Clinical

The use of mime therapy as a

rehabilitation method for
patients with facial nerve paresis
Carien HG Beurskens, Pieter P Devriese, Ide van Heiningen, Rob AB Oostendorp

Since 1980, patients with sequelae of peripheral facial nerve paresis have been treated with mime therapy at
the physiotherapy department of the University Medical Centre in Nijmegen, which aims to rehabilitate facial
expression. Mime therapy was developed by Jan Bronk (a mime actor) and Pieter Devriese (an
otolaryngologist) in the 1970s, using the principles of mime for patients suffering from either lack of facial
movement or uncontrolled movements. Both therapists and patients reported benefits of mime therapy;
most importantly, an improved symmetry of the face.
There is a belief within the profession that evidence-based treatment is required to scientifically
substantiate physiotherapy. A detailed description of the mime therapy treatment is essential for performing
a randomized controlled trial, which is currently underway.
This article aims to comprehensively describe the historical development and clinical characteristics of mime
therapy and to give insight into its usefulness as a tool in the treatment of patients with facial nerve paresis.
Key words: facial nerve paresis, mime therapy, physiotherapy
Beurskens CHG, Devriese PP, van Heiningen I, Oostendorp RAB (2004) The use of mime therapy as a rehabilitation
method for patients with facial nerve paresis. Int J Ther Rehabil 11(5): 206–10

T
o date, more than 1000 people with trauma or other causes. In 1974, they explored the
facial nerve paresis have been success- possibilities of mime with patients. A treatment plan
fully treated with mime therapy in was devised, consisting of a series of exercises, with
Nijmegen, the Netherlands. The House- most patients receiving individual treatment. Patients
Brackmann scale (House and Brackmann, 1985) started therapy after a minimum of 1 year following
Carien HG Beurskens
is Physiotherapist, and a more detailed grading system – the later onset of the paralysis, as sequelae had to be stable.
Department of Sunnybrook Facial Grading System (Ross et al, From 1977 to 1979, 24 patients were treated.
Physiotherapy, University 1994) – are used as outcome measures. These Initially, mime therapy consisted of massage of
Medical Centre, 6500 tools have shown that facial symmetry at rest and the face and neck, breathing and relaxation exer-
HB Nijmegen, the
during movements improves and synkinesis cises, exercises to coordinate both halves of the face
Netherlands, Pieter P
Devriese is decreases after mime therapy. and expression exercises. The conceptual basis of
Otolaryngologist, Ear mime therapy in the 1970s was that when facial
Nose and Throat THE HISTORY OF MIME THERAPY expressions are damaged, it is essential to mobilize
Department, Academic the whole body to re-facilitate emotional and com-
Medical Centre, the
In 1975, the Department of Facial Research at the municational possibilities. Massage, breathing and
Netherlands, Ide van
Heiningen is Mime Wilhelmina Gasthuis in Amsterdam introduced a relaxation exercises will relax the whole body,
Artist, Dutch Mime film entitled Peripheral Facial Paralysis. Jan Bronk which will consequently relax the face.
Centre, the Netherlands (1927–1985), director of the Dutch Mime Centre, Coordination exercises will result in symmetry of
and Rob AB illustrated in this film the function of the mimetic the face, while other exercises are necessary tore-
Oostendorp is
muscles (Figure 1). This film, aimed at medical stu- educate expressive possibilities.
Physiotherapist,
Professor in Allied dents and doctors, emphasized the importance of In 1976, a report was given at the International
Health Care, University early examination and treatment of patients with Facial Nerve Symposium in Zurich on the first
Medical Centre, the facial nerve paralysis, or paresis. During the making experiences of treating patients with facial paresis
Netherlands of this film, Jan Bronk and otolaryngologist Pieter (Devriese and Bronk, 1977). The year 1981 saw the
Devriese came into contact with each other. publication of a booklet giving details of mime ther-
Correspondence to:
Carien HG Beurskens It occurred to Bronk and Devriese that mime apy, which had to be revised several times and trans-
c.beurskens@fysioth. might help in rehabilitating patients with an lated into English (Devriese and Bronk, 1981;
umcn.nl impaired facial expression as a result of Bell’s palsy, Beurskens et al, 1988; Devriese et al, 1998).

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WHAT IS MIME?
Mime is a performance art based on non-verbal
expression. The best-known form of mime is pan-
tomime and may be compared to figurative painting
– the picture tells the story. The best-known pan-
tomime players are the masked players of Greek
antiquity, the actors of the 16th Century Commedia
dell’Arte, the great silent film actors and Marcel
Marceau. The movements used in mime are dis-
tilled from reality. Real life is analysed and inter-
preted as new theatrical signs and images. Mime
demands a highly refined control of the body.
MIME CORPOREL
A new form of mime – mime corporel, was founded
by Etienne Decroux (1987). The body and movement
analysis in mime corporel is fundamentally different
from that of the medical world. Whereas practitioners
such as physiotherapists analyse the body in terms of
its anatomical structure and relate movement to func-
tion, mime corporel analyses the body and its move-
ments entirely in terms of expression possibilities in
space. The basic principles of mime corporel are:
■ Movement is rhythm of the body in space and time
■ The essence of movement is made visible by
exaggerated movements.
To perform, the mime artist has to learn to ‘isolate’
and to ‘articulate’, respectively to move and to
emphasize, specific movements.
DEVELOPMENT OF MIME THERAPY
Jan Bronk took the analysis of Decroux a step fur-
ther. As a teacher at the mime school, he developed
the analytical principles into a teaching model. In
addition, he adapted mime for a wider social appli-
cation and was especially interested in its possibili-
ties in the area of health care. He developed a way
of working using functioning capabilities to help
activation in less well functioning areas. He also
made an analysis of the face, especially emotional
expressions, in order to help patients with facial
nerve paresis.
In analysing the face, it is not possible to consider
an expression as a separate entity as every facial
movement, however slight (or even an absence of
movement), results in an expression of some kind.
Analysis using the principles of mime corporel
includes:
■ Breathing. Facial expression is a part of a total
‘mood’ reflected in the body. The impairment of
facial expression will be reflected by tension
elsewhere in the body. Breathing will reduce
tension.
■ Articulation – i.e. helping to prevent differing
expressions becoming mixed up. Mime teaches
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the expressive possibilities of movement normally
occurring unconsciously. For example, the mouth
corner can be pulled down extremely fast, which
gives a completely different expression than that
caused by allowing the mouth corner to drop
gradually.
■ Alertness and awareness of the direction of
movement. The direction can be towards or away
from the body, displaying different emotions.
■ Expression. Mime is an art of movement and an
art of communication. The purpose of mime is to
deepen the individual’s capacity for non-verbal
communication.
Physiotherapy and mime therapy
In 1980, after being trained by Jan Bronk, physio-
therapists began to treat patients. They were moti-
vated to learn mime therapy as results of other
treatments were dissatisfying (Beurskens et al,
1994). Specific items were elaborated, such as
stretching of facial muscles, the inhibition of synki-
neses by counteracting movements and coordina-
tion exercises between the affected and normal side
of the face. The medical history and anamnesis
were improved by the introduction of standardized
intakes. Measurement instruments were used, which
were necessary for objectifying the sequelae of the
paresis and for evaluating the therapy.
On 11 January 1985, Jan Bronk died at the age of
57 years. After his death, the first two trained phys-
iotherapists continued to give courses. A grant in
Figure 1. Jan Bronk,
illustrating the mimetic
musculature (drawn in red)
and the facial nerve (in
yellow).
207
 Clinical
1990 made it possible to start a mime therapy
course for 18 paramedics, given by eight teachers
from various disciplines. The course leads to clini-
cal specialization in treating patients with peripheral
facial paresis. The names of the mime therapists
(physiotherapists and speech therapists) who have
followed the course are included in a register.
MIME THERAPY TODAY
The aim of mime treatment is to promote symmetry
of the face at rest and during movement; the patient
being simultaneously taught to control synkineses.
This will result in reduced stiffness and increased
emotional readability. On a disability level, it results
in fewer problems with eating, drinking and speak-
ing, and on a health level it promotes wellbeing and
improves participation in social activities. Mime
therapy nowadays consists of:
■ Anamnesis, patient information about treatment
and prognosis
■ Self-massage of face and neck
■ Breathing and relaxation exercises
■ Specific exercises to coordinate both facial
halves and to decrease synkineses
■ Eye and lip closure exercises
■ Letter and word exercises
■ Expression exercises (Devriese et al, 1998).
The average number of treatment sessions is ten
(each session lasting approximately 45 minutes) and
the patient attends once weekly or less. Follow-up
treatment is usually planned after 3 or 6 months.
The therapy is composed of sequentially structured
exercises. Patients have to complete homework on a
daily basis, helped by a homework book.
Nowadays, owing to new insights and experience,
mime therapy starts when degeneration is visible
(synkinesis). This can be after 3 months following
onset of the paralysis. A mirror is used as feedback
instrument, as it is necessary to see how exercises
are performed and whether synkinesis is present
when treatment is started.
Anamnesis, patient information about treatment
and prognosis
Often patients referred for physiotherapy have
received a minimum amount of information
regarding prognosis, treatment possibilities and
coping with their problems. The first treatment
session is used to explain the cause, course and
prognosis. To objectify the actual situation of the
facial paresis, the Sunnybrook Facial Grading
System, the House-Brackmannn scale and the Facial
Disability Index (VanSwearingen and Brach, 1996)
are used. Photos and/or videos of the patient at rest
and making five facial expressions are made. The
patients also receive information regarding mime
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therapy, the necessity of doing homework and the
integration of exercises into daily life.
Self-massage
Patients are taught to massage their face and neck
daily for about 10–15 minutes, to relax the facial
musculature and promote circulation. Massage
involves knowing one’s own face and discovering
which areas have reduced or heightened tension. It
consists of effluerage and massage of both sides of
the face. Stretching exercises of the affected side
follow to relieve mimetic muscles involved in
synkinesis. Stretching is performed in a slow manner,
following the course of the muscles, with the thumb
of the heterolateral hand placed into the mouth on the
affected side and opposed to the fingers (Diels,
1995). In cases of lagophthalmos (inability to close
the eyelids fully), the upper eyelid can be stretched
for about 15 seconds (Aramideh et al, 2002).
Breathing and relaxation exercises
As a result of the facial nerve paresis, increased
muscle tone can be present not only in the face, but
in the whole body. In the presence of synkineses,
muscle tone is increased and stress will only further
this. From a holistic point of view, the mind does not
function separately from the body, thus relaxing the
face also requires relaxation of the body. Patients are
taught to recognize tension and to feel the difference
between tension and relaxation in general, especially
in the facial musculature. Relaxation exercises are
carried out as described by Schultz (1960).
Coordinating both facial halves and decreasing
synkinesis
This is done through:
■ Basic exercises with variation in amplitude and
speed
■ Exercises for one side of the face
■ Relaxation of the lower jaw
■ Exercises of the mouth (e.g. smiling, pouting)
and of the eye, with simultaneous inhibition of
synkinesis through slow, small movements and
counteraction (Figure 2).
These exercises will create an improved coordina-
tion between the two halves of the face, enabling
the patient to display facial movements and emo-
tions in a more symmetrical way.
Eye and lip closure exercises
These exercises are necessary when the eye does not
close properly. Exercises are performed with
variations in speed and force. Lip closure exercises
are necessary for eating, drinking and rinsing and
comprise exercises of the cheek (filling the cheeks
with differing amounts of air) and eating and
drinking exercises while keeping the eye open
 (small movements). Helping to create a better lip
closure enables the patient to feel better during
functional and social activities.
Articulation
These exercises are performed to increase the
patient’s awareness of lip movements and the posi-
tion of the mouth for various sounds. Vowels as a, e,
i and o and consonants such as p and b are used for
the position of the lips. Word exercises concentrate
on the correct position of the mouth. An increased
articulation will give patients more self-esteem dur-
ing communication.
Expression
Throughout the therapy, it is vital to try to develop a
conscious connection between the use of certain
muscles and facial emotional expression. Exercises
can be performed in two ways: working from the
use of certain muscles towards a mood, or working
from a certain mood as a starting point for a move-
ment. For example; the patient can be asked to raise
his or her forehead, or to perform an expression
depicting amazement.
Various moods may be evoked by asking the
patient to knit the brow, open the eyes wide, stick
out the lower lip or tighten the lips. These expres-
sive exercises can be used throughout the whole
mime therapy programme. Learning to use the
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facial muscles more consciously while expressing
emotions can help the patient to cope with the dis-
tressing after-effects of the paralysis.
PRESENT SITUATION
In the Netherlands, 200–250 patients are treated
yearly with mime therapy. Currently, there are
approximately 30 mime therapists working mainly in
an academic setting. Mime therapy courses are given
at the physiotherapy department of the University
Medical Centre in Nijmegen.
Nowadays, mime therapy can also be applied (in an
adapted way) for patients after a nerve and/or muscle
reconstruction (Beurskens et al, 1998). Besides plastic
surgery and psychological guidance, mime therapy is
available as a third modality to treat sequelae of facial
nerve paralysis. The authors feel that all three modali-
ties should be available in medical centres where
patients are referred (Devriese et al, 1998).
SUMMARY
Mime therapy is a promising treatment based upon
clinical reports and is predominantly used in the
Netherlands. Both therapists and patients report
positive changes in facial symmetry following Figure 2. (a) Synkinesis of
mime therapy. Evaluating patients who have under- the eye while pouting and
gone mime therapy in the past few years with the (b) inhibition of synkinesis.
a. b.
209
 Clinical

House-Brackmann scale reveals that most of them
improve by one grade.
Mime therapy is not yet implicated for patients
with neurological conditions such as stroke, owing to
the fact that central facial paralysis is associated with
many other problems (such as aphasia).
Physiotherapy for patients with stroke is more
focused upon other impairments and health prob-
lems, such as mobility of the upper extremities.
For an international introduction of mime therapy,
there has to be an evidence base. A randomized
controlled trial has just been completed at the
University Medical Centre in Nijmegan, studying
the effectiveness of mime therapy in correcting
facial asymmetry, disabilities in eating, drinking
and speaking and psychosocial problems. The
results of this study will provide evidence for the
efficacy of this treatment.
KEY POINTS
■ Elements of mime and physiotherapy are combined to create a new treatment
for patients with facial nerve paresis.
■ Emotional expression exercises are essential for patients with facial nerve paresis.
■ Mime therapy is a promising treatment based upon clinical reports.
■ Plastic surgery, psychological guidance and mime therapy should be available in
medical centres where patients with facial nerve paralysis are referred.
■ A randomized controlled trial is needed to give mime therapy an evidence base.
There is not much known about the working
mechanism of mime therapy – for example, is it
plasticity of the nervous system or a learning of
new motor skills? Further research has to be carried
out concerning this aspect. IJTR
Conflict of interest: none.
Aramideh M, Koelman JHTM, Devriese PP, Speelman JD,
Ongerboer de Visser BW (2002) Thixotropy of the levator
palpebrae muscle as the cause of lagophthalmus after peripheral
facial nerve palsy. J Neurol Neurosurg Psychiatr 72: 665–7
Beurskens C, Burgers-Bots I, Devriese PP, Idler J (1988)
Mimetherapie. Huisdrukkerij AZU, Amsterdam
Beurskens CHG, Oosterhof J, Elvers JWH, Oostendorp RAB,
Herraets MEJ (1994) The role of physical therapy in patients
with facial paralysis: state of the art. In: Stennert ER, ed. The
Facial Nerve. Proceedings of the VIIth International Symposium
on the Facial Nerve. Springer-Verlag, New York: 125–6
Beurskens CHG, van Rossum-Herraets MEJ, Manni JJ, Nicolai
J-PA (1998) Physiotherapy following a hypoglossal-facial
nerve interpositional jump graft. J Clin Rehabil 1: 37–45
Decroux E (1987) Words on Mime. 2nd edn. Ed Drama
Publishers, Seattle
Devriese PP, Bronk J (1977) Non-surgical rehabilitation of facial
expression. In: Fisch U, ed. Facial Nerve Surgery. Kugler
Medical Publications, the Netherlands: 290–4
Devriese PP, Bronk J (1981) Rehabilitation of facial expression.
Theoretical backgrounds and exercises. Huisdrukkerij AZU,
Amsterdam
Devriese PP, Beurskens C, Heiningen van I (1998) Rehabilitation
of facial expression by mime. Huisdrukkerij AZU, Amsterdam
Diels HJ (1995) New concepts in nonsurgical facial nerve reha-
bilitation. Otolaryngol Head Neck Surg 9: 289–315
House JW, Brackmann DE (1985) Facial nerve grading sys-
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Ross BR, Fradet G, Nedzelski JM (1994) Development of a sensi-
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(suppl): 180–1
Schultz IH (1960) Das Autogene Training. Thieme Verlag, Stuttgart
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COMMENTARIES

Neuromuscular facial retraining pro-
grammes are receiving more recog-
nition in the United States as a result
of evidence-based outcomes being
reported. However, the use of mime
therapy for facial nerve rehabilitation
is a lesser-known treatment
approach. After reviewing this arti-
cle, this approach sounds very
promising and worth a closer view.
The authors of this article did a
nice job of overviewing the histori-
cal development and providing a
thorough description of mime
therapy principles. The basis of
mime therapy is non-verbal com-
munication that can be used as a
communication art. Obviously,
non-verbal expression is extremely
important in facial nerve rehabilita-
tion. The overwhelming problem
voiced by this population is their
lack of normal facial expression.
The key points addressed in the
article in describing mime therapy
components were head and neck
massage, breathing and relaxation
exercises, coordination and expres-
sion exercises, letter and word exer-
cises and eye and lip closure
exercises. This programme sounds
comprehensive and definitely
addresses facial function, as well as
rehabilitation.
Mime therapy emphasizes facial
emotional expression, which is so
valuable in working with this popu-
lation. The use of mime therapy
may help the patient psychologi-
cally, because of the importance
placed upon the patient being in
touch with his/her face, mood and
expressions.
In the treatment of patients
with facial nerve paresis, many
appear depressed owing to their
change of facial function, expres-
sion and self-image. With mime
therapy, the patient may be able to
‘act out’ some of his or her emo-
tion and use this non-verbal com-
munication art as he/she develops
improved facial expression and
movement.
The article also included the use
of mime therapy for reduction of
synkinesis, through gentle, slow
stretches and exercises. Synkinesis
can greatly decrease normal facial
expression and should be
addressed in all facial retraining
programmes.
The use of universally recognized
facial grading scales to measure
progress, such as the House-
Brackmann and Sunnybrook
grading scales, helped to lend
further creditability to mime
therapy. Also, the inclusion of the
randomized controlled trial study
that is underway sounded encour-
aging for validating mime therapy
efficacy.
A barrier to this type of approach
may be the view of the health-care
community that mime therapy is
superfluous. But, the objectives of
mime therapy described in this arti-
cle and the ongoing research of this
type of intervention should help to
decrease criticism.
Mime therapy certainly sounds
like a treatment approach that
should be further investigated.
Gaye W Cronin
Director
Neuromuscular Facial Retraining
Program
Atlanta Ear Clinic
Atlanta
Georgia 30342
USA

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