Pain intensity and quality of life in elderly women with osteoporosis: a cross-sectional study exploring the mediating role of kinesiophobia and the potential moderating role of fall-related fractures

To examine the associations between pain intensity, kinesiophobia, fall-related fracture history, and quality of life in older women with osteoporosis, and to test the potential mediating role of kinesiophobia and the potential moderating role of fall-related fracture history in this association, and to provide a scientific basis for pain management, psychological intervention, and stratified prevention and control of high-risk individuals in this population. We conducted a cross-sectional study of 258 elderly female patients with osteoporosis recruited from a tertiary orthopedic hospital in China between April and June 2026. We collected data using a demographic questionnaire, the Numerical Rating Scale (NRS), the 11-item Tampa Scale for Kinesiophobia (TSK-11), and the Osteoporosis Quality of Life Scale (ECOS-16). We tested the moderated mediation model using the PROCESS macro (Models 4, 7, and 14). Pain intensity among older women with osteoporosis was significantly positively correlated with kinesiophobia, history of fall-related fractures, and quality of life scores ( r = 0.426, 0.555, and 0.443, respectively; all P < 0.001). Higher pain intensity was positively associated with worse quality of life; kinesiophobia partially mediated the relationship between pain intensity and quality of life, accounting for 47.89% of the total effect. In the primary analysis, fall-related fracture history appeared to moderate the second stage of the indirect pathway from kinesiophobia to quality of life ( P < 0.05), with a more pronounced effect in the ≥ 2 fracture group. However, in the sensitivity analysis, this moderating effect was attenuated. The mediating effect appeared robust, whereas the moderation finding should be considered exploratory. In this cross-sectional study, greater pain intensity was associated with greater quality-of-life impairment. Exploratory analysis suggested that this association may be stronger in women with ≥ 2 fall-related fractures. These correlational findings may inform the development of individualized rehabilitation programs for patients with multiple fractures by combining pain management and kinesiophobia intervention.