Lower Motor Neuron Facial Palsy Assessment

Original Editor - Wendy Walker

Top Contributors - Wendy Walker and Vidya Acharya  

Subjective Assessment

History of Present Condition

Note whether left or right side.

Date of onset

Make note of the date of onset, and the date steroids were initiated - there is good evidence that the efficacy of steroids in cases of facial palsy is highest if the medication begins within 72 hours of onset of palsy

Diagnosis/cause of Facial Palsy

Most patients who attend for physiotherapy assessment will have a diagnosis to explain the cause of their facial palsy. Often they will have attended A&E or their GP soon after onset, and will have had appropriate tests to exclude upper motor neuron causes, the most common being Stroke.

The most common cause (up to 75% of patients) is Bell's Palsy, AKA Idiopathic Facial Paralysis.

Of facial palsies caused by infection, the most common cause is Ramsay Hunt Syndrome.

The most common surgical causes: removal of Acoustic Neuroma, parotidectomy.

Other less common causes of lower motor neuron facial palsy are detailed on the Facial Palsy page.

Red Flags

• Gradual onset of palsy over weeks to months: this suggests a likely neoplastic cause and requires further investigation and imaging
• Deteriorating function after initial improvement: this is not the usual pattern in lower motor neuron facial palsy, and may indicate ongoing pathology such as a tumour or progressive disease
• If accompanied by unexplained weight loss, night sweats, skin rashes, joint pain and oedema, persistent fever and fatigue, this suggests malignancy or systemic disease
• Bilateral involvement: this is very unusual and requires immediate investigation
• Additional cranial nerve deficits: further investigation required as this may indicate a brain tumour or progressive disease

Clinical Pointers

When to suspect upper motor neuron cause:

• Forehead not affected by palsy
• Other neurological signs, such as weakness or paralysis in limbs, altered sensation in limbs
• Multiple cranial nerves involved
• Gradual onset

When to suspect systemic disease:

• Systemic symptoms, eg. fever, malaise, skin rashes
• Bilateral facial palsy
• Recurrent episodes of facial palsy
• Deteriorating function after initial improvement

When to suspect malignancy:

• Palpable masses
• Constitutional symptoms, eg. weight loss
• Gradual onset over weeks or months

Medical Treatment already received for facial palsy

In cases of Bell's Palsy and Ramsay Hunt Syndrome, the patient will have usually been given a course of steroids (and possibly antiviral medication too, particularly in Ramsay Hunt Syndrome).

Past Medical History

Include current medication.

Social History

Make note of work issues which may be impacted by facial palsy, eg. dry eye issues in people working long hours at a computer.

Note hobbies which may be affected by facial palsy, eg. playing wind or brass instruments.

Subjective Assessment Questions

Acute onset (under 5 months)

• When did you first notice changes in your face (exact date if possible)?
• Have you had a similar episode before?
• Did the weakness develop suddenly or gradually?
• Was there any pain before or during onset (pain in the region of the mastoid is not uncommon in Bell's Palsy, and often occurs - occasionally being severe - in Ramsay Hunt Syndrome)?
• Any recent ear symptoms? eg. pain, hearing changes, hyperacusis (sensitivity to loud noises)
• Any recent illnesses or infections, or any recent trauma or surgery to the head, neck or ear?
• Any changes in taste sensation or saliva production?
• Any changes in eating, drinking or speech?
• Is the eye on the affected side dry, irritated or sore?

In cases of severe palsy with no or minimal movement, also consider asking:

• Have you been given eye protection advice? (taping, drops, ointment etc.)
• Are you able to keep food & drink in your mouth?
• Do you experience drooling?
• Do other people find your speech more difficult to understand?

In cases of mild palsy, consider also asking:

• Which particular movements feel weaker or different?
• Are there any facial expressions you avoid?
• Do you experience fatigue in your facial muscles by the end of the day, or after talking for a period of time?

Chronic Facial Palsy (over 5 months)

An important aim in this group of patients is to identify whether or not synkinesis is present.

• When did your facial weakness start, and how has it changed since then?
• If the patient has had recovery of movement, ask Which movements came back first?
• Have you developed any unwanted facial movements, eg. eye closing/becoming smaller when smiling? This linking of movements is one of the things people notice as they develop synkinesis.
• Do you experience tightness, cramping or discomfort in your facial muscles?
• What difficulties (if any) do you have with eating, drinking and speaking now?
• Are you performing any exercises, massage or having any other treatment including Botox?
• What are your main priorities for improvement?

In cases of severe palsy with no or minimal movement, also consider asking:

• How do you manage eye dryness/irritation and any inability to close the eye?
• Do you get episodes of acute redness and soreness in the eye? If so, have you been taught what to do when this occurs?
• Do you use any adaptive strategies to make eating and drinking easier?

In cases of mild palsy, consider also asking:

• Which facial expressions still feel restricted?
• Are you satisfied with your currently facial symmetry at rest and also on movement?
• Do you experience fatigue or tension in the face after smiling for long periods?

Associated Symptoms

Note the following:

• Any pain associated with the palsy (both at onset and now)
• Hearing loss or hyperacusis
• Taste changes
• Dry eye or increased tearing

Objective Assessment

Baseline Static photographs are an effective way to record progress in facial palsy, so taking the following photographs at initial assessment is helpful. As most cases of facial palsy are unilateral, photographs show the full range of movement on the unaffected side.

The following poses can be taken, with the aim of showing the whole range of movements of the face:

• Face at rest (eyes open) ie. not moving
• Smile without showing teeth (small, closed lip smile)
• Large smile showing teeth
• Close eyes
• Raise eyebrows
• Snarl/show top teeth
• Lip pucker
• Open mouth wide

Range of Movement Assessment

As with photographs, the unaffected side of the face provides a useful reference for range of movement.

Video

Video recording is an effective method of recording range of movement in the face, as well as providing clear information about the blink function of the eye: ie. whether the blink is incomplete in range and also whether it is slower than the unaffected side. A short video of the patient at rest (this is particularly useful for evaluation of the blink) for approximately 10 seconds, followed by completing each of the movements listed in the above paragraph on static photography (being sure to return to the rest position for 3 to 4 seconds after each movement, gives a comprehensive record in which it is easy for the viewer to compare the affected side to the unaffected side.

ROM Score

The most useful way to score range of movement is through use of the Facial Grading System [FGS]. Components of the FGS: resting symmetry, symmetry of voluntary movement and a deductive score for synkinesis. The scoring of FGS is on a 0-100 scale, with higher scores indicating better range of movement.

The FGS is extremely useful for measuring improvements made in facial therapy, and its sensitivity means that even small changes in range of movement will be identified. additionally, the synkinesis section enables an increased score even when there is no increase in range of movement, provided that synkinesis is reduced.

These factors mean that the FGS can be used on a regular basis to quantify progress made in therapy, providing useful feedback to the patient of the gains made, and helping with motivation.

It is for these reasons that many physiotherapists working with facial palsy use the FGS in preference to the House-Brackmann Scale.

Outcome Measures

Patient Reported OM

If the affected side of the face is flaccid, use the Facial Disability Index [FDI] as a Patient-reported outcome measure.

If the affected side demonstrates synkinesis, ie. linking of movements, then use the Synkinesis Asssessment Questionnaire [SAQ] as the Patient-reported outcome measure.

Clinician Rated Scales

For all patients, whether flaccid or in synkinesis, whether recent onset or chronic palsy, the Sunnybrook Facial Grading System [FGS] should be used; it provides a detailed ROM assessment score which is sufficiently sensitive to show even small changes in range of movement, so is extremely useful for monitoring the effects of rehab. It is also easy for the patient to understand as it is expressed as a percentage, with higher scores occurring as range of movement increases. In addition, it shows improvement in synkinesis, as when the deductive score for this reduces, the overall score increases.

Functional OM

Many patients have problems in function which they wish to improve with rehabilitation. Here are some common ones:

• Unable to drink from cup/glass without dribbling fluid from the affected side
• Frequently bite lip, cheek or tongue on the affected side when eating
• Unable to close affected eye

Each of these functions can be used as a goal with its own specific OM, phrased "Able to drink from.... without dribbling fluid", "Able to eat without biting..." and "Able to close affected eye". Partial improvement can be expressed as the patient begins to improve: "Reduced tendancy to dribble fluid when drinking from cup, used to happen with every mouthful, now occurs only with 50%...", "Able to close affected eye 70% of range", etc.

Smile as OM

It is very common for patients to be particularly concerned about their lack of range of movement on smile, as this is such an important means of non-verbal communication to express pleasure, and is used very frequently throughout the day. Therefore, it can be helpful to have a specific outcome measure for smile range of movement.

This can be achieved be using the smile portion of the FGS, of course, but often for patient motivation and ease of use it is helpful to have a separate functional outcome measure for smile. Here is a a quick and easy example:

• Excursion of affected corner of mouth, expressed as a percentage of non-affected side, achieved on smile [specify whether closed lip or showing teeth]

Goals

Here are some examples of SMART Goals for people with lower motor neuron facial palsy, split into goals suitable in flaccid faces and goals for people with synkinesis. Please note the time frames are just suggestions - tailor these to each patient.

Flaccid Face

1. Improve eye closure: Achieve full eye closure without finger assistance in 4 consecutive repetitions, within 8 weeks. (NB. the eye movement score on the FGS can be used to monitor this.)
2. Improve oral continence: Reduce loss of liquid (drinks) from affected corner of the mouth from frequent to rarely within 12 weeks. (the FDI physical subscale can be used to monitor this.)
3. Improved symmetry at rest: Reduced droop of affected corner of the mouth, so this is level with unaffected side within 12 weeks.

Synkinesis

1. Reduce involuntary eye narrowing during smile from "every time" to 50% of attempts within 12 weeks. (The SAQ and FGS both have subscores for this.)
2. Isolate frontalis activity, so patient is able to achieve an isolated eyebrow raise of 50% ROM without oral/cheek movement within 8 weeks. (FGS can be used to monitor this.)
3. Reduce resting hypertonicity in cheek muscles, so that the nasolabial fold sits at the same level as the unaffected side at rest., within 8 weeks (FGS synkinesis resting score can be used to monitor this.)
4. 4. Reduce biting of the cheek on eating, from "frequently" to "seldom" within 12 weeks. (Can use SAQ to monitor this.)