Transcutaneous Electrical Nerve Stimulation (TENS) and Ultrasound (US) both are the most common therapeutic intervention modalities applied for Bell’s palsy treatment. The study was conducted in a tertiary care hospital in order to evaluate the perception of physiotherapist regarding the effects of TENS and US in comparison for the treatment of grade V Bell’s palsy.


It is an observational study based on cross sectional survey based on questionnaire from the physical therapists of a tertiary care hospital with the clinical experience of one year or more. The sample size was 45 based on convenient sampling technique with the mean age of 27.4 ± 7.75 years.


The results of the study indicated that preference of therapist for the effective treatment of grade 5 Bell’s palsy is TENS in comparison to US for early prognosis and patient’s satisfaction. Further, the therapist prefers burst mode of TENS for effective results.


Though the study favors use of TENS
However, due to small sample size, further studies are required to be conducted in domain to strengthen the role of Burst Mode of TENS as an effective intervention for Bell’s palsy.



Bell’s Palsy, Tens, Ultrasound, House brackmann Scale, Physiotherapist, Treatment

Farida Shaheen

Consultant PT

Sindh Govt Hospital

Karachi, Pakistan.

[Shaheen F. Perception Of Physiotherapist On Effects Of Transcutaneous Electrical Nerve Stimulation In Comparison To Therapeutic Ultrasound For The Treatment Of Grade V Bell’s Palsy Pak.j.rehabil. 2021;10(2):70-77] DOI: 10.36283/pjr.zu.10.2/010


This is an open-access article distributed under the terms of the Creative
Commons Attribution Licence (CC BY) 4.0



Among the other causes responsible for paralysis of face, Bell’s palsy accounts for about 75%1. Bell’s palsy has been experienced by 11 to 40 persons from 100,000 worldwide every year2. The mean age ranges between 15 to 40 years with both genders being equally influenced, however 45% cases per 10,000 reported are pregnant females3.

Bell’s palsy is a unilateral paralysis of the facial nerve causing muscular weakness at one side of the face, resulting from traumatic, infectious, inflammatory, compressive or metabolic abnormalities, in most of the cases with the unknown cause4.It causes loss of sensation, muscular weakness, difficulty in functions like eating, talking etc.5 The major symptoms for Bell’s palsy includes drooping of jaw, loss of nasolabial fold, loss of facial expression, deviation of mouth to opposite side, failure of eye-lid to close, or loss of wrinkles of forehead on looking up6. However, Viral infections caused by Herpes zoster,7 Mumps, E.B. virus results in inflamed VII cranial nerve during its course through the bony labyrinth part of the facial canal, where compression and demyelination of the axons and blood supply to the nerve occurs8.

House and brackmann in 2017 developed a grading scale to evaluate facial paralysis in relation to extent of nerve damage. This scale measures six grades. In this scale grade I allocates normal activity of face muscles, grade II represents slight weakness, dysfunction and slight dissymmetry of facial muscles, grade III meant to be moderate dysfunction is apparent but not obvious difference of symmetry between both sides, grade IV represents moderately intense dysfunction apparent and causes asymmetry on each sides, grade V means to be intense dysfunction hardly detectable movement and in grade VI there is complete loss of function of facial muscles 9.

Multiple approaches are used in order to treat the Bell’s palsy including both conservative and surgical approaches. In addition, Physical therapy approaches including electrotherapy, massage and exercises of face to stimulate the denervated muscles shows promising results when applied for rehabilitation of a patients with Bell’s palsy. Further, electrical stimulation like TENS, Ultrasound, electro-acupuncture10, pulsed signal therapy (PST) 11 and Russian current have shown to be effective in axonal outgrowth and myelination, and partial activation of facial muscles in Bell’s palsy 12. Significant effects were observed in the functional limitations of bell’s palsy by the use of low level laser therapy13. In addition, kabat rehabilitation along with nerve stimulation has shown promising results in the improvement of physical and social functions14. Mustafa in 2017 found out the combination of kabat exercise, kinesiotherapy and electrotherapy reduces facial muscle asymmetry15. Similarly, K-taping and acupuncture with support of physiotherapy is safe and supportive therapy to manage early stage of ringer’s paralays16. Another research concludes that the use of PNF technique is more effective than kinesio taping17.   Similar results were reported by Pooja kumari et al in her study18.

Electrical stimulation is applied to re-establish or get outward appearance (for example, rumination, blowing, flickering eyes, grinning, sucking, and others) and accessory muscles including those of neck and eyes are also stimulated to achieve better result19. Among other electrical stimulations, Transcutaneous electrical nerve stimulation (TENS) is most commonly used to enhance the quality of facial muscle’s proprioception and neuromuscular coordination in the chronic stage of bell’s palsy 13  It is known for providing pulsed currents for depolarizing peripheral nerve fibers from skin. TENS have five modes of delivery that are conventional, acupuncture like, brief intense, burst, and modulation20. Most common sites used for innervation of facial nerve via TENS includes the orbicularis oculi for blinking of eye, the frontalis muscle used for raising eyebrow, the zygomaticus major muscle for grinning, and the orbicularis oris muscle for lip pucker4. Further, therapeutic Ultrasound in its conventional mode, is known to treat soft tissue pathologies, wounds, and bone fractures20 .

In patients with bell’s palsy ; generally  features  settle down  completely except for some patients who  experience  hardship  for prolonged  periods of time as symptoms do not settle by 3 weeks14. Usually prognosis is appreciative when symptoms seem to be recovered within 21 days of onset of disease21. However, in cases of absolute facial paralysis, worst pain, people older than 60 years of age, herpes zoster virus, in contagious disease conditions like pregnant women, hypertensive patient and diabetic patient or   in case of severe degeneration of facial nerve poor prognosis has been recorded14.The main aim of this study is to evaluate the effective of TENS in comparison to Therapeutic ultrasound in the perspective of physical therapist for the treatment of Bell’s palsy.



Study Setting

Data was collected from tertiary care hospital in Karachi.

Target Population:

Physical therapist with the experience of = or ≥1 years.

Study Design

Cross sectional study

Duration of Study

This research took 6 – 8 months after the approval of synopsis.

Sample Size


Sampling Technique

Simple convenience sampling.

Sample selection

Physical therapist with clinical experience of one or more than one year and have treated patients with Grade V house brackmann score Bell’s palsy without any secondary complications. However, professional with experience of less than one year or lack experience of less than two week in the treatment of bell’s palsy.

Data Collection Tool

Data was collected by a Questionnaire designed by researchers which included 10 questions.

Question were based on the therapist opinion regarding grades of House Brackmann’s scale, effects of TENS and ultrasound and its modes on prognosis of Bell’s palsy and  safest modality  for Bell’s palsy.

Data Collection Procedure

Research questionnaire was provided to the physical therapist at a tertiary care hospital who gave their consent to participate in the study.


Data Analysis

Data analysis was done with the help of METCALC SPSC.

Ethical Considerations:

Written consent was taken from the participants of the study and autonomy to participate in the study was given to the participants. Participants were given the right to with draw from the study anytime. Confidentiality of the participants was not breached nor was any harm caused to them during the course of research.


The total numbers of 45 participants, 14 male and 31 females, were recruited for the identification of their perception in the effectiveness of TENS for the early treatment of Bell’s palsy. The mean age of the participants was 27.4 ± 7.75 years with the clinical experience of 3.51 ± 4.97 years.

95.55% of our subjects considered TENS as best modality while remaining 4.45% were in favor of ultrasound as safest modality for the Bell’s palsy treatment. In this cross sectional study when subjects were asked about the best mode of TENS for Bell’s palsy treatment according to their clinical experience, 88.88% responded in favor of Burst mode while other 11.12%  were comfortable to use conventional mode on their Patient’s with grade V Bell’s palsy. Meanwhile 71.11% subjects consider that Electrotherapy may cause complications on patients with Bell’s palsy.

Question Response 1 Response 2
Knowledge of participants about house brackmanns scale 86.66% were affirmative 13.34% were negative
Effective treatment for Bell’s palsy 95.55% responded with tens 4.45% responded with ultrasound
Safest modality for Bell’s palsy treatment 95.55% responded with tens 4.45% responded with ultrasound
Modality aiding for early recovery 95.55% responded with tens 4.45% responded with ultrasound
Effective mode of TENS for the treatment of Bell’s palsy 88.88% responded with burst mode of TENS 11.12%  responded with conventional mode of TENS
Effective mode of ultrasound for the treatment of Bell’s palsy 84.44% participants responded with pulsed mode of ultrasound 15.56%  participants responded with continuous mode of ultrasound
Duration the treatment of Bell’s palsy 39 participants responded that it takes 6-7 sessions 6 responded that it take 4-5 sessions
Patient’s satisfaction for the treatment modality 41 responded for TENS 4 participants responded for Ultrasound
Complications of using electrotherapy for treating Bell’s palsy grade V. 71.11% were affirmative 28.89% were negative

Table 1: Responses of participants to the close ended questions provided

Moreover, 39.7% subjects that a patient with grade V Bell’s palsy can recover completely on the other hand 31.7% subjects responded negatively. The results of the study indicates the preference of therapist for the effective treatment of grade 5 Bell’s palsy is tense in comparison to ultrasound in reference to early prognosis and patient’s satisfaction.


The findings of our study highlight the perspective of physical therapist that favors TENS for the treatment of Bell’s palsy. Similar findings were observed in a study conducted by Alice (2020) where she reported the beneficial results of electrical stimulation in patients of acute case of Bell’s palsy5. Further, study also stated majority of the therapists favored the use of electrical therapy in clinical practice to treat Bell’s palsy 5.

Multiple studies have stated the effects of neuromuscular electrical stimulation are significant in term to enhance of strength of facial muscles post paralysis or paresis 22,23. Further, evidence has proved that paralyzed muscle can be evoked by electrical stimulation along with massage for facial muscles relaxation and facial exercises for muscular strengthening4. It has also been observed that NMES (neuromuscular electrical stimulation) when combined with SWD (shortwave diathermy) and exercises for the treatment of Bell’s palsy reduces complexity and recover functional activities24.

Moreover, according to the subjects of our study, TENS is most effective, safe, and less complicated electrotherapy to treat bell’s palsy grade V whereas Ultrasound has very low or negligible usage in treating bell’s palsy. Efficacy of TENS on bell’s palsy patients is also proved by J.Lylykangas et al25 in their article, stating the effectiveness of TENS on eye blinking and surrounding muscles. Makel el al also researched on re animation of facial muscles by TENS. Simon goldie with his co member’s conduct this case study in which they observe after applying electrical stimulation on bell’s palsy patients result was quite favorable with this treatment26. Electrical stimulation has shown non observable effects initially and showed positive results after a month27. Contradictory, Anoop Kurian in his case study on acute case of Bell’s palsy reported TENS treatment to have considerably low healing rate28. On the adequacy of electrical incitement as a source of facial nerve stimulator in loss of motion, no significant results were observed29.

However, Study finding also revealed the significant side effects and complication of electrotherapy were observed by therapist during the treatment course. Such results were also reported by Allison in a study where therapist was asked about the effects of TENS on facial paralysis5. In opposition, Wiebke (2020) suggested that Surface electrical stimulation for facial paralysis is not harmful nor does it delays or prevents reinnervation or increase synkinesis in facial paralysis30. Since a perception based study is not enough to support the role of electrical stimulation on grade V Bell’s palsy, further evidence is required to support it.


To conclude, this perception based study favors the use of TENS as the efficient modality to use for the innervation of facial nerve in Grade V Bell’s palsy patients. However, being conducted on a very small sample, further studies are required to be conducted in domain to strengthen the role of electrical stimulation as an effective intervention for Bell’s palsy.


  1. Usman, M., Nawaz, S. and Rehman, S., Spectrum of bell’s palsy : an experience at DHQ teaching hospital DI KHAN, PAKISTAN. PAKISTAN JOURNAL OF HEALTH SCIENCES, 2018. 2(2), 73-76.
  2. Kim SY, Lee CH, Lim JS, Kong IG, Sim S, Choi HG. Increased risk of Bell palsy in patient with migraine: A longitudinal follow-up study. Medicine. 2019 May; 98(21).
  3. Ferreira M, Firmino-Machado J, Marques EA, Santos PC, Simões AD, Duarte JA. Prognostic factors for recovery in Portuguese patients with Bell’s palsy. Neurological research. 2016 Oct 2;38(10):851-6.
  4. Ilves M, Lylykangas J, Rantanen V, Mäkelä E, Vehkaoja A, Verho J, Lekkala J, Rautiainen M, Surakka V. Facial muscle activations by functional electrical stimulation. Biomedical Signal Processing and Control. 2019 Feb 1; 48:248-54.
  5. Munn A, Cameron M, Loyo M. Trends in Electric Stimulation for Facial Paralysis: Electronic Survey of Physical Therapists in Oregon. Archives of Physiotherapy and Rehabilitation. 2020; 3:001-8.
  6. Oshaghi S, Ghadimi K, Rezaeian A, Dokhanchi Z. Retracted Article: Effect of Short Term Use of Repetitive Transcranial Stimulation as an Adjuvant Therapy for Bell’s palsy. Archives of Neuroscience. 2019 Jan 31; 6(1).
  7. Eviston TJ, Croxson GR, Kennedy PG, Hadlock T, Krishnan AV. Bell’s palsy: aetiology, clinical features and multidisciplinary care. Journal of Neurology, Neurosurgery & Psychiatry. 2015 Dec 1; 86(12):1356-61.
  8. Bhargava P, Toshniwal OD, Sharma R, Das M, Mohapatra S, Verma A. Bell’s Palsy: A Systematic Review of Two Cases. Indian Journal of Contemporary Dentistry. 2016; 4(1):84-7.
  9. Scheller C, Wienke A, Tatagiba M, Gharabaghi A, Ramina KF, Scheller K, Prell J, Zenk J, Ganslandt O, Bischoff B, Matthies C. Interobserver variability of the House-Brackmann facial nerve grading system for the analysis of a randomized multi-center phase III trial. Acta neurochirurgica. 2017 Apr 1; 159(4):733-8.
  10. Liu ZD, He JB, Guo SS, Yang ZX, Shen J, Li XY, Liang W, and Shen WD. Effects of electroacupuncture therapy for Bell ’s palsy from acute stage: study protocol for a randomized controlled trial. Trials. 2015 Dec; 16(1):1-7.
  11. Gorelick L, Rozano-Gorelick A. Full Recovery of the Patient With Bell’s Palsy Within Two to Six Weeks After Single Course of Pulsed Electromagnetic Therapy-Case Reports.
  12. Deng Y, Xu Y, Liu H, Peng H, Tao Q, Liu H, Liu H, Wu J, Chen X, Fan J. Electrical stimulation promotes regeneration and re-myelination of axons of injured facial nerve in rats. Neurological research. 2018 Mar 4; 40(3):231-8.
  13. Banu HB, Rahman S, Hossain S, Khan EH, Mahmood K, Rahman DL, Ahmed M. Effect of Infrared Radiation (IRR) on Patients with Bell’s Palsy. Bangladesh Medical Journal. 2017 Nov 21; 46(1):1-6.
  14. Khanzada K, Gondal MJ, Qamar MM, Basharat A, Ahmad W, Ali S. Comparison of efficacy of Kabat rehabilitation and facial exercises along with nerve stimulation in patients with Bell’s palsy. BLDE University Journal of Health Sciences. 2018 Jan 1; 3(1):31.
  15. Qamar MM, Basharat A, Basharat S, Rasul A, Ramzan M, Afzal F, Islam A, Waqas M, Atif MM, Munem HA, Rasheed MA. Kabat Technique incorporated with Kinesiotherapy and electric muscle stimulation can be handy in patients with bell’s palsy. International journal of medicine and applied health. 2017; 5(1):7-10.
  16. Alptekin DÖ. Acupuncture and Kinesio Taping for the acute management of Bell’s palsy: A case report. Complementary Therapies in Medicine. 2017 Dec 1; 35:1-5.
  17. Ghous M, Yaqoob I, Kanwal M, Malik AN. Effects of Kabat rehabilitation verses taping to reduce facial disability and synkinesis in Bell’s palsy. Rawal Medical Journal. 2018 Jul 1; 43(3):543-6.
  18. Digra PK, Bharti R, Singh N. Proprioceptive Neuromuscular Facilitation in LMN Facial Palsy: A Case Report. Indian Journal of Physiotherapy & Occupational Therapy. 2020 Jul 22; 14(3):171-4.
  19. Ramos-Jimenez A. Effectiveness of Electro-stimulation as a Treatment for Bell ’s palsy: An Update Review.
  20. Electro-Physical Therapy, Second Edition, Alain
  21. Hu K, Taw LB. Integrative East-West Approach to Acute Treatment of Bell ’s palsy. Proceedings of UCLA Healthcare. 2016; 20.
  22. Safi MF, Wright-Harp W, Lucker JR, Payne JC, Harris O. Effect of Neuromuscular Electrical Stimulation on Labial and Lingual Weakness. Topics in Geriatric Rehabilitation. 2018 Apr 1; 34(2):145-54.
  23. Choi JB. Effect of neuromuscular electrical stimulation on facial muscle strength and oral function in stroke patients with facial palsy. Journal of physical therapy science. 2016; 28(9):2541-3.
  24. Kumar C, Bagga TK. Comparison between proprioceptive neuromuscular facilitation and neuromuscular re-education for reducing facial disability and synkinesis in patients with Bell’s palsy: A randomized clinical trial. Int J Phys Med Rehabil. 2015; 3(4):1-8.
  25. Marotta N, Demeco A, Inzitari MT, Caruso MG, Ammendolia A. Neuromuscular electrical stimulation and shortwave diathermy in unrecovered Bell palsy: A randomized controlled study. Medicine. 2020 Feb;99(8).
  26. Goldie S, Sandeman J, Cole R, Dennis S, Swain I. Electrical stimulation treatment for facial palsy after revision pleomorphic adenoma surgery. Journal of surgical case reports. 2016 Apr 1; 2016(4).
  27. Qamar MM, Basharat A, Basharat S, Rasul A, Ramzan M, Afzal F, Islam A, Waqas M, Atif MM, Munem HA, Rasheed MA. Kabat Technique incorporated with Kinesiotherapy and electric muscle stimulation can be handy in patients with Bell ’s palsy. International journal of medicine and applied health. 2017; 5(1):7-10.
  28. Alyassiri AM, Zaidan TF. Comparison between the beneficial Effects of Low Level Laser Therapy (Diode Laser) and Transcutenous Electrical Nerve Stimulation in Recovery of Patients with Bell’s palsy. Indian Journal of Forensic Medicine & Toxicology. 2019; 13(1):332-7.
  29. Fargher, K.A. and Coulson, S.E.,. Effectiveness of electrical stimulation for rehabilitation of facial nerve paralysis. Physical Therapy Reviews, 2 20172(3-4), 169-176.
  30. Puls WC, Jarvis JC, Ruck A, Lehmann T, Guntinas‐Lichius O, Volk GF. Surface electrical stimulation for facial paralysis is not harmful. Muscle & Nerve. 2020 Mar; 61(3):347-53.
  31. Al Shalawi, A.A., Effect of Tens in the Management of Bell’s Palsy-Case Study.
  32. Bafna, G. and Kumawat, A., Prevalence of nerve conduction study to determine the prognostic value in Bell’s palsies patients
  33. Croisé, B., Paré, A., Marmouset, F., Bregeaut, P., Joly, A. and Laure, B., 2019. Lengthening temporalis myoplasty and reduction of the swallowing oral phase dysfunction in facial palsy patients. Journal of Plastic, Reconstructive & Aesthetic Surgery, 72(7), pp.1157-1163.
  34. Fabrin, S., Soares, N., Regalo, S.C.H. and Verri, E.D., 2015. The effects of acupuncture on peripheral facial palsy sequelae after 20 years via electromyography. Journal of acupuncture and meridian studies, 8(5), pp.245-248
  35. Frigerio, A., Heaton, J.T., Cavallari, P., Knox, C., Hohman, M.H. and Hadlock, T.A., 2015. Electrical stimulation of eye blink in individuals with acute facial palsy: progress toward a bionic blink. Plastic and reconstructive surgery, 136(4), pp.515e-523e
  36. Khair, A.M. and Ibrahim, K., 2018. Idiopathic non-traumatic facial nerve palsy (Bell’s palsy) in neonates; an atypical age and management dilemma. Oman medical journal, 33(1), p.65.
  37. Lylykangas, J., Ilves, M., Venesvirta, H., Rantanen, V., Mäkelä, E., Vehkaoja, A., Verho, J., Lekkala, J., Rautiainen, M. and Surakka, V., 2019, May. Electrical stimulation of eye blink in individuals with dry eye symptoms caused by chronic unilateral facial palsy. In International Conference on Medical and Biological Engineering (pp. 7-11). Springer, Cham.
  38. Mäkelä, E., Venesvirta, H., Ilves, M., Lylykangas, J., Rantanen, V., Ylä-Kotola, T., Suominen, S., Vehkaoja, A., Verho, J., Lekkala, J. and Surakka, V., 2019. Facial muscle reanimation by transcutaneous electrical stimulation for peripheral facial nerve palsy. Journal of medical engineering & technology, 43(3), pp.155-164.
  39. Mathew, A.K., Hameed, S., Rawther, N.N., Shaji, J. and Mathai, R., 2020. Idiopathic facial paralysis and tens therapy-A case report. The Journal of Medical Research, 6(2), pp.48-50.
  40. Priya, B.S., Srinivasan, K.R., Lakshmanan, P. and Selvi, P., 2017. Facial Nerve Injury Following TMJ Surgery and its Management by Electrical Stimulation–A Case Study. Biomedical and Pharmacology Journal, 10(4), pp.1855-1861
  41. Ton, G., Lee, L.W., Ng, H.P., Liao, H.Y., Chen, Y.H., Tu, C.H., Tseng, C.H., Ho, W.C. and Lee, Y.C., 2019. Efficacy of laser acupuncture for patients with chronic Bell’s palsy: A study protocol for a randomized, double-blind, sham-controlled pilot trial. Medicine, 98(15).
  42. Brenner MJ, Neely JG. Approaches to grading facial nerve function. InSeminars in plastic surgery 2004 Feb (Vol. 18, No. 1, p. 13). Thieme Medical Publishers.