Joel Alcantara, DC, Gregory Plaugher, DC, Darwin L. Van Wyngarden, DC
Life Chiropractic College West,
2001 Industrial Blvd,
Hayward, CA 94545, USA;
OBJECTIVE: To describe the chiropractic care of a patient medically diagnosed with Bell’s palsy and discuss issues clinically relevant to this disorder, such as its epidemiology, etiology, diagnosis, care, and prognosis.
CLINICAL FEATURES: A 49-year-old woman with a medical diagnosis of Bell’s palsy sought chiropractic care. Her symptoms included right facial paralysis, extreme phonophobia, pain in the right temporomandibular joint (TMJ), and neck pain. Signs of cervical vertebral and TMJ subluxations included edema, tenderness, asymmetry of motion and posture, and malalignment detected from plain film radiographs.
INTERVENTION AND OUTCOME: The patient was cared for with full spine contact-specific, high-velocity, low-amplitude adjustments (Gonstead Technique) to sites of vertebral and occipital subluxations. The patient’s left TMJ was also adjusted. The initial symptomatic response to care was positive, and the patient made continued improvements during the 6 months of care.
CONCLUSION: There are indications that patients suffering from Bell’s palsy may benefit from a holistic chiropractic approach that not only includes a focus of examination and care of the primary regional areas of complaint (eg, face, TMJ) but also potentially from significant vertebral subluxation concomitants.
From the Full-Text Article:
There is general agreement that Bell’s palsy is an acute, idiopathic, commonly unilateral, peripheral facial paralysis. Simultaneous bilateral facial paralysis is rare with a frequency of less than 1% as compared to unilateral facial paralysis.  The syndrome occurs more commonly in those aged 15 to 45 years, with the peak incidence for individuals in their 30s. The right and left sides are affected equally, and there is no gender predominance. 
Etiological considerations place Bell’s palsy with an unknown pathogenesis. However, edema and subsequent nerve entrapment of the facial nerve secondary to infection remains as an accepted theory. Works by Fisch et al  and Fisch  support this theory. They propose that the entrapment occurs in the labyrinthine segment of the facial canal, creating interference with nerve transmission. Add to this the lack of protective epineural sheath and poor blood supply at this region of the nerve and there results a greater risk for entrapment. Evidence for viral infection as a cause of Bell’s palsy exists. [23-25] Pregnant women and those suffering from diabetes mellitus have a greater incidence of Bell’s palsy. [22, 26] The usual site of injury is between the internal acoustic meatus and the stylomastoid foramen. In this patient, involvement of other branches of cranial nerve (CN) VII is indicated by the increase in lacrimation and hyperacusis. The stapedius muscle dampens sound waves and its dysfunction leads to hypersensitivity to sound (hyperacusis). In addition, taste to the anterior two thirds of the tongue may be affected, as well as the submaxillary and sublingual glands. 
Patients with complaints of facial paralysis should be assessed with a thorough history including onset, course, and duration of the complaint, as well as precipitating factors and other symptoms. Specific questions would be past episodes of said complaint, head trauma, ear infection, diabetes, Lyme disease, and pregnancy. The patient should be given a thorough examination of the head and cervical spine, including cranial nerve testing. Gross assessment of the facial nerve involves eye closure, elevation of the eyebrows, smiling, frowning, and pursing of the lips.
Differential diagnosis for patients presenting with facial paralysis include idiopathic, bacterial (ie, pseudomonas species), viral (ie, IV virus, herpes simplex, herpes zoster), and spirochete (ie, syphilis, Lyme disease) infection; neoplasms (ie, neuromas, metastasis, lymphoma); neuropathy (ie, cerebrovascular accident, Guillain-Barré syndrome, multiple sclerosis); and trauma (ie, birth, fractures of the mandible or temporal bone).  Diagnosis of Bell’s palsy is oftentimes one of exclusion.
Medical management of Bell’s palsy involves the use of corticosteroid for its anti-inflammatory effects and pain management, as well as surgical intervention for nerve decompression and restoration of muscle tone. [28, 29] Beyond medical intervention, Jaskoviak et al  described the use of acupuncture to treat Bell’s palsy. They described 9 patients who were provided an average of 9.3 acupuncture treatments over an average period of 6.7 weeks. At the end of this time, 1 patient was completely symptom free, 4 were greatly improved (80% to 95% recovery), 3 were moderately improved (60% to 65% recovery), and 1 was slightly improved (25% recovery). Ulrich  describes the successful osteopathic cranial manipulative treatment of a patient with Bell’s palsy. Within the realm of chiropractic intervention, previous reports in this journal involve the following. [6, 7] Frach et al  presented a case series of 2 patients with Bell’s palsy. Chiropractic care was described as consisting of mechanical force, manually-assisted (MFMA) chiropractic adjusting and high voltage therapy as “indicated by palpatory and leg-length equality evaluation.” From the authors’ description, we are unable to determine which, if any, vertebral segments were adjusted or if the TMJ received an adjustment. The finding that our patient had dental care, as well as the patients of Frach et al,  alludes to a possible etiology of Bell’s palsy and may be underappreciated by dentists. There is documentation that Bell’s palsy can occur following dental care. [32, 33] As discussed previously, the precise cause of Bell’s palsy remains unclear; however, a variety of mechanisms have been linked to this palsy, including viral reactivation, demyelination, edema, vasospasm, and trauma,  in addition to the ones described previously. It is also worth noting that in addition to Bell’s palsy, the patient presented and those of Frach had TMJ problems. Shrode  also presented 2 cases of pediatric patients with Bell’s palsy cared for through chiropractic means. The care was described as consisting of “high-voltage pulsed galvanic current at 80 peaks/s with a 7-inch handheld prove, with intensity to the patient’s tolerance for 10 minutes” and adjustments to the cervical spine. The outcome for these patients under these care strategies was reported to be positive. Insofar as we can deduce from the 2 previous published papers, this is the first report that describes manual adjustments to sites of spinal (ie, full spine) and extraspinal (TMJ) subluxations using the Gonstead Technique in a patient with Bell’s palsy.
Since multiple spinal segments as well as the TMJ was adjusted, it was difficult for the clinician to determine if one particular area or segment that was adjusted was responsible for the patient’s symptom resolution. The case report by Shrode  supports that adjustments of the cervical spine combined with high-voltage galvanism in patients with Bell’s palsy may be beneficial, but their case report does not describe in whole or in part the detection and removal of spinal subluxations. The case report presented here did not utilize adjunct physical therapy modalities. Kessinger et al  reported on the chiropractic care of 2 patients with Bell’s palsy utilizing adjustments to the upper cervical spine. Of interest and important to address are the findings that adjustments to the cervical spine in the case presented, as well as those of Shrode  and Kessinger et al,  are associated with alleviation of symptoms of Bell’s palsy — a facial paralysis. Is this merely an association or is there causation? We discuss this issue when we address the pathophysiology of Bell’s palsy and the possible effects of chiropractic care, the intimate relationship of the craniocervical-mandibular system and how adjustments to the cervical spine can lead to amelioration of symptoms and dysfunction to the TMJ. 
The outcome of any health care intervention must be examined with respect to the natural history of the offending disorder. The rate of recovery from Bell’s palsy has been given at 80% to 85%. [2, 37] According to Petersen et al  in a study of 1000 patients with Bell’s palsy, 94% of those with incomplete paralysis totally recovered without any intervention, with an overall complete recovery of 71% of cases, 13% having some residual weakness, and 16% with fair to poor recovery. One must consider to what extent the natural history of Bell’s palsy played a role in the recovery of the patient we presented. Alternatively, one can also consider weighing the positive effects of chiropractic care seen in the patient presented (ie, cervical spinal adjustments), particularly with 1 week of chiropractic care. In a study by Katusic et al,  of the patients with no identifiable risk factors, 96% experienced complete recovery, regardless of the type of medical treatment. Kenrick et al  showed that no specific treatment, surgical or corticosteroid, was superior over the other. To delineate the role of chiropractic care on patients with Bell’s palsy, more controlled studies are required. To date, no studies have been performed or published beyond case reports on the effectiveness of chiropractic care on these types of patients. Additionally, if indeed spontaneous remission rates are high for Bell’s palsy (usually within 3 to 6 months),  then the conservative role (ie, drugless) of chiropractic care in decreasing the discomfort and disability of the disease in patients with Bell’s palsy requires further examination.
One of the etiological mechanisms put forth in the pathogenesis of this disease is compression neuropathy as a result of vascular distension due to vasospasm. According to Gussen,  this apparently occurs in a retrograde fashion via the chorda tympani or other facial nerve branches, such as the greater petrosal nerve and its blood vessels. This retrograde vascular distension results in edematous compression of the facial nerve outside its neural sheath, resulting in reversible or irreversible ischemic degeneration. The degeneration of nerve elements is dependent on the degree of compression. Accompanying degrees of fibrosis within the epineurium as a result of the compression and degeneration may further affect vascular drainage of all connective tissue compartments, ultimately disturbing metabolic ionic exchange within the epineural, perineural, and endoneural structures.
Since its inception, traditional chiropractic approach to patient care has been the detection and removal of vertebral and extravertebral subluxations to maintain health and prevent disease.  Such an approach to patient care was illustrated in this case utilizing the Gonstead Technique. An obvious issue to address would be the relationship of this disease (ie, Bell’s palsy) to subluxation findings in the spine, more specifically the cervical spine. Such clinical scenarios are not unusual to the chiropractor wherein addressing patient complaints associated with the spine (and extraspinal) results in resolution of a patient’s “unrelated” complaint(s). [42, 43] Reconciliation of this scenario in the paradigm of evidenced-based care remains the challenge to our profession. For the patient presented, we provide the following. Neurologically, it is appreciated that reflex effects may exist involving the craniocervical-mandibular system as described elsewhere. [36, 44] When one considers the sharing of neuronal pools from cranial nerves V, VII, IX, and X, [35, 45] one may hypothesize that adjustments to the cervical spine may activate such reflex effects with salutary outcomes. Furthermore, in previous cases cited in this article as well as ours, there is the observation that the patient’s symptomatology (ie, cervical-mastoid pain) developed prior to the onset of the facial palsy.  Additionally, theories of the vertebral subluxation complex account for vascular involvement in addition to the classic nerve compression hypothesis. [46, 47] Furthermore, adjustments have been shown to cause relaxation effects of muscles and increase range of motion within articulations in addition to its overall analgesic effects. [48, 49] Overall, these effects may aid in increasing regional blood flow to the involved areas, especially in the upper cervical spine, and thus improve vascular drainage and resorption of edema causing compression to the facial nerve as discussed above. Reflex effects affecting vasospasm among vascular structures following the facial nerve and its branches may also occur.  This may again further prevent the resultant neural degeneration as previously described. Overall, the exact mechanisms of our proposed theories are as yet undefined and remain a research challenge.
There are indications that patients suffering from Bell’s palsy may benefit from a holistic chiropractic approach that not only includes a focus on the primary regional areas of complaint (eg, cranium, neck) but also potentially from significant vertebral subluxation concomitants. The chiropractor is well placed, by virtue of his or her emphasis on examination of the nervous system, as well as articular biomechanics, to care for individuals suffering from afflictions in both areas.
The unique approach of chiropractic care in which vertebral and extravertebral disorders are managed in concomitant with nervous system afflictions such as Bell’s palsy is not well described in the literature. This descriptive case report of Gonstead Technique procedures adds to the paucity of knowledge currently available regarding chiropractic in patients with Bell’s palsy.