Follow-Up
Changes in Facial Movement and Synkinesis
with Facial Neuromuscular Reeducation
Jessie M. VanSwearingen, Ph.D., P.T., and Jennifer S. Brach, Ph.D., P.T.
Pittsburgh, Pa.
Synkinesis, a problem of facial movement
control in which abnormal movements accom-
pany intended voluntary facial movements, can
occur during recovery after facial nerve inju-
ries.1– 6 Unresolved synkinesis distorts facial
movements and expressions and may result in
soft-tissue contractures and disrupted resting
facial posture.5,7,8 We previously demonstrated
that synkinesis decreased among individuals
with facial nerve disorders during participation
in a neuromuscular reeducation program for
facial rehabilitation.2 In our previous work, we
did not address changes in intended voluntary
movements with facial rehabilitation.
During treatment of synkinesis with facial
rehabilitation, small intended voluntary move-
ments that do not provoke the accompanying
abnormal movements are often encouraged.9,10
The outcomes of such facial rehabilitation can
be decreased synkinesis but also decreased in-
tended voluntary movement. The purpose of
this report is to describe the outcomes of neu-
romuscular reeducation for treatment of syn-
kinesis, with a description of changes in in-
tended voluntary movements in addition to a
description of changes in abnormal synkinetic
movements. We considered the success of neu-
romuscular reeducation to be demonstrated by
the association of a reduction in synkinetic
movements with an increase in intended move-
ments after intervention. We present a more
extensive review of the outcomes of facial re-
habilitation for the treatment of synkinesis,
and we describe changes in our rehabilitation
From the Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh. Received for publication
December 5, 2001; revised October 10, 2002.
Follow-up to Brach, J. S., VanSwearingen, J. M., Lenert, J., and Johnson, P. C. Facial neuromuscular retraining for oral synkinesis. Plast.
Reconstr. Surg. 99: 1922, 1997. This study was presented in part at the American Physical Therapy Association Combined Sections Meeting, in
New Orleans, Louisiana, February 3 to 6, 2000.
DOI: 10.1097/01.PRS.0000061007.36637.88
2370
practices based on the finding of a relationship
between synkinesis and intended movement.
PATIENTS AND METHODS
Patients
Sixty-six consecutive adult patients who were
referred for facial rehabilitation between No-
vember of 1993 and June of 1998, who pre-
sented with moderate-to-severe synkinesis or
mild-to-moderate multiway synkinesis (synkine-
sis with more than one intended movement),
and who participated in physical therapy for
facial neuromuscular reeducation were in-
cluded. Patients were included if the synkinesis
component scale score of the facial grading
system, which is an observational measure of
facial impairment,11 was 3 or more, indicating
moderate-to-severe synkinesis or mild-to-
moderate multiway synkinesis. This study was
approved by the Biomedical Institutional Re-
view Board of the University of Pittsburgh and
was conducted at the Facial Nerve Center, Cen-
ters for Rehabilitation Services, University of
Pittsburgh Medical Center Health System.
Measures
The facial grading system, which is an obser-
vational rating of facial resting posture, volun-
tary movement, and synkinesis,11 was used to
determine facial impairment before and after
intervention for facial rehabilitation. The sys-
tem is a valid reliable measure of facial impair-
ment.11,12 A composite facial grading system
Vol. 111, No. 7 / FACIAL REHABILITATION FOR SYNKINESIS
score between 0 and 100 is determined from
the sum of the subscale scores for resting pos-
ture (range, 0 to 20), voluntary movement
(range, 20 to 100), and synkinesis (range, 0 to
15). The voluntary movement and synkinesis
subscale scores were used to determine inter-
vention outcomes in this study. Reductions in
the synkinesis scores and increases in the vol-
untary movement scores with intervention rep-
resent improvement (e.g., less facial
impairment).
Intervention
All patients participated in neuromuscular
reeducation in physical therapy. The neuro-
muscular reeducation involved intermittent
physical therapy sessions for surface electro-
myographic biofeedback-assisted facial muscle
reeducation. The goals of reeducation were to
reduce synkinesis and to improve facial move-
ment control. Between sessions, patients con-
tinued the facial muscle reeducation with indi-
vidualized home exercise programs of specific
facial movements. The exercises were designed
to reduce synkinesis and to promote the recov-
ery of desired patterns of muscle activation for
intended facial expressions and functions. Pa-
tients did not use surface electromyographic
biofeedback at home but were free to use a
mirror for feedback if they found it helpful.
Data Analyses
Changes in synkinesis and the desired move-
ments with intervention were statistically de-
scribed. A multivariate analysis of variance with
repeated measures13 was used to evaluate the
changes in synkinesis and movement with in-
tervention. A multivariate analysis was used be-
cause we were interested in describing the ef-
fects of intervention on two characteristics of
TABLE I
Patient Characteristics According to Facial Neuromotor Disorder
Bell Palsy Acoustic Neuroma
(n ⫽ 30) (n ⫽ 12)
Age (yr)
Mean ⫾ SD 53 ⫾ 15 61 ⫾ 15
Range 27–94 26–80
Disorder duration (mo)
Mean ⫾ SD 43 ⫾ 55 65 ⫾ 125
Range 3–228 5–360
Rehabilitation duration (mo)
Mean ⫾ SD 6.3 ⫾ 5.9 16.4 ⫾ 12
Range 0.10–24 1–39
* Tumors other than acoustic neuromas (e.g., parotid tumors, meningiomas, and primary facial nerve tumors).
† Other, an individual with an arteriovenous malformation.
2371
patients with facial paralysis, namely, synkinesis
and intended movement. Simultaneous analy-
sis of changes in both characteristics with in-
tervention could provide more information
than analyses of synkinesis and intended move-
ment individually, and the multivariate analysis
could account for correlation between the vari-
ables not accounted for in separate analyses.14
RESULTS
Synkinesis followed a variety of insults to the
facial neuromotor system for the 66 patients
with moderate-to-severe synkinesis, secondary
to facial paralysis, who participated in neuro-
muscular reeducation (Table I). Patients ex-
hibited reduced synkinesis and increased in-
tended facial movement after neuromuscular
reeducation for facial rehabilitation (Table II).
The reduction in synkinesis was associated with
increases in intended facial movement (F ⫽
622.3; df ⫽ 1,65; p ⬍ 0.001) (Fig. 1). The
synkinesis scores were reduced for 54 of the 66
individuals with synkinesis after neuromuscu-
lar reeducation. Four individuals demon-
strated increases in their facial grading system
synkinesis scores, and eight exhibited no
change in synkinesis scores (before versus after
intervention) (Fig. 2). Of the four individuals
who exhibited increases in facial grading sys-
tem synkinesis scores, three also exhibited in-
creases in grading system movement scores;
the other individual demonstrated no change
in movement score.
Movement scores for intended facial move-
ments were increased for 59 of the 66 individ-
uals with the facial neuromotor disorder, syn-
kinesis. Intended facial movement scores were
decreased after intervention in four individu-
als, and movement scores were unchanged in
three (Fig. 3). Only two of the 66 participants
Trauma Tumors* Hemifacial Spasm Total ⫹ 1 Other†
(n ⫽ 13) (n ⫽ 7) (n ⫽ 3) (n ⫽ 66)
38 ⫾ 15 56 ⫾ 13 48 ⫾ 9 52.2 ⫾ 15.9
23–72 41–72 38–55 23–94
86 ⫾ 101 94 ⫾ 110 32 ⫾ 23 57.1 ⫾ 80.3
12–264 7–288 16–48 3–360
11.9 ⫾ 12.7 16.4 ⫾ 15 15 ⫾ 4.2 11 ⫾ 10.8
1–44 1–43 12–18 0.10–44
2372 PLASTIC AND RECONSTRUCTIVE SURGERY, June 2003
TABLE II cle group responsible for the synkinetic move-
Mean Synkinesis and Movement Scores before and after ment of the face.2 For example, a person with
Intervention (n ⫽ 66) unilateral oral-ocular synkinesis (specifically,
smiling accompanied by abnormal closing of
Confidence the right eye) might demonstrate the pattern
Score Before* After* Change† Interval
of muscle activity presented in Figure 4. The
Synkinesis 6.2 ⫾ 2.6 4.0 ⫾ 1.4 2.2 ⫾ 0.3‡ 1.5–2.8 muscle activity of the right zygomaticus muscle
Movement 51.3 ⫾ 12.3 64.2 ⫾ 12.1 12.9 ⫾ 1.4‡ 10.1–15.8
group, which is associated with the intended
* Mean ⫾ SD.
† Mean ⫾ standard error. voluntary action of smiling, is accompanied by
‡ p ⬍ 0.05. the synkinetic activity of the right orbicularis
oculi (recorded from the inferior portion of
demonstrated decreases in synkinesis associ- the muscle). The patient uses electromyo-
ated with decreases in intended facial graphic biofeedback during physical therapy
movements. sessions to learn to reduce the abnormal orbic-
DISCUSSION
ularis oculi activity on the right, and practices
specific exercises at home each day, to rein-
Changes in Observations force the newly learned patterns of recruit-
The surface electromyographic recordings ment of these muscles for smiling. With prac-
of facial muscle activity during rehabilitation tice, small shifts in the muscle activation
sessions illustrated some of the changes in re- patterns that are frequently observed in physi-
cruitment with facial neuromuscular reeduca- cal therapy sessions became more obvious
tion for persons with facial nerve insults and changes in facial movements. The presented
synkinesis. Surface electromyography records patient learned to reduce the unintended ac-
the electrical activity of the muscles beneath tivity of the right orbicularis oculi muscle from
the pair of recording electrodes. A pair of elec- approximately 10 ␮V to 4 ␮V in 2 months.
trodes from one recording channel are placed Reduction of synkinetic muscle activity was as-
on the skin over the region of the facial muscle sociated with a more than twofold increase in
or muscle group primarily responsible for the the intended muscle activity of the right zygo-
intended facial movement, and a pair of elec- maticus muscle, from the original amplitude of
trodes from a second channel are placed on approximately 15 ␮V to more than 30 ␮V (Fig.
the skin over the region of the muscle or mus- 4). Clinicians and investigators contend that

FIG. 1. Relationship of synkinesis and movement scores before (pre) and after (post) neuro-
muscular reeducation. Low scores for synkinesis and high scores for movement represent better
performance (e.g., less impairment).
Vol. 111, No. 7 / FACIAL REHABILITATION FOR SYNKINESIS
FIG. 2. Synkinesis scores before (pre) and after (post) neuromuscular reeducation.
FIG. 3. Movement scores before (pre) and after (post) neuromuscular reeducation.
the process of neuromuscular reeducation fo-
cuses the brain on the new role or identity of
facial neurons and the brain again learns to
recruit appropriate neurons for the intended
facial movement or task.2,15–17
Changes in Practice
As a result of our observations of increases in
intended voluntary movement with the reduc-
tion of synkinesis, we recently modified our
approach to facial rehabilitation for patients
with facial nerve insults and synkinesis. Previ-
ously, the goal of neuromuscular reeducation
for all patients with synkinesis was to reduce or
eliminate the synkinesis. For some patients,
reducing synkinesis was very difficult because
the patients seemed to be unable to move if the
2373
synkinesis was to be limited. Based on the ob-
served interaction between synkinesis and in-
tended voluntary movement, we have trained
some patients to focus on increasing the in-
tended movement, allowing synkinesis to occur
initially. As the patient is able to increase the
intended movement, we gradually shift atten-
tion to maintaining the intended movement
while attempting to reduce the synkinetic
movement. The patient learns to produce the
intended movement and seems to use the syn-
kinetic movement pattern less for facial
functions.
The strength of the evidence regarding the
outcomes of facial neuromuscular reeducation
for patients with facial neuromotor disorders
and synkinesis is limited because of the lack of
2374
FIG. 4. Surface electromyographic recordings of muscle
activity from the regions of the face over the inferior orbic-
ularis oculi (light gray) and the zygomaticus muscle group
(dark gray) during smiling, initially (above) and 2 months later
(below).
a control (nonintervention) group, for assess-
ment of changes with time without interven-
tion. We studied the outcomes of the usual
clinical practice for facial rehabilitation in our
center; therefore, the intent was to treat pa-
tients who were referred for physical therapy.
Although spontaneous or natural recovery of
the facial neuromotor system might have con-
tributed to the facial rehabilitation outcomes
presented, the possibility seems unlikely. Only
two individuals had histories of facial dysfunc-
tion of less than 5 months (a time at or beyond
the usual period needed for spontaneous un-
complicated recovery). Eighteen of the 66 pa-
tients with facial neuromotor disorders had his-
tories of the facial movement problem of less
than 12 months, and the majority (44 of 66 pa-
tients) had histories of the disorder of 2 years or
PLASTIC AND RECONSTRUCTIVE SURGERY, June 2003
more before participation in the physical therapy
for facial rehabilitation reported in this article.
CONCLUSIONS
We demonstrated a pattern of reductions in
synkinesis and increases in intended facial
movement after neuromuscular reeducation in
physical therapy for individuals with the facial
neuromotor disorder of synkinesis. The pat-
tern of changes after neuromuscular reeduca-
tion indicates an interaction between synkine-
sis and the intended movements of the face
during recovery of facial function after insults.
Neuromuscular reeducation that focuses on in-
creasing intended movement and reducing
synkinesis may be effective in the process of
facial rehabilitation. We suggest that the pat-
tern of changes in facial movement with neu-
romuscular reeducation for facial rehabilita-
tion illustrates the plasticity of the facial
neuromotor system after insults. The brain
learns to assign new roles to neurons, reducing
abnormal patterns of movement and restoring
appropriate patterns of facial muscle activity
for intended facial actions.
Jessie M. VanSwearingen, Ph.D., P.T.
Department of Physical Therapy
University of Pittsburgh
6035 Forbes Tower
Pittsburgh, Pa. 15260
jessievs@pitt.edu
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