The relationship between kinesiophobia severity and clinical parameters in patients with mechanical low back pain

Abstract

BACKGROUND:

Low back pain is an important widespread health problem that can occur at any age, causing serious socioeconomic losses.

OBJECTIVE:

The objective of this study is to investigate the relationship between kinesiophobia severity and pain severity, depression, and quality of life in patients with mechanical low back pain.

METHODS:

The study sample consisted of 155 patients, of whom 72 were female and 83 were male, aged between 18 and 75 years with mechanical low back pain. Quality of life was assessed with the 36-Item Short Form Health Survey (SF-36), pain intensity with the Visual Analogue Scale (VAS), kinesiophobia with the Tampa Kinesiophobia Scale (TKS), and depression with the Beck Depression Inventory (BDI). Patients were divided into the low (TKS $\leqslant$ 37) and high kinesiophobia (TKS $>$ 37) groups according to the scores they obtained from TKS.

RESULTS:

VAS-pain severity and BDI scores were significantly higher in the high kinesiophobia group than in the low kinesiophobia group ( $p<$ 0.001). On the other hand, the SF-36 subscale scores were significantly higher in the low kinesiophobia group than in the high kinesiophobia group ( $p<$ 0.001). The TKS scores were moderately correlated with VAS-pain severity ( $r=$ 0.470; $p<$ 0.001) and BDI scores ( $r=$ 0.584; $p<$ 0.001) in the positive direction, and strongly correlated with all sub-parameters of quality of life in the negative direction ( $p<$ 0.001).

CONCLUSION:

The results indicated that the severity of kinesiophobia in patients with non-inflammatory low back pain is associated with pain severity, depression, and poor quality of life.

Keywords

Kinesiophobia pain quality of life depression

1. Introduction

Low back pain is an important widespread health problem that can occur at any age, causing serious socioeconomic losses [1]. The lifetime prevalence of low back pain, which is the most common ailment after the common cold, was found to be 59–80% in developed countries and 44–79% in Turkey [2, 3]. Physical factors such as sedentary life, heavy physical load, frequent weight lifting, vibration, and postural stress, as well as low vitamin D levels, can cause low back pain [4]. In vitro, Vitamin D has been shown to stimulate the synthesis of proteoglycans, the most important extracellular matrix component of bone and cartilage. It has been stated that vitamin D deficiency affects the structure and amount of the extracellular matrix of the intervertebral disc by causing structural defects in proteoglycans and contributes to the formation of disc degeneration [5]. Vitamin D also plays an important role in the inflammatory/immune response mechanism of inflammatory diseases. Vitamin D deficiency can exacerbate chronic inflammatory pain through enhanced inflammatory cell infiltration and inflammatory cytokine release [6]. Determining the specific etiology of low back pain can be challenging. Investigating the symptoms and signs pointing to a serious underlying pathology, the ‘red flags’ so to speak, will provide a great convenience for the physician in classifying the low back pain. Most low back pain is of mechanical origin $\geqslant$ 70% of mechanical low back pain is caused by lumbar sprain and strain, 10% by disc or facet joint degeneration, 4% by a herniated disc, 4% by compression fracture, 3% by spinal stenosis, and 2% by spondylolisthesis [7]. Mechanical low back pain (MLBP) usually develops as a result of excessive use, strain, traumatization, or deformation of the structures that make up the spine. In order to classify low back pain as MLBP, inflammatory, infectious, and tumoral causes accompanied by high C-reactive protein (CRP) levels, as well as all organic causes such as metabolic causes, fractures and pain reflected from internal organs should be ruled out [7, 8, 9]. In chronic low back pain, patients also complain of physical inadequacy and psychological distress in addition to pain. Patients with chronic low back pain may have trouble working and become depressed [10]. Mood and cognitive behaviors of patients with low back pain may also adversely affect the rehabilitation process [11]. Kinesiophobia, or fear of movement, is defined as the avoidance of physical activity caused by a feeling of sensitivity to painful injury or repetitive injury. Kinesiophobia has been researched in the context of many disease groups such as chronic low back pain and found to be associated with increased pain, limitation in physical activities, decreased physical activity, and deterioration of psychological state [12].

Considering that kinesiophobia affects rehabilitation strategies, it should be given due attention in the clinical setting in order to prevent the disability of the patient [13]. As a reason, fear of movement due to the possibility of experiencing pain may result in disability, worsening in functional status, and depression in the patient in the long term. In order to establish an effective treatment, medical therapy, physical therapy modalities, and invasive interventions, as well as kinesiophobia affecting physical exercise should not be overlooked and the factors affecting kinesiophobia should be put forward. Understanding the role of pain-related fear and avoidance behaviors can make a significant contribution to the treatment of low back pain and reduce the disability rate, thereby helping patients to return to their daily activities. Therefore, it is crucial to inform clinicians about the presence of kinesiophobia and the factors that increase kinesiophobia.

In light of this information, this study was carried out to determine the level of kinesiophobia in patients with low back pain and evaluate the relationship between kinesiophobia and pain severity, depression, and quality of life (QoL).

2. Materials and method

2.1 Research design

This study was designed as a cross-sectional descriptive study. The study protocol was approved by the Ethics Committee of Mustafa Kemal University (2022–11/2022–23). Informed consent was obtained from all patients prior to the study. The study was carried out in accordance with the principles set forth in the Declaration of Helsinki. Patients were administered the assessment tools under the supervision of a medical doctor in order to obtain objective data.

2.2 Population and sample

The population of this cross-sectional descriptive study consisted of the patients diagnosed with MLBP at the Algology Outpatient Clinic of Hatay Training and Research Hospital between January and June 2022. Patients aged between 18 and 75, with normal hip and sacroiliac joint examination findings, less than 30 minutes of morning stiffness in the waist, a diagnosis of MLBP that increases with physical exercise, decreases with rest, and at a level that would not wake them up at night were included in the study. On the other hand, patients who underwent any surgical procedure in the last 6 months, had a history of malignancy or spinal fracture, had an orthopedic or neurological disease that affects ambulation, a cognitive dysfunction, an inflammatory joint disease, and were illiterate were excluded from the study.

2.2.1 Sample size

G*Power (G*Power Ver. 3.1.9.2, Franz Faul, Universität Kiel, Germany) software package was used to determine the effective sample size for the study. With reference to the study conducted by Uçurum et al., based on a mean Tampa Kinesiophobia Scale (TKS) score of 43.14 $\pm$ 6.16, $\alpha=$ 0.05 type I error, $r=$ 0.3 effect size, and 90% power, the minimum sample size was calculated as 120.

2.3 Data collection

Demographic and clinical characteristics of the pa-tients, including age, gender, height, weight, body mass index (BMI) (kg/m²), and educational level, were recorded. Patients’ CRP (mg/L) and serum vitamin D3 levels measured in the last 3 months were also recorded. Tests were performed on blood samples taken from peripheral venous veins of the forearm. CRP (mg/dL) and 25(OH)D (ng/ml) levels of all patients were recorded. CRP serum levels were measured with a modified latex-enhanced immunoturbidimetric assay using a CRP Latex kit (Olympus Life and Material Science Europe) according to the manufacturer’s instructions. Serum levels of 0–5 mg/L were defined as normal. Vitamin D level was studied with chemiluminescence measurement method in Beckman Coulter Dxl 800 brand and model device. Patients’ kinesiophobia status was assessed with the Turkish version of TKS, pain intensity with the Visual Analogue Scale (VAS), QoL with the 36-Item Short Form Health Survey (SF-36), and psychological condition with Beck Depression Inventory (BDI).

2.3.1 Kinesiophobia

The kinesiophobia status of the patients was assessed with the Turkish version of TKS. The reliability and validity studies of the Turkish version of TKS were completed previously [12]. TKS is a 17-item scale used in assessing acute and chronic low back pain, fibromyalgia and musculoskeletal injuries, and whiplash-related health problems. TKS is a 4-point Likert-type scale. Thus, one can get between 17 and 68 points from the scale [14]. The cut-off value for TKS was determined as 37 in previous studies [15, 16]. Accordingly, patients with a TKS score of $\geqslant$ 37 were included in the high kinesiophobia group, whereas patients with a TKS score of $<$ 37 were included in the low kinesiophobia group, in order to better assess the relationship between kinesiophobia severity and clinical parameters.

2.3.2 Quality of life

The QoL of the patients was assessed with the Turkish version of SF-36. The reliability and validity studies of the Turkish version of SF-36 were completed previously [17]. SF-36, which consists of 36 items and 8 subscales, is the most commonly used assessment tool in medicine in assessing physical and mental health. The subscales of SF-36 are physical functioning, Role limitations due to Physical Health Problems, Role Limitations due to Emotional Problems, Energy/Fatigue, Emotional Well-Being, Social Functioning, Bodily Pain, and General Health Perceptions.

2.3.3 Psychological condition

The depression status of the patients was assessed with BDI. BDI consists of 21 items that address the characteristic attitudes and symptoms of depression. BDI scores of 10 and above indicate depression [18].

2.3.4 Pain

The pain levels of the patients were evaluated with VAS. VAS is a widely used and validated measurement tool for assessing bodily pains. In assessing pain with VAS, one end of a 100 mm (10 cm) ruler is considered to indicate zero pain level and the other end severe pain level, and patients are asked to show the point corresponding to the pain they feel on this ruler. Higher values indicate more severe pains.

2.4 Statistical analysis

The statistical analyses were conducted with the SPSS 23.0 software package (IBM Corp., Armonk, NY, USA). The descriptive statistics obtained from the research data were expressed as numbers (n) and percentage (%) values in the case of categorical variables and as mean $\pm$ standard deviation (min-max) and median (min-max) values in the case of numerical variables. The normal distribution characteristics of the numerical variables were analyzed with the Shapiro-Wilk test. Additionally, the student’s t-test was used to compare kinesiophobia groups, and Pearson’s correlation analysis was used to determine the correlations between the parameters investigated in the study. Probability ( $p$ ) values of $<$ 0.05 were deemed to indicate statistical significance.

Table 1
Distribution of patients’ demographic characteristics by low and high kinesiophobia groups

	Low kinesiophobia group ( $n$ :71)	High kinesiophobia group ( $n$ :84)	p-value
Age	43.15 $\pm$ 13.84 (18–75)	47.79 $\pm$ 12.31 (18–75)	0.362
Gender
Female	32 (45)	40 (47.6)	0.751
Male	39 (55)	44 (52.4)
Educational Level
Primary education	28 (39.4)	32 (38.1)	0.952
Secondary education	27 (38)	34 (40.4)
Higher education	16 (22.5)	18 (21.4)
Comorbidities
Yes	40 (56.3)	49 (58.3)	0.802
No	31 (43.6)	35 (41.6)
BMI	25.36 $\pm$ 3.45	25.03 $\pm$ 3.83	0.311

Descriptive data were expressed as $n$ (%), mean $\pm$ SD (min-max), and median (min-max) values. Student’s $t$ -test, Mann-Whitney U test, and Pearson’s chi-squared test were used for statistical analyses. BMI: Body mass index, SD: standard deviation.

Table 2

Distribution of patients’ clinical characteristics by low and high kinesiophobia groups

	Low kinesiophobia group ( $n$ :71)	High kinesiophobia group ( $n$ :84)	p-value
CRP	0.2 (0–1.56)	0.3 (0–2.41)	0.807
Serum Vitamin D3	19.3 (3.1–48)	18.1 (2.3–62.1)	0.904
VAS-Pain severity	4.5 (1–10)	7.5 (1–10)	$<$ 0.001
BDI	8 (1–24)	17 (0–41)	$<$ 0.001
0–9-minimal	50 (70.42)	8 (20.98)	$<$ 0.001
10–16-mild	15 (21.12)	27 (32.14)
17–29-moderate	6 (8.45)	40 (47.61)
30–63-severe	0 (0)	9 (10.71)
SF36-Physical Functioning	78 (50–100)	52 (5–100)	$<$ 0.001
SF36-Role limitations due to Physical Health Problems	81 (0–100)	23 (0–100)	$<$ 0.001
SF36-Role Limitations due to Emotional Problems	95 (0–100)	29.3 (0–100)	$<$ 0.001
SF36-Energy/Fatigue	74 (0–95)	33 (0–100)	$<$ 0.001
SF36-Emotional Well-Being	76 (0–96)	48 (8–92)	$<$ 0.001
SF36-Social Functioning	68 (50–100)	48 (0–100)	$<$ 0.001
SF36-Bodily Pain	57.5 (0–90)	24 (0–77.5)	$<$ 0.001
SF36-General Health Perceptions	75 (10–95)	32 (0–80)	$<$ 0.001

Descriptive data were expressed as $n$ (%), mean $\pm$ SD (min-max), and median (min-max) values. Student’s t-test, Mann-Whitney U test, and Pearson’s chi-squared test were used for statistical analyses. CRP: C-reactive protein, VAS: Visual Analogue Scale, BDI: Beck’s Depression Inventory, SF: 36: 36-Item Short Form Health Survey, SD: standard deviation.

Table 3

Correlation of TKS scores with other variables

	$r$	$p$
Age	$-$ 0.012	0.853
BMI	$-$ 0.076	0.502
CRP	0.112	0.614
Serum vitamin D3	0.061	0.743
VAS-Pain severity	0.470	$<$ 0.001
BDI	0.584	$<$ 0.001
SF36-Physical Functioning	$-$ 0.544	$<$ 0.001
SF36-Role limitations due to Physical Health Problems	$-$ 0.702	$<$ 0.001
SF36-Role Limitations due to Emotional Problems	$-$ 0.483	$<$ 0.001
SF36-Energy/Fatigue	$-$ 0.502	$<$ 0.001
SF36-Emotional Well-Being	$-$ 0.495	$<$ 0.001
SF36-Social Functioning	$-$ 0.596	$<$ 0.001
SF36-Bodily Pain	$-$ 0.612	$<$ 0.001
SF36-General Health Perceptions	$-$ 0.712	$<$ 0.001

Spearman’s and Pearson’s analyses were used in the correlation analysis. TKS: Tampa Kinesiophobia Scale, BMI: body mass index, CRP: C-reactive protein, VAS: Visual Analogue Scale, BDI: Beck’s Depression Inventory, SF: 36: 36-Item Short Form Health Survey.

3. Results

The study sample consisted of 155 MLBP patients, 72 female and 83 male, aged between 18 and 75 years. The distribution of the patients’ characteristics by low and high kinesiophobia groups is given in Table 1. Accordingly, 54.2% of the patients had a high (TKS score $>$ 37) level of kinesiophobia, whereas 45.8% had a low (TKS score $\leqslant$ 37) level of kinesiophobia. There was no significant difference between the kinesiophobia groups in terms of age, gender, BMI, CRP, and serum vitamin D3 values ( $p>$ 0.05). On the other hand, VAS-pain severity and BDI scores were significantly higher in the high kinesiophobia group than in the low kinesiophobia group ( $p<$ 0.001). The analysis of the BDI scores revealed that the rate of patients with minimal depression was significantly higher in the low kinesiophobia group, whereas the rates of patients with mild, moderate, and severe depression were significantly higher in the high kinesiophobia group ( $p<$ 0.001). The SF-36 subscale scores were significantly higher in the low kinesiophobia group than in the high kinesiophobia group ( $p<$ 0.001) (Table 2). The TKS scores were moderately correlated with VAS-pain severity and BDI scores in the positive direction, and strongly correlated with all SF-36 subscale scores in the negative direction ( $p<$ 0.001). In contrast, there was no significant correlation between TKS scores and other variables, i.e., age, BMI CRP values, and serum vitamin D3 levels ( $p>$ 0.05) (Table 3). The results of the correlation analysis are shown in Figs 1–10.

Figure 1.

Correlation between TKS and SF36-General health perceptions.

Figure 2.

Correlation between TKS and SF36-body pain.

Figure 3.

Correlation between TKS and SF36-Social functioning.

Figure 4.

Correlation between TKS and SF36-Emotional well-being.

Figure 5.

Correlation between TKS and SF36-Energy/Fatigue.

Figure 6.

Correlation between TKS and SF36-Role limitations due to emotional problems.

Figure 7.

Correlation between TKS and SF36-Role limitations due to physical health problems.

Figure 8.

Correlation between TKS and SF36-physical functioning.

Figure 9.

Correlation between TKS and Beck’s depression inventory.

Figure 10.

Correlation between TKS and visual analogue scale.

4. Discussion

Understanding the role of pain-related kinesiophobia may contribute significantly to the treatment of low back pain. It is important to inform clinicians about the presence of kinesiophobia and the factors that increase kinesiophobia. In this context, this study was carried out to evaluate kinesiophobia and determine the relationship between kinesiophobia severity and pain severity, depression, and QoL in patients with MLBP. Consequentially, the study’s findings revealed a positive correlation between kinesiophobia and pain severity and depression, and a negative correlation between kinesiophobia and QoL. In other words, the QoL levels of patients with high kinesiophobia levels were significantly lower, whereas their pain severity and depression levels were significantly higher than those with low kinesiophobia levels. On the other hand, there was no significant relationship between kinesiophobia and age, educational status, BMI, Vitamin D, and CRP levels.

The results of the relevant studies in the literature are contradictory. For instance, while a study found a significant relationship between educational status and kinesiophobia [19], another study [20], as in this study, did not find any relationship between educational status and kinesiophobia. Similarly, while a study found a weak significant relationship between BMI and kinesiophobia [21], another study [22], as in this study, did not find any relationship between BMI and kinesiophobia. However, further prospective studies are needed to elucidate the relationship between kinesiophobia and BMI in patients with low back pain.

In a meta-analysis, vitamin D deficiency was reported to be associated with low back pain. However, it has been stated that the relationship between vitamin D levels and pain severity is controversial [6]. In the current study, although the VAS score was high in the group with high motion phobia, no statistically significant difference was found in terms of vitamin D levels in the comparison between the groups.

A thorough literature review did not reveal any study on the relationship between vitamin D concentrations and kinesiophobia in patients with low back pain. The only study available in the literature on the relationship between vitamin D concentrations and kinesiophobia was conducted with fibromyalgia patients [23]. In the said study, contrary to this study, a significant relationship was found between low vitamin D concentrations and kinesiophobia. Large-scale studies may further elucidate the relationship between vitamin D concentrations and kinesiophobia.

QoLis a multidimensional concept that includes the physical, psychological, and social aspects of health and is often considered an important outcome of healthcare services. Health-related QoL, on the other hand, contributes to the assessment of the health status of an individual and the development of individual treatment plans, primarily through health screenings, disease burden, and epidemiological studies [24].

There are many benefits of assessing health-related QoL in patients with low back pain. QoL data help clinicians assess the care needs of patients with low back pain, establish treatment goals and plan treatments for these patients. In addition, QoL data provide potentially useful information for monitoring patients with low back pain outside working hours and evaluating treatment outcomes. Studies have reported that chronic low back pain patients have worse health-related QoL, especially in physical components of QoL, compared to healthy individuals. Pain severity as well as poor clinical and functional status associated with low back pain negatively affect the physical components of the QoL [25, 26, 27]. The studies on the relationship between kinesiophobia and QoL parameters in patients with chronic low back pain reported that the presence of kinesiophobia was negatively correlated with QoL parameters of general health perceptions, physical functioning, social functioning, bodily pain, and role limitations due to physical health problems [28, 29, 30, 31]. In contrast, a study conducted with 94 patients did not find any significant relationship between kinesiophobia and QoL parameters, even though kinesiophobia values were higher in patients with low back pain [32]. In comparison, the assessment of the health-related QoL of the MLBP patients included in this study with the SF-36 questionnaire revealed that the scores obtained from all eight subscales of SF-36 were significantly lower in the high kinesiophobia group compared to the low kinesiophobia group. Based on these data, high kinesiophobia can be said to adversely affect QoL. On the other hand, no significant relationship was found between low and high-risk kinesiophobia groups in terms of pre- and post-treatment QoL parameters, i.e., Numeric Pain Scale scores, Modified Low Back Outcome scores, and occupational status (employed or unemployed), in patients with low back pain who were included in a rehabilitation program [33]. In the current study, Numeric Pain Scale, Modified Low Back Outcome Score and occupational status were used as QoL. Instead, the SF-36 QoL scale used in our study evaluates general health, emotional state, and social activities as well as physical functions. Assessing the psychological risk factors and especially kinesiophobia in patients with chronic pain helps determine treatment outcomes, and also contributes to the adoption of a positive approach by the medical staff to the patients and the planning of relevant physical therapies and exercises [34]. Therefore, the discrepancy between the aforementioned study and this study might be attributed to the fact that patients’ emotional and mental statuses were not evaluated within the scope of the assessment of QoL and that no individualized multidisciplinary treatments were administered in the said study.

Depressed individuals with chronic low back pain reportedly fear movement, physical activity, and exercise, rendering themselves more sensitive to pain and re-injury [35, 36]. Studies have reported higher pain, depression, and disability scores in those with high levels of kinesiophobia [16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37]. In comparison, in this study, patients in the high kinesiophobia group had significantly higher pain and depression scores than those in the low kinesiophobia group. In parallel, a significant correlation was found between the TKS and BDI scores in the positive direction. These findings indicate the need for early diagnosis and treatment of psychological disorders such as fear of movement and depression in patients with chronic low back pain, considering that such psychological disorders predict worse prognosis. It has been reported that fear of movement is significantly related to pain in the context of chronic low back [38, 39, 40]. Accordingly, both pain severity and pain-related fear are among the primary factors negatively affecting routine daily and social activities. Chronic pain causes fear of movement and avoidance of movement causes pain, creating a vicious cycle. In line with the findings reported in the literature, the findings of this study support the hypothesis that pain causes fear of movement and fear of movement causes pain, creating a vicious circle.

The strengths of this study are that it addressed the relationship between kinesiophobia and QoL, functional status and psychological state between low and high kinesiophobia groups in patients with MLBP and that it is the first study to examine the relationship between kinesiophobia and Vitamin D levels in this patient group. In addition, patients were administered the assessment tools under the supervision of a medical doctor in order to obtain objective data.

4.1 Limitations of the study

Apart from the strengths mentioned above, there were also some limitations to the study. First, the sample size was relatively small. Increasing the sample size could help minimize the margin of error. Secondly, low back pain could have been classified as acute, subacute, and chronic according to the durations that the patients have been suffering from low back pain. Such a classification could allow assessing the pain, kinesiophobia, and QoL separately in each stage, and thereby guide physiotherapists in terms of treatment management.

5. Conclusion

The study findings revealed that kinesiophobia was negatively correlated with all QoL subscale scores and positively correlated with depression and pain scores in patients with MLBP. Understanding the role of pain-related fear of movement and avoidance behaviors in the development of chronic low back pain and functional disability is key to planning the right treatment modality for the treatment of low back pain and reducing the rate of related disabilities. Kinesiophobia is one of the most significant factors that reduce exercise compliance in individuals with low back pain. Therefore, early detection of kinesiophobia is crucial in order to increase exercise compliance and prevent chronic pain. Clinicians and therapists should keep in mind the fear of movement in patients with low back pain and take the necessary measures to prevent complications that may arise from inactivity. It is important to adopt a multidisciplinary approach toward these patients and assess them also psychiatrically to increase the efficacy of the treatment modalities used in the treatment of kinesiophobia.

Ethics statement

The study protocol was approved by the ethics reviewing committee guidelines of Mustafa Kemal University, Hatay, Turkey (2022–11/2022–23).

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Informed consent

Written informed consent was obtained from each subject.

Footnotes

Acknowledgments

Not applicable.

Conflict of interest

The authors have no conflicts of interest to declare.

References

George

Fritz

Silfies

Schneider

Beneciuk

Lentz

Gilliam

Hendren

Norman

. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021 Nov; 51(11): CPG1-CPG60. doi: 10.2519/jospt.2021.0304..

Gilgil

Kaçar

Bütün

Tuncer

Urhan

Yildirim

Sünbüloglu

Arikan

Tekeoglu

Oksüz

Dündar

. Prevalence of low back pain in a developing urban setting. Spine (Phila Pa 1976). 2005 May 1; 30(9): 1093-8. doi: 10.1097/01.brs.0000161007.46849.4c.8.

Buchbinder

Jolley

Wyatt

. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 2001 Jun 23; 322(7301): 1516-20. doi: 10.1136/bmj.322.7301.1516.

Urits

Burshtein

Sharma

Testa

Gold

Orhurhu

Viswanath

Jones

Sidransky

Spektor

Kaye

. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep. 2019 Mar 11; 23(3): 23. doi: 10.1007/s11916-019-0757-1.

Chan

Song

Sham

Cheung

. Genetics of disc degeneration. Eur Spine J. 2006; 3: 317-325.

Zhang

, et al. Relationship between Vitamin D and Nonspecific Low Back Pain May Be Mediated by Inflammatory Markers. Pain Physician. 2021; 24(7): E1015-E1023.

Borenstein

. Law back pain. Klippel JH, Dieppe P, editors. Rheumatology. London: Mosby Ltd., 1994; p. 41.

Kinkade

. Evaluation and treatment of acute low back pain. Am Fam Physician. 2007 Apr 15; 75(8): 1181-8.

Ketenci

. Bel ağrılarında fonksiyonel değerlendirme. Özcan, edt. Bel ağrısı tanı ve tedavisi’nde. İstanbul: Nobel Kitabevi, 2002; 73-83.

10.

Bogduk

McGuirk

. Medical management of acute and chronic low back pain: an evidence-based approach. Amsterdam: Elsevier, 2002; doi: 10.1093/occmed/kql102.

11.

Pagé

Gauvin

Sylvestre

Nitulescu

Dyachenko

Choinière

. An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain. J Pain. 2022 Jul; 23(7): 1151-1166. doi: 10.1016/j.jpain.2022.01.001. Epub 2022 Jan 21.

12.

Luque-Suarez

Martinez-Calderon

Falla

. 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 May; 53(9): 554-559. doi: 10.1136/bjsports-2017-098673. Epub 2018 Apr 17.

13.

Neblett

Hartzell

Mayer

Bradford

Gatchel

. Establishing clinically meaningful severity levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain. 2016 May; 20(5): 701-10. doi: 10.1002/ejp.795. Epub 2015 Oct 30.

14.

Tunca Yılmaz

Yakut

Uygur

Uluğ

. Tampa Kinezyofobi ölçeği’nin Türkçe versiyonu ve test-tekrar test güvenirliği. Fizyoter Rehabil. 2011; 22: 44-49.

15.

Vlaeyen

Kole-Snijders

Rotteveel

Ruesink

Heuts

. The role of fear of movement/(re)injury in pain disability. J Occup Rehabil. 1995 Dec; 5(4): 235-52. doi: 10.1007/BF02109988.

16.

Oskay

Tuna

Düzgün

Elbasan

Yakut

Tufan

. Relationship between kinesiophobia and pain, quality of life, functional status, disease activity, mobility, and depression in patients with ankylosing spondylitis. Turk J Med Sci. 2017 Nov 13; 47(5): 1340-1347. doi: 10.3906/sag-1702-93.

17.

Koçyiğit

Aydemir

Fişek

Ölmez

Memiş

. Kısa Form-36 (KF-36)’nın Türkçe versiyonunun güvenilirliği ve geçerliliği. Ilaç ve Tedavi Dergisi. 1999; 12: 102-106.

18.

Uçurum

Aybuke

. “Bel ağrılı hastalarda ağrı, kinezy-ofobi ve yaşam kalitesi arasındaki ilişki”. Ege Tıp Dergisi. 2018; 57(3): 131-135.

19.

Erden

Altuğ

. A Malkoç Diz Osteoartritli Bireylerde Kinezyofobi, Ağrı Şiddeti, Anksiyete-Depresyon Durumu Ve Yaşam Kalitesinin İncelenmesi, Ortopedi Travmatoloji Ve Spor Hekimligği Dergisi, 2017, cilt 7, 1-17, s8.

20.

Beck

Ward

Mendelson

Mock

Erbaugh

. An inventory for measuring depression. Archives of General Psychiatry. 1961; 4: 561-71. doi: 10.1001/archpsyc.1961.01710120031004.

21.

Alaca

. The relationships between pain beliefs and kinesiophobia and clinical parameters in Turkish patients with chronic knee osteoarthritis: a cross-sectional study. J Pak Med Assoc. 2019; 69(6): 823-7.

22.

Comachio

Magalhães

Campos Carvalho E Silva

APM

Marques

. A cross-sectional study of associations between kinesiophobia, pain, disability, and quality of life in patients with chronic low back pain. Adv Rheumatol. 2018 Jun 22; 58(1): 8. doi: 10.1186/s42358-018-0011-2.

23.

Zadro

Shirley

Ferreira

Carvalho-Silva

Lamb

Cooper

Ferreira

. Mapping the Association between Vitamin D and Low Back Pain: A Systematic Review and Meta-Analysis of Observational Studies. Pain Physician. 2017 Nov; 20(7): 611-640. PMID: 29149142.

24.

Wells

Russell

Haraoui

Bissonnette

Ware

. Validity of quality of life measurement tools – from generic to disease-specific. J Rheumatol Suppl. 2011 Nov; 88: 2-6. doi: 10.3899/jrheum.110906.

25.

Tüzün

Eker

. Sağlık değerlendirme ölçütleri ve yaşam kalitesi. Sağlık ve Toplum Dergisi. 2003; 2: 3-8.

26.

Veresciagina

Ambrozaitis

Spakauskas

. Health-related quality-of-life assessment in patients with low back pain using SF-36 questionnaire. Medicana (Kaunas). 2007; 43: 607-13.

27.

Kosinski

Schein

Vallow

Ascher

Harte

Shikiar

Frank

Margolis

Vorsanger

. An observational study of health-related quality of life and pain outcomes in chronic low back pain patients treated with fentanyl transdermal system. Curr Med Res Opin. 2005 Jun; 21(6): 849-62. doi: 10.1185/030079905X46377.

28.

Taylor

Foy

Fogg

. Responsiveness of common outcome measures for patients with low back pain. Spine (Phila Pa 1976). 1999; 24: 1805-12.

29.

Svensson

Lundberg

Ostgaard

Wendt

. High degree of kinesiophobia after lumbar disc herniation surgery: a cross-sectional study of 84 patients. Acta Orthop. 2011 Dec; 82(6): 732-6. doi: 10.3109/17453674.2011.636674. Epub 2011 Nov 9.

30.

Antunes

de Macedo

Amaral Tda

Gomes Hde

Pereira

Rocha

. Pain, kinesiophobia and quality of life in chronic low back pain and depression. Acta Ortop Bras. 2013 Jan; 21(1): 27-9. doi: 10.1590/S1413-78522013000100005.

31.

Altuğ

Ünal

Kilavuz

Kavlak

Çitişli

Cavlak

. Investigation of the relationship between kinesiophobia, physical activity level and quality of life in patients with chronic low back pain1. J Back Musculoskelet Rehabil. 2016 Aug 10; 29(3): 527-31. doi: 10.3233/BMR-150653.

32.

Özmen

et al. “Kronik bel ağrılı hastalarda kinezyofobi ve yaşam kalitesi arasındaki ilişki”. FÜ Sağ. Bil. Tıp Derg. 2016; 30(1): 1-4.

33.

Gregg

McIntosh

Hall

Watson

Williams

Hoffman

. The relationship between the Tampa Scale of Kinesiophobia and low back pain rehabilitation outcomes. Spine J. 2015 Dec 1; 15(12): 2466-71. doi: 10.1016/j.spinee.2015.08.018. Epub 2015 Aug 14.

34.

McCracken

Turk

. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine (Phila Pa 1976). 2002 Nov 15; 27(22): 2564-73. doi: 10.1097/00007632-200211150-00033.

35.

Silva

BAMD

Gelain

Candotti

. The influence of physical exercise on behavioral habits, kinesiophobia, and disability in people with low back pain: A retrospective cross-sectional study. J Bodyw Mov Ther. 2021 Oct; 28: 348-353. doi: 10.1016/j.jbmt.2021.07.002. Epub 2021 Jul 13.

36.

Koçyiğit

Akaltun

. Kinesiophobia Levels in Fibromyalgia Syndrome and the Relationship Between Pain, Disease Activity, Depression. Arch Rheumatol. 2020 Feb 7; 35(2): 214-219. doi: 10.46497/ArchRheumatol.2020.7432.

37.

Turk

Robinson

Burwinkle

. Prevalence of fear of pain and activity in patients with fibromyalgia syndrome. J Pain. 2004 Nov; 5(9): 483-90. doi: 10.1016/j.jpain.2004.08.002.

38.

Marshall

PWM

Schabrun

Knox

. Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain. PLoS One. 2017 Jul 7; 12(7): e0180788. doi: 10.1371/journal.pone.0180788.

39.

Gheldof

Crombez

Van den Bussche

Vinck

Van Nieuwenhuyse

Moens

Mairiaux