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5 Articles in this Series
Cannabinoids Offer Some Hope for Oral Cancer Pain
Does Emotional Recovery After Accidents Influence Chronic Pain?
Fear of Movement and Pain Affect Post-ACL Reconstruction Recovery
High Prevalence of Falls Among Elderly in Pain
There’s an App for That—Mobile Technology Meets Pain Management

Fear of Movement and Pain Affect Post-ACL Reconstruction Recovery

Kinesiophobia, or the fear of movement, may be a significant contributor to poor outcomes following knee surgery. One year after undergoing anterior cruciate ligament (ACL) reconstruction, 40% of patients were not back to presurgery activity levels. Fear of reinjury is a major obstacle to rehabilitation starting in the early stages of post-operative recovery, according to Trevor Lentz, PT, SCS, CSCS, staff physical therapist at the UF Health Orthopedics and Sports Medicine Institute in Gainesville, Florida.

Mr. Lentz is part of a team of researchers at the University of Florida, led by Dr. Terese Chmielewski, examining the influence of kinesiophobia and pain catastrophizing (thinking this is the worse pain imaginable) on knee pain intensity.1 They also looked at the influence of knee pain, kinesiophobia, and pain catastrophizing on self-reported knee function during the first year following surgery.

Mr. Lentz reported that measurements were taken on 34 patients (mean age 24 years) at 1 week and 3, 6, and 12 months. The investigators found that at 1 week, pain catastrophizing contributed to knee pain intensity and kinesiophobia influenced knee function. At 3 months, psychosocial factors had little to no influence on pain intensity, but kinesiophobia contributed to poorer knee function. At 6 months, pain intensity adversely influenced knee function. And by 12 months, kinesiophobia and fear of reinjury contributed to pain intensity and poorer knee function.

“The only significant finding from the longitudinal analysis was that knee pain intensity at 6 months predicted 12-month knee function [P=0.016],” Mr. Lentz told Practical Pain Management. “Pain catastrophizing influenced pain intensity at 1 week. Fear of movement was consistently related to function at all time points except at 6 months, and may or may not have direct and indirect effects on function at 12 months. Pain intensity, while generally low at 6 and 12 months, influenced function at both time points and may be an important predictor of function,” he added.

The take home message, said Mr. Lentz, is that more effort should be made to address patients’ fear of movement following ACL reconstruction. “Unfortunately, there are no high-quality studies to my knowledge that have examined interventions for reducing fear of movement after ACL reconstruction. So most of my suggestions are based on the existing literature for reducing fear of movement in patients with low back pain,” noted Mr. Lentz. “Education is an important intervention—teaching patients what types of activities place them at greatest risk for reinjury and how long that elevated risk persists. For instance, jumping may be risky in the first month, but less risky in the third or fourth month after training. Many patients may assume the risk persists indefinitely.”

Other promising interventions include cognitive behavioral therapy, graded exposure/exercise, and mental imagery. However, the efficacy and comparative effectiveness of these interventions need to be studied further. “My sense is that the most important component of any intervention for fear of movement will be matching the right patients to the right treatments,” he added. “Many of these treatments may be effective but, right now, we are only starting to understand the pertinent personal qualities and situational characteristics in this patient population. So we still have a long way to go in understanding how to match patients to treatments.”

For pain management, Mr. Lentz noted that pain intensity influenced recovery in the later stages of rehabilitation, indicating that pain reduction techniques should be emphasized (ice, heat, stretching, etc.) to help recovery. If pain is not sufficiently managed through more traditional OTC and prescription NSAIDs, “then we refer patients back to their surgeon for evaluation of biomechanical issues and pain management. If there are significantly elevated psychological or social factors that are impeding progress, then we may refer to a psychologist. In my experience, the majority of the psychosocial factors we see impeding progress in this population have the potential to be managed appropriately in the physical therapy setting. This should be done throughout rehabilitation,” he noted.


1. Lentz T, George S, Zeppieri G, et al. Pain intensity, pain catastrophizing, kinesiophobia, and self-reported function in the first year following anterior cruciate ligament reconstruction. Poster presented at: American Pain Society 2014 Annual Meeting, Tampa, FL, April 30-May 3, 2014. Poster 113.

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