Published on February 24, 2014
FACIAL PALSY- AN UPDATE Prof. K Hari Ohm MPT MSAJ collage of PT The Indian centre for evidence based Neuro- rehabilitation
Objectives 1. Update knowledge on facial palsy 2. Understanding the chronic facial palsy 3. Critically review the treatment options
• Introduction• face and its function
Facial functions • Facial functions are multidimensional, serving emotional, social and physical aspects of an individual’s 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. 2. 3. 4. 5. 6. Controls muscles of facial expression. Taste perception from the anterior two-thirds of the tongue; Perception of cutaneous stimuli in the external auditory canal and over part of the pinna and mastoid region; Innervation of the stapedius muscle in the middle ear; Innervation of the lacrimal gland 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
communication Control Facial expression Voluntary Involuntary (Cortical) (limbic system) Context
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.
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 FacialNerve 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. 10. 11. Trauma, Hypertension, Eclampsia, Lyme disease, Sarcoidosis, Diabetes mellitus, Ramsay hunt syndrome Sjogren’s syndrome, Tumours of the parotid gland, Amyloidosis, or Complication of intranasal influenza vaccine.
Bells palsy When the cause of the peripheral facial weakness cannot be determined, a diagnosis of Bell’s palsy is made.
Bells palsy • The incidence of Bell’s 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. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of diff erent etiologies. Acta Otolaryngol 2002; 549 (suppl): 4–30. • 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 Bell’s palsy in the population of Rochester, Minnesota. Mayo Clin Proc 1971;46:258-64. – Hypertension Adour KK, Wingerd J. Idiopathic facial paralysis (Bell’s 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 Bell’s 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 anterior part of the tongue
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 Impaired ability to express context specific emotions Facial Paralysis Depression, maladaptive coping strategies, social isolation Inability to close the eyes, Slurring of speech, leaking of fluid during drinking and eating etc.,
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 Title Method sample Outcome Result/ conclusion Otol Neurotol. 2003 Jul;24(4):67781. Positive effects of mime 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 50 Sunnybrook Improvement in Facial Grading symmetry System House facial grading 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):177RCT 83. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial
• Mime – combination of mime and physiotherapy • Performing expression • Can also be helpful in chronic facial paralysis
Functional exercise • Developed as a multi dimensional and patientcentered 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;92:605–613. • Encompasses major facial functions • The functional training program consists of patient education, functional training and complementary exercises
Functional training Improved ability to express context specific emotions and other physical functions of face Patient education Positive coping strategies and Improved social interaction skills Functional Training Program Functional training Complimentary exercise Improved ability to activate various facial muscles
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
Tile and author Electrical stimulation Design Sample size Outcome Effect / result Physiotherapy for Bell's palsy. British Medical Journal 1958;2(5097):675-7 RCT 83 Exp- ES N= 43 (exp) Con- massage N=40 (con) 1 year follow up No significant advantage Tratamiento de la parálisis facial periférica idiopática: terapia física versus prednisona Revista médica del Instituto Mexicano del Seguro Social1998;36(3):217-21. RCT Group1- ES Group2prednisone 149 n-=76 May scale No difference at 3 months Physical therapy for Bell´ s palsy (idiopathic facial paralysis) (Review) . Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006283. review 294 participants
Title and author Electrical stimulation Design Sample Outcome Effect / result size measure Effects of electrical stimulation A pretest posttest on House-Brackmann scores in control vs. early Bell's palsy. Rev Med Inst experimental Mex Seguro Soc. 2009 Julgroups design Aug;47(4):413-20 N=8 in each group HouseBrackmann scores No significant difference [Observation on non-invasive electrode pulse electric stimulation for treatment of Bell's palsy]. Zhongguo Zhen Jiu. 2006 Dec;26(12):857-8. RCT N=138 ? EC No Therapeutic effect on Bell palsy. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial. Clin Rehab 2007;21(4):338-43 RCT Group1-exercise & ES Group2- ES 59 n-=30 N=29 Facial Grading Scale No difference at 3 months 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
• Not proven to be effective in UMN lesion • LMN lesion may work
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 to feel / act better even if the situation does not change. • To reconstruct one’s thoughts and perception of the problem like negative self-perception of facial attractiveness (body image), interpretation of others/society’s views towards one’s disability etc...
Synkinesis • Most common areas of injection are eye muscles (orbicularis), neck bands (platysma), and chin dimpling (mentalis).
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, 146–147
Synkinesis Assessment Questionnaire Validation of the Synkinesis Assessment Questionnaire Ritvik P. Mehta, MD; Mara WernickRobinson, PT, MS, NCS; Tessa A. Hadlock, MD Laryngoscope, 117:923–926, 2007
Conclusion • About 20- 23% of people with Bell's palsy are left with either moderate to severe symptoms • Don’t just think of it as a motor problem • Intervention needed to concentrate on all aspects of the disability • Update the interventional strategies
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