Public information Note:


The ABRAFIN, Brazilian Association of Neurofunctional Physiotherapy,
imbued with its responsibility to provide the public information
more reliable with respect to the exercise of specialty, comes
public express their repudiation of some of the information provided
in reporting on facial paralysis in the program
"FANTASTIC" last Sunday, 1/15/17.
On the report on the physiotherapy performance is several times
placed as ineffective at the expense of a "new method"
developed in the Netherlands, based on stretching techniques
myofascial and motor imagery (imagine the movement). Important
remember that both techniques are routinely used by physiotherapists for this and other purposes.

The emergence of new methods is beneficial and ABRAFIN applauds the scientific, but the creation of an approach that excludes the scientific evidence underlying an entire profession is questionable. For science develops, it is not necessary to belittle the already established experiences. Rather, it is from these that science develops. The Neurofunctional Physiotherapy is the science that includes the use of various methods and resources used at the right time and for
particular purpose, it can never be tied to a particular technique, method or resource.

It is necessary to warn people that a facial paralysis (PFP) is a function of nerve injury, that is, the structure that connects the brain to the muscles. The degree of recovery depends on how this nerve is affected. As the facial nerve (nerve affected in cases of facial paralysis) is predominantly a motor nerve, the most frequently found signs are weakness of the muscles of unilateral face. Thus, to test for PFP, we request the individual to "close your eyes" and "show teeth". In the case of PFP, the work of physical therapy is given to maintain facial symmetry so that the weak muscles, but some activity may have possibility to
strengthen and act in their full potential. Importantly, generally non Idiopathic forms of facial paralysis, as it was presented in Fantastic story, often more severe and therefore more difficult recovery.

To contribute to the better understanding of the population on the subject, the ABRAFIN below sends a
short description of what is recommended and what is not, in the case of being affected by facial paralysis.

What say the general scientific evidence and latest on the treatment of paralysis
facial (1)?

It is recommended:

  • eye protection if eye closure is incomplete, which may include lubrication drops by
    example and duct tape eyelid;
  • Drug treatment: In the case of idiopathic facial paralysis (or Bell), in the early days is
    recommended the use of corticosteroids, over the first few weeks, it increases the likelihood
    complete recovery of facial motor function; Antiviral drugs can be used in
    association with corticosteroids, but not alone (Note: The prescription drug is
    competence of the medical professional and not Physiotherapist);

physical therapy:

  • Personalized facial exercises can help with improved functional recovery in patients with facial paralysis, especially in more severe cases and in chronic cases;
  • Acupuncture can improve the results of the use of medication + Physiotherapy.

Not recommended:

  • There is insufficient evidence to support the use of facial nerve decompression surgery (NOTE: Acirurgia is the responsibility of the medical professional and not Physiotherapist).

Some recommendations of ABRAFIN:

  1. About the query, functional kinesiological evaluation, prognosis and guidance on
    functional recovery:
    • It is necessary to assess the degree of impairment of functions related to the facial nerve. It is suggested assess facial symmetry at rest, facial symmetry during movement, and whether or not synkinesis (involuntary movements) or facial contracture ( "hardness / tension" of the muscles). Registration on photo or videos is convenient.
    • Evaluate the return movement after the onset of muscle weakness, because the payback period of the movements (and other functions of the facial nerve) are prognostic factors that should be considered in the first days / weeks of physical therapy monitoring for guidance to patients and their families in addition to equalize expectations as physical therapy
    • Consider, in addition to the face of the functions, possible limitations of the activities and interests of the individual in society (go out to eat in public places, leisure, etc.), personal factors (pre-existing diseases, age, pregnancy, etc.) and some factors environment that can serve as facilitators or barriers. All these criteria can influence the prognosis for recovery of global functionality.
  2. About treatment (1)
    1. If there is a gradual return of the movements in the first three weeks: guidance on the problem and its spontaneous recovery should be provided and only a weekly physical therapy monitoring is recommended until the complete return of motor function and symmetry of the face. Facial exercises and intensive monitoring are not indicated for these individuals with mild dysfunction and recovery
      spontaneous;
    2. Individuals without signs of recovery in the first few days / weeks: should be more closely monitored. Guidance on the chances of recovery in the first three months training for facial symmetry at rest, facial massage therapy (mainly for the side opposite the lesion) and facilitation exercises and motion control as the gradual recovery are possible strategies for this subgroup patients;
    3. chronic cases: Symmetry at rest, the movement and inhibition of synkinesis outcomes should be pursued in these cases, too direction under the influence of tension in the face feature. Features such as facial massage, relaxation and imagery can be useful.
    4. There are suggestions in the literature progression of exercises that may follow multidisciplinary models as suggested below:

      Category Treatment repetitions Frequency
      start:

      • Asymmetry to rest
      • Initial movements or minimum
      • severe functional impairment
      ADM assisted active symmetrical movements Guidance on process improvement
      Low (<10)
      High (3-4x / day)
      Facilitation

      • Minimum Asymmetry to rest
      • mild or moderate weakness
      ADM – Active resistance exercises
      High (10-20)
      Moderate (1-2x / day)
      Control of the movement

      • narrow eye, deep nasolabial folds
      • mild or moderate weakness Synkinesis
      isolated movements
      symmetrical movements
      Control synkinesis
      High (30)
      Quality, not
      amount
      Control, not force
      High (3-4x / day)
      Relaxation

      • facial tension to rest
      • facial spasm
      • psychosocial limitations
      • accented
      Massage, stretching
      Relaxation (Jacobson and
      meditation)
      rhythmical movements
      Low to moderate
      As indicated by symptoms

      Legend: ADM = Range of motion. Source: Brack and VanSweringen (2, 4).

      Finally, ABRAFIN suggests the general population that seeks information and monitoring
      Physical therapy preferably with professional experts physiotherapists registered in
      Neurofunctional physiotherapy.
      Questions, contributions and search for professional specialists can be obtained on the site
      www.abrafin.org.br

      References:

      1. DynaMed. Record No. 116940, Bell palsy Ipswich (MA): EBSCO Information Services. 1995; 2016[atualizado em: 09 dez 2016; acessado em: 18 jan 2017]. Available in:
        http://search.ebscohost.com/login.aspx?direct=true&db=dnh&AN=116940&site=dynamed-live&scope=site.
        Must register and login.
      2. Brach JS, VanSwearingen JM. Physical therapy for facial paralysis: a tailored treatment approach.
        Physical Therapy. 1999; 79 (4): 397-404.
      3. Robinson MW, Baiungo J Hohman M, Hadlock T. Facial Rehabilitation. Facial Rehabilitation Operative
        Techniques in Otolaryngology. 2012; 23 (4): 288-96.
      4. VanSwearingen J. Facial Rehabilitation: neuromuscular reeducation, patient-centered approach. Facial Plastic Surgery. 2008; 24: 250-9.
      5. The authors declare no conflicts of interest (professional, financial and direct or indirect benefits) that might influence the document's content.

        This clarification note was written by:
        MEMBERS OF THE BOARD OF DIRECTORS ABRAFIN TRIENNIUM 2017-2020:

        Chief Executive Officer – Dr. Sibel de Andrade Melo Knaut (PR)
        Vice President – Dr. Felipe Lemos (SP)
        Managing Director – Dr. Lázaro Juliano Teixeira (SC)
        Scientific Director – Dr. Sheila Schneiberg Valencia Days (SE)
        Chief Financial Officer – Dr. Geciely Munaretto Fogaça De Almeida (SC)
        Director Secretary – Dr. Livia Fachinetti (RJ)
        1st Alternate – Dr. Suriani Diogo (GO)
        2nd Alternate – Dra. Baggio Bruna (RS)
        3 Alternate – Dr. Matheus D'Alencar (BA)
        WITH THE COLLABORATION AND CONSENT OF:
        Dra. Solange Canavarro (Delegate of ABRAFIN – RJ)
        Dra. Katia Monte-Silva (Member of the Scientific Committee of ABRAFIN – PE)
        Dra. Cristiane Sousa Nascimento Garcia Baez (Member of the Scientific Committee of ABRAFIN – RJ)
        Dr. André Rocha (Member of the Supervisory Board – SC)

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