Background: The relationship of low back pain, the world's top disabling condition, with functional disability is often explained by the mediation effect of fear, catastrophizing, and psychological distress. These relationships have not been explored within chronic back pain patients from a low socioeconomic , predominantly Muslim country. Thus, it was unclear whether previously established pathways would be consistent in Pakistani pain patients to help guide Pakistani clinicians caring for back pain patients. This cross-sectional study translated English versions of questionnaires within the fear-avoidance model into Urdu, tested the clinimetric properties of the Urdu versions for people with chronic low back pain (CLBP) in Pakistan, and performed mediation analysis to investigate pathways of the fear-avoidance model. Methods: Translation of questionnaires was completed in 4 steps using the forward-backward technique, with subsequent analyses for internal consistency (Cronbach's α), construct validity (Pearson's r-value), and test-retest reliability (ICC r-value). Multiple mediation analysis with bootstrapping was performed to analyze pathways within the fear-avoidance model from the Urdu translated questionnaires. Results: A total of 151 people from Pakistan with CLBP completed the questionnaires, with good results for internal consistency (r > 0.85), convergent validity (r > 0.59), and test-retest reliability (ICC r > 0.85). The association of pain with disability was significant (B=2.36, r 2 = 0.19, p<0.001), and the indirect effect of the mediators explained 81% of pain intensity's total effect on disability. All mediators, apart from physical activity-related fear-avoidance beliefs, were significant mediators of the effect of pain intensity on disability. Conclusion: The Urdu versions of the fear-avoidance questionnaires show good clinimetric properties for use in clinical settings and research in Pakistan. These analyses support existing data for the mediation effect of catastrophizing, psychological distress, and selfefficacy on pain-related disability, and extends these findings to suggest that fear about work may be more important in a relatively lower socioeconomic sample of pain patients.

Insufficient physical activity and Sedentary lifestyle is making youth susceptible to several chronic diseases globally and in Pakistan. This research assessed the association between levels of physical activity and health related fitness status of school and college students from different regions of Khyber Pakhtunkhwa.  Data was collected from 390 students at secondary schools and colleges. International Self-report measure was used to measure physical activity levels and health related fitness tests (BMI, Harvard step test, push up test and sit and reach test) were used for evaluation of body mass, cardiorespiratory endurance, muscular endurance, and flexibility. Descriptive statistics were used for demographic data. Group differences and associations were analysed using MANOVA, Kruskal-Wallis test, Pearson’s correlation coefficients and linear regression. Only 3.84% participants were engaging in vigorous intensity physical activity and all the participants had poor/ below average cardiorespiratory endurance (56.6 ± 4%). Moderate intensity activity was significantly correlated with cardiorespiratory endurance, whereas participation in different sports had significant association with flexibility. The adolescents of Khyber Pakhtunkhwa did not meet the minimum requirements for physical activity levels and had poor cardiorespiratory endurance. Thus, a minimum of 60 minutes of vigorous exercise/ structured physical activity every day should be emphasized in schools and colleges to reduce risk of chronic diseases.

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