Physicians - Prescribing Practitioners

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For approximately the first 6-8 weeks following a first time  injury or surgery it is important to closely monitor post operative progress --- your patient’s rate of progress in recovering joint motion. Situationally,  the physical therapist may or may not draw your attention to abnormal deficits, in range of motion, but it is an important healing period.

As an example, we heard (from numerous treating physical therapists, treating knee flexion deficits) that a normal knee patient who begins conventional therapy, experiences a normal gain of  about 5 degrees of flexion  per week. Any pace slower than that is cause for concern. The short timeframe for development of intractable contractures means that staying alert is essential.

When communication about patients is good, a physical therapist may suggest that you order an ERMI device when they notice that a patient is failing to make satisfactory progress. It is important to follow this suggestion promptly. Again, the window of opportunity to avoid a permanent loss of motion may be closing.

However, many therapists are unaware of the ERMI option. Others resist using an ERMI device and prefer treating a patient longer manually themselves, despite some early signs of  lack of motion gains. Other therapists believe that all home mechanical therapy is the same and compliance is low.

When you experience the difference, you can help any of these types of therapists understand that ERMI devices are different and will improve their clinical outcomes.

It is important to note that problems can occur in detecting failure to recover range of motion in time to correct it because:

  • Some PTs do not habitually measure range of motion precisely, which is a best practice.
  • Communication gaps occur between Physical Therapists and Physicians when patients are in rehab and do not go back to the physician’s office for a check up for several weeks. Others neglect to draw your attention to the big picture, and expect you to pour over the detailed patient notes, buried in their report and see their implications.
  • Communication gaps and separate visits to physician and physical therapy offices can often cause lags in the detailed patient notes about how little range of motion progress is being made, so the implications associated with deficits in motion and the necessity to medically treat the condition can be unintentionally buried.

A good way to prevent these problems is to communicate more and work with PTs closer, who you know are alert to these issues, or to include in your order a request for the PT to measure and report the actual number of degrees of progress or loss each week.

If you are dealing with a therapist whose clinical track record is unknown to you, be sure to stay alert for lack of progress. Take the initiative to determine if there is lack of progress, and consider introducing or ordering an ERMI device.

Alternatively, a trained ERMI representative will work and partner with you, your team, and the therapist to identify patients who are failing to make gains under usual therapy, and before the scar tissue matures further beyond 8-12 weeks post surgery in the natural history of this small segment of patients. In cases where the patient has a history of failing to make motion gains, some physicians order ERMI devices to support rehab and physical therapy more aggressively after second surgeries or manipulation under anesthesia (MUAs). These physicians treat known outliers earlier by ordering ERMI devices for use immediately after a second procedure on the joint to avoid further medical complications.

Cincinnati SportsMedicine and Orthopaedic Center

I have been asked by our therapists at the Cincinnati SportsMedicine & Orthopaedic Center to provide a physician's perspective on the utilization and benefit of the ERMI (end range of motion improvement) extension and flexion equipment to our Medicare population and as well our population of all patients.

The extension and flexion equipment has received an enthusiastic endorsement not only by all of the physicians and therapists at our center, but as well more importantly, our patients. First, it must be noted that there are already devices and splints which allow a patient to gain knee extension and flexion after major total knee replacement or other complex knee surgery. These devices are, however, much less efficient in my clinical experience. The devices, which our company has utilized on our patients, allows the patients to adjust the level of tension. Therefore, the patient can start the course of treatment in a graduated fashion thus allowing progressive increasing amounts of tension which translates to increasing knee extension and flexion as a beneficial result. It should be noted that between 10-25% of all patients undergoing major knee surgery have difficulties achieving the limits of motion. We have used the knee extensionator extensively to assist with achieving full knee extension. Achieving this end range is functionally critical for a normal symmetric gait pattern. I feel this device has been very effective for our patients achieving this functional goal. Of equal importance is the utilization of the knee flexionator. This device has made a very dramatic impact on our practice. This is the only device that I know of that truly provides an increase in gentle tension and flexion allowing the patients to administer the tension themselves.

In the past, we have had to utilize rather primitive methods including ropes, which pull against the knee in different positions. The flexionator allows the patient to sit in. a comfortable position applying increasing tension, and there have been numerous instances where manipulation under anesthesia of the knee joint has been avoided. I feel this increased tolerance of the exercise and the associated objective feedback improved the compliance of a range of motion over pressure program. As a rule, increased compliance equals increased results.

I would, therefore, provide a high recommendation for these machines because they have had an exceedingly strong positive impact on our patient outcomes.

I would note that I do not have a conflict of interest with this company as I do not own any shares.


Frank R. Noyes, M.D.
Clinical Professor of Orthopaedic ·surgery
President and Medical Director
Cincinnati Sportsmedicine and Orthopaedic Center
Cincinnati Sportsmedicine Research and Education Foundation