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Background:  Continuous passive motion (CPM) is frequently used during rehabilitation following total knee arthroplasty (TKA). Low-load resistance training (LLRT) using continuous active motion (CAM) devices is a promising alternative. We investigated the effectiveness of CPM compared to LLRT using the affected leg (CAMuni) and both legs (CAMbi) in the early post-operative rehabilitation. Hypotheses: (I) LLRT (CAMuni and CAMbi) is superior to CPM, (II) additional training of the unaffected leg (CAMbi) is more effective than unilateral training (CAMuni).   Materials and Methods:  Eighty-five TKA patients were randomly assigned to three groups, respectively: (i) unilateral CPM of the operated leg; (ii) unilateral CAM of the operated leg (CAMuni); (iii) bilateral alternating CAM (CAMbi). Patients were assessed 1 day before TKA (pre-test), 1 day before discharge (post-test), and 3 months post-operatively (follow-up). Primary outcome: active knee flexion range of motion (ROM Flex ). Secondary outcomes: active knee extension ROM (ROM Ext ), swelling, pain, C-reactive protein, quality of life (Qol), physical activity, timed-up-and-go performance, stair-climbing performance, quadriceps muscle strength. Analyses of covariances were performed (modified intention-to-treat and per-protocol).   Results:  Hypothesis I: Primary outcome: CAMbi resulted in a higher ROM Flex  of 9.0° (95%CI −18.03–0.04°,  d  = 0.76) and 6.3° (95%CI −14.31–0.99°,  d  = 0.61) compared to CPM at post-test and follow-up, respectively. Secondary outcomes: At post-test, C-reactive protein was lower in both CAM groups compared with CPM. Knee pain was lower in CAMuni compared to CPM. Improved ROM Ext , reduced swelling, better stair-climbing and timed-up-and-go performance were observed for CAMbi compared to CPM. At follow-up, both CAM groups reported higher Qol and CAMbi showed a better timed-up-and-go performance. Hypothesis II: Primary outcome: CAMbi resulted in a higher knee ROM Flex  of 6.5° (95%CI −2.16–15.21°,  d  = 0.56) compared to CAMuni at post-test. Secondary outcomes: At post-test, improved ROM Ext , reduced swelling, and better timed-up-and-go performance were observed in CAMbi compared to CAMuni.   Conclusions:  Additional LLRT of the unaffected leg (CAMbi) seems to be more effective for recovery of function than training of the affected leg only (CAMuni), which may be mediated by positive transfer effects from the unaffected to the affected limb (cross education) and/or preserved neuromuscular function of the trained, unaffected leg.   Trial Registration:   ClinicalTrials.gov  Identifier: NCT02062138.

frontiers in medicine

Low-Load Unilateral and Bilateral Resistance Training to Restore Lower Limb Function in the Early Rehabilitation After Total Knee Arthroplasty: A Randomized Active-Controlled Clinical Trial