|Year : 2020 | Volume
| Issue : 2 | Page : 40-43
Kinesiophobia in anterior cruciate ligament reconstruction patient: A questionnaire‑based study
Naif Alhamam1, Fatimah Mustafa ALthabit2, Arwa Hussain AlOnayzan2, Zahrah Ahmed AlAbdullah2, Khadijah Mustafa Alali2
1 Department of Orthopaedics, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
2 Medical interns, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
|Date of Submission||20-Oct-2020|
|Date of Acceptance||20-Dec-2020|
|Date of Web Publication||20-Jan-2021|
Dr. Fatimah Mustafa ALthabit
College of Medicine, King Faisal University, Riyadh
Source of Support: None, Conflict of Interest: None
Objectives: This study aimed to assess the prevalence of kinesiophobia in anterior cruciate ligament (ACL) reconstruction to reach a successful outcome in rehabilitation strategies.
Patients and Methods: A cross-sectional study was conducted in Al-Ahsa Region, Saudi Arabia, in the period between 2019 and 2020. One hundred and thirty-five post-ACL reconstruction patients participated in this study. They were asked to fill out the Arabic version of the Kinesiophobia' Tampa scale to assess their fear of movement post-ACL. Categorical variables were displayed as numbers and percentages, while we used mean (+, _−) standard deviation, and median for continuous variable. Data were analyzed using Mann–Whitney U-test, and the Shapiro–Wilk test at a level of significant P < 0.05.
Results: The prevalence of kinesiophobia after ACL reconstruction was very high. According to the Tampa scale, about 77% of patients had a high score of kinesiophobia, and 31% had low scores of kinesiophobia. Age, gender, marital status, and occupational status did not show any significant role in the level of kinesiophobia.
Conclusion: Kinesiophobia prevalence was very high after ACL reconstruction. Furthermore, more studies are needed to adjust the rehabilitation and physiotherapy postoperation.
Keywords: Anterior cruciate ligament injury, kinesiophobia, knee injury, reconstruction, rehabilitation
|How to cite this article:|
Alhamam N, ALthabit FM, AlOnayzan AH, AlAbdullah ZA, Alali KM. Kinesiophobia in anterior cruciate ligament reconstruction patient: A questionnaire‑based study. Saudi J Sports Med 2020;20:40-3
|How to cite this URL:|
Alhamam N, ALthabit FM, AlOnayzan AH, AlAbdullah ZA, Alali KM. Kinesiophobia in anterior cruciate ligament reconstruction patient: A questionnaire‑based study. Saudi J Sports Med [serial online] 2020 [cited 2023 May 31];20:40-3. Available from: https://www.sjosm.org/text.asp?2020/20/2/40/307523
| Introduction|| |
The knee is a complex joint where many ligaments control its stability. The anterior cruciate ligament (ACL) is the most important one, that maintain knee stability and its inner rotation. Therefore, ACL injuries are crucial and common injuries and exceeded more than 50% of all knee injuries., In the USA, ACL injury incidence reached 200,000 per year with almost 100,000 ACL reconstructions annually., Surgical reconstruction is a standard procedure to manage ACL injuries to restores the knee's mechanical stability. Inability to restore knee function postsurgery has been attributed to many factors, such as knee symptoms such as swelling, instability, or lack of knee motion. Some studies emphasized that expanded worry of re-injury might diminish the physical activities. Regarding patients' fear of re-injury, it was reported that 24% of ACL reconstruction patients could not return practicing sport., In addition, Clifford et al. supported these results. Also, it was reported that the athlete's short-term rehabilitation and long-term goals of return to sport, were negatively impacted due to kinesiophobia or fear of re-injury, because kinesiophobia is a psychological barrier that preventing individuals to return to their preinjury activities. In 2020, Boulding confirmed all previous results and indicated that despite of regaining full physical knee function; many patients could not return to their preinjury activities. In medical settings, to improve patient's outcomes in rehabilitation strategies, fear as a crucial factor of patient disability should be recognized., Tampa Scale of Kinesiophobia (TSK) was developed to assess kinesiophobia and its impact on fear of activities, fear-avoidance, fear of re-injury.,
The rehabilitation process after ACL injury included some physical and psychological barriers. Kinesiophobia is a psychological barrier that plays a significant role in limiting individuals to return to their preinjury activities. No study has investigated kinesiophobia in post-ACL reconstruction patients among the Saudi population to the best of our knowledge. Therefore, this research aimed to study the prevalence of kinesiophobia in post-ACL reconstruction to achieve a successful outcome in the rehabilitation strategies.
| Patients and Methods|| |
A quantitative cross-sectional study was carried out in the AlAhsa region of Saudi Arabia from January 2019 to February 2020. Approximately 135 patients responded and participated in our research. Saudi patients who underwent ACL surgery previously were recruited from orthopedic clinics and rehabilitation centers. They were interviewed personally during the follow-up. Data collection included patients' demographics characteristics such as age, gender, marital status, and the occupational state. All patients who have ACL injury within 6 months to 1 year and undergone rehabilitation were included in the study. Patients who did not preformed ACL reconstruction and those with other than ACL injury were excluded from the study. A validated Arabic version of the TSK has been used to assess patients' fear of re-injury post-ACL reconstruction.
Tampa scale for Kinesiophobia
It consisted of 17 questions; each addressed the intensity of pain and symptoms. A 4-point Likert scale was applied to measure the degree of response “strongly disagree” is equivalent to one point, two for “disagree,” “agree,” and “strongly agree” were three and four points, respectively. Questions 4, 8, 12, and 16 were negative questions, which needed reversing the scores to obtain the final score. A possible score ranged from a minimum of 17 to a maximum of 68 points. A higher level of kinesiophobia was indicated by getting a higher score. The results were divided into two levels of score: <37 points were considered low score, and ≥37 points were regarded as high.
Data were analyzed using Statistical Product and Service Solutions (IBM SPSS Inc., version 21, Armonk, New York, United States); numbers and percentages (%) were used for all categorical variables. Mean ± standard deviation (SD) and median (interquartile range) were used for continuous variables. Mann–Whitney U-test (nonparametric test) was used to compare between TSK total score and patients' basic demographic data. Normality tests were conducted using the Shapiro–Wilk test. A P < 0.05 at 95% confidence interval was considered statistically significant.
| Results|| |
One hundred and thirty-five post-ACL reconstruction patients participated in this study. The participants' age ranged from 19 to 49 years old (mean = 30.4). Approximately more than half of the participants (55.6%) aged ≤30 years. Males dominated the females (97.8% vs. 2.2%), approximately two-third of the respondents (63%) were married, and 85.2% were working, as shown in [Table 1].
|Table 1: Basic demographic characteristics of patients who underwent anterior cruciate ligament reconstruction (n=135)|
Click here to view
The mean TSK score was 41.6 (SD 7.30), out of 68 points, median 42.0 (22.0–60.0). The prevalence of patients with high TSK score was 77% (n = 77), and the rest were with a low score (23%; n = 31).
These factors; age group (T = 0.554; P = 0.811), gender (T = 0.464; P = 0.386), marital status (T = 0.234; P = 0.742), and occupational status (T = −1.033; P = 0.387) did not show statistically significant differences when compared to the TSK score [Table 2].
|Table 2: Statistical association between Tampa Scale of Kinesiophobia total score and the essential demographic characteristics of patients who underwent anterior cruciate ligament reconstruction (n=135)|
Click here to view
| Discussion|| |
Our study showed that most of the participants (77%) had Kinesiophobia based on the TSK score. This finding is consistent with a previous study addressing that the patients who did not return to preinjury activities were afraid of re-injury. Clifford et al. reported in his study that the majority of the participants around (78.4%) found to have high levels of Kinesiophobia after ACL reconstruction which is consistent with this study.
This current study showed no significant difference between the gender and the TSK, which agreed with a previous study. While these findings disagreed with Shah et al., at which women showed a higher risk of Kinesiophobia (67.44%) than males (60.12%). Furthermore, Bränström and Fahlström stated that males are more affected with Kinesiophobia than females.
The current study demonstrated that no significant difference was recorded between different age groups regarding TSK. In contrast with a previous study which found that as the age increase, the TSK score increases. More research is needed to study the age effects on Kinesiophobia after ACL reconstruction. Our study results agreed with Shah et al. who reported a high prevalence of Kinesiophobia (61.69%) in 4–8 weeks post-ACL reconstruction among young groups of patients aged <35 years old (mean = 25.7) that might be attributed to their fear of re-injury and might be a reason of not returning to preinjury level. In addition, Medvecky and Nelson stated that the prevalence of Kinesiophobia was high (63%) that might be returned to fear of injury that prevented them to go back to their full functional activity.
Hartigan et al. reported a high prevalence of Kinesiophobia and a higher score of TSK. While the level of Kinesiophobia was reduced by applying for a neuromuscular training program among all patients who underwent ACL reconstruction. Fitzgerald et al. reported a positive impact of disturbance training on knee stability among patients who underwent ACL reconstruction.
The study is designed to answer TSK one time after the procedure; further studies are needed to observe the changes in Kinesiophobia in different periods after ACL reconstruction. This study also did not investigate the relation between sports' type, time from injury to surgery, and their effect on Kinesiophobia. In addition, the current study did not investigate their level of participation whether professional athletes or just recreational
Data collection was done in orthopedics clinics and rehabilitation centers and the information were taken in details from patients themselves. This was helpful in strength the results of the study.
In the future, more studies are needed with a larger sample size, and more rehabilitation strategies should be applied to assess patient status before and after rehabilitation. In addition, more studies are required to investigate the relation between sports' type, time from injury to surgery and their effect on Kinesiophobia, and their level of participation whether professional athletes or just recreational
| Conclusion|| |
A high level of Kinesiophobia and fear of movement were reported among patients post-ACL reconstruction based on TSK score in the current study. Furthermore, more studies are needed to adjust the rehabilitation and physiotherapy postoperation. Additionally, the efficacy of psychological approaches for enhancing the physical activities post-ACL reconstruction should be determined.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Markolf KL, Mensch JS, Amstutz HC. Stiffness and laxity of the knee – The contributions of the supporting structures. A quantitative in vitro
study. J Bone Joint Surg Am 1976;58:583-94.
Risberg MA, Lewek M, Snyder-Mackler L. A systematic review of the evidence for anterior cruciate ligament rehabilitation: How much and what type? Phys Ther Sport 2004;5:125-45.
Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med 2013;41:216-24.
Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J Knee Surg 1991;4:43-8.
Brown CH Jr., Carson EW. Revision anterior cruciate ligament surgery. Clin Sports Med 1999;18:109-71.
Chmielewski TL, Zeppieri G Jr., Lentz TA, Tillman SM, Moser MW, Indelicato PA, et al
. Longitudinal changes in psychosocial factors and their association with knee pain and function after anterior cruciate ligament reconstruction. Phys Ther 2011;91:1355-66.
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;43:821-32.
Gregg CD, McIntosh G, Hall H, Watson H, Williams D, Hoffman CW, et al
. The relationship between the Tampa scale of kinesiophobia and low back pain rehabilitation outcomes. Spine J 2015;15:2466-71.
Clifford A, Buckley E, O'Farrell D, Louw Q, Moloney C. Fear of movement in patients after anterior cruciate ligament reconstruction. Physiother Pract Res 2017;38:113-20.
Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: A critical review of the related measures. Pain Res Treat 2011;2011:26.
Lüning Bergsten C, Lundberg M, Lindberg P, Elfving B. Change in kinesiophobia and its relation to activity limitation after multidisciplinary rehabilitation in patients with chronic back pain. Disabil Rehabil 2012;34:852-8.
Houben RM, Leeuw M, Vlaeyen JW, Goubert L, Picavet HS. Fear of movement/injury in the general population: Factor structure and psychometric properties of an adapted version of the Tampa Scale for Kinesiophobia. J Behav Med 2005;28:415-24.
Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re) injury in chronic low back pain and its relation to behavioural performance. Pain 1995;62:363-72.
Lentz TA, Zeppieri G Jr., George SZ, Tillman SM, Moser MW, Farmer KW, et al
. Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med 2015;43:345-53.
Kori SH, Miller RP, Todd DD. Kinesiophobia: A new view of chronic pain behavior. Pain Manag 1990;3:35-43.
Vlaeyen S, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re) injury in chronic low back pain and its relation to behavioural performance. Pain1995;62:363-72.
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;13:393-7.
Larsson C, Hansson EE, Sundquist K, Jakobsson U. Psychometric properties of the Tampa Scale of Kinesiophobia (TSK-11) among older people with chronic pain. Physiother Theory Pract 2014;30:421-8.
Shah RC, Ghagare J, Shyam A, Sancheti P. Prevalence of Kinesiophobia in young adults post ACL reconstruction. Int J Physiother Res 2017;5:1798-801.
Bränström H, Fahlström M. Kinesiophobia in patients with chronic musculoskeletal pain: Differences between men and women. J Rehabil Med 2008;40:375-80.
Patil N, Kahile M, Pimpale S, Nagulkar J. Prevalence of kinesiophobia in low back pain in first day physiotherapy OPD patient. Indian J Physiother Occup Ther 2017;11:111-4.
Medvecky MJ, Nelson S. Kinesiophobia and return to sports after anterior cruciate ligament reconstruction. Conn Med 2015;79:155-7.
Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther 2000;80:128-40.
[Table 1], [Table 2]