low back and neck pain are commonly seen in the workplace , and are the two most common 
 spinal problems encountered in clinical practice . back and
neck pain are important clinical 
 conditions that can limit the ability to perform routine daily activities , decrease 
 productivity , and negatively affect quality of life .
it is reported that 80% of individuals 
 have complained of back pain in some period of their lives1 .
although neck pain does not occur as frequently as low back pain , 
 it is also a common problem , with a 10% lifetime prevalence2 . in turkey , as in other countries1 , low back and neck pain are major health problems that affect 
 individual motivation , and result in physical and psychological problems .
kinesiophobia is among the most extreme forms of fear of pain due to movement or re - injury . 
 in chronic cases , pain severity and cognitive responses to pain
. 
 a person with chronic pain may develop negative beliefs about their experience of pain or 
 negative thoughts about themselves3 . 

patients with kinesiophobia believe that movement will cause re - injury and additional pain ; 
 therefore , kinesiophobia is a risk factor for persistent pain . in the long term , 

kinesiophobia causes physical deconditioning , avoidance of physical activity , functional 
 disability , and symptoms of depression .
it is reported that psychological factors play an 
 important role in the process of chronicity of the disease3,4,5,6 .
several scoring systems have been reported , such as the tampa scale for kinesiophobia 
 ( tsk ) , fear avoidance beliefs questionnaire ( fabq ) , and pictorial fear of activity 
 scale - cervical ( pfacts - c ) , and are used to assess fear of movement - related pain / re - injury in 
 patients with low back and neck pain7 . in 
 a study on patients with neck and shoulder pain , a strong relationship between 
 kinesiophobia , disability , and musculoskeletal system injuries was reported8 .
in addition , patients who have chronic low 
 back pain with high levels of fear of movement - related pain have high pain and disability 
 scores8 .
pain and restricted movement in 
 patients with chronic low back and neck pain result in boredom , anxiety , and depression , 
 negatively affecting the quality of life and causing disability9,10,11,12 .
pain results in 
 varying degrees of kinesiophobia , affective problems , and ultimately negatively affects the 
 quality of life . the present study aimed to compare pain , kinesiophobia , and quality of life 
 scores in patients with low back and neck pain .
the study was performed at hacettepe university hospital , department of physical medicine 
 and rehabilitation , ankara , turkey .
patients 2065 years old with various diagnoses such as 
 disc herniation , spondylosis , strain , sprain , or mechanical pain in the cervical ( neck , 
 n=300 ) or lumbar ( low back , n=300 ) region with 6 months of pain were included in the study . 

patients who had any history of malignancy or a spinal fracture , had undergone any surgical 
 procedure in the previous 6 months , or had orthopedic or neurological disease affecting 
 ambulation were excluded from the study .
patients who agreed to participate in this study 
 signed informed consent forms , and the study was approved by the hacettepe university , 
 non - invasive medical research and ethics committee , protocol number lut 09/41 - 56 .
demographic data including gender , diagnosis , age ( years ) , height ( cm ) , weight ( kg ) , body 
 mass index ( bmi ,  kg / cm ) , and duration of pain ( months ) were recorded .
the turkish version of the short - form mcgill pain questionnaire ( sf - mpq ) was used to assess 
 pain severity and properties13 .
the main 
 component of the sf - mpq consists of 15 descriptive adjectives for the sensation of pain ( 11 
 sensory and 4 affective ) that are self - rated according to their level of intensity on a 
 4-point likert - type scale ( 0=none , 1=mild , 2=moderate , 3=severe ) .
the 3 pain scores are 
 derived from the sum of the intensity scores for sensory , affective , and total description . 

the sensory and affective scores are calculated by adding the sensory and affective 
 intensity scores .
sf - mpq also includes a 
 visual analogue scale ( vas ) for measuring the severity of pain .
the total pain severity 
 score was evaluated using a 6-point likert - type scale ( 0=no pain , 1=mild , 2=uncomfortable , 
 3=distressing , 4=horrible , 5=intolerable)14 . the nottingham health profile ( nhp )
this 
 scale is preferred for its detailed dimensions including many items used to elicit quality 
 of life impressions in patients with kinesiophobia .
part i of 
 the scale includes 38 yes / no questions across 6 dimensions of health : pain , physical 
 mobility , affective reactions , energy , social isolation , and sleep .
the 2 parts can be used 
 independently and part ii was not used in the present study .
part i is scored using weighted 
 values that provide a range of possible scores from zero ( no problems at all ) to 100 
 ( presence of all problems within a dimension ) . in this study , the validated and reliable 
 turkish version of nhp developed by kkdeveci et al .
kinesiophobia was assessed by using the tampa scale for kinesiophobia - turkish version 
 ( tsk ) .
the tsk is used to assess patients with diseases associated with acute and chronic 
 low back pain , fibromyalgia , and musculoskeletal and whiplash injuries .
each item is scored by using 
 a 4-point likert - type scale ranging from strongly disagree to strongly agree . a total score 

is calculated after inversion of the individual scores of items 4 , 8 , 12 , and 16 .
vlaeyen et al . defined a cut - off score of 37 as a high degree of 
 kinesiophobia4 . in this study , the 
 validated and reliable turkish version of the tsk reported by ylmaz et al .
was used to 
 assess kinesiophobia in patients with low back and neck pain16 , 17 . in statistical analysis ,
mean  standard deviation ( sd ) values were calculated for the 
 quantitative variables and percentages were calculated for qualitative variables .
the scores 
 of the above - mentioned tests were compared using the  test for qualitative and 
 student s t - test and mann whitney - u test for quantitative variables in low back and neck 
 pain groups .
the diagnostic distribution of 600 patients is shown in table 1table 1.distribution of diagnosis in the low back pain ( n=300 ) and neck pain ( n=300 ) 
 groupsdistribution of diagnosisn%low back pain grouplumbar disc herniation27391lumbar spondylosis144.7low back strain134.3total300100neck pain groupcervical disc herniation21471.3cervical spondylosis6822.7neck strain186total300100 .
of 300 patients in the low back pain group , 273 ( 91% ) were diagnosed with 
 lumbar disc herniation , while 214 ( 71.3% ) of 300 in the neck pain group had cervical disc 
 herniation ( table 1 ) .
demographic data and comparison of the groups are shown in table 2table 2.demographic characteristics of the patients and comparison between low back 
 ( n=300 ) and neck pain ( n=300 ) groupsdemographiccharacteristicslow back pain groupneck pain groupx  sdx  sdage ( years)43.2  10.942.8  10.2height ( cm)166.2  9.3164.9  7.8weight ( kg)73.6  13.870.4  12.8bmi ( kg / cm)*26.7  4.525.9  4.5duration of pain ( months)66.8  78.146  63.1p<0.05 , p<0.01 .
mean age ( t=0.473 ; p>0.05 ) and height ( t=1.844 ; p>0.05 ) in both groups 
 were similar ; weight ( t=2.992 ; p<0.05 ) and bmi ( t=2.162 ; p<0.05 ) were significantly 
 greater and duration of pain ( t=3.586 ; p<0.05 ) was longer in the low back pain group 
 ( table 2 ) . in the low back pain group , 208 
 ( 69.3% ) were female and 92 ( 30.7% ) were male ; 230 ( 76.7% ) were female and 70 ( 23.3% ) were 
 male in the neck pain group .
the results related to pain severity and other pain characteristics of the sf - mpq such as 
 sensory , affective , total pain , vas pain , and total density scores are shown in table 3table 3.short form - mcgill pain questionnaire [ sf - mpq ] scores and their comparison in low 
 back ( n=300 ) and neck pain ( n=300 ) groupspain characteristics of short form - mcgill pain questionnairelow back pain groupneck pain groupx  sdx  sdsf - mpq sensory pain ( 033)7.9  5.97.8 6.1sf - mpq affective pain ( 012)3.2  3.13.2  3sf - mpq total score ( 045)11.2  8.311  8.3sf - mpq vas score ( 010)6.7  2.16.8  2sf - mpq total pain severity ( 05)2.5  1.12.5  1.1 .
the subscores of the sf - mpq were similar in both groups ( p>0.05 ) .
pain ( z=4.132 ; p<0.01 ) and physical activity ( z=5.640 ; p<0.01 ) sub - scores of the 
 nhp were significantly higher in the low back pain group than the neck pain group while 
 other nhp domain scores were similar between groups ( p>0.05 ) ( table 4table 4.nottingham health profile and tampa scale for kinesiophobia 
 scores and their comparison in low back ( n=300 ) and neck pain ( n=300 ) groupsnottingham health profile domains and 
 kinesiophobialow back pain groupneck pain groupx  sdx  sdenergy level ( 0100)50.2  36.452.2  35.3pain ( 0100)*54.9  26.245.1  29.5affective reactions ( 0100)26.4  27.228.7  26.4sleep ( 0100)18.2  25.119.8  26.4social isolation ( 0100)24.7  27.326.6  28.3physical activity ( 0100)*33.4  16.225.7  17.5nottingham health profile total score ( 0600)208  113.2199.3  113.2tampa scale for kinesiophobia ( 1768)*42.1  5.939.7  6p<0.01 ) .
kinesiophobia scores measured by the tsk were significantly more severe in the low back 
 pain group ( z=4.732 ; p<0.01 ) ( table 4 ) .
our study was performed to evaluate and compare the characteristics of pain , kinesiophobia , 
 and quality of life in patients with low back and neck pain .
pain duration was longer , body 
 weight was greater , kinesiophobia was more severe , and pain and physical activity domains of 
 quality of life scales were worse in the low back pain group , without any difference in pain 
 severity or other pain characteristics between the groups .
kinesiophobia was defined by kori et al . as excessive , irrational , and debilitating fear of 
 physical movement that limits physical activity , and is a result of a painful injury19 .
patients with kinesiophobia believe that 
 physical movement will cause additional pain . in the long term
, kinesiophobia is reported to 
 be associated with decreased physical fitness , avoidance of physical activity , functional 
 disability , inability to fulfill social roles , and depression4 , 20 , 21 .
many studies have examined fear of movement - related pain / re - injury 
 in patients with low back and neck pain .
used tsk in their research on 
 patients with neck and shoulder pain and reported that there was a strong relationship 
 between kinesiophobia and musculoskeletal disorders7 .
studies that assessed patients with chronic low back and neck pain 
 reported that pain and disability scores increased as the fear of movement - related pain 
 increased20,21,22,23,24 .
wilgen et al.21 used the tsk and pain disability index to 
 evaluate fear of movement and disability in patients with low back pain .
their findings 
 showed that there was a significant relationship between kinesiophobia , leg pain , and 
 disability21 . a relationship between 
 kinesiophobia , disability , and quality of life in patients with chronic low back pain
gheldof 
 et al . reported that both pain severity and pain - related fear were factors negatively 
 affecting routine daily and social activities in individuals with low back pain24 . in patients with neck pain because of 
 whiplash syndrome , vangronsveld et al . found a relationship between kinesiophobia ( based on 
 tsk ) and the severity of pain , difficulty in concentrating , and falling asleep23 .
thompson et al . studied chronic whiplash 
 patients and reported that the severity of pain was associated with the severity of 
 kinesiophobia20 . according to our 
 findings , although the severity of pain was moderate and similar in the low back and neck 
 pain groups , kinesiophobia was more severe in the low back pain group .
the decreased 
 physical activity levels in the low back pain group derived from quality of life assessment 
 also support this movement - related fear ; patients with lumbar problems are thought to limit 
 physical activities that require great muscle effort such as walking because of 
 kinesiophobia .
this finding may highlight an important difference between patients with 
 lumbar and cervical problems in terms of fear of movement or re - injury .
clinicians and 
 therapists should consider the tendency toward inactivity in patients with lumbar problems 
 rather than in those with cervical problems , and institute measures to prevent complications 
 caused by inactivity .
it is well known that there is an interaction between pain and quality of life at different 
 levels in patients with low back and neck pain .
dndar et al . showed that physical activity 
 and quality of life were decreased and depression was more severe in patients with chronic 
 low back pain compared with healthy controls5 . in a study by yazc et al .
, all quality of life parameters were 
 statistically significantly decreased in patients with back pain25 .
studied 1,100 neck pain patients and healthy 
 controls aged 2069 , and used the chronic pain questionnaire to assess pain and the sf-36 to 
 evaluate health - related quality of life .
they reported that there was a weak correlation 
 between neck pain and the physical component of health - related quality of life26 .
ay et al . evaluated the severity of pain 
 based on a vas ( 010 cm ) , quality of life based on the nhp , and the severity of depression 
 using the beck depression inventory .
the quality of life decreased as the severity of pain and symptoms 
 of depression increased9 .
lin et al . 
 studied 52 chronic neck pain patients , and assessed health - related quality of life and 
 psychological factors .
the researchers concluded that health - related quality of life in 
 patients with chronic neck pain was lower than in healthy controls , and that patients with 
 neck pain had many physical and mental health symptoms .
in addition , the majority of 
 patients had psychiatric disorders , including psychosomatic symptoms , depression , and 
 anxiety27 . in another study on 195 
 patients with low back pain by kovacs et al .
, a weak correlation was found between the 
 severity of pain , disability , and quality of life28 . in our study
, nhp pain and physical activity scores significantly differed between the low 
 back and neck pain groups .
our nhp findings showed that the perception of pain was lower and 
 the level of physical activity was higher in patients with neck pain ; consequently , quality 
 of life was higher in the neck pain group than in the low back pain group .
the severity of 
 pain in both groups did not differ according to sf - mpq scores , but when the quality of life 
 is considered , the negative effect of pain perception in the low back pain group calls 
 attention to another difference between the groups . the longer duration of pain and higher 
 levels of kinesiophobia in the low back pain group may also be associated with lower quality 
 of life .
bener et al . reported that 
 there was a moderate positive relationship between obesity and low back pain29 .
webb et al . reported that there was a 
 significant relationship between obesity and low back pain .
they also showed that the 
 severity of pain and disability in patients with low back pain increased as the bmi 
 increased30 . in our study ,
greater body weight may also 
 be a predisposing factor for increased pain perception and may indirectly affect 
 kinesiophobia in patients with low back pain .
the primary goal of treatment in patients with low back and neck pain is to reduce the 
 severity of pain ; however , our findings indicate that the differences observed between the 
 groups in terms of pain perception , body weight , kinesiophobia , and physical activity should 
 be taken into consideration when planning preventive and curative physical therapy programs 
 for patients with low back and neck pain .
patients should be educated about kinesiophobia , 
 and the long - term goals of treatment should include increasing patient confidence and 
 reducing the severity of kinesiophobia .
the primary aim of this study was not to determine the factors that cause kinesiophobia . 

therefore , the lack of evaluation for the causes of kinesiophobia in patients with neck and 
 low back pain is a limitation of our study .
 [ purpose ] the purpose of this study was to compare patients with low back and neck pain 
 with respect to kinesiophobia , pain , and quality of life . 
 [ subjects and methods ] 
 three - hundred patients with low back ( mean age 43.211  years ) and 300 with neck pain ( mean 
 age 42.810.2  years ) were included in this study . 
 pain severity was evaluated by using the 
 short - form mcgill pain questionnaire , which includes a visual analogue scale , quality of 
 life by the nottingham health profile , and kinesiophobia by the tampa scale for 
 kinesiophobia . 
 [ results ] pain severity was similar in both groups , with a visual analogue 
 scale score of 6.72 in the low back pain and 6.82 in the neck pain group . 
 nottingham 
 health profile pain [ z=4.132 ] and physical activity scores [ z=5.640 ] in the low back 
 pain group were significantly higher . 
 kinesiophobia was also more severe in the low back 
 pain group , with a mean 42.055.91 versus 39.76.0 tampa scale for kinesiophobia score 
 [ z=4.732 ] . 
 [ conclusion ] patients with low back pain developed more severe kinesiophobia , 
 regardless of the pain severity , and had greater pain perception and lower physical 
 activity levels . 
 kinesiophobia adversely affects the quality of life and requires 
 effective management of low back pain . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION