Facial palsy rehabilitation is a non-surgical therapy that helps you relearn to move your face muscles in a natural way after an injury to the facial nerve. This therapy is sometimes also called facial nerve rehab or facial neuromuscular retraining. It is an individualized treatment program to improve face movement, coordination, and expression.

Read on to learn more about the facial muscles and nerve, facial paralysis, synkinesis, and how physiotherapy can help face muscle weakness.

What is facial palsy?

Facial palsy is weakness of the muscles that move your face. The face muscles are what allow us to make expressions, chew, and close our eyes. Facial palsy, facial paresis, and facial paralysis are terms that are often used interchangeably. Facial paresis usually refers to mild to moderate face muscle weakness. Facial paralysis usually refers to severe or complete loss of muscle activity and control.

Our face muscles attach to bone or fascia, and pull on our skin to generate facial expressions. Some of the muscles that move our face include:

Frontalis - lifts our eyebrows
Zygomaticus - helps us smile
Orbicularis oculi - closes our eyelids
Orbicularis oris - moves our mouth and lips

Muscles of facial expression from Mehdizadeh et al., 2016

The facial nerve (cranial nerve VII) sends signals from the brain to the face muscles, allowing us to produce and control movement. There are different branches of the facial nerve, which send signals to different parts of the face and to different muscles. The facial nerve is also responsible for sending signals about taste from the front two thirds of the tongue, and helps produce tears from the lacrimal gland. A branch of the facial nerve supplies the stapedius muscle, which is a very small muscle in the ear that helps dampen sound vibration.

Facial nerve branches - commons.wikimedia.org

What causes facial palsy?

Facial nerve palsy is caused by inflammation or damage to the facial nerve (cranial nerve VII), which controls the muscles of the face. This results in sudden weakness and inability to move one side of your face. Paralysis of the face muscles can cause a number of challenges- this can include drooping of your eye brow and mouth, difficulty with closing the eye, dryness or excessive tearing of one eye, difficulty eating, drinking or speaking and problems communicating with facial expression. Some patients also develop hypersensitivity to sound, problems with taste and pain/abnormal sensations in the face.

The most common cause of facial paralysis is Bell’s Palsy - this causes weakness on one side of the face that is usually temporary. In Bell’s Palsy, inflammation of the facial nerve is thought to be due to a viral infection but in many cases the cause is unknown. Symptoms usually start suddenly and gradually worsen over about 48 hours. Recovery usually begins around two weeks after onset but full recovery can take six months. For a small percentage of people, a degree of facial muscle weakness is permanent.

Ramsay Hunt syndrome (herpes zoster oticus) also causes face muscle weakness, along with vestibular symptoms. It can also cause hearing loss and tinnitus. This condition is usually associated with a rash and pain in or around one ear. Ramsay Hunt syndrome is caused by shingles (reactivation of varicella-zoster virus) affecting your facial nerve and vestibulocochlear nerve.

Vestibular schwannoma can cause facial weakness, because the vestibular nerve and facial nerve are located close together.

Facial palsy can also result from direct trauma to the facial nerve.

What is synkinesis?

Facial palsy rehabilitation can help improve synkinesis, which is when delayed facial nerve recovery results in abnormal and undesired movements. Synkinesis is when there are involuntary and unwanted movements that occur during voluntary face movements.

Signs of synkinesis may include:

Tightness in face muscles
Neck muscle tightness with face movements
Mouth movements like smiling or chewing cause your eye to narrow or close
Closing your eye causes your mouth to move or neck to tighten
Deeper nasolabial fold (the crease that runs from the side of the nose to the side of the mouth) on the affected side

The facial nerve does heal and regenerate after injury, if it has not been completely cut. As the nerve regrows, parts of the nerve branches can be “miswired”. For example, an injured part of the nerve that previously sent signals to the eye has regrown and now sends signals to the mouth instead. This is referred to as aberrant facial nerve regeneration. This faulty rewiring causes synkinesis - for example, when you close your eye the corner of your mouth lifts up. These linked movements, poor coordination or sequencing of muscle contractions, and increased muscle tone are common symptoms of synkinesis.

Facial neuromuscular retraining exercises help to improve synkinesis by retraining your brain - your brain can learn to update its “address book” for your face muscles and improve habitual movement patterns. The goal is not to strengthen the muscles, but to improve coordination and symmetry.

How do you treat facial palsy?

Acute stage

At the initial onset of facial muscle paralysis, medical management may include medications like steroids (e.g. prednisone) and/or antivirals (e.g. acyclovir or valacyclovir).

Subacute stages

Flaccid stage: When you have not yet regained active movement of your face muscles, treatment includes monitoring for recovery and making sure you care for your eye. When you are not able to close your eyelid, it is important to protect your eye by using lubricating drops/gel, patches or moisture shields, and/or taping as prescribed by your healthcare provider.

Recovery of movement: As you begin to recover the ability to actively move your face muscles, treatment involves monitoring your muscle function and starting gentle soft tissue and muscle work to help normalize muscle tone and coordination.

Chronic stage

Synkinesis: If you have developed abnormal or unwanted face movements or tightness in your face muscles, you may benefit from facial neuromuscular retraining with a physiotherapist. Botox injections can also be used to treat synkinesis.

Surgery: If you do not recover any movement of your face muscles, treatment can include surgery or other procedures to improve the symmetry of your appearance and facial expressions. Facial reanimation surgery involves nerve grafts/transfers and/or muscle transfers to improve your ability to smile and close your eye. Surgery can also involve implanting gold weights in your eyelid to improve eye closure. Face lift, brow lift, and eyelid procedures may also be used to improve the symmetry of your face at rest.

What is facial palsy rehabilitation?

Physiotherapy treatment for facial nerve weakness is often referred to as facial palsy rehab, facial nerve rehab, or facial neuromuscular retraining. This therapy helps you relearn to move your face muscles in a natural way after an injury to the facial nerve. It is an individualized treatment program that can improve face movement, coordination, and expression.

What happens in facial palsy rehab?

Assessment and treatment sessions can be done in the clinic, and by virtual care through online video-conferencing. At your first visit, the physiotherapist will ask you questions about your symptoms and evaluate how your face moves.

Assessment involves:

Evaluating facial muscle function, your face movements and expressions
Photos and videos to track your recovery
Understanding your symptoms and how they are affecting you

Treatment depends on the cause of your facial palsy, how long you have had it, and the type of damage to your facial nerve.

Treatment involves:

Helping you understand how the facial nerve and muscles work
Advice about eye care
Advice on how to make speaking, drinking, and eating easier,
Advice on managing symptoms of dry mouth or dry eye
Soft tissue work to do at home daily, including massage and stretching to help normalize muscle tone on both sides of your face
Muscle work to help you relearn precise coordination for movement and facial expressions
Retraining imbalanced or unwanted face movements

Is treatment effective?

Facial palsy rehab can help:

Bell’s Palsy
Ramsay Hunt syndrome 
Facial weakness due to vestibular schwannoma/acoustic neuroma
Facial weakness due to facial nerve schwannoma
Synkinesis

This treatment is not designed for people with facial muscle paralysis due to stroke or brain injury.

When should I start rehab?

Early on in your recovery, you can still see a facial palsy physiotherapist for education and support even if you are not able to move your face actively yet. A physiotherapist can give you recommendations for eye care and strategies to make speaking, eating, and drinking easier.

They can help you learn what to expect and when to seek further care.

When you start to have return of movement, a facial palsy physiotherapist can help monitor your recovery and determine when to start soft tissue or muscle work.

You may benefit from physiotherapy assessment even if you have chronic facial palsy, since facial neuromuscular retraining can help improve synkinesis.

It can be very helpful to have an experienced and knowledgeable physiotherapist follow you over time and monitor your progress.

Book a facial palsy physiotherapy assessment

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Physiotherapy for facial nerve palsy