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Kinesiophobia in patients after cardiac surgery: a scoping review

BMC Cardiovascular Disorders volume 24, Article number: 469 (2024) Cite this article

Abstract

Background

This paper reviews the scope of research on kinesiophobia in patients after cardiac surgery. Further, it reviews the current situation, evaluation tools, risk factors, adverse effects, and intervention methods of kinesiophobia to provide a reference for promoting early rehabilitation of patients after cardiac surgery.

Methods

Guided by the scoping methodology, the Web of Science, PubMed, CINAHL, Cochrane Library, China Biomedical Literature Database, VIP Database, Wanfang Database, CNKI, and other databases were searched from database inception until July 31, 2024. The studies obtained were screened, summarised and systematically analysed by two researchers.

Results

Eighteen studies (16 cross-sectional studies, one qualitative study, and one randomised controlled trial) were included. The incidence of kinesiophobia in patients after cardiac surgery was 39.20–82.57%, and the Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) was used to evaluate this incidence. The influencing factors of kinesiophobia in patients after cardiac surgery included demographic characteristics, pain severity, frailty, exercise self-efficacy, disease-related factors, and psychosocial factors. Kinesiophobia led to adverse health outcomes such as reduced recovery, prolonged hospital stays, and decreased quality of life in patients after cardiac surgery, and there were few studies on intervention methods for postoperative kinesiophobia.

Conclusion

The kinesiophobia assessment tools suitable for patients after cardiac surgery should be improved, and intervention methods to promote the early recovery of patients after major clinical surgery and those with difficult and critical diseases should be actively researched.

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Introduction

According to the World Health Organization, cardiovascular diseases account for 32% of all deaths worldwide [1]. Cardiac surgery is the ultimate treatment for most cardiovascular diseases; according to the American Heart Association [2], the total number of cardiac surgeries has been increasing yearly. Studies have shown that exercise-centred cardiac rehabilitation is safe and effective for patients after cardiac surgery [3], but Bäck et al. [4] showed that 50–87% of patients who were able to exercise did not participate regularly, and that more than 70% of patients had some degree of kinesiophobia.

Kinesiophobia is defined as “an irrational and excessive fear of physical activity due to increased sensitivity to pain and fear that secondary injury from activity will be detrimental to recovery” [5]. The concept was originally studied in patients with chronic pain [6] and then gradually extended to orthopaedic postoperative patients [7]. Universal tools are frequently used for evaluation, and the interventions are few and mostly focused on hospitalised patients. Thus, the long-term effects need to be verified; more importantly, existing studies have paid less attention to patients after cardiac surgery. Kinesiophobia can directly affect patient adherence with exercise rehabilitation, promote muscle atrophy, reduce cardiovascular health, and increase the economic burden on families and society [8, 9].

Although mini-thoracotomy and endoscopic minimally invasive cardiac surgery have been widely used in clinical practice, median sternotomy remains a common surgical modality in cardiac surgery [10]. Severe surgical trauma is more likely to trigger negative emotions such as anxiety and depression, as well as more worries about sudden physical accidents during exercise. This may aggravate patients’ fear of exercise, thereby reducing physical activity, exercise tolerance, and early exercise participation [11]. Therefore, this article summarises the research on kinesiophobia in patients after cardiac surgery under the guidance of scoping methodology [12]. We aimed to clarify the research status of kinesiophobia, promote the development of measurement tools, and guide intervention methods to provide a reference for promoting early rehabilitation of patients after cardiac surgery.

Information and methodology

This research review protocol has been registered in the Open Science Framework (DOI:https://doi.org/10.17605/OSF.IO/TMB89).Ethical approval was not required for a review of the existing literature.

Research questions

  1. (a)

    What is the incidence of kinesiophobia in patients after cardiac surgery? (b) What are the assessment tools for kinesiophobia in patients after cardiac surgery? (c) What are the influencing factors and adverse effects of kinesiophobia in patients after cardiac surgery? (d) At present, what are the intervention methods for kinesiophobia in patients after cardiac surgery?

Inclusion and exclusion criteria

Inclusion criteria: (a) The subjects of the study were patients aged ≥ 18 years after cardiac surgery, and the surgical methods were coronary artery bypass grafting, valve replacement, heart transplantation, and cardiac macrovascular surgery in the anterior thoracic position under general anaesthesia; (b) the report focused on the study of kinesiophobia in patients after cardiac surgery; (c) the study scenario involved the postoperative rehabilitation stage of cardiac surgery; and (d) the report was original, regardless of the type of research design.

Exclusion criteria: (a) reports with incomplete information or data; (b) conference abstracts, reviews, experimental protocols, and news reports; (c) duplicate publications; and (d) publications in languages other than Chinese and English.

Search strategy

The databases that were searched included PubMed, Web of Science, Cochrane Library, Embase, Scopus, CINAHL, CNKI, Wanfang, VIP, and CBM. The search used a combination of subject headings, free words, and Boolean logic operators, and the search time limit was set from database establishment until July 31, 2024. The search keywords were: “Cardiac Surgical Procedures”, “heart Surgical Procedure”, “cardiac surgery”, “cardiac operation”, “heart surgery”, “cardiovascular surgery”, “coronary artery bypass”, “valve surgery”、“valve replacement”, “Kinesiophobia”, “fear of movement”, “pain-related activity avoidance”, “movement fear”, and “movement phobia”. The search strategy is shown in Fig. 1 using PubMed as an example of the English databases.

Fig. 1
figure 1

PubMed search strategy

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Literature screening and data extraction

The retrieved documents were imported into NoteExpress V4.0. After duplicates were removed, primary screening of the literature was carried out by two evidence-based trained investigators who independently read all the literature titles and abstracts. After the initial screening, the full text of the remaining articles was read. The investigators extracted data according to the content of the literature, including the name of the first author, date of publication, country, study design, sample size, incidence, evaluation tools, and study results. If there was a disagreement at the literature selection and data extraction stage, a decision was made after discussion with a third investigator.

Outcome

Literature search results

A total of 720 articles were retrieved, and 265 articles remained after removing duplicates. The title and abstract of each publication were read, and 222 articles were excluded. The remaining 43 articles were re-screened. Twenty-five studies were further excluded based on the following incompatibility criteria: (a) study subject, (b) study context, (c) study participants, and (4) literature type. Thus, 18 articles were included. The literature screening process is shown in Fig. 2.

Fig. 2
figure 2

PRISMA flowchart

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Basic characteristics of the literature

The 18 articles included [13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30] were from five countries: China, Spain, Switzerland, India, and Pakistan. Seven publications were in English and 11 were in Chinese. There were 16 cross-sectional studies, one qualitative study, and one interventional study. Regarding surgical methods, there were six reports of coronary artery bypass grafting, three reports of heart valve replacement, two reports of heart transplantation, one report of aortic dissection surgery, and six publications that did not report the surgical methods in detail. A brief overview of the included literature is shown in Table 1.

Table 1 Basic information of the included literature
Full size table

Incidence of kinesiophobia in patients after cardiac surgery

A total of 3396 patients after cardiac surgery were included. Ten studies [14, 16, 19,20,21,22,23,24,25, 27] indicated that kinesiophobia was common in patients after cardiac surgery, with an incidence of 39.20–82.57%. The incidences of kinesiophobia in patients after coronary artery bypass grafting, heart valve replacement, and aortic dissection surgery were 65.69–77.91%, 44.3–82.57%, and 46.20%, respectively.

An assessment tool for kinesiophobia in patients after cardiac surgery

In the 18 included studies, except for one qualitative study, the following seven assessment tools were used: the Chinese Tampa Kinesiophobia Heart Scale (TSK-Heart-C) [21], Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) [14, 16, 17, 20, 23, 24, 27, 30], Chinese version of TSK-SV Heart [21, 26], Tampa Scale of Kinesiophobia (TSK) [25], Chinese Simplified TSK-17 [19, 22, 29], Chinese Simplified TSK-11 [18, 28], and Kinesiophobia Causes Scale (KCS) [15]. The TSK-SV Heart [28], adapted from the TSK, is the most widely used assessment tool. The scale was sinicised by Lei et al. [31] in 2019, including four dimensions of danger perception, motor fear, motor avoidance, and dysfunction, with a total of 17 items. Each item uses the Likert 4 score, with a total score of 17–68 points. The higher the score, the more severe the degree of kinesiophobia, with > 37 points indicating a high level of kinesiophobia. The total Cronbach’s α coefficient of the scale was 0.859, and the test-retest reliability was 0.792. However, this scale is mainly used for the evaluation of kinesiophobia in patients with coronary heart disease and heart failure.

Influencing factors of kinesiophobia in patients after cardiac surgery

A total of 15 articles [14,15,16,17,18,19,20,21, 23,24,25,26,27,28,29] reported the influencing factors of kinesiophobia in patients after cardiac surgery. (1) Demographic factors: age [14, 20, 21, 25], sex [20, 24, 27], education level [14, 19], and economic level [19, 23, 29]. Advanced age is a risk factor for kinesiophobia in patients after cardiac surgery, and the degree of kinesiophobia increases with age as patients have more comorbidities and decreased physical activity [32]. Two studies [20, 24] concluded that the degree of kinesiophobia was higher in women than in men. However, Segura et al. [28] concluded that there was no statistical difference between sexes, and more research is needed to clarify the relationship between sex and the degree of kinesiophobia. Lin et al. [14] found that patients with low education levels were more likely to develop kinesiophobia due to their lack of understanding of the disease and coping strategies. Luo et al. [19] believed that patients with high education levels had a wider range of access to disease- and surgery-related knowledge than patients with low education levels, but could not correctly identify the information obtained, leading them to repeatedly magnify the risks of surgery and then develop a strong fear of exercise. In addition, patients with low economic levels, as well as their families are anxious and worried about high medical costs, leading to reduced time for cognitive illness and rehabilitation exercises; along with impairing the prognosis of patients, this aggravates their fear of exercise [19, 23, 29]. (2) Pain level: Kinesiophobia is closely related to the pain level patients experience after cardiac surgery. The surgical incision is located in the anterior chest, which is traumatic, and the patient has a high degree of pain. The misperception of pain (pain catastrophising) increases the fear of exercise [19, 23, 25, 29]. (3) Degree of debilitation: The patient’s increase in frailty after surgery, exercise tolerance reduces, difficulty in completing the exercise increases, and the patient becomes more likely to fear exercise [15, 24, 27]. (4) Disease-related factors: A long postoperative stay in the intensive care unit [16], slowness to get out of bed after surgery [23], high body mass index [18, 24], low cardiac function [20, 25], and high-risk pipelines [20] are risk factors for kinesiophobia in patients after cardiac surgery. (5) Psychosocial factors: Patients with greater fear of falling [23]; more anxiety, depression, and negative emotions [16, 19,20,21, 29]; and lower exercise self-efficacy [17] have less confidence in disease recovery and are more likely to exhibit kinesiophobia. A lower level of social support [19, 21], leads to an increased lack of family care [23], a lower family care index [14], and a more negative medical coping style [14], which also corresponds with a higher degree of kinesiophobia in patients after cardiac surgery.

Adverse effects of kinesiophobia in patients after cardiac surgery

Three [17, 22, 26] studies analysed the effect of postoperative kinesiophobia on health outcomes in patients who had cardiac surgery. (1) Reducing the postoperative rehabilitation effect: Patients after cardiac surgery tend to worry that exercise will increase the risk of postoperative pain and increase the burden of cardiac disease. Even if exercise occurs under the guidance of exercise prescription, the patient’s rehabilitation adherence may remain unsatisfactory, hindering postoperative cardiac rehabilitation and reducing its effectiveness [17]. (2) Prolonged hospital stay: Kinesiophobia is the main factor prolonging the hospital stay of patients after cardiac surgery; patients with kinesiophobia have a lower sense of self-identity and cannot complete early exercise routines, resulting in prolonged postoperative bed confinement and longer hospital stays [22]. (3) Reducing patient quality of life: The degree of kinesiophobia correlated negatively with quality of life after surgery. Patients with low levels of kinesiophobia can adapt more quickly to changes in their status, actively participate in rehabilitation exercises, and achieve a higher quality of life [26].

Measures of kinaesthesia in patients undergoing cardiac surgery

Kiran et al. [30] reported that three sessions of inspiratory muscle training combined with breathing exercises and chest clearing techniques for 30–40 min per session significantly reduced kinesiophobia and intensive care unit stay time after cardiac surgery. In addition, Wang et al. [13] interviewed 21 patients with kinesiophobia after cardiac surgery and proposed a strategy for the prevention and control of kinesiophobia. This involved taking the beginning of cardiac rehabilitation as the key node, strengthening the professional help and supervision of medical staff, correcting the erroneous summary of patient disease experience, strengthening support of the patient’s family and peers, and constructing an overall care plan for the improvement of physical and psychosomatic symptoms.

Discussion

This scoping review examines the current status, assessment tools, risk factors, adverse effects, and intervention methods of kinesiophobia in patients after cardiac surgery; highlights the shortcomings of previous studies; and clarifies future research directions.

Patients after cardiac surgery are at high risk of kinesiophobia, necessitating early identification and intervention

This scoping review found that the incidence of kinesiophobia in patients after cardiac surgery was as high as 82.57%, which was much higher than that of patients who underwent other types of surgery [33, 34]. This prolonged the discharge time of patients, reduced their quality of life, and seriously affected recovery outcomes. However, this phenomenon has not attracted the attention of relevant medical personnel, and we only observed studies of relevant patient-related factors and not those related to medical staff. Most of the studies were cross-sectional; only one intervention study and one qualitative study were included. Therefore, medical staff should improve the early identification and prevention of kinesiophobia in patients after cardiac surgery, and kinesiophobia should be included in the routine evaluation of patients in the cardiac perioperative period. Since kinesiophobia is affected by physiological, psychological, and social factors, a multidisciplinary intervention team should be established [35] to educate and train medical staff in early identification, health education, auxiliary intervention, exercise supervision, etc., in conjunction with professional rehabilitation therapists and psychotherapists. This will guide patients after cardiac surgery to improve their perspectives of disease rehabilitation, enhance their confidence in rehabilitation exercises, and improve their adherence. Finally, considering the higher incidence of kinesiophobia after cardiac surgery than after percutaneous coronary intervention and thoracoscopic cardiac surgery [36], it is recommended that endoscopic minimally invasive cardiac surgery, stepwise endo-/epicardial catheter ablation, pulsed field ablation, and robotic cardiac surgery be actively carried out when possible to ensure the safety and effectiveness of the procedure. This will reduce the surgical trauma, patient pain level, and recovery time [37,38,39].

Incidence of kinesiophobia in patients after cardiac surgery varies greatly, and targeted evaluation tools need to be developed urgently.

This scoping review found that the incidence of kinesiophobia in patients after cardiac surgery varied greatly, ranging from 39.20 to 82.57%, which may be related to the large number of surgical procedures, the lack of representativeness of the study samples, and the lack of pertinence of evaluation tools. At present, TSK-SV Heart is the most used kinesia measurement tool and has been translated and applied in China, Thailand, Poland, and other countries [40]. Kiran et al. [30] analysed the effectiveness of this scale in patients after coronary artery bypass grafting. However, most current evaluation tools for predicting the outcomes of patients after cardiac surgery focus on the physiological state of patients, and there is a need for specific kinesiophobia tools to assess the psychological states of patients [41, 42]. With advances in accelerated recovery surgery, kinesiophobia creates challenges for the postoperative rehabilitation of patients, which has attracted the attention of multidisciplinary fields. Accurate and comprehensive evaluation tools are needed for the early identification of kinesiophobia in patients after cardiac surgery.

Coping strategies for kinesiophobia in patients after cardiac surgery need to be enriched and developed

Through this scope review, most research on postoperative kinesiophobia in patients after cardiac surgery was found to involve cross-sectional studies, and there was a lack of comprehensive, whole-process, and targeted intervention strategies, such as those involving multidisciplinary collaboration of medical staff, rehabilitation therapists, and psychotherapists. Regarding support from patients and their families, preoperative health education and prehabilitation training, intraoperative analgesia, postoperative coping measures, and post-discharge continuous care, among others, should be considered. Studies have shown that patient and family involvement can improve the patient’s subjective initiative in disease understanding and enable them to actively cooperate with treatment [43]. It is recommended to respect the patient’s preferences and develop a postoperative exercise plan with the patient and family to improve the patient’s exercise self-efficacy. Providing long-term follow-up for discharged patients, addressing “modifiable factors” such as family care and social support, and using social resources to carry out diversified interventions for kinesiophobia should be included to ensure the continuity of intervention. In addition, the immersive, interactive, and conceptual educational environment provided by virtual reality can be used to construct different virtual scenarios according to the patient’s cultural background, interests, and age, and this interaction with virtual objects can be used to improve the patient’s enthusiasm for participating in rehabilitation exercises [44].

Conclusion

The incidence of kinesiophobia in patients after cardiac surgery is high, which seriously affects their prognosis. Medical staff should pay attention to the prevention and control of kinesiophobia in patients after cardiac surgery. However, research is still in its infancy, and there is a lack of evaluation tools and intervention strategies for kinesiophobia in patients after cardiac surgery. Thus, it is necessary to continue carrying out relevant research in the future, pay close attention to the actual exercise needs of patients, form multidisciplinary intervention teams, make full use of community resources and emerging technologies, and formulate individualised continuous intervention programs to improve the rehabilitation of patients after cardiac surgery, shorten hospital stays, and improve quality of life.

Availability of data and materials

No datasets were generated or analysed during the current study.

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Acknowledgements

Not applicable.

Clinical trial number

The review protocol was registered in the Open Science Framework(DOI:https://doi.org/10.17605/OSF.IO/TMB89), and ethical approval was not required for a review of the existing literature.

This study is a review and does not involve clinical trials, therefore, there are no clinical trial numbers.

Funding

This research was supported by the Health Humanities Research Center of Zigong Key Research Base of Philosophy and Social Sciences [Grant Nos. YDJKY23-35], the Health Humanities Research Center of Zigong Key Research Base of Philosophy and Social Sciences [Grant Nos.JKRWZC22-01].

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Author notes

  1. Zhi Zeng, Yuqi Shen and Li Wan contributed equally to this work.

Authors and Affiliations

  1. School of Nursing, North Sichuan Medical College, Nanchong, Sichuan, China

    Zhi Zeng

  2. Affiliated with the School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan, China

    Zhi Zeng, Yuqi Shen, Li Wan, Xiuru Yang, Qin Hu, Huaili Luo & Mei He

  3. Department of Nursing, Affiliated with the School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, No.12 Changjia Alley, Jingzhong Street, Fucheng District, Mianyang, Sichuan, 621000, China

    Mei He

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Contributions

The study design for this scoping review was proposed by [Zhi Zeng] 、 [Li Wan] and [Yuqi Shen]. Literature search strategy and database selection were the responsibility of [Zhi Zeng], and initial literature screening was performed in conjunction with [ Li Wan]. [ Yuqi Shen] were responsible for detailed literature selection and application of inclusion exclusion criteria. [ Xiuru Yang] 、 [Qin Hu] and [Huaili Luo] performed data extraction and quality assessment. All authors were involved in the analysis and interpretation of the data. [ Mei He] was responsible for drafting the first draft and made several revisions with the joint efforts of all authors. Each author made a substantial contribution to the content of the final manuscript and approved the final version for publication. In addition, all authors agree to take responsibility for all aspects of the work and to ensure the accuracy and completeness of any issues related to the work.

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Correspondence to Mei He.

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Zeng, Z., Shen, Y., Wan, L. et al. Kinesiophobia in patients after cardiac surgery: a scoping review. BMC Cardiovasc Disord 24, 469 (2024). https://doi.org/10.1186/s12872-024-04140-2

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Keywords

BMC Cardiovascular Disorders

ISSN: 1471-2261

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