facial rehabilitation.pdf

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Facial Rehabilitation: A NeuromuscularReeducation, Patient-Centered ApproachJessie VanSwearingen, Ph.D., P.T.1,2

ABSTRACT

Individuals with facial paralysis and distorted facial expressions and movementssecondary to a facial neuromotor disorder experience substantial physical, psychological,and social disability. Previously, facial rehabilitation has not been widely available orconsidered to be of much benefit. An emerging rehabilitation science of neuromuscular

reeducation and evidence for the efficacy of facial neuromuscular reeducation, a process offacilitating the return of intended facial movement patterns and eliminating unwantedpatterns of facial movement and expression, may provide patients with disorders of facialparalysis or facial movement control opportunity for the recovery of facial movement andfunction. We provide a brief overview of the scientific rationale for facial neuromuscularreeducation in the structure and function of the facial neuromotor system, the neuro-psychology of facial expression, and relations among expressions, movement, andemotion. The primary purpose is to describe principles of neuromuscular reeducation,assessment and outcome measures, approach to treatment, the process, including surface-electromyographic biofeedback as an adjunct to reeducation, and the goal of enhancingthe recovery of facial expression and function in a patient-centered approach to facialrehabilitation.

KEYWORDS: Facial rehabilitation, neuromuscular reeducation, facial paralysis

Rehabilitation for facial paralysis or facial move-ment dysfunction after insult to the facial neuromotorsystem has previously been of little expected benefit.

Thus, the availability of facial rehabilitation is limited,and most individuals with facial movement disordershave been told to await (spontaneous) recovery or toldno effective intervention exists.1,2 Consequently, individ-uals with paralysis of or disfiguring facial expressions deal

with physical, psychological, and social disability daily.27

Facial neuromuscular reeducation is a process of facilitat-ing the return of intended facial movement patterns andeliminating unwanted patterns of facial movement andexpression.2,3,6,814 Surface-electromyographic (EMG)biofeedback or mirror feedback serve as adjuncts to the

reeducation process, providing accurate informationabout specific muscles and the timing of activation; thetherapist coaches patients to (1) enhance facial muscleactivity in desired patterns for facial functions and ex-pressions, and (2) reduce (abnormal) facial muscle activitydisrupting or preventing intended facial func-tions.3,8,10,14,15 Based on the biological plausibility andgradual but steadily emerging evidence of the efficacy of

facial neuromuscular reeducation,8,14,16,17

patients withdisorders of facial paralysis or facial movement controlhave an opportunity to explore conservative options forthe recovery of facial movement and function.

Characteristics of the facial neuromotor system,an understanding of the neuropsychology of facial

1Department of Physical Therapy, University of Pittsburgh,Pittsburgh, Pennsylvania; 2Facial Nerve Center, University ofPittsburgh Medical Center, Pittsburgh, Pennsylvania.

Address for correspondence and reprint requests: JessieVanSwearingen, Ph.D., P.T., University of Pittsburgh, DepartmentPhysical Therapy, 6035 Forbes Tower, Pittsburgh, PA 15260.

Facial Paralysis; Guest Editor, Patrick J. Byrne, M.D., F.A.C.S.Facial Plast Surg 2008;24:250259. Copyright# 2008 by Thieme

Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel: +1(212) 584-4662.DOI 10.1055/s-2008-1075841. ISSN 0736-6825.

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expression, and an intent to map a path that relatesspecific processes of care of the patient to specific out-comes and to the patients general health status underlieour focus on facial neuromuscular reeducation and apatient-centered approach to facial rehabilitation. Thefollowing sections include (1) a brief description ofstructure and function of the facial neuromotor system;

(2) concepts of the neuropsychology of facial expressionand relations among expressions, movement, and emo-tion; and (3) principles of neuromuscular reeducation infacial rehabilitation to enhance the patients recovery offacial function, expression, and well-being. An overviewof assessment and outcome measures, approach to treat-ment, some specific treatment options, and the processand goal of facial rehabilitation follow the rationale.

THE FACIAL MOTOR SYSTEMThe facial motor system is responsible for multiple

human functions critical for physical, social, and psycho-logical well-being, such as the physical acts of eating,drinking, and speaking, conversational signals, and evenconveying intimate human information.4,7 The facialnerve branches and ramifies among nerve fibers withina single bundle of seventh cranial nerve fibers,18 a factthat underlies an array of unique spatial patterns ofmuscle activity and varied synergetic movements dem-onstrated by individuals with facial nerve disorders.Most often, functional facial movements or expressionsare a result of a combination of facial muscle contractionsand not the outcome of a single isolated muscle con-traction.19 For this reason, facial movement is easilydistorted by changes in resting facial posture or voluntarymovement in any region of the face.

Unlike other skeletal muscles, the facial muscleslack fascial encasement and tendons attaching the facialmuscles to bones, thus enabling the origin and insertionof facial muscles to move freely.18 The neuromotorcontrol of facial movements also appears different fromthe usual motor control mechanisms of skeletal musclesdue to the limited ability of the facial muscles to providefeedback. Intrinsic muscle receptors and joint receptors,primary sources for peripheral proprioceptive feedbackto the central nervous system, are few or absent in the

face.2022 With static and dynamic information aboutfacial muscle posture and movement lacking, voluntaryattempts to guide facial movements rarely result in anaccurate approximation of the desired movement with-out some sort of compensatory feedback (e.g., mirror)and motor practice (see later).

NEUROPSYCHOLOGY OF FACIAL

EXPRESSIONFacial expressions result from either brain activity in-

volving the motor cortex (cortical behaviors) or by

activity of a less clearly defined network of subcorticalnuclei and brain-stem areas (subcortical behaviors) ulti-mately converging on neurons in the facial nuclei.Cortical-mediated expressions are usually voluntary ac-tions with an intended facial function outcome. Sub-cortical behaviors of the face are usually reactional, anelicited response to previous events, such as surprise,

laughter, or sneezing.23

Communication or punctuationsignals accompanying purposeful language may be acombination of cortical and subcortical behaviors ofthe face.23,24

Highly skilled observers using the Facial ActionCoding System distinguish posed (e.g., cortical) andfelt (e.g., subcortical) expressions.24 The ability toactivate facial muscles, alone, is not sufficient for thecomplex interactions of facial expressions with humanbehavior. Electromyographic studies of facial expressionassociated with emotion indicate that the activity ofspecific facial muscles change when a person is thinking

versus feeling an emotion for individuals with mooddisorders.25 The dissonance experienced with any at-tempt to dissociate a patterned facial muscle responsefrom a felt emotion illustrates the intimate associationbetween emotion and facial expression.4,7 As emotionselicit a set of stereotyped facial muscle contractions of anexpression, the alternative may also be true, facial muscleactivity may elicit or reinforce emotions(e.g., facial feed-back hypothesis).4,25,26 Given the absence of proprio-ceptive feedback from facial muscles, the mechanism isunclear, yet some clinical evidence supports the concept.Psychological distress mediates the association betweenimpairment and disability in individuals with a facialneuromotor disorder.27 The presence of a marker ofpositive affect predicts greater response to therapy toincrease lip corner movement with smiling in individuals

with a facial neuromotor disorder.19,28 The degree ofdistortion of the pattern for smiling from the patterndefined for a smile of happiness was associated withgreater psychological dysfunction.29,30 Evidence sup-porting the facial feedback hypothesis could significantlyimpact therapeutic interventions for individuals withdistorted or weakened facial movements and the under-standing of psychosocial disorders among the patientpopulation.

Little specific information is known about thecontribution of deficient facial feedback to the psycho-social problems of individuals with facial dysfunction.31

Investigators describing problems related to facial dis-figurement emphasized the impact of facial dysfunctionon social interactions, including psychological andphysical fatigue from managing social interactions(e.g., making interactions easier for those who interact

with the one with disfigurement). Such issues of thecontrol of facial motor activity of facial expressions havean important bearing on the recovery of facial neuro-motor function through rehabilitation after insult to the

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facial motor system.32 Training muscle activity under-lying specific facial expressions may be more effective orefficacious for true recovery (e.g., improved quality oflife) than is training muscle activity for restoration offacial movement (at the impairment level) for theindividual with a facial neuromuscular disorder.30,32,33

Particularly (1) the pattern of facial muscle activity of

an expression may guide the physical therapist indeveloping tailored treatment strategies using neuro-muscular reeducation; (2) emotions or other subcort-ical-initiated expressions may be valuable adjuncts totreatment of facial neuromotor disorders; and (3) emo-tional status or mood may influence the facial muscleactivity and alter the course and outcome of treatmentfor individuals with facial nerve disorders.

REHABILITATION FOR FACIAL

NEUROMOTOR DISORDERS

Traditional Approach to Facial RehabilitationRehabilitation for facial neuromotor disorders throughphysical therapy using nonspecific light massage, elec-trical stimulation, and repetitions of common facialexpressions in a general exercise regimen have beenconsidered to be of little benefit.34,35 In fact, someinterventions may even adversely affect recovery of facialneuromotor function.3537 Evidence from animal studiessuggest electrical stimulation of facial neuromusculatureduring recovery from nerve injury may be disruptive toreinnervation3739 (however, see Refs. 40, 41). Someindividuals treated with electrical stimulation duringrehabilitation of the facial nerve injury have been ob-served to produce mass action, a generalized contrac-tion of all or many of the facial muscles with attempted

voluntary facial movements or expressions.15,42 The useof nonspecific electrical stimulation of the peripheralfacial neuromuscular system during the recovery processreinforces abnormal (synkinetic) patterns of facial muscleactivity. If the electrical stimulus is not carefully localizedto the facial muscle nerve branch serving the specificintended facial movement or expression, peripheral nervefibers within a nerve trunk serving many facial muscles43

will be simultaneously recruited. In our clinical experi-

ence, many patients who have had prior electricalstimulation therapy demonstrate facial movements

with reinforced synkinetic muscle activity and inaccu-rate patterns of facial expressions.44

Facial Neuromuscular Reeducation Approach

to Facial RehabilitationSeveral investigators have described improvements infacial movement as an outcome of facial neuromuscularreeducation using surface EMG biofeedback or mirrorfeedback.3,6,814,17 Facial neuromuscular reeducation is a

process of relearning facial movement using specific andaccurate feedback to (1) facilitate facial muscle activity infunctional patterns of facial movement and expression and(2) suppress abnormal muscle activity interfering withfacial function.3,6,15,45 To date, few studies have definedeither a specific approach to the use of EMG biofeedbackor measurable outcomes of the treatment.6,32,44

The theoretical benefit of using EMG biofeed-back as an adjunct to facial muscle reeducation in thetreatment of facial paralysis (little or no movement) orsynkinesis (abnormal movement accompanies the in-tended movement) is the ability to provide the individualaccurate and immediate feedback about facial muscleactivity. In the case of little or no facial movement,surface EMG provides immediate and accurate infor-mation about the patients attempts to increase facialmuscle activity. For patients with abnormal facial move-ment accompanying and distorting the intended facialaction (too much movement), surface EMG provides the

information about the patients attempts to decrease theabnormal muscle activity while maintaining or increas-ing activity of the muscles underlying the intended facialaction. Individuals with intact proprioception (mecha-nism for feedback) relearn the movements of walkingafter injury of the lower extremity peripheral neuro-muscular system. The absence of feedback intrinsic tothe facial muscles presumably renders the brain unin-formed of facial muscle performance. Given adequateinformation about performance for the purpose of motorlearning, the facial neuromotor system has the sameability to relearn movement patterns, as the peripheralneuromuscular system of the lower extremity. Individu-als who are provided precise, extrinsic feedback aboutfacial muscle activity (e.g., surface EMG) learn to recruitthe appropriate motor units for the desired expressionand learn which motor units are inappropriate to recruitfor the intended task.3,6,10,14

Inadequacy of the Description of the Problem,

Treatment, and Treatment OutcomeThe evidence for efficacy of neuromuscular reeducationfor recovery of facial function and expressions in in-dividuals with a facial neuromotor problem stems from

descriptive (case reports or retrospective outcome stud-ies) and a few randomized controlled clinical trials withsmall sample sizes, with feedback-assisted (surfaceEMG or mirror or both) neuromuscular reeducationdemonstrated to be associated with generally better orequivalent outcomes to the comparison standard of carefor patients with facial neuromotor disorders.6,17,44

None of the studies clearly defined what patients dowell with what treatments, nor did the investigatorsdefine an adequate measurement of treatment outcome,including impairment and disability level, patient-centered outcomes.

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A systematic means of defining specific charac-teristics of the patients facial neuromotor disorder,particularly impairment and disability problems, andtargeting physical therapy in facial rehabilitation for thepatient-specific problem areas may improve the deliveryand outcomes of facial rehabilitation.46 A treatment-based classification system could be used in the process

of further defining facial neuromotor problems47

andproviding a guide to the appropriate treatment ap-proach.4749 Treatment-based classification also servesas a means of validating specific interventions relative tothe effectiveness of treatments matched for a treatmentcategory.

The role of classification in rehabilitation mimicsthe role of diagnosis in medicineidentification of aclinical problems based on sets of signs and symptoms,for the purpose of applying a known treatment.50,51

Multiple pathologies underlie a facial neuromotor dis-order (e.g., Bells palsy, tumors, trauma),5155 yet the

pathology provides little information useful in match-ing the appropriate treatment to the problem. Instead,treatments are matched to the patients specific signsand symptoms of facial neuromotor dysfunction asso-ciated with the pathology. For example, an individual

with Bells palsy could have severe weakness or littleweakness but marked synkinesis (abnormal move-ment). The treatments differ markedly for a primaryproblem of facial weakness versus a problem of abnor-mal facial movement, yet the same pathology. In ourclinical experience, among patients treated based onphysical signs of facial neuromuscular dysfunctionand symptoms of difficulties in activities of daily livinginvolving the face, certain treatments got certainpatients better.

ASSESSMENT INTO PRACTICE:

DESCRIBING THE PROBLEM AND

RECOGNIZING THE OUTCOMEA clinical practice and research goal in the rehabilitationof facial neuromotor disorders is to trace a path thatrelates specific processes of care of the patient to spe-cific outcomes to the patients general health status.56

Using the International Classification of Impairments,

Disabilities and Handicaps (ICIDH) developed by theWorld Health Organization (WHO) as a conceptualframework,49,57 we defined assessment measures in do-mains of impairment, disability, and aspects of health-related quality of life (HRQL) useful in assessment anddetermining outcomes of treatment. The Facial GradingSystem58 measure of facial impairment and the FacialDisability Index59 measure of disability, with otherfactors of the illness, combined accounted for 72% ofthe variance (impairment, 28.64%, disability, 25.17%,and temporal characteristics of disease, 18.16%) in de-scribing patients with a facial neuromotor disorder.46

Impairment TestingThe Facial Grading System (FGS) is a performance-based measure58 of facial impairment in three areas:(1) resting posture of the eye, the nasolabial (cheek)fold, and the corner of the mouth; (2) voluntary move-ment for five expressions in five regions of the face,forehead wrinkles, eye closure, open mouth smile, snarl,

and pucker; and (3) synkinesis, associated with thevoluntary movement tests. The psychometric propertiesof the FGS have been defined, including construct

validity and responsiveness of the FGS for clinicallymeaningful change for patients with a facial neuromotordisorder,58 and interrater and intrarater reliability forscale use in assessment of patients with facial neuro-motor disorders (reliability coefficients 0.90).46

Measuring Facial DisabilityThe Facial Disability Index (FDI) is a disease-specific,

self-report instrument for the assessment of the disabil-ities of patients with facial nerve disorders, scored as twosubscales: the FDI physical and FDI social subscales.59

Reliability59 and construct validity of the FDI subscaleshas been demonstrated by correlation with clinicalmeasures of facial movement and psychosocial statusand by comparison with the Short Form-3660 generalHRQL measure.59

Treatment-Based Classification CategoriesBased on physical signs and symptoms identified byusing the FGS impairment and FDI disability measures,

we classify patients with facial neuromotor disorders intoone of four treatment-based categories (initiation, facil-itation, movement control,andrelaxation).47The physicaltherapy approach (suggested by the name of the treat-ment category) specifically targeted for the set of signsand symptoms of each category are based on the bio-logical plausibility that the underlying neuromuscularphysiology differed by treatment category.

INITIATION

In the initiation category, patients typically demonstratemoderate to marked asymmetry of the face at rest (e.g., a

drooped face, including lower eyelid, depressed cheek,and drooped mouth corner) and marked asymmetry with

voluntary movement or spontaneous expressions orfunctions (e.g., little or no ability to initiate movementon the involved side), without abnormal movements(synkinesis). Activity of the uninvolved facial muscula-ture, in the presence of the profound involved side facial

weakness, may actually shift the face toward the unin-volved side with facial functions and expressions. Facialfunctions, such as closing the eye, eating and drinking,speaking, or rinsing the mouth are most difficult forpatients in this category. The appearance of obvious



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facial disfigurement at rest and with movement has amajor negative impact on psychosocial well-being anddaily interpersonal interactions.

Treatment specific for patients in the initiationcategory includes active assisted range of motion exer-cises and small range movement practice to avoid over-powering by the muscle function of the uninvolved side

of the face. Describing the usual process of recovery andrehabilitation and expected signs of recovery of facialmovement and function also seems to be beneficial.

FACILITATION

Mild to moderate facial asymmetry at rest (e.g., slightlower eyelid droop, minimal flattening of the cheek fold,and minimal droop of the corner of the mouth), ability toinitiate facial muscle activity, but mild to moderateasymmetry of the face with attempted voluntary move-ment and with expressions (e.g., incomplete facial func-tions and expressions), and typically no or little

synkinesis characterize the presentation of patients inthe facilitation category. Primary movement problemsinclude insufficient protection of the eye, secondary todifficulty closing or sustaining eye closure for moisteningand protection on a windy day or when washing the face,and mild but notable problems eating, drinking, andrinsing the mouth, without loss of food or fluid (essen-tially a milder version of the initiation category prob-lems). Psychosocial distress is typically less than forinitiation, mirroring the lesser severity of resting and

voluntary facial asymmetry and physical disabilities.The patients in the facilitation category initiate

facial movement, so active and resistive exercises toincrease facial movement excursion are appropriate.Education includes emphasizing the importance of ac-curate exercise practice over quantity and an awareness ofsigns of some typical abnormal movement patterns(synkinesis) that may develop with the increasing move-ment. The recognition of any synkinetic movement mayindicate the need to return for a therapy visit to avoidcontinued exercise with synkinesis reinforcing undesir-able patterns of facial movement.

MOVEMENT CONTROL

Most characterized by asymmetry, some at rest, and

usually more obvious with movement, the asymmetrycharacteristic of patients in the movement category is notdroop but tightening or retraction of the face. Anarrowed aperture between the eyelids (usually lowereyelid raised), a deepened cheek fold, and sometimespuffy or plumped cheek appearance, with or without alateral and upward pull on the corner of the mouth, ischaracteristic, and the center of the lips (philtrum) maybe shifted laterally toward the involved side of the face.

Weakness as for the facilitation category is common, butthe key sign is the unintended movement of one regionof the face, associated with an intended facial movement

or expression, synkinesis (e.g., eye closure with smile,and retraction of the corner of the mouth and deepeningof the cheek fold with a raise of the brow). Though thereason for the problem differs for the movement controlcompared with the facilitation category, the physicalproblems are similar arising largely from the abnormalmovement patterns, not weakness. Patients report ex-

cessive tearing of the eye, difficulty keeping the eye openwhen speaking or eating, biting the inside of the cheekwhen eating, and speech problems when speakingquickly. The synkinetic movements, not intended yetaccompanying every performance of the associatedintended facial movement, function, or expression, seri-ously disrupt personal and work relations, and thepatients with movement control problems frequentlyreport moderate to marked psychosocial distress.

Facial neuromuscular reeducation for the prob-lems of facial movement control involve guiding thepatient in learning (relearning) to isolate muscle con-

tractions and reduce the muscle activity of abnormalpatterns of movement. With a short-term treatment goalof producing desired facial movements or expressionpatterns without the accompanying synkinetic move-ment, some therapists recommend small movementtherapy.8,42,44 However, facilitating the desired move-ment pattern (and increasing facial muscle activity of theintended movement) and accepting some but minimalsynkinetic movement in the process may also be effectivein the recovery process.14 The presumed process ofreorganization in the brain to learn to recruit theappropriate neurons to increase facial movement sup-presses the recruitment of neurons for the synkineticmovement. As the patient learns appropriate patterns ofmovement control, the patient may be reclassified intothe facilitation category for continued treatment andrecovery. Stretching exercises are also indicated tolengthen facial muscle tissues shortened secondary toabnormal patterns of movement and even facial muscleguarding, as patients try to restrict all movement to avoidthe synkinesis and disfiguring movement.

RELAXATION

Characteristic of the relaxation treatment category is acombination of marked asymmetry of facial posture at

rest (as for the movement control category), with spon-taneous twitching and facial muscle spasms. The facialmuscle spasms often increase in frequency and amplitude

with greater movement effort. Muscle strength is typi-cally not the major problem, yet the observed facialmovement may be moderately restricted as the patientguards against the next spasm. Specifically, uncon-trolled orbicularis oculi spasms close the eye uninten-tionally and make some instrumental activities of dailyliving unsafe and others such as hobbies too fatiguing tocontinue. Psychosocial problems are common andmarked, as individuals with facial twitches and spasms



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spend much energy and time controlling facial move-ment and worrying that the spasm can or will return,interfering with the activities of the day.

The primary treatment goal for problems of facialtwitches and spasms is relaxation exercises, such asmodifications of the standard relaxation exercises orig-inally described by Jacobson61 and small rhythmic,

alternating movements to relax the muscles. Techniquesto inhibit muscle activation include sustained stretchingand cross-friction massage to reduce passive tissuerestrictions.

DIFFICULT CHALLENGES IN

REEDUCATION FOR FACIAL MOVEMENT

DISORDERSRestoring symmetry to facial movements, particularly inspontaneous facial expressions and functions character-istic of everyday facial actions and not practiced, volun-

tarily guided facial movements such as posing for a photoor to please the therapist, represents one of the mostdifficult challenges in facial rehabilitation. The lack ofsymmetry in movement of the face may be due to weakmuscles unable to produce adequate force to participateequally with the muscles of the uninvolved side of theface. Asymmetry may also be secondary to abnormalmovement of the involved side restricting or distortingfacial muscle activity of the uninvolved side because ofa mismatch in force, speed, and amplitude of facialmovement side to side. A compensatory or perhapsovercompensation by muscles of the uninvolved side ofthe face may eliminate a need for the involved side action,redefining the muscle pattern for the task or renderingthe involved side muscle less effective or ineffectivebecause of timing delays or altered position or length ofthe involved side muscle prior to or during the desiredfacial action. Such asymmetrical facial movements, mostoften recognized as distortion of the face during move-ment (e.g., talks out of one side of the mouth) maydevelop and persist, in part because of the lack ofproprioceptive feedback to inform the brain of the errorsin facial movement patterns, and because the facial actionsubserved by the asymmetrical pattern of facial movementis necessary and common, thus practiced in the distorted

fashion repeatedly throughout the day.The example, talks out of one side of the mouth

is common for patients in the initiation category, and themaladaptive pattern of facial movement develops andgets practiced because speech is necessary. With pro-found weakness, movements of the lips may be impos-sible, yet talking must go on! The brain meets thechallenge of intelligible speech by altering the muscleactivation pattern to bring the lips together at any pointin space (and any side of the face) to produce theintended speech sounds. Thus, speaking, may promoteasymmetrical facial movement patterns. Even with the

reinnervation, rehabilitation, and recovery of facialmuscle activity on the involved side of the face, withoutthe brain recognizing the muscle pattern for speech isaltered (lack of feedback from muscles), the distortedpattern likely persists.

Repeated attempts to smile as much as possible torehabilitate the smiling muscles on the involved side may

be a specific and effective conditioning program for theuninvolved smiling muscles. Unfortunately, the repeatedattempts to smile as much as possible may do little toactivate the involved-side smiling muscles. In fact, anabnormal lengthening of the partially or completelyparalyzed involved-side smiling muscles may result inpart from the impact of repeated smiling attempts on theinvolved-side smiling muscles, too weak to oppose ormatch the pull of the uninvolved facial musculature.

Exercises that tend to center the face so that thecenter of the lips moves more to the center with theexercise or for which the lip center is shifted little or not

at all with the exercise help avoid the problem ofabnormal lengthening and enable involved-side musclemotor practice. Several exercises by observation andclinical experience help integrate involved-side muscleactivity with the uninvolved, provide opportunities forthe involved-side muscle to exercise, particularly indesired patterns of movement, and promote coordina-tion (e.g., simultaneous activation of involved withuninvolved muscles for the facial task). For example:(1) suck the cheeks between the teeth; (2) wrap your lipsover the teeth; (3) make the f sound (sustained,fffffffffff sound); and (4) blowing, as if blowing bub-bles in your drink, through a straw, or blowing bubblesthrough a bubble wand. The blowing exercise incorpo-rates the benefit of context of the movement to enhancethe amplitude and coordination, more so than found forthe deliberate, voluntary (e.g., cortically mediated)movement of pucker, despite the fact that both tasksrequire a similar muscle for the action, the orbicularisoris.33 The exercises described for enhancing symmetryare in part or wholly well-learned, semiautomatic (sub-cortically mediated) facial actions, and most peopleclearly understand the exercise goal.

The facial centering exercises for integrating andcoordinating involved with uninvolved facial muscle

activity and enabling the involved side to participate inexercises and facial functions also serve as the basis forexercises to regain mid-cheek lift and a real smile.Elevation of the mid-cheek region, a responsibility ofthe levator labii, superior orbicularis oris, and even themedial aspect of the orbicularis oculi muscles, accompa-nies many facial expressions and functions, such as smil-ing, speech sounds (e.g., sh, f, b, p . . .), sniffling, andfacial expressions of disgust and perplexity. In mostfunctions, the role of the mid-cheek muscles remainsone of synergist, or quiet but necessary companion to thefacial task. Thus, few individuals with a facial neuromotor



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disorder, and perhaps even those without, understandand activate the mid-cheek muscles easily or consistentlyon voluntary request to do so. And, voluntary attempts toactivate the mid-cheek lift muscles frequently result in a

wide variety of funny faces, many without mid-cheekmuscle activation. Activation of the mid-cheek musclesintegrated between the involved and uninvolved side also

further serves to reinforce the centering of the face andenhance coordinated movement between the sides of theface. For example: (1) blowing as if blowing bubbles, keepblowing and try to add knit eyebrows together as ifthinking; (2) blowing as if blowing bubbles, keep theair blowing, and transition to a fffff sound, alternatebetween blowing and fffff trying to keep air movingthrough the lips; (3) make the fffff sound, keep thefffff sound and try to add a smile, from the cornerof your eyes; (4) blowing as if blowing bubbles and adda smile from the corner of your eyes. The smile fromthe corner of your eyes directive in the above exercises

is designed to facilitate the pattern of muscles and timingof muscle activity characteristic of a smile of happi-ness.4,6264 The Duchenne marker or positive affectmarker of a smile of joy or happiness is the activationof the orbicularis oculi muscle with the zygomaticusmuscle group (typical smiling muscles) and mid-cheeksynergists. Actually, encouraging the individual with afacial movement disorder to blow as if blowing bubblesand then to try to relive (think about) a time when theindividual was really happy may be the most effectivemethod for performing the exercise, as reliving happi-ness tends to activate the positive affect marker,4,6264

the orbicularis oculi contraction in association withsmiling.

The recovery of eye closure and related functionsof the orbicularis oculi muscle of the eye with the eyerepresent similarly challenging problems in facialrehabilitation. A major problem is recovery of theexquisite integration of eye movements with eyelidand face movements and the ability to use the appro-priate pattern of muscle activation and relaxation forthe intended task, most tasks that are largely performed

with little or no conscious attention. Gentle eye closureinvolves relaxation of the levator muscle of the eyelidserved by the oculomotor nerve.43 (Muellers muscle, a

smooth muscle of the upper eyelid innervated bysympathetic nerve fibers, also participates, butthe muscle has not been included here to streamlinethe discussion.) The relaxation of the levator allows theupper eyelid to descend. A contraction of the superiorrectus muscle (extraocular muscle for moving the eye-ball), which moves the eyeball in an upward direction,immediately follows the relaxation of the upper lid.6567

Only the brief contraction of the orbicularis oculiinhibits the superior rectus muscle and prevents theupward migration of the eyeball. As a result of theorbicularis oculi contraction timed to inhibit the supe-

rior rectus muscle ongoing activation, the eye followsthe descent of the eyelid to come to rest in a slightlydownward position behind the closed eyelid. Weaknessof the orbicularis oculi muscle (innervated by the facialnerve) results in the Bells phenomenon, commonlyobserved with eye closure in individuals with a facialneuromotor disorder. The Bells phenomenon, or the

upward movement of the eyeball (superior rectusmuscle action uninhibited by the paralyzed orbicularisoculi muscle), prevents or interferes with the descent ofthe relaxed upper eyelid.67 The characteristic incom-plete eye closure, inability to effectively blink, eyes openat night when sleeping, and the high risk of drying ofthe eye and serious damage to the cornea are associated

with the disruption of coordinated eye closure.43 Evenwith reinnervation and recovery of facial movement, theBells phenomenon pattern may persist.8

Several neuromuscular reeducation strategiesbased on an understanding of the physiologic pattern

of muscle actions for eye closure have been imple-mented to overcome the Bells phenomenon barrier tousual eye functions and facilitate eye closure. Onestrategy, eye closure while looking down, is an attemptto relax the superior rectus muscle of the eye. Theexercise instructions for the sequential steps of theexercise, look down, close eyes, once closed continueto look down, aim to voluntarily reduce the tendencyof Bells phenomenon to lead to sustained superiorrectus activation and difficulty closing. A second strat-egy, more appropriate when the patient has some returnof orbicularis oculi muscle activation, relies on volun-tary activation of the orbicularis oculi to assist inrelaxing the superior rectus activation. The sequentialexercise instructions, squint, look down, and closeeyes, then relax squint, is intended to activate theorbicularis oculi, add relaxation of the superior rectus(look down), and then follow with voluntary relaxationof the orbicularis oculi to achieve the eye closure restingstate.68

EXERCISE PRACTICE INTO LIFEIn addition to clinical training sessions, an individu-alized home facial movement exercise program de-

signed to reinforce the desired facial movementpatterns provides the practice component of motorlearning necessary for neuromuscular reeducation.Only exercises that the patient demonstrates the abilityto perform accurately for the goal of treatment or for

which the patient may not consistently perform accu-rately but recognizes accurate and not so accurateperformance and can correct or redo exercise to opti-mize practice are recommended for the home program.

The exercise program usually consists of 5 to 10repetitions of 3 to 5 exercises to be done twice daily.Use of a mirror for visual feedback during exercise can



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be helpful for the patient, but mirror images, watchingoneself move with facial paralysis, and the psychologicaldistress of looking at an abnormal facial appearancemay be more detrimental to recovery than beneficial.Striving to design home exercise and train patientsduring the clinical sessions to perform a couple ofexercises accurately without the need for feedback

guidance, or with only an occasional need to look inthe mirror once the exercise has begun to check thatthe motion or position of the face during the exercise isas desired, has had positive results both in terms of therecovery of facial function and the patients experienceof the process. The success of neuromuscular reeduca-tion, much like any exercise program to enhance motorskill (e.g., learning to play tennis or golf) depends inpart on attention and practice, practice, practice tobecome a highly skilled mover.69 Patients to be suc-cessful through facial neuromuscular reeducation com-mit sometimes to tedious thoughtful exercises for a

long duration, thus a reason to monitor and care aboutthe patients experience during rehabilitation. Someusual or not so usual tasks automatically involve facialmuscles in movement patterns that enhance facialmovement outcomes and may be effective componentsof the home exercise program; for example, suckingthrough a straw, attempting to play a harmonica, sayingall the words you can think of that begin with thesounds sh, f, p, or b with theteeth together(teethtogether facilitates lip movements and avoids jawmovement sometimes used to substitute for weak lipmovements [personal experience]), and think of a time

you were happy and smile every time you pass someonewalking on the street. Such exercises may also serve totransition the process of facial rehabilitation into usingthe face in everyday life.

Instructions for exercises, massage, and repeti-tions are individualized and written down for patients;the therapist often writing the exercise description asthe patient demonstrates exercise performance at theend of the therapeutic session and leaves for one ormore weeks of daily, solo practice. As indicated by thesigns and symptoms noted in reevaluations at subsequentphysical therapy sessions, regular updates to the facialexercise home program are important. Replacing

previous exercise regimens with a new set of 3 to 5exercises is indicated to match the exercises to the current(and evolving) movement problems but also to enhancethe patients interest in the reeducation process and tochallenge the brain in learning or relearning the reper-toire of facial movements, expressions, and functions.

SIGNIFICANCE OF FACIAL

REHABILITATIONTo trace the path that relates specific process of care ofthe patient with a facial neuromotor disorder to specific

patient-centered outcomes and restored or improvedhealth-related quality of life requires a foundation forassessment and treatment, based in biological plausibilityand supported by evidence from clinical practice andtrials.51,56 The use of treatment approaches tailored tothe pretreatment classification may result in more cost-effective treatment for an underserved clinical popula-

tion. Second, treatment of facial neuromotor disordersprovides a rich and complex integration of the neuro-science of movement control, the linkage of emotion andmovement, and the impact of psychosocial factors in thepresentation of motor disorders, which may be applica-ble in understanding movement problems in individuals

with other types of neuromotor disorders.

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