Episode 20 – Therapeutic Exercise – Decision Making

A patient two days post arthroscopy of the knee attempts to complete a quadriceps setting exercise while lying supine on a mat table. The patient attempts to perform the exercise twice unsuccessfully and reports that they experienced severe pain. Which of the following actions is the MOST appropriate for the physical therapist to take?

1. Have the patient perform the exercise in sidelying
2. Have the patient flex the knee prior to initiating the exercise
3. Place a pillow under the ankle
4. Discontinue the exercise

Welcome back to the Scorebuilders’ Question and Answer Podcast! This podcast provides members of the Scorebuilders’ team with the opportunity to explore challenging multiple-choice examination questions with students actively preparing for the licensing examination. My name is Scott Giles and I will be your host for today’s journey.

Ready? Let’s go!

A patient two days post arthroscopy of the knee attempts to complete a quadriceps setting exercise while lying supine on a mat table. The patient attempts to perform the exercise twice unsuccessfully and reports that they experienced severe pain. Which of the following actions is the MOST appropriate for the physical therapist to take?

1. Have the patient perform the exercise in sidelying
2. Have the patient flex the knee prior to initiating the exercise
3. Place a pillow under the ankle
4. Discontinue the exercise

A quadriceps setting exercise requires the patient to perform an isometric contraction of the quadriceps muscle. The resistive activity places minimal stress on the knee compared to many other resistive activities and as a result is often utilized early in a post-operative program.

The fact that the patient experiences severe pain with this typically mild form of resistive exercise is significant even in cases where the patient is only a few days post arthroscopy.

It’s often challenging in an open-ended question like this to generate a specific answer without first examining the presented options. However, my initial thought would be to attempt to modify the activity in a manner that would clearly be more comfortable for the patient or to discontinue the exercise completely.

Let’s explore each of the options:

Option 1 - Have the patient perform the exercise in sidelying
Sidelying is often used to diminish the influence of gravity. However, in the described scenario, the patient is performing an isometric activity with the lower extremity supported. As a result, it’s unlikely that the modification would diminish the patient’s pain. In fact, it is more likely that the patient would experience more pain when performing the isometric exercise in sidelying. 

Option 2 - Have the patient flex the knee prior to initiating the exercise
Flexing the knee prior to initiating the exercise may decrease the patient’s discomfort if the discomfort is related to the knee being in an extended position. However, the question does not offer any direct evidence to support this hypothesis. 

Option 3 - Place a pillow under the ankle
Placing a pillow under the ankle would result in further extension of the knee. Given the patient’s relative acuity secondary to their post-operative status, this position would likely increase the patient’s pain.

Option 4 - Discontinue the exercise
Severe pain in a patient rehabilitating from a surgical procedure is an acceptable reason to immediately discontinue an exercise. If the intensity of the pain was markedly less, modifying the exercise would be a more desirable option. The intensity of the pain during the two attempts combined with the absence of information related to the cause of the pain makes discontinuing the exercise the most appropriate option. 

Remember, discontinuing the exercise does not mean that at some point in the patient’s rehabilitation program, the same exercise will not be used. Instead, it simply indicates that presently the exercise is not appropriate for the patient.

The correct answer is Option 4

Questions like this can be extremely challenging for many students since they tend to be somewhat subjective, relying on students to consider all of the presented information and then identify the best option. These questions are rarely slam dunks and instead require students to make informed decisions based on a preponderance of the presented evidence.

I find it extremely helpful in questions like this to closely inspect the all student data. It’s my favorite method to determine how mainstream a student’s thinking was compared to that of other candidates.

Let’s explore the all student data
13% of students selected Option 1, Have the patient perform the exercise in sidelying
16% of students selected Option 2, Have the patient flex the knee prior to initiating the exercise
11% of students selected Option 3, Place a pillow under the ankle
60% of students selected Option 4, Discontinue the exercise, the correct response

System Classification
This question is a Musculoskeletal System question which represents approximately 27% of all exam items.

Content Outline Classification
This question is an Intervention question which represents approximately 29% of all exam items.

Level Classification
This question is a Level 3 question since the question requires candidates to systematically analyze and often interpret information to determine an appropriate course of action. The questions tend to have some degree of subjectivity and candidates are required to assign varying degrees of importance to different variables. Remediation of Level 3 questions occurs by continuing to refine decision making processes when answering examination questions and differentiating between good, better, and best options.

Thanks for joining us on the Scorebuilders Q and A podcast! See you next week!

Watch the video version of this Q&A episode on YouTube – https://youtu.be/0kSVtLVhET4