Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.

Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.

In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.

Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.

With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.

In the medical world, professionals refer to this fear of movement or reinjury as kinesiophobia. It is known as an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury (1). I see this fear slow down rehab and prevent clients from getting back to their sport completely. According to Kori et al., the highly fear-avoidant people interpret pain as a sign of a harmful bodily process and any physical activity that causes pain as dangerous (1).

So how do we deal with this? In my opinion, it requires 3 critical steps along the way:

1. Identify the presence of kinesiophobia early on in the recovery process. Look for apprehension, pain catastrophizing behaviors, depression, abnormal pain or emotional responses to routine movements in therapy, and generally overprotective behavior patterns. If you don’t acknowledge it and try to sidestep it by pushing harder physically before the client is ready, you will fail them. It is absolutely critical that you do not label the client as being soft, weak or exaggerating his/her symptoms.

2. Connect with your client. This seems simple enough, but your attitude and communication will ultimately set you up for success or doom you to failure. As rehab professionals and strength coaches, we must emotionally connect with them in our initial encounter to gain their trust and respect. They have to believe that we are 100% invested in their success and safety at all times. We need them to believe in us and our ability to get them back to their prior level of health.

Once they believe in the process, the walls of fear will come crumbling down. Be sure to involve the client in terms of outlining the recovery plan, while allowing them to actively participate in the process along the way. This partnership is essential for a full recovery.

3. Assess kinesiophobia throughout the recovery using a standardized tool. I utilize the 11-Item Tampa Scale for Kinesiophobia (TSK-11) with all my patients who have ACL reconstruction. I typically assess their responses at 6 and 12 weeks post-op, again between weeks 16 and 20 and finally at discharge. The original 17-item TSK was revised to create an 11-itme version in 2005 to exclude six psychometrically poor items (2). This scale has been used in patients with chronic pain, but research also suggests fear of pain may cause people to withdrawal or avoid physical activities (3). I have found that the TSK-11 matches up pretty well with my clients that are behind physically or those that can be labeled as “non-copers.”

Other scales (to name a few) that can be used include:

ACL-Return to Sport After Injury Scale (ACL-RSI)

Sport domain of Knee Injury and Osteoarthritis Outcome Score (KOOS)

ACL- Quality of Life scale (ACL-QoL)

Pain Catastrophizing Scale (PCS)

I have found that being a partner and advocate for the patient is extremely helpful in mitigating or eliminating kinesiophobia. Sharing prior success stories that they can relate to eases their worry along the way. Most importantly, treating each client as an individual and understanding the process will not always be the same is key. Educating the parents, coaches and care givers about proper expectations and how best to support the patient along the way is also necessary to ensure a successful outcome.

It is our duty as healthcare professionals to identify those with higher levels of kinesipophobia so that we can equip them to conquer it. This may require additional outside help in the form of a sports psychologist, so it is good to have someone in your network to refer to. This can also be a delicate issue, so you may need to tread lightly, and in the case of minors, I usually speak privately with parents before discussing it with the athlete.

Based on experience, patients will always fall somewhere on the continuum between copers and non-copers. The best therapists find a way to connect with each person on an individual level in such a way that they feel at ease and able to trust in the rehab plan. Be sensitive to the fact that differences in pain perception and coping strategies will exist, and work to facilitate mental and physical recovery throughout the journey. There are many tools available to assess kinesiophobia. I like the simplicity of the TSK-11. While it gets it roots in chronic pain, it can be used for any patient.

The PT wears many hats in the clinic, but perhaps none are more important than the one of a mental coach or “cheerleader” as we help the the physically wounded get their “mojo” back again. In the end, awareness, mindfulness, patience, persistence and ongoing assessment will allow the therapist to help the patient achieve an optimal outcome.

References:

1. Kori SH, Miller RP, Todd DD. Kinesiophobia: a new view of chronic pain behavior. Pain Manag. 1990;3:35-43.

2. Woby SR, Raoch NK, Urmston et al. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117(1-2):137-44.

3. Phillips HC. Avoidance behavior and its role in sustaining chronic pain. Behave Res Ther. 1987;25(4):273-9.

Click here for an additional abstract examining the psychometric properties of the TSK-11 in patients with heterogeneous chronic pain.