Management of Paresis

If you have had a very slow recovery, we strongly advise you to seek referral to a specialist facial therapist. These videos explain the Management of Paresis and are intended for patients where recovery has taken at least three months. Although the paresis stage will occur earlier in patients with a faster recovery, it is important to wait three months until all normal recovery has taken place before attempting these exercises.

Paresis means the stage when the face is still weak after paralysis but not completely floppy. This stage would normally occur at least three months after diagnosis of facial palsy but as mentioned above, in some people it happens earlier, but you should still not do these exercises earlier than three months. Some basic exercises are included in the videos below but these should never be done when the face is still floppy as you could make things worse rather than better. For a bespoke exercise plan including more detailed exercises you will need guidance from a specialist therapist. The videos in this set demonstrate basic smile, lip rounding and eye exercises which may be helpful. They should not be done by anyone who has had their facial palsy less than three months. Please listen carefully to the instructions. If you have facial palsy due to Stroke please consult your health care team for further advice because these videos relate to facial nerve injury.

Important: The best way to prevent synkinesis occurring is to massage your face daily as demonstrated in the flaccid video and also to avoid the urge to ‘push’ your face to move faster. Nerve recovery takes time and patience. If you can use your face as gently as possible throughout your recovery rather than as hard as possible you are likely to get a better recovery with less side effects. This is why these exercises should not be done by anyone who has had facial palsy for less than three months. Doing the exercises in the paresis video will not prevent synkinesis.

Very important: You should not do these exercises if you have undergone dynamic or static surgery to restore facial symmetry and/or movement. You should follow the guidance given by your surgeon or clinician in charge of your care.

Frequently asked questions:

Can you still do these exercises if you receive Botulinum toxin injections for synkinesis?

You should not do any massage on the same day as the injections but you should start massage again the next day. It takes two weeks for Botulinum toxin injections to reach full effect. While it’s settling down during those first two weeks and the face is changing it might be harder to do the exercises but it is okay to still do them if you feel you are able to. People who receive botulinum toxin injections should definitely still be doing brain/movement retraining exercises, the injections calm down synkinesis giving a window of opportunity where exercise and soft tissue work can be more easily carried out. The movement relearning process should eventually lessen and remove the need for injections long term.

Are these exercises beneficial to someone who has had a facial nerve graft?

In terms of facial nerve grafting then yes if the facial nerve itself has been reconstructed, patients would also need to do appropriate massage and soft tissue release to reduce facial muscle stiffness facilitating movement. For people who have had surgery to replace the facial nerve with another nerve or have had muscle transfers these exercises would NOT be appropriate and they need a specific exercise programme from a specialist therapist.

If you are newly diagnosed and watch this video, please don’t be alarmed by the statement that says ‘After a facial palsy it is not possible for the face to simply start working again as it did before. Movements have to be learned from scratch.’ This video is aimed at people who have not made a complete recovery after three months.

I’ve been given movement exercises by a health professional who I am unsure is an expert in facial palsy, am I safe to do them?

If you are practising movement exercises do be very careful. If you are not sure whether you are doing them correctly or are unsure whether you have received the correct advice then don’t do them because you may be encouraging the development of synkinesis. Experience shows that people often think they are strengthening facial muscles and so are too forceful when practising facial expressions. The following are the most important things to remember when practising any facial expressions:

Low effort. 2/10 effort is sufficient to move the very light delicate facial muscles.
SLOW, GENTLE SYMMETRICAL –
Never practice asymmetric movements – you are aiming to practice correct movement patterns which are symmetrical.
The strong side always wants to take over but if when you smile your weak side can only smile 1mm then your strong side must only smile 1mm.
Both sides must move together, the movements must start at the same time, and the strong side must not move faster, further, or before the weak side.

Movement exercises take great concentration and should only be done under guidance from a specially trained therapist. If you experience any synkinesis during your movement exercise then discontinue until you get face-to-face advice. Only work for one minute on each movement but you can do this throughout the day.