Introduction ARTICLE INFO. Key Words: osteoarthritis, knee, function, pain AUTHORS AFFILIATIONS 1

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1 International Journal of Therapies and Rehabilitation Research [E-ISSN: ] IJTRR 15, 4: 4 I doi:.5455/ijtrr.76 Original Article Open Access Correlation of fear avoidance beliefs with pain and physical function in subjects with osteoarthritis of knee (OA knee) Noopur G Bhatt 1, Dr. Megha S Sheth 2, Dr. Neeta J Vyas 3 ARTICLE INFO Article History: Received: June, 15 Accepted: July 2, 15 Published: July 15, 15 Key Words: osteoarthritis, knee, function, pain AUTHORS AFFILIATIONS 1 Post graduate student, 2 Lecturer, 3 Principal, Affiliation: S.B.B. College of physiotherapy, V.S hospital Campus, Ellisbridge, Ahmedabad-386. Correspondence: Noopur G Bhatt ID: noopur.bhatt18@gmail.com ABSTRACT Introduction: Osteoarthritis (OA) is the most common cause of musculoskeletal pain and disability in the knee joint. There is also increasing evidence that psychological factors such as fear, anxiety, and depression have adverse effects on disability in people with OA knee. Objective: To identify whether the fearavoidance beliefs are correlated with physical function & severity of pain in subjects with knee OA. Method: severity of pain, fear avoidance beliefs and functional limitations were assessed in 32 subjects both males and females diagnosed with OA knee. Subjects with any other musculoskeletal, neurological, vascular disorder or trauma affecting lower extremity function were excluded. Outcome measures included Western Ontario and MacMaster Universities Osteoarthritis index (WOMAC), Fear Avoidance Beliefs Questionnaire (FABQ), and Numeric Pain Rating Scale (NRS) Procedure: Nature and purpose of the study was explained. Consent was obtained from the participants prior to the study. Severity of pain, fear avoidance beliefs & physical function limitation were assessed in 32 subjects with OA knee using NRS, FABQ and WOMAC respectively. Level of significance was kept at 5%. Result: A statistically significant moderate correlation was found between fear avoidance beliefs with pain(r=.683, p<.1) and strong correlation was found in between correlation and with functional limitation (r=.719, p <.1). A statistically significant strong correlation found between severity of pain & functional limitation (r=.843, p<.1). Conclusion: There is a moderate to strong correlation between fear avoidance beliefs with severity of pain and function respectively. There is a strong correlation between severity of pain with function in subjects with OA knee. Introduction Osteoarthritis (OA) is one of the most common diseases of the skeletal system, and can be defined as a degenerative condition affecting synovial joints, being the most prevalent form of joint disease, which does not lead to systemic involvement, without associated mortality. 1 Knee OA is a disease of inflammatory and degenerative nature causing joint cartilage destruction, leading to joint deformity. It can be seen as a two-part degenerative, chronic, and often progressive joint disease, which is characterized by a repetitive inflammatory response of the articular cartilage due to focal loss or erosion of the articular cartilage and a hypertrophy of osteoblastic activity or a reparative bone response known as

2 osteophytosis. Both of these defining characteristics result in a joint space narrowing or subchondral sclerosis, leading to pain, immobility, and often disability. The symptoms of OA, such as pain and stiffness of the joints and muscle weakness, are serious risk factors for mobility limitation and lead to impaired quality of life for the affected population. As per a report published in the Times of India () regarding OA, over 4% of the Indian population in the age group of 7 years or above suffer from OA. Nearly 2% of these undergo severe knee pain and disability. As per a statement quoted by Piramal Healthcare Limited in a nationwide campaign against chronic diseases, India is expected to be the chronic disease capital, with 6 million people with arthritis, by Individuals with OA of the lower extremity may have limitations that impair their ability to perform activities of daily living (ADLs), such as walking, bathing, dressing, use of the toilet, and performing household chores. Physical therapy and occupational therapy play central roles in the management of patients with functional limitations. 3 Improvements in pain and physical function are important clinical outcomes for people with knee osteoarthritis. Although exercise therapy is helpful, a systematic review indicate that the effects of exercise on pain and function yield small to moderate effects for people with knee OA. 4 Exercise therapy programs for knee OA have traditionally been designed to address impairments in physical factors associated with knee OA. There is increasing evidence that psychological factors such as fear, anxiety, and depression have adverse effects on disability in people with knee OA. 5 People with OA frequently report fear and avoidance of activity when they believe that exercise will further damage their joints or activity is to blame for their condition. 6 The fear-avoidance model (FAM) of musculoskeletal pain describes a psychological process for the development of chronic pain syndromes. The FAM suggests that, following musculoskeletal injury, there are 2 potential recovery pathways, depending on the presence of negative effect, threatening-illness information, pain catastrophizing, fear of pain, and pain anxiety. When these psychological factors are not engaged by patients, a normal recovery is expected. However, when elevated, these psychological factors increase the potential for avoidance and escape behaviors that may lead to chronic musculoskeletal pain syndromes. Fear-avoidance beliefs are a clinical aspect of the FAM that has been previously studied in patients with low back pain. In cross-sectional studies, patients with elevated fear-avoidance beliefs were more likely to have higher pain and disability scores, even in multivariate analyses that control for potential confounding factors. 7, 8 Collectively, these studies support the clinical application of the FAM for patients with low back pain. 9 With regard to a psychological factor, pain and disability are associated with coping style, self efficacy beliefs and negative effects. Negative effects are thought to enhance patients tendency to avoid pain related activities. Avoidance causes muscle weakness and thus increases pain and disability. 9 Thus the aim of the study was, to identify whether the fearavoidance beliefs are correlated with physical function limitation & severity of pain in subjects with OA knee. Methods A prospective cross sectional study was conducted at S.B.B College of physiotherapy for 1 month using convenience sample of 32 subjects diagnosed as having OA knee by orthopedic department according to ACR criteria. The inclusion criteria were males & females with bilateral OA knee in the age group between -65 years. Subjects with any other musculoskeletal disorder, neurological or vascular disorder affecting lower extremity function & any trauma of Lower extremity were excluded from the study. The Outcome measurers were, The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), The WOMAC consists of 24 items divided into 3 subscales; Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing; Stiffness (2 items): after first waking and later in the day; Physical Function (17 items): stair use, rising from sitting, standing, bending, walking, getting in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy household duties, light household duties. 11 Fear Avoidance Beliefs Questionnaire (FABQ), The Fear- Avoidance Belief Questionnaire (FABQ) quantifies pain related fears and beliefs about the need to change behavior to avoid pain. The FABQ has 16 items, each scored from to 6; a higher number indicates a higher level of fear avoidance beliefs. The FABQ comprises 2 subscales, the seven-item work (FABQ-W) and four-item physical activity (FABQ-PA) subscale respectively. The reliability of the FABQ-W and FABQ-PA has been reported to be high (ICC =.9 and.77, respectively). Fear-avoidance beliefs were measured using the physical activity subscale of the FABQ. The physical activity subscale of the FABQ quantifies the level of fear about physical activity and has primarily been studied in patients with low-back pain. The FABQ also has a work subscale, which quantifies the level of fear about work related activities. The work subscale of the FABQ was not used as a method of assessment in this study, as many of the subjects were females and they were homemakers. The instrument consists of five items, which are scored from to 6. Possible scores range from to, with higher scores representing increased fear-avoidance beliefs. To apply the FABQ in the present study the descriptors of physical activities were changed such as bending, lifting, walking, or driving to physical activities such as walking, running, kneeling, or driving, and the word back was changed to knee throughout the form, prior to the descriptive study. It is a reliable scale to measure fear avoidance beliefs in OA knee. (intraclass correlation coefficient =.92)

3 Fear avoidance beliefs(fabq- PA) Fear avoidance beliefs(fabq-pa) FUNCTION (WOMAC) Numeric Pain Rating Scale (NRS), The patients were asked to make three pain ratings, corresponding to current, best and worst pain experienced over the past 24 hours. The average of the 3 ratings was used to represent the patient s level of pain over the previous 24 hours. 15 Procedure: Nature and purpose of the study was explained. Consent was obtained from the participants prior to the study. To identify physical function limitations WOMAC was used. To identify fear avoidance beliefs during physical activity, Physical Activity sub scale of FABQ (FABQ-PA) was used. To identify severity of pain NRS was used. Severity of pain, fear avoidance beliefs & physical function were assessed in 32 subjects with OA knee. Level of significance was kept at 5%. Results: There were 12 males & females in the study. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) VERSION 16. Table-1 shows mean values of variables. Spearman s correlation coefficient test was used to identify the relationship of fear avoidance beliefs with severity of pain and functional limitation and relationship of severity of pain with functional limitation. Correlation between variables is presented in Graphs 1-3. Table-2 shows correlation values of variables. There was a statistically significant moderate positive correlation found between physical activity component of fear avoidance beliefs with pain and strong positive correlation found with functional limitation. There was also a statistically significant strong positive correlation found between severity of pain & functional limitation. Moderate level of pain was found in the subjects with moderate limitation of physical activity and moderate levels of fear avoidance beliefs. Table 1: Mean value of variables Variables Mean S.D Age (years) NRS WOMAC FABQ-PA Table 2: Correlation values of outcomes Outcomes Correlation p value value(r) FABQ-PA & NRS r=.683 p<.1 FABQ-PA & WOMAC r=.719 p<.1 NRS & WOMAC r=.843 p<.1 Discussion: In the present study there was a statically significant strong correlation found between fear avoidance beliefs with functional limitations and severity of pain with functional limitations. The results of the present study are Graph 1: Correlation of NRS and WOMAC PAIN (NRS) Graph 2: Correlation of NRS and FABQ-PA PAIN(NRS) Graph 3: Correlation of FABQ-PA and WOMAC FUNCTION (WOMAC)

4 consistent with several studies conducted by George SZ and Fitzgerald et al. 9, 5 George SZ et al, in their study investigated fear-avoidance beliefs and musculoskeletal pain across 4 anatomical regions (cervical spine, lumbar spine, upper extremity and lower extremity) found similar levels of fear-avoidance beliefs across these 4 anatomical regions. Furthermore, they found that elevated fear-avoidance beliefs were associated with higher pain intensity ratings for all anatomical regions except the upper extremity, and with lower function scores for all anatomical regions. In the multiple regression models that controlled for potential confounding factors (age, sex, and duration of symptoms), fear-avoidance beliefs were the strongest contributor to pain intensity ratings for each anatomical region. Fear-avoidance beliefs and pain intensity were the 2 strongest contributors to function scores for each region, indicating that fear-avoidance adversely impacts function, even after controlling for pain intensity. 9 The studies conducted to identify the relationship of fear avoidance beliefs with pain and other factors (e.g disability, fear) in low back pain also showed similar results. 7,15 Steven et al found elevated Fear-Avoidance Beliefs for patients with low back pain. Findings of the study showed that, the FABQ work scale was the better predictor of self-report of disability in the sample of patients participating in physical therapy clinical trials. 7 Brox et al compared disability, pain, psychological factors and physical performance in healthy subjects and patients with sub acute and chronic low back pain found out a stepwise deterioration of pain, disability, psychological factors and physical performance from healthy controls to patients with CLBP. 16 Fitzgerald et al, conducted a study to find associations for change in physical and psychological factors and treatment response following exercise in knee Osteoarthritis, concluded that, in the sample of patients with PFPS, change in FABs-PA was the strongest predictor of function and pain outcomes. The fact that patients who decreased their FABs improved function and decreased pain indicates that perhaps FABs should be specifically targeted during the treatment of patients with PFPS. It is possible that strategies used to overcome FABs may be beneficial in the rehabilitation of such patients. 5 A study conducted by Van bar et al to identify the kinesiological, articular and psychological characteristics of pain and disability in hip and knee OA showed that muscle strength, pain coping strategies and joint range of motion are each associated with disability in patients with hip or knee OA. Pain coping was associated with pain in hip or knee OA. Hip and knee patients who reported higher levels of resting and of fear avoidance beliefs felt more pain. In knee patients psychological well being was associated with pain. Those who had lower levels of cheerfulness felt more pain. Also muscle strength and pain both were associated with disability. Those who had muscle weakness and higher levels of pain were more disabled. Decrease muscle strength could be due to disuse and fear avoidance beliefs. Reducing demands, worrying, resting and low level of distraction were associated with greater disability. This suggested that in addition to the pathways through muscle strength and ROM, the psychological characteristic affect the disability through other pathways. One possible pathway is reduced aerobic fitness; avoidance of pain related activity may induce reduced aerobic fitness and thus disability. Another pathway could be through the patients self efficacy beliefs. After sustained avoidance of pain related activity patient with OA no longer believes in his or her capacity to perform certain activities, which causes disability. 17 Limitations of the study: The sample size was small. Work component of fear avoidance beliefs could not be examined as most of the participants were homemakers. Confounding factors such as age, gender and duration of symptoms were not considered. Future studies can be carried out with larger sample size and work component of FABQ can be examined in patients with OA knee. Fear avoidance beliefs can be examined following treatment. Clinical implication includes modifying the fear avoidance beliefs in the management of OA knee. Conclusion: There is a moderate to strong correlation between fear avoidance beliefs with severity of pain and function respectively. There is a strong correlation between severity of pain with function in subjects with OA knee. Conflict of interest: none References: 1. Silva ALP, Imoto DM, Croci AT. Comparison of cryotherapy, exercise and short waves for in knee osteoarthritis treatment. Acta Ortop Bras. 7; 15(4): Bhatia D, Bejarano T, and Novo M. current interventions in the management of knee osteoarthritis. Journal of Pharmacy and Bio Allied Sciences. 13; 5(1): Arthritis & Rheumatizm, American College of Rheumatology. ; 43(9): , Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev 3; 3: CD Fitzgerald GK, White DK, Piva SR. Associations for Change in Physical and Psychological Factors and Treatment Response Following Exercise in Knee Osteoarthritis: An Exploratory Study. Arthritis Care & Research. 12; 64(11): Kabel A, Dannecker EA, Shaffer VA, Mocca KC, and Murray AM. Osteoarthritis and Social Embarrassment: Risk, Pain, and Avoidance. SAGE Open. 14: George SZ, Fritz JM, and Childs JD. Investigation of Elevated Fear-Avoidance Beliefs for Patients With Low Back Pain: A Secondary Analysis Involving Patients Enrolled

5 in Physical Therapy Clinical Trials. J Orthop Sports Phys Ther. 8; 38(2): Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52: George SZ, Stryker SE. Fear-Avoidance Beliefs and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain Conditions. J Orthop Sports Phys Ther. 11;41(4): R. Altman, E. Asch, D. Bloch, G. Bole, D. Borenstein, K. Brandt, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the knee. Arthritis Rheum. 1986; 29: Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988; 15: Hart DL, Werneke MW, George SZ, et al. Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient therapy. Phys Ther. 9; 89: Cai C, Pua YH, Lim KC; Correlates of Self-reported Disability in Patients with Low Back Pain: The Role of Fear-avoidance Beliefs. Annals Academy of Medicine. 7; 36: Ross MD. The relationship between functional levels and fear-avoidance beliefs following anterior cruciate ligament reconstruction. J Orthopaed Traumatol. ; 11: McCaffery, M, Beebe A, et al. Clinical manual for nursing practice. Pain. (1989). 16. Brox JI, Storheim K, Holm I, Friis A and Reikera O. Disability, pain, psychological and physical performance in healthy controls,patient with sub acute and chronic low back pain: A case control stydy. J Rehabil Med. 5; 37: Vaan baar ME, Dekker J, Lemmens AM. Pain and disability in patients with osteoarthritis of hip or knee: the relationship with articular, kinesiological and psychological characteristics. Pain

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