Kinesiophobia, Postoperative Pain, and Early Mobilization After Elective Abdominal Surgery

Postoperative early mobilization is one of the most important components of the post-surgical recovery process, playing a critical role in preventing complications such as deep vein thrombosis, pulmonary complications, and bowel dysfunction, and in shortening hospital stay and accelerating functional recovery. However, a substantial proportion of patients undergoing elective abdominal surgery avoid movement due to concerns about postoperative pain, the surgical incision, drains, and possible complications; this phenomenon is described in the literature as 'kinesiophobia' (fear of movement). Kinesiophobia is defined as an excessive, irrational fear of movement resulting from a feeling of vulnerability to painful injury or re-injury. In recent years, kinesiophobia has increasingly been studied in cardiac surgery and various other surgical patient groups, but studies examining the relationship between kinesiophobia and postoperative pain and early mobilization in elective abdominal surgery patients are limited.

This descriptive and cross-sectional study aims to determine the level of kinesiophobia in patients undergoing elective abdominal surgery and to examine its relationship with postoperative pain severity and early mobilization (time to first standing and first walking duration).

Research Questions:

1. What are the kinesiophobia levels of patients undergoing elective abdominal surgery?
2. What are the patients' postoperative pain severity and early mobilization (time to first standing, first walking duration) levels?
3. Is there a relationship between patients' kinesiophobia levels and postoperative pain severity?
4. Is there a relationship between patients' kinesiophobia levels and early mobilization levels?
5. Do patients' sociodemographic and clinical characteristics (age, sex, body mass index, type of surgery, prior surgical experience) affect their kinesiophobia levels?

Hypotheses:

H1: There is a significant positive relationship between patients' kinesiophobia levels and postoperative pain severity.

H2: There is a significant positive relationship between patients' kinesiophobia levels and time to first standing (kinesiophobia level increases as mobilization is delayed).

H3: There is a significant relationship between patients' kinesiophobia levels and first walking duration/distance.

H4: Patients without prior surgical experience have significantly higher kinesiophobia levels than patients with prior surgical experience.

The study will be conducted at the General Surgery clinics of two centers, Agri Training and Research Hospital and Taksim Training and Research Hospital (multicenter). Data will be collected in a single cross-section, during the period when patients complete their first postoperative mobilization (typically postoperative day 1); no experimental intervention will be applied within the scope of the study.

The study population will consist of adult patients who undergo elective abdominal surgery in the General Surgery clinics of the two participating hospitals and complete their first postoperative mobilization on postoperative day 1. Inclusion criteria: age 18 years or older; having undergone elective (planned) abdominal surgery; having had surgery under general anesthesia; ASA (American Society of Anesthesiologists) physical status class I-II; having completed first mobilization on postoperative day 1; able to communicate in Turkish and understand written/verbal directions; conscious and oriented; willing to voluntarily participate and provide informed consent. Exclusion criteria: a known pre-existing walking/movement disorder, balance problem, or orthopedic-neurological disease history; having undergone emergency surgery; being followed in an intensive care unit; having a significant cognitive impairment or communication difficulty that prevents responding to data collection tools; having a visual or hearing impairment that prevents completing the forms/scales; being in a state of heavy postoperative sedation or delirium; having previously been enrolled in the same study; refusing to participate.

Sample size was calculated using G*Power 3.1 based on the bivariate correlation between two variables. Using a medium effect size (r=0.30) reported in similar studies examining the kinesiophobia-pain relationship, with alpha=0.05 and power (1-beta)=0.80, a minimum of 85 patients was calculated as necessary. Accounting for possible data loss, a total sample size of 120 patients (60 per center) is targeted.

Data will be collected using a data collection form and clinical observation record consisting of three sections: (1) a Patient Identification and Clinical Characteristics Form developed by the researchers based on the literature, recording age, sex, body mass index, education level, ASA physical status class, chronic disease history, prior surgical experience, type and duration of the surgical procedure, type of anesthesia, and time elapsed after surgery; (2) the Tampa Scale for Kinesiophobia (TSK), developed by Kori et al. and adapted into Turkish with validity and reliability testing by Tunca Yilmaz et al., a 17-item, 4-point Likert-type scale (1=strongly disagree to 4=strongly agree) with total scores ranging from 17-68, with higher scores indicating greater kinesiophobia (written permission for use of the scale items will be obtained from the Turkish adaptation authors prior to use); (3) the Numeric Rating Scale (NRS), scored from 0 (no pain) to 10 (worst imaginable pain), used to assess postoperative pain severity both at rest and during movement; and (4) an Early Mobilization Record Form developed by the researchers, recording the time of first standing after surgery, the duration the patient was able to remain standing at first mobilization, and the distance/duration of the first walk, based on nursing observation records and patient self-report. Completion of the data collection form and scale is expected to take approximately 10-15 minutes.

Study data will be collected by the researchers after obtaining ethics committee and institutional approvals. After patients meeting the inclusion criteria complete their first postoperative mobilization, the purpose of the study will be explained and written informed consent obtained. In a face-to-face interview with consenting patients, the Patient Identification and Clinical Characteristics Form and the Tampa Scale for Kinesiophobia will be completed, and postoperative pain severity will be queried with the NRS during the same interview. The time and duration of first mobilization will be recorded on the Early Mobilization Record Form based on nursing observation records together with patient self-report. Data collection will be carried out in an environment appropriate to each patient's clinical condition and ensuring privacy.

Data obtained from the study will be analyzed using IBM SPSS Statistics (Statistical Package for the Social Sciences). The distributional characteristics of the data will first be evaluated with the Shapiro-Wilk test. Descriptive statistics will use counts and percentages for categorical variables, and means, standard deviations, medians, and minimum-maximum values for continuous variables. The relationship between TSK total score and NRS pain score and mobilization durations will be evaluated with Pearson or Spearman correlation analysis depending on the distributional characteristics of the data. Two-group comparisons (e.g., patients with/without prior surgical experience) will use the independent samples t-test or Mann-Whitney U test depending on distribution; comparisons among more than two groups will use one-way ANOVA or the Kruskal-Wallis test. Multiple linear regression analysis will be applied to identify variables predicting kinesiophobia level. Statistical significance will be accepted at p<0.05; relationship magnitudes and 95% confidence intervals will be reported.

Anticipated difficulties include: patients' participation in data collection may be limited by postoperative pain, fatigue, or sedation; the timing of first mobilization may vary from patient to patient and according to clinical workload; mobilization information in nursing observation records may be incomplete or non-standardized; conducting the study at two different hospitals may make it difficult to standardize clinical practice for data collection; there is a possibility of social desirability bias given that kinesiophobia is assessed with a self-report scale; and if the planned sample size cannot be reached within the planned timeframe, the data collection period may need to be extended.

Limitations: due to the cross-sectional design of the study, the relationships among kinesiophobia, pain, and mobilization cannot be interpreted as cause-and-effect, but only at the level of association. Additionally, since the study will be conducted at only two hospitals and with patients who agree to participate, the generalizability of the findings to the broader elective abdominal surgery patient population is limited.