Dr. Caitlin A. Bender, OTD, OTR/L
Dopamine’s Role
Facial masking or hypomimia is characterized by slow and constrained facial movements, which leads to a flat expression. When thinking of our facial expressions we have to think in the context of 43 muscles working together rapidly in a specific moment of social and emotional situations, so it is a unique, fast, and complex movement. Since Parkinson’s Disease is defined by its cardinal symptoms of: tremor, bradykinesia, rigidity, and postural changes, which are all abnormal motor manifestations related to the dopamine insufficiency within the basal ganglia and other dopamine pathways, it could be implied that the changes within the basal ganglia contribute to facial bradykinesia; however research has shown evidence that the nerve cells within our limbic system are also affected by degeneration due to Parkinson’s Disease.
Furthermore, there is evidence to suggest that damage within structures of the limbic system had a similar onset as the damage within the basal ganglia. Since the limbic system is integral for emotions, learning, sleep, and memory, there has been increasing recognition that changes in this system substantially contribute to the wide symptom complex which characterizes PD. With that in mind it can be implied that dopamine plays a significant role in both our ability to perceive emotions typically, as well as produce high amplitude facial reactions, which can both contribute to facial masking. It is estimated that up to 65% of people diagnosed with Parkinson’s Disease experience facial masking, however research into facial masking and the process involved is ongoing.
Daily Impact
Noticeable loss of facial movement is believed to start as early as stage 1 of Parkinson’s Disease, however it may go unnoticed at first. Facial masking may present early on as reduced blinking, and continue on to decreased spontaneous smiling, and difficulty keeping the lips closed which leads to drooling. Since facial expressions are key in non-verbal communication, facial masking can have wide consequences ranging from misdiagnosis due to misattribution of emotional responses, or as difficulty engaging with family members or employers. Those diagnosed with Parkinson’s Disease also may find it harder to recognize emotion in others, which can lead to feelings of frustration. Facial masking can closely be tied to speech impairments such as low voice volume and difficulty modulating the tone of the voice, which can further impact performance in social settings. This can lead to the individual with Parkinson’s Disease feeling isolated, or embarrassed and withdrawing from social participation. Reduced social interactions can have significant impacts on quality of life for those diagnosed with Parkinson’s Disease, however there are ways to combat facial masking.
Medications
The basal ganglia is responsible for coordinating complex movements throughout the body, however since it relies on dopamine pathways to execute those actions, the cardinal motor symptoms develop, which can include bradykinesia of the face. Slower and smaller movements of the face can lead to difficulty expressing facial reactions, or facial masking, which can have significant impacts on quality of life. However, evidence suggests medications targeting rigidity and bradykinesia may reduce facial masking. Notably there were significant improvements in voluntary facial reactions and timing for individuals using Levodopa during the “on” phase. Furthermore, the amygdala, which is involved in our emotional regulation, has also shown that dopamine repletion appeared to partially restore the response of the amygdala in those with PD, during the perceptual processing of facial expressions. This implies that proper medication management, and the “on” phase can reduce the effects of facial masking caused by dopamine insufficiency.
Strategies for managing facial masking:
Reach out for a referral to a speech therapist:
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.
Non-verbal communication strategies:
Attempt to make eye contact while talking and listening to stay engaged, lean in to show interest, or try nodding in agreement.
Use your words:
Try cues:
Have a care partner use a hand gesture or a verbal prompt to remind the person with Parkinson’s disease to smile or frown.
Use mirrors as visual aids to practice larger amplitude facial movements.
Stay active:
Stay active in your social participation activities. This will help to naturally maintain recognition of facial expressions and result in improved performance in facial movements.
Incorporate facial exercises into your daily routine
Raise your eyebrows as high as you can, then furrow them together.
Open your eyes as wide as you can, then squeeze them shut.
Pucker up and blow a “oooo” then transition to an “EEEEEE”(SMILE BIG!)
Functional practice: try playing games that may elicit facial expressions such as charades.
References
Aragon, A., & Kings, J. (2010). Occupational Therapy for People with Parkinson’s Disease: Best Practice Guidelines.
Ma HI, Gunnery SD, Stevenson MT, Saint-Hilaire M, Thomas CA, Tickle-Degnen L. (2019). Experienced facial masking indirectly compromises quality of life through stigmatization of women and men with Parkinson's disease. Stigma Health. 4(4):462-472. doi: 10.1037/sah0000168. PMID: 33225063; PMCID: PMC7678084.
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