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Abstract: Background: It is assumed that youth who experience a knee injury while playing sports have an initial decline in health that resolves with time, leaving no lasting impact. Health-related quality of life (HRQoL) encompasses the physical, psychological, and social domains of health. It can represent overall health (generic HRQoL) or health relative to a specific condition or body part (e.g., knee-specific HRQoL). Our knowledge of how sport-related knee injuries impact HRQoL is mostly based on adults and one injury type [anterior cruciate ligament (ACL) rupture]. To appreciate the full consequence of sport-related knee injuries on active youth, a broader understanding of how these injuries impact HRQoL is needed. Objectives: To improve our understanding of 1) how to measure HRQoL of active youth, 2) how HRQoL is altered by a youth sport-related knee injury at varying timepoints, and 3) what physical, psychological, and social consequences of injury are associated with HRQoL in active youth at varying timepoints. Methods: This thesis consists of 4 studies: 1) a systematic review evaluating patient-reported outcome measures (PROMs) for measuring generic and condition-specific HRQoL of active youth according to COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) guidelines; 2) a secondary analysis of a historical cohort study comparing generic and knee-specific HRQoL between individuals with and without a 3-12-year history of a youth sport-related knee injury; 3) a preliminary analysis of a prospective cohort study describing differences in knee-specific HRQoL and associated health outcomes between youth with and without a sport-related knee injury over an initial 6-month period; and 4) a prospective cohort study comparing knee-specific HRQoL between youth with and without a sport-related knee injury and assessing the influence of associated health outcomes on this relationship over a 12-month period. Results: The systematic review identified and evaluated 11 generic and 7 condition-specific HRQoL PROMs used in active youth. No existing PROM was deemed robust due to lacking sufficient measurement properties. Two generic and 1 upper extremity-specific HRQoL PROMs were judged as the most suitable based on sufficient structural validity and internal consistency. The historical and prospective cohort studies reveal that a wide range of youth sport-related knee injuries are associated with reduced knee-specific HRQoL at baseline, 6-month, 12-month and 3-12 year follow-ups compared to uninjured controls, regardless of sex. Conversely, no differences in generic HRQoL were found at 3-12 year follow-up. Exploratory analyses suggest that intermittent knee pain, knee muscle strength, physical activity, kinesiophobia, injury type, and baseline HRQoL may influence the relationship between knee injury and HRQoL. Conclusions: Taken together, these studies reveal that youth who experience a wide range of sport-related knee injuries – not just ACL ruptures – experience significant and persistent deficits in knee-specific HRQoL but not generic HRQoL compared to uninjured controls. Intermittent knee pain, knee extensor strength, physical activity, kinesiophobia, and injury type may be potential determinants of HRQoL in this population. Novel contributions from this thesis can guide future development and evaluation of HRQoL PROMs and inform future efforts to better understand and optimize HRQoL following a youth sport-related knee injury.

Background: Anterior cruciate ligament injury (ACL) is one of the most common knee injuries in physically active populations. ACL injuries are typically treated by surgical reconstruction and post-surgical rehabilitation in the United States. However, even after completing rehabilitation and being cleared by physicians, there is a high percentage of re-injury risk in ACL injury patients. The high re-injury rate could be explained by neuromuscular deficits: which are one of the key factors which contribute to re-injury. In addition to the neuromuscular deficits, movement pattern and physical activity levels could be affected by psychological status after ACL reconstruction (ACLR). Kinesiophobia, fear of movement, is one of the psychological factors we can measure after ACLR. Elevated levels of kinesiophobia is reported in 61% of ACLR patients within 1-2 months after surgery. Also, kinesiophobia correlates with post-surgical activity level and return to play status. However, there is limited knowledge of association between kinesiophobia and knee motor control neural activity after ACLR. Purpose: The purpose of the current study was to determine the correlation between the Tampa Scale for kinesiophobia (TSK) and brain activation during hip-knee joint movement in ACLR patients. Method: Cross-sectional study, ten participants were included in current study (4 males and 6 females, 20.3±2.00 years, 1.72±0.11 m, 68.72 ±14.79 kg, 29.1±25.7 months from injury). All participants completed the TSK prior to the functional neuroimaging season. Functional magnetic resonance imaging (fMRI) technique was used to measure brain activation during hip-knee joint extension-flexion movements in a supine position. The task consisted of a total of four cycles for 30 seconds of activation and 30 seconds of rest. Result: Mean TSK score was 31.3±3.65 (range: 26-37). Higher TSK scores were positively correlated with three clusters. Cluster 1 included the left thalamus (z=5.41, p

BACKGROUND: Exercise is an established treatment to alleviate pain and improve function among adults with knee osteoarthritis (KOA). However, long-term adherence to exercise is poor and effective approaches to support adherence are limited. The objective of this dissertation was to 'gain a new look' into long-term exercise adherence. With study #1, the experiences of participants in the Boston Overcoming Osteoarthritis through Strength Training (BOOST) study, were explored to identify participants' experiences, feelings and perspectives with exercise over 2-years and factors that influenced adherence to a prescribed exercise program after 2 years. With study #2, we examined if kinesiophobia: i) was associated with physical performance measures, ii) improved after a 6-week exercise program and iii) change was associated with change in pain and function among adults with KOA. METHODS: Participants of both studies completed a 6-week exercise program. For study #1 all participants received an automated telephone reminder to continue with their exercises and complete their logs, in addition, those randomized into the intervention group received a motivational computer adaptive telephone program. Participants were purposively sampled and in-depth interviews were conducted at the 2-year assessment. For study #2, data analysis was conducted prior to randomization with a sample of participants who completed the Tampa Scale of Kinesiophobia (TSK) questionnaire. Additional data included stair negotiation, 5 and 10 time sit-to-stand, and timed-up-and go tests. RESULTS: Study #1: Three themes were identified describing beliefs about exercise: i) monitoring, ii) knowledge of how to manage exercise behaviors, and iii) benefits of exercise. Those who reported high-adherence exhibited self-determination and self-efficacy, those who reported low-adherence expressed ambivalence about the benefits of exercise and a desire for more social support. Participants valued monitoring by peers and instructors during the exercise class and telephone technology. Study #2: Higher TSK was associated with slower stair and 5 time sit-to-stand times. TSK decreased after the exercise class but did not attain statistical significance. Change in TSK was associated with change in self-report physical function. CONCLUSIONS: Future research on the use of telephone technology and importance of self-determination and kinesiophobia on exercise adherence among adults with KOA is warranted.

Articular cartilage defects (ACD) in the knee are isolated lesions in the articular cartilage of the knee, surrounded by healthy cartilage. Most common in young, active adults, ACDs are often accompanied by pain, swelling, and muscle weakness that leads to activity restriction and reduced participation in desired activities. For this reason, individuals with ACDs report low knee-related quality of life, on par with older individuals preparing for total knee replacements. Unfortunately, the presence of the ACD can alter the stress distribution within the existing cartilage, raising concern that individuals with ACDs in the knee may develop osteoarthritis at an accelerated pace compared to individuals with healthy knees. While numerous surgical interventions have been developed in efforts to restore the friction-free and resilient cartilage surface, conservative and palliative treatments remain the most common choice. However, little is known regarding individuals with ACDs without or prior to a cartilage restoration procedure in a manner that can inform the development of rehabilitation interventions.As a first step toward understanding modifiable factors affecting individuals with ACDs, the overall objective of this dissertation is to evaluate muscle activation and joint loading patterns in individuals with ACDs during walking, with specific interest in its relationship to kinesiophobia (fear of movement/reinjury). Chapter 1 reviews the pertinent background regarding ACDs and presents a conceptual framework that links the subsequent chapters. Chapter 2 presents the results of systematic review of the kinesiophobia, as measured by the Tampa Scale for Kinesiophobia, across individuals with knee pathologies that found while kinesiophobia is generally low, there are many gaps in our current understanding. Chapter 3 finds that individuals with ACDs demonstrate muscle co-contraction during gait to a similar extent as healthy individuals, and is largely influenced by quadriceps muscle strength. In Chapter 4, we observed that individuals with ACDs in the tibiofemoral joint demonstrate reduced loading of the tibiofemoral and patellofemoral joint compared to individuals with patellofemoral ACDs and to healthy controls. Further, this unloading pattern in individuals with tibiofemoral ACDs appears to be achieved by walking slower. In Chapter 5, musculoskeletal modeling was used to identify the unique contribution of increased muscle co-contraction to patellofemoral joint reaction force during gait. The results indicate that patellofemoral joint reaction forces increase to a similar extent as tibiofemoral joint reaction forces in response to increasing muscle co-contraction. The series of studies in this dissertation are the first to specifically evaluate modifiable factors that affect individuals with ACDs without or prior to cartilage restoration procedures.

Ankle sprains, specifically to the lateral ligament complex, are one of the most common injuries seen during athletic participation and may lead to chronic ankle instability (CAI).1 Residual symptoms of CAI can include feelings of giving way and instability as well as, persistent weakness, pain during activity, and self-reported disability, which may affect postural control and functional performance.2 The purpose of this study was to determine if there was a relationship between perceived kinesiophobia and dorsiflexion range of motion (DROM), measures of dynamic postural control, and measures of functional performance, within active individuals with CAI. Thirty-seven physically active individuals with self-reported CAI, filled out the Foot and Ankle Ability Measure (FAAM), Cumberland Ankle Instability Tool (CAIT), Tampa Scale of Kinesiophobia 11 (TSK-11), and the NASA Physical Activity Scale (NASA-PAS). Of those, five qualified as having CAI based on the 5th International Ankle Consortium guidelines for CAI classification1 and completed one test session lasting approximately 45 minutes that included basic demographic data, leg length measurements, DROM, three directions of the Star Excursion Balance Test (SEBT), triple crossover hop test, and figure 8 hop test.Means and standard deviations were calculated and reported for all measures. Due to small sample size, only observational analysis could be performed between perceived kinesiophobia and dorsiflexion range of motion (DROM), measures of dynamic postural control, and measures of functional performance. Although only five participants classified as CAI, 36 of 37 participants reported some degree of kinesiophobia. Therefore we chose to examine the inclusionary questionnaires, and how they relate to our measure of kinesiophobia (TSK-11) and the number of reported ankle sprains. Pearson product-moment correlations were used to determine these relationships. Based on observational analysis there may be trends between kinesiophobia and DROM, and figure-8 hop test time. A strong positive relationship between the FAAM activities of daily living (FAAM-ADL) and FAAM-Sport subscales (r = 0.815, p ˂ 0.001), a moderate negative relationship between the FAAM-ADL subscale and TSK-11 scores (r = -0.509, p=0.001), and a moderate negative relationship between the FAAM-Sport subscale and TSK-11 scores (r= -0.599, p ˂ 0.001) were shown. There was also a moderate negative relationship between number of sprains and both the FAAM-ADL (r= -0.436, p= 0.007) and FAAM-Sport (r= -0.464, p=0.004) subscales. The current study showed potential trends between kinesiophobia and DROM, as well as functional performance specific to agility. Measures of functional performance and DROM in the current study when wearing ankle braces did not appear similar to previously published data. The TSK-11 was only moderately correlated to the FAAM. Therefore, perceived kinesiophobia may be independent of self-reported disability, and should be accounted for within the CAI population. Future research should further investigate the relationship between kinesiophobia and measures of dynamic postural control and functional performance.

Background: The socioeconomic burden of low back pain highlights the need for effective management of this problem. Healthcare practitioner beliefs are thought to influence the advice and management given to patients with low back pain. The psychometric properties of instruments that measure practitioner beliefs have not previously been rigorously tested with manual therapists. Objectives: To investigate internal consistency, test-retest reliability and construct validity of the FABT, the TSK-HC, the Back-PAQ and the HC-PAIRS. A secondary aim was to explore the beliefs of NZ osteopaths and manipulative physiotherapists about low back pain. Method: An online and postal survey was administered twice, 14 days apart; the first generated the psychometric properties of the FABT, the TSK-HC, the Back-PAQ and the HC-PAIRS and gather descriptive characteristics of respondents. The second gathered test-retest information. Results: Data from n=91 osteopaths and n=35 manipulative physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated acceptable internal consistency, (Cronbach’s α=0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). All instruments showed moderate correlation (Pearson’s r =0.51-0.78, p0.47) for the mean difference in scores, for all instruments, between professions. Conclusions: This study established adequate internal consistency, test-retest reliability and construct validity for the FABT, the TSK-HC and the Back-PAQ. Previously reported internal consistency, test-retest and construct validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. Osteopathy and manipulative physiotherapy respondents in this study reported attitudes and beliefs that were moderately unhelpful to recovery from low back pain.

The current study examined pain and harm appraisals of healthy college students asked to complete a reaching task prior to and following induction of Delayed Onset Muscle Soreness (DOMS) to the lower back. Participants were classified as “high” versus “low kinesiophobia” based on responses to the Tampa Scale of Kinesiophobia (TSK). Predicted pain and potential harm/injury ratings were collected using a visual analog scale at each reaching trial. Movement of the lumbar spine, thoracic spine, and hip was recorded using Vicon motion capture technology. In comparison to low kinesiophobia participants, high kinesiophobia participants predicted greater pain and harm for low target reaches following DOMS induction but not at baseline testing. In contrast to low kinesiophobia, high kinesiophobia participants showed a pattern of increasing kinematic caution across low target trials during Baseline testing session, evidenced by gradually declining lumbar flexion. A similar pattern was observed for thoracic spine flexion irrespective of testing session. Results are discussed in the context of the fear-avoidance model; potential reasons and implications for the observed findings are discussed.

According to the fear-avoidance model, kinesiophobia (pain-related fear) is an important factor in the development of chronic pain and disability. The current research project investigated the extent to which expectancy corrections (i.e., the tendency to bring expected pain/harm in line with experienced pain/harm) following exposure to one movement generalize to identical movements of increased intensity in chronic low back pain patients with high versus low levels of kinesiophobia. Additionally, the study addressed the impact of increased exposure on generalization. Participants were asked to consecutively perform four adaptations of a reaching task, each introducing a discrete element of increased intensity. Expected and experienced pain and harm ratings were collected for each trial. It was predicted that highly kinesiophobic participants will demonstrate greater overprediction of pain and harm relative to their low-kinesiophobic counterparts. It is also predicted that in highly kinesiophobic participants, expectancy corrections evidenced in the later trials of a given movement will show less generalization to the subsequent movement performed.