Bell's Palsy, Acupuncture and Complementary Medicine

Paul Reller, L.Ac.

Bell's Palsy, or idiopathic facial paralysis, is diagnosed 40,000 times per year in the United States, and is thought to affect approximately 1 person in 65 during a lifetime. The term idiopathic means that no objective known cause of the pathology is apparent. This disease is characterized by a sudden onset of facial paralysis on one side of the face, affecting mainly the Facial Nerve, or Cranial Nerve 7. The disease strikes mainly healthy individuals, of any age, and has a wide variety of degrees of severity and manifestation of symptoms. The Facial Nerve branches into 3 distinct pathways, and Bell's Palsy often affects all three, the forehead and eyelid, the cheek, and the mouth, tongue and sometimes the throat. The origin of the facial nerve is the brainstem, and the emergence of this cranial nerve is near the mastoid protuberance behind the ear. The facial nerve travels through two distinct narrow foramens, at the mastoid in the temporal bone, and in the fallopian tube (drainage from the inner ear). It is believed that swelling and compression at these sites of narrow passage of the facial nerve are responsible for the dysfunction and paralysis. The facial nerve has both motor and sensory aspects, and parasympathetic fibers to the tear glands in the eyes, to the nose, and to the mouth, account for symptoms of excess tearing or dryness as well.

Arterial blood vessels that travel alongside the facial nerve may also be implicated in the nerve irritation, and many experts think that a combination of vascular ischemia and inflammatory swelling cause the nerve irritation and damage. In the first few days of onset, the symptoms of facial sensory and motor dysfunction may change and worsen, and many patients report an initial pain near the mastoid or ear preceding sensory dysesthesia, and then rapidly progressive facial paralysis or paresis (partial paralysis) during the next 48 hours. In the past, cold exposure was considered the only trigger to Bell's Palsy, since the majority of patients report unusual exposure to cold wind, sleeping near window air conditioners, or driving in cold weather with the window down. Since then, though, a percentage of patients studied did not have exposure to cold air preceding the onset. Sudden or unusual cold, especially at night, when the immune system is more interior in response, would contribute much to vascular ischemia, though, and perhaps to an unusual sudden immune reaction, allowing latent viruses or low-grade bacterial infections to cause the sudden inflammatory reaction. A variety of symptoms beside facial hemiparalysis, or more rarely, bilateral facial paralysis, may be seen in Bell's Palsy. The mastoid pain and dryness to the eyes, nose and mouth have already been mentioned. Taste disturbances, and hyperacusis, or auditory sensitivity to certain frequency ranges, is also sometimes noted. Facial numbness is a common sensory symptom, and pain on the side of the face opposite to the paresis is sometimes noticed as well.

Even among the young healthy population, Bell's Palsy has a rate of incidence similar to the general population. A study by the U.S. Armed Services in 1999 found that the incidence among this healthy young population was about 43 per 100,000 person-years, and incidence rates increased with age and was higher among females, Blacks, Hispanics, and married persons (KE Campbell, JF Brundage: Am J Epidemiol 2002;156:32-9). Incidence was also increased in persons in a cold and/or dry climate, and is thought to occur in the diabetic population four times as much as the non-diabetic population. Theories related to such studies, and confirmed with modern testing, support the hypotheses that various viral and retroviral pathogens are related to the onset of Bell's Palsy. The array of identified viruses and pathogens include Herpes simplex (HSV-1), Herpes Zoster, Epstein-Barr, cytomegolvirus, rubella, mumps, and HIV. Bacterial pathogens have also been identified in specific cases, and may have caused the disease, such as Typhus (usually spread by fleas and lice), Borrelia burgdorferi (Lyme's disease - tic bites), Moraxella catarrhalis, Haemophilus influenzae, and Streptococcus pneumoniae (causes of middle ear infections). Unfortunately, no single pathogen has been found in a majority of cases studied. Therefore, no single antiviral or antibacterial medicine, synthetic or herbal, is guaranteed to benefit the individual patient. A more thorough holistic approach to treatment is needed.

While approximately 65% of cases are self-limiting, meaning that the person affected, even receiving no therapy that is considered effective (such as synthetic corticosteroids and acyclovir) will recover completely within about 12 weeks to a year (and many in 3-6 weeks), about 35% of patients are left with a partial paresis of the facial muscles, and about 20% are left with serious consequences, including severe paroxysmal facial pain in a small percent of patients. About 80% are left with either no symptoms, or mild motor dysfunction, often not too noticeable. No pharmaceutical medication has been proven effective in the treatment of Bell's Palsy (see additional information below). A protocol of Prednisone (synthetic corticosteroid), acyclovir (Herpes medication), and Vitamin B12 injection (to aid nerve repair and regeneration) is routinely prescribed as a potential aid to the patient recovery. The considerations by the patient afflicted with this disease are 1) what if I am in the approximately 35% that don't spontaneously recover, and 2) what can I do to hasten recovery and decrease the risks of permanent neurological deficit and facial paresis. This is the role of Integrative and Complementary Medicine, providing the patient with the most reliable information and holistic protocol to achieve the best outcome.

Bell's Palsy, or Idiopathic Facial Paralysis, is currently a diagnosis of exclusion (no other cause is objectively found) and is still a poorly understood disease, despite a wealth of research around the world for the last 100 years. The obvious reason for this is that the underlying causes must be multifactorial and more complex than science had hoped for. Currently, no pharmaceutical medicine is proven effective, although there is weak evidence that an early injection of a synthetic corticosteroid (Prednisone) may alter the course of the disease. Bell's Palsy has been a consistent disease across time and population, though, and a number of traditional therapies have been utilized, refined, and proven effective with clinical observation for centuries. In China, almost all cases are treated in the hospital and clinic with acupuncture, and appropriate use of moxibustion stimulation, electrical stimulation, and herbal and nutrient medicine are well known to increase the degree of success when combined with acupuncture.

In countries where acupuncture and professional herbal medicine are an established (and paid for) part of the standard medical establishment, such as Japan, Korea and China, these therapies are accepted as the only known effective and proven treatment for Bell's Palsy, and are routinely prescribed, along with medications that may help the course of the disease. Medical doctors in the United States are still not referring patients with Bell's Palsy for a short course of acupuncture and related therapies, despite having no effective treatment to offer themselves. While standard medicine in the United States points out that no large randomized placebo-controlled human clinical trials of acupuncture have proven this course of therapy to be effective, the patient must fully realize what this actually means.

Number one, no randomized placebo-controlled human clinical trials have clearly demonstrated effectiveness of any therapy, pharmaceutical or other, in the treatment of Bell's Palsy, in the United States. Many human clinical trials in China have established the efficacy of acupucture and related therapies in the treatment of Bell's Palsy, though, as well as other diseases and injuries causing facial paralysis. There are no large human studies with acupuncture that utilize a placebo, or no treatment, for this disease, mainly due to the fact that no patients want to have no treatment or a placebo treatment when their face is paralyzed. Placebo acupuncture is also very difficult to achieve, especially when treating the face. A fake sticking of a needle into the face is really not practical. Clinical studies also show that the best effects of acupuncture occur when the needles are manipulated, when the acupuncture point prescription is somewhat varied, and when modalities such as moxibustion, Chinese herbal medicine, and electroacupuncture are used appropriately in the course of the disease. Such variance is not allowed in randomized placebo-controlled human clinical trials. Another problem with these human placebo-controlled trials of acupuncture, or any other treatment for that matter, is that a disease that is so variable, with a high rate of spontaneous recovery, even without any treatment, and a wide variety of disease courses and manifestations, is almost impossible to statistically evaluate. The statement that acupuncture is not a proven treatment for Bell's Palsy by standard medicine in the United States is more of a competitive discouragement, and a philosophical, or sociopolitical statement, than it is a real concern for the welfare of the patient. Much of this is driven by the insurance industry, which largely determines treatment guidelines and decisions in the United States, rather than public health experts. The patient population today wants an integration of useful treatment expertise, and MDs need to find a competent Licensed Acupuncturist to whom referrals can be made.

Is there really no scientific proof that acupuncture and TCM therapy works to encourage improved recovery from Bell's Palsy? Currently, there are large randomized human controlled trials of acupuncture for the treatment of Bell's palsy, designed to overcome the problems mentioned above. The U.S. National Institutes of Health are sponsoring such trials, indicating that medical experts in the U.S. find that acupuncture appears to be a viable treatment option. In China, a large multicenter randomized controlled trial was conducted, comparing acupuncture to either standard therapy with prednisone, dibazole (an immune stimulant), and periodic B12 injections, or a combination of this standard therapy combined with the acupuncture (see additional information below). In both situations, acupuncture compared to standard therapy, and acupuncture combined with standard therapy, the acupuncture group had significantly better outcomes than standard therapy alone. Despite these large peer-reviewed studies by medical doctors in China, the medical doctors in the U.S. are still trying to suggest that there is not sufficient evidence to support this widely accepted therapy, utilized successfully for centuries, for Bell's Palsy. This type of game playing only hurts the patient population, and eventually, the standard medical profession is faced with an embarassing situation. They are not supporting real evidence-based medicine. They are only being motivated by economic and philosophical considerations.

The patients most at risk for a poor long term outcome with Bell's Palsy

The patients that should worry the most about long-term problems are those that are over age 60, have significant pain in the first week of onset, have all three areas of the face affected substantially (40% of patients with complete palsy are left with permanent paresis or paralysis), have diabetes or high blood pressure, are pregnant, have a worsening of symptoms after the first 10 days, have inner ear pain as well (Ramsay Hunt Syndrome), don't start to recover by week six, or are tested and found to have severe injury to the facial nerve. Many patients are given either injection or pills with Prednisone, or other corticosteroid, and acyclovir (just in case the Herpes virus is present), and told to go home and hope for the best. Patients with the inability to close the eyelid are given a lubricant and tape to protect the eye at night. Many intelligent patients then seek out a competent and experienced Licensed Acupuncturist to provide more therapy to insure a better and quicker outcome. In standard medicine, if you don't recover in 12 weeks to a year, or if the symptoms worsen and you are left with facial pain or an eyelid that doesn't fully close at night, or problems eating and swallowing, then a surgical evaluation is performed, and the possibility of severing a nerve permanently is discussed.

The first question of almost every patient that seeks acupuncture and related therapies for Bell's Palsy is will this work. The truth is that no therapy for any condition is guaranteed to work 100% of the time. The success with a proper protocol and technique in acupuncture and TCM medicine is very high, though. The disease may resolve on its own, so the exact evaluation of whether the acupuncture and other therapies resolved the condition, or whether it resolved on its own, can never be fully answered in each case. The point to keep in mind is that acupuncture works by stimulating the body to heal itself better. The patient is utilizing the best therapy that is known, with success documented over thousands of years, and confirmed with modern study, as much as can be accomplished in this realm. The patient is utilizing the best available medical approach to minimize the chances of a bad outcome, and to speed recovery. The therapy is usually relatively inexpensive. Even a short course of acupuncture and herbal medicine, followed by a high dosage of sublingual B12 and other B vitamins, is a smart choice, and can be very inexpensive. Waiting to see if you lose the lottery may not be the best choice.

Many scientific studies have created a sense of outrage at the standard treatment protocol for Bell's Palsy. No proof that prednisone produces a better long-term outcome exists, and many studies cited the frequently noted false sense of euphoria induced by this synthetic corticosteroid hormone, giving patients in the first week the impression that they were feeling better (see the study cited below). Electromyographic studies did not show any actual improvement with this corticosteroid therapy. Acyclovir, a drug that may inhibit expression of the herpes virus, but has a questionable level of actual efficacy, may help a small number of patients, especially those with an inner ear pain or blistering, or blisters evident on the tongue. Concurrent use of bitter melon extract is proven to enhance the effectiveness of acyclovir. Studies have shown that the prescence of a latent or active Herpes virus is not apparent, though, in a majority of cases. A more comprehensive herbal formula may address low grade infection from a variety of pathogens. A B12 injection may help substantially in the period of nerve sheath recovery and repair, but not in the first 2 weeks. Subsequent B12 injections with patients experiencing some nerve recovery down the road, say in the second or fifth month, may also be helpful. Because there is no actual proven therapy in standard medicine, many MDs around the world are now expressing concern that standard medicine perhaps should not discourage the treatment with acupuncture and herbal/nutrient medicine. This therapy is inexpensive, harmless, and proven effective in so many diseases and injuries, including nerve injuries, and proven to stimulate increased immune responses.

Of course, each patient must make the choice of what type of therapy is going to potentially help them. Patients more at risk may have a greater concern about the outcome. I hope this article elucidates the question of utilizing acupuncture and TCM therapies, and that many more patients are helped by Licensed Acupuncturists in the future. In my practice, I have seen an almost 100% benefit with proper treatment. Of course, some patients have only come to seek this therapy after being left with permanent pain and dysfunction, but even in these cases, I have seen considerable success with therapy. The patient that seeks therapy within the first 2 weeks have shown the best outcome, with a rapid and full recovery and no relapse in almost every case. It is gratifying to see the rapid recovery of this disease, which presents so much stress to the individual with the embarassment of facial distortion, poor sleep, and often difficulty with chewing and swallowing food. The benefits of treatment in acupuncture and Traditional Chinese Medicine provide more than just the relief of symptoms, and always deliver potentially improved health in many ways, and potentially decreased risk of future health problems, making it one of the most effective preventive medicines on the planet.

The diagnosis of Bell's Palsy

Bell's Palsy, or idiopathic facial paralysis, is a diagnosis of exclusion, meaning that all other causes and diseases must be first ruled out when a patient is evaluated. Approximately two thirds to three fourths of all cases of facial paralysis are attributed to Bell's Palsy each year. The other one third to one fourth of cases are caused by trauma, herpes zoster (Ramsay Hunt syndrome), Lyme disease, sarcoidosis parotid tumors, Sjogren's autoimmune disease or syndrome, amyloidosis, or are related to diabetes mellitus, pregnancy, intranasal flu vaccine, or Guillain-Barre viral syndrome. It is rare that a stroke will cause facial hemiparesis alone. Almost always, facial droop in stroke patients is accompanied by upper or lower extremity weakness, as well as aphasia, and visual field deficits, as well as confusion. If the patient reports a gradual onset of facial paralysis, weakness of the opposite side of the face as well, or a history of recent infection or facial or head trauma, other causes must be strongly considered and tests and exams performed. If the facial paralysis on the same side of the face is recurrent, evaluation for a tumor is necessary. Some insurance companies now will only acknowledge a diagnosis of Bell's Palsy if a positive blink reflex test is positive. This may be performed in a lab with equipment, or in the doctor's office with a simple neurological exam, usually a light touch stimulating a blink reflex, with each side compared.

Types of trauma that would cause facial palsy include fractures to the petrous bone along the nose, although other head trauma, and a basilar fracture could damage the facial nerve. Ramsay Hunt syndrome type 2 is also known as herpes zoster oticus (of the ear), and usually other symptoms besides facial palsy are seen, such as pain in the ear, taste loss on the front two thirds of the tongue, dry mouth and eyes, and a red rash in the ear canal and on the tongue or hard palate, with small blisters. When just the facial paralysis is seen, this is diagnosed as a Bell's Palsy. Lyme's disease causing only facial paralysis is somewhat rare, but would be diagnosed with a spinal tap analysis and brain CT or MRI scan. The spinal fluid and blood would show antibodies to the Borrelia burgdorferi. Sarcoidosis is a disease in which small clumps of inflammatory cells accumulate mainly in the lymph nodes, eyes, skin and lungs, and results from an abnormal immune response. Sarcoidosis is not fully understood, and the symptom presentation and course is highly variable. It is difficult to diagnose, but X-ray and CT scans may reveal the clumps of inflammatory cells, and blood tests and kidney function are analyzed, as well as lung function tests. If swollen lymph nodes, parotid gland, or skin accumulations are noted in physical exam, these can also be biopsied.

Sjogren's Syndrome, a now common autoimmune disease syndrome, will generally show as dry eyes and mouth with facial paralysis symptoms. An array of tests will be analyzed to confirm a diagnosis, including blood test that include rheumatoid factor, antinnuclear antibodies, Sjogren's antibodies, antithyroid antibodies, and immunoglobulins. A salivary gland biopsy is the best way to diagnose Sjogren's Syndrome in relation to dry mouth. Symptom presentation in Sjogren's Syndrome is variable, though, and specific symptoms do not always present concurrently. It is also a slowly progressive disease that can be secondary to another autoimmune disease. The presentation of facial hemiparesis alone is very uncommon. The most typical symptoms seen are lack of fluid in the eyes and mouth (keratoconjunctivities sicca and xerostomia), and parotid gland enlargement (a large gland near the temporomandibular joint).

Amyloidosis is a very complex disease of protein abnormalities. Amyloid deposits can accumulate in many organs and tissues of the body. Salivary gland amyloidosis may be associated with facial hemiparesis, and a biopsy of the salivary glands confirms this. Urine or blood samples may reveal altered proteins related to amyloidosis as well. Guillane-Barre syndrome is an inflammatory demyelinating neuropathy, acutely caused by an abnormal immune reactivity to various foreign antigens, the most common being Campylobacter jejuni, but in most cases the infectious agent is not identified, and thought to be a virus, with many viruses implicated. Guillane-Barre Syndrome is a somewhat rare side effect of flu vaccines as well. It is reported as a side effect of flu vaccines at the rate of 1 per million, but this is considered underreported. The manifestation of Guillane-Barre Syndrome, though, is typically a progressive bilateral symmetrical neuropathy, starting in the legs and advancing upward. Diagnosis usually involved a cerebral spinal fluid analysis and electrodiagnostics of muscle weakness. Sometimes the neural symptoms are not dramatic, though, and often Guillane-Barre affects the facial nerve. This facial paralysis would almost always be affecting both sides of the face symmetrically, though. Bell's palsy may affect both sides of the face as well, though. About 23% of bilateral facial paralysis ends up diagnosed as Bell's Palsy.

Diabetic patients are four times as likely to have Bell's Palsy than nondiabetic patients, and 30% more likely to have only partial recovery. Recurrence of Bell's Palsy is also more common among diabetics. Diabetes mellitus alone is not a significant cause of facial paralysis.

Information Resources

1. A 2010 analysis Bell's Palsy research in South Korea describes the current knowledge of this difficult disease and points to the findings of new pathogenic causes each year. Predominant known causes include Herpes viruses (HSV-1 and Zoster), but association of the disease with HIV vaccine, diabetes mellitus, Lyme disease, hypertension, HIV infection, sarcoidosis and amyloidosis, as well as a number of low grade viral and bacterial infections, indicate that a complexity to the etiopathogenesis may be the reason that this is still a poorly understood disease: http://docs.google.com/
2. A study of the electrical potential in the facial muscles of 87 randomly chosen patients with Bell's Palsy found that 36 had a full recovery within a short period (unspecified), while the others showed an abscence of electrical activity in 10% of the facial muscles in the first 2 weeks, and denervation of the facial nerve was seen in 38% of the patients at 2 months. Even in patients with some motor activity, increased denervation was measured in the second month, particularly affecting the frontalis and depressor labii inferioris muscles, which lifts the eyebrow and lowers the bottom lip. Marked denervation was noted in the second to third month. Patients with long term deficits and poor recovery showed marked degeneration of the Facial nerve after the second week, indicating that early treatment of Bell's Palsy, within the first 2 weeks of onset, may insure a much better outcome: http://www.springerlink.com/content/w260177560464564/
3. A study of 2500 cases of Bell's Palsy in 2002 in Denmark found that initially 70% had a complete palsy (all 3 branches of the Facial nerve), and that in the 71% of patient that recovered, sufficient function of facial muscles returned for 85% of these patients in 3 weeks, and by the fifth month in the other 15%. About 30% did not recover normal facial motor function, and 29% experienced various degress of sequelae, with about 17% left with varying presentations of facial pain and contracture, and about 16% with abnormal facial movements, such as twitch and tic. No treatment in standard medicine, including prednisone, was found to give any better prognosis. As the study pointed out, many MDs and health authorities question the use of prednisone in therapy, as it has shown no benefit, has significant risk of side effect and long-term harm, and induces a false sense of euphoria that gives the patient a false feeling of benefit in the crucial first 2 weeks. : http://www.ncbi.nlm.nih.gov/pubmed/12482166
4. A 2010 interview with a reknowned physician acupuncturist, Xiaoming Tian, L.Ac., C.M.D., who received his medical degree from Beijing Medical University in China, and now is the director of the Academy of Acupuncture and Chinese Medicine in Bethesda, Maryland, and an adjunct professor of preventive medicine at the Uniformed Services University of Health Sciences (training military doctors and nurses), states in an interview that in his private practice at Wildwood Center in Bethesda, Maryland, that treatment of Bell's Palsy is the tenth most commonly treated disease or injury at his clinic: http://search2.google.cit.nih.gov/
5. The success of acupuncture therapy for Bell's Palsy has long been acknowledged by American physicians. This 1999 review of the success rates with acupuncture by Dr. David P. Sniezek, M.D. of Washington, DC, shows that an almost 100% success rate is seen with patients seeking acupuncture therapy within the first 4 days of onset, and even with patients that sought treatment with acupuncture only after chronic nerve demyelination had occurred at 2 months or later after onset, and in severe cases, 80% of patients still were either cured or had excellent outcomes. : http://www.medicalacupuncture.org/aama_marf/journal/vol10_2/bells.html
6. A 2004 multicenter human randomized controlled clinical trial with acupuncture and moxibustion sponsored by the Chengdu University in China, found that a statistically significant benefit was found with the use of acupuncture and moxibustion in the treatment of Bell's Palsy, both as an adjunct to standard treatment with prednisone, dibazole and B12 injections, and alone, compared to this standard treatment. 439 patients completed these studies, and 314 evaluated at 3 months post-treatment, and 207 at 6 months post-treatment. A number of variables were measured in these trials : http:/www.cmj.org/periodical/PaperList.asp?id=LW7809

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.