strength of the normal extremity.

Movable devices that can

be attached to a patients bed, wheelchair, or standard chair
are available. The circumference of motion as well as excursion
of the extremities can be adjusted. A reciprocal exercise
unit has additional exercise benefits in that it can be used for
reciprocal patterning, endurance training, and strengthening
by changing the parameters of the exercise and monitoring the
heart rate and fatigue. (See Chapter 6 for principles of resistance
exercise and Chapter 7 for principles of aerobic exercise.)

Continuous Passive Motion

Continuous passive motion (CPM) refers to passive motion
performed by a mechanical device that moves a joint slowly
and continuously through a controlled ROM. The mechanical
devices that exist for nearly every joint in the body (Fig. 3.36)
were developed as a result of research by Robert Salter, who
demonstrated that continual passive motion has beneficial
(scapular elevation) or lean the trunk. Guide and instruct the
patient so there is smooth motion.
PRECAUTION: Assistive pulley activities for the shoulder are
easily misused by the patient, resulting in compression of the
humerus against the acromion process. Continual compression
leads to pain and decreased function. Proper patient selection
and appropriate instruction can avoid this problem. If a patient
cannot learn to use the pulley with proper shoulder mechanics,
these exercises should not be performed. Discontinue this
activity if there is increased pain or decreased mobility.
Elbow Flexion
With the arm stabilized along the side of the trunk, the patient
lifts the forearm and bends the elbow.

Skate Board/Powder Board

Use of a friction-free surface may encourage movement without
the resistance of gravity or friction. If available, a skate
with rollers may be used. Other methods include using powder
on the surface or placing a towel under the extremity so it
can slide along the smooth surface of the board. Any motion
can be done, but most common are abduction/adduction of
the hip while supine and horizontal abduction/adduction of
the shoulder while sitting.

Reciprocal Exercise Unit

Several devices, such as a bicycle, upper body or lower body
ergometer, or a reciprocal exercise unit, can be set up to provide
some flexion and extension to an involved extremity using the
68 Continuous Passive Motion
FIGURE 3.35 Use of overhead pulleys to assist shoulder elevation.
A
B
FIGURE 3.36 Continuous Motion Devices for (A) the shoulder and
(B) the knee.
healing effects on diseased or injured joint structures and soft
tissues in animal and clinical studies.20-25 Since the development
of CPM, many studies have been done to determine the
parameters of application; but because the devices are used
for many conditions and studies have used various protocols
with varying research designs, no definitive delineation has
been established.4,13,17

Benefits of CPM
CPM has been reported to be effective in lessening the negative
effects of joint immobilization in conditions such as
arthritis, contractures, and intra-articular fractures; it has also
improved the recovery rate and ROM after a variety of surgical
procedures.13,17,20-25,27 Basic research and clinical studies
reported by Salter have demonstrated the effectiveness of
CPM in a number of areas.
Prevents development of adhesions and contractures and
thus joint stiffness
Provides a stimulating effect on the healing of tendons and
ligaments
Enhances healing of incisions over the moving joint
Increases synovial fluid lubrication of the joint and thus
increases the rate of intra-articular cartilage healing and
regeneration
Prevents the degrading effects of immobilization
Provides a quicker return of ROM
Decreases postoperative pain
FOCUS ON EVIDENCE
Various studies have compared short and long-term outcomes
of CPM use after various types of surgery using
various parameters as well as CPM with other methods of
early movement and positioning.1,5,6,11,12,17-19,28,30 Some
studies have shown no significant difference between patients
undergoing CPM and those undergoing PROM or other
forms of early motion.5,11,12,19,29 Many studies support
the short-term benefits of CPM use after surgery in that
patients gain ROM more quickly and, therefore, may experience
earlier discharge from the hospital when CPM is
used compared with other forms of intervention. However,
long-term functional gains are reported to be no different
from those in patients who underwent other forms of early
motion.4,28,30
The authors of a Cochrane Review of 14 randomized controlled
trials in which CPM was used following total knee
arthroplasty summarized that for patients who had CPM
combined with physical therapy, there was a significant increase
in active knee flexion and decrease in length of hospital
stay as well as a decreased need for post-operative manipulation
compared to those receiving physical therapy alone.
There was no significant difference in passive knee flexion or
passive or active knee extension.14a
Some studies have identified detrimental effects, such as
the need for greater analgesic intervention and increased
postoperative blood drainage, when using CPM18,29 in
contrast to claims that CPM decreases postoperative pain
and postoperative complications.21-25,27 Cost-effectiveness
of the CPM equipment, patient compliance, utilization
and supervision of equipment by trained personnel, length
of hospital stay, speed of recovery, and determination of
appropriate patient populations become issues to consider
when making the choice of whether or not to utilize CPM
devices.12,15

General Guidelines for CPM

General guidelines for CPM are as follows3,4,10,13,14,20,25:
1. The device may be applied to the involved extremity immediately
after surgery while the patient is still under anesthesia
or as soon as possible if bulky dressings prevent early
motion.
2. The arc of motion for the joint is determined. Often a
low arc of 20 to 30 is used initially and progressed 10 to
15 per day as tolerated. The portion of the range used
initially is based on the range available and patient tolerance.
One study looked at accelerating the range of knee
flexion after total knee arthroplasty and found that a
greater range and earlier discharge were attained for that
group of patients,30 although there was no difference
between the groups at 4 weeks.
3. The rate of motion is determined; usually 1 cycle/45 sec or
2 min is well tolerated.
4. The amount of time on the CPM machine varies for different
protocolsanywhere from continuous for 24 hours
to continuous for 1 hour three times a day.10,14,25 The longer
periods of time per day reportedly result in a shorter hospital
stay, fewer postoperative complications, and greater
ROM at discharge,10 although no significant difference
was found in a study comparing CPM for 5 hr/day
with CPM for 20 hr/day.3 A recent study compared shortduration
CPM (3 to 5 hr/day) with long-duration CPM
(10 to 12 hr/day) and found that patient compliance and
the most gained range occurred with a CPM duration of
4 to 8 hours.4
5. Physical therapy treatments are usually initiated during
periods when the patient is not on CPM, including activeassistive
and muscle-setting exercises. It is important that
patients learn to use and develop motor control of the
ROM as motion improves.
6. The duration minimum for CPM is usually less than
1 week or when a satisfactory range of motion is reached.
Because CPM devices are portable, home use is possible
in cases in which the therapist or physician deems additional
time would be beneficial. In these cases, the patient,
a family member, or a caregiver is instructed in proper
application.
CHAPTER 3 Range of Motion 69

7. CPM machines are designed to be adjustable, easily controlled,

versatile, and portable. Some are battery operated
(with rechargeable batteries) to allow the individual to
wear the device for up to 8 hours while functioning with
daily activities.

ROM Through Functional

Patterns
To accomplish motion through functional patterns, first determine
what pattern of movement is desired and then
move the extremity through that pattern using manual
assistance, mechanical assistance if it is appropriate, or selfassistance
from the patient. Functional patterning can be
beneficial in initiating the teaching of ADL and instrumental
activities of daily living (IADL) as well as in instructing
patients with visual impairments in functional activities.
Utilizing functional patterns helps the patient recognize the
purpose and value of ROM exercises and develop motor
patterns that can be used in daily activities as strength and
endurance improves. Box 3.3 identifies some examples and
the basic motions that are utilized. When the patient no
longer requires assistance to perform the pattern safely and
correctly, the activity is incorporated into his or her daily
activities so motor learning is reinforced and the motion
becomes functional.
70 ROM Through Functional Patterns
BOX 3.3 Functional Range of Motion Activities
Early ROM training for functional upper extremity and neck
patterns may include activities such as:
Grasping an eating utensil; utilizing finger extension and flexion
Eating (hand to mouth); utilizing elbow flexion and forearm
supination and some shoulder flexion, abduction, and lateral
rotation
Reaching to various shelf heights; utilizing shoulder flexion and
elbow extension
Brushing or combing back of hair; utilizing shoulder abduction
and lateral rotation, elbow flexion, and cervical rotation
Holding a phone to the ear; shoulder lateral rotation, forearm
supination, and cervical side bend
Donning or doffing a shirt or jacket; utilizing shoulder
extension, lateral rotation, elbow flexion and extension
Reaching out a car window to an ATM machine; utilizing
shoulder abduction, lateral rotation, elbow extension, and
some lateral bending of the trunk
Early ROM training for functional lower extremity and trunk
patterns may include activities such as:
Going from supine to sitting at the side of a bed; utilizing hip
abduction and adduction followed by hip and knee flexion
Standing up/sitting down and walking; utilizing hip and knee
flexion and extension, ankle dorsi and plantarflexion, and
some hip rotation
Putting on socks and shoes; utilizing hip external rotation and
abduction, knee flexion and ankle dorsi and plantarflexion, and
trunk flexion

Independent Learning Activities

Critical Thinking and Discussion
1. Analyze a variety of functional activities, such as grooming,
dressing, and bathing, and determine the functional
ranges needed to perform each task.
2. Look at the effects of gravity or other forces on the ROM
for each activity in #1. If you had a patient who was unable
to do the activity because of an inability to control the
range needed, determine how you would establish an
exercise program to begin preparing the individual to
develop the desired function.
Laboratory Practice
1. Perform PROM of the upper and lower extremities with
your partner placed in the following positions: prone, sidelying,
sitting.
a. What are the advantages and disadvantages of each of
the positions for some of the ranges, such as shoulder
and hip extension, knee flexion with the hip extended,
rotation of the hip?
b. Progress the PROM to A-AROM and AROM and determine
the effects of gravity and the effort required
in these positions compared to that in the supine
position.
2. Compare the ROMs of the hip, knee, and ankle when each
of the two joint muscles is elongated over its respective
joint versus when each of the muscles is slack.