Central facial paresis and its impact on mimicry, psyche and quality of life in patients after stroke

The role of oral and pharyngeal motor exercises in post-stroke recovery: A scoping review

OBJECTIVE

To analyze intervention goals, protocols, and outcome measures used for oral and pharyngeal motor exercises in post-stroke recovery.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsychINFO, and Cochrane databases were searched in September 2022.

METHODS

Studies were included if they (1) recruited post-stroke adult patients, (2) administered exercises for the oral and/ or pharyngeal muscles, and (3) reported results at baseline and post-exercise. The extracted data included intervention goals, protocols, and outcomes. All outcomes were classified according to the International Classification of Functioning, Disability and Health (ICF).

RESULTS

A total of 26 studies were identified. Their intervention goals aimed to rehabilitate a broad spectrum of muscle groups within the oral cavity and pharynx and to improve the functions of swallowing, speech, facial expressions, or sleep breathing. Protocol duration ranged from 1 to 13 weeks, with various exercise repetitions (times per day) and frequency (days per week). Half of the studies reported using feedback to support the training, and these studies varied in the feedback strategy and technology tool. A total of 37 unique outcome measures were identified. Most measures represented the body functions and body structure component of the ICF, and several of these measures showed large treatment effects.

CONCLUSIONS

This review demonstrated inconsistency across published studies in intervention goals and exercise protocols. It has also identified current limitations and provided recommendations for the selection of outcome measures while advancing a multidisciplinary view of oral and pharyngeal exercises in post-stroke recovery across relevant functions.

Physical rehabilitation of central facial palsy: A survey of current multidisciplinary practice

Purpose: The role of allied health practitioners providing physical rehabilitation of central facial palsy (CFP) is minimally reported in the literature. This study explores current practice and the roles, attitudes and perceptions of allied health professionals (AHPs) working with people with CFP.Method: An electronic survey was distributed to speech-language pathologists (SLPs), occupational therapists and physiotherapists. Responses (n = 78) were analysed using qualitative and quantitative methods.Result: SLPs often lead management of CFP; however, their role is not clearly defined nor well recognised. Several barriers were identified which prevent AHPs from providing consistent specialist rehabilitation to people with CFP. These included a lack of training, no clear delegation of role, limited evidence and lack of resources.Conclusion: Survey respondents viewed CFP to be within SLP scope of practice; although, ownership of management varies between countries and professions. Most SLPs recognise the negative impact of CFP and feel a sense of responsibility to provide assessment and treatment of this impairment, but many barriers to doing so have been identified. Suggestions to improve access to rehabilitation for people with CFP included increased access to training for SLPs, more evidence, clinical practice guidelines and more clinical resources. Further research is required to ensure people suffering from CFP can access services that provide skilled management of their impairment.

Assessment and rehabilitation interventions for central facial palsy in patients with acquired brain injury: a systematic review

Objectives: To do a systematic review covering assessments and interventions for central facial palsy (CFP) in patients with acquired brain injury.Methods: PubMed, Embase, Cinahl, PsycInfo, and Web of Science were screened until April 2019. Assessments were defined as clinical- and instrumental tools and rating scales. Interventions were defined as rehabilitation interventions alleviating CFP.Results: 690 articles were screened based on the title and abstract. Interrater agreement was 98.12%. Sixteen articles were included: six clinical trials and 10 observational studies. Assessment: Commonest scale for assessing CFP was the House-Brackmann facial nerve Grading System. Strain gauges for measuring lip and cheek strength were applied in five studies and neurophysiological methods of assessing motor neuron pathways were applied in three studies. Interventions: An oral screen for improving lip strength was reported in three studies. Other interventions reported were neuromuscular electrical stimulation, Castillo Morales therapy, mirror therapy, exercises with electromyography feedback, and acupuncture.Conclusions: Scales for assessing peripheral facial palsy were applied for assessing CFP. Based on neurophysiological differences in the manifestation of peripheral facial palsy and CFP, these scales should be validated in patients with CFP. More studies on interventions for CFP are required before conclusions may be drawn about their effectiveness.

A Systematic Review of Physical Rehabilitation of Facial Palsy

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.

Facial motor and non-motor disabilities in patients with central facial paresis: a prospective cohort study

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.

Effects of Mirror Therapy Using a Tablet PC on Central Facial Paresis in Stroke Patients

Objective

To investigate the effects of mirror therapy using a tablet PC for post-stroke central facial paresis.

Methods

A prospective, randomized controlled study was performed. Twenty-one post-stroke patients were enrolled. All patients performed 15 minutes of orofacial exercise twice daily for 14 days. The mirror group (n=10) underwent mirror therapy using a tablet PC while exercising, whereas the control group (n=11) did not. All patients were evaluated using the Regional House–Brackmann Grading Scale (R-HBGS), and the length between the corner of the mouth and the ipsilateral earlobe during rest and smiling before and after therapy were measured bilaterally. We calculated facial movement by subtracting the smile length from resting length. Differences and ratios between bilateral sides of facial movement were evaluated as the final outcome measure.

Results

Baseline characteristics were similar for the two groups. There were no differences in the scores for the basal Modified Barthel Index, the Korean version of Mini-Mental State Examination, National Institutes of Health Stroke Scale, R-HBGS, and bilateral differences and ratios of facial movements. The R-HBGS as well as the bilateral differences and ratios of facial movement showed significant improvement after therapy in both groups. The degree of improvement of facial movement was significantly larger in the mirror group than in the control group.

Conclusion

Mirror therapy using a tablet PC might be an effective tool for treating central facial paresis after stroke.