CPM Helps Patients Regain Motion Before Strength

by Bill McGovern

After joint surgery, a patient's range of motion is the first function to regain, according to Dean Zieglar, MD, an orthopedic surgeon at the Blount Orthopedic Clinic, Milwaukee. Zieglar prescribes continuous passive motion (CPM) because it enablespatients to get back quickly-or never lose-good motion. "I use it for almost all of my outpatient shoulder surgeries, whenever I am going into the joint and it is not a labral repair or an instability case," he says. Zieglar also uses CPM followingdistal clavicle excisions and acromioplasties, if a rotator cuff repair is not done.

At the Center for Orthopaedics and Sports Medicine in Marietta, Ga, Rick Hammesfahr, MD, routinely prescribes CPM following total knee replacements, ligament reconstructions, and fractures, "procedures that are high risk for developing stiffness,"he says. CPM has also produced significant benefits following newer articular cartilage resurfacing procedures that result from isolated chip fractures on the ends of bone. "CPM not only helps prevent stiffness, but promotes nutrition of the articularcartilage that you are trying to heal," he says.

The benefits of CPM are recognized, although quantifying its value has been difficult. Its use early in recovery, Hammesfahr says, has a significant impact overall. "If you look at people who use CPM very early versus those who do not, there is aquicker, less costly rehab process."

Capitalizing on the 2 to 8 weeks immediately after surgery with passive stretching and movement before restrengthening muscle is significant, according to Zieglar. "Some patients are put in a sling for 4 to 6 weeks after rotator cuff repairs. Thenyou are fighting pain and stiffness and a weakened muscle after weeks of no motion."

CPM keeps the joint region stretched and warm, increasing blood flow and elasticity. "Patients get their motion back faster, they are off crutches sooner," Hammesfahr says. They also find that it relaxes the area and provides pain relief.

After setting up and training patients in the CPM machine before surgery, Zieglar begins them on CPM immediately post surgery, "that day, if they get home in time, or the next day for sure," he says. Patients are recommended to spend 4 to 6 hours aday in the machine. Most divide up the therapy an hour at a time into hour-long segments.

Additional increased motion and stretching exercises are demonstrated to patients during visits in the first and third weeks following surgery. With good motion after the first 3 weeks following the procedure, patients are well ahead in the healingcurve when they begin physical therapy. "Up until that time, they should not be doing any active motion, just passive motion and stretching," Zieglar says. "CPM gets the area jump-started in healing and ultimately we can avoid a lot of therapy."

In the past, managed care companies eyed CPM with cost-cutting scrutiny. The mistake, Hammesfahr says, was thinking money saved by eliminating CPM would outweigh money saved in the duration of physical therapy or additional surgeries if scar tissuedeveloped. Attaining 110° to 120° of motion prior to physical therapy is usually the goal, he adds, and while many procedures have become more packaged, CPM's use varies at his clinic. "It depends a lot on the procedure," he says.

Studies have also been unreliable in determining CPM's impact on healing the joint. Most have looked at patients 1 or 2 years after surgery, another mistake according to these physicians. Accurate short-term studies require testing a singlesurgical procedure, as well as splitting patients into those who receive and those who do not receive CPM. Good patient pools are difficult to attain and the ethical issues are obvious, Zieglar says. "Most physicians can't justify withholding therapy."

Studies have shown CPM's value in pain reduction and its benefits after certain procedures. "Articular surface injury studies done 20 years ago showed that CPM therapy is beneficial for articular cartilage healing," Hammesfahr says. The number andduration of prescribed medications are also reduced because tightness is lessened.

Smaller, informal studies of the overall benefits of CPM have convinced Hammesfahr, as well as many insurance companies. Letters of medical necessity, common 5 years ago, are much less common today. "I probably do one a year now. It is not a realissue anymore," he says.

While most HMOs have tightened coverage for both CPM and physical therapy following some procedures, preferred provider groups have followed the lead of companies providing workers' compensation coverage in offering CPM. "Workers' compensationproviders are very good at covering this therapy because they recognize that return to work is faster," Zieglar says.

The ability to shorten recovery time by 2 months is significant in return-to-work claims. Getting a patient back to work in 3 months rather than 4 to 6 months is important to everyone, he says. "There is a huge amount of money saved, and thepatient is back and healthy."

The end costs in time, pain management, and physical therapy are reduced. Some patients require very little or no physical therapy, just stretching and time in the CPM machine, Zieglar adds. "The people that I have seen that get stiff are miserablefor 2 to 8 weeks until they can get some therapy to loosen up again."

Fighting that stiffness early also eliminates a setback in what PTs are trying to do-strengthen muscle around the joint. The result, Zieglar says, benefits everyone. Patients benefit because they are active in less time, payors pay less, andtherapists end up with a patient at 6 to 8 weeks who has good passive motion. "Now they can start working on re-strengthening and not have to start with a patient who is still very stiff."

Bill McGovern is a contributing writer for Orthopedic Technology Review.

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