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Acute Management

Management Of Facial Nerve Paresis

Facial paralysis results from injury to the facial nerve. Depending on the degree of damage to the facial nerve, the amount of recovery and the time period for recovery will vary. The majority of patients with Bell's Palsy have complete recovery within three to six months (up to 80%). Recovery can take place slowly for periods up to eighteen months.

When there is facial paralysis, there are typically two stages of recovery.

Stage 1 (up to 3 to 6 months)

In the early stage, facial movement may be weak or there may be no facial movement at all. The face may droop at rest and you may find that the face tends to pull to the normal side without your control.

The eye may be unable to blink or completely close and tearing may be decreased. You will have to take special care of your eye at this time.

Nerve healing and regeneration is taking place to varying degrees. Nerve regeneration is a slow process and it may take up to a year to realize significant recovery. There is nothing that can be done at this time to improve the rate and amount of recovery. The facial nerve needs time to heal.

Facial exercises, are not appropriate during this stage since the nerve needs ample time to heal (like a broken bone in a cast has to heal). At this time, exercises performed with maximum effort will have little effect and may be harmful later as they can reinforce abnormal movement patterns.

Electrical stimulation is not appropriate in the treatment of facial paralysis since it reinforces abnormal movement patterns and can be harmful to the healing process of the nerve.

It is important to schedule regular appointments with your physician or facial therapist to monitor your health and to note any changes to your face. Regular follow-up will ensure that if facial rehabilitation is appropriate, it will be started at the optimal time (Stage 2).

Stage 2

The first signs of recovery are usually subtle. You may first notice a gradual straightening of the mouth and the reappearance of the facial line running from your nose down to the side of the mouth (the naso-labial fold).

As nerve recovery takes place, small facial movements begin with some function naturally following. Generally this occurs somewhere between one month and six months after onset. You will naturally begin to use these new movements with your speaking, expressing and eating. If after six months, which is ample time for healing of the facial nerve, and full recovery has not been realized, it may be time to begin a rehabilitation program with a therapist (physiotherapist or occupational therapist) who has been specifically trained in facial retraining to help you strengthen weak facial muscles or to help you learn to control your facial movements. Your physician will refer you for therapy.

Speech Therapy may be helpful if you are experiencing any difficulty in pronouncing specific sounds or managing food.

As recovery continues, you may notice movements in areas of your face that you are not trying to move. This is referred to as synkinesis. Facial retraining techniques will help to improve this inco-ordination problem.

What is facial retraining?

Facial retraining or muscle re-education is a problem solving, individualized approach used to produce symmetrical movements and control undesired movements of the face. Since treatment is based on individual function, a therapist can help you develop a personalized exercise program to give you the greatest benefit.

Techniques include a detailed facial evaluation, specific retraining strategies (e.g. strengthening exercises or relaxation exercises), sensory feedback and an individualized home based exercise program.

A warm facecloth placed on the face and/or gentle massage will help to relax your facial muscles and prepare it for exercise. When exercises are done, the movements should be as symmetrical as possible using a mirror in a quiet area. Exercises should not be done when you are tired or upset. You may find that alcohol, nicotine, caffeine and stress may make your face feel tighter.

Acknowledgment to facial therapists:

Brenda Ross, PT, Sunnybrook & Women's College Health Sciences Centre
Joanne Dorion, PT, Sunnybrook & Women's College Health Sciences Centre
Jacqueline Diels, OTR, Neuromuscular Retraining Clinic, Madison, Wisconsin
Susan Rankin, PT, Rankin Physiotherapy, Victoria, B.C.
Janey Veneziano, PT, Montreal Jewish General, Montreal, Quebec