Zheng Qiao-ping, Zhang Bi-meng

1 Department of Acupuncture and Moxibustion, Branch of First People’s Hospital of Shanghai, Shanghai 200081, China

2 Department of Acupuncture and Moxibustion, First People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200080, China

CLINICAL STUDY

Therapeutic Efficacy Observation on Mild Lifting and Superficial Pulling Point-towards-point Needling for Intractable Facial Palsy

Zheng Qiao-ping1, Zhang Bi-meng2

1 Department of Acupuncture and Moxibustion, Branch of First People’s Hospital of Shanghai, Shanghai 200081, China

2 Department of Acupuncture and Moxibustion, First People’s Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200080, China

Author: Zheng Qiao-ping, attending physician

Objective: To observe and compare the clinical effects of combining mild lifting and superficial pulling point-towards-point needling and point injection and integrated standard electroacupuncture (EA) with intramuscular injection of Mecobalamin for intractable facial palsy.

Methods: Eighty cases with intractable facial palsy were randomized into a treatment group and a control group, 40 in each group. Cases in the treatment group were treated with mild lifting and superficial pulling point-towards-point needling Xiaguan (ST 7) coupled with point injection of Mecobalamin. Cases in the control group were treated with standard EA coupled with intramuscular injection of Mecobalamin. After three courses of treatment, the between-group comparisons of Portmann scores and clinical effects were conducted.

Results: After three courses of treatment, the Portmann scores in both groups were higher than the scores before treatment (P＜0.01); the Portmann score in the treatment group was higher than that in the control group (P＜0.05) and the total effective rate in the treatment group was higher than that in the control group (P＜0.05).

Conclusion: Combining mild lifting and superficial pulling point-towardspoint needling and point injection of Mecobalamin could obtain better effect for intractable facial palsy than standard EA coupled with intramuscular injection of Mecobalamin.

Acupuncture Therapy; Point-towards-point Needling; Point Injection; Hydro-acupuncture; Electroacupuncture; Facial Palsy

Facial palsy is a common condition resulting from motor dysfunction of facial muscles and clinically characterized by deviation of the mouth and eyes to one side. Patients with facial palsy cannot raise eyebrows, close eyes and blow[1]. Delayed, mistaken or loss of treatment, excessive pathogens and deficiency of anti-pathogenic qi may contribute to persistent facial palsy. As a result, other than facial palsy, sequela such as synkinesis, perversion, crocodile tears, facial spasm and facial atrophy may also occur, known as intractable facial palsy[2], which can greatly affect the patients’quality of life and requires a long period of treatment.

In Chinese medicine, this condition falls under the category of ‘wind stroke’, ‘stroke of meridians’ and ‘deviation of the mouth and eyes’[3]. Among other therapies, acupuncture is one of the common methods for facial palsy. We’ve treated 40 intractable facial palsy cases with combining mild lifting and superficial pulling point-towards-point needling and pointinjection since January 2009 and compared with integrated standard electroacupuncture (EA) with intramuscular injection. The results are now summarized as follows.

1 Clinical Materials

1.1 Diagnostic criteria

This was made on the basis of diagnostic criteria for facial palsy inShanghai Diagnostic and Therapeutic Guidelines of Traditional Chinese Medicine[4]: a history of contracting cold or pain or fever on one-sided cheek, ear and mastoid bone behind the ear; one-sided facial stiffness or numbness; lacrimation, absence of forehead wrinkles, shallowness of the nasolabial groove, incomplete closure of the eye and deviation of the mouth towards the healthy side; inability to close eyes, blow and grin; abnormal EMG findings; having a duration of at least 2 months.

1.2 Inclusion criteria

Those who met the diagnostic criteria; the condition lasted between 60 and 90 d; around 3 weeks since the onset, electroneurogram (ENOG) showed the injured facial nerve fibers on the affected side ≥90%.

1.3 Exclusion criteria

Those having facial palsy secondary to other conditions such as cerebrovascular accidents, trauma and tumor; pregnant or breast-feeding women; having received other therapies during the study; having complications of hematological system disorders, diabetes, malignant tumor, psychosis and systemic failure.

1.4 General data

A total of 80 cases treated in our hospital between January 2009 and December 2012 were randomized into a treatment group and a control group, 40 in each group and all patients suffered from one-side facial palsy. Before treatment, all patients were scored according to the revised Portmann’s assessment (RPA)[5]and there was no between-group statistical significant difference (P＞0.05). There were also no between-group statistical significant differences in gender, age and duration (P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Between-group comparison of general data

2 Treatment Methods

2.1 Treatment group

2.1.1 Mild lifting and superficial pulling point-towardspoint needling

Major points: Xiaguan (ST 7), Yangbai (GB 14), Sibai (ST 2), Yintang (GV 29), Sizhukong (TE 23), Dicang (ST 4), Chengjiang (CV 24) and Wangu (GB 12).

Adjunct points: Bilateral Hegu (LI 4) and Zusanli (ST 36) on the affected side.

Method: Before acupuncture, apply a gentle 2-min digital Rou-kneading, Tui-pushing and Ca-rubbing to the drooped or deviated area using fingers or the palm from Jiache (ST 6) to Xiaguan (ST 7); then apply An-pressing and Rou-kneading to Xiaguan (ST 7) until a sensation of soreness and distension occurs in the local area and follow this with a 2-minute Tui-pushing and Mo-rubbing towards Taiyang (EX-HN 5). After this, insert disposable filiform needles of 0.3 mm in diameter and 40 mm in length obliquely (45° between the needle body and skin) into Xiaguan (ST 7), making the needle tip towards the inner canthus on both sides. Then conduct mild lifting and superficial pulling until soreness, numbness and distension occur in the cheeks, nasal area and upper lips. For the rest points, puncture Yangbai (GB 14) towards Yuyao (EX-HN 4), Sibai (ST 2) towards Yingxiang (LI 20), Yintang (GV 29) towards Cuanzhu (BL 2), Sizhukong (TE 23) towards Taiyang (EX-HN 5), Dicang (ST 4) towards Jiache (ST 6), Chengjiang (CV 24) towards Dicang (ST 4) and Wangu (GB 12) towards Yifeng (TE 17). Upon arrival of qi, connect three pairs of points with KWD-808Ⅰelectric stimulator, using low frequency, continuous wave and tolerable intensity. For adjunct points, conduct even reinforcing-reducing manipulation following arrival of qi. Each treatment lasted 30 min, once every other day.

In addition, ask the patients to warm the face using a warm wet towel for 15 min, once every day during the treatment.

2.1.2 Point injection

Points: Taiyang (EX-HN 5) and Dicang (ST 4) for the first group; Yangbai (GB 14) and Qianzheng (locates at 0.5 cun anterior to the ear lobe and at the same level with middle point of the ear) for the second group; and Yingxiang (LI 20) and Yifeng (TE 17) for the third group.

Method: Extract 0.5 mg/mL Mecobalamin injection using disposable 1 mL aseptic syringe and inject upon routine sterilization. The three groups of points were used alternately. Except for perpendicular puncture on Yifeng (TE 17) and Qianzheng (Extra), the other points were punctured obliquely. Inject slowly after making sure there is no blood, 0.5 mL for each point. Point injection was conducted after EA.

2.2 Control group

2.2.1 Standard EA therapy

Points: Yangbai (GB 14), Taiyang (EX-HN 5), Yingxiang (LI 20), Dicang (ST 4), Qianzheng (Extra) and Jiache (ST 6).

Adjunct points: Bilateral Hegu (LI 4) and Zusanli (ST 36) on the affected side.

Method: Upon the arrival of qi, conduct 1-minute reinforcing manipulation by twirling manipulation for each point until a subjective warm or relaxing sensation occurs. Then connect needles with an electric stimulator, using a low frequency, continuous wave and tolerable intensity. For adjunct points, apply even reinforcing-reducing manipulation to Hegu (LI 4) and reinforcing manipulation to Zusanli (ST 36). Each treatment lasted 30 min, once every other day. 2.2.2 Intramuscular injection

Extract 0.5 mg/mL Mecobalamin injection using disposable 1 mL aseptic syringe and conduct intramuscular inject upon routine sterilization, once every other day.

2.3 Course of treatment

For both groups, 10 times made up one course of treatment and there was a 3-day interval between two courses. The therapeutic efficacies were evaluated after three courses of treatment.

3 Treatment Results

3.1 Criteria for therapeutic efficacy

This is based on the therapeutic efficacy criteria for facial palsy inShanghai Diagnostic and Therapeutic Guidelines of Traditional Chinese Medicine[4].

Recovery: Complete closure of eyes, symmetrical forehead wrinkles and bilateral nasolabial grooves and no difficulty blowing or grinning.

Improvement: Almost symmetrical forehead wrinkles and bilateral nasolabial grooves and mild difficulty closing eyes and grinning.

Failure: Asymmetrical forehead wrinkles and bilateral nasolabial grooves and great difficulty closing eyes and grinning.

3.2 Revised Portmann assessment (RPA)[6]

Facial symmetry during a resting state: 2 points for normal recording; 0 point for asymmetrical.

Voluntary movements of 6 groups of facial expression muscles: 0 point for no movements of frontal muscle (frowning) musculi orbicularis oculi (eye closing), levator alae nasi (lifting nasal ala), musculus orbicularis oris (whistling), distortor oris muscle (force to smile) and buccinator muscle (chewing); 1 point for slight movements; 2 points for almost normal range of movement; and 3 points for normal movements.

The global score is 20 by adding each item score.

The actual RPA score was calculated respectively before and after treatment by using the normal global score as the denominator and actual scores as the numerator.

3.3 Statistical method

The SPSS 13.0 version software was employed for statistical management,t-test for measurement data [expressed withand Chi-square test for numeration data.P＜0.05 indicated a statistical significance.

3.4 Treatment results

3.4.1 Loss of follow-up in two groups

During the study, 1 case in the treatment group and 2 cases in the control group lost follow-up. Among the 77 effective cases, there were 38 in the control group and 39 in the treatment group. Statistical management showed the loss of follow-up remained less than 5%. The flow chart is shown in Figure 1.

Figure 1. Trial flow chart

3.4.2 Between-group comparison of RPA scores

Before treatment, there was no between-group statistically significant difference in RPA scores (P＜0.01). After treatment, the RPA scores in bothgroups were increased and there was between-group statistically significant differences in RPA scores (P＜0.05) and sequelae scores (P＜0.01). This indicates that after three courses of treatment, functions of facial muscles in both groups were improved; however, the improvement was more significant in the treatment group (Table 2).

No allergic or infection occurred in either group during the treatment.

3.4.3 Between-group comparison of clinical effects

The recovery rate and total effective rate were 59.0% and 94.9% respectively in the treatment group, versus 5.3% and 68.5% in the control group, showing statistically significant differences (P＜0.05) and indicating a better effect in the treatment group compared with that in the control group (Table 3).

Table 2. Between-group comparison of RPA scores before and after treatmentpoint)

Table 2. Between-group comparison of RPA scores before and after treatmentpoint)

Note: Compared with the intra-group results before treatment, 1) P＜0.01; compared with the control group, 2) P＜0.05, 3) P＜0.01

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Table 3. Between-group comparison of clinical effects (case)

4 Discussion

The earliest recordings of facial palsy were seen in theHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine). This condition is caused by obstruction of qi and blood, malnourishment of Shaoyang and Yangming Meridians on the face and flaccidity of facial muscles, which often occur as a result of deficiency of anti-pathogenic qi, disharmony between Ying-nutrient and Wei-defensive, insecurity of Wei-defensive qi, coupled with attack by pathogenic wind-cold[7]. Consequently, the principles of treatment are to reinforce anti-pathogenic qi, remove pathogenic factors and unblock meridians. According toHuang Di Nei Jing(Yellow Emperor’s Classic of Internal Medicine), acupuncture has a long history of being used for treatment of facial palsy. Since facial palsy is directly associated with deficiency of anti-pathogenic qi and attack by external pathogens, it can be diagnosed as an exterior syndrome in a superficial location and should therefore be treated with shallow needling to dredge meridians, dissipate cold, remove wind and harmonize qi and blood[8].

Currently, therapies of traditional Chinese medicine for facial palsy include classical acupuncture, EA, moxibustion, point injection, point-towards-point needling and comprehensive method[9-14].

Combining mild lifting and superficial pulling point-towards-point needling and point injection employed in this study is based on traditional Chinese medical theory, modern medical knowledge and long-term clinical experience. By stimulating the scalp points on the affected side, mild lifting and superficial pulling point-towards-point needling[15]acts to pull the affected facial muscle, enhance the facial muscle strength and gradually increase the muscle movement on the affected side. As for drooped or deviated area, digital pushing and rubbing are conducted using the fingers or palm, followed by superficial point-towards-point needling against the direction of drooping or deviation. Point injection is a method to inject Chinese or Western medicine into the points. This can exert immediate acupuncture effect and subsequent drug effect which is often enhanced[16]. As a Methylating Vitamin B12, Mecobalamin has a longer half-life period than common Vitamin B12and can be easily transferred into organelles of nerve cell tissue, which in turn fortify the synthesis of intra-neuronal nucleic acid and protein and thus promote the synthesis of lecithin: a major component of myelin sheath. Studies have proven[17]that Methycobal can stimulate regeneration of axon, accelerate the recovery of synaptic transmission, repair injured nerve tissue and remodel the paralyzed facial nerve. This can further help to recover functions of facial nerve, increase the RPA scores and shorten the ENOG nerve action potential.

This study has proven that combining mild lifting and superficial pulling point-towards-point needling and point injection of Methycobal can improve local symptoms and the recovery of facial nerve functions in patients with intractable facial palsy. A good compliance and synergistic action of acupuncture and point injection contribute a better clinical effect.Additionally, this method requires further large sample standardized clinical trial to prove its safety and efficacy.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

This work was supported by Famous Traditional Chinese Medicine Doctor Construction Project of Yan Jun-bai’s Academic Experience Work Room (No. ZYSNXD-CCMZY023).

Statement of Informed Consent

All of the patients in the study signed the informed consent.

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Translator:Han Chou-ping

Zhang Bi-meng, M.D., associate chief physician.

E-mail: pjzhtiger08@aliyun.com

R246.6

: A

Date:October 12, 2013