MPT Therapeutic Exercise and Functional Rehabilitation 2 — Questions and Answers
Question 1: A patient is 6 weeks post total knee arthroplasty (TKA). They have full passive knee extension and 95 degrees flexion. The primary rehabilitation goal at this stage is:
- Return to running
- Achieving 120 degrees flexion, independent stair climbing, and safe community ambulation (Correct answer)
- Initiating aquatic therapy only
- Discontinuing all strengthening exercises
Correct answer: Achieving 120 degrees flexion, independent stair climbing, and safe community ambulation
At 6 weeks post-TKA, goals include achieving functional ROM (greater than 120 degrees for most ADLs), independence with functional mobility (stairs, transfers), and reducing pain and swelling.
TKA rehabilitation milestones: Week 1-2: ambulation with assistive device, 90 degree flexion goal, DVT precautions. Week 3-6: wean assistive device, stair training, ROM toward 110 degrees. Week 6-12: community ambulation, stair reciprocal pattern, ROM goal 120 degrees or greater (needed for rising from low chairs, climbing stairs). Long-term: return to low-impact recreational activities (golf, cycling, swimming). PTs document ROM progress, functional mobility, and pain with standardized tools (KOOS, WOMAC). Evidence supports early mobilization and home PT as equivalent to inpatient rehabilitation for uncomplicated TKA.
Question 2: Which term describes resistance training in which the muscle lengthens while producing force against an external load?
- Concentric contraction
- Isometric contraction
- Eccentric contraction (Correct answer)
- Isokinetic contraction
Correct answer: Eccentric contraction
Eccentric contractions occur when the external load exceeds the muscle force, causing the muscle to lengthen while still producing tension (e.g., lowering a weight, descending stairs).
Muscle contractions: Concentric = muscle shortens, force greater than load. Isometric = muscle maintains length, force equals load. Eccentric = muscle lengthens, load greater than force. Isokinetic = constant velocity throughout ROM. Eccentric training is crucial in PT because it produces greater force per motor unit, causes more muscle damage and DOMS (important for tendon remodeling), and is the primary mechanism of injury in muscle strains. Heavy-load eccentric training (Alfredson protocol for Achilles tendinopathy, reverse Nordic for hamstring injuries) is evidence-based for tendinopathy rehabilitation.
Question 3: Which balance training progression is most appropriate for an elderly patient at high fall risk who currently requires bilateral upper extremity support for standing?
- Begin with dynamic balance training on foam surfaces
- Progress from bilateral UE support to unilateral UE support to fingertip support to no support while standing on a firm surface (Correct answer)
- Immediately practice tandem walking
- Start with treadmill walking at 2.0 mph
Correct answer: Progress from bilateral UE support to unilateral UE support to fingertip support to no support while standing on a firm surface
Fall prevention balance training follows a systematic progression from maximum support (bilateral UE) to reduced support (unilateral, fingertip), on stable surfaces before progressing to unstable surfaces.
Balance rehabilitation follows the principles of progressive challenge within the patient's stability limits. The progression: bilateral to unilateral UE support; eyes open to eyes closed (removing visual compensation); firm to compliant surfaces (foam, rocker boards); static to dynamic activities. The OTAGO program, Tai Chi, and stepping exercises are evidence-based fall prevention interventions for older adults. PTs use validated balance tools (Berg Balance Scale, Timed Up and Go, Functional Gait Assessment) to identify fall risk and measure outcomes. Patients with BBS score less than 45 have significantly elevated fall risk.
Question 4: Reactive neuromuscular training (RNT) in therapeutic exercise is best described as:
- Electrical stimulation applied during exercise to facilitate weak muscles
- External perturbations that facilitate appropriate motor responses and enhance neuromuscular control (Correct answer)
- Passive ROM performed by the therapist to improve joint mobility
- Proprioceptive taping to restrict abnormal movement patterns
Correct answer: External perturbations that facilitate appropriate motor responses and enhance neuromuscular control
RNT uses external perturbations (band resistance, manual force) to accentuate an error and facilitate the patient's automatic corrective neuromuscular response, training the nervous system to self-correct.
Reactive neuromuscular training uses sensory perturbations to facilitate automatic motor corrections. For example, a band pulling the knee into valgus during a squat automatically triggers hip abductor and external rotator activation to resist the perturbation. This approach trains movement patterns at a subconscious level, improving functional stability. RNT is used for ACL rehabilitation, ankle instability, and movement pattern dysfunction. It differs from deliberate motor training (conscious correction) by training automatic, reflexive neuromuscular responses.
Question 5: According to the Cyriax model of orthopedic assessment, a capsular pattern of the hip joint presents as:
- Equal limitation of all hip movements
- Greatest limitation in hip flexion, then abduction, then internal rotation
- Greatest limitation in hip internal rotation, followed by abduction, then flexion (Correct answer)
- Greatest limitation in hip extension with full internal rotation
Correct answer: Greatest limitation in hip internal rotation, followed by abduction, then flexion
Cyriax capsular pattern for the hip is: most limited in internal rotation, then abduction, then flexion. This pattern indicates intra-articular hip pathology (osteoarthritis, capsular fibrosis).
Cyriax described capsular patterns as proportional restrictions suggesting joint capsule involvement. Hip capsular pattern: internal rotation greater than abduction greater than flexion (with extension and adduction relatively preserved). This pattern is classic for hip osteoarthritis and capsular fibrosis. Non-capsular patterns (limited only in one plane) suggest non-capsular structures (ligament sprain, muscle contracture, bursitis). The shoulder capsular pattern is external rotation greater than abduction greater than internal rotation. Knowledge of capsular patterns guides PT diagnosis of joint pathology and mobilization planning.
Question 6: Plyometric training is most appropriate at which stage of rehabilitation following a lower extremity injury?
- Immediately post-surgery to maintain neural drive
- When the patient has achieved greater than 90% limb symmetry index on strength tests and passed criteria-based functional tests (Correct answer)
- When pain is completely absent during all daily activities
- At 6 weeks post-surgery regardless of strength level
Correct answer: When the patient has achieved greater than 90% limb symmetry index on strength tests and passed criteria-based functional tests
Plyometric training should begin when the patient has achieved greater than 90% limb symmetry on strength tests (typically single-leg hop, triple hop), acceptable pain levels, and full functional ROM.
Plyometric readiness criteria post-ACL reconstruction typically include: greater than 90% limb symmetry index on quadriceps and hamstring strength; single-leg hop test greater than 90% symmetry; pain 2 or less out of 10 during all activities; adequate neuromuscular control (single-leg squat, landing mechanics). Plyometric progression follows a volume-intensity matrix: beginning with low-intensity bilateral jumps, progressing to unilateral, reactive, and sport-specific drills. Premature plyometric loading increases re-injury risk. Time-based criteria alone (6-month rule) is insufficient — criteria-based clearance is evidence-based best practice.
MPT Therapeutic Exercise and Functional Rehabilitation 2
A patient is 6 weeks post total knee arthroplasty (TKA).
They have full passive knee extension and 95 degrees flexion.
The primary rehabilitation goal at this stage is: