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prior to CPM therapy and attempts were made at resiz-ing the machine for comfort. On the third postoperativeday, it was discovered that the patient had a wound onthe posterior thigh where it rested against the CPM ma-chine. The sheepskin covering for the machine hadcome loose and exposed the plastic plate as the machinewas operating. The movement of the machine causedthe CPM machine to slowly move away from the patienttoward the foot of the bed, creating the wound in theprocess because the patient’s skin was rubbing againstthe plastic plate of the CPM. The resulting wound wasdeep, extremely painful for the patient, and requiredextra nursing care. Further surgery was required toclean and close the wound. The hospital assumed theexpense of the surgery and care.

Although such a case is rare, it does highlight the po-tential risk to patients receiving CPM therapy.

Issues With CPM TherapySTAFF KNOWLEDGE

In 2005, a survey of nursing staff on an orthopaedicunit at a large urban hospital in Seattle, WA, wherethis case occurred, revealed that staff had learnedabout the setup, use, and ordered therapy of CPM ma-chines while performing patient care. Multiple ordersand a lack of familiarity and comfort with setup of themachines led to confusion and increased risks to pa-tients. Orders were cited as being vague and difficult tofollow. Implementation of CPM therapy varied widely,with range of therapy from an hour to overnight. Staffbelieved CPM machines were always correctly sizedand ready for patient use when they were in patientrooms.

Staff members cited the conflicting research and thelack of time as reasons for their ambivalence towardCPM therapy and proper application of the machines.

Orthopaedic nursing often involves the use of equipment,and nurses may learn about the use of equipment on thejob in informal ways. Staff may have difficulty attending in-services, may be off during quick informal in-services, ormay not use equipment for a period of time after an in-service. Due to lack of knowledge, inconsistency in theimplementation of ordered therapies resulting in pooroutcomes, including pressure wounds and patient dissatis-faction, frequently occurs. Using continuous passive motiontherapy as an example, an interactive educational approachto equipment training is presented. Such an approach helpsformalize equipment training, provides a standard approachto implementing ordered therapy, provides references forstaff after in-services, and improves patient outcomes.

The Agency for Healthcare Research and Quality(2003) stated that one of the most commonlyperformed orthopaedic procedures is total kneearthroplasty (TKA). Care of patients after total

knee replacement surgery may include the use of con-tinuous passive motion (CPM) as part of postoperativetherapy. Orthopaedic nurses traditionally have learnedabout the use of these machines on the job, leading to avariety of approaches to implementing ordered therapyand patient care during use. As a result, patients may ex-perience poor outcomes such as increased pain and skinwounds from friction and pressure. This can lead tocostly medical care for wound treatment and dissatis-faction with care. An interactive education programwith hands-on practice for nursing staff that includesorder interpretation, setup of the CPM machine fortherapy, and care of the patient can improve clinicaloutcomes and satisfaction for patients receiving CPMtherapy.

Case StudyA patient receiving CPM therapy after a TKA com-plained to nursing staff about increasing pain on theposterior thigh and discomfort during therapy. Over thecourse of the next 2 days, pain medication was given

Jennifer Spotted Horse, MSN, RN, ONC, Clinical Nurse Specialist,Allenmore Hospital, Tacoma, WA.

The author has disclosed that she has no financial relationships relatedto this article.

Improving Clinical Outcomes WithContinuous Passive Motion An Interactive Education Approach

Jennifer Spotted Horse

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Introduction of CPM into treatment after TKA wasbased on the work of Salter et al. (1965). Their workwith rabbit joints showed that joint immobilization haddeleterious effects on the articular cartilage of joints(O’Driscoll & Giori, 2000). Lenssen, de Bie, Bulstra, andVan Steyn (2003) noted that the first randomized con-trolled trials on the efficacy of CPM in TKA were con-ducted in the late 1980s, about 10 years after the intro-duction of CPM as a treatment modality. Studies duringthe years since have produced conflicting results on theefficacy of CPM as a treatment modality after TKA(Brosseau et al., 2004), yet it remains a standard treat-ment for many patients after TKA.

WOUNDS

The Harvard Health Letter notes that immobility fromillness, injury, or anesthesia can cause pressure on spe-cific areas of the body (Harvard Medical School, 2006).Reddy, Gill, and Rochon (2006) point out that pressureulcers are common and preventable. Given the evidencerelating the development of decubitus ulcers to pres-sure, it is interesting to note that there is no literatureassociated with skin breakdown about CPM therapy.This could be due to the short time periods used in moststudies; however, the design of CPM machines leads toareas of pressure that need nursing attention to preventskin complications. In addition, patients are at in-creased risk for pressure complications due to regionaland local anesthesia causing a lack of sensation in theoperative leg. O’Driscoll and Giori (2000) noted thatfrequent assessment can prevent pressure-relatedproblems associated with CPM therapy. As the patientwith the posterior thigh wound demonstrates, therecan be significant injury associated with CPM ther-apy. Additional assessment is needed specifically tar-geted to areas in contact with the CPM machine. Toprevent pressure-related complications, CPM framesmust have the sheepskin firmly and appropriatelyplaced on the machine to prevent pressure and rub-bing. Supplemental sheepskin padding may beneeded. The frame also needs to be correctly sized ac-cording to the patient, properly aligned, and braced toprevent slippage.

In a short 2-month period in 2005, the surveyed unithad three incidents of skin injury from CPM use, in-cluding the case study example. The other injuries in-cluded significant bruising and hematoma related to ex-posed knobs and rubbing from the CPM frame.

Patient SatisfactionAn issue leading to patient dissatisfaction with CPMtherapy is that staff may appear unsure of how to workwith the machines if an issue arises with the sheepskinpadding, a need for supplemental padding, or bracing.If staff is unable to rectify these problems to provideadequate support and protection, skin complicationsrelated to pressure or rubbing will lead to increasedpain. Patients will not have a good experience withCPM therapy and be less satisfied with their care, es-pecially if their experience includes preventable andcostly complications. This proved to be the case on thesurveyed unit both anecdotally and by patient com-

plaints after injury, using the hospital’s incident re-porting forms.

Plan for Staff EducationStaff education was planned as a quality improvementproject to address the injuries known to be caused byCPM therapy. On the basis of the significant CPM-related wound, survey of orthopaedic nurses, painmeasures, and patient satisfaction, a plan for educa-tion on CPM therapy was developed. In designing theeducation, it was important to acknowledge the expe-rience of the nurses and to create an activity that wasrelevant to their daily practice, which is key to workingwith adult learners (Eshleman, 2008). Ragsdale andMueller (2005) point out that one must assess for bar-riers to conducting education and be sure to create ed-ucation opportunities that engage the adult learner,allow the sharing of information, and allow the inte-gration of the new information. On the busy nursingunit, nurses often found leaving the unit to attend edu-cational activities difficult. Bringing education to theunit increased the likelihood that nursing staff wouldbe able to participate. It was determined that a unit-based, hands-on experience, where staff memberscould both set up a machine and be the “patient,”would allow the greatest opportunity for participation.Staff members would then be able to discuss issuesrelated to CPM therapy and share their experiences.The learning experience began in the spring of 2006after completion of education resources and materialsand was led by a clinical educator and the orthopaedicequipment technician.

Education MaterialsBefore conducting education sessions, it was neces-sary to develop education materials and a skills check-list competency for staff to document completion ofthe education.

ORDER INTERPRETATION REFERENCE

Given the variety of orders related to CPM therapy, anorder interpretation reference (see Figure 1) was devel-oped in collaboration with physical therapy (PT) andphysician groups. The reference provides a unit CPMstandard of care, in addition to instructions to follow re-garding the interpretation of various orders by physi-cians that are not evident on the order set currentlyused. Instructions include ensuring the sheepskin se-curely placed, providing extra padding, limiting CPMtherapy to 4 hr at a time, and assessing skin after eachtherapy session.

ONLINE RESOURCE

A PowerPoint resource was developed to post on theunit’s intranet. The online slides provide a shortdemonstration of common issues seen with CPM ma-chines on the unit as well as the solutions. Problemstargeted are loose sheepskin, improper sizing, and fail-ure to brace the machines to prevent sliding away fromthe patient.

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GRAPHIC REFERENCE

A single page graphic reference (see Figure 2) was createdto keep on the unit. The reference demonstrates a CPMcorrectly sized, applied, and braced. On the reference itself, key points are noted. The reverse side of the refer-ence contains the different CPM machines seen on theunit, with tips for sizing related to patient height andweight.

PATIENT EDUCATION SHEET

A patient education sheet (see Figure 3) was also cre-ated. This small instruction sheet is provided to the pa-tients after instructions are given on their ordered ther-apy and order parameters are filled in by theorthopaedic equipment technician. The form provides

the patient with written information on the physicianorder, when to call for the nurse, and guidelines forlength of use. A larger version of the form was also cre-ated to be posted on the board in the patient’s room forpatient and staff reference.

SKILLS CHECKLIST

The final component for education was the develop-ment of a skills checklist (see Figure 4). Step by step, thechecklist takes the learner through the process of settingup a CPM machine for patient use, application to a pa-tient, and trouble shooting. The checklist itself is con-sistent with organizational standards for demonstratingskills competency that is completed by observeddemonstration of each step in the process.

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FIGURE 1. Continuous passive motion (CPM) order interpretation reference sheet for staff.

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Education ImplementationHour-long sessions were scheduled on the unit with aclinical educator and the orthopaedic equipment tech-nician, allowing nursing staff members to attend ac-cording to their availability. Attendance was mandatoryfor all orthopaedic unit staff members. Sessions wereheld throughout the day and included discussion ofstaff experiences, a review of the research related toCPM therapy, skin assessment, complications experi-enced on the unit, and hands-on practice with the ma-chines. The clinical educator presented research infor-mation, facilitated discussion, and assessed skillscompetency. The orthopaedic equipment techniciandemonstrated the basics of CPM machine setup and ap-plication and assessed skills competency. Resource ma-terials were explained during the sessions and given ashandouts.

Discussion of the research included the conflictingresults of the studies that have been done on CPM ther-apy as noted by Brosseau et al. (2004) on the long-term

benefit of CPM therapy. Studies have generally shownno long-term benefit for patients. Many staff membersnoted the absence of nursing research into CPM ther-apy. Topics for nursing research related to CPM therapydiscussed by the group included pain control, edemacontrol, and patient satisfaction.

Skin assessment included a targeted assessment re-lated to areas of contact with the CPM machine. Skinassessments by staff were largely targeted at the surgi-cal area and areas of known pressure such as the coc-cyx. With CPM therapy more limited in time, nursesstated that they were less likely to carefully assess skinin contact with the CPM unless a patient complained ofdiscomfort.

Hands-on practice included setup and the “patientexperience.” Staff members were able to both set up theCPM machine for application and have the machine ap-plied as if they were the “patient.” The group discussionon areas of pressure and targeted assessment fits wellwith the hands-on practice and gave the staff greater ap-preciation of the need for targeted skin assessment.

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FIGURE 2. Staff graphic reference for the application of continuous passive motion (CPM).

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Nursing staff, including nursing assistants, on the or-thopaedic unit was the target audience for the initial ed-ucational offering. The rehabilitation services depart-ment expressed interest in the program and had staffcome to the nursing unit to participate in the sessions,though it was not required of the department. Sessionswere also scheduled for the postanesthesia care unitafter completion of the inpatient nursing staff educa-tion. Education sessions were held throughout thespring and summer of 2006 with approximately 120staff members.

OutcomesSTAFF KNOWLEDGE

As was noted by O’Driscoll and Giori (2000), nurses maynot have sufficient experience to look after the needs ofCPM therapy, and this proved to be the case on the unit.Nursing staff members initially expressed some hesita-tion to attend an educational activity on a device thatthey considered themselves to be familiar with. Afterthe first few sessions were held, the attitude on the unitbegan to change. Staff members shared with each otherthat they had learned more about the patient experiencethrough the hands-on experience, the setup of the ma-chines, and caring for the patient receiving CPM ther-apy. Sessions were lively with discussion regarding theresearch about and use of CPM therapy for TKA and tar-geted assessments for skin assessment.

WOUNDS

Following completion of education sessions, the unitexperienced an elimination of known pressure and fric-tion wounds related to CPM therapy. Staff membersstated that they were more aware of the length of timepatients spent with the CPM machine, the extra paddingneeded, and the need to assess skin carefully for signs ofpressure or rubbing.

PATIENT SATISFACTION

Anecdotal evidence demonstrated an increase in patientsatisfaction. Nursing staff members expressed that theyfelt more confident with the machines and felt that pa-tients had more confidence with the therapy as a result.Fewer complaints of pain and skin discomfort werenoted through the incident form process, with an in-crease in patients participating in therapy per physicianorders. Patient satisfaction tracking by the organizationdoes not currently address specific therapies such asCPM.

MULTIDISCIPLINARY REACTION

Physical therapy and physician groups had input intothe materials used in the educational activity presentedto nursing staff. The PT and physician groups noted thatit was helpful to have the larger version of the patienteducation sheet posted in the room. Both groups ex-pressed an opinion that patients were participating inCPM therapy more consistently.

DiscussionOrthopaedic nursing requires knowledge of a variety ofequipment, including CPM machines. Although CPMmay be a controversial treatment, there is no indicationthat surgeons will discontinue the use of this therapy asa way to maximize knee flexion (Temple, 2006). Nurseshave traditionally learned about the use of orthopaedicequipment, such as CPM machines, while caring for pa-tients. The result is inconsistent orientation toward theuse of the equipment and a variety of approaches to theimplementation of ordered therapy. Such variety inpractice can have significant implications for the pa-tient, including increased risk of complications. Nursesand other caregivers associated with CPM therapyshould strive to reduce skin- and pain-associated com-plications that exist with these machines.

By designing a program that standardizes educa-tion, staff members are given the tools to be confidentin their approach to using orthopaedic equipment andprevent complications. Similar methods are used toteach new skills, such as catheterization and centralcatheter care, both in nursing school and in the hospi-tal setting. Although this program focused on CPMtherapy, the approach is relevant to other orthopaedicequipment as well. Creating an educational opportu-nity based on adult learning principles that is easily ac-cessible on the nursing unit, relevant to current prac-tice, and that provides a chance for staff members toshare their varied experience is key to successful imple-mentation. The resulting improved staff confidencewith ordered therapy, prevention of pressure/friction

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FIGURE 3. Patient education sheet with place to write currentorders and instructions on use and calling for the nurse. CPM = continuous passive motion.

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wounds, and increased patient satisfaction are evi-dence that such educational activities have multiplebenefits for healthcare organizations.

Continuing mandatory education is necessary tomaintain skills and to update information. Further de-termination is also needed regarding skin assessmentand complications, as well as patient satisfaction withCPM therapy, which was not determined directly dur-ing this educational project.

Further research and collaboration are needed re-garding CPM therapy. A multidisciplinary approach

that includes physical therapy, physician, and nursinginvolvement would add knowledge to the many aspectsof this common therapy.

ACKNOWLEDGMENT

The author thanks Keith Ferguson, NA-C, orthopaedicequipment technician, for his help in collaborating withphysicians and physical therapists for recommenda-tions on order interpretation, producing the materialsfor this project, and his involvement in the staff educa-tion process. His careful observation and attention to

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FIGURE 4. Continuous passive motion (CPM) skills checklist for staff completion with hands-on practice for setup and use.

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detail while assisting patients with CPM therapy helpedmake this project a success.

REFERENCESAgency for Healthcare Research and Quality. (2003). Total

knee replacement. Retrieved February 23, 2009, from thePubMed Web site: http://www.ncbi.nlm.nih.gov

Brosseau, L., Milne, S., Wells, G., Tugwell, P., Robinson,V., Casimiro, L., et al. (2004). Efficacy of continuous pas-sive motion following total knee arthroplasty: A meta-analysis. Journal of Rheumatology, 31, 2251–2264.Retrieved February 23, 2009, from the EBSCOhost Website: http://www.web.ebscohost.com

Eshleman, K. Y. (2008). Adapting teaching styles to accom-modate learning preferences for effective hospital devel-opment. Progress in Transplantation, 18(4), 297–300.Retrieved February 28, 2009, from the ProQuest Web site:http://www.proquest.umi.com

Harvard Medical School. (2006). Preventing bedsores.Harvard Health Letter, 32(1), 1–3. Retrieved February 23,2009, from the ProQuest Web site: http://www.proquest.umi.com

Lenssen, A. F., de Bie, R. A., Bulstra, S. K., & Van Steyn, M.J. A. (2003). Continuous passive motion (CPM) in reha-bilitation following total knee arthroplasty: A random-ized controlled trial. Physical Therapy Reviews, 8,

123–129. Retrieved February 23, 2009, from theEBSCOhost Web site: http://www.web.ebscohost.com

O’Driscoll, S. W., & Giori, N. J. (2000). Continuous passivemotion (CPM): Theory and principles of clinicalapplication. Journal of Rehabilitation Research andDevelopment, 37(2), 179–188. Retrieved February 23, 2009,from the ProQuest Web site: http://www.proquest.umi.com

Ragsdale, M., & Mueller, J. (2005). Plan, do, study, act modelto improve an orientation program. Journal of NursingCare Quality, 20(3), 268–272. Retrieved February 28,2009, from the EBSCOhost Web site: http://www.web.ebscohost.com

Reddy, M., Gill, S.S., & Rochon, P. (2006). Preventing pres-sure ulcers: A systematic review. Journal of the AmericanMedical Association, 296(8), 974–984. Retrieved February23, 2009, from the ProQuest Web site: http://www.proquest.umi.com

Salter, R. B., McNeill, O. R., Carbin, R. (1965). The patholog-ical changes in articular cartilage associated with persis-tent joint deformity: An experimental investigation. Studiesof the Rheumatoid Disease. Third Canadian Conference onResearch in Rheumatic Diseases. Toronto, 33–47.

Temple, J. (2006). Care of patients undergoing knee re-placement surgery. Nursing Standard, 20(48), 48–56.Retrieved February 23, 2009, from the ProQuest Website: http://www.proquest.umi.com

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For more than 32 additional continuing nursing education articles on orthopaedic topics, go to nursingcenter.com/ce.

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