title: Long-term facial improvement after repeated BoNT-A injections and mirror biofeedback exercises for chronic facial synkinesis: a case-series study.
abstract: BACKGROUND
  Only few studies have considered the effects of the combined treatment with onabotulinumtoxinA (BoNT-A) injections and biofeedback (BFB) rehabilitation in the recovery of postparetic facial synkinesis (PPFS).
  
  
  OBJECTIVE
  To explore the presence of a persistent improvement in facial function out of the pharmacological effect of BoNT-A in subjects with established PPFS, after repeated sessions of BoNT-A injections combined with an educational facial training program using mirror biofeedback (BFB) exercises. Secondary objective was to investigate the trend of the presumed persistent improvement.
  
  
  METHODS
  Case-series study.
  
  
  METHODS
  Outpatient Clinic of Physical Medicine and Rehabilitation Unit.
  
  
  METHODS
  Twenty-seven patients (22 females; mean age 45±16 years) affected by an established peripheral facial palsy, treated with a minimum of three BoNT-A injections in association with mirror BFB rehabilitation. The interval between consecutive BoNT-A injections was at least five months.
  
  
  METHODS
  At baseline and before every BoNT-A injection+mirror BFB session (when the effect of the previous BoNT-A injection had vanished), patients were assessed with the Italian version of Sunnybrook Facial Grading System (SB). The statistical analysis considered SB composite and partial scores before each treatment session compared to the baseline scores.
  
  
  RESULTS
  A significant improvement of the SB composite and partial scores was observed until the fourth session. Considering the "Symmetry of Voluntary Movement" partial score, the main improvement was observed in the muscles of the lower part of the face.
  
  
  CONCLUSIONS
  In a chronic stage of postparetic facial synkinesis, patients may benefit from a combined therapy with repeated BoNT-A injections and an educational facial training program with mirror BFB exercises, gaining an improvement of the facial function up to the fourth session. This improvement reflects the acquired ability to use facial muscle correctly. It doesn't involve the injected muscles but those trained with mirror biofeedback exercises and it persists also when BoNT-A action has vanished.
  
  
  CONCLUSIONS
  The combined therapy with repeated BoNT-A injections and an educational facial training program using mirror BFB exercises may be useful in the motor recovery of the muscles of the lower part of the face not injected but trained.
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Mandrini
authors.affiliation: Department of Brain and Behaviour Science, University of Pavia, Pavia, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Comelli
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Dall'angelo
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
authors.forename: Rossella
authors.initials: R
authors.lastname: Togni
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
authors.forename: Miriam
authors.initials: M
authors.lastname: Cecini
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Pavese
authors.affiliation: Physical Medicine and Rehabilitation Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy - elena.dallatoffola@unipv.it.
authors.forename: Elena
authors.initials: E
authors.lastname: Dalla Toffola
mesh_terms: D001676:Biofeedback, Psychology; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D005081:Exercise Therapy / Q000379:methods*; D005158:Facial Paralysis / Q000503:physiopathology / Q000534:rehabilitation*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D020127:Recovery of Function; D046608:Synkinesis / Q000503:physiopathology / Q000534:rehabilitation*; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A; C545476:incobotulinumtoxinA