Facial Plastic Clinic

Ear, Nose & Throat Journal

2020, Vol. 93(9) E11–E15
Mirror Book Therapy for the treatment ª The Author(s) 2020
Article reuse guidelines:
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of Idiopathic Facial Palsy DOI: 10.1177/0145561320913211
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Jodi Maron Barth, PT1, Gincy L. Stezar, PTA1, Gabriela C. Acierno, SPT1,
Thomas J. Kim, MS2, and Michael J. Reilly, MD2

Abstract
Objective: To determine the utility of treating facial palsy with mirror book therapy in conjunction with facial physical reha-
bilitation. Methods: We randomly selected and reviewed the charts of 25 patients with idiopathic facial palsy. 10 of these patients
received facial physical rehabilitation including manual therapy and postural exercises. 15 of these patients received mirror book
therapy in conjunction with standard facial rehabilitation. Before and after treatment, patients in both groups were rated using the
Facial Grading System (FGS) score, the Facial Disability Index–Physical (FDIP) score, and the Facial Disability Index–Social (FDIS)
score. Differences in response to therapy were analyzed. Results: Patients in the facial physical rehabilitation group without
mirror book therapy group showed on average a 20.8% increase in the FGS score, a 19% increase in the FDIP score, and a 14.6%
increase in the FDIS score. Patients in the mirror book therapy group showed an average of 24.9% increase in the Facial Grading
System (FGS) score, a 21.6% increase in the Facial Disability Index–Physical (FDIP) score, and a 24.5% increase in the Facial
Disability Index–Social (FDIS) score. Conclusion: The addition of mirror book therapy to standard facial rehabilitation treat-
ments does significantly improve outcomes in the treatment of idiopathic facial palsy.

Introduction Patients and Methods

The facial nerve has a long and tortuous course that predisposes
it to a broad range of injuries, illness, and inflammation, with
associated subsequent facial weakness. The incidence of facial
paralysis is estimated to be between 20 to 30 per 100,000 per
year in the United States.1-3
Bell’s palsy is an idiopathic, acute peripheral nerve palsy of
cranial nerve VII, and it is the most common cause of facial
nerve palsy. Cardinal signs include, but are not limited to facial
weakness, unilateral paralysis, xerophthalmia, xerostomia, and
dysgeusia. The cause is still unclear, but there studies suggest a
viral etiology in up to 79% of cases.4 Other known causes of
facial paralysis include Lyme disease, HIV infection, acoustic
neuromas, meningiomas, tumors, and trauma.5
Without intervention, 71% of idiopathic facial palsy patients
have a complete recovery after 1 year, 13% have a slight resi-
dual weakness, and 16% have fair to poor recovery.6 The
advantages of early intervention include increased patient edu-
cation in the disease process, proper eye care, and initial home
exercises. Given the likelihood of spontaneous recovery in
idiopathic causes of facial paralysis, the optimal treatment for
this condition remains controversial. The purpose of this retro-
spective review is to evaluate the usefulness of mirror book
therapy in conjunction with traditional rehabilitation therapy
for idiopathic facial palsy patients.
Forty-five patient charts were selected at random from a
pool of approximately 100 patients treated for facial palsy
between 1997 and 2008. This was done using a third-party
selector who was blinded as to the etiology of the condition,
treatment methods utilized, and the success of the patient’s
rehabilitation. Of the 45 patients, 25 were found to have
idiopathic facial palsy. These charts were selected out for
further review and statistical analysis. 15 of these patients
received a mirror book therapy treatment plan, while the
remaining 10 patients received standard facial rehabilitation
treatment consisting of neuromuscular re-education, mas-
sage, myofascial release, stretching, taping, and postural
training. Each of these patients received a personalized
1
National Rehabilitation Hospital, Regional Rehab, Rockville, MD, USA
2
Department of Otolaryngology, Georgetown University Hospital,
Washington, DC, USA
Corresponding Author:
Michael J. Reilly, MD, Assistant Professor, Facial Plastic & Reconstructive
Surgery, Georgetown University Hospital, Department of Otolaryngology—
Head & Neck Surgery, 3800 Reservoir Rd NW, 1st Floor Gorman Building,
Washington, DC 20007, USA.
Email: Mjr100@gunet.georgetown.edu

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E12 Ear, Nose & Throat Journal

Exercises

Mirror Book Instructions

Tips for Success 1. Raise eyebrows, holding for 2. Wrinkle nose, holding for
5 seconds, repeating 10x. 5 seconds, repeating 10x.
• Perform all exercises with natural effort.
• Do not force or exaggerate the expression.
• Before beginning an expression, think about it, visualize it, and then
perform the movement.

Get Started

1. Sit upright, maintaining good posture

2. Keep mirror at eye level. The mirror should be opened to a right angle with
your nose touching the outer edge of the mirror.

3. With both eyes open, look into the mirror with 3. Snarl, holding for 5 seconds, 4. Smile, holding for 5 seconds,
only the only the unaffected half of your face re repeating 10x. repeating 10x.
flecting back. For example, if the right side of the
face is the weaker side, the left side should be
looking in the mirror. You should see the
unaffected side of the face twice reflecting, giving
the appearance of a full face reflection.

4. Set a timer for 15 minutes and repeat the cycle of exercises.

5. When the timer goes off, you are done. Do not allow yourself to fatigue. If you
feel your face is tiring, stop.

Mirror Book Maintenance 5. Pucker lips, holding for 5 6. Show lower teeth, holding for
seconds, repeating 10x. 5 seconds, repeating 10x.
To preserve the integrity of your Mirror Book, avoid bending the book backwards.
Clean with a soft, damp cloth.

Figure 1. Mirror Book Therapy.

treatment plan designed by expert facial physical therapists.
While no plan was identical, the same methods were uti-
lized, in varying degrees, to best treat the palsy and help the
patient regain as much of his or her normal facial function
and characteristics.
Mirror book therapy is an adaptation from the mirror
box originally created by Ramachandran to treat phantom
limb pain and paralysis.7 Our version of this therapy uses a
bi-fold mirror to twice reflect the unaffected half of a
patient’s face, such that the patient sees a full, unaffected
face (Figure 1). The patient then performs a number of
facial expression exercises.
In the mirror book therapy group, average time between
onset of facial palsy and initiation of rehabilitative treatment
was 21.5 months (Table 1: Mirror Book Group and Non-mirror
Book group visits). In the standard rehabilitation group average
time between onset of facial palsy and initiation of rehabilita-
tive treatment was 15.7 months. In the mirror book therapy
group, patient treatment duration ranged from 2 to 19 sessions,
with a mean of 7.6 visits. In the standard rehabilitation group,
patient treatment duration ranged from 2 to 22 sessions, with a
mean of 9.1 visits. The mirror book therapy as well as the
various rehabilitation methods used in the standard rehabilita-
tion group are discussed below.
Results
The Sunnybrook Facial Grading System (FGS) Observational
Scale and the Facial Disability Index (FDI) were measured pre-
treatment and post-treatment. The FGS is assessed by the facial
physical therapist and the FDI is self-reported. Each of these
scales uses a 100-point score
The FGS scale is composed of three sections: resting pos-
ture, voluntary movement, and synkinesis (Figure 2). A higher
score indicates less impairment, and a lower score indicates
greater impairment. The reliability coefficients have been
shown to be  0.9.8 Construct validity and reliability have been
demonstrated for this scale.9
The FDI is a self-reported instrument for the assessment
of physical and psychosocial disability in patients with
facial nerve disorders (Figure 3). First described by
Van Swearingen and Brach, this score is split into two
subscales: physical and social (FDIP and FDIS
respectively).10
Barth et al E13

Pre-treatment, the average FGS, FDIP, and FDIS scores for
the standard rehabilitation group were 61.4%, 68%, and 74%
respectively. Pretreatment, the average FGS, FDIP, FDIS
scores for the mirror book therapy group were 53.1%, 70%,
and 73% respectively. After treatment, the average FGS, FDIP,
and FDIS scores for the standard rehabilitation group were
82.2%, 87%, and 88.6% respectively. After treatment, the aver-
age FGS, FDIP, and FDIS scores for the mirror book group
were 78%, 92%, and 98% respectively. For the standard reha-
bilitation group there was on average a 20.8% increase in the
FGS score, a 19% increase in the FDIP score, and a 14.6%
increase in the FDIS score. For the mirror book therapy group
there was on average a 24.9% increase in the FGS score, a
21.6% increase in the FDIP score, and a 24.5% increase in the
FDIS score (Table 2 & 3: Pre and Post-treatment FGS/FDIP/
Table 1. Mirror Book Group and Non-mirror Book group visits.
Mirror Book
Group
Mean duration between onset 21.5
and initial evaluation (months)
Mean number of visits 7.6
Range number of visits 2-19
FDIS measurements for mirror book therapy group/standard
rehabilitation group).
Discussion
The mainstay for nonsurgical treatment for facial palsy has
generally been physical rehabilitative therapy. Mirror bio-
feedback has been used in addition to standard physical
rehabilitation techniques,. Commonly known as ‘‘mime
therapy’’, mirror biofeedback therapy is linked to positive
outcomes in the treatment of idiopathic facial palsy.11-16
Mirror book therapy is based on a stimulus-response-control
hypothesis and allows the patient to visually appreciate the
return of muscle activity. By seeing the unaffected face per-
form the exercises in a normal manner, increased activity of
motor command pathways from the unaffected region are uti-
lized to supplement the damaged region. The psychological
Non-Mirror reinforcement from seeing their normal face provides patients
Book Group with additional motivation to perform their home exercise. This
new technique is a form of biofeedback that has been used in a
15.7
number of different studies.11-16
9.1 Unfortunately, the outcome measures used in each of the
2-22 studies have differed from the rest, rendering a meta-analysis
difficult to impossible. A recent systematic review on the use of

Sunnybrook Facial Grading System

Resting Symmetry Symmetry of Voluntary Movement Synkinesis
Degree of muscle EXCURSION Rate the degree of INVOLUNTARY MUSCLE
Compared to normal side
compared to normal side CONTRACTION assocaited with each expression

usclle nkiinesis

/
esis
Eye (choose one only)

nkin
0
ith

normal
s of

sy
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excu ement w

usclle iis

es
narrow 1
plete

scle nt
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es

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s ma sffiiguriin
or m t synkiin

viio
te

s
com ent almo

s mo ynkin

eyelid surgery
om

re m
mov to initia

1
rsion

ent

of on ATE: ob
i
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more
re m
ov

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os

ore
nt

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slliigh
tes m

Cheek (naso-labial fold) ss

tes s

plete
eme

eme

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ERE

0
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normal
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ER
Unab

LD:
Initia

Initia

absent 2
mo v

Standard
mild

M OD

of se
Mov

Mov

NON

gros
mas

SEV
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MIIL

less pronounced 1 Expressions

1 Brow lift (FRO) 1 2 3 4 5 0 0 1 2 3 0

more pronounced

Geltle eye
1 2 3 4 5 0 0 1 2 3 0
Mouth closure (OCS)
normal 0
Open mouth
corner drooped 1 Smile (SYG/RIS) 1 2 3 4 5 0 0 1 2 3 0
corner pulled up/out 1
Snarl
1 2 3 4 5 0 0 1 2 3 0
(LLA/LLS)
(LLA/
A LLS)
Total 0
Resting Lip Pucker 1 2 3 4 5 0 0 1 2 3 0
Symmetry score (OOS/OOI)
Total X 5 0
Asym Mild
Asym rate
y
Asym ross

y
Asym rmal
Asym vere
metr

metr

metr

metr

metr

0
e
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No
Mod

Total

Patient's Name
Voluntary movement score: Total X 4
0 Synkinesis score: Total
0

Diagnosis
Vol Resting
5/19/2020 mov't 0 - symm 0 - Synk 0 = Composite Score: 0
Date score score score

© 1992 Ross BG, Fradet G, Nedzelski JM

Sunnybrook Health Science Centre
Permission not required to produce unaltered

Figure 2. Facial Grading System Observational Scale (FGS).

E14 Ear, Nose & Throat Journal

Figure 3. FDIP/FDIS.

Table 2. Pre- and Post-treatment FGS/FDI measurements for mirror book therapy group.

Pre-treatment % Post-treatment % Change % P value 95% CI

FGS mean 53.1 78 þ24.9 <0.05 13.28 – 36.45

FDIP mean 70 92 þ22 <0.05 9.75 – 34.25
FDIS mean 73 98 þ25 <0.05 14.38 – 35.62

Table 3. Pre- and Post-treatment FGS/FDI measurements for standard rehabilitation therapy group.

Pre-treatment % Post-treatment % Change % P value 95% CI

FGS mean 61.4 82.2 þ20.8 <0.05 6.91 – 34.79

FDIP mean 68 87 þ19 <0.05 3.67 – 34.32
FDIS mean 74 88.6 þ14.6 <0.05 0.39 – 28.81

mirror book therapy in the treatment of idiopathic facial palsy
showed a significant improvement in functionality for the mir-
ror therapy group.17
There are drawbacks to the use of traditional exaggerated
normal facial movement exercises. They are non-specific
and can further reinforce abnormal movement patterns. This
could cause recruitment of excessive motor units producing
patterns that are atypical with facial activity. With the use
of mirror book therapy, a patient can see his or her own
facial movements. Thus, the patient can more effectively
use facial exercises to reinforce normal movement patterns.
In our study, we did not experience any deterioration or
worsening of the facial palsy in either group. The purpose
of our study was to add to the current literature on the
benefits of mirror biofeedback therapy using two well-
validated grading scales. The results of our study indicate
a clear benefit to including mirror book therapy within the
rehabilitation process of facial palsy patients. All three
grading scales showed a significantly greater increase in the
mirror book therapy group.
Barth et al
Of note, the mirror book therapy group had a signifi-
cantly greater increase in the FDIS scores as compared to
the FGS and FDIP scores. One reason for this may be that
the mirror book therapy had a greater benefit for the psy-
chological reinforcement of the patient. The FDIS is a sub-
jective measure of a patient’s social rehabilitation. It
measures whether or not a patient feels ‘‘calm’’, ‘‘peace-
ful’’, and other more psychosocial goals such as whether
one feels comfortable going outside in public. Mirror book
therapy would benefit patients much in the psychosocial
realm, as the treatment involves repeatedly seeing oneself
with a normal face through the mirror. Another reason for
this discrepancy may be that the different weighting indices
of each scale lead to a lower pre-treatment score with the
FGS. Regardless of the discrepancy, the improvement in
both scales was indeed found to be statistically significant.
Conclusion
Individualized facial rehabilitation therapy with the use of
mirror book therapy provides favorable results in the treat-
ment of facial palsy. There is still a dearth of randomized
controlled trials that clearly show a favorable benefit of the
mirror book therapy. Considering the low costs, and ease
of use of this therapy, we recommend including mirror
book therapy in the treatment of this condition.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
1. Yanagihara N.Incidence of Bell’s palsy. Ann Otol Rhinol Laryn-
gol Suppl. Nov-Dec 1988;137:3-4.
2. De Diego JI, Prim MP, Madero R, Gavilan J. Seasonal patterns of
idiopathic facial paralysis: a 16-year study. Otolaryngol Head
Neck Surg. Feb 1999;120(2):269-271.
3. Brandenburg NA, Annegers JF. Incidence and risk factors for
Bell’s palsy in Laredo, Texas: 1974-1982. Neuroepidemiology.
1993;12(6):313-325.
E15
4. Hato N, Murakami S, Gyo K. Steroid and antiviral treatment for
Bell’s palsy. Lancet. May 31 2008;371(9627):1818-1820.
5. Ropper AH, Adams RD, Victor M, Brown RH, Victor M. Adams
and Victor’s principles of neurology. 8th ed. New York: McGraw-
Hill Medical Pub. Division; 2005.
6. Peitersen E.The natural history of Bell’s palsy. Am J Otol. Oct
1982;4(2):107-111.
7. Ramachandran VS, Rogers-Ramachandran D. Synaesthesia in
phantom limbs induced with mirrors. Proc Biol Sci. Apr 22
1996;263(1369):377-386.
8. Brach JS, VanSwearingen JM. Physical therapy for facial paraly-
sis: a tailored treatment approach. Phys Ther. Apr 1999;79(4):
397-404.
9. Ross BG, Fradet G, Nedzelski JM. Development of a sensitive
clinical facial grading system. Otolaryngol Head Neck Surg. Mar
1996;114(3):380-386.
10. VanSwearingen JM, Brach JS. The Facial Disability Index: relia-
bility and validity of a disability assessment instrument for dis-
orders of the facial neuromuscular system. Phys Ther. Dec 1996;
76(12):1288-1298; discussion 1298-1300.
11. Diels HJ. Facial paralysis: is there a role for a therapist? Facial
Plast Surg. 2000;16(4):361-364.
12. Manikandan N. Effect of facial neuromuscular re-education on
facial symmetry in patients with Bell’s palsy: a randomized con-
trolled trial. Clin Rehabil. Apr 2007;21(4):338-343.
13. Peitersen E. Bell’s palsy: the spontaneous course of 2,500 periph-
eral facial nerve palsies of different etiologies. Acta Otolaryngol
Suppl. 2002;(549):4-30.
14. Nakamura K, Toda N, Sakamaki K, Kashima K, Takeda N.
Biofeedback rehabilitation for prevention of synkinesis after
facial palsy. Otolaryngol Head Neck Surg 2003; 128:
539-543
15. Ross B, Nedzelski JM, McLean A. Efficacy of feedback training
in long-standing facial nerve paresis. Laryngoscope 1991;101:
744Y50
16. 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.
17. Pereira LM, Obara K, Dias JM, Menacho MO, Lavado EL, Car-
doso JR. Facial exercise therapy for facial palsy: systematic
review and meta-analysis. Clin Rehabil. 2011 Mar 7. [Epub ahead
of print]