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Bell’s Palsy Diagnosis/Condition: Discipline: ICD‐9 Codes: ICD‐10 Codes: Origination Date: Review/Revised Date: Next Review Date: Bell’s Palsy
LAc
351.0
G51.0
03/2001
07/2014
07/2016
Bell’s Palsy is the most common form of facial paralysis. The incidence rate of this disorder is about 20 per 100,000, or about 1 in 60 or 70 persons in a lifetime. The pathogenesis of the paralysis is unknown. Current theories suggest a viral (herpes simplex) etiology, however clinical trials show a limited benefit of anti‐viral medication. In addition, the autopsied cases of this disease have shown only nondescript changes in the facial nerve but no inflammatory changes, as is commonly presumed. The evidence suggesting a beneficial effect for the treatment of Bell’s Palsy with acupuncture is promising but limited at this point. In Acupuncture and Oriental Medicine (AOM), deviation of the eye and the mouth is due to invasion of pathogenic wind and/or cold on the Yangming and Shaoyang Meridians in the facial region. This causes the paralysis and malnutrition of the facial muscles. The symptoms are a direct result of these energetic changes. Subjective Findings and History 
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Paralysis or weakness of one side of the face Sudden onset of paralysis and/or weakness with maximum effect being attained by 48 hours Pain around the ear and face and pain behind the ear may precede the paralysis for a day or 2 and persist through the first few weeks of paralysis Occasionally taste sensation is lost; hyperacusis may be present Dryness of the eye or mouth Risk factors include pregnancy, obesity, hypertension, diabetes, immunodeficiency, upper respiratory ailments Objective Findings 
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Facial paralysis on one side Incomplete closure of the eye on the affected side Drooping of the angle of the mouth Assessment 
Clinicians should ensure that the facial paralysis is not associated with other signs and symptoms that may indicate other diagnoses such as stroke, mass lesions/tumors, systemic and infectious diseases such as Lyme disease, herpes, zoster, sarcoidosis. These patients should be referred to their primary care physicians for further evaluations. The CHP Group Bell’s Palsy Clinical Pathway Copyright 2014 The CHP Group. All rights reserved. 1 
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Clinical impressions should be correlated to history, complaints, and objective findings to differentiate syndromes according to TCM or other acupuncture paradigms. Invasion of pathogenic wind and cold will cause paralysis and malnutrition of the muscles. Plan 
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Acupuncture treatment for this condition is most effective in the early phases of the condition. Best results are obtained if treatments are started within the first week of the condition. Even without treatment patients improve within 3 weeks and most completely recover within 6 months. Approximately 30% of patients have notable symptoms beyond 6 months. Therapeutic results after 6 months of the disease are still possible but much less likely. Acupuncture treatments can be based on a variety of different approaches including TCM, French Energetics, Korean Hand acupuncture, Auricular acupuncture, etc. If these different techniques are used, practitioners should be able to justify point selection based on the theories of these different systems. Acupuncture according to TCM syndrome differentiation: Eliminate wind and remove the obstruction of meridians by applying even‐movement mainly to the points of Yangming and Shaoyang Meridians. Suggested point selections include: SJ 17, GB 14, Taiyang (Extra), SI 18, ST 7, ST 4, ST 6, LI 20, GV 26, and LI 4. Suggested supplementary points: headache: GB 20; Incomplete eye closure: BL 2, GB 1, Yuyao (Extra), SJ 23; mouth droop: ST 3, tinnitis and deafness GB 2; and tenderness at the mastoid region: GB 12, SJ 5. If the healthy side of the face is stiff, shallow puncture and needle retention at the local points of the healthy side can be applied in combination with needling of the affected side. Electrical acupuncture and moxibustion can be used where appropriate, after acupuncture without electrical stimulation has been tried. Caution should be used in electrical stimulation to the affected area. Herbal/nutritional therapies can be prescribed, but practitioners should be aware of the potential interactions and toxicities. Chinese herbs should be prescribed to eliminate wind/cold and to address patient's underlying deficiencies. Other herbal/nutritional therapies can include Gingko biloba and vitamin B complex. Other therapies: o Protection of the eye during sleep and for patients with incomplete eye closure. o Massage of the weakened muscles o Referral to primary care: Current guidelines suggest initiation of oral steroids within 72 hours of symptoms. Anti‐viral medication may also be appropriate in combination with oral steroids, per physician discretion. Length of Treatment 
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Initial treatment course: 2‐3 times a week for 2‐3 weeks. Patients should be noticeably better by treatment number 5 or 6. If there are no changes and the patient has had the condition for more than 6 months additional treatments are unlikely to result in further clinical improvements. Treatments should be discontinued at this point. If the patient has only partial improvement, treatments at weekly intervals for another month may be needed to reach medically stationary status. The CHP Group Bell’s Palsy Clinical Pathway Copyright 2014 The CHP Group. All rights reserved. 2 Outcome Assessment Tools 
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Facial Disability Index (FDI) House‐Brackmann Scale, objective grading system for facial nerve palsy Referral Criteria 
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New or worsening neurological findings Ocular symptoms developing at any point Incomplete facial recovery in 3 months Resources for Clinicians Lo B. Bell Palsy. eMedicine from WebMD. http://www.emedicine.com/emerg/TOPIC56.HTM Pao F. Bell’s Palsy. http://acupuncture.com/newsletters/m_july05/main2.htm Resources for Patients Bell’s Palsy Information Site. http://www.bellspalsy.ws/ National Institute of Neurological Disorders and Stroke. NINDS Bell’s Palsey Information Page. http://www.ninds.nih.gov/disorders/bells/bells.htm The Evidence Gliden DH. Bell’s palsy.N Eng J Med 2004;351:1323‐31 Gao HB, Chen D. Clinical observation on 60 cases of peripheral facial paralysis treated with acupointure penetration needling. Int J Clin Acup 1991; 2(1),25‐28. NIH Consensus Development Conference on Acupuncture, National Institutes of Health, Bethesda MD, Nov 1997; 93‐109. Chen ZZ, Ming SP, and Chen WX. Treatment of Bell's Palsy with acupuncture and moxibustion clinical observation of 61 cases. Intl J Orient Med 1999;24(4):199‐201. Gao S and Gao Q. Can the addition of moxibustion during acupuncture therapy improve recovery from Bell's Palsy? Amer J Acupunct 1998;26(1):33‐36. He L, Zhou D, Wu B, Li N, and Zhou M. Acupuncture for Bell's palsy. Cochrane Database Syst Rev 2004;1(CD002914) Kajdos V. Peripheral paresis of facial nerve treated with acupuncture. Am J Acupunct 1975;3(3):233‐237. Li Y, Liang FR, Yu SG, Li Cd, Hu LX, Zhou D, Yuan XL, Li Y, and Xia XH. Efficacy of acupuncture and moxibustion in treating Bell's palsy: a multicenter randomized controlled trial in China. Chin Med J (Engl ) 2004;117(10):1502‐1506. The CHP Group Bell’s Palsy Clinical Pathway Copyright 2014 The CHP Group. All rights reserved. 3 Liu Y. A new classification system and combined treatment method for idiopathic facial nerve paralysis. Amer J Acupunct 1995;23(3):205‐210. Sing G, Xieyun, and Xiang F. Clinical observation of 211 cases of facial palsy treated with 11 acupuncture points and lead to symmetry powder. Int J Med 2003;28(2):124‐126. Sniezek D. ACUPUNCTURE TREATMENT OF BELL'S PALSY: A CASE REPORT Medical Acupuncture Fall / Winter 1998 / 1999 ‐ Volume 10 / Number 2. Peitersen E. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta oto‐laryngologica. Supplementum. 2002(549):4‐30. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg. Nov 2013;149(3 Suppl):S1‐27. Gronseth GS, Paduga R. Evidence‐based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. Nov 27 2012;79(22):2209‐2213. Engstrom M, Berg T, Stjernquist‐Desatnik A, et al. Prednisolone and valaciclovir in Bell's palsy: a randomised, double‐blind, placebo‐controlled, multicentre trial. Lancet Neurol. Nov 2008;7(11):993‐1000. Berg T, Axelsson S, Engstrom M, et al. The course of pain in Bell's palsy: treatment with prednisolone and valacyclovir. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. Sep 2009;30(6):842‐846. Rowlands S, Hooper R, Hughes R, Burney P. The epidemiology and treatment of Bell's palsy in the UK. Eur J Neurol. Jan 2002;9(1):63‐67. Chen N, Zhou M, He L, Zhou D, Li N. Acupuncture for Bell's palsy. Cochrane Database Syst Rev. 2010(8):CD002914. Kim JI, Lee MS, Choi TY, Lee H, Kwon HJ. Acupuncture for Bell's palsy: a systematic review and meta‐analysis. Chin J Integr Med. Jan 2012;18(1):48‐55. Xu SB, Huang B, Zhang CY, et al. Effectiveness of strengthened stimulation during acupuncture for the treatment of Bell palsy: a randomized controlled trial. CMAJ. Apr 2 2013;185(6):473‐479. Li Y, Liang FR, Yu SG, et al. Efficacy of acupuncture and moxibustion in treating Bell's palsy: a multicenter randomized controlled trial in China. Chin Med J (Engl). Oct 2004;117(10):1502‐1506. Wang XH, Zhang LM, Han M, Zhang KQ, Jiang JJ. [Treatment of Bell's palsy with combination of traditional Chinese medicine and western medicine]. Hua xi kou qiang yi xue za zhi = Huaxi kouqiang yixue zazhi = West China journal of stomatology. Jun 2004;22(3):211‐213. The CHP Group Bell’s Palsy Clinical Pathway Copyright 2014 The CHP Group. All rights reserved. 4 Tong FM, Chow SK, Chan PY, et al. A prospective randomised controlled study on efficacies of acupuncture and steroid in treatment of idiopathic peripheral facial paralysis. Acupunct Med. 2009;27(4):169‐173.
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