FACIAL PALSY- AN UPDATE

Prof. K Hari Ohm MPT

MSAJ collage of PT
The Indian centre for evidence
based Neuro- rehabilitation

Objective
s

1.Update knowledge
on facial palsy
2.Understanding the
chronic facial palsy
3.Critically review the
treatment options

Pa
rt
I

Introduction face and its function

Facial functions
Facial functions are
multidimensional, serving
emotional, social and physical
aspects of an individuals health.
The primary functions of the face
include displaying affective
emotions, identifying and
communicating with other human
beings.
Sensory- motor function

Sensory motor functions of

face

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 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 activityemotion

Attractiveness- symmetry

communication

Control Facial expression

Conte
xt

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.

I
Pa
rt
I

Facial nerve lesions

1. Central lesions
2. Peripheral lesions

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

Peripheral facial weakness- causes

1.
2.
3.
4.
5.
6.
7.
8.
9.

Trauma,
Hypertension,
Eclampsia,
Lyme disease,
Sarcoidosis,
Diabetes mellitus,
Ramsay hunt syndrome
Sjogrens syndrome,
Tumours of the parotid
gland,
10. Amyloidosis, or
11. Complication of intranasal
influenza vaccine.

Bells palsy

When the cause of the peripheral facial

weakness cannot be determined, a
diagnosis of Bells palsy is made.

Bells palsy
The incidence of Bells 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. Bells palsy:

the spontaneous course of 2,500 peripheral facial nerve palsies of diff erent etiologies. Acta
Otolaryngol 2002; 549 (suppl): 430.

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

Hypertension

Adour KK, Wingerd J. Idiopathic facial paralysis (Bells 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 Bells 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

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).

Persistent asymmetry

Symmetry is the mark of attractiveness

Health

Asymmetrical face

Symmetrical face

 unanticipated pronunciation errors

while speaking, leaking of fluid or
food while drinking and eating
especially in a social context
Asymmetry

Psychological and social

impact
People being
subjected to
unwanted intrusions
such as staring or
comments

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

Treatment for bells palsy

A 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 .

MIME
sample

Title

Metho
d

Outcome

Result/
conclusion

Otol Neurotol.2003
Jul;24(4):677-81. Positive

RCT

50 patients
HouseBrackmann
score of
Grade IV.

Facial
Disability
Index

Facial
Disability
Index
improved
substantially

Follow
up of
the
above
RCT

48

9 months

majority
absence of
deterioration

RCT

50

Sunnybroo
k Facial
Grading

Improvement
in symmetry

effects of mime
therapy on sequelae
of facial paralysis:
stiffness, lip mobility,
and social and
physical aspects of
facial disability.
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.
Aust J
Physiother.2006;52(3):177-83.

Mime therapy

 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;92:605613.

Encompasses major facial functions

The functional training program
consists of patient education,
functional training and

Functional training
Functional
training

Patient education

Complimentary
exercise

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
Design
Sample
Outcome Effect /

Tile and author

size
Physiotherapy for
Bell's palsy.British
Medical
Journal1958;2(5097):67
5-7

RCT
Exp- ES
Conmassage

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

Tratamiento de la
parlisis facial
perifrica idioptica:
terapia fsica versus
prednisona Revista
mdica del Instituto
Mexicano del Seguro
Social1998;36(3):21721.

RCT
149
Group1- ES n-=76
Group2prednisone

Physical therapy for

Bell s palsy
(idiopathic facial
paralysis)

review

294
participan
ts

result
1 year
follow up

No
significant
advantage

May scale

No
difference at
3 months

Electrical
stimulation
Title and author
Design
Sample Outcome Effect /
size

measure

result

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

A pretest
posttest
control vs.
experimental
groups design

N=8 in
each
group

HouseNo
Brackman significant
n scores
difference

[Observation on noninvasive electrode

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

RCT

N=138

EC No
Therapeuti
c effect on
Bell palsy.

Effect of facial
neuromuscular reeducation on facial

RCT
Group1exercise & ES

59
n-=30
N=29

Facial
Grading
Scale

No
difference
at 3

Compared with
prednisone etc

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 tofeel /
act better even if the situation does
not change.
To reconstruct ones thoughts and
perception of the problem like
negative self-perception of facial
attractiveness (body image),
interpretation of others/societys
views towards ones 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, 146147

Synkinesis Assessment Questionnaire

Validation of the Synkinesis Assessment Questionnaire Ritvik P. Mehta, MD;

Mara WernickRobinson, PT, MS, NCS; Tessa A. Hadlock, MD Laryngoscope,
117:923926, 2007

Conclusion
About 20- 23% of people with Bell's
palsy are left with either moderate to
severe symptoms
Dont just think of it as a motor
problem
Intervention needed to concentrate
on all aspects of the disability
Update the interventional strategies

Thank you