Continuous passive motion following total knee arthroplasty in people with arthritis

Lisa A Harvey, Lucie Brosseau, Robert D Herbert, Lisa A Harvey, Lucie Brosseau, Robert D Herbert

Abstract

Background: Arthritis of the knee is a common problem causing pain and disability. If severe, knee arthritis can be surgically managed with a total knee arthroplasty. Rehabilitation following knee arthroplasty often includes continuous passive motion (CPM). CPM is applied by a machine that passively and repeatedly moves the knee through a specified range of motion (ROM). It is believed that CPM increases recovery of knee ROM and has other therapeutic benefits. However, it is not clear whether CPM is effective.

Objectives: To assess the benefits and harms of CPM and standard postoperative care versus similar postoperative care, with or without additional knee exercises, in people with knee arthroplasty. This review is an update of a 2003 and 2010 version of the same review.

Search methods: We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE (January 1966 to 24 January 2013), EMBASE (January 1980 to 24 January 2013), CINAHL (January 1982 to 24 January 2013), AMED (January 1985 to 24 January 2013) and PEDro (to 24 January 2013).

Selection criteria: Randomised controlled trials in which the experimental group received CPM, and both the experimental and control groups received similar postoperative care and therapy following total knee arthroplasty in people with arthritis.

Data collection and analysis: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. The primary outcomes of interest were active knee flexion ROM, pain, quality of life, function, participants' global assessment of treatment effectiveness, incidence of manipulation under anaesthesia and adverse events. The secondary outcomes were passive knee flexion ROM, active knee extension ROM, passive knee extension ROM, length of hospital stay, swelling and quadriceps strength. We estimated effects for continuous data as mean differences or standardised mean differences (SMD), and effects for dichotomous data as risk ratios; all with 95% confidence intervals (CI). If appropriate, we performed meta-analyses using random-effects models.

Main results: We identified 684 papers from the electronic searches after removal of duplicates and retrieved the full reports of 62 potentially eligible trials. Twenty-four randomised controlled trials of 1445 participants met the inclusion criteria; four of these trials were new to this update.There was moderate-quality evidence to indicate that CPM does not have clinically important short-term effects on active knee flexion ROM: mean knee flexion was 78 degrees in the control group, CPM increased active knee flexion ROM by 2 degrees (95% CI 0 to 5) or absolute improvement of 2% (95% CI 0% to 4%). The medium- and long-term effects are similar although the quality of evidence is lower.There was low-quality evidence to indicate that CPM does not have clinically important short-term effects on pain: mean pain was 3 points in the control group, CPM reduced pain by 0.4 points on a 10-point scale (95% CI -0.8 to 0.1) or absolute reduction of -4% (95% CI -8% to 1%).There was moderate-quality evidence to indicate that CPM does not have clinically important medium-term effects on function: mean function in the control group was 56 points, CPM decreased function by 1.6 points (95% CI -6.1 to 2.0) on a 100-point scale or absolute reduction of -2% (95% CI -5% to 2%). The SMD was -0.1 standard deviations (SD) (95% CI -0.3 to 0.1).There was moderate-quality evidence to indicate that CPM does not have clinically important medium-term effects on quality of life: mean quality of life was 40 points in the control group, CPM improved quality of life by 1 point on a 100-point scale (95% CI -3 to 4) or absolute improvement of 1% (95% CI -3% to 4%).There was very low-quality evidence to indicate that CPM reduces the risk of manipulation under anaesthesia; risk of manipulation in the control group was 7.2%, risk of manipulation in the experimental group was 1.6%, CPM decreased the risk of manipulation by 25 fewer manipulations per 1000 (95% CI 9 to 64) or absolute risk reduction of -4% (95% CI -8% to 0%). The risk ratio was 0.3 (95% CI 0.1 to 0.9).There was low-quality evidence to indicate that CPM reduces the risk of adverse events; risk of adverse events in the control group was 16.3%, risk of adverse events in the experimental group was 17.9%, CPM decreased the risk of adverse event by 150 fewer adverse events per 1000 (95% CI 103 to 216) or absolute risk reduction of -1% (95% CI -5% to 3%). The risk ratio was 0.9 (95% CI 0.6 to 1.3). The estimates for risk of manipulation and adverse events are very imprecise and the estimate for the risk of adverse events does not distinguish between a clinically important increase and decrease in risk.There was insufficient evidence to determine the effect of CPM on participants' global assessment of treatment effectiveness.

Authors' conclusions: CPM does not have clinically important effects on active knee flexion ROM, pain, function or quality of life to justify its routine use. It may reduce the risk of manipulation under anaesthesia and risk of developing adverse events although the quality of evidence supporting these findings are very low and low, respectively. The effects of CPM on other outcomes are unclear.

Conflict of interest statement

None known.

Figures

1
Study flow diagram. Results from the 2003 version of this systematic review are included in the 2009 search results because a full search was re‐done in 2009 using a new search strategy.

2
Methodological quality summary: review authors' judgements about each methodological quality item for each included trial.

3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

**1.1. Analysis**
Comparison 1 Main comparison, Outcome 1 Active knee flexion ROM ‐ short‐term effects.

**1.2. Analysis**
Comparison 1 Main comparison, Outcome 2 Active knee flexion ROM ‐ medium‐term effects.

**1.3. Analysis**
Comparison 1 Main comparison, Outcome 3 Active knee flexion ROM ‐ long‐term effects.

**1.4. Analysis**
Comparison 1 Main comparison, Outcome 4 Pain ‐ short‐term effects.

**1.5. Analysis**
Comparison 1 Main comparison, Outcome 5 Pain ‐ medium‐term effects.

**1.6. Analysis**
Comparison 1 Main comparison, Outcome 6 Pain ‐ long‐term effects.

**1.7. Analysis**
Comparison 1 Main comparison, Outcome 7 Function ‐ short‐term effects [standardised mean].

**1.8. Analysis**
Comparison 1 Main comparison, Outcome 8 Function ‐ medium‐term effects [standardised mean].

**1.9. Analysis**
Comparison 1 Main comparison, Outcome 9 Function ‐ long‐term effects [standardised mean].

**1.10. Analysis**
Comparison 1 Main comparison, Outcome 10 Quality of life ‐ medium‐term effects.

**1.11. Analysis**
Comparison 1 Main comparison, Outcome 11 Quality of life ‐ long‐term effects.

**1.12. Analysis**
Comparison 1 Main comparison, Outcome 12 Participants' global assessment of treatment effectiveness ‐ short‐term effects [points].

**1.13. Analysis**
Comparison 1 Main comparison, Outcome 13 Participants' global assessment of treatment effectiveness ‐ medium‐term effects.

**1.14. Analysis**
Comparison 1 Main comparison, Outcome 14 Manipulation under anaesthesia [number].

**1.15. Analysis**
Comparison 1 Main comparison, Outcome 15 Adverse events [number].

**1.16. Analysis**
Comparison 1 Main comparison, Outcome 16 Passive knee flexion ROM ‐ short‐term effects.

**1.17. Analysis**
Comparison 1 Main comparison, Outcome 17 Passive knee flexion ROM ‐ medium‐term effects.

**1.18. Analysis**
Comparison 1 Main comparison, Outcome 18 Passive knee flexion ROM ‐ long‐term effects.

**1.19. Analysis**
Comparison 1 Main comparison, Outcome 19 Active knee extension ROM ‐ short‐term effects.

**1.20. Analysis**
Comparison 1 Main comparison, Outcome 20 Active knee extension ROM ‐ medium‐term effects.

**1.21. Analysis**
Comparison 1 Main comparison, Outcome 21 Active knee extension ROM ‐ long‐term effects.

**1.22. Analysis**
Comparison 1 Main comparison, Outcome 22 Passive knee extension ROM ‐ short‐term effects.

**1.23. Analysis**
Comparison 1 Main comparison, Outcome 23 Passive knee extension ROM ‐ medium‐term effects.

**1.24. Analysis**
Comparison 1 Main comparison, Outcome 24 Passive knee extension ROM ‐ long‐term effects.

**1.25. Analysis**
Comparison 1 Main comparison, Outcome 25 Length of hospital stay.

**1.26. Analysis**
Comparison 1 Main comparison, Outcome 26 Swelling ‐ short‐term effects.

**1.27. Analysis**
Comparison 1 Main comparison, Outcome 27 Swelling ‐ medium‐term effects.

**1.28. Analysis**
Comparison 1 Main comparison, Outcome 28 Quadriceps strength ‐ short‐term effects [standardised mean].

**2.1. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 1 Active knee flexion ROM.

**2.2. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 2 Passive knee flexion ROM.

**2.3. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 3 Active knee extension ROM.

**2.4. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 4 Passive knee extension ROM.

**2.5. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 5 Length of hospital stay.

**2.6. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 6 Function.

**2.7. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 7 Pain.

**2.8. Analysis**
Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 8 Swelling.

**3.1. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 1 Active knee flexion ROM ‐ short‐term effects.

**3.2. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 2 Active knee flexion ROM ‐ medium‐term effects.

**3.3. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 3 Active knee flexion ROM ‐ long‐term effects.

**3.4. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 4 Pain ‐ short‐term effects.

**3.5. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 5 Pain ‐ medium‐term effects.

**3.6. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 6 Pain ‐ long‐term effects.

**3.7. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 7 Function ‐ short‐term effects [standardised mean].

**3.8. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 8 Function ‐ medium‐term effects [standardised mean].

**3.9. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 9 Function ‐ long‐term effects [standardised mean].

**3.10. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 10 Quality of life ‐ medium‐term effects.

**3.11. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 11 Quality of life ‐ long‐term effects [points].

**3.12. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 12 Participants' global assessment of treatment effectiveness ‐ short‐term effects [points].

**3.13. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 13 Participants' global assessment of treatment effectiveness ‐ medium‐term effects.

**3.14. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 14 Manipulation under anaesthesia [number].

**3.15. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 15 Adverse events [number].

**3.16. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 16 Passive knee flexion ROM ‐ short‐term effects.

**3.17. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 17 Passive knee flexion ROM ‐ medium‐term effects.

**3.18. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 18 Passive knee flexion ROM ‐ long‐term effects.

**3.19. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 19 Active knee extension ROM ‐ short‐term effects.

**3.20. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 20 Active knee extension ROM ‐ medium‐term effects.

**3.21. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 21 Active knee extension ROM ‐ long‐term effects.

**3.22. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 22 Passive knee extension ROM ‐ short‐term effects.

**3.23. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 23 Passive knee extension ROM ‐ medium‐term effects.

**3.24. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 24 Passive knee extension ROM ‐ long‐term effects.

**3.25. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 25 Quadriceps strength ‐ short‐term effects [standardised mean].

**3.26. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 26 Length of hospital stay.

**3.27. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 27 Swelling ‐ short‐term effects.

**3.28. Analysis**
Comparison 3 Main comparison ‐ sensitivity analysis using fixed‐effect model, Outcome 28 Swelling ‐ medium‐term effects.

References

References to studies included in this review Alkire 2010 {published data only}

1. Alkire MR, Swank M. Use of inpatient continuous passive motion versus no CPM in computer‐assisted total knee arthroplasty. Orthopaedic Nursing 2010;29:36‐40.

Bennett 2005 {published data only}

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Harms 1991 {published data only}

1. Harms M, Engstrom B. Continuous passive motion as an adjunct to treatment in the physiotherapy management of the total knee arthroplasty patient. Physiotherapy 1991;7(4):301‐7.

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References to studies excluded from this review Beaupré 2001 {published data only}

1. Beaupré LA, Davies DM, Jones CA, Cinats JG. Exercise combined with continuous passive motion or slider board therapy compared with exercise only: a randomized controlled trial of patients following total knee arthroplasty. Physical Therapy 2001;81(4):1029‐37.

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Johnson 1992 {published data only}

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Kim 1995 {published data only}

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Kim 2009 {published data only}

1. Kim TK, Park KK, Yoon SW, Kim SJ, Chang CB, Seong SC. Clinical value of regular passive ROM exercise by a physical therapist after total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2009;17:1152‐8.

Leach 2006 {published data only}

1. Leach W, Reid J, Murphy F. Continuous passive motion following total knee replacement: a prospective randomized trial with follow‐up to 1 year. Knee Surgery, Sports Traumatology, Arthroscopy 2006;14:922‐6.

Leonard 2007 {published data only}

1. Leonard GM, Tremblay LE, Chabot M, Lariviere J, Papadopoulos P. The effects of early continuous passive motion after total knee arthroplasty. Physiotherapy Canada 2007;59:111‐7.

Lynch 1988 {published data only}

1. Lynch AF, Bourne RB, Rorabeck CH, Rankin RN, Donald A. Deep‐vein thrombosis and continuous passive motion after total knee arthroplasty. Journal of Bone and Joint Surgery 1988;70‐A(1):11‐4.

Maloney 1990 {published data only}

1. Maloney WJ, Schurmann DJ, Hangen D, Goodman SB, Edworthy S, Bloch DA. The influence of continuous passive motion on outcome in total knee arthroplasty. Clinical Orthopaedics and Related Research 1990;256:162‐8.

Odenbring 1989 {published data only}

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Pope 1997 {published data only}

1. Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty: does it offer any benefits?. Journal of Bone and Joint Surgery 1997;79‐B(6):914‐7.

Simkin 1999 {published data only}

1. Simkin PA, Lateur BJ, Alquist AD, Wuestad KA, Beardsley RM, Esselman PC. Continuous passive motion for osteoarthritis of the hip: a pilot study. Journal of Rheumatology 1999;26:1987‐91.

Ververeli 1995 {published data only}

1. Ververeli PA, Sutton DC, Hearn SL, Booth RE, Hozack WJ, Rothman RR. Continuous passive motion after total knee arthroplasty. Analysis of costs and benefits. Clinical Orthopaedics and Related Research 1995;321:208‐15.

Walker 1991 {published data only}

1. Walker RH, Morris BA, Angulo DL, Schneider J, Colwell CW. Postoperative use of continuous passive motion, transcutaneous electrical nerve stimulation, and continuous cooling pad following total knee arthroplasty [Phase 1]. Journal of Arthroplasty 1991;6(2):151‐6.

Woog 2008 {published data only}

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Yashar 1997 {published data only}

1. Yashar AA, Venn‐Watson E, Welsh T, Colwell CW, Lotke P. Continuous passive motion with accelerated flexion after total knee arthroplasty. Clinical Orthopaedics and Related Research 1997;345:38‐43.

Young 1984 {published data only}

1. Young JS, Kroll MA. Continuous passive motion compared to active assisted range of motion. Physical Therapy 1984;64:721.

References to studies awaiting assessment Aubriot 1993 {published data only}

1. Aubriot JH, Guincestre JY, Grandbastien B. Rehabilitation following total knee arthroplasty. Role of passive motion. A randomised study about 120 subjects [Intérêt des appareils arthromoteurs dans la rééducation précoce des arthroplasties totales de genou. Étude prospective à propos de 120 dossiers]. Revue de Chirurgie Orthopédique 1993;79:586‐90.

Cui 2009 {published data only}

1. Cui XQ, Wang HZ, Li W. Influence of time for continuous passive activities on range of motion following total knee arthroplasty. Journal of Clinical Rehabilitative Tissue Engineering Research 2009;13:4237‐40.

Ersozlu 2009 {published data only}

1. Ersozlu S, Sahin O, Ozgur AF, Tuncay IC. The effects of two different continuous passive motion protocols on knee range of motion after total knee arthroplasty: a prospective analysis [Iki farkli surekli pasif hareket protokolunun total diz protezi sonrasi diz hareket acikligina etkileri: Ileriye donuk bir calisma]. Acta Orthopaedica et Traumatologica Turcica 2009;43:412‐8.

Li 2010 {published data only}

1. Li XL. Velocity factor of continuous passive motion following knee replacement: differences between treatment and control groups. Journal of Clinical Rehabilitative Tissue Engineering Research 2010;14:2349‐52.

Li 2010a {published data only}

1. Li XL, Zhao XO. Continuous passive joint motion following total knee replacement: 48 cases analysis. Journal of Clinical Rehabilitative Tissue Engineering Research 2010;14:665‐8.

Liu 2011 {published data only}

1. Liu W, Wu YL, Cong RJ, Fu PL, Li XH, Wu HS. Controlled active motion and continuous passive motion are beneficial to function rehabilitation after total knee arthroplasty. Journal of Clinical Rehabilitative Tissue Engineering Research 2011;15:6509‐13.

Sosin 2000 {published data only}

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References to other published versions of this review Harvey 2010

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Source: PubMed

Continuous passive motion following total knee arthroplasty in people with arthritis

Abstract

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