Close Window
Aetna Aetna
Clinical Policy Bulletin:
Back Pain - Non Invasive Treatments
Number: 0232


Policy

  1. Quantitative Muscle Testing Devices

    Aetna considers the use of quantitative muscle testing devices (e.g., MedX Lumbar and Cervical Extension Devices, Isostation B-200 Lumbar Dynamometer, Kin-Com Physical Therapy Isokinetic Equipment, Cybex Back System, Biodex System 3, JTECH Tracker Freedom Wireless Muscle Testing) experimental and investigational when used for muscle testing because there is insufficient evidence that use of these devices improves the assessment of muscle strength over standard manual strength testing such that clinical outcomes are improved.

    Note: Isokinetic devices (e.g., Biodex, Cybex, and Kin-Com) and other exercise and testing machines (e.g., Isostation B-2000 and MedX) are considered acceptable alternatives for provision of medically necessary exercise in physical therapy.  In addition to use in muscle testing, the MedX and other machines have also been used for administering exercise therapy.  These devices can be used as exercise machines for administering physical therapy.  However, these particular brands of exercise devices have not been proven to be superior to standard brands of exercise equipment (e.g., Nautilus, etc.) when used for administering physical therapy.

  2. Orthotrac Pneumatic Vest

    Aetna considers the Orthotrac pneumatic vest, a non-surgical spinal treatment device that has been promoted to relieve back pain of various etiologies, experimental and investigational.

    The Orthotrac is an inflatable pneumatic vest that has been used to relieve back pain from a variety of causes (e.g., herniated disc, spinal stenosis, facet syndrome, spondylolysthesis, etc).  There is insufficient peer-reviewed published clinical evidence of the effectiveness of the Orthotrac pneumatic vest in relieving back pain. 

  3. Back School

    Aetna considers back school medically necessary for the treatment of persons with chronic or recurrent back pain, when such a program is prescribed by the member’s doctor and the program is conducted by a physical therapist or other appropriate recognized healthcare professional.  See CPB 0325 - Physical Therapy Services

    Note: Back school for occupational purposes may be excluded from coverage.  See CPB 0250 - Occupational Therapy Services; and CPB 0198 - Work Hardening Programs.  Please check benefit plan descriptions for details.

  4. Spinal Adjusting Instruments

    See CPB 0107 - Chiropractic Services.

  5. Khan Kinetic Treatment

    Aetna considers the Khan Kinetic Treatment experimental and investigational for the treatment of back pain or any other indications because its effectiveness has not been established.

See also CPB 0011 - Electrical Stimulation for Pain, CPB 0016 - Back Pain - Invasive ProceduresCPB 0132 - BiofeedbackCPB 0135 - Acupuncture, CPB 0180 - Vertebral Axial Decompression Therapy, CPB 0204 - Manipulation Under General AnesthesiaCPB 0207 - Prolotherapy, and CPB 0569 - Lumbar Traction Devices.



Background

Quantitative Muscle Testing Devices

Muscle strength testing may be used to determine bilateral differences in strength or other differences in patient resistance.  These differences may be characterized by the experienced examiner based on various technologies, i.e., manual, mechanized and computerized muscle testing.  These changes may be a result of alterations of function at various levels of the neuromuscular system and/or any other system related to the patient.  Computerized muscle testing has been used in clinical research to quantify muscle strength and enables the investigator to produce comparison reports, quantifying patient response to rehabilitation and therapy.  However, manual muscle testing is sufficiently reliable for clinical practice.  There is insufficient peer-reviewed published scientific evidence that computerized muscle testing leads to better patient outcomes.

The MedX lumbar/cervical extension machine has been proposed for use for isometric and isokinetic muscle testing and rehabilitation in persons with low back pain (LBP) and/or neck pain.  The MedX lumbar/cervical extension device has not been adequately validated as a test of isometric and isokinetic muscle strength in persons with back or neck pain.  In addition, the MedX machine has not been shown to be superior to any other particular brand of exercise equipment when used for administering physical therapy.  A technology assessment of the MedX Lumbar Extension Machine for the treatment of LBP by the Washington State Department of Labor and Industries (2003) concluded: “The evidence suggests that MedX may help to increase lumbar muscle strength.  However, studies do not clearly show MedX’s efficacy over other exercise programs.”  

Although there is limited evidence that when used as a training device, the MedX system can help to increase the strength of the lumbar as well as the cervical extensors, it has not been proven that the MedX machines are more effective than standard exercise equipment in functional strengthening.  Further investigation, especially controlled studies with pain patients is needed to demonstrate the accuracy of differentiation between normal subjects and patients, especially patients with non-spinal cord injuries of the cervical spine.  Additionally, more research is needed to define the contribution of this equipment to patient management, especially in relation to the significant outcomes of psychological distress, changes in daily activities, and ability to return to work in such patients.

The Isostation B-200 lumbar dynamometry equipment has been suggested for use for the evaluation and rehabilitation of persons with LBP.  Available evidence fails to establish the clinical effectiveness and significance of the use of the Isostation B-200 lumbar dynamometer for isometric and isokinetic muscle testing (spinal motion and trunk function) and rehabilitation in patients with LBP.  More research is needed to establish the ability of this technology to discriminate between normal subjects and patients, to establish test-retest reliability, and to define its contribution to and role in patient management.  Additionally, further research is needed to evaluate the relationship between dynamometric technology, psychological tests and behavior assessments.

The Cybex back system has been proposed for use for evaluation and rehabilitation of persons with LBP.  In addition, the Cybex back system has not been proven to be superior to any other particular brand of exercise equipment for administering physical therapy.

It has not been proven that the Cybex system is more effective than standard exercise equipment in functional strengthening.  More research is needed to increase confidence in interpretation of abnormal range of motion and strength data, to define rehabilitation goals, and more importantly to define the contribution of this equipment to the management of persons with LBP, especially in relation to health outcomes.

Other brands of isokinetic devices used for quantification of muscle strength include the Kin-Com Isokinetic Muscle Testing Device and the Biodex Muscle Testing Device.

In a cross-sectional study, Gruther and colleagues (2009) examined the accuracy and long-term reliability of dynamometric trunk muscle strength and endurance tests in patients with chronic LBP.  A total of 32 patients with chronic LBP, 19 healthy controls and 15 patients with chronic headache matched for age, sex and body mass index were included in the study.  Both patient groups and healthy controls performed isokinetic and isometric trunk extensor and flexor tests on a Biodex 2000 dynamometer.  The Biering-Sørensen test served to examine back muscle endurance.  Borg-Category-Ratio-Scales CR-10 rated participants' body experience immediately before and after the testing.  Patients with chronic LBP repeated measurements after 3 weeks.  Among dynamometric tests, isokinetic measurements revealed the best area under the curve (AUC = 0.89) for the discrimination between patients with chronic LBP and healthy controls.  Reliability testing revealed highly significant learning effects for isometric trunk flexion and isokinetic measurements.  The Biering-Sørensen test demonstrated excellent accuracy (AUC = 0.93) and no learning effects.  Borg-category-ratio-scale ratings were not associated with the observed changes.  The authors concluded that in patients with chronic LBP, dynamometric trunk muscle measures are limited to muscle function assessment purposes.  Monitoring treatment outcome in these patients with these measures appears to be problematic because of learning effects.  Based on these findings, the authors recommended the Biering-Sørensen test for management of chronic LBP rehabilitation.

Khan Kinetic Treatment

The Khan Kinetic Treatment (KKT), manufactured by Datrend Systems Inc (Richmond, British Columbia, Canada), is a medical device for the treatment of spine-related abnormalities causing pain.  According to the manufacturer, the KKT uses high-frequency small-amplitude sinusoidal waves to vibrate the vertebrae and repeatedly activate associated neuromuscular structures, which evoke multiple mechanisms of pain relief.  There is also a small unblinded randomized trial without placebo control, which found that, compared with a control group, the treatment group lowered both their self-recorded neck pain scores (p = 0.012) and pain medication dose (p = 0.048), although current functional assessment questionnaires (range of motion, overall activity, and recreation/work activities) did not detect changes (p = 0.233, 0.311, and 0.472, respectively) (Desmoulin et al, 2007).  Limitations of this study included a lack of blinding and lack of placebo control.  Other published literature on KKT spine treatment consists of a study of the effect of KKT treatment in an animal model (Desmoulin et al, 2010).

JTECH Tracker System

The JTECH Tracker Freedom Wireless Muscle Testing is designed for testing and documentation of strength loss due to injury or disease.  However, there is a lack of evidence regarding the effectiveness of the JTECH Tracker muscle testing system.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if criteria are met::
97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
CPT codes not covered for indications listed in the CPB::
95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)
97545 Work hardening/conditioning; initial 2 hours
+97546    each additional hour (List separately in addition to code for primary procedure)
97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes
HCPCS codes covered if selection criteria are met: :
S9117 Back school, per visit
Other ICD-9 codes related to the CPB: :
720.0 - 724.9 Dorsopathies
756.11 Spondylolysis, lumbosacral region
756.12 Spondylolisthesis
907.2 Late effect of spinal cord injury
907.3 Late effect of injury to nerve root(s), spinal plexus(es), and other nerves of trunk
V57.1 Other physical therapy


The above policy is based on the following references:

Quantitative Muscle Testing Devices

  1. Newton M, Waddell G. Trunk strength testing with iso-machines. Part 1: Review of a decade of scientific evidence. Spine. 1993;18(7):801-811. 
  2. Newton M, Thow M, Somerville D, et al. Trunk strength testing with iso-machines. Part 2: Experimental evaluation of the Cybex II back testing system in normal subjects and patients with chronic low back pain. Spine. 1993;18(7):812-824. 
  3. Mostardi RA, Noe DA, Kovacik MW, Porterfield JA. Isokinetic lifting strength and occupational injury. A prospective study. Spine. 1992;17(2):189-193. 
  4. Mellin G, Harkapaa K, Vanharanta H, et al. Outcome of a multimodal treatment including intensive physical training of patients with chronic low back pain. Spine. 1993;18(7):825-829. 
  5. Mooney V, Kenney K, Leggett S, Holmes B. Relationship of lumbar strength in shipyard workers to workplace injury claims. Spine. 1996;21(17):2001-2005. 
  6. Teasell RW, Harth M. Functional restoration: Returning patients with chronic low back pain to work -- revolution of fad? Spine. 1996;21(7):844-847. 
  7. Timm KE. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther. 1994;20(6):276-286. 
  8. Madsen OR. Trunk extensor and flexor strength measured by the Cybex 6000 dynamometer. Spine. 1996;21:2770-2776. 
  9. Dueker JA, Ritchie SM, Knox TJ, Rose SJ. Isokinetic trunk testing and employment. J Occup Med. 1994;36(1):42-48. 
  10. Sachs BL, Ahmad SS, LaCroix M, et al. Objective assessment for exercise treatment on the B-200 Isostation as part of work tolerance rehabilitation: A random prospective blind evaluation with comparison control population. Spine. 1994;19(1):49-52. 
  11. Ohnmeiss DD, Vanharanta H, Estlander AM, et al. The relationship of disability (Oswestry) and pain drawings to functional testing. Eur Spine J. 2000;9(3):208-212. 
  12. Ganzit GP, Chisotti L, Albertini G, et al. Isokinetic testing of flexor and extensor muscles in athletes suffering from low back pain. J Sports Med Phys Fitness. 1998;38(4):330-336. 
  13. Bronfort G, Evans R, Nelson B, et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine. 2001;26(7):788-799. 
  14. Bouilland S, Loslever P, Lepoutre FX. Biomechanical comparison of isokinetic lifting and free lifting when applied to chronic low back pain rehabilitation. Med Biol Eng Comput. 2002;40(2):183-192.
  15. Jackson N. Exercise therapy for the treatment of chronic low back pain. Evidence Centre Evidence Report. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2002.
  16. Evans R, Bronfort G, Nelson B, Goldsmith CH.  Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain.  Spine. 2002;27(21):2383-2389.
  17. Helmhout PH, Harts CC, Staal JB, et al. Comparison of a high-intensity and a low-intensity lumbar extensor training program as minimal intervention treatment in low back pain: A randomized trial. Eur Spine J. 2004;13(6):537-547.
  18. Walsworth M. Lumbar paraspinal electromyographic activity during trunk extension exercises on two types of exercise machines. Electromyogr Clin Neurophysiol. 2004;44(4):201-207.
  19. Washington State Department of Labor and Industries, Office of the Medical Director.  MedX Lumbar Extension Machine for the treatment of low back pain. Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries; November 7, 2003. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedXTa110703.pdf. Accessed November 4, 2005.
  20. de Koning CH, van den Heuvel SP, Staal JB, et al. Clinimetric evaluation of methods to measure muscle functioning in patients with non-specific neck pain: A systematic review. BMC Musculoskelet Disord. 2008;9:142.
  21. Gruther W, Wick F, Paul B, et al. Diagnostic accuracy and reliability of muscle strength and endurance measurements in patients with chronic low back pain. J Rehabil Med. 2009;41(8):613-619.

Orthotrac Pneumatic Vest

  1. Orthofix Inc. Orthotrac™ pneumatic decompression. McKinney, TX: Orthofix; 2005. Available at: http://www.orthofix.com/ofus/mainbody.htm. Accessed April 8, 2005.
  2. van Duijvenbode ICD, Jellema P, van Poppel MNM, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008;(2):CD001823.
  3. Dallolio V. Lumbar spinal decompression with a pneumatic orthosis (Orthotrac): Preliminary study. Acta Neurochir Suppl. 2005;92:133-137.
  4. Mahoney CB. Treating low back pain: The effect of the Orthotrac Pneumatic Vest on the cost of treatment and quality of life. CareManagement. 2001;7(4):27-31.

Back Schools

  1. Bigos S, Boyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research (AHCPR); December 1994. 
  2. Nordin M, Cedraschi C, Balague F, Roux EB. Back schools in prevention of chronicity. Baillieres Clin Rheumatol. 1992;6(3):685-703. 
  3. Raspe H, Kohlmann T, Luhmann D. The evaluation of back school programmes as medical technology - systematic review. Koln, Germany: German Agency for Health Technology Assessment at the German Institute for Medical Documentation and Information; 1997.
  4. Koes BW, van Tulder MW, van der Windt WM, Bouter LM. The efficacy of back schools: A review of randomized clinical trials. J Clin Epidemiol. 1994;47(8):851-862.
  5. Di Fabio RP. Efficacy of comprehensive rehabilitation programs and back school for patients with low back pain: A meta-analysis. Physical Ther. 1995;75(10):865-878.
  6. Revel M. Rehabilitation of low back pain patients. A review. Rev Rhum Engl Ed. 1995;62(1):35-44. 
  7. Linton SJ, Kamwendo K. Low back schools. A critical review. Phys Ther. 1987;67(9):1375-1383. 
  8. Nachemson A, Carlsson CA, Englund L, Goossens M. Back and neck pain. Report No. 145. Stockholm, Sweden: Swedish Council on Technology Assessment in Health Care (SBU); 2000. 
  9. NHS Centre for Reviews and Dissemination. Acute and chronic low back pain. Effective Health Care. York, UK: NHS Centre for Reviews and Dissemination; 2000;6(5).
  10. Heymans MW, van Tulder MW, Esmail R, et al. Back schools for non-specific low back pain. Cochrane Database Syst Rev. 2004;(4):CD000261.
  11. Heymans MW, Van Tulder MW, Esmail R, et al. Back schools for nonspecific low back pain: A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2005;30(19):2153-2163.
  12. McIntosh G, Hall H. Low back pain (acute). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.
  13. McIntosh G, Hall H. Low back pain (chonic). In: BMJ Clinical Evidence. London, UK: BMJ Publishing Group; May 2007.
  14. Tavafian SS, Jamshidi AR, Montazeri A. A randomized study of back school in women with chronic low back pain: Quality of life at three, six, and twelve months follow-up. Spine. 2008;33(15):1617-1621.
  15. Andrade SC, Araújo AG, Vilar MJ. Back school for patients with non-specific chronic low-back pain: Benefits from the association of an exercise program with patient's education. Acta Reumatol Port. 2008;33(4):443-450.

Khan Kinetic Treatment

  1. Desmoulin GT, Yasin NI, Chen DW. Spinal mechanisms of pain control. Clin J Pain. 2007;23(7):576-585.
  2. Desmoulin GT, Reno CR, Hunter CJ. Free axial vibrations at 0 to 200 Hz positively affect extracellular matrix messenger ribonucleic acid expression in bovine nucleus pulposi. Spine (Phila Pa 1976). 2010;35(15):1437-1444.


email this page   


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Aetna
Back to top