|Year : 1989 | Volume
| Issue : 4 | Page : 204-8
Continuous passive motion for prevention and rehabilitation of knee stiffness--(a clinical evaluation).
AB Mullaji, MN Shahane
A B Mullaji
This is a study of 43 knees in 42 patients, in whom a continuous passive motion was used to prevent stiffness of the knee and to assist restoration of a range of motion for a variety of disorders of the knee joint. CPM was given for an average of 6 hours daily in split sessions for a total duration of 3 weeks. Various clinical parameters were maintained and a scoring system was designed. It was observed that CPM caused little or no pain and elicited excellent patient compliance. There was a rapid subsidence of edema and effusion and a shorter hospital stay. 83% of cases had excellent or good results. There were no adverse effects, but there were a few minor complications. The study revealed that CPM is a valuable component of the therapeutic programme for preventing knee stiffness and aiding the speedy restoration of joint function without compromising healing of tissues.
|How to cite this article:|
Mullaji A B, Shahane M N. Continuous passive motion for prevention and rehabilitation of knee stiffness--(a clinical evaluation). J Postgrad Med 1989;35:204-8
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Mullaji A B, Shahane M N. Continuous passive motion for prevention and rehabilitation of knee stiffness--(a clinical evaluation). J Postgrad Med [serial online] 1989 [cited 2022 May 25 ];35:204-8
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Injured joints have been treated with immobilisation due to intuition that injury demands a period of rest for healing to occur, and a common sense that moving a painful part would produce more pain, and also due to the "wisdom" of the forefathers of Orthopaedics, who strongly advocated enforced, uninterrupted and prolonged rest. The end results often were atrophy, stiffness and even, ankylosis. However, other workers,, have advocated early motion. Encouraging results with the latter procedure led to the studies of biology of repair under the influence of motion ,,,, and the adverse effects of immobilisation of the joint. These were mostly experimental animal and basic studies.
This paper is a clinical study of evaluation of the role of continuous passive motion (CPM) in preventing knee stiffness and assisting restoration of a range of motion (ROM), following a variety of conditions, in which the knee joint is frequently involved and is very susceptible to stiffness in a population placing a high premium on the ability to squat and sit cross-legged.
MATERIAL AND METHODS
This is a study of 43 knees in 42 indoor patients, admitted during October 1986 to September 1988 in the Department of Orthopaedics, K.E.M. Hospital, Bombay. There were 32 males and 10 females (one had rheumatoid arthritis of both knees), their ages ranging from 14 to 63 years (average 35.9 years).
The indications for CPM are given in[Table 1]. CPM was applied only for fractures which had been fixed stably; antibiotics, anti-inflammatory and other medications were administered as indicated.
We used a CPM machine made by an electronics firm and modified to our specifications. The speed fast kept constant, so that a full cycle lasted for 45 to 60 seconds. CPM was started as early as was feasible, usually 24-48 hours after the surgery and given on an average, for 6 hours daily, in split sessions, supervised by a physiotherapist and a resident. The range was adjusted individually and increased gradually by 10 degrees daily within limits of pain. A safety switch held by the patient enabled immediate reversal of direction, if excess pain occurred. CPM was given for 3 weeks during which various parameters were monitored and later, assigned scores [Table 2]. As there was little or no pain except initially, and compliance was excellent, both these factors have been excluded from the scoring system.
[Table 3]shows the results at the end of 3 weeks of CPM. We had excellent or good results in almost 83< of cases [Figs. 1], [Figs. 2] AND [Figs. 3] with a 90° flexion being achieved by the end of the first week itself Effusion and distal edema subsided within a few days. There was little or no pain, and patient compliance was excellent after the initial period of hesitancy. The hospital stay decreased and patients could be sent home by the end of the third week with excellent function. X-rays taken a the end of the study revealed no deleterious effects on fracture anatomy or on the original pathology.
The adverse effects detected are listed in[Table 4]. Only 2 cases had significant extensor lag; both were having tumours of the distal femur. The low incidence of lag was perhaps due to our insistence that occasionally the patients should actively extend for the last few degrees. The cases which showed weakness and laxity were due to the underlying pathology or the procedure performed, rather than the direct result of CPM. Mild effusion was found, mainly in the intra-articular fractures, subsiding after a few weeks. Superficial infection and slight gaping of wounds were managed well with antibiotics and deference of CPM for a few days.
The healing of joint stiffness at the microscopic level, its biochemistry and biomechanics have been well elucidated by Akeson et al. Adhesions form in the joint and between the synovium and capsule; cartilage undergoes necrosis; ligament structure disorganises; bone gets porotic; muscles weaken and ligaments undergo deformation. Water and glycosaminoglycan contents reduce. Collagen gets degraded and most importantly, disorganisation of the fibrillar arrangement of ligaments, capsule and synovium occurs. Cross-linking between fibres increases with impeded fibre-fibre gliding and loss of adaptation to changing shape. Thus, stiffness results.
On the other hand, "motion is life". Motion at the primordial interzone results in the development of synovial joints in early fetal life. Motion nourishes and lubricates the cartilage. Salter et al,, and O'Driscol et al have demonstrated the beneficial effects of CPM, not only on healing of articular cartilage defects, but also on fluid exchange and have justified its use for septic arthritis, effusion and abnormal fluids in the joint.
The results of the present study highlight the role of CPM. In 83% cases, a score more than 30 was achieved, indicating increased ability of flexion, decreased edema and lack of stiffness. This may be due to prevention of the abnormal cross-linking of fibrils that lead to contracture and stiffness and of disorganisation of collagen structure due to stress deprivation, without harming the normal healing of connective tissue.,
Active motion has the disadvantage of compressing joint surfaces, which is deleterious to the cartilage. In addition, it stresses any implant which may have been used. Worse, it increases tissue tension and so the pain, thereby reducing patient's compliance. Besides, it needs vigilant therapists and surgeons. Patient boredom and fatigue limit it to short durations. Accurate regulation of the range is difficult.
The hazards of passive stretching are too well known to bear repetition. CPM, however, avoids the physiologic indolence of total rest, without introducing deleterious compressive forces of muscle action. It allows nearly pain-free and optimum healing of articular cartilage, ligament and infection, with early restoration of ROM even in patients with decreased compliance. It allows precise regulation of ROM. CPM helps to boost the patient's morale with speedier rehabilitation and return to activity, thereby also cutting down the socioeconomic burden of prolonged hospital stay, both on the patient and the society.,
We are grateful to the Dean, G.S. Medical College and K.E.M. Hospital, for allowing us to publish hospital data; the Research Society of G.S. Medical College and K.E.M. Hospital for the grant which enabled us to carry out this work; and the enthusiastic physiotherapists attached to our unit.
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