Fear avoidance and catastrophizing are associated with both knee awareness and quality of life in knee osteoarthritis patients: a secondary report of a cross-sectional study
DOI:
https://doi.org/10.2340/17453674.2025.45070Keywords:
Anxiety, Catastrophizing, Depression, Fear avoidance of physical activity, Knee awarenessAbstract
Background and purpose: In patients with knee osteoarthritis (OA), psychological factors (anxiety, depression, and pain-related catastrophizing) are associated with more pain and worse physical function. Low knee awareness and high knee-related quality of life (QoL) are key indicators of a well-functioning knee. The objective of our study was to evaluate associations between psychological factors and knee awareness and knee-related QoL in patients with knee OA.
Methods: In this Norwegian cross-sectional study of 653 patients with knee OA, 4 psychological factors were assessed: anxiety, depression, pain-related catastrophizing, and fear avoidance of physical activity. Associations between these factors and knee awareness and knee-related QoL were examined in unadjusted and adjusted regression models, controlling for age, sex, BMI, pain, and whether patients accepted or declined inclusion in a randomized controlled trial (ClinicalTrials.gov: NCT03771430). Regression coefficients with values below zero indicate negative associations between the independent and dependent factors and values above zero indicate positive associations.
Results: Worse scores on all 4 psychological measures were associated with higher knee awareness and poorer knee-related QoL in unadjusted analyses. Standardized estimates (βs) ranged from –0.38 (95% confidence intervals [CI] –0.45 to –0.31) to –0.16 (CI –0.23 to –0.08). In adjusted analyses, pain catastrophizing (β –0.07, CI –0.14 to –0.01) and fear-avoidance (β –0.11, CI –0.18 to –0.05) remained associated with higher knee awareness, whereas poorer knee-related QoL remained associated with more anxiety (β –0.10, CI –0.16 to –0.03) and depression (β –0.14, CI –0.20 to –0.08), as well as more pain catastrophizing (β –0.19, CI –0.26 to –0.12) and fear-avoidance (β –0.19, CI –0.25 to –0.13).
Conclusion: Higher fear avoidance of physical activity and more pain catastrophizing had the strongest associations with higher knee awareness and poorer knee-related QoL.
Downloads
References
Edwards R R, Bingham C O 3rd, Bathon J, Haythornthwaite JA. Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis Rheum 2006; 55(2): 325-32. doi: 10.1002/art.21865. DOI: https://doi.org/10.1002/art.21865
Wood T J, Gazendam A M, Kabali C B. Postoperative outcomes following total hip and knee arthroplasty in patients with pain catastrophizing, anxiety, or depression. J Arthroplasty 2021; 36(6): 1908-14. doi: 10.1016/j.arth.2021.02.018. DOI: https://doi.org/10.1016/j.arth.2021.02.018
Birch S, Stilling M, Mechlenburg I, Hansen T B. The association between pain catastrophizing, physical function and pain in a cohort of patients undergoing knee arthroplasty. BMC Musculoskelet Disord 2019; 20(1): 421. doi: 10.1016/j.knee.2019.08.012. DOI: https://doi.org/10.1186/s12891-019-2787-6
Leeuw M, Goossens M E, Linton S J, Crombez G, Boersma K, Vlaeyen J W. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30(1): 77-94. doi: 10.1007/s10865-006-9085-0. DOI: https://doi.org/10.1007/s10865-006-9085-0
Behrend H, Giesinger K, Giesinger J M, Kuster M S. The “forgotten joint” as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty 2012; 27(3): 430-6.e1. doi: 10.1016/j.arth.2011.06.035. DOI: https://doi.org/10.1016/j.arth.2011.06.035
Yan H, Guo J, Zhou W, Dong C, Liu J. Health-related quality of life in osteoarthritis patients: a systematic review and meta-analysis. Psychol Health Med 2022; 27(8): 1859-74. doi: 10.1080/13548506.2021.1971725. DOI: https://doi.org/10.1080/13548506.2021.1971725
Thomsen M G, Latifi R, Kallemose T, Husted H, Troelsen A. Does knee awareness differ between different knee arthroplasty prostheses? A matched, case-control, cross-sectional study. BMC Musculoskelet Disord 2016; 17: 141. doi: 10.1186/s12891-016-1001-3. DOI: https://doi.org/10.1186/s12891-016-1001-3
Lindberg M F, Aamodt A, Badawy M, Bergvad I B, Borchgrevink P, Furnes O, et al. The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis: study protocol for the MultiKnee trial. BMC Musculoskelet Disord 2021; 22(1): 021-04924. doi: 10.1186/s12891-021-04924-z. DOI: https://doi.org/10.1186/s12891-021-04924-z
Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019; 13(Suppl 1): S31-s4. doi: 10.4103/sja.SJA_543_18. DOI: https://doi.org/10.4103/sja.SJA_543_18
Kellgren J H, Lawrence J S. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957; 16(4): 494-502. doi: 10.1136/ard.16.4.494. DOI: https://doi.org/10.1136/ard.16.4.494
USIT Tsg-Id. Service for Sensitive Data (TSD) University of Oslo. Available from: https://www.uio.no/english/services/it/research/sensitive-data/index.html
Roos E M, Toksvig-Larsen S. Knee injury and Osteoarthritis Outcome Score (KOOS): validation and comparison to the WOMAC in total knee replacement. Health Qual Life Outcomes 2003; 1: 17. doi: 10.1186/1477-7525-1-17. DOI: https://doi.org/10.1186/1477-7525-1-17
Gandek B, Ware J E Jr. Validity and responsiveness of the Knee Injury and Osteoarthritis Outcome Score: a comparative study among total knee replacement patients. Arthritis Care Res (Hoboken) 2017; 69(6): 817-25. doi: 10.1002/acr.2319. DOI: https://doi.org/10.1002/acr.23193
Adriani M, Malahias M A, Gu A, Kahlenberg C A, Ast M P, Sculco P K. Determining the validity, reliability, and utility of the Forgotten Joint Score: a systematic review. J Arthroplasty 2020; 35(4): 1137-44. doi: 10.1016/j.arth.2019.10.058. DOI: https://doi.org/10.1016/j.arth.2019.10.058
Fernandes L, Storheim K, Lochting I, Grotle M. Cross-cultural adaptation and validation of the Norwegian pain catastrophizing scale in patients with low back pain. BMC Musculoskelet Disord 2012; 13: 111. doi: 10.1186/1471-2474-13-111. DOI: https://doi.org/10.1186/1471-2474-13-111
Waddell G, Newton M, Henderson I, Somerville D, Main C J. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52(2): 157-68. doi: 10.1016/0304-3959(93)90127-B. DOI: https://doi.org/10.1016/0304-3959(93)90127-B
Zigmond A S, Snaith R P. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67(6): 361-70. doi: 10.2340/17453674.2023.11656. DOI: https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
Bjelland I, Dahl A A, Haug T T, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res 2002; 52(2): 69-77. doi: 10.1111/j.1600-0447.1983.tb09716.x. DOI: https://doi.org/10.1016/S0022-3999(01)00296-3
Christensen R, Ranstam J, Overgaard S, Wagner P. Guidelines for a structured manuscript: statistical methods and reporting in biomedical research journals. Acta Orthop 2023; 94: 243-9. doi:10.1016/s0022-3999(01)00296-3. DOI: https://doi.org/10.2340/17453674.2023.11656
Bender R, Lange S. Adjusting for multiple testing: when and how? J Clin Epidemiol 2001; 54(4): 343-9. doi: 10.1016/s0895-4356(00)00314-0. DOI: https://doi.org/10.1016/S0895-4356(00)00314-0
Vlaeyen J W S, Crombez G, Linton S J. The fear-avoidance model of pain. Pain 2016; 157(8): 1588-9. doi: 10.1097/j.pain.0000000000000574. DOI: https://doi.org/10.1097/j.pain.0000000000000574
van Dieën J H, Flor H, Hodges P W. Low-back pain patients learn to adapt motor behavior with adverse secondary consequences. Exerc Sport Sci Rev 2017; 45(4): 223-9. doi: 10.1249/JES.0000000000000121. DOI: https://doi.org/10.1249/JES.0000000000000121
Sorel J C, Veltman E S, Honig A, Poolman R W. The influence of preoperative psychological distress on pain and function after total knee arthroplasty: a systematic review and meta-analysis. Bone Joint J 2019; 101-b(1): 7-14. doi: 10.1302/0301-620X.101B1.BJJ-2018-0672.R1. DOI: https://doi.org/10.1302/0301-620X.101B1.BJJ-2018-0672.R1
Burns L C, Ritvo S E, Ferguson M K, Clarke H, Seltzer Z, Katz J. Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review. J Pain Res 2015; 8: 21-32. doi: 10.2147/JPR.S64730. DOI: https://doi.org/10.2147/JPR.S64730
Olsen U, Lindberg M F, Rose C, Denison E, Gay C, Aamodt A, et al. Factors correlated with pain after total knee arthroplasty: s systematic review and meta-analysis. PLoS One 2023; 18(3): e0283446. doi: 10.1371/journal.pone.0283446. DOI: https://doi.org/10.1371/journal.pone.0283446
Edwards R R, Cahalan C, Mensing G, Smith M, Haythornthwaite J A. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol 2011; 7(4): 216-24. doi: 10.1038/nrrheum.2011.2. DOI: https://doi.org/10.1038/nrrheum.2011.2
Norwegian Arthroplasty Registry, Annual Report 2023. Helse Bergen H F, Haukeland universitetssjukehus; 2024. Available from: https://www.kvalitetsregistre.no/4a25e0/siteassets/dokumenter/arsrapporter/leddproteseregister/arsrapport-2023-leddregisteret.pdf
Jung K H, Park J H, Ahn J W, Park K B. Surgery-related anxiety on geriatric patients undergoing total knee arthroplasty: a retrospective observational study. BMC Musculoskelet Disord 2023; 24(1): 161. doi: 10.1186/s12891-023-06252-w. DOI: https://doi.org/10.1186/s12891-023-06252-w
Baumann F, Weber J, Mahr D, Bäumlein M, Kerschbaum M, Müller K, et al. Joint awareness in posttraumatic osteoarthritis of the knee: validation of the forgotten joint score in long term condition after tibial plateau fracture. Health Qual Life Outcomes 2017; 15(1): 233. doi: 10.1186/s12955-017-0801-y. DOI: https://doi.org/10.1186/s12955-017-0801-y
Lin H M, Hsieh P S, Chen N C, Tsai C H, Kuo W F, Lee Y L, et al. Impact of cognitive behavior therapy on osteoarthritis-associated pain, insomnia, depression, fatigue, and physical function in patients with knee/hip osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne) 2022; 9: 1083095. doi: 10.3389/fmed.2022.1083095. DOI: https://doi.org/10.3389/fmed.2022.1083095
Additional Files
Published
How to Cite
License
Copyright (c) 2025 Nina Jullum Kise, Siri Eliassen, Ove Furnes, Caryl Gay, Stig Heir, Anners Lerdal, Maren Falch Lindberg, Turid Rognsvåg, Arild Aamodt, Tor Kjetil Nerhus
This work is licensed under a Creative Commons Attribution 4.0 International License.
