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A Systematic Review of Physical Rehabilitation of Facial Palsy

published: 31 March 2020
doi: 10.3389/fneur.2020.00222
Frontiers in Neurology | 1March 2020 | Volume 11 | Article 222
Edited by:
Limor Avivi-Arber,
University of Toronto, Canada
Reviewed by:
Meg E. Morris,
La Trobe University, Australia
Orlando Guntinas-Lichius,
University Hospital Jena, Germany
Adriaan Grobbelaar,
University College London,
United Kingdom
Annabelle Vaughan
Specialty section:
This article was submitted to
a section of the journal
Frontiers in Neurology
Received: 27 September 2019
Accepted: 10 March 2020
Published: 31 March 2020
Vaughan A, Gardner D, Miles A,
Copley A, Wenke R and Coulson S
(2020) A Systematic Review of
Physical Rehabilitation of Facial Palsy.
Front. Neurol. 11:222.
doi: 10.3389/fneur.2020.00222
A Systematic Review of Physical
Rehabilitation of Facial Palsy
Annabelle Vaughan 1,2,3
*, Danielle Gardner 1, Anna Miles 4, Anna Copley 2, Rachel Wenke 1,3
and Susan Coulson 5
1Speech Pathology Service, Gold Coast University Hospital, Gold Coast, QLD, Australia, 2School of Health and
Rehabilitation Sciences, University of Queensland, Brisbane, QLD, Australia, 3School of Allied Health Sciences, Griffith
University, Gold Coast, QLD, Australia, 4Speech Science, The University of Auckland, Auckland, New Zealand, 5School of
Health Sciences, Discipline of Physiotherapy, The University of Sydney, Camperdown, NSW, Australia
Background: Facial palsy is a frequent and debilitating sequela of stroke and brain injury,
causing functional and aesthetic deficits as well as significant adverse effects on quality
of life and well-being. Current literature reports many cases of acquired facial palsy that
do not recover spontaneously, and more information is needed regarding the efficacy of
physical therapies used in this population.
Methods: A systematic search of eight electronic databases was performed from
database inception to December 2018. Gray literature searches were then performed
to identify additional articles. Studies were included if they addressed physical
rehabilitation interventions for adults with acquired facial palsy. Reasons for exclusion
were documented. Independent data extraction, quality assessment, and risk of
bias assessment followed the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines.
Results: Following abstract screening, a total of 13 full-text articles were identified for
independent screening by two reviewers. This included four randomized control trials,
two non-randomized control trials, one cohort study, and six prospective case series
studies. Twelve out of the 13 included studies reported on facial palsy as a sequela of
stroke. A total of 539 participants received intervention for facial palsy across the 13
included studies. Therapy design, length and frequency of intervention varied across the
studies, and a wide range of outcome measures were used. Improvement on various
outcome measures was reported across all 13 studies. The quality of the evidence was
low overall, and most studies were found to have high risk of bias.
Conclusions: All the studies in this review report improvement of facial movement
or function following application of various methods of physical rehabilitation for facial
palsy. Methodological limitations and heterogeneity of design affect the strength of
the evidence and prevent reliable comparison between intervention methods. Strong
evidence supporting physical rehabilitation was not found; well-designed rigorous
research is required.
Keywords: central facial palsy, rehabilitation, exercise, systematic review, therapy
Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
The facial nerve (CNVII) plays a critical role in multiple complex
functions of human life including mastication, speech, and
successful social communication through expression of mood
and emotion (14). Central facial palsy (CFP) results from
damage to the central segment of this nerve (facial nucleus in
the pons, motor cortex, or connections between the two) (5)
and manifests typically as a unilateral impairment of movement
opposite to the side of the injury, with predominance in the
lower face (6). In contrast, peripheral facial palsy (PFP) results
from injury or damage to extratemporal segments of the facial
nerve (7), for example in idiopathic “Bell’s” palsy, surgery such as
mastoidectomy, or inflammation such as herpes zoster (Ramsay
Hunt syndrome) (8).
CFP is a frequent initial symptom in patients after stroke and
other neurological injury. A study conducted by Cattaneo and
Pavesi (9) found that 60% of patients with first-time ischemic
cortical stroke (MCA and ACA territories) presented with CFP.
Other studies of stroke populations have reported a prevalence
of approximately 45% (6). It is evident from multiple searches
of libraries and online evidence repositories during clinical
management of CFP that most of the available literature relates
to rehabilitation of peripheral facial palsy (PFP), and there is very
little evidence available to guide therapists working with people
suffering from CFP. Whilst systematic reviews have evaluated
physical rehabilitation and other management for PFP (1012),
the different etiopathogenesis of CFP suggests that rehabilitation
approaches should be specifically modified for this group (13).
Spontaneous recovery of CFP has been reported in two-thirds
of people at 6 months post-stroke, with approximately one-
third of patients after stroke continue to present with persisting
facial palsy after 6 months (14). More recently, differing opinions
are emerging in the literature regarding rates of spontaneous
resolution of CFP (including associated functional and QOL
deficits), with some authors noting that in the absence of
rehabilitation, symptoms seem unlikely to improve (15). In their
study, Volk et al. (6) reported that a high percentage of patients
continued to present with CFP 3 weeks post-onset, and over 60%
of these patients were discharged from sub-acute rehabilitation
with deficits persisting for more than 41 days post-stroke. As the
available literature suggests that CFP can persist past the initial
acute phase of stroke and not resolve spontaneously, people
with CFP may benefit from access to a specific rehabilitation
program aimed at maximizing recovery of facial movement and
function (6,13,16).
Facial palsy can be distressing and debilitating for those
affected, causing both functional and aesthetic deficits (16).
Functional deficits may be characterized by facial asymmetry and
weakness of the lower half of the face, drooping of the corner
of the mouth, dribbling from the corner of the mouth at rest
or during oral intake, reduced masticatory force and efficiency,
asymmetrical smile and dysarthria (slurring or reduced clarity of
speech) (15). It is well-recognized in the literature that in addition
to functional deficits, facial palsy has a negative effect on quality
of life (QOL) and emotional well-being (7,1721). In their 2016
study comparing QOL between individuals with pure CFP post
stroke vs. pure dysarthria, Chang et al. (21) found that the CFP
group had significantly worse scores on QOL and depression
scales. Interestingly, it has been found that the presence of facial
palsy alone regardless of its severity has a detrimental effect on
the psychological well-being of those who experience it (19).
Currently, there is minimal evidence available to guide clinical
decision-making in the rehabilitation of CFP (22,23) and very
little information available regarding the effectiveness of popular
intervention techniques (21,23). As mentioned above, CFP may
not resolve spontaneously and the negative impacts of CFP
on people who experience this disorder can be wide-ranging.
Rehabilitation may maximize functional recovery and improve
the quality of life and psychological well-being of people with
CFP (6,13,16) however there is currently no comprehensive
or systematic review of the literature specific to this disorder
to inform therapy planning and provision. This has significant
implications for patient management, as it is still not clear to
health professionals whether physical rehabilitation techniques
work, or which technique is most effective.
The purpose of this review is to identify and examine the
available literature specifically relating to physical rehabilitation
of CFP. This review aims to (1) identify the types of physical
rehabilitation methods used in remediation of CFP, (2) review
the effectiveness of various methods of physical rehabilitation,
and (3) review the methodological quality of the studies retrieved.
The findings will be pertinent to clinicians working with patients
with CFP as this is the only review that the authors are aware of
that systematically evaluates the evidence base for rehabilitation
of this disorder.
Research Question
What is the effectiveness of physical rehabilitation for acquired
central facial palsy in adults?
Study Design and Search Strategy
This review follows the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement. The review
protocol is registered on PROSPERO (CRD42018115303). A
systematic search strategy was devised in conjunction with a
senior librarian, using the core concepts of facial paralysis,
central nervous system disease, and physical rehabilitation.
The Medical Subject Headings (MeSH) database was used to
obtain terms that were related to these concepts to ensure
a comprehensive search of the literature was performed. The
search strategy was designed and performed using Medline
(Ovid) terminology (see Appendix 1). No limitations were used
for year published, language, or publication type. The search
strategy was then translated for searching the following databases:
Embase (Elsevier), CINAHL (Ebsco), Cochrane Central Register
of Controlled Trials, Proquest Dissertations and Theses Global,
PEDro, Speechbite, and Web of Science (Clarivate).
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
Gray literature searches included searches of WHO ICTRP
(3) and ANZCTR (0) using the terms central facial pa,with
no completed studies (3 currently registered trials) retrieved. was searched using the heading facial palsy
with 18 completed studies retrieved, however all retrieved studies
either pertained to peripheral facial palsy or did not have
results available and were therefore not included in this review.
Clinical practice guidelines and best practice statements were
searched for relevant literature/references, including Clinical
Guidelines for Stroke Management 2017 (24), United Kingdom
National Clinical Guideline for Stroke (25), and American Speech
and Hearing Association Evidence Maps (
Further hand-searching of library and clinical databases were
conducted. Specialists from facial therapy services in Australia
and internationally were asked to provide any relevant literature
which informs their current clinical practice. The reference lists
of articles eligible for inclusion following full text screening
were searched, and any titles that appeared to fit the criteria set
were retrieved.
Participants, Interventions, Comparators
The inclusion and exclusion criteria for the review are presented
in Table 1.
Systematic Review Protocol
The systematic search strategy is presented in Figure 1. A senior
health service librarian performed database searching. Articles
retrieved in the database searches were deduplicated using the
Bond University CREB SRA deduplicating tool (http://crebp- and then further screened to remove other duplicates.
Abstracts of all articles remaining following deduplication were
then collated into an Endnote library, which was then uploaded
TABLE 1 | Selection criteria.
Inclusion Criteria Exclusion Criteria
Participant Adults with acquired CFP Pediatrics (<18 yrs)
Intervention Physical rehabilitation of CFP Surgical or pharmacological
intervention with no physical
rehabilitation component
Comparator None or placebo treatment,
drug/surgical treatment, or
other physical rehabilitation
No outcomes reported
Outcomes Quantitative or qualitative
outcomes in subjective or
objective measures of motor
function or
symmetry/appearance or QOL
Case series
Separate data for CFP
and PFP
Single case study design,
secondary research (i.e.,
Combined data for CFP and
PFP or unclear delineation
Articles from research journals
Articles in English
Book chapters, thesis
publications, opinion pieces
Articles not in English
to Covidence (Veritas Health Innovation Ltd, Melbourne,
Australia) for blind review by two independent reviewers
(AV and DG). Titles and abstracts were screened against the
predetermined inclusion/exclusion criteria and subsequently
added to full text screening lists. Articles included by both
independent reviewers and articles that were marked as “maybe”
by one or both reviewers were considered eligible for further
review. Full texts of eligible studies were then retrieved and
independently assessed for inclusion/exclusion. Any conflicts
that arose during eligibility assessment were resolved by (a)
discussion between reviewers, or where agreement could not be
reached, by (b) discussion with the review team and relevant
experts in the field.
Data Extraction
For all included articles, a range of variables including study
population/participant details, selection criteria, methodology,
interventions (therapy approach, intensity, follow-up) and
outcomes were extracted and are presented in a descriptive
summary in Table 2. These variables were identified as most
relevant to our clinical question. Data extraction was performed
initially by the second author (DG), and then amended and
expanded where necessary by the first author (AV) using
Google Sheets (Google, CA, USA). Due to heterogeneity
in the included studies a meta-analysis was not able to
be performed.
Quality Assessment
Risk of bias was assessed using tools appropriate to the study
methodology determined during the data extraction process:
case series reports were assessed using the JBI Critical Appraisal
Checklist for Case Series (35), cohort studies were assessed using
the JBI Critical Appraisal Checklist for Cohort Studies (35), and
control trials were assessed using the Physiotherapy Evidence
Database—Psychbite scale (PEDro-P) (36). No mixed-method
studies were identified during the search, therefore the tools used
to assess risk of bias were altered from the original PROSPERO
protocol to be more appropriate to the various study designs
retrieved (control trials, case series, cohort study). Risk of bias
analyses were performed independently by two reviewers (AV
and RW) and discrepancies were discussed by the two authors
until consensus was achieved.
Data Analysis
Meta-analysis of the results was not indicated due to the
clinical diversity of the studies retrieved, as recommended
by the Cochrane Handbook for Systematic Reviews of
Interventions (37). Each of the studies retrieved described
differing experimental designs, treatment protocols, and
methods of outcome measurement, and there was inadequate
reporting of data and statistics necessary for appropriate and
meaningful meta-analysis. Types of physical rehabilitation used
in CFP have been broadly grouped as having used either an
active approach (recipients actively move their own muscles or
structures to perform exercises or volitional muscle movements),
passive approach (movement is facilitated by external force,
person or device e.g., massage/stretching, acupuncture, electrical
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
FIGURE 1 | Preferred reporting items systematic reviews and meta-analyses (PRISMA) flow diagram detailing search strategy and selection criteria.
stimulation), or a combination of the two. The effectiveness of
physical rehabilitation has been determined by the examination
of the reported results in those studies that provided sufficient
data and is discussed in the context of the various grouped
approaches. Rating of the overall quality of the evidence has
been performed by applying relevant sections of the Grades of
Recommendation, Assessment, Development, and Evaluation
(GRADE) approach to individual studies (38).
Study Selection
The results from database searching and selection processes are
shown in Figure 1.
Study Characteristics
Six case series (total no. of subjects =108) one cohort study (total
no. of subjects =112), and six control trials (total no. of subjects
=133) were identified. Methodological details are outlined
in Table 2. Of the four RCTs, two appeared to use identical
participant populations and outcome data and are subsequently
discussed as one study in parts of this review (n=99 (13,16). All
the included studies used a pre-test post-test design.
Participant Demographics
Participant demographics for all included studies are reported in
Table 2. Twelve out of the 13 included studies reported on facial
palsy as a sequela of stroke, and one study reported facial palsy
secondary to acquired brain injury. A total of 539 participants
received intervention for facial palsy in the 13 studies included in
this review (age range 48–88 yr old). There was a large range in
time post-onset of facial palsy from acute (e.g., “days”) to chronic
(e.g., 6–10 years) stages of recovery.
Types of Physical Rehabilitation for Facial
There was a high degree of heterogeneity in physical
rehabilitation methods described for adults with CFP. Seven
studies reported interventions aimed at remediation of facial
palsy as their primary objective (6,2629,31,33), and six
reported targeting lip function or movement in the context
of post-stroke dysphagia therapy (13,16,23,30,32,34). Four
studies reported on active intervention methods for remediation
of oromotor function or facial palsy (23,2628); two used
muscle strengthening exercises alone (26,27) and the other
two used biofeedback (via mirror or device) while performing
orofacial exercises (23,28). Four studies reported on passive
intervention techniques such as massage, stretching or electrical
stimulation for the remediation of facial muscle strength or facial
palsy (13,16,29,30). Acupuncture is classified in this review
as passive rehabilitation; one study (30) reported on the use of
scalp acupuncture compared to a group that received “western
medicine.” Five studies combined active and passive approaches
in the rehabilitation of CFP (6,3134); therapy varied across
these studies but all included elements of active exercise, massage,
stretching or passive manipulation, or application of various
devices (Table 2).
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TABLE 2 | Extracted data.
Study ID
N Dx time
post onset
Methodology Interventions Intensity
length of Tx freq
Outcome measures Results
Group A Group B
Hagg and
30 (24 with
UFP) Stroke 2
case series
Lip muscle training N/A >5 weeks 3 ×3/day
5–10 s
Swallowing capacity (ml/s) Lip force Stat sig improvement in both OMs
(p<0.05) FP ’improved’
Hee-Su et al.
10 Stroke <6
case series
Traditional therapy +
resistance training of OO
N/A 4 weeks 5×/wk not
Orbicularis oris strength Lip closure
Stat sig improvement in both OMs
4 Brain injury
>2 mths
control trial
Mirror therapy Mirror therapy +
10 days (in 2 week
period) Daily 30min
Muscle grade Improvement in both pairs although
3×greater in EMG vs. mirror
Kang et al.
21 Stroke
<12 wks
Orofacial exercises Orofacial
exercises +
mirror therapy
14 days 2×/day
15 min
HBGS Facial movement difference
(m-dif) Facial movement ratio (m-rat)
Stat sig improvement in all OMs
(p<0.05), greater in mirror vs. control
9 Stroke <3
case series
Neuromuscular ES +
dysphagia therapy
N/A 4 weeks 5×/wk 30
Max cheek strength (MCS) Max lip
strength (MLS) Dysphagia (VDS)
Stat sig improvement in MCS and
MLS Stat sig decrease on VDS
Konecny et al.
99 Stroke
4 weeks Daily not
HBGS Distance measure BDI-II Stat sig improvement in all OMs
(p<0.05), greater in experimental vs.
Konecny et al.
99 Stroke
4 weeks Daily not
As above +Bartel index Mod. Rankin
Stat sig improvement in both QOL
OMs (p<0.05), greater in
experimental vs. control
Zhou and Zhang
165 Stroke
Scalp acupuncture Western
24 days? Daily
50 min
Clinical indexes / function grading
Improvement in 88.57% of
acupuncture group and 76.67% of
western medicine group
Hagg and
7 Stroke 6
mths4 yrs
case series
Body regulation, manual
orofacial regulation,
palatal plate activation +
velopharyngeal closure
N/A 5 weeks 5×/wk 120
min/session +HEP
Swallowing capacity (ml/s) Meal
observation Oral motor performance
Orofacial sensory function
Velopharyngeal closure VFSS
Improvement on raw scores in at
least one variable for all OMs
Hagg Tibbling
31 Stroke
Days10 yrs
control trial
Palatal Plate (PP) Oral IQoroR
screen (IQS)
3 months 3×/day
PP 10–30min; IQS
30 s
Swallowing capacity (ml/s) Facial
Activity Testing (FAT)
Stat sig improvement in both OMs for
both groups (p<0.05) Improvements
maintained at 1 yr f/up
Noor et al.
50 Stroke Not
case series
Massage, ES, KOBAT N/A ?3 weeks 3×/wk
not stated
Spasticity grade Reduction in spasticity grade for all
Van Gelder et al.
2 Stroke
case series
Neuro Developmental
N/A 9–12 weeks Weekly
not stated
Mimic expressions Orofacial function
Asymmetry and adequacy
2/2 improved mimic expressions +
symmetry 1/2 improved orofacial
function +adequacy
Volk et al.
112 Stroke 20
days (median)
cohort study
Physical training of related
muscles, tapping, mirror
N/A 21 days (median)
not stated not stated
Bartel index HBGS Sunnybrook FGS
Stennert index Action units (AU) FaCE
questionnaire FDI
Stat sig improvement in activity, facial
nerve motor function, self-reported
non/motor abilities (p<0.05)
Dx, Diagnosis; EMG, Electromyography; ES, Electrical stimulation; HBGS, House Brackmann Grading Scale; FGS, Facial Grading System; FDI, Facial Disability Index; FP, Facial palsy; HEP, Home exercise program; OM, Outcome
measures; OO, Orbicularis oris; OT, Occupational therapist; PT, Physiotherapist; QOL, Quality of life; SP, Speech pathologist; SSRI, Selective serotonin reuptake inhibitor; Tx, Therapy; UFP, Unilateral facial palsy; VDS VFSS, Dysphagia
Scale; VFSS, Videofluroscopic Swallow Study.
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Length and frequency of therapy varied across the studies, with
participants receiving multiple therapy sessions per week for
between 10 days and 9 weeks. Details relating to intensity of
therapy (length, frequency, and duration of intervention) are
presented in Table 2.
Outcome Measures
A wide range of outcome measures for muscle strength and
facial movements were used including measures of muscle
strength, facial movement, and symmetry; details are outlined
in Table 2. No validated outcome measurement tools were used.
The majority of studies did not provide detailed descriptions
of grading scales; only three studies (6,13,16,23) used well-
known outcome measures specific to facial palsy. Facial palsy
was often measured in conjunction with other deficits of speech,
swallowing, emotional and psychological well-being.
Effectiveness of Physical Rehabilitation of
Facial Palsy
Four RCTs and nine observational studies reported
improvements in various measures of facial palsy or facial
motor function, which are outlined below in the context of the
rehabilitation approach used (active, passive or combination).
Eight of the 13 studies included comments about the statistical
significance of the results (p-values), however none performed
calculations of effect size, and therefore none of the studies
provided sufficient data to assess imprecision or inconsistency as
outlined in the GRADE approach. There were also insufficient
data reported to facilitate judgement of indirectness; the nine
observational studies do not undertake comparison with an
alternative therapy or control group, and none of the RCTs
provided calculations of risk ratio or effect size that would enable
meaningful direct comparison.
Active Therapy
Four studies reported on active therapy methods; one RCT (23),
one nRCT (28), and two case series’ (26,27). All four studies
reported improvements in treatment variables measured. Kang
et al. (23) reported improvement in HBGS scores and functional
measures (facial movement ratios) in both the control group
and the experimental group (both groups performed the exercise
protocol with the experimental group receiving mirror feedback
as the experimental condition). Huffman (28) also reported
improvement in all subjects on an unvalidated ‘muscle grade’
rating scale mentioned but not detailed by the authors; as well
as improvements three times greater for the subjects receiving
EMG feedback compared to mirror feedback. Both the case series’
implemented protocols of lip strengthening using instrument-
based exercise. Hee-su et al. (27) reported improvements in
orbicularis oris muscle strength and lip closure function during
swallowing; no outcomes specific to facial palsy (e.g., measures of
movement or symmetry) were used. Hagg and Anniko (26) also
reported improvement in raw scores of lip force from baseline
measures taken using a Lip Force Meter instrument however did
not specifically report on outcomes for facial palsy.
Passive Therapy
Four studies reported on passive therapy methods, including a
case series study (29) and three RCTs (13,16,30); two RCTs
are discussed together (13,16) for reasons mentioned previously.
All four reported improvements in relevant measures. Choi (29)
reported changes in facial muscle strength compared to baseline
measures however did not explicitly report outcomes for facial
palsy. Zhou and Zhang (30) reported a larger change in all
outcome measures (including a facial movement grading scale
not described in the study) for the group receiving acupuncture
compared to those receiving “western medicine.” There was no
detail provided regarding the method for administration of this
grading scale. Konecny et al. (13,16) reported improvements in
formal facial nerve assessment measures (HBGS) as well as in a
variety of other functional and quality-of-life scales.
Combination Therapy
Five studies reported on therapy protocols that combined passive
and active methods (e.g., massage/manipulation with active
exercise regime). These included three case series’ (31,33,34),
one non-randomized control trial (32) and one cohort study
(6). One case series (33) reported improvements in spasticity of
facial muscles; this was demonstrated by reporting the number
of participants per scoring level (grade I–V) pre and post
treatment on an unnamed grading tool. There were no individual
assessment outcomes reported and there was an absence of
statistical analysis of the data. One (31) reported improvements
in raw scores of orofacial motility on an informal four-point scale
as well as improvement in mean severity score of oral motor
performance. The authors provided raw pre and post assessment
data for each participant as rated by multiple assessors; there was
an absence of further analysis of this data and overall outcomes
were focused on dysphagia rather than facial palsy. The case series
reported by Volk (6) reported improvements in three well-known
tools to assess facial palsy [HBGS (39), Sunnybrook Grading
Scale (40), and Stennert Index (41)], two validated quality of
life instruments [FaCE Questionnaire (42) and FDI (43)], and
a system of automated facial movement analysis described in
the study.
Maintenance of Therapeutic Effects
Eleven of the 13 included studies did not report any follow
up assessment, and therefore no evaluation of the maintenance
of therapeutic effects was available. One study (32) reported
maintenance of improved facial activity at follow-up assessment
at least 1 year post treatment in both groups. Van Gelder et al.
(34) reported on follow-up assessment 9 weeks post treatment in
only one of the two participants. Their results showed a decline
in function between completion of treatment and re-assessment,
which the authors interpreted as showing treatment effects were
not maintained.
Methodological Quality and Risk of Bias
A summary of the consensus ratings for methodological
assessment is shown using modified harvest plots, which have
been used previously in systematic reviews to present data that
is not able to be graphed using traditional methods (44,45).
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TABLE 3 | PEDro-P and JBI ratings.
PEDro-P Item Condensed
JBI item (Case series) Condensed
JBI item (Cohort)
Participant Eligibility criteria specified
Concealed allocation
Participant Eligibility criteria specified
Standard, reliable measurement of
Valid identification of condition
Participant Both groups similar, recruited
from same population
Intervention Prognostic similarity at baseline
between intervention groups
Design Consecutive inclusion
Complete inclusion
Participant demographics
Participant clinical information
Outcomes or follow-up
Design Exposures measured similarly
Standard, reliable measurement
of exposure
Confounding factors identified
Groups/participants free of
outcome initially
Outcome measurement valid
and reliable
Blinding Subject blinding
Therapist blinding
Assessor blinding
Outcomes >85% of the subjects followed up for
at least 1 key outcome
Intention-to-treat analysis
Between group statistical analysis for
at least 1 key outcome
Site Site demographics Follow-up Follow up sufficient and reported
Complete follow up
Incomplete follow up managed
Variability Point estimates of variability provided
for at least 1 key outcome
Statistics Appropriate statistical analysis Statistics Appropriate statistical analysis
These modified harvest plots were created by grouping similar
criteria together for each appraisal tool, as detailed in Table 3.
As in previous studies where modified harvest plots have been
used, methodological quality is represented by bar height (45).
“Unclear” consensus ratings have been scored as zero when
calculating scores for each criterion on the JBI tools.
Control Trials
Across the control trials, scores on the PEDRO-P ranged from
3 to 9 with an average of 5.5 out of 11 (see Figure 2). Of the
RCTs, 2 of the 4 specified eligibility criteria for inclusion in the
study, and while the majority allocated subjects randomly to
interventions only one concealed this allocation. Blinding was
an area of significant risk across the RCTs, with 1 of 4 studies
blinding subjects and assessors and no blinding of therapists in
any study. The nRCTs showed similar shortcomings in allocation
and blinding items. The intervention groups were similar at
baseline regarding the most important prognostic indicators in
>90% of the studies. Outcome measurement was an area of
strength for all the control studies; 100% obtained measures of at
least one key outcome from >85% of subjects and demonstrated
that all subjects for whom outcome measures were available
received the treatment or control condition. Overall the quality of
the control trials is low due to the significant limitations present
in the majority of studies.
Case Series and Cohort Study
Scores on the JBI tool for case series evaluation ranged from 2 to
7 with an average of 3.8 out of 10 (see Figure 3). Four (27,29,33,
34) of the six case studies were judged to be at high risk of bias;
2 of the 6 of studies failed to outline clear criteria, only 30% used
valid methods for identification of the condition, >80% did not
report consecutive recruitment of subjects and failed to clearly
report clinical information of the participants. Two case studies
were judged to have an unclear risk of bias (26,31); strengths of
both these studies were found in reliable condition measurement
and clear reporting of participant demographics. Limitations of
the case series’ judged as “unclear risk of bias” were varied—
in one (31) it was not clear if the study included consecutive
and complete inclusion and methods of statistical analysis were
ambiguous; in the other (26) criteria were not clearly defined and
it was not possible to determine if valid methods for identification
of the condition were used.
This review has shown that despite trends demonstrating
improvement in CFP following various types of physical
rehabilitation, there is a lack of high-quality evidence currently
available to inform clinical practice. Many questions remain for
clinicians planning and providing therapy for this population.
Literature is emerging which recognizes CFP as an impairment
in its own right (separate to its impact on speech or swallowing
function), and therapies specifically targeting this disorder are
being investigated with increasing frequency. All the studies in
this review report improvement on various parameters of facial
movement or function and, although lacking in rigor, indicate
potential benefit from using physical rehabilitation approaches.
Effectiveness of Therapy
Improvement in facial muscle strength or movement was
reported across all 13 studies, and positive changes in other
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
FIGURE 2 | Study identification number: 1. (32) 2. (28) 3. (23) 4. (16) 5. (13) 6. (30) Max. indicates the highest possible score that an article could receive in each
FIGURE 3 | Study identification number: 7. (29) 8. (28) 9. (26) 10. (27) 11. (33) 12. (34) 13. (6) Max. indicates the highest possible score that an article could receive in
each category.
outcome measures such as swallow function and quality of
life were also shown (where measured). Only one study
provided data for maintained effects of therapy at >1 year post
intervention (32), and while this study had comparative strengths
in methodology, its lack of overall rigor reduced the strength
of the data. All 13 studies reported statistically significant
improvements from baseline measures, however none performed
calculations of optimal sample size or treatment effect measures.
It is therefore unclear if the improvements reported can be
attributed to the physical therapy provided or if other variables
influenced the outcomes. Overall, the studies included in this
review provide insufficient evidence to draw strong conclusions
regarding the effectiveness of physical rehabilitation for CFP.
Comparison of the effectiveness of differing therapy
approaches remains unclear following this review. Of the
four studies that were found to be the most methodologically
sound (as per risk of bias assessments), two provided active
therapy (one involved strengthening exercises only) (23,26), one
provided passive therapy (16), and one described a combination
of these two approaches (32). Active and passive approaches
were explored by only a small number of methodologically
weak RCTs, and there were no RCT designs that investigated
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
a combination of approaches. As well as insufficient reporting
of treatment effect size or precision, there was a large amount
of variation in all aspects of the design of the studies—each
study described different participant variables (e.g., time post
onset), dosage and treatment duration. These factors restrict
any meaningful comparison being made between outcomes,
which leads to a lack of support for one method of rehabilitation
over another.
This review highlights the need for further well-designed
and rigorous research to examine the efficacy of physical
rehabilitation of CFP. The trend of improvement across various
outcome measures reported in all studies provides some
indication that physical therapy may be of benefit, however
overall there were significant limitations that impact on confident
application of these findings to current clinical practice. These
include a lack of comprehensive reporting and analysis of data
in all studies, and methodological limitations (e.g., lack of RCT
designs, lack of concealed allocation, minimal use of blinding,
and lack of follow-up assessment). The majority of studies also
failed to use standardized, reliable outcome measurements, which
creates questions about the validity of findings and makes any
comparison of outcomes difficult. Future studies should aim
for more rigor in their design, for example by using RCTs to
minimize risk of bias and strengthen the validity of findings
and including follow-up assessment to measure maintenance of
therapeutic effect.
A major challenge for evaluation of methods of physical
rehabilitation of CFP is the heterogeneity of assessment tools
(and subsequently outcome measures) described. Only four of
the 13 included studies utilized any standardized method of
assessing facial palsy (6,13,16,23,32) and only three of these
used widely-accepted quantitative outcome measures (6,13,16,
23). The remainder of the studies described a variety of informal
clinical measures of muscle strength or facial movement and
function. As such, comparison of findings between the studies in
an effort to establish which methods were more effective is not
able to be reliably performed.
Clinical Implications
Positive trends in favor of physical rehabilitation were found. All
the studies retrieved by this review process do appear to show
improvements in facial palsy with rehabilitation, which lends
support to the rationale for continuation of therapy provision
as well as ongoing research. The strength of the evidence is low
overall, which should be considered when planning intervention
for this population.
Future Directions
Future studies should aim to use objective and standardized
assessment tools. Objective assessment of facial palsy is
notoriously difficult (42,46). Due to the lack of published,
validated assessment tools available specific to CFP, further
validation of tools designed for broader use (including peripheral
types of facial palsy) may be indicated. Literature specific to
PFP recommends use of the Sunnybrook Facial Grading System
(40), and the House-Brackmann Grading Scale (39), and these
tools have been used with some effectiveness to measure CFP
in studies by Volk et al. (6), Kang et al. (23), and Konecny
et al. (13,16). There are limitations in both tools including
subjective ordinal grading systems with limited items (47,
48). The Electronic Facial Paralysis Assessment (eFACE) was
developed to provide clinicians with a tool that “has greater
sensitivity and objectivity when assessing incomplete paralysis
and post-interventional improvement. . . in cases of both acute
peripheral nerve palsy and recovery” (49). This tool has been
found to have high test-retest reliability (50), have high validity
and reliability (49), and had positive feedback from a panel of
international facial nerve experts (51). The tool needs further
validation in a CFP population. In addition to measuring facial
function, the inclusion of reliable outcome measures that evaluate
the emotional and psychological impact of CFP would enable a
broader assessment of the holistic impacts of rehabilitation. Two
examples of validated patient-graded tools that are referenced
in current CFP literature are the Facial Clinometric Evaluation
(FaCE Scale) (42) and the Facial Disability Index (FDI) (43).
Studies of CFP should include use of one of these tools, as non-
motor impacts of facial palsy have been shown to be as important
as motor function to people with this impairment (52).
It would be beneficial to have a comprehensive picture
of current clinical practice to incorporate into future studies.
Clinical physiotherapists and speech pathologists provide
rehabilitation for CFP for using principles derived from
peripheral nerve damage literature due to the lack of studies
specific to CFP, despite these therapies also having low quality
supporting evidence (12) and varying significantly in mechanism
of impairment. A comprehensive survey of current practice
would enable “expert opinion” to be integrated into the
development of a gold standard of evidence-based physical
rehabilitation, along with stronger evidence from well-designed
clinical trials.
Exercise-based physical rehabilitation for facial palsy must
be performed in a controlled and precise manner, and repeated
sufficient times to induce long-term synaptic change (53). These
exercises are often performed using some method of biofeedback
(e.g., mirror); primarily relying on the visual system to obtain
accurate proprioceptive information about position of facial
muscles during slow, controlled movements that focus on
symmetry (54). Without some form of external proprioceptive
feedback, it is extremely difficult for patients to precisely
and effectively judge and monitor the movements of facial
structures (54). Exercise protocols can therefore be difficult for
people to perform accurately if they have concomitant visual-
perceptual, cognitive or behavioral changes secondary to stroke.
Well-designed research which evaluates the effectiveness of
interventions which are accessible to a wider clinical population
would be of great benefit to people suffering from central facial
palsy whose other impairments prevent them from engaging in
strict exercise-based protocols. Regardless of the intervention
strategy employed, clear and detailed reporting should be
ensured to enable replicable therapeutic protocols.
Further investigation of physical rehabilitation methods for
CFP is required to determine effective types and approaches for
therapy and to guide clinical decision-making. There is a gap in
services currently available for people wishing to access therapy
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
for CFP and is not possible to base a strong case for clinical input
on the current literature, even though trends have been identified
that indicate potential benefit of physical rehabilitation.
Although every effort was made to ensure database and other
searches were comprehensive it is possible that some records
were not retrieved via the search methods. Due to the difficulties
and cost associated with obtaining verified and reliable document
translation, this review was unable to include articles where the
full text was not available in English. This may have resulted
in some studies being missed; the authors are aware of at least
one non-English study (14) which may have contributed toward
this review. Our systematic review also had limitations relating
to methodological quality and available data in the existing
literature; only four RCTs were retrieved, which were of low
quality, and the observational studies all lacked sufficient data
to draw strong conclusions or perform calculation of treatment
effect size. It is recognized that in many areas of health care, some
interventions are supported by evidence from RCTs and others
are not (55). It is also acknowledged in medical research literature
that decision-making is often necessary even when there is
imperfect evidence (56). As clinicians who provide assessment
and therapy to patients with central facial palsy, we included the
smaller observational studies due to a lack of larger or more well-
designed trials—as per Balshem et al. “in the absence of high-
quality evidence, clinicians must look to lower quality evidence
to guide their decisions” (57). While we are aware that the
limitations in methodology affect the reliability of these studies,
and thus also affect the strength of recommendations that can be
drawn from their findings, the reality is that there are not enough
large well-designed RCTs available to rely solely on this level of
evidence for clinical decision-making and intervention.
The studies in this review report improvement of facial
movement or function following application of various methods
of physical rehabilitation for CFP. Methodological limitations
and heterogeneity of design affect the strength of the evidence
and prevent reliable comparison between intervention methods.
Strong conclusions regarding the effectiveness of intervention
cannot be drawn using the studies identified by this review as
good quality, robust evidence supporting physical rehabilitation
of central facial palsy was not found.
The datasets generated for this study are available on request to
the corresponding author.
AV and DG conceived the idea for this review. AV, DG, RW,
AM, and SC formulated the question for review and designed the
search strategy. AV and DG performed the abstract screening,
full text review, and extracted data from included studies. AV
and RW performed the risk of bias assessments. AV analyzed
and interpreted the data and drafted the manuscript. AC and AM
provided overall supervision of the project and final approval of
the version to be published. All authors provided critical feedback
and helped shape the research, analysis, and manuscript.
This study was undertaken with support from a Gold Coast
Health Allied Health Clinical Backfill for Research grant, which
provided AV and DG with four weeks of funded offline time.
Assistance with funding open-access publication was granted via
the Gold Coast Health Study, Education and Research Trust.
The review team thanks Sarah Thorning for her valuable
assistance with database searching and deduplication of search
results. We also thank the Speech Pathology and Audiology
Service (Allied Health Services|Gold Coast Health).
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Vaughan, Gardner, Miles, Copley, Wenke and Coulson. This is an
open-access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
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Vaughan et al. Systematic Review of Facial Palsy Rehabilitation
Search Strategy (Example)
Database: Ovid MEDLINE(R) ALL <1946 to December 31, 2018>
1. exp Facial Paralysis/ (11721)
2. ((facial or orofacial or oro-facial) adj3 (paralysor paresis or
droopor palsy or asymmetror impair)).tw. (14536)
3. ((facial or orofacial or oro-facial) adj3 (expressor nerveor
muscleor moveor reanimat)).tw. (26746)
4. or/1-3 (38981)
5. exp Physical Therapy Modalities/ (140199)
6. (exercisor therapor physiotherapor rehabilit
or retrainor trainor treator managor
intervention).tw. (7745138)
7. (mimeor miming or mirroror tapor massagor
stretchor acupuncturor needlingor biofeedback or
neuromuscularor kinesioor cryo).tw. (382977)
8. (electricadj2 stimul).tw. (62989)
9. (e-stimor electromyographor semg).tw. (39537)
10. or/5-9 (8084566)
11. 4 and 10 (15595)
12. exp Central Nervous System Diseases/ (1342443)
13. (central nervous system adj2 (diseasor injuror
infect)).tw. (9406)
14. upper motor (1424)
15. (218936)
16. brain (57635)
17. (21035)
18. (central adj3 ( adj2 (paralysor paresis or palsy or
palsies))).tw. (144)
19. or/12-18 (1463675)
20. 11 and 19 (1970).
Frontiers in Neurology | 13 March 2020 | Volume 11 | Article 222
... Facial palsy adalah suatu kondisi neurologis yang memengaruhi fungsi motorik wajah, terdiri dari central facial palsy dan peripheral facial palsy. Central facial palsy terjadi akibat kerusakan segmen sentral saraf yaitu lesi pada upper motor neuron (UMN) sedangkan peripheral facial palsy terjadi akibat kerusakan perifer saraf yaitu lesi pada lower motor neuron (LMN) (Bharathi et al., 2019;Vaughan et al., 2020). ...
... Central facial palsy adalah gejala awal yang umumnya terjadi pada pasien pasca stroke dan cedera neurologis lainnya. Peripheral facial palsy yang belum diketahui penyebabnya (idiopatik) disebut Bell's palsy, merupakan penyebab paling umum yaitu sekitar 75% dari facial palsy (Vaughan et al., 2020;Hassan et al., 2020). ...
... Central facial palsy menyebabkan defisit fungsional pada wajah yang memengaruhi ekspresi wajah dan dapat ditandai dengan asimetri wajah dan kelemahan hanya pada bagian bawah wajah seperti sudut mulut terkulai, berkurangnya kekuatan dan efisiensi pengunyahan, senyum asimetris dan disartria, sedangkan peripheral facial palsy dapat memengaruhi bagian bawah wajah dan dahi seperti sudut mulut terkulai, garis dahi menghilang, lipatan palpebra melebar, dan lid margin mata tidak tertutup, kantung mata bawah dan punctum jatuh, disertai air mata yang menetes tanpa disadari. Pada penderita facial palsy fungsi saraf wajah terganggu sehingga dapat menyebabkan gangguan aktivitas sehari-hari (Vaughan et al., 2020;Adam, 2019;Chang et al., 2016). ...
Latar Belakang : Facial palsy adalah suatu kondisi neurologis yang memengaruhi fungsi motorik wajah ditandai dengan asimetri dan kelemahan otot sebagian atau seluruh wajah sehingga menurunkan kemampuan fungsional wajah. Mirror therapy exercise merupakan suatu latihan berupa senam wajah dengan meggunakan cermin atau software untuk menghasilkan umpan balik visual dari bagian tubuh yang terkena lesi dan menghasilkan gerakan di sisi tubuh yang terkena. Tujuan : Untuk mengetahui efektivitas mirror therapy exercise terhadap kemampuan fungsional wajah penderita facial palsy melalui kajian literatur. Metode Penelitian : Jenis penelitian ini deskriptif dengan desain studi literatur. Literatur 10 tahun terakhir dikumpulkan dari 16 search engine dengan menggunakan teknik PICOS. Selanjutnya diseleksi awal dan metodologi, lalu dimasukan ke aplikasi Mendeley untuk literatur terduplikasi. Literatur yang eligible diekstraksi dengan filterisasi metode CONSORT. Hasil : Berdasarkan7 literatur yang eligible, mirror therapy exercise dengan kombinasi ataupun modifikasi efektif dalam meningkatkan kemampuan fungsional wajah penderita facial palsy. Kesimpulan : Berdasarkan kajian literatur, mirror therapy exercise dapat digunakan untuk meningkatkan kemampuan fungsional wajah penderita facial palsy.
... Upon comparison of the content quality of the analyzed websites with the topics featured on the UpToDate patient information page, it was determined that approximately 20% of the pages had an adequate level of content (that have a minimum of seven topics). Although numerous studies (1,4,28) have recommended exercise and rehabilitation techniques to expedite the duration of treatment and disease in cases of facial paralysis, 65.1% of the HP websites did not include any mention of these proven practices. ...
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Background/Aims: Known as Bell's palsy, is a neurological disorder characterized by partial or complete paralysis of the muscles of the face, results from impairment or dysfunction of the facial nerve. This study aims to evaluate the readability, content, and quality and determine the level of accuracy and reliability of websites in Turkish language that provide information about facial paralysis. Methods: This descriptive, cross-sectional study analyzed the quality, usability, content and readability of Turkish facial paralysis websites using the Ateşman and Bezirci-Yılmaz Readability Formula, reading time, number of images, JAMA Benchmark Criteria, DISCERN Scale and UpToDate topics. was used to assess aesthetic appeal and user experience. Results: After reviewing 200 websites, 110 Turkish sites about facial paralysis were included in the study. Average reading time was 5.5 minutes. Bezirci-Yılmaz score was 13.8. Ateşman readability levels were moderate. News, blog and "other" sites had the most visual content, followed by Health Professionals (HP) sites. Average quality of sites was poor. Conclusions: The DISCERN scale found 60% of Turkish health websites had poor-to-very poor content quality. UpToDate's benchmarking revealed 58.2% of sites contained less than half of the basic topics. This indicates inadequate, outdated info for facial paralysis patients. State Institutions and Health Related Associations should provide valid, reliable info on modern websites.
... However, our study results are similar with the existing studies conducted on similar principles of treatment approach on changing the behavioural output of a person with disability. [25][26][27][28][29] Future research with rigorous methodologies can make this claim certain. ...
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Background: This study aimed to examine the effects of a functional training in improving function of facial muscles in people with facial palsy due to trauma. Settings and Design: Saveetha Physiotherapy OPD, Two group pre-test post-test non-equivalent design. Methods: 20 participants based on convenient sampling were assigned to either receive Functional training group or conventional treatment group. The primary outcome measures are House Brackman score and facial disability index (FDI). Statistical analysis used: Mann Whitney U test was used to compare the data sets between the groups. Results: Between group analysis of post-test mean and standard deviation for House-Brackman score for Func-tional training group and conventional treatment were 1.6(1) and 3.67(0.72) respectively. It was statistically significant with p<0.05.Between group analysis for FDI were statistically significant with p=0.01 at the end of 4 weeks for both subscales of physical and social. Conclusions: Functional training may improve function of facial muscles and can be recommended for people affected with facial palsy due to trauma. Keywords: functional training, traumatic facial palsy, facial exercises, recovery of function, facial rehabilitation, FDI, House-Brackman, Task training
... Given that a proportion of facial paralysis patients develop facial muscle weakness and synkinesis, long term rehabilitation must focus on voluntary movement control and synkinesis limitation. 28,[33][34][35] Surgical treatment Sir Harold Gillies noted in 1919 that the purpose of surgical reconstruction is to restore normal shape; this is done initially to regain function and later to address aesthetics. Concerning facial paralysis, the critical challenge is that there is currently no feasible method to recover the 17 facial expression muscles. ...
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Facial nerve paralysis is a debilitating condition with multiple etiologies, with aesthetic, functional, psychological and social impact. Given the complex multitude of causes that may generate such condition, a therapeutic algorithm is mandatory when attempting reconstruction. Severity, timing, patient adherence to a rehabilitation program, status of ipsilateral and contralateral facial nerves and particularities of each patient are all criteria which should be accounted when choosing a treatment option. After initial assessment, a variable treatment panel is available based on condition type include medicamentous therapy, rehabilitation program, dynamic and static procedures surgical procedures, having as primary aim functional restoration achieving aesthetic balanced facial features. This paper summarizes current knowledge in facial paralysis reconstruction and presents an algorithmic approach that eases decision making and therapeutic strategy.
... Most of the works that focus on face rehabilitation for recovering from facial paralysis appeared in the medical domain (see for example the work by Vaughan et al. [8]). A computer vision based survey was recently published by Debnath et al. [9], but for body motion rather than for faces. ...
... A similar evidence base for facial palsy following stroke is currently lacking. 85 Because this form of central facial palsy is clinically distinct, 86 current review findings are not directly transferrable. But, the lessons learned here might be applied to improve the evidence base for these patients. ...
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Objective To conduct a systematic review of the effectiveness of facial exercise therapy for facial palsy patients, updating an earlier broader Cochrane review; and to provide evidence to inform the development of telerehabilitation for these patients. Data Sources MEDLINE, EMBASE, CINAHL, Cochrane Library, PEDro and AMED for relevant studies published between 01 January 2011 and 30 September 2020. Methods Predetermined inclusion/exclusion criteria were utilised to shortlist abstracts. Two reviewers independently appraised articles, systematically extracted data and assessed the quality of individual studies and reviews (using GRADE and AMSTAR-2, respectively). Thematic analysis used for evidence synthesis; no quantitative meta-analysis conducted. The review was registered with PROSPERO (CRD42017073067). Results Seven new randomised controlled trials, nine observational studies, and three quasi-experimental or pilot studies were identified ( n = 854 participants). 75% utilised validated measures to record changes in facial function and/or patient-rated outcomes. High-quality trials (4/7) all reported positive impacts; as did observational studies rated as high/moderate quality (3/9). The benefit of therapy at different time points post-onset and for cases of varying clinical severity is discussed. Differences in study design prevented data pooling to strengthen estimates of therapy effects. Six new review articles identified were all rated critically low quality. Conclusion The findings of this targeted review reinforce those of the earlier more general Cochrane review. New research studies strengthen previous conclusions about the benefits of facial exercise therapy early in recovery and add to evidence of the value in chronic cases. Further standardisation of study design/outcome measures and evaluation of cost-effectiveness are recommended.
... (2,3) Clinical assessment of these symptoms remains a challenge in medicine and clinical research. (4,5) Existing clinical assessments, such as clinician-reported outcomes (ClinROs) or patientreported outcomes (PROs) may require the patient to frequently visit sites, primarily rely on subjective measures, and may not necessarily reflect a patient's condition(s) in the real world. ...
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Many neuromuscular disorders impair function of cranial nerve enervated muscles. Clinical assessment of cranial muscle function has several limitations. Clinician rating of symptoms suffers from inter-rater variation, qualitative or semi-quantitative scoring, and limited ability to capture infrequent or fluctuating symptoms. Patient-reported outcomes are limited by recall bias and poor precision. Current tools to measure orofacial and oculomotor function are cumbersome, difficult to implement, and non-portable. Here, we show how Earable, a wearable device, can discriminate certain cranial muscle activities such as chewing, talking, and swallowing. We demonstrate using data from a pilot study of 10 healthy participants how Earable can be used to measure features from EMG, EEG, and EOG waveforms from subjects performing mock Performance Outcome Assessments (mock-PerfOs), utilized widely in clinical research. Our analysis pipeline provides a framework for how to computationally process and statistically rank features from the Earable device. Finally, we demonstrate that Earable data may be used to classify these activities. Our results, conducted in a pilot study of healthy participants, enable a more comprehensive strategy for the design, development, and analysis of wearable sensor data for investigating clinical populations. Additionally, the results from this study support further evaluation of Earable or similar devices as tools to objectively measure cranial muscle activity in the context of a clinical research setting. Future work will be conducted in clinical disease populations, with a focus on detecting disease signatures, as well as monitoring intra-subject treatment responses. Readily available quantitative metrics from wearable sensor devices like Earable support strategies for the development of novel digital endpoints, a hallmark goal of clinical research.
Objective: This study investigates the efficacy of Korean medical treatment for a patient with peripheral facial palsy caused by cerebellar artery infarction.Methods: A 45-year-old male patient with right facial palsy and left side numbness from cerebellar artery infarction was treated with herbal medicine (ligigeopoongsan), acupuncture, pharmacopuncture, and cupping therapy for 37 days. The effects were evaluated using the House-Brackmann (H-B) and Yanagihara’s unweighted grading systems.Results: Following treatment, the patient’s H-B grade decreased and Yanagihara score improved.Conclusion: Korean medical treatment improved peripheral facial palsy in a patient with cerebellar artery infarction.
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Objective To analyze the morphofunctional regeneration process of facial nerve injury in the presence of insulin-like growth factor-1 and mesenchymal stem cells. Methods Fourteen Wistar rats suffered unilateral facial nerve crushing and were randomly divided into two groups. All received insulin-like growth factor-1 inoculation, but only half of the animals received an additional inoculation of mesenchymal stem cells. The animals were followed for 90 days and facial nerve regeneration was analyzed via spontaneous facial motor function tests and immunohistochemistry in the nerve motor nucleus. Results The group that received the growth factor and stem cells showed a statistically superior mean in vibrissae movements (p < 0.01), touch reflex (p = 0.05) and eye closure (p < 0.01), in addition to better immunohistochemistry reactivity. There was a statistically significant difference in the mean number of cells in the facial nerve nucleus between the experimental groups (p = 0.025), with the group that received the growth factor and stem cells showing the highest mean. Conclusion The association between growth factor and stem cells potentiates the morphofunctional regeneration of the facial nerve, occurring faster and more effectively. Level of Evidence 4, degree of recommendation C.
Background: Facial nerve palsy can have ophthalmological, Otological, rhinological, taste, and swallowing consequences, in addition to the psychological impact of altered facial expression. Electrical Stimulation (ES) is one of the most debatable and non-evidence-based adjunctive therapies for facial palsy. MATERIAL/METHODS We retrieved the literature on ES in facial nerve injury using the Cochrane Database of Systematic Reviews, PubMed, and Google Scholar. Emphasis was placed on articles and randomised controlled trials (RCTs) published within the last 20 years. Results: The reviewed studies, clinical trials and systematic reviews did not support ES due to a lack of quality evidence to support significant b e n e fi t o r h a r m fr o m E S . T h e v a ri e d methodologies used and the small number of subjects included in the studies could not wholly prove the efficacy of electrotherapy for treating facial nerve injury. CONCLUSION T h o u g h m a n y s t u d i e s h a v e r e p o rt e d improvement of facial movement or function following ES for facial nerve injury, substantial evidence supporting the use of ES in facial palsy is lacking; well-designed rigorous research is required. KEYWORDS Electrical Stimulation, Facial Nerve Palsy, Facial Paralysis
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[Purpose] We aimed to investigate the effect of resistance training of the orbicularis oris muscles on lip muscle strength and closure function in patients with swallowing disorder with facial palsy after stroke. [Participants and Methods] This study recruited 10 patients with swallowing disorder and facial palsy after stroke. All the participants received orbicularis oris muscle training at an intensity of 70% of 1 repetition maximum by using an Iowa oral performance instrument. Muscle strength and lip closure function were evaluated after orbicularis oris muscle training. [Results] After the intervention, the orbicularis oris muscle strength showed a statistically significant increase from 20.5 ± 5.15 to 25.3 ± 4.2 kilopascal. Lip closure function showed a statistically significant improvement from 2.6 ± 1.5 to 1.2 ± 1.0. [Conclusion] This study recommends to train at an intensity of 70% of 1 repetition maximum for 4 weeks to increase theorbicularis oris muscle strength and improve lip closure function.
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Although central facial paresis (CFP) is a major symptom of stroke, there is a lack of studies on the motor and non-motor disabilities in stroke patients. A prospective cohort study was performed at admission for inpatient rehabilitation and discharge of post-stroke phase of 112 patients (44% female, median age: 64 years, median Barthel index: 70) with CFP. Motor function was evaluated using House-Brackmann grading, Sunnybrook grading and Stennert Index. Automated action unit (AU) analysis was performed to analyze mimic function in detail. Non-motor function was assessed using the Facial Disability Index (FDI) and the Facial Clinimetric Evaluation (FaCE). Median interval from stroke to rehabilitation was 21 days. Rehabilitation lasted 20 days. House-Brackmann grading was ≥ grade III for 79% at admission. AU activation in the lower face was significantly lower in patients with right hemispheric infarction compared to left hemispheric infarction (all p < 0.05). Median total FDI and FaCE score were 46.5 and 69, respectively. Facial grading and FDI/FaCE scores improved during inpatient rehabilitation (all p < 0.05). There was a significant increase of the activation of AU12 (Zygomaticus major muscle), AU13 (Levator anguli oris muscle), and AU24 (Orbicularis oris muscle) during inpatient rehabilitation (all p < 0.05). Multivariate analysis revealed that activation of AU10 (Levator labii superioris), AU12, AU17 (Depressor labii), and AU 38 (Nasalis) were independent predictors for better quality of life. These results demonstrate that CFP has a significant impact on patient’s quality of life. Therapy of CFP with focus on specific AUs should be part of post-stroke rehabilitation.
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[This corrects the article on p. 347 in vol. 41, PMID: 28758071.].
Planning for the ‘Summary of findings’ table starts early in the systematic review, with the selection of the outcomes to be included in: the review; and the ‘Summary of findings’ table. This is a crucial step, and one that review authors need to address carefully. To ensure production of optimally useful information, Cochrane Reviews begin by developing a review question and by listing all main outcomes that are important to patients and other decision makers. The GRADE approach to assessing the certainty of the evidence defines and operationalizes a rating process that helps separate outcomes into those that are critical, important or not important for decision making. Review authors should report the grading of the certainty of evidence in the Results section for each outcome for which this has been performed, providing the rationale for downgrading or upgrading the evidence, and referring to the ‘Summary of findings’ table where applicable.
Masseter and temporalis muscle transfer is an effective technique for restoring facial symmetry and commissure excursion in flaccid facial paralysis. Adherence to the principles and biomechanics of muscle transfer is essential for achieving optimal results. Muscle transfer has the advantage of being single staged with fast recovery of function. It is particularly useful in patients with low life expectancy or multiple comorbidities where a more complex, multiple stage procedure may be detrimental.
Facial expression is of critical importance in interpersonal interactions. Thus, patients with impaired facial expression due to facial paralysis experience impaired social interactions. Numerous studies have shown that patients with facial paralysis and impaired facial expression suffer social consequences as demonstrated by being rated negatively with regards to attractiveness, affect display, and other traits. This has been demonstrated subjectively and objectively. Fortunately, reconstructive surgeries that restore the ability to express emotion can restore normalcy in these patients.
The facial nerve, the seventh cranial nerve, is of great clinical significance to oral health professionals. Most published literature either addresses the central connections of the nerve or its peripheral distribution but few integrate both of these components and also highlight the main disorders affecting the nerve that have clinical implications in dentistry. The aim of the current study is to provide a comprehensive description of the facial nerve. Multiple aspects of the facial nerve are discussed and integrated, including its neuroanatomy, functional anatomy, gross anatomy, clinical problems that may involve the nerve, and the use of detailed anatomical knowledge in the diagnosis of the site of facial nerve lesion in clinical neurology. Examples are provided of disorders that can affect the facial nerve during its intra-cranial, intra-temporal and extra-cranial pathways, and key aspects of clinical management are discussed. The current study is complemented by original detailed dissections and sketches that highlight key anatomical features and emphasise the extent and nature of anatomical variations displayed by the facial nerve.
Background: The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement. Methods: Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user. Results: eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement. Conclusions: The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.
Background: Facial paralysis remains a debilitating condition despite advances in medical, surgical and adjunctive interventions. Established grading systems used to assess facial paralysis and interventional outcomes have well described limitations. The Electronic Facial Paralysis Assessment (the eFACE), a clinician-graded zone-based facial function scale, has recently emerged as a grading tool that may provide greater sensitivity when assessing incomplete paralysis and post-surgical improvement. We perform the first comprehensive validation of the eFACE. Methods: Video recordings of eighty-three facial paralysis patients were assessed. Grading was performed in two sittings by three individuals with varying degrees of experience in assessing facial paralysis. Inter-observer reliability, intra-observer reliability, administration time, and agreement with the Facial Disability Index, House-Brackmann, Sunnybrook and Sydney facial grading systems were assessed. Results: eFACE scores demonstrated high intra-observer and inter-observer reliability (intraclass correlation coefficient 0.84-0.91and 0.81-0.83, respectively). The eFACE correlated well with the House-Brackmann, Sunnybrook and Sydney facial grading systems (Spearman rho 0.73, 0.77 and 0.77, respectively). In sub-domain analysis, the eFACE correlated well with the Sunnybrook and Sydney systems in dynamic movement (Spearman rho 0.90 and 0.89, respectively) and synkinesis (Spearman rho range 0.74 and 0.72, respectively). Agreement between the eFACE and the Facial Disability Index was poor (Spearman rho 0.25). The mean time to completion of the tool was 116±61 seconds. Conclusion: The eFACE is a valid facial assessment tool with high reliability and correlation with the established facial paralysis grading systems. It also provides an efficient and detailed analysis of paralysis according to each zone of the face.