Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study

Abstract

Background:

Nonsurgical rehabilitation of unilateral peripheral facial palsy (FP) varies globally with controversy regarding best practice.

Objective:

To develop facial therapist consensus regarding what should be included or excluded in rehabilitation of adults with FP of any etiology. Three clinical presentations: flaccid, paretic and synkinetic, were separately considered.

Methodology:

A two-stage study was conducted: a nominal group technique (NGT) to develop a questionnaire plus Delphi study. Delphi participants were recruited worldwide, through an experience-based inclusion questionnaire. The final Delphi questionnaire included 166 items for each clinical presentation covering assessment, outcome measures, and interventions, for example, education, eye care, neuromuscular retraining, and electrical modalities. Inclusion/exclusion agreement was set at 80%, indicating participant consensus. Items reaching 70–79% were deemed “near-included/near-excluded.”

Results:

Averaged across all presentations, 24.9% of the 166 items were included, (e.g., Sunnybrook Facial Grading System, patient education and neuromuscular retraining), 26.9% of the 166 items were excluded, (e.g., gross strengthening and electrical stimulation); 48.2% were neither included nor excluded.

Conclusion:

This study brings together the global community's expertise as a first step toward establishing best practice for specialist facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

KEY POINTS

Question: Is there consensus on best practice in specialist facial therapy management of adult patients with unilateral peripheral facial palsy (FP) of any etiology?

Findings: There is consensus on inclusions and exclusions in specialist facial therapy best practice within assessment, outcome measures, patient education, eye care, eating, drinking, communication, taping, relaxation, sensory and circulatory techniques, improving symmetry, use of modalities, self-administered rehabilitation techniques, and home program delivery.

Meaning: Items included or excluded by consensus should guide specialist facial therapy.

Introduction

Facial therapy improves facial function, expression, and quality of life for people with FP.¹ Historically, facial therapy has been provided by generalist therapists with no training regarding the unique facial neuromuscular system or effective facial treatment methods. As a result, nonspecific, ineffective techniques, such as gross facial exercises and electrical stimulation, have taken a foothold and continue to be used today.^2,3 Specialized facial therapists develop advanced skills through postgraduate training, which emphasizes the significant differences in anatomy/physiology, function and rehabilitation between the face and other parts of the body.² Therapy administered by trained facial specialists is now a cornerstone of FP treatment,⁴ but varies greatly worldwide with no agreement on optimal methods.⁵

Facial therapy encompasses a range of interventions, including assessment, outcome measures (e.g., Sunnybrook Facial Grading System [SFGS],⁶ Facial Disability Index [FDI],⁷ Facial Assessment Clinimetric Evaluation [FaCE],⁸ and Synkinesis Assessment Questionnaire [SAQ]⁹) and rehabilitation techniques (e.g., facial neuromuscular retraining [fNMR],^10–13 mime therapy,¹⁴ and massage/soft tissue mobilization^2,10,15–18). SFGS is currently regarded as the best “objective” measure.^15,16,19

Studies concluding that facial therapy improves function in chronic patients and reduces sequelae in acute cases^16,20–23 are strengthened by a recent systematic review.⁵ A randomized controlled trial of 50 FP patients concluded that facial therapy significantly improves symmetry and reduces paresis severity.¹⁴ A retrospective review of 75 patients receiving therapy 6–24 months postonset displayed less synkinesis and better physical scores than patients seen later.²³

There remains a need for more evidence across the breadth of facial therapy interventions. To address this, Delphi methods and nominal group technique (NGT), commonly used in health research, were chosen to establish consensus.^24–26 The Delphi technique transforms opinion into consensus by gathering information from expert respondents until consensus is reached.^27,28 The method facilitates consensus from geographically distinct locations, without external influences.²⁹ Consensus from many experts further reduces potential bias and gives authority to final conclusions.³⁰

A 2014 survey showed great variability in assessment methods within a specialized medical group dedicated to FP treatment.³¹ To date, no such survey, or consensus, regarding best facial therapy practice exists. Our study will guide practice alongside clinical expertise and patient values. Additionally, it will direct future research and facilitate developing evidence-based guidelines.

Objective

To develop expert facial therapist consensus regarding what should be included or excluded in assessment and management/rehabilitation of adults presenting with unilateral FP of any etiology. The three clinical presentations: flaccid, paretic, and synkinetic, were separately considered.

Since treatment prioritizes the dominant presentation, mixed presentations (e.g., paretic/synkinetic) were not included as separate categories. Partial FP, postsurgical, pediatric, central, and bilateral facial therapies were beyond the scope of this project.

Literature review

The lead author was concurrently involved in a recent facial therapy systematic review. This provided the literature search to determine the highest quality evidence to develop this project. See referenced open-access publication for sources and methods utilized in the systematic review.⁵

Method

A two-stage study was conducted utilizing NGT and a Delphi study: NGT to develop a questionnaire and Delphi to obtain consensus on assessment, outcome measures, and interventions in FP therapy for example, education, eye care, neuromuscular retraining, and electrical modalities. This study followed NGT and Delphi methods and reporting guidelines.^{25–27,30,32}

NGT literature recommends five to nine participants, representative of the profession, with significant expertise.²⁶ The lead author selected four additional participants through Facial Therapy Specialists International (FTSI)³³ with attention to geographical diversity. Selection criteria included: over 10 years' experience as FP specialist (range 11–37 years), English speaking, meeting availability and significant professional activity within the preceding 2 years (e.g., publications, conference presentations, postgraduate instruction).

The expert panel used the NGT process to develop questionnaire items for round 1 (R1) of the Delphi study, meeting virtually to determine categories.²⁶ Using available literature and experience, interventions used within facial therapy were listed until all ideas were exhausted. This list was developed into a 13-category, 138-item questionnaire covering assessment, outcome measures, and rehabilitation techniques.

To ensure strong consensus, our threshold for including/excluding items was set at 80% agreement. Items reaching 70–79% (“near-included, near-excluded” in our study) are also discussed and included in our results tables. They remain valid based on a systematic review of 100 Delphi studies, which found 75% was the median threshold for consensus.³⁴

The project description and an inclusion questionnaire were distributed through global FP organizations. Recipients were asked to share the document widely to reach as many therapists as possible.

Inclusion criteria were:

minimum 5 years' experience,

minimum 7 h FP treatment weekly,

licensed as physical therapist (PT), occupational therapist (OT), or speech/language pathologist (SLP).

The 138-item Delphi questionnaire was distributed to R1 respondents who completed it three times, once for each of the three post-FP clinical presentations (total items answered 414 [3 × 138]). To ensure content validity and reduce bias, respondents were invited to suggest additional items for inclusion in subsequent Delphi rounds. Twenty-eight items were subsequently added resulting in the 166-item final Delphi Questionnaire circulated in round 2 (R2). This was also completed three times by respondents, once for each of the three post-FP clinical presentations (total items answered 498 [3 × 166]). See Supplementary Information S1 for complete, final R2 questionnaire.

R1 participants rated items using a 5-point Likert scale from “1” (never used) to “5” (always used). Nonresponders were contacted twice after each round to improve response rates. Participants responded that certain interventions were unavailable to them, therefore in R2, “1” changed to should never be used and “5” changed to should always be used. Termination criterion that no further items or amendments were suggested, was reached after R2.

Statistics were generated through Microsoft Excel for Mac (version 16.62) to determine items reaching inclusion/exclusion consensus. In R2, participants were presented the mean, median, and mode R1 scores, alongside their R1 score, for consideration. Participant comments were reviewed to aid interpretation of results.

Ethics

This study was completed in accordance with the Declaration of Helsinki (2013) and submitted to the International Review Board at Franciscan Missionaries of Our Lady University, who waived the requirement for oversight stating it does not qualify as human subject research.

Delphi studies require minimal 70% response each round.³⁵ To pursue nonresponders, researchers knew participant identities. The term “quasi-anonymity” was used to reassure respondents that responses known to the researchers would otherwise remain anonymous. All participants gave informed consent.

Results

Of 103 Delphi respondents, 59 (from 15 countries) met the inclusion criteria. Fifty-one (86%) completed R1. Of these, 49 completed R2 (96%). Most participants were United Kingdom (24%) and United States (20%) based, 72% were PTs (Table 1).

Table 1.

Demographics of specialist facial therapists included in nominal group technique and Delphi study

NGT study demographics

Profession

PTs—4

OTs—1

Geographical distribution

Canada—1

Netherlands—1

UK—1

US—2

Delphi study demographics

Profession

Physical therapists—37

Speech and language therapists—11

Occupational therapists—3

Geographical distribution (15 countries in total)

Australia—1

Belgium—1

Brazil—5

Canada—5

France—2

Germany—1

Italy—1

Japan—1

Mexico—1

Netherlands—2

Spain—4

Sweden—3

Switzerland—1

United Kingdom—12

United States of America—10^a

Two facial therapists from the USA did not respond in R2.

NGT, nominal group technique; R2, round 2.

Averaged across all presentations, 24.9% of the 166 R2-questionnaire items were included, 26.9% of the 166 items were excluded, and 48.2% were neither included nor excluded (Table 2).

Table 2.

Number of final items (n = 166) included, near-included, excluded, near-excluded, and not reaching consensus

	Flaccid presentation	Paretic presentation	Synkinetic presentation
Included items	38 (22.9%)	38 (22.9%)	48 (28.9%)
Near-included items	9 (5.4%)	14 (8.4%)	6 (3.6%)
Excluded items	45 (27.1%)	46 (27.7%)	43 (25.9%)
Near-excluded items	7 (4.2%)	2 (1.2%)	10 (6.0%)
Items not reaching consensus	67 (40.4%)	66 (39.8%)	59 (35.6%)

Tables 3 –5 present all final included/near-included, excluded/near-excluded items per presentation. See Supplementary Information S2 for complete results, including those not reaching consensus.

Table 3.

Flaccid results: included, near-included, excluded, and near-excluded items

	Included (80%+)	Near-included (70–79%)	Excluded (80%+)	Near-excluded (70–79%)
Assessment and outcome measures (from initial 43 items)
Photographs	100% R2
Facial movement videos	92% R2
Sunnybrook SFGS	92% R1
FDI		78% R2
VAS—confidence			80% R1
eFACE			84% R1
Live chart for BTX-A			92% R1
FACEgram			96% R1
FACE Q			96% R1
Palpation (by therapist and/or patient)	88% R2
GAD 7			88% R1
PHQ 9			88% R1
Yanagihara scale			96% R1
Sydney scale			96% R1
CORE-10			96% R1
3D scanning			86% R1
Ultrasound-guided muscle measurement			90% R1
SEMG				71% R2
Needle EMG			80% R1
ENOG			92% R1
Glasgow scale			96% R1
Derriford appearance scale			100% R1
SF36			82% R1
Euroqol EQ-5D			84% R1
Caliper measurements (smile)			84% R1
NOSE scale			82% R1
Hilger facial nerve assessment				76% R2
Use of other nonvalidated or self-developed PROMS				74% R2
Working with psychological therapists (if available)		72% R2
Education (from initial 15 items)
Diagnosis	98% R1
Prognosis	92% R1
Degrees of injury of the nerve	88% R1
Phases of recovery	92% R1
Timing of recovery	94% R1
Typical recovery of facial nerve	96% R1
Anatomy and function of facial nerve	98% R1
Muscle anatomy	94% R1
How muscles work—normal facial movement	96% R1
Impact of muscle tightness on movement		76% R2
Differences between face and body physiology	80% R2
What to do and what to avoid doing	96% R1
Resources for local support groups/counseling	85% R2
Educate on concepts/theories for treatment before using treatments	89% R2
Eye care and eye protection (from initial 13 items)
Advice on eye drops and ointments	96% R1
Advice re careful showering, using sensitive shampoo	85% R2
Using swim goggles when showering to protect eye		78% R2
Avoiding air con, fans, heaters, smoke for eye	83% R2
Avoidance of cotton wool pads directly against eye	90% R2
Use of wraparound sunglasses		78% R2
Recommendations for eye specialists	90% R1
Advice on external lid weights		71% R2
Eating/drinking and oral/nasal care (from initial nine items)
Taking smaller bites	80% R1
Advice to experiment with different drinking vessels to see what works		77% R2
Advice on using thin lipped cups	80% R1
Communication and speaking (from initial five items)
Communication tips for improving nonverbal communication e.g., use of hands etc.	81% R2
Supporting mouth/taping during speech		77% R2
Slowing down speech	89% R2
Avoiding suppression of emotional expression	89% R2
Taping (from initial six item)
Eye closure taping	82% R1
Lower lid support—ectropion taping	89% R2
Increasing symmetry/BTX-A use (from initial nine items)
Reducing overactivity of unaffected side, contralateral inhibition strategies	84% R1
Contralateral soft tissue stretching	81% R2
Mapping, planning, and/or administering BTX-A to contralateral side or referring to a BTX-A practitioner				96% R1
Mapping, planning, and/or administering BTX-A to ipsilateral side for synkinesis or referring to a BTX-A practitioner			96% R1
Referring patients for BTX A before therapy			89% R2
Modalities (from initial 24 items)
Electrical stimulation			98% R1
Laser			90% R1
Infrared			94% R1
Shortwave diathermy			98% R1
Microcurrent			100% R1
Ultrasound (diagnostic)			96% R1
Ultrasound (therapeutic)			92% R1
Acupuncture			84% R1
Dry needling			94% R1
Facial cupping			92% R1
Kabat rehabilitation			98% R1
Feldenkrais therapy			92% R1
Craniosacral therapy			82% R1
PNF			94% R1
EMG Biofeedback for relaxation at rest contralateral side				72% R2
EMG Biofeedback for relaxation at rest ipsilateral side			94% R1
EMG Biofeedback for facilitation of active movement contralateral side			90% R1
EMG Biofeedback for facilitation of active movement ipsilateral side			82% R1
EMG Biofeedback for synkinetic inhibition			98% R1
Provision of psychosocial support and advice by facial therapist	88% R2
Rehabilitation self-administered by patient (from initial 20 items)
Massage for tissue mobility	94% R2
Stretching the upper eyelid	85% R2
Soft tissue mobilization		71% R2
Use of external aids e.g., facial massager				73% R2
Using manual blink	83% R2
Gross facial exercises, strength training			92% R1
Gum chewing			94% R1
Place and hold/active assisted exercise				78% R2
Resistance training			96% R1
Relaxation techniques (from initial eight items)
Techniques for delinking/inhibiting synkinesis, ipsilateral inhibition strategies			90% R1
Sensory and circulatory techniques (from initial eight items)
Massage for sensory awareness	82% R1
Touching for sensory awareness	85% R2
Ice/cryotherapy			90% R1
Home program delivery (from initial six items)
Therapist documented bespoke program	82% R1

Items scoring 0–69% and therefore neither included/near-included or excluded/near-excluded are not listed here but can be found in the Supplementary Information S2.

BTX-A, Botulinum toxin; EMG, electromyography; ENOG, electroneurography; eFACE, electronic, clinician graded facial function scale; FACE Q, Face Questionnaire (Paralysis); FDI, Facial Disability Index; FGS, Facial Grading Scale; GAD 7, General Anxiety Disorder 7; NOSE, Nasal Obstruction & Septoplasty Effect; PHQ 9, Patient Health Questionnaire 9; PNF, proprioceptive neuromuscular facilitation; PROMS, Patient reported outcome measures; R1, round 1; SEMG, Surface EMG; VAS, visual analogue scale.

Table 4.

Paretic results: included, near-included, excluded, and near-excluded items

	Included (80%+)	Near-included (70–79%)	Excluded (80%+)	Near-excluded (70–79%)
Assessment and outcome measures (from initial 43 items)
Photographs	82% R1
Facial movement videos	94% R2
Sunnybrook FGS	94% R1
FDI	80% R2
FaCE		76% R2
HB2			82% R1
VAS—confidence			82% R1
eFACE			84% R1
Live chart for Botulinum Toxin			90% R1
FACEgram			96% R1
FACE Q			96% R1
Palpation (by therapist and/or patient)	82% R1
GAD 7			88% R1
PHQ 9			88% R1
Yanagihara scale			96% R1
Sydney scale			96% R1
CORE-10			90% R1
3D scanning			88% R1
Ultrasound-guided muscle measurement			90% R1
Needle EMG			82% R1
ENOG			92% R1
Glasgow scale			96% R1
Derriford appearance scale			100% R1
Computer-assisted quantitative assessment from photographs or video images			82% R2
SF36			84% R1
Euroqol EQ-5D			82% R1
Caliper measurements (smile)			86% R1
NOSE scale			84% R1
Working with psychological therapists (if available)		78% R2
Education (from initial 15 items)
Diagnosis	98% R1
Prognosis	96% R1
Degrees of injury of the nerve	96% R1
Phases of recovery	96% R1
Timing of recovery	98% R1
Typical recovery of facial nerve	98% R1
Anatomy and function of facial nerve	98% R1
Muscle anatomy	96% R1
How muscles work—normal facial movement	98% R1
Impact of muscle tightness on movement	90% R1
Differences between face and body physiology	84% R2
What to do and what to avoid doing	98% R1
Impact of co-contractions on movement	92% R2
Resources for local support groups/counseling	86% R2
Educate on concepts/theories for treatment before using treatments	94% R2
Eye care and eye protection (from initial 13 items)
Advice on eye drops and ointments	86% R1
Advice re careful showering, using sensitive shampoo		71% R2
Avoiding air con, fans, heaters, smoke for eye		73% R2
Avoidance of cotton wool pads directly against eye		76% R2
Recommendations for eye specialists	92% R2
Eating/drinking and oral/nasal care (from initial nine items)
Taking smaller bites	85% R2)
Advice on using thin lipped cups		71% R2
Communication and speaking (from initial five items)
Slowing down speech		77% R2
Avoiding suppression of emotional expression	93% R2
Increasing symmetry (from initial nine items)
Reducing overactivity of unaffected side, contralateral inhibition strategies	84% R1
Contralateral soft tissue stretching		77% R2
Mapping, planning, and/or administering BTX-A to contralateral side or referring to a BTX-A practitioner				71% R2
Mapping, planning, and/or administering BTX-A to ipsilateral side for synkinesis or referring to a BTX-A practitioner			80% R2
Refer for BTX A before therapy			97% R2
In general, only refer patients 1–2 months after therapy for BTX A		70% R2
Modalities (from initial 24 items)
Neuromuscular retraining	92% R1
Electrical stimulation			100% R1
Laser			92% R1
Infrared			96% R1
Shortwave diathermy			100% R1
Microcurrent			100% R1
Ultrasound (diagnostic)			96% R1
Ultrasound (therapeutic)			92% R1
Acupuncture			92% R1
Dry needling			94% R1
Facial cupping			92% R1
Kabat rehabilitation			98% R1
Feldenkrais therapy			92% R1
Craniosacral therapy			80% R1
PNF			92% R1
EMG Biofeedback for relaxation at rest contralateral side				71% R2
EMG Biofeedback for relaxation at rest ipsilateral side				73% R2
EMG Biofeedback for facilitation of active movement contralateral side			80% R1
EMG Biofeedback for synkinetic inhibition				73% R2
Provision of psychosocial support and advice by facial therapist		71% R2
Facilitation techniques: e.g., quick stretch, vibration, tapping, icing				76% R2
Rehabilitation self-administered by patient (from initial 20 items)
Massage for tissue mobility	88% R1
Stretching the upper eyelid	90% R2
Soft tissue mobilization	90% R2
Gross facial exercises, strength training			86% R1
Proprioceptive feedback during movement (mental attention to feel of movement)	90% R1
Comparison of unaffected side to affected side muscle length/thickness (90% R2)	90% R2
Visualization	90% R2
Gum chewing			92% R1
Resistance training			86% R1
Ipsilateral facial muscle stretching		76% R2
Touch feedback during movement		76% R2
Relaxation techniques (from initial eight items)
Co-ordinated movement pattern retraining—small, slow, symmetrical movements, using unaffected side as a model	82% R1
Use of emotion within expression rehabilitation	82% R1
Mindfulness	84% R1
Guided relaxation	82% R1
Sensory and circulatory techniques (from initial eight items)
Massage for sensory awareness	85% R1
Touching for sensory awareness		77% R2
Ice/cryotherapy			86% R1
Touching for biofeedback during movement		73% R2
Home program delivery (from initial six items)
Therapist-documented bespoke program	84% R1
Patient takes their own notes to document specifically tailored (bespoke) program		71% R2

Items scoring 0–69% and therefore neither included/near-included or excluded/near-excluded are not listed here but can be found in the Supplementary Information S2.

FaCE, Facial Assessment Clinimetric Evaluation; HB2, House Brackmann 2 Scale.

Table 5.

Synkinetic results: included, near-included, excluded, and near-excluded items

	Included (80%+)	Near-included (70–79%)	Excluded (80%+)	Near-excluded (70–79%)
Assessment and outcome measures (from initial 43 items)
Photographs	80% R1
Facial movement videos	96% R2
Sunnybrook FGS	94% R1
FDI	84% R2
Synkinesis Assessment Questionnaire	90% R2
VAS—confidence			80% R1
eFACE			84% R1
FACEgram			96% R1
FACE Q			96% R1
Palpation (by therapist and/or patient)	86% R1
FaCE	80% R2
GAD 7			82% R1
PHQ 9			84% R1
Yanagihara scale			94% R1
Sydney scale			96% R1
CORE-10			90% R1
3D scanning			80% R1
Ultrasound-guided muscle measurement			90% R1
Computer-assisted quantitative assessment from photographs or video images			84% R2
Needle EMG			80% R1
ENOG			92% R1
Glasgow scale			96% R1
Derriford appearance scale			100% R1
SF36			86% R1
Euroqol EQ-5D			84% R1
Caliper measurements (smile)			86% R1
NOSE scale			86% R1
use of other nonvalidated or self-developed PROMS				70% R2
Working with psychological therapists (if available)	80% R2
Education (from initial 15 items)
Diagnosis	100% R1
Prognosis	96% R1
Degrees of injury of the nerve	96% R1
Phases of recovery	96% R1
Timing of recovery	98% R1
Typical recovery of facial nerve	96% R1
Anatomy and function of facial nerve	98% R1
Muscle anatomy	96% R1
How muscles work—normal facial movement	100% R1
Impact of muscle tightness on movement	100% R1
Impact of co-contractions on movement	98% R1
Differences between face and body physiology	82% R1
What to do and what to avoid doing	98% R1
Resources for local support groups/counseling	90% R2
Educate on concepts/theories for treatment before using treatments	96% R2
Eye care and eye protection (from initial 13 items)
Advice on eye drops and ointments	90% R2
Recommendations for eye specialists	84% R2
Use of neck buff over eyes				71% R2
Padded eye mask				71% R2
Press and seal wrap/saran wrap/clingfilm				71% R2
Eating/drinking and oral/nasal care (from initial nine items)
Taking smaller bites	80% R2
Communication and speaking (from initial five items)
Supporting mouth/taping during speech				71% R2
Slowing down speech	80% R2
Avoiding suppression of emotional expression	83% R2
Taping (from initial six item)
Eye closure				77% R2
Lower lid support—ectropion taping			80% R2
Supporting cheek with tape			84% R1
Kinesiotaping			86% R1
Lifting the eyebrow with tape			81% R2
Horizontal taping upper lid				77% R2
Increasing symmetry (from initial nine items)
Reducing overactivity of unaffected side, contralateral inhibition strategies	87% R2
Mapping, planning, and/or administering BTX-A to ipsilateral side for synkinesis or referring to a BTX-A practitioner	91% R2
Refer patients for BTX A before therapy			85% R2
Modalities (from initial 24 items)
Neuromuscular retraining	96% R1
Electrical stimulation			100% R1
Laser			94% R1
Infrared			98% R1
Shortwave diathermy			100% R1
Microcurrent			100% R1
Ultrasound (diagnostic)			94% R1
Ultrasound (therapeutic)			94% R1
Acupuncture			90% R1
Dry needling			94% R1
Facial cupping			90% R1
Kabat rehabilitation			98% R1
Feldenkrais therapy			92% R1
Craniosacral therapy				79% R2
PNF			94% R1
EMG Biofeedback for facilitation of active movement contralateral side			80% R1
Mimicking movements performed by therapist		73% R2
Facilitation techniques: e.g., quick stretch, vibration, tapping, icing				77% R2
Provision of psychosocial support and advice by facial therapist		77% R2
Rehabilitation self-administered by patient (from initial 20 items)
Massage for tissue mobility	90% R1
Stretching the upper eyelid		79% R2
Soft tissue mobilization	98% R1
Touch feedback during movement	84% R1
Proprioceptive feedback during movement (mental attention to feel of movement)	96% R1
Gross facial exercises, strength training			84% R1
Gum chewing			94% R1
Comparison of unaffected side to affected side muscle length/thickness	84% R1
Resistance training			90% R1
Ipsilateral facial muscle stretching	94% R1
Trigger point release	85% R2
Visualization	90% R2
Passive range of motion				79% R2
Relaxation techniques (from initial eight items)
Techniques for delinking/inhibiting synkinesis, ipsilateral inhibition strategies	91% R1
Deep breathing, breathing techniques	83% R2
Co-ordinated movement pattern retraining—small, slow, symmetrical movements, using unaffected side as a model	89% R1
Use of emotion within expression rehabilitation	94% R1
Guided relaxation		75% R2
Mindfulness		80% R2
Sensory and circulatory techniques (from initial eight items)
Massage for sensory awareness	80% R2
Touching for sensory awareness	83% R2
Ice/cryotherapy			91% R1
Touching for biofeedback during movement	81% R2
Heat	83% R2
Lymph drainage				73% R2
Home program delivery (from initial six items)
Therapist-documented bespoke program	84% R1
Patient takes their own notes to document specifically tailored (bespoke) program		71% R2

Items scoring 0–69% and therefore neither included/near-included or excluded/near-excluded are not listed here, but can be found in the Supplementary Information S2.

Assessment and outcome measures

Of the 43 items in this category only the SFGS, use of photographs/videos, and palpation were included across all presentations. In synkinesis, the FDI, FaCE, and SAQ were also included. Working with psychological therapists (if available) was included, however, no psychological screening measures were included. Averaged across all presentations, 48.1% of assessment and outcome measures were excluded, for example, computer-assisted quantitative assessment, electronic, clinican-graded facial function scale and Face Questionnaire (Paralysis).

Patient education and eye care advice

On average, 95.6% of patient education items were included, the highest rate of any category, for example, education on normal facial movement patterns, facial muscle anatomy/physiology, facial nerve injury/recovery, diagnosis, and prognosis. Providing psychological support resources, explanation of treatments before implementation and advice regarding multiple aspects of eye care were included. There were no exclusions.

Eating/drinking and oral/nasal care

From nine items, only taking small bites while eating was included for all presentations. Recommendations regarding oral/nasal care were not included.

Communication and speaking

Avoiding suppression of emotion when communicating was included. Slowing speech to ensure intelligibility was included for flaccid and synkinetic patients.

Taping

Taping for eye closure and lower lid support were only included in flaccid presentations.

Increasing symmetry

Of nine items, reducing overactivity of the unaffected side was included throughout, with contralateral soft tissue stretching added in flaccidity. Botulinum toxin type A (BTX-A) referral before starting therapy was excluded. For chronic, synkinetic patients, ipsilateral BTX-A was included, but without consensus regarding timing.

Modalities

FNMR was the only modality of 24 included in this category. Mime therapy was not included. On average 65.3% of modalities were excluded (e.g., proprioceptive neuromuscular facilitation, ultrasound, acupuncture, dry needling). Electrical stimulation was excluded in all presentations at nearly 100% agreement (flaccid; 98%, paretic; 100%, synkinetic; 100%).

Self-administered rehabilitation techniques, relaxation techniques, and sensory/circulatory techniques

Of 36 items, gross facial exercises, strength/resistance training, and gum chewing were excluded for everyone. Ice/cryotherapy was also excluded with participants indicating that cold increases facial rigidity. Massage for soft tissue mobility and sensory awareness was included for all presentations.

Upper eyelid stretching and manual blink were included for flaccid patients. For synkinesis, trigger point release, breathing techniques for relaxation, and touch biofeedback to inhibit synkinesis during movement were included.

Movement pattern retraining using the unaffected side as a model, proprioceptive attention to movement, incorporation of emotion with movement, bilateral comparison of muscle length/thickness, visualization, and soft tissue mobilization were included for paresis and synkinesis.

Home program delivery

Provision of a documented, individualized home rehabilitation program was included for all patients.

Discussion

Therapists who treat unilateral FP receive training through various methods, with no consensus on best practice. This can lead to discrepancies in education, treatment provision and potentially, patient outcomes. Developing an international consensus document was an essential next step to improving consistency in therapist training thereby advancing care for all patients with peripheral FP. Several results, worth noting, emerged on analyzing the survey responses. There was wide agreement on a select few validated, clinically practical assessment and outcome measures. The critical importance of patient education was apparent as was agreement on the use of fNMR. The rejection of historically used modalities highlights the evolution of this advancing therapy field. Finally, it was evident that individualized training and home program development is considered crucial.

Outcome measures

SFGS⁶ was used by the majority in this study and is recommended as the preferred clinician-reported outcome measure. Regarding PROMs, although measuring similar outcomes, FDI was slightly preferred over FaCE.^7,8 FDI has been in use longer, however, if choosing one, the authors recommend the FaCE as it demonstrates statistically significant changes more reliably.³⁶ Computer-assisted quantitative assessments, for example, Emotrics, were excluded. Although used in research, these are currently less practical for quick implementation in a clinical setting. Surface electrode myography^2,37,38 was not included for any presentation, likely due to lack of access and time constraints.

Recent guidelines demonstrate the association between FP and psychosocial distress and state that all health professionals should be able to provide basic psychosocial assessment/screening and advice/referral.^39,40 The fact that psychological assessments were not included might be explained by therapists' comments that they lacked qualification and confidence in this area. CORE-10 is recommended as a simple, license-free, valid/reliable psychological measure for adults.⁴¹

Patient education

The importance of patient education was reflected in the high level of inclusion. Education optimizes patient compliance by improving understanding (e.g., explaining that synkinesis is rigidity/antagonist co-contraction, not weakness) thereby dispelling common misconceptions regarding facial function.^2,42 This is especially relevant given the prevalence of inaccurate/inappropriate advice from nonspecialist clinicians and the online community.

Although oral care recommendations were not included, a recent article outlining the impact of FP on oral health, recommended simple strategies for reducing deleterious sequelae.⁴³

All treatment options

The only modality included by consensus in paresis and synkinesis was fNMR (which, unlike the other modalities, is an all-encompassing method). Its lack of inclusion in flaccidity is appropriate since there can be no facial movement without innervation to the facial musculature. Surprisingly, mime therapy did not reach consensus for inclusion. Use of the term “mime therapy” is limited to regions with few respondents and this geographical nomenclature may not have been recognized in other locations. In retrospect, the two methods, which are essentially the same, should have been combined.

The use of many therapeutic modalities (e.g., electrical stimulation, ultrasound, laser etc.) is often debated. There are no conclusive studies or recommendations on their use.^3,10,44 They were excluded by strong consensus. High-quality research is needed in this area. Although commonly recommended by therapists without specialist training, gross strengthening, resistance training, and gum chewing were excluded. They are contradictory to fNMR/mime therapy, which use precise, coordinated movements.^13,45 Stronger exclusion was anticipated for facilitation techniques, quick stretch, vibration, and tapping. These techniques to elicit contraction through muscle spindles in skeletal muscles are ineffective in facial muscles, which do not contain muscle spindles.⁴⁶

The facial feedback hypothesis states that there is a reciprocal relationship between facial expression and emotional experience.⁴⁷ Avoiding suppression of emotional expression when communicating is important as FP patients are already prone to depression and/or anxiety.⁴⁸

In this study, ipsilateral chemodenervation was recommended for synkinetic patients. Its use on the contralateral side is debated among clinicians as is its optimal timing.^49,50 Respondents agreed that facial therapy should be initiated before chemodenervation, as supported in the literature.²³ While BTX-A can reduce hyperactivity, it cannot stretch contracted muscle or retrain appropriate cortical motor control. Anecdotally, in poorly educated patients, BTX-A has been seen to reduce compliance with fNMR. However, in a well-educated patient it can be a highly effective adjunctive treatment and may further enhance learning.

Individualized training/home program

Each patient is unique. Just as surgical interventions cannot be standardized, facial therapy also must be individualized to address each person's unique physiology, recovery, psychosocial response, cognitive abilities, learning style, and personal goals.

The majority of facial therapy is performed by the patient independently at home, therefore, the use of home programs is imperative, as indicated in the results. Evidence supports video, photographic, and/or written instructions provided by the therapist or self-recorded by the patient to assist in accurate home performance.^38,51

General discussion

While we acknowledge the role of surgical interventions, they were not addressed in this survey. Not all facial therapists are aware of the range of surgical interventions or practice in a region with specialized surgeons. Therapists should refer patients requiring such interventions to their surgical colleagues, either locally or elsewhere.

Items that were not included/excluded should not necessarily be discarded from the therapist's “toolbox” but, if used, should be supported by evidence and clinical reasoning. Clinical developments may result in items currently excluded for therapeutic use becoming appropriate and vice versa. For example, while computer-assisted quantitative measures are currently prohibitively time-consuming for use in therapy, they may become more feasible in the future. For this reason, it is advisable for therapists to stay current with the literature and repeat consensus studies.

While this project will guide development of best practice and future research in this field, it remains essential to monitor treatment effectiveness and analyze outcomes for each individual patient. Consensus study inclusion does not guarantee effectiveness for individuals.

Limitations

The nominal group was limited at five therapists. While a greater number could have reduced potential bias, this number was felt to be efficient for the structured NGT process. The nominal group was unable to review foreign language literature. In addition, no SLPs participated in the NGT group. However, the 2-phase study did enable all participating international facial therapists, including 11 SLPs, to add items for subsequent Delphi rounds ensuring minimization of bias.

Our Delphi inclusion criteria may have limited skilled therapists with <5 years' experience from participating, however, inclusion criteria were necessary to ensure participants had suitable FP experience. Although all Delphi respondents had 5 years or more experience, we did not specify therapists having particular postgraduate specialist training. Future studies should consider this inclusion criterion.

While we endeavored to reach all therapists meeting the Delphi inclusion criteria, significantly more therapists from the United Kingdom (24%) and the United States (20%) participated in this study. It is hoped that future studies will access therapists from more countries. The sole use of the English language may have limited participation. This study was limited to unilateral, adult, facial palsy patients to the exclusion of partial, postsurgical, pediatric, central, and bilateral FP patients.

Conclusion

A two-stage study consisting of NGT and Delphi methods was conducted to obtain consensus regarding nonsurgical management of FP patients as a first step toward establishing best practice in this field. Utilizing an established protocol, the NGT developed statements based on available evidence and expert opinion into questionnaires, which were circulated to PT, OT, and SLPs meeting specific study inclusion criteria. Consensus for inclusion/exclusion of items was reached after two Delphi rounds. Notable inclusions were simple assessment tools (e.g., SFGS, FDI, FaCE, SAQ), patient education, treatment using fNMR, individualized training, and home programs. Many treatments used by general therapists were excluded for example, gross strengthening, electrical stimulation, and other modalities.

This consensus study highlights areas within the specialist facial therapy field requiring further study to improve evidence-based practice. It is a first step toward bringing together the global community's expertise to establish best practice in facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

Footnotes

Acknowledgments

The authors would like to thank the facial therapy experts around the world that agreed to participate in this project.

Authors' Contributions

C.N.: conceptualization; methodology; validation; formal analysis; investigation; resources; data curation; writing—original draft, review, and editing; visualization; supervision; and project administration. C.B.: conceptualization; methodology; validation; formal analysis; investigation; resources; data curation; writing—original draft, review, and editing; visualization; supervision; and project administration. J.D.: conceptualization; methodology; validation; formal analysis; investigation; resources; data curation; writing—original draft, review, and editing; visualization; supervision; and project administration. S.M.: conceptualization; methodology; validation; formal analysis; investigation; resources; data curation; writing—original draft, review, and editing; visualization; supervision; and project administration. S.R.: conceptualization; methodology; validation; formal analysis; investigation; resources; data curation; writing—original draft, review, and editing; visualization; supervision; and project administration.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

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