EVALUATION METHODS

Clinical Instruments
Evaluation of facial function has been the topic of much discussion.^63-65 The definitive evaluation tool must be objective, sensitive to subtle dynamic changes and easy to administer, however this instrument has not yet been developed.

The adoption of the International Grading scale in 1984 established a universal measuring system, developed for the needs of physicians and surgeons.⁶⁶ However, for the practitioner of facial neuromuscular retraining, the International scale does not detect the subtle changes that occur during the course of treatment.⁴⁷ Other methods, such as measuring facial landmarks,⁶⁷ and the more complicated facial grading systems,⁶⁸ are cumbersome and difficult to apply consistently. The Facial Grading System (FGS) is a new tool currently undergoing multicenter trials. It is easy to administer and sensitive to small functional changes that occur during the course of treatment.⁶⁹

Whatever tools are used, each muscle group must be evaluated to determine available volitional movement (excursion), spontaneous movement and presence of synkinesis/mass action.

Videotape
There is no substitute for videotape evaluation as an objective measure of facial motion. Videotape captures sequential facial movements as they occur allowing the therapist and patient to review movements in detail and compare progress over time.

Patients are asked to perform specific facial movements using an established protocol (Table 3)⁶⁸

Table 3 - Videotape Protocol

Muscles

Volitional movement

FRO COR, PRO OCS, OCI OCS, OCI OCS, OCI DIN RIS, ZYJ, ZYN, LAO, LLS RIS, ZYJ, ZYN, LAO, LLS LLS, LAO LLS, LAO RIS OOS, OOI OOS, OOI OOS, OOI OOS, OOI OOI, DAO, DLI DAO, DLI DAO, DLI MEN PLA

Raise your eyebrows Bring eyebrows down and together Gently close eyes Squint your lower eyelids up Close your eyes tightly Flare nostrils Smile evenly with your lips together A big wide smile with your lips apart Raise your upper lip while wrinkling your nose Raise your L or R upper lip while wrinkling your nose (start with non-involved side) Move the corner of your mouth back towards your ear (start with non-involved side) Pucker your lips Press your lips together Pull your lips back and in over your teeth Push your lips out as far as they will go Roll your lower lip out and down Turn the corners of your mouth downward Pull your lower lip down to expose lower teeth Tighten your chin Tighten your neck

Table 3: Modified from Balliet R: Facial Paralysis and Other Neuromuscular Dysfunctions of the Peripheral Nervous System, in Payton OD (ed): Manual of Physical Therapy, Churchill Livingstone, New York, 1989. Used by permission.

Photographic
Photographic evaluation allows the patient to easily compare one treatment session to the next. Because functional change occurs slowly, having photos in hand enables the patient to see small changes over time that otherwise may not be readily visible.

Patients should view photographs reflected in a mirror to preserve the relative position of the paralyzed side.

Self-Assessment
Patient self-assessment is an important aspect of the evaluation process because it provides insight into the patient's self-esteem. Ultimately, it is the patient's self-perception that determines the success of treatment.

Part 1 - Introduction to neuromuscular facial retraining
Part 2 - History of non-surgical treatment and facial neuromuscular retraining for facial paralysis
Part 3 - General treatment principles of facial retraining
Part 4 - Evaluation Methods
Part 5 - Elements for effective neuromuscular retraining
Part 6 - Techniques for treating flaccid paralysis & synkinesis
Part 7 - Case Studies
Acknowledgements and references