Understanding fear of movement and reinjury with the Tampa Scale of Kinesiophobia (TSK) in individuals with musculoskeletal knee pathology: A systematic review

Abstract

Purpose: Fear of movement and reinjury, quantified with the Tampa Scale of Kinesiophobia (TSK), is increasingly recognized for its role in the prognosis and function of individuals with musculoskeletal knee pathology. However, it remains unclear how fear of movement and reinjury affects individuals across the spectrum of knee pathology. The purpose of this systematic review was to (1) summarize TSK scores across all musculoskeletal knee pathology (including acute, chronic, surgical, and non-surgical pathologies) (2) summarize the relationship between the TSK score and knee function (including self-reported or performance-based), and (3) summarize the change in the TSK during recovery or in response to an intervention. Methods: We searched five databases from 1993 (inception of the TSK) to November 2014: Pubmed, CINAHL, SportsDiscus, Medline, ERIC, PsycInfo. Studies were included if they assessed the TSK in a knee pathology population and were available in English. Exclusion criteria included: (1) TSK results for knee pathologies not reported independently (ie. combined with hip pathology), (2) populations with nonmusculoskeletal pathologies, (3) case studies or commentaries. Methodology was quality assessed with the Critical Assessment of Quantitative Studies (Scored 0-16, higher scores indicating better higher quality). Results: The search resulted in 1176 unique references. Full texts articles that assessed the TSK in a knee pathology population were reviewed (n=26). Four articles did not report the results for the knee groups independently from other pathologies and were excluded. Twenty-two articles were included in the final review, and received varied methodology scores (Range 9-16). At least seven versions of the TSK were identified, varying in item number (11, 13, or 17) or language (English, Italian, Swedish, Turkish, French). Eleven of the 22 studies originated from four institutions; it was unclear when samples were independent or similar between studies. The study designs varied (8 prospective longitudinal cohorts, 1 retrospective cohort, 11 cross-sectional, 2 randomized controlled trials). Study populations included surgical (anterior cruciate ligament reconstruction [ACLR] n=11; total knee arthroplasty [TKA], n=6), non-surgical (anterior knee pain, n=2; osteoarthritis, n=1), and mixed pathologies (n=2). In all populations, lower TSK scores, indicating lower fear, were often correlated to better self-report and performance-based function. However, many relationships did not persist after accounting for other psychosocial (pain catastrophizing, self-efficacy, etc) and clinical (pain, etc) variables. After ACLR, TSK scores consistently correlated to return to sport/prior level of activity; however TSK did not always contribute to a full prediction model when other factors were considered. Six studies reported TSK scores at multiple time points (2 intervention studies targeting kinesiophobia, 3 evaluating recovery following standard post-operative care, and 1 investigating longitudinal changes). After ACLR, two studies demonstrated improvement in TSK over the course of standard rehabilitation, whereas two studies did not. The two intervention studies targeting kinesiophobia (1 after ACLR, 1 after TKA) demonstrated improvements in the intervention groups, but not the control groups. A meta-analysis was not performed due to the heterogeneity among the included studies. Conclusions: Due to the high variety in TSK versions and potential of repeated samples between studies from the same institutions, it was difficult to summarize TSK scores across the spectrum of knee pathology. Lower TSK scores correlated with better knee function in most studies; however, these relationships did not always persist in more robust prediction models. It remains unclear if TSK consistently improves with standard post-surgical rehabilitation, or requires targeted intervention strategies. To improve our understanding of the role of fear of movement and reinjury in the prognosis, recovery, and function of individuals with knee inju ies, it is imperative to develop a universal, psychometrically sound outcome measure.