Ep 179: Tackling apprehension after Bankart repair (part 1), with Marianne van Gastel & Karin Hekman

[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] to quality practice.

[00:00:12] I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical

[00:00:16] Therapy.

[00:00:17] It's great to have you listening today.

[00:00:22] Today I'm joined by two clinician researchers who helped lead a new rehabilitation guideline

[00:00:27] on managing apprehension with people who have had an anterior shoulder dislocation

[00:00:32] and bankout repair.

[00:00:34] Marianne Van Gastel is a specialist shoulder physiotherapist and manual therapist.

[00:00:39] She's also a clinical epidemiologist and is currently completing her PhD on the topic

[00:00:44] of anterior instability.

[00:00:46] Karen Heckman is a specialist shoulder physiotherapist and advanced clinical practitioner.

[00:00:52] She leads a multidisciplinary shoulder and elbow rehabilitation centre that's staffed

[00:00:56] by shoulder elbow physios, occupational therapists and psychologists.

[00:01:02] Over the next two episodes of JOSPT Insights, Marianne and Karen will take us through the

[00:01:07] rehabilitation guideline, explain what's new in shoulder rehabilitation and share

[00:01:12] their approaches to helping people feel confident to get back to the sports and

[00:01:16] recreation activities they love after shoulder dislocation.

[00:01:21] You can find a link to the guideline in today's show notes and while you're

[00:01:24] there, why not check out the link to the JOSPT and Young Athletes Hip Research

[00:01:29] Collaborative Webinar mini-series.

[00:01:31] The first webinar was on the 1st of May and the second is happening on the 5th of June.

[00:01:37] In these webinars you'll hear more from experienced clinician researchers including

[00:01:41] doctors Josh Heery, Joe Kemp, Kate Jokomson and Mike Ryman.

[00:01:46] Dr Lindsay Plass and Luke Kearney who both have lived experience of hip pain limiting

[00:01:51] their sporting careers will also join the webinars to bring that important athlete perspective.

[00:01:57] Okay, here's today's episode.

[00:02:00] Welcome to JOSPT Insights, Marianne and Karen.

[00:02:03] Thank you for having us.

[00:02:04] We are very excited to take part in your podcast.

[00:02:09] It's wonderful to hear from you both as senior experienced clinicians in shoulder

[00:02:15] rehabilitation and you've both been leaders in some very important new international

[00:02:20] guidelines for how to design rehabilitation for people after a bank art repair for

[00:02:26] traumatic shoulder dislocation.

[00:02:29] JOSPT published the rehab guideline at the end of April and listeners can find a

[00:02:34] link to the guideline in the show notes.

[00:02:37] We're going to take a dive into the rehabilitation guideline in a moment with

[00:02:40] both of you but first I would really like to take one step back and talk a

[00:02:46] little bit about anterior instability and dislocation.

[00:02:50] So Marianne, who are the types of patients you usually see in your clinical

[00:02:55] practice who are presenting with anterior instability?

[00:02:58] Male and between 16 and 30 years of age and most of the time they're involved in

[00:03:07] contact or collision sports like soccer which is very popular in the Netherlands.

[00:03:14] Or they're involved in other challenging overhead activities such as climbing,

[00:03:20] swimming, throwing sports or water polo.

[00:03:25] And since we live quite near to the coast in the western part of the Netherlands,

[00:03:31] we also see kite surfers who dislocate their shoulder during a fall during

[00:03:38] kite surfing.

[00:03:40] So Karin is it fair to say that these are typically younger more active populations?

[00:03:46] Yes it is and especially the young male patients.

[00:03:52] Today I was talking with my colleague about is it only males and no it's also

[00:03:58] females but it's like one out of three is a female.

[00:04:04] They're quite active, they want to sport.

[00:04:07] We don't really see the inactive young people with children's instability.

[00:04:13] We do see this children's instability but with the typical anterior traumatic

[00:04:18] instability that's mostly the young and active people.

[00:04:21] And for this consensus we only talk about the traumatic anterior instability and we

[00:04:28] do like instabilities is a more broad range of symptoms and presentations like

[00:04:35] you also have the posterior instability and the multi-directional instability.

[00:04:40] But this is not the type of instability we talk about in this consensus and it's

[00:04:45] only about traumatic anterior instability and then after bank cut repair.

[00:04:52] Yeah that's a really important note to put on this podcast that as you say

[00:04:57] anterior instability and traumatic.

[00:04:59] Now what are the typical approaches that you tend to use Karin when you're

[00:05:03] managing anterior instability?

[00:05:05] Okay well the last decade the intention to get a surgical anatomical

[00:05:10] repair becomes more and more the first choice of treatment where in the earlier

[00:05:15] days the patients were starting a conservative approach and then waited who

[00:05:20] was suffering recurrent instability and then they decide to choose whether or

[00:05:25] not to stabilize surgically.

[00:05:27] So now we know better that if you are young and active that the risk of

[00:05:32] recurrence is a lot higher when you follow a conservative treatment and

[00:05:37] especially when you dominant arm is involved and we also know that the last

[00:05:43] years we know more that if you suffer from kinesiophobia, if you've got some

[00:05:47] anxiety then the intention to get recurrence is higher.

[00:05:53] Lately we also know that a high SPADI score which is a patient related

[00:05:59] outcome measurement and a lack of immobilization after the acute event

[00:06:04] might also be associated with a recurrence.

[00:06:07] So then we intend to stabilize earlier and choose for immediate operation then

[00:06:16] try a conservative treatment first.

[00:06:19] Marianne what proportion of patients who are coming through your clinic

[00:06:24] would you see with surgery versus starting with rehabilitation like Karin

[00:06:29] talks about?

[00:06:29] Most people you're seeing also having surgery?

[00:06:32] No I think it's 50-50.

[00:06:36] I see both.

[00:06:37] I see patients having had a stabilizing operation but I definitely also see

[00:06:45] young people not having undergone surgery yet who have the preference of

[00:06:51] trying physical therapy in the first place.

[00:06:55] And let's before we move on to the rehabilitation guideline, I'm

[00:06:59] interested in what do we know about the prevalence of re-dislocation?

[00:07:05] Once someone's had a first traumatic dislocation they might have had

[00:07:09] surgery and or they've had a rehabilitation program, how likely is it

[00:07:13] for that anterior dislocation to happen again?

[00:07:17] So in our earlier paper from 2019 I think we saw that approximately 10% of

[00:07:26] the patients within 15 years have a real dislocation again and approximately

[00:07:36] I think correct me if I'm wrong around 20% experiences subluxations.

[00:07:43] So it's above 30% experience recurrent instability.

[00:07:51] After banked repair?

[00:07:52] After banked repair, yeah.

[00:07:54] And when patients are not operated or not having a banked repair the

[00:08:00] range of recurrence is higher.

[00:08:03] Now Corinne, can you tell us a little bit about what happens in the

[00:08:06] banked out repair?

[00:08:07] What does that surgical procedure look like and what is it aiming to do?

[00:08:12] Actually when you dislocate your shoulder there's a fairly high

[00:08:16] chance of your labral, your capsular labral complex to have been

[00:08:21] torn and what a banked repair is is that the capsule labral complex is

[00:08:26] resuched onto the glenoid rim which is the socket of the shoulder joint.

[00:08:34] So this is an anatomical repair.

[00:08:37] There is another type of surgery which is called the bony procedure and one

[00:08:43] of the bony procedures is for example a latargeia.

[00:08:47] This is where they choose to make a broader socket so they get a bone block

[00:08:54] of your scapula, coracoid process and then they have to conjoin tendons with

[00:09:00] it and they replace it onto the glenoid rim so it has a stability and

[00:09:06] a broader range of the socket to be that the ball is able to

[00:09:11] translate on a wider area.

[00:09:15] Thank you.

[00:09:15] I think that's a great starting point.

[00:09:17] So now let's talk about the rehabilitation guideline itself.

[00:09:21] Why did you think, Karin, that a consensus on managing apprehension in

[00:09:26] particular because that is part of the focus of this guideline,

[00:09:29] why was that needed?

[00:09:32] Yes, that's a very good question actually.

[00:09:34] This is always a good question if you start research that you have to

[00:09:38] ask yourself why am I doing this?

[00:09:40] Well, there was absolutely a reason for it and the reason for it is that

[00:09:46] late research is telling us that there's so many, there's a high

[00:09:50] prevalence of recurrence and we were wondering why is this?

[00:09:55] And people intend not to go back to sports, a lot of percent,

[00:09:59] over a high percentage of people do not intend to go back to sports

[00:10:03] and we were asking ourselves why is this?

[00:10:06] And then a good friend of ours and a colleague of ours, Ted from ESL,

[00:10:10] did a qualitative study amongst traumatic anterior instability patients

[00:10:14] and that showed us that these remaining, that the people that did not go

[00:10:20] back to sport were talking about a remaining feeling of insecureness

[00:10:25] and apprehension and they told us that they did not get enough attention

[00:10:30] during rehabilitation and they also reported that the specialist or

[00:10:35] the shoulder physiotherapist did not take their feeling of apprehension seriously.

[00:10:41] So therefore we found that a new approach in this post-operative

[00:10:46] rehabilitation should be considered and since the usual care guideline

[00:10:52] was made in 2010 by the ESSET, which was a very detailed

[00:10:58] and well documented guideline and it fitted for a long time

[00:11:03] as usual care after bank repare.

[00:11:05] But with this new insight we might address that apprehensive feeling more.

[00:11:11] Because of the lack, the feeling of the patients that we lacked attention

[00:11:17] for their apprehension and also our own feeling of this,

[00:11:24] what is this apprehension?

[00:11:25] What can we do about it?

[00:11:26] Because even if the patient has undergone a stabilizing surgery,

[00:11:32] the apprehension is quite often still present.

[00:11:35] So how do we treat this apprehension to get the patient going again

[00:11:44] and feeling less apprehensive?

[00:11:46] So that was why we had the intention of also asking the rest of the world,

[00:11:55] in our case, 11 European countries and also experts in the States on their opinion.

[00:12:03] What can we do if we think out of the box,

[00:12:07] if you have the opportunity to tell the rest of the world,

[00:12:12] what would you like to do about this apprehension?

[00:12:15] That was our intention and why we set up the stealthy study.

[00:12:21] And you also had patients involved in this study too, which is important.

[00:12:25] You talked about the genesis of the idea coming from the qualitative research

[00:12:30] and patients feeling like, hey, this is something that's important to me

[00:12:34] and it's not being addressed in a way that is meaningful,

[00:12:37] at least for me as a patient in practice.

[00:12:40] And you also incorporated patients into this consensus process.

[00:12:44] Can you tell us a little bit about that, Marianne?

[00:12:46] How did that work?

[00:12:47] And how did patients contribute to developing the consensus?

[00:12:52] We asked an amount of patients of their opinion,

[00:12:58] the activities or interventions that they had gone through in their rehabilitation.

[00:13:04] So we asked them simply to state which activity or intervention

[00:13:10] was the most effective for you to diminish your apprehension.

[00:13:16] They answered that question, of course.

[00:13:20] We were very happy to see that actually that was almost all of their suggestions

[00:13:27] or not suggestions, their opinion corresponded with the suggestions

[00:13:31] of the experts that participated in our studies.

[00:13:37] Yeah, I think it's that whole idea of patients as experts

[00:13:40] in their experience of the injury and the trauma and then the recovery.

[00:13:45] And as you say, it's nice when that experience and what patients are looking for

[00:13:50] is also aligning with what clinicians and other researchers

[00:13:54] as you involved in your consensus process are also thinking about.

[00:13:58] So Karin, the interventions that reached consensus finally

[00:14:02] in this multi-stage Delphi were education, range of motion,

[00:14:07] neuromuscular control, strength, kinetic chain,

[00:14:11] modified cognitive behavioural therapy and sports specific,

[00:14:15] first let's talk a bit about the neuromuscular control

[00:14:19] and the kinetic chain elements or domains here.

[00:14:23] How should our listeners think about approaching neuromuscular control

[00:14:28] and kinetic chain when they're designing rehabilitation programs?

[00:14:31] These topics like education, range of motion, neuromuscular control,

[00:14:35] kinetic chain strength, this is not new.

[00:14:38] This is usual care what we also address in the usual care.

[00:14:44] What is new is that the key focus throughout this whole guideline

[00:14:50] in these domains are all focusing on diminishing apprehension in every stage.

[00:14:58] So in Dutch we say it's the red thread of your rehabilitation.

[00:15:03] And consensus is reached not using a time-based progression,

[00:15:08] but more focusing on the individual treatment goals

[00:15:11] and clinical features focus on reduction of the symptoms of apprehension.

[00:15:16] And we divided this guideline into an immobilisation phase,

[00:15:20] an early protective phase, an intermediate phase and an advanced phase.

[00:15:25] And this rehabilitation should contain a tailor-made progression,

[00:15:29] individual based with the flexibility to change these exercising

[00:15:34] according to the symptoms of the patient.

[00:15:37] For example, if we talk about this neuromuscular control,

[00:15:41] if this patient is very anxious in a control movement

[00:15:46] in external rotation and abduction,

[00:15:49] the therapist can choose to put more focus on this

[00:15:52] and have more focus on this neuromuscular control

[00:15:55] in this typical mobility exercise.

[00:15:59] And when apprehension then is faded,

[00:16:02] you can choose to be more active doing strength exercises

[00:16:06] in the same range of motion.

[00:16:09] So the progression will start when apprehension fades.

[00:16:15] And this is with mobility and this is with neuromuscular control,

[00:16:18] this is with strength.

[00:16:20] So you can do the same movement with a focus on more speed

[00:16:25] if apprehension is presented less.

[00:16:29] So this is to build up all focus on diminishment of anxiety in this movement.

[00:16:35] Yeah, and that's it.

[00:16:36] I think it's a nice way to think about progressing as well,

[00:16:39] that you're monitoring that apprehension as you talk about

[00:16:42] and really watching to see what's happening is that

[00:16:44] when it's diminishing, then we can move forward.

[00:16:48] It sounds like a nice way to guide rather than thinking about,

[00:16:50] oh, what do I measure?

[00:16:51] Which questionnaires do I use?

[00:16:52] It's really focusing on the apprehension side of things.

[00:16:55] Yeah, in the usual care guideline,

[00:16:58] we focus more on a stated range of motion.

[00:17:01] So at six weeks, we want you to be at 50 degrees of abduction,

[00:17:06] like this, like this.

[00:17:07] And then in this guideline, we focus more on how do you feel?

[00:17:11] Does it feel safe?

[00:17:13] Is the coordination in your neuromuscular control OK?

[00:17:17] Then we can move on.

[00:17:19] We can do it quicker.

[00:17:20] We can do with more strength.

[00:17:22] We can integrate kinetic chain activities and so on.

[00:17:27] You work to the more sport specific area.

[00:17:29] If somebody is not progressing,

[00:17:31] we start also in this new rehabilitation guideline

[00:17:36] with early patient education on, for example,

[00:17:41] the negative impacts of psychosocial factors,

[00:17:45] such as stress and anxiety,

[00:17:48] the effect it has on the healing process.

[00:17:51] And also there's focus on the nature of apprehension.

[00:17:56] What is apprehension?

[00:17:58] For example, just talking about the feeling of apprehension

[00:18:02] already gives acknowledgement of the anxiety.

[00:18:08] Also, we think it's important to explain the difference

[00:18:12] between apprehension being triggered by instability

[00:18:17] versus apprehension being triggered by your memory

[00:18:21] of the trauma or dislocation itself.

[00:18:25] So an instability induced apprehension

[00:18:29] versus a memory induced apprehension.

[00:18:32] Because sometimes the apprehension

[00:18:35] of the apprehensive feeling

[00:18:37] does not mean that the shoulder is unstable in itself.

[00:18:42] It can also be that the symptoms you feel,

[00:18:46] a stretchy feeling in the shoulder during exercises,

[00:18:50] that that triggers your memory

[00:18:52] of the trauma you have gone through.

[00:18:56] And that is what makes you really anxious again.

[00:19:00] Please join us next week for part two

[00:19:03] of the Rehabilitation Guideline Chat

[00:19:05] when Marianne and Karin focus

[00:19:07] on the high level progressions back to sport.

[00:19:10] We also talk about how they incorporate

[00:19:12] the principles of cognitive behavioural therapy

[00:19:14] into their clinical practise

[00:19:16] to help people reframe their anxieties

[00:19:18] about re-dislocating their shoulder.

[00:19:20] It's a great listen, so don't miss it.

[00:19:27] Thanks for listening to this episode of JOSPT Insights.

[00:19:30] For more discussion of the issues

[00:19:32] in musculoskeletal rehabilitation

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