Central facial paralysis is a frequent sequela of stroke, compromising the musculature of the lower third of the face and affecting communication, feeding, and quality of life. Although distinct in mechanism from peripheral paralysis — for which more abundant studies exist — the central forms represent a field still lacking evidence-based guidelines for the use of acupuncture. A network meta-analysis published in March 2026 in Frontiers in Neurology fills this gap by comparing, for the first time systematically, eight acupuncture modalities in this specific population.
Conducted by Juanshu Cao and colleagues from the Department of Rehabilitation Medicine of Shenzhen People’s Hospital, the analysis included 22 randomized clinical trials published in Chinese and international databases through January 1, 2026, totaling 1,888 participants. Risk of bias was assessed by RoB2; the comparison among modalities used a random-effects model within the frequentist framework of network meta-analysis, with SUCRA (Surface Under the Cumulative Ranking curve) rankings to hierarchize the interventions.
STUDY DIMENSIONS
Methodology: three outcomes, eight modalities
The researchers stratified results according to the assessment criterion used in each study, recognizing that House-Brackmann (HB), Traditional Chinese Medicine (TCM) criteria, and the Facial Disability Index (FDI) capture distinct dimensions of recovery — degree of paresis, overall clinical response, and quality of life, respectively. The eight modalities evaluated were: conventional acupuncture (A), fire needle (FN), thumbtack needle (TN), scalp acupuncture (SA), functional acupuncture (FA), acupoint application (PA), and combinations — acupuncture + conventional treatment (A+CT), acupuncture + TCM (A+TCM), deep penetration + moxibustion (PN+MT), botulinum type A + acupuncture (BTX+A), and cupping + acupuncture (V+A). The most frequent treatment occurred once daily; fire and thumbtack needles were applied every two days. The standard duration was four weeks, with extension to six to eight weeks according to clinical evolution.
Results: which modality wins on each criterion?
The analysis showed that the hierarchy of modalities varies substantially according to the outcome evaluated. By the House-Brackmann criterion — a standard widely used in Western clinical practice — the combination acupuncture + conventional treatment (A+CT) obtained the highest SUCRA (0.84), followed by acupuncture + TCM (SUCRA=0.73) and deep penetration + moxibustion (SUCRA=0.68). By the TCM criterion, fire needle assumed the lead (SUCRA=0.82), with acupuncture + TCM in second (SUCRA=0.79) and scalp acupuncture in third (SUCRA=0.78). For the Facial Disability Index, which measures the subjective impact on the patient’s quality of life, the combination botulinum type A + acupuncture led with an impressive SUCRA of 0.90, followed by cupping + acupuncture (SUCRA=0.81) and deep penetration + moxibustion (SUCRA=0.79). Heterogeneity was low across all outcomes (I²=3 to 7%), and inconsistency and publication tests did not reveal significant distortions.
SUCRA RANKINGS BY OUTCOME
Implications for the practice of medical acupuncture
The authors recommend that the protocol selection be guided by the assessment criterion adopted in the consultation: for objective functional outcomes (HB), prioritize A+CT or A+TCM; for response by the TCM criterion, consider fire needle or scalp acupuncture; for improvement in quality of life and subjective facial disability (FDI), BTX+A and V+A demonstrated the best performance. The meta-regression did not find a significant correlation between treatment frequency or duration and efficacy, suggesting that the quality of the technique and the selection of acupoints carry greater weight than simply increasing sessions. The five most-used acupoints — Hegu (LI-4), Dicang (ST-4), Jiache (ST-6), Sishui, and Xianle — provided the foundation on which the modality variations were applied.
Frequently Asked Questions
This meta-analysis included patients with chronology of 28 days to 3 years post-stroke, and positive results were observed throughout this entire spectrum. Although recovery is more robust in the acute and subacute phases — when neuroplasticity is greater — chronic patients also present functional gains, especially with protocols that include scalp acupuncture, whose direct cortical stimulation may mobilize alternative neural circuits. The decision about initiating treatment should be individualized by the medical acupuncturist considering the complete clinical profile.
In central paralysis, only the lower third of the face contralateral to the stroke is affected — forehead and periorbital region are spared. In peripheral paralysis, the entire hemiface is compromised. This requires distinct protocols: in central paralysis, acupoints such as Dicang (ST-4), Jiache (ST-6), and Hegu (LI-4) are prioritized, with a neurologic approach considering the underlying stroke; in peripheral paralysis, points along the trajectory of the facial nerve have greater relevance. The presence of other neurologic sequelae (hemiplegia, dysphagia, cognitive impairment) also directly influences therapeutic planning.
Fire needle is a modality that uses needles rapidly heated and applied to specific points. In this analysis, it was the best-performing method by the TCM criterion, but requires specialized training. The adverse events reported in the included studies were mild and transient — local pain, ecchymosis, and dizziness — without serious complications. In medical practice, the modality selection should consider the experience of the medical acupuncturist, the patient’s clinical profile (such as coagulopathies, post-stroke anticoagulant use), and patient preferences.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).
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