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Centre for Orthopaedics
Suite 10-33/34/35 Mount Elizabeth Novena Specialist Centre
38 Irrawaddy Road
Singapore, 329563, Singapore
Ph: (65) 6684 5828
Fax: (65) 6684 5829

Child Orthopedics
Pain Management
Spine - Cervical
Spine - General
Spine - Lumbar
Spine - Thoracic

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I think I'm probably not a good person to have a knee replacement but maybe you can tell me for sure. I have what they call fear avoidance. I'm afraid to do much because if I do, the pain shoots up from a three to a 10 immediately. My husband thinks if I just have the knee replaced, I'll be fine. But I'm secretly worried I won't be any be any better off after surgery than before. You probably know about these things. What can you tell me?

Before reaching the point of needing, wanting, and accepting a total knee replacement for joint arthritis, like you, many people become fearful of movement (kinesiophobic). Their level of pain causes them to start avoiding certain movements and activities at home and work. As you have found out for yourself, this pattern of behavior is called fear-avoidance. Long periods of time in the fear-avoidance mode of thinking and acting can eventually lead to loss of function and disability. Without movement, knee osteoarthritis is known to get worse, causing more pain. Before you know it, you become kinesiophobic (afraid to move), sacrificing everyday activities and tasks. A viscious cycle of pain-fear-disability-pain develops that can be hard to break. In fact, just as you susptected, this pattern of pain-related fear does not automatically go away after the joint is replaced. But the good news is that it is possible to restore full motion and function without the element of fear preventing recovery. You can return to all your previous activities. A study was done in Italy comparing two different ways to approach this problem. The first was to provide patients with a functional exercise program. This refers to a type of program designed to do more than just regain 90-degrees of knee flexion or lift the leg off the bed ten times. Functional exercise-based rehabilitation programs are geared toward improving motion and strength while preventing blood clot formation and while restoring specific activities. Walking; climbing stairs; and making sudden starts, stops, and turns are just a few examples of the skills functional exercises work to restore. The exercise group also received a book designed to help them understand their own unwillingness to go out shopping, go for a walk, return to work, or ride a bike. By practicing physical activities and movements at home, the patients in this group were encouraged to perform all these things without fear. The goal was to increase activities previously considered "dangerous" (i.e., before surgery). This was to be done slowly but steadily over the six months' period of time after surgery. The second (control) group was just advised to stay active. They were told to gradually increase their activity level until they returned to normal (defined as their "usual" activities). Patients were randomly assigned to one of these two groups (experimental or control). After six months, it was clear that the experimental group had much better results compared with the control group. Disability level was much lower and quality of life was much higher in the experimental group. Fear-avoidance behaviors were also less common among the exercise group. Based on their findings in this study, the authors proposed the following:
  • Before knee replacement, all patients should be screened to identify those individuals who have pain-related fear of movement.
  • Anyone at risk for problems after total knee replacement because of fear-avoidance behaviors should receive education about kinesiophobia and a special rehab program.
  • Specific "graded" (in other words, slowly progressed) functional exercises should be prescribed and supervised until knee motion, daily activities, and physical function can be done with confidence and without fear.
  • Such a program can be taught to the patient while still in the hospital for the surgery. A follow-up home program may be enough to take care of the problem. Future studies are needed to know for sure exactly what type of rehab program (and for how long the program) should be provided. So, it is possible to pre-identify (before surgery) patients whose recovery from a total knee replacement may be compromised by fear-avoidance thinking and behaviors. Education and exercise can help correct these behaviors and aid in overcoming barriers to full recovery. Addressing and treating kinesiophobia in this way puts the burden of responsibility for recovery from mistaken beliefs and thoughts squarely on the patient's shoulders. But since you are asking the question, it sounds like you are already aware of (and concerned about) the problem. And that's the first step toward full recovery! Let your surgeon know about your fears and worries right up front. He or she should be able to guide and direct you through this process toward a successful knee replacement!

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