Motion-Restoring Surgery versus Non-Operative Stretch-Assist Devices for Treatment of Joint Contracture: Utilization, Timing, Cost, and Outcomes from Medicare and Commercial Claims

Motion-Restoring Surgery versus Non-Operative Stretch-Assist Devices for Treatment of Joint Contracture: Utilization, Timing, Cost, and Outcomes from Medicare and Commercial Claims | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Motion-Restoring Surgery versus Non-Operative Stretch-Assist Devices for Treatment of Joint Contracture: Utilization, Timing, Cost, and Outcomes from Medicare and Commercial Claims Shaun Stinton, Samantha Beckley, Thomas Branch This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8555717/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background This study aimed to assess national treatment patterns, timing, and costs of interventions for joint contracture using Medicare and commercial claims data. Emphasis was placed on comparing the frequency, cost, and recovery outcomes associated with continuous passive motion (CPM), motion-restoring surgery (MRS), and wearable stretch-assist devices, including dynamic and turnbuckle/wormgear stretch-assist splints. Methods A retrospective cohort analysis of the Centers for Medicare & Medicaid Services (CMS) and IBM MarketScan databases (2015–2018) was conducted. Patients diagnosed with contracture of the knee, shoulder, elbow, wrist, or ankle were identified through medical diagnosis codes. Incidence, prescriptive patterns, recovery time, and costs were determined using corresponding claims-based information. Recovery duration was defined as the time from index treatment to the last rehabilitation claim. Comparative analyses were conducted using the Wilcoxon Signed-Rank and Mood’s Median tests. Results MRS was the predominant treatment across all joints and accounted for the majority of costs associated with contracture care. Across joints, MRS-treated patients experienced significantly higher total costs and longer recovery durations, with an average 234-day delay relative to non-operative care. Wearable dynamic and turnbuckle/wormgear splints were prescribed in fewer than 8% of cases and were typically initiated months after primary surgery and often following MRS. CPM demonstrated no measurable benefit in recovery or prevention of contracture and was associated with higher costs. Only dynamic splint use after elbow fracture was associated with significantly shorter recovery compared to MRS. Conclusions Current clinical practice heavily favors MRS despite prolonged recovery and higher expenses. Non-operative mechanical stretch-assist devices are underutilized and typically prescribed too late to influence outcomes suggesting that the healthcare community does not consider them a viable option. The greater adoption of elbow splints may reflect providers' reluctance to use elbow MRS. joint contracture motion-restoring surgery dynamic stretch-assist splint static progressive splint turnbuckle/wormgear splint continuous passive motion recovery outcomes healthcare costs claims-based analysis Medicare Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Healing after an injury to a joint flows through four distinct phases: 1) hemostasis, 2) inflammatory, 3) proliferative, and 4) remodeling [ 1 ]. Failure to complete this sequence can result in joint contracture and loss of motion. Mechanical stress associated with the stretching of a joint is required during the remodeling phase of healing to guide the appropriate cellular and collagen response [ 1 ]. Accordingly, stretching is a critical component of the postoperative or postinjury rehabilitation plan. Both insufficient and excessive stretching can disrupt tissue remodeling and result in a joint contracture [ 1 ]. Accurate differentiation between joint contracture (M24.5x), ankylosis (M24.6x), and stiffness (M25.6x) is critical, as they are distinct etiologies requiring distinct management strategies. Joint ankylosis describes a fixed motion loss with no possibility of recovery while joint stiffness describes a joint that is hard to move with no motion loss. Neither condition can be addressed through stretching or surgical release. Motion loss due to joint contracture can severely limit activities of daily living, including self-care, mobility, and workplace function, and can persist for years after surgery or injury [ 2 ]. The consequences are particularly severe in older adults, as joint contracture can lead to institutionalization and permanent disability, but at any age, contracture is associated with delayed recovery and an increased risk of complications [ 3 , 4 ]. Management strategies for joint contracture have existed for centuries. Non-operative treatment of contracture has evolved from wooden pulleys and ropes to custom turnbuckle casting, to continuous passive motion (CPM), and, more recently, to wearable stretch-assist splints [ 5 – 10 ]. These wearable stretch-assist splints are divided into two categories: dynamic stretch-assist splints and turnbuckle/worm gear stretch-assist splints. The dynamic splints use a constant low load to stretch the joint in one direction, ie, flexion or extension. The turnbuckle/worm gear splints use progressive fixed positioning to force a joint into one direction, ie, flexion or extension. These wearable stretch assist splints have been approved for Medicare reimbursement for over 20 years, each with its own distinct Healthcare Common Procedure Coding System (HCPCS) code within the E1800–E1841 series. Unfortunately, Medicare has named the turnbuckle/wormgear stretch-assist splints using a physical therapy technique called static progressive stretch, which has created confusion in the orthopedic world. Operative treatment of joint contracture, collectively termed motion-restoring surgery (MRS), includes manipulation under anesthesia (MUA), arthroscopic or open lysis of adhesions, synovectomy, and scar tissue release. Despite the availability of other non-operative treatment options, MRS remains the predominant clinical response to postoperative stiffness [ 11 – 15 ]. While often effective, MRS carries risks of anesthesia, infection, thromboembolic events, and reoperation [ 16 – 18 ]. Previous studies have also shown that MRS is associated with prolonged rehabilitation and elevated costs after total knee arthroplasty (TKA), rotator cuff repair (RCR), knee ligament repair, and fracture repair in the elbow, ankle, and wrist [ 19 – 24 ]. Despite decades of availability, the real-world utilization, timing, and effectiveness of wearable stretch-assist splints remain poorly characterized. Clinical evidence from smaller studies suggests that these devices are most effective when prescribed early in the postoperative course, before secondary fibrosis and adhesions develop [ 8 , 25 , 26 ]. After 20 years of availability, the current clinical adoption of CPM, wearable stretch-assist splints, and MRS needs to be characterized. Clarification of the timing, duration of use, and frequency of these treatments across large, diverse populations is essential for identifying optimal pathways to full joint recovery. This study addresses the lack of large-scale evidence comparing the use and outcomes of non-operative versus operative treatment of joint contractures. By using large-scale data from both Medicare and commercial databases, this study aimed to: Determine the incidence of joint contracture across major joints (knee, shoulder, ankle, elbow, and wrist) Determine the incidence and costs related to the most common treatment for contracture, motion-restoring surgery (MRS) Evaluate prescriptive patterns and timing of CPM and wearable stretch-assist splints Compare recovery duration and associated costs across treatment modalities Evaluate whether the use of non-operative stretch assist devices is associated with shorter recovery durations and lower costs when compared to MRS. We hypothesized that earlier or more consistent use of CPM and/or wearable stretch-assist splints for the treatment of joint contracture would be associated with shorter recovery durations and lower treatment costs than motion restoring surgery. Methods Study Design This retrospective cohort analysis used data from two sources: 1) the Centers for Medicare & Medicaid Services (CMS) database (5% random sample, scaled to population incidence); and 2) the IBM MarketScan Commercial Claims and Encounters database. Both datasets include longitudinal healthcare claims linked by a patient identifier, allowing evaluation of prescriptive behavior and timing, along with associated costs and recovery time. This study was conducted in accordance with the Declaration of Helsinki and was deemed exempt from Institutional Review Board (IRB) review. As the study used previously collected, de-identified data, individual patient consent was not required. Inclusion Criteria Patients with ICD-9/10 codes consistent with joint contracture (718.4x, M24.5x) were included if they had at least two consecutive years of insurance coverage. Shoulder adhesive capsulitis (M75.0) and Achilles contracture (M67.0) were grouped with the shoulder and ankle categories, respectively, given their similar clinical courses, which result in motion loss addressable through stretching or release [ 27 – 29 ]. The study period was from January 2015 to December 2018. All costs are presented in U.S. dollars and correspond to the same time period. Treatment Patterns Prescription frequencies for wearable stretch-assist devices were determined by examining associated HCPCS codes for dynamic splints and turnbuckle/wormgear splints within the E1800-E1841 series of codes (Table 1 ). The incidence of MRS was determined using Current Procedural Terminology (CPT) codes for procedures such as MUA, arthroscopic/open lysis of adhesions, arthroscopic/open synovectomy, or arthroscopic/open scar tissue debridement/release for each joint type (Table 2 ). The incidence of CPM could be determined only for the knee, as it is the only joint with its own unique billing code (E0935). All other joints are combined into a single code (E0936). Table 1 HCPCS codes for dynamic and turnbuckle/wormgear (SPS) stretch-assist splints. E1800- Elbow Dynamic Splint E1801- Elbow SPS Splint E1802- Forearm Sup/Pro Dynamic Splint E1805- Wrist Flex/Ext Dynamic Splint E1806- Wrist Flex/Ext SPS Splint E1810- Knee Dynamic Splint E1811- Knee SPS Splint E1815- Ankle Dynamic Splint E1816- Ankle SPS Splint E1818- Forearm SPS Splint E1840- Shoulder Dynamic Splint E1841- Shoulder SPS Splint Table 2 Motion restoring surgery CPT codes for the shoulder joint. CPT Code Description 23700 Manipulation under anesthesia, shoulder joint, including the application of a fixation apparatus, but excluding dislocation 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) 29820 Arthroscopy, shoulder, surgical, synovectomy, partial 29821 Arthroscopy, shoulder, surgical, synovectomy, complete 29822 Arthroscopy, shoulder, surgical, debridement, limited 29823 Arthroscopy, shoulder, surgical, debridement, extensive 29825 Arthroscopy, shoulder, surgical, with lysis and resection of adhesions, with or without manipulation 23020 Release shoulder joint Outcome Measures The primary outcomes were incidence of each treatment modality, treatment cost, and recovery duration (defined as the time from the index surgery or treatment to the last physical or occupational therapy claim). A secondary outcome was the timing of device initiation relative to surgery or MRS. Data Analysis Data were analyzed using the R statistical programming language (version 4.3.3). Given the large sample size, results are presented as medians and interquartile ranges. The Wilcoxon Signed-Rank and Mood’s Median tests were used to compare recovery time and cost between modalities. Statistical significance was set at p < 0.05. Results Incidence The incidence of joint contracture diagnosis, MRS, and wearable splint prescriptions was calculated from the CMS database. From 2015–2018, an estimated 114,830 patients were diagnosed annually with joint contracture across five major joints (Table 3 ). MRS was the dominant treatment, exceeding splint use at least threefold in all joints except the elbow. For example, among 47,255 shoulder contracture cases, 32,120 underwent MRS, while only 375 received any wearable stretch-assist splint (Fig. 1 ). Alternatively, in the elbow, prescriptive frequency was essentially equal between MRS (1,155 cases/year) and wearable stretch-assist splints (1,435 cases/year). This analysis included 3,165 Ermi Knee Extensionaters (791/year) prescribed to Medicare patients from 2015 to 2018, lumped into E1811, representing 38.5% of the 2,055 knee turnbuckle/wormgear splints prescribed to Medicare patients each year. (Note that the Ermi Knee Extensionaters are not a turnbuckle/wormgear stretch-assist splint.) However, the analysis excluded Ermi Flexionaters, as they were not prescribed to commercial or Medicare patients during the same period. The use of CPM devices was far more common than both dynamic splints and turnbuckle/wormgear splints, with a nearly sevenfold higher frequency than splints (Fig. 2 ). Table 3 Number of yearly Medicare claims estimated from a 5% sample. Shoulder Wrist Knee Ankle Elbow Joint Contracture 47,255 28,615 16,690 16,630 5,640 Motion Restoring Surgery 32,120 27,225 17,720 3,760 1,155 Dynamic Splint Use 260 1,075 3,560 610 935 Turnbuckle/wormgear Splint Use 115 305 2,055 150 505 Costs Treatment for joint contracture represented a substantial economic burden, exceeding $ 750 million annually in the Medicare population (Table 4 ). The majority of these dollars were related to MRS ( $ 630 million or 83% of all costs). Wearable splints accounted for < 1% of total expenditures. Table 4 Estimate of yearly Medicare dollars spent on patients with the diagnosis of joint contracture, the use of motion restoring surgery, dynamic stretch-assist splint or turnbuckle/wormgear stretch-assist splint from a 5% sample of Revenue Center Total Charge Amount in the CMS Database. Mean Yearly $ Spent Shoulder Wrist Knee Ankle Elbow Total Contracture (M24.5x) $ 282,247,706 $ 136,820,704 $ 98,522,071 $ 212,570,904 $ 28,000,604 $ 758,161,989 Motion Restoring Surgery $ 165,615,000 $ 175,070,580 $ 88,541,026 $ 192,861,033 $ 8,066,861 $ 630,154,500 Dynamic Splint Use $ 20,844 $ 858,284 $ 1,846,547 $ 1,053,319 $ 622,722 $ 4,401,715 Turnbuckle/wormgear Splint Use $ 10,309 $ 132,720 $ 1,260,167 $ 126,585 $ 299,734 $ 1,829,494 Treatment Efficacy Across the shoulder, knee, and ankle, CPM showed no improvement in recovery duration, contracture prevention, or avoidance of MRS (Tables 5 – 7 ). CPM patients had median costs 1.1–15 times higher and recovery times 1.1–7.2 times longer than non-CPM cohorts. The use of CPM in patients with a unilateral TKA increased contracture diagnosis (M24.56) and the need for MRS (Table 6 ). The findings were similar for the shoulder (Table 7 ). Table 5 Cost and recovery time comparison between patients treated with CPM and those treated without CPM. Shoulder RCR Wrist Fx Knee TKA Ankle Fx Elbow Fx Median Cost No CPM $ 2,933 $ 2,329 $ 4,186 $ 2,543 $ 2,819 Median Cost CPM $ 3,498 $ 8,988 $ 4,562 $ 3,505 $ 42,565 Difference Range ( $ 330 to $ 854) ( $ 16,051 to – $ 4,126) ( $ 237 to $ 533) ( $ 3,184 to – $ 3,965) ( $ 51,584 to – $ 21,819) Total Cost p-value < 0.01 < 0.01 < 0.01 0.82 < 0.01 Median PT Days No CPM 153 98 122 88 100 Median PT Days CPM 169 542 147 630 434 Difference Range (26 to − 3) (554 to 104) (9 to 0) (1184 to − 43) (387 to 129) PT days p-value 0.11 0.01 0.06 0.06 0.01 No CPM Patients (n) 14,627 6,050 8,575 7,109 2,669 CPM Patients (n) 320 8 2,361 3 11 Total Patients (n) 14,947 6,058 10,936 7,112 2,680 Table 6 Effect of continuous passive motion (CPM) usage on subsequent joint contracture diagnosis. Total Knee Arthroplasty CPM No CPM Contracture 11% 7% Motion Restoring Surgery 15% 5% Table 7 Effect of continuous passive motion (CPM) usage on subsequent need for motion restoring surgery. Shoulder Rotator Cuff Repair CPM No CPM Contracture 8% 7% Motion Restoring Surgery 10% 5% Dynamic stretch-assist splints were prescribed in fewer than 8% of cases and were not associated with a significant change in treatment cost or duration for knee, shoulder, wrist, or ankle contractures. Total costs for patients who received a dynamic stretch-assist splint were 1.7-4 times higher than for patients who did not receive a dynamic stretch-assist splint. Out of 14,947 unilateral RCR patients, only 25 were prescribed a shoulder dynamic stretch-assist splint. Its use did not significantly change the need for MRS (Table 7 ). Furthermore, among those RCR patients who underwent MRS, 66% had a splint prescribed after surgery. Patients using the dynamic splint for knee TKA, shoulder RCR, elbow fracture, and wrist fracture had the device prescribed after MRS in over 50% of cases (Table 8 ). Use of a dynamic stretch-assist splint was not associated with a change in recovery duration after TKA, RCR, wrist fracture, or ankle fracture (Fig. 3 ). However, in treating elbow fractures, dynamic stretch-assist splinting was associated with shorter recovery time and lower total costs than MRS (Fig. 4 , Table 8 ). Across all joints, dynamic stretch-assist splints were prescribed late in the recovery timeline, with treatment starting on average over 5 months after primary surgery (Table 9). Table 8 Cost and recovery time comparison between patients treated with dynamic low-load progressive stretch (LLPS) splints and those treated without LLPS. Shoulder RCR Wrist Fx Knee TKA Ankle Fx Elbow Fx Median Cost Normal Course $ 2,945 $ 2,316 $ 4,226 $ 2,540 $ 2,777 Median Cost LLPS $ 11,777 $ 8,320 $ 7,543 $ 5,822 $ 4,841 Difference Range ( $ 5,950 to $ 9,386) ( $ 2,123 to $ 6,388) ( $ 2,041 to $ 3,475) ( $ 1,049 to $ 7,149) ( $ 1,300 to $ 2,952) Total Cost p-value < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Median PT Days Normal Course 153 98 123 88 98 Median PT Days LLPS 359 421 264 328 203 Difference Range (-54 to 135) (44 to 234) (29 to 83) (-35 to 292) (15 to 87) PT Days p-value 0.64 < 0.01 < 0.01 0.15 < 0.01 Median Cost MRS $ 22,498 $ 17,075 $ 11,249 $ 30,319 $ 30,689 Median Cost LLPS $ 12,827 $ 15,654 $ 7,543 $ 9,684 $ 14,950 Difference Range (- $ 1,625 to - $ 9,804) (- $ 968 to - $ 5,922) (- $ 2,472 to - $ 4,443) (- $ 5,035 to - $ 20,527) (- $ 7,171 to - $ 15,718) Total Cost p-value < 0.001 0.01 < 0.001 < 0.001 < 0.001 Median PT Days MRS 451 265 321 357 333 Median PT Days LLPS 359 421 264 328 203 Difference Range (8 to -251) (135 to -26) (25 to -36) (108 to -320) (-16 to -189) PT Days p-value 0.07 0.19 0.68 0.60 0.02 MRS Patients (n) 714 510 979 232 75 LLPS Patients (n) 25 41 183 10 71 Total Patients 14,947 6,058 10,936 7,112 2,680 Shoulder RCR Wrist Fx Knee TKA Ankle Fx Elbow Fx Mean Days from Primary to splint 115.8 155.2 143 253 112.6 % of Patients with both MRS and splint 24% 34% 44% 30% 13% % of Patients with splint ordered after MRS 66% 57% 69% 33% 56% Turnbuckle/wormgear stretch-assist splints were prescribed even less frequently than dynamic stretch-assist splints. In a series of 14,947 patients, only one shoulder turnbuckle splint was prescribed to a patient two months after RCR surgery, without a diagnosis of shoulder contracture or adhesive capsulitis. Four out of the 11 turnbuckle splints used in patients with TKA were prescribed before their primary surgery (unilateral TKA). The seven turnbuckle stretch-assist splints used after TKA did not have a significant impact on postoperative recovery compared with MRS (Table 10 ). Although sample sizes were small, the use of a turnbuckle/wormgear stretch-assist splint was associated with lower costs than MRS, with a comparable recovery duration. Table 10 Cost and recovery time comparison between static progressive splints and motion restoring surgery. Shoulder RCR Wrist Fx Knee TKA Ankle Fx Elbow Fx Median Cost MRS $ 12,061 $ 11,249 $ 20,061 Median Cost SPS $ 8,864 $ 10,200 $ 6,178 Difference Range (- $ 12,018 to $ 2,040) (- $ 6,639 to $ 3,353) (- $ 19,981 to $ 3,192) Total Cost p-value 0.24 0.42 0.09 Median PT Days MRS Median PT Days SPS Difference Range PT days p-value 0.13 1.0 0.96 MRS Patients (n) 0 510 979 0 75 SPS Patients (n) 1 6 11 0 8 Total Patients (n) 14,947 6,058 10,936 7,112 2,680 Discussion Despite being on the market and available with an HCPCS code for over 20 years, wearable stretch-assist splints are underutilized as a treatment option for joint contractures, suggesting that the healthcare community does not consider them a viable option. On the other hand, MRS remains both the most commonly used and the most expensive treatment for joint contracture. Across the knee, shoulder, ankle, and wrist, MRS was prescribed far more often than any stretch-assist splint and accounted for more than 80% of contracture-related costs. These findings reflect a continued reliance on surgical management, even though non-operative alternatives, such as prolonged physical therapy, exist. The observed 234-day average delay in recovery after MRS highlights the long-term costs and quality-of-life implications for patients and payers, reinforcing the need for earlier, more effective non-operative treatment as an alternative to MRS. Despite a decades-long history of Medicare coverage and clinical validation, providers prescribed wearable stretch-assist splints in fewer than 8% of contracture patients across all joints except the elbow. Moreover, providers initiated use too late, an average of 5 months after the primary surgery, and after MRS in more than half of cases. The data show that splints are being used reactively rather than proactively as a primary non-operative option. When applied too late, the ability to prevent further procedures, accelerate recovery, and reduce healthcare costs is greatly diminished (Fig. 5 ). Mechanical stretch therapy is a critical element of the remodeling phase of joint healing. It works by signalling to cells which collagen to produce, Type I vs Type III, and in which direction to be laid down. Stretching provides these “stress lines” for remodeling, with its effectiveness greater when initiated during the proliferation phase of healing. Clearly, MRS restarts the joint-healing process by sending it back to the hemostasis phase or, at least, to the inflammatory phase, resulting in a marked delay in recovery. Stretching after MRS should be delayed until the proliferative phase to allow joint inflammation to settle. Joint healing is not complete until the remodeling phase is completed. The presence of joint contractures, or delayed joint motion recovery, has plagued the healthcare community for centuries. With the advent of CPM for intra-articular joint healing in the 1980s, providers adopted it as both a preventive and reactive treatment for this problem [ 30 ]. Given the low prescription rate of wearable stretch-assist splints, possibly due to difficulty of use, the continued use of CPM suggests that the healthcare community seeks an easy-to-use, effective non-operative treatment for motion loss due to joint contractures. Interestingly, this study confirms that the use of the CPM was not associated with improved patient outcomes in unilateral TKA, shoulder RCR, elbow fractures, wrist fractures, or ankle fractures [ 31 – 35 ], despite the healthcare community’s faith in its efficacy. This may merely reflect the ease of CPM use, the positive feedback patients using CPM provide to providers, or the success seen among a subset of CPM users. The elbow fracture cohort, in which non-operative treatment with wearable stretch-assist splinting demonstrated faster recovery and lower cost than MRS, illustrates the opportunity for success when devices are prescribed at the appropriate time for the appropriate joint. Unlike in other joints, the elbow showed near parity between surgical and non-operative prescriptions, suggesting greater clinician acceptance of wearable stretch-assist splint use, perhaps due to the known complexity of elbow MRS [ 36 – 38 ]. However, even in the elbow, many wearable stretch-assist splints were prescribed late in recovery, limiting their potential benefit. Limitations Claims-based analyses cannot capture all clinical nuances. Coding variability, lack of functional outcome data, and absence of patient-level context limit granularity. Recovery time was estimated from therapy claim closure, potentially resulting in an underestimate of residual stiffness. Nonetheless, the large sample size, dual-database validation, and consistent cross-joint trends strengthen the reliability of these findings. Results regarding any stretch-assist device use may partly reflect selection bias toward more severe joint contracture or joint motion loss cases. Conclusions Treatment of joint contracture in the United States remains dominated by expensive surgical procedures that prolong recovery and drive the high cost of healthcare spending. Despite being on the market and available with an HCPCS code for over 20 years, wearable stretch-assist splints are underutilized as a treatment option for joint contractures, suggesting that the healthcare community does not consider them a viable option. The greater adoption of wearable stretch-assist splints for treating elbow joint contractures may reflect providers' reluctance to use elbow MRS. Declarations Ethics approval and consent to participate: This retrospective study was determined to be exempt from Institutional Review Board (IRB) review by Sterling IRB. As this observational study used previously collected, de-identified data, consent to participate was not applicable. Consent for publication: Not Applicable Competing Interests SS and SB are employees of ArthroResearch LLC; TB is founder and CEO of Ermi LLC. Funding: No specific funding was received for this research. Author Contribution SS, SB, and TB contributed to study design, analysis, interpretation, and manuscript preparation. All authors approved the final version. Data Availability Data are proprietary to IBM MarketScan and CMS and available upon reasonable request under license. References Koller T. Mechanosensitive Aspects of Cell Biology in Manual Scar Therapy for Deep Dermal Defects. Int J Mol Sci. 2020;21(6):2055. Merrill A, Ritter JD, Lutgring KE, Davis ME, Berend JL, Pierson RM, Meneghini. 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Bonutti PM, McGrath MS, Ulrich SD, McKenzie SA, Seyler TM, Mont MA. Static progressive stretch for the treatment of knee stiffness. Knee. 2008;15(4):272–6. 10.1016/j.knee.2008.04.002 . Veltman ES, Doornberg JN, Eygendaal D, van den Bekerom MPJ. Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients. Arch Orthop Trauma Surg. 2015;135(5):613–7. 10.1007/s00402-015-2199-5 . Hospital for Special Surgery website accessed on November 12. 2025. https://www.hss.edu/health-library/conditions-and-treatments/list/frozen-shoulder National Health System of Scotland website accessed on November 12. 2025. https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/arm-shoulder-and-hand-problems-and-conditions/frozen-shoulder/ Amis J. The Split Second Effect: The Mechanism of How Equinus Can Damage the Human Foot and Ankle. Frontier in Surgery. 2016;3:38. 10.3389/fsurg.2016.00038 . PMID: 27512692; PMCID: PMC4961717. Salter RB, Simmonds DF, Malcolm BW, Rumble EJ, MacMichael D, Clements ND. The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. An experimental investigation in the rabbit. J Bone Joint Surg Am. 1980;62(8):1232–51. PMID: 7440603. Garofalo R, Conti M, Notarnicola A, Maradei L, Giardella A, Castagna A. Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: results at 1-year follow-up of a prospective randomized study. Musculoskeletal Surgery. 2010;94 Suppl 1:S79-83. 10.1007/s12306-010-0058-7 . PMID: 20383685. Jia Z, Zhang Y, Zhang W et al. Efficacy and safety of continuous passive motion and physical therapy in recovery from knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2024;19:68. https://doi.org/10.1186/s13018-024-04536-y . Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic review. J Hand Ther. 2004;17(2):118–31. Yang X, Li GH, Wang HJ, Wang CY. Continuous Passive Motion After Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Associated Effects on Clinical Outcomes. Arch Phys Med Rehabil. 2019;100(9):1763–78. Epub 2019 Mar 2. PMID: 30831093. Yi A, Villacis D, Yalamanchili R, Hatch GF 3. rd. A Comparison of Rehabilitation Methods After Arthroscopic Rotator Cuff Repair: A Systematic Review. Sports Health. 2015;7(4):326–34. PMID: 26137178; PMCID: PMC4481677. Lindenhovius ALC, Jupiter JB. The posttraumatic stiff elbow: a review of the literature. J Hand Surg Am. 2007;32(10):1605–23. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872–7. O’Driscoll SW, Morrey BF, Korinek S, An KN. Elbow contracture: pathology and treatment. Instr Course Lect. 1999;48:365–72. Additional Declarations Competing interest reported. SS and SB are employees of ArthroResearch LLC; TB is founder and CEO of Ermi LLC. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 24 Feb, 2026 Editor invited by journal 02 Feb, 2026 Editor assigned by journal 15 Jan, 2026 Submission checks completed at journal 15 Jan, 2026 First submitted to journal 08 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8555717","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596435300,"identity":"daa71c02-485f-451c-9bbe-cac67e656552","order_by":0,"name":"Shaun Stinton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIie3PMWrDMBSA4WcC0aIDKDTIV5ARJHTJWSQCnkwXT900yUuhq6GXCHTJ0EHGtF7cPaVQbArx0sVkMmRoE9OlyEnGDvoGDU/8PAnAcf4rcTiQAvDUn+EATwlgANgAZBcncEiIuDDxFWqqer2n88nndteuP+g8Seqqe1rcAMqfV5aEGRwoWTJ+/RDyNCtjPi1LHtxtlzHgMNzYEsCekprJ1bvgkGkhUxKNCTZGKoJntuTnYXWfvBW7PvGbptufSMBA0Ccb/LsFZqNTW1iOg1RqzlkZxfCqBSc44ldTs5R64C9+klRtpyllRfEIt1pQgoq6/TILeY/yF+vDRrbh0XjwxnEcxznnG5vha4z+bzPzAAAAAElFTkSuQmCC","orcid":"","institution":"ArthroResearch LLC","correspondingAuthor":true,"prefix":"","firstName":"Shaun","middleName":"","lastName":"Stinton","suffix":""},{"id":596435301,"identity":"c9626ebc-846d-4b2b-9247-e9def86968a0","order_by":1,"name":"Samantha Beckley","email":"","orcid":"","institution":"ArthroResearch LLC","correspondingAuthor":false,"prefix":"","firstName":"Samantha","middleName":"","lastName":"Beckley","suffix":""},{"id":596435302,"identity":"c5e7bca9-b94d-4c13-a4ae-396daa67853c","order_by":2,"name":"Thomas Branch","email":"","orcid":"","institution":"Ermi LLC","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Branch","suffix":""}],"badges":[],"createdAt":"2026-01-09 01:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8555717/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8555717/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104779281,"identity":"19dc9bd2-c58c-4355-bf2c-8ef066bf263c","added_by":"auto","created_at":"2026-03-17 07:38:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17800,"visible":true,"origin":"","legend":"\u003cp\u003eYearly data calculated from a 5% sample of CMS frequency data (2015-2018). The Medicare treatment of choice for all motion loss due to joint contractures is Motion Restoring Surgery.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/fadb1079a8dd824899c51d0b.png"},{"id":104398023,"identity":"cee720f0-1925-4852-a6e9-933a7b0ddbbf","added_by":"auto","created_at":"2026-03-11 11:59:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":8098,"visible":true,"origin":"","legend":"\u003cp\u003eProviders are still prescribing continuous passive motion (CPM) for the prevention of knee contractures at a 12.1 times greater rate than dynamic stretch-assist splints despite the lack of proven benefit with CPM (Medicare/CMS data).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/63e953f8d79c269e36587ca2.png"},{"id":104398668,"identity":"47961dfb-068c-423c-a726-d70562e82493","added_by":"auto","created_at":"2026-03-11 12:03:15","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28413,"visible":true,"origin":"","legend":"\u003cp\u003eKnee (TKA) recovery durations show no difference between dynamic stretch-assist splinting and MRS.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/15bf77ea943f6a665d0571f7.jpg"},{"id":104398692,"identity":"f7892249-2b8a-42ba-8cbc-3fb09cd0f8cb","added_by":"auto","created_at":"2026-03-11 12:03:17","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":28134,"visible":true,"origin":"","legend":"\u003cp\u003eElbow fracture recovery improved significantly with dynamic stretch-assist splinting versus MRS (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.02); however, one must be careful using the median as a representation of the distribution (Mood’s Median Test p \u0026lt; 0.10) rather than mean due to the large sample size.\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/b650761590ac2484322460d2.jpg"},{"id":103590010,"identity":"b1fcded1-25ae-49f2-8379-dda6cff3914f","added_by":"auto","created_at":"2026-02-27 12:01:27","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":36025,"visible":true,"origin":"","legend":"\u003cp\u003eA stretch assist device must be prescribed BEFORE motion restoring surgery and it must be given time to work to be most effective. Furthermore, they should be initiated early to have the most effect.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/3d298d76658a7fa233832f6f.png"},{"id":104783709,"identity":"76d5a7f6-59e3-46c8-8602-9eb181884a2c","added_by":"auto","created_at":"2026-03-17 08:03:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1000520,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8555717/v1/d4ec97c3-eda0-41c5-b80f-5ac8c6e76b6d.pdf"}],"financialInterests":"Competing interest reported. SS and SB are employees of ArthroResearch LLC; TB is founder and CEO of Ermi LLC.","formattedTitle":"Motion-Restoring Surgery versus Non-Operative Stretch-Assist Devices for Treatment of Joint Contracture: Utilization, Timing, Cost, and Outcomes from Medicare and Commercial Claims","fulltext":[{"header":"Background","content":"\u003cp\u003eHealing after an injury to a joint flows through four distinct phases: 1) hemostasis, 2) inflammatory, 3) proliferative, and 4) remodeling [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Failure to complete this sequence can result in joint contracture and loss of motion. Mechanical stress associated with the stretching of a joint is required during the remodeling phase of healing to guide the appropriate cellular and collagen response [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Accordingly, stretching is a critical component of the postoperative or postinjury rehabilitation plan. Both insufficient and excessive stretching can disrupt tissue remodeling and result in a joint contracture [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Accurate differentiation between joint contracture (M24.5x), ankylosis (M24.6x), and stiffness (M25.6x) is critical, as they are distinct etiologies requiring distinct management strategies. Joint ankylosis describes a fixed motion loss with no possibility of recovery while joint stiffness describes a joint that is hard to move with no motion loss. Neither condition can be addressed through stretching or surgical release.\u003c/p\u003e \u003cp\u003eMotion loss due to joint contracture can severely limit activities of daily living, including self-care, mobility, and workplace function, and can persist for years after surgery or injury [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The consequences are particularly severe in older adults, as joint contracture can lead to institutionalization and permanent disability, but at any age, contracture is associated with delayed recovery and an increased risk of complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eManagement strategies for joint contracture have existed for centuries. Non-operative treatment of contracture has evolved from wooden pulleys and ropes to custom turnbuckle casting, to continuous passive motion (CPM), and, more recently, to wearable stretch-assist splints [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These wearable stretch-assist splints are divided into two categories: dynamic stretch-assist splints and turnbuckle/worm gear stretch-assist splints. The dynamic splints use a constant low load to stretch the joint in one direction, ie, flexion or extension. The turnbuckle/worm gear splints use progressive fixed positioning to force a joint into one direction, ie, flexion or extension. These wearable stretch assist splints have been approved for Medicare reimbursement for over 20 years, each with its own distinct Healthcare Common Procedure Coding System (HCPCS) code within the E1800\u0026ndash;E1841 series. Unfortunately, Medicare has named the turnbuckle/wormgear stretch-assist splints using a physical therapy technique called static progressive stretch, which has created confusion in the orthopedic world.\u003c/p\u003e \u003cp\u003eOperative treatment of joint contracture, collectively termed motion-restoring surgery (MRS), includes manipulation under anesthesia (MUA), arthroscopic or open lysis of adhesions, synovectomy, and scar tissue release. Despite the availability of other non-operative treatment options, MRS remains the predominant clinical response to postoperative stiffness [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. While often effective, MRS carries risks of anesthesia, infection, thromboembolic events, and reoperation [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Previous studies have also shown that MRS is associated with prolonged rehabilitation and elevated costs after total knee arthroplasty (TKA), rotator cuff repair (RCR), knee ligament repair, and fracture repair in the elbow, ankle, and wrist [\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite decades of availability, the real-world utilization, timing, and effectiveness of wearable stretch-assist splints remain poorly characterized. Clinical evidence from smaller studies suggests that these devices are most effective when prescribed early in the postoperative course, before secondary fibrosis and adhesions develop [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. After 20 years of availability, the current clinical adoption of CPM, wearable stretch-assist splints, and MRS needs to be characterized. Clarification of the timing, duration of use, and frequency of these treatments across large, diverse populations is essential for identifying optimal pathways to full joint recovery.\u003c/p\u003e \u003cp\u003eThis study addresses the lack of large-scale evidence comparing the use and outcomes of non-operative versus operative treatment of joint contractures. By using large-scale data from both Medicare and commercial databases, this study aimed to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetermine the incidence of joint contracture across major joints (knee, shoulder, ankle, elbow, and wrist)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetermine the incidence and costs related to the most common treatment for contracture, motion-restoring surgery (MRS)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluate prescriptive patterns and timing of CPM and wearable stretch-assist splints\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCompare recovery duration and associated costs across treatment modalities\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluate whether the use of non-operative stretch assist devices is associated with shorter recovery durations and lower costs when compared to MRS.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWe hypothesized that earlier or more consistent use of CPM and/or wearable stretch-assist splints for the treatment of joint contracture would be associated with shorter recovery durations and lower treatment costs than motion restoring surgery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis retrospective cohort analysis used data from two sources: 1) the Centers for Medicare \u0026amp; Medicaid Services (CMS) database (5% random sample, scaled to population incidence); and 2) the IBM MarketScan Commercial Claims and Encounters database. Both datasets include longitudinal healthcare claims linked by a patient identifier, allowing evaluation of prescriptive behavior and timing, along with associated costs and recovery time. This study was conducted in accordance with the Declaration of Helsinki and was deemed exempt from Institutional Review Board (IRB) review. As the study used previously collected, de-identified data, individual patient consent was not required.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion Criteria\u003c/h3\u003e\n\u003cp\u003ePatients with ICD-9/10 codes consistent with joint contracture (718.4x, M24.5x) were included if they had at least two consecutive years of insurance coverage. Shoulder adhesive capsulitis (M75.0) and Achilles contracture (M67.0) were grouped with the shoulder and ankle categories, respectively, given their similar clinical courses, which result in motion loss addressable through stretching or release [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The study period was from January 2015 to December 2018. All costs are presented in U.S. dollars and correspond to the same time period.\u003c/p\u003e\n\u003ch3\u003eTreatment Patterns\u003c/h3\u003e\n\u003cp\u003ePrescription frequencies for wearable stretch-assist devices were determined by examining associated HCPCS codes for dynamic splints and turnbuckle/wormgear splints within the E1800-E1841 series of codes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The incidence of MRS was determined using Current Procedural Terminology (CPT) codes for procedures such as MUA, arthroscopic/open lysis of adhesions, arthroscopic/open synovectomy, or arthroscopic/open scar tissue debridement/release for each joint type (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The incidence of CPM could be determined only for the knee, as it is the only joint with its own unique billing code (E0935). All other joints are combined into a single code (E0936).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHCPCS codes for dynamic and turnbuckle/wormgear (SPS) stretch-assist splints.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1800- Elbow Dynamic Splint\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1801- Elbow SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1802- Forearm Sup/Pro Dynamic Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1805- Wrist Flex/Ext Dynamic Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1806- Wrist Flex/Ext SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1810- Knee Dynamic Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1811- Knee SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1815- Ankle Dynamic Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1816- Ankle SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1818- Forearm SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1840- Shoulder Dynamic Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE1841- Shoulder SPS Splint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMotion restoring surgery CPT codes for the shoulder joint.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPT Code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManipulation under anesthesia, shoulder joint, including the application of a fixation apparatus, but excluding dislocation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29805\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29820\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, surgical, synovectomy, partial\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29821\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, surgical, synovectomy, complete\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29822\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, surgical, debridement, limited\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29823\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, surgical, debridement, extensive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29825\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArthroscopy, shoulder, surgical, with lysis and resection of adhesions, with or without manipulation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRelease shoulder joint\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were incidence of each treatment modality, treatment cost, and recovery duration (defined as the time from the index surgery or treatment to the last physical or occupational therapy claim). A secondary outcome was the timing of device initiation relative to surgery or MRS.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using the R statistical programming language (version 4.3.3). Given the large sample size, results are presented as medians and interquartile ranges. The Wilcoxon Signed-Rank and Mood\u0026rsquo;s Median tests were used to compare recovery time and cost between modalities. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eIncidence\u003c/h2\u003e \u003cp\u003eThe incidence of joint contracture diagnosis, MRS, and wearable splint prescriptions was calculated from the CMS database. From 2015\u0026ndash;2018, an estimated 114,830 patients were diagnosed annually with joint contracture across five major joints (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). MRS was the dominant treatment, exceeding splint use at least threefold in all joints except the elbow. For example, among 47,255 shoulder contracture cases, 32,120 underwent MRS, while only 375 received any wearable stretch-assist splint (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Alternatively, in the elbow, prescriptive frequency was essentially equal between MRS (1,155 cases/year) and wearable stretch-assist splints (1,435 cases/year). This analysis included 3,165 Ermi Knee Extensionaters (791/year) prescribed to Medicare patients from 2015 to 2018, lumped into E1811, representing 38.5% of the 2,055 knee turnbuckle/wormgear splints prescribed to Medicare patients each year. (Note that the Ermi Knee Extensionaters are not a turnbuckle/wormgear stretch-assist splint.) However, the analysis excluded Ermi Flexionaters, as they were not prescribed to commercial or Medicare patients during the same period. The use of CPM devices was far more common than both dynamic splints and turnbuckle/wormgear splints, with a nearly sevenfold higher frequency than splints (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of yearly Medicare claims estimated from a 5% sample.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint Contracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47,255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28,615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16,690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16,630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5,640\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion Restoring Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32,120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27,225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17,720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1,155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDynamic Splint Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e610\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e935\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnbuckle/wormgear Splint Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCosts\u003c/h3\u003e\n\u003cp\u003eTreatment for joint contracture represented a substantial economic burden, exceeding \u003cspan\u003e$\u003c/span\u003e750\u0026nbsp;million annually in the Medicare population (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The majority of these dollars were related to MRS (\u003cspan\u003e$\u003c/span\u003e630\u0026nbsp;million or 83% of all costs). Wearable splints accounted for \u0026lt;\u0026thinsp;1% of total expenditures.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEstimate of yearly Medicare dollars spent on patients with the diagnosis of joint contracture, the use of motion restoring surgery, dynamic stretch-assist splint or turnbuckle/wormgear stretch-assist splint from a 5% sample of Revenue Center Total Charge Amount in the CMS Database.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eMean Yearly \u003cspan\u003e$\u003c/span\u003e Spent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContracture (M24.5x)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e282,247,706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e136,820,704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e98,522,071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e212,570,904\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e28,000,604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e758,161,989\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion Restoring Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e165,615,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e175,070,580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e88,541,026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e192,861,033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8,066,861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e630,154,500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDynamic Splint Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e20,844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e858,284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,846,547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,053,319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e622,722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,401,715\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTurnbuckle/wormgear Splint Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10,309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e132,720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,260,167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e126,585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e299,734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1,829,494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Efficacy\u003c/h2\u003e \u003cp\u003eAcross the shoulder, knee, and ankle, CPM showed no improvement in recovery duration, contracture prevention, or avoidance of MRS (Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). CPM patients had median costs 1.1\u0026ndash;15 times higher and recovery times 1.1\u0026ndash;7.2 times longer than non-CPM cohorts. The use of CPM in patients with a unilateral TKA increased contracture diagnosis (M24.56) and the need for MRS (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The findings were similar for the shoulder (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCost and recovery time comparison between patients treated with CPM and those treated without CPM.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder RCR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee TKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow Fx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost No CPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,933\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost CPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8,988\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e3,505\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e42,565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e330 to \u003cspan\u003e$\u003c/span\u003e854)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e16,051 to \u0026ndash;\u003cspan\u003e$\u003c/span\u003e4,126)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e237 to \u003cspan\u003e$\u003c/span\u003e533)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e3,184 to \u0026ndash;\u003cspan\u003e$\u003c/span\u003e3,965)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e51,584 to \u0026ndash;\u003cspan\u003e$\u003c/span\u003e21,819)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cost p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days No CPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days CPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e434\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(26 to \u0026minus;\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(554 to 104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9 to 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(1184 to \u0026minus;\u0026thinsp;43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(387 to 129)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT days p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo CPM Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,627\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,575\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,669\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPM Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect of continuous passive motion (CPM) usage on subsequent joint contracture diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTotal Knee Arthroplasty\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo CPM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion Restoring Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect of continuous passive motion (CPM) usage on subsequent need for motion restoring surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eShoulder Rotator Cuff Repair\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCPM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo CPM\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotion Restoring Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDynamic stretch-assist splints were prescribed in fewer than 8% of cases and were not associated with a significant change in treatment cost or duration for knee, shoulder, wrist, or ankle contractures. Total costs for patients who received a dynamic stretch-assist splint were 1.7-4 times higher than for patients who did not receive a dynamic stretch-assist splint. Out of 14,947 unilateral RCR patients, only 25 were prescribed a shoulder dynamic stretch-assist splint. Its use did not significantly change the need for MRS (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Furthermore, among those RCR patients who underwent MRS, 66% had a splint prescribed after surgery. Patients using the dynamic splint for knee TKA, shoulder RCR, elbow fracture, and wrist fracture had the device prescribed after MRS in over 50% of cases (Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Use of a dynamic stretch-assist splint was not associated with a change in recovery duration after TKA, RCR, wrist fracture, or ankle fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, in treating elbow fractures, dynamic stretch-assist splinting was associated with shorter recovery time and lower total costs than MRS (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). Across all joints, dynamic stretch-assist splints were prescribed late in the recovery timeline, with treatment starting on average over 5 months after primary surgery (Table\u0026nbsp;9).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCost and recovery time comparison between patients treated with dynamic low-load progressive stretch (LLPS) splints and those treated without LLPS.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder RCR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee TKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow Fx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost Normal Course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2,777\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost LLPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e11,777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8,320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5,822\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e4,841\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e5,950 to \u003cspan\u003e$\u003c/span\u003e9,386)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e2,123 to \u003cspan\u003e$\u003c/span\u003e6,388)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e2,041 to \u003cspan\u003e$\u003c/span\u003e3,475)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e1,049 to \u003cspan\u003e$\u003c/span\u003e7,149)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(\u003cspan\u003e$\u003c/span\u003e1,300 to \u003cspan\u003e$\u003c/span\u003e2,952)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cost p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days Normal Course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days LLPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(-54 to 135)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(44 to 234)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(29 to 83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-35 to 292)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(15 to 87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT Days p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost MRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e22,498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e17,075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e11,249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost LLPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e12,827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e15,654\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e7,543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e9,684\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e14,950\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e1,625 to -\u003cspan\u003e$\u003c/span\u003e9,804)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e968 to -\u003cspan\u003e$\u003c/span\u003e5,922)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e2,472 to -\u003cspan\u003e$\u003c/span\u003e4,443)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e5,035 to -\u003cspan\u003e$\u003c/span\u003e20,527)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e7,171 to -\u003cspan\u003e$\u003c/span\u003e15,718)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cost p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days MRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e333\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days LLPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(8 to -251)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(135 to -26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(25 to -36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(108 to -320)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-16 to -189)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT Days p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRS Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLPS Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14,947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7,112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder RCR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee TKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow Fx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Days from Primary to splint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e112.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% of Patients with both MRS and splint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% of Patients with splint ordered after MRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTurnbuckle/wormgear stretch-assist splints were prescribed even less frequently than dynamic stretch-assist splints. In a series of 14,947 patients, only one shoulder turnbuckle splint was prescribed to a patient two months after RCR surgery, without a diagnosis of shoulder contracture or adhesive capsulitis. Four out of the 11 turnbuckle splints used in patients with TKA were prescribed before their primary surgery (unilateral TKA). The seven turnbuckle stretch-assist splints used after TKA did not have a significant impact on postoperative recovery compared with MRS (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e10\u003c/span\u003e). Although sample sizes were small, the use of a turnbuckle/wormgear stretch-assist splint was associated with lower costs than MRS, with a comparable recovery duration.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCost and recovery time comparison between static progressive splints and motion restoring surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShoulder RCR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWrist Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee TKA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAnkle Fx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow Fx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost MRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e12,061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e11,249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e20,061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Cost SPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8,864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e10,200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e6,178\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e12,018 to \u003cspan\u003e$\u003c/span\u003e2,040)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e6,639 to \u003cspan\u003e$\u003c/span\u003e3,353)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-\u003cspan\u003e$\u003c/span\u003e19,981 to \u003cspan\u003e$\u003c/span\u003e3,192)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Cost p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days MRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian PT Days SPS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifference Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT days p-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRS Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e979\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSPS Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Patients (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14,947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6,058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,936\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7,112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2,680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite being on the market and available with an HCPCS code for over 20 years, wearable stretch-assist splints are underutilized as a treatment option for joint contractures, suggesting that the healthcare community does not consider them a viable option. On the other hand, MRS remains both the most commonly used and the most expensive treatment for joint contracture. Across the knee, shoulder, ankle, and wrist, MRS was prescribed far more often than any stretch-assist splint and accounted for more than 80% of contracture-related costs. These findings reflect a continued reliance on surgical management, even though non-operative alternatives, such as prolonged physical therapy, exist. The observed 234-day average delay in recovery after MRS highlights the long-term costs and quality-of-life implications for patients and payers, reinforcing the need for earlier, more effective non-operative treatment as an alternative to MRS.\u003c/p\u003e \u003cp\u003eDespite a decades-long history of Medicare coverage and clinical validation, providers prescribed wearable stretch-assist splints in fewer than 8% of contracture patients across all joints except the elbow. Moreover, providers initiated use too late, an average of 5 months after the primary surgery, and after MRS in more than half of cases. The data show that splints are being used reactively rather than proactively as a primary non-operative option. When applied too late, the ability to prevent further procedures, accelerate recovery, and reduce healthcare costs is greatly diminished (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Mechanical stretch therapy is a critical element of the remodeling phase of joint healing. It works by signalling to cells which collagen to produce, Type I vs Type III, and in which direction to be laid down. Stretching provides these \u0026ldquo;stress lines\u0026rdquo; for remodeling, with its effectiveness greater when initiated during the proliferation phase of healing. Clearly, MRS restarts the joint-healing process by sending it back to the hemostasis phase or, at least, to the inflammatory phase, resulting in a marked delay in recovery. Stretching after MRS should be delayed until the proliferative phase to allow joint inflammation to settle. Joint healing is not complete until the remodeling phase is completed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe presence of joint contractures, or delayed joint motion recovery, has plagued the healthcare community for centuries. With the advent of CPM for intra-articular joint healing in the 1980s, providers adopted it as both a preventive and reactive treatment for this problem [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Given the low prescription rate of wearable stretch-assist splints, possibly due to difficulty of use, the continued use of CPM suggests that the healthcare community seeks an easy-to-use, effective non-operative treatment for motion loss due to joint contractures. Interestingly, this study confirms that the use of the CPM was not associated with improved patient outcomes in unilateral TKA, shoulder RCR, elbow fractures, wrist fractures, or ankle fractures [\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], despite the healthcare community\u0026rsquo;s faith in its efficacy. This may merely reflect the ease of CPM use, the positive feedback patients using CPM provide to providers, or the success seen among a subset of CPM users.\u003c/p\u003e \u003cp\u003eThe elbow fracture cohort, in which non-operative treatment with wearable stretch-assist splinting demonstrated faster recovery and lower cost than MRS, illustrates the opportunity for success when devices are prescribed at the appropriate time for the appropriate joint. Unlike in other joints, the elbow showed near parity between surgical and non-operative prescriptions, suggesting greater clinician acceptance of wearable stretch-assist splint use, perhaps due to the known complexity of elbow MRS [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. However, even in the elbow, many wearable stretch-assist splints were prescribed late in recovery, limiting their potential benefit.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eClaims-based analyses cannot capture all clinical nuances. Coding variability, lack of functional outcome data, and absence of patient-level context limit granularity. Recovery time was estimated from therapy claim closure, potentially resulting in an underestimate of residual stiffness. Nonetheless, the large sample size, dual-database validation, and consistent cross-joint trends strengthen the reliability of these findings. Results regarding any stretch-assist device use may partly reflect selection bias toward more severe joint contracture or joint motion loss cases.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTreatment of joint contracture in the United States remains dominated by expensive surgical procedures that prolong recovery and drive the high cost of healthcare spending. Despite being on the market and available with an HCPCS code for over 20 years, wearable stretch-assist splints are underutilized as a treatment option for joint contractures, suggesting that the healthcare community does not consider them a viable option. The greater adoption of wearable stretch-assist splints for treating elbow joint contractures may reflect providers' reluctance to use elbow MRS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003eThis retrospective study was determined to be exempt from Institutional Review Board (IRB) review by Sterling IRB. As this observational study used previously collected, de-identified data, consent to participate was not applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eSS and SB are employees of ArthroResearch LLC; TB is founder and CEO of Ermi LLC.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo specific funding was received for this research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSS, SB, and TB contributed to study design, analysis, interpretation, and manuscript preparation. 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A Comparison of Rehabilitation Methods After Arthroscopic Rotator Cuff Repair: A Systematic Review. Sports Health. 2015;7(4):326\u0026ndash;34. PMID: 26137178; PMCID: PMC4481677.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindenhovius ALC, Jupiter JB. The posttraumatic stiff elbow: a review of the literature. J Hand Surg Am. 2007;32(10):1605\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrey BF, Askew LJ, Chao EY. A biomechanical study of normal functional elbow motion. J Bone Joint Surg Am. 1981;63(6):872\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Driscoll SW, Morrey BF, Korinek S, An KN. Elbow contracture: pathology and treatment. Instr Course Lect. 1999;48:365\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"joint contracture, motion-restoring surgery, dynamic stretch-assist splint, static progressive splint, turnbuckle/wormgear splint, continuous passive motion, recovery outcomes, healthcare costs, claims-based analysis, Medicare","lastPublishedDoi":"10.21203/rs.3.rs-8555717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8555717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to assess national treatment patterns, timing, and costs of interventions for joint contracture using Medicare and commercial claims data. Emphasis was placed on comparing the frequency, cost, and recovery outcomes associated with continuous passive motion (CPM), motion-restoring surgery (MRS), and wearable stretch-assist devices, including dynamic and turnbuckle/wormgear stretch-assist splints.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort analysis of the Centers for Medicare \u0026amp; Medicaid Services (CMS) and IBM MarketScan databases (2015\u0026ndash;2018) was conducted. Patients diagnosed with contracture of the knee, shoulder, elbow, wrist, or ankle were identified through medical diagnosis codes. Incidence, prescriptive patterns, recovery time, and costs were determined using corresponding claims-based information. Recovery duration was defined as the time from index treatment to the last rehabilitation claim. Comparative analyses were conducted using the Wilcoxon Signed-Rank and Mood\u0026rsquo;s Median tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMRS was the predominant treatment across all joints and accounted for the majority of costs associated with contracture care. Across joints, MRS-treated patients experienced significantly higher total costs and longer recovery durations, with an average 234-day delay relative to non-operative care. Wearable dynamic and turnbuckle/wormgear splints were prescribed in fewer than 8% of cases and were typically initiated months after primary surgery and often following MRS. CPM demonstrated no measurable benefit in recovery or prevention of contracture and was associated with higher costs. Only dynamic splint use after elbow fracture was associated with significantly shorter recovery compared to MRS.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCurrent clinical practice heavily favors MRS despite prolonged recovery and higher expenses. Non-operative mechanical stretch-assist devices are underutilized and typically prescribed too late to influence outcomes suggesting that the healthcare community does not consider them a viable option. The greater adoption of elbow splints may reflect providers' reluctance to use elbow MRS.\u003c/p\u003e","manuscriptTitle":"Motion-Restoring Surgery versus Non-Operative Stretch-Assist Devices for Treatment of Joint Contracture: Utilization, Timing, Cost, and Outcomes from Medicare and Commercial Claims","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 12:01:20","doi":"10.21203/rs.3.rs-8555717/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-24T11:17:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T19:06:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-16T04:39:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-16T04:37:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-01-09T01:24:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a89f23ca-ebad-4d72-99da-51d0fa3649b8","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T12:01:21+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 12:01:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8555717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8555717","identity":"rs-8555717","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}