teborg,
Sweden
c
Department of Otorhinolaryngology, Sahlgren's University Hospital, G teborg,
Sweden
d
Departments of Plastic Surgery, Sahlgren's University Hospital, G teborg,
Sweden
e
Rikshospitalet, Oslo, Norway

Online Publication Date: 01 April 2006

To cite this Article: Cederwall, Elisabet, Olsén, Monika Fagevik, Hanner, Per and Fogdestam, Ingemar (2006)
'Evaluation of a physiotherapeutic treatment intervention in “Bell's” facial palsy', Physiotherapy Theory and Practice,
22:1, 43 — 52
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 Physiotherapy Theory and Practice, 22(1):43 52, 2006
Copyright # Taylor & Francis LLC
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DOI: 10.1080/09593980500422529

Evaluation of a physiotherapeutic treatment

intervention in ‘‘Bell’s’’ facial palsy
Elisabet Cederwall, RPT, MSc,1 Monika Fagevik Olsén, RPT, PhD,2
Per Hanner,1 MD, PhD,3 and Ingemar Fogdestam, MD, PhD4
Department of Physiotherapy, Skene lasarett, Skene, Sweden
2
Department of Physical Therapy, Sahlgren’s University Hospital, Göteborg, Sweden
3
Department of Otorhinolaryngology, Sahlgren’s University Hospital, Göteborg, Sweden
4
Departments of Plastic Surgery, Sahlgren’s University Hospital, Göteborg, Sweden, and Rikshospitalet, Oslo, Norway

The aim of this study was to evaluate a physiotherapeutic treatment intervention in Bell’s palsy. A
consecutive series of nine patients with Bell’s palsy participated in the study. The subjects were enrolled
4 21 weeks after the onset of facial paralysis. The study had a single subject experimental design with
a baseline period of 2 6 weeks and a treatment period of 26 42 weeks. The patients were evaluated
using a facial grading score, a paresis index and a written questionnaire created for this study. Every
patient was taught to perform an exercise program twice daily, including movements of the muscles sur-
rounding the mouth, nose, eyes and forehead. All the patients improved in terms of symmetry at rest,
movement and function. In conclusion, patients with remaining symptoms of Bell’s palsy appear to
experience positive effects from a specific training program. A larger study, however, is needed to fully
evaluate the treatment.

Introduction affected by subsequent disability after the palsy

Bell’s palsy, named after Sir Charles Bell
(1774 1842), comprises about 70% of the facial
palsies and is defined as ‘‘A facial paralysis of
acute onset, presumed to be due to non-
suppurative inflammation of the facial nerve
within its canal above the stylomastoid foramen’’
(Walton, 1993, pp. 108 109, see also Bleicher,
Hamiel, Genger, and Antimariona, 1996;
Brackmann, 1974; Edström et al, 1992; Eneroth
et al, 1982; Engervall et al, 1995; Salam and
Elyahky, 1968). The onset is often sudden, but
the symptoms may also develop over a few days
(Eneroth et al, 1982; Peitersen, 1982; Walton,
1993). In 70% of the cases, the paralysis is
complete and at least 25% of the patients are
(Eneroth et al, 1982; Walton, 1993).
Facial palsy may depend on local axonal
damage. Within a few days after the infliction
of the primary injury, the distal parts of the
affected axons degenerate. Significant initial
damage normally leaves sequelæ with incom-
plete facial function (Dumitru, Walsh, and
Porter, 1988; Eneroth et al, 1982). Due to immo-
bilization, skeletal muscles atrophy very quickly.
A reduction in fiber size and diameter appears to
be the most striking morphologic finding,
together with a simultaneous increase in intra-
muscular connective tissue and a reduction in
capillary density (Kannus et al, 1992). Facial
muscles differ from other skeletal muscles
and do not react in the same way during

Accepted for publication 17 January 2005.

Address correspondence to Monika Fagevik Olsen, Department of Physical Therapy, Sahlgrenska University Hospital,
SE-413 45 Göteborg, Sweden. E-mail: monika.fagevik-olsen@vgregion.se

43
 44 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52
periods without movement. These muscles are
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relatively slow to degenerate, have small motor
units and are principally without muscle spindles
(Adour, Byl, Hilzinger, and Sheldom, 1978;
Diels, 1995, 1997, 1998; Dubner, Sessle,
and Storey, 1978). Restitution occurs slowly
(months), through the growth of new neurons
from the area of the injury, or distally
through the growth of branches from remain-
ing axons (Dumitru, Walsh, and Porter, 1988;
Eneroth et al, 1982).
There are three major hypotheses concerning
the etiology of Bell’s palsy. It may be caused by
problems related to vascular ischemia, viral
infections, or it may have a hereditary origin
(Adour, Byl, Hilzinger, and Sheldom, 1978;
Brackmann, 1974). It is also believed that com-
binations of these possible causes are relevant
for the development of the disease. The most
common explanation of Bell’s palsy assumes that
it is due to acute inflammation of the seventh
cranial nerve, n. facialis, and edema compressing
the nerve within its canal (Brackmann, 1974;
Eneroth et al, 1982; Walton, 1993).
The most common symptom is facial muscle
weakness, illustrated in Figure 1. Disorders of
the facial neuromuscular system can result in
paralysis of the muscles of expression. This
results in functional difficulties in activities of
daily living, such as eating, drinking and com-
municating, and in the esthetic disfigurement
of the face (Brackmann, 1974; Eneroth et al,
1982; van Swearingen and Brach, 1996; Walton,
1993). Lip and cheek flaccidity results in the cor-
ner of the mouth drooping. Voice resonance
may be affected and articulation problems are
common. Synkinesis may be present (Diels,
1997). The facial nerve also plays a basic role
in the expression of human feelings. Many
people with facial palsy are unable to express
emotions such as surprise and happiness
(Eneroth et al, 1982; van Swearingen and Brach,
1996). Voluntary, emotional and associated
movements are involved. The eyebrow droops
and the wrinkles of the brow are smoothed out.
Closure of the eye is often impossible, due to par-
alysis of m. orbicularis oculi, and the patient risks
damage to the cornea. These negative effects are
partly compensated for by the reflectory Bell’s
phenomenon, which occurs when the patient
attempts to close the eye. Ectropion and damage
to the muscle movements of saccus lacrimalis
impair the drainage of tears, which tend to over-
flow the lower lid. Dysfunction of m. orbicularis
oculi has the most immediate consequences, the
most serious complication being permanent cor-
neal damage (Brackmann, 1974; Eneroth et al,
1982).
When the facial nerve is involved in the
inflammatory process above the point at which
the chorda tympani leaves it, there is loss of
taste in the anterior two-thirds of the tongue.
In about a third of the cases, the branch to the
stapedius is also involved, causing the patient
to suffer from hyperacusis (Walton, 1993). The
forehead branch of n. facialis is possibly the
least important of the three major branches,
but damage can result in cosmetic and func-
tional impairments (House, 1983).
In a Swedish study comprising 250 people
with facial palsy (about 60% were Bell’s palsy),
23% had symptoms related to the eye, 21% to
the mouth and 24% to the eye and mouth
(Edström et al, 1992).
According to Eneroth, the majority of peri-
pheral nerve injuries involve a combination of
neurapraxia and axonal degeneration (Eneroth
et al, 1982). Between 50 and 85% of cases of Bell’s
palsy recover completely (Bleicher, Hamiel,
Gengler, and Antimariono, 1996; Dumitru,
Walsh, and Porter, 1988; Edström et al, 1992;
Eneroth et al, 1982; Huizing, Mechelse, and Staal,
1981; Laranne et al, 1995; Staal, Huizing, and
Mechelse, 1979). There is no reliable method for
predicting the prognosis at an early stage of the
disease (Eneroth et al, 1982; Huizing, Mechelse,
and Staal, 1981).
If there is a partial return of voluntary power in
the face at the end of three weeks from the onset,
recovery is likely to be rapid and probably com-
plete in a few weeks (Dumitru, Walsh, and Porter,
1988; Eneroth et al, 1982; Peitersen, 1982;
Walton, 1993). A satisfactory recovery is usually
possible if return appears between 21 days and
two months from onset. If return is noted after
two to four months, an unsatisfactory outcome
is often the result (Dumitru, Walsh, and Porter,
1988). General factors associated with a poorer
prognosis than average include age over 60 years,
diabetes mellitus and special factors like hyper-
tension, hyperacusis and diminished lacrimation
(Eneroth et al, 1982; Walton, 1993).
Patients suffering from partial paresis recover
better than patients with total paralysis. The
 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52 45
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Figure 1. Patient examples (a) and (b), Smiling before and after the intervention period.
 46 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52

taste becomes normal in 82%, tear function in Subjects and method

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97% and stapedius function in 86%. The prog-

nosis is related to the rate of recovery. The Subjects
longer the duration before improvement, the
worse the prognosis (Eneroth et al, 1982). There A consecutive series of nine patients, within the
is no patient with Bell’s palsy who remains framework of the inclusion criteria, participated in
totally paralyzed (Eneroth et al, 1982). The risk this study. Only patients older than 18 years with
of recurrence is 6 11%, where patients with dia- unilateral Bell’s palsy and onset within 1 24
betes run the greatest risk. In the case of incom- months were included. Patients were excluded if
plete recovery, contractures usually develop and they had serious pain or disability in the contralat-
give rise to the improved appearance of the face eral side of the face, difficulty communicating, or
at rest (Eneroth et al, 1982). any serious physical or psychological disease that
There are different methods for treating facial made the treatment impossible.
paralysis. The treatment can be medical, phy- The patients were referred in 1998 and 1999
siotherapeutic or surgical (Brackmann, 1974; from the Department of Plastic Surgery and
Edström et al, 1992; Huizing, Mechelse, and the Department of Otorhinolaryngology at
Staal, 1981) and benefits can most probably be Sahlgren’s University Hospital, Göteborg,
obtained from a combination of these methods. Sweden. The nine patients who met the inclusion
It is estimated that about 2% of the total num- criteria consented to participate. One patient
ber of facial palsy patients benefit from recon- was excluded because he did not come to his
structive surgery (Edström et al, 1992). appointments and his compliance with the train-
Physical therapists and occupational thera- ing and keeping the training diary was poor. The
pists have been treating patients with facial palsy demographic data and the respective times from
since the 1920s (Diels, 1997). In physical ther- palsy onset to baseline assessment are presented
apy, electrical stimulation of the nerve has been in Table 1. The duration of the paresis at the
used, consistent with an earlier belief that the beginning of the investigation varied between 4
facial muscles would degenerate without neural and 21 weeks.
signals (Brackmann, 1974; Diels, 1997; Edström
et al, 1992). There are several studies recommend-
ing electrical stimulation to prevent the negative Method
effects of immobilization on muscle tissue in other
In this study, a single-subject experimental
parts of the body (Kannus et al, 1992). In animal
design (SSED), type AB, was used. ‘‘A’’ represents
experiments, electrical stimulation has suppressed
sprouting. Theoretically, it should have a similar
effect in humans, and could impede and delay
nerve outgrowth. The result of the electrical stimu- Table 1. Demographic data from the 8 subjects including
lation of other body musculature cannot easily be gender, age, weeks from the onset of the palsy, length of
transferred to the treatment of facial muscles, due baseline and paretic side of the face (Left=Right).
to their different morphology. Electrical stimu-
Weeks Baseline Side of
lation should, however, probably not be used
Subject Sex Age from period paresis
(Brown and Holland, 1979; Cohan and Kater,
number F=M (years) onset (weeks) (L=R)
1986; Diels, 1995, 1997, 1998; Edström et al,
1992; Huizing, Mechelse, and Staal, 1981). 1 M 40 14 4 R
To our knowledge, there are only two trials eval- 2 F 51 21 6 R
uating the effects of specific exercises, but with 3 M 52 6 2 R
addition of EMG or the patients included have a 4 F 32 4 3 R
variety or of facial palsies (Balliet, Shinn, and 5 M 52 6 2 L
Bach-y-Rita, 1981; Cronin and Steenerson, 2003). 6 M 66 4 7 R
The aim of this study was therefore to evalu- 7 F 77 6 5 L
ate a physiotherapeutic intervention, consisting 8 F 28 5 6 L
of active movements, exclusively for patients Mean 49.8 8.2 4.4
with Bell’s palsy.
 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52
the baseline, or non-treatment, condition, while
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‘‘B’’ refers to the first identified treatment or
intervention phase (Bobrovitz and Ottenbacher,
1998; Zhan and Ottenbacher, 2001). The study
was approved by the local ethics committee at
Sahlgren’s University Hospital. After informed
consent was obtained, the baseline assessments
were performed.
Instrumentation
At each measurement, the patient completed
a written questionnaire (QS, Appendix 1) to
quantify his or her palsy-related problems. The
facial grading score (FGS, Ross, Fradet, and
Nedzelski, 1996) and the paresis index (Eneroth
et al, 1982) were completed by the physio-
therapist. The FGS is based on an evaluation
of resting symmetry, degree of voluntary excur-
sion of facial muscles and degree of synkinesis
associated with specified voluntary movement.
Different regions of the face are examined separ-
ately using five standard expressions. All the
items are evaluated on point scales and a cumu-
lative score is tabulated. The possible score is
0 100. The higher the score, the better the func-
tion. The FGS has been tested for validity and
reliability (Ross, Fradet, and Nedzelski, 1996).
During observation of the active facial move-
ments, the patient was instructed to wrinkle
the forehead, close the eyes gently, smile, snarl
and pucker his or her lips.
The paresis index was used to evaluate facial
paresis at rest and during activity. Ten items are
scored ‘‘yes’’ or ‘‘no,’’ resulting in a total index
of 0 10. Four of the items describe facial tone
at rest and the remainders describe functional
movements such as wrinkling the forehead, clos-
ing the eyes and puckering the lips. The higher
the index, the more pronounced the paresis
(Eneroth et al, 1982).
To evaluate the inter-rater reliability, all the
patients were videotaped during one session
each. Three experienced examiners, one physio-
therapist, one plastic surgeon and one otolaryn-
gologist, graded the videotaped facial images
independently. The scores that were used were
the FGS and the paresis index. The score sums
of each evaluator were also ranked.
The question score (QS) is a subjective instru-
ment designed by the investigator (EC). The
47
patient indicates the existence and degree of
nuisance of common symptoms of facial palsy.
A total score of 0 56 is possible, where 0 sig-
nifies the absence of problems and 56 the highest
possible degree of problems. During the start of
the baseline period and immediately after the
intervention period, the photographers at the
Department of Plastic Surgery took pictures of
each patient at rest and during the standardized
exercises.
Procedures
The baseline period consisted of three to four
measurement sessions during a period of two to
seven weeks, as a difference between the subjects
is desirable in SSED. This was followed by an
intervention period of 26 to 42 weeks, during
which 6 to 7 measurements were performed,
until the measured scores were relatively stable,
see Figure 3. The values that are given are the
exact values on every occasion. The time from
the baseline assessment to the start of the inter-
vention period is presented in Table 1.
On the last baseline test occasion, the patient
was instructed individually to perform facial
movement exercises. They were performed in
front of a mirror; 5 10 repetitions of each
exercise, twice a day, according to the specific
program in Appendix 2. The instructions during
training were to perform a few, well-coordinated
repetitions with a maximum of concentration
rather than performing as many repetitions as
possible. The training took about 10 15 minutes
on each occasion. The patient was instructed to
document the training in a diary. In all, the sub-
jects were observed for at least 30 weeks. All the
‘‘face to face observations’’ were made by the
same observer.
Statistical analysis
The data did not fulfil the criteria for any
refined statistical evaluation. Only descriptive
statistics were used according to the method-
ology of the SSED (Bobrovitz and Ottenbacher,
1998). In order to eliminate systematic errors in
the inter-rater reliability, it was calculated with
adjusted scores (score minus mean value). The
inter-rater reliability is presented as adjusted
and unadjusted numbers in Table 3. A visual
 48 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52
comparison of the coefficients of variation for
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the test values of the different evaluators was
made (Box, Hunter, and Hunter, 1978). The
coefficient of variation was calculated by divid-
ing the standard deviation with the mean of
the unadjusted values.
Results
All the patients improved their scores on the
FGS, paresis index and written questionnaire.
There appears to be a positive trend for the scores
related to function and disability. A summary of
the FGS for the patients is presented in Figure 2
and for the QS in Figure 3. The paresis index for
all subjects is presented in Table 2.
The results for inter-rater reliability are pre-
sented in Table 3. A comparison of the coefficient
of variation for the test values of the different
raters indicates good reproducibility for the
experimenter (evaluator 3) and satisfactory agree-
ment between the different evaluators. Photos
were taken to illustrate the changes (Figure 1)
An analysis of the exercise diaries suggests
that the compliance was good for all subjects.
The subjects performed the exercises 10 14
times a week.
Figure 2. Facial grading score in every subject during the baseline and treatment period. Values are based on the live observations.
Discussion
The SSED is a well-described method for
evaluating the effects of treatment and the
design is advantageous when the study groups
are small (Bobrovitz and Ottenbacher, 1998;
Zhan and Ottenbacher, 2001). The results of this
kind of study are, however, not as strong as
those of randomized, controlled trials. The part-
icipants constitute their own controls and, if fol-
lowed for a sufficient period of time, it is
possible to see trends over time. A positive trend
for the FGS, QS and paresis index was observed
for all the subjects in this trial, but larger groups
of patients must be studied before any definite
conclusion about the effect of the treatment used
in this study can be drawn.
It is also difficult to evaluate the effect of any
therapy in a disease with such a high spontaneous
recovery rate (50 75%) as Bell’s palsy (House,
1983). A complete recovery is seldom seen if the
voluntary power in the face is absent after the
end of three weeks from the onset. If a return is
first noted after two to four months, an unsatis-
factory outcome is often the result (Dumitru,
Walsh, and Porter, 1988; Eneroth et al, 1982;
Peitersen, 1982; Walton, 1993). The subjects in
 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52 49
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Figure 3. Questionnaire score (QS) for every subject during the baseline and treatment period. Values are based on the live
observations.

our study were included 4 21 weeks after the treatment lies in the subjective methods of
onset, but they were then only observed during assessment and reporting (House, 1983). The
a baseline period of 2 6 weeks (i.e., the patients analysis of the inter-rater data provides an exter-
started the treatment 7 28 weeks, median 11 nal test of the reliability of the measurements.
weeks, after onset). When scrutinizing the results, One important observation is that the phy-
most patients had a stable baseline period, fol- siotherapist’s FGS ratings (average score 56)
lowed by a positive change during the period of tend to be more positive than those of the other
training. It is then possible to conclude that the evaluators (average score 45). The different eva-
results for the patients included in this trial were luators’ rankings of subjects are almost identical
not only the result of a spontaneous recovery but (Table 3).
also an effect of the training. The observable difference between the phy-
The main problem when assessing the results siotherapist’s ratings based on live evaluations
of physiotherapy, facial nerve surgery or medical and video recordings is very small. In a more
comprehensive comparative study of evalua-
tion techniques, observations based on video
Table 2. Paresis index during the baseline versus training recordings were shown to be less reliable than
period in the eight subjects. both direct observations and photo slides
(Smith, Murray, Cull, and Slattery, 1991). The
Subject
actual rates given to a specific subject differ
number Baseline Treatment
between the evaluators, up to 23 points for the
1 4 2 2 2 1 0 0 0 0 0 FGS and 2 points for the paresis index. The
2 4 3 2 1 1 1 1 1 1 1 adjusted values for FGS ratings in Table 3 were
3 8 8 9 8 7 6 2 2 2 2 obtained by subtracting the mean value of all
4 8 8 5 5 6 6 4 4 2 2 ratings allocated by the evaluator. This table
5 9 9 9 8 7 4 3 3 3 3 shows good agreement between the adjusted
6 10 10 10 10 10 10 7 7 4 ratings allocated by different evaluators to the
7 9 9 8 9 8 4 3 1 2 7 same subject. The span of values over subjects
8 8 8 8 7 6 6 5 4 4 is reduced from between 6 and 23 for the unad-
justed values to between 5 and 12 for the adjusted
 50 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52

Table 3. Inter-rater reliability of facial grading score. Three evaluators’ ratings made from video observations of the eight
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subjects and the span between the ratings. Each subject’s ranking (1 8) by the three evaluators is also given, as well as ratings
from the live observation made by one of the evaluators.

Evaluator 3,
Subject Evaluator Evaluator Evaluator live
number 1 2 3 Span Ranking observation
Unadjusted 1 80 77 94 17 1,1,1 94
values 2 26 17 26 9 7,7,8 34
3 18 13 27 14 8,8,7 22
4 59 49 56 10 4,4,4 55
5 60 57 80 23 3,3,2 90
6 69 66 75 6 2,2,3 78
7 41 23 42 19 5,6,6 43
8 29 33 47 18 6,5,5 47
Mean 48 42 56 58
Adjusted 1 32 35 38 6 36
values 2 22 25 30 8 24
3 30 29 29 10 36
4 11 7 0 11 3
5 12 15 24 12 32
6 24 24 19 5 20
7 7 19 14 12 15
8 19 9 9 10 11
Standard 21 22 24 25
deviation
Coefficient 0.44 0.52 0.43 0.43
of variation

values, demonstrating a large, systematic error in
the subtracted values. In this adjustment, only
the video observations are included. Simul-
taneous inclusion of the live evaluations would
involve the uncontrolled mixing of different
kinds of systematic error. What is also important
is that the ranking of the subjects is almost unani-
mous. This analysis supports the conclusion that
the correlation among raters is in fact good. The
reliability is then within 10 points for an individ-
ual measurement and, of course, much less for
longer measurement series. However, in the light
of the relative smoothness of the curves describ-
ing the measurement series for the different
patients, a ‘‘stochastic’’ error limit of 10 points
must be an exaggeration. Visual inspection of
the individual curves in Figures 2 and 3 indicates
that the ‘‘noise level’’ is lower than this. Needless
to say, this does not exclude systematic errors,
which may vary between patients, but, as the
aim is to study the change in each patient’s
individual ratings over time, any such systematic
error is irrelevant. It simply moves an entire
curve up or down in the diagram. The conclusion
of ratings over time indicates that the scores
reported in Figures 2 and 3 are reliable.
There are three factors that evaluate and
determine the grade of sequelae: 1) the degree
of paresis, 2) contracture, and 3) associated
movements. The final functional and esthetic
results depend on a combination of these three
elements (Peitersen, 1982). These various aspects
should be evaluated individually and expressed
quantitatively (Huizing, Mechelse, and Staal,
1981). All these factors can be estimated by the
measurements used in this study. The paresis
index is a clinically widespread tool introduced
in 1976. It provides a very rough measurement
of the status of the subject. The FGS is more
precise; it separately measures resting symmetry,
voluntary movements and synkinesis. Each of
the three parts evaluates different regions of
 Cederwall et al/Physiotherapy Theory and Practice 22 (2006) 43 52
the face. The mouth region is naturally more
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important than the forehead and therefore
obtains a higher weight in the FGS total. Only
the results of the FGS inter-rater reliability are
therefore presented.
Judging on the basis of photographs is also an
appropriate method (Huizing, Mechelse, and
Staal, 1981). The photos (Figure 1) are enclosed
to exemplify the motor and cosmetic problems
experienced by a person with Bell’s palsy.
The duration of each training session, the
length of the training period, frequency of train-
ing and the quality of the exercises performed
are all essential factors when evaluating an
intervention like the one used in this trial.
The instructions during training were to make
a few, well-coordinated repetitions with a maxi-
mum of concentration rather than only perform-
ing as many repetitions as possible. The goal was
to perform 10 repetitions of each exercise, but
the time until that was realized varied. The dif-
ference in the length of the interventions may
have affected the results, but this is a strength
of the SSED design, where the patients are their
own controls and the results that are presented
are only trends based on the participating sub-
jects’ results. Another study design would have
required more standardized training instruc-
tions, but we believe this would have a negative
effect on the patients, as this category of patients
is heterogeneous.
In future investigations, a much larger sample
of persons with Bell’s palsy will be needed. It
would be of value to follow randomized treat-
ment and control groups for a longer baseline
period and to study patients receiving other forms
of treatment. It is possible that recovery is partly
spontaneous, but this study suggests that the
exercise training program has positive effects. A
patient participating in a training program is less
likely to stagnate in that aspect of recovery.
In conclusion, patients with remaining symp-
toms of Bell’s palsy appear to experience posi-
tive effects from a specific training program,
but a larger study is needed to fully evaluate
the treatment.
Acknowledgements
The study was supported by grants from the
Renée Eander memory foundation and The Swed-
ish Association of Registered Physiotherapists.
51
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weakness. Archives of Otolaryngology-Head & Neck
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1 8 3. Do you have a dry eye?
4. Do you have a wet eye?
Appendix 1 5. Does food remain in your cheek while you
are eating?
Exercise program 6. Does it overflow while you are drinking?
7. Is your speech affected?
Mouth: 8. Do you have pain in your face?
9. Is the sensibility in your face affected?
1. Pucker your mouth with closed lips (like 10. Is there anything else you would like to
making little kiss). add?