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Background Facial nerve palsy leaves people unable to move muscles on the affected side of their face. Challenges exist in patients accessing facial neuromuscular retraining (NMR), a therapy used to strengthen muscle and improve nerve function. Access to therapy could potentially be improved through the use of digital technology. However, there is limited research available on patients’ and clinicians’ views about the potential benefits of such telerehabilitation based on their lived experiences of treatment pathways. Objective This study aims to gather information about facial palsy treatment pathways in the United Kingdom, barriers to accessing NMR, factors influencing patient adherence, measures used to monitor recovery, and the potential value of emerging wearable digital technology. Methods Separate surveys of patients with facial palsy and facial therapy specialists were conducted. Questionnaires explored treatment pathways and views on telerehabilitation, were co-designed with users, and followed a similar format to enable cross-referencing of responses. A follow-up survey of national specialists investigated methods used to monitor recovery in greater detail. Analysis of quantitative data was conducted allowing for data distribution. Open-text responses were analyzed using thematic content analysis. Results A total of 216 patients with facial palsy and 25 specialist therapists completed the national surveys. Significant variations were observed in individual treatment pathways. Patients reported an average of 3.27 (SD 1.60) different treatments provided by various specialists, but multidisciplinary team reviews were rare. For patients diagnosed most recently, there was evidence of more rapid initial prescribing of corticosteroids (prednisolone) and earlier referral for NMR therapy. Barriers to NMR referral included difficulties accessing funding, shortage of specialist therapists, and limited awareness of NMR among general practitioners. Patients traveled long distances to reach an NMR specialist center; 9% (8/93) of adults reported traveling ≥115 miles. The thematic content analysis demonstrates positive attitudes to the introduction of digital technology, with similar incentives and barriers identified by both patients and clinicians. The follow-up survey of 28 specialists uncovered variations in the measures currently used to monitor recovery and no agreed definitions of a clinically significant change for any of these. The main barriers to NMR adherence identified by patients and therapists could all be addressed by using suitable real-time digital technology. Conclusions The study findings provide valuable information on facial palsy treatment pathways and views on the future introduction of digital technology. Possible ways in which emerging sensor-based digital technology can improve rehabilitation and provide more rigorous evidence on effectiveness are described. It is suggested that one legacy of the COVID-19 pandemic will be lower organizational barriers to this introduction of digital technology to assist NMR delivery, especially if cost-effectiveness can be demonstrated.

Purpose To describe the occurrence and severity of upper eyelid skin contracture in facial nerve palsy (FNP). Methods We enroled consecutive patients with unilateral FNP into this study. Patients with previous upper eyelid surgery for either side were excluded. We developed a standardised technique to measure the distance between the upper eyelid margin and the lower border of brow (LMBD). FNP was graded using the Sunnybrook grading scale. Its aetiology, duration, and treatment were noted. Upper and lower marginal reflex distance and lagophthalmos were also noted. Results Sixty-six patients (mean age 51 years) were included. FNP was owing to a variety of aetiologies. LMBD on the paralytic side was shorter than the normal contralateral side in 47 (71%), equal in 15 (23%), and larger in four (6%) patients. The mean contracture was 3.4 mm (median: 3, range: 1-12) with 11 (17%) patients showing 5 mm or more of skin contracture. The mean LMBD on the paralytic side in all patients was significantly smaller than the contralateral side; 30 ± 3.7 (median: 30; 95% CI 29-31) compared with 32 ± 3.7 (median: 32; 95% CI 32-33), respectively, Po0.0001, two-tailed paired t-test. Conclusion To our knowledge, this is the first study that quantitatively demonstrates contraction of the upper eyelid skin in FNP. This finding is valuable in directing optimal early management to minimise skin contracture and to caution surgeons against unnecessary upper eyelid skin excision.

Objective To conduct a systematic review of the effectiveness of facial exercise therapy for facial palsy patients, updating an earlier broader Cochrane review; and to provide evidence to inform the development of telerehabilitation for these patients. Data Sources MEDLINE, EMBASE, CINAHL, Cochrane Library, PEDro and AMED for relevant studies published between 01 January 2011 and 30 September 2020. Methods Predetermined inclusion/exclusion criteria were utilised to shortlist abstracts. Two reviewers independently appraised articles, systematically extracted data and assessed the quality of individual studies and reviews (using GRADE and AMSTAR-2, respectively). Thematic analysis used for evidence synthesis; no quantitative meta-analysis conducted. The review was registered with PROSPERO (CRD42017073067). Results Seven new randomised controlled trials, nine observational studies, and three quasi-experimental or pilot studies were identified ( n  =  854 participants). 75% utilised validated measures to record changes in facial function and/or patient-rated outcomes. High-quality trials (4/7) all reported positive impacts; as did observational studies rated as high/moderate quality (3/9). The benefit of therapy at different time points post-onset and for cases of varying clinical severity is discussed. Differences in study design prevented data pooling to strengthen estimates of therapy effects. Six new review articles identified were all rated critically low quality. Conclusion The findings of this targeted review reinforce those of the earlier more general Cochrane review. New research studies strengthen previous conclusions about the benefits of facial exercise therapy early in recovery and add to evidence of the value in chronic cases. Further standardisation of study design/outcome measures and evaluation of cost-effectiveness are recommended.

This study highlights the phenomenon of paradoxical frontalis activation during eye closure. This is often underrecognized and may contribute to lagophthalmos. The authors found it to be present in 27 percent of patients with moderate or severe synkinesis. Further dynamic studies are required to understand the relationship among frontalis activity, eye closure, and the effects of its inhibition.