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Facial Rehabilitation

 

Smile-Surgery.com describes the features of facial paralysis and their personal effects. It outlines the treatment which is provided by the Toronto Facial Paralysis Group. To read more, navigate to: www.smile-surgery.com

Articles:

Neuromuscular Retraining For Facial Paralysis

Jacqueline Diels, OTR
Facial Retraining Specialist
Neuromuscular Retraining Clinic
University of Wisconsin Research Park
621 Science Drive
Madison, WI, 53711

The face is the image of the soul... Cicero, 43 B.C.

Our face is the first thing people see and the way we present ourselves to the world. As human beings, our primary form of non-verbal communication relies upon the minute changes in facial expression that reveal our innermost feelings. Facial paralysis is still considered by some to be a cosmetic deformity. It is also a disability of communication with associated functional problems. In 1991, a survey conducted by the Acoustic Neuroma Association revealed facial paralysis to be the most significant problem experienced after acoustic neuroma resection.1 Although facial paralysis can create an obvious deformity, little effort is expended on therapy for the facial muscles after paralysis. Restoring function and expression to the highest level possible results in improved health, self-esteem, acceptance by others, and quality of life.

Neuromuscular retraining is gaining recognition as an effective element for achieving optimal recovery from facial paralysis.2 It is a problem solving approach used by physical, occupational and speech therapists who have been specifically trained to use facial muscle reeducation techniques to produce symmetrical movement and control undesired movement patterns.

Facial paralysis can result from any injury to the facial nerve. This injury can occur from tumors, Bell's palsy, traumatic injury or congenital problems. Acoustic neuroma (vestibular schwannoma), a nonmalignant tumor which grows on the eighth cranial (vestibulocochlear) nerve, is one of the most common causes of facial paralysis. The facial or seventh cranial nerve is located directly next to the eighth nerve as it exits the brain stem. As the neuroma grows, it can stretch, press or wrap around the facial nerve, causing damage.

One of the most difficult challenges facing the surgeon is to remove the tumor completely without further damaging the facial nerve. Although new techniques, such as electrical monitoring of the facial nerve during surgery, are improving outcomes, facial nerve damage is unavoidable in some cases.

For the person who has facial paralysis after surgery there are typically two stages of recovery. In the first stage, there may be no facial movement at all. In this phase nerve healing or regeneration, is slowly taking place. The face may droop. The eye may be unable to close or blink and tearing may be decreased. There is risk of corneal exposure and damage. Extra measures must be taken to protect the eye and may include lubrication, patching or other more involved procedures. Patients are followed closely by an ophthalmologist during this period to ensure a healthy eye. Weakness of the mouth muscles may cause difficulty with eating, drinking and speaking. The face may pull uncontrollably toward the unaffected side.

Intensive therapy is not attempted during this early stage since the nerve has to heal (like a broken bone in a cast has to heal) before therapy can be effective. This is a frustrating time for both patients and therapists who want to do anything they can to get the face moving again. Lists of exercises in which the patient performs movements as hard as you can do not produce the desired facial symmetry and control required for normalized facial function. In this phase exercises performed with maximum effort will have little effect and will almost certainly be harmful later as they can reinforce abnormal movement patterns.

Electrical stimulation continues to be used in the early treatment of facial paralysis despite mounting evidence that it may be harmful to the nerve's ability to regenerate. Electrical stimulation may also cause a mass contraction of the facial muscles producing an undesirable, uncoordinated muscle response. Electrical stimulation is not used in facial neuromuscular retraining.

As nerve recovery takes place you may notice small facial movements beginning. People recover at different rates, but generally this occurs somewhere between six and twelve months after surgery (unless there has been a nerve graft, in which case the recovery period will be longer). This is the time to begin therapy with a therapist who has been specifically trained in facial retraining techniques.

As recovery continues you may notice movements beginning in areas of the face that you are not even trying to move. For example, when you smile the eye may twitch or close, or when you shut your eye the corner of your mouth may pull up or to the side. This condition, known as synkinesis, results in uncoordinated or unsynchronized facial movements. Synkinesis varies in severity from mild to severe. In its worst form, mass action, it can result in uncontrollable movement of the facial muscles on the affected side during any attempted expression. The affected side of the face may feel tight and be painful as the result of the uncontrolled muscle contractions. This characterizes the second stage of recovery.

As you might expect, the treatment of these two types of facial paralysis will be different. And, because no two people have the same functional profile, no two treatment programs will be the same. Instructions like smile as hard as you can or pucker as hard as you can do not take into account what happens to the other facial muscles during those movements. Does the eye twitch or close? Does the corner of the mouth pull down as though you are frowning? In practicing exercises as hard as you can, the patient continuously reinforces improper movement patterns thereby promoting the synkinesis. It is important to remember that normal facial movements are subtle, never harsh or performed with maximum effort. A facial therapist can help you develop treatment strategies or exercises to improve coordination by decreasing the abnormal movements.

Treatment begins with a thorough evaluation which usually includes videotape and photographic assessments. Education is the most basic aspect of the therapy process and lays the foundation necessary for learning the movement patterns that will improve function. The facial therapist provides training in the basic facial anatomy and physiology pertinent to each specific situation. Because each person has different functional abilities, there are no generic lists of exercises. Treatment is based on individual function, and as a result, each treatment program is different.

Treatment sessions may range from two hours per month (for local patients) to an intensive treatment session of 9-12 hours spaced over 3-4 days, every six months (for patients traveling a great distance). This differs significantly from a typical therapy schedule in which patients are treated on a weekly basis. A limited schedule can be maintained in a neuromuscular retraining program because the therapist provides educational rather than hands on treatment and the patient directly controls the practice of his or her own therapy program at home.

The home exercises will be different than any exercises you have done before. They will focus on promoting symmetrical, isolated and synchronized movements rather than on strengthening muscles. Movements will be slow, small and equal on both sides in order to achieve symmetrical expression. Complete concentration in a non-distracting environment is essential because the greatest effort expended will be mental rather than physical.

During practice a mirror is used to provide feedback that the movements are being produced correctly. The patient must also focus on how the movement feels as it is being produced. Surface electrode EMG biofeedback may also be used to provide feedback.

A patient is typically involved in a neuromuscular retraining program for one to three years. During this time approximately 90 percent of the treatment is performed by the patient at home. Structuring therapy in this manner results in a cost-effective treatment program that reduces the number of billed clinic hours while increasing the overall number of practice hours. It requires a highly motivated person to follow through with 30 to 60 minutes of consistent, concentrated practice per day. Patients return to the clinic periodically to refine movement patterns, learn new exercises, document progress and establish new treatment goals.

Because many factors contribute to successful neuromuscular retraining, it is impossible to predict outcomes without evaluating each patient individually. With good compliance to the home program most people who are appropriate candidates demonstrate significant improvement in facial function.

Neuromuscular retraining provides an important element in the continuity of care for the post-surgical patient. Working as a team with the patient and other health care professionals, facial therapists strive to provide the best possible outcome after facial paralysis. Neuromuscular retraining cannot restore perfect function. However, these action-oriented techniques enable patients to become their own best therapist, and assume control of their recovery resulting in improved physical function, self-esteem, satisfaction and hope.

References

1. Schaitkin B: Facial weaknesses #1 problem for most acoustic neuroma patients. Acoustic Neuroma Association NOTES 1991, 38:1-5.
2. Ross B, Nedzelski JM, McLean JA: Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope 1991, 101(7):744-750.
3. Diels HJ: New concepts in non-surgical facial nerve rehabilitation. Advances in Otolaryngology Head and Neck Surgery 1995, 9:289-315.