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Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients

  • Knee
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To evaluate the effects of kinesiophobia on the outcomes of total knee arthroplasty (TKA), and to investigate whether kinesiophobia represents an independent factor influencing the surgery success or whether the observed effects are driven by other physical or psychological aspects such as anxiety and depression.

Methods

Two hundred patients were evaluated prospectively (mean age 65.7 ± 9.1 years, 134 women and 66 men) at 12 months after TKA. Kinesiophobia was assessed with the Tampa Scale for kinesiophobia (TSK: Activity Avoidance—TSK1 and Harm—TSK2 subscales); anxiety and depression were assessed with STAI and BDI, respectively, and preoperative pain and function, sex, age, BMI, education level, number of painful joints and years of symptoms’ duration before surgery were documented as well. Results were evaluated with pain and function on 0–10 numeric rating scales, while the overall clinical outcome was documented with WOMAC and SF-12 (Physical and Mental subscales) scores.

Results

TSK1 was correlated with WOMAC results at 12 months (p = 0.005, ρ = 0.197). STAI (p = 0.002, ρ = 0.222), BDI (p < 0.0005, ρ = 0.307), and sex (p = 0.004) also influenced the outcome after TKA, while other parameters, such as age, BMI, education level, and number of painful joints and years of symptoms’ duration before surgery, did not correlate with the clinical outcome. The multivariate analysis confirmed the role of BDI (p = 0.006, partial η 2 = 0.038), TSK1 (p = 0.011, partial η 2 = 0.033), and sex (p = 0.048, partial η 2 = 0.020), and a synergic interaction of BDI and TSK1, which together presented an even stronger correlation (p < 0.0005, partial η 2 = 0.111) with WOMAC at 12-month follow-up.

Conclusions

Kinesiophobia is a factor influencing the outcome after TKA independently from other psychological and physical variables. This risk factor may affect TKA results, especially in women, and shows a further synergic interaction with depression in terms of lower surgical outcome. These findings are of clinical relevance because they show the impact of psychological factors such as kinesiophobia, and suggest the possibility of adopting co-interventions to overcome the fear of physical activity, and in the end improve patient recovery and final outcome after TKA.

Level of evidence

IV.

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References

  1. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15(12):1833–1840

    CAS  PubMed  Google Scholar 

  2. Bonnin MP, Basiglini L, Archbold HA (2011) What are the factors of residual pain after uncomplicated TKA? Knee Surg Sports Traumatol Arthrosc 19(9):1411–1417

    Article  PubMed  Google Scholar 

  3. Brander V, Gondek S, Martin E, Stulberg SD (2007) Pain and depression influence outcome 5 years after knee replacement surgery. Clin Orthop Relat Res 464:21–26

    PubMed  Google Scholar 

  4. Brander VA, Stulberg SD, Adams AD, Harden RN, Bruehl S, Stanos SP, Houle T (2003) Predicting total knee replacement pain: a prospective, observational study. Clin Orthop Relat Res 416:27–36

    Article  Google Scholar 

  5. Brown ML, Plate JF, Von Thaer S, Fino NF, Smith BP, Seyler TM, Lang JE (2016) Decreased range of motion after total knee arthroplasty is predicted by the Tampa Scale of Kinesiophobia. J Arthroplasty 31(4):793–797

    Article  PubMed  Google Scholar 

  6. Burns LC, Ritvo SE, Ferguson MK, Clarke H, Seltzer Z, Katz J (2015) Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res 5(8):21–32

    Google Scholar 

  7. Doménech J, Sanchis-Alfonso V, Espejo B (2014) Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc 22(10):2295–2300

    Article  PubMed  Google Scholar 

  8. Dominick GM, Zeni JA, White DK (2016) The association of psychosocial factors with physical activity and function after total knee replacement: an exploratory study. Arch Phys Med Rehabil. doi:10.1016/j.apmr.2015.09.028

  9. Doury-Panchout F, Metivier JC, Fouquet B (2015) Kinesiophobia negatively influences recovery of joint function following total knee arthroplasty. Eur J Phys Rehabil Med 51(2):155–161

    CAS  PubMed  Google Scholar 

  10. Duivenvoorden T, Vissers MM, Verhaar JA, Busschbach JJ, Gosens T, Bloem RM, Bierma-Zeinstra SM, Reijman M (2013) Anxiety and depressive symptoms before and after total hip and knee arthroplasty: a prospective multicentre study. Osteoarthr Cartil 21(12):1834–1840

    Article  CAS  PubMed  Google Scholar 

  11. Edwards RR, Bingham CO 3rd, Bathon J, Haythornthwaite JA (2006) Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis Rheum 55(2):325–332

    Article  PubMed  Google Scholar 

  12. Edwards RR, Haythornthwaite JA, Smith MT, Klick B, Katz JN (2009) Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement. Pain Res Manag 14(4):307–311

    Article  PubMed  PubMed Central  Google Scholar 

  13. Faller H, Kirschner S, König A (2003) Psychological distress predicts functional outcomes at three and twelve months after total knee arthroplasty. Gen Hosp Psychiatry 25(5):372–373

    Article  PubMed  Google Scholar 

  14. Filardo G, Roffi A, Merli G, Marcacci T, Ceroni FB, Raboni D, Bortolotti B, De Pasqual L, Marcacci M (2015) Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3898-8

  15. Fisher DA, Dierckman B, Watts MR, Davis K (2007) Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J Arthroplasty 22(6 Suppl 2):39–42

    Article  PubMed  Google Scholar 

  16. Flanigan DC, Everhart JS, Glassman AH (2015) Psychological factors affecting rehabilitation and outcomes following elective orthopaedic surgery. J Am Acad Orthop Surg 23(9):563–570

    Article  PubMed  Google Scholar 

  17. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, Phillips C, Partridge AJ, Bélisle P, Fossel AH, Mahomed N, Sledge CB, Katz JN (1999) Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum 42(8):1722–1728

    Article  CAS  PubMed  Google Scholar 

  18. Goodin BR, McGuire L, Allshouse M, Stapleton L, Haythornthwaite JA, Burns N, Mayes LA, Edwards RR (2009) Associations between catastrophizing and endogenous pain-inhibitory processes: sex differences. J Pain 10(2):180–190

    Article  PubMed  Google Scholar 

  19. Gracely RH, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, Clauw DJ (2004) Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 127(Pt 4):835–843

    Article  CAS  PubMed  Google Scholar 

  20. Granot M (2009) Can we predict persistent postoperative pain by testing preoperative experimental pain? Curr Opin Anaesthesiol 22(3):425–430

    Article  PubMed  Google Scholar 

  21. Gros DF, Antony MM, Simms LJ, McCabe RE (2007) Psychometric properties of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA): comparison to the State-Trait Anxiety Inventory (STAI). Psychol Assess 19:369–381

    Article  PubMed  Google Scholar 

  22. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, Katz B, Bombardier C, Heck D, Freund D (1998) Health-related quality of life after knee replacement. J Bone Joint Surg Am 80(2):163–173

    Article  CAS  PubMed  Google Scholar 

  23. Hirakawa Y, Hara M, Fujiwara A, Hanada H, Morioka S (2014) The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty. Pain Res Manag 19(5):251–256

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hirschmann MT, Testa E, Amsler F, Friederich NF (2013) The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA. Knee Surg Sports Traumatol Arthrosc 21(10):2405–2411

    Article  PubMed  Google Scholar 

  25. Kocic M, Stankovic A, Lazovic M, Dimitrijevic L, Stankovic I, Spalevic M, Stojiljkovic P, Milenkovic M, Stojanovic Z, Nikolic D (2015) Influence of fear of movement on total knee arthroplasty outcome. Ann Ital Chir 86:148–155

    PubMed  Google Scholar 

  26. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW (2007) The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 30(1):77–94

    Article  PubMed  Google Scholar 

  27. Lewis GN, Rice DA, McNair PJ, Kluger M (2015) Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth 114(4):551–561

    Article  CAS  PubMed  Google Scholar 

  28. Lykke J, Hesse M, Austin SF, Oestrich I (2008) Validity of the BPRS, the BDI and the BAI in dual diagnosis patients. Addict Behav 33(2):292–300

    Article  PubMed  Google Scholar 

  29. Monticone M, Ferrante S, Rocca B, Salvaderi S, Fiorentini R, Restelli M, Foti C (2013) 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 94(2):231–239

    Article  PubMed  Google Scholar 

  30. Monticone M, Giorgi I, Baiardi P, Barbieri M, Rocca B, Bonezzi C (2010) Development of the Italian version of the Tampa Scale of Kinesiophobia (TSK-I): cross-cultural adaptation, factor analysis, reliability, and validity. Spine 35(12):1241–1246

    Article  PubMed  Google Scholar 

  31. Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, Dunbar M (2009) Psychological determinants of problematic outcomes following total knee arthroplasty. Pain 143(1–2):123–129

    Article  PubMed  Google Scholar 

  32. Turner JA, Mancl L, Aaron LA (2006) Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial. Pain 121(3):181–194

    Article  PubMed  Google Scholar 

  33. Unver B, Ertekin Ö, Karatosun V (2014) Pain, fear of falling and stair climbing ability in patients with knee osteoarthritis before and after knee replacement: 6 month follow-up study. J Back Musculoskelet Rehabil 27(1):77–84

    Article  PubMed  Google Scholar 

  34. Vlaeyen JW, Linton SJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85(3):317–332

    Article  CAS  PubMed  Google Scholar 

  35. Wade JB, Riddle DL, Thacker LR (2012) Is pain catastrophizing a stable trait or dynamic state in patients scheduled for knee arthroplasty? Clin J Pain 28(2):122–128

    Article  PubMed  Google Scholar 

  36. Ware J Jr, Kosinski M, Keller SD (1996) A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34(3):220–233

    Article  PubMed  Google Scholar 

  37. Witvrouw E, Pattyn E, Almqvist KF, Crombez G, Accoe C, Cambier D, Verdonk R (2009) Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study. Knee Surg Sports Traumatol Arthrosc 17(10):1189–1194

    Article  PubMed  Google Scholar 

  38. Wylde V, Dieppe P, Hewlett S, Learmonth ID (2007) Total knee replacement: is it really an effective procedure for all? Knee 14(6):417–423

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thank Dr. Elettra Pignotti for her statistical assistance.

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Authors and Affiliations

  1. Laboratory of Biomechanics and Technology Innovation/Ist Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna University, Via di Barbiano 1/10, Bologna, Italy

    G. Filardo & M. Marcacci

  2. Laboratory of NanoBiotechnology (NABI), Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, Bologna, Italy

    G. Merli, A. Roffi & E. Kon

  3. Mood, Centro per lo studio e la cura dei disturbi emotivi, Bologna, Italy

    T. Marcacci, F. Berti Ceroni & D. Raboni

  4. Mental Health Department, AUSL Bologna, Bologna, Italy

    B. Bortolotti

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  1. G. Filardo
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Correspondence to A. Roffi.

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Filardo, G., Merli, G., Roffi, A. 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 25, 3417–3423 (2017). https://doi.org/10.1007/s00167-016-4201-3

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  • DOI: https://doi.org/10.1007/s00167-016-4201-3

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