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On "Puckering and blowing facial expressions..." Denlinger RL, et al. Phys Ther. 2008;88:909–915.

First, although the authors noted that their participants were an average of 25 months from onset of the facial movement disorder, they did not note which patients were in the acute phase (which has a temporary hypotonic presentation) and which patients were in the residual phase (which can have a more stable hypertonic presentation with the presence of synkinesis or a stable hypotonic presentation such as the one seen at times after acoustic neuroma surgery). The importance in making this distinction is that, although the reason for the facial asymmetry in a hypotonic presentation is paresis of the orbicularis oris muscle of the involved side and/or overactivity of the contralateral side, the reason for the asymmetry in the hypertonic and synkinetic presentation often is a coactivation of the orbicularis oris together with the mouth depressors and the platysma muscle.

Second, because of the issue described in the first point, the use of only the video motion analysis system, regardless of how sophisticated the analysis is, will fail to recognize the difference between the hypertonic case, in which there is lack of motion due to coactivation of 2 muscle groups, and the hypotonic scenario, in which there is lack of motion because of paresis in the primary mover (in this case, the orbicularis oris muscle). To address this issue, the video analysis should be coupled with evaluation using surface electromyography (sEMG).

Third, because of the lack recognition of the hypertonic scenario (which probably represents the majority of cases in this study), the true implications of the phenomenon are perhaps missed by the authors. Taking into consideration synkinesis between the orbicularis oris muscle and the mouth depressors and platysma muscles, 2 possible theories should be further investigated:

1. In the blowing movement, the platysma muscle is normally activated; in the puckering movement, it is not. Therefore, while the coactivation is normal in one movement, it is abnormal in another and, therefore, there is greater asymmetry in the puckering movement (where the coactivation is abnormal) and less in the blowing movement (where there is coactivation in both sides of the face and, therefore, less asymmetry).
   
2. The second possible explanation is that, while in a puckering movement, the orbicularis oris is actively moving, in the blowing movement, the orbicularis oris is held in more of an isotonic contraction. From anecdotal observation of hundreds of patients with synkinesis, it could be clearly noted that synkinesis is more easily integrated (controlled) when the primary mover (in this case, the orbicularis oris muscle) is in isotonic contraction rather than actually moving. Therefore, greater asymmetry is produced in the puckering movement than in the blowing movement. As a matter of fact, this principle is widely used in our neuromuscular retraining protocol to create a "stepping stone" stage in the retraining of integration.
   

Adi Halili

A Halili, PT, DPT, is a physical therapist, Halili Physical Therapy, Tucson, Arizona.

	Footnotes

 
This letter was posted as a Rapid Response on August 6, 2008, at www.ptjournal.org.

Reference

1. Denlinger RL, Van Swearingen JM, Cohn JF, Schmidt KL. Puckering and blowing facial expressions in people with facial movement disorders. Phys Ther. 2008;88:909–915.[Abstract/Free Full Text]

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This Article Full Text (PDF) Submit a response Read responses to this article Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Halili, A. Search for Related Content PubMed PubMed Citation Articles by Halili, A. Related Collections Neurology/Neuromuscular System: Other Tests and Measurements Social Bookmarking                      What's this?