3 min read

Issue 40 Blue Crab Edition - Reduce Fear of Falling and Rethink Rotator Cuff Rehab

This week, we’re breaking down a meta-analysis of exercise programs to reduce fear of falling in neurologic disorders and rethinking how we approach rotator cuff rehabilitation. Also this week, care about animal rehab too? If you’re interested at all, check out this awesome episode from The Nagging Naturalist, who talks to an expert about rehabilitating box turtles: https://anchor.fm/the-nagging-naturalist/episodes/Box-Turtles-etirnm. Also, don’t take wild box turtles home! Please! They’re wild. Let them be.

With that out of the way, let’s dive in!

What reduces fear of falling?

The Gist - This piece from the Archive of PM&R broke down the best way to prevent fear of falling across neurologic diseases, coming up with recommendations for MS, SCI, stroke, and PD. All of the pooled studies involved showed small, but clinically significant effects. And here’s the headline: balance training alone was not effective in reducing fear of falling in PD, SCI, or MS. Wowsers. What was? In PD, stretching combined with treadmill training was best. MS? Leisure exercise and cycling combined with balance training did well. SCI? VR training was our winner. This is another meta-analysis that goes deep with the cross-tabs, so check out the whole thing for a whole lot more.

Tell Me More - Aside from the specific interventions highlighted above, the vast majority of studies they covered in the systematic review showed almost no difference between specific training and “usual care” for fear of falling. Almost all the studies were balanced around the MCID. Some loped slightly above, some fell a bit below, but most of them were right around that target. The GRADE assessment of evidence didn’t show anything above low-to-moderate quality evidence across the categories as well. Most of what came out of this (for me) is a desire and exhortation for better, more complex RCTs designed to find treatments for fear of falling because we’re just not there yet.

I love cross tabs! Then you’ll like this paper.

Exercise for Rotator Cuff Rehab? Think Twice

The Gist - Not a research report, but a viewpoint here from JOSPT about rehabilitation for non-traumatic rotator cuff-related shoulder pain. Over the last few years, research has shown that nonsurgical management is the way (yay!), but these researchers are concerned that PTs rely too heavily on resistance exercise and don’t dig into the research to find the best approach. According to them, movement and strength deficits do characterize the disease, but improving shoulder strength does not always relieve pain and improve function. They cite a couple of studies saying that even strength gains from the prescribed resistance exercises aren’t too impressive, often clinically unimportant.

What do they recommend? Nothing, really. They stress that PTs should be approaching this type of shoulder pain as a complex, biopsychosocial problem, more like LBP. They’re not saying that resistance exercise shouldn’t be done, just that it should be integrated into a full program and dosed properly.

Tell Me More - There’s not a lot more beyond that, and it’s a short, two-page paper if you want to read the whole thing. They did have some alarming quotes for your consideration that I’ll pop down below, including their strongest argument, here:

Manual therapy, once a mainstay of nonsurgical management of RCRSP, has not stood the test of rigorous trials. Many proponents of, “You only need to get strong” may suffer a similar demise, as the next-generation treatment approach, strength training, has not yet passed muster through rigorous clinical trials. Telling a person with RCRSP, “You are weak—all you need is to get stronger,” may be as counterproductive as telling the person, “You have poor posture, and it needs to be improved.” It is essential that clinical trials test modern strength and conditioning principles to establish the relationship between strength, function, and shoulder pain.

And the closer, here:

We are concerned that resistance exercise for managing RCRSP is at risk of use without critical thought in a classic recipe-based approach. Awkwardly, this is an illustration of the type of biomedical clinical reasoning the profession of physical therapy has spent the past 2 decades (or more) trying to avoid.

They make a strong case. Keep an open mind with your next rotator cuff patients and see where it leads you.

It’s just two pages, I’ll give it a read. Noice! Here you go. APTA members have full access to JOSPT, jsyk.


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