JCPSLP Vol 20 No 2 July 2018

Despite these limitations, the findings do suggest that speech-language pathologists may increase their confidence with clients who have facial nerve palsy through provision of more specific education of their facial anatomy. Through encouraging the appropriate activation of targeted muscles, as well as the prevention of over-activation of preserved musculature or unwanted increased tension of the head and neck, clients can more actively participate in their own therapy, with increased intensity and accuracy during home practice. Complementing the use of the mirror, sEMG can play an important role in both the client’s education and the clinician’s confidence that the prescribed exercise program is producing muscle activation towards the targeted level. Future directions Further research into this approach to FNP treatment is needed to confirm the maintenance of treatment gains, the timing and delivery of therapy in relation to different aetiologies of FNP (e.g., central versus peripheral), and the specific contribution of the different biofeedback approaches in the recovery of FNP. However, of key importance is the need for more rigorous design, particularly with regard to increased experimental control to monitor spontaneous recovery with greater confidence, and for comparisons with no treatment, different treatment, or combined treatment approaches. Stepp (2012) further suggested that, as sEMG is a non-invasive tool, we need to explore the reliability of repeated measurement. Conclusion In summary, this study has provided promising evidence towards the benefits of a combined sEMG and mirror biofeedback training in a tailored, early and intensive treatment program delivered by speech-language pathologists within routine clinical practice. Further research into this approach to FNP treatment is needed to confirm the maintenance of treatment gains, the timing and delivery of therapy in relation to different aetiologies of FNP (e.g., central versus peripheral), and the specific contribution of the different biofeedback approaches in the recovery of FNP. Perhaps of equal priority, however, is the need for raising awareness within the speech-language pathology profession as to our professional role in diagnosing and treating FNPs that present among the client populations seen in routine practice, and the significant gains that can be achieved in function and quality of life for these clients. Discussions with other members of the team, in particular physiotherapists, to explore ways of working together to maximise gains should also be pursued. Acknowledgements This study was conducted as a quality improvement project at the site of the primary author. The authors wish to acknowledge the contribution of Julie Varian for her clinical involvement in the study and Kim Brookes for her enthusiastic managerial support. References Barr, ML. (1975). The human nervous system: An anatomical viewpoint (2nd ed.). New York: Harper & Row Publishers. Baricich, A., Cabrio, C., Paggio, R., Cisari, C., & Aluffi, P. (2012). Peripheral facial nerve palsy: How effective is rehabilitation? Otology and Neurotology , 33 , 1118–1126.

Figure 2. Photos showing pre- and post-intervention for one client.

closing/squinting, head/jaw movement, and increased tension such as raised shoulder position (as frequently noted within treatment sessions). Biofeedback with the mirror alone, however, was not be able to provide the same feedback regarding small movements in the initial stages, nor allow for appropriate micro adjustments to movement effort required to judge participant fatigue and when to challenge effort. When initially unable to see sufficient movement in the mirror on their affected side, participants were made aware of changes occurring during the sEMG biofeedback in the session with the clinician. The role of speech language pathology The promising early results of this intervention support the profession considering a combination of (a) increased education offered through the provision of handouts to clients for self-directed home exercises after a brief trial of target movements, (b) correctly practised and tailored, graded exercise programs with massed practice (Manikandan, 2007; Segal, Zompa et al., 1995), and (c) application of the emerging evidence for biofeedback. Persistent effort of sufficient massed practice in an intensive program is difficult to achieve without the biofeedback offered by an approach such as sEMG, reinforcing the need to increase familiarity and skills with this approach. Indeed, without sEMG, the carefully graded initial assessment of the client’s facial nerve weakness and the determination of the potential for movement activation on the affected side of the face, will not occur, placing the client at risk of practising incorrectly, and impacting on the potential neuroplastic changes which occur post nerve damage. Study limitations Several limitations are present in the study. The absence of a control group receiving no or an alternative intervention, possibly without biofeedback, limited comparison and richer interpretation of gains. As this study was evaluating standard care within the speech-language pathology services offered, only a combined approach was offered to all participants. This should be considered in future studies, especially if seeking to obtain insight into issues around, for example, dose or intensity. The unknown degree of spontaneous recovery also limited interpretation as time post onset covered a wide range. Further, as this program was offered within an existing home-based speech-language pathology service delivery model that offered a short-term intensive intervention period, no follow-up measurements were possible to evaluate any maintenance of gains. Monitoring the clients over a longer period would be recommended in any future study, coupled with closer monitoring of levels of home practice, potentially through the use of daily dairies, to obtain information, in particular, on dosage.

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JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology