Facial Paralysis Treatment by Chinese Medicine by Zhenbo Li Abstract Although the prognosis for peripheral facial paralysis is generally good, up to 15% of patients may be left with sequelae in the form of persistent asymmetry. Early treatment by acupuncture and Chinese herbal medicine is therefore encouraged to assist in the prevention of such lingering symptoms. This article analyses facial paralysis in terms of Chinese medicine pathological theory, addresses the differentiation of patterns, and recommends appropriate treatment including selection of acupuncture points and herbs, and needling techniques. Facial paralysis, or Bell’s palsy, is a disease where the muscles of the face become weak or paralysed due to unilateral damage to the facial nerve (seventh cranial nerve). The condition usually comes on suddenly, often overnight, and within one or two days the paralysis has usually reached its peak. In most cases of Bell’s palsy, the nerve is damaged by inflammation. The facial nerve controls facial expressions,carries taste sensation from the front of the tongue to the brain, and controls the production of tears and saliva. Clinical manifestations of damage to the nerve include unilateral flaccidity of the facial muscles, inability to close the eyelid or blink, excess or decreased lacrimation, drooling, difficulty in chewing, decreased sense of taste, pain or numbness behind the ear, and numbness, pain or twitching of the facial muscles on the affected side. Aetiology, pathology and pattern differentiation according to TCM From the traditional Chinese medicine perspective, facial paralysis is usually caused by underlying deficiency of the channels and collaterals of the face, and attack by wind-cold,which penetrates and blocks the flow of qi and blood in the channels and collaterals. Wind-cold can also combine with pre-existing internal phlegm with similar results. Wind has a tendency to go upwards, and is characterised by rapid changes and movement. Facial paralysis, therefore, occurs suddenly and gives rise to abnormal movement of the muscles in the form of twitching. Blockage of the channels and collaterals results in malnourishment of the tendons and muscles, with ensuing paralysis and numbness. In patients with an excess yang constitution, original yin deficiency,stagnant heat due to Liver qi stagnation, or a history of overconsumption of hot energy foods and herbs, wind-cold and wind-cold-phlegm may quickly transform into windheat and wind-phlegm-heat. Facial paralysis can further develop into a chronic condition, leading to yin deficiency with empty heat or deficiency wind, with resulting chronic facial muscle spasm or tic. Differentiation of diseases Prompt medical evaluation of facial paralysis is very important to rule out other diseases or conditions that maybe causing the weakness of the facial muscles, for example stroke, Lyme disease and brain tumour. Facial nerve damage can also be caused by progressive nerve diseases such as multiple sclerosis. Prognosis of facial paralysis The prognosis for Bell’s palsy is generally very good. 75% ofpatients recover completely, mostly within 2 to 3 weeks, 15% recover well but may have persistent facial asymmetry, whilst 5-10% have poor recovery at four months, with persistent neurologic impairment and cosmetic disfigurement. In the early stage, therefore, acupuncture and herbs that can cure the facial paralysis are highly recommended. Treatment by Chinese medicine Acupuncture and Chinese herbal therapy can regulate qi, activate blood circulation, dispel wind and remove obstruction in the channels and collaterals. This increases local nerve irritability, improves local nutritional metabolism and accelerates recovery of function to the nerve and facial muscles. Acupuncture treatment of facial paralysis Acupuncture points along the yangming channels of hand and foot are generally selected as primary points, and those of the shaoyang channels of hand and foot serve as secondary points.For the pattern of wind-cold, the treatment principle is to disperse wind-cold, promote circulation of qi and blood,open the channels to expel wind-cold, and activate and unblock the channels and collaterals. For complication by phlegm, heat or deficiency, the treatment principle is amended accordingly. Commonly used points include: • Dicang ST-4, Jiache ST-6 and Sibai ST-2, of foot yangmingchannel, as local points to regulate qi and blood in the channel. • Yifeng SJ-17, of hand shaoyang channel, to activate qi andblood in that channel and relieve pain at the back of ear. • Quanliao SI-18, as a local point to unblock the channel. • Fengchi GB-20 to disperse wind-cold • Hegu L.I.-4, as a distal point to regulate qi and bloodin hand yangming channel and treat face and mouth problems • Taichong LIV-3, as a distal point to extinguish wind internally, and as an effective point to treat deviation of the mouth. • When there is widening of the palpebral fissure with failure of the eye to close, add Zanzhu BL-2, Yangbai GB-14and Yuyao (M-HN-6) as local points to activate the channels,and Zhaohai KID-6 (confluent point of the Yin Qiao/YinMotility vessel) and Shenmai BL-62 (confluent point of theYang Qiao/Yang Motility vessel), because these vessels control the opening and closing of the eyes. • For symptoms of pain or numbness behind the ear on the affected side, add Tinghui GB-2, Tinggong SI-19 and Ermen SJ-21 as local points to regulate qi and blood in these channels. • If there is flattening of the nasolabial groove, add local points Yingxiang L.I.-20 and Heliao L.I.-19. • For deviation of the nasolabial groove add RenzhongDU-26. • For internal phlegm add Fenglong ST-40 to dissolve phlegm, and Zusanli ST-36 to strengthen the Spleen and stop the generation of phlegm. • For heat add Quchi L.I.-11 and Neiting ST-44. • In chronic cases with yin deficiency and empty heat add Zhaohai KID-6 to nourish yin and clear empty heat. • For chronic facial twitching add Zusanli ST-36, of footyangming channel which is full of qi and blood, to strengthen the muscles. The patient should come as soon as possible after onset,and receive treatment every day or every other day. Only the affected side should be needled. Needle stimulation should be mild during the first week, subsequently becoming a little stronger, as too strong manipulation in the early stages may cause the symptoms to worsen due to aggravation of the inflammation. An electrical device, to provide stable stimulation, is usually used one week after onset. In acute cases treatment should be administered once daily or every other day for a 10-day course, with a three-day rest from treatment after every two courses, and in chronic cases treatment should be given every few days. Acupuncture method and manipulationF or points Dicang ST-4, Jiache ST-6, Sibai ST-2, YifengSJ–17, Quanliao SI-18, Zanzhu BL-2, Yangbai GB-14, Yuyao(M-HN–6), Tinghui GB-2, Tinggong SI-19, Ermen SJ-21,Yingxiang L.I.-20, Heliao L.I.-19, Renzhong DU-26, ShenmaiBL-62, and Zhaohai KI-6, 30 gauge needles are used with even manipulation, and retained for 20 minutes. For points Hegu L.I.-4, Fengchi GB-20, Fenglong ST-40,Quchi L.I.-11, Neiting ST-44 and Taichong LIV-3, 30 gauge needles are used with reducing manipulation and retained for 20 minutes.For points Zusanli ST-36 and Zhaohai KI-6, 30 gauge needles are used with reinforcing manipulation and retained for 20 minutes. Electro-acupuncture: The paired points of Hegu L.I.-4 andJiache ST-6, Hegu L.I.-4 and Dicang ST-4, and Hegu L.I.-4 and Yangbai GB-14 are treated with electro-acupuncture alternately. Electro-acupuncture is applied intermittently (10-40 cycles/minute) for 15 minutes at a strength that the patient can feel,and which causes slight contraction of the muscles. Herbal treatment Chinese herbs are highly recommended, and can improve the therapeutic effect of acupuncture. The commonly used formula is Qian Zheng San (Lead to Symmetry Powder) with modifications : Bai Fu Zi (Rhizoma Typhonii Gigantei seuRadix Aconiti Coreani), Bai Jiang Can (Bombyx Batryticatus)and Quan Xie (Buthus Martensi). • For wind-cold Fang Feng (Radix Ledebouriellae Sesloidis)is added. • For phlegm obstruction Er Chen Tang (Two Cured Decoction) is added along with some extinguishing Liver wind herbs such as Tian Ma (Rhizoma Gastrodiae Elatae) and Gou Teng (Ramulus Uncariae Cum Uncis). • For blood stasis Chuan Xiong (Radix Ligustici Wallichii) and Hong Hua (Flos Carthami Tinctorii) are added. • For wind-phlegm-heat Dan Nan Xing (Pulvis Arisaemaecum Felle Bovis) is added. • For phlegm-heat Quan Gua Lou (Fructus Trichosanthis)is added. Self-care Self-care is very important. Patients should wear a scarf or mask to protect their face and prevent exposure to wind and cold. If the eye on the affected side does not close completely,it is essential to maintain conscientious eye care to prevent eye damage, for example using eyedrops to moisten the eye and a soft towel to cover the unclosed eye during sleep. If eye pain develops or if the eye becomes damaged,the patient should be referred to an ophthalmologist. When there is no feeling on one side of the mouth with reduced secretion of saliva, food particles may lodge causing gum disease or tooth decay. The patient must be sure to brush and floss their teeth frequently and carefully. As the facial nerve begins to function again, patients should carry out self-massage to strengthen the facial muscles and speed their recovery Case examples Case one A 50-year-old female suffered with a headache for 5 days.Last night she noticed that she had developed left facial numbness, twitching of the facial muscles, and difficulty closing her left eye and blinking. There was slight pain in her left face and ear, and deviation of her mouth, which could not close tightly. There was no food lodged in her mouth, no nausea and vomiting, and neither dizziness nor tinnitus. Her blood pressure was 150/80 mmHg. She had no history of hypertension or high cholesterol. The function of her extremities was normal. Her tongue was red at the tip,with a slightly yellow and dry coating, and her pulse was wiry. She was sent to a medical doctor in order to rule out stroke and to receive a western medicinal diagnosis. After MRI examination showed there were no brain abnormalities,she was diagnosed with Bell’s palsy and was prescribed aspirin for headache relief. She then returned to the acupuncture clinic. The TCM diagnosis was facial paralysis and the pattern differentiation was wind-cold-phlegm blocking the channels and collaterals and transforming into heat. Acupuncture was given at SibaiST-2, Dicang ST-4, Jiache ST-6, Yangbai GB-14, TongziliaoGB-1, Zhigou SJ-6, Hegu L.I.-4, Quchi L.I.-11, Zusanli ST-36 and Taichong LIV-3, all on the left side, with either ErmenSJ-21 or Quanliao SI-18 added at alternate treatments. Acupuncture was given every day, with mild manipulationon the first two days of treatment. One week after the onset of the disorder, stronger stimulation was given, together with electro-acupuncture alternately at either Hegu L.I.-4 and Dicang ST-4, or Hegu L.I.-4 and Jiache ST-6. All needles were retained for 20 minutes at each treatment.The herbal medicine formula prescribed was Qian Zheng San (Lead to Symmetry Powder) with modifications: Quan Xie (Buthus Martensi) 6g, Bai Jiang Can (BombyxBatryticatus) 10g, Bai Fu Zi (Rhizoma Typhonii Gigantei seuRadix Aconiti Coreani) 5g, Tian Ma (Rhizoma GastrodiaeElatae) 10g, Gou Teng (Ramulus Uncariae Cum Uncis) 12g(added later), Dan Nan Xing (Pulvis Arisaemae cum FelleBovis) 4g, Di Long (Lumbricus) 10g and Chuan Xiong (RadixLigustici Wallichii) 10g. After one acupuncture treatment and one dose of this formula, her condition had stabilised. There was no pain in her face and ear but she continued to experience discomfort in these areas. Her left eye still could not close well. After taking the herbs, she had slight diarrhoea with three bowel movements a day, but without abdominal pain or discomfort. The dosage was therefore reduced to one bag every two days. Following one week of treatment her face was much better, with normal sensation and no obvious deviation. Because she was a visitor to our city, she was told to continue the acupuncture treatment in her home town to consolidate the effects. Case Two A 37-year-old female had suffered from facial paralysis for 2months. It began two weeks after minor abdominal surgery.The right side of her face was paralysed and her mouth was deviated; she was experiencing pain in the muscles of the right side of her face and inside her right ear; she could not close or blink her right eye; food was always getting stuck in the right side of her mouth when she was eating, and her mouth could not close tightly. She had occasional headaches and she also suffered hair loss and stress. She had bad breath,a good appetite and normal bowel movement. Her tongue was pale red with a yellow, greasy and thick tongue coating,and her pulse was wiry and slippery. A Western medical examination ruled out other medical problems that might be causing the facial paralysis, and she was diagnosed with Bell’s palsy but received no treatment. I diagnosed her with obstruction of wind-phlegm in the channels and collaterals,transforming into heat. The treatment principle was to disperse wind, clear heat, transform phlegm and unblock the channels and collaterals.The following points were used: Hegu L.I.-4, QuchiL.I.–11, Taichong LIV-3, Yanglingquan GB-34, YangbaiGB–14, Zanzhu BL-2, Sibai ST-2, Dicang ST-4, Jiache ST-6and Tinggong SI-19, all on the right side.The herbal prescription was modified Qian Zheng San (Lead to Symmetry Powder): Bai Fu Zi (Rhizoma TyphoniiGigantei seu Radix Aconiti Coreani) 6g, Bai Jiang Can(Bombyx Batryticatus) 10g, Quan Xie (Buthus Martensi)10g, Ban Xia (Rhizoma Pinelliae Ternatae) 12g, Fu Ling(Sclerotium Poriae Cocos) 15g, Chen Pi (Pericarpium CitriReticulatae) 6g, Da Huang (Radix et Rhizoma Rhei) 9g(added later), Quan Gua Lou (Fructus Trichosanthis) 15gand Sheng Gan Cao (Radix Glycyrrhizae Uralensis) 6g. One bag was given to her to take over two days.Three days later, on her second visit, her tongue had changed greatly, being pale red with a slightly red tip and a thin white coating, but the symptoms had not improved. Acupuncture was broadly the same, with Tinggong SI-19 omitted, and Zusanli ST-36 and Sanyinjiao SP-6 added. Electro-acupuncture stimulation was given at Hegu L.I.-4and Dicang ST-4.The herbal prescription remained a modified Qian Zheng San (Lead to Symmetry Powder): Bai Fu Zi (Rhizoma Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia) was prescribed to nourish Kidneyyin, 3 pills three times daily. No raw herbs were prescribedat this visit. A week later, on her fifth visit, her condition was evenbetter. The pain in her face and ear was 90% improved and the food lodging in her mouth was 80% better, but her eye still could not close fully. Her tongue was the same as before,and her pulse was slippery and no longer wiry. I changed the acupuncture prescription slightly as follows: Tinghui GB-2,Sizhukong SI-23, Juliao ST-3, Yangbai GB-14, Jiache ST-6,Hegu L.I.-4, Waiguan SJ-5, Fenglong ST-40, Zusanli ST-36,Sanyinjiao SP-6, Yinlingquan SP-9 and Taixi KI-3. The herbal prescription remained modified Qian Zheng San (Lead to Symmetry Powder): Bai Fu Zi (Rhizoma Typhonii Giganteiseu Radix Aconiti Coreani) 6g, Bai Jiang Can (BombyxBatryticatus) 10g, Quan Xie (Buthus Martensi) 6g, Ban Xia(Rhizoma Pinelliae Ternatae) 10g, Fu Ling (SclerotiumPoriae Cocos) 12g, Quan Gua Lou (Fructus Trichosanthis)12g, Chen Pi (Pericarpium Citri Reticulatae) 6g and Zhi GanCao (Radix Glycyrrhizae Praeparatae) 6g, one bag for twodays, with continued use of Liu Wei Di Huang Wan. Acupuncture treatment continued. Altogether she received treatment for two and half months,a total of 9 treatments. Her facial paralysis was virtually cured except for her right eye which did not close entirely,but this did not cause her any concern, and she was pleased that her hair loss had improved. Dr. Zhenbo Li, Ph.D., L.Ac., Dipl.C.H., is a professor of Traditional Chinese Medicine and has taught and practised Chinese medicinein the United States for many years. She received her degrees from Shandong University of Traditional Chinese Medicine and Guangzhou University of Traditional Chinese Medicine. She has worked as an associate professor in the Internal Medicine Department of the Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. |
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