Neuromuscular Reeducation in Facial Palsy

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Introduction

The loss or decrease in facial movements, expressions, and functions such as eating, drinking or talking produces a negative impact on the psychosocial well-being of people with neuromotor facial disorders. Therefore, the quality of life of this patient is affected in all aspects 

The incomplete recovery of a facial disorder, specifically a facial paralysis, produces sequelae that interfere in facial expressions and, therefore, in self-esteem and social interaction. The most common are:

• Asymmetry
• Muscle contracture
• Muscular facial weakness
• Synkinesis

It is very important to implement an efficient treatment that reduces the presence of sequelae. Neuromuscular facial reeducation as a conservative treatment protocol has proven to be the most effective because it recovers the symmetrical movement in the face and eliminates or reduces the problems in the patient's facial functions.

Basic Concepts

Facial Movement System

The complex branch of the facial nerve gives rise to the distribution of unique patterns of muscular activation and, therefore, varied muscular synergies of movement.

The facial muscles are small and have no tendons, which bind them directly to the bones, like the skeletal muscles in the rest of the body. They also lack internal sensory receptors that provide them with intrinsic proprioceptive feedback. These facts make movement patterns easily change

Facial movements, expressions and functions are the result of a combination of different muscle contractions

Influence of emotions in the rehabilitation process

It has been associated that the increase of movement in the corner of the lips represents for the patient, the pattern that would belong to a smile of happiness. By noticing less distortion in this pattern, the psychological aspect in the patient improves, therefore, the treatment results will improve

Useful tools for the rehabilitation process

Due to the lack of intrinsic biofeedback in the facial muscles, surface EMG biofeedback and mirror feedback provide the patient with specific information on activation so that the patient can modify muscle activity by increasing or decreasing muscle contraction.

The activation of the facial muscles is not enough to recover the facial expressions, therefore incorporating emotions or expressions of reaction to the rehabilitation process as well as using the increase of movement in the lips as a positive marker, make the treatment more effective

Neuromuscular Facial Re-education

Neuromuscular Facial Re-education is "the process to facilitate the return of the desired facial movement patterns and the elimination of unwanted facial movements and expression patterns”. It is based on patient education and the use of extrinsic feedback to achieve reeducation or physical learning

Its effectiveness is supported by the lack of intrinsic feedback information and the variety of muscle synergies that can be created by the small contraction of a single muscle. All this aims to achieve neuroplasticity by reducing as much as possible the probability of creating abnormal patterns of movement (synkinesis)

The physiotherapist must educate the patient to be aware of his motor disability and can recognize the patterns he wants to achieve (correct pattern of muscle activation) and those he wishes to avoid (abnormal pattern of muscle activation) to reduce the likelihood of producing sequelae

The education of the patient plus the use of some extrinsic biofeedback tool allows the patient to modify his muscular action in the following way:

• Increase muscle activation in muscles that must move, but do not move
• Decreased muscle activation in muscles that do not have to move, but move

In this way, they can correct the movement pattern learning neurologically to recruit appropriate motor units for the desired movements or expressions and avoid those that do not want to perpetuate themselves. Therefore, it is possible to recover the symmetry of the movement

Evaluation for the appropriate treatment

The evidence supports the use of assessment tools that could guide the physiotherapist in the process of determining the specific goals of treatment of each patient based on the signs and symptoms or sequelae. Among the most used for this purpose are:

• Facial grading system (FGS)
• Facial disability index (FDI)
• House Brakeman
• Photoshop method 

Treatment categorization

Evidence proposes 4 categories in which patients can be classified to begin the rehabilitation process according to the characteristics that the patient presents: 

Initiation or group 1 (Acute phase)

Characteristics:

• moderate-marked asymmetry at rest that increases with voluntary movement, expressions or functions
• without abnormal movement
• facial functions involved: eye closure to blink, eat, drink, talk)
• contraction of the affected side very little or absent

Treatment:

1. Active-assisted exercise: the patient starts the movement with the help of his hand and performs small range movements to prevent the unaffected side from acting (avoid contraction of the unaffected side and that the unaffected side does not cause stretch of the affected side)
2. Massage and stretch for affected side: improves blood flow in soft tissue
3. Education: explain the usual process of recovery and what signs indicate recovery that is expected

Facilitation or group 2 (≥ 6 months of impairment)

Characteristics:

• medium-moderate asymmetry at rest
• the patient can start the movement, but the asymmetry is noticeable if he continues
• nothing or little synkinesis
• difficulty in facial functions: the patient can not completely close the eye and the food or liquid can come out of his mouth

Treatment

1. Active-assisted exercise: the patient initiates the movement to where the unaffected side does not act. Once the patient manages to improve this, he can perform active-resisted exercise
2. Education: the patient must understand the importance of performing the exercises accurately and must be able to identify the signs that indicate that he is performing abnormal movement patterns to correct them or return to the physiotherapist to avoid reinforcing synkinesis

Movement control or Group 3

Characteristics

• little asymmetry at rest: generated no longer by weakness but by contraction or retraction of soft tissues
• synkinesis: noticeable involuntary movement of a facial region when performing any movement or facial expression
• abnormal movement patterns during facial functions: difficulty keeping the eye open while talking, yawning or eating and eating biting the inside of the cheek

Treatment

1. Thermotherapy
2. Massage and stretching for facial retraction
3. For short term: create movements and facial expressions without synkinesis. This can be achieved by making small movements or accepting very few synkinetic movements until correct
4. For long-term: guide the patient to re-learn to isolate muscle contractions and thus decrease the activation of abnormal patterns of movement (While the patient relearns the appropriate patterns of activation, he will be reclassified in the facilitation group for their rehabilitation process.)

Relaxation or Group 4

Characteristics

• voluntary movements are produced 50% by the unaffected side; this generates contracture or tension of the soft tissue of the affected side
• marked facial asymmetry at rest but accompanied by spontaneous spasms that occur more frequently and amplitude while there is more effort to perform a movement, due to this fact, the movement will be restricted by the patient as a protection strategy for the next spasm

Treatment

1. Thermotherapy
2. Relaxation exercises: Jacobson's relaxation technique 
3. Alternating rhythmic movements 3
4. Muscle inhibition techniques: sustained stretching or cross friction massage

Suggested exercises

Due to the multifactorial nature with which facial movements occur, the repetition of maximal movements as a rehabilitation program does not have great efficacy in the recovery of movement patterns in the patient with facial movement disorders.

Evidence suggests performing exercises that keep the center of the face from moving sideways during exercise. In this way the affected side would be integrated during muscular activation without having changes in its length and therefore the simultaneous activation of both facial sides during the facial activity that is requested would be achieved. it also proposed a program at home with 3 to 5 facial centering exercises of 5 to 10 repetitions twice a day, using a biofeedback tool

Exercises to recover mid-cheek lift

Activation of the upper portion of the levator muscle of the lips and orbicularis of the lips; and medial portion of the orbicular muscle of the eyes.

1. suck the cheeks between the teeth
2. wrap your lips
3. make sustained‘‘f’’ sound
4. blowing through a straw

Because these muscles accompany other facial expressions and functions, such as smiling, speech sounds, whining and facial expressions of disgust and perplexity. It is also suggested to practice the following exercises.

1. blowing while eyebrows come together as if thinking
2. blowing and transitioning to a '' fffff '' sound, alternating
3. make the sound '' fffff '' and add a smile
4. blow and add a smile

(smile instruction has to be said to remember a very happy moment to add emotional aspects for expression recovery)

Exercises for recovering orbicularis oculi

eye closure while looking down