Bell’s palsy is a flaccid paralysis of the face caused by inflammation or damage to the cranial nerve VII (CNVII), the facial nerve.  The facial nerve leaves the brain stem and passes through the geniculate ganglion, the stylomastoid foramen and the parotid gland before is separates into two divisions, a motor division and a sensory & autonomic division. It then innervates the muscles of facial expression and the functions of taste sensations from the anterior two-thirds of the tongue. It also supplies some preganglionic parasympathetic fibers to several of the head and neck ganglia.

Causes of Bells Palsy
Bell’s palsy is caused by nerve compression from edema and swelling either as a primary complaint or secondary to trauma, or by conditions affecting the parotid gland, or in some cases by exposure to a chill or draft.

Signs & Symptoms
Bell’s palsy presents with a rapid onset of unilateral facial weakness followed by flaccid paralysis of the muscles of facial expression.  This includes symptoms like the inability to raise the eyebrow or completely close the eye, the loss of the blinking reflex and the inability to flare the nostrils or raise the corner of the mouth, whistle or pucker lips. Patients often have difficulty eating, articulating some sounds and holding their lower lip to drink out of a glass.

There is also sensory and autonomic involvement which may present as loss of tear production, decreased salivation, reduced taste from the anterior two-thirds of the tongue and a heightened sense of hearing.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• Visually inspect the patient’s face in a neutral expression and/or the patient may be asked to perform a number of different facial expressions.
• Sensation may be tested on the posterior portion of the auditory canal (ear).
• The therapist may tap of the patient’s glabella in order to test the Corneal (blink) reflex.
• The patient may be asked to perform active ranges of motion of the neck, eyes and/or mouth

Massage Treatment Goals
Massage therapy should be used as a tool to increase circulation and maintain tissue health of the affected areas, to stimulate the muscles affected by flaccid paralysis and to prevent fibrosis and contracture, and to over all maintain ranges of motion.  In addition, massage therapy can be used as a tool to decrease sympathetic nervous system firing which in turn reduces stress.  Therapeutic massage can also be used to treat the compensatory structures like the neck and shoulders for hypertonicity, pain and stiffness, and to decrease any edema.

Typical Massage Treatment
The patient is treated supine (face up) and the unaffected side is treated first from lateral to medial.  The affected side of the face will be treated after from the midline to the lateral side.  The treatment may consist of compressions, vibrations, stroking and fingertip kneading. General Swedish massage techniques may be used on the anterior chest and neck, and the posterior neck and shoulders.  The Platysma muscle (on the anterior of the neck) may be treated from the direction of the clavicle (collar bone) to the mandible (jaw) using segmental stroking and fingertip kneading. The massage therapist may passively raise the patient’s eyebrows, draw the eyes together, close the eye or shape the patients mouth.  Manual lymph drainage and/or gentle stimulatory techniques such as ROODs brushing or quick stretches may also be incorporated in the massage.

Massage Contraindications & Precautions
The patient should not be positioned prone (face down), and palpation should be performed lightly due to potential sensation changes caused by Bell’s palsy.  The patient may have difficulty articulating some words and as such the therapist needs to be mindful of this to ensure that the patient’s needs are met.  Edema may be present and if that is the case, local heat should be avoided.  The patient may have difficulty closing the eye and as such the area around the eye should be avoided by the massage therapist in order to prevent damage or infection.  Flaccid muscles should never be stretched and no long strokes or fascial work should be done on the affected side.

Typical Suggested Homecare
The patient may be asked to perform passive movements in front of a mirror, even if only one side of the face is working  In addition they may be asked to try imagining or visualizing the paralysed side of the face as moving properly along with the unaffected side.  The patient may also be asked to apply mild heat, like a facial steam, an infrared sauna or even contrast bathing in order to assist with circulation.