The Modified Tampa-Scale of Kinesiophobia for Anterior Shoulder Instability

Abstract

Purpose

To assess content validity and to modify the Tampa Scale of Kinesiophobia (TSK) to make it suitable for application in patients with anterior shoulder instability.

Methods

A four-round Delphi method was performed to establish expert consensus on developing the Tampa Scale of Kinesiophobia for patients with anterior shoulder instability (TSK-SI) using an expert group of Dutch shoulder-specialized orthopedic surgeons and physiotherapists. During round 1, experts were asked to score the 17 items of the original TSK on relevance and construction using the COSMIN guidelines. With this feedback, questions were reviewed and modified. During round 2, experts were asked to score the modified items. This process was repeated until consensus was established. Then, patients were asked to participate in a moderator-guided, three-step-test interview using a Web-based platform to assess the modified scale. Sessions were recorded and evaluated by the working group. The modified scale was finally adjusted on the basis of the input of these patients.

Results

Thirty Dutch shoulder experts were included, of which 25 completed all 4 rounds, after which consensus was established. One question was added to the modified scale based on feedback in round 1, establishing the 18-item TSK-SI. Sixteen patients with shoulder instability were included, which all completed the three-step test interview. Following this, question 4 (changed to present tense) and question 7 (hypothetical component added) were adjusted, resulting in the final TSK-SI.

Conclusions

This consensus modification of the TSK to TSK-SI can support the content validity of the instrument to assess kinesiophobia in patients with anterior shoulder instability. These modifications may improve the responsiveness and validity of the TSK-SI, as it does not match all the items of the original TSK.

Level of evidence

Level V, consensus statement.

Introduction

Shoulder instability is frequently seen in active young patients and can be a disabling condition.1, 2, 3 It can be treated both nonsurgically and surgically. Nonsurgical treatment includes temporary immobilization of the shoulder combined with pain management and physiotherapy. In contrast, surgical treatment often consists of either capsulolabral repair or a bony reconstruction procedure.^4,5 Compared to surgical treatment, nonsurgical treatment more often results in recurrent or persistent shoulder instability and lower rates of patients returning to sport.6, 7, 8

Recent literature shows that fear of (recurrent) dislocation is a well-known phenomenon among patients, following both nonsurgical and surgical treatment of shoulder instability, which can lead to fear of shoulder movement. This fear sometimes persists after both nonsurgical and surgical treatment and can also be present in patients without signs of recurrent subluxations.⁹ Larsson et al. defined kinesiophobia as “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability due to painful injury or reinjury”.¹⁰ This fear can be expressed during physical examination as discomfort during passive external rotation and abduction of the shoulder. Moreover, it can lead to maladaptive movement patterns that can maintain or aggravate the instability of the shoulder.¹¹ It might also lead to impaired physical function or diminished quality of life, as already shown in other musculoskeletal disorders.12, 13, 14, 15, 16, 17, 18 Return to sport (RTS) is often a critical outcome and expectation following surgical management of shoulder instability.⁹ A recent study reported that 74% failed to RTS following surgical treatment of shoulder instability.¹⁹ The majority reported that failure to return was related to fear of reinjury or a lack of confidence in their affected shoulder. These results were confirmed by the meta-analyses by Kim et al. and van Iersel et al., with most patients discontinuing sport due to reasons, such as fear of reinjury or diminished confidence.^8,20 This might implicate that there is an association between failure to RTS and kinesiophobia.

Kinesiophobia can be assessed using a psychosocial model, based on the theory that physical health is associated with both psychological and environmental factors of a patient.^21,22 To assess both of these factors, the 17-item Tampa Scale of Kinesiophobia (TSK) was created in 1991.²³ Although developed for patients with low back pain, the questionnaire has recently been used in multiple studies investigating anterior shoulder instability.^12,24,25 These studies mentioned in their discussion that the TSK is not validated in patients with shoulder instability and that it might not be a responsive measure for this specific population. Compared to low back pain, pain is not the only component of shoulder instability. Besides pain, there could also be loss of function and instability of the shoulder. In addition, the fear in relation to shoulder instability is caused by multiple factors like trauma-related memories, cerebral changes, and glenohumeral lesions. Because pain is hypothesized not to be the most prominent cause of kinesiophobia in patients with shoulder instability, the TSK might be unsuitable for this population. The purposes of this study were to assess content validity and to modify the TSK and make it suitable for application in patients with anterior shoulder instability. We hypothesized that shoulder experts do not find the current TSK is suitable for application in patients with shoulder instability and, therefore, recommend modifications into a new version.

Methods

Study Design

A multidisciplinary group of 4 healthcare professionals (T.P.I., A.V., I.S. and B.F.P.B.), consisting of two physicians, a psychiatrist, and an epidemiologist was responsible for facilitating the development of the Tampa Scale of Kinesiophobia for patients with anterior shoulder instability (TSK-SI) using a 4-round modified Delphi technique with shoulder specialized healthcare professionals and patient interviews.26, 27, 28 The study was performed in 2 phases: 1) expert consensus using a modified Delphi method and 2) patient interviews using a 3-step test model. Ethical approval was provided by the local medical ethics committee of OLVG Amsterdam (WO21.012). All healthcare professionals and patients provided written informed consent for the Delphi process appointments and interviews in this study, which were hosted between November 2021 and April 2022.

Phase 1: Expert Consensus Using a Delphi Method

A modified Delphi method was used to establish expert consensus on the assessment of content validity and development of the TSK-SI. Instead of using focus groups, this modified version of the Delphi method used online questionnaires. Healthcare professionals were defined as “shoulder experts” when they were either orthopedic surgeons or physiotherapists, who specialized in the care of patients with anterior shoulder instability. Shoulder experts across the Netherlands were eligible to participate if they fluently mastered the Dutch language. The shoulder experts participated in 4 survey rounds. During round 1, the experts were asked to score the 17 items of the original TSK developed for patients with low back pain. Scoring was based on 3 items: 1) relevance of the questions, 2) construction of the questions, and 3) language used in the questions, using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guideline.^23,29 These questions were as follows:

• 1.Do you think question X is relevant for the TAMPA scale taking into account that it will be used in patients with shoulder instability, or do you think it should be changed? And if so, how could the question be changed to make it more relevant for this population?
• 2.Do you think question X is constructed well for the TAMPA scale, taking into account that it will be used in patients with shoulder instability or do you think it should be changed? And if so, how could the question be better constructed?
• 3.Do you think the appropriate language is used in question X taking into account that the TAMPA scale will be used in patients with shoulder instability or do you think other language should be used? And if so, what language would be more appropriate?

The group of experts reviewed the questionnaire after the first round of feedback. Questions were retained if >75% of experts (at least 21 out of 30) agreed on a question. In the first round, experts were also asked if they wanted to add new questions to the questionnaire. If not, questions were modified and proposed in round 2. During this second round, the experts were asked to score the modified items of round 1 based on relevance and construction again.²⁹ This modification process was repeated until expert consensus was established. This was defined as >75% agreement on the entire questionnaire, based on recent methodologic studies and the COSMIN guidelines.29, 30, 31 If 90-99% agreement was reached, the consensus was defined as a strong consensus (SC). If 100% agreement was reached, the consensus was defined as unanimous (UN).

Phase 2: Patient Interviews Using a 3-Step-Test Model

After the expert consensus was reached, patients who underwent surgical or nonsurgical treatment of anterior shoulder instability were invited to participate in phase 2 of this study (Fig 1). Patients were eligible to participate if they were admitted to the emergency department or outpatient clinic between 2020 and 2022 with either a first-time or recurrent anterior dislocation of the shoulder. In addition, patients had to master the Dutch language fluently, which was verified by one of the researchers during the interview. A purposeful sampling strategy was used to obtain variation in sex, age, treatment type, and outcomes.³²

Fig 1.

Two-phased modification Tampa Scale of Kinesiophobia (TSK).

During the study’s second phase, online one-on-one interviews were held to assess patient responses to the developed scale using a moderator guided 3-strep-test model.³³ These one-on-one interviews were hosted using a Web-based interactive platform (Zoom 5.11.0, San Jose, CA). During these interviews, patients were asked to think out loud while filling in the 18-item TSK-SI, as produced during the expert consensus rounds. The moderator (T.P.I.) guided the online sessions and observed nonverbal communication. If needed, the moderator asked questions like: ‘’Why do you hesitate when filling in this question?’’, ‘’In what way do you believe this question has to be modified for it to be more understandable?’’ and ‘’Do you think this question is suitable for patients with anterior shoulder instability?’’. These sessions were recorded with the informed consent of the participants. One of the physicians (A.V.) also viewed and analyzed the recordings. After analysis, they were shared with the working group. When thought necessary by the working group, the TSK-SI was adjusted as a result of the feedback of patients.

Results

Expert Consensus

Experts participated in 4 rounds of surveys between November 2021 and April 2022. The expert group consisted of 30 experts, of which 13 orthopedic surgeons, 16 physiotherapists, and 1 physician assistant with a mean clinical experience of 13.9 ± 7.2 years in treating patients with anterior shoulder instability and a mean of 6.6 ± 13.6 published peer-reviewed articles. A total of 25 experts (83%) completed 4 rounds of surveys (Fig 2).

Fig 2.

Participation expert consensus Delphi rounds.

Consensus Rounds

In round 1, 30 experts evaluated the original TSK, as used in patients with chronic low back pain. On the basis of feedback derived from round 1, 2-5 new modification options were created for each item by the working group. After thorough discussion, 1 new option was proposed for every question during round 1, in which 29 experts remained. One expert was lost to follow-up after round 1 due to personal reasons. After round 2, consensus was reached at 12 out of 17 items. These were all modified compared to the original questions based on the expert feedback. Experts were also given the option to maintain the original question. However, the majority of the experts chose not to do so. Question 18 was a newly added question regarding the fear to return to daily activities, based on the expert feedback. In round 3, 27 experts remained as 2 experts were lost to follow-up due to lack of time. Consensus was reached consensus regarding questions 6, 9, 11, and 15. During the last round, round 4, the 25 remaining experts reached expert consensus regarding the remaining question (question 2). Two experts were lost to follow-up before the last round of surveys, again due to lack of time. Details about expert agreement, consensus, and modifications of items are shown in Table 1, together with the final questions. Also, the table shows in which round consensus was reached. Experts agreed (83%; consensus) in round one that the 4-point scale, as used in the original TSK should be maintained. The scale ranges from 18 to 72, with 18 being the “best” score (no fear of movement/kinesiophobia) and 72 being the “worst” score (severe fear of movement/kinesiophobia). Every question has a 1-to-4 scale, ranging from totally agree to totally disagree (Supplements 1 and 2).

Table 1.

Final Version TSK-SI, Expert Consensus Agreement and Changes Based on Patient Interviews

Final question proposed during the roundsa Changes made after patient interviews	Expert Agreement Relevance | Construction	Expert Consensusb, c, d Relevance | Construction
Q1: When I exercise, I am concerned that I will damage my shoulder.	100% | 97%	UN | SC (round 2)
Q2: If I ignore my complaints related to my shoulder, the complaints will worsen.	88% | 84%	C | C (round 4)
Q3: My body tells me that the situation related to my shoulder is serious.	100% | 100%	UN | UN (round 2)
Q4: When I exercise, the complaint related to my shoulder will likely decrease. Change of “If I would exercise” to “When I exercise” because patients often already exercise	100% | 97%	UN | SC (round 2)
Q5: Others negate the seriousness of my complaint related to my shoulder.	93% | 97%	SC | SC (round 2)
Q6: Because of my shoulder-related complaint, my body is in danger for the remainder of my life.	93% | 78%	SC | C (round 3)
Q7: Pain is a sign of damage. Change of “My pain means..” to “Pain is a sign of..” because not all patients experience pain with their shoulder	97% | 83%	SC | C (round 2)
Q8: If my complaint related to my shoulder worsens, it doesn‘t mean that it is a dangerous development.	97% | 93%	SC | SC (round 2)
Q9: I am scared to accidently cause damage.	100% | 85%	UN | C (round 3)
Q10: A safe way to avoid increasing damage to my shoulder is to simply avoid unnecessary movements with my arm.	100% | 83%	UN | C (round 2)
Q11: If I didn’t have serious issues related to my shoulder, it would be likely that my complaint would decrease.	100% | 93%	UN | SC (round 3)
Q12: Although I have complaints related to my shoulder, my overall state would improve if I were more active.	100% | 79 %	UN | C (round 2)
Q13: My complaints related to my shoulder inform me that I need to cease my exercises to avoid further damage.	97% | 86%	SC | C (round 2)
Q14: For a person with my type of shoulder complaint, exercise is not a good idea.	100% | 86%	UN | C (round 2)
Q15: I am not able to perform as well as others, as I am at an increased risk of developing damage to my shoulder.	100% | 93%	UN | SC (round 3)
Q16: Even when my complaints related to my shoulder increase, I don’t consider this to be dangerous.	93% | 93%	SC | SC (round 2)
Q17: I shouldn’t be required to exercise when I am experiencing shoulder-related complaints.	97% | 86%	SC | C (round 2)
Q18: I am worried that I will dislocate my shoulder during my activities of daily life.	100% | 79 %	UN | C (round 2)
Scoring questions: 4-point scale (similar to TSK)	83%	C

^aQ, question

^bC, consensus

^cSC, strong consensus

^dUN, unanimous.

Patient Interviews

A total of 16 patients with anterior shoulder instability were included in the online interviews, of which demographics are displayed in Table 2. The average age of the participants was 33.6 years old. Half of the participants were male (50.0%). Of the 16 patients, 10 underwent surgical treatment, 4 underwent nonsurgical treatment, and 2 patients did not receive any type of treatment at the time of the interviews (Table 2). The average time after the initial start of treatment was 4.5 ± 3.6 years. Five (35.7%) out of 14 patients who underwent treatment reported recurrence, while seven (50.0%) patients reported subjective feeling of persistent shoulder instability after treatment. The interviews lasted 30 to 60 minutes, depending on the pace of the participant. On the basis of feedback derived from the patient interviews, question 4 (changed to present tense) and question 7 (hypothetical component added) were modified. Patients were also asked whether they agreed with the answering format using the 4-point scale. All patients agreed with the proposed format and believed it was appropriate. Together with the expert consensus process, this resulted in the adjusted TSK, the TSK-SI, of which the Dutch version is shown in Supplement 1. The final adjusted version of the TSK-SI was checked for inconsistencies by a native Dutch lingual expert. In addition, the provisional English version is shown in Supplement 2. This version was translated using the Dutch version of the TSK-SI by a native English speaker.

Table 2.

Baseline Characteristics Patient Interviews

Patient	Sex (male/female)	Age (years)	Initial Treatment	Time After Initial Treatment (years)	Reoperation (yes/no)	Recurrence	Patient-reported Fear (yes/no)| VASf (1-10)	Patient Reported Feeling of Shoulder Instability
1	M	30	Surgical: ABRb	3	Yes	Yes	Yes | VAS 9	Yes
2	M	31	Surgical: OLPc	3	No	No	No | VAS 1	No
3	F	30	Surgical: ABRb	4	No	No	Yes | VAS 7	No
4	M	33	Surgical: OLPc	2	No	No	No | VAS 4	No
5	F	46	NSd	5	No	No	Yes | VAS 9	Yes
6	M	31	Surgical: ABRb	4	No	No	Yes | VAS 6	No
7	F	32	Surgical: ABRb	6	No	No	Yes | VAS 9	Yes
8	F	25	NS d	7	Yes	Yes	No | VAS 1	No
9	F	48	Surgical: ABRb	8	Yes	Yes	No | VAS 1	Yes
10	M	40	Surgical: ABRb	9	Yes	No	Yes | VAS 9	Yes
11	M	18	Surgical: ABRb	1	No	No	Yes | VAS 5	No
12	F	35	NTYe	0	NAa	No	Yes | VAS 8	Yes
13	M	42	NSd	1	No	Yes	No | VAS 2	Yes
14	M	22	NTYe	0	NAa	No	No | VAS 4	Yes
15	F	39	NSd	5	No	Yes	Yes | VAS 5	Yes
16	F	36	Surgical: ABRb	14	No	No	No | VAS 1	No
Average or distribution	8 Male /8 Female	33.6	2 NTY / 4 NS 8 ABR / 2 OLP	4.5 ± 3.6	2 NA / 4 Yes / 10 No	5 Yes / 11 No	9 Yes / 7 No | VAS 5.1	9 Yes / 7 No

^aNA, Not applicable

^bABR, arthroscopic Bankart repair

^cOLP, open Latarjet procedure

^dNS, nonsurgical

^eNTY, no treatment yet

^fVAS, visual analogue scale.

Discussion

The most important finding of this study was that it reached expert and patient consensus regarding the modification of the current TSK, to make it suitable for application in patients with anterior shoulder instability, using a Delphi-guided method. All 17 items were modified compared to the original TSK, used in patients with low back pain. Moreover, 1 question was added, according to expert feedback. This resulted in the newly formed 18-item TSK-SI. This scale is important in order to provide healthcare professionals with a tool to assess and evaluate the severity of fear of movement, specifically in patients experiencing anterior shoulder instability. This tool may assist healthcare professionals in patient assessment at the outpatient clinic or general practitioner’s office. Identifying patients with kinesiophobia might help provide timely interventions to reduce fear of movement, which may eventually lead to improved patient-reported outcomes, patient’s satisfaction, and health-related quality of life.³⁴

Two recent studies underline the relationship between the physical and psychological aspects of shoulder instability.^35,36 The study by Gottlieb et al. showed that following surgery, fear avoidance beliefs are associated with disability of the shoulder. Although the TSK scale has been used previously in shoulder instability, these studies raise concerns that this scale is not validated for patients with shoulder instability questioning its responsive measure in this population.^12,24,25 The newly formed TSK-SI does not solely focus on pain but also on other components of shoulder instability, potentially increasing the utility of the diagnostic tool in this population.

This study, together with recent studies regarding patient-centered care and psychosocial impart of physical trauma, underline the importance of a more multifactorial approach following surgical treatment, integrating fear-reducing treatment modalities into standard care.^34,35,37,38 Current practice is mainly focused on the physical side of shoulder instability rather than adding the psychosocial impact of physical trauma to this. This study might enable healthcare professionals to quantify the patients’ kinesiophobia and add a new perspective to current clinical practice.

Current treatment strategies of kinesiophobia in patients with shoulder impairment are limited and mainly focus on reducing pain. A recent review by Bordeleau et al. looked at the current treatment strategies for kinesiophobia in patients experiencing chronic pain, which mainly comprised physical exercises.³⁹ Another recent study showed that multimodal therapy might be more effective in reducing kinesiophobia compared to unimodal treatment of only physical therapy or psychosocial intervention.⁴⁰ By using these kinds of therapy, shoulder function, pain, and quality of life might possibly improve.^21,34 Also, patients might have less delay in return to sport when kinesiophobia in patients with shoulder instability is adequately addressed.¹³

This study included patient feedback in the study process, creating an integral view of the relationship between physical trauma and the subsequent psychological impact of this trauma. By not overlooking the primary population facing this type of shoulder impairment, this study adds a new dimension to care. Future research should focus on the reproducibility, responsiveness, and validation of the TSK-SI.

Limitations

This study is not without limitations. First, a modified Delphi method was used for expert consensus, which is a noninteractive way of asking experts what their thoughts are regarding a subject. It does not allow for interactive discussion. Moreover, a Delphi process is opinion based, making it hard to assess the external validity. Lastly, there might be a selection bias in selecting participants for the process, because only shoulder-specialized experts were recruited in this study.^26,27 Furthermore, the consensus experts and patients included in this study were all Dutch, which could potentially limit the generalizability of the study. Last, this study used relatively small patient and expert groups.

Conclusions

This expert and patient consensus modification of the TSK to TSK-SI can support the content validity of the instrument to assess kinesiophobia in patients with anterior shoulder instability. These modifications may improve the responsiveness and validity of the TSK-SI, as it does not match all the items of the original TSK.

Supplement 1. First Dutch version of the TSK-SI 2022

TAMPA Schaal voor Kinesiofobie Anterieure Schouderinstabiliteit (TSK-SI 2022)

Geef van onderstaande beweringen aan in welke mate u het eens of oneens bent met de gegeven stelling. De vragenlijst bestaat in totaal uit 18 vragen. Mocht een vraag niet van toepassing zijn op uw situatie, vult u dan het antwoord in wat daar het dichtstbij ligt.

• 1.
  Ik ben bang dat ik mijn schouder beschadig bij het doen van oefeningen

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 2.
  Als ik de schouderklachten negeer, dan worden deze klachten erger

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 3.
  Mijn lichaam zegt me dat er iets gevaarlijks mis is met mijn schouder

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 4.
  Als ik oefeningen doe, dan worden mijn schouderklachten waarschijnlijk minder

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 5.
  Mijn schouderklachten worden door anderen niet serieus genomen

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 6.
  Door mijn schouderklachten loopt mijn lichaam de rest van mijn leven gevaar

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 7.
  Als ik pijn heb, betekent dat dat er sprake is van schade

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 8.
  Als mijn schouderklachten erger worden door iets, betekent dat nog niet dat het gevaarlijk is

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 9.
  Ik ben bang om per ongeluk schade op te lopen

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 10.
  De veiligste manier om te voorkomen dat mijn schouderklachten erger worden is gewoon oppassen dat ik geen onnodige bewegingen maak met mijn arm

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 11.
  Ik had wellicht minder klachten als er niets gevaarlijks aan de hand zou zijn met mijn schouder

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 12.
  Hoewel ik schouderklachten heb, zou ik er beter aan toe zijn als ik lichamelijk actief was

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 13.
  Mijn schouderklachten zeggen mij wanneer ik moet stoppen met oefeningen doen om geen (verdere) schade op te lopen

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 14.
  Voor iemand met mijn schouderklachten is het echt af te raden lichamelijk actief te zijn

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 15.
  Ik kan niet alles doen wat gewone mensen doen, omdat ik te gemakkelijk schade oploop aan mijn schouder

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 16.
  Zelfs als ik ergens veel schouderklachten door krijg geloof ik niet dat dat gevaarlijk is

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 17.
  Ik zou geen oefeningen moeten doen wanneer ik schouderklachten heb

  • •
    In hoge mate mee eens
  • •
    Enigszins mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens
• 18.
  Ik ben tijdens dagelijkse activiteiten bang dat mijn schouder (opnieuw) volledig of deels uit de kom gaat

  • •
    In hoge mate mee eens
  • •
    Enigszins mate mee eens
  • •
    Enigszins mee oneens
  • •
    In hoge mate mee oneens

Supplement 2. First English version of the TSK-SI 2022

TAMPA Scale Of Kinesiophobia Anterior Schoulder Instability (TSK-SI 2022)

Please answer the following questions and score each statement from strongly disagree to strongly agree by tapping the appropriate box. The questionnaire consists of 18 questions. If you feel a question does not apply to you, please try to fill in the answer that is most applicable to your current situation.

• 1.
  When I exercise, I am concerned that I will damage my shoulder.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 2.
  If I ignore my complaints related to my shoulder, the complaints will worsen.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 3.
  My body tells me that the situation related to my shoulder is serious.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 4.
  When I exercise, the complaint related to my shoulder will likely decrease.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 5.
  Others negate the seriousness of my complaint related to my shoulder.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 6.
  Because of my shoulder-related complaint, my body is in danger for the remainder of my life.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 7.
  Pain is a sign of damage.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 8.
  If my complaint related to my shoulder worsens, it doesn’t mean that it is a dangerous development.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 9.
  I am scared to accidently occur damages.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 10.
  A safe way to avoid increasing damage to my shoulder is to simply avoid unnecessary movements with my arm.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 11.
  If I didn’t have serious issues related to my shoulder, it would be likely that my complaint would decrease.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 12.
  Although I have complaints related to my shoulder, my overall state would improve if I were more active.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 13.
  My complaints related to my shoulder inform me that I need to cease my exercises to avoid further damage.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 14.
  For a person with my type of shoulder complaint, exercise is not a good idea.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 15.
  I am not able to perform as well as others, as I am at an increased risk to develop damage to my shoulder.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 16.
  Even when my complaints related to my shoulder increase, it doesn’t cause me to consider this to be dangerous.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 17.
  I shouldn’t be required to exercise when I am experiencing shoulder-related complaints.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree
• 18.
  I am worried that I will dislocate my shoulder during my activities of daily life.

  • •
    Strongly agree
  • •
    Slightly agree
  • •
    Slightly disagree
  • •
    Strongly disagree