From Facial Palsy to Synkinesis: The Impact of Specialised Physiotherapy

Facial paralysis occurs due to an injury to the facial nerve (VII cranial nerve), resulting in partial or total loss of facial movements. As a consequence of disorganised nerve regeneration, synkinesias may appear, which are involuntary movements associated with voluntary actions. These changes can affect facial expressions, speech and other essential functions. Early recognition of synkinesias and monitoring by a specialised physiotherapist are key to minimising their impact. In this article, we'll find out what synkinesias are, what warning signs they give us and how to prevent them.

What are synkinesias?

Syncinesia (also known as aberrant regeneration) occurs after an injury to the facial nerve and is a common sequela of facial paralysis. The term synkinesis derives from the Greek: “syn”, which means “together”, e “kinesis”, which means “movement”. Thus, synkinesis refers to movements that occur simultaneously or together. In simplified terms, it is described as an involuntary movement that accompanies a voluntary movement, i.e. when we contract a muscle and, at the same time, there is a contraction of another muscle that shouldn't happen.

The type of syncinesia is usually classified according to the muscle groups involved, with the first term referring to the muscle group that is activated voluntarily and the second to the muscle group that moves involuntarily. For example:

- Ocular-oral synkinesia - when a voluntary contraction of the eye muscles, such as blinking or raising an eyebrow, causes an involuntary movement of the mouth.

- Oral-ocular synkinesia - when a voluntary movement of the mouth, such as smiling or pursing the lips, causes an involuntary movement of the eyes.

And why do synkinesias occur?

Involuntary or mass movements are the result of disorganised regeneration of the facial nerve after compression or injury. There are several mechanisms that can cause synkinesia:

1. Aberrant regeneration (miss-wiring): After an injury, the axons of the facial nerve can regenerate in a disorganised way, reconnecting to the wrong muscles, resulting in involuntary movements.

1. Ephatic transmission (electrical cross-talk between nerve branches): Due to the loss of the myelin sheath, electrical impulses can “cross over” between different branches of the facial nerve, activating muscles inappropriately.
2. Nuclear hyperexcitabilityNerve cells in the facial nerve nucleus become more sensitive after the axons have degenerated, reacting to signals from neighbouring nerves and causing involuntary contractions.
3. Maladaptive cortical plasticity: Changes in the brain, particularly in the motor cortex, can lead to abnormal activation patterns that result in synkinesia.

The most likely hypothesis is that most cases of synkinesis result from a combination of these mechanisms.

Syncinesias tend to manifest from the fifth or sixth month after the onset of paralysis, and can appear as early as the third month and continue to intensify until around two years after the onset of the condition.

How can synkinesis be detected early?

To avoid the intensification of synkinesias, it is essential to be aware of the following signs and adjust the therapeutic approach as necessary:

• Involuntary movements during voluntary actions: For example, if you close your eyes when you smile or move your mouth when you blink. If you notice that certain movements activate other unwanted ones, it's important to reduce the intensity and gain greater control of the voluntary action.
• Increased muscle tension at rest: A feeling of stiffness or “constant tension” in the muscles of the face, even without movement, can indicate muscular hyperactivity and the need for relaxation and inhibition techniques.
• Progressive asymmetry over time: If one side of the face appears more tense, with more pronounced folds (deeper nasolabial fold, smaller eye), this could be a sign of overuse of the affected muscles.
• Difficulty isolating movements: If, when you try to raise your eyebrow or smile, there is an exaggerated activation of other muscles, it means that neuromuscular coordination is compromised and should be worked on with specialised physiotherapy.
• Facial fatigue: Tiredness or discomfort when speaking, chewing or making facial expressions indicates that the muscles are overloaded.
• Decreased control over facial expressions: If you notice that you are losing the ability to relax your face or control small movements, it could be an indication that the synkinesis is intensifying.
• Increased involuntary contractions with excessive effort: Intense or repetitive facial exercises without proper control can reinforce the wrong patterns of muscle activation.

How can synkinesis be prevented?

• Perform the gentle, controlled movements guided by the specialised physiotherapist, avoiding excessive repetition.
• Focus on quality of movement rather than strength - facial muscles need coordination, not power.
• Don't do facial mimicry exercises in front of the mirror
• Avoid aggressive massages or electrical stimulation, as they can reinforce wrong patterns.
• Relax the muscles with light stretches, relaxation techniques or gentle massage.
• Consult a physiotherapist specialising in facial paralysis for a personalised neuromuscular re-education plan.

Remember that each person has a unique face and a different recovery process, so rehabilitation programmes should always be tailored to each patient's individual needs and goals. The appearance of synkinesis in facial paralysis is not just a problem of appearance, it can have a significant impact on functionality and mental health, drastically reducing quality of life. Effective treatment makes it possible to recover essential movements for facial expression, communicating with others, eating, speaking, blinking and many other functions that, without realising it, occur naturally and spontaneously.

Recovery from facial paralysis and synkinesis requires a specialised approach to restore balance and harmony to facial movements. Specialised physiotherapy plays an essential role in promoting neuromuscular re-education, helping to correct disorganised movement patterns and regain facial control. Through specific techniques, it is possible to minimise the impact of synkinesis, improve functionality and restore naturalness to expressions. Adequate support not only favours physical recovery, but also contributes to patients' emotional well-being and quality of life.

If you're recovering from facial paralysis and notice involuntary movements or difficulty controlling expressions, don't wait to seek help.

At Integrativa, we have Physiotherapists specialising in facial neuromuscular rehabilitation, They use specific techniques to reduce synkinesis, restore symmetry and improve control of facial movements.

Book your appointment and take the first step towards restoring the naturalness of your expressions and confidence in your smile.