The relationship of fear of pain, pain anxiety, and fear-avoidance beliefs with perceived stress in surgical patients with postoperative kinesiophobia

Abstract

Background

Kinesiophobia is one of the most prevalent postoperative problems with negative effects on patient mobility. Fear of pain (FOP), pain anxiety (PA), and fear of avoidance beliefs (FABs) are influential factors on postoperative mobility and may be affected by perceived stress (PS). The present study examined whether perceived stress serves to mediate the relationship between fear of pain, pain anxiety, and fear of avoidance beliefs with kinesiophobia (fear of movement) in postoperative patients.

Methods

The study was conducted in the neurosurgery, general surgery, and orthopedic wards of a hospital in Amol, Iran. A total of 330 patients (178 men and 152 women), aged 18 to 74 years, who had undergone various surgical procedures, were included. Participants were recruited using a consecutive sampling technique over a defined period to account for the staggered timing of surgeries and ensure broader representation. All patients were assessed six hours post-surgery using validated instruments, including the Tampa Scale for Kinesiophobia, Pain Anxiety Symptoms Scale, Fear of Pain Questionnaire, Fear-Avoidance Beliefs Questionnaire, and Perceived Stress Scale.

Findings

The majority of the sample were men (53.9%), married (80%), with a mean age of 44.38 (SD = 13.49) years. Of the participants, 119 (36.1%) underwent orthopedic surgery, 139 (42.1%) underwent abdominal surgery, and 72 (21.8%) underwent surgery for discopathy. The path analysis revealed that kinesiophobia exhibited a significant relationship with FABs (β = 0.206; p < 0.001; 95% CI: 0.009 to 0.017) and PA (β = 0.474; p < 0.001; 95% CI: 0.021 to 0.031), while no significant relationship was found with FOP (β = 0.072; p = 0.408; 95% CI: -0.011 to 0.011). Also, the findings indicated that PS as mediator had a significant relationship with FABs (ß = 0.191; P < 0.001; 95% CI: 0.009 to 0.017), PA (ß = 0.393; P < 0.001;95% CI: 0.021 to 0.031), and kinesiophobia (ß = 0.812; P < 0.001; 95% CI: 0.021 to 0.031.

Conclusion

The study found that pain anxiety and fear-avoidance beliefs are key factors contributing to kinesiophobia after surgery. Addressing these fears is important for improving postoperative mobility. Perceived stress mediated the relationship between these factors and kinesiophobia. Managing stress may be a helpful intervention to improve outcomes for postoperative patients. Healthcare providers should assess and address psychological factors like pain anxiety and fear-avoidance beliefs to promote better recovery and mobility in patients after surgery.

Introduction

Around 310 million major surgeries are performed worldwide annually [1]. Among these, accident-related injuries account for approximately 48 million cases each year [2]. The significant financial burden of surgeries has led to a shift in resources from social services to postoperative and hospitalization-related care [3]. Ineffective postoperative nursing care can prolong hospital stays [3] and increase the incidence of in-hospital postoperative complications [4, 5].

Pain is a common postoperative complication, affecting 10–50% of patients and it increases the risk of postoperative complications by 20% [6, 7]. Following surgery, pain receptors are continuously stimulated due to tissue injury, which leads to hypersensitization of central nervous system neurons [8, 9]. This pain experience is not only a physiological response but also involves emotional, cognitive, sociocultural, and behavioral factors. Without effective pain management, postoperative pain may lead to a cycle of disability and suffering, particularly when patients develop avoidance behaviors due to pain-related fear [10].

Fear of pain (FOP) is one of the psychological consequences of postoperative pain [11]. Movement-related physical threats following surgery elevate FOP [12], prompting hypervigilant behaviors to prevent further pain [13]. FOP is particularly prevalent among surgical patients and individuals with musculoskeletal disorders [14]. It can result in pain catastrophizing, avoidance, and disability, thereby increasing the risk of depression [15]. Some studies conceptualized FOP within the framework of the fear-avoidance model, which posits that individuals with FOP and pain catastrophizing are more susceptible to chronic pain and prolonged disability [16,17,18,19].

Kinesiophobia, or fear of movement, is another postoperative complication. It is defined as an excessive, irrational, and debilitating fear of movement due to a perceived vulnerability to pain or reinjury [20]. It occurs when patients believe that physical movement can lead to additional pain, eventually progressing to a state where even minimal movements becomes painful [18]. Studies indicate that the prevalence of kinesiophobia among individuals experiencing persistent pain is approximately 50–70% [21].

Psychological factors such as FOP, pain anxiety (PA), and fear-avoidance beliefs (FABs) play a significant role in the development of postoperative kinesiophobia. Zale and Datre introduced an anxiety-based fear-avoidance model that explains how PA exacerbates fear of movement and avoidance behaviors, ultimately leading to increased kinesiophobia [21]. Additionally, several studies have shown that perceived stress serves as a crucial mediator in this process, influencing how patients perceive and respond to pain in the postoperative period [22,23,24]. Kinesiophobia negatively impacts patients’ mobility and pain perception [24]. It reduces quality of life, prolongs recovery, aggravates pain, and increases the risk of chronic pain, disability, immobility, and depression [21, 25, 26]. Asmundson expanded the fear-avoidance model by incorporating anxiety, differentiating fear from anxiety in an anxiety-based fear-avoidance model [19]. PA refers to concerns and worries about prospective pain [27], that emerges due to FOP, and perpetuates a vicious cycle of fear [28]. These three concepts—PA, FOP, and kinesiophobia—are interrelated [27, 29, 30]. Because kinesiophobia can impair postoperative movement [31,32,33], effective management strategies may improve recovery and mobility while reducing stress and complications such as thromboembolism, pulmonary embolism, atelectasis, and pressure ulcers [34, 35].

Many factors contribute to kinesiophobia, including avoidance behaviors, pain, fear, and postoperative complications [36, 37]. If a patient avoids movement due to fear of pain, kinesiophobia is likely to develop [38]. To understand these psychological responses, Reinforcement Sensitivity Theory (RST) provides a valuable framework [39]. RST is a biological model that postulates that ndividual differences in fear and anxiety responses, distinguish between fear and anxiety based on three hypothesized brain systems. These include the behavioral activation system (BAS), which regulates approach behavior; the behavioral inhibition system (BIS), which mediates conflict and underlying anxiety; and the fight-flight-freeze system (FFFS), which mediates responses to aversive stimuli and underlies fear [40]. Therefore, fear and anxiety in postoperative patients can trigger avoidance or motivational reactions [41, 42]. If avoidance occurs, kinesiophobia develops [38].

Stress is another prevalent postoperative complication [43,44,45,46,47,48], often referred to as the epidemic of the 21st century due to its widespread impact and economic burden [49]. It affects physical, emotional, and biopsychosocial health, worker’s productivity, and environmental adaptation [49,50,51]. The perception of unpredictable and uncontrollable stress is termed PS [23]. Chronic pain can disrupt the normal adaptation process associated with stress [52], transforming it into a debilitating phenomenon that exacerbates severe stress [53]. Pain and stress interact on multiple levels, influencing physiological, cognitive, and behavioral responses. For instance, stress and negative emotions negatively impact endocrine function and pain perception [54]. At the cognitive-behavioral level, PS shapes pain perception and related behaviors, such as avoidance and adaptation [52]. It also alters patients’ perception of fear, anxiety, and avoidance.

Studies have demonstrated significant relationships among kinesiophobia, PA, and FABs in patients with back pain [29] and upper extremity disabilities [55]. Investigating the interrelationships among FOP, PA, PS, and FABs may help predict treatment outcomes, reduce postoperative complications, determine optimal treatment strategies, and enhance self-management. However, limited data exist regarding postoperative kinesiophobia [37] and its predictors [36, 56], as well as the influence of postoperative PS on factors like kinesiophobia, fear, pain, avoidance, and anxiety [29, 52, 55, 57, 58]. Further research is needed to bridge this knowledge gap.

Theoretical framework

In terms of theoretical framework, Reinforcement Sensitivity Theory is one of the major biological models of individual differences in fear and anxiety responses. The theory distinguishes between fear and anxiety, and links reinforcement processes to personality. Gray’s model of personality was based on three hypothesized brain systems: Behavioral activation system (BAS) proposed to facilitate reactions to all appetitive/rewarding stimuli and regulates approach behavior. The behavioral inhibition system (BIS) is thought to mediate conflict both within and between Fight-flight-freeze system (avoidance) and BAS (approach). These conflicts underlie anxiety. Fight-flight-freeze system (FFFS) proposed to mediate reactions to all aversive/ punishing stimuli, regulate avoidance behavior, and underlies fear [40]. Thus, the fear and anxiety of postoperative patients can provoke an avoidance or motivational reaction [41, 42]. If the patient avoids movement due to fear of pain or reinjury, kinesiophobia is likely to develop [38].

The relationship between kinesiophobia, FOP, PA, FABs, and PS creates a complex network that impacts postoperative recovery. Kinesiophobia, characterized by an excessive fear of movement due to the expectation of pain or injury, is rooted in cognitive-behavioral responses to past pain experiences. This fear can lead to avoidance behaviors that worsens physical limitations and psychological distress [10].

Fear of pain significantly contributes to kinesiophobia. When patients view pain as a threat, they may develop increased vigilance and avoidance behaviors, resulting in reduced mobility and heightened disability [59]. This aligns with the Fear-Avoidance Model, which suggests that individuals who catastrophize their pain are more likely to avoid movement, perpetuating a cycle of fear and disability [60]. Research shows that individuals with high levels of FOP are at a higher risk of developing chronic pain conditions due to their avoidance behaviors hindering necessary rehabilitation activities [61]Anxiety about pain further complicates this dynamic. It involves anticipatory fears about future pain experiences and can exacerbate FOP, leading to maladaptive coping mechanisms like avoidance and hyper-vigilance [62]. The anxiety-based fear-avoidance model proposed by Zale and Datre demonstrates how PA can heighten the fear of movement, contributing to kinesiophobia [63].

Additionally, Fear-avoidance beliefs play a critical role in shaping how patients perceive their pain. These beliefs can create a self-fulfilling prophecy where the expectation of pain leads to avoidance behaviors that increase the chances of experiencing pain during movement [64]. Studies indicate that patients with strong FABs are more likely to develop kinesiophobia after surgery, as they view movement as inherently dangerous [65].

Perceived stress plays a crucial role as a mediating factor within this framework. It encompasses the individual’s subjective experience of stress triggered by perceived threats, such as pain and the anticipation of injury [22]. Elevated levels of perceived stress can worsen the fear of pain and physical activity, ultimately resulting in increased kinesiophobia [66]. This interplay is supported by the fear-avoidance model, which highlights how psychological distress—including perceived stress—can exacerbate avoidance behaviors and movement-related fear, ultimately contributing to disability [19]. Empirical research further supports this relationship, demonstrating that high levels of perceived stress increase pain sensitivity and maladaptive responses to movement-related fear [22]. Additionally, chronic stress has been shown to disrupt pain regulation mechanisms, leading to heightened pain perception and reinforcing the cycle of fear and avoidance [23]. By addressing perceived stress as a key mediator, interventions aimed at reducing psychological distress may offer an effective strategy for mitigating kinesiophobia and improving postoperative recovery outcomes. The interplay between perceived stress and these psychological factors establishes a feedback loop: heightened stress levels can intensify the perception of pain and anxiety, subsequently reinforcing avoidance behaviors and kinesiophobia.

The primary objective of this study is to evaluate the mediating role of PS in the relationships between FOP, PA, and FABs with postoperative kinesiophobia. Specifically, the study aims to investigate how FOP, PA, and FABs influence kinesiophobia by impacting patients’ perceived stress, hypothesizing that higher levels of FOP, PA, and FABs will lead to increased perceived stress, which in turn, will heighten the kinesiophobia among postoperative patients.

Methods

This study was conducted from October to December 2023 using a cross-sectional design. A correlational-predictive design is a research approach that looks at relationships between variables without changing them. It helps researchers understand how different factors are connected in natural settings [67].

Study settings were the neurosurgery, general surgery, and orthopedic wards of hospital in Amol, Iran. The study population consisted of all patients who had undergone surgery in the study setting. Participants in the study were chosen using a convenience sampling method, where individuals who were easily accessible and willing to participate were selected. While this method could introduce bias and limit generalizability, a random selection process within the convenience sample was implemented to increase representativeness compared to the larger population of surgical patients.

Inclusion criteria were: age greater than eighteen years, postoperative hospitalization in hospital ward, not pregnancy, and no history of cognitive disorder, altered consciousness, unstable angina, uncontrolled severe dysrhythmia, mobility restriction due to serious physical problems (such as poliomyelitis, arthritis, and brain paralysis), malignancy, drug addiction or dependence, and psychiatric problems (such as schizophrenia or anxiety disorders).

Patients who voluntarily withdrew from the study or did not fully complete the study instruments were excluded from participation. Those patients who were scheduled for surgery were admitted to the hospital either as an emergency or elective procedure. Following a thorough examination of the inclusion and exclusion criteria, suitable patients were chosen to participate in the study.

After undergoing surgery, these selected patients were discharged from the recovery room and transferred to the inpatient ward. Once the patients were fully awake and composed, the objectives and procedures of the research were explained to them. An approved by the Approval by the Ethics Committee of Mazandaran University of Medical Sciences was obtained., Written informed consent was obtained.

It is important to note that a minimum of 6 h had elapsed since the patient was transferred to the recovery department before the questionnaires were administered. The questionnaires were given to the patients while they were still in bed and not yet mobile. Questionnaires were not administered to patients who were restless or asleep. Patients were encouraged to ask for clarification if they encountered any confusion while completing the questionnaires. The patients were responsible for self-administering the questionnaires.

The sample size was estimated to be 305, utilizing a sample size estimation formula [68] that incorporated an anticipated effect size of 0.22, a statistical power of 0.80, five latent factors, and a total of 72 items.

Instruments

Data collection instruments were a demographic form, the Tampa Scale for Kinesiophobia, the Pain Anxiety Symptoms Scale, the Fear of Pain Questionnaire, the Fear-Avoidance Beliefs Questionnaire, and the Perceived Stress Scale.

The demographic and clinical form

This demographic and clinical form included age, sex, marital status, educational level, occupation. Clinical variables: underlying condition, type of surgery, height, weight, admission type, and anesthesia type.

The Tampa scale for kinesiophobia

Miller et al. introduced this scale in 1991 [20]. It has 17 items scored on a four-point Likert scale as follows: 1: “Strongly disagree”; 2: “Disagree”; 3: “Agree”; and 4: “Strongly agree”. Items 4, 8, 12, and 16 were reverse scored. Means were calculated with higher scores showing more severe kinesiophobia. Patients with total scores ≥ 37 (a mean of 3.31) are at risk for kinesiophobia [69, 70]. The validity and reliability of the current scale were assessed in Iranian patients undergoing surgery and were deemed satisfactory [10]. The Cronbach’s alpha of the scale was 0.97 in the present study.

Fear-avoidance beliefs questionnaire

This questionnaire has 16 items on patients’ beliefs about the effects of physical activity and work on their current pain. A 0–6 scale is used for item scoring and the possible total score of the questionnaire is 0–96. Although the questionnaire was intended to include two dimensions (a physical activity dimension and a work dimension) it functions as a single factor scale (Eigenvalue of 9.43, Cronbach’s alpha of 0.96). Items were averaged with higher scores indicating higher levels of FABs [71]. The current scale’s validity and reliability were assessed in Iranian surgical patients, and were determined to be satisfactory [72].

The fear of pain questionnaire

The nine items of this questionnaire are scored 1–5 with higher scores reflecting higher fear of pain. Previous studies reported significant correlations between the score of this questionnaire and the score of the main FOP questionnaire. The validity and reliability of the current scale were evaluated in Iranian patients undergoing surgery and were found to be satisfactory [73]. The Cronbach’s alpha of the scale in the present study was 0.91. One potential concern with this variable is that it is highly “zero-inflated,” meaning the lowest possible mean (1.00) was recorded by 13.9% of respondents. This requires us to pay close attention to model assumptions.

The perceived stress scale

This scale measures individuals’ perceptions of discomfort, stress, and irritation in response to different stressful conditions. It has 10 items on the predictability, controllability, and burden of stress [74]. Items are scored from zero (“Never”) to 4 (“Mostly”) and items 4, 5, 7, and 8 are reversely scored. One issue with this scale is that it is zero-inflated, with 12.7% of respondents having a mean of 0.00. This requires us to pay particular attention to assumptions of our model. The current scale’s validity and reliability were assessed in Iranian surgical patients, and were determined to be satisfactory [75]. Cronbach’s alpha in our study was 0.98.

The pain anxiety symptoms scale

McCracken and Dhingra developed this 20 scale based on the 40-item Pain Anxiety Symptoms Scale. Items are on avoidance (seven items), fear (eight items), and physiological anxiety (five items), and are scored from zero (“Never”) to 5 (“Always”). Therefore, the possible total scores of the scale and its avoidance, fear, and physiological response are 0–100, 0–35, 0–40, and 0–25, respectively [76]. While there are three theoretical subscales, the instrument functions as a unidimensional scale (Eigenvalue > 10, Cronbach’s alpha = 0.95). For this study the mean was calculated with higher numbers reflecting more severe pain anxiety. The validity and reliability of the current scale were evaluated in Iranian patients undergoing surgery, and were found to be satisfactory [77].

Statistical analysis

Data analysis was conducted using SPSS27, AMOS24, and JASP19.0.1 software. Data were summarized using absolute and relative frequency measures for categorical variables and mean and standard deviation or standard error for numerical variables. Correlations among the main study variables were tested through Pearson’s correlation analysis. An independent t-test and one-way analysis of variance (ANOVA) was conducted to examine differences in TSK scores among the groups.

Handling of missing data

Missing data were addressed using multiple imputation techniques to ensure that the analysis retained as much information as possible while minimizing bias. This approach allowed us to create several complete datasets, which were then analyzed separately, and the results were pooled to provide final estimates.

Assumptions testing

Prior to conducting path analysis, several assumptions were tested.

• Normality: The normality of the data distribution was assessed using the Shapiro-Wilk test and visual inspections of Q-Q plots.

• Linearity: The linearity between independent and dependent variables was examined through scatterplots.

• Homoscedasticity: The assumption of homoscedasticity was evaluated using residual plots to ensure that the variance of errors was consistent across levels of the independent variables.

• Multicollinearity: Variance Inflation Factor (VIF) values were calculated to check for multicollinearity among predictors, ensuring that no predictor variable was excessively correlated with others.

Direct correlations of the independent and dependent variables were tested using path analysis, and then PS was entered into the model as a mediator. The independent variables of FOP, FABs, and PA indirectly affected kinesiophobia, both directly and through PS. The coefficients of all paths were estimated using maximum likelihood estimation based on the multivariate normality of the observable variables, and their significance was evaluated through bootstrapping with 2000 repetitions. The level of significance for all statistical analyses was set at p < 0.05.

Ethical considerations

The protocol for this study was reviewed and approved by the Ethics Committee of Mazandaran University of Medical Sciences (IR.MAZUMS.REC.1402.367). In accordance with the Declaration of Helsinki, all participants were informed about the objectives and procedures of the study. Participants had the right to voluntarily participate in the study or withdraw from it at any time, and they received comprehensive information regarding the confidentiality of their data, their freedom to share or avoid sharing their information, and their access to the findings of the study.

Informed consent

for participation was obtained from all participants after surgery. To ensure study confidentiality, all data were anonymized, and identifying information was removed prior to analysis and reporting. Access to the data was restricted to authorized research personnel only, and findings were reported in aggregate form to prevent any potential identification of individual participants. The results of the study were published anonymously, ensuring that no personal identifiers were disclosed in any publications or presentations.

Findings

Participants were 330 patients who had undergone surgery. All participants provided complete responses to the questionnaire items, resulting in a response rate of 100. Most of participant were male (53.9%) and married (80%) and around half had junior secondary education (44.5%). The mean age was 44.38 (SD = 13.49) years. years for male participants the mean age was 43.01 (SD = 13.47) years, and for female participants the mean age was 45.98 (SD = 13.39) years. A total of 36% of participants underwent orthopedic-related procedures, while 41% of participants had non-orthopedic procedures, including various types of abdominal surgeries. A total of 249 individuals (75.5%) underwent emergency operation, and 249 individuals (75.5%) received general anesthesia. Only 93 individuals (28.2%) reported a history of prior surgical procedures. The demographic details are presented in Table 1.

Table 1 Demographic characteristics of participants (n = 330)

Table 2 shows the mean kinesiophobia (TSK) scores for men and women were virtually identical, with similar standard errors (SE). Indeed, there were no sex differences for any of the other variables (Fear of avoidance beliefs, fear of pain, perceived stress, and pain anxiety).

Table 2 Comparison of scale means between the gender and type of admission (n = 330)

There were higher TSK scores for elective admissions than for emergency admissions (2.91 vs. 2.64, p < 0.01). Fear of avoidance beliefs (FAB) scores for elective admissions were also significantly higher than those for emergency admissions (3.44 vs. 2.78, p < 0.001). No other variable showed differences across admission type.

A one-way analysis of variance (ANOVA) was conducted to examine differences in TSK scores between the surgery groups. The results indicated that the effect of surgery on TSK scores was not statistically significant, F = 1.45, p = 0.24. The mean and standard deviation of TSK scores for each group were as follows: Orthopedic surgery (M = 45.74, SD = 15.24), Abdominal surgery (M = 45.59, SD = 14.42), and Discopathy (M = 49.07, SD = 15.93). These findings suggest that the type of surgery did not significantly influence TSK scores. Also, an independent t-test was conducted to examine differences in TSK scores among the anesthesia groups. The results indicated that the type of anesthesia did not have a statistically significant effect on TSK scores, t = 0.46, p = 0.63. The mean and standard deviation of TSK scores for each group were as follows: Spinal (M = 47.00, SD = 15.75) and General (M = 45.62, SD = 14.83). These findings suggest that variations in anesthesia type did not contribute to significant differences in postoperative kinesiophobia levels.

A descriptive analysis showed that the mean and standard deviation for the study variables were as follows: The mean TSK score was 42.50 (SD = 15.07), while the FABQ had a mean of 52.84 (SD = 24.99). The mean FPQ score was 27.00 (SD = 8.60), and the PSS had a mean of 19.87 (SD = 13.40). Lastly, the PASS, assessed for 330 participants, had a mean of 41.20 (SD = 23.03).

Correlation analysis

Table 3 presents a simple (zero-order) correlation analysis that revealed that all relevant variables had significant positive correlations (r ranging from 0.58 to 0.80, all p < 0.01).

Table 3 Correlation coefficient matrix of kinesiophobia

Test of mediation hypothesis

The hypothesis that perceived stress mediates the relationship between kinesiophobia and the three predictors (pain anxiety, fear of pain, and fear avoidance beliefs) was tested using multiple regression analysis and is presented in Fig. 1 as a path diagram. In addition to the typical assumptions required for multiple regression analysis, to establish mediation, we advanced the analysis demonstrating multiple conditions (e.g., Baron and Kenny, 1986) [78]:

• 1. The exogenous (predictor) variables are significantly related to the outcome variable;

• 2. The exogenous (predictor) variables are significantly related to the hypothesized mediator;

• 3. The mediator is significantly related to the outcome variable; and.

• 4. When the mediator is entered into the analysis, the relationship between the exogenous (predictor) variable(s) and the outcome variable is significantly attenuated.

Fig. 1

The results of the mediation model assessment; ^***p < 0.001, ^*p < 0.05, ^ns Non-significant

While there has been discussion of more modern approaches to mediation analysis (such as directly testing the significance of the indirect effects) the original framework proposed by Baron and Kenny (1986) remains useful for framing the steps in our analyses.

Step 1: Exogenous variables are related to the outcome. In Table 3, the zero-order correlations between fear avoidance beliefs, fear of pain, and pain anxiety are significantly correlated with the outcome, kinesiophobia, with correlations ranging from 0.59 to 0.76. When they were entered simultaneously into a multiple regression equation, the unique (semipartial) correlations ranged from 0.03 (not significant) to 0.32, with R² = 0.72. The standardized regression coefficients (beta), significance level, and 95%CI for beta are reported in Table 4.

Table 4 The Mediation Model via Baron & Kenny (1986)

Thus, our first condition is met for two of the three hypothesized predictors.

Step 2: Exogenous variables are related to the mediator. In Table 3, the zero-order correlations between fear avoidance beliefs, fear of pain, and pain anxiety are significantly correlated with the mediator, perceived stress, with correlations ranging from 0.63 to 0.73, all p < 0.01. When the three predictors are entered into a multiple regression analysis predicting perceived stress, the unique (semipartial) correlations ranged from 0.12 to 0.29, all p < 0.001, with R² = 0.76. The standardized regression coefficients (beta), significance level, and 95%CI for beta are reported in Table 4.

Thus, our second condition is met for the three hypothesized predictors.

Step 3. The mediator is related to the outcome. In Table 3 the correlation between perceived stress and kinesiophobia is 0.72, is significant at p < 0.01. The third condition is therefore met for potential mediation.

Step 4: When the mediator is entered into the regression equation, the relationship between the predictors and outcome are attenuated. This final analysis, summarized in Fig. 1, is estimated in several steps. First, the paths from the predictors to the mediator are established in Step 2, above, and entered into the path diagram. Next, predicting Kinesiophobia, the predictors are entered into the equation per Step 1, along with the mediator. This allows us to estimate the unique effects of these variables controlling for all other variables. These effects are all summarized in Table 4; Fig. 1.

First, we can compare the attenuation of the direct effects of fear of avoidance beliefs, fear of pain, and pain anxiety on kinesiophobia because the mediator was entered into the equation.

For fear of avoidance beliefs, the beta is 0.37, and once the mediator is accounted for, the beta is 0.34. Examining the semipartial correlations (0.25 vs. 0.22, respectively), this variable accounted for 6.3% unique variance prior to entry of the mediator, and 4.9% after entry, a decrease of 21.7%. For fear of pain, the original beta is 0.035, which is not significant, and thus there is no effect to mediate.

Finally, the original beta for pain anxiety is 0.51 which is reduced to 0.41 following addition of the mediator to the analysis. This final change is marked. The semipartial correlation is 0.32 prior to entry of the mediator, and 0.23 following entry of the mediator. This equates to 10.2% unique variance accounted for vs. 5.4% following entry of the mediator- a 46.7% decrease in effect, this provides evidence for partial mediation.

We calculated indirect effects and performed a bootstrap analysis to estimate the likely confidence intervals for the indirect effects. By multiplying the standardized regression coefficients for the paths between the predictors and mediator (0.17, 0.20, and 0.47, respectively) and by the standardized regression coefficient from the mediator to the outcome (0.22), the unique indirect effects of these predictors on the outcome as mediated by perceived stress are: 0.037, 0.044, and 0.10 respectively. Preacher and Hayes [79, 80] recommended that testing the indirect effects for statistical significance can be valuable and provided a macro for performing bootstrap analysis to directly evaluate these effects. Ten thousand resamples were performed using the provided macro.

Using these methods, we can estimate the indirect relationship of a single predictor at a time, so these estimates will not account for the relationships between the predicators. However, they are instructive in evaluating the proposition that perceived stress mediates the relationship between these variables and kinesiophobia.

The indirect relationship between fear of avoidance beliefs and kinesiophobia was estimated to be β = 0.25 (SE = 0.0395), with a 95%CI of [0.181, 0.335]. The estimated point value was significant (Z = 8.14, p < 0.001).

The indirect relationship between fear of pain and kinesiophobia was estimated to be β = 0.35 (SE = 0.04), with a 95%CI of [0.27, 0.44]. The estimated point value was significant (Z = 9.23, p < 0.001). Note that this relationship was not significant when estimated in the Baron & Kenny (1986) framework, but when the highly correlated predictors were removed from the equation, there was a highly significant indirect effect mediated by perceived stress.

The indirect relationship between pain anxiety and kinesiophobia was estimated to be β = 0.21 (SE = 0.04), with a 95%CI of [0.13, 0.30]. The estimated point value was significant (Z = 6.03, p < 0.001). Note that this relationship had the strongest unique direct relationship once other predictors were covaried but it was not the strongest indirect (mediated) effect.

In summary, all three variables have highly significant indirect effects on kinesiophobia as mediated through perceived stress, strongly supporting the main hypothesis of the study. Furthermore, both fear of avoidance behaviors and pain anxiety maintained significant unique direct relationships with kinesiophobia (as Fig. 1 shows) once perceived stress is covaried. The model for kinesiophobia had a good fit (CFI = 0.955, TLI = 0.944, SRMR = 0.029, RMSEA = 0.057), it explained %75 of the kinesiophobia.

Discussion

This study assessed the relationship of postoperative kinesiophobia with FOP, PA, and FABs, with the mediating role of PS in participants post-operation. Findings revealed that FABs and PA had significant relationships with postoperative kinesiophobia, while FOP did not directly influence kinesiophobia.

The findings of this study indicate that among the psychological factors assessed, only FAB showed a statistically significant difference between participant admitted on an emergency basis and those undergoing elective procedures. Participants admitted for elective surgeries reported significantly higher FAB scores compared to those admitted in emergency settings (p < 0.001). This result aligns with previous research suggesting that individuals undergoing planned surgical procedures may have greater anticipatory anxiety and heightened avoidance beliefs due to prolonged contemplation and expectation of pain and disability [81]. Since elective patients have more time to process their upcoming procedure, they might develop stronger avoidance behaviors based on fear of postoperative pain and functional limitations. Conversely, no significant differences were observed in kinesiophobia, pain anxiety, perceived stress, or fear of pain between emergency and elective admissions. This finding contrasts with some prior studies that have suggested higher levels of psychological distress in emergency surgery patients due to the sudden and unexpected nature of their condition [15]. However, it is possible that the urgency of the situation in emergency cases leaves patients with less time to develop strong psychological responses such as kinesiophobia and FAB, whereas elective patients may undergo cognitive and emotional processing that reinforces avoidance behaviors. Similarly, no significant differences were found between males and females in any of the measured psychological constructs. This is consistent with some previous research indicating that while sex differences in pain perception and psychological responses to pain exist, they may not always be substantial in surgical populations [82]. The lack of significant sex differences in our study could be due to the specific characteristics of the sample or the influence of other moderating variables, such as individual coping strategies or previous pain experiences.

In terms of the relative importance of factors influencing kinesiophobia, perceived stress emerges as the strongest predictor, impacting kinesiophobia both directly and indirectly through its connections with FABs and PA. Pain anxiety is particularly critical, holding the highest direct influence on kinesiophobia; thus, managing anxiety related to pain could potentially alleviate fears associated with movement. Fear-Avoidance Beliefs, while still significant, exert a mediation influence on kinesiophobia, less strong as that of perceived stress and pain anxiety. Conversely, the analysis revealed no significant correlation between FOP and kinesiophobia, suggesting that although fear of pain is relevant, it may not directly contribute to the development of kinesiophobia in the same manner as the other factors.

Perceived stress plays a crucial role as a mediator in the complex relationships between FABs, PA, and kinesiophobia through various interconnected mechanisms. FOP, PA, and FABs contribute to perceived stress through distinct psychological mechanisms. Fear of pain heightens anticipation of pain-related suffering, leading to increased distress and stress responses [11]. Pain anxiety exacerbates stress by amplifying hypervigilance and negative cognitive appraisals related to pain [28]. Similarly, fear-avoidance beliefs reinforce avoidance behaviors, fostering anxiety and a sense of helplessness, which, in turn, heightens perceived stress [19]. These psychological processes create a feedback loop where stress reinforces fear and avoidance, ultimately increasing kinesiophobia [23, 54]. High levels of perceived stress can worsen negative cognitive appraisals related to pain and movement, leading individuals to develop heightened fear-avoidance behaviors. This concept aligns with the fear-avoidance model, which suggests that negative beliefs about pain can trigger avoidance of activities perceived as threatening, thus reinforcing kinesiophobia [83].

Moreover, stress can intensify physiological responses to pain, increasing sensitivity and creating a harmful cycle where individuals become more anxious about potential movement-related pain. Additionally, perceived stress may impact emotional regulation, making it difficult for individuals to cope with pain or engage in adaptive behaviors, perpetuating feelings of helplessness and anxiety. This emotional dysregulation can further enhance kinesiophobia by creating a feedback loop where the fear of pain leads to increased stress and avoidance behaviors, ultimately reducing physical activity levels and contributing to a decline in overall well-being [84].

Therefore, addressing perceived stress through interventions such as mindfulness or cognitive-behavioral strategies is crucial for breaking this cycle and improving outcomes for participant experiencing kinesiophobia postoperatively. By targeting perceived stress, particiapants can better manage their pain, reduce fear-avoidance behaviors, and ultimately enhance their overall well-being.

Study findings showed that in the presence of PS, as a mediator, the relationship of FOP and kinesiophobia was not significant. Moreover, the direct model showed that FOP had no significant relationship with kinesiophobia. This finding contradicts the findings of several previous studies [84,85,86]. Parr et al. (2012) confirmed an association between fear of pain and kinesiophobia in particiapants with musculoskeletal pain [87]. Also, the study of George et al. (2010) on participants with chronic back pain has rejected the present results [88]. While Finley et al., (2020) conducted a study on patients with spinal cord injury and the results demonstrated the non-significance between fear of pain and kinesiophobia. Thus, thei findings are consistent with ours [89]. The items of the FOP address different painful conditions and hence, particiapants with previous experiences of those conditions may rate the items higher and hence, report greater postoperative FOP [90]. Previous experiences of pain can significantly affect patients’ FOP [91]. The perception of patients towards fear and pain is differs [90]. Since the experience of pain affects the participants fear of pain [91], the perception and behaviors related to the fear of pain are significantly influenced by the socio-cultural structure of people. Religious beliefs also play an important role in fear response to pain [92, 93]. In a religious country like Iran, despite the existence of different cultures, people have different reactions to fear and pain. In fact, this reaction is different from other countries where fear of pain has been investigated. In cultures where independence is highly valued, people may feel ashamed or reluctant to ask for help when they are afraid of movement due to injury or pain (kinesiophobia) [94].

Beliefs about fate and spirituality in Iranian culture can influence how people view pain and recovery. Iranian participants may see pain as a test of their faith, making them more resilient but also hesitant to show vulnerability. This perspective can increase pain tolerance but may also lead to a fear of movement affecting spiritual or physical health [10]. In summary, anxiety about movement can lead to kinesiophobia, where participants avoid activities due to fear of judgment. Factors such as cultural context, anxiety, depression, and social support play a crucial role in understanding kinesiophobia. Cultural perceptions of mental health can impact how iparticipants express emotions and seek help, with stigmatized cultures making participantss less likely to acknowledge fears or seek psychological support, worsening kinesiophobia [10]. Some authors reported that fear and pain is influenced by sex [95]. The role of male and female hormones is effective in the perception of pain and fear. Estrogen and progesterone changes in women cause changes in pain intensity in women. Also, menstruation affects women’s level of fear, pain, and mobility [96]. Men’s perception of pain and fear is different due to testosterone hormones. Whereas, the prevalence of anxiety and stress disorders is higher in women than in men [97].

Our FAB-related findings showed participants’ belief in the heaviness of physical and occupational activities after surgery, which denotes that they would avoid these activities for a while after surgery. This FOP-induced avoidance approach increases kinesiophobia. This agrees with the findings of a study on patients with back pain which reported that those with higher FABs scores were more at risk for kinesiophobia [29]. Another study on older participants with chronic pain also showed significant positive relationship between FABs and kinesiophobia [85]. Physical activity and functional capacity decreases after surgery and hence, unmanaged pain may increase movement-related pain, avoidance behaviors, and pain intensity [81]. FABs in the present study changed kinesiophobia through the mediating role of PS. PS has significant effects on postoperative recovery and mental health and increases the risk of postoperative physical and mental complications [98]. High levels of postoperative PS may cause particiapants to believe that they should avoid physical and occupational activities and thereby this can increase postoperative kinesiophobia.

Another finding of the present study was the significant relationship of PA with kinesiophobia. Two studies concur with our findings, they found that PA had significant positive relationship with kinesiophobia among participants with back pain [29, 30]. In the present model, the coefficient determination of pain anxiety had the greatest effect in the presence of the mediation of perceived stress. Surgery is a painful procedure for patients. Therefore, patients show symptoms of anxiety caused by pain [44]. In fact, PA pertains to a concern in the future so that participants are anxious about postoperative pain and show avoidance behaviors and experience fear and physiological changes. Therefore, patients with higher PA scores are more likely to attribute postoperative pain and injury to movement and are more at risk for kinesiophobia [99]. Moreover, our findings indicated that PA increased kinesiophobia through increasing PS. This denotes that higher PS is associated with higher PA and higher risk of kinesiophobia due to anxiety and stress over pain and injury.

Stress and anxiety are two overlapping concepts and are highly prevalent after surgery [98]. In fact, surgery is a stressful procedure [17, 100]. Low levels of stress may have positive effects on participants’ postoperative functioning, motivation, adaptation, and responses. However, the high levels can lead to biological, mental, and social problems. Stress may be due to participants’ inner perceptions or environmental factors [51, 101]. For example, preoperative stressful life events, low resilience, and limited perceived social support may increase PS [74, 102]. Patients with higher levels of PS due to stressful life events have lower adaptation to postoperative complications [51] and hence, may show apparent behavioral alterations such as kinesiophobia [51, 103, 104].

The path analysis in our study showed a significant positive relationship of kinesiophobia with FABs and PA which agrees with the findings of several previous studies [29, 30, 57, 105]. This finding denotes that particiapants with postoperative pain have fear over movement due to their fear over movement-induced injury. On the other hand, participants may be anxious over potential postoperative pain even in the absence of pain. Moreover, they may believe that they should avoid daily physical and occupational activities because these activities may be too demanding for them. These fears, anxiety, and avoidance may lead to immobility [18, 29, 106]. On the other hand, our findings revealed that postoperative PS increased the effects of anxiety and FABs on postoperative outcomes such as pain and immobility. High levels of preoperative PS cause participants fear and anxiety over postoperative injury and make them avoid movements—the higher the PS, the higher the kinesiophobia due to FABs and anxiety.

Conclusion

The results of this study emphasize the significant connections between kinesiophobia and psychological factors such as FABs and PA, while also shedding light on the mediating role of PS. The strong positive correlations between kinesiophobia, FABs, and PA suggest that these psychological factors play a crucial role in the development of kinesiophobia in postoperative participants. Notably, perceived stress was identified as a significant mediator, influencing how participants perceived and responded to pain after surgery.

Further analysis confirms that while kinesiophobia is linked to FABs and PA, it does not directly correlate with FOP. This highlights the importance of targeted interventions focusing on FABs and PA to address kinesiophobia and improve recovery outcomes. The model’s ability to explain 75% of the variance in kinesiophobia underscores the significance of these psychological factors in understanding patient experiences post-surgery.

Given the high prevalence of kinesiophobia among surgical participants, healthcare providers should prioritize psychological assessments and interventions to address these fears. Future research should explore the effectiveness of therapeutic strategies aimed at reducing perceived stress and its impact on kinesiophobia, as well as investigate other potential predictors of postoperative complications. By addressing these psychological barriers, we can enhance participants mobility, improve recovery times, and ultimately reduce the risk of chronic pain and disability.

Clinical implication and health policy

The study emphasizes the critical role of PS in mediating the relationship between pain anxiety and fear-avoidance beliefs with postoperative kinesiophobia. This discovery indicates that healthcare providers should take into account the impact of stress on participants’ mental and physical responses following surgery. By addressing perceived stress through stress management techniques such as relaxation methods, cognitive-behavioral therapy, or stress-reducing medications, healthcare providers can potentially alleviate the adverse effects of pain anxiety and fear-avoidance beliefs on postoperative kinesiophobia. This approach has the potential to enhance participants outcomes, including improved mobility and reduced anxiety, ultimately elevating the overall quality of life for participants undergoing surgery.

Pre-Surgery training and counseling

Prior to surgery, participants can benefit from receiving comprehensive information about the surgical procedure, pain management options, and potential complications in order to alleviate fears and anxiety related to pain. Counseling sessions can also be provided to address any concerns or fears that participants may have, helping them adopt a positive mindset towards the upcoming surgery.

Pain management strategies

A specialized team focused on pain management can create personalized plans for each participant, utilizing a range of techniques including both pharmacological and non-pharmacological methods to effectively address their pain needs.

Stress reduction and management

In addition to traditional pain management, stress reduction techniques such as meditation, deep breathing, and progressive muscle relaxation can be offered to patients both before and after surgery. Encouraging patients to participate in stress-reducing activities like yoga or tai chi as part of their recovery process can also be beneficial.

Overcoming fear and managing kinesiophobia

Educating participants on the importance of gradually exposing themselves to activities and exercises can help them understand the connection between fear-avoidance beliefs and phobic movement.

Limitation and recommendations for future research

This study encountered several limitations that warrant acknowledgment. Firstly, data collection was confined to a single hospital center, potentially restricting the applicability of the findings to broader populations. Furthermore, the sample size was unbalanced in terms of gender, which may have introduced selection bias into the results. Future research endeavors should strive to replicate the model across multiple hospitals and diverse cultural contexts to bolster external validity and ensure a more equitable representation of genders. A convenience sample limits the generalizability of our results.

Additionally, potential confounding variables were not fully addressed in this analysis. Factors such as socioeconomic status, medical history, psychological comorbidities, and cultural dimensions like spirituality, religious beliefs, and faith could influence the observed relationships and were not measured in this study. These elements are particularly relevant in understanding pain perception and coping strategies, as previous research has highlighted their potential impact on psychological well-being and pain management. Future investigations should consider these variables to provide a more comprehensive understanding of the relationships examined. Expanding research to include a more diverse array of populations and chronic pain conditions will further validate the findings.

Lastly, qualitative studies can enhance our understanding of patients’ experiences with kinesiophobia and inform tailored interventions. By integrating qualitative perspectives with quantitative findings, researchers can develop more comprehensive treatment strategies to improve postoperative outcomes.