Prof. K Hari Ohm MPTMSAJ collage of PTThe Indian centre for evidence based Neuro- rehabilitation

FACIAL PALSY- AN UPDATE

Obj

ectiv

es

1. Update knowledge on facial palsy

2. Understanding the chronic facial palsy

3. Critically review the treatment options

• Introduction- • face and its function

Part

I

Facial functions

• Facial functions are multidimensional, serving emotional, social and physical aspects of an individual’s health.

• The primary functions of the face include displaying affective emotions, identifying and communicating with other human beings.

• Sensory- motor function

1. Controls muscles of facial expression. 2. Taste perception from the anterior two-thirds of the tongue;3. Perception of cutaneous stimuli in the external auditory canal and over part

of the pinna and mastoid region; 4. Innervation of the stapedius muscle in the middle ear; 5. Innervation of the lacrimal gland 6. Two of the salivary glands (the submaxillary and submandibular

Sensory motor functions of face

Sensory motor function

• Face also play a major role in – eye protection, – eating,– drinking – speech.

Communication function

• We communicate and with facial expression

• Display affective emotion• Emotions are contextual in

turn facial expression are also

• Emotion determine – facial muscle activity

• Facial muscle activity- emotion

Attractiveness- symmetry

Control Facial expression

Voluntary (Cortical)

Involuntary(limbic system)

com

mun

icati

on

Context

Example Smile • Fake smiles can be

performed at will, because the brain signals that create them come from the conscious part of the brain and prompt the zygomaticus major muscles in the cheeks to contract.

• Muscles pull the corners of the mouth outwards.

• Genuine smiles, on the other hand, are generated by the unconscious brain, so are automatic.

• As well as making the mouth muscles move, the muscles that raise the cheeks – the orbicularis oculi and the pars orbitalis – also contract, making the eyes crease up, and the eyebrows dip slightly.

Facial nerve lesions1. Central lesions 2. Peripheral lesions Pa

rt II

Central lesions-Supra-nuclear lesions

unilateral facial paralysis with forehead sparing.

Clinical and Anatomical Features of Facial-Nerve Damage

Central facial weakness

Cortical lesion- voluntary central facial weakness is greater than mimetic central facial weakness

• LMN lesion of the facial nerve

1. Trauma,2. Hypertension, 3. Eclampsia, 4. Lyme disease,5. Sarcoidosis, 6. Diabetes mellitus,7. Ramsay hunt syndrome8. Sjogren’s syndrome, 9. Tumours of the parotid gland, 10. Amyloidosis, or 11. Complication of intranasal

influenza vaccine.

Peripheral facial weakness- causes

When the cause of the peripheral facial weakness cannot be determined, a diagnosis of Bell’s palsy is made.

Bells palsy

Bells palsy

• The incidence of Bell’s palsy is 20 to 30 cases per 100,000 people per year

• 60 to 75 percent of all cases of unilateral facial paralysis.

• Most recover fully- 70- 80% Peitersen E. Bell’s palsy: the spontaneous course

of 2,500 peripheral facial nerve palsies of diff erent etiologies. Acta Otolaryngol 2002; 549 (suppl): 4–30.

• Residual facial paralysis

RISK FACTORS/ etiology

• Viral infection, • Vascular • Ischemia• Autoimmune diseases

Who might not recover fully• Poor prognostic factors:– older age,Hauser WA, Karnes WE, Annis J, Kurland LT. Incidence and prognosis of Bell’s

palsy in the population of Rochester, Minnesota. Mayo Clin Proc 1971;46:258-64.

– Hypertension Adour KK, Wingerd J. Idiopathic facial paralysis (Bell’s palsy): factors

affecting severity and outcome in 446 patients. Neurology 1974;24:1112-6.

– impairment of taste, Diamant H, Ekstrand T, Wiberg A. Prognosis of

idiopathic Bell’s palsy. Arch Otolaryngol 1972;95:431-3.

– pain other than in the ear, and complete facial weakness. Cawthorne T, Wilson T. Indications for intratemporal facial nerve surgery.

Arch Otolaryngol 1963;78:429-34.

Pathology of bells palsy

• The facial nerve to swelling• Inflamed in reaction to the

infection?• Swelling can cause the nerve

to become pinched in the bony canal

• Death of nerve cells due to insufficient blood or oxygen supply

Symptoms

• Classic presentation of Bell's palsy is weakness on one side of the face.

• Drooling after brushing the teeth or when drinking, • An asymmetrical appearance of the mouth noticed

in the mirror• Drooping of the face, such as the eyelid or corner of

the mouth• Hard to close one eye• Problems smiling, grimacing, or making facial

expressions

Symptoms

• Twitching or weakness of the muscles in the face

• An inability to whistle, or excessive tearing in one eye.

• Unable to blow out his cheeks when shaving• Synkinesis

Symptoms • Pain in or behind the ear, • Numbness or tingling in

the affected side of the face usually without any objective deficit on neurological examination,

• Hyperacusis• Disturbed taste on the

ipsilateral anterior part of the tongue

LATER SYMPTOMS

• Persistent Asymmetry • Hemispasms • Synkinesis• Psychological and social issues

Synkinesis

• Most distressing consequences of facial paralysis.

• Synkinesis refers to the abnormal involuntary facial movement that occurs with voluntary movement of a different facial muscle group.

• Abnormal regeneration of facial nerve fibers to the facial muscle groups

Synergy lookout for closure of the eyes while attempting facial expression

Positive coping

Crocodile tears • After acute facial

paralysis, preganglionic parasympathetic fibers that previously projected to the submandibular ganglion may regrow and enter the major superficial petrosal nerve.

• Such aberrant regeneration may lead to lacrimation after a salivary stimulus (the syndrome of crocodile tears).

Symmetry is the mark of attractiveness Health

Persistent asymmetry

Asymmetrical face Symmetrical face

• unanticipated pronunciation errors while speaking, leaking of fluid or food while drinking and eating especially in a social context

• Asymmetry

People being subjected to unwanted intrusions such as staring or comments

Psychological and social impact

The Negative feedback loop. PARTRIDGE, J. (1998). Changing Faces: taking up Macgregor’ s challenge. Journal of Burn Care and Rehabilitation, 19, 174- 180.

Interaction of Factors that Contribute to Disability in Persons with Chronic Facial Paralysis

Facial Paralysis

Impaired ability to express context specific

emotions

Inability to close the eyes,

Slurring of speech, leaking of fluid during drinking and eating etc.,

Depression, maladaptive

coping strategies,

social isolation

Treatment for bells palsyA critical evaluation of the current treatment

option

Acute Bells palsy

• 20 to 30 percent who do not recover fully remain the focus of treatment.

• Facial-nerve swelling, MRI changes consistent with inflammation– Steroids- Prednisone – Antiviral drugs ?!

Types of physical therapy interventions for facial palsy

• Facial exercises, such as – Strengthening and Stretching, – Endurance, – Therapeutic and facial mimic exercises ("mime therapy")

• Electrotherapy, • Biofeedback,• Transcutaneous electrical nerve stimulation (TENS)• Thermal methods or massage, alone or in

combination with any other therapy.

Exercise therapy

• Simple movement retraining• Expression training- mime• Functional training • PNF?• Massage

Simple traditional exercise

• To improve the activation level of various group of facial muscles– Suck the cheeks between the teeth– Wrap the lips over the teeth– Puckering of the lips– Speech sounding “sh”, “P”, “B”, “F” with teeth held

together or fixed– Eye closing exercise; “look down, close the eyes,

once closed continue to look down” .

MIMETitle Method sample Outcome Result/

conclusion Otol Neurotol. 2003 Jul;24(4):677-81. Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability.

RCT 50 patientsHouse-Brackmann score of Grade IV.

Facial Disability Index

Facial Disability Index improved substantially

Otol Neurotol. 2006 Oct;27(7):1037-42.Stability of benefits of mime therapy in sequelae of facial nerve paresis during a 1-year period.

Follow up of the above RCT

48 9 months majority absence of deterioration

Aust J Physiother. 2006;52(3):177-83. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial

RCT 50 Sunnybrook Facial Grading SystemHouse facial grading

Improvement in symmetry

• Mime – combination of mime and physiotherapy

• Performing expression • Can also be helpful in chronic facial paralysis

Functional exercise • Developed as a multi dimensional and patient-

centered approach to rehabilitation of individuals with facial paralysis Prakash V, Hariohm K, Vijayakumar P, Thangjam Bindiya D. Functional training in the management of chronic facial paralysis. Phys Ther. 2012;92:605–613.

• Encompasses major facial functions• The functional training program consists of

patient education, functional training and complementary exercises

Functional training

Functional Training Program

Improved ability to express context specific emotions

and other physical functions of face

Improved ability to activate various facial

muscles

Positive coping strategies and Improved social interaction skills

Functional training

Complimentary exercise

Patient education

Functional training

• To facilitate context specific spontaneous and voluntary emotions

1. Watch movies, television programs and funny videos.

2. Narrate them during the treatment session in the clinic.

3. Think about the funny incidents that had happened in your life or the jokes you heard or read recently and share it with friends or family members.

Functional training

• To facilitate motor functions of facial muscles around the eyes, lips and mouth.

1. Hum or sing songs that you like as frequently as possible

2. Play games like peek -a- boo, blowing bubbles with your kids.

3. Rinse the mouth and spit the water down slowly.4. Blow a pipe while imagining that you are cooking in the

kitchen and suddenly the fire puts off in the wood stove; you have to blow the pipe to make the fire again.

Functional training

• Still no clinical trial to prove effectiveness

Electrical stimulation Tile and author Design Sample size Outcome Effect / result

Physiotherapy for Bell's palsy. British Medical Journal 1958;2(5097):675-7

RCTExp- ESCon- massage

83N= 43 (exp)N=40 (con)

1 year follow up

No significant advantage

Tratamiento de la parálisis facial periférica idiopática: terapia física versus prednisona Revista médica del Instituto Mexicano del Seguro Social1998;36(3):217-21.

RCTGroup1- ESGroup2- prednisone

149n-=76

May scale No difference at 3 months

Physical therapy for Bell´ s palsy (idiopathic facial paralysis)(Review) . CochraneDatabase of Systematic Reviews 2008, Issue 3. Art. No.: CD006283.

review 294 participants

Electrical stimulationTitle and author Design Sample

sizeOutcome measure

Effect / result

Effects of electrical stimulation on House-Brackmann scores in early Bell's palsy. Rev Med Inst Mex Seguro Soc. 2009 Jul-Aug;47(4):413-20

A pretest posttest control vs. experimental groups design

N=8 in each group

House-Brackmann scores

No significant difference

[Observation on non-invasive electrode pulse electric stimulation for treatment of Bell's palsy]. Zhongguo Zhen Jiu. 2006 Dec;26(12):857-8.

RCT

Compared with prednisone etc

N=138 ? EC No Therapeutic effect on Bell palsy.

Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clin Rehab 2007;21(4):338-43

RCTGroup1-exercise & ESGroup2- ES

59n-=30N=29

Facial Grading Scale

No difference at 3 months

Electrotherapy ES

• May have an adverse effect on recovery • Avoid in acute stage• Poor evidence to show it may be helpful in

chronic facial paralysis.

Feedback

• Mirror feedback• EMG feedback• Lack of proprioceptors

Evidence Summary

• Not proven to be effective in UMN lesion• LMN lesion may work

Strapping ?!

Education- assumptions and content

• Behaviour of the individual rather than physical appearance can be instrumental in influencing the response from other people

• Coping strategies

Coping strategies

• To change the way one think to feel / act better even if the situation does not change.

• To reconstruct one’s thoughts and perception of the problem like negative self-perception of facial attractiveness (body image), interpretation of others/society’s views towards one’s disability etc...

Synkinesis

• Most common areas of injection are eye muscles (orbicularis), neck bands (platysma), and chin dimpling (mentalis).

Outcome measures

Outcome measures

• Content- all dimensions of the functions of the face

• Disability after loss of facial function

House-Brackmann Scale

House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system.Otolaryngol. Head Neck Surg., 93, 146–147

Synkinesis Assessment Questionnaire

Validation of the Synkinesis Assessment Questionnaire Ritvik P. Mehta, MD; Mara WernickRobinson, PT, MS, NCS; Tessa A. Hadlock, MD Laryngoscope, 117:923–926, 2007

Conclusion

• About 20- 23% of people with Bell's palsy are left with either moderate to severe symptoms

• Don’t just think of it as a motor problem • Intervention needed to concentrate on all

aspects of the disability• Update the interventional strategies

Thank you