Is There a Relationship Between Kinesiophobia and Physical Activity Level in Patients With Knee Osteoarthritis?
Conditions: Fear of Pain, Knee Osteoarthritis, Physical Activity
Sponsor: Aksaray University Training and Research Hospital

19.03.19 
Is There a Relationship Between Kinesiophobia and Physical Activity Level in Patients 
with Knee Osteoarthritis? 
 
Running Title: Knee Osteoarthritis, Kinesiophobia and Physical Activity 
 
Melek Aykut Selçuk, MD*, Ahmet Karakoyun, MD† 
 
*Physical Medicine and Rehabilitation Clinic, Ankara Akyurt Public Hospital 
†Department of Physical Medicine and Rehabilitation, Aksaray University Medical Faculty 
 
Corresponding Author: Melek Aykut Selçuk 
Mail address: mlk.aykut@gmail.com 
Phone number: 905555289493 
Fax number:  90312 844 30 16 
Adress: Physical Medicine and Rehabilitation Clinic, Ankara Akyurt Public Hospital, 
Yıldırım Mahallesi Dr. Neslihan Özenli Caddesi No: 19 Akyurt/ANKARA, Turkey 
Postal Code: 06750 
 
Funding sources: None 
Conflict of interest: The authors declared that they have no conflict of interest. 
 
 
 
 
 

 
Abstract 
 
Is There a Relationship Between Kinesiophobia and Physical Activity Level in Patients 
with Knee Osteoarthritis? 
 
Objective: To investigate the levels of kinesiophobia, physical activity, depression, 
disability and quality of life in patients with knee osteoarthritis. 
Design: A cross-sectional study. 
Setting: A tertiary healthcare center. 
Subjects: Ninety-six patients with knee osteoarthritis. 
Methods: Pain intensity was evaluated by the Visual Analog Scale, kinesiophobia by the 
Tampa Scale of Kinesiophobia and Brief Fear of Movement Scale, depression by the Beck 
Depression Inventory, disability by the Western Ontario and McMaster Universities 
Arthritis Index, physical activity level by the International Physical Activity Questionnaire 
short form, and quality of life by the Short Form 12 Health Survey Questionnaire. 
Results: Of the patients, 80.4% had high-level kinesiophobia, 61.9% had depression, and 
60.4% had low, 26% moderate and 7.3% high physical activity. The pain and night pain score 
of the Visual Analog Scale, the Tampa Scale of Kinesiophobia and Brief Fear of Movement 
Scale scores, and the Western Ontario and McMaster Universities Arthritis Index and Beck 
Depression Inventory scores were higher in the group with high-level kinesiophobia, while 
the mental, physical and total scores obtained from the Short Form 12 Health Survey 
Questionnaire were higher in the group with low-level kinesiophobia (P<0.05). 
Conclusions 
Since the treatment of pain alone in patients with knee osteoarthritis is not sufficient to reduce 

the fear of movement, we consider that approaches to increase physical activity and cognitive 
behavioral therapy related to fear of movement should be included in the treatment program. 
 
Key words: Knee osteoarthritis, fear of movement, disability, Tampa, kinesiophobia 
 
 
 
 
 
 
 
 
 
 

Is There a Relationship Between Kinesiophobia and Physical Activity Level in Patients 
with Knee Osteoarthritis? 
 
Introduction 
 
Knee osteoarthritis (OA) is a clinical syndrome with the pathological findings of degeneration 
of the joint cartilage, subchondral sclerosis, and new bone formation, presents with pain and 
stiffness in the joints, and causes loss of function and restrictions in activities of daily living 
(1). The prevalence of symptomatic knee OA is 14.9% in females, 8.7% in males, and 12.2% 
in the general population, and the risk of developing knee OA is increased by 12% for every 
one-year increase in age (2). Knee OA is radiologically classified into five grades using the 
Kellgren-Lawrence (KL) classification, with the radiological findings gradually deteriorating 
from Grade 0 to 4 (3). Studies have shown no correlation between radiological findings and 
pain intensity in patients with knee OA, but a weak relationship has been reported between 
disability and radiological findings (4). Advanced age, female gender, low level of education, 
high body mass index (BMI), structural damage, central and peripheral pain mechanisms, and 
psychological factors have been associated with pain intensity and disability in patients with 
knee OA (5, 6). Researchers revealed that psychological factors, such as anxiety and 
depression are more common in women with OA, they play a decisive role in the continuity 
of pain, and the rate of depression in patients with OA is 49.3% (7, 8). Although it is known 
that regular physical activity and specific exercises slow the progression of the disease, reduce 
pain, and improve function (9), physical activity levels in patients with OA are lower than in 
the general population and 37% are reported to be absolutely inactive (10). It has also been 
suggested that a sedentary lifestyle may be related to age, gender, BMI, educational status, 
functional limitations, availability of access to sports centers, and disorders, such as anxiety 

and depression (11). Recent research in the area focus on pain catastrophizing referring to the 
tendency to describe pain in an amplified and worsened manner, kinesiophobia defined as 
developing fear-avoidance behavior against physical activity due to painful injury, and self-
efficacy, which allows patients to develop positive attitudes to managing pain. Previous 
studies have reported that kinesiophobia is associated with high pain severity, poor functional 
status, and high psychological and physical disability in musculoskeletal diseases (12, 13). 
Fear of movement is commonly evaluated using the Tampa Scale of Kinesiophobia (TSK-17), 
a 17-item questionnaire; however, Shelby et al. proposed the Brief Fear of Movement Scale 
(BFOM), a shorter, thus clinically more practical version of TSK-17 containing six questions 
that are more specific to OA and reported this questionnaire to be reliable in patients with this 
condition. Although the importance of regular physical activity in patients with knee OA is 
known, and fear of movement is considered as one of the causes of physical inactivity and is 
widely researched in terms of its role in the pathogenesis of pain, there remains to be limited 
number of studies on kinesiophobia in these patients. In this study, we aimed to evaluate the 
levels of kinesiophobia and physical activity in patients with knee OA and to investigate 
whether they were associated with demographic characteristics, BMI, pain intensity, 
depression, disability, radiological grade, and quality of life. 
 
Methods 
 
Participants  
 
A total of 96 female and male patients aged 50 to 75 years with knee OA and knee pain 
lasting for more than three months (knee pain intensity over 20 mm on Visual Analog Scale-
VAS) were included in the study. Excluded from the study were patients with a history of 

knee operation, those that had malignancies, systemic infectious disease, inflammatory 
disease, or fibromyalgia syndrome, those that received physical therapy and/or a knee 
injection within the last three months, and those having a history of using antidepressants, 
pregabalin or duloxetine. 
 
Design 
 
All patients gave informed consent before the recruitment. Ethics committee approval was 
obtained from Aksaray University on 19.04.2018 with decision number 2018/67. The 
ClinicalTrials.gov identifier of the study is NCT03875040. All the patients presenting to 
Aksaray Training and Research Hospital Physical Medicine and Rehabilitation Outpatient 
Clinic between April 2018 and October 2018, who volunteered to participate in the study and 
fulfilled the inclusion criteria, completed the questionnaire forms. The severity of pain at 
night, pain at rest and activity-related pain was evaluated by VAS, kinesiophobia by TSK-17 
and BFOM, depression by the Beck Depression Inventory (BDI), disability by the Western 
Ontario and McMaster Universities Arthritis Index (WOMAC), physical activity level by the 
International Physical Activity Questionnaire (IPAQ) short form and quality of life by the 
Short Form 12 Health Survey Questionnaire (SF-12). Age, gender, marital status, educational 
status, additional disease, drug history, and sociodemographic data such as BMI were 
obtained from the patients and recorded in the evaluation form. 
 
Outcome measures 
 
TSK-17: A 17-item questionnaire based on a four-point Likert scale (1 = Strongly disagree, 2 
= Disagree, 3 = Agree, 4 = Strongly agree) used to evaluate kinesiophobia. A TSK-17 score 

above 37 is considered as high-level kinesiophobia (14). 
BFOM: A shorter and clinically more practical version of TSK-17, containing the TSK-17 
items 1, 2, 9, 10, 14 and 15 that are more specific to OA (15). 
VAS: A 10-cm line consisting of “no pain” on one end and “extreme pain” on the other, used 
to measure and monitor intensity of pain. The patients mark the point that best describes their 
pain intensity. The higher the score, the higher the intensity of pain. In the current study, we 
evaluated the patients’ pain at night, pain at rest and activity-related pain using this tool (16). 
SF-12: A scale used to evaluate the quality of life, consisting of 12 items inquiring general 
health, physical condition, physical limitations, mental status, social status, pain, energy and 
mental limitation over a total score of 100 points. SF-12 is an abbreviated version of SF-36 
and has been proven to be reliable and valid. In this study, we evaluated the patients’ total, 
physical and mental SF-12 scores (17). 
BDI: A depression-rating scale consisting of 21 questions, each evaluated based on a score of 
0-3. A total score of 10 or above is considered to indicate the presence of depression 
(18). 
WOMAC: A 24-item measure that was developed to evaluate pain, joint stiffness and 
physical functions in individuals with knee and hip OA. A higher score indicates a higher 
level of pain, stiffness and functional limitation (19). In our study, we used the WOMAC total 
score. 
IPAQ Short Form: A seven-item questionnaire that evaluates the patients’ physical activity 
level and walking and sitting times based on the MET-min/week unit over the last seven days. 
According to their mean MET-min/week values obtained from this questionnaire, the patients 
are classified to have a low, medium or high level of physical activity (20). 
 
 

Statistical Analysis 
 
All data were analyzed using the Statistical Analysis for Social Sciences (SPSS) v. 15.0 data 
analysis program, and the significance level was set to P < 0.05. Descriptive statistics were 
generated for the sociodemographic data, VAS, TSK-17, BFOM, BDI, WOMAC, SF-12 and 
physical activity level variables. The continuous variables were presented as means ± standard 
deviation (SD) and ranges, and the categorical variables as absolute numbers and relative 
frequency. We chose to use the Kolmogorov-Smirnov test as a normality test. We employed 
the independent t-test for the bivariate analysis of normally distributed (age, SF-12 mental and 
BDI) and parametric variables, and the Mann-Whitney U and chi-square tests for non-
parametric variables. We evaluated the relationship between our variables using Spearman’s 
correlation analysis. The descriptive statistics calculated through the sample analysis 
examined using scatter plot and box plot methods and revealed no outliers. In the multiple 
regression model, the significance of the model and that of the independent variables were 
examined at the P < 0.05 significance level, and predictive equations were determined 
according to these criteria. Multiple regression analysis was performed to investigate the 
relationship between WOMAC, SF-12 physical, SF-12 mental and SF-12 total dependent 
variables and independent variables that were found to be significant. The strength of 
association was calculated using confidence interval (CI) for regression coefficients, P values, 
and R2. 
 
Results 
 
Of the 96 patients included in the study, 69.1% were female and 29.9% were male, and the 
mean age was 60.9 ± 7.9 years. High-level kinesiophobia was present in 80.4% of the patients 

and depression in 61.9%. The level of physical activity was low in 60.4% of the patients, 
moderate in 26%, and high in 7.3%. The sociodemographic and descriptive data of the 
patients are given in Table 1. Of the female patients, 80.5% had high-level kinesiophobia and 
65.6% had depression, while in male patients, the rates of high-level kinesiophobia and 
depression were 75.8% and 55.1%, respectively. The rates of low, moderate and high level of 
physical activity were calculated as 64.1%, 23.8% and 5.9%, respectively in women, and 
51.7%, 31% and 10.3%, respectively in men. There was no significant difference between the 
female and male patients with knee OA in terms of high-level kinesiophobia (P: 0.490), 
depression (P: 0.118) and physical activity level (P: 0.688). Similarly, no significant 
difference was detected by gender concerning age and TSK-17 score; however, the female 
patients had a significantly higher BMI (P: 0.001) and VAS-at rest (P: 0.005), VAS-
movement (P: 0.041), VAS-at night (P: 0.001), BFOM (P: 0.016), WOMAC (P: 0.008) and 
BDI (P: 0.034 ) scores, and significantly lower SF-12 physical (P: 0.046), mental (P: 0.042) 
and total (P: 0.028) scores compared to men. Table 2 presents the descriptive data of the 
female and male patients with knee OA. 
There was no significant difference in the BMI value (P: 0.106) and VAS-at rest score (P: 
0.727) between the patients with low and high-level kinesiophobia. Age (P: 0.000), VAS-
activity related (P: 0.015), VAS-at night (P: 0.050), TSK-17 (P: 0.000), BFOM (P: 0.000), 
WOMAC (P: 0.000) and BDI (P: 0.015) scores were higher in patients with high-level 
kinesiophobia, whereas SF-12 physical (P: 0.000), mental (P: 0.004) and total (P: 0.000) 
scores were higher in those with low-level kinesiophobia. The rate of depression was 75.6% 
and 36.3% in the groups with high- and low-level kinesiophobia, respectively, and the 
difference was statistically significant (P: 0.013). The level of physical activity was low in 
68%, moderate in 28% and high in 4% of the patients with high-level kinesiophobia, and low 
in 46.1%, moderate in 23% and high in 30.7% in the group with low-level kinesiophobia, with 

a statistically significant difference between the two groups (P: 0.011). There was also a 
significant difference between the two kinesiophobia groups in terms of KL staging (P: 0.001) 
and educational status (P: 0.001), whereas no significant difference was observed in relation 
to occupation (P: 0.137). Table 3 presents the demographic and descriptive data of the knee 
OA groups with low- and high-level kinesiophobia. 
On the BFOM scale, the most commonly approved item was “Simply being careful that I do 
not make unnecessary movements is the safest thing I can do to prevent the pain from 
worsening”, with which more than half (68.1%) of the participants agreed or strongly agreed. 
The least commonly approved item was “If I were to try to overcome it, my pain would 
increase”. Only 36.1% of the participants agreed or strongly agreed with this item (Table 4). 
BMI, VAS-at rest, VAS-activity related, VAS-at night, TSK-17, BDI and BFOM scores, KL 
grade and physical activity level were correlated with WOMAC and SF-12 physical scores (P 
< 0.05). The SF-12 mental and SF-12 total scores were additionally correlated with age (P < 
0.05), but not with BMI (P > 0.05), in contrast to WOMAC and SF-12 physical scores. The 
results of correlation analysis in patients with knee OA are given in Table 5. 
TSK-17 was correlated with WOMAC, SF-12 physical, mental and total, BDI and BFOM 
scores and presence of depression in women with knee OA (P < 0.05), and with age, BFOM, 
BDI, SF-12 physical and total scores in men with knee OA (P < 0.05). BFOM was correlated 
with age, VAS-activity related, VAS-at night, TSK-17, WOMAC, SF-12 physical, mental and 
total and BDI scores and high-level kinesiophobia in female patients and with age, TSK-17, 
SF-12 physical and total scores, and high-level kinesiophobia in male patients. Table 6 
presents the correlation data for TSK-17 and BFOM in male and female patients with knee 
OA. 
According to the data obtained from the multiple regression analysis (Table 7), it was 
concluded that independent variables KL grade, TSK-17 score and TSK-17 item 15 score 

predicted the WOMAC dependent variable (rate of explanation: 51.7%, 95% CI for β); the 
independent variable KL grade predicted the SF-12 physical dependent variable (41.6%, 95% 
CI for β); the independent variable BDI score predicted the dependent variable SF-12 mental 
score (38.7%, 95% CI for β); and the independent variables KL grade and BDI score 
predicted the dependent variable SF-12 total score (56.5%, 95% CI for β). However, age, 
BMI, VAS-at rest, VAS-at night, VAS-activity related, BDI and BFOM scores, educational 
status, occupation, physical activity level, and scores of TSK-17 items 1, 2, 9, 10 and 14 did 
not significantly predict WOMAC scores (P > 0.05). Similarly, age, BMI, VAS-at rest, VAS-
at night, VAS-activity related, TSK-17 and BFOM scores, educational status, occupation and 
physical activity level did not significantly predict the SF-12 scores (P > 0.05). 
 
Discussion 
 
We determined that the rates of kinesiophobia, depression and physical inactivity were 
significantly high in patients with knee OA, and there was a significant relationship between 
BMI, pain intensity, depression, kinesiophobia, KL grade and physical activity level in these 
patients. Thompson et al. (21) reported that 65% of the participants were obese or morbidly 
obese, 23% were overweight, and the mean BMI was 33 kg/m2. In our study, 39.5% of the 
patients were overweight, 55.1% were obese or morbidly obese, and the mean BMI was 
calculated as 31.2 kg/m2. In a study evaluating 358 patients with knee and hip OA, the mean 
BMI score was 29.7 in females and 28.9 in males, but there was no significant difference in 
BMI between men and women (22). In the current study, the mean BMI of female patients 
was significantly higher than that of males. However, BMI did not significantly differ 
between patients with high- and low-level kinesiophobia. Although research on kinesiophobia 
in patients with knee OA is limited, a few published studies reported that pain catastrophizing 

affects pain intensity, walking speed, and psychological and physical disability in obese knee 
OA cases (13, 23). It was also noted that in patients with knee OA, a high BMI was correlated 
with lower physical performance (6), and regular exercise was useful in improving functional 
status and reducing pain (24). Similar to the literature, we observed that BMI was related to 
disability in patients with knee OA. 
As reported in the literature, we determined that the KL grade was significantly associated 
with disability and quality of life and was significant in predicting these parameters (5, 6). 
The KL grade was significantly higher in patients with high-level kinesiophobia than those 
with low-level kinesiophobia, but no significant relationship was detected between 
kinesiophobia and KL grade. 
In a previous study, it was reported that 27.5% of the patients had finished primary school,   
52.9% completed middle school, and 19.6% were university graduates (22). The educational 
level of the patients included in our study was much lower compared to the literature. The 
educational level of the patients with high-level kinesiophobia was lower than those with low-
level kinesiophobia, but no significant relationship was found between kinesiophobia and 
educational status. 
In this study, we found that the activity-related pain score was higher than the pain at night 
and pain at rest scores, and pain intensity was higher in female patients compared to males. It 
has been previously reported that gradually increased physical activity worsened pain 
intensity in patients with knee pain (25-30), and knee OA cases with a high level of pain 
catastrophizing had greater activity-related pain intensity (31). In consistent with the 
literature, we determined that activity-related knee pain was significantly higher in patients 
with high-level kinesiophobia compared to those with low-level kinesiophobia. Furthermore, 
night pain was slightly more intense in the former group, but no significant difference was 
detected between the two groups in terms of pain at rest. While there was no significant 

relationship between the TSK-17 score and pain intensity in women, the BFOM score was 
significantly correlated with night pain and activity-related pain. In male patients, there was 
no significant relationship between pain intensity and TSK-17 and BFOM scores. The results 
also revealed that in patients with knee OA, activity-related, night and rest pain were 
significantly correlated with disability and quality of life but were not effective in predicting 
these variables. Based on this result, we consider that in knee OA cases, treatment of pain 
alone is not sufficient to reduce disability and improve quality of life. 
In a study by Baert et al., the mean TSK-17 score was found to be 37.1 in symptomatic 
patients with knee OA, and it was reported that kinesiophobia was related to pain intensity but 
not disability (32). In two other studies investigating knee OA, the mean TSK-17 score was 
reported as 41 and 34.1, and kinesiophobia and disability were found to be related (21, 33). In 
the current study, we determined a higher mean TSK-17 score compared to the literature. 
Although the TSK-17 score was higher in females than in males with knee OA, there was no 
statistically significant difference between the two groups. There was a strong relationship 
between the TSK-17 score and disability and quality of life in patients with knee OA. The 
TSK-17 score was additionally correlated with depression in female patients, and age and 
depression in male patients, but no significant relationship existed between TSK-17 and 
disability in the latter. Similar to the literature, we found that disability and quality of life 
were correlated with kinesiophobia; however, we did not observe a significant relationship 
between pain intensity and kinesiophobia.  
In the multiple regression analysis, the TSK-17 score and the score obtained from the item, “I 
can’t do all the things normal people do because it’s too easy to get injured” corresponding to 
TSK item 15 and BFOM item 6 predicted disability, but not quality of life in this patient 
group. According to the TSK-17 score, in patients with high-level kinesiophobia, age, 
activity-related pain intensity, disability, depression, and KL grade were higher and physical 

activity level, quality of life and educational status were lower compared to those with low-
level kinesiophobia. 
More than half of the patients agreed or strongly agreed with the BFOM items, “Simply being 
careful that I do not make unnecessary movements is the safest thing I can do to prevent pain 
from worsening” (68.1%), “I am afraid that I may injure myself accidently” (67%), and “I 
can’t do all the things normal people do because it’s too easy to get injured” (63.9%). 
Similarly, Gunn et al. evaluated 350 knee OA cases (71.7% women) with a mean age of 65.3 
years and reported that 58.1% of the patients agreed or strongly agreed with the BFOM item, 
“Simply being careful that I do not make unnecessary movements is the safest thing I can do 
to prevent pain from worsening”. The authors also noted that fear of movement was less seen 
in patients with a better functional status and higher in females than in males, and BFOM was 
appropriate and practical in evaluating fear of movement in patients with knee OA (34). In 
another study, Shelby et al. assessed fear of movement using TSK-17 and BFOM in 1,136 
patients with hip and knee OA (68.7% women) with a mean age of 71.5 years. They found a 
positive relationship between pain catastrophizing and pain intensity, and a negative 
relationship between the BFOM scores and physical-mental functions and WOMAC scores. 
The authors concluded that BFOM was correlated with physical and psychological functional 
status and pain, and was a valid tool for assessing fear of movement in patients with knee OA 
(15). Similar to the studies mentioned above, we observed that the BFOM score was higher in 
female patients with knee OA than in male cases and was associated with disability in 
women. Unlike the literature, we detected no relationship between BFOM and disability in 
male patients. In addition, the BFOM score was positively correlated with age, activity-related 
pain, night pain and depression, and negatively correlated with quality of life in women, and 
positively correlated with age and negatively correlated with quality of life in men. Although 
the BFOM score was correlated with quality of life and disability in patients with knee OA, it 

predicted neither of these variables. The patients with high-level kinesiophobia based on the 
TSK-17 score had a significantly higher BFOM score than those with low-level 
kinesiophobia. Gunn et al. concluded that in patients with knee OA, adoption of joint 
protection strategies and avoidance of behavior with high potential of damage to joints is part 
of the disease management, but in some patients, pain-related fear leads to a general limitation 
of movement and a sedentary lifestyle (34). Somers et al. also reported that individuals with 
pain-related fear exhibited fear avoidance behavior and low physical activity levels, 
supporting the data obtained from the current study (13). Our multiple regression analysis 
revealed that the KL grade, kinesiophobia and TSK-17 item 15/BFOM item 6 (“I can’t do all 
the things normal people do because it’s too easy to get injured”) successfully predicted 
disability, and KL grade and depression were effective in predicting quality of life; however, 
the remaining variables did not adequately predict either parameter. In the literature, in 
contrast to many studies associating fear of movement with low functional status (13, 34, 35), 
Gunn et al. did not detect a significant association between pain and fear of movement in 
multiple regression analysis despite the presence of a significant relationship in the paired 
analysis, and thus noted that reducing pain alone was not sufficient to manage fear of 
movement (34). In the current study, consistent with the literature, we observed that 
radiological findings were correlated with disability (4) and quality of life, and depression 
negatively affected quality of life (13). 
Gay et al. (36) evaluated 548 knee OA patients comprising 73.9% women, with a mean age of 
67.6 years, reporting that the physical activity level was low in 18.8% of the patients, 
moderate in 38.6%, and high in 42.6%. In the current study, the physical activity level of the 
patients was significantly lower compared to the previous study, and we found no significant 
difference in physical activity level between male and female patients. In a study of 55 
patients over 65 years of age, the BDI and WOMAC scores were higher and the SF-36 score 

was lower in the physically inactive group (37). In our study, the physical activity level was 
significantly lower in those with high-level kinesiophobia than those with low-level 
kinesiophobia, but we observed no significant relationship between the physical activity level 
and TSK-17 and BFOM scores. It was previously reported that high-level pain catastrophizing 
was correlated with a low level of physical activity (38-42), and patients with OA tended to 
avoid painful physical activity with the idea that it might increase the pain or severity of their 
disease (13, 43-45) and exhibited sedentary behavior (46). In contrast, we determined that 
although the physical activity level was correlated with disability and quality of life in 
patients with knee OA, it did not sufficiently predict these two parameters. 
It was previously reported that psychological factors, such as anxiety and depression were 
more common and played a decisive role in the continuity of pain in women with OA, and the 
rate of depression in patients with knee OA was 49.3% (7, 8). Researchers also noted that 
patients with depressive symptoms had greater fear of movement compared to those with 
exercise-related self-efficacy (13, 23, 35). Pain catastrophizing and pain-related fear were 
shown to be correlated with psychological disability in patients with knee OA, psychological 
disability was more common in patients with a high level of pain (13), and the BFOM score 
was moderately correlated with pain and psychological functions (13, 23). In the current 
study, we observed a higher rate of depression in women than in men and in patients with 
high-level kinesiophobia compared to those with low-level kinesiophobia. Depression was 
correlated with both TSK-17 and BFOM scores in women, whereas it was only correlated 
with the TSK-17 score in men. The literature contains studies supporting that psychological 
factors, such as affective, cognitive and behavioral variables are predictors of pain and 
disability in patients with OA (12, 47). We determined that depression was correlated with 
both disability and quality of life in patients with knee OA, but it was only valuable in 
predicting quality of life and not sufficient to predict disability. It was previously reported that 

pain catastrophizing was a determinant of pain development, and therefore it should be 
evaluated as a risk factor for the chronicity of pain in patients with OA (13). 
Alkan et al. noted that all scores related to the SF-36 assessment were lower in patients with 
knee OA compared to the healthy controls, and quality of life was correlated with pain 
intensity and disability (48). Webster et al. compared SF-12 and SF-36 scores in patients with 
knee OA who had undergone replacement surgery and reported that SF-12 was a more 
practical and appropriate evaluation method in these patients (49). Vennu et al. assessed 
quality of life of 4,484 patients with knee OA using SF-12 and reported the scores as 47.3 ± 
9.3 and 53.0 ± 8.6 for the physical and mental components, respectively (50). In our study, the 
quality of life of patients with knee OA was significantly lower than in the literature. 
Furthermore, the quality of life was worse than that of males and it was significantly lower in 
patients with high level kinesiophobia than those with low level kinesiophobia. The TSK-17 
and BFOM scores were correlated with the SF-12 total, physical and mental scores in female 
patients, and the SF-12 total and physical scores in male patients. Depression was valuable in 
predicting the mental component of SF-12, and the KL grade successfully predicted the 
physical component of SF-12. 
The small size of the sample, lower number of male patients, absence of a control group, and 
higher number of patients with high-level kinesiophobia than those with low-level 
kinesiophobia are among the limitations of the current study. 
 
Conclusions 
 
Fear of movement is a condition commonly seen in patients with knee OA and may cause 
disability and physical inactivity. Since physical activity is an important component in the 
management of knee OA, the treatment outcomes may be poor in patients with fear of 

movement. Considering that in patients with knee OA, treatment of pain alone is not 
sufficient to reduce fear of movement, we suggest that approaches to increase physical 
activity and cognitive behavioral therapy to overcome this fear should be included in the 
treatment program. 
 
 
Acknowledgments: None 
 
Conflict of Interest: There was no conflict of interest. 
 
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Table 1. Sociodemographic and descriptive data of the patients with knee osteoarthritis 
Characteristics 
Frequency (n/%) 
Characteristics 
Value (Mean±SD) 
Gender (F/M) 
67 (69.1)/ 29 (29.9) 
Age 
60.92±7.99 
Level of Education 
 
BMI 
31.28±4.70 
No formal education 
33 (34.3) 
VAS 
 
Primary School 
40 (41.6) 
VAS-at rest  
36.77±24.51 
Middle School 
12 (12.5) 
VAS-activity related 
72.13±17.70 
High School 
5(5.2) 
VAS-at night 
72.13±17.70 
University 
6(6.2) 
TSK-17 
40.72±14.05 
Occupation 
 
BFOM 
14.58±5.85 
Unemployed  
82(85.4) 
Kinesiophobia rate (n/%) 
78 (80.4) 
Desk work 
2  (2.0) 
WOMAC total 
51.00±22.37 
Physical work 
12(12) 
BDI 
12.43±8.84 
BMI Evaluation 
 
Depression rate (n/%) 
60 (61.9) 
Underweight 
1  (1) 
SF-12 
 
Normal weight  
4  (4.1) 
SF-12 physical 
9.36±3.65 
Overweight 
38(39.5) 
SF-12 mental 
13.57±5.63 
Mildly obese 
51(53.1) 
SF-12 total 
22.93±8.89 
Morbid obese 
2  (2) 
Physical activity (n/%) 
 
KL Classification 
 
Low  
58 (60.4) 
Grade 1 
7  (7.2) 
Moderate  
25 (26) 
Grade 2 
47(48.9) 
High  
7 (7.3) 
Grade 3 
36(37.5) 
 
 
Grade 4 
4  (4.1) 
 
 
 
F: Female, M: Male, BMI: Body Mass Index, KL: Kellgren-Lawrence Classification, VAS: 
Visual Analog Scale, TSK-17: Tampa Scale of Kinesiophobia, BFOM: Brief Fear of 
Movement Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index, 
BDI: Beck Depression Inventory, SF-12: Short Form-12 Health Survey Questionnaire. 
 
 
 
 
 
 
  

Table 2. Evaluation of parameters by gender in patients with knee osteoarthritis 
 
BMI: Body Mass Index, VAS: Visual Analog Scale, TSK-17: Tampa Scale of Kinesiophobia, 
BFOM: Brief Fear of Movement Scale, WOMAC: Western Ontario and McMaster 
Universities Arthritis Index, BDI: Beck Depression Inventory, SF-12: Short Form-12 Health 
Survey Questionnaire. 
 
 
 
 
  
  
 
 
 
Parameters (mean±SD) 
Female (n:67)   
Male (n:29) 
P 
Age 
60.598.00 
61.65±8.08 
0.555 
BMI 
32.35±4.53 
28.81±4.19 
0.001 
VAS-at rest 
45.52±27.09 
28.96±23.04 
0.005 
VAS-activity related 
74.55±16.71 
66.55±18.95 
0.041 
VAS-at night 
53.73±26.31 
33.79±28.33 
0.001 
TSK-17 
44.77±8.87 
42.00±7.06 
0.154 
BFOM 
16.59±3.91 
14.37±3.84 
0.016 
Kinesiophobia rate (n/%) 
54(80.5) 
22(75.8) 
0.490 
WOMAC total 
54.95±22.78 
41.88±18.75 
0.008 
BDI 
15.31±8.69 
11.33±5.92 
0.034 
Depression rate (n/%) 
44(65.67) 
16(55.1) 
0.118 
SF-12 physical 
9.74±2.63 
10.92±2.46 
0.046 
SF-12 mental 
14.03±4.29 
16.03±4.02 
0.042 
SF-12 total 
23.77±6.39 
26.96±5.73 
0.028 
Physical activity (n/%)  
 
Low 
 
Moderate 
 
High 
 
43(64.1) 
16 (23.8) 
4 (5.9) 
 
15 (51.7) 
9 (31) 
3 (10.3) 
0.688 

Table 3. Sociodemographic and descriptive data of the patients with knee osteoarthritis 
according to their level of kinesiophobia (n: 89)† 
†: Seven participants had incomplete responses in TSK-17. 
BMI: Body Mass Index, VAS: Visual Analog Scale, TSK: Tampa Scale of Kinesiophobia, 
BFOM: Brief Fear of Movement Scale, WOMAC: Western Ontario and McMaster 
Universities Arthritis Index, BDI: Beck Depression Inventory, SF-12: Short Form-12 Health 
Survey Questionnaire.  
Parameters  
High-level kinesiophobia 
(n:76) 
Low-level kinesiophobia 
(n:13)  
p 
Age 
62.01±8.28 
55.07±3.09 
0.000 
BMI 
31.57±4.90 
29.42 ±4.08 
0.106 
VAS-at rest 
43.28±26.35 
31.53±24.09 
0.136 
VAS-activity related 
74.73±16.77 
62.30±15.89 
0.015 
VAS-at night 
50.46±27.83 
33.84±27.54 
0.050 
TSK-17 
46.55±5.54 
28.61±5.56 
0.000 
BFOM 
17.05±3.01 
9.30±2.21 
0.000 
WOMAC total 
55.01±19.90 
27.20±20.44 
0.000 
BDI 
14.86±8.12 
8.54±5.57 
0.015 
Depression rate (n/%) 
56(75.6) 
4(36.3) 
0.013 
SF-12 physical 
9.60±2.27 
13.00±2.85 
0.000 
SF-12 mental 
14.06±4.08 
17.76±4.34 
0.004 
SF-12 total 
23.66±5.8 
30.76±6.33 
0.000 
Physical activity (n/%)  
 
 
0.011 
Low 
51 (68) 
6 (46.15) 
 
Moderate 
21 (28) 
3 (23.07) 
 
High 
3 (4) 
4 (30.76) 
 
BMI Evaluation (n/%) 
 
 
0.727 
Underweight 
1(1.3) 
0(0) 
 
Normal weight  
3(3.9) 
1(7.6) 
 
Overweight 
29(38.1) 
7(53.8) 
 
Mildly obese 
41(53.9) 
5(38.4) 
 
Morbidly obese 
2(2.6) 
0(0) 
 
KL Classification (n/%) 
 
 
0.001 
Grade 1 
3(3.9) 
3(23) 
 
Grade 2 
33(43.4) 
10(76.9) 
 
Grade 3 
36(47.3) 
0(0) 
 
Grade 4 
4(5.2) 
0(0) 
 
Level of Education (n/%) 
 
 
0.001 
No formal education 
25 (32.8) 
5 (38.4) 
 
Primary School 
36 (47.3) 
1 (7.6) 
 
Middle School 
9 (11.8) 
2 (15.3) 
 
High School 
4 (5.2) 
1 (7.6) 
 
University 
2 (2.6) 
4 (30.7) 
 
Occupation (n/%) 
 
 
0.137 
Unemployed  
66 (86.8) 
11 (84.6) 
 
Desk job 
1 (1.3) 
1 (7.6) 
 
Physically demanding job  
9 (11.8) 
1 (7.6) 
 

Table 4. Distribution of the patients’ responses to the items in the Brief Fear of Movement 
Scale (n: 89†) 
Item 
Strongly 
agree, %  
Agree, 
% 
Disagree, 
% 
Strongly 
disagree, % 
I am afraid that I may injure myself if I exercise (TSK 
1) 
17.5 
21.6 
28.9 
22.7 
If I were to try to overcome it, my pain would increase 
(TSK 2) 
6.2 
29.9 
35.1 
19.6 
I am afraid that I might injure myself accidently (TSK 
9) 
33.0 
34. 
15.5 
8.2 
Simply being careful that I do not make unnecessary 
movements is the safest thing I can do to prevent pain 
from worsening (TSK 10) 
25.8 
42.3 
14.4 
8.2 
It’s really not safe for a person with a condition like 
mine to be physically active (TSK 14) 
9.3 
38.1 
26.8 
16.5 
I can’t do all the things normal people do because it’s 
too easy to get injured (TSK 15) 
29.9 
34.0 
21.6 
5.2 
 
†: Seven participants had incomplete responses in BFOM. 
 
 
 
 
 
 
 
  
  
 
 
 

Table 5. Parameters correlated with disability and quality of life in patients with knee 
osteoarthritis (n: 85†) 
Parameters  
 
WOMAC total 
SF-12 physical 
SF-12 mental 
SF-12 total 
Age  
r 
.199 
.068 
-.454 
.000 
-.259 
.017 
-.351 
.001 
p 
BMI 
r 
.304 
.005 
-.004 
.973 
-.163 
.135 
-.127 
.245 
p 
VAS-at rest 
r 
.427 
.000 
-.471 
.000 
-.419 
.000 
-.480 
.000 
p 
VAS-activity related 
r 
.422 
.000 
-.565 
.000 
-.432 
.000 
-.516 
.000 
p 
VAS-at night 
r 
.390 
.000 
-.428 
.000 
-.423 
0.000 
-.474 
.000 
p 
KL grade 
r 
.489 
.000 
-.651 
.000 
-.518 
.000 
-.611 
.000 
p 
TSK-17 score 
r 
.526 
.000 
-.334 
.002 
-.409 
.000 
-.423 
.000 
p 
BDI score 
r 
.470 
.000 
-.451 
.000 
-.646 
.000 
-.619 
.000 
p 
Physical activity level 
r 
-.422 
.000 
.628 
.000 
.515 
.000 
.604 
.000 
p 
BFOM score 
r 
.499 
.000 
-.475 
.000 
-.504 
.000 
-.545 
.000 
p 
 
†: Correlation analyses conducted for 85 patients. 
BMI: Body Mass Index, VAS: Visual Analog Scale, TSK: Tampa Scale of Kinesiophobia, 
BFOM: Brief Fear of Movement Scale, WOMAC: Western Ontario and McMaster 
Universities Arthritis Index, BDI: Beck Depression Inventory, SF-12: Short Form-12 Health 
Survey Questionnaire, KL: Kellgren-Lawrence Classification. 
 
 
  
 
 
 
 

Table 6. Parameters correlated with TSK and BFOM scores in patients with knee 
osteoarthritis 
 
 
Female 
 
 
 
 
 
Male 
 
Parameters 
 
TSK 
BFOM 
 
 
 
TSK 
BFOM 
Age 
r 
0.039 
0.370 
 
Age 
r 
0.511 
0.492 
 
p 0.761 
0.003 
 
 
p 
0.006 
0.009 
VAS-activity 
related 
r 
0.155 
0.417 
 
TSK-17 
r 
1.000 
0.776 
 
p 0.228 
0.001 
 
 
p 
. 
0.000 
VAS-at night 
r 
0.051 
0.282 
 
Kinesiophobia rate 
r 
0.679 
0.615 
 
p 0.692 
0.028 
 
 
p 
0.000 
0.001 
TSK-17 
r 
1.000 
0.709 
 
SF-12 physical 
r 
-0.458 
-0.518 
 
p . 
0.000 
 
 
p 
0.016 
0.006 
Kinesiophobia rate 
r 
0.582 
0.578 
 
SF-12 total 
r 
-0.430 
-0.475 
 
p 0.000 
0.000 
 
 
p 
0.025 
0.012 
WOMAC total 
r 
0.527 
0.489 
 
BDI 
r 
0.405 
0.346 
 
p 0.000 
0.000 
 
 
p 
0.036 
0.077 
SF-12 physical 
r 
-0.311 
-0.444 
 
Depression rate 
r 
0.381 
0.379 
 
p 0.015 
0.000 
 
 
p 
0.050 
0.051 
SF-12 mental 
r 
-0.450 
-0.521 
 
BFOM 
r 
0.776 
1.000 
 
p 0.000 
0.000 
 
 
p 
0.000 
. 
SF-12 total 
r 
-0.435 
-0.547 
 
 
 
 
 
 
p 0.000 
0.000 
 
 
 
 
 
BDI 
r 
0.364 
0.404 
 
 
 
 
 
 
p 0.005 
0.002 
 
 
 
 
 
Depression rate 
r 
0.339 
0.353 
 
 
 
 
 
 
p 0.009 
0.006 
 
 
 
 
 
BFOM 
r 
0.709 
1.000 
 
 
 
 
 
 
p 0.000 
. 
 
 
 
 
 
 
VAS: Visual Analog Scale, TSK: Tampa Scale of Kinesiophobia, BFOM: Brief Fear of 
Movement Scale, WOMAC: Western Ontario and McMaster Universities Arthritis Index, 
BDI: Beck Depression Inventory, SF-12: Short Form-12 Health Survey Questionnaire.

 
Table 7. Multivariable associations of patient characteristics with WOMAC and SF-12 physical, 
mental and total scores. 
 
Independent 
variables 
Dependent variables 
 
WOMAC 
SF-12 physical 
SF-12 mental 
SF-12 total 
 
β 
(95% 
CI) 
(lower, 
upper) 
p 
r2 
β 
(95% 
CI) 
(lower, 
upper) 
p 
r2 
β 
(95% 
CI) 
(lower, 
upper) 
p 
r2 
β 
(95% 
CI) 
(lower, 
upper) 
p 
r2 
KL grade 
4.843-
20.367 
0.002 
0.624 
-2.987 
-1.760 
0.000 
0.416 
- 
- 
- 
-5.726 
-2.946 
0.000 
0.565 
TSK score 
0.715-
2.745 
0.001 
0.624 
- 
- 
- 
- 
- 
- 
- 
- 
- 
TSK 
question 15 
-
14.970 
-0.173 
0.045 
0.624 
- 
- 
- 
- 
- 
- 
- 
- 
- 
BDI score 
- 
- 
- 
- 
- 
- 
-0.422 
-0.240 
0.000 
0.387 
-0.459 
-0.219 
0.000 
0.565 
 
 
 
 
 
 
KL: Kellgren-Lawrence Classification, TSK: Tampa Scale of Kinesiophobia, WOMAC: 
Western Ontario and McMaster Universities Arthritis Index, BDI: Beck Depression 
Inventory, SF-12: Short Form-12 Health Survey Questionnaire, CI: Confidence Interval.