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Overcoming Synkinesis: A Guide to Rehabilitation and Hope for Bell’s Palsy Patients

First, a few facts about synkinesis.
It is the third stage of Bell’s palsy, which most of you will never, thankfully, experience.
It is a complication of facial paralysis that develop from a combination of tightness, nerve injury and abnormal facial movement patterns.

It is a very complex condition to rehabilitate, is slow and recovery will require patience and dedication from the patient.
Frustration and distress tends to be a mainstay of patients with synkinesis.

As a facial specialist physical therapist, my first advice is to not go at it on your own. It is hard enough to treat with supports from a team of professionals. Always consult with a professional to manage your synkinesis.
Restoration of soft tissue mobility and flexibility, relaxation, neuromuscular reeducation, education are all needed and sometimes chemo-denervation, more often known as botox injections, and surgery can be necessary.

It takes a good understanding of the anatomy of the facial muscles and knowing what movement these muscles do to have a chance at improving.
When practicing facial movement, it should be slow, gentle, controlled, subtle, graceful. It requires knowing where the muscles “address” is, which directions each muscles contraction pull the skin towards, what “tug-o-war” is happening that is preventing normal movement.

Synkinesis is NOT due to weakness of facial muscles. It is due to incorrect muscles activation for a specific facial movement, lack of coordination for that same movement, lack of soft tissue mobility, tightness of specific muscles, overworking of the involved sides( too many muscles firing at same time). Normal facial movement will not come back without proper retraining.

The good news is that improvement can happened even long after the nerve has healed. So it is never too late to address your synkinesis. But of course, the earlier in the process you start working on it, the highest chance for a more prompt recovery.  And of course, the goal being to never reach the synkinesis stage by massaging and stretching and avoiding gross mass facial contraction.
During the synkinesis stage, your nerve is working! Otherwise, you would not see that overactivity nor tightness.

Treating synkinesis does not require, contrary to many’s belief, strengthening the muscles, forcing movement.
One of the reason why synkinesis happens only in the face is that only in the face are a muscle performing one movement and its antagonist( muscles performing the opposite movement) innervated by the same nerve, the facial nerve.

If you take your arm for example, your biceps which flex your elbow, is innervated by the musculocutaneous nerve while its antagonist, the triceps is innervated by the radial nerve and so one nerve injury does not prevent the antagonist  from working…which is not the case here in the face.

When you look at a diagram of the face, you can see the different  muscles, all pulling in a specific direction. The balance of relaxation and pulling has to be coordinated in order to produce the correct movement.

P168 F1

To restore soft tissue mobility, massage, trigger point release, use of heat and stretching are the hallmark.

Stretching is the bulk of the treatment I start with patient coming to see me for synkinesis.

Stretching and releasing the right muscles will help the face relax and make facial movement less forceful and more natural.Just from stretching , I see my patient make improvement and their synkinesis can sometimes decrease in one treatment.

The key is knowing which stretch(es) to work on. Hence working with a facial specialist.

You want to stretch in the opposite direction that tight muscles is pulling. This is why you need to know what way is that muscles pulling. and this can be difficult for a non trained individual.

To release muscles, Let’s review this again. 

Always start by comparing each side. How does your left vs your right feels? I would try to give a grade to that tightness and write it down, document it…which is a great way to monitor progress.

The areas of your face that feels the most different ( highest difference in tightness grade) are the area you want to focus on.

It is about letting the muscles melt, using the analogy of the ice cube melting between two fingers ( your thumb and index).

Apply gentle pressure between 2 fingers, make sure it is pain free and hold for a minutes.

Here are common spot for trigger point.

​​Make sure to perform these frequently when you first start treating your synkinesis: I advise my patient to perform, if possible, every couple hours.

Relaxation is important for treating synkinesis.
Here is a link to an audio self guided facial relaxation session.
It is free:.

http://www.facialpalsy.org.uk/support/self-help- videos/calming-practice-for-the-face-and-neck/ 

The next part of treating synkinesis is neuromuscular reeducation.

That part of treatment is the most difficult and it is unique to each patient. You need one on one help for this as there is not one technique that will work for everyone.

Working with a specialist, you wil be taught how to analyze a particular facial motion: compare it to the non affected side and use that sounds side as a model for the movement pattern to relearn. Learning what other muscles movement are “in the way” and blocking that movement from happening correctly and then suppressing that movement to prevent pull in the wrong directions…

Learning to feel your face instead of using visual cueing and seeing it will be helpful in this retraining as well.

Botox injection can be a good adjunct to what we just discussed.

Botulinum toxin works by decreasing the activity of overactive muscles to a more normal level. The person you are receiving the injections from must be trained in facial palsy and be a facial specialist.

These injections can allow better relearning of correct and more precise facial movements during the time the antagonist are quieter from the botox.
These injections, depending on the presentation of the patient, can be either in the non involved or involved side.

Many type of surgeries, done by a facial surgeon that specialize in facial palsy, could be performed depending on the presentation and response to previous treatment.
It is beyond the scope of this article.

I want to reiterate that treating Synkinesis is a slow complicated process.

Just like any other nerve injury, you cannot expect being cured overnight. Think of a spinal cord injury or a stroke…

No quick fix exist and lots of work from the patient, with the support of a facial specialist, needs to be put in. Dedication, focus and concentration are needed but patience will pay off.

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1 thought on “Overcoming Synkinesis: A Guide to Rehabilitation and Hope for Bell’s Palsy Patients”

  1. I am trying to figure out how to send this article and see kinesis and recovery to my email so I can read it easier with my left eye squinted and watery it’s hard to read the small print on my phone. Is there anyway to send this to my email?

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