Kinesiophobia in Multiple Sclerosis: Associations with Age, Anxiety, and Physical Activity

Introduction

Multiple sclerosis (MS) is a chronic immune-related disease of the central nervous system characterized by inflammation, demyelination, gliosis, and loss of neurons. Pathologically, perivascular lymphocyte infiltration and macrophage activity are involved in the degradation of the myelin sheaths surrounding neurons, leading to a wide range of neurological symptoms depending on the location of the lesions [1]. MS is the most common cause of non-traumatic neurological disability in young adults and affects approximately 2.8 million people worldwide [2]. Neurological symptoms of MS lead to activity limitations and reduced quality of life [1].

Studies consistently show that people with MS have significantly lower quality of life scores than the healthy population [3–5]. The main negative predictors of quality of life include higher rates of disability, fatigue, pain, depression, and anxiety, while social support and self-efficacy in managing the disease have a positive effect [6–8].

Treatment of multiple sclerosis requires a comprehensive and interdisciplinary approach that includes managing acute relapses, alleviating adverse or debilitating symptoms, and administering disease-modifying therapy (DMT) [9]. In recent decades, significant progress has been made in the treatment of all forms of the disease, with the most significant shift occurring in the treatment of the recurrent form, which is positively reflected in the long-term prognosis of patients. DMTs include, in particular, interferon-β preparations, glatiramer acetate, natalizumab, teriflunomide, and other modern pharmacological interventions that reduce the frequency of relapses and slow progression of the disease [10]. Symptomatic treatment is focused on managing the patient’s specific difficulties and uses corticosteroids, muscle relaxants, antidepressants, or anticonvulsants [11]. An important part of comprehensive care is also support for overall quality of life, which may include lifestyle modifications, cognitive-behavioral therapy, and various forms of rehabilitation procedures [4,10,12].

Physical activity is one of the factors that can positively affect the course of the disease, relieve symptoms and improve the quality of life in people with MS [10,13–15]. Current evidence confirms that the safety profile of exercise in patients with MS is comparable to that of the general population [16,17]. A systematic review by Learmonth et al [17] showed that patients regularly engaged in physical activity do not have an increased risk of relapse or adverse effects compared to physically inactive persons. Despite the clear benefits, however, available research repeatedly points to very low levels of physical activity among people with MS [18–20], with a tendency toward lower intensity and frequency of exercise compared to the healthy population. The most common barriers to physical activity include fatigue, physical limitations, pain, lack of time, and psychological factors [20–22].

One psychological factor is kinesiophobia, defined as an excessive, irrational, and debilitating fear of movement and physical activity triggered by a feeling of vulnerability to pain, injury, or worsening of symptoms [23–25]. Kinesiophobia can lead to avoidance of physical activities, to the development of a sedentary lifestyle, and, consequently, to deterioration of physical condition, functional independence, and psychosocial well-being [26,27].

Kinesiophobia and its clinical context remain relatively unexplored in the field of neurological diseases, which points to the need for further systematic studies, especially in patients with MS. Identifying precise predictors of kinesiophobia is a crucial step in developing targeted therapeutic strategies, as reducing maladaptive fear of movement is essential for effective physiotherapy and the safe enhancement of physical activity levels in patients with multiple sclerosis. Although previous research has highlighted associations between kinesiophobia and variables such as acceptance of disease, pain, disability [28], fatigue [29], and depressive symptomatology [21], comprehensive analyses integrating psychological factors, behavioral indicators of physical activity, and key demographic and clinical characteristics remain limited. Our study therefore aimed to address this gap by providing a more integrated perspective on the risk profile associated with kinesiophobia in individuals with multiple sclerosis.

This study aimed to evaluate the factors associated with kinesiophobia in multiple sclerosis patients, including disability, fatigue, anxiety, depression, physical activity, and quality of life. The study pursued specific objectives: (1) to examine the relationships between kinesiophobia and physical activity, quality of life, fatigue, depressive and anxiety symptoms, and the degree of neurological disability; (2) to compare clinical and psychosocial characteristics between patients with low and high levels of kinesiophobia; and (3) to identify independent predictors of kinesiophobia using an adjusted multivariable regression model. We hypothesized that higher TSK scores would be associated with lower levels of physical activity and quality of life, and with higher levels of anxiety, depression, fatigue, and disability.

Material and Methods

CALCULATION OF THE MINIMUM SAMPLE SIZE:

We used the formula recommended by Khamis and Kepler to calculate the minimum sample size in a multiple regression model [34]: n=20+5k, where k=number of predictors. With 12 monitored potential prognostic factors, the minimum sample size was estimated to be 80. The total number of respondents was 148 patients.

MEASUREMENTS:

For the purposes of this research, a cross-sectional study combining clinical examination and a questionnaire survey was conducted among patients with multiple sclerosis living in Slovakia. Clinical parameters such as the degree of disability, disease duration, course, and type of immunomodulatory treatment were provided by the attending physician. For the purposes of this study, we relied solely on a dichotomous variable indicating whether participants were receiving immunomodulatory therapy, with no additional data on specific agents or treatment regimens. In the Slovak Republic, immunomodulatory therapy is prescribed in specialized MS centers, and all commercially authorized disease-modifying therapies (DMTs) are available, including beta-interferons, glatiramer acetate, monoclonal antibodies (natalizumab, ocrelizumab, alemtuzumab, ofatumumab), dimethyl fumarate, teriflunomide, cladribine, and S1P receptor modulators. Neurological assessments, including the evaluation of the EDSS, were conducted by board-certified neurologists with specialized expertise in the diagnosis and management of multiple sclerosis. All questionnaires were administered during a subsequent appointment within 1 week. Data were obtained through personal interviews between the researcher and the patients. A structured questionnaire was used to collect socio-demographic information, including gender, education, and work capacity. The study used standardized and validated questionnaires that are commonly applied in clinical practice. The Tampa Scale for Kinesiophobia (TSK) was used to assess the fear of movement. The quality of life was assessed by the SF-36 Health Survey Questionnaire (SF-36), the fatigue rate by the Modified Fatigue Impact Scale (MFIS) and the level of physical activity by the Godin Leisure-Time Exercise Questionnaire (GLTEQ). The Zung Self-Rating Depression Scale (SDS) was used to identify depressive symptoms, and the severity of anxiety was assessed through the Beck Anxiety Inventory (BAI).

EXPANDED DISABILITY STATUS SCALE (EDSS): To determine the degree of disability of MS patients, we used a 20-point evaluation system developed by Dr. John Kurtzke: the Expanded Disability Status Scale (EDSS). The neurologist first evaluates the level of damage in the 8 functional systems of the CNS and compares the score obtained with the standards for patient mobility (eg, ability to walk a certain distance). The combination of results in functional systems and walking ability determines the overall EDSS score, indicating the degree of functional incapacity and disability [35].

TAMPA SCALE FOR KINESIOPHOBIA (TSK): The Slovak version of the Tampa Scale for Kinesiophobia (TSK) consists of 17 items aimed at assessing the subjective degree of fear of movement. Responses are recorded on a 4-point Likert scale from “strongly disagree” to “strongly agree.” Each item is rated from 1 to 4 points, and using reverse scoring (4-1) for negatively formulated items (4, 8, 12, and 16). The total score ranges from 17 to 68 points. A score of 17 indicates absence or very low level of kinesiophobia, while higher values reflect increasing intensity. Vlaeyen [36] proposed a cut-off value of >37 points, which is associated with a worse prognosis and indicates a high level of kinesiophobia (higher=worse). The internal consistency in our sample was α=0.77.

GODIN LEISURE-TIME EXERCISE QUESTIONNAIRE (GLTEQ): The GLTEQ questionnaire was used to measure the level of physical activity [37]. This tool contains 3 questions about how often during a typical week intense (eg, running), moderate (eg, fast walking), and light (eg, slow walking) physical activity lasting more than 15 minutes is performed. The number of activities per week is recalculated using coefficients – 9 for intensive, 5 for medium-demanding, and 3 for light activities – and their sum forms the total score of leisure activity. The formula determines this weekly leisure activity score: (9×strenuous)+(5×moderate)+(3×light). Interpretation: A score of 24 or more points indicates active individuals, 14–23 points indicates moderately active individuals, and a score of less than 14 units indicates inadequate physical activity [37]. Cronbach’s alpha for internal consistency in our sample was α=0.59.

SHORT FORM 36 HEALTH SURVEY QUESTIONNAIRE (SF-36): Quality of life in patients with multiple sclerosis was assessed using the Slovak version of the SF-36 questionnaire. This standardized instrument comprises 36 items and assesses 2 major dimensions of quality of life: the physical (PCS – Physical Component Summary) and the mental (MCS – Mental Component Summary) components. The PCS includes 4 domains: Physical Functioning (10 items), Role Physical (limitations due to physical problems; 4 items), Body Pain (2 items), and General Health (overall perception of health; 5 items). The MCS encompasses Social Functioning (2 items), Role Emotional (limitations due to emotional problems; 3 items), Mental Health (5 items), and Vitality (4 items). The responses are coded, summed, and transformed into domain scores ranging from 0 (worst health) to 100 (best possible health). SF-36 items were recoded and aggregated into domain scores, which were subsequently transformed to a 0–100 scale according to the scoring manual. The PCS and MCS summary scores were derived using the original SF-36 weighting algorithm and are presented as raw, non–norm-based scores [38]. The internal consistency of the instrument in our sample was α=0.95.

MODIFIED FATIGUE IMPACT SCALE (MFIS): The Slovak version of the MFIS was used to evaluate fatigue in patients. It evaluates the effect of fatigue on the physical, mental, and psychosocial areas. Items are evaluated from 0 points (no problem) to 4 points (extreme problem) based on the patient’s feelings over the last month. The physical subscale contains 8 items (0–36 points), the cognitive subscale contains 10 items (0–40 points), and the psychosocial subscale contains 2 items (0–8 points). The total MFIS score is 0–84 points. A higher score means a greater impact of fatigue on the quality of life. MFIS was analyzed exclusively as a continuous variable in all inferential analyses. The commonly used clinical threshold MFIS ≥39, indicating clinically significant fatigue, was reported only descriptively to characterize fatigue severity, not for statistical modelling [39,40]. The internal consistency in our sample was α=0.98.

ZUNG SELF-RATING DEPRESSION SCALE (SDS): The Slovak version of the standardized SDS was used to assess depression. It contains 20 items, each rated from 1 (never or rarely) to 4 (most or all of the time). A gross score of 20–80 is converted to a 100-point SDS index (gross score×1.25). Interpretation: <50 without depressive symptoms, 50–59 minimal/mild depression, 60–69 moderate depression, ≥70 severe depression [41]. SDS was treated as a continuous variable in all primary analyses, while established cut-offs were reported only descriptively to provide clinical context. The internal consistency in our sample was α=0.96.

BECK ANXIETY INVENTORY (BAI): Anxiety was assessed using the Slovak version of the Beck Anxiety Inventory (BAI). BAI is a self-assessment inventory with 21 items to measure the intensity of anxiety. Participants evaluate the extent to which individual symptoms bothered them in the last week on a 4-point scale. Total score 0–63: 0–7 minimal anxiety, 8–15 mild, 16–25 moderate, 26–63 severe. BAI shows a high internal consistency (α=0.92) [42]. BAI was analyzed as a continuous variable, with severity categories provided only for descriptive purposes. Cronbach’s alpha for internal consistency in our sample was α=0.91.

MINI-MENTAL STATE EXAMINATION (MMSE): Cognitive functions were assessed using the MMSE (Folstein Test), which is one of the most widely used screening tools. It contains 30 items in 6 cognitive domains [43].

STATISTICAL ANALYSIS:

All calculations were performed using MedCalc^® Statistical Software version 23. The Shapiro-Wilk test showed that all variables except TSK were non-normally distributed; therefore, nonparametric statistics were used for descriptive analyses and correlations. Continuous variables between the 2 groups were compared using the Mann-Whitney U test, and associations between monitored factors were assessed using Spearman’s correlation coefficient. The primary outcome was the TSK score analyzed as a continuous variable. In addition, a secondary outcome was created by dichotomizing TSK using the established cut-off of >37 to indicate high kinesiophobia; this categorical variable was used only for descriptive contrasts and not for inferential modelling.

The adjusted multivariable model included all pre-specified covariates: age, gender, disease duration, MS course, and DMT use, together with clinical and psychological predictors (EDSS, PCS, MCS, MFIS, SDS, BAI, and GLTEQ). Because SF-36 comprises 8 domains, we minimized the risk of multiple testing by using only the 2 validated composite scores (PCS and MCS); therefore, no additional false-discovery correction was required. Multiple regression analysis with sigma-restrictive parameterization was used to evaluate the independent contribution of all predictors to kinesiophobia. All analyses were performed using complete-case data without imputation, and statistical significance was set at α=0.05 (2-tailed).

Results

The research group consisted of 148 people with a confirmed diagnosis of multiple sclerosis, of which 43 were men (29.05%) and 105 were women (70.95%). The average age of the participants was 42.21±9.84 years, with the youngest respondent being 21 and the oldest 71 years old. The duration of the disease ranged from 1 to 37 years, with an average value of 10.14±6.70 years. In terms of the clinical course, the relapsing-remitting form of the disease dominated (n=107; 72.30%), the secondary progressive form was recorded in 29 people (19.59%), and the primary progressive form was present in 12 patients (8.11%). The median EDSS was 4.00 (range 1.0–6.0). A lower degree of disability (EDSS 1–3.5) was present in 68 subjects (45.95%), while a moderate degree (EDSS 4–6) in 80 subjects (54.05%). The educational structure showed that most patients had completed secondary education (n=84; 56.76%), 62 people achieved higher education (41.89%), and only 2 respondents had primary education (1.35%). In the field of work capacity, 46 participants (31.08%) did not indicate any restrictions, 19 (12.84%) had limited work capacity, and 83 (56.08%) were recipients of an invalidity pension. There were 92 patients (62.16%) who received immunomodulatory therapy, while 56 (37.84%) did not (Table 1).

The distribution of the monitored variables, expressed as median, interquartile range, mean, standard deviation, and minimum–maximum values, is presented in Table 2. The average value of kinesiophobia assessed using the TSK scale was 39.27 points (SD±6.73). A higher degree of kinesiophobia was found in 87 patients (58.78%), while a lower degree was found in 61 patients (41.22%). The physical component summary (PCS) reached a median of 47.19 (31.88), while the mental component summary (MCS) was 50.38 (31.50). Fatigue assessed by the MFIS showed a median total score of 39.00 (28.50), with lower fatigue levels (MFIS 0–38) in 49.32% of participants and higher levels (MFIS 39–84) in 50.68%. The median SDS score was 52.50 (13.75), with no depressive symptoms in 37.84% of participants, mild depression in 35.13%, and moderate depression in 27.03% of the sample. Anxiety (BAI) reached a median of 15.50 (13.00), with moderate or severe anxiety reported by 50.00% of participants, based on the sum of those scoring 16–25 points (33.11%) and 26–63 points (16.89%). Physical activity measured by the GLTEQ was 17.00 (16.75), with 33.78% reporting high activity (≥24 points).

Table 3 presents a comparison of clinical and quality of life parameters between patients with low kinesiophobia (n=61) and those with high kinesiophobia (n=87). Significant differences were observed in several SF-36 domains. Patients with high kinesiophobia showed substantially worse General Health (P<0.001, r=−0.367), Body Pain (P<0.001, r=−0.296), Vitality (P=0.001, r=−0.268), Role Emotional (P=0.001, r=−0.272), and Mental Health (P<0.001, r=−0.298). A significant reduction was also found in Role Physical (P=0.008, r=−0.219).

Both summary components of quality of life were markedly lower in the high-kinesiophobia group: Physical Component Summary (PCS) (P<0.001, r=−0.292) and Mental Component Summary (MCS) (P<0.001, r=−0.331). Physical Functioning and Social Functioning did not differ significantly (P=0.092 and P=0.106). Neurological disability measured by EDSS was slightly but significantly higher in the high-kinesiophobia group (P=0.023, r=−0.187). Fatigue levels differed strongly across all MFIS subscales: physical (P<0.001, r=−0.320), cognitive (P<0.001, r=−0.384), and psychosocial (P<0.001, r=−0.312), as well as in the total MFIS score (P<0.001, r=−0.381). Depressive symptoms (SDS) were higher in the high kinesiophobia group (P=0.001, r=−0.266), and significantly higher anxiety levels were also observed (BAI; P=0.010, r=−0.212). Physical activity measured by GLTEQ showed one of the strongest effects: patients with high kinesiophobia had significantly lower activity levels (P<0.001), with the largest effect size in the table (r=−0.477).

The results of the correlation analysis showed that a higher level of kinesiophobia in patients with multiple sclerosis is significantly related to older age (P=0.009) and greater neurological disability as measured by EDSS (P=0.004). Kinesiophobia was also associated with poorer self-reported general health and reduced physical and mental health components of quality of life (P<0.001). In addition, higher levels of kinesiophobia were linked to higher fatigue, increased depressive and anxiety symptoms, and lower physical activity (P<0.001) (Table 4).

The adjusted multivariable regression model identified 3 significant independent predictors of kinesiophobia in patients with MS. Higher anxiety levels assessed by the BAI were associated with greater kinesiophobia (β=0.252, 95% CI: 0.053 to 0.331). Lower physical activity measured by the GLTEQ showed the strongest association with kinesiophobia (β=−0.353, 95% CI: −0.208 to −0.086), indicating that more active individuals reported less fear of movement. Additionally, older age showed a positive association with kinesiophobia (β=0.205, 95% CI: 0.022 to 0.258). No other variables including gender, disease duration, MS course, disability level (EDSS), depression (SDS), fatigue (MFIS), PCS, or MCS exhibited a significant independent contribution to the variance in TSK scores in the fully adjusted model (Table 5).

Discussion

Our study confirmed a high prevalence of kinesiophobia (58.78%) in patients with multiple sclerosis, regardless of the degree of physical disability. This result corresponds to previous findings that approximately 60% of patients with multiple sclerosis show moderate to extreme levels of kinesiophobia [28,44,45]. Ruiz Sánchez et al [44] found a significantly higher incidence of kinesiophobia in patients with multiple sclerosis compared to the healthy population.

As in previous studies, the bivariate analyses confirmed significant associations with disability, fatigue, depression, anxiety, quality of life, and physical activity [21,28]. However, the adjusted model refined these relationships: only anxiety, low physical activity, and older age remained independent predictors of kinesiophobia, whereas disability, fatigue, depression, and health-related quality of life (PCS, and MCS) showed no independent effect. Our findings suggest that manifestations of kinesiophobia in multiple sclerosis may be primarily modulated by affective and behavioral mechanisms. These results underscore the importance of incorporating these mechanisms into comprehensive clinical assessment frameworks and into the development of individualized therapeutic strategies. The level of physical activity is a significant independent predictor of kinesiophobia in patients with multiple sclerosis, and a lower level of physical activity was associated with higher TSK scores. This result is in line with the findings of several studies showing that kinesiophobia is a limiting factor in the development of strategies aimed at promoting physical activity in inactive patients [27]. A similar study by Wasiuk-Zowada et al [28] indicated that the problem of kinesiophobia is significant in patients with MS and its predictor may be a low level of physical activity. The median score of the GLTEQ questionnaire in our group reached 17.0 points, which is comparable to the results of [20] both the Czech study and the American study [13], where the average value was 22.4 points. Most of our patients belonged to the category of insufficiently or only moderately active, which is a significant risk factor for an unfavorable prognosis of disease progression.

Physical activity is an integral part of the comprehensive treatment of patients with multiple sclerosis and can alleviate several symptoms of the disease, including gait disorders, depression, and fatigue. Experts in the field of neurology and neurorehabilitation emphasize that a healthy lifestyle based also on regular physical activity is a key factor in maintaining the functional capacity and quality of life of patients with multiple sclerosis [10,14,19,46]. However, despite clearly proven benefits, adherence to regular physical activity in this population remains low. As several studies show, patients with multiple sclerosis are less physically active than the healthy population; they engage in physical activity less often, for a shorter time, and with a lower intensity [10,20,47].

Our observations show that anxiety is an independent predictor of kinesiophobia in MS patients. This finding is particularly significant as anxiety symptoms and depression are among the most common psychiatric comorbidities in this population, and their prevalence is significantly higher than in the healthy population [48]. Although depression did not emerge as an independent predictor of kinesiophobia in our model, its high prevalence in people with MS underscores the need to consider psychological status when interpreting their attitudes toward physical activity.

Psychological factors such as low motivation, depressive symptoms, and worsening physical or cognitive fatigue play a fundamental role in forming a negative attitude towards physical activity [15,47]. The early stage of the disease has a fundamental effect on changes in the behavior of patients and in the field of engaging in physical activity. Frau et al [49] showed that up to 38% of patients stopped performing physical activity shortly after diagnosis. This decrease is conditioned by several factors; the most common are the lack of information about the benefits and appropriate forms of physical activity in MS, concerns about the worsening of symptoms, as well as observation of negative consequences of the disease in other patients who live with MS longer. These experiences often provoke stress, fear, and denial of diagnosis in the early stages of the disease. The prevalence of self-reported anxiety symptoms is estimated at 2.7% over the duration of the disease, reaching up to 6.2% at the time of diagnosis of MS [48].

The results of our study emphasize the key role of anxiety level and regular physical activity in the formation of kinesiophobic behavior. Patients with more pronounced anxiety symptoms tend to approach physical activity with greater caution, lower motivation, and heightened concerns, which can be reflected in higher TSK scores. Although depression did not emerge as an independent predictor in our model, its high prevalence in the MS population and its interaction with anxiety indicate that the overall psychological profile of the patient should be considered when interpreting kinesiophobic responses [25,30].

The importance of evaluation and targeted intervention of kinesiophobia lies in the ability to disrupt the pathological cycle of fear of movement, which leads to physical inactivity, accelerated progression of disease symptoms and, consequently, a further reduction in the level of physical activity [51]. The inclusion of systematic screening and assessment of fear of movement in routine clinical practice could enable the early identification of patients at higher risk and the setting of a targeted therapeutic intervention to reduce fears of physical activity. A qualitative study by Huynh et al [52] found the decision to engage in physical activity in patients newly diagnosed with multiple sclerosis (IND-MS) is influenced by factors at the level of skills, opportunities, and motivation (COM-B model). Lack of knowledge about appropriate recommendations and exercise procedures is a significant barrier that can lead to postponement or complete omission of physical activity. On the contrary, sufficient awareness of the potential benefits of exercise in the management of multiple sclerosis facilitates participation in physical activities and strengthens patients’ motivation. The conclusions of other international works emphasize the importance of education, accessible environment, and targeted motivation to support an active lifestyle among people with MS [10,20,47]. They point to the need for systematic education and counseling to helps overcome barriers and maintain regular physical activity. Physicians, physiotherapists, specialized nurses, and peer support play important roles in this process [52].

Therefore, within the biopsychosocial model, the application of an interdisciplinary therapeutic approach that integrates physiotherapy, psychological intervention, education, and adapted movement programs is recommended to reduce the fear of movement, support active participation in physical activities, improve mental well-being, and strengthen long-term adherence to treatment and rehabilitation. Ultimately, this approach contributes to the optimization of functional capacity, prevention of long-term consequences, and overall improvement in quality of life [29].

In our study, kinesiophobia was also associated with older age, which is an adverse finding, as aging is typically accompanied by a natural decline in mobility and physical activity in the general population. Similar observations were reported by Wasiuk-Zowada et al [45], who likewise noted higher kinesiophobia levels in older individuals with MS. The coexistence of age-related physiological changes and kinesiophobia may therefore further accelerate functional deterioration, intensify avoidance behaviors, and reduce long-term adherence to physical activity in people with MS. These findings underscore the need for targeted and intensified support for older individuals with MS.

Our analyses explicitly focused on the core research topic linked to the determinants of kinesiophobia in patients with multiple sclerosis, revealing fresh insights that could assist in establishing individualized intervention methods targeted to alleviate symptoms and promote quality of life. The considerable independent significance of anxiety highlights the importance of specialized psychological therapies such as cognitive-behavioral therapy, emotion regulation training, and strategies meant to change maladaptive ideas surrounding physical activity. The link to physical inactivity underlines a critical modifiable factor, indicating that planned, tailored exercise plans with progressive advancement, behavioral guidance, and continual feedback can reduce fear-avoidant behaviors and promote persistent commitment to physical activity.

In addition, comprehensive patient education appears to be crucial. Educational programs focusing on symptom management, realistic expectations of physical activity, the safety of exercise in MS, and the biopsychosocial understanding of kinesiophobia may help reduce misconceptions that contribute to exercise avoidance. Integrating physiotherapy with psychological support and evidence-based educational interventions may therefore be the most effective strategy.

Given the strong association between kinesiophobia and anxiety identified in this study, both constructs should be routinely screened in clinical practice, ideally using brief and validated tools such as the Tampa Scale of Kinesiophobia and the Beck Anxiety Inventory. Early identification of fear-related avoidance and anxiety symptoms may help clinicians detect individuals at higher risk of physical inactivity, functional decline, or reduced adherence to rehabilitation programs. Future research should evaluate targeted interventions combining psychological counseling and physical activity programs to reduce kinesiophobia and improve adherence to exercise regimens.

Conclusions

LIMITATIONS OF THE STUDY:

This study has several limitations. Its cross-sectional design does not allow causal interpretation. All outcomes were self-reported, which may have introduced recall or response bias. Although all questionnaires were available in Slovak language versions, most instruments have not been formally validated in the Slovak MS population, which may affect measurement precision. The Short Form-36 (SF-36) questionnaire is generally regarded as the gold standard for assessing overall health status [38]. Although other instruments have been specifically developed to measure quality of life in individuals with multiple sclerosis, such as the Multiple Sclerosis International Quality of Life questionnaire and the Multiple Sclerosis Quality of Life-54 (MSQOL-54) [53], none of these tools were available in a validated Slovak version at the time the research was conducted. In contrast, the SF-36 had already been translated into Slovak and was therefore selected as the most appropriate option. Nevertheless, previous studies have examined the applicability of this instrument in clinical research involving patients with multiple sclerosis [3,4]. Our sample was recruited from a single region, which may limit the generalizability of the findings. Although detailed clinical parameters such as MRI findings, initial presenting syndromes, or specific neurological signs were available at the center, they were not incorporated into the current analysis because they fell outside the predefined scope and objectives of the study, which focused primarily on behavioral, psychological, and functional correlates of kinesiophobia. Several potentially relevant factors, such as pain, spasticity, sleep quality, or self-efficacy, were not assessed. Physical activity was measured solely using the GLTEQ, which does not provide information on activity intensity or sedentary behavior. Future longitudinal studies with objective activity monitoring are needed to confirm and extend these results.