Facial Masking in Parkinson’s Disease

The face’s expressions can change with Parkinson’s disease, and facial masking (also called masked facies, or hypomimia) occurs in roughly half to 70% of all people diagnosed with the neurodegenerative condition.12 It’s the reason for the mask-like loss of facial expression often seen along with stiffness, tremors, changes in balance, and slower movement.

With Parkinson’s disease, facial masking is typically caused by a progressive loss of motor control. Reduction in dopamine levels (a neurotransmitter in the brain) can affect facial muscle use.2 Yet given its complexity, more studies are needed to identify causes and treatment options for hypomimia.3

Facial Masking Effects

Facial masking is symptomatic of the degenerative nature of Parkinson’s disease. The hallmark feature of the disease is the progressive loss of motor control.1 This loss of control affects major limbs, but it also affects the finer muscle movement of the hands, mouth, tongue, and face.

Facial masking affects:4

• Facial motion you might choose, like smiling or frowning
• Involuntary expressions that occur when you are surprised or afraid

This “mask” can make it harder to share feelings or for those around someone with Parkinson’s to connect with their loved one, especially when it’s combined with other common symptoms, like trouble speaking.

Keep in mind that some studies show no change in cognition linked with hypomimia, so it’s not a sign of dementia. Nor is it necessarily associated with depression or anxiety in the person with facial masking, though more research is needed to understand these connections.2 It does, however, affect quality of life.

Video: “Rehabilitation of the patients with Parkinson’s Disease”

SET OF EXERCISES №1 FOR PARKINSON’S DISEASE: IMPROVING JOINT MOBILITY AND INCREASING BODY FLEXIBILITY

For additional information about Rehabilitation of the patients with Parkinson’s Disease you can watch a video demonstrating exercises and rehabilitation recommendations.

Diagnosis

Parkinson’s disease is diagnosed based on a physical examination, which includes a comprehensive neurological examination. Sometimes brain imaging or other tests are ordered to rule out a stroke, brain injury, or a tumor that could be causing facial masking and other symptoms.

The Unified Parkinson’s Disease Rating Scale (UPDRS) section for facial expression includes a scale to help healthcare providers track the progression of the disorder.

The UPDRS scale values include:5

• 0 – Normal facial expression
• 1 – Slight hypomimia, poker-faced
• 2 – Slight but definitely abnormal loss of facial movement
• 3 – Moderate loss most of the time, lips are sometimes parted
• 4 – Marked loss most of the time, lips parted more than 0.25 inches

It’s important to remember that some people living with Parkinson’s disease also find it difficult to identify emotion in other people’s faces. The inability to recognize sadness, fear, and other emotions creates a barrier in relationships.6

SET OF EXERCISES №2 FOR PARKINSON’S DISEASE: STRENGTHENING OF THE MUSCULOSKELETAL AND MUSCULAR SYSTEM, ENDURANCE

Treatment

Facial expression matters. Research has shown that quality of life is better in persons with Parkinson’s who have undergone therapy to improve facial control than those who have not.6 Healthcare providers typically prescribe medication as well.

Medication for Facial Masking

Some medications have been found to improve symptoms of a masked face with Parkinson’s disease. They include levodopa (L-dopa), a drug often used to replace dopamine. Researchers have demonstrated a link between facial masking symptoms and low dopamine responses.2

Because levodopa alone leads to side effects of nausea and vomiting, it’s usually given as a combined drug with carbidopa, such as Sinemet or Parcopa.

For some people, a surgically implanted device in the abdomen will deliver Duopa, a carbidopa-levodopa combination that is continually administered and reduces what’s known as “off time,” when drug benefits are reduced.7 An inhaled product called Inbrija also is available.

Other medications used to treat facial masking include:8

• Stalevo, adding entacapone to the carbidopa-levodopa mix
• Mirapex (pramipexole), a dopamine agonist
• Requip (ropinirole), also an agonist
• Neupro (rotigotine) patches and APOKYN (apomorphine hydrochloride) injections

Other drugs, such as catechol-o-methyl transferase (COMT) inhibitors and monoamine oxidase type B (MAO-B) inhibitors, may be used to boost the effects of levodopa.

A SET OF EXERCISES №3 FOR PARKINSON’S DISEASE: IMPROVING THE COORDINATION AND “COMPOSITION” OF MOVEMENT – DIVIDING IT INTO COMPONENTS

Physical Therapy for Facial Masking

Therapy typically demands an intensive, therapist-guided program with a speech and language specialist. which would initially focus on broader facial movements, such as lifting the eyebrows, stretching the mouth, or puckering the face.

One technique called the Lee Silverman voice treatment (LSVT) is used by some to help people with Parkinson’s speak louder and more clearly.3 It employs articulation exercises that are similar to stage acting techniques, in which a person is taught to project and enact “speaking behavior” by:9

• Straightening the posture
• Looking a person directly in the face
• Keeping the chin up
• Taking deep breaths before speaking
• Focusing on big, loud sounds and slow, short phrases

The LSVT technique and similar rehabilitative approaches (such as choir singing or voice amplification) have proven valuable in helping people living with Parkinson’s. It teaches them to isolate and control specific facial muscles more effectively when communicating in groups or one on one.

A SET OF EXERCISES №4 FOR PARKINSON’S DISEASE: BALANCE, GAIT IMPROVEMENT AND FALL PREVENTION

Tips for Living With Facial Masking

While there’s no effective way to prevent facial masking associated with Parkinson’s disease, there are steps you can take to limit the communication challenges. You can try the following:9

• Speak out on your feelings. Use words to convey what your expressions don’t.
• Make eye contact to ensure connection between people.
• Use body language, like leaning forward to show interest or nodding as you listen.

Don’t hesitate to ask trusted friends and family members to help you communicate in social settings, like ordering in a restaurant.

Summary

Facial masking is a common symptom of Parkinson’s disease. The inability to move the face, also called hypomimia, limits expression and connection with others. In later stages, someone with facial masking may have it almost all the time and not be able to close their mouths as well.

Your healthcare provider can assess facial masking symptoms using standard tools and examinations. Therapy and medications can help people to manage their symptoms and improve their quality of life.

By Patrick McNamara, PhD
Patrick McNamara, PhD, is an associate professor of neurology and the director of the Evolutionary Neurobehavior Laboratory.