Case Report: Recognition and Diagnosis of Kinesiophobia in a Patient Following Calcaneal Fracture

Transcription

1 Case Report: Recognition and Diagnosis of Kinesiophobia in a Patient Following Calcaneal Fracture Ross Jacques, SPT Garret Naze, DPT, OCS, FAAOMPT Carroll University Waukesha, WI Spring

2 Case Report: Recognition and Diagnosis of Kinesiophobia in a Patient Following Calcaneal Fracture AUTHORS/INSTITUTIONS: R. Jacques, Physical Therapy, Carroll University, Waukesha, WI; G. Naze, Physical Therapy, Carroll University, Waukesha, WI Abstract: Background and Purpose The intensity of a patient s fear of movement, or kinesiophobia, can occur independently from their current pain. Little discussion has been had regarding the patient who reports no pain yet demonstrates avoidant behaviors or movements. The purpose of this case report is to describe the presentation of catastrophization and kinesiophobia, to help clinicians appropriately diagnose, measure, and treat these conditions. Case Description The patient was a 71-year-old female who sustained a right anterior calcaneus fracture. At ten weeks from the date of injury, it was found that the patient had a mal-union calcaneal fracture. She was then casted and placed on non-weight bearing status for six weeks, followed by use of a walking boot for one week. Three weeks after discontinuation of the cast and boot the patient began outpatient physical therapy services. During pre-gait weight shifting activities and gait training she demonstrated abnormalities that appeared to be avoidance of right lower extremity weight bearing, despite no reports of pain. Outcomes The patient felt she had the progressed well and had the tools to continue to recover on her own and chose to discontinue therapy after 12 visits. She showed improved but persistent gait deviations, very slow gait velocity, decreased functional mobility scores, and elevated kinesiophobia scores. Discussion This patient demonstrated movement patterns and subjective information suggestive of kinesiophobia. Her Tampa Scale for Kinesiophobia scores were elevated from intake until discharge. The challenge for physical therapists is to begin to recognize, acknowledge, and treat this portion of the psychosocial domain to the best of their ability. Key Words: Kinesiophobia, Fear, TSK

3 A. Background and Purpose When a patient has pain, or the prospect of encountering pain, they must choose to confront (adaptive) or avoid (maladaptive) the daily activities that cause their pain. 1 Often there is a compromise or a combination of confrontation and avoidance based on the cost (pain) versus benefit (achieved task or fulfilled role). Long-term avoidance can lead to a disuse syndrome that may consist of heightened pain perception, psychological distress, and disability. 2 The decision to choose an avoidant behavior over confrontation can be influenced by a patient s pain catastrophization as well as the severity of a patient s pain. 3 Beck et al. describes catastrophizing as, dwelling on the worst possible outcome of any situation in which there is a possibility for an unpleasant outcome 4. It appears that the intensity of a patient s fear of movement, or kinesiophobia, can occur independently from their current visual analog scale (VAS) pain score. 5,6 Little discussion has been had regarding the patient who reports no pain, yet demonstrates avoidant behaviors and movement compensations, presumably to avoid an unpleasant outcome. 7 A model for the relationship between catastrophization and kinesiophobia has been made, describing the misinterpretation of innocuous stimuli leading to a fear of those movements causing those stimuli. 8 A clinician can use this model to help guide diagnosis of these conditions as well as intervention. According to the Guide to Physical Therapy Practice, pain is an impairment that may lead to subsequent functional limitations and disabilities. 9 When a patient experiences pain, there is often an element of fear or anxiety related to encountering, or the expectation of encountering, pain. It is also possible for a patient to present with pain-precipitated functional limitations long after they have experienced the related pain. 5 When this occurs, the treating physical therapist should address fear and avoidant behavior as the primary impairment, not the pain specifically. The purpose of this case report

4 is to describe a patient with kinesiophobia with low pain scores in order to appropriately diagnose, measure, and treat kinesiophobia. B. Case Description: Patient History and Systems Review The patient in this case report was referred by her podiatrist to outpatient physical therapy. The patient was a healthy, retired, 71-year-old female who sustained a right anterior calcaneus fracture after tripping and everting her ankle while playing basketball in her driveway with her grandson. She reports that she did not fall. The date of injury was twenty weeks prior to her initial physical therapy evaluation. Following the incident she went to urgent care for treatment of then present pain and swelling. A radiograph was ordered and the radiologist reported negative findings for a fracture. The following week, the patient was evaluated by her primary physician who ordered further imaging and diagnosed a right anterior calcaneus fracture. The physician prescribed a CAM walking boot which she was to wear during all weight bearing activities. Later that week, the physician contacted the patient stating there was not a fracture and he discontinued the CAM walking boot. For ten weeks from the date of injury, the patient ambulated without an assistive device or weight bearing precautions. However, she continued to have fluctuating levels of edema and pain and visited a local podiatrist for a second opinion. The podiatrist ordered magnetic resonance (MR) imaging and found that the patient had a right mal-union anterior calcaneal fracture. The podiatrist casted the patient s right foot in a non-weight bearing cast for six weeks, and then ordered a walking boot for one week. Three weeks after discontinuation of the cast and boot the patient began outpatient physical therapy services. At physical therapy evaluation, the patient reported using no prescription pain medications. The only medication she was taking daily was Atorvastatin and she reported no other comorbid health conditions. She reported that she had been using topical Voltaren (Diclofenac) gel on the right foot for

5 pain and inflammation with minimal effect. She also reported that she using an elastic wrap on the right foot to decreasing edema with moderate effect. The patient ambulated with bilateral axillary crutches and reported feeling pain and a burning sensation in the plantar surface of the foot that increased in intensity as the day progressed. At this time, she was medically cleared for full weight bearing by the referring podiatrist but she reported she was afraid to evenly weight bear. Functional limitations reported by the patient included an inability to ambulate without the use of two axillary crutches and an inability to ascend or descend stairs required for her to reach her bedroom, bathroom, and basement laundry. She stated she had been scooting on her backside to ascend and descend carpeted home stairs and she had discontinued going to the basement for laundry. She also reported being unable to complete cooking or cleaning tasks that requiring standing while using her hands as she was unable to let go of her crutches. Pain was rated as 0/10 (VAS) at rest and 5/10 at most when she was active and weight bearing. She reported 3/10 average foot pain on the day of the examination. Her pain was described as sharp and along the full length and width of the right plantar surface of the foot. Though did not plan to return to shooting hoops, her goal was to return to her prior level of function, which was very active and able to complete all activities of daily living and leisure. C. Clinical Impression The primary problem noted at the time of the examination was the limited weight bearing tolerated by the patient. Tests and measures such as gastrocnemius and soleus muscle testing and gait analysis would not be possible during the examination because of the patients unwillingness to stand without the majority of her weight being supported by her noninvolved leg and two axillary crutches. The subjective history was significant due to two critical items being present; the inconsistent, long, and painful process leading to the diagnosis and treatment of a right calcaneal fracture, and the mention of

6 being afraid of weight bearing on the right lower extremity despite being cleared for a full weight bearing status. At this point, it was important to determine what the patient feared about weight bearing on the involved extremity. The subjective history did not indicate confounding impairments or lack of healing at the tissue level, but instead possible concerns within the psychosocial domain. It was decided that this patient was a good candidate for a case report because more research is needed regarding early subjective reports of fear of movement in patients without significantly high pain reports. D. Examination Clinical observation was used to search for contributing factors that may explain why the patient had apprehension or fear related to weight bearing. The patient was a slender, light built woman. Gait and functional movement analysis showed that the patient had become efficient and comfortable ambulating, transferring, and negotiating the community with two axillary crutches. Further gait analysis was not possible as the patient was very apprehensive toward even 50% weight bearing on the affected foot. The patient also appeared apprehensive and showed a lack of weight shifting during all ambulation, standing, and sit-stand transfers. Closer observation showed that there was mild edema throughout the right ankle and foot, with a slight loss of contour and definition visible. Left and right figure-8 ankle anthropometrics were equal at 48.5 cm. The circumference at the left malleolus was 23 cm and the right was 24 cm. The circumference at the bases of the metatarsals on the left was 21.7 cm and on the right it was 22.1 cm. Palpation revealed slight tenderness in the plantar surface of the right foot near the calcaneus. Range of motion (ROM) goniometric measurements of the right ankle demonstrated limitations in inversion, dorsiflexion, and plantarflexion (Table 1). The patient also completed the Lower Extremity Functional Scale (LEFS) scoring a 35/80 (Figure 1). 10

7 E. Clinical Impression #2 The data gathered during the initial evaluation was limited, as more functional tests and measures were not assessable due to the patient s unwillingness to ambulate without axillary crutches. Her ankle range of motion was limited which was consistent with her prior immobilization. The gait and functional mobility observations appeared to be the most relevant piece of information related to upcoming procedural and educational intervention choice. On the day of the evaluation, it was noted by both the physical therapist and student physical therapist assessing the patient that there was fear of movement present, as the patient verbalized she had a sense of fear despite limited pain, as well as demonstrating it through limited weight bearing using the crutches for support. At the conclusion of the initial examination it was unclear to what extent the palpable tenderness present in the plantar surface of the right foot was contributing to her fear of weight shifting or ambulation. Following the examination and evaluation it was concluded that the patient s impairments and level of functional limitations warranted skilled physical therapy intervention. The patient was deemed to have a good rehabilitation potential due to the full union of her fracture, low pain level, and a previous high level of function. The treatment plan was for the patient to return to therapy two times per week for 6-8 weeks to resolve impairments such as loss of range of motion, strength, and pain as well as improve upon her functional mobility status, discontinuing the use of an assistive device, and improving her gait quality and speed. The treatment plan was to increase the active ROM of her right ankle to that of the left through strengthening, stretching, and possible joint mobilization. Follow-up treatments would also include functional movement and gait training. Depending on the behavior of her foot pain symptoms, future examination and treatment choice would be adjusted accordingly.

8 F. Intervention To reduce the impact of immobilization on the tissues of the foot and ankle, progressive resistive exercises for right ankle inversion, eversion, and plantarflexion were introduced and advanced as tolerated with resisted dorsiflexion being added later in the treatment plan. Cross friction massage was also implemented early to effectively decrease the irritability of the plantar surface of the foot. The primary focus of treatment was to increase the patient s awareness and confidence while weight shifting onto the affected foot. Treatment began with bipedal weight shifting activities progressing to static single-limb tasks and dynamic single-leg tasks. Exercises were performed between parallel bars to decrease the patient s anxiety and a mirror was used to increase sensorimotor feedback. Gait training began with the use of a single crutch and was progressed to a single point cane, and then to no assistive device. During gait training, the patient kept her leg in an abducted position during stance phase on the right to decrease the amount of weight shift to that side. Progress was delayed between the sixth and ninth visit as the patient was limited in weight bearing by 3/10 (VAS) medial knee pain, which was likely a result of the valgus stress she was applying while ambulating on an abducted right lower extremity. After this pain subsided with rest and ice, the patient was able to return to gait training, weight shift training, and single limb activities. G. Clinical Impression #3 Based on the patient s presentation in the first few visits, it was determined that focusing on the patient s lack of confidence, fear, and motor planning with weight bearing was a priority over aggressive strengthening or range of motion interventions. An early, significant development was an almost complete resolution of the pain in the plantar aspect of her right foot. She consistently reported 0/10 (VAS) pain rating in her foot during the first few follow-up visits. What also occurred was a progressive positive attitude about her perceived progress. She felt as though she was making improvements, but

9 also frequently reported that she did not want to push it too hard for fear of setting herself back. The patient was very slow to wean off of the use of an assistive device and never progressed past a single point can with daily activities. During follow-up visits, non-weight bearing ankle multi-planar resistance exercises were tolerated well, however, avoidance behaviors continued throughout weight bearing activity. For example, during pre-gait weight shifting activities or gait training she would occasionally quickly shift her weight away from the affected foot and onto the left lower extremity or support herself on a nearby object as if there was a sudden onset of sharp pain. However, subjective reports would deny the presence of pain and instead the patient would state the movement did not feel right for a moment. She would then assure the therapists that she felt no pain and proceed with the intervention. This presentation led to the use of the Tampa Scale for Kinesiophobia (TSK) to begin to track changes in the patient s fear of movement. 6 It also led treatment focus toward increasing body awareness and confidence to correct functional limitations more than impairments seen in ROM and strength. The patient completed the TSK, and a score of 41/68 was found. A score of 37 has been found to be indicative of a high degree of kinesiophobia. 6, 11 The individual answers were reviewed and statements such as 4. My accident has put my body at risk for the rest of my life and 13. Pain lets me know when to stop exercising so that I don t injure myself were recognized as the highest scored statements with Strongly Agree selected. This appeared to indicate that the patient felt her fracture was somewhat of a liability for further activity. While the patient arrived each day reporting she felt as though she was making great progress, feeling little discomfort, and reporting improvements in her level of function, she continued to demonstrate avoidance behaviors. In other words, there was a mismatch between her subjective report and her objective findings and outcome measures.

10 H. Outcome After a total of twelve visits the patient felt as though she was making consistent progress, was equipped with the tools to continue to progress, and had decided that she did not want to continue formal therapy. At the time of discharge her ankle inversion and eversion AROM measurements were equal from left to right. Her plantarflexion AROM was measured and showed 51 o on the left and 47 o on the right. Dorsiflexion was measured and showed 6 o on the left and 7 o on the right (Table 1). The patient was at this point still unable and/or unwilling to support all of her body weight during a right heel raise and therefore plantarflexor strength could not be accurately assessed. Gait velocity was measured and was.125 meters/second without the use of a gait aid. She reported 0/10 pain at all times, except for occasional right medial knee pain yielding a 1-3/10 (VAS). Gait analysis during ambulation without the use of an assistive device showed what had become a rather symmetrical hip drop of the contralateral hip during left and right stance phases, but this motion was more pronounced on the right and was likely in an attempt to cushion or slow the loading effect on the right side. The patient also demonstrated increased right ankle plantarflexion at initial contact and landed with a flat foot rather than using a heel strike. Notably, the patient was able to complete a right single leg stance 5-point star excursion drill two days before discharge. The LEFS was collected at intake, TSK initially at visit 4, both were collected at visit 6, and again at visit 12 (discharge) (Figures 1 and 2). I. Discussion This patient did arrive initially with a low level of pain in the plantar surface of her foot which quickly resolved. This resolution of symptoms led the treating therapists to attribute the patient s gait abnormalities to an abnormal motor plan driven by fear avoidant behavior. With this assessment it was decided that administering the TSK was the best way to track this patient s kinesiophobia. From there,

11 treatment was devoted to treating the patient s musculoskeletal impairments, as well as her psychological and neuromotor impairments. Her level of perceived functional limitation did improve by a clinically important margin from intake to discharge as reflected in the LEFS, but she had not returned to her prior level of function. One of the treatment goals was to decrease her kinesiophobia and thereby indirectly lessen her level of disability. Vlaeyen et al. proposed that pain catastrophizing can be a predisposing factor for patients to develop kinesiophobia, increasing the risk for disability and increased 5, 12 pain perception. It is within the scope of physical therapy practice to collect clinimetrics about the psychosocial and emotional domains, but rarely are these measures taken in clinical settings. 9, 13, 14, 15 The challenge for physical therapists and other clinicians is to interpret the TSK score and apply the gathered data in a clinically meaningful way. 7 When compared alongside the LEFS, the TSK showed a similar trend and change from intake to outcome, but making prognostic statements from this data was not possible. Most of the TSK s validation research has been done using subjects with spinal pain, making the application to a patient with a lower extremity condition less clear. 16 For physical therapists working with patients with various conditions and possible kinesiophobia, it is important for them to recognize, acknowledge, and treat this portion of the psychosocial domain to the best of their ability, and refer to mental health specialists when indicated. 7,9,12 Future research is needed for the prognostic interpretation and scope of use for both physical therapists and mental health professionals.

12 References: 1. Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception I. Behav Res Ther. 1983;21(4): doi: / (83) Hirsh AT, George SZ, Bialosky JE, Robinson ME. Fear of pain, pain catastrophizing, and acute pain perception: Relative prediction and timing of assessment. The Journal of Pain. 2008;9(9): doi: /j.jpain Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17(1): Beck AT, Emery G, Greenberg RL. Anxiety disorders and phobias. New York: Basic Books, Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62(3): doi: / (94)00279-N. 6. K.S. kori, R.P. miller, D.D. todd kinisophobia: A new view of chronic pain behaviour, pain manag, 3 (1990), pp Davenport TE. How should we interpret measures of patients' fear of movement, injury, or reinjury in physical therapist practice? Journal of Orthopaedic & Sports Physical Therapy. 2008;38(10): Picavet SJ, Vlaeyen JW, Schouten SA. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. Am J Epidemiol. 2002; 156(11): Guide to physical therapist practice. 2nd ed. phys ther. 2001;81: Binkley JM, Stratford PW, Lott SA, Riddle DL, The North American Orthopaedic Rehabilitation Research Network. The lower extremity functional scale (LEFS): Scale development, measurement 16. properties, and clinical application. Physical Therapy. 1999;79(4): Lundberg, M.K.E., Styf, J., & Carlsson, S.G. (2004). A psychometric evaluation of the Tampa Scale for Kinesiophobia- from a physiotherapeutic perspective. Physiotherapy Theory and Practice. 20: , 12. 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(2): doi: / (93)90127-B. 13. Battie MC, Cherkin DC, Dunn R, Ciol MA, Wheeler KJ. Managing low back pain: Attitudes and treatment preferences of physical therapists. Phys Ther. 1994;74(3): Foster NE, Thompson KA, Baxter GD, Allen JM. Management of nonspecific low back pain by physiotherapists in britain and ireland. A descriptive questionnaire of current clinical practice. Spine (Phila Pa 1976). 1999;24(13):

13 15. Li LC, Bombardier C. Physical therapy management of low back pain: An exploratory survey of therapist approaches. Phys Ther. 2001;81(4): French DJ, France CR, Vigneau F, French JA, Evans RT. Fear of movement/(re)injury in chronic pain: A psychometric assessment of the original english version of the tampa scale for kinesiophobia (TSK). Pain. 2007;127(1 2): doi: /j.pain

14 Table 1: Ankle ROM Pre-/Post-Testing At Initial Examination At Discharge Ankle Motion Left Right Left Right Inversion Eversion Dorsiflexion Plantarflexion Figure 1: LEFS Scores LEFS Scores Intake 6 Weeks 12 Weeks *MCID = 9 points 10

15 Figure 2: TSK Scores TSK Scores Visit 4 Visit 6 Visit 12