Physical activity is an important factor in managing chronic pain. It offers benefits like improved physical function, reduced disability, and enhanced mood. However, individuals living with chronic pain often face challenges in maintaining regular activity because of pain-related fear and avoidance. Among the psychological influences of this relationship, kinesiophobia, the fear of movement-induced pain, has been extensively studied and is known to contribute to reduced physical activity and poorer outcomes.
A recent study has focused on positive psychological factors such as pain resilience, which refers to the ability to maintain positive physical and emotional functioning despite ongoing pain. Resilient individuals are thought to cope more effectively with the pain, remain active, and experience less distress.
This study aimed to evaluate whether pain is indirectly linked to physical activity through pain resilience in adults with chronic musculoskeletal pain. It also investigated the combined roles of pain resilience and kinesiophobia in explaining the relationship between pain intensity and physical activity levels.
A cross-sectional online study was conducted from February 5 to 13, 2024, using the Prolific platform for recruitment and Gorilla for data collection. Participants were eligible if they were 18 years or older and had pain lasting or recurring for more than 3 months. Individuals with uncorrected vision impairment were excluded. Of the 222 participants who began the survey, 172 met the inclusion criteria (mean age = 41.9 years, 50% female). After providing informed consent, participants completed validated questionnaires presented in random order, including visual analogue scale (VAS) to assess average and worst pain over the past week, tampa scale of Kinesiophobia (TSK) to measure fear of movement, the pain resilience scale (PRS) to assess resilience in the context of pain, the FRAIL Scale to evaluate frailty status and recent physical activity questionnaire (RPAQ) to quantify the physical activity energy expenditure (PAEE). Participants also reported demographic information and pain characteristics such as duration, diagnosis, and location.
Data analyses were conducted in R. Mediation analyses were performed using the lavaan package to examine the indirect effects of pain on physical activity by pain resilience and kenosiophobia, individually and jointly, with 5000 bootstrap samples. Linear regression models were used to detect predictors of physical activity after controlling for pain intensity, frailty, and other covariates.
The average pain experienced during the past week was significantly and indirectly linked with decreased physical activity through pain resilience (ACME: -0.09, p = 0.01), accounting for about 43% of the total relationship between pain and physical activity. Kinesiophobia showed a smaller but significant indirect effect (ACME: -0.06, p = 0.04), accounting for 29% of the total association. When both variables were included in the model, only pain resilience remained a significant mediator (ACME: -0.08, p = 0.01). Whereas the effect of kinesiophobia was no longer significant. Regression analysis showed that pain resilience (β: 0.34, p = <0.01) and male gender (β: 0.23, p = <0.01) were significant predictors of higher physical activity levels, together explaining about 22% of the variance in PAEE.
These results highlight pain resilience as a key psychological mechanism that helps to maintain physical activity in the presence of chronic pain. Individuals with higher pain resilience may use adaptive coping methods, maintain a positive outlook, and reinterpret the pain sensations in ways that support continued engagement in physical activity. Kinesiophobia appears to play a less crucial role when resilience is considered. The observed gender difference, seen with men showing higher activity levels, aligns with earlier evidence, which suggests that both biological and motivational factors contribute to physical activity disparities.
In conclusion, this study provides evidence that pain resilience plays an important role in sustaining physical activity among individuals with chronic pain. It acts as a buffer against the negative impact of pain. The findings emphasize the importance of targeting resilience in pain management interventions to promote activity and overall well-being. Future research should focus on developing and testing interventions that strengthen resilience and on exploring the causal relationship between pain and activity using longitudinal and experimental designs.
Reference: Niederstrasser NG, Attridge N, Slepian PM. Indirect associations of pain resilience and kinesiophobia with the relationship between physical activity and chronic pain. PLoS One. 2025;20(10):e0334144. doi:10.1371/journal.pone.0334144
