Small and Restricted Facial Movements in Parkinson’s Disease

Small, limited, constricted, constrained, slow – these words describe the movements and overall functioning of many people with Parkinson’s disease (PD). In PD, steps are often short, posture can be stooped, voice volume can be low, and handwriting can become small. These symptoms are part of the common motor features of PD, with a decreased level of dopamine causing slowness and stiffness of movement.

In addition, small movements seem to occur because the brain has the wrong set-point for how big a movement should be. The person with PD thinks that they are moving or positioning their body correctly, when in fact their calibration is off, and their movements are too limited.

How can I counteract restricted movement symptoms?

The best strategy to counteract this problem is to train the brain to better judge how big of a movement it needs to make. Physical therapy techniques that encourage exaggerated, big movements and upright posture can be very helpful in this effort. Speech therapy techniques that similarly encourage the person to recalibrate their voice volume, can be helpful to counteract the low volume that can be a problem for people with PD. The LSVT BIG^® and LOUD^® programs are examples of these types of therapy.

What is Facial Masking?

Part of this propensity for limited and restricted movement in PD is the tendency for facial expression to be decreased, also known as facial masking or hypomimia. Instead of responding when speaking, the face doesn’t move enough, and instead looks flat and emotionless.

Since facial expression is a key part of non-verbal communication, facial masking can make it difficult for people with PD to communicate effectively with others. When the conversation lacks the emotional cues that facial expression provides, those attempting to engage in the conversation often assume that the person with PD is uninterested, disengaged, depressed, or even cognitively impaired.

This can be frustrating for the person with PD as well as the other individuals in the conversation. If not addressed, this impaired level of communication can lead to isolation for the person with PD which is detrimental because social interaction is integral for mental health and quality of life.  Withdrawing from social situations can be one of several elements that can lead to depression. There is also data in the medical literature, that PD patients who do not express emotion on their faces also have an impaired ability at recognizing emotion in others.

How to Combat Facial Masking

For those who are dealing with facial masking, there are several ways you can work to improve your facial expressions and find additional ways to convey your emotions so you can still have meaningful interactions and social connections.

LSVT LOUD

As mentioned above, LSVT LOUD has been shown to increase facial expression along with vocal loudness. It is an evidence-based therapy modality to help people with PD improve their voice volume and articulation and is available throughout the country and beyond.

Nonverbal Communication

If you know you cannot rely on your facial expressions to relay your feelings, there are some strategies to help improve nonverbal communication:

• Always make eye contact with your conversation partner, both when you are talking and when you are listening. This will show that you are interested and engaged in the conversation.
• Use your body posture to show feelings when talking and listening to others. For example, if you lean slightly forward in your chair, it demonstrates interest; leaning back in your chair and breaking eye contact indicates that you are disinterested in the conversation. Nodding your head and occasionally tilting it to the side while the other person is speaking conveys that you are actively processing and agreeing with what they are saying.

Use Your Words

Express your emotions verbally. Instead of relying on your facial expressions, tell people with words if something they say makes you happy, sad, or upset. Don’t be afraid to tell them how you are feeling. It can help them understand you and your point of view better and can help keep the conversation going.

Partner Cues

Another approach to improving facial expression is for a care partner to use cues such as a hand gesture or a verbal prompt to remind the person with Parkinson’s disease to smile or frown.  

Medications

Increasing PD medication has also been shown to help improve facial expression as it can reduce the stiffness of the muscles of the face. Be sure to speak with your doctor before adjusting any medications.

Facial Masking Therapy

In a similar vein to LSVT BIG and LOUD therapy, facial masking therapy can help to recalibrate a person’s set point of how animated their face should be. Exercises may be designed to target the muscles around the mouth, eyes, or forehead and may involve movements such as smiling, frowning, raising the eyebrows, and opening and closing the mouth.

Exercises may involve:

• Exaggerated mimicking of certain emotions that are manifest with facial movements such as surprise (eyebrows elevated, mouth in an ‘O’ shape) or anger (furrowed brow, lips pursed).  
• The exercises are typically performed in front of a mirror so that the person with Parkinson’s disease can see their facial expressions and adjust as needed. A speech language pathologist can help guide a person with techniques, cuing, or exercises to address hypomimia.

Does Facial Masking Therapy Work?

There have been only a few small studies evaluating whether facial masking therapy is effective in improving facial expressions in people with Parkinson’s disease. One trial on Rehabilitation of hypomimia in Parkinson’s disease investigated the effects of facial masking therapy on 20 people with PD who received facial masking therapy as compared to 16 who did not. The facial masking rehabilitation was conducted in one of two ways – either having the participants practice with a recorded set of exercises or utilizing a therapist-guided approach. Both approaches resulted in improved facial expression.  

In a second study, 21 patients with PD were randomly assigned to either receive or not receive facial rehabilitation exercises performed for 60 minutes once a week for 12 weeks. Results supported the conclusions that facial rehabilitation exercise not only improved facial expression by patient report, but by objective measurement of facial movement via surface EMG. More importantly, the therapy also improved mood.

Talk to Your Doctor about Facial Masking

Your ability to talk, engage, and interact with others is so important. If you or your care partner are bothered by your lack of facial expression, be sure to talk to your neurologist about it. He or she may consider increasing your PD medications or refer you to a speech language pathologist to help improve this symptom and potentially your quality of life.

Tips and Takeaways

• Decreased facial expression, also known as facial masking, or hypomimia, is a common symptom of Parkinson’s disease which can impede communication and impact quality of life.
• Decreased facial expression can be treated by a speech language pathologist with various strategies including cueing and facial masking therapy.
• Increased dopaminergic medication may help hypomimia.
• Facial masking therapy, supported by data from small clinical trials involves performance of exaggerated facial expression exercises.

---