Restricted accessResearch articleFirst published online 2025-7
Testing the mediatory role of kinesiophobia in the association between perceived greenspace and physical activity among individuals with chronic low back pain
To test the mediatory role of kinesiophobia between greenspace and physical activity, we conducted a cross-sectional survey and recruited 801 participants with chronic low back pain. The level of greenspace was assessed using both perceived greenspace and the Normalized Difference Vegetation Index (NDVI). The frequency of walking and moderate and vigorous physical activities was measured using a brief assessment, while kinesiophobia was evaluated using the 11-item Tampa Scale for Kinesiophobia (TSK-11). The results revealed that perceived greenspace was positively associated with all measured physical activities, and was negatively associated with kinesiophobia. Meanwhile, NDVI was only positively associated with moderate and vigorous physical activity. Kinesiophobia played a marginal but significant mediating role in the association of perceived greenspace with walking, moderate physical activity, and vigorous physical activity. In conclusion, our findings offer early evidence of associations and pathways between greenspace and physical activity among individuals with chronic low back pain.
AbdullahAYMLawJPerlmanCM, et al. (2022) Age- and sex-specific association between vegetation cover and mental health disorders: Bayesian spatial study. JMIR Public Health and Surveillance8: e34782.
2.
AilyJBde AlmeidaACRamírezPC, et al. (2021) Lower education is an associated factor with the combination of pain catastrophizing and kinesiophobia in patients with knee osteoarthritis?Clinical Rheumatology40: 2361–2367.
3.
AntunesRSMacedoBGdAmaralTdS, et al. (2013) Pain, kinesiophobia and quality of life in chronic low back pain and depression. Acta Ortopedica Brasileira21: 27–29.
4.
Astell-BurtTFengXKoltGS (2014a) Green space is associated with walking and moderate-to-vigorous physical activity (MVPA) in middle-to-older-aged adults: Findings from 203 883 Australians in the 45 and Up Study. British Journal of Sports Medicine48: 404–406.
5.
Astell-BurtTFengXKoltGS (2014b) Is neighborhood green space associated with a lower risk of type 2 diabetes? Evidence from 267,072 Australians. Diabetes Care37: 197–201.
6.
BeyerKMMKaltenbachASzaboA, et al. (2014) Exposure to neighborhood green space and mental health: Evidence from the survey of the health of Wisconsin. International Journal of Environmental Research and Public Health11: 3453–3472.
7.
BilginSCetinHKarakayaJ, et al. (2019) Multivariate analysis of risk factors predisposing to kinesiophobia in persons with chronic low back and neck pain. Journal of Manipulative and Physiological Therapeutics42: 565–571.
8.
BolteGNanningaSDandoloL (2019) Sex/gender differences in the association between residential green space and self-rated health—A sex/gender-focused systematic review. International Journal of Environmental Research and Public Health16: 4818.
9.
BosEHVan der MeulenLWichersM, et al. (2016) A primrose path? Moderating effects of age and gender in the association between green space and mental health. International Journal of Environmental Research and Public Health13: 492.
10.
BraçeOGarrido-CumbreraMCorrea-FernándezJ (2021) Gender differences in the perceptions of green spaces characteristics. Social Science Quarterly102: 2640–2648.
11.
BrownTA (2015) Confirmatory Factor Analysis for Applied Research. New York, NY: Guilford Press.
12.
BuerNLintonSJ (2002) Fear-avoidance beliefs and catastrophizing: Occurrence and risk factor in back pain and ADL in the general population. Pain99: 485–491.
13.
CaiLLiuYWobySR, et al. (2019) Cross-cultural adaptation, reliability, and validity of the Chinese version of the Tampa Scale for Kinesiophobia-11 among patients who have undergone total knee arthroplasty. The Journal of Arthroplasty34: 1116–1121.
14.
CohenSDoyleWJBaumA (2006) Socioeconomic status is associated with stress hormones. Psychosomatic Medicine68: 414–420.
15.
ColdwellDFEvansKL (2018) Visits to urban green-space and the countryside associate with different components of mental well-being and are better predictors than perceived or actual local urbanisation intensity. Landscape and Urban Planning175: 114–122.
16.
CuschieriS (2019) The STROBE guidelines. Saudi Journal of Anaesthesia13: S31.
17.
DinsaGDGoryakinYFumagalliE, et al. (2012) Obesity and socioeconomic status in developing countries: A systematic review. Obesity Reviews13: 1067–1079.
18.
DzhambovAHartigTMarkevychI, et al. (2018) Urban residential greenspace and mental health in youth: Different approaches to testing multiple pathways yield different conclusions. Environmental Research160: 47–59.
19.
ElfvingBAnderssonTGrootenWJ (2007) Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing. Physiotherapy Research International12: 14–24.
20.
ElsadekMLiuBXieJ (2020) Window view and relaxation: Viewing green space from a high-rise estate improves urban dwellers’ wellbeing. Urban Forestry & Urban Greening55: 126846.
21.
Fernández NúñezM-BCampos SuzmanLManejaR, et al. (2022) The differences by sex and gender in the relationship between urban greenness and cardiometabolic health: A systematic review. Journal of Urban Health99: 1054–1067.
22.
FordESMerrittRKHeathGW, et al. (1991) Physical activity behaviors in lower and higher socioeconomic status populations. American Journal of Epidemiology133: 1246–1256.
23.
FreburgerJKHolmesGMAgansRP, et al. (2009) The rising prevalence of chronic low back pain. Archives of Internal Medicine169: 251–258.
24.
GongYGallacherJPalmerS, et al. (2014) Neighbourhood green space, physical function and participation in physical activities among elderly men: The Caerphilly Prospective study. International Journal of Behavioral Nutrition and Physical Activity11: 40.
25.
GrindeBPatilGG (2009) Biophilia: Does visual contact with nature impact on health and well-being?International Journal of Environmental Research and Public Health6(9): 2332–2343.
26.
GuzmánJEsmailRKarjalainenK, et al. (2001) Multidisciplinary rehabilitation for chronic low back pain: Systematic review. BMJ322: 1511–1516.
27.
HaukoosJSLewisRJ (2005) Advanced statistics: Bootstrapping confidence intervals for statistics with “difficult” distributions. Academic Emergency Medicine12: 360–365.
28.
HayesAF (2017) Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York, NY: Guilford Press.
29.
HayesAFScharkowM (2013) The relative trustworthiness of inferential tests of the indirect effect in statistical mediation analysis: Does method really matter?Psychological Science24: 1918–1927.
30.
HeneweerHStaesFAufdemkampeG, et al. (2011) Physical activity and low back pain: A systematic review of recent literature. European Spine Journal20: 826–845.
31.
HoffimannEBarrosHRibeiroAI (2017) Socioeconomic inequalities in green space quality and accessibility—Evidence from a Southern European City. International Journal of Environmental Research and Public Health14(8): 916.
32.
IslamHGibalaMJLittleJP (2022) Exercise snacks: A novel strategy to improve cardiometabolic health. Exercise and Sport Sciences Reviews50: 31–37.
33.
JanssenIRosuA (2015) Undeveloped green space and free-time physical activity in 11 to 13-year-old children. International Journal of Behavioral Nutrition and Physical Activity12: 26.
34.
JeonSMKangMKimSJ, et al. (2021) Psychological and physiological responses to different views through a window in apartment complexes. Journal of People, Plants, and Environment24: 545–550.
35.
KabischNHaaseD (2013) Green spaces of European cities revisited for 1990–2006. Landscape and Urban Planning110: 113–122.
36.
KanjilalSGreggEWChengYJ, et al. (2006) Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971–2002. Archives of Internal Medicine166: 2348–2355.
37.
KelleyK (2005) The effects of nonnormal distributions on confidence intervals around the standardized mean difference: Bootstrap and parametric confidence intervals. Educational and Psychological Measurement65: 51–69.
38.
KlineGA (2009) Does a view of nature promote relief from acute pain?Journal of Holistic Nursing27: 159–166.
39.
KoteraYLyonsMVioneKC, et al. (2021) Effect of nature walks on depression and anxiety: A systematic review. Sustainability13(7): 4015.
40.
LarssonCEkvall HanssonESundquistK, et al. (2016) Impact of pain characteristics and fear-avoidance beliefs on physical activity levels among older adults with chronic pain: A population-based, longitudinal study. BMC Geriatrics16: 1–8.
41.
LiHBrowningMHEMCaoY, et al. (2022a) From childhood residential green space to adult mental wellbeing: A pathway analysis among Chinese adults. Behavioral Sciences12: 84.
42.
LiHBrowningMHEMDzhambovAM, et al. (2022b) Green space for mental health in the COVID-19 era: A pathway analysis in residential green space users. Land11: 1128.
43.
LiHBrowningMHEMDzhambovAM, et al. (2023a) Potential pathways of association from green space to smartphone addiction. Environmental Pollution331: 121852.
44.
LiHLiYWangZ, et al. (2023b) Green physical activity for leisure connects perceived residential greenspace and mental well-being. Frontiers in Public Health11: 1254185.
45.
LiHZhangG (2023) How can plant-enriched natural environments benefit human health: A narrative review of relevant theories. International Journal of Environmental Health Research34(3): 1–14.
46.
LiHZhangXBiS, et al. (2021) Can residential greenspace exposure improve pain experience? A comparison between physical visit and image viewing. Healthcare. MDPI9(7): 918.
47.
LiHZhangXZhangX, et al. (2023c) Can intelligence affect alcohol-, smoking-, and physical activity-related behaviors? A Mendelian randomization study. Journal of Intelligence11(2): 29.
48.
LiZXiang-JuanXJing-XinD (2019) Discrimination perception, depression, and academic performance of left behind children in rural areas: A longitudinal mediation model. Psychology Science20(3): 584–590.
49.
LiuX-XMaX-LHuangW-Z, et al. (2022) Green space and cardiovascular disease: A systematic review with meta-analysis. Environmental Pollution301: 118990.
50.
LiuYWangRGrekousisG, et al. (2019) Neighbourhood greenness and mental wellbeing in Guangzhou, China: What are the pathways?Landscape and Urban Planning190: 103602.
51.
LiuZChenXCuiH, et al. (2023) Green space exposure on depression and anxiety outcomes: A meta-analysis. Environmental Research231: 116303.
52.
Lopez-de-Uralde-VillanuevaINotario-PerezRDel CorralT, et al. (2017) Functional limitations and associated psychological factors in military personnel with chronic nonspecific neck pain with higher levels of kinesiophobia. Work58: 287–297.
53.
LundbergMStyfJ (2009) Kinesiophobia among physiological overusers with musculoskeletal pain. European Journal of Pain13: 655–659.
54.
Luque-SuarezAMartinez-CalderonJFallaD (2019) Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: A systematic review. British Journal of Sports Medicine53(9): 554–559.
55.
MarkevychISchoiererJHartigT, et al. (2017) Exploring pathways linking greenspace to health: Theoretical and methodological guidance. Environmental Research158: 301–317.
56.
MeucciRDFassaAGFariaNMX (2015) Prevalence of chronic low back pain: Systematic review. Revista de Saúde Pública49: 73.
57.
MillerRPKoriSHToddDD (1991) The Tampa Scale: A measure of kinesiophobia. The Clinical Journal of Pain7(1): 51–52.
58.
NaugleKMBlytheCNaugleKE, et al. (2022) Kinesiophobia predicts physical function and physical activity levels in chronic pain-free older adults. Frontiers in Pain Research3: 874205.
59.
Ode SangÅKnezIGunnarssonB, et al. (2016) The effects of naturalness, gender, and age on how urban green space is perceived and used. Urban Forestry & Urban Greening18: 268–276.
60.
OzerAYKaracaSSenocakE, et al. (2022) Does kinesiophobia limit physical activity and quality of life in asthmatic patients?International Journal of Rehabilitation Research45: 230–236.
61.
RemmeRPFrumkinHGuerryAD, et al. (2021) An ecosystem service perspective on urban nature, physical activity, and health. Proceedings of the National Academy of Sciences118: e2018472118.
62.
RhewICVander StoepAKearneyA, et al. (2011) Validation of the Normalized Difference Vegetation Index as a measure of neighborhood greenness. Annals of Epidemiology21: 946–952.
63.
RoeJJThompsonCWAspinallPA, et al. (2013) Green space and stress: Evidence from cortisol measures in deprived urban communities. International Journal of Environmental Research and Public Health10: 4086–4103.
64.
RugelEJHendersonSBCarpianoRM, et al. (2017) Beyond the Normalized Difference Vegetation Index (NDVI): Developing a Natural Space Index for population-level health research. Environmental Research159: 474–483.
65.
ScandurraCMezzaFMaldonatoNM, et al. (2019) Health of non-binary and genderqueer people: A systematic review. Frontiers in Psychology10: 1453.
66.
Serrano-HernanzGAngulo-CarrereTArdizone-GarcíaI, et al. (2023) Pressure Release Technique versus placebo applied to cervical and masticatory muscles in patients with chronic painful myofascial Temporomandibular Disorder. A randomized clinical trial. Journal of Oral Rehabilitation50(9): 782–791.
67.
SillmanDRigolonABrowningMHEM, et al. (2022) Do sex and gender modify the association between green space and physical health? A systematic review. Environmental Research209: 112869.
68.
SitthipornvorakulEJanwantanakulPPurepongN, et al. (2011) The association between physical activity and neck and low back pain: A systematic review. European Spine Journal20: 677–689.
69.
SmithBJMarshallALHuangN (2005) Screening for physical activity in family practice: Evaluation of two brief assessment tools. American Journal of Preventive Medicine29: 256–264.
70.
SoyiriINAlcockI (2018) Green spaces could reduce asthma admissions. The Lancet Respiratory Medicine6: e1.
71.
StanhopeJBreedMFWeinsteinP (2020) Exposure to greenspaces could reduce the high global burden of pain. Environmental Research187: 109641.
72.
Subiza-PérezMGarcía-BaqueroGBabarroI, et al. (2021) Does the perceived neighborhood environment promote mental health during pregnancy? Confirmation of a pathway through social cohesion in two Spanish samples. Environmental Research197: 111192.
73.
SüralIGriffithsMDKircaburunK, et al. (2019) Trait emotional intelligence and problematic social media use among adults: The mediating role of social media use motives. International Journal of Mental Health and Addiction17: 336–345.
74.
TranISabolOMoteJ (2022) The relationship between greenspace exposure and psychopathology symptoms: A systematic review. Biological Psychiatry Global Open Science2: 206–222.
75.
TrocoliTOBotelhoRV (2016) Prevalence of anxiety, depression and kinesiophobia in patients with low back pain and their association with the symptoms of low back spinal pain. Revista Brasileira de Reumatologia56: 330–336.
76.
TuckerCJ (1979) Red and photographic infrared linear combinations for monitoring vegetation. Remote Sensing of Environment8: 127–150.
77.
VandenbrouckeJPElmEvAltmanDG, et al. (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. Annals of Internal Medicine147: W-163–W-194.
78.
VlaeyenJWKole-SnijdersAMRotteveelAM, et al. (1995) The role of fear of movement/(re) injury in pain disability. Journal of Occupational Rehabilitation5: 235–252.
79.
VlaeyenJWLintonSJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain85: 317–332.
80.
Von ElmEAltmanDGEggerM, et al. (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. The Lancet370: 1453–1457.
81.
WangRHelbichMYaoY, et al. (2019) Urban greenery and mental wellbeing in adults: Cross-sectional mediation analyses on multiple pathways across different greenery measures. Environmental Research176: 108535.
82.
WobySRRoachNKUrmstonM, et al. (2005) Psychometric properties of the TSK-11: A shortened version of the Tampa Scale for Kinesiophobia. Pain117: 137–144.
83.
World Health Organization Regional Office for Europe (2017) Urban green spaces: A brief for action. World Health Organization. Abgerufen von. Available at: https://apps.who.int/iris/handle/10665/344116.
84.
YeonP-SJeonJ-YJungM-S, et al. (2021) Effect of forest therapy on depression and anxiety: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health18(23): 12685.
85.
YuYWilliamsDR (1999) Socioeconomic status and mental health. In: AneshenselCSPhelanJC (eds) Handbook of the Sociology of Mental Health. Boston, MA: Springer, pp.151–166.
86.
ZhangYVan DijkTTangJ, et al. (2015) Green space attachment and health: A comparative study in two urban neighborhoods. International Journal of Environmental Research and Public Health12: 14342–14363.
87.
ZhaoXLynchJGJrChenQ (2010) Reconsidering Baron and Kenny: Myths and truths about mediation analysis. Journal of Consumer Research37: 197–206.
88.
ZhouHLongL (2004) Statistical remedies for common method biases. Advances in Psychological Science12: 942.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
