Assessment of kinesiophobia and analysis of its influencing factors in patients who underwent traumatic elbow arthrolysis: a cross-sectional survey

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This study aimed to investigate the incidence of kinesiophobia in patients who underwent elbow arthrolysis and analyze its influencing factors to provide a theoretical basis for developing intervention programs for kinesiophobia. Methods A cross-sectional survey was conducted involving 160 patients who underwent elbow arthrolysis at a general hospital in Shanghai, China. Data were collected using a sociodemographic-clinical questionnaire, the Tampa Scale for Kinesiophobia-11, the Numeric Rating Scale, the General Self-Efficacy Scale, the Self-Rating Depression Scale, the Self-Rating Anxiety Scale, an assessment of elbow joint mobility, and the Mayo Elbow Performance Index. SPSS 22.0 was utilized for univariate and logistic regression analyses. Results Among the 160 patients, kinesiophobia incidence was approximately 73.12%. Logistic regression analysis revealed that preoperative heterotopic ossification (odds ratio (OR) = 0.071, 95% confidence interval (CI): 0.006 to 0.835), anxiety (OR = 1.191, 95%CI: 1.055 to 1.345), depression (OR = 1.184, 95%CI: 1.045 to 1.261), self-efficacy (OR = 0.178, 95%CI: 0.039 to 0.812), and preoperative pain scores during activity (OR = 4.013, 95%CI: 1.782 to 9.034) were factors influencing kinesiophobia in patients who underwent elbow arthrolysis. Conclusions Fear of movement in patients who have undergone elbow arthrolysis warrants greater attention. Moreover, particular emphasis should be placed on the evaluation of factors influencing kinesiophobia, such as anxiety, self-efficacy, and preoperative pain scores during activity. Post-elbow arthrolysis kinesiophobia should be managed to reduce its incidence and promote the rapid recovery of elbow function. Elbow Joint Traumatic Stiffness Arthrolysis Kinesiophobia Influencing Factors Figures Figure 1 Background Posttraumatic elbow stiffness is characterized by a limited range of motion (ROM) in the elbow due to traumatic injury. It can be induced by heterotopic ossification (HO), soft tissue contracture, intra- and extra-articular malunion or non-union, and articular cartilage defects, among others [ 1 ]. HO is the most common extra-articular culprit factor [ 2 , 3 ]. Approximately 3–20% of patients develop posttraumatic elbow stiffness following elbow trauma, which can seriously affect their daily lives and work [ 4 , 5 ]. Surgical arthrolysis is a well-established intervention for elbow stiffness with proven efficacy. However, elbow arthrolysis involves a large surgical area, and both open and arthroscopic arthrolysis can result in pronounced postoperative pain [ 6 ]. Kinesiophobia is an excessive, irrational fear of activity or movement in patients due to increased pain sensitivity resulting from painful injury or damage [ 7 ]. Patients in the perioperative period of elbow arthrolysis tend to reduce or refuse to perform functional exercises due to fear, affecting their motivation and compliance during the rehabilitation process. However, the efficacy of treatment for elbow stiffness is highly dependent on patient compliance with early postoperative functional exercises. This cross-sectional survey investigated the risk factors for kinesiophobia following elbow arthrolysis and aimed to provide a reference for the development of appropriate management strategies. Methods Study population Patients were recruited using a universal sampling approach from the orthopedics department of a Grade III Class A Comprehensive Hospital in Shanghai, China, between January 2019 and June 2021. We included patients who had posttraumatic elbow stiffness, those with an ROM 8 years. We excluded patients with severe craniocerebral trauma; nerve and vascular injury in the upper limb; Gustilo type III open fracture; elbow arthritis; severe cognitive impairment; serious lesions in the heart, kidneys, lungs, and other essential organs; elbow joint dysfunction and deformity before fracture; and severe endocrine and immune system diseases. The study protocol was approved by the Medical Ethics Committee of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (approval No: 2021 − 153). The informed consent was obtained prior to the interview. The Declaration of Helsinki was adhered to throughout all phases of this study. Data and scales General information The patients' demographic characteristics and disease-related information, including sex, age, educational background, occupation, marital status, family relationship, self-care ability, sides of the dominant and affected limbs, disease duration (duration of the occurrence of elbow stiffness), and initial injury type (simple fracture, dislocated/complex fracture, or dislocation), were obtained using questionnaires (see Supplementary Material 1). Tampa Scale for Kinesiophobia (TSK) The TSK is a self-reported scale developed in 1991 [ 8 ]. Seventeen items were used to assess the patients' symptoms regarding risk perception, kinesiophobia, movement avoidance, and dysfunction on a four-point Likert scale. The TSK scores range from 1 to 4, indicating "strongly disagree" to "strongly agree." The total score ranges from 17 to 68 points. Patients with TSK scores > 37 were considered to have kinesiophobia. In 2012, Wen Hu translated the scale into Chinese, with Cronbach's α 0.778 and test–retest reliability 0.860. The Visual Analog Scale (VAS) The VAS is a 10-point numeric scale, ranging from 0 to 10, with "0" representing no pain and "10" representing unbearable, severe pain. Pain severity was indirectly evaluated based on the patient's subjective perception of their current pain level. Pain severity was categorized into four levels based on the scores: no pain (0), mild pain (1–3), moderate pain (4–6), and severe pain (7–10). General Self-Efficacy Scale (GSES) The GSES was developed in 1981 [ 9 ] with empirical Cronbach's α 0.75 to 0.94. It was translated and revised into a Chinese version by Wang et al. with Cronbach's α 0.87. The scale comprises 10 items and is unidimensional in nature. The patients were assessed using a four-point Likert scale, with a higher score indicating better self-efficacy. Categorization included 10–30 points suggesting a low level of self-efficacy and 31–40 points suggesting a high level of self-efficacy. Self-Rating Depression Scale (SDS) The SDS [ 10 ] consists of 20 items across four dimensions: psychogenic movement disorder, psychological depression disorder, psychotic affective symptoms, and somatic disorders. Among the 20 items, 10 were reverse-scored on a four-point Likert scale ranging from 1 representing "none or very little of the time" to 4 representing "most of the time or all of the time." The total score was the sum of the scores for each question, multiplied by 1.25 to obtain the standard score. A standard score of ≥ 53 indicates a tendency toward depression, and the higher the score, the more pronounced the tendency. Cronbach's α for this scale is 0.784. Self-Rating Anxiety Scale (SAS) The SAS developed in 1971 [ 11 ], assesses anxiety-related symptoms in adults and is used to monitor changes in conditions during the treatment of anxiety. It comprises 20 items, each scored on a scale of 1 to 4, depending on its frequency of occurrence. The standard score was obtained by adding the score of each item, multiplying the sum by 1.25, and rounding the results to the closest integer. The threshold of the standard score was 50, and the higher the score, the more pronounced the anxiety tendency. Assessment of elbow joint mobility Elbow joint mobility was assessed using ROM testing. Briefly, the forearm was fixed in a neutral position, and the ROMs of the affected elbow joint were measured using a protractor during flexion, extension, internal rotation, and external rotation. Functional evaluation of the elbow joint The recovery of elbow function in terms of joint pain, mobility, stability, and activity of daily living ability was determined and analyzed using the Mayo Elbow Performance Index. This is a 100-point scoring system, with scores categorized ≥ 90 (excellent), 75–89 (good), 60–74 (fair), and < 60 (poor). Data collection All questionnaires were administered the day following elbow arthrolysis. The investigators explained the study's purpose to the patients and their family members using standardized instructional language. When patients were unable to fill out the questionnaires independently due to factors such as impaired visual acuity, physical condition, or educational level, the researcher explained and completed the questionnaire entries on their behalf. After the patients returned the questionnaires, the investigator checked whether they were fully completed. If any items were missing, the patients were asked to complete them before the questionnaires were rechecked and collected. A total of 180 surveys were distributed to eligible participants. Of these, 160 were completed and returned, resulting in a valid response rate of 88.89%. Statistical analysis SPSS software (version 22.0) was used for analyses. Count data are described using frequencies and percentages. Intergroup comparisons were conducted using the χ 2 test or Fisher's exact probability method. The effects of sex, age, place of residence, and educational background on kinesiophobia were investigated using univariate analysis. Statistically significant factors identified by the univariate analysis were included in the logistic regression model. Statistical significance was set at P < 0.05. Results Incidence of kinesiophobia after elbow arthrolysis In total, 180 questionnaires were distributed; however, eight individuals declined to participate. Additionally, 12 individuals did not meet the inclusion criteria and were, therefore, excluded from the study. A total of 160 patients who underwent elbow arthrolysis were included in this study, with 117 patients experiencing kinesiophobia (incidence of kinesiophobia, 73.12%; Fig. 1 ) Univariate analysis of kinesiophobia after elbow arthrolysis The occurrence of kinesiophobia was used as the dependent variable, and sociodemographic characteristics, self-rated depression, self-rated anxiety, elbow function evaluation, and general self-efficacy were used as independent variables in the univariate analysis. The factors influencing the occurrence of kinesiophobia were extension angle, preoperative elbow ROM, preoperative pain score during activity, preoperative HO, self-efficacy, depression, and anxiety. The details are presented in Table 1 . Table 1 Univariate analysis of kinesiophobia in patients that underwent elbow arthrolysis Characteristics Kinesiophobia group (n = 118) Non-Kinesiophobia group (n = 42) χ2/t P-value Age (years) 37.31 ± 10.36 34.52 ± 10.18 -1.501 0.135 Sex 1.799 0.180 Male 73 (77.7) 21 (22.3) Female 45 (68.2) 21 (31.8) BMI (kg/m 2 ) 21.95 ± 1.97 21.48 ± 2.25 -1.297 0.197 Residence 0.036 0.849 Rural area 43 (72.9) 16 (27.1) Urban area 75 (74.3) 26 (25.7) Marital status 3.315 0.191 Single 28 (66.7) 14 (33.3) Married 84 (75) 28 (25) Divorced/widowed 6 (100) 0 (0) Education level 6.469 0.091 Primary school 26 (78.8) 7 (21.2) Middle school 40 (81.6) 9 (18.4) High school 33 (73.3) 12 (26.7) College or higher 19 (57.6) 14 (42.4) Occupation 9.454 0.051 Nonphysical labor 32 (28.9) 13 (71.1) Light physical labor 37 (67.3) 18 (32.7) Heavy physical labor 22 (78.6) 6 (21.4) Retired/unemployed 19 (100) 0 (0) Student 8 (61.5) 5 (38.5) Self-care ability 2.219 0.136 Unable 6 (100) 0 (0) Able 112 (72.7) 42 (26.3) Smoking habit 0.904 0.342 No 28 (80) 7 (20) Yes 90 (72) 35 (28) Disease duration (months) 21.77 ± 39.64 25.76 ± 41.22 0.555 0.580 Initial injury type 0.055 0.814 Simple fracture/dislocation 82 (73.2) 30 (26.8) Complex fracture/dislocation 36 (75) 12 (25) Flexion (°) 85.58 ± 25.64 87.07 ± 31.23 0.306 0.760 Extension (°) 44.47 ± 19.71 33.38 ± 20.25 -3.108 0.002 Preoperative ROM 53.64 ± 12.08 57.38 ± 16.65 2.174 0.031 MEPI 53.64 ± 12.08 57.38 ± 16.65 1.335 0.187 VAS for pain at rest (points) 0.54 ± 0.71 0.36 ± 0.62 -1.601 0.113 VAS for pain on movement (points) 2.8 ± 1.11 1.38 ± 0.96 -7.320 0.000 ROM of forearm rotation 0.005 0.942 ≥ 100° 71 (74) 25 (26) < 100° 47 (73.4) 17 (26.6) Violent exercise 0.125 0.724 Yes 25 (71.4) 10 (28.6) No 93 (74.4) 32 (25.6) Preoperative clinically significant HO 19.331 0.000 Yes 45 (97.8) 1 (2.2) No 73 (64) 41 (36) Self-efficacy 7.532 0.006 Low 79 (81.4) 18 (18.6) High 39 (61.9) 24 (38.1) Depression 43.33 ± 8.39 59.68 ± 7.48 -11.915 0.000 Anxiety 59.07 ± 8.22 43.78 ± 8.12 -10.387 0.000 BMI, body mass index; HO, heterotopic ossification; MEPI, Mayo Elbow Performance Index; ROM, range of motion; VAS, Visual Analog Scale. Multivariate analysis of kinesiophobia after elbow arthrolysis Variables with P < 0.05 in the univariate analysis and those that might influence the occurrence of kinesiophobia, as determined by professional analysis, were used as independent variables with values assigned as indicated in Table 2 . Logistic regression was performed with the occurrence of kinesiophobia as the dependent variable, and the results showed that preoperative HO, anxiety, depression, self-efficacy, and preoperative pain scores during activities were independent factors influencing kinesiophobia (Table 3 ). Table 2 Assignment of independent variables for multivariate analysis Variable labels Assignment description Preoperative clinically significant HO Yes = 1; No = 2 Self-efficacy Low = 1; High = 2 HO, heterotopic ossification Table 3 Multivariate logistic regression analysis results regarding the factors affecting kinesiophobia in patients who underwent elbow arthrolysis Independent variables Β SE Walds OR (95%CI) P-value Extension (per 1° loss) 0.02 0.02 0.993 1.02 (0.981–1.06) 0.319 Preoperative ROM 0.024 0.015 2.624 1.024 (0.995–1.055) 0.105 Preoperative clinically significant HO Yes 2.643 1.257 4.426 0.071 (0.006–0.835) 0.035 No 0 1 Anxiety 0.175 0.062 7.928 1.191 (1.055–1.345) 0.005 Depression 0.138 0.048 8.277 1.148 (1.045–1.261) 0.004 Self-efficacy High lever -1.727 0.774 4.971 0.178 (0.039–0.812) 0.026 Low lever 0 1 VAS for pain on movement (points) (per 1-point increase) 1.389 0.414 11.261 4.013 (1.782–9.034) 0.001 HO, heterotopic ossification; ROM, range of motion; VAS, Visual Analog Scale; OR, odds ratio; CI, confidence interval. Discussion In this study, the incidence of kinesiophobia was 73.1% among patients who underwent traumatic elbow arthrolysis. Kinesiophobia was significantly associated with several psychological and clinical factors in this population. Specifically, higher levels of anxiety, depression, and movement-related pain (VAS score) were positively correlated with the presence of kinesiophobia, suggesting that psychological distress and pain perception may exacerbate the fear of movement. Conversely, self-efficacy was negatively correlated with kinesiophobia, indicating that patients with higher levels of self-efficacy are less likely to experience psychological fear related to movement. Furthermore, the presence of clinically significant HO prior to surgery was identified as a protective factor against kinesiophobia. Collectively, these results suggest that anxiety, depression, pain intensity, and self-efficacy are key predictors of kinesiophobia in patients undergoing elbow arthrolysis, underscoring the importance of integrating psychological support and effective pain management strategies into postoperative rehabilitation programs. High incidence of kinesiophobia in patients who underwent elbow arthrolysis Kinesiophobia was first described by Kori in 1990 and was initially observed in patients with chronic pain. It has since been widely used to evaluate the fear of movement in postoperative patients. The factors influencing kinesiophobia in patients who have undergone elbow arthrolysis have not been reported nationally or internationally. Here, the TSK score of the patients was 42.09. The incidence of kinesiophobia was 73.12%, higher than those reported in 862 patients who underwent total knee arthroplasty (TKA, 24.4%) [ 12 ] and in 78 patients who underwent TKA (21.8%) [ 13 ]. The prevalence of kinesiophobia in patients with persistent pain is between 50% and 70% [ 14 ]. The incidence was also higher than those observed in patients with chronic musculoskeletal pain (56%) [ 15 ], cervical degenerative disc disease (81.5%) [ 16 ], lumbar disc herniation (45%) [ 17 ], and traumatic bone injuries (58.2%) [ 18 ]. This suggests that kinesiophobia is prevalent in patients with chronic diseases and those who have undergone surgical procedures. Patients with elbow stiffness and HO had a higher risk of postoperative kinesiophobia The hip joint has the highest incidence of HO in joint trauma and surgery, followed by the elbow and knee joints. The incidence of HO after initial total knee replacement is 5% [ 19 ], whereas the incidence of HO after elbow trauma is as high as 28.7% [ 20 ]. The incidence of HO before surgery has been reported at 20% [ 21 ], and the presence of HO is a main factor affecting limb function either before or after surgery [ 21 ]. The incidence of preoperative HO among our patients was 28.8%, likely because the effect of HO on elbow function is more pronounced than on the hip, knee, and other commonly affected large joints. Additionally, HO is frequently present in patients requiring surgical release. We could find no report on the influence of HO on the incidence of kinesiophobia in patients with elbow joint injury and dysfunction. This may be related to the fact that relevant orthopedic research has mainly focused on the knee joint, and the incidence of HO of the knee joint was significantly lower than that of the elbow joint. Additionally, the assessment of HO requires professional imaging, which can be easily ignored. Prostaglandin E2 (PGE2) is an important molecule mediating pain and an osteogenic factor [ 22 ]. The osteogenesis level in patients with HO is significantly higher than that in the general population. The osteogenic PGE2 sensory nerve EP4 axis is involved in the intraosseous perception system, which is related to the hypothalamic neuroendocrine system [ 23 , 24 ]. Therefore, the specific reason preoperative HO is a risk factor for postoperative kinesiophobia requires further investigation. Relevant research results will hopefully provide key guidance for the prevention and treatment of orthopedic postoperative kinesiophobia. Patients with elbow stiffness complicated by anxiety and depression had a higher risk of developing postoperative kinesiophobia The SAS score was significantly and positively correlated with the risk of developing postoperative kinesiophobia (B = 0.175 > 0, p = 0.005 < 0.05). This suggests that a higher SAS score indicates a more substantial likelihood of developing postoperative kinesiophobia. When the SAS score was 1 point higher, postoperative kinesiophobia was 1.191 times more likely to develop. The SDS score was also significantly and positively correlated with the risk of developing postoperative kinesiophobia (B = 0.138 > 0, P = 0.004 < 0.05). A higher SDS score indicated a more substantial likelihood of developing postoperative kinesiophobia. Moreover, a one-point increase in the SDS score increased the possibility of developing postoperative kinesiophobia by 1.148 times. These results align with previous findings [ 19 , 20 ]. Anxiety and depression were directly linked to kinesiophobia, likely because patients in different emotional states respond differently to pain. Generally, patients who have undergone elbow arthrolysis respond in two ways when provoked by pain. Patients with positive emotions tend to cope more effectively and regard pain as a normal physiological response. Then, the patients try to overcome the discomfort caused by pain and continue performing functional exercises. However, those with negative emotions will exaggerate their pain perception and regard functional exercises as a potential threat to aggravate pain when pain develops during exercise. Moreover, they focus more on pain stimuli, resulting in increased pain sensitivity, leading to resistance or even avoidance of functional exercises and eventually to kinesiophobia. This suggests that clinical workers should focus on the influence of depression when evaluating patients with kinesiophobia, provide prompt emotional support to patients, and offer appropriate psychological guidance and relaxation training, such as music therapy, positive meditation, muscle relaxation training, art videos, and positive dialog, to ameliorate patients' negative emotions and encourage them to start postoperative functional exercises as early as possible. Patients with elbow stiffness and low self-efficacy were at a higher risk of developing postoperative kinesiophobia Self-efficacy was a protective factor against kinesiophobia, consistent with previous findings [ 16 ]. We found that patients with elbow stiffness had more confidence in overcoming fears of pain and actively performing postoperative rehabilitation exercises when they had higher levels of self-efficacy. Some studies have reported that self-efficacy is a mediator of pain-related fear and prognosis in patients with pain [ 25 ]. Moreover, enhancing self-efficacy reduces pain-related fear, pain severity, and disability. Therefore, management strategies based on Bandura's self-efficacy theory can be established by healthcare professionals to improve patients' self-efficacy levels, bolster their confidence in overcoming the disease, and thereby reduce the incidence of kinesiophobia. Patients with elbow stiffness who had preoperative pain during activities had a higher risk of developing postoperative kinesiophobia The VAS score during preoperative activity was a risk factor for postoperative kinesiophobia. Traumatic elbow stiffness is associated with anxiety and depression [ 26 , 27 ], with more than half the affected patients experiencing these conditions. Pain during elbow movement is an independent risk factor for both anxiety and depression [ 27 ]. Additionally, HO is an independent risk factor for anxiety in patients with posttraumatic elbow stiffness [ 27 ]. From the characteristics of the history of patients with elbow stiffness, most experience a painful rehabilitation process and fear pain during activities. This type of pain injury and increased sensitivity (closely related to anxiety and depression) are core mechanisms causing excessive fear in the rehabilitation of patients with elbow stiffness after surgery. This is critical because scientific pain education, preoperative rehabilitation education, and other methods for such patients have a positive effect on improving patients' anxiety and reducing the occurrence of postoperative kinesiophobia, thus helping improve surgical efficacy and overall prognosis. Limitations This study had some limitations. First, it was a single-center study; therefore, multicenter data are needed to validate the extrapolation of the current results further. Second, the mechanisms of action of the factors influencing kinesiophobia need to be further elucidated to provide a theoretical foundation for developing precise interventions for kinesiophobia. Conclusions This study demonstrated that kinesiophobia was significantly associated with anxiety, depression, movement-related pain intensity, self-efficacy, and the presence of preoperative HO, identifying these variables as key predictors. Patients with higher levels of anxiety, depression, and pain reported greater levels of kinesiophobia, while higher self-efficacy was associated with a reduced risk. Interestingly, the presence of clinically significant heterotopic ossification prior to surgery was correlated with a lower likelihood of kinesiophobia, suggesting a potential protective role; however, this association may reflect more complex adaptive mechanisms and should not be interpreted as a definitive absence of fear of movement in such patients. These findings highlight the multifactorial nature of kinesiophobia following traumatic elbow arthrolysis, involving both psychological and physical components. The implications for clinical management are substantial. Early screening for psychological distress and pain sensitivity, along with interventions aimed at enhancing self-efficacy and addressing pain proactively, may help reduce the development of kinesiophobia. Integrating these strategies into postoperative rehabilitation programs could promote functional recovery, improve patient engagement, and optimize long-term outcomes. Abbreviations OR odds ratio CI confidence interval ROM range of motion HO heterotopic ossification TSK Tampa Scale for Kinesiophobia NRS Numeric Rating Scale GSES General Self-Efficacy Scale SDS Self-Rating Depression Scale SAS Self-Rating Anxiety Scale TKA total knee arthroplasty PGE2 prostaglandin E2 Declarations Ethics approval and consent to participate The study protocol was approved by the Medical Ethics Committee of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (approval No: 2021-153). The informed consent was obtained prior to the interview. The Declaration of Helsinki was adhered to throughout all phases of this study. Consent for publication The participants have written informed consented to the submission of this study to the journal. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Clinical trial number Not applicable. Authors' contributions FW was responsible for conceptualization, investigation, data curation, formal analysis, methodology, and resources, and was a major contributor in writing the original draft and in review and editing. YB contributed to supervision, project administration, methodology, and manuscript review and editing. QC contributed to software, methodology, data curation, supervision, and manuscript review and editing. WW contributed to supervision, methodology, resources, and manuscript review and editing. 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Gkiatas I, Xiang W, Karasavvidis T, Windsor EN, Malahias MA, Tarity TD, et al. Relatively low rate of heterotopic ossification following primary total knee arthroplasty: A systematic review and meta-analysis. J Am Acad Orthop Surg Glob Res Rev. 2021;5:e21.00096. doi:10.5435/JAAOSGlobal-D-21-00096. Herman ZJ, Edelman DG, Ilyas AM. Heterotopic ossification after elbow fractures. Orthopedics. 2021;44:10-6. doi:10.3928/01477447-20201119-03. Gkiatas I, Xiang W, Nocon AA, Youssef MP, Tarity TD, Sculco PK. Heterotopic ossification negatively influences range of motion after revision total knee arthroplasty. J Arthroplasty. 2021;36:2907-12. doi:10.1016/j.arth.2021.03.023. Uppal S, Diggle CP, Carr IM, Fishwick CWG, Ahmed M, Ibrahim GH, et al. Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy. Nat Genet. 2008;40:789-93. doi:10.1038/ng.153. Lv X, Gao F, Cao X. Skeletal interoception in bone homeostasis and pain. 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Supplementary Files GeneralInformationQuestionnaire.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 08 Feb, 2026 Reviews received at journal 06 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers invited by journal 04 Nov, 2025 Editor assigned by journal 30 Sep, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7412540","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":541295094,"identity":"0532e3de-e9a6-4f54-a03f-1fb1110073f7","order_by":0,"name":"Fei Wang","email":"","orcid":"","institution":"Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Wang","suffix":""},{"id":541295095,"identity":"2c572f96-8043-4166-95da-d027ed94afa2","order_by":1,"name":"Qiuhua Cheng","email":"","orcid":"","institution":"Shanghai Sixth 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09:22:46","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111136,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7412540/v1/a4e24d2031afb2a57fb497cd.html"},{"id":95905524,"identity":"530e9f2b-c10a-40f5-bbb6-881edacc2e63","added_by":"auto","created_at":"2025-11-14 09:22:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63027,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of participant recruitment\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7412540/v1/ab99e821f7804ec6f8d31552.png"},{"id":96363214,"identity":"49bdefce-3718-4fc0-ae49-256377622a67","added_by":"auto","created_at":"2025-11-20 10:05:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1248041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7412540/v1/2f92c316-e0c3-43ec-9930-3f731c5003e0.pdf"},{"id":96243090,"identity":"3390c725-fd3a-4140-80f1-5b23c16674e7","added_by":"auto","created_at":"2025-11-19 07:15:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":62648,"visible":true,"origin":"","legend":"","description":"","filename":"GeneralInformationQuestionnaire.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7412540/v1/f9c817a6f72f1b071f165ade.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of kinesiophobia and analysis of its influencing factors in patients who underwent traumatic elbow arthrolysis: a cross-sectional survey","fulltext":[{"header":"Background","content":"\u003cp\u003ePosttraumatic elbow stiffness is characterized by a limited range of motion (ROM) in the elbow due to traumatic injury. It can be induced by heterotopic ossification (HO), soft tissue contracture, intra- and extra-articular malunion or non-union, and articular cartilage defects, among others [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. HO is the most common extra-articular culprit factor [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately 3\u0026ndash;20% of patients develop posttraumatic elbow stiffness following elbow trauma, which can seriously affect their daily lives and work [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Surgical arthrolysis is a well-established intervention for elbow stiffness with proven efficacy. However, elbow arthrolysis involves a large surgical area, and both open and arthroscopic arthrolysis can result in pronounced postoperative pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eKinesiophobia is an excessive, irrational fear of activity or movement in patients due to increased pain sensitivity resulting from painful injury or damage [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Patients in the perioperative period of elbow arthrolysis tend to reduce or refuse to perform functional exercises due to fear, affecting their motivation and compliance during the rehabilitation process. However, the efficacy of treatment for elbow stiffness is highly dependent on patient compliance with early postoperative functional exercises. This cross-sectional survey investigated the risk factors for kinesiophobia following elbow arthrolysis and aimed to provide a reference for the development of appropriate management strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy population\u003c/h2\u003e\u003cp\u003ePatients were recruited using a universal sampling approach from the orthopedics department of a Grade III Class A Comprehensive Hospital in Shanghai, China, between January 2019 and June 2021. We included patients who had posttraumatic elbow stiffness, those with an ROM\u0026thinsp;\u0026lt;\u0026thinsp;100, and those aged\u0026thinsp;\u0026gt;\u0026thinsp;8 years. We excluded patients with severe craniocerebral trauma; nerve and vascular injury in the upper limb; Gustilo type III open fracture; elbow arthritis; severe cognitive impairment; serious lesions in the heart, kidneys, lungs, and other essential organs; elbow joint dysfunction and deformity before fracture; and severe endocrine and immune system diseases. The study protocol was approved by the Medical Ethics Committee of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (approval No: 2021\u0026thinsp;\u0026minus;\u0026thinsp;153). The informed consent was obtained prior to the interview. The Declaration of Helsinki was adhered to throughout all phases of this study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData and scales\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eGeneral information\u003c/h2\u003e\u003cp\u003eThe patients' demographic characteristics and disease-related information, including sex, age, educational background, occupation, marital status, family relationship, self-care ability, sides of the dominant and affected limbs, disease duration (duration of the occurrence of elbow stiffness), and initial injury type (simple fracture, dislocated/complex fracture, or dislocation), were obtained using questionnaires (see Supplementary Material 1).\u003c/p\u003e\u003cp\u003eTampa Scale for Kinesiophobia (TSK)\u003c/p\u003e\u003cp\u003eThe TSK is a self-reported scale developed in 1991 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Seventeen items were used to assess the patients' symptoms regarding risk perception, kinesiophobia, movement avoidance, and dysfunction on a four-point Likert scale. The TSK scores range from 1 to 4, indicating \"strongly disagree\" to \"strongly agree.\" The total score ranges from 17 to 68 points. Patients with TSK scores\u0026thinsp;\u0026gt;\u0026thinsp;37 were considered to have kinesiophobia. In 2012, Wen Hu translated the scale into Chinese, with Cronbach's α 0.778 and test\u0026ndash;retest reliability 0.860.\u003c/p\u003e\u003cp\u003eThe Visual Analog Scale (VAS)\u003c/p\u003e\u003cp\u003eThe VAS is a 10-point numeric scale, ranging from 0 to 10, with \"0\" representing no pain and \"10\" representing unbearable, severe pain. Pain severity was indirectly evaluated based on the patient's subjective perception of their current pain level. Pain severity was categorized into four levels based on the scores: no pain (0), mild pain (1\u0026ndash;3), moderate pain (4\u0026ndash;6), and severe pain (7\u0026ndash;10).\u003c/p\u003e\u003cp\u003eGeneral Self-Efficacy Scale (GSES)\u003c/p\u003e\u003cp\u003eThe GSES was developed in 1981 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] with empirical Cronbach's α 0.75 to 0.94. It was translated and revised into a Chinese version by Wang et al. with Cronbach's α 0.87. The scale comprises 10 items and is unidimensional in nature. The patients were assessed using a four-point Likert scale, with a higher score indicating better self-efficacy. Categorization included 10\u0026ndash;30 points suggesting a low level of self-efficacy and 31\u0026ndash;40 points suggesting a high level of self-efficacy.\u003c/p\u003e\u003cp\u003eSelf-Rating Depression Scale (SDS)\u003c/p\u003e\u003cp\u003eThe SDS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] consists of 20 items across four dimensions: psychogenic movement disorder, psychological depression disorder, psychotic affective symptoms, and somatic disorders. Among the 20 items, 10 were reverse-scored on a four-point Likert scale ranging from 1 representing \"none or very little of the time\" to 4 representing \"most of the time or all of the time.\" The total score was the sum of the scores for each question, multiplied by 1.25 to obtain the standard score. A standard score of \u0026ge;\u0026thinsp;53 indicates a tendency toward depression, and the higher the score, the more pronounced the tendency. Cronbach's α for this scale is 0.784.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSelf-Rating Anxiety Scale (SAS)\u003c/h3\u003e\n\u003cp\u003eThe SAS developed in 1971 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], assesses anxiety-related symptoms in adults and is used to monitor changes in conditions during the treatment of anxiety. It comprises 20 items, each scored on a scale of 1 to 4, depending on its frequency of occurrence. The standard score was obtained by adding the score of each item, multiplying the sum by 1.25, and rounding the results to the closest integer. The threshold of the standard score was 50, and the higher the score, the more pronounced the anxiety tendency.\u003c/p\u003e\n\u003ch3\u003eAssessment of elbow joint mobility\u003c/h3\u003e\n\u003cp\u003eElbow joint mobility was assessed using ROM testing. Briefly, the forearm was fixed in a neutral position, and the ROMs of the affected elbow joint were measured using a protractor during flexion, extension, internal rotation, and external rotation.\u003c/p\u003e\u003cp\u003eFunctional evaluation of the elbow joint\u003c/p\u003e\u003cp\u003eThe recovery of elbow function in terms of joint pain, mobility, stability, and activity of daily living ability was determined and analyzed using the Mayo Elbow Performance Index. This is a 100-point scoring system, with scores categorized\u0026thinsp;\u0026ge;\u0026thinsp;90 (excellent), 75\u0026ndash;89 (good), 60\u0026ndash;74 (fair), and \u0026lt;\u0026thinsp;60 (poor).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eAll questionnaires were administered the day following elbow arthrolysis. The investigators explained the study's purpose to the patients and their family members using standardized instructional language. When patients were unable to fill out the questionnaires independently due to factors such as impaired visual acuity, physical condition, or educational level, the researcher explained and completed the questionnaire entries on their behalf. After the patients returned the questionnaires, the investigator checked whether they were fully completed. If any items were missing, the patients were asked to complete them before the questionnaires were rechecked and collected. A total of 180 surveys were distributed to eligible participants. Of these, 160 were completed and returned, resulting in a valid response rate of 88.89%.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eSPSS software (version 22.0) was used for analyses. Count data are described using frequencies and percentages. Intergroup comparisons were conducted using the χ\u003csup\u003e2\u003c/sup\u003e test or Fisher's exact probability method. The effects of sex, age, place of residence, and educational background on kinesiophobia were investigated using univariate analysis. Statistically significant factors identified by the univariate analysis were included in the logistic regression model. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eIncidence of kinesiophobia after elbow arthrolysis\u003c/h2\u003e\u003cp\u003eIn total, 180 questionnaires were distributed; however, eight individuals declined to participate. Additionally, 12 individuals did not meet the inclusion criteria and were, therefore, excluded from the study. A total of 160 patients who underwent elbow arthrolysis were included in this study, with 117 patients experiencing kinesiophobia (incidence of kinesiophobia, 73.12%; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eUnivariate analysis of kinesiophobia after elbow arthrolysis\u003c/h2\u003e\u003cp\u003eThe occurrence of kinesiophobia was used as the dependent variable, and sociodemographic characteristics, self-rated depression, self-rated anxiety, elbow function evaluation, and general self-efficacy were used as independent variables in the univariate analysis. The factors influencing the occurrence of kinesiophobia were extension angle, preoperative elbow ROM, preoperative pain score during activity, preoperative HO, self-efficacy, depression, and anxiety. The details are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnivariate analysis of kinesiophobia in patients that underwent elbow arthrolysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKinesiophobia group (n\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-Kinesiophobia group (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ2/t\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.31\u0026thinsp;\u0026plusmn;\u0026thinsp;10.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.52\u0026thinsp;\u0026plusmn;\u0026thinsp;10.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.135\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.799\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.180\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 (77.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (22.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (68.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.297\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.197\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43 (72.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (74.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (25.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.315\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.191\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorced/widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.469\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (78.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (21.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (81.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (18.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (73.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (57.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (42.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.454\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNonphysical labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (71.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLight physical labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (67.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (32.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeavy physical labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (78.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetired/unemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (61.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (38.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-care ability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAble\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112 (72.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking habit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.904\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.342\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease duration (months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.77\u0026thinsp;\u0026plusmn;\u0026thinsp;39.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.76\u0026thinsp;\u0026plusmn;\u0026thinsp;41.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.555\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.580\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInitial injury type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.814\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSimple fracture/dislocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82 (73.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (26.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplex fracture/dislocation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFlexion (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.58\u0026thinsp;\u0026plusmn;\u0026thinsp;25.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.07\u0026thinsp;\u0026plusmn;\u0026thinsp;31.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.306\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.760\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtension (\u0026deg;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.47\u0026thinsp;\u0026plusmn;\u0026thinsp;19.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.38\u0026thinsp;\u0026plusmn;\u0026thinsp;20.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-3.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative ROM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.64\u0026thinsp;\u0026plusmn;\u0026thinsp;12.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMEPI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.64\u0026thinsp;\u0026plusmn;\u0026thinsp;12.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.335\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.187\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS for pain at rest (points)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.54\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-1.601\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS for pain on movement (points)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-7.320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eROM of forearm rotation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.942\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;100\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;100\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (73.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eViolent exercise\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.724\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93 (74.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (25.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative clinically significant HO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e19.331\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45 (97.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 (64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (36)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.532\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79 (81.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (61.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (38.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.33\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.68\u0026thinsp;\u0026plusmn;\u0026thinsp;7.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-11.915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59.07\u0026thinsp;\u0026plusmn;\u0026thinsp;8.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.78\u0026thinsp;\u0026plusmn;\u0026thinsp;8.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-10.387\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI, body mass index; HO, heterotopic ossification; MEPI, Mayo Elbow Performance Index; ROM, range of motion; VAS, Visual Analog Scale.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eMultivariate analysis of kinesiophobia after elbow arthrolysis\u003c/h2\u003e\u003cp\u003eVariables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in the univariate analysis and those that might influence the occurrence of kinesiophobia, as determined by professional analysis, were used as independent variables with values assigned as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Logistic regression was performed with the occurrence of kinesiophobia as the dependent variable, and the results showed that preoperative HO, anxiety, depression, self-efficacy, and preoperative pain scores during activities were independent factors influencing kinesiophobia (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssignment of independent variables for multivariate analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable labels\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssignment description\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative clinically significant HO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u0026thinsp;=\u0026thinsp;1; No\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow\u0026thinsp;=\u0026thinsp;1; High\u0026thinsp;=\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eHO, heterotopic ossification\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultivariate logistic regression analysis results regarding the factors affecting kinesiophobia in patients who underwent elbow arthrolysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eIndependent variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eΒ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWalds\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOR (95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eExtension (per 1\u0026deg; loss)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.993\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.02 (0.981\u0026ndash;1.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.319\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePreoperative ROM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.624\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.024 (0.995\u0026ndash;1.055)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePreoperative clinically significant HO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e2.643\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.426\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.071 (0.006\u0026ndash;0.835)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e0.175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.928\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.191 (1.055\u0026ndash;1.345)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.277\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.148 (1.045\u0026ndash;1.261)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh lever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e-1.727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.774\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.178 (0.039\u0026ndash;0.812)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow lever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS for pain on movement (points) (per 1-point increase)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e1.389\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.414\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.013 (1.782\u0026ndash;9.034)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eHO, heterotopic ossification; ROM, range of motion; VAS, Visual Analog Scale; OR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the incidence of kinesiophobia was 73.1% among patients who underwent traumatic elbow arthrolysis. Kinesiophobia was significantly associated with several psychological and clinical factors in this population. Specifically, higher levels of anxiety, depression, and movement-related pain (VAS score) were positively correlated with the presence of kinesiophobia, suggesting that psychological distress and pain perception may exacerbate the fear of movement. Conversely, self-efficacy was negatively correlated with kinesiophobia, indicating that patients with higher levels of self-efficacy are less likely to experience psychological fear related to movement. Furthermore, the presence of clinically significant HO prior to surgery was identified as a protective factor against kinesiophobia. Collectively, these results suggest that anxiety, depression, pain intensity, and self-efficacy are key predictors of kinesiophobia in patients undergoing elbow arthrolysis, underscoring the importance of integrating psychological support and effective pain management strategies into postoperative rehabilitation programs.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eHigh incidence of kinesiophobia in patients who underwent elbow arthrolysis\u003c/h2\u003e\u003cp\u003eKinesiophobia was first described by Kori in 1990 and was initially observed in patients with chronic pain. It has since been widely used to evaluate the fear of movement in postoperative patients. The factors influencing kinesiophobia in patients who have undergone elbow arthrolysis have not been reported nationally or internationally. Here, the TSK score of the patients was 42.09. The incidence of kinesiophobia was 73.12%, higher than those reported in 862 patients who underwent total knee arthroplasty (TKA, 24.4%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and in 78 patients who underwent TKA (21.8%) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The prevalence of kinesiophobia in patients with persistent pain is between 50% and 70% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The incidence was also higher than those observed in patients with chronic musculoskeletal pain (56%) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], cervical degenerative disc disease (81.5%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], lumbar disc herniation (45%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and traumatic bone injuries (58.2%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This suggests that kinesiophobia is prevalent in patients with chronic diseases and those who have undergone surgical procedures.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePatients with elbow stiffness and HO had a higher risk of postoperative kinesiophobia\u003c/h2\u003e\u003cp\u003eThe hip joint has the highest incidence of HO in joint trauma and surgery, followed by the elbow and knee joints. The incidence of HO after initial total knee replacement is 5% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], whereas the incidence of HO after elbow trauma is as high as 28.7% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The incidence of HO before surgery has been reported at 20% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and the presence of HO is a main factor affecting limb function either before or after surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The incidence of preoperative HO among our patients was 28.8%, likely because the effect of HO on elbow function is more pronounced than on the hip, knee, and other commonly affected large joints.\u003c/p\u003e\u003cp\u003eAdditionally, HO is frequently present in patients requiring surgical release. We could find no report on the influence of HO on the incidence of kinesiophobia in patients with elbow joint injury and dysfunction. This may be related to the fact that relevant orthopedic research has mainly focused on the knee joint, and the incidence of HO of the knee joint was significantly lower than that of the elbow joint. Additionally, the assessment of HO requires professional imaging, which can be easily ignored.\u003c/p\u003e\u003cp\u003eProstaglandin E2 (PGE2) is an important molecule mediating pain and an osteogenic factor [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The osteogenesis level in patients with HO is significantly higher than that in the general population. The osteogenic PGE2 sensory nerve EP4 axis is involved in the intraosseous perception system, which is related to the hypothalamic neuroendocrine system [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, the specific reason preoperative HO is a risk factor for postoperative kinesiophobia requires further investigation. Relevant research results will hopefully provide key guidance for the prevention and treatment of orthopedic postoperative kinesiophobia.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatients with elbow stiffness complicated by anxiety and depression had a higher risk of developing postoperative kinesiophobia\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe SAS score was significantly and positively correlated with the risk of developing postoperative kinesiophobia (B\u0026thinsp;=\u0026thinsp;0.175\u0026thinsp;\u0026gt;\u0026thinsp;0, p\u0026thinsp;=\u0026thinsp;0.005\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This suggests that a higher SAS score indicates a more substantial likelihood of developing postoperative kinesiophobia. When the SAS score was 1 point higher, postoperative kinesiophobia was 1.191 times more likely to develop. The SDS score was also significantly and positively correlated with the risk of developing postoperative kinesiophobia (B\u0026thinsp;=\u0026thinsp;0.138\u0026thinsp;\u0026gt;\u0026thinsp;0, P\u0026thinsp;=\u0026thinsp;0.004\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A higher SDS score indicated a more substantial likelihood of developing postoperative kinesiophobia. Moreover, a one-point increase in the SDS score increased the possibility of developing postoperative kinesiophobia by 1.148 times. These results align with previous findings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Anxiety and depression were directly linked to kinesiophobia, likely because patients in different emotional states respond differently to pain.\u003c/p\u003e\u003cp\u003eGenerally, patients who have undergone elbow arthrolysis respond in two ways when provoked by pain. Patients with positive emotions tend to cope more effectively and regard pain as a normal physiological response. Then, the patients try to overcome the discomfort caused by pain and continue performing functional exercises. However, those with negative emotions will exaggerate their pain perception and regard functional exercises as a potential threat to aggravate pain when pain develops during exercise. Moreover, they focus more on pain stimuli, resulting in increased pain sensitivity, leading to resistance or even avoidance of functional exercises and eventually to kinesiophobia. This suggests that clinical workers should focus on the influence of depression when evaluating patients with kinesiophobia, provide prompt emotional support to patients, and offer appropriate psychological guidance and relaxation training, such as music therapy, positive meditation, muscle relaxation training, art videos, and positive dialog, to ameliorate patients' negative emotions and encourage them to start postoperative functional exercises as early as possible.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatients with elbow stiffness and low self-efficacy were at a higher risk of developing postoperative kinesiophobia\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSelf-efficacy was a protective factor against kinesiophobia, consistent with previous findings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We found that patients with elbow stiffness had more confidence in overcoming fears of pain and actively performing postoperative rehabilitation exercises when they had higher levels of self-efficacy. Some studies have reported that self-efficacy is a mediator of pain-related fear and prognosis in patients with pain [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Moreover, enhancing self-efficacy reduces pain-related fear, pain severity, and disability. Therefore, management strategies based on Bandura's self-efficacy theory can be established by healthcare professionals to improve patients' self-efficacy levels, bolster their confidence in overcoming the disease, and thereby reduce the incidence of kinesiophobia.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatients with elbow stiffness who had preoperative pain during activities had a higher risk of developing postoperative kinesiophobia\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe VAS score during preoperative activity was a risk factor for postoperative kinesiophobia. Traumatic elbow stiffness is associated with anxiety and depression [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], with more than half the affected patients experiencing these conditions. Pain during elbow movement is an independent risk factor for both anxiety and depression [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, HO is an independent risk factor for anxiety in patients with posttraumatic elbow stiffness [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. From the characteristics of the history of patients with elbow stiffness, most experience a painful rehabilitation process and fear pain during activities. This type of pain injury and increased sensitivity (closely related to anxiety and depression) are core mechanisms causing excessive fear in the rehabilitation of patients with elbow stiffness after surgery. This is critical because scientific pain education, preoperative rehabilitation education, and other methods for such patients have a positive effect on improving patients' anxiety and reducing the occurrence of postoperative kinesiophobia, thus helping improve surgical efficacy and overall prognosis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study had some limitations. First, it was a single-center study; therefore, multicenter data are needed to validate the extrapolation of the current results further. Second, the mechanisms of action of the factors influencing kinesiophobia need to be further elucidated to provide a theoretical foundation for developing precise interventions for kinesiophobia.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrated that kinesiophobia was significantly associated with anxiety, depression, movement-related pain intensity, self-efficacy, and the presence of preoperative HO, identifying these variables as key predictors. Patients with higher levels of anxiety, depression, and pain reported greater levels of kinesiophobia, while higher self-efficacy was associated with a reduced risk. Interestingly, the presence of clinically significant heterotopic ossification prior to surgery was correlated with a lower likelihood of kinesiophobia, suggesting a potential protective role; however, this association may reflect more complex adaptive mechanisms and should not be interpreted as a definitive absence of fear of movement in such patients.\u003c/p\u003e\u003cp\u003eThese findings highlight the multifactorial nature of kinesiophobia following traumatic elbow arthrolysis, involving both psychological and physical components. The implications for clinical management are substantial. Early screening for psychological distress and pain sensitivity, along with interventions aimed at enhancing self-efficacy and addressing pain proactively, may help reduce the development of kinesiophobia. Integrating these strategies into postoperative rehabilitation programs could promote functional recovery, improve patient engagement, and optimize long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eodds ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003erange of motion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eheterotopic ossification\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTSK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTampa Scale for Kinesiophobia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNumeric Rating Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGSES\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Self-Efficacy Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSelf-Rating Depression Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSelf-Rating Anxiety Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTKA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etotal knee arthroplasty\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePGE2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eprostaglandin E2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Medical Ethics Committee of\u0026nbsp;Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (approval No: 2021-153). The informed consent was obtained prior to the interview. The Declaration of Helsinki was adhered to throughout all phases of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants have written informed consented to the submission of this study to the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFW was responsible for conceptualization, investigation, data curation, formal analysis, methodology, and resources, and was a major contributor in writing the original draft and in review and editing. YB contributed to supervision, project administration, methodology, and manuscript review and editing. QC contributed to software, methodology, data curation, supervision, and manuscript review and editing. WW contributed to supervision, methodology, resources, and manuscript review and editing. YS contributed to investigation, data curation, resources, and manuscript review and editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to all participants for dedicating precious time to this study. We also thank the hospital managers and nursing administrators for their strong support and help to this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMellema JJ, Lindenhovius ALC, Jupiter JB. The posttraumatic stiff elbow: an update. Curr Rev Musculoskelet Med. 2016;9:190-8. doi: 10.1007/s12178-016-9336-9.\u003c/li\u003e\n\u003cli\u003eSun Z, Liu W, Li J, Fan C. Open elbow arthrolysis for posttraumatic elbow stiffness: an update. Bone Jt Open. 2020;1:576-84. doi: 10.1302/2633-1462.19.BJO-2020-0098.R1.\u003c/li\u003e\n\u003cli\u003eYu SY, Chen S, Yan HD, Fan CY. Effect of cryotherapy after elbow arthrolysis: A prospective, single-blinded, randomized controlled study. Arch Phys Med Rehabil. 2015;96:1-6. doi: 10.1016/j.apmr.2014.08.011.\u003c/li\u003e\n\u003cli\u003eZhou Y, Cai JY, Chen S, Liu S, Wang W, Fan CY. Application of distal radius\u0026ndash;positioned hinged external fixator in complete open release for severe elbow stiffness. J Shoulder Elbow Surg. 2017;26:e44-51. doi: 10.1016/j.jse.2016.09.019.\u003c/li\u003e\n\u003cli\u003eM\u0026uuml;ller AM, Sadoghi P, Lucas R, Audige L, Delaney R, Klein M, et al. Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies. J Shoulder Elbow Surg. 2013;22:1146-52. doi: 10.1016/j.jse.2013.04.003.\u003c/li\u003e\n\u003cli\u003ePederzini LA, Milandri L, Tosi M, Prandini M, Nicoletta F. Preliminary clinical experience with hyaluronan anti-adhesion gel in arthroscopic arthrolysis for posttraumatic elbow stiffness. J Orthop Traumatol. 2013;14:109-14. doi: 10.1007/s10195-013-0229-z.\u003c/li\u003e\n\u003cli\u003eKori S. Kinesiophobia: a new view of chronic pain behavior. Pain Manag. 1990;3:35-43.\u003c/li\u003e\n\u003cli\u003eMiller RP, Kori SH, Todd DD. The Tampa Scale: a measure of Kinisophobia. Clin J Pain. 1991;7:51. doi: 10.1097/00002508-199103000-00053.\u003c/li\u003e\n\u003cli\u003eLuszczynska A, Scholz U, Schwarzer R. The general self-efficacy scale: multicultural validation studies. J Psychol. 2005;139:439-57. doi: 10.3200/JRLP.139.5.439-457.\u003c/li\u003e\n\u003cli\u003eZung WW. A Self-Rating Depression Scale. Arch Gen Psychiatry. 1965;12:63-70. doi: 10.1001/archpsyc.1965.01720310065008.\u003c/li\u003e\n\u003cli\u003eZung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12:371-9. doi: 10.1016/S0033-3182(71)71479-0.\u003c/li\u003e\n\u003cli\u003eCai L, Liu Y, Xu H, Xu Q, Wang Y, Lyu P. Incidence and risk factors of kinesiophobia after total knee arthroplasty in Zhengzhou, China: A cross-sectional study. J Arthroplasty. 2018;33:2858-62. doi: 10.1016/j.arth.2018.04.028.\u003c/li\u003e\n\u003cli\u003eKocic M, Stankovic A, Lazovic M, Dimitrijevic L, Stankovic I, Spalevic M, et al. Influence of fear of movement on total knee arthroplasty outcome. Ann Ital Chir. 2015;86:148-55.\u003c/li\u003e\n\u003cli\u003eLuque-Suarez A, Martinez-Calderon J, Falla D. Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. Br J Sports Med. 2019;53:554-9. doi: 10.1136/bjsports-2017-098673.\u003c/li\u003e\n\u003cli\u003eBr\u0026auml;nstr\u0026ouml;m H, Fahlstr\u0026ouml;m M. Kinesiophobia in patients with chronic musculoskeletal pain: differences between men and women. J Rehabil Med. 2008;40:375-80. doi: 10.2340/16501977-0186.\u003c/li\u003e\n\u003cli\u003eMisterska E, Jankowski R, Głowacki J, Shadi M, Walczak M, Głowacki M. Kinesiophobia in preoperative patients with cervical discopathy and coexisting degenerative changes in relation to pain-related variables, psychological state and sports activity. Med Sci Monit. 2015;21:181-94. doi: 10.12659/MSM.891045.\u003c/li\u003e\n\u003cli\u003eSvensson GL, Lundberg M, Ostgaard HC, Wendt GK. High degree of kinesiophobia after lumbar disc herniation surgery A cross-sectional study of 84 patients. Acta Orthop. 2011;82:732-6. doi: 10.3109/17453674.2011.636674.\u003c/li\u003e\n\u003cli\u003eMorgounovski J, Vuistiner P, L\u0026eacute;ger B, Luthi F. The fear\u0026ndash;avoidance model to predict return to work after an orthopedic trauma. Ann Phys Rehabil Med. 2016;59:e110-1. doi:10.1016/j.rehab.2016.07.246.\u003c/li\u003e\n\u003cli\u003eGkiatas I, Xiang W, Karasavvidis T, Windsor EN, Malahias MA, Tarity TD, et al. Relatively low rate of heterotopic ossification following primary total knee arthroplasty: A systematic review and meta-analysis. J Am Acad Orthop Surg Glob Res Rev. 2021;5:e21.00096. doi:10.5435/JAAOSGlobal-D-21-00096.\u003c/li\u003e\n\u003cli\u003eHerman ZJ, Edelman DG, Ilyas AM. Heterotopic ossification after elbow fractures. Orthopedics. 2021;44:10-6. doi:10.3928/01477447-20201119-03.\u003c/li\u003e\n\u003cli\u003eGkiatas I, Xiang W, Nocon AA, Youssef MP, Tarity TD, Sculco PK. Heterotopic ossification negatively influences range of motion after revision total knee arthroplasty. J Arthroplasty. 2021;36:2907-12. doi:10.1016/j.arth.2021.03.023.\u003c/li\u003e\n\u003cli\u003eUppal S, Diggle CP, Carr IM, Fishwick CWG, Ahmed M, Ibrahim GH, et al. Mutations in 15-hydroxyprostaglandin dehydrogenase cause primary hypertrophic osteoarthropathy. Nat Genet. 2008;40:789-93. doi:10.1038/ng.153.\u003c/li\u003e\n\u003cli\u003eLv X, Gao F, Cao X. Skeletal interoception in bone homeostasis and pain. Cell Metab. 2022;34:1914-31. doi:10.1016/j.cmet.2022.09.025.\u003c/li\u003e\n\u003cli\u003eChen H, Hu B, Lv X, Zhu S, Zhen G, Wan M, et al. Prostaglandin E2 mediates sensory nerve regulation of bone homeostasis. Nat Commun. 2019;10:181. doi:10.1038/s41467-018-08097-7.\u003c/li\u003e\n\u003cli\u003eWoby SR, Urmston M, Watson PJ. Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients. Eur J Pain. 2007;11:711-8. doi:10.1016/j.ejpain.2006.10.009.\u003c/li\u003e\n\u003cli\u003eSun W, Jiang X, Gong M. Concomitant anxiety in posttraumatic elbow stiffness and risk factors for stiffness. Chin J Orthop Trauma. 2018:1020-5.\u003c/li\u003e\n\u003cli\u003eLiu W, Sun Z, Xiong H, Liu J, Lu J, Cai B, et al. What are the prevalence of and factors independently associated with depression and anxiety among patients with posttraumatic elbow stiffness? A cross-sectional, multicenter study. J Shoulder Elbow Surg. 2022;31:469-80. doi:10.1016/j.jse.2021.11.014.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Elbow Joint, Traumatic, Stiffness, Arthrolysis, Kinesiophobia, Influencing Factors","lastPublishedDoi":"10.21203/rs.3.rs-7412540/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7412540/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eKinesiophobia has not explicitly been reported in patients following elbow arthrolysis. This study aimed to investigate the incidence of kinesiophobia in patients who underwent elbow arthrolysis and analyze its influencing factors to provide a theoretical basis for developing intervention programs for kinesiophobia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was conducted involving 160 patients who underwent elbow arthrolysis at a general hospital in Shanghai, China. Data were collected using a sociodemographic-clinical questionnaire, the Tampa Scale for Kinesiophobia-11, the Numeric Rating Scale, the General Self-Efficacy Scale, the Self-Rating Depression Scale, the Self-Rating Anxiety Scale, an assessment of elbow joint mobility, and the Mayo Elbow Performance Index. SPSS 22.0 was utilized for univariate and logistic regression analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong the 160 patients, kinesiophobia incidence was approximately 73.12%. Logistic regression analysis revealed that preoperative heterotopic ossification (odds ratio (OR)\u0026thinsp;=\u0026thinsp;0.071, 95% confidence interval (CI): 0.006 to 0.835), anxiety (OR\u0026thinsp;=\u0026thinsp;1.191, 95%CI: 1.055 to 1.345), depression (OR\u0026thinsp;=\u0026thinsp;1.184, 95%CI: 1.045 to 1.261), self-efficacy (OR\u0026thinsp;=\u0026thinsp;0.178, 95%CI: 0.039 to 0.812), and preoperative pain scores during activity (OR\u0026thinsp;=\u0026thinsp;4.013, 95%CI: 1.782 to 9.034) were factors influencing kinesiophobia in patients who underwent elbow arthrolysis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFear of movement in patients who have undergone elbow arthrolysis warrants greater attention. Moreover, particular emphasis should be placed on the evaluation of factors influencing kinesiophobia, such as anxiety, self-efficacy, and preoperative pain scores during activity. Post-elbow arthrolysis kinesiophobia should be managed to reduce its incidence and promote the rapid recovery of elbow function.\u003c/p\u003e","manuscriptTitle":"Assessment of kinesiophobia and analysis of its influencing factors in patients who underwent traumatic elbow arthrolysis: a cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-14 09:22:41","doi":"10.21203/rs.3.rs-7412540/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-27T08:54:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T23:04:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147020855423323870610538132504271258893","date":"2026-02-08T22:01:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-07T03:25:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21394198338061974133724994951205278413","date":"2025-11-06T22:20:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-04T19:04:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-30T13:51:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-29T13:59:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-09-29T13:56:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9cf7e00-04e4-4322-b308-6d2ff9ef0567","owner":[],"postedDate":"November 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T09:08:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-14 09:22:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7412540","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7412540","identity":"rs-7412540","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}