Continuous Passive Motion (CPM) Machines

Number: 0010

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses continuous passive motion (CPM) machines.

Medical Necessity

Aetna considers continuous passive motion (CPM) machines medically necessary durable medical equipment (DME) to improve range of motion in any of the following circumstances:
1. During the post-operative rehabilitation period for members who have received a total knee arthroplasty (TKA) or revision TKA as an adjunct to ongoing physical therapy (PT); or
2. Members undergoing surgical release of arthrofibrosis/adhesive capsulitis or manipulation under anesthesia of any joint (knee, shoulder, and elbow the commonest) until the member is participating in an active PT program; or
3. To promote cartilage growth and enhance cartilage healing during the non weight-bearing period following any of the following until the member begins the weight-bearing phase of recovery:
  - After abrasion arthroplasty or microfracture procedure; or
  - Autologous chondrocyte transplantation; or
  - Chondroplasties of focal cartilage defects; or
  - Surgery for intra-articular cartilage fractures; or
  - Surgical treatment of osteochondritis dissecans; or
  - Treatment of an intra-articular fracture of the knee (e.g., tibial plateau fracture repair); or
4. Members who have undergone certain surgeries and may not be able to benefit optimally from active PT, for example members with:
  - Dupuytren's contracture; or
  - Extensive tendon fibrosis; or
  - Mental and behavioral disorders; or
  - Reflex sympathetic dystrophy; or
5. Members who are unable to undergo active PT.
Note: Where the CPM device is used for surgical rehabilitation, the use of this device must commence within 2 days following surgery to meet medical necessity guidelines. Although the usual duration of CPM usage is 7 to 10 days, up to 3 weeks of CPM therapy may be considered medically necessary upon individual consideration. Use of the CPM machine beyond 21 days post-op is not supported by the medical literature. There is insufficient evidence to justify use of these devices for longer periods of time or for other applications.
Experimental, Investigational, or Unproven

Aetna considers CPM machines experimental, investigational, or unproven for all other indications, including the ones listed below (not an all-inclusive list), because there is insufficient scientific evidence to support the use of these machines for other indications:
1. Burn rehabiliation
2. For use in the lower extremities for individuals in the intensive care unit
3. Hand rehabilitation following stroke
4. Motion or strength following metacarpophalangeal arthroplasty
5. Osteochondral allograft implantation in the knee
6. Phalanx fracture
7. Rehabilitation following anterior cruciate ligament reconstruction
8. Rehabilitation following back surgery
9. Rehabilitation following foot surgery (e.g., for congenital talipes equinovarus (clubfoot))
10. Rehabilitation following hip arthroscopy
11. Rehabilitation following quadriceps tear
12. Rehabilitation following shoulder surgery (e.g., rotator cuff repair and shoulder arthroplasty)
13. Rehabilitation following surgical release for elbow contractures
14. Rehabilitation following temporomandibular joint repair
15. Rehabilitation following total hip replacement
16. Rehabilitation of distal radial fractures
17. Rheumatoid arthritis in the absence of a covered indication
18. Treatment of breast cancer-related lymphedema
19. Treatment of low back pain or trauma.
Policy Limitations and Exclusons

Note: Sheepskin pad for CPM machines is considered a supply integral to the CPM device; therefore, not separately reimbursable.

Table:
CPT Codes / HCPCS Codes/ ICD-10 Codes
Code	Code Description
Other CPT codes related to the CPB:
21240 - 21243	Arthroplasty, temporomandibular joint
23000 - 23921	Non arthroscopic shoulder surgery
27415	Osteochondral allograft, knee, open
27430	Quadricepsplasty (eg, Bennett or Thompson type)
27486	Revision of total knee arthroplasty, with or without allograft; 1 component
27487	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component
29805 - 29828	Arthroscopic shoulder surgery
29860 - 29916	Arthroscopy, hip
97110	Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97140	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
HCPCS codes covered if selection criteria are met:
E0935	Continuous passive motion exercise device for use on knee only
E0936	Continuous passive motion exercise device for use other than knee
Other HCPCS codes related to the CPB:
E0188	Synthetic sheepskin pad
E0189	Lambswool sheepskin pad, any size
E1700	Jaw motion rehabilitation system
E1701	Replacement cushions for jaw motion rehabilitation system, package of 6
E1702	Replacement measuring scales for jaw motion rehabilitation system, package of 200
E1800	Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1802	Dynamic adjustable forearm pronation/supination device, includes soft interface material
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1810	Dynamic adjustable knee extension/flexion device, includes soft interface material
E1812	Dynamic knee, extension/flexion device with active resistance control
E1815	Dynamic adjustable ankle extension/flexion device, includes soft interface material
E1820	Replacement soft interface material, dynamic adjustable extension/flexion device
E1825	Dynamic adjustable finger extension/flexion device, includes soft interface material
E1830	Dynamic adjustable toe extension/flexion device, includes soft interface material
E1840	Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
ICD-10 codes covered if selection criteria are met:
G90.50 - G90.59	Complex regional pain syndrome I (CRPS I)
M23.200 - M23.369 M24.80 - M24.9	Internal derangement of knee and other joints
M72.0	Palmar fascial fibromatosis [Dupuytren]
M75.00 - M77.9	Peripheral and other enthesopathies
Numerous options	Musculoskeletal and connective tissue injuries, sequela
M93.20 - M93.29	Osteochondritis dissecans
S83.501+ - S83. 529+	Sprain of cruciate ligament of knee
T84.042+ - T84.043+	Periprosthetic fracture around internal prosthetic right or left knee joint
T84.052+ - T84.053+	Periprosthetic osteolysis of internal prosthetic right or left knee joint
T84.062+ - T84.063+	Wear of articular bearing surface of internal prosthetic right or left knee joint
T84.092+ - T84.093+	Other mechanical complication of internal right or left knee prosthesis
T84.53 - T84.54	Infection and inflammatory reaction due to internal right or left knee prosthesis
Z96.60 - Z96.698	Presence of orthopedic joint implants
ICD-10 codes not covered for indications listed in the CPB:
I97.2	Postmastectomy lymphedema syndrome
M05.00 - M14.89	Inflammatory polyarthropathies [in the absence of a listed covered condition]
M24.521 - M24.529	Contracture, elbow
M24.60 - M24.676	Ankylosis of joint
M26.601 - M26.609	Temporomandibular joint disorders
M43.20 - M43.28	Fusion of spine
M43.8x9, M53.84 - M53.9	Other spinal dorsopathies
M48.04 - M48.08	Spinal stenosis (other than cervical)
M53.2x7 - M53.2x8, M53.3, M53.87 - M53.88	Disorders of the sacrum
M54.00 - M54.09	Panniculitis affecting regions of the neck and back
M54.10 - M54.18	Radiculopathy
M54.30 - M54.9	Sciatica, lumbago, low back pain and other dorsalgia
M54.6	Pain in thoracic spine
Q66.0	Congenital talipes equinovarus
S12.000+ - S12.9xx+, S22.000+ - S22.9xx+, S32.000+ - S32.9xx+	Fracture of spine and trunk [includes sequela]
S13.100+ - S13.29x+, S23.100+ - S23.29x+, S33.100+ - S33.39x+	Dislocations of vertebra, other, and unspecified
S13.4xx+, S13.8xx+ - S13.9xx+, S23.3xx+, S23.9xx+, S33.5xx+ - S33.9xx+	Sprains of back, other and unspecified
S14.101+ - S14.159+, S24.101+ - S24.159+, S34.101+ - S34.139+	Spinal cord injury [includes sequela]
S52.501+ - S52.599+	Fracture of lower end of radius (open or closed)
S62.501A - S62.526S	Fracture of thumb
S62.600A - S62.669S	Fracture of other and unspecified finger(s)
S72.141+ - S72.26x+	Intertrochanteric or subtrochanteric fracture of femur
S83.501A - S83.529S	Sprain of cruciate ligament of knee
S92.00 - S92.066	Fracture of calcaneus
S92.201(A or B) - S92.356 (A or B)	Fracture of other and unspecified tarsal and metatarsal bone(s) [closed and open]
S93.601 - S93.699	Sprain of foot
T20.00xA - T32.99	Burns and corrosions
Z47.89	Encounter for other orthopedic aftercare [rehabilitation following hip arthroscopy and following surgical release for elbow contractures]
Z96.641 - Z96.649	Presence of artificial hip joint

Background

Published studies suggest that continuous passive motion (CPM) can improve range of motion (ROM) in those patients undergoing surgical release of arthrofibrosis of the knee or manipulation of the knee under anesthesia. In these settings, CPM provides for early post-operative motion and is considered a substitute for active physical therapy (PT). Once the patient is participating in active PT, CPM is no longer medically necessary. These observations may be extended to other joints, such as the elbow where arthrofibrosis is a common complication of trauma.

Of all the applications of CPM, the scientific evidence is perhaps strongest for its use in promoting cartilage growth. In addition, clinical studies suggest that CPM can enhance cartilage healing during the non weight-bearing period following surgery for intra-articular cartilage fractures, chondroplasties of focal cartilage defects and surgical treatment of osteochondritis dissecans. Once the patient is weight-bearing, CPM is no longer necessary.

Systematic evidence reviews have found weak or limited evidence for CPM for a number of indications. In a Cochrane review, Handoll et al (2006) evaluated the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures. Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilization, in all but 27 participants whose fractures were fixed surgically. Though some studies were well-conducted, others were methodologically compromised. For interventions started during immobilization, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing 1 month later (1 trial). There was weak evidence of improved hand function in the short- term, but not in the longer term (3 months), for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial). For interventions started post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (4 trials), passive mobilization (2 trials), ice or pulsed electromagnetic field (1 trial), or whirlpool immersion (1 trial) compared with no intervention. There was weak evidence of a short-term benefit of CPM (post-external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial). The authors concluded that available evidence from randomized controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

A systematic evidence review by Michlovitz et al (2004) of non-surgical interventions to restore ROM to persons with injuries to the upper extremities found insufficient evidence to support the use of continuous passive motion. The systematic evidence review identified 1 cohort study, which found CPM to be similar to ROM exercises at improving ROM and extension, but better at improving flexion, after surgery for elbow flexion contractures. The review identified another cohort study that found CPM to be no better than passive ROM exercises after rotator cuff repair. The investigators concluded that "[t]he quality and quantity of evidence in this area were moderate to low."

In a Cochrane review, Massy-Westropp et al (2008) compared the effectiveness of post-operative therapeutic regimens for increasing hand function following metacarpophalangeal (MCP) arthroplasty in adults with rheumatoid arthritis. Randomized controlled trials and controlled clinical trials were accepted if they evaluated the efficacy of a post-operative therapeutic regimen for MCP arthroplasty. No data analyses were performed as only 1 controlled clinical trial was found. The data from that study were described. These investigators' search only identified 1 controlled clinical trial involving 22 subjects. The majority of the evidence for various splinting and exercise regimens consisted of case series and case studies. Results from the 1 (poor quality) trial suggested that the use of CPM is not effective in increasing motion or strength after MCP arthroplasty. The authors concluded that well-designed randomized controlled trials which compare the effectiveness of different therapeutic splinting programs following MCP arthroplasty are required. At this time, the results of 1 study suggested that CPM alone is not recommended for increasing motion or strength after MCP arthroplasty.

In a randomized controlled study, Lenssen and colleagues (2008) examined the effectiveness of prolonged CPM use in the home setting as an adjunct to standardized PT. Effectiveness was assessed in terms of faster improvements in ROM as well as functional recovery, measured at the end of the active treatment period, 17 days after surgery. A total of 60 patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and experiencing early post-operative flexion impairment were randomized into 2 treatment groups. The experimental group received CPM + PT for 17 consecutive days after surgery, whereas the usual care group received the same treatment during the in-hospital phase (i.e., about 4 days), followed by PT alone (usual care) in the first 2 weeks after hospital discharge. From 18 days to 3 months following surgery, both groups received standardized PT. The primary focus of rehabilitation was functional recovery (e.g., ambulation) and regaining ROM in the knee. Prolonged use of CPM slightly improved short-term ROM in patients with limited ROM at the time of discharge after TKA when added to a semi-standard PT program. Assessment at 6 weeks and 3 months after surgery found no long-term effects of this intervention. These researchers also did not detect functional benefits of the improved ROM at any of the outcome assessments. The authors concluded that although results indicate that prolonged CPM use might have a small short-term effect on ROM, routine use of prolonged CPM in patients with limited ROM at hospital discharge should be re-considered, since neither long-term effects nor transfer to better functional performance was detected.

In a Cochrane review, Gray et al (2012) evaluated the effectiveness of interventions for congenital talipes equinovarus (CTEV). The review found, among other things, a lack of evidence for continuous passive motion treatment following major foot surgery. The authors could draw no conclusions from other included trials because of the limited use of validated outcome measures and lack of available raw data; and future randomized controlled trials should address these issues.

There is also a scarcity of peer-reviewed evidence on the use of CPM for other conditions including degenerative joint diseases (e.g., rheumatoid arthritis) as well as rehabilitation following quadriceps tear and temporo-mandibular joint repair.

Ring and colleagues (1998) examined if a post-operative rehabilitation protocol incorporating CPM would increase the total ROM obtained 6 months following silicone interposition arthroplasty of the metacarpophalangeal joints in patients with rheumatoid arthritis. A prospective trial randomizing patients to receive either CPM or the standard dynamic splint protocol (modified Madden protocol) was undertaken. A total of 15 hands (60 joints) were treated with the modified Madden protocol and 10 hands (40 joints) had CPM. The mean 6-month post-operative ROM was 7 degrees in the modified Madden cohort compared with 39 degrees in the CPM cohort, representing an improvement of 22 degrees in the modified Madden cohort compared with an improvement of only 5 degrees in the CPM cohort. Residual ulnar deviation 8 degrees versus 12 degrees and grip strength (2.3 kgf versus 3.7 kgf) were both lower in the CPM cohort. The authors concluded that incorporation of the CPM machine in the post-operative rehabilitation protocol does not offer sufficient advantages to justify the added costs.

An UpToDate review on "Total joint replacement for severe rheumatoid arthritis" (Weisman and Rinaldi, 2013) states that "It is unclear whether the use of continuous passive motion devices in the postoperative management of total knee arthroplasty results in enough clinical benefit to justify the inconvenience and expense of the procedure".

In a systematic review, Rogan and colleagues (2013) evaluated treatment effects of CPM after surgical cartilage repair. These researchers performed a literature search in the Cochrane Central Register of Controlled Trials, EMBASE, International Clinical Trials Registry Platform, MEDLINE, Trip Database and in bibliographies of included studies. Two independent researchers evaluated the quality of original investigations by the Cochrane Risk of Bias tool. Systematic reviews were checked by the CBO/Dutch Cochrane Centre Guideline. A total of 1,541 studies were initially retrieved from the databases. After screening for inclusion criteria, 1 review and 10 original papers could be included for further evaluation. Studies showed methodological weaknesses. Heterogeneity of outcome measures and the fact that 6 of 9 studies with a 1-group pre-post design measured the combined effect of surgical treatment and CPM prevented a meta-analysis. The authors concluded that 3 studies described significant improvements with regard to subjective outcome such as pain, swelling, Quality Life Survey, Knee Society score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score or rating Cincinnati due to the surgical treatment and the CPM intervention of cartilage defects in the knee; 6 (case) studies suggested an enhanced cartilage quality of the patients after CPM. They stated that more high-quality randomized controlled trials (RCTs) are needed to provide high-level evidence.

Tabor (2013) determined which total knee replacement (TKR) patients, if any, benefit from the use of the CPM machine. For the study period, most patients received active PT. Patients were placed in the CPM machine if, on post-operative day 1, they had a ROM less than or equal to 45° and/or pain score of 8 or greater on a numeric rating scale (NRS) of 0 to 10, 0 being no pain and 10 being the worst pain. Both groups of patients healed at similar rates. The incidence of adverse events, length of stay, and functional outcomes was comparable between groups. The author concluded that given the demonstrated lack of relative benefit to the patient and the cost of the CPM, this study supported discontinuing the routine use of the CPM.

Nikolaou and colleagues (2014) noted that TKR is a widely used operation that has radically improved the quality of life of millions of people during the last few decades. However, some technical details, concerning the surgical procedure and the rehabilitation following TKA, are still a matter of a strong debate. In this review of the literature, these investigators have included the best evidence available of the last decade, in an effort to shed light on some of the most controversial subjects related to TKR surgery:

Posterior-stabilized or cruciate-retaining prosthesis?
To use a tourniquet during operation or not?
Do patients need CPM for their post-surgery rehabilitation? and
To resurface patella or not?

These are some of the most controversial topics that until now have been persistent dilemmas for the orthopedic surgeon. Results of this systematic review of the literature were highly controversial. These conflicting results were an indication that larger and more well-conducted high-quality trials are needed in order to gain more secure answers.

In a RCT, Herbold et al (2014) examined the effects of using a CPM device for individuals with poor ROM after a TKR admitted for post-acute rehabilitation. Adults (n = 141) after TKR with initial active knee flexion less than 75° on admission to the Inpatient rehabilitation facility (IRF) were included in this study. Two randomized groups: group 1 (n = 71) received the conventional 3 hours of therapy per day, and group 2 (n = 70) received the addition of daily CPM use for 2 hours throughout their length of stay. The primary outcome measure was active knee flexion ROM. Secondary outcome measures included active knee extension ROM, length of stay, estimate of function using the FIM and Timed Up and Go test, girth measurement, and self-reported Western Ontario and McMaster Universities Osteoarthritis Index scores. All subjects significantly improved from admission to discharge in all outcome measures. However, there were no statistically significant differences in any of the discharge outcome measures of the CPM group compared with the non-CPM group. The authors concluded that CPM did not provide an additional benefit over the conventional interventions used in an IRF for patient after TKR, specifically in patients with poor initial knee flexion ROM after surgery.

In a RCT, Boese and colleagues (2014) determined the effectiveness of CPM following TKA. Post-operative outcomes of interest were: swelling, drop in hemoglobin, self-reported pain scores, ROM, and hospital length of stay. A total of 160 subjects were randomized into 1 of 3 treatment groups:

CPM device on and moving from the immediate post-operative period,
CPM device on and stationary at 90 degree flexion for the first night and then moving throughout the rest of their stay, and
no CPM (n = 55, 51, and 54, respectfully).

Subjects were followed during the first and second post-operative day until their first follow-up appointment approximately 3 to 4 weeks post-operatively. Cost of CPM was further evaluated. The authors concluded that CPM provided no benefit to patients recovering from TKA.

On behalf of the National Health and Medical Research Council (NHMRC) of Australia, Mak et al (2014) evaluated the evidence for different interventions in the pre-operative, peri-operative and post-operative care for people undergoing elective TKR and total hip replacement (THR). A multi-disciplinary working group comprising consumers, managers and clinicians from the areas of orthopedics, rheumatology, aged care and rehabilitation evaluated RCTs and systematic reviews/meta-analyses concerning aspects of pre-operative, peri-operative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence was assessed and specific recommendations made according to NHMRC guidelines. A total of 25 aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multi-disciplinary preparation, pre-operative exercise, smoking cessation, interventions for co-morbid conditions, predictors of outcome, clinical pathways, implementation of a blood management program, antibiotic prophylaxis, regional anesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and CPM. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations. The authors concluded that there was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.

In a Cochrane review, He and colleagues (2014) examined the effectiveness of CPM therapy for preventing venous thromboembolism (VTE) in patients after TKA. For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Coordinator searched the Specialised Register (last searched February 2014), CENTRAL (2014, Issue 1), Ovid MEDLINE (to week 1 February 2014) and EMBASE (to Week 07 2014). Randomized controlled trials comparing the use of CPM with control in preventing deep venous thrombosis (DVT) or pulmonary embolism (PE) following TKA were selected for analysis. People aged 18 years and older who had undergone TKA were included in this review. These researchers excluded studies of patients who presented with DVT at baseline. The experimental and control groups received similar postoperative care and therapy other than the CPM. Two review authors independently assessed the citations retrieved by the search strategies for reports of relevant RCTs. They independently selected trials that satisfied the inclusion criteria, extracted data and undertook quality assessment. Effects were estimated as risk ratios (RRs), mean differences or standardized mean differences (SMD) with 95 % CIs. Meta-analyses were performed using a fixed-effect model for continuous variables. Where heterogeneity existed (determined by the I(2) statistic) a random-effects model was used. A total of 11 RCTs involving 808 participants met the inclusion criteria. The methodological quality of the included studies was variable and most of the pre-defined outcomes were reported by only 1 or 2 studies, therefore the quality of the evidence was low. Five studies with a total of 405 patients reported the incidence of DVT. In the CPM group (205 patients) 36 developed DVT (18 %) compared to 29 (15 %) in the control group (200 patients). The results of the meta-analysis showed no evidence that CPM had any effect on preventing VTE after TKA (RR 1.22, 95 % CI: 0.84 to 1.79). One trial (150 participants) did not find PE in any of the patients during hospitalization or in the subsequent 3 months. Pulmonary embolism was not reported in the other included studies. None of the trials reported deaths among the included participants. The authors concluded that there is not enough evidence from the available RCTs to conclude that CPM reduces VTE after TKA. These researchers cannot assess the effect of CPM on mortality because no such events occurred among the participants of these trials. The quality of the evidence was low. The results were supported by only a small number of studies, most of which are of low to moderate quality.

In a Cochrane review, Harvey et al (2014) evaluated the benefits and harms of CPM and standard post-operative care versus similar post-operative care, with or without additional knee exercises, in people with TKA. These investigators searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE (January 1966 to 24 January 2013), EMBASE (January 1980 to 24 January 2013), CINAHL (January 1982 to 24 January 2013), AMED (January 1985 to 24 January 2013) and PEDro (to 24 January 2013). Randomized controlled trials in which the experimental group received CPM, and both the experimental and control groups received similar post-operative care and therapy following TKA in people with arthritis were selected for analysis. Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. The primary outcomes of interest were active knee flexion ROM, pain, quality of life, function, participants' global assessment of treatment effectiveness, incidence of manipulation under anesthesia and adverse events. The secondary outcomes were passive knee flexion ROM, active knee extension ROM, passive knee extension ROM, length of hospital stay, swelling and quadriceps strength. These researchers estimated effects for continuous data as mean differences or SMD, and effects for dichotomous data as risk ratios; all with 95 % CIs. If appropriate, these investigators performed meta-analyses using random-effects models. They identified 684 papers from the electronic searches after removal of duplicates and retrieved the full reports of 62 potentially eligible trials. A total of 24 RCTs of 1,445 participants met the inclusion criteria; 4 of these trials were new to this update. There was moderate-quality evidence to indicate that CPM does not have clinically important short-term effects on active knee flexion ROM: mean knee flexion was 78 degrees in the control group, CPM increased active knee flexion ROM by 2 degrees (95 % CI: 0 to 5) or absolute improvement of 2 % (95 % CI: 0 % to 4 %). The medium- and long-term effects were similar although the quality of evidence is lower. There was low-quality evidence to indicate that CPM does not have clinically important short-term effects on pain: mean pain was 3 points in the control group, CPM reduced pain by 0.4 points on a 10-point scale (95 % CI: -0.8 to 0.1) or absolute reduction of -4 % (95 % CI: -8 % to 1 %). There was moderate-quality evidence to indicate that CPM does not have clinically important medium-term effects on function: mean function in the control group was 56 points, CPM decreased function by 1.6 points (95 % CI: -6.1 to 2.0) on a 100-point scale or absolute reduction of -2 % (95 % CI: -5 % to 2 %). The SMD was -0.1 standard deviations (SD) (95 % CI: -0.3 to 0.1). There was moderate-quality evidence to indicate that CPM does not have clinically important medium-term effects on quality of life: mean quality of life was 40 points in the control group, CPM improved quality of life by 1 point on a 100-point scale (95 % CI: -3 to 4) or absolute improvement of 1 % (95 % CI: -3 % to 4 %). There was very low-quality evidence to indicate that CPM reduces the risk of manipulation under anesthesia; risk of manipulation in the control group was 7.2 %, risk of manipulation in the experimental group was 1.6 %, CPM decreased the risk of manipulation by 25 fewer manipulations per 1,000 (95 % CI: 9 to 64) or absolute risk reduction of -4 % (95 % CI: -8 % to 0 %). The risk ratio (RR) was 0.3 (95 % CI: 0.1 to 0.9). There was low-quality evidence to indicate that CPM reduces the risk of adverse events; risk of adverse events in the control group was 16.3 %, risk of adverse events in the experimental group was 17.9 %, CPM decreased the risk of adverse event by 150 fewer adverse events per 1,000 (95 % CI: 103 to 216) or absolute risk reduction of -1 % (95 % CI: -5 % to 3 %). The RR was 0.9 (95 % CI: 0.6 to 1.3). The estimates for risk of manipulation and adverse events were very imprecise and the estimate for the risk of adverse events did not distinguish between a clinically important increase and decrease in risk. There was insufficient evidence to determine the effect of CPM on participants' global assessment of treatment effectiveness. The authors concluded that CPM does not have clinically important effects on active knee flexion ROM, pain, function or quality of life to justify its routine use. It may reduce the risk of manipulation under anesthesia and risk of developing adverse events although the quality of evidence supporting these findings is very low and low, respectively. The effects of CPM on other outcomes are unclear.

Husted et al (2014) noted that traditions are passed on from experienced surgeons to younger fellows and become "the right way to do it". Traditions associated with arthroplasty surgery may, however, not be evidence-based and may be potentially deleterious to both patients as well as society, increasing morbidity and mortality, slowing early functional recovery, and increasing cost. These investigators identified selected traditions and performed a literature search using relevant search criteria (June 2014). They presented a narrative review grading the studies according to evidence, and suggested some lines of future research. These researchers presented traditions and evaluated them against the published evidence. Pre-operative removal of hair, urine testing for bacteria, use of plastic adhesive drapes intra-operatively, and pre-warming of the operation room should be abandoned; as should use of a tourniquet, a space suit, a urinary catheter, and closure of the knee in extension. The safety and effectiveness of tranexamic acid is supported by meta-analyses. Post-operatively, there is no evidence to support postponement of showering or postponement of changing of dressings to after 48 hours. They also stated that there is no evidence to recommend routine dental antibiotic prophylaxis, CPM, the use of compression stockings, cooling for pain control or reduction of swelling, flexion of at least 90 degrees as a discharge criterion following TKA, or having restrictions after THA. The authors presented evidence supporting the use of NSAIDs, early mobilization, allowing early travel, and a low hemoglobin trigger for transfusion. Moreover, they stated that revision of traditions and myths surrounding hip and knee arthroplasty towards more contemporary evidence-based principles can be expected to improve early functional recovery, thus reducing morbidity, mortality, and costs.

Also, an UpToDate review on "Total knee arthroplasty" (Martin et al, 2014) states that "The use of continuous passive motion (CPM) devices to improve knee range of motion is common in postoperative rehabilitative care in many institutions, but there is uncertainty regarding whether the clinical benefits justify the inconvenience and expense of CPM". Also, an UpToDate review on "Total joint replacement for severe rheumatoid arthritis" (Weisman and Rinaldi, 2014) states that "It is unclear whether the use of continuous passive motion devices in the postoperative management of total knee arthroplasty results in enough clinical benefit to justify the inconvenience and expense of the procedure".

Furthermore, the American Physical Therapy Association (APTA) recommended against CPM following TKR. In the Choosing Wisely Campaign, the APTA stated "Don’t use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement". The APTA stated that CPM treatment does not lead to clinically important effects on short- or long-term knee extension, long-term knee flexion, long-term function, pain and quality of life in patients undergoing TKA.

In a Cochrane review, Gray et al (2014) evaluated the effectiveness of interventions for congenital talipes equinovarus (CTEV). On April 29, 2013, these investigators searched CENTRAL (2013, Issue 3 in The Cochrane Library), MEDLINE (January 1966 to April 2013), EMBASE (January 1980 to April 2013), CINAHL Plus (January 1937 to April 2013), AMED (1985 to April 2013), and the Physiotherapy Evidence Database (PEDro to April 2013). They also searched for ongoing trials in the WHO International Clinical Trials Registry Platform (2006 to July 2013) and ClinicalTrials.gov (to November 2013); and checked the references of included studies. They searched NHSEED, DARE and HTA for information for inclusion in the Discussion. Randomized controlled trials and quasi-RCTs evaluating interventions for CTEV were selected for analysis. Participants were people of all ages with CTEV of either 1 or both feet. Two authors independently assessed risk of bias in included trials and extracted the data. They contacted authors of included trials for missing information; and collected adverse event information from trials when it was available. These researchers identified 14 trials in which there were 607 participants; 1 of the trials was newly included at this 2014 update. The use of different outcome measures prevented pooling of data for meta-analysis even when interventions and participants were comparable. All trials displayed bias in 4 or more areas. One trial reported on the primary outcome of function, though raw data were not available to be analyzed. These investigators were able to analyze data on foot alignment (Pirani score), a secondary outcome, from 3 trials. Two of the trials involved participants at initial presentation. One reported that the Ponseti technique significantly improved foot alignment compared to the Kite technique. After 10 weeks of serial casting, the average total Pirani score of the Ponseti group was 1.15 (95 % CI: 0.98 to 1.32) lower than that of the Kite group. The second trial found the Ponseti technique to be superior to a traditional technique, with average total Pirani scores of the Ponseti participants 1.50 lower (95 % CI: 0.72 to 2.28) after serial casting and Achilles tenotomy. A trial in which the type of presentation was not reported found no difference between an accelerated Ponseti or standard Ponseti treatment. At the end of serial casting, the average total Pirani scores in the standard group were 0.31 lower (95 % CI: -0.40 to 1.02) than the accelerated group. Two trials in initial cases found relapse following Ponseti treatment was more likely to be corrected with further serial casting compared to the Kite groups which more often required major surgery (risk difference 25 % and 50 %). There is a lack of evidence for different plaster casting products, the addition of botulinum toxin A during the Ponseti technique, different types of major foot surgery, CPM treatment following major foot surgery, or treatment of relapsed or neglected cases of CTEV. Most trials did not report on adverse events. In trials evaluating serial casting techniques, adverse events included cast slippage (needing replacement), plaster sores (pressure areas) and skin irritation. Adverse events following surgical procedures included infection and the need for skin grafting. The authors concluded that from the limited evidence available, the Ponseti technique produced significantly better short-term foot alignment compared to the Kite technique and compared to a traditional technique. The quality of this evidence was low to very low. An accelerated Ponseti technique may be as effective as a standard technique, according to moderate quality evidence. Relapse following the Kite technique more often led to major surgery compared to relapse following the Ponseti technique. These investigators also noted that no conclusions could be drawn from other included trials because of the limited use of validated outcome measures and lack of available raw data. They stated that future RCTs should address these issues,

Hill et al (2014) stated that the use of CPM in the post-operative treatment of intra-articular fractures around the knee is increasing. These researchers determined the effects of a CPM device on knee ROM after operative treatment of intra-articular fractures around the knee. A total of 40 patients with intra-articular fractures of either the proximal part of the tibia or the distal end of the femur were prospectively randomized to the use of CPM or standardized PT in the immediate post-operative period for 48 hours. The primary outcome was knee ROM. Secondary outcome measures included pain scores, Lower Limb Outcomes Questionnaire scores, and Short Musculoskeletal Function Assessment scores. Evaluations were conducted at 48 hours, 2 weeks, 6 weeks, 3 months, and 6 months post-operatively. There was no significant difference in knee extension between the groups at any time-point measured. Knee flexion was significantly greater at 48 hours in the group managed with the CPM device than in the group managed without the CPM device (p < 0.005). However, there was no significant difference in knee flexion at any other time-point. There was no significant difference in knee pain at 48 hours between groups. Six (30 %) of 20 patients were unable to tolerate the use of the CPM device. There were no significant differences in overall complications. The authors concluded that the findings of this study suggested that the use of CPM in the immediate post-operative period following the treatment of intra-articular fractures offered no benefit with regard to knee motion at 6 months and was not tolerated by all patients.

In a prospective, randomized, waiting-list-controlled (WLC) trial, Gavish et al (2015) evaluated the effectiveness of a novel, angular, CPM device for self-treatment at home in patients with mild-to-moderate, non-specific, chronic low back pain (LBP). A total of 36 patients with a score less than or equal to 6 on the NRS for pain were enrolled; 28 patients completed treatment. Participants were randomized to receive the Kyrobak (Radiancy, Hod-hasharon, Israel) at enrollment [immediate treatment (IT) group] or 3 weeks later (WLC group). Self-treatment was prescribed for 10 minutes, 1 to 3 times per day, for 3 weeks. The treatment period was followed by a 3-week follow-up period. Primary outcome was self-reported pain level (NRS). Three weeks of self-treatment with the Kyrobak reduced pain levels significantly in the IT group compared with the WLC group {mean [standard deviation (SD)] ΔNRS score from baseline to post-treatment: IT group, 1.4 (1.5), 95 % CI: 0.5 to 2.3; WLC group, -0.1 (2.2), 95 % CI: -1.1 to 1.2; effect mean difference 1.5}. This benefit was maintained over the follow-up period [from baseline to end of follow-up, mean (SD) ΔNRS score 1.1 (1.8), 95 % CI: 0.4 to 1.8]. Multi-linear regression analysis found that higher baseline pain resulted in greater pain reduction (p = 0.003). Eighty-three percent of participants with a baseline NRS score greater than 4.35 (threshold determined by logistic regression, p = 0.01) achieved the minimal important change criterion of ΔNRS score greater than or equal to 2. Daily NRS score reduced gradually over the treatment period [regression slope -0.052 (0.01), 95 % CI: -0.07 to -0.03]. The authors concluded that preliminary evidence suggested that the Kyrobak may be beneficial for short-term relief of non-specific, chronic LBP, particularly in participants with a moderate level of pain. They stated that a longer treatment period may lead to a further reduction in pain. These preliminary findings need to be validated by well-designed studies with larger sample size and longer follow-up periods.

In a Cochrane review, Handoll and Elliott (2015) examined the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures. These investigators searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2014; Issue 12), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, trial registers, conference proceedings and reference lists of articles. We did not apply any language restrictions. The date of the last search was January 12, 2015. Randomized controlled trials or quasi-RCTs evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults were selected for analysis. Rehabilitation interventions such as active and passive mobilization exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians. The review authors independently screened and selected trials, and reviewed eligible trials. They contacted study authors for additional information; and did not pool data. These researchers included 26 trials, involving 1,269 mainly female and older patients. With few exceptions, these studies did not include people with serious fracture or treatment-related complications, or older people with comorbidities and poor overall function that would have precluded trial participation or required more intensive treatment. Only 4 of the 23 comparisons covered by these 26 trials were evaluated by more than 1 trial. Participants of 15 trials were initially treated conservatively, involving plaster cast immobilization. Initial treatment was surgery (external fixation or internal fixation) for all participants in 5 trials. Initial treatment was either surgery or plaster cast alone in 6 trials. Rehabilitation started during immobilization in 7 trials and after post-immobilization in the other 19 trials. As well as being small, the majority of the included trials had methodological shortcomings and were at high-risk of bias, usually related to lack of blinding, that could affect the validity of their findings. Based on GRADE criteria for assessment quality, these researchers rated the evidence for each of the 23 comparisons as either low or very low quality; both ratings indicated considerable uncertainty in the findings. For interventions started during immobilization, there was very low quality evidence of improved hand function for hand therapy compared with instructions only at 4 days after plaster cast removal, with some beneficial effects continuing 1 month later (1 trial, 17 participants). There was very low quality evidence of improved hand function in the short-term, but not in the longer-term (3 months), for early occupational therapy (1 trial, 40 participants), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial, 96 participants). Four trials separately provided very low quality evidence of clinically marginal benefits of specific interventions applied in addition to standard care (therapist-applied program of digit mobilization during external fixation (22 participants); pulsed electromagnetic field (PEMF) during cast immobilization (60 participants); cyclic pneumatic soft tissue compression using an inflatable cuff placed under the plaster cast (19 participants); and cross-education involving strength training of the non-fractured hand during cast immobilization with or without surgical repair (39 participants)). For interventions started post-immobilization, there was very low quality evidence from 1 study (47 participants) of improved function for a single session of physiotherapy, primarily advice and instructions for a home exercise program, compared with "no intervention" after cast removal. There was low quality evidence from 4 heterogeneous trials (30, 33, 66 and 75 participants) of a lack of clinically important differences in outcome in patients receiving routine physiotherapy or occupational therapy in addition to instructions for home exercises versus instructions for home exercises from a therapist. There was very low quality evidence of better short-term hand function in participants given physiotherapy than in those given either instructions for home exercises by a surgeon (16 participants, 1 trial) or a progressive home exercise program (20 participants, 1 trial). Both trials (46 and 76 participants) comparing physiotherapy or occupational therapy versus a progressive home exercise program after volar plate fixation provided low quality evidence in favor of a structured program of home exercises preceded by instructions or coaching. One trial (63 participants) provided very low quality evidence of a short-term, but not persisting, benefit of accelerated compared with usual rehabilitation after volar plate fixation. For trials testing single interventions applied post-immobilization, there was very low quality evidence of no clinically significant differences in outcome in patients receiving passive mobilization (69 participants, 2 trials), ice (83 participants, 1 trial), PEMF (83 participants, 1 trial), PEMF plus ice (39 participants, 1 trial), whirlpool immersion (24 participants, 1 trial), and dynamic extension splint for patients with wrist contracture (40 participants, 1 trial), compared with no intervention. This finding applied also to the trial (44 participants) comparing PEMF versus ice, and the trial (29 participants) comparing manual edema mobilization versus traditional edema treatment. There was very low quality evidence from single trials of a short-term benefit of CPM post-external fixation (7 participants), intermittent pneumatic compression (31 participants) and ultrasound (38 participants). The authors concluded that the available evidence from RCTs is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius. They stated that further randomized trials are needed. However, in order to optimize research effort and engender the large multi-center randomized trials that are required to inform practice, these should be preceded by research that aims to identify priority questions.

Rehabilitation Following Makoplasty (Partial Knee Arthroplasty)

Joshi et al (2015) stated that conflicting evidence has created substantial controversy regarding the use of CPM in the in-patient setting post-TKA. A total of 109 patients were randomly assigned to 2 groups:

CPM, or
no CPM, applied after TKA.

All patients received the same PT protocol (3 sessions per day), with the only exception being the CPM. Both groups had a knee flexion of 115° at 6 weeks and 120° at 3 months, with no significant differences (p = 0.69 and p = 0.41, respectively); length of stay (LOS) was significantly less for the group who did not receive CPM. The authors concluded that the use of CPM had no clinically relevant benefits with respect to active ROM (AROM), clinical outcomes or discharge disposition and was associated with a cost of $235.50 per TKA.

In a RCT, Baloch et al (2015) compared mean knee flexion in patients on CPM and those without it after TKA. Patients were randomly assigned to either;

Group A receiving standardized PT from first post-operative day, or
Group B receiving PT and 1-hour of CPM twice-daily from first post-operative day until discharge.

Outcome assessment was done on the day of discharge. Of the 76 patients, there were 38 (50 %) in each group. There were 61 (80 %) women and 15 (20 %) men, with a mean age of 65.5 ± 7.9 years in Group A and 61.6 ± 9.1 years in Group B. The mean pre-operative knee flexion in Group A was 90.3 ± 13.2° and in Group B it was 96.9 ± 11.5°. Mean maximum flexion at the time of discharge was 96.3 ± 5.7° in Group A; and 94.3 ± 8.4° in Group B (p = 0.22). The mean LOS in Group A was 6.1 ± 1.4 days; and in Group B it was 8.6 ± 2.4 days (p = 0.01). The authors concluded that CPM had no influence on knee ROM after TKA at the time of discharge.

It is also interesting to note that an UpToDate review on "Total knee arthroplasty" (Martin et al, 2016) states that "The use of continuous passive motion (CPM) devices to improve knee range of motion and prevent venous thromboembolism is common in postoperative rehabilitative care in many institutions. However, CPM does not provide sufficient benefit to justify its inconvenience and expense. Two meta-analyses published in 2014 found that the addition of CPM to standard therapies did not have clinically significant effects on range of motion, pain, function, quality of life, or prevention of venous thromboembolic events".

It is clear that the evidence to support the use of CPB following TKA is weak; moreover, that there is a lack of evidence regarding the clinical value of CPM following Makoplasty (partial knee arthroplasty).

Hand Rehabilitation Following Stroke

Zhang and colleagues (2015) proposed a wearable hand exoskeleton with circuitous joint for hand rehabilitation of stroke patients. The circuitous joint adopts the symmetric pinion and rack mechanism (SPRM) with the parallel mechanism. The exoskeleton finger is a serial mechanism composed of 3 closed-chain SPRM joints in series. The kinematic equations of the open chain of the finger and the closed chains of the SPRM joints were built to analyze the kinematics of the hand rehabilitation exoskeleton. The experimental set-up of the hand rehabilitation exoskeleton was built and the CPM rehabilitation experiment and the test of human-robot interaction force measurement were conducted. The authors noted that experiment results showed that the mechanical design of the hand rehabilitation robot is reasonable and that the kinematic analysis is correct, thus the exoskeleton can be used for the hand rehabilitation of stroke patients.

Rehabilitation Following Hip Arthroscopy

Smith and colleagues (2016) conducted a survey analyzing pre-, intra- and post-hip arthroscopy practice patterns among hip arthroscopists world-wide. These investigators performed a 21-question, institutional review board (IRB)-exempt, health insurance portability and accountability Act (HIPAA)-compliant, cross-sectional survey via e-mail using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. A total of 75 respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing antero-posterior (AP) pelvis, false profile and Dunn 45 were the most common radiographs utilized; computed tomography (CT) scans were utilized by 54 % of surgeons at least some of the time. Only 56 % of participants recommended an arthrogram with magnetic resonance imaging (MRI). Nearly all surgeons either never (40 %) or infrequently (58 %) performed arthroscopy in Tonnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51 % never; 44 % infrequently). Only 25 % of participants performed a routine T-capsulotomy and 41 % closed the capsule if the patient was at risk for post-operative instability. Post-operatively, 52 % never used a brace, nearly half (48 %) either never (39 %) or rarely (9 %) used a CPM, 32 % always used one; 11 % never recommended heterotopic ossification prophylaxis and 30 % never recommended formal thrombo-embolic disease prophylaxis. The authors concluded that within this cohort of respondents, several areas of patient evaluation and management remained discordant and controversial without universal agreement. They that future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Cunningham and associates (2017) stated that the early post-operative course after hip arthroscopy for femoro-acetabular impingement (FAI) syndrome has not been thoroughly characterized or correlated to factors that may influence recovery. In a prospective, observational study, these investigators reported on early pain, function and attitudes towards rehabilitation and determined predictors of early recovery after hip arthroscopy. A total of 62 patients reported pre-operative pain, International Hip Outcome Tool (iHOT)-12 (hip functional score), psychological status and other baseline characteristics. Pain, iHOT-12, hip flexion and several other outcomes were measured through 6 weeks post-operative. Baseline characteristics were correlated with outcomes using uni-variate and multi-variable models. Pain relief started on post-operative day 1 and consistently improved throughout the 6 weeks of follow-up. The average patient's pain was reduced from a pre-operative level of 5/10 to 2/10 by 6 weeks post-operative. Similarly, iHOT-12 improved from 33/100 to 57/100; whereas hip flexion increased by 9° by 6 weeks post-operative. At 2 weeks post-operative, pre-operative anti-inflammatory usage was associated with greater improvement in pain and swelling; pre-operative opioid usage with poorer patient-reported helpfulness of and adherence to rehabilitation; and higher American Society of Anesthesiologists (ASA) score and lower procedure time with improvement of the pre-operative pain complaint. At 6 weeks, greater depression was associated with lower post-operative pain reduction but greater pre-operative pain complaint improvement. Continuous passive motion (CPM) usage was associated with increased hip flexion. Pain improved from pre-operative by Day 1 after hip arthroscopy, and early functional improvements were seen by 6 weeks post-operative. The authors concluded that pre-operative anti-inflammatory and opioid usage, depression, race, ASA score, procedure time and CPM usage were significantly associated with study outcomes. This was an observational study with a relatively small sample size (n = 62); its findings need to be validated by well-designed studies.

Rehabilitation Following Surgical Release for Elbow Contractures

Viveen and colleagues (2017) noted that the elbow is prone to stiffness after trauma. To regain functional elbow motion, several conservative and surgical therapeutic options are available. Conservative treatment includes physical therapy (PT), intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the post-traumatic stiff elbow is often performed. The best evidence-based rehabilitation protocol for patients after a surgical release is unknown to-date and differs among surgeons, hospitals and countries. Options include early or delayed motion supervised by a physical therapist, immediate CPM, (night) splinting and a static progressive or dynamic splinting program. The SET-Study (Stiff Elbow Trial) is a single-center, prospective, RCT. The primary objective of this study is to compare the active ROM (flexion arc and rotational arc) 12 months after surgery between 3 groups. The first group will receive in-hospital CPM in combination with early motion PT supervised by a physical therapist; the second group will receive only in-hospital early motion PT supervised by a physical therapist; and the third group will receive out-patient supervised PT from post-operative day 7 till day 10. Secondary outcome measures will be patient reported outcome measures (PROMs) including the Mayo elbow performance score (MEPS), the Oxford elbow score (OES), the quick disabilities of arm, shoulder and hand (qDASH) score, visual analog pain scale in rest and activity (VAS), pain catastrophizing scale (PCS), the short form (SF)-36, the revised Centre for Epidemiological Studies depression scale (CESD-R) and the work rehabilitation questionnaire (WORQ) for the upper limb. These investigators stated that successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow. Patient enrolment will commence in March 2017 and these researchers expect to enroll 4 patients per month. Considering the 1-year follow-up, publication of data will be expected in 2020.

O'Driscoll et al (2022) stated that CPM has been used for decades; however, these investigators were unaware of any RCTs in which CPM has been compared with PT for rehabilitation following release of elbow contracture. In a single-blinded, single-center RCT, these researchers randomly assigned patients undergoing arthroscopic release of elbow contracture to a rehabilitation protocol involving either CPM or PT. The primary outcomes were the rate of recovery and the arc of elbow motion (ROM) at 1 year. The rate of recovery was evaluated by measuring ROM at 6 weeks and 3 months. The secondary outcomes included other ROM-related outcomes, PROMs, flexion strength and endurance, grip strength, and forearm circumference at multiple time-points. A total of 24 patients were assigned to receive CPM, and 27 were assigned to receive PT. At 1 year, CPM was superior to PT with regard to the ROM, with an estimated treatment difference of 9° (95 % CI: 3° to 16°; p = 0.007). Similarly, the use of CPM resulted in a greater ROM at 6 weeks and 3 months than PT. The percentage of lost motion recovered at 1 year was higher in the CPM group (51 %) than in the PT group (36 %) (p = 0.01). The probability of restoring a functional ROM at 1 year was 62 % higher in the CPM group than in the PT group (RR for functional ROM, 1.62; 95 % CI: 1.01 to 2.61; p = 0.04). PROM scores were similar in the 2 groups at all time-points, except for a difference in the American Shoulder and Elbow Surgeons (ASES) elbow function subscale, in favor of CPM, at 6 weeks. The use of CPM decreased swelling and reduced the loss of flexion strength, flexion endurance, and grip strength on day 3, with no between-group differences thereafter. The authors concluded that among patients undergoing arthroscopic release of elbow contracture, those who received CPM obtained a faster recovery and a greater ROM at 1 year, with a higher chance of restoration of functional elbow motion than those who underwent routine PT. Level of Evidence = I.

Treatment of Breast Cancer-Related Lymphedema

In a RCT, Kizil and colleagues (2018) examined the effect of shoulder flexion exercise using CPM on lymphedema during the treatment of breast cancer-related lymphedema (BCRL). A total of 30 patients with BCRL were enrolled and completed the study; 14 patients were treated with complete decongestive therapy (CDT) and CPM in the intervention group, and 16 patients were treated with CDT alone (control group) for 15 sessions. Main outcome measures included the shoulder ROM assessed with a goniometer, limb volume difference measured using the water immersion method, function with DASH, and the quality of life (QOL) using the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B4). Lymphedema volume measures were taken at baseline, on days 1, 2, 3, 4, 5, 10, and 15; and shoulder ROM, FACT-B4, and DASH were taken at baseline and on day 15. All subjects were similar at baseline. After treatment significant improvement was found in ROM, volumetric differences, DASH, and FACT-B4 scores in both groups. No significant differences were observed in the volumetric differences, ROM, and the DASH, and FACT-B4 scores between the groups, except for the FACT-B4 physical well-being sub-scores, which were better in intervention group. The authors concluded that the findings of this study r showed that CPM did not contribute to the reduction of BCRL.

Rehabilitation of Distal Radial Fractures

In a randomized clinical trial, Shirzadi and colleagues (2020) examined if applying CPM in addition to routine exercises is more effective than routine exercises alone in pain reduction, ROM and function improvement after distal radius fractures (DRFs). This study included 21 patients with non-stabilized DRF after pin removal; they were randomly assigned to experimental and control groups. The experimental group received stretching exercises with CPM machine for 2×15 mins per session. Both groups received routine exercises for 1 hour, 3 times a week for 4 weeks. The primary outcome measure was pain evaluated on a VAS, and the secondary outcome measures were disability evaluated by the patient-rated wrist/hand evaluation and ROM (goniometry) at 4, 6, and 12 weeks. Univariate analysis of covariance (ANCOVA) and a 1-way repeated measure mixed model analysis of variance (ANOVA) were used for data analysis. All subjects completed the 12-week follow-up. Pain relief, ROM and functional improvement revealed that the treatment was successful in both groups. These investigators detected no significant differences (p > 0.05) between the 2 groups at the end of the follow-up period regarding pain, ROM, and function. The authors concluded that the use of a CPM machine had no additional effect on pain reduction, ROM and function improvement compared with routine exercises in patients with DRF.

Rehabilitation Following Anterior Cruciate Ligament Reconstruction

Gatewood and co-workers (2017) noted that there is a wide array of device modalities available for post-operative treatment following arthroscopic knee surgery; however, it remains unclear which types and duration of modality are the most effective. In a systematic review, these investigators examined the effectiveness of device modalities used following arthroscopic knee surgery. They carried out a systematic search of the literature using PubMed; Scopus; Medline; Embase; PEDro; SportDiscus; and CINAHL databases (1995 to 2015) for clinical trials using device modalities following arthroscopic knee surgery: cryotherapy, CPM, neuromuscular electrical stimulation (NMES), surface electromyographic (sEMG) biofeedback and shockwave therapy (ESWT). Only level 1 and 2 studies were included; and the methodological quality of studies was assessed using Physiotherapy Evidence Database (PEDro) scores. Outcome measures included: muscle strength, ROM, swelling, blood loss, pain relief, narcotic use, knee function evaluation and scores, patient satisfaction and hospital LOS. A total of 25 studies were included in this systematic review, 19 of which found a significant difference in outcomes. For alleviating pain and decreasing narcotic consumption following arthroscopic knee surgery, cryo-compression devices were more effective than traditional icing alone, although not more than compression alone; CPM did not affect post-operative outcomes; sEMG biofeedback and NMES improved quadriceps strength and overall knee functional outcomes following knee surgery. There was limited evidence regarding the effects of ESWT. The authors concluded that cryotherapy, NMES and sEMG were recommended for inclusion into rehabilitation protocols following arthroscopic knee surgery to aid in providing pain relief, recovery of muscle strength and knee function, which were all essential to accelerate recovery. CPM was not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee ROM, and additional studies are needed to examine the effects of ESWT. Anterior cruciate ligament reconstruction (ACLR) is one of the key words in this study. Level of evidence: II.

Thrush and colleagues (2018) stated that ACL rupture commonly occurs in conjunction with articular cartilage injury; however, there is no consensus on the most appropriate rehabilitation that should be performed for ACLR and the surgical management of articular cartilage lesions of the knee. In a systematic review, these investigators examined the recommended rehabilitation protocol for patients undergoing ACLR with concomitant articular cartilage injury with a view to develop guidelines on the most appropriate treatment. Two reviewers independently searched 5 databases for RCTs, non-randomized comparative and retrospective cohort studies (CS) describing the management of concomitant ACL rupture and articular cartilage injury and the post-operative rehabilitation regimen. Risk of bias was performed using a modified Downs & Black's checklist. The primary outcome was specific rehabilitation protocols including weight-bearing status, immobilization, CPM, and return-to-play criteria. Secondary outcomes included patient-reported outcomes (PROs). A best evidence synthesis was performed. The review yielded 6 studies that reported on rehabilitation techniques. All studies were of low methodological quality. There was considerable variability in not only the chondral lesion reported but also the treatment techniques used and especially the rehabilitation regimens. No consensus was found on weight-bearing status, post-operative immobilization, the use of CPM, or return-to-play criteria. Given the quality of the papers, there was no evidence to recommend any specific rehabilitation regimen in the post-operative management of concomitant ACLR and articular cartilage lesions. The authors concluded that this systematic review revealed that despite how common concomitant ACL rupture and articular cartilage injury is, there is no evidence to support one, most appropriate rehabilitation protocol. From a clinical perspective, decisions on post-operative rehabilitation for patients undergoing ACLR and treatment of articular cartilage lesions should be made on a case-by-case basis with criteria-based progression until more robust evidence becomes available. Level of Evidence = IV.

In a systematic review and meta-analysis, Jaspers and associates (2019) examined the results of empirical studies on the effects of CPM on rehabilitation after ACLR. The research question was: What were the effects of CPM on ROM, swelling and pain after ACLR? These investigators searched in Medline, Embase, CINAHL, Cochrane and PEDro up to January 2018; SMD were expressed as Hedges' g, in order to correct for over-estimation of the true effect in small study samples. The 95 % confidence intervals (95 % CI) were calculated for both the individual studies and the overall weighted estimate. Outcomes were pain, ROM and swelling. A total of 8 studies comprising 442 subjects were included in the meta-analysis. Beneficial effects of CPM could be identified for the need for pain medication (Hedges' g = 0.93; 95 % CI: 0.41 to 1.45 during the first 24 hours after surgery), the number of patient-controlled analgesia button pushes by the patient during the first 24 hours after surgery (MD = 31.20; 95 % CI: 11.35 to 51.05), on regaining knee flexion on the 3rd to the 7th post-operative day (MD = 11.6°; 95 % CI: 1.96 to 21.33) as well as in the 3rd to the 6th post-operative week (Hedges' g = 0.93; 95 % CI: 0.41 to 1.44) and on swelling of the knee in the 4th to 6th post-operative week (Hedges' g = 0.77; 95 % CI: 0.35 to 1.18). The authors concluded that the findings of this meta-analysis suggested that CPM had beneficial effects on pain reduction during the first 2 post-operative days, on knee flexion during the 1st to the 6th post-operative weeks and on swelling between the 4th and the 6th post-operative weeks; however, the risk-of-bias scores did not allow a high level of evidence.

Bram et al (2019) stated that joint immobilization following ACL R may lead to intra-articular adhesions and ROM deficits; therefore, some practitioners advocated for the use of post-operative CPM machine protocols. However, previous studies have failed to show CPM to be effective in increasing post-operative ROM. Continuous passive motion has, however, been shown to reduce rates of arthrofibrosis requiring manipulation under anesthesia (MUA) in adult populations. To-date, there has been no study of the effectiveness of CPM after ACL reconstruction in a pediatric population. In a retrospective, cohort study, these researchers examined if the use of CPM would reduce rates of arthrofibrosis in pediatric patients (age of less than 20 years) who underwent primary ACLR. Clinically significant arthrofibrosis was defined as reduced knee flexion requiring MUA within 6 months of surgery. The final dataset included 163 patients. There was no significant difference between cohorts in ROM at the 1-week, 1-month, 3-month, and 6-month time-points (p = 0.137, 0.695, 0.897, and 0.339, respectively). The 2 cohorts also did not differ significantly in pain scores at these time-points (p = 0.684, 0.623, 0.507, and 1.000, respectively). At 3 and 6 months, neither quadriceps nor hamstrings strength differed significantly between cohorts; 4 patients (7.4 %) in the no-CPM cohort required MUA for arthrofibrosis within 6 months of surgery, while no patients in the CPM cohort required MUA (p = 0.023). The authors concluded that the findings of this study suggested that the use of CPM machine reduced arthrofibrosis requiring MUA in pediatric patients after ACLR. Moreover, these researchers stated that future work may better define the clinical utility and cost-effectiveness of CPM in rehabilitation after these surgeries.

In a systematic review of clinical practice guidelines (CPGs), Andrade and co-workers (2020) summarized recommendations and appraised the quality of international (CPGs for rehabilitation following ACLR. These investigators searched PubMed, Embase, Cochrane, SPORTDiscus, PEDro and grey literature databases up to September 30, 2018. English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations were included in this review. These researchers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. They summarized recommendations for rehabilitation after ACR. A total of 6 CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63 % were included – 1 CPG had an overall score below the 50 % (poor quality score) and 2 CPGs scored above 80 % (higher quality score). The lowest domain score was “applicability” (can clinicians implement this in practice?) (29 %) and the highest “scope and purpose” (78 %) and “clarity of presentation” (75 %). CPGs recommended immediate knee mobilization and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electro-stimulation may be used according individual circumstances. The CPGs recommend against CPM and functional bracing. The authors concluded that the quality of the CPGs in ACL post-operative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilization as well as strength/neuromuscular training should be used. Moreover, these investigators stated that CPM and functional bracing should be eschewed.

D’Amore and colleagues (2021) noted that the use of CPM following ACLR was popularized in the 1990s; however, advancements in the understanding of ACLR rehabilitation have made the use of CPM controversial. Many sports-medicine fellowship-trained surgeons reported using CPM machines post-operatively. In a systematic review, these researchers examined the effectiveness of CPM use for recovery following ACLR with respect to knee ROM, knee swelling, post-operative pain, and post-operative complications. PubMed (Medline), Embase, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels I to III on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated post-operative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM. A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final post-operative ROM, or subjective pain scores. Furthermore, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during post-operative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room. The authors concluded that a clinical benefit of post-operative CPM use after ACLR was not identified in this review. While this systematic review identified a number of studies that suggested CPM use may be associated with lower usage of pain medication in hospitalized patients, this could not be confirmed without further investigation with standardized CPM protocols and larger sample sizes. These researchers stated that routine CPM use following ACLR was not supported by this systematic review. Level of Evidence = III.

The authors stated that this study had several drawbacks. The quality of a systematic review is based on the quality of the studies included. Many of these studies examining CPM used outdated surgical and rehabilitation techniques and were of low quality overall. Most included studies contained small sample sizes in which patients were not randomized for risk factors such as sex and age. Furthermore, the heterogeneity of CPM protocols made it difficult to compare all of the papers, and because of this, these investigators were unable to carry out a meta-analysis.

Kuroda et al (2021) stated that the use of CPM in orthopedic rehabilitation has been around for 20 years and is most commonly reported after TKR; and has been primarily advocated to improve knee flexion recovery. A recent meta-analysis provided statistically significant, moderate evidence, indicating that CPM reduced pain, restored knee ROM and enhanced functional recovery after TKR regardless of follow-up duration (Liao et al, 2019). CPM is widely used in hospitals in the post-operative period allowing therapists to streamline their workload and improve their capacity to see other patients. CPM has also been used for the rehabilitation of other knee conditions such as ligament reconstruction surgery in both adults and children. CPM is also being studied for the treatment of other joints, such as the elbow and shoulder, but so far, no advantage to CPM has been definitively reported.

Furthermore, an UpToDate review on “Anterior cruciate ligament injury” (Friedberg, 2021) states that “A number of devices have been used as part of rehabilitation, but often there is little evidence of effectiveness. A systematic review found no benefit from the use of passive-motion machines following surgery”.

Rehabilitation Following Anterior Cruciate Ligament Reconstruction

Zhang et al (2022) examined current elements for post-operative rehabilitation protocol after quadriceps tendon-ACLR (QT-ACLR) outline general timelines for progression of those elements; and explored their associated complication rates and profiles. In accordance with PRISMA guidelines, 5 online databases (Embase, Medline, CINAHL, Cochrane, and PubMed) were searched and screened in duplicate using pre-determined criteria for studies on the afore-mentioned patient population. Descriptive statistics were presented. A total of 56 studies were included, with 31 studies using quadriceps tendon with bone block (B-QT) and 26 studies using all-soft tissue quadriceps tendon (S-QT). The majority of studies permitted full weight-bearing and ROM within the first 12 post-operative weeks, and motion-controlled braces within 6 weeks. Isometric exercises were initiated within 1 week after surgery, closed-chain exercises within 12 weeks, and open-chain and sports-specific exercises within 36 weeks. Complication profiles were similar between graft types and included graft failure (1.2 % to 1.6 %), cyclops syndrome (0.4 % to 0.7 %), and persistent stiffness (0.9 %). The authors concluded that current post-operative rehabilitation strategies in ACLR with QT offer a complication profile comparable to those reported with other graft types. Based on the included rehabilitation regimen, these protocols should focus on early ROM, specifically on achieving full extension, alongside isometric quadriceps strengthening. Progression to closed- and open-chain exercises should follow in a progressive manner, similar to existing protocols in ACLR. Adjuncts such as motion-controlled bracing and CPM machines may be used if graft protection is prioritized. This review highlighted the need for comparison of defined protocols against one another in the setting of QT-ACLR. Level of Evidence = IV.

Continuous Passive Motion After Hip Arthroscopy

Cunningham et al (2017) noted that the early post-operative course after hip arthroscopy for femoro-acetabular impingement (FAI) syndrome has not been fully characterized or correlated to factors that may influence recovery. In a prospective, observational study, these investigators reported on early pain, function and attitudes towards rehabilitation and determined predictors of early recovery after hip arthroscopy. A total of 62 patients reported pre-operative pain, iHOT-12 (hip functional score), psychological status and other baseline characteristics. Pain, iHOT-12, hip flexion and several other outcomes were measured through 6 weeks post-operative. Baseline characteristics were correlated with outcomes using univariate and multivariable models. Pain relief started on post-operative day 1 and consistently improved throughout the 6 weeks of follow-up. The average patient's pain was reduced from a pre-operative level of 5/10 to 2/10 by 6 weeks post-operative. Similarly, iHOT-12 improved from 33/100 to 57/100 whereas hip flexion increased by 9° by 6 weeks post-operative. At 2 weeks post-operative, pre-operative anti-inflammatory usage was associated with greater improvement in pain and swelling; pre-operative opioid usage with poorer patient-reported helpfulness of and adherence to rehabilitation; and higher ASA (American Society of Anesthesiologists) score and lower procedure time with improvement of the pre-operative pain complaint. At 6 weeks, greater depression was associated with lower post-operative pain reduction but greater pre-operative pain complaint improvement; CPM usage was associated with increased hip flexion. Pain improved from pre-operative by day 1 after hip arthroscopy, and early functional improvements were observed by 6 weeks post-operative. Pre-operative anti-inflammatory and opioid usage, depression, race, ASA score, procedure time and CPM usage were significantly associated with study outcomes. The authors concluded that this prospective, observational study of early recovery after hip arthroscopy for FAI syndrome provided evidence to guide patient and provider expectations. Clinically significant improvements in pain, function, and hip flexion were observed by the 6-week visit. Several factors were associated with improved study outcomes including pre-operative anti-inflammatory usage, lack of pre-operative opioid usage, CPM and decreased depression. Optimization of potentially modifiable factors could be prospectively studied to examine if pre-operative changes result in improved post-operative results.

These researchers stated that this study was limited in its follow-up time; especially functional recovery was not complete at 6 weeks and care must be taken in drawing conclusions regarding functional recovery. Collection of longer-term outcomes is important to verify the findings of this observational study. Furthermore, sample size was based on the potential impact of one of the factors (differential rehabilitation strategies) that was thought to potentially relate to outcomes after hip arthroscopy. These investigators stated that association of other binary factors with outcomes could be further evaluated with greater sample size.

In a RCT, Munsch et al (2021) examined if the use of CPM would improve outcomes after arthroscopic hip surgery entailing acetabular labral repair. These researchers hypothesized that the use of CPM would reduce pain and pain medication use and improve QOL in patients who undergo hip arthroscopy. This trial included a total of 54 patients who underwent arthroscopic acetabular labral repair. Subjects were randomized to 2 groups, one with CPM use post-operatively and one without. Primary outcomes measured were pain level, patient satisfaction, and QOL. Parameters used to measure these outcomes were self-reported pain scores on Likert scale, frequency of analgesic medication use, and self-reported scores on Hip Outcome Score Activity of Daily Living (HOS ADL). These parameters were compared between the 2 randomized groups using t-test for statistical analysis. There was no statistical difference between the treatment and control groups in terms of patient characteristics. There was no statistical difference between the 2 groups in terms of HOS ADL scores, although the patients in the control group showed a trend toward higher HOS ADL scores. Subjects in the CPM group had a statistically significant decrease in pain levels following surgery compared to patients in the control group. The total morphine equivalent dose consumed in the first 2 post-operative weeks was higher in the control group compared to the CPM group, although this difference was not statistically significant. The authors concluded that the use of CPM resulted in lower pain level scores in patients after hip arthroscopy. Although there was no statistical difference in QOL or quantity of analgesics consumed post-operatively, patients who used CPM tended to have lower HOS ADL scores (which was desirable) and less consumption of pain medication. These investigators stated that a study with a larger sample of participants and broader scope might elucidate more differences between the 2 groups. Level of Evidence = II.

The authors stated that the drawbacks of this trial were that, as previously mentioned, it might have been under-powered to detect some of the differences between the CPM and control groups, specifically the quantity of analgesic medication consumed by patients. Another drawback was its relatively narrow scope. Only the pain level, consumption of narcotics, and functional level after surgery were considered between the intervention and control groups. Other outcomes such as ROM, strength, and need for MUA could have been considered; in fact, these measures have all been shown to be affected by CPM use in joint arthroplasty literature.

Continuous Passive Motion of the Lower Extremities in Sedated and Ventilated Patients in the Intensive Care Unit

Vollenweider et al (2022) stated that early mobilization, which includes active / passive motion in bed along with mobilization out of bed, is recommended to prevent the development of intensive care unit acquired-weakness (ICU-AW) for patients with critical illness on the ICU. Currently, the impact of passive motion of the lower extremities in sedated and ventilated patients remains unclear. In a systematic review, these researchers examined the available RCTs in English or German language on the impact of passive motion of the lower extremities in sedated and ventilated patients 18 years of age or older in the ICU on musculature, inflammation and immune system and the development of ICU-AW and to examine the replicability of interventions and the methodological quality of included studies. They carried out a systematic literature search up to February 20, 2022 in the databases Medline, Embase, Cochrane Library, CINAHL and PEDro. The description of the intervention (TIDieR checklist) and the methodological quality (Downs and Black checklist) were assessed. A total of 5 studies were included in the qualitative syntheses. On average, the studies were rated with 6.8 out of 12 points according to the TIDieR checklist. For the methodological quality an average of 19.8 out of 27 points on the Downs and Black checklist was reported. The results of included studies indicated that muscle loss may be reduced by passive manual movement, passive cycling and passive motion on a CPM unit. Furthermore, positive effects were reported on the reduction of nitrosative stress and the immune response. The impact on the development of ICU-AW remains unclear. The authors concluded that passive movement showed a slight tendency for beneficial changes on cellular level in sedated and ventilated patients in the ICU within the first days of admission, which may indicate a reduction of muscle wasting and could prevent the development of ICU-AW. Moreover, these investigators stated that future RCTs should possibly record both the acute and the long-term effects of the interventions. Furthermore, studies with larger populations, longer intervention periods or higher dosages, rigorous methodological quality as well as the start of early mobilization within 48 to 72 hours in the ICU are needed. These studies should preferably adhere to guidelines for reporting (e.g., the Tidier checklist), since that would allow the full replication of successful interventions in clinical settings.

The authors stated that this systematic review had several drawbacks that should be mentioned. First, the included studies examined the effects of the interventions with different methodological measures, which prohibited the performance of a meta-analysis. Second, it must be mentioned that the calculated effect sizes could be affected by biases of individual studies. Third, a language bias must be assumed in the conduct of the present systematic review due to the exclusion of studies in a language other than German and English. Fourth, publication bias could not be ruled out.

Osteochondral Allograft Implantation in the Knee

In a systematic review, Fazala et al (2010) examined the clinical evidence of using continuous passive motion (CPM) post-operatively after treating articular cartilage lesions of the knee. These researchers hypothesized that post-operatively, the use of CPM improves the outcomes of cartilage restoration procedures. Multiple medical databases (Medline, Embase, CINAHL, PubMed, Sport-Discus, and Cochrane) were searched for Level I through IV evidence with specific study inclusion and exclusion criteria. The following key words were searched: microfracture, mosaicplasty, OATS, ACI, osteochondral autograft, osteochondral allograft, autologous chondrocyte implantation, autologous chondrocyte transplantation, CPM, continuous passive motion, motion therapy, postoperative knee rehabilitation, cartilage, knee. All studies were independently reviewed by the authors and the references were checked for any missed articles. A total of 4 Level III studies were identified that met inclusion criteria for the hypothesis. No randomized, controlled studies were identified. A meta-analysis could not be carried out as a result of the heterogeneity of the procedures and outcome measures. Definitive conclusions regarding the benefits of CPM post-operatively in knee cartilage surgery could not be made secondary to this heterogeneity. Continuous passive motion is commonly used post-operatively following cartilage surgery. Unfortunately, the clinical evidence (only 4 studies) to support the use of CPM is lacking despite an overwhelming abundance of basic science support and the common clinical practice of CPM implementation post-operatively in knee cartilage restoration procedures. The authors stated that there is a great need for well-conducted, high-level evidence studies to address this void in the literature.

Howard et al (2010) examined the literature regarding post-operative rehabilitation for articular cartilage repair: (i) does the use of CPM enhance healing, and if so, what parameters should be applied? (ii) Can active range of motion (AROM) be used in place of or with CPM? (iii) When can individuals safely resume weight bearing (WB) following repair? These investigators carried out a search using Medline, SportsDiscus, and CINAHL databases with the following keywords: articular cartilage, AROM, CPM, microfracture, osteochondral allograft, autologous chondrocyte implantation, rehabilitation, weight bearing, and knee. Studies on basic science or clinical outcomes examining the effects of CPM, AROM, or WB on knee articular cartilage healing were selected for analysis. Selected articles were rated using the Strength of Recommendation Taxonomy (SORT) to determine evidence for clinical application. A total of 16 articles met selection criteria: 12 were basic science studies; 4 were clinical studies. Basic science evidence supporting CPM exists; however, few patient-oriented outcomes have been documented resulting in a SORT rating of C. Early WB and AROM received a SORT rating of B based on limited clinical research and patient-oriented outcomes. The authors concluded that basic science evidence supported CPM to maintain ROM, reduce pain, and promote healing. Patient-oriented research is needed to strengthen CPM's recommendation. Limited evidence exists regarding early WB and AROM post cartilage repair. There is insufficient evidence to confidently address when to begin WB for maximum healing. Appropriate basic science and patient-oriented research are needed for rehabilitation protocols to maximize benefits of cartilage repair procedures.

Wagner et al (2022) noted that focal cartilage defects of the knee are painful and difficult to treat, especially in younger patients. Observed in up to 60 % of patients who undergo knee arthroscopy, chondral lesions are most common on the patella and medial femoral condyle. Although the majority of lesions are asymptomatic, a variety of therapeutic options exist for those who are symptomatic; however, no clear gold-standard treatment has been established. In recent years, osteochondral allograft transplantation has been increasingly used because of its versatility and encouraging outcomes. The procedure entails replacing damaged cartilage with a graft of subchondral bone and cartilage from a deceased donor. Indications for this procedure include a symptomatic, full-thickness osteochondral defect typically 2 cm2 or larger in size in patients who has failed conservative management. Relative indications include patient age of less than 40 years and a unipolar defect. Osteochondral allograft transplantation requires meticulous planning, beginning with pre-operative radiographs to evaluate the patient's alignment, estimate the lesion size, and aid in matching of a donor femoral condyle. The procedure begins with the patient supine and the knee flexed. A standard arthrotomy incision is carried out on the operative side. Once exposure is obtained, a bore is employed to remove host tissue from the lesion typically to a depth of 5 to 8 mm. Measurements are taken and the donor condyle is appropriately sized to match. A coring reamer is used to create the plug from donor tissue, which is trimmed to the corresponding depth. After marrow elements are removed via pulse lavage, the allograft plug is placed within the femoral condyle lesion through minimal force. Non-operative treatment entails a reduction in high-impact activities and physical therapy (PT). Surgical alternatives include chondroplasty, microfracture, and osteochondral autograft transplantation (OAT); however, these options are typically performed for smaller lesions (less than 2 cm). For larger lesions (2 cm or larger), matrix-induced autologous chondrocyte implantation (MACI) can be utilized, but requires 2 surgical procedures. Osteochondral allograft transplantation is selected against other procedures for various reasons related to patient goals, preferences, and expectations. Typically, this procedure is favored over microfracture or autograft transplantation when the patient has a large lesion. Allograft transplantation might be favored over MACI because of patient preference for a single surgical procedure instead of 2. To the authors’ knowledge, there are currently no Level-I or Level-II trials comparing osteochondral allograft transplantation against other treatments for cartilage defects. There are, however, many systematic reviews of case studies and cohorts that report on outcomes. A 2016 review of 291 patients showed significantly improved patient-reported outcomes (PROs) at a mean follow-up of 12.3 years. The mean survival of grafts was 94 % at 5 years and 84 % at 10 years. Overall, data on long-term survival are lacking because interest in and use of this procedure have only increased over the past few decades. Finally, the rate of return to sport is promising, with the systematic review by Campbell et al showing rates as high as 88 % with an average time to return-to-sport of 9.6 months. Post-operatively, patients can expect to immediately begin passive range of motion. Progression of heel-touch WB begins at 6 weeks, and patients may return to sport-specific activity after 8 months, as tolerated.

Phalanx Fracture

Ramos et al (1997) developed a protocol to improve the final total active motion for patients with isolated unicondylar fractures of the head of the proximal phalanx. The protocol includes surgical treatment followed by hand therapy. Surgical fixation is obtained using lag screw technique. Therapy includes immediate mobilization by use of a CPM machine and controlled active motion. Specially designed splints and Coban wrap are used to control the position of the digit during the first 6 months following surgery. Silastic gel is used to control scarring. These investigators treated 5 consecutive patients over a 4-year period using this protocol. Final total active motion of the injured digit averaged 241 degrees -- approximately 90 % of the normal range of 260 to 270 degrees. No patients required secondary surgery.

Furthermore, UpToDate reviews on “Overview of finger, hand, and wrist fractures” (Muttath et al, 2023), “Distal phalanx fractures” (Bassett, 2023a), “Middle phalanx fractures” (Bassett, 2023b), and “Proximal phalanx fractures” (Bassett, 2023c) do NOT mention the use of a continuous passive motion machine as a management / therapeutic option.

References

The above policy is based on the following references:

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Last Review 03/15/2024

Effective: 08/02/1995

Next Review: 01/09/2025
Review History
Definitions

Continuous Passive Motion (CPM) Machines

Table Of Contents

Policy

Scope of Policy

Medical Necessity

Experimental, Investigational, or Unproven

Policy Limitations and Exclusons

CPT Codes / HCPCS Codes/ ICD-10 Codes

Other CPT codes related to the CPB:

HCPCS codes covered if selection criteria are met:

Other HCPCS codes related to the CPB:

ICD-10 codes covered if selection criteria are met:

ICD-10 codes not covered for indications listed in the CPB:

Background

Rehabilitation Following Makoplasty (Partial Knee Arthroplasty)

Hand Rehabilitation Following Stroke

Rehabilitation Following Hip Arthroscopy

Rehabilitation Following Surgical Release for Elbow Contractures

Treatment of Breast Cancer-Related Lymphedema

Rehabilitation of Distal Radial Fractures

Rehabilitation Following Anterior Cruciate Ligament Reconstruction

Rehabilitation Following Anterior Cruciate Ligament Reconstruction

Continuous Passive Motion After Hip Arthroscopy

Continuous Passive Motion of the Lower Extremities in Sedated and Ventilated Patients in the Intensive Care Unit

Osteochondral Allograft Implantation in the Knee

Phalanx Fracture

References

Policy History

Additional Information

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