Prevention and management of kinesiophobia after total knee arthroplasty: an evidence-informed narrative review and proposed stepped-care pathway

Abstract

Kinesiophobia is a potentially modifiable biopsychosocial barrier to recovery after total knee arthroplasty (TKA), yet evidence specific to fear of movement is dispersed across rehabilitation, psychological, nursing, and perioperative literature and is often conflated with evidence for general TKA rehabilitation. This evidence-informed narrative review aimed to synthesize current evidence for the assessment, prevention-oriented management, and treatment of kinesiophobia across the TKA pathway while distinguishing fear-specific findings from broader rehabilitation evidence. PubMed/MEDLINE and the Physiotherapy Evidence Database (PEDro) were searched from inception through 15 September 2026; the Cochrane Library, current rehabilitation guidance, backward and forward citation tracking, and bibliographic verification were also used. Evidence was interpreted according to study design, directness to kinesiophobia outcomes, consistency, and reported limitations. Available studies indicate that kinesiophobia is associated with pain, pain catastrophizing, lower self-efficacy, impaired physical performance, and poorer participation after TKA, although causal relationships remain uncertain. Direct TKA studies have reported reductions in kinesiophobia with multicomponent fear-focused functional exercise, selected educational or cognitive-behavioral approaches, and some technology-supported interventions; however, effects on pain and physical function are inconsistent, and many trials are small or single-center. Multimodal analgesia, early supported mobilization, progressive strengthening, and telerehabilitation remain important components of TKA rehabilitation, but their general effectiveness should not be interpreted as evidence of a specific antikinesiophobia effect unless fear outcomes were assessed. Tampa Scale for Kinesiophobia measures can support repeated multidomain assessment, but thresholds and clinically important changes are not interchangeable across versions, languages, populations, or postoperative time points. On this basis, we outline a clinically oriented screening schedule and a stepped-care pathway that prioritize exclusion of medical or surgical barriers, realistic education, supported movement, fear-focused functional practice, self-efficacy enhancement, and selective psychological or digital adjuncts. These frameworks are intended for local adaptation and prospective validation. More rigorous multicenter studies are needed to establish clinically meaningful change in kinesiophobia and to determine which patients benefit from targeted interventions, as well as optimal dose, durability, safety, and cost-effectiveness.