Kinesiophobia and its association with treatment choice in individuals with idiopathic scoliosis

Abstract

BACKGROUND:

Previous studies have reported increased kinesiophobia in adults with degenerative scoliosis or adolescents who have undergone spinal surgery. However, little is known about the phenomenon of kinesiophobia among adolescents with idiopathic scoliosis (IS).

OBJECTIVES:

The aim of this study was to investigate levels of kinesiophobia and its association with treatment choice in IS.

METHODS:

The study included 98 IS patients with a mean age of 14 years and 20 healthy controls. Participants with IS were divided into groups based on treatment conditions, as follows: (1) untreated ( $n=$ 33); (2) treated with exercise ( $n=$ 32); and (3) treated with a brace ( $n=$ 33). Kinesiophobia was measured using the Tampa Scale for Kinesiophobia (TSK). Comparisons were made between four groups.

RESULTS:

Untreated participants with IS were found to have greater kinesiophobia than healthy controls ( $p<$ 0.001). Participants treated with a brace ( $p=$ 0.046) and exercise ( $p=$ 0.064) had similar kinesiophobia levels as the healthy control group.

CONCLUSIONS:

Kinesiophobia was found to be higher in adolescents with IS compared to healthy peers. Brace or exercise treatment both had a positive impact on kinesiophobia. These findings should be considered when organizing rehabilitation programs to achieve the best results for adolescents with IS.

Keywords

Scoliosis fear movement exercise therapy brace

1. Introduction

İdiopathic scoliosis (IS) is a trunk deformity characterized by lateral deviation and axial rotation of the spine, as well as structural alterations within the vertebral bodies. The natural history of IS is progressive during growth. Signs and symptoms associated with this progression include an increase in curve magnitude, cosmetic trunk deformity, back pain, limited physical function and mobility, defects in social adaptation ability, and negatively affected self-image, self-esteem, or psychological function. Therefore, IS decreases the health-related quality of life [1, 2].

Several previous studies have reported reduced physical activity among adolescents with IS [3, 4, 5]. But regular physical activity/exercise has been considered as the fundamental therapy to control curve progression, to improve trunk deformity, to restore functional biomechanics, to maintain physical fitness and thereby to improve health related quality of life in individuals with IS [6]. The literature has consistently supported a strong association with physical inactivity and kinesiophobia, pain, and improper psychosocial functioning in patients with various musculoskeletal conditions [7]. Kinesiophobia was first theorized as “fear of injury due to movements” and defined as “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability due to painful injury or reinjury” [8]. Especially, there is growing emphasis on the clinical impact of kinesiophobia in orthopaedic conditions in recent years. Patients’ perception of fear of movement has been reported to influence physical function, psycho-social function and promote poor quality rehabilitation by limiting physical performance in many orthopedic diseases such as chronic back and neck pain [9], and degenerative spine diseases [10].

Besides alterations in physical activity, many cognitive and emotional factors like high anxiety, pain catastrophizing, depression, low self-efficacy and coping strategies to chronic diseases and environmental factors such as family behaviors could play a role in kinesiophobia levels [11, 12, 13, 14]. Adolescent scoliosis patients may have a high risk of developing kinesiophobia in terms of such multifactorial components. Detecting kinesiophobia earlier is of high importance because the ultimate goal will be to give importance to patient education with a multidisciplinary approach to improve rehabilitation success and compliance to conservative treatments. Also, by minimizing the kinesiophobia the patients would not draw back from their daily tasks and as a result increase their quality of life.

The two-effective conservative therapy approaches in IS are bracing and exercise [6]. Bracing is the main treatment method for moderate primary curves, between 20–45 degree of scoliosis [6]. Rigid braces are typically prescribed for full-time wear (20–24 hours/day) and minimum 10–13 hours of brace wearing per day are needed for brace success during skeletal growth period [15]. But also bracing have been reported to be able to restrict motion and physical activity in daily life [16]. Therefore, the previously mentioned relationship between physical activity level, psychosocial functioning, and kinesiophobia increases the need to research the possible risk of kinesiophobia in adolescents with IS. However, only a few studies have examined the relationship between kinesiophobia and outcomes in patients with scoliosis. Haddas et al. reported that kinesiophobia affected gait parameters among adults with degenerative scoliosis [17]. Greater kinesiophobia was reported in adolescents with IS following spinal surgery by Ye et al. [18].

For mild curves (i.e., those approximately below 20 ${}^{\circ}$ ), primary treatment method is exercise. Once the diagnosis of a progressive curve has been made, adolescents with IS must perform exercise or sports activity regularly during their treatment period [19]. Physiotherapeutic Scoliosis specific exercises (PSSEs) are main exercise therapies to reduce curve progression, brace prescription and to improve quality of life. Some of these effective PSSEs include Schroth, SEAS (Scientific Exercise Approach to Scoliosis), BSPTS (Barcelona Scoliosis Physical Therapy School), FITS (Functional Individual Therapy of Scoliosis), and Lyon methods [20]. Previously spine rehabilitation exercises addressed to increase spine flexibility, strength and lifting capacity were found to improve kinesiophobia in patients with low back pain [21]. On the other hand, exercise therapy did not show any benefit in terms of kinesiophobia with three-month home based application in chronic whiplash [22] and twelve month application in postsurgical spondylolisthesis [23]. Which factors influence kinesiophobia remains controversial.

The conservative treatment included exercise and brace prescription based on curve magnitude and progression in patients with IS. However, only a few studies have evaluated influences of these treatment methods on kinesiophobia in patients with scoliosis. Early recognition of patients with IS exhibiting fear-avoidance behavior, psychological distress, or pessimistic believes about movement can be used to improve treatment outcomes in rehabilitation process. Therefore, the main purpose of this study was to assess kinesiophobia in groups of patients with IS. Additionally, the study aimed to investigate whether kinesiophobia differed in the various groups studied, which included untreated IS adolescents, adolescents treated with exercise, adolescents treated with brace, and healthy controls.

2. Methods

A prospective case-controlled study was conducted to compare kinesiophobia levels according to treatment choice in individuals with IS. The study was approved by the Hacettepe University Research Ethics Board (approval number: GO 16/543-05).

2.1 Participants

This study was conducted at the Faculty of Physical Therapy and Rehabilitation at University. Participants included 98 female adolescents with IS and 20 age-matched healthy controls. Participants were selected from the Physiotherapy and Rehabilitation Clinic of the Faculty. Participants with IS were consisted of three following groups, based on treatment conditions: (1) untreated ( $n=$ 33); (2) treated with exercise ( $n=$ 32); and (3) treated with brace ( $n=$ 33). Untreated participants consisted of individuals with no prior treatment history at the evaluation. Participants treated with exercise and treated with brace included individuals who received exercise or brace interventions for at least one year. All participants and their parents were informed about the study and confirmed their voluntary participation with written and oral informed consent.

The inclusion criteria for subjects with IS were as follows: the subjects were 11 to 17 years in age, had IS above 10 degrees and diagnosed (untreated group) or under any conservative treatment for at least 1 year (for exercise or brace groups). The inclusion criteria for the healthy group included a normal weight with a body mass index of 18.5 to 25.5 kg/m ${}^{2}$ , an age of 11 to 17 years, the absence of any disease, and the absence of medication usage. Exclusion criteria for subjects with scoliosis were as follows: (1) having scoliosis associated with another pathology, such as neuromuscular or rheumatoid diseases, (2) having any known systemic disorders, or (3) having previous spine surgery. Patients had no relevant back pain and have no functional limitation of limbs.

Control group was selected from healthy people who have no scoliosis and spinal asymmetry. Observational postural analysis and scoliometer assessment was done to all the people in control group. Alignment problems, body asymmetry detected and a spinal asymmetry seen at even one degree was not included in the control group.

2.2 Conservative treatment history

Untreated scoliosis samples consisted of individuals diagnosed with IS at least one year before the study with no treatment history. Treated with exercise group included subjects treated with home-based physiotherapy scoliosis specific exercises (PSSE) including 20 min per day, every day, during about at least one year by the first author [24]. Follow up visits were scheduled within one to two-month period (1–2 month intervals between visits) and exercises were updated for each patient in these sessions at clinic. Treated with brace group included subjects treated with the thoraco-lumbo-sacral brace, which was a modification of the Boston brace and had three-dimensional correction for their scoliosis [25]. The patients consisted of those who used their braces for more than 18 hours a day but did not have any adherence to their exercise programme.

2.3 Measurements

All clinical measurements were performed by the second author. Radiographic measurements were done by the orthopaedic surgeon. The following measurements were obtained at the initial evaluation:

1.
Demographic data, including the participant’s age, gender, body weight, height, body mass index, and duration of intervention.
2.
Clinical characteristics, as recorded through the curve pattern of the participants.

a.
Curve magnitude was determined according to the Cobb angle and axial trunk rotation.
b.
The Cobb angle was measured by a standing postero-anterior radiograph performed by a single senior clinician [26].
c.
Axial trunk rotation measurement was performed with scoliometer in forward bending [27].

3.
Kinesiophobia was measured with the Turkish version of the TSK [28].

The TSK is a 17-item questionnaire that assesses kinesiophobia and fear of (re)injury using a 4-point Likert-type scale. Each item is scored from 1 (strongly disagree) to 4 (strongly agree). A total score is calculated after inversion of the individual scores of items 4, 8, 12, and 16. The total score ranges from 17 (absence of fear) to 68 (highest fear). Higher scores indicate greater kinesiophobia. The TSK has also two following subscales: Somatic focus (items 3, 5, 6, 7, 11) and activity avoidance (items 1, 2, 9, 10, 13, 14, 15) [29]. A cut-off $>$ 37 for the total TSK score is considered to be a high degree of kinesiophobia [30]. All participants were classified according to this TSK cut-off threshold as “kinesiophobia in normal limits” and a “high degree of kinesiophobia.” The TSK has been suggested as a measurement of kinesiophobia in adolescent IS populations [18, 31].

Figure 1.
Flow diagram for participant recruitment, allocation and analysis.

2.4 Data analysis

Data analyses were performed using the Statistical Package for the Social Sciences (SPSS) software version 20.0 (SPSS, Chicago, IL, USA). A sample size calculation was performed with G*Power 3.1 to determine the necessary number of patients needed for this study based upon the results of the pilot study with the ten participants per group. The sample size calculation was based on the difference of TSK outcome between untreated (mean $=$ 80) and treated with exercise (mean $=$ 73) and treated with brace groups (mean $=$ 60) with the standard deviation of 14.8. Power analysis recommended that 18 patients would be required in each group to achieve a power of 0.95 for detecting minimum differences. An alpha error of 5% was considered statistically significant. With 10% dropout calculation, the final sample size was 20 participants per group.

All data were expressed as means with standard deviations or frequencies. Normality was tested group wise using the Shapiro-Wilk test for each of the variables. Because the parameters were not normally distributed, nonparametric tests were used for statistical analysis. The Kruskal Wallis test was used to compare the participant characteristics and TSK scores for the four groups (untreated, treated with exercise, treated with brace, and healthy groups). If a difference was found among the four groups, comparisons were then made between each group by using the two-sample Wilcoxon test, with Bonferroni adjustments for multiple comparisons. Results were considered statistically significant when the significance values, $p$ , were $<$ 0.05.

3. Results

The flow diagram is shown in Fig. 1. The mean age of the participants with scoliosis ( $n=$ 98) was 14 $\pm$ 2 years (range: 11 to 17). Participant demographics, clinical characteristics, and comparisons between the four groups are shown in Table 1 Participant demographics and baseline characteristics were similar for all four groups in the study. Curve patterns of groups and pairwise comparisons for curve magnitude variables are shown in Table 1. The group treated with exercise and untreated scoliosis group had similar curve magnitudes (Table 1).

Table 2 shows the overall results of the TSK. Differences in the TSK subscale scores and total scores existed among the four groups. Pairwise comparisons for total TSK score revealed significant differences between the untreated group and the healthy control group (Table 3). Untreated participants with IS had higher

Table 1
Demographic and clinical characteristics of the participants

Participant characteristics	Participants with scoliosis			Healthy controls ( $N=$ 20)	$P$ value	Pairwise comparison	$P$ value
	Untreated ( $N=$ 33)	Treated with exercise ( $N=$ 32)	Treated with brace ( $N=$ 33)
Age (years)	14.5 $\pm$ 2.1	13.8 $\pm$ 2.2	13.8 $\pm$ 1.7	14.1 $\pm$ 1.7	0.371	n/a
Height (cm)	157.4 $\pm$ 13.5	157.8 $\pm$ 10.4	161.3 $\pm$ 9.0	160.2 $\pm$ 10.0	0.677	n/a
Weight (kg)	48.9 $\pm$ 16.0	46.6 $\pm$ 12.4	47.6 $\pm$ 8.1	51.3 $\pm$ 11.9	0.451	n/a
BMI (kg/m ${}^{2}$ )	19.3 $\pm$ 3.6	18.4 $\pm$ 3.3	18.2 $\pm$ 1.9	19.8 $\pm$ 2.9	0.152	n/a
Intervention duration (months)	n/a	14.9 $\pm$ 1.9	15.2 $\pm$ 2.2	n/a	0.470	n/a
Curve pattern $n$ (%)
Single thoracic	13 (39.4)	2 (6.3)	4 (12.1)	n/a	n/a	n/a
Single lumbar	1 (3.0)	12 (37.5)	8 (24.2)
Single thoracolumbar	15 (45.5)	12 (40.6)	7 (21.2)
Double curve	4 (12.1)	5 (15.6)	14 (42.4)
Cobb angle of the main curve ( ${}^{\circ}$ )	19.6 (5.6)	17.7 (6.3)	30.3 (6.9)	n/a	$p<$ 0.001 ${}^{*}$	Untreated vs treated with exercise	0.150
						Untreated vs treated with brace	$<$ 0.001 ${}^{**}$
						Treated with exercise vs treated with brace	$<$ 0.001 ${}^{**}$
Axial trunk rotation of the main curve ( ${}^{\circ}$ )	5.0 (1.7)	5.2 (2.9)	7.9 (3.5)	n/a	$p<$ 0.001 ${}^{*}$	Untreated vs treated with exercise	0.326
						Untreated vs treated with brace	$<$ 0.001 ${}^{**}$
						Treated with exercise vs treated with brace	$<$ 0.001 ${}^{**}$

Values are means $\pm$ standard deviations, or frequence (percentage) of the groups. BMI, body mass index. Significant results of group comparisons, ${}^{*}p<$ 0.05, ${}^{**}p<$ 0.001. Bonferroni correction of pairwise comparisons, $p<$ 0.017.

total score on the TSK, which indicated greater kinesiophobia than in the healthy group. For only TSK subscale of Somatic Focus, untreated participants with IS had greater kinesiophobia scores than healthy control group. In addition, based on classification according to the TSK cut-off threshold, the majority of participants in the healthy control group were within the normal limits of kinesiophobia. But in the untreated group, the majority of participants had a high degree of kinesiophobia.

Table 2

Comparison of Tampa Scale of Kinesiophobia scores among groups

	Participants with scoliosis			Healthy controls ( $N=$ 20)	$P$ value
	Untreated ( $N=$ 33)	Treated with exercise ( $N=$ 32)	Treated with brace ( $N=$ 33)
TSK (mean $\pm$ SD)
Somatic focus subscale	11.7 $\pm$ 2.3	10.2 $\pm$ 2.7	10.2 $\pm$ 2.5	8.4 $\pm$ 2.2	$<$ 0.001 ${}^{**}$
Activity avoidance subscale	18.0 $\pm$ 4.3	16.8 $\pm$ 4.0	16.9 $\pm$ 3.6	14.1 $\pm$ 4.6	0.032 ${}^{*}$
Total score	38.3 $\pm$ 6.0	35.9 $\pm$ 5.2	36.3 $\pm$ 5.1	30.5 $\pm$ 7.1	$<$ 0.001 ${}^{**}$
TSK cut off $n$ (%)
$\leqslant$ 37 normal limits	8 (24.2)	18 (56.3)	14 (42.4)	17 (85.0)	n/a
$>$ 37 high degree of kinesiophobia	25 (75.8)	14 (43.8)	19 (57.6)	3 (15.0)

Values are means $\pm$ standard deviations, or frequence (percentage) of the groups. TSK, Tampa Scale of Kinesiophobia. Significant results ${}^{*}p<$ 0.05, ${}^{**}p<$ 0.001.

Table 3

Pairwise comparisons for Tampa Scale of Kinesiophobia variable

TSK	Group comparison	$P$ value
Somatic focus subscale	Untreated vs treated with exercise		0.135
	Untreated vs treated with brace		0.134
	Untreated vs Healthy control	$<$	0.001 ${}^{*}$
	Treated with exercise vs healthy control		0.133
	Treated with brace vs healthy control		0.124
	Treated with exercise vs treated with brace		1.000
Activity avoidance subscale	Untreated vs treated with exercise		1.000
	Untreated vs treated with brace		1.000
	Untreated vs healthy control		0.019
	Treated with exercise vs healthy control		0.452
	Treated with brace vs healthy control		0.247
	Treated with exercise vs treated with brace		1.000
Total score	Untreated vs treated with exercise		0.334
	Untreated vs treated with brace		0.419
	Untreated vs healthy control	$<$	0.001 ${}^{*}$
	Treated with exercise vs healthy control		0.064
	Treated with brace vs healthy control		0.046
	Treated with exercise vs treated with brace		1.000
TSK cut off (kinesiophobia in normal limits	Untreated		0.012
vs high degree of kinesiophobia)	Treated with exercise		0.751
	Treated with brace		0.887
	Healthy control		0.005 ${}^{*}$

TSK, Tampa Scale of Kinesiophobia. ${}^{*}$ Significant results of pairwise comparisons. Bonferroni correction of pairwise comparisons, $p<$ 0.008.

Table 4

The Tampa Scale of Kinesiophobia (TSK) item responses for untreated group ( $N=$ 33), the group treated with exercise ( $N=$ 32), and the group treated with brace ( $N=$ 33) suffering from idiopathic scoliosis and healthy control groups ( $N=$ 20)

TSK item	1 $n$ (%)		2 $n$ (%)		3 $n$ (%)		4 $n$ (%)
1. I am afraid that I might injure myself if I exercise
Untreated	17	(51.5)	11	(33.3)	4	(12.1)	1	(3.0)
Treated with exercise	15	(46.9)	15	(46.9)	2	(6.3)	3	(9.4)
Treated with brace	21	(63.6)	7	(21.2)	2	(6.1)	3	(9.1)
Healthy control	12	(60.0)	6	(30.0)	2	(10.0)	–
2. If I were to try to overcome it, my pain would increase
Untreated	8	(24.2)	14	(42.4)	3	(9.1)	8	(24.2)
Treated with exercise	10	(31.3)	18	(56.3)	4	(12.5)	–
Treated with brace	12	(36.4)	16	(48.5)	4	(12.1)	1	(3.0)
Healthy control	8	(40.0)	8	(40.0)	4	(20.0)	–
3. My body is telling me I have something dangerously wrong
Untreated	3	(9.1)	21	(63.6)	8	(24.2)	1	(3.0)
Treated with exercise	9	(28.1)	14	(43.8)	9	(28.1)	–
Treated with brace	7	(21.2)	16	(48.5)	10	(30.3)	–
Healthy control	7	(35.0)	11	(55.0)	2	(10.0)	–
4. My pain would probably be relieved if I were to exercise
Untreated	–		4	(12.1)	19	(57.6)	10	(30.3)
Treated with exercise	3	(9.4)	5	(15.6)	14	(43.8)	10	(31.3)
Treated with brace	2	(6.1)	7	(21.2)	12	(36.4)	12	(36.4)
Healthy control	–		1	(5.0)	11	(55.0)	8	(40.0)
5. People are not taking my medical condition seriously enough
Untreated	14	(42.4)	16	(48.5)	3	(9.1)	–
Treated with exercise	14	(43.8)	9	(28.1)	9	(28.1)	–
Treated with brace	16	(48.5)	10	(30.3)	7	(21.2)	–
Healthy control	12	(60.0)	8	(40)	–		–
6. My accident has put my body at risk for the rest of my life
Untreated	4	(12.1)	12	(36.4)	7	(21.2)	10	(30.3)
Treated with exercise	10	(31.3)	14	(43.8)	6	(18.8)	2	(6.3)
Treated with brace	8	(24.2)	12	(36.4)	11	(33.3)	2	(6.1)
Healthy control	12	(60.0)	6	(30.0)	1	(5.0)	1	(5.0)
7. Pain always means I have injured my body
Untreated	3	(9.1)	25	(75.8)	5	(15.2)	–
Treated with exercise	7	(21.9)	14	(43.8)	11	(34.4)	–
Treated with brace	14	(42.4)	14	(42.4)	4	(12.1)	1	(3.0)
Healthy control	10	(50.0)	10	(50.0)	–		–
8. Just because something aggravates my pain does not mean it is dangerous
Untreated	–		6	(18.2)	27	(81.8)	–
Treated with exercise	1	(3.1)	13	(40.6)	10	(31.3)	8	(25.0)
Treated with brace	1	(3.0)	9	(27.3)	14	(42.4)	9	(27.3)
Healthy control	2	(10.0)	8	(40.0)	8	(40.0)	2	(10.0)
9. I am afraid that I might injure myself accidentally
Untreated	6	(18.2)	12	(36.4)	5	(15.2)	10	(30.3)
Treated with exercise	4	(12.5)	9	(28.1)	12	(37.5)	7	(21.9)
Treated with brace	7	(21.2)	8	(24.2)	11	(33.3)	7	(21.2)
Healthy control	10	(50.0)	3	(15.0)	6	(30.0)	1	(5.0)
10. Simply being careful that I do not make any unnecessary movements is
the safest thing I can do to prevent my pain from worsening
Untreated	6	(18.2)	9	(27.3)	8	(24.2)	10	(30.3)
Treated with exercise	5	(15.6)	8	(25.0)	16	(50.0)	3	(9.4)
Treated with brace	2	(6.1)	11	(33.3)	17	(51.5)	3	(9.1)
Healthy control	8	(40.0)	7	(35.0)	5	(25.0)	–
11. I would not have this much pain if there were not something potentially
dangerous going on in my body
Untreated	–		12	(36.4)	8	(24.2)	13	(39.4)
Treated with exercise	7	(21.9)	12	(37.5)	13	(40.6)	–
Treated with brace	4	(12.1)	17	(51.5)	7	(21.2)	5	(15.2)
Healthy control	2	(10.0)	12	(60.0)	6	(30.0)	–

Table 4, continued
TSK item	1 $n$ (%)		2 $n$ (%)		3 $n$ (%)		4 $n$ (%)
12. Although my condition is painful, I would be better off if I were
physically active
Untreated	2	(6.1)	7	(21.2)	13	(39.4)	11	(33.3)
Treated with exercise	6	(18.8)	8	(25.0)	10	(31.3)	8	(25.0)
Treated with brace	5	(15.2)	11	(33.3)	7	(21.2)	10	(30.3)
Healthy control	1	(5.0)	6	(30.0)	6	(30.0)	7	(35.0)
13. Pain lets me know when to stop exercising so that I do not injure myself
Untreated	7	(21.2)	13	(39.4)	8	(24.2)	5	(15.2)
Treated with exercise	9	(28.1)	13	(40.6)	6	(18.8)	4	(12.5)
Treated with brace	9	(27.3)	11	(33.3)	9	(27.3)	4	(12.1)
Healthy control	11	(55.0)	7	(35.0)	2	(10.0)	–
14. It is really not safe for a person with a condition like mine to be
physically active
Untreated	9	(27.3)	14	(42.4)	8	(24.2)	2	(6.1)
Treated with exercise	17	(53.1)	11	(34.4)	4	(12.5)	–
Treated with brace	14	(42.4)	11	(33.3)	6	(18.2)	2	(6.1)
Healthy control	8	(40.0)	9	(45.0)	2	(10.0)	1	(5.0)
15. I cannot do all the things normal people do because it is too easy for me
to get injured
Untreated	7	(21.2)	19	(57.6)	4	(12.1)	3	(9.1)
Treated with exercise	11	(34.4)	11	(34.4)	9	(28.1)	1	(3.1)
Treated with brace	12	(36.4)	10	(30.3)	10	(10.3)	–
Healthy control	7	(35.0)	9	(45.0)	3	(15.0)	–
16. Even though something is causing me a lot of pain, I do not think it is
actually dangerous
Untreated	4	(12.1)	8	(24.2)	17	(51.5)	4	(12.1)
Treated with exercise	1	(3.1)	17	(53.1)	10	(31.3)	4	(12.5)
Treated with brace	2	(6.1)	11	(33.3)	15	(45.5)	5	(15.2)
Healthy control	2	(10.0)	–		8	(40.0)	10	(50.0)
17. No one should have to exercise when he/she is in pain
Untreated	2	(6.1)	24	(72.7)	3	(9.1)	4	(12.1)
Treated with exercise	9	(28.1)	12	(37.5)	10	(31.3)	1	(3.1)
Treated with brace	4	(12.1)	18	(54.5)	10	(30.3)	1	(3.0)
Healthy control	7	(35.0)	7	(35.0)	5	(25.0)	1	(5.0)

Values are presented as proportions of patients who report the TSK responses: 1 $=$ strongly disagree, 2 $=$ somewhat disagree, 3 $=$ somewhat agree, and 4 $=$ strongly agree.

Although no significant difference was found between the group treated with exercise and the healthy group, higher kinesiophobia scores were seen in the group treated with brace than in the healthy group according to Wilcoxon test. After Bonferroni correction of subgroup analysis, statistically significant reductions exhibited in the brace group and same as the exercise group, brace treatment has also no statistically difference than the healthy group in order to have kinesiophobia. The distribution of participants treated with exercise and treated with brace into TSK groups regarding normal and high kinesiofobia seemed similar (Table 3). Table 4 shows adolescent’s responses for the TSK survey.

4. Discussion

The present study provided descriptive information regarding kinesiophobia in adolescents with IS. The study investigated whether individuals with IS had differences in kinesiophobia when compared to healthy individuals. This study also established whether kinesiophobia differed between the two most commonly used treatment options for preventing curve progression in IS rehabilitation (exercise or bracing). The results of this research showed that adolescents with IS had greater kinesiophobia compared with healthy peers. Kinesiophobia did not show a significant difference according to the type of treatment received by the participants. No difference was observed between participants treated with exercise or brace than the healthy control group.

In the present study, high levels of kinesiophobia according to the TSK were found among adolescents with IS. Statistically significant differences were found in activity avoidance and somatic focus subscales but activity avoidance subscale has failed to show significance after bonferroni correction. Somatic focus subscale and total score of TSK were still statistically significant after Bonferroni correction between untreated participants with IS and the healthy control; untreated participants had higher kinesiophobia scores than the healthy group. Somatic focus subscale of TSK represents movement fears due to somatic focus (tendency to notice and report physical symptoms in relation to medical condition, while activity avoidance subscale defines fear-avoidance beliefs about physical activities [32]. From these, we can infer those individuals with IS who did not have any conservative treatment yet, does not tend to develop negative beliefs about physical activity by focusing on the medical condition at the first year from diagnosis but activity avoidance could be a risk for their future which we can predict from the high somatic focus subscale levels. Also some researchers conclude that surgery highly influences participants’ tendency to report activity avoidance related to kinesiophobia [33]. In this population with no surgery or surgery plan somatic focus subscale would be the first given sign of kinesiophobia development.

The difference between groups was also clinically meaningful. At least four points of change in the TSK was found as minimal clinically important difference in chronic spine conditions [34]. Furthermore, even small changes in TSK scores has been related with pain, poorer perceived health and poorer psychological health [35]. Previously, kinesiophobia, which negatively affects biomechanical gait parameters, was found in patients with adult degenerative scoliosis [17]. The mean TSK scores in these adults with spine deformity was reported as 41.0 $\pm$ 8.9. In the adult surgical spine population (such as spinal stenosis, spondylosis, and spondylolisthesis), the kinesiophobia score was found to be 39.0 $\pm$ 5.5 [36]. These results are similar to those shown in this present study. Based on this finding, we may suggest to add patient education against the development of kinesiophobia before treatment when the scoliosis is diagnosed.

Previously, an increased kinesiophobia score was found after surgery in adolescents with IS [18] and for postoperative spine in adults [36]. However, no comparative study of the effect of conservative treatment regarding exercise or bracing treatments on kinesiophobia in IS has been done. Based on our findings, brace treatment does not seem to have negative long-term consequences on kinesiophobia as the exercise treatment had positive impact on kinesiophobia in individuals with IS. Recovered kinesiophobia levels in both conservative treatments may show us scoliotic patients who met with physiotherapy assessments and take advices about their condition, could feel safer in terms of movement or exercise. In physiotherapy visits, they could have a chance to ask about their future fears and negative beliefs about movements in daily tasks, any sports or exercises. The people in the untreated group are the ones who was not consulted in any physical therapy department so they were not able to take the patient education in that field. This maybe could cause them to create negative beliefs about their illness more easily and so it would be hard them to cope with pain or emotional aspects of kinesiophobia. Also, in the exercise group patients experienced that exercise does not aggravate the pain so their movement phobia and pain expectations with movement decreased in the long term.

When considering item responses, we may have detected what were main problems associated with fear of movement. According to TKS item by item analysis, we may say that adolescents with IS considered scoliosis as a serious and dangerous medical condition and physical activity would be a risk for accidents and injuries throughout life. Especially untreated adolescents had feelings of fear related to physical activity and exercise. They believed that if they do exercise or physical activity, they can injure themselves and their pain would increase. This could be interpreted as fear of movement and pain hypersensitivity. These findings also show us the necessity of patient education in developing positive beliefs about exercise, which is the fundamental therapy method of IS.

The TSK score has been used to classify patients with a high degree or normal level of kinesiophobia; with a mean of $>$ 37 as the cut-off score of a high degree of kinesiophobia [30]. In this study, the majority of participants with a high degree of kinesiophobia were in the untreated scoliosis group, while the majority of participants with a normal limit of kinesiophobia were in the healthy control group. Approximately 76% of the participants showed a high degree of kinesiophobia in the untreated scoliosis group, compared with 24% who had normal limits of kinesiophobia. The high degree-normal degree ratio was 15:85% for the healthy group. The distribution of participants treated with exercise or braces in high and normal kinesiophobia categories was similar. The total kinesiophobia score of 30.5 in healthy population may interpretable as relatively high. In a study of structural validation of Tampa scale among adolescents with idiopathic scoliosis undergoing spinal fusion surgery, the researchers have concluded that somatic focus subscale revealed poor internal variability in relevant population [33]. This could be a factor that healthy populations high scores of kinesiophobia and maybe the scale would better have adapted to children and adolescents in the future studies.

One of the possible limitations of this study was that pain was not measured. Therefore, the relationship between pain and kinesiophobia was not investigated. Another limitation was a lack of baseline data; therefore, evaluating the effects of exercise or brace treatment on kinesiophobia directly was impossible. Additionally, the results may not be generalizable to adolescents with other spine diagnoses requiring exercise or brace treatment or to other age groups. Future studies should investigate associated factors, such as pain, physical activity, and psychosocial health to determine their independent contribution on kinesiophobia in IS.

5. Conclusion

In conclusion, the results showed that participants with scoliosis had higher mean kinesiophobia scores compared with healthy peers. Adolescents treated with conservative treatment, brace or exercise, tended not to develop kinesiophobia. Positive effects of exercise or brace treatments on kinesiophobia emphasizes the importance of patient observation and the timing of conservative treatment in participants with IS. We may suggest that special attention should be given to kinesiophobia when planning rehabilitation programs in adolescents with scoliosis. An additional patient education against the development of kinesiophobia seems to be necessary at the beginning of the program.

Footnotes

Conflict of interest

The authors have no conflict of interest to report.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

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Kinesiophobia and its association with treatment choice in individuals with idiopathic scoliosis

Abstract

BACKGROUND:

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Participants

2.2 Conservative treatment history

2.3 Measurements

3. Results

Table 1 Demographic and clinical characteristics of the participants

5. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Demographic and clinical characteristics of the participants