Continuous Passive Motion (CPM) Device
Durable Medical Equipment
© Blue Cross and Blue Shield of Montana
Current Effective Date:
July 18, 2013
Original Effective Date:
January 01, 1988
April 18, 2013
August 25, 2004; March 1, 2010; March 16, 2011; August 17, 2012; April 17, 2013
Physical therapy of joints following surgery focuses both on passive motion to restore mobility and active exercises to restore strength. While passive motion can be administered by a therapist, continuous passive motion (CPM) devices have also been used. CPM is thought to improve recovery by stimulating the healing of articular tissues and circulation of synovial fluid; reduce local edema; and prevent adhesions, joint stiffness or contractures, or cartilage degeneration. CPM has been most thoroughly investigated in the knee, particularly after total knee arthroplasty (TKA) or ligamentous or cartilage repair, but its acceptance in the knee joint has created interest in extrapolating this experience to other weight-bearing joints (i.e., hip, ankle, metatarsals) and non-weight-bearing joints (i.e., shoulder, elbow, metacarpals, and interphalangeal joints). Use of CPM in stroke and burn patients is also being explored.
The device moves the joint (e.g., flexion/extension), without patient assistance, continuously for extended periods of time, i.e., up to 24 hours/day. An electrical power unit is used to set the variable range of motion (ROM) and speed. The initial settings for ROM are based on a patient’s level of comfort, and other factors that are assessed intra-operatively. The ROM is increased by 3–5 degrees per day, as tolerated. The speed and ROM can be varied, depending on joint stability. The use of the devices may be initiated in the immediate postoperative period and then continued at home for a variable period of time.
BCBSMT may consider C
- Under conditions of low postoperative mobility or inability to comply with rehabilitation exercises following a total knee arthroplasty (TKA) or TKA revision. This may include patients with complex regional pain syndrome (reflex sympathetic dystrophy), extensive arthrofibrosis or tendon fibrosis, or physical, mental or behavioral inability to participate in active physical therapy. Use of the CPM device must begin within 48 hours of the surgical procedure (or on discharge from facility following the procedure) and may continue for ONLY up to 21 days postoperatively. OR
- For up to 6 weeks during the non-weight bearing rehabilitation period following intra-articular cartilage repair procedures of the knee (e.g., microfracture, osteochondral grafting, autologous chondrocyte implantation, treatment of osteochondritis dissecans, repair of tibial plateau fractures, reconstruction of the anterior cruciate ligament [ACL]).
337.22, 715.16, 715.26, 715.36, 715.96, 716.16, 717.83, 718.06, 718.56, 718.86, 719.86, 732.7, 821.20-821.39, 822.0-822.1, 823.00, 823.10, 959,7, V43.65 , V54.81
G57.70-G57.72, G90.521-G90.529, M12.561-M12.569, M17.0-M17.9, M23.50-M23.52, M23.8x1-M23.92, M24.661 - M24.669, M93.261 - M93.269, S72.401A - S72.499S, S82.001A - S82.099S, S82.101A - S82.199S, S89.90xA - S89.92xS, Z47.1, Z96.651 - Z96.659
E0935, E0936, E1399
- Salter RB. The biologic concept of continuous passive motion of synovial joints. The first 18 years of basic research and its clinical application. Clin Orthop Relat Res 1989; (242):12-25.
- Gelberman RH, Nunley JA, Osterman AL et al. Influences on the protected passive mobilization interval on flexor tendon healing. A prospective randomized clinical study. Clin Orthop 1991; 264:189- 96.
- McInnes, J., Larson, M.G., et al. A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. Journal of the American Medical Association (JAMA) (1992) 268(11):1423-8.
- Kumar PJ, McPherson EJ, Dorr LD et al. Rehabilitation after total knee arthroplasty: a comparison of 2 rehabilitation techniques. Clin Orthop 1996; 331:93-101.
- Raab MG, Rzeszutko D, O'Connor W et al. Early results of continuous passive motion after rotator cuff repair: a prospective, randomized, blinded, controlled study. Am J Orthop (Belle Mead NJ) 1996; 25(3):214-20.
- Pope RO, Corcoran S, McCaul K et al. Continuous passive motion after primary total knee arthroplasty. Does it offer any benefits? J Bone Joint Surg Br 1997; 79(6):914-7.
- Continuous Passive Motion as an Adjunct to Physical Therapy for Joint Rehabilitation. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1997 January) 11(20):1-15.
- Yashar AA, Venn-Watson E, Welsh T et al. Continuous passive motion with accelerated flexion after total knee arthroplasty. Clin Orthop 1997; 345:38-43.
- Ring D, Simmons BP, Hayes M. Continuous passive motion following metacarpophalangeal joint arthroplasty. J Hand Surg [Am] 1998; 23(3):505-11.
- Lastayo, P.C., et al. Continuous passive motion after repair of the rotator cuff. A prospective outcome study. Journal of Bone and Joint Surgery - American Volume (1998 July) 80(7):1002-11.
- Worland, R.L., et al. Home continuous passive motion machine versus professional physical therapy following total knee replacement. Journal of Arthroplasty (1998 October) 13(7):784-7.
- Simkin, P.A., et al. Continuous passive motion for osteoarthritis of the hip: a pilot study. Journal of Rheumatology (1999 September) 26(9):1987-91.
- Chen B, Zimmerman JR, Soulen L et al. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil 2000; 79(5):421-6.
- MacDonald SJ, Bourne RB, Rorabeck CH et al. Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop 2000; 380:30-5.
- Milne, S., Brosseau, L., et al. Continuous passive motion following total knee arthroplasty. Cochrane Database System Review (2003) (2):CD004260.
- Brosseau, L., Milne, S., et al. Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. Journal of Rheumatology (2004 November) 31(11):2251-64.
- Browne JE, Anderson AF, Arciero R et al. Clinical outcome of autologous chondrocyte implantation at 5 years in US subjects. Clin Orthop Relat Res 2005; (436):237-45.
- Lynch D, Ferraro M, Krol J et al. Continuous passive motion improves shoulder joint integrity following stroke. Clin Rehabil 2005; 19(6):594-9.
- Zeifang F, Carstens C, Schneider S et al. Continuous passive motion versus immobilisation in a cast after surgical treatment of idiopathic club foot in infants: a prospective, blinded, randomised, clinical study. J Bone Joint Surg Br 2005; 87(12):1663-5.
- Denis M, Moffet H, Caron F et al. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Phys Ther 2006; 86(2):174-85.
- Leach W, Reid J, Murphy F. Continuous passive motion following total knee replacement: a prospective randomized trial with follow-up to 1 year. Knee Surg Sports Traumatol Arthrosc 2006; 14(10):922-6.
- Kasten P, Geiger F, Zeifang F et al. Compliance with continuous passive movement is low after surgical treatment of idiopathic club foot in infants: a prospective, double-blinded clinical study. J Bone Joint Surg Br 2007; 89(3):375-7.
- Postel, J.M., Thoumie, P., et al. Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Annales de Readaptation et de Medecine Physique (2007 May) 50(4):244-57.
- Nugent-Derfus GE, Takara T, O'neill JK, et al. Continuous passive motion applied to whole joints stimulates chondrocyte biosynthesis of PRG4. Osteoarthritis Cartilage 2007; 15(5):566-74.
- Farr J. Autologous chondrocyte implantation improves patellofemoral cartilage treatment outcomes. Clin Orthop Relat Res 2007; 463:187-94.
- Rosenberger RE, Gomoll AH, Bryant T et al. Repair of large chondral defects of the knee with autologous chondrocyte implantation in patients 45 years or older. Am J Sports Med 2008; 36(12):2336-44.
- Lenssen TA, van Steyn MJ, Crijns YH et al. Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. BMC Musculoskelet Disord 2008; 9:60.
- Wright RW, Preston E, Fleming BC, et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg 2008; 21(3):217-24.
- Schwartz DA, Chafetz R. Continuous passive motion after tenolysis in hand therapy patients: a retrospective study. J Hand Ther 2008; 21(3):261-6; quiz 67.
- Bruun-Olsen V, Heiberg KE, Mengshoel AM. Continuous passive motion as an adjunct to active exercises in early rehabilitation following total knee arthroplasty - a randomized controlled trial. Disabil Rehabil 2009; 31(4):277-83.
- Dundar U, Toktas H, Cakir T et al. Continuous passive motion provides good pain control in patients with adhesive capsulitis. Int J Rehabil Res 2009; 32(3):193-8.
- Lindenhovius AL, van de Luijtgaarden K, Ring D et al. Open elbow contracture release: postoperative management with and without continuous passive motion. J Hand Surg Am 2009; 34(5):858-65.
- Harvey LA, Brosseau L, Herbert RD. Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev 2010; (3):CD004260.
- Fazalare JA, Griesser MJ, Siston RA et al. The use of continuous passive motion following knee cartilage defect surgery: a systematic review. Orthopedics 2010; 33(12):878.
- Garofalo R, Conti M, Notarnicola A et al. Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: results at 1-year follow-up of a prospective randomized study. Musculoskelet Surg 2010; 94 Suppl 1:S79-83.
- Continuous Passive Motion (CPM) in the Home Setting. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2011 July) Durable Medical Equipment 1.01.10.
||Policy updated with literature review through May 2012; reference 24 added; policy statements unchanged|
||Title changed from "Continuous Passive Motion Device in the Home Setting" to "Continuous Passive Motion (CPM) Device". Criteria added to Medically Necessary statement that CPM for low postoperative mobility must begin within 48 hours of the surgical procedure and may continue for only 21 days. Criteria added that CPM may be Medically Necessary only up to 6 weeks during the non-weight bearing status. Not Medically Necessary statement changed to Investigational. Rationale and references updated.|