Article ID: CR-25-0038
Background: Recent studies indicate a high prevalence of kinesiophobia among patients with cardiovascular disease (CVD). However, there remains a lack of consensus regarding the impact of kinesiophobia on rehabilitation outcomes. The objective of this study is to provide a comprehensive summary and synthesis of the extant evidence regarding the impact of kinesiophobia on rehabilitation outcomes in patients with CVD.
Methods and Results: This systematic review will adhere to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 8 February, 2025 (Registration no. CRD42025623535). Electronic searches will be performed in the following databases: MEDLINE, PubMed, Web of Science, PsycINFO, and CINAHL electronic databases, with a date range from the start date to January 2025. The study designs were observational, encompassing cohort, case-control, or cross-sectional studies. Narrative reviews, editorials, clinical guidelines and conference abstracts will be excluded. We will consider articles that are published in English. In addition, only officially published papers are included and grey literature is excluded from the review. The specific outcomes of interest include physical function, activities of daily living, physical activity, and quality of life.
Conclusions: This systematic review will provide comprehensive evidence on the relationship between kinesiophobia and rehabilitation outcomes in patients with CVD.
Cardiovascular disease (CVD) is a leading cause of death worldwide. In 2021, CVD was estimated to account for approximately 20.5 million deaths worldwide, representing one-third of all global deaths.1 In Japan, the crude mortality rate for heart disease has been increasing annually with the aging population.2 CVD encompasses conditions such as coronary artery disease, heart failure, valvular heart disease, and arrhythmias. Globally, cardiac rehabilitation (CR) for patients with CVD has become widely established, and its effectiveness has been demonstrated in numerous studies. Exercise-based CR has been reported to improve physical function, activities of daily living (ADL), and quality of life (QOL), as well as positively influencing outcomes such as readmission rates, recurrence rates, and mortality rates.3–10
Although providing CR to patients with CVD has been shown to be beneficial, there are several challenges that need to be addressed. In clinical settings, many patients with CVD face difficulties participating in and continuing exercise-based CR due to fears of cardiac stress caused by physical activity (PA), the risk of recurrence, and worsening symptoms.11 Kinesiophobia refers to an excessive and irrational fear of exercise, primarily driven by concerns about potential physical harm or the risk of disease recurrence.12 Fear of pain-related movements or activities leads patients to refuse necessary exercise and rehabilitation. Originally, the concept of kinesiophobia was proposed for patients with chronic pain and later expanded to include postoperative patients with orthopedic conditions.13,14
Study RationaleRecent studies have revealed a high prevalence of kinesiophobia among patients with CVD.15–17 The presence of kinesiophobia in these patients often leads to excessive rest, resulting in declines in physical function and ADL, which can eventually necessitate caregiving and increase social and economic burdens. Patients with CVD are more prone to experiencing negative emotions such as depression and anxiety, which heightens their concerns about symptom exacerbation or delayed recovery due to exercise. These factors may slow the progress of rehabilitation, potentially leading to insufficient improvement in physical function and ADL. Several factors have been identified as influencing kinesiophobia in patients with CVD, including educational background, anxiety, economic status, and level of social support.15–17 In the fear-avoidance model proposed by Vlaeyen et al., fear of pain or exercise is reported to result in avoidance behavior, which subsequently leads to further functional decline and psychological deterioration.18 Yifan et al. reported that ADL and kinesiophobia partially mediate the relationship between cardiac function and health status in heart failure patients, and that both ADL and kinesiophobia have a significant mediating effect on this relationship.19
Another study reported that the presence of kinesiophobia reduced the likelihood of initiating CR.20 These considerations suggest that kinesiophobia may influence CR, highlighting the need for a systematic analysis of the findings from these studies. Previous reviews have not examined the relationship between rehabilitation outcomes and kinesiophobia. By clarifying the impact of kinesiophobia on patients with CVD in this review, effective clinical interventions to reduce kinesiophobia can be considered, potentially leading to improved outcomes for patients with CVD.
Review ObjectivesThe aim of this study is to summarize the impact of kinesiophobia on rehabilitation outcomes – namely physical function, ADL, PA, and QOL – in patients with CVD and to integrate the available evidence.
This systematic review was preregistered in the International Prospective Register of Systematic Reviews database (Registration no. CRD42025623535). The review methodology will adhere to the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P). The results of this systematic review will be reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA 2020 statement).
Inclusion CriteriaParticipants Patients with CVD.
Exposures Patients with CVD with kinesiophobia.
Comparators The control group consists of patients with CVD who do not exhibit kinesiophobia.
Outcomes The main outcomes of this study will be physical function, PA, ADL, and QOL.
Studies Eligible study designs include observational studies, such as cohort, case-control, or cross-sectional studies. Narrative reviews, editorials, clinical guidelines and conference abstracts will be excluded.
Publications We will consider articles that are published in English. In addition, only officially published papers are included and grey literature is excluded from the review.
Search StrategyThe search strategy will include electronic databases such as MEDLINE, PubMed, Web of Science, PsycINFO, and CINAHL, covering literature from inception to January 2025. The search strategy was developed in collaboration with experienced researchers. The search strategy (Supplementary Table) was composed of blocks of key terms related to the target population, kinesiophobia, outcomes. In addition, we plan to conduct a manual review of the relevant literature cited in the identified studies.
Study Selection and Data Selection ProcessThe authors, Y.N. and R.F., will independently carry out the screening process and detailed analysis of the full text, without concealing details such as publisher, author or year of publication, with another author, K.T., acting as a mediator in cases of disagreement. After this thorough evaluation of the full texts, the articles that meet our criteria will be selected and a flow chart will be created according to the PRISMA checklist.
Assessment of Methodological QualityThe risk of bias of the included studies is assessed independently by 2 trained researchers. Discordances will be resolved collegially among the team of authors. Cross-sectional studies will be conducted according to the quality assessment criteria for cross-sectional studies by the Agency for Healthcare Research and Quality; cohort and case-control studies will use the Newcastle-Ottawa Scale.21–23
Data ExtractionStudies will be selected by screening the literature for potentially eligible studies, and a 2-step eligibility assessment (title and/or abstract and full text) will be conducted independently by 2 reviewers. In the event of disagreement, a third researcher will mediate to reach a consensus. The following data will be extracted: (1) title; (2) authors; (3) publication year; (4) sample size; (5) nationality; (6) participants characteristics (e.g., age, sex, disease); (7) analysis; (8) main outcome; and (9) type of CVD.
Data Synthesis and AnalysisWe will conduct a meta-analysis if studies are sufficiently homogeneous in terms of design, population, interventions, and outcomes. If an insufficient number of studies are identified or if extreme heterogeneity is observed, a meta-analysis will not be conducted. Instead, results will be synthesized using a narrative synthesis approach. Specifically, we will: (1) summarize the characteristics of the studies; (2) compare the direction of study findings; (3) interpret the results considering bias assessments; and (4) analyze trends within subgroups. The exact number of studies required for meta-analysis is not clearly defined; however, a larger number is generally preferable. Based on previous reports, we will consider conducting a meta-analysis for subgroup analyses by type of heart disease when at least 2 studies are available.17 Heterogeneity will be assessed using the I² statistic, with thresholds of 25%, 50%, and 75% interpreted as low, moderate, and high heterogeneity, respectively. In cases of substantial heterogeneity (I2 >50%), we will use a random-effects model; otherwise, a fixed-effects model will be applied. Subgroup analyses will be performed based on predefined variables such as age, gender, and intervention duration. If the number of studies is insufficient to conduct a subgroup analysis by type of CVD, we will consider analyzing all types of CVD collectively. Sensitivity analyses will be conducted by excluding studies with a high risk of bias. The meta-analysis will be performed using EZR, and results will be presented as forest plots with pooled estimates expressed as risk ratios or mean differences with 95% confidence intervals.
This systematic review aims to examine the impact of kinesiophobia on physical function, PA, ADL and QOL in patients with CVD. Originally conceptualized for patients with chronic pain, kinesiophobia has since been widely applied to postoperative orthopedic patients and, more recently, to those with CVD. In recent years, several systematic reviews have discussed the prevalence of kinesiophobia and its determinants in patients with CVD.15–17 In addition, an increasing number of studies have examined the impact of kinesiophobia on the rehabilitation of patients with CVD.19,20 However, variations in patient characteristics across studies necessitate the integration of findings from multiple studies.
Kinesiophobia is defined as a fear of movement, which directly leads to physical inactivity and can influence the worsening or recurrence of symptoms. Consequently, kinesiophobia may hinder the initiation of rehabilitation, thereby preventing optimal improvements in physical function and ADL. Previous reviews have reported the prevalence of kinesiophobia among patients with CVD to range from 39.20% to 82.57%.15–17 Given this context, it is essential to collect substantial evidence regarding the effects of kinesiophobia on key rehabilitation outcomes, including physical function, ADL, and QOL, in patients with CVD. There are various types of CVD, and the relationship with kinesiophobia should be considered based on the characteristics of each condition. For example, atrial fibrillation can lead to kinesiophobia due to its unpredictability and distressing symptoms, suggesting that postoperative patients may avoid PA to prevent recurrence.17 Based on these findings, if this review identifies a strong relationship between kinesiophobia and rehabilitation outcomes in patients with CVD, psychological support and patient education on exercise safety should be integrated into early stage interventions alongside exercise therapy, depending on the type of CVD. In addition to physical factors, it is crucial to enhance self-efficacy, identify and address psychological issues such as anxiety and depression at an early stage, and strengthen social support.
This review seeks to summarize the existing evidence on kinesiophobia in patients with CVD and contribute to the advancement of CR practices.
Study LimitationsThis protocol has certain limitations, such as restricting the review to English-language studies, focusing solely on peer-reviewed publications, and limiting the search to specific databases. However, these measures are crucial to ensuring the reliability and reproducibility of the findings. Furthermore, employing 2 independent reviewers for study selection and data extraction ensures the accuracy and trustworthiness of the findings. Caution must be exercised when interpreting meta-analyses in clinical practice, as those with limited sample sizes are highly influenced by the findings of individual studies.
The results of this review might provide valuable insights for future clinical research, including intervention studies aimed at mitigating kinesiophobia and longitudinal studies investigating long-term effects and prognoses.
The authors thank Yumiko Miyao, Mei Kodama, Tomoharu Nakamura, and staff members of the Kyusyu University Medical Library for their contribution to the development of the search strategy. The authors used DeepL to assist in verifying the English language in this manuscript.
The authors declare that there are no conflicts of interest to disclose.
This study is a systematic review and meta-analysis protocol of previously published studies, and no new data were collected directly from human participants. Therefore, ethical approval and informed consent were not required.
All data analyzed in this study were extracted from publicly available publications or databases as cited in the manuscript. No new data were generated for this study.
Please find supplementary file(s);
https://doi.org/10.1253/circrep.CR-25-0038
