Journal of Sport Rehabilitation, 2015, 24, 434 -439 http://dx.doi.org/10.1123/jsr.2014-0196 © 2015 Human Kinetics, Inc.
CRITICALLY APPRAISED TOPIC
Kinesiophobia After Anterior Cruciate Ligament Reconstruction in Physically Active Individuals Arika L. Cozzi, Kristina L. Dunn, Josie L. Harding, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon Clinical Scenario: There are approximately 200,000 anterior cruciate ligament (ACL) tears reported annually in the United States. Patients who undergo ACL reconstruction followed by an aggressive rehabilitation protocol can often structurally and functionally progress to a preinjury level. Despite physical improvements with ACL-rehabilitation protocols, however, there are still a substantial number of individuals who do not return to preinjury level, particularly physically active individuals, of whom only 63% return to their full potential preinjury level. This may be due to continued pain, swelling, stiffness, and weakness in the knee. In addition, research concerning the topic of kinesiophobia (ie, fear of reinjury), which may prevent individuals from returning to their activities, has increased over the past several years. Kinesiophobia is defined as the irrational or debilitating movement of physical activity resulting in the feeling of vulnerability to painful injury or reinjury. Kinesiophobia may have a significant impact on physically active individuals, considering the proportion of patients who do not return to their sport. However, it is unknown whether kinesiophobia is associated with patients’ perceived physical-impairment levels after ACL reconstruction. Focused Clinical Question: Is kinesiophobia associated with self-perceived levels of knee function after ACL reconstruction? Keywords: fear of reinjury, psychological, knee, outcomes, Tampa Scale of Kinesiophobia
Clinical Scenario There are approximately 200,000 anterior cruciate ligament (ACL) tears reported annually in the United States. 1 Patients who undergo ACL reconstruction followed by an aggressive rehabilitation protocol can often structurally and functionally progress to a preinjury level. 2 Despite physical improvements with ACL-rehabilitation protocols, however, there are still a substantial number of individuals who do not return to preinjury level, particularly physically active individuals, of whom only 63% return to their full potential preinjury level.3 This may be due to continued pain, swelling, stiffness, and weakness in the knee. In addition, research concerning the topic of kinesiophobia (ie, fear of reinjury), which may prevent individuals from returning to their activities, has increased over the past several years. Kinesiophobia is defined as the irrational or debilitating movement of physical activity resulting in the feeling of vulnerability to painful injury or reinjury.4 Kinesiophobia may have a significant impact on physically active individuals, considering the proportion
The authors are with the Athletic Training Programs, A.T. Still University, Mesa, AZ. Address author correspondence to Cailee Welch Bacon at [email protected].
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of patients who do not return to their sport. However, it is unknown whether kinesiophobia is associated with patients’ perceived physical-impairment levels after ACL reconstruction.
Focused Clinical Question Is kinesiophobia associated with self-perceived levels of knee function after ACL reconstruction?
Summary of Search, Best Evidence Appraised, and Key Findings • The literature was searched for studies of level 3 evidence or higher pertaining to self-perceived levels of knee function associated with kinesiophobia after ACL reconstruction. • The literature search returned 9 possible studies related to the clinical question; 3 studies2,5,6 met the inclusion criteria and were included. • The studies suggested that better knee function is associated with lower kinesiophobia levels. Decreasing kinesiophobia levels are associated with the improvement of self-reported knee function during daily activities with increased progression of ACL rehabilitation.2,5,6
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• Kinesiophobia levels are higher early after ACL rupture, and psychological interventions aimed to decrease fear of reinjury need to be warranted and further researched.2,5
• Ovid • MEDLINE/PubMed • CINAHL • Additional resources obtained via review of reference lists and hand search
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Clinical Bottom Line There is moderate evidence to support that kinesiophobia is associated with self-perceived knee function after ACL reconstruction. It has been demonstrated that there is a relationship between kinesiophobia and activity restriction, knee instability, and/or self-reported knee function.2 Along with knee pain and function, kinesiophobia has been identified as a detriment to return to participation after ACL reconstruction.2,5–10 Therefore, clinicians should be cognizant that kinesiophobia may explain any potential discrepancies between generally favorable International Knee Documentation Committee (IKDC) scores, Knee Outcome Survey Activities of Daily Living (KOS-ADL) scores, or clinician-based outcomes and poor return-to-play rates.2–5 To ensure that clinicians are providing optimal whole-person, patient-centered care, it is essential to assess kinesiophobia, particularly among physically active individuals who aspire to return to activity after ACL reconstruction. Incorporating a patient-reported outcome (PRO) instrument such as the Tampa Scale of Kinesiophobia (TSK-11) to assess kinesiophobia can assist clinicians during the clinical decision-making process by providing a better understanding of psychosocial factors that may affect successful recovery and return to activity. Strength of Recommendation: Due to the results and the moderate consistency of the studies reviewed, there is grade B evidence to support the idea that kinesiophobia is associated with self-perceived levels of knee pain and function after ACL reconstruction.
Search Strategy Terms Used to Guide Search Strategy • Patient/Client group: physically active individual and ACL reconstruction • Intervention/Assessment): kinesiophobia or fear of reinjury, and knee pain or knee function, ACL reconstruction • Comparison: Not applicable • Outcomes: Tampa Scale of Kinesiophobia-11 or TSK-11, International Knee Documentation Committee form or IKDC, and Knee Outcome Survey Activities of Daily Living or KOS-ADL
Sources of Evidence Searched • The Cochrane Library • EBSCO • Clinical Key
Inclusion and Exclusion Criteria Inclusion Criteria • Level 3 evidence or higher • Studies that investigated kinesiophobia (TSK-11) and self-reported knee function (as measured by the IKDC or KOS-ADL) after ACL reconstruction • Limited to English language • Limited to the past 10 years (2004–2013)
Exclusion Criteria • Studies that included participants that did not undergo ACL reconstruction • Studies that investigated fear avoidance via the FearAvoidance Belief Questionnaire • Studies that did not include a knee-specific PRO instrument to measure knee function after ACL reconstruction
Results of Search Three relevant studies2,5,6 were located and categorized as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2011).
Best Evidence The studies in Table 2 were identified as the best evidence and selected for inclusion in this critically appraised topic (CAT). These studies were selected because they were considered level 3 evidence or higher and investigated whether kinesiophobia is associated with knee-specific quality of life among physically active individuals after ACL reconstruction. Table 1 Summary of Study Designs of Articles Retrieved Level of evidence
Study design
Number located
2
Longitudinal cohort study
1
Hartigan et al4
3
Prospective longitudinal
1
Chmielewski et al5
3
Cross-sectional survey
1
Chmielewski et al6
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Reference
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Hartigan et al4
Longitudinal cohort
Patients with ACL surgery. This was a secondary analysis of data from 2 longitudinal studies. 132 patients (79 noncopers, 53 potential copers) met the inclusion criteria. Of those, 111 (61 noncopers. 50 potential copers) completed the TSK-11. Inclusion Criteria: 13–55 y of age, unilateral ACL rupture confirmed with MRI and at least a 3-mm side-to-side difference in anterior knee laxity determined with a knee arthrometer, regularly participated (more than 50 h/y) in level 1 or 2 sports (jumping, cutting, pivoting, and lateral movements) before surgery and desired to return to a level 1 or 2 sport, ACLR, TSK-11 scores collected at least once. Exclusion Criteria: bilateral injury, concomitant injury (eg, other ligamentous injury of grade 3, full-thickness chondral defect of greater than 1 cm2), concomitant surgery that required a modified rehabilitation protocol (eg, meniscal repair or articular cartilage microfracture), pregnancy, previous knee surgery.
Data were collected at 4 times: before preoperative treatment, after a preoperative treatment, 6 mo after ACLR, and 12 mo after ACLR. Data collected included a quadriceps strength index, 4 single-leg hop tests, and self-reported questionnaires rating daily knee function.
The Knee Outcome Survey activities of daily living subscale, global knee function (global rating scale), and the TSK-11 were administered.
Study
Design
Participants
Intervention investigated
Outcome measures
Table 2 Characteristics of Included Studies
(continued)
TSK-11, IKDC, and SF-8 were administered to investigate the general quality of life in the physical and mental domains.
When the TSK-11, IKDC, and the SF-8 were administered, the ACLR patients completed the questionnaires and were scored to investigate pain related to fear, knee symptoms, and functional limitations and to look at the patients’ overall physical and mental well-being.
Data were collected at 4 times after surgery (baseline and 4, 8, and 12 wk). Demographic information was collected at initial visit only. Self-report questionnaires for knee-pain intensity, psychosocial constructs, and knee function were administered at all 4 times using a numeric rating scale (NRS), the IKDC-SKF, the TSK-11, and the SER. Self-report questionnaires for average knee-pain intensity (NRS), IKDC-SKF, TSK-11, SER.
Cross-sectional survey Patients with a unilateral, primary, isolated, and acute ACLR. Total of 97 participants: 60 males and 37 females. Participants were separated into 3 groups based on time from surgery to completed questionnaire. Group 1: ≤90 d (n = 39), 25 males and 14 females age 26.3 ± 9.2 y. 14 participants received an autograph and 25 were allograph. Injury-to-surgery time was 89.9 ± 70.4 d. Time from surgery to questionnaire was 42.8 ± 24.1 d. Group 2: 91–180 d (n = 31), 15 males and 16 females age 25.3 ± 11 y. 12 participants received autograph and 19 received autograph. Injury-to-surgery time was 75.7 ± 65.5 d. Time from surgery to questionnaire was 147 ± 33.1 d. Exclusion Criteria: bilateral injury, concomitant injury, concomitant surgery that required a modified rehab protocol, previous knee surgery, time from injury to surgery >365 d, or time from surgery to questionnaire completion >372 d.
Prospective, longitudinal
Chmielewski et al6
Patients with an ACL reconstruction who began rehabilitation. 97 participants enrolled in the study. Of those, only 77 participated in all testing sessions: 41 males, 36 females (22.4 ± 7.1 y). 21 contact, 56 noncontact, 38 autograft, 39 allograft, 70 sports, 7 nonsport, 38 with accompanying surgical procedures, 39 without, 11 with previous knee injury, 66 without. Inclusion criteria: unilateral ACLR, age 15–45 y, time from injury to surgery ≤12 mo. Exclusion Criteria: bilateral injury, concomitant ligamentous injury greater than grade 1.
Chmielewski et al5
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N/A
Noncopers showed greater kinesiophobia on the TSK-11 during presurgery evaluation. Noncopers tended to show a greater decrease in kinesiophobia postsurgery than those who were considered potential copers. Kinesiophobia levels remained high even up to 6 mo postsurgery. These levels typically decreased 6–12 mo postsurgery. An improvement in knee stability led to a decrease in kinesiophobia in ACLR patients. However, kinesiophobia still needs to be addressed, even if there are no strength or functional-testing deficits.
Validity score
Conclusion
N/A Pain was associated with function throughout the study. Pain tended to decrease as the ACLRrehabilitation process progressed. Kinesiophobia declined with time postsurgery and was only present during the return-to-sport phase.
N/A Results from this study demonstrated that psychological status for fear of movement or reinjury, pain catastrophizing, and self-efficacy for rehabilitation tasks improved over the early postoperative phase after ACLR. Baseline levels of the psychosocial factors did not influence knee pain or function 12 wk postsurgery. Future studies should focus on the psychometric properties of psychosocial factors. This study only focused on short-term outcomes using only self-report measures.
3
The mean TSK-11 score was approximately 3.7 points less in group 3 than in group 1. Group 1 participants were 90 d or less postoperative ACLR. Group 2 participants were 91–180 d postoperative ACLR. Group 3 participants were 181–372 d postoperative ACLR. Mean scores on the TSK-11, IKDC, and SF-8 differed between groups. TSK-11 scores were significantly higher in group 1 (20.7 ± 5.3) than group 3 (17.0 ± 4.3, P = .016). In group 3 SF-8 (P < .001) pain rating decreased compared to groups 1 and 2 (0.6 ± 0.8). IKDC score increased with greater time after surgery (86.4 ± 12.29, P < .001). Age and sex in the SF-8 bodily-pain rating were the only significant factors in the standardized coefficients that indicated that being older and male with lower pain intensity was associated with higher IKDC scores for group 1.
None of the baseline psychosocial factors were associated with knee pain or function at 12 wk for the NRS (0.4 ± 0.8, CI = 0.2,0.6), TSK-11 (17.9 ± 5.9, CI = 16.5,19.2), and PCS (4.0 ± 7.3, CI = 2.4,5.7). 12-wk improvement in SER (standardized beta = 0.262) and score for rehabilitation tasks were associated with reduced knee pain and improvement in function in IKDC-SKF scores (r2 = .120), and 12-wk improvement in fear of movement or reinjury in TSK-11 (standardized beta = –0.216) was associated with improvement in knee function.
2
Chmielewski et al6
Chmielewski et al5
Note: ACL indicates anterior cruciate ligament; MRI, magnetic resonance imaging; ACLR, ACL reconstruction; TSK-11, Tampa Scale of Kinesiophobia; IKDC-SKF, International Knee Documentation Committee Subjective Knee Evaluation Form; SER, Self-Efficacy for Rehabilitation Tasks; SF-8, Medical Outcomes Short Form–8.
2
TSK-11 scores statistically decreased (showed less kinesiophobia) in noncopers than in copers between the preoperative neuromuscular training program and 6 mo post-ACLR-surgery. However, both groups’ TSK-11 scores decreased between presurgery and postsurgery.
Main findings
Level of evidence
Hartigan et al4
Study
Table 2 (continued)
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Implications for Practice, Education, and Future Research While many patients return to preinjury levels of physical activity and return to sports, some may struggle with this return for reasons other than physical impairments. In patients who seem hesitant to return, clinicians should suspect kinesiophobia and administer an appropriate scale to determine whether this is the case. The studies identified in this CAT found moderate evidence to indicate that levels of kinesiophobia are negatively associated with self-perceived knee pain and function and may explain why physically active individuals are not returning to participation when clinicians see generally favorable knee-specific PRO instrument scores with the IKDC and the KOS-ADL.2,5,6 For the studies that met the inclusion criteria for this CAT, participants’ self-perceived knee function was assessed using either the IKDC or the KOS-ADL. The IKDC is a PRO instrument in which patients report their perceptions of their knee function. The IKDC consists of 10 items broken into 2 subsections. The first section includes 7 items regarding knee-related symptoms, and the second section includes 3 items about knee function.11 This PRO instrument, which is scored from 0 to 100, helps clinicians evaluate how patients feel about their knee and how well they do with their daily activities.11 Higher scores on the IKDC indicate lower levels of perceived disability.11 Similar to the IKDC, the KOS-ADL PRO instrument is a 14-item questionnaire that asks patients to report how their knee symptoms affect their daily activities, as well as their functional tasks.12 Each item is scored from 0 to 5, and the highest possible score is 70 points; higher scores indicate lower levels of perceived disability.12 Clinicians should note that the IKDC includes a component that specifically asks about sport-related components of injury, whereas the KOS-ADL does not. All of the studies included in this CAT used the shortened version of the TSK-11 to assess patients’ perceived levels of kinesiophobia. The TSK-11 is a PRO instrument designed to detect the level of fear physically active individuals may have regarding their functional movements due to their injury.13 This instrument includes 11 items addressing fear related to injury.13 Each item is rated on a 4-point Likert scale, and the TSK-11 is scored between 11 and 44 points.13 Higher scores indicate elevated levels of fear. All 3 studies2,5,6 included in this CAT reported decreased levels of fear of reinjury in the later phases of the ACL-rehabilitation process. These studies also indicated that there were increased levels of fear in the early phases of ACL rehabilitation.2,5,6 Chmielewski et al6 reported that fear of movement and reinjury happen in a phase-specific manner. Hartigan et al4 determined that there was a statistically significant improvement in TSK-11 scores in the potential noncopers group between the preoperation phase and the postoperation phase.2 There was also an improvement in TSK-11 scores in the potential copers group between the preoperative and
postoperation phases, but it was not as significant as that of the noncopers group.4 Chmielewski et al5 found significant changes in the 12-week time interval with a major decrease in the TSK-11 and an increase with IKDC scores between baseline and 4 weeks postoperation. Thus, the findings from these studies indicate that there was an improvement in the level of fear of returning to participation among patients as they went through the phases of ACL rehabilitation.2,5,6 Along with the improvement of TSK-11 scores across all 3 studies, there was an improvement in patients’ levels of self-reported knee function. 2,5,6 More specifically, there was a correlation between selfreported knee-function scores and kinesiophobia levels, suggesting that higher perceived levels of knee function may decrease patients’ perceptions of kinesiophobia.2,5,6 The perception of knee function may be dependent on the stage of rehabilitation and the nature of the exercises prescribed. For example, Hartigan et al4 determined that neuromuscular training had a positive effect on knee function in patients classified as noncopers, possibly highlighting the need for specific, targeted exercises aimed at higher-functioning activities to improve patient self-perceived function. Furthermore, Chmielewski et al5 suggested that rehabilitation interventions with the goal to increase self-efficacy or decrease kinesiophobia have potential to improve short-term outcomes in knee function. While TSK-11 values for minimal detectable change and minimal clinically importance difference have not been established for patients after ACL reconstruction, the incorporation of this PRO instrument during patient care can provide clinicians with information pertaining to a patient’s perceived levels of fear of reinjury. However, it is important to note that the TSK-11 was not specifically designed for an athletic population and to date has not been validated in an athletic population. Therefore, clinicians who provide care for athletic populations may consider using other patient-rated outcome instruments to assess fear of reinjury, such as the Re-Injury Anxiety Inventory14 or the ACL–Return to Sport after Injury scale.15 The results collected from the studies appraised in this CAT can guide future research on the psychological factors in patient populations who present with kinesiophobia after ACL reconstruction. Future studies should include the TSK-11 to quantify kinesiophobia in other injuries; most of the current research in the literature includes studies that only assess kinesiophobia among ACL reconstruction patients or patients experiencing low back pain. More longitudinal studies need to be conducted in other athletic populations such as recreational, high school, college, and professional athletes. Patients’ kinesiophobia levels should be continuously monitored from the time of actual ACL injury to the time that patients are discharged.4 Clinicians should consider administering the TSK-11 after an injury to patients who may have significant time loss or may require significant rehabilitation, since the
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information obtained from this PRO instrument can guide informed clinical decision making by measuring patients’ perceived levels of kinesiophobia. Information obtained from the TSK-11 will allow clinicians to gain a better understanding patients’ pain-related fear, which will provide a more patient-centered approach to patients’ rehabilitation. Furthermore, understanding patients’ levels of kinesiophobia will permit clinicians to consider various healthy coaching techniques10 to guide patients as they attempt to physically and mentally return to their sport. For instance, motivational interviewing, goal setting, and cognitive-behavioral strategies are techniques may help clinicians reach out to physically active individuals.10 However, not all clinicians may feel comfortable dealing with these issues. Those who feel they have limited training or experience in dealing with the psychological aspect of injury should seek out or build relationships with psychologists, sports psychologists, or other mental health experts and establish lines of communication and referral for patients who need additional support during recovery and rehabilitation. Finally, clinicians should consider administering the TSK-11 occasionally to gain a baseline and in-progress assessment of kinesiophobia levels. Since ACL reconstruction has a positive prognosis in physically active individuals, there is no reason that physically active individuals should not meet those expectations functionally.4 This CAT should be reviewed in 2 years or when additional best evidence becomes available to determine whether additional best evidence has been published that may change the clinical bottom line for the research question posed herein.
References 1. Meisterling SW, Schoderbek RJ Jr, Andrews JR. Anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2009;17(1):2–10. http://dx.doi.org/10.1053/j. otsm.2009.02.003 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606. PubMed doi:10.1136/bjsm.2010.076364 3. Kori SH, Miller RP, Todd DD. Kinesiophobia: a new view of chronic pain behaviour. Pain Manag. 1990;3(1):35–43. 4. Hartigan EH, Lynch AD, Logerstedt DS, Chmielewski TL, Snyder-Mackler L. Kinesiophobia after anterior cruciate ligament rupture and reconstruction: noncopers versus potential copers. J Orthop Sports Phys Ther. 2013;43(11):821–832. PubMed doi:10.2519/ jospt.2013.4514
5. Chmielewski TL, Zeppieri G, Lentz TA, et al. Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther. 2011;91(9):1355–1366. PubMed 6. Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ. The Association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther. 2008;38(12):746–753. PubMed doi:10.2519/ jospt.2008.2887 7. Lentz TA, Zeppieri G, Tillman SM, et al. Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment and self-report measures. J Orthop Sports Phys Ther. 2012;42(11):893–901. PubMed doi:10.2519/ jospt.2012.4077 8. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393–397. PubMed doi:10.1007/s00167004-0591-8 9. Tjong VK, Murnaghan ML, Nyhof-Young JM, OglvieHarris DJ. A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(2):336–342. PubMed 10. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(7):1549–1558. PubMed 11. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613. PubMed 12. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132– 1145. PubMed 13. Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117:137–144. PubMed doi:10.1016/j.pain.2005.05.029 14. Walker N, Thatcher J, Lavallee D. A preliminary development of the Re-Injury Anxiety Inventory (RIAI). Phys Ther Sport. 2010;11:23–29. PubMed doi:10.1016/j. ptsp.2009.09.003 15. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9:9–15. PubMed doi:10.1016/j.ptsp.2007.09.003
JSR Vol. 24, No. 4, 2015
CRITICALLY APPRAISED TOPIC
Kinesiophobia After Anterior Cruciate Ligament Reconstruction in Physically Active Individuals Arika L. Cozzi, Kristina L. Dunn, Josie L. Harding, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon Clinical Scenario: There are approximately 200,000 anterior cruciate ligament (ACL) tears reported annually in the United States. Patients who undergo ACL reconstruction followed by an aggressive rehabilitation protocol can often structurally and functionally progress to a preinjury level. Despite physical improvements with ACL-rehabilitation protocols, however, there are still a substantial number of individuals who do not return to preinjury level, particularly physically active individuals, of whom only 63% return to their full potential preinjury level. This may be due to continued pain, swelling, stiffness, and weakness in the knee. In addition, research concerning the topic of kinesiophobia (ie, fear of reinjury), which may prevent individuals from returning to their activities, has increased over the past several years. Kinesiophobia is defined as the irrational or debilitating movement of physical activity resulting in the feeling of vulnerability to painful injury or reinjury. Kinesiophobia may have a significant impact on physically active individuals, considering the proportion of patients who do not return to their sport. However, it is unknown whether kinesiophobia is associated with patients’ perceived physical-impairment levels after ACL reconstruction. Focused Clinical Question: Is kinesiophobia associated with self-perceived levels of knee function after ACL reconstruction? Keywords: fear of reinjury, psychological, knee, outcomes, Tampa Scale of Kinesiophobia
Clinical Scenario There are approximately 200,000 anterior cruciate ligament (ACL) tears reported annually in the United States. 1 Patients who undergo ACL reconstruction followed by an aggressive rehabilitation protocol can often structurally and functionally progress to a preinjury level. 2 Despite physical improvements with ACL-rehabilitation protocols, however, there are still a substantial number of individuals who do not return to preinjury level, particularly physically active individuals, of whom only 63% return to their full potential preinjury level.3 This may be due to continued pain, swelling, stiffness, and weakness in the knee. In addition, research concerning the topic of kinesiophobia (ie, fear of reinjury), which may prevent individuals from returning to their activities, has increased over the past several years. Kinesiophobia is defined as the irrational or debilitating movement of physical activity resulting in the feeling of vulnerability to painful injury or reinjury.4 Kinesiophobia may have a significant impact on physically active individuals, considering the proportion
The authors are with the Athletic Training Programs, A.T. Still University, Mesa, AZ. Address author correspondence to Cailee Welch Bacon at [email protected].
434
of patients who do not return to their sport. However, it is unknown whether kinesiophobia is associated with patients’ perceived physical-impairment levels after ACL reconstruction.
Focused Clinical Question Is kinesiophobia associated with self-perceived levels of knee function after ACL reconstruction?
Summary of Search, Best Evidence Appraised, and Key Findings • The literature was searched for studies of level 3 evidence or higher pertaining to self-perceived levels of knee function associated with kinesiophobia after ACL reconstruction. • The literature search returned 9 possible studies related to the clinical question; 3 studies2,5,6 met the inclusion criteria and were included. • The studies suggested that better knee function is associated with lower kinesiophobia levels. Decreasing kinesiophobia levels are associated with the improvement of self-reported knee function during daily activities with increased progression of ACL rehabilitation.2,5,6
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• Kinesiophobia levels are higher early after ACL rupture, and psychological interventions aimed to decrease fear of reinjury need to be warranted and further researched.2,5
• Ovid • MEDLINE/PubMed • CINAHL • Additional resources obtained via review of reference lists and hand search
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Clinical Bottom Line There is moderate evidence to support that kinesiophobia is associated with self-perceived knee function after ACL reconstruction. It has been demonstrated that there is a relationship between kinesiophobia and activity restriction, knee instability, and/or self-reported knee function.2 Along with knee pain and function, kinesiophobia has been identified as a detriment to return to participation after ACL reconstruction.2,5–10 Therefore, clinicians should be cognizant that kinesiophobia may explain any potential discrepancies between generally favorable International Knee Documentation Committee (IKDC) scores, Knee Outcome Survey Activities of Daily Living (KOS-ADL) scores, or clinician-based outcomes and poor return-to-play rates.2–5 To ensure that clinicians are providing optimal whole-person, patient-centered care, it is essential to assess kinesiophobia, particularly among physically active individuals who aspire to return to activity after ACL reconstruction. Incorporating a patient-reported outcome (PRO) instrument such as the Tampa Scale of Kinesiophobia (TSK-11) to assess kinesiophobia can assist clinicians during the clinical decision-making process by providing a better understanding of psychosocial factors that may affect successful recovery and return to activity. Strength of Recommendation: Due to the results and the moderate consistency of the studies reviewed, there is grade B evidence to support the idea that kinesiophobia is associated with self-perceived levels of knee pain and function after ACL reconstruction.
Search Strategy Terms Used to Guide Search Strategy • Patient/Client group: physically active individual and ACL reconstruction • Intervention/Assessment): kinesiophobia or fear of reinjury, and knee pain or knee function, ACL reconstruction • Comparison: Not applicable • Outcomes: Tampa Scale of Kinesiophobia-11 or TSK-11, International Knee Documentation Committee form or IKDC, and Knee Outcome Survey Activities of Daily Living or KOS-ADL
Sources of Evidence Searched • The Cochrane Library • EBSCO • Clinical Key
Inclusion and Exclusion Criteria Inclusion Criteria • Level 3 evidence or higher • Studies that investigated kinesiophobia (TSK-11) and self-reported knee function (as measured by the IKDC or KOS-ADL) after ACL reconstruction • Limited to English language • Limited to the past 10 years (2004–2013)
Exclusion Criteria • Studies that included participants that did not undergo ACL reconstruction • Studies that investigated fear avoidance via the FearAvoidance Belief Questionnaire • Studies that did not include a knee-specific PRO instrument to measure knee function after ACL reconstruction
Results of Search Three relevant studies2,5,6 were located and categorized as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2011).
Best Evidence The studies in Table 2 were identified as the best evidence and selected for inclusion in this critically appraised topic (CAT). These studies were selected because they were considered level 3 evidence or higher and investigated whether kinesiophobia is associated with knee-specific quality of life among physically active individuals after ACL reconstruction. Table 1 Summary of Study Designs of Articles Retrieved Level of evidence
Study design
Number located
2
Longitudinal cohort study
1
Hartigan et al4
3
Prospective longitudinal
1
Chmielewski et al5
3
Cross-sectional survey
1
Chmielewski et al6
JSR Vol. 24, No. 4, 2015
Reference
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JSR Vol. 24, No. 4, 2015
Hartigan et al4
Longitudinal cohort
Patients with ACL surgery. This was a secondary analysis of data from 2 longitudinal studies. 132 patients (79 noncopers, 53 potential copers) met the inclusion criteria. Of those, 111 (61 noncopers. 50 potential copers) completed the TSK-11. Inclusion Criteria: 13–55 y of age, unilateral ACL rupture confirmed with MRI and at least a 3-mm side-to-side difference in anterior knee laxity determined with a knee arthrometer, regularly participated (more than 50 h/y) in level 1 or 2 sports (jumping, cutting, pivoting, and lateral movements) before surgery and desired to return to a level 1 or 2 sport, ACLR, TSK-11 scores collected at least once. Exclusion Criteria: bilateral injury, concomitant injury (eg, other ligamentous injury of grade 3, full-thickness chondral defect of greater than 1 cm2), concomitant surgery that required a modified rehabilitation protocol (eg, meniscal repair or articular cartilage microfracture), pregnancy, previous knee surgery.
Data were collected at 4 times: before preoperative treatment, after a preoperative treatment, 6 mo after ACLR, and 12 mo after ACLR. Data collected included a quadriceps strength index, 4 single-leg hop tests, and self-reported questionnaires rating daily knee function.
The Knee Outcome Survey activities of daily living subscale, global knee function (global rating scale), and the TSK-11 were administered.
Study
Design
Participants
Intervention investigated
Outcome measures
Table 2 Characteristics of Included Studies
(continued)
TSK-11, IKDC, and SF-8 were administered to investigate the general quality of life in the physical and mental domains.
When the TSK-11, IKDC, and the SF-8 were administered, the ACLR patients completed the questionnaires and were scored to investigate pain related to fear, knee symptoms, and functional limitations and to look at the patients’ overall physical and mental well-being.
Data were collected at 4 times after surgery (baseline and 4, 8, and 12 wk). Demographic information was collected at initial visit only. Self-report questionnaires for knee-pain intensity, psychosocial constructs, and knee function were administered at all 4 times using a numeric rating scale (NRS), the IKDC-SKF, the TSK-11, and the SER. Self-report questionnaires for average knee-pain intensity (NRS), IKDC-SKF, TSK-11, SER.
Cross-sectional survey Patients with a unilateral, primary, isolated, and acute ACLR. Total of 97 participants: 60 males and 37 females. Participants were separated into 3 groups based on time from surgery to completed questionnaire. Group 1: ≤90 d (n = 39), 25 males and 14 females age 26.3 ± 9.2 y. 14 participants received an autograph and 25 were allograph. Injury-to-surgery time was 89.9 ± 70.4 d. Time from surgery to questionnaire was 42.8 ± 24.1 d. Group 2: 91–180 d (n = 31), 15 males and 16 females age 25.3 ± 11 y. 12 participants received autograph and 19 received autograph. Injury-to-surgery time was 75.7 ± 65.5 d. Time from surgery to questionnaire was 147 ± 33.1 d. Exclusion Criteria: bilateral injury, concomitant injury, concomitant surgery that required a modified rehab protocol, previous knee surgery, time from injury to surgery >365 d, or time from surgery to questionnaire completion >372 d.
Prospective, longitudinal
Chmielewski et al6
Patients with an ACL reconstruction who began rehabilitation. 97 participants enrolled in the study. Of those, only 77 participated in all testing sessions: 41 males, 36 females (22.4 ± 7.1 y). 21 contact, 56 noncontact, 38 autograft, 39 allograft, 70 sports, 7 nonsport, 38 with accompanying surgical procedures, 39 without, 11 with previous knee injury, 66 without. Inclusion criteria: unilateral ACLR, age 15–45 y, time from injury to surgery ≤12 mo. Exclusion Criteria: bilateral injury, concomitant ligamentous injury greater than grade 1.
Chmielewski et al5
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N/A
Noncopers showed greater kinesiophobia on the TSK-11 during presurgery evaluation. Noncopers tended to show a greater decrease in kinesiophobia postsurgery than those who were considered potential copers. Kinesiophobia levels remained high even up to 6 mo postsurgery. These levels typically decreased 6–12 mo postsurgery. An improvement in knee stability led to a decrease in kinesiophobia in ACLR patients. However, kinesiophobia still needs to be addressed, even if there are no strength or functional-testing deficits.
Validity score
Conclusion
N/A Pain was associated with function throughout the study. Pain tended to decrease as the ACLRrehabilitation process progressed. Kinesiophobia declined with time postsurgery and was only present during the return-to-sport phase.
N/A Results from this study demonstrated that psychological status for fear of movement or reinjury, pain catastrophizing, and self-efficacy for rehabilitation tasks improved over the early postoperative phase after ACLR. Baseline levels of the psychosocial factors did not influence knee pain or function 12 wk postsurgery. Future studies should focus on the psychometric properties of psychosocial factors. This study only focused on short-term outcomes using only self-report measures.
3
The mean TSK-11 score was approximately 3.7 points less in group 3 than in group 1. Group 1 participants were 90 d or less postoperative ACLR. Group 2 participants were 91–180 d postoperative ACLR. Group 3 participants were 181–372 d postoperative ACLR. Mean scores on the TSK-11, IKDC, and SF-8 differed between groups. TSK-11 scores were significantly higher in group 1 (20.7 ± 5.3) than group 3 (17.0 ± 4.3, P = .016). In group 3 SF-8 (P < .001) pain rating decreased compared to groups 1 and 2 (0.6 ± 0.8). IKDC score increased with greater time after surgery (86.4 ± 12.29, P < .001). Age and sex in the SF-8 bodily-pain rating were the only significant factors in the standardized coefficients that indicated that being older and male with lower pain intensity was associated with higher IKDC scores for group 1.
None of the baseline psychosocial factors were associated with knee pain or function at 12 wk for the NRS (0.4 ± 0.8, CI = 0.2,0.6), TSK-11 (17.9 ± 5.9, CI = 16.5,19.2), and PCS (4.0 ± 7.3, CI = 2.4,5.7). 12-wk improvement in SER (standardized beta = 0.262) and score for rehabilitation tasks were associated with reduced knee pain and improvement in function in IKDC-SKF scores (r2 = .120), and 12-wk improvement in fear of movement or reinjury in TSK-11 (standardized beta = –0.216) was associated with improvement in knee function.
2
Chmielewski et al6
Chmielewski et al5
Note: ACL indicates anterior cruciate ligament; MRI, magnetic resonance imaging; ACLR, ACL reconstruction; TSK-11, Tampa Scale of Kinesiophobia; IKDC-SKF, International Knee Documentation Committee Subjective Knee Evaluation Form; SER, Self-Efficacy for Rehabilitation Tasks; SF-8, Medical Outcomes Short Form–8.
2
TSK-11 scores statistically decreased (showed less kinesiophobia) in noncopers than in copers between the preoperative neuromuscular training program and 6 mo post-ACLR-surgery. However, both groups’ TSK-11 scores decreased between presurgery and postsurgery.
Main findings
Level of evidence
Hartigan et al4
Study
Table 2 (continued)
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Implications for Practice, Education, and Future Research While many patients return to preinjury levels of physical activity and return to sports, some may struggle with this return for reasons other than physical impairments. In patients who seem hesitant to return, clinicians should suspect kinesiophobia and administer an appropriate scale to determine whether this is the case. The studies identified in this CAT found moderate evidence to indicate that levels of kinesiophobia are negatively associated with self-perceived knee pain and function and may explain why physically active individuals are not returning to participation when clinicians see generally favorable knee-specific PRO instrument scores with the IKDC and the KOS-ADL.2,5,6 For the studies that met the inclusion criteria for this CAT, participants’ self-perceived knee function was assessed using either the IKDC or the KOS-ADL. The IKDC is a PRO instrument in which patients report their perceptions of their knee function. The IKDC consists of 10 items broken into 2 subsections. The first section includes 7 items regarding knee-related symptoms, and the second section includes 3 items about knee function.11 This PRO instrument, which is scored from 0 to 100, helps clinicians evaluate how patients feel about their knee and how well they do with their daily activities.11 Higher scores on the IKDC indicate lower levels of perceived disability.11 Similar to the IKDC, the KOS-ADL PRO instrument is a 14-item questionnaire that asks patients to report how their knee symptoms affect their daily activities, as well as their functional tasks.12 Each item is scored from 0 to 5, and the highest possible score is 70 points; higher scores indicate lower levels of perceived disability.12 Clinicians should note that the IKDC includes a component that specifically asks about sport-related components of injury, whereas the KOS-ADL does not. All of the studies included in this CAT used the shortened version of the TSK-11 to assess patients’ perceived levels of kinesiophobia. The TSK-11 is a PRO instrument designed to detect the level of fear physically active individuals may have regarding their functional movements due to their injury.13 This instrument includes 11 items addressing fear related to injury.13 Each item is rated on a 4-point Likert scale, and the TSK-11 is scored between 11 and 44 points.13 Higher scores indicate elevated levels of fear. All 3 studies2,5,6 included in this CAT reported decreased levels of fear of reinjury in the later phases of the ACL-rehabilitation process. These studies also indicated that there were increased levels of fear in the early phases of ACL rehabilitation.2,5,6 Chmielewski et al6 reported that fear of movement and reinjury happen in a phase-specific manner. Hartigan et al4 determined that there was a statistically significant improvement in TSK-11 scores in the potential noncopers group between the preoperation phase and the postoperation phase.2 There was also an improvement in TSK-11 scores in the potential copers group between the preoperative and
postoperation phases, but it was not as significant as that of the noncopers group.4 Chmielewski et al5 found significant changes in the 12-week time interval with a major decrease in the TSK-11 and an increase with IKDC scores between baseline and 4 weeks postoperation. Thus, the findings from these studies indicate that there was an improvement in the level of fear of returning to participation among patients as they went through the phases of ACL rehabilitation.2,5,6 Along with the improvement of TSK-11 scores across all 3 studies, there was an improvement in patients’ levels of self-reported knee function. 2,5,6 More specifically, there was a correlation between selfreported knee-function scores and kinesiophobia levels, suggesting that higher perceived levels of knee function may decrease patients’ perceptions of kinesiophobia.2,5,6 The perception of knee function may be dependent on the stage of rehabilitation and the nature of the exercises prescribed. For example, Hartigan et al4 determined that neuromuscular training had a positive effect on knee function in patients classified as noncopers, possibly highlighting the need for specific, targeted exercises aimed at higher-functioning activities to improve patient self-perceived function. Furthermore, Chmielewski et al5 suggested that rehabilitation interventions with the goal to increase self-efficacy or decrease kinesiophobia have potential to improve short-term outcomes in knee function. While TSK-11 values for minimal detectable change and minimal clinically importance difference have not been established for patients after ACL reconstruction, the incorporation of this PRO instrument during patient care can provide clinicians with information pertaining to a patient’s perceived levels of fear of reinjury. However, it is important to note that the TSK-11 was not specifically designed for an athletic population and to date has not been validated in an athletic population. Therefore, clinicians who provide care for athletic populations may consider using other patient-rated outcome instruments to assess fear of reinjury, such as the Re-Injury Anxiety Inventory14 or the ACL–Return to Sport after Injury scale.15 The results collected from the studies appraised in this CAT can guide future research on the psychological factors in patient populations who present with kinesiophobia after ACL reconstruction. Future studies should include the TSK-11 to quantify kinesiophobia in other injuries; most of the current research in the literature includes studies that only assess kinesiophobia among ACL reconstruction patients or patients experiencing low back pain. More longitudinal studies need to be conducted in other athletic populations such as recreational, high school, college, and professional athletes. Patients’ kinesiophobia levels should be continuously monitored from the time of actual ACL injury to the time that patients are discharged.4 Clinicians should consider administering the TSK-11 after an injury to patients who may have significant time loss or may require significant rehabilitation, since the
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information obtained from this PRO instrument can guide informed clinical decision making by measuring patients’ perceived levels of kinesiophobia. Information obtained from the TSK-11 will allow clinicians to gain a better understanding patients’ pain-related fear, which will provide a more patient-centered approach to patients’ rehabilitation. Furthermore, understanding patients’ levels of kinesiophobia will permit clinicians to consider various healthy coaching techniques10 to guide patients as they attempt to physically and mentally return to their sport. For instance, motivational interviewing, goal setting, and cognitive-behavioral strategies are techniques may help clinicians reach out to physically active individuals.10 However, not all clinicians may feel comfortable dealing with these issues. Those who feel they have limited training or experience in dealing with the psychological aspect of injury should seek out or build relationships with psychologists, sports psychologists, or other mental health experts and establish lines of communication and referral for patients who need additional support during recovery and rehabilitation. Finally, clinicians should consider administering the TSK-11 occasionally to gain a baseline and in-progress assessment of kinesiophobia levels. Since ACL reconstruction has a positive prognosis in physically active individuals, there is no reason that physically active individuals should not meet those expectations functionally.4 This CAT should be reviewed in 2 years or when additional best evidence becomes available to determine whether additional best evidence has been published that may change the clinical bottom line for the research question posed herein.
References 1. Meisterling SW, Schoderbek RJ Jr, Andrews JR. Anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2009;17(1):2–10. http://dx.doi.org/10.1053/j. otsm.2009.02.003 2. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606. PubMed doi:10.1136/bjsm.2010.076364 3. Kori SH, Miller RP, Todd DD. Kinesiophobia: a new view of chronic pain behaviour. Pain Manag. 1990;3(1):35–43. 4. Hartigan EH, Lynch AD, Logerstedt DS, Chmielewski TL, Snyder-Mackler L. Kinesiophobia after anterior cruciate ligament rupture and reconstruction: noncopers versus potential copers. J Orthop Sports Phys Ther. 2013;43(11):821–832. PubMed doi:10.2519/ jospt.2013.4514
5. Chmielewski TL, Zeppieri G, Lentz TA, et al. Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther. 2011;91(9):1355–1366. PubMed 6. Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ. The Association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther. 2008;38(12):746–753. PubMed doi:10.2519/ jospt.2008.2887 7. Lentz TA, Zeppieri G, Tillman SM, et al. Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment and self-report measures. J Orthop Sports Phys Ther. 2012;42(11):893–901. PubMed doi:10.2519/ jospt.2012.4077 8. Kvist J, Ek A, Sporrstedt K, Good L. Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2005;13:393–397. PubMed doi:10.1007/s00167004-0591-8 9. Tjong VK, Murnaghan ML, Nyhof-Young JM, OglvieHarris DJ. A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(2):336–342. PubMed 10. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(7):1549–1558. PubMed 11. Irrgang JJ, Anderson AF, Boland AL, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613. PubMed 12. Irrgang JJ, Snyder-Mackler L, Wainner RS, Fu FH, Harner CD. Development of a patient-reported measure of function of the knee. J Bone Joint Surg Am. 1998;80:1132– 1145. PubMed 13. Woby SR, Roach NK, Urmston M, Watson PJ. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117:137–144. PubMed doi:10.1016/j.pain.2005.05.029 14. Walker N, Thatcher J, Lavallee D. A preliminary development of the Re-Injury Anxiety Inventory (RIAI). Phys Ther Sport. 2010;11:23–29. PubMed doi:10.1016/j. ptsp.2009.09.003 15. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9:9–15. PubMed doi:10.1016/j.ptsp.2007.09.003
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