Case Report Physical Therapy for Facial Paralysis

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Case Report Physical Therapy for Facial Paralysis:

A Tailored Treatment Approach Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў Background and Purpose. Bell palsy is an acute facial paralysis of unknown etiology. Although recovery from Bell palsy is expected without intervention, clinical experience suggests that recovery is often incomplete. This case report describes a classification system used to guide treatment and to monitor recovery of an individual with facial paralysis. Case Description. The patient was a 71-year-old woman with complete left facial paralysis secondary to Bell palsy. Signs and symptoms were assessed using a standardized measure of facial impairment (Facial Grading System [FGS]) and questions regarding functional limitations. A treatment-based category was assigned based on signs and symptoms. Rehabilitation involved muscle re-education exercises tailored to the treatment-based category. Outcomes. In 14 physical therapy sessions over 13 months, the patient had improved facial impairments (initial FGS scoreϭ17/100, final FGS scoreϭ68/100) and no reported functional limitations. Discussion. Recovery from Bell

ўўўўўўўўўўўўўўўўўўўўўўўўўўў palsy can be a complicated and lengthy process. The use of a classification system may help simplify the rehabilitation process. ͓Brach JS, VanSwearingen JM. Physical therapy for facial paralysis: a tailored treatment approach. Phys Ther. 1999;79:397–404.͔

Key Words: Bell palsy, Classification system, Facial neuromuscular re-education, Facial paralysis.

Jennifer S Brach

Jessie M VanSwearingen ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

Physical Therapy . Volume 79 . Number 4 . April 1999 397 ell palsy is an acute facial paralysis of unknown Facial patients had characteris- etiology. Bell palsy most commonly occurs tic signs and symptoms between the ages of 15 and 60 years, with 15- to neuromuscular that could be recog- 44-year-olds experiencing the highest inci- nized prior to treat- B1 1 dence. In 1982, Peitersen outlined the natural history re-education ment. Based on these of Bell palsy after studying 1,011 patients for 1 year signs and symptoms, we following their development of facial paralysis. Thirty- techniques address found that we could one percent of the patients had incomplete paralysis, the impairments and identify the impairment and 69% of the patients had complete paralysis of the that would respond to facial muscles. Normal facial function returned in 71% functional limitations a certain intervention. of the patients, and this recovery occurred within 3 to 8 Therefore, we devel- weeks after the onset of paralysis.1 Peitersen1 reported of patients with oped a classification that age has a strong influence on the recovery process. scheme based on the Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 Ninety percent of the patients aged 0 to 14 years facial paralysis. intervention tailored to recovered completely, whereas only 37% of the patients the signs and symptoms over 60 years of age recovered completely. Peitersen that could also be used concluded that the sooner some facial function to guide treatment (Tab. 1).13 After the treatment-based returned, the more favorable the overall outcome. category is identified, a physical therapy program consisting of neuromuscular re-education matched to the Individuals with Bell palsy, in our opinion, seldom assigned category is then initiated. receive physical therapy. Typically, the patients are told to do nothing and that facial movement will return Surface electromyography (sEMG) biofeedback or a without intervention.2–4 Patients referred for physical mirror may be used as an adjunct to the retraining therapy are often treated with electrical stimulation of exercises in each of the treatment-based categories. The the facial muscles and facial movement exercises to be sEMG biofeedback is not the treatment; exercises are the completed with maximal effort.4 The outcomes of such treatment. The facial muscles have few, if any, muscle interventions were less than optimal, with the patients spindles.12,14,15 Thus, little information about muscle often developing mass action or synkinesis (abnormal length and action is available to the individual. Learning movement of the face accompanying a desired motion).5 facial movements is difficult without the feedback. We Several studies on animal models indicate that the use of have found that the use of sEMG or a hand mirror is a electrical stimulation is disruptive to reinnervation6–8 means of providing a visual or auditory representation of and thus may be contraindicated for individuals with facial muscle activity (sEMG) or movement (mirror). facial nerve disorders.5 Patients are also instructed in a home facial movement exercise program, which is based on the treatment-based Facial neuromuscular re-education is a conservative category (Tab. 1) and the patients’ performance during approach to facial rehabilitation. Demonstrated out- the rehabilitation session. The purpose of this case comes of facial neuromuscular re-education include report is to describe the facial rehabilitation process improvements in impairments associated with facial using facial neuromuscular re-education and a treatment- 9–12 paralysis. Facial neuromuscular re-education consists based classification system in the treatment of an individual of an evaluation of facial impairments and functional with Bell palsy. limitations, guided training sessions of correct movement patterns, and instruction in a specific facial move- Case Description 5,12,13 ment exercise program. The patient (“MC”) was a 71-year-old woman who was diagnosed with Bell palsy of the left facial nerve and From our clinical experience in treating individuals with complete left facial paralysis. The initial physical therapy facial nerve disorders, we found that subgroups of

JS Brach, PT, GCS, is Clinical Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260 (USA) (jsbst6ϩ@pitt.edu), and Doctoral Student, Department of Epidemiology, University of Pittsburgh. She was Staff Physical Therapist, Facial Nerve Center, CORE Network, LLC, Pittsburgh, Pa, at the time of this study. Address all correspondence to Ms Brach.

JM VanSwearingen, PhD, PT, is Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, and Director of Rehabilitation, Facial Nerve Center, CORE Network, LLC.

This article was submitted April 15, 1998, and was accepted September 3, 1998.

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Table 1. Treatment-based Categories and Matched Treatment

Category and Representative Signs and Symptoms Treatmenta Repetitions Frequency

Initiation AAROM Low (Ͻ10) High (3–4 times a day) Drooped resting posture Matched movements Barely initiates movement or very minimal Education of the recovery process movement Marked functional problems Facilitation AROM High (10–20) Moderate (1–2 times a day) Minimal droop at rest Resistive exercises Mild to moderate facial muscle weakness Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 Movement control Isolated movements Quality, not quantity High (3–4 times a day) Narrowed eye, deepened cheek crease Matched movements Mild to moderate facial muscle weakness Controlled synkinesis Synkinesis Relaxation Stretching Low to moderate (Ͻ10) As indicated by symptoms Resting facial tension Massage Facial twitches/spasms Jacobson’s relaxation exercises19 Marked psychosocial difficulties Rhythmic movement aAAROMϭactive assisted range of motion, AROMϭactive range of motion, matched movementsϭsymmetrical movements of the left and right sides of the face. evaluation was conducted 2 weeks following the onset of (normal ͓0͔, absent ͓2͔, less pronounced ͓1͔, or more the facial paralysis. At the time of the initial evaluation, pronounced ͓1͔), and (3) corner of the mouth (normal the patient had no other active medical problems. The ͓0͔, drooped ͓1͔, or pulled up and out ͓1͔). patient reported that her facial paralysis came on sud- denly and was accompanied by pain in her left ear and a The FGS rest section scores range from 0 to 4 and are funny feeling in her tongue. The paralysis was associated weighted by a multiplier of 5 for a total FGS rest score of with no pain or sensory deficits in the left side of the 0 to 20. The symmetry of 5 voluntary facial movements face. The patient reported no hearing loss, but she (brow raise, eye closure, snarl, smile, and pucker) are reported hearing swishing sounds in her left ear. She rated on a 5-point scale to determine the FGS movement had a magnetic resonance imaging scan of her head, and score. The FGS movement scores range from 5 to 25 and no abnormalities were found. Electrodiagnostic testing are weighted by a multiplier of 4 for a total FGS was not performed. One week after the onset of her movement score of 20 to 100. The degree of synkinesis symptoms, she started a 7-day tapered dosage of steroid associated with each of the voluntary movements is therapy. graded on a 4-point scale from 0 (no synkinesis, or no abnormal or pass movement patterns) to 3 (severe The physical therapy evaluation consisted of grading synkinesis, or disfiguring abnormal movement or gross resting posture, voluntary movement, and the presence mass movement of several muscles). The FGS synkinesis of synkinesis or abnormal movement, using the Facial scores range from 0 to 15. For both the FGS rest and FGS Grading System (FGS) developed by Ross and col- synkinesis sections, a higher score relates to greater leagues.16 The FGS is an observer-based rating scale that impairments. For the FGS movement section, a lower is responsive to change.16 Ross et al indicated that the score relates to greater impairment. The FGS score is changes in scores on the resting symmetry component of calculated as follows: FGSϭFGS movementϪFGS the scale occur more slowly with rehabilitation than restϪFGS synkinesis. The reliability17 and construct scores on the movement or synkinesis components of validity16,17 for the use of the FGS have been demon- the scale. The scores of the FGS range from 0 (complete strated. Interrater reliability (r ϭ.90) and intrarater reli- paralysis) to 100 (normal facial function). ability (r ϭ.94) of the FGS scores were determined, using the type 2,1 intraclass correlation coefficient, for 2 The 3 sections to the FGS—resting posture (FGS rest), physical therapists who scored videotapes of 15 individ- voluntary movement (FGS movement), and synkinesis uals with facial nerve disorders.17 Construct validity was (FGS synkinesis)—are scored individually, and the determined for the FGS by comparison with a quantita- scores are combined for a total or composite score. The tive measure of facial motion16,17 (Spearman rank-order FGS rest section consists of rating 3 facial areas for correlationϭ.70–.87) and with the House-Brackmann symmetry: (1) palpebral fissure (normal ͓0͔, narrow ͓1͔, facial grading system.16 Ross et al16 demonstrated that wide ͓1͔, or eyelid surgery ͓1͔), (2) nasolabial fold the FGS is sensitive to change by comparing prerehabili-

Physical Therapy . Volume 79 . Number 4 . April 1999 Brach and VanSwearingen . 399 Table 2. on the evaluation findings and on treatment-based catego- Physical Therapy Schedule ries. Treatment sessions were one on one with a physical therapist for approximately 1 hour (see Tab. 2 and the Frequency of Sessions No. of Months Total Sessions “Service Delivery” section for details). A typical physical 2–4 times per month 3 8 therapy session consisted of a brief re-evaluation, training 1 time per month 4 4 with sEMG or a mirror, and instruction in an exercise 1 time every 3 months 6 2 program to be completed at home. 13 14 Surface EMG biofeedback was used initially to measure muscle activity associated with voluntary facial movements. Surface EMG biofeedback devices can be used to tation and postrehabilitation scores for 19 patients with record and display small changes in muscle activity that facial nerve disorders. cannot be seen in a mirror. MC found this information Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 helpful when she started regain movement. As she was We used the FGS to monitor progress and to describe able to move more, she used the surface EMG biofeed- the patient at different stages of recovery. The FGS back less and a mirror more. scores were not used to determine the treatment-based category. When MC developed abnormal movement patterns or synkinesis, the surface EMG biofeedback again played an The patient’s functional limitations were determined important role in the physical therapy session. She through an interview process consisting of a set of developed an abnormal movement pattern such that questions asked at each subsequent visit. The patient was when she snarled, her left eye would close while her asked questions regarding her eye and mouth function right eye stayed open. MC was unaware that this was and how this function may have interfered with her daily happening. Surface EMG biofeedback during exercise activities. sessions helped to make her more aware of the abnormal movement. We placed the recording electrodes over the During the initial evaluation, the patient had severe levator labii muscle (snarl muscle) and the inferior oculi asymmetry in resting facial posture. The left side of her muscle (eye closure). MC would practice snarling and face was markedly drooped, and her left eye was much raising the line on the sEMG biofeedback screen associ- ϭ wider than her right eye (FGS rest score 15). Voluntary ated with the levator labii muscle activity while keeping movement, as compared with movement of the unin- the activity from the inferior oculi muscle to a minimum. volved side, was trace to minimal. She initiated slight The sEMG biofeedback would often record activity in movement with severe asymmetry throughout all regions the inferior oculi muscle prior to any visible eye closure, ϭ of the face (FGS movement score 32). As is typical in providing MC with the information necessary to correct this stage of recovery when movement is minimal, the her movements. patient had no signs of synkinesis or abnormal move- ϭ ment patterns (FGS synkinesis score 0). Her composite Initiation FGS score on the initial evaluation was 17/100 Based on the initial signs and symptoms (severe resting Ϫ Ϫ ϭ (ie, 32 15 0 17). asymmetry, minimal voluntary movement, absent synkinesis, and impaired function), MC was considered to be MC was retired and lived alone. She reported little in an initiation treatment category (Tab. 1). Exercises difficulty in eating, drinking, speaking, and closing her typical for the initiation category include active assisted eye; however, she relied on compensatory techniques range of motion exercises, during which the patient such as drinking from the uninvolved side of her mouth, used the fingers of her hand to position a part of her lifting her cheek with her hand while speaking, and face at a position in the range of motion for a specific manually closing her eye. Because of her poor corneal movement and tried to hold the position using the protection, she had to stop her regular swimming exer- targeted facial muscle while removing the passive assist. cise program, and she appeared motivated to improve Often, patients find that it is easier to hold a position her facial function so that she could return to swimming. with a muscle than it is to move to the desired position (eg, having a patient passively raise the involved eyebrow Intervention with a hand, then slowly removing the passive assist as the patient tries to activate the frontalis muscle and Overview of Intervention maintain the brow raise). MC used these techniques, as To assist the patient in her goal of improved facial part of her home exercise program, for the following functioning, she was treated with facial neuromuscular facial expressions: smile, pucker, brow raise, and frown. retraining (NMR) techniques, using a hand-held mirror or sEMG biofeedback.5,11–13 Treatment planning was based

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Because MC could not voluntarily close her eye and had the uninvolved side of the face to distort the movement signs and symptoms of corneal irritation typical of of the involved side of the face. Maintaining symmetry is patients in the initiation category, exercises focusing on an important part of facial movement exercises. When closing the eye. Squinting or raising the lower eyelid was the uninvolved facial muscles overpower the involved also included in the home facial exercise program. An facial muscles, the facial posture tends to shift to the exercise that appears to allow the patient control over uninvolved side. When the facial posture shifts, the the Bell reflex18 (eye rolling backward) is helpful to involved muscles are placed at a less-than-optimal length achieve a more complete eye closure. The patient is for functioning (stretched). By maintaining symmetry instructed to focus both eyes on an object positioned and a more optimal length of the involved facial muscles 30.5 cm (12 in) down and in front of the patient and during voluntary facial movements, we believe that the then to attempt to close both eyes. The eyes are to involved muscles have a better chance of functioning. In remain focused on this point until they are closed. our opinion, small symmetrical facial movements also Focusing the eyes downward helps to initiate the lower- make it easier to detect small amounts of facial motion Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 ing of the upper eyelid. Maintaining the focused posi- that may not be apparent if the resting facial posture is tion until the eyes are closed prevents the Bell reflex, shifted due to overpowering of the uninvolved facial which can trick the patient into thinking that the eye is muscles. closed. When some active movements are difficult to perform, Muscle fatigue is often a concern when a patient is such as lowering the bottom lip, functional activities, learning to initiate facial movements. To help avoid such as saying specific sounds, are used for exercise. The fatigue, MC was instructed to do 5 to 10 repetitions of activity of lowering the bottom lip is an important the facial exercises (smile, pucker, brow raise, frown, component of saying words that begin with the letter “F.” and eye closure) 3 times a day. The number of exercises MC reported practicing a word list to be easier than was kept to a minimum (3–5 exercises) because, in our doing lip movement exercises, presumably because of experience, patients are more likely to adhere to a her greater familiarity with the word task than with regimen consisting of a few exercises than to a regimen isolated oral movements. consisting of many exercises. MC often reported doing more exercises than were given to her because she Resistive facial exercises may be appropriate if the wanted to expedite her recovery. patient has no signs of synkinesis. Manual resistance is applied in the opposite direction of the desired move- Facilitation ment. Resistance should be applied to only isolated A re-evaluation done 6 weeks and 3 physical therapy facial movements, without causing mass action or synki- sessions later (1 visit every other week) revealed that the nesis. Care must be taken not to overstrengthen the patient’s resting posture was unchanged, as measured by uninvolved facial muscles, which would cause an even the FGS (FGS rest scoreϭ15). Her face was less drooped greater imbalance. An example of resistive facial exer- but still not symmetrical. Voluntary movement had cises would be for the patient to provide resistance to the increased to minimal to moderate movement. She initi- upper lip with a finger while attempting to pucker. ated movement with mid-excursion and moderate asymmetry for all facial movements (FGS movement Facial muscle fatigue is no longer a primary concern scoreϭ56), and there was no evidence of synkinesis (FGS when the patient is in the facilitation category. The synkinesis scoreϭ0). The composite or total FGS score patient is instructed to do a large number of repetitions was 41/100. MC reported less difficulty with eating and (10–20) of active or resistive exercises 1 to 2 times a day. drinking than at the initiation of treatment, but she had Again, the number of exercises is limited to 3 to 5 to continued difficulty protecting the cornea of her eye. keep the patient focused on the area needing the most She was able to close her eye completely, but only with work and to improve adherence to the exercise pro- conscious effort. She was still unable to return to gram. A typical exercise program for MC at this time swimming. would be 10 to 20 repetitions of 3 to 5 exercises to be completed 1 to 2 times a day. Based on the increased voluntary movement and absent synkinesis, the patient was considered to be in the Movement Control facilitation category of treatment. The patient was Seven months after the initiation of therapy and 11 instructed in active and resisted facial movement exer- physical therapy sessions, MC’s resting posture had cises typical for patients with some movement, no abnor- changed from a drooping brow, lower eyelid, cheek, and mal movement, and no difficulty with activities of daily mouth corner to a raised lower eyelid and a retracted living. She was instructed to do symmetrical active facial cheek and mouth corner. The FGS rest score remained movements without allowing the voluntary movement of 15 but now represented the narrowing of her left eye as

Physical Therapy . Volume 79 . Number 4 . April 1999 Brach and VanSwearingen . 401 compared with her right eye, and the retraction of the ing exercises (10–20 repetitions), 1 to 2 times a day, as left cheek and mouth corner. Voluntary movement had explained in the “Facilitation” section. improved throughout the left side of the patient’s face and was almost symmetrical with that of the uninvolved The patient’s last physical therapy visit was 13 months side (FGS movement scoreϭ84). At this point, MC had after the initiation of therapy. She continued to demon- started to develop mild abnormal movement patterns or strate asymmetry in resting posture, which consisted of a synkinesis with brow raise and snarl motions (FGS syn- narrow eye and a tight cheek (FGS rest scoreϭ15). kinesis scoreϭ2). When she would raise her eyebrows or Voluntary movement had improved slightly to almost snarl, her left eye would close slightly. Her FGS score was complete to complete movement between the sides 67/100. (FGS movement scoreϭ88), and the abnormal movement or synkinesis had increased slightly to minimal The patient’s facial functioning had continued to with all movements (FGS synkinesis scoreϭ5). Her FGS improve. She had no problems with eating or perform- score was 68/100. The biggest change appeared to be in Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 ing oral hygiene (brushing her teeth). She reported only function. The patient reported no difficulties with eat- slight difficulty drinking from a glass without compensa- ing, drinking, speaking, or protecting the cornea of her tion techniques and only occasional problems with eye eye. She had even resumed swimming. Patient satisfac- closure and protection. She was still unable to resume tion was high by patient report. swimming because she could not adequately protect her cornea. Based on these signs and symptoms, we still considered the patient to be in the movement control treatment Based on the appearance of inappropriate muscle activ- category, with relaxation the secondary treatment cate- ity and the presence of abnormal movement, the patient gory. Because minimal changes were noticed in volun- was now considered to be in the movement control tary movement in the previous 7 months, strengthening category of treatment, with the facilitation category a was no longer, in our opinion, a reasonable goal. We secondary classification. Exercises focused on control- instructed the patient in a final program to help main- ling the abnormal or synkinetic movement, such as tain her facial function and to prevent any inappropriate raising the brow while keeping the eye open and con- muscle activity or synkinesis. The program consisted of trolling the ocular synkinesis. Movement control facial isolated facial movements, stretching, facial massage, exercises emphasize moving only as much as the patient and relaxation exercises19 typical for patients in the can without triggering the abnormal facial movement. movement control and relaxation treatment categories. The range of the movement is increased as long as the Jacobsen’s relaxation exercises19 and the same tech- abnormal movement is controlled. The patient is told to nique of progressively contracting and relaxing of mus- concentrate on the quality of the exercise and not the cles was applied to specific facial muscles. For example, quantity of the exercises completed. It is better for a MC was told to wrinkle her nose and to raise her upper patient to do 5 repetitions of an exercise correctly than lip as much as she could, holding the contraction for 3 it is to do 20 repetitions incorrectly. MC was instructed to to 5 seconds, and then to “let go,” releasing the muscle do as many repetitions of the control exercises that she contraction completely. MC was instructed to continue could do correctly and to perform these exercises several with this program one time a day, gradually weaning times a day. herself from the exercise program. She was told to continue with the facial muscle stretches at least one Because facial muscle tightness often accompanies syn- time a day or more as she felt she needed it to prevent kinesis, it is important to teach the patient facial muscle further facial muscle tightness. stretching exercises. The patient was instructed in a stretching exercise that consisted of placing her right Outcomes thumb inside her mouth, grasping the left cheek, and pulling the cheek down and across her face, thus apply- Service Delivery ing a stretch to the cheek musculature. The stretch was The patient was treated over a 13-month period and seen held for 20 seconds. The patient was instructed to stretch for only 14 physical therapy sessions. Initially, the treat- her cheek 2 to 3 times, twice a day, to prevent shortening ment sessions were more frequent (2–4 times per of muscle tissue. She was instructed to stretch her cheek month) because of the need for instruction and for the more often if she experienced cheek muscle tightness patient to become familiar with the exercise process. As throughout the day. the patient became more aware of her facial movements, she was treated less frequently (once every 3 months). Strengthening exercises for specific movements were Table 2 shows the physical therapy schedule. continued as long as they did not cause synkinesis. MC was instructed to continue with 2 to 3 of the strengthen-

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Table 3. Facial Grading System (FGS) Scores and Ability to Swim

FGS Section Month(s) Rest Movement Synkinesis FGS Swimming

Initial 15 32 0 17 No 1.5 15 56 0 41 No 7 15 84 2 67 No 14 15 88 5 68 Yes

Impairment and Functional Limitation a patient, the total number of physical therapy visits was Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 The patient demonstrated improvements as facial only 14 visits. impairments and functional limitations became less severe (Tab. 3). In our opinion, moderate improvements Physical therapy for patients with facial paralysis tradition- were made in symmetry of the face at rest, even though ally has consisted of generic facial exercises or electrical these improvements were not evident in the FGS rest stimulation.4 Facial neuromuscular re-education tech- scores. The FGS grades resting posture as being either niques (ie, the use of facial exercises to address a patient’s symmetrical or asymmetrical and does not account for impairments and functional limitations) are different from levels of severity. The most noticeable changes were the the traditional intervention for facial paralysis. In our improvement of her voluntary movement (FGS move- approach, the exercise program changes over time as the ment), which occurred in the first 7 months of treat- patient’s impairments change with recovery. The facial ment, and the development of synkinesis (FGS synkine- neuromuscular re-education exercise program emphasizes sis) in the seventh month. accuracy of facial movement patterns and isolated muscle control, and it excludes exercises that promote mass con- The patient’s functional activities improved so that after traction of muscles related to more than one facial expres- 13 months she had no difficulty eating, drinking, speak- sion. In our approach, the number of exercise repetitions ing, or protecting the cornea of her eye. She no longer and the frequency of the exercise program depend on the had to rely on compensatory techniques to complete her treatment-based categories, which are based on the activities of daily living. She had even returned to patient’s impairments (Tab. 1). swimming between the 7th and 13th months of treatment. The patient was highly satisfied with her outcome. Continued research is needed to determine the best treatment for individuals with facial neuromuscular dis- Discussion orders. A first step could be to validate the treatment- In our experience, individuals with Bell palsy are seldom based classification system based on the physical signs referred for physical therapy at the onset of the disorder. and symptoms of individuals with facial neuromuscular Often, they are told to wait and that this condition will disorders. If the classification system is validated, the get better on its own. Complete recovery does not always effectiveness of physical therapy intervention with a occur, especially in high-risk populations such as people “tailored” treatment approach for each of the treatment who are elderly or who have delayed recovery.1 categories can be determined.

Physical therapists rarely continue to treat patients for 13 References months. We believed, however, that this treatment dura- 1 Peitersen E. Natural history of Bell’s palsy. In: Graham MD, House tion was necessary to achieve the outcomes for this WF, eds. Disorders of the Facial Nerve. New York, NY: Raven Press; 1982:307–312. patient. For the first 7 months, the patient had facial weakness and was treated with strengthening exercises. 2 Ohye RG, Altenberger EA. Bell’s palsy. Am Fam Physician. At the 7-month visit, she had facial muscle overactivity 1989;40:159–166. and synkinesis. At this point, the treatment plan was 3 Bateman DE. Facial palsy. Br J Hosp Med. 1992;47:430–431. adjusted to fit the changes in her facial impairments. If 4 Waxman B. Electrotherapy for treatment of facial nerve paralysis the physical therapy had been terminated prior to this (Bell’s palsy). In: Anonymous Health Technology Assessment Reports. 3rd ed. 7-month mark, her problems of facial muscle tightness Rockville, Md: National Center for Health Services Research; 1984:27. and synkinesis would not have been addressed. Instruct- 5 Diels JH. New concepts in nonsurgical facial nerve rehabilitation. ing the patient in a maintenance program at the last Advances in Otolaryngology–Head and Neck Surgery. 1995;9:289–315. physical therapy session may help to prevent an increase 6 Cohan CS, Kater SB. Suppression of neurite elongation and growth in facial muscle tightness and synkinesis over time. cone motility by electrical activity. Science. 1986;232:1638–1640. Although 13 months may seem like a long time to treat

Physical Therapy . Volume 79 . Number 4 . April 1999 Brach and VanSwearingen . 403 7 Brown MC, Holland RL. A central role for denervated tissues in 14 Baumel JJ. Trigeminal-facial nerve communications: their function causing nerve sprouting. Nature. 1979;282:724–726. in facial muscle innervation and reinnervation. Arch Otolaryngol. 1974;99:34–44. 8 Girlanda P, Dattola R, Vita G, et al. Effect of electrotherapy on denervated muscles in rabbits: an electrophysiological and morpholog- 15 Burgess PR, Wei JY, Clark FJ, Simon J. Signaling of kinesthetic ical study. Exp Neurol. 1982;77:483–491. information by peripheral sensory receptors. Annu Rev Neurosci. 1982;5:171–187. 9 Ross B, Nedzelski JM, McLean JA. Efficacy of feedback training in long-standing facial nerve paresis. Laryngoscope. 1991;101:744–750. 16 Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngol Head Neck Surg. 1996;114:380–386. 10 Brudny J, Hammerschlag PE, Cohen NL, Ransehoff J. Electromyo- graphic rehabilitation of facial function and introduction of a facial 17 Brach JS, VanSwearingen JM, Delitto A, Johnson PC. Impairment paralysis grading scale for hypoglossal-facial nerve anastomosis. Laryn- and disability in patients with facial neuromuscular dysfunction. Oto- goscope. 1988;98:405–410. laryngol Head Neck Surg. 1997;117:315–321. 11 Brach JS, VanSwearingen JM, Lennert J, Johnson PC. Facial neuro- 18 Jelks GW, Smith B, Bosniak S. The evaluation and management of

muscular retraining for oral synkinesis. Plast Reconstr Surg. the eye in facial palsy. Clin Plast Surg. 1979;6:397–419. Downloaded from https://academic.oup.com/ptj/article/79/4/397/2857760 by guest on 27 September 2021 1997;99:1922–1931. 19 Jacobson E. Progressive Relaxation. 2nd ed. Chicago, Ill: University of 12 Brudny J. Biofeedback in facial paralysis: electromyographic reha- Chicago Press; 1938. bilitation. In: Rubin L, ed. The Paralyzed Face. St Louis, Mo: Mosby-Year Book; 1991:247–264. 13 VanSwearingen JM, Brach JS. Validation of a treatment-based classification system for individuals with facial neuromotor disorders. Phys Ther. 1998;78:678–689.

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