What is biofeedback?

At some point following facial paralysis, no matter what the onset, there is a disruption in the nerve supply to the muscle. It follows therefore that there has also been a disruption in the feedback to the brain about that side of the face and its activities. The brain restructures very quickly and begins to rely on the ‘good side’ for communication and soon the unaffected side begins to dominate. The brain effectively ‘forgets’ about the affected side. So once we have worked really hard with our rehabilitation and are getting the system back into a state at which it can operate it doesn’t just happen – it needs a little help.

So if we accept that there has been a disruption to the brain’s input and that this is now affecting the brain’s perception of the face then it follows that what the face tells the brain is not getting through accurately. Ever tried telling your mother you don’t wear jumpers but still get that hand knitted thing at Christmas – you say the words but just somehow the message doesn’t get through – well that’s what I mean. So instead of accepting the jumper situation we look for another input route to the brain that hasn’t been affected by the palsy (usually vision) and we use that to re-educate the brain (biofeedback) – akin to showing your mother the jumper in the charity shop window in the hope that she will make the link with the pre Christmas conversation about knitwear!

So by utilising the theories of biofeedback the therapist aims to provide reliable information about the faces activities to the brain. We use an external feedback channel that has not been damaged i.e. the eyes. Auditory feedback can be used but in Acoustic Neuroma patients there are problems with this loop as well (unilateral deafness) and it is not reliable so we prefer to use the eyes..

Once the brain has the message then we can move towards good behaviour patterns – ok here the analogy breaks down – it may be too much to ask of your mother to adopt good behaviour patterns!

When do we use it?

Biofeedback can be used to improve the amount of activity in weak muscles i.e. make a movement towards a smile or to decrease activity in overactive ones for example increasing the range and control of movements in synkinesis by starting from a returning to a good resting level.

Once recovery reaches the stage of Synkinesis your face may feel incredibly tight, your eye may shut when talking or it can feel like you are grimacing or pulling funny faces when you are in fact performing a balanced smile. It is the communications systems that are letting you down and the internal feedback loops that are not working properly. So what the world sees may be much better than it feels to you.

How do we do it?

At the clinic we use a technique called emg biofeedback which uses the electrical signal sent by the facial nerve, when you are performing an activity, to give your brain instant feedback on how well it is performing. By looking at the graphics on the computer screen the patient can receive feedback about their facial function from a reliable external loop. This in turn teaches the brain to aim for feedback from the internal loop akin to that being received when the external loop tells it that the face is moving correctly. In other words we use the computer to teach the brain how the face feels when it is performing the task and then with repetition you become able to reproduce this feeling or movement as desired. Think of it like toddler training it takes patience and repetition but we get there in the end. So the in clinic sessions are aimed at perfecting specific exercises based on the electrical activity in your facial nerve.

We have two specialised systems at our disposal in the clinic. One is linked to our electromyographic testing kit and involves the use of red and green bars – not the most advanced graphics in this computer age but highly effective. We also have a system dubbed by younger patients as the smiley face machine where you can turn a boy into a superhero, fly a plane or quite literally make the computer smile at you. The training sessions will include finding the ‘cartoons’ to suit you and of course matching the feedback requirements to your specific stage of recovery. The onscreen animation only responds to appropriate facial nerve activity.

When do you know you are ready for biofeedback?

Biofeedback is undertaken as part of our rehabilitation package. It requires a degree of cognitive ability and reasoning and so we do not typically embark on this aspect of rehabilitation with children under 6 years of age (despite the fact age is no bar to starting TES) – you may be pleased to know there is no upper age limit and you will require no computer skills!

The physiotherapist at the clinic will advise you when you are ready to add this aspect into your treatment. It is not necessary to purchase any equipment for these sessions. Sessions are typically 1 hour long and can be combined with your review session, if required, in order to prevent too many miles being travelled to the clinic.

We do not generally speaking offer biofeedback alone, only as part of the rehabilitation package, and due to technical constraints this is only available for patients attending the clinic in person (i.e. not postal or phone consultations).

When do you know you have finished with biofeedback?

Well this is a much harder question and I will draw on a couple of examples:-

I had a conversation recently with a patient who told me he doesn’t smile – he did several times during the course of the conversation. ‘Oh yes he said I can smile but I don’t ever do it without thinking about it’ The point I am trying to make is that with biofeedback we are teaching you a set of rules to follow when you want to smile – you have to think about these every time you smile. Its like when you first learn to drive (I’m on a roll with analogies!) and you have to look down at the gear stick to change gear – you can do it but you have to think through the procedure.

One day you will start to change gear without thinking about it and without looking down at the gear stick. Well biofeedback teaches you to smile again – one day you will find that the internal loop is re-established and so strong that you will see a photo of yourself, for example, where you are smiling but you didn’t stop and pose – the learning cycle is complete.

There may always be days when you are tired and have to think it thorough a bit more – but I spoke a lady recently 4 years post discharge who told me she hadn’t thought about her face in over a year – the point is eventually smiling reverts to the subconscious where it belongs.

Is this treatment only for faces?

Definitely not! There is a massive library of literature relating to the use of these techniques for other muscle groups in the body. A lot depends on your stage of recovery and your treatment goals. If you think you may benefit then please feel free to ask us and we will let you know if this is something that you should look to incorporate into your treatment.