Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain
Larsson et al. BMC Geriatrics
Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain
Caroline Larsson 0 3
Eva Ekvall Hansson 2
Kristina Sundquist 0 1 3
Ulf Jakobsson 0 3
0 Center for Primary Health Care Research, Faculty of Medicine, Clinical Research Centre (CRC), Lund University, Skåne University Hospital , Building 28, floor 11, Jan Waldenströms gata 35, SE-205 02 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, Faculty of Medicine, Clinical Research Centre (CRC), Lund University, Skåne University Hospital , Building 28, floor 11, Jan Waldenströms gata 35, SE-205 02 Malmö , Sweden
Background: The contribution of kinesiophobia (fear of movement) to the pain experience among older adults has been poorly evaluated. The aim of this study was to study prevalence at baseline, development over a 12-month period and cognitive-affective variables of kinesiophobia in a population-based sample of older adults with chronic pain. Methods: The study included 433 older adults (+65 years) with chronic pain (mean age 74.8 years) randomly selected using a Swedish register of inhabitants. Kinesiophobia was measured at baseline and 12-month follow-up with the 11-item version of the Tampa Scale of Kinesiophobia (TSK-11). Associations of demographic-, cognitive affective - and pain-related variables to kinesiophobia were analysed with linear regression analyses. Results: The mean level of kinesiophobia was low. Worsening and recovering from kinesiophobia occurred over time, but the mean level of kinesiophobia remained unchanged (p = 0.972). High levels of kinesiophobia (TSK ≥35) were found among frailer and older adults predominately living in care homes, but not dependent on sex. Poor self-perceived health (OR = 8.84) and high pain intensity (OR = 1.22) were significantly associated with kinesiophobia. Conclusion: Results indicate that potential interventions regarding kinesiophobia among older adults should aim to decrease pain intensity and strengthen health beliefs.
Kinesiophobia; Prevalence; Chronic pain; Older adults
Kinesiophobia, defined as “an excessive, irrational, and
debilitating fear of physical movement and activity
resulting from a feeling of vulnerability due to painful
injury or reinjury” [
] is found to be a central factor in
the process of pain developing from acute to chronic
]. The Cognitive Fear Avoidance Model
describes that when a painful experience is interpreted as
threatening, it can generate catastrophising cognitions
that activity will result in more pain and re/injury. As
this goes on, this can lead to avoidance behaviour, which
in the long run causes disability, disuse and depression
as well as a patient trapped in a cycle of increased fear
of pain, more pain and disability [
]. For older adults the
consequences of disuse and decreased activity can be
serious, increasing the risk for a wide range of health
problems, functional decline and premature death [
Several studies [
], support the validity of the
Cognitive Fear Avoidance Model among the elderly [
but there are also some reports of age-related
differences. For example, pain-related cognitions might
particularly account for age-related differences in the
relationship between pain and depression [
is also a lack of generalisability of the fear avoidance
model to general populations of older adults.
Considering that older adults are especially predisposed to pain
as a result of age and that pain among older adults is
often of unknown origin [
]. This underlines the need
to investigate kinesiophobia in relation to pain in more
general populations of older adults too, including the
Except for the mechanisms outlined in the fear
avoidance model, increasing attention has been given to
selfefficacy as a mediating factor between pain-related fear
(kinesiophobia) and avoidance behaviour [
relates to the belief in one’s own capacities and individuals
with high self-efficacy seem to have a higher ability to
manage challenging situations and setbacks than
individuals with low self-efficacy [
]. Another cognitive aspect
that is strongly associated with the occurrence of pain
among older adults is self-perception of health [
self-perceived health has also been found to relate to poor
recovery from chronic pain [
]. However, the
contributions of self-efficacy and health perceptions to the
cognitive fear avoidance model among older adults have not
been established. Therefore the primary objective of the
current study was to explore prevalence at baseline and
development of kinesiophobia over a 12-month period in a
population-based sample of older adults with chronic pain.
In addition, a second aim was to examine the relationships
between kinesiophobia, pain characteristics and cognitive
affective variables (i.e., self-efficacy, depressed mood and
This study is part of an ongoing prospective population
study, in which older adults aged 65 years and older were
selected randomly using a Swedish national register of
inhabitants (SPAR). At baseline the population study included
2000 older adults who received a questionnaire in the post
to which 1141 replied (mean age 74.4 years, range 65–103
years) giving a response rate of 57.8 %. Among those
replying to the baseline questionnaire, 433(37.9 %) reported to
be suffering from chronic pain (pain duration >3 months)
and this group constitutes the sample of the current study
(63.5 % women, mean age 74.8, 65–78 years). Subsequent
to the baseline questionnaire a follow-up questionnaire was
sent to the respondents 12 months later to analyse the
development over time.
An analysis of the attrition between those replying at
baseline (n = 433) and follow up (n = 284) indicated that
those who were lost at follow-up were slightly older
(mean age 78.4 years vs. 74.39 years) but only revealed
minor differences for: sex, pain intensity, pain duration.
Procedure and measurements
All questionnaires were distributed by post together with
an accompanying letter explaining the study procedure.
It was requested that the questionnaires be returned
using enclosed self-addressed, prepaid envelopes. A
reminder, letter was sent after 2 weeks.
Kinesiophobia was measured by an 11-item version of the
Tampa Scale of Kinesiophobia (TSK-11) [
]. The 11 items
of the scale each have 4 response options; all anchored
with the answers “strongly disagree”, which scores 1 point,
and “strongly agree”, which scores 4 points. The total sum
score is calculated and can range between 11 and 44
points. A high score indicates strong fear of movement/
(re)injury, i.e. high kinesiophobia. TSK-11 has been
psychometrically evaluated and has shown good construct validity
and reliability among older people (i.e. internal consistency
(Cronbach alpha, 0.74–0.87) and test-retest reliability (ICC
r = 0.747) [
Individual demographic variables included sex, age,
housing (own home or care homes) and living arrangements
(alone or with someone) and marital status (married, never
married, widowed or divorced).
“Chronic pain” was defined as having pain for at least
3 months [
]. Extracted items from the brief screening
version of the Multidimensional Pain Inventory (Swedish
] were used to measure intensity, duration, and
localisation of pain. “Pain intensity” was measured using
the item “Rate the average level of your pain during the
last week” responding to a 6-point Likert scale with
answers ranging from “No pain at all” (value of 1 point) to
“Tremendous amount of pain” (value of 6 points). “Pain
duration” was measured in years with pain. “Pain
localisation” was measured using a question consisting of 6
answers (upper extremities, lower extremities, shoulder and
neck, back and pelvis and other locations). Due to low
response rate on the categories “hands” and “feet”, these
were combined into the item named “other locations”.
Cognitive affective variables
Self-perceived health was measured with a single item
“How would you generally describe your health is?” This
item was extracted from the 12-item Short-Form Health
Survey (SF-12) [
]. Self-perceived health was classified
by one of the following 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 [
Depressed mood was measured with the question; “Have
you in the past 3 months been bothered by depressed
mood”?, with four response alternatives; “no, not at all”,
“yes, little”, “yes rather much” and “yes, very much”. The
responses dichotomised into Yes (“yes, little”, “yes, rather
much” and “yes, very much”) and No (“No, not at all”).
The question about depressed mood originates from a
battery of questions about health symptoms previously
used among older adults [
The General Self-Efficacy scale, GSE, is a generic
instrument aiming to measure “optimistic self-beliefs to cope
with a variety of difficult demands in life” [
]. The scale
consists of 10 items with four answering options. The total
sum score is used and ranges between 4–40 points, where
a high score indicates high self-efficacy. GSE is commonly
used among older people as well as pain patients [
has demonstrated good concurrent validity and reliability
qualities (internal consistency [alpha: 0.75–0.91],
testretest reliability [r = 0, 55–0.67]) [
The study was conducted in accordance with the basic
ethical principles of medical research according to the
Declaration of Helsinki [
] and was approved by the
Regional Ethical Review Board in Lund (Reg. no. 2010/683).
Continuous variables are expressed as means and
standard deviations while categorical data is presented with
ranges and percentiles. Paired sample t-test was used in
order to compare mean TSK (TSK-11) and the subscales
(activity avoidance and somatic focus) between baseline
and 12 months follow-up.
To estimate associations for baseline demographic-,
cognitive affective - and pain-related variables as a function of
TSK-11, simple and multiple linear regression analyses were
performed. Variables with p -value < 0.05 in the univariate
analysis were retained and included in the multiple linear
regression analysis. No collinearity problem was detected for
any of the models. Analyses were made using PASW 21.0.
Demographic descriptions of the sample
In the included sample of older adults with chronic pain
(n = 433), 275 (63.5 %) were women. The mean duration
of pain was 10.2 years and mean pain intensity was 3.2
(SD 1.1). The mean age was 74.8 years (range 65–98)
and a majority of the participants were living in their
own accommodation (97.4 %) and together with
someone (61.7 %) (Table 1).
The mean score of kinesiophobia was 22.8 (SD 8.3), 10 %
of the subjects had a score ≥ 35 points. There was no
significant change for the mean scores between baseline and
follow-up (p = 0.97), nor over time for the two sub-scales
TSK- activity avoidance (p = 0.76) or TSK-somatic focus
(p = 1.00) (Table 2). However, individual change in
kinesiophobia scores (±1) between baselines and follow up was
seen among 89.8 % of the subjects and this change ranged
between -26 to 24 points (Fig. 1).
Variables associated with kinesiophobia at baseline
Age, pain intensity and living arrangements, self-efficacy
and “General health-perceived as fair and poor” were all
statistically significant associated (p < 0.05) with
kinesiophobia (Table 3). While the univariate analysis yielded no
significant associations between kinesiophobia and the
variables sex and pain localisation. Self-efficacy was
associated with lower levels of kinesiophobia. When the retained
variables were entered into the multiple linear regression
analysis as a second step, significant associations with
higher levels of kinesiophobia (p < 0.05) were found for
“pain intensity” (B = 1.22) and “general health” -perceived
poor (B = 8.84). However, when comparing the beta values
Tampa Scale of Kinesiophobia (TSK-11), sores ranging from 11–44 points with
high scores indicating high self-efficacy
aPain of duration ≥3 months
the strongest association was found for pain intensity
(β = 0.44) compared to (β = 0.26) for poor health. The
adjusted R squared value was 0.18. Among those reporting
poor health 43.8 % were living alone, 68.8 % were living in
their own accommodation, and a majority (81.1 %) were
women and the mean age was 80.1 years (not shown in
table). Predictive models were not possible due to the
stability of the outcome variable.
The main findings of this study were that worsening as
well as recovering from kinesiophobia occurred over
time, but the mean level of kinesiophobia remained
unchanged. Kinesiophobia was significantly associated with
pain intensity and poor self-perceived health at baseline.
High levels of kinesiophobia were found among frailer
and older adults predominately living in care homes, but
not dependently of sex.
In this study the mean score of kinesiophobia at baseline
was 22.8. It is important to note that kinesiophobia is not
a dichotomous characteristic; rather it is expressed as a
syndrome which varies in degree [
]. For TSK-11, no
cutoff value differentiating between high and low
kinesiophobia exists. However, for the 17-item TSK, the total score
ranges from17 to 68 and scores > 37 are generally
considered as a high level of kinesiophobia [
]. If using the
hypothesis that 37 (57 %) on the 68-graded scale represents
high kinesiophobia, it would be equal to 35 points on a
44-graded scale. In the current sample, a small proportion
(i.e. only the 90th percentile) reached beyond this limit,
which in this case would mean that the prevalence of high
degrees of kinesiophobia could be considered to be low.
Compared to previous studies among younger samples
using the 11-item version of TSK scale (where mean values
ranged between 25.6 - 36.4) [
], lower levels of
kinesiophobia were found in this sample representing a general
population of older adults with heterogeneous chronic
pain. The results correspond to a previous study in a
heterogeneous chronic pain sample where a subgroup aged
55–81 years were found to have lower levels of
painrelated fear than middle-aged patients [
], indicating that
the burden of high kinesiophobia is lower among general
populations of older adults compared to younger.
No changes over time were seen when comparing the
means of either the subscales (i.e., TSK-AA and TSK-SF) or
the total scale. This may indicate that the level of
kinesiophobia can be considered relatively constant over time (at
least over the period of 1 year) at the group level. However,
at the individual level most participants changed their level
of kinesiophobia. About 20 % of the participants showed
changes greater than one standard deviation. However,
what level can be considered clinically relevant has not
been established for TSK-11 among older adults with
chronic pain. Considering the whole range of the scale
(11–44 points), a change of more than 10 % should
reasonably be corresponding to a clinically relevant change and
equivalent to a change of more than 3 points on TSK-11.
Woby et al. [
], suggested in their study that a reduction
of 3 points is needed to be 95 % confident that a change
has occurred. With regards to our study sample, this
suggestion would mean that a clinically relevant change of
kinesiophobia occurred among 51.0 % of the participants,
and indicating that both worsening (24.6 %) and recovering
(26.4 %) from kinesiophobia occurs at old ages.
We also evaluated the relationship between kinesiophobia
and possible determinants known to be involved in the pain
experience, such as sex, pain intensity, pain localisation
depressed mood, self-efficacy and self-perceived health. Apart
from sex and pain localisation all variables were individually
associated with kinesiophobia in the univariate analysis.
Though, for the variable perceived health only the response
options “fair” and “poor” health were significant (compared
to the reference excellent health). The result of the multiple
regression analysis indicated the same result as shown in
the univariate analysis but only poor health and pain
intensity remained significant. It should be noted that the final
model was not completely successful in that it only
explained 17 % of the variance, indicating that there might be
a risk for multicollinearity, although the tests for
multicollinearity did not show this.
The relation between poor health and kinesiophobia is
not unexpected given that pain itself may be regarded as a
health factor, and found strongly associated with other pain
related variables [
], however the result indicates that the
contribution of health in the fear avoidance models merits
further investigation among elderly populations.
Increasing attention has been given to self-efficacy in
explaining pain and pain disability [
]. Woby et al.
 analysed several cognitive measures in the same
model in a sample of chronic low back pain patients.
They identified self-efficacy as the strongest predictor of
pain disability, suggesting self-efficacy as a mediator
between pain-related fear and avoidance behaviours in the
fear avoidance model [
]. However, the mediating effect
was dependent on the level of self-efficacy, i.e., when
selfefficacy was high, elevated pain-related fear did not lead to
greater pain and disability. But where self-efficacy was low,
elevated pain-related fear was more likely to lead to greater
pain and disability. In a recent study among a
heterogeneous pain sample a similar mediating effect of self-efficacy
was found between pain-related fear and disability but not
between pain-related fear and pain severity and depression
]. In contrast to previous findings, the association of
self-efficacy found in the univariate models did not remain
significant in the multiple regression analysis in the current
study (Table 3). It is possible that a more context-specific
measure of pain-related self-efficacy might have a greater
impact on kinesiophobia than detected by the General Self
Efficacy Scale. For depressed mood, the lack of associations
to kinesiophobia is surprising but could be explained by
older adults expecting pain and lower activity (i.e. as a part
of ageing) and therefore employing different mechanisms
for dealing with the pain (i.e. taking medication or ignoring
There are some limitations in this study that need to be
considered. First, and as always in survey-conducted
studies, data rely upon self-reported measures and are
thus subjective reports. Interpretation of the result must
be done with this in mind. Important to note is that
longitudinal research in an older population is unavoidably
affected by loss to follow-up. The survey-based
datacollection may have increased the risk for selection bias
where those most fragile are more likely to not respond.
Such systematic attrition may thus undermine the
possibility of generalisations. However, an analysis of the
attrition between those replying at baseline (n = 433) and
follow-up (n = 284) indicated that those who were lost at
follow-up were slightly older (mean age 78.4 years vs.
74.39 years) but only revealed minor differences for sex,
pain intensity and pain duration. The details of the
attrition analysis have been described previously [
no measures of co-morbidity or any specific origin or site
of pain were included. Previous studies have shown the
applicability of the Cognitive Fear Avoidance Model to
vary between different pain types and this may thus have
affected the result [
]. However, the current study aimed
to explore the kinesiophobia among older adults at
population level irrespective of the underlying cause of pain.
Moreover, given the fact that only a small change in
kinesiophobia was found over a period of 1 year, a longer
follow-up period would be merited.
Low levels of kinesiophobia were found in this
heterogeneous sample of older adults with chronic pain. Although
both worsening and recovering from kinesiophobia
occurred over time, the mean level of kinesiophobia remained
unchanged. High levels of kinesiophobia were found among
frailer and older adults predominately living in care homes,
but not dependent of sex. Poor self-perceived health and
high pain intensity were associated in correlation with
kinesiophobia and the result of this study will help clinicians in
identifying who is most likely to suffer from high
kinesiophobia. The results indicate that potential interventions
regarding kinesiophobia should aim to decrease pain
intensity and strengthen these individuals’ health beliefs.
GSE, General Self-Efficacy scale; ICC, Inter class correlation; PASW, Predictive
Analytics SoftWare; SD, Standard deviation; SF-12, Short Form Health Survey;
SPAR, Swedish personal address register; TSK-11, Tampa Scale of kinesiophobia
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
King Gustav V and Queen Victoria’s Foundation of Freemasons, Ragnhild and
Einar Lundström’s Foundation, Gyllenstiernska Krapperup Foundation.
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 Jakobsson ().
All authors were involved planning and designing the study. UJ and CL
performed the collection of data, data analyses, and drafted the paper. All
authors suggested revisions, provided oversight and consultation during all
aspects of the study. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written consent to publish was collected from all participants.
Ethics approval and consent to participate
The study was conducted in accordance with the basic ethical principles of
medical research according to the Declaration of Helsinki [
] and was approved
by the Regional Ethical Review Board in Lund (Reg. no. 2010/683). Written
consent to participate was collected from all participants.
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1. Kori S , Miller R , Todd D. Kineisiophobia: a new view of chronic pain behavior . Pain Manag . 1990 ; 3 ( 1 ): 35 - 43 .
2. Vlaeyen JW , KoleSnijders AM , Rotteveel AM , Ruesink R , Heuts PH . The role of fear of movement (re)injury in pain disability . J Occup Rehabil . 1995 ; 5 ( 4 ): 235 - 52 .
3. Tak E , Kuiper R , Chorus A , Hopman-Rock M . Prevention of onset and progression of basic ADL disability by physical activity in community dwelling older adults: A meta-analysis . Ageing Res Rev . 2013 ; 12 ( 1 ): 329 - 38 .
4. Manini TM , Everhart JE , Patel KV , Schoeller DA , Colbert LH , Visser M , Tylavsky F , Bauer DC , Goodpaster BH , Harris TB . Daily activity energy expenditure and mortality among older adults . JAMA . 2006 ; 296 ( 2 ): 171 - 9 .
5. Sawatzky R , Liu-Ambrose T , Miller WC , Marra CA. Physical activity as a mediator of the impact of chronic conditions on quality of life in older adults . Health Qual Life Outcomes . 2007 ; 5 ( 1 ): 1 - 11 .
6. Sengul Y , Unver B , Karatosun V , Gunal I. Assessment of pain-related fear in patients with the thrust plate prosthesis (TPP): Due to hip fracture and hip osteoarthritis . Arch Gerontol Geriatr . 2011 ; 53 ( 2 ): 249 - 52 .
7. Cook AJ , Brawer PA , Vowles KE . The fear-avoidance model of chronic pain: Validation and age analysis using structural equation modeling . Pain . 2006 ; 121 ( 3 ): 195 - 206 .
8. Kovacs F , Noguera J , Abraira V , Royuela A , Cano A , Gil del Real MT , Zamora J , Gestoso M , Muriel A , Mufraggi N. The Influence of Psychological Factors on Low Back Pain-Related Disability in Community Dwelling Older Persons . Pain Med . 2008 ; 9 ( 7 ): 871 - 80 .
9. Basler HD , Luckmann J , Wolf U , Quint S . Fear-avoidance beliefs, physical activity, and disability in elderly individuals with chronic low back pain and healthy controls . Clin J Pain . 2008 ; 24 ( 7 ): 604 - 10 .
10. Ledoux E , Dubois JD , Descarreaux M. Physical and psychosocial predictors of functional trunk capacity in older adults with and without low back pain . J Manipulative Physiol Ther . 2012 ; 35 ( 5 ): 338 - 45 .
11. Wood BM , Nicholas MK , Blyth F , Asghari A , Gibson S. Catastrophizing Mediates the Relationship Between Pain Intensity and Depressed Mood in Older Adults With Persistent Pain . J Pain . 2013 ; 14 ( 2 ): 149 - 57 .
12. Raftery MN , Sarma K , Murphy AW , De la Harpe D , Normand C , McGuire BE . Chronic pain in the Republic of Ireland-Community prevalence, psychosocial profile and predictors of pain-related disability: Results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, Part 1 . Pain . 2011 ; 152 ( 5 ): 1096 - 103 .
13. Woby SR , Urmston M , Watson PJ . Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients . Eur J Pain . 2007 ; 11 ( 7 ): 711 - 8 .
14. Bandura A . Self-Efficacy in Changing Societies . NewYork: Cambridge University Press; 1995 .
15. Pereira LV , de Vasconcelos PP , Souza LAF , Pereira Gde A , Nakatani AYK , Bachion MM . Prevalence and intensity of chronic pain and self-perceived health among elderly people: a population-based study . Rev Lat Am Enfermagem . 2014 ; 22 ( 4 ): 662 - 9 .
16. Elliott AM , Smith BH , Hannaford PC , Smith WC , Chambers WA . The course of chronic pain in the community: results of a 4-year follow-up study . Pain . 2002 ; 99 ( 1-2 ): 299 - 307 .
17. Larsson C , Hansson EE , Sundquist K , Jakobsson U. Psychometric properties of the Tampa Scale of Kinesiophobia (TSK-11) among older people with chronic pain . Physiother Theory Pract . 2014 ; 30 ( 6 ): 421 - 428 .
18. IASP : Subcommitte on Taxonomi. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms . Pain . 1986 , Suppl 3 : S1 - S226 .
19. Jakobsson U , Horstmann V . Psychometric evaluation of multidimensional pain inventory (Swedish version) in a sample of elderly people . Eur J Pain . 2006 ; 10 ( 7 ): 645 - 51 .
20. Ware JEJ , Kosinski M , Keller SD. A 12 -Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity . Med Care . 1996 ; 34 ( 3 ): 220 - 33 .
21. Jakobsson U. Using the 12-item Short Form health survey (SF-12) to measure quality of life among older people . Aging Clin Exp Res . 2007 ; 19 ( 6 ): 457 - 64 .
22. Tibblin G , Bengtsson C , Furunes B , Lapidus L . Symptoms by Age and Sex: The Population Studies of Men and Women in Gothenburg, Sweden . Scand J Prim Health Care . 1990 ; 8 ( 1 ): 9 - 17 .
23. Jakobsson U , Klevsgård R , Westergren A , Rahm-Hallberg I . Old people in pain: A comparative study . J Pain Symptom Manag . 2003 ; 26 ( 1 ): 625 - 36 .
24. Schwarzer R , Jerusalem M. Generalized Self-Efficacy scale . In: Weinman J , Wright S , Johnston M , editors. Measures in health psychology: A user's portfolio Causal and control beliefs . Windsor: Nfer-Nelson; 1995 . p. 35 - 7 .
25. Luszczynska A , Scholz U , Schwarzer R. The General Self-Efficacy Scale : Multicultural Validation Studies . J Psychol . 2005 ; 139 ( 5 ): 439 - 57 .
26. Scholz U , Doña BG , Sud S , Schwarzer R. Is General Self-Efficacy a Universal Construct? Psychometric Findings from 25 Countries . Eur J Psychol Assess . 2002 ; 18 ( 3 ): 242 - 51 .
27. WMA declaration of Helsinki- Ethical Principles for medical Research Involving Human subjects . The World Medical Assosiation . webpage http:// www.wma.net/en/30publications/10policies/b3/. Accessed 4 June 2016 .
28. Lundberg M. Begrepp och definitioner relaterade till kinesiophobi . In: Kinesiofobi- teori och tillämpning. Pozkal , Poland: Studentlitteratur; 2008 . p. 123 .
29. Tkachuk GA , Harris CA. Psychometric Properties of the Tampa Scale for Kinesiophobia-11 (TSK-11) . J Pain . 2012 ; 13 ( 10 ): 970 - 7 .
30. Gomez-Perez L , Lopez-Martinez AE , Ruiz-Parraga GT . Psychometric Properties of the Spanish Version of the Tampa Scale for Kinesiophobia (TSK) . Pain . 2011 ; 12 ( 4 ): 425 - 35 .
31. Roelofs J , Sluiter JK , Frings-Dresen MHW , Goossens M , Thibault P , Boersma K , Vlaeyen JWS . Fear of movement and (re)injury in chronic musculoskeletal pain: Evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples . Pain . 2007 ; 131 ( 1-2 ): 181 - 90 .
32. Woby SR , Roach NK , Urmston M , Watson PJ . Psychometric properties of the TSK-11: A shortened version of the Tampa Scale for Kinesiophobia . Pain . 2005 ; 117 ( 1-2 ): 137 - 44 .
33. Denison E , Asenlof P , Lindberg P . Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care . Pain . 2004 ; 111 ( 3 ): 245 - 52 .
34. Perry EV , Francis AJ . Self-efficacy, pain-related fear, and disability in a heterogeneous pain sample . Pain Manag Nurs . 2013 ; 14 ( 4 ): e124 - 34 .
35. Larsson C , Ekvall Hansson E , Sundquist K , Jakobsson U. Impact of pain characteristics and fear-avoidance beliefs on physical activity levels among older adults with chronic pain: a population-based, longitudinal study . BMC Geriatr . 2016 ; 16 ( 1 ): 1 - 8 .
36. Roelofs J , van Breukelen G , Sluiter J , Frings-Dresen MHW , Goossens M , Thibault P , Boersma K , Vlaeyen JWS . Norming of the Tampa Scale for Kinesiophobia across pain diagnoses and various countries . Pain . 2011 ; 152 ( 5 ): 1090 - 5 .