
==== Front
BMC Public Health
BMC Public Health
BMC Public Health
1471-2458
BioMed Central London

39300388
19953
10.1186/s12889-024-19953-1
Research
The link between childhood physical activity enjoyment and adult kinesiophobia in individuals with chronic low back pain
Liu Haowei 1
Li Hansen 1
Huang Li 1
Tian Haodong 1
Wu Jinlong 1
Guan Qinwen 2
Wang Zhenhuan 3
Zhang Xing 4
Yang Zhou yangz@swu.edu.cn

5
Peng Li 804455169@qq.com

1
1 https://ror.org/01kj4z117 grid.263906.8 0000 0001 0362 4044 Key Laboratory of Physical Fitness Evaluation and Motor Function Monitoring, College of Physical Education, Southwest University, Tiansheng Road No.2, Beibei District, Chongqing, 400715 China
2 grid.437806.e 0000 0004 0644 5828 Institute of Physical Education, Southwest Petroleum University, Sichuan, China
3 https://ror.org/04j757h98 grid.1019.9 0000 0001 0396 9544 Institute for Health and Sport, Victoria University, Footscray, Melbourne, Australia
4 https://ror.org/04njjy449 grid.4489.1 0000 0001 2167 8994 Department of Physical Education and Sport, Faculty of Sport Sciences, University of Granada, Granada, Spain
5 https://ror.org/01kj4z117 grid.263906.8 0000 0001 0362 4044 Key Laboratory of Cognition and Personality, Faculty of Psychology, Southwest University, Chongqing, China
19 9 2024
19 9 2024
2024
24 255717 10 2023
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

This study aimed to investigate the relationship between childhood physical activity enjoyment and current kinesiophobia among individuals with chronic low back pain (CLBP), considering the mediating influence of adult physical activity.

Methods

We recruited 648 adults (474 males, 174 females) with CLBP through an online platform. Of these, 99.1% (n = 642) were aged 18–60 years, and 0.9% (n = 6) were older than 60 years. Childhood physical activity enjoyment was retrospectively assessed using a single-item question to gauge participants’ enjoyment during primary school. Kinesiophobia was measured with the 11-item Tampa Scale for Kinesiophobia (TSK-11), and physical activity was assessed focusing on walking, moderate, and vigorous physical activities. Age, sex, education, and income served as control variables in the analysis.

Results

A significant negative association was found between childhood physical activity enjoyment and adult kinesiophobia. Additionally, childhood physical activity enjoyment was positively associated with adult physical activity across the three types of physical activities. In the adjusted mediation model, walking was identified as the only statistically significant partial mediator.

Conclusion

The findings highlight the long-term protective role of childhood physical activity enjoyment against the development of kinesiophobia in adulthood. Walking, in particular, holds unique therapeutic potential, emphasizing the importance of fostering physical activity enjoyment early in life for sustained physical activity and reduced risk of kinesiophobia among CLBP patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-19953-1.

Keywords

Low back pain
Kinesiophobia
Childhood
Physical activity
Walking
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcIntroduction

Chronic Low Back Pain (CLBP), a global health concern, significantly degrades quality of life [1]. It is intricately linked with psychological factors, most notably kinesiophobia, defined as an exaggerated and debilitating fear of physical activity stemming from the anticipation of pain or re-injury [2]. The fear avoidance model (FAM) well explains this cognitive-behavioral response, describing how the “catastrophic” interpretation of pain as a sign of damage catalyzes a vicious cycle of fear and avoidance [3]. Avoiding movement or activities associated with pain reduces opportunities for positive exposure, sustaining pain and disability.

Previous studies have provided insights into the impact of kinesiophobia on the exacerbation of CLBP and disability [4, 5]. Many studies report a negative correlation between kinesiophobia and physical activity levels in individuals with chronic pain [6–8]. However, the causality in this relationship is better supported by longitudinal studies, such as the work by Demmelmaier et al. [9], which observed that higher baseline physical activity can predict lower fear-avoidance beliefs in individuals with rheumatoid arthritis.

Several mechanisms may explain how physical activity influences kinesiophobia. Engaging in regular physical activity may help individuals maintain a higher level of self-efficacy and confidence in their physical abilities, which could reduce the fear of movement and pain [10]. Moreover, physical activity has been shown to have pain-reducing effects through various mechanisms, such as the release of endorphins and the modulation of pain perception [11, 12]. From a psychological perspective, physical activity has been shown to reduce stress, anxiety, and depression, which are common psychological comorbidities associated with chronic pain and kinesiophobia [13, 14]. These factors may help break the fear-avoidance cycle and reduce kinesiophobia severity.

Childhood is a critical phase for the development of behaviors and interests [15, 16]. Various studies have confirmed that lifestyle choices during childhood, particularly levels of physical activity, are strongly predictive of adult health behaviors and associated risks, including obesity, cardiovascular diseases, and type 2 diabetes [17–19]. Participation in physical activities during childhood not only enhances physical well-being but also shapes the psychological mindset towards physical activity in adulthood [20]. Moreover, regular physical activity in youth has been found to be a significant predictor of adult activity levels [21]. Conversely, children less involved in physical activities tend to develop a lower self-evaluation of their physical abilities [22] and heightened perceptions of pain [23]. These early experiences may lay the groundwork for the development of CLBP and its associated kinesiophobia in adulthood.

Based on an extensive literature search up to 2023, we found that studies specifically investigating the potential role of engagement in physical activity during childhood in the development of kinesiophobia among adults with CLBP are not prevalent. Considering the crucial role of childhood experiences in shaping adult behaviors and the established association between low levels of physical activity and the prevalence of kinesiophobia, it is plausible that enjoyment of physical activity during childhood may have a long-term protective effect against kinesiophobia in adulthood. This protective effect may be mediated by higher levels of physical activity in adulthood, as individuals who enjoyed physical activity in childhood may be more likely to maintain an active lifestyle, which in turn could reduce the risk of developing kinesiophobia. While a recent study did establish a link between childhood activity levels and kinesiophobia, the potential mediating factors were not thoroughly examined [24]. Given these considerations and the fact that psychological and physiological outcomes in adulthood are seldom the result of isolated childhood factors but rather an interaction between past and present behaviors [20, 25], we decided to examine adult physical activities as potential mediators.

This study aimed to explore the relationship between childhood physical activity enjoyment and adult kinesiophobia in individuals with CLBP. Specifically, we analyzed the mediating role of adult physical activity levels (walking, moderate, and vigorous) to determine whether they contribute to the potential long-term protective effect of childhood physical activity enjoyment against adult kinesiophobia (Fig. 1). The following hypotheses guided our research:

Fig. 1 Conceptual mediation model linking childhood physical activity enjoyment to current kinesiophobia

H1

A positive response to childhood physical activity enjoyment is associated with higher adult physical activity and lower kinesiophobia.

H2

The level of physical activity in adulthood serves as a mediator linking childhood physical activity enjoyment and kinesiophobia in adulthood.

Materials and methods

Study design and participants

This cross-sectional investigation was conducted from June to August 2023. As part of our convenience sampling strategy, we posted advertisements on various Chinese social media platforms, particularly WeChat groups dedicated to health and chronic pain management, to recruit individuals experiencing chronic low back pain. The inclusion criteria were: (1) Aged over 18 years; (2) Normal cognitive abilities; (3) Normal language expression abilities; (4) No communication or physical issues that could hinder questionnaire completion; (5) Persistent or intermittent lower back pain lasting more than 3 months. Exclusion criteria encompassed: (1) Intolerable pain in the acute phase that would prevent questionnaire completion; (2) Previous history of lumbar trauma or surgery; (3) History of mental illness or cognitive disorders; (4) Low back pain resulting from other diseases. We initially reached out to 1083 individuals through online platforms. Of these, 756 responded to our invitation. After applying our inclusion and exclusion criteria, we excluded 108 individuals. The final sample consisted of 648 participants who provided valid and complete responses.

Sample size calculation

The sample size for the study was calculated using the formula for cross-sectional studies [26].\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:n=\:\frac{{Z}^{2}p(1-p)}{{d}^{2}}$$\end{document}

where:

n is the minimum sample size required for the study,

Z is the standard normal variate, which is set at 1.96 to correspond to a 5% type 1 error (P < 0.05),

p is the prevalence of the outcome of interest, which in this case is kinesiophobia. Based on a previous study conducted in Tianjin City, China, the prevalence of kinesiophobia in CLBP was found to be 46.3% [27],

d is the acceptable margin of error, which is usually set at 0.05 or 5%, representing the maximum deviation from the true population parameter that we are willing to tolerate.

Plugging the values into the formula gives: n = \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:\frac{{1.96}^{2}\:\times\:\:0.463(1\:-\:0.463)}{{0.05}^{2}}=382.1$$\end{document}

After rounding up, the minimum sample size required for the study was 382.

Procedure

Potential participants who saw these advertisements and were interested in the study were encouraged to directly contact the research team. Upon initial contact via WeChat, the research team provided detailed information about the study objectives and procedures. Participants were then invited to complete a detailed questionnaire on “Questionnaire Star” (www.wjx.cn), a widely-used Chinese online survey platform. The questionnaire included both screening questions and additional questions relevant to the study. The screening questions were designed to establish eligibility based on their pain experience, including the presence and location of body pain, the intensity of this pain assessed via Visual Analog Scale (VAS) from 0 to 10 over the past week, and the duration of the pain. Only participants who indicated experiencing low back pain, provided a VAS score greater than 0, and met the duration criteria (> 3 months), were included in the study. In addition to the screening questions, the online questionnaire consisted of the following sections: basic background information about participants, such as age, sex, education level, and occupation; the Tampa Scale for Kinesiophobia (TSK-11); a modified version of the three-item scale for physical activity level; and a single-item question on childhood enjoyment of physical activity.

After completing the survey, participants were compensated with 5 to 10 CNY (approximately 0.7 to 1.4 USD). To ensure authenticity, participants were required to use WeChat accounts linked to their personal legal IDs. To prevent duplicate submissions, the survey platform’s standard settings were utilized, which included restrictions on IP addresses, device cookies, and WeChat account usage. These measures are common practices in online surveys and were explained to participants during the consent process. No personal data was stored or used beyond preventing multiple submissions.

Instruments

Kinesiophobia

In the present study, kinesiophobia was assessed using the Chinese version of the Tampa Scale for Kinesiophobia (TSK-11) [28]. The TSK-11 comprises 11 items, each rated on a 4-point Likert scale. Scoring ranges from “strongly disagree” (1 point) to “strongly agree” (4 points), with possible total scores varying between 11 and 44. Higher scores are indicative of greater levels of kinesiophobia. In the original validation study, the scale demonstrated strong psychometric properties, with a high Cronbach’s alpha of 0.883 and a test-retest reliability of 0.798 [28]. In our current study, we calculated the Cronbach’s alpha for the TSK-11 using our sample and obtained a value of 0.810, which indicates satisfactory internal consistency.

Physical activity in adulthood

We employed a modified version of the three-item scale introduced by Smith et al. [29] to measure physical activity levels. The original scale assesses the frequency of walking, moderate physical activity, and vigorous physical activity, with activities lasting a minimum of 30 min. Recognizing that numerous fragmented non-leisure activities, even if shorter, can still yield significant benefits [30], we adopted a threshold of “at least 10 minutes” as delineated in the UK Biobank questionnaire surveys [31]. Additionally, we introduced a “recall period” of one month. This decision was made with careful consideration of our study’s specific context and in alignment with the COSMIN guidelines’ principles [32], which emphasize the importance of clearly specifying the recall period in self-report measures. The exact wording from our questionnaire was: (1) “Over the past month, how many times a week do you usually do 10 minutes or more of walking? (e.g., walking from place to place for exercise, leisure, or recreation)”; (2) “Over the past month, how many times a week do you usually do 10 minutes or more of moderate-intensity physical activity that increases your heart rate or makes you breathe harder than normal? (e.g., carrying light loads, bicycling at a regular pace, or doubles tennis)”; (3) “Over the past month, how many times a week do you usually do 10 minutes or more of vigorous-intensity physical activity that makes you sweat or puff and pant? (e.g., heavy lifting, digging, jogging, aerobics, or fast bicycling)”. This revised measure inquired about activities over the preceding month, and responses were recorded on a 7-point Likert scale, with 1 denoting “once a week or less” and 7 indicating “almost every day”. The scale demonstrated good reliability, with a Cronbach’s alpha coefficient of 0.813.

Childhood physical activity enjoyment

We assessed participants’ enjoyment of physical activities during their primary school years using a straightforward question: “Did you enjoy participating in physical activities during your primary school stage?“. Here, “1” signified “enjoyed”, while “0” indicated “did not enjoy”. This single-item question was inspired by the concept of the Physical Activity Enjoyment Scale (PACES) [33, 34]. However, it is important to note that our single-item measure is a significant departure from the original 16-item, 5-point Likert scale format of the PACES. We chose to use a simplified question to facilitate recall and minimize potential memory biases associated with the retrospective evaluation of childhood physical activity enjoyment. Furthermore, to simplify the recall process for participants, we chose to reference the “primary school stage” rather than specific ages (e.g., < 12 years).

Control variables

To accurately assess the effects of the paths in our model, our analyses adjusted for several control variables. Age can significantly influence kinesiophobia [35, 36] and physical activity [37]. Sex can impact childhood physical activity enjoyment [38, 39], physical activity [40], and kinesiophobia [36, 41]. Income and education level serve as core indicators of socioeconomic status and have been evidenced to affect physical activity and kinesiophobia [42–45]. For the above reasons, these variables were selected to control for potential confounding between the core variables of interest.

Statistical analysis

All statistical procedures were performed using SPSS 26.0 and AMOS 26.0 software. Initially, descriptive statistics were utilized to analyze baseline data. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented in frequencies and percentages. To assess the differences between sexes in various outcomes such as walking, moderate-intensity physical activity, high-intensity physical activity, and TSK-11 total scores, Mann-Whitney U tests were conducted. A significance level of 0.05 was used for all analyses.

Common method bias assessment

To address potential common method bias inherent in questionnaire-based studies, we employed Harman’s single-factor test [46]. The test results indicated the existence of four factors with eigenvalues exceeding 1, with the first factor explaining 28.57% of the variance. Since this percentage falls short of the recommended 40% threshold [47], we concluded that common method bias was not a substantial concern in our study.

Linear regression

We conducted a series of simple and multiple linear regression analyses to explore the relationships between childhood physical activity enjoyment and adult physical activity levels and kinesiophobia. In each analysis, childhood physical activity enjoyment served as the predictor variable, while kinesiophobia, walking, moderate physical activity, and vigorous physical activity were treated as separate outcome variables. The crude model represents a series of simple linear regressions, each including only the predictor and one outcome variable. The adjusted model represents a series of multiple linear regressions, controlling for potential confounding variables such as age, sex, education, and income.

Mediation analysis

To examine the proposed associations and mediating effect, we employed Structural Equation Modeling (SEM) using the Maximum Likelihood (ML) estimator. In this mediation model, kinesiophobia was set as the dependent variable, childhood physical activity enjoyment as the independent variable, and adult physical activity levels (walking, moderate, vigorous) as potential mediators. Before conducting the mediation analysis, we checked for multicollinearity among the predictors using the Variance Inflation Factor (VIF). VIF values ranging from 0 to 5 suggest that there is no multicollinearity problem [48]. Due to the deviation from multivariate normality in our dataset (kurtosis = 2.436, c.r. > 1.96), the bias-corrected bootstrap method [49] was utilized, employing 10,000 replications to derive the corresponding standard errors and confidence intervals for all pathways [50–52]. Concurrently, the Bollen-Stine statistic, recognized for its robustness against nonnormality, was deployed to evaluate the overall model fit [53–55]. A Bollen-Stine p-value exceeding 0.05 was interpreted as an endorsement of acceptable model fit.

In addition, we documented several common model fitting indices, which included: χ2/df < 3 (p > 0.05); Standardized Root Mean Square Residual (SRMR) < 0.08; Goodness of Fit Index (GFI) > 0.95; Comparative Fit Index (CFI) > 0.95; and Root Mean Square Error of Approximation (RMSEA) < 0.05 [56]. Evidence of mediation was inferred when an indirect effect, that is, a product of coefficients for the constituent links, was significantly greater than zero [49, 57]. It is noteworthy that the total effects within the model were not construed as causal relationships, but rather as the sum of associations captured via both direct and indirect pathways. In some cases, we refer to the observed associations/paths in the SEM as “effects” in line with standard terminology in the literature, but we attach no formal claims of causality to this term [58].

Results

Participants’ characteristics

Participants’ characteristics are displayed in Table 1. Among the 648 participants, 73.1% were male. The age distribution revealed that the largest age groups were those aged between 26 and 30 (32.1%) and 31–40 (36.6%). In terms of educational background, the majority (54.8%) had an undergraduate degree. A substantial portion (38.6%) reported a monthly household income exceeding 10,000 CNY.

The mean score for kinesiophobia, as measured by the TSK-11, was 26.55 (SD = 6.82), indicating a moderate level of fear of movement among participants. Regarding physical activity, the average frequencies per week were as follows: walking 3.82 times (SD = 1.96), moderate physical activity 3.24 times (SD = 1.65), and vigorous physical activity 2.87 times (SD = 1.72). Mann-Whitney U tests showed no significant sex differences in walking, moderate-intensity, vigorous-intensity physical activities, or TSK-11 scores (Supplementary Table S5).

Table 1 Participants’ characteristics

Variables	Category	N (%)	
Sex	Male	474 (73.1)	
	Female	174 (26.9)	
Age	18–25	128 (19.8)	
	26–30	208 (32.1)	
	31–40	237 (36.6)	
	41–50	58 (9.0)	
	51–60	11 (1.7)	
	> 60 year	6 (0.9)	
Education	Middle school or below	17 (2.6)	
	High school or equivalent	105 (16.2)	
	Junior college	160 (24.7)	
	Undergraduate	355 (54.8)	
	Master’s degree or Higher	11 (1.7)	
Income (CNY)	≤ 3000	12 (1.9)	
	3001–5000	125 (19.3)	
	5001–10,000	261 (40.3)	
	> 10,000 CNY	250 (38.6)	

The associations of childhood physical activity enjoyment with kinesiophobia and physical activity (walking, moderate, and vigorous) in adulthood

A series of simple and multiple linear regression analyses were conducted to examine the associations between childhood physical activity enjoyment and adult outcomes (Table 2). The crude models revealed significant associations between childhood physical activity enjoyment and all adult outcomes. After adjusting for potential confounders (age, sex, education, and income), these associations remained significant. Childhood physical activity enjoyment was negatively associated with kinesiophobia (B = -2.252, 95% CI [-3.165, -1.338], p < 0.001) and positively associated with levels of walking (B = 0.847, 95% CI [0.439, 1.255], p < 0.001), moderate physical activity (B = 1.182, 95% CI [0.854, 1.511], p < 0.001), and vigorous physical activity (B = 0.958, 95% CI [0.639, 1.276], p < 0.001). The regression analysis results demonstrating the impact of these control variables (age, sex, education, and income) on the relationship between childhood physical activity enjoyment and adult kinesiophobia, as well as on physical activity level, are provided in Supplementary Tables S1-S4.

Table 2 Associations of childhood physical activity enjoyment with physical activity and kinesiophobia

Predictor	Outcome	Crude model	Adjusted model	
B	p	B	p	
Childhood PAE	Kinesiophobia	-2.308(-3.224, -1.393)	< 0.001	-2.252(-3.165, -1.338)	< 0.001	
Walking	0.897(0.486, 1.307)	< 0.001	0.847(0.439, 1.255)	< 0.001	
Moderate PA	1.243(0.911, 1.575)	< 0.001	1.182(0.854, 1.511)	< 0.001	
Vigorous PA	0.988(0.669, 1.307)	< 0.001	0.958(0.639, 1.276)	< 0.001	
Note The adjusted model was adjusted for age, sex, education, and income. Childhood PAE, Childhood physical activity enjoyment; Moderate PA, moderate physical activity; Vigorous PA, vigorous physical activity

Mediating effects of adulthood PA and childhood physical activity enjoyment on kinesiophobia

When assessing the individual mediating roles of different types of adult physical activity—namely walking, moderate physical activity (PA), and vigorous PA—in the relationship between childhood physical activity enjoyment and kinesiophobia, our simple mediation analyses revealed that all three activity types partially mediated this relationship. The specific findings of these analyses are detailed in Table 3.

Table 3 Total, direct and indirect effects of childhood physical activity enjoyment on kinesiophobia

Path description	B (95% CI)	p	
Childhood PAE → Walking → Kinesiophobia	-0.225 ( -0.512, -0.041)	0.010	
Childhood PAE → Moderate PA → Kinesiophobia	-0.225 ( -0.752, 0.197)	0.291	
Childhood PAE →Vigorous PA → Kinesiophobia	-0.095 ( -0.420, 0.244)	0.527	
Childhood PAE → Kinesiophobia (direct effect)	-1.707 (-2.599, -0.826)	0.001	
Total effect	-2.252 ( -3.135, -1.430)	0.001	
Note Childhood PAE, childhood physical activity enjoyment; Moderate PA, moderate physical activity; Vigorous PA, vigorous physical activity

In individual simple mediation analyses, each considering one of the three types of physical activity in adulthood—walking, moderate PA, and vigorous PA—the models demonstrated an acceptable fit to the data. Notably, all analyses revealed significant indirect, direct, and total effects, suggesting partial mediation by each type of physical activity. Specifically, the models for walking, moderate PA, and vigorous PA demonstrated the following fit indices respectively: walking (pBollen−Stine=0.099; χ2/df = 2.256; SRMR = 0.021; GFI = 0.977; CFI = 0.980; RMSEA = 0.044), moderate PA (pBollen−Stine =0.099; χ2/df = 2.256; SRMR = 0.022; GFI = 0.977; CFI = 0.983; RMSEA = 0.044) and vigorous PA (pBollen−Stine =0.099; χ2/df = 2.256; SRMR = 0.021; GFI = 0.980; CFI = 0.980; RMSEA = 0.044). In terms of three types of physical activity in adulthood, the indirect effects accounted for 14.5%, 24.1%, and 16.4% of the total effects with regards to kinesiophobia.

In a subsequent analysis, we employed a parallel mediation model to examine the collective mediating effects of walking, moderate PA, and vigorous PA in adulthood. The model demonstrated a good fit to the data (χ2/df = 2.256; SRMR = 0.018; GFI = 0.998; CFI = 0.997; RMSEA = 0.044). The total effect of childhood physical activity enjoyment on kinesiophobia via the parallel mediators was significant (B = -2.252, 95% CI [-3.135, -1.430], p = 0.001). However, only the indirect effect through walking was significant (B = -0.225, 95% CI [-0.512, -0.041], p = 0.010), accounting for 10.0% of the total effect. Whereas moderate activity PA (B = -0.225, 95% CI [-0.752, 0.197], p = 0.291) and Vigorous PA (B = -0.095, 95% CI [-0.420, 0.244], p = 0.527) were not significant (Fig. 2).

Fig. 2 The final models with coefficients. The numbers in brackets indicate p-values of the pathway Note Childhood PAE, childhood physical activity enjoyment; Moderate PA, moderate physical activity; Vigorous PA, vigorous physical activity

Discussion

In this study, we aimed to investigate the relationship between childhood physical activity enjoyment and current levels of kinesiophobia among individuals with CLBP. Key findings are: (1) Our regression analyses (both crude and adjusted) revealed a significant positive association between childhood physical activity enjoyment and higher levels of physical activity in adulthood. (2) We also found a significant negative association between childhood physical activity enjoyment and the levels of kinesiophobia in adulthood. (3) Importantly, our analysis identified walking in adulthood as the only significant mediator in the relationship between childhood enjoyment of physical activity and adult kinesiophobia.

From childhood physical activity enjoyment to adult physical activity and kinesiophobia

The series of simple and multiple linear regression analyses supported our first hypothesis (H1), demonstrating significant associations between childhood physical activity enjoyment and adult physical activity levels and kinesiophobia, even after adjusting for potential confounders. Our finding concerning childhood physical activity enjoyment and adulthood physical activity is similar to that from another cross-sectional pathway analysis, where childhood physical activity experience is positively associated with adulthood physical activity engagement [59]. Similar findings have been reported in longitudinal research as well, although only certain forms or types of physical activities were monitored and studied [60–62]. Our results suggest that enjoying physical activity in childhood is linked to higher activity levels and reduced kinesiophobia in adulthood, a pattern reflecting behavioral persistence. This persistence may be attributed to the formation of long-lasting habits, attitudes, and preferences related to physical activity during the critical developmental period of childhood [63–65].

Regarding kinesiophobia, our findings are in alignment with a previous study by Saulicz et al. [24], which demonstrated that adults who were physically active during their youth exhibited lower levels of kinesiophobia. It is noteworthy that Saulicz et al.‘s study utilized the Kinesiophobia Causes Scale (KCS) to assess kinesiophobia, an instrument that is not as extensively researched [66]. In contrast, the TSK is frequently employed and is generally regarded as the gold standard for assessing kinesiophobia [67]. Therefore, our study may build upon and provide more robust evidence linking childhood physical activity to adulthood kinesiophobia.

Previous studies have identified several factors that are associated with kinesiophobia in adults with CLBP, including pain intensity, pain duration, and injury history [2, 68]. The Fear-Avoidance Model (FAM) provides a framework for understanding the development and maintenance of kinesiophobia in CLBP patients [3]. In the context of the FAM, our findings suggest that childhood physical activity enjoyment may be an important protective factor against the development of kinesiophobia in adults with CLBP by increasing the likelihood of maintaining higher levels of physical activity in adulthood, thus helping to break the fear-avoidance cycle [69]. This highlights the potential long-term benefits of promoting physical activity enjoyment in childhood for preventing the onset of kinesiophobia and its associated negative health outcomes in adulthood.

The mediating role of walking between childhood physical activity enjoyment and kinesiophobia

In our simple mediation analyses, three specific categories of physical activity based on intensity—including walking, moderate PA, and vigorous PA—showed partial mediation effects. However, when these activities were examined in a parallel mediation model, only walking emerged as a significant mediator, accounting for 10.0% of the total effect. These findings only partially support our second hypothesis (H2).

In our study, the tool we used to assess levels of physical activity, a modified version of the three-item scale introduced by Smith et al., did not differentiate the purpose of walking activities. This means that the observed influence of walking on kinesiophobia could be partly attributed to less sedentary behavior, rather than purely the act of walking as a form of exercise. Therefore, both leisure walking and walking in daily activities could have contributed to the effects we observed. Furthermore, it is possible that these two types of walking contribute differently to the observed outcomes. Increasing daily activity outside of leisure walking may act as a buffer to ailments, providing additional health benefits. Future studies should aim to differentiate these types of activities to better understand their individual contributions.

Although this study did not involve any designs or results to disclose the mechanism underneath the phenomenon, some other studies may help explain this discrepancy. Specifically, altered neuromuscular control in patients with CLBP provides a compelling rationale for walking’s pivotal mediating role [70, 71], as it presents a less intimidating and potentially protective avenue of physical activity [72, 73]. Further supporting this notion, a study found that individuals with moderate pain levels were still inclined to engage in walking [74]. Previous studies have provided evidence supporting the idea that individuals with low back pain (LBP) tend to employ a default strategy aimed at restricting movement of the trunk [75, 76]. Therefore, the act of walking might encourage more physical activity while simultaneously serving to reduce kinesiophobia, creating a beneficial feedback loop. Additionally, considering the propensity for CLBP patients to restrict or even avoid physical activity, it is reasonable that moderate and vigorous activities did not emerge as effective mediators. This notion aligns with the principles of graded activity, a therapeutic strategy aiming to increase physical activity levels through positive reinforcement [77]. Graded activity often starts with low-intensity exercises, making it relevant to our finding that only walking—a low-intensity form of activity—served as a significant mediator. The success of graded activity in treating CLBP further corroborates the importance of our results. Our study gains additional validation from a meta-analysis [78], which supported the clinical efficacy of walking in reducing both pain and disability in CLBP patients. This strengthens the clinical relevance of our study, positing that walking could serve as an accessible and feasible form of exercise capable of not only managing CLBP but also mitigating symptoms of kinesiophobia.

In addition to our main findings, we explored the potential influence of sex on kinesiophobia in our study. Our analysis revealed no significant sex differences in TSK-11 scores among CLBP individuals. This finding aligns with some previous studies that reported no sex differences in kinesiophobia among musculoskeletal pain patients [79]. However, it contrasts with other studies that have found sex differences among chronic musculoskeletal pain patients [36, 41]. This variability in the literature suggests that the relationship between sex and kinesiophobia may be complex and influenced by various factors such as pain intensity, past personal experiences of pain, societal beliefs, and co-morbidities [80, 81].

Implications for CLBP management

Our findings highlight the potential association between childhood physical activity enjoyment and adult kinesiophobia in individuals with CLBP. Notably, walking was found to mediate this relationship. Walking, due to its accessibility and ease, may be a practical choice for interventions in CLBP management. It not only strengthens back muscles and reduces stiffness, serving as a preventive measure against back pain, but has also been associated with inducing isometric contractions and improving muscle flexibility, which may be particularly beneficial for CLBP patients with limited hip and back flexibility. Despite the fact that a majority of CLBP sufferers recognize the importance of exercise, many fail to maintain consistent physical activity. Therefore, promoting walking as a form of physical activity may be an effective strategy to encourage regular exercise and manage kinesiophobia in this population.

Limitations and future directions

This study has several limitations. First, due to the cross-sectional design of our study, we cannot establish the temporal sequence of events and thus infer causality from the observed relationships. Therefore, these findings should be interpreted as associations rather than causative relationships. Moreover, beyond the mediation model proposed in our study, future research might consider the possibility that adult physical activity could serve as a moderator in the relationship between childhood physical activity enjoyment and adult kinesiophobia. Future research employing a longitudinal design could provide more robust insights and help establish causality. Second, the convenience sampling strategy employed, while efficient, might not yield a sample representative of the broader CLBP population. This methodological choice could limit the generalizability of our findings to broader demographic settings. Future research should aim to validate our results using more diverse and representative samples to assess the robustness and generalizability of our findings across different populations and contexts. Third, we used a single-item question inspired by the Physical Activity Enjoyment Scale (PACES) for data collection convenience within a large-scale framework. However, this single-item question has not been validated or tested for reliability, which is a limitation. It may not fully capture the complex nature of childhood physical activity enjoyment. Additionally, our study relies on participants’ recollections of their enjoyment of physical activity during childhood, which may be susceptible to recall bias [82]. These limitations may affect the precision and generalizability of our findings. Future investigations might benefit from employing more detailed measurement techniques to explore this aspect comprehensively. Fourth, our study has a limitation in the measurement of physical activity. We assessed frequency and intensity separately, which may have resulted in an incomplete representation of the relationship between total physical activity and kinesiophobia. Future research could consider incorporating methods to calculate total physical activity, such as those used in the International Physical Activity Questionnaire (IPAQ), particularly when the total volume of activity is directly relevant to the outcomes of interest. Fifth, to simplify the questionnaire experience for participants, we categorized age into different groups. However, this introduces a level of simplification, potentially not capturing the detailed influence of age on our variables of interest. Lastly, our categorization of physical activity frequency as “once a week or less” may have led to somewhat limited variation in this variable. The floor effect calculation of 15.3% is marginally above the 15% threshold [83], suggesting a potential skew in the data. This should be interpreted with caution and suggests that future research might benefit from considering a more detailed categorization of physical activity frequency for a more precise analysis.

Conclusion

In our study, we identified a significant association between childhood physical activity enjoyment and kinesiophobia in adulthood among individuals with CLBP. Positive experiences with physical activity during childhood may not only foster sustained physical activity into adulthood, but may also act as a protective factor against the development of kinesiophobia. Notably, walking was found to be a distinctive mediator in the pathway from childhood physical activity enjoyment to adult kinesiophobia, emphasizing its therapeutic potential. These findings underscore the importance of childhood physical activity and offer valuable insights for policymakers and parents. Encouraging children’s active participation in and enjoyment of physical activity can pave the way for long-term health-promoting behaviors.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Acknowledgements

Not applicable.

Author contributions

HWL and HSL conceptualized and initiated this research project. XZ and ZW conducted the literature review for the background and discussion sections. LH and QG contributed to psychological measures, oversaw data collection, and assisted in participant recruitment. HT and JW performed the primary data analysis and drafted the statistical methods and results sections. ZY and LP played a pivotal role in shaping the research design and participated in iterative discussions that informed the manuscript’s direction. All authors (HWL, HSL, LH, HT, JW, QG, ZW, XZ, ZY and LP) critically reviewed and revised the manuscript for significant intellectual content and approved the final version for publication.

Funding

This work was supported by the Chongqing Doctoral Student Science and Innovation Project under Grant CYB21086.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was performed in accordance with the Declaration of Helsinki principles and was approved by the Ethics Committee of Southwest University Hospital, Chongqing, China (SWU-ETH-2023-09-12-002). All participants provided their informed consent by electronically selecting the “Voluntarily Participate” option at the beginning of the online survey. The consent process included information about the study purpose, voluntary participation, compensation, use of standard survey platform settings to prevent duplicate submissions, and data privacy measures. Participants were informed that proceeding with the survey indicated their understanding and agreement with these terms.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

CLBP Chronic low back pain

PACES Physical Activity Enjoyment Scale

TSK-11 11-item Tampa scale of kinesiophobia

FAM Fear avoidance model

VAS Visual analog scale

PA Physical activity

SEM Structural equation modeling

ML Maximum likelihood

SRMR Standardized root mean square residual

GFI Goodness of fit index

CFI Comparative fit index

RMSEA Root mean square error of approximation

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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