Exercises are initiated when there are signs of recovery and so of

movement. PNF is efficacious in the both upper and lower motor neuron
type facial paly. However, the underlying causes for upper motor neuron
type facil palsy should be addressed. PNF was orininated in USA and many
physiotherapists from all over the world visited USA to learn that. Now these
technques are know world wide among physiotherapists. A description of
techniques of PNF for facial palsy has been described below.

The normal facial movements are bilateral symmetrical in character: both

sides of face move in indentical motions. The normal subject is capable of
innumerable combination of facial movements which include unilateral and
bilaterally symmetrical motions. Although the normal subject may isolate
certain motions to a degree, in situation of emotional stress facial motions
are usually bilaterally symmetrical in character. During vigorous physical
activity, facial motions may take on bilaterally asymmetrical character when
facial movements are brought into play as reinforcement. Inability to
perform bilaterally symmetrical motions voluntarily is an indication of
weakness resulting in asymmetry of facial expression.

Facial movements may be grouped as antagonistic motions involving three

pivots of action: mouth, nose and the eyes. Extreme ranges of motion of any
one pivot bring into play related movements of other pivots. Antagonistic
motions may be considered as follows:

Elevation of Eye brows upwards and lateral ward

Depression of eye brows downward and medial ward

Opening of eyelids, lateral ward

Closing of eyelids medial ward

Elevation and opening of nostrils lateral ward

Depression and closing of nostrils, medial wards

Retraction of angle of mouth upward

Protraction of lips downward

Retraction of angle of mouth, downward

Protraction of lips upward

Closing of lips with protrusion

Opening of lips with inversion

The facial muscles are spiral and diagonal in character and are arranged for
symmetrical motions. Strong contraction of cicular muscles about the mouth
and eyes demand lenghthening and shortening reactions of other facial
groups including those of scalp. Strong contraction of nasal groups in turn
demands cooperation of muscles responsible for motion about the eyes and
mouth. The various techniques of PNF that may be applied to facial motions
include pressure, stretch, resistance, reinforcement, repeated contractions
and reversal of antagonistics. Relaxation techniques may be used as
indicated. The physical therapist uses the tips of the fingers as manual
contacts. Stronger motions are resisted in order to stimulate and reinforce
weaker motions.

For example, a patient may present with weakness of elevation of the left
eye brow. The physial therapist places her finger tips on both sides of
patients brows and applies pressure and stretch in a downward and medial
direction. Having achieved the stretch, he instruct the patient, "Look up at
me! Raise your eyebrows" At this point physical therapist resist strongly the
motion on the right and allows range of motion to occur on the left. The
patient is instructed to raise his eye brows, and the physical therapist
applies the technique of repeated contractions. Reversing motion and
relaxation techniques may be used to increase mobility of the elevation and
depression of eye brows.

Motions of the eye brows may be used to reinforce opening and closing of
eyes; motion of lips may be used to reinforce about the nose and the eyes.
Study of normal subject will reveal the relationship of facial motions. Neck
patterns are used as reinforcement. Any facial motion that requires
elevation or upward motion is reinforced by neck extension. Facial motion
that require depression or downward motion are reinforced by neck flexion.
Neck rotation reinforces the motion of the side of face to which the head is
turned. If it is desired to reinforce the motion on the left, the head is turned
to the left.

Examples:

Elevation and depression of eyebrows, diagonal direction

A- Ready ( Str downward and medial ward)

B- Look up ! Raise your eye brows
C- Hold it! Now Look up some more! And higher! and Higher! Now look down
and in."

Opening and closing of eyelids, diagonal direction

A-Open your eyes wide! Hold them open

B- Now close your eyes! Don't let me open them! (MR) and Relax.

Retraction of the angle of mouth upward, protruction of lips downward.

A- Smile wide! Hold it there!

B- Pull your lips together forward and downward, Hold it! (MR, SR-H). And
Smile gaian and Hold!
Retraction of the angle of mouth downward, protruction of lips upward.

A-Frown! Hold it! (Str, MR)

B- Pucker up and hold it ! Now pucker up some more! And some more!
(MR,RC)

Lips open with inversion, Lips close with protrusion as cheek compress.

A- Close your lips (Str, MR)

B- Hold it ! Now close tightly! And again and relax. (RC)