Physiotherapy in Patients With Facial Nerve

Paresis: Description of Outcomes

Carien H.G. Beurskens, PT, PhD,* and Peter G. Heymans, PhD

Purpose: The purpose of this study was to describe changes and stabilities of long-term
sequelae of facial paresis in outpatients receiving Mime therapy, a form of physiother-
apy.
Material and Methods: Archived data of 155 patients with peripheral facial nerve paresis
were analyzed. Main outcome measures were (1) impairments: facial symmetry in rest and
during movements and synkineses; (2) disabilities: eating, drinking, and speaking; and (3)
quality of life.
Results: Symmetry at rest improved significantly; the average severity of the asymmetry in
all movements decreased. The number of synkineses increased for 3 out of 8 movements;
however, the group average severities decreased for 6 movements; substantially fewer
patients reported disabilities in eating, drinking, and speaking; and quality of life improved
significantly.
Conclusion: During a period of approximately 3 months, significant changes in many
aspects of facial functioning were observed, the relative position of patients remaining stable
over time. Observed changes occurred while the patients participated in a program for facial
rehabilitation (Mime therapy), replicating the randomized controlled trialproven benefits of
Mime therapy in a more varied sample of outpatients.
(Am J Otolaryngol 2004;25:394-400. 2004 Elsevier Inc. All rights reserved.)

This report describes the results of the clin-
ical application of a modality of physiother-
apy, Mime therapy, in patients with periph-
eral facial nerve paresis. Pre- and posttherapy
data from these patients, collected over a de-
cade, were systematically explored for signals
that Mime therapy was followed by an im-
provement in sequelae. Such signals are de-
scribed later; they have shaped a randomized
controlled trial (RCT), in which Mime therapy
was shown to be an effective tool for facial
rehabilitation.1 The present study, although
completed 1 year before the RCT started, is of
interest to clinicians because it replicates the
Mime therapyinduced changes found in the
RCT in the setting of an outpatient clinic. A
larger group of patients was followed; indica-
tions, previous treatments, commencement of
From the *Department of Physiotherapy, University
Medical Centre, Nijmegen, The Netherlands; and De-
partment of Developmental Psychology, Utrecht Uni-
versity, Utrecht, The Netherlands.
Address correspondence to Carien H.G. Beurskens,
PT, PhD, PO Box 9101, 6500 HB Nijmegen, The Neth-
erlands. E-mail: c.beurskens@fysioth.umcn.nl
2004 Elsevier Inc. All rights reserved.
0196-0709/$ - see front matter
doi:10.1016/j.amjoto.2004.04.010
therapy, and treatment session frequencies
were more varied. Stabilities, changes, and
their eventual predictors will be reported con-
cerning sequelae of facial nerve paralysis in-
cluding impairments, disabilities, and quality
of life.
BACKGROUND
A peripheral facial nerve paralysis is a
paralysis of the muscles innervated by the
seventh cranial nerve caused by a lesion
located in the peripheral part of the nerve.
The cause of the paralysis is in approxi-
mately 50% of cases a Bells palsy. Other
etiologies of facial paralysis can be herpes
zoster, traumatic injury, operative trauma,
otitis media, and so on. The incidence of
Bells palsy in the Netherlands, as described
by Devriese et al2 in 1990, is estimated at
approximately 20:100,000 per year. In ap-
proximately 70% of the patients with a
Bells palsy, the voluntary motor function
spontaneously normalizes,3,4 mostly within
3 months. The other 30% of patients remain
with a paresis with sequelae varying from
very mild to very severe.

394 American Journal of Otolaryngology, Vol 25, No 6 (November-December), 2004: pp 394-400

FACIAL NERVE PARESIS
PHYSIOTHERAPY IN PATIENTS WITH
FACIAL NERVE PARESIS: STATE OF THE
ART
Although there have been several reports
indicating the success of physiotherapy in pa-
tients with facial nerve paresis, few scientific
evidence is available. In a review5 covering
1958 to 1991 concerning the effects of phys-
iotherapy in patients with peripheral facial
nerve paresis, only 1 RCT was found among
70 articles.6 This RCT showed no significant
effect of electrotherapy. The non-RCT studies
indicated benefits from exercise therapy,
biofeedback, low-frequency electrotherapy,
and massage. A literature search in Medline
and Cinahl covering the period 1991 to 2001,
revealed 2 RCTs performed by Ross et al7 and
Segal et al8 claiming significant improve-
ments using biofeedback and exercise ther-
apy.
Since 1980, patients with peripheral facial
nerve paresis have been treated at the Physio-
therapy Department, University Medical Cen-
tre Nijmegen with Mime therapy aimed at the
rehabilitation of facial expression.9,10 This re-
port is based on archived data covering a
decade (1987-1997) and consists of pre- and
posttreatment analyses of 175 patients treated
with Mime therapy.
Mime therapy was developed approxi-
mately 25 years ago in Amsterdam by the late
Jan Bronk, mime actor, and Pieter Devriese,
otolaryngologist. Mime therapy is a combina-
tion of stimulation of facial expression, func-
tional movements, and relaxation techniques
including breathing control.11 The aim of the
treatment is to promote symmetry of the face
at rest and during movement, the patient be-
ing taught to simultaneously control synkine-
ses or mass movements.
MATERIALS AND METHODS
Patients Files
Physiotherapy files from patients with peripheral
facial nerve paresis, treated with Mime therapy at
the outpatient clinic of the Physiotherapy Depart-
ment of the University Medical Center Nijmegen
between 1987 and 1998, served as database for this
study. These files contained a letter from the gen-
eral practitioner or referring specialist, anamnesis
and patient well-being reported at beginning and
395
end of the treatment, and the physiotherapist re-
corded observations and tests at beginning and end
of the treatment. Incomplete files were excluded, as
well as files from patients with recent onset of
paresis (3 months) and from patients receiving
concurrent treatments.
Mime Therapy
Patients were treated with Mime therapy, which
consists of information concerning treatment and
prognosis, automassage of face and neck (a combi-
nation of effleurages, kneading, and muscle
stretching); and breathing and relaxation exercises.
Relaxing the face requires relaxation of the whole
body, and expiration exercises are used to create
relaxation. Specific exercises are taught to co-ordi-
nate both halves of the face and to decrease syn-
kineses. These consist of controlled executions of
slow and small movements of the various parts of
the face, exercises for eye and lip closure, letter and
word exercises, and emotional expression exer-
cises.
A mirror is used as a feedback device. The num-
ber of treatment sessions is on average 10, each
session lasting approximately 45 minutes; the pa-
tient attends once weekly or less. Follow-up treat-
ment is usually planned after 3 or 6 months. Pa-
tients have to execute homework on a daily basis,
assisted by a homework book.12
Methods and Analyses
Participants and Handling of Archival Data. The
hospital archives contained the files of 203 patients
treated by Mime therapy in the decade 1987 to
1997. Previous files were not available because
they had been destroyed as part of the hospital
privacy policy. As many patients as possible were
required to have maximal variance in our data set.
However, for only 175 patients was their file com-
plete; 20 of these patients had a paresis with a
duration of less than 4 months. Each complete file
contained information collected at the first and last
treatment session concerning 3 groups of variables:
demographic variables (age and sex); medical
variables (diagnosis, affected side and previous
therapies); and variables reflecting impairments,
disabilities, and quality of life. For this last group
of variables, information was extracted from a
standardized form in the file containing items
with verbally graded categories scored at patient
encounter. At the end of 1997, all graded infor-
mation was translated into numerical codes by a
physiotherapist (first author) for analysis by
the SPSS-package (Statistical Package for the So-
cial Sciences, SPSS Inc, Chicago, IL); the second
author checked a sample of patient codes.
Instruments. The House-Brackmann Facial Grad-
ing System (HB-FGS)13 has been used as an overall
measure of facial impairment. The HB-FGS classi-
396
fies facial functioning in 6 levels or grades; grade I
is normal functioning and grade VI is a complete
paralysis. HB-FGS is a reliable and widely accepted
facial grading system.14 However, this instrument
is rather coarse; therefore, more detailed informa-
tion on facial functioning was collected with a
standardized form. This form contains items and
their associated graded answer categories in which
the therapist had reported at patient encounter the
observations on impairments and disabilities and
had noted patients complaints and judgement of
quality of life.
More detailed measures of facial impairment
were made as follows: the physiotherapist ob-
served (1) asymmetry at rest (3-point scale: normal
tone, hypotone, hypertone) in 4 facial areas (fore-
head, eye region, nasolabial fold, and mouth re-
gion), (2) asymmetry during 8 requested facial
movements (raising forehead, frowning, eye clo-
sure, sniffing, smiling, pouting, depressing lower
lip, and ballooning cheeks) on a 5-point scale (nor-
mal, mild, moderate, severe, gross), and (3) syn-
kineses associated with these 8 movements scored
on a 3 point scale (no, mild, severe). These 20 items
form an item pool that was considered to have
content validity. A similar item pool formed in the
mid-90s the basis of a reliable and valid facial
grading system and is known as the Sunnybrook
FGS.15 Patients subjective judgment of quantified
impairment was elicited orally with respect to 6
indicators: pain (9 point scale), stiffness (5 point
scale), involuntary movements (5 point scale), lac-
rimation (3 point scale), nasal obstruction (2 point
scale), and sensation (2 point scale).
Facial disability was assessed on the basis of
patients reports concerning difficulties in 4 fields:
eating (8-point scale), drinking (5-point scale),
speaking (5-point scale), and hearing (3-point
scale). Similar items now comprise part of the
Facial Disability Index.16 Finally, quality of life
was assessed by a quantitative patient judgement
(10-point scale, 1 very good), a procedure with
accepted reliability, validity, and sensitivity.17,18
Analyses
All analyses were performed with the SPSS
package. Tests for paired samples were used for
statistical analysis of the pre- and posttreatment
comparisons. Because the nature of the analyses
was descriptive and exploratory, statistical tests
were performed 2 sided.19 If not otherwise men-
tioned, chi-square tests were used. Stabilities of
interpatient differences were calculated with Pear-
son correlation coefficients except for House-
Brackman scores, for which Spearmans rank order
correlation rho was used.
RESULTS
Of the 203 archived files of patients who
had received Mime therapy, 155 complete
BEURSKENS AND HEYMANS
files of patients meting the inclusion criteria
were available for analysis. Because of incom-
pleteness, 28 files were excluded; 20 patients
with a paresis of 3 months or less were also
excluded. No patients were receiving concur-
rent treatments. Firstly, the general character-
istics of the patients will be described; subse-
quently, patients changes and stabilities in
sequelae will be reported.
Patient Characteristics
Of the 155 patients, 21% were referred for
facial rehabilitation after a Bells palsy, 33%
after surgical removal of an acoustic neuroma,
herpes zoster in 8%, (operative) trauma in
15%, otitis media in 6%, and congenital facial
nerve paresis in 7%. The remaining 10% of
the diagnoses was unknown. Diagnosis and
sex show no relationship (P .11, not signif-
icant), and most patients (74%) had had pre-
vious therapy (medication, electrotherapy, ex-
ercise therapy, acupuncture, speech therapy,
or surgical treatment) before starting Mime
therapy. The right side was significantly (right
99, left 56; P .001) more often affected than
the left side, both for men and women.
The age range was 6 to 85 years. Of the 155
patients, significantly more women (94) than
men (61) (P .01) were treated. The mean age
of all patients was 42 years (SD, 18.2), the age
distributions being the same for men and
women (t .82, P .41). The median time
between onset of the paralysis and start of the
treatment was 15 months (mean 31.7 months,
SD 34.5, range 4-99). At intake, only 25% of
the patients had a mild form of facial paresis
(HB score 2 or 3), 50% having a serious pare-
sis (HB score 5 or 6).
Patient-Perceived Impairments, Disabilities,
and Quality of Life
Patients impairments, disabilities, and
quality of life were assessed directly before
the initial and after the final treatment ses-
sion. The mean time between T1 (beginning of
treatment) and T2 (end of treatment) was 5.7
months (SD 5.7, range 1 to 40 months, median
4.0). The wide range is caused by the fact
that there were 7 patients treated who had
undergone nerve and/or muscle transplanta-
tion, requiring a long-range treatment with a
FACIAL NERVE PARESIS 397

TABLE 1. Patient-Reported Impairments, Disabilities, and Quality of Life in 155 Patients With Facial Paresis Receiving
Mime Therapy and Their Changes Over the Therapy Period (T1-T2)

1 2 3 4
Changes in Average Correlation of
T1 Mean (SD) T2 Mean (SD) Severity T1-T2 T1, T2 Severity

Impairments
Pain 1.4 (2,2) 0.5 (1.6) Decreased 0.58*
Stiffness 1.7 (1.5) 0.6 (0.9) Decreased 0.71*
Involuntary movements 1.7 (2.8) 0.6 (1.7) Decreased 0.56*
Nasal passage 0.23 (0.4) 0.16 (0.6) Improved 0.80*
Sensation 0.3 (0.5) 0.26 (0.4) Improved 0.91*
Disabilities in
Eating 2.4 (1.8) 1.0 (1.3) Improved 0.57*
Drinking 1.4 (1.4) 0.5 (0.7) Improved 0.60*
Speaking 1.3 (1.1) 0.4 (0.6) Improved 0.52*
Hearing 0.7 (0.9) 0.7 (0.9) No difference, NS 0.98*
Quality of life 3.2 (2.6) 1.1 (1.4) Improved 0.57*

Abbreviation: NS, not significant.

*P .05.
P .01.
A paired sample t test was used.

low-session frequency. The average number of Facial Functioning

therapy sessions was 8, range 2 to 14. Table 1
gives an overview of the average severity of
sequelae at T1 and T2.
With regard to the severity of a complaint
on all 3 sequelae levels, the patients improved
on average on all indices except for hearing
problems. Patients differed at intake in the
amount and severity of their complaints. High
correlations between pre- and posttreatment
measures reveal that such interindividual dif-
ferences are stable over time. Table 1 (column
4) shows that for stiffness, nasal passage, sen-
sation, and hearing, the posttest interpatient
differences align quite well with preexisting
differences at T1. The scores at intake regard-
ing the other impairments and disabilities
predict to a moderate degree their relative
position at discharge.
Face at Rest. Facial symmetry at rest im-
proved (ie, asymmetry on all indicators [re-
spectively forehead, eye region, nasolabial
fold, and mouth region] decreased signifi-
cantly) (Table 2).
Face During Voluntary Movement. Both
the movements and the synkineses variables
indicate the presence and degree of severity of
the sequelae. Table 3 shows the results. Asym-
metry in facial movement remains present to a
substantial degree (columns 1 and 2), but, nev-
ertheless, the average severity of this asymmetry
decreases in all movements (column 3),
whereas interpatient differences at intake are
preserved over time (high correlations between
T1 and T2, shown in Table 3, column 4).

TABLE 2. Observed Asymmetry of the Face at Rest and Its Changes During Mime Therapy (n 155)

1 2 3 4
Asymmetry in Facial Areas T1 Mean (SD) T2 Mean (SD) Changes T1-T2 Correlation T1, T2

Forehead 0.7 (0.8) 0.5 (0.7) Improved 0.83*

Eye 1.1 (0.8) 0.7 (0.7) Improved 0.63*
Naso-labial fold 1.2 (0.8) 0.5 (0.6) Improved 0.60*
Mouth 1.7 (1.1) 1.1 (1.3) Improved 0.21

*P .05.
P .01.
A paired sample t test was used.
398 BEURSKENS AND HEYMANS

TABLE 3. Observed Facial Functioning During Voluntary Movement, Severity of Synkineses, and Their Changes During
Mime Therapy (n 155)

1 2 3 4 5 6 7 8
Voluntary T1 Mean T2 Mean Change Correl. Synk. T1 Synk. T2 Change Correl.
Movement (SD) (SD) T1-Tt2 T1, T2 Mean (SD) Mean (SD) T1-T2 T1, T2

Raising
forehead 4.1 (1.3) 3.7 (1.5) 0.89* 0.5 (0.7) 0.4 (0.5) 0.75*
Frowning 3.8 (1.4) 3.3 (1.5) 0.87* 0.5 (0.6) 0.4 (0.5) 0.65*
Eye closure 3.1 (1.3) 2.4 (1.1) 0.76* 0.7 (0.7) 0.6 (0.5) * 0.57*
Sniffing 3.9 (1.1) 3.1 (1.3) 0.79* 0.3 (0.6) 0.2 (0.4) 0.63*
Smiling 3.5 (1.1) 2.3 (0.9) 0.76* 0.6 (0.7) 0.4 (0.5) 0.51*
Pouting 3.5 (1.1) 2.7 (1.0) 0.74* 0.9 (0.8) 0.7 (0.6) 0.61*
Depressing
lower lip 4.2 (1.2) 3.5 (1.5) 0.74* 0.4 (0.7) 0.3 (0.5) 0.62*
Ballooning
cheeks 3.5 (1.1) 2.5 (1.0) 0.71* 0.7 (0.8) 0.5 (0.6) 0.67*

NOTE. Lower scores indicate a better function.

*P .05.
P .01.
A paired sample t test was used.

An increase in the number of patients show- for the HB-FGS at pre- and posttest and the
ing a synkinesis was observed for 3 out of 8 transitions between HB-FGS stages.
movements (eye closure 5, pouting 15,
and ballooning cheeks 8). Nevertheless, the Predictors of Changes
group average of severity of synkineses signif-
icantly decreased for all 8 movements (Table Improvements have been reported in many
3, columns 5-7). Interpatient differences in aspects of the patients complaints and ob-
degree of synkineses tended to persist over served facial functioning. Does the possibility
time for all movements (Table 3, column 8). exist to predict these changes on the basis of
objective patient information available at in-
Sequelae Assessed by the HB-FGS. Ac- take? Age, sex, and affected side of the face
cording to the HB-FGS, at T2, most patients might be such predictors. In our analyses,
had a lower score than at T1 indicating im- changes in scores were assessed by taking
provement. Of the group of 155 patients, 41 residuals from the post-pretest regressions.
patients (26%) improved at least 2 stages, 105 For the 10 complaints in Table 1, there were
patients (68%) improved 1 stage between in- no significant relations between age, sex, or
take and discharge, no patients showed dete- affected side and changes in complaints, with
rioration, and 9 patients (6%) showed no
change in the HB stage. Of the 77 patients
functioning at intake on HB-FGS stage 5 or
higher, only 19 remained at these low func-
tion stages at discharge. Prepost-comparison
of HB-FGS scores (which in fact are rank or-
ders) with a nonparametric statistical test
(Wilcoxon signed ranks test) showed a signif-
icant (P .01) difference. The high correla-
tion between pre- and posttest (rho 0.85)
indicates that, although there is change, the
relative position of patients changed mini-
mally between intake and discharge. HB-FGS
Fig 1. Transitions between beginning (HB1) and end
stage after Mime therapy is rather accurately (HB2) of Mime therapy in levels of House-Brackmann
predicted by HB-FGS stage at intake. See Fig 1 Facial Grading System (N 155 patients).
FACIAL NERVE PARESIS
2 exceptions: older patients showed less
progress in eating and speaking and nasal
passage improved less in women than in men.
However, all these effects were small, al-
though statistically significant. Taking HB
scores as representing a summary of the de-
tailed measures of facial functioning in Tables
2 and 3, analyses did not show predictive
validities of age, sex, or affected side in regard
to progress in HB scores.
DISCUSSION AND CONCLUSIONS
This study aimed at describing changes in
sequelae of facial nerve paresis during a pe-
riod in which physiotherapy was given. For
almost all sequelae of facial nerve paresis on
all 3 levels (impairments, disabilities, and
quality of life), significant improvements were
observed. The improvements observed in this
rather unselected group of 155 patients shows
concordance with the benefits obtained from
Mime therapy in 48 patients participating in
an RCT.1,20
However, some notes of caution are in or-
der. Could the recorded changes be inherent
to the patient or to the measurement proce-
dure? Assessment of the patients functioning
and therapy were done by the same physio-
therapist (CB). This could influence the valid-
ity of the data in an adverse way, especially
the change data. This physiotherapist had at
the time of availability of the first patient
records 8 years of experience working with
patients with facial nerve paresis; this allows
for a stable cognitive frame of reference when
assessing patients at intake and discharge. In
a recent project,20 interrater agreements
were assessed concerning facial functioning.
Twenty-five patients (mean age 45 years,
range 13-74) with a mean severity of III on the
HB-FGS were videotaped. Three raters inde-
pendently scored the patients using the Sun-
nybrook FGS.15 The Sunnybrook FGS covers
the same areas of facial functioning as mea-
sured in this study and uses a comparable
item pool. The intrarater reliabilities of the
composite scale for the observers were deter-
mined to be intraclass correlation coefficient
between 0.89 and 0.98. The interrater reli-
abilities varied between intraclass correlation
coefficient 0.90 and 0.95. One of the 3 raters
was the physiotherapist from the present
399
study. No information about interrater agree-
ment can be given in this study because no
data of a second rater were available. The
hypothetical possibility of therapist/observer
bias is less plausible given the fact that there
was a considerable convergence in changes
based on the reports from 2 different sources
(patient and physiotherapist) and the changes
found in this study are similar to the changes
observed in the RCT by the same observer
under blinded conditions. Nevertheless, this
is a limitation. Assessments of physiotherapy
outcomes in facial nerve paresis performed by
a single observer/physiotherapist are also
found in the literature in a pre-experimental
study by Coulson and Croxon.21 In the exper-
imental studies by Ross et al7 and Segal et al,8
the assessments were also done by a single
therapist.
Many patients showed improvement, but is
this sample not atypical? Our group of pa-
tients can be considered as a sample from the
patient stream referred to the University Med-
ical Centre Nijmegen for facial rehabilitation
at that time. No indications were found denot-
ing that the composition of this patient popu-
lation has changed over the years. The com-
position of the patient sample in the recently
completed RCT was similar in age, gender,
time between onset and intake, and nearly
similar in severity of facial paresis. One might
speculate that our conclusions are only valid
for the local situation because a data set ob-
tained from another Dutch center for facial
rehabilitation in Amsterdam2 reports for the
period 1974 to 1983 a sex ratio of 1.0 in their
group of patients, whereas in this study it was
3:2 favoring women. This Amsterdam group
only consisted of patients with Bells palsy,
which is expected to affect both sexes alike,
whereas our group included patients with fa-
cial nerve paresis of other etiologies. For our
Bells palsy patients, the sex ratio is 5:3. The
Nijmegen hospital apparently sees relatively
more women than men for facial rehabilita-
tion. One could speculate about the reasons;
we will not do this. Because there is no cor-
relation between sex and the changes ob-
served (except for nasal passage), we do not
believe that overrepresentation of women bi-
ases the results concerning the changes during
the physiotherapy episode.
400
CONCLUSIONS CONCERNING CHANGES
IN FACIAL FUNCTIONING
After a period of 3 to 5 months of Mime
therapy, a significant degree of improvement
was observed in all areas investigated including
facial impairments, disabilities, and quality of
life. Asymmetry in the face at rest decreased
for each of the 4 facial areas investigated, all 8
aspects of measured voluntary facial move-
ment improved, and synkineses associated
with each of these 8 facial movements de-
creased significantly. Patients reported less
serious complaints concerning pain, stiffness,
involuntary movements, sensation, eating,
drinking, speaking, and quality of life. Ac-
cording to the HB-FGS, almost all patients
improved at least 1 stage in 8 to 10 sessions.
Age, sex, and affected side were not predictive
of the observed changes in HB-scores or of
most changes in complaints. A high degree of
stability of interindividual differences in
nearly all facial aspects was observed except
for asymmetry of the mouth at rest. A reason
for this could be that the increase of the
amount of synkineses was greatest for the
mouth region, perhaps indicating that the ten-
sion in the mimetic muscles could have in-
creased, thus giving a changed asymmetry
score.
The improvements observed in patients af-
ter being treated with Mime therapy are con-
sistent with the recently RCT-proven effec-
tiveness of Mime therapy even though the
patient sample in this 10-year study was more
varied in age, number of treatment sessions,
cause of facial paralysis, and duration of the
paresis.
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