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Reflection Paper
Nyjel
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Project Narrative: Many strength and conditioning (S&C) specialists and sports coaches are
unfamiliar with the word Kinesiophobia. Concerning the postoperative Anterior Cruciate
Ligament Reconstruction (ACLR) knee athlete—the subject of this discussion—kinesiophobia
is a potentially significant phenomenon of injury and/or surgery that prevents an athlete from
returning to their previous level of athletic performance if they return to their sport of
participation at all. Various practices and interventions to reduce Kinesiophobia include
psychomotor exercise (i.e., driving a car, hand-eye coordination tasks) and first aid support
(i.e., primary medical care) to enable a return to sports competition at an optimal (prior physical
performance) level. This paper will examine published studies that provide guidelines for early
physical recovery and identify which specific interventions reduce Kinesiophobia in athletes
during the rehabilitation process.
Summary Abstract:
Reports show that 20-50 percent of the more than 200,000 ACL reconstructions performed in
the United States each year will not return to the same sport of involvement following surgery,
and 10-70 percent of those who do return to sports participation will do so at a subpar level of
performance (Kvist et al., 2005). Younger athletes (under the age of 20) who sustained a
second ACL injury showed inferior "psychological readiness" 12 months following ACLR. The
start of kinesiophobia has been observed to occur early during the rehabilitation process (the
first 4-8 weeks) and to have a high incidence of prevalence (61%) in the athletic ACLR
population. Although rehabilitation and surgery seek to enable recovery from pains and
physical impairments, the psychological impact caused by the injury plays a significant role in
an athlete’s rehabilitation process. Indeed, the rehabilitation process can be slowed by
psychological issues, further delaying the athlete from returning to their sport (Hsu et al., 2017).
The vast majority of studies examining interventions to reduce Kinesiophobia are in non-athlete
populations. However, positive psychological factors (e.g., self-acceptance, personal growth,
purpose in life, autonomy) (Iani et al., 2020) and various interventions (e.g., driving, sewing,
throwing a ball, typing) (Macdonald et al., 2016) have been used to reduce the fear of
movement (Kinesiophobia) and increase confidence in patients with pain of following surgical
procedures.
Cognitive-behavioral physical therapy (i.e., setting daily intention, present mindedness,
managing setbacks) was assessed with respect to the feasibility, and 6-month outcomes of
patients undergoing ACL reconstructive surgery. Overall, patients reported that CBPT was
helpful during rehabilitation. In addition, physical therapists have used education, quota-based
exercise, and graded exposure to reduce the fear-avoidance belief amongst patients who
experience lower back pain, which can reduce chronic knee osteoarthritis (Harput et al., 2016).
Another study evaluated the effectiveness of a 12-week Pilates intervention on pain and
Kinesiophobia in patients with chronic pain (Cruz-Díaz et al., 2018); patients reported a
reduction in kinesiophobia at six weeks, with a significant improvement at 12 weeks between
the intervention group and controlled group. Many other interventions like home-based
exercises aimed at managing kinesiophobia with patients who had experienced a total knee
arthroplasty have also been shown to be effective (Harput et al., 2016). In conclusion, picking
Cognitive Behavioral Theory (CBT) for this reason places a greater emphasis on conversing
with the client during the therapy process. Despite various techniques such as psychodynamic,
integrative, and third wave CBT, this theory performs exceptionally well in keeping clients who
remain with therapy compared to other pharmacological trials. Furthermore, CBT employs a
method that entails the application of real-world solutions by teaching clients how to think
effectively and respond to a variety of stressful situations. In athletes, CBT appears to be the
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ideal option because it is a suggested treatment for the majority of the issues she is dealing
with, including depression, phobias, a lack of food, and relationship concerns.
Although these findings are encouraging, a few research have looked at comparable
approaches with athletes. One research, for example, discovered that relaxation/guided
imagery, positive self-talk, goal setting, and counseling were useful in encouraging healing and
enhancing joint function following musculoskeletal sports injury (Gennarelli et al., 2020). It is
expected that psychological therapy combined with a modest exercise program may lessen
high levels of kinesiophobia in athletes, increasing return to play compared to those who do not
get psychological intervention.
References
Coronado, R. A., Sterling, E. K., Fenster, D. E., Bird, M. L., Heritage, A. J., Woosley, V.
L., Burston, A. M., Henry, A. L., Huston, L. J., Vanston, S. W., Cox, C. L., 3rd, Sullivan,
J. P., Wegener, S. T., Spindler, K. P., & Archer, K. R. (2020). Cognitive-behavioralbased physical therapy to enhance return to sport after anterior cruciate ligament
reconstruction: An open pilot study. Physical Therapy in Sport: Official Journal of the
Association of Chartered Physiotherapists in Sports Medicine, 42, 82–90.
https://doi.org/10.1016/j.ptsp.2020.01.004
An open pilot study was used to assess the feasibility of cognitive-behavioral-based
physical therapy intervention on improving postoperative recovery after anterior cruciate
ligament reconstruction. The outcomes from 8 athletes (mean age 20.1; 6 females)
showed that some patients showed an increase on the KOOS QOL subscale to up to 6
months. Seven sessions of telephone-based CBPT-ACLR intervention were
administered for eight weeks post-surgery. CBPT is found to address psychological risk
factors after ACLR effectively. There is a distinction that has been established currently
and past works on psychologically informed restoration. The study examined in-person
psychological interventions targeting anxiety and fear of movement. Notably, there was
a high adherence to the CBPT-ACLR intervention, where close to all patients managed
to complete the entire program. Future randomized clinical trials are required to
evaluate the long-term efficacy of this strategy and if telehealth delivery generates the
same results as in-person psychologically-informed rehabilitation programs.
Cruz-Díaz, D., Romeu, M., Velasco-González, C., Martínez-Amat, A., & Hita-Contreras, F.
(2018). The effectiveness of 12 weeks of Pilates intervention on disability, pain and
kinesiophobia in patients with chronic low back pain: a randomized controlled trial.
Clinical Rehabilitation, 32(9), 1249–1257. https://doi.org/10.1177/0269215518768393
Gennarelli, S. M., Brown, S. M., & Mulcahey, M. K. (2020). Psychosocial interventions help
facilitate recovery following musculoskeletal sports injuries: a systematic review. The
Physician and Sportsmedicine, 48(4), 370–377.
https://doi.org/10.1080/00913847.2020.1744486
There is an established link between psychological aspects and return to play after a
musculoskeletal sports injury. Although it has been demonstrated that psychological
factors can influence when and if an athlete returns to play, it is unknown whether
implementing psychosocial interventions during the recovery process can address
these factors and potentially increase the likelihood of returning to play after physical
recovery from injury. The systematic review examined if psychological interventions
during the rehabilitation process can increase play return in athletes who’ve
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experienced musculoskeletal sports injuries. Studies met inclusion if the efficacy of
psychosocial programs were administered to injured athletes. Relaxation, guided
imagery, positive talk, counseling, etc., were found to be affecting in promoting recovery
after musculoskeletal sports injuries. The psychosocial interventions can facilitate a
quick post-injury recovery in athletes, which is a positive indicator.
Hanel, J., Owen, P. J., Held, S., Tagliaferri, S. D., Miller, C. T., Donath, L., & Belavy, D. L.
(2020). Effects of Exercise Training on Fear-Avoidance in Pain and Pain-Free
Populations: Systematic Review and Meta-analysis. Sports Medicine , 50(12), 2193–
2207. https://doi.org/10.1007/s40279-020-01345-1
This systematic review and meta-analysis examined the effects that exercise training
can have on decreasing fear-avoidance beliefs when compared to non-exercise training
comparators. In the identified records of 4603, 17(2014participants) and 13 (1152
participants) qualified for qualitative and quantitative synthesis. Randomized clinical
studies examined exercise training in adults vs. non-exercising adults who had fearavoidance issues. There was low-quality evidence that exercise training is effective for
reducing kinesiophobia. However, evidence that non-exercise interventions
(e.g.exercise training interventions) were even less effective. For patients with back
pain, and more specifically chronic low back pain, exercise training may effectively
reduce fear-avoidance behavior. However, further high-quality studies are warranted to
extend the observations found in this review, as the low quality of evidence currently
limits them.
Harput, G., Ulusoy, B., Ozer, H., Baltaci, G., & Richards, J. (2016). External supports improve
knee performance in anterior cruciate ligament reconstructed individuals with higher
kinesiophobia levels. The Knee, 23(5), 807–812.
https://doi.org/10.1016/j.knee.2016.05.008
Kamonseki, D. H., Christenson, P., Rezvanifar, S. C., & Calixtre, L. B. (2021). Effects of
manual therapy on fear avoidance, kinesiophobia and pain catastrophizing in
individuals with chronic musculoskeletal pain: Systematic review and meta-analysis.
Musculoskeletal Science & Practice, 51, 102311.
https://doi.org/10.1016/j.msksp.2020.102311
Randomized control trials investigated the effects of manual therapy in conjunction or
isolation on fear-avoidance and pain in patients with chronic musculoskeletal pain.
Based on extremely low or low-quality data, manual therapy may not be preferable to
no treatment or other medicines for reducing fear-avoidance, kinesiophobia, and pain
catastrophizing. More research is needed to increase the evidence for the effects of
manual therapy on pain-related fear outcomes.
Hsu, C.-J., Meierbachtol, A., George, S. Z., & Chmielewski, T. L. (2017). Fear of Reinjury in
Athletes. Sports Health, 9(2), 162–167. https://doi.org/10.1177/1941738116666813
This article addressed the implications of fear of reinjury on the rehabilitation of athletes
and potential interventions that may handle the fear of reinjury during restoration. This
clinical review examined publications related to fear of reinjury in athletes published
over the past 16 years. Fear of reinjury can lead to poor rehabilitation outcomes;
however, incorporating psychologically informed practices into the rehabilitation process
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for athletes with high kinesiophobia levels could reduce injury anxiety. For those with
low levels of kinesiophobia, grades exposure intervention is recommended.
Iani, L., Quinto, R. M., Porcelli, P., Angeramo, A.-R., Schiralli, A., & Abeni, D. (2020). Positive
Psychological Factors Are Associated With Better Spiritual Well-Being and Lower
Distress in Individuals With Skin Diseases. Frontiers in Psychology, 11, 552764.
https://doi.org/10.3389/fpsyg.2020.552764
Kvist, J., Ek, A., Sporrstedt, K., & Good, L. (2005). Fear of re-injury: a hindrance for returning to
sports after anterior cruciate ligament reconstruction. Knee Surgery, Sports
Traumatology, Arthroscopy: Official Journal of the ESSKA, 13(5), 393–397.
https://doi.org/10.1007/s00167-004-0591-8
Macdonald, G., Livingstone, N., Hanratty, J., McCartan, C., Cotmore, R., Cary, M., Glaser, D.,
Byford, S., Welton, N. J., Bosqui, T., Bowes, L., Audrey, S., Mezey, G., Fisher, H. L.,
Riches, W., & Churchill, R. (2016). Types of interventions. NIHR Journals Library.
https://www.ncbi.nlm.nih.gov/books/NBK385382/
Monticone, M., Ferrante, S., Rocca, B., Salvaderi, S., Fiorentini, R., Restelli, M., & Foti, C.
(2013). Home-based functional exercises aimed at managing kinesiophobia improve
the disability and quality of life of patients undergoing total knee arthroplasty: a
randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94(2),
231–239. https://doi.org/10.1016/j.apmr.2012.10.003
This randomized study consisted of 40 men (average age 67) who had undergone total
knee arthroplasty (TKA) to determine what interventions would help manage pain,
disability, and kinesiophobia. One group was given a home-based program based on
functional exercises and the management of kinesiophobia (experimental group). In
contrast, the other group was advised to stay active and progressively recover (control
group). The study's findings suggested that a home-based functional exercise and
kinesiophobia treatment program is more effective in alleviating disability and
kinesiophobia in addition to TKA. A future recommendation was the deployment of
secondary care tools whose staff with expertise in chronic pain management.