Julie Penfold gets under the skin of facial therapy, a physio specialism with particular rewards
As an advanced specialism of physiotherapy, facial therapy is the rehabilitation and treatment of injuries and conditions affecting the face, including the muscles and nerves. Facial therapists are qualified physiotherapists and work within multidisciplinary teams.
Sally Glover is a clinical specialist physiotherapist and is based at Queen Elizabeth Hospital Birmingham, part of University Hospitals Birmingham NHS Trust. She specialises in facial palsy rehabilitation and the treatment of movement disorders, including dystonia. Ms Glover is part of the lead team for the hospital’s facial palsy and movement disorder services and works across the ear, nose and throat (ENT) and neurology departments. She has provided botulism toxin as part of treatment for facial palsy and movement disorders since 2008.
‘When I look at the face, I don’t see the skin on the surface – I see the muscles underneath
Queen Elizabeth is a major trauma centre and hosts the Royal Centre for Defence Medicine, treating all seriously injured British military personnel. Ms Glover is involved in the treatment of a wide range of injuries and conditions affecting the face and body.
‘We receive around 100 referrals a month, mainly for patients with movement disorders, facial conditions and neuromuscular disease,’ says Ms Glover. ‘We also see a number of facial trauma injuries including knife attacks, gunshot wounds and sometimes shrapnel injuries. Facial nerve tumours are a particular skill of the team here. We also treat acoustic neuromas, road traffic accident trauma, head injuries and cholesteatomas [benign tumours of the inner ear], which are a speciality for the ENT team. In terms of movement disorders, I mainly treat dystonia and this can occur anywhere from face to foot. I can inject from head to toe. Patients can have focal dystonia within the face, upper limb, trunk or lower limb.’
Movements made by facial muscles
- raising the eyebrows
- wrinkling nose
- lifting top lip
- open and closed mouth
- closing the eye
- pulling lower lip down
- sticking bottom lip out
- pulling jaw and corners of mouth down gently
Making the news
As a renowned major trauma centre, the Queen Elizabeth team also treats international patients. Ms Glover’s facial work was featured on BBC Panorama in 2013 as a result of a world-famous patient. When Nobel laureate Malala Yousafzai came to Britain from Pakistan, aged 16, for urgent treatment after a Taliban ambush, Ms Glover was involved in her post-operative care. ‘It took around two years to get the best recovery for Malala,’ Ms Glover says. ‘Her facial nerve was reconstructed slightly differently as the gunshot wound had destroyed a lot of her inner ear. It was a technique the surgery team had not used before and it has been used since with good effect.’ (To find out more, see our previous news story on Malala.
Ms Glover’s interest in facial therapy developed following training on the Bobath concept, an approach to neurological rehabilitation. At the time, she was working on a stroke unit and found the facial aspect of stroke was often overlooked. ‘The more I developed my facial handling and mobilisation skills, the more passionate I became about restoring facial expression as well as function,’ she says. When she moved to the Birmingham in 1994 as a band 7, Ms Glover took over the facial palsy service from a fellow physiotherapist who was leaving the trust.
‘I was lucky enough to have my own facial palsy clinic from day one,’ Ms Glover explains. ‘I worked on GP patient referrals for Bell’s palsy and post-operative acoustic neuroma patients. I saw five patients in my first year. We now see over 160 patients a year from all over the UK. I am supported by an amazing team of physiotherapists and physiotherapy assistants. The neuroscience outpatient physiotherapy service has grown from just me to a team of 10.’
Ms Glover worked on her own, delivering the facial palsy service, until 1998 when she began working with an ENT consultant, Richard Irving, who had a particular interest in facial nerves. Six years ago, a multidisciplinary facial palsy clinic was formed along with consultant plastic surgeon Demetrius Evriviades. ‘Mr Irving and Mr Evriviades and I all see patients together,’ she says. Two years ago, the team was extended with a second ENT consultant, plastic surgeon and physiotherapist. ‘We now have two clinics running side by side, a weekly and fortnightly clinic. I think we are the only team that sees patients together with input from a surgeon, ENT consultant and physiotherapist.’
The movement disorder clinic has two consultant neurologists, a clinical nurse specialist and a physiotherapist. ‘We work as a team,’ Ms Glover says. ‘We have clinics alongside each other and work together to discuss any concerns. It is great to have such an open working environment where there is no professional hierarchy.’
Ms Glover says that her photographic memory enables her to assess patient movement in an unusual way. ‘The real skill of facial therapists is understanding the dynamic activity of the muscles during expression,’ she explains.
It’s the same when I treat movement disorders. I can transpose that picture of anatomy straight on to the patient to assess what’s not moving and what is overactive.
‘I tend to deal with the most complex patient cases, those that require long-term rehabilitation over two years. I do miss the acute side sometimes,’ she admits. ‘The complexity of cases is most challenging, both physically and psychologically. However, the patient feedback and the results that we get are most rewarding. If patients are really compliant with their treatment programme, they do incredibly well.’
Sally Glover is a co-founder of Facial Therapy Specialists-UK (FTS-UK)
Sally Glover’s tips
How do I learn more?
Get yourself on to an introduction to facial rehabilitation FTS-UK training course. Additionally, I would advise working with someone who has a particular interest in facial therapy. Catriona Neville and I would welcome physiotherapists to come and work with us and observe.
With faces, you have to know your anatomy well to understand how expression is created. You will also need to learn how to look at the face as you are talking to a patient so you can assess how their face moves without being intrusive.
You have to engage and motivate patients. And making people believe they can get back to normal is quite a big part of our role. As physiotherapists, we develop a certain amount of counselling skills over time. This is especially the case in neurology as some of the diagnoses are incredibly sad. Even if a patient’s face is slightly different, it’s vital to help them realise that no one really has a perfectly symmetrical face.
None. You can do facial therapy from day one, although you may find it a little daunting. An interest in the face is key.
Dedicated neuroscience outpatient services are dwindling. However, we hope to introduce a facial palsy NHS pathway as we feel every emergency department should provide specialist care. It’s something we’re looking at as it would mean job openings for facial therapists. You wouldn’t necessarily have a facial palsy service but emergency departments would have a team member with experience in how to treat facial palsy. We hope that over time there will be more clinical commissioning group (CCG) funding for facial palsy services throughout the UK. We are looking into all CCGs across the UK to find out why some do and some don’t fund these services. Our aim is to build on that and to fund more facial rehabilitation services.
Facial Therapy Specialists-UK www.fts-uk.org
Facial Therapy Specialist-UK (FTS-UK) is a membership organisation for therapists specialising in facial palsy. It promotes best practice and provides a peer support forum and multidisciplinary training courses. FTS-UK was set up by Sally Glover, Lorraine Clapham, a specialist neurological physiotherapist at Southampton General Hospital, Catriona Neville, an extended scope practitioner physiotherapist at Queen Victoria Hospital NHS Trust in West Sussex and Vanessa Venables, an advanced speech and language therapist at the Queen Victoria trust. FTS-UK will host the International Facial Therapy conference in Birmingham in October.
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