Zhang Jun-feng (張峻峰), Wu Yao-chi (吳耀持)

Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China

Observation on clinical effect of acupuncture for peripheral facial paralysis in acute period and facial nerve F-wave

Zhang Jun-feng (張峻峰), Wu Yao-chi (吳耀持)

Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China

Objective:To observe the clinical effect of acupuncture on peripheral facial paralysis in acute period and changes in facial nerve F-wave.

Acupuncture Therapy; Point-towards-point Needling; Acupuncture Medication Combined; Facial Paralysis; Electromyography

Peripheral facial paralysis (Bell’s palsy) is a common condition seen in acupuncture department. Today, the timing of needling the affected side remains controversial. We’ve treated this condition with oral Western medication combined with point-towardspoint needling therapy between March 2013 and December 2014 and evaluated the clinical effect using electromyography (EMG) F-wave. The results are now summarized as follows.

1 Clinical Materials

1.1 Diagnostic criteria

This was based on the diagnosis for facial paralysis in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[1]andShanghai Diagnostic and Therapeutic Guidelines of Traditional Chinese Medicine[2]: a sudden onset, commonly seen in spring and autumn seasons, ahistory of contracting cold and fever or pain in one-sided facial cheek, ear and mastoid process; facial stiffness, lacrimation, numbness, absence of forehead wrinkles, shallowing of nasolabial folds, incomplete eye closure and mouth corner deviated to the healthy side; inability to close eye, expose teeth and blow cheek; and abnormal EMG findings.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; aged between 20 and 60 years; duration ≤7 d; having clear consciousness and could cooperate for clinical data collection; those who were willing to participate in the trial and sign the informed consent.

1.3 Exclusion criteria

Those who failed to meet the above diagnosis or inclusion criteria; having trauma-related or iatrogenic facial paralysis; having central facial paralysis due to tumor or cerebrovascular accidents (CVA); pregnant women; having complications of diabetic neuropathy, other major diseases and mental illness; those whox±s). Thet-test was used for measurement data evaluation and Chi-square test for enumeration data analysis. APvalue of less than 0.05 indicated a statistical significance.

1.5 General materials

A total of 148 eligible cases were randomly allocated into an observation group (n=74) and a control group (n=74). There were no dropouts during the treatment. Patients in the observation group were aged between 21 and 60 years and their duration lasted from 1 to 7 d. Patients in the control group were aged between 20 and 60 years and their duration lasted from 2 to 7 d. There were no significant between-group differences in age, gender, duration and affected side (P＞0.05), indicating that the two groups were comparable (Table 1). failed to follow the treatment protocol in this trial; and those with incomplete data for efficacy evaluation.

1.4 Statistical method

The SPSS 16.0 version software was used for statistical analysis. The measurement data was expressed as (

Table 1. Between-group comparison in baseline data

2 Treatment Methods

Patients in both groups took oral Prednisone and Aciclovir tablets (Sine Pharmaceutical Corporation, Shanghai Pharmaceutical Group, China) as well as Vitamin B1(Shanghai Xinpasi Pharmacy Co., Ltd., China). Specifically, patients took 1 dose of oral Prednisone a day (30 mg, 3 d; 15 mg, 3 d; 5 mg, 3 d), 3 doses of Aciclovir tablets a day (0.4 g for each dose) and 3 doses of Vitamin B1a day (10 mg for each dose) with warm water after meals, for a total of 9 d.

2.1 Observation group

Based on the above Western medication, patients in the observation group also received the following acupuncture therapy.

Major points: Dicang (ST 4) towards Jiache (ST 6), Dicang (ST 4) towards Xiaguan (ST 7), Dicang (ST 4) towards Sibai (ST 2), Qianzheng (Extra, 0.5-1.0 cun in front of the ear lobe), and Yangbai (GB 14) on the affected side.

Distal point: Hegu (LI 4) on the healthy side.

Points based on syndrome differentiation: Fengchi (GB 20) was combined for wind cold; Quchi (LI 11) was combined for wind heat.

Method: After sterilization using 75% alcoholic cotton ball, stainless filiform needles of 0.30 mm in diameter and 25-40 mm in length were used to puncture the above points. Qianzheng (Extra) was punctured 0.5 cun perpendicularly. Dicang (ST 4) was punctured 1.0 cun towards Jiache (ST 6), Xiaguan (ST 7) and Sibai (ST 2) respectively. Upon presence of needling sensation, even reinforcing-reducing manipulation was applied to each point. Hegu (LI 4) and Quchi (LI 11) were punctured 1.0 cun perpendicularly. Fengchi (GB 20) was punctured 0.8 cun obliquely towards the tip of the nose. The needles were retained for 20 min. The treatment was done once a day, 6 times made up a course of treatment. Patients were treated for 2 courses of treatment and there was a 3-day interval between two courses.

No electric stimulation was used during the first course of treatment. Electric stimulation apparatus (G6805-II) was connected to Dicang (ST 4) and Qianzheng (Extra) during the second course of treatment for 20 min, using a continuous wave, frequency of 4.0 Hz, and current intensity of 2 mA.

2.2 Control group

Based on the above Western medication, patients in the control group also received the following routine acupuncture therapy.

Major points: Dicang (ST 4), Jiache (ST 6), Xiaguan (ST 7), Sibai (ST 2), Qianzheng (Extra), and Yangbai(GB 14) on the affected side.

Distal point: Hegu (LI 4) on the healthy side.

Points based on syndrome differentiation were same as that in the observation group.

Method: After sterilization using 75% alcoholic cotton ball, same stainless filiform needles were used to puncture above points. Dicang (ST 4), Jiache (ST 6), Xiaguan (ST 7) and Sibai (ST 2) were punctured 0.5 cun either perpendicularly or obliquely. Qianzheng (Extra) was punctured 0.5 cun perpendicularly. Upon presence of needling sensation, even reinforcing-reducing manipulation was applied to each point. Hegu (LI 4), Quchi (LI 11) and Fengchi (GB 20) were punctured with the same methods as that for the observation group. The treatment time, course and electric stimulation were same as that in the observation group.

3 Clinical Efficacy Evaluation

3.1 Observation indicators

Before treatment, the F-wave was detected in a quiet room with constant room temperature. The subjects were asked to take a supine lying position on the treatment table and relax for 5 min. The Dantec Keypoint digital electromyography with evoked potential (made in Denmark) was used to examine the right side first and then the left side. The surface electrode was used to record the orbicularis oculi and depressor anguli oris. The anterior auricular facial nerve was stimulated 20 times using a square wave of 0.3 ms and frequency of 1 Hz. Then gradually increased the stimulation up to intensity of 120%-130% and started to record. The filtering range was between 100-5 000 Hz and the analysis time was 50 ms. The mean F-wave latency of the facial nerve was measured and its occurrence rate was calculated (F-wave frequency/total stimulation times).

3.2 Therapeutic efficacy criteria

This was based on the scoring system for facial paralysis[3]. The following 10 items have been observed using the healthy side as reference.

Palpebral fissure: ＜3 mm, 0 point; ≥3 mm, 1 point.

Ectropion: Absence, 0 point; presence, 1 point.

Nasolabial fold: Presence, 0 point; absence, 1 point.

Drooping of mouth corner: ＜3 mm, 0 point;≥3 mm, 1 point.

Frown (50% of the healthy side): Yes, 0 point; no, 1 point.

Complete eye closure without extra effort: Yes, 0 point; no, 1 point.

Complete eye closure with extra effort: Yes, 0 point; no, 1 point.

Exposure of the 4 canines: No, 0 point; yes, 1 point.

Exposure of the second upper incisor: No, 0 point; yes, 1 point.

Whistle blowing (diminished distance between the philtrum and mouth corner): ≥50%, 0 point; ＜50%, 1 point.

The total score is 10 points. A higher score indicates a more severe facial paralysis. Based on the lesion severity,≥8 points: severe; ≥5 points but ＜8 points: moderate; ＜5 points: mild.

The recovery rate is calculated according to the changes in total scores before and after treatment.

Recovery rate ＝ (Pre-treatment score－Posttreatment score) ÷ Pre-treatment score × 100%.

Recovery: Recovery rate ≥90%.

Marked effect: Recovery rate ≥50% but ＜90%.

Improvement: Recovery rate ＞0 but＜50%.

Failure: Recovery rate ≤0.

3.3 Treatment results

3.3.1 Between-group comparison in clinical effect

After 2 courses of treatment, the recovery rate and total effective rate were 47.3% and 94.6% respectively in the observation group, versus 20.3% and 82.4% in the control group, showing statistical differences (P＜0.01) by the Chi-square test, indicating better recovery rate and total effective rate in the observation group than that in the control group (Table 2).

3.3.2 Between-group comparison in EMG F-wave

Before treatment, there were no significant betweengroup differences in F-wave frequency and latency (P＞0.05). After treatment, the F-wave frequency and latency were significantly improved in both groups (P＜0.05) and there were significant between-group differences (P＜0.05), indicating a better improvement in facial nerve function in the observation group than that in the control group (Table 3).

Table 2. Between-group comparison in clinical effect (case)

Table 3. Between-group comparison in F-wave

Table 3. Between-group comparison in F-wave

Note: Intra-group comparison before and after treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

Group n Occurrence rate (%) Latency (ms) Before treatment After treatment Before treatment After treatment Observation 74 28.67 68.881)2) 6.34±1.21 2.13±1.411)2)Control 7427.79 48.341) 6.16±1.18 3.88±1.821)

4 Discussion

In traditional Chinese medicine (TCM), Bell’s palsy falls under the category of ‘deviation of the mouth corner’ or ‘deviation of the mouth and eye’. It often results from malfunction of muscle regions of the Large Intestine Meridian of Hand Yangming and the Stomach Meridian of Foot Yangming due to deficiency of qi and blood coupled with external contraction of wind[4]. In modern medicine, etiological factors include vasospasm[5], compression edema with ischemia of the facial nerve, viral infection and unstable autonomic nerve[6-7].

Some scholars believe it’s not appropriate to apply acupuncture to acute facial paralysis, because it may aggravate inflammatory edema of the facial nerve and further damage the facial nerve[8]. Some scholars, however, believe intervention in acute stage can obtain better effect[9-10]. In our experience, it’s advisable to use fewer needles with mild stimulation during an acute stage to reinforce qi, nourish and unblock meridians and remove pathogenic factors[11].

Facial nerve F-wave is a simple and sensitive objective indicator to evaluate the function of intracranial segment of facial nerve and diagnose Bell’s palsy[12-16]. This study has found that the mean F-wave latency on the affected side was significantly prolonged and its frequency of occurrence was significantly decreased. After treatment, the F-wave latency was shortened and its frequency of occurrence was increased. This indicates that acupuncture, especially point-towards-point therapy can directly or indirectly stimulate afferent nerve fibers and receptors, regulate muscle innervated by sympathetic and parasympathetic nerves, promote local circulation of blood, increase oxygen supply, speed up the absorption of facial nerve edema, increase facial nerve excitability, and thus repair the damaged nerve[17].

After 2-course treatment, there were significant between-group differences in the recovery rate and the total effective rate (P＜0.01), indicating a better efficacy in the observation group. This study has provided an objective basis for acupuncture treatment in acute Bell’s palsy.

Conflict of Interest

The authors declared that there was no conflict of interest in this article.

Acknowledgments

This work was supported by Shanghai Cultivation Plan of New Stars in Xinglin (上海市“杏林新星”人才培養(yǎng)計(jì)劃, No. ZYSNXD011-RC-XLXX-20130046); Shanghai Science & Technology Commission Project (上海市科委科技項(xiàng)目, No.14401971500); Lu’s Acupuncture Inheritance Study of Shanghai Schools of Traditional Chinese Medicine (海派中醫(yī)流派陸氏針灸傳承研究, No. ZYSNXD-CC-HPGC-JD-004).

Statement of Informed Consent

Informed consent was obtained from all individual participants included in this study.

Received: 5 June 2015/Accepted: 28 June 2015

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Translator: Han Chou-ping (韓丑萍)

針刺治療急性期周圍性面癱的療效及面神經(jīng)F波觀察

目的：觀察針刺治療急性期周圍性面癱的臨床療效及面神經(jīng)F波的變化。方法：將148例急性期周圍性面癱患者根據(jù)就診先后順序隨機(jī)分為觀察組和對(duì)照組, 每組74例。兩組患者均接受口服強(qiáng)的松片和阿昔洛韋片治療, 觀察組在此基礎(chǔ)上接受透刺法針刺治療, 對(duì)照組接受常規(guī)針刺治療。每日1次, 6次為1個(gè)療程, 治療2個(gè)療程后進(jìn)行療效評(píng)價(jià), 并在治療前后進(jìn)行肌電圖F波檢測(cè)。結(jié)果：治療2個(gè)療程后, 治療組治愈率為47.3%, 總有效率為 94.6%, 對(duì)照組治愈率為 20.3%, 總有效率為 82.4%, 兩組治愈率及總有效率差異均具有統(tǒng)計(jì)學(xué)意義(P＜0.01)。治療前, 兩組患者患側(cè)面神經(jīng)F波潛伏期延長(zhǎng), 出現(xiàn)頻率減少。治療后, 兩組患者F波潛伏期及出現(xiàn)率均較本組治療前明顯好轉(zhuǎn)(P＜0.05), 且觀察組改善情況優(yōu)于對(duì)照組(P＜0.05）。結(jié)論: 在口服常規(guī)西藥基礎(chǔ)上,透刺法針刺治療急性期周圍性面癱療效確切, 可有效改善面神經(jīng)功能, 其療效優(yōu)于常規(guī)針刺治療。

針刺療法; 透針; 針?biāo)幉⒂? 面神經(jīng)麻痹; 肌電描記術(shù)

R246.6 【

】A

Author: Zhang Jun-feng, attending physician

Wu Yao-chi, professor, chief physician, doctoral supervisor.

E-mail: wuyaochi@online.sh.cn

Methods:A total of 148 eligible cases were randomly allocated into an observation group (n=74) and a control group (n=74) by their visiting sequence. In addition to oral Prednisone and Aciclovir tablets, patients in the observation group received point-towards-point acupuncture therapy, whereas patients in the control group received routine acupuncture therapy. The treatment was done once a day and 6 times made up a course of treatment. The efficacy evaluation was made after 2 courses. The electromyography (EMG) F-wave was monitored before and after treatment.

Results:After 2 courses of treatment, the recovery rate and total effective rate were 47.3% and 94.6% respectively in the observation group, versus 20.3% and 82.4% in the control group, showing statistical differences (P＜0.01). Before treatment, the facial nerve F-wave latency on the affected side was prolonged and its frequency of occurrence was decreased in both groups. After treatment, the F-wave latency and frequency of occurrence were significantly improved in both groups (P＜0.05) and there were significant between-group differences (P＜0.05).

Conclusion:In addition to Western medication, point-towards-point acupuncture therapy can obtain more accurate and better effect than routine acupuncture therapy for acute peripheral facial paralysis.