Facial Palsy Physiotherapy
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Direct answer
Spare the forehead and you have an upper motor neuron lesion — the upper face receives bilateral cortical innervation, so a stroke flattens only the lower face, while a Bell's palsy (lower motor neuron, idiopathic, VII nerve) kills the whole hemiface: forehead unfurrowable, eye will not close, mouth droops, and food lodges in the cheek. Grading runs on the House-Brackmann scale I to VI (I normal through VI total paralysis, with grades III-IV — obvious weakness with then without complete eye closure — the common therapeutic band), and medical care is time-bound: prednisolone within 72 hours of onset measurably improves recovery, while antivirals add little. Physiotherapy layers eye protection first — lubricants and night taping against exposure keratitis — then neuromuscular re-education, massage, mime therapy and mirror or biofeedback training, with electrical stimulation remaining controversial and aggressive exercising in the early flaccid stage actively discouraged.
What you must remember
- Forehead rule: bilateral upper facial innervation means forehead sparing marks an upper motor neuron (central) lesion; full hemifacial involvement including frontalis marks a lower motor neuron (peripheral) lesion — the first split in any exam answer.
- House-Brackmann grades: I normal; II mild, detectable on close inspection; III obvious weakness, complete eye closure, slight mouth asymmetry with effort; IV obvious disfiguring weakness, cannot close eye, symmetric at rest with some movement; V barely perceptible movement; VI total paralysis — grades III-IV form the common middle band where therapy decisions concentrate.
- Steroid evidence: prednisolone (about 60 mg daily for several days with taper) within 72 hours improves complete-recovery rates; antivirals alone add marginal or no benefit.
- Eye care hierarchy: preservative-free artificial tears by day, lubricating ointment and taping or a moisture chamber at night, and referral if redness or pain develops — untreated exposure keratitis is the blinding complication of a "cosmetic" palsy.
- Rehabilitation toolkit: soft tissue massage and gentle stretching toward the affected side, symmetrical facial exercises in front of a mirror, mime therapy (the Dutch protocol combining exercises, massage and relaxation), surface EMG or mirror biofeedback, and proprioceptive neuromuscular facilitation for the facial muscles.
- Synkinesis: involuntary co-contraction (eye closing during smiling, mouth movement on blinking) in recovering nerves — managed with motor re-education, selective muscle training, relaxation, botulinum toxin injections for severe cases; teaching "maximal effort" exercises late worsens it.
One hemiface managed from day one
A 32-year-old call-centre executive wakes with a drooping right mouth and an eye that will not shut; he is grade IV on House-Brackmann, two days in. Day one covers three things: steroids now, inside the 72-hour window; eye care tonight — drops by day, ointment and tape at sleep; and instruction not to force exercises into a flaccid face, since early overuse promotes synkinesis. Weeks one to three are gentle: massage, relaxation of the unaffected side (which works overtime and pulls the midline), and small symmetrical movements in the mirror — both sides attempting the same task, so the brain relearns equal recruitment. As movement returns at week four, mime-therapy-style selective training enters — puckering, smiling with the eyes relaxed, raising brows separately — with surface biofeedback where available. At month three a flicker of synkinesis appears as the eye narrows on smiling; the programme answers with slow, low-intensity selective activation and relaxation, not stronger contractions. He ends at grade I, the statistically likely destination when steroids and disciplined, gentle rehabilitation align.
Exam framing and Indian practice notes
Theory papers ask to differentiate upper from lower motor neuron facial palsy, grade severity with House-Brackmann, and outline physiotherapy management of Bell's palsy — where the eye-care-first ordering and the anti-overexercising principle distinguish clinical answers from exercise-list recitations. Short notes recycle House-Brackmann, synkinesis and mime therapy; the viva favourite is why steroids help only within 72 hours (they limit the inflammatory compression of the nerve in the fallopian canal during the active oedematous phase). Indian realities earn their line: much facial palsy follows untreated otitis media, leprosy-endemic regions add nerve thickening to the LMN differential, and Ramsay Hunt cases arrive late after misdiagnosis as dental pain or "heat". Because mirror biofeedback costs nothing, a mirror and twice-daily symmetrical exercise is itself the treatment for most patients — precisely the low-resource answer examiners reward.
Frequently asked questions
How does an upper motor neuron facial palsy differ from Bell's palsy?
UMN lesions spare the forehead because the upper face has bilateral cortical input, whereas Bell's palsy paralyses the entire hemiface including frontalis and eye closure.
What is the House-Brackmann grade IV picture?
Obvious disfiguring weakness with inability to close the eye fully and an asymmetric mouth with movement, resting symmetry preserved.
Why must steroid treatment start within 72 hours?
Corticosteroids suppress the inflammatory oedema compressing the facial nerve in its bony canal during the early phase; beyond about 72 hours the window of benefit largely closes.
What is synkinesis and how is it managed?
Involuntary associated movement, such as eye narrowing during smiling, from misdirected nerve regeneration — treated with selective motor re-education, relaxation training and botulinum toxin in severe cases, not stronger exercises.
Which facial palsy patients have the worst prognosis?
Those with complete paralysis at onset, diabetes, or Ramsay Hunt syndrome, whereas incomplete palsy and recovery beginning within three weeks predict full return.