Volume 5, Number 3 | Fall 2010

Japanese Acupuncture - Current Research
Acupuncture Treatment for Peripheral Facial Paralysis
Hiroyuki Tsuru
Department of Clinical Acupuncture and Moxibustion
Meiji University of Integrative Medicine

In

the

"Facial

Guidelines2)

Nerve

Palsy

Treatment

prepared by the Japan Society ofFacial Nerve Research treatment with steroids orantiviral

drugs

or

also

facialnerve

decompression is recommended depending on theseverity of the paralysis during the acute phase of

1. Introduction
The causes of facial nerve palsy may either becentral or peripheral, but in this manuscript I will
focus on the peripheral type of facial nerve palsy,
for which comparatively numerous reports havebeen published in Japan and discuss the effects of
the acupuncture and moxibustion treatment forthis condition.
Bell’s palsy and Ramsay Hunt syndrome are
frequently observed among patients with
peripheral facial nerve palsy, these two
conditions being responsible for about 70% of allcases of facial nerve palsy in Japan1,2).
Accordingly, research reports (or case reports)
about the relevant acupuncture and moxibustion
treatment in Japan also concentrate mostly onthese two diseases3-9). The incidence of Bell's
palsy ranges from 25 to 32 persons per 100,000
population, while that of Hunt syndrome has
been reported2) to be 2-3. Etiologic details for
Bell's palsy remain obscure, but ischemia or virus
infections have been pointed out as possible
causes. In recent years reactivation of herpes
simplex virus type 1 within the geniculate
ganglion has been postulated as an importantfactor. On the other hand, Hunt syndrome is said
to be caused by latent infection within the
geniculate ganglion by varicella-zoster virus(VZV). The inflammation of the facial nerve
results in any case in the development of edema
and a resulting compression within the facial
nerve canal then causes the development ofischemia, which in turn aggravates the edema
and thus leads to a progressive affection of the
facial nerve that then finally leads to thedevelopment of paralysis.

facialnerve

palsy.

recommendation

for

In
oral

particulartheadministrationofsteroids is ranked "A", meaning that it is strongly
recommended and thus represents the mostrecommended

form

of

treatment.

monotherapy

has

been

Steroidclassified

asrecommendability A for the treatment during theacute phase, while the recommendability B was
assigned only to massive dose steroid therapy forsevere Bell's palsy. In this paper2) I "could notverify the effectiveness of at the present moment"of the acupuncture and moxibustion treatment
administeredduring

the

acute

phase

and

therefore judged it to be of recommendability C2(cannot be recommended due to a lack of scientificproof). Low frequency electrical stimulation could
lead in case of ENoG (Electroneuronography)
values of less than 40% to the development ofsynkinesis and as such has been classified asrecommendability D (it is recommend not toadminister this treatment). On the other hand,
there are no treatment forms classified asrecommendability A or B for the chronic phaseand acupuncture and moxibustion treatment forchronic peripheral facial nerve palsy has not been
mentioned. While there have been reports inJapan about the effectiveness of acupuncture andmoxibustion treatment for Bell's palsy or Hunt
syndrome its classification as C2 is truly
regrettable, but this is probably the inevitable
result of the importance in recent years attachedtoresearch

results

obtainedthrough

RCT(randomized control led trials), today considered
to be the mainstream research tool.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 5, Number 3 | Fall 2010

2.

Reportsonacupunctureandmoxibustion

treatment for peripheral facial nerve palsy in Japan
While there have been no reports in Japan

ENoG value of 0% and in whom the test
instrument

scaledout

duringexcitability test (NET). Thisthetreatise4)

nerve

describes

about the effectiveness of acupuncture andthat the initial treatment administered in themoxibustion treatment for Bell's palsy or Huntdepartment of otolaryngology was basically a

syndrome3,4,6-9)

describing effects promoting thetapered administration of 30 mg of predonine,

recovery from the palsy, there have also been no

ATP preparations, vitamins, antiviral drugs etc.

reports5) about any adverse effects delaying the

The average age of the patients was 44.3±12.8

recovery.

years (mean±S.D.), duration of the morbidity
43.2±23.9 days, paralysis score 10.2±2.7 points,

Ando et al.3) reported about their performancethe acupuncture treatment (Fig. 1) consisted ofof more than 5 acupuncture and moxibustion

retaining the needles (n=17) for 15 minutes ontreatment sessions in 28 patients (20 patientsthe affected site at GB3, GB14, GB2, ST2, ST6,

with Bell’s palsy；8 patients with Ramsay Hunt

ST4, above the angle of the mouth, below thesyndrome), who had received within 6 months

angle of the mouth and LI4 as well as

following the onset of peripheral facial nerve

electroacupuncture applied to the point pairs

palsy

stimulants,

GB3-GB14, GB2-ST2, ST6-ST4, above-below theperipheral vasodilators, stellate blocks or vitaminangle of the mouth for 20 minutes with ancomplexes.

lowintensity that did not cause the patients any

frequency electrical acupuncture was applied to

discomfort (n=12). For the evaluation the 40-point

GB14, Taiyang, ST2, ST3, ST4, ST6, ST7, ST18,

paralysis

TE17 and LI4 on the hand of the affected side

presence of synkinesis or crocodile tears, facialwith maximal intensity that did not cause any

spasm, or else the sequel score for the evaluation

pain (Fig. 1). Once or twice weekly was chosen asof facial stiffness (modified method of sequelfrequency for the acupuncture treatment and theassessment developed by Nishimoto and Murata

severity of the palsy was assessed using theet al.) were used.

steroids,
As

brain

metabolicacupuncture

treatment

score

describedbyYanagihara,

40-point paralysis score described by Japan
Society of Facial Nerve Research. The resultsMoreover, according to the Japan Society ofshowed, that when acupuncture treatment was

Facial Nerve Research a score of less than 10

started later than 30 days after the onset forpoints of the 40-point full score represents

patients in whom recovery after the onset had

incomplete paralysis, while a score of less than 8been slow, led to improvements in the palsy andpoints is a complete paralysis and a score of more

the recovery trend reportedly continued over athan 20 points indicates a mild case, 10-18 points

duration of more than 6 months, while there werea moderately severe and a score of less than 8

no side effects or complications associated withpoints a severe case. Patients reaching a score of

the acupuncture treatment.

more than 36 points and do not have any morethan moderately severe conjugated movements

Ebiko

et

al.4)

of

were judged as cured2) and the paralysis score

acupuncture treatments for a total of 29 patients

described in this paper4) returned within 6

with refractory Bell's palsy (n=14) and Huntmonths to more 36 points, while no apparent after

syndrome (n=15) presenting with a minimal

effects were observed in these cases of complete

4reportedtheresults

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 3 | Fall 2010

recovery. The remaining cases were classified asvalue of over 21% no significant differences

incomplete recovery. In this paper4) the paralysis

between the oral steroid treatment group andscore of the 29 patients at the start of theacupuncture combination therapy group were

acupuncture treatment was 10.2±2.7 points andobserved. Thus, in "between a group of patients

had improved 6 months later to 30.5±4.6 points.

with ENoG values of 1-20% treatment withAmong the 14 patients with Bell's palsy 4

massive steroid doses and a massive steroid dosepatients reportedly recovered within these 6

and acupuncture combination therapy group nomonths so far, that the paralysis score reachedsignificant differences were observed." Thus, nothe normal range of more than 36 points andrecovery promoting effects could be observed inamong the 15 patients with Hunt syndrome 1

the medication monotherapy group and thepatient recovered within these 6 months to

medication and acupuncture combination therapy

achieve a more than 36 points score. The

group, but reportedly no effects delaying recovery

remaining

were

24

patients

wereclassified

asobserved

either.

Moreover,

for

the

presenting incomplete recovery. There were no

acupuncture treatment (Fig. 1) apart from thesignificant differences in the recovery processapplication of electroacupuncture to TE17 on the

between the groups of patients with Bell's palsy

affected side for 15 minutes GB14, ST1, ST2, ST4,

and

above

ST7, BL10, GB20, GB21, SI14 etc. application ofacupuncture treatment for peripheral facial nerve

hot packs to the face for 10 minutes served as anpalsy has been reported to be effective.

additional thermotherapy. Over a period of 1-2

Hunt

syndrome.

As

described

months after the onset the patients were treated
Conversely, Kasuya et al.5) reported the resultsof a retrospective study, where the authors

twice weekly and after that the acupuncture
treatment was administered once per week.

determined the degree of nerve degeneration 2-3
weeks following the onset in a total of 111

Again, in the form of case reports thepatients with peripheral facial nerve palsy andacupuncture treatment of a 70-year old patient6)

used the 40-point paralysis score described bywith Bell's palsy presenting with synkinesis 10

Japan Society of Facial Nerve Research tomonthscompare a group treated with acupuncture (n=61)

treatment of a 29-year old patient with Bell'sand drugs as well as the differences in recovery

palsy 2 years after onset were reported7). In casebetween an acupuncture and pharmacologicof (6) electroacupuncture was applied to the

combination therapy group as compared to aaffected side of the face, resulting in relief of thepharmacologic monotherapy group (n=50). Apartsuffering from synkinesis and facial contracturefrom the steroids used for the pharmacotherapy

as assessed with a VAS (visual analogue scale)

ATP preparations, administration of drugs forand the 40-point paralysis score described by

improving microcirculation, vitamin preparations

Japan Society of Facial Nerve Research as well as

etc. was also described. This paper5) states, that

ENoG.

"the recovery from paralysis was in the group of

performed on the points GB14, ST2, SI18, ST4,

patients with an ENoG value of over 41% andusing two different pulse generators to avoid

treatedsynchronizedwithacupuncture

onlysignificantly

after

onset

and

Electroacupuncturemuscletheacupuncture(Fig.

contractions

1)

from

was

the

inferior to that in the oral steroid treatment

GB14-ST2 and SI18-ST4 pairs. In the lattergroup", while comparison of groups with an ENoG

report7) electroacupuncture was performed on the

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 5, Number 3 | Fall 2010

affected side of the face at TE17, ST7, GB1, ST4,

The first case was a 43-year old patient8)

LI19 and GB14, using also the points Taiyang,diagnosed with Hunt syndrome, who was treated

ST2, ST3 etc. for the treatment (Fig.1). This

18 days after onset with the Koshi method on the

resulted reportedly in improvements of theface using the retaining needle technique for theparalysis score and reduction of the temperature

treatment.

difference between the affected and healthy side

pharmacotherapy with steroids, antiviral drugs,of the face as measured with thermography.

cerebral circulation and metabolism ameliorators,This

patient

received

vitamin preparations and eye drops to prevent
Considering the contents of these reports wedehydration of the eye, but according to theconcluded that a combination therapy establishedpatient "the left side of the face almost does notin cooperation with an otorhinologist rather thanmove and the discomfort is not alleviated".

an acupuncture monotherapy for peripheral facial

Moreover, the attending physician asked thenerve palsy is important. In particular during theauthor "not to perform acupuncture treatment on

acute phase of the peripheral facial nerve palsy

thesteroid

measurescomplaints were impaired movement of theadministered by the otorhinologist should bemuscles and discomfort on the left side of the face,

given

with

simultaneously observing associated symptoms ofacupuncture later considered on the basis of theinability to taste food, shoulder stiffness, dryness

degree of recovery or severity of symptoms.

of the eye, insomnia, constipation etc. At the starttherapypriority

and
and

a

similarcombination

3. Application of the Koshi method of traditional
acupuncture during the acupuncture treatment
for peripheral facial nerve palsy

acupuncture treatment for peripheral facial nerve
palsy in Japan, but since electroacupuncture
treatment can cause synkinesia as describedabove, otolaryngologists currently seem to haveregardingstimulation

on

the

affected side (worries about the development ofconjugated movements8,10).

Thus,

since

the

chief

of the acupuncture treatment (18 days after onsetof the condition) the 40-point paralysis score as
described by Yanagihara was 10 points. The VAS
left side of the face and discomfort were 55 mm
and

56

mm

respectively.

A

total

of

11

acupuncture treatment sessions was given at rateof 1-3 times per week. All needles only pierced theskin to a depth of about 5 mm and were thenretained for 10 minutes (retaining acupuncturetechnique). For the acupuncture of the face thepoints GB14, Taiyang, SI18, ST4, TE17 and SI19
were needled (Fig. 2, upper row). Otherwise,

Regarding case reports in this context theauthor has reported about the application of the
Koshi method of traditional acupuncture to theface integrated in the acupuncture treatment for
peripheral facial nerve palsy (Bell's palsy, Hunt
syndrome). When symptoms are present on theleft side, the Koshi method is applied to the rightside, and for symptoms on the right side theacupuncture treatment is applied to the left side.
6

side".

values representing the difficulties in moving the

So far I have introduced reports about

reservations

affected

based on (1) determination of the treatment
according to pattern identification (bian zheng
lun zhi) needles were inserted and retained at
LR3, KI3, KI7 and SP6, (2) to improve blood
circulation through the muscles of the shoulder
girdle and relief muscle tension needles wereretained in the point GB21 (Fig. 2, upper row).
Acupoints not in the facial region were needled on
both sides. This resulted in an improvement of

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 3 | Fall 2010

the paralysis score to 38 points by the tenth

the neck and shoulder and relief muscle tension

acupuncture treatment (39 days after onset),needles were retained at GB21, SI11, SI13, SI14,

while both the difficulties in moving the muscles

SI15, BL23, BL25, BL52 and EX-B3 (Fig. 2, lower

and the discomfort of the left side of the face had

upper row). Acupoints not in the facial region

been alleviated and the associated symptoms

were needled on both sides. This resulted in anshoulderstiffness,

constipation

and

the

eye,

improvement of the paralysis score to 38 points by

subjectively

been

the 27th acupuncture treatment (242 days after

drynesstasteofimproved.

onset), the difficulties in moving the muscles ofthe face had been alleviated to a VAS score of 2

The second case was 60-year old patient

mm. The VAS score for the associated symptoms

diagnosed with Bell's palsy who I started treatingof shoulder stiffness and low back pain had

using the retaining needle acupuncture technique

improved to 22 mm and 14 mm respectively.

50 days after the onset9). This patient too received

Otherwise the patient commented on the effects

pharmacotherapy including steroids, cerebralof the received acupuncture treatment as "Icirculation and metabolism ameliorators, vitamin

started to sleep well", "the constipation is gone",preparations

prevent"my stomach is feeling just fine", "my tinnitus has

dehydration of the eye, had undergone facialdecreased", "I don't have any palpitations any

nerve decompression and underwent stellatemore" etc.

and

eye

drops

to

blocks once a week, but the "mobility of the right
side

of

the

face

did

not

improvemuch".

Based

on

the

above

described

results

Accordingly, in addition to the chief complaint ofapplication of the Koshi method as an integral

impaired mobility of the right side of the face (atpart of the acupuncture treatment for peripheral

the beginning of the acupuncture treatment the

facial nerve palsy indicates the possibility that it

relevant VAS value was 83 mm) there were also

promotes recovery, but it remains difficult toassociated symptoms including shoulder stiffness

explain the exact mechanism at work during the(VAS of 57 mm), low back pain (VAS of 25 mm)

promotionand the paralysis score was 12 points. The
acupuncture treatment was administered once or
twice a week, where all needles were inserted
only to a depth of about 5 mm and retained for 10
minutes (retaining acupuncture technique). All
needles in the facial region were placed on thehealthy side at GB14, Taiyang, SI18, ST4, TE17,
SI19 and ST7 (Fig. 2, lower row). Otherwise,based on (1) determination of the treatment
according to pattern identification needles wereinserted and retained at LR3, KI3, KI7 and SP6,
and (2) as for a selection of points on the affectedchannel needles were placed and retained in
distinctly tender points at LI4, TE5, LI10, (3) toimprove blood circulation through the muscles of

thisrecovery,includingtheimprovement of associated symptoms. However,mainly animal experiments revealed that theacupuncture

stimulationhas

effectsthatreportedly include reduction of muscle tension11),
improvementofmuscularblood

flow12,13),

improvementofneuronal

blood

flow14,15),

promotion of physical and mental relaxation16),
promotion of peristaltic bowel movements17) andthe like. Moreover, some reports also indicate,that the acupuncture stimulation does not only
increase muscular blood flow at the stimulation
site, but affects muscular blood flow on thecontralateral side also18). This suggests thepossibility that the acupuncture stimulation

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 5, Number 3 | Fall 2010

applied to the healthy side in this case somehow
affectedthecontralateral

side

via

higher

Also,

while

complaint(s)improvement

andassociated

of

the

chief

symptoms

isneuronal centers, or else the possibility, as

important regarding the acupuncture treatment

described

thefor facial palsy, inhibition of the development ofacupuncture stimulation improves symptoms insynkinesis is considered to be another importantthe facial region as well as associated symptoms

aspect of the treatment. Thus, treatment forlike shoulder stiffness, low back pain, insomnia,

facialconstipation etc. On the other hand, however, theobservation

administrationacupuncture basically a combination therapy

above,

that

of

the

effects

steroids

or

of

other

palsy

the

shouldandbeinguidedcase

pharmacotherapy, the performance of facial nerve

withtreatment

decompression, stellate ganglion blocks etc. may

otorhinologists is essential.

ofbycarefulperforming

administeredbypossibly have contributed to limiting the facial

Moreover, ENoG measurements made before

nerve conduction disturbances, or else the drugs

and after the acupuncture treatment as well as

may possibly have promoted repair of the facial

RCTs conducted appear to be an important task

nerve, indicating the possibility that combination

for the future in order to objectively assess thetherapy including acupuncture, pharmacotherapy

effects of acupuncture treatment for peripheral

and surgery promotes recovery.

facial nerve paralysis.

Chart with the acupoints used in references 3) through 7)
Acupuncture treatment was performed on the affected side of the face.
8

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 5, Number 3 | Fall 2010

Chart with the acupoints used in references 8 through 9
Application of the Koshi method during acupuncture treatment performed on the healthy side of the face.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

9Volume 5, Number 3 | Fall 2010

References
1) Murakami S. (editor): Treatment of facial palsy
update. ENTONI Book 111. Japan Hospital
Press: 1-10, Tokyo; 2010; Japanese only
2) Japan Society of Facial Nerve Research(edition): Facial Nerve Palsy Treatment
Guidelines – Bell's Palsy and Hunt syndrome– KANEHARA & Co., LTD; Tokyo; 2011;
Japanese only
3) Ando F., et al.: Evaluation of acupuncture-combined
therapy for peripheral facial palsy. Facial N Res.
Jpn 8:167-170, 1988.
4) Ebiko K., et al.: Effects of acupuncture on
refractory Bell’s paralysis and Hunt’s
syndrome. Kampo Med 60(3): 347-355, 2009.
5) Kasuya, et al.: Acupuncture treatment for
peripheral facial paralysis. Jpn Society of
Acupuncture and Moxibustion 52(1): 32-42, 2002.
6) Okada T., et al.: Electro-acupuncture for facial
palsy with synkinesis. Jpn Society of Acupunctureand Moxibustion 55(4): 601-607, 2005.
7) Morito A., et al.: Acupuncture treatment in aperipheral facial paralysis with the sequelae.
Jpn Society of Acupuncture and Moxibustion
53(2): 190-194, 2003.
8) Tsuru H., et al.: A case of acupuncture
treatment for facial paralysis. Facial N Res.
Jpn 30: 160-162, 2010.
9) Tsuru H., et al.: A case of acupuncture
treatment for Bell’s palsy. Quarterly
published Oriental Medicine 17(3): 2011.
10) Murakami S. (editor): Treatment of facial palsy
update. ENTONI Book 111. Japan Hospital
Press: 73, Tokyo; 2010; Japanese only
11) Kinoshita H.: Experimental research into theeffects of acupuncture on local pain II: Effects
of retained acupuncture needles on theprocess of posttetanic high level contraction
recovery; Showa Med. J. 41:393-403; 1981;
Japanese only

1012) Tsuru H., et al.: Effect of acupuncture
stimulation on the blood flow of the skeletal
muscle in rabbits. Jpn Society of Acupunctureand Moxibustion 49(1): 6-14, 1999.
13) Shinhara

H.:

Influenceof

acupuncture

stimulation on the induction of variations inskeletalmuscleblood flowandenergymetabolism in ischemia-reperfusion stressed
rats; Meiji University of Integrative Medicine
23:41-54,1998; Japanese only
14) Yamaguchi D., et al.: Effect of acupuncture
stimulation to the low back on blood flow to
the sciatic nerve trunk in rabbits. Jpn SocietyofAcupuncture

andMoxibustion

47(3):

165-172, 1997.
15) Inoue M., et al.: Effects of lumbar acupuncture
stimulation

andsciatic

nerve

electricalstimulation on blood flow to the sciatic nerve
trunk. Jpn Society of Acupuncture andMoxibustion 48(2): 130-14-, 1998.
16) Yano T., et al.: The effects of electro-acupuncture
and TENS on EEG Topogram. The Bulletin of
Meiji University of Oriental Medicine 1: 55-64,
1985.
17) Iwa M., et al.: Electroacupuncture elicits dual
effects,

stimulationofdelayedgastric

emptying and inhibition of accelerated colonictransit induced by restraint stress in rats.
Dig Dis Sci 51: 1493-1500, 200618) Tsuru H., et al.: Acupuncture on the blood
flow

of

variousorgansmeasuredsimultaneously by colored microspheres inrats. Evid Bsed Complement Alterate Med 6:
77-83, 2009

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)