Primary osteoporosis is a systemic bone disease associated with age, characterized by bone loss, degradation of bone microstructure, increased bone fragility and susceptibility to fracture.1,2 Globally, the prevalence of osteoporosis stands at 19.7 %,3 with a higher prevalence observed in the older population (21.7 %).4 In China, the age-standardized prevalence of osteoporosis is estimated at 33.5 % among the middle-aged and older demographic.5 Alongside the decline in bone density, age-related muscular changes contribute to skeletal deformities, joint imbalances, and structural strains, often culminating in chronic back pain and kyphotic postures.6, 7, 8 Population-based studies consistently link osteoporosis to back pain, emphasizing that deformities in axial posture heighten the risks of balance disorders, falls, and subsequent fractures.9,10 Moreover, chronic back pain, history of falls and fractures can lead to an increase in the fear of movements, resulting in a reduction in daily activities,11,12 commonly referred to as kinesiophobia in the context of psychology.13

Kinesiophobia, a broader concept than fear of falling, encompassing excessive and irrational fear of physical activity or movement, often driven by heightened sensitivity to pain.14,15 Kinesiophobia serves as a significant barrier to patients with osteoporosis participating in exercise.16 This fear may impede daily activities,17,18 and negatively impact the quality of life.19 Physical activity is crucial for bone and overall health; however, avoiding necessary exercise or activities could exacerbate osteoporosis.20 In addition, a significant correlation exists between kinesiophobia, anxiety, and depression,12 where these negative emotions may stimulate the sympathetic nervous system, leading to decreased bone density, increased pain, and further worsening of osteoporosis.21,22

Mindfulness, defined as "paying attention, on purpose, in the present moment, and as nonjudgmentally as possible",23 has demonstrated effectiveness in alleviating pain, pain-related fear of movement, anxiety, and depression.24,25 However, there is currently a gap in research exploring the relationship between mindfulness and kinesiophobia in depth.

Overcoming the challenge of maintaining a physically active lifestyle and fostering exercise adherence in older patients with osteoporosis remains a formidable task, with kinesiophobia emerging as a prominent barrier. While existing studies have examined the prevalence and influencing factors of kinesiophobia in patients with osteoarthritis and those who have undergone total knee arthroplasty,26,27 our understanding of this phenomenon in the context of primary osteoporosis is limited. Previous studies have explored factors such as pain, social support, self-perceived burden, and self-efficacy that are associated with kinesiophobia.26,27 However, the reliance on the numerical rating scale (NRS) for pain assessment may present limitations, as it primarily gauges pain intensity without capturing its broader impact on emotions and daily activities. In contrast, the global pain scale (GPS) could offer a more comprehensive evaluation. Moreover, despite the potential of mindfulness-based interventions to mitigate kinesiophobia,28 there is a scarcity of studies investigating the relationship between mindfulness and kinesiophobia. Furthermore, the influence of anxiety and depression on kinesiophobia in older patients with primary osteoporosis remains unknown.

Therefore, this study aims to explore the prevalence of kinesiophobia in older patients with primary osteoporosis, and to analyze the factors influencing its occurrence, including background information, chronic back pain, mindfulness, anxiety, and depression. The results of the study are envisioned to serve as a foundational step in developing a clinical prediction model for kinesiophobia in older patients with primary osteoporosis. The data obtained will be instrumental in shaping future intervention programs designed to modify physical activity behaviour and enhance adherence to exercise participation, ultimately contributing to improved overall well-being in this population.