Physical Therapy Reviews

ISSN: 1083-3196 (Print) 1743-288X (Online) Journal homepage: http://www.tandfonline.com/loi/yptr20

Effectiveness of electrical stimulation for

rehabilitation of facial nerve paralysis

Katie A Fargher & Susan E Coulson

To cite this article: Katie A Fargher & Susan E Coulson (2017): Effectiveness of electrical
stimulation for rehabilitation of facial nerve paralysis, Physical Therapy Reviews, DOI:
10.1080/10833196.2017.1368967

To link to this article: http://dx.doi.org/10.1080/10833196.2017.1368967

Published online: 31 Aug 2017.

Submit your article to this journal

Article views: 12

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=yptr20

Download by: [Australian Catholic University] Date: 20 September 2017, At: 00:02
 Effectiveness of electrical stimulation for
rehabilitation of facial nerve paralysis
Katie A Fargher, Susan E Coulson 
Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia

Background: Despite no significant advantage being demonstrated for its use and no standardization of treatment
guidelines, electrical stimulation is still applied by therapists to treat facial paralysis. The aim of this investigation
was to determine whether electrical stimulation therapy for patients with acute or chronic facial nerve paralysis
improves time to, and rates of full recovery and facial function compared with no intervention.
Method: A systematic review of randomized and quasi-randomized controlled trials through Scopus, Medline,
Downloaded by [Australian Catholic University] at 00:02 20 September 2017

PEDro, Embase, CINAHL, Pubmed, and Cochrane Library search engines for studies published up until August
2016. Reference lists were reviewed for further studies. Review Manager was used to extract data and review
quality of the studies. Studies were assessed for randomization of participants, allocation concealment, blinding
of participants, assessors and physiotherapists, presence and reporting of outcome data.
Results: Five studies were included for analysis – four during acute recovery and one in chronic facial nerve
paralysis. In acute facial nerve paralysis, two studies found no benefit of electrical stimulation and two studies
found improvement. A meta-analysis on changes in the House–Brackmann Score after treatment, rates of full
recovery and time to full recovery showed no statistically significant difference between intervention and control
groups. In chronic facial nerve paralysis, one study found improvements after extensive electrical stimulation on
the Facial Paralysis Recovery Profile.
Conclusions: There is no evidence to support the use of electrical stimulation during the acute phase of recovery
after Bell’s palsy and there is low-level evidence for patients with chronic symptoms. Furthermore, there is no
evidence available on the use of electrical stimulation for other causes of facial nerve paralysis.
Keywords:  Bell palsy, Facial nerve, Electrical stimulation therapy, Facial paralysis, Physiotherapy, Rehabilitation

Introduction
Facial nerve paralysis (FNP) affects social interaction,
communication, and self-esteem, leading to long-lasting
negative impacts on daily life.1 Idiopathic Bell’s palsy
accounts for 75% of all cases, with trauma and Herpes
Zoster Oticus the next most common causes.2,3 There is a
variable degree of recovery after FNP without intervention
and this is dependent on the severity, cause, and location
of the nerve damage.4 With neuropraxia, or partial degen-
eration of the nerve, clinically observable facial move-
ment usually begins within a few weeks.4 When complete
degeneration of the nerve occurs, as with axonotmesis or
neurotmesis, movement only begins after the nerve regen-
erates.2,5 The nerve grows at a rate of 0.5 to 3 mm per day6
and reinnervation may be disordered due to scar tissue
and disruption of nerve fibers.5 Regeneration can lead to
altered patterns of muscle contraction, salivation, and tear-
ing (motor and autonomic synkinesis).7 Earlier recovery of
function indicates a milder injury with better prognosis.2
All patients with Bell’s palsy experience some recovery,
with 71% achieving full recovery. Outcomes after surgery
Correspondence to: Susan E Coulson, Discipline of Physiotherapy Faculty
of Health Sciences, University of Sydney, Sydney, Australia. Email: susan.
coulson@sydney.edu.au
and trauma vary depending upon the site and severity of
the injury.
Along with pharmacology8 and surgery, physiotherapy
is undertaken after FNP to improve function. Patients are
referred to physiotherapists during acute and chronic
phases of recovery. Electrical stimulation has been used
since the 1950s with the goal of improving facial function
and minimizing sequelae.9 The aim of electrical stimula-
tion is to encourage nerve regeneration,10 and to main-
tain muscle bulk and contractile properties.10–12 In animal
studies, the quality of the muscle reinnervation is also
examined on a cellular level, with electrical stimulation
aiming to minimize polyinnervation, collateral branching,
interstitial fibrosis,13 Wallerian degeneration and demyeli-
nation.14 The types of electrical stimulation that have been
used by therapists include galvanic,9 eutrophic,15 mono-
phasic,11 biphasic,12 subthreshold,13 and contraction level.11
A systematic review in 200316 concluded that using
electrical stimulation was beneficial, however it included
case studies and case series which do not control for nat-
ural recovery. A Cochrane Review in 201117 addressed
multiple physiotherapy modalities for acute Bell’s palsy
and concluded no benefits of electrical stimulation at

© 2017 Informa UK Limited, trading as Taylor & Francis Group

DOI 10.1080/10833196.2017.1368967 Physical Therapy Reviews   2017 1
 Fargher and Coulson  A systematic review and meta-analysis of the literature
6 months post onset. This review aims to address the
question ‘Does electrical stimulation therapy for patients
with acute or chronic FNP improve time to full recovery,
rates of full recovery and facial function compared to no
intervention?’.
Method
Identification and selection of studies
Literature searches were completed on Scopus, Medline,
PEDro, Embase, CINAHL, Pubmed, and Cochrane Library
search engines. Search terms used were ‘facial nerve’,
‘facial paralysis’, ‘facial palsy’, ‘Bell$ palsy’, ‘electrical
stimulation’, ‘electrotherapy’, ‘physical therapy’, ‘physi-
otherapy’, and ‘rehab*’. Reference lists of retrieved arti-
cles were also reviewed for further relevant studies. All
searches were completed between 26 May 2015 and 19
August 2016 by KF. Screening of titles and abstracts for
Downloaded by [Australian Catholic University] at 00:02 20 September 2017
inclusion was completed by KF and SC. Disagreement
was resolved by discussion.
Wide inclusion criteria were necessary to draw con-
clusions relevant to variable etiologies and different
phases of rehabilitation (Figure 1). Only human studies
were included. Electrical stimulation delivered through
acupuncture needles was excluded. Randomized control
trials and quasi-randomized control trials were included
for analysis. Articles were excluded if electrical stimu-
lation was combined with another intervention that the
comparison group did not receive. Only published work
available in English through the document search were
used. Studies were excluded if they did not meet one of
the inclusion criteria.
Assessment of study characteristics and data
analysis
Variables sought from the studies are listed in Table 1. The
information was extracted by KF and reviewed by SC. The
risk of bias analysis was completed in Review Manager
(RevMan version 5.3; Copenhagen, Denmark: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2014)18
and addressed randomization of participants, allocation
concealment, blinding of participants, assessors and phys-
iotherapists, presence and reporting of outcome data. The
Figure 1  Inclusion criteria.
2 Physical Therapy Reviews   2017
summary is presented in Figure 2. The PRISM-A state-
ment was followed during data extraction.19 Data analysis
was completed in Review Manager (RevMan version 5.3;
Copenhagen, Denmark: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014)18 using mean difference
and odds ratios with 95% confidence intervals. Kim and
Choi10 were the only paper to include a standard deviation
in their pre-treatment data. As it was calculated from a
large population (n = 60), it was the best estimate availa-
ble and was used across the studies to allow the pooling
of data.
Results
Included studies
Twenty-one papers were reviewed. Eight studies were
excluded for being case series20–27, two for a lack of rand-
omization28,29 and one for comparing ES to an alternative
therapy with no control group.30 Four reviews16,31–33 and
one retrospective chart review3 were also excluded. Five
studies were found to meet final criteria – four in acute
phase of recovery and one in chronic phase (Figure 3).
Characteristics of studies
Two randomized9,11 and two quasi-randomized controlled
trials10,12 applied electrical stimulation during acute phases
of recovery and one quasi-randomized controlled trial15 in
chronic phase. The dominant etiology was Bell’s palsy.
Full details of included studies are in Table 2. The quality
of each study was assessed using individual domains of
selection, performance, detection, attrition, and reporting
bias. A lack of blinding of the participants impacted on all
study outcomes. This would likely bias participants in their
compliance with therapy and home programs, as they are
aware that they are in the active therapy group. Conclusions
of some studies were considered with respect to low partic-
ipant numbers in treatment and control groups. No study
used intention-to-treat analysis. The risk of selection bias
was high in three studies,10,12,15 unclear in one,9 and low
in one.11 The impact of selection bias in unclear. Results
may have been affected by participants being preferen-
tially allocated to treatment or control groups depending
on their prognosis. Blinding of assessors was only clearly
stated in one study.11 This places the other studies at high
risk of bias toward the predispositions of the researchers.
Electrical stimulation parameters
In the acute studies, three used similar therapy parameters
to maintain muscle properties (Table 2).9,11,12 The program
started between two- and four-week post injury and was
administered by a therapist. Minimal muscle contractions
were used during sessions. The frequency of treatment var-
ied from 1 day per week12 to 5 days per week.11 Electrical
stimulation was continued for a variable length of time
from 3 weeks11 to 3 months.12
Kim and Choi10 used electrical parameters that were
different to the other studies. Stimulation was at a
 Fargher and Coulson  A systematic review and meta-analysis of the literature

Table 1  Variables sought from studies

Patient factors Cause of paralysis, length of injury, specific surgery (if relevant), presence of denervation
Intervention information Machine used, intensity, frequency, length of each session, number of sessions per day/week, length of
total intervention, type of pulse, type of electrical stimulation (galvanic/faradic), pulse duration, interval, pulse
rate, who applied electrical stimulation, size and location of electrodes, time post injury intervention was
started
Comparisons Other treatments used in control and experimental groups
Outcomes Number and type of outcome measures used, functional outcomes, electrophysical results, adverse out-
comes, patient tolerance, dropout rate, blinding of assessors, type of data analysis
Study Size of trial, duration of follow-up, bias including sources of financial assistance, publication location, num-
information ber of times cited, intention to treat

Outcome measures
The outcomes considered were the length of time to full
recovery, rates of full recovery, improvements in facial
function, and rates of complications. The outcomes used in
the studies included the House–Brackmann Facial Nerve
Grading System, the Facial Paralysis Recovery Profile
Downloaded by [Australian Catholic University] at 00:02 20 September 2017

(FPRP), the Facial Paralysis Recovery Index (FPRI),

Facial Disability Index, and Sunnybrook Facial Grading
System. Video-based motion analysis and various point
rating systems to grade motion were also used.

Length of time to full recovery

Figure 2  Risk of Bias.
Figure 3  Selection of studies.
subthreshold level, and applied continuously for the first
2 months of recovery to limit Wallerian degeneration of
the nerve. The electrodes were placed near the mastoid
process instead of the muscles and the equipment was
applied by the participant.
Like the majority of the acute studies, participants in the
chronic stages were instructed to use electrical stimulation
at the muscle contraction threshold with the aim being to
maintain muscles and encourage return of structure and
function.15 The intervention was used for much longer
durations in the chronic population (see Table 2).
In Mosforth and Taverner’s study,9 participants were
divided into two subgroups: those with and without
nerve degeneration as assessed by EMG data. They
reported no difference in the length of time to full recov-
ery between groups for participants without denerva-
tion (treatment group mean 43 days, range 14–90 days;
control group mean 39 days, range 14–134 days). For
participants with denervation, time to initial movement
return in the intervention group was 53 days (range
10–104 days) compared with 66 days (14–90 days) in
the control group. The inclusion of infrared radiation as
part of the intervention protocol, however, confounds
this study’s findings.
Kim and Choi10 included only participants with
less severe forms of Bell’s palsy (House–Brackmann
score < IV). The initial House–Brackmann scores of
some of the patients were higher than the inclusion cri-
terion (mean = 3.5 ± 1.2) and some patients enrolled
after three weeks post onset. There was a faster time to
full recovery in the intervention group (Kruskal-Wallis
one-way ANOVA, p < 0.05). It is unclear whether the
assessments were blinded and what confidence intervals
were used.
As Kim and Choi10 were the only researchers to
include a standard deviation in their initial data, their
average standard deviation was used across the studies
to allow the pooling of data. The time to full recov-
ery after acute facial nerve injury was also assessed in
Review Manager (RevMan version 5.3; Copenhagen,
Denmark: The Nordic Cochrane Centre, The Cochrane
Collaboration, 2014)18 and found to have no significant
difference between groups (mean difference −0.79, 95%
CI −2.71–1.13, Figure 4).

 Physical Therapy Reviews  2017 3

 Downloaded by [Australian Catholic University] at 00:02 20 September 2017

4
Table 2  Characteristics of included studies

Participants and groups

Diagnosis:
Length after injury:
Supports electrical
Study stimulation? Groups: Intervention Electrical stimulation parameters
Mosforth and Tavern- No Diagnosis: Bells palsy, n = 83 Administration: therapist Type: galvanic
er (1958) Saline electrodes
Length of injury: <2 weeks Pulse: 100 ms
Location: 12 muscles Machine: Ritchie-Sneath

Physical Therapy Reviews   2017

Groups: control and electrical stimulation. Sessions: 3 sets of 30 contractions
Both groups: self-massage daily. Sessions per week: 3
Threshold: minimal contraction
Length of intervention: variable, up to
1 year.
Kim and Choi (2016) Yes Diagnosis: Bells palsy; n = 60; House–Brackmann Grade less than IV Administration: self Duration: 10 ms
Frequency: 20 Hz
Length of injury: <3 weeks Location: cathode on main branches of Voltage: 20 MV–10 V
Groups: control and electrical stimulation. facial nerve, anode on mastoid process. Intensity: just below sensory threshold
Sessions: ‘continuous’
Fargher and Coulson  A systematic review and meta-analysis of the literature

Sessions per week: ‘continuous’ Electrodes: 2 cm surface electrodes

Both groups: prednisolone and acyclovir Threshold: subsensory
Length of intervention: 2 months
Tuncay et al. (2014) Yes Diagnosis: Bells palsy; n = 60 Administration: therapist Type: Monophasic
Length of injury: 4 weeks Location: 11 facial muscles Pulse duration: 100 ms
Groups: Control and electrical stimulation. Interval: 300 ms
Both groups: hot pack, facial expression exercises, massage, oral corticoster- Sessions: 3 sets of 30 contractions Pulse rate: 2.5 pulses/sec
oids. Sessions per week: 5 Intensity: muscle contraction
Threshold: minimal contraction Machine: Dynatron 438
Length of intervention: 1 month Delivery: carbon-rubber electrode
Alakram and Puckree No Diagnosis: Bells palsy, n = 16 Administration: therapist Type: Biphasic
(2010) Length of injury: mean 2 weeks Location: 3 facial muscles Pulse duration: 10microsec
Groups: Control and electrical stimulation. Sessions: 30 min. Frequency: 10 Hz Intensity: visible twich
Sessions per week: 1 Machine: EV-803 Digital SD TENS
Both groups: prednisolone, hot pack, massage, and facial expression exercis- Threshold: minimal contraction
es, home exercise program with exercises. Length of intervention: 3 months
Farragher et al. Yes Diagnosis: Bells palsy, n = 39, HZO, n = 1 Administration: self Type: eutrophic 
(1987) Location: 2 facial muscles Delivery: Carbon rubber electrodes
Length of injury: mean 77 months Sessions: 3–5 h Voltage: 18 (muscle contraction
­threshold)
Groups: Initial treatment (n = 20), crossover at 6 weeks15 cross over at Sessions per week: 7 Pulse duration: 80microsec
12 weeks,3 cross over at 18 weeks.2 All groups: advice, mirror exercises, mas- ­compensated rectangular monophasic
sage at beginning of study pulses
Threshold: muscle contraction threshold.
Length of intervention: unknown.

Figure 4  Forest plot of length of time to full recovery.
Downloaded by [Australian Catholic University] at 00:02 20 September 2017
Figure 5  Forest plot of rate of full recovery.
Achievement of full recovery
Mosforth and Taverner reported full recovery in 100% of
9 meta-analysis.
participants who had a conduction block without dener-
vation. In the subgroup with denervation, no participant
achieved full recovery by 12 months. Kim and Choi10
reported at one-year follow-up, 3 out of 30 participants in
the control group and 1 out of 30 in the intervention group
had incomplete recovery. Analysis of the data from the
two studies found no difference between the intervention
and control groups (odds ratio 1.38, 95% CI 0.62–3.08,
Figure 5).
Improvement in facial function
Improvement in facial function was the most commonly
reported outcome in the studies, although each study
used a different measure to quantify this outcome. After
acute Bell’s palsy, Mosforth and Taverner9 scored the
improvement in function in patients who did not achieve
full recovery (n = 33) and found no difference between
the intervention and control groups. Tuncay et al.11
reported that both control and intervention groups had
a statistically significant improvement on the House–
Brackmann Scale. The post-intervention measures
were compared using the Mann–Whitney U test and
the difference was found to be statistically significant
in favor of the intervention group (p = 0.03). The rate
of change in facial function was not statistically deter-
mined between the two groups. It is unclear how many
participants were in each House–Brackmann grade.
Alakram and Puckree12 found no difference in facial
function improvement between control and interven-
tion groups (p = 0.36, Mann–Whitney test rank). Using
the House–Brackmann scale, Kim and Choi10 reported
a significantly higher change in facial function in the
intervention group compared to control group at all data
collection visits except for 4, 10, and 12 weeks post
symptom onset. The Sunnybrook Facial Nerve Grading
System scores were not significantly different between
 Physical Therapy Reviews  2017
Fargher and Coulson  A systematic review and meta-analysis of the literature
groups. The House–Brackmann data were included for
Alakram and Puckree12 reported each patient’s results
as a recovery rate by taking their change in House–
Brackmann score and dividing it by the number of weeks
to recovery. In order to analyze the data and calculate
mean House–Brackmann scores, the equation used in
the paper was reversed. To retrieve the average recov-
ery time, the treatment time in each group (9 weeks in
control, 8 weeks in intervention) was added to the time
to commencement of physiotherapy (2 weeks). Tuncay
et al.11 reported median and range of House–Brackmann
values. They tested the difference between the groups
at pre-treatment, reported the p-value and did the same
at post-treatment. It was therefore possible to consider
a parametric test between two means that produced the
same p-value, and calculate the difference between the
means to determine the treatment effect. The treatment
effect was entered into Review Manager (RevMan version
5.3; Copenhagen, Denmark: The Nordic Cochrane Centre,
The Cochrane Collaboration, 2014)18 by setting the control
group difference to 1 (the difference between the reported
median values) and the intervention group difference as
1 + Treatment Effect. There was no improvement in facial
function after electrical stimulation found in the pooled
House–Brackmann results (mean difference −0.38, 95%
CI −0.78 – 0.03, Figure 6).
Farragher et al.15 reported no change in facial function
prior to electrical stimulation treatment in the crossover
groups with chronic FNP. Improvement was reported at 6,
12, and 18 weeks after treatment was commenced; how-
ever the number of patients assessed declined by over 50%
(n = 35 at 6 weeks and 11 at 18 weeks). Assessment at
6 months after the completion of treatment reported ‘no
decline’, however no data were provided. The FPRP was
not reported separately, therefore the stated improvement
in voluntary movement is inseparable from the reported
complications.
5
 Fargher and Coulson  A systematic review and meta-analysis of the literature
Figure 6  Forest plot of improvement in House–Brackmann Score.
Complications
The rate of development of contracture after FNP was not
altered by the use of electrical stimulation.9 One study
reported contact dermatitis in four out of thirty participants
in the electrical stimulation group.10 ‘No indications of any
adverse response to the treatment’ was reported in one
study12 however overall there was not a comprehensive
Downloaded by [Australian Catholic University] at 00:02 20 September 2017
and standardized reporting of complications.
Discussion
The main goal of this review is to examine the efficacy
of electrical stimulation on recovery after FNP. In the
acute phase of recovery, there are two randomized9,11 and
two quasi-randomized controlled trials.10,12 Alakram and
Puckree12 found no benefit in facial function with Tuncay11
presenting positive findings in the electrical stimulation
group. Kim and Choi10 found improvements in length of
time and rates of return to facial function by adding elec-
trical stimulation while Mosforth and Taverner9 reported
no difference. Three studies did not use true randomization
techniques instead using alternate enrollment,12 division
by specialist,10 or unclear list methods.9 There was also no
attempt to blind assessors in three studies placing them at
high risk of bias of the predisposition of the researchers,
likely in favor of active intervention.9,10,12 Tuncay et al.11
was the only study to include randomization for group
selection and blinding of assessors. The lack of blinding
of participants potentially biases the intervention group.
When the studies were combined for meta-analysis, there
was no statistically significant difference between treat-
ment and control groups for improvement in function,
time to full recovery and achievement of full recovery
(Figures 4–6).
The participants with chronic FNP in Farragher’s
study who were initially enrolled in the control group,
all received electrical stimulation when they crossed over
into the treatment group, therefore they could not be post-
tested to compare with the intervention group.15 As noted
by Tuncay et al., by losing the control group, it is difficult
to assess whether the positive impacts are due to electri-
cal stimulation or intensive attention from a therapist.11
Additionally, there was a greater than 50% decline in par-
ticipants reported in the results after 18 weeks.
The included studies used a variety of intervention
protocols (Table 2). Three studies used similar muscle
contraction electrical stimulation in the acute phase of
6 Physical Therapy Reviews   2017
recovery, however, there is variation in frequency of treat-
ment from one to five days per week.9,11,12 The other study
in the acute phase used continuous subthreshold stimula-
tion and placed the electrodes over the main branch of the
facial nerve rather than the muscles.10
Electrical stimulation does not alter the speed or rate
of full recovery, nor does it improve facial function in the
acute phase. In the chronic phase of recovery, there is low
quality evidence in one study 15 that extensive electrical
stimulation may have a positive impact on facial function.
Reasons for this may include extrapolation of study results
from other areas of the body to the facial region, giving
the impression of movement to the patient, and equip-
ment manufacture. There is no evidence that electrical
stimulation will result in full recovery when used with
chronic FNP.
There are potential negative outcomes from using
electrical stimulation. Complications after FNP such as
reinforcing synkinesis34 have been reported in the liter-
ature for human subjects. In studies examining facial
nerve regeneration in rats, no change in polyinnervation
or collateral branching was found with axonal projec-
tion disorganized in the electrical stimulation and sham
stimulation groups.13 Additionally, the number of motor
endplates in the facial muscles was reduced to 24% of
the value of the sham stimulation group,13 leading to
partial innervation instead of complete, which would
detrimentally impact on return of facial function. Animal
studies using electrical stimulation in other areas of the
body have also demonstrated a halt in growth cone
advancement,35 prevention of terminal sprouting,36,37
limiting growth of axons and terminal Schwann cells,38
and decreased reinnervation.39
This current metanalysis provides no clear evidence
of benefit to support patients spending time and money
on electrical stimulation following facial nerve paraly-
sis. There is, however, evidence of effective interventions
which are currently used following FNP such as mime
therapy,40 video self-modeling,41 and tailored facial exer-
cises.17 An animal model study has also demonstrated
support for manual stimulation in favor of electrical stim-
ulation for improving outcomes.42
Implications for clinicians
This review found no evidence to support the use of
electrical stimulation in the acute stages of Bell’s palsy

as it has not been shown to improve either the rate of
recovery or the quality of facial function. In the chronic
stage, one study reported low-level evidence of limited
beneficial changes in facial function following large
quantities of electrical stimulation. No studies reported
complete recovery. Although there is some suggestion in
animal studies that axon regeneration may be accelerated
by brief periods of electrical stimulation,43 this review
concludes that there is no evidence in human studies to
support electrical stimulation in the acute phase of facial
nerve paralysis.
Implications for future research
Quality randomized control trials of humans are needed in
the area of chronic FNP of various etiologies using inter-
nationally recognized outcome measures, consideration
of potential safety concerns in study design, standardized
Downloaded by [Australian Catholic University] at 00:02 20 September 2017
electrical stimulation programs and consistent follow-up.
An objective and systematic recording of complications
should be included in all studies.
Notes on contributors
Katie Fargher, BAppSc, is a clinical physiotherapist, and
research interests are in both pediatrics and in rehabilita-
tion of facial nerve disorders.
Susan Coulson, PhD (Physio); MAppSc(Ex & Sport Sc);
BAppSc(Physio), is a lecturer discipline of Physiotherapy,
Faculty of Health Sciences, The University of Sydney.
Her research interest is in rehabilitation of facial nerve
disorders.
ORCID
Susan E Coulson   http://orcid.org/0000-0002-3586-2562
References
  1 Coulson SE, O’Dwyer NJ, Adams RD, Croxson GR. Expression of
emotion and quality of life after facial nerve paralysis. Otol Neurotol.
2004;25(6):1014–9. Epub 2004/11/18 PubMed PMID: 15547436.
  2 Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral
facial nerve palsies of different etiologies. Acta Otolaryngol Suppl.
2002;122:4–30. Epub 2002/12/17 PubMed PMID: 12482166.
  3 Hohman MH, Hadlock TA. Etiology, diagnosis, and management
of facial palsy: 2000 patients at a facial nerve center. Laryngoscope.
2014;124(7):E283–E93. doi:10.1002/lary.24542;10.1001/jamafacial.
2013.1382
  4 May M. The facial nerve. New York, NY: Thieme; 1986.
  5 Sunderland S. Nerves and nerve injuries. 2nd ed. New York, NY:
Churchill Livingstone; 1978.
  6 Ross MH, Pawlina W. Histoloy: a text and atlas. 5th ed. Baltimore,
MD: Lippincott Williams & Wilkins; 2006.
 7 May M. Facial paralysis, peripheral type: a proposed method of
reporting. (Emphasis on diagnosis and prognosis, as well as electrical
and chorda tympani nerve testing). Laryngoscope 1970;80(3):331–90.
  8 Madhok V, Gagyor I, Daly F, Somasundara D, Sullivan M, Gammie
F, et al. Corticosteroids for Bell’s palsy (idiopathic facial paralysis).
Cochrane Database Syst Rev. 2016;7.
  9 Mosforth J, Taverner D. Physiotherapy for Bell’s palsy. Br Med J.
1958;2(5097):675–7.
10 Kim J, Choi JY. The effect of subthreshold continuous electrical
stimulation on the facial function of patients with Bell’s palsy. Acta
Otolaryngol. 2016;136(1):100–5. doi:10.3109/00016489.2015.1083121
 Physical Therapy Reviews  2017
Fargher and Coulson  A systematic review and meta-analysis of the literature
PubMed PMID: 111313094. Language: English. Entry Date: 20151207.
Revision Date: 20160428. PublicationType: Article. Journal Subset:
Allied Health
11 Tuncay F, Borman P, Taşer B, Ünlü I, Samim E. Role of electrical
stimulation added to conventional therapy in patients with idiopathic
facial (bell) palsy. Am J Phys Med Rehabil. 2015;222–8. doi:10.1097/
PHM.0000000000000171
12 Alakram P, Puckree T. Effects of electrical stimulation on house-
brackmann scores in early Bells palsy. Physiother Theory Pract.
2010;26(3):160–6. doi:10.3109/09593980902886339
13 Sinis N, Horn F, Genchev B, Skouras E, Merkel D, Angelova SK, et al.
Electrical stimulation of paralyzed vibrissal muscles reduces endplate
reinnervation and does not promote motor recovery after facial
nerve repair in rats. Ann AnaT. 2009;191(4):356–70. doi:10.1016/j.
aanat.2009.03.004
14 Kim J, Han SJ, Shin DH, Lee WS, Choi JY. Subthreshold continuous
electrical stimulation facilitates functional recovery of facial nerve
after crush injury in rabbit. Muscle Nerve. 2011;43(2):251–8.
doi:10.1002/mus.21840
15 Farragher D, Kidd G, Tallis R. Eutrophic electrical stimulation for
Bell’s palsy. Clin Rehabil. 1987;1:265–71.
16 Quinn R, Cramp F. The efficacy of electrotherapy for Bell’s palsy: a
systematic review. Phys Ther Rev. 2003;8:151–64.
17 Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell’s
palsy (idiopathic facial paralysis). Cochrane Database Syst Rev.
2011;12:CD006283. doi: 10.1002/14651858.CD006283.pub3
18 Review Manager (RevMan). 5.3 ed. Copenhagen: The Nordic
Cochrane Centre, the Cochrane Collaboration; 2014.
19 Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew
M, et al. Preferred reporting items for systematic review and meta-
analysis protocols (prisma-p) 2015: elaboration and explanation.
BMJ. 2015;349. doi:10.1136/bmj.g7647
20 Wilson CMR SL. Rehabilitation postfacial reanimation surgery after
removal of acoustic neuroma: a case study. J Neurol Phys Ther.
2010;34(1):41–9. doi:10.1097/NPT.0b013e3181cfc324
21 Shrode LW. Treatment of facial muscles affected by Bell’s palsy with
high-voltage electrical muscle stimulation. J Manipulative Physiol
Ther. 1993;16(5):347–52.
22 Weiss MH. Case report: successful treatment of Bell’s palsy. Dent
Surv. 1976;52(8):32–3.
23 Frach JP, Osterbauer PJ, Fuhr AW. Treatment of Bell’s palsy by
mechanical force, manually assisted chiropractic adjusting and high-
voltage electrotherapy. J Manipulative Physiol Ther. 1992;15(9):596–
8.
24 Targan RS, Alon G, Kay SL. Effect of long-term electrical stimulation
on motor recovery and improvement of clinical residuals in patients
with unresolved facial nerve palsy. Otolaryngol Head Neck Surg.
2000;122(2):246–52. PubMed PMID: 10652399.
25 Hyvarinen A, Tarkka IM, Mervaala E, Paakkonen A, Valtonen H,
Nuutinen J, et al. Cutaneous electrical stimulation treatment in
unresolved facial nerve paralysis: an exploratory study. Am J Phys
Med Rehabil. 2008;87(12):992–7. PubMed PMID: 18787496.
26 Gittins J, Martin K, Sheldrick J, Reddy A, Thean L. Electrical
stimulation as a therapeutic option to improve eyelid function
in chronic facial nerve disorders. Invest Ophthalmol Vis Sci.
1999;40(3):547–54. PubMed PMID: 10067956.
27 Paniora L. The treatment of Bell’s palsy using the Respond unit. New
Zealand J Physiother. 1994;22(3):30–2.
28 Guzelant AYS, AB, Saraçoğlu, GV, Can, I, ünal, A. Impact of
electrical stimulation on rehabilitation process in peripheral facial
paralysis. Acta Medica Mediterranea. 2014;30(6):1375–9.
29 Narin S, Barutçu A. Treatment of prolonged facial paralysis with
temporalis myoplasty and electrical stimulation. J Neurol Sci.
2012;28(4):513–9.
30 Manikandan N. Effect of facial neuromuscular re-education on facial
symmetry in patients with Bell’s palsy: a randomized controlled trial.
Clin Rehabil. 2007;21(4):338–43. doi:10.1177/0269215507070790
31 de Almeida JR, Guyatt GH, Sud S, Dorion J, Hill MD, Kolber MR,
et al. Management of Bell palsy: clinical practice guideline. CMAJ.
2014;186(12):917–22. doi:10.1503/cmaj.131801
32 Murray JAM. Ancilliary aids in the treatment of facial paralysis. Facial
Plast Surg. 1992;8(2):127–30.
33 Buttress S, Herren K. Electrical stimulation and Bell’s palsy. Emerg
Med J. 2002;19(5):428.
34 Diels HJ. Facial paralysis: is there a role for a therapist? Facial Plast
Surg. 2000;16(4):361–4. PubMed PMID: 11460303.
35 Cohan CS, Kater SB. Suppression of neurite elongation and growth
cone motility by electrical activity. Science. 1986;232(4758):1638–40.
7
 Fargher and Coulson  A systematic review and meta-analysis of the literature

36 Brown MC, Holland RL, Ironton R. Nodal and terminal sprouting
from motor nerves in fast and slow muscles of the mouse. J Physiol.
1980;306:493–510. PubMed PMID: 7463373.
37 Tam SL, Archibald V, Jassar B, Tyreman N, Gordon T. Increased
neuromuscular activity reduces sprouting in partially denervated
muscles. J Neurosci. 2001;21(2):654–67. PubMed PMID: 11160444.
38 Love FM, Son YJ, Thompson WJ, Love FM, Son Y-J, Thompson WJ.
Activity alters muscle reinnervation and terminal sprouting by reducing
the number of schwann cell pathways that grow to link synaptic sites. J
Neurobiol. 2003;54(4):566–76. PubMed PMID: 12555269.
39 Hennig R. Late reinnervation of the rat soleus muscle is
differentially suppressed by chronic stimulation and by ectopic
innervation. Acta Physiol Scand. 1987;130(1):153–60. PubMed
PMID: 3591386.
40 Beurskens CHG, Heymans PG. Mime therapy improves facial
symmetry in people with long-term facial nerve paresis: a randomised
controlled trial. Aust J Physio. 2006;52(3):177–83.
41 Coulson SE, Adams R, O’Dwyer N, Croxson GR. Physiotherapy
rehabilitation of the smile after long-term facial nerve palsy using
video self-modeling and implementation intentions. Otolaryngol Head
Neck Surg. 2006;134:48–55.
42 Angelov DN. Physical rehabilitation of paralysed facial muscles:
Functional and morphological correlates. Adv Anat Embryol Cell
Biol. 2011;210:1–153.
Downloaded by [Australian Catholic University] at 00:02 20 September 2017
Appendix A. Detailed search strategy – Medline
Medline, Scopus, Medline, Embase, CINAHL, Pubmed: three
topic areas combined with ‘AND’
(1) Subject headings: Bell Palsy, Facial Paralysis, Facial
Nerve. Keyword search: facial paralysis, facial nerve,
Bell$ palsy, Bell$ paralysis, facial palsy.
(2) Subject headings: Physical Therapy Modalities,
Rehabilitation. Keyword search: physical therapy, phys-
iotherapy, rehab*
(3) Subject headings: Electric Stimulation, Electric
Stimulation Therapy. Keyword search: electrical stimu-
lation, electrotherapy.
(4) English
PEDro and cochrane library:
(1) Facial nerve
(2) Facial paralysis

(3) Facial palsy
43 Gordon T, Borschel GH. The use of the rat as a model for studying
peripheral nerve regeneration and sprouting after complete and partial
(4) Bell’s palsy
nerve injuries. Exp Neurol. 2017;287:331–47. (5) Bell’s paralysis

8 Physical Therapy Reviews   2017