Preoperative range of motion and applications of continuous passive motion predict outcomes after knee arthroplasty in patients with arthritis

  • Chun-De Liao
  • Jau-Yih Tsauo
  • Shih-Wei Huang
  • Hung-Chou Chen
  • Yen-Shuo Chiu
  • Tsan-Hon LiouEmail author



This study evaluated the clinical efficacy of continuous passive motion (CPM) following knee arthroplasty and determined the predictors of effect sizes of range of motion (ROM) and functional outcomes in patients with knee arthritis.


A comprehensive electronic database search was performed for randomized controlled trials (RCTs), without publication year or language restrictions. The included RCTs were analyzed through meta-analysis and risk of bias assessment. Study methodological quality (MQ) was assessed using the Physiotherapy Evidence Database (PEDro) scale. Inverse-variance weighted univariate and multivariate metaregression analyses were performed to determine the predictors of treatment outcomes.


A total of 77 RCTs with PEDro scores ranging from 6/10 to 8/10 were included. Meta-analyses revealed an overall significant favorable effect of CPM on treatment success rates [odds ratio: 3.64, 95% confidence interval (CI) 2.21–6.00]. Significant immediate [postoperative day 14; standard mean difference (SMD): 1.06; 95% CI 0.61–1.51] and short-term (3-month follow-up; SMD: 0.80; 95% CI 0.45–1.15) effects on knee ROM and a long-term effect on function (12-month follow-up; SMD: 1.08; 95% CI 0.28–1.89) were observed. The preoperative ROM, postoperative day of CPM initiation, daily ROM increment, and total application days were significant independent predictors of CPM efficacy.


Early CPM initiation with rapid progress over a long duration of CPM application predicts higher treatment effect on knee ROM and function. The results were based on a moderate level of evidence, with good MQ and potential blinding biases in the included RCTs. An aggressive protocol of CPM has clinically relevant beneficial short-term and long-term effects on postoperative outcomes.

Level of evidence



Knee arthroplasty Arthritis Range of motion Continuous passive motion Functional outcome 



This study was funded by grants from Taipei Medical University-Shuang Ho Hospital, Ministry of Health and Welfare, Taiwan (grant no. W107HCP-04). The funding source had no role in the design, implementation, data analysis and interpretation, or reporting of the study. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of the funding sources.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest related to the publication of this article.

Ethical approval

This study dealt with published data only, no ethical approval has been necessary since sensitive information has not been provided or utilized in this review.

Supplementary material

167_2018_5257_MOESM1_ESM.pdf (3.4 mb)
Supplementary material 1 (PDF 3459 KB)


  1. 1.
    Alzahrani K, Gandhi R, Debeer J, Petruccelli D, Mahomed N (2011) Prevalence of clinically significant improvement following total knee replacement. J Rheumatol 38(4):753–759CrossRefPubMedGoogle Scholar
  2. 2.
    Basso DM, Knapp L (1987) Comparison of two continuous passive motion protocols for patients with total knee implants. Phys Ther 67(3):360–363CrossRefPubMedGoogle Scholar
  3. 3.
    Bennett LA, Brearley SC, Hart JA, Bailey MJ (2005) A comparison of 2 continuous passive motion protocols after total knee arthroplasty: a controlled and randomized study. J Arthroplasty 20(2):225–233CrossRefPubMedGoogle Scholar
  4. 4.
    Bowden J, Tierney JF, Copas AJ, Burdett S (2011) Quantifying, displaying and accounting for heterogeneity in the meta-analysis of RCTs using standard and generalised Q statistics. BMC Med Res Methodol 11:41–53CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira Silva D, Azevedo FM (2018) What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. Br J Sports Med 52(16):1031–1038CrossRefPubMedGoogle Scholar
  6. 6.
    Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L et al (2004) Efficacy of continuous passive motion following total knee arthroplasty: a metaanalysis. J Rheumatol 31(11):2251–2264PubMedGoogle Scholar
  7. 7.
    Carifio J, Perla RJ (2007) Ten common misunderstandings, misconceptions, persistent myths and urban legends about likert. J Soc Sci 3(3):106–116Google Scholar
  8. 8.
    Chiarello CM, Gundersen L, O’Halloran T (1997) The effect of continuous passive motion duration and increment on range of motion in total knee arthroplasty patients. J Orthop Sports Phys Ther 25(2):119–127CrossRefPubMedGoogle Scholar
  9. 9.
    Cohen J (1988) The analysis of variance. In: Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates, Hillsdale, pp 273–406Google Scholar
  10. 10.
    de Morton NA (2009) The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother 55(2):129–133CrossRefPubMedGoogle Scholar
  11. 11.
    Dennis DA, Komistek RD, Scuderi GR, Zingde S (2007) Factors affecting flexion after total knee arthroplasty. Clin Orthop Relat Res 464:53–60PubMedGoogle Scholar
  12. 12.
    Dorrestijn O, Stevens M, Winters JC, van der Meer K, Diercks RL (2009) Conservative or surgical treatment for subacromial impingement syndrome? A systematic review. J Shoulder Elbow Surg 18(4):652–660CrossRefPubMedGoogle Scholar
  13. 13.
    Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315(7109):629–634CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Farahini H, Moghtadaei M, Bagheri A, Akbarian E (2012) Factors influencing range of motion after total knee arthroplasty. Iran Red Crescent Med J 14(7):417–421PubMedPubMedCentralGoogle Scholar
  15. 15.
    Grella RJ (2008) Continuous passive motion following total knee arthroplasty: a useful adjunct to early mobilisation? Phys Ther Rev 13(4):269–279CrossRefGoogle Scholar
  16. 16.
    Harvey IA, Barry K, Kirby SP, Johnson R, Elloy MA (1993) Factors affecting the range of movement of total knee arthroplasty. J Bone Joint Surg Br 75(6):950–955CrossRefPubMedGoogle Scholar
  17. 17.
    Harvey LA, Brosseau L, Herbert RD (2014) Continuous passive motion following total knee arthroplasty in people with arthritis. Cochrane Database Syst Rev 2:CD004260Google Scholar
  18. 18.
    Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD et al (2011) The cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Higgins JPT, Deeks JJ, Altman DG (2011) Chapter 16: special topics in statistics. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]: the cochrane collaboration. Accessed Jun 04, 2018
  20. 20.
    Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The cochrane collaboration. Accessed Jun 04, 2018
  21. 21.
    Hopkins WG (2002) A scale of magnitudes for effect statistics a new view of statistics. Accessed Jun 04, 2018
  22. 22.
    Jarvenpaa J, Kettunen J, Kroger H, Miettinen H (2010) Obesity may impair the early outcome of total knee arthroplasty. Scand J Surg 99(1):45–49CrossRefPubMedGoogle Scholar
  23. 23.
    Johnson DP, Eastwood DM (1992) Beneficial effects of continuous passive motion after total condylar knee arthroplasty. Ann R Coll Surg Engl 74(6):412–416PubMedPubMedCentralGoogle Scholar
  24. 24.
    Lachiewicz PF (2000) The role of continuous passive motion after total knee arthroplasty. Clin Orthop Relat Res 380:144–150CrossRefGoogle Scholar
  25. 25.
    Liao CD, Huang YC, Chiu YS, Liou TH (2017) Effect of body mass index on knee function outcome following continuous passive motion in patients with osteoarthritis after total knee replacement. Physiotherapy 103(3):266–275CrossRefPubMedGoogle Scholar
  26. 26.
    Liao CD, Huang YC, Lin LF, Chiu YS, Tsai JC, Chen CL et al (2016) Continuous passive motion and its effects on knee flexion after total knee arthroplasty in patients with knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 24(8):2578–2586CrossRefPubMedGoogle Scholar
  27. 27.
    Liao CD, Huang YC, Lin LF, Huang SW, Liou TH (2015) Body mass index and functional mobility outcome following early rehabilitation after a total knee replacement: a retrospective study in taiwan. Arthr Care Res (Hoboken) 67(6):799–808CrossRefGoogle Scholar
  28. 28.
    MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW, Kramer J, Vaz M (2000) Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop Relat Res (380):30–35Google Scholar
  29. 29.
    Maniar RN, Baviskar JV, Singhi T, Rathi SS (2012) To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty 27(2):193–200 e1CrossRefPubMedGoogle Scholar
  30. 30.
    Mayo BS, Rodriguez-Mansilla J, Sanchez BG (2015) Recovery from total knee arthroplasty through continuous passive motion. An Sist Sanit Navar 38(2):297–310CrossRefGoogle Scholar
  31. 31.
    Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 4:1CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Moseley AM, Herbert RD, Sherrington C, Maher CG (2002) Evidence for physiotherapy practice: a survey of the physiotherapy evidence database (PEDro). Aust J Physiother 48(1):43–49CrossRefPubMedGoogle Scholar
  33. 33.
    Naylor JM, Ko V, Rougellis S, Green N, Mittal R, Heard R et al (2012) Is discharge knee range of motion a useful and relevant clinical indicator after total knee replacement? Part 2. J Eval Clin Pract 18(3):652–658CrossRefPubMedGoogle Scholar
  34. 34.
    Norman G (2010) Likert scales, levels of measurement and the “laws” of statistics. Adv Health Sci Educ Theory Pract 15(5):625–632CrossRefPubMedGoogle Scholar
  35. 35.
    O’Driscoll SW, Giori NJ (2000) Continuous passive motion (CPM): theory and principles of clinical application. J Rehabil Res Dev 37(2):179–188PubMedGoogle Scholar
  36. 36.
    Postel JM, Thoumie P, Missaoui B, Biau D, Ribinik P, Revel M et al (2007) Continuous passive motion compared with intermittent mobilization after total knee arthroplasty. Elaboration of French clinical practice guidelines. Ann Readapt Med Phys 50(4):244–257CrossRefPubMedGoogle Scholar
  37. 37.
    Ritter MA, Harty LD, Davis KE, Meding JB, Berend ME (2003) Predicting range of motion after total knee arthroplasty. Clustering, log-linear regression, and regression tree analysis. J Bone Joint Surg Am 85-A(7):1278–1285CrossRefPubMedGoogle Scholar
  38. 38.
    Salter RB (1989) The biologic concept of continuous passive motion of synovial joints. The first 18 years of basic research and its clinical application. Clin Orthop Relat Res (242):12–25Google Scholar
  39. 39.
    Sedgwick P, Marston L (2015) How to read a funnel plot in a meta-analysis. BMJ 351:1–3Google Scholar
  40. 40.
    Sterne JAC, Egger M, Moher D (2011) Chapter 10: addressing reporting biases. In: Higgins JPT, Green S (eds) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The cochrane collaboration. Accessed 12 Oct 2018
  41. 41.
    Tedesco D, Gori D, Desai KR, Asch S, Carroll IR, Curtin C et al (2017) Drug-free interventions to reduce pain or opioid consumption after total knee arthroplasty: a systematic review and meta-analysis. JAMA Surg 152(10):e172872CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    van Dijk HJD, Elvers JWH, Ruijter A, Oostendorp RAB (2007) Effect of continuous passive motion after total knee arthroplasty: a systematic review. Phys Singap 10(4):9–19Google Scholar
  43. 43.
    van Tulder M, Furlan A, Bombardier C, Bouter L (2003) Updated method guidelines for systematic reviews in the cochrane collaboration back review group. Spine (Phila Pa 1976) 28(12):1290–1299Google Scholar
  44. 44.
    Viswanathan PKM (2010) Effect of continuous passive motion following total knee arthroplasty on knee range of motion and function: a systematic review. New Zeal J Physiother 38(3):14–22Google Scholar
  45. 45.
    Winemaker M, Rahman WA, Petruccelli D, de Beer J (2012) Preoperative knee stiffness and total knee arthroplasty outcomes. J Arthroplasty 27(8):1437–1441CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Chun-De Liao
    • 1
    • 2
  • Jau-Yih Tsauo
    • 1
  • Shih-Wei Huang
    • 2
    • 3
  • Hung-Chou Chen
    • 2
    • 4
    • 5
  • Yen-Shuo Chiu
    • 6
  • Tsan-Hon Liou
    • 2
    • 5
    • 7
    Email author
  1. 1.School and Graduate Institute of Physical Therapy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
  2. 2.Department of Physical Medicine and Rehabilitation, Shuang Ho HospitalTaipei Medical UniversityTaipeiTaiwan
  3. 3.Graduate Institute of Sports ScienceNational Taiwan Sport UniversityTaoyuanTaiwan
  4. 4.Center for Evidence-Based Health Care, Shuang Ho HospitalTaipei Medical UniversityTaipeiTaiwan
  5. 5.Department of Physical Medicine and Rehabilitation, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan
  6. 6.Department of Orthopedics, Shuang Ho HospitalTaipei Medical UniversityTaipeiTaiwan
  7. 7.Graduate Institute of Injury Prevention and ControlTaipei Medical UniversityTaipeiTaiwan

Personalised recommendations