Mime therapy

Related Terms

Bell's palsy, electromyogram biofeedback, EMG biofeedback, facial nerve palsy, facial palsy, facial symmetry, House-Brackmann Scale, massage, mime, MIME training, physiotherapy, relaxation technique, sequelae of facial paralysis, stroke, Sunnybrook Facial Scale, synkinesis.

Background

Mime therapy is a type of physiotherapy. It was developed in the Netherlands in the 1970s by a mime actor named Jan Bronk and an otolaryngologist named Pieter Devriese. Mime therapy was created to help patients who had limited or restricted facial movement or a lack of facial muscle control.
Conventionally speaking, miming is a performance art that relies on expression and body movement to communicate without speaking. Miming demands a highly-refined sense of body and muscle control.
During mime therapy, patients perform a series of mime-like facial exercises and assume certain expressions in particular sequences. Mime therapy may be used to treat patients with partially paralyzed facial nerves and patients who have had facial nerve or muscle reconstruction. For instance, patients with Bell's palsy (the most common cause of facial paralysis), may undergo mime this form of therapy. Bell's palsy typically results in paralysis or weakness on one side of the face; some patients may also develop synkinesis. Synkinesis consists of involuntary facial movements, such as grimacing, that accompany voluntary movements, such as closing of the eyes. Most people who are afflicted with Bell's palsy recover fully, regardless of treatment.
The goal of mime therapy is to improve the symmetry of facial features and to help patients regain expression and control of their facial muscles. For example, damage to facial nerves may result in a droopy facial appearance; patients may also have difficulty using their facial muscles to express emotion. In addition, patients may have problems with speaking, eating, and drinking.
Bronk and Devriese collaborated on a plan to treat individual patients using a series of facial exercises; these treatments were combined with massage for the face and neck, along with breathing and relaxation exercises. To create mime therapy, Bronk modified mime principles by developing a detailed analysis of the face that looked at movements involved in breathing, articulation, alertness and expression.
Bronk began to train physiotherapists in mime therapy in 1980. After his death in 1985, the first two physiotherapists whom he had trained continued to teach his methods to other physiotherapists. Speech therapists and physiotherapists who have successfully completed these courses are able to treat patients who have peripheral facial paresis (paralysis).
About 30 mime therapists are currently practicing in the Netherlands, where they treat around 250 patients per year. Mime therapy is also practiced in Belgium, Italy, and Portugal.
Some researchers suggest that mime therapy may one day be part of the physiotherapy protocol for patients who are dealing with stroke and other neurological conditions. Because well-designed research is lacking in this area, however, mime therapy should not be used as the only treatment approach for serious medical conditions: Its use may delay the consideration of more proven therapies.
Mime therapy should not be confused with MIME (Mirror Image Movement Enhancer) training. The latter uses robotic devices to assist stroke patients with arm and hand function and other skills.

Theory / Evidence

General: Based on limited research and anecdotal evidence, it appears that both therapists and their patients have noted improvements in patients' facial symmetry following mime therapy. Some research suggests that mime therapy patients may improve by one grade on the House-Brackmann scale. This commonly-used scale assigns a grade of one to six based on how completely the patient is able to close his or her eyes and whether or not synkinesis is present. Synkinesis is defined as involuntary facial movements, such as grimacing, that accompany voluntary movements, such as closing of the eyes.
There have been few randomized controlled trials involving mime therapy. Researchers have noted that more (and stronger) evidence from well-designed trials is necessary before mime therapy is integrated into evidence-based clinical practice.
Researchers hope to learn more about the potential mechanisms of mime therapy. It has been suggested, but not proven, that mime therapy may cause changes in the nervous system. Some suspect that this success is due to the relearning of motor skills by patients, or it may be due to the fact that patients are working in cooperation with a therapist who gives them full attention.
Recent research: A recent review of clinical trial treatments for Bell's palsy looked at the use of mime therapy and electromyogram (EMG) biofeedback, among other possible treatments. Researchers concluded that there were not enough randomized controlled trials to properly analyze whether the techniques under review were effective.
By 2003, reportedly more than 1,000 patients had been successfully treated with mime therapy in Nijmegen, the Netherlands. Treatment was initially monitored with the House-Brackmann scale and later with the Sunnybrook Facial Grading System (the Sunnybrook Facial Scale is an internationally-used grading system for judging facial paralysis; some research has shown the Sunnybrook scale to be more reliable than House-Brackmann.) Both reporting systems showed that patients who underwent mime therapy had improved facial symmetry at rest and in motion, and that synkinesis had decreased following treatment.
Additional research in the Netherlands showed that, compared to a control group, patients who underwent mime therapy improved by 20 points on a facial symmetry grading system; the patients also reduced the severity of paresis (paralysis) by 0.6 of a grade point. Results were measured in two ways: Symmetry was measured with the Sunnybrook Facial Grading System, and the degree of paralysis was measured with the House-Brackmann Facial Grading system.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Beurskens CH, Heymans PG. Mime therapy improves facial symmetry in people with long-term facial nerve paresis: a randomised controlled trial. Aust J Physiother. 2006;52(3):177-83.
Beurskens CH, Heymans PG. Positive effects of mime therapy on sequelae of facial paralysis: stiffness, lip mobility, and social and physical aspects of facial disability. Otol Neurotol. 2003 Jul;24(4):677-81.
Beurskens CH, Heymans PG, Oostendorp RA. Stability of benefits of mime therapy in sequelae of facial nerve paresis during a 1-year period. Otol Neurotol. 2006 Oct;27(7):1037-42.
Cardoso JR, Teixeira EC, Moreira MD, et al. Effects of exercises on Bell's palsy: systematic review of randomized controlled trials. Otol Neurotol. 2008 Jun;29(4):557-60.
Cederwall E, Ols?n MF, Hanner P, et al. Evaluation of a physiotherapeutic treatment intervention in "Bell's" facial palsy. Physiother Theory Pract. 2006 Jan;22(1):43-52.
Finsterer, J. Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol. 2008 Jul;265(7):743-52. Epub 2008 Mar 27.
Natural Standard: The Authority on Integrative Medicine.
Teixeira LJ, Soares BG, Vieira VP, et al. Physical therapy for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006283.

Technique

General: Mime therapy is primarily used in the Netherlands to treat patients with Bell's palsy and other types of facial paralysis.
Evolution of mime therapy: Jan Bronk, a mime actor, and Pieter Devriese, an otolaryngologist, are the founders of mime therapy. They believed that when a patient is unable to form facial expressions, then the focus of treatment must be on the whole body. Bronk and Devriese theorized that a combination of massage, breathing exercises and relaxation exercises would help to relax the entire body, which would, in turn, relax the face. Specific exercises would help patients to regain their facial symmetry, by re-training their facial muscles to make facial expressions. Current mime therapists credit Bronk, in particular, for using the parts of the face that functioned well in order to help the parts that did not. He is also recognized for using emotional expressions as a major element of regaining nerve control the face.
Initially, Bronk and Devriese waited one year after the onset of a patient's facial paralysis before starting mime therapy for treatment: This was to ensure that a patient's synkinesis (involuntary facial movements, such as grimacing, that accompany voluntary movements, such as closing of the eyes) was not going to worsen. The co-developers of mime therapy eventually learned that treatment could begin as soon as synkinesis developed, rather than waiting a full year.
After the death of Bronk, the original physiotherapists whom he had trained continued the teaching of his methods. Reportedly, speech therapists and physiotherapists who have successfully completed mime therapy training are considered specialists in treating patients with peripheral facial paresis (paralysis).
As other physiotherapists began practicing mime therapy in the early 1980s, the treatment became a combination of mime therapy and physiotherapy: There was more emphasis on the stretching of facial muscles, as well as the addition of oppositional movements to help improve the problem of synkinesis. Therapists also included exercises designed to coordinate movements between both sides of the face (both the side of the face that was functioning normally and the side that needed treatment).
In the mid-1980s, therapists began to use standardized scales (such as the House-Brackmann test), to objectively measure the effectiveness of mime therapy.
Current method of practice: Mime therapy typically begins as soon as a patient exhibits synkinesis, which studies indicate may occur three months after the development of facial paralysis.
Mime therapy currently includes about 10, 45-minute sessions, held weekly. In the first session, the therapist typically explains the treatment plan, measures the current status of paresis through the use of a grading system, photos and video, and then offers a prognosis.
Each session starts with an exchange of information. This is followed by massage of the face and neck, along with breathing and relaxation exercises. The patient then engages in exercises to coordinate movements of both sides of the face, in order to reduce synkinesis. This training is followed by speech exercises. The session ends with exercises that focus on facial expressions.
While patients may mimic therapists at first to learn how to perform the exercises properly, the goal of mime therapy is for patients to learn how to communicate effectively by controlling their facial expressions and movements.
Patients often use a mirror when performing facial exercises, which helps them to gauge their progress and to observe the severity of their synkinesis.
Practicing at home between therapy sessions is an essential part of mime therapy. Practice includes self-massage of the face and neck for 10-15 minutes daily, breathing and relaxation exercises, and other facial exercises that are to be done in a specific order.
Follow-up typically extends for 3-6 months after a patient completes treatment. Patients usually continue to do stretching exercises on their own after therapy ends.
Goals of therapy: Mime therapy generally has two goals: 1) to improve symmetry of the face, whether it is in motion or at rest; and 2) to control the involuntary facial movements known as synkinesis. When these goals are met, a patient's face appears less affected; facial expressions are more easily read; and the patient may have fewer difficulties with eating, drinking, and speaking. As a result, the patient's self-esteem may improve. Patients typically begin to see benefits from mime therapy after about one month of treatment.
Training: Courses in mime therapy are offered at the physiotherapy department of the Radboud University Nijmegen Medical Centre in the Netherlands. Enrollees are typically speech therapists and physiotherapists.