Management of Facial Synkinesis with a Combination of BTX-A and Biofeedback: A Randomized Trial

Document Type: Original

Authors

1 Department of Physical Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.

2 Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Abstract

Introduction:
Synkinesis and facial asymmetry due to facial nerve palsy are distressing conditions that affect quality of life. Unfortunately, these sequelae of facial nerve palsy are unresolved. The aim of this study was to investigate the efficacy of a combination of biofeedback therapy and botulinum toxin A (BTX-A) injection for the management of synkinesis and asymmetry of facial muscles.
 
Materials and Methods:
Among referrals from three university hospitals, 34 patients with facial synkinesis were divided randomly into two groups. All participants wereevaluated using Photoshop software, videotape, and facial grading system (FGS). The firstgroup received a single dose of BTX-A at the start of treatment, while the second group received normal saline as a control. Bothgroups received electromyography (EMG) biofeedback threetimes a week for 4 months.
 
Results:
The mean FGS values for the BTX group before and after treatment were 55.17and 74.17, respectively, and those for the biofeedback group were 66.31 and 81.37,respectively. Moreover, it was shown that in both groups oral-ocular and oculo-oral synkinesisdecreased significantly after treatment compared with before treatment (P0.05).
 
Conclusion:
Biofeedback therapy is as effective as the combination of biofeedback and BTX in reducing synkinesis and recovery of facialsymmetry in Bell's palsy.

Keywords

Main Subjects


1.  Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta oto-Laringologica 2002; 122(7):4-30.

2.  Beurkens C, HG BIA. Literature Review of Evidenece Based Physiotherapy in Patients with Facial Nerve Paresis. J Jpn phys Ther Assoc 2004; 7(1): 35-9.

3. Beurskens CH, Heymans PG. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial. Australian Journal of Physiotherapy 2006; 52(3):  177-83.

4. Ma MS, Van der Hoeven JH, Nicolai JPA, Meek MF. Sound-induced facial synkinesis following facial nerve paralysis  2009; 62(8):1025-9.

5. Patel BC, Anderson RL, May M. Management of facial hyperkinesis, selective myectomy. In: May M. The Facial Nerve. 2nd ed. New York: Thieme; 2000:467-81.

6. Cronin GW, Steenerson RL. The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otolaryngology-Head and Neck Surgery 2003; 128:534-8.

7. Celik M, Forta H, Vural C. The development of synkinesis after facial nerve paralysis. European Neurology 2000;43(3):147-51.

8. Azuma T, Nakamura K, Takahashi M, Ohyamam S, Toda N, Lwasaki H, et al. Mirror Biofeedback Rehabilitation after Administration of Single-Dose Botulinum Toxin for Treatment of Facial Synkinesis. Otolaryngol Head Neck Surg 2012; 146(1):40-45.

9. Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N. Biofeedback rehabilitation for prevention of synkinesis after facial palsy. Otolaryngology - Head and Neck Surgery 2003; 128(4):539-43.

10. Pepper J-P, Kim JC. Selective chemodenervation with botulinum toxin in facial nerve disorders. Operative Techniques in Otolaryngology-Head and Neck Surgery 2012; 23(4):297-305.

11. Terzis JK, Karypidis D. Therapeutic strategies in post-facial paralysis synkinesis in pediatric patients. Journal of Plastic, Reconstructive & Aesthetic Surgery 2012; 65(8): 1009-18.

12. May M. Management of facial hyperkinesis, overview of hyperkinesis. The Facial nerve. 2nd ed. New York: Thieme; 2000:431-39.

13. May M. Psychological aspects of facial paralysis in may. In: May, ed. The facial Nerve. New York: Thieme, 1986.

14. Pourmomeny AA, Zadmehr H, Mirshamsi M. Mahmodi Z. Prevention of synkinesis by biofeedback therapy: A randomized clinical trial. Otology & Neurotology 2013; 35(4):739-42.

15. VanSwearingen JM, Brach JS. Changes in facial movement and synkinesis with facial neuromuscular reeducation. Plastic & Reconstructive Surgery 2003 Jun; 111(7): 2370-5.

16. Bentsianov B, Zalvan C, Blitzer A, Blitzer A. Noncosmetic uses of botulinum toxin. Clinics in Dermatology 2004; 22(1): 82-8.

17. Armstrong MWJ, Mountain RE, Murray JAM. Treatment of facial synkinesis and facial asymmetry with botulinum toxin type A following facial nerve palsy.Clin Otolaryngol Allied Scik 1996; 21(1):15-20.

18. Choi KI,  Rho SH,  Lee JM,  Jeon JH,  Park SY, Kim J. Botulinum toxin injection of both sides of the face to treat post-paralytic facial synkinesis. J Plast Reconstr Aesthet Surg 2013; 66(8):1058-63.

19. Ito H, Nakano S, Kusaka H. Low-dose subcutaneous injection of botulinum toxin type A for facial synkinesis and hyperlacrimation. Acta Neurol Scand 2007; 115(4): 271-4.

20. Pourmomeni AA, Asiaei H, Mirshamsi M,  Amirrajab AR, Hasanzadeh A. Anthropometric measurements of lip-nose complex in 11-17 years old males of Mashhad using photographic analysis. The Iraninan journal of Otorhinolaryngology 2010; 22 (59):15-20.

21. Ross BG, Fradet G, Nedzelski JM. Development of a sensitive clinical facial grading system. Otolaryngology - Head and Neck Surgery 1996; 114(3):380-6.

22. Drake RL, Vogl AW, Mitchell AWM. Head and Neck. Gray's anatomy for students. 2th ed. Churchill Livingstone: Elsevier; 2010. p. 856-69.

23. Monini S, De Carlo A, Biagini M, Buffoni A, Volpini L, Lazzarino A, Barbara M. Combined protocol for treatment of secondary effects from facial nerve palsy. Acta Otolaryngol 2011;131:882-6.

24. Brodal A. Neurological Anatomy in Relation to Clinical Medicine. 3rd ed. New York: Oxford University Press; 1981.

25. Schaitkin B, Eisenman D. Anatomy of Facial Muscles. In: May M, Schaitkin B, eds. The Facial Nerve.  2nd ed. New Yourk: Thieme; 2000:95-105.

26. Robinson MW, Baiungo J, Hohman M, Hadlock T. Facial rehabilitation. Operative Techniques in Otolaryngology- Head and Neck Surgery 2012; 23(4):288-96.

27. Diels HJ, Combs D. Neuromuscular  retraining for facial paralysis.  Clin Otolaryngol 1997; 30(5): 727-43.

28. VanSwearingen J. Facial Rehabilitation: A Neuromuscular Reeducation, Patient-Centered Approach Jessie.Facial Plastic Surgery 2008;24: 250-9.

29. Pourmomeny AA, Asadi S. Management of synkinesis and asymmetry in facial nerve palsy: A review article. Iranian Journal of Otorhinolaryngology 2014;26(4): 251-56.