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INTRODUCTION incurred less total cost to the hospital compared

Total knee arthroplasty (TKA) is a common
procedure used for patients with osteoarthritis (OA).
As time spent in hospital post surgery is rapidly
decreasing, it is important to find rehabilitation
techniques that quickly re-establish knee range
of motion (ROM) (Lenssen et al 2003a). Ninety-five
degrees of knee flexion has been shown to allow
activities of daily living to be carried out (Lenssen
et al 2008), therefore restoration of post-operative
ROM is considered a major indicator of the success
of a TKA (Beaupre et al 2001).
Continuous passive motion (CPM) is a machine
with an external motor which passively moves a
joint within a certain ROM (Lenssen et al 2008). It
is used widely in the rehabilitation of TKA. Having
outlined four stages of stiffness (bleeding, oedema,
granulation tissue and fibrosis), O’Driscoll and
Giori (2000) proposed that CPM works like a pump,
encouraging blood and fluid away from the joint in
the bleeding and oedema stages, thus preventing
the joint from becoming stiff.
Proposed benefits of CPM include: reduced
knee manipulation rates, decreased analgesia
requirement, reduced incidence of deep vein
thrombosis (DVT), and increased ROM (Lachiewicz
2000). It has also been suggested that patients
who have received CPM following TKA have
with “conventional rehabilitation” (p. 146) due to
decreased length of stay and reduced rate of post-
operative manipulations (Lachiewicz 2000).
Although Fuchs et al (2005) reported CPM as
being protective against deep vein thrombosis, not
all authors agree with this (Lynch et al 1988, Ververli
et al 1995, Vince et al 1987). Detrimental effects
such as increased bleeding and complications of the
wound have been reported (Lachiewicz 2000). In
addition, CPM is expensive because of the increased
time it takes for staff to set up, maintain and adjust
the machine as well as the cost of renting and
buying additional equipment needed when using
CPM (Ritter et al 1989). Since the effects of CPM
as an intervention post-TKA remain contentious,
this systematic review aims to evaluate the recent
literature on the efficacy of CPM after TKA. In
drawing conclusions about the clinical value of CPM
following TKA, the authors aim to identify areas for
further research.
METHOD
An extensive search was conducted by one
author (PV) in March 2009 to locate randomised
controlled trials deemed relevant to the review topic.
The authors chose to exclude studies published
before 2000, since they felt earlier studies were

14 NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)

 reviewed in an earlier publication on the same topic
(Milne et al 2003).
Studies were identified using electronic
databases (Medline, PEDro, Cochrane, CINAHL
and Google scholar) and reference lists of relevant
articles. Keywords used for database searching are
documented in Table 1a and the search strategy
used for Medline is presented in Table 1b.
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RZC&Z&/39&RX
R_C&RN&/39&RM&/39&RX
Inclusion/exclusion criteria (Table 2) were
applied to studies identified from the search
strategy by the searching author (PV). Studies
satisfying the criteria were assessed using the
PEDro scale to determine their methodological
quality (score out of ten). The PEDro scale is created
specifically to assess the methodological quality
of physiotherapy studies. The scale’s scoring is
approximately two times less variable than the
Jadad scale which is another commonly used scale
(Bhogal et al 2005). The PEDro scale has also been
shown to have fair to good inter-rater reliability
with an intraclass correlation coefficient of 0.55-
0.56 (Maher et al 2003). Furthermore, the PEDro
scale encompasses a much wider range of criteria
when assessing quality than the Jadad scale which
NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)
B-U0#&I8&W($0*+)'(X#Y$0*+)'(&$4)%#4)-&"'4&+%*7)#+&"'4&%5)+&4#.)#1G
W($0*+)'(&F4)%#4)-8 !Y$0*+)'(&F4)%#4)-8
RC&(/,+-3,*&#/9&839-.6$3-&/&0.+@/.)&?VH RC&Y-4+-;&H.,+"%-*
MC& =(A& ;/*& 8*-9& /*& /& .-#/D+%+,/,+$3& MC&!,89+-*&;+,#&(F7.$&
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SC& 58,"$@-& @-/*8.-*& +3"%89-9& B3--&
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considers only three criteria and focuses on double
blinding as its main indicator of quality (Bhogal et
al 2005). For these reasons, the authors believed
the PEDro scale to be the most appropriate for
this review. The components of the PEDro scale
are described in Table 3. The PEDro scale also
considers introduction of bias through questions
on blinding and intention to treat. Thus the total
PEDro score attributed to a study depends partially
on whether the study protected itself against bias.
One study was not found on the PEDro database
(Bruun-Olsen et al 2009), but was evaluated using
the PEDro scale by an author of this review (PV)
and independently cross checked by the second
author (MK).
B-U0#&P8&:!A4'&+$-0#&$'/,'(#(%+&*+#7&%'&+$'4#&4-(7'/)V#7&
$'(%4'00#7&%4)-0+&'*%&'"&%#(&H$'/,'(#(%&K&)+&('%&$'(+)7#4#7&,-4%&
'"&%5#&+$'4#LG
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`L&a/*-%+3-&"$@0/.+*$3 RNL&&a-,;--3&6.$80&"$@0/.+*$3
]L&!8Db-",&a%+39+36 RRL& ($+3,&@-/*8.-*&E,.-/,@-3,&
-''-",L
cL&?#-./0+*,&D%+39+36
d&(F7.$&#,,0QTT(F7.$C$.6C/8T*"/%-e+,-@C#,@%f&A/#-.&-,&/%&MNNSf&
a#$6/%&-,&/%&MNN]f&A$*-%-)&-,&/%&MNNMC&
A cut off score of 4/10 was chosen for this review.
Six out of ten is usually used for the PEDro scale
(Maher et al 2003). However, it has been shown that
whilst a cut off score of 4/10 generally does not
change the conclusion of a review it may increase the
level of evidence for a given conclusion (Maher 2003).
Data from included studies were extracted by
one author (PV), documented into tables then
checked by the second author (MK) (Table 4).
Results documented included: PEDro score, sample
size, length of follow up, outcome measures used,
interventions used, participant characteristics and
the significance of results (p value). Specifically,
this review focused on knee ROM measures and
functional status of subjects post-operatively.
This review compared the difference in means
of studies using CPM as an intervention against
control interventions. Statistically significant
results are described using p values (a statistically
significant finding for this review was defined as
p<0.05).
15
16
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NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)

7/)&]1S& j-P+$3&B3--&Y5A& O&!-406&F:<&E3l`ZLf&,;+"-& 3$,&D%+39-9 ]&;/*&*,/,+*,+"/%%)& "%+3+"/%%)&*+63+U"/3,&.-*8%,*&,$&b8*,+')&
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c1&RM1&Mc& O&V3--&'83",+$3&EV3--& =(A&*,/.,-9&+3&.-"$4-.)& O&>$%%$;&80&;/*&3$,&
;--B*1&R& !$"+-,)&!"$.-L .$$@&'$.&RZOM`&#$8.*C /9-[8/,-
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17
 RESULTS

O&G,&/%*$&*#$;-9f&+@@$D+%+*/,+$3&'$.&$3-&
Study selection

,-.@&/94/3,/6-*&,#/,&@/)&D-&8*-'8%&+'&
-/.%)&9+*"#/.6-&+*&9-*+.-9&D8,&3$&%$36&

;--B&/',-.&*8.6-.)&9+9&3$,&/''-",&,#-&
O&?#+*&*,89)&*#$;*&,#/,&=(A&#/*&*#$.,&
A database search (Medline, PEDro, Cochrane,
CINAHL and Google scholar) and reference list
searching yielded 42 randomised control trials
relating to this review. However, nineteen were
published before 2000, four did not use CPM after
a TKA or did not use CPM on the knee, and four
F0)()$-0&)/,0)$-%)'(+

were not in English. Of the remaining 15 articles,

HDD.-4+/,+$3*Q&=(A&t&=$3,+38$8*&0/**+4-&@$,+$31&Y5A&t&Y/36-&$'&@$,+$31&5H&t&5*,-$/.,#.+,+*1&!F&t&!,/39/.9&-P-."+*-1&!a&t&!%+9-.&D$/.91&?VH&t&?$,/%&B3--&/.,#.$0%/*,)C&
six were excluded: one due to poor quality - 2/10
,-.@&D-3-U,*C

U3/%&Y5AC PEDro scale (Leach, et al 2006); four were deemed

not relevant once read (Davies et al 2003, Fuchs
et al 2005, Lenssen et al 2006, Salter, 2004) and
one did not have a non-CPM control (Leonard et al
2007). Figure 1 illustrates this selection process.
*+63+U"/3,&.-*8%,*&;-.-&
9+*/00-/.-9&D)&9/)&

The nine articles included in this review are

'$839&'$.&/3)&$,#-.&
j-P+$3&4-.*8*&cRCS^&
+@@$D+%+*-9&6.$80&

?#-*-&9+''-.-3"-*&
OH",+4-&j-P+$3f&/,&

summarised in Table 5.
O&:$&*,/,+*,+"/%%)&
#/9&_Nq&&/",+4-&
9/)&X1&``CZ^&$'&

$'&=(A&6.$80C&

Z)2*4#&K8&@%*76&+#0#$%)'(&`'1$5-4%&H-"%#4&<'5#4&#%&-0&IJJaL
$8,"$@-C
E#+*0%+

!"#$%&'(%)*$+)&,-+.+&)$-/%(01/$ !4"$2))+-+(,25$%&'(%)*$
)2-232*&$*&2%'/+,1$ +)&,-+.+&)$-/%(01/$%&.&%&,'&$
R`C

5+*-*$

678$%&'(%)*$2.-&%$)095+'2-&*$%&:(;&)$
O&:$&+3,-3,+$3&,$&,.-/,
O&X&@/%-QSc&'-@/%-
O&H%%$"/,+$3&3$,&

86$%&'(%)*$*'%&&,&)$ 67$%&'(%)*$&<'50)&)$
"$@0/./D+%+,)
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W(%#4.#(%)'(

"$3"-/%-9

2.-&%$%&2)+,1$23*-%2'-$

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2**&**&)$.(%$&5+1+3+5+->$ "$.055=-&<-$2%-+'5&*$
&<'50)&)A$@+-/$%&2*(,*$
@$D+%+*/,+$3*&k&'8%%&;-+6#,&

?$*-0)+&*$+,'50)&)$+,$
,$%-./3"-C&MS&#$8.*&9/+%)&

.-"-+4-9&(#)*+$,#-./0)f&
NOcNq1&+3".-/*+36&,$&0/+3&

%&;+&@$$
83,+%&/',-.&9/)&XC&EH',-.&
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[*%$'/#&.-4)-U0#+

,#+*1&D$,#&6.$80*&

D-/.+36&;/%B+36L

d&:$,&*"$.-9&D)&(F7.$&t&*"$.-9&D)&,#-&/8,#$.*&E(n1&AVL&8*+36&(F7.$&*"$.+36&".+,-.+/

Methodological quality
'$.&c&9/)*C

Table 4 compares the methodological features

of each study. Random allocation, between group
comparisons and point measures were adequate
in all studies whereas no study had subject or
therapist blinding. All studies except Lau and
B-U0#&R8&9&"*00&+*//-46&'"&%5#&()(#&+%*7)#+&)($0*7#7&)(&%5)+&4#.)#1

-P,-3*+$3&B3--&Y5A&
[*%$'/#&.-4)-U0#+O&

Chiu (2001) had assessor blinding. Concealment of

O&?$,/%&9./+3&$8,08,
O&?$,/%&#$*0+,/%&*,/)

allocation and intention to treat were also factors

H",+4-&j-P+$3&k&

E6$3+$@-,-.L

missing from many studies.

Range of motion
All nine studies measured ROM. Five studies
(Bruun-Olsen et al 2009, Chen et al 2000, Denis
et al 2006, Lenssen et al 2003a, Lenssen et al
@-/,0#&@)V#&

`M1&S&/39&c&
-(7&Z'00'1&

`S&!8Db-",*

@$3,#*1&R&

2008), compared the effect of CPM as an adjunct

Z'00'1&*,
7/)&S1&]1&
X1&R`1&MZ1&

to physiotherapy (intervention) with physiotherapy

)-/.

alone (control). Three of the five studies (Bruun-

*,&

Olsen et al 2009, Chen et al 2000, Denis et al

2006) found no statistically significant differences
@$'4#&
:!A4'&

in ROM. Lenssen et al (2008), detected a non-

`TRN

significant improvement of 5º in the intervention

group at day seventeen (p=0.06-0.07). At follow-
@%*76&M-/#&

up (six weeks and three months) no difference

J/8&o&=#+8&

was found. Lenssen et al (2003a), found passive

EMNNRLC

extension improved significantly in the intervention

group compared to the control group at the end of
their study (p=0.029).

18 NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)

 B-U0#&_8&F'/,-4)+'(&'"&%5#&/#%5'7'0'2)$-0&b*-0)%6&'"&%5#&+%*7)#+&)($0*7#7&)(&%5)+&4#.)#1&-+&'*%0)(#7&U6&%5#&:!A4'&+$-0#TG&E#"#4&%'&
%-U0#&P&"'4&7#+$4),%)'(&'"&%5#&$'/,'(#(%+&(*/U#4#7&KSKKG

@%*76 K I P R _ c ] Q a KJ KK @$'4#

7-3+*&-,&/%&EMNNcL u u u u u u u u u Z

a-33-,,&-,&/%&EMNN]L u u u u u u u c

a-/80.-&-,&/%&EMNNRL u u u u u u u u u Z

J-3**-3&-,&/%&EMNNS/L u u u u u u u u X

=#-3&-,&/%&EMNNNL u u u u u u ]

A"7$3/%9&-,&/%&EMNNNL u u u u u u ]

J/8&o&=#+8&EMNNRL u u u u u `

J-3**-3&-,&/%&EMNNZL u u u u u u u u u Z

a.883O5%*-3&-,&/%&EMNN_L u u u u u u u u X

d&:$,&*"$.-9&D)&(F7.$&t&*"$.-9&D)&,#-&/8,#$.*&E(n1&AVL&8*+36&(F7.$&*"$.+36&".+,-.+/

Three studies (Bennett et al 2005, Lau and Chiu
2001, McDonald et al 2000), compared the use of
CPM with a control group that did not receive CPM
as part of post-TKA rehabilitation. McDonald et al
(2000), found no significant difference between the
groups. Bennett et al (2005), observed a statistically
significant difference at day five in the early CPM
group for active and passive knee flexion (p=.008
and p<.0001). However, at the three month and one
year follow-up, no differences were seen. Lau and
Chiu (2001), found active flexion improved in the
CPM group; (61.3% of CPM group had 90° active
flexion at day seven versus 44.8% of no-CPM group
p<0.05) however, this difference disappeared by
day 14. Beaupre et al (2001) divided participants
into three intervention groups: one group received
standard exercises (SE) and CPM; the second
group received SE and sliding board therapy (SB);
the third group received only SE. They found no
significant differences in recovery of ROM between
any of the groups.
Knee Function
Six of the nine studies considered knee function
as an outcome measure. Out of the five studies
investigating CPM and standard physiotherapy
compared to standard physiotherapy alone, three
(Denis et al 2006, Lenssen et al 2003a, Lenssen
et al 2008) explored knee function. Denis et al
(2006) used the Western Ontario and McMaster
Universities (WOMAC) osteoarthritis index (a 24
item questionnaire that focuses on lower limb
activity and covers pain, stiffness and functional
difficulty) while Lenssen et al (2008) used both
the WOMAC osteoarthritis index and Knee Society
Score (KSS) which considers both knee assessment
(pain, stability and ROM) and functional ability
to climb stairs and walk. Both studies found no
significant differences between intervention groups.
Lenssen et al (2003a) used the Hospital for Special
Surgery Score, which focuses on pain, function
(including strength) and the knee joint itself. They
found that the standard physiotherapy group’s knee
function scores were significantly lower (p= 0.003)
than the group receiving CPM after seventeen days.
Two (Bennett et al 2005, McDonald et al 2000)
of the three studies comparing a CPM group with
a non-CPM group considered knee function. Both
studies used the KSS and found no significant
difference between the groups. In addition, the
Beaupre et al (2001) study investigated knee
function using the WOMAC osteoarthritis index
and found no significant differences between the
three participant groups.
DISCUSSION
This systematic review investigated the efficacy of
CPM after TKA with results from nine randomised
control trials. These ranged in quality from 4/10
to 8/10 on the PEDro scale.
Overall, three types of post-TKA intervention
were used: CPM and physiotherapy compared to
physiotherapy alone (five studies); CPM compared
to no CPM (three studies); and a mixture of
standard exercises, sliding board exercises, and
CPM (one study).
CPM intervention parameters were different
in each study. The initiation of intervention was
also found to be varied. Six studies began their
intervention day one post-operatively. One study
started day two after surgery, while another
started day two or three depending on the group
the participant was in. Finally, one study gave all

NZ Journal of Physiotherapy – March 2010, Vol. 38 (1) 19

 patients standard physiotherapy including CPM for
four days before initiating the intervention. These
variations mean reliable comparison of the results
is difficult.
Among the participants in all the studies, there
were an unequal proportion of males and females
(generally the number of females outweighed males).
As gender characteristics may influence results, the
results are thus likely to be more generalizable to
females. Another noticeable feature of six of the
nine studies was the inclusion of only participants
with osteoarthritis of the knee and these tended to
be older patients. Thus results may not apply to
patients who received a TKA for reasons other than
osteoarthritis (for example rheumatoid arthritis).
This review focused specifically on ROM and
function, which are important outcomes when
gauging the success of a TKA.
Range of Motion
In all nine studies, a goniometer was used to
measure ROM. However, what was measured
differed from study to study. Three studies
measured active flexion and extension, two
measured passive flexion and extension, while a
further two measured active and passive flexion and
extension. Quadriceps lag, passive extension and
active & passive flexion were measured in Bennett
et al (2005). McDonald et al (2000) did not define
whether flexion and extension was active or passive.
Notwithstanding variation in measurement, five
(Beaupre et al 2001, Bruun-Olsen et al 2009, Denis
et al 2006, Chen et al 2000, McDonald et al 2000)
of the nine studies found no statistically significant
change in ROM. Only one study found a significant
difference (p=0.029) in passive extension that
lasted to post-operative day 17, the end of follow-
up (Lenssen et al 2003a). Follow-up did not extend
for long enough after cessation of the intervention
for conclusions to be made on long term effects of
CPM on ROM; nonetheless, the findings seem to
indicate that if CPM has any benefit for ROM, it
may be short term.
Knee Function
Of the six studies which investigated the effect
of CPM on knee function, five found no significant
differences between intervention groups. It should
be noted, however, that different tools were used
to measure knee function (WOMAC osteoarthritis
index, Knee Society Score and Hospital for Special
Surgery Score). Each of these tools differs slightly
in focus, which may affect comparability of results.
However in general it appears CPM has no superior
effect over standard physiotherapy in terms of
improving knee function.
General Discussion
Statistical power illustrates the strength of a
study. Four studies did not define their power.
Denis et al (2006) had a power of 86% while Lenssen
et al (2008), Bennett et al (2005), Beaupre et al
20
(2001), and Bruun-Olsen et al (2009) had powers
of 80%. Chen et al (2000) required 32 participants
per group for a power of 80% but the study failed
to meet this requirement.
The lack of blinding in the studies (subject
and therapist) could introduce performance bias.
However, considering the intervention, blinding
would be difficult to achieve. Nonetheless, to reduce
bias as much as possible, assessor blinding should
be present in all studies. This was the case in all
studies except Lau and Chiu (2001).
The possibility of publication bias must also
be considered when interpreting the findings of a
study. Positive or desirable results may be more
likely to be published. This can cause results to
inaccurately represent true research findings.
Furthermore, limiting the language of included
studies to English means there could be a language
bias on the types of results identified. Therefore
a limitation of the review is that only published
English material was included. Unpublished
material was not considered.
Adequate follow-up which ensures results are
not influenced by loss of potentially significant data
was not present in two studies. Intention-to-treat
was lacking in five of the nine trials: studies which
exclude data from participants who do not complete
the study may alter the results and introduce
exclusion bias. Finally, only four of the studies
exhibited concealed allocation.
As the length of follow up between included
studies was varied, it is difficult to draw conclusions
on the long term effects of CPM after a TKA. Whilst
the majority of studies had a follow up period of
at least three months and found no statistically
significant differences between intervention
groups, Denis et al (2006), Lenssen et al (2003a)
and Chen et al (2000) had much shorter follow up
periods. Therefore whether CPM use had a long-
term effect on subjects of those studies could not
be determined. Lenssen et al (2003a) reported
significant improvement in extension in the CPM
group as well as decreased functional status in
their control group at day 17. However, as follow up
did not extend beyond day 17 it is difficult to draw
conclusions on the maintenance of the short-term
ROM improvement due to CPM. Though further
research would be required to determine the exact
time frame involved, the studies reviewed show
that any benefit to ROM and functional recovery
in the post-TKA knee due to CPM disappears over
a relatively short period of time, and there is no
evidence to indicate that CPM groups recover at a
different rate from control groups in the long-term.
Whilst many of the studies had poor methodology,
and varied interventions (which made robust
comparison difficult), the results appear to illustrate
that any benefit of CPM over physiotherapy alone
is short lived. In the long term it seems CPM does
not improve ROM or knee function any more than
physiotherapy.
NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)
 Although CPM seems to be a commonly accepted
and current rehabilitation technique after TKA, it
is a contentious and potentially costly and time-
consuming intervention post-TKA. Based on the
results of this review, the use of CPM does not seem
justified as an adjunct to standard physiotherapy.
An earlier systematic review by Milne et al (2003)
concluded that CPM with physiotherapy may be
beneficial over physiotherapy alone only in the
short term. Similarly, Lenssen et al (2003b) found
CPM provided no long term effects on ROM. They
recommended CPM be used if ROM needed to be
regained quickly. The results of this review are in
agreement with both of these studies.
CONCLUSION
Recent evidence for the use of CPM after TKA
is varied and conflicting. The majority of studies
found either no significant benefit or a small benefit
in ROM that disappeared during medium-term
follow-up. There is no evidence to support the use
of CPM in achieving long-term benefits in either
knee ROM or function. Consequently, regardless
of the possible costs and effort associated with
application of CPM (itself a contentious issue),
it seems physiotherapy is the more valuable
rehabilitation technique. It is suggested that
physiotherapy is primarily used after TKA but if
cost and effort are not limiting factors, CPM may
offer faster rehabilitation than physiotherapy alone.
This review has focused primarily on the effects of
CPM on ROM and knee function. However, other
proposed CPM benefits such as reduction in need
for analgesia and reduced DVT incidence were
not reviewed, and may form the basis of further
research. Furthermore, as many different doses of
both physiotherapy and CPM were used, this review
cannot favour one particular dosage as being most
beneficial. Research on the optimal dosage of CPM
is needed so that clinicians can have confidence
in CPM protocols, and a gold standard in CPM
application post-TKA may be found.
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NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)
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22 NZ Journal of Physiotherapy – March 2010, Vol. 38 (1)