Impact of pain characteristics and fear-avoidance beliefs on physical activity levels among older adults with chronic pain: a population-based, longitudinal study
Larsson et al. BMC Geriatrics
Impact of pain characteristics and fear- avoidance beliefs on physical activity levels among older adults with chronic pain: a population-based, longitudinal study
Caroline Larsson 0 3
Eva Ekvall Hansson 2
Kristina Sundquist 0 1 3
Ulf Jakobsson 0 3
0 Center for Primary Health Care Research, Lund University/Region Skåne , Malmö , Sweden
1 Stanford Prevention Research Center, Stanford University School of Medicine , Stanford, CA , USA
2 Department of health Science, Lund University , Lund , Sweden
3 Center for Primary Health Care Research, Lund University/Region Skåne , Malmö , Sweden
Background: To explore the level of physical activity in a population based sample of older adults; to analyze the influence of pain characteristics and fear-avoidance beliefs as predictors of physical activity among older adults reporting chronic pain. Methods: Demographics, pain characteristics (duration, intensity), physical activity, kinesiophobia (excessive fear of movement/(re) injury), self-efficacy and self-rated health were measured with questionnaires at baseline and 12months later. Logistic regression analyses were done to identify associations at baseline and predictors of physical activity 12-months later during follow-up. Results: Of the 1141 older adults (mean age 74.4 range 65-103 years, 53.5 % women) included in the study, 31.1 % of those with chronic pain were sufficiently active (scoring ≥ 4 on Grimby's physical activity scale) compared to 56.9 % of those without chronic pain. Lower age (OR = 0.93, 95 % CI = 0.88-0.99), low kinesiophobia OR = 0.95, 95 % CI = 0.91-0.99), and higher activity level at baseline (OR = 10.0, 95 % CI = 4.98-20.67) significantly predicted higher levels of physical activity in individuals with chronic pain. Conclusion: The level of physical activity was significantly lower among those with chronic pain and was significantly associated with kinesiophobia. Our findings suggest that fear- avoidance believes plays a more important role in predicting future physical activity levels than pain characteristics. Thus our findings are important to consider when aiming to increase physical activity in older adults that have chronic pain.
Older adults; Physical activity; Predictors; Kinesiophobia
Chronic pain is common in older adults [
] and is
repeatedly found to be a significant risk factor for
decreased functional capacity and onset and
progression of disability in old age [
1, 3, 4
]. For example,
studies of community-dwelling older adults have
shown that pain is associated with falls , poorer
physical performance [
], as well as elevated
depression symptoms [
Physical activity is established as a significant moderator
of both the physical and psychological dimensions of
chronic pain, and hence an essential non-pharmacological
strategy in the management of chronic pain [
Moreover, physical activity is also known to decrease the risk
of a myriad of health related problems such as type 2
diabetes, cardiovascular diseases and cancer as well as
preventing disability, morbidity and mortality at old age
]. Contrary to this, previous research has shown
that older adults with chronic pain are less physically
active when compared to older adults without chronic
pain. For example, Griffin et al. (2012) found
significantly lower levels of physical activity in older adults
with chronic low back pain compared to asymptomatic
individuals . A recent meta-analysis by Stubbs et al.
(2013) also showed that older adults with pain were
significantly less active than those without chronic pain [
In general these studies were based on patients with back
pain and the results suggested an increased risk for
maintenance of pain but also for functional decline and
additional chronic diseases, compared to older adults without
chronic pain [
]. However, to increase the generalizability
of the findings, the relationship between chronic pain and
physical activity also needs to be investigated more
generally, i.e., regardless of specific pain location in the body.
For healthy older adults the etiology of physical activity
is well-known and includes risk factors such as: younger
age, being male, being married, having better health
scores, previous activity levels, self-efficacy, impaired
mobility status and smoking [
]. Yet, there are reasons
to believe that that the etiology of physical activity may
differ in older adults that have chronic pain. Pain
characteristics, such as duration of pain and pain intensity, have
been identified as an important predictor for both
selfreported and performance reported disability among older
] and may thus be assumed to interact with
physical activity levels in older people with chronic pain.
Another important consideration is fear-avoidance beliefs.
The fear-avoidance model implies that daily activities and
functional capacity may be reduced to avoid pain. Hence,
untreated pain may lead to a negative spiral with the
following: increased fear of movement, avoidance behavior
and ultimately disuse, depression and further exacerbation
of chronic pain [
]. For the general population the
existing literature is inconsistent regarding the
relationship between fear-avoidance and physical activity levels.
Some results suggest that fear-avoidance beliefs may
not be directly associated with physical activity levels
13, 18, 21
], but there are also several studies that
conclude that the presence of fear-avoidance beliefs are
significantly associated with increases in pain and reduced
levels of physical activity [
Despite the inconclusive results of previous research,
most indications are that a relationship between the
concepts can be assumed. However, the previous findings are
primarily based on cross-sectional results. Thus the direct
cause and influence of pain characteristics and fear
avoidance beliefs on physical activity levels remains elusive.
Identification of risk factors is important for prevention
and can also allow identification possible targets for
intervention. This is important when aiming to increase
activity levels among older adults with chronic pain.
The present study aimed to explore the level of physical
activity in a population based sample of older adults,
and to analyze the influence of pain characteristics and
fear- avoidance beliefs as predictors of physical activity
among older adults reporting chronic pain.
This longitudinal survey study included people aged
65 years and older, selected randomly using a Swedish
national register of inhabitants (SPAR), which includes
all persons who are registered as resident in Sweden.
The randomization was performed by a
governmentengaged company (Infodata). All individuals 65 years or
over were eligible for inclusion and no other exclusion
criteria were used. Data were collected between May
2011 and May 2013. The sampling frame was Sweden’s
whole population in the selected age group (65+ years).
At baseline a total of 2,000 questionnaires were mailed
out and 1,141 were completed and sent back. A total of
12 questionnaires were returned without having been
filled in for the reason “address unknown” and 13 people
were classified as deceased.
Procedure and measurements
The baseline questionnaires were distributed by post
together with an accompanying letter explaining the aim
and procedure of the project. It was requested that the
questionnaires be sent back with the enclosed
selfaddressed prepaid envelopes. Reminder letters were sent
after a fortnight. For the 12-month follow-up we used
the same procedure as for the baseline assessment,
although no reminder letters were sent. The
questionnaires contained demographic questions about: sex, age,
BMI, smoking habits (“No, I have never smoked”, “Yes,
but I have quit”, “Yes, occasionally”, and “Yes, daily”),
housing (own home or special housing) and living
arrangements (alone or with someone) and marital status.
Pain-related questions were also included in the
questionnaires. Chronic pain, defined as pain that had lasted
longer than three months [
] and was noted by
responding YES or NO to the question “Have you been
troubled by pain for the last three months or more?”
Pain characteristic (intensity, duration, location) was
measured using single items extracted from the brief
Screening version of the Multidimensional Pain
Inventory (Swedish version) [
]. Pain intensity was measured
using the item “Rate the average level of your pain
during the last week” with responses on a 6-point Likert
scale ranging from No pain at all (1 point) to
Tremendous amount of pain (6 points). Duration of pain was
measured in years. Primary pain localization was also
identified. The respondents could choose between 7
alternatives; upper extremities, shoulder and neck, lower
extremities, thorax and abdomen, back and pelvis, head
and other locations (including hand and feet). The brief
Swedish version of MPI has been psychometrically tested
and shown to have acceptable validity and reliability
among the elderly, aged 60–89 years old [
Kinesiophobia (excessive fear of movement/(re) injury)
related to pain was measured using an 11-item version of
the Tampa Scale of Kinesiophobia (TSK-11) [
]. The 11
items each had four response options, all anchored with
the answers Strongly disagree, which scored one point,
and Strongly agree, which scored four points. A total
summary score was then calculated and could range between
11 and 44 points. A high score indicated strong fear of
movement/(re) injury, i.e. high kinesiophobia. The TSK-11
scale has been psychometrically evaluated and shown
good construct validity and reliability in older adults
(Cronbach’s alpha for internal consistency = 0.74–0.87)
and good test-retest reliability (r = 0.747 for intraclass
correlation (ICC)) [
Self-efficacy was measured using the General
SelfEfficacy scale (GSE), a generic instrument that aims to
measure “optimistic self-beliefs to cope with a variety of
difficult demands in life”, recommended for use among
adults with chronic pain [
]. The scale consists of 10 items
with alternative responses: 1 = “not at all true”, 2 = “hardly
true”, 3 = “moderately true”, and 4 = “exactly true”. A sum
score, ranging from 10 to 40, is then calculated. A high
score indicates high self-efficacy. The scale has commonly
been used in older adults as well as in pain patients [
and has been translated into Swedish [
]. The GSE has
been tested for its psychometric properties and has
demonstrated good validity and reliability (Cronbach’s alpha for
internal consistency = 0.75–0.91) and good test-retest
reliability (r = 0.55–0.67) [
Self-rated health was measured using an item extracted
from the 12-item Short-Form Health Survey (SF-12) [
The SF-12 measures health-related quality of life. The
item used in the present study was: “How would you
generally like to say that your health is?” The item had five
alternative responses: (“Excellent health”, “Very good
health”, “Good health”, “Fair health” and “Poor health”).
SF-12 has been found to be valid and reliable in Swedish
older adults [
Physical activity recommendations from international
health guidelines state that older adults should be
moderately physically active (i.e. a moderate amount of effort
that noticeably accelerates the heart rate) at least five
days a week for a minimum of 30 min a day [
], but a
study from 2011 suggested that only 30 % in the group
aged 60+ years seemed to reach these recommended
levels of physical activity [
]. Levels of physical activity
were measured with Grimby’s Activity Scale; a scale
developed to evaluate self-rated physical activity in older
]. Levels of physical activity were classified
using the question: “How physically active do you think
you have been during the last six months?” Physical
activity was classified by one of the following responses:
1. Hardly any physical activity.
2. Mostly sitting, sometimes a walk, light gardening or
similar tasks, sometimes light household activities
such as heating up food, dusting or clearing away.
3. Light physical exercise around 2–4 h a week, such
as walks, fishing, dancing, ordinary gardening etc.
including walks to and from shops. Main
responsibility for light domestic work such as;
cooking, dusting, clearing away and making beds.
Performs or takes part in weekly cleaning.
4. Moderate exercise 1–2 h a week, such as jogging,
swimming, gymnastics, heavy gardening,
homerepairs or light physical activities more than four
hours a week. Responsible for all domestic activities,
light as well as heavy. Weekly cleaning such as doing
vacuum cleaning, washing floors and window
5. Moderate exercise at least three hours a week such
as tennis, swimming, jogging etc.
6. Hard or very hard exercise regularly and several
times a week where the physical exertion is great,
such as jogging or skiing.
Response options 4–6 have previously been used to
correspond to WHO’s recommended levels of physical
]. The physical activity scale has been
psychometrically evaluated in older adults and has
demonstrated acceptable construct validity when validated
against measures of physical performance [
also demonstrated acceptable construct validity when
validated against various physical measures and has been
found to be able to discriminate between groups, who
were more active and less active, as assessed by
measuring maximal oxygen uptake .
The study was conducted in accordance with the basic
ethical principles of medical research and was approved
by the Regional Ethical Review Board in Lund
(registration no. 2010/683). Written consent to participate was
collected from all participants.
Descriptive statistics are presented as the mean, standard
deviation, and range, and percentiles were calculated. The
Chi-squared test was used to compare categorical data;
the Mann–Whitney U-test was used for ordinal data and
the Student’s t-test for interval/ratio data. McNemar’s test,
the Wilcoxon signed rank test, and the paired sample
ttest were also used for paired group comparisons. To
study the associations between the variables at baseline in
those reporting chronic pain, two binary logistic
regression analyses were done (by the backward stepwise
likelihood ratio method) with physical activity, dichotomized
as inactive (1–3) and active (4–6) [
], as the dependent
variable. One logistic regression analysis was done to find
associations at baseline and one logistic regression
analyses was performed in order to find possible predictors of
physical activity. Psychosocial and demographic variables
were included based on empiric relations to physical
activity found in previous studies [
variables (housing and living arrangements), pain-related
variables (intensity, duration), psychological variables
(kinesiophobia and self-efficacy), and health-related
variables (BMI, self-rated health) were entered as independent
variables. To test the quality of the logistic models, the
Hosmer–Lemeshow goodness-of-fit test and Nagelkerke’s
R-squared were used. A value of p > 0.05 indicates a good
model fit in the Hosmer–Lemeshow goodness-of-fit test
. Analyses were done using SPSS Statistics, version
18.0 (SPSS Inc., Chicago, IL).
This study included 1,141 people aged 65+ years (mean
age 74.4 range 65–103 years, 53.5 % female). The
response rate was 57.8 %. The only variable available for
analysis for the non-responders (dropout analysis) was
sex, for which no significant difference (p = 0.322) was
found between participants (53.2 % women) and
nonparticipants (55.8 % women).
Among the respondents, 433 (37.9 %) reported
suffering from chronic pain for more than three months and
they constituted the sample with chronic pain used for
analyses in the present study (63.5 % women, mean age
74.8, 65–78 years). Of the 433 participants, who
reported chronic pain in the baseline questionnaire, 284
responded to a follow-up questionnaire 12 months later.
When comparing baseline characteristics in the chronic
pain sample between those responding at baseline versus
responding at follow up; only minor differences were
found for: sex (63.5 % vs. 64.4 % women), pain intensity
(3.2 vs. 3.2), duration (10.2 vs. 9.0), and kinesiophobia
(22.8 vs. 21.9). However, regarding mean age (78.4 years
vs. 74.39 years) the result indicated that those who were
lost at follow-up were slightly older.
Characteristics for the sample at baseline are shown for
chronic pain participants and non-chronic pain
participants (Table 1). Significant differences between participants
with chronic pain and those with no chronic pain were
found for all variables, except for mean age and living
condition (Table 1). In the total sample, 38.5 % of participants
were found to be physically active. Assuming that none of
the non-responders were physically active would give a
lowest estimated prevalence of 33.3 %. However, assuming
that all of the non-responders were active would give a
total prevalence of 76.4 %. Participants with chronic pain
were less active (31.1 %) than those without chronic pain
(56.9 %) (p < 0.001). In the total population, men reported
Lighter physical exercise, 211 (50.8)
around 2–4 h/week
More strenuous exercise, 101 (24.3)
More strenuous exercise, 23 (5.5)
at least 3 h/week
significantly higher levels of physical activity than women
(p < 0.001), whereas among those suffering from chronic
pain there was no gender difference (Table 1).
Among the participants with chronic pain, the mean
duration of chronic pain was 10.2 (SD 12.2) years and
the mean intensity 3.2 (SD1.1). Back/pelvis (34.1 %),
lower extremities (30.7 %), followed by the upper
extremities (13.4 %) were the three most common
primary localizations of pain. Multiple locations were
reported by 16.7 % of the participants. The mean level of
kinesiophobia among those reporting chronic pain at
baseline was 22.8 (SD 8.3). For the subsample with
chronic pain, logistic regression analyses were performed
to assess associations between baseline physical activity
and variables previously shown to be related to physical
activity levels. At baseline, low age, low BMI, high
selfefficacy and lack of kinesiophobia showed statistically
significant associations (p < 0.01) with physical activity
(4–6 points on physical activity scale; Table 2).
For the subsample with chronic pain, a 12-month
follow-up was used to identify potential predictors of
physical activity levels. When comparing characteristics - in
those reporting chronic pain - only the variables “Self-rated
health” and “Pain intensity” showed significant differences
between baseline and the 12-month follow-up (Table 3).
For the variable “Pain intensity”, the score increased by 0.5
units and for the variable “Self-rated health” the response
option “Poor health” showed the largest decrease in
frequency, from 5.3 % at baseline down to 3.5 % at follow-up
Table 4 shows the results of regression analysis
focusing on potential predictors of physical activity at
12 months follow-up for the subsample with chronic
pain. Younger age (OR = 0.9), baseline physical activity
(OR = 10.0), and low scores on the kinesiophobia test
aPain of duration ≥3 months
The dependent variable, physical activity at baseline, was coded as 0 = inactive
and 1 = active
The independent variables entered into the model were self-reported health
(extracted from the SF-12), BMI, marital status, living conditions, smoking (yes/
no), pain duration in years, pain intensity, self-efficacy (GSE) score, and kinesiophobia
(TSK-11) score. The model was controlled for age (in years) and sex
(0 = man, 1 = woman)
Nagelkerke’s R-square: 0.420
Hosmer–Lemeshow test: 0.819
(TSK-11) (OR = 0.9), all measured at baseline, predicted
high levels of physical activity 12 months later.
The average level of physical activity was unchanged
after 12-months. In the total population, men reported
higher levels of physical activity (p < 0.001), whereas
among those suffering from chronic pain there was no
difference between the genders. Younger age, baseline
physical activity and low kinesiophobia were associated
with higher physical activity levels in older adults with
The prevalence of physical activity (4–6 on physical
activity scale) differed significantly between older healthy
adults (56.9 %) and older adults with chronic pain
(31.1 %). Those in chronic pain reported significantly
lower levels of physical activity compared to those
without chronic pain (Table 1). A number of studies have
illustrated a similar association for older adults with
chronic low back pain [
]. However, although the
participants with chronic pain in this study were not
substantially less active compared to activity levels
previously reported for healthy older adults [
36, 41, 42
the significantly lower levels of physical activity
between the subgroups may suggest that older adults with
chronic pain are at higher risk of functional decline and
additional chronic diseases, compared to older adults
without pain .
In the bivariate analysis, the variable “Pain intensity”
showed a significant increase between baseline and the
12-month follow-up (Table 3). In the adjusted regression
analyses, pain intensity was, however, not identified as a
predictor of physical activity. Similar results have been
found in studies including objective measurements of
physical activity, indicating the impact of pain intensity
to be more present in the establishment of pain
behaviors than in its maintenance over time [
]. The fact
that pain intensity was not identified as a predictor of
physical activity in our study can be explained by a
strong correlation with other independent variables in
the regression analysis. Then only one of them may be
identified as a predictor. It is also notable that “Pain
intensity” was registered as “average pain intensity
during the last week” in our study. Pain intensity can thus,
among these individuals (with, on average, a pain
duration of 10 years), demonstrate temporal variation. It is
also possible that the group of people that are
characterized as “without pain” are actually people who don’t have
chronic pain, but may have pain lasting less than
Furthermore, the adjusted regression analyses indicate
that the variables (age, baseline physical activity and
kinesiophobia) rather than pain characteristics, such as
pain-intensity and pain-duration, affect the level of
physical activity in older adults with chronic pain. Age and
baseline physical activity are well-known to be associated
with physical activity levels in healthy older adults. Our
findings, despite their conformity, are of major relevance
because dissimilar factors might require diverse
interventions in promoting physical activity in older adults
with chronic pain, compared to those without. In
addition it can be seen in this study that kinesiophobia
relates to levels of physical activity, also when controlled
for age, gender and baseline physical activity. The
association to kinesiophobia in this study is in contrast to
some previous studies conducted among general
populations. In these studies it has been suggested that
fearavoidance beliefs are associated with disability through
other mechanisms (such as type of activity), and not
specifically with the amount or level of physical activity
13, 18, 21
]. The relation of physical activity to the
constructs of fear-avoidance among older adults in the
current study might indicate that fear avoidance beliefs
may be related directly to physical activity among older
adults. This may be due to feelings of frailty and more
severe consequences of a possible injury at old age. For
example, a recent study identified avoidance of
activities due to fear of falling as an important contributor
of sedentary behavior among older adults with chronic
muskoloskeletal pain [
]. Interventions targeted at
reducing fear-avoidance beliefs (e.g. cognitive-behavioral
therapies) have shown positive effects regarding both
disability and the experience of pain [
]. Whether the
same interventions also have an effect on the level of
physical activity among older adults also needs further
investigation. Nevertheless, the results indicate that fear
avoidance-beliefs are important to consider in clinical
settings and when designing treatment programs
aiming to increase physical activity levels in older adults
with chronic pain.
Study limitations and strengths
This study has some limitations that need to be
mentioned. Firstly, other factors than those investigated in this
study, may underlie the association between chronic pain
and physical activity in older adults. Such determinants
may include comorbidity and socioeconomic variables but
also factors relating to the built environment, such as
walkability, may explain physical activity in older adults
]. Unfortunately these factors were not possible to
consider in this study. Another possible confounder is
cognitive status, which may have influenced both level
and recall of physical activity. Unfortunately no screening
for cognitive status was possible due to the study design,
aiming to include population based sample of all older
adults. Thus, the effects of cognitive status on physical
activity and the role of proxy respondents have not been
investigated. Secondly, the results of the study are based
solely on self-reported measurements. Using more
objective measures might have given slightly different results.
For example, it must be considered that Grimby’s
activity scale gives a quite crude measurement of physical
activity. Objective measurement, using accelerometers
for example, might have identified smaller changes and
decreased the risk of recall bias. There is also
documented under-estimation of inactivity for self-report
questionnaires  and hence the true prevalence of
inactivity may be even higher than that reported in the
current study. However, a self-report questionnaire was
deemed to be preferable due to the large sample size
in this study. In addition, an important strength of
Grimby’s activity scale is that it was developed for
older adults and it has been shown to distinguish
between active and non-active people. It is thus a
superior choice for use in older adults compared to other
available instruments for measuring physical activity,
e.g., IPAQ, which has been shown to have
questionable psychometric properties in this group [
The pain characteristics were measured using single
items extracted from the brief Screening version of the
Multidimensional Pain Inventory (Swedish version) [
Although the single items have not been psychometrically
evaluated, the face validity is acceptable. We acknowledge
that selection of these single items may complicate
comparison with studies that used the full screening or
Data were collected through questionnaires, which may
have resulted in under-sampling of older adults who are
not able to comprehend the data collection process (e.g.,
due to sight or cognitive difficulties). This may also have
influenced the drop-out between baseline and follow-up
and thus the oldest and possibly frailest elderly may not
have been included. This means that the results may not
reflect the attitudes and beliefs of the entire population of
older adults with chronic pain. Systematic attrition and
low response rates can be considered threats to internal
validity. Generalization of our results must be done with
this in mind. However, the response rate in the present
study (57 %) is comparable to the rates for other studies of
older adults [
]. Furthermore, an attrition analysis
based on gender did not identify any differences when
comparing our respondents to non-respondents
sample, indicating that the drop-out may not be systematic
regarding this variable.
The level of physical activity was significantly lower
among older adults with chronic pain compared to
older adults without chronic pain. Low kinesiophobia
was found to be associated with higher levels of
physical activity among those with chronic pain, also when
controlled for baseline physical activity and age. Our
findings suggest that fear avoidance beliefs are
important to consider, both in clinical settings and in
research, when aiming to increase physical activity in
older adults with chronic pain.
Availability of data and materials
The dataset supporting the conclusions of this article is
available on request. For further information on this
database, you may contact the PI of the project, Ulf
SPAR: swedish personal address register; BMI: body-mass index; SPSS: statistical
package for the Social Sciences; OR: odds ratio; TSK-11: tampa scale of
kinesiophobia (11-item version); GSE: general self-efficacy scale; SF-12: short
form health survey; IPAQ: the international physical activity questionnaire.
The authors declare that they have no competing interests.
CL, EEH, KS and UJ, were all involved in planning and designing the study.
UJ and CL performed the collection of data, data analyses, and drafted the
paper. All authors CL, EEH, KS and UJ suggested revisions, provided oversight
and consultation during all aspects of the study. All authors CL, EEH, KS and
UJ read and approved the final manuscript.
The authors wish to acknowledge the respondents for participating in the
study. We are also most grateful to Patrick Reilly for revising the English in
this manuscript and to Per Condelius and Karolina Eriksson for help with the
collection and input of data. This study was funded through generous grants
from the King Gustav V and Queen Victoria’s Foundation of Freemasons, the
Gyllenstiernska Krapperup Foundation, and Ragnhild and Einar Lundström’s
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