Lancashire and South Cumbria Clinical Commissioning Groups

 Policies for the Commissioning of Healthcare

 Facial Nerve Physiotherapy and Electrotherapy Policy

            This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right but will be applied with reference to other polices in that suite.

1         Policy Criteria         

1.1     The CCG considers that neither physical therapy rehabilitation nor electrotherapy  for facial nerve damage accord with the Principles of Effectiveness or Cost-Effectiveness and therefore the CCG will only commission this service when exceptionality has been demonstrated in accordance with section 8 below.

2         Scope and definitions        

2.1      This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).         

2.2     Unilateral lower motor neurone pattern facial weakness, affecting appearance and some function, such as eye closure, is known as Bell’s Palsy.  Other causes of facial nerve palsy include iatrogenic injuries during surgical procedures, tumours (most commonly acoustic neuroma, facial neuroma and tumours of the parotid gland), trauma and inflammatory causes such as Ramsay Hunt syndrome and Lyme’s disease

NICE guidance NG 127¹  makes recommendations on usual care and management of uncomplicated Bell’s  palsy, including referrals by general practitioners to secondary care.         

2.3      The scope of this policy includes requests for physical therapy rehabilitation and / or electrotherapy services following damage to the facial nerve resulting in a loss of function.         

2.4     The CCG recognises that a patient may have certain features, such as

• Having experienced damage to the facial nerve;
• Wishing to have NHS funded physical therapy to improve and restore function of the facial nerve and muscles;
• Having been advised that they are clinically suitable for physical therapy, and
• Being distressed by the facial nerve damage and by the fact that they may not meet the criteria specified in this commissioning policy.

Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.                                                           

3         Appropriate Healthcare         

3.1      The purpose of physical therapy is to improve and/or restore function of facial muscles.  Damage to the facial nerve leading to a loss of functional capacity is a health problem and the consequences can be severe and can manifest in a variety of forms.  Therefore, the CCG regards services to address the functional consequences of facial nerve damage as according to the Principle of Appropriateness.           

3.2       The CCG regards the achievement of this purpose as according with the Principle of Appropriateness.  Therefore this policy does not rely on the principle of appropriateness.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider the principle of appropriateness in the particular circumstances of the patient in question when considering an application to provide funding.          

3.3      However, when the problem associated with facial nerve damage is predominantly cosmetic or aesthetic, the CCG would regard services to address it as not according with the Principle of Appropriateness.

4         Effective Healthcare          

4 .1     This policy relies on the criterion of effectiveness in that the CCG considers that neither physiotherapy nor electrotherapy rehabilitation for damaged facial nerves accord with the criterion for effectiveness in the Statement of Principles. A high quality (Cochrane) systematic review forms the basis of the evidence used to determine the effectiveness of these treatments².

• There is no high-quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. 
• There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases.
• There is low quality evidence that facial exercise reduces recovery time and consequences in acute cases.
• There is insufficient evidence to determine the effectiveness of electrical stimulation or to identify risks of these treatments.
• There is insufficient evidence to determine the effectiveness of massage and myofascial release.
• There is insufficient evidence to support the addition of acupuncture to facial exercises or other physical therapy.

5         Cost Effectiveness          

5.1       This policy relies on the criterion of effectiveness in that the CCG considers that if an intervention is not effective, it cannot be cost-effective.

6         Ethics           

6.1       This policy does not rely on the principle of ethics, and therefore the issue of ethics of facial nerve rehabilitation has not been considered in developing the policy.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise ethical concerns in this patient before confirming a decision to provide funding.

7         Affordability          

7.1       This policy does not rely on the principle of affordability, and therefore the issue of affordability of facial nerve rehabilitation has not been considered in developing the policy.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise affordability concerns in this patient before confirming a decision to provide funding.

8         Exceptions         

8.1      The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.         

8.2      In the event of inconsistency, this policy will take precedence over any non-mandatory NICE guidance in driving decisions of this CCG.  A circumstance in which a patient satisfies NICE guidance but does not satisfy the criteria in this policy does not amount to exceptionality.

9         Force            

9.1       This policy remains in force until it is superseded by a revised policy.         

9.2     In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:

• If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.

If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly.  However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.

10       References         

1. NICE Suspected neurological conditions: recognition and referral.  NICE guideline [NG127]Published: 01 May 2019 Last updated: 04 July 2019.  Section 1.7 Limb or facial weakness in adults https://www.nice.org.uk/guidance/ng127/chapter/Recommendations-for-adults-aged-over-16#limb-or-facial-weakness-in-adults
2. Teixeira LJ, Valbuza JS, PradoGF. Physical therapy for Bell’s palsy (idiopathic facial paralysis). Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD006283. DOI: 10.1002/14651858.CD006283.pub3.

11       Appendices        

11.1    Codes

The codes applicable to this policy are:

OPCS codes                                                    

U531, U538, U539, Z041, Z501, Z508, Z09    

ICD codes

G51, G51.8, G51.9

Date of adoption:     12.01.2018

Date for review:       12.01.2021