Move Forward Guide
Physical Therapist's Guide to
There are several causes of facial paralysis, such as tumors of the facial nerve or tumors of the base of the brain, trauma, or a congenital condition (a condition that you're born with). Bell palsy usually begins with a sudden weakness on one side of your face or a sudden feeling that you can’t move one side of your face. It's important for you to know that these can be symptoms of such conditions as stroke. Seek medical care immediately, especially if your facial weakness is accompanied by:
- Pain in the ear, cheek, or teeth
- Loss of facial sensation
- Weakness of arms or legs
- Vision changes
- Severe headache
What Is Bell Palsy?
Bell palsy is a form of temporary facial paralysis. It occurs when the nerve that controls movement on one side of your face becomes inflamed. The condition often comes on suddenly but improves on its own within a few weeks. Although the cause of Bell palsy remains unclear, it’s thought that some cases might be caused by the herpes virus that also causes cold sores.
Signs and Symptoms
Bell palsy usually begins with a sudden weakness on one side of your face or a sudden feeling that you can’t move one side of your face. The weakness gets worse quickly. Other symptoms include:
- Inability to close the eye on the affected side
- Drooping of the affected side (within a few hours to overnight)
- Teariness or dryness of the eye
- Pain in or behind your ear
- Sensitivity to sound
- Loss of sense of taste
How Can a Physical Therapist Help?
In the first couple of days to a week after symptoms start, your physical therapist will evaluate your condition, including:
- Review your medical history, and discuss any previous surgery or health conditions
- Review when your current symptoms started and what makes them worse or better
- Conduct a physical examination, focusing on identifying the patterns of weakness that are caused by Bell palsy:
- Facial movements of the eyebrow
- Eye closure
- Ability to use the cheek in smiling
- Ability to use the lips in a pucker
- Ability to suck the cheeks between the teeth
- Raising the upper lip
- Raising or lowering the lower lip
Your physical therapist will immediately:
- Educate you about how to protect your face and your eye
- Show you how to manage your daily life functions while you have facial paralysis
- Explain the expected path to recovery, so that you will know the signs and symptoms of recovery
- Evaluate your progress, and determine whether you need to be referred to a specialist if progress is not being made
The first priority is to protect your eye. The inability to completely and quickly close your eye makes the eye vulnerable to injury from dryness and debris. Debris can scratch the cornea—the transparent front part of the eye that covers the iris, pupil, and front chamber of the eye—and could permanently harm your vision. Your physical therapist will immediately show you how to protect your eye, such as:
- Using self-made and commercial patches
- Setting a regular schedule for refreshing eye fluids
- Carefully closing the eye with your fingers
If you have partial facial movement, your therapist will teach you a few general facial exercises to do at home. These exercises will help you learn to move the weak side of your face and help you use both sides of your face together. One of the exercises is a gentle blowing action through your lips.
Your physical therapist will help you regain the healthy pattern of movements that you need for facial expressions and function. Recovery can be challenging because:
- Normally, the ability to make facial expressions and many facial movements is "automatic";—that is, you're born with this ability and never had to think about it before
- Unlike other muscles in your body, the facial muscles do not have sensors that tell your brain all of the necessary "details" about how to move
Your physical therapist will be your coach throughout this challenging time, guiding you through special exercises that are designed to help you relearn facial movements based on your particular movement problems. Your exercises may change over the course of recovery:
"Initiation" exercises. In the early stages, when you might have difficulty producing any facial movement at all, your therapist will teach you exercises that cause ("initiate") facial movement. Your therapist will show you how to position your face to make it easier to move (called "assisted range of motion") or how to "trigger" the facial muscles to do what you want them to do.
"Facilitation" exercises. Once you're able to initiate movement of the facial muscles, your therapist will design exercises to increase the activity of the muscles, strengthen the muscles, and improve your ability to use the muscles for longer periods of time ("facilitate" muscle activity).
Movement control exercises. Your therapist will design exercises to:
- Improve the coordination of your facial muscles
- Refine your facial movements for specific functions, such as speaking or closing your eye
- Refine movements for facial expressions, such as smiling
- Correct abnormal patterns of facial movement that can occur during recovery
To work on coordinating your facial muscles, you'll need to have a sufficient level of activation of facial muscles first. Your therapist will determine when you're ready.
Relaxation.During recovery, you might have facial spasms or twitches. Your physical therapist will design exercises to reduce this unwanted muscle activity. The therapist will teach you how to recognize when you are activating the facial muscle and when the muscle is at rest. By learning to contract the facial muscle forcefully and then stop, you will be able to relax your facial muscles at will and decrease twitches and spasms.
Some people might have greater difficulty moving their face after a period of improvement in facial movement, which can make them worry that the facial paralysis is returning. However, actual recurrence of facial paralysis of the Bell Palsy type is uncommon.
New difficulty in moving the face is more likely the result of increasing the strength of the facial muscles without improving the ability to coordinate and control the movement. To keep this from happening, your physical therapist will show you what facial movements you should avoid during recovery. For instance, the following might lead to abnormal patterns of facial muscle use:
- Trying to make the biggest facial movement or muscle contraction that you can, such as smiling as much as you can
- Chewing gum with great force
- Blowing up a balloon with all of your effort to work the facial muscles
Your therapist will coach you to use your face as naturally as possible, without trying to restrict facial expressions because they look "different."
Real Life Experiences
Doris W. wakes in the morning and washes her face. She's surprised to find that she gets soap in one of her eyes. Then, when she brushes her teeth and rinses, she feels the water running out of only one side of her mouth. Doris looks in the mirror and sees that on one side of her face, her cheek is drooped, and one corner of her mouth is lower than the other. Her first thought is that she's having a stroke, and she's even more concerned when she tries to speak and has trouble saying certain words. Because she has no other weakness of the arms or legs or changes in vision or ability to think, a stroke is less likely.
What does she do next?
First, she gets immediate medical attention in an urgent care center or the emergency department of her local hospital. This assessment is necessary to diagnose the problem as paralysis or partial paralysis of only one side of her face and to rule out other causes of facial weakness, such as stroke. Early treatment of facial paralysis due to Bell Palsy is either "do nothing" (wait and see) or prescribe anti-inflammatory or antiviral medications. Doris is instructed to protect the eye from drying of the cornea and is referred to her physician for follow up. Her physician recommends that she see a physical therapist to help her regain normal use and movement of her facial muscles.
Her physical therapist first makes sure that she is protecting her eye appropriately. Doris is using an eye patch, and the therapist shows her how to look down and focus on something, to keep the eye in the downward position, and to close the eye when washing her face or when she's outside and the wind picks up. Because her paralysis is partial, the therapist begins "facilitation" exercises to keep the lips in a better position for the cheek to lift into a smile (gently press the lips together and continue pressing while attempting to smile). The therapist recommends that Doris try using a straw positioned close to the center of her lips when drinking, which will help the weak side of the lips to "work" with the uninvolved side in sucking.
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological focus.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in neurologic physical therapy has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool that built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapist for an appointment, be sure to ask about his or her experience in helping people with Bell palsy or facial paralysis.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of Bell palsy. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Sullivan FM, Swan IR, Donnan PT, et al. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007;357:1598–1607. Free Article.
Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;549:4–30. Article Summary on PubMed.
VanSwearingen J. Facial rehabilitation: a neuromuscular reeducation, patient-centered approach. Facial Plast Surg. 2008;24:250–259. Article Summary on PubMed.
VanSwearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther. 1998;78:678–689. Free Article.
Brach, JS, VanSwearingen, JM. Physical therapy for facial paralysis: a tailored treatment approach. Phys Ther. 1999;79:397–404. Free Article.
Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Larynogoscope. 1991;101(7 Pt 1):744 –750. Article Summary on PubMed.
Acknowledgments: Jessie M. VanSwearingen, PT, PhD