Perceived Instability, Pain, and Psychological Factors for Prediction of Function and Disability in Individuals With Chronic Ankle Instability

Abstract

Context: Chronic ankle instability (CAI) is associated with residual instability, pain, decreased function, and increased disablement. Injury-related fear has been associated with CAI, although its relationship to other impairments is unclear. The Fear-Avoidance Model is a theoretical framework hypothesizing a relationship between injury-related fear, chronic pain, pain catastrophizing, and disability. It has been useful in understanding fear's influence in other musculoskeletal conditions but has yet to be studied in those with CAI. Objective: To explore relationships between instability, pain catastrophizing, injury-related fear, pain, ankle function, and global disability in individuals with CAI. Design: Cross-Sectional Study Setting: Anonymous online survey Patients or Other Participants: A total of 259 people, recruited via e-mail and social media, with a history of ankle sprain completed the survey; of those, 126 participants (age=32.69±4.38, female=84.92%, highly active=73.81%) were identified to have CAI and were included in the analysis. Main Outcome Measure(s): Demographics included gender identity, age, and physical activity level. Assessments encompassed the Identification of Functional Ankle Instability (instability), the Pain Catastrophizing Scale (pain catastrophizing), the Tampa Scale of Kinesiophobia-11 (injury-related fear), a numeric pain rating scale and activity-based question (pain presence), the Quick-FAAM (ankle function), and the modified Disablement in the Physically Active Scale (disability). Relationships between variables were explored through correlation and regression analyses. Results: After controlling for instability and pain, pain catastrophizing and injury-related fear were significantly related to function and disability ratings in individuals with CAI. Together, the variables predicted 48.7% (P<.001) variance in function and 44.2% (P<.001) variance in disability. Conclusions: Greater instability, pain, greater pain catastrophizing, and greater injury-related fear were predictive of decreased function and greater disability in those with CAI. This is consistent with the hypothesized relationships in the Fear-Avoidance Model, although further investigation is needed to determine causality of these factors in the development of CAI.

Kinesiophobia and physical activity: A systematic review and meta-analysis

“…The 74 articles identified by the systematic review included a total of 13388 participants aged 11 to 85 years, including 7308 women, 4729 men, and 1351 participants whose gender and sex was not reported. The studies investigated populations with pain (n = 37) 62,64–71,73,76–81,83,88,89,111–128 cardiac conditions (n = 6) 86,87,104,129–131 , surgery (n = 8) 63,131–137 , arthritis (n = 10) 75,82,84,85,91,138–142 , neurologic conditions (n = 3) 90,143,144 , pulmonary conditions (n = 3) 145–147 , cancer (n = 1) 74 , women health conditions (n = 2) 72,148 , as well as healthy adults (n = 6) 29,85,107,149–151 (Table 1).…”

“…Most of these questionnaire-based studies used the short form of the International Physical Activity Questionnaire (IPAQ-SF; n = 20) 29,73,76,78,79,82,85,86,112,114,116,130,131,133,138–141,146,147 which consists of 6 items assessing time spent in light (i.e., walking), moderate (e.g., carrying light loads, cycling at moderate speed, doubles tennis), and vigorous physical activity (e.g., digging, fast cycling, heavy lifting, aerobics) over the last 7 days 159 . Other questionnaires were used to assess physical activity, such as the Baecke Habitual Physical Activity Questionnaire 160 (BHPAQ; n = 5) 64,89,90,107,113 , Saltin-Grimby Physical Activity Level Scale 161 (SGPALS; n = 5) 80,104,115,125,135 , Godin-Shephard Leisure-Time Exercise Questionnaire 162 (GLTEQ; n = 2) 121,134 , Minnesota Leisure Time Physical Activity Questionnaire 163 (MLTPAQ; n = 1) 136 , Physical Activity Scale for the Elderly 164 (PASE; n = 2) 123,149 , Physical Activity Questionnaire for the Elderly 164 (PAQE; n = 1) 72 , Short Questionnaire to Assess Health Enhancing Physical Activity 165 (SQUASH; n = 1) 142 , the Tegner Assessment Scale 166 (TAS; n = 1) 63 , University of California Los Angeles (UCLA) activity score 167 (n = 1) 84 , Leisure Time Physical Activity Index 168 (LTPAI; n = 1) 67 , Global Physical Activity Questionnaire 169 (GPAQ; n = 2) 77,83 , Freiburger Questionnaire on Physical Activity 170 (FQPA; n = 1) 127 , Jurka Physical Activity Scale 171 (JPAS; n = 1) 81 , Rapid Assessment of Physical Activity questionnaire 172 (RAPAQ; n = 1) 68 , Tecumseh Occupational Activity Questionnaire 173 (TOAQ; n = 1) 136 , and Australian Health Survey-derived questions (AHS; n = 1) 71 .…”

“…To assess physical activity, the studies used the following outcomes: Score from a questionnaire (e.g., TAS, PAQE, BHPAQ, SGPALS, LTPAQ, n = 24) 63,64,67,68,72,80,81,84,87,89,90,104,107,113,115,119,121,123,125,127,134,137,149 , MET-min/week (n = 23) 31,73,76,77–79,83,85,86,112,114,116,130,131,133,136,138–142,146,147 , steps per day (n = 14) 63,65,75,78,88,113,120,126,128,132,143–145,150 , hours per day or week (n = 12) 62,65,69–71,74,91,113,120,138,143,145 , counts per minute (n = 4) 111,113,117,137 , kilocalories per day (n = 2) 129,144 , or percentage of active time (n = 1) 122 . Nine studies used multiple physical activity outcomes 63,65,78,91,113,120,143–145 .…”

The influence of local pain on balance control in patients with chronic ankle instability

“…Patients with CAI were found to have injury-related fear that prevented them from rehabilitation training and returning to sports, leading to disuse of function, which further limited the recovery of the functional activity of ankles [51]. Suttmiller et al [23] recruited 126 CAI patients and evaluated the results of multiple pain and ankle function questionnaires. It was concluded that pain was strongly associated with worse ankle function, and pain might be a predictive factor of decline in the function of ankle joints.…”

“…The NRS-11 is a segmented numeric version of the Visual Analog Scale (VAS) in which a respondent selects a whole number (0-10 integers) that best reflects the intensity of their pain [20]. Previous literature related to CAI that measured pain intensity on a numeric rating scale used a score > 0 to define the presence of pain [21][22][23]. Therefore, the presence of pain was determined if subjects rated their pain as no less than 1.…”