Background The Facial Grading Scale (FGS) is a quantitative instrument used to evaluate facial function after facial nerve injury. However, quantitative improvements in function after facial rehabilitation in people with chronic facial paralysis have not been shown.
Objective The objectives of this study were to use the FGS in a large series of consecutive subjects with facial paralysis to quantitatively evaluate improvements in facial function after facial nerve rehabilitation and to describe the management of chronic facial paralysis.
Design The study was a retrospective review.
Methods A total of 303 individuals with facial paralysis were evaluated by 1 physical therapist at a tertiary care facial nerve center during a 5-year period. Facial rehabilitation included education, neuromuscular training, massage, meditation-relaxation, and an individualized home program. After 2 months of home exercises, the participants were re-evaluated, and the home program was tailored as necessary. All participants were evaluated with the FGS before the initiation of facial rehabilitation, and 160 participants were re-evaluated after receiving treatment. All participants underwent the initial evaluation at least 4 months after the onset of facial paralysis; for 49 participants, the evaluation took place more than 3 years after onset.
Results Statistically significant increases in FGS scores were seen after treatment (P<.001, t test). The average initial score was 56 (SD=21, range=13–98), and the average score after treatment was 70 (SD=18, range=25–100).
Limitations A limitation of this study was that evaluations were performed by only 1 therapist.
Conclusions For 160 patients with facial paralysis, statistically significant improvements after facial rehabilitation were shown; the improvements appeared to be long lasting with continued treatment. The improvements in the FGS scores indicated that patients can successfully manage symptoms with rehabilitation and underscored the importance of specialized therapy in the management of facial paralysis.
People with long-standing facial paresis experience facial disfigurement and psychological difficulties and may be unable to convey emotions through facial expressions.1 These people often have been told by health care providers that nothing further can be done to improve their facial movements. Many treatments have been used to manage the evolving clinical presentation of facial paralysis as it progresses from the flaccid face to a hypotonic or hypertonic state. Electrical stimulation and regimens of facial movement exercises to be performed with maximal effort are common recommendations; however, both approaches are thought by some clinicians to be harmful, perhaps leading to increased synkinesis.2,3 More recently, facial neuromuscular retraining designed to address the synkinesis associated with partial recovery from facial paralysis2,4–7 has been shown to benefit people with facial nerve disorders. However, a validated instrument has not been used to quantitatively measure results in a large series of patients.
The Facial Grading Scale (FGS) is a quantitative instrument used by clinicians to evaluate and monitor facial function after facial nerve insult. The FGS is a reliable and validated tool that measures facial dysfunction by scoring resting symmetry, active motion, and synkinesis, the phenomenon of aberrant regeneration.2,8,9 Despite anecdotal evidence to suggest the benefit of facial rehabilitation, to date there is no quantitative evidence to support the use of comprehensive therapies, such as neuromuscular reeducation, soft-tissue mobilization of the facial muscles, and meditation-relaxation strategies.10
Our objectives were to evaluate a large series of subjects with prolonged facial dysfunction in a facial nerve center setting, to quantitatively evaluate (with FGS scores) improvements after comprehensive facial retraining, and to describe the physical therapy techniques used for these patients.
A retrospective chart review was performed for all patients who were referred to a multidisciplinary facial nerve center (Massachusetts Eye and Ear Infirmary Facial Nerve Center) from October 2003 through October 2008 and who received evaluation and treatment by 1 facial nerve physical therapist (M.R.). All patients were evaluated at the facial nerve center by a facial plastic surgeon; the evaluation included a thorough history, physical examination, still photography, and video analysis. Patients who continued to have poor recovery of facial nerve function at least 4 months after the insult were referred for physical therapy evaluation and measurement with the FGS.9 Pretreatment and posttreatment FGS scores were analyzed with paired 1-tailed t tests.
Of the 990 patients evaluated at the Massachusetts Eye and Ear Infirmary Facial Nerve Center during the 5-year period, 303 were evaluated by 1 facial nerve physical therapist. These 303 patients were evaluated with the FGS before the initiation of physical therapy, and 160 were re-evaluated after receiving treatment; all underwent the initial evaluation at least 4 months after the onset of facial paralysis. Of the 160 patients for whom pretreatment and posttreatment FGS scores were available, 23% were male (n=37) and 77% were female (n=123). The average age of the participants was 46 years (SD=17, range=6–81).
Facial Rehabilitation Interventions
The initial therapy session for all participants included education on the anatomy of the facial nerve and musculature and synkinesis. Instructions on eye protection were provided; these instructions included an eyelid stretch of the levator palpebrae superioris muscle. In addition, participants’ expectations for recovery were discussed.
Next, the FGS score was determined by the facial nerve physical therapist. The FGS was used to categorize the face into 5 main regions—brow, ocular region, oral commissure, nasal region, and lips—and to identify the areas of asymmetry and dysfunction. The facial regions were further classified as being flaccid, as having active motion without synkinesis, or as having active motion with synkinesis and hypertonicity. This process allowed appropriate placement into 1 of 4 treatment classification categories: initiation, facilitation, movement control, and relaxation11,12 (Fig. 1; see video).
Initiation treatment category.
Participants who had moderate to severe facial asymmetry at rest, who had flaccid facial regions, and who were unable to initiate movement on the affected side were placed in the initiation treatment category.11 Participants in this category were given instructions on gentle superficial massage and active assistive movement exercises and were advised to avoid mass movement patterns (ie, avoid overuse of the uninvolved side, such as by forming a wide smile or chewing gum).
Facilitation treatment category.
Participants who had mild to moderate facial asymmetry at rest, who were able to initiate slight movement (scores of >2 on the voluntary movement section of the FGS) in any or all regions of the face, and who did not have synkinesis were placed in the facilitation treatment category.11 For these participants, the physical therapy approach had 2 parts: more aggressive soft tissue mobilization of the facial muscles and platysma muscle and neuromuscular reeducation in front of a mirror.
First, the participants were given instructions on an individualized soft tissue stretch of the involved musculature. Most participants required attention to the midface, specifically the zygomaticus major and minor muscles. At follow-up appointments, the soft tissue stretching regimen was broadened to involve the upper and lower facial regions. Second, neuromuscular re-education exercises were prescribed on the basis of a participant's impairments of facial motor control, with emphasis on small movements to gain symmetry between the affected and unaffected sides of the face. The strategy used in neuromuscular re-education for this category was to instruct the participants to perform slow, controlled, graded facial expressions to generate symmetry between the sides of the face. It was imperative that the participants initially performed these small-movement exercises with a mirror for visual feedback. Proprioceptive input regarding movement is lacking in facial muscles because they have few, if any, spindle fibers. Thus, visual feedback from the mirror regarding facial movements was necessary for the participants to appreciate the simultaneous motor control of the small facial muscles. Electromyographic biofeedback also was used to guide the appropriate muscle action to produce symmetry.13 Participants were informed that some typical abnormal movement patterns (synkinesis) might develop with increasing movement. The recognition of any synkinetic movement warranted prompt return to the center so that the participants could be taught how to avoid unwanted movement patterns.
Movement control category.
Participants who had mild to moderate facial asymmetry at rest and were able to initiate at least slight movement (scores of >2 on the voluntary movement section of the FGS) in any or all regions of the face, but who had developed synkinesis, were placed in the movement control category. For these participants, the physical therapy approach had 3 parts: aggressive deep soft tissue mobilization of the facial muscles and neck, neuromuscular re-education in front of a mirror, and the initiation of meditation-relaxation strategies. The primary cause of facial asymmetry in the movement control group was synkinesis, not weakness, as in the facilitation group. Nevertheless, the physical problems were similar, arising largely from abnormal movement patterns. Therefore, the strategy used in neuromuscular re-education for this category was to instruct the participants to perform slow, controlled, graded facial expressions to generate symmetry between the sides of the face while simultaneously controlling synkinetic movements in other regions of the face. For example, when participants complained of ocular synkinesis with smiling or puckering their lips for eating, drinking, or talking, small-movement exercises were taught. They were trained to form a small, symmetric smile while controlling synkinesis of the obicularis oris muscle by widening the orbital region. For midfacial synkinesis, the participants were instructed to gently close their eyes while releasing the synkinesis in the midface. When participants developed synkinesis of the platysma muscle, soft tissue massage of the platysma muscle and active practice in minimizing the synkinesis were used to prevent the overactive depressor function of the platysma muscle from overcoming the effort of the impaired zygomaticus muscle. At follow-up visits, the neuromuscular re-education exercises were advanced to teach the participants how to control other zones of the face while still minimizing synkinesis.
Participants with severe pan-facial tightness attributable to synkinesis and hypertonicity were placed in the relaxation category. For these individuals, the physical therapy approach had 3 parts: aggressive deep soft tissue mobilization of the facial muscles and neck, neuromuscular re-education in front of a mirror, and a strong focus on meditation-relaxation strategies. These participants had limited movement because of tightness rather than weakness. Therefore, the emphasis of treatment for these participants was on relaxation-meditation exercises. Meditation with guided visual imagery was focused on relieving the tension in the synkinetic musculature. Verbal cues to help minimize synkinesis included “drain the tension around the eye” (ie, for ocular synkinesis) and “deflate the fully inflated balloon in your cheek” (ie, for midfacial synkinesis felt during closing of the eyes). In addition, our clinic provided participants with a relaxation audio CD to facilitate integration of the relaxation strategies at home.
The typical guideline for neuromuscular re-education exercises was 20 to 40 repetitions 2 to 4 times per day. However, more frequent repetition was encouraged, the notion being that repetition improves motor learning.3 The guideline for soft tissue massage was 10 repetitions 1 or 2 times per day. The frequency of relaxation was 1 or 2 times per day. Monthly or bimonthly appointments were scheduled well ahead of time to tailor and further advance a participant's home program and to reevaluate impairments and functional goals. Frequently, a participant's treatment category changed as movement returned or synkinesis developed, requiring changes in the treatment regimen.
All participants who developed synkinesis were considered to be eligible to receive chemodenervation for the further management of synkinesis; this technique has been shown to improve the quality of life in subjects with facial paralysis.14 Botulinum toxin is a potent neurotoxin that causes temporary paralysis of the hyperkinetic musculature. The philosophy at the Massachusetts Eye and Ear Infirmary Facial Nerve Center is for patients to participate in facial muscle retraining for a minimum of 16 weeks before the initiation of botulinum toxin injections.15 The premise underlying this philosophy is that patients gain an appreciation of the role of each muscle in the face and an understanding of how synkinesis affects their facial expressions.
Figure 2 summarizes the etiologies of facial nerve paralysis. The average initial FGS score was 56 (SD=21, range=13–98), and the average score after treatment was 70 (SD=18, range=25–100). Statistically significant increases in FGS scores were seen after treatment (P<.005, paired 1-tailed t test) (Fig. 3). Forty-nine participants were evaluated more than 3 years after the onset of facial paralysis. For this subset of subjects, the average initial FGS score was 55 (SD=20, range=32–90), and the average score after treatment was 67 (SD=17, range=41–94); these values indicated significant improvements after therapy (P<.001, paired 1-tailed t test).
Eighty-seven participants had Bell palsy. For this subset of participants, the average initial FGS score was 60 (SD=21, range=13–98), and the average score after treatment was 75 (SD=17, range=25–100). Statistically significant increases in FGS scores were seen after treatment (P<.001, paired 1-tailed t test). Twenty-three participants were evaluated after acoustic neuroma removal. For these participants, the average initial FGS score was 50 (SD=22, range=20–93), and the average score after treatment was 65 (SD=17, range=35–95). Eleven participants had Ramsay Hunt syndrome. For this subset of participants, the average initial FGS score was 54 (SD=19, range=46–88), and the average score after treatment was 66 (SD=19, range=46.5–98.5). Statistically significant increases in FGS scores were seen after treatment (P<.001, paired 1-tailed t test) for both participants with acoustic neuroma and participants with Ramsay Hunt syndrome. In addition, 7 participants diagnosed with Lyme disease showed statistically significant improvements after therapy (P<.001, paired 1-tailed t test). For this subset of participants, the average initial FGS score was 63 (SD=20, range=30.5–82.5), and the average score after treatment was 76 (SD=12, range=61.0–89.5). Figure 4 shows the appearance of a typical participant before treatment and after treatment (physical therapy and chemodenervation).
Several investigators have attempted to examine the effects of physical therapy on Bell palsy; however, recent reviews have not established convincing evidence to support integrating physical therapy into clinical practice.9,16 One randomized controlled trial did show a statistically significant improvement in facial symmetry with neuromuscular re-education in participants with Bell palsy; however, the control group was treated with electrostimulation, which might have impaired recovery.3,5 In addition, the initial FGS scores were obtained at the onset of facial paralysis, and the posttreatment scores were obtained after 3 months; up to 95% of participants would be expected to recover during this time period without physical therapy if treated with prednisone and valacyclovir.17
In the present study, a subset of participants with poor recovery of function after Bell palsy were evaluated and treated by a physical therapist at least 4 months after the onset of paralysis. Ten percent of people with Bell palsy never regain normal function, and 5% to 15% experience severe sequelae, including residual paralysis, facial contracture, synkinesis, or spasm.1,17,18 Using FGS scores, we showed a quantitative benefit of comprehensive facial rehabilitation for participants who failed to recover from either Bell palsy or other facial nerve insults during an adequate observation period (4 months).
Incomplete or aberrant recovery affects some people with delayed recovery after facial paralysis. Our study established the benefit of standardized, well-documented facial rehabilitation for both participants with Bell palsy and participants with chronic facial paralysis of other etiologies. On the basis of our observations, participants with minimal clinical signs of recovery after 16 weeks tended to lag significantly behind those with earlier recovery. We have repeatedly noted delayed recovery with a high degree of synkinesis in people who have skull base tumors and in whom the facial nerve is left anatomically intact but does not stimulate movement at the conclusion of extirpation, as in people with Ramsay Hunt syndrome and Lyme disease. Even in people with a poor prognosis for recovery of facial function, physical therapy was found to increase FGS scores. We also noted that many participants benefited from physical therapy even when their facial nerve insults had occurred more than 3 years before the initiation of physical therapy. In fact, of the 160 participants for whom FGS scores before and after therapy were available, 49 participants were beyond the 3-year time frame (range=3–30 years), suggesting that there is no impairment beyond which a window for nerve recovery does not exist.
The significant quantitative improvements in FGS scores that we found with facial rehabilitation support the integration of physical therapy into the treatment strategy for people with poor recovery after facial nerve insults. Training therapists in subspecialties to adequately treat this underserved patient population would likely provide significant benefits.
Facial rehabilitation with neuromuscular re-education, soft tissue mobilization of the facial muscles, meditation-relaxation strategies, and chemodenervation, when needed, resulted in statistically significant improvements in participants with chronic facial paralysis; the improvements appeared to be long lasting with continued treatment. Improvements in FGS scores indicate that people can successfully manage symptoms with comprehensive interventions and highlight the importance of specialized physical therapy in the management of facial paralysis and teaching people self-management strategies. Thus, facial rehabilitation should be offered to people with chronic facial dysfunction to optimize their facial movements, their social functioning, and their facial expression of emotions. Facial rehabilitation should be delivered by a provider skilled in neuromuscular reeducation to manage the complex and changing needs of people with facial paralysis.
All authors provided concept/idea/research design, writing, data collection, data analysis, and consultation (including review of manuscript before submission). Dr Lindsay and Ms Robinson provided project management. Ms Robinson and Dr Hadlock provided subjects. Dr Hadlock provided facilities/equipment.
This study was approved by the Institutional Review Board at the Massachusetts Eye and Ear Infirmary.
This work was presented at the XI International Facial Nerve Symposium; April 25–28, 2009; Rome, Italy.
- Received May 29, 2009.
- Accepted September 21, 2009.
- © 2010 American Physical Therapy Association