OCCUPATIONAL THERAPY INTERNATIONAL

Occup. Ther. Int. 16(1): 7181 (2009)

Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/oti.267

Case study of Bells palsy applying

complementary treatment within an
occupational therapy model
EMILY HALTIWANGER, College of Health Sciences, University of Texas at
El Paso, El Paso, TX, USA
THERESA HUBER, Advanced Clinical Therapeutics of the Western Slope,
Grand Junction, CO, USA
JOE C. CHANG, Fort Hood Resilience and Restoration Center Warrier Combat
Stress R.
ARMANDO GONZALES-STUART, University of Texas at El Paso/University
of Texas Austin Cooperative Pharmacy Program, EI Paso TX, USA
ABSTRACT: For 7% of people with Bells palsy, facial impairment is permanent.
The case study patient was a 48-year-old female who had no recovery from paralysis
12 weeks after onset. Goals were to restore facial sensory-motor functions, functional
abilities and reduce depression. Facial paralysis was assessed by clinical observations,
the Facial Disability Index and Beck Depression Index. Complementary interventions of aromatherapy, reflexology and electro-acupuncture were used with common
physical agent modalities in an intensive home activity and exercise programme. The
patient had 100% return of function and resolution of depression after 10 days of
intervention. The limitation of this study is that it was a retrospective case study and
the investigators reconstructed the case from clinical notes. Further research using a
prospective approach is recommended to replicate this study. Copyright 2009 John
Wiley & Sons, Ltd.
Key words: aromatherapy, Bells palsy, complementary treatment, electroacupuncture, physical agent modalities

Introduction
The purpose of this retrospective case study was to evaluate a complementary
approach to occupational therapy-based treatment of a patient with facial paralysis, secondary to Bells palsy.

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Incidence
Worldwide statistics indicate a frequency of Bells palsy to be about 0.02% of
the population (Tha and Swierzewski III, 2008), with peak incidence between
the ages of 15 and 40 years (Holland, 2004). It is more commonly seen in young
adults and persons of Japanese descent (Swierzewski III, 2000). Men and women
are equally affected, although the incidence may be increased in pregnant
women and people with diabetes (Holland, 2008).
Etiology
Bells palsy or idiopathic unilateral palsy is an acute disorder of the cranial nerve
VII that affects motor neurons for voluntary facial movement (VanSwearingen,
1998). The condition may arise overnight with maximized paralysis within 1 or
2 days. It may be preceded by otalgia, ear infection, oversensitivity or hyperacusis, low-grade fever, stiff neck, weakness and/or stiffness localized to one side of
the face National Organization of Rare Diseases (NORD) Database, 2008.
An inflammatory process leading to ischaemia and/or compression of the
cranial nerve VII damages the facial nerve. The clinical picture may involve
unilateral flaccidity of facial muscles, an inability to close the eyelid fully or
blink, excess or decreased tearing, drooling on the affected side, difficulty
chewing, decreased perception of taste, pain or numbness behind the ear, and
either numbness, pain or twitching of facial muscles on the affected side (NORD
Database, 2008). In the landmark Copenhagen Facial Nerve Study lasting 25
years, Peitersen (2002) reported 1701 cases with Bells palsy, with 70% experiencing complete paralysis and chances of full recovery being 61%. The remaining
30% had incomplete paralysis with 94% achieving full recovery. Of those with
complete paralysis, 85% experience spontaneous recovery within 3 weeks. The
remaining 15% showed some improvement 35 months later. He reported that
those showing no recovery in 6 months will have permanent loss of function
and contractures. Prognosis for recovery is linked to age, symptoms at onset,
and time until the first sign of remission, lack of post-auricular pain, normal
taste and lacrimination (Peitersen, 2002).
Psychosocial issues
Untreated, Bells palsy will afflict some people with continued functional facial
distortion that leads to diminished quality of life (Holland and Weiner, 2006).
Disfiguring paralysis has an overwhelming psychosocial impact, especially in
cases where the paralysis extends for long duration (Elliot, 2006). Batra and
Batra (2007), in an occupational therapy study, stated, Facial paralysis has
been primarily considered a cosmetic inconvenience . . . (p. 39); but a Bells
palsy chat website implies that only someone who has had similar experience
can comprehend the depth of emotion and how intensely the self-esteem of
Copyright 2009 John Wiley & Sons, Ltd

Occup. Ther. Int. 16(1): 7181 (2009)

DOI: 10.1002/oti

Case study of Bells palsy

the individual can be affected by facial paralysis (Bells Palsy Information Sites,
2008).
Rumsey et al. (2004) reported psychosocial difficulties may include the perception of an altered body image, secondary to visible facial disfigurement,
resulting in perceived social embarrassment. Bull and Rumsey (1988) confer
manifestations of social discomfort, and awkwardness results in avoidance
behaviours. Social situations bring challenges of distorted speaking and facial
expression, resulting in altered self-image (Butler, 2000).
Medical options
The principles of medical treatment by physicians have remained relatively
constant (Adour, 1982). Routine care involves a trial of antibiotics, antiviral
agents, anti-inflammatory agents, corticosteroids and lubricating eye drops, or
viscous ointments (Grogan and Gronseth, 2001). Surgical decompression of the
cranial nerve VII may be non-restorative in 20% of cases (Sinha et al., 1994).
Other treatments are biofeedback (Dalla-Tofola et al., 2005), EMG and
mirror feedback (Ross et al., 1991), periodic botulism toxin injections (Bulstrode
and Harrison, 2005), hyperbaric oxygen (Holland et al., 2008), electrical stimulation (Ohtake et al., 2006), acupuncture (Liang et al., 2006), and chiropractic
manipulation (Alcantara et al., 2003).
Current therapeutic interventions
Diels (1997) reported that occupational and physical therapists have been
serving people with facial palsy since the 1920s. Physical therapy has been
effective in reducing facial paralysis and improving functional outcomes
(VanSwearingen and Brach, 1998). Physical therapy techniques have included
kinesiotherapy, biofeedback, EMG (Dalla-Tofola et al., 2005) and active assistive
exercise of specific facial movements (Elliott, 2006).
Occupational therapy
Five articles were identified in the occupational therapy literature. Several
authors reported facial splints developed for facial paralysis (Jennerjohn, 1956;
Kuntavanish, 1974; Pomerantz, 1974). Beals (1951) reported two case reports of
success with home programmes using poetry recited with muscles on stretch in
various head positions, resistive activities with candy suckers and pantomime of
emotions. Cronin (1998) described neuromuscular facial retraining. Batra and
Batra (2007) compared a conventional approach of facial massage, passive stimulation and exercise to occupational therapy treatment to a functional dynamic
taping protocol for 30 matched subjects. Results evaluated by paired t-test
showed that the taping was more effective at the p < 0.5 level.
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As rehabilitation therapists who comprehend both the psychological effects

of facial disfigurement and its impact on choices of occupation, there is a strong
need for occupational therapists (OTs) to further explore their unique role and
contribution to treatment of people with Bells palsy who are not progressing
toward recovery. Furthermore, OTs have their focus on balance, occupational
functioning, spirituality, lifestyle, physical activity, stress and sleep, which are
all aspects of complementary medicine.
Aromatherapy and acupuncture
Aromatherapy can be defined as the art and science of using essential oils as a
therapeutic option. In France, aromatherapy is a form of pharmacology and
complementary medical treatment (Pnol and Pnol, 1998). Essential oils
enhance the bodys ability to heal by activating the immune system, the endocrine system, the nervous system, the psyche and other systems of the body
(Pnol and Pnol, 1998; Price and Price, 2007).
Acupuncture consists of inserting needles into specific points of the body
known as acupoints, which helps to promote the adequate flow of vital energy
throughout the body. Although aromatherapy and the therapeutic application
of essential oils have been used for many decades in Western medicine, the
combination of traditional Chinese medicine (TCM) and essential oils is a fairly
recent modality. TCM recognizes 365 acupoints distributed throughout the
human body. Each acupoint serves as an insertion point for an acupuncture
needle. The same acupoints can also be a site for application of essential oils
according to their chemical and medicinal properties (Willmont, 2007).
Treatment of peripheral facial paralysis with electro-acupuncture
TCM is based on balancing ones energy system, which is not clearly defined in
Western medicine. The etiology of peripheral facial paralysis is derived from an
invasion of wind-cold, due to an underlying deficiency of qi (pronounced chi or
chee). The blockage of qi (energy flow) causes illness. In facial paralysis, qi
impacts the blood circulation in the channels and collaterals in the facial
region. This leads to the stagnation of qi and blood. Placement of hair thin
needles at points along energy pathways called meridians will restore flow and
homeostasis, thus returning the body toward balance to resolve facial paralysis
(Mayer, 2007).
Acupoints are selected based upon the distribution of the main branches of
the facial nerve (CNVII) or by the pattern of differentiation. For the function
and location of acupoints pertaining to the distribution of the main branches
of the facial nerve (temporal, zygomatic, buccal and mandibular) used in the
treatment of facial paralysis, see Lian et al. (2005).
Several Bells palsy studies show use of acupuncture compared to Western
approaches. A collaborative Chinese and Western Medicine study occurred in
Copyright 2009 John Wiley & Sons, Ltd

Occup. Ther. Int. 16(1): 7181 (2009)

DOI: 10.1002/oti

Case study of Bells palsy

a Chinese hospital with 83 subjects (Wang et al., 2004). The intervention group
received physical therapy, acupuncture and medication. The control group had
massage and functional exercise. Improvement of functional facial scores and
index score was p < 0.01 over the control group, with the combined approach,
suggesting that Chinese and Western Medicine work well together. A large
randomized trial, 439 subjects in four Chinese clinical centers, verified the
effects of acu-moxi treatment using the facial Disability Index (FDI) at p < 0.05
by providing acupuncture and moxibustion (a technique using heat of a burning
moxa herb on acupuncture points to move qi) and comparing it with control
groups receiving vitamin therapy and medication (Li et al., 2004).
Clinical features of the retrospective case
Ellie (fictitious name), a 48-year-old married Caucasian female, was self-employed
full time operating her own costume business. Her duties included facing the
public daily with a perfect smile. After 3 weeks of a right ear infection with
continued pain, Ellie developed Bells palsy (ipsilateral regional facial paralysis
on the right). The otolaryngologist predicted she would have maximum recovery
in 6 months and should return to the doctor at the end of that time period.
Three courses of antibiotics did not appear to be resolving the bacterial process,
as evidenced by the facial swelling on the right.
The home health OT requested the referral for evaluation and treatment,
due to the patients history of depression and unresolved facial paralysis. Ellie
had a history of pre-morbid conditions: a major depressive episode with suicidal
ideation, neck pain, back disability, thoracic outlet syndrome, restless leg syndrome and sleep apnea. She was taking antidepressants. Post-paralysis, Ellie
rarely left home, and when doing so, she held her head down and covered her
mouth. She stated, I will hide socially from others, quit my job and stay home.
Ellie was emotionally devastated stating, My doctor doesnt care.
The initial occupational therapy evaluation was conducted 12 weeks following the onset of symptoms of facial paralysis, because the patient was not
recovering spontaneously on her own, as 70% of cases do. Evaluation consisted
of appraisal of her resting facial posture and active movements, with photos used
for pictorial history of progress. Ellie presented with right side paralysis, swelling
and markedly decreased sensation, intense otalgia and reduced tear production
and irritating dry eye, but no hyperacusis or aural fullness. She had difficulty
smiling, puckering, pursing lips, snarling and frowning, but was able to drink,
eat and speak with normal tongue movements. She could only partially close
the right upper and lower eyelids, which she taped to sleep. A positive Bell reflex
in the right eye (Jelks et al., 1979) was found to be consistent with eye closure
difficulty.
Facial posture revealed severe asymmetry with a right-sided droop. Voluntary
movement was barely visible, whereas the uninvolved left side facial musculature
was fully intact. There was a partial contraction of the obicularis oris, obicularis
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occuli, corrugator and labii inferioris muscles. The occiptofrontalis and platysma
muscles showed trace contraction. There was no perceptible movement of the
zygomatic major and minor, levator anguli oris, levator labii superiouris, and
labii inferioris muscles.
Case study methodology
This retrospective study used pre- and post-outcome measures with a patient
who received occupational therapy intervention in 2003 for 5 days. To assess
self-reported disability, two questionnaires were given at admission and 10 days
later upon restoration of muscle strength and functional skills. The FDI is a
10-item self-report questionnaire that was normed on 46 patients with facial
disability (VanSwearingen and Brach, 1998). It assesses the severity of the physical disability and the relationship between the impairment and psychosocial
status occurring with facial nerve disorders. The FDI consists of physical function (items 15) and social well-being (items 610) subscales. The scores range
from 0 (complete paralysis) to 100 (normal facial function) and from irritability
and withdrawal (impaired function) to social comfort, calmness and peacefulness (social/well-being). The FDI is considered a reliable, valid instrument
(VanSwearingen and Brach, 1998). Theta reliability scores were 0.88 for the
physical function subscale and 0.83 for the social/well-being scale, and construct
validity was correlated with physician examinations (VanSwearingen and Brach,
1998). The Beck Depression Inventory (BDI) is used worldwide as an indicator
of the severity of depression that was normed on psychiatric patients (Beck,
1972). The BDI has 21 items that link attitude and symptoms to depression.
The testretest reliability was above 0.90, the Spearman-Brown correlation for
reliability at 0.96, and the internal consistency of test items being 0.86.
Ellies initial score on the FDI (VanSwearingen and Brach, 1998) revealed
physical function subscale scores = 11/100; social/well-being subscale scores =
12/100 indicated moderate difficulties on both subscales. The BDI score of 25
indicated moderate depression.
Treatment intervention
Aromatherapy and electrical acupuncture (EA) were implemented along
with traditional approaches to facilitate change. Familiar treatment modalities
of ice, heat and vibration were used in addition to the complementary modalities
to reduce the inflammatory response during the first 3 days, and to re-establish
sensory and motor function in the face and restoration of functional activities
during the remainder of treatment. The purpose of the home programme was to
facilitate active movements and to restore habitual abilities like blowing, smiling,
puckering, sniffling, flaring nostrils and frowning. Motor gains occurred quickly
with the stimulation programme, after reduction of swelling and pain.
Copyright 2009 John Wiley & Sons, Ltd

Occup. Ther. Int. 16(1): 7181 (2009)

DOI: 10.1002/oti

Case study of Bells palsy

The first goal was to reduce swelling of the face, so that motor function could
be achieved. To this end, diluted essential oils were applied to the face and feet
with an infrared facial massager (available in retail stores), and hot caster oil
compresses to infuse the oils through the skin, as Bharkatiya et al. (2008)
reported that heat and moisture can increase absorption of the oils at the point
of application. Subsequent to attendance at a medical aromatherapy course
given in Las Cruces, New Mexico in 2003 by a physician who used medical
aromatherapy in his medical practice, the OT consulted the physician by phone
to discuss the case (Raphael deAngelo, personal communication, 17 April
2003). Dr. deAngelo recommended a treatment protocol that included 12 drops
of the blended essential oils called Breath of Life, Frankincense/Lavender and
First Defense (Ancient Legacy, n.d.) that were added to 1 ounce of jojoba oil
(as a carrier oil) and were applied to facial acupoints. In addition, Dr. deAngelo
recommended that a tea tree oil blend consisting of tea tree, eucalyptus and
peppermint oil be placed behind the right ear along the mastoid process. Oils
were applied as instructed to facial acupoints every 15 minutes for the first 2
hours, then during every waking hour for 3 days, and to foot reflexology points
bilaterally, which were located on the balls of the feet, the weight-bearing area
of the big toes, and the general area around and below the metatarsals. These
points corresponded to primary reflex points for head and neck. Cold packs were
applied three times daily. Initially, the patient ingested one to two drops of
blended tea tree oil, eucalyptus and peppermint, directly on her tongue, without
dilution to reduce the inflammatory and/or infectious process, every hour. The
Pointer-Plus, an inexpensive battery-powered electrical spatial stimulator that
finds the location of acupuncture points by generating auditory and flashing
light cues, was used on an investigational basis to provide EA stimulation to
facial points. The pulse frequency was fixed at 10 Hz. A sound and flashing light
facilitates the detection of a point. Other devices for acupoint stimulation are
Electro-Therapeutic Point Stimulation (ETPS) NeuroMechanical therapy
(Hocking, 1998) and Acu-Health (Richards, 1989). Stimulation of various acupoints was performed to move energy and promote homeostasis. EA was supervised by an OT during the study, who was also an acupuncturist.

Outcome
On the first day, sessions began with the OT applying EA to acupoints with
the Pointer-Plus device, followed by quick ice, vibration and tapping. The OT
also applied diluted oils with the infrared massager to facial acupoints and feet.
By the second day, Ellie and her husband had learned by demonstration techniques, pictures and foot reflexology maps to provide the above treatments,
including quick ice, tapping, sweeping and vibration. Using these techniques
repetitively, six to eight times daily, Ellies facial pain and swelling was abated
by the third day. Once the swelling was under control, the patient was ready
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for acupoint stimulation to facilitate motor function. Due to reduction of pain

and swelling, Ellie was able to perform approximations of muscle contractions
with contract and hold techniques, use of antagonist muscle co-contractions,
and practice of pucker, smile, frown, snarl and surprise facial expressions with
her husband in front of a mirror. An online website provided a list of exercises
that were turned into enjoyable games for her delight, to facilitate actions and
motions (Bells Palsy Information Site and Forums, 2000). For example, Ellie
would blow into a straw to make ink paintings or stack straws with her lips.
These occupation-based activities were enjoyable to Ellie, as they strengthened
her facial motions. As she became more adept, Ellie chose her stimulation activities and created her own games to play with family members.
By the fourth day, Ellie was able to whistle gleefully. Every improvement was
celebrated and reinforced by family members, building her enthusiasm with
every gain. Photographs were taken every day to show progress. On the fifth
day, Ellie had approximately 80% return of function. When she could kiss her
husband, she appeared to be restored to her fun-loving, giggly and playful self.
Ellie continued with her home programme of activities and exercises for five
more days, until she had regained full motor function. Initially, Ellies baseline
score on the FDI indicated scores on the physical function subscale of 11; social/
well-being subscale = 12, which indicated moderate facial disability and psychosocial discomfort. The pretest Beck Depression Scale score of 25 indicated that
Ellie was moderately depressed. By comparison, post-test scores after 10 days of
treatment revealed FDI physical function subscale = 100 or full functioning, and
social/well-being = 80 indicated no difficulties. The final score on the Beck
Depression Scale of 1 indicated normal mood.
Role of caregivers in the intervention
Ellie and her family members were cooperative during a 5-day intensive multisensory stimulation home programme, and later with a home exercise and
functional activities programme for five more days, until her full recovery. Ellies
recovery might have taken longer, had it not been for the devotion of her family
members and her belief that the OT could help restore her functional ability.
The OT communicated with the family daily to review the documentation of
all modalities performed on schedule and functional improvements.

Summary of the intervention and outcomes

In summary, the first goal was the frequent application of a systematic multisensory complementary protocol to help decrease swelling, inflammation and
nerve compression. Once the oedema was reduced after 3 days, a 2-day protocol
was initiated to activate paralyzed musculature and improvement of functional
abilities. In total, the patient received 5 days of treatment with an intensive
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barrage of sensory stimuli accomplished with a home programme that was

implemented by her dedicated family members during waking hours. In 5 days,
she experienced 80% return of sensory and motor function, and by the 10th
day, she had complete return. Final post-test scores on the Beck Depression
Scale revealed normal mood. Scores on the FDI indicated no facial disability
and a sense of social comfort and well-being with the absence of paralysis. Facial
symmetry was restored, as evidenced by photos for comparison.
Conclusion
Complementary approaches were used by the OT to treat a patient diagnosed
with Bells palsy. A case study such as this stimulates a number of questions for
readers. Would the patient have recovered without treatment given for 6 months?
Would Ellies depression worsen without any intervention? Might there be a
strong role for occupational therapy in early treatment of Bells palsy because
of the intense psychosocial distress associated with facial paralysis? As OTs, we
must broaden our skills by collaborating with other practitioners to advance our
field. This case study suggests the need for OTs to broaden their horizons to
look for solutions to problems that enhance functioning and provide the evidence to inform future practice.
Limitations
This pilot project provides an example of using aromatherapy and acupressure
with a patient who has symptoms of Bells palsy. It is speculative as to whether
the patient would have fully recovered motor function in 6 months without
treatment (suggested by her physician) or whether she would have been among
the unlucky who do not recover at all. However, this paper substantiated that
the patient was significantly depressed about her facial distortion and frustrated
by her lack of progress and subsequently made progress following the therapy
protocol.
Implications
Experimental research is essential to evaluate a complementary protocol for
subjects with Bells palsy who show no signs of recovery status post 3 months
in comparison with control group members receiving traditional intervention,
in order to advance practice and create new interventions.
Acknowledgements
The authors would like to thank the following for their guidance and support
of this project: Wendy G. Spielman, MAOM, OTR, L.Ac; Raphael dAngelo,
MD, A.T.; and Alexandra Brighton, Master Blender.
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Address correspondence to Emily Haltiwanger, College of Health Sciences, University of Texas
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