Kinesiophobia and associated factors among patients with cardiac disease attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024: a multicentre cross-sectional study

Abstract

Background

Kinesiophobia is a catastrophic fear of physical activity due to a patient’s overwhelming concerns and sense of vulnerability about cardiac consequences due to activities. However, there was a lack of information regarding kinesiophobia among patients with cardiac disease, particularly in low- and middle-income countries, including Ethiopia.

Aim

This study aimed to assess the prevalence of kinesiophobia and its associated factors among patients with cardiac disease attending cardiac units at hospitals in Addis Ababa, Ethiopia.

Design

An institutional-based multicentre cross-sectional study was conducted.

Setting and participants

The study was conducted through a systematic random sampling technique in six comprehensive specialised hospitals to select 405 study participants.

Primary tool and analysis

Kinesiophobia was assessed by the Tampa Scale Kinesiophobia-heart questionnaire. The collected data were analysed on SPSS V.25. Bivariate analysis was used to determine potential candidate variables. Finally, an adjusted OR (AOR) with a p value of <0.05 and a 95% CI was considered statistically significant.

Result

The prevalence of kinesiophobia was 67.4% (95% CI: 62.6% to 72%). An older age group (AOR=3.84; 95% CI=1.663 to 8.864), cardiac function classification class II (AOR=2.639; 95% CI=1.090 to 6.388), class III (AOR=5.646; 95% CI=2.299 to 13.868), class IV (AOR=9.229; 95% CI=3.026 to 28.142), being physically inactive (AOR=2.642; 95% CI=1.490 to 4.685), being anxious (AOR=2.730; 95% CI=1.487 to 5.011) and moderate (AOR=2.172; 95% CI=1.063 to 4.437) and high perceived threat (AOR=6.146; 95% CI=2.955 to 12.786) were significantly associated with kinesiophobia.

Conclusion

The results of this research imply that kinesiophobia is a common health concern among patients with cardiac disease. Being above 50 years, advanced stage of cardiac disease, physical inactivity, anxiety and having higher threat illness perceptions were significantly associated with kinesiophobia among patients with cardiac disease.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study considered variables from different perspectives, including contextual aspects such as lifestyle factors and psychological factors, as well as disease-related factors like cardiac function and cardiac disease duration.

• The study was carried out across multiple centres in six specialised hospitals with a large randomly selected sample of 405 patients with cardiac disease.

• Some of the variables that need follow-up or qualitative designs, like quality of life and awareness of physical activity, were not assessed in this study.

Background

Cardiovascular diseases (CVDs) are among the types of diseases that involve the heart structure, the vessels and the conduction system abnormalities.¹ They are highly increasing non-communicable diseases in Ethiopia, Africa and worldwide. CVDs are the leading causes of mortality and morbidity in the globe, accounting for 17.9 million fatalities annually, of which low- and middle-income nations account for more than three-quarters of all fatalities and result in significant medical costs. In Ethiopia, the prevalence of CVDs ranges from 7.2% to 24%, and the age-standardised CVD disability-adjusted life years were 3549.6 per 100 000 populations.²

Following cardiac disease (CD), a wide range of complications, including psychological and physiological issues, may manifest. Kinesiophobia is among the most common complications that happen to patients with CD; it happens when patients believe that exposure to movements can exacerbate pain and suffering, which is frequently accompanied by dread that is mediated by prior suffering.³ In patients with CD, kinesiophobia is an excessive and irrational fear of physical activity resulting from a feeling of vulnerability and excessive concerns about cardiac deterioration and other negative consequences of activities, including rhythm disorders, cardiac arrest and sudden death.⁴

Compared with patients with other diseases, patients with CD are more likely to experience kinesiophobia because fear and associated avoidance behaviours are common psychological reactions to an acute CD.⁵ Depending on the type of cardiac ailment and study population, different nations have different prevalence rates of kinesiophobia among patients with CD; based on an analysis done in 2024, the global prevalence of kinesiophobia is 61% among patients with CD, with a varied prevalence ranging from 20.0% to 87.2%.⁴

There are numerous reasons why patients referred for cardiac treatments and rehabilitation frequently experience kinesiophobia. These include sociodemographic factors, psychological factors, physical factors and factors related to heart function, which are the most important factors. These factors can all affect the prognosis of kinesiophobia among patients with CD during intervention and rehabilitation.^{6 7}

Kinesiophobia can directly affect the prognosis of patients, and it is a significant obstacle to daily activities, which may lead to adverse outcomes in patients with CD, leading to long-term physical inactivity in patients, which can result in increased risk of cardiac events and psychological problems like solitude, hopelessness and a loss of self-worth.^{8 9}

Exercise rehabilitation—such as resistance exercise, inspiratory muscle training and intermittent or continual aerobic training—and counselling, as cardiac rehabilitation’s principal method, can enhance physical well-being, including reducing fear of physical activity and improving quality of life.¹⁰ Among the cardioprotective components that exercise affects, the endothelium has been identified as a primary target; exercise has been shown to increase coronary endothelial function, endothelium-dependent vasodilation, myocardial perfusion and decrease the progression of cardiac symptoms.¹¹

Most studies had been conducted in developed countries, and to the limit of the search result, this area was not focused on; the prevalence and associated factors of kinesiophobia among patients with CD remain unclear in Ethiopia and also in African countries. Therefore, the aim of this study was to determine the prevalence and associated factors of kinesiophobia among patients with CD in Addis Ababa, Ethiopia.

Method

Study aim, design and period

An institutional-based, multicentre, cross-sectional study was conducted to assess the prevalence of kinesiophobia and its associated factors among patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia. The study period was in August 2024, at cardiac units in selected hospitals in Addis Ababa, Ethiopia.

Study setting, participants and eligibility criteria

The study was conducted at a cardiac unit in selected public hospitals in Addis Ababa, Ethiopia. Addis Ababa is the capital of Ethiopia and among Africa’s largest and most populated cities.¹² The city has 15 public hospitals,¹³ of which some have cardiac services from examining patients to critical care and follow-up in their cardiology unit. In the study, patients with CD aged 18 years and older who visited cardiac units at selected comprehensive specialised hospitals (Tikur Anbesa Hospital, St. Paulo’s Hospital, St. Peter’s Hospital, Yekatit 12 Hospital, Alert Hospital and Armed Forces Specialised Hospital) in Addis Ababa, Ethiopia, were included. Exclusion criteria were as follows: (1) patients with CD with cognitive impairment that impedes data collection, (2) cardiac artery bypass surgery in the last 3 weeks and (3) acute traumatic injuries and neurological conditions, and seriously ill participants during the data collection were excluded.

Sample size determination, sampling technique and procedure

The sample size was determined by using the single population proportion formula using the following assumptions. The prevalence of kinesiophobia among patients with CD was assumed to be 50% to ensure the study was adequately powered due to no previous study having been found locally and with a similar population. Assuming a 5% margin of error (d), a 95% confidence level (alpha, α=0.05), where: P=50% (expected prevalence of kinesiophobia due to lack of previous studies in our country, so to obtain the maximum sample size, P was taken as 50%), Zα/2=critical value of the Z score at a 95% CI of certainty, d=margin of sampling error tolerated (desired precision), 5% (0.05), ${\displaystyle \mathrm{n}=\frac{{\left(Z\alpha /2\right)}^2\mathrm{P}\left(1-\mathrm{P}\right)}{{\mathrm{d}}^2}\approx 385}$. By considering a 10% non-response rate, the minimum sample size was ≈424.

A systematic random sampling technique was employed for selecting study participants. The sampling interval, Kth, was calculated by dividing the total number of study participants at selected hospitals during the study period by the study sample (N/n), which is more than 2000 patients per month, then 2000/424≈5. The first patient was selected using the lottery method between 1 and ‘k’=1–5, and it was 1, and other patients were selected by the systematic random sampling method within every kth value until the required sample size was obtained in each hospital.

Data collection procedures and data quality control

The data were collected through a five-section questionnaire by face-to-face interviews and patient medical chart review. The questionnaire had five sections: Part I: sociodemographic variables sections (age, sex, household income, marital status, employment, residency, educational level, body mass index (BMI)), Part II: health-related factors questionnaire sections (comorbidity, CD duration and cardiac functioning classification), Part III: lifestyle factors questionnaire sections (smoking, alcohol consumption and physical activity), Part IV: psychosocial factors questionnaire sections (anxiety, depression, illness perception and social support) and Part V: kinesiophobia assessment using the Tampa scale Kinesiophobia-heart questionnaire. Data collection was started by screening patients with CD who volunteered to participate in the study based on the inclusion and exclusion criteria. After the importance of the study was explained, and informed consent was obtained, trained nurses collected the data and interviewed the participants using the translated version of the questionnaire.

The quality of the data was controlled starting at the time of questionnaire preparation. To ensure the quality of the data, the questionnaire was first prepared in English and then translated into the local language Amharic and then back to English to maintain its consistency by three translators. The data collectors were six nurses working in each selected hospital. The supervision was done on the spot by the principal investigator. To maintain the quality of the data, all data collectors were trained by the principal investigator for one day on how to approach, how to collect the data on study participants, how to use the questionnaire, how to get informed consent from the study participants and important issues were raised about the data collection.

Before the actual data collection time, the tool was pretested to check for the accuracy of responses, language clarity, consistency and appropriateness of the tools with 5% of the total sample size of 424 (22 patients). Then the necessary correction and modification of the questionnaire was done before the actual data collection period. During each data collection period, close supervision was done. Later on, the questionnaire was reviewed and checked for completeness and consistency by the principal investigator.

Operational definition

Kinesiophobia

A total score of >37 on the TSK-heart questionnaire was used to indicate the presence of kinesiophobia (0=no kinesiophobia, 1=have kinesiophobia).¹⁴

Body mass index

The BMI is measured by dividing weight in kilograms by the square of height in metres (kg/m²). Individuals are considered underweight (<18.50), normal (18.50–24.99), overweight (≥25.00–29.9) and obese (30.0 and above).¹⁵

Physical activity

Physically active if any kind of moderate-intensity exercise (such as walking, cycling or planned exercise and strength exercise) is done at least 150 min/week.¹⁶

Smoker

Current smoker: someone who has smoked greater than 100 cigarettes in their lifetime and who now smokes every day and previous smoker: someone who has smoked greater than 100 cigarettes in their lifetime but has not smoked in the last 28 days.¹⁷

Alcohol consumption

Based on the Alcohol Use Disorders Identification Test, a screening tool to assess alcohol consumption and drinking behaviours, a score ≥5 from a total score of 12 is considered as alcohol consumers or alcohol users.¹⁸

Cardiac functioning classification

According to the New York Heart Association’s (NYHA) functional class, it can be classified into four classes: Class I: no symptoms of heart failure, Class II: symptoms of heart failure with moderate exertion, such as ambulating two blocks or two flights of stairs, Class III: symptoms of heart failure with minimal exertion, such as ambulating one block or one flight of stairs, but no symptoms at rest and Class IV: symptoms of heart failure at rest.¹⁹

Comorbidity

Coexistence of chronic health conditions with the present CD includes systemic, physical or mental health conditions.²⁰

Anxiety

Based on the Hospital Anxiety Disorder Scale (HAD-A), a score ≥8 is used to indicate the presence of anxiety disorder.²¹

Depression

According to the Hospital Depression Scale (HAD-D), a score ≥8 is considered as depression.^{21 22}

Illness perception

Based on Brief Illness Perception Questionnaire: <42 indicates low perceived threat, 42–49 indicates moderate perceived threat and ≥50 indicates high perceived threat in patients.²³

Social support

According to the Oslo Social Support Scale, social support can be operationalised into three broad categories of social support: 3–8 indicates poor social support, 9–11 indicates moderate social support and 12–14 indicates strong social support.²⁴

Statistical methods

The data were collected using Kobo Toolbox and exported to the SPSS V.25 for data analysis and summary presentation. Descriptive statistics were done for all the variables in the study using statistical measurements, and those findings were presented using texts, frequency tables, graphs and charts to describe the study population.

All explanatory variables were entered into the bivariate logistic regression analysis, and a multivariable logistic regression model was used to handle the effect of possible confounders and identify factors associated with outcome variables. In bivariate logistic regression analysis, variables with a p value <0.25 were considered as potential candidates in the final multivariable logistic regression analysis, as p value <0.25 offers a balance between identifying truly significant candidates and avoiding the inclusion of spurious associations. The results were considered statistically significant in the multivariable logistic regression with a p value <0.05. Finally, an adjusted OR (AOR) with a 95% CI at a p value <0.05 was interpreted and reported. The model fitness was checked using Hosmer and Lemeshow’s goodness of fit test, which shows that the model is fit, and the multicollinearity diagnostic was performed by the variance inflation factor (<10) (online supplemental file 1).

Patient and public involvement

Neither patients nor the public are involved in the design, conduct, reporting or dissemination plans associated with this research.

Results

Characteristics of study participants

Sociodemographic characteristics of study participants

A total of 405 participants with CD participated in this study, yielding a response rate of 95.5%. The common reasons for non-responses were feeling tiresome and constraint of time. Among the participants, 223 (55.1%) were men, and the age range was from 18 to 69 years, with the mean (±SD) age of participants being 44.06 (±13.4), with the majority of the participants being above the age of 50 years, 141 (34.8%) (table 1).

Table 1. Sociodemographic characteristics of patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024.

Variable	Frequency	Per cent
Age
18–29	80	19.8
30–39	86	21.2
40–49	98	24.2
≥50	141	34.8
Gender
Male	223	55.1
Female	182	44.9
Educational level
No formal education	50	12.3
Primary school (1–8)	86	21.2
High school (9–12)	94	23.2
College and above	175	43.2
Residence
Urban	207	51.1
Rural	198	48.9
Income (ETB)
≤2500	69	17
2500–7000	262	64.7
≥7000	74	18.3
BMI
Underweight	120	29.6
Normal	224	55.3
Overweight and obese	61	15.1

BMI, body mass index; CD, cardiac disease; ETB, Ethiopian Birr.

Health-related characteristics of study participants

Among the study participants, 177 (43.7%) had been confirmed to have medical comorbidities. Most of the study participants from total participants, 143 (35.3%), had a disease duration of more than 5 years. In addition, more than half of the study participants, 269, had cardiac function class II and class III (128 and 141, respectively) (figure 1).

Figure 1. Health-related characteristics (presence of comorbidity, cardiac disease duration and cardiac function class) of patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024. CD, cardiac disease.

Lifestyle-related and psychosocial characteristics of study participants

Among the study participants, more than half of the study participants, 259 (64%), were not participating in regular physical activity. Among the study participants, 319 (78.8%) were non-alcohol users and 249 (61.5%) were non-smokers. Regarding psychosocial-related characteristics, around half of the study participants, 189 (46.7%), had high experienced threat. Of the total study participants, 264 (65.2%) had anxiety, and around two-thirds of the total participants, 265 (65.4%), were depressed. And also around half of the study participants, 202 (49.9%), had low social support (table 2).

Table 2. Lifestyle-related and Psychosocial characteristics of patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024.

Variable	Frequency	Per cent
Physical activity
No	259	64.0
Yes	146	36.0
Alcohol consumption
Non-alcohol users	319	78.8
Alcohol users	86	21.2
Smoking status
Never smoker	249	61.5
Current smoker	64	15.8
Previous smoker	92	22.7
Illness perception
Low threat	95	23.5
Moderate threat	121	29.9
High threat	189	46.7
Social support
Low social support	202	49.9
Moderate social support	130	32.1
High social support	73	18.0
Anxiety
No	141	34.8
Yes	264	65.2
Depression
No	140	34.6
Yes	265	65.4

CD, cardiac disease.

Prevalence of kinesiophobia among patients with CD

The overall prevalence of kinesiophobia among study participants was 67.4% (95% CI: 62.6% to 72%) (figure 2).

Figure 2. Prevalence of kinesiophobia among patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024. CD, cardiac disease.

Factors associated with kinesiophobia among patients with CD

During bivariate logistic analysis, 11 variables showed significant association at p<0.25 (age group, gender, educational level, confirmed medical comorbidities, duration of CD, cardiac function class, physical inactivity, smoking status, illness perception, anxiety and depression) considered together in multivariable analysis. In multivariable logistic analysis, factors that showed significant associations with a p value <0.05 were five: age group above 50 (AOR=3.84; 95% CI=1.663 to 8.864); cardiac function class II (AOR=2.639; 95% CI=1.090 to 6.388), class III (AOR=5.646; 95% CI=2.299 to 13.868) and class IV (AOR=5.646; 95% CI=2.299 to 13.868); physical inactivity (AOR=2.642; 95% CI=1.490 to 4.685); anxiety (AOR=2.730; 95% CI=1.487 to 5.011); moderate threat (AOR=2.172; 95% CI=1.063 to 4.437) and high threat illness perception (AOR=6.146; 95% CI=2.955 to 12.786) with a p value at 95% CI (table 3).

Table 3. A bivariate and multivariable logistic regression analyses of factors associated with kinesiophobia among patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, 2024.

Variable	Kinesiophobia		COR (95% CI)	AOR (95% CI)	P value
	No	Yes
Age
18–29	42	38	1
30–39	36	50	1.535 (0.831 to 2.834)	1.717 (0.791 to 3.728)	0.172
40–49	34	64	2.080 (1.137 to 3.808)	2.167 (0.955 to 4.917)	0.064
50+	20	121	6.687 (3.507 to 12.748	3.840 (1.663 to 8.864)*	0.002
Cardiac function class
Class I	45	15	1
Class II	50	78	4.680 (2.362 to 9.273)	2.639 (1.090 to 6.388)*	0.032
Class III	28	113	12.107 (5.917 to 24.774)	5.646 (2.299 to 13.868)†	<0.001
Class IV	9	67	22.33 (9.002 to 55.408)	9.229 (3.026 to 28.142)†	<0.001
Physical activity
No	53	206	4.583 (2.940 to 7.144)	2.642 (1.490 to 4.685)†	<0.001
Yes	79	67	1
Illness perception
Low threat	54	41	1
Moderate threat	44	77	2.305 (1.330 to 3.993)	2.172 (1.063 to 4.437)*	0.033
High threat	34	155	6.004 (3.464 to 10.408)	6.146 (2.955 to 12.786)†	<0.001
Anxiety
No	80	61	1
Yes	52	212	5.347 (3.407 to 8.390	2.730 (1.487 to 5.011)†	<0.001

^*Statistically significant.

^†Highly statistically significant

1, Reference; AOR, adjusted OR; CD, cardiac disease; COR, crude OR.

Discussion

The purpose of this study was to determine the prevalence of kinesiophobia and its associated factors among patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia. In this study, the prevalence of kinesiophobia among patients with CD attending cardiac units at hospitals in Addis Ababa, Ethiopia, was found to be 67.4% (95% CI 62.6% to 72%). The age group of patients, cardiac function classification, being physically inactive, being anxious and illness perception were significantly associated with kinesiophobia among patients with CD.

The prevalence of kinesiophobia in our study, 67.4%, was comparable with a study done in Turkey, 71.4%,²⁵ Nanjing China, 69.5%,²⁶ and Poland, 70%.²⁷ Likewise, the studies done in Poland, Turkey and Nanjing, China found that most participants were men and that equal gender distributions may be attributed to a comparable rate of kinesiophobia with our study; this is because women have a high tendency to experience anxiety,²⁸ which can influence the occurrence of kinesiophobia.

However, the prevalence of kinesiophobia in our study was lower than the findings of the previous studies; in two cross-sectional and one follow-up study in Turkey (87.2%, 85.3%, 74.5%), China (75.7%), Italy (83%), India (83.87%) and Poland (76%).625 29,33 Age group differences among the participants might be a possible reason for this discrepancy; relative to our study, in which the mean age of the participants was 44.06 years, three studies in Turkey, China, Italy, India and Poland had participants with a mean age greater than our study (58, 56.76, 58.1, 62.29, 60, 57, 71.8 years, respectively). As age increases, the physiological and psychological functions of the body deteriorate, which results in the overestimation of the dangers associated with physical activity,³⁴ that might be one of the possible reasons for the discrepancy.

On the contrary, the prevalence of kinesiophobia in this study was higher than in cross-sectional studies conducted in China (58.4%),³⁵ Sweden (20%)³⁶ and the Netherlands (29%, 40.9%, 45.4%).37,39 It is also higher than study findings from Amsterdam-Netherlands, and another study done in Gothenburg, Sweden, aimed at assessing changes in fear of movement (40% pre-cardiac and 26% post-cardiac rehabilitation in the Netherlands and 25.4% at baseline and 21.1% after 4 months in the Sweden study).^{40 41} This difference might be due to different methodologies, study settings and better health access facilities in those countries. In the Netherlands’ studies,^{38 39} participants were recruited from rehabilitation centres, so they had a better understanding and awareness of physical activity and movement. Similarly, the discrepancy between our study and studies in Sweden could be that patients in Sweden have better access to physical activity and rehabilitation programmes.⁴² The likely rationale for the variations between our study and the studies done in China³⁵ and another study in the Netherlands³⁷ might be that unlike our study, in which most participants had class III cardiac function, more than half of the participants in the China and Netherlands study had class II and class I cardiac function, respectively. Patients with reduced cardiac function may overestimate the risks associated with physical activity. This cognitive appraisal can lead to an increased fear of the potential consequences of movement.²⁶

In the present study, it was found that the age group was a significant predictor of kinesiophobia among patients with CD, where respondents above 50 years were 3.8 times more likely to have kinesiophobia than those aged 18–30 years. This result was in line with a study done in Italy and Turkey.^{7 32} The possible reason may be that an increasing age will result in a deteriorating sense of balance and an exaggerated perception of the potential danger, including fatigue and falls, that makes older people experience a greater sense of vulnerability⁴³; these aspects of ageing may contribute to a high rate of kinesiophobia in patients above 50 years old.

According to our study, cardiac functions based on NYHA functional classification were significantly associated with kinesiophobia. Our study implies that participants who had a class II, class III and class IV cardiac function classification were 2.6, 5.6 and 9.2 times more likely to develop kinesiophobia as compared with those with a class I cardiac function classification, respectively. This direct relation was supported by two studies conducted in China and one study conducted in Turkey.^{26 33 44} As cardiac function decreases, primary symptoms of CDs, such as fatigue, dyspnoea and precordial pain, worsen, causing frustration in doing any activities,⁴⁵ hence leading to kinesiophobia.

In the current study, physical inactivity was positively associated with kinesiophobia compared with those participants who were physically active, in which kinesiophobia was about 2.6 times more common among physically inactive participants than those who do regular physical activity. Studies done in Sweden and Turkey aligned with this study finding.^{41 46} A possible explanation for this is that physical inactivity may cease the recovery of cardiac symptoms that lead to refusal of performing any task,⁴⁷ which eventually results in kinesiophobia.

Concerning the existence of psychological characteristics, our study found that those patients with anxiety symptoms were 2.7 times more likely to have kinesiophobia compared with those who did not experience anxiety. That is supported by a systematic review and meta-analysis conducted in China and a prospective cohort study conducted in the Netherlands.^{4 38} Cross-sectional studies done in Poland and Rhode Island, USA also suggest patients with CD who had anxiety were more likely to have kinesiophobia.^{48 49} This might be due to expecting the worst and being sensitive to physical cues and ordinary bodily sensations being among the faulty thought patterns that anxiety can cause. This kind of thinking might exacerbate kinesiophobia by making movement appear more dangerous than it actually is.⁵⁰

In our study, it was found that those with moderate perceived threat were 2.2 times more likely to experience kinesiophobia, and those who had high perceived threats were 6.1 times more likely to have kinesiophobia than those with low perceived threats. This relation between illness perception and kinesiophobia was supported by studies carried out in China and the Netherlands.^{51 52} The possible reason may be that individuals with a high threat perception may doubt their ability to manage pain or engage in physical activity safely.⁵³

Conclusion and recommendation

As the study involves multiple institutions and used a random sample, the results of this research imply that kinesiophobia is emerging as a significant health concern among patients with CD. Key factors contributing to the occurrence of kinesiophobia among patients with CD include age (specifically those over 50 years), cardiac function classification class II, III and IV, physical inactivity, anxiety and higher threat perceptions of an illness.

Health bureaus and policymakers need to develop and implement preventative strategies and treatment guidelines for kinesiophobia to correct the misinterpretation of physical activity among patients, to be aware of the benefits of physical activity, as well as better to consider the early screening of kinesiophobia for beneficial intervention and prevent future impacts of kinesiophobia. Health professionals, including physiotherapists, should place more emphasis on physical activity participation and engage in the treatment of patients with CD by drawing attention to deteriorating aspects of age, incorporating exercise therapy, cognitive behavioural therapy and other management techniques based on those factors associated with kinesiophobia. In future studies, it might be interesting to conduct follow-up research that tracks changes over time in various variables, as well as qualitative research designed to address factors such as quality of life and awareness of physical activity.

Data availability statement

Data are available upon reasonable request.