To determine if the effect of manipulative acupuncture monitored by laser speckle contrast imaging (LSCI) can improve facial blood perfusion in patients with severe Bell's palsy. This randomized, single-blind, controlled trial included 120 newly diagnosed patients (within 14 days) with severe Bell's palsy (House-Brackmann grading system (HBGS) ≥ grade IV). The patients were randomized (1 : 1) to receive either acupoints acupuncture combined with manipulations of twirling, lifting, and thrusting treatments (manipulative acupuncture) or acupoints acupuncture therapy alone (simple acupuncture). These treatments consisted of a total of 24 sessions, three times per week, and each treatment lasted for 30 min. Following 8 weeks of treatment and 6 months after the initial onset of facial palsy, facial nerve functioning was scored (HBGS) and clinical efficacy was measured. The patients' facial blood perfusion significantly improved following manipulative acupuncture assisted by LSCI compared with that at baseline (P < 0.01). At the conclusion of the 8-week treatment, both groups showed improvement; however, the recovery rate was significantly different (manipulative acupuncture 53.3% vs. simple acupuncture 33.9%, P < 0.05). Follow-up analysis at 6 months after the onset of facial palsy revealed a significantly higher recovery rate (91.7% vs. 78.0%; P < 0.05). In addition, the number of treatments in the observation group was less than that in the simple acupuncture therapy group (P < 0.05). Compared with simple acupuncture therapy, manipulative acupuncture therapy led to a more significant recovery rate in the treatment of severe Bell's palsy and required a shorter course of treatment. This trial was registered with ChiCTR1800019463. Copyright © 2020 Weizheng Zhong et al.