Exploring the interplay: Kinesiophobia prevalence and its relationship with cognitive impairment following upper limb fractures

Abha Shirish Khisty; Seema Saini; Kush Jadhav; Tushar J Palekar

doi:10.4103/ijptr.ijptr_115_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 5 | Issue : 1 | Page : 41-45

Exploring the interplay: Kinesiophobia prevalence and its relationship with cognitive impairment following upper limb fractures

Abha Shirish Khisty, Seema Saini, Kush Jadhav, Tushar J Palekar
Department of Physiotherapy, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission	02-Aug-2022
Date of Decision	19-Jun-2023
Date of Acceptance	30-Jun-2023
Date of Web Publication	11-Aug-2023

Correspondence Address:
Dr. Abha Shirish Khisty
Department of Physiotherapy, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Sant-Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_115_22

Abstract

Context: Pain-related fear is more disabling than pain itself. Assessment of kinesiophobia should be practiced as a regular basis for any traumatic painful conditions. As upper limb fractures are most prevalent among all the other types of fractures, this study aims to assess the prevalence of kinesiophobia in posttraumatic upper limb conditions and its correlation with cognitive status.
Aim: The aim of this study was to determine the prevalence of kinesiophobia in upper limb traumatic fractures and observe its correlation with cognitive status.
Settings and Design: This cross-sectional study was conducted at tertiary care hospital, and data were obtained from the orthopedics department of the hospital.
Subjects and Methods: Three hundred (n = 300) patients with upper limb fractures were screened for kinesiophobia and cognitive impairment. Kinesiophobia was assessed using Tampa Scale for Kinesiophobia and cognition was assessed using Mini–Mental State Examination Scale.
Statistical Analysis: Descriptive statistics were applied and frequency distribution in percentages to see the prevalence of kinesiophobia in upper limb fractures. Karl's Pearson's coefficient correlation test was applied to evaluate the correlation between cognitive status.
Results: There is an inverse negative correlation between cognitive status and kinesiophobia (r = 0.06, P = 0.002). There was 58% of overall prevalence in upper limb fractures but the highest was observed in fractures of the shoulder complex which was 32%.
Conclusions: The overall prevalence of kinesiophobia in upper limb fractures was high, however, it was highest in fractures of the shoulder complex with compound fractures. This study also concludes that reduced cognitive status leads to increased kinesiophobia.

Keywords: Disability, Movement fear, Pain, Stress

How to cite this article:
Khisty AS, Saini S, Jadhav K, Palekar TJ. Exploring the interplay: Kinesiophobia prevalence and its relationship with cognitive impairment following upper limb fractures. Indian J Phys Ther Res 2023;5:41-5

How to cite this URL:
Khisty AS, Saini S, Jadhav K, Palekar TJ. Exploring the interplay: Kinesiophobia prevalence and its relationship with cognitive impairment following upper limb fractures. Indian J Phys Ther Res [serial online] 2023 [cited 2023 Oct 1];5:41-5. Available from: https://www.ijptr.org/text.asp?2023/5/1/41/383668

Introduction

Kinesiophobia is an unreasonable and devitalizing fear of physical movement and activity resulting from a feeling of vulnerability to painful injury which eventually leads to immobility, disuse atrophy, and depression. Perhaps, pain-related fear is more disabling than pain itself.^{[1],[2],[3],[4],[5]} A systematic review of multimodal approaches in managing the kinesiophobia was conducted by Yining et al.,^[5] they observed that the prevalence of kinesiophobia in patients with humerus fracture, radius fracture, and hand bone fractures was 78% after discharge from hospitals.^[6] There are certain contributing factors which undertakes kinesiophiobia that should be addressed during regular clinical assessments by incorporating the knowledge of patients about exercise adherence, duration of physiotherapy treatment, and patient's counseling.^{[7],[8],[9],[10]} A descriptive study done on facilitators and barriers to home-based exercises concluded that patients were having difficulty in performing exercises at the prescribed dosage after getting discharge from the hospital, this might in turn accelerate kinesiophobia.^{[8],[11],[12],[13],[14],[15]}

There are known contributing factors for kinesiophobia which include impaired cognitive status, postsurgery brain fog, stress, and anxiety, hence it is crucial to assess these elements in the acute stage of rehabilitation to present further pain-related fear of movement.^{[16],[17],[18],[19]} Assessment of kinesiophobia is an integral part of any evaluation pro forma. Tampa Scale most reliable measure in assessing kinesiophobia (r = 0.91) was used as an outcome measure. This scale has clinical and cognitive domains.^[8] Clinical questions are focused on the level and intensity of pain whereas cognitive queries are defining the understanding of the relation between pain, injury, and fear of movement.^[20]

Pain-related fear of movement being cognitive and psychological phenomenon, it is essential to assess the risk of kinesiophobia in patients having reduced cognitive and psychological status for that matter it is crucial to assess the correlation between them.^[21] Larsson et al. conducted a similar, however, the correlation of fear of movement with degree of cognitive impairment was not considered in their study subjects selected by them were heterogenous including both traumatic and nontraumatic conditions, hence to generate the evidence, the population has to homogenous to generalize the study findings.^[9]

Therefore, shorter measures of kinesiophobia and cognition would aid preventive measures in patient care. Assessment of kinesiophobia should be practiced on regular basis for any traumatic-painful conditions. Upper limb is used in almost all the activities of daily life, therefore, trauma and posttraumatic kinesiophobia should addressed at an early stage.^[12] It is essential to know the biomechanical relationship of trauma, pain, and fear of movement so it is crucial to assess the prevalence of kinesiophobia in patients suffering from traumatic fractures. Phobia being a cognitive domain, the current cognitive status of patients affects the severity of kinesiophobia. Therefore, this study aimed to find the prevalence of kinesiophobia in upper limb fractures and its correlation with cognitive status.

Subjects and Methods

A total of 300 patients were screened for kinesiophobia according to selection criteria out of which 100 patients between the age group of 20 and 45 years with upper limb fracture, history of fracture between 2 and 4 months were included in the study. Psychologically unstable patients and patients with extreme pain including allodynia and complex regional pain syndrome were excluded from the study. Informed voluntary consent was obtained from patients. Pain was assessed used Numerical Pain Rating Scale (NPRS) and movement restriction was assessed using universal goniometer.

Outcome measures

Selected patients were screened for kinesiophobia using Tampa Scale for Kinesiophobia (TSK) which is a Likert-type scale. Patients were instructed to document their responses on the scale. It had four responses ranging from strongly disagree to strongly agree. Responses were coded and it was calculated as total score. Patients were also screened for cognition using Mini–Mental State Examination Scale (MMSE). This scale has a total score of 30; patients were instructed to document the responses on the scale, a score of 24 and above is considered normal cognition. The mean score of the MMSE scale of included patients in this study was 23 confounding biases including the presence of preexisting stress, depression, and educational level were considered and baseline matching was done for the same.

Statistical analysis

Descriptive statistics were applied and frequency distribution in percentages was analyzed. Statistics were made using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp). Sample size calculation was done using Win. Pipe Software version 11.34, confidence interval, and mean of the previous study were used to estimate the sample size.^[2] Online statistical calculator was used to estimate sample size. Estimated sample size was 84, however, considering participant loss, 100 samples were included.

Results

Baseline variables including age, gender, hand dominance, and MMSE in English and vernacular language were evaluated. The mean age was 32 ± 5.5, among 66% were females and 34% were males. Eighty-eight percentage of patients were right dominant and 6% were having left dominant, a total of 49% of patients MMSE Score <24 indicating the presence of mild cognitive impairment (Mean-23), whereas 51% (51) of patients had a score more than 26 indicating normal cognition [Table 1].

Table 1: Interpretation of baseline variables in percentage and actual count

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Clinical characteristics were assessed including fracture area, bone fractured, type of fracture, NPRS score, Tampa score, and posttraumatic duration using frequency distribution table. Thirty-two percentage (32) of patients had fracture in shoulder complex, in which 34% (34) were having humerus fractures, 30% (30) of patients had fractures at elbow complex, in which 15% (15) were having radius fractures, and 8% (15) were having scaphoid fracture. Compound fractures were more in number with 24% (24) and segmental fractures were 10% (10) [Table 2]. The mean duration of postfracture period was 3 ± 3.4 months, the mean NPRS score was 6 ± 2, and the mean Tampa score was 29 ± 5 [Table 3] and [Table 4]. Distribution of Tampa score, in which 21 patients were from 11 to 22 score and 29 patients is of 13–33 score. The prevalence of kinesiophobia in upper limb posttraumatic fractures was calculated by descriptive statistics using a frequency distribution table was 58% [Table 4].

Table 2: Clinical characteristics including area of fracture, bone fractured, and type of fracture in percentages and actual count

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Table 3: Pain characteristics including duration of posttraumatic event and Numerical Pain Rating Scale score

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Table 4: Prevalence of kinesiophobia in upper limb fractures

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Correlational study variables were assessed using parametric test since the population distribution was normal. Pearson's correlation coefficient test was used to study the correlation between different variables. The correlation analysis was carried out to understand the relationship between the MMSE score giving cognitive status and the Tampa Scale giving kinesiophobia score. There is an inverse correlation between the Tampa Scale score and MMSE with r = 0.06 (P = 0.002). This suggested that there is a negative inverse correlation between cognition and kinesiophobia [Table 5].

Table 5: Correlation of Mini–Mental State Examination score and Tampa score

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Discussion

Adherence to physical exercises lowers the risk of long-term complications of pain including immobility and disability. It is known that patients with chronic musculoskeletal pain have panic while performing movements which restricts the performance of prescribed exercises and further leads to an inactive attitude. This attitude creates a barrier to home adherence of exercise protocol which leads to restricted function.^[9] This further aids the ill behavior and understanding toward physical exercises, which is an important clinical issue physiotherapists might face.

Musculoskeletal disabilities create a huge social burden, it increases overall hospital stay and financial load. It is the second-most common cause of disability in the general population. There are various contributing factors for fear of movement. Cognitive factors play an important role in the overall understanding of pain and movement-induced pain. Therefore, there is a need to emphasize on the significance of cognitive deviations in patients suffering from kinesiophobia.^[2] Upper limb being the most functional unit of the human body and prevalent fracture area, the current study aimed to investigate the prevalence of kinesiophobia in postupper limb fractures and establish its correlation with cognitive status.

TSK is the most accepted tool to assess the severity of kinesiophibia and was used to assess the prevalence in this study. The prevalence of kinesiophobia in persistent pain ranges from 50% to 70%. The current study supports the existing literature as there is an increased prevalence of kinesiophobia in posttraumatic upper limb fractures. The most common bone fracture found was humerus fracture with more of transverse types of fractures, also the least observed fracture were fractures of carpal bones, and the least type of fracture found was compression fractures. The score of Tampa score was from 13 to 33 which implicates a moderate level of kinesiophobia. It can happen because after fracture patient is stuck into vicious cycle of pain-immobility-pain. Initially, kinesiophobia modifies the movement to reduce or avoid the appearance of pain. It affects the motor control system and overall coordination of agonist-antagonist-fixator and prime movers. It also further delays the timing of reciprocal inhibition leading to awkward movements.^[12] The identification of shoulder complex fractures and compound fractures as the most common contributors to kinesiophobia is an important finding. It suggests that the specific characteristics and challenges associated with these types of fractures, such as the complexity of the shoulder joint and the severity of compound fractures, significantly impact individuals' fear of movement. This finding has practical implications for health-care professionals, as it emphasizes the need for targeted interventions and support for individuals with these types of fractures to address their heightened kinesiophobia.

Moreover, the study also highlights an intriguing relationship between cognitive function and kinesiophobia. The conclusion indicates that a decline in cognitive function is associated with increased levels of kinesiophobia. This finding suggests that cognitive factors, such as fear-avoidance beliefs and catastrophizing tendencies, may play a role in amplifying kinesiophobia among individuals with fractures. Understanding this relationship can help health-care providers identify patients who may be more susceptible to heightened kinesiophobia due to cognitive impairments and tailor their rehabilitation strategies accordingly.

The significance of these conclusions lies in their implications for fracture management and rehabilitation. By recognizing the high prevalence of kinesiophobia among individuals with upper limb fractures, health-care professionals can prioritize interventions aimed at addressing and alleviating kinesiophobia throughout the recovery process. In addition, understanding the impact of cognitive function on kinesiophobia underscores the importance of assessing and addressing psychological factors in fracture rehabilitation programs. This will aid in reducing the fear-avoidance pattern in patients with acute musculoskeletal injuries. For better clinical decision-making, assessment of kinesiophobia in an acute state should be considered an integral part of the musculoskeletal assessment to prevent further occurrence of movement-related pain which would eventually lead to movement-related fear. The current study did not have a follow-up regarding the status of kinesiophobia in chronic stages, therefore, studies creating its awareness can be conducted in future directions.

Conclusions

The study concludes that kinesiophobia was common in fractures of the upper limb generally, but it was most common in fractures of the shoulder complex with compound fractures. This study also came to the conclusion that a decline in cognitive function increases kinesiophobia.

Acknowledgment

We thank Dr. D. Y. Patil Vidyapeeth for funding this research.

Financial support and sponsorship

The research was funded by Dr. D. Y. Patil Vidyapeeth, Pune, India. (DPU/05/01/2016).

Conflicts of interest

There are no conflicts of interest.

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