Facial Plast Surg 2008; 24(2): 250-259
DOI: 10.1055/s-2008-1075841
© Thieme Medical Publishers

Facial Rehabilitation: A Neuromuscular Reeducation, Patient-Centered Approach

Jessie VanSwearingen1 , 2
  • 1Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Facial Nerve Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Further Information

Publication History

Publication Date:
09 May 2008 (online)

ABSTRACT

Individuals with facial paralysis and distorted facial expressions and movements secondary to a facial neuromotor disorder experience substantial physical, psychological, and social disability. Previously, facial rehabilitation has not been widely available or considered to be of much benefit. An emerging rehabilitation science of neuromuscular reeducation and evidence for the efficacy of facial neuromuscular reeducation, a process of facilitating the return of intended facial movement patterns and eliminating unwanted patterns of facial movement and expression, may provide patients with disorders of facial paralysis or facial movement control opportunity for the recovery of facial movement and function. We provide a brief overview of the scientific rationale for facial neuromuscular reeducation in the structure and function of the facial neuromotor system, the neuropsychology of facial expression, and relations among expressions, movement, and emotion. 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 enhancing the recovery of facial expression and function in a patient-centered approach to facial rehabilitation.

REFERENCES

  • 1 Bateman D E. Facial palsy.  Br J Hosp Med. 1992;  47 430-431
  • 2 Ohye R G, Altenberger E A. Bell's palsy.  Am Fam Physician. 1989;  40 159-166
  • 3 Brudny J, Hammerschlag P E, Cohen N L et al.. Electromyographic rehabilitation of facial function and introduction of a facial paralysis grading scale for hypoglossalfacial nerve anastomosis.  Laryngoscope. 1988;  98 405-410
  • 4 Ekman P. Psychosocial aspects of facial paralysis. In: May M The Facial Nerve. New York, NY; Thieme Medical Publishers 1986: 781-787
  • 5 Neely J G, Neufeld P S. Defining functional limitation, disability, and societal limitations in patients with facial paresis: initial pilot questionnaire.  Am J Otol. 1996;  17 340-342
  • 6 Ross B, Nedzelski J M, McLean J A. Efficacy of feedback training in longstanding facial nerve paresis.  Laryngoscope. 1991;  101 744-750
  • 7 Twerski A J, Twerski B. The emotional impact of facial paralysis. In: May M The Facial Nerve. New York, NY; Thieme Medical Publishers 1986: 788-794
  • 8 Brach J S, VanSwearingen J M, Lenert J, Johnson P C. Facial neuromuscular retraining for oral synkinesis.  Plast Reconstr Surg. 1997;  99 1922-1933
  • 9 Brown D M, Nahai F, Wolf S et al.. Electromyographic biofeedback in the re-education of facial palsy.  Am J Phys Med. 1978;  57 183-190
  • 10 Hammerschlag P E, Brudny J, Cusumano R et al.. Hypoglossal-facial nerve anastomosis and electromyographic feedback rehabilitation.  Laryngoscope. 1987;  97 705-709
  • 11 Jankel W R. Bell's palsy: muscle re-education by electromyographic feedback.  Arch Phys Med Rehabil. 1978;  59 240-242
  • 12 Schram G, Burres S. Nonsurgical rehabilitation after facial paralysis: a 25 year study. In: Portmann M Facial Nerve. New York, NY; Masson 1981: 461-462
  • 13 Walravens S. Using EMG biofeedback in the treatment of facial paralysis.  Acta Otorhinolaryngol Belg. 1986;  40 174-177
  • 14 VanSwearingen J M, Brach J S. Changes in facial movement and synkinesis with facial neuromuscular reeducation.  Plast Reconstr Surg. 2003;  111 2370-2375
  • 15 Diels H J. New concepts in nonsurgical facial nerve rehabilitation. In: Meyers E Advances in Otolaryngology Head and Neck Surgery. Chicago, IL; Mosby Year Book, Inc. 1995 9: 289-315
  • 16 Deleyiannis F W, Akari M, Schmidt K L, Henkelmann T C, Swearingen J M, Manders E K. Muscle activity in the partially paralyzed face after placement of a fascial sling.  Ann Plast Surg. 2005;  55 449-455
  • 17 Manikandan N. Effect of facial neuromuscular re-education on facial symmetry in patients with Bell's palsy: a randomized controlled trial.  Clin Rehabil. 2007;  21 338-343
  • 18 Brodal A. Neurological Anatomy in Relation to Clinical Medicine. Third ed. New York, NY; Oxford University Press 1981
  • 19 Schmidt K L, VanSwearingen J M, Levenstein R M. Speed, amplitude, and asymmetry of lip movement in voluntary puckering and blowing expressions: implications fo facial assessment.  Motor Control. 2005;  9 270-280
  • 20 Baumel J J. Trigeminal-facial nerve communications.  Arch Otolaryngol. 1974;  99 34-44
  • 21 Brudny J. Biofeedback in facial paralysis: electromyographic rehabilitation. In: Rubin L The Paralyzed Face. St. Louis, MO; Mosby Yearbook 1991: 247-264
  • 22 Burgess P R, Wei J Y, Clark F J et al.. Signaling of kinesthetic information by peripheral sensory receptors.  Annu Rev Neurosci. 1982;  5 171-187
  • 23 Rinn W E. The neuropsychology of facial expression: a review of the neurological and psychological mechanisms for producing facial expressions.  Psychol Bull. 1984;  95 52-77
  • 24 Ekman P, Friesen W V. Measuring facial movement.  Environ Psychol Nonverb Behav.. 1976;  1 56-75
  • 25 Schwartz G E, Fair P L, Salt P et al.. Facial muscle patterning to affective imagery in depressed and nondepressed subjects.  Science. 1976;  192 489-491
  • 26 Tomkins S S. Affect, Imagery, and Consciousness: Vol. I. The Positive Effects. New York, NY; Springer 1960
  • 27 VanSwearingen J M, Cohn J F, Turnbull J, Mrzai T, Johnson P C. Psychological distress: linking impairment with disability in facial neuromuscular disorders.  Otolaryngol Head Neck Surg. 1998;  118 790-796
  • 28 Merkel K E, Schmidt K L, Levenstein R M, VanSwearingen J M, Bentley B C. Positive affect predicts improved lip movement in facial movement disorder.  Otolaryngol Head Neck Surg. 2007;  137 100-104
  • 29 VanSwearingen J M, Cohn J F. Smiling in facial paralysis. In: Beurskens CHG, vanGelder RS, Heymans PG, Manni JJ, Nicolai JPA The Facial Palsies: Complementary Approaches. Utrecht, The Netherlands; LEMMA Publishers 2005: 373-386
  • 30 VanSwearingen J M, Cohn J F, Bajaj-Luthra A. Specific impairment of smiling increases the severity of depressive symptoms in patients with facial neuromuscular disorders.  Aesthetic Plast Surg. 1999;  23 416-423
  • 31 MacGregor F C. Facial disfigurement: problems and management of social interaction and implications for mental health.  Aesthetic Plast Surg. 1990;  14 249-257
  • 32 Byrne P J. Importance of facial expressio in facial nerve rehabilitation.  Curr Opin Otolaryngol Head Neck Surg. 2004;  12 332-335
  • 33 Schmidt K L, VanSwearingen J M, Levenstein R M. Speed, amplitude, and asymmetry of lip movement in voluntary puckering and blowing expressions: implications fo facial assessment.  Motor Control. 2005;  9 270-280
  • 34 Waxman B. Electrotherapy for treatment of facial paralysis (Bell's palsy). Health Technology Assessment Reports. 3rd ed. National Centre for Health Services Research, US Dept of Health 1984: 27
  • 35 Miehlke A, Stennert E, Chilla R. New aspects in facial narve surgery.  Clin Plast Surg. 1979;  6 451-470
  • 36 Mosforth J, Taverner D. Physiotherapy for Bell's palsy.  BMJ. 1958;  2 675-677
  • 37 Jansen J K, Lomo T, Nicolaysen K, Westgaard R H. Hyperinnervation of skeletal muscle fibers: dependence on muscle activity.  Science. 1973;  181 559-561
  • 38 Cohan C S, Kater S B. Suppression of neurite elongation and growth cone motility by electrical activity.  Science. 1986;  232 1638-1640
  • 39 Brown M C, Holland R L. A central role for denervated tissues in causing nerve sprouting.  Nature. 1979;  282 724-726
  • 40 Farragher D, Kidd G L, Tallis R. Eutrophic electrical stimulation for Bell's palsy.  Clin Rehabil. 1987;  1 265-271
  • 41 Cole J, Zimmerman S, Gerson S. Nonsurgical neuromuscular rehabilitation of facial muscle paresis. In: Rubin LR The Paralyzed Face. St. Louis, MO; Mosby 1991: 107-112
  • 42 Balliet R. Facial paralysis and other neuromuscular dysfunctions of the peripheral nervous system. In: Payton OD Manual of Physical Therapy Techniques. New York, NY; Churchill Livingston 1989: 41-76
  • 43 Moldaver J. Mimetic muscles and variations of expressions. In: Moldaver J, Conley J, Brown D The Facial Palsies: Their Physiopathology and Therapeutic Approaches. Springfield, IL; Charles C. Thomas Books 1980: 11-19
  • 44 Segal B, Hunter T, Danys I, Freedman C, Black M. Minimizing synkinesis during rehabilitation of the paralyzed face; preliminary assessment of a new small-movement therapy.  J Otolaryngol. 1995;  24 149-153
  • 45 Balliet R, Shinn J B, Bach-y-Rita P. Facial paralysis rehabiitation: retraining selective muscle control.  Int Rehabil Med. 1982;  4 67-74
  • 46 Brach J S, VanSwearingen J, Delitto A, Johnson P C. Impairment and disability in patients with facial neuromuscular dysfunction.  Otolaryngol Head Neck Surg. 1997;  117 315-321
  • 47 VanSwearingen J M, Brach J S. Validation of a treatment-based classification system and tailored treatment approach for individuals with facial neuromotor disorders.  Phys Ther. 1998;  78 678-689
  • 48 Delitto A, Erhard R E, Bowling R W. A treatment-based classification approach to low back syndrome: Identifying and staging patients for conservative treatment.  Phys Ther. 1995;  75 470-489
  • 49 Jette A M. Diagnosis and classification by physical therapists: a special communication.  Phys Ther. 1989;  69 967-969
  • 50 Buchbinder R, Goel V, Bombardier C, Hogg-Hohnson S. Classification systems of soft tissue disorder of the neck and upper limb: Do they satisfy methodological guidelines?.  J Clin Epidemiol. 1996;  49 141-149
  • 51 Sackett D L, Haynes R B, Guyatt G H, Tugwell P. Clinical Eipdemiology. Second ed. Boston, MA; Little Brown 1991
  • 52 Andersen R G, Newsom H T. Facial nerve disorders.  Selected Readings Plastic Surgery.. 1987;  4 1-28
  • 53 Borodic G E, Cozzolino D. Blepharospasm and its treatment, with emphasis on the use of botulinum toxin.  Plast Reconstr Surg. 1989;  83 546-554
  • 54 May M. Facial nerve disorders.  Am J Otol. 1982;  4 77-87
  • 55 May M, Croxson G R, Klein S R. Management of sequalae using EMG rehabilitation, botulinum toxin and surgery.  Am J Otol. 1989;  10 220-229
  • 56 Brook R H, Kamberg C J. General health status measures and outcome measurement: a commmentary on measuring functional status.  J Chronic Dis. 1987;  1 131-165
  • 57 World Health Organization .International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland; World Health Organization 1980
  • 58 Ross B G, Fradet G, Nedzelski J M. Development of a sensitive clinical facial grading system.  Otolaryngol Head Neck Surg. 1996;  114 380-386
  • 59 VanSwearingen J M, Brach J S. The facial disability index: reliability and validity of a disability assessment instrument for disorders of the facial neuromuscular system.  Phys Ther. 1996;  76 1288-1300
  • 60 Ware J E, Sherbourne C D. The MOS 36-item short-form health survey (SF-36).  Med Care. 1992;  30 473-483
  • 61 Jacobson E. Progressive Relaxation. Second ed. Chicago, IL; University of Chicago Press 1938
  • 62 Ekman P, Friesen W V. Facial Action Coding System. Palo Alto, CA; Consulting Psychological Press 1978
  • 63 Ekman P. Symposium on emotion. Facial expressions of emotion: new findings, new questions.  Psychol Sci. 1992;  3 34-38
  • 64 Levenson R W, Ekman P, Friesen W V. Voluntary facial action generates emotion-specific autonomic nervous system activity.  Psychophysiology. 1990;  27 363-384
  • 65 Bender M B, Bruyn G W, Vinken P J. Disorders of eye movements. In: Vinken, Bruyn Handbook of Clinical Neurology. Amsterdam, The Netherlands; North-Holland 1969: 574-630
  • 66 Bender M B. Comments on the physiology and pathology of eye movements in the vertical plane.  J Nerv Ment Dis. 1960;  130 156-166
  • 67 Esteban A, Salinero E. Reciprocal reflex activity in ocular muscels: implications in spontaneous blinking and Bell's phenomenon.  Eur Neurol. 1979;  18 157-165
  • 68 VanSwearingen J, Henkelmann T C, Wachtman G S, Manders E K, Cohn J F. Evidence for neuromuscular reeducation of eye closure in persons with facial palsy. (Abstract) presented at: Science 2005, University of Pittsbugh, Pittsbugh, PA 2005
  • 69 Brooks V B. The Neural Basis of Motor Control. New York, NY; Oxford University Press 1986

Jessie VanSwearingenPh.D. P.T. 

University of Pittsburgh, Department Physical Therapy, 6035 Forbes Tower

Pittsburgh, PA 15260