Fluidized Therapy (Fluidotherapy)

Number: 0450

Table Of Contents

Policy

Scope of Policy

This Clinical Policy Bulletin addresses fluidized therapy (fluidotherapy).

1. Medical Necessity

   Aetna considers fluidized therapy medically necessary for the treatment of acute or subacute traumatic or non-traumatic musculoskeletal disorders of the extremities.

2. Experimental, Investigational, or Unproven

   Aetna considers fluidized therapy experimental, investigational, or unproven for all other indications (e.g., breast cancer-related lymphedema, carpal tunnel syndrome, limb edema after stroke, re-warming hypothermic subjects, and rheumatoid arthritis) because of insufficient evidence in the peer-reviewed literature for indications other than the ones listed above.

3. Policy Limitations and Exclusions

   Notes: 

   Fluidized therapy is considered to be a physical therapy modality subject to the physical therapy guidelines and any applicable plan benefit limits for physical therapy.

   Aetna will cover only the professional charges of a physical therapist or other recognized, licensed providers for fluidized therapy and other physical therapy modalities that require direct, one-on-one, patient contact.  Please check benefit plan descriptions.

4. Related Policies

   • CPB 0174 - Pool Therapy, Aquatic Therapy or Hydrotherapy
   • CPB 0325 - Physical Therapy

Background

Fluidized therapy (Fluidotherapy) is a high-intensity heat modality consisting of a dry whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid. In addition to the superficial heat, it provides tactile stimulation while also allowing for active range of motion.

Studies comparing its effective heating with that of a paraffin bath and whirlpool have found them to be similar. The indications for fluidized therapy are similar to paraffin baths and whirlpool.  Use of fluidized therapy dry heat is an acceptable alternative to other heat therapy modalities in reducing pain, edema, and muscle spasm from acute or subacute traumatic or non-traumatic musculoskeletal disorders of the extremities.  Fluidized therapy is contraindicated in patients with local sensory loss, open lesions, severe circulatory obstruction disorders (eg, arterial, lymphatic or venous disorders) or systemic infectious diseases.

The maximum duration of treatment is generally four weeks.

The Work Loss Data Institute's clinical practice guideline on "Carpal tunnel syndrome (acute & chronic)" (2011) listed fluidotherapy as one of the interventions/procedures that were considered, but are not currently recommended.

The Work Loss Data Institute's clinical practice guideline on "Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome" (2013) listed fluidotherapy as one of the interventions/procedures that were considered, but are not currently recommended.

Mild Hypothermia Re-Warming

Limb Edema after Stroke

Han and Lee (2017) examined the effect of fluidotherapy on hand's dexterity and activities of daily living (ADL) for stroke patients with upper limb edema.  The objective of the present study was to treat 30 stroke patients with a 3-week course of fluidotherapy to investigate the efficacy of such therapy for reduction of edema.  For accurate baseline and post-intervention assessment of edema volume, hand edema was measured in the morning using a forearm volumeter.  Mean edematous volume in the affected side measured 600.53 ± 29.94 ml prior to intervention, significantly decreasing to 533.53 ± 27.85 ml after 3 weeks of fluidotherapy.  To examine how such reduction may have enhanced the ability to perform ADL, Korean Version of Modified Barthel Index assessment was performed.  The results showed 46.10 ± 4.27 points at baseline and significantly improved to a mean score of 49.96 ± 4.34 points at the time of re-assessment.  Furthermore, Box and Block Test was performed to examine hand dexterity.  Before fluidotherapy, affected patients transferred 21.13 ± 3.63 blocks in 1 min, increasing to 23.20 ± 3.42 blocks transferred in 1 min following 3 weeks of treatment.  Although the number of blocks transferred did increase slightly, the difference was not statistically significant.  The authors concluded that the findings of this study suggested that using fluidotherapy could reduce edema, and such a reduction may have a positive effect on ADL.  Based on the current findings, these researchers hypothesized that long-term fluidotherapy treatment may be more effective in reducing edema.

The authors stated that a major drawback of this study was that it did not compare the experimental group with the control group.  Also, the number of subjects was insufficient and various evaluation tools related to the function of the hand were not used.  These investigators stated that future studies should be performed to prove the effect of reducing the edema and improving the hand function by using the control design and more various evaluation tools.

Rheumatoid Arthritis

In a prospective, randomized controlled trial (RCT), Erdinc and colleagues (2019) examined the efficacy of dry heat treatment (fluidotherapy) in improving hand function in patients with rheumatoid arthritis (RA).  All patients were randomly divided into 2 groups: Group 1 underwent fluidotherapy; and group 2 was a control group.  Patients in both groups participated in a joint protection and exercise program.  Primary outcome measures were Health Assessment Questionnaire and Duruoz Hand Index; secondary outcome measures were pain and stiffness, Grip Ability Test, Disease Activity Score-28, and grip strength.  These assessments were performed at the hospital at baseline, week 3, and week 12.  A total of 93 subjects were allocated to Group 1 (n = 47) and Group 2 (n = 46).  The mean age of these groups was 54.19 ± 11.15 years and 53.00 ± 10.15 years, respectively (p = 0.592).  At baseline, there were no significant differences between the groups in any parameter except significantly poorer Health Assessment Questionnaire score in Group 1 (p = 0.007).  At week 3, there were no significant differences between the groups in any of the parameters (p > 0.005).  At week 12, Duruoz Hand Index scores were significantly better in Group 2 (p = 0.039).  The authors concluded that fluidotherapy was not effective in improving hand function in patients with RA.  Moreover, no positive effect on any other clinical parameters was observed.

Complex Regional Pain Syndrome

Kanika et al (2023) stated that complex regional pain syndrome (CRPS) is an umbrella term for a variety of clinical presentations characterized by persistent pain usually in the hands or feet that is disproportionate to any preceding injury and characterized by many autonomic, sensory, and motor symptoms.  CRPS is among the most common causes of post-stroke shoulder pain in approximately 80 % of stroke survivors.  These investigators examined the available evidence on physiotherapy treatment for CRPS following a stroke.  Two electronic databases -- PubMed and Google Scholar -- were searched to screen studies published from 2008 to March 2021 to be included in the study.  Meta-analysis was carried out using the RevMan version 5.4 software.  Higgins I2 and Chi-square (Tau2) statistical tests were used to assess heterogeneity.  Out of all 389 studies, only 4 RCT's were included for systematic review and meta-analysis.  Mirror therapy, laser therapy, and fluidotherapy were found to be more effective than control in improving pain intensity (SMD 4.13, 95 % CI: 3.51 to 4.74, I2 = 99 %) and functional independence (SMD 2.07, 95 % CI: 1.45 to 2.70, I2 = 100 %) in patients with CRPS following stroke.  The authors concluded that physiotherapy interventions in the form of exercise therapy and electrotherapy has proven to be effective in treating symptoms of CRPS following stroke.  This commonest and devastating condition has not been studied to an extent in clinical settings.  These researchers stated that there is an urgent need for further studies.

Breast Cancer-Related Lymphedema

In a RCT, Cakıt and Vural (2024) examined if fluidotherapy added to complete decongestive therapy (CDT) would provide additional contribution to edema reduction in patients with breast cancer-related lymphedema (BCRL).  A total of 32 patients with unilateral BCRL were randomly divided into 2 groups: standard treatment with CDT only (Group 1), and CDT + fluidotherapy (Group 2).  All patients underwent phase-1 CDT, which included manual lymphatic drainage, multi-layer bandaging, supervised exercises, and skin care for a total of 15 sessions, 5 times/week for 3 weeks.  Only Group 2 received a total of 15 sessions application of fluidotherapy.  Before and after CDT, patients were evaluated for extremity volumes and excess volumes, according to circumferential measurements of the extremity.  Arm pain was evaluated with visual analog scale (VAS-Pain).  A total of 17 patients in Group 1, and 15 patients in Group 2 completed the study.  Subjects' demographic data and volume measurements were similar at the beginning of the treatment.  Limb volumes of both groups were significantly reduced after treatment (p < 0.001 for both group).  Pain significantly decreased (p = 0.001 for both group).  No adverse reactions were recorded.  The mean change in volume measurements and VAS-Pain scores of patients in CDT+fluidotherapy group before and after treatment were significantly higher than those in only CDT group (p = 0.028, p = 0.020 respectively).  The authors concluded that fluidotherapy added to CDT reduced pain and edema severity more than standard CDT in the patients with BCRL.  Moreover, these researchers stated that as a non-invasive, novel, and effective method, fluidotherapy may be a promising treatment modality for the treatment of BC-related lymphedema.

Furthermore, an UpToDate review on “Breast cancer-associated lymphedema” (Mehrara, 2024) does not mention fluidotherapy/dry heat treatment as a management / therapeutic option.

References