TCM Approaches for Bell's Palsy

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Article originally published August 2024

Bell’s palsy is one of those ailments that I believe is effectively treated with acupuncture. From a modern medicine standpoint, Bell’s palsy is often viewed as a benign condition that resolves on its own in most cases. Yet, some patients do not make a full recovery, which makes one wonder: is it genuinely benign when some patients are left with lifelong sequelae? My answer is a resounding no, because those long-term effects can have a lasting impact on functionality, self-esteem and confidence, and some may also have permanent facial paralysis.

Let’s start with a little refresher on Bell’s palsy: what it is, what we know about it, how it’s treated, and, of course, how we, as acupuncturists and other allied healthcare professionals, can support patients with this condition.

Symptoms

Even though symptoms of Bell’s palsy often begin a few days before the paralysis stage, patients may not be aware that anything is wrong. They might notice increased fatigue, headache, ear, neck, or jaw pain, or mild paresthesias on the affected side, and then a day or so later, noticeable paralysis may set in.

Common symptoms, which may occur over a few hours or days, include:

• Facial drooping
• Drooling
• Facial paralysis or weakness on one side of the face
• Jaw pain: Pain in or behind the ear on the paralyzed side of the face
• Headache
• Sensitivity to sound on the paralyzed side
• Altered taste
• Changes in saliva and tear production

Acute-onset paralysis is always referred to emergency medicine. In the emergency department (ED), they will rule out stroke or other etiology before typically sending patient home with a course of steroids and usually antiviral medication like valacyclovir. We will talk about the importance of steroids later as they are crucial to the patient’s full recovery.

Etiology

The etiology of Bell’s palsy remains a mystery, but the leading theory on causes of Bell’s palsy focuses on a viral etiology, particularly on herpes simplex virus, type 1 (HSV-1), and herpes varicella-zoster (commonly known as shingles), human herpesvirus 6 (HHV-6), COVID-19, and Usutu virus (USUV). Understanding the viral etiology of Bell’s palsy and herpes viruses can help us educate our patients on their potential for prognosis and how the disease process progresses and heals.

Bell’s palsy stemming from herpes zoster for instance, will take a longer course of treatment because the viral shedding period is longer than HSV-1. When patients understand this, it can help them adhere to treatment plans and maintain a more positive outlook on their recovery because we now have a proper timeline to give them.

In cases that do not resolve, studies have implicated secondary ischemia, tertiary ischemia, or their sequelae, and this, in turn, can result in the thickening of the facial nerve sheath, forming one or more fibrous bands that cause nerve strangulation and compression, thereby hampering recovery. Primary ischemia is the initial reduction or cessation of blood flow to a tissue or organ, which can be due to a blockage in a blood vessel (e.g., a thrombus or embolus), severe hypotension, or vascular constriction. Secondary ischemia is the progressive injury that occurs after the initial ischemic event, often due to reperfusion (the restoration of blood flow). This phase can involve inflammatory responses, oxidative stress, and the release of harmful substances like free radicals and cytokines that exacerbate tissue damage. Finally, tertiary ischemia is a more advanced and chronic stage of ischemic injury, often involving long-term or delayed complications of the initial event, which can result from persistent ischemia, scarring, fibrosis, or other long-term structural changes in the tissue following the initial injury. In Bell’s palsy there is the risk of all three levels of ischemia due to differences in anatomy, treatment, etiology and the patient’s unique healing trajectory, and this is how we can classify ongoing sequalae from Bell’s palsy as chronic or acute.

Additionally, lack of significant anastomoses between the petrosal branches and stylomastoid may predispose individuals to ischemia. Endoneurial capillary density corresponds to susceptibility for ischemic nerve damage, and when this vascular layer is compromised, local ischemia and palsy may result. From a TCM lens, the ischemia represents a stagnation of Qi and Blood, and result of this long-term stagnation can cause more stagnation or a deposition of Phlegm and Dampness, thus complicating the healing processes.

Numerous lines of evidence have suggested that Bell's palsy results from acute, inflammation-caused demyelination. Inflammation is a significant factor in Bell’s palsy and is one of the reasons that treatment with acupuncture and steroids can be so beneficial.

There is also a clear correlation between the cold season and the number of cases observed. More substantial wind speeds on the day preceding Bell’s palsy onset might be related to its occurrence, as noted in the Zhang, W., Xu, L., Luo, T. et al. study. This correlation is no different from our traditional Chinese medicine point of view that Cold and Wind are the primary pathogens involved in the disease process.

Differential Diagnosis

Bell’s Palsy is often thought of as a diagnosis of exclusion, meaning if the physicians can find no cause of the paralysis, the patient is given the diagnosis of Bell’s palsy. However, physicians who see Bell’s palsy patients are generally looking to rule out life-threatening causes of disease and not other possible etiologies, which can lead to misdiagnoses.

Possible Differential Diagnosis for One-Sided Facial Paralysis:

• Viral: leukemia, Lyme disease, tuberculosis, Covid-19
• Miller Fischer: A variety of Guillan-Barre syndrome that first affects the head. Paralysis may be bilateral
• Ramsay Hunt: Hearing loss, ear pain, rash in the ear canal, associated with herpes zoster
• Tumor: Multiple types of tumors can cause facial paralysis, e.g. brainstem glioma, neurofibroma, parotid gland tumors, tumors of facial nerve
• Stroke

Disease Process

Provided Bell’s palsy is caused by the herpes virus, the disease process is understood as follows. Once the virus gets into the ganglion upon initial infection, it resides in its nucleus. It waits there in a latent stage until it is reactivated and then causes ganglionitis. The virus then migrates down the nerve to cause mucocutaneous vesicles, and up the nerve to cause a localized meningoencephalitis at the brainstem. When the virus leaves the neural cell membrane, it creates a coat of neurolipoprotein around it, and deposits that neurolipoprotein in the perineural compartment. This neurolipoprotein causes an immune-mediated reaction, which causes demyelination in 4 - 5 days and is completed in 8 – 10 days after the disease process has taken place.

Herpes zoster and simplex behave differently in the disease process of Bell’s palsy. Differentiating between the two can give your patient an additional understanding of what their recovery will be like.

Herpes simplex has often been clinically recognized as ‘the big masquerader’ because it causes inflammatory ganglionitis, which then causes a viral-induced immunological response, not autoimmune. In addition, a metabolic response is invoked by local changes, and the virus can also cause vasospasm. In TCM we might view the herpes virus for its Wind qualities; it moves, shifts and changes in unpredictable ways.

In zoster, the virus lies dormant, and it takes the body up to 2 weeks to re-create antibodies. If zoster is the cause, all major nerve damage is complete 14-21 days from the onset. In simplex, all major nerve damage is complete 8-10 days from the onset. The disease process is active up to day 18 in simplex and up to day 21 in zoster. This tells us that we are unlikely to see any significant improvements in paralysis until this disease process is complete, and informing the patient of this timeline helps them set realistic expectations for their recovery. We might find this information in our patient history to differentiate if the cause is zoster or simplex; a history of cold sores would indicate simplex. In contrast, a possible history of shingles may indicate zoster. Symptomatically, it is less obvious. In zoster, there may be more pain associated at onset, specifically in and around the ear on the affected side. Usually, we can determine the cause once this window of disease progression has passed and we begin seeing improvements.

Medical Treatments

When a patient is newly diagnosed with Bell’s palsy, they generally receive the following treatment for the acute phase of the disease.

• Steroids: A course of steroids is given to patients with BP and can make a considerable improvement in the completion of healing.
• Anti-virals: Valacyclovir / acyclovir anti-herpes virus medication is given to most patients presenting with BP

A course of corticosteroids, starting within 72 hours of the disease onset, is generally used as first-line therapy and drastically improves the likelihood of complete recovery. Patients who did not take steroids had twice the rate of incomplete recovery than those who did, and roughly 25% of patients who do take steroids will make a complete recovery. The treatment of paralysis is aimed at preventing damage to the neuronal tissue, and Western medicine only has antiviral treatment and steroids, which influence the pathological process – and are not 100% effective at all.

No other acute-phase treatments are commonly given to patients, except steroids and antivirals. They are usually instructed to wait it out, and that full recovery should take place within 1-3 months.

Additional treatments that can be utilized in the later phases of illness include:

• Exercises & physical therapy: To prevent overcompensation of accessory muscles of the face, PT and facial exercises can help minimize and improve healing time.
• Botox and surgery: Botox relaxes the functional side of the face to create more symmetry. Surgery can include selective neurolysis, masseter-to-facial nerve transfer, nerve transplants, and muscle transplants.

Acupuncture & Bell’s Palsy

One treatment that can be utilized in the acute and chronic phases of Bell’s palsy is acupuncture. The benefit of acupuncture in the acute phase is to mediate inflammation and potentially interrupt the disease process, which helps the patient make a full recovery. In chronic Bell’s palsy, with long-term paralysis or sequelae beyond 3 months, acupuncture can still provide benefits by reducing inflammation and re-activating muscles. Receiving acupuncture treatments is particularly impactful during the acute phase of illness and patients can begin this therapy immediately after diagnosis.

As an acupuncturist who commonly treats this condition, my knowledge of the disease process and being able to coach patients about their progress and potential for a complete recovery is incredibly helpful. Being left with facial paralysis and told to ‘wait it out’ is often not enough information for patients to sit with. By seeking out treatment, they can also address underlying connected factors like stress and overwhelm, which frequently accompany the onset of a Bell’s palsy diagnosis. As we know, acupuncture is a mind-body modality and can help address multiple layers of illness rather than just the presenting symptom, which allows patients to make a more complete recovery and enhance their body’s healing response.

My treatment protocol for Bell’s palsy cases begins with a thorough intake and evaluation, I treat the patient’s underlying constitutional pattern and local treatment to the affected side of the face. A multi-needle approach is utilized to offer more stimulation without electricity, and I do not use electrostimulation during the first three months of illness. Not utilizing e-stim during the acute phase was taught to me in acupuncture school. In my clinical experience, when someone with chronic Bell’s palsy comes to me for treatment, they have invariably been previously treated with electrostimulation during the acute phase. I don’t see the risk of chronic paralysis being worth the potential benefit of faster recovery. After the acute phase, I will use it on occasion. If possible, treatments are given bi-weekly until symptoms resolve, which is usually in 4-8 weeks.

Commonly Used Acupuncture Points for Treating Bell’s Palsy & Facial Paralysis

When choosing a point protocol for facial paralysis, think about the nerve pathway. The seventh cranial nerve (CN VII) extends from around the ear, with three branches jutting out and across the face, along the chin, cheek and around the eye. These pathways coincide with the Stomach, Gallbladder and Small Intestine channels.

Stomach 2-7, Gallbladder 2 and 14, and Small Intestine 17-19 would all be appropriate points to utilize. We can also address specific muscles of the face in later stage diagnosis. In the acute phase, our focus is on reducing nerve inflammation and preserving nerve activity, in chronic phases, we are still focusing on nerve regeneration but also can add points to improve muscle firing. Body points should always be used, and the focus of these points would be to help keep the patient grounded and to treat their underlying TCM pattern or other complaints.

Recovery Process

Many patients have longstanding sequelae beyond the average six-month timeframe. As we know, steroid treatment is crucial to recovery, only 25% of patients who do not receive steroids will make a full recovery in 3-5 months. Early treatment with steroids reduces long-term sequelae to 10%. Examining for oral herpes involvement is also helpful. Symptoms such as taste disturbance and/or lesions in the mouth may indicate an etiology of HSV-1.

It is helpful to use the House-Brackman facial paralysis grading scale to gauge paralysis severity and track recovery. This scale provides a standard guideline for rating facial paralysis.

According to this scale, if partial paralysis (paresis) occurs, it will recover completely within 3-4 weeks because the nerve suffers mostly from neuropraxia only (temporary physiologic block of the nerve impulses).

A total paralysis can recover totally within 4 weeks if not more than 20% of the fibers sustain severe damage (axonotmesis). The damaged fibers will then regrow within 12 – 18 weeks, resulting in a very satisfactory recovery with practically no sequelae.

A total paralysis that persists after 3 – 4 weeks indicates total nerve degeneration (axonotmesis). Regrowth of nerve fibers will occur, and the first movements of the face will start 12 –14 weeks after the onset of the paralysis. However, the recovery will be incomplete (about 60 – 70% movement only), and sequelae will always be present to a certain extent.

85% of Bell’s palsy patients will recover from Bell’s palsy without any lingering health issues. 10% of Bell’s palsy patients will suffer synkinesis, which is involuntary facial movement or spasms during routine facial movement, such as eye closure while attempting to smile. Others will have lingering partial facial paralysis. The remaining 5% of Bell’s palsy patients will require comprehensive Bell’s palsy treatment and will likely not make a complete or satisfactory recovery. By utilizing the House-Brackman scale, we can assess the severity of the patient’s paralysis and use the above guidelines to counsel them on their probable recovery. Understating the timing of recovery also makes a big difference in the patient's outlook and adherence to treatment protocols.

Failure to receive immediate treatment after an initial Bell’s palsy diagnosis, pregnancy, severe symptoms such as facial droop and paralyzed face and not receiving steroid medications are all factors that complicate and often impede the recovery process.

Acupuncture treatment can be an enormously helpful therapeutic intervention to assist with recovery and healing in our patients with Bell’s palsy. Communication with the patient on the disease progression is one of the most beneficial things we can offer, and this thorough understanding can help us give patients proper information and manage expected treatment outcomes. For more information, please see lionsheartwellness.com.

References

• House Brackmann Grading Systemhttps://facialparalysisinstitute.com/conditions/house-brackmann-grading-system/
• Zhang, W., Xu, L., Luo, T. et al. The etiology of Bell’s palsy: a review. Journal of Neurology 267, 1896–1905 (2020).
• Balchander, D., Cabrera, C. I., Qureshi, H., Perez, J. A., Goslawski, A., Tranchito, E., Johnson, B. R., Tamaki, A., & Rabbani, C. C. (2024). Bell's Palsy and COVID-19: Insights from a Population-Based Analysis. Facial plastic surgery & aesthetic medicine, 26(1), 41–46. https://pubmed.ncbi.nlm.nih.gov/37751178/
• Corticosteroids improve recovery rates after Bell’s palsy. Brain and Nerves 29.11.16 https://link.springer.com/article/10.1007/s00415-019-09282-4
• Bell’s Palsy - Bell’s Palsy symptoms and treatment. (n.d.). https://facialparalysisinstitute.com/conditions/bells-palsy