CLINICAL ISSUES

Aggressive continuous passive motion exercise does not improve knee

range of motion after total knee arthroplasty
Lan-Hui Chen, Chung-Hwan Chen, Sung-Yen Lin, Song-Hsiung Chien, Jiing Yuan Su,
Chao-Yung Huang, Hui-Yu Wang, Chih-Liang Chou, Tsung-Yu Tsai, Yuh-Min Cheng and
Hsuan-Ti Huang

Aims and objectives. The aim of this study was to evaluate the effects of continuous passive motion on the range of motion,
postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation.
Background. Total knee arthroplasty reduces pain and improves range of motion of the osteoarthritic knee joint. Continuous
passive motion increases postoperative movement, but there is some controversy regarding whether aggressive continuous
passive motion can improve range of motion or life quality, and whether it induces more pain.
Design. A prospective controlled study was conducted in a medical centre in Taiwan from January to December 2006.
Methods. One hundred and seven patients were recruited. The patients underwent the basic rehabilitation protocols (the control
group) or the basic rehabilitation protocols and additional daily use of continuous passive motion for more than six hours per
day (the experimental group). The range of motion, modified Short Form-36 (SF-36) and semi-quantitative visual analogue scale
were recorded.
Results. Range of motion increased from 109 preoperatively to 125 at six months postoperatively in the treatment group and
from 111 preoperatively to 125 at six months postoperatively in the control group. Visual analogue scale decreased from 778
preoperatively to 037 at six months postoperatively in the treatment group and from 792 preoperatively to 021 at six months
postoperatively in the control group. The SF-36 improved from 376 preoperatively to 177 at six months postoperatively in the
treatment group and from 368 preoperatively to 183 at six months postoperatively in the control group. There was no
Authors: Lan-Hui Chen, MHA, RN, Clinical Nurse, Department of
Nursing, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, Kaohsiung; Chung-Hwan Chen, MD, Assistant
Professor, Department of Orthopaedics, Kaohsiung Medical
University Hospital, Kaohsiung Medical University, Kaohsiung and
Department of Orthopaedics and Department of Sports Medicine,
Faculty of Medicine, College of Medicine, Kaohsiung Medical
University, Kaohsiung; Sung-Yen Lin, MD, Doctor, Department of
Orthopaedics, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, Kaohsiung and Department of Orthopaedics,
Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical
University, Kaohsiung; Song-Hsiung Chien, MD, Assistant
Professor, Department of Orthopaedics, Kaohsiung Medical
University Hospital, Kaohsiung Medical University, Kaohsiung and
Department of Orthopaedics, Faculty of Medicine, College of
Medicine, Kaohsiung Medical University, Kaohsiung; Jiing Yuan
Su, MD, Assistant Professor, Department of Orthopaedics,
Kaohsiung Medical University Hospital, Kaohsiung Medical
University, Kaohsiung and Department of Orthopaedics, Faculty of
Medicine, College of Medicine, Kaohsiung Medical University,
Kaohsiung; Chao-Yung Huang, BSc, RN, Clinical Nurse,
Department of Nursing, Kaohsiung Medical University Hospital,
Kaohsiung Medical University, Kaohsiung; Hui-Yu Wang, BSc, RN,

Clinical Nurse, Department of Nursing, Kaohsiung Medical

University Hospital, Kaohsiung Medical University, Kaohsiung;
Chih-Liang Chou, BSc, Physical Therapist, Department of
Rehabilitation, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, Kaohsiung; Tsung-Yu Tsai, BSc, Physical
Therapist, Department of Rehabilitation, Kaohsiung Medical
University Hospital, Kaohsiung Medical University, Kaohsiung;
Yuh-Min Cheng, MHA, MD, Professor, Department of
Orthopaedics, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, Kaohsiung and Department of Orthopaedics,
Faculty of Medicine, College of Medicine, Kaohsiung Medical
University, Kaohsiung; Hsuan-Ti Huang, MD, Assistant Professor,
Department of Orthopaedics, Kaohsiung Medical University
Hospital, Kaohsiung Medical University, Kaohsiung and
Department of Orthopaedics, Faculty of Medicine, College of
Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence: Hsuan-Ti Huang, Assistant Professor, Department
of Orthopedics, Kaohsiung Medical University Hospital, Kaohsiung
Medical University, No. 100, Tzyou 1st Road, Kaohsiung 80708,
Taiwan. Telephone: +886 7 3208209.
E-mail: timei@seed.net.tw
The first and second authors contributed equally to this work.

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389

L-H Chen et al.

significant difference in range of motion, visual analogue scale and SF-36 between groups at each visit.
Conclusion. With the advances in total knee arthroplasty surgical technique, aggressive continuous passive motion does not
provide obvious benefits.
Relevance to clinical practice. Total knee arthroplasty can alleviate pain and improve range of motion, but aggressive continuous passive motion does not provide additional benefits.
Key words: continuous passive motion, life quality, osteoarthritis, pain, range of motion, total knee arthroplasty
Accepted for publication: 22 January 2012

Introduction
With the improvements in medical care, life expectancy has
been extended, and with this, more and more older persons
require total knee arthroplasty (TKA) for advanced knee
osteoarthritis. TKA has been proven a successful treatment
for advanced arthritis of the knee (Laughman et al. 1984,
Stern & Insall 1992, Font-Rodriguez et al. 1997, Pavone
et al. 2001, Kelly & Clarke 2002, Huang et al. 2005).
According to publicly available information from the Health
Insurance Bureau, Taiwan, the expenditure for TKA in 2000
was 263 billion NT dollars, making it the second costliest
medical expenditure. The therapeutic effects of TKA rely on
not only the surgical technique but also the postoperative
rehabilitation protocol.
The main purposes of TKA are to reduce pain and improve
the range of motion (ROM) of the knee joint, thereby
enhancing the patients ability to sit down, rise from a sitting
position and climb stairs, and improving quality of life
(MacDonald et al. 2000, Huang et al. 2007). As early
postoperative ROM is an important prognostic factor for
the patients ability to walk later (MacDonald et al. 2000), it
is important to achieve the best possible knee ROM while the
patient is in hospital (MacDonald et al. 2000). Thus, the
rehabilitation protocol in the hospital might have considerable consequences for the patient in the longer term.
Continuous passive motion (CPM) was first introduced by
Salter (1989) in the 1960s. CPM has been advocated in the
belief that it increases knee ROM (Salter 1989, McCarthy
et al. 1992). An increase in postoperative ROM will be
achieved, although perhaps at the cost of increased postoperative pain. Pain in the early postoperative rehabilitation
period will play a deleterious role in recovery by delaying
mobilisation and limiting exercise potential. Therefore, a
proper rehabilitation protocol to optimise ROM may offer
patients great benefits. The aims of the study were to
investigate whether aggressive CPM during hospitalisation
had an effect on pain, knee ROM and quality of life above

390

the effect of active postoperative physiotherapy in patients

with TKA within six months after operation, and whether
there was any association between knee ROM and quality of
life. We hypothesised (1) aggressive CPM in the early
postoperative period would improve knee ROM, (2) aggressive CPM would induce more pain, and (3) aggressive CPM
would improve quality of life. In this study, we compared the
effect of prolonged CPM in the early postoperative period
with basic rehabilitation protocols, including straight leg
raising training, walking with a walker and ROM at will.

Materials and methods

Study design
This study was a prospective controlled study involving
patients with degenerative osteoarthritis who had received
TKA for the first time. The patients were allocated into two
groups with two different postoperative exercise regimes
either the basic rehabilitation protocols (the control group) or
the daily use of CPM for more than six hours together with
basic rehabilitation protocols (the experimental group). The
basic rehabilitation protocols consisted of assisted and active
flexion and extension of the hip/knee, active isometric
contraction of the quadriceps, straight leg raising training,
walking with a high walker or crutches and eventually
climbing stairs on crutches. Based on Altmans nomogram
with a standard difference of 075 (i.e. a clinically relevant
difference of 158 with a standard deviation of 208), a power
of 80% and a significance level of 005, the sample size was
calculated to reach 55 patients (for two groups) (Altman
1999). A group of more than 30 subjects were chosen.

Patients
All patients with osteoarthritis admitted to Kaohsiung
Medical University Hospital by two experienced surgeons
specialising in adult reconstruction were enroled. Before

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Journal of Clinical Nursing, 22, 389394

Clinical issues

operation, all patients could walk with and/or without a

walking aid. The knee on one side was operated on in each
patient because advanced osteoarthritis. Patients with rheumatoid arthritis or prosthesis in the ipsilateral hip were
excluded. All patients were available for follow-up.

Procedure
The choice of epidural anaesthesia or general anaesthesia was
made by the anaesthetist. The prosthesis used in all patients
was a fixed-bearing posterior-stabilised high-flex knee (Legacy High Flex; Zimmer, Warsaw, IN, USA). The patella was
resurfaced in every patient. All the components were fixed
with cement.
The same postoperative rehabilitation protocol guidelines
were used for all patients, except the addition of CPM. The
exercises were performed for 30 minutes daily, starting on
the first day after surgery and were adjusted to the patients
degree of pain. For the CPM, the patient lay in a supine
position in the CPM machine. On the first day after
operation, the machine was set to at least 70 as tolerated
and to as much as 100 for flexion, and the knee was moved
continuously for at least two hours each in the morning,
afternoon and evening. The next day the machine was set at
100 flexion. Between sessions, the knee was placed in the
extended position. All patients were discharged at the fourth
day after operation and followed the exercise protocol given
by the hospital after discharge. Outpatient treatment was not
standardised.

Measures and follow-up

Knee ROM, in terms of active and passive flexion and
extension, was measured by a goniometer with the patient in
a supine position. Knee flexion was measured with the hip at
90 flexion. The goniometer swivel centre was placed on the
lateral side of the knee centre, with one arm aligned with the
greater trochanter and the other along the line running from
the fibular head to the lateral malleolus of the ankle (Norkin
& White 1995). The knee was moved to maximum flexion
and the range measured in degrees.
Pain intensity in the knee was measured by means of a
100 mm visual analogue scale (VAS), where 0 indicated no
pain and 100 indicated unbearable pain (Boeckstyns & Backer
1989). During hospitalisation, VAS was recorded every day.
The quality of life of the patients was evaluated with the
modified Short Form-36 (SF-36) (IQOLA SF-36 Taiwan
Standard Version 1.0, Taoyuan, Taiwan) questionnaire. The
SF-36 contains 11 dimensions, including: (1) Self-evaluation of
general health condition, (2) Comparing the current health
2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 389394

Aggressive CPM does not improve ROM after TKA

condition with the condition one year ago, (3) The restriction
of daily activity including vigorous exercise, moderate exercise, stair climbing and walking distance by health condition,
(4) The restriction of work by health condition, (5) The effect
of emotion on work, (6) The impairment of daily activity with
family, neighbours and community because of health condition and emotion, (7) The extent of pain during the past
month, (8) The effect of pain on daily activity and work during
the past month, (9) The feeling during the past month, (10) The
effect of health and emotional problems on social activity, and
(11) The concept of self-health. The scores ranged from 15 on
each item, with the lowest score indicating the best condition,
and the highest, the worst condition. The SF-36 result was
calculated by taking the mean of all 11 items. The ROM and
semi-quantitative VAS were recorded by a well-trained study
nurse. All the parameters were evaluated at the time of
admission and followed up by the same study nurse. The
patients were scheduled to return for evaluation at two, six
weeks, three and six months postoperation. The ROM, VAS
and Short Form-36 were evaluated at every visit by the same
study nurse.

Statistical analysis
All data were presented as mean standard deviation (SD).
The MannWhitney test was used to analyse the efficacy
between study groups. Repeated analysis of variance (ANOVA )
was implemented to examine the differences at various time
points. All tests were two-sided and performed at the 5%
level and analysed with SPSS statistical software (version 14.0;
SPSS Inc., Chicago, IL, USA).

Results
Baseline characteristics
Between January 2007 and June 2007, 107 patients who had
undergone TKA were assigned to one of two groups, the
control and the experimental group. The detailed preopera-

Table 1 Demography and symptom duration of the patients

Number of patients
Age (year)
Body weight (kg)
Preoperative ROM
(degree)
Symptom duration
(months)

Treatment group

Control group

p-value

68
6925 679
6448 1083
9269 1414

39
6946 817
6541 1035
9513 935

089
067
076

8216 7047

6815 5107

028

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L-H Chen et al.

tive comparison of the two groups is shown in Table 1. There

was no difference between these two groups in terms of
demography and the duration of painful osteoarthritis
symptoms (Table 1).

Range of motion
During hospitalisation, the patients in the treatment group
used CPM significantly longer (1690 695 hours) than
those in the control group (0). Although the patients in the
treatment group used CPM more than six hours daily, they
did not have greater ROM and pain during hospitalisation.
ROM was nearly the same in the treatment group
(9269 1414) as in the control group (9513 935).
ROM increased from 109 preoperatively to 125 at six
months after operation in the treatment group and from 111
preoperatively to 125 at six months after operation in the
control group. There was no significant difference in ROM
between groups at each visit (Table 2). No patients received
manipulation under anaesthesia because poor ROM. The
results disproved our hypothesis.

Pain
The VAS of the patients in the treatment group (644 174)
and the control group (626 192) did not differ significantly. VAS decreased from 778 preoperatively to 037 at six
months after operation in the treatment group and from 792
preoperatively to 021 at six months after operation in the
control group. There was no significant difference in VAS
between groups at each visit (Table 2). The results disproved
our hypothesis.

Quality of life
The SF-36 improved from 376 preoperatively to 177 at six
months postoperatively in the treatment group and decreased
from 368 preoperatively to 183 at six months postoperatively in the control group. There was no significant difference in SF-36 between groups at each visit (Table 2). The
results disproved our hypothesis.

Discussion
In our study, we found that compared with active exercises
alone, CPM had no additional effect on knee ROM, pain or
quality of life postoperatively up to six months after TKA.
Two weeks after TKA, both groups had a statistically
significant reduction in pain intensity compared with baseline. Six weeks after TKA, both groups had the same knee
ROM compared with baseline and less pain than before. Pain
decreased and ROM increased with time, from two weeks to
six months postoperatively. At the end of follow-up, nearly
all patients had an average of 125 ROM and less than one in
the VAS. In every measurable parameter, there was no
significant difference between groups.
A meta-analysis showed improved flexion at two weeks
postoperatively, a decreased length of hospital stay and a
decreased incidence of manipulation under anaesthetic with
CPM use (Milne et al. 2003). Our results are compatible with
those of previous studies by Beaupre et al. (2001), Leach
et al. (2006), Chen et al. (2000) and Milne et al. (2003). In
both groups, ROM at three months after TKA was better
than the preoperative ROM. This improvement may be due
to the healing of the structures surrounding the joint (BruunOlsen et al. 2009). In some studies, ROM at three months

Table 2 The results of the preoperative and postoperative ROM, VAS and SF-36
Preoperative

Two weeks after TKA

Six weeks after TKA

Three months after TKA

Six months after TKA

ROM
Treatment group
Control group
p-value

9269 1414
9513 935
076

10233 917
10500 1076
078

11051 974
11321 1003
086

11926 886
11910 931
088

12551 599
12513 644
081

VAS
Treatment group
Control group
p-value

778 216
792 233
078

512 139
477 156
062

322 128
305 154
081

143 100
103 111
057

037 060
021 047
037

SF-36
Treatment group
Control group
p-value

376 018
368 019
067

338 016
347 014
072

253 014
256 016
081

208 014
201 018
074

177 015
183 016
087

ROM, range of motion; VAS, visual analogue scale.

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Journal of Clinical Nursing, 22, 389394

Clinical issues

Aggressive CPM does not improve ROM after TKA

after TKA did not reach the preoperative level (Bruun-Olsen

et al. 2009). But another study showed that at six weeks after
TKA, ROM had returned to the preoperative level, similar to
our result (Leach et al. 2006). No patient with poor ROM
required manipulation of the knee joint in our study, even in
the control group.
The difference between preoperative ROM and ROM at
six months after TKA was even greater. Our patients did not
receive special rehabilitation at local hospitals or rehabilitation clinics after discharge, which meant that if the patients
could maintain the rehabilitation protocols learned in the
hospital, ROM could increase with time, even though we do
not know how conscientious they were about practicing the
exercises.
There are some limitations to this study. First, this was not
a randomised controlled study. Second, the rehabilitation
protocol after discharge was not standardised. Third, the
number of patients was not so large, which sometimes may
result in less ability to tell the difference between groups.
However; according to the sample size calculation, our
sample size was adequate to make this distinction.

Conclusion
In conclusion, with the advances in TKA surgical techniques,
aggressive CPM does not provide obvious benefits in ROM
and quality of life. However, aggressive CPM does not induce
more pain.

Relevance to clinical practice

Alleviating pain and improving ROM are the central components of nursing in the postoperative care of patients
receiving TKA. It is important to monitor the effects of
aggressive CPM on pain and ROM. The results of this study
indicate that patients undergoing TKA can have less pain and
better ROM and life quality six months after operation, but
aggressive CPM during hospitalisation does not provide
additional benefits. Therefore, we do not suggest routine use
of aggressive CPM after TKA.

Acknowledgements
This research was supported by and National Health
Research Institute of Taiwan (NHRI-EX99-9935EI) and
Kaohsiung Medical University Hospital (KMUH95-5N52
and KMUH96-6R08).

Contributions
Study design: H-TH, L-HC, JYS, Y-MC; data collection and
analysis: S-YL, S-HC, C-YH, H-YW, C-LC, T-YT and
manuscript preparation: L-HC, C-HC, H-TH.

Conflicts of interest
The authors declare that they have no conflict of interests.

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