Why is specialist facial therapy needed to treat Facial Palsy?

Facial Palsy management is a specialised subset of Physiotherapy. Caitriona completed The Advanced Management Facial Palsy Course in 2015 run by the Facial Therapy Specialists UK founder Trina Neville and Sally Glover. Caitriona was involved in the induction of the first dedicated Paediatric Facial Palsy Clinic in the National Paediatric Craniofacial Centre in Temple Street in 2015. As part of her training, she also conducted a site visit to the centre of excellence in Paediatric Facial Palsy, Alderhey Children’s Hospital, Liverpool. She continues to update her knowledge in this field, most recently attending an Advanced Neuromuscular Retraining Course hosted by world renowned leaders in this area, Jackie Diels and Susan Rankin. Caitriona is a member of Facial Therapy Specialists International group.

As a Facial Therapy Specialist, Caitriona is trained in completing comprehensive assessments of the facial muscles, including identification of abnormal movement patterns in the face (often referred to as synkinesis). This training is founded on the knowledge that the facial muscles are unique in the body, and general muscle rehab principles do not apply in Facial Palsy management.

They are made differently:
1. They don’t have muscle spindles; this means they don’t respond to stimulus, such as a stretch or vibration, like other muscles do.
2. They have small motor units; this means they get a bigger amount of electrical input into a smaller amount of muscle, which allows for very precise subtle movements.
3. They degenerate or waste away slowly, so treatment recommendations such as muscle stimulation, to keep them viable, are unfounded.
4. They get both emotional and volitional (under our conscious control) neural input. In other words, facial muscles don’t just have a mechanical action (raising the corner of the mouth for a smile) but also a specific emotional expression (to show we are happy or being cheeky etc).
5. Facial muscles move skin. Unlike other muscles in our body, facial muscles are only attached to bone at one end, if at all. So, if a muscle in your leg contracts, it will move a joint or limb, a muscle in your face is only responsible for moving the skin and so a very low effort or amplitude movement is all that is required. (Diels J, 2022)

Synkinesis is the abnormal facial movements that accompany the intended facial movement, for example, when you smile the eyebrow raises or when you close your eyes, the corner of your mouth twitches or raises up. This represents the faulty rewiring that has occurred as the facial nerve recovers following injury. This abnormal nerve regrowth can occur anytime from 3-4 months following injury and can continue to increase for up to 2 years. These undesired movements can result in aesthetically and functionally distressing symptoms, and ultimately affect a person’s quality of life. (Shokri et al, 2021)

In order for the body to move, the brain (light switch) generates a signal for the movement to occur, this is then transmitted down the length of the nerve (electric cable) to the muscle (light bulb).

Peripheral Facial Palsy occurs when there has been an injury to the facial nerve (electric cable). Although the brain has generated the signal for movement, it cannot get through the injured nerve (electric cable) to the muscle (light bulb). Depending on the severity of injury, the nerve that is downstream to the injury will waste away. As healing occurs, the nerve tissue can, and in most cases will, regrow. The facial nerve has 5 main branches and many smaller branches off these, so as the facial nerve recovers it is very possible for the nerve to take the incorrect path and activate muscles that the brain did not intend to work for that particular expression.

Sometimes a person might refer to their face as still feeling numb or frozen well after the initial injury and the assumption is often that “my nerve has not recovered”. In fact, often the nerve has recovered, but with the faulty rewiring, rather than having all the muscles work in harmony with each other as the person tries to smile for example (up to 9 muscles on each side of the face are involved in creating a smile), the desired and undesired muscles all fire at the same time, resulting in a sort of tug-of-war with each other and gives the feeling and appearance of no movement.

**There is another type of Facial Palsy, called central Facial Palsy, this occurs with damage to the brain, as in a stroke. This type of Facial Palsy does not respond to the same type of therapy as that offered for peripheral Facial Palsy, and therefore is not considered for the Facial NeuroMuscular Retraining (fNMR).

Facial rehabilitation, including fNMR, soft tissue massage, and relaxation therapy in addition to chemodenervation with Botox, is the cornerstone of treatment. (Shokri et al, 2021)

A large study carried out in a Facial Palsy Specialist Centre in US (Lindsay et al, 2010) reported significant improvements for those with facial palsy, who underwent facial rehabilitation, including education, fNMR, massage, meditation-relaxation and individualised home programmes.

Facial NeuroMuscular Retraining aims to reduce the tightening sensation in the face, facilitate symmetrical movement and avoid or control the excessive mass movement of the face. FNMR also appreciates that each patient is unique so will respond to specific emotional stimulus, sensory feedback and instruction, tailored to their individual presentation. Basically, there is not, nor should there be, a general “hand-out sheet of exercises” to suit all.

To execute fNMR It is essential to use low amplitude (low effort), precise, co-ordinated or harmonious movement patterns that mimic natural expressions. This approach is similar to what an individual would do if trying to master a new skill such as playing a musical instrument.

These very precise, harmonious patterns of movement involved in FNMR are in stark contrast to a general therapist’s approach that may include non-specific, maximal effort strengthening exercises that don’t take into account the importance of shutting off or calming down those overactive muscles. Correct application of this type of training requires the supervision of a Facial Therapist that can readily identify and hone the desired movement pattern. (Diels J, 2022)

During the acute or flaccid phase of Facial Palsy, education regarding eyecare is crucial. So too, is oral and dental hygiene.

Education regarding avoidance of general active facial exercises. If a signal cannot travel through the injured nerve, the muscle is simply not able to carry out the task, and the person will start to compensate and use different muscles, already starting the cycle of abnormal movement patterns.

Although Electrical Muscle Stimulation is often offered as a treatment, evidence suggests it may interfere with the nerve regeneration (Rink et al, 2019) and the expert clinical opinion is that it can reinforce already abnormal movement patterns and actually increase an individual’s development of synkinesis. Therefore, here in PMC Physiotherapy Dunboyne we do not use Electrical Muscle Stimulation (This also includes avoidance of any electrical stimulation during Acupuncture). (Diels J, 2014)

As the nerve recovers and muscles become overactive with the faulty rewiring, soft tissue release techniques, massage, stretching and relaxation therapy are hugely beneficial in reducing the tightening and often painful sensation in the face. They may also promote nerve recovery (Rink et al, 2019). Using these techniques prior to starting fNMR gives better results in regaining more desirable movement patterns. (Shokri et al, 2021)

Botox can be a powerful adjunct to the fNMR programme to further decrease unwanted movements or synkinesis and Caitriona can liaise with your consultant, who may choose to administer Botox. She will identify the synkinetic muscles which are mostly restricting normal function for the individual, and if injected, would be of greatest benefit for progressing new motor learning during retraining. Ideally a person with facial palsy should complete a course of at least 6 months of fNMR prior to injections, to allow enough time to learn new strategies to control the synkinesis or undesired movements. (Diels JH, 2022).

Although active movements are not advised in the acute phase or just following the onset of Facial Palsy, getting a baseline assessment of your facial muscles is important. Treatment and advice at this stage is about preventing complications (such as issues with your eye) and incorporating management strategies, such as soft tissue massage and relaxation, that will help promote nerve recovery.

The fNMR can commence anytime from when synkinesis is noted. This is anywhere between 3-5 months following the onset of Facial Palsy, though this timeframe is highly variable and also sometimes people confuse lack of movement with weakness (flaccid face) rather than the overactivity or synkinesis (all muscles pulling against each other in opposing directions).

There is no time that is too late from the onset of Facial Palsy, to gain something from Specialist Facial Therapy input as fNMR can be started anytime once synkinesis is present.

If you have been diagnosed with Facial Palsy and wish to find out more about facial NeuroMuscular Retraining or other therapy available to you, please contact Caitriona at PMC Physiotherapy Dunboyne on 01 8253997 or at info@pmcphysiotherapy.ie