This study included elderly patients with kinesiophobia following total hip arthroplasty (THA), who were admitted to the Department of Trauma Surgery and the Department of Joint Surgery at a tertiary general hospital in Chongqing, China, from December 2023 to December 2024. Patients who met the inclusion and exclusion criteria were enrolled consecutively: those admitted between December 2023 and June 2024 were allocated to the control group, and those admitted between July 2024 and December 2024 were allocated to the intervention group.

Inclusion criteria were: (1) elderly patients undergoing primary unilateral THA with stable postoperative vital signs; (2) a score > 37 on the Chinese version of the Tampa Scale for Kinesiophobia (TSK) within 24 h after surgery (24); (3) age ≥ 65 years; (4) conscious, able to communicate effectively, and free from mental illness; (5) voluntary participation with written informed consent. Exclusion criteria were: (1) cognitive impairment or consciousness disorders; (2) severe restriction of lower limb movement unrelated to THA; (3) inability to communicate normally; (4) withdrawal during the study period or non-cooperation. During the study period, 120 patients scheduled for primary THA were assessed. Of these, 56 were excluded (54 did not meet the inclusion criteria; 2 declined to participate). Consequently, 64 eligible patients were enrolled and allocated sequentially to the control group (n = 31) and intervention group (n = 33).

During follow-up, 3 patients were lost (control group: n = 1 due to incorrect contact information; intervention group: n = 2, including one with incorrect contact information and one transferred to a rehabilitation hospital). The final analysis included 61 patients who completed the study (Figure 1).

The study protocol was reviewed and approved by the Ethics Committee of the Army Medical Center of the Chinese People’s Liberation Army (Approval No. [2020] 194–01) and was prospectively registered with the Chinese Clinical Trial Registry (Identifier: ChiCTR2400094636). All participants provided written informed consent prior to enrollment. Baseline characteristics of the participants are presented in Table 1.

Data were collected at four time points: admission, discharge, one month post-surgery, and 3 months post-surgery. The following outcomes were assessed: (1) time to first ambulation (days); (2) kinesiophobia, assessed using the TSK score (24) (the TSK is a 17-item scale with total scores ranging from 17 to 68, with a score >37 indicating the presence of kinesiophobia and higher scores reflecting more severe fear of movement); (3) hip joint function, assessed using the Harris Hip Score (25); (4) pain intensity, measured using the Numeric Rating Scale (NRS) (26) (ranging from 0 for no pain to 10 for worst possible pain); (5) activities of daily living, assessed using the Barthel Index (27) (which evaluates independence in 10 ADLs with total scores ranging from 0 to 100, where scores ≤20 indicate complete dependence); and (6) length of hospital stay (days) and hospitalization expenses (CNY).

No statistically significant differences were observed between the two groups in baseline characteristics, including age, gender, body mass index (BMI), admission NRS score, education level, marital status, comorbidities, smoking status, and alcohol consumption (all p > 0.05) (Table 1).

As shown in Table 4, the time to first ambulation was significantly shorter in the intervention group (1.23 ± 0.72 days) compared to the control group (3.30 ± 2.15 days, p < 0.001). The intervention group also had significantly shorter hospital stays (7.35 ± 1.78 days vs. 9.83 ± 3.36 days, p < 0.001) and lower hospitalization expenses (3704.91 ± 605.24 CNY vs. 4761.83 ± 1201.51 CNY, p < 0.001).

At baseline, no statistically significant differences were observed between the two groups for any of the outcome measures (p > 0.05) (Table 3). Repeated measures ANOVA revealed significant main effects of time for all outcome measures (p < 0.05) (Table 5). Significant time × group interaction effects were observed, indicating that the intervention group showed greater improvements over time compared to the control group. Specifically, at discharge, 1 month post-surgery, and 3 months post-surgery, the intervention group demonstrated more pronounced reductions in kinesiophobia and pain scores, as well as greater improvements in hip function and activities of daily living (all p < 0.05) (Figure 2). These preliminary findings provide initial evidence that the CBT-based early ambulation program may be associated with reduced kinesiophobia and improved functional recovery in elderly THA patients, although these results require confirmation in larger studies.

In this study, the intervention group demonstrated more favorable trends than the control group in time to first ambulation, length of hospital stay, and pain and kinesiophobia scores at discharge. These observations suggest that integrating CBT components into postoperative rehabilitation may help influence the fear-avoidance psychological cycle. Through health education, cognitive restructuring, and progressive activity scheduling, the program was associated with a trend toward reduced patient concerns regarding the perceived severity and susceptibility of adverse events related to early ambulation. As fear levels decreased, patients’ willingness to mobilize showed an improving trend. Enhanced feelings of being cared for, as reported by patients and their families, may be associated with earlier initiation of functional exercise. This interpretation is consistent with findings from Kamp et al. (33), who reported that increased external support benefits hip and knee functional recovery. However, it is important to clarify that this study is a pragmatic preliminary effectiveness trial, not a mechanistic study. Therefore, any interpretations related to theoretical mechanisms remain hypothetical, as no mediating variables were measured.

Notably, nutritional support was a standard baseline measure common to both groups. The advantage of the intervention group lay in the integration of nutritional support with rehabilitation goals at both cognitive and behavioral levels through the CBT framework, thereby enhancing implementation systematization and adherence. The nutritional support provided post-admission contributed to strengthening patients’ lower limb muscle strength, laying the foundation for early ambulation. This study provides preliminary empirical support for the positive effects of a CBT-based early ambulation program on patient health outcomes.

Previous studies have established that kinesiophobia is a significant barrier to long-term recovery in patients following total hip arthroplasty. The retrospective study by Al-Amiry et al. (34) confirmed that 6–8 years post-THA, patients with kinesiophobia exhibited lower hip function scores and higher rates of walking aid dependence compared to those without kinesiophobia. However, that study did not explore intervention strategies targeting kinesiophobia itself. Subsequent research has provided directions for intervention. A systematic review by Rhamelani et al. (35) indicated that early ambulation after orthopedic surgery constitutes a comprehensive intervention; the five categories of interventions identified (range of motion interventions, progressive muscle relaxation, weight-bearing interventions, positioning interventions, and neuromuscular electrical stimulation) all contributed to shortened hospital length of stay. Among these, interventions based on progressive muscle relaxation demonstrated potential for alleviating short-term kinesiophobia, suggesting that integrating psychological components into traditional rehabilitation may enhance therapeutic effects.

Regarding active interventions for kinesiophobia, relatively mature CBT frameworks have been established in other orthopedic surgical populations. For instance, Scarone et al. (36) randomized 150 patients following lumbar fusion surgery and found that those receiving CBT (including pain education, cognitive restructuring, etc.) combined with exercise showed significantly greater improvements in disability reduction, pain relief, and quality of life compared to the control group receiving only traditional health education and exercise, with effects sustained for at least 12 months. Studies by Abbott et al. (37) (n = 107) and Cai et al. (28) (n = 108) further confirmed the effectiveness of psychomotor therapy and cognitive-behavioral interventions in improving function, pain, and kinesiophobia levels in patients following lumbar fusion surgery and total knee arthroplasty, respectively.

It should be noted that the above evidence originates from other orthopedic surgical populations and does not constitute direct evidence for THA patients. This validated CBT intervention model has not yet been systematically applied to elderly THA patients with kinesiophobia. Several studies provide indirect support for this approach: Emporiti et al. (38) implemented preoperative action observation and motor imagery training in 80 THA patients and demonstrated that preoperative psychological preparation benefits postoperative activity, which aligns with the preoperative cognitive education concept of the present study. Research by Vasconcelos et al. (39, 40) and Smith et al. (41) supports the positive role of psychological interventions in hip functional recovery from the perspectives of physiological mechanisms (the association between muscle strength and kinesiophobia) and clinical efficacy, respectively. Accordingly, the present study provides a foundational reference for future research in this field.

This study has several limitations. First, the quasi-experimental design with sequential group allocation is susceptible to temporal bias and precludes assessor blinding. Although we controlled for key covariates and used independent assessors for outcome measurement, unmeasured systematic changes during the intervention period may have confounded effect estimates. Second, the single-center design within a specific cultural context limits the generalizability of our findings, as local factors such as family caregiving patterns and healthcare delivery models may have influenced outcomes. Third, the relatively short follow-up period of 3 months precludes assessment of longer-term effect sustainability. Fourth, selection bias may be present, with a 46.7% exclusion rate potentially limiting generalizability. Fifth, surgical complexity metrics such as operative time, blood loss, and surgical approach were not recorded or adjusted for, representing a potential source of unmeasured confounding. Additionally, the modest sample size, reliance on self-report measures, and elevated risk of Type I error due to multiple comparisons mean that positive findings should be viewed as exploratory.

To address the limitations outlined above, future research should employ factorial or component-dismantling designs to isolate the effects of specific intervention elements, routinely collect and adjust for potential confounders including surgical complexity, conduct multi-center randomized controlled trials with objective measures such as activity trackers and functional performance tests, plan formal mediation analyses to explore mechanisms of action, and perform a priori sample size calculations based on the effect sizes observed in the present study. The present study provides preliminary groundwork and methodological reference to inform such future research.