Idiopathic brow underaction

Idiopathic brow underaction (IBU) is a condition where the patient is unable to raise their eyebrows to a normal degree. It is a fairly common condition, though underdiagnosed. In this report, we provide a brief introduction and review of the literature and present a case study.
IBU becomes increasingly common with age until the fifth decade when the incidence falls again (Elliott, 2000). It is typically bilateral (although unilateral cases do occur) and is thought to have a multifactorial, possibly polygenic aetiology. There may be an autoimmune component (Madge et al, 1999). In this respect it has been found to be more prevalent in patients with rheumatoid arthritis, systemic lupus erythematosus and Wegener's granulomatosis. Eyebrow range of movement is on average 12.7mm 5.1mm in a healthy young adult population and decreases with age to a mean of 10.5 5.8mm at approximately 70 years of age (Healey, 1997). Some studies have suggested that regular eye exercises can limit this age-related reduction (eg Marx, 1998) but these studies were not carefully controlled. IBU can be a particularly debilitating state of affairs for people who use their eyebrows as a major communication tool, such as actors, teachers, lecturers, politicians and educational facilitators.
Typically, idiopathic brow underaction arises during the third or fourth decade, in some cases after several years of overuse. There is also some evidence that neural 'rewiring' occurs with new connections being made between the basal ganglia, first-order neurones in the motor cortex and second-order neurones leaving the spinal cord to supply the upper limbs (Ball and Locks, 1997a). These new connections may be made at the expense of facial nerve connections (Ball and Locks, 1997b) that innervate the muscles of facial expression (including frontalis). It is thought that certain unnecessary hand and arm movements, repeated over the years (such as the index finger/middle finger movement to denote inverted commas, Figures 1a and 1b) induce this neural rewiring.
A series of techniques to strengthen the frontalis muscle (and so increase brow movement) are known as 'brow underaction reinforcement lessons' (BURL) and were developed at the College of Optometry in Seattle. Optometrists in the US have used such exercises for some years and the technique has been billable under Medicare/Medicaid for the last four months. A case study illustrates the technique.

Case study and discussion
AF, a 30-year-old educational facilitator was noted to have a blunted facial expression during a routine optometric examination. During the case history, AF recounted how, over the last few months, she had noticed difficulties in 'connecting' with her classes. She had tried to reflect on her problems, but could not identify where the problem lay.
We instigated brow underaction reinforcement lessons using Steri-Strips (3M) attached to the brow and the junction between the outer two-thirds and inner third of the zygomatic arch (cheekbone). This position of the Steri-Strip provides the necessary resistance against lifting the brow, yet allows eye contact to be maintained. AF was instructed to perform brow lifting against resistance in an attempt to strengthen frontalis (Figures 2 and 3). This she carried out for one hour a day for one week. The next stage involved the exercise of emphasising a point using only the brow; the hands should be sat on for this part of the exercise. Again, one hour a day for one week was all that was required.
At the end of this short but intense exercise regime, AF had regained the full use of her eyebrows. However, the pressure effects sustained from sitting on her hands caused her to have a short episode of carpal tunnel syndrome in her right hand which, thankfully, settled after four days.
A famous recipient of BURL in the early days of the technique's development was the actor, Roger Moore, famous for playing both The Saint and James Bond. Interestingly, he acted as his own control case, only receiving BURL on one eyebrow. However, the staggering results are there for all to see.
A new training school has been established near Leicester. Taking ideas from the US, and calling itself 'Seattle Holistic Eye Training' (SHET), it offers courses for interested practitioners, which begin on April 1, 2005. During the writing of this report, we have also learned that the technique can be claimed for using Voucher value 'C' as long as the clinician has been accredited by SHET. To make a claim, the Voucher should be endorsed with BURL-SHET in the prescription box. This voucher may be issued in addition to any spectacle or contact lens voucher, should one be required (and as long as the patient belongs to one of the eligible professions listed on the Health Service Circular HSC 0104 which all optometrists and ophthalmic medical practitioners should have received).
In summary, this is a new, safe, exciting technique, which should gain widespread acceptance in the treatment of this troublesome disorder. It provides yet another opportunity for optometry to expand its primary eye care role.

References are available from the authors on request.

Dr Russell Watkins works in the department of pathology, Leeds General Infirmary, Leeds (r.j.watkins@aprilfirst.com) and Professor David Elliott at the department of optometry, University of Bradford (d.b.elliott@aprilfirst.com)

Figures 1 - Positions of the hands when denoting 'inverted commas'. The movement is repeated three or four times. This particular muscle activity is thought to promote neural rewiring in the motor cortex

Figure 2 - Subject with gross brow underaction of her right eye. Note the loss of normal muscle tone and absence of any sense of expression.

Figure 3 - .
OP33808
1 Apr 05