Facial Plastic Surgery & Aesthetic Medicine

Volume 26, Number 2, 2024

ª American Academy of Facial Plastic and Reconstructive Surgery, Inc.
DOI: 10.1089/fpsam.2023.0087

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ORIGINAL INVESTIGATION Facial Nerve

Comparison of Objective Facial Metrics on Both Sides

of the Face Among Patients with Severe Bell’s Palsy
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Treated with Mirror Effect Plus Protocol

Rehabilitation Versus Controls
Sarah Martineau, PhD,1–3,* Lucie Perrin, BSc,4 Hélène Kerleau, BSc,4 Akram Rahal, MD,1,3 and Karine Marcotte, PhD2,3

Abstract
Objective: The extent to which the healthy hemiface dynamically contributes to facial synchronization dur-
ing facial rehabilitation has been largely unstudied. This study compares the synchronization of both hemi-
faces in severe Bell’s palsy patients who either received facial rehabilitation called ‘‘Mirror Effect Plus
Protocol’’ (MEPP) or basic counseling.
Methods: Baseline and 1-year postonset data from 39 patients (19 = MEPP and 20 = basic counseling) were
retrospectively analyzed using Emotrics+, a software that generates facial metrics with artificial intelligence
(AI) algorithms. Paired t-tests were used for intrasubject comparisons of hemifaces, and mixed model anal-
ysis were used to compare between groups.
Results: For voluntary movements, a significant difference in favor of the MEPP group was only found for
smiling ( p = 0.025*). However, at 1-year postonset, the control group showed significant variability between
hemifaces for most synkinesis measurements [nasolabial fold ( p = 0.029*); eye area ( p = 0.043*); palpebral
fissure ( p = 0.011*)].
Conclusion: In this study, a better synchronization of both hemifaces was found in the MEPP group. Inter-
estingly, motor adaptation in movement amplitude of the healthy hemiface seemed to contribute to this
synchronization in MEPP patients. Further studies are needed to standardize the procedure of AI measure-
ments and to adapt it for clinical use.

Introduction Many recent studies have reported the advantages of

Each year, up to 30% of Bell’s palsy (BP) cases are
expected to experience enduring sequelae,1,2 which is
devastating for patients and requires a multidisciplinary
approach to alleviate the psychosocial, functional, and
aesthetic consequences.3
early multimodal facial rehabilitation to reduce long-
term sequelae of severe BP.4–10 Our group conducted a
randomized control trial10 on the Mirror Effect Plus Pro-
tocol (MEPP)—a multimodal therapy that uses principles
of neuromuscular retraining, motor imagery, and mirror

1
Département de chirurgie et Direction des Services Multidisciplinaires, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada.
2
Centre de recherche du Centre intégré universitaire de santé et services sociaux du Nord-de-l’ı̂le-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada.
3
École d’Orthophonie et d’Audiologie, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada.
4
Département universitaire d’enseignement et de formation en orthophonie, Faculté de Médecine, Université de Sorbonne, Paris, France.
*Address correspondence to: Sarah Martineau, PhD, Direction des Services Multidisciplinaires, Maisonneuve-Rosemont Hospital, 5415 boul. De l’Assomption, Montréal H1T 2M4,
Canada, Email: sarah.martineau.2@umontreal.ca

172
 MEPP AND EMOTRICS+
KEY POINTS
Question: This study analyzed both sides of the face (affected
and healthy) on two groups of patients with severe Bell’s palsy
(controls + Mirror Effect Plus Protocol [MEPP] rehabilitation’ pa-
tients) with the artificial intelligence (AI) Emotrics+ software.
Findings: Both groups showed improvements of their facial
function over time.
Meaning: Emotrics+ measures suggest a better synchroniza-
tion of both sides of the face with MEPP patients, which was
partially obtained by adaptations of the healthy hemiface.
therapy. Briefly, MEPP patients presented a significant
improvement in facial symmetry, synkinesis, and self-
reported quality of life compared to the control group.10
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Recent evidence strongly suggests that motor control of
spontaneous facial expressions is predominantly orga-
nized across the sagittal plane, meaning that the synchro-
nization of right and left hemifaces is a key component of
the facial neurophysiology.11,12
Thus, one hypothesis about the operant mechanisms of
the MEPP could be attributed to its mirror therapy compo-
nent, which normalizes the sagittal plane during facial
motor execution. Indeed, the mirror therapy component re-
places the affected hemiface with a mirrored image of the
healthy hemiface, allowing the brain to see a corrected visual
representation of balanced, synchronized facial movement.
To fully report on the facial motor execution in BP, descrip-
tions of the movements in the healthy hemiface should be in-
cluded, but this is surprisingly rare in the literature.
Although the MEPP showed interesting results with
moderately severe to total BP patients as evaluated by pa-
tients, lay persons, and clinicians,10 there is no description
of its effects on the healthy hemiface. Novel objective
measures such as machine learning algorithms extracting
facial metrics could be valid tools to gather such informa-
tion. Facial metrics extracted from such tools specifically
used with peripheral facial palsy patients could accurately
predict facial landmarks of both hemifaces in a photograph
minimizing human intervention.13,14 The use of rapid and
fully automated tracking of facial movements based on ma-
chine learning-based algorithms would enable one to ob-
jectively quantify facial measurements in research, thus
enabling to correct subjectivity of clinical outcomes.13,14
This study aims to objectively compare the synchroni-
zation between the affected and healthy hemifaces and
the potential benefit of the MEPP on facial dynamics.
This study compares a group of patients who received
the MEPP and a control group over 1-year considering
voluntary movements and synkinesis.
Materials and Methods
This retrospective study was approved by the Ethics
Committee of the Centre de recherche du Centre intégré
173
universitaire de santé et services sociaux du Nord-de-
l’ıˆle-de-Montréal (MP-32-2017-1365). Data analyzed in
this study were gathered within a previous control ran-
domized trial,10 which followed the CONSORT guide-
lines for transparent controlled trials (registered at
ISRCTN93896690). Written, free, and informed consent
to participate was gathered for every patient.
Participants
Patients were recruited from the Emergency and the Oto-
rhinolaryngology Departments of two tertiary acute care
centers and were examined in ambulatory care settings.
They were medically stable before the BP onset. Inclu-
sion criteria were (1) a first episode of moderately severe
to total BP (i.e., House-Brackmann 2.0 grade 4, 5, and 6)
at baseline (i.e., 10–14 days postonset); (2) recommended
drug regimen for severe and total BP (1000 mg valacy-
clovir three times daily for 7 days and 50 mg prednisone
once daily for 10 days) started within 72 h postonset and
completed15; and (3) a score of 26 or above on the Mon-
treal Cognitive Assessment.16 Exclusion criteria included
(1) active psychiatric interventions; (2) history of head
and neck cancer with chemo or radiotherapy; and (3) bi-
lateral facial palsy. When eligible, patients were allo-
cated to the control or MEPP group by computerized
balanced (1:1 ratio) block randomization by a blind re-
searcher (K.M.) with no direct contact with patients.
This procedure used a sealed e-mail that was sent and
opened in front of the patient.
Procedure
Assessments. Assessments included standardized
video recordings of every patient’s face, at rest, during
speech, and during volitional facial movements. Patients
were first assessed 10–14 days after the BP onset (before
any facial therapy) and then monthly until 6-month post-
onset and again at 12-month postonset. Assessments were
video-recorded using a Samsung Galaxy S5-Neo placed
*1 m in front of the patient or with the institutional
Zoom application during the COVID-19 pandemic. The
electronic video files were transferred to a laptop and
then converted to mp4 video files and jpeg files. Only
the baseline (10–14 days postonset) and 1-year assess-
ments were analyzed in this study.
MEPP group versus control. The MEPP has been previ-
ously described in detail by Martineau et al.10,17,18
Briefly, the MEPP is a facial rehabilitation program in-
corporating education, facial manipulations (from pas-
sive mobilization to stretching—provided over a year
of facial rehabilitation and accordingly to the evolution,
from flaccid to spastic), and controlled specific facial
movements. It is executed according to neuromuscular
retraining principles and with a mirror therapy software
 174 MARTINEAU ET AL.

(https://mirroreffectplus.org/#/login) that duplicates the group during a specific movement (i.e., differences of
healthy side of the face. This should encourage nonforced nasolabial angles during brow raise, differences of naso-
and symmetrical natural facial movement. Patients labial angles during eye closure, and differences in eye
attended four in-clinic therapy sessions during the first 2 areas and palpebral fissures during pucker). For greater
weeks following baseline and then monthly for follow- clarity, all parameters analyzed in this study, with their
up. They also completed two daily 15-min home sessions, appropriate units and visual representations, are summa-
which is thought to promote motor learning and avoid rized in Supplementary Data S1.
muscular fatigue.17
Participants in the control group did not attend therapy
sessions. However, they received instructions to avoid
excessive facial movements. Their concerns or questions
were addressed if needed.

Facial symmetry and synkinesis analysis with Emotrics+.

For each patient, photographs (jpeg files) displaying the
facial rest state as well as the best range of motion for
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brow raise, eye closure, smile, and pucker were extracted

from the videos at baseline and 1 year after onset (which
corresponds to pre- and posttreatment) by two indepen-
dent judges (L.P. and H.K.) blinded to the group assign-
ments and assessment time. Each picture was then
analyzed with Emotrics+ software (Massachusetts Eye
and Ear, Boston, MA), an open-access Python-based ap-
plication specifically developed for the automatic estima-
tion of facial measurements for peripheral facial palsies.
Each picture was uploaded in the application, and fa-
cial landmarks were manually verified and adjusted if
needed by the blind judges following standardized in-
structions in the manual. Emotrics+ uses a scaling factor
based on the interocular plane to measure different facial
features in millimeters and degrees and can sometimes
generate absolute measurements in percentages.19 Emo-
trics+ requires standardization of recordings to ade-
quately measure facial metrics.20 In this study each
picture was standardized for frontal view, facial expres-
sion, and a medium-to-high resolution in pixels (lowest
resolution 462 · 643 pixels).
To measure the potential benefit of the MEPP on the
dynamic aspects of the face (dynamic symmetry, synki-
nesis), measures comparing resting state versus four dif-
ferent expressions of the face (i.e., brow raise, eye
closure, smiling, and pucker) were generated. Thus, a
two-state comparison represented by a single measure
of symmetry (the difference between resting state vs. ex-
pressive state) was generated for each movement for both
the affected and healthy hemiface and the selected facial Fig. 1. Mean values of symmetry during facial
movements. expressions (from rest position to the targeted
In a nutshell, changes in the smile were measured with movement) representing hemifaces’
both the commissure position and with the nasolabial synchronization. (A) Commissure position
angle. The brow raise was measured with brow height,
during smiling. (B) Nasolabial angle during
and the pucker was measured with the commissure posi-
smiling. (C) Brow height during brow raise.
tion with respect to the midline lower lip. Similarly, ob-
(D) Commissure position during pucker. MEPP,
jective assessment of synkinesis consisted of the
Mirror Effect Plus Protocol.
generation of a two-state comparison between the resting
state of the face and the presumed synkinetic muscle
 MEPP AND EMOTRICS+ 175

Inter-rater reliability sessments). Mixed model analyses were conducted to

All facial landmarks on each picture were manually ver-
ified and compared against the Emotrics+ Instruction
Manual to ensure that the software had correctly placed
the landmarks despite occasionally reduced image qual-
ity (e.g., pictures gathered with Zoom during the pandem-
ic). Because of this manual intervention, four participants
(10% of the group) were analyzed by a second rater to de-
termine consistency between blind raters. Both raters
standardly verified this 10% subset of measurements.
Two-way random effects intraclass correlation coeffi-
cients (ICCs) and their respective 95% confidence inter-
val (CI) were calculated. All ICCs were interpreted based
on Koo and Li guidelines21: excellent (ICC >0.9), good
(0.75–0.9), moderate (0.5–0.75), and poor (<0.5).
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compare between treatment modalities with a heteroge-
nous compound symmetry (CSH) matrix of covariance,
time as a repeated effect, and condition as a fixed effect.
Results
Of the 40 participants included in the randomized control
trial by Martineau et al.,10 only one patient in the MEPP
group had pictures that could not be analyzed with Emo-
trics+ due to insufficient image quality. Thus, data from
19 MEPP patients and 20 controls were analyzed for this
study. Each participant had one picture at rest and four pic-
tures displaying facial expression, including baseline and
1-year postonset, for a total of 390 pictures analysed over-
all. The basic demographics of the included participants are

shown in the Supplementary Data S2.

Statistical analysis
Statistical analyses were performed with SPSS (IBM ver-
sion 28.0.1). Descriptive statistics were obtained for the
healthy and the affected side at baseline and 1-year poston-
set for each selected movement. Quantile-Quantile-plots
were generated to visually verify normality in data distri-
bution for each variable. Paired t-tests were conducted
on continuous variables of interest for intrasubject compar-
isons in hemiface coordination as well as for intrasubject
comparisons between time points (initial and 12-month as-
Inter-rater reliability
For each measure of facial expression, the inter-rater re-
liability was above the threshold of high reliability ICC
>0.80.22 Specifically, the ICC (95% CI) values were
0.848 (0.564–0.947) for brow raise, 0.972 (0.921–0.990)
for smiling, 0.918 (0.765–0.971) for eye closure, and
0.930 (0.885–0.957) for pucker, demonstrating the inter-
rater reliability of the measures obtained with Emotrics+.

Table 1. Mean Values (Standard Deviation) of Symmetry During Facial Expressions (From a Rest Position to the Targeted
Movement) Representing Hemifaces’ Synchronization with Intrasubject Analysis for Evolution of Each Hemiface and Mixed
Model Analyses for Differences Between Groups

Assessment time Statistical analysis

12 months Differences over time Differences between groups

Side Initial postonset for each side (paired t-test) over time (interaction)

Smiling (variation in commissure MEPP

position in mm) Affected side 0.30 (3.98) 11.32 (3.44) t = 12.620 (p = 0.001) F = 5.447 ( p = 0.025)
Healthy side 10.75 (4.87) 11.40 (3.38) t = 0.711 ( p = 0.481)
Control
Affected side 1.40 (3.71) 9.07 (0.27) t = 5.909 (p = 0.001)
Healthy side 9.58 (4.54) 11.43 (4.85) t = 1.141 ( p = 0.268)
Smiling (variation in nasolabial MEPP F = 1.531 ( p = 0.224)
angle in degrees) Affected side 2.96 (12.83) 14.81 (13.26) t = 5.063 (p = 0.001)
Healthy side 11.12 (11.32) 15.41 (11.61) t = 1.693 ( p = 0.108)
Controls
Affected side 0.14 (14.50) 9.95 (14.76) t = 1.884 ( p = 0.075)
Healthy side 8.71 (5.37) 11.90 (12.35) t = 1.1171 ( p = 0.278)
Variation in brow height during MEPP F = 0.150 ( p = 0.701)
brow raise in % Affected side 7.95 (13.98) 32.35 (17.41) t = 5.103 (p = 0.001)
Healthy side 29.87 (25.18) 36.81 (19.46) t = 1.147 ( p = 0.266)
Controls
Affected side 2.17 (13.30) 23.81 (29.84) t = 3.390 (p = 0.003)
Healthy side 22.52 (21.97) 30.22 (23.30) t = 1.287 ( p = 0.214)
Variation in commissure position MEPP F = 0.104 ( p = 0.748)
during pucker in mm Affected side 2.92 (3.30) 4.51 (3.17) t = 1.432 ( p = 0.19)
Healthy side 1.15 (4.15) 5.57 (4.37) t = 3.234 (p = 0.005)
Controls
Affected side 2.40 (3.69) 4.51 (4.13) t = 1.923 ( p = 0.071)
Healthy side 0.11 (2.26) 4.01 (3.28) t = 4.273 (p = 0.001)

Significant results are presented in bold.

Alpha, 0.05; F, mixed model analysis for interaction between time and groups; MEPP, Mirror Effect Plus Protocol; mm, millimeters; SD, standard
deviation; t, paired t-tests.
 176 MARTINEAU ET AL.

Table 2. Intrasubject Comparison of Affected Versus Healthy Side Synchronization at 12 Months for Voluntary Movements
with Paired t-Tests with Their 95% Confidence Intervals

MEPP Controls

Volitional movement measures t 95% CI p t 95% CI p

Variation in commissure position during smiling 0.511 ( 1.893 to 3.104) 0.308 1.981 ( 11.116 to 5.255) 0.031
Variation in nasolabial angle during smiling 0.182 ( 7.711 to 6.479) 0.429 0.403 ( 12.092 to 8.191) 0.346
Variation in brow height during brow raise 1.361 ( 8.024 to 1.748) 0.096 1.831 ( 13.876 to 0.950) 0.042
Variation in commissure position during pucker 1.208 (0.880 to 0.785) 0.121 0.462 (1.056 to 2.708) 0.325

Significant results are presented in bold.

Alpha, 0.05; CI, confidence interval.

Facial symmetry and dynamic synchronization which suggests that synchronization between both hemi-
in voluntary movements faces tended to be greater for the MEPP group.
Figure 1 represents the evolution of the facial expressions
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for each hemiface in the control and MEPP groups for the
three following voluntary movements: smiling, brow raise,
and pucker. Results of the dynamic synchronization in
these three voluntary movements are reported in Table 1.
Overall, the healthy side did not significantly vary over
time in both groups, except for the pucker (MEPP:
t = 3.234; p = 0.005 and controls: 4.273; p = 0.001).
The pucker showed a larger negative (under 0) variation
at 12 months, which could be interpreted as a generally
more ample commissure movement bilaterally toward
midline. As expected, the affected side tended to show sig-
nificant variation over time, demonstrating greater move-
ment at 12 months. In addition, results of the mixed
model analysis for comparison between treatment modali-
ties demonstrated no significant differences between con-
trols and MEPP patients over time regarding symmetry
of voluntary movements, except for the commissure posi-
tion in smiling.
In Table 2, intrasubject analyses demonstrated no sig-
nificant differences between the healthy and affected
sides of the face for the MEPP group at 12-month poston-
set. However, the control group demonstrated a signifi-
cant difference across hemifaces for commissure
position during smiling (t = 1.981; p = 0.031) and
brow height during brow raise (t = 1.361; p = 0.042),
Co-contractions and synkinesis
Table 3 and Figure 2 report the mean values of potential
co-contractions (for the healthy side) or synkinesis of the
affected side for both groups at 12 months.
Measures of co-contractions were expected to show very
little variation on the healthy side, because synkinesis only
occurs as a result of the reinnervation process on the affected
side. However, variations in movements of the healthy side
are depicted here alongside synkinetic movements, because
they convey information about general movement ampli-
tude and patients’ overall tendency to harmonize move-
ments between their hemifaces. Importantly, amplitude of
the healthy side movement during synkinesis is information
that could not be analyzed in our previous work.
In Figure 2, when comparing groups, the nasolabial
angle of the affected side tended to augment during
brow raise and eye closure only in the control group,
which is representative of a cheek synkinesis. During
pucker, the percentage of eye area and palpebral fissure
decreased in both groups, demonstrating an eye synkinesis
in both groups. The control group showed significantly
more variation between hemifaces than the MEPP
group, for measures of synkinesis during eye closure
(nasolabial angle variation: t = 2.032; p = 0.029*), and
pucker (eye area: t = 1,814; p = 0.043* and palpebral

Table 3. Mean Values (Standard Deviation) of Synkinesis at 12-Month Postonset and Intrasubject Comparisons of Affected
Versus Healthy Side Synchronization in Both Groups

MEPP Controls

Sides Affected Healthy Affected Healthy

Variation in nasolabial angle during brow raise in degrees 0.55 (3.218) 0.64 (2.05) 0.99 (3.98) 0.35 (4.58)
Paired t-test values ( p values) t = 0.073 ( p = 0.471) t = 0.526 ( p = 0.303)
Variation in nasolabial angle during eye closure in degrees 1.16 (1.63) 0.52 (2.61) 0.60 (2.94) 0.80 (1.84)
Paired t-test values ( p values) t = 1.032 ( p = 0.158) t = 2.032 (p = 0.029)
Variation in eye area during pucker in % 25.76 (27.83) 20.89 (26.45) 27.39 (32.41) 11.21 (21.99)
Paired t-test values ( p values) t = 0.918 ( p = 0.185) t = 1.814 (p = 0.043)
Variation in palpebral fissure width during pucker in % 24.15 (26.78) 15.58 (26.54) 30.86 (27.32) 11.45 (17.68)
Paired t-test values ( p values) t = 1.445 ( p = 0.083) t = 2.5 (p = 0.011)

Significant results are presented in bold.

Alpha, 0.05.
 MEPP AND EMOTRICS+
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Fig. 2. Mean values of co-contractions for
healthy side and of synkinesis of the affected
side during facial expressions at 12 months.
(A) Nasolabial angle during brow raise smiling.
(B) Nasolabial angle during eye closure. (C) Eye
area during pucker. (D) Palpebral fissure width
during pucker.
fissure: t = 2.5; p = 0.011*). These significant variations
between the affected and healthy sides affect the balance
of the face in the control group.
Discussion
This study is the first to report on the long-term evolution
of facial symmetry and synkinesis with regard to intrain-
177
dividual synchronization of both hemifaces on partici-
pants for a control group and a behavioral rehabilitation
group (MEPP group). Artificial intelligence (AI) objec-
tive measurements were generated by a machine-learning
algorithm. To the best of our knowledge, this is the first
study to measure outcomes of a facial retraining program
using AI measurements, comparing the mobility of the
healthy hemiface with the paralyzed one. Consequently,
this study adds new knowledge to the existing literature
about MEPP by exploring its effects with the perspective
of a new methodology using Emotrics+.
In both groups, the healthy hemiface was relatively
stable over time, and the affected side significantly im-
proved its mobility, as expected with natural recovery.
The MEPP group improved significantly compared to
the control group only when considering the variation
in commissure position during smiling. Smiling is often
a very important movement for patients to work on dur-
ing facial rehabilitation, so maybe the quantity of practice
with that specific movement positively impacted the sig-
nificance of this result.23 Also, earlier literature previ-
ously reported positive effects of mirror therapy on
smiling rehabilitation following facial palsy.24,25
The chosen measures of synkinesis also demonstrated
a difference between healthy and affected hemifaces.
Specifically, for 3 measures of synkinesis out of 4, the
differences across hemifaces were larger in the control
group than in the MEPP group, demonstrating more syn-
kinesis for the control group, which is in line with previ-
ously obtained results with clinician grading systems.10
In general, clinical research outcomes in facial palsy
are limited by a lack of objective and quantitative evalu-
ation.13 Clinician-based grading systems always compare
the dynamic symmetry of the affected hemiface against a
presumed full amplitude movement of the healthy side
(100%), which does not consider the natural intraindivid-
ual variability of facial movements, particularly after fa-
cial palsy.26 In this study, descriptive results not only
demonstrated that the dynamic movements of the af-
fected hemiface improved with time but also that the dy-
namic amplitude of the patients’ healthy hemifaces
varied to a certain degree over time. The variation of
some of the variables studied, that is, the pucker, revealed
a potential dynamic adaptation of the healthy hemiface.
This adaptation seemed generally greater in the MEPP
patients, thus demonstrating a potentially greater intrain-
dividual synchronization of the hemifaces, which is a
new result compared to our previous work. Indeed, our
intrasubject analyses demonstrated that MEPP patients
never reached statistically significant differences in am-
plitude of movements between hemifaces, while most
controls did. Controls demonstrated more variability in
movements between intraindividual hemifaces, which
probably affected their facial symmetry. In other words,
the MEPP seems to help patients achieving the balance
 178
between the healthy and affected hemiface, which is a
key component that affects the perception of facial
palsy severity and quality of life in patients.27
Based on our previous10,28 and present studies, we next
hypothesized that the better synchronization of both hem-
ifaces by the MEPP participants could be partly
explained by an accentuation of the natural neurophysio-
logical organization of the facial motor system, thanks to
its mirror therapy component.29 The present results are
also consistent with that of Ross et al.,30 who found ro-
bust evidence for a predominantly independent hemi-
spheric motor control of the lower versus upper face.
This independence leads to a relative easiness in execut-
ing asymmetrical (or emotionally distinctive) movements
in the inferior versus superior quadrant of the face. How-
ever, those asymmetrical movements were not easily pro-
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duced across the sagittal plane (right vs. left) of the face.
Clinically, for BP patients, this could mean that a rehabil-
itation focusing on the synchronization at the horizontal
axis, such as the MEPP, could sustain natural recovery.
This study does have some limitations. Data of one
MEPP patient could not be analyzed due to low-quality
pictures gathered during the pandemic. In addition,
while AI is a promising tool to automate analysis and
minimize human bias, not all pictures completely con-
formed to the criteria of those used for training the algo-
rithm, for example, blue background,14 which led to
manual adjustments of the reference points in some pic-
tures by blinded judges. Finally, very little research
until now has used Emotrics+ to calculate dynamic sym-
metry and synkinesis following an intervention; thus, the
procedure described in the methodology has not yet been
standardized and should be replicated in further studies.
However, the results can be the basis for future power
calculations about mirror therapy.
Conclusion
The results in this study suggest that AI facial metrics
could be used to successfully differentiate between intra-
individual differences in hemifaces’ evolution in two
groups of BP patients. Furthermore, a slightly greater
motor adaptation of the healthy hemiface was seen in pa-
tients who benefited from the MEPP, a facial retraining
program that includes a mirror therapy component,
which could have led to improved synchronization of
both hemifaces.
Acknowledgments
We deeply thank our participants and their families for
their commitment to this project. We are also grateful
to the Massachusetts Eye and Ear Center who kindly
shared their Emotrics+ software with the SCBS commu-
nity. We also thank our collaborators who participated
either in recruitment, analysis, or as blind judges:
Anne-Marie Chouinard, Camille Rivest, Marie Julien,
MARTINEAU ET AL.
Khawla Kharra, Nadim T. Saydy, Laurence Gascon,
Ariane Poulin, and Stéphanie Des Ormeaux.
Authors’ Contributions
S.M. was responsible for study design, literature review,
data collection, data analysis, and was a major contributor
in writing and revising the manuscript. L.P. and H.K. con-
tributed to data collection and revising the manuscript.
A.R. contributed largely to study design, to literature
reviewing, and revising the manuscript. K.M. contributed
largely to study design, literature review, data collection,
data analysis, and revising the manuscript.
Author Disclosure Statement
The authors declare no conflict of interest.
Funding Information
The authors disclose receipt of the following financial
support for the research, authorship, and/or publication
of this article: This work was supported by REPAR-
OOAQ grant (No. 5080); a La Division ORL grant; and
Fonds de Recherche du Québec—Santé grants (Nos.
266532 and 33310).
Supplementary Material
Supplementary Data S1
Supplementary Data S2
References
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