Journal of Chinese Medicine Number 84 June 2007 1 Electroacupuncture: An introduction and its use for peripheral facial paralysis

Electroacupuncture: An
introduction and its use for
peripheral facial paralysis
By: David F
Mayor
Keywords:
Acupuncture,
electro-
acupuncture,
electrotherapy,
Bells palsy,
facial paralysis,
neurapraxia
(neuropraxia),
neurotmesis,
nerve, muscle,
stages,
motor point,
denervation,
tetany, clinical
studies
database,
supercial
needling,
point-to-point
needling,
synkinesis,
contracture,
exercise, heat
Abstract
Acupuncture and electrotherapy interface in the practice of electroacupuncture (EA). This article introduces some of
the basic concepts and terminology of EA, its advantages and electrical parameters. The aetiology and incidence of
peripheral facial paralysis (PFP), its pathology and prognosis are then covered. Conventional treatment of PFP is briefly
mentioned, followed by a more detailed discussion of Western electrotherapy for the condition and the evidence for its
clinical use. Background information on manual acupuncture (MA) and PFP is given. The literature on EA is reviewed,
and EA treatment is then described according to the stage and severity of paralysis. Comparisons between EA and other
modalities and combinations with ancillary methods are outlined, and the acupoints and electrical parameters used
are analysed in some detail. A final discussion summarises some suggestions for safe and effective treatment.
This article is based on the chapter on peripheral motor disorders in the authors recently published
textbook on electroacupuncture,
1
together with material from the clinical studies database
at wwww.electroacupunctureknowledge.com and an internet trawl of recent research.
Note: This article is abridged due to space constraints. The full article at www.jcm.co.uk/JCM Journal/Latest Issue
includes a comprehensive table of facial muscles, nerves and corresponding acupuncture points and full references.
Electroacupuncture, electrotherapy
and peripheral facial paralysis - the
background
Electroacupuncture: an introduction
A
cupuncture and electrotherapy interface in
the practice of electroacupuncture (EA). Here
this is dened as the electrical stimulation
of acupuncture points (acupoints) through needles.
After the needles are inserted and deqi obtained in
the usual way, electricity is passed through pairs of
needles to give a continued stimulation, usually for
20-30 minutes.
Related treatments include probe or point TENS
(pTENS, electrical stimulation using a small diameter
handheld probe) and transcutaneous electrical
acupoint stimulation (TEAS, stimulation of acupoints
via surface electrodes). Another approach is laser
acupuncture (LA), the application of low intensity
laser light to acupoints, either transcutaneously or
through an inserted hollow needle. pTENS, TEAS and
non-invasive LA are useful if patients nd needles
unacceptable, although their effects are not identical.
EA is applied at the same points as traditional or
manual acupuncture (MA), and has been used for
most conditions for which MA is indicated, especially
when manual stimulation has not brought a response,
or when strong reduction is appropriate (e.g. for
severe or acute qi and/or blood stagnation). It is less
commonly used in deciency conditions.
Like other forms of electrotherapy, EA is particularly
indicated for pain (as in painful obstruction [bi]
syndrome), paralysis (both accid and spastic)
and muscle wasting (as in atrophy disorder [wei
syndrome]). It has benecial effects on microcirculation,
inammation and nerve damage.
1
Advantages of EA include:
EA is more effective than MA in some situations,
and often potentiates the effects of traditional
methods, particularly when strong, continued
stimulation is required, as when treating paralysis
or some forms of pain.
2
EA can be less time consuming and less demanding
of the practitioner than MA, in both training and
practice.
Results may in some cases be more rapid,
3
and
longer lasting.
4
EA may have specic effects on pain, relaxation,
circulation and muscle that are different from those
of MA.
5
EA is more readily controlled, standardised and
objectively measurable than MA.
Non-invasive stimulation methods can also be cost
effective for home treatments, perhaps between
sessions with a practitioner, although some forms
of treatment will require supervision.
EA allows stronger, more continuous stimulation
than MA,
6
and with less tissue damage.
Journal of Chinese Medicine Number 84 June 2007 2 Electroacupuncture: An introduction and its use for peripheral facial paralysis
EA differs from MA in several respects (see table 1):
The parameters of EA
The electric current used in EA has various
characteristics: polarity, frequency, amplitude/
intensity, mode, pulse duration, waveform.
Polarity (and pulse duration)
Current should be biphasic (as in alternating current)
rather than monophasic (as in direct current). In other
words, current should ow one way and then the
other way between the needles, rather than always
the same way:
Fig 1. (a) Biphasic square wave current; (b) Monophasic
square wave current. This gure also shows pulse duration.
(Adapted from Mayor 2007, with permission.)
Frequency
Frequency (more accurately, the pulse repetition rate
or number of pulses delivered per second) is measured
in units of Hertz (Hz). In EA, a low frequency (LF)
would be approximately 2-4 Hz or pulses per second.
A high frequency (HF) would be 50-200 Hz.
Amplitude/intensity
Depending on the type of equipment used, amplitude
may be a measure of current or voltage. In EA,
maximum amplitude may be of the order of 12
mA (milliampres), or 9 V (volts), but these gures
will vary considerably depending on equipment
design, and will take account of safety issues for
the particular device in question. The strength of
sensation experienced by the patient depends on
amplitude more than on frequency. Sometimes the
level of stimulation is described as sensory (feelable),
motor (resulting in muscle twitching) or noxious
(frankly painful).
Mode
Stimulation may be continuous (CW) (as in Fig.
1a above), intermittent (burst), dense-disperse
(DD, alternating higher and lower frequencies), or
otherwise modulated:
Fig 2. (a) 2 Hz intermittent (or burst) current, with an
internal frequency of 20 Hz; (b) Dense-disperse mode (4/30
Hz DD), repeating every 4 seconds. (Adapted from Mayor
2007, with permission.)
MA EA
Needle manipulation is brief and intermittent
Only low frequency is possible (twirling or lifting-thrusting)
Strong manipulation risks tissue damage
Stimulation is continued for the duration of treatment
No limitation to frequency of stimulus (frequency-specic effects occur)
Strength of stimulation only limited by patient tolerance
Table 1: Some
differences
between MA
and EA
Phase
duration
Pulse
duration i(mA)
+
_
(a)
Pulse duration
= phase duration
i(mA)
(b)
+
_
i
1 sec
Interburst
duration
Burst
duration
0.25 sec
5 pulses per
burst
t
(a)
i
30 Hz
t
(b)
4 Hz
2 4 6 8
Journal of Chinese Medicine Number 84 June 2007 3
Acupuncture-like stimulation (ALS)
LF (high intensity)
TENS-like stimulation (TLS)
HF (lowintensity)
2-4 Hz 50-200 Hz
Pulse duration of around 200 sec appropriate Pulse duration of 80-100 sec optimum
May be used locally or distally (at extrasegmental or contralateral acupoints,
for example)
Used locally (for instance at ipsilateral rather than
contralateral points)
Has segmental and supraspinal neurophysiological effects
Has segmental effects (large diameter bres inhibit pain
signals in small diameter bres in the spine)
Releases -endorphin and Met- enkephalin neurotransmitters in the brain
Releases dynorphin in the spinal cord (and other peptides
in the brain)
Strong stimulation elicits deqi-like sensation High intensity may be uncomfortable
LF does not produce muscle spasm at high intensity (in normal muscle)
HF may result in uncomfortable tetany (but may also be
useful for spasticity)
Intermittent pulse trains at high intensity may result in uncomfortable tetany Intermittent pulse trains at low intensity enhance comfort
Central effects mean analgesia has slow onset and lasts longer 30 minutes
may sufce for ongoing effect (cumulative)
Spinal mechanism means analgesia has rapid onset and
does not last long longer periods of treatment may be
necessary
No tolerance develops from such short treatments Tolerance may develop from longterm use
Tends to be used more for chronic pain Tends to be used more for acute pain
For deep, aching, throbbing pain For supercial pain associated with inammation
May be helpful for neuralgia and other neuropathic pain (contralateral or
distal)
May be helpful for neuralgia and other neuropathic pain
(local)
May benet peripheral (sensory) nerve injury
May be used in hyperaesthesia (especially if cutaneous) May aggravate hyperaesthesia
Used for accid paralysis (stroke, Bells palsy) Used for spasticity
Electroacupuncture: An introduction and its use for peripheral facial paralysis
Waveform
We usually think of waves as curving, rolling,
moving forms in nature. In EA, however, square (or
rectangular) waves are mostly used, as illustrated
here, although some EA devices produce spike or
other waveforms.
Stimulation ranges
It is helpful to consider two main types of stimulation:
low frequency (LF)/high intensity (subjectively strong,
though still tolerable), and high frequency (HF)/low
intensity (subjectively gentle and comfortable). Because
of the way these were developed and researched the
former predominantly as EA in China and the latter
predominantly as TENS (transcutaneous electrical
nerve stimulation) in the West, I have called them
acupuncture-like stimulation (ALS) and TENS-like
stimulation (TLS), whether they are applied through
needles or surface electrodes.
At around 15 Hz, a frequency between the LF and
HF ranges, effects may depend on both mechanisms.
There is still lack of agreement on whether frequency
or intensity is more important in terms of outcome.
EA is frequently used in the treatment of peripheral
facial paralysis. The discussion that follows illustrates
some of the basic principles involved.
Cautionary note
Electroacupuncture, like any form of electrotherapy,
should only be practised following proper instruction
and with knowledge of its safety aspects.
(Based on Mayor 2007
1
)
Table 2: Some
differences
between
acupuncture-
like and TENS-
like stimulation
Journal of Chinese Medicine Number 84 June 2007 4 Electroacupuncture: An introduction and its use for peripheral facial paralysis
Peripheral facial paralysis (PFP) (Bells palsy,
idiopathic facial paralysis)
Aetiology and incidence
Facial paralysis is the result of a motor neuron lesion. This
may be peripheral (lower, below the nucleus of the nerve
cell, or infranuclear) or central (upper, supranuclear).
Most cases (around 60-75%
7
) of peripheral facial
paralysis (PFP) result from virally induced inammation
of the peripheral facial nerve (cranial nerve VII),
8
or its
compression due to vasospasm or oedema, generally
in the mastoid region. Occasionally the condition is
bilateral.
9
It is particularly associated with herpes simplex
or zoster infection, and may be precipitated by exposure
to draughts on the face.
10
An unpleasant variant is Ramsay
Hunts syndrome (herpes zoster oticus), in which paralysis
is associated with a herpetic rash in or around the ear or
on the roof the mouth.
11
This condition also involves the
acoustic nerve (cranial nerve VIII), which emerges from
the brain just behind the facial nerve.
12
The facial nerve may also be damaged by surgery for
removal of an acoustic neuroma, or by trauma. In one
standard physical therapy textbook, surgical damage was
estimated to be responsible for 13% of cases of PFP, and
other trauma for about 6%.
13

As with any nerve injury, compression to the facial
nerve results in neurapraxia (often spelled neuropraxia), a
localised conduction block that recovers relatively quickly
(within days or weeks) or, if more severe, in axonotmesis,
degeneration of the nerve beyond the injury, with
subsequent slow regrowth of the nerve (at an average
of some 1 mm daily). Complete severance of the nerve,
neurotmesis, may mean that it is highly unlikely to grow
back to its target tissue.
PFP or Bells palsy is not uncommon, with a reported
incidence of 13-34 per 100,000 according to different
epidemiological surveys,
14
occurring most frequently
between the ages of 20 and 40
15
(although I had it myself
as a teenager, after sitting in a draught after suffering
chicken pox).
In some instances, the supranuclear pathway is
involved as a result of cerebrovascular accident,
with cortical or corticobulbar lesions, dissociation of
voluntary and involuntary facial movements, and
possibly other ipsilateral paralysis or aphasia. This
can be differentiated from PFP by assessing the effects
of magnetic stimulation of the cortex and facial nerve
on the electromyogram (EMG) of the mentalis (chin)
muscle.
16
However, the possibility of simultaneous PFP
and asymptomatic cerebral infarction should not be
overlooked.
17
Furthermore, as with sensory disorders and
the development of chronic pain, when motor conditions
become chronic the distinction between peripheral and
central may be less clear as cortical reorganisation occurs.
18

Treatment may need to take this into account, working
with neuroplasticity within the central nervous system
as well as being directed at peripheral regeneration and
repair.
Apart from stroke, Lyme disease, brain tumour and
other possible causes such as multiple sclerosis and
Guillain-Barr syndrome should be ruled out before
treating as PSP.
19,20,21

Pathology and prognosis
Pain behind or in front of the ear may precede the paralysis,
which affects the muscles of expression (mimesis), such
as those above the eyes (frontalis and orbicularis oculi
superioris). Clinical symptoms are likely to include
incomplete closure of the eye, drooping of the mouth,
and an inability to frown, raise the eyebrow, close the eye,
blow out the cheek, show the teeth or whistle.
22
Disordered
lacrimation and salivation (too much or too little
21
) occur
not only because of loss of muscle control, but also because
bres from the facial nerve innervate both the lacrimal
gland and the parotid gland and plexus (parotidectomy
may in fact induce temporary facial paresis,
23
or even,
unfortunately, permanent paralysis
21
). Further symptoms
may include continued pain or numbness,
19
loss of taste
in the anterior two-thirds of the tongue due to lesion of
the (sensory) geniculate ganglion of the facial nerve, and
hyperacusis due to paralysis of the stapedius muscle
(innervated by the stapedial branch of the nerve).
24

Muscle twitching may also occur,
19
and one unfortunate
sequela can be synkinesis, abnormal involuntary muscle
movement accompanying voluntary movements of other
facial muscles (jaw winking, or twitching of the eyelid
with voluntary movement of the lips, for example
25
). These
sometimes develop as recovery progresses.
26
Contractures
were reported in one early electrotherapy RCT to occur in
23% of those with initial complete muscle denervation.
27

(Early brillation is not, unfortunately, a sign that muscle
is recovering.
28
)
Chinese acupuncture studies usually describe three (or
sometimes four) stages of PFP:
1. Acute phase (up to 7 days), during which symptoms
usually worsen.
2. Stable (or resting) period (8-14 days).
3. Convalescence (from 15 days), during which there is
usually a gradual improvement in symptoms.
22
4. Chronic phase (from 2 months onwards).
29
Without treatment, some 85% of PSP patients show
initial signs of recovery within 3 weeks, a further 15%
within 3-5 months. Around 66% are fully recovered by
3 months.
30
Thus in one study of 54 patients, voluntary
movement appeared 16 days post onset on average, with
full recovery by 6.3 weeks.
31

Overall, a fortunate 80%-84%
32
recover to an acceptable
level within weeks to months, although 20-30%,
14
or even
one-third
30
of patients may be left with some residual
symptoms. More optimistic gures have been given by
one Chinese author
19
(75% complete recovery, mostly
Journal of Chinese Medicine Number 84 June 2007 5 Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
within 2-3 weeks, 15% with persistent facial asymmetry,
and only 5-10% showing poor recovery at 4 months).
For those who suffer Ramsay Hunts syndrome, there is
a less than 20% chance of spontaneous recovery.
11

Prognosis is better for those with milder symptoms at
onset, and who start to recover more quickly, indicating the
presence of a neurapraxia and only partial denervation of
muscle.
33
A less favourable outcome is likely in those with
complete facial weakness (suggesting axonotmesis or even
neurotmesis and total muscle denervation), pain other
than in or around the ear, and systemic hypertension,
34
as
well as in those aged over 50
15
or 60
35
at onset.
Conventional treatment and electrotherapy
Conventional treatment of PFP tends to be based on anti-
viral medication (Acyclovir, Valtrex
36
) and a steroid such
as Prednisolone in the acute phase,
8,37, 38,39,40
with surgical
decompression reserved for serious cases (compound
muscle action potential amplitude decrease greater than
90% within 2-3 weeks after onset).
41
It may also include
EMG biofeedback,
14
and neuromuscular retraining to
inhibit the development of synkinesis.
26
Electrotherapy originally developed in the West
following the discovery in the ancient world that discharges
from electric sh, particularly the mediterrranean torpedo
and Nile catsh (malopterus electricus), could be used
therapeutically (although not to my knowledge for PFP).
It is intriguing that Li Shizhen mentions the use of a
different catsh (parasilurus asota) as a treatment for facial
paralysis in his Bencao Gangmu,
42
but this particular species
(like other known species of sh in Chinese waters) does
not have the shocking potential of its distant cousins in the
Nile.
43
Electrotherapy in China is a Western import.
Electrotherapy has been used for various forms of
paralysis since the mid-eighteenth century, usually with
the notion that eliciting muscle twitches will somehow
encourage recovery. Where applied electrical stimulation
results in maximum contraction is termed the muscles
motor point. However, whereas in neurapraxia (partial
denervation) it is still possible to excite facial muscle via
the motor nerve, in neurotmesis (complete denervation)
muscle no longer has any motor point/s and muscle
bre has to be stimulated directly. Without electrical
and neurochemical input, muscle soon atrophies, with
increasing degeneration and brosis, a process beginning
within 1 to 2 weeks after the initial lesion and complete
(and very possibly irreversible) by about 3 years.
44
Facial
muscle, however, tends to atrophy somewhat more slowly
than other larger muscles,
14
and perhaps for this reason
electrical stimulation can have a greater effect on the small
muscles involved in PFP than on larger muscles elsewhere
in the body.
32
There is much controversy over the usefulness of
stimulating denervated muscle. With reduced circulation,
self-repair becomes more difcult in the event of
trauma, so excessive exercise (electrically induced or
otherwise) is best avoided as it may increase brosis. It
may also delay reconnection of nerve and muscle,
28
and
activate neurochemical feedback that in fact slows nerve
regrowth.
45
Thus poorly selected electrical parameters
may even inhibit neural regeneration after peripheral
nerve injury.
46,47
However, stimulation can benet the
muscle by maintaining nourishment to the tissue and
aiding repair, so delaying atrophy and brosis even if not
completely preventing them
.44,48
It also fosters a return to
normal voluntary use once reinnervation occurs.
49

One form of muscle stimulation called trophic electrical
stimulation (TES) uses low frequencies and amplitudes
based on the patterned ring characteristics of motor
units themselves, rather than the more is better tradition
of most methods that use constant frequencies.
50
It is
therefore less fatiguing,
51
and appears to maintain muscle
tone by altering metabolism rather than by providing a
form of induced exercise.
14,52
For PFP, TES uses a range
of frequencies between 5 Hz and 15 Hz.
53
Interestingly,
frequencies in the physiological tremor range (~10 Hz)
may be more effective than twitch (slower) or tetanic
(faster) frequencies in stimulating circulation (and so
enhancing tissue repair).
54,55,56,57
Sustained contraction of muscle (tetany) occurs if
completely denervated muscle is stimulated at around 3
10 Hz (a much lower frequency than in normal muscle).
58

It would thus seem logical to use low-intensity LF
59,60

stimulation with short pulse durations, rather as in TES, in
preference to the strong and long higher-frequency tetanic
pulses often advocated in the past.
61
Long interruptions
(of 30 seconds,
62
4 minutes,
63
even 15 minutes
64
) between
contractions have also been advocated, with short
treatments repeated at least twice or even three times
65

daily to reduce muscle fatigue,
63
although muscle fatigue
as such may have little effect either way on the rate
of reinnervation.
66
Despite these various suggestions,
there are no generally accepted guidelines on optimum
parameters.
If reinnervation is possible, except in simple neurapraxia
it is in a race against muscle degeneration. Clearly then
it is important to begin stimulation as soon as possible
after the lesion,
66,67
while it may appear futile to attempt
to work an apparently brosed muscle. In between these
two extremes, it is a matter of clinical judgement whether
to stimulate or not.
Once normal innervation is re-established, there is little
to be gained by continuing stimulation.
49

Electrotherapy for PFP: the evidence
Experimentally, electrical stimulation has been shown
to benet axon regeneration in rabbits with traumatic
facial nerve injury.
68
Despite such evidence, and despite
considerable theoretical support for the application of
electrical methods in the treatment of PFP, there are
Journal of Chinese Medicine Number 84 June 2007 6 Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
surprisingly few clinical studies that unequivocally
support the use of electrotherapy for this condition.
14,52
In
their 2003 review, Rosie Quinn and Fiona Cramp found for
example that conclusive ndings relating to the efcacy
of electrotherapy in Bells palsy are still lacking (as so
often, because of methodological shortcomings in clinical
studies). However, they also suggested that there is no
evidence to suggest that electrical stimulation is benecial
to patients with acute Bells palsy, but evidence does exist
to suggest benecial effects of electrical stimulation in
patients with chronic Bells palsy. Another best evidence
review again found no evidence (published in English)
that electrotherapy is benecial in acute PFP, although
stating that its use might be justiable in long term Bells
palsy.
69
When it comes to other electrotherapy modalities,
Quinn and Cramp concluded that ultrasound may benet
acute Bells palsy, but that there is no convincing evidence
that shortwave diathermy and low intensity laser therapy
(LILT) are useful for the condition.
14
Given the paucity of good quality research, it is hardly
surprising that an ofcial US report from 1984 found that
electrotherapy has no demonstrable benecial effect in
enhancing the functional or cosmetic outcomes in patients
with Bell's palsy,
70
or that in 1989, a standard physical
therapy textbook still concluded that electrotherapy
may not be clinically effective for this condition.
13
Some
authors even state categorically that electrical stimulation
should not be used for facial paralysis.
71
Others suggest
that any electrical stimulation is contraindicated if its
purpose is to stimulate accid muscles, as this may foster
the development of synkinesis, where the aim should be
to inhibit contracture rather than to encourage it.
26
Thus
Medicare in the USA does not cover electrotherapy for
the treatment of PFP,
72
while some insurance companies
consider electrical stimulation only as investigational/
not medically necessary.
7
It is interesting that the one study that meets with the
approval of all the reviewers is one on TES.
73

Acupuncture
Acupuncture has frequently been used for Bells palsy.
One Chinese review of the acupuncture literature on
PFP over 50 years cites over a thousand articles, of which
just over 15% were randomised controlled trials (RCTs)
or controlled trials (CTs).
74
Traditionally, acupuncture is
considered very effective for the condition. Thus another
Chinese non-systematic review of 50 studies carried out
over a 10-year period found a complete recovery rate
averaging some 81% (37% - 100%).
75
There are other claims
of 95%
76
or even 99.6%.
77

Given the ~80% spontaneous recovery rate, it is perhaps
not surprising that there are many reports of MA being
helpful for facial paralysis.
78,79,80,81,82
MA has also been
employed for facial paralysis due to diabetic (motor)
neuropathy, particularly of the oculomotor nerve,
80,83

and is sometimes combined with other traditional
interventions such as bleeding
84
or cupping.
85
Reviews
of the many acupuncture-based methods used have been
published,
75,29,86
as well as a 2003 Cochrane systematic
review on the subject. This authoritative if poorly
Abbreviations used
~ Approximately
ALS acupuncture-like stimulation
CT Controlled trial (non-randomised)
CW Continuous stimulation (at constant
frequency)
DD Dense-disperse (alternating
frequencies)
EA Electroacupuncture
EHF Extremely high frequency
EMG Electromyogram
HF High frequency
LA Laser acupuncture
LF Low frequency
MA Manual or traditional acupuncture
MUAP Motor unit action potential
N Number of patients in a study
NMES Neuromuscular electrical stimulation
PFP Peripheral facial paralysis (Bells palsy)
pTENS probe or point TENS, using a small
diameter handheld probe
RCT Randomised controlled trial
TCM Traditional Chinese medicine
TDP Te ding dian ci bo pu (type of far-infrared
lamp)
TEAS Transcutaneous electrical acupoint
stimulation
TES Trophic electrical stimulation
TENS Transcutaneous electrical nerve
stimulation
TLS TENS-like stimulation
WM Western medicine
Terms that may be unfamiliar to some readers
Axonotmesis = Degeneration of nerve beyond the
point of injury
Compound muscle action potential amplitude
= A measure of electrical activity in a group of
muscles
Contralateral = Pertaining to the opposite side
Cortical = Pertaining to the (cerebral) cortex
Corticobulbar = Pertaining to the cerebral cortex
and brainstem
Denervation = Interruption of nerve supply to
tissue (may be partial or total)
Hyperaesthesia = Increased, sometimes extreme,
sensitivity to stimuli
Hyperacusis = Exceptionally acute hearing,
sometimes accompanied by pain
Infranuclear = Below or peripheral to the nucleus
of a neuron
Ipsilateral = Situated on the same side
Neurapraxia (neuropraxia) = Conduction block in
injured nerve that recovers relatively quickly
Neuropathic pain = Pain that originates from
trauma or injury to the nervous system itself
Neurotmesis = Complete severance of a nerve
Ramsay Hunts syndrome = Facial paralysis
associated with a herpetic rash in or around the
ear or on the roof the mouth
Segment = Section of the spinal cord, with the
skin, muscle, bone and organ regions innervated
by the associated spinal nerves
Supranuclear = Above or central to the nucleus of
a neuron
Supraspinal = Pertaining to the region above the
spine
Synkinesis = Abnormal involuntary muscle
movement accompanying voluntary movements
of other muscles
Tolerance = Reduced response to treatment
following prolonged or repeated us
Journal of Chinese Medicine Number 84 June 2007 7
reported and very limited source, based on a total of
only 288 patients in three RCTs in which acupuncture (or
acupuncture plus medication) was reported as superior
to medication alone, found that there is still insufcient
evidence from randomised trials to decide whether
acupuncture is helpful for Bells palsy.
15
It is important to
note that this review was limited to cases treated within 14
days from onset and excluded chronic sequelae and cases
involving diabetes, herpes zoster or other causes. Also
excluded were TEAS, pTENS and LA.
In general, clinicians and less systematic reviewers
have concluded, like Zhang Hong in this journal,
22
that
acupuncture, whether MA or EA, can shorten time to
recovery and enhance curative effect.
87,88,89,90

Predictably, less good results are reported for Ramsay
Hunts syndrome,
91
while in one large Russian review
facial paralysis of vascular origin had the least good
prognosis of all the types treated.
35
(However, any
intervention that improves local circulation is likely not
only to help release local nerve compression but also to
assist nerve regeneration.
92
MA, for instance, has been
found to increase facial temperature in patients with Bells
palsy,
93,94
with temperature also increasing in response to
auricular MA in one successful case.
95
)
Traditional Chinese medicine (TCM) and PFP
In TCM terms, PFP is usually considered to result from
the invasion of wind-cold due to an underlying deciency
of qi or poor circulation in the channels and collaterals
in the face, with resultant stagnation of qi and blood.
The condition may also be complicated by pre-existing
phlegm.
19
Disharmony of Liver qi has also been proposed
as a contributory factor.
96
Acupoints may be selected
according to a further differentiation (channel blockage
due to wind-cold or wind-heat, qi and blood stagnation, or
qi and blood deciency).
29
Once PFP has become chronic,
Liver and Kidney yin deciency may complicate the
picture.
29
One author has suggested that PFP caused by
invasion of wind-cold is most responsive to acupuncture
treatment.
97
It is instructive that Julius Althaus, one of
the greatest European electrotherapists of the nineteenth
century, attributed most cases of Bells palsy to the
inuence of damp and cold.
98

Bleeding (at jing-well points),
99
and bleeding and
cupping,
100
have been used in the acute phase of PFP,
as well as bleeding alone for chronic PFP with blood
stagnation.
101
In keeping with conventional electrotherapy ndings,
better results have been reported with MA when higher
electrical potentials are found at acupoints on the affected
side than at symmetrical points on the opposite side,
particularly if these potentials increase markedly with
the rst treatment.
102
One group of researchers has also
used temperature differentials between the affected and
unaffected side to determine MA point selection.
103

Electroacupuncture in the treatment of peripheral facial
paralysis
Because of its effects on pain, paralysis, muscle wasting,
microcirculation, inammation and nerve damage, we
would expect EA to be perfectly suited to the treatment of
PFP (although Bruce Pomeranz has suggested that simple
manual needling may in fact induce electrical current of
injury levels and densities in precisely the range required
for nerve regrowth
104
).
Indeed, in experimental studies EA has been found to
benet facial nerve regeneration following trauma,
105,106

while a quick Medline search (February 2007) using the
terms facial paralysis AND electr* reveals more studies
on EA than on all other forms of electrotherapy for PFP, at
least in recent years.
Furthermore, in the present journal (Journal of Chinese
Medicine, 1979-2006
107
), 8 of 16 articles, case studies or
abstracts on PFP included discussion of EA. And in one
2005 comprehensive review of the Korean acupuncture
literature (1983-2001),
108
of 124 studies retrieved, 9 were on
PFP, and of these only one did not make use of electrical
stimulation.
The clinical studies database at www.elecroacupunc
tureknowledge.com currently includes 167 studies on
PFP, including full details of acupoints and electrical
parameters used in each study (if known). Please note
that this database does not include or exclude studies
on the basis of methodological merit. While it provides
an essential contribution for the formulation of further
treatment and research protocols, authors claims as
to outcome may not be sustainable when subjected to
rigorous scientic criteria.
Analysis of the clinical studies database indicates that
many authors have observed that EA gives better results
than MA for PFP
75
(see too below, under Comparisons and
Combinations). Some have gone so far as to suggest that
acupoint electrostimulation (without needles) is a method
of choice for Bells palsy,
109
although others, more cautious,
have stated categorically that electrical stimulation should
not be used for facial paralysis.
78

Treatment according to stage and severity of paralysis
The three standard stages of PFP described in the
Chinese literature have been mentioned above. Selecting
appropriate acupuncture treatment at each stage may
speed up recovery
110
and improve results.
111,112
1. Acute phase
Symptoms normally worsen during the 7 days or so of
this phase and then level off. Thus early aggravation may
be erroneously attributed to acupuncture (although it may
also result from incorrect treatment).
22
On the other hand,
stability of symptoms in one case study when treatment
was started only towards the end of the acute phase was
attributed to EA!
19
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 8
Except in cases of simple neurapraxia it is usually
considered important to begin stimulation as soon as
possible after the lesion occurs, even though the effects of
acupuncture may not be evident until the acute phase is
over
113
(except perhaps to the electrophysiologist
114
). Thus
in acupuncture generally, the emphasis is very much on
early treatment.
97,115,116,117,118,119,120,121,122
In one small study (N
= 22) of EA initiated between 1 and 30 days after onset
of PFP, for example, results were better in those treated
earlier.
123
Similarly with LILT, with better results in those
treated less than 15 days after onset reported in another
small study (N = 17).
9
Despite such plausible evidence,
Zheng Qiwei and Li Zhenbo have cautioned that EA
should not be used initially, for fear of inducing spasm.
124,19

Authors such as Cui Shugai,
125
Qiu Meihua
126
and Wu
Yixin et al
120
have followed this approach.
One approach to initiating treatment during the acute
phase is to use points on the healthy side of the face, and
points on the affected side only in the stable period. In one
MA study this gave better results than routine acupuncture
and moxibustion in all three phases.
127
In another, results
with contralateral MA were better than with TDP to
the affected side along with intravenous medication.
128

Surprisingly, there appear to be very few studies in which
EA was applied on the nonparalysed side,
129
although
there are some in which it was used bilaterally on facial
points.
130,131,132
Supercial needling has been used in several
acupuncture studies,
133
in at least one explicitly during
the acute phase and early stable period (with better
results for MA than standard Western medicine, WM).
134

In another such study, although overall results were
similar for both supercial needling and conventional
acupuncture (MA), sequelae were less with the former,
135

and in one RCT supercial needling was better than
point-to-point needling (disease stage unclear from the
study abstract).
136
Supercial needling has also been used
for chronic PFP.
85

Gentle needling was found superior to strong stimulation
in one MA report on early stage PFP
137
(and to improve and
speed up results with standard WM in another).
87
However,
this may not be a universal nding: strong stimulation (with
point-to-point needling) in a study of acute stage and early
stable period PFP resulted in a 100% total effective rate
(herbal medication and a steroid only providing 55%).
138
Although in one large RCT on acute PFP (N = 477),
supercial MA was found superior to 1 Hz EA,
139
EA
with carefully controlled parameters
140,141,142,123
(as well as
other forms of acupoint electrostimulation
143
) has been
found helpful during the acute phase. Thus, in another
controlled trial (N = 80) where gentle (just perceptible)
EA was started within 14 days of onset, results were
considerably better than when treatment was begun
later.
22
Such studies appear to contradict the cautions of
Zheng Qiwei and Li Zhenbo against using EA at all during
the initial acute phase (of course relatively gentle EA is by
no means contraindicated later on
144
).
Nonetheless it should not be forgotten that strong
local electrical stimulation of the affected side may
well be counterproductive.
145,19
Such stimulation of
denervated muscle may potentially lead to contractures
and synkinesis,
146
especially early on.
124
However, one
much cited electrotherapy RCT from 1958 found that
interrrupted galvanic stimulation (pTENS) sufcient to
elicit only minimal contractions did not adversely affect
the development of facial muscle contracture despite
being used in the acute phase of PSP.
27
Provided treatment
is carefully designed and carried out, electrical stimulation
is not contraindicated during the acute phase of PFP.
There is also some justication for using both
ultrasound
14
and (possibly) microwave diathermy
147
or
TDP
148
during the acute phase.
2. Stable period
Most MA and EA studies consider the acute phase and
stable period together, dividing treatment into that started
in the rst two weeks after onset and treatment begun
later.
3. Convalescence (and chronic phase)
Prolonged sequelae of PFP (more likely in older patients)
tend to be refractory to both MA and EA. Thus, as already
stated, most sources emphasise the importance of starting
treatment early. In a comparison of two EA case histories
by Li Zhenbo, for example, PFP rst treated at two months
responded more slowly and less well than acute Bells
palsy treated only ve days after onset.
19
In contrast, one
standard NMES (neuromuscular electrical stimulation)
protocol, perhaps erring on the side of caution, advocates
delaying treatment until two months after onset.
149
In line with standard acupuncture practice, treatment
may usefully be continued for some weeks after apparent
clinical recovery, depending on EMG ndings,
150
although
not all agree that this is essential once normal innervation
is re-established.
In contrast to acute phase PSP, strong stimulation
may now be appropriate.
121
This was found superior to
uniform reinforcing-reducing in one comparative trial of
MA, for example.
151,152
Similarly, in a number of EA studies
in the clinical studies database treatment is started gently,
gradually increasing intensity (and sometimes frequency)
as the condition becomes more chronic.
Severity of the condition
The severity of a nerve injury will determine how rapidly
recovery will take place, and what effect EA will have on
this. Treatment will give poorer results in those with more
severe pathology.
153

The presence of incomplete paralysis in the rst week is
a favourable prognostic sign.
154
The response of affected
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 9
muscles to an initial session of intermittent EA has itself
been used to assess prognosis
155
(more accurate prognosis
may be obtained through electrical measurement
31,156,157,158
,159,102
or other methods
160
). In simple neurapraxia, EA may
not even be needed.
If recovery is delayed, then more than a simple
neurapraxia may be involved, with axonotmesis or
degeneration of the nerve peripheral to the lesion (as
often occurs following neuroma surgery). In these cases,
recovery is likely to be incomplete. As degeneration
can set in within a few days, many physical therapists
consider early treatment to be important, directed at
rst to relieving pressure on the nerve in the case of
neurapraxia.
161
However, even treatment several years
after the initial insult can produce useful results in cases
of axonotmesis if patients (and practitioners) are willing
to persist with it.
146
At this stage, the aim of treatment is to
assist nerve repair and facilitate muscle reeducation.
Lesion location
Several studies indicate that the lower (more peripheral)
the lesion along the facial nerve, the better the therapeutic
effect of acupuncture
162,163,24
and moxibustion.
164
The authors
of one RCT found that whereas cases with lesions outside
the facial (nerve) canal tend to recover spontaneously,
lesions within the canal benet from acupuncture.
165
Comparisons and combinations
Comparisons
EA is more effective than MA according to a number of
studies,
166,167,168,117,169
with fewer treatments required.
117,170

However, in a large RCT (N = 477) on acute PFP, MA (with
multiple supercial needling) was superior to 1 Hz EA.
139

On the other hand, LF EA gave better results than vitamin
B12 acupoint injection plus medication in another report
171

(in another RCT, point injection was found better than
routine MA
172
).
pTENS (galvano-acupuncture) was found to be more
effective than ordinary acupuncture in one RCT.
173
TEAS was more effective than MA in one study, with
fewer treatments required.
174
In another, the effects of
EA and TEAS were similar,
175
whereas in a third the
combination of TEAS and TDP with MA improved the
results compared with those from MA alone.
176
LA and MA were equally effective in some studies,
177,178

although LA was less useful than MA (or MA plus
moxibustion) in one large RCT.
179
However, the addition
of Helium-Neon LA to LF EA improved rate of cure (but
not overall effective rate) in one 2003 CT.
180
TDP (plus medication) gave similar results to MA in one
CT, but took longer to achieve them.
128
Combinations
Somewhat surprisingly, EA appears from the clinical
studies database to be combined most commonly with
acupoint injection for PFP.
EA has frequently been combined with TDP (possibly
even more than with moxibustion), and in recent years
with microwave diathermy (giving better results than
diathermy alone in one report on acute stage PFP
142
).
Given the TCM aetiology of the condition, it is quite
surprising that there are not more studies combining MA
and moxibustion.
Moxibustion in combination with EA has been used in
the treatment of facial paralysis,
181
with heat considered
particularly appropriate in chronic cases by some
authors.
182,183
A common sunlamp has also been used,
86
as
has far infrared.
184

185
Both moxibustion (in one study at
Yangbai GB-14, Xiaguan ST-7 and Qianzheng N-HN-20,
183

in another at Yifeng SJ-17
186
) and far infrared (TDP)
148

appear to improve the results of EA, as well as MA.
176,184

The combination of far infrared with MA has also been
claimed to reduce the amount of treatment needed.
185
In
keeping with reports that EA often gives better results
than MA, the combination of EA with moxibustion was
found superior to MA in one RCT.
168

Further analysis of comparisons and combinations may
be found in my textbook.
1
The role of exercise
LF EA has been combined with functional exercises.
170
In
studies comparing acupuncture plus facial exercises with
acupuncture alone, results were signicantly better in the
former group.
187
,
188
Adjunctive exercises (whether volitional
or induced) have an important role to play in PFP,
52

particularly once recovery begins,
115
although exercises
have also been effectively combined with LF EA in acute
phase PFP.
189
However, too much emphasis on mirror work
(making faces) can be disheartening if progress is slow.
190

Exercise has to be tailored to recovery stage.
26

Points used
A TCM approach
Traditionally, points are selected according to pattern of
differentiation. Ren Xiaoqun, for example, suggests the
following points:
For channel blockage due to wind-cold: Fengchi GB-20,
Hegu L.I.-4 (with moxibustion).
For channel blockage due to wind-heat: Yifeng SJ-17,
Yanglingquan GB-34.
For qi and blood stagnation: Waiguan SJ-5, Sanyangluo
SJ-8, Taichong LIV-3
For qi and blood deciency: Zusanli ST-36, Sanyinjiao
SP-6.
29
Anatomical acupuncture
Others have preferred a Westernised approach (see Table 3
on the website version of this article), one group suggesting
that selecting points according to the distribution of the
main branches of the facial nerve can be effective even
with gentle or supercial MA,
133
another author using
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 10
such points for stronger MA with point-to-point needling
in cases of more chronic PFP (ST-6 to ST-4; an empirical
point midway between Yangbai GB-14 and Sizhukong
SJ-23 to Xiaguan ST-7; Yifeng SJ-17).
152
A rational selection
of points might include Zanzhu BL-2, Sizhukong SJ-23,
Yangbai GB-14 and Taiyang M-HN-9 for involvement of
the rst (temporal) branch of the facial nerve, Quanliao
SI-18 and Chengqi ST-1 for second (zygomatic) branch
involvement and Dicang ST-4 with Jiache ST-6 for the
third (mandibular) branch.
182
(See too Table 3). An
important point is Yifeng SJ-17, located where the facial
nerve emerges from within the skull.
191
Incidentally, there are very few PFP studies comparing
the effects of stimulation at acupoints and non-acupoints.
In one, EA at points over the nerve trunk had a better effect
than similar EA at standard acupoints,
192
while in another
EA at Hegu L.I.-4 and the auricular Mouth point gave
superior results to MA at nonspecic points
193
(hardly a
fair comparison). Non-acupoints over the trajectory of the
facial nerve were stimulated in one very small uncontrolled
LILT study (N = 4).
194

An alternative approach is based more on the muscles
involved rather than the nerves (see Table 3). Thus
Zanzhu BL-2 and Yangbai GB-14 have been recommended
for difculty in frowning, Sizhukong SJ-23 and Yangbai
GB-14 for difculty in raising the eyebrow, Juliao ST-3 and
Dicang ST-4 for an inability to smile, and Yifeng SJ-17,
Dicang ST-4 and Jiache ST-6 as general points.
195
Point-to-
point needling from Zanzhu BL-2 to Yuyao M-HN-6, with
Yangbai GB-14, is another method taught for incomplete
eye closure in China.
196
Other points for EA have been
suggested by Zheng Qiwei: Taiyang M-HN-9 and Zanzhu
BL-2 or Sibai ST-2 for incomplete eye closure; Yingxiang
L.I.-20 and Quanliao SI-18 or Xiaguan ST-7 for difculty
snifng; either Dicang ST-4 and Jiache ST-6 or Xiaguan ST-7
and Dicang ST-4 for difculty in pufng out the cheeks;
and Kouheliao L.I.-19 and Dicang ST-4 for deviation of the
philtrum.
124
Wong has given a useful account of some non-
traditional muscle levator points.
191

Staging treatment
Ren Xiaoqun suggests that during the acute (and resting)
stage, only distal and proximal but not facial points should
be utilised (Yifeng SJ-17, Wangu GB-12, Fengchi GB-20,
Taichong LIV-3, Hegu L.I.-4, for example). If facial points
are used at all, only a few should be stimulated (Xiaguan
ST-7 to Taiyang M-HN-9, Jiache ST-6 to Dicang ST-4, for
instance).
29
Zheng Qiwei also recommends that not many
points should be stimulated initially, maybe two to four
from the affected area.
124
Chen Kezhen, another experienced
reviewer, suggests Dicang ST-4 and Xiaguan ST-7, with
Yingxiang L.I.-20 and Taiyang M-HN-9 on the affected side,
together with Hegu L.I.-4 on the opposite side.
86

Rather than connecting points on the face, Li Zhenbo
in one case report paired Hegu L.I.-4 with Dicang
ST-4 and Hegu L.I.-4 with Jiache ST-6, alternately.
19

Simple combinations of Yangbai GB-14Hegu L.I.-4, Sibai
ST-2Xiaguan ST-7 or Dicang ST-4Hegu L.I.-4 have been
recommended for use with single-output stimulators.
197

The use of distal points
Although Wong is rather disparaging about the use of
distal points,
191
the authors of one MA study consider
that stimulating distally does add to the effect of purely
local treatment.
198
When using EA, one advantage of
stimulating points away from the affected area is of
course that there is no risk of inducing contracture or
synkinesis in the early stages of PFP. Thus Zheng Qiwei
quite happily recommends the early use of EA at Hegu
L.I.-4 and Waiguan SJ-5 (with bilateral Hegu L.I.-4 points
connected to one output of the EA device and the Waiguan
SJ-5 points to a separate output).
124
In the clinical studies
database there are many reports in which distal points on
the limbs are used bilaterally in this way, and probably
almost as many in which Hegu L.I.-4 is used, but only
on the healthy side (although in one MA study, bilateral
stimulation of hand points was found to be more effective
than unilateral treatment
97
).
Mining the clinical studies database
Looking through the numerous studies in the database, it
is clear that predominantly local points are used, selected
to activate particular paralysed muscles, together with
some distal points. The most commonly used points
appear to be Yangbai GB-14, Dicang ST-4, Jiache ST-6 and
Xiaguan ST-7, with Hegu L.I.-4 (indicated > 70 times in
the database ), followed by Yifeng SJ-17, Yingxiang L.I.-20,
Sibai ST-2 and Taiyang M-HN-9 (> 50 times), Zanzhu BL-2
and Fengchi GB-20 (> 40 times), Sizhukong SJ-23, Quanliao
SI-18, Chengqiang REN-24, Renzhong DU-26 and Yuyao
M-HN-6, with Zusanli ST-36 (> 20 times). Mentions of
the stellate ganglion
199
and the crossing point of the Large
Intestine and Gall Bladder channels above the clavicle
200

are intriguing.
It should not be forgotten that stimulation of totally
denervated muscle (without sensation as well as
movement) is unlikely to give good results.
Parameters used
Intensity and pulse duration
Chen Kezheng has suggested that low-intensity EA
should be used, just strong enough to elicit muscle
contraction.
86
Alexander Meng and Gertrude Kubiena
also suggest gentle motor level stimulation locally (10-15
minutes of DD or intermittent), stronger stimulation being
appropriate at distal points,
182
with the option of gentle
and brief TEAS, daily initially for 4-5 days, then twice
weekly, and so on. Only 5-10 minutes of mild motor level
LF EA (every other day) is recommended in one Hong
Kong text.
5
However, in the clinical studies database, while
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 11
motor level stimulation (to induce slight contraction of
facial muscle) is emphasised, gentle stimulation or
stimulation to patients comfort occurs far less frequently
than the standard Chinese intensity to tolerance (or even
maximum tolerance).
To obtain movement in muscle that is completely
paralysed, longer pulse durations will be required
201
(even
as long as 1-100 msec
146
).
Frequency and mode
From the clinical studies database, the most frequently
used frequencies and modes for EA treatment are LF,
intermittent or DD stimulation, although 20 Hz, 50 Hz, 80
Hz and even 125 Hz are also mentioned. The Acupad NT
10, a TENS-like device found useful in home treatment of
PFP, provides an output at a xed 22 Hz.
1
In one interesting RCT (N = 147), a combination of
continuous (CW) followed by DD stimulation gave
better results than CW alone.
202
In another RCT (N =
80), intermittent stimulation gave better and more rapid
results than LF CW (TDP was used in both groups).
203
This
appears to be in line with standard electrotherapy practice
involving interrrupted HF stimulation to patient tolerance,
eliciting visible muscle contractions if possible.
149
On the other hand, the authors of one case study
suggested that for elderly or debilitated patients, weaker
(HF) EA is more appropriate than strong (LF) EA.
204

Another approach (extrapolating from MA studies)
could be LF stimulation of scalp points at around 3.3 Hz.
79

Users of the Likon device were at one time taught to utilise
frequencies in the 510 Hz range, modulated at 0.250.33
Hz, for PFP.
197

Treatment frequency
One RCT comparing daily and twice-weekly EA for
PFP found no signicant difference in therapeutic effect
when treatment was initiated within three months of
onset.
205
Other approaches
As a form of supervised self-treatment, low-intensity
trophic electrical stimulation (TES) using low variable
frequencies as found in normal motor unit action potentials
(MUAPs) may be benecial: 5-8 Hz, 80 s, alternating two
seconds on and off, for up to eight hours daily,
44
or with
submotor stimulation as described in a study by Robert
Targan and colleagues.
146
A useful patient handbook on
facial paralysis by one of the originators of TES is now
available.
206

In a wonderfully simple protocol by He Qinglin, suited
to an unsophisticated rural practice, Dicang ST-4 and
Jiache ST-6 are stimulated using from one to four ordinary
1.5 V batteries (economic, convenient and effective).
207

If such non-charge-balanced stimulation really has to be
used (which with needles it should not), it may be helpful
to position needles or electrodes so that the more distal
one is negative.
1
Staging treatment
Many authors emphasise gentle stimulation (with
more supercial needling) during the acute phase, as
mentioned above. During the convalescent stage, stronger
EA becomes appropriate, with point-to-point needling
29

to maximise stimulation of the facial muscles themselves
(rather than just the nerve bres that feed them).
After limiting treatment to mild stimulation in the rst
week (acute phase), it can then be made a little stronger.
This strategy is frequently found in the clinical studies
database. Interestingly, the authors of one report on
TEAS for various stages of PFP gradually increased both
frequency and amplitude to their patients tolerance.
173

Bearing in mind MA studies by Yu
208
and Ni
209
on
the relation between duration of needle retention and
therapeutic effect, it would seem sensible to start with
shorter treatments and only lengthen them after the acute
(or even resting) phase. This approach was adopted in
EA studies by Wang,
210
Liu and Li,
211
Tang and Fang,
140,

141

and Yang et al,
212
for example. Electrostimulation for long
periods should be avoided in the early stages of PFP or if
spasm is already present.
197,

29

On the other hand, in keeping with traditional guidelines
on acupuncture treatment, Li Zhenbo suggests that early
on treatment should be given daily, or every other day, but
only every few days if the condition is chronic.
19
Discussion: some thoughts on treatment
In this article, electroacupuncture and electrotherapy
are introduced, and their application in the treatment of
PFP is outlined. There is a lack of good quality data on
treating PFP with electrotherapy, but a surprising amount
of information is available on its treatment with EA. Each
can learn from the other.
What is clear from reviewing the literature is that many
different approaches have been adopted. There is no one
right way to treat PFP, although there do seem to be some
wrong ways. The following guidelines are suggested:
Treatment must be adapted to the three (four) stages of
PFP, with only gentle stimulation applied in the acute
phase and at only a few acupoints.
In terms of needle technique, this means supercial
rather than point-to-point needling.
For EA, it means using a low frequency at a low intensity
(and possibly with a relatively brief pulse duration):
sensory (even submotor) level rst, motor level later.
Initially, 15-20 minutes of EA may sufce, later 20-30
minutes.
If in doubt, use EA during the rst week only at distal
points, away from the face altogether.
In general, however, the same points are used with
EA as with MA, although it is helpful to select points
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 12
according to their anatomical (muscle/nerve)
location as well as their TCM function.
The combination of local and distal points is likely
to give better results than using just one or the
other.
Despite the frequent use of TLS for acute pain
disorders, LF EA should be used initially (although
not at high intensity, as in ALS), and possibly even
through to stage 3 PFP (with increasing intensity).
In general, DD is more likely to be effective than
CW, but chronic (stage 4) PFP may perhaps respond
to HF or intermittent stimulation.
However, given that the one study that meets with
the approval of all the electrotherapy reviewers is
one on TES, it would seem sensible to adapt the
parameters developed for this method for use with
EA, perhaps using variable frequencies in the 5-8
Hz range or at around 10 Hz, rather than the more
common 2-4 Hz. Treatment should be designed to
foster local circulation and nerve healing, rather
than simply provide induced exercise for paralysed
muscles.
Concomitant use of heat and other ancillary
treatments may potentiate the effect of EA. Facial
exercises are also very important.
Treatment twice a week may be as effective as
daily treatment when using standard EA (but not
with protocols based on TES).
This article on the JCM website
The References to this article can be found on the JCM
website at www.jcm.co.uk/JCM Journal/Latest Issue,
together with the following Tables:
Table 3. The main muscles affected by peripheral
facial paralysis, their innervation and possible motor
point/acupoint correspondences
Table 4. Studies on EA and related modalities for PFP
Acknowledgements
To Elsevier (Churchill Livingstone) for permission to
adapt and reprint material used in my textbook on
electroacupuncture.
To Diana Farragher OBE FCSP and Wendy Walker
MCSP of the Lindens Clinic in Sale, Cheshire, for
taking the time to read this paper and for their helpful
criticism, comments and references (I have found the
website www.bellspalsy.com particularly useful).
To Professor Huang Longxiang of the China
Academy of Chinese Medical Sciences for his
assistance with translation of electrical and other
terms in some of the more recent studies used.
To Danny Maxwell for his skilful editorial help.
To Ruben de Semprun at Allerton Press for
assistance with references in the International Journal
of Clinical Acupuncture.
David F Mayor is the editor of Electroacupuncture:
A practical manual and resource (Elsevier/Churchill
Livingstone 2007) and the online clinical studies database at
www.electroacupunctureknowledge.com.
This searchable database contains more than 8,000
clinical studies on EA and associated modalities, and is
available on the CD version of his electroacupuncture
textbook as well as freely accessible on the website.
Full details of acupoints and electrical parameters
used in each study are given where possible.
A traditionally trained acupuncturist in private practice
in Welwyn Garden City, David Mayor lectures on
electroacupuncture at a number of acupuncture colleges
in the UK. He was rst exposed to electrotherapy when
he contracted Bells palsy as a teenager. An interest in
electroacupuncture developed some fteen years later,
when he translated some of Ioan Dumitrescu's work on
acupuncture from the Romanian. He is a member of the
British Acupuncture Council and an honorary member of the
UK Acupuncture Association of Chartered Physiotherapists
(AACP).
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 13
Facial nerve branch and
associated muscles
MP or nerve stimulation pt
(acupoint correspondence)
Other acupoints in these muscles
Temporal
Frontalis
Corrugator
Orbicularis oculi
superioris
Procerus
tounie (N-HN-31)?
Above GB-14
touguangming (M-HN-5)?
Below yuyao (M-HN-6)
BL-3, BL-4, BL-5, GB-13,
GB-14, GB-15, ST-8, DU-24
BL-2
BL-1, BL-2, SJ-23, (GB-1),
yuyao (M-HN-6), taiyang
(M-HN-9)
yintang (M-HN-3)
Zygomatic
Orbicularis oculi
inferioris
Risorius [lat]
Zygomaticus major [sup]
Zygomaticus minor [sup]
Levator anguli oris [sup]
Levator labii superioris [sup]
Levator labii alaeque nasi [sup]
Procerus
Compressor naris [med]
Orbicularis oris
superioris
Anterior to qianzheng
(N-HN-20)
ST-1
SI-18?
sanxiao (M-HN-17)?
ST-2?
bitong (M-HN-14)?
ST-2, (GB-1), qiuhou
(M-HN-8)
(ST-6)
ST-3
ST-2, ST-3
LI-20, (ST-4), (ST-6), DU-26,
DU-27, (DU-28)
Buccal
Risorius [med]
Zygomaticus major [inf]
Zygomaticus minor [inf]
Levator anguli oris [inf]
Levator labii superioris [inf]
Levator labii alaeque nasi [inf]
Compressor naris [lat]
Dilator naris
Orbicularis oris inferioris [lat]
Depressor anguli oris
Anterior to qianzheng
(N-HN-20)
ST-3?
ST-4?
(ST-6)
LI-20
(LI-20)
(ST-6)
(ST-6)
Mandibular
Orbicularis oris inferioris [med]
Depressor labii inferioris
Mentalis
Anterior to ST-6
jiachengjiang (M-HN-18)? (ST-4), REN-24
REN-24, jiachengjiang (M-HN-18)
REN-24
Table 3. The main muscles affected by peripheral facial paralysis, their innervation
1
and possible motor point/acupoint
correspondences
2
(Points in brackets may require needling at an angle to enter indicated muscle)
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Journal of Chinese Medicine Number 84 June 2007 14
Table 4. Studies on EA and related modalities for PFP
Electroacupuncture: An introduction and its use for peripheral facial paralysis Electroacupuncture: An introduction and its use for peripheral facial paralysis
Modality Totals RCT CT Case series Case report
MA 9 (32) 1 (11) (8) 4 (6) 3 (5)
EA 106 (125) 13 (23) 13 (17) 69 (71) 9 (12)
pTENS 2 (2) (1) 1 (1)
TEAS 8 (8) 2 (2) 1 (1) 5 (5)
TENS 0 (3) 0 (1) 0 (2)
LA 16 (17) 2 (2) 8 (9) 4 (4) 2 (2)
LILT 1 (2) 1 (1) 0 (1)
Other methods 18 (31) 2 (7) 2 (7) 13 (15) 1 (2)
(Figures in brackets show numbers of studies in an update currently in progress)
MA = manual acupuncture; EA = electroacupuncture; pTENS = probe or point TENS; TEAS = transcutaneous electrical
acupoint stimulation; TENS = transcutaneous electrical nerve stimulation; LA = laser acupuncture; LILT = low intensity laser
(or light) therapy (d) = descriptive study; (r) = review; (u) = uncertain
Other methods include more traditional ones such as moxibustion, cupping, massage, bleeding, hot compresses,
catgut embedding and blister therapy, as well as modern methods of heating (far infrared TDP lamp, microwave or
ultrashort wave diathermy and other imprecisely specied forms of electronic moxibustion), ultrasound, various
forms of magnetic treatment, extremely high frequency (EHF) stimulation using millimetre wavelengths, and even
hyperbaric oxygen. Studies on measurement or providing insufcient data for any meaningful analysis have been
excluded from this Table.
Although this is a biased selection of studies, it is clear that EA is commonly used for PFP, and that a wide range of other
electrical modalities has also been explored.
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Journal of Chinese Medicine Number 84 June 2007 15
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