WHAT IS BELL'S PALSY?
Bells palsy is a condition that causes the facial muscles to weaken or become paralyzed. It's caused by trauma to the 7th cranial nerve, and is not permanent.

WHY IS IT CALLED BELL'S PALSY?
The condition is named for Sir Charles Bell, a Scottish surgeon who studied the nerve and its innervation of the facial muscles 200 years ago.

HOW COMMON IS BELL'S PALSY?
Bells palsy is not as uncommon as is generally believed. Worldwide statistics set the frequency at approximately .02% of the population (with geographical variations). In human terms this is 1 of every 5000 people, and 40,000 Americans every year.

IS BELL'S PALSY ALWAYS ON THE SAME SIDE?
The percentage of left or right side cases is approximately equal, and remains equal for recurrences.

IS THERE ANY DIFFERENCE BECAUSE OF GENDER OR RACE?
The incidence of Bells palsy in males and females, as well as in the various races is also approximately equal. The chances of the condition being mild or severe, and the rate of recovery is also equal.

WHAT CONDITIONS CAN INCREASE THE CHANCE OF HAVING BELL'S PALSY?
Older people are more likely to be afflicted, but children are not immune to it. Children tend to recover well. Diabetics are more than 4 times more likely to develop Bells palsy than the general population. The last trimester of pregnancy is considered to be a time of increased risk for Bell's palsy. Conditions that compromise the immune system such as HIV or sarcoidosis increase the odds of facial paralysis occurring and recurring.

CAN BELL'S PALSY AFFECT BOTH SIDES OF THE FACE?
It is possible to have bilateral Bells palsy, but it's rare, accounting for less than 1% of cases. With bilateral facial palsy, it's important to rule out all other possible diagnoses with thorough diagnostic tests.

CAN BELL'S PALSY AFFECT OTHER PARTS OF THE BODY?
Bells palsy should not cause any other part of the body to become paralyzed, weak or numb. If any other areas are affected Bell's palsy is not the cause of the symptoms, and further testing must be done.

HOW DO THE SYMPTOMS OF BELL'S PALSY PROGRESS?
Very quickly. Most people either wake up to find they have Bells palsy, or have symptoms such as a dry eye or tingling around their lips that progress to classic Bell's palsy during that same day. Occasionally symptoms may take a few days to be recognizable as Bells palsy. The degree of paralysis should peak within several days of onset - never in longer than 2 weeks (3 weeks maximum for Ramsey Hunt syndrome). A warning sign may be neck pain, or pain in or behind the ear prior to palsy, but it is not usually recognized in first-time cases.

IS BELL'S PALSY CONTAGIOUS?
No, it is not contagious. People with Bells palsy can return to work and resume normal activity as soon as they feel up to it.

WHAT ABOUT RECOVERY FROM BELL'S PALSY?
Approximately 50% of Bells palsy patients will have essentially complete recoveries in a short time. Another 35% will have good recoveries in less than a year.

Regardless of the trigger, Bell's palsy is best described as an event - trauma to the nerve. As with any other injury, healing follows. The quality and duration of recovery is dependent on the severity of the initial injury. If the nerve has suffered nothing more than a mild trauma, recovery can be very fast, taking several days to several weeks. An "average" recovery is likely to take between a few weeks and a few months. The nerve regenerates at a rate of approximately 1-2 millimeters per day, and can continue to regenerate for 18 months, probably even longer. Improvement of appearance can continue beyond that time frame.

IS MUSCLE ATROPHY A CONCERN?
Not as a rule. It takes longer for the muscles to start to atrophy than it takes for most people to fully recover.

IS BELL'S PALSY LIKELY TO HAPPEN AGAIN?
The possibility of recurrence had been thought to be as high as 10 - 20%. These figures have been lowered as more has been learned about conditions that are now diagnosed as other types of facial palsies. Estimates of the rate of recurrence still vary widely, from around 4 - 14%. Most recent reports hover at 5 - 9%. The average timespan between recurrences is 10 years.
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The nerve that is injured with Bell's Palsy is CN-VII (7th cranial nerve). It originates in an area of the brain stem known as the Pons. The 7th nerve passes through the stylomastoid foramen and enters the parotid gland. It divides into its main branches inside the parotid gland. These branches then further divide into 7000 smaller nerve fibers that reach into the face, neck, salivary glands and the outer ear. The nerve controls the muscles of the neck, the forehead and facial expressions, as well as perceived sound volume. It also stimulates secretions of the lower jaw, the tear glands and the salivary glands in the front of the mouth. Taste sensations at the front 2/3 of the tongue and sensations at the outer ear are transmitted by the 7th nerve.

Bells Palsy is caused by an inflammation within a small bony tube called the fallopian canal. The canal is an extremely narrow area. An inflammation within it is likely to exert pressure on the nerve, compressing it. Likewise, if the nerve itself becomes inflamed within this small canal, it can encounter pressure, with the same result of compression. The nerve has not yet exited the skull and divided into its several branches, resulting in impairment of all functions controlled by the 7th nerve. If only part of the face is affected, the condition is not Bell's palsy. If, for example, the mouth area is weak but the forehead moves, Bells palsy is ruled out. Trauma induced by tumor, surgery, etc. can occur at a location where the nerve has already divided into its main branches. This type of trauma may spare one or more branches and allow some muscles to remain functional.
The image at left illustrates the parotid gland area, where the facial nerve divides into its major branches after exiting the skull at the stylomastoid foramen. The major branches then continue to divide into thousands of microscopic nerve fibers.

The face has many muscles, each with its own unique function. Some, but not all, are controlled by CN-VII. These muscles are known as "the muscles of facial expression". Unlike other muscles, the facial muscles insert directly into the skin. Contraction of the muscles causes the skin to move. Signals from the complex array of nerves to the various muscles instruct the muscles to move in combinations as well as individually. Bell's Palsy temporarily prevents the nerve from transmitting signals to the muscles, causing weakness or paralysis. Another way the facial muscles differ from skeletal muscles is that they do not immediately begin to atrophy from lack of use. Estimates of the time it takes for significant atrophy to begin varies, but it is now believed to be years before this occurs.

CN-VII is one of 12 pairs of cranial nerves. This explains why not all the facial muscles are affected. The muscles that close the eyelid are controlled by CN-VII, but the muscles that control other eye movements and the ability to focus are not. Hence, the dry and wide open, but otherwise functioning eye. The sense of taste is affected, but tongue motion is not. Skin sensation may be affected near the ear, but sensation over the rest of the face usually remains normal. Chewing and swallowing are other examples of functions controlled by cranial nerves that are not involved with 7th nerve disorders.

More information about the muscles and their individual functions can be accessed from the link on the exercise page.

Viral and bacterial infections, as well as autoimmune disorders, appear to be emerging as the most frequent common thread in the etiology of Bells palsy.

HERPES SIMPLEX 1
As far back as 1970, Herpes Simplex 1 was suggested as a cause of Bell's palsy (Dr. Kedar Adour). Some Bells palsy must still be designated as idiopathic, but a 1995 study (Dr. Shingo Murakami and others) points compellingly to the herpes simplex virus (HSV-1) as the most frequent cause of Bell's palsy, possibly accounting for at least 60 - 70% of cases. Additional research since this study was published has been reinforcing the conclusion.

Exposure to HSV-1 is common; a vast majority of the population has been exposed to it. Most people are exposed during childhood. Kissing between relatives is the most frequent source of exposure, but it may be possible that the virus is also spread while sharing towels, utensils, etc. The active virus is commonly associated with cold sores, but the virus often runs its course without causing any blisters - blisters actually appear only 15% of the time. This results in a large population of HSV-1 carriers who do not know they've been exposed to the virus. HSV-1 is infectious for a short time following the incubation period. It then enters a dormant state, residing on nerve tissue. There are several triggers that can cause the dormant virus to reactivate. As this site is about Bell's Palsy, rather than herpes, we will not address issues concerning herpes outbreaks where the reactivated virus sheds to the skin. When the latent virus reactivates at the facial nerve the immune system begins to produce antibodies, causing an inflammation. This is a normal function, and is part of the process that eliminates harmful foreign bodies such as viruses and bacteria so that we can recover from illness and injury. If the location of the inflammation is within the fallopian canal (described above) there is no room for the swelling to expand. The nerve itself becomes inflamed, or the inflammation within the canal exerts pressure on the nerve. The result is that the nerve is compressed inside its bony tube. Compression of the nerve is the injury that stops transmission of signals to muscles. Unable to receive signals to contract and relax, the muscles become temporarily weakened or paralyzed.

The triggers for reactivation of the virus prior to the onset of Bell's palsy have not been proven conclusively. Impaired immunity, whether temporary (stress, lack of sleep, minor illness, physical trauma, upper respiratory infection, etc.) or long-term (autoimmune syndromes, chronic disease, etc.) are strongly targeted as the most likely triggers.

OTHER VIRAL LINKS
There has been research implicating other viruses, including cytomegalovirus, Epstein-Barr, rubella and mumps, in the etiology of Bell's palsy. As with the herpes virus, potential triggers appear to be related to conditions that affect the immune system. The internal process that would cause the nerve to become compressed and result in Bells palsy is currently thought to be the same as described above for the Herpes virus.

RAMSEY HUNT SYNDROME
Ramsey Hunt syndrome is similar to Bell's palsy. Unlike Bells palsy, the virus that causes Ramsey-Hunt syndrome has been conclusively identified. It is varicella zoster virus (VZV), which is the virus that causes chicken pox, and is a strain of the Herpes virus. Like HSV-1, it remains in the body, residing on nerve tissue in a dormant state on nerve ganglia after the initial infectious stage has passed. VZV typically remains dormant for decades. The incidence of Ramsey Hunt syndrome increases significantly after age 50. Younger patients with Ramsey-Hunt syndrome are often advised to be tested for autoimmune deficiencies.

Ramsey-Hunt syndrome results in symptoms that are in many respects identical to Bell's palsy. The symptoms are so alike that a diagnosis of Ramsey Hunt syndrome can easily be missed.
When the VSV virus is reactivated the resulting eruptions (blisters) are known as shingles. The first symptom is usually severe pain. There may also be a fever, headache, and localized tenderness. Blisters typically begin to emerge 1.5 to 3 days after the onset of these symptoms, although they may emerge with no prior symptoms.

Symptoms of Ramsey Hunt Syndrome
In addition to the "classic" symptoms of Bells palsy, Ramsey Hunt syndrome is associated with some additional symptoms that help differentiate it. Knowledge of these symptoms is key to an early diagnosis, and should be brought to a doctor's attention during the first visit, or when any of these symptoms become apparent.

1. Pain: Bell's palsy patients may complain of pain (often in or behind the ear) which can be acute. However, it will tend to fade within a week or two. The pain associated with Ramsey Hunt syndrome is often more severe, and more likely to be felt inside the ear. It may start before muscle weakness is apparent, and may last for weeks or months - sometimes longer. Medications such as Neurontin can ease the post-herpatic pain of Ramsey Hunt syndrome.

2. Vertigo: Dizziness is occasionally reported by Bells palsy patients, but is often associated with Ramsey Hunt syndrome. It can be more severe, and longer lasting.

3. Hearing loss: Unlike Bell's palsy, Ramsey Hunt syndrome can also affect the auditory nerve (CN-VIII), resulting in hearing deficit. This should not occur with Bells palsy, and is an important clue to the diagnosing physician. In some cases hearing loss will continue after facial muscle function returns.

4. Blisters: The primary symptom that makes a diagnosis of Ramsey Hunt syndrome likely is the appearance of blisters (known as shingles, or herpes zoster) in the ear. The blisters can appear prior to, concurrent to, or after the onset of facial paralysis. They can be expected to last 2 - 5 weeks, and can be quite painful. The pain can continue after the blisters have disappeared. Blisters are often the only clearly visible symptom that identifies Ramsay Hunt. Unfortunately, they may not be evident during the diagnostic examination. They can be present, but too deep within the ear to be visible. Or they can be too small to be seen. In some cases they may not appear until a week or more after the onset of muscle weakness. At times they do not appear in the ear at all, but may be present in the mouth or throat. It is also possible for the virus to reactivate without blisters at all.

5. Swollen and tender lymph nodes near the affected area.

While Bell's palsy is not contagious, shingles blisters are infectious. Contact with an open blister by someone who has never had chickenpox can result in transmission of the virus. The result will be chickenpox, not shingles or facial paralysis.

** If you've been diagnosed with Bell's palsy, but later see blisters that may be shingles, its important that you notify your health care professional. **

HIV / AIDS
HIV can cause facial paralysis and increases the chance of developing Ramsey Hunt syndrome, as well as Bell's palsy. In the early stage of HIV, paralysis can be directly due to the viral infection. In later stages paralysis is more likely to be associated with the opportunistic infections or tumors associated with severe immune deficiency. Herpes zoster has been confirmed to be associated with suppressed immune systems.

BACTERIAL TRIGGERS...
Lyme disease can cause facial paralysis and the same symptoms as Bells palsy. Bacteria enter the body through the skin at the site of the tick bite. Typical early symptoms of Lyme disease are a red ring around the site of the bite and flu-like symptoms. Unfortunately these symptoms do not always appear. The early symptoms will pass, but administration of an antibiotic as early as possible is important to avoid serious problems later. Without an antibiotic the bacteria can spread throughout the body, causing arthritis, heart disease, and nervous system disorders such as facial paralysis.

Otitis Media - Bacteria from some acute or chronic middle ear infections can invade the canal around the nerve through small portals. As with viruses, the presence of bacteria can evoke an inflammatory response, and compress the nerve.

BILATERAL ...
Bell's palsy and Ramsey Hunt syndrome can be bilateral, but it's extremely rare. Mononucleosis, the flu, Guillain - Barre Syndrome, leukemia, lyme disease, sarcoidosis and Heerdfort's Syndrome are among the potential triggers of bilateral palsy.

MELKERSSON-ROSENTHAL SYNDROME
Melkersson-Rosenthal syndrome can result in unilateral or bilateral palsy. The palsy will tend to be recurrent, to such an extent that it's sometimes described as intermittant or bilateral. Recurrences don't follow any pattern - each recurrence can be on the same side, alternating side, or bilateral.

Diagnosis of this syndrome can easily be missed, as the obvious symptoms may look like Bells palsy. However, unlike Melkersson-Rosenthal syndrome Bell's palsy recurrences tend to be separated by wide timespans.

OTHER CAUSES ...
Facial and surgical wounds, trauma due to a blunt force, temporal bone fractures, brain stem injuries, acoustic neuromas, cysts and tumors can result in facial palsy. Diabetes and thyroid conditions are also associated with facial palsy. Lupus, Sjogrens syndrome and congenital defects can, infrequently, cause facial paralysis.

The onset of paralysis is sudden with Bells palsy and Ramsey Hunt syndrome, although symptoms can worsen during the early days. Bell's palsy symptoms typically peak within a few days, although it can take as long as 2 weeks. Ramsey Hunt syndrome symptoms will peak within 3 weeks. If paralysis develops slowly, tests for other causes of the palsy must be done. Patients with recurrences, particularly if within close time frames, should also be re-evaluated as a precautionary measure.

Psychologically, facial paralysis can be devastating, particularly in cases that extend for a long period, or where residuals are significant. Friends, family and doctors often have no true concept of how deeply the patient's sense of self and self-esteem is affected. You will also find that they have little or no understanding of your physical discomfort, difficulty and frustration as you struggle to do seemingly simple things that they take for granted.

There are many physical symptoms associated with facial paralysis, but the effects will differ between individuals. They can vary in accordance with the degree of nerve damage, and the location of the damage.

GENERAL	EYE RELATED
Muscle weakness or paralysis Forehead wrinkles disappear Overall droopy appearance Impossible or difficult to blink Nose runs Nose is constantly stuffed Difficulty speaking Difficulty eating and drinking Sensitivity to sound (hyperacusis) Excess or reduced salivation Facial swelling Diminished or distorted taste Pain in or near the ear Drooling	Eye closure difficult or impossible Lack of tears Excessive tearing Brow droop Tears fail to coat cornea Lower eyelid droop Sensitivity to light ADDITIONAL SYMPTOMS WITH RAMSEY HUNT SYNDROME Hearing deficit Severe pain Long lasting pain Vertigo Blisters in ear or other areas Nausea
RESIDUAL EFFECTS Eye appears smaller Blink remains incomplete or infrequent Tearing abnormalities Asymmetrical smile Mouth pulls up and outward Sinus problems Nose runs during physical exertion Post paralytic hemifacial spasm Hypertonic muscles Co-contracting muscles Synkinesis (oral/ocular well known, but can affect any muscle group) Sweating while eating or during physical exertion Muscles become more flaccid when tired, or during minor illness Muscles stiffen when exposed to cold, when tired, or during illness

Although the damage that causes the paralysis is specific to the 7th nerve, other nerves may be temporarily irritated. For example, temporary facial numbness or pain can result when CN-V is irritated.

Recovery is not consistent among patients. For some people the mouth may move before the ability to blink returns; in others it will be eyelids first and mouth last. Twitching may precede movement, but it doesn't always. Pain in areas starting to "wake up" may occur, or may not. The sense of taste can be odd as the sensation returns, or the sense of taste may return without any awareness of the change. Recovery can be gradual, rapid, or hit occassional plateaus. Et cetera.

RESIDUAL EFFECTS
Residuals may be due to one, or a combination of several factors. Initial trauma to the nerve can be minor and temporary, or significant and long lasting. When the damage is minor, recovery is likely to be essentially complete, and rapid. With more extensive damage, other factors begin to effect recovery.

In longer recoveries, other cranial nerves may try to take over for the 7th nerve, growing into passageways formerly occupied by the 7th nerve. Also, the 7th nerve can regenerate incorrectly, taking some different paths than it had followed before Bells palsy. The result is "crossed wiring" and synkinesis, which is further described in the next section.

After paralysis facial muscles have a tendancy to become hypertonic. This means they tend to be overactive, contracting when they should be at rest. Typical signs are a squinty eye, the mouth pulling up, a sore or swollen cheek, and deepened creases. Unlike skeletal muscles, facial muscles lack spindles. Muscle spindles sense when a muscle is in a contracted state, and nerves can send the appropriate signal to the muscle telling it to relax. Without these spindles, there is no awareness of the contraction, and the muscles remain in a state of tension. A muscle that can not fully relax also can not fully contract, so the range of motion becomes limited.

Learned misuse and disuse of the muscles also can effect both appearance and mobility. While the muscles are paralysed, it's natural to try to eat, drink and speak, etc., as well as you can. New habits may be learned while you're compensating for the nonworking muscles. You may inadvertantly call on inappropriate muscles to join forces and work together to accomplish movements that aren't happening on their own (learned misuse). Or you may become accustomed to compensating without using the lazy muscles (learned disuse). The effects of both may remain after nerve function returns. Both can also effect the "good" side, which may have learned unnatural patterns while its muscles were assisting the nonworking muscles.

Physical therapy can minimize asymmetrical appearance and improve mobility, even when therapy is started years after the initial paralysis.

Residual Effects of Bell's Palsy
by H. Jacqueline Diels, Occupational Therapist

Most people who develop Bells palsy will recover completely and spontaneously (i.e. without any physical therapy) within 3 months. The following discussion is intended to review and clarify the possible residual effects that can be present in cases where recovery from Bell's palsy is delayed beyond the 3 months point. Generally, the longer the recovery takes beyond the initial three months, the more severe the residual effects.

Residual effects can include eye problems (decreased lid closure / increased lid closure, dryness / excessive watering / watering during eating [crocodile tears]), nasal problems (running nose, dryness, collapsed nostril), and others. This discussion will focus primarily on the residual effects as they pertain to facial movement.

For the person who has facial paralysis after Bell's palsy there are typically 2 stages of recovery. In the first stage (first 3 months) there may be no facial movement at all. In this phase, nerve healing is taking place as the inflammation caused by the virus subsides. The affected side of the face may droop. The eye may be unable to close or blink and tearing may be decreased. There can be corneal dryness due to decreased lubrication coupled with exposure to air. There is risk of corneal damage. Patients should be followed by an ophthalmologist during this period to ensure a healthy eye. Weakness of the mouth muscles may cause difficulty with eating, drinking and speaking. The face may pull uncontrollably toward the unaffected side.

As nerve recovery takes place you may notice small facial movements beginning. People recover at different rates, but generally this process will be complete in the three months after onset. If recovery is delayed you may begin to notice movements in areas of the face that you are not even trying to move. For example, when you smile the eye may close or twitch or when you close you eye the corner of your mouth may pull up or out to the side. This condition is known as synkinesis. It is characterized by uncoordinated or unsynchronized facial movements that occur along with normal movements. Synkinesis varies in severity from mild to severe. In its worst form, mass action, it can result in uncontrollable movement of the facial muscles on the affected side during any attempted expression. The affected side of the face may feel tight as the result of the uncontrolled muscle contractions (spasms).

Many people, when describing their history of facial paralysis after Bell's palsy describe it something like this: "I had no movement for about 3 months and then it started to come back. It was getting better and better and then suddenly it started getting worse again". So what happens in this transition between getting better and getting worse again? Specific areas of synkinesis can sometimes be difficult to identify, because in a severe form it can result in what appears to be no active facial movement. So how do you differentiate this condition from the first phase of facial paralysis when you have no movement? It is the difference between lack of muscle function resulting in no movement and too much muscle contraction resulting in completely restricted movement.

Synkinesis is theorized to be the effect of abnormal nerve regeneration, where some of the healing facial nerve fibers can actually implant themselves into the wrong muscles. Think of the facial nerve as a telephone cable. If you cut through a telephone cable you see many different color-coded wires. The telephone repair person can repair the broken cable by reconnecting the wires according to their color. The facial nerve cable is about the diameter of a strand of thin spaghetti. Within that strand are between 6000-7000 different nerve fibers (wires) which conduct the electrical signal from the brain to the facial muscles causing them to contract. They are very delicate and obviously have no color-coding. Inflammation from the Bell's palsy can harm, or "break" some of these very frail fibers. In time the damaged fibers heal. They regenerate at the rate of about 1-2mm per day. But there's no mechanism that directs these fibers back into their original muscles. The brain sends the signal for the muscle to contract thinking the nerve fiber is still connected to the original muscle, but instead, the nerve may be lodged in an entirely different muscle, which then contracts at the same time.

Synkinesis can affect any of the facial muscles, in any imaginable pattern. An easy to see example is eye closure during a smile. When the person tries to smile the eye twitches or closes. We could speculate that some of the nerve fibers that used to go to the smile muscles (zygomaticus) got rerouted during recovery and implanted in the muscles that close the eye (orbicularis oculi). Other synkinetic patterns may be more difficult to observe, but can be much more limiting to facial movement. Let's consider one of the most common: The inability to smile. First we need to acknowledge that there is a distinct difference between inability to smile just after onset (flaccid paralysis) and in the synkinetic face. On casual observation, it can appear that the smile muscle is simply not working because the corner of the mouth does not go up during a smile. There's an easy way to determine whether the smile muscle is "working" or not. Please refer to the muscle diagram as you read this. Most of us think we smile with our mouths because the corner of the mouth moves. In actuality the smile muscles reside in the cheek. The bottom end of the muscle implants near the corner of the mouth. When the muscle contracts the cheek lifts, pulling the corner of the mouth "along for the ride". Look in the mirror at your cheek on your unaffected side and smile. Watch for the "apple" of the cheek as you smile and you will see it "bulge" as you smile and then flatten out again as you stop smiling. Don't watch the corner of your mouth. Do the same movement now and watch the affected side cheek. In most cases you will also see the "apple" of the cheek bulge up and then release. The shape of the two cheeks may be similar or different. So now you see that the smile muscle is working (even if it's not exactly the same as the other side). So now the question is: If the smile muscle is working why doesn't the corner of the mouth go up?

To answer that question we need to go back to basic facial anatomy and high school physics. The facial muscles are designed differently than other muscles in the body. Their only purpose is to move the skin of the face. The facial muscles don't move bones around joints like leg or arm muscles. They don't carry heavy loads or provide postural support. They simply move skin. Different combinations of muscle contractions move the skin in various directions (more than 2000 distinct facial expressions have been catalogued!). Going back to physics we can describe the movement produced in a specific direction as a vector, or a directional movement. The vector of the smile muscle generally pulls the corner of the mouth up toward the cheekbone. What if another muscle is contracting out of sequence and pulling the skin along a vector in an opposite direction? Which way will the skin move? Can it possibly move in a normal pattern? Let's go back to the smile example. Assuming that the smile muscle is contracting based on our previous mirror observation, why doesn't the corner of the mouth go up? Try smiling again and this time watch your neck in the mirror. Do you see cords or bands "pop out" on the affected side of the neck? This demonstrates synkinesis or abnormal contraction of the platysma muscle. This is a superficial muscle on the neck that is innervated by the facial nerve. We can speculate that some nerve fibers abnormally regenerated into the platysma (since it doesn't contract during the smile on the unaffected side). The normal action of the platysma muscle is to pull down the corners of the mouth. If the smile muscle is pulling up the corner of the mouth and the platysma is pulling it down, where does it wind up? Usually stuck, going nowhere. It is totally restricted from performing normal movement and expression. Think of it as being comparable to a tug of war. Typically, you have two very strong teams pulling with all their might and yet the rope doesn't move much- until one team lets go.

So what do we do about it? The first step is to accurately identify which muscles are contracting both normally and abnormally. This usually requires a therapist who is experienced in this fine type of observation. The next step is to learn how to inhibit the activity of the muscles that are contracting out of sequence. For example, learning how to keep the platysma relaxed while producing a smile will allow the corner of the mouth to begin to move upward. A byproduct of this process is that associated tightness and spasm subsides, leaving the person much more comfortable. The therapy is less like typical therapy and more like athletic or music training. Minimal, successful movements are practiced and then progressed as success is achieved. Electrical stimulation is not helpful. It does not improve coordination of synkinesis and can actually activate already overactive and uncoordinated muscle movements further reinforcing abnormal patterns.

Treatment for residual synkinesis can be effective at any time after it is noticed. There is no time limit. That is because the focus of the treatment is on re-coordinating rather than stimulating muscles. We know that when synkinesis is present the facial muscles are viable, or "alive". Even an abnormal movement is still a movement! So even many years after synkinesis develops it is possible to restore more normal movement patterns and expression with specific, appropriate training.

THE DIAGNOSIS ...
Bell's palsy is a diagnosis of exclusion. During the first visit to a doctor, questions will be asked, and tests may be ordered. These procedures will help the doctor determine the cause of the facial weakness, or rule out conditions which are known to be linked to facial paralysis. When no underlying cause is found, Bells palsy is the diagnosis. For example, blisters in the ear or mouth, dizziness or reduced hearing on the affected side may suggest a diagnosis of Ramsey Hunt syndrome.

Slowly progressing paralysis, weakness in areas other than the face, an enlarged parotid gland or paralysis that spares the eye and brow are also among the symptoms may indicate the presence of an underlying condition requiring additional medical attention.

After taking a history and carefully observing the symptoms, tests that may be ordered include various blood tests, MRI, or CAT scan. These tests shouldn't be a cause for concern. They will either add conviction to a diagnosis of Bell's palsy, or provide the physician with the information needed to proceed in another direction.

Facial paralysis is a result of nerve damage, and many people look no further for help than to a neurologist. Patients may be unaware that the condition also falls into the realm of otolaryngology, and that (ENTs) are generally quite knowledgeable in diagnostics and treatment.

IN GENERAL ...
The first priority in treating Bell's palsy or any type of facial paralysis is to eliminate the source of damage to the nerve as quickly as possible. Minor compression for a short time period can result in mild and temporary damage. As time goes on with constant or increasing compression, damage to the nerve can also increase. If you decide to use medications that may help relieve the compression (Prednisone and antivirals), they should be started as quickly as possible. The "window of opportunity" for starting these medications is thought to be 7 days from the onset of Bell's palsy. Prednisone may be prescribed later if it appears the inflammation has not subsided.

Rest is important. The body has had an injury, and will heal most efficiently with enough rest to maintain strength and immunity at peak levels. It's normal to feel more tired than is usual during recovery. If you choose to work or exercise immediately after onset, be smart about it - when your body tells you it needs a break, indulge it if you have that option.

Food particles can lodge between the gum and cheek, so take extra steps to maintain oral hygiene.

Wear eyeglasses with tinted lenses, or sunglasses (see eye care for additional important information).

Take extra care to keep your eye moist while working on a computer. Even under normal circumstances people tend to blink less frequently while at a computer. For a dry, non-blinking eye, this can be more of a problem. Keep eye drops handy, and remember to manually blink your eye with the back of the index finger.

If sounds appear painfully loud, don't hesitate to ask people to speak softly. Exaggerated perception of volume isn't a symptom that people are likely to be aware of, so you may need to explain that it's a symptom associated with Bells Palsy. An earplug can help, although if you have a history of any inner or middle ear problems or have had surgery in the ear, check with your doctor before using an earplug.

Immediate exercising is not recommended. Unlike skeletal muscles, facial muscles do not immediately start to atrophy. Until the nerve starts to send a signal to the muscles, the muscles simply cannot move. Forcing movement before seeing signs that the nerve is starting to transmit signals again may create long-term problems. Even while the muscles appear flaccid, some nerve threads may be functional. When you try to force movement under these circumstances, you can inadvertently signal the wrong muscles to jump in and help. As time goes on, these inappropriate movement patterns can become automatic. They can result in asymmetrical and synkinetic types of motion. Instead of pushing it in the early days, try to be patient, and remind yourself that in time movement will return. Massage or tapping can provide gentle stimulation without risk.

For pain or discomfort, moist heat can help. There are gel packs and thera-bead packs that can be heated in a microwave for fast, easy and portable help with the soreness. They can usually be found in drugstores and pharmacies, in the section with old fashioned heating pads. In a pinch, ordinary rice in a sock can be heated in a microwave. For a treat, try an herbal heating pack. Doctors are not all aware that significant pain can be part of the ordeal. If you need medication, ask for it. If the doctor doubts the pain is real, refer him to the recently published "The Facial Nerve, 2nd Edition" for documentation. Severe, or long lasting pain is more consistently associated with Ramsey Hunt Syndrome. There are several medications that provide relief including Neurontin. This is a relatively new drug for neuropathic and post-herpetic pain. It's effective for the pain caused by shingles and Ramsay Hunt syndrome, and has relatively minimal adverse effects. Common side effects include drowziness, dizziness and nausea. Interactions with other drugs are nearly non-existent.

In a study released by the Quality Standards Subcommittee of the American Academy of Neurology (May 2001), Drs. Patrick Grogan and Gary Gronseth pooled the data of existing studies published from 1996 through 2000 regarding the effectiveness of steroids, anti-virals, and decompression surgery as treatment for Bell's palsy. Their conclusions are:

1. Regarding the use of steroids:
Steroids are "safe and probably effective in improving facial functional outcomes in patients with Bell’s palsy." Results show significantly better outcomes with steroids. However, they do not find any difference in the time frame for recovery.

2. Regarding the use of antivirals used in combination with steroids:
Based on the limited data available, "acyclovir (combined with prednisone) is safe and possibly effective in improving facial functional outcomes in patients with Bell’s palsy."

3. Regarding decompression surgery:
"The risk of bias in all studies describing facial outcomes in surgically treated Bell's palsy patients was too high to support evidence-based conclusions. Additionally, serious complications, including permanent hearing loss, were reported from surgical facial nerve decompression."

The number of well controlled, unbiased studies available was limited. It is clear that further research is necessary to fully assess the potential benefit of these treatments.

Part 1 - Diagnosis and General Information
Part 2 - Medication and Vitamins

MEDICATION
If the origin of the palsy is viral, both the virus and the inflammation are likely to run their natural course in a short period of time even without medication. There is no firm proof that medication is beneficial for Bell's palsy. The number of quality studies published to date (non-biased with correct controls methods) is limited. It is likely that medications will be effective only if administered shortly after onset. For Bell's palsy, seven days is viewed as the outside limit. For Ramsey Hunt Syndrome, if no anti-viral was given immediately after paralysis, it can be started at any time blisters appear, even if the 7-day period has passed.

The medications currently used for Bells palsy and Ramsey Hunt Syndrome are the same: an anti-viral and Prednisone, which is an efficient, fast acting anti-inflammatory agent.

PREDNISONE FOR BELL'S PALSY...
Prednisone is a synthetic hormone that mimics a natural steroid called cortisol that the body produces. Under stress (injury or illness) cortisol production is increased fourfold as part of the body's normal reaction to the stress. Prednisone has approximately five times the potency of cortisol. 20mg of Prednisone is roughly equal to the amount of cortisol the body normally produces in a day while under stress.

Inflammation is an integral component of the body's response to an injury or illness. Among the many things that occur, substances called cytokines are secreted as part of the immune system response to the stress. Cytokines work to "rev up" the immune system. As the immune system functions increase under stress, antibodies are produced and inflammation results. The antibodies kill cells that the body interprets are foreign, such as viruses and bacteria.

In part, Prednisone works as an anti-inflammatory by its effect on immune cells. It acts as an immuno-suppressant, inhibiting the secretion of cytokines. The result is that antibody production is suppressed, and the inflammatory process is slowed and weakened, quickly reducing the inflammation compressing the nerve. Because Prednisone works by an immuno-suppressant process, it cannot be administered to patients with existing immune system problems.

Prednisone's rapid anti-inflammatory action makes it a worthwhile medication for most patients in spite of its effect on the immune system.

Assuming there are no medical conditions that would negate the use of Prednisone, it can be used by children and adults.

BEFORE TAKING PREDNISONE

Some conditions that may affect a doctor's decision to prescribe Prednisone...
Diabetes Heart Problems Recent Surgery Pending Surgery Seizures Some cancers	Stomach or intestinal disorders Under-active thyroid Pregnancy Nursing Compromised immune system HIV
Medications that may interact or interfere with Prednisone
Diuretics Birth Control Pills Blood Thinners NSAIDS Ibuprofen Barbutuates	Acetazolamide Amphotericin B Digoxin Phenytoin Rifampin Rifabutin

Adverse effects
Side effects are sometimes associated with Prednisone. They tend to be directly related to the amount of Prednisone taken, and how long it's taken. For facial paralysis, usage is short term. The effects tend to decrease as you reduce your dosage, and disappear rapidly when you stop taking the medication.

Potential side effects
Stomach pain (take medication with a meal, milk or antacid)
High blood pressure (restrict salt usage)
Increased appetite weight gain
Acne
Sweating
Insomnia (take the medication in the morning if possible)
Mood swings
Personality changes
Sensitivity to the sun
Temporary muscle weakness
Fluid retention (restrict salt usage)
Hyperglycemia
Reduced immunity to infections
Increased potassium depletion (eat fruit with high potassium levels)
Swelling of the face, back of neck or ankles

ANTI-VIRALS FOR BELL'S PALSY AND RAMSEY HUNT SYNDROME
Antivirals work by binding to viral enzymes so that the cells cannot replicate. Unable to replicate, the virus runs its course faster. The inflammation at the nerve should be less than without an anti-viral and is eliminated in a shorter time.

Famciclovir (Famvir) and acyclovir (Zovirax) are frequently prescribed anti-virals. A newer anti-viral, valacyclovir (Valtrex) appears to work faster. Adverse effects of valacyclovir can include headache, nausea, diarrhea, constipation and dizziness.

With a diagnosis of Ramsay Hunt syndrome, administration of an anti-viral should start within 72 hours of the blisters' appearance, even if blisters do not appear until a week or more after onset of facial palsy. Secondary infections may occur with RHS. The patient should be made aware of this, and be instructed to notify the physician of any signs indicating a bacterial infection. An antibiotic will be prescribed in addtion to the antiviral.

HIV carriers may find they are resistant to the standard anti-virals. Immuno-compromised patients should ask about Foscarnet (Foscavir), a recently approved anti-viral that may be more effective for compromised immune systems.

The AAN 2001 evaluation mentioned above states that antivirals are possibly effective. It should be noted that the term "possibly" must be used with only one study considered acceptable for evaluation. A single study can not provide sufficient data for a firm conclusion or recommendation. The conclusions of that single study (Adour '96) were favorable to treatment with acyclovir plus Prednisone.

B VITAMINS..
Many of the B vitamins are essential for proper nervous system functioning. Addition of a basic B-complex vitamin to the daily routine may be a good idea during recovery. Some B's that may be particularly beneficial are:

B1 - enhances circulation (circulation is reduced in muscles that are not active) and may retard muscle atrophy.

B6 - assists in the creation of amino acids needed in the creation of new cells.

B12 - when taken as part of a "B-complex" vitamin, may help reduce inflammations and strengthen the immune system. Methylcobalamin is a form of B12 that is not a component of basic B-complex vitamins, and is important to nerve growth and maintenance.

METHYLCOBALAMIN ...
Methylcobalamin is an essential component in the process of building nervous tissue. It is important contributor to nerve growth, and maintains and repairs the critical, protective nerve sheath.

Methylcobalamin's action is directed at the nerve's myelin sheath, which is like a layer of insulation around the nerve. It protects the nerve and helps the signal travel along its designated path correctly. It appears to promote protein synthesis, accelerating cell division. Myelin sheath formation at the site of the damage is enhanced. This may, in part, explain recent findings that ultra-high doses may enhance nerve regeneration.

A small 1995 Malaysian study (MA Jalaludin) concluded that the subjects had faster recoveries with Prednisone plus methylcobalamin versus Prednisone alone. However, the results of this study have not been validated, and the quality of the study and its references require evaluation. While methylcobalamin is showing potential as treatment for some neuropathologies, it is not acknowledged as a treatment with any benefit for Bell's palsy. The primary therapeutic benefit of methylcobalamin relates to pernicious anemia, which is not a factor in Bell's palsy. There is no proof of its effectiveness for Bell's palsy. Its benefit, even for new cases, is still considered to be questionable. There don't appear to be any adverse effects associated with high doses of methylcobalamin, so it may best come under a heading of "it can't hurt to try". Methylcobalamin is not known to be therapeutically beneficial in cases of longstanding facial paralysis, nor is there reason to believe that it can help prevent recurrences.

Part 1 - Diagnosis and General Information
Part 2 - Medication and Vitamins

In the early days of Bells palsy, eye care is the most important concern. Maintenance of moisture and protection from debris are important functions that are frequently disrupted with 7th nerve damage. Permanent damage to the cornea is a risk if care is not taken to protect the eye. Acoustic neuroma patients may also encounter corneal dryness after surgery, even when the facial nerve remains intact.

CAUSE OF THE DRY EYE
The dry eye and the associated problems are caused by a combination of things. For some people the tear gland may not be producing moisture. Blinking is the mechanism that protects the eye from external debris and spreads tears over the cornea. Under normal circumstances we blink every 5-7 seconds. With every blink the eyelid spreads moisture over the cornea. With facial paralysis the ability to blink may be disrupted. Eyelid closure can be weak or the eye can be stuck wide open.

Take action if the eye feels uncomfortable. A stinging or burning sensation can mean the eye is too dry, even if tears are apparent. The 7th nerve does not control focus, so if you are experiencing blurred vision, don't ignore it. It may be a warning of a dry cornea that needs to be protected.

For many, although the lacrimal gland produces tears, without a blink the tears cannot coat the eye. The eye may appear to be tearing excessively. It actually only seems that way because the tears are not being spread over eye, but instead are collecting in the limp lower lid or running out of the eye. Or, the eye may tear excessively, especially while chewing. We refer to this as "Crocodile Tears". Crocodile tears can occur from the onset of Bell's palsy, or can develop during recovery.

PROTECTING THE EYE
Manually blink your eye using the back of your finger at regular intervals, and especially when it feels dry.

In some cases all that is needed for extra help maintaining moisture during the day is artificial tears. Look for a brand that is labeled "for sensitive eyes", "non-allergic", or "preservative free", etc. Thimerosal is a preservative that can be particularly irritating. Eye-drops don't last long, and are not the solution for everyone.

Bion Tears is a commonly used brand.

GenTeal uses a natural preservative, which makes it more comfortable for many people. It does the job well.

Tears Naturale has the same active ingredient as Gen-Teal. It's available with a preservative similar to GenTeal, as well as preservative-free (Tears Naturale Free).

Celluvisc is thicker than Tears Naturale, and will afford excellent lubrication. However, it is costly, and because of its high viscosity, vision may not be as clear as with Tears Naturale or Gen-Teal. For additional moisture retention, as well as protection from wind and debris, try a patch.

A moisture chamber will provide the same, or better protection than a patch, but is clear to allow better vision. One type is very much like goggles designed for just one eye, and it works well. If it becomes foggy due to the tight seal, a tiny pinhole will solve the problem. Your ophthalmologist should be able to provide you with the patch. There are also moisture chambers that clip onto eyeglasses.

The examples shown are (top) Eagle Vision, Inc.'s "Rectangular Moist Eye Moisture Panel" and (bottom) Franel Optical Supply's "Moisture Chamber". These items can not be purchased directly from the manufacturer by the patient, but can be purchased by an opthalmologist for your use. As an alternative to a moisture chamber you can make your own patch with plastic wrap over your eye, and taped to your face. Surgical tape will be gentler for your skin and easier to remove than other types. Vaseline can also be used to hold it in place.

Wraparound sunglasses or swimming goggles are other helpful alternatives to a moisture chamber.

For nighttime protection if your eye will not close, lubricants (gels ointments), or lubricants combined with a patch are a good solution. Gels are thicker than artificial tears due to the addition of mineral oil. The consistency is very much like Vaseline. By adding a "pirate's patch", you not only add protection from debris and injury, you also keep light out and may find it easier to fall asleep. If you use a pirate's patch, think about using a plastic wrap patch beneath it for added protection if the patch shifts, or create your own dark patch. Franel Optical Supply makes a "Peel-n-Press Occluder" that should eliminate the problem of the patch shifting during the night.

Lacrilube, ViscoTears and HypoTears are gels for nighttime protection.

Refresh PM is an option if a bit less protection is needed. Its thinner consistency makes it easier and more pleasant to wake up with.

Gels and ointments can be used during the day for more lubrication than eye-drops provide. However, because they are thick, vision can be blurry.

The eye can be taped closed at night, but a note of caution is appropriate. It is too often suggested to patients without proper instructions. If not done correctly the eyelid can easily pop open, exposing the eye to worse damage than without the tape. Make sure to use a gentle, non-abrasive and easily removed tape (such as paper surgical tape), and learn the correct way to apply it.

If stinging or burning occurs with any of the gels or drops, you may be sensitive to one of the components. Try other brands, and if that doesn't help, see your ophthalmologist for further help - Never ignore symptoms of a dry eye!

WHEN GELS PATCHES AREN'T ENOUGH
Consider a visit to an ophthalmologist, even if you believe you can manage eye care on your own. There is no a substitute for professional evaluation and advice. When your eye stings or burns, it's sending a message. Try changing to a gentler eye-drop or gel, and see your ophthalmologist, who may recommend one of several procedures.

Punctal Plug Insertion is a simple procedure to partially block the tear duct, so that natural or artificial tears will remain on the eye longer. They cause little or no discomfort, and removal is often as simple as a saline pressure wash. Collagen plugs are an option for short term use. They are self-dissolving, and are effective for approximately 10 days.

Eyelid weights (available from MedDev Corp.)
Skin Tone External Eyelid Weights are the newest development, and work quite well. The weight on the eyelid works with gravity to assist blinking. It's worn on the upper eyelid, just above the eyelashes, and is attached daily with a double-sided adhesive strip. They're available only with a prescription. Potential downsides are irritation caused by the adhesive, and problems with the adhesive lasting during long days. For Bell's palsy patients, where paralysis is temporary, it can be an excellent short-term solution. For patients with permanent paralysis it's useful for calculation of the weight to be permanently implanted, and helps the patient adjust to living with an eye weight prior to implantation.

Gold Eyelid Weights are also used to help eyelid closure. They work on the same gravity-assist principle, but are sewn into the eyelid. (Shown here on the eyelid surface. When sewn into the eyelid it's visually undetectable.) The smaller weights are not uncomfortable for most people. The weight is removed as soon as enough function returns to the eyelid. In cases of permanent facial paralysis it can be left in place indefinitely. It is, however, a surgical procedure, and should be done only after careful consideration. As with any surgery, infection can occur, and swelling can last for several weeks. The eyelid and crease area can appear distorted, and vision can be affected. The weight, particularly if above 1.2 grams can cause the eyelid to droop. In spite of the cautions noted, it is well tolerated by most patients, and provides good protection for the cornea, as well as an improved appearance. Spring insertion is another, less frequently used type of surgical implantation.

Because we sleep in a horizontal position eye weights do not help keep the eye closed while sleeping. The effects of gravity are key to the success of eyelid weights, so its possible that even with an eyelid weight, additional protection may be needed while sleeping.

Lower lid elevations and surgical tightening of the lower lid can help prevent moisture from accumulating between the eye and a droopy bottom lid instead of spreading over the cornea.

Tarsorrhaphy is a procedure to sew a portion of the upper and lower lids together. When possible, only 5mm at the outer corner of the lids (lateral tarsorrhaphy) are stitched to maintain good vision, comfort and best possible appearance. If limited to 5mm or less, the appearance is not as bad as its description sounds. The eyelashes are undisturbed, and make-up can be worn. However, the procedure is not always effective unless a larger area is stitched, and a larger area may interfere with peripheral vision, and become more noticeable. If a medial tarsorrhaphy is suggested (rare even for permanent FP; shouldn't be needed for BP), it might be wise to seek a second opinion. This procedure is done over the center of the lids. It is disfiguring and functionally disruptive - a procedure of last resort.

CONTACT LENSES
Contact lenses are hydrophilic (hold water). They can provide a source of moisture directly over the cornea, and help protect the eye from injury due to debris. The eyelids help to hold a contact lens in place. If the lids become limp, contacts cannot be worn until function begins to return. Important notes of caution: Wearing the lens helps, but it is not a complete replacement for your tears - use plenty of saline or eye drops designed for use with contacts. At the acute stage, the eye can be so dry that it is impossible to keep a contact lens moist for more than a few minutes at a time. In this situation, contacts can not be worn.

**DO NOT LET THE LENS DRY OUT! A dry contact directly over the cornea is dangerous. This is very important - IF YOU CANNOT KEEP THE LENS MOIST, DO NOT WEAR IT! **

Before you start to exercise, get familiar with your face. We suggest you print the diagram of the muscles and the list of the muscles' actions. Refer to them as you exercise. Use them to get to know your facial muscles and what each muscle is doing as it moves. This can help you learn to isolate muscle actions as well as coordinate multiple muscle movement. Regaining balanced, symmetrical movements is key to restoring the face as it was before.

Moist heat and massage can be part of the routine at all stages of recovery. Mirror feedback is important from the moment any movement returns.

Therapists who specialize in facial retraining can offer further assistance with programs customized to your specific needs. Facial neuromuscular retraining is a highly specialized field, and involves training beyond the standard curriculum for physical therapy. There is no substitute for the experience of certified facial NMR therapists, and the tools available with physical therapy, such as EMG feedback.

The majority of Bell's palsy cases will resolve without intervention or exercise. Patience is more important during recovery than pushing to exercise muscles that are likely to return to full function without assistance. Some cases will result in incomplete recovery or leave residuals. These exercises are not meant to replace a customized program under the supervision of a professional facial retraining therapist - If you feel you need professional help, don't hesitate to get it.

GENERAL GUIDELINES FOR OLD AND NEW CASES...
Keep a couple of things in mind as you exercise with Bells palsy ... You need to be patient, and work the muscles gently. The idea is not only to regain motion, but for the motion to be balanced with the good side. Don't force things to the point that the two sides pull against each other. If you see a motion pulling other muscles that shouldn't be moving, back off a little, and freeze it at that point, and relax the muscles that shouldn't be moving. Keep your eyes on those eager-beaver muscles in the cheek area as you work your eye or mouth. And check the muscle that runs down your neck to make sure it doesn't "pop out". Keep the muscle movements appropriately isolated. Pay attention to your face as you exercise - focus on watching and feeling what the good side is doing, and then mentally visualize it on the Bell's palsy side and try to recreate it in tiny increments. Use a mirror - the feeling of motion you get while exercising can be very deceptive, so this is important. The mirror will also help you avoid letting the good side overcompensate by moving in an exaggerated way.

Remember not to push it - better to hold a position at the point it can go without inappropriate muscles jumping in to help than to try too hard to do things your face isn't ready for. Movements will elongate with time.

Exercise in short sessions, but repeat the routine 2-3 times a day, more if you can. Quantity is not as important as quality, so don't do your exercises when you're tired.

** It's better to exercise correctly just a few times than to do it incorrectly many times.**

During the earliest days of Bells palsy, when muscles are completely flaccid, it's probably advisable to limit therapy to moist heat (to ease soreness and reduce swelling), massage (also to ease soreness, plus to provide a degree of motion stimulation to the muscles and increase circulation) and mental exercises (to retain the "memory" of facial motions).

Facial muscles are not at risk of permanent atrophy for quite a long time. Focus your exercise energy on maintaining the brain-to-nerve-to-muscle connection. This is more important than the physical motions your muscles did before, and will do again. The signal begins with your brain when you're healthy - you can use your mind to help maintain the connection while your body rests and begins to recovery. Do this by visualizing normal movement. Use your mind to see it, sense it and feel it. This will help maintain the memory of the signal that must be transmitted to the muscles when the time comes for everything to start to move. Avoiding excessive facial exercises in the early days will give the nerve time to recover from the trauma, start the healing and regrowth processes, and help to avoid promoting synkinesis. Pushing muscles that have been weakened with Bell's palsy before they're capable of correctly coordinated movement may promote synkinesis and incorrect movement patterns that are difficult to "unlearn". Remember that you're recovering from an injury. Give your nerve the chance to rest and heal just as you would if it were a broken bone.

When its time to start exercising, read the section for longtimers, and follow the same principles, but for these exercises:

Sniffle. Wrinkle nose. Flare nostrils.

Curl upper lip up and raise and protrude upper lip.

Compress lips together. Pucker lips attempt to whistle.

Smile without showing teeth; then smile showing teeth.

Try moving your lips into a small smile slowly. Then gently pucker slowly using equal strength from both sides.

Draw angle of mouth upward so as to deepen furrow from side of nose to side of mouth.

Harden (wrinkle) the chin; "stick out" the chin (like a boxer).

Using your index finger and thumb pull the corners of your lips in toward the center. Slowly and smoothly push out and up into a smile. Continue the movement up to the cheekbone. Use a firm pressure.

Placing 4 fingertips on the eyebrow rub using a firm stroke up to the hairline. Return downward to the eyebrow. Do the same type of massage in a circular motion on your cheeks and chin, and outward to your ear.

Try to close the eye slowly and gently, without letting your mouth pull up or your eyebrow move downward.

Raise eyebrows and hold for 10 -15 seconds (watch out for synkinesis - hold the brow at a point before the corner of your mouth starts to move or your cheek tries to help). Wrinkle forehead.

Frown and draw eyebrows downward.

Gently wink with one eye and then the other to the best of your ability. Don't push it.

Open eyes widely, but without involving your eyebrow. Stop if you see any inappropriate muscle actions.

Do not chew gum - it exercises the wrong muscles, and may promote synkinesis.

Do try to chew food using both sides of your mouth (at least when you're eating alone). This will help maintain normal patterns when movement returns.

FOR EYE CLOSURE...
Bell's Phenomenon may occur. It actually performs a good function, as it helps protect the non-closing eye. With Bells Phenomenon the eyeball turns upward as we attempt to close the eye. So you can think the eye is closed when it actually is not. Have someone observe you while you try closing the eye. If you have Bell's Phenomenon, concentrate on looking downward toward the floor as you practice eyelid closure.

FOR LONGTIMERS...
With longstanding cases of Bells palsy mental work is half the battle. You're likely to be dealing with residuals such as synkinesis, cross-wiring, hypertonic muscles and spasms. For some people, the muscles have had time to develop inappropriate movements. These movements must be unlearned, and correctly coordinated actions slowly relearned. Muscles that are holding other muscles captive have to be retrained in order to free-up other muscles to move correctly. With slower recoveries from Bell's palsy, synkinesis, hypertonic muscles and spasms become more likely. The basic idea is to slowly recreate the brain-to-nerve-to-muscle routine. At first the goal is to regain the capability of doing correct movements voluntarily (while mentally focusing on the action). Over a period of time (and hard work) these movements may finally become automatic, natural movements and expressions. Patience and diligence are key - it's a slow process, and really does have to be worked on daily (or as close to daily as life's responsibilities and human nature allows).

To relax the cheek: (if the side of your mouth is pulling up and to the side, or your cheek feels tight)...
Put your thumb inside your cheek at an angle toward the center of your ear. Grasp the outside of your cheek with your fingers, and pull down and forward (yes, it may hurt just a bit). Hold it for a minimum of 10 seconds; up to 30 seconds is good. Shift the position toward the center and repeat the stretch hold. Shift still further toward the center and repeat. Shift the position to grasp at an angle from the jaw and pull forward and up; hold. Shift a bit toward the center below your lower lip and repeat.

If you find a thick or sore point as you are doing the exercises or massaging, apply and hold pressure at that spot for 15-20 seconds to help relax the muscle or clear a spasm.

To help isolate eye and mouth movements...
Close and compress your lips (lightly!). While doing this, observe in the mirror the unwanted eye muscle movement. Release, and then lightly compress your lips again. Maintain the lip compression at a point just before your eyelid starts to become involved, and focus on relaxing the muscles around the eye. Very small movements at first - remember that with time you will be able to take the movement farther without involving your eye. Have patience.

Pucker your lips, using the same technique as for compressing them.

Snarl, using the same technique.

Smile (again, start small!). Watch your eye area, particularly the lower lid. Find the point that it starts to move. Then concentrate on the smile in your mind first, let your mouth follow the thought, and hold at the point where the eyelid is not yet involved. Also watch the neck muscle and don't let it pop out.

Practice speaking in front of a mirror, repeating words that use M, B, F and P while keeping your eyelids open. In the beginning, speak softly and slowly.

Raise your eyebrows evenly on both sides. Stop when the corner of your mouth starts to move, hold for 15 seconds while keeping the muscles around your mouth relaxed.

Stretch the neck muscle by tilting your head to the side and slightly back, hold for 10 seconds. Do it again to the other side.

** If you have any cervical spine problems, speak to your doctor before doing the neck exercise **

Gently open your eye as widely as you can without raising your eyebrow or letting your lower lid pull up. Hold for 15 seconds.

Starting with lips slightly open, mentally concentrate on relaxing the chin dimple. Do the same thing with lips closed.

Pull your lower lip down (take it forward and down in a circular move) evenly on both sides. Don't let the good side take control of the effort. Keep the eye open, and keep the neck muscle relaxed. Hold 15 seconds.

Massage your face (both sides) using firm circular motions. Start in the center and work your way out. Massage with the circular motion at your forehead, cheeks, nose, and chin. Then follow the jaw line from your mouth outward as well as from your chin outward.

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