"Why go to a physiotherapist to learn how to exercise your face? You can't help exercising your face it just happens".

These words were spoken by an eminent neurosurgeon when his patient asked if physiotherapy would help her facial recovery. When I was invited to contribute to the Bana newsletter I decided to expose some of the frequently aired myths about facial nerve recovery. If you have been subject to these sorts of statements do write to Bana and let us know.

Over the next 3 editions I shall cover some of the myths heard on a daily basis in our clinic.

The Myths of Facial Rehabilitation

1) Facial Exercise

"Why wouldn't you exercise your face? You cannot help but use your face! Why would you need somebody to teach you?"

2) Synkinesis

"Nerves sometimes grow back in the wrong place. The nerve to your chin could end up in the forehead!!!"

3) Nerve transplants

"Wait and see, it just works by itself."
"Of course sometimes it doesn't, but there really isn’t much you can do about that."

Today we will cover what you may need to be taught about facial exercise and what it involves.

I am a chartered physiotherapist and I have spent nearly 30 years exploring this question and specialising in techniques to help faces regain their previous ability to express emotion.

At the Lindens Clinic for facial rehabilitation we treat acoustic neuroma patients in different stages of recovery. Literally in one day we may assess a patient just released from the hospital after surgery and another who has been told there is no treatment for 20 + years since the event. What a dangerous myth to allow patients to go this long without intervention.When we analyse the problems the long term patients have we are able to build strategies to prevent the early patients developing 'bad habits'. In unravelling 20 years of poor use and the effects on facial expression we gently guide the face to normal manoeuvres and hopefully expression. From this we learn how to eliminate risks and spot potential problems for the early group and in this way we are constantly learning and developing our treatments.

In the beginning.

The facial nerve controls all the little muscles on one side of the face and the immediate response when it stops working is that the affected eye stops blinking, watering and closing. In addition when cranial nerve 5 is involved it could also stop feeling. A stray eyelash could be damaging a dry eye all day without you even noticing it. No wonder eye care is a top priority!

What else is involved?

In normal circumstances the two facial nerves right and left work as partners to produce facial expression within certain limits of symmetry.
When one partner stops working the other one ends up doing the work of two. Whilst doing all the work –having all its 'own way' it is able to influence the muscles of the good side of the face to increase their normal range of movement. Even the nose bends to the good side- the side which has been left to express all your feelings. The other side with the staring eye, the slanted mouth, the floppy cheek isn't able to pull its own weight and has only one expression, sad.

The information going to the brain about facial expression becomes very much distorted and a new facial map needs to be built up within the brain working on this new information. Fortunately it saves the original facial map the engram for facial expression which you painstakingly built up as a baby. The engram will be accessible as soon as normal service is resumed.

Exercises What can you do?

At this stage exercise and even day to day activities only strengthen the good side and create a stronger and more distorted face map in the higher brain. If it were only possible to give the face a rest. But this is not compatible with life; we've got to carry on eating and drinking.

A physiotherapist would teach you to keep symmetrical pose as often as possible. She would also instruct you in the art of gently massaging the cheek upwards, care of the eye and how to close the eye without straining. The beginning is a stage of waiting and can be tedious but it is also a stage of convalescence and it is good to keep a record of all progress made. Each step to good health should be measured. As far as the face is concerned a good way to record progress is to use serial photographs. The last thing you want in the beginning but you wont regret it in the long run. Have some taken today and hide them for a few months nobody else needs to see them.

At the Lindens Clinic we use electrical testing of the nerve (emg) and the graphs obtained plot the progress of the nerve as it re-grows. It’s a real boost to the ego to see how much recovery the nerve has actually made especially during those long spells when nothing seems to be happening in the mirror. We had a very exciting session in clinic last week when a lady 2 years post acoustic surgery managed to send a signal down her new nerve for the first time. She was presented with her graphs on screen as she acted as a model for an advanced training day. Having identified the feeling associated with the increase in current flow down the nerve she was the able intensify her efforts to such a level that an active flicker could be seen clearly by everybody in the room even her husband. Meantime she is happier to continue with her daily dose of trophic stimulation which will keep the muscle in good shape with the energy to support the growing nerve. Now she knows that the nerve is working she is in control and there is no stopping her from doing her treatment. So we now know exactly what her exercise is and she will continue to reproduce that feeling until she achieves the movement which everybody will recognise as smile.