Chua Shaun Kai Kiat, Lim Chien Joo, Pua Yong Hao, Yang Su-Yin, Tan Bryan Yijia
Ministry of Health, College of Medicine Building, Singapore.
Department of Orthopedic Surgery, Woodlands Health, National Healthcare Group, Singapore.
Clin Orthop Relat Res. 2025 Apr 1;483(4):667-676. doi: 10.1097/CORR.0000000000003278. Epub 2024 Oct 9.
Beyond knee pain itself, the fear of movement, also known as kinesiophobia, recently has been proposed as a potential factor contributing to disability and functional limitation in patients with knee osteoarthritis (OA). Nevertheless, the available evidence on the association of kinesiophobia with patient-reported outcome measures (PROMs) in knee OA remains limited.
QUESTIONS/PURPOSES: Among patients with nonoperatively treated knee OA, we asked: (1) Is kinesiophobia associated with decreased quality of life (QoL), functional outcomes, and physical activity? (2) What are the patient disease and psychosocial demographic factors associated with kinesiophobia?
This was a multicenter, cross-sectional study of 406 general orthopaedic patients from two urban, referral-based tertiary hospitals in Singapore under a single healthcare group who received nonoperative treatment for knee OA. Between July 2020 and January 2022, a total of 1541 patients were treated for knee OA nonoperatively. Based on that, 60% (923) of patients were rejected due to refusal to participate in the study, 3% (52) of patients were enrolled but did not show up for their appointments for data collection, and a further 10% (160) had incomplete data sets, leaving 26% (406) for this study's analysis. The mean age of patients was 64 ± 8 years, 69% were women, and 81% were Chinese. The level of kinesiophobia in patients was measured using the Brief Fear of Movement scale, a validated 6-item questionnaire ranging from a score of 6 to 24 to measure kinesiophobia in OA, with higher scores representing higher levels of kinesiophobia. In terms of PROMs, the QoL and functional level of patients were measured using the QoL and activities of daily living (ADL) components of the widely validated 12-item Knee Injury and Osteoarthritis Outcome Score (KOOS-12). The KOOS-12 is a questionnaire consisting of 12 items encompassing three domains (QoL, ADL, and pain), with each item ranging from 0 to 4 and higher scores representing worse outcomes. The University of California, Los Angeles (UCLA) Activity Scale was used to measure the level of physical activity in patients. The UCLA score is a descriptive 10-level activity scale ranging from a score of 1 to 10, with higher scores representing greater physical activity levels. A directed acyclic graph, which is a relationship map used to depict and visualize the confounders between the studied variables, was used to identify the confounders between kinesiophobia and PROMs (QoL, function, and physical activity). An ordinal regression model was used to explore: (1) the association between kinesiophobia (as measured using the Brief Fear of Movement scale) and PROMs (as measured using KOOS QoL, KOOS ADL, and the UCLA Activity Scale), adjusting for key confounders such as age, gender, pain, side of arthritis, OA duration/severity, and psychosocial factors (for example, depression, anxiety, and education levels), and (2) the association between kinesiophobia (Brief Fear of Movement scale) and various patient disease and psychosocial demographic factors.
After accounting for confounders, greater kinesiophobia (higher Brief Fear of Movement scores) was associated with lower QoL (KOOS QoL score adjusted IQR OR 0.69 [95% confidence interval (CI) 0.53 to 0.90]; p = 0.007) and lower physical activity (UCLA score adjusted IQR OR 0.68 [95% CI 0.52 to 0.90]; p = 0.007); however, there was no association between kinesiophobia and function (KOOS ADL score adjusted IQR OR 0.90 [95% CI 0.70 to 1.17]; p = 0.45). After adjusting for age, gender, OA duration, pain, and BMI, higher levels of anxiety (Patient Health Questionnaire 2 [PHQ-2] anxiety score adjusted OR 2.49 [95% CI 1.36 to 4.58]; p = 0.003) and depression (PHQ-2 depression score adjusted OR 3.38 [95% CI 1.73 to 6.62]; p < 0.001) were associated with higher levels of kinesiophobia. Education level, OA disease severity, side of arthritis (unilateral versus bilateral), and history of previous injury or surgery on the knee were not associated with kinesiophobia.
Clinicians should assess for kinesiophobia and other psychological comorbidities such as depression and anxiety at the point of initial evaluation and subsequent follow-up of knee OA with simple validated tools like the Brief Fear of Movement scale (kinesiophobia) in the clinic. This allows for clinicians to identify high-risk individuals and offer evidence-based treatment such as cognitive behavioral therapies with a multidisciplinary team, including a physical therapist and psychologist, to manage these psychological comorbidities and improve outcomes in patients with knee OA. While kinesiophobia was found to be associated with poorer QoL and physical activity, future studies including larger observational cohort studies should be conducted to determine causal and prognostic relationships between kinesiophobia and outcomes in knee OA.
Level III, prognostic study.
除了膝关节疼痛本身，对运动的恐惧，也称为运动恐惧，最近被认为是导致膝关节骨关节炎（OA）患者残疾和功能受限的一个潜在因素。然而，关于运动恐惧与膝关节OA患者报告结局量表（PROMs）之间关联的现有证据仍然有限。
问题/目的：在接受非手术治疗的膝关节OA患者中，我们提出以下问题：（1）运动恐惧是否与生活质量（QoL）下降、功能结局和身体活动减少有关？（2）与运动恐惧相关的患者疾病和社会心理人口统计学因素有哪些？
这是一项多中心横断面研究，研究对象为来自新加坡一个医疗集团下属的两家城市转诊型三级医院的406名普通骨科患者，他们因膝关节OA接受了非手术治疗。在2020年7月至2022年1月期间，共有1541名患者接受了膝关节OA的非手术治疗。基于此，60%（923名）患者因拒绝参与研究被排除，3%（52名）患者已登记但未前来参加数据收集预约，另有10%（160名）患者数据集不完整，最终26%（406名）患者纳入本研究分析。患者的平均年龄为64±8岁，69%为女性，81%为华裔。使用简明运动恐惧量表测量患者的运动恐惧水平，该量表是一份经过验证的包含6个条目的问卷，评分范围为6至24分，用于测量OA患者的运动恐惧，分数越高表示运动恐惧水平越高。在PROMs方面，使用广泛验证的12项膝关节损伤和骨关节炎结局评分（KOOS - 12）中的生活质量和日常生活活动（ADL）部分来测量患者的生活质量和功能水平。KOOS - 12是一份包含12个条目的问卷，涵盖三个领域（生活质量、ADL和疼痛），每个条目评分范围为0至4分，分数越高表示结局越差。使用加利福尼亚大学洛杉矶分校（UCLA）活动量表测量患者的身体活动水平。UCLA评分是一个描述性的10级活动量表，评分范围为1至10分，分数越高表示身体活动水平越高。使用有向无环图（一种用于描绘和可视化研究变量之间混杂因素的关系图）来识别运动恐惧与PROMs（生活质量、功能和身体活动）之间存在的混杂因素。使用有序回归模型来探究：（1）运动恐惧（使用简明运动恐惧量表测量）与PROMs（使用KOOS生活质量、KOOS ADL和UCLA活动量表测量）之间的关联，并对年龄、性别、疼痛、关节炎患侧、OA病程/严重程度和社会心理因素（如抑郁、焦虑和教育水平）等关键混杂因素进行校正；（2）运动恐惧（简明运动恐惧量表）与各种患者疾病和社会心理人口统计学因素之间的关联。
在考虑混杂因素后，更高的运动恐惧（更高的简明运动恐惧量表评分）与更低的生活质量（KOOS生活质量评分调整后的四分位间距比值比为0.69 [95%置信区间（CI）0.53至0.90]；p = 0.007）和更低的身体活动水平（UCLA评分调整后的四分位间距比值比为0.68 [95% CI 0.52至0.90]；p = 0.007）相关；然而，运动恐惧与功能之间没有关联（KOOS ADL评分调整后的四分位间距比值比为0.90 [95% CI 0.70至1.17]；p = 0.45）。在对年龄、性别、OA病程、疼痛和体重指数进行校正后，更高水平的焦虑（患者健康问卷2 [PHQ - 2]焦虑评分调整后的比值比为2.49 [95% CI 1.36至4.58]；p = 0.003）和抑郁（PHQ - 2抑郁评分调整后的比值比为3.38 [95% CI 1.73至6.62]；p < 0.001）与更高水平的运动恐惧相关。教育水平、OA疾病严重程度、关节炎患侧（单侧与双侧）以及膝关节既往受伤或手术史与运动恐惧无关。
临床医生应在膝关节OA的初始评估和后续随访时，使用如临床简明运动恐惧量表（运动恐惧）等经过验证的简单工具评估运动恐惧及其他心理合并症，如抑郁和焦虑。这使临床医生能够识别高危个体，并提供基于证据的治疗，如与多学科团队（包括物理治疗师和心理学家）一起进行认知行为疗法，以管理这些心理合并症并改善膝关节OA患者的结局。虽然运动恐惧与较差的生活质量和身体活动相关，但未来应开展包括更大规模观察性队列研究在内的研究，以确定运动恐惧与膝关节OA结局之间的因果关系和预后关系。
III级，预后研究。
