Key words
kinesiophobia - quality of life - function - disability - depression
Schlüsselwörter
Kinesiophobie - Lebensqualität - Funktion - Behinderung - Depressionpublished online 2022
Introduction
Osteoarthritis is a common chronic degenerative disease, causing disruptions in
joints, muscle weakness and loss of deep joint sense, as well as limitations in
daily life [1]
[2]
[3]
[4]. Occupying the first place in terms of the
incidence of musculoskeletal diseases, OA has become a major health problem in the
aging world. A radiographic study reported that the annual incidence of knee OA was
2.3%, progression rate was 2.8% per year and worsening rate was
3% per year [5]
[6]. For all these reasons, the burden of this
disease on the health system is also quite high [7]. OA is one of the most important causes of musculoskeletal pain [8]. Moreover, it can cause disability by
causing muscle strength and flexibility loss, and impairing functionality [9]. As a result of all these changes,
depression and anxiety disorders can develop while the quality of life declines
[10]. Due to increased pain sensation, the
person may be afraid to move and may respond with avoidance or confrontation in
coping with pain. Avoidance of activity increases with fear. This vicious cycle
forms the basis of kinesiophobia, that is, the fear of movement [11]. According to Kori and his colleagues who
studied the relationship between chronic pain and physical activity in 1990,
kinesiophobia was defined as “a condition in which patients had a fear of
physical activity in an excessive, unreasonable and debilitating way, or developed a
feeling of a painful injury or re-injury after an activity” [11]. Vlaeyen and his colleagues describe
kinesiophobia as a special fear of believing in injury, such as “fear of
movement/(re)injury” [12].
Although there are numerous studies in knee-osteoarthritic individuals with regard to
parameters such as joint degeneration, pain, muscular strength and functionality
[13]. There are a limited number of
studies examining the factors associated with kinesiophobia [8]
[14]
[15]. However there can be
potential connection between kinesiophobia and functional outcomes of OA such as
pain intensity, quadriceps, hamstring strength, balance, mobility, physical activity
level, disability, quality of life, depression and anxiety. Severe chronic pain,
fear and anxiety associated with pain lead to evading activity and depression, all
of which contribute to even more impairment of functional status and quality of life
[16]
[17]. Previous studies demonstrated cognitive and behavioural aspects
associated with knee OA [18]
[19]
[20].
Individuals with knee OA may prefer to avoid daily life activities that can cause
their pain to start, such as sitting up and down, going up and down stairs, and
doing things that require bending the knee. It has been repeatedly stated that pain
is a biopsychosocial concept and may affect both psychological and social conditions
and functionalities of patients [21]
[22]. Especially in patients with chronic pain,
kinesophobia due to the effects of both physical and psychosocial components is
thought to be able to worsen the quality of life and mood of the patient and may
have effects on disease progression. As a result of the studies, although it is
thought that it will contribute to the development of kinesophobia in psychosocial
components such as anxiety, depression and quality of life as well as physical
components such as pain, ROM, strength, physical activity level and function, there
is no consensus on which factor can be more effective [16]
[17]
[18]
[19]
[20].
There are a limited number of studies investigating factors that contribute to the
development of kinesiophobia pain patients with OA [18]
[19]
[20]. For all these reasons, it is very
important to determine the factors that affect kinesiophobia in OA and to draw an
appropriate treatment plan for disease progression.The research question of this
study are which factors are more related to kinesiophobia in patients with knee
OA.Thus, it was aimed to reveal the capacity of OA to affect the functional
outcomes.It was aimed to determine the factors that cause fear of movement in knee
osteoarthritis, and to form a guiding qualification for clinicians who work in this
field to primarily focus on these factors while shaping treatment programs.
Subjects and Methods
60 individuals (64±11 years) who were diagnosed with grade 2-3 bilateral,
primary knee OA according to Kellgren Lawrence scoring, [23] were included in the study. Patients with
the knee OA were recruited by a physician during routine consultations at the
University Hospital. The demographic characteristics of the patients participating
in the study are shown in [Table 1]. All
participants were informed verbally and in writing about the purpose of the research
and the evaluation methods to be applied. Written informed consents were obtained
from each participant. Permission was taken from the Clinical Trials Ethical
Committee for the study. The criteria for inclusion in the study were the acceptance
of participation in the study, being between the ages of 40-80, and being diagnosed
with grade 2-3 osteoarthritis according to the Kellgren Lawrence scoring. Patients
with other neurological, musculoskeletal, rheumatic diseases and trauma-induced OA
that affect balance and muscle strength, patients with past knee surgery, patients
with severe comorbidities, and pregnants were excluded from the study.
Table 1 The demographic characteristics of the
patients.
|
Mean±SD (n=60)
|
|
Age
|
64±11
|
|
Height(cm)
|
159,5±22
|
|
Weight (kg)
|
75,3±14,2
|
|
BMI(kg/m²)
|
28,7±5
|
SD: Standard deviation, BMI: Body Mass Index.
Evaluation methods
Kinesiophobia
A transculturally adapted version of the Tampa Scale of Kinesiophobia (TSK),
which was developed to measure the fear of movement/re-injury of
patients, was used [24]. The scale
contains 17 questions including injury/re-injury and fear-avoidance
parameters that are about falling and fear of movement; and, it is used in
acute and chronic back pain, fibromyalgia and musculoskeletal injuries and
whiplash-related diseases [12]
[25]. The 4-point Likert scale (from
strongly disagree (score=1) to strongly agree (score=4)) is
used on the scale. The high score (maximum 68) indicates that the
patient’s fear of falls and movements is excessive [26]. The test-retest reliability of the
transcultural version of the Tampa Scale of Kinesiophobia was shown to be
0.806 (95% CI=0.720-0.867) [19].
Pain Intensity
Knee pain severities of all the cases participating in the study were
measured using the Visual Analog Scale (VAS) during activity and rest. The
cases were asked to mark the pain levels they felt on a horizontal line of
100 millimeters (mm). 0 indicated no pain, 10 indicated maximum pain
refering to too much pain to tolerate. The point marked on the line was
measured with a ruler, and the intensity of the pain felt by the persons was
recorded in cm [27].
Physical Evaluations
Quadriceps muscle strength
The muscle strength was measured using the Lafayette manual muscle testing
system (Range: 0-300lbs; 136.1 kg). In order to measure the
quadriceps muscle strength, the patient was asked to perform a knee
extension against the dynamometer stabilized in the bed by placing
perpendicularly on the tibia immediately above the malleoli, while the
patient was in sitting position with the knees in a 90-degree flexion
position. The value displayed in the digital dynamometer was recorded as the
quadriceps muscle strength [28].
Hamstring muscle strength
While the patient was lying in the supine position, the dynamometer was
placed just above the ankle joint, and the patient was asked to flex his
leg. The value displayed in the digital dynamometer was recorded as the knee
flexion muscle strength [28].
Range of Motion
The patient was placed in a supine position, and the normal joint motion
range of the knee joint in the direction of flexion and extension was
passively measured using a manual goniometer [29].
Balance
The Berg Balance Scale (BBS) was used to assess the balance [30]. This test assesses the ability of
individuals to maintain their balances while performing their functional
activities. This balance test consists of 14 items, and each section is
rated between “0”, the lowest level of function, and
“4” the highest level of function. It measures the level of
dependence and/or independence when performing positions, such as
standing up from the sitting stance, standing with the feed together,
standing in tandem stance and balancing on one leg. It also measures whether
the person can switch positions. The highest score from the BBS shows the
best balance. A score of 0-20 shows high, 21-40 medium and 41-64 low risk of
fall [31].
Mobility
The Timed Up and Go (TUG) Test was used to measure the main balance and
mobility including ambulance, transfer and turning ability [32]. The cases, while in sitting stance
on a chair, were asked to get up and walk for 3 meters. And then they were
asked to turn and sit back. The elapsing time was recorded [33].
Physical activity level
The validated version of International Physical Activity Questionnaire (IPAQ)
short form was used to determine the level of physical activity [34]. The questionnaire was developed by
Craig et al. to determine the physical activity levels of adults [35]. In the evaluation of all the
activities in the questionnaire, it is taken as a criterion that each
activity is done at least 10 minutes at a time. A score of
“MET-minute/week” is obtained by multiplying the
minutes, days and MET values. Physical activity levels were classified as
physically inactive (<600 MET-min/week), low in physical
activity (600-3000 MET-min/week) and adequate in physical activity
(>3000 MET-min/week) [35].
Psychosocial Evaluations
Disability
The assessment of the pain, stiffness and physical function of the
individuals included in the study was made using transcultural adaptation of
the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
[36]. WOMAC is an OA-specific,
valid and reliable measure that includes 24 questions in three sub-headings
consisting of pain, stiffness and physical function. Each question was rated
according to the Likert scale, by accepting 0=None,
1=Slight, 2=Moderate, 3=Very, 4=Extremely.
The score of each section was calculated within itself. A high score
indicates an increase in pain and stiffness, and physical function
impairment [37].
Health-related quality of life (HRQOL)
The transcultural adaptation version of the Nottingham Health Profile (NHP)
was used to assess the health-related quality of life [38]. The Nottingham Health Profile is a
general quality of life questionnaire designed to measure perceived health
problems and the extent to which these problems affect normal daily
activities. The survey had a total of 38 questions consisting of six
sub-sections: lack of energy (3 items), pain (8 items), emotional reaction
(9 items), sleep disturbance (5 items), social isolation (5 items), and
physical mobility (9 items). The questions are answered as
“yes” or “no” by the cases; and the best
score to be taken in the sub-sections is “0”, and the worst
score is “100”.
Depression and anxiety
A valid and reliable version of the Hospital Anxiety and Depression Scale
(HADS) was used to assess the psychological status of the patients [39]. The scale was prepared to screen
for anxiety and depression in those with bodily disease. It was developed by
Zigmond and Snaith [40] to determine
the risk of anxiety and depression, and to assess its level, severity and
change. A 3-point Likert scale was used in this scale consisting of 14
questions. The cut-off points of the Turkish version of HADS were set to be
10 for the anxiety sub-scale and 7 for the depression sub-scale [39].
Statistical Analysis
The statistical package program SPPS 20 (IBM Corp. Released 2011. IBM SPSS
Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) was used to
evaluate the data. The variables are expressed as mean±standard
deviation, percent and frequency values. The assumption of normality was checked
by the “Shapiro-Wilk” test. The relationship between two
continuous variables was assessed by the Pearson Correlation Coefficient. It was
assessed by the Spearman Correlation Coefficient when parametric test
assumptions were not met. Forward stepwise multiple regression analysis was
performed to ascertain which combination of variables related most closely to
the Tampa scale. The statistical significance level was accepted as
p<0.05. A sample size of 60 produces a two-sided 95% confidence
interval with a width equal to 0.397 when the sample correlation is 0.480. In
this case, it is expected that the power of the test will be about
80.03%.
Results
The demographic characteristics of the patients participating in the study are shown
in [Table 1]. The mean scores of all measured
parameters are given in [Table 2]. There was
a statistically significant weak negative correlation between the Tampa score and
the Nottingham Health Profile total score, pain score, emotional reaction score and
physical activity score ([Table 3]). There
was a statistically significant weak positive correlation between the Tampa score
and the depression score measured by HAD, and all sub-scales of WOMAC ([Table 3]). There was no statistically
significant relationship between the Tampa score and pain intensity, muscle
strength, ROM, physical activity level, balance, mobility and anxiety values ([Table 3]). Forward stepwise regression
revealed that 34,4% of the variation in Tampa sacle of kinesiophobia could
be explained by a combination of nothingham health profile (17,9%)
(p<0.001), and womac disability scale (16,5%) (p<0.001).
Table 2 The mean scores of all measured
parameters.
|
|
Mean±SD (n=60)
|
|
TUG
|
|
1,46±0,50
|
|
Berg Balance Scale
|
|
50,26±6,47
|
|
IPAQ
|
|
810,51±1856,21
|
|
Tampa Scale
|
|
40,26±5,51
|
|
Nottingham Health Profile
|
Energy
|
47,42±35,86
|
|
Pain
|
49,16±24,91
|
|
Emotional reaction
|
63,98±32,13
|
|
Sleep
|
61,53±33,88
|
|
Social isolation
|
78,00±35,06
|
|
Physical mobility
|
58,80±21,98
|
|
Total
|
24,38±8,04
|
|
HAD Scale
|
Anxiety
|
5,76±4,39
|
|
Depression
|
6,40±4,17
|
|
WOMAC
|
Pain
|
7,50±4,16
|
|
Stiffness
|
2,80±1,83
|
|
Physical function
|
25,86±14,94
|
|
Total
|
36,06±19,63
|
|
Quadriceps muscle strength
|
Right
|
79,20±35,32
|
|
Left
|
75,40±30,15
|
|
Hamstring muscle strength
|
Right
|
67,49±29,18
|
|
Left
|
67,83±30,02
|
|
Extension ROM
|
Right
|
12,72±27,62
|
|
Left
|
14,02±30,30
|
|
Flexion ROM
|
Right
|
104,24±18,42
|
|
Left
|
104,42±17,82
|
|
Pain intensity
|
During the activity
|
4,79±2,96
|
|
During rest
|
1,58±2,03
|
|
Night
|
2,87±3,02
|
ROM: Range of Motion, SD: Standard deviation, TUG: Timed Up and Go, IPAQ: The
International Physical Activity Questionnaire, HAD: Hospital Anxiety and
Depression Scale, WOMAC: Western Ontario and McMaster Universities
Osteoarthritis Index, SD: Standard deviation.
Table 3 Correlation between the Tampa score and and parameters
related to quality of life and physical performance.
|
|
Tampa Scale
|
|
|
r
|
p
|
|
TUG
|
|
0,14
|
0,27
|
|
Berg Balance Scale
|
|
0,01
|
0,95
|
|
IPAQ
|
|
-0,05
|
0,68
|
|
Nottingham Health Profile
|
Energy
|
-0,21
|
0,09
|
|
Pain
|
-0,29
|
0,02*
|
|
Emotional reaction
|
-0,30
|
0,01*
|
|
Sleep
|
-0,21
|
0,10
|
|
Social isolation
|
-0,05
|
0,68
|
|
Physical mobility
|
-0,28
|
0,02*
|
|
Total
|
-0,34
|
0,00*
|
|
HAD Scale
|
Anxiety
|
0,23
|
0,06
|
|
Depression
|
0,28
|
0,02*
|
|
WOMAC
|
Pain
|
0,26
|
0,03*
|
|
Stiffness
|
0,28
|
0,02*
|
|
Physical function
|
0,27
|
0,03*
|
|
Total
|
0,29
|
0,24*
|
|
Quadriceps muscle strength
|
Right
|
0,12
|
0,34
|
|
Left
|
0,13
|
0,29
|
|
Hamstring muscle strength
|
Right
|
0,12
|
0,33
|
|
Left
|
0,09
|
0,45
|
|
Extension ROM
|
Right
|
0,06
|
0,64
|
|
Left
|
0,04
|
0,70
|
|
Flexion ROM
|
Right
|
-0,05
|
0,69
|
|
Left
|
-0,01
|
0,92
|
|
Pain intensity
|
During the activity
|
0,07
|
0,56
|
|
During rest
|
-0,02
|
0,87
|
|
Night
|
0,09
|
0,46
|
ROM: Range of Motion, SD: Standard deviation, TUG: Timed Up and Go, IPAQ: The
International Physical Activity Questionnaire, HAD: Hospital Anxiety and
Depression Scale, WOMAC: Western Ontario and McMaster Universities
Osteoarthritis Index, r: Pearson’s correlation coefficient,
*p<0,05.
Discussion
This study examined the relationship between kinesiophobia and parameters related to
quality of life and physical performance in patients with knee OA. The main findings
of this study show that kinesiophobia is related to quality of life, disability and
depression, but there is no statistical correlation between kinesiophobia and pain
intensity, muscle strength, shortness, ROM, physical activity level, balance,
mobility and anxiety.
Pain
There was no significant relationship between pain intensity and kinesiophobia in
our study. When the literature is examined, it is seen that there are
contradictory publications on this subject. Studies show that chronic pain, not
only in OA but also in various musculoskeletal problems such as back pain,
fibromyalgia and whiplash, is a factor affecting kinesiophobia [8]
[26]
[41]
[42]
[43]. However, there are also publications showing that pain intensity
is not related to kinesiophobia [44]. In
our study, the absence of a direct relationship between kinesiophobia and pain
intensity as assessed by using VAS may not mean that pain does not cause
kinesiophobia. Because, the “intensity of pain” and the
“presence of pain” are two different concepts. There was a
direct relationship between kinesiophobia and the presence of pain parameter
questioned as part of the quality of life index in our study. This suggests that
the presence of pain may be the cause of kinesiophobia, but it is not possible
to make a clear judgment on the effect of pain intensity on kinesiophobia.
Considering that the average level of pain intensity in the OA patients of our
study was mid-level (activity 4.7, resting 1.5), because the pain intensity was
not high enough to cause kinesiophobia, it can be suggested that we could not
find relationship. Therefore, the severity of the pain that is felt can be
creating a kinesiophobia when it rises above a certain level.
Disability and Depression
Another important finding of our study is that kinesiophobia is closely related
to disability and depression, and the sub-parameters of quality of life: pain,
sensory reaction and physical mobility. Vlaeyen et al. showed that the most
important determinant of fear of movement or fear of re-injury in patients with
back pain was the level of disability reported by the patient [12]
[26]. However, it is a debatable issue whether disability causes
kinesiophobia or disability develops due to kinesiophobia. The general opinion
is that fear of movement is the predecessor of disability, not a consequence
[26]. Patients’ basic
abilities are questioned at most of quality of life scales, so the occurrence of
disability is one of the main reasons for the deterioration of the quality of
life. However, it is a fact that not all patients with disability have
kinesiophobia. This suggests that the mechanism of kinesiophobia may be
multifactorial. However, there is insufficient evidence as to which factor
triggers the formation of kinesiophobia more.
In the present study, it is revealed in regression analysis that 17,9% of
the variation in the Tampa scale of kinesiophobia could be explained simply by
quality of life. An additional 16,5% of Tampa scale of kinesiophobia
changes could be explained by disability. These findings indicate that quality
of life and disability level should be closely monitored during rehabilitation
programmes designed to improve fear of movement among patients with OA.
The association of kinesiophobia with depression sub-scale in our study is an
indication of the close relationship of kinesiophobia with psychological
factors. Assessment of depression in the context of kinesiophobia has been shown
to result in higher fear of exercise, physical activity, and movement in
depressive individuals with chronic pain; and consequently, it has been shown to
develop due to being more sensitive to pain and fear of re-injury [45]. When the guidelines published in this
respect are examined, the identification and treatment of psychological aspects
such as fear of movement and depression in chronic pain sufferers are expressed
as one of the important steps in the prevention of worsening [46]. Interestingly, the anxiety sub-scale
was not found to be a factor associated with kinesiophobia. The probable cause
may be that scales measuring anxiety levels of concern and anxiety about the
mental state of the patient, such as “worrying thoughts are passing
through my mind,” and “I can easily sit, and I feel
relaxed”, in which the patient is inactive. Thus, sometimes in clinical
conditions, it may be inadequate to measure the effects of emotions such as
fear, concern and anxiety on function and movement. In the literature, it has
been shown that anxiety and depression also improve when kinesiophobia is
treated [47]
[48]. This supports the association of
kinesiophobia with psychosomatic factors.
Muscle strength, ROM, Mobility and Balance
In our study, kinesiophobia was not found to be associated with muscle strength,
ROM, and mobility. However, the deficits in these parameters are the ones that
are applied at the first stage in routine treatment programs and that clinicians
consider important to improve [49]
[50]. This approach creates an important
contradiction in managing the improvement of the functional capacity of the
patient with kinesiophobia. Recently, Demoulin et al. and Ihsak et al. found no
relationship between muscle strength and kinesiophobia in their studies
investigating factors affecting kinesiophobia in chronic back pain [44]. Because, pain-related fear is not only
related to the weakness of the physical performance measured in the laboratory.
In essence, how these parameters are influenced during their daily living
activities should be questioned [26]. The
results of our study also clearly show that there is no direct connection
between these basic functionality measures and kinesiophobia.
One of the basic requirements of functional movement is balance. Therefore,
balance-related parameters may be expected to change in the person with
kinesiophobia. Balance and mobility are among the factors associated with
kinesiophobia in musculoskeletal diseases seen in patients with vestibular and
neurological problems or in the elderly [44]
[51]
[52]. No relationship was found between
balance and kinesiophobia in our study. OA patients participating in our study
had an average of 50 in the Berg Balance Scale and were included in the group
with low risk of falling. In other words, the major functional impairment in OA
patients is not associated with loss of balance due to vestibular, neurological
or musculoskeletal system. Therefore, balance deficits in OA patients may not be
a factor strong enough to create kinesiophobia. This result supports the view
that the factor causing fear of movement is caused by the psychosocially-induced
kinesiophobia.
Physical Activity Level
In our study, there was no relationship between individuals’ levels of
physical activity measured with IPAQ and kinesiophobia. Kinesiophobia and
activity level seem to be related concepts, but the individuals participating in
our study already had a low level of physical activity with an IPAQ average of
800 MET/min [53]. Therefore, this result may be insufficient to show the
effect of kinesiophobia on activity level.
It is a limitation of the study that the sample consisted of sedentary OA
patients. These results should therefore be considered when making
generalizations to young and active patients experiencing kinesiophobia due to
other pathologies. However, since primary findings of our study such as pain,
disability, depression, and quality of life are less affected by age and
pathology, these results are valuable in terms of understanding the
kinesiophobia mechanism.
Conclusion
In conclusion, it can be said that in OA, factors such as quality of life, disability
and depression play an important role in the formation of kinesiophobia, whereas
parameters belonging to physical performance such as balance and muscle strength
stay ineffective. The most important factors affecting kinesiophobia in patients
with OA are quality of life and disability. Although the presence of pain was found
to be a factor affecting kinesiophobia, there was no correlation between pain
intensity and kinesiophobia. In terms of labor, time and cost, evaluation and
treatment of physical performance parameters have a high place in routine health
services. In OA cases with kinesiophobia, instead of focusing on these parameters,
it may increase treatment success by reducing workload and cost for clinicians to
try to develop treatment strategies to improve depression and quality of life. It
may be useful to evaluate and manage the psychological parameters as a part of the
problem and disability rather than as a separate subject so that the fear of
movement that prevents the person from daily life in the knee osteoarthritis can be
avoided more easily. Varied results may be reached by a larger sample and different
population. Further longitudinal studies with another knee disorders such as total
knee replacements to clarify the kinesiophobia related factors might be
interesting.
Funding
The study was not funded.
