Preprint
Article
Understanding Kinesiophobia: Predictors and Influence on Early Functional Outcomes in Patients with Total Knee Arthroplasty
Altmetrics
Downloads
224
Views
107
Comments
0
A peer-reviewed article of this preprint also exists.
This version is not peer-reviewed
Submitted:
13 February 2024
Posted:
15 February 2024
You are already at the latest version
Alerts
Abstract
Kinesiophobia (fear of movement) has been recognized as a significant barrier to recovery and rehabilitation in patients after total knee arthroplasty (TKA). Our goal was to identify predictors of kinesiophobia and examine its correlation with early functional outcomes in TKA recipients. On the first and fifth postoperative days (POD1 and POD5), we evaluated pain using the International Pain Outcomes Questionnaire (IPO-Q) and created multidimensional pain composite scores (PCS). Pain Composite Score-total (PCStotal) assesses the overall impact of pain, taking into account outcomes of pain intensity, pain-related interference with function, and emotions and side effects. Functional status on POD 5 was determined by the Barthel index, 6-minute walking test, and knee range of motion. Kinesiophobia was measured on POD5 using the Tampa Scale for Kinesiophobia (TSK) and multivariable logistic regression was used to assess factors associated with kinesiophobia. Among 75 TKA patients, 27% exhibited kinesiophobia. The final regression model highlighted PCStotal on POD5 (OR=6.2, CI=1.9-19.9), PCStotal (OR=2.1, CI=1.2-3.8) on POD1, and the intensity of chronic pain before surgery (OR=1.4, CI=1.1-2.1) as significant kinesiophobia predictors. On POD5, those with kinesiophobia showed increased dependency, slower gait, and poorer knee extension recovery. This study highlights the importance of identifying and addressing kinesiophobia in TKA patients to optimize functional outcomes and improve recovery. Also, it is important to assess not only pain intensity but also the physical and emotional interference caused by pain, which can contribute to the development of kinesiophobia.
Keywords:
Subject: Medicine and Pharmacology - Orthopedics and Sports Medicine
1. Introduction
Total knee arthroplasty (TKA) is an effective treatment option for patients with end-stage knee osteoarthritis providing pain relief, functional improvement, and health-related quality of life. Due to increasing levels of obesity, population aging, and growth in sports-related injuries, the incidence of TKA is high [1]. Between 2000 and 2014, the estimated annual numbers of primary TKA increased by 148% in the United States. Based on this data Sloan et al. showed that the projected growth for TKA procedures will reach 935,000 annually by 2030 in the US [2].
The primary outcomes of the procedure are to improve the patient’s mobility in the postoperative period, enhance their functionality, alleviate pain significantly, and enhance self-confidence due to improved functionality [3].
However, TKA is a painful procedure. The number of patients reporting moderate-severe pain after TKA remained relatively constant, with 58% reporting moderate-severe pain on postoperative day 1 (POD1), which only decreased to 43% by postoperative day 3 (POD3) [4]. Pain in the postoperative period affects rehabilitation and increases the risk of complications in the acute phases and of developing chronic pain after surgery. Furthermore, up to 20% of patients are dissatisfied with the results of their surgery due to persistent pain and disability [5].
Additional psychological factors, such as pain catastrophizing, pain-related fear of movement, and depression have been identified as contributors to prolonged pain and disability in individuals with different musculoskeletal conditions [6]. Patients may delay arthroplasty surgery due to the fear of acute postoperative pain [7]. Pain catastrophizing is a term used to describe the tendency to magnify the threat value of pain stimuli and to feel helpless in the context of pain. This can lead to an inability to inhibit pain-related thoughts during or after a painful encounter [8]. Kinesiophobia, on the other hand, is an excessive and debilitating fear of physical movement and activity due to a feeling of vulnerability from a painful injury or re-injury [9]. It is gaining more attention since it can lead to illness behavior and create a vicious cycle of pain and disability [10]. High levels of kinesiophobia after TKA negatively affect short [11,12,13] and long-term [6,10,13,14,15,16,17] functional outcomes. Investigating the presence of kinesiophobia early after surgery can help arrange personalized treatment for this vulnerable group of patients.
Despite the growing interest in the relation of kinesiophobia and TKA, there are limited studies about the etiology and psychological pattern of kinesiophobia in the literature. To the best of our knowledge, there are only two studies that examine the risk factors for the onset of kinesiophobia following TKA. Cai et al. showed that female sex, older age, lower levels of education, negative coping styles, lower self-efficacy, and pain were predictors of kinesiophobia after surgery [18]. Degirmenci et al. demonstrated that the choice of anesthesia techniques during total knee arthroplasty (TKA) significantly influences the development of postoperative kinesiophobia [19]. This study found that patients who received regional anesthesia and deep sedation were able to recover and move more confidently during the early postoperative period, while those who received regional anesthesia and light sedation experienced anxiety and fear, which made them hesitant to move [19]. Studies have highlighted the importance of kinesiophobia as a risk factor for higher pain intensity following TKA [10,11,15,16,17]. However, due to the lack of standardized pain measurements and the predominant use of unidimensional pain analysis, the relationship between patient-reported outcomes (PROs) and kinesiophobia has not been thoroughly investigated in any single study to date. PROs are reports coming directly from a patient, about how they feel or function about a health condition and its therapy without interpretation by healthcare professionals or anyone else. PROs can relate to symptoms, signs, functional status, perceptions, or other aspects such as convenience and tolerability. PROs are not only important when more objective measures of disease outcome are not available but also to represent what is most important to patients about a condition and its treatment [20]. Gewandter et al. suggested that the inclusion of multiple domains in the outcomes can be a significant advantage as it provides a more thorough evaluation of the experiences of the individuals under study, rather than relying on a single factor that may not be sufficient in describing their overall experience [21].
This study aimed to investigate the factors associated with kinesiophobia following TKA and to examine the relationship between kinesiophobia and early functional outcomes in TKA patients.
2. Materials and Methods
2.1. Setting
This observational study was conducted at the Clinic for Orthopaedic Surgery and Traumatology, University Clinical Center Serbia in Belgrade over a period of 6 months. The study followed the principles of the Helsinki Declaration and was approved by the local ethics committee (Number 2017-004244-37). The results presented in this study are based on the methods outlined by PAIN OUT (www.pain-out.eu), a registry focused on quality improvement and research. The registry provides resources to assess pain-related patient-reported outcomes (PROs) and management on the first postoperative day (POD1), as documented in clinicaltrials.gov NCT02083835 [22,23].
Patients who had undergone TKA were 18 years or older, could communicate, and provided written consent were invited to participate in the study. Written consent explained that the study aimed to improve pain treatment for patients after TKA in the future, and confirmed that no changes were made to the standard medical care at the moment.
2.2. Surgical Technique, Anesthesia, Pain Management, and Postoperative Rehabilitation Program
The surgical procedure for TKA involved the insertion of tricompartmental prostheses using a standard medial parapatellar approach, with the use of cruciate-substituting designs. A femoral tourniquet at 300 mmHg was employed to achieve a bloodless surgical field. A compression bandage was applied from the toes to the mid-thigh at the end of the surgery. Spinal anesthesia with 10-15 mg levobupivacaine 0.5% or general anesthesia with propofol and fentanyl was administered during the procedure. Local infiltration anesthesia was not used in our study group. The regular protocol for pain management involved scheduled assessment of pain, and administration of non-opioid drugs (such as Paracetamol, Ketorolac, Metamizol) and weak opioids (Tramadol) based on the severity of the pain reported by patients, and following the WHO’s approach to the use of analgesics based on pain severity. The pain was assessed at least once per shift. This treatment approach was implemented from POD1 to POD5.
All patients followed a standardized postoperative rehabilitation program beginning on POD1. Assisted ambulation and regular exercise to restore strength and mobility of the operated knee were performed 2 times a day for 20-30 minutes.
2.3. Data Collection
Patients were evaluated on POD1 and POD5.
- (1)
- Baseline characeristics
On POD1, patients were assessed regarding demographic and clinical data comprising of gender, year of birth (age), weight and height, intensity, and location of chronic pain before surgery. Furthermore, the type of anesthesia and duration of surgery were recorded.
- (2)
- EuroQol-5D
Health-related quality of life during the last week before TKA was rated with the use of the EuroQol-5D (EQ5D) index score on POD1. After the surgery, we evaluated the patients’ overall well-being on the POD5 using the same tool to determine the impact of TKA on their quality of life. An EQ5D index score of 0 indicates the worst possible health state and a value of 1 indicates full health [24].
- (3)
- Multi-dimensional assessment of pain on POD1 and POD5
The validated International Pain Outcomes Questionnaire (IPO-Q) was used to evaluate pain-related PROs [23]. This questionnaire evaluates the following domains: intensity of pain and relief from treatments; interference of pain with physical activities in and out of bed; negative affect due to pain (anxiety and helplessness); adverse effects (AE) (nausea, fatigue, dizziness, itch); perception of care (wish for more pain treatment, satisfaction with pain treatment, participation in decisions about pain treatment and receipt of information about treatment). Pain intensity and pain-related physical and affective interference were quantified by patients using an 11-point numerical rating scale (0 = null, 10 = worst possible). The patient’s perception of care was assessed with yes or no or percentage scales. The data were collected by surveyors who underwent training before they approached patients. To reduce interviewer bias, patients completed the questionnaire independently with no assistance from family or staff. However, if a patient requested help, the surveyor could assist.
- (4)
- Kinesiophobia on POD5
On POD5 kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK). The TSK is a 17-item questionnaire designed to assess a patient’s fear of movement or (re)injury [25]. Each point has a 4-point Likert scale, scoring alternatives from „strongly disagree” to „strongly agree“. The total score on the TSK ranges from 17 to 68 [26]. We used a pre-validated cut-off score of 37 on the TSK to categorize knee replacement patients into two groups: those with no or low degree of kinesiophobia (TSK‹37) and those with a high degree of kinesiophobia (TSK≥37) [25,27].
- (5)
- Functional outcome measures on POD5
On POD5, a functional assessment was conducted, which included three tests: knee range of motion (ROM), Barthel Index, and the 6-minute walking test (6-MWT). The Barthel Index is an ordinal scale used to assess a person’s ability to perform ADL. It involves scoring 10 variables related to mobility and ADL, with a higher score indicating greater independence [28]. The 6-MWT measures functional walking capacity. During the test, the patients were asked to walk for 6 minutes, and the distance covered in meters was recorded [29]. Knee ROM was assessed using a universal goniometer, and the average peak knee flexion and extension were recorded from three trials. Health-related quality of life after TKA was rated using the EQ-5D index score.
2.4. Study Outcomes
The primary focus of the study was to identify predictors of kinesiophobia, while the secondary objective was to examine the association of kinesiophobia and functional outcomes.
3. Data analysis
3.1. Creating Multidimensional Composite Scores
Multidimensional composite scores were created based on ratings obtained from the IPO-Q. For POD1 and POD5, continuous PROs were extracted from the questionnaires and combined to form composite scores, as described by Hofer D et al. [30]. Three subscores were generated to assess pain intensity, pain-related interference, and side effects. The Pain Composite Score (PCS) was calculated using the formula: worst pain * (% time in severe pain * 100) + least pain * (1 - % time in severe pain / 100). The Pain Interference Total Score (PITS) was calculated as the mean of pain-related interference with activities in bed, breathing deeply/coughing, sleep, and pain-related anxiety and helplessness. The Pain Side Effects (PSE) composite score was calculated from the scores for dizziness, drowsiness, nausea, and itching [30]. The Pain Composite Score-total (PCStotal) was formulated by averaging the continuous items derived from the pain intensity, pain interference, and side effects domains of the IPO-Q [31].
3.2. Statistics
Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL) version 22.0. Data were visually analyzed with histograms, Q–Q plots, and Kolmogorov–Smirnov tests for normality of distribution. Categorical and dichotomous data were presented as absolute frequencies and percentage of patients, continuous data by median, first quartile (Q1), and third quartile (Q3), and NRS scores by a median with interquartile range. The chi-square test was applied to test relationships between categorical variables. A two-sided independent samples t-test was used to compare the mean values of normally distributed data between 2 groups. Ordinal data were compared by the 2-sided Mann–Whitney U test.
Univariable and multivariable logistic regression analyses were performed to assess the factors associated with kinesiophobia. Variables with p-value < 0.20 in the unavailable analysis were retained and included in the multivariable regression for which the backward selection method was used. In the backward method, the model started with all variables in the equation. Using criteria for removal, variables that did not contribute to the solution were removed one at a time. The variable with the smallest partial correlation was taken out first. Steps proceed until no remaining variables are qualified for removal [32].
No collinearity problem was detected for any of the models. In all instances, a p-value <0.05 was considered statistically significant.
3. Results
3.1. Baseline Characteristics of the Study Group
A total of 81 patients were recruited for the study. During the study period, 3 patients declined to fill out the requested questionnaires, and 3 patients were excluded due to deep vein thrombosis. Therefore, 75 patients were included in the study analysis.
The patients were categorized into two groups based on their degree of kinesiophobia: a high kinesiophobia group (n=20) and a low kinesiophobia group (n=55).
Patient characteristics and clinical data are summarized in Table 1.
3.2. Analysis of Group Differences Regarding Pain-Related Outcome and Health Related Quality of Life Outcome
A significant difference in PROs at POD1 and POD5 was observed. Patients with kinesiophobia demonstrated significantly worse pain outcomes on the PCStotal of IPO-Q compared to patients without kinesiophobia on POD1 and POD5. We have provided data on the individual PROs as well. According to our findings, individuals with kinesiophobia exhibit higher scores on PCS and PITS subscales on POD1 and POD5, whereas no significant difference was observed in the results of PSE (Table 2).
Patients with kinesiophobia had also a lower percentage of pain relief, wished for more analgesics, and reported more interference of pain with activities out of bed on POD5.
A statistically significant difference in EQ-5D on POD5 between the groups was also observed (Table 3).
3.3. Predictors of Kinesiophobia
Univariable regression analysis revealed that patients who reported higher pain intensity before surgery and had worse quality of life preoperatively were more likely to develop kinesiophobia. As far as pain-related PROs are concerned, our results revealed that higher scores of PCStotal of IPO-Q were associated with higher kinesiophobia scores. Furthermore, a lower percentage of pain relief, wish for more pain treatment, interference of pain with activities out of bed, and higher scores on EQ-5D on POD5 were also related to higher kinesiophobia scores (Table 4).
Table 5 displays the results of the multivariable regression analysis. The final model included intensity of chronic pain before surgery, PCStotal on POD1 and POD5 and pain interfering with activities out of bed as significant predictors. With the independent variables added, the overall model was statistically significant (χ2= 28.286, p <.001). The model explained 45.8% (Nagelkerkes R²) of the variance of kinesiophobia and correctly classified 80% of cases. The strongest predictor of kinesiophobia was PCStotal on POD 5, whose odds ratio (OR) was 6.191 when adjusted for PCStotal on POD1, intensity of chronic pain before surgery and pain interfering with activities out od bed. PCStotal on POD1 was identified as the second strongest predictor of kinesiophobia.
3.4. Influence of Kinesiophobia on Recovery after TKA
Regarding functional outcomes on POD5 patients with kinesiophobia revealed significantly higher dependency levels as expressed with the Barthel score, had a slower gait speed on the 6 MWT, and showed worse recovery of knee extension (Table 6).
According to the results of univariable regression analysis, a significant association was found between the presence of kinesiophobia in patients and a slower rate of recovery (Table 7).
4. Discussion
In this study, we observed a kinesiophobia incidence of 27% which is close to the rates reported in earlier studies in TKA patients in Serbia (22%) [16] and China (24%) [18]. Our findings indicate that the presence of kinesiophobia might be impacted by the intensity of preoperative pain. This observation is consistent with Kroska’s et al. postulation that fear avoidance behavior is often associated with higher pain intensity [33].
The most important finding of our study was the confirmed link between PCStotal on POD1 and POD5 and the development of kinesiophobia. To the best of our knowledge, our results are the first ones that highlight the relationship of both the intensity of postoperative pain, and the physical and emotional interference caused by pain after TKA, as they are associated with the presence of kinesiophobia. Prior studies on TKA patients primarily relied on pain intensity and used single-dimensional measures to assess pain [16,18,19]. Moreover, research on risk factors for kinesiophobia after TKA found a direct link between high pain intensity levels within the first 24 hours after surgery and increased levels of kinesiophobia [18]. Composite scores for pain, which combine pain intensity, pain-related interference, and side effects, offer a unique approach that provides a holistic view of the pain experience [21,30]. This approach provides a broader perspective compared to using a single measure [21].
To evaluate the influence of kinesiophobia on early functional outcome we measured the 6-MTW, knee ROM, and Barthel index. Our study’s findings support previous research regarding the 6-MWT and its relation to kinesiophobia. Doury-Panchout et al. demonstrated that patients without kinesiophobia walked a significantly greater distance during the 6-MWT compared to those with kinesiophobia [15]. Additionally, Guney Deniz et al. found a positive correlation between higher TSK scores and improved 2-MWT scores [12]. Similarly, Degirmenci et al. discovered that higher TSK scores were associated with better 2-MWT scores and Timed Up and Go (TUG) test results on POD 2 and POD 5 [19]. Based on our findings, it appears that there might be an inverse correlation between active knee extension and kinesiophobia, while no correlation was observed with knee flexion. However, it is important to note that not all studies align with these results. Active knee flexion was found to be correlated with TSK in several studies [12,16,19,34]. In contrast, Doury-Panchout et al. did not observe any notable disparity in maximum passive flexion and maximum active extension on the day of discharge between high-TSK and low-TSK groups [15]. Similarly, Filardo et al. found no connection between high-TSK and low-TSK concerning active or passive ROM [35]. Also, our study revealed the negative relationship between higher levels of kinesiophobia and functional independence as measured with the Barthel index on POD5.
5. Study Strengths and Limitations
The main strength of our study is our innovative methodological approach. To the best of our knowledge this is the first study to evaluate the multidimensional impact of pain on kinesiophobia. There are several limitations of our study. First, composite scores used in our study require calculations, and are therefore not appropriate as a tool in everyday clinical routine. Second, sample size is relatively small. Third, the participants in this study are exclusively from a single hospital in Serbia. Therefore, it remains uncertain how these finding can be extrapolated to a wider general population. Finally, the pre- surgery kinesiophobia scores were not assessed.
6. Conclusions
Our research findings reveal a high prevalence of kinesiophobia after TKA, highlighting its importance during post-operative care. Moreover, our study identifies pain as a significant predictor of kinesiophobia and its impact on poor functional outcomes after surgery. Notably, composite scores for pain evaluation prove to be superior to unidimensional scales, offering a more comprehensive approach to understanding the connection between pain and kinesiophobia. By identifying individuals prone to kinesiophobia through multidimensional pain assessment, healthcare professionals can adjust strategies to improve outcomes and post-surgery recovery. Further research is expected to show the influence of improved pain treatment strategies on kinesiophobia levels in patients after TKA and to quantify the impact of individual PROs on kinesiophobia.
Author Contributions
Supervision, E.D.R.; methodology, formal analysis, and writing—original draft preparation M.A., E.D.R.; performed the measurements M.A.,S.T.V., I.S.; writing—review and editing, E.D.R.,R.Z.,W.M. M.A.; visualization, M.K., D.M.
Funding
This research received no external funding.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the Clinical Center of Serbia (Number 2017-004244-37).”
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study
Conflicts of Interest
The authors declare no conflict of interest
References
- Ackerman IN, Bohensky MA, Zomer E, Tacey M, Gorelik A, Brand CA, et al. The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030. BMC Musculoskelet Disord. 2019 Dec;20(1):90.
- Sloan M, Premkumar A, Sheth NP. Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am. 2018 Sep 5;100(17):1455–60.
- Cremeans-Smith JK, Boarts JM, Greene K, Delahanty DL. Patients’ reasons for electing to undergo total knee arthroplasty impact post-operative pain severity and range of motion. J Behav Med. 2009 Jun;32(3):223–33.
- Wylde V, Rooker J, Halliday L, Blom A. Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep. Orthop Traumatol Surg Res OTSR. 2011 Apr;97(2):139–44.
- Von Keudell A, Sodha S, Collins J, Minas T, Fitz W, Gomoll AH. Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis. The Knee. 2014 Jan;21(1):180–4.
- Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, et al. Psychological determinants of problematic outcomes following Total Knee Arthroplasty. Pain. 2009 May;143(1–2):123–9.
- Trousdale RT, McGrory BJ, Berry DJ, Becker MW, Harmsen WS. Patients’ concerns prior to undergoing total hip and total knee arthroplasty. Mayo Clin Proc. 1999 Oct;74(10):978–82.
- Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009 May;9(5):745–58.
- Swinkels-Meewisse EJCM, Swinkels R a. HM, Verbeek ALM, Vlaeyen JWS, Oostendorp R a. B. Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Man Ther. 2003 Feb;8(1):29–36.
- Monticone M, Ferrante S, Rocca B, Salvaderi S, Fiorentini R, Restelli M, et al. Home-based functional exercises aimed at managing kinesiophobia contribute to improving disability and quality of life of patients undergoing total knee arthroplasty: a randomized controlled trial. Arch Phys Med Rehabil. 2013 Feb;94(2):231–9.
- De Vroey H, Claeys K, Shariatmadar K, Weygers I, Vereecke E, Van Damme G, et al. High Levels of Kinesiophobia at Discharge from the Hospital May Negatively Affect the Short-Term Functional Outcome of Patients Who Have Undergone Knee Replacement Surgery. J Clin Med. 2020 Mar 9;9(3):738.
- Güney-Deniz H, Irem Kınıklı G, Çağlar Ö, Atilla B, Yüksel İ. Does kinesiophobia affect the early functional outcomes following total knee arthroplasty? Physiother Theory Pract. 2017 Jun;33(6):448–53.
- Brown OS, Hu L, Demetriou C, Smith TO, Hing CB. The effects of kinesiophobia on outcome following total knee replacement: a systematic review. Arch Orthop Trauma Surg. 2020 Dec;140(12):2057–70.
- Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435.
- Doury-Panchout F, Metivier JC, Fouquet B. Kinesiophobia negatively influences recovery of joint function following total knee arthroplasty. Eur J Phys Rehabil Med. 2015 Apr;51(2):155–61.
- Kocic M, Stankovic A, Lazovic M, Dimitrijevic L, Stankovic I, Spalevic M, et al. Influence of fear of movement on total knee arthroplasty outcome. Ann Ital Chir. 2015;86(2):148–55.
- Filardo G, Merli G, Roffi A, Marcacci T, Berti Ceroni F, Raboni D, et al. Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2017 Nov;25(11):3417–23.
- Cai L, Liu Y, Xu H, Xu Q, Wang Y, Lyu P. Incidence and Risk Factors of Kinesiophobia After Total Knee Arthroplasty in Zhengzhou, China: A Cross-Sectional Study. J Arthroplasty. 2018 Sep;33(9):2858–62.
- Degirmenci E, Ozturan KE, Kaya YE, Akkaya A, Yucel İ. Effect of sedation anesthesia on kinesiophobia and early outcomes after total knee arthroplasty. J Orthop Surg Hong Kong. 2020;28(1):2309499019895650.
- Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].
- Gewandter JS, McDermott MP, Evans S, Katz NP, Markman JD, Simon LS, et al. Composite outcomes for pain clinical trials: considerations for design and interpretation. Pain. 2021 Jul 1;162(7):1899–905.
- Zaslansky R, Rothaug J, Chapman CR, Bäckström R, Brill S, Fletcher D, et al. PAIN OUT: the making of an international acute pain registry. Eur J Pain Lond Engl. 2015 Apr;19(4):490–502.
- Rothaug J, Zaslansky R, Schwenkglenks M, Komann M, Allvin R, Backström R, et al. Patients’ perception of postoperative pain management: validation of the International Pain Outcomes (IPO) questionnaire. J Pain. 2013 Nov;14(11):1361–70.
- Brooks, R. EuroQol: the current state of play. Health Policy Amst Neth. 1996 Jul;37(1):53–72.
- Miller RP, Kori SH, Todd DD. The Tampa Scale: a Measure of Kinisophobia. Clin J Pain. 1991 Mar;7(1):51.
- Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995 Sep;62(3):363–72.
- Liu H, Huang L, Yang Z, Li H, Wang Z, Peng L. Fear of Movement/(Re)Injury: An Update to Descriptive Review of the Related Measures. Front Psychol. 2021;12:696762.
- Barthel Index (BI) – Strokengine [Internet]. [cited 2023 Dec 16]. Available from: https://strokengine.ca/en/assessments/barthel-index-bi/.
- ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002 Jul 1;166(1):111–7.
- Hofer DM, Lehmann T, Zaslansky R, Harnik M, Meissner W, Stüber F, et al. Rethinking the definition of chronic postsurgical pain: composites of patient-reported pain-related outcomes vs pain intensities alone. Pain. 2022 Dec;163(12):2457–65.
- Philipp Baumbach Ruth Zaslansky, Ruth Edry. Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data.
- Portney, LG. Foundations of clinical research: applications to evidence-based practice. Fourth edition. Philadelphia: F.A. Davis; 2020. 1 p.
- Kroska, EB. A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain. Scand J Pain. 2016 Oct;13:43–58.
- Brown ML, Plate JF, Von Thaer S, Fino NF, Smith BP, Seyler TM, et al. Decreased Range of Motion After Total Knee Arthroplasty Is Predicted by the Tampa Scale of Kinesiophobia. J Arthroplasty. 2016 Apr;31(4):793–7.
- Filardo G, Roffi A, Merli G, Marcacci T, Ceroni FB, Raboni D, et al. Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2016 Oct;24(10):3322–8.
Table 1.
Sample description for Continous and Dichotomous Variables.
| VARIABLE | median | Q1 | Q3 |
| Age(y.) § | 68 | 63 | 74 |
| Weight(kg) § | 82 | 70 | 90 |
| BMI(kg/m²)§ | 28.4 | 25.3 | 32 |
| Duration of surgery§ | 138 | 120 | 165 |
| Intensity of chronic pain before admission‡ | 6 | 5 | 8 |
| EQ5D preoperative | 0.636 | 0.416 | 0.750 |
| Pain Composite Score-total (PCStotal) POD1 | 2.07 | 1.31 | 2.79 |
| Pain Composite Score-total (PCStotal) POD5 | 0.41 | 0.09 | 1.11 |
| VARIABLE | N | % | - |
| Gender† Male Female |
20 55 |
27 73 |
|
| Marital status† Married Single |
69 6 |
92 8 |
|
| Education† Primary school or under Secondary school College |
18 44 13 |
24 59 17 |
|
| Type of anesthesia† General Spinal |
29 46 |
39 61 |
|
| Nonopioid administered (ward) Paracetamol Ketoprofen Ketrolac Metamizole |
71 36 15 32 6 |
96 48 20 43 8 |
|
| Systemic opioid (ward) | 63 | 85 |
* † The values are given as the number of patients with the percentage in parentheses; § the values are given as the mean± standard deviation (SD); ‡ the values are given as numerical rating scale scores by median with interquartile range (IQR); EQ5D= EuroQol-5D.
Table 2.
Comparasion of total composite scores and subscores between TKA patients with or without kinesiophobia.
Table 2.
Comparasion of total composite scores and subscores between TKA patients with or without kinesiophobia.
| Low kinesiophobia N(55) | High kinesiophobia (20) | P value | |||||
| Variable | median | Q1 | Q3 | median | Q1 | Q3 | |
| POD1 | |||||||
| PCStotal 1 † | 1.59 | 1.10 | 2.52 | 2.76 | 2.33 | 3.71 | 0.002 |
| PCS 1 | 2.6 | 1.40 | 4.00 | 4.7 | 3.35 | 5.55 | 0.002 |
| PITS1 | 1 | 1.00 | 2.00 | 2.00 | 1.00 | 3.75 | 0.039 |
| PSE1 | 0.50 | 0.00 | 2.00 | 1.12 | 0.00 | 2.75 | 0.180 |
| POD5 | |||||||
| PCStotal2 ‡ | 0.31 | 0.09 | 0.55 | 1.28 | 0.59 | 2.15 | 0.000 |
| PCS2 | 0.00 | 0.00 | 0.70 | 2.35 | 0.90 | 3.60 | 0.000 |
| PITS2 | 0.43 | 0.14 | 0.43 | 1.57 | 1.00 | 2.14 | 0.000 |
| PSE2 | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | 0.50 | 0.166 |
The values are given as numerical rating scale scores by a median with interquartile range (IQR); †PCStotal 1- composite score of patient-reported outcome measure on POD1; ‡PCS2 composite score of patient-reported outcome measure on POD5;.
Table 3.
Comparison of PROs that are not included in composite scores between TKA patients with or without kinesiophobia.
Table 3.
Comparison of PROs that are not included in composite scores between TKA patients with or without kinesiophobia.
| Low kinesiophobia N(55) | High kinesiophobia (20) | P value | |||||
| Variable | median | Q1 | Q3 | median | Q1 | Q3 | |
| Outcomes that are not included in composite scores on POD1 | |||||||
| Pain interfering with activities out of bed† | 3 | 2 | 5 | 5 | 3.5 | 6.5 | 0.811 |
| Participation in decisions regarding pain treatment | 9 | 6 | 10 | 7.5 | 6 | 10 | 0.355 |
| Satisfied with the result of pain treatment | 9 | 8 | 10 | 9 | 7 | 9 | 0.108 |
| mean | SD | mean | SD | ||||
| Percentage of pain relief§ | 75.82 | ±21.40 | - | 69.00 | ±25.11 | - | 0.205 |
| N | % | N | % | ||||
| Desire more pain treatment‡ Yes No |
29 26 |
73 47 |
11 9 |
55 45 |
|||
| Percetnage of patients getting out of bed Yes No |
34 21 |
62 38 |
13 7 |
65 35 |
1.000 |
||
| Outcomes that are not included in composite scores on POD5 | |||||||
| Pain interfering with activities out of bed | 1 | 0 | 3 | 3 | 1 | 5 | 0.047 |
| Participation in decisions regarding pain treatment | 9 | 9 | 10 | 9 | 4.25 | 10 | 0.518 |
| Satisfied with the result of pain treatment | 9 | 9 | 10 | 9.5 | 8.25 | 10 | 0.644 |
| mean | SD | mean | SD | ||||
| Percentage of pain relief§ | 86.48 | ± 17.82 | - | 68.75 | ± 18.21 | - | 0.001 |
| N | % | N | % | ||||
| Desire more pain treatment‡ Yes No |
3 52 |
5 95 |
7 13 |
8 65 |
0.003 |
||
| Health related quality of life | |||||||
| mean | SD | mean | SD | ||||
| EQ5D preoperative§ | 0.599 | ± 0.209 | 0.467 | ± 0.267 | 0.052 | ||
| EQ5D POD5 | 0.674 | ± 0.141 | 0.539 | ± 0.218 | 0.000 | ||
*† the values are given as numerical rating scale scores by median with interquartile range (IQR); § the values are given as the mean± standard deviation (SD); ‡The values are given as the number of patients with the percentage; EQ5D= EuroQol-5D
Table 4.
Univariable prediction model of kinesiophobia.
| OR | 95% CI | p-value | |
| EQ5Dpreoperative | 0.087 | 0.009-0.860 | 0.037 |
| Intensity of chronic pain before surgery | 1.359 | 1.016-1.817 | 0.038 |
| PCStoal on POD1 | 2.183 | 1.289-3.696 | 0.004 |
| PCStotal on POD5 | 3.051 | 1.546-6.022 | 0.001 |
| Percentage of pain relief on POD5 | 0.974 | 0.950-0.998 | 0.037 |
| Pain interfering with activities out of bed POD5 | 1.272 | 1.015-1.549 | 0.037 |
| Desire more pain treatment on POD5 | 0.107 | 0.024-0.472 | 0.003 |
| EQ5D POD5 | 0.014 | 0.001-0.378 | 0.011 |
| OR: Odds ratio; 95% CI confidence interval; |
Table 5.
Multivariable prediction model of kinesiophobia.
| OR | 95% CI | p-value | |
| PCStotal on POD1 | 2.139 | 1.202-3.807 | 0.010 |
| PCStotal on POD5 | 6.191 | 1.918-19.979 | 0.002 |
| Intensity of chronic pain before surgery | 1.462 | 1.017-2.103 | 0.040 |
| Pain interfering with activities out of bed | 0.692 | 0.444-1.080 | 0.105 |
| OR: Odds ratio; 95% CI confidence interval; |
Table 6.
Difference between groups regarding functional outcome.
| Without kinesiophobia N(55) | With kinesiophobia (20) | ||||
| Variable | mean | SD | mean | SD | P value |
| Barthel | 77 | 11.21 | 66.25 | 13.66 | 0.001 |
| 6MTW | 112.64 | 45.51 | 74.90 | 50.35 | 0.002 |
| Extension | -16.64 | 9.33 | -22.25 | 7.86 | 0.020 |
| Flexion | 65.55 | 17.73 | 63.25 | 14.26 | 0.468 |
6MWT= 6-minute walking test.
Table 7.
Univariable prediction model of functional recovery.
| B | 95% CI | p-value | |
| 6MTW | -0.340 | -32.102;-13.371 | 0.000 |
| BARTHEL | -0.376 | -16.939;-4.561 | 0.000 |
| EXTENSION | -0.270 | -10.283;-0.944 | 0.019 |
| FLEXION | -0.061 | -11.090;6.499 | 0.604 |
| 6MWT= 6-minute walking test |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
MDPI Initiatives
Important Links
© 2024 MDPI (Basel, Switzerland) unless otherwise stated