Trevor A. Lentz

The Association of Pain and Fear of Movement/Reinjury With Function During Anterior Cruciate Ligament Reconstruction Rehabilitation

STUDY DESIGN Cross-sectional. OBJECTIVES To measure fear of movement/reinjury levels and determine the association with function at different timeframes during anterior cruciate ligament (ACL) reconstruction rehabilitation. We hypothesized that fear of movement/reinjury would decrease during rehabilitation and be inversely related with function. BACKGROUND Fear of movement/reinjury can prevent return to sports after ACL reconstruction, but it has not been studied during rehabilitation. METHODS AND MEASURES Demographic data and responses on the shortened version of Tampa Scale for Kinesiophobia (TSK-11), 8-Item Short-Form Health Survey (SF-8), and International Knee Documentation Committee (IKDC) subjective form were extracted from a clinical database for 97 patients in the first year after ACL reconstruction. Three groups were formed: group 1, less than or equal to 90 days; group 2, 91 to 180 days; group 3: 181 to 372 days post-ACL reconstruction. Group differences in TSK-11 score, SF-8 bodily pain rating, and IKDC scores were determined. Hierarchical linear regression models were created for each group, with IKDC score as the dependent variable and demographic factors, SF-8 bodily pain rating, and TSK-11 score as independent variables. RESULTS TSK-11 score was higher in group 1 than in group 3 (P < .05). Across the groups, SF-8 bodily pain rating decreased (P < .001) and IKDC score increased (P < .001). SF-8 bodily pain rating was a significant factor in the regression model for all groups, whereas TSK-11 score only contributed to the regression model in group 3 (partial correlation, -0.529). CONCLUSIONS Pain was consistently associated with function across the timeframes studied. Fear of movement/reinjury levels appear to decrease during ACL reconstruction rehabilitation and are associated with function in the timeframe when patients return to sports. LEVEL OF EVIDENCE Prognosis, level 4.

Longitudinal Changes in Psychosocial Factors and Their Association With Knee Pain and Function After Anterior Cruciate Ligament Reconstruction

Background Evidence in the musculoskeletal rehabilitation literature suggests that psychosocial factors can influence pain levels and functional outcome. Objective The purpose of this study was to examine changes in select psychosocial factors and their association with knee pain and function over 12 weeks after anterior cruciate ligament (ACL) reconstruction. Design This was a prospective, longitudinal, observational study. Methods Patients with ACL reconstruction completed self-report questionnaires for average knee pain intensity (numeric rating scale [NRS]), knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), and psychosocial factors (pain catastrophizing [Pain Catastrophizing Scale], fear of movement or reinjury [shortened version of the Tampa Scale for Kinesiophobia (TSK-11)], and self-efficacy for rehabilitation tasks [modified Self-Efficacy for Rehabilitation Outcome Scale (SER)]). Data were collected at 4 time points after surgery (baseline and 4, 8, and 12 weeks). Repeated-measures analyses of variance determined changes in questionnaire scores across time. Hierarchical linear regression models were used to examine the association of psychosocial factors with knee pain and function. Results Seventy-seven participants completed the study. All questionnaire scores changed across 12 weeks. Baseline psychosocial factors did not predict the 12-week NRS or IKDC-SKF score. The 12-week change in modified SER score predicted the 12-week change in NRS score (r2=.061), and the 12-week change in modified SER and TSK-11 scores predicted the 12-week change in IKDC-SKF score (r2=.120). Limitations The psychometric properties of the psychosocial factor questionnaires are unknown in people with ACL reconstruction. The study focused on short-term outcomes using only self-report measures. Conclusions Psychosocial factors are potentially modifiable early after ACL reconstruction. Baseline psychosocial factor levels did not predict knee pain or function 12 weeks postoperatively. Interventions that increase self-efficacy for rehabilitation tasks or decrease fear of movement or reinjury may have potential to improve short-term outcomes for knee pain and function.

The Relationship of Pain Intensity, Physical Impairment, and Pain-Related Fear to Function in Patients With Shoulder Pathology

STUDY DESIGN Cross-sectional. OBJECTIVES This study examined the baseline relationship of pain intensity, physical impairment, and pain-related fear to shoulder function. BACKGROUND There is no consensus regarding the influence psychological variable have on function and recovery in individuals with shoulder pathologies. While pain-related fear has been shown to predict disability for patients with low-back and cervical pain, this relationship has not been consistently reported for patients with shoulder pain. METHODS AND MEASURES One hundred forty-two subjects (78 male, 64 female; mean age, 41.4 years) with nonoperative unilateral shoulder disorders were identified from a clinical database of impairment and outcome measures.Demographic information, duration of symptoms, mechanism of injury, pain intensity, pain-related fear, and range-of-motion (ROM) measures were collected. Self-report of function was measured with the Shoulder Pain and Disability Index (SPADI). Hierarchical regression analysis determined the proportions of explained variance in function. RESULTS Demographic variables (duration of symptoms, sex, age, and mechanism of injury) collectively contributed approximately 9% (P=.003) of the variance in function scores. Average pain intensity and flexion ROM contributed an additional 22% (P<.001) of the variance, and Tampa Scale of Kinesiophobia (TSK-11) scores contributed an additional 3% (P<.001). In the final parsimonious model, presence of symptoms longer than 3 months (beta=.23, P=.003), pain intensity (beta=.25, P=.002), shoulder flexion ROM index (beta=-.35, P=.001), and kinesiophobia (beta=.17, P=.026) explained 33% of the variance in SPADI function score (P<.001). CONCLUSIONS Presence of symptoms longer than 3 months, average pain intensity, flexion ROM index (strongest contributor in multivariate model), and fear-of-pain scores all contributed to baseline shoulder function. The immediate clinical relevance of these findings is unclear but they do provide direction for prospective studies.

Comparison of Physical Impairment, Functional, and Psychosocial Measures Based on Fear of Reinjury/Lack of Confidence and Return-to-Sport Status After ACL Reconstruction

Background: Fear of reinjury and lack of confidence influence return-to-sport outcomes after anterior cruciate ligament (ACL) reconstruction. The physical, psychosocial, and functional recovery of patients reporting fear of reinjury or lack of confidence as their primary barrier to resuming sports participation is unknown. Purpose: To compare physical impairment, functional, and psychosocial measures between subgroups based on return-to-sport status and fear of reinjury/lack of confidence in the return-to-sport stage and to determine the association of physical impairment and psychosocial measures with function for each subgroup at 6 months and 1 year after surgery. Study Design: Case-control study; Level of evidence, 3. Methods: Physical impairment (quadriceps index [QI], quadriceps strength/body weight [QSBW], hamstring:quadriceps strength ratio [HQ ratio], pain intensity), self-report of function (International Knee Documentation Committee [IKDC]), and psychosocial (Tampa Scale for Kinesiophobia–shortened form [TSK-11]) measures were collected at 6 months and 1 year after surgery in 73 patients with ACL reconstruction. At 1 year, subjects were divided into “return-to-sport” (YRTS) or “not return-to-sport” (NRTS) subgroups based on their self-reported return to preinjury sport status. Patients in the NRTS subgroup were subcategorized as NRTS-Fear/Confidence if fear of reinjury/lack of confidence was the primary reason for not returning to sports, and all others were categorized as NRTS-Other. Results: A total of 46 subjects were assigned to YRTS, 13 to NRTS-Other, and 14 to NRTS-Fear/Confidence. Compared with the YRTS subgroup, the NRTS-Fear/Confidence subgroup was older and had lower QSBW, lower IKDC score, and higher TSK-11 score at 6 months and 1 year; however, they had similar pain levels. In the NRTS-Fear/Confidence subgroup, the IKDC score was associated with QSBW and pain at 6 months and QSBW, QI, pain, and TSK-11 scores at 1 year. Conclusion: Elevated pain-related fear of movement/reinjury, quadriceps weakness, and reduced IKDC score distinguish patients who are unable to return to preinjury sports participation because of fear of reinjury/lack of confidence. Despite low average pain ratings, fear of pain may influence function in this subgroup. Assessment of fear of reinjury, quadriceps strength, and self-reported function at 6 months may help identify patients at risk for not returning to sports at 1 year and should be considered for inclusion in return-to-sport guidelines.

Factors Associated With Function After Anterior Cruciate Ligament Reconstruction

Background: Many individuals do not resume unrestricted, preinjury sports participation after anterior cruciate ligament reconstruction, thus a better understanding of factors associated with function is needed. The purpose of this study was to investigate the association of knee impairment and psychological variables with function in subjects with anterior cruciate ligament reconstruction. Hypothesis: After controlling for demographic variables, knee impairment and psychological variables contribute to function in subjects with anterior cruciate ligament reconstruction. Study Design: Cross-sectional study; Level of evidence, 4a. Methods: Fifty-eight subjects with a unilateral anterior cruciate ligament reconstruction completed a standardized testing battery for knee impairments (range of motion, effusion, quadriceps strength, anterior knee joint laxity, and pain intensity), kinesiophobia (shortened Tampa Scale for Kinesiophobia), and function (International Knee Documentation Committee subjective form and single-legged hop test). Separate 2-step regression analyses were conducted with International Knee Documentation Committee subjective form score and single-legged hop index as dependent variables. Demographic variables were entered into the model first, followed by knee impairment measures and Tampa Scale for Kinesiophobia score. Results: A combination of pain intensity, quadriceps index, Tampa Scale for Kinesiophobia score, and flexion motion deficit contributed to the International Knee Documentation Committee subjective form score (adjusted r 2 = 0.67; P < .001). Only effusion contributed to the single-legged hop index (adjusted r 2 = 0.346; P = .002). Conclusion: Knee impairment and psychological variables in this study were associated with self-report of function, not a performance test. Clinical Relevance: The results support focusing anterior cruciate ligament reconstruction rehabilitation on pain, knee motion deficits, and quadriceps strength, as well as indicate that kinesiophobia should be addressed. Further research is needed to reveal which clinical tests are associated with performance testing.

Analysis of shortened versions of the tampa scale for kinesiophobia and pain catastrophizing scale for patients after anterior cruciate ligament reconstruction.

ObjectiveRecent work suggests that psychological influence on pain intensity and knee function should be considered for patients after anterior cruciate ligament reconstruction (ACLR). The Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) have been used to determine psychological influence in these patients. However, TSK and PCS factor structures have not been described for patients with ACLR. This study investigated 2 groups of patients post-ACLR to determine if the use of shortened questionnaires is warranted. MethodsCross-sectional study in which patients completed measures during early (n=105, median days from surgery=56.0) and late (n=184, median days from surgery=195.0) postoperative phases of ACLR rehabilitation. ResultsShortened questionnaires for fear of pain, fear of injury, and somatic focus were generated for the TSK-11. A shortened questionnaire for magnification/helplessness and rumination was generated for the PCS in the late group only. There were minimal differences in the shortened questionnaires for clinical subgroups based on sex, ACLR graft type, method of injury, or nature of injury. Correlation and regression analyses suggested a shortened version of the TSK-11 for fear of injury was appropriate for use in the early postoperative phase, whereas the original TSK-11 scale may be appropriate for use in the late postoperative phase. There were no shortened versions of the PCS for consideration in the early postoperative phase, but a shortened version for magnification/helplessness was appropriate for use in the late postoperative phase. DiscussionShortened versions of the TSK-11 and PCS may be appropriate for ACLR populations, depending on the postoperative phase. These data may guide future research of psychological factors in ACLR populations so that levels predictive of risk for developing chronic pain and/or inability to return to pre-injury activity levels can be determined.

Pain-Related Fear Contributes to Self-Reported Disability in Patients With Foot and Ankle Pathology

OBJECTIVE To determine the unique influence of pain-related fear of movement on foot and ankle disability, after accounting for pain, demographic, and physical impairment variables. DESIGN Cross-sectional study using retrospective chart review. SETTING Outpatient rehabilitation clinic. PARTICIPANTS Referred sample of subjects with foot- and ankle-related disability (N=85, 40 men; mean age, 33y; range, 16-77y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Lower Extremity Functional Scale (LEFS), Shortened Tampa Scale of Kinesiophobia (TSK-11). RESULTS Hierarchical regression analysis determined the proportions of explained variance in disability (LEFS). Demographic variables were entered into the model first, followed by pain intensity and range-of-motion (ROM) deficit, and finally, TSK-11. Demographics collectively contributed 9% (P=.015) of the variance in disability scores. Pain intensity and overall ROM deficit contributed an additional 11% (P<.001) of the variance, and TSK-11 scores contributed an additional 14% (P<.001). In the overall model, age (beta=-.29, P=.004), chronicity of symptoms (beta=.23, P=.024), ROM deficit (beta=-.28, P=.003), and TSK-11 (beta=-.41, P<.001) explained 34% of the variance in the LEFS score (P<.001). CONCLUSIONS Age, chronicity of symptoms, ROM deficit, and TSK-11 scores all significantly contributed to baseline foot and ankle self-reported disability. Pain-related fear of movement was the strongest single contributor to disability in this group of patients.

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings

OBJECTIVES (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. DESIGN Cross-sectional study. SETTING Outpatient physical therapy clinic. PARTICIPANTS Consecutive patients (N=110) with complaints of musculoskeletal pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. RESULTS Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). CONCLUSIONS These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

Study Design Clinical measurement, cross-sectional. Background Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice. Objectives To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice. Methods A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool. Results Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain. Conclusion Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487.

Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior Cruciate Ligament Reconstruction

Background: Plyometric exercise is used during rehabilitation after anterior cruciate ligament (ACL) reconstruction to facilitate the return to sports participation. However, clinical outcomes have not been examined, and high loads on the lower extremity could be detrimental to knee articular cartilage. Purpose: To compare the immediate effect of low- and high-intensity plyometric exercise during rehabilitation after ACL reconstruction on knee function, articular cartilage metabolism, and other clinically relevant measures. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Twenty-four patients who underwent unilateral ACL reconstruction (mean, 14.3 weeks after surgery; range, 12.1-17.7 weeks) were assigned to 8 weeks (16 visits) of low- or high-intensity plyometric exercise consisting of running, jumping, and agility activities. Groups were distinguished by the expected magnitude of vertical ground-reaction forces. Testing was conducted before and after the intervention. Primary outcomes were self-reported knee function (International Knee Documentation Committee [IKDC] subjective knee form) and a biomarker of articular cartilage degradation (urine concentrations of crosslinked C-telopeptide fragments of type II collagen [uCTX-II]). Secondary outcomes included additional biomarkers of articular cartilage metabolism (urinary concentrations of the neoepitope of type II collagen cleavage at the C-terminal three-quarter–length fragment [uC2C], serum concentrations of the C-terminal propeptide of newly formed type II collagen [sCPII]) and inflammation (tumor necrosis factor–α), functional performance (maximal vertical jump and single-legged hop), knee impairments (anterior knee laxity, average knee pain intensity, normalized quadriceps strength, quadriceps symmetry index), and psychosocial status (kinesiophobia, knee activity self-efficacy, pain catastrophizing). The change in each measure was compared between groups. Values before and after the intervention were compared with the groups combined. Results: The groups did not significantly differ in the change of any primary or secondary outcome measure. Of interest, sCPII concentrations tended to change in opposite directions (mean ± SD: low-intensity group, 28.7 ± 185.5 ng/mL; high-intensity group, −200.6 ± 255.0 ng/mL; P = .097; Cohen d = 1.03). Across groups, significant changes after the intervention were increased the IKDC score, vertical jump height, normalized quadriceps strength, quadriceps symmetry index, and knee activity self-efficacy and decreased average knee pain intensity. Conclusion: No significant differences were detected between the low- and high-intensity plyometric exercise groups. Across both groups, plyometric exercise induced positive changes in knee function, knee impairments, and psychosocial status that would support the return to sports participation after ACL reconstruction. The effect of plyometric exercise intensity on articular cartilage requires further evaluation. Registration Number: Clinicaltrials.gov NCT01851655