Ep 191 – Bell’s Palsy: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this ground-breaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

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0:01:07.6 Ruth Werner: Hi, and welcome to I Have A Client Who... Pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks. Today's episode is on a topic requested by a listener, but with no specific story behind it. They just said, Please do an episode on Bell's palsy. However, it happens that I have a great Bell's palsy story that an attendee submitted for an ethics class that I teach, called the ethics of client communication, talking to clients about their health, which is essentially a communications class built on real life I Have A Client Who stories. And in this instance, here's how it went. A 45-year-old woman is recovering from a mild cold. She wakes up one morning and notices that one side of her face seems to be sagging. Her smile doesn't really lift, her eye isn't closing all the way.

0:02:48.5 RW: She has no other weakness or other... Sometimes, that might make her worried about a stroke, but the left side of her face is heavy, and the sound in her left ear seems to be especially loud, and her sense of taste is all wacky. Well, her doctor identifies Bell's palsy and he gives her a prescription for steroidal anti-inflammatories and tells her to tape her eye close that night and that she should see improvement maybe in a couple of months. This seems inadequate to her, so she went to the health food store to see if she could find some kind of supplement that might hurry things along. And there, the clerk who was not a massage therapist or a medical professional, told her she should definitely get a massage, and that would really help a lot. So, based on this advice, she called a massage therapist to get an appointment as soon as possible. Okay, so do we see some issues here? Well, we'll get back to this client and her massage therapist in a moment, but first, let's talk about why her face is drooping. Firstly, Bell's palsy has nothing to do with bells. This condition is named for Sir Charles Bell, a Scottish doctor who was early to explain it in detail, in 1821. It turns out that descriptions of facial paralysis go back much further.

0:04:13.2 RW: Of course, a Persian physician, Muḥammad ibn Zakariyyā al-Rāzī wrote some details about facial palsy in the ninth century, and a few others described what may be the same thing in the 16th and 1700s. But Dr. Bell got his name on it when he explained it's neuro and anatomical features to the Royal Society of London. Bell is also noted for figuring out the difference between motor nerves and sensory nerves in the spinal cord. He's a very important figure in the history of our understanding of anatomy. So in short, this condition arises from damage to the facial nerve, that's cranial nerve seven, and that is the main motor nerve for the face. You might remember that unlike the spinal nerves, some of our cranial nerves are almost entirely segregated in terms of motor versus sensory function. The facial nerve is almost completely composed of motor neurons that supply our facial muscles. It's only sensory components provide a sense of taste from a limited area on the tongue. So, when we smile or frown or bear our teeth or wink or raise our eyebrows, well, all of that is your facial nerve at work. Importantly, in its control of the eyelids, it allows us to blink and to protect our eyes. What can damage the facial nerve? Lots of things.

0:05:44.6 RW: You might remember that the facial nerve is vulnerable in a tight spot, right behind the ear lobe, anterior to the mastoid process. Go ahead and palpate that spot for a moment. If you like, maybe open and close your jaw and you can feel how delicate it feels back there. It has to run a complicated course from the ponds where it originates, through its exit at the stylomastoid foramen past the styloid process behind the ear lobe and out into the facial muscles. So if a person has any inflammation like from a cold or some other illness, that nerve may also become swollen and irritated. Bell's palsy is often a complication of some other condition. We see it a lot with Lyme disease, and in parts of the country where Lyme disease is common, if someone has Bell's Palsy, then they are sent for Lyme disease testing as a matter of course. It also has been seen with outbreak of herpes simplex, and we are noting it in people who have COVID-19 too. But for a lot of people, it just shows up one day, seemingly out of nowhere, and this pattern gives rise to its alternative name, idiopathic facial paralysis. Idiopathic means, of unknown origin.

0:07:00.8 RW: The net result is that this unlucky person experiences a sudden onset of flaccid paralysis on one side of the face, it can look alarmingly like they've had a stroke, although that facial weakness presents just a little bit differently. Bell's palsy is not typically extremely painful, although there can be pain related to how all those slack official muscles pull on other structures. The ear on the affected side sometimes becomes hypersensitive because the ear drum gets stretched, and taste can become distorted too. But an important feature of Bell's palsy is that the rest of facial sensation is intact, even though the muscles are weak and not working, the person can still feel their face, and this has big implications for massage, of course. Fortunately, most of the time, the damage with Bell's palsy only affects the superficial aspects of the facial nerve, and the prognosis for most people is really good, almost all patients get full or nearly full function back. But nerves heal so slowly, and it may take a long, long time to get better. I had a student who got it as a young man, and he did not seek early treatment, and consequently his situation probably dragged on longer than it needed to. He said he lost all use of his dimples and everything tasted like soapy beer, and those changes lasted for at least a year.

0:08:39.3 RW: So let's come back to our client. She woke up one day and she found that her face had just sort of collapsed on one side. Very alarming. Her doctor diagnosed her with Bell's palsy, gave her some heavy duty anti-inflammatories and told her to protect her eye while she was recovering, which could take a couple of months or more. The clerk at the health food store told her that she needed to get massage, and that would fix her right up, so here she is in your office. What is going to happen next? Well, fortunately, you both listen to this podcast and you have a pathology book or a pathology app close to hand, so you will find out quickly that Bell's palsy involves damage to the facial nerve, it's usually temporary, has a good prognosis, and most importantly, for your purposes, your client has full sensation even on the affected side. If you have time, you can scan the pubmed.gov literature too, but let me save you a little trouble. I find that all kinds of manual therapies are recommended for Bell's palsy along with electro stimulation and exercise. Of all of the options, specially-tailored facial exercises seem to have more reliably positive results, but truly there isn't a clear winner. That said, massage appears to be safe, and that is an important piece of information.

0:10:05.2 RW: Well, what else do we need to know? She's taking steroidal anti-inflammatories, and that means we have to be conservative about our work so as to not overpower the system and make inflammation worse. But you know? That's part of working around the face anyway, isn't it? Are there any other cautions you can identify? The main one I see is that thanks to that health food store clerk, she has an unrealistic expectation of what massage can do for her. If through clear and careful communication, we can educate her about what massage might be able to do, that is to reduce pain and work to keep muscles as healthy as possible while the nerve heals, and to reduce stress, well, then our work can be much more effective and she can get the best benefit from our skills. Bell's palsy can look really scary, but knowledge is power, and by knowing some parameters about this condition, that it requires some skill and gentleness, but because sensation is intact, skilled massage is safe, we can possibly be a helpful part of the recovery process. Will massage fix it instantly? No. Will massage speed the healing process? We don't know. It's hard to test, obviously. But could massage help with the pain and stress of a long-lasting nerve injury? Yes, with care and caution.

0:11:31.8 RW: So that's my little rundown on Bell's palsy. I wanna remind you that if you have a condition you'd like me to cover, especially if it comes with a good story about a client, I'd love to know about it. Hey, everybody, thanks for listening to I Have A Client Who pathology conversations with Ruth Werner. Remember, you can send me your I Have A Client Who stories to ihaveaclientwho@abmp.com. That's, ihaveaclientwho, all one word, all lowercase, @abmp.com. I can't wait to see what you send me, and I'll see you next time.

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