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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 55-58

Effect of Class IV LASER on Bell's Palsy: A case series


Department of Neuro Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission30-Nov-2018
Date of Acceptance09-Apr-2019
Date of Web Publication3-Jul-2019

Correspondence Address:
Dr. Sanjiv Kumar
Department of Neuro Physiotherapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_15_19

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  Abstract 


This case series describes the use of Class IV LASER in the treatment of Bells' palsy in five participants. Patients were given 7 days of physiotherapy intervention in the form of Class IV LASER for three sessions alternatively and four sessions of conservative physiotherapy based on history and clinical examination. The House-Brackmann Facial Nerve Grading System was used for the pre–post assessment. Majority of the participants showed a change with one patient returning to the normal grade. Three others had a good outcome with mild dysfunction with Grade II and one patient showed only a functional change from Grade VI to Grade IV.

Keywords: Class IV, Inflammation, LASER, Nerve, Regeneration


How to cite this article:
Kumar S. Effect of Class IV LASER on Bell's Palsy: A case series. Indian J Phys Ther Res 2019;1:55-8

How to cite this URL:
Kumar S. Effect of Class IV LASER on Bell's Palsy: A case series. Indian J Phys Ther Res [serial online] 2019 [cited 2019 Aug 21];1:55-8. Available from: http://www.ijptr.org/text.asp?2019/1/1/55/261990




  Introduction Top


Bell's palsy is a facial nerve paralysis of unknown cause [1] with a lifetime risk of 1 in 60.[2] It may cause an inability in the closure of eyelid and drooping of the corner of the mouth.[1] Treatment can include medical therapy, surgical decompression, rehabilitative procedures to normalize facial appearance,[1] and complementary and alternative therapies.[3] Exercise therapy, electrical stimulation, LASER therapy, and infrared radiation (IRR) are the current mainstay physiotherapy treatment of Bell's palsy. Electrical stimulation helps in the prevention of muscle atrophy and the maintenance of metabolic and contractile properties of the muscle till the inflammation subsides and nerves regenerate.[4] IRR increases the circulation and reduces the edema by vasodilatation.[5] Low-level LASER therapy (LLLT) enhances the activity of the damaged peripheral nerve by decreasing the degeneration of motor neurons and improves the growth of the axon and myelination.[6]

Class IV LASER or high-level LASER therapy (HLLT) was introduced as one of the potent electrotherapeutic modalities in physical therapy.[7] It works by resolving inflammation in the areas of radiation by causing multiple microcellular events.[8] When compared to IRR, LASER has a higher wavelength and a deeper penetration. In the treatment of Bell 's palsy, Class I LASER is effective, but the depth of penetration is not adequate to stimulate the deeper structures. Hence, this study is designed to obtain some empirical data and evidence regarding the effect of Class IV LASER in Bell's palsy.


  Case Report Top


This case series included participants who visited the physiotherapy outpatient department (OPD) of a tertiary healthcare hospital in Karnataka, with a primary report of the weakness of one-half of the face between 18 and 65 years. Five participants were recruited in the study. Exclusion criteria were disorders of the central, loss of sensation over the face, and more than one episode of Bell's palsy. This study was endorsed by the Institutional Ethical committee. Informed consent was obtained from the participants. The initial evaluation included the history and physical examination and grading based on the House–Brackmann scale conducted by a physical therapist. It is designed to quantify the functional recovery of the facial nerve in Bell's palsy. It has six grades with Grade 1 being normal and Grade 6 is total paralysis.[9] Demographic data collected included age, gender, medical history, and duration since the onset of the condition [Table 1]. Pre–post assessment was done with the House–Brackmann scale [Figure 1].
Table 1: Demographic data of all patients included in this case series

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Figure 1: Pre-posttest grades according to the House–Brackmann Scale

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  Case Reports Top


Patient 1

A 31-year-old male presented with left facial paralysis. Symptoms appeared 5 days before physiotherapy examination, which started after a brief period of the toothache. No diagnostic imaging was performed. The patient received medical management which included prednisolone and acyclovir on the same day as the onset of the condition.

Clinical examination

Angle of the mouth deviated to the right with sagging of the left eyelid. Inability to lift the left eyebrow and minimal eye closure were observed. The nasal crease was absent. Swelling was seen over the left mastoid area.

Intervention

The intervention was carried out over 7 days. Class IV LASER was given on alternate days for a total of three sessions. On the other days, conservative therapy in the form of electrical stimulation and facial exercises was continued. Treatment was given while maintaining the probe perpendicular and in contact with the motor points of the facial muscle on the affected side with the following dosage parameters: time of application: 7 s point, energy density: 10 J/cm 2, with a sum of 80 J/cm 2 energy delivered per se ssion [Figure 2].
Figure 2: Points of LASER application for the treatment of Bell's palsy

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Patient 2

A 57-year-old female reported left-sided facial weakness. Physiotherapy examination was done 60 days after the first symptom appeared. Weakness was noticed in the morning, for which patient received intervention after 02 days. No diagnostic imaging was performed.

Clinical examination

Mouth deviation to the right was observed with sagging of the left eyelid. The patient was unable to lift the left eyebrow and not able to close the eye. Bell's phenomenon was present. The nasal crease was absent. Swelling was seen over the left side of the face. This patient had a maximum disability in this study.

Intervention

As mentioned above.

Patient 3

A 32-year-old male presented with left facial weakness. Physiotherapy examination was done after 1 day of onset. Symptoms occurred suddenly after exposure to cold air. No diagnostic imaging was performed. The patient received medical management on the same day as the onset of the condition.

Clinical examination

On examination, the mouth to the left was observed with sagging of the right eyelid. The patient was unable to lift the right eyebrow and unable to close the right eye. Bell's phenomenon was present. He was unable to inflate the cheek. The nasal crease was absent.

Intervention

Same as patient 1.

Patient 4

A 39-year-old male presented with reports of right-sided facial weakness. After exposure to cold air, symptoms appeared 3 days before physiotherapy examination.

No diagnostic imaging was performed. The patient received medical management on the same day as the onset of the condition.

Clinical examination

Sagging of the right eyelid with mouth deviation to the left was seen. The patient reported an inability to lift the right eyebrow, close the right eye, and inflate the cheek. The nasal crease was absent.

Intervention

Same as patient #1.

Patient 5

A 29 year old patient reported to the Physiotherapy OPD 60 days after the onset of left facial weakness due to exposure to cold air. No diagnostic imaging was performed. The patient ignored the weakness and only after 60 days visited a hospital. He refused medical treatment.

Clinical examination

Sagging of the left eyelid with the angle of the mouth deviation to the right was noted. The patient had difficulty in closing the left eye, lifting the left eyebrow, and inflating the cheek. The nasal crease was absent.

Intervention

Same as patient 1.


  Discussion Top


This study assessed a treatment regime over 1 week after the initial diagnosis. Among all the participants, three patients returned to near normal, one patient recovered completely, and one patient showed a change in the grade but did not return to the normal grade.

Bell's palsy is an inflammatory condition of the facial nerve causing compression. This blocks the transmission of neural signals, resulting in ischemia and demyelination.[10] LASER therapy is known to show beneficial effects on inflammation, pain, and regeneration of the nerve.[11]

The release of angiogenic factors such as vascular endothelial growth factor, fibroblast growth factor, inducible nitric oxide synthase, and Type I collagen can increase revascularization and blood flow. These factors play a major role in angiogenesis, thus assisting and accelerating nerve regeneration. There is also a significant reduction in  Wallerian degeneration More Details after LLLT.[12] It also helps to reduce the inflammation by reducing interleukin-1 and tumor necrosis factor–α.[13] Extensive research is done with LLLT. Very limited number of studies are done at the cellular level using HLLT in nerve condition that may limit our understanding of the improvement caused by HLLT.

A study done by Mohamed Alayat et al. states that LASER therapy is more effective than exercises alone with HLLT showing significant change compared to LLLT in Bell's palsy.[6] Similar results were noted in this study with a functional change in the grades of House–Brackmann Facial Nerve Grading System. Research suggests that the prognosis is better if the patient is young.[14] Four of five participants in the present case series were younger. One patient over the age of 50 years showed a functional change but did not return to the normal grade, and she also had complete paralysis. Another study quotes that recovery is better in case of incomplete paralysis than in complete paralysis.

Studies suggest that the outcome is significantly good if medical management is commenced within 3 days after the start of palsy. In the present study, patient #3 showed a significant change returning to the normal grade. This can be attributed to the patient receiving physiotherapy treatment immediately after the onset along with medical management in the form of steroids which may have helped to reduce the inflammation. Similarly patient # 1, four returned to Grade II with mild dysfunction. However, patient#5 did not receive any medical management, but there was a significant change in the grade after physiotherapy treatment. This indicates that HLLT would have caused the change.

The severity of the lesion can determine the prognosis of the condition. Favorable outcome is seen if recovery occurs within 21 days of onset. A similar phenomenon was observed in the present study as most of the patients who reported to the hospital during the initial stage showed significant recovery within 7 days of treatment with one patient returning to normal stage.

The treatment in Patient 1, 3, and 4 was started within 5 days from the onset with pregrade of 2 or 3 and posttreatment the scores were either 1 or 2. Good outcome is observed in Grades I and II, moderate dysfunction in Grades III and IV, and poor result in Grades V and VI. Patient #2 had Bell's palsy secondary to herpes zoster infection. The prognosis is worse in Bell's palsy due to herpes zoster infection than that of idiopathic Bell's palsy.[15] Hence, although the functional change was seen, there was no major change in the grade of the outcome measure used.

Even though this case series suggests that Class IV LASER therapy is effective in the treatment of Bell's palsy, studies on a larger sample will help to generalize the results. Moreover, limited literature is available for cellular level studies of HILT for peripheral nerves.


  Conclusion Top


Class IV level LASER has shown to be beneficial in the treatment of Bell's palsy along with medical management. Beneficial effects may also be seen if used when a patient presents with side effects of corticosteroids. Even though it is claimed that Bell's palsy may recover spontaneously, there is a fraction of population in whom it may not recover at all without treatment. Hence, instead of waiting for spontaneous recovery to occur, treatment has to be started at the earliest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical practice guideline: Bell's palsy executive summary. Otolaryngol Head Neck Surg 2013;149:656-63.  Back to cited text no. 1
    
2.
Glass GE, Tzafetta K. Bell's palsy: A summary of current evidence and referral algorithm. Fam Pract 2014;31:631-42.  Back to cited text no. 2
    
3.
Marques AM, Soares LG, Nascimento CM, Neto AP, Marques RC, Pinheiro AB. Laser phototherapy in Bell's palsy: A case report. Laser Int Mag Laser Dent 2010;2:28-9. Available from: https://www.dental-tribune.com/epaper/ce-magazines/laser-c-e-archived/laser-c-e-no-3-2012-. [Last accessed on 2019 Jan 18].  Back to cited text no. 3
    
4.
Arnulfo RJ, Garcia-Rivera JM, Hernandez-Torres RP, Holguin E, Villalobos MR. Effectiveness of electro-stimulation as a treatment for Bell's palsy: An update review. J Novel Physiother 2015;5:1-4.  Back to cited text no. 4
    
5.
Banu HB, Rahman S, Hossain S, Khan EH, Mahmood K, Rahman DM, et al. Effect of infrared radiation (IRR) on patients with Bell's palsy. Bangladesh Med J 2017;46:1-6.  Back to cited text no. 5
    
6.
Mohamed Alayat MS, Mohamed Elsodany A, Raouf El Fiky AA. Efficacy of high and low level laser therapy in the treatment of Bell's palsy: A randomized double blind placebo controlled trial. Lasers Med Sci 2014;29:335-42. [DOI 10.1007/s10103-013-1352-z].  Back to cited text no. 6
    
7.
Mercola J. Discover the Benefits of K-Laser Class 4 Laser Therapy Treatments; July, 2013. Available from: http://www.articles.mercola.com/sites/articles/archive/2013/07/28/k-laser-benefits.aspx. [Last accessed on 2017 Apr 18].  Back to cited text no. 7
    
8.
Ottaviani G, Gobbo M, Sturnega M, Martinelli V, Mano M, Zanconati F, et al. Effect of class IV laser therapy on chemotherapy-induced oral mucositis: A clinical and experimental study. Am J Pathol 2013;183:1747-57.  Back to cited text no. 8
    
9.
Reitzen SD, Babb JS, Lalwani AK. Significance and reliability of the House-Brackmann grading system for regional facial nerve function. Otolaryngol Head Neck Surg 2009;140:154-8.  Back to cited text no. 9
    
10.
Balakrishnan A. Bell's palsy: Causes, symptoms, diagnosis and treatment. J Pharm Sci Res 2015;7:1004-6.  Back to cited text no. 10
    
11.
Alayat MS, Atya AM, Ali MM, Shosha TM. Long-term effect of high-intensity laser therapy in the treatment of patients with chronic low back pain: A randomized blinded placebo-controlled trial. Lasers Med Sci 2014;29:1065-73.  Back to cited text no. 11
    
12.
Mashhoudi Barez M, Tajziehchi M, Heidari MH, Bushehri A, Moayer F, Mansouri N, et al. Stimulation effect of low level laser therapy on sciatic nerve regeneration in rat. J Lasers Med Sci 2017;8:S32-7.  Back to cited text no. 12
    
13.
Rubis LM. Chiropractic management of Bell palsy with low level laser and manipulation: A case report. J Chiropract Med 2013;12:288-91.  Back to cited text no. 13
    
14.
Finsterer J. Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol 2008;265:743-52.  Back to cited text no. 14
    
15.
Ronthal M. Bell's Palsy: Prognosis and Treatment in Adults. Available from: http://www.cursoenarm.net/UPTODATE/contents/mobipreview.htm?7/5/7263?source=related_link. [Last accessed on 2018 May 17; Last updated on 2018 Apr 29].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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