title: Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients.
abstract: OBJECTIVE
  To evaluate the effects of kinesiophobia on the outcomes of total knee arthroplasty (TKA), and to investigate whether kinesiophobia represents an independent factor influencing the surgery success or whether the observed effects are driven by other physical or psychological aspects such as anxiety and depression.
  
  
  METHODS
  Two hundred patients were evaluated prospectively (mean age 65.7 ± 9.1 years, 134 women and 66 men) at 12 months after TKA. Kinesiophobia was assessed with the Tampa Scale for kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales); anxiety and depression were assessed with STAI and BDI, respectively, and preoperative pain and function, sex, age, BMI, education level, number of painful joints and years of symptoms' duration before surgery were documented as well. Results were evaluated with pain and function on 0-10 numeric rating scales, while the overall clinical outcome was documented with WOMAC and SF-12 (Physical and Mental subscales) scores.
  
  
  RESULTS
  TSK1 was correlated with WOMAC results at 12 months (p = 0.005, ρ = 0.197). STAI (p = 0.002, ρ = 0.222), BDI (p < 0.0005, ρ = 0.307), and sex (p = 0.004) also influenced the outcome after TKA, while other parameters, such as age, BMI, education level, and number of painful joints and years of symptoms' duration before surgery, did not correlate with the clinical outcome. The multivariate analysis confirmed the role of BDI (p = 0.006, partial η2= 0.038), TSK1 (p = 0.011, partial η2= 0.033), and sex (p = 0.048, partial η2= 0.020), and a synergic interaction of BDI and TSK1, which together presented an even stronger correlation (p < 0.0005, partial η2= 0.111) with WOMAC at 12-month follow-up.
  
  
  CONCLUSIONS
  Kinesiophobia is a factor influencing the outcome after TKA independently from other psychological and physical variables. This risk factor may affect TKA results, especially in women, and shows a further synergic interaction with depression in terms of lower surgical outcome. These findings are of clinical relevance because they show the impact of psychological factors such as kinesiophobia, and suggest the possibility of adopting co-interventions to overcome the fear of physical activity, and in the end improve patient recovery and final outcome after TKA.
  
  
  METHODS
  IV.
authors.affiliation: Laboratory of Biomechanics and Technology Innovation/Ist Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna University, Via di Barbiano 1/10, Bologna, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Filardo
authors.affiliation: Laboratory of NanoBiotechnology (NABI), Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, Bologna, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Merli
authors.affiliation: Laboratory of NanoBiotechnology (NABI), Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, Bologna, Italy. a.roffi@biomec.ior.it.
authors.forename: A
authors.identifier: http://orcid.org/0000-0002-2683-3743
authors.initials: A
authors.lastname: Roffi
authors.affiliation: Mood, Centro per lo studio e la cura dei disturbi emotivi, Bologna, Italy.
authors.forename: T
authors.initials: T
authors.lastname: Marcacci
authors.affiliation: Mood, Centro per lo studio e la cura dei disturbi emotivi, Bologna, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Berti Ceroni
authors.affiliation: Mood, Centro per lo studio e la cura dei disturbi emotivi, Bologna, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Raboni
authors.affiliation: Mental Health Department, AUSL Bologna, Bologna, Italy.
authors.forename: B
authors.initials: B
authors.lastname: Bortolotti
authors.affiliation: Laboratory of NanoBiotechnology (NABI), Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, Bologna, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Kon
authors.affiliation: Laboratory of Biomechanics and Technology Innovation/Ist Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Bologna University, Via di Barbiano 1/10, Bologna, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Marcacci
mesh_terms: D000368:Aged; D001007:Anxiety / Q000523:psychology; D018771:Arthralgia / Q000523:psychology; D019645:Arthroplasty, Replacement, Knee / Q000523:psychology* / Q000534:rehabilitation*; D003863:Depression / Q000523:psychology*; D005239:Fear / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009068:Movement; D015999:Multivariate Analysis; D010147:Pain Measurement; D010149:Postoperative Pain / Q000523:psychology*; D010698:Phobic Disorders / Q000523:psychology*
keywords: Anxiety; Catastrophizing; Depression; Kinesiophobia; TKA; Total knee arthroplasty