Facial Palsy: misunderstood and mismanaged

Facial Palsy (FP) is a complex disorder often misdiagnosed, misunderstood and mismanaged. Early specialist facial therapy can rule out underlying sinister pathology, improve outcomes and minimise the development of post-paralytic synkinesis, a devastating condition both functionally and psychosocially. 

Facial neuromuscular anatomy and physiology are unique. Facial therapy is a postgraduate specialism not covered in undergraduate training. General physiotherapy musculoskeletal approaches are not appropriate for facial rehabilitation. Non-specialist therapy can worsen outcomes in peripheral nerve FP patients. 

Facial therapists can differentiate between facial paralysis, paresis and synkinesis. Paralysis and synkinesis can appear similar to the untrained eye. However, lack of movement in paralysis is due to no nerve conduction. Conversely, lack of movement in synkinesis is not due to weakness but due to faulty reinnervation, causing mis-coordination, rigidity and antagonist co-contraction. 

The first international consensus guidelines for FP therapy were recently published.

Importantly, the guidelines exclude strengthening, gross movement exercises, gum chewing, icing and electrical stimulation. These should be avoided throughout all phases of recovery. The critical importance of patient education was emphasised in all phases, as was individualised gentle, precise, co-ordinated facial neuromuscular retraining once nerve continuity is restored. 

The management of each recovery phase is completely different. In flaccid paralysis exercise would be futile as there is no nerve activity. The focus is on accurate diagnosis, education, functional recommendations, contralateral stretching and massage to maintain mobility. Inability to close the eye can lead to corneal damage, necessitating careful eye care including upper lid stretching and taping. Psychological support is critical whilst waiting for restoration of expression. Synkinesis management requires detailed patient education to foster understanding, diligent soft tissue mobilisation, movement retraining including emotional cues and re-education of normal resting tone amongst other interventions.