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Medical Policy
|Electrical Bone Growth Stimulation
|Policy #:
|Current Effective Date:
|Last Review Date:
This document addresses the use of invasive, noninvasive, and semi-invasive electrical bone growth stimulation devices for the treatment of orthopedic and neurosurgical conditions including fresh fractures, fracture nonunions, delayed unions, pseudoarthroses, and failed spinal fusions.
Note: Please refer to the following document for additional information related to devices used to stimulate bone growth:
|Position Statement
Medically Necessary:
Not Medically Necessary:
Noninvasive electrical bone growth stimulation is considered not medically necessary when either of the following contraindications is present:
Investigational and Not Medically Necessary:
Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures
The efficacy of electrical bone stimulation as an adjunct to spinal fusion surgery or as a treatment of failed spinal fusion surgery (salvage therapy) is based on: 1) data from a randomized, controlled clinical trial of subjects meeting the criteria for high risk for development of failed fusion, suggesting that invasive or noninvasive electrical bone stimulation as an adjunct to spinal fusion surgery is associated with a significantly higher fusion success rate in the treated group compared with the control group (Foley, 2007; Goodwin, 1999; Kane, 1988; Linovitz, 2002; Mooney, 1990), and 2) data from uncontrolled case series of subjects with failed spinal fusion suggesting that noninvasive electrical stimulation results in a significantly higher fusion rate. The lack of controlled clinical trials is balanced by the fact that the participants served as their own controls. The following discussion focuses on different types of fusion procedures and different types of electrical stimulation.
Instrumented Spinal Fusion
Kucharzyk (1999) reported on a controlled prospective nonrandomized trial of implantable electrical stimulation in individuals undergoing instrumented posterior spinal fusion with pedicle screws. A case series of 65 subjects who did not use electrical stimulation was compared with a later series of similar subjects who did receive implantable electrical stimulation. Fusion success was 95.6% in the stimulated group compared to 87% in the nonstimulated group, a statistically significant difference. It appears that all subjects had at least one or more high risk factor for failed fusion, including smoking history, prior surgery, multiple fusion levels, or diabetes.
Rogozinski and Rogozinski (1996) reported on the outcomes of two consecutive series of subjects undergoing posterolateral fusions with autologous bone graft and pedicle screw fixation. The first series of 41 subjects were treated without electrical stimulation, while the second group of 53 subjects received invasive electrical stimulation. Those receiving electrical stimulation reported a 96% fusion rate, compared to an 85% fusion rate in the unstimulated group. The fusion rate for subjects receiving stimulation compared to no stimulation was also significantly higher among those considered at high risk due to previous back surgery or multiple fusion levels. There was not a significant increase in the fusion rate among non-smokers (without a risk factor), but the comparative fusion rates for all subjects without high risk factors was not presented.
Noninvasive Electrical Stimulation
Goodwin and colleagues (1999) reported on the results of a study that randomized 179 subjects undergoing lumbar spinal fusions to receive or not receive capacitive coupling (CC) electrical stimulation. A variety of surgical procedures, both with and without instrumentation, were used; subjects were not limited to "high risk" participants. Inclusion criteria did not describe an exact time of postoperative application of the device. The overall successful fusion rate was 84.7% for those in the active group compared to 64.9% in the placebo group, a statistically significant difference. While the actively treated group reported increased fusion success for all stratification groups (according to fusion procedure, single or multilevel fusion, smoking or nonsmoking groups), in many instances the differences did not reach statistical significance because of small numbers. For example, the subgroups in which there was not a significant difference in fusion between the active and placebo groups included subjects who had undergone previous surgery, smokers and those with multilevel fusion. In addition, there were numerous dropouts in the study and a 10% noncompliance rate with wearing the external device for up to 9 months.
Mooney and colleagues (1990) reported on the results of a randomized double-blind study of 195 subjects undergoing initial attempts at interbody lumbar fusions with or without fixation to receive or not receive pulsed electromagnetic fields (PEMF) stimulation. Subjects were not limited to high-risk groups. Those in the active treatment group were fitted postoperatively (onset of application was not described) with a special brace with electromagnetic coils, which they were instructed to wear at least 8 hours per day. The treatment group reported a 92% success rate with PEMF, compared to a 65% success rate in the placebo group. On subgroup analysis, the treatment group consistently reported an increased success rate. Subgroups included graft type, presence or absence of internal fixation, or presence or absence of smoking.
Linovitz and colleagues (2002) conducted a double-blinded clinical trial that randomized 201 subjects undergoing 1- or 2-level posterolateral fusion without instrumentation to undergo active or placebo electrical stimulation using a combined magnetic field (CMF) device. Unlike CC or PEMF devices, the CMF device requires a single 30-minute treatment per day with the device centered over the fusion site. In this trial, subjects applied the device within 30 days postoperatively and were treated for 9 months. Among all subjects, 64% of those in the active group showed fusion at 9 months compared to 43% of those with placebo devices, a statistically significant difference. On subgroup analysis, there was a significant difference among women, but not men.
Foley and colleagues (2008) reported results from a multicenter, single-blinded, randomized, placebo-controlled trial (n=323) using the Cervical-Stim® (Orthofix®, Inc., Lewisville, TX), a noninvasive, PEMF bone growth stimulator indicated as an adjunct to cervical spinal fusion surgery in subjects at high risk for nonunion, based either on smoking history or multilevel fusion procedures. In the treatment arm of the trial (n=163), the PEMF device was applied 1 week after cervical fusion; the device was worn for 4 hours per day for 3 months. At 6 months postoperatively, the PEMF group had a significantly higher fusion rate than the control group (83.6% vs. 68.6%, p=0.0065), which disappeared at 12 months (92.8% vs. 86.7%; p=0.1129).
In summary, studies in the peer-reviewed literature suggest that electrical stimulation may improve fusion rates in individuals undergoing instrumented or non-instrumented spinal surgery. These studies focus on individuals at high risk for fusion failure due to prior failed spinal fusion, Grade III or worse spondylolisthesis, and fusion performed at more than one level. Other comorbid risk factors for spinal fusion failure exist, including tobacco use or alcoholism, diabetes, renal or other metabolic diseases, nutritional deficiency, obesity, severe anemia or steroid therapy. Li and colleagues (2011) evaluated the effect of perioperative nonsteroidal anti-inflammatory drugs (NSAIDs, including COX-2 selective inhibitors) on the success rate of spinal fusion procedures. The analysis included five retrospective comparative studies, suggesting that short-time (< 14 days) exposure to normal-dose NSAIDs (celecoxib, diclofenac sodium, ketorolac, or rofecoxib) was safe after spinal fusion, whereas short-time (< 14 days) exposure to high-dose ketorolac increased the risk of nonunion, suggesting that the effect of perioperative NSAIDs on spinal fusion may be dose-dependent. The authors concluded that additional studies are needed to determine whether long-time exposure to normal-dose NSAIDs could increase the risk of nonunion and which type of NSAIDs would most likely have the worse effect on spinal fusion. At this time, there are no randomized controlled trials in the peer-reviewed literature that demonstrate an effect between NSAID use and spinal fusion failure.
There is insufficient evidence in the peer-reviewed medical literature to determine the magnitude of benefit associated with electrical stimulation in individuals considered at average risk for fusion failure (Akai, 2002) and for the treatment of spondylolysis or pars interarticularis defect (Fellander-Tsai and Micheli, 1998; Pettine, 1998). These two small case series suggest a treatment benefit of noninvasive electrical stimulation by decreasing pain and healing of the pars defects. Stasinopoulos (2004) performed a critical review of the literature which included these two case series, reporting that conclusions cannot be drawn concerning whether noninvasive electrical stimulation:
…is more effective than other conservative interventions or whether it can be used for the treatment of this condition, because the size of sample is too small and the results cannot be generalized to the rest of the population. Further studies with more patients and more detailed procedures are needed to establish what the exact role of external electrical stimulation should be in the management of patients with spondylolysis.
Finally, in the treatment arm of the clinical trials when noninvasive electrical bone growth stimulation was used as an adjunct to spinal fusion procedures, the timing of application of the device was variable, from 1 week to 30 days postoperatively. These clinical trials suggested significantly higher fusion success rates in the treatment group compared with the control group, despite the variation in device application time.
Other Considerations Regarding EBGS for Lumbar Spinal Fusion Procedures
The 2005 American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) guidelines (Resnick, 2005) for the performance of fusion procedures for degenerative disease of the lumbar spine, use of bone growth stimulators, states:
There have been a number of randomized studies supporting the use of ES for the promotion of bone healing following lumbar fusion. All of the published studies have methodological flaws that prevent the studies from providing Class I medical evidence. There is, however, Class II and III evidence to support the use of direct current stimulation or capacitative coupled stimulation (CCS) for enhancing fusions rates in high-risk patients undergoing lumbar PLF. A beneficial effect on fusion rates in patients not a "high risk" has not been convincingly demonstrated, nor has an effect been shown for these modalities in patients treated with interbody fusion. There is limited evidence both for and against the use of PEMFS for enhancing fusion rates following PLF. Class II and III medical evidence supports the use of PEMFS for promoting arthrodesis following interbody fusion. Although some studies have purported to demonstrate functional improvement in some patient subgroups, other studies have not detected differences. All of the reviewed studies are significantly flawed by the use of a four-point patient satisfaction scale as the primary outcome measure. This outcome measure is not validated. Because of the use of this flawed outcome measure and because of the conflicting results reported in the better-designed studies that assess functional outcome, there is no consistent medical evidence to support or refute use of these devices for improving patient outcomes.
A 2014 update published after the 2005 AANS/CNS guidelines states there is no evidence regarding bone growth stimulation that conflicts with the previous recommendations (Kaiser, 2014). Additional recommendations state:
The routine use of direct current stimulation (DCS) in patients over the age of 60 years is not recommended, as the evidence demonstrates no impact on fusion rates (single Level II study). For patients younger than 60 years of age, undergoing a lumbar fusion, the use of DCS is an option as studies have demonstrated a positive impact on fusion rate; however, there is insufficient evidence regarding its impact on clinical outcome (single level III study/multiple Level IV studies). There is insufficient evidence to recommend for or against the use of PEMFS as a treatment alternative to revision surgery in patients presenting with pseudarthrosis following posterior lumbar fusion (single Level IV study).
Electrical Stimulation for Non-Spinal Indications
A number of systematic reviews and meta-analyses of the randomized trials assessing electrical stimulation have been published in the peer-reviewed medical literature. Three of these meta-analyses suggest there is a treatment effect from electrical stimulation on bony union (Akai, 2002; Griffin, 2008; Walker, 2007). A meta-analysis conducted by Mollon and colleagues (2008) reviewed 11 articles using PEMF (8 trials) or CC field (3 trials) in the treatment of a variety of long-bone lesions, including fresh fractures, delayed or nonunions, osteotomies, and stress fractures. Evidence from four trials reporting on 106 delayed union or nonunions demonstrated an overall nonsignificant pooled relative risk of 1.76 (95% confidence interval [CI], 0.8 to 3.8; p=0.15) in favor of electrical stimulation. However, as evidenced by the confidence interval, this effect failed to reach significance. Single studies found a positive benefit of electrical stimulation on callus formation in femoral intertrochanteric osteotomies, a limited benefit for conservatively managed Colles fracture or for lower limb-lengthening, and no benefit on limb-length imbalance and the need for reoperation in surgically managed pseudarthroses or on time to clinical healing in tibial stress fractures (Beck, 2008). Clinical outcomes were examined in three of the trials, suggesting minimal or no benefit in pain reduction or fracture site tenderness when electrical stimulation was used as an adjunct to surgery for femoral neck fractures or to treat tibial shaft nonunions. Pooled analysis did not show a significant impact of electrical stimulation on delayed or nonunion long bone fractures as a number of limitations were apparent in methodological quality across the studies, including significant heterogeneity among the studies (I[2] = 60.4%). This meta-analysis also suggests the current evidence from randomized controlled trials is insufficient "to conclude a benefit of electromagnetic stimulation in improving the rate of union in patients with a fresh fracture, osteotomy, delayed union or nonunion" (Mollon, 2008). Goldstein and colleagues (2010) concluded that these meta-analyses "highlighted the fact that small methodologically limited trials make up the best available evidence on the use of electrical stimulation and fracture healing," despite limitations including wide confidence intervals with results and significant heterogeneity between trials.
In a Cochrane review and meta-analysis, Griffin and colleagues (2011) pooled data from four studies involving 125 participants to assess the effects of electromagnetic stimulation for treating delayed union or nonunion of long bone fractures in adults. Three studies evaluated the effects of PEMF and one study, CC electric fields; most data related to nonunion of the tibia. Although all studies were blinded randomized placebo-controlled trials, each study had limitations. The primary measure of the clinical effectiveness of electromagnetic stimulation was the proportion of participants whose fractures had united at a fixed time point. The overall pooled effect size was small and not statistically significant (risk ratio 1.96; 95% CI, 0.86 to 4.48; 4 trials). There was substantial clinical and statistical heterogeneity in this pooled analysis (I[2] = 58%). A sensitivity analysis conducted to determine the effect of multiple follow-up time-points on the heterogeneity amongst the studies showed that the effect size remained non-significant at 24 weeks (risk ratio 1.61; 95% CI 0.74 to 3.54; 3 trials), with similar heterogeneity (I[2] = 57%). No study reported functional outcome measures. The authors concluded that though the available evidence suggests that electromagnetic stimulation may offer some benefit in the treatment of delayed union and nonunion of long bone fractures, it is inconclusive and insufficient to inform current practice. More definitive conclusions on treatment effect await further well-conducted randomized controlled trials.
Shi and colleagues (2013) conducted a prospective, randomized controlled trial of PEMF as an adjunct for the management of delayed union (that is, between 16 weeks and 6 months) in 58 individuals with long-bone fractures. Clinical and radiological assessments were performed to evaluate the healing status. Treatment efficacy was assessed at 3-month intervals. At the end of the study, only the rate of healing at an average of 4.8 months with PEMF treatment was statistically significant; however, it was not clear if this was a prespecified endpoint. Participants in the PEMF group showed a higher rate of union than those in the control group after the first 3 months of treatment, but this difference failed to achieve statistical significance.
According to the U.S. Food and Drug Administration's (FDA) labeling for the various devices, electrical stimulation has not been cleared or indicated for use to enhance healing of fresh fractures that are considered to be at high risk for delayed or nonunion. Two multicenter, randomized, double-blind trials evaluating the use of electrical stimulation to accelerate healing in acute scaphoid fractures (Hannemann, 2012) or reduce the rate of surgical revision because of delayed union or nonunion in acute tibial shaft fractures (Adie, 2011) failed to demonstrate the effectiveness of PEMF stimulation for these indications. In follow-up to the 2012 pilot trial, Hannemann and colleagues (2014) found little advantage of 6 weeks of PEMF for the treatment of fresh (≤ 5 days from injury) scaphoid fractures when healing was assessed by computed tomography (CT) scans versus conventional scaphoid radiographs. Outcomes included the time to clinical and radiologic union and functional outcome at 6, 9, 12, 24, and 52 weeks. Radiologic union measured by CT was not significantly different between the two groups. The median time to clinical union was 6 weeks in both groups. The return to normal range of movement at the wrist was 12 weeks in both groups. Grip strength of the dominant hand returned to normal earlier with PEMF, but there was no significant difference in return of grip strength of the nondominant hand. This sham-controlled trial does not support a benefit for PEMF stimulation as an adjunctive treatment for fresh scaphoid fractures.
Overall, there are no well-designed, prospective, randomized controlled trials on the effectiveness of invasive electrical stimulation for fracture nonunion, or invasive or noninvasive electrical stimulation for the treatment of delayed/incomplete unions, patellar tendinopathy, or stress fractures. It is uncertain whether electrical stimulation offers an additional benefit compared to standard treatment alone (cast or brace immobilization, or surgery) for these types of fractures or joint deficiency/deformity.
Fracture Nonunions
Externally used CC and PEMF stimulation results in success rates for fracture nonunion that are consistently reported between 80% to 89% in appropriately selected individuals (Simonis, 2003). There is, however, no substantive clinical evidence to predict a specific duration of treatment when treating fracture nonunions with electrical stimulation. The location and type of fracture, risk factors of the individual, the duration of nonunion prior to treatment, and past failed bone graft or failed electrical therapy are factors that may affect the duration of electrical stimulation therapy. The medical literature, including prospective, double-blind, randomized controlled trials and retrospective case series, are limited in reporting time-to-heal outcomes as measured by radiographic evidence of bone healing. For those individuals where healing outcomes were reported for long bone fracture nonunions treated with electrical stimulation, healing rates were documented within 3 months of initiation of treatment to > 1 year (AHRQ, 2005).
While electrical stimulation for the treatment of orthopedic conditions has been shown to be of benefit in the treatment of long bone and short bone fracture nonunions, it is considered as either an alternative to surgical treatment or a salvage treatment for failed surgical interventions. It should not be used as an adjunct to surgical treatment. In these cases, surgical treatment is considered the definitive therapy and an adequate period of time should be allowed for evaluation of positive results.
Hallux valgus, commonly referred to as a bunion, is a complex group of disorders consisting of a lateral deviation of the great toe, outward angulation of the metatarsal toward the other foot, separation of the heads of the first and second metatarsals, and prominent soft-tissue thickening over the medial surface of the head of the first metatarsal. When conservative measures such as pads and cushions and functional foot orthotics fail to reduce the associated pain or slow the progression of the deformity, surgical correction may be indicated. The choice of surgical procedure is based on a biomechanical and radiographic examination of the foot. A bunionectomy procedure (such as an Akin, Chevron, Keller, Lapidus, or Mitchell metatarsal osteotomy) may be performed to correct a symptomatic hallux valgus by reconstructing the bones and joint to restore normal, pain-free function. The most common bunionectomy procedure performed is the first metatarsal neck osteotomy, which involves a controlled 'surgical fracture' of the bone by cutting and realigning the first metatarsal near the level of the joint; additional procedures may involve soft tissue correction along with concomitant bony correction. Complications following a bunionectomy procedure vary depending on the surgical technique and procedure, including, but are not limited to delayed healing of the incision, osseous malunion or nonunion, osteomyelitis, or avascular necrosis. The peer-reviewed medical literature includes prospective, comparative and evaluation studies and retrospective case series reporting low postsurgical complication rates following specific osteotomy procedures for hallux valgus (Dennis, 2011; Enan, 2010; Lee, 2010; Miller, 2011). While there is a lack of published, randomized controlled trials comparing the efficacy of electrical bone growth stimulation to sham treatment for postsurgical bunionectomy nonunion, the stimulation device may be a treatment option for individuals to reduce the need for further surgical revision when the individual's osteotomy site has demonstrated no evidence of progression of healing.
There are no studies in the peer-reviewed literature specifically focused on improved healing rates following uncomplicated bunionectomy procedures (first metatarsal osteotomy) as compared to a period of immobilization and limited weight bearing; in addition, these surgeries are not considered at high risk for post-surgical nonunion.
Arthrodesis of the Ankle or Knee
The use of noninvasive electrical stimulation has been studied as an adjunct treatment for joint fusion secondary to failed arthrodesis of the ankle and knee. While the evidence for this application is not extensive, there are several reports that illustrate the usefulness of this therapy. In this situation, the initial joint fusion should be considered the definitive treatment for these types of fractures. In the event that this treatment fails, it may be appropriate to apply electrical stimulation immediately following the revision procedure. The level of evidence to support this conclusion is reported in multiple case series in the medical literature.
A search of the peer-reviewed literature evaluating the use of implantable bone stimulators for lower extremity joint arthrodesis identified a small number of case series that focused on foot and ankle arthrodesis in individuals at high risk for nonunion (Petrisor, 2005). Risk factors for nonunion included smoking, diabetes mellitus, Charcot (diabetic) neuropathy, steroid use and previous nonunion. The largest case series described outcomes of foot or ankle arthrodesis in 38 high-risk subjects (Lau, 2007). Union was observed in 65% of cases by follow-up evaluation (n=18), or chart review (n=20). Complications were reported in 16 (40%) cases, including 6 cases of deep infection, 5 cases of painful or prominent bone stimulators necessitating stimulator removal. A multicenter retrospective review described outcomes from 28 high-risk subjects with arthrodesis of the foot and ankle (Saxena, 2005). Union was reported for 24 (86%) cases at an average of 10 weeks; complications included breakage of the stimulator cables in 2 subjects and hardware failure in 1 subject. Five subjects required additional surgery. There continues to be insufficient evidence to support the efficacy of invasive or semi-invasive electrical stimulation for these non-spinal indications.
Distraction Osteogenesis
There is currently a lack of large, randomized, sham-controlled trials of homogeneous study populations to support the use of PEMF for enhancing bone formation in distraction osteogenesis (DO) following limb-lengthening procedures. Sabharwal (2011) reported that a small number of adolescents who underwent limb lengthening during DO did not demonstrate a difference in the rate or amount of new bone formation in participants who received treatment from an active PEMF coil compared to sham coil treatment (Eyres, 1996). Luna Gonzalez and colleagues (2005) evaluated a small group of adolescents (n=30) of short stature who underwent bilateral humeral lengthening. At Day 10 after surgery, PEMF stimulation was started on one side, for 8 hours/day. The extremity managed with PEMF was reported as exhibiting faster callus formation and greater bone density then did the contralateral control side. Sabharwal (2010) concluded, however, that "Because of limited data and multiple variables, including duration of PEMF treatment and its use in upper versus lower extremities, the role of PEMF during DO remains unclear."
Other Considerations
Definitive selection criteria of candidates for noninvasive electrical bone growth stimulation have not been firmly established. However, there is sufficient evidence to conclude that this technology can provide benefit for individuals with persistent long bone nonunions. According to the product labeling for a noninvasive pulsed electromagnet bone growth stimulator used as an adjunct to cervical fusion surgery in individuals at high risk for nonunion (Cervical-Stim, Orthofix, Inc., Lewisville, TX), the device has not been evaluated in the treatment of individuals with the following conditions: osseous or ligamentous spinal trauma, spondylitis, infection, Paget's disease, moderate to severe osteoporosis, metastatic cancer, renal disease, rheumatoid arthritis, uncontrolled diabetes mellitus, individuals prone to vascular migraine headache, seizure, epilepsy, thyroid conditions or neurological diseases. The product label of the Physio-Stim® bone growth stimulator (Orthofix Inc., Lewisville, TX) states the device:
…is indicated for the treatment of an established nonunion acquired secondary to trauma, excluding vertebrae and all flat bones, where the width of the nonunion defect is less than one-half the width of the bone to be treated. A nonunion is considered to be established when the fracture site show no visibly progressive signs of healing.
Similar safety and effectiveness information is identified on the FDA premarket approval (PMA) applications for other devices. These summaries state the devices are contraindicated in individuals lacking skeletal maturity, individuals with a demand-type pacemaker or implantable cardioverter defibrillator (ICD), and pregnant women. Although indications vary among devices, the safety and effectiveness of electrical bone growth stimulation has not been established with a nonunion secondary to or in connection with a pathological condition, is not indicated for misaligned fracture nonunion, when a synovial pseudarthrosis exists, when the bone gap is ≥ 1 centimeter or > ½ the diameter of the bone, and for individuals who are unable to be compliant with the appropriate use of a noninvasive device and treatment regimens.
Electrical bone growth stimulation describes the use of a device, either implanted into the body or worn externally, that uses an electric field or current to stimulate the growth of bone tissue. These devices have proven effective in the treatment of failed bone growth, such as fracture nonunions or failed bone fusion procedures. Spinal fusion is a procedure that involves surgically fusing two or more vertebrae using bone grafts or bone graft substitutes. Various types of instrumentation may be used to promote union.
Standard management of fractures includes fracture site stabilization with external or internal fixation, compression devices, with or without casting. Risk factors for fracture nonunion include insufficient blood supply as a result of severe trauma, inadequate immobilization at the fracture site, contamination at the fracture site, a gap with no bone spanning the fracture site, infection, bone tissue loss, and other risk factors such as alcoholism, NSAID use in the postoperative period in traumatic long-bone fractures (Jeffcoach, 2014), smoking/tobacco use (Jefffcoach, 2014; Scolara, 2014), advanced age, poor nutrition, diabetes, osteoporosis, or metabolic dysfunctions. Delayed or incomplete fracture union occurs when fracture healing has not progressed within the expected timeframe for the site and type of fracture in a given individual despite ongoing bone growth activity. In contrast, fracture nonunion is the cessation of all healing processes, the absence of spontaneous healing, and the need for intervention for healing to resume. The diagnosis of fracture nonunion is based on pain and motion at the fracture site and on findings from radiographs, fluoroscopy, bone scintigraphy, and bone scanning. Further evaluation of healing and fracture nonunion may be established with CT scans, x-ray tomograms, and magnetic resonance imaging (MRI).
Electrical stimulation devices can be categorized as invasive, semi-invasive, or noninvasive. Invasive devices use a direct current (DC) delivered directly to the fracture site by way of implantable electrodes. This surgical procedure involves implantation of an induction coil, creation of a passage under the skin for the cable, and securing of the powerpack/control module at some distance from the bone lesion. According to Goldstein and colleagues (2009), implantable devices have the benefits of providing constant stimulation of the bone at the nonunion or fracture site, thus increasing compliance of the user and optimizing electrode positioning. However, drawbacks include the risk of the surgical procedures for implantation and removal, the possibility of infection, prominent or painful implants, and the potential for lead breakage or electrode dislodgement. Semi-invasive direct current stimulation devices involve implantation of induction wires, but the power pack is worn externally. The cable connecting the two passes through the skin, requires careful attention to prevent infection. To date, no semi-invasive electrical bone growth stimulator devices with FDA approval or clearance were identified in the FDA medical devices database.
Noninvasive devices deliver current by way of capacitive coupling (CC), pulsed electromagnetic field (PEMF) or combined electromagnetic field (CMF) technology. Some of the devices used for spinal indications may be worn like a belt or are in the form of patches attached to the skin with adhesive. For other indications, these devices may consist of a flexible foam covered metal ring that is molded to the area of concern and held in place with straps or adhesive. The power pack/control module is attached by wires and may be worn on a belt or placed in a pocket. The proper use of an externally applied device, whether CC or PEMF, requires compliance by the user and long-term immobilization of the limb using internal fixation, external fixation, casting or bracing. Adherence to the treatment plan is of particular importance with PEMF given the duration of daily treatment sessions required by the user.
Appendicular skeleton: Composed of bones of the upper and lower limbs, and the bones that anchor the upper and lower limbs to the axial skeleton:
Axial skeleton: Composed of bones that form the axis of the body and support and protect the organs of the head, neck, and trunk; includes the ribs, skull, sternum and vertebral column (including the coccyx and sacrum).
Bunionectomy: A surgical procedure to remove a bony bump (bunion) of the foot and realign the big toe (great toe).
Cervical: Referring to the bones of the neck.
Delayed/incomplete fracture union: A fracture that has not healed within the expected timeframe for the site and type of fracture in a given individual despite ongoing bone growth activity; demonstrated by slow radiographic progress and continued mobility and pain at the fracture site.
Distraction osteogenesis (DO): A procedure that moves two segments of a bone slowly apart in such a way that new bone fills in the gap.
Electrical bone growth stimulator: A medical device that uses an electric field or current to stimulate the growth of bone tissue. These devices may be worn on the outside of the body or can be surgically implanted around the area requiring treatment.
Flat bones: Bones that are thin and have broad surfaces; includes the scapula, ribs, and the sternum (breastbone).
Fracture nonunion: A fracture in which all evidence of bone growth activity at the fracture site has ceased, leaving a persistent unhealed fracture of the bone.
Fracture union: The point at which the fractured bone has regained sufficient strength and stiffness to function as a weight-bearing structure without external support.
Hallux valgus deformity (bunion): A medial deviation of the first metatarsal and lateral deviation and/or rotation of the hallux, with or without medial soft-tissue enlargement of the first metatarsal head. This condition can lead to painful motion of the joint or difficulty with footwear.
Ideal body weight (IBW): Obesity has been defined as anyone who is 50% over their ideal body weight. The ideal body weight is calculated according to the following formula (Note: 1 kg = 2.2 pounds):
Irregular bones: Bones that are irregular in size and shape and are usually quite compact; include the bones in the vertebral column, the carpal bones in the hands, tarsal bones in the feet, and the patella (kneecap).
Long bones: Bones found in the extremities comprised of a shaft (diaphysis) and 2 ends (epiphyses); includes the humerus, radius, ulna, femur, tibia, fibula, metatarsal, and metacarpal bones.
Osteotomy: A surgical procedure where a bone or segment of a bone is cut or removed, realigned, and allowed to heal in its new position; most often, performed to realign a deformed bone.
Pseudoarthrosis: A condition where a bone fracture has healed with fibrous material instead of bone tissue; referred to as pseudarthrosis or a "false joint."
Sesamoid bones: An ovoid, nodular mass of bone or cartilage within a tendon or joint capsule, principally in the hands and lower extremities; the patella is the largest sesamoid bone in the body.
Short bones: Bones with a tubular shaft and articular surfaces at each end but much smaller in size; includes all of the metacarpals and phalanges in the hands, the metatarsals and phalanges in the feet, and the clavicle (collarbone).
Spinal fusion: A surgical procedure that connects one or more back bones with metal rods and/or bone grafts in an effort to stabilize a spine that is weakened, abnormal or injured.
Spondylolisthesis: A condition when one or more of the bones of the back slip forward in relation to the bone below it resulting in pressure on the spinal cord.
Spondylolysis (pars interarticularis defect): A unilateral or bilateral defect of the isthmic portion of the pars interarticularis of a vertebra, without forward displacement of that vertebra on the adjacent vertebra; a stress or fatigue fracture seen most often in children and adolescents.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
Invasive Electrical Stimulation
When services may be Medically Necessary when criteria are met:
|Electrical stimulation to aid bone healing; invasive (operative)
|Osteogenesis stimulator; electrical, surgically implanted
|ICD-10 Procedure
|For the following codes for cervical and thoracic vertebrae:
|Insertion of bone growth stimulator into upper bone [by approach; includes codes 0PHY0MZ, 0PHY3MZ, 0PHY4MZ]
|For the following codes for lumbar and lumbosacral vertebrae:
|Insertion of bone growth stimulator into lower bone [by approach; includes codes 0QHY0MZ, 0QHY3MZ, 0QHY4MZ]
|ICD-10 Diagnosis
|Ankylosing spondylitis
|Other spondylosis with myelopathy
|Other spondylosis with radiculopathy
|Spondylosis without myelopathy or radiculopathy
|Other spondylosis
|Spondylosis, unspecified
|Other spondylopathies
|Spondylopathy in diseases classified elsewhere
|Cervical disc disorders
|Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders
|Other and unspecified dorsopathies, not elsewhere classified
|Pseudarthrosis after fusion or arthrodesis
|Congenital spondylolisthesis
|Breakdown (mechanical) of other bone devices, implants and grafts
|Other mechanical complication of other internal orthopedic devices, implants and grafts
|Arthrodesis status
When services are Investigational and Not Medically Necessary:
For procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
When Services are also Investigational and Not Medically Necessary:
|ICD-10 Procedure
|Insertion of bone growth stimulator into skull [by approach; includes codes 0NH00MZ, 0NH03MZ, 0NH04MZ]
|Insertion of bone growth stimulator into nasal bone [by approach; includes codes 0NHB0MZ, 0NHB3MZ, 0NHB4MZ]
|Insertion of bone growth stimulator into facial bone [by approach; includes codes 0NHW0MZ, 0NHW3MZ, 0NHW4MZ]
|For the following codes for upper and lower bones other than vertebrae:
|Insertion of bone growth stimulator into upper bone [by approach; includes codes 0PHY0MZ, 0PHY3MZ, 0PHY4MZ]
|Insertion of bone growth stimulator into lower bone [by approach; includes codes 0QHY0MZ, 0QHY3MZ, 0QHY4MZ]
|ICD-10 Diagnosis
|All diagnoses
Noninvasive Electrical Stimulation of the Spine and Appendicular Skeleton
When services may be Medically Necessary when criteria are met:
|Electrical stimulation to aid bone healing; noninvasive (nonoperative)
|Osteogenesis stimulator; electrical, noninvasive, other than spinal applications
|Osteogenesis stimulator; electrical, noninvasive, spinal applications
|ICD-10 Diagnosis
|Ankylosing spondylitis
|Other spondylosis with myelopathy
|Other spondylosis with radiculopathy
|Spondylosis without myelopathy or radiculopathy
|Other spondylosis
|Spondylosis, unspecified
|Other spondylopathies
|Spondylopathy in diseases classified elsewhere
|Cervical disc disorders
|Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders
|Other and unspecified dorsopathies, not elsewhere classified
|Pseudarthrosis after fusion or arthrodesis [ankle or knee]
|Congenital bowing of femur
|Congenital bowing of tibia and fibula
|Congenital bowing of long bones of leg, unspecified
|Other specified congenital musculoskeletal deformities
|Other congenital malformations of upper limb(s), including shoulder girdle (includes congenital pseudarthrosis of clavicle)
|Congenital spondylolisthesis
|Fracture of ilium, acetabulum, pubis, ischium, other pelvis, subsequent encounter for fracture with nonunion (code range with seventh digit K)
|Fracture of shoulder and upper arm, subsequent encounter for fracture with nonunion (code range with seventh digit K)
|Fracture of forearm, subsequent encounter for fracture with nonunion (code range with seventh digit K, M or N)
|Physeal fracture of ulna and radius, subsequent encounter for fracture with nonunion (code range with seventh digit K)
|Fracture at wrist and hand level, subsequent encounter for fracture with nonunion (code range with seventh digit K)
|Fracture of femur, subsequent encounter for fracture nonunion (code range with seventh digit K, M or N)
|Physeal fracture of femur, subsequent encounter for fracture nonunion (code range with seventh digit K)
|Fracture of lower leg, including ankle, subsequent encounter for nonunion (code range with seventh digit K, M or N)
|Physeal fracture of tibia, fibula, subsequent encounter for nonunion (code range with seventh digit K)
|Fracture of foot and toe, except ankle, subsequent encounter for fracture with nonunion (code range with seventh digit K)
|Breakdown (mechanical) of other bone devices, implants and grafts
|Other mechanical complication of other internal orthopedic devices, implants and grafts
|Arthrodesis status
When services are Not Medically Necessary:
For procedure codes listed above for the following diagnoses, or for the situations indicated in the Position Statement section as not medically necessary.
|ICD-10 Diagnosis
|Chronic osteomyelitis with draining sinus
When services are Investigational and Not Medically Necessary:
For procedure and diagnosis codes listed above when criteria are not met or for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.
When Services are also Investigational and Not Medically Necessary:
|Unlisted procedure, musculoskeletal system, general [when specified as insertion of semi-invasive electrical bone growth stimulator]
|Durable medical equipment, miscellaneous [when specified as semi-invasive electrical bone growth stimulator]
|ICD-10 Diagnosis
|All diagnoses
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information
Capacitive Coupling (CC) Stimulation
CMF OL1000 Bone Growth Stimulator
CMF SpinaLogic®
Combined Magnetic Field (CMF) Stimulation
Direct Current (DC) Stimulation
EBI Bone Healing System
OL-1000 Bone Growth Stimulator
OrthoPak® 2 Bone Growth Stimulator
OsteoGen™ Bone Growth Stimulator
OsteoGen™-Dual Lead Bone Growth Stimulator
OsteoGen™-M Bone Growth Stimulator
Pulsed Electromagnetic Field (PEMF) Stimulation
SpinaLogic Bone Growth Stimulator
SpinalPak® 2 Spine Fusion Stimulator
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Document History
|Medical Policy & Technology Assessment Committee (MPTAC) review. Updated formatting in Position Statement section. Revised ordering of criteria in the NMN and INV and NMN statements. Updated References and Websites for Additional Information sections. Removed ICD-9 codes from Coding section.
|MPTAC review. Updated Rationale, References, and Websites for Additional Information sections.
|MPTAC review. Minor format changes throughout document. Updated Rationale, Background, References, and Websites for Additional Information sections.
|MPTAC review. Minor format changes throughout document. Updated Rationale, References, and Websites for Additional Information sections.
|MPTAC review. Revised medically necessary statement for Invasive and Noninvasive Electrical Stimulation of the Spine, including the addition of nutritional deficiency, severe anemia, and steroid therapy to the list of risk factors for spinal fusion failure. Clarified medically necessary statement for Noninvasive Electrical Stimulation of the Appendicular Skeleton. Clarified not medically necessary statement to only address specific contraindications to noninvasive electrical stimulation. Clarified and revised the investigational and not medically necessary statement, adding as an adjunct to distraction osteogenesis procedures for any indication, patellar tendinopathy, pathological fracture due to bone pathology or tumor/malignancy, or stress fractures. Clarified and revised the not medically necessary statements for invasive and semi-invasive electrical bone growth stimulation, moving them to the investigational and not medically necessary section. Reformatted and updated the Rationale. Updated the Background, Definitions, Coding, References, and Index.
|MPTAC review. Clarified investigational and not medically necessary statement for bunionectomy procedures, defining "as an adjunct to" and adding a Note when to refer to the Fracture Nonunion criteria. Updated Rationale, Definitions, References and Websites for Additional Information.
|MPTAC review. Revised medically necessary statements for Invasive and Noninvasive Electrical Stimulation of the Spine as follows: 1) Removed the phrase "as an adjunct to" from the spinal fusion surgery statement for treatment of individuals at high risk for pseudoarthroses, replacing with "inserted at the time of surgery" for invasive and "beginning at any time from the time of surgery until up to 6 months after surgery" for noninvasive electrical bone growth stimulation for time-to-apply after spinal fusion surgery; 2) added Body Mass Index (BMI) greater than 30 as an index to determine when an individual is considered obese (comorbid risk factor); 3) for noninvasive electrical stimulation for failed spinal fusion, clarified statement and added "appropriate imaging studies" to criteria to confirm there is no evidence of progression of healing. Clarified criteria for the Noninvasive Electrical Stimulation of the Appendicular Skeleton medically necessary criteria. Reordered and reformatted the not medically necessary statements without revisions to the current positions and criteria. Added "spondylolysis or pars interarticularis defect" to the investigational and not medically necessary statement. Updated Rationale, Background, Definitions, Coding, and References. Added Websites for Additional Information.
|Medical Policy & Technology Assessment Committee (MPTAC) review. Reordered/clarified medically necessary risk factor criteria for invasive and noninvasive electrical stimulation as an adjunct for spinal fusion therapy. Added a Note to criterion for obese individuals with reference to a definition for ideal body weight. Revised medically necessary criteria for fracture nonunions: 1) added "appropriate imaging studies" to confirm that no progressive signs of healing have occurred; added criterion addressing the size of the fracture gap, i.e. "the fracture gap is less than 1 cm." Revised not medically necessary criterion, deleting "a bone gap greater than one half the diameter of the bone at the point of nonunion." Revised investigational and not medically necessary criteria, adding "as an adjunct to bunionectomy." Updated Rationale, Discussion, Definitions, and Index. Removed outdated/archived References, updated with new References.
|MPTAC review. Updated Rationale, Definitions, and References. Added device names to Index. Updated Coding section with 10/01/2008 ICD-9 changes.
|The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
|MPTAC review. Background, Discussion and References updated.
|MPTAC review. Clarified Position Statement for fracture nonunion. Rationale and References updated.
|MPTAC review. Clarified Position Statement. Rationale and References updated.
|MPTAC review. Updated References and Coding.
|Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
|MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. Updated Coding: added ICD-9 codes 278.01, 277.7-277.9, 722.01-722.09, 722.4, 722.51, 722.6, 722.70, 722.71, 722.72, 723.00-723.89, 724.00-724.89
|Pre-Merger Organizations
|Last Review Date
|Anthem, Inc.
|Electrical Bone Growth Stimulator
|WellPoint Health Networks, Inc.
|Electrical Bone Growth Stimulation of the Spine
|Electrical Bone Growth Stimulation (Appendicular Skeletal System)


text:
|OPINIONS | Sunday, 07 October 2007
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If you wish your comments to be published in our Letters pages please click here
07 October 2007
Forget low cost, go microlight!
Lowell lists 50 'traitors' marked for Van Helsing-style execution
Labour consultant drafted PN management plan
Two fans charged with fracas at football match
Setting the example on energy saving
Election overshadows MEPA's dramatic Ramla u-turn
AFM finally switch on voice recording system
New Hypogeum monitoring project launched
Creationism: alive, well and approved by Malta's educational authorities

subset: commoncrawl


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Gilligan's Island
665 Fans
Gilligan's Island centered around seven people stranded on an uncharted deserted island somewhere in the Pacific Ocean. They all were on a boat tour, which found itself in the middle of a storm leading them to crash on an island! Main cast was Gilligan, first mate on the boat SS Minnow; the Skipper; a millionaire T.Howell III and his wife Lovey; a movie star Ginger; a professor and Mary Ann.
Trivia Facts | Top Quotes | Goofs/Mistakes
- Jayne Mansfield turned down the role of Ginger; 'Carroll OConnor tested for the role of The Skipper; Dabney Coleman tested for the role of The Professor.
- Raquel Welch auditioned for the role of Mary Ann.
- Jerry Van Dyke turned down the role of Gilligan.
- The first season had the cast using cups that were made from real coconuts. However, they found that the cups were porous and soaked through like they were sweating. Thus in the later seasons, the coconut cups were ceramic replicas.
- Natalie Schafer's contract stipulated that there be no close-ups of her in the show. The reason was producers knew her real age, which was 13 years older than Jim Backus, who played her character's husband. It was not until years after the series ended that her co-stars found out her actual age.
- The show was originally slated to return for the 1967-68 season along with another new comedy show to replace the canceled "Gunsmoke" (1955)_. However, CBS reversed its decision and canceled "Gilligan" and kept "Gunsmoke", which ran for another eight seasons.
- The three-man folk singing group The Wellingtons sang the theme song for the first season, but were replaced by a similar sounding group, The Eligibles, for the following seasons. The Wellingtons (plus one) also portrayed "The Mosquitoes" in a classic episode of the series: "Gilligan's Island" (1964) {Don't Bug the Mosquitoes (#2.12)}.
- In the very first shot of the opening credits, the American flag over the harbor can be seen flying at half-mast. The reason was the assassination of President John F. Kennedy, shortly before the shot was filmed.
- The character of the Professor was supposedly a graduate from SMU, TCU and UCLA,
- In the first-season credits, Russell Johnson and Dawn Wells were relegated to being simply "the rest". That changed in the second season when Bob Denver demanded that they be given an equal share in the credits, thus changing the lyrics to "The Professor and Mary Ann". Sherwood Schwartz, who composed both themes, has said it didn't occur to him the Professor and Mary Ann would turn into prominent characters.
- The lagoon set was located at the CBS lot in Studio City, CA. If sequences there were filmed too early or too late in the day, microphones would record rush hour traffic noise from a nearby freeway.
- Phil Silvers was cast as a producer in an episode partly because his production company was actually producing the show.
- As the show progressed, producers planned to introduce a new character--a pet dinosaur--but decided against it because of the cost of special effects. The character, however, was incorporated into the animated Gilligan's Planet.
- The premise required that the characters use various devices that had to be constructed from only the various materials found on a tropical island. Thus the props had to be specially made and the prop department enjoyed the challenge, which was a change of pace from simply bringing in the standard props from storage. The bamboo foot pedal-powered car used in one episode was a particular favorite, with the cast lining up to try it out.
- It is revealed in "Gilligan's Island" (1964) {Two on a Raft (#1.1)}, (the second pilot) that the name of Mary-Ann's hometown was Winfield, Kansas. It is sometimes misreported as Horner's Corners, but that was the home of her boyfriend, Horace Higgenbotham.
- The ship's name, S.S. Minnow, was not named for the fish but rather for Newton Minow, head of the Federal Communications Commission in 1961. Minow was the one who called television "America's vast wasteland". Sherwood Schwartz did not care for Minow so he named the soon-to-be shipwrecked ship after him, though he later said that Minow actually enjoyed the joke and that the two eventually exchanged regular friendly correspondence.
- "The radio" seen in virtually every episode was a Packard-Bell AM Radio, Model AR-851. The small silver handle and telescoping antenna were added by the prop department (despite the fact that AM radios do not use telescoping antennas). The antenna was likely added to lend credence to the castaways' ability to pick up radio signals so far from civilization.
- Alan Hale Jr. was on location in Utah filming a movie when he got a call to come back to Los Angeles to do a test for the series. He rode a horse to a nearby highway, hitchhiked to Las Vegas and flew to L.A. to test with Bob Denver.
- The island shown in the opening and closing credits is actually located in Kaneohe Bay, about a mile offshore from the island of Oahu, in Hawaii.
- Sherwood Schwartz said he had a first name for Gilligan if the need to use it ever arose: Willie. This name is never spoken on screen, so it seems as if Gilligan only has one name as with celebrities such as Homer or Cher.
- The lagoon set was the same one used to make Creature from the Black Lagoon.
- In the backstory, The Professor had taken the three-hour tour to relax before he began writing a book, "Fun with Ferns".
- Partly inspired by the 1939 film Five Came Back (1939) starring Lucille Ball. The characters in that film included a wayward pilot and co-pilot, a botanist and his wife, a sultry woman with a shady past, and a rich playboy and his homespun wife.
- The song playing on Gilligan's radio is called "Coconut Boogie", performed by Jim Shipman and the Shipwrecks.
- Four vessels were used as the SS Minnow. One was towed to Kauai, Hawaii, for beach scenes, one was rented in Honolulu for the original opening credits and one was built at CBS Studios in the second season. The fourth one was used in the second-season opening credits. A subsequent owner was sailing it south from Alaska when it ran aground on a reef off the coast of British Columbia. It was purchased for salvage and restored. It was offered for sale in B.C. for $99,000. It was listed as a 37-foot twin-diesel, mahogany Wheeler Express Cruiser which sleeps five.
- The name "Ginger Grant" is believed to be taken from two stars of Hollywood's "Golden Era", Ginger Rogers and Cary Grant; the latter is frequently spoken of in this series. "Ginger" is a nickname in many places (including England) for someone with red hair.
- Jim Backus' name of Thurston Howell III was named after "Hubart Updyke III", a character on "The Alan Young Show" on radio, written by this series' producer, Sherwood Schwartz--and also played by Backus..
- Alan Hale Jr. had a tendency to address people as "little buddy". Because of this, "little buddy" became the Skipper's signature term of affection for Gilligan. It is now widely used by fans as a nickname for Bob Denver.
- One of the most burning questions among male viewers of the show has always been, "Ginger or Mary Ann?". Though there is no real answer to that question, the consensus seems to be that Dawn Wells got more fan mail from young boys, while Tina Louise got more fan mail from grown men. The difference is attributed to the fact that Mary Ann was the pretty and sweetly sexy girl next door that every teenage boy would love to go out with, while Ginger was the gorgeous, smoking-hot sex bomb that is every adult male's fantasy.
- The theme song is the winner of the 2013 Yahoo TV Best TV Theme Song Ever. The 12th seed in a bracketed competition, it beat the theme from Cheers in the finals.


text:
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Disc Reviews
Wall City
Disc Pal Posted 07-01-06
Submitted by Adam email@example.com
Location: New Jersey
Level: Amateur
Review: This bag is an inexpensive, entry-level accessory suitable for beginners or the recreational player. It is solidly built with everything the beginning disc golfer needs to keep their discs and incidentals together. However, while this bag is an excellent first bag for anyone starting out, it is also quickly outgrown. The bag is constructed of a light weight nylon fabric which is well sewn and finished. It is comprised of a zippered main compartment which comfortably holds 10 discs, as well as front and back mesh pockets for putters or mini discs. There is also a zipper pocket between the rear mesh pocket and the main compartment for miscellaneous items such as keys or score cards; as well as a large mesh bottle sleeve on one side and a plastic ring at the base of one end of the shoulder strap for a towel. The strap itself is a standard weight adjustable length 2 inch nylon web strap with a sliding rubber shoulder pad. All the zippers are of sufficient strength and move smoothly. Perhaps the three best features of this bag are its durability, ease of maintenance, and weight. At little less than half a pound, this bag bag is not substantially heavier than the average disc (454 grams = 1 pound). Additionally, the light weight fabric and lack of structure make this bag easily cleaned after a muddy round and quick to dry as well. Finally, the toughness of the Disc Pal is excellent. It will take years of abuse with little defect and seems highly resistant to tears and pulls in the fabric. Unfortunately, these attributes are not without their detractors. Despite its solidly rugged construction, the Disc Pal does have some significant shortcomings. Firstly, the light weight nylon fabric lacks any stiffness which would allow it to hold its shape, nor does it have any sort of frame or padding. The net result is a bag which, while very easily rolled up and stuffd in a drawer when empty, also allows for contents to shift with even the slightest movement causing the entire bag to quite often sit uncomfortably on the shoulder. In addition, the rudimentary rubber pad on the shoulder strap does not effectively disperse the weight of a full bag; increasing shoulder fatigue and contributing to the general lack of comfort. The mesh putter pockets are somewhat shallow as well. With the main compartment fully loaded, there is little room left for these pockets to truly be effective; a situation compounded at times by the amount of items placed in the smaller zippered accessory pocket. Finally, the mesh bottle sleeve has no real floor to it. While this does allow for condensation from a water bottle to effectively drip away rather than pool in the bottom of the sleeve, it also creates certain limitations. The one inch nylon web used to close the bottom of the sleeve means that only large bottles similar to a one liter Nalgene bottle, will fit without sliding past the webbing and falling through the bottom. Despite these pitfalls, the Wall City Disc Pal is a tough and durable companion for discs and will provide many years of use. I began using this bag when I started playing in 1999. It was given to me by a friend who had been using it for several years and was upgrading to a larger bag. A few years later, after having upgraded to a different bag myself, I gave this bag to someone who has used it consistently for some time now. Three owners and ten years later, the bag is in almost the same condition as when it was new. At the $14.95 to $19.99 range, this bag is well worth its price for beginners and the recreational player alike.
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text:
WE are RAF Changi Association and are searching for old pals who served there from 1946 to 1971. We are non-profit and our aim is to bring old pals together and find new ones.
For more information and a free enquiry pack, contact Malcolm Flack, 01494 728 562 or web site www.rafchangi.com.
B. W. Lloyd RAF Changi Assn


text:
Ionopsis abbreviated as Inps in horticultural trade, is a genus of around five species.
Plants are found in Florida and from Mexico to Bolivia and Paraguay
The lip of species in this genus has a short column, which has a foot and the 2 hard pollina are attached to a stipe.
Grow in cool to warm conditions with moderate to bright light. Water the plant right before the potting mix starts to dry. Plants should be potted in a well drain medium such as medium fir bark, treefern, or osmunda. Plants prefer to be mounted
The plant is named after the Greek words "ion" and "opsis" which means appearing like a violet which refers to the appearance of the flowers in this genus
- Cybelion Spreng
- Iantha Hkr. 1824
- Inopsis Steud.
Species Edit
- Ionopsis burchellii Rchb.f., 1876.
- Ionopsis minutiflora (Dodson & N.Williams) Pupulin, 1998.
- Ionopsis papillosa Pupulin, 1998.
- Ionopsis satyrioides (Sw.) Rchb.f. in W.G.Walpers, 1863.
- Ionopsis utricularioides (Sw.) Lindl.,1826.
- Ionopsis zebrina Kraenzl., 1920.


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This series was an early favorite of ours. My son just loved Nate, the "great" independent, young detective in the series. He is such an endearing character, walking around the neighborhood in his rainboots, which are part of his "detective outfit." After finding a case to solve, Nate will go home and make his own pancakes, which he eats to help him think about his case. Sure, he's quite the independent young man, but he never fails to leave a note for his mom. This is the first in the series, but there are many more to choose from.

Publisher Recommended Reading Level: 4-8

This series is fun, not just because the main character solves mysteries, but also because he loves jigsaw puzzles! So many gifted kids also love jigsaw puzzles, so it makes the stories even more fun to read. Jigsaw Jones solves his mysteries the same way he works his jigsaw puzzles. He looks at the individual pieces and figures out how they fit together. Adding to the fun are his two older brothers who call him "Worm" and "Shorty" and his slobbering, sock-eating dog, Rags.This book is just one of many to choose from.

Publisher Recommended Reading Level: 4-8

This series was another of our very favorite series. Flatfoot Fox and his friend, Secretary Bird, are the animal world equivalents of Sherlock Holmes and Dr. Watson. Together the two encounter a number of interesting characters such as Bashfull Beaver and Scatterbrain Squirrel as they solve various mysteries. These books are quite funny and if your child enjoys tongue twisters and other language fun, she will love this series. Your child may be able to read these books long before she turns 9. My son was reading them when he was around 5.

Publisher Recommended Reading Level: 9-12

This series is another one full of word play. Some of the word play is obvious from the title of the books: Farewell, My Lunch Bag; The Big Nap; The Malted Falcon. If you're a fan of film noir, you'll recognize hints of films made from Raymond Chandler's mysteries, like Farewell, My Lovely, The Big Sleep, and The Maltese Falcon. Even the style of the writing is a child's version of Chandler's style, which is part of what makes the books so much fun. Oh...and did I mention Chet is a lizard? In the 4th grade?

Publisher Recommended Reading Level: 9-12

The Great Brain is actually a little "con artist" whose real name is Tom. He uses his "great brain" for his schemes - and for getting out of trouble. Some parents of gifted kids will no doubt recognize some of Tom's traits and behaviors! But Tom also uses his mental abilities to help other kids, like those who got lost in Skeleton Cave, and for solving mysteries. The stories, which take place in the early 1900's, are told by J.D., Tom's younger and adoring little brother, and are both charming and entertaining.

Publisher Recommended Reading Level: 9-12

One trait gifted kids are known for is a great memory. And that is a prominent trait of the main character in this series. In fact, Cam Jansen, gets her name from her photographic memory, particularly since when she wants to remember something, she says, "click," as if she is taking a picture. Cam uses that great memory to help her solve various mysteries. There are actually two different series with Cam Jansen. One is just the Cam Jansen series and the other is Young Cam Jansen meant for the younger kids.

Publisher Recommended Reading Level: 7-10

The series gets its name from the Aldren children, who after finding themselves parentless, live for a time in a boxcar of a train. As they travel around the country, the get involved in many exciting mysteries. The children (and their dog Watch) don't remain without family forever. Their wealthy grandfather finds them and provides them with a good home - but their adventures don't end once they settled down into a loving home!

Publisher Recommended Reading Level: 9-12

This series is more than a series of mystery stories. The stories in the books encourage kids to use critical thinking and practice their analytical and problem solving skills. Encyclopedia Brown, an 11 year old boy whose real name is Leroy, helps solve myteries that his father, the Chief of Police, talks about at home. Each book in the series consists of several short mysteries. Encyclopedia solves each case by the end of the story, and the readers are asked to figure out how he did it, with questions like "how did Encyclopedia know that X was responsible for the crime?" If a reader can't figure out the answers as easily as Encyclopedia does, he can find the answers in the back of the book.

Publisher Recommended Reading Level: 9-12


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A full 12 years since their remarkable run to the World Cup semi-finals, South Korea will be again out to cause a shock in Brazil.
This summer's tournament will be the Red Devils' eighth in succession, having enjoyed mixed performances in years gone by.
They managed to reach the the last-16 in South Africa in 2010 and that will again be the target this summer, after they were handed a favourable group.
Tournament dark horses Belgium look certain to top Group H, with South Korea hoping to overcome Russia and Algeria for the all-important second spot.
Key players
Ki Sung-Yeung - The 25-year-old enjoyed a fine season with Sunderland, playing a key role in their fight against relegation and run to the Capital One Cup final.
He will be a key component in Hong Myung Bo's midfield during the tournament.
Kim Bo-Kyung - The midfielder will be desperate to bounce back from a sorry season with Cardiff this summer.
Kim has made over 20 appearances for his country and will line up alongside fellow English-based star Ki in Brazil.
Ji Dong-Won - A name recognised by Sunderland fans, most notably for a famous winner against Manchester City in 2012.
The 23-year-old was loaned out to Augsburg last season - where he scored once - and will join Borussia Dortmund after the World Cup.
Rising star
Son Heung-Min - Both Liverpool and Tottenham have been linked with the Bayer Leverkusen striker, who turns 22 during the tournament.
He bagged 10 goals for the German side last season having previously shone for Hamburg and is becoming an idol in his homeland.
Mixed would be the best word to describe Korea's form, although they haven't played a competitive fixture for nigh on a year.
They have enjoyed friendly wins over fellow World Cup qualifiers Costa Rica and Greece since the turn of the year, but disappointingly lost 1-0 to Tunisia at the end of May.
A repeat of their remarkable 2002 run appears out of the question for South Korea, who will simply want to get out of their group.
A Round of 16 tie with Germany or Portugal would then probably lie in wait but most fans would settle for the knockout stages.
Quirky fact
Coach Hong Myung-Bo appeared at four World Cups and is the country's most capped player, making a staggering 136 appearances.
Full squad
Goalkeepers: Jung Sung-ryeong (Suwon Bluewings), Kim Seung-gyu (Ulsan Horang-i), Lee Bum-young (Busan I'Park).
Defenders: Yun Suk-young (QPR), Kim Young-kwon (Guangzhou Evergrande), Hwang Seok-ho (Sanfrecce Hiroshima), Hong Jeong-ho (Augsburg), Kwak Tae-hwi (Al Hilal), Lee Yong (Ulsan Horang-i), Kim Chang-soo (Kashiwa Reysol), Park Joo-ho (Mainz) .
Midfielders: Ki Seung-yueng (Sunderland, on loan from Swansea), Ha Dae-sung (Beijing Guoan), Han Kook-young (Kashiwa Reysol), Park Jung-woo (Guangzhou R&F), Son Heung-min (Bayer Leverkusen), Kim Bo-kyung (Cardiff City), Lee Chung-yong (Bolton Wanderers), Ji Dong-won (Augsburg).
Forwards: Koo Ja-cheol (Mainz), Lee Keun-ho (Sangju Sangmu), Park Chu-young (Arsenal), Kim Shin-wook (Ulsan Horang-i).
June 17 - Russia
June 22 - Algeria
June 26 - Belgium


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Sharee in Charlotte, North Carolina
101 months ago
I had an interview with Windstream about three weeks ago and haven't heard from them since. I've called twice and left a voicemail so see if a decision has been made and to also find out if I would be notified either way and no one will return my phone call. Is this normal protocol for this company not to notify you even if were not selected as a candidate.
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text:
Collepedrino rankings
Difficulty ranking world: 2278 (all)
Ranking Italy: 634 (all)
Ranking Alps: 825(all)
Difficulty score: 86.28 what?
Collepedrino ratings
(rate it)
The Collepedrino is situated in Lombardy. This climb belongs to the Alps.
Starting from Palazzago,
the Collepedrino ascent is 6.65 km long. Over this distance, you climb 635 heightmeters.
The average percentage thus is 9.5 %.
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Get an overview of this hotel3-star Istanbul hotel in Old City, walk to Hagia Sophia
Popular property highlights
Located in Old City, this hotel is within a 10-minute walk of New Mosque, Hagia Sophia, and Basilica Cistern. Istanbul Archaeology Museum and Cagaloglu Hamami are also within 10 minutes.
Hotel Features
This hotel features a bar/lounge, a conference center, and valet parking. Free buffet breakfast is provided, as well as free WiFi in public areas, free self parking, and a free manager's reception. Additionally, coffee/tea in a common area, a meeting room, and concierge services are onsite.
Room Amenities
All 52 rooms offer free WiFi and free wired Internet, plus refrigerators and LCD TVs with satellite channels. Guests will also find minibars, room service, and premium bedding.Information missing or incorrect? Tell us!Opens in a new window
Orient Express Hotel
Hotel Amenities
Hotel Amenities
A bar/lounge is on site where guests can unwind with a drink. Guests can enjoy a complimentary breakfast each morning as well as a complimentary manager's reception. A computer station is located on site and wireless Internet access is complimentary.
This business-friendly hotel also offers a terrace, tour/ticket assistance, and multilingual staff. For a surcharge, a roundtrip airport shuttle (available 24 hours) is offered to guests. Onsite self parking is complimentary.
Orient Express Hotel has designated areas for smoking.
- 24-hour front desk
- Babysitting or childcare (surcharge)
- Airport transportation (surcharge)
- Total number of rooms - 52
- Number of floors - 7
- Babysitting or childcare
- Bar/lounge
- Coffee/tea in common areas
- Free breakfast
- Concierge services
- Elevator/lift
- Express check-in
- Express check-out
- Designated smoking areas
- Computer station
- Designated smoking areas (fines apply)
- Laundry facilities
- One meeting room
- Multilingual staff
- Valet parking (surcharge)
- Terrace
- Porter/bellhop
- Luggage storage
- Safe-deposit box at front desk
- Free self parking
- Conference center
- Free reception
- Year Built 2000
- Number of buildings/towers - 1
- Television in common areas
- Wedding services
- Dry cleaning/laundry service
- Free WiFi
- Tours/ticket assistance
Family Friendly Amenities
- Family Hotel
- Free Wi-Fi
- Laundry facilities
- Babysitting or childcare (surcharge)
- Refrigerator
Available in all rooms: Free WiFi , Free wired Internet
Available in some public areas: Free WiFi
Room Amenities
- Premium bedding
- Air conditioning
- Refrigerator
- Minibar
- Daily housekeeping
- Private bathroom
- Hair dryer
- Slippers
- Shower only
- Desk
- In-room safe (laptop compatible)
- Satellite TV service
- Free wired Internet
- Free toiletries
- Room service (limited hours)
- Iron/ironing board (on request)
- Free WiFi
Where to Eat
A complimentary buffet breakfast is served each morning between 7 AM and 10:30 AM. A complimentary manager's reception is offered each day.
Room service (during limited hours) is available.
Nearby Things to Do
The recreational activities listed below are available either on site or nearby; fees may apply.
- Ecotours nearby
Hotel Policies
Check-in time starts at 2 PM
Minimum check-in age is 18
Check-in time ends at midnight
Special check-in instructions:
Check-out time is noon
Payment types
Children and extra beds
- Children are welcome.
- Kids stay free! One child 6 years old or younger stays free when using existing bedding. Children may not be eligible for complimentary breakfast.
- Rollaway/extra beds are available for EUR 20 per night.
- No pets or service animals allowed
You need to know
Extra-person charges may apply and vary depending on property policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- No onsite parking is available.
- The name on the credit card used at check-in to pay for incidentals must be the primary name on the guestroom reservation.
No pets or service animals allowed
Noise-free rooms not guaranteed
- Airport shuttle transfer per adult: EUR 5 (one way)
- Transfer service fee per child: EUR 5 (one way), (from 6 to 12 years old)
Optional extras
- Airport shuttle fee: EUR 30 per room (one way)
- Airport shuttle fee per child: EUR 0 (one-way)
- Valet parking fee: EUR 15 per day
- Early check-in fee: EUR 100
- Late check-out fee: EUR 100
- Rollaway bed fee: EUR 20 per night
Hotel Name
- Hotel Orient Express
- Orient Express Hotel
- Orient Express Hotel Istanbul
- Orient Express Istanbul
- Orient Hotel Express
We should mention
This property offers transfers from the airport (surcharges may apply). Guests must contact the property with arrival details before travel, using the contact information on the booking confirmation. One child 6 years old or younger stays free when occupying the parent or guardian's room, using existing bedding. Children may not be eligible for complimentary breakfast. No pets and no service animals are allowed at this property.
Awards & Affiliations
- Orient Express Hotel is listed in the 2016 Condé Nast Traveler Gold List of the world's best places to stay and the 2016 Travel + Leisure 500.


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Tony Fisher
Trouble with Men and Women
Heartbroken after being dumped by his girlfriend, Matt (Joseph McFadden) sets out to find a new love interest and try to understand what women want. Through a series of one-night stands and failed romances, Matt's quest leads him to the realization that the right woman for him may actually be his best friend's girl (Kate Ashfield). Writer-director Tony Fisher makes his debut with this quirky independent drama from Britain.