The Mirror Effect Plus Protocol for acute Bell's palsy: a randomised and longitudinal study on facial rehabilitation

The Use of Mirror Therapy in Peripheral Seventh Nerve Palsy: A Systematic Review

BACKGROUND

Conservative therapy is currently the elective treatment for peripheric facial palsy according to scientific literature. The success of conservative therapy is due to physiotherapy and the application of its methods. The aim of this systematic review was to assess mirror therapy, a physiotherapeutic method.

OBJECTIVES

The aim of the following systematic review is to evaluate the effectiveness of using mirror therapy in patients with peripheral paralysis of the seventh cranial nerve.

METHODS

This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The screening of literature was carried out on Cochrane, PEDro, PubMed/Medline, Scopus and Web of Science databases up until August 2022. All studies were randomized controlled trials (RCTs) and 5 articles met the inclusion criteria and were included in this study. The risk of bias was evaluated with PEDro and Jadad scales.

DISCUSSION

In the present study, we reviewed 5 RCTs that compared mirror therapy with other physiotherapy treatments or placebo to reduce pain, depression and improve range of motion in patients with peripheric facial nerve palsy.

CONCLUSIONS

Further studies are needed to determine the effectiveness of this type of treatment, but nevertheless the data obtained are very encouraging.

Comparison of Objective Facial Metrics on Both Sides of the Face Among Patients with Severe Bell's Palsy Treated with Mirror Effect Plus Protocol Rehabilitation Versus Controls

Objective: The extent to which the healthy hemiface dynamically contributes to facial synchronization during facial rehabilitation has been largely unstudied. This study compares the synchronization of both hemifaces 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 analysis 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. Interestingly, 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 measurements and to adapt it for clinical use.

Selective zygomaticus muscle activation by ball electrodes in synkinetically reinnervated patients after facial paralysis

Introduction

Although many different treatments were developed for facial palsy, only a few therapeutic options are available for facial synkinesis. Electrical stimulation of specific muscles via implants could be useful in restoring facial symmetry in synkinetic patients. A challenge in developing stimulation devices is finding the right stimulation location, type, and amplitude. This work assesses the ability to selectively stimulate the zygomaticus muscle (ZYG) in patients with oral-ocular synkinesis to elicit a visually detectable response of the ipsilateral corner of the mouth (COM), without causing a reaction of the orbicularis oculi muscle (OOM). We aimed to assess how close to the COM the stimulation should be delivered in order to be selective.

Methods

A total of 10 patients (eight females, two males) were enrolled. Facial function was graded according to the Sunnybrook facial grading system. Needle EMG was used to test the activities of the muscles, during volitional and "unintended" movements, and the degree of synkinesis of the ZYG and OOM. Two ball electrodes connected to an external stimulator were placed on the paretic ZYG, as close as possible to the COM.

Results

Independent of the waveform with which the stimulation was presented, a selective ZYG response was observed within 4.5 cm of the horizontal plane and 3 cm of the vertical plane of the COM. When the distance between the electrodes was kept to ≤2 cm, the amplitude necessary to trigger a response ranged between 3 and 6 mA when the stimulation was delivered with triangular pulses and between 2.5 and 3.5 mA for rectangular pulses. The required amplitude did not seem to be dependent on the applied phase duration (PD), as long as the PD was ≥5 ms.

Conclusion

Our results show that selective stimulation of the ZYG presenting synkinetic ZYG-OOM reinnervation can be achieved using a broad PD range (25-1,000 ms) and an average amplitude ≤6 mA, which may be further decreased to 3.5 mA if the stimulation is delivered via rectangular rather than triangular waves. The most comfortable and effective results were observed with PDs between 50 and 250 ms, suggesting that this range should be selected in future studies.

Clinical Trial Registration

[https://drks.de/search/de/trial/DRKS00019992], identifier (DRKS00019992).

Measuring the Potential Effects of Mirror Therapy Added to the Gold Standard Facial Neuromuscular Retraining in Patients With Chronic Peripheral Facial Palsy: Protocol for a Randomized Controlled Trial

BACKGROUND

Facial neuromuscular retraining (fNMR) is a noninvasive physical therapy widely used to treat peripheral facial palsies. It consists of different intervention methods that aim to reduce the debilitating sequelae of the disease. Recently, the use of mirror therapy in the acute facial palsy and postsurgical rehabilitation contexts has shown promising results, suggesting its use as an adjunct to fNMR in treating patients with later stages of paralysis, such as the paretic, early, or chronic synkinetic.

OBJECTIVE

The main aim of this study is to compare the efficacy of an added mirror therapy component with fNMR in patients with peripheral facial palsy (PFP) sequelae in 3 different stages. The specific objectives of this study are to measure the effects of combined therapy compared to fNMR alone on (1) participants' facial symmetry and synkinesis, (2) quality of life and psychological aspects of the participants, (3) motivation and treatment adherence, and (4) different stages of facial palsies.

METHODS

This study is a randomized controlled trial that compares the effect of fNMR combined with mirror therapy (experimental group: n=45) with fNMR alone (control group: n=45) in 90 patients with peripheral facial palsy presenting with sequelae 3-12 months after onset. Both groups will receive 6 months of rehabilitation training. Facial symmetry and synkinesis; participants' quality of life; and their psychological factors, motivation, and compliance will be assessed at baseline (T0), 3 months (T1), 6 months (T2), and 12 months (T3) postintervention. Outcome measures are (1) changes in facial symmetry and synkinesis assessed with facial grading tools, (2) quality of life changes with patient questionnaires, and (3) therapy motivation with a standardized scale, as well as adherence to treatment with metadata. Changes in facial symmetry and synkinesis will be judged by 3 assessors blinded to group assignment. Mixed models and Kruskal-Wallis, chi-square, and multilevel analyses will be conducted according to the appropriate variable type.

RESULTS

Inclusion will start in 2024 and is anticipated to be completed in 2027. The 12-month follow-up will be completed with the last patient in 2028. We expect patients included in this study to experience improvement in facial symmetry, synkinesis, and quality of life, regardless of group assignments. A potential benefit of mirror therapy for facial symmetry and synkinesis could be noted for patients in the paretic phase. We hypothesize better motivation and adherence to treatment for the mirror therapy group.

CONCLUSIONS

The results of this trial may provide new guidelines for PFP rehabilitation with patients dealing with long-term sequelae. It also fills the need for robust evidence-based data in behavioral facial rehabilitation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/47709.

Development of an open-source and free facial rehabilitation website for severe bell's palsy: a within-subject study on user experience and patient's compliance with the MEPP-website

PURPOSE

An open source and free website called Mirror Effect Plus Protocol (MEPP)-website was developed with features to diminish cognitive load and support motor learning during facial exercises. Assessing patient's perceptions is crucial when developing rehabilitation tools because patients' willingness to use the tools strongly affect engagement in the rehabilitation process. This study compared clinicians' and patients' user experience with the MEPP-website versus a hobby-designed website.

MATERIALS AND METHODS

Ten patients with acute severe Bell's palsy and five clinicians were enrolled in a within-subject and crossover design. User experience was assessed with the Modular evaluation of Components of User Experience questionnaire. Wilcoxon-Signed-Rank test analysed user experience, and descriptive analyses explored the order effect. Therapeutic compliance was verified for the MEPP-website by an integrated feature. Clinicians' descriptive statistics and subjective observations were also reported.

RESULTS

Both patients and clinicians demonstrated a preference for the MEPP-website, whether they used it first or second. Despite this preference, compliance with the MEPP-website was reduced, although it tended to be better when used first.

CONCLUSIONS

MEPP- website during facial rehabilitation improved user experience. Better user experience likely optimizes how patients perform and facilitate their exercises. Factors affecting compliance with facial rehabilitation remain to be addressed.Implications for rehabilitationRecent data suggests that mirror effect therapy combined with drug therapy supports the recovery of severe Bell's Palsy.The specialized Mirror Effect Plus Protocol (MEPP)- website is a clinical computer-based tool developed to promote patients' motor learning and diminish cognitive load during mirror therapy.The MEPP-website increase clinicians' accessibility to a specialized facial rehabilitation tool for mirror therapy.Clinicians using the MEPP-website can also objectively and easily measure compliance to facial therapy with the MEPP-website.

The "Mirror Effect Plus Protocol" for acute Bell's palsy: A randomized controlled trial with 1-year follow-up

Objective

To study the effects of the “Mirror Effect Plus Protocol” (MEPP) on global facial function in acute and severe Bell's Palsy.

Design

Single blind and randomized controlled trial to compare the effects of basic counseling (control group) versus MEPP (experimental group) over one year.

Setting

Outpatient clinic following referrals from Emergency or Otorhinolaryngology Departments.

Subjects

40 patients (n = 20 per group) with moderately severe to total palsy who received standard medication were recruited within 14 days of onset. Baseline characteristics were comparable between the groups.

Interventions

The experimental group received the MEPP program (motor imagery + manipulations + facial mirror therapy) while the control group received basic counseling. Both groups met the clinician monthly until 6 months and at one-year post-onset for assessments.

Outcome measures

Facial symmetry, synkinesis, and quality of life were measured using standardized scales. Perceived speech intelligibility was rated before and after therapy by naïve judges.

Results

Descriptive statistics demonstrated improvements in favor of the MEPP for each measured variable. Significant differences were found for one facial symmetry score (House-Brackmann 2.0 mean (SD) = 7.40 (3.15) for controls versus 5.1 (1.44) for MEPP), for synkinesis measures (p = 0.008) and for quality-of-life ratings (mean (SD) score = 83.17% (17.383) for controls versus 98.36% (3.608) for MEPP (p = 0.002)). No group difference was found for perceived speech intelligibility.

Conclusion

The MEPP demonstrates promising long-term results when started during the acute phase of moderately severe to total Bell's Palsy.