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01.12.2017 | Research article | Ausgabe 1/2017 Open Access

BMC Musculoskeletal Disorders 1/2017

Measuring individual hierarchy of anxiety invoking sports related activities: development and validation of the Photographic Series of Sports Activities for Anterior Cruciate Ligament Reconstruction (PHOSA-ACLR)

BMC Musculoskeletal Disorders > Ausgabe 1/2017
Wim van Lankveld, Nicky van Melick, Bas Habets, Eefje Roelofsen, J. Bart Staal, Robert van Cingel
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12891-017-1643-9) contains supplementary material, which is available to authorized users.



Fear of harm (FoH) after Anterior Cruciate Ligament Reconstruction (ACLR) should be addressed in physical therapy as it hampers return to sports. However, there are no instruments assessing FoH specific for ACLR. The objective of this study is to describe the development and measurement properties of the Photograph Series of Sports Activities for ACLR (PHOSA-ACLR) measuring ACL injury related FoH.


Based on literature and opinion of physical therapists with extensive experience in ACLR treatment, photographs depicting FoH inducing situations in ACL injury were considered for inclusion in the instrument. For each photograph the patients is asked to report perceived harmfulness. The set of photographs was completed by two samples of patients with ACLR: 1 cross-sectional sample (n = 55), and 1 test-retest reliability sample (n = 58). Internal consistency and structural validity were assessed in 109 patients. In 58 patients criterion validity was assessed by calculating pearson correlations with the Tampa Scale of Kinesiophobia (TSK). Correlations with self-reported knee function (KOOS and Lysholm score), and Knee Self-efficacy Scale (K-SES) were computed for hypothesis testing. Test-retest reliability was determined in a group of 55 patients, assessed twice with 1 week between assessments.


Twelve photographs depicting sports related movements that are likely to invoke FoH after ACLR were selected. Two items were deleted because of lack of discrimination. The remaining 10 items were included in the PHOSA-ACLR, and the scale showed excellent internal consistency (Cronbach’s Alpha is .95). Items reflected one dimension, and was strongly correlated with TSK (r = .59). A priori formulated hypotheses are confirmed and test-retest correlation was excellent (ICC = .86).


The PHOSA-ACLR showed acceptable measurement properties. The PHOSA-ACLR gives specific information about fear invoking sports situations that are not measured by other kinesophobia measures. Therefore, the PHOSA-ACLR might be a valuable additional tool in rehabilitation of ACLR patients. Additional research is needed to determine responsiveness to change.
Additional file 1: PHOSA-ACLR: Photograph Series of Sport Activities after Anterior Cruciate Ligament- Reconstruction. (DOCX 1399 kb)
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