Cai L, Gao H, Xu H, et al. Does a Program Based on Cognitive Behavioral Therapy Affect Kinesiophobia in Patients Following Total Knee Arthroplasty? A Randomized, Controlled Trial With a 6-Month Follow-Up. J Arthroplasty. 2017 Oct 28. pii: S0883-5403(17)30947-6. doi: 10.1016/j.arth.2017.10.035.
Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Psychologist 5 / 7
Physician 5 / 7
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  Knee Pain and Injury

BACKGROUND: To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).

METHODS: This was a parallel-group, randomized, controlled pilot study in which 100 patients who exhibited kinesiophobia after TKA were randomly assigned to participate in a CBT (experimental group) or standard care (control group) program. Each group included 50 patients. Before intervention (preintervention), 4 weeks after intervention (postintervention), and 6 months after the end of intervention (follow-up), patients were assessed via the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a numerical rating scale, and the Hospital for Special Surgery knee rating scale. Repeated-measures analysis of variance was used to test the significance of each outcome measure.

RESULTS: The CBT program had significant group (P < .001), time (P < .001), and group-by-time interaction (P < .001) effects on kinesiophobia, pain catastrophizing, and knee function, and these effects lasted for at least 6 months after the end of the intervention. Pain was reduced in both groups after the intervention, but there were significant time and group effects (P = .003) in favor of the experimental group.

CONCLUSION: The CBT program was superior to standard care in reducing kinesiophobia, pain catastrophizing, and knee pain and in enhancing knee function in patients who have a high level of kinesiophobia following TKA. The treatment effect was clinically significant and lasted for at least 6 months after the end of the intervention.

Comments from MORE raters

Physician rater

This is a well-designed study showing the benefits of CBT in improving outcome after total knee replacement. This intervention is clearly of benefit but I might cavil with the authors in their statement that CBT overcomes kinesiophobia. Many of the participants in this study were not phobic of pain yet overall those receiving CBT did well. The behavioural physiotherapeutic component of CBT may well have been the main factor in contributing to the improvement of the experimental group, particularly immediately after surgery, when physiotherapy is vital.

Physician rater

The difference between intervention and control group was statistically significant with regards to pain, but not clinically significant. The question is if it is so also with regards to kinesiophobia?

Psychologist rater

This is a replication of previous work and the first study of its kind to be done in China. I have concerns about the methodology. It was not an intention to treat but a per protocol analysis (11 patients were excluded from the analysis). The clinical significance of the differences between the groups was not ascertained. The intervention probably works but is there a simpler intervention that can be done at less cost and equal effect?

Rehab Clinician (OT/PT) rater

This article on the positive effect of CBT on kinesiophobia in patients post TKA provides OT practitioners with a tool for assisting patients in tackling ADLs post-operatively. I found it very useful.

Rehab Clinician (OT/PT) rater

More and more evidence is suggesting the importance of psychological factors on orthopedic outcomes. We need more detailed studies outlining the content of the psychosocial intervention. This study provides more detail than most. This study adds to the growing evidence that the biomedical approach to recovery is insufficient for patients after TKA.

Rehab Clinician (OT/PT) rater

These results are consistent with those from other musculoskeletal conditions and with the fear-avoidance model of musculoskeletal pain. The findings reinforce the recommendations to routinely assess for yellow flags that might impact the degree of function recovery experienced by patients with these conditions.
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