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Prior Authorization Review PanelMCO Policy Submission
A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date:07/01/2019
Policy Number: 0405 Effective Date: Revision Date: 06/24/2016
Policy Name: Mechanical Stretching Devices for Contracture and Joint Stiffness
Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions
*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:
CPB 0405 Mechanical Stretching Devices for Contracture and Joint Stiffness
Clinical content was last revised on 06/24/2016 . Additional non-clinical updates were made by Corporate since the last PARP submission, as documented below.
Update History since the last PARP Submission:
03/12/2019-This CPB has been updated with additional coding.
Name of Authorized Individual (Please type or print):
Dr. Bernard Lewin, M.D.
Signature of Authorized Individual:
http://www.aetna.com/cpb/medical/data/400_499/0405.html
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(https://www.aetna.com/)
Mechanical Stretching Devices forContracture and Joint Stiffness
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Policy History
Last Revi
ew
03/12/2019
Effective: 04/04/200
Next Review:
04/11/2019
Review Hi
story
Definitions
Additional Information
Number: 0405
Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Dynamic Splinting Devices
Aetna considers dynamic splinting devices for the knee, elbow, wrist, finger, or toe
medically necessary durable medical equipment (DME) if either of the following two
selection criteria is met:
1. As an adjunct to physical therapy in members with documented signs and
symptoms of significant motion stiffness/loss in the sub-acute injury or post-
operative period (i.e., at least 3 weeks after injury or surgery); or
2. For members who have a prior documented history of motion stiffness/loss in a
joint, have had a surgery or procedure done to improve motion to that joint, and
are in the acute post-operative period following a second or subsequent surgery
or procedure.
Note: Dynamic splinting systems include, but are not limited to, such products as
Advance Dynamic ROM, Dynasplint, EMPI Advance Dynamic ROM, LMB Pro-glide,
Pro-glide Dynamic ROM, SaeboFlex, SaeboReach, Stat-A-Dyne, and Ultraflex.
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Note: The SaeboMas dynamic mobile arm support system is considered
experimental and investigational because of insufficient published evidence of its
clinical value.
Aetna considers the prophylactic use of dynamic splinting experimental and
investigational in the management of chronic contractures (no significant change in
motion for a 4-month period) and joint stiffness due to joint trauma, fractures, burns,
head and spinal cord injuries, rheumatoid arthritis, multiple sclerosis, muscular
dystrophy or cerebral palsy because of insufficient evidence in the peer-reviewed
literature. However, if surgery is being performed for a “chronic” condition, the use
of a dynamic splinting system may be considered medically necessary if the
member meets the selection criteria stated above.
Aetna considers the use of dynamic splinting experimental and investigational for
the following indications (not an all-inclusive list) because there is a lack of scientific
evidence regarding its effectiveness for these indications.
Carpal tunnel syndrome
Cerebral palsy
Foot drop associated with neuromuscular diseases
Head and spinal cord injuries
Improvement of outcomes following botulinum toxin injection for treatment
of limb spasticity
Injuries of the ankle, and shoulder
Multiple sclerosis
Muscular dystrophy
Plantar fasciitis
Rheumatoid arthritis
Stroke
Trismus
Flexionators and Extensionators
Aetna considers patient-actuated serial stretch (PASS) devices (e.g., the
ERMI Knee/Ankle flexionator, the ERMI Shoulder flexionator, the ERMI Elbow
extensionator, the ERMI Knee extensionator, the ERMI MPJ extensionator, JAS EZ
(ankle, elbow, finger, knee extension, knee flexion, pronation/ supination, shoulder,
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toe and wrist), and knee extension devices (e.g., the Elite Seat) experimental and
investigational because of insufficient scientific evidence of the effectiveness of
these devices.
Joint Active Systems (JAS) Splints
Aetna considers JAS splints (e.g., JAS Elbow, JAS Shoulder, JAS Ankle, JAS
Knee, JAS Wrist, and JAS Pronation-Supination) experimental and investigational
because there is insufficient evidence in the peer-reviewed published medical
literature concerning their effectiveness.
Aetna considers the use of the EZ Turnbuckle orthosis (JAS orthosis) after open
reduction internal fixation (ORIF) for radial head fracture experimental and
investigational because its effectiveness has not been established.
Background
Mechanical stretching devices differ from continuous passive motion devices in that
they are nonmotorized and include the following types: low-load prolonged-duration
stretch (LLPS) devices, patient-actuated serial stretch (PASS) devices and static
progressive stretch (SPS) devices. Mechanical stretching devices are generally
proposed as an adjunct treatment to PT and/or exercise.
LLPS devices, also referred to as dynamic splinting, permit active and
passive motion with elastic traction within a limited range and maintain a
set level of tension by means of incorporated springs. Examples of LLPS
devices include, but may not be limited to, Advance Dynamic ROM,
Dynasplint, EMPI Advance Dynamic ROM, Proglide Advance Dynamic ROM,
LMB Pro-Glide, SaeboFlex, SaeboReach, Stat-A-Dyne and Ultraflex.
PASS devices are purported to permit active and passive motion with elastic
traction within a limited range, but also provide a low- to high-level load to
the joint using pneumatic, hydraulic or tensioning systems that can be
adjusted by the individual. Examples of PASS devices include, but may not
be limited to, Elite Seat, ERMI Elbow Extensionater, ERMI Knee
Extensionater, ERMI Knee/Ankle Flexionater and ERMI Shoulder Flexionater,
JAS EZ Systems (ankle, elbow, finger, knee extension, knee flexion,
pronation/supination, shoulder, toe and wrist).
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SPS devices hold the joint in a set position but are purported to allow for
manual modification of the joint angle without exerting stress on the tissue
unless the angle is set to the joint’s limitations. While these devices allow for
movement (passive or active) within a limited range, the motion is free and
does not provide elastic traction. Examples of SPS devices include, but may
not be limited to, Joint Active Systems (JAS) Splints (eg, JAS Ankle, JAS Elbow,
JAS Knee, JAS Pronation-Supination, JAS Shoulder, JAS Wrist).
Jaw mobility mechanical stretching devices are suggested for use in the
treatment of temporomandibular joint (TMJ) disorders, trismus or other
conditions in which jaw movement is limited. Examples of this type of
mechanical stretching device include, but may not be limited to, TheraBite
Jaw Motion Rehabilitation System, Dynasplint Trismus System or Orastretch.
Dynamic Splinting Systems
Dynamic splinting systems are spring-loaded, adjustable devices designed to
provide low-load prolonged stretch while patients are asleep or at rest. Dynamic
splinting units (for both extension as well as flexion) are available for elbow, wrist,
fingers, knee, ankle and toes. These units are being marketed for the treatment of
joint stiffness due to immobilization or limited range of motion (ROM) as a
consequence of fractures, dislocations, tendon and ligament repairs, joint
arthroplasties, total knee replacements, burns, rheumatoid arthritis, hemophilia,
tendon releases, head trauma, spinal cord injuries, cerebral palsy (CP), multiple
sclerosis, and other traumatic and non-traumatic disorders.
Dynamic splinting is commonly used in the post-operative period for the prevention
or treatment of motion stiffness/loss in the knee, elbow, wrist or finger. It is not
generally used in other joints such as the hip, ankle or foot.
Product names commonly encountered on the market for dynamic splinting include:
Dynasplint™, Ultraflex™, LMB Pro-glide™, EMPI Advance™ and SaeboFlex™.
The SaeboFlex has been promoted for use in rehabilitation in persons with
hemiplegia following cerebrovascular accident. However, there is no peer-reviewed
published medical literature of the effectiveness of the device for this indication.
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Goodyear-Smith and Arroll (2004) undertook a literature review to produce evidence-
based recommendations for non-surgical family physician management of carpal
tunnel syndrome (CTS). These investigators assessed 2 systematic reviews, 16
randomized controlled trials, and 1 before-and-after study using historical controls. A
considerable percentage of CTS resolves spontaneously.
There is strong evidence that local corticosteroid injections, and to a lesser extent
oral corticosteroids, give short-term relief for CTS sufferers. There is limited
evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic
ultrasound may be effective in the short-to-medium term (up to 6 months).
Graham et al (2004) evaluated the role of steroid injections combined with wrist
splinting for the management of CTS. A total of 73 patients with 99 affected hands
were studied. Patients presenting with known medical causes or muscle wasting
were excluded. Diagnosis was made clinically and electrodiagnostic studies were
performed only when equivocal clinical signs were present. Each patient received
up to 3 betamethasone injections into the carpal tunnel and wore a neutral-position
wrist splint continuously for 9 weeks. After that period, symptomatic patients
received an open carpal tunnel release, and those who remained asymptomatic
were followed-up regularly for at least 1 year. Patients who relapsed were
scheduled for surgery. At a minimum follow-up of 1 year, 7 patients (9.6 %) with 10
affected hands (10.1 %) remained asymptomatic. This group had a significantly
shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039, Mann-
Whitney test) and significantly less sensory change (40 % versus 72 %; p = 0.048,
Fisher's exact test) at presentation when compared with the group who had
surgery. It is concluded that steroid injections and wrist splinting are effective for
relief of CTS symptoms; but have a long-term effect in only 10 % of patients.
In a systematic review, Larson and Jerosch-Herold (2008) examined the clinical
effectiveness of post-operative splinting after surgical release of Dupuytren's
contracture. Studies were included if they met the following inclusion criteria:
prospective or retrospective, experimental, quasi-experimental or observational
studies investigating the effectiveness of static or dynamic splints worn day and/or
night-time for at least 6 weeks after surgery and reporting either individual joint or
composite finger range of motion and/or hand function. The methodological quality
of the selected articles was independently assessed by the two authors using the
guidelines for evaluating the quality of intervention studies developed by
McDermid. Four studies, with sample sizes ranging from 23 to 268, met the
inclusion criteria for the systematic review. Designs included retrospective case
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review, prospective observational and one controlled trial without randomization.
Interventions included dynamic and static splinting with a mean follow-up ranging
from 9 weeks to 2 years. Pooling of results was not possible due to the
heterogeneity of interventions (splint type, duration and wearing regimen) and the
way outcomes were reported. The authors concluded that there is empirical
evidence to support the use of low-load prolonged stretch through splinting after
hand surgery and trauma, however only a few studies have investigated this
specifically in Dupuytren's contracture. The low level evidence regarding the effect
of post-operative static and dynamic splints on final extension deficit in severe PIP
joint contracture (greater than 40 degrees) is equivocal, as is the effect of patient
adherence on outcome. While total active extension deficit improved in some
patients wearing a splint, there were also deficits in composite finger flexion and
hand function. The lack of data on the magnitude of this effect makes it difficult to
interpret whether this is of clinical significance. There is a need for well-designed
controlled trials with proper randomization to evaluate the short-term and long-term
effectiveness of splinting following Dupuytren's surgery.
Foot drop usually refers to weakness or contracture of the muscles around the
ankle joint. It may arise from many neuromuscular diseases. In a Cochrane
review, Sackley and colleagues (2009) performed a systematic review of
randomized trials for the treatment of foot drop resulting from neuromuscular
disease. Randomized and quasi-randomized trials of physical, orthotic and surgical
treatments for foot drop resulting from lower motor neuron or muscle disease and
related contractures were included. People with primary joint disease were
excluded. Interventions included a "wait and see" approach, physiotherapy,
orthoses, surgery and pharmacological therapy. The primary outcome measure
was quantified ability to walk while secondary outcome measures included range
of motion (ROM), dorsiflexor torque and strength, measures of activity and
participation, quality of life and adverse effects. Methodological quality was
evaluated by 2 authors using the van Tulder criteria. Four studies with a total of
152 participants were included in the review. Heterogeneity of the studies
precluded pooling the data. Early surgery did not significantly affect walking speed
in a trial including 20 children with Duchenne muscular dystrophy. Both groups
deteriorated during the 12 months follow-up. After 1 year, the mean difference
(MD) of the 28-feet walking time was 0.00 seconds (95 % confidence interval [CI]:
-0.83 to 0.83) and the MD of the 150-feet walking time was -2.88 seconds, favoring
the control group (95 % CI: -8.18 to 2.42). Night splinting of the ankle did not
significantly affect muscle force or ROM about the ankle in a trial of 26 participants
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with Charcot-Marie-Tooth disease. Improvements were observed in both the
splinting and control groups. In a trial of 26 participants with Charcot-Marie-Tooth
disease and 28 participants with myotonic dystrophy, 24 weeks of strength training
significantly improved 6-meter timed walk in the Charcot-Marie-Tooth group
compared to the control group (MD 0.70 seconds, favoring strength training, 95 %
CI: 0.23 to 1.17), but not in the myotonic dystrophy group (MD -0.20 seconds,
favoring the control group, 95 % CI: -0.79 to 0.39). No significant differences were
observed for the 50-meter timed walk in the Charcot-Marie-Tooth disease group
(MD 1.90 seconds, favoring the training group, 95 % CI: -0.29 to 4.09) or the
myotonic dystrophy group (MD -0.80 seconds, favoring the control group, 95 % CI:
-5.29 to 3.69). In a trial of 65 participants with facio-scapulo-humeral muscular
dystrophy, 26 weeks of strength training did not significantly affect ankle strength.
After 1 year, the mean difference in maximum voluntary isometric contraction was
-0.43 kg, favoring the control group (95 %CI: -2.49 to 1.63) and the mean difference
in dynamic strength was 0.44 kg, favoring the training group (95 % CI: -0.89 to
1.77). The authors concluded that only 1 study, involving people with Charcot- Marie-
Tooth disease, demonstrated a statistically significant positive effect of strength
training. No effect of strength training was found in people with either myotonic
dystrophy or facio-scapulo-humeral muscular dystrophy. Surgery had no significant
effect in children with Duchenne muscular dystrophy and night splinting of the ankle
had no significant effect in people with Charcot-Marie-Tooth disease.
They stated that more evidence generated by methodologically sound studies is
needed.
In another Cochrane review, Rose et al (2010) evaluated the effect of interventions
to reduce or resolve ankle equinus in people with neuromuscular disease.
Randomized controlled trials evaluating interventions for increasing ankle
dorsiflexion ROM in neuromuscular disease. Outcomes included ankle dorsiflexion
ROM, functional improvement, foot alignment, foot and ankle muscle strength, health-
related quality of life, satisfaction with the intervention and adverse events. Two
authors independently selected papers, assessed trial quality and extracted data.
Four studies involving 149 participants met inclusion criteria for this review. Two
studies assessed the effect of night splinting in a total of 26 children and adults with
Charcot-Marie-Tooth disease type 1A. There were no statistically or clinically
significant differences between wearing a night splint and not wearing a night
splint. One study assessed the efficacy of prednisone treatment in 103 boys with
Duchenne muscular dystrophy. While a daily dose of prednisone at 0.75 mg/kg/day
resulted in significant improvements in some strength and function parameters
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compared with placebo, there was no significant difference in ankle ROM between
groups. Increasing the prednisone dose to 1.5 mg/kg/day had no significant effect
on ankle ROM. One study evaluated early surgery in 20 young boys with
Duchenne muscular dystrophy. Surgery resulted in increased ankle dorsiflexion
range at 12 months but functional outcomes favored the control group. By 24
months, many boys in the surgical group experienced a relapse of achilles tendon
contractures. The authors concluded that there is no evidence of significant benefit
from any intervention for increasing ankle ROM in Charcot-Marie-Tooth disease
type 1A or Duchenne muscular dystrophy. They stated that more research is
needed.
In a pilot study, Postans and colleagues (2010) investigated the feasibility of
applying the combination of dynamic splinting and neuromuscular electrical
stimulation (NMES) in order to improve wrist and elbow function, and ROM, in
children with upper limb contractures due to CP. A total of 6 children aged 7 to 16,
with contractures at the wrist or elbow, were recruited. Following a 12-week
baseline period all subjects underwent a 12-week treatment period where dynamic
splinting was used for 1 hour per day and combined with NMES for the second half
of the 1-hr treatment. A 12-week follow-up period then ensued. Upper limb
function was assessed with the Melbourne assessment, physical disability with the
Pediatric Evaluation of Disability Index and the Activity Scale for Kids, and quality of
life with the Pediatric Quality of Life Scale. Passive and active ROM at the wrist
and elbow were measured using manual and electrical goniometers. The
technique of using combined NMES and dynamic splinting was demonstrated to be
feasible and compliance with the intervention was good. There was an increase in
passive elbow extension in 2 subjects treated for elbow contractures, although no
accompanying change in upper limb function was reported. Wrist ROM improved
in 1 subject treated for wrist contracture. The findings of this pilot study need to be
validated by well-designed studies.
John et al (2011) stated that hallux limitus (HL) is a pathology of degenerative
arthritis in the first metatarsophalangeal joint (MTJ) of the great toe. Chief
complaints of HL include inflammation, edema, pain, and reduced flexibility. The
onset of HL commonly occurs after one of the two most common surgical
procedures for foot pathologies, a bunionectomy or a cheilectomy. These
investigators determined the effectiveness of dynamic splinting in treating patients
with post-operative hallux limitus, in a randomized, controlled trial. A total of 50
patients (aged 29 to 69 years) were enrolled after diagnosis of HL following
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surgery. The duration of this study was 8 weeks, and all patients received non-
steroidal anti-inflammatory drugs, orthotics, and instructions for a home exercise
program. Experimental patients were also treated with dynamic splinting for first
MTJ extension (60 mins, 3 times per day). The dependent variable was change in
active ROM (AROM). A repeated measures analysis of variance was used with
independent variables of patient categories, surgical procedure (cheilectomy versus
bunionectomy) and duration since surgery. There was a significant difference in
change of AROM for experimental versus control patients (p < 0.001, T = 4.224, n =
48); there was also a significant difference for patient treated within 2 months of
surgery (p = 0.0221). The authors concluded that dynamic splinting was effective
in reducing contracture of post-operative hallux limitus in this study; experimental
patients gained a mean 250 % improvement in AROM. This modality should be
considered for standard of care in treating post-operative hallux limitus.
Sameem et al (2011) stated that controversy exists as to which rehabilitation
protocol provides the best outcomes for patients after surgical repair of the extensor
tendons of the hand. These researchers determined which rehabilitation protocol
yields the best outcomes with respect to ROM and grip strength in extensor zones V-
VIII of the hand. A comprehensive literature review and assessment was undertaken
by 2 independent reviewers. Methodological quality of randomized controlled trials
(RCTs) and cohort studies was assessed using the Scottish Intercollegiate Guidelines
Network scale. A total of 17 articles were included in the final analysis (κ = 0.9). From
this total, 7 evaluated static splinting, 12 evaluated dynamic splinting, and 4 evaluated
early active splinting. Static splinting yielded "excellent/good" results ranging from 63
% (minimum) to 100 % (maximum) on the total active motion (TAM) classification
scheme and TAM ranging from 185° (minimum) to 258° (maximum) across zones V-
VIII. Dynamic splinting studies demonstrated a percentage of "excellent/good" results
ranging from 81 % (minimum) and 100 % (maximum) and TAM ranging from 214°
(minimum) and 261° (maximum). Early active splinting studies showed
"excellent/good" results ranging from 81 % (minimum) and 100 % (maximum). Only
1 study evaluated TAM in zones V-VIII, which ranged from 160° (minimum) and 165°
(maximum) when using 2 different early active modalities. The authors concluded that
the available level 3 evidence suggested better outcomes when using dynamic
splinting over static splinting. Moreover, they stated that additional studies comparing
dynamic and early active motion protocols are needed before a conclusive
recommendation can be made.
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Trismus refers to the spastic contraction of the muscles of mastication, which can
lead to mandibular hypomobility. Mandibular hypomobility is a condition in which
the patient lacks normal ROM in the temporomandibular joint (TMJ). Patients
suffering from this condition are unable to separate the maxilla and mandible
without pain, or simply are unable to open the mouth to the extent of functional
disability. They are unable to chew or eat normally or without pain, and may be
unable to speak normally or maintain proper oral hygiene. Severe jaw hypomobility
can lead to malnutrition, infection, and serious disability.
The Dynasplint Trismus System is designed to aid in restoring physical function in
patients suffering from joint or muscle stiffness and limited range ROM in the
posterior mandibular or TMJ region. These functional limitations can be caused by
a variety of conditions, such as: TMJ dysfunction, head and neck cancers, head
and neck surgery, radiation therapy, fractures, trauma, infection, burns,
congenital/developmental conditions, osteoarthritis, scleroderma, and others.
Stubblefield et al (2010) conducted a retrospective cohort study examining the
effectiveness of a dynamic jaw opening device (Dynasplint Trismus System [DTS])
as part of a multi-modal treatment strategy for trismus in 20 patients with head and
neck cancer. All patients underwent assessment by a board-certified physiatrist
and were referred to physical therapy for delivery of the DTS and instructed to
progress use of the DTS to 30 minutes 3 times a day. Additional modalities for the
treatment of trismus including pain medications and botulinum toxin injections were
prescribed as clinically indicated. Change in maximal interincisal distance (MID) as
documented in the medical record. The use of the DTS as part of multi-modal
therapy including physical therapy, pain medications, and botulinum toxin injections
as deemed clinically appropriate resulted in an overall improvement of the MID from
16.5 mm to 23.5 mm (p < 0.001). Patients who could comply with the treatment
recommendations for DTS treatment did better than those who could not, with an
improvement of the MID from 16 mm to 27 mm (p < 0.001) versus 17 mm to 22 mm
(p = 0.88).
In a retrospective clinical trial, Schulman and colleagues (2008) evaluated the effect
of the DTS (Dynasplint Systems Inc, Severna Park, MD) for patients recently
diagnosed with trismus following radiation therapy, dental treatment, oral surgery,
or following a neural pathology such as a stroke. The histories of 48 patient
(treated in 2006 to 2007) were reviewed, and divided into 4 cohort groups (radiation
therapy for head/neck cancer, dental treatment, oral surgery, or stroke), to measure
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the efficacy of this treatment's modality. Patients were prescribed the DTS after
diagnosis of trismus based on examination that showed less than 40 mm MID. The
DTS uses low-load, prolonged-duration stretch with replicable, dynamic tension to
achieve longer time at end ROM. Each patient used this device for 20 to 30 mins, 3
times per day. In this cohort case series the results showed that there was a
statistically significant difference within all patient groups (p < 0.0001; t = 10.3289),
but there was not a significant difference between groups (p = 0.374). The
biomechanical modality of DTS with a low-load, prolonged-duration stretch was
attributed to the success in reducing contracture in this study. This improved ROM
allowed patients to regain the eating, hygiene and speaking patterns they had
before developing trismus.
Guidelines from the International Society for Oral Oncology (2011) state that "[n]o
guideline [is] possible regarding use of Dynasplint® Trismus System in the reduction
of RT-induced trismus, although may have some benefit for reduction of contracture
of the muscles of mastication (Level of evidence III, Recommendation grade B)."
Furia et al (2013) evaluated the safety and effectiveness of dynamic splinting as it
is used to treat joint contracture in lower extremities, and determined if duration on
total hours of stretching had an effect on outcomes. Reviews of PubMed, Science
Direct, Medline, AMED, and EMBASE websites were conducted to identify the term
'contracture reduction' in manuscripts published from January 2002 to January
2012. Publications selected for inclusion were controlled trials, cohort studies, or
case series studies employing prolonged, passive stretching for lower extremity
contracture reduction. A total of 354 abstracts were screened and 8 studies (487
subjects) met the inclusion criteria. The primary outcome measure was change in
active ROM (AROM). The mean aggregate change in AROM was 23.5º in the 8
studies examined. Dynamic splinting with prolonged, passive stretching as home
therapy treatment showed a significant direct, linear correlation between the total
number of hours in stretching and restored AROM. No adverse events were
reported. The authors concluded that dynamic splinting is a safe and effective
treatment for lower extremity joint contractures. Joint specific stretching protocols
accomplished greater durations of end-range stretching that may be considered to
be responsible for connective tissue elongation.
Veltman et al (2015) performed a comprehensive review of the literature to evaluate
the best current evidence for non-operative treatment options for post-traumatic
elbow stiffness. These investigators performed a search of all studies on non-
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operative treatment for elbow stiffness in human adults. All articles describing non-
operative treatment of elbow stiffness, written in the English, German, French or
Dutch language, including human adult patients and with the functional outcome
reported were included in this study. A total of 8 studies (including 232 patients)
met the eligibility criteria and were included for data analysis and pooling. These
studies included 1 RCT and 7 retrospective cohort studies. Static progressive
splinting was evaluated in 160 patients. The average pre-splinting ROM of all
elbows was 72°, which improved by 36° after splinting to an average post-splinting
arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an
average pre-splinting ROM of 63°. The average improvement was 37° to an average
post-splinting arc of motion of 100°. The authors concluded that both dynamic
orthoses and static progressive splinting showed good results for the treatment of
elbow stiffness, regardless of etiology. The choice for one treatment over the other
is based on the preference of the surgeon and patient. These investigators
recommended continuing non-operative treatment with dynamic or static bracing for
12 months or until patients stop making progression in ROM of the elbow.
Dynamic Splinting to Improve Outcomes following Botulinum Toxin Injection for Treatment of Limb Spasticity
Mills and colleagues (2016) examined the quality of evidence from RCTs on the
effectiveness of adjunct therapies following botulinum toxin (BTX) injections for limb
spasticity. MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of
Controlled Trials electronic databases were searched for English language human
studies from 1980 to May 21, 2015. Randomized controlled trials evaluating
adjunct therapies post-BTX injection for treatment of spasticity were included. Of
the 268 studies screened, 17 met selection criteria. Two reviewers independently
assessed risk of bias using the Physiotherapy Evidence Database (PEDro) scale
and graded according to Sackett's levels of evidence. A total of 10 adjunct
therapies were identified. Evidence suggested that adjunctive use of ES, modified
constraint-induced movement therapy, physiotherapy (all Level 1), casting and
dynamic splinting (both Level 2) result in improved Modified Ashworth Scale scores
by at least 1 grade. There is Level 1 and 2 evidence that adjunctive taping,
segmental muscle vibration, cyclic functional ES, and motorized arm ergometer
may not improve outcomes compared with BTX injections alone. There is Level 1
evidence that casting is better than taping, taping is better than ES and stretching,
and extra-corporeal shock wave therapy is better than ES for outcomes including
the Modified Ashworth Scale, ROM and gait. All results are based on single
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studies. The authors concluded that there is high level evidence to suggest that
adjunctive therapies may improve outcomes following BTX injection. Moreover,
they stated that no results have been confirmed by independent replication; all
interventions would benefit from further study.
Flexionators and Extensionators
The shoulder flexionator (ERMI Shoulder Flexionater) is designed to isolate and
treat decreased glenohumeral abduction and external rotation. The device is
intended to addresses the needs of patients with excessive scar tissue. This
customizable device has biomechanically and anatomically located pads to focus
treatment on the glenohumeral joint, without stressing the other shoulder joints.
Once customized, the shoulder flexionator can be used by the patient at home
without assistance to perform serial stretching exercises, alternately stretching and
relaxing the scar tissue surrounding the glenohumeral joint. The device has 3
sections, the main frame, arm unit and pump unit. The shoulder flexionator was
listed with the FDA in 2001, and is Class I exempt.
The knee/ankle flexionator (ERMI Knee/Ankle Flexionater) is a self-contained
device that facilitates recovery from decreased range of motion of the knee and/or
ankle joints. The knee flexionator is designed to address the needs of patients with
arthrofibrosis (excessive scar tissue within and around a joint). The knee/ankle
flexionator is a variable load/variable position device that uses a hydraulic pump
and quick-release mechanism to allow patients to perform dynamic stretching
exercises in the home without assistance, alternately stretching and relaxing the
scar tissue surrounding affected joints. The knee/ankle flexionator includes a frame
to house hydraulic components, a pump handle and quick release valve for patient
control, supporting footplate and specially incorporated padded chair. The frame
attaches to a folding chair and is adjustable to accommodate treatment of either
extremity, or both extremities simultaneously. The load potential ranges from a few
ounces up to 500 foot-pounds. The knee/ankle flexionator was listed with the FDA
in 2002, and is Class 1 exempt.
The knee extensionator (ERMI Knee Extensionater) and elbow extensionator
(ERMI Shoulder Extensionater) provide serial stretching, using a patient-controlled
pneumatic device that can deliver variable loads to the affected joint. The
manufacturer claims that the knee and shoulder extensionators are the only
devices on the market that can “consistently stretch scar tissue, without causing
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vascular re-injury and thereby significantly reduce the need for additional
surgery” (ERMI, 2002). The extensionator telescopes to the appropriate length,
and is applied to the leg with Velcro straps. During a typical training session, the
joint is stretched from 1 to 5 mins, and then is allowed to recover for an equal
length of time, and is then stretched again. A typical training session lasts 15 mins,
and the usual prescription is to perform 4 to 8 training sessions per day. There are
no controlled published peer-reviewed studies on the effectiveness of the
knee/ankle flexionator, the shoulder flexionator, the knee extensionator, or the
elbow extensionator. There is insufficient scientific evidence to support the
manufacturer's claims that these home-based stretching devices can consistently
stretch scar tissues without causing vascular re-injury and thus significantly reduce
the need for additional surgery (e.g., surgery for arthrofibrosis after knee surgery).
Furthermore, there is a lack of published data to support the claim that these
devices can reduce the need for surgery manipulation under anesthesia.
Therefore, extensionator and flexionator devices are considered experimental and
investigational.
The Elite Seat is a portable knee hyper-extension rehabilitation device that is used
to correct the loss of knee extension, increase ROM, decrease knee pain and
improve function. However, there is insufficient evidence to support the use of the
Elite Seat.
Joint Active Systems (JAS) Splints
JAS splints (e.g., JAS Elbow, JAS Shoulder, JAS Ankle, JAS Knee, JAS Wrist, and
JAS Pronation-Supination) (Joint Active Systems, Effingham, IL) use static
progressive stretch. According to the manufacturer's website, "Static Progressive
Stretch (SPS) and dynamic splinting are two fundamentally different techniques
used to permanently lengthen shortened connective tissues." Typically, the patient
sets the device angle at the beginning of the session, and every several mins the
angle is increased. A typical session lasts 30 mins, and sessions may be repeated
up to 3 times per day. Unlike the flexionator, the joint is not allowed to recover
during the stretch period. According to the manufacturer, JAS systems are
designed to simulate manual therapy. The manufacturer claims that JAS devices
eliminate the risk of joint compression, provide soft tissue distraction, and “achieve
permanent soft tissue lengthening in a short amount of time.” Published reports of
the effectiveness of JAS splints are limited to case reports and small
uncontrolled observational studies. There are no prospective randomized studies
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demonstrating that the addition of the use of JAS devices to the physical therapy
management of patients with joint injury or surgery significantly improves patient's
clinical outcomes. Thus, JAS splints are considered experimental and
investigational.
EZ Turnbuckle Orthosis (Joint Active Systems Orthosis)
Green and McCoy (1979) reported the findings of 15 patients with acute flexion
contractures of the elbow after injuries or operations were treated with a turnbuckle
splint. Satisfactory correction was achieved in 12 patients. An average reduction in
deformity of about 37 degrees was recorded after an average treatment period of
20 weeks. The treatment was unsuccessful in 3 patients with severe intra-articular
damage because the splint caused excessive discomfort. The average
improvement in the arc of motion of the elbow was approximately 43 degrees. This
was a small study (n = 15); its findings need to be validated in well-designed
studies.
Gelinas et al (2000) treated 22 patients with an elbow contracture using a static
progressive turnbuckle splint for a mean of 4.5 +/- 1.8 months. All had failed to
improve with supervised physiotherapy and splinting. The mean range of flexion
before splintage was from 32 +/- 10 degrees to 108 +/- 19 degrees and afterwards
from 26 + 10 (p = 0.02) to 127 +/- 12 degrees (p = 0.0001). A total of 11 patients
gained a “functional arc of movement”, defined as at least 30 degrees to 130
degrees. In 8 patients movement improved with turnbuckle splinting, but the
functional arc was not achieved; 6 of these were satisfied and did not wish to
proceed with surgical treatment and 2 had release of the elbow contracture. In 3
patients, movement did not improve with the use of the turnbuckle splint and 1
subsequently had surgical treatment. The authors concluded that these findings
showed that turnbuckle splinting is a safe and effective treatment that should be
considered in patients whose established elbow contractures have failed to respond
to conventional physiotherapy. This was a small study (n = 22); its findings need to
be validated in well-designed studies.
Bhat et al (2010) evaluated the effectiveness of a turnbuckle orthosis as a means of
improving the range of motion (ROM) in patients with elbow stiffness. A total of 17
males and 11 females aged 8 to 68 (mean of 32) years underwent static
progressive stretching using a turnbuckle orthosis for elbow stiffness secondary to
trauma or surgery. Patients were instructed to wear the orthosis during the daytime
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for a mean of 15 hours and remove it during sleep as well as at breakfast, lunch,
and dinner. One hour of ROM exercise was performed during each break.
Patients were followed-up every month and ROM was recorded with a standard
goniometer. The use of orthosis was discontinued when there was no further
improvement; ROM exercise was encouraged thereafter to maintain the results.
The extent of flexion contracture and ROM before and after the treatment were
compared. The mean duration of orthosis use was 5 (range of 3 to 8) months. The
mean flexion contracture reduced from 59 degrees to 27 degrees and ROM
improved from 57 degrees to 102 degrees; 19 of the patients achieved functional
ROM. Improvement in ROM was excellent in 6 patients, good in 11, satisfactory in
7; at the end of follow-up (mean of 29 months), the results were maintained or
improved further in 20 patients (even in those with long-standing contractures).
The authors concluded that static progressive stretching using a turnbuckle orthosis
is reliable and cost-effective for treating elbow stiffness. Again, this was a small
study (n = 28); its findings need to be validated in well-designed studies.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
29126 Application of short arm splint (forearm to hand); dynamic [not covered
for carpal tunnel syndrome]
29131 Application of finger splint; dynamic
Other CPT codes related to the CPB:
25515 Open treatment of radial shaft fracture, includes internal fixation, when
performed
29105 Application of long arm splint (shoulder to hand)
29505 Application of long leg splint (thigh to ankle or toes)
29515 Application of short leg splint (calf to foot)
97760 Orthotic(s) management and training (including assessment and fitting
when not otherwise reported), upper extremity(s), lower extremity(s)
and/or trunk, each 15 minutes
HCPCS codes covered if selection criteria are met:
Advance Dynamic ROM, Pro-glide dynamic ROM, SaeboReach, EZ Turnbuckle Orthosis:
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Code Code Description
No specific code
E1800 Dynamic adjustable elbow extension/flexion device, includes soft
interface material
E1802 Dynamic adjustable forearm pronation/supination device, includes soft
interface material [not covered for carpal tunnelsyndrome]
E1805 Dynamic adjustable wrist extension/flexion device, includes soft
interface material [not covered for carpal tunnel syndrome]
E1810 Dynamic adjustable knee extension/flexion device, includes soft
interface material
E1825 Dynamic adjustable finger extension/flexion device, includes soft
interface material
E1830 Dynamic adjustable toe extension/flexion device, includes soft interface
material
E1831 Static progressive stretch toe device, extension and/or flexion, with or
without range of motion adjustment, includes all components and
accessories
HCPCS codes not covered for indications listed in the CPB:
ERMI Knee/Ankle Flexionator, MPJ Extensionator, ERMI Elbow Extensionator , ERMI Shoulder Flexionator, ERMI Knee Extensionator, SaeboMas, JAZ EZ:
No specific code
E1801 Static progressive stretch elbow device, extension and/or flexion, woth
or without range of motion adjustment, includes all components and
accessories
E1806 Static progressive stretch wrist device, flexion and/or extension, with or
without range of motion adjustment, includes all components and
accessories
E1811 Static progressive stretch knee device, extension and/or flexion, with or
without range of motion adjustment, includes all components and
accessories
E1815 Dynamic adjustable ankle extension/flexion device, includes soft
interface material
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Code Code Description
E1816 Static progressive stretch ankle device, flexion and/or extension, with or
without range of motion adjustment, includes all components and
accessories
E1818 Static progressive stretch forearm pronation/supination device, with or
without range of motion adjustment, includes all components and
accessories
E1821 Replacement soft interface material/cuffs for bi-directional static
progressive stretch device
E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes
soft interface material
E1841 Static progressive stretch shoulder device, with or without range of
motion adjustment, includes all components and accessories
Other HCPCS codes related to the CPB:
J0585 Injection, onabotulinumtoxinA, 1 unit
J0586 Injection, abobotulinumtoxinA, 5 units
J0587 Injection, rimabotulinumtoxinB, 100 units
J0588 Injection, incobotulinumtoxinA, 1 unit ICD
10 codes not covered for indications listed in the CPB: G35
Multiple sclerosis
G56.00 - G56.03 Carpal tunnel syndrome
G71.00 - G72.9,
G73.7
Primary disorders of muscles and other and unspecified myopathies
G80.0 - G80.9 Cerebral palsy
G97.31 - G97.32 Intraoperative hemorrhage and hematoma of a nervous system organ or
structure complicating a procedure
I63.00 - I66.9 Occlusion and stenosis of precerebral and cerebral arteries [stroke]
I97.810 -
I97.821
Intraoperative and postprocedural cerebrovascular infarction
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M21.379
M72.2
R25.2
S06.0x0+ -
S06.9x9+
S09.90x+
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The above policy is based on the following references:
1. Halar EM, Bell KR. Contracture and other deleterious effects of immobility. In:
Rehabilitation Medicine: Principles and Practice. 2nd ed. JA DeLisa, ed.
Philadelphia, PA: J.B. Lippincott Co.; 1993; Ch. 33: 681-699.
2. McClure PW, Blackburn LG, Dusold C. The use of splints in the treatment
of joint stiffness: Biologic rationale and an algorithm for making clinical
decisions. Phys Ther. 1994;74(12):1101-1107.
3. Hepburn GR, Crivelli KJ. Use of elbow Dynasplint for reduction of elbow
flexion contractures: A case study. J Orthop Sports Phys Ther. 1984;5
(5):269-274.
4. Richard RL. Use of the Dynasplint to correct elbow flexion burn
contracture: A case report. J Burn Care Rehabil. 1986;7(2):151-152.
5. Mackay-Lyons M. Low-load, prolonged stretch in treatment of elbow
flexion contractures secondary to head trauma: A case report. Phys Ther.
1989;69(4):292-296.
6. Richard RL, Jones LM, Miller SF, Finley RK Jr. Treatment of exposed bilateral
Achilles tendons with use of the Dynasplint. Phys Ther. 1988;68(6):989
991.
7. Hepburn GR. Case studies: Contracture and stiff joint management with
Dynasplint. J Orthop Sports Phys Ther. 1987;8:498-504.
8. Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of
knee flexion contractures in nursing home residents. Phys Ther. 1995;75
(10):886-897.
9. Chow JA, Thomes LJ, Dovelle S, et al. Controlled motion rehabilitation after
flexor tendon repair and grafting. J Bone Joint Surg. 1988;70(4):591-595.
10. Chow JA, Dovelle S, Thomes LJ, et al. A comparison of results of extensor
tendon repair followed by early controlled mobilization versus static
immobilization. J Hand Surg. 1989;14(1):18-20.
11. Browne EZ Jr, Ribik CA. Early dynamic splinting for extensor tendon
injuries. J Hand Surg [Am]. 1989;14(1):72-76.
12. Kerr CD, Burczak JR. Dynamic traction after extensor tendon repair in zone
6, 7, and 8: A retrospective study. J Hand Surg [Br]. 1989;14(1):21-25.
13. Saldana MJ, Chow JA, Gerbino P 2nd, et al. Further experience in
rehabilitation of zone II flexor tendon repair with dynamic traction
splinting. Plast Reconstr Surg. 1991;87(3):543-546.
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14. Hung LK, Chan A, Chang J, et al. Early controlled active mobilization with
dynamic splintage for treatment of extensor tendon injuries. J Hand Surg
[Am]. 1990;15 (2):251-257.
15. Saldana MJ, Choban S, Westerbeck P, Schacherer TG. Results of acute zone
III extensor tendon injuries treated with dynamic extension splinting. J
Hand Surg [Am]. 1991;16 (6):1145-1150.
16. Rives K, Gelberman R, Smith B, Carney K. Severe contractures of the
proximal interphalangeal joint in Dupuytren's disease: Results of a
prospective trial of operative correction and dynamic extension splinting. J
Hand Surg [Am]. 1992;17 (6):1153-1159.
17. May EJ, Silfverskiold KL, Sollerman CJ. The correlation between controlled
range of motion with dynamic traction and results after flexor tendon
repair in zone II. J Hand Surg [Am]. 1992;17 (6):1133-1139.
18. Blair WF, Steyers CM. Extensor tendon injuries. Orthop Clin North Am.
1992;23(1):141-148.
19. Center for Medicare and Medicaid Services (CMS). Payment and coding
determinations for new durable medical equipment. CMS Public Meeting
Agenda. Baltimore, MD: CMS; June 17, 2002. Available
at: http://www.hcfa.gov/medicare/jun2dme.pdf. Accessed July 25, 2002.
20. ERMI, Inc. Insurance Provider Information Folder. Decatur, GA: ERMI; 2002.
21. Bonutti PM, Windau JE, Ables BA, et al. Static progressive stretch to
reestablish elbow range of motion. Clin Orthop. 1994;303:128-134.
22. Steffan TM, Mollinger LA. Low-load, prolonged stretch in the treatment of
knee flexion contractures in nursing home residents. Phys Ther.
1995;75:886-897.
23. Jansen CM, Windau JE, Bonutti PM, et al. Treatment of a knee contracture
using a knee orthosis incorporating stress-relaxation techniques. Phys
Ther. 1996;76(2):182-186.
24. Cohen EJ. Adjunctive therapy devices: Restoring ROM outside of the clinic.
Phys Ther Magazine. 1995 Mar:10-13.
25. Crosby CA, Wehbe MA. Early protected motion after extensor tendon
repair. J Hand Surg [Am]. 1999;24(5):1061-1070.
26. Joint Active Systems, Inc. JAS OnLine [website]. Effingham, IL: Joint Active
Systems; 2002. Available at: http://www.jointactivesystems.com. Accessed
September 11, 2002.
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27. Khandwala AR, Webb J, Harris B, et al. A comparison of dynamic extension
splinting and controlled active mobilization of complete divisions of
extensor tendons in zones 5 and 6. J Hand Surg [Br]. 2000;25(2):140-146.
28. Hewitt B, Shakespeare D. Flexion vs. extension: A comparison of post
operative total knee arthroplasty mobilisation regimes. Knee. 2001;8
(4):305-309.
29. Harvey L, Herbert R, Crosbie J. Does stretching induce lasting increases in
joint ROM? A systematic review. Physiother Res Int. 2002;7(1):1-13.
30. Branch TP, Karsch RE, Mills TJ, Palmer MT. Mechanical therapy for loss of
knee flexion. Am J Orthop. 2003;32(4):195-200.
31. Washington State Department of Labor and Industries, Office of the
Medical Director. ERMI Flexionators and Extensionators. Health
Technology Assessment Brief. Olympia, WA: Washington State
Department of Labor and Industries; updated June 6, 2003. Available
at: www.lni.wa.gov/ClaimsInsurance/Files/OMD/ermi.pdf. Accessed June 3,
2004.
32. Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving
joint range of motion: A systematic review. J Hand Ther. 2004;17(2):118
131.
33. Thien TB, Becker JH, Theis J-C. Rehabilitation after surgery for flexor
tendon injuries in the hand. Cochrane Database Syst Rev. 2004;
(4):CD003979.
34. Joint Active Systems, Inc. Principles of static progressive stretch. JAS
Professionals. Joint Active Systems: The Static Progressive Stretch
Company [website]. Effingham, IL: Joint Active Systems; 2008. Available at:
http://www.jointactivesystems.com/pf_principles.html. Accessed May 29,
2008.
35. Germann G, Wagner H, Blome-Eberwein S, Karle B, Wittemann. Early
dynamic motion versus postoperative immobilization in patients with
extensor indicis proprius transfer to restore thumb extension: A
prospective study. J Hand Surg. 2001;26A:1111-1115.
36. Chester DL, Beale S, Beveridge L, et al. A prospective, controlled,
randomized trial comparing early active extension with passive extension
using a dynamic splint in the rehabilitation of repaired extensor tendons. J
Hand Surg (Br). 2002; 27N(3):283-288.
37. Bruner A, Whittemann A, Jester A, et al. Dynamic splinting after extensor
tendon repair in zones V to VII. J Hand Surg (Br). 2003;28B(3):224-227.
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38. Greer MA, Miklos-Essenberg ME. Early mobilization using dynamic
splinting with acute triceps tendon avulsion. J Hand Ther. 2005;18:365-371.
39. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting for simple
zone V and zone VI extensor tendon repairs: A prospective, randomized,
controlled study. Plast Recontr Surg. 2005;115:482-487.
40. Ring D, Hotchkiss RN, Guss D, Jupiter JB. Hinged elbow external fixation for
severe elbow contracture. J Bone Joint Surg Am. 2005;87(6):1293-1296.
41. Farmer SE, Woollam PJ, Patrick JH, et al. Dynamic orthoses in the
management of joint contracture. J Bone Joint Surg Br. 2005;87(3):291-295.
42. Doornberg JN, Ring D, Jupiter JB. Static progressive splinting for
posttraumatic elbow stiffness. J Orthop Trauma. 2006;20(6):400-404.
43. Tan O, Atik B, Dogan A, et al. Postoperative dynamic extension splinting
compared with fixation with Kirschner wires and static splinting in
contractures of burned hands: A comparative study of 57 cases in 9 years.
Scand J Plast Reconstr Surg Hand Surg. 2007;41(4):197-202.
44. Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgical versus non-surgical
treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;
(3):CD001552.
45. Goodyear-Smith F, Arroll B. What can family physicians offer patients with
carpal tunnel syndrome other than surgery? A systematic review of
nonsurgical management. Ann Fam Med. 2004;2(3):267-273.
46. Graham RG, Hudson DA, Solomons M, Singer M. A prospective study to
assess the outcome of steroid injections and wrist splinting for the
treatment of carpal tunnel syndrome. Plast Reconstr Surg. 2004;113
(2):550-556.
47. Larson D, Jerosch-Herold C. Clinical effectiveness of post-operative
splinting after surgical release of Dupuytren's contracture: A systematic
review. BMC Musculoskelet Disord. 2008;9:104.
48. Sackley C, Disler PB, Turner-Stokes L, et al. Rehabilitation interventions for
foot drop in neuromuscular disease. Cochrane Database Syst Rev. 2009;
(3):CD003908.
49. Evans PJ, Nandi S, Maschke S, et al. Prevention and treatment of elbow
stiffness. J Hand Surg Am. 2009;34(4):769-778.
50. Lucado AM, Li Z. Static progressive splinting to improve wrist stiffness
after distal radius fracture: A prospective, case series study. Physiother
Theory Pract. 2009;25:297-309.
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51. Bonutti PM, McGrath MS, Ulrich SD, et al. Static progressive stretch for the
treatment of knee stiffness. Knee. 2008;15(4):272-276.
52. McGrath MS, Ulrich SD, Bonutti PM, et al. Evaluation of static progressive
stretch for the treatment of wrist stiffness. J Hand Surg Am. 2008;33
(9):1498-1504.
53. McGrath MS, Bonutti PM, Marker DR, et al. Static progressive splinting for
restoration of rotational motion of the forearm. J Hand Ther. 2009;22 (1):3
9.
54. Sharma NK, Loudon JK. Static progressive stretch brace as a treatment of
pain and functional limitations associated with plantar fasciitis: a pilot
study. Foot Ankle Spec. 2010;3:117-124.
55. Bonutti PM, Marulanda GA, McGrath MS, et al. Static progressive stretch
improves range of motion in arthrofibrosis following total knee
arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):194-199.
56. Ulrich SD, Bonutti PM, Seyler TM, et al. Restoring range of motion via
stress relaxation and static progressive stretch in posttraumatic elbow
contractures. J Shoulder Elbow Surg. 2010;19(2):196-201.
57. Rose KJ, Burns J, Wheeler DM, North KN. Interventions for increasing ankle
range of motion in patients with neuromuscular disease. Cochrane
Database Syst Rev. 2010;(2):CD006973.
58. Berner SH, Willis FB. Dynamic splinting in wrist extension following distal
radius fractures. J Orthop Surg Res. 2010;5:53.
59. Sheridan L, Lopez A, Perez A, et al. Plantar fasciopathy treated with
dynamic splinting: A randomized controlled trial. J Am Podiatr Med Assoc.
2010;100(3):161-165.
60. Postans N, Wright P, Bromwich W, et al. The combined effect of dynamic
splinting and neuromuscular electrical stimulation in reducing wrist and
elbow contractures in six children with cerebral palsy. Prosthet Orthot Int.
2010;34(1):10-19.
61. John MM, Kalish S, Perns SV, Willis FB. Dynamic splinting for postoperative
hallux limitus: A randomized, controlled trial. J Am Podiatr Med Assoc.
2011;101(4):285-288.
62. Sameem M, Wood T, Ignacy T, et al. A systematic review of rehabilitation
protocols after surgical repair of the extensor tendons in zones V-VIII of
the hand. J Hand Ther. 2011;24(4):365-372.
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63. Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early
motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand
Surg Am. 2012;37(5):933-937.
64. Shulman DH et al. Treating trismus with dynamic splinting: a cohort, case
series. Adv Ther. 2008;25(1): 9-16.
65. Stubblefield MD et al. A preliminary report on the efficacy of a dynamic
jaw opening device (dynasplint trismus system) as part of the multimodal
treatment of trismus in patients with head and neck cancer. Arch Phys
Med Rehabil. 2010;91(8): 1278-1282.
66. Kitis A, Ozcan RH, Bagdatli D, et al. Comparison of static and dynamic
splinting regimens for extensor tendon repairs in zones V to VII. J Plast
Surg Hand Surg. 2012;46(3-4):267-271.
67. Lindenhovius AL, Doornberg JN, Brouwer KM, et al. A prospective
randomized controlled trial of dynamic versus static progressive elbow
splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am. 2012;94
(8):694-700.
68. Stephenson JJ, Quimbo RA, Gu T. Knee-attributable medical costs and risk
of re-surgery among patients utilizing non-surgical treatment options for
knee arthrofibrosis in a managed care population. Curr Med Res Opin.
2010;26(5):1109-1118.
69. Uhl TL, Jacobs CA. Torque measures of common therapies for the
treatment of flexion contractures. J Arthroplasty. 2011;26(2):328-334.
70. Dempsey AL, Mills T, Karsch RM, Branch TP. Maximizing total end range
time is safe and effective for the conservative treatment of frozen
shoulder patients. Am J Phys Med Rehabil. 2011;90(9):738-745.
71. Papotto BA, Mills T. Treatment of severe flexion deficits following total
knee arthroplasty: A randomized clinical trial. Orthop Nurs. 2012;31(1):29
34.
72. International Society for Oral Oncology (ISOO), Multinational Association
of Supportive Care in Cancer (MASCC), Oral Cancer Study Group. Evidence-
Based Management Strategies for Oral Complication from Cancer
Treatment. Hillerød, Denmark: MASCC; 2011.
73. Furia JP, Willis FB, Shanmugam R, Curran SA. Systematic review of
contracture reduction in the lower extremity with dynamic splinting. Adv
Ther. 2013;30(8):763-770.
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74. Veltman ES, Doornberg JN, Eygendaal D, et al. Static progressive versus
dynamic splinting for posttraumatic elbow stiffness: A systematic review of
232 patients. Arch Orthop Trauma Surg. 2015;135(5):613-617.
75. Green DP, McCoy H. Turnbuckle orthotic correction of elbow-flexion
contractures after acute injuries. J Bone Joint Surg Am. 1979;61(7):1092
1095.
76. Gelinas JJ, Faber KJ, Patterson SD, King GJ. The effectiveness of turnbuckle
splinting for elbow contractures. J Bone Joint Surg Br. 2000;82(1):74-78.
77. Bhat AK, Bhaskaranand K, Nair SG. Static progressive stretching using a
turnbuckle orthosis for elbow stiffness: A prospective study. J Orthop Surg
(Hong Kong). 2010;18(1):76-79.
78. Mills PB, Finlayson H, Sudol M, O'Connor R. Systematic review of adjunct
therapies to improve outcomes following botulinum toxin injection for
treatment of limb spasticity. Clin Rehabil. 2016;30(6):537-548.
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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan
benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial,
general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care
services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in
private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible
for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to
change.
Copyright © 2001-2019 Aetna Inc.
http://www.aetna.com/cpb/medical/data/400_499/0405.html 06/28/2019
AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0405 Mechanical
Stretching Devices for Contracture and Joint Stiffness
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania updated 03/12/2019
Recommended