Bell’s Palsy: who to see and what helps

Bell’s Palsy · Kitchener, Waterloo & Cambridge

Bell’s palsy is weakness or paralysis of one side of the face that builds over one to three days, from a problem with the facial nerve and with no other cause found. A face that suddenly droops is also a sign of a stroke, so call 911: Bell’s palsy is the diagnosis a physician makes once a stroke and other causes have been ruled out. The steroid tablets a Canadian guideline recommends are best started early, and most people recover within six months. CARESPACE does not diagnose Bell’s palsy or prescribe for it; a physiotherapist’s part is facial exercise, alongside your medical care.

A drooping face can be a stroke: when to call 911

Call 911 right away for the signs of a stroke. The Heart and Stroke Foundation of Canada teaches them as FAST: Face, is it drooping? Arms, can you raise both? Speech, is it slurred or jumbled? Time to call 911. Do not drive to the hospital: an ambulance will take you to the closest hospital that provides urgent stroke care.

Less common signs are vision changes (blurred or double vision), a sudden severe headache, numbness (usually on one side of the body) and problems with balance. Not everyone has every sign. Call 911 even when the signs last only a few minutes and then pass: that can be a transient ischemic attack (TIA, or mini-stroke), which is also a medical emergency. Note the exact time the signs began and tell the hospital staff. Nobody at CARESPACE can rule out a stroke.

A drooping face is the first of those signs. Heart and Stroke’s instruction is to call 911 for any one of the FAST signs, so a face that suddenly droops or weakens on one side is a 911 call, whether or not another sign comes with it. Bell’s palsy and a stroke cannot be told apart at home: Bell’s palsy is the diagnosis made once an examination has ruled out a stroke and other causes. Being seen straight away also leaves time for its medicine, which guidance in the UK and the United States says to start within 72 hours.

What Bell’s palsy is

In Bell’s palsy the facial nerve is damaged by swelling and pressure. The exact cause is not known; an infection of the nerve by the herpes simplex virus is believed to be the main one. By the Canadian guideline’s figures it affects 20 to 30 people in every 100,000 each year, and 1 person in 60 over a lifetime.

It is reported more often with diabetes, high blood pressure or a weakened immune system, in pregnancy, and after influenza or another upper respiratory illness.

Symptoms of Bell’s palsy

• Weakness on one side of the face, or being unable to move it
• A drooping eyelid or corner of the mouth
• Trouble closing the eye on that side
• An eye that is dry, or that waters
• Drooling
• A dry mouth
• Loss of taste

The weakness usually peaks within the first week. Weakness on both sides of the face is rare in Bell’s palsy and is a reason to look for another cause.

How Bell’s palsy is diagnosed

A physician or nurse practitioner diagnoses it from your history and an examination, by excluding other identifiable causes of facial weakness. The US guideline says routine blood tests and scans should not be ordered for new Bell’s palsy.

Signs that point somewhere else include a forehead that still moves normally, abnormal eye movements, hearing loss, ringing in the ear, vertigo, weakness in an arm or leg, and weakness that crept in gradually. Lyme disease can weaken the face too, so mention any tick bite, rash or joint pain. Strong pain followed by blisters in the ear canal or throat suggests Ramsay Hunt syndrome, which is caused by the shingles virus.

What the evidence says about treating Bell’s palsy

• The sources. A Canadian guideline from 2014, a US guideline from 2013, three systematic reviews and a 2023 US evidence review. The Canadian panel labels each position strong (“we recommend”) or weak (“we suggest”). The label reflects how sure the panel is that the benefits outweigh the downsides, taking in people’s preferences and cost, not only how good the studies are.
• Steroid tablets, early. Corticosteroids are recommended for everyone with Bell’s palsy (strong, moderate confidence). The US guideline says to prescribe them within 72 hours of the first symptoms for people 16 and older. The Canadian panel calls the window unclear and notes a subgroup analysis of one trial that suggested a benefit only when treatment began within 48 hours.
• Antivirals are not a treatment on their own. The Canadian guideline recommends against an antiviral alone (strong). It suggests against adding one to steroids for mild to moderate weakness, and suggests the combination when paralysis is severe to complete (both weak).
• Protect an eye that will not close. Routine eye protection, with lubricating drops and ointments to prevent damage to the cornea, is a strong recommendation, made on very low confidence in the evidence.
• Facial exercise: suggested for weakness that persists, with newer trials supporting an early start. The Canadian panel could not agree on physiotherapy in the early phase and makes no recommendation; it suggests exercise physiotherapy for persistent weakness (weak, very low confidence). A Cochrane review of 12 studies with 872 participants, most at high risk of bias and three of them (199 participants) on exercise, found no high-quality evidence of significant benefit or harm from any physical therapy, and low-quality evidence that tailored facial exercises improve function, mainly in moderate paralysis and long-standing cases. In a 2022 review, four of seven newer randomized trials were rated high quality and all described a positive effect; the results could not be pooled. Its authors concluded that the new studies strengthen the case for facial exercise therapy early in recovery. A 2023 US review says facial physical therapy should be offered for severe or complete paralysis, and for paralysis lasting more than three months.
• Electrical stimulation: suggested against. In one randomized study, recovery was significantly poorer with it than with facial exercise (weak, very low confidence).
• Acupuncture: no conclusion possible. A Cochrane review of six studies with 537 participants, whose searches ended in 2010, judged their quality inadequate to allow any conclusion. A 2023 US review found the high-quality evidence insufficient to recommend acupuncture for early Bell’s palsy, and the US guideline makes no recommendation.
• Surgery is not routine. The Canadian guideline suggests against routine surgical decompression of the nerve (weak).

What a physician or nurse practitioner provides

CARESPACE does not provide these, but it helps to know where they fit. A physician or nurse practitioner makes the diagnosis, prescribes the steroid tablets (a 10-day course in UK practice, sometimes with an antiviral) and shows you how to protect the eye. A new sign from the stroke list above is always a 911 call. Go back to your physician or nurse practitioner for any other new or worsening neurological sign, for eye symptoms at any point, and if recovery is incomplete three months after it began, when reassessment or referral to a facial nerve specialist is due. With no improvement, or weakness that keeps progressing after the diagnosis, specialist referral and imaging to rule out other diagnoses are recommended.

How CARESPACE services help with Bell’s palsy

Physiotherapy

A physiotherapist can assess which facial movements are weak and teach exercises tailored to them. In one study, exercise was combined with stretching and massage of the face. This sits alongside your medical care, not in place of it. Not every physiotherapist works with facial palsy, so ask when you book whether one with that experience is available.

See our physiotherapy team →

Other services people ask about

Acupuncture. The trials are too weak to show whether it helps, and none of them reported harmful side effects. Massage therapy. Facial massage appears in the research only as part of a physiotherapy program; we found no trial of massage on its own. Speech-language pathology. Some people are left with difficulty eating and drinking, but neither guideline makes a recommendation about speech-language pathology. Counselling. Bell’s palsy can affect mental health. Tell your physician if you feel depressed, stressed or anxious; counselling is there if you want it.

Where most people start

With a 911 call the day the face droops, then with the physician or nurse practitioner who makes the diagnosis and prescribes. Physiotherapy follows the diagnosis, and many people recover without it. Book with a physiotherapist if your paralysis was severe or complete, or if weakness has lasted more than three months; you can also ask about starting facial exercise sooner. Physiotherapists assess and begin treatment at the first visit.

How your team works together

At CARESPACE this is mostly one practitioner, a physiotherapist, working alongside the physician or nurse practitioner who diagnosed you. Eye symptoms, weakness that keeps progressing and stalled progress go back to them.

Browse by service: physiotherapists.

What to expect at your first visit

1. The story so far. When the weakness started, who diagnosed it, which medicines you were prescribed and how you are looking after the eye.
2. Your face, movement by movement. Raising the eyebrows, closing the eyes, smiling, puckering. A physiotherapist may score these on a facial grading scale so that change can be tracked.
3. Anything for your physician. Eye symptoms or weakness that keeps progressing go back to the person who diagnosed you.
4. A start on treatment. Treatment begins at this visit, and you leave with a plan.

What you can do at home

• Take the prescribed tablets as directed.
• Use the eye drops and ointment you are given to stop the eye drying out, and ask to be shown how to tape it closed at bedtime with surgical tape.
• See your physician if the face is not improving after three weeks.
• Tell your physician if you feel depressed, stressed or anxious.

How long Bell’s palsy lasts

Most people recover within six months, and some take longer. Between 66% and 85% of people recover completely on their own within three weeks, by one US review’s count. How severe it was at the start matters: in a large study from a single centre, 94% of people whose paralysis was incomplete recovered, against 61% of those whose paralysis was complete. Some people are left with lasting weakness, a constantly watering eye, changes in taste or sensitivity to loud sounds, and up to 16% with involuntary facial movements called synkinesis.

Physiotherapy for Bell’s palsy in Kitchener, Waterloo and Cambridge

Kitchener. Physiotherapy in Kitchener. Locations: Victoria North, Fischer-Hallman, Westmount East and Deer Ridge.

Waterloo. Physiotherapy in Waterloo. Locations: Weber North, Uptown Waterloo and Waterloo GoodLife.

Cambridge. Physiotherapy in Cambridge. Location: Hespeler Road.

The city pages linked above show the locations and practitioners for each service, with their next availability.

Common questions

Is Bell’s palsy a stroke?

No. Bell’s palsy is a problem of the facial nerve, but the two cannot be told apart at home. A face that suddenly droops is a 911 call; Bell’s palsy is diagnosed once a stroke has been ruled out.

Should I start facial exercises right away?

The two guidelines, from 2013 and 2014, make no recommendation for or against exercise in the first weeks. A 2022 review of newer trials, several of them rated high quality, supports facial exercise early in recovery, so it is reasonable to ask a physiotherapist about it. The tablets and protecting the eye still come first.

Can Bell’s palsy come back?

It usually happens only once; rarely it comes back, sometimes years later. A face that droops again is a 911 call like the first time. Tell the hospital about the earlier episode, because a second one on the same side can point to another cause.

I am pregnant. Is Bell’s palsy different for me?

Pregnancy is one of the times it is reported more often, and up to 90% of pregnant people recover completely on their own. Which medicines to take in pregnancy is a decision for your physician or nurse practitioner.

Where can I get help with Bell’s palsy in Waterloo?

Once a physician or nurse practitioner has diagnosed Bell’s palsy, CARESPACE offers Physiotherapy in Waterloo. Book online or call 519-208-2273 and our Central Reception Team will find the closest location with an opening.

Do I need a referral?

No. Book online or call 519-208-2273. You pay at each visit and receive a receipt for your extended health plan. More on fees and insurance →

Sources

• de Almeida JR, et al. Management of Bell palsy: clinical practice guideline. CMAJ, 2014;186(12):917–922.
• Baugh RF, et al. Clinical practice guideline: Bell’s palsy. Otolaryngology–Head and Neck Surgery, 2013. Read as the American Academy of Otolaryngology–Head and Neck Surgery Foundation’s fact sheet of the guideline’s statements.
• Dalrymple SN, Row JH, Gazewood J. Bell palsy: rapid evidence review. American Family Physician, 2023.
• Teixeira LJ, Valbuza JS, Prado GF. Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews, 2011.
• Khan AJ, et al. Physical therapy for facial nerve paralysis (Bell’s palsy): an updated and extended systematic review of the evidence for facial exercise therapy. Clinical Rehabilitation, 2022.
• Chen N, et al. Acupuncture for Bell’s palsy. Cochrane Database of Systematic Reviews; the version on cochrane.org is dated 2022, Issue 3, and its searches ended in May 2010.
• NHS. Bell’s palsy. Reviewed July 2023; its next review was due in July 2026.
• Heart and Stroke Foundation of Canada. Signs of stroke, FAST signs of stroke: are there other signs? and the FAST poster.

Related conditions

Stroke Rehab
Shingles
Trigeminal Neuralgia
Neurological Conditions

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