CPM: The Key to Successful Rehabilitation

By Rick Hammesfahr, MD, and Mark T. Serafino, MS, PT

Continuous Passive Motion (CPM) is a postoperative treatment method that is designed to
aid recovery after joint surgery. In most patients after extensive joint surgery, attempts at joint
motion cause pain and as a result, the patientfails to move the joint. This allows the tissue
around the joint to become stiff and for scar tissue to form resulting in a joint which has
limited range of motion and often may take months of physical therapy to recovery that
motion.
Passive range of motion means that the joint is moved without the patient's muscles being
used. Continuous Passive Motion devices are machines that have been developed for patients
to use after surgery.

Applied postoperatively, this device may be used on an inpatient or an outpatient basis. By

using a motorized device to very gradually move the joint, it is possible to significantly
accelerate recovery time by decreasing soft tissue stiffness,increasing range of motion,
promoting healing of joint surfaces and soft tissue, and preventing the development of
motion-limiting adhesions (scar tissue). Interestingly, this is accomplished without patient
effort (passively) as the machine moves ajoint through a defined (prescribed) range of motion
for an extended period of time. Even more surprisingly, studies have shown that patients
using CPM devices require less pain medication then patients who have had the same type of
surgery and are notusing this devie..
CPM may be prescribed by orthopaedic surgeons following total knee replacement, anterior
cruciate ligament reconstruction (ARTHROSCOPIC ACL RECONSTRUCTION), tendon
repair, joint manipulation under anesthesia, arthroscopicdebridement of adhesions, open
reduction and internal fixation (stabilization) of intra-articular fractures, rotator cuff repair,
articular cartilage microfracture, articular cartilage transplantation (CHONDROCYTE

(CARTICEL)GRAFTING) and MENISCAL REPAIR. There are CPM devices for the knee,
ankle, shoulder, elbow, wrist, and hand.
The physician prescribes how the CPM unit should be
used by the patient (speed, duration of usage, amount of
motion, rate of increase of motion, etc.).

Continuous passive motion following total hip

arthroplasty can be instrumental in alleviating
pain, edema, stiffness, deep vein thrombosis,
and dislocation, as well as in containing costs.
For all of the individuals who have had traumatic orthopedic
surgery, it is probably safe to argue that the effects of the
surgery on the soft tissue are more detrimental to patient
progress and recovery than the issue resolved by the
procedure itself.
Total joint arthroplasty is a perfect example. Replacement of
the osteoarthritic joint components significantly reduces the
patients joint pain and improves the likelihood of voluntary
movement, but the trauma to the soft tissue and resultant
immobility can cause long-lasting impairment and disability if not addressed immediately and
appropriately. Continuous passive motion (CPM) is one of the primary methods for decreasing the
deleterious effects of immobilization and can deliver orthopedic, neurological, and even circulatory
benefits to the patient. Immobilization, in turn, can create deleterious sequelae of physiological and
functional impairments.

Effects of Immobilization
The effects of immobilization vs early motion, including those on the circulatory, respiratory, and
musculoskeletal systems, have long been studied and debated, as evidence exists that rest and
motion have varied as the treatment of choice following surgery or injury for many centuries. 1,2
Orthostatic hypotension, pneumonia, and soft tissue contractures are several of the many detrimental
effects of immobilization. Others include edema, stiffness, and pain at the affected site, many of which
correlate to the structure and function of connective tissues (CT).
To better understand the effects of immobilization and the need for early motion, it is important to first
examine the composition of connective tissue, which is found in nearly every structure in the body and
performs a myriad of physiological functions. Several of these functions include mechanical support,
movement, fluid transport, and control of metabolic processes, with the structure of the particular
connective tissue lending heavily to the role it plays within the body.3
The two main fibrous components of CT are collagen and elastin, components best represented by
the aligned fibers of ligaments and tendons, which together give connective tissue its strength and
extensibility. They have a strong capability of resisting tensile forces and torsion. 3,4
Proteoglycans and glycoproteins, the other two main components of CT, are found in varying
abundance depending on the primary role of the connective tissue. Proteoglycans and glycoproteins

have mechanical roles such as hydrating the connective tissue matrix, stabilizing the collagen fibers,
and resisting compressive forces, such as in articular cartilage. 3
With such important roles in a majority of the soft tissue structures in the body, it is vital that CT avoid
degradation, such as that which occurs in osteoarthritis and osteoporosis, wherein a progressive
destruction of the articular cartilage or bony connective tissue matrix occurs, respectively.3
Additionally, trauma can cause CT dysfunction, as is the case with the soft tissue damage associated
with orthopedic surgery. Lying primarily in a parallel fashion, 3 the structure and function of these fibers
are greatly impacted by the healing process. Immobilized, these components will heal in a haphazard
fashion, lying down in a variety of directions, causing a phenomenon known as cross-linking.1 This
cross-linking can lead to adhesion formation in the soft tissues, stiffness, and the subsequent loss of
passive and active motion in the patient.
Finally, immobilization has clear, detrimental effects on CT and the surrounding tissues, including
shortening, decreased tensile strength, edema formation, venous stasis, and atrophy. All of these may
lead to injury and impairments, such as tissue failure under normal loading, muscular weakness,
decreases in range of motion (ROM), and synovial joint dysfunction 2,4,5; conditions that inevitably
produce dysfunction and/or disability in the individual.
With all of the negative effects of immobilization, an argument can be made for early motion following
trauma or surgery. Some methods include active motion, passive ROM by a skilled therapist, and
passive ROM by means of an external device or CPM.

Rest vs Motion
As stated earlier, passive motion following injury or surgery has long been the topic of controversy
and debate. Early practitioners such as Hugh Owen Thomas vehemently opposed the use of passive
motion; however, at the beginning of the 20th century, Championniere and others started a trend
toward manipulation and mobilization.1 Through alternating periods of acceptance and rebuke,
passive motion has become a commonly practiced therapeutic modality following trauma.
CPM, as was developed by Robert Salter, MD, evolved over the course of several decades, and is
based on deductions that the inventor formulated through clinical observation and practice. The first of
these is that prolonged immobilization of synovial joints causes many problems, including persistent
stiffness and pain, muscle atrophy, disuse osteoporosis, and eventually degenerative arthritis when
the joints are actively mobilized at a later time.2 Second, beneficial effects of early active motion were
seen clinically, such as decreased edema, decreased pain, and shorter rehabilitation time. 2
Finally, observations of cardiac surgery wherein the heart muscle heals properly in the presence of
constant motion, and in the costovertebral joints, where constant motion occurs throughout the life of
the individual, yet where degenerative arthritis is rarely seen, led the inventor to pursue CPM
development.2
Salter hypothesized that CPM would accelerate the healing of articular cartilage and periarticular
structures, such as the joint capsule, ligaments, and tendons. 2 He also believed that CPM would
decrease the likelihood of joint contractures, therefore maintaining the ROM achieved during surgery.
The textbook definition of CPM might state, CPM is a postoperative therapeutic modality that
passively (without patient effort) moves a synovial joint through a prescribed ROM for an extended
period of time.

Early CPM machines were primitive-looking devices, often composed of noisy motors, gears, pulleys,
ropes, and bars. Functionally, they were designed to take a particular joint (initially the knee), through
a specific and limited ROM in a predictable pattern. Though more advanced than their predecessors
in design and function, modern CPM machines adhere to the same basic principles, and have been
developed for almost every joint imaginable, including the hip.

Total Hip Arthroplasty

Total hip arthroplasty (THA), like many other joint replacements, is a complex procedure involving
many soft tissue structures in addition to the primary bony targets.
Access to the hip joint takes the surgeon through cutaneous, musculoskeletal, and capsular
structures, which are primarily composed of the iliofemoral, ischiofemoral, and pubofemoral
ligaments.6
Postsurgically, many issues arise in relation to rehabilitation, patient safety, and cost-control in the
managed care setting. Choosing the proper treatment modalities and methods can help address all of
these issues.
With surgical trauma to the soft tissues, secondary complications from the THA are more likely to
occur. Natural byproducts of the surgery include pain, stiffness, edema, and possible deep vein
thrombosis in the surgical area. If not addressed properly, these effects of trauma, inflammation, and
immobilization can become inhibitors to rehabilitation and patient function. 7
Pain, a normal response to trauma, can often limit an individuals ability to function, especially when
due to the combination of site pain as well as the pain of muscle guarding. Active exercises initiated
immediately after surgery can be exceptionally painful, while slow, controlled passive motion actually
helps to alleviate pain through the gate control mechanism of pain control. 2
Stiffness, as a result of connective tissue cross-linking and adhesions, may occur readily in a
postsurgical patient. If not addressed, functional limitations in ROM, particularly seen in gait, may
occur in patients. It has been shown that early motion following surgery can assist connective tissue
to heal in an acceptable manner, resulting in the typical parallel arrangement of collagen and elastin
fibers.2,7,8
A product of inflammation and healing, edema is a concern for many physicians and patients.
Particularly with immobilization, edema has a tendency to pool in the tissues secondary to the lack of
muscle pumping and venous flow. CPM has been shown to significantly increase venous flow over
active and passive ankle dorsiflexion, pneumatic compression, and manual calf compressions.9
Finally, deep vein thrombosis is a concern in many postsurgical patients, especially the elderly. Due to
the vascular stasis that occurs secondary to bed rest and the immobility of the limb, deep vein
thrombosis is a common occurrence following hip surgery with an incidence rate ranging from 34% to
75% following lower extremity surgery.9
In correlating the beneficial effects of CPM on venous flow, there is a positive beneficial effect on the
ability of CPM to decrease the effects of limb immobility and venous stasis, the primary causes of a
deep vein thrombosis. As the CPM creates alternating muscular tension and then relaxation, it can
assist the venous pump and keep fluids moving.
A serious complication following THA, hip dislocation occurs with loosening of the prosthetic
components, laxity of the supporting soft tissue structures, and/or excessive hip motion in the

directions of flexion, adduction, and internal rotation on the part of the patient or caregiver. 11 If
unknowledgeable caregivers or inconsistent methods of manual passive ROM and/or active ROM are
utilized post-THA, the patient might be at risk for dislocation. Conversely, early motion can be
controlled consistently and accurately with the use of CPM. As most CPM devices support the limb in
neutral alignment and limit the ROM through which the joints can travel, it is a modality, if applied
correctly, that can help to prevent issues of hip dislocation following THA.

CPM vs Manual ROM

In the world of modern medicine and managed care, cost is inevitably an issue when deciding on
treatment modalities postsurgically. With shorter length of stays following surgery, patients returning
home sooner need to have the byproducts of surgery, as discussed earlier, addressed promptly and
efficiently. Again, options for ROM include active ROM, passive ROM by a physical therapist, and
CPM. In a study by Worland et al, it was found that in a group of patients who underwent total knee
arthroplasty and received only CPM upon discharge from the hospital (as opposed to professional
physical therapy), the cost was $10,582, as opposed to $23,994 for the physical therapy treatment
group, with no statistically significant difference in ROM achieved. 12

Hip CPM Machines

Although the variety of devices designed truly for the hip is limited, there are several devices that
accommodate the need for early motion following THA.
One such device, although applied to the knee, can take the patients hip through a substantial ROM
keeping the lower extremity in a neutral alignment with respect to the frontal and transverse planes,
thus avoiding the possibility of excessive motion and hip dislocation. Additionally, the application of
the device to the knee and lower leg helps to avoid discomfort and possible irritation at the incision
site over the hip.
Finally, this device can take the hip through a safe ROM within the limits of the precautions for flexion,
adduction, and internal rotation.
Early motion following surgery can be a valuable treatment modality. Issues of pain, edema, stiffness,
deep vein thrombosis, hip dislocation, and cost containment, as well as the myriad of functional
impairments for the patient, can be addressed through sound medical practice and the use of
valuable treatment modalities.
Applied appropriately, CPM machines can work for the benefit of the patient in decreasing the
deleterious effects of immobilization, while providing a safe, comfortable treatment to the patient.