Correlation analysis between kinesiophobia and physical function in patients with hip osteoarthritis

Análise de correlação entre cinesiofobia e função física em pacientes com osteoartrite do quadril

Abstract

Introduction:  To better understand the aspects that may influence the functional status and health of individuals with hip osteoarthritis (HO), a deeper understanding of the factors that may increase fear of movement and reduce function in these patients is necessary.

Objective:  To correlate physical function and kinesiophobia in patients with HO.

Methods:  This cross-sectional study included participants of both sexes, aged between 30 and 70 years, with a clinical diagnosis of HO. Patients performed the Six-Minute Walk Test (6MWT), the Timed Up and Go test (TUG), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to assess physical function; the Numeric Pain Rating Scale to assess pain level; and the Tampa Scale for Kinesiophobia (TSK) to assess kinesiophobia.

Results:  Ninety-eight patients were included. When comparing sexes regarding physical function and kinesiophobia, no statistically significant differences were observed in the median values of the 6MWT and TUG; however, women presented poorer physical function outcomes and higher TSK scores. There was a correlation between TUG and TSK (r = 0.29, p = 0.02), but no significant correlation was found between 6MWT and TSK.

Conclusion:  There is a significant correlation between the level of kinesiophobia and the physical function of patients with HO. Women present higher pain levels and lower physical function compared to men. These findings suggest that fear of movement may reduce functional mobility in these individuals and should be assessed by clinicians, as it may represent a risk factor for functional decline.

Keywords:
Osteoarthritis; Hip osteoarthritis; Functional physical performance; Kinesiophobia

Resumo

Introdução:  Para melhor compreender os aspectos que podem influenciar o estado funcional e a saúde de indivíduos com osteoartrite do quadril (OAQ), é necessário um melhor entendimento dos fatores que podem aumentar o medo do movimento e reduzir a função nesses pacientes.

Objetivo:  Correlacionar a função física e a cinesiofobia em pacientes com OAQ.

Métodos:  Este estudo transversal incluiu participantes com diagnóstico clínico de OAQ, de ambos os sexos, entre 30 e 70 anos. Os pacientes realizaram o Teste de Caminhada de Seis Minutos (TC6), o Timed Up and Go (TUG) e o Índice de Osteoartrite das Universidades de Western Ontario e McMaster (WOMAC), para avaliar a função física; a Escala Numérica da Dor para avaliar o nível de dor; e a Escala de Tampa de Cinesiofobia (TSK) para avaliar a cinesiofobia.

Resultados:  Noventa e oito pacientes foram incluídos. Comparando os sexos para a função física e a cinesiofobia, não foram observadas diferenças estatisticamente significativas nas medianas do TC6 e do TUG, mas as mulheres apresentaram resultados inferiores na função física e pontuações superiores no TSK. Houve correlação entre TUG e TSK (r = 0,29, p = 0,02), mas não houve correlação significativa entre 6MWK e TSK.

Conclusão:  Há correlação significativa entre o nível de cinesiofobia e a função física de pacientes com OAQ. Mulheres apresentam maior nível de dor e menor função física em comparação aos homens. Esses resultados sugerem que o medo do movimento pode reduzir a mobilidade funcional nesses indivíduos e deve ser uma variável avaliada pelos clínicos, pois pode ser um fator de risco para declínio funcional.

Palavras-chave:
Osteoartrite; Osteoartrite de quadril; Desempenho físico funcional; Cinesiofobia

Introduction

Osteoarthritis is an emerging disease and is currently one of the main complaints reported by older adults during medical consultations, with greater prevalence in the lower limbs, especially the knee and hip.¹,²,³ Its general clinical characteristics include limitations in joint mobility, pain, crepitus, and deformities, as well as decreased muscle strength and proprioceptive alterations.⁴

In addition, it promotes peripheral and central sensitization, which may lead to pain perpetuation and contribute to the chronic aspects of the disease.⁵ Individuals with reduced mobility may present kinesiophobia, defined as an excessive fear of performing movements related to physical or daily activities.⁶ Patients with this condition perceive exercise as a predictor of pain and develop an avoidance mechanism, further worsening their functional level.⁷

According to a scoping review published in 2022 by Bordeleau et al.,⁸ studies evaluating patients with chronic pain should pay special attention to the level of kinesiophobia. Furthermore, a study assessing the relationship between strength and physical activity with fear of movement in patients with knee osteoarthritis suggested that evaluating the level of kinesiophobia may help identify patients who are less likely to respond positively to exercise interventions. In addition, it may help clinicians develop better strategies to reduce kinesiophobia and increase physical activity levels.⁸,⁹,¹⁰,¹¹

Although the association between pain catastrophizing, quality of life, and physical function in individuals with knee osteoarthritis is well established,⁷ studies involving patients with hip osteoarthritis (HO) are limited, and information regarding kinesiophobia remains insufficient.¹²,¹³ Therefore, it is necessary to clarify the real impact of kinesiophobia on the functional mobility of individuals with HO in order to support the future development of effective therapeutic strategies tailored to each patient profile.

The relationship between kinesiophobia and functional mobility tests has been demonstrated in other conditions.¹⁴ However, there is no consensus regarding HO. The hypothesis of the present study is that higher levels of kinesiophobia are associated with poorer performance on physical function tests in patients with HO and may also be influenced by sex. Thus, this study aims to correlate physical function and kinesiophobia in patients with HO and, secondarily, to compare physical function performance between men and women.

Methods

This was a cross-sectional study involving participants with a clinical diagnosis of HO, reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.¹⁵ All study procedures were approved by the Research Ethics Committee of the Federal University of Sergipe (approval no. 6,699,195). Informed consent was obtained from all participants involved in the study.

Setting

All assessments were conducted between 2024 and 2025 and completed during the afternoon of a single day. Patients were recruited from the waiting list of the Orthopedic Physical Therapy Clinic at the University Hospital of the Federal University of Sergipe (HU-UFS). All patients underwent the same assessment flow. The first researcher received the patients for anthropometric and sociodemographic data collection and questionnaire assessment. Subsequently, the second researcher conducted the physical tests. At this stage, the researcher explained the test procedures before initiation and informed participants that the time or repetition limits were not harmful, encouraging continuation only when permitted according to the test guidelines.

Participants

One hundred and thirty-two participants with HO who were on the clinic waiting list for hip arthroplasty were invited to participate by telephone. The inclusion criteria were: both sexes, age between 30 and 70 years, and a clinical diagnosis of unilateral or bilateral HO. Patients with total or partial knee or hip arthroplasty, body mass index above 40 kg/m², cardiorespiratory diseases that limited exercise performance, or neurological or cognitive impairments were excluded.

Variables and measures

Baseline data: age, sex, weight, height, employment status, affected limb, and pain intensity, using the Numeric Pain Rating Scale (NPRS).¹⁶

Kinesiophobia: the Tampa Scale for Kinesiophobia (TSK) consists of 17 questions, with scores ranging from 1 to 4, resulting in a total score ranging from 17 to 68. According to the scale, 1 point represents “strongly disagree,” 2 points “partially disagree,” 3 points “partially agree,” and 4 points “strongly agree,” except for questions 4, 8, 12, and 16, in which these values must be reversed to obtain the final score. The higher the score, the greater the patient’s degree of kinesiophobia.¹⁷ The degree of kinesiophobia is classified as mild (17–34 points), moderate (35–50 points), or severe (51–68 points).¹⁸ The TSK is a reliable and valid measure in chronic pain populations.¹⁰,¹¹,¹²,¹³,¹⁴,¹⁷,¹⁸

Physical function: all physical function tests used to assess the included individuals are recommended by the Osteoarthritis Research Society International (OARSI).¹⁹ This variable was assessed using a set of functional tests:

1. Six-Minute Walk Test (6MWT), performed according to the guidelines of the American Cardiothoracic Society.²⁰

2. Timed Up and Go Test (TUG), that measures the time in seconds taken to complete a circuit. The test requires the participant to rise from a chair to a standing position, walk three meters, turn around, return, and sit down again.¹³,¹⁹ The time required to complete the test is strongly correlated with the level of functional mobility.²¹

3. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), which assesses self-reported physical function.²²

Statistical analysis

Data were analyzed descriptively and analytically using IBM SPSS Statistics (IBM Corp., Armonk, NY, USA). For all tests, a 95% confidence interval and a significance level of 5% (p < 0.05) were adopted. The Shapiro–Wilk test was used to assess data normality. The initial analysis was performed by dividing the sample into men and women and comparing groups using the Mann–Whitney test. For correlation analyses, the Spearman’s correlation test was used. Correlations were interpreted as very strong when the coefficient was greater than 0.9, strong between 0.7 and 0.89, moderate between 0.5 and 0.69, weak between 0.3 and 0.49, and very weak when values ranged from 0 to 0.29.

Considering that the study sample was obtained by convenience sampling from individuals in the HU-UFS database, the effect size was calculated based on the studied sample. A post hoc power analysis was performed using G*Power (Franz Faul, Kiel University, Germany) to verify whether the sample size was sufficient to detect statistically significant effects. An alpha level (α) of 0.05 and a sample size of 98 were adopted. Assuming a moderate effect size of 0.4, the analysis indicated a statistical power of 99%.

Results

From the original sample of 132 participants, 26 were excluded (Figure 1). All participants were on the waiting list for hip arthroplasty and were classified as having moderate to advanced osteoarthritis according to the Kellgren–Lawrence classification.²³

Figure 1
Study flowchart.

Therefore, the final sample consisted of 98 patients with a mean age of 53 years (14.9 years), and approximately 63.26% were women (Table 1).

Table 1
Sample characteristics

	All (n = 98)	F (n = 62)	M (n = 36)
Age (years)	53.00 ± 14.90	55.90 ± 13.60	48.00 ± 15.90
Working	36 (36.7)	19 (19.4)	17 (17.3)
Unemployed	62 (63.3)	43 (43.9)	19 (19.4)
NRS	6.22 ± 3.00	6.68 ± 2.80	5.44 ± 3.24
WOMAC	54.40 ± 25.70	45.00 ± 26.80	59.80 ± 23.60
Affected limb
Unilateral	58 (59.2)	34 (34.7)	24 (24.5)
Bilateral	40 (40.8)	28 (28.6)	28 (28.6)
TSK
Mild	7 (7.6)	3 (3.3)	4 (4.3)
Moderate	46 (50.0)	30 (32.6)	16 (17.4)
Severe	39 (42.4)	26 (28.3)	13 (14.1)

• Note: F = female; M = male. Data are presented as n (%), except for age, NRS (Numeric Rating Scale), and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), which are presented as mean (± standard deviation).

As presented in Table 1, regarding the affected limb, 59.2% of the patients presented unilateral involvement, while 40.8% presented bilateral involvement. The mean pain score on the Numeric Rating Scale (NRS) was 6.22 ± 3.00, with women presenting higher scores than men (6.68 ± 2.80). The mean WOMAC score was 54.4 ± 25.7, with women presenting lower scores than men, indicating reduced self-reported physical function. Furthermore, the prevalence of severe kinesiophobia was higher among women (28.3%) compared to men (14.1%), and most individuals were retired (63.3%) compared to those who were actively working (36.7%).

When comparing men and women regarding physical function and kinesiophobia, statistically significant moderate correlations were observed for the 6MWT and kinesiophobia (r = -0.386; p = 0.0032) and for TUG (r = 0.363; p = 0.005), with women presenting higher levels of kinesiophobia and poorer performance, as shown in Table 2. In addition, kinesiophobia was moderately associated with worse self-reported physical function according to WOMAC (r = 0.429; p = 0.0009). In contrast, among men, there were no significant correlations between kinesiophobia and performance-based tests. However, a significant correlation was observed between ki-nesiophobia and WOMAC scores (r = 0.472; p = 0.011).

Table 2
Comparison of physical function and kinesiophobia between men and women with hip osteoarthritis (Tampa Scale for Kinesiophobia)

Tests	Male			Female
	Mean ± SD	r	p	Mean± SD	r	p
Six-Minute Walk Test (m)	384 ± 140	-0,32	0,08	323 ± 131	-0,38	0,0030*
Timed Up and Go Test (s)	7,69 ± 5,35 [RC1.1]	0,25	0,18	12,70 ±10,30	0,36	0,0050*
WOMAC	45,00 ± 26,80	0,47	0,01*	59,80 ± 23,60	0,42	0,0009*

• Note: SD = standard deviation; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index. *p < 0.05.

There was a moderate and significant correlation between performance-based and self-reported physical function in both sexes (Table 3). Among men, the correlation between the variables was stronger (r = 0.570) compared to women.

Table 3
Comparison between performance-based physical function and self-reported physical function (WOMAC) in men and women with hip osteoarthritis

Tests	Male		Female
	r	p	r	p
6MWT (m)	-0,3910	0,0390*	-0,3600	0,0063*
TUG (s)	0,5700	0,0015*	0,4180	0,0013*

• Note: WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; 6MWT = Six-Minute Walk Test (meters); TUG = Timed Up and Go Test (seconds). *p < 0.05.

There was a significant correlation between TSK and 6MWT (p = 0.0002), TSK and TUG (p = 0.002), and TSK and WOMAC (p < 0.001). Despite this, all correlations were weak (r = -0.38; r = 0.32; r = 0.46, respectively), as shown in Figure 2.

Figure 2
Scatter plots for Spearman correlation between the Tampa Scale for Kinesiophobia and physical function.

Discussion

The present study provides evidence that kinesiophobia is significantly associated with physical function in individuals with HO, with important differences between sexes. There was a significant and moderate correlation between TSK and TUG, 6MWT, and perceived physical function in women. In contrast, among men, kinesiophobia was associated only with self-reported physical function. Although the magnitudes of the correlations were weak to moderate, the findings suggest the influence of psychosocial factors on the functional limitations of this population.

Although men presented significantly better physical function scores than women, the correlation between kinesiophobia and perceived function was stronger in the male group. These results may be directly related to biopsychosocial and behavioral mechanisms between sexes, including variations in pain sensitivity, hormonal influences, central sensitization, and distinct forms of pain perception, which tend to be greater in women than in men.²⁴,²⁵,²⁶,²⁷,²⁸ Furthermore, culturally, men tend to have greater difficulty admitting painful symptoms or seeking medical assistance,²⁶,²⁹ so fear of movement may only become relevant when it begins to interfere with their perceived function.

The negative correlation between kinesiophobia and the walking test may be explained by the prolonged and continuous nature of the test, which requires greater tolerance to exertion and may exacerbate fear of sustained movements, thereby reducing the distance walked. Therefore, the greater the functional demand, the greater the influence of fear of movement on physical function tends to be. These findings are supported by studies demonstrating that kinesiophobia has a substantial impact on the physical activity level of individuals with osteoarthritis.³⁰,³¹

Participants in this study presented pain levels above the average score on the NRS. This reinforces the relevance of pain as a predominant and impactful symptom in patients with HO. In addition, pain is typically the primary reason for the emergence of fear of movement in patients with HO and is predictive of longer times to complete the TUG and shorter distances in the 6MWT.³²

It is important to consider that the relationship between kinesiophobia and functional mobility may be bidirectional. Therefore, both the level of kinesiophobia may influence performance-based physical function, and limitations in functional mobility may increase fear of movement. The experience of pain and difficulty moving may reinforce and worsen the condition, leading to a vicious cycle of fear of movement – reduced physical function – fear of movement.³³,³⁴,³⁵

Understanding movement-related aspects in patients with HO is important to support the management of kinesiophobia in these individuals, since psychological and personal factors better explain the magnitude of physisical limitations in these patients.³¹,³⁶ There are limited studies regarding the best approaches to treat fear of movement in patients with HO. However, considering the chronicity of the disease, exposure to physical exercise⁸ and pain education aimed at coping strategies and self-efficacy³¹ may reduce negative effects. Thus, incorporating these strategies into care protocols may help reduce psychological barriers to physical activity.

It is important to recognize that this study has some limitations. Although a correlation was found, the cross-sectional nature of the study does not imply causality. Furthermore, in patients with the mean age observed in the present study and with a chronic pain profile due to the degenerative nature of osteoarthritis, other factors should be explored in future studies, such as the presence of comorbidities, level of physical activity, severity of osteoarthritis, medication use, and quality of life.¹⁴

Overall, individuals with HO experience difficulty performing daily activities such as walking or rising from a chair.⁶,²⁸ This reinforces the importance of addressing kinesiophobia in therapeutic interventions for patients with HO, considering that reducing fear of movement has the potential to improve physical performance and patients’ quality of life. The use of assessment instruments addressing both physical and psychological dimensions in osteoarthritis management is also necessary, considering the individuality of each patient. Therefore, treatment approaches integrating cognitive-behavioral therapy techniques, pain education, and exercise therapy are essential to promote the multidimensional recovery of patients with HO.

Conclusion

The results of this study suggest that there is a significant correlation between the level of kinesiophobia and performance-based physical function in patients with HO, with women presenting higher pain levels and lower physical function. Although the correlations showed weak to moderate magnitudes, they suggest that fear of movement may contribute to functional limitations in this population. These findings indicate that kinesiophobia should be assessed by clinicians, as it may represent a risk factor for functional decline. Longitudinal studies are recommended to further clarify the role of kinesiophobia over time in these individuals.

Data availability statement

Data are available from the corresponding author upon reasonable request.

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Edited by

• Associate editor:
  Ana Paula Cunha Loureiro

Publication Dates

• Publication in this collection
  24 July 2026
• Date of issue
  2026

History

• Received
  12 Sept 2025
• Reviewed
  09 Feb 2026
• Accepted
  20 Apr 2026