Article

Clinical Rehabilitation
25(7) 649–658
Facial exercise therapy for facial ! The Author(s) 2011
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DOI: 10.1177/0269215510395634
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meta-analysis

LM Pereira1,2, K Obara2,3, JM Dias2,3,

MO Menacho2,4, EL Lavado2,3,5 and JR Cardoso1–3,5

Abstract
The effectiveness of facial exercises therapy for facial palsy has been debated in systematic reviews but its
effects are still not totally explained.
Objective: To perform a systematic review with meta-analysis to evaluate the effects of facial exercise
therapy for facial palsy.
Data sources: A search was performed in the following databases: Cochrane Controlled Trials Register
Library, Cochrane Disease Group Trials Register, MEDLINE, EMBASE, LILACS, PEDro, Scielo and DARE
from 1966 to 2010; the following keywords were used: ‘idiopathic facial palsy’, ‘facial paralysis’, ‘Bell’s
palsy’, ‘physical therapy’, ‘exercise movement techniques’, ‘facial exercises’, ‘mime therapy’ ‘facial expres-
sion’, ‘massage’ and ‘randomized controlled trials’.
Review methods: The inclusion criteria were studies with facial exercises, associated or not with mirror
biofeedback, to treat facial palsy.
Results: One hundred and thirty-two studies were found but only six met the inclusion criteria. All the
studies were evaluated by two independent reviewers, following the recommendations of Cochrane
Collaboration Handbook for assessment of risk of bias (kappa coefficient ¼ 0.8). Only one study pre-
sented sufficient data to perform the meta-analysis, and significant improvements in functionality was
found for the experimental group (standardized mean difference (SMD) ¼ 13.90; 95% confidence interval
(CI) 4.31, 23.49; P ¼ 0.005).
Conclusion: Facial exercise therapy is effective for facial palsy for the outcome functionality.

Keywords
Physical therapy, exercise, meta-analysis, neurological rehabilitation
Received 31 May 2010; accepted 5 December 2010

4
Faculdades Integradas Aparicio Carvalho and Faculdade
Interamericana of Porto Velho, Brazil
5
Physiotherapy Department, Universidade Estadual de Londrina,
1
MSc Programme in Physical Education, Universidade Estadual Londrina, Brazil
de Londrina-UEM, Londrina, Brazil Corresponding author:
2
Laboratory of Kinesiologic Electromyography and Kinematic, Jefferson Rosa Cardoso, Physiotherapy Department, University
Londrina, Parana, Brazil Hospital, Universidade Estadual de Londrina, Av. Robert Koch,
3
MSc Programme in Rehabilitation, Universidade Estadual de 60. Londrina PR, Brazil 86038-440
Londrina-UNOPAR, Londrina, Brazil Email: jeffcar@uel.br

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650
Introduction
Peripheral facial palsy is a lesion in the seventh
cranial nerve. This is clinically distinguishable
from central palsy because of the involvement
of the facial muscles surrounding the eye.
In peripheral lesions, the frontal branches of
the facial nerve are impaired, whereas in central
lesions the forehead can still be innervated due
to an ipsi- and contralateral central innervation
of the forehead.1 The incidence of facial palsy is
between 23 to 35 cases per 100 000, affecting
both genders with peaks from 30 to 50 and
60 to 70 years old.2 Moreover, with inappropri-
ate treatment, patients may suffer from incom-
plete recovery and presented contracture,
hyperkinesis or synkinesis; the latter can vary
between 1.7% and 42%.3
The aetiology of facial palsy is still not totally
explained. Cases featured in some studies have
shown positive serology for varicella-zoster,
mononucleosis, herpes simplex virus, mumps
and measles.4 Some studies, using the viral
DNA technique with polymerase chain reaction
(PCR), have found type I herpes simplex virus
DNA in the facial nerve endoneurium fluid,
tears, saliva and the geniculate ganglia of
patients with facial palsy. The virus is reacti-
vated in the geniculate ganglion, migrates
through the facial nerve and reaches the salivary
gland via the chorda tympani nerve. After this,
it is likely that an inflammatory process occurs
in the facial nerve tympanic-mastoid segment
and thus includes the involvement of its stape-
dial branch.5
Physical therapy strategies for treating
patients with facial palsy have been described
and refined over the last century, and inconsis-
tent results using current rehabilitative tech-
niques have been described.6 A systematic
review of the effects of electrotherapy and ther-
motherapy on facial palsy was published in
2003.7 Several modalities were investigated
separately: electrical stimulation, short-wave,
ultrasound, laser and EMG mirror biofeedback.
The authors pointed out the use of these modal-
ities, but no one form of treatment seemed to
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Clinical Rehabilitation 25(7)
be superior. It is worth emphasizing that the
authors included studies such as non-controlled
clinical trials, case series reports and retrospec-
tive studies, which indicates a selection bias. In
contrast, other authors have reported that the
combination of electrical and photo stimulation
together with the use of corticosteroids seems to
produce complete functional recovery.8,9
In 2008, a systematic review by the Cochrane
Collaboration about the physical therapy for
Bell’s palsy included six studies, three analysing
the efficacy of electrical stimulation (294 partic-
ipants) and three examining mime therapy
(253 participants). The authors concluded that
no treatment produced significantly more
improvement than was observed in untreated
control groups.10 That same year, two system-
atic reviews about the effects of facial exercise,
associated or not with mirror biofeedback, were
published. In the first,11 five of the six analysed
studies demonstrated improvement in facial
symmetry and mobility and a decrease in syn-
kinesis. In the second review,12 which included
four studies, it was not possible to determine if
mime therapy was effective for facial functional-
ity, although all the studies reported clinical and
statistically significant differences among the
treatment groups. All three reviews were pub-
lished without meta-analyses and none of them
found evidence that mime therapy had a signif-
icant benefit on facial palsy. The objective of this
systematic review with meta-analysis was to
evaluate the efficacy of exercise therapy for
facial palsy.
Methods
Searching
A computerized database search was performed
to identify relevant abstracts that correlated the
types of disease, intervention and studies. The
strategy was applied to the following databases:
Cochrane Controlled Trials Register Library
(Issue 8, 2010), Cochrane Disease Group
Trials Register, Medline (1966–2010), Embase
(1980–2010), Lilacs (Latin American and
Pereira et al.
Caribbean Health Science, 1982–2010), Pedro
(Physiotherapy Evidence Database), Cinahl
(1982–2010), Dare (Database of Reviews of
Effects), and Scielo (Scientific Electronic
Library Online, 1998–2010). There were no
restrictions with regard to language or publica-
tion date. This search strategy combined the fol-
lowing specific subject (MeSH) headings and
free-text words: (a) type of disease – idiopathic
facial palsy, facial paralysis and Bell’s palsy; (b)
type of intervention – physical therapy, exercise
movement techniques, facial exercises, mime
therapy or facial expression and massage; and,
(c) type of study – randomized controlled trials,
controlled clinical trials, systematic review and
meta-analysis. Manual searches were also per-
formed in specialized journals.
Selection
The studies selected for this review were ran-
domized controlled trials that analysed both
mirror biofeedback facial exercises and conven-
tional exercises performed with a therapist as
treatment for patients with facial palsy. Facial
mime or expression exercises serve the following
functions: to stimulate both functional move-
ments of the face and facial expression, to pro-
mote the symmetry of the face, to control and to
reduce synkinesis, to reintegrate emotional
expressions and to maintain active musculature
and movement perception.13 Studies that
reported the use of any other type of treatment,
such as drugs, surgery, electrotherapy or combi-
nations of these, were excluded. The outcome
measures considered were: facial symmetry,
synkinesis, muscle stiffness, labial mobility and
patient physical and psychosocial aspects relat-
ing to facial palsy. For evaluation of these out-
comes, therapists scored their patients using the
scales described as follows:
(a) House–Brackmann Scale. Classified as a
universal scale by the American Academy of
Otolaryngology – Head and Neck Surgery –
Committee of Disorders of the Facial Nerve,
it was proposed and modified by House and
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651
Brackmann in 1985. This scale analyses the sym-
metry, synkinesis, stiffness and global mobility
of the face. It is divided into six categories
(normal, mild dysfunction, moderate dysfunc-
tion, moderately severe dysfunction, severe dys-
function and total paralysis) and is a 0–6 point
scale with 6 representing total paralysis.14
(b) Linear Measurement Index. This is an
alternative to the House–Brackmann Scale
developed by Burres and Fisch.15 It analyses
the symmetry and global function of the face
in an objective and quantitative form. It uses a
100-point scale, with higher scores indicating
less impairment and handicap.
(c) Facial Disability Index. Developed by Van
Swearingen and Brach,16 this questionnaire has
ten items that evaluate patients’ physical and
social aspects (mastication, deglutition, commu-
nication, labial mobility, emotional alterations
and social integration). It uses a 100-point
scale, with higher scores indicating less impair-
ment and handicap.
(d) Lip-length (LL) and Snout (S)
Indices. These use the ratio between the inter-
commissural distances (ICD) to assess the func-
tioning of the perioral muscles by mouth
mobility. The length of the lips can be measured
in two ways: by pulling the corners of the mouth
apart as far as possible and by pushing the cor-
ners together. Labial mobility is evaluated by
the distance between the labial joints in various
movements.17
(e) Five-Point Scale. This is a subjective scale
that evaluates synkinesis and stiffness. Patients
indicate the stiffness they experience on a
5-point scale, with 5 being very stiff.18
(f) Sunnybrook Facial Grading System. The
system measures three components of facial
asymmetry: Resting asymmetry (scored from
0–4 with 4 being the most asymmetrical), sym-
metry of voluntary movement (scored from 0–5
with 5 being the most symmetrical) and
652
synkinesis (scored from 0–3 with 3 being the
worst). A perfect score of 100 points represents
normal facial symmetry.19
Validity assessment
The two authors collected and analysed titles
and abstracts of all studies found, as well as
the information about participants, differences
at baseline, interventions, outcomes and results
of the randomized controlled trials using a data
collection form. When data were not available
or were unclear, the author of the original study
was contacted to request relevant information.
Two independent authors evaluated the risk of
bias of the included studies following the recom-
mendations of the Cochrane Collaboration
Handbook20 and assigned a score according to the
criteria. In case of disagreement, a third reviewer
intervened and made a judgement to prevent any
inter-observer bias. The assessed items were: ade-
quate sequence generation, allocation concealment,
blinding, follow-up, intention-to-treat analysis,
incomplete outcome data and selective outcome
reporting. All items were classified as ‘Yes’ when
the criteria were clearly described or ‘No’ when the
item was unclear or not cited. All data were entered
into the analysis program by one review author.
This review following the PRISMA Statement.21
The descriptive results were presented in
tables. Meta-analysis was performed in order
to compare the outcomes of functionality
between the mime therapy group and the control
group. The standardized mean difference (SMD)
with 95% confidence intervals (CI) was calcu-
lated because the outcome was measured using
different instruments. The kappa coefficient
was used to assess agreement among assessors
for quality of randomized controlled trial.
Statistical analysis was performed using
Review Manager 5 software and SPSS 15.0
(SPSS Inc., Chicago, IL, USA).
Results
The literature search resulted in 132 abstracts,
distributed as follows: Cochrane Controlled
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Clinical Rehabilitation 25(7)
Trials Register Library ¼ 12, Embase ¼ 28,
Medline ¼ 24, Lilacs ¼ 43, Pedro ¼ 04,
Dare ¼ 08 and Scielo ¼ 13. Twenty-six studies
were indexed in two or more databases resulting
in duplication. One hundred studies were
excluded because they did not match the inclu-
sion criteria (Figure 1). Six studies met the inclu-
sion criteria (Table 1).
Ross et al.22 randomized 31 patients who had
been suffering from facial palsy for a minimum
of 18 months into three groups. Group I
included 13 patients who did only mirror exer-
cises. Group II included 11 patients who did
mirror exercises as well as 30-minute electromy-
ography biofeedback sessions. Group III
included 7 patients did not undergo treatment
and served as controls. All patients were objec-
tively evaluated prior to the study and at six and
twelve months afterwards using three different
techniques described in Table 1.
Segal et al.23 analysed 10 patients who had
had from 0.5 to 27 years of facial palsy, random-
izing them into two groups with five participants
each. Group I was treated with a conventional
neuromuscular retraining programme consisting
of patient facial anatomy education, relaxation,
face-tapping exercises, biofeedback training
using a mirror or electromyography and specific
facial exercises. Group II received the same
treatment except that each patient performed a
single maximal movement and was obliged to
stop when synkinesis occurred. Subsequent
movements were at half of this maximum. All
patients did therapy three times a week for four
weeks, totalling 12 sessions. Subjects were also
assessed weekly using the House Scale.
Beurskens and Heymans18 divided 50 patients
who had had unilateral peripheral facial paraly-
sis for at least nine months into two groups. The
control group had 25 participants and received
no intervention. The experimental group
received mime therapy during ten weekly
45-minute sessions. The therapy was composed
of self-massage of the face and neck, breathing
and relaxation exercises, specific exercises for the
face to coordinate both halves and to decrease
synkinesis, lip-closure exercises, letter and word
Pereira et al. 653

Medline Embase Lilacs PEDro DARE Cochrane Scielo

24 28 43 4 8 12 13
citations citations citations citations citations citations citations

Potentially relevant citations identified after electronic

database search and removal of duplicates (n =106)

Citations excluded
(n =44)

Abstracts excluded
(n= 30)

Full text retrieved

(n=26)

Studies included in the

systematic review (n= 6)

Figure 1. Diagram of search strategy.

pronunciation exercises, emotional expression
exercises and guidance about communication
possibilities. Patients performed the exercises
daily at home using a homework manual.
Nakamura et al.24 studied 27 patients, 10 of
whom had a diagnosis of Bell’s palsy and 17 of
herpes zoster oticus. Twelve patients did 30 min-
utes of daily home training that consisted of
trying to keep their eyes open symmetrically
during three designated mouth movements
(pursing the lips, baring the teeth, and puffing
out the cheeks) with mirror biofeedback. Fifteen
patients served as controls and did not receive
any kind of intervention.
Manikandan25 did a study with 59 patients
diagnosed with Bell’s palsy who were allocated
into an experimental group (n ¼ 29) and a control
group (n ¼ 30). The experimental group was trea-
ted with techniques tailored to each patient that
involved mirror biofeedback. The patients did
5–10 repetitions of facial exercises three times a
day in the initial stages. They were instructed to
perform facial movements on the affected side
without the voluntary movement of the unaf-
fected side. The control group received electrical
stimulation six days a week for a period of two
weeks, gross facial expression exercises and mas-
sage. Both groups were instructed to do these
exercises daily at home for three months.
Barbara et al.26 published a randomized trial
with 20 patients who underwent medical treat-
ment, a combination of antiviral and steroid

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Table 1. Characteristics of included studies
Study Participants
22
Ross et al. (1991) G1 ¼ 11 patients with PFP
 G2 ¼ 13 patients with
the same diagnosis
 G3 ¼ 7 patients served
as controls
Segal et al. (1995)23 G1 ¼ 5 patients with PFP
 G2 ¼ 5 patients with the
same diagnosis
Beurskens and G1 ¼ 25 patients with unilat-
Heymans eral PFP for at least nine
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(2003)18 months
 G2 ¼ 25 patients with
PFP on a waiting list for
three months
Nakamura et al. G1 ¼ 12 patients with com-
(2003)24 plete PFP
 G2 ¼ 15 patients served
as controls
Interventions
G1 ¼ Mirror exercises in
combination with one-half
hour of EMG biofeedback
G2 ¼ Specific retraining
strategies using mirror
exercises alone
Training programme: 2
sessions per week for 2
weeks; 1 session per week
for 6 weeks and 2 sessions
per month for 10 months.
Total of treatment: 1 year
G1 ¼ conventional
neuromuscular retraining
programme: relaxation,
face-tapping exercises, and
biofeedback training.
G2 ¼ Identical treatment
but must stop the exercise
when synkinesis occurred
All patients were seen 3
times a week for 4 weeks
Mime therapy with a home-
work manual (exercises to
stimulate facial emotional
expression and functional
movements) for 3 months;
45-minute weekly sessions
30 minutes of daily home
training for a period of 10
months. Patients were
instructed to try to keep
their eyes open
Outcome
Linear measurement of facial
movement; blinded visual
assessment movements
(forehead elevation, eye
closure, even smile with
mouth closed, broad smile
with mouth open, bilateral
snarl, unilateral smirk,
pucker, lower lip out and
down) using a videotape
Movement symmetry was
graded on an 8-level scale
and assessed using the
Burres method. Synkinesis
was objectively assessed
by counting the number of
synkinetic muscles and
synkinesis was subjectively
classified according to a
4-level scale
Stiffness, lip mobility, Facial
Disability Index (physical
and social components)
The degree of eye closure
during mouth movements
was evaluated and com-
pared the right and left
sides. These measure was
654
Results/Conclusions
The results demonstrate the
significant beneficial effect
of feedback training with
either mirror feedback
alone or with the addition
of EMG feedback. Patients
in the control group dem-
onstrated facial function
measurements which indi-
cated either deterioration
or maintenance of the
status quo
The reduction of synkinesis
was not significant. Both
groups showed more
symmetric facial move-
ments after treatment
Mime therapy seems to be an
important treatment
option for patients with
sequelae of longstanding
peripheral facial paralysis
The percent asymmetry of
eye opening was signifi-
cantly greater in the train-
ing group than the control
group. The result indicates
Clinical Rehabilitation 25(7)

Manikandan G1 ¼ 29 subjects with Bell’s
(2007)25 palsy
 G2 ¼ 30 subjects with
the same diagnosis served
as controls
Barbara et al. G1 ¼ 10 patients with Bell’s
(2009)26 palsy
 G2 ¼ 9 patients with the
same diagnosis were
placed on a waiting list for
three months.
 G3 ¼ Patients from
group 2 who did not show
signs of clinical recovery
after 2 weeks of exclusive
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medical treatment
PFP, peripheral facial palsy; EMG, electromyography.
symmetrically during 3
designated mouth move-
ments using a mirror
G1 ¼ Patients received tech-
niques (facial neuromuscu-
lar re-education) that were
tailored to each patient in
3 sessions per day for 6
days per week for a period
of 2 weeks
G2 ¼ Received conven-
tional therapeutic mea-
sures (electrical
stimulation, gross facial
expression exercises and
massage for the same
period as G1
Medical treatment for 10
days. Then, patients were
divided in two groups:
G1 ¼ Patients who
received physical therapy
for 15 days, once a day
G2 ¼ Non-rehabilitation
group
G3 ¼ Kabat́s rehabilitation
(after day 15)
made using Adobe
Photoshop
Facial grading scale prior to
the onset treatment and
after a period of 3 months
House–Brackmann Facial
Grading System (Six
grades, where grade I rep-
resents normal function
and grade VI represents
total paralysis)
Amplitude of the com-
pound motor action
potential
that training is effective to
prevent synkinesis
Facial muscular re-education
Pereira et al.
is more effective than
conventional therapeutic
measures in improving the
facial symmetry in patients
with Bell’s palsy
When applied at an early
stage, Kabat’s rehabilita-
tion was proved to achieve
better and faster recovery
in comparison to the non-
rehab patients
655
656
drugs, continuously for 15 days. After that, they
were divided in two groups: The first group, with
nine patients, did a rehabilitation programme
with one session per day for six days, and con-
tinued for 15 days. The second group, with 11
patients did not undergo the physical rehabilita-
tion. These second group was divided again and
formed a third group with patients who did not
show signs of clinical recovery after two weeks
of exclusive medical treatment and then under-
went a delayed Kabat rehabilitation. This study
was not included in this review because the
second group division was not randomized. In
addition to this it creates unnecessary confusion.
Agreement between reviewers regarding the
studies’ risk of bias assessment was considered
perfect (kappa coefficient ¼ 0.8). The most
common risks of bias compromising the quality
of the included studies were: allocation conceal-
ment, blinding and intention-to-treat analysis.
Figure 2 represents the meta-analysis for the func-
tionality outcome of patients who received phys-
ical therapy (25) and the control group (25). The
experimental group did mime therapy for ten
weekly 45-minute sessions, for three months.
The control group received no intervention.
This analysis demonstrated a significant improve-
ment in functionality for the experimental group
(SMD ¼ 13.90; 95% CI 4.31, 23.49; P ¼ 0.005).
Discussion
The main goal of this study was to carry out the
meta-analysis to determine the effect of mime
therapy on facial palsy. This analysis is relevant
when making decisions about an effective treat-
ment protocol for these patients. In this study,
only three randomized controlled trials
Figure 2. Meta-analyses of facial exercise therapy for functionality outcome.
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Clinical Rehabilitation 25(7)
presented the mean and standard deviation for
functionality. This is for both pre- and
post-treatment experimental and control group
outcomes. The scarcity of the randomized con-
trolled trials as well as the low quality of the
randomized controlled trials found in this
review should be a cause for concern to health
professionals since few studies for this type of
therapy have been carried out.
A systematic review about mime therapy for
facial palsy was published in 200812 with four
studies. Meta-analysis was not performed
because the studies had an incompatible combi-
nation of characteristics such as treatment type,
time of duration of the intervention and out-
come measures. The study did not demonstrate
clinical or statistically significant differences
among the different treatment groups.
In 2008 the Cochrane Library published a
systematic review of articles about physical ther-
apy and Bell’s palsy15 including six studies with
patients who had an exclusive diagnosis of
Bell’s palsy and underwent several types of
treatment: faradic stimulation, galvanic current,
infrared treatment, massage, self-massage, acu-
puncture and drugs. No statistically significant
inter-group differences were found. Because of
differences in inclusion criteria, only two of the
studies included in the above-mentioned review
coincide with those in our systematic review.
The aetiology of facial palsy in the studies
included in our review was heterogeneous: 67%
had Bell’s palsy, 13% herpes zoster, 1% Lyme
disease, 1% trauma, 1% operation trauma, 2%
meningioma and 1% facial neuronal apoptosis.
Future studies must include patients with a sin-
gle diagnosis in order to better substantiate
the effects of mime therapy on facial palsy.
Pereira et al.
Studies analysing the progression of such patients
are also necessary. Only one study with one year
of follow-up was found, and the authors con-
cluded that benefits continued to be stable at
three and twelve months.27
The differences in evaluation and description
of outcomes were limitations for this study. Ross
et al.22 used distances between points at rest and
during facial expressions, standardized photog-
raphy from video tapes and facial nerve response
to electroneurography and presented the out-
comes in unclear graphics. Segal et al.23 used
the House–Brackmann Scale weekly but did
not show the results of this measure. Their results
are described in an unclear table where muscle
movement symmetry score values were counted
and evaluated using an eight-level scale, but the
number of synkinetic muscles was counted and
classified with a four-level scale. Nakamura
et al.24 recorded facial movements and analysed
them with a computer program to evaluate
movement symmetry, but the results appear in
unclear graphics. All the authors were contacted
in order to collect better information but we
received no responses. For this reason, only
three studies were included in the meta-analysis.
Allocation concealment and intention-
to-treat analysis were the most common risks
of bias found. Allocation concealment is neces-
sary to prevent differences in measured or
unmeasured baseline characteristics because of
the way participants were selected or assigned.
The intention-to-treat analysis is necessary to
prevent bias caused by the loss of participants,
which may disrupt the baseline equivalence
established. Blinding is difficult for this type of
treatment because both therapist and patient are
aware of treatment. The bias found in the stud-
ies we reviewed can be partially explained by the
fact that the CONSORT Statement was only
established in 1999.
Implications for research
Future randomized controlled trials about facial
palsy must follow the rules of the CONSORT
Statement28 and be careful and clear in their
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657
outcome descriptions. They must include
patients with the same diagnosis and use valid
instruments for outcome measures (e.g. House–
Brackmann, Facial Disability System). Outcome
measures must provide information about rest-
ing asymmetry, symmetry of voluntary move-
ment and synkinesis. The patients must be
evaluated prior to treatment, during treatment,
immediately after the course of treatment and
again some months later. Quality of life data
both before and after treatment is also impor-
tant. Such measures will lead to advances in
our understanding of the efficacy of physical
treatment for these patients.
Implications for practice
Mime therapy can improve functionality for
patients with facial palsy. The therapy must consist
of exercises with mirrors, which are both low cost
and easily available, and the patient must help in
the execution of the movements for both biofeed-
back purposes and to prevent synkinesis. A daily
home programme should be prescribed for
patients in order to help the evolution of treatment.
Conclusion
This systematic review suggests that mime ther-
apy is effective for facial palsy for the outcome
functionality.
Clinical messages
. Facial exercises therapy may improve
facial functionality.
. This therapy may be included to assist
with the functionality recovery of patients
with facial palsy.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or
not-for-profit sectors.
658 Clinical Rehabilitation 25(7)

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