Effects of Therapeutic Aquatic Exercise Versus Physical Therapy Modalities on Pain and Disability in People With Chronic Low Back Pain: Potential Mediating Roles of Kinesiophobia, Anxiety, and Depression

Pain Res Manag. 2026;2026(1):e5537314. doi: 10.1155/prm/5537314.

ABSTRACT

OBJECTIVE: To examine whether kinesiophobia, anxiety, and depression mediate the effects of therapeutic aquatic exercise (TAE) versus physical therapy modalities (PTMs) on pain and disability in patients with chronic low back pain (CLBP).

METHODS: This study was a secondary analysis of data derived from a previously conducted randomized controlled trial, applying mediation analysis to explore potential psychological mediators. A total of 113 participants received 60-min sessions of TAE or PTMs twice weekly for 3 months. The Roland-Morris Disability Questionnaire (RMDQ) and the numeric rating scale (NRS) were employed to measure the main outcome; the mediators included the Tampa Scale for Kinesiophobia (TSK), the Self-Rating Anxiety Scale (SAS), and the Zung Self-Rating Depression Scale (SDS). All mediation models reported causal pathway parameters, including intervention-mediator and mediator-outcome coefficients, with decomposition of total effect into direct and indirect effect (IE).

RESULTS: The mediation analysis found that kinesiophobia and depression mediated the effects of TAE compared with PTMs on the average pain (TSK [IE -0.203, 95% confidence interval, CI, -0.467 to -0.025]; SDS [IE -0.173, 95% CI -0.426 to -0.010]), the current pain (TSK [IE -0.151, 95% CI -0.371 to -0.013]; SDS [IE -0.220, 95% CI -0.495 to -0.030]), and the most severe pain (SDS [IE -0.186, 95% CI -0.476 to 0.004]) at 12 months. Meanwhile, kinesiophobia and depression mediated the TAE intervention effects on disability at 12 months (TSK [IE -0.174, 95% CI -2.176 to -0.270]; SDS [IE -0.555, 95% CI -1.470 to -0.014]). Anxiety mediated the effect of TAE on disability at 3 months (IE -0.365, 95% CI -0.832 to -0.065).

CONCLUSION: Kinesiophobia, anxiety, and depression mediated noticeable improvements in pain and disability for patients with CLBP when conducting TAE intervention.

TRIAL REGISTRATION: Chinese Registry of Clinical Trial: ChiCTR1800016396.

PMID:41968847 | DOI:10.1155/prm/5537314