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The use of mime therapy as a rehabilitation method for patients with facial nerve paresis
Abstract
Since 1980, patients with sequelae of peripheral facial nerve paresis have been treated with mime therapy at the physiotherapy department of the University Medical Centre in Nijmegen, which aims to rehabilitate facial expression. Mime therapy was developed by Jan Bronk (a mime actor) and Pieter Devriese (an otolaryngologist) in the 1970s, using the principles of mime for patients suffering from either lack of facial movement or uncontrolled movements. Both therapists and patients reported benefits of mime therapy; most importantly, an improved symmetry of the face.
There is a belief within the profession that evidence-based treatment is required to scientifically substantiate physiotherapy. A detailed description of the mime therapy treatment is essential for performing a randomized controlled trial, which is currently underway.
This article aims to comprehensively describe the historical development and clinical characteristics of mime therapy and to give insight into its usefulness as a tool in the treatment of patients with facial nerve paresis.
... It was created to help patients who had limited or restricted facial movement or a lack of facial muscle control. [10] The aim of mime therapy is to promote symmetry of the face at rest and through movement. [10] Components of Mime therapy include:-1) Anamnesis, patient information about treatment and prognosis. ...
... [10] The aim of mime therapy is to promote symmetry of the face at rest and through movement. [10] Components of Mime therapy include:-1) Anamnesis, patient information about treatment and prognosis. 2) Self massage of face and neck. ...
... 6) Expression exercises. [10] Motor imagery can be defined as a dynamic state during which an individual Mentally stimulates a physical action. This kind of extraordinary expertise implies that the subject feels themselves that performing the action. ...
Background: Bell's palsy is an acute-onset Peripheral facial pathology and is the commonest explanation for lower motor nerve fiber facial palsy. The physical therapy treatment for Bell's palsy includes Electrical stimulation of affected facial muscle and mime therapy. Aim: To seek out whether there is any significant difference between effectiveness of electrical stimulation with Mime therapy and electrical stimulation with motor imagery technique in patients with Bell's Palsy. Objective: To improve motor function and strength of facial muscles. Methodology: On the premise of inclusion and exclusion criteria 30 participants were elect. They were treated with Electrical stimulation with Mime therapy and electrical stimulation with motor imagery technique for 5 days / week for 6 weeks, subsequently that re-assessment was infatuated HBS, MMT and SD curve. Results: using SPSS Version 26.Parametric test was used. In Group A improvement was seen The data was analyzed. Conclusion: Electrical stimulation with mime therapy is effective to improve strength and motor function in patients with Bell's Palsy.
... Electrotherapeutic modalities include electrical stimulation, electromyography feedback, ultrasound, laser, and shortwave diathermy [10,11]. Besides, mime therapy was created to help patients who experience limited or restricted facial movement or the loss of facial muscle control [12]. Mime therapy is a combination of mime and physiotherapy and aims to promote the symmetry of the face at rest and control synkinesis during movement [13]. ...
... Mime therapy is a combination of mime and physiotherapy and aims to promote the symmetry of the face at rest and control synkinesis during movement [13]. Studies showed that mime therapy improved facial symmetry and functions more than conventional therapy and home exercise programs, in people with acute Bell palsy [12][13][14][15]. ...
... Whenever these exercises are performed, they activate the reticular system that adds to the muscle control, thereby, reduce synkinesis [33]. Performing these facial exercises causes a constant increase in muscle tension followed by bilateral relaxation that improves facial circulation [12,19] and also coordination between the two halves of the face, which enables them to display facial movements and emotions in a symmetrical form [12]. ...
Background and Objectives: Bell palsy is the sudden lower motor neuron paralysis of the facial nerve, characterized by acute unilateral peripheral facial muscle weakness. Physiotherapy has been proven to be beneficial in the rehabilitation of patients with Bell palsy and is important to prevent permanent contractures of the paralyzed facial muscles. A physiotherapy technique includes electrical stimulation and mime therapy to help in restoring lost muscle functions. Also, sensory exercises include varied normality solutions administered. This study aimed to find the effects of mime therapy with sensory exercises on facial symmetry and functional abilities among Bell palsy patients.
Methods: A total number of 30 participants were recruited for an interventional study and conveniently assigned into three groups (n=10), where group A received electrical stimulation with facial exercises, group B received electrical stimulation with mime therapy, and group C received a combination of electrical stimulation, mime therapy, and sensory exercises. Each group received 18 sessions; each session was for 60 minutes per day, six days per week, for three weeks. Then, all the participants were assessed using the Sunnybrook facial grading system and the facial disability index.
Results: Intragroup analysis showed a significant difference within all three groups (P
... In contrast to most passive therapeutic interventions, mime therapy and neuromuscular re-education are two active, patient-centric approaches for facial rehabilitation that can promote recovery and improve facial function through the use of exercise and feedback (Beurskens et al, 2004;VanSwearingen, 2008). Both techniques have been proven to be superior to conventional physiotherapy techniques (Manikandan, 2007;Mistry et al, 2014), but no studies have compared both interventions with each other. ...
... Group A received mime therapy based on the work of Beurskens et al (2004). It included patient education, self-massage of face and neck, breathing and relaxation exercises, facial exercises, articulation, and facial expression exercises. ...
... These interventions make the patient more independent and involved in their recovery since the therapist only acts as a supervisor for most of the treatment duration. Each intervention is provided with a detailed and lucid treatment plan as described in the works of Beurskens et al (2004) and VanSwearingen (2008), including an elaborate, outlined home exercise programme. This allows patients to be able to continue treatment at home by themselves, which will drastically reduce expenses, in contrast to receiving daily treatment in a clinic. ...
Background/aims:
Untreated Bell's palsy may lead to disability and reduced quality of life, while early intervention can improve prognosis. This pilot randomised clinical trial aims to compare the effectiveness of mime therapy and neuromuscular re-education in improving facial symmetry and function in patients with acute Bell's palsy.
Methods:
A total of 20 patients diagnosed with Bell's palsy were included in this study after meeting the inclusion criteria. Patients were randomly divided into two groups of ten. Group A received mime therapy while group B received neuromuscular re-education. Each participant received 12 sessions of the respective treatment over 2 weeks and was assessed for facial symmetry and function using the Sunnybrook Facial Grading System and the Facial Clinimetric Evaluation Scale respectively.
Results:
Although both mime therapy and neuromuscular re-education showed highly significant improvements within each group for both the Sunnybrook Facial Grading System (P=0.005) and Facial Clinimetric Evaluation Scale (P=0.005); they showed no difference between each group for the Sunnybrook Facial Grading System (P=0.212) and Facial Clinimetric Evaluation Scale (P=0.97).
Conclusions:
Mime therapy and neuromuscular re-education are equally effective in the recovery of facial symmetry and function in acute Bell's palsy. Physiotherapists can choose between either technique based on their skills and preference or based on patient comfort and expectation.
... The patient became more cooperative in examinations and starts an exercise program at home when he realized the changes in his condition for the better. This is supported by the research of Beurskens et al (2004) which states that facial massage and exercise as physical therapy can increase the growth and production of collagen and connective tissue in facial muscles and restore facial muscle function. 16 Visual feedback is also said to control muscle activity in the facial muscles. ...
... This is supported by the research of Beurskens et al (2004) which states that facial massage and exercise as physical therapy can increase the growth and production of collagen and connective tissue in facial muscles and restore facial muscle function. 16 Visual feedback is also said to control muscle activity in the facial muscles. Research by Hu et al (2001) have also shown that exercise and facial massage can improve facial symmetry in patients with long-term facial nerve paresis. ...
... A cochrane review found moderate quality evidence from one trial by Beurskens et al (2004) and suggested that this type of therapy has some benefit in chronic cases of idiopathic facial paralysis. 8,16 ...
Background: Ramsay Hunt Syndrome (RHS) is a scarce diagnosis involving unilateral facial paralysis resulting from the reactivation of Varicella-Zoster Virus (VZV) infection in the past, which causes pain, asymmetrical facial expressions, and difficulty in speaking, eating and drinking. The most effective treatment is still debatable, and limited research is available. Rehabilitation program is considered as the core treatment that gives functional improvement. The aim of this case study is to present clinical findings in RHS and the rehabilitation program to maximize facial expression recovery.Case Description: A 59-year-old man came to rehabilitation medicine outpatient clinic two weeks after diagnosed as RHS, with complaints of fever; severe pain and rashes on the left side of the face; and ear discomfort on the same side. Physical examination revealed peripheral facial nerve palsy on the left side with drooping of the left eyelid, left end of the mouth, and difficulty in oral communication. Electroneuromyography (ENMG) examination showed axonal facial nerve paralysis on the left side. The patient was referred to the physiatrist and got rehabilitation program with neuromuscular electrical stimulation (NMES), facial massage and biofeedback exercise for facial muscle 3 times a week for 4 weeks.Discussion: After 4 weeks rehabilitation program, the patient showed improvement as House-Brackmann grades improved from a grade IV to a grade II; improvements in communication, facial symmetry at both rest and motion; significant improvement in experiencing pain. Conclusions: This study suggested that rehabilitation program with NMES, facial massage and biofeedback exercise are safe, efficacious and provide good outcomes in the treatment of Ramsay Hunt Syndrome.
... Mime therapy [8,9] and facial neuromuscular retraining (fNMR) [10] are 2 rehabilitation techniques for managing facial palsy sequelae that stand out in the literature [11]. Mime therapy consists of facial massage and specific facial retraining to coordinate both hemifaces by using emotional cues to express a particular facial movement or by starting to use a specific muscle to create an expression [8]. ...
... Mime therapy [8,9] and facial neuromuscular retraining (fNMR) [10] are 2 rehabilitation techniques for managing facial palsy sequelae that stand out in the literature [11]. Mime therapy consists of facial massage and specific facial retraining to coordinate both hemifaces by using emotional cues to express a particular facial movement or by starting to use a specific muscle to create an expression [8]. Similarly, fNMR consists of relearning motor patterns to improve facial movements through conscious, consistent, and slow selective activation of facial muscles using individualized training programs made by qualified facial therapists [12]. ...
Background
Facial neuromuscular retraining (fNMR) is a noninvasive physical therapy widely used to treat peripheral facial palsies. It consists of different intervention methods that aim to reduce the debilitating sequelae of the disease. Recently, the use of mirror therapy in the acute facial palsy and postsurgical rehabilitation contexts has shown promising results, suggesting its use as an adjunct to fNMR in treating patients with later stages of paralysis, such as the paretic, early, or chronic synkinetic.
Objective
The main aim of this study is to compare the efficacy of an added mirror therapy component with fNMR in patients with peripheral facial palsy (PFP) sequelae in 3 different stages. The specific objectives of this study are to measure the effects of combined therapy compared to fNMR alone on (1) participants’ facial symmetry and synkinesis, (2) quality of life and psychological aspects of the participants, (3) motivation and treatment adherence, and (4) different stages of facial palsies.
Methods
This study is a randomized controlled trial that compares the effect of fNMR combined with mirror therapy (experimental group: n=45) with fNMR alone (control group: n=45) in 90 patients with peripheral facial palsy presenting with sequelae 3-12 months after onset. Both groups will receive 6 months of rehabilitation training. Facial symmetry and synkinesis; participants’ quality of life; and their psychological factors, motivation, and compliance will be assessed at baseline (T0), 3 months (T1), 6 months (T2), and 12 months (T3) postintervention. Outcome measures are (1) changes in facial symmetry and synkinesis assessed with facial grading tools, (2) quality of life changes with patient questionnaires, and (3) therapy motivation with a standardized scale, as well as adherence to treatment with metadata. Changes in facial symmetry and synkinesis will be judged by 3 assessors blinded to group assignment. Mixed models and Kruskal-Wallis, chi-square, and multilevel analyses will be conducted according to the appropriate variable type.
Results
Inclusion will start in 2024 and is anticipated to be completed in 2027. The 12-month follow-up will be completed with the last patient in 2028. We expect patients included in this study to experience improvement in facial symmetry, synkinesis, and quality of life, regardless of group assignments. A potential benefit of mirror therapy for facial symmetry and synkinesis could be noted for patients in the paretic phase. We hypothesize better motivation and adherence to treatment for the mirror therapy group.
Conclusions
The results of this trial may provide new guidelines for PFP rehabilitation with patients dealing with long-term sequelae. It also fills the need for robust evidence-based data in behavioral facial rehabilitation.
International Registered Report Identifier (IRRID)
PRR1-10.2196/47709
... 110 Moreover, recently some improvement in facial outcomes have been reported with the use of mime therapy. 111 Cochleovestibular Nerve (Cranial Nerve VIII) ...
This article aims to clearly understand the historical development of cranial nerve-implanted stimulators in otolaryngology. The authors also discuss cranial nerve history; initial theory of the functional concept of animal spirit; electrical nerve impulse theory; first electrical otolaryngology cranial nerve stimulation devices; and the development of implanted stimulators.
... For example, we could not implement mime therapy as part of management strategy for facial paralysis, because the information provided in clinical trials about mime therapy was inadequate. 4,5 Even for traditional interventions, such as strength or endurance training programs for clinical populations, clinicians require specific and clear details on the dosage (type of exercise, intensity, frequency, duration, and progression criteria used) provided for the study participants to carry out the treatment based on the information provided in the published reports. ...
Background:
Amongst several barriers to the application of quality clinical evidence and clinical guidelines into routine daily practice, poor description of interventions reported in clinical trials has received less attention. Although some studies have investigated the completeness of descriptions of non-pharmacological interventions in randomized trials, studies that exclusively analyzed physical therapy interventions reported in published trials are scarce.
Objectives:
To evaluate the quality of descriptions of interventions in both experimental and control groups in randomized controlled trials published in four core physical therapy journals.
Methods:
We included all randomized controlled trials published from the Physical Therapy Journal, Journal of Physiotherapy, Clinical Rehabilitation, and Archives of Physical Medicine and Rehabilitation between June 2012 and December 2013. Each randomized controlled trial (RCT) was analyzed and coded for description of interventions using the checklist developed by Schroter et al.
Results:
Out of 100 RCTs selected, only 35 RCTs (35%) fully described the interventions in both the intervention and control groups. Control group interventions were poorly described in the remaining RCTs (65%).
Conclusions:
Interventions, especially in the control group, are poorly described in the clinical trials published in leading physical therapy journals. A complete description of the intervention in a published report is crucial for physical therapists to be able to use the intervention in clinical practice.
Werd een perifere aangezichtsverlamming vroeger met elektrotherapie behandeld, tegenwoordig ligt het accent op bewegingstherapie. De oefentherapie is gericht op het behandelen van de gevolgen van een niet volledig herstelde aangezichtsverlamming. Behandelbare restverschijnselen zijn asymmetrie in rust en bij bewegen (zowel bewust bewegen als synkinesen) met daaraan gekoppelde functiestoornissen (eten, drinken, spreken) en participatiestoornissen zoals sociale beperkingen. Hoewel het aantal effectstudies beperkt is heeft onderzoek, in het bijzonder naar mimetherapie, laten zien dat er een significante verbetering te verwachten valt bij deze patiëntencategorie op zowel functie-, activiteiten- en participatieniveau.
Background/Aim:
There are limited physiotherapy interventions and lack of significant outcome for Ramsay Hunt syndrome. This case report is the first to our knowledge that uses mime therapy as physiotherapy treatment for Ramsay Hunt syndrome.
Method:
A 53-year-old male patient received mime therapy along with electrical stimulation at two and half months post-diagnosis. The patient received electrical stimulation at the first week intervention as 30 minutes per session for 5 days a week and was discontinued at the third week intervention because the patient could not continue with facial muscle stimulation at home. Mime therapy was given three times a week for 13 weeks, with a total of 24 visits spread over 3 months.
Findings:
Facial symmetry was measured using the Sunnybrook Facial Grading System and severity of paresis was measured using the House-Brackmann scale throughout the course of treatment. House-Brackmann grades improved from grade V to grade II. Facial symmetry and synkinesis also improved. The facial disability index also showed improvement in both the physical function and social/wellbeing subscale components (Initial scores: physical subscale = 35/100; social/wellbeing subscale = 55/100. The final scores: physical subscale = 75/100; social/wellbeing subscale = 85/100).
Conclusions:
Overall, mime therapy was effective and benefits are stable for the short term. Therefore, mime therapy can be a good treatment choice for patients with Ramsay Hunt syndrome. Further research should include randomised controlled trials with a large sample size to prove its long-term effects.
This research aimed to address smile deficits after long-term facial nerve paralysis (FNP) by implementing two treatments not previously used for FNP: video self-modelling and implementation intentions. Two FNP subjects were studied, who were both experiencing difficulty producing symmetrical smiles, particularly in social situations. Smile types measured were a symmetrical (adapted) smile and an asymmetric (everyday) smile. Treatment involved each subject observing only his or her best adapted smiles on videotape, three times a day for 2 weeks. Time from onset to smile completion was recorded and to assess quality, 20 observers rated randomly ordered smiles.
For adapted smiles, there was both a significant post-treatment decrease in time from initiation to completion and a rated improvement on the dimensions of overall smile quality, movement control and symmetry. Therefore, with increased speed, the more symmetrical adapted smile could be used spontaneously during designated social interactions. These case studies suggest that smile symmetry and control can still be improved some years after FNP, and that video self-modelling and implementation intentions warrant further research.
Although there have been several reports indicating the success of physical therapy, few scientific data seem to be available. To assess the efficacy of physical therapy, a so-called criteria-based meta-analysis was conducted [1].
Clinicians require a reliable and valid method of evaluating facial function following facial nerve injury. This tool should be clinically relevant, easy to administer, provide a quantitative score for reporting purposes, and be sensitive enough to detect clinically important change over time or with treatment. The objectives of this study were to develop and validate a well-defined grading system that would address the above mentioned points. All essential information, including precise definitions for each item, is presented on one page (Fig. 1, see next page). The facial grading system (FGS) is based on the evaluation of resting symmetry, degree of excursion of facial muscles and degree of synkinesis associated with each voluntary movement. Different regions of the face are examined separately using five standard expressions. All items are graded on point scales and a cumulative composite score, tabulated.
Construct validity was addressed by comparing the proposed FGS to pre- and post-rehabilitation treatment scores of 19 patients that had documented change in a controlled study of facial feedback training [1]. It succeeds in reporting results in a more continuous manner with a wider response range than the gross House-Brackmann grades [2]. Tests of internal consistency confirmed that each component of the grading system is sensitive to change and individually contributes to a change in the composite score [3].
The proposed FGS, as an evaluative measure requires little time or specialized equipment, and is responsive to clinically important change. Test of intra-rater and inter-rater reliability are currently ongoing.
Patients with facial nerve palsy are at risk of developing corneal ulceration because of lagophthalmos (incomplete closure of the affected eyelid). Lagophthalmos could result from thixotropy of the levator palpebrae muscle—that is, the formation of tight crossbridges between the actin and myosin filaments of the muscle fibres causing stiffness of the muscle—rather than from paralysis of the orbicularis occuli muscle as previously supposed. This possibility was investigated in 13 patients with a peripheral facial nerve palsy in a prospective open study. The levator muscle of the affected eyelid was stretched by manipulation and downward movement of the passively closed upper eyelid for ∼15 seconds. The amount of lagophthalmos was measured before and immediately after this manoeuvre. In all patients except one there was a clear reduction in lagophthalmos (mean reduction 72%; range 60–100%). Thus in this setting the lagophthalmos appears to be caused by thixotropy of the levator palpebrae muscle, which has implications for treatment.
Patients with facial nerve palsy are at risk of developing corneal ulceration because of lagophthalmos (incomplete closure of the affected eyelid). Lagophthalmos could result from thixotropy of the levator palpebrae muscle--that is, the formation of tight crossbridges between the actin and myosin filaments of the muscle fibres causing stiffness of the muscle--rather than from paralysis of the orbicularis occuli muscle as previously supposed. This possibility was investigated in 13 patients with a peripheral facial nerve palsy in a prospective open study. The levator muscle of the affected eyelid was stretched by manipulation and downward movement of the passively closed upper eyelid for approximately 15 seconds. The amount of lagophthalmos was measured before and immediately after this manoeuvre. In all patients except one there was a clear reduction in lagophthalmos (mean reduction 72%; range 60-100%). Thus in this setting the lagophthalmos appears to be caused by thixotropy of the levator palpebrae muscle, which has implications for treatment.