Introduction
Coronary heart disease is characterized by atherosclerotic lesions in the coronary arteries, resulting in vascular stenosis or occlusion and causing the myocardium to experience ischemia and hypoxia [1]. Cardiovascular diseases have emerged as one of the leading causes of mortality worldwide [2, 3]. According to the “China Cardiovascular Disease Report 2020”, cardiovascular diseases affect approximately 300 million individuals in China, with 11.39 million of these cases being coronary heart disease [4]. Percutaneous Coronary Intervention (PCI), a common treatment for coronary heart disease, requires consistent exercise rehabilitation after the procedure is completed [5]. However, many patients opt to reduce their physical activity or avoid exercise due to concerns that it may increase cardiac strain, and this condition is known as Kinesiophobia [6]. Research indicates that Kinesiophobia is prevalent among patients with coronary heart disease, and particularly high levels have been observed in those who have undergone stent implantation, especially following emergency PCI, due to the urgency and severity of their conditions [7, 8]. Currently, most research in China focuses on quantitative analyses of the factors influencing Kinesiophobia in patients with coronary heart disease, with relatively few qualitative studies. Existing studies have shown that sociodemographic factors (e.g., age, gender, education level, economic income, social support), disease-related factors (e.g., severity of pain, type and severity of complications), and psychological factors can contribute to patients’ fear of exercise [6‐8]. However, there is a lack of subjective descriptions regarding the causes of exercise fear following PCI, limiting the ability to fully understand and articulate patients’ perspectives and experiences. Therefore, in this study, we conducted semi-structured interviews with patients and healthcare providers to explore the underlying causes of exercise fear in post-PCI patients, providing a reference for developing intervention strategies in clinical practice.
Objectives and methods
Study population
Between May 2023 and June 2023, purposive sampling was used to identify patients with post-PCI Kinesiophobia and medical staff from the cardiology department of a tertiary A-level hospital. The inclusion criteria were: age ≥ 18 years; first-time PCI surgery via the radial artery; scores ≥ 37 on the Cardiac Disease Kinesiophobia Scale; Heart Function Classification I-III according to the New York Heart Association Functional Classification; and informed consent obtained from both patients and their families. Exclusion criteria were: severe mental illness; reduced ability to understand and communicate; severe complications such as arrhythmia, shock, or impaired liver and kidney function; complete occlusion of the coronary artery; development of arrhythmia or unstable hemodynamics within 24 h after PCI; and inability to participate in exercise rehabilitation. Inclusion criteria for medical staff were: experience in the treatment or nursing of patients undergoing PCI; a bachelor’s degree or higher, with the ability to summarize and generalize experience. Exclusion criteria for medical staff were: not currently working in the cardiology department; on leave for further studies or absence due to sick leave. The sample size was determined based on the principle of theoretical saturation, where no new themes emerged. In this study, 14 patients and 4 healthcare staff were interviewed. General information on the study subjects is presented in Tables 1 and 2. The study was approved by the Ethics Committee of the Affiliated Taizhou People’s Hospital of Nanjing Medical University (KY 2023-003-01).
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Table 1
Overall patient characteristics (n = 14)
No. | Gender | Age (y) | Education status | Occupation | Type of financial support for medical care | TSK heart score |
|---|---|---|---|---|---|---|
P1 | Male | 67 | Primary school graduate | Retiree | New rural cooperative medical care | 40 |
P2 | Male | 46 | Undergraduate | Civil servant | Medical insurance | 38 |
P3 | Female | 54 | High school graduate | Clerk | Medical insurance | 42 |
P4 | Male | 76 | Illiterate | Peasant | New rural cooperative medical care | 42 |
P5 | Male | 71 | Primary school graduate | Peasant | New rural cooperative medical care | 39 |
P6 | Male | 58 | Middle school graduate | Freelance | Medical insurance | 41 |
P7 | Female | 55 | High school graduate | Clerk | Medical insurance | 42 |
P8 | Female | 68 | Primary school graduate | Peasant | New rural cooperative medical care | 45 |
P9 | Female | 62 | Primary school graduate | Peasant | New rural cooperative medical care | 37 |
P10 | Male | 47 | High school graduate | Teacher | Medical insurance | 39 |
P11 | Male | 53 | Middle school graduate | Clerk | Medical insurance | 42 |
P12 | Male | 69 | Illiterate | Peasant | New rural cooperative medical care | 39 |
P13 | Male | 74 | Primary school graduate | Peasant | New rural cooperative medical care | 41 |
P14 | Male | 64 | High school graduate | Freelance | New rural cooperative medical care | 38 |
Table 2
Overall characteristics of the medical staff (n = 4)
No. | Gender | Age (y) | Education status | Department | Seniority | Out for Further training (Y/N) |
|---|---|---|---|---|---|---|
D1 | Male | 45 | PhD | Cardiology | 13 | Y |
D2 | Female | 37 | Master | Cardiology | 7 | Y |
N1 | Female | 35 | Undergraduate | Cardiology | 11 | Y |
N2 | Female | 33 | Undergraduate | Cardiology | 9 | Y |
Methods
Data collection
Semi-structured interviews were conducted with the participants. Prior to the interviews, the study’s purpose was explained to the patients, and they were assured that all data would be coded anonymously and used solely for the study. Informed consent forms were signed after obtaining the patients’ agreement. The initial interview outline was developed through a combination of literature review and group discussions, based on the Fear-Avoidance model theory. This theory provides a comprehensive explanation of the causes of exercise fear in patients with coronary heart disease. It suggests that when patients perceive pain as a frightening experience and believe it poses a threat to their health, they tend to avoid or reduce physical activity, leading to the development of exercise fear. This fear of exercise stems from patients’ excessive worry about pain and an exaggerated perception of its potential harm. Preliminary interviews were conducted with one doctor, one nurse, and two patients who were experiencing post-PCI kinesiophobia. The interview outline was refined based on feedback from these preliminary interviews, resulting in the following final version. Patient interview outline: (1) Can you share your understanding of PCI treatment? (2) What is your opinion on exercise rehabilitation? (3) Are you currently experiencing any physical discomfort or psychological concerns? (4) What do you think are the reasons that impact your daily activities or exercise? (5) Do you think exercise is beneficial for you? Why do you feel that way? Medical staff interview outline: (1) What is your opinion on patient’s adherence to exercise rehabilitation after PCI? (2) What is your understanding of the kinesiophobia experienced by patients after PCI? (3) What do you think causes kinesiophobia in patients after PCI? (4) Do you have strategies to help patients deal with their kinesiophobia? Formal interviews were conducted in the demonstration classroom of the department ward from May 2023 to June 2023. A dedicated interviewer conducted face-to-face interviews with each participant, lasting approximately 30 min. The entire interview was recorded with the informed consent of the interviewee.
Data analysis
Within 24 h after each interview, the recorded content was transcribed into text. The psychological state of the interviewees was thoroughly analyzed, incorporating observations of their expressions, gestures, and emotions during the interviews. Data analysis was conducted independently by two members of the research team, both with over five years of clinical experience, using Colaizzi’s seven-step method, which includes: carefully reading through the interview transcripts, extracting significant statements, coding recurring points of view, organizing and summarizing these coded points into common themes [9]. For contentious sections, panel discussions were held to minimize bias. The final analysis results were then shared with the patients for their feedback.
Results
Theme 1: increment of psychological stress
Patients who have undergone PCI surgery may develop kinesiophobia due to changes in their health status and anticipated lifestyle adjustments, the possibility of recurrence post-rehabilitation, and the increased burden on their families. From a physiological perspective, some interviewees expressed significant challenges in coping with aging, declining health, and the emotional impact of heart-related issues. They described their physical condition as “declining” and emphasized the need for ample rest to allow their continuously working hearts to recover. They also noted that they would need to live cautiously in the future, acknowledging their vulnerability. To prevent illness from recurring, they needed to pay closer attention to exercise, diet, and medication. From an economic perspective, some interviewees may retire, either voluntarily or involuntarily, due to coronary heart disease. The transition from being the family’s primary economic provider to becoming a dependent individual can be challenging to adapt to, resulting in increased psychological stress. These negative emotions may lead to a refusal to engage in exercise and rehabilitation. For instance, one participant (P4) stated, “I have worked hard all my life, and now I am exhausted. I am uncertain if I will ever recover. I can no longer perform work that requires intense activity and cannot earn sufficient money to support my family.” Another participant (P7) remarked, “When I had my heart attack, my chest hurt so much that it felt like I was dying. I do not want to experience that again. I will stay in bed to avoid causing any more trouble.”
Theme 2: increased uncertainty of physical exercise
Uncertainty of effects of physical exercise
The benefits of exercise rehabilitation accrue gradually and may not produce immediate effects, causing patients to question the significance of the exercise regimen. For example, one participant (P1) stated, “I have been exercising as advised for the past few days, but I do not feel any better. Will I benefit from continuing this regimen?”
Uncertainty in the amount, frequency, and mode of exercise
Due to uncertainty regarding the appropriate amount, frequency, and type of exercise, patients experience increased fear and anxiety about physical activity, resulting in poor adherence to exercise regimens. As one participant (P2) stated, “I used to swim and work out at the gym frequently. Now, after being discharged, I am unsure if I can still go to the gym. I have no idea how much I should reduce my exercise.”
Uncertainty in the safety of the exercise process
Due to physical illness, the fear of aerobic exercise may be pronounced, potentially intensifying the discomfort associated with bodily sensations [10]. This fear can lead patients to avoid activities that cause physical discomfort, such as aerobic exercise, or to cease exercising when experiencing uncomfortable symptoms, such as dyspnea. As noted by one participant (D1), “Some patients, despite being medically cleared for exercise after treatment, remain concerned that something might unexpectedly occur during exercise, such as difficulty breathing, and therefore reduce or discontinue exercise when they feel unwell.”
Theme 3: decrement in self-efficacy
Self-efficacy refers to an individual’s confidence in their ability to engage in and persist with exercise behavior, and it is a significant predictor of kinesiophobia [11]. There is a negative correlation between self-efficacy and kinesiophobia and a positive correlation between self-efficacy and adherence to exercise [12]. In other words, lower self-efficacy is associated with higher kinesiophobia and reduced exercise compliance. Due to the prominent symptoms of coronary disease and its tendency to recur, patients may experience negative psychological states such as anxiety and depression, which can undermine their confidence in exercising. This lack of confidence may exacerbate kinesiophobia and further diminish exercise compliance [13]. For instance, one participant (P6) remarked, “Given my current condition, what exercise can I possibly do? Resting is all that I can do.” Another participant (P3) reflected, “I now value my health greatly and avoid physical labor, except for necessary daily activities. My family handles the housework and they do not allow me to engage in any risky activities. Avoiding illness and hospitalization is the best way I can contribute.” Additionally, a healthcare professional (D2) noted, “Many patients psychologically resist early exercise rehabilitation. Although they may verbally agree with our recommendations, their actual adherence is low. Despite having only minor blood vessel blockages, they perceive their extremities as completely immobile. This resistance is primarily due to psychological fear and rejection.”
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Theme 4: lack of support systems
Lack of family support system
The lack of a family support system, including careful attention from family members and unconditional financial support, may exacerbate negative emotions in patients and heighten uncertainty and fear during exercise. Research has shown that social and family support is inversely related to kinesiophobia. Adequate social support can effectively alleviate adverse emotions, thereby reducing psychological burden [14]. Additionally, family support and supervision play a crucial role in the cardiac rehabilitation of patients following discharge. Behavioral changes are often implemented without professional assistance or supervision but are frequently supported by family members. The involvement of family members can facilitate behavior change, as illustrated by one participant (P11), who noted, “In the future, I will need to change my lifestyle, but I lack sufficient self-control. Having family members to accompany or supervise me may improve my adherence to these changes.”
The absence of professional support
All participants reported receiving guidance from medical staff regarding treatment, including early exercise rehabilitation methods and expectations for their condition after discharge. However, they experienced difficulties in comprehending and retaining the information provided. Many participants struggled to recall the details of verbal instructions. Written or visual materials, such as videos or rehabilitation manuals, appeared to enhance adherence to medical advice. One participant (P7) noted, “The doctors and nurses provided extensive instructions on diet, exercise, and disease prevention, but I cannot remember all the details. While I understood the instructions initially, I had questions later during exercise. A small amount of exercise might not be effective, while too much could raise concerns about worsening my condition. The medical staff were often busy, and I felt uncomfortable asking for clarification.” Another participant (N1) commented, “For non-professionals, a single explanation in health education is often insufficient, just as students cannot recall all key points from a single lecture. Improved retention can be achieved through repeated explanations or reference materials. Therefore, it is advisable to compile essential information, such as secondary prevention guidelines for coronary heart disease and exercise plans, into a booklet for patients to enhance compliance.”
Discussion
Early identification and alleviation of psychological stress
Kinesiophobia is a psychological phenomenon characterized by an excessive and irrational fear related to exercise rehabilitation and daily activities [15]. This condition can lead patients to avoid physical activities, potentially resulting in complications such as tachycardia, orthostatic hypotension, and thromboembolism, as well as inducing negative emotions such as anxiety and depression. Kinesiophobia has been shown to significantly impact patient rehabilitation [16]. In this study, patients experiencing kinesiophobia following PCI exhibited increased psychological stress, greater uncertainty about exercise, and diminished self-efficacy, consistent with the findings of Bäck et al. [17] Contributing factors may include concerns about potential relapse or worsening of their condition, fear of previous complications, impaired self-esteem, and various influences from family and society.
Enhancing the dissemination of knowledge and education, refining exercise plans, improving self-efficacy, and increasing exercise compliance
Evidence-based research indicates that exercise-centered cardiac rehabilitation can effectively prevent myocardial remodeling, alleviate cardiac symptoms, and reduce both rehospitalization and mortality rates [18, 19]. However, current exercise rehabilitation programs encounter several challenges, including overly simplistic exercise regimens, imprecise step formulation, limited research populations, biased assessment of exercise intensity, uncertain long-term effects, and incomplete evaluation systems, all of which contribute to low patient compliance. To address these issues, it is recommended that physicians carefully consider each patient’s cardiac function and exercise tolerance when designing rehabilitation programs, increase sample sizes, and enhance the development of tailored cardiac rehabilitation programs for various heart conditions. Prompt post-discharge follow-up and tracking are also crucial.
Additionally, Cognitive Behavioral Therapy (CBT) has been shown to effectively modify patients’ thoughts and beliefs, correct misconceptions, and improve exercise self-efficacy, thereby enhancing exercise compliance [20, 21]. Based on the findings of this study, it is essential for cardiac exercise rehabilitation programs to not only enable patients to directly experience the benefits of exercise on heart health but also to use positive demonstrations and peer encouragement. This approach aims to stimulate patients’ intrinsic motivation, strengthen their commitment to exercise rehabilitation, and ultimately foster the development of sustained and consistent exercise habits.
A comprehensive approach involving family, medical, and social support is essential for alleviating kinesiophobia in patients with coronary heart disease
In terms of family support, relatives should actively engage in caring for patients, offering companionship and encouragement to enhance their confidence in recovery. From a medical standpoint, healthcare professionals should address the kinesiophobia of patients with coronary heart disease by providing comprehensive professional support. This includes developing detailed exercise plans that specify the type, duration, and frequency of exercises, thereby mitigating unsafe factors during exercise and reducing kinesiophobia associated with inadequate knowledge. From a social perspective, cardiac rehabilitation in China is still developing, with approximately one-fifth of hospitals nationwide offering such programs and only 8% of these hospitals providing Phase I and Phase II cardiac rehabilitation [22]. Therefore, there is a need to advance the national cardiac rehabilitation sector, improve the quality of rehabilitation services, and offer specialized cardiac rehabilitation services to patients. Contrary to the findings of Tang Liya, which suggested that kinesiophobia in patients with coronary artery disease is unrelated to social support, this study discovered a different result [23]. This discrepancy may arise from variations in research subjects and individual differences. Future research should further investigate the relationship between kinesiophobia and social support.
Conclusion
This study utilized semi-structured interviews to explore the factors influencing exercise fear in post-PCI patients in China. A total of four themes were identified: increased psychological stress, heightened uncertainty about exercise (including uncertainty about exercise outcomes, safety during exercise, and exercise quantity, frequency, and methods), decreased self-efficacy, and lack of support systems (including insufficient family support and inadequate professional technical support). These findings provide a foundation for developing intervention strategies to address exercise fear in post-PCI patients in the future.
Limitations
There are significant disparities in the availability and quality of cardiac rehabilitation services across various regions in China, resulting in differences in the levels and causes of kinesiophobia among patients with coronary artery disease in these areas. This study, conducted exclusively at a tertiary A-level hospital, has certain limitations. In addition, the sample size was relatively small, which may not represent all patients with coronary artery disease, especially those outside the research institution’s context.
Acknowledgements
Not applicable.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of The Affiliated Taizhou People’s Hospital of Nanjing Medical University (Approval number: 2023-003-01). A written informed consent was obtained from all participants.
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Consent for publication
Consent for publication was obtained from every individual whose data are included in this manuscript.
Competing interests
The authors declare no competing interests.
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