Kinesiophobia is negatively associated with physical activity: What factors influence this relationship?

In a accurate study posted to medRxiv*, researchers examined the association between physical activity and kinesiophobia.

Study: Kinesiophobia and Physical Activity: A Systematic Review and Meta-Analysis. Image Credit: GP PIXSTOCK/Shutterstock.com

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

The health benefits of physical activity have been well documented in the literature, including lower risks of disease, disability, and death. In particular, increased physical activity reduces the risk of obesity, cardiovascular disease, cancer, hypertension, dementia, and depression.

Kinesiophobia is the irrational, debilitating, and excessive fear of movement and activity due to a sense of vulnerability to a medical condition, injury, or pain.

The perception of physical activity-related cues automatically activates the physical activity concept and associated pleasant or unpleasant affective memories, leading to an impulsive tendency to approach or avoid physical activity.

Likewise, aversive fear of injury, pain, or worsening of a medical condition associated with the concept of movement may lead to automatic avoidance behaviors contributing to this fear. It may result in a phobic state (kinesiophobia).

In the present study, researchers systematically reviewed and meta-analyzed the relationship between physical activity and kinesiophobia. Medline, Cumulative Index to Allied and Nursing Health Literature (CINAHL), and PsycINFO databases were searched for potential studies using relevant keywords.

Studies were eligible if they reported original data from human participants, included at least one measure of physical activity and kinesiophobia, and evaluated their association.

Conference abstracts, study protocols, book chapters, and studies incorporating physical fitness measures were excluded. Duplicates were removed, and titles/abstracts were reviewed.

The team extracted data on participant characteristics, body mass index, pain intensity, health status, type and level of kinesiophobia, type of physical activity measure, and statistical estimates.

The risk of bias was estimated using the appraisal tool for cross-sectional studies. In the meta-analysis, Pearson product-moment correlations were pooled from studies to analyze the relationship between physical activity and kinesiophobia.

The heterogeneity variance (Tau-squared) was calculated using the restricted maximum likelihood estimator. Besides, the I-squared statistic was used to quantify between-study heterogeneity.

Publication bias was assessed using Egger’s regression test and p-curve analysis. Several sub-group analyses were performed. In addition, a secondary meta-analysis was performed to assess the relationship between device-measured physical activity and kinesiophobia.

A sensitivity analysis examined whether the quality of studies influenced results.

The authors identified 395 potential hits from the primary search. After exclusions, 49 studies with 6,084 participants were selected for the systematic review. The studies evaluated healthy individuals and those with pain, arthritis, cancer, surgery, and cardiovascular, neurological, and pulmonary conditions. Most studies used the Tampa scale of kinesiophobia to assess kinesiophobia.

Studies reporting the highest kinesiophobia levels involved individuals with a cardiovascular condition, arthritis, chronic pain, or pulmonary condition. Kinesiophobia levels were lower in healthy individuals and those with neurological or surgical conditions.

Thirty-four studies assessed physical activity using self-reported questionnaires. Accelerometers and pedometers were used in others.

The meta-analysis, which included 41 studies, revealed a significant moderate negative correlation between physical activity and kinesiophobia. Nevertheless, there was substantial between-study heterogeneity and publication bias.

The association between physical activity and kinesiophobia was significant only in patients with arthritis or cardiovascular disease. Heterogeneity was higher in studies with arthritis populations than those comprising cardiovascular disease patients.

Moreover, only self-reported physical activity measures correlated with physical activity and kinesiophobia. The secondary meta-analysis revealed no evidence of an association between accelerometer-based physical activity measures and kinesiophobia. Finally, the sensitivity analysis revealed that the quality of studies did not impact the correlation.

The findings reveal a moderate negative correlation between physical activity and kinesiophobia, suggesting that the fear of movement induces an impulse to avoid physical activity. Moreover, arthritis or cardiovascular disease patients may be at an elevated risk than others.

Although there was no association between kinesiophobia and physical activity in other health conditions (cancer, surgery, acute pain, and neurological or pulmonary disorders), the effects of kinesiophobia cannot be ruled out.

Notably, the association was statistically significant only in studies incorporating self-reported measures of physical activity, with the secondary meta-analysis supporting this finding.

This raises the question of the robustness of the association, given the higher reliability and validity of device-based measures than self-reports. Thus, future studies using device-based measures of physical activity are required to corroborate the findings.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Crossed Wires: Ischemia Testing and Monomorphic VT Storm

Patients with a severe form of ventricular arrhythmia who may be referred for catheter ablation are often first tested for coronary artery disease (CAD) or ischemia. But such testing seldom makes a difference to downstream management or outcomes, researchers conclude, based on registry data.

The findings, they say, question such routine CAD/ischemia testing in patients like those studied, who had episodes of monomorphic ventricular tachycardia (VT) storm but not an acute coronary syndrome (ACS) and ultimately went to ablation.

Of 97 such patients, about 44% underwent CAD/ischemia testing by invasive angiography, myocardial functional imaging, or both. But the tests didn't predict important ablation outcomes, including pre- or postablation VT inducibility. Nor did they significantly affect the likelihood or outcomes of preablation revascularization or 2-year survival.

The findings "argue against performing routine evaluations to rule out coronary [disease] or myocardial ischemia as culprits in monomorphic VT storm" in patients without evidence of ACS, write Feras Alkhalaileh, MD, Heart and Vascular Institute, Cleveland Clinic, Ohio, and colleagues in their report published August 2 in JACC: Clinical Electrophysiology.

They suggest it's "reasonable" not to perform tests for CAD or ischemia in such patients, senior author Ayman A. Hussein, MD, from the same center, told theheart.org | Medscape Cardiology. Although such tests may be considered "case by case," performed routinely they "aren't going to add much to patient care, and as a matter of fact, may delay proper care and expose them to risks," Hussein said.

It's "reasonable" to test for CAD or ischemia in patients with polymorphic VT storm, which is likely ischemia-driven, he observed. In contrast, monomorphic VT storm is likely caused by myocardial scar, which revascularization cannot treat. "Because there's scar substrate, they find that ischemic evaluations are technically without much yield."

These issues are "not very controversial" among cardiac electrophysiologists, Hussein said, but it remains "common practice" for other certified to order angiography or ischemia testing for patients with monomorphic VT storm, typically in the cardiac care unit (CCU), before considering ablation.

"Sometimes, as electrophysiologists, they don't get to see them before an ischemic evaluation has already been done," he added.

It's "very hard to convince interventional cardiologists, CCU intensivists, or general cardiologists" that a VT may not be caused by ischemia, said electrophysiologist Roderick Tung, MD, University of Arizona College of Medicine, Phoenix, who was not involved in the current study.

In patients with monomorphic VT storm, "By the time we're consulted, they've already had a cath. And it's probably just not necessary," Tung said. "That's why this is such a great paper, because it has an immediate message" for nonelectrophysiologist clinicians and "the potential to change clinical practice."

The study included 97 patients with monomorphic VT storm from a prospective VT-ablation registry covering about 7 years at a major referral center. Their mean age was 64 years and 88% were men. Two-thirds were known to have ischemic cardiomyopathy and were in NYHA functional class II.

As reported, 10% of the cohort underwent coronary angiography after presentation with monomorphic VT storm, 26% had CT or PET myocardial functional imaging, and 9% had both tests.

Only four patients ultimately underwent coronary revascularization; no acute coronary occlusions were involved. Monomorphic VT recurred in all four cases, the report notes.

The 43 and 54 patients who did or did not get the CAD/ischemia tests, respectively, showed no significant procedural differences in extent of scar modification, prevalence of clinical or hemodynamically stable VT, or use of mechanical circulatory support; or in postablation, VT inducibility or overall mortality during follow-up averaging 24.3 months.

To address possible concerns about selection bias in the main cohort, all of whom underwent ablation, a secondary analysis was conducted with 91 patients with known asymptomatic coronary disease and monomorphic VT storm who were selected from the registry without regard to whether they underwent catheter ablation.

Of that cohort, 21 went to invasive angiography and 25 underwent stress testing; six of the latter went on to coronary angiography, the report states. Monomorphic VT later recurred in four of the five patients, who then underwent coronary revascularization.

Such patients with known coronary disease, Hussein said, are those "possibly more likely to get an ischemic evaluation." And yet, "regardless of whether they had ablation, the yield of ischemic evaluations in these patients was low."

By far most of the CAD/ischemia tests in the study's primary cohort were performed using noninvasive imaging, notes an editorial accompanying the new report. "This raises the possibility of false negatives with very proximal and multivessel CAD, and with balanced ischemia," write Saurabh Kumar, BSc (Med)/MBBS, PhD, and Ashwin Bhaskaran, MBBS, MSc, University of Sydney, New South Wales, Australia.

Ideally, the issues addressed by the study should be tested in large randomized, controlled trials, they state. "Achieving sufficient recruitment to address this clinical question may be difficult, leaving clinicians with the challenge of applying observational data to their patients."

J Am Coll Cardiol EP. Published online August 2, 2023. Full Text, Editorial

Alkhalaileh, Hussein, and their coauthors report no relevant financial relationships. Tung has previously disclosed receiving speaking fees from and serving on advisory boards for Abbott, Biotronik, Boston Scientific, and Medtronic, and receiving research grants from Abbott. Kumar has received research grants from Abbott Medical and Biotronik; and honoraria from Biosense Webster, Abbott Medical, Biotronik, and Sanofi. Bhaskaran declared no relevant financial disclosures.

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