Is impaired knee confidence related to worse kinesiophobia, symptoms, and physical function in people with knee osteoarthritis after anterior cruciate ligament reconstruction?

doi:10.1016/j.jsams.2014.09.011

Journal of Science and Medicine in Sport

Volume 18, Issue 5, September 2015, Pages 512-517

https://doi.org/10.1016/j.jsams.2014.09.011 Get rights and content

Abstract

Objectives

To compare knee confidence and kinesiophobia (fear of re-injury) in those with and without knee osteoarthritis following anterior cruciate ligament reconstruction, and determine whether poorer knee confidence is associated with greater kinesiophobia, worse knee-related symptoms, and functional impairments in those with knee osteoarthritis.

Design

Cross-sectional.

Methods

Sixty-six individuals, 5–12 years following anterior cruciate ligament reconstruction, with (n = 30) and without (n = 36) knee osteoarthritis were included. Knee injury and Osteoarthritis Outcome Score quality-of-life question (Q3), assessed knee confidence and Tampa Scale of Kinesiophobia assessed kinesiophobia. In the osteoarthritis group, knee-related symptoms (International Knee Documentation Committee and Anterior Knee Pain Scale), self-reported function (Knee injury and Osteoarthritis Outcome Score activities daily living), sport/recreation (Knee injury and Osteoarthritis Outcome Score-sport and recreation), and performance-based function (hopping, one leg rise tasks) were assessed. Between-group differences in knee confidence and kinesiophobia were evaluated with the Chi square test and analysis of variance, respectively. In the osteoarthritis group, between-group differences (none, mild/moderate and severe/extreme problems with knee confidence) in kinesiophobia, symptoms and function were determined with analysis of variances: p < 0.05.

Results

Following anterior cruciate ligament reconstruction, participants with knee osteoarthritis had significantly worse knee confidence (p = 0.010) and greater kinesiophobia (p = 0.006) than those without osteoarthritis. In those with knee osteoarthritis, poorer knee confidence was significantly associated with worse symptoms (Anterior Knee Pain Scale, p = 0.001; International Knee Documentation Committee, p < 0.001), kinesiophobia (p = 0.030), Knee injury and Osteoarthritis Outcome Score-activities of daily living (p = 0.005), Knee injury and Osteoarthritis Outcome Score-sport and recreation (p = 0.001), single-leg hop (p = 0.011), side-to-side hop (p = 0.013) and one leg rise (p = 0.001).

Conclusions

Psychological impairments are evident in people with knee osteoarthritis following anterior cruciate ligament reconstruction, compared to those without. Future studies should further investigate the psychological impairments associated with knee osteoarthritis after anterior cruciate ligament reconstruction.

Introduction

Anterior cruciate ligament (ACL) injury is a well-recognised risk factor for post-traumatic knee osteoarthritis (OA), with 50–70% of people developing knee OA 10–15 years following injury.1, 2 Surgical reconstruction (ACLR) does not reduce the risk of OA.³ Knee OA after ACLR primarily affects younger adults,⁴ with potential to limit physical activity.⁵ Consequently, any physical and psychological impairments may adversely impact quality of life and work participation. Recently, our research team observed that greater knee OA severity is associated with worse symptoms and poorer function at 5–10 years following ACLR.⁶ While functional impairments such as muscle weakness and poorer functional performance are well-described in ACLR populations,5, 7 the nature and impact of psychological impairments remain largely unknown, especially in those with knee OA.

Knee confidence and kinesiophobia are two psychological factors that are likely to be impaired in those with knee OA following ACLR. Kinesiophobia, defined as “an irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or (re) injury”,⁸ predicts return to sport after ACLR.9, 10 Furthermore, people who have not returned to sport are less confident about their ACLR knee than those who have.9, 10 Worse knee confidence is also described in people with knee OA, and associated with higher pain and greater knee instability.¹¹ Knee OA is highly prevalent after ACLR, and factors such as knee confidence and kinesiophobia play a key role in those recovering from ACL injury9, 10 and in those at risk of¹² or with knee OA.¹¹ Thus, it is important to understand whether the presence of knee OA following ACLR in younger adults increases these psychological impairments, beyond those seen after ACLR alone.

Psychological and functional impairments are likely to co-exist and be inter-related.9, 11, 12 Worse kinesiophobia is associated with lower physical activity levels after ACLR⁹ and reduced daily functioning¹³ in those with knee OA. While no studies have investigated knee confidence in those with knee OA after ACLR, lower knee-related confidence is associated with lower physical function¹² and quadriceps strength¹¹ in older knee OA populations. Thus, it appears that knee confidence and kinesiophobia are psychological impairments that may contribute to, or result from, functional impairments. It is important to understand whether the relationship between psychological and functional impairments is seen in young adults with knee OA following ACLR. Knowledge of this relationship may provide a more comprehensive approach to rehabilitation.

The aims of this study were twofold. Firstly, to compare knee confidence and kinesiophobia between those with and without knee OA after ACLR; and secondly, to investigate the relationship between knee confidence and kinesiophobia, knee-related symptoms, and functional impairments in those with knee OA after ACLR. We hypothesized that those with knee OA after ACLR would have poorer knee confidence and greater kinesiophobia than those without knee OA. In addition, we hypothesized that poorer knee confidence would be associated with greater kinesiophobia, worse knee-related symptoms and worse functional impairments in those with knee OA after ACLR.

Section snippets

Materials and methods

Volunteers who had undergone a primary ACLR (hamstring-tendon or patellar-tendon graft) five to 12 years prior were recruited from the community via advertisements and referrals from orthopedic surgeons, allied health and medical practitioners. Exclusion criteria for all participants were: (i) aged <18 years at the time of ACLR; (ii) subsequent arthroplasty performed on the reconstructed knee; (iii) concomitant pain from the hips, ankles, feet or lumbar spine; (iv) neurological or medical

Results

Thirty OA participants (mean ± SD: age 45 ± 11 years, height 1.72 ± 0.08 m, body weight 78 ± 14 kg, BMI 26 ± 4 kg m⁻², time since ACLR 9 ± 2years) and 36 no-OA participants (age 39 ± 9 years, height 1.71 ± 0.08 m, body weight 79 ± 15 kg, BMI 27 ± 4 kg m⁻² time since ACLR 8 ± 2years) were included. There were no significant differences in height (p = 0.070), body weight (p = 0.598), BMI (p = 0.533), and time since ACLR (p = 0.167); however there was a significant difference in age (p = 0.022). The participants in the OA group had mild

Discussion

We observed that those participants with OA following ACLR had lower knee confidence and higher kinesiophobia than those without knee OA. In the OA group, poorer knee confidence was associated with greater kinesiophobia and worse patient-reported and performance-based functional impairments.

The proportion of participants troubled with severe to extreme lack of knee confidence was similar to that observed in older individuals (62 ± 7 years) with medial compartment OA and varus knee malalignment

Conclusion

In summary, this study identified the presence of two psychological impairments in individuals with knee OA after ACLR: reduced knee confidence and greater kinesiophobia. Further research is needed to determine whether these psychological impairments are a precursor or consequence of knee OA after ACLR. The inter-relationship between knee confidence, kinesiophobia and patient-reported and performance-based functional impairments indicates that psychological impairments associated with this

Practical implications

•
People with knee OA after ACLR have greater trouble with knee confidence and fear of re-injury.
•
Worse knee confidence in people with knee OA after ACLR is related to greater fear of re-injury, worse knee symptoms and worse physical function.
•
Improvements in knee confidence may aid in improving knee symptoms and physical function.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors were involved in drafting the article and all authors approved the final version submitted for publication.

Acknowledgements

DJO Global provided funding for the radiographs. Harvi Hart is supported by a National Health and Medical Research Council (NHMRC) Post-graduate Scholarship (Australia) (#813021) and Natalie Collins is supported by a NHMRC (Australia) Research Training (Post-Doctoral) Fellowship (#628918). Harvi Hart was awarded the ASICS Ken Maquire Award for Best New Investigator for this paper at Be Active 2012.

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It is considered that psychological factors are important in determining exercise regression outcomes of patients with anterior cruciate ligament reconstruction (ACLR). This review summarizes the definition and research progress of current undefined psychological factors related to returning to sports (RTS) after ACLR, as well as the application of corresponding measuring scales, and common psychological interventions in the field. The aim is to understand and clarify the impact of psychological factors in the ACL injury and rehabilitation, and to provide a theoretical basis for the application of psychological evaluation and intervention in the later stage. It is believed that there are still many prospects for the research in this field.
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One-hundred-fifty participants with FAI syndrome (51% women) completed assessment of the following: kinesiophobia with the Tampa Scale for Kinesiophobia; patient reported outcome measures (PROMs) (pain, physical function, health- and hip-related QoL); physical function (side bridge, hop for distance, and one leg rise); and active hip range of motion (flexion, external rotation, internal rotation).
Greater kinesiophobia was correlated with worse hip-related QoL (rho=-0.58; p<0.001), self-reported physical function (rho=-0.42; p<0.001), health-related QoL (rho=-0.46; p<0.001), and pain levels (rho=-0.46; p<0.001). In women, kinesiophobia was also associated with worse physical function (hop for distance r=-0.38; p=0.001 and side bridge rho=-0.24; p=0.036) explaining 36% of the variation of the hip-related QoL, 29% of the health-related QoL, and 27% of the self-reported physical function. In men, kinesiophobia explained 35%, 12%, and 10%, respectively.
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Citation Excerpt :
The extent of knee confidence was assessed using a single question from the KOOS-QOL subscale and the validity of this question has not been evaluated. However, the question is reliable (Colbert et al., 2012) and commonly used measure to report knee-related confidence (Colbert et al., 2012; Hart et al., 2015; Skou et al., 2014, 2015). There is no established tool to assess knee confidence during performance-based functional tasks; therefore, task-specific knee confidence was assessed using a VAS yet to be validated.
To determine whether knee confidence, fear of movement, psychological readiness to return-to-sport or pain are associated with patient-reported and performance-based function and return to pivoting sport in individuals one-year after anterior cruciate ligament reconstruction (ACLR).
Cross-sectional study.
University-laboratory.
118 individuals one-year post-ACLR.
The KOOS-sport/recreation and IKDC and three hopping tasks were used to assess patient-reported and performance-based function, respectively. Questions regarding return to pivoting sport assessed return-to-sport status. Fear of movement (Tampa Scale), knee confidence (an item from KOOS, Visual Analogue Scale-VAS confidence during hopping tasks), knee pain (KOOS-pain, VAS pain during hopping tasks) and psychological readiness to return-to-sport (ACL-RSI) were also assessed.
Worse fear of movement (p = 0.019), KOOS-pain (p < 0.001), ACL-RSI (p < 0.001), task-specific knee confidence and pain were associated with poorer patient-reported function. Worse task-specific knee confidence (p < 0.001) and pain (p < 0006) and ACL-RSI (p < 0.016) were associated with poorer performance-based function. Higher ACL-RSI scores were associated with higher odds of returning to pivoting sport one-year post-ACLR (p < 0.001).
Individual’s fear of movement, knee confidence, psychological readiness to return-to-sport and pain are related to function. Evaluating and considering knee confidence, fear of movement, and psychological readiness should be an important part of comprehensive post-ACLR rehabilitation.
A pragmatic approach to prevent post-traumatic osteoarthritis after sport or exercise-related joint injury
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Lower extremity musculoskeletal injuries are common in sport and exercise, and associated with increased risk of obesity and post-traumatic osteoarthritis (PTOA). Unlike other forms of osteoarthritis, PTOA is common at a younger age and associated with more rapid progression, which may impact career choices, long-term general health and reduce quality of life. Individuals who suffer an activity-related joint injury and present with abnormal joint morphology, elevated adiposity, weak musculature, or become physically inactive are at increased risk of PTOA. Insufficient exercise therapy or incomplete rehabilitation, premature return-to-sport and re-injury, unrealistic expectations, or poor nutrition may further elevate this risk. Delay in surgical interventions in lieu of exercise therapy to optimize muscle strength and neuromuscular control while addressing fear of movement to guarantee resumption of physical activity, completeness of rehabilitation before return-to-sport, education that promotes realistic expectations and self-management, and nutritional counseling are the best approaches for delaying or preventing PTOA.
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Little is known about the correlates between pain intensity (PI) and physical function (PF) and psychosocial factors {kinesiophobia (K), Pain Catastrophizing (PC) and Self-efficacy (SE)} among patients diagnosed with knee osteoarthritis in developing countries like Nigeria.
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Eighty-nine consecutively sampled patients diagnosed with knee osteoarthritis from three selected public hospitals in Enugu, South-East Nigeria, participated in this cross-sectional survey.
Brief Fear of Movement Scale for Osteoarthritis, Pain Catastrophizing Scale and Arthritis Self-Efficacy Scale-8 item were used to assess kinesiophobia, pain catastrophizing and Self-efficacy respectively. Visual Analogue Scale and Ibadan Knee or Hip Osteoarthritis Measure were used to assess PI and PF respectively. Data were analysed using Pearson's correlation coefficient and multiple regression at p = 0.05.
Participants were aged 59.11 ± 12.46years involving male (17.9%) and female (82.1%) participants. There were no significant gender differences in the scores of kinesiophobia, PI, PF, PC and self-efficacy. Pain intensity was significantly proportional to kinesiophobia (r = 0.38), and PC(r = 0.39). Better physical function was associated with high self-efficacy (r = 0.35), low kinesiophobia (r = −0.43) and low PC(r = −0.28). Significant predictive markers of PI included kinesiophobia (β = 0.24) and PC(β = 0.11) while that of PF, included kinesiophobia (β = −0.41) and SE(β = 2.39).
Kinesiophobia and pain catastrophizing correlate and predict PI significantly. Kinesiophobia and SE are significant correlates and predictors of PF among patients with knee osteoarthritis in Nigeria.
Hip abductor muscle volumes are smaller in individuals affected by patellofemoral joint osteoarthritis
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The aims of this study were twofold: firstly, to compare hip abductor muscle volumes in individuals with patellofemoral joint (PFJ) osteoarthritis (PFJ OA) against those of healthy controls; and secondly, to determine whether hip muscle volumes and hip kinematics during walking are related in individuals with PFJ OA and healthy controls.
Fifty-one individuals with PFJ OA and thirteen asymptomatic, age-matched healthy controls ≥40 years were recruited. Volumes of the gluteus medius, gluteus minimus and tensor fasciae latae were obtained from magnetic resonance (MR) images. Video motion capture was used to measure three-dimensional hip joint kinematics during overground walking.
Significantly smaller gluteus medius (P = 0.017), gluteus minimus (P = 0.001) and tensor fasciae latae (P = 0.027) muscle volumes were observed in PFJ OA participants compared to controls. Weak correlations were observed between smaller gluteus minimus volume and larger hip flexion angle at contralateral heel strike (CHS) (r = −0.279, P = 0.038) as well as between smaller gluteus minimus volume and increased hip adduction angle at CHS (r = −0.286, P = 0.046).
Reduced hip abductor muscle volume is a feature of PFJ OA and is associated with increased hip flexion and adduction angles during the late stance phase of walking for PFJ OA participants and healthy controls.

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¹: Division of Physiotherapy, School of Health & Rehabilitation Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia.

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Original researchIs impaired knee confidence related to worse kinesiophobia, symptoms, and physical function in people with knee osteoarthritis after anterior cruciate ligament reconstruction?

Abstract

Objectives

Design

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Practical implications

Competing interests

Authors’ contributions

Acknowledgements

Physical Ther Sport

Pain

Pain

Arthroscopy

Arch Phys Med Rehabil

Clin Biochem

Clin Sports Med

Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up

Am J Sports Med

The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis

Am J Sports Med

Knee osteoarthritis after anterior cruciate ligament injury a systematic review

Am J Sports Med

Joint injury causes knee osteoarthritis in young adults

Curr Opin Rheumatol

High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes

Ann Rheum Dis

Patellofemoral osteoarthritis is prevalent and associated with worse symptoms and function after hamstring tendon autograft ACL reconstruction

Br J Sports Med

Muscle strength and functional performance in patients with anterior cruciate ligament injury treated with training and surgical reconstruction or training only: a two to five-year followup

Arthritis Rheum

Kinesophobia: a new view of chronic pain behaviour

Pain Manag

Original research
Is impaired knee confidence related to worse kinesiophobia, symptoms, and physical function in people with knee osteoarthritis after anterior cruciate ligament reconstruction?