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Best practices for facial nerve palsy include synergistic, multidisciplinary care
Researchers recommended neuromuscular retraining physical therapy for patients with facial nerve palsy and said that care is best delivered in a multidisciplinary setting, according to a recent review in Current Opinion in Ophthalmology.
Facial neuromuscular retraining (NMR) therapy for the facial neuromuscular system is intended to improve function in patients with facial paralysis, paresis and/or synkinesis after facial nerve injury. The therapy aims to normalize resting tone and improve expression by limiting synkinetic movements. Patients are educated on understanding facial anatomy, which helps them isolate specific muscles.
Surface electromyography (sEMG) may be used to teach more accurate movement patterns.
Patients undergoing NMR practice an individual, daily program at home between sessions with a therapist.
“Although synkinesis is not expected to entirely disappear, more coordinated physiologic facial expressions are expected to emerge over time,” researchers wrote.
NMR has been successful in multiple cohorts in significantly improving objective measures of voluntary movements and facial symmetry compared to those receiving no therapy, according to the researchers. They recommend therapy for 18 months to 3 years. Good candidates for NMR are cognitively intact and are motivated to participate in therapy, they wrote.
Mime therapy, a form of physiotherapy, incorporates massage, awareness of facial tensions, mirror biofeedback and a series of exercises to coordinate the two halves of the face.
Massage can be used alone or in conjunction with other therapies to help alleviate tension, pain and soreness.
The researchers believe, “brief electrical stimulation could be detrimental to recovery by reinforcing synkinetic patterns.” They also recommend against gross facial exercises in the treatment of paralysis/paresis, which could lead to reinforcement of abnormal movements through the exercises.
Low-level facial laser treatment has been proposed as an adjunct, but the researchers cannot recommend this, “as there is lack of scientific rationale for the treatment,” they wrote.
Botulinum toxin is a popular and adequate method for treating facial synkinesis, although no botulinum toxin formulation has FDA approval for the indication.
The researchers recommend a period of at least 6 months of NMR prior to initiating botulinum toxin treatment. Treatment is best performed by a physician working closely with the patient’s therapist, they wrote. They also recommend 3- to 6-month intervals for botulinum toxin treatment to amplify and maintain the effects of NMR.
“The authors strongly believe in the synergy of NMR and botulinum toxin injections for synkinesis,” they wrote, despite a lack of strong data to support this.
It is generally believed that patients should undergo a trial of NMR prior to pursuing surgical intervention in cases where the facial nerve is intact, according to researchers.
“Physicians treating these patients should partner with a therapist who has received advanced training in the treatment of facial nerve disorders in order to optimize the response to medication and surgical interventions,” they wrote. – by Abigail Sutton
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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Lubricate, tape lids or patch during sleep, manage corneal involvement and treat underlying viral infections. These are the primary ways I was taught to manage facial nerve or Bell’s palsy. I’d recommend these and hope that the patient fell into the 70% who improved over time. But what about everyone else?
Van Landingham and colleagues recommend another option: NMR physical therapy. It aims to reduce muscle spasm and improve facial expression. It teaches patients how to use their facial muscles again via feedback. For some, botulinum toxin can be used after 6 months of NMR to boost and help maintain any progress made.
The authors state few drawbacks to NMR therapy. It has shown success in several cohorts. It improves quality of life and function and can help augment existing treatments. And it’s noninvasive and can be done at home. Integrating NMR into our multidisciplinary treatment regimen seems like it could be a win-win to me.