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Physical Rehabilitation
Recovery of Facial Muscle Strength in the Disabled Through a Mechanically Aided
Resistance Exercise Program

By Judith Creed, M.A., CCC, SLP, Joseph R. Spiegel, M.D., Jesse Selber, B.A.

INTRODUCTION
Physical rehabilitation is principally comprised of movement through an appropriate range of motion, most often opposed by varying specific levels of resistance. The primary objective of the therapy is to improve function and regain maximum range of motion and strength within the circumstances of any specific disability. Physical rehabilitation of craneo-oral facial disabilities, including disorders of the throat, is generally performed by a physical therapist or speech-language pathologist. Such therapy is often performed in conjunction with treatment by an attending physician, depending upon the etiology and severity of the disability. Craneo-facial therapy often incorporates some form of resistance to movement. The practice of speech-language pathology for the improvement of oral-facial motor function is typically centered on resistance-based, oral-motor muscle exercise. Current practice employs a variety of relatively crude devices to apply this resistance. These include whistles, tongue depressors, fingers, etc. Until recently, there has been no device which provides constant, dynamic external resistance during exercise of oral-motor musculature. Absent such a device, there is no controllable level of resistance that can be applied during therapy. Therefore, range of motion exercises go unopposed by dynamic external resistance, and outcomes are unquantifiable.

Facial-Flex is a lightweight, mouthpiece-size device, which provides external dynamic resistance during oral-motor exercises. As a rehabilitation instrument, Facial-Flex satisfies all the criteria that have, until now, been absent from exercise programs for the oral musculature. Either the patient or the therapist can set the specific level of resistance, so the patient can take the therapy home and work independently of a therapist. Constant, dynamic external resistance opposes the full range of motion during oral motor exercise. Changes in oral muscle strength can be precisely and objectively quantified by measuring changes in a patient's ability to perform an exercise against a specific level of resistance.

The efficacy of Facial-Flex has already been firmly established in use on healthy individuals to improve facial muscle tone (Grove, Rimdzius, Grove 1992 and Grove, Rimdzius, Zerweck 1994). Because of its effectiveness, more than 1,000,000 Facial-Flex products have been sold in the aesthetics market in 12 years. There is every reason to believe Facial-Flex would be effective in the rehabilitation of patients with disabilities affecting the oral-facial musculature. Many disorders, such as cerebrovascular accidents, traumatic brain injury, CNS diseases such as Parkinson's and developmental diseases, can all cause loss of oral-facial strength and control, resulting in dysarthria, oral dysphagia and hypomimmia. The importance of facial expressions and speaking and eating in everyday human experience cannot be overemphasized.

The following is a preliminary and informal presentation of findings in 3 residents of a skilled nursing facility. Each patient had a baseline measure of oral-facial muscle strength using Facial-Flex. The strength level is determined by having the patient repeat the exercise using Facial-Flex until the point of muscle fatigue. To disambiguate the effect of other therapy from the use of Facial-Flex, no other exercises of the oral-facial musculature were employed during the trial period. The therapy period lasted for 3 weeks. During that time, the patients were treated 3 times a week, twice a day by a speech-language pathologist.

CASE 1: LEFT CEREBROVASCULAR ACCIDENT
The first patient is a 90-year-old female who suffered a left middle cerebral vascular occlusion. Baseline was established 1 month after the patient suffered her stroke. Speech-language pathology diagnosed the patient as dysarthric, with weak bilabial phonemes. There was difficulty maintaining oral muscular form to articulate the vowels p and b. The patient also experienced oral dysphagia, with interior leakage of solids and liquids. A right facial droop was evident. Baseline facial strength was measured by the number of repetitions performed with the Facial-Flex device. This patient was able to complete 7 repetitions.

At the end of the 3-week exercise period, the patient had moved from 7 repetitions to 40 repetitions. Dysarthria on bilabials had abated. The patient had no trouble articulating p and b. During eating and drinking, there was no anterior leakage, and the right facial droop had approached symmetry.

CASE 2: IDIOPATHIC PARKINSONISM
This patient is an 85-year-old male with idiopathic Parkinsonism. The patient had generalized oral-neurological weakness with hypomimmia and dysarthria. Subjective speech-language pathology judged intelligibility at 60%. During the establishment of baseline strength, the patient performed 3 repetitions with Facial-Flex, with a severe oral action tremor.

At the end of the 3-week exercise period, the patient was able to perform 20 repetitions. Significantly, the action tremor had completely resolved. Speech-language pathology's subjective intelligibility evaluation had increased to 90%.

CASE 3: RIGHT CEREBROVASCULAR ACCIDENT
This patient is an 80-year-old male who suffered right middle cerebral artery occlusion. Speech-language pathology diagnosis determined oral dysphagia and apraxia characterized by the inability to maintain the oral pucker to sip from a straw. Generalized oral motor weakness was also noted. Baseline evaluation of oral muscle strength was made 1 month after the cerebrovascular accident occurred. The patient was able to perform 5 repetitions at that time. At the completion of the 3-week exercise period, the patient was able to perform 45 repetitions and was able to drink from a straw.

CONCLUSIONS
The difficulty with a set of informal case studies such as these is that without a control group of stroke patients who had not undergone treatment, it is difficult to judge what is attributable to spontaneous recovery and what is due to the increase in muscle strength as a result of the therapy. One way to get an idea about this, however, is to look at the recovery of the Parkinsonism patient, who should have experienced no spontaneous recovery. The first stroke patient improved the number of repetitions with Facial-Flex by 571%. The second stroke patient improved in number of repetitions by 900%. The patient with idiopathic Parkinsonism improved by 667%. All these improvements were on the same order of magnitude, suggesting that results gained during the trial therapy period came as a result of the therapy itself and not spontaneous recovery.

Facial-Flex is a valuable instrument for improving oral muscle strength. It has been proven in published studies on normal patient populations and has experienced great popularity in aesthetic markets for improving oral facial muscle tone. There is no device which ameliorates some of the very devastating disabilities associated with many of the diseases of the CNS which affect the facial musculature. Preliminary findings of this study suggest dramatic rehabilitation of facial musculature in a population for whom such improvement is essential.

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