The use of (surgical) masks during the actual pandemic situation Thoughts and challenges for clinicians like musculoskeletal therapist

Introduction

As we all face new and unforeseeable challenges due to the current COVID-19 or “Corona-Virus” pandemic, more and more clinical thoughts and implementations turn up. Next to possibilities and applications of new and modern technologies in rehabilitation, like telemedicine, tele-rehabilitation or the use of virtual reality, the patients´ and the therapists´ safety have to be considered, especially when a stepwise return to face-to-face therapy occurs (Eccleston et al., 2020; Haines & Berney, 2020).

Another point that has to be considered is the way we cover our faces by (surgical) masks, which cover our mouth and nose so only the eyes and forehead is free. Whereas the daily and common use of these masks is very established in Asiatic states (Yang, 2020) the everyday viewing is still very unusual in middle-European countries. The World Health Organization (WHO) is constantly adapting its recommendation of when and how to use different kinds of masks during the ongoing pandemic (WHO, 2020). Different guidelines in several countries advise the use of face mask protection for the patients and the therapists during face-to-face work with but this normally applies to the acute care setting and patients (Physio Austria, 2020).

We may ask ourselves what´s happening with our nonverbal communication skills where it is known, that most of our emotions and feelings are expressed by the face. In this blog, we discuss some thoughts and ideas about how to deal with this situation in a daily clinic in the future.

Our face as a communication tool

Our face has a unique tool to communicate in a nonverbal manner (von Piekartz & Mohr, 2014). Nonverbal communication is dependent on facial emotional expression, which often works as an early warning system and shows us how the person might feel at the moment (von Korn et al., 2014). Empirical evidence confirms that our own facial expressions´ feedback modulates our emotional experiences (Price et al., 2015). For instance, smiling of a person (stimulus) initiates directly the smiling facial motor activity in another person’s “facial mimicry.” This may facilitate an emotional response (happiness) and other physical reactions like autonomic arousal (sweating, heartbeat changes) and bodily motor responses (smile) which is called “facial mimicry.” Besides storing this somato-sensory-motor experience occurs, the brain scrutinizes it with the other millions of facial mimicry experiences is have experience which leads to subtle individual non-verbal communication and empathy (Wood et al., 2016).

Another idea is the emotion-circum-flex-model, where there is a mixture of different “fused” facial expressed emotions with different durations and intensity which may be expressed in positive/negative feelings or moods with variability of intensity (Russel et al., 2003). In this case more than 6-8000 different fused facial expressions may act to clarify what we mean and what we want and feel to another person in different contexts and tasks. From different studies it is known, that our first reflex is scanning of another person’s face, mainly the eyes and mouth, where we from an evolutionary point of view and conclude if there is a threat or not (Ross et al., 2007). This is confirmed in different studies, where especially the lower part of our face (mouth region) plays a role in recognition of disgust, anger, and happiness (Wegrzyn et al., 2017).

A schematic representation of the affective circumplex. The horizontal axis represents the valence dimension (pleasure–unpleasure), and the vertical axis represents the arousal dimension .(Modified after Rusell 2003)

Partial covering our face. What does it do with us?

Partial covering (occlusion) of faces (eyes and the mouth) has influences on accuracy and speed of the emotion recognition which may occur in children and also in adults (Roberson et al., 2012). The results indicate that mouth occlusion, in general, causes a greater decrease in facial expression recognition than the occlusion of the eyes. Mouth occlusion affects more anger, fear, happiness, and sadness, while eye occlusion affects the remaining disgust (Kotsia et al., 2007). This data is the result of clinical research and mostly occurred during a short time face occlusion. There us no data long term face occlusion available, but it has to be mentioned that persons with, e.g. general chronic pain, facial pain, Parkinson’s disease, after stroke, facial paresis and depression are less accurate and slower in emotion recognition and expression which may lead to emotion blindness, called Alexithymia (Taylor & Bagby, 2004).

Can blending your face be an advantage?

Partial covering our face, mostly the lower part as a reflex can also help us covering our real emotion if we are not allowed to express it, because of norms and values in that particular situation (e.g. somebody tells you a joke during a classic concert and you have to laugh OR smelling disgusting food cooked by a friend special for you). This phenomenon is called “facial blending” (Ross et al., 2007).

At a property company in Northern China’s

Handan province everybody wears masks on Tuesday as part of their "faceless day”. This is the most relaxed day for every employee because you can’t see if somebody is smiling or angry, so you can make what ever face you want to, without getting a written warning.

Upload, 17 july 2015

Wearing of mouth-nose (surgical) masks. Does it have real consequences for us in our society?

Could long time wearing of surgical masks influence or change our facial mimicry which may lead to a kind of alexithymia – let´s say, “surgical mask Alexithymia” based on the “Russell Model” (2003)? Will our emotions be flatter and less intense and show less changes in the balance of negativity?

Are we becoming more human individuals when our unique variability and intensity of emotions becomes less in a world where we are “locked down“ by a pandemic situation with no time limit? If you believe in conspiracy theories of the “New World Order”, where (world) authorities commit us of wearing masks, this could be a powerful contributing instrument to fulfill the globalist agenda faster then usual? ((https://www.cbc.ca/news/canada/british-columbia/pandemic-conspiracy-theories-1.5513662)

From a different travel blog April 2020

All faces in the same direction. Can long term wearing of surgical masks change or unique the way of emotion expression and make our emotions less intense and variable?

Does it have consequences for musculoskeletal therapist special in the head-neck and face region ?

Part-time face blend in a fearful pandemic society with no time limit may have a strong impact for (cranio-facial) patients and clinicians.

Some questions we may ask ourselves:

• Will masks, worn by therapists and patients, disturb communication, due to lack of facial reflexes and mood estimation?
• Do facial expression restrictions have consequences for the quality of life of orofacial patient with for example TMD, bruxism, traumatic face pain?
• Depression and catastrophizing often are comorbidities in this patient group. Does it have more impact on their complaints?
• How can we recognize/test if lack or changed emotion responses and processing may be a risk or contributing factor for the patients´ complaints?
• If we recognize it, what are the possibilities for intervention?

A musculoskeletal physical therapist in the Netherlands before a consult with a patient with head-face pain.

Bizarre ‘surgical masks’ that look like your face aimed at coronavirus-fearing smartphone owner

That people need their lower face in daily life to express themselves is clear. Commercial agencies already have an answer to it. You can design a unique medical mask that apparently works with facial recognition software on your smartphone you may send it to agencies and several days you receive you unique mask with one emotion expression. Is that what we want for the future?

The Sun 19 Febr 2020 . Design you own surgical mask

Challenges for musculoskeletal research and treatment

The 1.5-meter (6 foot) social distancing and the facial blends by the surgical masks force us to adapt our thoughts about research and assessment/treatment strategies.

For example:

• Is (surgical) “mask Alexithymia” more often seen by craniofacial patients with mask compared to without?
• Is specialized manual treatment and Neuroscience Education (PNE) enough for reaching the proposed goals?
• Do we have to imbed the consequences of facial blending by masks during PNE?
• Do we have to test the status quo of emotion recognition/expression and the change of cognitive style patients use?
• If emotion recognition/expression is blurred, can we train them by facial motor function training, motor imagery and emotion training?

Maybe there are more questions to ask, so please don't’ hesitate to react or write us an email

Testing and Training

At least we can start testing and try to integrate emotion (face) training:

• For example in psychological studies the Reading-the-mind-in the-eyes Test is often used which, shows a good accuracy of recognizing the emotional and behavioral state in the persons eyes (Sato et al., 2016).
• The Facially Expressed Emotion Labeling (FEEL) Test, which is a computer-based test, measures one’s ability to recognize facially expressed basic emotions (Braun et al., 2005).
• My facetraining (https://www.myfacetraining.com) is a software program for PC and mobile devices as an APP, where the emotion recognition/expression can be tested and transformed in training. It has also a mirror function!
• Face training App CRAFTA® is a simple APP to test and to train laterality and basic emotions.

Conclusion

• Clinicians have to be aware, that facial deprivation during the COVID-15 pandemic in combination with imposed social restriction for an indefinitely time may have a deep impact on quality of life and pain, especially in craniofacial sufferers.
• Clinicians has to be aware of these possible new clinical patterns and have to test emotion responses by standardized tests and train them if necessary.

Do you have ideas or thoughts on this topic? write a mail or share it in the IMTA Facebook

Bernhard Taxer ,MSc PT, PhD Cand.,CRAFTA,OMT(IMTA),CRAFTAAustria

Harry von Piekartz , PhD, MSc PT,CRAFTA, Senior IMTA Teacher, CRAFTA,The Netherlands

References

Braun, M., Traue, H. C., Frisch, S., Deighton, R. M., & Kessler, H. (2005). Emotion recognition in stroke patients with left and right hemispheric lesion: Results with a new instrument—the FEEL Test. Brain and Cognition, 58(2), 193-201.

Eccleston, C., Blyth, F. M., Dear, B. F., Fisher, E. A., Keefe, F. J., Lynch, M. E., Palermo, T. M., Reid, M. C., & Williams, A. C. de C. (2020). Managing patients with chronic pain during the Covid-19 outbreak: Considerations for the rapid introduction of remotely supported (e-health) pain management services. PAIN, Articles in Press. https://doi.org/10.1097/j.pain.0000000000001885

Haines, K., & Berney, S. (2020). Physiotherapists during COVID-19: Usual business, in unusual times. Journal of Physiotherapy. https://doi.org/10.1016/j.jphys.2020.03.012

Kotsia, I., Buciu, I., & Pitas, I. (2008). An analysis of facial expression recognition under partial facial image occlusion. Image and Vision Computing,26(7), 1052-1067.

Physio Austria. (2020). Coronavirus: LAUFEND neue Informationen für PhysiotherapeutInnen | physioaustria.at. https://www.physioaustria.at/news/coronavirus-laufend-neue-informationen-fuer-physiotherapeutinnen

Price, T.F. and Harmon-Jones, E. (2015) Embodied emotion: the influence of manipulated facial and bodily states on emotive responses. Wiley Interdiscip. Rev. Cogn. Sci. 6, 461–473

Roberson, D., Kikutani, M., Döge, P., Whitaker, L., & Majid, A. (2012). Shades of emotion: What the addition of sunglasses or masks to faces reveals about the development of facial expression processing. Cognition, 125(2), 195-206.

Ross ED, Prodan CI, Monnot M. (2007): Human Facial Expressions are organized functionally across the upper-lower facial axis. Neuroscientist, Vol. 13(5): 433-446

Russell, J. A. (2003). Core affect and the psychological construction of emotion. Psychological Review, 110, 145–172.

Sato, W., Kochiyama, T., Uono, S., Sawada, R., Kubota, Y., Yoshimura, S., & Toichi, M. (2016). Structural Neural Substrates of Reading the Mind in the Eyes. Frontiers in Human Neuroscience, 10. https://doi.org/10.3389/fnhum.2016.00151

Taylor, G. J., & Bagby, R. M. (2004). New trends in alexithymia research. Psychotherapy and psychosomatics, 73(2), 68-77.

von Korn, K., Richter, M., & von Piekartz, H. (2014). Einschränkungen in der Erkennung von Basisemotionen bei Patienten mit chronischem Kreuzschmerz. Der Schmerz, 28(4), 391–397. https://doi.org/10.1007/s00482-014-1395-5

von Piekartz, H., & Mohr, G. (2014). Reduction of head and face pain by challenging lateralization and basic emotions: A proposal for future assessment and rehabilitation strategies. The Journal of Manual & Manipulative Therapy, 22(1), 24–35. https://doi.org/10.1179/2042618613Y.0000000063

Wegrzyn, M., Vogt, M., Kireclioglu, B., Schneider, J., & Kissler, J. (2017). Mapping the emotional face. How individual face parts contribute to successful emotion recognition. PloS one, 12(5).

WHO (2020). When and how to use masks. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks

Wood, A., Rychlowska, M., Korb, S., & Niedenthal, P. (2016). Fashioning the face: sensorimotor simulation contributes to facial expression recognition. Trends in cognitive sciences, 20(3), 227-240.

Yang, J. (2020). A quick history of why Asians wear surgical masks in public. Quartz. https://qz.com/299003/a-quick-history-of-why-asians-wear-surgical-masks-in-public/

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