Ep 180: Tackling apprehension after Bankart repair (part 2), 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.

[00:00:11] 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 Specialist shoulder physiotherapists Marianne van Gestel and Karin Heckman

[00:00:27] are back on JOSPT Insights.

[00:00:29] We've got the second half of our chat about their rehabilitation guideline for managing

[00:00:33] apprehension with people with shoulder dislocation and bank art repair.

[00:00:39] In today's episode we focus on supporting patients to return to high levels of function,

[00:00:44] including sport after their shoulder surgery.

[00:00:47] Marianne and Karin share how they use a psychologically informed practice type of

[00:00:51] approach to support athletes and patients to work through and overcome anxiety and

[00:00:56] apprehension.

[00:00:58] You'll find a link to the rehabilitation guideline in the show notes.

[00:01:01] And don't forget about the second Young Athletes Hip Research Collaborative JOSPT

[00:01:06] mini webinar with speakers Drs Jo Kemp, Lindsay Plass and Mike Ryman.

[00:01:11] It's coming up on the 5th of June and you'll find more details in the show

[00:01:15] notes.

[00:01:16] Okay, here's today's episode.

[00:01:19] One of the other topics in your consensus is cognitive behavioural therapy or modified

[00:01:25] cognitive behavioural therapy.

[00:01:27] And it sounds like the education piece could also link quite closely with the modified

[00:01:33] cognitive behavioural therapy.

[00:01:34] Can you tell us a little bit about how modified cognitive behavioural therapy comes into

[00:01:39] your rehabilitation guide?

[00:01:41] The cognitive behavioural therapy, it's quite an interesting thing because it's

[00:01:47] not typical for physiotherapists to do psychological intervention.

[00:01:52] This is why we called it modified because it's not we're not psychologists, right?

[00:01:57] But it is a acknowledgement for this patient about that it is essential to create

[00:02:04] awareness of the relationship between cognition or their understanding and behaviour

[00:02:11] and apprehension.

[00:02:12] So if your thoughts about the feeling are instability, for example, the trauma

[00:02:20] had been in external rotation, abduction while throwing a ball, then if you have

[00:02:28] an apprehensive feeling after your operation in this same activity, then your

[00:02:35] cognition might say, well, this is still unstable because I get the same feelings

[00:02:40] and it gives me anxiety and I don't want to do that.

[00:02:42] So that gives me a behaviour of avoiding that function and avoiding the function

[00:02:49] makes the apprehension worse because you avoid an area where you need to train in

[00:02:55] to get more stable because you want your rotator cuff to recruit in that area of

[00:03:01] throwing.

[00:03:02] But if you don't go there, you will never train it.

[00:03:05] So it's an understanding that there is a visual loop, a vicious circle.

[00:03:10] Sorry, it's not visual.

[00:03:11] It's a vicious circle of your cognition, your behaviour and this apprehension.

[00:03:18] And if you talk about that and you give them their understanding, this is part of

[00:03:23] that cognitive behavioural therapy to go to that position and see this is what you

[00:03:29] feel. And does it feel unstable?

[00:03:31] And said no, but it's very anxious to be there.

[00:03:34] OK, then just be there and try to relax in this position.

[00:03:38] And let's do it again and try to be there and go there all the time.

[00:03:42] So, for example, they give them a ball in this abduction external rotation position

[00:03:49] and go there and let them become more comfortable.

[00:03:52] And then after a while, they realise that they shouldn't avoid that area because

[00:03:57] there's nothing happening.

[00:03:59] So in function, trying to get more comfortable.

[00:04:03] I think it's indeed a question of making the through a graduate build up,

[00:04:09] confronting the patient with this feeling of apprehension, building up, trying to

[00:04:15] distract the patient sometimes, but still building up towards the more scary

[00:04:23] movements. And that is for all patients different which trauma mechanism they've

[00:04:31] had. So that's again really tailoring your rehabilitation.

[00:04:38] See, what does this particular patient find scary to do?

[00:04:44] Is this approach something that you only do in the clinic with the patient or are

[00:04:49] you sending the person home with homework exercises that they're doing as part of

[00:04:54] your cognitive or modified cognitive behavioural therapy approach?

[00:04:58] Yeah, definitely.

[00:05:00] We definitely do that because that is it's definitely not enough.

[00:05:05] Have them work once, two times a week with us in the clinic.

[00:05:11] They need to do this at home, exercise on a daily basis to diminish this

[00:05:18] apprehension. You need to exercise a lot and also exercise in a lot of

[00:05:26] different positions around if you say the arbor, the external rotation

[00:05:32] abduction movement where a lot of people feel apprehensive of our patients

[00:05:37] feel apprehensive. So different movements in and around that area that feels

[00:05:44] more or less threatening. But the use of a ball with the use of kinetic

[00:05:53] chain exercises, they can do a lot of different exercises at home.

[00:05:58] I was just thinking about a patient I had a couple of years ago where we

[00:06:04] gradually build up the strength and the mobility and this kinetic chain.

[00:06:08] And he had a very good range of motion.

[00:06:11] He had an equal left right strength and perfect control and very strong in

[00:06:17] his kinetic chain. So he was about to stop and to restart to the sport.

[00:06:22] And then we asked him, would you like to play football again?

[00:06:25] How ready are you to play football again?

[00:06:27] And then he said, Oh no, I'm not going to play football.

[00:06:29] So why not? Well, well, he couldn't describe it.

[00:06:33] Then we started more sport specific and we weren't ready yet.

[00:06:37] But the sport specific part for him was to throw a ball from the

[00:06:42] sideline into the field.

[00:06:45] And when we tried asked him to do that, he said, well, I cannot do

[00:06:49] that. And I said, why can you not do that?

[00:06:51] You've got the range of motion. You've got the strength.

[00:06:53] You've you're you're strong in your legs.

[00:06:55] You're strong in your core.

[00:06:57] What? Well, this was my trauma in the last time the shoulder went out of

[00:07:03] socket was while throwing a ball into the field and we didn't address that

[00:07:08] yet. He could do it, but he never did.

[00:07:12] So I was anxious to do it.

[00:07:13] So when I had done this before and then I started in a in a far earlier

[00:07:19] phase addressing that feeling, then he would not have a problem at the end.

[00:07:24] Now, I'm thinking we should talk a little bit about the sport specific

[00:07:28] part of it. And you've given us a really nice lead in there, Karen.

[00:07:32] So can you tell us a bit more about the sport specific topic or the

[00:07:36] sport specific domain of interventions that's in the in the

[00:07:39] consensus statement?

[00:07:40] Actually, there is also individual based because you're not treating

[00:07:47] the tennis player the same as the swimmer.

[00:07:50] In a very early stage, you already address the abilities he needs to

[00:07:56] have for playing tennis and the abilities he needs to have for

[00:08:01] for for swimming or boss crawl or whatever he needs to do in an

[00:08:07] early phase in rehabilitation.

[00:08:09] You start building up these sports specific capacities.

[00:08:13] For example, the swimmer, you do more exercises lying on a gym ball

[00:08:17] like they are lying in the water.

[00:08:20] And tennis player you challenge more on balance work and lower

[00:08:24] extremity and speed with ball exercises.

[00:08:28] Also, I think it's very good to already do in a very early stage

[00:08:34] contact talk about the context of the sport and also try to contact

[00:08:40] the coach to combine the specific training exercises in the last bit of

[00:08:45] your rehabilitation to optimize this return to sport.

[00:08:49] Yeah, you really have to look at the type of sports and the

[00:08:53] capacities they need for that.

[00:08:55] Marianne, how long does this period tend to last?

[00:08:59] I know we're not stuck.

[00:09:01] We're not sticking to particular timelines.

[00:09:04] Roughly, how long are you spending in this sport specific

[00:09:08] interventions area before you feel like this person's ready to go

[00:09:12] back to unrestricted sport and they're going to do well?

[00:09:16] Very much depending on the patient.

[00:09:19] And I must say that with these very often young men, sometimes

[00:09:27] they believe that they're ready for sport before I do.

[00:09:33] And sometimes they stop the rehabilitation on own initiative

[00:09:41] because they are very enthusiastic.

[00:09:44] So sometimes they're ready before I am.

[00:09:48] And it very much depends on the level of sport and on which type of sport.

[00:09:56] And also we start very early actually in the rehabilitation with

[00:10:02] which sports like interventions where we try to mimic the

[00:10:09] motions that they need to make in their own sport.

[00:10:13] So when does the sport specific phase start and end?

[00:10:18] Yeah, the end is clear, but where it starts is sometimes a bit more vague.

[00:10:23] About the starting point, what I like to do is when they have

[00:10:29] their arm in a sling and they cannot do, they intend to lose

[00:10:34] their endurance and their general stamina.

[00:10:38] So I really like to get them going with the arm in a sling and do all kinds of

[00:10:44] sport, sport specific lower extremity exercises, like jumps and squats and

[00:10:49] lunches.

[00:10:50] And I also, if they are overhead throw, then I'd like to do this

[00:10:57] exercise with the other arm, the non-involved arm, like throwing in

[00:11:02] a trampoline while standing on one leg in a very, very early phase.

[00:11:06] So they already get their mind on going back in this function.

[00:11:13] And it really works during cross education, cerebral stimulation.

[00:11:19] Now we're just about to the end of the podcast.

[00:11:21] So I would really like to hear from both of you.

[00:11:24] What are the main messages or the main pearls of clinical wisdom that

[00:11:29] you would like to share with our listeners today?

[00:11:32] To get them more confident.

[00:11:36] That I think that is the most thing, the most important thing to get somebody

[00:11:41] confident again in moving this confidence is needs a lot of coaching.

[00:11:49] And this coaching is you as a physio.

[00:11:52] If you do this with a lot of fun and if you do this with a lot of playing

[00:11:56] around and talking about it, that anxiety is okay to have.

[00:12:02] And that everybody has this anxiety on a different level.

[00:12:05] Maybe it's normal and that it will fade away once you address it.

[00:12:10] And when she talk about it, don't focus too much on range of motion.

[00:12:14] Don't focus too much on strength.

[00:12:16] Let the control be first.

[00:12:18] Neuromuscular control and kinetic chain are the most important things

[00:12:21] to address and then fun and confidence will come itself.

[00:12:27] Having fun while training is really important.

[00:12:31] And also not being afraid of training in the positions where

[00:12:38] the patient is being fearful.

[00:12:40] I think it's really important to dare to go there with the patient,

[00:12:46] to search for the more instable areas to get rid of this fear,

[00:12:53] to tackle the fear by building up slowly, finding confidence and

[00:12:59] daring using this range of motion again.

[00:13:03] So many wonderful pearls of clinical wisdom there.

[00:13:06] Thank you both for joining me on JOSPT Insights.

[00:13:09] Marianne van Gastel and Karen Heckman.

[00:13:12] It's been great to chat with you today.

[00:13:14] Thank you very much.

[00:13:15] Thank you very much, Claire.

[00:13:20] Thanks for listening to this episode of JOSPT Insights.

[00:13:23] For more discussion of the issues in musculoskeletal rehabilitation that

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