Leonard Schrager Patient / Client Management II 11/29/2020

Effectiveness of Continuous Passive Motion Following Total Knee Arthroplasty

Annotated Bibliography

Milne  S, Brosseau  L, Welch  V, Noel  MJ, Davis  J, Drouin  H, Wells  GA, Tugwell  P.
Continuous passive motion following total knee arthroplasty. Cochrane Database of
Systematic Reviews 2003, Issue 2. Art. No.: CD004260. DOI: 10.1002/14651858.CD004260.
Accessed 29 November 2020.

This study focused on the effectiveness of continuous passive motion (CPM) and
physical therapy after a knee replacement surgery (knee arthroplasty). This was done through
means of meta-analysis in which the control group received physical therapy but did not receive
CPM. The measures which were used to determine effectiveness were: passive and active range
of motion, duration of hospitalization, pain level, knee inflammation, knee contracture, and
strength of quadriceps muscles. This study only included randomized controlled trials for the
meta-analysis. The inclusion criteria for this study were: patients were at least 18 years old,
preoperative diagnosis was either rheumatoid arthritis or osteoarthritis. Exclusion criteria
depended on treatment variations which were not being studied. Thus, the exclusion criteria
were: CPM combined with electrotherapy, hydrotherapy, or heat. These were excluded because
they may have interfered with the isolation of CPM as an independent variable. 
The methods of measurement for this study consisted of multiple reviewers who
determined whether a study was relevant to determine its inclusion in the meta-analysis. Studies
were analyzed qualitatively (method and design) and quantitatively (CPM with PT- physical
therapy - vs PT alone). The qualitative measures which were used for inclusion in the meta-
analysis were: type of randomization, type of blinding, patient withdrawal, and follow-ups.
Quantitatively, data were analyzed in such a way to determine how effective CPM with PT was
compared to PT alone. Therefore, the purpose of this study was to assess the efficacy of CMP
after knee surgery paired with PT versus PT alone after knee surgery. The researchers chose to
study this because there is no definitive data on the effectiveness of CPM. 
This study concluded that CPM with PT helped improve active knee range of motion
within two weeks after knee surgery when compared to only PT after knee surgery. Additionally,
this study found that CPM was effective in shortening the duration of hospitalization. Although
these results seem promising, the researchers pointed out a number of limitations and
implications in their study. An implication of their data is that even though CPM increased
ROM, it only increased ROM by approximately four degrees which is not functionally
significant. Many functional daily activities require a greater ROM, which was not achieved.
Additionally, even though hospitalization duration was reduced due to improved ROM, there are
many factors which influence duration of hospitalization which were not considered. A
limitation of their study was that they found very limited data on pain reduction even though this
was one of their initially hypothesized measures. 
Furthermore, other weaknesses of this study include different biases. One such bias was
that ROM values in some of the studies which were used, were not recorded as active or passive.
Therefore, in the studies which analyzed passive range, the value was most likely greater, thus
skewing some of the total data in the meta-analysis. Additionally, there was variance in data as to
whether the patients studied had a cemented knee arthroplasty or an uncemented arthroplasty.
Blinding was another bias which was seen in most studies used for the meta-analysis. This is due
to the fact that blinding is difficult (and in most cases, not possible) when studying the
effectiveness of a physical mechanism as a type of intervention. Since this study compared CPM
with PT versus PT alone, there was a lot of variation in the PT which was given to the control
group as well as PT which was given to the group which received CPM. The researchers state
that they are unsure how this may have affected the measures of the effectiveness of CPM. Other
factors such as pre-surgery therapeutic exercise and measurement of performance of functional
activity might have also caused bias in this meta-analysis study. 
The researchers suggest that any future studies could attempt to have more consistent
methods in testing CPM and consistent routines for PT. To conclude, this study has many
limitations since it was done as a meta-analysis. A different study design such as a controlled
study with a smaller sample size might be more effective in this field of research. This may
reduce the difficulties in consistency of PT given to patients and consistency of CPM duration
and intensity. However, the disadvantage to this type of study is the small sample size, whereas
the current meta-analysis had a much larger sample size. In addition to the aforementioned
limitations and biases, some of the studies which were used for this meta-analysis had patients
undergo use of CPM for 20 hours per day and some studies had patients undergo CPM for 5
hours per day. Despite attempts to prove the effectiveness of CPM, 20 hours per day is excessive
for many patients. If this study were to be reproduced, there should be an exclusion criterion for
duration or intensity of CPM. Additionally, if this study were to be reproduced, it should focus
on the efficacy of CPM regarding improvement of ROM for functional activities as mentioned
by the researchers. Thus, CPM was found to be effective for improving ROM slightly and
reducing duration of hospitalization. However, whether CPM effectively improved ROM enough
for functional activities was not found. Lastly, CPM was only found to be effective for short term
improvement of ROM. Immediate future studies should focus on possible long-term
improvement of ROM using CPM.