acupuncture treatment of facial palsy

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J Ayub Med Coll Abbottabad 2010;22(4)
ORIGINAL ARTICLE
ACUPUNCTURE TREATMENT OF FACIAL PALSY
Syed Zahid Hussain Bokhari, Syeda Samina Zahid*
Pain and Plegia Centre, Dabgari Gardens Peshawar, *Khyber Girls Medical College Hayatabad Peshawar, Pakistan
Background: Bell’s palsy is an idiopathic, acute peripheral-nerve palsy involving the facial nerve
which supplies all the muscles of facial expression. This study was conducted to evaluate the
effects of Electro-Acupuncture on patients with Facial Palsy. Methods: This study was conducted
on patients with facial palsy at a private clinic at Peshawar during 1999–2009, and 49 cases were
included in the study. All those cases that were within first two weeks of illness or who had related
history of stroke or they had upper motor neuron lesion were not included in the study. Electroacupuncture was used as the main therapeutic technique to treat these cases. Patients were
subjected to acupuncture treatment at four major points on the face for 20–25 minutes everyday
for 10 days. Specific points were used for nasolabial fold and watering of the eye. After rest for a
week patients were again evaluated and another course of treatment comprising of 5–10 days was
sufficient in most cases. Frequency of electro-acupuncture is kept at 60–80 cycles per minute.
Results: Total number of patients studied was 49 with duration of illness as early as 3 weeks to a
year and above. Cases with duration of illness from 3 weeks onward showed rapid recovery of
palsy symptoms with electro-acupuncture. All cases showed recovery. Palsy of the angle of the
mouth did not recover completely. Conclusion: Electro-acupuncture is effective in treating facial
palsy cases.
Keywords: Facial palsy, Bell’s palsy, Electro-acupuncture
INTRODUCTION
Bell’s palsy is an idiopathic, acute peripheral-nerve
palsy involving the facial nerve which supplies all the
muscles of facial expression. Bell’s palsy is named
after Sir Charles Bell (1774–1842), who first
described the syndrome along with the anatomy and
function of the facial nerve. Affected patients
develop unilateral facial paralysis over 1–3 days with
forehead involvement and no other neurologic
abnormalities. Patients with Bell’s palsy typically
complain of weakness or complete paralysis of all the
muscles on one side of the face. The facial creases
and nasolabial fold disappear, the forehead
unfurrows, and the corner of the mouth droops. The
eyelids will not close and the lower lid sags. On
attempted closure, the eye rolls upward (Bell’s
phenomenon). Eye irritation often results from lack
of lubrication and constant exposure. Tear production
decreases, however, the eye may appear to tear
excessively because of loss of lid control, which
allows tears to spill freely from the eye. Food and
saliva can pool in the affected side of the mouth and
may spill out from the corner.1
Symptoms typically peak in the first week
and then gradually resolve over 3 weeks to 3 months.
Bell’s palsy has been traditionally defined as
idiopathic; however, one possible aetiology is
infection with herpes simplex virus type-1. A
common short-term complication of Bell’s palsy is
incomplete eyelid closure with resultant dry eye. A
less common long-term complication is permanent
facial weakness with muscle contractures.
70
Approximately 70–80% of patients will
recover spontaneously; however, treatment with a 7-day
course of acyclovir or Val-acyclovir along with
prednisone typically prescribed in a 10-day tapering
course starting at 60 mg per day, initiated within 3 days
of the onset of symptoms, is recommended to reduce the
time to full recovery and increase the likelihood of
complete recuperation.2 The incidence of Bell’s palsy is
15–30 per 100,000 persons, with equal numbers of men
and women affected. There is no predilection for either
side of the face. Patients who have had one episode of
Bell’s palsy have an 8% risk of recurrence.3,4
Patients with Bell’s palsy usually progress
from onset of symptoms to maximal weakness within 3
days and almost always within one week. Left
untreated, 85% of patients will show at least partial
recovery within 3 weeks of onset.5 Bell’s palsy is
believed to be caused by inflammation of the facial
nerve at the geniculate ganglion, which leads to
compression and possible ischemia and demyelination.
In upper motor neuron lesion affecting the facial nerve
causing facial palsy will not paralyse the forehead on the
affected side, resulting in a unilateral facial paralysis
with forehead sparing.
Acupuncture is a technique that has proved
effective in treating palsy cases. In WHO’s
recommendations facial palsy is a diseases in which
acupuncture form of treatment is effective. It is an
old technique of traditional Chinese medicine that is
now being vastly studied in the western world in the
medical sectors as alternative medicine and has been
introduced as alternative treatment in many diseases.6
Fine filiform needles are used at acupuncture points
http://www.ayubmed.edu.pk/JAMC/PAST/22-4/Zahid.pdf
J Ayub Med Coll Abbottabad 2010;22(4)
that are explained on different parts of body. In old
traditional technique hand stimulation was used to
achieve the desired effects.
Electro-acupuncture is a relative modern
innovation. In electro-acupuncture stimulators are
used to give pulsatile stimulation parting passive
contractions to muscles/group of muscles. Electro
acupuncture achieves early results in certain
conditions and is specifically indicated in treatment
of palsies and in pain management.7,8 TENS is
innovation from principles of acupuncture. This
technique is crude with compromised results and thus
has limited application.
ranging from 5–10 days was then given in the light of
residual disability. In most of the cases this treatment
regimen was sufficient. These patients were
prescribed methylcobalamin one injection daily for
five days at the commencement of treatment.
MATERIAL AND METHODS
Majority of cases that reported to us had been
diagnosed as Bell’s palsy cases by their physicians.
They had already undergone conventional treatment
of steroids and had been subjected to varied durations
of physiotherapy. Most of them had passed the acute
stage and had partial recovery of different symptoms.
These were those leftover cases in which recovery
had standstill or was very slow. Few cases found
their way to our clinic in early stage of disease.
(Table-1)
Table-1: Total number of cases and duration of
illness
Total
Cases
49
3–4
weeks
18
5–30
weeks
25
31–45
weeks
4
1 year
and above
2
The cases diagnosed as Bell’s palsy by
physicians and treated on conventional methods but
without recovery were included in this study. Cases
with unilateral facial palsy were included. Only those
cases that had passed into 3rd week of illness and had
not shown signs of recovery were included in this
study. All those cases of facial palsy that had related
history of stroke or upper motor neuron lesion and
cases of Bell’s palsy in first 2 weeks of illness were
excluded. A referred case of traumatic facial palsy
with history of head injury was also not included in
this study.
The patients were subjected to electroacupuncture at four points: Jiache (S6) Dicang (S4)
(Corresponding to buccinator and angle of the
mouth), and Zanzhu (B2), Sizhukong (SJ23)
(corresponding to eyebrow). Yanbai (G14) Yifeng
(SJ17), and Jingming (B1) were used for weakness of
occipitofrontalis, nasolabial fold and watering of the
eye respectively (Figure-1).
Daily stimulation was given for 20–25
minutes. Frequency was kept at 60–80 cycles per
minute. Treatment was given for 10 days. Patient is
then given rest for a week. Improvement is evaluated
at the end of this period. Second course of treatment
Figure-1: Needle insertion shown at the
acupuncture points
(Adopted from American Family Physician Vol: 76, No. 7)
RESULTS
All the 49 cases treated had satisfactory recovery within
a very short time span of two weeks. Long standing
cases in which recovery had virtually stopped or was
very slow, in them recovery was expedited and was
satisfactorily completed in two weeks (Table-2).
In the recovery phase, the symptoms of
collection of food underneath the effected cheek
recovered completely within a week of treatment.
Closure of the eye was symptom next to recover.
Watering of affected eye and drooping at the nasolabial
fold required specific points for treatment and they
responded well. Frowning of the forehead showed
moderately good recovery. Recovery of this symptom
was taken as the limiting point to stop further treatment.
Angle of mouth showed partial recovery. This required
long term management as residual symptoms persist
giving mild to moderate cosmetic effects and grin on the
effected side is not completely restored. All cases
recovered from disability (Table-3).
Table-2: Duration of illness and response to
electro-acupuncture treatment in Bell’s palsy
Duration of illness
First week
Second week
3–4 weeks
5 weeks and beyond
http://www.ayubmed.edu.pk/JAMC/PAST/22-4/Zahid.pdf
Response
No
Slow
Good
Good
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J Ayub Med Coll Abbottabad 2010;22(4)
Table-3: Response to treatment in specific facial
muscles in patients of Bell’s palsy with duration of
illness from third week onwards
Risorius,
Orbicularis Orbicularis OccipitoBuccinator
oculi
Oris
frontalis
Muscles
Good
Good
Very slow
Slow
Response
5–10
10–15
Full
10–20
Recovered
sittings
sittings
recovery not
sittings
in
achieved*
Angle of the Frowning of
Symptom Collection of Closure of
the eye is
mouth is
the forehead
recovered food under
cheek on the achieved
partially
on the
effected side and watering restored in
effected side
is relieved
of the eye is place
is gradually
relieved
achieved
*Residual symptoms persist, causing mild to moderate cosmetic
effect at the angle of the mouth.
DISCUSSION
Bell’s palsy has a fair prognosis without treatment,
with almost three quarters of patients recovering
normal mimetical function and just over a tenth
having minor sequelae. In patients who recover
without treatment, major improvement occurs within
3 weeks mostly. Inflammation of the nerve initially
results in a reversible neurapraxia, but ultimately
Wallerian degeneration ensues. If recovery does not
occur within this time, then it is unlikely to be seen
until 4–6 months, when nerve re-growth and reinnervation have occurred.9 Patients who have
complete facial palsy, who have no recovery by three
weeks or who have suffered from herpes zoster virus
(Ramsay Hunt Syndrome) have poor prognosis in
Bell’s palsy. Untreated Bell’s palsy leaves some
patients with major facial dysfunction and a reduced
quality of life.
A Study evaluated 2,570 persons with
untreated facial nerve palsy, including 1,701 with
idiopathic (Bell’s) palsy and 869 with palsy from
other causes; 70% had complete paralysis. Function
returned within three weeks in 85% of patients, 29%
of patients had sequel.5 However, patients who have
incomplete recovery will have obvious cosmetic
sequel and will often be dissatisfied with their
outcome.10 Some published studies have reported
benefit with acupuncture versus steroids and placebo,
but all had serious flaws in study design and
reporting.11
Among the medicinal treatment steroids and
antiviral drugs are prescribed within 72 hours of
Bell’s palsy and are reported with mixed effects.12,13
Till date physiotherapy has been only option and
even in that, options are limited to transcutaneous
electrical stimulation with uncertain effects.14
In our study the effect of electroacupuncture that is a simple physical treatment
technique has proved most effective in restoring
functions in different muscles that were affected by
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facial palsy. This has been indicated in various
studies.1–11,15–19
It seems that the facial nerve suffers
neurapraxia and stands a good chance at recovery
when treated by electro acupuncture in recovery
phase. This will specially prevent the left out cases
going into Wallerian degeneration as the time factor
towards recovery is the most important factor
preventing complication such as permanent facial
weakness with muscle contractures. We studied the
results in patients with Bell’s palsy with duration of
illness from 3 weeks onward. We limited our
observation of response to treatment in cases, from
third week onwards as this is the time period when
the nerve is in the recovery phase and the results are
uniform. Electro-acupuncture restored the normal
function is all forty-nine cases. It is thus indicated
that a new algorithm be established and following
antiviral and steroid therapy in patients of facial palsy
electro-acupuncture therapy be introduced in the
recovery phase for optimum and early results. Thirtyone cases had fallen in the time period from 5th week
onwards. Up to 3 weeks is the time period that is
considered in most studies as the period of
spontaneous recovery. Beyond this, cases are
considered as having gone into sequel. For these
cases conventional form of treatment have no
effective valid options. All these cases responded to
treatment and recovered. This confirms affectivity of
electro-acupuncture in treating facial palsy.
CONCLUSION
Electro acupuncture is effective in restoring functions
of muscles affected in facial palsy. In the new
algorithm, following antiviral and steroid therapy
patients failing to show recovery of facial palsy may
be subjected to electro-acupuncture treatment in the
recovery phase, i.e., third week onwards, for optimum
and early recovery.
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Address for Correspondence:
Dr. Syed Zahid Hussain Bokhari, Pain and Plegia Centre, Dabgari Gardens, Peshawar, Pakistan.
Email: [email protected]
http://www.ayubmed.edu.pk/JAMC/PAST/22-4/Zahid.pdf
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