Continuous passive motion following total knee arthroplasty in people with arthritis

Lisa A Harvey; Lucie Brosseau; Robert D Herbert

doi:10.1002/14651858.CD004260.pub2

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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 2

Forest plot of primary comparison. Outcome: 7.1 Active knee flexion ROM [degrees].

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Figure 3

Forest plot of primary comparison. Outcome: 7.2 Passive knee flexion ROM [degrees].

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Figure 4

Forest plot of primary comparison. Outcome: 7.3 Active knee extension ROM [degrees]. The SD of the CPM group for Worland 1998 was zero but entered as 0.001 to enable calculation of a point estimate.

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Figure 5

Forest plot of primary comparison. Outcome: 7.4 Passive knee extension ROM [degrees].

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Figure 6

Forest plot of primary comparison. Outcome: 7.6 Length of hospital stay [days].

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Figure 7

Forest plot of primary comparison. Outcome: 7.11 Function [standardised mean].

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Figure 8

Forest plot of primary comparison. Outcome: 7.7 Manipulation under anaesthesia [number].

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Figure 9

Forest plot of primary comparison. Outcome: 7.8 Pain [points].

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Figure 10

Forest plot of primary comparison. Outcome: 7.9 Swelling [cm].

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Figure 11

Forest plot of primary comparison. Outcome: 7.10 Quadricep strength [standardised mean].

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Analysis 1.1

Comparison 1 Primary comparison ‐ all studies, Outcome 1 Active knee flexion ROM.

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Analysis 1.2

Comparison 1 Primary comparison ‐ all studies, Outcome 2 Passive knee flexion ROM.

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Analysis 1.3

Comparison 1 Primary comparison ‐ all studies, Outcome 3 Active knee extension ROM.

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Analysis 1.4

Comparison 1 Primary comparison ‐ all studies, Outcome 4 Passive knee extension ROM.

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Analysis 1.5

Comparison 1 Primary comparison ‐ all studies, Outcome 5 Length of hospital stay.

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Analysis 1.6

Comparison 1 Primary comparison ‐ all studies, Outcome 6 Function [standardised mean].

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Analysis 1.7

Comparison 1 Primary comparison ‐ all studies, Outcome 7 Manipulation under anaesthesia [number].

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Analysis 1.8

Comparison 1 Primary comparison ‐ all studies, Outcome 8 Pain.

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Analysis 1.9

Comparison 1 Primary comparison ‐ all studies, Outcome 9 Swelling.

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Analysis 1.10

Comparison 1 Primary comparison ‐ all studies, Outcome 10 Quadriceps strength [standardised mean].

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Analysis 2.1

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 1 Active knee flexion ROM.

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Analysis 2.2

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 2 Passive knee flexion ROM.

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Analysis 2.3

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 3 Active knee extension ROM.

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Analysis 2.4

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 4 Passive knee extension ROM.

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Analysis 2.5

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 5 Length of hospital stay.

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Analysis 2.6

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 6 Function.

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Analysis 2.7

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 7 Pain.

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Analysis 2.8

Comparison 2 Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises, Outcome 8 Swelling.

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Summary of findings for the main comparison. Primary comparison ‐ short‐term effect (less than 6 wks) ‐ all studies

Primary comparison ‐ short‐term effect (less than 6wks) ‐ all studies
Patient or population: patients with patients with arthritis Settings: post‐operative (in‐hospital or rehabilitation facility) Intervention: CPM Comparison: standard care with or without additional exercises
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	standard care with or without additional exercises	CPM
Active knee flexion ROM degrees	The mean active knee flexion rom in the control groups was 75 degrees	The mean Active knee flexion ROM in the intervention groups was 3 higher (0 to 6 higher)		379 (9 studies)	⊕⊕⊕⊕ high¹
Passive knee flexion ROM degrees	The mean passive knee flexion rom in the control groups was 82 degrees	The mean Passive knee flexion ROM in the intervention groups was 2 higher (0 to 4 higher)		634 (13 studies)	⊕⊕⊕⊕ high¹
Active knee extension ROM degrees	The mean active knee extension rom in the control groups was ‐12 degrees	The mean Active knee extension ROM in the intervention groups was 1 higher (0 to 2 higher)		743 (12 studies)	⊕⊕⊕⊕ high¹
Passive knee extension ROM degrees	The mean passive knee extension rom in the control groups was ‐7 degrees	The mean Passive knee extension ROM in the intervention groups was 0 higher (0 to 1 higher)		749 (13 studies)	⊕⊕⊕⊕ high¹
Length of hospital stay days	The mean length of hospital stay in the control groups was 13 days	The mean Length of hospital stay in the intervention groups was 0.3 lower (0.9 lower to 0.2 higher)		748 (12 studies)	⊕⊕⊝⊝ low^1,2
Function [standardised mean]	See comment	See comment	Not estimable	0 (4 studies)	⊕⊕⊝⊝ low^1,3,4
Manipulation under anaesthesia	Study population		RR 0.15 (0.03 to 0.7)	234 (3 studies)	⊕⊕⊝⊝ low^1,5,6
	119 per 1000	18 per 1000 (4 to 83)
	Medium risk population
	81 per 1000	12 per 1000 (2 to 57)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Too few trials to enable estimation of risk of publication bias. ² Decisions about length of hospital stay would have been made by treating clinicians. In trials of CPM it is difficult or impossible to blind treating clinicians. ³ Inconsistency may reflect use of different measures of function. ⁴ Imprecision may reflect use of different measures to function. ⁵ Decisions about manipulation under anaesthesia would have been determined by treating clinicians. It trials of CPM it is difficult or impossible to blind treating clinicians. ⁶ The effect size is large but associated with imprecision.

Summary of findings for the main comparison. Primary comparison ‐ short‐term effect (less than 6 wks) ‐ all studies

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Comparison 1. Primary comparison ‐ all studies

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Active knee flexion ROM Show forest plot	9		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Short‐term effects (< 6 wks)	8	379	Mean Difference (IV, Random, 95% CI)	3.08 [‐0.10, 6.25]
1.2 Medium‐term effects (6 wks to 6 mo)	2	104	Mean Difference (IV, Random, 95% CI)	2.86 [‐5.29, 11.00]
1.3 Long‐term effects (> 6 mo)	2	104	Mean Difference (IV, Random, 95% CI)	4.86 [2.83, 6.89]
2 Passive knee flexion ROM Show forest plot	11		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Short‐term effects (< 6 wks)	9	551	Mean Difference (IV, Random, 95% CI)	2.46 [0.39, 4.52]
2.2 Medium‐term effects (6 wks to 6 mo)	3	201	Mean Difference (IV, Random, 95% CI)	‐1.51 [‐5.73, 2.72]
2.3 Long‐term effects (> 6 mo)	2	160	Mean Difference (IV, Random, 95% CI)	0.06 [‐2.22, 2.35]
3 Active knee extension ROM Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Short‐term effects (< 6 wks)	12	743	Mean Difference (IV, Random, 95% CI)	0.59 [‐0.49, 1.66]
3.2 Medium‐term effects (6 wks to 6 mo)	2	104	Mean Difference (IV, Random, 95% CI)	0.22 [‐1.37, 1.80]
3.3 Long‐term effects (> 6 mo)	1	80	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.06, 0.18]
4 Passive knee extension ROM Show forest plot	14		Mean Difference (IV, Random, 95% CI)	Subtotals only

4.1 Short‐term effects (< 6 wks)	13	749	Mean Difference (IV, Random, 95% CI)	0.32 [‐0.46, 1.10]
4.2 Medium‐term effects (6 wks to 6 mo)	3	165	Mean Difference (IV, Random, 95% CI)	‐0.70 [‐2.50, 1.11]
4.3 Long‐term effects (> 6 mo)	3	204	Mean Difference (IV, Random, 95% CI)	0.13 [‐0.34, 0.59]
5 Length of hospital stay Show forest plot	12	748	Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.85, 0.17]

6 Function [standardised mean] Show forest plot	8		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

6.1 Short‐term effects (6 wks to 6 mo)	4	171	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.50, 0.70]
6.2 Medium‐term effects (6 wks to 6 mo)	4	286	Std. Mean Difference (IV, Random, 95% CI)	‐0.04 [‐0.27, 0.19]
6.3 Long‐term effects (> 6 mo)	3	260	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.26, 0.23]
7 Manipulation under anaesthesia [number] Show forest plot	3	234	Risk Ratio (M‐H, Random, 95% CI)	0.15 [0.03, 0.70]

8 Pain Show forest plot	6		Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 Short‐term effects (< 6 wks)	6		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8.2 Medium‐term effects (6 wks to 6 mo)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
9 Swelling Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

9.1 Short‐term effects (6wks to 6mo)	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
10 Quadriceps strength [standardised mean] Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

10.1 Short‐term effects (6 wks to 6 mo) group	2	130	Std. Mean Difference (IV, Random, 95% CI)	0.27 [‐0.08, 0.61]

Comparison 1. Primary comparison ‐ all studies

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Comparison 2. Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Active knee flexion ROM Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 Short‐term effects (< 6 wks)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Passive knee flexion ROM Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Short‐term effects (< 6 wks) subgroup	3	240	Mean Difference (IV, Random, 95% CI)	1.14 [‐1.09, 3.38]
2.2 Medium‐term effects (6 wks to 6 mo)	1	80	Mean Difference (IV, Random, 95% CI)	0.10 [‐4.11, 4.31]
2.3 Long‐term effects (> 6 mo)	1	80	Mean Difference (IV, Random, 95% CI)	‐0.5 [‐3.40, 2.40]
3 Active knee extension ROM Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Short‐term effects (< 6 wks)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Long‐term effects (> 6 mo)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Passive knee extension ROM Show forest plot	3		Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 Short‐term effects (< 6 wks)	3		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 Medium‐term effects (6 wks to 6 mo)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.3 Long‐term effects (> 6 mo)	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Length of hospital stay Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

6 Function Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

6.1 Short‐term effect (< 6 wks)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6.2 Medium‐term effects (6 wks to 6 mo)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6.3 Long‐term effects (> 6 mo)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
7 Pain Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

7.1 Short‐term effects (6 wks to 6 mo)	2		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8 Swelling Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 Short‐term effects (6 wks to 6 mo)	2		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Secondary comparison ‐ subgroup of studies in which control participants received additional knee exercises

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