Retraining the Muscles of the Face
MADISON - Jackie Diels, OT, a facial rehabilitation specialist at UW Health's Research Park Rehabilitation Clinic, is the most prominent and experienced practitioner of facial retraining in the United States.
She has been honing her skills for nearly 20 years, sees patients from all over the world and has trained the vast majority of therapists who offer similar services.
But her profile is relatively low. Why?
"In the scheme of the medical community, there isn't as much facial paralysis as there is stroke or hip fractures," says Diels. "The population is really small."
Diels sees patients with partial facial paralysis, which most often stems from one of two sources. The first, Bell's Palsy, a disorder caused by damage to the seventh cranial nerve, affects two in 10,000 people, according to National Institutes of Health (NIH) estimates.
The second and most common source is an acoustic neuroma, a benign tumor that disturbs the auditory or eighth cranial nerve. Because these tumors grow in close proximity to the seventh cranial nerve, which controls the facial muscles, facial paralysis can result when the facial nerve is crowded by tumor growth or brushed during surgery to remove the tumor.
Acoustic neuromas are even more rare than Bell's Palsy, occurring in one out of 100,000 people. But the disturbance that results is obvious to even the mildly attentive observer. The muscles on one side of the face go dormant and often the eye isn't able to close, which increases the risk of corneal abrasion and ulceration.
"It's very caved-in looking," Diels explains. "A lot of people have trouble speaking, eating and drinking."
Facial paralysis isn't life-threatening, but Diels believes her services provide a benefit that cannot be measured with an EKG or blood pressure cuff. To Diels, working through the difficulty of partial facial paralysis isn't merely an exercise in vanity. It's about restoring non-verbal communication.
"They lose that," she says. "People don't read them correctly. They stare. It's very emotional."
The retraining sessions
Eighty-five percent of those who experience partial facial paralysis from Bell's Palsy heal completely without therapy. For that reason, Diels asks her patients to wait three months before coming to her. For those who notice no improvement in those three months, Diels has devised a three-day therapy regimen that re-coordinates the facial muscles so they function the way they are supposed to.
These patients often come to her with a variety of facial tics and twitches, because as the seventh cranial nerve heals, it often compels muscles it didn't originally trigger for a particular expression.
"They get uncoordinated facial movement," says Diels. "For example, when they go to smile their eye may shut. Or they get what's called mass action, which is when all the muscles fire at the same time, or synkinesis, where you have abnormal movement happening at the same time as normal movement.
"It's like a tug-of-war. There are two guys pulling on the same object here."
During her therapy sessions, which she refers to as "educational programs," Diels teaches patients to recognize and minimize the unwanted muscle movements.
The first day of facial retraining involves a comprehensive evaluation, which includes photographs, videotape and a review of the face's muscles. These muscles, says Diels, have only one purpose - moving the skin of the face - and by identifying each muscle's responsibility, patients can learn how to focus on problem areas.
Patients are released from the day one session with a series of exercises designed to loosen the muscles of the face, which they practice that evening. Returning the second day, Diels conducts a review session and they continue with the exercises.
"It varies by individual," Diels says. "We identify the things that are working correctly and are not working correctly, and then we have them tease away the things that aren't supposed to be moving."
The sessions are intellectual as well as physical. By thinking about each muscle's appropriate movement, patients are able to manipulate the muscle to move in the proper way. It can be a difficult concept to grasp, because intentionally activating the facial muscles is uncharted territory for many.
"Most people don't have to learn how to use the face. It's automatic," Diels says. "But we do have the capability of making it do certain things if we think about it."
And once the patients start catching on, the results are quickly evident.
"Many times they'll start making improvements while they're here in the clinic. It's very motivational," Diels says.
The third and final day of therapy is an extensive review of the previous two days' activities. Most patients will have to continue with the exercises for as many as 18 months to three years, so Diels wants them to attain a certain level of comfort and familiarity.
"We talk about taking those movement patterns and making a cohesive plan that they can do at home," she says. "When they leave here by the end of that third day, they feel confident in what they're supposed to be doing."
Diels cannot guarantee a 100 percent recovery, a fact she makes clear to all of her patients.
"Nobody gets back to perfect," she says. "Once that nerve gets damaged, you can't fully undo the damage. We're optimizing the level of activity. I tell that to everybody."
But improvement, though difficult to quantify, is noticeable. Diels estimates that approximately 70 percent of normal facial function can often be recaptured.
"There's always improvement if the person works at it," she says.
Which allows them to once again interact the way most of us take for granted. Diels says that many of her patients say they don't know why they've come to her, because they've never thought of themselves as the kind of people who worry about how they look. Diels quickly corrects them, saying what they are feeling isn't simply excessive pride or self-importance.
"It's your face," she says. "It's not about the cosmetic effect. It's about interpersonal communication."
Date Published: 08/03/2007