The Journal of Arthroplasty 29 (2014) 11581162

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

The Efcacy of Continuous Passive Motion After Total Knee

Arthroplasty: A Comparison of Three Protocols
C. Kent Boese, MD a, Marcia Weis, RN, MSN, ONC b, Tamra Phillips, MSPT, DPT b,
Sheila Lawton-Peters, MSN, APRN, CCRN, CNS NP-BC b, Theresa Gallo, PA-C, MPA a, Leslie Centeno, BA a
a
b

Miller Orthopedic Specialists One Edmundson Place, Council Bluffs, Iowa

Alegent Creighton Health Mercy Hospital, Council Bluffs, Iowa

a r t i c l e

i n f o

Article history:
Received 2 October 2013
Accepted 3 December 2013
Keywords:
total knee arthroplasty
continuous passive motion
CPM
knee arthroplasty
knee replacement
postoperative rehabilitation

a b s t r a c t
We conducted a randomized, controlled trial to determine the efcacy of CPM following total knee arthroplasty (TKA). Postoperative outcomes of interest were: swelling, drop in hemoglobin, self-reported pain
scores, range of motion, and hospital length of stay. A total of 160 subjects were randomized into one of three
treatment groups: CPM device on and moving from the immediate post-operative period, CPM device on and
stationary at 90 degree exion for the rst night and then moving throughout the rest of their stay, and no
CPM (N = 55, 51, and 54, respectfully). Subjects were followed during the rst and second postoperative day
until their rst follow-up appointment approximately 34 weeks post-operatively. Cost of CPM was further
evaluated. CPM provided no benet to patients recovering from TKA.
2014 Elsevier Inc. All rights reserved.

Since the early 1980s, the adjunctive use of CPM has grown rapidly
to augment patients rehabilitation following TKA [13]. Reported
benets of CPM include facilitated improvements in range of motion,
decreased pain and swelling, reduced need for manipulation under
anesthesia, decreased hospital length of stay and a reduction in overall
cost. However, these benets remain controversial as the literature on
CPM has not conclusively conrmed these results since the initial
trials by Salter and colleagues [2,3]. For instance, research suggests
there are no long-term advantages associated with CPM use [48],
while other studies present no clinical differences between patients
given a CPM versus patients who complete standard physical therapy
alone [7,911].
The existing literature may be difcult to generalize and apply to
modern community practice. Multiple different CPM protocols have
been used and length of hospital stays had varied from 756 days. In
current practice, the average hospital stay following TKA has since
decreased to 3.5 days [12].
Additionally, not all studies specify the type of anesthetic and
prosthesis used, and whether or not the surgeries were performed by a
single surgeon or a team of surgeons under the same orthopedic unit.
Other variables loosely controlled include: discharge criteria, measures
of patient outcomes, and post-operative physical therapy protocols.

Our study was done in the setting of a community practice using

regional anesthetics, a multi-modal pain protocol, functional based
physical therapy, and a dened care path resulting in a short hospital length of stay. The aim of this investigation was to evaluate the
effects of early aggressive CPM and xed exion proceeding progressive CPM on short-term outcomes compared to standardized
physical therapy alone. Primary outcomes of interest include: active
exion and extension achieved, pain visual analog scores (VAS), blood
loss as measured by postoperative drop in hemoglobin, and hospital
length of stay. We also recorded complications, discharge disposition,
and need for manipulation under anesthesia. Cost of CPM at our
institution was evaluated.

Methods
Study Design
This clinical study utilized a prospective, randomized, experimental design. Power analysis determined that a total sample size of
150, or 50 subjects in each group, would be needed to yield 81.74%
power to detect signicant differences in the dependent variables.
Participants

The Conict of Interest statement associated with this article can be found at
http://dx.doi.org/10.1016/j.arth.2013.12.005.
Reprint requests: Leslie Centeno, BA, Research Coordinator Miller Orthopedic
Specialists One Edmundson Place, Suite #500 Council Bluffs, IA 51503.
http://dx.doi.org/10.1016/j.arth.2013.12.005
0883-5403/ 2014 Elsevier Inc. All rights reserved.

Following IRB approval, patients were actively recruited from

December 2007 to May 2010. We obtained consent from 218 patients.
Of these, there were 10 surgery cancellations, 6 patients who met the

C.K. Boese et al. / The Journal of Arthroplasty 29 (2014) 11581162

1159

Fig. 1. Number of patients divided by surgeon.

exclusion criteria, and 42 patients removed due to staff errors, missing

data, requests to withdraw from the study, and poor health for participation. Total 160 patients completed the study (See Fig. 1).
Individuals were assigned by consecutive sequencing into one of
three protocol groups, A, B, C, during pre-operative classes. The nature of
CPM prevented blinding in this study. The protocol groups were
as follows: inclusion criteria consisted of patients aged 1890 years
who were scheduled to undergo a primary TKA by one of four surgeons
at Alegent Creighton Health Mercy Hospital in Council Bluffs, Iowa.
Exclusion criteria were: bilateral TKA, non-English speaking, a body mass
index (BMI) greater than 40, and starting knee range of motion of greater
than 15 exion contracture or less than 80 exion. Patients transferred
off the orthopedic unit during their hospital stay were excluded.
Group A patients receiving a moving CPM immediately upon
arrival to the orthopedic oor moving from 0110 degree range of
motion. Degrees of exion were adjusted per patient tolerance. CPM
continued daily for a minimum of 5 hours per day as tolerated for a
minimum of two days and was continued until 90 degrees of active
exion was obtained.
Group B patients receiving a non-moving CPM immediately upon
arrival to the orthopedic oor. The operative leg was placed in a xed,
bent position following surgery and held in this position during the
rst night for a minimum of 8 hours and a maximum of 19 hours. The
goal was to hold the knee stationary at 90 degrees; however, exion
was decreased as needed for patient comfort. During all subsequent
hospital days, the Group A protocol was followed.
Group C patients who did not receive a CPM machine during
their hospital stay. The operative leg rested on the hospital bed and
the patient was repositioned for comfort by nursing staff.

Procedure
The operating surgeon was blind to the randomization at the time
of surgery. All patients received a DePuy posterior stabilized knee
prosthesis with the majority under epidural anesthesia. While 47
patients in Group A, 43 patients in Group B, and 47 patients in Group C
received an epidural anesthetic, 7 patients in Group A, 8 patients in
Group B, and 7 patients in Group C received a general anesthetic.
Electrocautery and a pneumatic tourniquet were used for hemostasis
and Coumadin was administered as a postoperative anticoagulant.
Postoperative pain protocol consisted of Tylenol (1000 mg QID),
Tramadol (50 mg QID), Celebrex (400 mg pre-op, 200 mg BID post-

op), and oxycodone (5-10 mg, 20 minutes prior to physical therapy).

Patient controlled epidural anesthesia (PCEA) was initiated in the
recovery room and was continued overnight then discontinued at
7:00a.m the next day.
With the exception of the CPM protocol used, patients received the
same care during their hospital stay. Physical therapy targeted active
motion of the knee and functional mobility. Patients were encouraged
to ambulate on the morning of the rst post-operative day. Twice
daily therapy protocol included quad sets, short arc quads, long arc
quads, hip abduction, straight leg raises, ankle pumps and gluteal sets
beginning on the rst postoperative day. Patients were encouraged to
rock in a rocking chair four times a day for 20 minutes to reduce joint
stiffness. A ve pound sand bag was placed on the operative knee
(Ottoman stretch) four times a day for 10 minutes to promote knee
extension as tolerated.
Patients were discharged home if able to ambulate independently
100 feet with assistive device, perform activities of daily living with
minimum assistance, temperature b 38.3C and/or trending down,
range of motion exion N 90, extension b15 and pain controlled with
oral analgesics. Those patients still requiring physical assistance to
ambulate after postoperative day 3 were transferred to a skilled
rehabilitation facility.

Outcome Measures
Prospective data collection included: change in hemoglobin from
the pre-operative period till the rst and second postoperative day;
self-reported pain scores 30 minutes prior to morning and afternoon
Table 1
Demographic Data Means and ANOVA Test Results.

Age (years)
Body mass index
Gender (% male)
10 cm above joint line (cm)a
At joint line (cm)a
10 cm below joint line (cm)a
Pre-op hemoglobin (gm/dl)b
Pre-op range of motion ()
a
b

Pre-operative girth.
Group B N = 50.

Group A
N = 55

Group B
N = 51

Group C
N = 54

P-Value

69.1
31.3
30.9
45.5
41.8
37.7
13.9
107.3

66.7
32.6
29.4
47.7
42.3
39.2
13.9
107.0

68.3
31.9
38.9
45.9
41.5
38.4
13.9
106.8

0.48
0.47
0.54
0.12
0.59
0.23
0.95
0.98

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C.K. Boese et al. / The Journal of Arthroplasty 29 (2014) 11581162

Table 2
Day One Results.

10 cm above joint line (cm)^

At joint line (cm)^
10 cm below joint line (cm)^
Drop in hemoglobin (gm/dl)
AM pain (110 VAS)
PM pain (110 VAS)
AM extension ()
AM exion ()
PM extension ()
PM exion ()
Overall p-value (Wilks Lambda)

Group A
N = 48

Group B
N = 47

Group C
N = 50

1.9
1.8
1.1
3.2
3.6
2.9
9.9
76.8
8.0
82.1

1.6
2.0
1.1
3.2
3.3
2.7
9.2
75.6
7.2
84.3

2.3
1.9
1.2
3.2
2.4
2.0
8.5
78.1
6.2
82.5

P-Value
0.40
0.96
0.94
0.98
0.13
0.09
0.37
0.62
0.14
0.58
0.65
Fig. 2. Knee extension.

^ = Change in girth (from pre-operative).

+ = Visual Analog Scale.

physical therapy sessions each postoperative day using the visual

analog scale; girth measurements (at the joint line, 10 cm above and
10 cm below the joint line) pre-operatively and on each postoperative
day; and hospital length of stay.
Active range of motion measurements were collected preoperatively, at each morning physical therapy session postoperatively, and
at the patients rst follow-up in the surgeons clinic approximately
three weeks after their surgery.
Two staff nurses and one physical therapist recorded all inpatient girth measurements. All evaluating staff of ROM were trained
prior to data collection. Number of evaluators for ROM could not be
tracked as there were multiple sites for data collection. For instance,
three week post-operative ROM was completed at the nearest location to the patient.
Cost Data
Our institution paid a monthly at rate for renting CPM devices
from Ottobock. Cost data was extracted from billing charges from the
company. Additional costs for nursing staff to operate the device were
extracted from a nancial database at our institution.
Results
There were 55 subjects in Group A, 51 in Group B and 54 subjects
in Group C. Data were analyzed using a MANOVA test for outcomes
on each post-operative day and at nal follow-up; individual ANOVA
tests were used as needed.
ANOVA tests showed that the randomization procedure created
demographically similar groups (see Table 1). There was one subject
for whom there was no pre-operative hemoglobin score recorded.
Table 3
Day Two Results.

10 cm above joint line (cm)^

At joint line (cm)^
10 cm below joint line (cm)^
Drop in hemoglobin (gm/dl)
AM pain (110 VAS)
PM pain (110 VAS)
AM extension ()
AM exion ()
PM extension ()
PM exion ()
Overall p-value (Wilks Lambda)

Group A
N = 29

Group B
N = 25

Group C
N = 22

4.7
3.7
3.4
3.6
2.1
1.8
7.0
86.7
5.1
87.9

3.5
2.8
2.1
2.9
2.4
2.5
6.8
87.2
5.7
89.6

4.1
3.8
1.4
3.5
2.3
1.6
6.2
87.8
5.0
88.1

^ = Change in girth (from pre-operative).

+ = Visual Analog Scale.
* = Indicates statistical signicance.

P-Value
0.31
0.34
b0.01*
0.07
0.91
0.14
0.82
0.92
0.79
0.77
0.06

Although many patients stayed longer than the second postoperative day, there were not enough inpatients to adequately
compare the groups past post-operative day two.
There were no signicant MANOVA test differences between the
groups for any variable.
The overall MANOVA test for range of motion, change in hemoglobin, girth measurements and pain scores were not signicant. (See
Tables 23 and Figs. 24). Evening pain scores were greatest in the
moving CPM group (Group A) and lowest in the no CPM group (Group
C), but was not statistically signicant. This was the most clinically
signicant nding for post-operative day one.
Drop in Hgb from pre-operative to post-operative day two was
lowest in Group B (goal of 90 degrees stationary CPM on the rst
post-operative night), although this difference was not statistically
signicant. During post-operative day two, Group A patients did show
a larger change in leg girth 10 cm below the joint line (P b .01). The
overall MANOVA test for length of stay was close to signicance at
0.09 (see Table 4). As the other four factors all had p-values ranging
from 0.940.96, the researchers conclude that the most signicant
difference between groups comes from the length of stay factor. The
raw values for length of stay (2.7, 3.2, and 2.6) days for Groups A, B,
and C, respectfully) show a clinically signicant difference (See
Table 4). The ANOVA test for length of stay showed a signicantly
longer stay for patients who received the stationary CPM (Group B) on
the rst night than for any other group (P b .01).
One patient in Group C and two patients in Group A underwent a
manipulation under anesthesia (See Table 5). No wound complications were seen in Group B, while one patient in Group A was admitted to the ER for swelling and one patient in Group C experienced a
hematoma. There were no signicant differences in the rate of complications between the groups.
Our institution rented 10 CPM devices at a time. Billing charges
indicate our institution was spending $1500 for the device rentals and
$350 for the accompanying software. Additionally, it cost $35 per hour
in labor for the nursing staff to apply, adjust, and monitor the CPM
device for an average of four hours.
Discussion
CPM provided no apparent benet to our patients recovering from
TKA in all outcome variables. We found no clinically signicant differences in ROM, swelling, blood loss, pain scores, or active ROM
achieved between any of the groups at any time.
Range of Motion
All treatment groups achieved similar ROM measurements in our
study. These results contradict reports of early increases in active ROM
with CPM use. McInnes and colleagues (1992) reported increases in
active exion by postoperative day seven after administering CPM on

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1161

Table 4
Final Results.

Length of stay (days)

Post-op extension ()a
Post-op exion ()a
Post-op range of motion ()a
Overall p-value (Wilks Lambda)
a
b

Group A
N = 55

Group B
N = 51

Group C
N = 53

2.7
2.3
111.9
109.6

3.2
2.2
111.2
109.0

2.6
2.1
111.7
109.5

P-Value
b0.01b
0.94
0.94
0.96
0.09

Measured at rst clinical follow-up.

Indicates statistical signicance.

patients 24 hours after surgery [8]. Lenssen and colleagues (2008)

similarly found increases in active exion by postoperative day 17,
though contrary to our study design, the control for surgeons or type
of implant was not specied [13]. While the early benets in ROM
with prolonged CPM use are evident in these trials, no long-term
advantages were found in each examination.

ences in blood loss between our study groups. Although we found

patients in the static overnight CPM group experienced a smaller
drop in Hgb on the second postoperative day, this difference was not
statistically signicant.
Results from Harms and Engstrom (1991) and Pope and colleagues
(1997) suggested CPM use increased patients blood loss versus a
control [18,19]. Pope and colleagues (1997) attribute the increase in
blood loss to utilizing a 0 to 70 degree CPM on patients compared to
previous research assigning a less intense CPM [19,20]. Nonetheless,
we provided our patients a more aggressive CPM, moving from 0 to
110 degrees, and found no effect on patients blood loss.

Swelling

Hospital Length of Stay and Discharge Disposition

It is suggested that CPM may decrease swelling due to its pumping

action pushing blood and edema uid away from the joint and
periarticular tissues [2,14]. Despite this basis, most studies have found
no signicant differences in swelling between patients given a CPM
versus a control [2,15,16]. Our results are in accord with this larger
consensus. Although there was an increase in swelling in the immediate CPM group A 10 cm below the joint line on the second postoperative day, this was not seen at any other time or location and it
is the principal investigators belief that this difference held no
clinical signicance.
Interestingly, results from Maniar and colleagues (2012) suggested
CPM use delayed the return of suprapatellar girth measurements to
preoperative status compared to a control group, averaging 3 months in
the CPM protocol groups versus 42 days in the control [2]. These results
contrast outcomes from McInnes and Larson (1992) and Montgomery
and Eliasson (1996). Both trials suggest CPM use is associated with less
swelling following TKA. However, these trials lacked control for implant
type, anesthetic, or participating surgeons [8,17].

It is questionable whether or not CPM reduces patients hospital

stay. A meta-analysis conducted by Brosseau and colleagues (2004)
found patients given a CPM had an earlier hospital discharge [6],
whereas results from Hewitt and Shakespeare (2005) indicate CPM
use increased patients length of stay [11]. Contrary to these reports,
McInnes and colleagues (1992) and Bennett and colleagues (2005)
found no relationship between CPM use and patients hospital discharge [4,8]. In our examination, we detected an actual increase in
length of stay by half a day in the static overnight CPM group, while
there was no difference in hospital stay between the immediate,
moving CPM and no CPM groups.

Fig. 3. Knee exion.

Blood Loss

Cost
Our institution was spending $1,850 for CPM device rentals and its
accompanying software. Patients were not billed for these devices, as
it was included in their hospital stay. If CPM devices were not included
in our post-operative rehabilitation protocol, our institution could
have saved $22,200 per year.
Conclusions

CPM use does not to appear to impact patients blood loss following TKA [7]. We similarly found no clinically signicant differ-

This study beneted from a randomized design and a relatively

large sample size. All patients received the same physical therapy
regime, which focused on active ROM and early functional mobility.
All patients also received the same posterior stabilized knee design
implanted by one of four surgeons at a community hospital. While
most patients received the same epidural anesthetic and post-op
Table 5
Complications.

Fig. 4. Average VAS Pain Scores before physical therapy.

Pulmonary Embolism
Hypoxia
Headache
Hematoma
AFIB
Emergency Room Visit
Manipulation Under Anesthesia

Group A
N = 55

Group B
N = 51

Group C
N = 54

0
0
0
1
0
0
2

1
0
2
0
1
0
0

1
1
0
0
0
1
1

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C.K. Boese et al. / The Journal of Arthroplasty 29 (2014) 11581162

PCEA, all patients received the same postoperative multi-modal pain

control program and the same care path.
Unfortunately, there will always be bias in any CPM study, as it is not
possible to blind patients or clinical staff. One limitation of this study is
the fact that patients were in control of the duration of CPM use, within
the boundaries of their study group. However, this was necessary to
provide for patient comfort. It may be difcult to generalize the
results of this study to other practices that use different knee implants
or surgical techniques, different anesthetics or postoperative pain
control protocols, or a different physical therapy regime.
These results provide evidence that CPM is not benecial, at least
in a facility that is focused on early mobility and a short hospital
length of stay following TKA surgery. As a result of this study, our
institution no longer routinely uses CPM after TKA.
Acknowledgments
We would like to thank Brian Cooley, RN, MSN, ONC and Rebecca
Baker, RN, BSN, ONC for their assistance with the patient consenting
and data collection processes. We also greatly appreciate Carla
Plantikow, MSC, for assisting with the preparation of this paper.
References
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 Surg
Sports Traumatol Arthrosc 2006;14:922.
2. Maniar RN, Baviskar JB, Singhi T, et al. To use or not to use continuous passive
motion post-total knee arthroplasty: presenting functional assessment results in
early recovery. J Arthroplasty 2012;27(2):193.
3. Salter RB, Simmonds DF, Malcolm BW, et al. J Bone Joint Surg Am 1980;62(8):1232.
4. Bennett LA, Brearly SC, Hart JA, et al. A comparison of 2 continuous passive motion
protocols after total knee arthroplasty: a controlled randomized study.
J Arthroplasty 2005;2(20):225.

5. Bequpr LA, Davies DM, Jones AC, et al. Exercise combined with continuous
passive motion or slider board therapy compared with exercise only: a
randomized controlled trial of patients following total knee arthroplasty. Phys
Ther 2000;81:1029.
6. Brosseau L, Mile S, Wells G, et al. Continuous passive motion following total knee
arthroplasty. J Rheumatol 2004;31(11):2251.
7. Lau S, Chiu K. Use of continuous passive motion after total knee arthroplasty.
J Arthroplasty 2001;16(3):336.
8. McInnes J, Larson MG, Daltroy LH, et al. A controlled evaluation of continuous
passive motion in patients undergoing total knee arthroplasty. JAMA 1992;
268(11):1423.
9. Davies DM, Johnston WC, Beaupre LA, et al. Effect of adjunctive range-of-motion
therapy after total knee arthroplasty on the use of health services after hospital
discharge. Can J Surg 2002;46(1):30.
10. Denis M, Moffet H, Caron F, et al. Effectiveness of continuous passive motion and
conventional physical therapy after total knee arthroplasty: a randomized clinical
trial. Phys Ther 2006;86(2):174.
11. Hewitt B, Shakespeare D. Flexion vs. extension: a comparison of post-operative
total knee arthroplasty mobilization regimes. Knee 2001;8:305.
12. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total Knee Arthroplasty Voume,
Utilization, and Outcomes Among Medicare Beneciaries, 19912010. JAMA
308(12);1227.
13. Lenssen TAF, Van Steyn MJA, Crijns YHF, Waltje EMH, Roox GM, Geesink RJT,
Van den Brandt PA, De Bie RA. BMC Musculoskelet Disord 9(60).
14. ODriscoll SW, Giori NJ. Continuous passive motion (CPM): theory and principles of
clinical application. J Rehabil Res Dev 2000;37(2):179.
15. Chen LH, Chen CH, Chien SH, et al. Aggressive continuous passive motion exercise
does not improve knee range of motion after total knee arthroplasty. J Clin Nurs
2012;22:389.
16. Polit DF, Beck CT. Nursing research: principles and methods. 7th ed.Philadelphia:
Lippincott Williams & Wilkins; 2004.
17. Montgomery F, Eliasson M. Continuous passive motion compared to active physical
therapy after knee arthroplasty. Acta Orthop Scand 1996;67(1):7.
18. Harms M, Engstrom B. Continuous passive motion as an adjunct to treatment in the
physiotherapy management of the total knee arthroplasty patient. Physiother
1991;77(4):301.
19. Pope R, Corcoran S, McCaul K, et al. Continuous passive motion after primary
total knee arthroplasty: does it offer any benets? J Bone Joint Surg Br 1997;
79-B(6):914.
20. Ritter MA, Gandolf VS, Holston KS. Continuous passive motion versus physical
therapy in total knee arthroplasty. Clin Orthop Relat Res 1989;244:239.