An update to facial palsy and bells palsy. Based on our experience, evidence and our case report.

1. FACIAL PALSY- AN UPDATE
Prof. K Hari Ohm MPT
MSAJ collage of PT
The Indian centre for evidence
based Neuro- rehabilitation

2. Objectives
1. Update knowledge on
facial palsy
2. Understanding the
chronic facial palsy
3. Critically review the
treatment options

3. • Introduction• face and its function

4. 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

5. 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

6. Sensory motor function
• Face also play a major role in
– eye protection,
– eating,
– drinking
– speech.

7. 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

8. Attractiveness- symmetry

9. communication
Control Facial
expression
Voluntary
Involuntary
(Cortical)
(limbic system)
Context

10. 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.

11. Facial nerve lesions
1. Central lesions
2. Peripheral lesions

12. Central lesions-Supra-nuclear lesions
unilateral facial paralysis with forehead sparing.

13. Clinical and Anatomical Features of FacialNerve Damage

14. Central facial weakness
Cortical lesion- voluntary central facial weakness is
greater than mimetic central facial weakness

15. • LMN lesion of the
facial nerve

16. 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.

17. Bells palsy
When the cause of the peripheral facial weakness
cannot be determined, a diagnosis of Bell’s palsy is
made.

18. 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

19. RISK FACTORS/ etiology
•
•
•
•
Viral infection,
Vascular
Ischemia
Autoimmune diseases

20. 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.

21. 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

22. 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

23. 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

24. 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

25. LATER SYMPTOMS
•
•
•
•
Persistent Asymmetry
Hemispasms
Synkinesis
Psychological and social issues

26. 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

27. Synergy lookout for
closure of the eyes
while attempting facial
expression
Positive coping

28. 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).

29. Persistent asymmetry
Symmetry is the mark of attractiveness
Health

30. Asymmetrical face
Symmetrical face

31. • unanticipated pronunciation errors while
speaking, leaking of fluid or food while
drinking and eating especially in a social
context
• Asymmetry

32. 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.

33. 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.,

34. Treatment for bells palsy
A critical evaluation of the current treatment
option

35. 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 ?!

36. 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.

37. Exercise therapy
•
•
•
•
•
Simple movement retraining
Expression training- mime
Functional training
PNF?
Massage

38. 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” .

39. 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

40. • Mime – combination of mime and
physiotherapy
• Performing expression
• Can also be helpful in chronic facial paralysis

41. 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

42. 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

43. 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.

44. 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.

45. Functional training
• Still no clinical trial to prove effectiveness

46. 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

47. 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

48. 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.

49. Feedback
• Mirror feedback
• EMG feedback
• Lack of proprioceptors

50. Evidence Summary

51. • Not proven to be effective in UMN lesion
• LMN lesion may work

52. Strapping ?!

53. Education- assumptions and content
• Behaviour of the individual rather than
physical appearance can be instrumental in
influencing the response from other people
• Coping strategies

54. 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...

55. Synkinesis
• Most common areas of
injection are eye
muscles (orbicularis),
neck bands (platysma),
and chin dimpling
(mentalis).

56. Outcome measures

57. Outcome measures
• Content- all dimensions of the functions of the
face
• Disability after loss of facial function

58. House-Brackmann Scale
House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system.Otolaryngol. Head Neck Surg., 93,
146–147

60. 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

64. 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

65. Thank you