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PATHOLOGY PERSPECTIVES associated with several other tissue dysfunctions as well, where Bell's palsy is limited strictly to the facial nerve. POSSIBLE COMPLICATIONS The most important short-term complication of Bell's palsy is the risk of damage to the eye, because the facial muscles cannot close the eyelid completely. Patients may be counseled to sleep with an eye patch to avoid scratching the eye. While tear production is impaired and patients need to supplement with moistening drops frequently, many people also have the experience of excessive tearing, which shows how the muscles that control the eyelid have been weakened. Once the first few weeks have passed and the affected eye is safe, Bell's palsy usually has an excellent prognosis. Recovery generally occurs within three weeks to three months, but it can take longer. Up to 85 percent of all people experience full or nearly full recovery within a year of onset. About 10 percent have some level of permanent asymmetry in nerve function, and 5 percent have permanent, severe damage.6 Of those who don't fully recover, their long-term consequences can take several shapes. Incomplete motor recovery may mean that the facial muscles never become fully functional again. One person described it this way: "My dad had Bell's palsy. He improved over time, but his eye still teared up on him, and he never did get his whistle back." In other cases, a person may experience sensory distortion involving the taste buds supplied by the facial nerve. A common complaint: "Everything tastes like soapy beer!"7 A rare but important complication of Bell's palsy is called synkinesis. Literally this translates to with movement, but in this situation it refers to a malfunction in how the motor neurons of the facial nerve regenerate. A person with synkinesis may experience faulty motor functioning, specifically of the tear ducts and the salivary glands. When he smells something delicious, instead of having his mouth water, he may drip tears. When he is hurt or sad, he may salivate instead of weeping. And finally, the unopposed muscles on the contralateral side of the face may become chronically tight or even spasmodic. The term hyperkinesis describes the tendency toward spasm that long-term Bell's palsy patients sometimes experience. Injections with Botolinum toxin are sometimes recommended to temporarily paralyze these overactive muscles.8 Perhaps the most profound effect of Bell's palsy is on a person's self- image. One massage therapist describes this client: "I find that what bothers people with Bell's palsy the most is their appearance. One of my clients was a particularly beautiful woman who was so mortified at the way her face looked that she basically became a hermit until it went away. She started getting house calls instead of coming to the office, she sent her husband or teenagers to do every errand, she pulled a hat way down over her face when she had a doctor's appointment or something she couldn't get out of. It lasted for a couple of months or so, and she had been a very social person, too. Basically she let Bell's palsy take away her whole life while she had it." WHAT ABOUT MASSAGE? Bell's palsy treatment protocols often include massage along with electrical stimulation, exercises, and biofeedback. The general goal with these strategies is to maintain the health and function of the facial muscles while the nerve heals. Research indicates that massage may be helpful in this setting, but no large scale or specifically massage-targeted studies have yet been published.9 Because facial sensation is intact with Bell's palsy, massage within pain tolerance is probably not only safe, but an important intervention to keep flaccid muscles elastic and well nourished. Massage can specifically stretch and, with client participation, exercise facial muscles that control the eyebrows and mouth for the best possible outcome. teaches several courses at the Myotherapy College of Utah and is approved by the NCBTMB as a provider of continuing education. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com. Ruth Werner is a writer and educator who NOTES 1. B. Lo, "Bell Palsy," Medscape. Available at http:// emedicine.medscape.com/article/791311- overview (accessed May 2009). 2. J. Tiemstra and N. Khatkhate," Bell's Palsy: Diagnosis and Management," American Academy of Family Physicians (2007). Available at www.aafp.org/ afp/20071001/997.html (accessed May 2009). 3. D.G. James, "All That Palsies is Not Bell's," Journal of the Royal Society of Medicine 89 (1996): 184–87. Available at www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=1295731 (accessed May 2009). 4. N. Holland and G. Weiner, "Recent Developments in Bell's Palsy," British Medical Journal 329 (2004): 553–7. Available at www.bmj.com/cgi/content/ full/329/7465/553?etoc (accessed May 2009). 5. D.P. Markby, "Lyme Disease Facial Palsy: Differentiation From Bell's Palsy," British Medical Journal 299 (1989): 605–6. Available at www.pubmedcentral. nih.gov/picrender.fcgi?artid=1837468&blobtype=pdf (accessed May 2009). 6. B. Lo, "Bell Palsy." 7. Ruth Werner, A Massage Therapist's Guide to Pathology (Baltimore: Lippincott Williams & Wilkins, 2009). 8. T.S. Shafshak, "The Treatment of Facial Palsy From the Point of View of Physical and Rehabilitative Medicine," Eura Medicophys 42 (2006): 41–7. Available at www.ncbi.nlm.nih.gov/ pubmed/16565685 (accessed May 2009). 9. Ibid. visit massageandbodywork.com to access your digital magazine 103