Pain mediates the association between fear-avoidance beliefs and disease activity in ankylosing spondylitis, a pathway that appears to be attenuated by regular exercise, supporting a biopsychosocial approach in AS management.
Abnormal anxiety and depression were prevalent in the ankylosing spondylitis patient sample.
Pain significantly mediated the pathway between fear-avoidance beliefs and disease activity (BASDAI).
Exercise significantly moderated the mediated pathway from fear-avoidance beliefs through pain to disease activity.
A prediction model for high disease activity demonstrated strong discriminative ability with minimal overfitting.
Psychosocial factors, including fear-avoidance beliefs, anxiety, and depression, were significant predictors of disease activity in AS.
This research suggests that psychological factors — specifically fear of movement and avoidance behaviors (called 'fear-avoidance beliefs'), anxiety, and depression — play a meaningful role in how active ankylosing spondylitis (AS), a chronic inflammatory spinal disease, appears to be in patients. In a study of 77 AS patients, roughly one in four had clinically significant anxiety and about one in eight had clinically significant depression. The study found that fear-avoidance beliefs do not directly worsen disease activity on their own; instead, pain acts as the 'bridge' — fear of movement leads to greater pain experience, which in turn drives higher disease activity scores. This pain-mediated pathway explained about half of the total relationship between fear-avoidance and disease activity. Importantly, regular exercise appeared to weaken this harmful chain of events. Among patients who exercised more, the link between fear-avoidance beliefs, pain, and disease activity was notably reduced compared to those who exercised less. A statistical model built from these psychological and physical factors was able to distinguish between patients with high and low disease activity with good accuracy (AUC = 0.863), and this held up well when tested for reliability. This research suggests that treating AS solely as a physical or inflammatory condition may miss important contributors to how patients feel and function. Addressing psychological factors like fear of movement and mood disturbances, alongside encouraging regular physical activity, could be an important part of comprehensive AS care. The authors call for routine psychosocial screening in AS management and note that future studies following patients over time are needed to confirm whether these relationships are truly cause-and-effect.
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Upload Your LabsKoç E, Badak S, Erdoğan E, Gökçen N, Arslan D. (2026). Fear-avoidance beliefs, anxiety, and depression in ankylosing spondylitis: the mediating role of pain and moderating role of exercise.. Clinical rheumatology. https://doi.org/10.1007/s10067-026-08098-8