Evaluation of Kinesiophobia and Physical Activity Levels in Patients With Fibromyalgia Syndrome and Chronic Neck Pain
Conditions: Fibromyalgia, Neck Pain, Healthy
Sponsor: Aksaray University Training and Research Hospital

01.10.2018 
 
         Evaluation of Kinesiophobia and Physical Activity Levels in Patients with 
Fibromyalgia Syndrome and Chronic Neck Pain 
          Melek Aykut Selçuk1  
         1.Aksaray University Training and Research Hospital, Aksaray, Turkey.  
 
Principal Investigator  
Phone number: 90 555 528 94 93  
Mail address: mlk.aykut@gmail.com 
 Address: Physical Medicine and Rehabilitation Outpatients Clinic of Aksaray University 
Training and Research Hospital, Aksaray, Turkey  
Approval date and reference number of Ethical Committee of Aksaray University Training 
and Research Hospital: 26.9.18, 2018/155  
The study has no clinical trials registration number yet 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

         Evaluation of Kinesiophobia and Physical Activity Levels in Patients with 
Fibromyalgia Syndrome and Chronic Neck Pain 
         ABSTRACT  
         Introduction: Kinesiophobia which is described as fear of movement reduces 
physical activity levels and increases the risk of chronic pain. Kinesiophobia has not been 
studied in detail in patients with fibromyalgia syndrome and chronic neck pain.  
        Objective: To evaluate pain, kinesiophobia, physical activity, depression, disease 
severity, and fatigue in patients with fibromyalgia syndrome or chronic neck pain and 
healthy controls.  
        Design: Cross-sectional study. Setting: Tertiary Health Care Center, Aksaray, Turkey 
Participants: 30 patients with fibromyalgia syndrome (Group 1), 30 patients with chronic 
neck pain (Group 2), and 30 healthy individuals (Group 3) were included.  
       Main Outcome Measures: Outcome measures were Visual Analogue Scale (VAS)- 
pain and fatigue, Tampa Scale of Kinesiophobia (TSK), Beck Depression Inventory 
(BDI), International Physical Activity Questionnaire (IPAQ) Short Form, Fibromyalgia 
Impact Questionnaire (FIQ), Neck Pain Disability Index (NPDI). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
INTRODUCTION  
Fibromyalgia syndrome (FS) is a condition that generally affects young adult women aged 
20 to 55 years, with a prevalence of 2-3% in the general population and unknown etiology. 
In addition to the widespread pain in the body, FS has a wide range of other symptoms, 
including sleep disorder, fatigue, depression, anxiety, cognitive impairment, headache, and 
gastrointestinal complaints (1). Almost all patients with FS complain of fatigue and report 
difficulty even performing daily tasks due to this complaint (2). Although exercise has an 
important role in the treatment of FS, the level of physical activity is reported to be lower 
in patients with FS than in healthy controls. It is considered that physical inactivity is 
caused by several factors, including fatigue, pain, and kinesiophobia. In addition to 
fatigue, FS patients with low levels of physical activity have been shown to have reduced 
pain threshold and pain inhibition, depression, pain catastrophizing, and fear of movement 
(3, 4). Described as fear of movement, kinesiophobia refers to avoidance of physical 
activity due to excessive fear and anxiety concerning pain, which reduces mobility and 
muscle strength and triggers more fear of movement, and this vicious circle increases the 
risk of chronic pain (5). In a study evaluating the fear of movement in FS cases, patients 
with a high level of fear and anxiety were found to have more insomnia, catastrophic 
thoughts, disability, negative emotions, depression, high pain intensity, lower physical 
performance, reduced cognitive performance, and a lower quality of life (6, 7). Thirty to 
fifty percent of the general population experience neck pain, one of the most common 
musculoskeletal complaints, in their lifetime. Neck pain is a common symptom among 
office workers, of whom 50% associated this pain with their occupation and 14% stated 
that it restricted their daily life activities (8, 9). In general, it has been shown that the 
frequency and severity of neck pain are reduced in office workers who exercise or engage 
in sportive activities and that the risk of chronic pain increases in those that are physically 
inactive (10, 11). In patients with neck pain, fear of movement caused by fear avoidance 
beliefs and behaviors results in restriction of physical activity and development of chronic 
pain, leading to depression, disability, and reduced job performance and quality of life (12, 
13). In this study, we evaluated pain, kinesiophobia, physical activity, depression, disease 
severity, and fatigue in patients with FS and chronic neck pain (CNP), and healthy 
controls. We aimed to identify the factors related to kinesiophobia and restricted physical 
activity to take the necessary measures to prevent these behaviors.  
METHODS  
Study Design  
We assessed pain intensity, kinesiophobia, fatigue, depression, physical activity level and 
disability in patients with FS and CNP, and healthy individuals in this cross-sectional 
study. The patients were recruited from a physical medicine and rehabilitation outpatients 
clinic of Aksaray University Training and Research Hospital, Aksaray, Turkey. The 
healthy control group was consisting of doctors, nurses, medical secretaries who work in 
Aksaray University Training and Research Hospital, and patient care providers that have 
no pain and additional diseases. Following the Helsinki Declaration, our study was 
approved by the Ethics Committee of Aksaray University Training and Research Hospital 

(26.9.18, reference number: 2018/155) and written informed consent was obtained from 
all the participants.  
Participants  
Thirty patients with a diagnosis of FS according to the 2016 revised ACR FS diagnostic 
criteria and a disease duration of longer than three months; 30 patients with CNP lasting 
for more than three months, and 30 healthy controls without pain or additional disease 
were included in the study that was conducted between October 2018 and December 
2018. All the participants were aged 18 to 65 years. The exclusion criteria were 
malignancy, systemic infectious and rheumatic diseases, history of operation, having 
received physical therapy or intra-articular or intra-ligamentary injection within the last 
three months, previous diagnosis of a psychological or cognitive disorder, and history of 
pregnancy.  
Main Outcome Measures  
The demographic data of the participants were recorded on a personal information form. 
Pain intensity and fatigue were evaluated by the Visual Analogue Scale (VAS), 
kinesiophobia by the Tampa Scale of Kinesiophobia (TSK), depression by the Beck 
Depression Inventory (BDI), physical activity level by the International Physical Activity 
Questionnaire (IPAQ) Short Form, functional status in patients with FS by the 
Fibromyalgia Impact Questionnaire (FIQ), and neck pain-related disability in the neck 
pain group by the Neck Pain Disability Index (NPDI). The details of the implementation 
of the instruments are as follows: Visual Analog Scale (VAS) for the Evaluation of Pain 
and Fatigue For this evaluation, the patient is asked to mark his/her severity of pain and 
fatigue on a horizontal 10-cm line with number 0 on one end representing “no pain or no 
fatigue” and number 10 on the other end indicating “very severe pain or very severe 
fatigue” (14, 15). Tampa Scale of Kinesiophobia (TSK) Based on a four-point Likert type, 
this scale contains 17 items that evaluate fear and anxiety related to physical activity. A 
total score of greater than 37 is accepted as statistically significant and interpreted as a 
high level of kinesiophobia. The validity and reliability analysis of the Turkish version of 
TSK was undertaken by Yilmaz et al. (16). Beck Depression Inventory (BDI) This is a 21-
item questionnaire that investigates the characteristic attitudes and symptoms of 
depression. A score of 10 or higher indicates depression (17). International Physical 
Activity Questionnaire (IPAQ) Short Form IPAQ consists of seven items that measure the 
duration of the participants’ physical activity, walking and sitting within the last seven 
days in the MET-min/week unit (18). Fibromyalgia Impact Questionnaire (FIQ) FIQ aims 
to evaluate the arthritis symptoms and functional status of patients with FS through 21 
questions that inquire about physical functions, work-related situations, depression, 
anxiety, waking up tired, pain, stiffness, and fatigue. The validity and reliability of the 
Turkish version of FIQ was tested by Ediz et al. (19). Neck Pain Disability Index (NPDI) 
This index consists of 20 questions that assess severity of neck pain and the extent to 
which the pain affects the social, professional and daily activities of patients (20).  
Statistical Analysis  
Statistical analysis was performed using the Statistical Package for the Social Sciences 
(SPSS) v. 15.0. Descriptive statistics were given as mean ± standard deviation (SD) for 

variables with normal distribution, and frequency tables for ordinal and categorical 
variables. We chose to conduct the Kolmogorov-Smirnov test for the normalization 
analysis. The MannWhitney U test was employed for paired comparisons of numerical 
sociodemographic data, chi-square test for the paired comparison of categorical 
sociodemographic data and the comparison of sociodemographic data (except age and 
disease duration) between three groups, and one-way analysis of variance (ANOVA) for 
the comparison of age and disease duration between the three groups. Before conducting 
one-way ANOVA, the Levene test was performed to test the homogeneity of variance. 
Since the result of this test was p > 0.05 for VAS-fatigue, TSK and BDI, the Tukey test 
was employed for post hoc analysis. For VASpain and FIQ that produced p < 0.05 in the 
Levene test, the Games-Howell post hoc test was preferred. Spearman’s correlation 
analysis was undertaken individually for each group. The level of statistical significance 
was accepted as p < 0.05