After damage or injury to the facial nerve, including after any type of tissue manipulation for facial paralysis, it is critical to optimize the cosmetic and functional outcome by learning to control facial movement. Physical therapy uses facial neuromuscular retraining to improve the motor control of the facial muscles. A comprehensive review of the literature supports the use of neuromuscular retraining, including both acute (less than one year since injury or surgery) and post acute stages of recovery. The use of electrical stimulation to improve the motor control in the face is not recommended; it is a treatment technique that is not supported in the literature.
Neuromuscular retraining uses selective motor training techniques to facilitate symmetrical movement and to control undesired gross motor activity (synkinesis). Tools such as surface electromyography (EMG) and specific mirror exercises provide augmented sensory information to enhance neural adaptation and learning. Motivation through individualized instruction and active patient participation are crucial to success. Because each patient presents differently, there are no generic lists of exercises. Although each patient’s program differs, some general principles apply. For example, it is imperative the movement of the face be initiated slowly, not rapidly. Small movements, rather than large motions of the facial muscles are taught to improve coordination and accuracy.
The length of treatment time and number of physical therapy sessions varies from patient to patient, and typically depends on patients’ motivation, compliance, need for EMG, third party payers, and geographic location. Patients are typically seen for an hour initial evaluation; follow-up appointments are usually 30 minutes and can be as frequently as once a week or as infrequently as once every 4 to 6 weeks over the course of 4 to 6 months. Some patients are followed for up to one year.
During the initial physical therapy evaluation, the patient undergoes a complete examination of all zones of the face and neck, as well as a brief screening of other systems (e.g. posture, balance). The evaluation includes the use of photography and videography, as well as objective data analysis using the Facial Grading Scale, the FaCE instrument, and the Modified Synkinesis Survey. An individualized treatment program is then designed to address the patient’s specific impairments and functional limitations. The initial physical therapy treatment session is typically 45-60 minutes. The session includes education about the anatomy of the facial muscles, and the mechanism underlying synkinesis. An individualized home exercise program of soft tissue mobilization and neuromuscular retraining with mirror feedback is then provided, and is designed for the patient to do on their own at home.
The home exercise program only takes about 15-20 minutes and we typically advise that it initially be done at least 2x/day. More often may lead to more improvement. Think about it this way: practice, practice, practice. We are teaching your brain and your facial muscles to start working again in a very specific and intentional way. Prior to the facial nerve injury, your facial muscles worked automatically, often in response to your emotions. Now, we have to retrain those muscles, so the more you practice, the easier it will be to eventually move those muscles automatically. After the initial months of intense practice (i.e. 3-6 months), the recommended practice at home is 3-5x/week in order to maintain the motor control you just re-learned.
Quarterly team meetings are held to discuss individual cases. Physical therapy works closely with the team of doctors and nurses to ensure that the optimal treatment is provided. For example, after a 2-3 month trial of physical therapy exercises, botox treatment can be initiated.
*A comprehensive review of the literature supports the use of neuromuscular retraining, in both the acute stage (less than one year since injury or surgery) and in the post acute stages of recovery. The use of electrical stimulation to improve the motor control in the face is not recommended, and it is a treatment technique that is not supported in the literature.
Although neuromuscular retraining cannot restore perfect function, it can make a difference in facial muscle control with the ultimate goal of improved physical function, enhanced cosmesis, and increased self confidence. Functional outcomes that can be expected include improved ability to smile, eat, drink, speak clearly, and blink/close the eye.
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