Facial Retraining – Introduction
NEW CONCEPTS IN NON-SURGICAL FACIAL NERVE REHABILITATION
H. Jacqueline Diels, OTR, Facial Rehabilitation Specialist
Neuromuscular Retraining Clinic, Dept. of Rehabilitation Medicine
University of Wisconsin Hospital and Clinics
“The face is the image of the soul.”1
Facial paralysis has been primarily considered a cosmetic inconvenience with associated functional problems. In reality, facial paralysis is a disability of communication. As human beings, our primary form of non-verbal communication relies upon minute changes in facial expression that reveal our innermost feelings. Just as an aphasic person cannot communicate verbally after a stroke, the patient with facial paralysis cannot convey the normal social signals of interpersonal communication. Although therapeutic treatment for aphasia is commonplace, by and large, non-surgical rehabilitation for facial paralysis has been neglected and patients have been “left to their own devices”.2 Those who work with facial paralysis patients are acutely aware of the need for rehabilitating both the physiological and psychosocial aspects of this disability. Restoring function and expression to the highest level possible results in improved health, self-esteem, self- acceptance, acceptance by others, and quality of life.
Neuromuscular retraining is gaining recognition as an effective element for optimal recovery from facial nerve paresis. Retraining techniques have been developed for treating sequelae that range from flaccidity to mass action and synkinesis, improving facial motor control and enhancing patient satisfaction and outcomes.
Neuromuscular retraining for facial paralysis is a growing field of practice in the U.S. and Canada.3 Physical, occupational and speech therapists trained specifically in facial neuromuscular retraining provide an important element in the continuity of care for the patient with facial paralysis.
Treatment begins with a thorough clinical evaluation. Realistic goals are established and a comprehensive, individualized home program is developed. This is accomplished through specific neuromuscular retraining techniques and augmented sensory feedback (including surface EMG) within an educational model.
This chapter will introduce the concept and practice of neuromuscular retraining for facial paralysis. Qualities that differentiate neuromuscular retraining from other non-surgical therapies will be discussed. Appropriate candidates for treatment will be identified and optimal timelines for referral presented. Specific techniques for treating flaccid paralysis as well as synkinesis will be outlined.
PHYSIOLOGICAL AND PSYCHOSOCIAL CONSEQUENCES OF FACIAL PARALYSIS
Loss of ability to move the face can be devastating. In a survey conducted by the Acoustic Neuroma Association, facial paralysis was reported to be the most significant problem experienced post acoustic neuroma resection.4 Psychological adjustment to facial paralysis varies with each individual5 and does not necessarily correlate with the degree of dysfunction. Depression, guilt, anger, hostility, anxiety, rejection and paranoia have been noted after facial paralysis.6 Patients may be considered mentally deficient7 and experience difficulties with interpersonal relationships, employability, making friends and coping with looks of disgust or horror in other’s faces.8
A variety of surgical procedures have been developed for rehabilitation of the face after paralysis including techniques designed to reduce synkinesis.2, 9-14 No method has been found that can restore normal expression.9 Though the integrity of the facial nerve may be intact postoperatively, its continuity is not necessarily an indicator of functional outcome15, and what may be thought of as a good result by the surgeon, may not be noted as such by the patient.16 The addition of neuromuscular retraining for further improving physical and psychological function in the patient with incomplete recovery is a natural complement to surgical treatment for refining facial movement.