Therapeutic efficacy observation on needling Yangming method for facial palsy

Zhang Li-hua (张丽华), Zhang Shu (张姝), Li Yan-hong (李艳红), Wang Yan-jun (王艳君), Zhang Yan-chun (张艳春)

1 Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Hebei 061000, China

2 Hebei Provincial Hospital of Traditional Chinese Medicine, Hebei 050011, China

3 Cangzhou Central Hospital, Hebei 061000, China

Special Topic Study

Therapeutic efficacy observation on needling Yangming method for facial palsy

Zhang Li-hua (张丽华)1, Zhang Shu (张姝)1, Li Yan-hong (李艳红)2, Wang Yan-jun (王艳君)2, Zhang Yan-chun (张艳春)3

1 Hebei Province Cangzhou Hospital of Integrated Traditional and Western Medicine, Hebei 061000, China

2 Hebei Provincial Hospital of Traditional Chinese Medicine, Hebei 050011, China

3 Cangzhou Central Hospital, Hebei 061000, China

Objective:To observe the clinical efficacy of Prof. Gao Yu-chun’s needling Yangming method for facial palsy, as well as to inherit and further develop the academic idea.

Acupuncture Therapy; Facial Paralysis; Yangming Meridians; Point, Hegu (LI 4); Point, Zusanli (ST 36); Point, Zhongwan (CV 12)

Facial palsy (Bell’s palsy), known as facial neuritis in modern medicine, is mainly characterized by deviation of the eye and mouth corner to one side. In Chinese medicine, it’s called ‘deviation of the mouth’ or‘deviation of the mouth and eye’. Epidemiological survey has shown that facial palsy affects 26-34/100 000 people in China, i.e., 3.35 million Chinese people on a yearly basis[1]. Acupuncture has an exact efficacy for facial palsy.

Needling Yangming method was based on Gao’s academic idea and clinical experience. We’ve observed the clinical efficacy of this method for Bell’s palsy. The results are now summarized as follows.

1 Materials and Methods

1.1 Diagnostic criteria

1.1.1 Diagnostic criteria in Chinese medicine

This was based on the diagnosis for facial palsy in the national textbookScience of Acupuncture and Moxibustion[2]: a sudden onset, commonly seen in spring and autumn seasons, a history of contractingcold and fever or pain in one-sided 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 electromyography (EMG) findings.

1.1.2 Diagnostic criteria in Western medicine

This was based on the diagnosis for idiopathic facial neuritis in theNeurology[3].

Case history: A sudden onset, a history of contracting cold or wind or a history of viral infection.

Clinical manifestations: Sudden paralysis of one-side mimetic muscle, absence of forehead wrinkles on the affected side, incomplete eye closure, shallowing nasolabial folds, drooping of the mouth corner, incomplete cheek blowing or whistling, food retention in the mouth, taste loss involving the anterior 2/3 of the tongue on the affected side, increased sensitivity to sound, and lacrimation; and normal CT scan and MRI findings.

1.2 Inclusion criteria

Those who met the above diagnostic criteria in Chinese and Western medicine; disease duration lasted from 1 d to 30 d; having initial unilateral onset; House-Brackmann (H-B) grade III-VI[4]; and those who were willing to participate in this study and sign the informed consent.

1.3 Exclusion criteria

Bell’s palsy secondary to brain diseases, inner ear problems, tumor, trauma or other systemic conditions; having severe heart, liver and kidney problems; pregnant or breast-feeding women; having mental illnesses; and those who were receiving other acupuncture therapies.

1.4 Statistical management

The SPSS 19.0 version software was used for statistical analysis. Thewas used to express measurement data. Thet-test was used for intra-group comparison before and after treatment. The Chi-square test was used to express enumeration data and rank sum test to express ranked data. APvalue of less than 0.05 indicated a statistical significance.

1.5 General data

A total of 70 outpatients treated at the Rehabilitation Department, Hebei Province Cangzhou Hospital of Integrated Chinese and Western Medicine between January 2013 and June 2014 were randomly allocated into a treatment group (n=35) and a control group (n=35). Patients were aged between 13 and 75 years in the treatment group and between 15 and 77 years in the control group. The disease duration was 1-28 d in the treatment group and 2-30 d in the control group. There were no between-group statistical differences in baseline data (P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Between-group comparison in baseline data

2 Treatment Methods

2.1 Treatment group

Patients in the treatment group were treated with needling Yangming method.

Points: Zhongwan (CV 12), bilateral Tianshu (ST 25), Zusanli (ST 36), Jiexi (ST 41) and Hegu (LI 4) as well as Chengqi (ST 1), Sibai (ST 2), Taiyang (EX-HN 5), Sizhukong (TE 23), Quanliao (SI 18), Jiache (ST 6), Dicang (ST 4), Yingxiang (LI 20) and Qianzheng (Extra, 0.5-1.0 cun anterior to the ear lobe) on the affected side.

Method: Disposable filiform needles of 0.3 mm in diameter and 25-40 mm in length were used to puncture the following points in sequence: Tianshu (ST 25), Zhongwan (CV 12), points on the face and distal points on the four limbs, followed by even reinforcingreducing manipulation by small-amplitude lifting, thrusting and twirling upon needling sensation. The needles were retained for 20 min. The treatment was done once a day (6 times a week) for a total of 6 weeks.

2.2 Control group

Patients in the control group were treated with traditional acupuncture method.

Points: Chengqi (ST 1), Sibai (ST 2), Taiyang (EX-HN 7), Sizhukong (SJ 23), Quanliao (SI 19), Jiache (ST 6), Dicang (ST 4), Yingxiang (LI 20) and Qianzheng (Extra) on the affected side as well as Hegu (LI 4) on the healthy side.

Method: Same filiform needles as those used in the treatment group were used to puncture above points from top to bottom, followed by even reinforcingreducing manipulation upon needling sensation. The needles were retained for 20 min. The treatment was done once a day (6 times a week) for a total of 6 weeks.

3 Therapeutic Efficacy Observation

The evaluation indicators and therapeutic efficacy have been assessed before treatment and after 2, 4 and 6 weeks treatment.

3.1 Evaluation indicators

3.1.1 Facial nerve function

The facial nerve function was assessed using the H-B scale[4]. Grade I indicates normal, grade II indicates mild facial nerve damage, grade III indicates moderate facial nerve damage, grade IV indicates moderately severe facial nerve damage, grade V indicates severe facial nerve damage and grade VI indicates total paralysis.

3.1.2 Scores of signs and symptoms

This was based on the quantitative score of signs and symptoms[5]. It consists of 12 items, including frontal muscle movement, eyelid opening and closing, nasolabial folds, nose crinkling and deviation of the mouth corner (comprehensive evaluation during rest, cheek blowing and smiling), incomplete cheek blowing, food retention in the mouth, platysma muscle contraction, taste disturbance, increased sensitivity to sound, lacrimation and pain in the forehead, ear or mastoid process. Each item is scored 0 (normal), 1 (mild), 2 (moderate) and 3 (severe). A total score ≤12 points indicates mild Bell’s palsy, a total score between 12 and 24 points indicates moderate Bell’s palsy and a total score ≥24 points indicates severe Bell’s palsy.

3.2 Therapeutic efficacy criteria

This was based on the H-B score for facial nerve function[4].

Recovery: Completely normal.

Marked effect: Mildly impaired function and possible coupled motion; facial symmetry with normal muscle tension during rest; normal forehead movement, complete eye closure with an effort and mild asymmetry of the mouth corner.

Improvement: Significantly impaired function, absence of harmful facial symmetry, mild coupled motion, contracture and spasm on the affected side, normal muscle tension during rest, mild forehead movement, complete eye closure with an effort and apparent asymmetry of the mouth corner.

Failure: Facial asymmetry during rest, absence of forehead movement, incomplete eye closure and mild twitching of the mouth.

3.3 Results

3.3.1 Between-group comparison in H-B score for facial nerve function before and after treatment

Before treatment, there was no between-group statistical difference (P＞0.05) in facial nerve function. After treatment, there were intra-group statistical differences in each time period (bothP＜0.01). There were between-group statistical differences after 2 and 4 weeks of treatment (P＜0.05). There were no between-group statistical differences after 6 weeks of treatment (P＞0.05). This indicates that patients in the treatment group obtained faster recovery of the facial nerve function than those in the control group (Table 2).

3.3.2 Between-group comparison in scores of signs and symptoms

Before treatment, there were no between-group statistical differences in scores of signs and symptoms (P＞0.05). After treatment, there were intra-group statistical significances in each time period (P＜0.01). There were no between-group statistical significances after 2 and 6 weeks of treatment (P＞0.05). There were between-group statistical significances after 4 weeks of treatment (P＜0.01), (Table 3).

3.3.3 Between-group comparison on clinical efficacy

There was no between-group statistical significance (P＞0.05) in total effective rate after 2, 4 and 6 weeks of treatment; there were between-group statistical differences (P＜0.05) in recovery rate after 2 and 4 weeks of treatment; and there was no between-group statistical difference in recovery rate after 6 weeks of treatment (P＞0.05), (Table 4).

Table 2.Between-group comparison in H-B score for facial nerve function (case)

Table 3. Between-group comparison in scores of signs and symptoms before and after treatment

Table 3. Between-group comparison in scores of signs and symptoms before and after treatment

Note: Intra-group comparison before and after treatment, 1)P＜0.01; inter-group comparison over the same time period, 2)P＜0.01

Group Before treatment After 2 weeks After 4 weeks After 6 weeks Treatment 20.94±4.76 9.74±2.841) 2.43±2.921)2) 0.91±1.291)Control 19.49±5.23 10.74±2.691) 5.11±4.831) 1.43±1.591)

Table 4. Between-group comparison on clinical efficacy after treatment (case)

4 Discussion

Meridian differentiation for facial palsy is based on the academic idea that ‘meridian points are indicated for any problems along its pathway’. From the perspective of meridian theory, inability to close the eyelids results from dysfunctions of the muscle regions of the Bladder Meridian and the Stomach Meridian. In addition, the face and cheek are located along the pathways of the Large Intestine Meridian and the Stomach Meridian. As a result, facial palsy is often treated with Yangming and Taiyang Meridians[6-8].

Prof. Gao Yu-chun is the main successor of Gao’s acupuncture school. At the age of 85, she’s still treating patients today[9]. Prof. Gao started to learn Chinese medicine from his father since she was 16. His father Gao Ji-pei (1908-1987) learned from well-known Chinese medical practitioners including Xiao Long-you, Guo Mei-chen and Wang Chun-yuan and was an expert on stroke. The protocol of Yangming needling method is based on traditional theory (Yangming Meridian for facial palsy) and 60 years of Prof. Gao’s clinical experience. This protocol has special points, needling techniques and three core concepts. First, unlike the traditional way of selecting local Yangming points, this protocol selects points in three layers: muscle regions, meridians and Zang-fu organs[10]. For muscle regions, this protocol selects local points on the head and face. For meridians, this protocol selects distal points such as Hegu (LI 4), Zusanli (ST 36) and Jiexi (ST 41). For Zang-fu organs, this protocol selects Tianshu (ST 25) (the Front-Mu point of the large intestine) and Zhongwan (CV 12) (the Front-Mu point of the stomach) to activate meridian qi and reinforce the spleen and stomach. Second, this protocol highlights the needling sequence to guide qi and blood to circulate. The needling sequence has long been recorded in ancient texts. For example, the Wu Se Chapter of Ling Shu (Five Colors of Spiritual Pivot) states: for internal problems, it’s advisable to treat yin meridians first and then yang meridians; otherwise, you may aggravate the patients’condition. For external problems, it’s advisable to treat yang meridians first and then yin meridians; otherwise, you may aggravate the patients’ condition. Prof. Fu Wen-bin also believes the needling sequence is an important part of acupuncture formula and it's directly associated with the treatment effect in some conditions. The general principle in acupuncture treatment is to puncture major points first and then adjunct points and to target symptoms first and then the root cause[11]. In this protocol, Tianshu (ST 25) and Zhongwan (CV 12) were punctured first to activate Yang qi in the middle jiao and regulate qi activities of the entire body; then the points on the face were punctured to remove pathogenic factors (symptoms); and finally, distal points were punctured to unblock meridian qi, tonify the spleen and stomach and promote qi and blood generation (root cause). Third, this protocol adopts different needle-removing methods for deficiency and excess syndrome[12]. For excess syndrome, the needles were removed using a reducing technique, i.e., to slightly lift and shake the needle to enlarge the needle hole. For deficiency syndrome, the needles were removed using a reinforcing technique, i.e., to shorten the needle retaining time (＜20 min) and puncture and remove needles gently. In summary, Gao Yu-chun’s protocol on needling Yangming for Bell’s palsy emphasizes three aspects: point selection principle, needling sequence and needle removal method.

We’ve treated Bell’s palsy with needling Yangming method and compared it with traditional acupuncture method. The results have shown that there was no between-group statistical difference in H-B grade after 6 weeks of treatment. However, the recovery rates in the treatment group were significantly higher than those in the control group after 2 and 4 weeks. This indicates that needling Yangming method can obtain a faster effect. Judging from the scores of signs and symptoms, there were no between-group statistical differences after 2 and 6 weeks of treatment. However, the scores in the treatment group were better than that in the control group after 4 weeks of treatment. This also confirms that needling Yangming method can obtain faster effect in improving the associated symptoms of facial palsy. There were no between-group statistical differences in recovery and total effective rate after 6 weeks, suggesting that the two methods can obtain similar treatment effect.

In conclusion, compared with traditional acupuncture method, needling Yangming method can achieve a higher recovery rate in early stage and obtain a faster effect in improving the associated signs and symptoms of 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 Hebei Provincial Administration of Traditional Chinese Medicine (河北省中医药管理局资助课题, No. 2014038).

Statement of Informed Consent

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

Received: 26 May 2015/Accepted: 21 June 2015

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Translator: Han Chou-ping (韩丑萍)

阳明论治针法治疗面瘫疗效观察

目的：观察高玉瑃教授“阳明论治针法”治疗周围性面瘫的临床疗效, 继承燕赵高氏针灸学术思想。方法：共纳入70例周围性面瘫患者, 以随机数字表法随机分为两组, 每组35例。治疗组采用“阳明论治针法”治疗, 对照组采用传统针刺法治疗, 两组均每日治疗 1次, 每星期治疗 6次, 共治疗 6星期。治疗前后根据House-Brackmann (H-B)面神经功能评价分级、临床疗效和症状体征量化评分进行疗效评价。结果：治疗2星期后，治疗组H-B分级及治愈率均优于对照组(P＜0.05)。治疗4星期后, 治疗组H-B分级、症状体征评分及治愈率均优于对照组(P＜0.05,P＜0.01,P＜0.05)。治疗6星期后两组各方面比较差异均没有统计学意义(P＞0.05)。结论：“阳明论治针法”治疗面瘫较传统针刺法起效快, 早期治愈率高, 可缩短疗程。

针刺疗法; 面神经麻痹; 阳明经; 穴, 合谷; 穴, 足三里; 穴, 中脘

R246.6 【

】A

Author: Zhang Li-hua, vice chief physician

Wang Yan-jun, chief physician, professor.

E-mail: wangyj8055@sina.com

Methods:A total of 70 cases were randomly allocated into a treatment group (n=35) and a control group (n=35). Cases in the treatment group were treated with needling Yangming method, whereas cases in the control group were treated with traditional acupuncture method. The treatment was done once a day in both groups (6 times a week) for a total of 6 weeks. Then the therapeutic efficacies were evaluated before and after treatment using the House-Brackmann (H-B) scale and scores of signs and symptoms.

Results:After 2 weeks of treatment, patients in the treatment group obtained a better H-B score and recovery rate than those in the control group (P＜0.05). After 4 weeks of treatment, the H-B score, scores of signs and symptoms and recovery rate in the treatment group were better than those in the control group (P＜0.05,P＜0.01,P＜0.05). After 6 weeks of treatment, there were no between-group statistical differences in the above aspects (P＞0.05).

Conclusion:Needling Yangming method can obtain a faster effect, a higher early-stage recovery rate and shorter course of treatment than traditional acupuncture method.