A Comparative Study on the Effect of Cupping Therapy Combined with Korean Medicine Treatment in Peripheral Facial Paralysis

Abstract

Background The aim of this study was to compare the effects of different cupping therapy methodscombined with Korean medicine treatments for peripheral facial paralysis. Methods 105 patients treated for peripheral facial paralysis with cupping therapy and other Korean medicine treatment at Gil Korean medicine hospital, Gachon University between May 19, 2014 and June 30, 2018 were selected and their medical charts retrospectively analyzed. 48 patients who met the inclusion criteria were divided into 2 groups: wet cupping (WC) therapy, or dry cupping (DC) therapy combined with Korean medicine treatment. The duration of treatment ranged from 2 weeks for inpatient treatment to 2 months for outpatient treatment. Both WC and DC therapy were performed on TE13, 3 times per week during the treatment period. The effect of cupping therapy was evaluated by using the Gross Grading System of the House-Brackmann (HB score) and the Yanagihara’s Unweighted Grading System (Y score). Results For both WC and DC treatment of symptoms related to peripheral facial paralysis, HB scores showed a significant decrease and Y scores showed a significant increase from baseline to end of treatment, indicating a beneficial improvement in patient symptoms for both WC and DC. Conclusions In this study, both DC and WC treatment had significant improvements on peripheral facial paralysis symptoms, with WC having significantly greater beneficial effects than DC.

Full text

Background: The aim of this study was to compare the effects of different cupping therapy methods
combined with Korean medicine treatments for peripheral facial paralysis.
Methods: 105 patients treated for peripheral facial paralysis with cupping therapy and other Korean medicine
treatment at Gil Korean medicine hospital, Gachon University between May 19, 2014 and June 30, 2018
were selected and their medical charts retrospectively analyzed. 48 patients who met the inclusion criteria
were divided into 2 groups: wet cupping (WC) therapy, or dry cupping (DC) therapy combined with Korean
medicine treatment. The duration of treatment ranged from 2 weeks for inpatient treatment to 2 months
for outpatient treatment. Both WC and DC therapy were performed on TE13, 3 times per week during the
treatment period. The effect of cupping therapy was evaluated by using the Gross Grading System of the
House-Brackmann (HB score) and the Yanagihara’s Unweighted Grading System (Y score).
Results: For both WC and DC treatment of symptoms related to peripheral facial paralysis, HB scores
showed a signicant decrease and Y scores showed a signicant increase from baseline to end of treatment,
indicating a benecial improvement in patient symptoms for both WC and DC.
Conclusion: In this study, both DC and WC treatment had signicant improvements on peripheral facial
paralysis symptoms, with WC having signicantly greater benecial eects than DC.
©2018 Korean Acupuncture & Moxibustion Medicine Society. is is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Article history :
Submitted: July 25, 2018
Revised: August 9, 2018
Accepted: September 11, 2018
Keywords:
Bell’s palsy,
Korean traditional medicine,
peripheral facial paralysis, therapy
https://doi.org/10.13045/jar.2018.00185
pISSN 2586-288X eISSN 2586-2898
J Acupunct Res 2018;35(4):187-192
Original Article
A Comparative Study on the Eect of Cupping erapy
Combined with Korean Medicine Treatment in Peripheral
Facial Paralysis
Chul-Hoon Choi 1, Deok-Hyun Kim 1, 2, Ho-Sueb Song 1, 2, *
1 Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Gachon University, Seongnam, Korea
2 Department of Acupuncture & Moxibustion Medicine, Gil Korean Medical Hospital of Gachon University, Incheon, Korea
ABSTRACT
Journal of Acupuncture Research
Journal homepage: http://www.e-jar.org
Introduction
Cupping therapy restores the health of the human body by
applying negative pressure to acupuncture points to clean the
blood. It is used to treat inammation and pain, and to improve
blood circulation by influencing the purification of blood and
tissue fluids, and the acid/base equilibrium of body fluids. It is
a method of physical therapy that is commonly used in Korean
medical institutions [1]. Cupping therapy can be categorized as
herb-based, needle-based, wet cupping (WC), or dry cupping
(DC) depending on the method of use. Of these, WC is mainly
used for rst-aid purposes, whilst DC is used for preventing or
treating diseases by removing the gas accumulated in the muscles
by the physical action generated by attaching the cup to cleanse
the blood [2].
Peripheral facial nerve palsy is a common and easily accessible
disease, and there have been clinical studies of various treatments
including cupping therapy as well as electroacupuncture [3-
5], pharmacopuncture [6,7], bee-venom acupuncture [8,9],
moxibustion therapy [10], Master Tung’s acupuncture [11], scalp
acupuncture [12], miso facial rejuvenation acupuncture [13]
and collateral vessel pricking therapy [14]. Among the cupping
therapies, there are also treatments using ash cupping to obtain
eective clinical results [15], and reports of hematologic changes
after WC and DC treatment [16]. However, there has been no
direct comparison between WC and DC treatment in patients
with peripheral facial nerve palsy. Therefore, the following study
was designed to compare the therapeutic eect of WC and DC to
determine the basis of treatment of peripheral facial nerve palsy.
*Corresponding author.
Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Gachon University, Incheon, Korea
E-mail: hssong70@gachon.ac.kr
©2018 Korean Acupuncture & Moxibustion Medicine Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
nov-026

J Acupunct Res 2018;35(4):187-192188
Materials and Methods
Patients
e charts of patients with peripheral facial paralysis who had
visited Gil Korean medicine hospital, Gachon university between
May 19, 2014 and June 30, 2018 were reviewed retrospectively.
Of the 105 patients who received more than 2 weeks of inpatient
treatment and more than 2 months of outpatient treatment, 65
patients were divided into either the WC group or DC group,
according to the inclusion and exclusion criteria. In the WC group,
10 out of 32 patients were excluded and the nal 22 were selected.
In the DC group, 7 out of 33 patients were excluded and the nal
26 were selected. A total of 48 patients were enrolled in this study
(Fig. 1).
Inclusion criteria and group classication
e patients who came to Gil Korean Hospital for treatment of
peripheral facial nerve palsy were identied. In the present study,
48 patients were included who had facial nerve palsy symptoms
according to House-Brackmann grading scores of Grade Ⅱ or
Ⅲ, with onset within 30 days, and treatment duration more
than 3 weeks but less than 4 weeks. There were 22 patients who
underwent WC on TE17 (Yifeng), and 26 patients who underwent
DC on TE17 (Yifeng) with more than 10 treatments.
Symptoms of Bell’s palsy generally begin to resolve within 2 to 3
weeks aer onset [17], so patients are aware of the improvements
in their progress.
Exclusion criteria
Patients were excluded from the analysis if they had a history of
peripheral facial nerve paralysis, infectious diseases such as herpes,
brain disease, heart disease, ophthalmic disease, facial deformity,
superficial wounds, facial skin disorders, diabetic peripheral
neuropathy, or those receiving insulin injections, systemic disease,
significant adverse reactions during hospital stay, or treatment
withdrawal before peripheral facial nerve palsy was resolved.
Ethics statement
is study was a retrospective study approved by the Institutional
Review Board (IRB) of Gil Korean Hospital of Gachon University
and adhered to research ethics. In order to protect the patient’s
personal information, the patient’s medical record was obtained
from the IRB of the Gil Korean Medicine Hospital. (IRB No.:
GIRB-18-111)
Acupuncture treatment
Acupuncture was performed with stainless steel needles (0.25 ×
30 mm) and hand needles (0.18 × 8 mm; Dongbang Inc., Korea),
and each acupuncture treatment was performed once for 20
minutes, for 3 times per week. Acupoints used were unilateral
EX-HN3 (Yintang), BL2 (Cuanzhu), EX-HN3 (Yuyao), TE23
(Sizhukong), GB14 (Yangbai), LI20 (Yingxiang), ST4 (Dicang), ST6
(Jiache), ST7 (Xiaguan), SI18 (Quanliao) points and contralateral
LI4 (Hegu), SI3 (Houxi), ST36 (Zusanli), ST41 (Jiexi), LR3
(Taichong) points. Acupuncture treatment was performed with
electrical stimulation for 15 minutes (mixed 3 Hz, within tolerable
strength) using an electro-stimulator (STN-330; StraTek Inc.,
Korea).
Cupping therapy
Cupping therapy was performed once for 3 minutes, 3 times per
week using disposable cups (No. 5) with an inner diameter of 23
mm and a height of 65 mm (Dongbang Inc., Korea). Among the
acupoints that have a “dispel wind and dissipate cold” and “move
qi and activate blood” eect on patients with facial nerve palsy it
was likely to be a “pattern of wind assailing the exterior” and “dual
stasis of qi and blood” acupoints belonging to yang brightness
meridian and acupoints mentioned in “Chimgugapeulgyung” [8].
Specically, in “Chimgugapeulgyung, Soo-jok-yang-myung-maek-
dong-bal-gu-chi-byeong,” it is suggested that the acupoints such as
ST5 (Daying), TE17 (Yifeng) and LU9 (Taiyuan) are selected [18].
The facial nerve divides the sensory nerve fibers in the auditory
canal and the auditory nerve bers, and branches the motor nerve
fibers in the posterior and posterior gyrus muscles. In addition,
the anterior facial branch and the gauze facial branch are branched
in the parotid gland and divided into facial muscles in the facial
and neck regions [19]. In this study, cupping therapy was selected
as the site of TE17 (Yifeng), and WC and DC treatments were
performed 3 times per week.
In the case of the WC treatment group, pathogens from the body
surface were removed at the puncture operation site (TE17) [2],
and the cup was attached for 3 minutes at a pressure of 30-40 cm/
Hg In adults, the amount of bleeding at one time of operation was
controlled so that it did not exceed 30 mL.
e DC group was also treated with the same site and pressure
as the WC treatment group according to Lim and Lee [2].
Herbal Medicine Treatment
Herbal medicine was used according to the patient’s condition,
“Boikyangwui”-decoction, which mainly had the eect of “tonifying
the spleen and invigorate the stomach” (Table 1).
Treatments with infrared light therapy and others
Transcutaneous infrared irradiation was performed with
acupuncture treatment. Facial muscle exercise and facial massage
were used in combination.
Fig. 1. Process for selecting the charts of patients with peripheral facial nerve paralysis.

Chul-Hoon Choi et al / Cupping Therapy on Peripheral Facial Paralysis 189
Assessment methods
House-Brackmann (H-B grade, Table 2) was used, for evaluating
facial paralysis and secondary symptoms at the same time.
Yanagihara’s Unweighted Grading System Score (Y-system)
was also used to record paralysis. Total paralysis is 0, severe- 1,
moderate- 2, slight paresis- 3 and normal- 4 (Table 3) [20,21]. e
evaluation method was defined as before treatment (HBs, YGs)
and aer treatment (HBf, YGf).
Data analysis method
The results were statistically analyzed using SPSS® 18.0 for
windows program (SPSS Inc., Chicago, IL, USA). Results were
expressed as means ± standard deviations. To test the homogeneity
of categorical data for WC and DC, Fisher’s exact test was used
to test whether the data followed a normal distribution. Mann–
Whitney U test was used to test for continuous data that were not
normally distributed. Wilcoxon signed rank test was used to test
the significance of each group during the treatment period. The
level of statistical signicance was set at p < 0.05.
Results
General characteristics of the subject
There were no significant differences in demographic
Scientic name Dose (g)
Astragalus mongholicus Bunge 30
Zingiber ocinale Rosc. 30
Zizyphus jujuba Mill. 30
Atractylodes ovata 20
Dioscorea japonica unb. 20
Amomum xanthioides Wall 20
Crataegus pinnatida Bge 20
Glycyrrhiza glabra L. 20
Cyperus rotundus L. 15
Magnolia ocinalis Rehder et Wilson 15
Citrus reticulata Blanco 15
Pinellia pedatisecta Schott 15
Amomum cardamomum L. 15
Poria cocos (Schw.) Wolf 15
Triticum aestivum L. 15
Hordeum vulgare L. 15
Alpinia oxyphylla Miq. 10
Vladimiria souliei Ling 10
Panax japonicus C. A. Meyer 10
Tot a l 340
Table 1. Prescription Contents of Boikyangwui-decoction.
Grade Description
ⅠNormal Normal facial function all areas
ⅡMild
dysfunction
Gross: slight weakness is noted on close inspection
may have a slight synkinesis
At rest: normal symmetry and tone is noted
Motion
Forehead: motion is moderate to good function
Eye: complete closure with minimal eort
Mouth: slight asymmetry
ⅢModerate
dysfunction
Gross: obvious but not disguring dierence between
both the sides, noticeable but not severe synkinesis,
contracture, or hemifacial spasm
At rest: normal symmetry and tone
Motion
Forehead: slight to moderate movement
Eye: complete closure with eort
Mouth: slightly weak with maximum eort
ⅣModerately severe
dysfunction
Gross: obvious weakness and/or disfiguring
asymmetry
At rest: normal symmetry and tone
Motion
Forehead: none
Eye: incomplete closure
Mouth: asymmetric with maximum eort
ⅤSevere
dysfunction
Gross only barely perceptible
At rest asymmetry
Motion
Forehead: none
Eye: incomplete closure
Mouth: slight movement
ⅥTotal paralysis No movement
Table 2. Gross Grading System of House-Brackmann.
Scale of rating Scale of 3
rating
1. At rest 0 1 2 3 4 0 2 4
2. Wrinkle forehead 0 1 2 3 4 0 2 4
3. Blink 0 1 2 3 4 0 2 4
4. Closure of eye lightly 0 1 2 3 4 0 2 4
5. Closure of eye tightly 0 1 2 3 4 0 2 4
6. Closure of eye on involved side only 0 1 2 3 4 0 2 4
7. Wrinkle nose 0 1 2 3 4 0 2 4
8. Whistle 0 1 2 3 4 0 2 4
9. Grin 0 1 2 3 4 0 2 4
10. Depress lower lip 0 1 2 3 4 0 2 4
Table 3. Yanagihara’s Unweighted Grading System.
characteristics and facial palsy measurements between the WC
and DC groups (Table 4). Of the 48 cases in the study, there were
22 patients in the WC treatment group consisting of 11 males and
11 females, with 13 cases of paralysis on the left and 9 cases on
the right side. The average age of the patients was 47.09 ± 14.20
years. e average number of days aer the longitudinal onset visit
was 7.45 ± 6.86 days. The average treatment period was 44.50 ±
24.90 days. The DC treatment group had 26 patients, consisting

J Acupunct Res 2018;35(4):187-192190
Comparison of WC and DC treatment of peripheral facial paraly-
sis symptoms
WC treatment group
Wilcoxon signed rank test H-B grade and Z of Y-system were
-3.985 and -4.110, respectively, indicating a significant decrease
in symptoms (p < 0.01) aer the end of treatment compared with
pretreatment scores (Table 5).
DC treatment group
Results of Wilcoxon signed rank test H-B grade and Z of
Y-system were -4.427 and -4.462, respectively, indicating a
significant decrease in symptoms (p < 0.01) after the end of
treatment compared with pretreatment (Table 6).
Comparison of pre- and post-treatment results between WC and
DC treatment
In the WC treatment group, the mean (± SD) H-B grade was
4.14 ± 0.99, whilst the mean (± SD) DC treatment group grade
was 4.04 ± 0.66. Aer WC treatment, the H-B grade (1.88 ± 0.77)
was signicantly lower than the DC treatment group (2.38 ± 0.80;
p < 0.05).
In the Y-system, the mean (± SD) score at pretreatment in the
WC treatment group was 19.50 ± 4.86, compared with 20.00 ± 4.07
in the DC treatment group. After treatment, the WC treatment
group had a signicantly higher Y-system score (35.18 ± 4.56) than
the DC treatment group (32.69 ± 4.85; p < 0.05; Table 7).
Discussion
e facial nerve paralysis is referred to as “wabyuk” in “Essential
prescriptions of the golden cabinet,” “poongguwahoo” in
“Treatise on the Pathogenesis and Manifestations of All Diseases,”
and “guanwasa” in “SanYinFang” [22] since it was referred to
as “gubyuk” in “Yellow Emperor’s Inner Canon. Youngchu.
gyeonggeun” [23]. The causes of peripheral facial paralysis in
Korean medicine are due to insufficiency of the “healthy qi,”
which may result in the deciency of the meridian vessel, and the
worsening of the wind and cold may invade facial circulation,
resulting in a disorder of qi-blood circulation [24].
From a medical point of view, peripheral facial paralysis can
be divided into nuclear paralysis and nuclear false paralysis.
Nuclear paralysis is caused by vascular injuries in the brain, tumor,
inammation, joint syndrome, etc. Sometimes the obstruction to
the epilepsy nerve and corticospinal tract is merged. Nuclear festival
paralysis is a causative disease caused by facial neuropathy on the
peripheral side of the facial nucleus, tumor, infectious disease,
sarcograde syndrome, dehydration, that may induce stress and
cold exposure. Patients with Bell’s palsy who do not have obvious
features of idiopathic facial nerve palsy, cannot make wrinkles on
their foreheads, upper lips are low, and are unable to whistle. When
the mouth is opened, the paralyzed side is distorted and the mouth
becomes oblique oval shape, with the tongue resting towards the
healthy side. Also, when the eyes are tightly closed, the eyelashes
on the paralyzed side remain outside the eyelids. Usually, Bell’s
palsy is the most common cause of facial nerve paralysis [17,25].
These facial nerve palsies occur in 20-30 people per 100,000,
with similar male to female ratios, occurring in all ages, especially
in the 20-30s. In the 20 years old or younger age group, this is
predominantly in women, whilst in the 40 years or older category,
this is more common in men. e same incidence was observed on
the le and right side, with the paralysis being mostly unilateral,
with 30% of patients having incomplete paralysis, whilst 70% had
Table 4. General Demographics and Facial Palsy Characteristics.
WC group
(n = 22)
DC group
(n = 26)
p
Age 47.09 ± 14.20* 48.04 ± 16.94* 0.852§
Gender (Male/Female) 11/11 15/11 0.772†
Le/Right 13/9 17/9 0.788†
Period of disease 7.45 ± 6.86* 6.85 ± 7.29* 0.306§
Period of treatment 44.50 ± 24.90* 64.69 ± 43.96* 0.279§
H-B grade 4.14 ± 0.99* 4.04 ± 0.66* 0.481§
Y-system 19.50 ± 4.86* 20.00 ± 4.07* 0.378§
*Mean ± SD. †Fischer’s exact test. §Mann-Whitney U test.
DC, dry cupping; WC, wet cupping.
HBs-HBf YGs-YGf
Z -3.995 -4.110
p0.01* 0.01*
*Wilcoxon signed rank test p < 0.01.
HBf, H-B grade at final; HBs, H-B grade at baseline; YGf, Y-system at final; YGs,
Y-system at baseline.
Table 5. Improvement in Symptoms Related to Peripheral Facial Paralysis in the WC
Treatment Group According to Period of Treatment.
Table 6. Improvement in Symptoms Related to Peripheral Facial Paralysis in the DC
Treatment Group According to Period of Treatment (HBs-HBf, YGs-YGf).
HBs-HBf YGs-YGf
Z -4.427 -4.462
p0.01* 0.01*
*Wilcoxon signed rank test p < 0.01.
HBs:, H-B grade at baseline; HBf, H-B grade at final; YGs, Y-system at baseline; YGf,
Y-system at nal.
WC (n = 22) DC (n = 26) p
Before Treatment (H-B grade) 4.14 ± 0.99 4.04 ± 0.66 0.481
Aer nal treatment (H-B grade) 1.86 ± 0.77 2.38 ± 0.80 0.035*
Before Treatment (Y-system) 19.50 ± 4.86 20.00 ± 4.07 0.378
Aer nal treatment (Y-system) 35.18 ± 4.56 32.69 ± 4.85 0.039*
Data are presented as mean ± SD.
*Mann Whitney U test p < 0.05.
Table 7. Comparison of H-B Grade and Y-system Score Between WC and DC Treatment
Groups.
of 15 males and 11 females, with 17 cases of paralysis on the le,
and 9 cases on the right side. e average age of the patients was
48.04 ± 16.94 years. e average number of days aer longitudinal
incidence was 6.85 ± 7.29 days. e average treatment period was
64.69 ± 43.96 days.

Chul-Hoon Choi et al / Cupping Therapy on Peripheral Facial Paralysis 191
complete paralysis, with 0.3% of patients having paralysis on both
sides. There were 9% of patients who had a previous history of
idiopathic paralysis and 8% with a previous family history of facial
paralysis [17,26].
Especially when looking at Bell’s palsy, recovery generally
begins 2 to 3 weeks after onset with complete recovery within 2
to 3 months, although nerve damage and degeneration does not
recover naturally in 86% of cases [17,25,27]. According to Kwon et
al [28], Lee et al [11], Park et al [29], Kim et al [30], Ahn et al [5]
and Kim et al [9], if the appropriate Korean medical treatment and
modern medical treatment are performed, the progress of recovery
is shortened and eective.
Kim et al [15] demonstrated that “flash cupping treatment” is
eective for facial nerve palsy, focusing on the fact that peripheral
facial paralysis is usually a deficiency pattern and the face is
paralyzed. In addition, Lee et al [14] also demonstrated that
combined therapy utilizing “Collateral vessel pricking therapy” in
the treatment of peripheral facial nerve palsy accompanied by a
follow-up enhances therapeutic eect and minimizes sequelae. In
addition to this cupping therapy, there have been various clinical
trials using electroacupuncture, pharmacopuncture, bee-venom
acupuncture, moxibustion therapy, Master Tung’s acupuncture,
scalp acupuncture, Miso facial rejuvenation acupuncture and
collateral vessel pricking therapy, with reports of effective
hematologic changes aer WC and DC procedures [16].
ere have been no direct comparisons between WC treatment
and DC treatment for peripheral facial nerve palsy. Therefore,
this study was designed to compare the therapeutic eect of WC
and DC to determine the basis of treatment of peripheral facial
nerve palsy. In the WC and DC treatment groups, the treatment
results before and after treatment showed a significant decrease
or increase in the HB grade and Y-system, respectively, so that all
treatments during the treatment period signicantly improved the
recovery.
Comparing the results of the WC group and DC group, the
H-B grades of the WC group were signicantly lower than those
of the DC treatment group aer end of treatment. In addition, in
the Y-system, the WC treatment group had significantly higher
scores compared with the DC treatment group, indicating that
the treatment effect and prognosis of WC treatment was more
eective.
The results of this study suggest that WC treatment has
significantly greater treatment performance than DC treatment.
However, the number of patients in this study was not high
enough to provide meaningful clinical significance. Because of
the large variation in treatment period, it would be necessary to
further investigate using an expanded population, with a blinded,
randomized control group. is study was limited because it was
a retrospective study of the effects of WC and DC on peripheral
facial nerve palsy. In addition, we could not compare the eect of
cupping therapy with the eect of Korean medicine combination
treatment. Therefore, more controlled clinical studies will be
needed in the future.
Conclusion
The treatment of peripheral facial nerve palsy using both the
WC and DC method, showed significant improvements in the
treatment results after the end of treatment compared with pre-
treatment scores (as assessed by HB grade and Y system).
Conflicts of Interest
e authors have no conicts of interest to declare.
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