Determinants of kinesiophobia in patients with hidradenitis suppurativa: the role of pain, fatigue, physical activity and depression

Abstract

Background

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease associated with substantial physical and psychosocial burden. Pain, fatigue, and psychological symptoms are common in HS and may influence behavioral responses such as fear of movement. Kinesiophobia, defined as an excessive fear of movement due to pain or fear of injury, has been widely studied in chronic pain conditions; however, its role in HS has not been previously investigated. This study aimed to evaluate the level of kinesiophobia in patients with HS and to investigate its associations with disease severity, pain, fatigue, psychological symptoms, and physical activity.

Methods

This cross-sectional study included patients with HS and age- and sex-matched healthy controls. Disease severity was assessed using the International Hidradenitis Suppurativa Severity Score System (IHS4). Pain intensity was evaluated using the Visual Analog Scale (VAS), fatigue using the Fatigue Severity Scale (FSS), depressive symptoms using the Beck Depression Inventory (BDI), anxiety using the Beck Anxiety Inventory (BAI), physical activity using the MET scale, and kinesiophobia using the Tampa Scale for Kinesiophobia (TSK). Group comparisons, correlation analyses, and multivariable regression analysis were performed to identify factors independently associated with kinesiophobia.

Results

Patients with HS had significantly higher levels of kinesiophobia and fatigue and lower levels of physical activity compared with healthy controls. Kinesiophobia was positively correlated with disease severity, pain intensity, fatigue, and depressive symptoms, and negatively correlated with physical activity levels. In multivariable regression analysis, pain intensity, fatigue, and depressive symptoms emerged as independent determinants of kinesiophobia.

Conclusions

Kinesiophobia appears to be an important yet underrecognized component of disease burden in HS. Pain, fatigue, and depressive symptoms may contribute to the development of movement-related fear, which may in turn reduce physical activity levels. Multidisciplinary management strategies addressing pain control, fatigue, psychological well-being, and safe physical activity may help improve patient outcomes in HS.

Introduction

Hidradenitis suppurativa (HS) is a chronic, recurrent, inflammatory skin disease affecting intertriginous areas and is characterized by painful nodules, abscesses, sinus tract formation, and scarring [1]. The clinical spectrum and disease burden of HS are not limited to cutaneous manifestations but are also associated with substantial functional impairment and deterioration in quality of life [2]. In recent years, HS has increasingly been recognized as a complex disease associated with systemic inflammatory processes, and the contribution of comorbidities and chronic inflammation to the overall disease burden has gained growing importance [3].

Pain is one of the most prominent and frequently reported symptoms of HS; it substantially affects daily functioning, psychosocial well-being, and quality of life, thereby increasing the overall disease burden [4, 5]. However, chronic pain should not be regarded merely as a direct consequence of peripheral inflammation or tissue damage [6]. In the chronic pain literature, pain experience is conceptualized as a multidimensional process shaped not only by biological inputs but also by psychological status, previous learning experiences, cognitive appraisals, and sociocultural context [7]. Therefore, pain in HS should be considered a multidimensional experience that influences patients’ emotional responses, behaviors, and participation in daily life.

Kinesiophobia is defined as an excessive and disabling fear of movement arising from pain or the expectation of reinjury [8]. In chronic pain conditions, kinesiophobia has been associated with avoidance of physical activity, functional limitations, and reduced quality of life [9]. According to the Fear-Avoidance Model, pain-related fear of movement may progressively increase avoidance behaviors and contribute to functional decline [10]. Similarly, the Cognitive Behavioral Model of Chronic Pain suggests that pain is not merely a sensory experience but may also be shaped by threat appraisal, cognitive distortions, and catastrophic interpretations [11]. This process may reinforce movement avoidance and create a self-perpetuating cycle among pain, fear, and functional limitation [12]. Despite the marked chronic pain and inflammatory burden in HS, to the best of our knowledge, kinesiophobia has not yet been investigated in this patient group within a comprehensive biopsychosocial framework.

Psychological comorbidities such as depression and anxiety have been reported to be more common in patients with HS than in the general population [13]. Psychological symptoms may increase pain perception and reinforce pain-related avoidance behaviors, thereby contributing to the mechanisms underlying kinesiophobia [14]. Similarly, social anxiety, shame, and body image-related concerns may further restrict activity in patients with HS. The biopsychosocial model provides an appropriate theoretical framework for understanding this process in a holistic manner. This model recognizes that the experience of chronic illness cannot be explained solely by biological processes; rather, biological, psychological, and social factors interact to shape illness perception, symptom experience, and functional outcomes [15]. Therefore, evaluating psychological and psychosocial variables is important for understanding whether fear of movement in HS is driven primarily by pain or whether it is also related to disease visibility and fear of negative social evaluation.

Fatigue is also a common symptom in HS and may significantly reduce patients’ functional capacity [16]. The adverse effects of fatigue on physical performance, motivation, and daily activities are well established in chronic diseases [17]. Although physical activity is known to have beneficial effects on inflammation, pain modulation, and psychological well-being, reduced physical activity levels have been demonstrated in chronic inflammatory diseases [18]. In patients with HS, physical activity may be further restricted by pain, mechanical discomfort, social concerns related to the visibility of lesions, and fear of symptom exacerbation [19].

Therefore, the aim of this study was to investigate the clinical and psychological determinants of kinesiophobia in patients with HS. In this context, the relationships between kinesiophobia (TSK) and disease severity (IHS4), pain intensity (VAS), fatigue (FSS), depression and anxiety levels (BDI and BAI), and physical activity levels (MET scale) were evaluated. In addition, multivariable regression analysis was performed to identify the independent determinants of kinesiophobia.

Materials and methods

Study design and participants

This cross-sectional case–control study included 182 participants, comprising 91 patients with hidradenitis suppurativa (HS) and 91 age- and sex-matched healthy controls.

HS patients were consecutively recruited during routine dermatology outpatient visits. During the study period, 103 eligible patients with HS were invited to participate; 91 agreed and were included in the final analysis, yielding a response rate of 88.3%. The diagnosis of HS was confirmed by a dermatologist based on established clinical criteria.

Disease severity was assessed using the International Hidradenitis Suppurativa Severity Score System (IHS4). IHS4 was calculated using the following formula: number of inflammatory nodules × 1 + number of abscesses × 2 + number of draining tunnels × 4. Higher IHS4 scores indicate greater inflammatory disease activity. In the present study, IHS4 was analyzed as a continuous variable. IHS4 is a validated dynamic scoring system developed to assess HS severity in both clinical practice and research settings [20].

Pain intensity was assessed using a 0–10 Visual Analog Scale (VAS), where 0 indicated “no pain” and 10 indicated “the worst imaginable pain.” Patients were asked to rate their average HS-related skin pain during the previous 7 days. VAS was selected because it is a simple and widely used measure of pain intensity and has been used in previous HS and chronic pain studies [21].

The control group consisted of age- and sex-matched healthy volunteers who presented for routine check-up purposes and were not under follow-up for any known chronic disease. They were not recruited from a special health promotion program. During the study period, 130 eligible healthy controls were invited to participate; 91 agreed and were included in the final analysis, yielding a response rate of 70.0%.

Exclusion criteria for both groups included chronic inflammatory skin diseases other than HS, chronic pain conditions, active psychiatric treatment, or any systemic, neurological, musculoskeletal, or cardiopulmonary condition that could affect physical activity levels. These included severe cardiopulmonary disease, recent surgery, limb amputation, neurological disorders, or musculoskeletal conditions limiting mobility.

The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee (Approval No: E-10840098-202.3.02-1399), and written informed consent was obtained from all participants prior to enrollment.

Clinical and demographic data

Demographic data including age, sex, BMI, education level, marital status, occupation, and lifestyle habits were recorded. In the HS group, disease duration (years), IHS4 score, and VAS pain score were documented.

Outcome measures

Kinesiophobia

The kinesiophobia level was assessed using the TSK which includes 17 items and assesses the subjective rating of kinesiophobia. Each item is scored using a 4-point Likert-type scale, (1 point is reporting complete disagreement and 4 points are reporting complete agreement). The total points range between 17 and 68. Higher scores refer a higher severity of kinesiophobia. Scores higher than 37 points mean high levels of kinesiophobia and scores less than or equal to 37 mean low levels of kinesiophobia [22, 23]. The Turkish version of the scale was previously validated and shown to be reliable by Acar et al. [24].

Fatigue

FSS is a nine-item scale that assesses the level and severity of fatigue and is rated on a 7-point Likert scale (1 point means “absolutely disagree” and 7 points means “strongly agree”). The total score of this scale varies between 0 and 7 point, thus the maximum score is seven. FSS evaluates the extent to which fatigue affects physical function, motivation, exercise, and whether fatigue affects the work, family or social life of patients [25]. Turkish validation study of the scale has been conducted in patients with FMS [26].

Physical activity

Physical activity was evaluated using the short form of the International Physical Activity Questionnaire (IPAQ-SF). IPAQ-SF contains 7 questions that provide information about sitting, walking, and moderate to vigorous-intensity activities. The total score includes the duration (minutes) and frequency (days) of intense activity. The sitting score (sedentary behavior level) is calculated separately. Each activity needs to be done for at least 10 min at a time. The metabolic task equivalent (MET) - minute/week score is provided by multiplying the minutes, days, and MET values. According to standard MET values, 1.5 MET sitting, walking time (minutes) multiplied by 3.3 MET. In the calculation, 4 METs are considered medium activity and 8 METs are considered an intense activity. As a result of the IPAQ score, PA levels are classified as low (< 600 MET-min/week), medium (600–3000 MET-min/week) and high (> 3000 MET-min/week) physical activity level [27, 28]. The reliability and validity of the Turkish version of the questionnaire were conducted [29].

Psychological assessment

Depressive symptoms were evaluated using the Beck Depression Inventory (BDI), a 21-item self-report Likert-type scale developed by Beck et al. [30]. Total scores range from 0 to 63, with higher scores indicating greater severity of depressive symptoms. The Turkish validity and reliability study was conducted by Hisli [31], and the validated Turkish version was used.

Anxiety symptoms were assessed using the Beck Anxiety Inventory (BAI), a 21-item self-report Likert-type scale developed by Beck et al. [32]. Total scores range from 0 to 63, with higher scores indicating greater severity of anxiety symptoms. The Turkish version validated by Ulusoy et al. was used [33].

BDI and BAI were selected because both instruments have validated Turkish versions, are widely used in clinical research, and allow dimensional assessment of depressive and anxiety symptom severity. In the present study, these scales were used as screening tools rather than diagnostic psychiatric instruments. No structured psychiatric interview was performed.

All questionnaires were administered in face-to-face sessions.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics version 25.0. Continuous variables were expressed as mean ± standard deviation and median (minimum–maximum), while categorical variables were presented as number and percentage.

Normality was assessed using the Kolmogorov–Smirnov test. Between-group comparisons were conducted using the independent samples t-test or Mann–Whitney U test as appropriate. Categorical variables were compared using the chi-square or Fisher’s exact test.

Associations between clinical variables and TSK, FSS, and MET scores were evaluated using Spearman correlation analysis.

To identify independent predictors of kinesiophobia, multivariable linear regression analysis was performed using TSK score as the dependent variable. Robust standard errors (HC3) were applied to account for potential heteroscedasticity.

A p value < 0.05 was considered statistically significant.

Sample size calculation

Sample size estimation was performed using G*Power software (version 3.1). Assuming a medium effect size (d = 0.5), a power of 95%, and a significance level of 0.05, the required minimum sample size was calculated as 176 participants. To account for potential data loss, a total of 182 participants were included.

Results

Comparison of demographic and clinical characteristics between patients and controls

A total of 182 participants were included in the study, comprising 91 patients with hidradenitis suppurativa (HS) and 91 age- and sex-matched healthy controls. Demographic and clinical characteristics of the study population are presented in Table 1.

Table 1.

Demographic and clinical characteristics of the study population

Mean + SD Median (Min-Max)		Control (n = 91)		Patient (n = 91)		p 1
Age (years)		36 ± 6.8 35- (24–52)		37.2 ± 7.2 36- (24–52)		0.226
BMI		28.2 ± 3.1 28.1- (23–36)		28.3 ± 3.1 28.1- (23.2–36.2)		0.762
IHS4 score		-		11.9 ± 6.8 10- (2–29)		-
VAS Pain		-		5 ± 1.9 5- (2–9)		-
MET scale		2.2 ± 0.8 2- (1–3)		1.8 ± 0.7 2- (1–3)		0,003
TSK		34.7 ± 4.8 35- (26–47)		41.4 ± 7.6 41- (28–62)		< 0.001
FSS		3.8 ± 0.6 4- (2–5)		4.4 ± 0.4 4.4- (4–6)		< 0.001
BDI		11.7 ± 3.56 11- (5–24)		15.7 ± 5.2 17- (4–26)		< 0.001
BAI		8.5 ± 1.7 8- (6–13)		12.2 ± 2.3 12- (6–18)		< 0.001
Disease duration (years)		-		9.2 ± 6.17 8- (1–24)		-

		N	%	N	%	p 2
Gender	Female	46	50.5%	49	53.8%	0.767
	Male	45	49.5%	42	46.2%
Education level	Primary school	16	17,6%	20	22%	0.873
	Middle school	7	7.7%	8	8.8%
	High School	39	42.9%	36	39.6%
	University	29	31.9%	27	29.7%
Occupation	Desk worker	45	49.5%	40	44%	0.852
	Physically demanding	28	30.8%	29	31.9%
	Housewife	13	14.3%	15	16.5%
	Retired	5	5.5%	7	7.7%
Marital Status	Married	52	57.1%	57	62.6%	0.513
	Single	34	37.4%	26	28.6%
	Divorced	3	3.3%	6	6.6%
	Widowed	2	2.2%	2	2.2%
Habits	None	49	53.8%	35	38.5%	0.967
	Cigarette	28	30.8%	36	39.6%
	Alcohol	10	11%	14	15.4%
	Cigarette+Alcohol	4	4.4%	6	6.6%
MET scale	1	22	24.2%	33	36.3%	0.004
	2	29	31.9%	39	42.9%
	3	40	44%	19	20.9%

Values are presented as mean ± standard deviation and median (minimum–maximum) for continuous variables, and number (percentage) for categorical variables. Bold values indicate statistically significant results (p< 0.05)

HS Hidradenitis suppurativa, IHS4 International Hidradenitis Suppurativa Severity Score System, VAS Visual Analog Scale, MET Metabolic Equivalent of Task, TSK Tampa Scale for Kinesiophobia, BDI Beck Depression Inventory, BAI Beck Anxiety Inventory, FSS Fatigue Severity Score

Mann-Whitney U test¹, Fisher’s Exact test²

p¹ values were calculated using the Mann–Whitney U test

p² values were calculated using Fisher’s Exact test

There were no statistically significant differences between patients and controls in terms of age (p = 0.226) or BMI (p = 0.762). The distribution of gender, education level, occupation, marital status, and lifestyle habits did not differ significantly between groups (all p > 0.05). Disease-specific parameters, including IHS4 score, VAS pain score, and disease duration, were recorded only in the patient group.

MET scale scores were significantly lower in patients with HS compared with controls (1.8 ± 0.7 vs. 2.2 ± 0.8, p = 0.003). When MET scale was evaluated categorically, the distribution of activity levels differed significantly between groups (p = 0.004) (Table 1).

TSK scores were significantly higher in patients with HS than in controls (41.4 ± 7.6 vs. 34.7 ± 4.8, p < 0.001). FSS scores were also significantly higher in the HS group compared with controls (4.4 ± 0.4 vs. 3.8 ± 0.6, p < 0.001).

Comparison according to kinesiophobia levels

Patients were stratified according to TSK scores using a predefined cut-off value: TSK ≤ 37 was defined as low kinesiophobia (n = 36), and TSK > 37 as high kinesiophobia (n = 55). Clinical and demographic characteristics of these subgroups are presented in Table 2.

Table 2.

Comparison of clinical characteristics according to kinesiophobia levels

Mean + SD Median (Min-Max)	Low Levels TSK (n = 36) %40	High Levels TSK (n = 55) %60	p*
Age (years)	36.6 ± 8.2 36- (24–52)	37.6 ± 6.6 36- (24–52)	0.520
BMI	27.9 ± 2.6 27.6- (23.5–35)	28.6 ± 3.4 28.7- (23.2–36.2)	0.278
IHS4 score	9.7 ± 6.5 7.5- (3–28)	13.4 ± 6.6 11- (2–29)	0.004
VAS Pain	4.8 ± 2.2 4- (2–9)	5.2 ± 1.7 5- (2–9)	0.179
MET scale	2.1 ± 0.7 2- (1–3)	1.7 ± 0.7 2- (1–3)	0.027
FSS	4.3 ± 0.4 4.3- (3.6–5.6)	4.5 ± 0.4 4.5- (3.5–5.8)	0.091
BDI	14.5 ± 4.2 16- (4–20)	16.5 ± 5.7 18.0 (5–26)	0.010
BAI	11.6 ± 2.6 12- (6–17)	12.5 ± 2.0 12- (8–18)	0.079
Disease duration (years)	8.2 ± 5.2 7- (1–20)	9.8 ± 6.7 9- (1–24)	0.405

Values are presented as mean ± standard deviation and median (minimum–maximum). Bold values indicate statistically significant results (p< 0.05)

TSK Tampa Scale for Kinesiophobia, IHS4 International Hidradenitis Suppurativa Severity Score System, VAS Visual Analog Scale, MET Metabolic Equivalent of Task, FSS Fatigue Severity Score, BDI Beck Depression Inventory, BAI Beck Anxiety Inventory

Mann-Whitney U test*

p values were calculated using the Mann–Whitney U test

There were no significant differences between the low and high TSK groups in terms of age, BMI, disease duration, VAS pain scores, FSS scores, or BAI scores (all p > 0.05).

IHS4 scores were significantly higher in the high TSK group compared with the low TSK group (13.4 ± 6.6 vs. 9.7 ± 6.5, p = 0.004). BDI scores were also significantly higher in the high TSK group (16.5 ± 5.7 vs. 14.5 ± 4.2, p = 0.010). MET scale scores were significantly lower in the high TSK group compared with the low TSK group (1.7 ± 0.7 vs. 2.1 ± 0.7, p = 0.027).

Correlation analysis between clinical parameters, kinesiophobia, fatigue, and physical activity

Spearman correlation analyses were performed to evaluate the associations between clinical parameters and TSK, FSS, and MET scale scores (Table 3).

Table 3.

Spearman correlation analysis of clinical variables with TSK, FSS, and MET scale

Variable	TSK r (p)	FSS r (p)	MET scale r (p)
Age (years)	0.034 (0.748)	0.036 (0.737)	0.113 (0.288)
BMI	0.073 (0.493)	0.004 (0.972)	-0.144 (0.174)
Disease duration (years)	0.142 (0.180)	-0.076 (0.473)	-0.117 (0.271)
IHS4	0.289 (0.005)	0.223 (0.033)	-0.213 (0.042)
VAS Pain	0.281 (0.007)	0.093 (0.379)	-0.135 (0.202)
MET scale	-0.277 (0.008)	-0.118 (0.265)	—
TSK	—	0.236 (0.025)	-0.277 (0.008)
FSS	0.236 (0.025)	—	-0.118 (0.265)
BDI	0.364 (0.000)	0.145 (0.172)	-0.130 (0.219)
BAI	0.096 (0.366)	-0.039 (0.711)	-0.104 (0.329)

Values are presented as Spearman correlation coefficient (r) with corresponding p values. Bold values indicate statistically significant results (p< 0.05)

TSK Tampa Scale for Kinesiophobia, FSS Fatigue Severity Score, MET Metabolic Equivalent of Task, BDI Beck Depression Inventory, BAI Beck Anxiety Inventory, IHS4 International Hidradenitis Suppurativa Severity Score System, VAS Visual Analog Scale

TSK scores were positively correlated with IHS4 (r = 0.289, p = 0.005), VAS pain score (r = 0.281, p = 0.007), FSS score (r = 0.236, p = 0.025), and BDI score (r = 0.364, p < 0.001). TSK scores were negatively correlated with MET scale scores (r = − 0.277, p = 0.008). No significant correlations were observed between TSK scores and age, BMI, disease duration, or BAI scores (all p > 0.05).

FSS scores were positively correlated with IHS4 (r = 0.223, p = 0.033) and TSK scores (r = 0.236, p = 0.025). No significant correlations were observed between FSS scores and VAS pain, BDI, BAI, MET scale, age, BMI, or disease duration (all p > 0.05).

MET scale scores were negatively correlated with IHS4 (r = − 0.213, p = 0.042) and TSK scores (r = − 0.277, p = 0.008). No significant correlations were observed between MET scale scores and FSS, VAS pain, BDI, BAI, age, BMI, or disease duration (all p > 0.05).

Multivariable linear regression analysis for TSK

A multivariable linear regression analysis was performed with TSK score as the dependent variable (Table 4). The overall model was statistically significant (R² = 0.279, adjusted R² = 0.210, p = 0.001).

Table 4.

Multivariable linear regression analysis for TSK

Variable	β	SE	t	p	95% CI Lower	95% CI Upper
Intercept	10.273	10.936	0.939	0.350	-11.483	32.029
BMI	0.050	0.235	0.213	0.832	-0.417	0.517
Disease duration (years)	0.175	0.118	1.485	0.141	-0.059	0.410
IHS4 score	0.136	0.115	1.188	0.238	-0.092	0.364
VAS Pain	0.792	0.386	2.050	0.044	0.023	1.561
MET scale	-1.217	1.010	-1.205	0.232	-3.225	0.792
FSS	3.726	1.632	2.283	0.025	0.479	6.973
BDI	0.294	0.141	2.079	0.041	0.013	0.575
BAI	0.296	0.320	0.927	0.357	-0.340	0.933

β unstandardized regression coefficient, SE robust standard error (HC3), CI confidence interval, R² coefficient of determination, Adj. R² adjusted coefficient of determination, VAS Visual Analog Scale, MET Metabolic Equivalent of Task, BDI Beck Depression Inventory, BAI Beck Anxiety Inventory, FSS Fatigue Severity Score, IHS4 International Hidradenitis Suppurativa Severity Score System, TSK Tampa Scale for Kinesiophobia. Bold values indicate statistically significant results (p< 0.05)

R² = 0.279 Adjusted R² = 0.210 F(8, 82) = 3.98 p = 0.001

Dependent variable: Tampa Scale for Kinesiophobia (TSK)

Independent variables: BMI, disease duration, IHS4 score, VAS pain, MET scale, FSS, BDI, and BAI

VAS pain score (B = 0.792, 95% CI: 0.023–1.561, p = 0.044), FSS score (B = 3.726, 95% CI: 0.479–6.973, p = 0.025), and BDI score (B = 0.294, 95% CI: 0.013–0.575, p = 0.041) were independently associated with TSK scores. BMI, disease duration, IHS4 score, MET scale score, and BAI score were not independently associated with TSK scores (all p > 0.05).

Discussion

This cross-sectional study demonstrated that patients with HS had significantly higher levels of kinesiophobia and fatigue compared with healthy controls and exhibited lower levels of physical activity. In addition, the level of kinesiophobia was found to be associated with disease severity, pain intensity, fatigue, and depressive symptoms, while it was inversely associated with physical activity levels. In multivariable regression analysis, pain intensity, fatigue, and depression emerged as independent determinants of kinesiophobia. To the best of our knowledge, this study is the first to investigate the level of kinesiophobia in patients with HS and its relationship with pain, fatigue, physical activity, and psychological symptoms.

Kinesiophobia is a multidimensional clinical phenomenon that emerges through the interaction of pain-related threat appraisal, fear-avoidance beliefs, psychological symptoms, and behavioral avoidance responses in chronic pain conditions [34].Particularly in diseases associated with chronic pain, this fear-avoidance behavior may reduce physical activity and thereby increase the functional burden of the disease. In the present study, patients with hidradenitis suppurativa demonstrated significantly higher levels of kinesiophobia compared with healthy controls. Similarly, increased levels of kinesiophobia have been reported in chronic pain conditions such as systemic lupus erythematosus, rheumatoid arthritis, fibromyalgia, and migraine compared with healthy individuals [35–39]. These findings suggest that fear of movement may represent an important yet often overlooked dimension of disease burden in HS. Furthermore, when patients were classified according to their level of kinesiophobia, approximately 60% of patients were found to have high TSK scores, and this group demonstrated significantly higher disease severity and depression scores, as well as lower physical activity levels compared with patients with lower levels of kinesiophobia. These findings indicate that kinesiophobia should be considered a multidimensional component of disease burden in HS.

Psychological factors may play an important role in the development of kinesiophobia. In the present study, patients with HS had higher levels of depression and anxiety than healthy controls. This finding is consistent with the frequently reported burden of depressive and anxiety symptoms in the literature and may reflect the chronic, recurrent nature of the disease and its substantial impact on quality of life [40–42]. Moreover, the positive association between depression scores and kinesiophobia, together with the identification of depressive symptoms as an independent determinant of kinesiophobia in our analysis, suggests that fear of movement in HS cannot be explained solely by pain severity.

Similar associations have been reported in rheumatologic diseases such as systemic lupus erythematosus and rheumatoid arthritis, as well as in musculoskeletal conditions such as back and shoulder pain, where depression has been associated with greater pain severity, functional limitation, and increased fear of movement [14, 26, 39, 43]. These findings may be interpreted within the framework of the biopsychosocial model, the fear-avoidance model, and the cognitive-behavioral model of chronic pain [44]. According to these models, pain and fatigue may contribute to the perception of movement as threatening, whereas depressive symptoms, negative illness perceptions, and catastrophic interpretations of pain may reinforce fear-avoidance behaviors [45]. In line with this interpretation, studies in patients with psoriatic arthritis have also reported that depression and fatigue are associated with kinesiophobia, further supporting our findings [46].

However, movement avoidance in HS may not be explained solely by the anticipation of pain. Disease-specific physical and social factors, such as sweating, friction, discharge, odor, lesion visibility, embarrassment, and stigmatization, may also contribute to avoidance of physical activity. The reported associations between body image disturbance, depression, and anxiety in patients with HS further support this interpretation [47]. Therefore, kinesiophobia in HS should be considered not merely as a consequence of nociceptive pain mechanisms, but rather as a multidimensional behavioral response shaped by the interaction of inflammatory disease activity, pain, fatigue, depressive and anxiety symptoms, body image, illness perceptions, and social concerns. In clinical practice, this suggests that the psychological status and disease-specific psychosocial burden of patients should be taken into account when assessing fear of movement in HS. When necessary, psychological assessment, counseling, and multidisciplinary follow-up may contribute to the management of HS.

Pain is one of the most prominent and frequently reported symptoms of HS and is considered a major component of the overall disease burden [4, 48, 49]. Previous studies have shown that HS-related pain significantly affects daily activities, functional capacity, and quality of life [50]. In our study, a significant positive correlation was observed between pain intensity and kinesiophobia, and pain intensity emerged as an independent determinant of kinesiophobia in multivariable analysis. A similar relationship between pain and kinesiophobia has been demonstrated in studies conducted in chronic pain conditions such as rheumatoid arthritis and fibromyalgia [37–39]. These findings are consistent with the fear-avoidance model described in chronic pain conditions [51]. According to this model, fear of movement arising from pain may lead to avoidance behaviors over time, resulting in reduced physical activity and functional limitations. Therefore, effective and multidisciplinary pain management may play an important role in breaking the vicious cycle that may develop between fear of movement and a sedentary lifestyle.

Another important finding of our study is the relationship between fatigue and kinesiophobia. Fatigue levels were significantly higher in patients with HS compared with the control group, and fatigue scores showed a positive correlation with kinesiophobia. Previous studies have also reported that patients with HS experience higher levels of fatigue than the general population, which has been attributed to the chronic inflammatory nature of the disease [16, 52]. Furthermore, in our multivariable regression analysis, fatigue emerged as an independent determinant of kinesiophobia. Chronic inflammation, pain, and the psychosocial burden associated with HS may contribute to the development of fatigue. Increased fatigue may reduce motivation for physical activity, thereby increasing avoidance behaviors and contributing to the development of kinesiophobia.

When physical activity levels were evaluated, patients with HS demonstrated significantly lower MET scale scores compared with healthy controls. In the literature, a large population-based study reported that moderate and vigorous physical activity levels were significantly lower in patients with HS than in controls, suggesting that reduced physical activity may represent a lifestyle factor associated with HS [53]. In addition, in our study, patients with higher levels of kinesiophobia had lower levels of physical activity. Correlation analysis also revealed a significant negative relationship between kinesiophobia and physical activity. These findings suggest that fear of movement may contribute to avoidance of physical activity. Indeed, exercise may pose several challenges for patients with HS; painful and draining lesions, chronic scar tissue, sweating, and mechanical friction may reduce exercise tolerance and contribute to avoidance of physical activity [54]. Moreover, lifestyle factors have been suggested to play an important role in the development and course of HS, and lower levels of physical activity may be associated with increased inflammatory burden [55]. Some studies have also reported that higher levels of physical activity may be associated with lower disease activity, potentially influencing disease course through weight control and modulation of inflammation [56, 57]. Therefore, understanding the reasons underlying kinesiophobic attitudes in this patient group and developing safe, individualized physical activity programs may be of clinical importance. In this context, multidisciplinary approaches involving dermatologists, physiotherapists, and when necessary psychosocial support teams may help increase patients’ participation in physical activity.

Although disease severity (IHS4) was correlated with kinesiophobia in the correlation analysis, it did not emerge as an independent predictor in the multivariable regression analysis. Previous studies in chronic pain conditions have shown that the relationship between disease severity and kinesiophobia may be heterogeneous [36–38]. Indeed, in a study conducted among patients with fibromyalgia, pain, depression, and disease activity scores were higher in patients with high levels of kinesiophobia; however, the independent factors associated with kinesiophobia differed in the multivariable analysis [58]. Similarly, in our study, the finding that depressive symptoms emerged as an independent predictor, whereas IHS4 did not, suggests that the effect of disease severity on kinesiophobia in HS may not be direct and may instead operate through mediating factors such as pain, fatigue, or psychological symptoms. Future studies investigating these potential mediating mechanisms may better clarify the role of disease severity in the development of kinesiophobia.

This study has several limitations. First, its cross-sectional and single-center design limits causal inference and the generalizability of the findings. Although the sample size was calculated a priori and the required number of patients was reached, the HS sample remained relatively limited for a cross-sectional clinical study. Because Hurley staging was not available, chronic structural disease severity could not be included in the analyses; therefore, disease severity was assessed only using IHS4, which reflects inflammatory disease activity.

In addition, most variables were evaluated using self-report questionnaires, and the BDI and BAI were used as screening tools. The lack of a structured psychiatric interview limits the interpretation of depressive and anxiety symptoms at the level of clinical diagnoses. Furthermore, HS-specific psychosocial variables such as stigmatization, body image disturbance, social anxiety, and embarrassment were not assessed using specific scales. This limits the ability to distinguish whether fear of movement was driven primarily by pain-related mechanisms or by visibility-, embarrassment-, and social concern-related psychosocial mechanisms.

Another limitation of the study is that the comparison group consisted of healthy controls. This limits the ability to determine whether the observed kinesiophobia and related psychosocial outcomes are specific to HS or whether they reflect a more general response to chronic pain and chronic disease burden. The inclusion of an additional disease control group consisting of individuals with chronic pain conditions such as fibromyalgia, chronic low back pain, osteoarthritis, or rheumatoid arthritis could have helped to clarify the HS-specific aspects of the findings. Therefore, the present results should be interpreted in light of these limitations.

In conclusion, this study suggests that kinesiophobia may be an important but often overlooked problem in patients with HS. Our findings indicate that fear of movement in HS should not be considered merely as a pain-related response, but rather as a biopsychosocial phenomenon shaped by the interaction of pain, fatigue, depressive and anxiety symptoms, illness perceptions, and physical activity avoidance behaviors. Therefore, HS management should consider not only dermatological disease activity, but also multidisciplinary approaches that include pain control, fatigue management, psychological support, and the promotion of safe physical activity.

Abbreviations

HS

Hidradenitis suppurativa

TSK

Tampa Scale for Kinesiophobia

FSS

Fatigue Severity Scale

VAS

Visual Analog Scale

IHS4

International Hidradenitis Suppurativa Severity Score System

IPAQ-SF

International Physical Activity Questionnaire – Short Form

MET

Metabolic Equivalent of Task

BDI

Beck Depression Inventory

BAI

Beck Anxiety Inventory

Authors’ contributions

BMK: Conceptualization, Methodology, Investigation, Formal analysis, Data curation, Visualization, Writing – original draft. HBM: Methodology, Validation, Resources, Writing – review & editing, Supervision, Project administration. ZMO: Methodology, Validation, Resources, Writing – review & editing, Supervision, Project administration.

Funding

No funding was received for this study.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

All participants received a comprehensive explanation of the study procedures, and written informed consent was obtained from all participants. The study protocol was approved by the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee (Approval No: E-10840098-202.3.02-1399).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.