The effects of fear-avoidance beliefs on anterior knee pain and physical therapy visit count for young individuals: A retrospective study

Highlights

• Fear-avoidance beliefs correlated with level of disability at evaluation, but did not impact total visit count.

• Fear-avoidance beliefs are present in young individuals with anterior knee pain.

• Activity-related fear is often present in young individuals with anterior knee pain.

• Fear-avoidance beliefs did not impact the number of visits to treat anterior knee pain or functional ability at discharge.

Abstract

Objectives

1) Report levels of fear-avoidance beliefs in adolescents with anterior knee pain, 2) determine if fear-avoidance beliefs predict the number of therapy visits used to treat anterior knee pain, and 3) determine if initial fear-avoidance beliefs predict functional ability at discharge.

Design

A retrospective review.

Setting

Pediatric outpatient hospital.

Participants

Patients ages 10–21 years with a diagnosis of anterior knee pain between 2009 and 2016.

Main outcome measures

The predictor variable was initial fear avoidance beliefs physical activity subscale (FABQ-PA) score and the outcome variable was total physical therapy visit count. Functional ability was assessed using the Anterior Knee Pain Scale (AKPS).

Results

Adolescents with anterior knee pain reported moderate fear-avoidance beliefs with an average initial FABQ-PA score of 13.2 ± 5. The FABQ-PA score did not significantly contribute to the visit count (p = 0.22, R²=<0.01). Fear-avoidance beliefs were most correlated with initial score on the AKPS (r = −0.44).

Conclusion

Fear-avoidance beliefs in adolescents are similar to that seen in adults. FABQ-PA scores did not impact the number of visits used to treat anterior knee pain or functional ability at discharge.

Introduction

Anterior knee pain (AKP), one of the most common knee conditions among adolescents, affects 6–10% of this population (Molgaard et al., 2011, Rathleff, 2016, Rathleff et al., 2015, Witvrouw et al., 2000). AKP is even more common in active athletes with a prevalence rate reaching 29% (Smith et al., 2018). Anterior knee pain is typically exacerbated during activities that increase load on the patellofemoral joint such as walking, running, jumping, stair climbing, and squatting (Lack, Barton, Vicenzino, & Morrissey, 2014). Physical therapy is the most commonly utilized conservative treatment intervention for anterior knee pain, but even with intervention many individuals continue to experience pain that can last for years (Piva et al., 2009a, Rathleff et al., 2016, Stathopulu and Baildam, 2003).

Anterior knee pain has a psychological component in addition to the commonly considered physical impairments (Domenech et al., 2013, Domenech et al., 2014, Piva et al., 2009a). Individuals with anterior knee pain who perceive pain as threatening can develop poor coping behaviors including catastrophizing, fear avoidance, and hypervigilance (Leeuw et al., 2007). Elevated anxiety, depression, catastrophizing, and pain-related fear correlate with pain and reduced physical function (Domenech et al., 2013, Maclachlan et al., 2017). Changes in these psychological components are predictors in decreasing pain and improving function in patients with anterior knee pain (Domenech et al., 2013, Domenech et al., 2014, Maclachlan et al., 2017, Piva et al., 2009a). A decrease in fear-avoidance beliefs with physical activity has been reported as the strongest predictor in decreasing pain and improving function in patients with anterior knee pain (Piva et al., 2009a, Piva et al., 2009b). These studies assessed fear-avoidance beliefs in young adults, but the importance of fear-avoidance beliefs in adolescents in unknown.

Healthcare costs have continued to escalate in the United States, and payers are examining methods to reduce expenditures. As payment systems evolve, the ability to deliver healthcare to the consumer and payers at the lowest cost is increasingly important (Chesworth, Culham, Tata, & Peat, 1989). Fear-avoidance behaviors may negatively impact patient outcomes, and therefore may require additional physical therapy visits. Understanding how psychosocial factors will affect the plan of care in physical therapy is important information for all stakeholders including the patient and family, physical therapist, and payer.

Cognitive factors are predictive of recovery and should receive focused intervention. It is unknown if additional physical therapy visits are required to resolve anterior knee pain in an individual with elevated fear-avoidance beliefs. Individuals with elevated fear-avoidance beliefs may require additional interventions prolonging the physical therapy plan of care beyond treatments targeting physical impairments (Maclachlan et al., 2017). Therefore, the purpose of this study was to 1) report levels of fear-avoidance beliefs in adolescents with anterior knee pain, 2) determine if fear-avoidance beliefs predict the number of therapy visits used to treat anterior knee pain, and 3) determine if initial fear-avoidance beliefs predict functional ability at discharge. We hypothesized that higher fear-avoidance beliefs would result in additional physical therapy visits and lower levels of functional ability at discharge.