University of Groningen
Therapists' perceptions and attitudes in facial palsy rehabilitation therapy
van Veen, Martinus M; Ten Hoope, Britt W T; Bruins, Tessa E; Stewart, Roy E; Werker, Paul
M N; Dijkstra, Pieter U
Published in:
Physiotherapy Theory & Practice DOI:
10.1080/09593985.2021.1920074
IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below.
Document Version
Publisher's PDF, also known as Version of record
Publication date: 2021
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):
van Veen, M. M., Ten Hoope, B. W. T., Bruins, T. E., Stewart, R. E., Werker, P. M. N., & Dijkstra, P. U. (2021). Therapists' perceptions and attitudes in facial palsy rehabilitation therapy: A mixed methods study. Physiotherapy Theory & Practice, 1-11. https://doi.org/10.1080/09593985.2021.1920074
Copyright
Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).
Take-down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.
Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=iptp20
Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20
Therapists’ perceptions and attitudes in facial
palsy rehabilitation therapy: A mixed methods
study
Martinus M. van Veen, Britt W.T. ten Hoope, Tessa E. Bruins, Roy E. Stewart,
Paul M.N. Werker & Pieter U. Dijkstra
To cite this article: Martinus M. van Veen, Britt W.T. ten Hoope, Tessa E. Bruins, Roy E. Stewart, Paul M.N. Werker & Pieter U. Dijkstra (2021): Therapists’ perceptions and attitudes in facial palsy rehabilitation therapy: A mixed methods study, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2021.1920074
To link to this article: https://doi.org/10.1080/09593985.2021.1920074
© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC. Published online: 23 Apr 2021.
Submit your article to this journal
Article views: 70
View related articles
Therapists’ perceptions and attitudes in facial palsy rehabilitation therapy: A
mixed methods study
Martinus M. van Veen MD, PhDa, Britt W.T ten Hoope MDa, Tessa E. Bruins MDa, Roy E. Stewart PhDb, Paul M.
N. Werker MD, PhDa, and Pieter U. Dijkstra PT. PhDc,d
aDepartment of Plastic Surgery, University of Groningen, University Medical Center Groningen, GZ, Groningen, Netherlands; bDepartment of
Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, , GZ, Groningen, Netherlands; cDepartment of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen,, GZ, Groningen,
Netherlands; dDepartment of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, GZ, Groningen,
Netherlands ABSTRACT
Background: Facial palsy rehabilitation therapy plays an essential role in treating facial palsy. Purpose: This study aimed to gain insight into therapists’ perceptions and attitudes toward facial
palsy rehabilitation therapy and to examine whether therapists could be categorized into distinct groups based on these attitudes and perceptions.
Methods: Thirteen semi-structured, in-depth interviews were conducted in a purposive sample of
therapists. Interviews were analyzed using thematic analysis. Next, a questionnaire containing questions about therapists’ characteristics and perceptions and attitudes toward facial palsy rehabilitation therapy was sent to all facial palsy rehabilitation therapists in the Netherlands and Flanders (n = 292). Latent class analysis (LCA) was performed to identify and analyze distinct groups of therapists.
Results: Seven themes were derived from the interviews: treatment goals, therapy content,
indications, measurement instruments, factors influencing success, emotional support, and coop-eration with colleagues. The questionnaire was filled out by 127 therapists. A 2-group structure consisting of a positive class and a negative class was found to fit the questionnaire data best. No distinction could be made regarding therapists’ characteristics.
Conclusion: Considerable variation in stated treatment practices was present among therapists.
Therapists could be classified into 2 groups. This study raises several hypotheses that require further study. ARTICLE HISTORY Received 18 February 2020 Revised 5 December 2020 Accepted 20 March 2021 KEYWORDS
Mime therapy; facial rehabilitation; facial therapy; facial palsy; facial paralysis
Introduction
Facial palsy is a peripheral nerve injury characterized by the inability to contract the facial muscles, resulting in (partial) loss of facial expression. Approximately half of all facial palsies are idiopathic, commonly referred to as Bell’s palsy (incidence of 20–30/100,000 individuals per year) (Myers et al., 1991); the other half are due to a wide variety of causes such as iatrogenic or traumatic injuries, head and neck neoplasms, otologic diseases, and congenital birth defects (Hohman and Hadlock,
2014). Facial palsy patients experience various func-tional and psychosocial difficulties related to their inability to voluntarily contract the facial muscles. Myriad treatment options are available, including surgi-cal, pharmacologisurgi-cal, and physical therapeutic measures, all aimed at improving facial function and psychological wellbeing (Kleiss, 2015; Luijmes et al., 2017). Ultimately, treating facial palsy is a multidisciplinary team effort, in
which the facial palsy rehabilitation therapist plays an essential role (Butler and Grobbelaar, 2017; Hohman and Hadlock, 2014; Van Landingham, Diels, and Lucarelli, 2018).
Although many different types of facial palsy rehabi-litation therapy have been described in the literature, only a small amount of evidence is available on their efficacy (Baricich et al., 2012; Pereira et al., 2011). In the Netherlands, mime therapy was developed in the 1980s through collaboration between a mime artist and an otolaryngologist (Devriese, 1994). The treatment con-sists of facial movement exercises, self-massaging, relaxation exercises, stretching, mirror exercises, and education about verbal and non-verbal communication (Beurskens, 2003).
Although previous studies have shown a beneficial effect of rehabilitation therapy on facial palsy outcomes, there is some variation in the types of treatments used
CONTACT Martinus M. Van Veen, MD PhD m.m.van.veen@umcg.nl University Medical Center Groningen Department of plastic surgery, HPC BB81 PO box 30.001 9700 RB Groningen, the Netherlands
PHYSIOTHERAPY THEORY AND PRACTICE https://doi.org/10.1080/09593985.2021.1920074
© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc- nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.
and in the heterogeneity of the study populations (e.g. difference in etiology of facial palsy) (Barbara et al.,
2010; Beurskens and Heymans, 2003, 2006; Manikandan, 2007; Nakamura et al., 2003; Paolucci et al., 2019; Ross, Nedzelski, and McLean, 1991; Segal et al., 1995). Studies from various medical fields such as gynecology, urology, cardiology, orthopedic surgery, and physical therapy reported an association between practice patterns and care provider characteristics (Archer et al., 2009a; Archer, MacKenzie, Castillo, and Bosse, 2009b; Graham, Maddox, Itani, and Hawn, 2013; Hamilton et al., 2012; Harper, Brown, Foster-Rosales, and Raine, 2010; Li and Bombardier, 2001; Mikhail, Korner-Bitensky, Rossignol, and Dumas, 2005). Similarly, treatment practices among facial palsy reha-bilitation therapists may vary, possibly leading to differ-ent treatmdiffer-ent outcomes. In order to better understand the outcomes of facial palsy rehabilitation therapy, it is important to gain insight into the therapists’ perceptions and attitudes regarding the therapy and how these are related to the therapists’ characteristics.
Methods
A mixed methods study that combined qualitative and quantitative research methods was performed in mime therapists in the Netherlands and Dutch-speaking Belgium (Flanders). A sequential design was used, in
which a qualitative study was followed by
a quantitative study (Figure 1). Approval from the Medical Ethics Committee was obtained from the University Medical Center Groningen prior to the start of this study (METc 2018/326). All participants provided written consent to participate in this study.
Qualitative Study
All mime therapists in the Netherlands and Flanders were eligible for participation with the exception of the mime therapist involved in this study. In both the Netherlands and Flanders, mime therapists are either physical therapists or speech and language therapists, and they have all received structured education in the field of mime therapy. Purposive sampling with a maximum variation strategy was performed, aiming at the inclusion of different perspectives. Initially, five mime therapists were actively contacted by the first author: four leading figures in the professional commu-nity and one practicing in the same medical center as the authors. For further participant selection, a snowballing technique was used: participants were asked to name colleagues who would possibly be interesting to inter-view, preferably with different views on mime therapy than their own. Therapists were approached via e-mail. Additionally, a balance between male and female
therapists, physical therapists and speech and language therapists, and hospital-affiliated and non-hospital affiliated therapists was actively sought.
The in-depth interviews were semi-structured and audio-recorded. All interviews were performed at the work location of the mime therapist. An interview guide was used to ensure all relevant topics would be covered (Appendix 1 – Interview guide). The interview guide was updated during the interview process based on new themes emerging from the concurrent initial thematic analysis. Questions such as “What do you mean by that?” or “Could you elaborate on that?” were used to ensure the perspective of the mime therapist was covered and to limit interviewer bias. The main inter-viewer was the first author, who is trained as a physician and who received training on qualitative research meth-ods before the start of this study.
Interviews were transcribed verbatim and sent back to the mime therapists for member checking. Afterward, the transcripts were analyzed by two researchers, who independently used the principles of thematic analysis (Braun and Clarke, 2006). This is a method for identify-ing, analyzidentify-ing, organizidentify-ing, describidentify-ing, and reporting themes found within a data set. Thematic analysis is a useful method for examining the perspectives of dif-ferent research participants, as it highlights similarities and differences. First, transcripts were coded using line- by-line readings. Important statements and sentences were identified and initial codes generated. Initial codes were cross-referenced between the coding inves-tigators and initial themes were generated. After every few interviews, research meetings were held by the first, second, and last author so as to gradually generate the list of final themes and quotes.
Quantitative Study
After the qualitative study was finalized and themes were established, a quantitative, cross-sectional study was performed to gain insight into the perspectives of the therapist group in its entirety and ultimately identify different types of mime therapists. A questionnaire was developed covering all seven themes generated from the interviews. The questionnaire statements were derived from the most important or contradictory findings from the interviews. The final questionnaire consisted of two parts. The participant’s personal and work -related char-acteristics were collected. Additionally, questions were asked covering the most important and most controver-sial themes from the interviews. The majority of the questions concerned treatment dilemmas (e.g. “What would be more important in the treatment of the above described patient according to you? (A) relaxation and massage or (B) controlled coordination exercises?”). Participants were also asked to what extent they agreed
with a certain statement on a 100-mm visual analogue scale (0 = absolutely disagree, 100 = absolutely agree). The content of the questionnaire was discussed within the research group including a mime therapist in detail in the developmental phase and subsequently pilot tested for comprehensibility in 3 mime therapists work-ing at our institution who were not involved in the study. The questionnaire was distributed via RedCap (Vanderbilt University, TN, USA), an online survey distribution system, to all registered mime therapists in the Netherlands and Flanders who were on a list
provided by the mime therapy course coordinator except for the therapist involved in this study (PUD). Multiple imputation, 20 imputations with predictive mean matching was performed using the IBM statistical package for the Social Sciences (SPSS) version 25.0 (IBM, NY, USA) to estimate missing data in the ques-tionnaire for the mime therapy-related questions.
To identify different groups of mime therapists, a latent class analysis (LCA) with robust maximum- likelihood estimation was performed in Mplus version 7.1. LCA models that ranged from 1 to 3 classes were
Figure 1. Schematic representation of the longitudinal mixed methods study design. Shown are all individual steps in the study in the order in time.
tested primarily based on several criteria: Bayesian infor-mation criterion (BIC), Akaike inforinfor-mation criterion (AIC), bootstrap likelihood ratio test (BLRT) and Vuong–Lo–Mendell – Rubin likelihood ratio test (VLMR) for relative fit; entropy for class separation. Lower BIC and AIC values indicate a better fit. Significant BLRT and VLMR values indicate that the K-class model has a better fit to the data than the K-1 class model (Jung and Wickrama, 2008; Nylund, Asparouhov, and Muthén, 2007). A model with higher entropy is considered to have better class separation (Nylund, Asparouhov, and Muthén, 2007). Second, clin-ical interpretation (e.g. class prevalence and subgroup size) was used to select a model. Each participant was assigned to a class based on the latent class posterior distribution of the selected model. A 4-class model was run but contained a class with only two persons. Therefore, the 4-class model was considered to be unfa-vorable and was not further examined.
Descriptive data were presented using numbers and frequencies, means and standard deviations (SD), and medians and interquartile ranges (IQR). Statistical dif-ferences in mime therapists’ characteristics were tested using SPSS. In case of nominal data, chi-square tests were used. For continuous data, Mann-Whitney U tests were performed due to non-normality of the data.
Results
Qualitative Study
Thirteen in-depth interviews with mime therapists were performed that lasted between 30 and 90 minutes. During the interviews, two researchers independently transcribed and analyzed the interviews. After the first seven interviews by the first author, a point of data saturation was reached. At this point, no new informa-tion could be gained from the therapists and interview transcripts. Therefore, the next three interviews were performed together with the second author, who indi-cated when a point of data saturation was reached. The last three interviews had already been scheduled at that point and were performed by the first interviewer.
In general, more experienced mime therapists were more explicit in voicing their opinions and beliefs (i.e. less use of phrases such as “I am not sure about that”) during the interviews. Their interviews also tended to take longer. However, the overall content of the opi-nions and beliefs of the experienced mime therapists was not considered to be drastically different from that of the less experienced mime therapists. In general, the interviews revealed that there is a need among mime therapists for more studies into mime therapy. Seven
major themes were developed from the interviews: 1) treatment goals; 2) content of therapy; 3) indications; 4) measurement instruments; 5) factors influencing suc-cess; 6) emotional support; and 7) cooperation with colleagues.
Treatment goals
Two main treatment goals were improving symmetry of the face and increasing the ability to convey emotions. The focus on emotional expression in particular was stated by some therapists to be specific to mime therapy, as opposed to other forms of facial palsy rehabilitation therapy, such as neuromuscular retraining. Some thera-pists adhered to less strictly defined treatment goals and stated that mime therapy entails providing a patient with tools in order to cope with both the physical and psy-chosocial aspects of living with facial palsy. Individual patient goals were established with the patient and could be very specific.
The goal [of mime therapy] is optimal symmetry and expression of emotion.
Content of therapy
During the interview, it was difficult for the interviewers to gain an in-depth understanding of differences in treatment strategies between individual mime therapists. The therapists stated that mime therapy is highly indi-vidual and tailored to the wishes and personal needs of the patients. Most therapists referred to techniques and exercises they learned during their mime therapy course, which is centralized and was only offered at 1 location in the Netherlands and Belgium until recently. Some mime therapists stated that the actual coordinated movement exercises in the context of synkinesis were the core business of mime therapy. Advice on how to cope with paralysis was described to be part of their practical work because, in their experience, physicians often have too little attention and time for patients diagnosed with facial palsy.
Mime therapy is a combination of massage and exercise therapy.
Indications
The largest group of patients treated by the therapists consisted of patients with synkinesis or at risk of devel-oping synkinesis, most of whom suffered from Bell’s palsy. These patients also have the most to gain from mime therapy because it requires at least some
movement of the facial muscles in order to be possible. In contrast, patients with chronic flaccid paralysis have much less to gain from mime therapy because there is no existing movement to strengthen or alter. Some mime therapists also treated facial palsy patients after smile reanimation surgery. These mime therapists expressed the belief that mime therapy is essential for all patients who undergo smile reanimation surgery.
“If there is no movement at all you can’t really do any-thing. Well, except for providing some tips and tricks on how to deal with more practical issues such as drooling or spill of food when eating.”
Although not stated to be part of the core business of mime therapy, advice of how to cope with some practical disabilities resulting from paralysis could be given to any patient suffering from facial palsy, flaccid or synkinetic.
Measurement instruments
All therapists stated they use some kind of measure-ment tool to assess changes in facial function; however, the tools themselves and the frequency with which they were used differed considerably. The Sunnybrook Facial Grading System (SFGS) (Ross, Fradet, and Nedzelski, 1996) was used by all therapists. An advan-tage of this tool over the widely known House- Brackmann score (House and Brackmann, 1985), which was only used by a few therapists, was said to be that it provides detailed regional information on facial function and has a dedicated section on synkin-esis, making a more detailed longitudinal assessment possible. Patient-reported outcome measures (PROM) were used less frequently and were not uniformly sta-ted to be important. The most widely used PROM was the Facial Disability Index (VanSwearingen and Brach,
1996).
The use of photographic and videographic material was even more heterogeneous. Most mime therapists did use one or both to document changes in patients, although some mime therapists fully relied on their SFGS assessments.
As mentioned before, the assessment frequency dif-fered greatly. Most mime therapists repeated their assessments as soon as they noted changes in facial function. Some only performed their assessment at the start and end of the treatment, and a very small number assessed at every visit.
The facial photographs, videos and, to a lesser extent, SFGS assessments, were used to remind patients during their treatment of how far they had come. Hence, they were used in managing patient expectations. Overall, measurement instruments were generally seen as
supporting the therapy and not as essential elements in providing mime therapy.
Factors influencing success
The intrinsic motivation of patients was unanimously seen as the determining factor for the success of mime therapy. All therapists literally said “they have to do it themselves.” This principle was seen as a basic prerequi-site for adherence to therapy.
(. . .) that someone is motivated is very important to me.
Another frequently mentioned factor for success was a certain level of intelligence. Mime therapy was con-sidered to be a rather difficult form of therapy, and a certain level of intelligence was thought be necessary in order for a patient to understand which exercises are indicated at what moment and how these should be performed. In addition, a certain level of motor skills was described to be beneficial, as some people are more in contact with their face and can coordinate facial movements more easily.
The therapists did not state that therapy would fail in case the patient’s intelligence or motor skills were found lacking. They would then proceed to adapt their ther-apeutic and educational strategies to fit the specific needs of that patient. For some patients, they simplified exercises or adjusted treatment goals. Some variations were seen in the extent to which the therapists indicated who is ultimately responsible for treatment success. One therapist went as far to state that it was solely her responsibility to make the therapy work, whereas other therapists took a coaching approach to mime therapy that included more responsibility for the patient.
Ultimately it is my responsibility to make sure someone is being treated correctly.
Other less frequently mentioned factors were age (both very young and very old patients were stated to be more difficult to treat); a good working relationship with the mime therapist; the patient’s personality; the experience of the mime therapist; a calm attitude of the patient; and a healthy lifestyle of the patient.
Emotional support
The importance of emotional support given by the mime therapist was a recurrent theme in the interviews. All mime therapists stated that emotional difficulties result-ing from facial palsy are a topic of discussion durresult-ing the consultation. However, all mime therapists also stated they are not trained psychologists. When a patient’s psy-chological burden is too high, the patient will be referred
to a psychologist. Clear differences in the extent of psy-chological involvement were present. Some mime thera-pists reported that emotional support for facial palsy patients is inseparable from the therapy itself, while others clearly stated that their primary focus is solely on the actual therapy and not on emotional support.
I feel that I should be open to [emotional support] I do not go too deep into psychological support myself. That is not what I am trained for.
Cooperation with colleagues
Because relatively few patients are treated with mime therapy, therapists who had a colleague working along-side them perceived this as pleasant. Others formed loco-regional teams to discuss difficult patients with someone outside their own organization. A few mime therapists worked together with physicians in the treat-ment of facial palsy patients. They described this rela-tionship as beneficial. The mime therapists without collegial support stated that this was generally not an issue because they could always discuss certain issues with the coordinator of the mime therapy course.
Quantitative Study
A total of 292 mime therapists were identified and invited to participate in the online questionnaire. After two reminder e-mails, 148 mime therapists (51%) responded, resulting in 106 fully completed question-naires. Of 21 questionnaires, sufficient data were present to perform multiple imputation (> 80% complete). A further 21 questionnaires were assessed as being too incomplete and were not used.
The vast majority of the 127 mime therapists included in this study were women (n = 117 (92%)). Median (IQR) age of the therapists was 43.8 years (36.9; 52.1), and the majority lived in the Netherlands (n = 106 (84%)). Most mime therapists completed a bachelor- level program and did not work in a hospital setting. The mime therapists treated between 1 to 180 new facial palsy patients per year (median = 6) (Table 1).
Identification of classes
A 2-class model was best fitting according to the BIC, whereas the AIC showed better a fit for a 3-class model. The 2-class structure had the highest entropy, indicating it had the best class separation. Based on the entropy, BIC, and clinical interpretability, a 2-class structure was chosen (Table 2).
Questionnaire questions and the answers of both classes are presented in Table 3 and Figure 2,
respectively. Class 2 generally gave higher scores or more positive answers to almost all questions from the questionnaire, compared with class 1 (Figure 1). Question 14 (“How much time do you spend on emo-tional support of your mime therapy patients?”) was the only exception, as class 2 stated that they spend less time on emotional support compared with class 1.
Association of classes with therapist characteristics
Therapist characteristics and work-related characteris-tics did not differ statistically significantly between both classes (Table 1). Therapists in class 2 did obtain a Master of Science degree more often (36.7% versus 23.0%), while physical therapists and speech and lan-guage therapists in the Netherlands commonly have a Bachelor of Science degree. Also, class 2 therapists had more experience regarding patient load (median 8.0 versus 5.5 new patients a year) and practiced mime therapy for a longer period of time (29.7% of class 2 practiced mime therapy training for more than 10 years versus 11.5% of class 1). Class 2 also worked in a university medical center more often (24.8% versus 3.8%), and a larger number of class 2 therapists valued working together with another professional (73.3% ver-sus 57.7% for therapists, and 71.3% verver-sus 61.5% for physicians).
Discussion
This study aimed to explore the attitudes and percep-tions of mime therapists regarding their work and to see whether groups of therapists could be identified that exhibited different views on facial rehabilitation therapy. Hypothetically, these differences in attitudes and per-ceptions could lead to differences in treatment, which suggests that treatment outcomes may also vary.
Analysis of the in-depth interviews led to the identi-fication of 7 major themes, some with more varying opinions between therapists (e.g. emotional support) than others (e.g. indications). As stated before, it was difficult to gain an in-depth understanding of the actual therapy practices because the therapists stated that these are highly individualized. However, several interesting findings resulted from the interviews. A certain level of intelligence and motor skills of patients was stated to be beneficial to treatment outcomes. Therapists said that they would adapt their therapies to the level of the patient, and sometimes this meant actually simplifying the exercises. Although it is not known whether this simplification changed the therapy outcomes for these patients, these outcomes and the methods to increase understandability of the therapy should be a topic of
future research to ensure all patients receive the best treatment. The extent to which therapists offered emo-tional support varied significantly between therapists. A relationship between emotional support and treat-ment outcomes has not yet been established; however, it is plausible to suggest that emotional support
influences the patient-therapist relationship and therapy adherence, among others. In general, very little is known about the psychological guidance of patients with facial palsy and the role of the therapist therein, making it a highly relevant topic for future studies. This was also corroborated by the mime therapists, who expressed a need for more research into this specific field during the interviews.
To generalize the qualitative findings, a questionnaire was created and sent to all registered mime therapists in the Netherlands and Flanders. From the LCA, a 2-class structure was found to best describe the data: class 2 generally gave higher scores or more positive answers compared with class 1. This indicates that those thera-pists expressed a more positive view toward the indica-tions for, and the importance and effectiveness of mime therapy. No significant differences were found in perso-nal and work-related characteristics, although it was noteworthy that class 2 therapists were more experi-enced and possibly more specialized. Differences between experienced and more inexperienced physical therapists in patient education practices have been described previously and could theoretically influence treatment outcomes (Forbes, Mandrusiak, Smith, and Russell, 2017). Studies comparing treatment results of experienced therapist and more inexperienced therapists could provide additional information.
The current study is the first to research the attitudes and perceptions of mime therapists regard-ing facial rehabilitation therapy and the possible differences therein. This study has, however, some limitations. The first limitation concerns the sample size. Although 292 therapists were invited to parti-cipate, only 127 questionnaires were collected, despite having sent out 2 reminders. This could imply a selection bias if the therapists that did not respond formed a distinct group that is now not included in the study. Therapists who treat very few facial palsy patients might not have felt the need to participate, which means that views of the more inexperienced therapists could be partially missing. Therapists with a very busy practice might
Table 1. Comparison of therapist and work-related characteris-tics between the total sample and the two classes of latent class analysis. Total sample (n = 127) Class 1 (n = 26) Class 2 (n = 101) p-value Sex (n (%)) 1.000† Male 10 (7.9) 2 (7.7) 8 (7.9) Female 117 (92.1) 24 (92.3) 93 (92.1) Age (median (IQR)) 43.8 (36.9;
52.1) 40.9 (33.7; 51.8) 44.8 (37.3; 52.4) 0.264‡ Country (n (%)) 1.000† Netherlands 106 (83.5) 22 (84.6) 84 (83.2) Belgium 21 (16.5) 4 (15.4) 17 (16.8) Education (n (%)) 0.390† BSc (University of Applied Sciences) 84 (66.1) 20 (76.9) 64 (63.4) MSc (University of Applied Sciences) 14 (11.0) 1 (3.8) 13 (12.9) MSc or PhD (University) 29 (22.8) 5 (19.2) 24 (23.8) Time of training (n (%)) 0.168§ <5 years ago 43 (33.9) 10 (38.5) 33 (32.7) 5– 10 years ago 51 (40.1) 13 (50.0) 38 (37.6) >10 years ago 33 (26.0) 3 (11.5) 30 (29.7) Work setting (n (%)) 0.792† Non-hospital affiliated 51 (40.1) 12 (46.2) 39 (38.6) General hospital 33 (26.0) 6 (23.1) 27 (26.7) University Medical Center 26 (20.5) 1 (3.8) 25 (24.8) Other* 17 (13.4) 7 (26.9) 10 (9.9) New patients (n (%)) 0.813§ <1/month 38 (29.9) 7 (26.9) 31 (30.7) >1/month 89 (70.1) 19 (73.1) 70 (69.3) New patients/year (median (IQR)) 6.0 (3.0; 24.0) 5.5 (2.0; 15.0) 8.0 (3.0; 24.0) 0.140‡ Colleague mime therapist (n (%)) 0.151§ Yes 89 (70.1) 15 (57.7) 74 (73.3) No 38 (29.9) 11 (42.3) 27 (26.7) Other colleague (n (%)) 0.349§ Yes 88 (69.3) 16 (61.5) 72 (71.3) No 39 (30.7) 10 (38.5) 29 (28.7)
* Including rehabilitation centers and nursing homes; † Fishers exact test; ‡ Mann Whitney U test; § Pearson Chi-squared test
Abbreviations: BSc – Bachelor of Science; IQR – interquartile range; MSc – Master of Science; n – number.
Table 2. Latent class structure selection.
Class prevalence # of classes BIC*† AIC*† Entropy*‡ BLRT*§ VLMR*§ 1 2 3
1 17,090.53 16,993.83 n/a n/a n/a 100%
2 17,029.35 (16,994.70; 17,056.07) 16,875.77 (16,841.12; 16,902.49) 0.905 (0.863; 0.927) 158.06|| (142.99; 169.02) 158.06ns (142.99; 169.02) 21% 79% 3 17,063.55 (17,028.81; 17,090.10) 16,853.08 (16,818.34; 16,879.63) 0.797 (0.761; 0.909) 62.63# (45.39; 102.10) 62.63ns (45.39; 102.10) 20% 42% 38% * Mean (min; max) values based on 20 imputations; †Lower BIC and AIC indicate a better fit; ‡A model with a higher entropy is considered to have better class
separation; §Significant BLRT and VLMR indicate that the “K class” model is better than the “K-1 class” model; || p < 0.001; # p < 0.05; AIC – Akaike information
criterion; BIC – bayesian information criterion; BLRT – bootstrap likelihood ratio test; NS – not significant; VLMR – Vuong–Lo–Mendell – Rubin likelihood ratio test.
have lacked time to participate, which means that views of the more experienced therapists could also be missing. Furthermore, with only 127 participants the strength of our LCA was limited, and structures with more than 3 classes could not be investigated. Multiple imputation was performed to make use of all the data present. This allowed for the inclusion of the answers of 21 therapists who only completed part of the questionnaire, even though multiple imputation does introduce imputation uncertainty to the data.
The interpretation of the 2-class structure was rather difficult. If both classes would have answered some questions very differently and other questions
very similarly, the class identification could have been more easily attributed to the questions answered differently by both classes. In this study, class 2 gave higher scores/more positive answers to all questions compared with class 1. As mentioned before, this answering pattern can imply that thera-pists in class 2 had a more positive view on mime therapy in general. This was also apparent from the interviews, in which some therapists were more positive about treatment outcomes than others. However, this cannot exclude the fact that our find-ings to some extent represent an underlying response tendency not related to actual beliefs or practices of the therapist.
Table 3. Developed questionnaire regarding mime therapy.
Treatment goals
1 What is the most important goal of mime therapy according to you? (0) Restoring symmetry of the face (both static and dynamic) (1) Improving expression of emotions
(2) Learning to live with facial palsy
Content of therapy
2 You are contacted by a otolaryngologist who has seen a 55-year old male patient today. The patient woke up yesterday with complete facial paralysis, and the otolaryngologist diagnosed the patient with Bell’s palsy. He has contacted you because he would like to know whether you can do something for this patient, and, if so, when you would like to see him.
(0) You would prefer to see the patient within a week
(1) You would prefer to see the patient when he starts to develop synkinesis
3 You see a 61-year old woman. Three years ago she experienced sudden facial paralysis, diagnosed as Ramsay-Hunt syndrome. Over the past three years, massive facial synkinesis developed. What do you consider most important in treating this patient?
(0) Relaxation and massage (1) Controlled coordination exercises
4 Providing information about compensation techniques (e.g., manual support of the lower lip while drinking or information about protection of the eye) is part of mime therapy.
(0) Absolutely disagree – (100) Absolutely agree
5 Exercise therapy is the most important element of mime therapy. (0) Absolutely disagree – (100) Absolutely agree
6 Speech and voice exercises are an important element of mime therapy. (0) Absolutely disagree – (100) Absolutely agree
Indications
7 Mime therapy is indicated in flaccid facial paralysis. (0) Absolutely disagree – (100) Absolutely agree
8 Mime therapy is indicated in paresis.
(0) Absolutely disagree – (100) Absolutely agree
9 Mime therapy is indicated in patients with synkinesis. (0) Absolutely disagree – (100) Absolutely agree
10 Mime therapy is indicated in patients undergoing dynamic reconstruction of the smile.
(0) Absolutely disagree – (100) Absolutely agree
Factors influencing success
11 Mime therapy has a higher success rate in intelligent patients compared with less intelligent patients.
(0) Absolutely disagree – (100) Absolutely agree
12 If mime therapy is initiated early on, the final result is better.
(0) Absolutely disagree – (100) Absolutely agree Emotional support
13 I think emotional support is important in mime therapy.
(0) Absolutely disagree – (100) Absolutely agree
14 How much time do you spend on emotional support of your mime therapy patients?
(0) 0% of the consult – (100) 100% of the consult Cooperation with colleagues
15 How important is cooperation with another mime therapist for you with regard to facial palsy?
(0) Very unimportant – (100) Very important
16 How important is cooperation with a physician for you with regard to facial palsy?
(0) Very unimportant – (100) Very important
Measurement instruments
17 Regularly performing a measurement of facial function (e.g. Sunnybrook or House-Brackmann) is important for correctly performing mime therapy.
(0) Absolutely disagree – (100) Absolutely agree
18 Regularly administering a quality of life questionnaire (e.g. Facial Disability Index or Facial Clinimetric Evaluation scale) is important for correctly
performing mime therapy
The findings from the current study are not directly applicable to clinical practice. Instead, they should be seen as a means to generate hypotheses that contribute to further research in this field. Considerable variation in attitudes and perceptions of facial rehabilitation therapists was found; how-ever, it is not known whether these actually lead to different treatment choices and treatment effects. Participating observations would be necessary to study these phenomena, although these are extre-mely time-consuming. The exact magnitude of therapist’s influence on the improvement of facial function is not known. Prospective longitudinal fol-low-up studies that include multiple therapists in multiple centers are necessary to evaluate this effect.
Surprisingly, and contradictory to the findings from the interviews, the results from the question-naire suggest that therapists think that teaching the patients compensation techniques (e.g. manual sup-port of the lower lip while drinking) is more impor-tant than facial movement exercises. It can be hypothesized that this is because therapists are aware of the lack of information given to patients by their medical specialists, which means they will benefit greatly from such practical advice.
Also, quite a considerable number of therapists believe facial rehabilitation therapists can play a role in the treatment of patients undergoing dynamic reconstruction of the smile. To the best of our knowledge, the only published article claiming to show a beneficial effect of therapy in smile
reanimation surgery is a before-after study in 11 masseter-to-facial nerve transfer patients without a control group (Pavese et al., 2016). Additionally, a recent meta-analysis found a beneficial effect of physical therapy after smile reanimation in terms of the development of a spontaneous smile (unpub-lished data). Although we do recognize the benefi-cial effect of physical therapy from our own clinic, we believe a true RCT with random allocation of patients to therapy or a waiting list after surgery would be a great addition to the knowledge about therapy in facial palsy patients.
In a recent report describing the experience of patients undergoing nerve-to-masseter-driven smile rea-nimation, only about half of the patients acknowledged the importance and beneficial effect of physical therapy and self-reported adherence to the physical therapy plan (Van Veen et al., 2019). Some therapists stated that their connection with a patient could influence the results patients get from their treatments. In other types of physical therapy, adherence to treatment and treatment outcomes are known to improve when the therapist- patient relationship is good (Hall et al., 2010). It would be interesting to see whether adherence to therapy and therapy outcomes differ depending not only on the actual treatment but also on the connection between a therapist and patient.
Conclusion
Facial rehabilitation therapy is known to be beneficial in patients with facial palsy. Previous clinical studies were limited because they were either highly controlled or obser-vational studies of single therapists/institutions, which decreases generalizability. In both our interviews and ques-tionnaires, considerable variation was found in the percep-tions and attitudes of mime therapists regarding mime therapy and its content and effectiveness. This heterogene-ity among therapists could potentially result in different treatment approaches and outcomes. Future studies should therefore measure treatment outcomes of facial palsy reha-bilitation therapy involving multiple clinics and multiple therapists, and they should research the influence of the individual therapist on facial function recovery.
Acknowledgments
The authors would like to thank all the therapists that have taken the time to be interviewed and/or fill out the question-naire. We would also like to thank Sonja Hinzen for her language editing services.
Figure 2. Answering patterns of the questionnaire questions of the 2 classes. Left are the thresholds for the categorical answer-ing options, right are the mean values of the continuous answer scales. Red represents class 1, blue represents class 2. these findings indicate that class 2 therapists gave higher mean answers to all questions except for question 14 compared with class 1.
Disclosure statement
The authors have no conflicts of interest to disclose.
References
Archer KR, MacKenzie EJ, Bosse MJ, Pollak AN, Riley LH 2009a Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: Results of a national survey of orthopedic trauma surgeons.
Physical Therapy 899:893–905 10.2522/ptj.20080321.
Archer KR, MacKenzie EJ, Castillo RC, Bosse MJ 2009 LEAP
study group 2009b orthopedic surgeons and physical thera-pists differ in assessment of need for physical therapy after
traumatic lower-extremity injury,Physical Therapy
8912:1337–1349 10.2522/ptj.20080200.
Barbara M, Antonini G, Vestri A, Volpini L, Monini S 2010 Role of kabat physical rehabilitation in Bell’s palsy: A randomized trial.Acta Oto-Laryngologica 130:167–172 10.3109/00016480902882469.
Baricich A, Cabrio C, Paggio R, Cisari C, Aluffi P 2012
Peripheral facial nerve palsy: How effective is rehabilitation?Otology and Neurotology 337:1118–1126 10.1097/MAO.0b013e318264270e.
Beurskens CH 2003 Mime Therapy: Rehabilitation of Facial
Expression. Nijmegen, the Netherlands: Radboud
University Press.
Beurskens CH, Heymans PG 2003 Positive effects of mime
therapy on sequelae of facial paralysis: Stiffness, lip mobi-lity, and social and physical aspects of facial disability.
Otology and Neurotology 244:677–681 10.1097/00129492-
200307000-00024.
Beurskens CH, Heymans PG 2006 Mime therapy improves
facial symmetry in people with long-term facial nerve par-esis: A randomised controlled trial.Australian Journal of
Physiotherapy 523:177–183 10.1016/S0004-9514(06)
70026-5.
Braun V, Clarke V 2006 Using thematic analysis in
psychology.Qualitative Research in Psychology 32:77–101 10.1191/1478088706qp063oa.
Butler DP, Grobbelaar AO 2017 Facial palsy: What can the
multidisciplinary team do?Journal of Multidisciplinary
Healthcare 10:377–381 10.2147/JMDH.S125574.
Devriese PP 1994 Rehabilitation of facial expression (“mime therapy”).European Archives of Oto-rhino-laryngology 12: s42–s43
Forbes R, Mandrusiak A, Smith M, Russell T 2017
A comparison of patient education practices and percep-tions of novice and experienced physiotherapists in Australian physiotherapy settings.Musculoskeletal Science
and Practice 28:46–53 10.1016/j.msksp.2017.01.007.
Graham LA, Maddox TM, Itani KM, Hawn MT 2013
Coronary stents and subsequent surgery: Reported provider
attitudes and practice patterns.American Surgeon
795:514–523 10.1177/000313481307900528.
Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML 2010
The influence of the therapist-patient relationship on
treatment outcome in physical rehabilitation: A systematic
review.Physical Therapy 90:1099–1110 10.2522/
ptj.20090245.
Hamilton AS, Wu X, Lipscomb J, Fleming ST, Lo M, Wang D,
Goodman M, Ho A, Owen JB, Rao C, et al. 2012 Regional,
provider, and economic factors associated with the choice of active surveillance in the treatment of men with localized prostate cancer.Journal of the National Cancer Institute
Monographs 4545:213–220 10.1093/jncimonographs/lgs033.
Harper CC, Brown BA, Foster-Rosales A, Raine TR 2010
Hormonal contraceptive method choice among young, low-income women: How important is the provider?
Patient Education and Counselling 813:349–354 10.1016/j.
pec.2010.08.010.
Hohman MH, Hadlock TA 2014 Etiology, diagnosis, and
management of facial palsy: 2000 patients at a facial
nerve center.Laryngoscope 1247:e283–e293 10.1002/
lary.24542.
House JW, Brackmann DE 1985 Facial nerve grading system.
Otolaryngology–Head and Neck Surgery 932:146–147 10.1177/019459988509300202.
Jung T, Wickrama KA 2008 An introduction to latent class
growth analysis and growth mixture modeling.Social and
Personality Psychology Compass 21:302–317 10.1111/
j.1751-9004.2007.00054.x.
Kleiss IJ 2015 Assessment of Facial Function in Peripheral Facial Palsy. Nijmegen, the Netherlands: Radboud University Press.
Li L, Bombardier C 2001 Physical therapy management of
low back pain: An exploratory survey of therapist
approaches.Physical Therapy 814:1018–1028 10.1093/ptj/
81.4.1018.
Luijmes RE, Pouwels S, Beurskens CH, Kleiss IJ, Siemann I, Ingels KJ 2017 Quality of life before and after different
treatment modalities in peripheral facial palsy:
A systematic review.Laryngoscope 1275:1044–1051
10.1002/lary.26356.
Manikandan N 2007 Effect of facial neuromuscular re-
education on facial symmetry in patients with Bell’s palsy: A randomized controlled trial.Clinical Rehabilitation
214:338–343 10.1177/0269215507070790.
Mikhail C, Korner-Bitensky N, Rossignol M, Dumas J-P 2005
Physical therapists’ use of interventions with high evidence of effectiveness in the management of a hypothetical typical patient with acute low back pain.Physical Therapy
8511:1151–1167 10.1093/ptj/85.11.1151.
Myers EN, De Diego JI, Prim MP, Madero R, Gavilan J 1991
Seasonal patters of idiopathic facial paralysis: A 16-year
study.Otolaryngology-Head and Neck Surgery
120:269–271 10.1016/S0194-5998(99)70418-3.
Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N, Toda N, Sakamaki K, Kashima K, Takeda N, Sakamaki K,
et al. 2003 Biofeedback rehabilitation for prevention of
synkinesis after facial palsy.Otolaryngology- Head and
Neck Surgery 1284:539–543 10.1016/S0194-5998(02)
23254-4.
Nylund KL, Asparouhov T, Muthén BO 2007 Deciding on the
mixture modeling: A monte carlo simulation study.
Structural Equation Modeling 144:535–569 10.1080/
10705510701575396.
Paolucci T, Cardarola A, Colonnelli P, Ferracuti G, Gonnella R, Murgia M, Santilli V, Paoloni M, Bernetti A,
Agostini F et al. 2019 Give me a kiss! An integrative
reha-bilitative training program with motor imagery and mirror therapy for recovery of facial palsy.European Journal of
Physical and Rehabilitation Medicine 561:58–67 10.23736/
S1973-9087.19.05757-5.
Pavese C, Cecini M, Lozza A, Biglioli F, Lisi C, Bejor M, Dalla Toffola E 2016 Rehabilitation and functional recov-ery after masseteric-facial nerve anastomosis.European Journal of Physical and Rehabilitation Medicine 523:379–388
Pereira L, Obara K, Dias J, Menacho M, Lavado E, Cardoso J 2011 Facial exercise therapy for facial palsy: Systematic
review and meta-analysis.Clinical Rehabilitation
257:649–658 10.1177/0269215510395634.
Ross B, Nedzelski JM, McLean JA 1991 Efficacy of feedback training in long-standing facial nerve paresis.Laryngoscope
1017:744–750 10.1288/00005537-199107000-00009.
Ross BG, Fradet G, Nedzelski JM 1996 Development of
a sensitive clinical facial grading system.Otolaryngology-
Head and Neck Surgery 1143:380–386 10.1016/S0194-
5998(96)70206-1.
Segal B, Hunter T, Danys I, Freedman C, Black M 1995
Minimizing synkinesis during rehabilitation of the
paral-yzed face: Preliminary assessment of a new
small-movement therapy.Journal of Otolaryngology
24:149–153
Van Landingham S, Diels J, Lucarelli M 2018 Physical therapy
for facial nerve palsy: Applications for the physician.
Current Opinion in Ophthalmology 295:469–475 10.1097/
ICU.0000000000000503.
Van Veen MM, Dusseldorp JR, Quatela O, Baiungo J,
Robinson M, Jowett N, Hadlock TA 2019 Patient
experience in nerve-to-masseter-driven smile
reanimation.Journal of Plastic, Reconstructive and
Aesthetic Surgery 728:1265–1271 10.1016/j.
bjps.2019.03.037.
VanSwearingen JM, Brach JS 1996 The facial disability index:
Reliability and validity of a disability assessment instrument
for disorders of the facial neuromuscular system.Physical
Therapy 7612:1288–1300 10.1093/ptj/76.12.1288.
Appendix 1 – Interview guide
Background
● Age
● Education/training
● Career path
● Description of work setting + facial palsy patient workload
General
● What is mime therapy?/What does mime therapy consist
of?
● Work mechanism mime therapy
● Indications?
○ Chronic versus acute paralysis ○ Flaccid versus non-flaccid paralysis ○ Smile reanimation surgery
● Botulinum toxin treatment
Mime Therapy Practice
● How to determine the exact treatment?
○ Different therapy for different types of palsy (e.g. flaccid versus synkinetic)?*
○ Changes in practices during your career path?*
● Intensity treatment? Time & frequency
○ How do you define when the therapy is completed?*
● Importance of education
○ How do you measure progress (e.g. sunnybrook, ques-tionnaires, etc)?*
Other
● Difference with other types of facial rehabilitation
therapy
● Electrostimulation/EMG/acupuncture or other
techniques?
○ E-modules/video programs?*
Other therapists (preferably with a divergent view toward mime therapy)
*Additional topic that was added to the interview guide during the interview process.
