Boahene

To date, the best reanimation surgeries have fallen far short of completely restoring the complex expressive movements and function characteristic of the normal unparalyzed face. This is partly because changes in the somatotopic arrangement that occur in the facial nucleus and the facial motor cortex cannot be directly corrected with reanimation surgery. To influence the inaccessible aspects of the facial neuromuscular network, nonsurgical therapies are needed. Various forms of nonsurgical therapy and intervention have been shown to minimize the effects of aberrant facial nerve regeneration, improve facial symmetry, help patients adapt a new social smile, and maximize the effectiveness of any reinnervated facial muscle or substitute muscle. Facial neuromuscular retraining, speech therapy, and the selective use of chemodenervation agents are the main nonsurgical interventions I recommend for facial paralysis.

Facial neuromuscular rehabilitation (fNMR) or mime therapy was introduced in 1980 in the Netherlands, specifically for patients with facial nerve paralysis, through collaborative work between mime actors and clinicians. Neuromuscular retraining unlinks undesired motions from desired ones using slow, small-amplitude, desired motions while consciously suppressing the undesired ones. As the undesired activity is suppressed, the range of the primary movement gradually extends, increasing excursion, strength, and motor control. Surface electromyographic (EMG) feedback, mirror feedback, and video biofeedback are essential complementary tools that help bring desired movements to conscious control. Although there is a paucity of well-designed, randomized controlled trials on the effectiveness of facial exercises on the functional outcome of facial paralysis, selected publications support its beneficial role. Pereira and colleagues performed a systematic review and meta-analysis of 132 studies that investigated the role of facial exercises in facial paralysis and concluded that it was effective. Beurskens and Heymans in a randomized controlled trial concluded that mime therapy improved facial symmetry and reduced the severity of facial paralysis.

My facial reanimation patients see a physical therapist before any intervention who specializes in fNMR. I also recommend early facial retraining exercises to Bell palsy patients to minimize the severity of any synkinesis that may occur. A study by Nakamura and colleagues showed that biofeedback works better for prevention of synkinesis as opposed to treatment of synkinesis. Due to the intense efforts needed to achieve visible improvement in their synkinesis, patients often fail to reach their desired goal because of the difficulty of maintaining motivation during training. Initiating biofeedback techniques soon after a facial injury motivates patients to prevent rather than treat synkinesis.

Once patients have become comfortable with their self-directed exercises, I often aid their progress with selective chemodenervation with botulinum toxin injection. The selective use of botulinum toxin helps uncouple facial muscle groups involved in synkinesis. I treat both the paralyzed and unparalyzed face to produce balance and symmetry. Patients with lip incontinence, masticatory difficulties, and articulation changes undergo speech therapy. A speech therapist measures interlabial pressures and provides exercises that aid with lip seal. In selected cases, I use injectable fillers to aid with lip continence.

Facial exercise therapy is also essential in the acquisition and adaption of a temporal smile after a temporalis tendon transfer procedure. The main goal of temporal smile therapy is to transfer upper lip excursion in smile function to the transposed temporalis muscle. There are 3 main phases in the therapy involved in acquiring the temporal smile:

• 1.
  

  The first phase, the mandibular phase, involves mobilizing the mandible to contract the transferred temporalis muscle to elevate the oral commissure.

  
  
• 2.
  

  The second phase, the voluntary temporal smile, replaces the mandibular phase and involves contraction of the temporalis muscle without movement of the mandible.

  
  
• 3.
  

  The third phase, the spontaneous temporal smile, concentrates on adapting the voluntary temporal smile as the expressive smile for social settings.

Patients with facial paralysis are increasingly inquiring about the role of acupuncture in the treatment of facial paralysis. I do not recommend for or against the adjunctive pursuit of acupuncture but caution my patients from delaying definitive care when nerve grafting is recommended. In addition, I caution my patients concerning the potential for direct nerve injury from the acupuncture needle when repaired nerves are superficial.

Byrne

I encourage physical therapy. Although functional electrical stimulation has a body of supportive literature for spinal cord injury, I do not believe this is the case for facial rehabilitation. The data for targeted facial retraining via traditional physical therapy—with or without biofeedback—are not conclusive either. There is a logical and neurophysiologic basis, however, for encouraging this. We work with a physical therapist who has a particular interest in facial retraining. The goals are 2-fold, depending on the nature of the paralysis:

• 1.
  

  The first goal is to encourage purposeful and appropriate movements.

  
  
• 2.
  

  An equally important second goal for many (most) patients is to limit synkinesis.

Schaitkin

I use physical therapy extensively in the rehabilitation of nonsurgical and surgical patients who have had facial paralysis. I have done so since 1991. Initially I referred patients to Richard Balliet and colleagues. Balliet used the phrase, “neuromuscular retraining of facial paralysis,” referring to combining patient education in basic facial anatomy, physiology, and kinesiology; relaxation training; sensory stimulation; EMG biofeedback; voluntary facial exercises with mirror feedback; and spontaneously elicited facial movements. Most recently I have been working with Todd Henklemann, using his physical therapy techniques. I have been impressed with the ability of these techniques to improve scores using the Ross-Fradet grading system. Much of this work owes it origins and proliferation to Jackie Diels. Her concepts of incorporating surface EMG biofeedback with a comprehensive rehabilitation strategy have solid foundation and are used effectively by therapists throughout the country. This is not a single modality approach to facial paralysis patients.

When evaluating these techniques, patients need to be separated into those who have an intact nerve after and are recovering from a viral facial paralysis and those who have had interruption of the nerve and nerve grafting, substitution, or other non-neural reanimation techniques. For the viral facial paralysis patients, I see no need to send patients who are in excellent prognostic groups: incomplete paralysis, excellent evoked electrical testing in the first 10 days, or early onset of recovery after complete paralysis (<4 weeks). I have seen benefits on multiple levels for sending patients who have are not in these groups. Early therapy is aimed at patients who have weakness without synkinesis.

Facial nerve physical therapy is often done in concert with the use of botulinum toxin. The Cochrane Collaboration in 2008 published an article, “Physical Therapy for Bell’s Palsy” (Idiopathic Facial Paralysis) (Review). They selected randomized and quasi-randomized controlled studies involving physical therapy. Their conclusion was that a review of available literature involved a wide variety of physical therapy techniques used for treating Bell palsy. They found a “lack of high quality evidence to support the use of these strategies.” It is my impression, however, that the use of physical therapy for these patients is not controversial (a statement that may, in and of itself, be controversial). The problem with this review is, that even the selected studies it is based on, begin therapy at a variety of times post-insult, making comparisons difficult. Patients not only benefit from the coaching and emotional support of a therapist, but also have documented recovery.

I find the area of electrical stimulation much more controversial, however. Although there are animal studies that suggest that electrical stimulation may have a positive effect in that it shortens the early stage of recovery after rodent facial nerve crush injury, I have not seen it beneficial in my patient population. The vast majority of patients who are seen in my practice after receiving electrical stimulation seem to follow the natural history of the disease, and those who are at the end of the natural history recovery have not shown improvement with additional electrical stimulation. Referring back to the Cochrane article regarding electrical stimulation, “almost all the outcomes reported failed to show any statistically significant difference between electro-therapy or exercises and conventional or no treatment.” Some of the results both in animals and humans have shown worse results in the electrical stimulation group.

Facial reanimation patients need physical therapy for the following reasons: their facial paralysis is much longer than in viral patients and extends while they wait for nerve growth to occur; they have emotional needs from a facial nerve and sometimes diagnostic point of view; and their best possible outcome, an House-Brackmann (HB) grade III, in the case of simple nerve repair, is considered a poor outcome from a viral facial paralysis standpoint. Patients with nerve substitutions, such as hypoglossal to facial jump grafts, and those with innervations of free muscle transfers must relearn their smile and they greatly benefit from facial retraining with experts who dedicate their practice to the care of facial paralysis patients. Hadlock and colleagues recently described a mixed group of reanimation patients, 111 of whom were sent for physical therapy. Of these, 83% reported subjective improvement and 97% had objective changes using a grading system.