Kinesophobia in patients with osteoporotic vertebral compression fractures: a latent profile analysis

Abstract

Objective

To explore the status of kinesophobia in patients with osteoporotic vertebral compression fractures and analyze the influencing factors of different kinesophobia profiles.

Design

Cross-sectional survey study

Participants

A total of 245 patients with osteoporotic vertebral compression fractures who underwent surgical treatment at our Department of Orthopedics between January 2023 and March 2024 were selected

Main Measure

A general data questionnaire and Tampa Scale for Kinesiophobia were used in the investigation. Latent profile analysis was conducted to categorise kinesophobia in patients with osteoporotic vertebral compression fractures, while univariate logistic regression was performed to identify the factors influencing the latent profiles of kinesophobia.

Results

The average kinesophobia score of the patients with osteoporotic vertebral compression fractures was 45.38 ± 7.12 points. The patients were divided into three latent profile categories, namely high, medium, and low kinesophobia, with mean probabilities of 0.958, 0.966, and 0.970, respectively. Furthermore, age, gender, pain score, injury cause, and other injuries were significant influencing factors in the kinesophobia groups (P < 0.05).

Conclusion

Kinesophobia in patients with osteoporotic vertebral compression fractures is heterogeneous and affected by age, gender, pain score, injury cause, and other injuries. Clinical staff should recognise the characteristics of patients in different kinesophobia categories and actively adopt appropriate measures for those in the high kinesophobia group to enhance the alleviation of their fear status and mitigate the occurrence of fear-induced adverse outcomes, such as disability and weakness.

Keywords

Influencing kinesophobia osteoporotic vertebral compression fracture

Introduction

Osteoporosis has become a serious public health concern in China owing to the gradually aging population. According to epidemiological statistics, approximately 8.9 million fractures occur in patients with Osteoporosis worldwide every year, with this incidence increasing annually.1 Among Osteoporosis fractures, osteoporotic vertebral compressed fractures are the most prevalent.2 Moreover, osteoporotic vertebral compressed fractures exhibit high morbidity, disability, and fatality rates, highlighting the need for timely and effective interventions to improve the quality of life of the affected patients.^3,4

Osteoporotic vertebral compressed fracture treatment presently involves conservative and surgical techniques.^5,6 In conservative treatment, patient compliance is poor, and the long-term effects are unsatisfactory.7 Currently, the most widely performed minimally invasive surgeries are percutaneous vertebroplasty and percutaneous kyphoplasty.^8,9 Effectively preventing vertebral fractures near the diseased vertebrae is challenging to achieve via operation due to the bone loss in patients,^10,11 with surgery increasing the hardness of the diseased vertebrae and making the adjacent vertebrae more prone to fracture.^12,13 Kinesiophobia is a psychological condition in which an individual has an excessive fear of physical activities following trauma, manifesting as an avoidance of sports or even physical activities.14 Fracture trauma and the varying degrees of postoperative lumbar discomfort render patients with osteoporotic vertebral compressed fracture more likely to develop kinesiophobia. This psychological condition can result in muscle atrophy, stiffness, and even deep vein thrombosis and disability, ultimately affecting patient prognosis and heightening the caregiver burden and economic strain on patient families. Up to now, no studies on the level of kinesophobia in OVCF patients have been reported. Assessing the level of kinesophobia is crucial for improving patient prognosis and decreasing family burden. Latent profile analysis (LPA) is an individual-centered analysis method that interprets the relationships between external continuous variables through latent categorical variables and differentiates the differences between external variables. In this study, LPA was used to determine the profile types of kinesophobia in patients with osteoporotic vertebral compressed fracture, as well as explore its characteristics and influencing factors.

Materials and methods

Study design and setting

This study enrolled 245 patients with osteoporotic vertebral compressed fracture who underwent surgical treatment at our Department of Orthopedics between January 2023 and March 2024. Patient inclusion criteria were as follows: (1) According to the diagnostic criteria of primary osteoporosis in the Guidelines for the Diagnosis and Treatment of Primary Osteoporosis, DXA was performed in our hospital to confirm osteoporosis and fracture. (2) the presence of basic communication and understanding skills, informed consent for this study, signed informed consent. Patient exclusion criteria encompassed any previous physical activity disorder, such as post-stroke limb disorders. According to the rough estimation method,15 the minimum sample size should be 5–10 times the maximum dimension of the employed survey scale, with loss to follow-up rate of 10%–20%. This study received ethical approval from the Second Affiliated Hospital of Xuzhou Medical University (approval number: zy2024010022).

Methods

Research tools (1) A self-made questionnaire was used to collect basic patient information, including demographic data, body mass index, pain score, injury cause, and other trauma.

(2) The Tampa Scale for Kinesiophobia was translated and validated this test in the Chinese language by Hu Wen.16 The scale comprises seven dimensions and 17 items, where each item is assigned 1–4 points. Additionally, the total score ranges from 17 to 68 points, and a score of 37 points is designated as the critical value.16 Patients having scores above the critical value were considered to have kinesophobia, with higher scores indicating a higher degree of fear. In this study, the Cronbach's α coefficient of this scale was 0.892, 95% CI (0.742, 0.920).

The investigation method of this study is the questionnaire survey was conducted face-to-face in the orthopedic ward after obtaining consent from the hospital and patients. The privacy of the patients was ensured by performing the survey in a confidential environment, and the patients were assured that their questionnaire responses would only be utilised in this study. Patients completed the questionnaire anonymously and did not disclose personal information or discuss personal factors separately. Moreover, patients with low literacy and dyslexia were instructed to repeat the scale items to the investigators to confirm accurate understanding, and the patients independently filled in their choices. The questionnaires were distributed to patients on the day following reoperation, comprising 30 items that included general information and the scale. Furthermore, the consistency of the patients’ responses in the questionnaire was examined based on the method used in the lie detector test. In this method, two questions with the same options in different order were placed in the 15th and 26th questions. Questionnaires with inconsistent responses for these two questions were eliminated to ensure questionnaire reliability and that each questionnaire reflected the genuine responses of the patients. Of the 245 distributed questionnaires, 224 were effectively collected (response rate: 91.43%). The average time for questionnaire completion was approximately 10 min.

Statistical methods

Latent profile analysis was conducted using Mplus 8.0 software. Considering the 17 items of the Tampa Scale for Kinesiophobia as explicit variables, 1–5 profile categories were selected for analysis. Subsequently, fitting indexes, including Akaike information criterion, Bayesian information criterion, and sample-corrected Bayesian information criterion, were compared to determine the number of optimal profile categories based on clinical practical significance. In this analysis, smaller statistical values imply better model fitting. Additionally, entropy represents classification accuracy, while P < 0.05 on the LoMendell-Rubin and the Bootstrap-based likelihood ratio test indicated that the K-class model is superior to the k-1 class model. Lastly, the test significance level was set to α = 0.05.

Results

A total of 224 valid questionnaires were collected in this study, and the basic demographic data of the included patients are summarised in Table 1. The kinesophobia scores of the patients with osteoporotic vertebral compressed fracture ranged from 24 to 48 points, with an average score of 45.38 ± 7.12 and an item average score of 2.67 ± 0.35.

Table 1.

Basic characteristics of the total 224 patients with osteoporotic vertebral compressed fracture.

Demographic	Classification	Number	(%)
Age (years)	70–79	35	15.63
	80–89	152	67.86
	≥90	37	16.51
Gender	Male	78	34.82
	Female	146	65.18
Marital status	Unmarried	12	5.36
	Married	189	84.38
	Divorced	23	10.26
Monthly income (Yuan)	<3000	65	29.02
	3000–5000	90	40.18
	5001–8000	47	20.98
	>8000	22	9.82
Educational level	Junior high school and below	154	68.75
	High school/technical secondary school	39	17.41
	College or above	31	13.84
Residence	City	84	37.50
	Rural/township	140	62.50
Residence type	Living alone	36	16.07
	Family residence	188	83.93

In this study, a single-category model was initially extracted, followed by the systematic addition of one category. A comparison of the fitting indexes with the increasing number of profile categories identified three potential profile categories as having the best fitting degree (Table 2).

Table 2.

Comparison of potential profiling indicators of kinesophobia in patients with osteoporotic vertebral compressed fracture.

Model	AIC	BIC	aBIC	LMR	BLRT	Entropy	Class probability
1	34253.731	34276.637	34235.684
2	30955.322	30837.268	30826.855	0.005	0.000	0.884	0.32/0.68
3	29791.527	29654.447	29643.534	0.013	0.000	0.899	0.28/0.51/0.21
4	26615.868	26458.776	26496.368	0.058	0.000	0.912	0.23/0.35/0.19/0.23
5	26397.138	26371.284	26353.259	0.162	0.000	0.933	0.18/0.11/0.12/0.36/0.23

Note: AIC: Akaike information criterion; BIC: Bayesian information criterion.

^aBIC: sample-corrected BIC; LMR: LoMendell–Rubin; BLRT: Bootstrap-based likelihood ratio test.

The average probability of kinesophobia of the patients with osteoporotic vertebral compressed fracture belonging to the three potential profile categories (i.e., C1, C2, and C3) was 0.958, 0.966, and 0.970, respectively, confirming the reliability of the model with these three potential profiles (Table 3). The three potential profiles were as follows: C1 comprising 63 patients (28.3%), C2 including 114 patients (50.8%), and C3 consisting of 47 patients (20.9%). According to the response probability of the 17 items in the Tampa Scale for Kinesiophobia and the characteristics of the three potential profiles (Figure 1), C1 was named the “high fear group,” C2 was the “medium fear group,” and C3 was the “low fear group.”

Table 3.

Average attribution rates of the three types of kinesophobia in patients with osteoporotic vertebral compressed fracture (n = 224).

Profile category	C1	C2	C3
C1	0.958	0.018	0.024
C2	0.028	0.966	0.006
C3	0.014	0.016	0.970

The general data of the patients with osteoporotic vertebral compressed fracture were compared after grouping according to the three potential profile categories of kinesophobia. The results showed that age (χ² = 16.132，P = 0.003), gender (χ² = 8.012，P = 0.018), pain score (χ² = 22.947，P ＜ 0.001), injury cause (χ² = 9.786，P = 0.007), and other injuries (χ² = 6.255，P = 0.044) were significant in the three kinesophobia groups, as presented in Table 4.

Table 4.

Comparison of the factors influencing kinesophobia across the three potential profile categories in patients with osteoporotic vertebral compressed fracture (n = 224).

Variable	High kinesophobia group (n = 63)	Medium kinesophobia group (n = 114)	Low kinesophobia group (n = 47)	χ ²	P
Age (years)				16.132	0.003
70–	7	18	10
80–	36	85	31
90–	20	11	6
Gender				8.012	0.018
Male	15	44	19
Female	48	52	28
Marital status				0.276	0.991
Unmarried	4	6	2
Married	53	96	40
Divorce	6	12	5
Educational level				1.823	0.768
Junior high school and below	44	75	35
High school/technical secondary school	10	21	8
College or above	9	18	4
Residence				2.161	0.339
City	20	48	16
Rural/township	43	66	31
Residence type				0.235	0.889
Living alone	11	17	8
Family residence	52	97	39
Monthly income (Yuan)				6.745	0.345
<3000	21	34	10
3000–5000	26	47	17
5001–8000	10	21	16
＞8000	6	12	4
BMI (kg/cm²)				6.670	0.352
<18.5	15	22	11
18.5–23.9	18	42	23
24–28	21	35	8
>28	9	15	5
Pain score (NRS)				22.947	＜0.001
0–3	15	57	32
4–7	43	53	14
8–10	5	4	1
Injury cause				9.786	0.007
Sports injury	41	55	18
Non-sports injury	22	59	32
Other injuries				6.255	0.044
Yes	23	24	9
No	40	90	38

Note: NRS means Numeric Rating Scale.

The three potential profiles underwent further multivariate logistic regression analysis, with the kinesophobia score of the patients with osteoporotic vertebral compressed fracture as the dependent variable and the indicators with significant differences in the univariate analysis as the independent variables. The analysis showed that with the C3 kinesophobia group as the reference, age (assigned: 70– years = 1, 80– years = 2, and 90– years = 3, with 70– years as the control), gender (male = 1, female = 2), pain score (0–3 points = 1, 4–7 points = 2, and 8–10 points = 3, with 0–3 points as the control), injury cause (sports injury = 1, non-sports injury = 2), and other injuries (yes = 1, no = 0) were the influencing factors of kinesophobia (all P < 0.05), as depicted in Table 5.

Table 5.

Multivariate analysis of the three potential profiles of kinesophobia in patients with osteoporotic vertebral compressed fracture (n = 224).

Variable	B	SE	Wald χ²	P	OR	95% CI
C1 vs. C3
Constant	0.633	0.187	11.458	<0.001	1.875	-
Age (years)
80–	0.431	0.129	11.163	<0.001	1.534	1.241–1.778
90–	0.685	0.216	10.057	<0.001	1.975	1.443–2.499
Gender
Female	0.209	0.094	4.944	0.029	1.231	1.028–1.345
Pain score (NRS)
4–7	0.897	0.314	8.161	0.005	2.437	1.886–3.258
8–10	1.218	0.370	10.837	<0.001	3.353	2.866–4.697
Injury cause
Non-sports injury	−0.203	0.091	4.976	0.028	0.817	0.725–0.901
Other injuries
Yes	0.452	0.205	4.861	0.032	1.567	1.225–1.839
C2 vs. C3
Constant	1.146	0.268	18.285	<0.001	3.121	-
Age (years)
80–	0.336	0.110	9.330	0.001	1.396	1.115–1.576
90–	0.525	0.184	8.141	0.007	1.686	1.257–2.013
Gender
Female	0.169	0.060	7.934	0.010	1.183	1.031–1.304
Pain score (NRS)
4–7	0.664	0.273	5.916	0.019	1.934	1.567–2.256
8–10	0.909	0.291	9.758	<0.001	2.467	1.883–3.024
Injury cause
Non-sports injury	−0.155	0.053	8.553	0.005	0.857	0.648–0.961
Other injuries
Yes	0.318	0.1478	4.680	0.035	1.371	1.123–1.566

Note: C1, high kinesophobia group; C2, medium kinesophobia group, C3, low kinesophobia group, NRS means numeric rating scale.

Discussion

In this study, we revealed that patients with osteoporotic vertebral compressed fracture have kinesophobia, consistent with the findings of domestic and international studies that investigated kinesophobia in those with chronic pain.^17,18 Osteoporotic vertebral compressed fracture may place a certain degree of psychological burden on patients, thereby inducing a kinesophobia.

Further, this finding highlighted the heterogeneity of kinesophobia among patients with osteoporotic vertebral compressed fracture. Moreover, 28.3% of the enrolled patients exhibited a high level of kinesophobia. The average scores of items 9 (i.e., “I am afraid of hurting myself suddenly”) and 14 (i.e., “It is really unsafe for people with physical conditions like me to do activities/exercises”) were higher than 3.85 points. Patients with such high kinesophobia scores typically show a lack of confidence in their physical conditions and exercise abilities and overemphasize their disease severity. These patients also assume an inevitable link between their fractures and exercise. Consequently, they reduce or refuse activities that may endanger their safety, promoting their kinesophobia. A total of 50.8% of the patients with osteoporotic vertebral compressed fracture had a moderate level of kinesophobia, constituting the largest proportion in this study. This result indicated that most patients with osteoporotic vertebral compressed fracture had a moderate degree of kinesophobia symptoms and that actively implementing physical and psychological interventions in this group can further reduce kinesophobia and improve their prognosis. However, only a relatively small proportion of patients (20.9%) exhibited a low level of kinesophobia in this study. Such patients were generally highly active in the rehabilitation exercise. Nevertheless, exercise without appropriate management may not be conducive to the postoperative rehabilitation of patients. Therefore, clinical staff should stress that postoperative rehabilitation is a long-term process, and activities should be meticulously performed to avoid fracture recurrence in adjacent vertebrae due to unguided activities.

The current study found significant differences in age, gender, pain score, injury cause, and other injuries in patients with osteoporotic vertebral compressed fracture. Age has emerged as a risk factor for kinesophobia, as demonstrated in the research by Lyu et al.19 Previous studies have suggested that the level of kinesophobia is elevated with the increasing age of the patient.20 This observation may be attributed to the physiological and psychological characteristics of older patients. For example, older patients may have varied chronic diseases that can cause prolonged debilitating progress, decreased daily activity ability, and diminished and inadequate exercise self-confidence, ultimately heightening the possibility of kinesophobia.^21,22 Additionally, our study suggested that female patients had a higher level of kinesophobia than male patients, with similar results noted by Kluszczynska et al.23 and contrasting findings reported by Rovner et al.24 These discrepancies in the findings may be explained by the relatively and cautious nature of female patients who show lower enthusiasm for postoperative exercise. Pain is a direct factor that can induce kinesophobia.^25,26 Moreover, pain catastrophizing potentially leads to the emergence of fear, while persistently high or escalating fear-avoidance beliefs may increase the risk of pain exacerbation. Pain causes most patients to adopt a passive approach, thereby greatly reducing their self-care ability and causing them to rely heavily on assistance for completing daily activities. Furthermore, patients often choose to minimize or even refuse activities to avoid pain. Individuals with osteoporotic vertebral compressed fracture attributed to sports injuries have relatively heightened levels of kinesophobia. These patients associate fracture incidence with exercise and perceive no or limited exercise as an effective way to lower fracture occurrence, thus resulting in a high level of fear. Patients with other injuries also possess an elevated level of kinesophobia, with most having complex injuries, relatively severe illnesses, a low enthusiasm for exercise, and a heightened level of kinesophobia.

There are also some limitations to this study. This study was conducted in only one center with a relatively small sample size, which may limit the generalizability of the findings. In addition, there may have been some omissions in exploring the factors influencing the different profiles of agoraphobia in OVCF patients, such as the severity of osteoporosis was not explored in subgroups. Follow-up studies will expand the sample size and include more influential factors to improve statistical power and obtain more realistic results.

Our study findings suggest that clinical staff should determine the characteristics of patients in different categories of kinesophobia, as well as actively adopt measures to extensively reduce the fear status in those with high kinesophobia to lower the incidence of fear-induced adverse events such as disability and weakness.

Clinical messages

The kinesiophobia in patients with osteoporotic vertebral compression fractures is divided into three latent profile categories, namely high, medium, and low kinesiophobia

The degree of kinesophobia in patients with osteoporotic vertebral compression fractures is influenced by factors such as age, gender, pain score, injury cause, and other injuries

Footnotes

Authors’ Contributions

HS designed this study. RL and ML built the study framework, RL wrote the manuscript, contributed to the article, and approved the submitted version. RL, ML, and YW contributed equally to this work and all authors read and approved the final version of the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Hong Song

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