Susan Coulson

Expression of emotion and quality of life after facial nerve paralysis.

Objective: To investigate the facial expression of emotion and quality of life in patients after long-term facial nerve paralysis. Study Design: Cross-sectional. Setting: Facial nerve paralysis clinic. Patients: Twenty-four patients with facial nerve paralysis and 24 significant others (partner, relative, friend). Intervention: Patients were assessed using Sunnybrook, Sydney, and House-Brackmann grading scales and SF-36, Glasgow Benefit Inventory, and Facial Disability Index quality-of-life measures. Results: When patients identified themselves as either effective or not effective at facially communicating each of Ekman’s primary emotions (happiness, disgust, surprise, anger, sadness, and fear), 50% classified themselves as not effective at expressing one or more of the six emotions. Significant others of the not effective patients rated the emotions as more difficult for their partner-patients to communicate facially than did the significant others of effective patients. The SF-36 quality-of-life survey revealed lower social functioning relative to physical functioning for not effective patients. From the Sunnybrook Facial Grading System, more synkinesis was found for those patients not effective at expressing happiness, less brow and eye movement for patients not effective at expressing sadness, and less voluntary movement for those not effective with surprise. Conclusion: Movement deficits associated with expressing specific emotions and an association with quality-of-life measures were identified in patients with long-term facial nerve paralysis who saw themselves as not effective at facial expression of emotions. To improve management of emotional expression in patients with facial nerve paralysis, a broader approach is recommended, linking the practitioner’s treatment goals with patient-driven outcome goals.

Reliability of the "Sydney," "Sunnybrook," and "House Brackmann" facial grading systems to assess voluntary movement and synkinesis after facial nerve paralysis.

OBJECTIVE: To investigate the extent of within-system reliability and between-system correlation for the “Sydney” and “Sunnybrook” systems of grading facial nerve paralysis, and to examine the interobserver reliability and agreement of the “House Brackmann” grading system. STUDY DESIGN: A fixed-effects reliability study in which 6 otolaryngologists viewed videotapes of patients with facial nerve paralysis. SETTING: University and medical Centers. PATIENTS: Patients with unilateral lower motor neurone facial nerve dysfunction greater than 1 year after onset, none of whom had undergone surgical reanimation procedures. INTERVENTION: Twenty-one patients with facial nerve paralysis were videotaped while they performed a protocol of facial movements. Six otolaryngologists viewed the videotapes and scored them with the Sydney and Sunnybrook systems, and then gave a House Brackmann grade. MAIN OUTCOME MEASURE: The 3 systems of grading facial nerve paralysis were evaluated and compared with the use of intraclass correlation coefficients, Pearsons weighted kappa, and percentage exact agreement values. RESULTS: The Sydney and the Sunnybrook systems had good intrasystem reliability and high intersystem association for the assessment of voluntary movement. Grading of synkinesis was found to have low reliability both within and between systems. The House Brackmann system had substantial reliability as shown by weighted kappa but had a percentage exact agreement of 44%. CONCLUSIONS: For clinical grading of voluntary movement, there is good correlation between ratings given on the Sydney and Sunnybrook systems, and within each system there is good reliability. The assessment of synkinesis was far less reliable within, and less related between, systems. Although the reliability of the House Brackmann system was found to be high, examination of individual grades revealed some wide variation between trained observers.

Three-Dimensional quantification of the symmetry of normal facial movement

Objective This study examined the right to left symmetry of the displacement of three-dimensional movement of the human face. Methods Displacement data on 42 subjects was collected and analyzed with the Expert Vision Motion Analysis System. Right and left three-dimensional facial displacements were quantified. Results Significantly greater left than right three-dimensional displacement across the whole face was measured. The three-dimensional displacement difference ranged from 0.48 mm to 2.28 mm between the right and left sides of the face. The 2-cm inferior pupil markers during the nose wrinkle expression had significantly greater left than right displacement. Conclusion The ranges of displacement differences, along with the mean three-dimensional displacement measures, must be accounted for in the creation of a baseline of the range of normal facial movement.

Physiotherapy Rehabilitation of the Smile after Long-Term Facial Nerve Palsy using Video Self-Modeling and Implementation Intentions

OBJECTIVES: To improve smiling after long-term facial nerve palsy (FNP). Physiotherapy rehabilitation of an adapted (more symmetrical) smile was investigated in FNP subjects 1 year post-onset, using video self-modeling (video replay of only best adapted smiles) and implementation intentions (preplanning adapted smiles for specific situations). STUDY DESIGN AND SETTING: Prospective, blinded clinical trial. Facial-Nerve-Palsy Clinic. RESULTS: After video self-modeling: 1) reaction time (RT) to initiation of adapted smiles became 224 ms faster whereas RT for everyday (asymmetrical) smiles became 153 ms slower; 2) adapted smiles were completed 544 ms faster; 3) adapted smiles had higher overall quality, movement control, and symmetry ratings; and 4) Facial Disability Index scores also improved. Implementation intentions after video self-modeling ensured transfer of adapted smile to everyday situations. CONCLUSION: Following intervention the smile improved, with significant changes in availability, execution speed, and quality. SIGNIFICANCE: This study supports these rehabilitation techniques to maximize quality of smiling following FNP. EBM rating: B-2b

Three-dimensional quantification of "still" points during normal facial movement.

This study investigated the 3-dimensional displacement of points on the face that were thought to be still during facial movement. These points are currently used to measure displacement of moving facial regions during assessment of normal facial movement and treatment interventions following facial nerve paralysis. It is, however, unknown if these places are “still” points. The Expert Vision Motion Analysis System was used to collect and analyze data on 42 normal subjects during facial movement. No point on the face was found to be still during facial expression. However, several points were present with very small movements for each individual expression. These were termed “reference” points. These small movements may be the result of system noise, physiological tremor, skin movement, or head-holder movement during facial expressions. Future studies of the displacement of the markers during facial movement in both normal subjects and patients with facial nerve paralysis may take into account the contribution of the “reference” point displacements to the overall facial movement.

Quantification of the three-dimensional displacement of normal facial movement

This study was undertaken to quantify 3-dimensional (3-D) facial movement in normal subjects, and to identify the individual axes in which this movement occurred. Displacement data on 42 subjects were collected and analyzed with the Expert Vision Motion Analysis System. The 3-D displacement was calculated by vectorially subtracting maximum marker movement from previously identified reference marker points. The 3-D range of normal facial movement was quantified, with the greatest displacement occurring during maximum smile. When the individual axes were examined, we found that most movement occurred in the vertical axes for the majority of expressions, followed by the anterior-posterior axis. These results may create an objective baseline from which disorders of the facial nerve, and hence, medical, surgical, and physiotherapy treatment interventions, can be analyzed in the future.

Infective causes of facial nerve paralysis.

Objective: To review the functional recovery in a cohort of patients with facial nerve paralysis (FNP) due to infective cause. Study Design: Retrospective review based on patients identified from a prospectively maintained database of patients with FNP. The case notes of identified patients were reviewed. Setting: Tertiary referral center. Patients: The patients were identified from a database of 1074 patients with FNP. One hundred twenty of the 150 patients identified as having FNP due to an infectious disease caused by herpes zoster oticus were excluded from the study. The remaining 30 patients were included in the study. Interventions: Patients were treated both operatively and nonoperatively. Operative treatment included myringotomy and ventilation tube placement, cortical mastoidectomy, modified radical (canal wall down) mastoidectomy, petrous apicectomy, and lateral temporal bone resection. Main Outcome Measures: This study used the House-Brackmann (HB) grade of facial function at 1 year after initial assessment. The patients were identified from a prospectively maintained database of all patients presenting with FNP to a single specialist otolaryngologist (G.R.C.) between June 1988 and April 2005. The database contains information including demographic details, dates of presentation, diagnostic modalities used, diagnosis, interventions, and HB grade. The patients in this series presented between August 4, 1989 and August 26, 2003. Results: Twenty-nine patients with 30 facial nerve paralyses were identified. The causes of FNP were acute otitis media (n = 10); cholesteatoma (n = 10 [acquired, 7; congenital, 3]); mastoid cavity infections (n = 2); malignant otitis externa (n = 2); noncholesteatomatous chronic suppurative otitis media (CSOM; n = 2); tuberculous mastoiditis (n = 1); suppurative parotitis (n = 1); and chronic granulomatosis (n = 1). The patients with noncholesteatomatous CSOM who presented sooner after the onset of facial nerve symptoms had greater facial nerve recovery when assessed using the HB grade at 1 year. Conclusion: FNP due to infective causes other than herpes zoster oticus is rare. Patients with noncholesteatomatous CSOM and FNP have a better outcome than those with FNP due to cholesteatoma. Patients with FNP due to acute otitis media tend to have a good prognosis without surgical decompression of the facial nerve being required.

Prognostic Factors in Herpes Zoster Oticus (Ramsay Hunt Syndrome)

Objectives: To determine if an accurate prognosis can be made in patients with Herpes zoster oticus (HZO), facial nerve outcomes were assessed at 1-year after onset and compared with symptoms and signs at presentation. Study Design: Individual retrospective cohort study of 101 records in a case series (level of evidence: Level 2b). Methods: Symptoms, signs, audiology, and treatment records were analyzed to determine their association with facial nerve outcome at 1 year. Results: Mean improvement at 1 year for the 101 patients was 3 House-Brackmann (HB) grade units. Initially, severity ranged from HB III to HB VI. Mean recovery was significantly greater for those patients who were initially more affected, although at 1 year, they had still not recovered to the same grade as those initially less affected. Having both incomplete eye closure and a dry eye was associated with less recovery at 1 year. The use of prednisone combined with an antiviral agent, and begun at or after Day 5 of the illness, was related to a better facial nerve outcome. No other symptom, sign, or audiologic feature was of prognostic value. Conclusion: All patients with HZO improved facial function to some degree, with the mean gain at 1 year after onset being 3 HB grade units. Improvement was less for patients who initially had both incomplete eye closure and dry eye. The group who received a combination of an antiviral medication with steroids given after 5 days had the best facial nerve outcome.

Relative contribution of motor impairments to limitations in activity and restrictions in participation in adults with hemiplegic cerebral palsy

Objective: To determine which motor impairments make a significant relative contribution to upper limb activity limitations, and whether activity limitations are related to participation restrictions in people with hemiplegic cerebral palsy. Design: An observational study. Setting: Neurological Rehabilitation Research Group at Faculty of Health Sciences, The University of Sydney. Subjects: Twenty-three people with hemiplegic cerebral palsy participated. Main measures: Four motor impairments (strength, coordination, spasticity and contracture), upper limb activity and participation were measured. Multiple regression was used to determine the relative contribution of motor impairments to activity limitations. Linear regression was used to determine the correlation between activity and participation. Results: The four motor impairments accounted for 63% of the variance in upper limb activity with coordination independently accounting for 21% (P<0.01). Upper limb activity accounted for 13% of the variance in participation (P=0.10). Conclusions: The findings imply that coordination of four motor impairments makes the largest independent relative contribution to activity limitations, whereas upper limb activity makes less contribution to participation in people with mild and moderate hemiplegic cerebral palsy.

Characteristics of associated reactions in people with hemiplegic cerebral palsy

PURPOSES To investigate the relationship between associated reactions and a) spasticity, b) contracture and c) coordination. METHODS Associated reactions were measured as magnitude of muscle activity in the affected limb during a 50% maximum voluntary contraction of muscles in the unaffected limb. Spasticity was measured as hyper-reflexia during passive muscle stretch, coordination as performance during a tracking task, and contracture as loss of range of motion. Chi-square analysis was used to examine the association between associated reactions and spasticity, and linear regression to examine the relationship between associated reactions and spasticity, coordination and contracture. RESULTS Twenty-three people with hemiplegic cerebral palsy aged from 15 to 47 years (mean [SD]: 29 years [9]) participated. Thirteen participants exhibited spasticity, and six participants exhibited associated reactions. Five of the six participants with associated reactions also had spasticity (χ2=2.37, p=0.12). Associated reactions were highly correlated with spasticity (r=0.77, p=0.001), but not with contracture (r=0.35, p=0.29) or coordination (r=-0.31, p=0.30). CONCLUSIONS Although 27% of participants exhibited associated reactions, and these were mostly small, associated reactions appear to be an expression of spasticity in hemiplegic cerebral palsy.