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Continuous passive motion

Continuous passive motion (CPM) is a postoperative rehabilitation therapy that employs a motorized device to passively move a patient's joint—such as the knee, hip, shoulder, or elbow—through a controlled range of motion without requiring active muscle contraction from the patient.^[1]^[2]^[3] Introduced in the early 1970s by Canadian orthopedic surgeon Robert B. Salter, who originated the concept based on research demonstrating the benefits of early, controlled motion for joint healing, the first practical CPM device was developed in 1978 through collaboration with engineer John Saringer.^[4]^[5]^[6] The primary goals of CPM therapy include reducing postoperative swelling, preventing intra-articular adhesions and joint stiffness (arthrofibrosis), improving synovial fluid circulation for nutrient delivery to cartilage, and facilitating earlier recovery of joint function.^[7]^[8]^[9] It is most commonly prescribed immediately after surgeries like total knee arthroplasty, anterior cruciate ligament reconstruction, or rotator cuff repair, with sessions typically lasting several hours daily during the initial recovery phase.^[10]^[11]^[12] Clinical evidence supporting CPM remains mixed, with systematic reviews indicating short-term improvements in range of motion and reduced pain medication use, but limited long-term benefits compared to standard physical therapy alone, particularly after total knee arthroplasty.^[13]^[14]^[15] Despite this, CPM continues to be widely utilized in hospital and home settings for its non-invasive nature and potential to enhance patient compliance in early mobilization protocols.^[16]^[17]

Overview and History

Definition and Purpose

Continuous passive motion (CPM) is a therapeutic technique that employs a motorized device to gently and continuously flex and extend a joint through a controlled range of motion, without requiring any voluntary muscle contraction or active effort from the patient.^[13] This method was pioneered by Canadian orthopedic surgeon Robert B. Salter in the 1970s as an alternative to traditional immobilization following joint surgery or injury.^[18] In CPM, the device applies smooth, repetitive cycles of movement to the affected joint, typically starting soon after the procedure to facilitate early rehabilitation.^[19] The primary purpose of CPM is to mitigate complications associated with postoperative recovery, such as joint stiffness known as arthrofibrosis, by promoting the maintenance and restoration of joint mobility.^[13] It also seeks to alleviate pain and edema through enhanced circulation of synovial fluid within the joint capsule, which nourishes articular cartilage and removes inflammatory byproducts.^[13] Additionally, CPM accelerates the overall recovery of range of motion (ROM) after trauma or surgical intervention, enabling patients to progress more rapidly to active rehabilitation phases.^[7] At its core, CPM distinguishes itself from active motion therapies by being entirely passive, meaning the joint is moved externally by the machine while the patient remains relaxed, avoiding muscle fatigue or compensatory strain that could occur with voluntary efforts.^[13] Clinicians customize the therapy by adjusting key parameters, including the ROM limits to match the patient's tolerance and surgical constraints, the speed of motion cycles (often 1 cycle every 20–60 seconds), and the duration of sessions (ranging from hours per day to continuous use over several days).^[13] These settings ensure safe, progressive application tailored to individual needs, prioritizing gentle mobilization over aggressive stretching.^[19]

Historical Development

The roots of continuous passive motion (CPM) therapy trace back to early 20th-century medical observations that emphasized the benefits of early passive movement following joint injuries or surgeries over prolonged immobilization, as evidence from animal and human studies showed that limited passive motion reduced adhesions and stiffness while promoting tissue healing.^[20] The modern concept of CPM was originated in 1970 by Canadian orthopedic surgeon Robert B. Salter, who drew from animal experiments demonstrating that continuous, controlled motion after immobilization enhanced articular cartilage repair in rabbit models compared to rest alone.^[4] Salter, collaborating with biomedical engineer John Saringer, developed the first prototype CPM device in 1978 specifically for the knee joint, marking the transition from theoretical research to practical application.^[21] Initial clinical trials, beginning in 1975, focused on post-surgical knee rehabilitation, where CPM was applied immediately after procedures to prevent joint stiffness.^[4] Key milestones in the 1980s included U.S. Food and Drug Administration clearance of early CPM devices through the 510(k) process, which facilitated wider availability.^[22] By the 1990s, CPM expanded beyond the knee to other joints such as the elbow, shoulder, and ankle, supported by growing clinical evidence for its role in reducing postoperative complications across orthopedic procedures.^[23] Into the early 2000s, CPM became integrated into standard rehabilitation protocols for total joint replacements and trauma recovery, reflecting its acceptance as a foundational element in multimodal therapy regimens.^[23] A seminal publication establishing the foundational evidence was Salter's 1980 study in the Journal of Bone and Joint Surgery, which detailed experimental results from rabbit models showing superior cartilage regeneration with CPM versus immobilization, influencing subsequent clinical adoption.^[24]

Mechanism and Technology

Principles of Operation

Continuous passive motion (CPM) operates on the biomechanical principle of applying low-load, prolonged stretch to joint tissues through passive flexion and extension cycles, which mimics natural joint motion without requiring active muscle contraction.^[13] This motion generates sinusoidal intra-articular pressure changes that function as a mechanical pump, facilitating the clearance of harmful substances such as hemarthrosis and inflammatory debris via trans-synovial flow, thereby preventing intra-articular adhesions and stiffness.^[13] The low-load aspect ensures that the stress applied to periarticular tissues remains below the threshold for injury, promoting gradual elongation of collagen fibers and reducing the risk of contracture formation.^[13] Physiologically, CPM enhances the production and distribution of synovial fluid, which nourishes avascular cartilage by improving nutrient diffusion and waste removal within the joint space.^[12] It reduces inflammation by limiting hematoma accumulation and suppressing pro-inflammatory cytokines such as IL-1β and enzymes such as COX-2, which in turn minimizes erosive damage to articular surfaces.^[13] Through mechanotransduction, the mechanical stimuli from CPM trigger cellular responses in chondrocytes and fibroblasts, including increased synthesis of proteoglycans, type II collagen, and lubricin (PRG4), fostering tissue repair and remodeling without active muscle involvement. Much of the mechanistic understanding derives from animal model research, with ongoing studies confirming applicability in humans.^[13]^[25] Typical operational parameters for CPM include cycles of flexion-extension at a rate of 0.5 to 2 cycles per minute, with session durations ranging from 2 to 8 hours daily, depending on the joint and recovery phase.^[12] Range of motion (ROM) adjustments are progressive, starting at limited arcs such as 0° to 40° flexion immediately post-intervention and gradually increasing to full joint ROM over days to weeks, ensuring tolerance and avoiding overload.^[13] These parameters are tailored to sustain continuous, non-fatiguing motion that supports physiological recovery.^[13] The underlying biology of CPM draws from principles like Wolff's law, which posits that osseous tissues adapt to imposed mechanical loads by remodeling in response to controlled stress; analogous mechanobiological principles apply to soft tissues in the joint.^[13] This mechanobiological adaptation promotes hyaline cartilage regeneration and prevents degenerative changes by stimulating anabolic pathways in response to the sustained, low-intensity loading.^[13] Seminal work by Salter et al. established these concepts, demonstrating that early passive motion enhances articular repair through such adaptive mechanisms.^[4]

Device Design and Variations

Continuous passive motion (CPM) devices consist of a motorized unit that drives controlled joint movement, equipped with programmable controls allowing clinicians to set parameters such as range of motion (ROM), speed, and pause duration to tailor therapy to individual patient needs.^[26] These units are paired with adjustable splints or braces designed for secure limb fixation, often featuring anatomically aligned supports like four-point systems to ensure proper positioning and minimize skin pressure during operation.^[27] Most models are portable, with weights typically ranging from 10 to 20 kg, facilitating easy transport between clinical settings or home use.^[28]^[29] Key design features enhance usability and safety, including remote controls—such as handheld interfaces or tablet-based systems—for patient-independent adjustments to ROM and speed without disrupting therapy.^[27] Safety mechanisms are integral, with many devices incorporating resistance detection systems, often via torque or pressure sensors, that automatically halt motion upon encountering excessive force to prevent injury.^[30] Some advanced models offer battery-powered operation for greater mobility in home environments, though most rely on AC power for sustained sessions.^[31] CPM devices vary by targeted joint, with knee-specific models being the most common, particularly for post-arthroplasty rehabilitation, offering ROM up to 120° flexion and -10° extension.^[3] Upper extremity variants address shoulder and elbow recovery, providing multi-plane motion like abduction and rotation for shoulders or flexion-extension for elbows.^[27] Full-limb devices for hip rehabilitation extend coverage to larger joints, accommodating abduction and rotation up to 120°.^[30] Emerging post-2020 developments include robotic versions integrating artificial intelligence for adaptive motion profiles that adjust in real-time based on patient feedback, enhancing personalization in rehabilitation.^[32] These devices adhere to medical standards, with many manufacturers ensuring compliance with ISO 13485 for quality management in design and production to guarantee reliability and safety.^[33] Typical purchase costs range from $2,000 to $5,000 per unit, varying by model complexity and joint specificity.^[34]^[35]

Clinical Applications

Post-Surgical Joint Rehabilitation

Continuous passive motion (CPM) plays a central role in the immediate postoperative phase of orthopedic surgeries involving major joints, facilitating controlled joint mobilization to prevent stiffness and promote early recovery of range of motion (ROM). It is typically initiated within 24-48 hours following procedures such as total knee arthroplasty (TKA), anterior cruciate ligament (ACL) reconstruction, or rotator cuff repair, allowing passive joint movement without active patient effort to minimize pain and swelling while initiating rehabilitation. This approach contrasts with traditional immobilization, aiming to restore functional mobility sooner through device-assisted flexion and extension cycles.^[3] In TKA recovery, CPM protocols commonly begin with a starting ROM of 0-60 degrees of flexion on the first postoperative day, gradually progressing to 0-120 degrees over approximately two weeks as tolerated by the patient.^[3] Sessions are prescribed for 2-4 hours per day initially, often combined with cryotherapy such as ice packs to manage inflammation and enhance comfort during use. For ACL reconstruction, similar early initiation targets controlled knee flexion to 90 degrees within the first few days, adjusting speed and cycle duration based on graft stability and surgeon preferences. Rotator cuff repair protocols emphasize gentle passive shoulder motion starting at low angles to protect the surgical site while preventing adhesions.^[3] Joint-specific adaptations ensure safety and efficacy across different anatomies. For shoulder surgeries like rotator cuff repair, CPM devices limit motion to 0-90 degrees of abduction and flexion, typically applied for 1-2 hours per session in the early postoperative period to avoid strain on repaired tendons.^[3] In hip arthroplasty, specialized CPM units restrict flexion to 90 degrees and abduction to 30 degrees to prevent posterior dislocation, with usage starting supine and progressing to seated positions as stability improves. These parameters are customized by orthopedic surgeons, often incorporating patient-specific factors like age and comorbidities. CPM is integrated into broader physical therapy regimens, serving as an adjunct to active exercises and manual therapy once pain subsides. Devices are used in both inpatient hospital settings for the initial 3-5 days and transitioned to home use via rental programs lasting 2-6 weeks, enabling consistent application during outpatient recovery. Rental durations align with protocol timelines, with patient education on setup and monitoring to ensure proper alignment and hygiene.

Neurological and Other Conditions

Continuous passive motion (CPM) has been applied in stroke rehabilitation to address upper and lower limb spasticity and improve motor control. In a randomized controlled trial involving patients shortly after unilateral stroke, daily CPM sessions targeting the shoulder enhanced joint stability compared to self-directed range-of-motion exercises, with a trend toward reduced subluxation (p=0.06).^[36] For paretic ankles, a 30-minute CPM protocol combined with manual therapy reduced spasticity as measured by the Modified Ashworth Scale and increased passive range of motion in dorsiflexion and plantarflexion, while also eliciting brain activation in sensorimotor areas via fMRI.^[37] In chronic stroke patients, brain-computer interface-controlled CPM for wrist extension over 20 sessions improved active range of motion by approximately 24 degrees, supporting its role in enhancing voluntary control.^[38] Protocols typically involve 1-2 hours per day at low speeds to minimize discomfort and promote neuroplasticity without exacerbating fatigue.^[37] In other neurological conditions such as cerebral palsy, CPM targets spasticity and joint mobility maintenance. A controlled trial in children with cerebral palsy demonstrated that 20-minute knee CPM sessions at 15 degrees per second reduced hypertonia on the Modified Ashworth Scale, increased active knee range of motion, and improved functional mobility as assessed by the Timed Up-and-Go test and 6-Minute Walk Test.^[39] For ankle involvement, a four-week program of 1-hour daily bilateral CPM decreased soleus hypertonia (p=0.006), lowered H/M ratios indicative of reduced excitability (p=0.001), and expanded passive ankle range of motion (p=0.049) in individuals with spastic cerebral palsy.^[40] In multiple sclerosis, robot-assisted ankle CPM over 18 sessions reduced spinal cord excitability via H-reflex measures (up to 96.5% decrease on affected sides) and modestly improved walking performance in five of eight participants on the 10-meter Walk Test.^[41] These applications emphasize CPM's utility in chronic spasticity management, with evidence from 2020s studies highlighting sustained reductions in muscle tone and better ambulatory outcomes.^[40] Emerging uses of CPM extend to non-traumatic settings, including ankle contracture prevention in intensive care unit (ICU) patients. In mechanically ventilated adults, unilateral ankle CPM preserved dorsiflexion range of motion (increasing from 9.90° to 12.99°, p=0.004) compared to contralateral controls, suggesting its potential as an early intervention to avert immobility-related complications.^[42] For post-fracture rehabilitation in the elderly, evidence remains limited as of 2025, with preliminary applications focusing on gentle motion to restore mobility without overloading healing tissues, though high-quality trials are lacking. In pediatric congenital conditions like clubfoot, postoperative CPM in infants yielded superior short-term improvements in Dimeglio scores (3.11 vs. 4.17 at 12 months) relative to cast immobilization, but long-term benefits at 48 months were comparable (4.47 vs. 3.89).^[43] Neurological adaptations of CPM often involve slower speeds (0.2-1 cycle per minute) to enhance patient tolerance and avoid sensory overload, as seen in robot-driven protocols for spastic limbs.^[44] Integration with functional electrical stimulation has shown promise in combined therapies for stroke recovery, where CPM augments muscle activation during passive cycles to facilitate motor relearning, though direct neurological studies are emerging.^[45] Device variations suitable for non-surgical use, such as portable ankle or wrist models, support these outpatient protocols.^[26]

Evidence and Benefits

Key Clinical Outcomes

Continuous passive motion (CPM) therapy has been associated with modest improvements in range of motion (ROM) following total knee arthroplasty (TKA), particularly when compared to traditional immobilization protocols. A 2004 meta-analysis indicated an average gain of approximately 4 degrees in active knee flexion at 2 weeks postoperatively, facilitating faster achievement of functional flexion milestones such as 90 degrees, which occurs approximately 4.7 days earlier with CPM.^[46] CPM also contributes to swelling reduction in the immediate postoperative period. Patients using CPM experience reduced knee swelling by an average of 1.79 units compared to controls. This is attributed to enhanced lymphatic drainage and decreased edema. The same meta-analysis found reduced analgesic requirements (mean 4.18 mg less at 2 weeks), though no significant pain reduction on VAS scores.^[46] In terms of functional recovery, CPM supports shorter hospital stays, typically by 0.69 days (95% CI -1.35 to -0.03), and enables earlier ambulation in TKA patients by promoting quicker mobilization and reducing dependency on extended inpatient care.^[46] Long-term effects include a lower incidence of manipulation under anesthesia (risk ratio 0.12, 95% CI 0.03–0.53) relative to non-CPM groups, as well as improved cartilage health in animal models, where CPM enhances chondrocyte viability and articular tissue repair compared to immobilization.^[46]^[13]

Research Findings and Comparisons

A 2014 Cochrane systematic review of 24 randomized controlled trials involving over 1,400 participants undergoing total knee arthroplasty found that continuous passive motion (CPM) provided small short-term improvements in active knee flexion range of motion (ROM), approximately 2 degrees greater than standard care at early follow-up, alongside modest gains in quality of life, though these effects were not deemed clinically significant and did not persist beyond the immediate postoperative period.^[47] A 2024 meta-analysis published in the Journal of Orthopaedic Surgery and Research, synthesizing data from 6 studies with 557 patients, confirmed no significant differences in pain as measured by visual analog scale scores compared to physical therapy alone, but demonstrated no long-term superiority in ROM, function, or patient satisfaction at 6 months or beyond, with CPM also associated with longer hospital stays.^[48] Recent evidence from 2020 to 2025 highlights expanding applications beyond orthopedics. A 2025 scoping review in Spinal Cord Series and Cases (Nature portfolio) examined passive movement interventions, including CPM, for spasticity management in spinal cord injury rehabilitation across 13 studies; it reported heterogeneous outcomes, with some trials showing reductions in spasticity scores via mechanisms like altered spinal reflex excitability, but emphasized limitations due to variable protocols and small sample sizes, calling for standardized RCTs.^[49] Regarding delivery settings, a 2025 retrospective cohort study published in Scientific Reports (PMC) compared home-based CPM to clinic-based physical therapy in 40 patients (20 per group) after arthroscopic release for degenerative elbow stiffness, finding superior ROM gains at 3 months (126.75° vs. 112.50°) and early pain control in the home group, attributed to flexible scheduling and reduced travel burden.^[50] Comparisons to alternative therapies underscore CPM's niche role. Versus physical therapy alone, CPM yields similar outcomes in ROM, function, and pain, per the 2024 meta-analysis.^[48] Against immobilization or no motion, CPM reduces joint stiffness and adhesions, as evidenced by lower incidence of manipulation under anesthesia in meta-analyses, though at increased cost without proportional long-term gains. For stroke rehabilitation, a 2025 systematic review and meta-analysis of 4 trials reported significant but low-certainty improvements in motor function (SMD 0.70, 95% CI 0.20–1.20) and disability scores (SMD 0.81, 95% CI 0.35–1.27) with passive movement including CPM, due to methodological flaws and small sample sizes.^[51] Professional guidelines, such as the American Academy of Orthopaedic Surgeons (AAOS) Choosing Wisely recommendation (as of 2020), advise against routine use of CPM following total knee arthroplasty due to insufficient evidence of clinically meaningful long-term benefits.^[52] Ongoing research gaps include the paucity of randomized controlled trials for non-knee applications, such as shoulder or ankle rehabilitation, where evidence is largely anecdotal or from small cohorts. Cost-effectiveness analyses indicate CPM adds $500-1,000 per patient in device rental and monitoring expenses for a typical 2-week course, often without offsetting savings in hospital days or readmissions, prompting calls for targeted implementation in high-risk cases only.^[53]

Risks and Considerations

Potential Complications

While continuous passive motion (CPM) is generally considered safe for post-surgical rehabilitation, particularly after total knee arthroplasty, it is associated with certain adverse effects, primarily related to mechanical stress on tissues and device fit. Common complications include joint irritation, localized bruising, and transient swelling, often resulting from overly aggressive range of motion settings or prolonged sessions.^[54] These issues may manifest as pain at the joint site or increased need for analgesia, with overall adverse events affecting approximately 15% of patients using CPM compared to similar rates (16.3%) in standard physical therapy groups.^[55] Skin breakdown, blistering, or irritation can also occur due to pressure from straps or poor device alignment, particularly in areas like the inner thigh or around surgical incisions.^[56] Rare but serious risks encompass device malfunctions that could lead to unintended hyperextension or excessive force, potentially exacerbating soft tissue damage, though such incidents are minimized by modern safety features like limit switches.^[3] Other infrequent complications include deep vein thrombosis, especially if patients remain immobile during extended sessions, and wound infections in the presence of open surgical sites.^[55] The incidence of serious adverse events is low, though specific rates are not well-quantified in recent reviews.^[10] Management of these complications involves close monitoring of pain thresholds during sessions, with immediate adjustment or discontinuation if discomfort exceeds tolerable levels or if range of motion plateaus or regresses.^[56] Proper device fitting with adequate padding and frequent skin inspections (at least daily) help prevent irritation and breakdown, while elevating the limb and combining CPM with active exercises can mitigate swelling.^[3] In cases of suspected infection or thrombosis, prompt medical evaluation is essential to avoid progression.^[55]

Absolute Contraindications

Continuous passive motion (CPM) therapy is contraindicated in cases of active infection at or near the joint, including septic tenosynovitis or diffuse cellulitis, as it may exacerbate the condition or spread infection. Unstable fractures, joint instability, or incomplete bone healing also represent absolute contraindications due to the risk of further displacement or injury during passive movement. Severe open wounds, deep lacerations surrounding the joint, or uncontrolled bleeding similarly preclude use to avoid worsening tissue damage or hemorrhage.^[26]^[8]^[21]

Relative Contraindications

Relative contraindications for CPM include acute inflammation or diffuse swelling, which could be aggravated by motion, and skin ulcers or lesions over the joint area that might lead to pressure sores from device contact. Patient intolerance to passive motion, manifested as severe pain during initial trials, warrants caution or temporary suspension to prevent psychological distress or guarding responses. In neurological conditions involving hypertonia or spasticity, CPM requires careful evaluation, as uncontrolled muscle activity may interfere with the device's function or cause injury, though it may still be applicable under close supervision. Patients with cognitive impairment or non-compliance may require additional supervision to ensure safe use and monitoring for complications.^[26]^[8]

Usage Guidelines

The American Academy of Orthopaedic Surgeons (AAOS) advises against the routine use of CPM following uncomplicated total knee arthroplasty (TKA), citing insufficient evidence for improved long-term range of motion, pain reduction, or function compared to standard physical therapy.^[57] When indicated, CPM should commence within 48 hours postoperatively for stable joints to maximize potential benefits in preventing stiffness, with treatment typically limited to 7-21 days under multidisciplinary oversight involving surgeons, therapists, and nurses. Range of motion should be progressively titrated based on patient tolerance, starting at comfortable levels and advancing only as pain allows, while ensuring the device does not impede wound care or nursing needs. Patient selection prioritizes motivated individuals with limited postoperative mobility after joint replacement surgery, such as TKA or anterior cruciate ligament reconstruction, but CPM is not recommended as standard care for all stroke patients or other neurological conditions due to variable evidence of efficacy.

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A CPM machine rental can cost between $250 and $500 per week. It's always a good idea to shop around and compare prices from different rental companies to get ...
[53]
Postoperative Continuous Passive Motion Does Not Improve the ...
This study found no advantage in the routine use of CPM post-MUA for stiff total knee replacement patients, suggesting it may not provide sustained ROM ...
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Continuous passive motion following total knee arthroplasty in ...
The review showed that CPM following knee replacement surgery probably improves the ability to bend the knee slightly and the person's quality of life but may ...
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Continuous Passive Motion - an overview | ScienceDirect Topics
Continuous passive motion (CPM) refers to a mechanical device that supports a joint and is designed to move slowly through a designated range of motion ...Missing: slower | Show results with:slower