Layout 1 Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 Osteoarthritis (OA) constitutes a significant public health concern, being a chronic condition that impacts a substantial portion of the global population. OA affected 7.6% of the global population in 2020 (equivalent to 595 million individuals). OA prevalence was higher in women than men, with a 2020 global age-standardized prevalence of 8058.9 per 100,000 for women and 5780.1 per 100,000 for men. The prevalence increased by 132.2% over 30 years and is projected to rise by 60 to 100% by 2050. The condition appears to disproportionately impact some racial and ethnic groups and individuals with lower socioeconomic status, with prevalence escalating with age, as ageing-associated changes promote the development of OA.1 The two main modifiable risk factors for developing (OA) are obesity and joint injury. Pain is the primary symptom of OA. A European study of patients with non-tumoral pain revealed that OA was the cause in almost 23% of reported pain instances.2 The pain associated with OA considerably restricts patients' normal activities, both indoors and outside, diminishing their qual- ity of life and adversely affecting their mental health.3 Pa- tients with OA and compromised mental health exhibited increased pain, more frequent hospital visits, higher medi- cation usage, and reported suboptimal outcomes.4 As a re- sult, individuals with OA find themselves in a vicious cycle where their pain deteriorates their mental health, which further exacerbates the pain they experience. Furthermore, the pain of OA increases the chance of mortality as it dis- courages patients from walking and exercising-related benefits.5 The pain associated with OA leads to heightened utilization of healthcare services, and when coupled with additional diseases such as insomnia and depression, the demand for healthcare services escalates further.6 Often patients with OA experience pain catastrophizing, which is defined by the propensity to exaggerate the per- ceived threat of pain stimuli, experience helplessness re- garding pain, and have a diminished capacity to suppress pain-related thoughts before, during, or after a painful ex- perience.7 Patients exhibiting heightened catastrophizing pain also endure more severe pain following their usual Abstract Aim of the present study was to assess the level of catastrophizing pain and kinesiophobia in patients with osteoarthritis and to investigate the association between catastrophizing pain and kinesiophobia. This follow-up study included 170 osteoarthritis patients undergoing surgery. They completed the Pain Catastrophizing Scale and the Tampa Scale for Kinesiophobia preoperatively (T0) and then postoperatively, at one (T1) and six months (T2). The mean score of catastrophizing pain preoperatively indicates moderate to high level of catastrophic pain. Multivariable linear regression analysis with total score of Pain Catastrophizing Scale preoperatively as the dependent variable found that increased age was associated with increased total score of Pain Catastrophizing Scale. The mean kinesiophobia score preoperatively indicates moderate to high level of kinesiophobia. Multivariable linear regression analysis with total score of the Tampa Scale for Kinesiophobia preoperatively as the dependent variable found that increased age and increased patients’ inability to manage pain (helplessness) were associated with increased total score of the Tampa Scale for Kinesiophobia. Increased age and catastrophizing pain are predictors of kinesiophobia. Surgical interventions tend to reduce both catastrophizing pain and kinesiophobia. Key Words: osteoarthritis, kinesiophobia, pain catastrophizing. Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 Levels of catastrophizing pain and kinesiophobia in patients with osteoarthritis and their association Aristea Vitsa,1 Ioannis Moisoglou,2 Petros Galanis,3 Anastasios Merkouris,1 Evridiki Papastavrou,1 Pavlos Sarafis4 1Department of Nursing, Cyprus University of Technology, Limassol, Cyprus; 2Department of Nursing, University of Thessaly, Larisa, Greece; 3Clinical Epidemiology Laboratory, Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece; 4Department of Nursing, University of Thessaly, Larisa, Greece. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 177 - Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 activities.8 Severe catastrophizing pain in the morning among OA patients adversely impacts their physical ac- tivity levels throughout the day, resulting in increased se- dentary behavior. Thus, patients with OA are ensnared in a vicious cycle of negative consequences stemming from the pain associated with their condition, and specifically from the catastrophizing pain they experience. Catastro- phizing pain may be the only independent variable in- fluencing pain and functionality post-operatively in individuals with OA.9 In addition to the catastrophizing pain that affects their ac- tivities, patients with OA may also experience kinesiopho- bia, which is defined as an excessive, irrational and debilitating fear to carry out a physical movement, due to a feeling of vulnerability to a painful injury or reinjury.10 Ap- proximately 50-85% of individuals with OA exhibit kine- siophobia.11 Patients with OA who exhibit elevated levels of kinesiophobia experience a decline in both their physical and mental quality of life, diminished physical activity, greater disability, heightened pain, and functional limita- tions.12 Evidence suggests that there are many effective interven- tions for kinesiophobia and catastrophizing pain, encom- passing surgical intervention, patient education, physiotherapy, cognitive behavioral therapy, psychologist- led therapy, nursing-led therapy, and pharmaceutical treat- ments.13 Interventions including rehabilitation programs, cognitive behavioral therapy, psychoeducation regarding pain, pain self-management instruction (e.g., reduction of pain behaviors, activity pacing), stress and mood manage- ment, biofeedback and relaxation training, occupational therapy, psychotherapy, and physiotherapy have proven ef- fective.14 In the realm of patient rehabilitation, non-immer- sive exergames serve as an effective approach for alleviating pain and mitigating kinesiophobia.15 Although there are a significant number of studies examin- ing the effect of catastrophizing pain and kinesiophobia in patients with OA, there is a significant gap in investigating the association between catastrophizing pain and kinesio- phobia. In this context, the aim of the present study was to preoperatively assess the level of catastrophizing pain and kinesiophobia in patients with OA and to investigate the ex- istence of an association between catastrophizing pain and kinesiophobia. A secondary aim was to explore pain per- ception levels, including catastrophizing and kinesiophobia, before and after surgery, and to correlate these levels with certain demographic characteristics. Materials and Methods Study Design This was a follow-up study. The study enrolled patients who were hospitalized in the orthopaedic departments of two public hospitals in Greece waiting to undergo surgery for the treatment of OA. The method of data collection was that of convenience sampling. The study duration was from Au- gust 1st 2021 to September 4th 2022. We assessed pain cata- strophizing and kinesiophobia before surgery (T0), and postoperatively at one (T1) and six months (T2), in an at- tempt to keep track of their progress during the rehabilita- tion period. The inclusion criteria included the following: (a) diagnosis of OA, (b) sufficient knowledge of the Greek language, and (c) hospitalization in orthopaedic department and upcoming surgery for OA. The exclusion criteria included: (a) insuf- ficient knowledge of the Greek language, (b) patients who were hospitalized in an orthopedic department, with a dia- gnosis other than OA, (c) patients with a diagnosis of OA but who would not undergo surgery to treat it, and (d) pa- tients who, when completing the questionnaire, wanted to stop the procedure for any reason. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Instruments The Pain Catastrophizing Scale (PCS) is a 13-item instru- ment and is currently one of the most widely used measures of catastrophic thinking related to pain.16 The PCS instruc- tions ask participants to reflect on past painful experiences, and to indicate the degree to which they experienced each of 13 thoughts or feelings when experiencing pain, on 5- point scales with the end points (0) not at all and (4) all the time. Possible scores range from 0 to 52. Higher values in- dicate worse catastrophizing pain. The PCS yields a total score and three subscale scores assessing rumination, mag- nification and helplessness.16 We used the Greek validated version.17 The Tampa Scale for Kinesiophobia (TSK) was used to as- sess the degree of kinesiophobia.18 The TSK consists of 17 items and participants record their degree of agreement or disagreement on a 4-point Likert scale (Strongly Disagree- Disagree-Agree-Strongly Agree). Individual item scores range from 1-4. The 17 items TSK total scores range from 17 to 68 where the lowest 17 means no or negligible kine- siophobia, and the higher scores indicate an increasing de- gree of kinesiophobia. The scale has two sub-scales, namely activity avoidance and somatic focus. We used the Greek validated version.19 Ethical Issues The Ethics Committees of both the General University Hos- pital of Patras “Rio” and the General Hospital of Patras “Agios Andreas” approved our study protocol (Committee Sitting 25/16.07.2021 and Committee Sitting 14/28.07.2021 respectively). We conducted our study on an anonymous and voluntary basis after providing full infor- mation to participants upon which they gave their written consent. Statistical analysis We use frequencies and percentages to describe categori- cal variables, while we use mean, standard deviation, me- dian, minimum value and maximum value to describe continuous variables. We used repeated measures analysis of variance to assess the changes of scores on scales dur- ing the three measurements. We used independent samples t-test, Pearson’s correlation coefficient and Spearman’s correlation coefficient to investigate bivariate relation- ships between demographic and clinical characteristics of patients and total score on scales. Then we performed mul- tivariable linear regression analysis with total score on scales as the dependent variables in order to eliminate con- - 178 - Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 founding. In multivariable models, we added independent variables with a p-value<0.2 in bivariate analysis conduct- ing backward method. In that case, we calculated coeffi- cient beta, 95% confidence interval and p-values. The alpha significance level was set at the level of 0.05. Sta- tistical analysis was performed with the Statistical Pack- age for Social Sciences software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Results Demographic characteristics The study population included 170 patients and their de- mographic characteristics are presented in Table 1. The mean age of the patients was 51.3 years, and about half of them were female (51.8%). Half of the patients were uni- versity educated (50%) and 57% of the patients were mar- ried/cohabiting, 74.1% had children and 77.1% were living with others. Clinical characteristics Table 2 displays the clinical characteristics of the patients. 46.5% of patients had a chronic disease, with the most prev- alent being cardiovascular issues, respiratory disorders, and diabetes. 45.3% had previously undergone surgery, with the most prevalent treatments being to orthopedic, gynecolog- ical, and ophthalmological issues. 42.4% of patients were undergoing pharmacological treatment for chronic disease. Catastrophizing pain The Cronbach's alpha coefficient of internal consistency for the PCS on the three consecutive measures ranged from 0.71 to 0.94 indicating very good reliability. The descriptive results for the PCS at the three consecutive measurements (preoperatively, one and six months postoperatively) are presented in Table 3. Higher values indicate worse catastro- phizing pain. In all scores, a statistically significant decrease in catastrophizing pain was found over time (p<0.001 in all cases) indicating that patients' experience of catastrophizing pain improved over time. The mean score of catastrophizing pain preoperatively and after one month indicates moderate to high level of catastrophic pain, while the mean score after six months indicates low level of catastrophic pain. The effect of demographic and clinical characteristics on total catastrophizing pain scores preoperatively was then investigated. Bivariate analysis between demographic and clinical characteristics of patients and total score on PCS preoperatively is shown in Table 4. Bivariate analysis re- vealed that increasing age and decreasing educational level were associated with worse experience of catastrophizing pain. In addition, patients with children, unemployed, pa- tients with comorbidities, patients with past surgery and pa- tients receiving medication for chronic disease experienced worse experience of catastrophizing pain. Then, we con- ducted multivariable linear regression analysis with total score on PCS preoperatively as the dependent variable. We found that only age was a significant predictor. In particular, increased age was associated with increased total score of PCS preoperatively (coefficient beta=0.28, 95% confidence interval=0.21 to 0.35, p<0.001). - 179 - Table 1. Demographic characteristics of patients. Characteristic Ν % Gender Female 88 51.8 Male 82 48.2 Age (mean, standard deviation) 51.3 17.9 Educational level Primary school 4 2.4 Secondary school 15 8.8 High school 23 13.5 Graduate of post-secondary education 43 25.3 University 60 35.3 Postgraduate degree 19 11.2 PhD degree 6 3.5 Family status Unmarried 39 22.9 Married 83 48.8 Cohabiting 14 8.2 Divorced 10 5.9 Widowed 24 14.1 Children No 61 35.9 Yes 10.9 74.1 Residence Alone 39 22.9 With parents 17 10 With roommate 1 0.6 With partner 100 58.8 With relatives 13 7.6 Place of residence Capital city 15 8.8 City 113 66.5 Rural town 16 9.4 Village 26 15.3 Employment Full-time 79 46.5 Part-time 11 6.5 Student 7 4.1 Household 18 10.6 Retired 48 28.2 Unemployed 7 4.1 Financial status Not good 5 2.9 Somewhat good 18 10.6 Fair 77 45.3 Fairly good 64 37.6 Very good 6 3.5 Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 Kinesiophobia The internal consistency coefficient Cronbach's alpha for the TSK in the three consecutive measurements was 0.87, 0.82 and 0.76 respectively indicating very good reliability. The descriptive results for the TSK on the three consecu- tive measures are presented in Table 5. A statistically sig- nificant decrease in patients' kinesiophobia was found over time (p<0.001). The mean kinesiophobia score pre- operatively indicates moderate to high level of kinesio- phobia, the mean score after one month indicates moderate kinesiophobia and the mean score after six months indicates moderate to low level of kinesiophobia. Bivariate analysis between demographic, clinical charac- teristics of patients and the three subscale scores of PCS and total score of TSK preoperatively revealed that in- creasing age, decreasing educational level and increasing catastrophizing pain were associated with an increase in kinesiophobia. In addition, it was found that patients with children, unemployed, patients with a chronic disease, pa- tients with past surgery and patients receiving medication for a chronic disease had greater kinesiophobia. Then, we conducted multivariable linear regression analysis with total score on TSK preoperatively as the dependent vari- able. We found that age and patients’ inability to manage pain (helplessness) were significant predictors. In particu- lar, increased age (coefficient beta=0.13, 95% confidence interval=0.07 to 0.19, p<0.001) and increased patients’ in- ability to manage pain (coefficient beta=0.83, 95% con- fidence interval=0.62 to 1.04, p<0.001) were associated with increased total score on TSK preoperatively. - 180 - Table 2. Clinical characteristics of patients. Characteristic Ν % Chronic disease No 91 53.5 Yes 79 46.5 Type of chronic disease Cardiovascular 36 45.6 Respiratory 15 11.4 Diabetes 9 11.4 Renal 8 10.1 Orthopaedic 6 7.6 Other 5 6.3 Previous surgery No 93 54.7 Yes 77 45.3 Type of previous surgery Orthopedic 29 37.7 Gynaecological 21 27.3 Ophthalmological 12 15.6 Other 6 7.8 Medication for chronic disease No 98 57.6 Yes 72 42.4 Table 3. Descriptive results for the PCS at the three consecutive measurements Mean Standard Median Minimum Maximum P-valuea deviation value value Rumination <0.001 Preoperatively 12.4 2.8 13 1 16 After one month 11.7 3.3 12 0 16 After six months 3.2 3 2.5 0 13 Magnification <0.001 Preoperatively 8.4 2.5 8 0 12 After one month 9.1 2.4 9.5 2 12 After six months 4.9 2.5 5 0 12 Helplessness <0.001 Preoperatively 16.9 5.2 18 0 24 After one month 16.1 5.0 17 0 24 After six months 3.6 3.7 2 0 18 Overall score <0.001 Preoperatively 37.7 9.4 39.5 4 52 After one month 36.9 9.8 39 3 52 After six months 11.7 8.1 10 0 37 aRepeated measures analysis of variance. Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 - 181 - Table 4. Bivariate analysis between demographic and clinical characteristics of patients and total score on PCS preoperatively. Characteristic Mean score Standard deviation P-value Gender 0.6a Female 37.4 9.8 Male 38.1 9 Age 0.5b <0.001b Educational level -0.3c <0.001c Family status 0.2a Unmarried/Divorced/Widowed 36.6 9.9 Married/Cohabiting 38.6 9 Children <0.001a No 33.3 9.7 Yes 40.2 8.3 Residence 0.2a Alone 36.1 9.6 Living with others 38.2 9.3 Place of residence 0.3a Capital city/City 37.2 9.5 Rural town/Village 39.2 9.1 Employment <0.001a No 40.6 8.1 Yes 35.1 9.8 Financial status -0.1c 0.3c Chronic disease <0.001a No 35.3 9.7 Yes 40.5 8.3 Previous surgery 0.01a No 35.9 10 Yes 39.8 8.2 Medication for chronic disease <0.001a No 35 9.9 Yes 41.4 7.3 aIndependent samples t-test; bPearson’s correlation coefficient; cSpearman’s correlation coefficient. Table 5. Descriptive results for the TSK at the three consecutive measurements. Mean Standard Median Minimum Maximum P-valuea deviation value value Kinesiophobia score <0.001 Preoperatively 52.4 8.6 52.5 29 68 After one month 48 7.3 48 33 65 After six months 37.2 6.5 37 19 53 aRepeated measures analysis of variance. Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 Discussion This study assessed preoperatively the extent of pain cat- astrophizing and kinesiophobia in patients diagnosed with OA and examined the relationship between the levels of pain catastrophizing and kinesiophobia. Find- ings showed that patients experienced high levels of cat- astrophizing pain and kinesiophobia preoperatively, with increased age positively influencing catastrophizing pain and kinesiophobia, while the PCS subscale, helplessness, positively influenced kinesiophobia. Moreover, despite the reduction in the values of catastrophizing pain and kinesiophobia postoperatively, they nevertheless per- sisted at levels signifying those patients encountered moderate degrees of both catastrophizing pain and kine- siophobia. Our results align with existing literature, in- dicating a reduction in both catastrophizing pain and kinesiophobia levels over time.20 Elevated levels of cat- astrophic pain and kinesiophobia postoperatively impede patient mobilization and rehabilitation. Their alleviation can be efficiently accomplished through a variety of in- terventions. Advanced patient age is a prognostic risk factor for heightened catastrophizing pain and kinesiophobia, as indicated by our data. This finding is consistent with similar findings in the literature.21 Kinesiophobia and catastrophic pain are prevalent among elderly patients, necessitating special attention for this age group to en- sure their inclusion in rehabilitation programs (incorpo- rating both pharmacological and non-pharmacological interventions) and to promote adherence to these pro- grams.22 Telecare emerged as a significant form of inter- vention during and following the COVID-19 pandemic. This therapy modality offers advantages such as de- creased patient travel and enhanced safety concerning infectious infections. Systematic reviews and meta-anal- yses have demonstrated the efficacy of telecare programs for patients with OA, which may also advantage older individuals.23-25 According to our findings the PCS subscale, helpless- ness, positively influenced kinesiophobia. The studies use catastrophizing pain and kinesiophobia as independ- ent variables and examine their effect on the physical and mental health of patients with OA. The present study is the first to explore and highlight the relationship be- tween catastrophizing pain and kinesiophobia. Studies have associated the existence of pain and perceptions of pain, but not catastrophizing pain, with kinesiophobia.26 Consequently, therapies aimed at alleviating catastro- phizing pain may also diminish kinesiophobia. A sub- stantial body of studies has evidenced the efficacy of interventions aimed at alleviating catastrophizing pain, such as cognitive-behavioral therapy, including internet- based interventions, multimodal treatment, self-efficacy and acceptance and commitment therapy. Moreover, therapies targeting sleep can markedly diminish pain cat- astrophizing.27-29 Our study had several limitations. First, we cannot estab- lish a causal relationship between catastrophizing pain and kinesiophobia since the estimation of these variables was cross-sectional. Second, we employed a convenience sam- ple to collect our data. Thus, our sample cannot be repre- sentative of the OA population in Greece. In addition, the sample is relatively small, as it consists of 170 patients from two hospitals. And finally, as our study included pa- tients who were hospitalized in public hospitals, the qual- ity of services provided in these hospitals may have influenced their perceptions of catastrophizing pain and kinesiophobia. A comparison with private hospitals in Greece might have been useful, as patients receiving pri- vate surgical care have greater expectations for their treat- ment and increased satisfaction.30 Conclusions OA constitutes a serious public health concern, since the pain endured by patients markedly impacts their quality of life and utilization of healthcare resources. A signifi- cant percentage of these patients exhibit catastrophizing pain and kinesiophobia, with older individuals being the most impacted, as per our findings. The tendency to cat- astrophize pain influences the level of kinesiophobia in preoperative OA patients, necessitating interventions to alleviate this pain to diminish kinesiophobia and opti- mize rehabilitation outcomes for these individuals. List of abbreviations OA, Osteoarthritis PCS, Pain Catastrophizing Scale TSK, Tampa Scale of Kinesiophobia Contributions AV prepared the research protocol, conducted the study and drafted the manuscript. IM helped in drafting the manuscript.PG provided the statistical analysis of the data. AM critically appraised the article. EP critically ap- praised the article. PS was responsible for the research protocol and critical review of the article. Funding None. Conflict of interest The authors declare no conflict of interest. Ethics approval The Ethics Committees of both the General University Hospital of Patras “Rio” and the General Hospital of Pa- tras “Agios Andreas” approved our study protocol (Com- mittee Sitting 25/16.07.2021 and Committee Sitting 14/28.07.2021 respectively). We conducted our study on an anonymous and voluntary basis after providing full information to participants upon which they gave their written consent. - 182 - Catastrophizing pain and kinesiophobia in patients with osteoarthritis Eur J Transl Myol 35 (2) 13636, 2025 doi: 10.4081/ejtm.2025.13636 Corresponding author Pavlos Sarafis, Department of Nursing, University of Thessaly, Gaiopolis Campus, Larissa-Trikala Ring-Road, 415 00, Larissa, Greece. ORCID ID: 0000-0001-9967-5152 E-mail: psarafis@uth.gr Co-authors Aristea Vitsa ORCID ID: 0009-0005-8334-7791 E-mail: aristeavitsa@gmail.com Ioannis Moisoglou ORCID ID: 0000-0002-6003-0733 E-mail: iomoysoglou@uth.gr Petros Galanis ORCID ID: 0000-0002-1308-5782 E-mail: pegalan@nurs.uoa.gr Anastasios Merkouris ORCID ID: 0000-0002-8515-007X E-mail: anastasios.merkouris@cut.ac.cy Evridiki Papastavrou ORCID ID: 0000-0001-5128-3651 E-mail: e.papastavrou@cut.ac.cy Pavlos Sarafis ORCID ID: 0000-0001-9967-5152 E-mail: psarafis@uth.gr References 1. Courties A, Kouki I, Soliman N, Mathieu S, Sellam J. Osteoarthritis year in review 2024: Epidemiology and therapy. Osteoarth Cartil 2024;32:1397-404. 2. O’Brien T, Breivik H. The impact of chronic pain-Eu- ropean patients’ perspective over 12 months. Scand J Pain 2012;3:23–9. 3. Park Y, Park S, Lee MY. 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