Kinesiophobia Severity Categories and Clinically Meaningful Symptom Change in Persons With Achilles Tendinopathy in a Cross-Sectional Study: Implications for Assessment and Willingness to Exercise

Abstract

Objectives: (1) Validate thresholds for minimal, low, moderate, and high fear of movement on the 11-item Tampa Scale of Kinesiophobia (TSK-11), and (2) Establish a patient-driven minimal clinically important difference (MCID) for Achilles tendinopathy (AT) symptoms of pain with heel raises and tendon stiffness. Methods: Four hundred and forty-two adults with chronic AT responded to an online survey, including psychosocial questionnaires and symptom-related questions (severity and willingness to complete heel raises and hops). Kinesiophobia subgroups (Minimal ≤ 22, Low 23-28, Moderate 29-35, High ≥ 36 scores on the TSK-11), pain MCID subgroups (10-, 20-, 30-, >30-points on a 0- to 100-point scale), and stiffness MCID subgroups (5, 10, 20, >20 min) were described as median [interquartile range] and compared using non-parametric statistics. Results: Subgroups with higher kinesiophobia reported were less likely to complete three heel raises (Minimal = 93%, Low = 74%, Moderate = 58%, High = 24%). Higher kinesiophobia was associated with higher expected pain (Minimal = 20.0 [9.3-40.0], Low = 43.0 [20.0-60.0], Moderate = 50.0 [24.0-64.0], High = 60.5 [41.3-71.0]) yet not with movement-evoked pain (Minimal = 25.0 [5.0-43.0], Low = 31.0 [18.0-59.0], Moderate = 35.0 [20.0-60.0], High = 43.0 [24.0-65.3]). The most common pain MCID was 10 points (39% of respondents). Half of respondents considered a 5-min (35% of sample) or 10-min (16%) decrease in morning stiffness as clinically meaningful. Conclusions: Convergent validity of TSK-11 thresholds was supported by association with pain catastrophizing, severity of expected pain with movement, and willingness to complete tendon loading exercises. Most participants indicated that reducing their pain severity to the mild range would be clinically meaningful.

Keywords: catastrophizing; chronic pain; fear of movement; minimal clinically importance difference; tendinopathy.

Conflict of interest statement

KGS receives speaker honoraria for talks on tendon injuries and for serving as an editor for Journal of Sports Physical Therapy. KAS serves as a consultant for Pfizer Consumer Health, Novartis Consumer Healthcare/GSK Consumer Healthcare, and receives royalties from IASP Press. GM receives royalties for key resources used for PNE (Explain Pain, Explain Pain Handbook: Protectometer, Explain Pain Supercharged, NOIgroup Publications, Adelaide, Australia), speaker fees for talks on contemporary pain education and has received support from: Reality Health, ConnectHealth UK, Seqirus, Kaiser Permanente, Workers' Compensation Boards in Australia, Europe and North America, AIA Australia, the International Olympic Committee, Port Adelaide Football Club, Arsenal Football Club. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain at scientific conferences/symposia. ER receives speaker fees for talks on tendinopathy and consults with various organizations on tendinopathy. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Chimenti, Post, Silbernagel, Hadlandsmyth, Sluka, Moseley and Rio.

Figures

Figure 1

CONSORT diagram indicating the number of individuals at enrollment, data collection, and analysis.

Figure 2

Images demonstrating performance of single leg heel raises on the (A) left side, and (B) right side.

Figure 3

Images demonstrating performance of single leg hops on the (A) left side, and (B) right side.

Figure 4

Flow chart for determining patient-driven MCID for pain with heel raises.

Figure 5

Flow chart for determining patient-driven MCID for Achilles tendon stiffness.

Figure 6

Receiver operating curves for using the TSK-11 score to predict willingness to complete (A) single leg heel raises, and (B) single leg hops. The y-axis represents sensitivity, and the x-axis represents (1-specificity).

Figure 7

Frequency of reasons why respondents were not willing to do (A) three single leg heel raises and/or (B) three single leg hops. Respondents who choose not to perform the activity were then asked to select why from the following options: Fear of Injury: “I'm afraid I would hurt myself if I did this exercise,” Too Painful: “It would be too painful to do this exercise,” Location: “I am not in a location where I can try this exercise,” Unable: “I am unable to do this exercise on my painful side.”