INTRODUCTION
Peripheral facial paralysis is characterized by facial expression and facial muscle group motor dysfunction. It originates from lesions of the downstream motor neurons of the facial nerve and may be caused by various medical conditions such as viral infection, trauma, tumors and autoimmune diseases[1]. Intractable peripheral facial paralysis can be characterized as a sequela of peripheral paralysis. It is a facial paralysis that lasts for more than 3 months but is still accompanied by facial sequelae[2]. It often causes difficulty in swallowing, drinking and speaking, and may also manifest as eye disorders due to an incapacity to close the eyelids[3]. In social interaction, facial appearance often plays a key role, and facial asymmetry caused by facial paralysis, especially in chronic cases, will significantly affect perceived quality of life and self-esteem[4]. Studies have shown that the prevalence of anxious and depressed feelings among patients with facial paralysis is markedly higher than in the general population[5]. Therefore, exploring a comprehensive treatment strategy that combines nerve repair and emotional regulation is of crucial clinical relevance for enhancing the rehabilitation outcomes of patients with intractable peripheral facial paralysis.
Acupuncture is a treatment approach in traditional Chinese medicine. It is administered by inserting needles into specific points on the body (acupoints) to treat and alleviate ailments[6]. Acupuncture can alleviate peripheral facial paralysis by enhancing motor-sensory cortical connectivity, modulating neuroplasticity, reducing inflammation, improving local microcirculation, and promoting multifaceted neural repair across structural and functional levels[7]. Warm acupuncture is a special form of combined acupuncture and moxibustion therapy It combines the mechanical stimulation of acupuncture with the warm stimulation of moxibustion on the needle body to create a new effect[8]. Compared with conventional acupuncture, warm acupuncture provides sustained thermal stimulation at the acupoint, which can reduce local inflammation, promote the resorption of inflammatory exudate, and improve regional microcirculation[9]. It can reduce facial nerve edema and promote nerve repair[10]. However, for patients with intractable peripheral facial paralysis, acupuncture alone often focuses on nerve repair and is difficult to solve the patient’s emotional problems. Positive emotion training, as a structured psychotherapy method based on dialectical behavior therapy, helps individuals effectively regulate emotional reactions by teaching mindfulness awareness, emotion management and cognitive reappraisal strategies, thereby alleviating anxiety and depression levels[11]. Positive emotion regulation does not primarily focus on reducing negative thoughts, but rather emphasizes the active cultivation of positive emotions and adaptive coping strategies[12]. This may be particularly suitable for individuals who struggle with low self-esteem, shame, and avoidance behaviors such as avoiding mirrors and social withdrawal - characteristics that are common among patients with facial disfigurement[13]. Positive emotion regulation-based interventions have been successfully applied in clinical populations, including patients with depression and anxiety disorders, showing beneficial effects on mood regulation and mental wellbeing[12,13]. At present, there are few studies that combine warm acupuncture with positive emotion training for intractable peripheral facial paralysis.
Against this backdrop, this study employs a retrospective cohort design to assess the therapeutic effects of positive emotion training coupled with warm acupuncture on anxiety, depression, and facial nerve dysfunction in individuals with intractable peripheral facial paralysis. The aim is to provide an integrated rehabilitation program that addresses both physical and mental health in clinical practice and to serve as a preliminary step toward future prospective researches.
MATERIALS AND METHODS
General information
A review of medical records was undertaken for patients with intractable peripheral facial paralysis accompanied by depression and anxiety receiving outpatient treatment at the Department of Acupuncture and Moxibustion of the First Affiliated Hospital of Sun Yat-sen University, Guizhou Hospital, from November 2024 to March 2026.
Inclusion criteria: (1) Meeting the diagnostic criteria for peripheral facial paralysis in the Clinical Practice Guidelines for Idiopathic Facial Paralysis published by the American Academy of Otorhinolaryngology Head and Neck Surgery in 2023[14]; (2) Disease duration ≥ 3 months, and the effect of standardized drug treatment or routine acupuncture treatment for more than 4 weeks was not good; (3) Age 18-75 years; (4) Clear consciousness and able to complete the scale assessment; (5) Having different degrees of anxiety and depression; and (6) Complete clinical data, including treatment plan and relevant scale assessment data.
Exclusion criteria: (1) Patients with secondary facial paralysis such as central facial paralysis, traumatic facial nerve rupture, or cerebellopontine angle tumor; (2) Concomitant severe multiple organ failure involving the heart, liver, kidneys, and other vital organs; (3) Patients with concurrent severe psychiatric disorders (i.e., schizophrenia, bipolar disorder, etc.) or impaired cognitive abilities; (4) Patients who are hypersensitive to or intolerant of the treatment methods employed in this study; (5) Patients who have received other acupuncture, minimally invasive, or neuromodulation treatments within the past month; and (6) Patients with missing information in their clinical records.
Based on the above criteria, a cohort of 120 patients was screened and enrolled; they were stratified into the control group (n = 60) and the observation group (n = 60) as per their treatment regimen.
Treatment methods
Control group: The control group was treated with warm acupuncture. The specific contents included: The patient lay supine, and five acupoints were selected: Hegu, Dicang, Yifeng, Jiache and Sibai. After routine disinfection, 0.30 mm × 25 mm disposable sterile acupuncture needles were used. Sibai was inserted perpendicularly to a depth of 10-15 mm; Dicang was inserted through to Jiache (15-20 mm), and conversely Jiache was inserted through to Dicang with the same depth; Yifeng was inserted perpendicularly to a depth of 10-15 mm; and Hegu was inserted perpendicularly to a depth of 20 mm. All the above manipulations were performed to achieve deqi. Then, three acupoints, Dicang, Yifeng and Jiache, were selected for warm acupuncture: A 0.1-0.2 cm long moxa stick was put on the needle handle, the lower end was lit, and each acupoint was moxibusted for approximately 10 minutes, until the local skin was slightly flushed and the patient felt warm and comfortable. The needles were retained for 30 minutes per session, once daily, for 5 sessions per week, over a 4-week period[15].
Observation group: In addition to the control group, positive emotion training was implemented. The training was conducted by a trained psychotherapist, twice a week for 30 minutes per session over a period of four consecutive weeks. Specific content included: (1) Positive recall training: Guide patients to recall specific and detailed positive events that happened in the past (such as a pleasant party or a successful rehabilitation progress), guide them to describe the details of the event, their feelings and emotional experiences at the time, and strengthen their ability to retrieve positive memories through repeated practice, helping patients to re-examine their own experiences from a positive perspective; (2) Positive future imagination training: Guide patients to imagine positive events that may occur in the future (such as a scene of having a pleasant conversation with family members after facial function gradually recovers), encourage patients to describe the scene, participants, their own expressions and actions as detailed as possible, as well as the resulting sense of pleasure and control, thereby enhancing their confidence and expectations for future rehabilitation; and (3) Taste and emotion regulation training: When patients experience positive emotions, guide them to consciously prolong and deepen this feeling, learn to “taste” the small joys of the moment (such as a smooth smile or a trip without needing to cover up), and at the same time identify and reduce the suppression or denial of positive emotions (such as “I don’t deserve to be happy”), and gradually establish a positive and open coping mechanism. After each training session, assign simple home exercises (such as recording a positive little thing that happened today), and share and exchange them during the next training session to consolidate the training effect[16].
Observation indicators
Facial nerve function assessment: The facial nerve function of patients was assessed using the Simplified Facial Grading Scale (SFGS). The scale contains 13 assessment items, divided into three dimensions: Static symmetry (3 items, 0-10 points each, total score 0-20 points), voluntary motor symmetry (5 movements, 1-5 points each, converted to 20-100 points) and synkinetic movement (5 items, 0-4 points each, totaling 0-20 points). The comprehensive score is the voluntary motor symmetry score minus the static symmetry score and the synkinetic movement score. The final score is on a scale of 0 to 100, with a higher score denoting better facial nerve function. SFGS has been proven to have good reliability and sensitivity, and can effectively assess the static, dynamic and synkinetic motor functions of patients with facial paralysis. It is suitable for evaluating the efficacy of unilateral facial paralysis of all degrees[17].
Anxiety symptoms: The Self-Rating Anxiety Scale (SAS) was utilized for measurement. This tool comprises 20 statements, each scored on a 1-4 points scale, yields a total score from 20 to 80, and is interpreted as follows: Higher scores signify more serious anxiety. A score of 50 indicates the existence of anxiety disorders[18].
Depressive symptoms: The Self-Rating Depression Scale (SDS) was utilized for measurement. It consists of 20 items, each graded from 1 to 4, and the total score is 20 to 80. A higher score reflects more pronounced depressive mood. A score of 53 indicates the presence of depressive symptoms[19].
Clinical efficacy assessment: The efficacy was assessed based on the improvement of the House-Brackmann (HB) grading scale: Cured: HB grade recovered to grade I; markedly effective: HB grade improved by ≥ 2 grades; effective: HB grade improved by 1 grade; ineffective: HB grade did not improve or worsened. Overall response rate = (complete remission + marked remission + remission)/total subjects × 100%[20].
Statistical analysis
Data was implemented utilizing SPSS 21.0 software. The measured data were presented as mean ± SD, and pairwise comparisons were tested using the two-sample t-tests. Count data were n (%), and intergroup differences were verified using the χ2 tests or Fisher’s exact tests. A P < 0.05 was considered statistically meaningful.
DISCUSSION
Facial paralysis is a disease caused by either partial or full loss of function in the muscles governing facial movements[21]. It is noted that 30% of patients with facial paralysis will endure lasting impacts, and 5% will encounter severe long-term complications after initial recovery[22]. Facial paralysis is classified by lesion location into peripheral facial paralysis (involving lower or peripheral motoneurons) and centralized facial paralysis (caused by damage to central or upper motor neurons)[23]. Among them, peripheral facial paralysis is the most frequent, which refers to lower motor neuron lesions of the facial nerve, manifested as unilateral muscle paralysis, reduced or absent forehead wrinkles, inadequate eyelid closed position, watery eyes, and an incapacity to lift the eyebrows or furrow the brow. Some patients may have dry eye, hyperacusis and altered taste[24]. The incidence rate is estimated to be 20 to 30 reported cases per 100000 people, with about 40000 new cases worldwide each year[25]. Clinically, intractable peripheral facial paralysis is deemed a condition in which facial paralysis that lasts for more than 3 months but is still accompanied by facial sequelae[2]. For most patients, facial deformity and inability to socialize normally remain major problems[26]. Studies have shown that changes in facial appearance can lead to social avoidance and feelings of inferiority in patients. Among them, female and young patients are more prone to social anxiety, and avoidance coping styles are significantly correlated with anxiety levels. This psychological burden, coupled with uncertainty about the prognosis of the disease, can easily form a vicious cycle in which negative emotions and functional impairment reinforce each other[27]. In addition, 40% and 31.2% of patients with facial paralysis suffer from depression and anxiety, respectfully, which substantially affects their daily lives and social activities[28]. In the present study, patients in the control group (warm acupuncture alone) already showed significant reductions in SAS scores (from 58.80 ± 3.91 to 44.32 ± 1.99) and SDS scores (from 59.07 ± 2.36 to 44.37 ± 2.46) after treatment, confirming the beneficial effect of warm acupuncture on mood. However, the observation group, which received additional positive emotion training, achieved even greater improvements (SAS: From 58.32 ± 3.42 to 34.90 ± 2.01; SDS: From 59.13 ± 2.53 to 34.22 ± 2.10), with posttreatment scores falling below the clinical cutoff for anxiety and depression (SAS < 50, SDS < 53). Therefore, exploring a holistic treatment plan that can facilitate facial nerve recovery and simultaneously alleviate the patient’s emotional state is of great clinical significance for breaking this vicious cycle and promoting the patient’s comprehensive recovery.
Acupuncture is a traditional Chinese medicine therapy and a beneficial treatment for facial paralysis. Evidence suggests that acupuncture can relieve facial complaints, improve the cure rate, and shorten the recovery time for patients with facial paralysis[29]. Traditional Chinese medicine holds that the primary pathological process of facial paralysis is restricted to the facial muscles. Acupuncture and other outpatient therapeutic approaches can remedy this condition, invigorate the body’s vital energy, and promote the swift restoration of facial nerve function[30]. Warm acupuncture is a classic method of treating intractable peripheral facial paralysis in traditional Chinese medicine. Combining the dual effects of acupuncture and moxibustion, it dilates blood vessels and improves microcirculation through local warm stimulation, reduces facial nerve edema, and activates the flow of qi and blood in the meridians, promoting nerve repair[10]. This study selected five acupoints for warm needling treatment: Hegu, Dicang, Yifeng, Jiache and Sibai. Yifeng is located near the exit of the trigeminal nerve trunk and can directly stimulate the facial nerve[31]. Dicang corresponds to the orbital muscle and can relieve drooping of the corners of the mouth in patients with facial paralysis[32]. Jiache and Sibai have nerve fiber tissue in their local areas, collectively constituting a distinct neural network. Acupuncture and moxibustion can stimulate these nerves as external signals, thereby dominating the muscles and blood vessels in the vicinity of the acupoints[32]. Hegu is the key acupoint for “facial and oral diseases”. It has unique curative effect on facial and oral disorders. Studies have shown that acupuncture at bilateral Hegu acupoints can improve facial blood perfusion and enhance facial microcirculation[31]. It can be seen that warm needling not only improves the local pathological state, but also promotes functional recovery by regulating the nerve and circulatory systems. In line with these mechanisms, the present study found that warm acupuncture alone significantly improved facial nerve function, with SFGS scores increasing from 35.02 ± 6.99 to 67.12 ± 6.62 in the control group. The addition of positive emotion training further enhanced this effect, raising the SFGS score to 84.20 ± 7.59 in the observation group (P < 0.001 vs control). This 17-point difference between groups is clinically meaningful, as the Sunnybrook scale is highly sensitive to changes in facial symmetry, voluntary movement, and synkinesis.
Emotion regulation includes the process by which an individual regulates their response to internal and external stimuli. It the purposeful or automatic use of techniques meant to alter thought and behavior patterns, ultimately affecting the creation, processing, and outward expression of emotions in order to pursue personal goals[33]. Positive emotion training is guided by cognitive-behavioral theory. It teaches patients cognitive reappraisal strategies and guides them to reconstruct their cognitive evaluation of emotional events, thereby improving their emotional experience and regulation abilities[34]. In this study, the specific content of positive emotion training includes positive memory training, positive future imagination training, and taste and emotion regulation training. By guiding patients to describe the details and feelings of positive events in detail, it strengthens the ability to retrieve positive memories and helps patients identify and reduce the suppression or denial of positive emotions. Preceding research has established that positive emotion training can significantly ameliorate the depressive state of patients with major depressive disorder, boost adherence to treatment, and enhance quality of life[35]. In the current study, the observation group receiving combined treatment achieved a higher overall response rate (91.67%, 55/60) compared to the control group (78.33%, 47/60, P = 0.041), indicating that adding positive emotion training to warm acupuncture increases the proportion of patients who attain clinically meaningful recovery. The synchronous improvement in facial nerve function (SFGS) and emotional scores (SAS, SDS) suggests that positive emotion training not only directly alleviates negative emotions but may also enhance the neuroreparative effects of warm acupuncture by reducing psychological stress and improving treatment compliance.
Consistent with the above results, the superior improvement in facial nerve function and emotional state in the observation group suggests that warm acupuncture may enhance facial nerve repair through multiple biological pathways. Acupuncture (including electroacupuncture) can increase facial blood perfusion (e.g., at Hegu acupoint) and upregulate glial cell linederived neurotrophic factor, with electroacupuncture reported to activate the phosphatidylinositol 3‑kinase/mammalian target of rapamycin signaling pathway, thereby potentially facilitating axonal regeneration and remyelination[31]. Meanwhile, previous research has shown that emotion regulation training significantly reduces anxiety symptoms and improves emotional control in stressed populations[9]. Furthermore, chronic stress and negative affect are known to dysregulate the hypothalamic-pituitary-adrenal axis, leading to elevated cortisol levels that can impair neurogenesis and exacerbate neuroinflammation[36]. Positive emotion regulation can activate the vagus nerve and the brain’s caregiving system, thereby downregulating the hypothalamic‑pituitary‑adrenal axis and lowering cortisol levels to counteract the physiological effects of stress[12]. Thus, the combination of neural stimulation via warm acupuncture and stress reduction via positive emotion training may synergistically contribute to the superior outcomes observed in the observation group.
Overall data indicated that the improvement of facial nerve function and the relief of anxiety and depression changed synchronously, suggesting that positive emotion training may enhance the nerve repair effect of warm acupuncture by reducing psychological stress and improving treatment compliance, thus forming a synergistic “physiological-psychological” benefit.
While this study clarified the clinical value of positive emotion training combined with warm acupuncture in treating intractable peripheral facial paralysis, certain limitations remain. First, this was a retrospective analysis; patients were grouped according to treatment method. Although baseline data were comparable between the two groups, the non-random assignment meant selection bias and confounding factors could not be completely avoided. Second, this study only included two control groups: “Warm acupuncture alone” and “combined treatment”, lacking a control group of “positive emotion training alone”. Therefore, the current results can only demonstrate that the combined treatment is superior to warm acupuncture alone, and cannot determine whether it is superior to positive emotion training alone. The independent efficacy of each treatment measure could not be clearly established, nor could a synergistic effect be fully verified. Third, the sample size of 120 cases was relatively limited, and all patients came from the same medical institution. Whether the results can be generalized to intractable peripheral facial paralysis patients in different regions and with different medical resource allocations requires further verification. Fourth, the follow-up period only covered the treatment period and short-term rehabilitation phase, failing to assess the long-term efficacy maintenance of the combined treatment and its impact on long-term rehabilitation outcomes. Finally, this study primarily relied on subjective scales such as the Sunnybrook score, SAS, and SDS to assess efficacy. While these scales have good reliability and validity, they lack objective standard indicators for facial nerve assessment such as facial nerve electrophysiological testing and neuroimaging examinations, as well as corroborating results from third-party assessments, which may introduce subjective reporting bias. Based on the limitations of this study and existing research progress, future research can explore the following directions: First, conduct large-scale, multicenter, prospective randomized controlled trials. The trial design should include a “simple warm acupuncture group”, a “simple positive emotion training group”, and a “combined treatment group”, using factorial design to clarify the independent effects and interactions of each component. Second, expand the sample size and include broader population characteristics, extending the follow-up period to 6 months or more, systematically evaluating the long-term effects of combined treatment on patients’ facial nerve function, emotional state, and quality of life, thereby improving the external validity and clinical applicability of the research results. Third, deepen mechanistic research, combining neurophysiological testing, neuroimaging techniques, and serum neurotrophic factor levels to reveal the intrinsic mechanism of the synergistic effect of warm acupuncture and positive emotion training from a molecular biology and neurophysiological perspective. Fourth, explore the optimal frequency and duration of positive emotion training, and establish standardized operating procedures to facilitate clinical application.
