Is Kinesiophobia Associated With Quality of Life, Level of Physical Activity, and Function in Older Adults With Knee Osteoarthritis?

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. 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.

Chua SKK ，Lim CJ ，Pua YH ，Yang SY ，Tan BY ... -  《-》

How Does Shame Relate to Clinical and Psychosocial Outcomes in Knee Osteoarthritis?

Knee osteoarthritis (OA) is a common and disabling condition that often carries severe psychosocial implications. Chronic illness-related shame has emerged as a substantial psychosocial factor affecting individuals with knee OA, but it is unclear how chronic illness-related shame is associated with the long-term clinical and psychosocial outcomes in individuals with knee OA. (1) Does a higher level of shame correlate with worse clinical and psychosocial outcomes at baseline among individuals with knee OA? (2) Is a higher level of shame at baseline associated with worse clinical and psychosocial outcomes at 4-month and 12-month follow-up among individuals with knee OA? (3) Are sociodemographic characteristics correlated with levels of shame among individuals with knee OA? Between June 2021 and February 2022, we screened 977 patients based on the inclusion criteria of (1) age 45 years or older, (2) independent in community mobility with or without walking aids, (3) proficient in English or Chinese language, and (4) met the clinical criteria for OA diagnosis outlined by the National Institute for Health and Care Excellence. Of these patients, 47% (460) were eligible and enrolled. A further 53% (517) were excluded for prespecified reasons. Of the 460 enrolled patients, 7% (30) dropped out before data collection began, and 46% (210) of patients did not complete the psychological questionnaires, leaving 48% (220) of patients for analysis. From this final sample, 25% (56) were lost to follow-up at 4 months, and an additional 7% (16) were lost by the 12-month follow-up, leaving 67% (148) of the original eligible group for analysis. All patients were recruited from the outpatient clinics of the orthopaedic and physiotherapy departments across two Singapore hospitals within the National Healthcare Group. The study population had a mean ± SD age of 64 ± 8 years, with 69% (152 of 220) women, and the mean ± SD duration of knee OA symptoms was 6 ± 6 years. Outcome measures used were the Chronic Illness-Related Shame Scale (CISS), the 12-item Knee Injury and Osteoarthritis Outcome Score (KOOS-12), Patient Health Questionnaire 4 (PHQ-4), the 8-item Arthritis Self-Efficacy Scale (ASES-8), and the Brief Fear of Movement Scale (BFOM). The CISS is a validated tool specifically designed to measure feelings of shame (internal and external shame) in individuals living with chronic illness. The scale has been validated for use among patients with knee OA in Singapore. The functional outcome measure used was the Modified Barthel Index. Data on demographic characteristics were collected. Data were collected at baseline, 4-month follow-up, and 12-month follow-up. Statistical analyses included the Spearman correlation, linear regression, and cluster analysis. At baseline, there was a weak to moderate negative correlation between CISS scores and KOOS-12 and ASES-8 scores (Spearman correlation coefficients ranged from -0.46 to -0.36; all p values < 0.001), indicating that higher levels of shame were associated with slightly to moderately worse knee function and lower self-efficacy. There was a modest positive correlation between CISS scores and PHQ-4 and BFOM scores (the Spearman correlation coefficients ranged from 0.43 to 0.46; all p values < 0.001), indicating that higher levels of shame were linked to more psychological distress and greater fear of movement. At the 4-month follow-up, a higher CISS score at baseline was associated with a decrease in KOOS-12 (adjusted coefficient -0.86 [95% confidence interval (CI) -1.33 to -0.40]; p < 0.001) and ASES-8 (adjusted coefficient -0.12 [95% CI -0.19 to -0.06]; p < 0.001) scores, indicating worsened knee function and reduced self-efficacy over time. Higher CISS scores at baseline were also associated with an increase in PHQ-4 (adjusted coefficient 0.23 [95% CI 0.14 to 0.31]; p < 0.001) and BFOM (adjusted coefficient 0.22 [95% CI 0.08 to 0.36]; p = 0.002) scores at the 4-month follow-up, reflecting greater psychological distress and greater fear of movement. At the 12-month follow-up, a higher CISS score at baseline was associated with a decrease in KOOS-12 (adjusted coefficient -0.72 [95% CI -1.25 to -0.19]; p = 0.008) and ASES-8 (adjusted coefficient -0.12 [95% CI -0.20 to -0.04]; p = 0.002) scores, indicating that those with higher initial levels of shame continued to experience poorer knee function and lower self-efficacy. Higher CISS scores at baseline were also associated with an increase in PHQ-4 (adjusted coefficient 0.13 [95% CI 0.04 to 0.21]; p = 0.004) as well as BFOM (adjusted coefficient 0.20 [95% CI 0.06 to 0.34]; p = 0.007) scores at the 12-month follow-up, indicating ongoing psychological distress and fear of movement. Cluster analysis found that unemployed older patients with lower CISS scores and BMI, as well as having unilateral arthritis and shorter duration of OA, were observed to have better knee function at 4 months (mean difference 7 [95% CI 1 to 12]; p = 0.02) and 12 months (mean difference 7 [95% CI 1 to 13]; p = 0.02) compared with the opposite. After controlling for age, gender, ethnicity, and employment status, the regression analysis found that higher BMI was related to higher CISS scores (adjusted coefficient 0.21 [95% CI 0.07 to 0.34]; p = 0.003). Chronic illness-related shame has a small to modest association with clinical and psychosocial outcomes for individuals with knee OA. Healthcare professionals should routinely incorporate psychosocial assessments to identify and manage shame early, potentially improving both clinical and psychosocial outcomes. Recognizing that higher BMI is linked to increased shame can specifically guide targeted emotional and psychosocial support. Additionally, integrating interventions such as acceptance and commitment therapy and peer support with traditional treatments could enhance adherence and overall patient outcomes, making comprehensive care more effective. Level II, prognostic study.

Yeo JY ，Lim CJ ，Yang SY ，Tan BY ... -  《-》

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. Level III, prognostic study.

Jayakumar P ，Crijns TJ ，Misciagna W ，Manickas-Hill O ，Malay M ，Jiranek W ，Mather RC 3rd ，Lentz TA ... -  《-》

Is Rotationplasty Still a Reasonable Reconstruction Option for Patients With a Femoral Bone Sarcoma? A Comparative Study of Patients With a Minimum of 20 Years of Follow-up After Rotationplasty and Lower Extremity Amputation.

Rotationplasty was first introduced as an alternative to above-the-knee amputation after resection of bone sarcomas of the distal femur by Salzer in 1974. Although the procedure involves a substantial body image issue, it has many advantages such as durability of the reconstruction (compared with limb salvage procedures) and avoidance of phantom pain (compared with amputation). Although several reports have shown intermediate outcomes of rotationplasty, very long-term results in terms of function, activity levels, and quality of life (QoL) in comparison with above-the-knee amputation have not been reported. This work aims to fill this gap left by prior reports. (1) Is there a difference in revision-free survival in very long-term follow-up after rotationplasty and transfemoral amputation or knee disarticulation? (2) Are patient activity levels after rotationplasty comparable with those after transfemoral amputation or knee disarticulation in the very long term? (3) Do activity levels differ in terms of QoL? (4) Within the group of patients who have undergone rotationplasty, is the ROM in the neo-knee associated with QoL 20 to 40 years later? Between 1961 and 1995, a total of 360 patients were treated for bone and soft tissue sarcoma of the lower extremity. Fifty-four patients were treated with A1 rotationplasty, 124 were treated with an amputation, and 182 were treated with a limb salvage procedure. Of those who underwent amputation or rotationplasty, 9% (11 of 124) and 15% (8 of 54), respectively, were lost to follow-up before a period of 20 years without meeting a study endpoint, and another 71% (88 of 124) and 44% (24 of 54), respectively, died prior to 20 years with intact residual limbs, leaving 20% (25 of 124) and 41% (22 of 54), respectively, of the original group who had a follow-up time of at least 20 years. Four patients with amputations declined to participate in the study, while three patients with transtibial amputations and one patient with a complete language barrier after rotationplasty were excluded. These 39 patients with a minimum follow-up time of 20 years (mean [range] 36 years [23 to 55]) were available and gave their consent to this retrospective comparative study at the local orthopaedic department. The decision between rotationplasty and endoprosthetic replacement was made after thorough consultation and according to the patient's choice. As general guidance, Salzer's idea was to provide rotationplasty to patients who had a strong desire for higher levels of activity. Endoprosthetic reconstructions were more likely indicated given a patient's preference for a cosmetically uncompromised limb. Amputation was primarily performed one decade before the availability of rotationplasty and was mostly an alternative to rotationplasty because of patient refusal or surgical limitations. Therefore, the two groups differed in age at follow-up; however, they did not differ in age at surgery, BMI, gender ratio, tumor entities, or tumor localization. All-cause revisions presented in Kaplan-Meier curves, pain sensation, and functional and QoL outcomes, such as ROM, University of California Los Angeles (UCLA) activity scores, 5-level EuroQol 5-domain (EQ-5D-5L) scores, and 36-Item Short Form survey scores, were assessed. There was no difference between patients after rotationplasty and amputation in terms of survivorship free from revision of unpredictable events at 20 years (86% [95% confidence interval (CI) 85% to 95%] versus 67% [95% CI 64% to 94%]; p = 0.27). There was no difference in median UCLA activity scores between the groups (rotationplasty 6 versus amputation 5; p = 0.18). Patients treated with a rotationplasty had less pain than those treated with amputation (EQ-5D-5L pain/discomfort, p < 0.01). The EuroQol (EQ) index was higher in patients who had rotationplasty in comparison with patients who underwent amputation (0.92 versus 0.81; p = 0.01). A linear regression model that controlled for length of follow-up, gender, age, and type of surgery found that having rotationplasty was associated with a better EQ index than undergoing amputation (R = 0.538, R2 corrected = 0.212; p = 0.011). There were positive correlations between the EQ index and both flexion (ρ = 0.53 [95% CI 0.03 to 0.82]; p = 0.03) and ROM (ρ = 0.54 [95% CI 0.05 to 0.82]; p = 0.03) in the neo-knee. After rotationplasty and amputation, patients show similarities at long-term follow-up in the use of external prostheses and in cosmetic issues after limb loss. Both groups might have benefitted from the advancements in prosthetics that have occurred and will continue to do so; however, in this study, patients seem to have better QoL after rotationplasty compared with those with amputation. This study intentionally did not compare outcomes after an extendible or modular endoprosthesis with outcomes after rotationplasty. However, failures after endoprosthetic reconstructions occur frequently in the long term, whereas they rarely exist after rotationplasty. The use of rotationplasty, therefore, might be a benefit not only to individual patients but also to stakeholders in healthcare systems. Furthermore, this study emphasizes the benefit of rotationplasty as a durable surgical method that enables patients for high physical performance. Therefore, tumor centers around the world should be aware of these benefits, and patients must be given the opportunity to receive information about it. Currently, rotationplasty might be beneficial in certain situations, at least when patients and/or parents accept this kind of reconstruction. Children younger than 5 to 7 years and small in height, patients considered for megaprostheses with borderline or insufficient soft tissue coverage, and even patients who are highly active and feel that sporting activities are most important for their lifestyle are potential candidates for rotationplasty. Furthermore, rotationplasty might be an option after failed limb salvage surgery. Level III, therapeutic study.

Hobusch GM ，Hofer C ，Döring K ，Ellersdorfer F ，Kelaridis T ，Windhager R ... -  《-》

Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate. Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors? New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status-as measured by the SDoH indices-among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05. There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively. Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application. We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry.

Bernstein DN ，Shin D ，Poolman RW ，Schwab JH ，Tobert DG ... -  《-》