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Fear-Based Problems After Total Knee Replacement

Before reaching the point of needing, wanting, and accepting a total knee replacement for joint arthritis, many people become fearful of movement (kinesiophobic). Their level of pain causes them to start avoiding certain movements and activities at home and work. This pattern of behavior is called fear-avoidance.

Long periods of time in the fear-avoidance mode of thinking and acting can eventually lead to loss of function and disability. Without movement, knee osteoarthritis is known to get worse, causing more pain. Before you know it, the person becomes kinesiophobic (afraid to move), sacrificing everyday activities and tasks. A viscious cycle of pain-fear-disability-pain develops that can be hard to break.

In fact, this pattern of pain-related fear does not automatically go away after the joint is replaced. That's why this study from Italy was done by a group of physicians and physical therapists. They wanted to compare two different approaches to rehabilitation based on measures of fear-avoidance, pain intensity, and quality of life. The idea is to find the best way to restore full motion and function without the element of fear preventing recovery and return to all activities.

The 110 patients in the study were divided into two groups. The experimental group was given a special exercise program and a book with information about how to manage (and overcome) kinesiophobia. The exercises were to be done twice a week for six months. Everyone in this group was instructed in functional exercises before leaving the hospital.

Functional exercises refers to a type of program designed to do more than just regain 90-degrees of knee flexion or lift the leg off the bed ten times. Functional exercise-based rehabilitation programs are geared toward improving motion and strength while preventing blood clot formation and while restoring specific activities. Walking; climbing stairs; and making sudden starts, stops, and turns are just a few examples of the skills functional exercises work to restore.

The book the experimental group received was designed to help them understand their own unwillingness to go out shopping, go for a walk, return to work, or ride a bike. By practicing physical activities and movements at home, the patients in this group were encouraged to perform all these things without fear. The goal was to increase activities previously considered "dangerous" (i.e., before surgery). This was to be done slowly but steadily over the six months' period of time after surgery.

The control group was just advised to stay active. They were told to gradually increase their activity level until they returned to normal (defined as their "usual" activities). Patients were randomly assigned to one of these two groups (experimental or control).

After six months, it was clear that the experimental group had much better results compared with the control group. Disability level was much lower and quality of life was much higher in the experimental group. Fear-avoidance behaviors were also less common among the exercise group. Based on their findings in this study, the authors proposed the following:

  • Before knee replacement, all patients should be screened to identify those individuals who have pain-related fear of movement.
  • Anyone at risk for problems after total knee replacement because of fear-avoidance behaviors should receive education about kinesiophobia and a special rehab program.
  • Specific "graded" (in other words, slowly progressed) functional exercises should be prescribed and supervised until knee motion, daily activities, and physical function can be done with confidence and without fear.
  • Such a program can be taught to the patient while still in the hospital for the surgery. A follow-up home program may be enough to take care of the problem. Future studies are needed to know for sure exactly what type of rehab program (and for how long the program) should be provided.

    The authors concluded that it is possible to pre-identify (before surgery) patients whose recovery from a total knee replacement may be compromised by fear-avoidance thinking and behaviors. Education and exercise can help correct these behaviors and aid patients in overcoming barriers to full recovery. Addressing and treating kinesiophobia in this way puts the burden of responsibility for recovery from mistaken beliefs and thoughts squarely on the patient's shoulders.

    Marco Monticone, MD, PhD, et al. 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. In Archives of Physical Medicine. February 2013. Vol. 94. No. 2. Pp. 231-239.


    *Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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