Summary of Best Evidence to Address Kinesiophobia Post Percutaneous Coronary Intervention: An Evidence-Based Review

Introduction

Coronary heart disease (CHD) occurs when coronary atherosclerosis induces vessel stenosis or occlusion, precipitating an ischemic and hypoxic state in the cardiac muscle. As per the Report on Cardiovascular Diseases in China 2020,¹ more than 300 million people suffer from cardiovascular disease in China, including 11.39 million with CHD. Percutaneous coronary intervention (PCI) is a primary mode of treating patients with CHD; however, they require continuous cardiac rehabilitation (CR) after the procedure due to irreversible arteriosclerosis.

Exercise rehabilitation is a crucial component of CR and can be conducted independently or in conjunction with the management of other disease-related risk factors within CR programs.² Despite the numerous benefits of exercise rehabilitation, patient compliance with rehabilitation is notably low.^3,4 It may be due to a fear that exercise will exacerbate cardiac strain and lead to a recurrence of their condition. This irrational fear of rehabilitative exercise and daily activities is known as kinesiophobia.⁵ Such fear significantly impacts patients’ adherence to exercise rehabilitation, causing them to avoid activities. This avoidance can result in complications like thromboembolism, disuse syndrome, or provoke conditions such as tachycardia and hypotension during normal activities. It can also lead to negative emotions such as anxiety and depression, severely affecting patient recovery.⁶ A previous study has found that six months after a cardiac event, 20% of CHD patients exhibited high levels of kinesiophobia.⁷ In another study, 86.7% of patients undergoing cardiac surgery had kinesiophobia before revascularization.⁸ In China, a survey revealed that out of 189 patients with CHD 107 exhibited kinesiophobia, accounting for 56.6% of the total surveyed population.⁹ Liu et al¹⁰ found that the kinesiophobia score for patients post-coronary stent implantation was 46.67±19.96, while Wang et al¹¹ reported a score of 40.27±4.68. The discrepancy in results may be due to differences in the selection of study subjects and the timing of questionnaire distribution. In summary, patients with CHD, especially those who have undergone coronary stent implantation, exhibit high levels of kinesiophobia. Research on kinesiophobia in cardiac patients in China is still in its early stages, lacking systematic, targeted, and effective intervention programs.

Hence, we conducted a comprehensive review of pertinent literature in this domain to assess the quality, extract evidence, and summarize the best available information on intervention programs for individuals experiencing kinesophobia post-PCI. The aim is to provide a reference for the clinical formulation of nursing management strategies and interventions aimed at addressing this concern.

Materials and Methods

Creation of a Specialized Team

A dedicated nine-member team was created to investigate the established evidence base, comprising 3 nursing managers, 3 clinical nurses, and 3 postgraduates in nursing. The nursing managers assumed responsibility for the overall coordination of the study; the nursing postgraduates were responsible for article search, evidence extraction, and evaluation; and the clinical nurses were responsible for analyzing the practical feasibility of the best evidence. All members underwent systemic training in evidence-based nursing.

Problem Determination

Evidence-based nursing problems were constructed using the PIPOST principle:¹² P (Population): the target population was patients with kinesophobia post-PCI; I (Intervention): interventions included exercise guidance, psychological interventions, health education, family support, and so on; P (Professional): the professionals involved were medical and healthcare personnel; O (Outcome): outcomes included the degree of cardiac kinesophobia, anxiety, and depression, the success rate of the 6-minute walk test, self-care ability in daily life, and self-efficacy in CHD exercises; S (Setting): the place where evidence was applied was mainly hospitals; T (Type of evidence): this included randomized controlled trials (RCTs), quasi-experiments, clinical practice guidelines, expert consensus statements, and systematic reviews.

Search Strategy

All articles related to post-PCI kinesophobia intervention were retrieved from the following sources as per the “6S” evidence model:¹³ 1) Clinical decision-making support systems: BMJ Best Practice and UpToDate; 2) Clinical practice guideline websites: the National Guideline Clearinghouse (NGC) guideline website, the UK guideline website (NICE), and the Medlive guideline website; 3) Websites of professional associations: websites of the American Heart Association, American College of Cardiology, and the European Society of Cardiology; 4) Integrated databases: China Biology Medicine disc (SinoMed), China National Knowledge Infrastructure (CNKI), Wanfang Database, PubMed, and Embase Database.

The English keywords used for the search were “Percutaneous coronary intervention/Coronary Intervention, Percutaneous/Coronary Interventions, Percutaneous/Intervention, Percutaneous Coronary/Interventions, Percutaneous Coronary/Percutaneous Coronary Interventions/Percutaneous Coronary Revascularization/Percutaneous Coronary Revascularization/Revascularization, Percutaneous Coronary”, “Exercise/Physical Activity/Activities, Physical/Activity, Physical/Exercise, Physical/Exercises, Physical/Acute Exercise/Exercise, Isometric/Exercise, Aerobic/Exercise Training” and “Anxiety/Nervousness/Anxiousness/dread/frightened/depressed”.

The following is an example of the search mode in PubMed:

#1 (Percutaneous coronary intervention[Title/Abstract]) OR (Coronary Intervention, Percutaneous[Title/Abstract]) OR (Coronary Interventions, Percutaneous[Title/Abstract]) OR (Intervention, Percutaneous Coronary[Title/Abstract]) OR (Interventions, Percutaneous Coronary[Title/Abstract]) OR (Percutaneous Coronary Interventions[Title/Abstract]) OR (Percutaneous Coronary Revascularization[Title/Abstract]) OR (Coronary Revascularization, Percutaneous[Title/Abstract]) OR (Coronary Revascularizations, Percutaneous [Title/Abstract]) OR (Percutaneous Coronary Revascularizations[Title/Abstract])

#2 (Exercise[Title/Abstract]) OR (Physical Activity[Title/ Abstract]) OR (Activities, Physical[Title/Abstract]) OR (Activity, Physical[Title/Abstract]) OR (Physical Activities[Title/Abstract]) OR (Exercise, Physical[Title/Abstract]) OR (Exercises, Physical[Title/Abstract]) OR (Physical Exercise[Title/Abstract]) OR (Acute Exercise[Title/Abstract]) OR (Acute Exercises[Title/Abstract]) OR (Exercise, Acute [Title/Abstract]) OR (Exercises, Acute[Title/Abstract]) OR (Exercise, Isometric[Title/Abstract]) OR (Isometric Exercise[Title /Abstract]) OR (Exercise, Aerobic[Title/Abstract]) OR (Aerobic Exercise [Title/Abstract]) OR (Exercises, Aerobic[Title/Abstract]) OR (Exercise Training[Title/Abstract]) OR (Training, Exercise[Title/Abstract])

#3 (Anxiety[Title/Abstract]) OR (Nervousness[Title/Abstract]) OR (Anxiousness[Title/Abstract]) OR (dread[Title/Abstract]) OR (frightened[Title/Abstract]) OR (depressed[Title/Abstract])

#4 #1 AND #2 AND #3

We conducted a search for evidence spanning from the inception of the databases up to May 10, 2022.

Inclusion and Exclusion Criteria for Articles

Inclusion criteria: 1) the target population was patients with kinesophobia post-PCI; 2) the intervention program included exercise, psychological interventions, health education, family support, and so on; 3) outcome indexes included the degree of cardiac kinesophobia, anxiety, and depression, the success rate of the 6-minute walk test, self-care ability in daily life, and self-efficacy in CHD exercises; 4) the types of articles included guidelines, evidence summaries, expert consensus statements, meta-analyses, RCTs, and systematic reviews published in China and other countries; 5) the languages of publication were Chinese and English.

Exclusion criteria: 1) articles where the full text was unavailable; 2) republished articles; 3) articles of poor quality; 4) meeting abstracts, drafts, excerpts, and such other publications; 5) articles in which the subjects had other systemic diseases or serious infections, shock, or other complications.

Article Screening and Data Extraction

Two evaluators independently screened the articles that were retrieved. They reviewed the title and abstract of the articles and then further read the full text of the articles that could be potentially included. In instances of disagreement, a third researcher decided on the inclusion of the concerned article. The relevant information from the selected articles was uploaded and managed in Excel. The main contents that were extracted included the title, article source, date of publication, and nature of the article.

Quality Evaluation of the Articles

The quality evaluation was as per the nature of the study design. The quality of RCTs was evaluated as per the Cochrane risk of bias assessment criteria.¹⁴ We evaluated the quality of quasi-experiments using the JBI quality evaluation tool for quasi-experiment studies. The evaluation of systematic reviews was conducted using AMSTAR.¹⁵ The quality of guidelines was evaluated using the AGREE II clinical practice guideline evaluation tool.¹⁶ Evaluation of the quality of expert consensuses was done using the expert consensus evaluation criteria of the JBI evidence-based healthcare center.¹⁷

Evidence Extraction, Summary, and Evaluation

We employed the evidence grading system of the JBI evidence-based healthcare center¹⁸ for quality evaluation. This assessment was conducted based on the evidence level and recommendation index of the included articles.

Results

Results of the Article Screening

A total of 1506 articles were searched, among which 14 articles were finally included after eliminating duplicates and those that did not meet the inclusion criteria.^19–32 These included 4 guidelines, 3 systematic reviews, 3 expert consensuses, and 4 RCTs from China, the USA, the UK, and other countries. The flowchart for article screening is shown in Figure 1, and the general information about the articles included in our review is shown in Table 1.

Table 1 General Information About Included Articles

Figure 1 Article screening flowchart. Abbreviations: BMJ, British Medical Journal; NGC, National Guideline Clearinghouse; NICE, the UK guideline website; AHA, American Heart Association; ECS, European Society of Cardiology. CNKI, China National Knowledge Infrastructure.

Results of the Quality Evaluation of Articles

Guidelines

The four guidelines included in our review^19–22 consisted of two from China, one from the UK, and one from the USA. The evaluation results indicated a grade of “B”, as shown in Table 2.

Table 2 Results of the Evaluation of Guidelines

Systematic Reviews

Three systematic reviews were included in our study. The evaluation of all items in the review by Albus et al²⁴ was positive, resulting in a quality rating of “grade A”, suggesting that they were of high quality. The evaluation of the review by Marino et al²³ was as follows: the evaluation results of item 1 (“Is a preliminary plan provided?”) and item 4 (“Is the publication status considered in the inclusion criteria, such as grey articles?”) were “unclear”, while those of other items were “yes”, and the quality was rated as “grade B”. For the review by Minmin et al,²⁵ the evaluation results of items 1, 4, and 11 (“Are conflicts of interest reported?”) were “unclear”, while those of other items were “yes”, and the overall quality was rated as “grade B”, suggesting that they were of high quality.

Expert Consensus

Three expert consensuses were included in this study.^26–28 For all three consensuses, the evaluation results of item 7 (“Are the recommended suggestions or ideas supported by peers?”) were “unclear”, while those of other items were “yes”, suggesting that they were of high quality.

RCTs

Four RCTs were included in this study. In the studies of Liu et al,²⁹ Wu,³⁰ Xu et al,³¹ and Yan et al,³² the evaluation results of items other than “allocation concealment” and “blindness” (“unclear”) were “low risk”, and the quality was rated as “grade B”.

Evidence Summary

Following the extraction and integration of evidence, we ultimately compiled 21 pieces of information categorized into six groups: pre-intervention assessment, psychological intervention, health education, social support, rehabilitation exercise, and quality control. These findings are detailed in Table 3.

Table 3 Summary of Best Evidence on Post-PCI Intervention Programs for Patients with Kinesophobia

Discussion

Conducting an Early Psychological Evaluation of Patients Who Have Undergone PCI Helps in the Timely Identification of Adverse Psychological States in Patients, Especially Those with Kinesophobia

Early cardiac rehabilitation is instrumental in facilitating patients’ recovery post-PCI and reducing their mortality and family burden. Patients experiencing poor emotional wellbeing, however, may be less enthusiastic to participate in early rehabilitation that is primarily focused on exercise. Studies have indicated the detrimental impact of kinesophobia on subsequent rehabilitation efforts.³³ Patients with kinesophobia may exhibit psychological resistance to exercise and an increased fear response following exercise. Such a vicious cycle leads to poor rehabilitation outcomes. In clinical practice in China, not much attention is paid to the psychological problems of patients post-PCI.²⁶

In light of these findings, healthcare professionals should prioritize the evaluation of kinesophobia in patients with CHD post-PCI and implement proactive interventions to improve patients’ compliance with exercise and help them return to a normal social life as soon as possible.

Development of Comprehensive Post-PCI Intervention Programs for Patients with Kinesophobia

Early Psychological Interventions are Conducted to Relieve Anxiety, Depression, and Other Negative Emotions, Consequently Addressing Kinesophobia

Psychological issues play an important role in the onset, development, and prognosis of cardiovascular diseases. Among these, anxiety and depression are the two key contributors that pose challenges to patients’ postoperative rehabilitation and social reintegration.³⁴ Studies⁷ have suggested that the severity of anxiety and depression is positively correlated with kinesophobia, which is consistent with the physiological understanding that anxiety is the primary emotion in phobias.

Therefore, to reduce patients’ kinesophobia, healthcare professionals should accurately identify psychological problems such as anxiety and depression, as well as symptoms like chest pain in patients, using psychological evaluation tools at the time of admission. Subsequent non-pharmacological or pharmacological interventions can be tailored based on the extent of anxiety and depression.

Health Education is Actively Carried Out to Rectify Patients’ Misconceptions and Promote Behavioral Changes

Studies have indicated that patients who have more awareness about their disease have less kinesophobia. This may be attributed to the fact that an accurate understanding of the disease can help reduce patients’ concern about exercise, enhance their confidence in actively participating in exercise rehabilitation, and thus improve their compliance with exercise intervention. Many experts consider “exercise rehabilitation education” the crucial first step in cardiac rehabilitation,³⁵ and health education in the initial stages of recovery can contribute to patients’ correct understanding of exercise rehabilitation and self-efficacy, thereby reducing their kinesophobia.

The timing for starting health education is thus essential. Specifically, patients undergoing elective PCI receive educational inputs prior to the procedure, while those who undergo emergency PCI are generally educated during rehabilitation in the hospital after the operation. Health education practices, often perceived as routine, lack emphasis on patients’ comprehension. However, through feedback teaching and enabling education, a more targeted and planned approach for teaching patients can be employed to enable them to become more confident and compliant with treatment and less fearful about exercise.³⁰

A Comprehensive Rehabilitation Plan is Developed to Help Patients Reduce Their Fear and Restore Their Confidence Through Gradual Exercise

According to the expert consensus,²⁸ a common issue among patients is the lack of awareness of when to initiate exercise as well as the quantum and frequency of exercise post-PCI, due to which they tend to avoid engaging in exercise. Cardiac rehabilitation therapists should develop comprehensive, personalized exercise plans based on the condition of individual patients. This approach can enable patients to perceive the physiological changes in their bodies during exercise and correctly understand the reasons for local and systemic reactions. Consequently, this heightened self-awareness can reduce their fears related to increased heart rates, breathing, and other exercise-induced symptoms.

The Social Support System of the Patient is Actively Mobilized to Improve Patients’ Motivation and Encourage Their Continuous Engagement in Cardiac Rehabilitation

Patients who are hospitalized get social support mainly from medical staff, wardmates, and family members, all of whom play a crucial role in promoting behavioral changes in them.³⁵ Patients who receive support from the treatment team tend to become more compliant.³⁶ Support from fellow wardmates can strengthen patients’ confidence, while support from family members, especially spouses, is a powerful motivating factor for patients. Therefore, involving the family in interventions to address kinesophobia can play a positive role in alleviating patients’ fears.

Quality Control Measures Should Be Rigorously Enforced Throughout the Entire Cardiac Rehabilitation Process to Ensure the Safety of Patients

Post-PCI, patients experience serious and rapidly changing medical conditions. This necessitates the prompt detection of problems by the medical team and the implementation of effective safeguard measures during exercise. In addition to developing detailed procedures for quality control, strengthening the training of medical staff and encouraging them to gain adequate practical experience are essential to ensuring patients’ safety.

Conclusion

In this review, we consolidated the best evidence pertaining to post-PCI intervention programs for individuals experiencing kinesophobia. The findings are organized into six categories: pre-intervention assessment, rehabilitation exercise, psychological interventions, health education, social support, and quality control. The aim is to provide a more comprehensive and secure foundation for evidence-based nursing practices aimed at alleviating post-PCI kinesophobia in patients. However, it is noteworthy that there is a lack of direct evidence within the identified articles and guidelines demonstrating the efficacy of interventions in reducing patients’ kinesophobia. However, this study has certain limitations. The included literature does not cover qualitative research on the needs and barriers of patients with post-PCI kinesiophobia. Future studies should incorporate relevant literature to provide a more comprehensive summary of the evidence.

To establish the validity of the evidence presented, it is imperative to subject these findings to verification through the implementation of clinical practices in various hospitals at different levels and in different regions. Feasible intervention programs should be developed by considering the actual working environment, experience of personnel, hospital resources, allocation of medical staff, and patients’ preferences. Additional investigations are warranted to contribute to acquiring more direct and substantiated evidence, thereby offering valuable insights and references for clinical practice.