NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Evidence based practice research is forever leading to changes in procedures, treatments, and policies within the healthcare industry. With the constant flow of new research data, it is important that we are routinely updating our policies and procedures to include the best practice options for our patients. Due to the increased longevity of the geriatric population, the need for Total Knee Replacement (TKA) is steadily increasing. “Approximately 700,000 knee replacement procedures are performed annually in the US. This number is projected to increase to 3.48 million procedures per year by 2030” (Gregory M Martin, 2016). The healthcare field is developing new and inventive techniques that allow for faster and healthier recovery times for post-surgical patients. One of these technologies is the use of Continuous Passive Motion (CPM) in postoperative total knee arthroplasty.
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Although surgeons still use CPM postoperatively, it has recently come under question rather its use makes a difference in increasing mobility and decreasing joint stiffness and swelling. When looking at the research available, there are many qualitative and quantitative research articles available proving the ineffectiveness of using CPM as a treatment option (Maniar, Baviskar, Singhi, & Rathi, 2012). The purpose of this paper is to support the PICOT statement below by reviewing both a qualitative “To Use or Not to Use Continuous Passive Motion Post–Total Knee Arthroplasty: Presenting Functional Assessment Results in Early Recovery” and a quantitative “Aggressive continuous passive motion exercise does not improve knee range of motion after total knee arthroplasty” research article. We will also discuss how the data presented supports the need for evidence based practice changes regarding the use of CPM as a treatment option for postoperative TKA.
 PICOT Statement
Problem
Upon arriving to the postoperative orthopedic unit within a few hours after surgery, patients are encouraged to begin physical therapy and range of motion exercises to their new surgical knee. Depending upon the surgeon’s choice of treatment, they may include CPM within the physical therapy regimen. Continuous passive motion is accomplished with the use of a CPM machine. The patients postoperative knee is placed within the machine at a designated degree that is determined by the physician (Brian Hatten, 2016). The machine then moves the knee joint through a controlled range of motions intent on reducing pain, inflammation, and joint stiffness. The larger the degree angle that the patients knee can tolerate, the greater the chance of increased mobility and a faster healing process.  However, there is limited research that suggests that the use of CPM alone or in conjunction with therapy is more effective than physical activity alone in reducing these postop complications (Brian Hatten, 2016).
Specific Question
In adult postoperative total knee arthroplasty patients, how effective is continuous passive motion therapy in conjunction with physical activity in relation to pain, joint stiffness, physical mobility, and recovery time compared with physical activity alone starting at post-op day zero until discharge form acute postoperative orthopedic unit/or completion of CPM therapy?
Intervention
The use of Continuous Passive Motion (CPM) in conjunction with physical activity when completing physical therapy.
 
Comparison
The use of CPM in conjunction with physical activity compared to the use of physical activity alone when performing physical therapy in the acute post-op setting.
Outcomes/Timing
The use of CPM with physical activity does not decrease pain, joint stiffness, or recovery time, as well as increase mobility compared to physical activity alone in the use of physical therapy in the acute post-op setting. The period used for the study is from post-op day 0 – until discharge form acute postoperative orthopedic unit/or completion of CPM therapy.
Qualitative Study
Background
            CPM use in postop total knee replacements is becoming increasingly common, although the research on the benefit of its use is conflicting. The authors of the article mention that CPM “in early postoperative recovery is again questionable, with a few studies supporting and others negating the short-term benefits” (Maniar, Baviskar, Singhi, & Rathi, 2012). Due to the questionable nature of the outcome of using CPM, research was conducted with the aim of determining the effect of CPM usage on pain, range of motion (ROM), wound healing, Suprapatellar and Calf Girth (or swelling), and functional mobility (Maniar, Baviskar, Singhi, & Rathi, 2012). The question that the research seeks to answer is if CPM usage after postop total knee replacement increase or decreases the patient’s physical recovery time? Does the amount of time (application time applied and days of usage) that CPM is used in therapy change the results of the healing time for patients? The purpose of this research study and the questions that it seeks to answer will help to determine if continuous passive motion should still be used as a form of therapy treatment in postop total knee arthroplasty.
Method
The hypothesis of this research project was that “CPM may be helpful with initializing knee bending so that further active and passive motion training becomes easier and patient tolerates exercises better” (Maniar, Baviskar, Singhi, & Rathi, 2012). Other research articles regarding the use and effectiveness of CPM were used as references by the authors in their own research. These articles consisted of both qualitative and quantitative data collection (books, articles, tables/figures, and research studies) with the oldest article published in 1982. Although some of the articles used were 20+ years old, they were still relevant and conducive to the authors research and study results. The authors also used the grounded theory as well as the development of graphs, tables, and diagrams to compartmentalize their research findings. This allowed for individuals reading their data to see the big picture of the results they obtained. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
 
There were several methods used to obtain data within the project. Eighty-four patients were selected and divided into three groups of twenty-eight individuals, who were all scheduled for total knee replacements. Individuals were excluded from the study if they had “medical conditions or diseases that could interfere with test performance, collaboration or comprehension problems, and neuromuscular or neurodegenerative disease” (Maniar, Baviskar, Singhi, & Rathi, 2012). Each patient received the same knee implant all placed by the same surgeon within a one year time span. The researchers understood the importance of minimizing the number of possible variables that could affect the results. The three groups of individuals were labeled no-CPM, 1-day-CPM, and 3-day-CPM. One group had physical therapy with no CPM after surgery, another group had one day of CPM with two segments of 15 minutes, and the third group had three days of CPM with two 15 minute segments each day (Maniar, Baviskar, Singhi, & Rathi, 2012). The VAS scale (0-10 pain scale, qualitative data) was used to measure patients pain level, the TUG test (patient ability to sit, get up from sitting, walk, and turn while walking) was used to determine physical mobility, ROM was evaluated of the postop knee, wound healing was measured by dressing saturation, wound color, and suture/staple approximation, and Suprapatellar and Calf Girth (or swelling) was measured by standard tape measure (Maniar, Baviskar, Singhi, & Rathi, 2012). Within the article the authors state that “All assessments were performed at the same time of day, that is, in the morning before subjecting the patient to physical therapy sessions” (Maniar, Baviskar, Singhi, & Rathi, 2012).
Findings
            The results of the authors study showed no significant difference in results between the individuals who received CPM and those who did not. For pain using the VAS score there was no change in pain level between all three groups within the same time intervals, when interviewed. When assessing ROM, it progressed at the same degree level for each group and resulted in everyone within the group returning to preoperative ROM by day forty-two (Maniar, Baviskar, Singhi, & Rathi, 2012). The TUG test values also showed no significant differences between the results within each of the three groups. For wound healing, it was shown to have a slight increase in wound drainage in the groups who received CPM. The Results showed “that at day 3, when both 1-day and 3-day-CPM groups had had equal duration of CPM application; that is, just 1 day of CPM on day 2, these 2 groups combined had 24.24% of patients with wound staining compared with only 12.12% in the control group who had not had any CPM application” (Maniar, Baviskar, Singhi, & Rathi, 2012). Lastly the results for Suprapatellar and Calf Girth (or swelling) indicated a longer recovery time back to preoperative size in the groups receiving CPM compared to the control group. Each group resumed preoperative state by day forty-two, however “suprapatellar girth took much longer to reduce to the preoperative status in both the CPM application groups compared with the control group” (Maniar, Baviskar, Singhi, & Rathi, 2012).  For each of the results obtained, the authors presented research studies that corresponded with the results they obtained, as well as some studies that had conflicting results to their own. In this case, the authors offered reasons for why the differing results may be present. Possible variables that could have affected the research results were type and frequency of pain medication administered as well as patients own perception of pain, motivation towards therapy, comorbidities such as diabetes that could have affected wound healing, and each patient’s height and weight affecting ROM and TUG test scores. Overall, the results from this study indicated that there is no benefit to patient’s physical mobility, pain level, wound healing, or swelling with use of the CPM compared to no CPM usage. In fact, results indicated increased swelling and wound drainage when CPM was used as a part of physical therapy. These results would suggest that the orthopedic nursing and medical boards take a closer look at the allowance of CPM usage in postop total knee arthroplasty.
Ethical Considerations
                        When it comes to ethical considerations the research essay does not specify rather an Institutional Review Board approved it. It does state however that “All participants who were eligible and agreed to participate signed an informed consent form” (Maniar, Baviskar, Singhi, & Rathi, 2012). This indicates that all participants were aware of what the research would be used for as well as their role in the study. Each individual was assigned an envelope upon the day of their surgery that designated they would be a part of the control group or one of the groups receiving CPM therapy. The authors also mentioned that “A university-based assistant professor of statistics evaluated the data” (Maniar, Baviskar, Singhi, & Rathi, 2012). The article however does not mention the steps it took to maintain patient privacy or the filing system in which it used.
Conclusions
            Through the data collected the answer was derived of the questions presented at the beginning of this paper. Does CPM usage after postop total knee replacement increase or decreases the patient’s physical recovery time? The results showed that the use of CPM does not significantly increase the patient’s recovery time, nor does it increase physical mobility or reduce pain. It does however lead to increased bleeding from operative site and cause a delay in the Suprapatellar and Calf Girths return to normal. This indicated a possible increase in swelling with the use of CPM. Lastly does the amount of time (application time applied and days of usage) that CPM is used in therapy change the results of the healing time for patients? There were also no significant findings to indicate that the duration of the CPM usage would change the data results. Overall the research maintained both certified and ethical planning while using both qualitative and quantitative means to achieve data collection. The article states that “After this study, we have stopped our routine practice of administering CPM in all our postoperative patients with no disadvantage” (Maniar, Baviskar, Singhi, & Rathi, 2012). This is important as the results obtained from this study have led to practice changes by surgeons within certain facilities. It is important for orthopedic nursing and medical boards alike to monitor this type of data collection as it may be of importance in the continual certification and use of CPM in the postoperative total knee arthroplasties.
 NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Quantitative Study
Background
            As the geriatric population is living longer and the need for TKA is increasing it is important that we discern the beneficence of CPM and rather it is best practice to continue its use as a form of treatment. The article states “As early postoperative ROM is an important prognostic factor for the patient’s ability to walk later, it is important to achieve the best possible knee ROM while the patient is in hospital. Thus, the rehabilitation protocol in the hospital might have consider-able consequences for the patient in the longer term.” (Chen, et al., 2013). The article states a clear identification of the problem that needs to be addressed. The aim of this research was “to evaluate the effects of continuous passive motion on the range of motion, postoperative pain and life quality of patients undergoing total knee arthroplasty within six months after the operation.” (Chen, et al., 2013). The researchers seek to answer the question of rather the use of aggressive CPM in the early postoperative stage increases or decreases the patient’s physical recovery time? Does the use of CPM increase ROM in the postop knee, reduce/increase pain, and overall improve the patient’s quality of life? The questions the study seeks to answer will provide data regarding rather the use of CPM is an appropriate form of treatment for postoperative total knees.
Method
            Before beginning the study, the researchers hypothesised that “aggressive CPM in the early postoperative period would improve knee ROM, induce more pain, and improve quality of life” (Chen, et al., 2013). The study was conducted using 107 patients with degenerative osteoarthritis, who were undergoing their first TKA. Patients with rheumatoid arthritis or prosthesis in the ipsilateral hip were excluded from the study. All patients included in the study before surgery could ambulate with/without a walking aid. The surgery was complete by one of two possible qualified surgeons at Kaohsiung Medical University Hospital, and each patient was fitted with the same prosthesis and fixed with cement (Chen, et al., 2013). The information provided in the article indicates that the researchers went to great lengths to minimize outside factors and manipulation of the independent (use of CPM) and dependent (ROM, pain, mobility, overall quality of life) variables. Experimental research design was used to conduct the study. The patients were split into two separate groups. The first group (control group) would receive only basic rehabilitation protocols and the second group (experimental group) would receive basic rehabilitation protocols in addition to six hours or more of CPM a day. The CPM was set to reach seventy degrees with the first treatment, with the intent to reach one-hundred degrees depending on the individual’s ability to tolerate it. “The basic rehabilitation protocols consisted of assisted and active flexion and extension of the hip/knee, active isometric contraction of the quadriceps, straight leg raising training, walking with a high walker or crutches, and eventually climbing stairs on crutches” (Chen, et al., 2013).
Several different types of data collection were used within this study. ROM was measured with the use of a goniometer while the patient was laying supine. “Knee flexion was measured with the hip at 90-degree flexion. The goniometer swivel center was placed on the lateral side of the knee center, with one arm aligned with the greater trochanter and the other along the line running from the fibular head to the lateral malleolus of the ankle. The knee was moved to maximum flexion and the range measured in degrees.” (Chen, et al., 2013). The patients pain scores were measured using the VAS scale (0-100, 0-no pain, 100-unbearable pain). This was recorded at least once per shift. Quality of life was measured through the “modified Short Form-36” questionnaire. This questionnaire had eleven dimensions with scores ranging from 1-5 (lowest score indicating the best condition, and the highest, the worst condition). This article used both quantitative (ROM measurements) and qualitative (Pain score and quality of life) research methods within their data collection process. The data parameters, were collected by the same nurse at both the admission, during the hospital stay, two and six-week follow-up, and three and six-month postop visit (Chen, et al., 2013). The ROM, VAS, and SF-36, were all measured each day during the post-op hospital stay and at each follow up appointment. “The Mann–Whitney test was used to analyze the efficacy between study groups. Repeated analysis of variance (ANOVA) was implemented to examine the differences at various timepoints. All tests were two-sided and performed at the 5% level and analyzed with SPSS statistical software between study groups.” (Chen, et al., 2013).
Findings
            The results were obtained within a six-month period (January 2007- June 2007). In terms of ROM, the results were nearly the same between the control and experimental group. “ROM increased from 109 degrees preoperatively to 125 degrees at six months after operation in the treatment group and from 111 degrees preoperatively to 125 degrees at six months after operation in the control group” (Chen, et al., 2013). When it came to patient pain scales using the VAS score, there was no significant differences in the data obtained. “VAS decreased from 7.78 preoperatively to 0.37 at six months after operation in the treatment group and from 7.92 preoperatively to 0.21 at six months after operation in the control group” (Chen, et al., 2013).  There was also no significant difference in data obtained from the SF-36 questionnaire used to determine patient quality of life. “The SF-36 improved from 3.76 preoperatively to 1.77 at six months postoperatively in the treatment group and decreased from 3.68 preoperatively to 1.83 at six months postoperatively in the control group.” (Chen, et al., 2013).  The data obtained from the research study is written within the article and organized within tables and graphs for easier visualization and understanding. The data comes across as both cohesive and accurate.
The authors of the article were quick to point out limitations within their research. “First, this was not a randomized controlled study. Second, the rehabilitation protocol after discharge was not standardized. Third, the number of patients was not so large, which sometimes may result in less ability to tell the difference between groups” (Chen, et al., 2013). One limitation that was not pointed out within the article was the use of the same nurse to collect all data within the study. This lets the possibility of bias or miscalculations enter the data, and would have been much more proficient to have more than one individual collect and analyzed the data. The implication to nursing practice is defined within the article. The number one aspect of patients who have undergone TKA are ROM and pain reduction. The study does conclude that it does not recommend routine use of aggressive CPM for postoperative TKA. “It is important to monitor the effects of aggressive CPM on pain and ROM. The results of this study indicate that patients undergoing TKA can have less pain and better ROM and life quality six months after operation, but aggressive CPM during hospitalization does not provide additional benefits” (Chen, et al., 2013). The results of the data gathered here would be important to orthopedic nursing and medical boards to assist in the determination if the use of CPM is still best practice for treatment in postoperative TKA patients. The data collected here can lead to evidence based practice changes regarding the physical therapy treatment regimen of postoperative TKA, including the removal of CPM as best practice treatment options.     
Ethical Considerations
            It was not specified within the research article if the participants signed any type of informed consent before taking part in the study. It can be inferred however that the individuals within the study were active participants as they would have had to give consent for not only the measurement of ROM and VAS scale by the nurse, but also actively participate in answering the questionnaire associated with the SF-36. The article does mention that is was supported by the National Health Research Institute of Taiwan and Kaohsiung Medical University Hospital (Chen, et al., 2013).  It was also mentioned that each of the research authors did not have a conflict of interest in relation to the research study. The patient’s privacy also seemed to be well respected, as it was mentioned in the article that the same nurse collected the data each time, minimizing the number of individuals to access patient confidential information. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay.
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Conclusions
            The data results from this study concluded that there is no significant difference in ROM, pain, and quality of life with implementation of CPM in postoperative TKA therapy. The researcher’s hypothesis “aggressive CPM in the early postoperative period would improve knee ROM, induce more pain, and improve quality of life”, was disproved by the results of the study. The answers to the question, at the beginning of this paper, were determined by the data presented. Does the use of aggressive CPM in the early postoperative stage increases or decreases the patient’s physical recovery time? The answer is that the use of aggressive CPM in TKA does increase physical recovery time, however it is not significantly different from the results obtained from just physical therapy alone. Does the use of CPM increase ROM in the postop knee, reduce/increase pain, and overall improve the patient’s quality of life? The answer again is yes, however there is no significant difference in the results of the above variables with the use of CPM compared to physical therapy alone. The use of CPM in therapy for TKA does not provide additional benefits to the patient. Overall the authors of this article do not recommend the use of CPM for treatment in TKA patients (Chen, et al., 2013). The data provided here is important to nursing research and evidence based practice. It provides nursing and physician national orthopedic boards with a greater knowledge base on rather CPM should still be considered as a certified safe and effective treatment option for total knee arthroplasties.
Evidence-based Practice Change
            Within both the qualitative and quantitative research articles provided the end results were both the same. These results both answered and supported the PICOT question above. The use of CPM in the treatment of post-op TKA does not reduce pain, swelling, joint stiffness, or increase physical mobility more substantially than physical therapy alone (Lenssen, et al., 2008). These results show that CPM therapy is neither needed nor does it provide benefits, that physical therapy alone cannot provide. The use of CPM is both time constraining and comes at a higher cost for both healthcare facilities and the patient. “Both rentals and purchased CPM machines are costly, challenge the nursing staff with time effectiveness in their daily tasks, and cause increased pain in some patients. Authors of the current literature also stated there are possibilities
for adverse effects, due to application errors, which can lead to a longer hospital stay” (University, 2015).
The evidence based research provided indicates a need to eliminate the use of CPM as a form of treatment in post-op TKA. The data can be used to show orthopedic nursing/physician boards the need to remove CPM form their choice of treatment regimen. “Decreasing the use of CPM machines creates a source of patient satisfaction as it relates to a decrease in pain, and a reduction in the need for pain medication prior to physical therapy which can reduce the instance of falls.” (University, 2015). Removing CPM as a treatment option will provide cost-effective changes for both orthopedic units within hospitals and rehab facilities. It is important that the data from both this paper and other research studies conducted on the use of CPM, be used to make evidence based practice changes to increase patient safety and health, reduce hospital stays, and increase cost effectiveness within healthcare facilities.
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
 
 
References
Brian Hatten, M. (2016, may). CPM Machine Assist your early motion after knee replacement. Retrieved from Mykneeguide.com: https://www.mykneeguide.com/the-hospital/cpm-machine
Chen, L.-H., Chen, C.-H., Lin, S.-Y., Chien, S.-H., Su, J. Y., Chao-Yung Huang, H.-Y. W.-L., . . . Huang, H.-T. (2013). Aggressive continuous passive motion exercise does not improve knee. Retrieved from Journal of Clinical Nursing : http://eds.b.ebscohost.com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?sid=5cc9803c-34c3-4521-86af-04e02436bf32%40sessionmgr101&vid=9&hid=127. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Gregory M Martin, M. (2016). Patient education: Total knee replacement (arthroplasty) (Beyond the Basics). Retrieved from UpToDate: http://www.uptodate.com/contents/total-knee-replacement-arthroplasty-beyond-the-basics. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay
Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding Nursing Research 6th edition . St. Louis, Missouri : Elsevier, Saunders.
Health, J. H. (2008). Managing Your Qualitative Data. Retrieved from Johns Hopkins Bloomberg School of Public Health: http://ocw.jhsph.edu/courses/QualitativeDataAnalysis/PDFs/Session2.pdf. NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay.
Lenssen, T. A., Steyn, M. J., Crijns, Y. H., Waltjé, E. M., Roox, G. M., Geesink, R. J., . . . Bie, R. A. (2008). Effectiveness of prolonged use of continuous passive motion (CPM), as an adjunct to physiotherapy, after total knee arthroplasty. Retrieved from Bio Med Central: http://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/1471-2474-9-60
Maniar, R. N., Baviskar, J. V., Singhi, T., & Rathi, S. S. (2012). To Use or Not to Use Continuous Passive Motion Post–Total Knee Arthroplasty : Presenting Functional Assessment Results in Early Recovery. Retrieved from ScienceDirect.com: http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S0883540311001689
NRS433 Introduction to Nursing Research – Research Critique and PICOT Statement: Continuous Passive Motion (CPM) and Total Knee Replacement (TKA) Essay