LIVE from the WCPT Conference in Geneva, Switzerland, I welcome Christina Le on the show to discuss youth kinesiophobia following knee injury in sport. Christina Le is a PhD candidate in Rehabilitation Sciences in the Faculty of Rehabilitation Medicine at the University of Alberta in Edmonton, Canada.

In this episode, we discuss:

-What is kinesiophobia?

-Preliminary results from the University of Alberta research team focused on prevention of early onset osteoarthritis

-Why clinicians should address kinesiophobia early and often in rehabilitation to minimize poor long-term health outcomes

-And so much more!


Christina Le Twitter

World Congress of Sports Physical Therapy 2019

Tampa Scale for Kinesiophobia

 ApexNetwork Physical Therapy

For more information on Christina:

Christina Le is a PhD candidate in Rehabilitation Sciences in the Faculty of Rehabilitation Medicine at the University of Alberta in Edmonton, Canada. As a clinician, she frequently treated athletes with anterior cruciate ligament (ACL) injuries. This experience has motivated her to pursue research to better understand health-related quality of life (HRQOL) following a sport-related knee injury in active youth. Her research include identifying what factors impact youth HRQOL during rehabilitation and developing strategies to improve long-term HRQOL.

Christina continues to work part-time as a physiotherapist at the Glen Sather Sports Medicine Clinic. She treats patients on weekends, participates in multidisciplinary clinics with sport medicine physicians and orthopedic surgeons, and teaches an ACL rehabilitation group class called the Functional Agility and Strength Training (FAST) Program. Find her on Twitter as @yegphysio or online at

Read the full transcript below:

Karen Litzy:                   00:00                Hey everybody. Welcome back to the podcast. I am coming to you live from Geneva, Switzerland at the WCPT meeting and right now I have the distinct pleasure of sitting across a table from Christina Lee. She is a PhD candidate at the University of Alberta and she’s also a physio therapist. So Christina, welcome to the podcast. And today Christina did a wonderful platform presentation on Kinesiophobia after knee injury and we’re going to definitely get to her study on that. But before we do, Christina, can you tell the listeners what is kinesiophobia?

Christina Le:                                          So kinesiophobia is taken from the chronic low back pain literature and has been applied in our knee injury population as well. And it’s an excessive and irrational fear of movement due to feeling vulnerable to pain or reinjury.

Karen Litzy:                                           And so now let’s get to your study. So what I’ll have you do first is maybe tell us why you thought this was an important thing to look at.

Christina Le:                  01:02                Yeah. So I think after knee injuries in sport, knee injuries in particular, and we’re looking more at our youth, we know that there are a ton of different consequences that happen after knee injuries and they spend the physical, psychological and social domains of health. And this is just one that hasn’t been studied to great length in our youth athletes in particular. And it’s something that I think can contribute to poor long term health outcomes because it’s the most common reason for kids quitting sport after they get injured. It’s related to physical activity. So it’s something that maybe we can manage a little bit better as clinicians and moving forward to help out with better long term outcomes.

Karen Litzy:                                           Right. And that sort of lack of return to activity, lack of return to sport can, like you said, have long term outcomes. So we know that inactivity can lead to obesity and childhood diabetes and a lot of downstream consequences.

Christina Le:                  01:58                Yeah, exactly. Posttraumatic osteoarthritis is probably one that’s stuck in my head right now. Just coming from the International World Congress as well. And we know that that can affect almost up to half of our youth injuries that have a knee injury as well.

Karen Litzy:                                           All right. So let’s break down the study for us. So I will just have you kind of take it away and talk about the study now that we know the why behind it. Go ahead.

Christina Le:                                          Yeah, so we are currently running an ongoing prospective cohort study at the University of Alberta. It’s a part of the prevention of early onset of osteoarthritis research group, I guess that was initiated out of the University of Calgary. And we’re looking at youth athletes aged 11 to 19 who have sustained a sport related knee injury. So tibial femoral Patella femoral injury within the last three months. They had to have seen a physio therapist, a doctor or some sort of medical professional and had to have missed at least one session or one game from their sport to be considered injured.

Christina Le:                  03:02                And then we’re comparing them to age, sex and sport match controls. I’d say kind of 75% maybe through our study right now. And so this study that I presented on today is just a preliminary analysis of what our baseline data was. And what we were looking at was self reported kinesiophobia. So using the Tampa scale for Kinesiophobia and its influence on bilateral knee strength, using isokinetic dynamometer and triple single leg hop and Y balance test.

Karen Litzy:                                           Okay. So those were all of the things that you are looking at, that’s the data you are collecting? All right. Before we go on, I think most people know what a single leg three hop test is and the Tampa kinesio phobia scale you can look up, but can you talk about what the Y balance test is really quick just so people have a frame of reference as to what you’re doing?

Christina Le:                  03:53                Yeah, sure. So the Y balance test is we ask our participants to stand on one leg, hands on hips, so they can’t use their upper extremity to help out with their balance. They’re reaching as far anteriorly as they can while standing on one leg. And then they also do a posterior lateral and a posterior medial reach as well. We do three trials and we take the average of the three direction reaches. So one point they’re planted on the injured or the index side and then the other time they’re on the other side.

Karen Litzy:                                           Perfect. All right. So continue. Now we know what you’re measuring. We know who you’re measuring. So now let’s talk about how?

Christina Le:                  04:41                So we are looking at our mean within paired differences.  So we take our injured scores, we subtract them from our uninjured scores in terms of study groups, and then we’re just looking at the differences between the two groups on all those variables listed. And then we’re also running a logistic regression model that’s accounting for our match design. So it means that we are looking at the odds of scoring higher than 37 on the TSK. And we’re looking at if there’s a difference between our injured in uninjured groups in scoring higher or lower than that 37 and the 37 is based off of chronic low back pain literature where a study dichotomize their participants based on high fear responders are low fear responders based on that TSK score.

Karen Litzy:                                           Right. And just so people know, the lower your score on the TSK, the less kinesiophobia you have and the higher score, the more kinesiophobia you are experiencing.

Christina Le:                  05:39                Yeah, exactly. So I always say TSK is like a golf score. So higher scores worse lower scores better. And then we’re also running separate multivariable linear regressions as well. So effectively looking at the Association of TSK on strength or triple single leg hop or Y balance.

Karen Litzy:                                           Okay. And what did you find with that analysis?

Christina Le:                                          So what we found was with our mean within pair differences, so when we’re looking at our injured versus uninjured groups, just based on these variables alone, that the injury group scored on average about eight points higher on the TSK than the uninjured, which means that they are reporting greater kinesiophobia or higher kinesiophobia as you said. And they’re also scoring lower on strength, which isn’t maybe the most surprising finding considering they’ve just been injured. So we’re testing them on a median of six weeks after injury.

Christina Le:                  06:39                With our odds ratio where we found that the odds of scoring higher than 37 on the TSK was about 10 times greater for the injured group than the uninjured groups, which again, just means that they’re more likely to be kind of in that high fear responders group. And then with our multivariable regression, we found that there is an association between our TSK scores and our knee extension strength bilaterally and actually flexion strength bilaterally as well. The differences or the relationship strength itself isn’t the strongest. So if we have a one unit increase in our knee extension strength on our injured side for example, it just corresponded to a 0.1 decrease in the Tampa scale for Kinesiophobia, which is a minor change.

Christina Le:                  07:40                It’s probably not something that we can detect in all honesty or that’s clinically relevant, but just tells us that there is some sort of association between Kinesiophobia and strength.

Karen Litzy:                                           Got It. And so we know the results of your findings. What are your recommendations? What conclusions did you come to as a result of this study?

Christina Le:                                          Yeah, so I think the two big take home messages is that kinesiophobia is present as early as the three months leading up to or after an injury. I think as clinicians we generally tend to look at this closer to the return to sport end of the spectrum of Rehab. But it’s something that might be early, as our present, as early as three months. So we should be dealing with it as early as three months. And that it’s potentially something that might affect both sides of the body as well.

Christina Le:                  08:28                So if you’ve had a right knee injury, doesn’t mean that you don’t necessarily have kinesiophobia on that left knee as well. So it’s just trying to get clinicians to think maybe a little bit more bigger picture here and that I think ultimately if we can address kinesiophobia early after an injury, then potentially we can set people up for more physically active lifestyles, that sort of thing. And then hopefully help out with that reduction of those poor long term negative health consequences.

Karen Litzy:                                           And so as a practicing clinician, so let’s say I am seeing a, just making this up off the top of my head this is not a patient I have I swear, I am seeing a 16 year old boy who plays Lacrosse and let’s say he will use a term sprained his knee, maybe let’s just say it’s an ACL strain or sprain.

Karen Litzy:                   09:22                So not a tear doesn’t need surgery. So they’re coming to me, should I be using the Tampa scale on the first visit that I see this person? Or do you wait for a little bit further down the line?

Christina Le:                                          I don’t think it hurts to be using that right away. I think that what these individuals with knee injuries or any MSK injury, realistically they might be fearful of different things at different times in their rehab. And I think picking that up early on might be able to detect that, oh, maybe he’s scared of going downstairs or something like that. Whereas later stage Rehab, maybe it means that he’s a little bit more fearful of changing directions with contact around. I don’t think it hurts to necessarily use that Tsk early by any means.

Karen Litzy:                   10:13                Okay, great. So that’s a nice take home for the clinicians listening that hey, this is easy. It’s simple, it’s free. You can get it online and just have your patient fill it out and it’s easy to score. We just heard if you’re over 37, maybe that’s something to worry about. The lower the number, the less kinesiophobia. So it’s something that we can easily incorporate as clinicians with youth knee injuries. Can this be extrapolated to other injuries outside the knee and let’s say the back?

Christina Le:                                          So the tricky part with the TSK is that it actually hasn’t been validated for knee injuries yet. So it’s hard to say is this something that we can use in other areas? I’d really think that there is a need to validate this tool or if it’s not, then to generate a tool specifically for knee injuries.

Christina Le:                  10:59                Cause I think it’s something that we discuss a lot as researchers, as clinicians with our patients. So for now I guess it’s the best tool that we have but it doesn’t mean that it’s necessarily the right tool yet.

Karen Litzy:                                           Yeah. Well something to add to your list. Get Jackie Whittaker and get your team together. And that’s another study you can do because you have the time. Right?

Christina Le:                                          Totally. Really hoping to bring on Doctor Johanna Krista at some points on this topic as well. So I think she’s a good one to look at if you’re curious about the kinesiophobia stuff in our knee injured population as well.

Karen Litzy:                                           Awesome. And then because you said you’re about 75% through the study of preliminary data. Where do you see this going?

Christina Le:                                          So in the grand scheme of things for my own PhD, I’m going to be using this data to look at more health related quality of life in our young adults and our young athletes with sport related knee injury.

Christina Le:                  11:55                I’m a big proponents of kind of that bigger picture. So again, I think as clinicians, we’re really honed in on the whole return to sport thing as are our indicator of successful recovery. And looking at the literature, we know that only 66% of people return to their pre injury sport at the pre-injury level. And we don’t really have great numbers for anything past probably two or three years either in terms of sport participation. So are we may be selling our patients short if we’re only focused on that one thing as recovery versus again, kind of thinking bigger picture. Can we set them up in terms of physical health, psychological health, in terms of Kinesiophobia specifically, social health as well, so that they are able to maintain these healthy, active lifestyles, avoid osteoarthritis, avoid obesity, all that kind of stuff.

Karen Litzy:                   12:47                Awesome. Well it sounds like you have big plans and I think it’s only going to help clinicians and help the young athletes and young adults and teenagers and tweens that we treat on a regular basis. So thank you for your work. And now I have one more question. I probably should have told you this ahead of time, but I didn’t cause I forgot. But the question is knowing where you are now in your career and in your life, what advice would you give to yourself as a new Grad out of physio school?

Christina Le:                                          I would’ve said seek mentorship early and often. I think it took me a long and windy road to kind of get where I am and in all honesty, that’s probably made me who I am now as well.

Christina Le:                  13:32                But I think it would’ve been great to have maybe a little bit early on into my career as a new Grad, a little bit more mentorships with somebody or some people to kind of cling on to more or less to have a little bit of guidance in terms of what I should be doing, where I should be focusing my efforts on and spending my energy on.

Karen Litzy:                                           Awesome, great advice. Now, where can people find you?

Christina Le:                                          I am a on Twitter, I’m @YegPhysio, Yeg is the airport code for Edmonton, Canada. So that’s why I’m that. And that’s pretty much the only thing I’m active on in tems of social media for professional stuff. So, yeah.

Karen Litzy:                                           Perfect. Well, thank you so much for taking some time out of your schedule here at WCPT to come on the podcast.

Christina Le:                  14:17                Thank you so much. I’m going to throw a quick plug in for the world sports physiotherapy Congress in October in 2019 I’m hoping that all of you guys are going to be there cause we are going to be there. So you should have a lot of fun of you’ll come.

Karen Litzy:                                           Yes. And it’s in Vancouver in and around that first weekend of October. Yes, the lineup looks fantastic and even if you don’t work with a sports specific population, you can take all of this information and you can pair it down or you can pair it up to the population that you’re seeing because it’s all about concepts. It’s not necessarily sports specific.

Christina Le:                                          Yeah, exactly. I think it’s something that’s going to be useful for every MSK general practitioner out there. Whether again, yeah, you’re in sport or not so highly, highly recommended. Yeah, you guys should all come out and hang out.

Karen Litzy:                                           Yes, absolutely. We will both be there and I’m definitely looking forward to it. So, Christina, thank you again and everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart.


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©2019 Karen Litzy Physical Therapy PLLC.
©2019 Karen Litzy Physical Therapy PLLC.