Asian Journal of Biomedical and Pharmaceutical Sciences

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Case Report - Asian Journal of Biomedical and Pharmaceutical Sciences (2022) Volume 12, Issue 87

Use of mirror therapy and PNF in bells palsy - Case report.

Muzahid k Sheikh1*, Bulbul Bhagikhaye2, Milind Kahile3, Shailesh Patil4, Shriram Kane5, Pratibha Dawande6, Amol Gaikwad7

1Assistant Professor Datta Meghe College of Physiotherapy Nagpur, India

2Student Datta Meghe College of Physiotherapy Nagpur, India

3Asso Professor, Datta Meghe College of Physiotherapy Nagpur, India

4Asso Professor, Datta Meghe College of Physiotherapy Nagpur, India

5Professor Department of Medicine Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences Sawangi (Meghe) Wardha, India

6Professor Department of Pathology Datta Meghe Medical College, Shalinitai Meghe Hospital and Research centre, Nagpur, India

7Information Technology Assistant Professor, Yeshwantrao Chavan College of Engineering, Nagpur, India

*Corresponding Author:
Muzahid k Sheikh
Assistant Professor Datta Meghe College of Physiotherapy Nagpur
E-mail: [email protected]

Received: 02-Mar-2022, Manuscript No. AABPS-22-58461; Editor assigned: 04-Mar-2022, Pre QC No. AABPS-22-58461(PQ); Reviewed: 18-Mar-2022, QC No. AABPS-22-58461; Revised: 21-Mar-2022, Manuscript No. AABPS-22-58461(R); Published: 28-Mar-2022, DOI:10.35841/2249-622X.87.113

Citation: Sheikh MK, Bhagikhaye B, Kahile M, et al. Use of mirror therapy and PNF in bell’s palsy -case report. Asian J Biomed Pharmaceut Sci. 2022;12(87):113


Bell’s palsy is a neurological condition involving VII Cranial nerve characterized by facial drooping and weakness. This is a case study on Bell’s palsy involving 32-year old women, Mrs. who was referred to physiotherapy (PT). The patient reported primary complaints of difficulty drinking, drooling of saliva, trouble speaking clearly and right eye dryness. Cranial Nerve VII examination findings found right sided facial droop and drooping at the corner of her right eye and right side of her mouth. The PT intervention included patient education, facial muscle strengthening, mirror therapy, PNF exercises. Following PT intervention, Mrs. G increased her facial muscle strength, with a near complete recovery at 2 weeks, and was discharged from PT. In the future, more high quality research and evidence is needed to support the role of PT in treating Bell’s palsy


Bell s palsy, Ear infection, Drooling, Mirror therapy.


Bell's palsy is an acute-onset peripheral facial neuropathy and is the most common cause of lower motor neuron facial palsy. It can occur at any age, but it is most common between 15-60 years of age, and is believed to be a possible reaction to a viral infection that causes inflammation and swelling to CN VII that occurs in 11–40 cases per 100,000 annually [1- 3] recent studies have shown that neuromuscular retraining is effective in treating people with palsy. [4,5] PNF provides outpatient rehabilitation programs to help patients regain symmetrical facial expressions and ease or eliminate speech and swallowing problems.

This case study describes a patient with Bell’s palsy who presents with moderate-severe symptoms of facial drooping and weakness on the right side leading to difficulties with drinking, speaking and controlling the muscles of facial expression. This report aims to describe methods for testing and managing Bell’s palsy and help physiotherapist create a treatment plan in the absence of high-quality evidence.

Patient information

• Name-G

• Age - 34

• Gender – Female

• Occupation – Farmer (own field)

• Dominance – Right

• Address – Wanadongri

Chief complaint – Drooling of saliva from left corner of mouth, smiling, difficulty in drinking water, unable to close left eye, trouble speaking clearly, left side facial weakness. Social History: Works as a farmer in her field. Lives with her husband who is a farmer, with 2 children in a 2-story home.

History of Present Illness

A 34 year old female farmer by occupation had a complain of pain in her right ear which was disturbing her associated with slight difficulty in closing her eyelids, she then visited hospital where Dr. prescribe her some medication and eye drops which should be continued for 3-4 days [6]. Foe that week she started experiencing difficulty in facial expression, drooling of saliva not able to smile and puff the cheeks, she then again visited the hospital and after some diagnosis Dr. diagnosed she as a case of Bell’s palsy associated with recent ear infection. She was then prescribed with some other medications and referred her to take physiotherapy treatment. As a result of her symptoms she is complaining with drooling of saliva, unable to close left eye, trouble speaking, smiling.

Diagnostic Assessment

• Patient profile- 34 year old female

• Present illness- drooling of saliva, unable to close left eye, trouble speaking, smiling

• Social history-farmer by occupation lives with her husband, 2 children

• Observation: Facial droop on left side, drooping at corner of left eye and left side of the mouth

CN VII testing

• Sensation testing: Taste to anterior 2/3 of tongue-intact

• Test: cotton swab dipped in salt vs sugar (Table 1)

Side of Face Lift corner of mouth/smiling Raise eyebrow Wrinkling of forehead Puff cheeks Open mouth Total
Right side Complete Complete Complete Complete Complete 06-Jun
Left side Incomplete Incomplete Incomplete Incomplete Complete 02-Jun

Table 1. CN VII Testing.

Outcome measure

House-Trackman Facial Nerve Scale: grade 4 (moderately severe dysfunction)

a) Forehead – grade 4 ( obviously weakness or disfiguring asymmetry)

b) Eye – grade 4 ( incomplete eye closure )

c) Mouth – grade 4 (asymmetry at rest)

Functional status

Speech slightly slurred, noticeable effort when talking.

Physiotherapy diagnosis

This case presented a patient, Mrs Age 32, with a diagnosis of Bell’s palsy, who presented with acute left -sided facial muscle weakness and facial droop, dry eye and functional difficulty with speaking and drinking. Her facial weakness is classified as moderately severe on the House-brakeman facial nerve scale. The patient’s primary concerns were eye pain, functional difficulties with speaking and drinking and closing left eye (Table 2) (Table 3).

Body Structure and Function Activity Participation
Right-sided facial muscle weakness Unable to drink fluids without spilling Trouble speaking on the phone at work
Dry left eye Unable to speak clearly/words are slurred Unable to work a full day in front of the computer
Facial droop on left side Difficulty eating hard/crunchy foods due to jaw pain Challenges with in-person 
Communication due to trouble
making facial expression

Table 2. Problem List.

Intervention Frequency Intensity Rationale Additional Notes
Mirror exercises        
Eye closing  and opening exercises  5 reps every hour Active Assisted (if needed) Improve lubrication of the eye to decrease eye dryness And strengthen the eye lid muscles. Focus on point 5 feet ahead of you on the ground and practice closing eyes fully.
 smile, eyebrow raise, frown, pucker lips, scrunching face 10 reps 3 times daily Isometric hold working up to 10 seconds Exercises to help Strengthen facial muscles. Do exercises in front of mirror for visual feedback.
Mouth Blowing and puffing  exercises With straw and balloon 10 reps 3 times daily Activate muscles as much as possible. Exercises to help Strengthen facial muscles. Activate muscles around lips ,cheeks  and buccinators muscles
PT Modalities like IG current is used for activating the muscles 3set 30 repetition to all affected muscles including upper and lower facial trunk. Ask the patient to do active movements along with IG current Reeducation of muscles In front of mirror to get a visual feedback
PNF exercises Action Procedure Frequency  
Frontalis Raise eyebrow wrinkled Apply resistance medially and downward on normal side and assistance of affected side  5 repetition
5 sec hold 
Zygomaticus major Smile Downward and medial pressure to corner of mouth 5 repetition
5 sec hold 
Corrugator supercilii Frowning and eye close Assisting on affected side .resisting on normal side 5 repetition
5 sec hold 

Table 3. Therapeutic intervention.

Follow up & outcome

At the time of initial assessment, it was discussed with Mrs. G that the prognosis for Bell’s palsy is very good and an almost full recovery would be expected at 2 weeks. Initially Mrs. G received PT daily until her level of functional disability was decreased such that her CN VII testing score was 4/6 and most of her patient goals were met. When these milestones were achieved, treatment sessions were reduced to biweekly until she scored a grade 2 on the House-Bracke0n Facial Nerve Scale.

After 2 weeks of therapy, Mrs. G reported that she had no issues with speaking, and no resting facial droop. Mrs. Gunjan Bante had demonstrated significant improvement in CN VII testing results. She completed 5/6 tests on the left side with the squint test remaining incomplete. Mrs. Gunjan Bante also achieved a grade 2 on the House-Brackmann Facial Nerve Scale [7]. At this time, Mrs. Gunjan Bante was discharged and encouraged to continue with the facial muscle exercises at home until she was back to her baseline function. Given that Bell’s palsy has good recovery outcomes, and most cases resolve on their own, it was unnecessary for Mrs. Gunjan Bante to continue PT until fully recovered.

Given that Bell’s palsy has good recovery outcomes, and most cases resolve on their own, it was unnecessary for Mrs. G to continue PT until fully recovered.

Patient perspective

Mrs. G was happy and satisfied towards the end of treatment as she had regained the functions and movements of face, overcome her difficulties and was able to actively participate in community.


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